G. Caputo

Iris fixation of foldable intraocular lenses for ectopia lentis in children

PURPOSE: To describe a technique for iris fixation of acrylic intraocular lenses (IOLs) in ectopia lentis and evaluate the medium‐term anatomical and functional results in children. SETTING: Pediatric Ophthalmology Department, Fondation Rothschild, Paris, France. METHODS: This retrospective study included 17 eyes of 9 children. The technique consisted of lens ablation, leaving in place the capsule in the zone of nonruptured zonule, and an IOL placement in the remaining sulcus with 2 iris sutures. The age of patients, postoperative complications, follow‐up, anatomical results, final refraction, and visual acuity were noted. RESULTS: Median age was 4.8 years. One case of postoperative hyphema and 1 case of aseptic endophthalmitis occurred and resolved after treatment. The anatomical outcome was favorable in all cases, with centered IOLs and round pupils. Mean follow‐up was 16.3 months. Mean final refraction was +0.18 diopter, and mean final best corrected visual acuity was 20/32 (range 20/50 to 20/20). CONCLUSIONS: The results suggest that iris fixation of foldable IOLs for ectopia lentis in children can lead to good anatomical and functional results. The use of the remaining part of the sulcus is helpful in reaching correct positioning of the IOL. The complication rate is similar to that with other techniques described in the literature, whereas the small incision and the absence of transscleral sutures could simplify the short‐term and long‐term evolution.

Management of retinal detachment in Coats disease. Study of 15 cases.

Purpose: To correlate the final outcome with the initial presentation and treatment in Coats disease retinal detachment. Methods: The records of 15 patients with retinal detachment were evaluated retrospectively regarding the age at the time of diagnosis, initial presentation, methods of treatment, visual and anatomic results, and complications. Changes in vision and retinal status were noted and correlated with the different methods of treatment to propose a therapeutic strategy. Results: In 15 patients (15 eyes), with a mean follow-up of 28 months (range, 6 months to 7 years), Coats disease was diagnosed at a mean age of 3.4 years (range 3 months to 15 years). Primary management was laser photocoagulation in seven patients, cryotherapy in two, and vitreoretinal surgery in six. Additional treatment was necessary in nine patients of whom six had laser photocoagulation, one had cryotherapy, and two had vitreoretinal surgery. Visual stability was achieved in 12 cases. Anatomic improvement was achieved in 12 eyes (3 cases of phthisis bulbi). No enucleation was ultimately necessary. Conclusions: Carefully selected treatment can improve almost each eye with Coats disease complicated by retinal detachment. Although visual outcome is poor, anatomic improvement or stability is the main goal of the management.

Encapsulation of scleral buckling materials: A study of sixty specimens

OBJECTIVE The purpose of the study was to obtain information on the encapsulation of two nonabsorbable biomaterials (silicone and hydrogel) used as explants in scleral buckling in retinal detachment surgery. DESIGN The study design was a histopathologic study on a cohort of capsule fractions and complete eyes. PARTICIPANTS Fifty-nine patients participated in this study, in which 60 specimens, including 37 hydrogel and 21 silicone capsule specimens as well as 2 whole eyes, were gathered. There were no control subjects. INTERVENTION The capsule specimens were obtained from eyes operated on previously for scleral buckling for retinal detachment. The two whole eyes were enucleated. All specimens were studied with routine optic microscopy. MAIN OUTCOME MEASURES Patient characteristics, type of scleral buckling, and number of operations performed were analyzed. Histologically, the capsular structure, its interface with the explant, and its different components also were studied. Remnants of the buckling material also were investigated. RESULTS There were 45 male and 14 female patients, with a mean age of 49 years. Histologically, capsule specimens had a fibrous matrix with fibroblasts and few inflammatory cells. Eighteen (48.6%) of 37 hydrogel capsule specimens displayed hydrogel fragments surrounded by a foreign body giant cell granuloma in 16 cases. CONCLUSION Nonabsorbable materials undergo encapsulation after implantation on the eye surface. Giant cell granuloma was observed in some hydrogel capsule specimens in relation to hydrogel fragmentation. The exact origin of this fragmentation remains unknown.

