Surgical management of dysthyroid diplopia with preservation of the anterior ciliary vascularization: review of ten cases.

PURPOSE: During the surgical correction of dysthyroid diplopia, the risk of ischemia by transection of the anterior ciliary arteries is well-known. In order to avoid this, we modified the classical surgical technique: (1) through the preservation of the vascular pedicles during muscle recession and (2) if necessary, through a plication (instead of a resection) of the ipsilateral antagonist muscle. The objective to be achieved is thus the resolution of the diplopia without ischemic complications. SUBJECTS AND METHODS: We report a prospective series of 10 patients with dysthyroid ophthalmopathy, causing strabismic diplopia, all operated on by the same surgeon (BR) after at least 12 months of euthyroidism. Data collection included: history of previous decompressive surgery, surgical procedure, and oculomotor status before and after surgery. RESULTS: Ten patients (8 females), aged 51 to 74 years (mean age, 58.00 ± 7.62 years), were collected between 2008 and 2012. All patients had one or more vascular risk factors (diabetes, smoking, obesity, high blood pressure). With a follow-up from 16 to 67 months (mean ± SD 27.7 months ± 14.87), surgical outcomes were excellent: diplopia was cured in all cases, with recovery of stereoscopic vision. We had no operative or postoperative complications. CONCLUSIONS: The technique of preservation of the anterior ciliary vascularization, which is particularly justified for these fragile patients, is compatible with moderate muscle recessions. For larger deviations, in which a larger recession might increase the proptosis, it is possible to add a plication of the ipsilateral antagonist. This surgical technique made possible the suppression of the diplopia in all cases.

[Surgical treatment of lower eyelid retraction occurring after inferior rectus recession: a case report of a patient with congenital fibrosis of the extraocular muscles]. / Traitement chirurgical d'une rétraction de la paupière inférieure survenant après un recul du muscle droit inférieur.

Lower eyelid retraction is a complication that frequently follows large inferior rectus recession. It may result in cosmetic problems or lagophthalmos with corneal exposure. We report the case of a child who had restrictive strabismus related to orbital fibrosis. He underwent bilateral inferior rectus recession and bilateral brow suspension. Retractor lysis was performed to treat a lower lid retraction that followed strabismus surgery. Lower lid retraction results from the anatomic connections between the inferior rectus muscle and the lower eyelid retractor. Several techniques have been proposed to prevent or treat lower eyelid retraction after inferior rectus recession.

[Management of acute visual loss in children]. / Conduite à tenir devant une baisse aiguë de l'acuité visuelle chez l'enfant.

Acute or rapidly progressive visual loss in children needs urgent attention and treatment. It may be unilateral orbilateral. Etiology depends upon the involved areas: eye ball, optic nerve, retro-chiasmatic pathways. Psychogenic origin is quite common in school-age children, however, it has to be considered last. Unilateral visual loss may be overlooked. Acute total transitory visual loss may be due to epilepsy or to migraine. Rapidly progressive visual loss may be due to retinal disease, optic neuritis or cortical blindness. Management of visual loss depends on clinical features, associated symptoms, and aspect of the optic disc. It needs collaboration between ophthalmologist,pediatrician and neuropediatrician. Retinal hemorrhages first call to mind a traumatic origin. Swelling of the optic disc may be due to increased intracranial pressure or due to optic neuritis. When the optic disc is normal it is necessary to rule out organic diseases before establishing the diagnosis of a psychogenic vision disturbance. In emergency, brain neuroimaging is the best way to diagnose intracranial mass and visualize optic pathways.

[Intrastromal epithelial cysts of the iris: two case studies]. / Kyste congénital du stroma irien.

AIM: Intrastromal epithelial cysts, congenital or acquired, are rare tumors of the anterior chamber. We report two cases, one in a 4-Month-old girl and one in a 14-Year-old teenage girl. MATERIAL AND METHODS: In the infant case, a large cyst with a superior base obstructed the visual axis. The child had already developed amblyopia and intermittent esotropia, with normal ocular pressure. Aspiration of the cyst with complete excision was done without iridectomy. Two Years later, a secondary corectopia required an inferior iridectomy. Finally, 4 Years later, endophthalmitis developed on a corneal stitch, and the eye was enucleated. In the second case, the teenage girl had noticed a modification in her iris due to an inferior temporal iris cyst. The cyst was excised with a peripheral iridectomy. Despite a first complete excision, a recurrence the following Year was treated by Yag laser. One Year later, the clinical aspect was stable. COMMENTS AND CONCLUSION: These benign tumors present the problem of local extension and recurrence. Surgical treatment with iridectomy is often proposed despite eventual aesthetic or functional consequences. Yag laser may be a therapeutic alternative. The two operations reported here did not prevent recurrence. In conclusion, intrastromal epithelial cysts of the iris are rare and benign tumors that may induce local complications and lead to recurrence. Many treatments can be discussed for each case.

