S. Arnavielle

Corneal Endothelial Cell Changes After Trabeculectomy and Deep Sclerectomy

Purpose To compare the effect of trabeculectomy and deep sclerectomy on the corneal endothelium. Methods This prospective comparative study investigated 62 eyes of 62 patients scheduled for a single trabeculectomy (n=18), a single deep sclerectomy (n=14), a combined trabeculectomy and phacoemulsification (n=11), or a combined deep sclerectomy and phacoemulsification (n=19). Exclusion criteria were history of corneal disease, ocular trauma, inflammation, or previous glaucoma or cataract surgery. Preoperative, 3-month and 1-year postoperative noncontact specular microscopies were performed on central and superior corneas. Endothelial cells were counted with a computer-assisted analyzer. Results In central cornea, a statistically significant postoperative endothelial cell loss was found after trabeculectomy and deep sclerectomy (alone and combined with cataract extraction) at 3 and 12 months. Cell loss was 7% after penetrating surgery and 2.6% after nonpenetrating surgery (noncombined surgeries). This difference in cell loss was statistically significant. Cell loss increased significantly over the course of the study at 12 months (9.6% and 4.5%, respectively). Cell loss was also significantly higher after trabeculectomy than sclerectomy in upper cornea only in noncombined surgeries. No statistically significant difference in coefficient of variation of cell size (CV) and percentage of cell hexagonality (Hex %) was noted. Conclusions Endothelial cell loss was moderate 3 and 12 months after glaucoma surgery. However, it was greater after trabeculectomy, suggesting less corneal damage after deep sclerectomy. This observation deserves further clinical study.

Chirurgie rétino-vitréenne en ambulatoire : une expérience enrichissante, mais coûteuse…

Vitreoretinal outpatient surgery: clinical and financial considerations C. Creuzot-Garcher, H. Aube, F. Cande, G. Dupont, A. Guillaubey, L. Malvitte, S. Arnavielle, A. Bron Introduction: Vitreoretinal surgery has benefited from great advances opening the opportunity for outpatient management. Methods: We report on the 6-month experience of outpatient surgery for vitreoretinal diseases. Results: From November 2007 to April 2008, 270 patients benefited from a vitreoretinal surgery, with 173 retinal detachments, 63 epiretinal membranes, and 34 other procedures. Only 8.5% (n=23) of the patients had to stay at the hospital one or two nights. The main reasons were the distance from the hospital and surgery on a single-eye patient. The questionnaire given after the surgery showed that almost all the patients were satisfied with the outpatient setting. In contrast, the financial results showed a loss of income of around 400,000 euros due to the low level of payment of outpatient surgery in France by the national health insurance system. Discussion: Vitreoretinal surgery can be achieved in outpatient surgery with an improvement in the information given to the patients and the overall organization of the hospitalization. However, the current income provided with vitreoretinal outpatient surgery is highly disadvantageous in France, preventing this method from being generalized.

Pachymétrie cornéenne centrale et épaisseur de la couche des fibres optiques chez les sujets normotones et hypertones

OBJECTIVE To evaluate the retinal nerve fiber layer thickness and the central corneal thickness in ocular hypertensive patients and healthy subjects. PATIENTS AND METHODS We prospectively included 55 ocular hypertensive patients (126 eyes) and 63 healthy subjects (110 eyes). In each individual we measured standard automatic perimetry, frequency doubling technique visual field, and central corneal thickness with an ultrasonic pachymeter and optical coherence tomography (OCT). Retinal nerve fiber layer thickness was evaluated with GDx-VCC and OCT. RESULTS Central corneal thickness was significantly thicker in ocular hypertensive patients (p<0.009 and p<0.033 respectively). We found a significant correlation between ultrasonic pachymeter and OCT central corneal thickness in both groups (p<0.0001). Retinal nerve fiber layer thickness was not statistically different between healthy and ocular hypertensive subjects, but was significantly thinner in ocular hypertensive patients with thin central corneal thickness only with GDx-VCC. In the control group, no statistically significant linear correlation was noted between central corneal thickness and retinal nerve fiber layer thickness. In the ocular hypertensive group, we found a linear correlation between ultrasonic pachymeter and OCT central corneal thickness and the average retinal nerve fiber layer thickness with the GDx-VCC. DISCUSSION Retinal nerve fiber layer thickness was globally similar in both healthy and ocular hypertensive subjects. CONCLUSION Although some statistically significant differences in the retinal nerve fiber layer thickness were observed between these two groups, they were not clinically relevant.

