[Intraorbital pressure measured before, during, and after surgical decompression in Graves' orbitopathy]. / Mesure de la pression intraorbitaire avant, pendant et après décompression orbitaire osseuse dans l'orbitopathie dysthyroïdienne.

PURPOSE: In Graves' orbitopathy, the volumetric increase of the oculomotor muscles and orbital fat leads to exophthalmia and a rise in orbital pressure. This rise in pressure may be implicated in the appearance of a compressive optic neuropathy. To investigate this increase in pressure and its variations accompanying surgical decompression, systematic measurements were taken before, during, and after every case of orbital decompression in Graves' disease. RESULTS: The intraorbital pressure before the surgical procedure was 14.05 mmHg ± 9.19 for a normal value estimated in the literature at 4 mmHg ± 1.5 (statistically significant difference, P<0.0001). In the group presenting a compressive optic neuropathy (NO), the preoperative pressure was 26.8 mmHg ± 7.85 versus 9.8 mmHg ± 4.2 in the group without NO: the pressure was significantly higher in the group with NO (P<0.001). After orbital decompression (one to three walls depending on the severity of the exophthalmia), the pressure was measured at 4.3 mmHg ± 2.53 for the entire series: 6.4 mmHg ± 2.07 in the group with NO versus 3.6 mmHg ± 2.32 in the group without NO (significant difference, P<0.05). The total decrease in pressure induced by the surgery was 9.75 mmHg ± 7.55 and was significantly greater for the group with NO: reduction of 20.4 mmHg versus 6.2 mmHg for the group without NO (P<0.001). The reduction in pressure was greater after collapse of the first wall (floor) than after collapse of following walls for all groups (P<0.001). The maximum pressure observed during the intervention (caused by the instruments) was measured at 78.3 mmHg ± 23.47 without pupillary changes. DISCUSSION: This study shows that the intraorbital pressure is increased in Graves' orbitopathy and more in serious forms with compressive optic neuropathy. Orbital decompression, as its name indicates, provides decompression and a return to a near-normal orbital pressure situation. Compressive optic neuropathy does not result only from the direct compression of the oculomotor muscles on the optic nerve, but also from an overall rise in the pressure level within the orbital cavity. CONCLUSION: Intraorbital pressure is increased in Graves' orbitopathy, participating in the appearance of compressive optic neuropathy. Orbital decompression provides a significant reduction in intraorbital pressure.

[Understanding refraction disorders and oculomotor problems during pregnancy]. / Comprendre les troubles de la réfraction et les problèmes oculomoteurs pendant la grossesse.

During pregnancy, hormonal and hemodynamic modifications can generate a number of organic consequences, specifically ocular, more or less regressive in systemic disease. Refraction disorders are marked by myopization, often not very significant and always regressive within six weeks after the childbirth. Pregnancy could cause a thickening of the cornea and a modification of its curvature. Likewise, contact lens intolerance is common, secondary to the modification of lacrimal film, but does not systematically contraindicate lens wearing. Photorefractive surgeries are ill-advised during pregnancy. Hemeralopia is the most common visual complaint of the pregnant woman. Oculomotor disorders are exceptional. Convergence insufficiency or accommodation disorders are the most common anomalies described. These disorders usually regress in the postpartum period. Oculomotor palsies could be the first symptoms of pre-eclampsia or an associated intracranial pathology. They are specific palsies such as in the abducens nerve and the oculomotor nerve in very unusual cases. Nevertheless, oculomotor paralysis in the pregnant woman should motivate neuroradiological exploration. Intensive labor can be rhegmatogenous in women with severe myopia. Examination of the retinal periphery is systematic before and during pregnancy in these cases. Systematic cesarean section is not formally indicated. It is nevertheless preferable to facilitate delivery with epidural anesthesia.

[Conjunctival Kaposi sarcoma]. / Sarcome conjonctival de Kaposi.

Kaposi sarcoma is rare and occurs in four forms (classic, endemic, post-transplant and epidemic), which all have the same histological appearance associated with the same viral agent: human herpes virus type 8 (HHV-8). Conjunctival and palpebral locations are, however, rare, and only 30 cases have been described in the literature. We present the case of a 34-year-old woman with conjunctival Kaposi angiosarcoma, with rare bulbar location associated with superior palpebral telangiectases against a rare immunodepression syndrome (common variable immunodeficiency). The treatment consisted of an excision biopsy with an over-and-over suture of a conjunctival rotation flap, combined with anti-HHV-8 chemotherapy to effect a regression of the palpebral lesion. However, the reappearance of a conjunctival lesion on the rim of the excision site required local radiotherapy of approximately 30 Gy, with no recurrence after 1 month.

