[New trends in corneal surgery. Grafting stem cells and performing lameliar graft]. / Ophtalmologie. Chirurgie cornéenne: greffes de cellules souches et greffes lamellaires.

Epithelial, stromal or endothelial diseases can generate corneal opacity. A lake of corneal epithelial cells leads to corneal opacity and low visual acuity. In these cases, corneal epithelial stem cells from the limbus of the healthy eye or from relatives or other people must be grafted to regenerate corneal epithelium. It is also possible to cultivate corneal stem cells harvested from the sick eye, the healthy eye (autologous culture) or from relatives (allotypic culture). Renewing epithelial cells is not always sufficient to restore corneal transparency. It can also be necessary to replace a part or the entire corneal stroma. We can use today surgical lamellar graft technics to replace only stromal corneal layers involved in the disease we cure.

Implantable contact lens for moderate to high myopia: short-term follow-up of 2 models.

PURPOSE: To confirm the safety, efficacy, and predictability of the surgical correction of moderate to high myopia by the ICM V3 and ICM V4 implantable contact lenses (ICLs), with emphasis on vaulting, intraocular pressure (IOP), and pigment dispersion. SETTING: University Eye Hospital, Lausanne, Switzerland. METHODS: Thirty-two eyes had implantation of an ICL. In 22 eyes with a mean spherical equivalent (SE) of -11.5 diopters (D), the target was emmetropia; in 10 eyes with a mean SE of -22.3 D, the goal was a reduction in the myopia. Nineteen eyes received the ICM V3 ICL and 13, the ICM V4 ICL. The mean follow-up was 7.4 months. RESULTS: The mean postoperative SE in the 32 eyes was -2.16 D. Best spectacle-corrected visual acuity was maintained or improved in all eyes. In the 22 eyes targeted to achieve emmetropia, 10 (45%) were within +/-1.00 D; 15 (68%) had an uncorrected visual acuity of 20/40 or better and 4 (18%), of 20/20 or better. Vaulting of the ICL over the crystalline lens was more pronounced with the V4 than with the V3, and the difference was statistically significant. Subtle, localized anterior subcapsular opacification was encountered in 4 eyes. In 3 of them, the ICL (model V3) vaulting was minimal and 1 ICL (model V4) did not show any vaulting. Eighteen eyes had an IOP higher than the preoperative level, and the difference was statistically significant. No correlation was seen between final IOP and vaulting. Pigment dispersion on the ICL did not appear to be related to vaulting or ICL thickness. CONCLUSION: Implantation of an ICL was effective in correcting moderate to high myopia of up to -17.50 D. Although the procedure appears to be safe, the predictability of the refractive outcome must be improved. The new generation of ICLs for myopia (ICM V4) offers a better vault over the crystalline lens than the older models (ICM V3), which should decrease the risk of cataract. No explanation was found for the IOP increase in several eyes 3 months or more after surgery.

Dexamethasone versus diclofenac sodium eyedrops to treat inflammation after cataract surgery.

We compared the postoperative anti-inflammatory effect of diclofenac sodium 0.1% and dexamethasone phosphate 0.1% in a prospective, randomized, double-masked pilot study. Anterior chamber inflammation was evaluated by measuring aqueous flare and cells with a laser flare-cell meter at one, three, 12, 30, and 60 days after cataract surgery. Flare values in the two groups did not significantly differ at any time, nor did aqueous cell counts at one, three, 12, and 60 days after surgery. At 30 days, however, cell count was significantly lower in the diclofenac group. Diclofenac sodium seems to be as potent as dexamethasone phosphate, as good as anti-inflammatory agent, and may replace corticosteroid therapy after cataract surgery.

[Anterior segment inflammation in cataract operation: comparison of intraocular lens implanted in the lens capsule and in the sulcus]. / La barrière hémato-aqueuse après opération de cataracte: comparison de l'implantation dans le sac capsulaire et dans le sulcus.

Intracapsular implantation of an intraocular lens (IOL) after cataract extraction is considered to be more "physiologic" than sulcus implantation. Using a laser flare-cell meter, we measured the degree of anterior segment inflammation in 24 eyes with an IOL implanted in the sulcus and 14 eyes with an IOL implanted "in the bag." All patients were followed for 1 year. The mean flare value was significantly lower in the bag-implanted eyes than in the sulcus-implanted eyes 1 day (p = 0.009) and 3 days (p = 0.012) after surgery; no significant difference in degree of flare was found between the groups after that time. At 1 year the sulcus-implanted group was found to have slightly higher flare values than a control group of 34 unoperated patients matched for age. Although this difference was statistically significant (p = 0.012), it should not be considered clinically relevant.

