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Resume But Evaluer la baisse de la PIO et la symptomatologie oculaire chez les patients nouvellement diagnostiques de GPAO et traites en monotherapie par le Latanoprost. Patients et methodes Il s’est agi d’une etude multicentrique, transversale et descriptive. Nous avons inclus les adultes nouvellement diagnostiques de GPAO. Tous les patients ont recu une goutte de Latanoprost 0,005 % conserve dans chaque œil tous les soirs pendant 12 semaines. La variation de la PIO et l’apparition des signes et symptomes oculaires etaient evalues pendant et a la fin du traitement. Resultats Au total, nous avons inclus 524 patients avec un taux de participation a 93,3 % a 12 semaines. La moyenne d’âge etait de 52,79 ± 17,33 ans et le sexe-ratio H/F etait de 1,39. La PIO moyenne a l’inclusion etait de 21,68 ± 9,72 mmHg. Apres 2 semaines de traitement, la PIO moyenne etait de 15,49 ± 5,81 mmHg, soit une reduction de 28,55 %. Apres 12 semaines de traitement, la PIO moyenne etait de 13,16 ± 3,54 mmHg, soit une reduction de 39,30 %. Les symptomes enregistres etaient domines par la sensation de grains de sable dont la frequence etait de 4,72 % a S2 et 2,45 % a S12. Les signes etaient majoritairement representes par l’hyperhemie conjonctivale (4,33 % a S2 et 1,84 % a S12). Conclusion Le Latanoprost donne en premiere intention et en monotherapie dans le GPAO chez le melanoderme baisse considerablement la PIO. L’incidence des effets indesirables reste faible ; elle est plus importante en debut de traitement.

This study aims to evaluate surgical training in ophthalmology through feedback from residents.An anonymous questionnaire was created, including 20 items which assessed the number of complete or partial surgical procedures performed during a semester, self-assessment of surgical skills, use of surgical simulators, an overall rating of the surgical training received and some suggestions to improve surgical training. It was sent by email to all residents in training in Île-de-France (DES Île-de-France and Inter-CHU), France.From October 23 to November 7, 2021, 89/137 residents responded to the questionnaire (65%). Since the beginning of their residency, ninety percent of the residents received training using simulators. Over 90% performed all of the technical steps of a "standard" cataract surgery at least once during the semester, and 60% 10 times or more. The least performed technical steps or procedures also received the lowest self-assessment: management of expulsive hemorrhage, open-globe or lacrimal laceration wound suturing, capsular tension ring injection, and intraocular lens explantation. Residents gave an overall average rating of 6.6/10 to their training and suggested some feedback on videos of resident surgeries (67%) and theoretical courses dealing with surgical techniques (61%).The increasing use of simulators should improve surgical training. Residents express the need for training regarding surgical complications and emergencies as well as improvement of their technical skills via improved feedback.Surgical teaching appears suitable for learning cataract surgery but seems less effective for the management of emergencies and intraoperative complications.

BackgroundNon-infectious scleritis refers to a rare and sight-threatening scleral inflammation. An association with an underlying systemic disease is noted in 30% to 40% of cases. Their management may require the use of nonsteroidal anti-inflammatory drugs, oral corticosteroids, and sometimes steroid-sparing immunosuppressive agents. Because of the low incidence and prevalence of scleritis, treatment guidelines are currently not available.ObjectivesWe analyzed in a retrospective observational study patients with scleritis referred to the Foundation Rothschild Hospital (Paris) from March 2011 to June 2021.MethodsCharacteristics, visual outcomes, ocular complications, associations with systemic diseases and efficacy of treatment were assessed in patients with non-infectious scleritis who needed steroid-sparing immunosuppressive agents.ResultsAmong 731 patients diagnosed with scleritis, 54 patients (71 eyes, 7%) were treated by steroid-sparing immunosuppressive agents. Mean follow up was 111.9 ± 84.5 weeks. Mean age was 48.4 years ± 18.3, and 31 patients (57%) were female. Scleritis was anterior in 51 eyes (72 %), including 25 (35%) with diffuse scleritis, 24 (34%) with nodular scleritis and 2 (3%) with necrotizing scleritis. Scleritis was posterior in 20 eyes (28%). Bilateral involvement was noted in 17 patients (32 %). Ocular complications were observed in 52 eyes (73 %): scleral thinning in 25 eyes (35%), anterior uveitis in 24 eyes (34 %), loss of vision in 20 eyes (28%), posterior segment ocular complications in 18 eyes (25%), ocular hypertension in 17 eyes (24%) and corneal involvement in 16 eyes (23%). An underlying systemic disease was identified in 28 patients (52 %), and scleritis was the first manifestation of the systemic disease in 17 out of 28 patients. Rheumatoid arthritis was the most frequently identified disease (n=12), followed by granulomatosis with polyangiitis (n=8) and relapsing polychondritis (n=4). All patients received at least one immunosuppressive agent. Corticosteroid sparing with a daily dose ≤ 5 mg of prednisone was achieved in 85% of patients. Conventional immunosuppressive agents were used as the first steroid-sparing agent in 38 patients (70%) (methotrexate n=33, azathioprine n=4, mycofenolate mofetil (MMF) n=1) and as second steroid-sparing agent in 1 patient (MMF). This treatment led to control scleral inflammation in 23 (59%) patients after a mean delay of 10.0 ± 6.0 weeks. Biologic therapy was used in 33 (61%) patients (TNF alpha inhibitor n=17, IL6-R inhibitor n=7, anti-CD20 n=9), and as the first steroid-sparing agent in 16 (30%) (TNF alpha inhibitor n=4, IL6-R inhibitor n=4, anti-CD20 n=8). This treatment led to control scleral inflammation after a mean delay of 4,9 ± 3,7 weeks in 29 patients (87.9%).ConclusionScleritis is a severe ocular inflammatory disease that requires repeated and thorough ophthalmologic and general examinations given the high frequency of complications and the possibility of an underlying systemic disease. This study reports real-life experience in management of non-infectious scleritis. Biological therapies seemed to be associated with a better outcome and a quicker reponse than conventional immunosuppressive agents. Further studies are warranted to develop specific guidelinesDisclosure of InterestsNone declared

