[New therapeutic approach of keratoconus with intracorneal ring segments aided by femtosecond laser (Tecnolas Perfect Vision): indications, operating technique and results]

OBJECTIVE

To assess the results of intracorneal ring segment implantation assisted by the Tecnolas Perfect Vision(®) femtosecond laser (Heidelberg, Germany).

SETTINGS

Retrospective observational study.

METHODS

The patients were operated on with the Tecnolas Perfect Vision(®) femtosecond laser. The following parameters were evaluated before and after surgery: uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), corneal topography, wavefront analysis, and central corneal thickness. The Wilcoxon test was used for statistical analysis.

RESULTS

Seventeen eyes of 15 patients were included. The mean follow-up was 6.9±0.71 months. Significant improvement of UCVA and BCVA was observed in 82.35% (P=0.027) and 94.12% (P=0.003) of the eyes, respectively. The subjective refraction showed a significant decrease of the sphere from -10.29±5.54 to -6.5±5.03D (P=0.002). The subjective cylinder significantly decreased from 5.43±3.20 to 3.69±2.30D (P=0.026). The SAI also decreased significantly (P=0.011).

CONCLUSION

Femtosecond-assisted intracorneal ring segment implantation is an effective treatment for corneal ectasia. Further studies are needed to improve surgical parameters and outcomes.

[New approach for determining the damage level of biological tissues using femtosecond laser: advantages and application to corneal surgery]

INTRODUCTION

Optimization of femtosecond laser characteristics in corneal surgery is still needed to improve clinical results. In this study, we describe an original characterization technique able to measure laser damage of corneal tissues precisely and to provide complementary physical results on the laser-matter interaction.

METHOD

A femtosecond laser was used to damage corneas not suitable for graft. The epithelium and the Bowman layer are exposed to a set of different single-shot fixed laser fluences. Optical microscopy can determine the probability of laser damage on the corneal surface. The high damage threshold (minimum fluence systematically damaging the cornea) roughly fixes the operating laser fluence conditions, while the low damage threshold sets the maximum laser fluence level preserving tissue integrity (safety level).

RESULTS

We precisely evaluate the damage fluence threshold of a tissue, using a statistical approach coupled with optical microscopy analysis. This technique gives essential information on laser-tissue interaction with a high rate of confidence. For corneal epithelium and the Bowman layer, we determine the maximum laser fluence level preserving tissue integrity (safety level) and the minimum fluence level systematically damaging the tissue. High and low threshold fluences of epithelium and the Bowman layers are (5.6 ± 0.4 J/cm(2); 2.7 ± 0.1 J/cm(2)), and (7.1 ± 1.1 J/cm(2); 3.4 ± 0.1 J/cm(2)), respectively.

CONCLUSION

These data constitute determinant parameters for clinical applications, since they determine a working window providing the minimal effective irradiation dose that is mandatory for the development of high-quality laser-cutting surgery processes with minimized side effects.

[Anterior segment analysis using OCT3]

PURPOSE

Optical coherence tomography has been used for many years, in particular in the field of the retinal imaging, and is a promising technique in the analysis of the anterior segment, providing a similar resolution to histology for ocular tissue.

MATERIAL AND METHODS

We present a collection of images obtained with the OCT3 (Carl Zeiss Meditec, Dublin, CA), with parameters set to obtain good-quality images of the iris and corneal structures.

RESULTS

The OCT provides detailed analysis of the cornea, precise assessment of the dimensions and locations of corneal lesions - in the anterior-posterior plane as well as transversally or obliquely - with 10-microm precision, and the study of the iridocorneal angle and its dynamics.

DISCUSSION

Using the highly precise OCT3 for retinal imaging, it is possible to obtain good-quality anterior segment imaging, which makes the device highly versatile and thus increases reasons for acquiring this type of apparatus.

CONCLUSIONS

OCT3 users should not neglect this potential of the device, already in wide use for examining the retina.

Kératoplastie lamellaire antérieure assistée par laser femtoseconde

INTRODUCTION

Automated lamellar keratoplasty remains a challenging surgical technique because of surgical difficulties and is associated with a high rate of complications. The precision of the corneal cut at any corneal depth with the femtosecond laser is an important improvement in this technique. We report the first case of femtosecond-assisted anterior lamellar keratoplasty.

MATERIAL AND METHODS

A 63-year-old woman with anterior stromal dystrophy underwent femtosecond laser-assisted ALTK on the left eye. A donor lenticula was prepared from a corneoscleral rim utilizing the Femtec 20/10 Perfectvision femtosecond laser device and an artificial anterior chamber (Moria, Antony, France). The anterior lamellar cut was also performed on the patient's eye with the femtosecond laser.

