[Shift of the insertion of the superior oblique muscle by scleral buckling: clinical features and surgery]. / Déplacement de l'insertion du muscle oblique supérieur par une indentation sclérale: clinique et chirurgie.

A 36-year-old man who had been operated on for left eye retinal detachment (silastic sponge, secondarily explanted), presented with an 18 PD left hypertropia in primary position, to a 40 PD hypertropia in abduction, with downgaze limitation, associated with esotropia and incyclotorsion. Surgical exploration showed extensive tissue scarring and fibrosis in the area of the superior rectus and the superior oblique muscles. The insertion of the superior oblique was found in the superomedial quadrant, very anteriorly from the equator of the eye, which made it an elevator and an adductor of the globe. The pathophysiology and the surgical planning are discussed.

[Slipped superior rectus in Grave's orbitopathy. A case report]. / Glissement du muscle droit supérieur dans l'orbitopathie dysthyroïdienne.

Superior rectus slippage after its surgical recession is characterized by short-term progressive overcorrection. Similarities with inferior rectus slippage are pronounced, especially a history of Grave's orbitopathy and the use of an adjustable suture. In the present clinical case, upper eyelid retraction and a history of upper eyelid elevator muscle surgery might be specific risk factors, due to the close anatomical links between the superior rectus and the upper eyelid elevator.

[Convergence excess associated with neurological diseases: surgical treatment]. / Excès de convergence associé à des pathologies neurologiques: traitement chirurgical.

BACKGROUND: Lesions of the supranuclear pathways for convergence control can lead to convergence deficit or convergence excess. Whereas pathophysiology of acquired convergence excess is now fully covered in the literature, no specific paper on its surgical treatment could be found. PATIENTS: Cases 1 and 2: Parinaud's syndrome with convergence excess in attempted upgaze (+ convergence retraction nystagmus and VIth nerve palsy in case 2). Case 3: opsoclonus and convergence excess due to hysterical conversion after head trauma. Case 4: acquired nystagmus, accommodative spasm due to hyperopia. Case 5: functional spasm of the near reflex (dubious medical history of multiple sclerosis). Case 6: medial recti palsy after artificial divergence surgery for congenital nystagmus, substitutive convergence. Cases 3 and 5 were not operated on, recession of the four horizontal recti in case 4, recession of the lateral recti in case 6, complex surgical procedure in cases 1 and 2. DISCUSSION: The following guidelines are suggested: Functional spasm of the near reflex: medical therapy. Organic spasm of the near reflex: retroequatorial myopexia on the medial recti. Parinaud's syndrome with convergence excess (spastic) or convergence retraction nystagmus (rhythmic): restoration of upgaze motility with a vertical Kestenbaum-type procedure, retroequatorial myopexia if insufficient. Thalamic esotropia (tonic): botulinum toxin injection, recession of the medial recti if insufficient. CONCLUSION: Convergence excess associated with neurological diseases should be looked for since it can be improved by effective surgical procedures.

[Recessed inferior rectus syndrome: surgical exploration and pathophysiology]. / Syndrome du droit inférieur reculé: exploration chirurgicale et concepts physiopathologiques.

INTRODUCTION: Progressive overcorrection after inferior rectus recession may occur in 10%-40% of cases, whatever the surgical indication, whatever the technique. The clinical features are hypertropia, inferior rectus underaction, and lid retraction. MATERIAL AND METHODS: The anatomy of the inferior rectus during surgical exploration is described in 11 cases initially operated on for different types of strabismus. RESULTS: Several types of slippage and several types of excessive fibrosis in the area of the inferior rectus are described. DISCUSSION: Our surgical data are compared to the pathophysiological hypothesis described in the literature. Preventive measures and curative treatment are discussed. CONCLUSION: Even a better understanding of the physiopathogenesis of overcorrection after inferior rectus recession could not prevent its occurrence, despite upgraded surgical technique. There is no consensual opinion on how to prevent and cure these overcorrections. Associating oculomotor surgery and lid surgery is an interesting direction for new research.

[Antinomic horizontal deviations: esodeviation associated with exodeviation. Clinical features and surgery]. / Déviations horizontales antinomiques: association d'une exodéviation et d'une ésodéviation. Aspects cliniques et chirurgie.

INTRODUCTION: Antinomic deviations are defined as a basic exoposition of the eyes associated with innervational convergence excess leading to an esoposition. PATIENTS AND METHODS: Thirty-four patients with both exodeviation and esodeviation were studied. Surgery consisted in lateral recti (LR) recess with fadenoperation on the medial recti. RESULTS: Four types of antinomic deviations were found: 1- Primitive exodeviation with an excess of physiological accommodative vergences; 2- Consecutive exodeviation due to surgical overcorrection of an accommodative esotropia; 3- Infantile exodeviation with fixation in adduction, DHD +/- convergence excess; 4- Consecutive infantile exodeviation: overcorrection of a congenital esotropia. CONCLUSION: Although fadenoperation on the medial recti may seem paradoxical in exodeviations, it is the most logical procedure to deal with convergence excess and fixation in adduction prevalence. Adjustable sutures for the lateral recti recess appear safer and more predictible in these difficult cases.

