[Gonococcal conjunctivitis complicated by perforating corneal abscess in an adult]. / Conjonctivite à gonocoque compliquée d'abcès cornéen perforant chez un adulte.

We present a case of bilateral purulent conjunctivitis complicated by ocular perforation of the right eye secondary to fulminant corneal melt in a 29-year-old man. He developed urethritis after a sexual contact with a prostitute 3 weeks previously. Microbiological analyses of conjunctival and urinary cultures were positive for Neisseria gonorrhoeae resistant to penicillins, tetracyclines, and fluoroquinolones. Progression was favorable with a 15-day course of high doses of parenterally administered antibiotics associating imipenem and fosfomycin. Keratoplasty was done after 3 months. This observation is a good example of the problems raised by gonococcal conjunctivitis in adults. Extremely rare in developed countries, it remains widely unrecognized by ophthalmologists. It is a sexually transmitted disease usually resulting from autoinoculation from an infected genital site. The risk of marginal purulent corneal melt, which can lead to fulminant perforation, warrants prompt microbiological analysis and early parenteral antibiotic treatment.

[Endophthalmitis after plana vitrectomy: incidence, microbiology, and visual outcome]. / Endophtalmies après vitrectomie postérieure: incidence, micro-organismes et devenir visuel.

INTRODUCTION: The aim of this retrospective study was to analyze incidence, microorganisms, and final visual acuity after pars plana vitrectomy. METHODS: Data on all patients with endophthalmitis after pars plana vitrectomy performed at Croix-Rousse Hospital, Lyon, France, between 1994 and 2004 were analyzed. RESULTS: Among 1632 posterior vitrectomies done over an 11-year period, 14 cases of endophthalmitis occurred (0.86%). Half of the patients were diabetic with poor glycemic control. The most frequent microorganism was negative coagulase Staphylococcus. One case of Bacillus cereus was noted. On the whole, visual prognosis was poor: final visual acuity never exceeded 20/200 in the best cases. The final visual acuity depended on the initial pathology requiring vitrectomy. One eye was enucleated because of phthisis. DISCUSSION: Historically, the incidence of endophthalmitis after vitrectomy is approximately 0.05%. It was higher in our series probably because of the high number of diabetic patients with poor glycemic control. Final visual acuity after pars plana vitrectomy in current series is low. Nevertheless it must be compared with the visual acuity before the vitrectomy because it depends greatly on the causal pathology which is very disabling. CONCLUSION: Endophthalmitis after pars plana vitrectomy is a serious complication. Prophylaxis is still the best treatment.

[Panuveitis following intravesical bacille Calmette-Guerin therapy]. / Pan-uvéite dans les suites d'instillations intravésicales de BCG (Bacille de Calmette et Guérin).

Uveitis occurring after bacille Calmette-Guerin (BCG) intravesical therapy for bladder carcinoma is rare: only nine cases have been described. In two previous reports, vitreous cultures proved Mycobacterium bovis presence. We describe the case of an 85-year-old woman who presented with bilateral panuveitis 2 months after the last BCG intravesical instillation, with no other systemic symptom. There was no evidence for any other etiology for this uveitis. She was given oral antibiotics that were effective against Mycobacterium species, oral steroids, and anti-inflammatory drops. Her ophthalmologic status dramatically improved. This case highlights that these patients may have a good visual outcome, as long as diagnosis and treatment are not delayed.

[Ciliary body melanomas. Survival and prognostic aspects after brachytherapy or proton therapy]. / Mélanomes uvéaux impliquant le corps ciliaire. Analyse de la survie après protonthérapie ou bêta-curiethérapie par ruthénium-106. A propos de 106 cas.

