FORMS OF OCULAR LARVAL TOXOCARIASIS IN CHILDHOOD. A REVIEW.

The aim of this paper is to present an outline of forms of ocular manifestations of visceral larva migrans in children, as illustrated by the extensive photographic documentation. Ocular larval toxocariasis (OLT) has various clinical manifestations even in childhood age, in which age representation has an influence. The most common is presence of peripheral granuloma of the eye, frequently with a tractional vitreal streak leading from the retinal periphery to the optic nerve papilla. This is followed by granuloma of the posterior pole of the eye, usually reaching from the macular landscape to the central retinal periphery, always with vitritis. In children OLT may be manifested also in affliction of the optic nerve (cystic granuloma of the head of the optic nerve or neuropathy with vitreal reaction), fulminant endophthalmitis and in rare cases also diffuse chorioretinitis. The diagnosis rests upon a clinical ophthalmological finding, as well as laboratory examination of the levels of antibodies with potential eosinophilia. Histological examination may demonstrate spherical polypoid ossification in the choroid at the posterior pole of the eye as a consequence of fibrotisation and calcification, proceeding from the surrounding area of the absorbed larva. General combined treatment with antihelminthics and corticosteroids is arduous and does not always produce the desired effect in the sense of a satisfactory improvement of visual acuity. In differential diagnostics, manifestations of OLT in small children are still associated with retinoblastoma and a clinical picture of other intraocular diseases.

ATYPICAL FORMS OF EYE TOXOPLASMOSIS IN CHILDHOOD. CASE REPORTS.

AIM: To present an outline of acquired atypical forms of ocular toxoplasmosis (OT) in childhood, with reference to the 100th anniversary of the discovery of this etiology by Professor Janků from Czechoslovakia, who was first to describe the clinical congenital picture of OT characterised by macular scar. MATERIAL AND METHODS: Symptoms of intraocular bilateral neuritis appeared in a 6-year-old girl, with visual acuity (VA) bilaterally 0.1. Toxoplasmic etiology was demonstrated in laboratory tests, and the patient was immunocompetent. Following treatment with macrolide antibiotic and parabulbar application of corticosteroid, the condition was normalised stably at VA 1.0 in both eyes. Bilateral retinal vasculitis was determined in an 8-year-old boy, with VA of 0.25 in the right eye and 0.25 in the left, with a medical history of strabismus detected after suffering from varicella. The examination for toxoplasmosis was negative, but pronounced general hypogammaglobulinaemia classes IgG, IgM and IgA was detected. Immunosuppressive and immunomodulatory therapy did not produce the desired effect, and the condition progressed to retinochoroiditis. Due to blindness and dolorous glaucoma, enucleation of the right eye was performed at the age of 15 years. Histologically toxoplasmic cysts with bradyzoites were detected, a subsequent laboratory test demonstrated toxoplasmic etiology upon a background of persistent regressing hypogammaglobulinaemia. General anti-toxoplasma and subsequent immunosuppressive treatment did not produce the desired effect, and at the age of 22 years the patient lost his sight also in the left eye. CONCLUSION: Atypical form of OT intraocular neuritis in an immunocompetent patient had a favourable course, whereas retinal vasculitis with retinochoroiditis in a temporarily immunocompromised patient ended in bilateral blindness.

BILATERAL AMYLOIDOSIS OF THREE EYELIDS. A CASE REPORT.

AIM: To present rare form of lids amyloidosis, in the context with literature and remind a Czech professor Vrabec, F., MD, an important pan-European ocular histologist. CASE REPORT: 37 years aged man was examined for eyelids mass on the department of ophthalmology of the Teaching Hospital Kralovske Vinohrady, Prague, Czech Republic in June 2018. The finding looked like chronic chalazion on the right side and chronic hordeolum on the left side. No acute phase was noted within last several months by the patient. Yellowish to lightly brown friable, partially transparent mass was obtained by excision. Amyloidosis of the AL type was revealed histologically, and diagnosis was followed by extended excision and plastic surgical reconstruction of the lower eyelids on both sides. No systemic disease underlying the amyloidosis was disclosed by following through diagnostic work-up of the patient. RESULTS: Amyloidosis was illustrated initially by Congo red staining with characteristic dichroism in the polarized light, then it was analysed immunohistochemically, with positivity for kappa light chains. Systemic amyloidosis was excluded, as well as monoclonal gamapathy. Only slightly increased number of plasmacytes (up to 10 %) was revealed in the bone marrow biopsy. The surgical solution was optimal for the patient, and he was without any recurrence and problems of lower eyelids three years. CONCLUSION: Described case of bilateral eyelids amyloidosis without underlying systemic disease belongs to rare cases and also illustrates necessity of complex interdisciplinary cooperation in the diagnostic process.

PRE-RETINOPATHY OF TYPE 1 DIABETES IN THE CONTEXT OF FUNCTIONAL, STRUCTURAL AND MICROCIRCULATORY CHANGES IN THE MACULAR AREA.