[Botulinum toxin in infantile estropia: long-term results]. / La toxine botulique dans les ésotropies précoces.

PURPOSE: To evaluate long term results of botulinum toxin in infantile esotropia. METHODS: Nineteen infants between 6 and 13 Months of age were treated with botulinum toxin injected into the medial recti. The amount of deviation, the different symptoms of infantile esotropia, and the need for surgery were studied. RESULTS: Esotropia reappears frequently with time. Dissociated vertical deviation and manifest/latent nystagmus are only partially improved. Surgery is usually mandatory over the long term. CONCLUSION: Despite some good results, a single botulinum toxin injection is less effective than incisional surgery in treating the different symptoms of infantile esotropia.

[Progression of subjective refraction after artificial divergence surgery and its relation to a possible myopic spasm]. / Evolution de la réfraction subjective après mise en divergence artificielle et ses rapports avec un éventuel spasme myopique.

PURPOSE: To study the effect on subjective refraction of artificial divergence surgery in congenital nystagmus with blocking convergence. METHODS: Retrospective study on 139 cases, with a study of visual acuity and optical correction with habitual glasses 1-5 years after operation, according to age and ocular alignment (orthophoria or exophoria). RESULTS: Increased myopia with glasses of approximatively 1 diopter, but likely to be due to eye growth in this young population (mean age, 14 years). This myopic shift is higher in the exophoric population, but there is a tendency to prescribe a stronger correction to help control the phoria. A few rare cases of true myopic spasm were noted. CONCLUSION: After artificial divergence surgery, true cases of increased myopia were rare. Tonic vergence is stronger than accommodative vergence.

[Melkersson-Rosenthal syndrome: anatomo-clinical and evolutive concepts]. / Syndrome de Melkersson-Rosenthal. Concepts anatomo-cliniques et évolutifs.

PURPOSE: To inform ophthalmologists about the Melkersson-Rosenthal Syndrome. A new clinical classification is suggested. METHODS: Commented observation and review of the litterature. RESULTS: The presented case is characterized by an exclusive involvement of orbital sphere, due to inflammation of palpebral and orbital fat. CONCLUSION: Melkersson-Rosenthal Syndrome can be divided into type 1 characterized by perioral lesions and type 2 characterized by periocular lesions, with preferential involvement of fat and evolution towards fibrosis.

[Complications of transpalpebral osseous orbital decompressions in thyroid orbitopathies]. / Complications des décompressions orbitaires osseuses transpalpébrales pour orbitopathie thyroïdienne.

INTRODUCTION: Complications of bony orbital decompression (BOD) are rather unreported and often neglected. The aim of this study was to assess the risks of this surgery. MATERIAL AND METHODS: 44 patients (76 orbits) were studied. There were 19 malignant orbitopathies and 57 cosmetic rehabilitations. All side-effects and true complications were reported. A questionnaire was send to the patient and to his ophthalmologist. RESULTS: Infra-orbital hypoesthesia, oculomotor disorders, entropion, changes of lid position were the most frequent complications. A case of hypoglobus, a case of lacrimal stenosis, a case of decreased visual acuity were reported. DISCUSSION: Side-effects of BOD are frequent. Higher rates are even found in the literature. These effects tend to decrease spontaneously or can be treated by adequate medical or surgical care. Some measures are proposed to perform surgery safer. CONCLUSION: More precise information should be given to the patients before surgery and a better prevention can be afforded.

[Oculomotor risk after trans-palpebral bony decompression for thyroid-related orbitopathy]. / Le risque oculomoteur des décompressions osseuses transpalpébrales pour orbitopathie thyroïdienne.

PURPOSE: To study oculomotor disorders after transpalpebral bony orbital decompression (TPBOD) for dysthyroid orbitopathy. Pathophysiology, risk factors, preventive and therapeutic care were examined. MATERIAL AND METHODS: Forty-four patients were included in this retrospective study (76 orbits). Thirteen patients underwent surgery for severe orbital inflammation or optic neuropathy and 31 for cosmetic rehabilitation. 21 previously had orbital radiotherapy. Class IV of NOSPECS classification, primary position of gaze, diplopia and Lancaster coordimetry were studied comparatively pre and postoperatively. RESULTS: Diplopia appeared in 23.6% of the cases without deviation before surgery (tropia or phoria-tropia). Predictive factors were age and amblyopia whereas amount of retrodisplacement of the globe and radiotherapy were not. Lack of oculomotor restriction did not prevent from diplopia but may decrease its incidence. Unilateral decompression is more likely to create a vertical disorder. Pathophysiology is discussed. CONCLUSION: Oculomotor disorders can be explained by several mechanisms. Some of them can be prevented. Each patient should be aware of the risk of diplopia.