INTRODUCTION: Our main goals were to study the survival of patients with uveal melanomas involving the ciliary body 5 and 10 years after treatment and to review prognosis. MATERIAL AND METHODS: This study investigated 106 tumors (27 ciliary body melanomas and 79 choroidal-ciliary melanomas) of patients treated between June 1983 and April 1998. Seventy-two patients were treated with 106-ruthenium applicators and 34 were treated with proton therapy. Some large tumors or recurrences required a second treatment. The mean follow-up period was 91 months. RESULTS: The mean tumor sizes before treatment were 6,6mm for melanoma thickness and 10.3mm for mean largest basal melanoma diameters (LTD). Of the patients studied, 71% were still alive at 5 years, 35% had metastasis and 27.7% developed recurrences. Multivariate analysis showed that the risk factors for melanoma-related death were LTD greater than 13mm, presence of exudative retinal detachment, macroscopic iris root involvement at the time of diagnosis, and choroidal-ciliary location. DISCUSSION AND CONCLUSION: With 71% of patients still alive at 5 years, this review shows that melanomas involving the ciliary body do not seem less severe than more posterior uveal tumors. Because of size differences between ciliary body melanomas and choroidal-ciliary melanomas, we cannot come to the conclusion that choroidal-ciliary melanomas have a poorer prognosis than ciliary body melanomas. Largest tumor diameter over 13mm, presence of exudative retinal detachment, and macroscopic iris root involvement at the time of diagnosis are important risk factors for melanoma-related death, as shown by the multivariate analysis.

[Sarcoid granuloma simulating amelanotic melanoma of the iris: a case report]. / Granulome sarcoïdosique simulant un mélanome achromique de l'iris.

We report the case of a unilateral vascular iris tumor in a 24-year-old patient. Clinically, the iris lesion appeared similar to amelanotic melanoma. A systemic work-up (initial check-up), including an angiotensin-converting enzyme determination, provided the diagnosis of sarcoid granuloma. A biopsy confirmation was not needed. We concluded that iris granuloma can be the only ocular manifestation of sarcoidosis and this context is likely to be confused with amelanotic melanoma and metastatic carcinoma.

[Choroidal nevi associated with serous macular detachment]. / Décompensation exsudative anatomique et fonctionnelle de 12 naevi choroïdiens.

PURPOSE: To describe the aspect and progression of choroidal nevi associated with macular serous detachment and to analyze different treatments. MATERIAL: and methods: Twelve posterior choroidal nevi were associated with subretinal fluid. The fovea was detached in 11 cases. Tumor thickness was 2 mm or less. RESULTS: No treatment was given in 6 cases and spontaneous subretinal fluid regression was observed in 3 of these 6 cases. Success was also observed in 2 of 3 cases treated with corticotherapy, but subretinal fluid recurred. Gas injection was performed in 1 case and transpupillary thermotherapy in 2 others, all 3 with successful definitive drying of the nevus. Visual acuity decreased in 6 cases (in 3 untreated cases and in 3 cases treated with corticotherapy), remained stable in 3 cases, and increased in 3 cases (in 1 untreated case, in 1 gas injection case, and in 1 case after thermotherapy). Tumor growth was observed in 3 cases, on the average 2 years after diagnosis (25%). CONCLUSION: Subretinal fluid is rarely observed with choroidal nevi and its progression is variable. Various treatments in addition to observation such as corticotherapy, gas injection, transpupillary thermotherapy seem effective in stabilizing or improving visual function. Supervision is nevertheless needed to detect tumor growth that can be frequent in these nevi associated with subretinal fluid.

[Argon laser photocoagulation of circumscribed choroidal hemangiomas]. / Hémangiomes choroïdiens circonscrits traités par photocoagulation au laser Argon.