To assess the reduction in IOP and ocular symptoms in patients newly diagnosed with POAG and treated with latanoprost as monotherapy.A multicentric, cross-sectional, descriptive study was conducted. We included adults newly diagnosed with POAG. All patients received one drop of preserved latanoprost 0.005% in each eye every night for 12 weeks. Changes in IOP and ophthalmic signs and symptoms were assessed during and at the end of treatment.A total of 524 patients were included, with a participation rate of 93% at 12 weeks. The mean age was 52.79±17.33 years, and the sex ratio M/F was 1.39. At inclusion, the mean IOP was 21.68±9.72mmHg. After 2 weeks of treatment, the mean IOP was 15.49±5.81mmHg, for a reduction of 28.55%. After 12 weeks of treatment, the mean IOP was 13.16±3.54mmHg, for a reduction of 39.30%. The main symptom recorded was a gritty foreign body sensation, the frequency of which was 4.72% at W2 and 2.45% at W12. The main sign was hyperemia (4.33% at W2 and 1.84% at W12).Latanoprost given as first-line monotherapy in POAG in blacks considerably reduces IOP. The incidence of side effects remains low; it is higher at the start of treatment.

Controlling long-term inflammation during non-infectious intermediate, posterior or panuveitis while limiting side effects remains challenging. There is no standardized pre-therapeutic evaluation providing diagnostic certainty, but some simple tests allow us to identifiy the main etiologies. The ophthalmologist identifies the type of uveitis, and the internist completes the investigations according to the ophthalmologist's findings. Fundus photographs, optical coherence tomography, and fluorescein and indocyanine green angiography should be considered during diagnosis and follow-up. Ocular complications of uveitis are numerous. They require close monitoring and specific medical and sometimes surgical management. The growing number of available drugs makes it possible to optimize the management of these conditions with varied etiologies and presentations. Currently, systemic corticosteroids remain the mainstay of therapy, and other alternatives are considered in the case of poor tolerance, steroid resistance or dependence. The choice of a systemic, periocular or intravitreal treatment depends on several factors: chronicity or recurrence of uveitis, duration, bilaterality, association with a systemic inflammatory disease, the presence of contraindications to certain treatments, and also socioeconomic constraints. It is of the utmost importance to find the best compromise allowing tight control of ocular inflammation by means of adapted systemic and/or local treatment while avoiding the main complications.

Introduction L’œdeme maculaire cystoide (OMC) peut representer une complication des uveites posterieures. La prise en charge de l’OMC en contexte d’inflammation peut etre difficile, avec une corticodependance a haut niveau, une dependance aux injections intravitreennes (IVT) de corticoides et une efficacite inconstante des DMARDS conventionnels et/ou des biotherapies. Nous rapportons notre experience du tocilizumab dans ces OMC refractaires. Observation Patiente 1. Femme de 31 ans. Aout 2015 : diagnostic d’uveite posterieure droite a type de MEWDS avec vascularite retinienne droite. Juillet 2016 : hemorragie intravitreenne en rapport avec des neovaisseaux inflammatoires, et OMC droit. Realisation de 3 bolus de solumedrol 1 g avec relais per os a 1 mg/kg puis decroissance, et injection intravitreenne de bevacizumab. Novembre 2016 : recidive d’hemorragie intra-vitreenne sous prednisone 12 mg/j. Injection intra-vitreenne de bevacizumab et reascension de la corticotherapie a 25 mg/j. Janvier 2017 : debut d’infliximab 5 mg/kg. Fevrier 2017 : reapparition de l’OMC sous prednisone 16 mg/j. Juin 2017 : remission de l’uveite en dehors de l’OMC avec possibilite d’arret de la corticotherapie ; realisation d’une IVT de dexamethasone, permettant le controle de l’OMC. Novembre 2017 : recidive de l’OMC ; realisation d’une nouvelle IVT de dexamethasone. Janvier 2018 : arret de l’infliximab, debut du tocilizumab 8 mg/kg mensuel. Fevrier 2018 (dernier suivi) : remission complete de l’uveite, pas de recidive de l’OMC. Bonne tolerance du traitement. Patiente 2. Femme de 79 ans. Octobre 2016 : panuveite granulomateuse bilaterale en rapport avec une sarcoidose. Realisation de 3 bolus de solumedrol 500 mg puis relais per os avec decroissance progressive. Fevrier 2017 : remission de l’uveite sous prednisone 25 mg/j. Mauvaise tolerance de la corticotherapie. Ajout de methotrexate SC 0,3 mg/kg a visee d’epargne cortisonee. Juin 2017 : echec du methotrexate a visee d’epargne cortisonee avec rechute sous forme d’OMC sous prednisone 15 mg/j. Debut d’infliximab 5 mg/kg/8 semaines. Decembre 2017 : echec de l’infliximab, avec persistance de l’OMC sous prednisone 5 mg/j. Debut du tocilizumab 8 mg/kg mensuel. Fevrier 2018 (dernier suivi) : remission complete de l’uveite hormis quelques vascularites peripheriques, regression complete de l’OMC. Bonne tolerance du traitement. Patient 3. Homme de 78 ans, avec insuffisance surrenalienne et glaucome severe. Fevrier 2017 : panuveite bilaterale non granulomateuse avec OMC, idiopathique. Realisation de 3 bolus de solumedrol de 500 mg avec relais per os et decroissance progressive. Juin 2017 : recidive de l’OMC bilateral sous prednisone 14 mg/j. Debut de l’azathioprine avec majoration jusqu’a 2 mg/kg, remontee de la corticotherapie a 30 mg/j. Aout 2017 : hepatite medicamenteuse sous azathioprine, debut du mycophenolate mofetil 1 g matin et soir. Decembre 2017 : echec du mycophenolate mofetil a visee d’epargne cortisonee, avec recidive de l’OMC bilateral sous prednisone 20 mg/j. Debut du tocilizumab 8 mg/kg mensuel. Fevrier 2018 (dernier suivi) : remission complete de l’uveite et de l’OMC, avec arret du mycophenolate mofetil et prednisone a 12 mg/j. Bonne tolerance du traitement. Discussion Dans cette serie de patient, le tocilizumab a eu une efficacite rapide, a la fois en traitement d’induction et en traitement d’entretien, sur l’OMC compliquant les uveites posterieures, avec une possibilite d’epargne cortisonee. Il n’a pas ete note d’evenements indesirables. Conclusion Le tocilizumab peut donc representer une option therapeutique interessante dans le cadre des OMC satellites d’uveite posterieure, corticodependants a haut niveau et/ou dependants aux IVT de corticoides, avec echec des DMARDS conventionnels et/ou des eventuelles biotherapies anterieures.