[Excimer laser: history, development and comparison of equipment]. / Laser excimer: histoire, développement et comparaison des machines.

We first present the history of the Excimer Laser technological development which began in 1975 with Velazco and Sester's research. We report various studies about lasers conceiving, treatment parameters, laser-tissues interactions, and treatments evolution. In the second part, we compare different Excimer laser systems and their capacities. Three current technologies are used for clinical application: the broad beam lasers, which use a diaphragm or a disc with multiple apertures, the scanning slits and the flying spots. Advantages and disadvantages of the various delivery systems are discussed.

[Corneal epithelial diseases related to limbal stem cell deficiency]. / Pathologies épithéliales cornéennes et insuffisance en cellules souches limbiques.

Treatment of corneal epithelial diseases induced by limbal stem cell deficiency is an important challenge in ocular surface reconstruction. Since the 1990s, corneal stem cells have been localized in the limbus. This new concept completely changed the way we consider ocular surface reconstruction, with new diseases now found to be isolated in the ocular surface. Limbus insufficiency syndromes are specific depending on their origin (congenital or acquired), their expression (unilateral or bilateral, partial or total), their progression (acute or chronic), and the mechanism involved (burn, infection, chronic inflammation, etc.). Some of these diseases are local diseases and others are systemic diseases. Clinically, limbus insufficiency is a switch of the normal corneal epithelial phenotype (expression of a specific keratin, avascularity, and transparency of the corneal matrix) in an opaque and fibrovascularized cornea. In terms of cellular biology, a phenotype is a terminal expression of a cell differentiation process. This process is the outcome of the interaction between the genome of a cell or a group of cells with their microenvironment. In limbus insufficiency, epithelial cells and corneal matrix are destroyed, and it is the destruction of these two components that leads to limbus insufficiency syndrome.

Subretinal neovascularization secondary to choroidal septic metastasis from acute bacterial endocarditis.

The clinical features of an infective embolic choroidopathy are described, from its early onset to late complications in a 45-year-old man with acute Staphylococcus aureus endocarditis of the aortic valve. Initial fundus examination revealed, in addition to fresh choroidal lesions, stigmata of a previous embolic episode secondary to endocarditis from Actinobacillus actinomycetemcomitans. The choroidal lesions were extremely asymmetrical, with a clear preference for localization in the left eye. Similar ocular findings were seen in a 78-year-old female with mitral valve prolapse and acute S. aureus endocarditis. In this case, however, choroidal involvement from septic emboli spread was bilateral and roughly symmetrical. Choroidal neovascular membranes arising in scars from choroidal septic emboli occurred in the macular area of the left eye of both patients, 10 months and 5 years after embolization, respectively.

[Familial occlusion of central veins associated with type II familial hyperlipoproteinemia]. / Occlusions veineuses centrales familiales associées à une hyperlipoprotéinémie familiale de type II.

We report, for the first time to the best of our knowledge, about a family in which 3 members (two of which were under 40 years of age) of two successive generations presented central retinal vein occlusions in relation to a type II hyperlipoproteinaemia. On the basis of the reported cases, it can be postulated that hyperlipoproteinaemia seems to be a serious potential risk factor for central retinal vein occlusion. The particular aspects of central vein occlusion in relation to hyperlipoproteinaemia are the elevated frequency of recurrences, the poor visual prognosis secondary to severity of veinous obstruction, and the increased incidence of these occlusions in younger patients. The discovery of a hyperlipoproteinaemia in young patients with central retinal vein occlusion should therefore incite prompt examination of other family members in order to initiate prophylactic hypolipaemic treatment.

[Subretinal neovascularization: evolution of cicatrix of photocoagulation in the absence of recurrence]. / Néovaisseaux sous-rétiniens: évolution des cicatrices de photocoagulation en l'absence de récidives.

Eleven patients successfully treated with the argon or krypton laser for macular subretinal neovascularization were followed up in order to determine the extent of long-term enlargement of the chorioretinal scars. The mean follow-up time was 51.5 months and the mean increase in choroidal scar size 46.5%. In 10 patients the scars enlarged more toward the fovea than toward the periphery (51% as opposed to 43%). The rate of enlargement per month decreased with time after treatment. Only one patient exhibited decreased visual acuity during the follow-up period, due to invasion of the foveola by the scar.

Ocular damage after implantation of oversized minus power anterior chamber intraocular lenses in myopic phakic eyes: case reports.