AIM: The authors assessed the development of intraocular changes in type 1 diabetes (T1DM) from the onset of the disease leading to diabetic retinopathy (DR). The quote: “There must be an intermediate stage between the physiological intraocular finding and the diabetic retinopathy itself “, (prof. Jan Vavřinec). METHODS: A two-year study (2018 and 2019) was conducted at the Department of Ophthalmology of the Teaching Hospital Kralovske Vinohrady in Prague (Czech Republic). There were 54 patients aged 17-42 years, the detection of T1DM ranged between the 1st and 14th year of life, with a duration of 12-35 years. Individual patients were always examined simultaneously by three methods: CS (contrast sensitivity), SD-OCT (spectral domain optical coherence tomography) and OCT-A (optical coherence tomography-angiography). We examined 106 eyes once and in a comprehensive manner. RESULTS: We have shown that there is an intermediate stage between the physiological finding on the retina and DR, so-called diabetic pre-retinopathy (DpR). Subsequent redistribution of the observed into two DpR subgroups was derived from the size of the FAZ, either with its smaller area or with a larger area determining the microvascularity of the central area of the retina. The results of both other methods were assigned to these values. For SD-OCT, the depth of the fovea (the difference between the central retinal thickness and the total average retinal thickness) was determined, which was affected by the increased the macular cubature. In all patients it was on average 10.3 μm3. The retina in the central area was significantly strengthened compared to the healthy population at the level of significance p 0,001. We divided the actual DpR into an image: DpR1 in 26.5 % of eyes - condition with an average shallower fovea only by 21.5 μm below the level of the surrounding retina and an average narrower FAZ: 0.165 mm2 and with a more significant decrease in CS; DpR2 in 40.5 % of eyes - condition with average deeper fovea by 42 μm, i.e., more significantly and average larger FAZ: 0.325 mm2 with lower decrease of CS. At the same time, other changes in microvascularity were noted, such as disorders in the sense of non-perfusion in the central part of the retina of various degrees. This finding differed significantly from changes in already established (non-proliferative) NPDR in 36 % of eyes, when a significant decrease in CS with normal visual acuity was found 4/4 ETDRS. Statistical differences in CS between DpR1 and DpR2 and NPDR were determined - always p 0.001. The average depth of the fovea was NPDR: 29.5 μm. NPDR had the largest average FAZ: 0.56 mm2. Also significant were the most significant changes in non-perfusion and especially the presence of microaneurysms. CONCLUSIONS: These three non - invasive methods helped to monitor the dynamics of the development of ocular changes in T1DM of better quality than the determination of visual acuity and ophthalmoscopic examination. Increased retinal volume induced hypoxia of visual cells with subsequent dual autoregulatory mechanism conditioning two types of diabetic pre-retinopathy before the onset of DR.

CHANGES OF THE FOVEAL AVASCULAR ZONE AND MACULAR MICROVASCULATURE WITHIN THE FRAMEWORK OF OCT ANGIOGRAPHY EXAMINATION IN YOUNG PATIENTS WITH TYPE 1 DIABETES (PILOT STUDY).

AIM: Learn about the development and changes in foveal avascular zone (FAZ) and vascularity of retina in the surrounding zone, depending on the duration in young diabetic patients type 1 (T1DM). METHODS: As part of regular one-year examinations of young T1DM patients at the Eye Clinic of the University Hospital Královské Vinohrady in Prague (Czech Republic, EU) from January to December 2019, OCT angiography using the device Spectralis (Heidelberg Engineering) was included. Forty patients aged 18 to 30 years were examined, median 21 years. T1DM was diagnosed in childhood and lasted for more than 10 years. At the same time, a control group of forty individuals of similar age, without metabolic and other general disease was examined, normal visual acuity and physiological fundoscopic finding were obligatory. The FAZ size was evaluated in both groups (using built-in function "Draw Region"), also its shape, density decrease and change in character of vascularity of the retina was assessed. RESULTS: In the control group, the FAZ area ranged from 0.06 to 0.4 mm², with an average of 0.253 ± 0.092 mm² and a median of 0.27 mm². It was not affected by a fundamental change in its round shape and the surrounding capillary netting was regular and reasonably dense. In T1DM patients, the FAZ area was in a wider range, from 0.05 to 0.64 mm², an average of 0.300 ± 0.132 mm², and a median of 0.31 mm². The difference in FAZ across-the-board evaluation was statistically significant (p = 0, 009). Diabetic preretinopathy (DpR) was defined by the irregularity of the capillary density up to the manifestation of non-perfusion, in 61% of cases the size of the FAZ was changed. In diabetic retinopathy (DR) there was always an irregularity of the FAZ shape with its enlargement, manifestation of non-perfusion, capillary dilatation and rare microaneurysms. CONCLUSION: Changes in FAZ size corresponded to the stage of T1DM on the fundoscopic finding of the eye depending on its duration. The initial increased amount of foveal capillaries, which resulted in decreased FAZ area, was followed by a gradual decrease in capillaries and increased FAZ area, consistent with the manifestations of DpR. It was accompanied by a change in capillary density in macula to eventual non-perfusion. On the contrary, the increase in the FAZ area and its irregularity accompanied by non-perfusion of the capillary net and microaneurysms corresponded to the development of DR already.

Merkel Cell Carcinoma of the Eyelids (Clinical-Histological Study).