607 Le syndrome du Morbihan

Introduction Tout examen precedant une blepharoplastie esthetique doit etre complet, afin de depister certaines situations a risque : ptosis palpebral, ptose du sourcil, malpositions palpebrales… Dans de rares cas, l’interrogatoire retrouve des antecedents d’œdeme palpebral a repetition pouvant etre un des signes d’appel du syndrome du Morbihan. Devant cet aspect clinique, on eliminera systematiquement un œdeme angioneurotique hereditaire par le dosage des differentes fractions du complement, ainsi qu’une proliferation lymphomateuse par une imagerie et un examen anatomopathologique. Materiels et Methodes Cinq patients, presentant un syndrome du Morbihan, ont ete inclus prospectivement dans le but de definir les criteres diagnostiques de ce syndrome. Les criteres cliniques etudies etaient : l’hypertrophie bilaterale des deux paupieres, l’aspect indure, la presence d’une rosacee, la duree d’evolution superieure a un an, l’intoxication alcoolo-tabagique chronique, l’effet de la corticotherapie, les antecedents allergiques, l’evolution par poussees, la cortico-sensibilite, et les autres localisations faciales associees. Les criteres anatomopathologiques etaient : l’œdeme, la mucosecretion, l’index mitotique et les autres signes de malignite. Discussion Les criteres cliniques retenus chez tous les patients etaient : des œdemes faciaux cortico-resistants, a repetition, evoluant par poussees, depuis plus d’un an, associes a une rosacee, de localisation palpebrale, inter-sourciliere et frontale. Les antecedents d’allergie ou d’intoxication alcoolo tabagique n’ont pas ete retrouves de maniere significative. L’examen anatomopathologique montrait chez l’ensemble des patients un tissu inflammatoire aspecifique sans signe de malignite. Conclusion Le syndrome du Morbihan est un syndrome associant des œdemes palpebraux, cortico-resistants, a repetition, evoluant par poussees, de facon chronique, dans un contexte de rosacee. Le traitement reside en une blepharoplastie apres avoir constate une rarefaction des poussees. L’examen anatomopathologique montre une inflammation aspecifique et elimine surtout une proliferation lymphomateuse. Le patient devra etre prevenu du risque de recidive, restant cependant rare en l’absence de nouvelles poussees.

021 - Techniques de neuro-navigation appliquées à la chirurgie des tumeurs orbitaires : voie d’abord, précision tridimensionnelle, résultats pratiques.

Introduction L’imagerie medicale est couramment utilisee par les neurochirurgiens pour guider leur geste depuis plus de 10 ans. Les progres constants de la precision de l’imagerie et de la localisation spatiale des instruments, l’apparition de systemes 3D sans reperes osteo-fixes, la fusion des differentes sources d’images (TDM, IRM, echographie per-operatoire) rendent possible l’extension de ces techniques aux lesions orbitaires. Materiels et Methodes Elles sont particulierement prometteuses pour les lesions posterieures, dont la chirurgie classique comporte un risque majore de complications graves : les principales indications sont les lesions proches de l’apex et du toit de l’orbite. Resultats Nous presentons les modalites pratiques de cette nouvelle technique chirurgicale prometteuse pour la biopsie des tumeurs orbitaires, ainsi que les difficultes rencontrees. Discussion Les techniques de neuro-navigation trouvent une extension naturelle en chirurgie orbitaire : l’acces difficile aux lesions posterieures, la proximite de structures nobles fragiles, la mobilite limitee des differents elements anatomiques dans cet espace clos, sont tres similaires aux problemes neurochirurgicaux. Conclusion Nos resultats encouragent a poursuivre cette application, notamment pour developper des outils specifiques surs pour les biopsies orbitaires posterieures.

Response to letter «Anterior chamber paracentesis in patients with acute elevation of intraocular pressure» by Pong et al.

We thank Dr Pong for his interest in our paper entitled «Anterior chamber paracentesis in patients with acute elevation of intraocular pressure» [1]. We acknowledge the pioneering role of Dr Lam in this field, and his paper has inspired our series [2]. Dr Pong does not believe that the IOP-lowering effect of anterior chamber paracentesis (ACP) was correctly evaluated in our study. He points out that Dr Lam has reported the IOP 2 hours after ACP. However, since we reported the IOP immediately after the ACP (i.e., 10 minutes), this time point seems a better reflection of the ACP effect because local and systemic IOP-lowering medications need a longer time to be effective. The duration of ACP on IOP is short; therefore the usual medical treatment is needed. It is clear that ACP does not treat the cause of acute angle-closure crisis. However, it permits an immediate relief of IOP elevation. To function properly, cells need a controlled environment with a small variation range of physical parameters such as temperature, pH, pressure etc. [3]. In cases referred with a short delay, the clearing of the cornea is spectacular within a few seconds after ACP, allowing a peripheral laser iridotomy with reduced delay. If we wait for 2 more hours for the IOP-lowering effect of systemic drugs, more cells will be lost, and the future is impaired. The poor outcome after acute primary angleclosure is well documented [4]. Is the risk of peripheral anterior synechiae and further loss of endothelial corneal cells higher after ACP or after having waited 2 additional hours of IOP an insult to ocular tissues? It has been shown that the decrease in retinal nerve fiber layer thickness is well correlated to the duration of acute primary angle-closure attack, thus suggesting that decreasing IOP is really an emergency [5]. We are more concerned by the duration of the insult than with the potential complications of ACP which, as mentioned by Dr Pong, are trivial. When we teach young residents, we like to draw a parallel between acute angle-closure crisis and endophthalmitis. The shorter the delay in treatment, the better for the eye. That is why injections of intravitreous antibiotics and ACP techniques are taught during the 1st week of their residency. We have some difficulty in understanding why it should be preferable to wait for a slow decrease of IOP. Is 40 or 50 mm/Hg better than 60 mm/Hg? We agree with Dr Pong that a better documentation of the iridocorneal angle status is needed in the long term. The spread of anterior segment imaging will certainly help us to be more objective with angle configuration assessment. We agree with Dr Pong that ACP was less effective in our secondary angle-closure cases; therefore, ACP in these cases is questionable, although we did not observe any complications in these eyes. Finally we would like to thank our Asian colleagues for sharing their huge experience in angle-closure presentations which are not so rare in our western countries. Either suspect, acute or chronic, angle closures remain difficult to diagnose and to manage [6].