Myxofibrosarcoma of the orbit: case report and review of literature.

A 17-year-old man was referred with a 6-month history of painless left inferior eyelid edema. Ophthalmic examination was normal except for the presence of a reddish conjunctiva in the left eye medial canthus. MRI demonstrated a 20-mm well-defined extraconical mass between the medial and inferior rectus muscle without destruction of the medial orbital wall. A low-grade myxofibrosarcoma was diagnosed on orbital biopsy. The tumor was locally excised, but the patient categorically refused left exenteration or conformal radiotherapy. He accepted to have annual clinical and radiologic checkup. To date, 2 years later, he has been followed up with no evidence of tumor recurrence. Orbital localization of myxofibrosarcoma is extremely rare, with only 2 cases reported in the literature. The differential diagnosis could be difficult: here, a fibromyxoid sarcoma and a myxoid variant of dedifferentiated liposarcoma have been especially discussed in terms of their histopathologic features. Risk of metastasis is related to the tumor grade. Management of these tumors associates surgery with orbital exenteration or globe-sparing approaches and postsurgical adjuvant radiation therapy.

Ophthalmologic outcome of direct and indirect carotid cavernous fistulas.

Carotid cavernous fistulas (CCFs) can be classified as direct and indirect, depending on their flow rates and their etiology. Both forms can cause the same characteristic ophthalmological symptoms and signs. We analyzed these ocular characteristics and determined the prognostics factors associated with treatment outcome. Forty-seven patients with an angiographically confirmed diagnosis of CCF, a preoperative ophthalmic evaluation and at least one ophthalmic sign or symptom at the initial presentation were retrospectively evaluated. The patients were followed-up ophthalmically until the end of treatment, and the complications and the remaining ophthalmological signs and symptoms were then recorded. The patients' ages ranged from 13 to 89 years, with an average of 55.78 (±20.73) years, and a predominance of 28 female (57.8 %) patients. The patients with a direct CCF had a lower average age (p = 0.02). The most common symptoms were blurred vision in 17 (36.2 %) and proptosis in 37 (78.7 %) patients. Elevated intraocular pressure (IOP) was more prevalent in patients with an indirect CCF (p = 0.02). Thrill was more prevalent in patients with direct CCF (p = 0.01). The presence of an initial decrease of visual acuity at the first ophthalmic evaluation was significantly associated with the persistence of ocular symptoms after fistula treatment (odds ratio 3.33). In conclusion our study shows a slight difference in ophthalmic symptoms among patients with different types of fistula. Elevated IOP was significantly associated with indirect fistulas, whereas thrill was significantly associated with direct fistulas. The presence of an initial decrease of visual acuity was significantly associated with a worse ophthalmic prognosis.

Intravitreal ranibizumab and bevacizumab in combination with full-fluence verteporfin therapy and dexamethasone for exudative age-related macular degeneration.

PURPOSE: To evaluate the efficacy and safety of triple therapy with intravitreal anti-vascular-endothelial-growth-factor (VEGF) antibody, dexamethasone and verteporfin photodynamic therapy (PDT) for exudative age-related macular degeneration (AMD). METHODS: Retrospective, comparative, interventional study. Records of treatment-naïve patients who received intravitreal bevacizumab or ranibizumab in monotherapy or in combination with dexamethasone and full-fluence verteporfin PDT in triple therapy were reviewed. logMAR visual acuity, foveal thickness (FT) on optical coherence tomography, intraocular pressure and endophthalmitis occurrence were recorded. RESULTS: Sixty-one eyes were included in the triple-therapy group, 40 eyes were included in the monotherapy group. The mean follow-up was 14.1 ± 3.4 months in the triple-therapy group and 16.3 ± 4.1 months in the monotherapy group. The triple-therapy group enjoyed a lower total number of treatments (1.92 ± 0.44 vs. 3.12 ± 0.37, p < 0.001) and a longer time before first retreatment (5.4 ± 3.3 vs. 3.6 ± 2.5 months, p = 0.001). A significant improvement of visual acuity and FT was present in both groups during the 12 months following first treatment. No adverse effects were observed. CONCLUSION: The combination of intravitreal bevacizumab or ranibizumabwith dexamethasone and full-fluence PDT for exudative AMD provided visual and anatomic improvement and a good safety profile. Triple therapy may reduce the number of retreatments when compared to anti-VEGF alone.

