Surgical management of dysthyroid diplopia with preservation of the anterior ciliary vascularization: review of ten cases

PURPOSE

During the surgical correction of dysthyroid diplopia, the risk of ischemia by transection of the anterior ciliary arteries is well-known. In order to avoid this, we modified the classical surgical technique: (1) through the preservation of the vascular pedicles during muscle recession and (2) if necessary, through a plication (instead of a resection) of the ipsilateral antagonist muscle. The objective to be achieved is thus the resolution of the diplopia without ischemic complications.

SUBJECTS AND METHODS

We report a prospective series of 10 patients with dysthyroid ophthalmopathy, causing strabismic diplopia, all operated on by the same surgeon (BR) after at least 12 months of euthyroidism. Data collection included: history of previous decompressive surgery, surgical procedure, and oculomotor status before and after surgery.

RESULTS

Ten patients (8 females), aged 51 to 74 years (mean age, 58.00 ± 7.62 years), were collected between 2008 and 2012. All patients had one or more vascular risk factors (diabetes, smoking, obesity, high blood pressure). With a follow-up from 16 to 67 months (mean ± SD 27.7 months ± 14.87), surgical outcomes were excellent: diplopia was cured in all cases, with recovery of stereoscopic vision. We had no operative or postoperative complications.

CONCLUSIONS

The technique of preservation of the anterior ciliary vascularization, which is particularly justified for these fragile patients, is compatible with moderate muscle recessions. For larger deviations, in which a larger recession might increase the proptosis, it is possible to add a plication of the ipsilateral antagonist. This surgical technique made possible the suppression of the diplopia in all cases.

Conduite à tenir devant une baisse aiguë de l'acuité visuelle chez l'enfant

Acute or rapidly progressive visual loss in children needs urgent attention and treatment. It may be unilateral orbilateral. Etiology depends upon the involved areas: eye ball, optic nerve, retro-chiasmatic pathways. Psychogenic origin is quite common in school-age children, however, it has to be considered last. Unilateral visual loss may be overlooked. Acute total transitory visual loss may be due to epilepsy or to migraine. Rapidly progressive visual loss may be due to retinal disease, optic neuritis or cortical blindness. Management of visual loss depends on clinical features, associated symptoms, and aspect of the optic disc. It needs collaboration between ophthalmologist,pediatrician and neuropediatrician. Retinal hemorrhages first call to mind a traumatic origin. Swelling of the optic disc may be due to increased intracranial pressure or due to optic neuritis. When the optic disc is normal it is necessary to rule out organic diseases before establishing the diagnosis of a psychogenic vision disturbance. In emergency, brain neuroimaging is the best way to diagnose intracranial mass and visualize optic pathways.

Kyste congénital du stroma irien

AIM

Intrastromal epithelial cysts, congenital or acquired, are rare tumors of the anterior chamber. We report two cases, one in a 4-Month-old girl and one in a 14-Year-old teenage girl.

MATERIAL AND METHODS

In the infant case, a large cyst with a superior base obstructed the visual axis. The child had already developed amblyopia and intermittent esotropia, with normal ocular pressure. Aspiration of the cyst with complete excision was done without iridectomy. Two Years later, a secondary corectopia required an inferior iridectomy. Finally, 4 Years later, endophthalmitis developed on a corneal stitch, and the eye was enucleated. In the second case, the teenage girl had noticed a modification in her iris due to an inferior temporal iris cyst. The cyst was excised with a peripheral iridectomy. Despite a first complete excision, a recurrence the following Year was treated by Yag laser. One Year later, the clinical aspect was stable.

COMMENTS AND CONCLUSION

These benign tumors present the problem of local extension and recurrence. Surgical treatment with iridectomy is often proposed despite eventual aesthetic or functional consequences. Yag laser may be a therapeutic alternative. The two operations reported here did not prevent recurrence. In conclusion, intrastromal epithelial cysts of the iris are rare and benign tumors that may induce local complications and lead to recurrence. Many treatments can be discussed for each case.