RESULTS

Postoperative examinations showed a well-adapted graft with a clear interface. OCT III (Carl Zeiss Meditech, Dublin) measurements showed a corneal pachymetry of 713 microm associated with a regular posterior bed and a central thickness of 132 microm.

DISCUSSION

Femtosecond laser corneal cutting may offer greater safety, reproducibility, predictability, and flexibility. The risks of irregular cutting and microperforation are reduced. A better graft congruence can limit the risk of secondary displacement and the smooth interface should improve visual results.

CONCLUSION

Donor lenticulae and corneal cuttings performed with the Femtec 20/10 Perfectvision( femtosecond laser device can be used in the successful management of eyes requiring anterior lamellar keratoplasty. Further studies are needed to evaluate outcomes of this procedure.

Oblitération de l’artère centrale de la rétine secondaire à une dissection de la carotide interne sur fibrodysplasie artérielle

INTRODUCTION

We report a case of a 66-year-old woman presenting a central retinal artery occlusion with no cardiovascular risk factor, with assessment using supra-aortic artery ultrasonography showing total internal carotid artery thrombosis.

OBSERVATION

When vascular thrombosis risk factors are absent, more in-depth assessment such as a supra-aortic artery angioscan can provide the diagnosis of arterial dissection on arterial fibromuscular dysplasia.

CONCLUSION

Central retinal artery occlusion is a rare but severe pathology. Therefore it is very important not to neglect the etiological assessment, because it can be the revealing element of a severe pathology.

[Bilateral corneal endothelial decompensation after postsepticemia coma]

We report a case of unexplained bilateral corneal endothelial decompensation after a coma. A 71-year-old man with no medical history presented with bilateral endothelial decompensation that required penetrating keratoplasty of the left eye combined with cataract surgery. This coma was caused by septicemia originally due to staphylococcus infection following catheter placement in preparation for a CT scan. Visual acuity of the left eye was 20/400 and 20/100 in the right eye when the patient awoke from the coma. After examination, we noted only stromal thickening and Descemet membrane folds causing corneal edema predominating OS. The rest of the exam was normal. Six months after surgery, visual acuity improved to 20/25. The most probable physiopathological mechanism of this decompensation is an iatrogenic complication from drugs administered during the patient's stay in intensive care (oxacillin), but we cannot rule out direct aggression of a bacterium or its toxin or the decompensation of a preexisting pathology.

Metabolic factors and the foveal avascular zone of the retina in diabetes mellitus

AIM

To study the foveal avascular zone (FAZ) of the central retina in diabetic patients with retinopathy having undergone metabolic evaluation.

METHODS

One hundred and ten digital fluorescein angiograms were chosen from our digital image bank after cross matching diabetic patient lists of the ophthalmology and endocrinology departments of our institution. The patients had undergone day visits with systemic, biological and ophthalmologic evaluation, including digital fluorescein angiography.

RESULTS

Sex ratio was M 62/F 48. Average age was 52.4 years (+/- 13.8) with 44 type 1 diabetics and 66 type 2. Retinopathy was present in all patients (54 background (BDR), 30 pre-proliferative (PPDR), 26 proliferative (PDR)). Age was positively correlated with FAZ grade (47.3 years +/- 13.2 for normal FAZ, 53.8 years +/- 13.7 for abnormal FAZ, P=0.03). Lipid profile showed a protective tendency of the Apo A1 fraction of cholesterol on macular vascularization (1.7 gr./l in normal FAZ patients vs 1.43 gr./l in abnormal FAZ patients, P=0.004). Body mass index was negatively correlated with macular ischemia (28.11 if FAZ not severely altered, 25.97 if FAZ severely altered, P=0.03).

CONCLUSIONS

We found possible relations between BMI and Apo A 1 cholesterol and macular vascularization which may warrant further investigation.

Foveal avascular zone in diabetic retinopathy: quantitative vs qualitative assessment

PURPOSE

To describe the relations between foveal avascular zone (FAZ) size and outline in patients presenting diabetic retinopathy.

