[Surgical indications for diabetic maculopathy]. / Indications de la chirurgie des maculopathies diabétiques.

INTRODUCTION: The place of surgery in the treatment of diabetic macular edema is still not clearly defined even though the functional benefits of photocoagulation are less than satisfactory. Key words: Diabetic maculopathy, vitrectomy, internal limitant layer, serous detachment, hard exsudates. EQUIPMENT AND METHODS: We conducted a retrospective study on 40 consecutive cases of diabetic patients, each suffering from serious diabetic maculopathy and for whom photocoagulation would be either impossible to carry out or ineffective. Eighty percent of this study sample exhibited solid vitreomacular adhesions at vitrectomy. The internal limitant layer was dissected systematically. In all cases, plugging by perfluorocarbon liquids during the operation helped posterior focal endophotocoagulation. A gas tamponade was used in all cases. In 18 cases, surgical extraction of large intra- and/or subretinal clumps of hard exudates was necessary to replace the posterior pole. RESULTS: The anatomical results were satisfactory in 97.5% of cases. The functional results were good but their interpretation is more difficult: the visual gain varied as a function of the clinical preoperative condition and how recent the condition was. The best results were obtained in edema with tractional predominance. The smallest visual gains were observed in cases of massive macular hard exudates. The most serious complication was a retinal detachment secondary to a parapapillary nasal retinal break occurring at a distance from the operation during a postoperative photocoagulation complement. DISCUSSION AND CONCLUSION: Vitrectomy released both tangential and axial tractional forces found in diabetic macular edema pathogenesis. The extraction of large clumps of exudates allowed us to replace serous retinal detachments and the photocoagulation of capillary anomalies. In addition, removing premacular vitreous body and gaseous plugging seemed to osmotically resorb the posterior pole edema. These surgical results have made us considerably reduce the use of photocoagulation for diffuse diabetic macular edema in the past four years.

[Place of "exploratory vitrectomy" in the treatment of retinal detachment without proliferative vitreoretinopathy]. / Place de la vitrectomie exploratrice dans le traitement du décollement de rétine sans prolifération vitréo-rétinienne.

INTRODUCTION: One of the principal causes that may contribute to failure in the treatment of retinal detachment without PVR is the inability to detect the retinal break before and during surgery. We propose in these cases the use of exploratory primary vitrectomy allowing the location and the treatment of the retinal break. MATERIAL AND METHODS: We have studied retrospectively 19 cases of retinal detachment without any preoperatively identified break. In 14 cases, it was a pseudophakic detachment (the IOL was in the posterior chamber with an optic between 5 and 6 mm), in 5 cases it was a phakic detachment. Peripheral fundus was examined with the vitrectomy probes with and without perfluorocarbon liquid injection. Cryotherapy or endophotocoagulations have been used to create a chorio-retinal adhesion and a gaz tamponade was used without scleral buckling procedure. RESULT: In 2 cases, no retinal break was found. In the other cases, the retinal tear has been identified during basal vitrectomy in 8 cases, during injection of perfluorocarbon in 2 cases and during the vitrectomy done forward the PFLC in 7 cases. The retinal break was identified as a small retinal tear along the posterior margin of the vitreous base in 15 cases (several in 2 cases) and as atrophic hole in 2 cases. DISCUSSION: Exploratory vitrectomy is an interesting technique to identify a retinal break when a scleral indentation cannot offer a good visualization of the anterior retina or retinal tears. In young phakic patients, a primary vitrectomy may be dangerous but seems to be justified in pseudophakic eyes. The research of the tear is sometimes facilitated by a peroperative tamponade of the retro equatorial retina.

[Retinitis pigmentosa and vitreo-macular traction syndrome. An anatomo-clinical and histopathological study apropos of a case]. / Rétinopathie pigmentaire et syndrome de traction vitréo-maculaire. Etude anatomo-clinique et histopathologique à propos d'un cas.

PURPOSE: A case of congenital epiretinal membrane associated with retinitis pigmentosa is reported. PATIENT: A 30 year old man with retinitis pigmentosa was operated for a vitreomacular traction syndrome. The epiretinal membrane removed during surgical procedure was analyzed in electronic microscopy. RESULTS: Visual acuity, 6 months after the intervention: improve at 20/400, because of amblyopia. The study in electronic microscopy reveals many fibroblasts in an abundant collagenic tissue without glial cells. DISCUSSION: The observation of such an epiretinal membrane is unusual during retinitis pigmentosa. Its origin is probably congenital and the vitreous may play some role in its evolution. The systematic examination of the vitreoretinal interface represents an important element of the surveillance of retinitis pigmentosa.

[Role of vitrectomy in the treatment of retinal arterial macroaneurysms]. / Place de la vitrectomie dans le traitement des macroanévrysmes artériels rétiniens.

