[Evisceration and secondary enucleation with implantation following endophthalmitis]. / Eviscération suivie d'énucléation avec implantation secondaire à la suite d'endophtalmie.

PURPOSE: Primary evisceration followed by secondary enucleation and implant placement makes it possible to use the sclera of a patient with endophthalmitis. This sclera will be used for secondary implantation. PATIENTS AND METHODS: Four patients with endophthalmitis and corneal perforation (bacterial infection in three cases and fungal infection in one case) underwent evisceration and, 4-6 weeks later, enucleation. During the secondary enucleation, the sclera was recovered and used as wrapping material for the alumina implant (Al2O3) (20 and 22 mm in diameter). Between the two operations, the patients were treated with systemic and topical antibiotics or antifungal agents. RESULTS: No complications were observed for both the first and the second operation. Enucleated sclera was crumpled and bent in all four cases. The sclera was spread out and used as wrapping material. Prosthetic fitting was performed 4-5 weeks after the second operation. No complications have been observed to date (10 to 32 months follow-up). CONCLUSION: Primary implantation following endophthalmitis is debatable because an infectious complication cannot be excluded. The use of sclera for implant wrapping decreases the risk of implant extrusion, especially when the conjunctiva and Tenon's facia have been weakened by previous surgery or infection. Primary evisceration with a conformer placement followed by enucleation and implantation is an ideal solution in endophthalmitis because this technique allows the use of patient's own sclera.

[Anterior segment necrosis in multidrug-resistant Fusarium keratomycosis: a case study]. / Nécrose du segment antérieur sur kératomycose à Fusarium polyrésistant. A propos d'un cas.

Keratomycosis is a rare sight-threatening infection of the cornea, with greater morbidity than bacterial keratitis. Predisposing factors in its pathogenesis are corneal trauma, mostly of plant origin, and overuse of topical corticosteroids, associated or not with antibiotics. We report a case of a 71-year-old man who developed Fusarium (lichenicola or solani) keratitis, 15 days after beginning topical therapy with a corticosteroid and antibiotic. Despite aggressive antifungal therapy with fluconazole, he required a penetrating keratoplasty for impending corneal perforation, and finally, even after systemic use of itraconazole and topical use of amphotericin B, the infection progressed and an evisceration was required. In the evisceration material, a multidrug-resistant Fusarium lichenicola or solani, was found, partially sensitive to voriconazole only.

[Posttraumatic syringomyelia]. / Die posttraumatische Syringomyelie.

The improvement of preclinical emergency medicine, better surgical and conservative therapies, and the development of intensive care units and specialized centers have improved the survival rate for patients with serious spinal cord injuries. Therefore, more sequelae of chronic spinal cord injuries such as post-traumatic spinal cord cavitations also occur. The first such case was described by Bastian in 1867. Generally, these cavitations were diagnosed from 2 months up to 32 years after the trauma. The overall prevalence of post-traumatic syringomyelia (PTS) is not known; however, with the increasing use of magnetic resonance imaging (MRI), its diagnosis has increased, ranging from 2.3% of paraplegic and tetraplegic patients in 1976 and 3.2% in 1985, to nearly 50% in a selected group of patients in 1991 and 1993. In 1995, a 4.45% incidence was reported. In our clinic we are currently treating 440 cases of syringomyelia, 140 of which are PTS. Several observations suggest more than one potential mechanism for the evolution of a post-traumatic cyst or PTS. Various factors, such as hemorrhage or, in particular, ischemia within the spinal cord, blockage of the cerebrospinal fluid (CSF) pathways around the cord or localized meningeal fibrosis either alone or in combination with other factors, may be involved. Clinically, sensory disturbances, loss of motor function, pain, and modification of the deep tendon reflexes are observed in most patients. On MRI, PTS is seen as a longitudinal, cystic cavity within the spinal cord, giving a hypointense signal on T1-weighted images and a hyperintense signal on T2-weighted images. For treatment planning it is mandatory to identify the lower and upper end of the PTS on the MRI.

[Emergencies in nontraumatic orbital diseases]. / Urgences en pathologie orbitaire non traumatique.

INTRODUCTION: Nontraumatic orbital diseases only exceptionally require emergency treatment. In this paper an emergency is considered when the diagnosis and/or treatment must be done within a maximal period of 1 week. MATERIALS AND METHODS: All patients with nontraumatic orbital diseases from the Department of Ophthalmology of the University of Lausanne and from the office of one of the authors (N.D.) over the last 35 years were studied, in view of their degree of emergency. Data from 77 patients (28 females and 49 males), aged from birth to 85 years, were collected. RESULTS: Idiopathic inflammations of the orbit (pseudotumors) were the most frequent diagnoses seen as an emergency, followed by rhinological diseases with orbital consequences (exteriorized sinusitis or mucoceles), dysthyroid orbital pathologies, bleeding in lymphangiomas and varices, rhabdomyosarcoma, and acute dacryoadenitis. Fast progressive proptosis, oculomotor disorders, and pain are the most frequent alarm signals. After the diagnostic procedure, a surgical or medical treatment is frequently proposed. CONCLUSION: Although rare, emergencies in orbital diseases are a challenge for the general ophthalmologist. The morbidity and sometimes the mortality due to these diseases are often reduced by proper management. Patients generally have to be referred to a specialized unit.