Introduction Le traitement des sclerites varie en fonction de leur type (diffuse, nodulaire, necrosante) et de la pathologie generale eventuellement sous-jacente. La corticotherapie systemique represente le plus souvent le traitement de 1re intention. Des immunomodulateurs classiques sont proposes en cas de corticodependance a haut niveau et/ou d’intolerance a la corticotherapie. Le cyclophosphamide represente le traitement de reference dans les formes necrosantes. L’efficacite des biotherapies (anti-TNF, anti-CD20…) est dependante de la pathologie generale sous-jacente. Nous rapportons notre experience du tocilizumab (anticorps anti-IL6) dans la prise en charge des patients presentant une sclerite refractaire, corticodependante a haut niveau, et en echec des DMARDS conventionnels et d’eventuelles biotherapies anterieures. Observation Patient 1 : homme de 49 ans. Decembre 2016 : diagnostic de sclerite nodulaire gauche. Description de 3 episodes precedents de chondrite auriculaire. Diagnostic de polychondrite atrophiante. Absence d’atteinte nasale, laryngee, tracheale, aortique ; pas d’arguments pour une myelodysplasie. Avril 2017 : debut d’une corticotherapie systemique par prednisone a 1 mg/kg. Corticosensibilite, mais intolerance et corticodependance a 30 mg/j avec recidive de la sclerite. Juin 2017 : introduction d’azathioprine 175 mg/j. Aout 2017 : echec de l’azathioprine a visee d’epargne cortisonee, avec rechute de la sclerite sous prednisone a 20 mg/j. Remontee de la corticotherapie a 50 mg/j et debut d’un traitement par tocilizumab 8 mg/kg mensuel. Septembre 2017 : remission clinique, avec possibilite de decroissance de la corticotherapie et arret de l’azathioprine. Fevrier 2018 (dernier suivi) : remission clinique sous prednisone 5 mg/j. Bonne tolerance du traitement. Patient 2 : homme de 41 ans. Keratosclerite bilaterale compliquee de scleromalacie et de keratopathie lipidique, evoluant depuis l’âge de 18 ans. Janvier 2017 : diagnostic de syndrome de Cogan atypique. Debut d’une corticotherapie a 1 mg/kg/j et de methotrexate per os a 0,3 mg/kg/sem. Corticosensibilite, mais corticodependance a 60 mg/j. Mars 2017 : debut d’un traitement par tocilizumab 8 mg/kg mensuel. Evolution favorable avec possibilite d’epargne cortisonee jusqu’a 12,5 mg/j. Nette dependance au tocilizumab avec effet fin de dose. Fevrier 2018 (dernier suivi) : corticodependance a 12,5 mg par jour (reprise moderee de la sclerite) en association au methotrexate 0,3 mg/kg/sem. Bonne tolerance du traitement. Patient 3 : homme de 67 ans. Septembre 2017 : diagnostic de sclerite nodulaire gauche. Explorations a visee etiologique negatives. Octobre 2017 : debut d’une corticotherapie per os a 1 mg/kg. Absence d’efficacite. Realisation de bolus de solumedrol 1000 mg/j pendant 3 jours. Corticosensibilite initiale, mais effet rebond majeur avec nouveau nodule de sclerite. Novembre 2017 : debut d’un traitement par tocilizumab 8 mg/kg mensuel. Evolution favorable avec possibilite d’epargne cortisonee. Fevrier 2018 (dernier suivi) : activite minime de la sclerite sous prednisone 20 mg/j, avec decroissance programmee. Bonne tolerance du traitement. Patient 4 : homme de 64 ans, aux antecedents d’hepatite B. Uveosclerite bilaterale chronique evoluant depuis 2015, corticodependante. Juin 2016 : diagnostic de polychondrite atrophiante devant un episode de chondrite auriculaire et d’une chondrite laryngee. Absence d’atteinte nasale, tracheale, aortique ; pas d’arguments pour une myelodysplasie. Debut d’une corticotherapie generale a 1 mg/kg en association a du methotrexate 0,3 mg/kg/sem. Mai 2017 : echec du methotrexate a visee d’epargne cortisonee. Debut d’un traitement par infliximab 5 mg/kg/8 sem. Octobre 2017 : echec de l’infliximab a visee d’epargne cortisonee, avec corticodependance a 20 mg/j. Debut d’un traitement par tocilizumab 8 mg/kg mensuel. Fevrier 2018 (dernier suivi) : remission clinique sous prednisone 8 mg/j, avec decroissance programmee. Bonne tolerance du traitement. Discussion Dans cette serie de patients (polychondrite atrophiante : 2 ; Cogan atypique : 1 ; idiopathique : 1) avec sclerite (nodulaire : 3 ; diffuse : 1), le tocilizumab a eu une efficacite rapide et nette sur le controle de la pathologie et l’effet d’epargne cortisonee. La tolerance a ete bonne, sans evenements indesirables severes. Conclusion Le tocilizumab peut representer une option therapeutique dans le cadre des sclerites non necrosantes refractaires, corticodependantes a haut niveau, en echec des DMARDS conventionnels et d’eventuelles biotherapies anterieures.