INTRODUCTION: Retinal arterial macroaneurysms are a rare cause of macular hemorrhage. Their treatment by photocoagulation is difficult and often ineffective. MATERIAL AND METHOD: Five aneurysmal cases complicated by a pre or retromacular hematoma or an intravitreal hemorrhage were treated surgically by vitrectomy with peeling of the vitreous cortex, hematoma drainage, dissection of the fibrinous aneurysmal body, perfluorocarbon fluid tamponade facilitating endophotocoagulation and temporary internal gas tamponade. RESULTS: Anatomical and functional results were satisfactory in this short series. One year after surgery, one case of secondary cataract was reported. DISCUSSION: Arterial abnormalities, located on the superior temporal retinal artery, are often discovered after assessment pre or submacular hemorrhage. Functional prognosis of aneurysmal rupture depends on the course of the retrofoveal hematoma. CONCLUSION: Early access to this surgery and good results in this series argue for rapid surgical treatment in sizeable submacular hemorrhage in order to avoid severe effects of subretinal fibrosis.

[Surgical treatment of serous detachments of the macular neuroepithelium in diabetics]. / Traitement chirurgical des décollements séreux du neuroépithélium maculaire chez le diabétique.

PURPOSE: Maculopathy in diabetes mellitus represents one of the most serious complications of the diabetic retinopathy. Retinal photocoagulations are often impossible and even dangerous. We propose a new method of surgical treatment for this macular serous detachment. MATERIAL AND METHOD: Thirteen eyes from 11 patients were treated using the same surgical procedure: vitrectomy, aspiration of subretinal liquid through a temporal retinotomy, fragmentation and extraction of the sub and intra retinal exsudates through one or several retinotomies, macular massaging with fluorodecaline, endophotocoagulations (focal on vascular anomalies and macular grid) and fluid-gas exchange (C3F8). RESULTS: Macular serous detachment and subretinal exsudates disappeared in all the cases, the fluorescein leakage decreased. A functional improvement was obtained in 11 eyes, a stabilization in 2. DISCUSSION: The clinical results of this new surgical treatment appear to depend on the preoperative macular ischemia and on the age of the detachment. This surgical procedure is very beneficial but could perhaps be technically improved.

Autocrine stimulation of AR4-2J rat pancreatic tumor cell growth by glycine-extended gastrin.

Glycine-extended gastrin (gastrin-Gly) stimulates proliferation of AR4-2J pancreatic tumor cell line through a specific receptor, different from the gastrin-cholecystokinin B receptor. Our purpose was to determine whether AR4-2J cells produced gastrin-Gly and then whether the peptide was involved in an autocrine loop. First, proliferation of AR4-2J cells in serum-free medium was inhibited by a gastrin anti-sense oligodeoxynucleotide phosphorothioate and by antibodies specific for gastrin-Gly. In contrast, antibodies specific for alpha-amidated gastrin were without effect. By using RT-PCR, we have shown that AR4-2J cells expressed gastrin mRNA. The presence of gastrin-Gly, but not alpha-amidated gastrin, in serum-free media was detected by radioimmunoanalysis. Gel chromatography revealed that the predominant molecular forms secreted were glycine-extended gastrin-34 and gastrin- 17. Furthermore, epidermal growth factor (EGF), a stimulator of gastrin gene transcription, modulates gastrin-Gly secretion by AR4-2J. These data together suggest that gastrin-Gly is an autocrine growth factor for AR4-2J cells and that it participates with EGF in the regulation of AR4-2J-cell proliferation.

Growth factors in vitreous and subretinal fluid cells from patients with proliferative vitreoretinopathy.

Mechanisms accounting for the development of proliferative vitreoretinopathy (PVR) in patients with rhegmatogenous retinal detachment remain poorly understood. In a previous study, we found the presence of various growth factors in preretinal membranes that were surgically removed from patients with PVR. The present immunohistological study was undertaken in intravitreal and subretinal fluid cells from patients suffering from PVR in various stages of development, in order to seek the presence of 4 growth-promoting factors for retinal pigment epithelial cells: acidic fibroblast growth factor (FGF), epidermal growth factor (EGF), insulin-like growth factor type I (IGF-I) and transforming growth factor-beta (TGF-beta). Results were quite similar in vitreous and subretinal fluid. Acidic FGF was found in all vitreous and subretinal specimens, in 30-100% of the examined cells. Immunoreactivity for EGF could be found in 53% of intravitreal cells and 69% of subretinal fluid cells. Positive cells were seen in all vitreous specimens and in all but 1 of the subretinal fluid specimens. IGF-I-containing cells were present in 13 of 15 vitreous specimens and in 18 of 20 subretinal fluid samples (mean percentages of reactivity in positive specimens 70% and 78%, respectively). In contrast, TGF-beta 1 reactivity was found in only 8 of 15 vitreous specimens and in 11 of 20 subretinal samples. Mean percentages of reactive cells were 30% and 50%, respectively. These results suggest that several growth factors could be involved in the proliferation and migration of retinal pigment epithelial cells during the course of PVR.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary uveal B immunoblastic lymphoma in a patient with AIDS.