Videonystagmography to assess eyelid dynamic disorders.

OBJECTIVES: Apply a videonystagmography (VNG) device to study indirectly blinking in patients with essential blepharospasm. PATIENTS AND METHODS: A VNG device was used to study the pupillary occlusion. It was recorded and analyzed as indirect parameters of blinking in 23 essential blepharospasm on day 0, month 1, and month 3 following botulinum toxin injection using VNG. RESULTS: Botulinum toxin significantly reduced pupillary occlusions (PO) frequency (9.6 PO/min on D0 and 4.7 PO/min on M1 (p = 0.004), and average PO time (0.95 sec on D0 and 0.58 sec on M1 (p = 0.03) for PO higher than 0.3 sec. On the other hand, it does not have any action on frequency (32.4 PO/min on D0 and 31.3 PO/min on M1 (p = 0.7) and average PO time (0.16 sec on D0 and 0.15 sec on M1 (p = 0.4) of PO lower than 0.3 sec. CONCLUSION: Video acquisition computer-assisted makes it possible to measure blinking parameters indirectly in real time and to assess essential blepharospasm objectively. The protocol analysis of PO is attractive for indirect analysis of blinking.

The survival of herpes simplex virus in preserved murine corneas.

BACKGROUND/AIMS: This study investigates the survival of HSV in infected mouse corneas, in the conditions of normal human eye bank preservation. METHODS: Hundred seventy-two BALB/C mice infected with herpes simplex virus 1 (HSV-1) (KOS) were randomly assigned to either: no preservation in group 1 (n = 62), 31 degrees C preservation for 3 weeks in group 2 (n = 70) or 4 degrees C preservation for 8 days in group 3 (n = 40). The presence of HSV-1 was thereafter detected by viral culture and PCR. RESULTS: In groups 1, 2 and 3, HSV-1 was detected by culture in 22 (35.5%), 1 (1.4%) and 0 (0.0%) of the corneas, and by PCR in 27 (43.7%), 3 (4.2%) and 7 (17.5%) of the corneas respectively. When compared to group 1, HSV was detected significantly less often in groups 2 (p < 0.0001) and 3 (p < 0.0001). CONCLUSIONS: HSV-1 DNA undergoes a degradation during corneal preservation.

Alcaligenes xylosoxidans endophthalmitis following phacoemulsification and intraocular lens implantation.

Five consecutive cases of endophthalmitis that developed after cataract extraction by a single surgeon using the same operating room during one morning session are described. Following preoperative topical administration of ciprofloxacin, surgery consisted of phacoemulsification with peristaltic pump and fluid venting, polymethylmethacrylate intraocular lens implantation, and corneal suture. No complications occurred during surgery. All five patients developed endophthalmitis caused by infection with Alcaligenes xylosoxidans in less than 24 hours. Pulsed-field gel electrophoresis was used to prove similarity between strains. Bacterial inquiry on contamination of the operating room environment revealed massive colonization of phacoemulsifier irrigation channels by Pseudomonas fluorescens bacteria from an unestablished source. Four of the five patients ultimately recovered visual acuity better than 20/60.

Extraocular muscle involvement in marginal zone B-cell lymphomas of the orbit.

