Effectiveness and safety comparison of three eye and orbital reconstruction techniques in facial plastic surgery.

PURPOSE: To compare the effectiveness and the safety of three eye reconstruction techniques with porous bioceramic implantation in facial surgery: the "four petals" eye evisceration (EE) technique, the "russian doll" EE technique and the enucleation with "on-the-table" evisceration technique. METHODS: Retrospective review of patients who underwent surgical orbit reconstruction with primary placement of a porous bioceramic orbital implant using three techniques at Quinze-Vingts National Center (Paris, France). We compared outcomes of three surgical orbit reconstruction techniques: the "four petal" EE technique, the "russian doll" EE technique and the enucleation with "on-the-table" evisceration technique. The primary endpoint was to determine the rate of implant exposure and the facial cosmetic result during the first year after surgery for each technique. The mean of the Numeric Pain Rating Scale (NRS) after surgery at day 1 was also a primary endpoint. In addition, data such as analgesic intake and rate of revision surgery were compared for each technique. RESULTS: One hundred and ten patients were included: 70 patients in the "four petals" procedure group, 31 in the "on-the-table" procedure group and 9 in the "russian doll" procedure group. NRS pain at day 1 was statistically significantly lower in the "four petals" procedure group 0.9 [standard deviation (SD)] (1.8) and in the "russian doll" procedure group 1 (1.7) than in the "on-the-table" procedure group 2.5 (2.4) (P=0.001). Implant exposure was statistically significantly lower in the "four petals" procedure group (2.9%) and in the "on-the-table" procedure group (3.2%) when compared to the "russian doll" procedure group (22.2%) (P=0.03). Rate of revision surgery was lower in the "four petals" procedure group (11.5%) than in the "russian doll" procedure group (33.3%) and the "on-the-table" procedure group (22.6%). "russian doll" evisceration procedure group had the highest orbital lipofilling rate due to the highest rate of enophthalmos. Therefore, the cosmetic result was better in the "four petals" and the "on-the-table" procedure group. CONCLUSION: The "four petals" EE technique for surgical eye and orbital reconstruction seems to be a method that reduce implant extrusion, postoperative pain and improve facial esthetic result.

[Boston Keratoprosthesis with temporal aponeurosis graft: A solution when there seems to be no more]. / Kératoprothèse de Boston avec greffe d'aponévrose temporale : une solution quand il semble ne plus y en avoir.

PURPOSE: To report cases of patients with severe bilateral corneal blindness and recurrent refractory perforation to keratoplasty and conventional treatment, for whom Boston keratoprosthesis (KP) was a satisfactory alternative when combined with a temporalis aponeurosis graft. DESCRIPTION OF CASES: The first patient had progressive Lyell syndrome with spontaneous corneal perforation. The second had a severe graft vs. host reaction with a persistent Seidel-positive descemetocele. Despite repeated penetrating keratoplasties, amniotic membrane (AM) transplantations, and buccal mucosal (BM) grafts, they both experienced recurrent corneal perforation. The only solution thus appeared to be Boston Type I KP surgery. One month postoperatively, the first patient had to receive a temporalis aponeurosis (TA) graft, due to thinning of the recipient graft. Six months postoperatively, his visual acuity (VA) was 1/10 without correction, and the corneal status had been stabilized. The second patient underwent KP and TA graft concurrently. Six months after surgery, VA was 2/10 uncorrected, and the local inflammation had been stabilized. OBSERVATION: Boston type I keratoprostheses constitute an alternative in cases of severe bilateral corneal blindness with perforation refractory to conventional treatment and surgery, with satisfactory visual results. DISCUSSION: Patients with preoperative severe ocular surface disease are at greater risk of postoperative keratolysis. For our patients with a higher risk, TA graft prevented corneal melt. TA seems to be more effective than AM or BM in preventing corneal thinning or melt. CONCLUSION: We would recommend performing a TA graft in combination with Boston KP surgery concurrently as first line treatment in eyes with severe ocular surface inflammation.

[Clinical polymorphism of myasthenia gravis beginning with isolated ocular symptoms; a five years retrospective analysis]. / Polymorphisme clinique de la myasthénie à point de départ oculaire; analyse rétrospective sur cinq ans.