Introduction Le syndrome de Vogt-Koyanagi-Harada (VKH) est une maladie auto-immune se manifestant par une panuveite granulomateuse chronique, responsable de decollements sereux retiniens bilateral et par des atteintes extra-ophtalmologiques touchant les meninges, l’appareil auditif et les teguments. La place des traitements immunosuppresseurs « de fond » n’est pas etablie en complement des corticoides. L’objectif de cette etude est de determiner l’existence de facteurs de mauvais pronostic justifiant de l’introduction d’un traitement de fond plus precoce. Patients et methodes Analyse retrospective des patients suivis dans un centre medico-ophtalmologique specialise entre 2009 et 2018. Les donnees cliniques, epidemiologiques et de suivis ont ete collectees de facon retrospective a partir des dossiers medicaux informatises. Deux patientes ont ete perdue de vue et ont ete exclues de l’analyse. L’analyse statistique a compare le groupe de patients ayant ete traites uniquement par corticoides par rapport aux patients ayant recus un traitement de fond complementaire (immunosuppresseurs, biotherapie). Resultats Dix-neuf patients repondant au diagnostic de VKH ont ete inclus. Tous ont ete traites par une corticotherapie systemique en premiere intention suivant un schema usuel : bolus de solumedrol suivi d’une corticotherapie orale a 1 mg/kg/j avec decroissance progressive. Parmi eux, 11 patients ont eu une evolution favorable avec une bonne recuperation de l’acuite visuelle et l’obtention d’une remission permettant l’interruption complete des corticoides. Au cours du suivi, 7 patients ont presente une ou plusieurs rechutes (recidive inflammatoire justifiant une re-augmentation de la corticotherapie), un patient a presente une complication de la corticotherapie (chorioretinopathie sereuse centrale) : 3 patients ont alors recus de l’azathioprine (2 mg/kg/j), 4 patients de l’infliximab (5 mg/kg toutes les 8 semaines apres dose de charge). Six patients ont presente des complications ophtalmologiques (atrophie maculaire, fibrose sous retinienne, neovaisseaux choroidiens maculaires, glaucome secondaire) responsable d’une recuperation de l’acuite visuelle incomplete : tous ont alors recus un traitement complementaire : 5/6 un immunosuppresseur ou une biotherapie et 1/6 un anti-VEGF en intra-vitreen (refus de l’immunosuppresseur). L’introduction du traitement de fond a ensuite permis un controle de l’inflammation. L’analyse statistique entre le groupe de patients ayant recus uniquement des corticoides et ceux qui ont beneficie d’un immunosuppresseur n’a pas montre de difference epidemiologique (âge, sexe, duree d’evolution), ni sur le type d’atteinte (atteinte neurologique, ORL ou dermatologique), caracteristique ophtalmologique (debut unilateral/bilateral, acuite visuelle). Discussion La corticotherapie reste donc le traitement de reference dans cette pathologie. Neanmoins, au vu des complications presentees chez certains patients, responsable de sequelles visuelles parfois importantes, et en l’absence de facteurs predictifs de cette mauvaise evolution, il est important de proposer un suivi du type « tight control » chez ces patients pour pouvoir leur proposer un traitement de fond complementaire plus tot. Les faibles effectifs de cette etude ne permettent pas de juger d’une superiorite entre l’azathioprine et l’infliximab sur l’acuite visuelle finale. Une seule patiente a beneficie d’un traitement par infliximab alors qu’elle etait en echec sous azathioprine, avec un bon controle inflammatoire par la suite. Conclusion La corticotherapie systemique precoce et intense reste le traitement de premiere intention dans le VKH. En l’absence de critere predictif de mauvais pronostic, il est cependant necessaire d’envisager un suivi du type « tight control » chez ces patients afin de pouvoir debuter au plus tot un traitement de fond complementaire et prevenir l’apparition des complications ophtalmologiques.

Resume Introduction La decouverte ophtalmoscopique d’une elevation bilaterale de la tete du nerf optique suggere la presence d’un œdeme papillaire de stase, mais doit egalement faire discuter et rechercher plus simplement la presence de drusen papillaires. Etat des connaissances et perspectives Les drusen du nerf optique sont des concretions calcaires qui peuvent etre visibles par ophtalmoscopie. Parfois, le diagnostic des drusen est plus difficile, lorsqu’ils sont enfouis dans la profondeur de la tete du nerf optique. L’analyse de la tete du nerf optique par echographie B permet alors d’identifier les drusen papillaires. D’evolution habituellement benigne, les drusen peuvent toutefois s’accompagner d’anomalies progressives du champ visuel et entrainer de tres rares complications aigues. Les drusen du nerf optique peuvent ainsi se compliquer d’un œdeme papillaire ischemique vrai, les autres causes de perte visuelle dues au drusen seuls demeurant exceptionnelles. Conclusion Le diagnostic de drusen papillaire doit etre elimine (si besoin a l’aide d’examens complementaires, notamment pour les drusen enfouis) en cas de surelevation bilaterale de la tete du nerf optique avant d’envisager des investigations a la recherche d’une hypertension intracrânienne.

A new long-acting (LA) formulation of carteolol 2% instilled once daily has been shown to provide a therapeutic effect similar to that of the regular formulation of carteolol 2% instilled twice daily. This study was designed to test whether the new formulation reduces the systemic delivery of carteolol.In this double-masked, randomised, intra-subject comparative study, 23 patients with bilateral primary open-angle glaucoma or bilateral ocular hypertension received sequentially, according to the randomised order of administration, each of the 2 following treatments: carteolol 2% LA once daily for 2 months and carteolol 2% regular twice daily for 2 months. Treatments were instilled in both eyes throughout the study period. At the end of each period of treatment, blood samples were taken immediately before the last morning instillation (residual time), then 30 min, 1 h, 2 h and 4 h after this instillation in order to measure the carteolol plasma concentrations.The mean values of maximal plasma concentration (C(max)), residual level and area under the curve obtained following carteolol 2% LA treatment were significantly lower than the values obtained after carteolol 2% regular treatment (mean+/-SD): C(max) (ng/ml): 1.72+/-0.85 versus 3.64+/-3.65; residual level (ng/ml): 0.70+/-0.58 versus 1.80+/-0.84; area under the curve (ng/mlxh): 5.50+/-2.66 versus 10.27+/-5.46. Regarding safety, two drug-related, non-serious adverse events were reported in the LA group: one case of moderate, superficial, punctate keratitis and one case of "bitter taste in the throat." Both treatments appeared to be well tolerated.The data from this study showed that the systemic delivery of carteolol is lower for the once-daily LA formulation than for the regular twice-daily formulation. Consequently, long-acting carteolol eye-drops should reduce the risk of beta-blocking systemic side effects.