PURPOSE: Therapeutic retrospective results obtained after Argon laser photocoagulation of 17 circumscribed choroidal hemangiomas were analyzed. MATERIAL AND METHODS: Seventeen circumscribed choroidal hemangiomas associated with serous retinal detachment were analyzed. All patients were symptomatic but one. Duration of visual symptoms varied from 2 weeks to 3 years. Mean tumor thickness was 3,3mm (1 to 6,5mm). Mean tumor diameter was 6,5mm (2.5 to 15mm). Tumors were juxtapapillary in 9 cases (57%). The mean distance from the fovea was 1,5mm (0 to 3mm), and the fovea was pathological in all cases but two. The tumoral surface was covered by Argon laser spots with the central avascular area spared in the case of subfoveal hemangioma. In the case of subretinal fluid persistence 3 months later, 1 or more photocoagulation sessions were carried out. Follow-up was 27 months (6 to 156 months). RESULTS: Success (complete subretinal fluid resolution) was obtained in 82.4% with 1 or 2 laser photocoagulation sessions. Recurrence was observed in 4 cases (23.5%) but treated with success. Final visual acuity, related to the initial foveal condition, was >=0.5 in 23.5% of cases, and >=0.1 in 70.6% of cases. DISCUSSION: Anatomical and functional results were satisfactory considering initial foveal conditions. Irradiation (external beam irradiation, proton beam therapy, brachytherapy) has been used with success for several years. However, radiation-induced damage was described in addition to a few practical disadvantages. CONCLUSION: Argon laser photocoagulation was an effective noninvasive therapy for circumscribed choroidal hemangioma. It remains for us the reference method for treating this tumor.

[Double irradiation for macroscopic radioresistance or recurrence of melanomas of the posterior uvea: clinical, ballistic, therapeutic and prognostic aspects. Series of 19 cases among 462 patients]. / Double irradiation pour radiorésistance macroscopique ou récidive dans les mélanomes de l'uvée postérieure: aspects cliniques, ballistiques, thérapeutiques et pronostiques: A propos de 19 cas sur 462 patients.

We describe two comparative series of patients treated with double-dose betaraysbrachytherapy (106 Ruthenium) between 1983 and 1994, and double-dose proton beam therapy between 1991 and 1996. The indications for double-dose irradiation with the same radio-element corresponded to "macroscopically abnormal" situations: immediate and prolonged radioresistance, recurrence or secondary radioresistance. Thirteen cases are called series 1 (Ruthenium) and 6 cases are called series 2 (protons). The series 1 allows a more reliable study as far as follow-up is higher (5.8 to 7.5 years) than in series 2 where the follow-up is shorter (13.6 to 29 months). Although double-dose irradiation was macroscopically efficient in 11 out of 13 cases in series 1, and in 3 out of 6 cases in series 2 (stabilization or decrease of tumour height measured before the second therapeutic session), 2 patients are deceased and 1 has a metastatic disease in the group "recurrence" of Ruthenium serie. Another one has also a metastatic disease in the group "recurrence" of protons series. Nevertheless double-dose radiotherapy allows a complementary decrease or stabilization of tumour height after a first session. It also decreases the indications for enucleation if there is no severe anatomic complications, when a tumour does not regress or recurs after a first session of radiations.

[Postoperative proliferative vitreoretinopathy in rhegmatogenous retinal detachment associated with stage B preoperative proliferative vitreoretinopathy: comparative results of trans-scleral retinopexy with diode laser or trans-pupillary retinopexy with argon laser]. / PVR postopératoire dans le décollement rhegmatogène de la rétine associé à une PVR préopératoire stade B: résultats comparés de la rétinopexie transsclérale au laser à Diode et de la rétinopexie transpupillaire au laser à l'Argon.

PURPOSE: To compare the rate of severe postoperative PVR in primary rhegmatogenous retinal detachments (RD) associated with preoperative grade B PVR and managed either with transpupillary Argon laser photocoagulation or transscleral Diode laser photocoagulation. MATERIAL AND METHODS: We evaluated 72 primary rhegmatogenous retinal detachment associated with preoperative grade B PVR (retinal tears with curled posterior edges), referred before any failed attempt to reattach the retina. Eleven RD were due to giant tear. The retinopexy was performed using transpupillary Argon laser. photocoagulation in 46 eyes, and transscleral Diode laser photocoagulation in 26 eyes. Follow up was 6 to 30 months. Statistical analysis used Chi-square test, and variance analysis. RESULTS: The overall rate of postoperative PVR was 6.9% (5/72 eyes). The rate of postoperative PVR was 6.5% (3/46) in eyes managed with Argon laser photocoagulation and 7.7% (2/26) in eyes managed with Diode laser photocoagulation (p > 0.05). The rate of postoperative PVR in RD due to horseshoe tears was 5.4% (2/37) in eyes managed with Argon laser and 8.3% (2/24) in eyes treated with Diode laser (p > 0.05). The rate of postoperative PVR in giant tear was 11.1% (1/9) in eyes managed with Argon laser photocoagulation and 0% (0/2) in eyes managed with Diode laser photocoagulation (p > 0.05). CONCLUSION: In the present series the rate of postoperative PVR was not influenced by the method of photocoagulation (transpupillary Argon laser or transscleral Diode laser). Therefore each technique can be used as the retinopexy method in primary rhegmatogenous retinal detachment associated with preoperative grade B PVR.