INTRODUCTION: Marginal zone B-cell lymphoma is the most frequent ocular adnexal lymphoma. It may involve the conjunctiva, lacrimal gland, eyelid, extraocular muscle, and orbital connective tissue. Extraocular muscle infiltration is rare. METHODS: We report here a series of 5 patients presenting with extraocular muscle infiltration due to marginal zone B-cell lymphoma, extracted from a retrospective study of 39 patients with primitive ocular adnexal marginal zone B-cell lymphoma presenting within a 15-year period, from 1993 to 2007, at two university hospitals. RESULTS: Out of 39 patients, two females and three males presented with extraocular muscle involvement (one levator muscle, one medial rectus muscle, one lateral rectus muscle, one inferior rectus muscle, and one inferior oblique muscle). In 4 cases, the right eye was involved. The median age of presentation was 60 years. Proptosis and diplopia were the main clinical signs. A mean duration of symptoms was 12 months before diagnosis was given. Three patients were stage IE at the diagnosis, according to Ann Arbor classification, and one was at stage IV. Three patients received radiotherapy and two received chemotherapy. Three patients underwent local relapses at a median time of 40 months. The patients with relapses were treated with chemotherapy alone in one case, radiotherapy alone in one case, and immunotherapy and chemotherapy in one case. The mean follow-up period was 54 months. DISCUSSION: When compared to other locations of marginal zone B-cell lymphomas of the orbit, extraocular involvement occurred in younger patients and had similar prognosis. CONCLUSION: Extraocular muscle involvement is a rare location of marginal zone B-cell lymphoma that had to be known and can simulate thyroid orbitopathy.

Comparative study of 3 exophthalmometers and computed tomographic biometry.

PURPOSE: Accurate and reproducible exophthalmometry is mandatory to diagnose and follow-up orbital patients, especially in Graves disease. However, many variations are described among the different commercially available exophthalmometers. METHODS: Sixty patients, who underwent a cerebral computed tomography (CT) scan, were included. External prebicanthal segments (EPBCS) for right and left eyes (RE and LE), interorbital distance, and globe axial length were recorded by a first observer (O1), more experienced than a second (O2). Intraobserver and interobserver reproducibility were evaluated, using intraclass correlation coefficient (ICC) and Bland and Altman plots. RESULTS: Concordance between each EPBCS measurement for each eye and CT scan biometry was moderate for the Luedde ruler for the 2 observers. For the Hertel exophthalmometer, concordance was moderate for O1 in the 2 eyes and moderate in RE but good in LE for O2. For the Mourits exophthalmometer, this concordance was very good in RE and good in LE for O1, and good whatever the eye for O2. Intraobserver (ICC varying from 0.75 to 0.95 for the 2 observers) and interobserver (ICC from 0.69 to 0.94) reproducibility were high, especially for the Mourits exophthalmometer. Bland and Altman plots showed underestimations when using the Luedde ruler, overestimations when using the Hertel exophthalmometer, and overestimation of small values and underestimation of high values when using the Mourits exophthalmometer when compared to CT scan biometry. CONCLUSIONS: We demonstrated great accuracy to CT scan biometry with 1-prism Mourits exophthalmometer, low accuracy with the Luedde instrument, and intermediate accuracy with the Hertel exophthalmometer, with fair intraobserver and interobserver reproducibility.

[Surgical treatment of blepharospasm: results of a study of 138 patients using an improved disability scale]. / Traitement chirurgical du blépharospasme: evaluation des résultats par une echelle d'invalidité clinique sur une etude de 138 patients.

We applied a new blepharospasm clinical disability scale to the evaluation of blepharospasm surgery in a group of 138 patients. This scale analyzes six parameters of daily life, namely reading, watching television, household tasks, walking, employment, and driving. The patients had either essential blepharospasm or pretarsal dystonia. Frontalis suspension of the eyelid gave slightly better functional results than orbicularis resection in some patient subgroups.

Transmission of viruses through corneal transplantation.

Transmission of viruses through transplantation has become a major concern for surgeons and tissue banks. Keratoplasty has been the first transplantation procedure in which transmission of a virus from the donor to the recipient has been proven, and recently, herpes has been suggested as a transmittable disease via corneal transplantation. In this article we review the history of viral transmission through transplantation, especially focusing on keratoplasty, and develop the recent updates on transmission of HSV through corneal grafting, its implications for surgeons and eye banks, and further insights into viral security in eye banks.

[Is incidence of diplopia after Fat Removal Orbital Decompression a predictive factor of choice of surgical technique for Graves' ophthalmopathy?]. / La diplopie est-elle un facteur déterminant du choix de la technique de décompression orbitaire au cours de l'orbitopathie dysthyroidienne?

