The trabeculum as a drain in aphakic glaucoma.

Glaucoma of the aphakic patient is often difficult to treat. The authors present a new surgical technique which uses a portion of the trabeculum as a drain placed in the anterior chamber. Thirty eyes (19 aphakic and 11 pseudophakic) in 28 patients presenting refractory glaucoma were operated on by the same surgeon. Sixteen eyes had already undergone glaucoma surgery, 17 presented vitreous in the anterior chamber. The average postoperative follow-up was 18 months. Eighteen eyes (60%) needed no further treatment, 6 eyes (20%) were stabilized with a local treatment, 6 eyes (20%) remained hypertonic. This new surgical technique, which uses a portion of the trabeculum as a drain, allows for long-lasting filtration in the aphakic or pseudophakic patient with refractory glaucoma.

[Trabeculo-intendation. A new surgical treatment of glaucoma of the aphakic eye]. / La trabéculo-indentation. Nouveau traitement chirurgical du glaucome de l'aphake.

INTRODUCTION: Glaucoma of the aphakic patient is often difficult to treat. Classical surgical management is limited by poor quality conjunctiva and by the presence of the vitreous gel opposite the fistula. We present a new surgical technique which uses a portion of the trabeculum as a drain placed in the anterior chamber. MATERIAL AND METHODS: Thirty eyes (19 aphakic and 11 pseudophakic) in 28 patients presenting refractory glaucoma were operated on by the same surgeon. Sixteen eyes had already undergone glaucoma surgery, 17 presented vitreous in the anterior chamber. Average post-operative follow-up was 18 months. RESULTS: Eighteen eyes (60%) needed no further treatment, 6 eyes (20%) were stabilized with a local treatment, 6 eyes (20%) remained hypertonic. CONCLUSION: This new surgical technique, which uses a portion of the trabeculum as a drain, allows for long lasting filtration in the aphakic or pseudophakic patient with refractory glaucoma.

[Sensitivity of the retinal pigment epithelium to spindle poisons]. / Sensibilité du cytosquelette de l'épithélium pigmentaire rétinien aux poisons du fuseau mitotique.

PURPOSE: The function of RPE is well known in PVR. Pharmacological agents have been extensively studied both experimentally and clinically. Few reports have detailed the interactions of antimitotic drugs on the microtubule network. The aim of this study is to visualize by indirect immunofluorescence the effects of colchicine and paclitaxel on the microtubule network of cultured pig RPE cells in interphase. METHODS: Pigs were killed at the slaughter-house, their eyes were enucleated. RPE cells were isolated and cultured. RPE cells were plated onto glass cover-slips at a density of 2,000,000 cells/ml, cultured and treated with the drugs during 4 and 24 hours at 37 degrees C at different concentrations. Immunofluorescence reaction was developped using antitubulin and fluoresceinated anti-mouse antibodies. The cytoskeletons were visualized employing a Zeiss photomicroscope equipped with epiilumination, a 63 x lens and appropriate filters for fluoresceine. RESULTS: The cytoplasmic microtubules of RPE cells were disrupted in a concentration and time-dependant manner by colchicine. Between 10 and 100 nm Veveral degrees of depolymarization of the microtubule network were observed. Paclitaxel between 1 micron and 10 microns was found to induce several degrees of microtubule "bundling" after 4 and 24 hours of incubation. Actin network was modified neither by colchicine and paclitaxel used in the same conditions. CONCLUSIONS: The results show that low doses of antimitotic drugs inhibit the microtubule network formation by depolymerization (colchicine) or stabilize it (paclitaxel). These actions inhibit cell division, which is one of the mechanisms implicated in PVR.

[Treatment of choroid melanoma by Gamma-Knife radiosurgery]. / Traitement du mélanome choroïdien par radiochirurgie Gamma-Knife.

Conservative treatment of uveal melanomas by Gamma Knife Radiosurgery is based on the use of cross fire technique with 201 Cobalt60 sources. A following of 13 months is available for the first case operated by Gamma-Knife Surgery in France. Technical baselines and one year preliminary results are reported. The diagnosis of uveal melanoma T3NOMO was established by converging results of clinical examination, angiography and echography. The definition of the target was based on stereotactic MRT examination. We delivered a dose of 50 Gys to the marginal isodose (50%). Today, one year after treatment the tumor decreased, the visual function was preserved. There were no side effect or complication.

[Experimental tolerability of perfluorodecalin in prolonged intraocular tamponade]. / Tolérance expérimentale de la perfluorodécaline en tamponnement prolongé intraoculaire.