METHODS

110 high-quality fluorescein angiograms from 110 diabetics were chosen from our digital retinal image databank. Patients with significant media opacities, macular scars, macular hard exsudates, high ametropia, and associated macular pathology were excluded. Both FAZ perimeter and surface area were measured with image analysis software. FAZ outline was graded according to ETDRS report Number 11 (from 0=normal to 4=capillary outline completely destroyed). Data were compared to that of 31 healthy controls. FAZ surface in diabetics was compared to that of controls and FAZ surface was compared to FAZ grade, FAZ perimeter and retinopathy stage in diabetics. Quantitative variables were compared using the U-test of Mann-Whitney or Kruskal-Wallis test and correlations between quantitative variables were estimated with the Spearmann coefficient.

RESULTS

All patients presented diabetic retinopathy (54 BDR, 30 PPDR, 26 PDR). FAZ size was larger in diabetics than controls (P<0.001). In diabetics, FAZ size increased with FAZ grade (P<or=0.006 except between grades 1 and 2=NS) and with retinopathy stage (P<or=0.024). As retinopathy advanced, there was a higher proportion of altered FAZ outlines (P=0.003).

CONCLUSIONS

This study confirms capillary alteration to be the cause of increase in FAZ size in diabetics and presents an alternative evaluation method of the FAZ to FAZ size measurement. No qualitative studies using the ETDRS FAZ grading scale have been performed to our knowledge.

[Quantitative and spatial analysis in image processing: study of drusen distribution from the foveal center in age-related macular degeneration]

Angiofluorograms were obtained from 58 patients presenting posterior pole drusen due to age-related macular degeneration. These frames underwent image processing by morphological mathematics algorithms. The detection sensitivity of this algorithm is 78%. We present a quantitative and spatial analysis of drusen distribution from the foveal center in the form of a graph. This technique may allow for multi-date comparisons, by using a graphic representation of this risk factor for age-related macular degeneration.

[Teaching phacosection in a tropical setting]

PURPOSE

The aim of this study was to prospectively evaluate the training of a Malagasy ophthalmologist, already proficient in classic manual extracapsular cataract extraction (ECCE), in a small incision manual technique (phacosection).

MATERIALS AND METHODS

Within the activity of the Sight First program to fight blindness in Madagascar, the ophthalmologist of Majunga recruited patients presenting total white cataracts. These patients were operated by phacosection using the local hospital's usual instrumentation along with two specific phacosection instruments and extra single-use material (a precalibrated 3.2 mm knife and viscoelastic products). Peribulbar anesthesia with eye pressure was provided. Postoperative follow-up (visual acuity and corneal status) was conducted on days 1, 7 and 30.

RESULTS

Forty-four eyes were operated, the first seven by the instructor assisted by the local ophthalmologist, the next 36 by the local ophthalmologist assisted by the instructor. Five postoperative complications were noted: two cases of posterior capsular rupture (one during implantation) and three cases needing reoperation with aspiration of residual cortical masses. Induced astigmatism was low and visual rehabilitation was good, with all corneas clear at day 30.

DISCUSSION

The results are quite acceptable given the training period, with only two marked complications (one not related to the operative technique) and good visual rehabilitation in less than 2 weeks. This small incision technique allowed reduction of induced astigmatism and risk-free management of total white cataracts (independent of operator).

CONCLUSION

Small incision manual ECCE by phacosection is a safe, possible management option for difficult cataracts in a tropical setting with only a small increase in cost. Moreover, the training of an ophthalmologist mastering classic manual ECCE appears rapid and risk-free for patients.

Endophtalmie à Penicillium chrysogenum

We report a case of Penicillium chrysogenum endophthalmitis after penetrating ocular trauma in a 9-year-old child, describing the initial management and the therapeutic adaptation after biopsy culture. After a review of endophthalmitis treatment, we discuss mycotic endophthalmitis treatment and recommend the use of intravitreal antibiotics. In this case, we used amphotericin B to treat the fungal disorder with success.

Métastase oculaire d’un mélanome cutané

We report a case of vitreal metastases from cutaneous melanoma. We describe the clinical findings and the histological aspects of the lesions, which allows us to discuss the diagnosis of masquerade syndrome and highlight the diagnostic importance of vitreous biopsy.

Occlusion de branche veineuse rétinienne révélatrice d’une maladie de Takayasu

We report a case of branch retinal vein occlusion in a 28-year-old woman that revealed Takayasu's arteritis. Somatic examination showed humeral blood pressure asymmetry and an abdominal murmur; a biological inflammatory syndrome was noted. Abdominal aortography showed marked stenosis of the superior mesenteric artery. Three of the six diagnostic criteria of Takayasu's arteritis were present in our patient, sufficing to make the diagnosis. This is the first case reported of branch retinal vein occlusion revealing Takayasu's arteritis. It is to be added to the List of atypical initial manifestations of Takayasu's arteritis such as anterior ischemic optic neuropathy. Branch retinal vein occlusion is a rare enough occurrence in a 28-year-old patient to warrant further clinical investigation.