Introduction Le risque de transmission des prions concerne les actes que les ophtalmologistes sont amenes a faire lors des consultations. Le depistage des patients a risque passe par le recueil des antecedents de patients et des donnees cliniques. Patients et methodes Les auteurs presentent une version allegee d’un questionnaire dans lequel seuls les antecedents des consultants sont colliges, par le patient lui-meme, puis valides par l’ophtalmologiste. Resultats La pertinence de ce recueil a ete evaluee a partir de 500 questionnaires comportant 3 questions. Seuls 5 patients ont repondu positivement a une des 3 questions et n’ont donc pas ete examines avec des systemes contacts. Apres enquete, aucun patient ne s’est avere reellement a risque. Conclusion Le questionnaire propose semble donc satisfaire aux contraintes de temps et de personnels rencontrees en ophtalmologie, quel qu’en soit le mode d’exercice.

Les nouvelles procedures comme les injections intravitreennes et les vitrectomies 23 G ou 25 G, meme si elles sont peu invasives, peuvent se compliquer d’endophtalmies. Certains produits injectes comme les corticoides ou les antimitotiques favorisent les infections. C’est pourquoi, meme si ces gestes semblent faciles et anodins, ils doivent neanmoins etre realises dans des conditions chirurgicales d’asepsie comme l’ont demontre les etudes sur les injections intravitreennes d’antiangiogeniques dans lesquelles l’incidence de l’endophtalmie a ete divisee par 4 en respectant une asepsie chirurgicale stricte. Apres injection intravitreenne de triamcinolone, le principal diagnostic differentiel est la pseudo-endophtalmie, reaction inflammatoire aseptique avec hypopion et hyalite qui survient dans les trois jours suivant l’injection, et regresse spontanement. L’endophtalmie apres vitrectomie 25 G est probablement favorisee par l’absence de sutures et par l’incarceration de meches de vitre dans l’orifice de sclerotomie.

Pathologie a la fois chronique et asymptomatique, la neuropathie glaucomateuse pose des problemes de compliance au traitement. La prise en charge par les patients eux-memes de leur maladie est un point crucial du pronostic du glaucome. Par une education accrue et un veritable soutien medico-psychologique, les ophtalmologistes amelioreront la prise en charge de ces patients tres angoisses.

Le traitement medical maximal peut-etre absolu utilisant toutes les associations possibles si aucune chirurgie ne peut etre raisonnablement faite, ou relatif, l’etape suivante etant la chirurgie. Le choix du traitement se fait en concertation avec le patient. Dans tous les cas, les explications au patient doivent etre attentives, detaillant l’ordonnance et l’adaptant au cas par cas, afin d’optimiser la compliance.

Ophthalmologists must take into account the possible emergence of unconventional transmissible agents in their daily practice. Official recommendations have been circulated; however, their routine application remains difficult, with technical and financial considerations limiting factors in the use of an ideal of one disposable medical device per patient. This review describes how these recommendations are followed and tries to provide insights into improving daily practice with these unconventional transmissible agents.

Endophthalmitis remains the main complication of intravitreal injections, especially because their repetition multiplicates the risks. Surgical antisepsis is required for the prevention of endophthalmitis, but the benefit/risk ratio of topical antibioprophylaxis has never been demonstrated. In contrast, the selection of resistant bacteria appears to be exponential with the wider use of topical antibioprophylaxis. It seems that more and more operators stop using anibioprophylaxis, provided that the antisepsis is surgical and that the injection is performed in accordance with the rules of good practice.

Purpose Ligneous conjunctivitis is a rare type of chronic membranous conjunctivitis. It is inherited as an autosomal recessive disorder, with low plasminogen levels reported in both homozygous and heterozygous individuals Methods we describe the clinical features and response to subconjunctival FRESH FROZEN PLASMA (FFP) in three patients with severe ligneous conjunctivitis with a mean follow-up of 12 months, among 15 patients followed in our department for the past 10 years. Results All our cases had bilateral ocular involvement except. They were all treated with subconjunctival injection of FFP after resection of the membranes. Topical heparin and rimexolone application was continued 1 month after surgery. As the case 2 presented a corneal perforation during the course of the disease, he was also treated with multiple inlay amniotic membrane graft. Conclusion FFP shortens the treatment period, reduces the probability of mid-term recurrences and is a good alternative to a long-term topical treatment with Heparin and steroid.

Intravitreal injections are very commonly performed in the daily practice of Ophthalmology and become a leading procedure in the management of age-related macular degeneration, diabetic retinopathy, infectious endophthalmitis or retinitis, uveitis and retinal vein occlusions. Based on the comments of a group of experts, including ophthalmologists, pharmacists and hygienists, the French Agency for the Safety of Health Products (AFSSAPS) edited a guide to good practice of intravitreal injections, revisiting those previously published in 2006. The overall experience accumulated during time is a valuable source of information to determine the most appropriate protocol. Therefore, the simplification of the procedure is reasonably proposed even though safety remains a major issue, in order to avoid complications, especially infections.