AIM: To get acquainted with the issues of Merkel cell carcinoma (MCC) when the eyelid is affected and with its surgical solution. MATERIALS: MCC of the right upper eyelid was at the Department of Ophthalmology in the Faculty Hospital Královské Vinohrady in Prague (Czech Republic, EU) in 1998 woman 78 year. Another cases of the MCC on the left upper eyelid were observed in two women aged 48 and 67 years and they were pick up in a retrospective study covered 1033 operated tumors eyelids years 2007 - 2015. 47,5% of operated tumors were benign and 52,5% malignant. Most common malignant processes were basal cell carcinoma in 77,3% and squamous cell carcinoma at 15,7%. RESULTS: The oldest patient died after three years of cardiopulmonary failure. 48 year old patient (age of diagnosis MCC) has been monitoring for five years without proven recurrence or metastasis dissemination. Oncological initial staging was negative regarding. An ultrasound examination of the lymphatic system of the neck was followed every six months. Another 67 year old patient (age of diagnosis MCC) was followed for 2,5 years. There was a suspicion of a metastatic process in the same side salivary gland and lungs, therefore chemotherapy was performed. Definitely, this process has not been proven. Now there is continuing follow up without sings of local recurrence or metastatic dissemination. CONCLUSION: The authors confirmed a rare occurrence of MCC, and only 0,37% among malignant eyelids tumors. Essential importance for successful treatment is a sufficiently radical excision supported by histological verification and a subsequent plastic surgery of the eyelid is also necessary. Key words: Merkel cell carcinoma, tumor of eyelid, ultrasound examination of nodes.

Vertical Strabismus - Indication of Surgical Techniques on the Inferior Rectus Muscle.

Aid: Familiarize themselves with the operating techniques in their own modulation to solve hypotropic states with elevation or hypotropic states with depression. METHODS: Surgery technique “cul-de-sac” is a procedure with fixed adjustable sutures (non-absorbable suture), which are guided in parallel on both peaks original insertion of inferior rectus muscle. The node itself of suture is done in cutting the muscle and through the original insertion only leads arc suture. During „counterclockwise transposition“ procedure sec. Knapp, the horizontal rectus muscles are fixed at the straight inferior rectus muscle level. The author included their graphical diagrams. MATERIAL: At the Department of Ophthalmology in the Faculty Hospital Královské Vinohrady in Prague (Czech Republic, EU) in the years 1996 - 2014 a release relaxing operation of the inferior rectus musle by the technique “cul-de-sac” on 49 eyes. Indication was double elevator palsy in 31 patients, congenital fibrosis of the extraocular muscles in 15 patients and in 3 cases, it was thyroid eye disease. “Counterclockwise transposition” procedure sec. Knapp was indicated twice for paresis of the inferior rectus muscle in 2015 and 2016. For the first time, it was a congenital form. It was detected histologically atrophy of stripped muscle with hypertrophy collagen. The second traumatic form was formed after an orbital injury. RESULTS: We provided adequate relaxation of the inferior rectus muscle and practical restoration of eye elevation by the technique “cul-de-sac“ in 18 preschool children with the double elevator palsy and three adult patients with thyreiod eye disease. We had to restore motility to complete the procedure by classical transposition procedure sec. Knapp of both horizontal rectus muscles to the direct superior rectus muscle in elderly children and adults with the double elevator palsy, as well as in all patients with the congenital fibrosis of the extraocular muscles. Indicate the inclusion of this transposition influenced the degree of fibrotic rectus inferior muscle given by age. “Counterclockwise transposition“ procedure sec. Knapp ensured the practical disappearance hypertropie in both cases of paresis of the inferior rectus muscle. The alignment of the position of the eyes without diplopia in the direct view was ensured by prismatic correction. CONCLUSIONS:   To release the fibrotically altered inferior rectus muscle in the double elevator palsy, the congenital fibrosis of the extraocular muscles and the thyroid eye disease, the operation of adjustable sutures was necessary in accordance with our experience with the technigue “cul-de-sac“ in its own modification. The transposition procedure sec. Knapp, either classical or “”counterclockwise” “ in its own modification, was of paramount importance for the solution of the vertical deviation of a paretic ethiology. Key words: adjustable sutures, congenital fibrosis of the extraocular muscles, double elevator palsy, thyroid eye disease, transposition procedure sec. Knapp, vertical strabismus.

The long-term monitoring of sympathetic ophthalmia in the diagnostic and terapeutic view. Review Department of Ophthalmology.

AIM: To evaluate options of diagnostic and therapeutic procedures of sympathetic ophthalmia (SO) compared with literature data. Backgroud: SO is an ocular autoimmune disease. It is characterized by disbalance in the imunoregulatory T-subsets within cell mediated immune response. METHODS: File examination of SO by evaluation humoral and cellular immunity was ranked nukleolar test (NT). It evaulates the current status of lymphocyte activation based on the nucleolar morphology and RNA transcription aktivity. The classical histological examination was supported by immunohistochemical analysis of lymphocytic subpopulations in the eyeball enucleated for. SO in one case. MATERIAL: Five boys and men overall were monitored and treated in two studies from 1979 to 1994 and from 1999 to 2017 with SO In four cases it was subsequent after penetrating injuries and once after lensectomy with vitrectomy. The age of patients in the time of onset of SO was between 4 and 24 years (average 12 years). The time interval between insult and onset of SO varied between 10 days and 3 months (average 1.7 months). The relaps of disease appeared in the all cases in the time interval from 3 months to 38 years (average 15 years). Another two patients with SO were examined only in consultation: 16 years old boy with relaps of SO after cataract extraction and 71 years old women with SO subsequent after lensectomy and vitrectomy. There was examined and compared group of 19 patients with other types of uveitis in the same time. The lens-associated uveitis were caused after ocular contusion and penetrating eye injury in 16 patients (13 male patients). In another three cases (young women) with uveitid underlined by II. or III. type of hypersenzitivity the enucleation of dolorous eyeball calmed down the secondary uveitis on their second eye without any change of immunosupressive treatment and without change in NT. RESULTS: There were changes in the complex immunological laboratory tests results in the SO cases in the counts of activated lymphocytes in the peripheral blood. The count of activated lymphocytes was increased in SO cases unlike in lens-associated uveitis. There was detected in NT statistically significant difference (p = 0,0134) between the two groups of uveitis. The histological examination (5 eyes with SO and 7 eyes without sympathetic uveitis) confirmed the diagnoses, supporting basically the clinical diagnosis. The immunohistochemical examination corfirmed the presence of populations of T-lymphocytes, macrophages and also B-lymphocytes. A basis of immunosuppressive therapy was the combination of prednisone and azathioprin at the first time. Effective therapy featured cyklosporine later. CONCLUSION: The nucleolar test of lymphocytes draws attention of their up-to-day increased activity without the diferentiation of subpopulations and their absolute number increase related to the current activation of type IV. hypersensitivity (cell-mediated) in uveitis mechanism. The immunosupressive therapy calmes down this activation predominantly in SO, but also in other case sof uveitis with different types of hypersensivity. The immunohistochemical examination illustrates different presence of lymphocytic types according to the stage of SO.