[Acute optic neuritis in children: clinical features and treatment. A study of 28 eyes in 20 children]. / Les neuropathies optiques aiguës de l'enfant: particularités cliniques et thérapeutiques. A propos de 28 yeux chez 20 enfants.

PURPOSE: Analyzing a personal series of children with acute optic neuritis (AON), we studied MATERIAL AND METHODS: A retrospective study of 28 eyes in 20 patients (mean age: 10;7 years), examined between 1982 and 1997, with a follow-up ranging from 6 months to 15 years (mean: 5;5 years). We recorded etiologic factors, clinical features (ocular and extra ocular), biological results, and neuroimaging findings. RESULTS: Initial involvement was uni- or bilateral with poor visual acuity (under 20/200 in 22 eyes of 28). Intracerebral inflammation was present in 9 of 13 cases where MRI was performed. We found a cause in only 7 cases (5 viral diseases and 2 recent vaccinations against hepatitis B). Visual recovery was good (over 20/25 in 20 eyes of 28) whatever the treatment, but AON recurred in 5 children. Four children later developed multiple sclerosis. CONCLUSIONS: The cause of AON is rarely found. After eliminating an infection, we retained viral disease, complication of a recent vaccination against hepatitis B, and neurological diseases. MRI was the imaging study of choice. Development of multiple sclerosis occurred in 4 cases of 20, the same frequency as in the literature. The risk of later development of multiple sclerosis was 20%. Progression of AON was often excellent. Nevertheless, corticotherapy was added, in form of intravenous boluses followed by decreasing oral therapy for one month.

[Exploration of retro-chiasmatic visual pathways in human albinism]. / Exploration des voies optiques rétro-chiasmatiques chez l'albinos.

PURPOSE: Several research studies have explored the abnormal crossing of the retinogeniculate and geniculocortical optic pathways in human albinos. This prospective study has dealt with visual evoked potentials (VEPs) of human subjects to identify the percentage of albinos with asymmetric VEPs. PATIENTS AND METHODS: A series of 16 albino patients ranging in age from 6 to 37 years were examined. They had measurable visual acuity, with or without nystagmus. Diffusion of flash stimuli not allowing selective study of the two visual pathways (direct and crossed), two stimulation patterns were used for VEP recordings: monocular full open field then hemi-field stimulation to isolate the activity of each visual pathway. ANALYSIS: In the normally pigmented subject, fibers derived from the nasal half of the retina of each eye decussate at the chiasma, while temporal retinal fibers are uncrossed and project to the ipsilateral hemisphere. In albinos, the majority of temporal retinal fibers subserving the nasal field (from fixation to an eccentricity of about 20 degrees ) anomalously cross with the nasal retinal fibers. Therefore with monocular stimulation, the evoked visual response should be obtained only in the contralateral hemisphere. The asymmetry, morphology and latency for the first major positive peak and the amplitude of the VEP were examined and compared with the normal population. CONCLUSION: We managed to demonstrate the characteristic VEP asymmetry only in 3 out of the 16 patients. The results presented herein lead to question the absolute validity of VEP abnormality in diagnosis of albinism for clinical purposes.

["Idiopathic" acute optic neuropathies in children]. / Les neuropathies optiques aiguës "idiopathiques" de l'enfant.

We reported a retrospective study of 27 children (mean age = 10 years), who presented a loss of vision due to an acute optic neuritis, between 1982 and 1997. The symptoms ar more likely bilateral in children, and frequently associated with systemic viral infection or hepatitis B vaccination. Multiple sclerosis occurs approximately in 20 p. cent of the cases, i.e. less frequently than by adults. Magnetic resonance imaging is now systematic: in 20 children hyperintense nodular abnormalities in a various distribution was demonstrated by 9 children. During the follow-up, 23 eyes of 27 have an excellent recovery of vision, but 4 patients have developed multiple sclerosis. Corticotherapy was uses in 23 cases, in the form of methylprednisolone intravenous flashes in 14 cases.

[Persistent and hyperplastic primary vitreous syndrome. Clinical and therapeutic aspects]. / Syndrome de persistance et d'hyperplasie du vitré primaire. Aspects cliniques et thérapeutiques.