In the treatment of patients with bacterial endophthalmitis, the intravitreal administration of antibiotics is suitable for induction therapy since it provides immediate high concentrations in the vitreous humor. Pefloxacin has been shown to have good intraocular penetration when given systemically. In order to extend the potential routes of administration of this agent, we have assessed the kinetics and toxicity of pefloxacin in rabbit phakic eyes following intravitreal instillation. Kinetic parameters were determined for 12 albino and 12 pigmented rabbits after a single injection of 80 micrograms. Pefloxacin was undetectable in the aqueous humor but high concentrations were found in the chorioretina. The vitreal half-life was short (3 h). These results were consistent with posterior elimination via the chorioretina. Pefloxacin concentrations in the iris and chorioretina of pigmented rabbits were two-fold greater than those in albino rabbits, probably because of binding to the pigmentary apparatus. Toxicity studies, including ophthalmological and histopathological investigations, identified a maximum non-toxic dosage of 400 micrograms. Intravitreal pefloxacin may therefore be suitable for induction therapy in patients with endophthalmitis, although further studies in primates are required to confirm the efficacy and tolerability of this route of administration.

According to the literature and to the advice of experts, the French Agency for the Safety of Health Products (AFSSAPS) edited recommendations about the antibioprophylaxis in ocular surgery. One goal was to avoid the extensive use of oral and topical fluoroquinolones in antibioprophylaxis, in order to preserve their antibacterial activity for curative treatments of severe eye infections. The medical team decides for the indication and the type of antibioprophylaxis for each patient. A topical antibiotic is recommended for any eye surgery until the etancheity of incisions. Due to the risk of selection of bacterial resistance topical fluoroquinolones are not recommended in this indication. In open eye surgery, an additional antibioprophylaxis is recommended: in cataract surgery, injection in the anterior chamber at the end of the procedure of 1mg of cefuroxime; in other open eye surgeries, only in case of risk factors for endophthalmitis, administration of 500 mg oral levofloxacin tablet 12 hours and two hours before surgery. For ocular punctures and intravitreal injections, only a topical postoperative antibiotic is recommended until healing.

Bacterial conjunctivitis is characterized by hyperemia and discharge of one or both eyes. These clinical signs appear quickly and are contagious. This study compares the clinical efficacy (signs and symptoms) and safety of azithromycin 1.5% eye drops with tobramycin 0.3%.This was a multicenter, randomized, investigator-masked study including 1,043 patients with purulent bacterial conjunctivitis. Patients received either azithromycin twice daily for 3 days or tobramycin, 1 drop every 2 hours for 2 days, then four times daily for 5 days. The primary variable was clinical cure at the test-of-cure (TOC) visit (D9) on the worst eye. The cure was defined as bulbar conjunctival injection and discharge scores of 0. Clinical signs were evaluated at D0, D3, and D9.In the azithromycin group 87.8% of patients and in the tobramycin group 89.4% were clinically cured at D9. Clinical cure with azithromycin was not inferior to tobramycin at D9: discharge was absent in 96.3% of patients treated with azithromycin and 95.1% with tobramycin. Azithromycin was well tolerated.Azithromycin 1.5% for 3 days (six drops) was as effective as tobramycin for 7 days (36 drops). Furthermore, patients on azithromycin presented earlier clinical cure on Day 3 than patients on tobramycin. Azyter, with its convenient dosing (bid for 3 days), is a step forward in the management of purulent bacterial conjunctivitis.

Cataract surgery is the most frequent surgery in France. The D1 consultation limits the extension of ambulatory care to patients who can return on their own the day after sugery. We assessed the usefulness of this systematic D1 consultation in terms of therapeutic modifications. MATERIAL AND MéTHODE: Retrospective study of patients who underwent cataract surgery in a teaching hospital from february to july 2006. The major parameter was the modification of postsurgical treatment after the D1 consultation.Of the 380 operated eyes studied, the patients included 145 men and 235 women, the mean age was 73.8 years (range, 43-92), 86% underwent conventional hospitalization, 70% had been operated by a senior surgeon, and 66% had no suture. At the D1 visit, 11 modifications (2.9%) were recorded: one case of athalamia, one Seidel-positive test, four cases of high IOP (30mmHg), and five severe inflammations of the anterior segment. All the treatment changes were reported in the group of hospitalized patients, none were reported in the ambulatory patients. Of the 380 eyes studied, only one required sutures at D1, the other treatment changes were minor.The low output of the D1 visit raises the problem of its relevance in terms of public health. In most of the English-speaking and Scandinavian countries, patients have only one postoperative visit at 1 month. Patients could receive written and oral recommendations and a hotline number to contact the surgical team, which could allow the D1 visit to be discontinued for standard patients with uncomplicated surgery.

We determined the ocular kinetics of pefloxacin, a new fluoroquinolone, when administered by the intramuscular route to albino and pigmented rabbits. In serum of albino rabbits, the area under the concentration-time curve (AUC) for the experimental period was 31.4 +/- 1.07 micrograms.h/ml (mean +/- standard deviation); the AUCs in the aqueous and vitreous humors were high (10.5 +/- 1.90 and 12.4 +/- 3.79 micrograms.h/ml, respectively). Pefloxacin was found in the avascular ocular tissues (30.15 +/- 3.79 micrograms.h/ml in the cornea and 6.98 +/- 1.06 micrograms.h/ml in the lens). In the vascularized tissues, the penetration ratio, defined as tissue AUC/serum AUC, was more than 1. The good intraocular diffusion of pefloxacin might be related to its low molecular weight and to its strong lipophilicity and could explain its clinical efficacy in the treatment of endophthalmitis. In pigmented rabbits, pefloxacin levels were high in the iris (1525 +/- 328 micrograms.h/ml, versus 40.2 +/- 5.08 micrograms.h/ml in albino rabbits) and chorioretina (2600 +/- 422 micrograms.h/ml, versus 48.3 +/- 7.52 micrograms.h/ml in albino rabbits), suggesting that it binds to the pigmentary apparatus.