Sarkoidosis and its Eye Ocular Manifestation (an Analysis of Six Case Report).

AIM: To introduce the range of eye changes in sarcoidosis in the individual casuistics. MATERIALS: At the Ophthalmic Clinic of Teaching Hospital Královské Vinohrady in Prague were examined and treated six patients with ocular forms of sarcoidosis in the years from 1998 to 2015. Three patients were unilateral lesions of the lacrimal gland without systemic symptoms. One patient experienced orbital inflammatory syndrome that accompanied the hilar form of pulmonar sarcoidosis. Two other patients underwent intraocular inflammation, panuveitis / iridocyclitis and bilateral intermedial uveitis. Both of these patients also had systemic affections of mediastinal lymph nodes and lung, in the first of these, signs of neurosarcoidosis first appeared. RESULTS: In the treatment of lacrimal glands, the diagnosis was determined by histological examination of the removed lacrimal gland in external orbitotomies, also, the orbital process has been verified by biopsy and the subsequent comprehensive examination revealed the systemic process. Definitive diagnosis of sarcoidosis was established bioptically in both uveitides and has also been demonstrated in imaging methodologies including galli scintigraphy. All patients were successfully treated with corticosteroid therapy. CONCLUSION: Biopsy results have always been a surprise in orbital processes. Both cases of uveitis were associated with systemic involvement and initiated comprehensive investigation which showed the need for interdisciplinary collaboration in the diagnosis and treatment of sarcoidosis. Key words: sarkoidosis, biopsy, corticosteroids, gallii scintigraphy, MRI, uveitis.

Results of the first 12 months treatment of macular edema complicating BRVO in patients treated with ranibizumab.

THE AIM OF THE STUDY: Retrospective evaluation of the first 12 months treatment of macular edema in BRVO with ranibizumab based on anatomical and functional parameters. METHODS: 54 eyes with macular edema complicating BRVO were included in the study, with an average initial best corrected visual acuity 4/16 ETDRS charts, an average central retinal thickness 512.3 µm, and in average 4 months till the beginning of treatment with ranibizumab. After 3 initial injections of 0.5 mg ranibizumab treatment was performed in pro re nata regimen, with adjuvant laser (grid laser photocoagulation) as an additional treatment option.  The number of injections administered, the number of eyes where grid laser photocoagulation was provided, functional parameters as a letter gain and BCVA (eyes with final BCVA ≥ 4/8 ETDRS, final BCVA in according to initial BCVA) and anatomical parameters as a mean CRT and  CRT ≤ 250 µm, respectively ≤ 300 µm were evaluated. RESULTS: In the whole group, an average of 4.8 injections of ranibizumab were administered in the first 12 months. Grid laser photocoagulation was performed in 42 eyes: in 8 eyes prior to the beginning of treatment with ranibizumab, 7 eyes before and during the treatment, 29 eyes only during the treatment. The main gain of letters after 12 months of treatment was +16.5 letters, with 63¨% (n = 34) eyes earning ≥ 15 letters. In the whole group 72 % (n = 39) eyes achieved the resulting BCVA ≥ 4/8 ETDRS after 12 months of treatment. The eyes with initial BCVA ≥ 4/10 ETDRS resulted in BCVA ≥ 4/8 ETDRS in 96 % (n = 23 eyes) and 11 eyes even  achieved BCVA ≥ 4/4. The mean CRT after 12 months of treatment was 290.3 µm, 33.3 %  of eyes had final CRT ≤ 250 µm, and 64.8 % had final CRT ≤ 300 µm. CONCLUSION: When applying a relatively low number of injections in the first year of treatment with ranibizumab, the final best corrected visual acuity was very good at the end of the observation period, and its dependence on the initial best corrected visual acuity was confirmed. Satisfactory results of central retinal thickness were found as well. Key words: branch retinal vein occlusion, macular edema, ranibizuma.

[Brown´s Syndrome: the Various forms and Their Treatment (Including an Expander own Design)]. / Brownuv syndrom: jednotlivé formy a jejich lécba (vcetne expanderu vlastní konstrukce).