[Dynamic phototherapy as a treatment for central serous chorioretinopathy]. / Traitement des choriorétinopathies séreuses centrales par photothérapie dynamique.

PURPOSE: To analyze the angiographic and tomographic results and the visual acuity of a group of patients presenting acute or chronic serous central chorioretinopathy (CSCR) treated with dynamic phototherapy. This treatment was guided by ICG angiography data. PATIENTS AND METHOD: We conducted a retrospective/prospective nonrandomized study on 31 eyes of 27 patients, including eight acute forms and 23 chronic forms. One or more spots were treated according to the age-related macular degeneration standard protocol on the zones of choroidal hyperpermeability highlighted by ICG angiography. The criteria for success were based on functional signs, visual acuity, persistence of a point of leakage in angiofluorographic follow-up at 3 months, and the OCT study of serous retinal detachment. RESULTS: An increase in visual acuity (3.58+/-3.22 lines, p<0.0001) was observed for all forms of treated CSCR; 90.32% patients presented a reapplication of serous retinal detachment within a period of 7.28+/-3.93 weeks. No retinal pigmentary epithelium tear or choroidal neovascularization was observed. Recurrence occurred in 12.9% patients within a period of 28+/-16.24 weeks; only chronic CSCR cases were concerned. At 8+/-4.2 months, the visual acuity of the patients who had no recurrence remained unchanged (0.356+/-0.4 LogMAR or 20/50-20/40). CONCLUSION: Although the number of patients included in this study is limited, dynamic phototherapy currently seems to be an effective and sure treatment of CRSC. A randomized study on a large series is necessary to confirm these results.

[Chronic central serous chorioretinopathy and photodynamic therapy: a case report]. / Choriorétinopathie séreuse centrale chronique et photothérapie dynamique, à propos d'un cas.

Chronic central serous chorioretinopathy (CCSC) with recurrent and prolonged exudative retinal detachment may cause multiple degenerative manifestations with poor visual acuity. By acting on choroidal hyperpermeability, photodynamic therapy seems to be a useful treatment for symptomatic CCSC. We present the case of a 60-year-old patient presenting with symptomatic CCSC complicated with serous retinal detachment lasting more than 1 year. Visual acuity on the left eye was 1/20. Photodynamic therapy with indocyanine green angiography guidance was provided. Subretinal fluid was rapidly resolved and visual acuity improved to 7/10. Photodynamic therapy influences choroidal hyperpermeability and thus resolves serous retinal detachment in CCSC. Visual acuity improvement particularly depends on preexisting macular atrophy.

[Surgical treatment of diffuse adult orbital lymphangioma: two case studies]. / Traitement chirurgical des lymphangiomes orbitaires diffus de l'adulte: à propos de deux cas.

PURPOSE: Orbital lymphangioma is a rare vascular malformation; it is a benign but severe anomaly because of its infiltrative, diffuse, and hemorrhagic nature, and its high morbidity rate. Surgical resection is a real challenge on account of the intricate architecture of the lesion. The authors report their surgical experience concerning two cases of diffuse orbital lymphangioma whose diagnosis was established in adulthood and whose surgical treatment was successful. CASE REPORTS: Two patients presented with adult orbital lymphangioma. Progression was slow during the first decade and then was quickly followed by complications: major exorbitism, compressive optic neuropathy, and corneal exposure. Neuroimaging showed a diffuse and cystic orbital malformation. Surgical resection was performed as completely as possible, in one case with a Krönlein orbitotomy and in the other case only via a conjunctive route. An aspirate drain was put in the orbit for 48 h so as to prevent dead spaces forming after resection, an essential risk factor of hemorrhagic or cystic recurrence. Systemic corticotherapy was administered for the 5 days following surgery. The resection was total in one case and subtotal in the other. The surgical follow-up was uneventful with an excellent aesthetic result and an improvement in visual acuity. After 12 months, no tumoral or hemorrhagic recurrence was noted. DISCUSSION: The surgical treatment of orbital lymphangiomas is challenging because of their infiltrative nature. In diffuse forms, a complete resection is rarely possible because of the risk of sacrificing visual function. In the two cases reported herein, the resection of the extraconal portion was complete, but the intraconal portion was completely removed only in one case. Using the aspirate drain, negative pressure was maintained in the orbital cavity, preventing the formation of chocolate cysts induced by surgery. Although the clinical result was very satisfying, long-term follow-up is necessary to evaluate recurrence. CONCLUSION: Diffuse orbital lymphangiomas can be treated successfully with a subtotal resection without clinical recurrence in the short term. These results are promising because they demonstrate that many orbital lymphangiomas can benefit from surgical treatment with an excellent esthetic and functional result.