["Idiopathic" acute optic neuropathies in children]

We reported a retrospective study of 27 children (mean age = 10 years), who presented a loss of vision due to an acute optic neuritis, between 1982 and 1997. The symptoms ar more likely bilateral in children, and frequently associated with systemic viral infection or hepatitis B vaccination. Multiple sclerosis occurs approximately in 20 p. cent of the cases, i.e. less frequently than by adults. Magnetic resonance imaging is now systematic: in 20 children hyperintense nodular abnormalities in a various distribution was demonstrated by 9 children. During the follow-up, 23 eyes of 27 have an excellent recovery of vision, but 4 patients have developed multiple sclerosis. Corticotherapy was uses in 23 cases, in the form of methylprednisolone intravenous flashes in 14 cases.

[Acute optic neuritis in children: clinical features and treatment. A study of 28 eyes in 20 children]

PURPOSE

Analyzing a personal series of children with acute optic neuritis (AON), we studied

MATERIAL AND METHODS

A retrospective study of 28 eyes in 20 patients (mean age: 10;7 years), examined between 1982 and 1997, with a follow-up ranging from 6 months to 15 years (mean: 5;5 years). We recorded etiologic factors, clinical features (ocular and extra ocular), biological results, and neuroimaging findings.

RESULTS

Initial involvement was uni- or bilateral with poor visual acuity (under 20/200 in 22 eyes of 28). Intracerebral inflammation was present in 9 of 13 cases where MRI was performed. We found a cause in only 7 cases (5 viral diseases and 2 recent vaccinations against hepatitis B). Visual recovery was good (over 20/25 in 20 eyes of 28) whatever the treatment, but AON recurred in 5 children. Four children later developed multiple sclerosis.

CONCLUSIONS

The cause of AON is rarely found. After eliminating an infection, we retained viral disease, complication of a recent vaccination against hepatitis B, and neurological diseases. MRI was the imaging study of choice. Development of multiple sclerosis occurred in 4 cases of 20, the same frequency as in the literature. The risk of later development of multiple sclerosis was 20%. Progression of AON was often excellent. Nevertheless, corticotherapy was added, in form of intravenous boluses followed by decreasing oral therapy for one month.

[Exploration of retro-chiasmatic visual pathways in human albinism]

PURPOSE

Several research studies have explored the abnormal crossing of the retinogeniculate and geniculocortical optic pathways in human albinos. This prospective study has dealt with visual evoked potentials (VEPs) of human subjects to identify the percentage of albinos with asymmetric VEPs.

PATIENTS AND METHODS

A series of 16 albino patients ranging in age from 6 to 37 years were examined. They had measurable visual acuity, with or without nystagmus. Diffusion of flash stimuli not allowing selective study of the two visual pathways (direct and crossed), two stimulation patterns were used for VEP recordings: monocular full open field then hemi-field stimulation to isolate the activity of each visual pathway.

ANALYSIS

In the normally pigmented subject, fibers derived from the nasal half of the retina of each eye decussate at the chiasma, while temporal retinal fibers are uncrossed and project to the ipsilateral hemisphere. In albinos, the majority of temporal retinal fibers subserving the nasal field (from fixation to an eccentricity of about 20 degrees ) anomalously cross with the nasal retinal fibers. Therefore with monocular stimulation, the evoked visual response should be obtained only in the contralateral hemisphere. The asymmetry, morphology and latency for the first major positive peak and the amplitude of the VEP were examined and compared with the normal population.

CONCLUSION

We managed to demonstrate the characteristic VEP asymmetry only in 3 out of the 16 patients. The results presented herein lead to question the absolute validity of VEP abnormality in diagnosis of albinism for clinical purposes.

[Persistent and hyperplastic primary vitreous syndrome. Clinical and therapeutic aspects]

PURPOSE

Persistent hyperplastic primary vitreous (PHPV) is a rare developmental malformation of the eye. This anomaly is usually unilateral and unassociated with other disease. PHPV may have clinical variations: an anterior and/or a posterior one. Diagnosis and treatment are exposed in our paper.

METHODS

We study 38 eyes in 34 patients. All patients had an anterior form of PHPV. Nine of them associated a posterior form. Eighteen eyes underwent surgery, the mean postoperative follow-up is 4.7 years. Treatment is discussed, depending on the initial form of PHPV. We report the evolution of the surgical eyes and the untreated eyes.