[Indocyanine green angiography in age-related macular degeneration]

Indocyanine green ocular angiography was developed more than 30 years ago, but has been used commonly for less than 10 years. In exudative age-related macular degeneration, certain cases of occult neovascularization may be converted into well-defined cases, in theory allowing treatment of more patients. Neovascularization is observed as either focal hyperfluorescence (hot spot) or diffuse hyperfluorescence (plaque). Scanning laser ophthalmoscopy imaging allows for better visualization of feeder vessels, allowing even more selective treatment. Even though a multicentric, prospective, randomized study has not yet been conducted, a number of pilot studies are very encouraging concerning indocyanine green angiography-guided laser treatment.

Simple, reliable and fast spectrofluorometric method for determination of plasma Verteporfin (Visudyne) levels during photodynamic therapy for choroidal neovascularization

Photodynamic therapy with Verteporfin, a potent photosensitizer dye, is a very effective treatment for age related macular degeneration due to choroidal neovascularization. Photodynamic therapy offers the potential for selective tissue injury in part attributable to preferential localization of Verteporfin, administrated by intravenous infusion, to the choroidal neovascularization complex and irradiation of the complex with non-laser thermal light at 690 nm resulting in at least temporary thrombosis and vessel closure. Verteporfin is a benzoporphyrin derivative monoacid ring A formulated as a unilamellar liposome. In the blood Verteporfin is associated with lipoprotein fractions and is rapidly cleared via a receptor-mediated uptake mechanism due the high expression of LDL receptors in neovascular tissues. Verteporfin was undetectable in plasma 24 hr after infusion of the recommended dose: 6 mg/m2 of body surface area. The main side effect is photosensitivity of skin which is usually short-lived (24-48 hr) with a low incidence (2.3%). As skin photosensitivity depends on circulating rather than tissue drug levels, we investigate the possibility of developing a simple, fast and reliable spectrofluorometric method to measure plasma Verteporfin levels. Fluorescence emission spectrum (550-750 nm) of 1:10 saline diluted plasma with lambda exc=430 nm showed a characteristic emission peak at 692 nm, the height being proportional to the Verteporfin levels. The sensitivity is around 100 ng/ml and the pharmacokinetics of Verteporfin has been studied from 0 to 5 hr after infusion in six patients older than 65 years with age-related macular degeneration.

[Bilateral exophthalmos diabetes insipidus: Erdheim-Chester disease. Clinical and radiological findings]

The authors report a case of a 61-year-old man presenting bilateral exophthalmos and diabetes insipidus. A retro-orbital biopsy revealed nonspecific fibrocollagenic infiltration. The diagnosis of Erdheim-Chester disease was evoked when a multivisceral affection (retroperitoneal and mediastinal periaortic fibrosis) with specific bone localization became evident. The histopatholgical study of a bone biopsy showed xanthogranulomatous infiltration. The patient died a few months later of an intercurrent infection.

Comparative morphology of epicorneal conjunctival membranes in rabbits and human pterygium

A rarely described ocular lesion in the rabbit is presented following the observation of four cases. It is a membrane of conjunctival origin that advances progressively, without adhering, towards the center of the cornea. Clinically the lesion in rabbits looks like pterygium in man, but with several differences: in rabbits, the conjunctival fold is absolutely free and does not penetrate into the superficial corneal layers. It originates from all the limbal circumference in a symetric growth. The cornea itself remains unaltered. The fold consists of fibroblasts and collagen. The microscopic findings suggest the lesion is possibly of a collagenous dysplasia.

Caterpillar setae-induced acute anterior uveitis: a case report

PURPOSE

To report uveitis secondary to ocular penetration of caterpillar hairs (setae).

METHODS

Case report. A documented attack of acute anterior uveitis was caused by initially overlooked penetration of caterpillar setae.

RESULTS

A 66-year-old man presenting with unilateral hypertensive keratouveitis was treated with antiherpes simplex medication (along with local anti-inflammatory and cycloplegic agents) after anterior chamber paracentesis and serologic testing. Laboratory testing was negative. Resolution occurred after 5 days, and corneal clearing showed a predescemetic caterpillar seta.

CONCLUSION

Patient history taken in an anterior uveitis setting should include gardening habits and searching for possible exposure to insects or arachnids.