INTRODUCTION: myasthenia gravis is a neuromuscular junction disorder that can jeopardize the patient's life and has a high clinical polymorphism that makes it difficult to diagnose. PATIENTS AND METHODS: after reviewing the disease physiology, its clinical symptoms, and the different means to diagnose and treat it, we present a 15-patient series that we cared for at the Rothschild ophthalmologic foundation from 2002 to 2007 for myasthenia gravis that began with isolated ocular symptoms, so as to highlight the clinical diversity of this pathology. RESULTS: when the disease was diagnosed, 11 patients out of 15 had a ptosis with diplopia, two had an isolated ptosis, and two had isolated diplopia. After investigations, we discovered that three patients had a malignant thymoma and one had thymic hyperplasia. An autoimmune disease association was found in two patients: the first one had Hashimoto thyroiditis and the second one developed optical neuromyelitis a few years after his myasthenia gravis. Only three patients secondarily developed a generalized myasthenia gravis. DISCUSSION: our series of patients has a low disease generalization rate in comparison with the published data in the medical literature, indicating that two-thirds of patients with ocular myasthenia gravis should develop generalized myasthenia gravis within approximately 2 years after the beginning of their illness. This could be explained by the early consultation of these patients and the common prescription of an immunosuppressive therapy, reducing the risk of secondarily generalized myasthenia gravis according to some studies. CONCLUSION: despite the small number of patients, this study underlines the clinical polymorphism of ocular myasthenia gravis and the risks it may cause. Close collaboration between ophthalmologists and neurologists is needed to ensure good care for these patients.

Visualization and rapid quantification of autoradiographic labeling in scanning electron microscopy applied to localization of receptor sites on the surface of whole cells.

The use of backscattered electron imaging (BEI) as a routine procedure for examining autoradiographic reactions in scanning electron microscopy (SEM) is described. This technique allows the determination of the number of receptor sites occupied by 125I-epidermal growth factor (EGF) on whole cells. The effect of 1.25 dihydroxyvitamin D3 (1,25 (OH)2D3) on the number of epidermal growth factor receptors (EGF-R) in the BT 20 human mammary carcinoma cell line (which is known to possess a very high number of EGF-R) has been evaluated with this method. To compare the silver grain density over the cells (controls and 1,25 (OH)2D3-treated cells) we used an image analysis system Quantimet 900. The results were compared with those of a previous study using transmission electron microscopy (TEM). This study confirmed the results obtained with TEM and showed the even distribution of receptors sites on a single cell and a large difference in the number of receptor sites from one cell to another. The use of BEI to visualize the autoradiographic reaction in SEM allowed the examination of a large surface with good contrast and resolution and eliminated artefacts not corresponding to the silver grains. It gave new information not delivered by quantitative TEM autoradiography and was easier and faster to use. The efficient use of SEM autoradiography combined with BEI could facilitate whole area distribution mapping of radioactive labeling.

Structure and composition of microcalcifications in benign and malignant lesions of the breast: study by light microscopy, transmission and scanning electron microscopy, microprobe analysis, and X-ray diffraction.

Microcalcifications previously located by radiography were extracted from 25 fresh specimens obtained from patients who had undergone tumorectomy or systematized mammary exeresis. Two principal types of microcalcifications were distinguished: Type I microcalcifications were amber in color and generally crystalline on scanning electron microscopy, with only one calcium peak on microprobe analysis; x-ray diffraction revealed that weddellite was involved. Type II microcalcifications were whitish, nonbirefringent under polarized light, and generally ovoid or fusiform, with two peaks, one calcium and the other phosphorus, on microprobe analysis; these microcalcifications were composed of calcium phosphate, the most characteristic form of which is hydroxyapatite, in the form of needles arranged in rosettes on transmission electron microscopy. Type I microcalcifications were observed in four of eight benign breast lesions, in two of three in situ lobular carcinomas, and in no intraductal adenocarcinomas or infiltrating carcinomas. Type II microcalcifications were present in all infiltrating carcinomas and intraductal adenocarcinomas; they were also found in benign lesions (four of eight) and even associated with type I microcalcifications in one in situ lobular carcinoma. There are, therefore, no "benign" or "malignant" microcalcifications; however, the presence of weddellite is a strong indication that a lesion is benign or, at most, an in situ lobular carcinoma.