RESULTS

Slit lamp examination and echographic findings (A-scan and B-scan) support the diagnosis. In some cases computed tomography or RMN can be useful. If the cataract is mild in the anterior form of PHPV, treatment of amblyopia and frequent clinical examination can be sufficient. If the cataract is dense, a lensectomy must to be performed. The surgical technique can be difficult. For the eyes with posterior PHPV, the surgical treatment is to be avoided, because of high risk of retinal detachment.

CONCLUSION

PHPV may have clinical variations, mostly with cataract as major sign. In purely anterior presentation, in absence of marked microphthalmos, lensectomy can be useful.

[Spasmus nutans: apropos of 16 cases]

Spasmus nutans is a syndrome occurring in early childhood. It consists of a triad of symptoms: head nodding, ocular oscillations and anomalous head position. Ophthalmologic and neurological findings are otherwise normal. This syndrome is benign and has spontaneous resolution.

PATIENTS AND METHOD

Sixteen patients with spasmus nutans seen from 1980 to 1995 were retrospectively studied. Their present status was evaluated by clinical examination or questionnaire.

RESULTS

The age at onset ranged from 1 to 15 months (average 7 months). Thirteen of 16 patients were referred for head nodding, which was a constant manifestation; its direction was horizontal, vertical or rotatory. Nystagmus was present in 14 infants. It was acquired, asymmetrical, bilateral (or unilateral in three cases), rapid, fine, pendular and horizontal. Both head nodding and nystagmus were intermittent. Anomalous head position was present in seven cases, consisting of head tilt or a chin upon/chin down posture. Neuroimaging (13 cases) was always normal. The follow-up in 12 children (up to 2 years) showed a complete resolution of the syndrome in 6 months to 6 years (average 2.5 years).

DISCUSSION

The diagnosis was established by the constancy of the characteristic triad and the elimination of the other causes of nystagmus. Isolated head nodding had to be distinguished from bobble head syndrome. In several reported cases, electronystagmography recordings have suggested that head nodding is a compensatory process against nystagmus and that the head tilt allows transient resolution of the nystagmus.

CONCLUSION

Spasmus nutans is a self-limiting benign clinical entity. Normal complete ophthalmologic and neurological examination, as well as magnetic resonance imaging (MRI) are necessary to confirm the diagnosis.

[Neuron-specific enolase in the aqueous humor. Its significance in the differential diagnosis of retinoblastoma]

Several studies support that retinoblastoma originates from a primitive neuroectodermal cell, the main argument being the expression of the neuron-specific enolase (NSE) by the retinoblastic cells. NSE was measured in the aqueous humor taken off: 1) in 19 patients with various eye disorders for which the diagnosis of retinoblastoma was definitely excluded (NSE = 5.0 +/- 7.7 micrograms/l); 2) at the time of the enucleation, in 7 cases of proved retinoblastoma (NSE = 83 to 17,900 micrograms/l); 3) in 2 cases of retinoblastoma held as cured for more than 5 years (NSE = 2.8 and 8.7 micrograms/l). The high level of NSE in the aqueous humor of the subjects with retinoblastoma is very significant, so that it can play a great part in the diagnosis, particularly in the case of atypic tumors. Specific indications of this determination may be considered for the survey of tumors under treatment or of the controlateral eye after a first tumor.

[Benign isolated 6th nerve paralysis in children. Developmental aspects apropos of 9 new cases]

Benign isolated VI nerve palsy in children is a rare but now well-established clinical entity. The diagnosis is essentially an exclusion one. We report nine additional cases. The evolution is discussed, with reference to the literature.

[A case of Richner-Hanhart syndrome (tyrosinosis with ocular, cutaneous and mental manifestations]

A case of Richner-Hanhart syndrom with tyrosinemia is being reported. The diagnosis was suggested from clinical manifestations of this syndrom : superficial opacities of the cornea in an infant preceeding hyperkeratosis of the palms and soles and mild mental retardation. It has been confirmed by the high levels of blood tyrosine. The introduction of a diet low in tyrosine and alanine has lead to a rapid improvement and finally a complete cure of the ophthalmological and dermatological symptoms. The normal metabolism of tyrosine is recalled as well as the specific metabolic aberration responsable for this syndrom (deficiency of cytosol tyrosine amino-transferase). This case is being compared with those which have been previously reported.