Bilateral optic disc drusen can mimic papilledema, raising the question of intracranial hypertension and sometimes prompting unnecessary or invasive procedures.Optic disc drusen are benign calcified masses, often visible within the optic nerve head. However, their clinical diagnosis can be more difficult at earlier stages of life, when they are buried within the optic nerve. Visual field loss can occur in patients with longstanding optic disc drusen.Ophthalmoscopy and B-scan ocular ultrasonography allow appropriate diagnosis of bilateral optic disc drusen mimicking papilledema. On rare occasions, optic disc drusen can be associated with ischemic complications, the other causes of drusen-related visual loss being exceptionally rare.

The aim of this study was to analyze the quality and functional result of epiretinal membrane (ERM) surgery using optical coherence tomography (OCT).We conducted a retrospective, non comparative study between January 2004 and June 2006. Thirty-two eyes were included and operated by vitrectomy for ERM. The OCT assessment of the macular profile was evaluated postoperatively on day 8, day 30 and every 3 months thereafter. The first outcome measure was postoperative abnormality of the OCT profile. The secondary outcome measure was analysis of the functional result with macular thickness and best visual acuity. The Student t-test and the paired series comparison were used for the statistical analysis.After surgery, 23 eyes (72%) showed abnormality of the reflectivity signal as assessed by OCT. Only nine eyes (28%) had or showed restored foveal depression and normal macular thickness. Dissociated optic nerve fiber layer appearance was observed in 43.7% (14 eyes). The best visual acuity increased from 0.58+/-0.23 LogMar to 0.25+/-0.24 after ERM surgery (p0.001). The macular thickness decreased from 374.6+/-78.7 microm to 271+/-44.6 microm postoperatively (p0.001).Epiretinal membrane surgery is safe and effective in terms of the functional result but most cases do not recover normal microanatomy. This feature does not influence the functional result. Mechanical traction due to peeling of the epiretinal membrane associated with peeling of the internal limiting membrane may be the cause of these microanatomical results.

New procedures such as intravitreal injections, 25-G or 23-G vitrectomies, and intravitreal implantations are less aggressive, but they can be complicated by bacterial endophthalmitis. Additionally, injected drugs such as corticosteroids or antimitotics might facilitate the occurrence of infections. Therefore, even if easy to perform, these new procedures must be performed in strict aseptic conditions, as demonstrated in the studies with antiangiogenic factors, where the incidence of endophthalmitis was divided by 4 when the rules of surgical asepsis were respected. In cases of intravitreal injection of triamcinolone, the main differential diagnosis is pseudoendophthalmitis, an aseptic inflammatory reaction with hyalitis and hypopyon, which occurs within 3 days and spontaneously resolves. Endophthalmitis after 25-G surgery might be related to the absence of suture and to the vitreous incarcerated in the sclerotomy.

Compliance is a major issue in glaucoma, a chronic and asymptomatic disease. The management of the disease by the patient himself is a key point in the prognosis of glaucoma. Ophthalmologists can increase glaucoma patient compliance through education and medicopsychological assistance.

To describe different forms of neuro-ophthalmologic onset of sarcoidosis: clinical signs, means of diagnosis, treatment, and progression.Retrospective study of 13 patients with neuro-ophthalmologic initial onset of sarcoidosis diagnosed in three departments between 1997 and 2003.There were ten women and three men, with a mean age of 36 years. Six patients suffered from diplopia. In three cases, the cavernous sinus was involved; the three other patients with diplopia had meningoradiculitis. Nine patients had infiltration of the anterior visual pathway: the optic nerve was involved in five cases, the chiasm in two cases, and two patients had papilledema. Two patients also had both symptoms. The dosage of the angiotensin-converting enzyme level was evaluated in 11 patients and was elevated in six cases. Nine patients underwent a lumbar puncture; the cerebrospinal fluid protein was high in seven cases. Chest radiography and CT were abnormal in nine cases of 11. Ten patients had histological proof of sarcoidosis; the three others had enough evidence to support this diagnosis. All of them were treated with systemic corticosteroids. The diplopia improved for the six patients. Among the seven patients with optic nerve or chiasmal infiltration, one recovered completely, two were partially improved, and four remained stable.Diplopia and anterior visual pathway abnormalities can be the manifestation of initial onset of sarcoidosis; therefore this diagnosis must be kept in mind when these frequent neuro-ophthalmologic signs are encountered. Complementary exams, mainly biopsy of the involved areas with histological analysis, are needed to confirm this diagnosis. Corticosteroid treatment is generally followed by improvement, but relapses may occur.

Maximal drug treatment can be absolute, using all the combinations possible if no surgery can reasonably be undertaken, or relative, with surgery as the next step. The drug treatment is chosen in collaboration with the patient, who should always receive attentive explanations, detailing the prescription and adapting it to each situation so as to achieve maximum compliance.

Use of a prostaglandin analog in cataract surgery can cause cystoid macular edema in the pseudophakic patient, but this is a rare complication that resolves when treatment is stopped. However, in the surgical context, this type of eye drop should not be prescribed as first-line treatment and in any case it should be associated with nonsteroidal anti-inflammatory agents.

Ophthalmologists must take into account the possible emergence of unconventional transmissible agents in their daily practice. Official recommendations have been circulated; however, their routine application remains difficult, with technical and financial considerations limiting factors in the use of an ideal of one disposable medical device per patient. This review describes how these recommendations are followed and tries to provide insights into improving daily practice with these unconventional transmissible agents.

In uveitis, ocular hypertension may have different meanings. Before corticotherapy, hypertensive uveitis has specific etiologies. During corticotherapy, hypertensive uveitis or ocular hypertension related to corticotherapy may be involved. Intra-ocular pressure monitoring is mandatory in uveitis and during corticotherapy.