UNLABELLED: Dysthroid orbitopathy or Graves ophthalmopathy is a frequent pathologic condition five times more frequent in females than males. The main symptoms are: proptosis, motility disorders related to eye muscles fibrosis, eyelid retraction, lagophthalmos, and finally the more severe ones: compressive optic neuropathy at the apex of the orbit, and corneal exposure. In order to reduce proptosis the classic approach is Bone Removal Orbital Decompression (BROD) either through eyelid skin, coronal, conjunctival, or endonasal approaches. Recently a new technique has been described by Olivari: Fat Removal Orbital Decompression (FROD). The purpose is to evaluate the incidence of diplopia after FROD and improve surgical indications for Graves' ophthalmopathy. MATERIAL AND METHODS: 35 patients were included in this retrospective study (58 orbits). FROD (OLIVARI technique) was performed in all cases (23 bilateral surgery, 12 unilateral; 12 men, 23 women). All patients with optic neuropathy (severe Graves'ophthalmopathy) were eliminated because bone decompression was always performed. The ocular motility was examined before and after surgery by orthoptic screening. The average follow up was 18 months. RESULTS AND DISCUSSION: Before FROD, 7 patients complained of moderate or severe diplopia: all remained with diplopia after FROD. After FROD 32% developed a new diplopia: only one patient remained with diplopia after strabismus surgery or adaptation by prisms glasses. Diplopia after BROD in moderate Graves' ophthalmopathy (with indications identical to our study) is reported from 23 to 34% in previous studies. CONCLUSION: Diplopia after FROD is a real risk whose incidence is identical after FROD and BROD and must be explained to each patient before surgical decision.

Effects of subconjunctival bevacizumab on corneal neovascularization: results of a prospective study.

PURPOSE: To evaluate the effect of subconjunctival bevacizumab injections in patients with corneal neovascularization resulting from different ocular surface disorders. METHODS: Prospective case series. Twelve eyes of 11 patients with corneal neovascularization caused by different ocular surface disorders, such as healed corneal ulcers, long-standing chronic inflammatory diseases, and corneal ischemia secondary to burn, were included. All eyes received a single subconjunctival injection of 2.5 mg (0.1 mL) of bevacizumab. Morphological changes in neovascularization were evaluated during 3 months using slit-lamp biomicroscopy, corneal digital photography, and computer-assisted semiautomatic analysis of corneal neovascularization area. RESULTS: Recession of corneal vessels was observed in all eyes at 1 week postinjection. The surface of the neovascular tree continued to decrease noticeably for 1 month and then increased again for the remainder of the follow-up period. The corneal neovascularization area amounted to 11.25 ± 4.49% of the corneal surface preinjection, compared with 8.44 ± 3.37% postinjection (P = 0.02), reflecting a mean decrease in corneal neovascularization of 25%. No local or systemic adverse events possibly related to subconjunctival bevacizumab injection were observed. CONCLUSIONS: Short-term results suggest that subconjunctival bevacizumab can be used safely and effectively for corneal neovascularization resulting from different ocular surface disorders, providing an additional strategy to improve success of corneal grafts.

Intracameral cefuroxime injection at the end of cataract surgery to reduce the incidence of endophthalmitis: French study.

PURPOSE: To determine whether an intracameral injection of cefuroxime at the end of cataract surgery decreases the incidence of postoperative endophthalmitis. SETTING: Dupuytren Hospital, Ophthalmology Department, Limoges, France. DESIGN: Clinical trials. METHODS: Patients having cataract surgery between April 2003 and June 2008 were included in a survey of operative-site infection. Intracameral cefuroxime injections started in June 2006. Preoperative data (beta-lactam allergy, a history of endophthalmitis, age, sex), intraoperative data (use of trypan blue, use of capsular ring or iris retractors, surgical time, senior or junior surgeon, corticosteroid injection, iris retractors), and the incidence of postoperative infections at 8 days and 1 month were prospectively collected. RESULTS: During the inclusion period, 5115 patients had cataract surgery; 2289 received cefuroxime and 2826 did not. The incidence of endophthalmitis was 35 (1.238%) of 2826 patients without intracameral cefuroxime and 1 (0.044%) of 2289 patients with intracameral cefuroxime; the difference was statistically significant (P<.0001). No intraoperative factor was significantly associated with postoperative infection. No allergic reaction was reported. CONCLUSION: Intracameral cefuroxime injection at the end of cataract surgery was safe and significantly decreased the incidence of endophthalmitis. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Videonystagmography as a tool to assess blepharospasm before and after botulinum toxin injection.