BACKGROUND: Perfluorocarbon liquids are used in vitreoretinal surgery due to their high specific gravity. Studies of retinal tolerance to prolonged tamponade with these liquids are discordant. Our experimental study uses a highly purified perfluorodecalin molecule (DKline) for prolonged retinal tamponade. The retinal lesions observed are described and analyzed. MATERIAL AND METHODS: [corrected] Twenty pigmented rabbit eyes were studied. 1.2 to 1.5 ml of DKline were injected into the vitreous cavity after pneumatic compression. Histological and ultrastructural studies were performed after tamponade lasting 48 hours (5 eyes), 12 days (6 eyes), 21 days (5 eyes) and controls (4 eyes). RESULTS: After 48 hours: vacuolization of the nerve fiber layer is observed without ultrastructural changes; undulation of the photoreceptor outer segments is seen. After 12 days: vacuolization and undulation increase, with modifications in the junction between photoreceptors and the pigment epithelium. After 21 days: major vacuolization is seen, with disorganization of the photoreceptor architecture. The inner limiting membrane is respected and no surface proliferation is observed. CONCLUSION: DKline used in prolonged tamponade induces histological lesions as early as 48 hours; they increase with time. The nerve fiber and photoreceptor outer segment layers are the most severely affected. These lesions appear to be mainly of mechanical origin. Prolonged retinal tamponade with DKline would not seem possible.

Effects of strabismus surgery on refraction in children.

We assessed 115 eyes of 59 children with esotropia 2-3 months postoperatively to evaluate the effects of strabismus surgery on refraction. Three variables were measured: spherical equivalent, and cylinder power and axis. The mean changes in spherical equivalent were non-significant. The axis of postoperative astigmatism moved towards 'with-the-rule', thus improving refraction. The amount of recession and the consequent changes in cylinder power were inversely related. The results showed a significant change in cylinder axis after recession of the inferior oblique. Recession-tucking procedures led to the largest changes in cylinder power.

Experimental tolerance to perfluorodecalin used in prolonged intraocular tamponade.

The authors report the results of an experimental study of a series of 16 rabbit eyes that underwent prolonged tamponade by a liquid perfluorocarbon (LPFC). After vitreous compression by C3F8, a complete gas/LPFC exchange is performed and left in place for 48 h, 12 days and 21 days. Study of the retina by light and electron microscopy showed numerous lesions: vacuolization in the nerve fiber layer, progressive defects of the outer photoreceptor segments and presence of pseudomyelinic bodies in the inner plexiform layer. The axonal fiber loss is shown by a specific marker. The analysis of the results underlines the mechanical toxicity of LPFCs used in prolonged tamponade, which are too heavy for the neurosensory retina.

Ocular findings in trigonocephaly.

BACKGROUND: Trigonocephaly, caused by premature closure of the metopic suture, is a rare form of craniosynostosis. The aim of this study was to assess the visual outcome in children operated on for trigonocephaly. METHODS: We present eight cases of children with trigonocephaly surgically corrected by the same craniofacial technique. CT with 3D reconstruction was performed in all cases. Genitori defined three types of trigonocephaly according to the severity of the deformity of the skull base only types II and III were included in this study directed at evaluation of the ocular disorder. A complete eye examination was performed on all children by the same observer, with a follow-up of 2-6 years. RESULTS: 3D-CT reconstruction of the skull base showed that the frontozygomatic region was affected by the deformation. Ocular examination showed considerable astigmatism in most children with late operation. A low degree of strabismus was observed in most children. CONCLUSION: This study demonstrated that reconstructive surgery should be performed by the age of 6 months, given the immaturity of the visual system up to that time. Close cooperation between neurosurgeons, pediatricians and ophthalmologists is of paramount importance in order to prevent this bone deformation exerting an adverse effect on visual development. The ophthalmologist must possess a basic understanding of the various craniosynostoses.

Refractive error and ocular motility in plagiocephaly.