Preoperative vitreous hemorrhage associated with rhegmatogenous retinal detachment: a risk factor for postoperative proliferative vitreoretinopathy?

BACKGROUND: We conducted a prospective clinical study to elucidate the role of preoperative vitreous hemorrhage in the development of postoperative proliferative vitreoretinopathy (PVR) in primary rhegmatogenous retinal detachment. MATERIALS AND METHODS: We prospectively evaluated 409 eyes of 390 patients affected by primary rhegmatogenous retinal detachment referred before any failed attempt to reattach the retina. Single and multiple logistic regression analysis were used to test 14 categories of variables. RESULTS: Postoperative PVR occurred in 48 (11.7% of 409 eyes). Postoperative PVR developed in 41 (11.8%) of the 347 eyes with no preoperative vitreous hemorrhage, and 7 (11.3%) of the 62 eyes with preoperative vitreous hemorrhage (P = 0.90). The results of multiple logistic regression analysis showed that only four variables were significant factors which had independently and jointly an effect on the risk of postoperative PVR: (1) 90 degrees or greater circumferential extent of the retinal tears; (2) preoperative PVR grade B; (3) preoperative PVR grade C-D; and (4) the use of cyrotreatment as the method of retinopexy. CONCLUSION: With the surgical techniques currently used, mild preoperative vitreous hemorrhage is not an independent risk factor for postoperative PVR in primary rhegmatogenous retinal detachment. The role of moderate and severe vitreous hemorrhage remains to be fully evaluated in a larger series of eyes.

[Has the incidence of postoperative PVR in rhegmatogenous retinal detachment decreased?]. / La fréquence de la PVR sévère postopératoire dans le décollement rhegmatogène de la rétine a-t-elle diminué?

PURPOSE: To determine whether the incidence of severe postoperative PVR in primary rhegmatogenous retinal detachment has decreased over the last twelve years. MATERIALS AND METHODS: We prospectively evaluated 595 eyes of 554 consecutive patients with primary rhegmatogenous retinal detachment, referred before any failed attempt to reattach the retina, managed by the same surgeon between March 1983 and December 1994. The eyes were divided into two consecutive series: 275 eyes operated on from March 1983 through February 1988 (series no. 1), and 320 eyes operated on from February 1988 through December 1994 (series no. 2). We conducted univariate and multivariate statistical analyses to compare the incidence of postoperative PVR in the two consecutive series. RESULTS: The overall incidence of postoperative PVR was 8.72% (24/275 eyes) in series no. 1, versus 2.81% (9/320 eyes) in series no. 2 (p < 0.01). The incidence of postoperative PVR in retinal detachments due to atrophic holes in lattice degeneration, oral dialyses, and macular holes in myopic eyes, was nil in both series. The incidence of postoperative PVR in retinal detachments due to horseshoe tears with mobile posterior edges was 1.16% (1/86 eyes) in series no. 1, and 0% (0/109 eyes) in series no. 2. The incidence of postoperative PVR in retinal detachments associated with horseshoe tears with curled posterior edges was 21.15% (11/52 eyes) in series no. 1 versus 3.2% (3/93 eyes) in series no. 2 (p < 0.001). The incidence of postoperative PVR in giant tears was 35.5% (11/31 eyes) in series no. 1. and 14.7% (5/34 eyes) in series no. 2 (chi square = 3.77; at the limit of significance). The incidence of postoperative PVR in retinal detachments du to paravascular tears of the post-equatorial region in myopic eyes was 25% (1/4 eyes) in series no. 1, and 14% (1/7 eyes) in series no. 2. CONCLUSION: In our own experience, the incidence of postoperative PVR in primary rhegmatogenous retinal detachment has decreased at a statistically significant level since 1988. We believe that the decreased incidence of postoperative PVR in our most recent series is mainly related to the use of laser photocoagulation retinopexy rather than cryopexy in the management of high risk eyes (retinal detachments associated with horseshoe tears with curled posterior edges, and giant tears).