AIM: Familiar with the treatment of various forms of Browns syndrome and its success. To document preparation of the expander own design. MATERIAL AND METHODS: In the years 1996-2016 was operated 33 pacients with congenital Browns syndrome by using an extension of its tendon expander at the Eye Clinic of the University Hospital Vinohrady in Prague. Author proves photographs preparing expander own design and modified surgical technique. It was also operated on 10 patients for accompanying Y-exotropia. Eleven patients with acute form of Brown´s syndrome in the pulley of upper oblique muscle applied Betamethasoni. RESULTS: The using expander own design - non-resorbable Ethibond 5-0 cauted silicone cannula - held at congenital form of Browns syndrome, without a weighty complication or its exclusion in the period. The result of the performance was determined age of patients at the time of implantation of the expander. Preschoolers postoperative condition was fully compliant, this expander standardized vertical mobility. The vertical alignment motility is reduced with advancing age, especially in adulthood. Optimal surgical procedures at Y-exotropia were antepozice with recession of the inferior oblique muscle possibly supplemented by retroposition ipsilateral external rectus. The application efficiency of Betamethasoni for acute form of Brown´s syndrome in the pulley of upper oblique muscle was successful in only two weeks after the initial symptoms vertical diplopia. CONCLUSION: Expander own design which represented non-resorbable Ethibond cauted silicone cannula was very effective in dealing with congenital form of Browns syndrome. The application of glucocorticoids in the pulley of upper oblique muscle should always be a quantity result.Key words: Browns syndrome, Betamethasoni, expander, Ethibond, silicone cannula, Y - exotropia.

[Anophthalmic conjunctival sac plastic surgery using the modified cul-de-sac method]. / Plastika anoftalmického spojivkového vaku upravenou metodikou cul-de-sac.

AIM: The author refers about the plastic surgery technique of deepening the conjunctival sac in acquired anophthalmos without the orbital implant. The condition without the implant was caused primarily or secondarily after the enucleation or evisceration. The principal of the cul-de-sac technique is the fixation of the lower fornix conjunctiva to the orbital periosteum. MATERIAL AND METHODS: The modification of the original surgery technique applied by the author is from the nineties of the last century. It consists of the use of long-term resorbable suturing material for vascular sutures made from polydiaxonone (PDS 6-0) and the suture primarily fixated to the orbital periosteum. Only in the second phase, the tarsal and bulbar part of the conjunctiva of the lower fornix is fixated to the orbital rim. The result is the deepening of the conjunctival sac making possible better positioning of the eye prosthesis in the interpalpebral fissure from the cosmetic and functional point of view. RESULTS: The author presents the successfulness of this surgical technique in six patients operated on during the period from 2009 to 2014, presenting photographs of four of them in the child and adult age. Shallow of the lower fornix was caused by spontaneous elimination of the implant at the school age after the enucleation due to the inborn malformation of the eye globe in three years old boy. Extrusion of the implants occurred also in two young men after previous enucleation due to the malignant intraocular tumors in infant age. In these cases, the influence of the growth to the physiognomy of the conjunctival - palpebral area was evident. Among included adults were: Eighty-three years old female patient, twelve years after the enucleation without the implant due to the endophthalmitis of unknown etiology; 62 years old man after the evisceration of the eyeball at the age of seven years due to the endophthalmitis after the perforating injury; and 55 years old male patient five years after the enucleation of the eye globe with adjacent fat tissue removal without implant due to the malignant intraocular tumor with the suspicion of its extrascleral growth. Always, the co-incidence of the involution process in the conjunctival sac itself took its part. CONCLUSION: The surgical technique of deepening the conjunctival sac using the cul-de-sac method and using the suturing material made from polydiaxonone (PDS 6-0) may be applied in shallow anophthalmic conjunctival sac in the lower fornix. At the same time, with this method, the possible ectropion of the lower eyelid is treated as well. To prevent the occurrence of the conjunctival sac not suitable for the orbital prosthesis application, it should be used the orbital implant during enucleation or evisceration surgery.Key words: anophthalmos, plastic surgery of the conjunctiva, polydiaxonone.

[Strabismus Sursoabductorius (put into the Context of eighteen Years of Strabismus Surgery Analysis)]. / Strabismus sursoabductorius (v kontextu osmnáctiletého rozboru operativy strabismu).