[Update of orbital rhabdomyosarcoma therapy in children]. / La thérapie actuelle du rhabdomyosarcome orbitaire de l'enfant.

INTRODUCTION: Rhabdomyosarcoma is the most frequent primitive orbital malignant tumor in children. If the treatment is started as soon as possible after discovery of the disease, the vital prognosis is considerably better than otherwise. The goal of this paper is to present the new therapeutic protocol and to report our experience in this field. MATERIAL AND METHOD: During the past 35 years, 102 cases of orbital tumors were collected in children under 15 years of age: 5 cases of rhabdomyosarcoma were cared for in our department. At the time of tumor diagnosis, the age of our patients ranged from 3 weeks to 13 years. After a biopsy or excision biopsy, all our cases were treated by chemotherapy with or without radiotherapy. Medication was mostly vincristine, ifosfamide and actinomycine D. When the result of the treatment was not satisfactory, carboplatine and epirubicine, vincristine as well as ifosfamide were given. Radiotherapy was performed only in particular cases or in recurrences. CONCLUSION: Rhabdomyosarcoma is a highly malignant tumor. Although rare, it is the most frequent of malignant tumors in children. It is important to keep it in mind in order to perform a biopsy enabling quick diagnosis and treatment following the modern protocol giving the highest chances of survival to these patients: about 98% in 3 years.

[Amniotic membrane transplantation for oculopalpebral and reconstructive surgery]. / Utilisation de la membrane amniotique dans la chirurgie de reconstruction oculo-palpébrale.

INTRODUCTION: Amniotic membrane has been used for many years for ocular surface defects. It is also commonly used in laboratories for cellular growth. Amniotic membrane has antiadhesive properties, can promote epithelialization, and decrease neovascularization, inflammation, and fibrosis. There is no histocompatibility problem, as amniotic membrane has no HLA antigens. In this study, amniotic membrane transplantation was used for oculopalpebral and reconstructive surgery as an alternative to the oral mucous graft, particularly in the reconstruction of the conjunctival fornices after inflammatory disease, burns, conjunctival tumors, and enucleation with orbital implants. MATERIAL AND METHOD: Forty-eight interventions using amniotic membrane transplantation were done on 44 patients. In 16 cases conjunctival fornices were created or reconstructed, allowing the installation of an ocular prosthesis; 14 had reconstruction of fornices for inflammatory disease, or chemical or thermal burns; 11 had palpebral skin and conjunctival reconstruction (malformations or skin tumours); and seven cases had conjunctival reconstruction after conjunctival tumor excision. RESULTS: Thirty-nine cases presented good functional and cosmetic results. One case had no follow-up. Eight cases gave poor results: four cases of conjunctival fornix refection (with two irradiated cavities), three cases of fornix reconstruction after chemical burn, and one case in whom palpebral reconstruction partially failed (coloboma). DISCUSSION AND CONCLUSION: Functional and cosmetic results were good for 39 cases, allowing ocular prosthetic equipment when necessary. In nine cases, two complete fornix retractions and two partial fornix retractions were observed; one palpebral reconstruction for malformation partially failed; and four cases (two with amniotic membrane and two with oral mucus graft) required a second surgery to obtain a satisfactory result. Amniotic membrane transplantation is an excellent alternative material to oral mucous membrane in oculopalpebral and reconstructive surgery except when graft rigidity is necessary. Its use is more difficult in cases of chemical burns or after orbital irradiation.

[Ocular and palpebral surgery: indications and limits]. / Chirurgie oculo-palpébrale: indications et limites.

Oculo-plastic surgery includes all the problems bound to the eyelids. In this presentation, we expose the most frequent oculo-palpebral pathologies, their treatment and some of the commonest complications. In all facial surgery, there is a plastic component, so it seems impossible to talk about this surgery without taking into account the cosmetical aspects.

Percentage of projection neurons and various types of interneurons in the human claustrum.

Each neuronal type of the human claustrum is differently pigmented. This has been demonstrated by combining a transparent Golgi technique with the specific staining of lipofuscin deposits. One type of projection cells and four varieties of interneurons have been distinguished. In this study the percentage of these different neuronal types has been evaluated using preparations stained for both Nissl material and pigment deposits.

[Cüpper myopexy as treatment of pseudoptosis; apropos of 2 cases]. / Myopexie de Cüppers comme traitement de la pseudoptose; a propos de deux exemples.