Plagiocephaly, which is caused by premature closure of one of the coronal sutures, leads to fronto-orbital asymmetry. The aim of this work was to study the repercussions of orbital deformation on the visual system. Twenty-one patients presenting with plagiocephaly at birth and operated on by the same craniofacial technique (bilateral approach with translation and advancement of the entire involved orbits) were included in the study. All of the patients were examined by clinical anthropometry with three-dimensional reconstruction and underwent complete eye examination by the same observer. Follow-up after craniofacial surgery ranged from 15 months to 4 years. In the last few years, three-dimensional reconstruction has shown that the anatomic region affected by the deformation is the frontozygomatic region and has thus made it possible to advance to another theory on the origins of ocular problems. The severe effect of orbital anomalies on the development of the visual system (binocular vision, strabismus with amblyopia, refractive errors) has been emphasized in the literature. The present study shows that the scheduling of reconstructive surgery is fundamental and must not exceed 6 months, given the immaturity of the visual system up until this time. This means that the ophthalmologist must be able to recognize the various craniostenoses in order to schedule reconstructive surgery as soon as possible. Cooperation between the neurosurgeon and the ophthalmologist is of paramount importance if the pathogenic effects of this bone deformation are to be stopped and proper visual development preserved.

The genetics of retinoblastoma.

Retinoblastoma is a malignant tumor of the eye that affects about one in 20,000 young children and occurs as hereditary and non-hereditary (sporadic) forms. It results from successive loss or inactivation of the two alleles of the Rb1 gene, located in 13q14. A chromosomal deletion in 13q14 is revealed by cytogenetic investigation in about 5% of affected patients. Molecular studies have confirmed that inactivation of both alleles of the Rb1 gene, even by point mutation, is required for tumorigenesis, leading to the concept of antioncogenes or tumor suppressor genes. The protein (p110RB) produced by the Rb1 gene is involved in cell cycle regulation. Absence or abnormal forms of the protein may result in deregulation of the cell cycle and subsequent cell proliferation. Association of p110RB with viral oncoproteins may be a step in tumorigenesis. Differences in penetrance and expressivity among families, could be explained by balanced insertional translocation and by defects of the Rb1 gene, which codes for a shortened Rb protein with partial oncosuppressor function. Techniques allowing analysis of Rb1 mutations can be successfully used to predict or exclude the development of retinoblastoma in newborn infants.

Walker-Warburg syndrome: a report of 3 cases.

Walker-Warburg syndrome is a congenital malformation syndrome of unknown etiology which is characterized by fatal neurological lesions. It was first described by Walker in 1942 as involving agyria, hydrocephalus and eye malformations. Its etiology has been discussed in all of the articles on the subject in the literature, but the majority of the authors describe it as an autosomal recessive syndrome. Ultrasonography plays a key role in detecting a cephalic anomaly by prenatal diagnosis as in our 2 cases. The aim of this article is to report 3 new cases of Walker-Warburg syndrome in two families. Knowledge of this syndrome emphasizes both the need for ultrasonographic observation and genetic counselling for families at risk.

Ocular growth in the fetus. 1. Comparative study of axial length and biometric parameters in the fetus.

The knowledge of ocular growth during fetal life, when compared with other fetal biometric parameters, could not only provide a better definition of malformation syndromes but could also give a better understanding of certain pathological processes in premature babies and in newborns. As the literature concerning prenatal ocular dimensions contains few data, the aim of this study was to measure the axial length of the globe (AL) in fetuses and compare this measurement with their gestational age, weight, height, head circumference (HC) and thoracic circumference (TC) in order to compile a reference table. In the present study, 76 globes from 38 fetuses (18-41 weeks gestational age) from the Department of Pathology (Timone University Hospital, Marseille) were examined. Ultrasonography A and B were used to measure the AL, and a pathological examination determined fetal weight, HC, TC and height. We were interested to find out which of the parameters studied would give the best correlation with ocular growth. Statistical analysis showed that HC remained the most discriminant factor and correlated best with ocular growth. We thus obtained an equation for ocular size according to HC that could serve as a basis for detecting pre- or postnatal ocular defects.

Ocular growth in the fetus. 2. Comparative study of the growth of the globe and the orbit and the parameters of fetal growth.

In a previous study, we showed that the growth of the eye during fetal development compared with the other parameters of the fetus was above all connected to the head circumference, which appeared to be the most discriminant measurement. In a second study, we measured the growth of the orbit of the fetus in order to compare it with the growth of the globe and the cranial circumference. Another 60 eyeballs of 30 fetuses of 18-41 weeks gestational age were examined. The corneal diameter (CD) of the cornea was a measurement added to those used in the method in the previous study, and orbital radiography was carried out: the parameters used were the same as in the previous study measured in relation to the CD, orbital diameter (OD) and the biparietal diameter (BPD). The aim of this study was to show the links between the variations in the measurements and to estimate them in relation to fetal growth. The results confirm those of the previous study, and this study also shows that, in estimating the head circumference, the OD and CD are the most accurate indicators. This study was also concerned with the BPD: the best correlation is obtained with the OD, which can be estimated accordingly from the BPD. Although the OD is not in an area studied by ultrasonography (highly dependent on the sectional plane), this study shows that it should perhaps be reconsidered in the prenatal diagnosis of orbital malformation. It would then be necessary to take into account not only the BPD but also the relationship between the OD and the BPD.