AIM: To familiarize with the form of combined horizontal and vertical deviations and its development and put it into the context of eighteen years of strabismus surgery analysis. MATERIAL AND METHODS: During the period from 1996 to 2014, there were at the Department of Ophthalmology, 2nd Medical Faculty, Charles University and Faculty Hospital Královské Vinohrady, Prague, Czech Republic, E.U., operated on 2 248 patients due to the eye position misalignment. The surgery of dynamic (comitant) strabismus (esotropia, exotropia, vertical deviations and their combinations) was altogether performed in 81.7 % of patients. Out of them, horizontal-vertical deviations comprised 12.9 % - it was the strabismus sursoadductorius in 211 patients. Strabismus sursoabductorius (SAB) comprised 3.5 %; the initial type without excess of divergence (I-SAB) was established in 39 patients, and in other 43 patients it was the type already with the excess of divergence (E-SAB). The remaining surgeries were dealing with paralytic strabismus (14.7 %), and torticollis due to horizontal and torsional nystagmus (3.6 %). RESULTS: In the clinical picture of SAB dominated the elevation of the eyeball in abduction as well as in adduction, which was at the same time insufficient, negatively influencing the second phase of convergence. The divergent part of the deviation for far vision was on average in I-SAB 12 prisms (prism diopters)(), and in E-SAB 30 . The age of the patients at the time of the surgery was on average 12 years in I-SAB and 19.5 years in E-SAB. The difference between both evaluations was significant (p < 0.005), confirming the developmental relation. The I-SAB with the increasing age changes into the E-SAB. Between the two forms of this vertical-horizontal deviation was not significant difference in the minimal deviation at near (I-SAB 2.5 and E-SAB 4.0 ). In the vertical part of the deviation was the difference even smaller (I-SAB 5.0 and E-SAB 6.0 ). The simple binocular vision was maintained in less than half of the patients with I-SAB and roughly in one-fifth of the patients with E-SAB. In I-SAB, the stereopsis was confirmed in one half of the patients, and it was rare (1/10) in E-SAB. The examination on the Hess screen confirmed extorsion, but excluded incomitant relationship as well. This sursoabduction includes in itself some separate signs of dissociated vertical deviation (DVD), and adduction activity of overactioning inferior rectus muscle (IOOA), but does not represent either of these clinical entities. Recession of the inferior oblique muscle with its eventual simultaneous resection (anteposition) of the insertion at the level of inferior rectus muscle, in E-SAB supplemented by recession of the lateral rectus muscle was found as the ultimate surgical solution. The stereoscopic functions after the surgeries restored in part only, they were present altogether in two-thirds of patients with I-SAB and in two-fifths of patients with E-SAB. Substantially improved the convergence. The vertical deviation improved and eventual residual divergence was corrected by means of prisms. CONCLUSIONS: The author expresses his own theory of this deviations appearance. Presumed decompensated exophoria was transformed into intermittent form of exotropia, which was probably accompanied by appendant abduction of the inferior oblique muscle, because it was overacting at the same time. Insufficient adduction and convergence corresponded with that. In further development, the horizontal deviation developed into the excess of divergence with the maintenance of the inferior oblique muscle overacting (hyperfunction) and above-mentioned motility disorders. Post-operative position of the inferior oblique muscle insertion weakened its function in elevation and, simultaneously, the function of abductor transformed to function of adductor, and thereby decreased the divergence part of pathological misalignment of the eye position. KEY WORDS: strabismus sursoabductorius, vertical deviation, horizontal deviation, exotrophia, hypertrophia, comitant strabismus, inferior oblique muscle recession.

[About Cryptophthalmos (2nd Czech Study)]. / O KRYPTOFTALMU (2. ceská studie).

AIM: To get acquainted with the 2nd Czech study about cryptophthamos and with self-surgical methods. MATERIAL: The boy with unilateral complete cryptophthalmos of left eye was treated from 2 to 20 years. The girls was treated from 4 month to 5 year yet for right abortive cryptophthalmos with microblepharon and left complete type still waiting for solutions.Surgical methods and results: Authors present a surgical procedures for correction of the upper and lower eyelids and ocular anomalies both patients studied. Successful reconstruction of palpebral fissure took place in several stages at the boy. The surgical procedure gradually contained: the insertion of gradually increased convex concave circular-shaped implant (silicone ruber) due a modeling of palpebral fissure, an enucleation of rudimentary eye, a reconstruction of bottom palpebral fissure by retro-auricular skin graf and a releasing of the lower transitory fold by the cul-de-sac method. An adequate depth of palpebral fissure to allow perfect position of an aesthetic protesis. Enucleated eye was atypically shaped, remiding partly sand-glass clock. The cornea was replaced by thick fibrous membrane, the iris and the lens were not revealed. Gliomatic retina was detached nearly totaly and the optic nerv was rudimental. The repairing the upper lid coloboma of girl by a lid rotation flap reconstruction using the inferior eyelid was performed at the age 17 month. Corneal dermoid simultaneously removed (histologically verified). Upper conjunctival fornix was formed using the spherical covering foil (silicone rubber) before and after the reconstruction of the lid. CONCLUSIONS: Plastic reconstructions required the need for patient access without trying immediate effect. An important role played silicone rubber implants (elastomer medical grade) which used temporarily. KEY WORDS: cryptophthalmos, microblepharon, relief surgery, silicon ruber implants.

[Contrast sensitivity and optic coherence tomography examinations in adolescent patients with diabetes type I preretinopathy (a pilot study)]. / Preretinopatie u mladistvých s diabetem 1. typu z pohledu vysetrení citlivosti na kontrast a koherencní tomografie (pilotní studie).

AIM: To evaluate the development of retinal changes in adolescent patients with diabetes type I (T1DM) with diseases duration more than 10 years, which started before 5 years of age. METHODS: The development of the findings on the posterior pole was followed up. The retinal functions were established by means of contrast sensitivity in four space frequencies: 3 cycles/degree (c/deg) (perimacular area), 6 c/deg and 12 c/deg (macular area), and, finally, 18 c/deg (foveola). The central retinal thickness, average retinal thickness of the specified quadrant of macular area, the foveolar depth of its own, and the volume of the perimacular area (perimacular cube volume) were measured by means of optical coherent tomography (OCT). MATERIAL: Altogether 20 patients with diabetes type I meeting the set criteria were examined, and their findings were compared with control group of healthy adolescent people. The values from the control group were used as our normative database. RESULTS: On the retina, there were found, during the diseases course lasting in average 13.3 years, changes of the macular area, especially tortuosity of macular final capillaries and pigmentation with disappearing of foveolar reflex, which, in 20 %, were followed by sporadic hard exsudates of the retina. Difference of the decreased values in adolescent patients, comparing to the control group, was recorded in contrast sensitivity in space frequencies of 3 c/deg (p 0.047) and 12 c/deg (p 0,0497), but statistically significant was the difference in space frequencies of 6 c/deg (p 0.0001) and 18 c/deg (p 0.0001). Using the OCT, no statistically significant difference was found in the central retinal thickness, but the values of foveolar depth in patients with diabetes type I were variable (p 0.0153); in four eyes it was much deeper, and in other four of them it was much shallower. Furthermore, there was higher the average thickness of the retina (p 0.0008) and the volume of the perimacular area (perimacular cube) (p 0,0001). CONCLUSION: The findings in eight eyes out of five patients with T1DM were evaluated as diabetic preretinopathy - pre-stage of beginning stage of diabetic retinopathy in central area of the retina from the functional and structural point of view of current pathological changes of contrast sensitivity and OCT. The findings of other three patients were rated as diabetic preretinopathy according to sporadic hard exsudates of the retina and OCT changes, but. until now, without contrast sensitivity changes. The one-year profile of glycated hemoglobin (HbA1c) was higher in patients with diabetic preretinopathy than without the eye involvement, but it was not statistically significant (p 0,0314).Key words: Contrast sensitivity (CS), Spectral Domain Optic Coherence Tomography (SD-OCT), diabetes mellitus type I (T1DM), diabetic preretinopathy (DpR), glycated hemoglobin (HbA1c).