[Surgical follow-up and importance of information and consent on behalf of patients undergoing esthetic blepharoplasty]

INTRODUCTION

Plastic surgery of the eyelids aims to improve the cosmetic aspect while correcting either an excess of palpebral skin, or an orbital septum dehiscence with fat porf2p4on in the palpebral spaces, after evaluation of horizontal and vertical palpebral laxity.

PATIENTS AND METHODS

The authors describe follow-up of upper and lower lid blepharoplasty by cutaneous and conjunctival approaches respectively, with case descriptions and a review of the literature.

RESULTS

A "calendar" is made of the different phases of healings, to the final aesthetic aspect desired.

DISCUSSION

The patients wishes as to technique and results of blepharoplasty must be discussed and understood. The surgeon must forewarn of eventual per and postoperative complications (hemorrhage, infection), but also the usual follow-up (hematoma, edema, scarring ...). This allows to avoid aggravation of the patients "legitimate" worrying when he/she looks in the mirror!

CONCLUSION

The authors underline the importance of patient information concerning the pre and postoperative aspects of aesthetic blepharoplasty.

[Brown syndrome: current status]

PURPOSE

Brown's syndrome is a form of anatomical strabismus, or retraction syndrome. It is defined by active and passive limitation of upward gaze in adduction in the field of action of the inferior oblique muscle. The etiology of Brown's syndrome remains unknown. The defect lies at the level of the superior oblique's tendonis trajectory via the trochlea. We studied the frequency of clinical signs and results after surgery in patients presenting congenital Brown's syndrome.

PATIENTS AND METHODS

Our study involved 18 children. They all underwent complete ophthalmological examination with orthoptic testing, pre and postoperatively.

RESULTS

Neither sidedness nor predominance of sex was noted. Compensatory head posture was noted in 7 of 18 cases. Limitation of upward gaze in adduction was a constant finding, with a positive duction test. Eleven cases underwent superior oblique recession. Results of surgery were satisfactory, with resolution of compensatory head posture in over 80% of cases.

CONCLUSION

The etiology of congenital Brown's syndrome remains unknown. The different surgical techniques give inconstant results. Operative indication is decided only when in the presence of well defined clinical manifestations: CHP, deviation in primary position with alteration of binocular vision.

[Ocular toxoplasmosis: value of immunoblotting for the determination of an intra-ocular synthesis of antibodies]

The aim of this study was to demonstrate the intraocular synthesis of specific antibodies in case of Toxoplasma retinochoroiditis on the basis of immunoblot analysis. Vitreous or aqueous and serum were analyzed by immunoblot in four cases of toxoplasmic chorioretinitis. The same assays were performed on samples from 16 control subjects. Immunoblot analysis of serum and ocular fluid from patients with toxoplasmic chorioretinitis showed IgG and IgA specific antibodies. Recognition patterns were different and demonstrated neo-antibodies in ocular fluid. In control samples only IgG were found and the same patterns were observed in the two compartments. Immunoblot is a useful technique to demonstrate the local synthesis of antibodies in ocular toxoplasmosis by comparison of recognition patterns between serum and ocular fluids. Integration of immunoblot patterns allows quantification of antibodies specific for each Toxoplasma antigen in the two compartments.

Diffuse choroidal hemangioma: report of a clinicopathological study in a 4-year-old boy

The authors examined the clinicopathologic features of a 4-year-old boy with a diffuse choroidal hemangioma, yet without any features of the Sturge-Weber syndrome. The tumor occurred as a grayish intraocular mass with an overlying retinal detachment and was highly reflective in the ultrasonic examination. After contrast, the CT scan revealed diffuse thickening of the ocular wall associated with an enhanced irregular orbital mass. The pathologic examination revealed a cavernous hemangioma involving the entire choroid with extrascleral extension. Diffuse choroidal hemangioma occurring in childhood and unrelated to the Sturge-Weber syndrome is a rare condition that should be included in the differential diagnosis of retinoblastoma.

[Changes in the visual fields following filtering surgery in advanced glaucoma]

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.

[Early postoperative campimetric outcome after trabecular surgery of chronic advanced glaucoma]

The authors report about the results of a preliminary study concerning the changes of glaucomatous visual field just after glaucoma filtering surgery in patients with advanced glaucoma. The visual field was established preoperatively, then 7 and 30 days in post operative period. Mesopic campimetry had been selected because of its precision for central field defects. The results appear to be favourable with 13 improvements 14 stabilizations, and 7 aggravations without loss of central vision. The authors have tried to determine predictive risk factors. The most important one are preoperative campimetric shape, angle anatomy, refraction and cardiovascular diseases.