[Unilateral idiopathic leopard-spot lesion of the retinal pigment epithelium: a fibroglial tractional complication]. / Lésion unilatérale idiopathique en taches léopard de l'épithélium pigmentaire: une complication fibrogliale tractionnelle.

The unilateral idiopathic leopard-spot lesion of the retinal pigment epithelium is a rare and acquired entity of the young adult whose clinical description is quite recent. This pathology presents a strong proliferative potential that is both neovascular and fibroglial. The authors report a case with severe fibroglial complications. Careful follow-up of these patients and their descendants seems to be essential in order to better characterize this lesion whose nature and etiopathogeny are still unknown.

[The eye and anorexia nervosa. A case report]. / Oeil et anorexie mentale. A propos d'un cas.

INTRODUCTION: Vitamin A deficiency occurs in the poor in developing countries and is one of the main causes of blindness by perforative corneal complications. It is a rare pathology in industrialized countries and it is associated with an absorption syndrome. The authors report the first case of hypovitaminosis A in a patient suffering from chronic and severe anorexia nervosa. CASE REPORT: The patient suffered from epiphora, photophobia, and hesperanopia. The ophthalmologic findings were keratoconjunctival xerosis with bilateral corneal ulcerations. The visual field showed a concentric bilateral restriction of isopters with tubular central vision, a similar aspect to retinitis pigmentosa. The ERG was modified with a b2 reduction and normal photopic and impaired scotopic responses. The fluorescein angiography was normal. The serum concentration of retinol confirmed the diagnosis of hypovitaminosis A. Corneoconjunctival improvement was obtained with vitamin supplementation, but no campimetric improvement was observed. DISCUSSION: The corneoconjunctival signs result from direct destruction of goblet cells, whereas the campimetric deficit is explained by a dysfunction of rod cells. Rhodopsin, necessary to the survival of the cell, cannot be renewed if retinol is not present, which causes a permanent bright light stimulation that is lethal for the photoreceptor. CONCLUSION: Vitamin A deficiency is rarely caused by psychiatric disease. Even if the main clinical finding is xerophthalmia with a high risk of keratomalacia, the visual prognosis can also be engaged by dysfunction of photoreceptors.

[Reconstruction of anophthalmic socket by adipocyte grafting using the Coleman technique, after extrusion of an orbital implant: a case study]. / Comblement d'une cavité orbitaire éviscérée par greffe d'adipocytes selon la technique de Coleman, après expulsion d'implant.

INTRODUCTION: Since the end of the 19th century, autologous fat grafting has often been used in plastic surgery. The first use was described in 1893 by Neurer and consisted in transferring a piece of fat tissue for facial reconstruction. Since then, this technique has evolved somewhat thanks to Coleman, who developed lipostructure. This technique is used in plastic surgery in the filling of orbital cul-de-sacs and unsightly scars. We report a clinical case where this technique was used to fill an anophthalmic socket after extrusion of an orbital implant. OBSERVATION: A 52-year-old man had evisceration of the right eye for ocular phthisis bulbi after injury to the eye. Two weeks later, he presented an expulsion of the hydroxyapatite eyeball with significant secretions. The bacteriological samples showed Staphylococcus aureus and Streptococcus anginous infection. Despite local and general antibiotic treatment and anti-inflammatory drugs, the secretions persisted. The implant material was initially ablated. Twenty days later, adipocyte was grafted in the residual scleral stump using the Coleman technique. Follow-up showed no complications; the adipocyte grafting made it possible to restore orbital volume so that the prosthesis could be adapted. After 6 months, secondary atrophy is moderate and a good esthetic result was obtained. DISCUSSION: The Coleman technique consists in taking adipocytes in abdominal or buttocks fat with nontraumatic liposuction. This is purified after centrifugation, then reinjected into the scars or the orbital cul-de-sacs to be filled. In general, these indications relate to small volumes. In our case, the procedure involved an anophthalmic socket with residual septated scleral tissue. This can explain the good esthetic result obtained. Indeed, the fat atrophy after surgery is more significant when there is no supporting tissue. CONCLUSION: This technique seems simpler and avoids an unsightly scar on the harvest site (contrary to the traditional dermis-fat graft). On the other hand, it is more expensive and requires a minimum of training.