BACKGROUND: The aim of this paper was to study blinking parameters using a videonystagmography device, in order to objectively determine disability, and to assess the efficiency of botulinum toxin injection in patients with essential blepharospasm. METHODS: Blinking was studied using the features of pupillary occlusion (PO) as recorded on a videonystagmography device. In 23 patients presenting with essential blepharospasm, we studied the frequency, the percentage, the mean duration of PO, and the longest PO in a 5-minute test period. Patients were tested prior to botulinum toxin injection, and 1 month and 3 months after injection, respectively. PO levels lower than 0.3 s and higher than 0.3 s were studied separately. RESULTS: At 1 month after injection, botulinum toxin significantly influenced PO higher than 0.3 s, both in frequency (9.6/min +/- 8.2 on Day 0 and 4.7/min +/- 7.2 at Month 1; p = 0.004), and in mean duration (0.95 s +/- 0.84 on Day 0 and 0.58 s +/- 0.34 at Month 1; p = 0.03). On the other hand, we found no significant effect on PO lower than 0.3 s, both in frequency (32.4/min +/- 28.4 on Day 0 and 31.3/min +/- 29.0 at Month 1; p = 0.7) and in mean duration (0.16 s +/- 0.04 on Day 0 and 0.15 s +/- 0.03 at Month 1; p = 0.04). Botulinum toxin also significantly influenced the mean duration of the longest PO (6.44 s +/- 9.4 on Day 0 and 1.55 s +/- 1.9 at Month 1; p = 0.004) as well as the percentage of PO (29.95% +/- 24.6 on Day 0 and 13.44% +/- 11.1 at Month 1; p = 0.003). CONCLUSIONS: PO can be used as the indirect sign of blinking. Videonystagmography provides a real-time result, and could be used to objectively evaluate the effect of botulinum toxin treatment in essential blepharospasm patients.

Videonystagmography to assess blinking.

BACKGROUND: In order to measure blinking, we developed a dynamic device consisting of a CCD camera connected to a videonystagmography machine. We developed an artificial pupil that allowed the camera to track movements of the upper eyelid. METHODS: Blinking parameters were measured in eight healthy volunteers, studying spontaneous blinking (SB) and voluntary blinking (VB) responses. Closing time, opening time, closing speed, vertical amplitude, horizontal amplitude and frequency of spontaneous blinking were recorded. RESULTS: In SB, opening time (0.21 +/- 0.04 s) was significantly longer than closing time (0.10 +/- 0.02 s) (p < 0.0001). Mean closing speed was 87 +/- 26 m/s in SB and 168 +/- 59 m/s in VB. Mean vertical amplitude was 9.1 +/- 2.2 mm. Mean vertical amplitude was lower in SB (9.1 +/- 2.2 mm) than in VB (12.3 +/- 1.9 mm) (p < 0.001). Mean horizontal amplitude was also lower in SB (2.7 +/- 0.9 mm) than in VB (3.8 +/- 0.9 mm) (p < 0.05). Frequency of SB was 18.4 +/- 3.4 per minute. CONCLUSIONS: Computer-assisted video acquisition provides real-time measurement of eyeblink dynamics. On healthy volunteers, this method enables accurate measurement of opening and closing responses as well as associated horizontal movement, and enables differentiating spontaneous and voluntary blinking.

Decrease of intraocular pressure after fat-removal orbital decompression in Graves disease.