BACKGROUND: According to Hering's law, the induced palsy of an extraocular muscle will result in an increased innervational flow to this muscle as well as to its contralateral synergist. A retroequatorial myopexy (Cüppers Faden Operation), with or without muscle recession, can be considered as an iatrogenic palsy. METHODS: Two patients, aged 16 and 5 years respectively, presented with hypotropia, the deviated eye showing limited ocular movements in elevation and pseudoptosis of the upper eye lid. Both patients underwent surgery, this consisting of a posterior fixation and recession of the superior rectus of the sound eye. RESULTS: After surgery, both cases showed a stable improvement of the opening of the palpebral fissure and of the vertical deviation. CONCLUSIONS: This surgical procedure was already described by Cüppers and, although rarely performed, does represent a useful surgical alternative in cases of partial ptosis of the upper eye lid together with hypotropia.

[Pain symptoms in paraplegic patients]. / Schmerzsymptomatik bei Querschnittlhmungen.

The number of paraplegics who survive their initial trauma by decades is on the increase. A considerable percentage of these patients will, sooner or later, temporarily or permanently, manifest a pain syndrome and/or phantom pain. Accurate differentiation of the disagreeable sensations, which are often difficult to describe (dysesthesia, paresthesia), is frequently a big problem. The pathogenesis still remains unclear, and therapy often proves unsatisfactory.

Selective and sequential therapy of oculomotor and palpebral sequelae resulting from biopsy of dorsal midbrain sarcoidosis.

BACKGROUND: Biopsy of a dorsal mesencephalon lesion often leads to neuro-ophthalmological complications, namely dorsal mesencephalic syndrome, skew deviation, IV (th) palsy, or Horner's syndrome. HISTORY AND SIGNS: A 26-year-old man underwent a biopsy of the quadrigeminal plate for a lesion which revealed to be neurosarcoidosis. Post-operative complications included a left homonymous hemianopia, a left III (rd) nucleus palsy, a bilateral IV (th) palsy and a bilateral internuclear ophthalmoplegia. Palpebral fissures were narrowed to 2 mm on both sides. In primary gaze there was 24 degrees of exotropia, 17 degrees of right hypertropia and 30 degrees of exyclorotation. THERAPY AND OUTCOME: After 24 months of stable evolution, three oculomotor surgical procedures were performed including: surgery on both horizontal muscles of the left eye; shortening of both superior oblique muscles; resection of the right lateral rectus muscle, and posterior fixation of an inferior rectus muscle. Bilateral brow suspension on the frontal muscle of both superior eyelids was then performed. Evolution was favorable with a binocular single field of vision measuring 17 degrees horizontally and 20 degrees vertically centered on the primary gaze. Palpebral fissures measured 7 to 8 mm in primary gaze. CONCLUSIONS: The neuro-ophthalmological sequelae which followed the biopsy of a neurosarcoidosis lesion of the quadrigeminal plate were so severe that this patient was completely handicapped. A four-step surgery correcting the horizontal, torsional, vertical components, then the bilateral ptosis allowed the patient to recover both a satisfying function and esthetical aspect.

Functional hand development in tetraplegia.

The development of the 'functional hand' in tetraplegics has been historically facilitated through specialized hand positioning schemes. However, clinical experience at the University Hospital Heidelberg demonstrates no direct relationship between various hand positioning techniques and the probability of functional hand development. The aim of this study was to document the various methods of hand positioning and the resulting functional outcome. In a multi-center study, the paralysed thumb and finger positioning of 64 tetraplegics and the resultant functional outcome was evaluated with a specially developed survey form. Results indicated that the functional outcome of the tetraplegic hand was highly dependent on the level of the spinal cord injury and only to a minor degree dependent upon the different methods of hand positioning employed. The conclusion drawn is that remaining neurologic function after injury determines the final functional outcome of the tetraplegic hand.

Multiple intraorbital neurofibromas: a rare cause of proptosis.

BACKGROUND: Orbital neurofibromas are rare, accounting for 0.5 to 2.4 % of all orbital tumors. Generally, they manifest as slowly progressive proptosis, in a young adult or middle-aged person, and are usually solitary lesions. Sometimes, they can be associated with type 1 neurofibromatosis. We present a case of proptosis related to multiple intraorbital neurofibromas in an 82-year-old woman without type 1 neurofibromatosis. HISTORY AND SIGNS: An 82-year-old woman was referred for slowly progressive left proptosis associated with an ocular burning sensation. Neuro-ophthalmic examination revealed 9.5 mm of left exophthalmos, signs of minimal left optic neuropathy but normal extraocular movements. Magnetic resonance imaging revealed the presence of 4 intraorbital lesions. THERAPY AND OUTCOME: The two most anterior tumors were removed. Pathological studies showed these tumors to be neurofibromas. Post-operative evolution was favorable with reduction of left proptosis to 7 mm and disappearance of the burning sensation of the left eye. No other signs of neurofibromatosis were found. CONCLUSIONS: Multiple circumscribed intraorbital tumors are rare. Slowly progressive proptosis with radiological imaging of multiple round lesions should evoke the diagnosis of orbital neurofibromas, even in patients outside the typical age range or without neurofibromatosis.