The effects of a new aldose reductase inhibitor (tolrestat) in galactosemic and diabetic rats.

Tolrestat(N-[[5-(trifluoromethyl)-6-methoxy-1-naphthalenyl] thioxomethyl]-N-methylglycine; AY-27,773; Alredase) is a potent, structurally novel inhibitor of aldose reductase (AR). In vitro, tolrestat inhibited in dose-dependent fashion the AR from bovine lenses (IC50, 3.5 X 10(-8) mol/L) and the formation of sorbitol in human RBC incubated with glucose (IC50, 3 X 10(-8) mol/L). Upon administration with the diet to rats made galactosemic or diabetic, tolrestat decreased, in a dose-related fashion, the accumulation of galactitol or sorbitol in the sciatic nerve and lens. The effectiveness of tolrestat depended upon the experimental conditions and tended to be higher in less severe galactosemia and after suitable pretreatment, particularly in galactosemic rats, resulting in ID50 of 5 mg/kg/d in the sciatic nerve and 12-15 mg/kg/d in the lens. Tolrestat also decreased, in dose-related manner, the RBC sorbitol levels in normal and in streptozotocin diabetic rats; in the latter, at less than 2 mg/kg/d, the RBC sorbitol was reduced to control levels.

Resistance of the diabetic rat nerve to ischemic inactivation.

The resistance of the action potential to ischemic inactivation observed in diabetic patients has been reproduced in vivo in rat rendered diabetic with streptozotocin and, acutely, in normal rats given p.o. a load of glucose. The resistance phenomenon was not detected in galactosemic rats. The preservation of the action potential was reversed by the administration of insulin, but not by treatment with an aldose reductase (AR) inhibitor. The ischemic resistance is attributed to the metabolic availability of excess glucose to the nerve. AR does not appear to be involved in the phenomenon.

Prevention of cataract development in severely galactosemic rats by the aldose reductase inhibitor, tolrestat.

With a fixed time period of galactose feeding, the rate of appearance of lenticular opacities depended on the severity of galactosemia, while with a fixed amount of galactose fed, the rate was time dependent. The capacity of tolrestat, a structurally novel inhibitor of aldose reductase (AR), to control cataract development was assessed in rats fed 30-50% galactose with the diet for 7 to 277 days. In rats fed 30% galactose for 31 days, the controlling effect of tolrestat was dose dependent, and no cataracts were detected at a dose of 35 mg/kg/day. In rats given tolrestat with the diet for 14 days, then rendered severely galactosemic with a diet containing 50% galactose, and subjected to continued treatment with tolrestat at a dose of 43 mg/kg/day, no changes were detected by slit-lamp microscopy after 207 days. The preventive effect was also dose dependent. In view of the established similarity in the pathogenesis of galactosemic and diabetic cataracts, the results obtained with tolrestat support its potential for controlling cataract development in diabetics.

Polyol accumulation in galactosemic and diabetic rats: control by an aldose reductase inhibitor.

An orally active inhibitor of aldose reductase, 1,3-dioxo-1H-benz[de]-isoquinoline-2(3H)acetic acid (AY-22,284), prevented cataractous changes in cultured lenses exposed to high concentrations of galactose. When given orally, AY-22,284 markedly decreased the accumulation of polyols in the lenses and sciatic nerves of galactosemic rats and rats with streptozotocin-induced diabetes. In addition, treatment of galactosemic rats with AY-22,284 effectively suppressed the formation of cataracts.