BACKGROUND: Positioning in the iridocorneal angle is one of the factors determining long-term tolerance of anterior chamber intraocular lenses (IOLs). This problem has again become topical with the use of myopic IOLs with angular supports. METHODS: The authors describe three eyes illustrating the possible complications resulting from the insertion of oversized minus power anterior chamber implants in myopic phakic eyes. RESULTS: The complications developed early or late after surgery. They consisted mainly of inflammatory reactions, stable or progressive pupillary deformation, and adherence of the iris to the implant. CONCLUSIONS: In myopic phakic eyes, the insertion of incorrectly sized IOLs with angular supports may cause complications which have already been reported for anterior chamber implants in aphakic eyes. Haptic flexibility does not always make up for incorrect sizing due to imprecise preoperative evaluation of iridocorneal angle diameter.

[Multiple evanescent white dot syndrome]. / Multiple evanescent white dot syndrome.

MEWDS is a benign acquired disorder of the retinal pigment epithelium of unknown etiology which has been first described in 1984. Actually more than 50 cases have been reported worldwide but only 5 cases from Europe. We report 10 other cases of MEWDS, seen in the past 5 years. Their clinical presentation, perimetric and electroretinographic results, as well as their differential diagnosis will be reported.

[Differential treatment of postoperative and uveitis-induced inflammatory cystoid macular edema]. / Traitement différencié de l'oedème maculaire cystoide inflammatoire postopératoire et secondaire aux uvéites.

Twenty-five eyes (23 patients) with inflammatory cystoid macular edema (CME) (11 after cataract surgery and 14 eyes (12 patients) with uveitis) were followed in a prospective open study. The aim was to determine the efficiency of a combined treatment of Diamox (acetazolamide), Voltaren Ophtha (diclofenac, a NSAID) and Ultracortenol (prednisolone acetate) and in the case of treatment failure, the usefulness of posterior subtenon's injections of corticosteroids (Kenacort 40 mg (triamcinolone)). Seven eyes (all pseudophakic CMEs) responded successfully to the initial therapy. Their mean visual acuity improved from 0.31 +/- 0.13 to 0.93 +/- 0.08 after 18 +/- 5 days (p less than or equal to 0.001). Of the sixteen of 18 evaluable eyes that were additionally treated with a mean of 3.28 +/- 1.07 three-weekly posterior subtenon's injections, 15 eyes including all uveitis CME responded to treatment. Their mean visual acuity improved from 0.49 +/- 0.20 to 0.96 +/- 0.31 (p less than or equal to 0.001). Two patients were excluded; in 22/23 eyes the sequential treatment was successful with an overall success rate of 95% of cases (improvement of five lines on the Snellen chart or final visual acuity of 0.8 or better). Initial angiographic cystoid macular edema was comparable and significantly improved after therapy in the two treatment groups. No mean intraocular pressure rise was noted after steroid injections. Measurement of anterior chamber inflammation with the laser flare-cell meter (Kowa FC-1000) showed elevated flare in all cases which significantly decreased in both treatment groups and represented a good follow-up parameter for the effect of antiinflammatory treatment and restoration of blood-ocular barrier.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute retinal necrosis: a new pathophysiological hypothesis.

A 76-year-old woman with unilateral acute retinal necrosis had an elevated titer of cytomegalovirus (CMV) antibodies with both in the aqueous humor and serum. The serological pattern indicated recent CMV infection, and the Goldmann-Witmer coefficient comparing aqueous and serum titers was above 4 indicating intraocular production of specific antibodies. The clinical characteristics and results as well as a new possible etiopathogenic hypothesis are presented.

Diclofenac drops to treat inflammation after cataract surgery.