We describe a new technique for restoring lacrimal pathway anatomy in common canaliculus surgery. Fourteen patients (4 men and 10 women), with a mean age of 59 +/- 19 years, suffering from chronic epiphora caused by common canaliculus stenosis were operated on (18 procedures: 14 unilateral, 4 bilateral). We used a modified Dupuy-Dutemps technique. The anterior face of the lacrimal sac was cut as a flap, which was secured with the posterior nasal mucosal flap for the posterior anastomosis plane. The common canaliculus stenosis and the external face of the lacrimal sac were excised guided by the operating microscope so as to put in place a bicanalicular device, which was left for 6 months. The anterior plane of anastomosis was made of a Goretex((R)) patch or PTFE((R)) (Polytetrafluoroethylene((R))) placed under the deep face of the orbicularis muscle. The procedure was successful in 15 of the 18 cases (success rate: 83.3%). Among the three failures, two were due to the early loss of the bicanalicular stent and one to anastomosis fibrosis. This technique made it possible to restore lacrimal pathway anatomy, which was severely modified by the dacryocystorhinostomy procedure and to protect the anastomosis from fibrosis by the surrounding tissues. Biomaterials such as Goretex((R)) and PTFE((R)) are valuable tools for this technique. In common canaliculus stenosis, restoring the lacrimal pathway with biomaterials such as Goretex((R)) or PTFE((R)) improves the functional results.

Glaucoma is a chronic optic neuropathy related to progressive loss of visual fibers. It can lead to complete blindness. There are several types of glaucoma: primitive open angle glaucomas, angle closure glaucomas, secondary glaucomas and congenital glaucomas. The diagnosis of the disease relies on the alterations of the visual field, the measure of intraocular pressure, the aspects of the optic disc and of the iridocorneal angle. As most of the glaucomas are asymptomatic, they often induce a severe loss of vision. Therefore, its systematic screening by ophthalmologists is mandatory.

Bioavailability is one of the major factors for therapeutic efficacy. The bioavailability of antiinflammatory drugs depends on the status of the eye (degree of inflammation, vitrectomy, aphakia) and on the drug (route of administration, regimen, concentration and presentation). The bioavailability of steroid drops increases with acetate compounds, frequency of administration, concentration and contact time. Peribulbar injections provide a long-delivery system but with a significant systemic diffusion. Intravitreal steroids have only a local effect due to the very low doses injected. The bioavailability of non steroidal antiinflammatory drugs is variable, but their effects are similar. Antimetabolites such as 5-fluorouracil or mitomycin C have short half-lives, but mitomycin C must be rinsed after use due to its toxicity.

To assess the efficacy and tolerability of high-dose (2000microg) intravitreous ganciclovir in the maintenance therapy of CMV retinitis in AIDS patients.and methods: Prospective open study in a single center. The maintenance therapy of CMV retinitis consisted of a single high-dose (2000microg) intravitreous injection per week. The evaluation criteria were clinical examinations, and photographs when necessary.Over a 44-week period, twenty-four eyes (15 patients) have been included. The relapse rate evaluated by the survival curves method was 5% at 44 weeks. No ocular toxicity was reported after a follow-up of 24 weeks.High-dose intravitreous ganciclovir induces a prolonged remission of CMV retinitis and is well tolerated. Therefore, we recommend the use of the 2000microg dosage per intravitreous injection instead of the classical dosage of 400microg.

To assess the tolerability and efficacy of intravitreal injections of foscarnet in cytomegalovirus (CMV) retinitis in acquired immunodeficiency syndrome (AIDS).Patients with CMV retinitis resistant and/or intolerant to intravenous foscarnet and ganciclovir and resistant to intravitreal ganciclovir were included. The induction therapy consisted of intravitreal injections of 2,400 micrograms of foscarnet twice a week. The assessment was performed by clinical examination and photographies of the fundus.Three patients (four eyes) have been included. Three eyes were administered seven and one eye eight intravitreal injections. The tolerability was good, but the efficacy was mere: the retinal lesions became less edematous, but they still extended.In these four eyes with CMV retinitis resistant to intravitreal ganciclovir, intravitreal injections of foscarnet were well tolerated but did not stop the progression of the retinitis.

To study a technique of self-sealing sclerotomies, recently described.After conjunctival peritomy, a tunnel incision is performed with a crescent knife, 2 mm posterior to the intended site of entry. Then a 20G microvitreoretinal blade is used to enter the vitreous cavity. From November 1996 to April 1997, 99 primary vitrectomies were prospectively studied.292 sclerotomies were performed with this technique. Self-sealing sclerotomies were observed in 270 cases (92.5%). In 22 cases, leakage of fluid required closure with 8-0 nylon sutures. Leakage was related to multiple instruments used through the sclerotomy, or more frequently to a thin scleral wall. In 1 case, transient hypotony was observed. Ocular pressure spontaneously returned to normal.Self-sealing sclerotomies are difficult to perform if the sclera is thin, and leakage can be observed if multiple instruments have to be used through the same sclerotomy. But this technique prevents vitreous and retinal herniation through the sclerotomy, and ocular hypotony. It also reduces the operative time, and prevents irritation related to nonabsorbable sutures.

Use of a prostaglandin analog in cataract surgery can cause cystoid macular edema in the pseudophakic patient, but this is a rare complication that resolves when treatment is stopped. However, in the surgical context, this type of eye drop should not be prescribed as first-line treatment and in any case it should be associated with nonsteroidal anti-inflammatory agents.

To evaluate the incidence and the prognosis of retinal detachment in CMV retinitis in AIDS. To test intravitreal injections of ganciclovir into the vitreal cavity filled with silicone.Among 136 eyes with CMV retinitis, 15 (11%) had retinal detachment. Ten eyes underwent intraocular surgery with injection of silicone oil, one extraocular surgery and four eyes were not operated. Later, four eyes filled with silicone received intravitreal injections of ganciclovir.At 2 months, the retina was flat in all the operated eyes, with a visual acuity improved or stabilized in 8 cases (73%). Conversely, visual acuity was lost in all the unoperated eyes. The 14 intravitreal injections of ganciclovir performed in four eyes (which received 2, 3, 3 or 6 injections, respectively) were well tolerated.Surgery of retinal detachment in CMV retinitis usually allows the conservation of ambulatory visual acuity. Its indications must be discussed together with the patient, the ophthalmologist and the physician. Intravitreal injections of ganciclovir in vitreal cavity filled with silicone oil are possible.