Transcriptomic Analysis of Human Retinal Detachment Reveals Both Inflammatory Response and Photoreceptor Death

Background Retinal detachment often leads to a severe and permanent loss of vision and its therapeutic management remains to this day exclusively surgical. We have used surgical specimens to perform a differential analysis of the transcriptome of human retinal tissues following detachment in order to identify new potential pharmacological targets that could be used in combination with surgery to further improve final outcome. Methodology/Principal Findings Statistical analysis reveals major involvement of the immune response in the disease. Interestingly, using a novel approach relying on coordinated expression, the interindividual variation was monitored to unravel a second crucial aspect of the pathological process: the death of photoreceptor cells. Within the genes identified, the expression of the major histocompatibility complex I gene HLA-C enables diagnosis of the disease, while PKD2L1 and SLCO4A1 -which are both down-regulated- act synergistically to provide an estimate of the duration of the retinal detachment process. Our analysis thus reveals the two complementary cellular and molecular aspects linked to retinal detachment: an immune response and the degeneration of photoreceptor cells. We also reveal that the human specimens have a higher clinical value as compared to artificial models that point to IL6 and oxidative stress, not implicated in the surgical specimens studied here. Conclusions/Significance This systematic analysis confirmed the occurrence of both neurodegeneration and inflammation during retinal detachment, and further identifies precisely the modification of expression of the different genes implicated in these two phenomena. Our data henceforth give a new insight into the disease process and provide a rationale for therapeutic strategies aimed at limiting inflammation and photoreceptor damage associated with retinal detachment and, in turn, improving visual prognosis after retinal surgery.

Ischemic retinopathy and neovascular proliferation secondary to shaken baby syndrome

Background: Ocular lesions known to occur after shaken baby syndrome (SBS) are epiretinal, intraretinal, and subretinal hemorrhages, which are present in up to 100% of patients. Retinoschisis and retinal folds have also been described. We describe three patients with SBS who presented with tractional retinal detachments secondary to neovascular proliferation and discuss the role of ischemia at the retinal level. Patients: Three patients (two 4-month-old babies and one 4-year-old child) with a history of SBS in the first year of life presented with tractional retinal detachment due to severe preretinal fibrovascular proliferation. Peripheral retinal ischemia and vascular disorganization were noted during clinical examination. Conclusion: Although physiopathology of SBS remains disputed, ischemia has been accepted as the main feature of cerebral lesions. Ischemia could also be present at the retinal level as suggested by our patients’ presentation. It could be induced by direct vitreous shearing of the capillary network or more probably by vascular leak due to brain edema and hypoxic damage of capillaries. Long-term ocular follow-up is necessary in SBS to treat these patients preventively.

Management of delayed massive suprachoroidal hemorrhage: a clinical retrospective study.

Suprachoroidal hemorrhages, both expulsive and delayed non-expulsive, are among the most devastating complications of intraocular surgery. We reviewed the charts of 13 patients with a delayed non-expulsive suprachoroidal hemorrhage (DNSCH) after cataract extraction (3 patients), glaucoma filtering surgery (6 patients), penetrating keratoplasty (3 patients), or vitrectomy (1 patient). All had large hemorrhagic choroidal detachments with nine eyes presenting kissing choroidal detachment, five eyes with associated retinal detachment, and one eye with intravitreous hemorrhage. All patients were treated with systemic corticosteroids before surgery. Eleven eyes underwent anterior drainage sclerotomy, followed by SF6 gas injection in eight eyes, and pars plana vitrectomy with silicon oil tamponade in three eyes. Mean follow-up was 22 months. These procedures gave good anatomical results in eleven cases and good visual results in nine. The results suggest that not all DNSCH need to be drained surgically but that, when surgical drainage is indicated, the use of gas to maintain internal tamponade appears to be beneficial.