PURPOSE: To compare the anti-inflammatory effect of topical diclofenac sodium 0.1% in a fixed combination with gentamicin 0.3% to the anti-inflammatory effect of dexamethasone phosphate 0.1% in a prospective randomized double-masked double-dummy study in patients undergoing cataract surgery. SETTING: Trial performed from June 1991 to April 1992 at the Hôpital Jules Gonin, Department of Ophthalmology, University of Lausanne, Lausanne, Switzerland. METHODS: Inclusion of patients scheduled for extracapsular cataract extraction (ECCE) with implantation of an all PMMA intraocular lens (IOL). Double-masked comparison of post-operative inflammation in two randomized treatment groups: (1) fixed diclofenac sodium 0.1%/gentamicin 0.3% and vehicle drops 4X/day until day 12-14 and diclofenac sodium 0.1% 3X/day until day 28. (2) dexamethasone phosphate 0.1% drops 4X/day until postoperative day 12-14 and 3X/day until day 28 and gentamicin 0.3% drops 4X/day until day 12-14. Anterior chamber flare and cells, measured by laser flare-cell photometry, were analyzed as the primary outcomes. RESULTS: Eighty-seven patients were recruited, 45 being assigned to the diclofenac group and 42 to the dexamethasone control group. Diclofenac was significantly better than dexamethasone at controlling flare at day 3 (p< or =0.01) and day 12-14 (p< or =0.002). Mean anterior chamber cells were also significantly lower at day 12-14 (p< or =0.021) and day 28 (p< or =0.012). The commonest adverse event was transient punctate keratitis, which occurred in 15 diclofenac and 3 dexamethasone patients. CONCLUSIONS: While both treatments were effective at controlling post-operative inflammation, the diclofenac-gentamicin combination followed by diclofenac alone was significantly better at suppressing flare and cells but showed a slightly higher incidence of punctate keratitis and eye discomfort.

Pathogenetic mechanisms in combined cilioretinal artery and retinal vein occlusion: a reappraisal.

We examined nine patients who presented cilioretinal artery occlusion (CLRAO) associated with retinal vein occlusion (RVO). CLRAO was probably secondary to the raised intraluminal resistance consequent to the RVO in patients showing initially a delayed filling of the cilioretinal artery in fluorescein angiography. Interestingly, these patients presented an ophthalmoscopically more severe form of RVO and had systemic predisposing factors for a RVO. In patients presenting a physiological perfusion of the cilioretinal artery in fluorescein angiography, RVO was a self limited disease and etiologic factors were not found. This may suggest that in these patients the CLRAO probably occurred simultaneously with the RVO after a decrease in perfusion pressure in both retinal and cilioretinal arterial systems. In this combined vaso-occlusive retinopathy the vulnerability of cilioretinal arteries can be explained either by the absence of autoregulation or by their lower perfusion pressure gradient in comparison with retinal arteries.

[Diclofenac-dexamethasone combination in treatment of postoperative inflammation: prospective double-blind study]. / Association diclofenac-dexamethasone dans le traitement de l'inflammation postopératoire: étude prospective en double-insu.

In a prospective randomized double masked study including 40 patients we evaluated the anti-inflammatory effect of a combination of dexamethasone acetate 0.1% + diclofenac 0.1% drops compared to dexamethasone acetate 0.1% + placebo drops, after ECCE + posterior chamber lens implantation. Anterior chamber (AC) flare and cells were measured with the laser flare-cell meter Kowa FC-1000. The group receiving the dexamethasone-diclofenac combination showed a more rapid decrease of AC flare which was significant at days D3 (P less than 0.003) and D12 (p less than 0.028). The reduction of AC cells was comparable in both groups, showing however a strong tendency toward a lower cell count in the group receiving diclofenac at days D12 and D30 (p less than 0.08). Tolerance of diclofenac was good and comparable to the placebo.

[Study of panophthalmitis after cataract surgery from 1997 to 1999]. / Etude sur les panophtalmies après chirurgie de la cataracte de 1997 à 1999.

PURPOSE: To define the clinical outcome and microbiological pattern of bacterial endophthalmitis that were referred at the Jules Gonin Eye Hospital from January 1997 to September 1999. METHODS: Patients were recorded in a computerised databank and were managed according to a standard protocol. An anterior chamber tap combined with a vitreous biopsy by the pars plana was performed in all patients. The treatment included an intravitreal injection of 1 mg Vancomycin and 400 micrograms Amikacin diluted in 0.2 ml NaCl 0.9%. Postoperatively hourly therapy Cefazolin 50 mg/ml and Garamycin 9 mg/ml was applied. To determine possible risks factors a standard form was sent to all referring surgeons. The following data were analysed: delay of onset, risk factors, initial and final visual acuity. RESULTS: From January 1997 to September 1999, 31 patients were referred. 18/31 (58%) of the cases were admitted between April and June of each years. The mean age was of 75 +/- 10 years. Initial visual acuity ranged from light perception to 20/40. 17/31 of the patient's cultures were positive. The major pathogen were Staphylococcus epidermidis in 9/31 patients and Staphylococcus aureus in 4/31 patients. No correlation between the endophthalmitis and the surgical technique or perioperative management of the patient, could be determined. Visual outcome was significantly improved in 56.7% of the patients. CONCLUSIONS: The severity of outcome could be correlated to the type of bacteria isolated. The high prevalence of panophthalmitis from March to June suggests that a climatic factors may be involved in its pathogenesis.