[Lymphangioma of the orbitopalpebral area]. / Lymfangiom orbitopalpebrální oblasti.

AIM: The authors refer about five patients with different types of lymphangioma, who were followed-up at the Department of Ophthalmology, Faculty Hospital Královské Vinohrady (Kings Vinegards), Charles University, Prague, Czech Republic, E.U., during the period 1995 - 2013; the follow-up period lasted from 5 to 17 years. The lymphangioma of the orbitopalpebral area is discussed according to the evaluation of the tumor development, histological verification, treatment, and its results. METHODS: In four boys, the first signs of tumor were eyeball protrusion (exophthalmos) and bleeding into the conjunctiva or palpebral skin before the age of 5 years. In all four patients, the histological confirmation of the orbital lymphangioma was performed in the beginning of the disease. In three cases, it was the orbital type, and the fourth one was frontal type with bilateral orbital lymphangiomatosis. In one girl, there were present conjunctival changes only, appearing as one-sided hyperplastic changes. For these changes, she was followed-up since her 13 years of age under the false diagnosis of chronic conjunctivitis. The definite histological confirmation of only conjunctival lymphangioma was done from the diagnostic probatory biopsy not until ten years of symptoms and unsatisfactory treatment. RESULTS: In the girl with superficial conjunctival lymphangioma and in the patient with lymphangiomatosis, the follow-up was recommended only. In two patients with extraconal type of orbital tumor, the total or sub-total resection was performed. In the years of the follow-up, the remission of the disease was observed. In the patient with mostly intraconal type of the tumor, causing decrease of the visual acuity according to the optic nerve neuropathy and macular cystoid edema, the focused actinotherapy by means of linear accelerator treatment with the dose of 30 Gy after previous evacuation of chocolate cysts under ultrasound control. The regression of the tumor and normalized visual functions lasted for 17 years. CONCLUSION: As method of treatment of extraconal lymphangiomas, it seems, it is its resection, and in the intraconal localization of the tumor it is the focused actinotherapy by means of linear accelerator.Key words: orbital lymphangioma, conjunctival lymphangioma, lymphangiomatosis, tumor resection, linear accelerator actinotherapy.

[Efficiency evaluation of non-infectious uveitis]. / Hodnocení efektivnosti lécby neinfekcních uveitid.

Authors compared clinical and economic effeciency of treatment of the classical corticosteroids therapy and modern immunosuppressive treatment or their combination. Retrospective evaluation carried out in 2012, covering 2006-2011, monitored sample of 27 patients, 16 women and 11 men, 45 eyes with disabilities. The average age in the last year of follow-up monitoring was 30.2, ranging from 14 to 76 years. The mean duration of disease for the whole sample is 16.5 years with a range from 6 to 36 years. Three basic diagnoses were included in investigated group: chronic iridocyclitis in 59 % of eyes, intermediate uveitis in 30 % of eyes and sympathetic ophthalmia in 11 % of eyes. The optimal treatment not be determined, however, combined corticosteroid sparing therapy was the most beneficial to maintain in terms of visual acuity with minimal side effects and cost effectiveness. Successful outcomes of treatment were observed for intermediate uveitis, because the visual acuity improved in nine letetters of ETDRS chart in the study. Satisfactory treatment was proved in chronic iridocyclitis and sympathetic ophthalmia in general, because visual acuity improved in a few letters of ETDRS chart, in the same line as in the beginning of the six-year follow-up. Rounded average annual prize for treatment including pharmacotherapy, outpatient and inpatient care and laboratory follow-up was in chronic iridocyclitis € 990, in intermediate uveitis € 310 and sympathetic ophthalmia € 1550. Pharmacotherapy exceeded the financial appraisal of specialized medical and inpatient care in total cost. Key words: uveitis, corticosteorids, immunosuppression, costeffectivness.

[Anterior uveitis caused by electrical discharge in whole body injuries (fifteen years study)]. / Prední uveitida vyvolaná elektrickým výbojem u celotelového poranení (patnáctiletá studie).

