[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.

[Use of contact lenses for correction of amblyopia in high unilateral myopia in children]. / Correction du vice de réfraction par lentilles de contact chez l'enfant amblyope atteint de myopie forte unilatérale.

Persistent amblyopia in high unilateral myopia (anisometropia higher than or equal to - 3.5 diopters) has different causes: missed early diagnosis or therapeutic strategy error. With the intention of preventing the latter, we investigated the use of contact lenses. With occlusion treatment, we obtained substantial improvement of visual acuity of the amblyopic eye. Exophoric and exotropic patients retained all binocular vision and binocular union, as did most (3/4) of the microesotropic patients. This treatment has the advantages of being permanent, esthetic, and well accepted by parents.

Descemet membrane detachment after nonpenetrating filtering surgery.

PURPOSE: To make surgeons performing nonpenetrating filtering surgery aware of an unusual complication namely Descemet membrane detachment. METHODS: We retrospectively reviewed nine eyes of nine patients seen in our hospital with Descemet membrane detachment occurring after nonpenetrating filtering surgery from January 1994 to December 2000. RESULTS: Both planar and nonplanar detachments were reported. Neither scrolls nor tears in the Descemet membrane were observed in any patient. After viscocanalostomy (four patients), the detachment was generally noticed shortly after the procedure and the cornea maintained its clarity. After deep sclerectomy with a collagen implant (five patients), it developed weeks to months postoperatively with adjacent corneal edema. Four patients had descemetopexy. None required more than one procedure. However, at the last visit, two detachments persisted although they had diminished in size: one after viscocanalostomy and conservative treatment and one after descemetopexy after deep sclerectomy with a collagen implant. To date otherwise, no signs of significant corneal damage could be observed clinically nor by specular microscopy and pachymetry. CONCLUSIONS: The diagnosis of Descemet membrane detachment can be easily overlooked or misdiagnosed. The clinical presentation, clinical course, and pathogenesis depend on the type of nonpenetrating filtering surgery performed. Ophthalmologists should be aware of this unusual complication, which is likely to be more common after nonpenetrating filtering surgery than after trabeculectomy. A period of observation before attempting descemetopexy is recommended.

Combined surgery for cataract and glaucoma: phacoemulsification and deep sclerectomy compared with phacoemulsification and trabeculectomy.

PURPOSE: To compare the outcome of phacoemulsification-intraocular lens (IOL) implantation combined with nonperforating deep sclerectomy (P-DS) with that of phacoemulsification-IOL implantation combined with trabeculectomy (P-T). SETTING: Glaucoma Unit, Department of Ophthalmology, University of Lausanne, Switzerland. METHODS: This prospective study involved 60 eyes of 60 patients with cataract and various types of open-angle glaucoma. Thirty eyes had P-DS and 30, P-T. Follow-up was performed at regular intervals for up to 18 months. RESULTS: Mean follow-up was 12.5 months +/- 6.5 (SD) and 12.6 +/- 4.9 months for the P-DS and P-T groups, respectively. Mean preoperative intraocular pressure (IOP) was similar in both groups (24.8 +/- 5.9 mm Hg in the P-DS group and 24.6 +/- 7.2 mm Hg in the P-T group). There was no statistically significant difference in IOP decrease (14.2 +/- 4.0 mm Hg in the P-DS group and 15.2 +/- 2.8 mm Hg in the P-T group). Visual outcome was similar in both groups. The P-DS group experienced significantly less inflammation (40.0% versus 83.0%; P = .0012) and hyphema (6.7% versus 36.7%; P = .010) than the P-T group. CONCLUSION: Deep sclerectomy combined with cataract surgery resulted in an IOP reduction similar to that with phacotrabeculectomy with the same visual outcome, but the lower complication rate makes ambulatory care easier.

[Skew deviation]. / Skew deviation.