A case of primary intraocular malignant lymphoma without cerebral involvement is reported in a 30-year-old man with acquired immunodeficiency syndrome. The study of the enucleation specimen showed a B immunoblastic lymphoma with a CD30 positive anaplastic large cell component. There was no involvement of the adnexal structures of the orbit. The patient subsequently completed non-surgical staging showing no extension of the tumour. The clinical course was rapidly fatal with dissemination to the pericardium and pleura.

Transferrin receptor expression by retinal pigment epithelial cells in proliferative vitreoretinopathy.

Immunotoxins directed against a membrane marker of cell proliferation, transferrin receptor, were investigated to inhibit the growth of retinal pigment epithelial (RPE) cells in proliferative vitreoretinopathy (PVR). We undertook an immunocytological study in specimens of vitreous, subretinal fluid, and epiretinal membranes from patients with PVR to address the expression of transferrin receptor by proliferating pigment epithelial cells during the course of PVR and in normal human ocular structures. Thirty four specimens of vitreous and subretinal fluid, as well as seven epiretinal membranes, were immunocytologically examined using monoclonal antibodies to transferrin receptor. They showed a strong expression of this marker by a large majority of the cells in these two periretinal fluids (mean percentages 80 and 91% in vitreous and subretinal fluid, respectively). In contrast, only a few cells within epiretinal membranes were found to express transferrin receptor. In normal human eye sections conjunctival and corneal epithelial cells, subcapsular epithelium of the lens strongly expressed transferrin receptor, whereas RPE cells remained negative to antitransferrin receptor antibodies. A few iris or ciliary pigment epithelial cells reacted weakly. Thus, this study shows that most intravitreal and subretinal fluid proliferating cells strongly express transferrin receptor on their surface. Also confirmed is that immunotoxins to this membrane antigen could constitute potentially useful therapeutic agents in PVR.

Acidic FGF and other growth factors in preretinal membranes from patients with diabetic retinopathy and proliferative vitreoretinopathy.

The development and extension of fibrovascular or fibroglial membranes onto the retinal surface are a major cause of visual loss in diabetic patients with proliferative retinopathy and in patients suffering from retinal detachment with proliferative vitreoretinopathy. The pathogenesis of these proliferative diseases, however, remain poorly understood and the nature of growth-promoting mediators implicated in these phenomena has not been determined yet. Using indirect immunofluorescence procedures, three different growth factors known to be mitogenic for various cell components of preretinal membranes, acidic fibroblast growth factor, epidermal growth factor and insulin-like growth factor type I, were sought in 14 specimens of preretinal proliferative tissues. Similar results were obtained in diabetic preretinal membranes and tissues from patients with proliferative vitreoretinopathy. The three different growth factors were found diffusely in the connective stroma and around new blood vessels within the vascular walls. Some fibroblast-like and pigment epithelial-derived cells more markedly reacted with anti-growth factor antibodies. These results provide indications on the eventual involvement of three potent growth factors in intraocular proliferative diseases, but whether or not these mediators play an active role in the development of preretinal membranes remains to be determined.

[Role of growth hormone in proliferative diabetic retinopathy. Clinical and immunohistochemical aspects]. / Rôle de l'hormone de croissance dans les rétinopathies diabétiques prolifératives. Aspects cliniques et immunohistochimiques.

The first part of this work deals with the various therapeutics with pituitary aims on ten patients with proliferative retinopathy. In the second part, the Growth Hormone involvement is considered, by the mean of IGF-I dosages in the serum and the vitreous of diabetic and non-diabetic patients. IGF-I is also sought in neovascular membranes by immunohistological methods. If radioimmunological dosages are negative, IGF-I deposits are found into new vessels wall. The significance of these immunohistological findings remains to be determined.

[Cryosurgery in the treatment of basal cell epithelioma of the eyelids]. / La cryochirurgie dans le traitement des épithéliomas baso-cellulaires des paupières.

Modern cryosurgery, based on impedance measurement, is a valuable addition to excisional surgery and radiation therapy in the management of eyelid malignancies. The advantages of the procedure are the good cosmetic and functional results. For the management of basal cell carcinoma situated near the punctum lacrimale and lacrimal canaliculus, cryosurgery may be preferred to surgery and radiotherapy. We review principles, methods, clinical and histological presentation of cryosurgery and describe our preliminary results.

[Malignant hyperthermia in ophthalmologic surgery]. / L'hyperthermie maligne dans la chirurgie ophtalmologique.

Malignant hyperthermia is a potentially fatal complication of general anesthesia that may occur with greater frequency in ptosis and strabismus surgery. The case of a two-year-old girl who suffered a malignant hyperthermia crisis during strabismus surgery is reported. The pathophysiology, clinical features, treatment and pre-anesthetic diagnosis are reviewed in detail.