Should unilateral congenital corneal opacities in Peters’ anomaly be grafted?

Purpose. To evaluate the surgical outcomes and visual results after penetrating keratoplasty for congenital unilateral corneal opacities in Peters anomaly. Methods. This was a retrospective study of 14 children who underwent keratoplasty for a unilateral Peters anomaly between 1999 and 2009. All patients received a topical treatment of cyclosporine and corticosteroids. Suture ablation was performed between the first and second postoperative month and all patients had spectacle correction and amblyopia treatment. Age at time of surgery, posterior segment status evaluated by ultrasonography, axial length, preoperative intraocular pressure, fellow eye status, mean follow-up time, early and late complications, final graft outcome, refraction, and visual acuity upon the last visit were noted. Results. Mean age at the time of surgery was 9 months. Posterior segment was normal in all cases. Mean axial length was 18 mm and mean intraocular pressure was 11 mmHg. Mean follow-up was 30 months. Four children had graft rejection episodes, 2 of which responded to medication. Four underwent cataract surgery, one developed pupil deformation requiring a pupilloplasty and 2 cases were complicated by surgical glaucoma. A total of 11 eyes (78.6%) had clear grafts at the end of the follow-up. Mean spherical equivalent was −1.5 D. Visual acuity was measurable in 3 cases and was 20/50 in one case, 20/63 in the second, and 20/2000 in the third. Concerning preverbal children, central, steady, and maintained fixation was found in 8 cases. Conclusions. Operating on a unilateral congenital corneal opacity is a challenging decision and should be taken after explaining the need for long-term follow-up to the parents. Useful vision can be achieved and maintained after strict amblyopia therapy. A multidisciplinary ophthalmologic follow-up is necessary.

En face spectral domain optical coherence tomography in a case of bilateral acute macular neuroretinopathy.

A 23-year-old woman experiencing bilateral paracentral scotomas for 5 months with preserved visual acuity was diagnosed with acute macular neuroretinopathy (AMN). Both eyes harbored similar features. Funduscopy showed discrete, deep brownish perifoveal spots (Figure 1A, right eye). Infrared (IR) and multicolor imaging that comprised of 100 averaged 30° images (Spectralis HRA + OCT; Heidelberg Engineering, Heidelberg, Germany) revealed welldefined petaloid perifoveal lesions (Figure 1, B and C). Fluorescein and indocyanine green angiography were unremarkable. Spectral domain optical coherence tomography (OCT) B-scans crossing the lesions showed discontinuity of the ellipsoid zone and disruptions of the interdigitation zone (Figure 1D). To obtain en face spectral domain OCT images, 145 sections, each comprising of 24 averaged enhanced depth imaging OCT B-scans at 30-mm intervals, were performed within a 20° · 15° rectangle encompassing the macula. The threedimensional view obtained was analyzed with the “transverse mode.” Two en face images were selected, 1 at the level of the ellipsoid zone, 57 mm from the retinal pigment epithelium (Figure 1E), and the second at the level of the interdigitation zone, 34 mm from the retinal pigment epithelium (Figure 1F). Both showed Fig. 1. A. Fundus color photograph focused on the macula in the right eye shows discrete, deep brownish perifoveal spots barely visible. B. Infrared imaging shows wedge-shaped, perifoveolar hyporeflective lesions with well-delineated borders. C. Multicolor imaging also shows well-defined partly confluent perifoveolar lesions with dark margins. D. Vertical (above) and horizontal (below) spectral domain OCT B-scan crossing the fovea of the right eye shows thinning of the outer nuclear layer, discontinuity of the ellipsoid zone, and focal disruption of the interdigitation zone at the level of the IR lesion (gray arrow). E. En face OCT at the level of the ellipsoid zone shows hyporeflective, well-defined petaloid lesions. F. En face OCT at the level of the interdigitation zone shows hyporeflective, well-defined lesions with a wider lateral extent best corresponding to the lesions seen on multicolor and IR imaging.