PURPOSE: Persistent hyperplastic primary vitreous (PHPV) is a rare developmental malformation of the eye. This anomaly is usually unilateral and unassociated with other disease. PHPV may have clinical variations: an anterior and/or a posterior one. Diagnosis and treatment are exposed in our paper. METHODS: We study 38 eyes in 34 patients. All patients had an anterior form of PHPV. Nine of them associated a posterior form. Eighteen eyes underwent surgery, the mean postoperative follow-up is 4.7 years. Treatment is discussed, depending on the initial form of PHPV. We report the evolution of the surgical eyes and the untreated eyes. RESULTS: Slit lamp examination and echographic findings (A-scan and B-scan) support the diagnosis. In some cases computed tomography or RMN can be useful. If the cataract is mild in the anterior form of PHPV, treatment of amblyopia and frequent clinical examination can be sufficient. If the cataract is dense, a lensectomy must to be performed. The surgical technique can be difficult. For the eyes with posterior PHPV, the surgical treatment is to be avoided, because of high risk of retinal detachment. CONCLUSION: PHPV may have clinical variations, mostly with cataract as major sign. In purely anterior presentation, in absence of marked microphthalmos, lensectomy can be useful.

[Spasmus nutans: apropos of 16 cases]. / Spasmus nutans: à propos de 16 cas.

UNLABELLED: Spasmus nutans is a syndrome occurring in early childhood. It consists of a triad of symptoms: head nodding, ocular oscillations and anomalous head position. Ophthalmologic and neurological findings are otherwise normal. This syndrome is benign and has spontaneous resolution. PATIENTS AND METHOD: Sixteen patients with spasmus nutans seen from 1980 to 1995 were retrospectively studied. Their present status was evaluated by clinical examination or questionnaire. RESULTS: The age at onset ranged from 1 to 15 months (average 7 months). Thirteen of 16 patients were referred for head nodding, which was a constant manifestation; its direction was horizontal, vertical or rotatory. Nystagmus was present in 14 infants. It was acquired, asymmetrical, bilateral (or unilateral in three cases), rapid, fine, pendular and horizontal. Both head nodding and nystagmus were intermittent. Anomalous head position was present in seven cases, consisting of head tilt or a chin upon/chin down posture. Neuroimaging (13 cases) was always normal. The follow-up in 12 children (up to 2 years) showed a complete resolution of the syndrome in 6 months to 6 years (average 2.5 years). DISCUSSION: The diagnosis was established by the constancy of the characteristic triad and the elimination of the other causes of nystagmus. Isolated head nodding had to be distinguished from bobble head syndrome. In several reported cases, electronystagmography recordings have suggested that head nodding is a compensatory process against nystagmus and that the head tilt allows transient resolution of the nystagmus. CONCLUSION: Spasmus nutans is a self-limiting benign clinical entity. Normal complete ophthalmologic and neurological examination, as well as magnetic resonance imaging (MRI) are necessary to confirm the diagnosis.

[Surgery of ectopia lentis in Marfan disease in children and young adults]. / Chirurgie de l'ectopie cristallinienne dans la maladie de Marfan chez l'enfant et l'adulte jeune.

INTRODUCTION: To determine the visual outcome of surgical therapy and conservative management, we retrospectively reviewed all our patients with ectopia lentis and Marfan's disease. MATERIAL AND METHOD: Thirty-five eyes of 18 patients (age 8 to 47, average 25.3) were studied. Eight eyes were followed conservatively, the remaining 27 eyes underwent a lensectomy either with the Klöti vitreous stripper (18) or using other techniques (9). RESULTS: Over follow-up periods ranging from 0.5 to 13 years (average 6.2 years) low visual acuity was found in non-operated eyes. Retinal detachment occurred in 2 out of 8 eyes. Eyes undergoing other surgical techniques had a mean final visual acuity of 0.2. Retinal detachment occurred with high frequency (6 out of 9 eyes). Lensectomy-vitrectomy was a safe and effective procedure with a mean final visual acuity of 0.6. No retinal detachment or secondary glaucoma were found. COMMENT: Our study suggests that performing lensectomy-vitrectomy with the Klöti vitreous stripper is the best surgical approach in ectopia lentis with Marfan's disease. This technique allows the vitreous to be handled more effectively and has led to improve results.

[In utero study of the eye of normal fetuses. Static ultrasonographic aspects and clinical implications]. / Etude in utero de l'oeil du foetus normal. Aspects échographiques statiques et implications cliniques.

PURPOSE OF THE STUDY: Some ocular diseases are detected by amniotic fluid analysis. However, some serious eye malformations are only detected at birth. By analogy to other organs, we were concerned by fetal sonography studying in utero ocular structures. METHODS: We performed 150 fetal sonograph with 2 abdominal probes and one vaginal probe. We defined: (a) Axes where ocular structures are best visualised, (b) sonographic images of these structures, (c) the date at which these structures are detected. RESULTS: Orbit are detected between 11th and 12th week amenorrhae. Lens are detected between 12th and 14th week. Hyaloid artery appears around the 18th and disappears around the 32nd. Lids were recognised at 16th week. These results were confirmed by similar studies. Pathologic cases described in the literature are discussed. CONCLUSION: Fetal sonography must include a precise study of the eye. However, the eye is a small organ, so its study implicates technically skilled and an experienced practitioner. Fetal sonography gives precise information about normal eye development and allows the detection of structural anomalies (anophthalmos, microphthalmos, cyclopia) or orbital prenatal malformations (hyaloid artery persistance).