Epiretinal membranes surrounding idiopathic macular holes.

PURPOSE: To describe the features of the epiretinal membranes (ERMs) surrounding idiopathic macular holes. METHODS: The charts of 83 consecutive patients (85 eyes) who underwent macular hole surgery with a systematic search for an ERM around the hole were reviewed. Visual acuity testing, fundus biomicroscopy, red free and blue filter fundus photographs, and fluorescein angiograms were performed before and after surgery. Eyes with and without ERM removal were compared. RESULTS: An ERM was removed from 26 of 85 eyes (30.6%). ERMs were found more frequently in stage 4 than in stage 3 macular holes (76.9% versus 24.6%; P < 0.01). Holes had been present for longer in eyes with ERM than in those without (14.7 versus 8.6 months; P = 0.05). Fewer stage 3 holes with an ERM had an operculum than those without (P = 0.01). The outcome and complication rates were similar in eyes with an ERM and those without. Of the 24 ERMs detectable on blue filter fundus photographs, only 11 (45.6%) were visible on red free photographs. CONCLUSION: We support the hypothesis that the presence of ERMs surrounding idiopathic macular holes is secondary to hole formation.

[Massive bone destruction: an atypical sign of orbital lymphoma]. / Destruction osseuse massive: un signe atypique de lymphome orbitaire.

A case of lacrimal sac malignant lymphoma with frank bony distruction visible on computed tomography is described. This is an unusual radiologic finding which does not rule out lymphoma. Biopsy is mandatory to complete the diagnosis.

Late reopening of successfully treated macular holes.

BACKGROUND: Most idiopathic macular holes can be closed by a surgical procedure combining vitrectomy, posterior hyaloid ablation, and fluid-gas exchange followed by postoperative positioning. Reopening of closed macular holes has been reported, but its frequency is not known. Here the incidence of reopening after successful macular hole surgery is reported. METHODS: 77 consecutive cases of idiopathic macular holes operated with autologous platelet injection between July 1993 and October 1995 were reviewed. The procedure consisted of three port vitrectomy, posterior hyaloid removal, nonexpansile fluid-gas exchange, and autologous platelet injection followed by face down positioning. The incidence of reopening was analysed in the cohort of the 72 anatomical successes. RESULTS: Mean follow up was 12.3 months. The macular hole reopened in five eyes of five patients (five out of 72 patients, 6.9%), in four cases after cataract extraction. In four cases too, an epiretinal membrane was noted, either clinically or during reoperation, and fluorescein leakage in the macular area was present in two cases. Three of the five cases of reopening were reoperated and all three were anatomical successes. CONCLUSION: Late macular hole reopening occurred in five out of 72 patient, and in four cases after cataract surgery. The presence of an epiretinal membrane around the hole in four of them suggested that tractional forces were responsible for the reopening. Reoperation, performed in three cases, again closed the macular holes.

Visual field loss after vitrectomy for full-thickness macular holes.

PURPOSE: To report the results of a prospective study of the incidence of peripheral visual field loss after macular hole surgery. METHODS: Prospectively, 30 eyes of 30 consecutive patients with full-thickness macular holes operated on between December 1995 and April 1996 had preoperative and postoperative Goldmann visual field tests. The surgical procedure consisted of three-port pars plana vitrectomy, posterior hyaloid removal, nonexpansile fluid-hexafluoroethane (C2F6) exchange, and, in 19 of 30 patients, autologous platelet injection, followed by face-down positioning. RESULTS: Twenty-nine of these 30 cases were considered to be anatomic successes. Comparison of preoperative and postoperative visual fields disclosed that four patients (13%) had a peripheral scotoma, including one patient with stage 4 macular hole. Three other patients (10%) had a postoperative relative arcuate defect. Mean postoperative intraocular pressure was higher in the latter group. None of the patients complained of peripheral scotoma. CONCLUSIONS: Overall, seven of 30 patients (23%) had a postoperative visual field defect. Two categories of scotomas were observed: peripheral and relative arcuate. The cause of peripheral visual field loss is unclear. Increased intraocular pressure may be the cause of relative arcuate scotomas.

[Papilledema and POEMS syndrome. Apropos of a case]. / OEdème papillaire et syndrome POEMS. A propos d'une observation.

The POEMS syndrome (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein, Skin Changes) is often unrecognized by ophthalmologists. We report the case of a 51-year-old female suffering from a POEMS syndrome with a bilateral optic disc edema.