080 Cataractes post traumatiques chez l’enfant

Introduction Les cataractes post-traumatiques representent une complication frequente des traumatismes oculaires chez l’enfant. Le but de cette etude etait de decrire la sequence de prise en charge et l’evolution des cataractes post-traumatiques chez l’enfant. Materiels et Methodes Il s’agit d’une etude retrospective portant sur tous les enfants operes de cataracte post-traumatique entre 2000 et 2008. Nous avons note l’âge du traumatisme, les circonstances de survenue et le type de traumatisme, le delai entre le traumatisme et la chirurgie, le bilan lesionnel initial, le type de chirurgie, l’evolution anatomique et fonctionnelle et le recul. Resultats Nous avons opere 24 enfants de cataracte post traumatique entre 2000 et 2008 dont 8 filles et 16 garcons d’une moyenne d’âge de 4.9 ans au moment du traumatisme. Pour 12 d’entre eux il s’agissait d’un traumatisme contusif, pour les 12 autres d’un traumatisme avec plaie de globe. L’acuite visuelle initiale etait ≤ CLD pour 5 enfants en cas de traumatisme contusif, pour 8 enfants en cas de traumatisme a globe ouvert (avec une effraction de la capsule anterieure du cristallin dans plus de la moitie des cas). Dans de nombreux cas, d’autres lesions etaient associees comme un hyphema, une desinsertion de l’iris, une hemorragie intra-vitreenne ou encore des lesions du pole posterieur. Apres phacoaspiration, vitrectomie anterieure et mise en place d’un implant dans le sac capsulaire dans la moitie des cas, nous avons observe en cas de traumatisme contusif une acuite visuelle finale ≥ 8/10 pour 3 patients, ≤ 3/10 pour 7 enfants ; en cas de traumatisme a globe ouvert une acuite visuelle finale ≥ 5/10 pour 2 enfants et ≤ 3/10 pour 9 patients. Discussion Les cataractes post traumatiques chez l’enfant sont secondaires a des mecanismes varies. Le delai de prise en charge chirurgicale est plus important en cas de traumatisme contusif. Dans de nombreux cas, le pronostic reste reserve surtout en cas de traumatisme a globe ouvert, en raison des lesions associees et des cicatrices corneennes responsables d’amblyopie. Conclusion Les cataractes post traumatiques chez l’enfant necessitent une prise en charge rapide en cas de traumatisme a globe ouvert, et gardent un pronostic reserve en raison des lesions associees et du risque d’amblyopie. Le meilleur traitement reste la prevention.

Hypertonie oculaire aiguë tardive compliquant une rétinopathie de la prématurité

Retinopathy of prematurity complicated by late glaucoma: a case report C. Faure, G. Caputo, J.-A. Sahel, M. Paques. Introduction: We report the case of an acute rise in intraocular pressure occurring decades after the treatment for prematurity (ROP). Case report: A 54-year-old preterm woman presented an acute rise in intraocular pressure in her right amblyopic eye. Prominent dilatation of iridal vessels was noted. Fundus was not visible at that time because of corneal edema. Ocular echography was normal. The fellow eye showed temporal attraction of temporal vessels suggestive of retinopathy of prematurity at the cicatricial stage. Neovascular glaucoma was postulated and pressure control was obtained after cyclodestruction and transscleral cryoapplication. After resolution of corneal edema, fundus examination revealed extensive peripheral retinal photocoagulation scars. Iridocorneal angle presented extensive iridocorneal synechias without true new vessels. Visual acuity remained limited to hand motion. Conclusion: Prominent iris dilatation seen in some preterm patients can mimic rubeosis, and, in the present case, mislead to a diagnosis of neovascular glaucoma. Diagnosis can be difficult if the patient is not specifically asked for a history of prematurity. The case underlines the notion that ROP patients may present very late complications of the disease.