[Changes in the visual fields following filtering surgery in advanced glaucoma]. / Modification du champ visuel au décours des interventions filtrantes dans les glaucomes évolués.

The authors report about the results of a preliminary study concerning the changes of glaucomatous field after glaucoma filtering surgery in patients with advanced glaucoma. Mesopic campimetry had been selected because of its precision for central field defects. The first results appear to be favourable. No patient lost central vision suddenly after surgery. The authors have tried to research predictive risk factors. The factors that seem to be the most important to consider are the preoperative campimetric shape and the angle anatomy.

[Anterior chamber cleavage syndromes]. / Les syndromes de clivage du segment antérieur.

Authors analyse the anatomic findings in the anterior chamber cleavage syndrome and emphasize necessity of genetics (heredity being well known) and supervision for detecting glaucoma which occurs in about 50% of these patients and usually appears between 5 and 30 years of age. (Juvenile glaucoma).

[Endogenous bacterial endophthalmitis. Report of 3 cases]. / Endophtalmie bactérienne endogène. A propos de trois observations.

Since the antibiotic era, endophthalmitis has been a rare complication of bacterial septicemia. The authors report hereby 3 cases of endogenous bacterial endophthalmitis. Both eyes were involved in one case. Causative bacteria were identified in blood. Cultures were positive respectively for Streptococcus pneumoniae, Staphylococcus aureus and Klebsiella pneumoniae. All patients received intravenous antibiotherapy, once intravitreal antibiotic was injected. Clinical manifestations were three times panophthalmitis with dramatic course. In one case, only the anterior segment was involved. The course became complicated with a cataract, but the patient finally recovered. Although several clinical types with distinct prognoses can be defined, endogenous bacterial endophthalmitis remains a devastating situation. Treatment is controversial because of the uncertainty about the value of intravitreal antibiotics and vitreous surgery.

[Bilateral serous detachment of neuroepithelium of the posterior pole disclosing acute leukemia]. / Décollement séreux bilatéral du neuroépithélium du pôle postérieur révélant une leucémie aiguë.

A 51 year-old woman presented with sudden loss of vision secondary to serous neuroretinal detachments of both maculas. Fluorescein angiography revealed multiple hyperfluorescent pin-point dots in the early phases. The areas of fluorescein hyperfluorescence became more diffuse as dye leaked into the subretinal space. The diagnostic of acute monoblastic leukemia was made. Following treatment, her vision improved. Fundus examination at that time showed resolution of the bilateral serous retinal detachment. She died one month after the onset of visual complaints and autopsy was refused. There have been 14 previous reports of acute leukemia with serous retinal detachment. In most cases, retinal detachment occurred as the presenting sign or during relapse of the systemic disease. It was often bilateral and located in the posterior pole. Histopathologic studies showed leukemic infiltration of the choroid with areas of degeneration and proliferation of the retinal pigment epithelium. Angiographic findings are similar to what is observed in choroidal ischemia. The relationships with macular serous retinal detachment and choriocapillaris occlusion are discussed.

[Retinal detachment in pseudophakia. Results apropos of 74 cases]. / Le décollement de rétine du pseudophake. Résultats à propos de 74 cas.

If the pseudophakic retinal detachment presents certain analogies with aphakic detachment; it as however a certain specificity: higher frequency of macular involvement, of proliferative vitreoretinopathy, of detachments without tears. In addition pseudophakic detachments must be analysed according to the mode of extraction and implantation.

[An uncommon clinical form of phakolytic glaucoma]. / A propos d'une forme clinique inhabituelle de glaucome phakolytique.

A 85 year old man was admitted with an acute endolphtalmitis, a high intraocular pressure (60 mm Hg) and a visual acuity with only light perception. The diagnosis was a phacolytic glaucoma by diffusion of lens proteins through the small preexisting perforation of the lens capsule. The lens was removed by an intracapsular extraction without intraocular lens. The intraocular pressure was normal on the first postoperative day and the visual acuity was improved to 6/10 P2.