[Neuron-specific enolase in the aqueous humor. Its significance in the differential diagnosis of retinoblastoma]. / L'énolase neurospécifique dans l'humeur aqueuse. Intérêt dans le diagnostic différentiel du rétinoblastome.

Several studies support that retinoblastoma originates from a primitive neuroectodermal cell, the main argument being the expression of the neuron-specific enolase (NSE) by the retinoblastic cells. NSE was measured in the aqueous humor taken off: 1) in 19 patients with various eye disorders for which the diagnosis of retinoblastoma was definitely excluded (NSE = 5.0 +/- 7.7 micrograms/l); 2) at the time of the enucleation, in 7 cases of proved retinoblastoma (NSE = 83 to 17,900 micrograms/l); 3) in 2 cases of retinoblastoma held as cured for more than 5 years (NSE = 2.8 and 8.7 micrograms/l). The high level of NSE in the aqueous humor of the subjects with retinoblastoma is very significant, so that it can play a great part in the diagnosis, particularly in the case of atypic tumors. Specific indications of this determination may be considered for the survey of tumors under treatment or of the controlateral eye after a first tumor.

[Cyclodiathermy: is it effective in the treatment of glaucoma?]. / La cyclodiathermie: a-t-elle encore une valeur dans le traitement du glaucome?

The authors describe the non penetrating technique of cyclodiathermy in the treatment of different types of glaucoma and publish the results and the complications of the application of this technique on thirty three eyes among their patients. These eyes included congenital glaucoma (8 eyes), aphakic glaucoma (5 eyes), after silicone surgery (5 eyes), neovascular glaucoma (4 eyes), traumatic glaucoma (4 eyes), secondary glaucoma (3 eyes), Sturge-Weber-Krabbe (2 eyes) and open angle glaucoma (2 eyes). Their study with a mean follow up of 2.5 years shows an overall success rate of 60%. The success is defined as an ocular tension less than or equal to 22 mmHg in the absence of serious complications. All the encountered complications are mentioned. Phtysis occurred in not more than 3% of cases (1 eye). They establish a comparison with the published results and complications of the other cyclodestructive procedures: Sonocare, transcleral laser Yag, transcleral laser Ruby and cyclocryotherapy. This comparison does not prove the superiority of these other procedures with regard to the non penetrating cyclodiathermy. They conclude that this non penetrating cyclodiathermy is a non expensive procedure which still have its good therapeutic value.

[Benign isolated 6th nerve paralysis in children. Developmental aspects apropos of 9 new cases]. / Les paralysies isolées et bénignes du VI nerf crânien chez l'enfant. Aspects évolutifs à propos de 9 nouveaux cas.

Benign isolated VI nerve palsy in children is a rare but now well-established clinical entity. The diagnosis is essentially an exclusion one. We report nine additional cases. The evolution is discussed, with reference to the literature.

[Foveal displacement after weakening of the inferior muscle. Study using retinophotography]. / Déplacement de la fovéa après affaiblissement du muscle petit oblique. Etude sur rétinophotographies.

Among oculomotor disturbances, the cyclotorsions are difficult to quantify. The most accurate and objective method seems to be the retinophotography, which give the measure of the displacement of the fovea relative to the horizontal line lying through the papillary center. The authors have compared this measure over 16 eyes, before and after inferior oblique weakening. A reduction of the cyclotorsion is established in all cases. However, no correlation has been noted between this result and the pre-surgical state.

[Retinal detachment: temporary internal tamponade with silicone oil after vitrectomy. Anatomic and functional results]. / Décollement de rétine: tamponnement interne provisoire par huile de silicone après vitrectomie. Résultats anatomiques et fonctionnels.

Forty-seven patients with retinal detachment treated by vitrectomy and silicone oil injection benefited from semi-premature ablation of the oil: after a mean of 5 months for supple retinal detachments and 6 1/2 months for those associated with vitreoretinal proliferation. Ablation was performed after obtaining a solid chorioretinal scar by cryopexy or endodiathermy, usually combined with laser panphotocoagulation. The technique used for ablation is described. After follow up for from 9 months to 3 1/2 years (mean 18 months) two-thirds of the patients had flat retinas. Recurrences developed usually during the first month. An explanation for these relapses is proposed.