[Surgical solutions to luxation of the IOL--capsular bag--capsular tension ring complex]. / Solutions chirurgicales à la luxation du complexe ICP--sac capsulaire--anneau de tension capsulaire.

INTRODUCTION: The spontaneous luxation of the intraocular lens-capsular bag-capsular tension ring complex is a serious but fortunately rare complication. The authors report a combined surgical procedure to reposition the complex in a patient who was operated on for bilateral lens subluxation 4 years before and whose enophthalmia made surgery difficult. CASE REPORT: Two surgical techniques can be considered to reposition the complex and avoid explantation. The McCannel modified stitch can capture the complex with the help of a transcorneal point and then a transscleral suture on the 12 o'clock meridian, despite the enophthalmia of the patient; the Moreno transscleral stitch. Both techniques suture the complex to the ciliary sulcus. CONCLUSION: Moreno's technique is easy and safe for the endothelium and must therefore be attempted first. In case of failure, the McCannel modified stitch remains a useful and satisfying procedure allowing transscleral fixation of the complex to the sulcus at the cost of a minimal corneal trauma.

[Acute spontaneous corneal hydrops in a patient with pellucid marginal corneal degeneration]. / Dégénérescence marginale pellucide compliquée d'un hydrops cornéen aigu spontané.

Pellucid marginal corneal degeneration (PMCD) is an ectatic corneal disorder characterized by a peripheral, noninflammatory band of thinning of the inferior cornea. This condition often is misdiagnosed with keratoconus, with which it shares several clinical, videotopographic, and histologic aspects. Furthermore, as with keratoconus, hydrops and spontaneous corneal perforation can occur. We report the case of a 56-year-old man with confirmed PMCD, emphasizing the diagnostic approach, the disease follow-up, and its complication in spontaneous acute corneal hydrops. Finally, regarding this case, authors collect the clinical and videotopographic characteristics of PMCD and discuss the different therapeutic options.

Influence of stimulation of the visual system on the activity of vestibular nuclear neurons in the frog.

In the frog (Rana esculenta L.) we have tested the possible existence of visual inputs in the vestibular nuclei by recording the activity of second-order vestibular neurons receiving primarily horizontal canal inputs, while the visual system was stimulated by either light pulses or optokinetic stimulation; moreover, combined visuovestibular stimulation (horizontal rotatory stimulation in light) was performed and the response compared to the one obtained during vestibular stimulation alone (horizontal rotatory stimulation in dark). 42.2% of the neurons tested (38/90) responded to light pulse stimulation of the retinae by an increase of their discharge frequency of about 150%, while the other neurons (57.8%) did not. Optokinetic stimulation was completely ineffective in modulating the discharge frequency of all the neurons (98) recorded. Among 30 neurons tested during constant-velocity horizontal rotation of the turntable (2.5-10%s) in the excitatory direction, 13 units (43.3%) had a discharge rate significantly greater than the spontaneous frequency during the constant-velocity phase when the rotation was performed in light, while a few seconds after beginning of the constant-velocity phase the discharge frequency returned to its resting value when the rotation was performed in dark. Moreover, the difference between the maximum discharge frequency and the resting discharge frequency (delta F) was significantly higher in light than in dark. The behavior of the 17 other neurons (56.7%) was similar whether the rotation was performed in light or in dark. When tested to sinusoidal rotation (0.05 Hz +/- 40 degrees or 0.1 Hz +/- 30 degrees), the characteristics of the responses were different in light and in dark.(ABSTRACT TRUNCATED AT 250 WORDS)

Responses to somatosensory input by afferent and efferent neurons in the vestibular nerve of the frog.