PURPOSE: To address the efficacy of fat-removal orbital decompression to reduce intraocular pressure in patients with Graves disease. METHODS: This cohort study included 64 eyes of 39 patients with Graves disease. Thirteen men and 36 women, with a mean age of 52.5 years (range, 27 to 80 years), underwent fat-removal orbital decompression. Intraocular pressure (applanation) and proptosis (Hertel exophthalmometry) were prospectively investigated before surgery and 1 week and 6 months after surgery. RESULTS: The volume of resected fat was 6.4+/- 4.5 (3 to 12) ml. The intraocular pressure in primary position decreased from 19.3+/- 4.4 mm Hg to 17.0+/- 2.9 mm Hg at 1 week (p<0.001) and 15.9+/- 3.7 mm Hg at 6 months (p<0.001). Mean proptosis dropped from 24.3+/- 2.5 mm before surgery to 19.9+/-3.0 mm at 1 week (p<0.01), and 19.9+/-3.1 mm at 6 months (p<0.01). Intraocular pressure decrease neither correlated to the volume of resected fat nor to proptosis reduction. CONCLUSIONS: Fat removal reduces intraocular pressure in patients with Graves disease, with no correlation to the volume of resected fat.

Specific antibody production in herpes keratitis: intraocular inflammation and corneal neovascularisation as predicting factors.

PURPOSE: The purpose of the study is to investigate whether analysis of specific antibody synthesis can aid the diagnosis of herpes keratitis. METHODS: Aqueous humor was collected from 39 patients with presumed recurrent herpes keratitis, including 23 consulting for keratitis and 16 patients scheduled for penetrating keratoplasty. Local antibody production was ascertained by analysis of paired aqueous humor/serum samples, using a modified micro-ELISA technique. RESULTS: Local production of antibodies was found in 32 patients (82%): anti-herpes simplex virus (HSV) antibodies in 26 (67%) and anti-varicella zoster virus (VZV) antibodies in 11 (28%). Twenty of 23 patients with active keratitis (87%), and 12 of 16 undergoing keratoplasty (75%), tested positive. Five patients had local production of both anti-HSV and anti-VZV antibodies, whereas seven patients tested negative. Local antibody production was significantly associated with intraocular inflammation (P<0.05), corneal neovascularisation (P<0.05), and positive response to anti-viral treatment (P<0.05). No complications were encountered in sampling aqueous humor. CONCLUSIONS: Assessment of local anti-HSV and -VZV antibody production is a safe and reliable diagnostic procedure for recurrent herpes keratitis. It might be particularly helpful in patients presenting with intraocular inflammation and neovascularisation since it discriminates between herpes and non-herpes pathologies and may therefore be useful for preventive and therapeutic strategies.

Assessment of blepharospasm surgery using an improved disability scale: study of 138 patients.

PURPOSE: To assess a new scale for grading functional disability in a series of patients operated on for blepharospasm resistant to treatment by botulinum toxin (BT) injections. METHODS: The bicentric study included 138 patients: 80 (58%) with essential blepharospasm; 46 (33%) with apraxia of eyelid opening; and 12 (9%) with intermediate forms. They had undergone orbicularis myectomy (92 cases, 67%), frontalis suspension (31 cases, 22%), or both (15 cases, 11%). Functional disability was assessed by using an original scale covering 6 daily life activities, each graded using 5 levels from 0 (no disability) to 4 (activity impossible). The score obtained was related to the total of activities actually performed to produce a functional disability score (FDS) from 0 to 100. Each patient's FDS was prospectively determined, before surgery and 3 months after surgery (M3). In patients who, after surgery, required a further course of BT injections, the FDS was assessed immediately before the third injection. RESULTS: The mean FDS fell significantly, from 78 +/- 15 (standard deviation) before surgery to 45 +/- 21 at M3 (p < 0.01%), whatever the clinical form of essential blepharospasm or surgical procedure. The mean postoperative FDS was significantly lower in the 62 patients (45%) weaned off BT than in the unweaned group, respectively (31 +/- 17 versus 56 +/- 18; p < 0.01). In the latter group, the mean FDS after BT reinjection (34 +/- 19) fell to a level comparable with that of the weaned patients. CONCLUSIONS: This accurate, easy-to-use scale makes it possible to quantify in patients with blepharospasm functional improvement as the result of surgery and, where applicable, of BT reinjection.