BACKGROUND: Skew deviation is a vertical ocular misalignment of prenuclear origin. Although well described in the literature, it is still probably underdiagnosed. Natural history of skew deviation is not well described in the literature. PURPOSE: To describe the clinical presentations, etiologies and follow-up of skew deviation. METHODS: Retrospective study of 29 patients diagnosed with skew deviation between 1993 and 1996. RESULTS: The commonest cause was cerebrovascular accident (12/29) and the commonest localisation was mesencephalic (9/29). Other causes included surgery (7/29), tumor (4/29), trauma (3/29), degeneration (3/29), inflammatory (2/29), increased intracranial pressure (1/29). Other localisations included cerebellum (5/29), ponto-mesencephalic (3/29), and medulla (2/29). Vertical diplopia was always accompanied by other neuro-ophthalmologic abnormalities. 69.2% (18/26) patients were totally asymptomatic after 7.5 months. 30.8% (8/26) were still symptomatic (diplopia). One patient required surgery, three patients were relieved with prisms, one patient needed monocular occlusion. One patient died during follow-up and precise data were lacking in two symptomatic patients. CONCLUSION: Skew deviation is not so rare, 10% of the cases referred to us for diplopia in 3 years. The diagnosis of skew deviation should be entertained when vertical diplopia cannot be explained by pathology of extraocular muscles, peripheral or central cranial nerve III or IV palsies, myasthenia, or orbital pathology. Prognosis for recovery in patients with skew deviation is good. 70% will recover, after a median time of 7.5 months. Surgery should be postponed at least for 12 months.

[Cataract-glaucoma combined surgery: comparison between phacoemulsification combined with deep sclerectomy, or trabeculectomy]. / Chirurgie combinée cataracte-glaucome: comparaison entre phacoemulsification associée à une sclerectomie profonde, ou a une trabéculectomie.

PURPOSE: To study the success rate of combined phaco-intraocular lens (IOL)-deep sclerectomy (P-DS), a new perforating filtering surgery, versus phaco-IOL-trabeculectomy (P-T). METHODS: Of 38 patients, 39 eyes with cataract and different types of glaucoma, 19 eyes underwent P-DS, and 20 eyes underwent P-T. Patients were prospectively studied. RESULTS: The follow-up of both groups was 11 +/- 6 months. The intraocular pressure (IOP) decrease in both groups was similar (from a mean preoperative IOP of 26.5 +/- 6.8 mmHg, to a mean postoperative IOP of 14.8 +/- 1.3 mmHg in the P-DS group, vs 25.9 +/- 7.7 mmHg preoperative and 14.8 +/- 2.7 mmHg postoperative in the P-T group). The visual acuity outcome was similar in both groups. The complication rate was significantly lower in the P-DS group. CONCLUSIONS: Deep sclerectomy associated with cataract surgery offers the same IOP reduction and visual acuity outcome. However, the complication rate is significantly lower and allows easier ambulatory care.

Serum 25-hydroxyvitamin D: distribution and determinants in the Swiss population.

The serum 25-hydroxyvitamin D [25(OH)D] concentration was measured in a representative sample of the general adult population in Switzerland (n = 3276). The median concentration was 46 nmol/L and no significant difference was found between men and women. Between the ages of 25 and 74 y, 25(OH)D was not significantly correlated with age (r2 = 0.01). Six percent of the population was vitamin D deficient [ie, 25(OH)D less than or equal to 20 nmol/L] and between 34% and 95% had a relatively low concentration of vitamin D (ie, less than 38 or less than 95 nmol/L, respectively). Among the determinants of low 25(OH)D were indicators of little sunshine exposure, such as the winter season [odds ratio (OR) 2.4, 1.5-3.7 (95% confidence interval)] and less than 30 min of time spent outdoors daily by individuals greater than 65 y of age (OR 5.6, 1.5-21.2), as well as indicators of low nutritional intake of vitamin D, such as the absence of regular intake of butter or margarine (OR 2.0, 1.3-3.1) and the consumption of few dairy products (OR 1.7, 1.2-2.4).