In the frog, we have recorded the activity of efferent and afferent fibers in the nerve of the horizontal semicircular canal in response to somatosensory stimulation. Recordings were made extracellularly by means of glass micropipettes filled with 2 M NaCl, and somatosensory stimulation was produced either by electrical stimulation of the sciatic nerve (ipsi- or contralateral to the recording side) or by vibratory stimulation of the gastrocnemius. The discharge frequency of 43% of the efferent fibers recorded was significantly increased by such stimulation, while the activity of the others was unaffected. The discharge rate of the afferent fibers was either significantly increased (in about 11% of the cases when the results were pooled together) or significantly decreased (in about 22% of the cases) by stimulation of the somatosensory system. The latencies of the responses ranged from 5 to 50 ms. These results show that: somatosensory input can influence the activity of the vestibular apparatus at the most peripheral level; modulation of the afferent discharge is mediated by the efferent vestibular system (EVS); the influence of the EVS on the vestibular afferent activity is both inhibitory and facilitatory, and the responses to somatosensory stimulation are mediated by both long-latency polysynaptic and short-latency oligosynaptic pathways. The functional significance of these two pathways is discussed.

Influence of stimulation of auditory and somatosensory systems on the activity of vestibular nuclear neurons in the frog.

In the frog, we have recorded extracellularly the activity of vestibular nuclear neurons driven by the horizontal semicircular canals. About 28% of the neurons recorded (n = 300) responded to auditory stimulation (clicks 150/s and pure tones 300-2,000 Hz, about 80 dB above threshold) or to somatosensory stimulation (electrical stimulation of the ipsilateral or contralateral sciatic nerve and vibratory stimulation of the ipsilateral gastrocnemius). Whatever the stimulus, the response was always an increase of the discharge frequency. Such a frequency increase was much more important for somatosensory stimulation (62-145%) than for auditory (20%) and sciatic nerve input was about twice as efficient as gastrocnemius input. Except for type IV units which were only exceptionally recorded, all the other neuronal types (according to Duensing and Schaefer 's classification, 1959) responded to auditory or somatosensory volleys. In particular, activation of type III units, which are partly efferent vestibular neurons ending at the base of the sensory hair cells, may result in a modulation of the peripheral vestibular discharges. The latencies of the responses varied over a wide range (5-40 ms); long latency responses are probably mediated by polysynaptic pathways including the reticular formation and/or the cerebellum, and short latency ones by oligosynaptic pathways. These pathways and the functional meaning of convergence of auditory and somatosensory input onto vestibular nuclei are discussed.

Responses of afferent and efferent neurons to visual inputs in the vestibular nerve of the frog.

In the frog immobilized by intralymphatic injection of D-tubocurarine, stimulation of the visual apparatus with either electrical shocks applied to the optic chiasma or light pulses elicited, in many cases, an increase and a decrease of firing of efferent and afferent vestibular neurons, respectively, recorded from the horizontal semicircular canal nerve. Optokinetic stimulation was completely inefficient in modulating the efferent and afferent discharge. These results show that stimulation of the visual system can modify vestibular apparatus fuctioning at the most peripheral level. However, it is likely that the effects observed were due to an arousal phenomenon or/and to a motor corollary discharge.

Tonic influence from one labyrinth onto the contralateral one. An electrophysiological study in the frog.

In the frog's isolated head preparations, spontaneous activity was recorded from the whole nerve of the left horizontal semicircular canal (HC) for 6 min before and 16 min after destruction of the right labyrinth by heating or administration of d-tubocurarine (0.5 microliter, 5.10(-6)M) into the perilymph of the right labyrinth. Just after destruction on the right labyrinth, spontaneous activity of the left HC nerve abruptly increased by 20-400% in 24 preparations out of the 40 studied; activity then increased slowly and regularly and in most cases reached a steady level. In the 16 other preparations such destruction had no effect (15 preparations) or elicited a slight decrease of the HC nerve activity (one preparation). After curare administration, the spontaneous activity of the left HC nerve decreased by 20-100% in 27 preparations out of the 40 studied; in most cases such a decrease was reversed 25-80 min after administration of the drug. The spontaneous discharges were unaffected in 11 preparations and slightly increased in the two others. Destruction of the right labyrinth or administration of curare never modified spontaneous activity recorded from the left HC nerve when the connections between the two labyrinths had been interrupted either by sagittal section of the medulla oblongata or section of the right vestibular nerve close to the brain stem. These results demonstrate that one labyrinth has a tonic inhibitory influence on the contralateral one.