AIM: To inform about clinical analysis of early ophthalmologic complication (uveitis) in patients sustained electric discharge injury. STUDY GROUP: The authors refer about fifteen years follow-up of pediatric patients at the Department of Burns Medicine, 3rd Medical Faculty, Charles University in Prague, Czech Republic, E.U., with electric discharge injury, in which the anterior uveitis was detected. Out of 43 patients after electric discharge injury, the always-unilateral iritis (iridocyclitis) was diagnosed in four (9 %) patients according to thorough going follow-up after first accidental diagnosis in the year 1998. Out of four boys aged 12 - 15 years, the first two were injured during the "play" - due to the contact with electrical trolley wire while running on railroad wagons roofs, and the two others were stuck by lighting under a tree by secondary electrical discharge. More serious skin burns were noticed in high-voltage current injury - 69 % or 55 % of body surface respectively, with the necessity of skin transplantation. The same was necessary in one boy injured by lighting with burns of 25 % of body surface, while the last one had on the skin the lighting signs only. In most of the patients, the resuscitation care due to unconsciousness and posttraumatic shock was necessary. The anterior uveitis was diagnosed subsequently, after initial preliminary diagnoses as conjunctivitis, episcleritis, or ophthalmia electrical. The iritis without visual function decrease was discovered in few days after the injury in three patients. Treatment and results: The inflammation was in these cases treated with short-term application of mydriatic and corticosteroid eye drops. Once only, the uveitis appeared after two months during the patients hospitalization and then the signs of iridocyclitis in the anterior chamber worsened and caused visual acuity decrease to hand movement in front of the eye. The condition was successfully treated by means of parabulbar betamethasone injection and long-term application of mydriatic and corticosteroid drops. CONCLUSION: Uveitis in electrical discharge injury of different origin is a rare early complication, which may be determined solely by regular ophthalmologic follow-up examinations of the patients.

[Treatment strategy of the lacrimal drainage system inborn obstruction. Part one - conservative and intervention procedures]. / Strategie lécby vrozené nepruchodnosti slzných cest I. cást - konzervativne intervencní postup.

The authors evaluated the successfulness of the conservative and intervention therapies combination in inborn lacrimal drainage system obstruction in a study group of 728 infants with 1154 eyes involved, treated at the Department of Ophthalmology, Faculty Hospital Královské Vinohrady (Kings Vineyards), Charles University, Prague, Czech Republic, E.U., during the period May 2004 - January 2011. The Fluoresceine Dye Dilution Test (FDDT) was used as the basic diagnostic test for the choice of the treatment procedure. The conservative therapy by itself, consisting of hydrostatic massages and application of germicide drops was helpful to canalize the lacrimal drainage system in 20 % of treated eyes, mostly in patients up to two months of age. The most of the patients (980 involved eyes), reached the Children outpatients of the Department of Ophthalmology at the age of approximately three months (average, 2.8 months). Since this age, the combination of the therapeutic irrigation with the probing, followed by the hydrostatic massages was indicated. The authors modified the probing technique according to their own experience gained during the endonasal intubation of the lacrimal drainage system by means of silicone tubing. At the phase of Bowmans probe entering the nasolacrimal sac, the probe was turned under the angle of 45 degrees to the vertical axis of the nose with simultaneous pressuring the probe against the orbital margin. By this procedure, the probe was introduced into the medial nasal meatus in the region of maxillary uncinate processus. Up to the end of the sixth month of age of the followed up infants, using the combination of conservative and intervention procedures, the lacrimal drainage system of 1036 eyes (90 %) was canalized. Out of 118 eyes with stenosis remaining even after 6 months of age, using the above-mentioned conservative therapy until the age of one year, 96 lacrimal drainage systems were further canalized. In the remaining 22 eyes (2 %) after the age of 1 year, the intubation of the lacrimal drainage system using the silicone tubing was performed. The total successfulness of our conservative intervention treatment strategy of lacrimal drainage system inborn obstruction up to the age of one year was 98 %.

[The application of Dysport® - the possibilities of the side effect on the eyelids position (a clinical - histological study)]. / Aplikace Dysportu® - moznost doprovodného vedlejsího efektu na postavení vícek (klinicko-histologická studie).

AIM: To inform about the possibility of negative influence of repeated application of the botulotoxine A derivate on the eye lid position with the changes of their tissue structure. At the same moment, the authors report on literature analysis of positive and negative influence of this neuro toxine from the medical point of view. MATERIALS AND METHODS: At the Department of Ophthalmology in the Faculty Hospital Královské Vinohrady, Prague, Czech Republic, E.U., there were surgically treated three patients after repeated applications of botulotoxine A derivates. The first case was bilateral ptosis of upper eyelids; the other two were indicated because of entropium with trichiasis of lower eyelids. In the medical history, there was recorded ten years lasting above-mentioned drug treatment for blepharospasm diagnosis in a 65 years old man introducing bilateral symmetrical ptosis. Because of the following frontal muscle involvement, and partial decreasing levator palpebrae muscles function, the positioning of the upper eyelids was treated by the aponeurosis plasty with good functional result. In two female patients, aged 72 and 90 years, the indication for successful surgical treatment was chronic entropium of lower eyelids; initially ineffectively treated by means of repeated intradermal injections of botulotoxin A derivates. RESULTS: Histological examinations of the excided skin and subcutis samples taken during ectropium plasties showed unfavorable and irreversible changes including especially scarring of the eyelid and atrophy of the striated muscles. CONCLUSION: The indication of botulotoxine A derivates application should be carefully weighted and the proper indication should be chosen. From the ophthalmologic point of view, blefarospasmus only is the appropriate diagnosis, and the relative indication is the temporary induced ptosis of the upper eyelid closing the interpalpebral fissure to prevent corneal changes in lagophthalmos of various etiologies as an alternative to the tarsoraphy. Always we have to consider the frequency of applications, because repeatedly used derivate of this neurotoxine causes irreversible changes in cutaneous and subcutaneous tissue.