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In 2021, WHO Member States endorsed a global target of a 40-percentage-point increase in effective refractive error coverage (eREC; with a 6/12 visual acuity threshold) by 2030. This study models global and regional estimates of eREC as a baseline for the WHO initiative.The Vision Loss Expert Group analysed data from 565 448 participants of 169 population-based eye surveys conducted since 2000 to calculate eREC (met need/[met need + undermet need + unmet need]). A binary logistic regression model was used to estimate eREC by Global Burden of Disease (GBD) Study super region among adults aged 50 years and older.In 2021, distance eREC was 79·1% (95% CI 72·4-85·0) in the high-income super region; 62·1% (54·7-68·8) in north Africa and Middle East; 49·5% (45·0-54·0) in central Europe, eastern Europe, and central Asia; 40·0% (31·7-48·2) in southeast Asia, east Asia, and Oceania; 34·5% (29·4-40·0) in Latin America and the Caribbean; 9·0% (6·5-12·0) in south Asia; and 5·7% (3·1-9·0) in sub-Saharan Africa. eREC was higher in men and reduced with increasing age. Global distance eREC increased from 2000 to 2021 by 19·0%. Global near vision eREC for 2021 was 20·5% (95% CI 17·8-24·4).Over the past 20 years, distance eREC has increased in each super region yet the WHO target will require substantial improvements in quantity and quality of refractive services in particular for near vision impairment.WHO, Sightsavers, The Fred Hollows Foundation, Fondation Thea, Brien Holden Vision Institute, Lions Clubs International Foundation.

We report a case of a 28-year-old otherwise healthy female patient who presented with blurred vision in her right eye related to multiple branch retinal artery occlusions confirmed by fluorescein angiography. Investigation revealed positive antinuclear antibodies and an interatrial septal aneurysm on transthoracic echocardiography. The patient was treated with oral prednisolone and aspirin. Two months after her initial presentation, she developed hearing loss and tinnitus. Ophthalmological examination revealed temporal inferior and nasal inferior branch retinal artery occlusions in the left eye. Magnetic resonance imaging of the brain showed multifocal T2 hyperintense lesions in cortical and subcortical areas as well as the corpus callosum consistent with Susac’s syndrome. The diagnosis of Susac’s syndrome should be kept in mind in young patients presenting with multiple or recurrent retinal artery occlusions even in the absence of associated systemic symptoms to not delay appropriate management.

Background: The Vision Loss Expert Group and Global Burden of Disease Study have extensively updated estimates of global vision loss burden in 2020, temporal changeover 3 decades and forecasts for 2050. Methods: A systematic review and meta-analysis was conducted of population-based datasets relevant to vision impairment (VI) from January 1980 to October 2018. Hierarchical models were fitted to estimate 2020 prevalence (with 95% uncertainty intervals, UI) of (1) mild VI (presenting visual acuity [PVA] 6/12). Findings: In 2020, an estimated 43.2 million (95% UI: 37.5-48.2 million; 55% female) people were blind, 295.3 (95% UI 267.0-325.5) million had MSVI, 257.3 (95% UI 232.2-284.7) million had mild VI, and 507.4 million (95% UI 369.3–663.8) were VI from uncorrected presbyopia. Globally among adults aged ≥50 years, age-standardised prevalence of blindness reduced by 29% between 1990 and 2020, while MSVI increased slightly (+2.4%). The number of blind people increased by 50.2% and MSVI by 91.6%. By 2050, we predict 895.5 million people blind/VI. Interpretation: It is encouraging that age-adjusted prevalence of blindness has reduced over the past 3 decades, yet due to population growth progress is not keeping pace with needs. We face enormous challenges in avoiding vision impairment as the global population grows and ages. Funding Statement: Brien Holden Vision Institute. Fondation Thea. Fred Hollows Foundation. Gates Foundation. Sightsavers International. University of Heidelberg. Declaration of Interests: A.M. Bron, Allergan (C) Baush and Lomb (C), Santen (C), Thea (C) - (C) stands for consultant. J Kempen: Consultant (DSMC Chair) for Gilead. Grants and contracts from National Institutes of Health/National Eye Institute; Sight for Souls; and Christoffel Blindenmission. No other authors had conflicts to declare.

Diabetic retinopathy is a major cause of reduced visual acuity and acquired blindness. The aim of this work was to analyze functional and vascular changes in diabetic Meriones shawi (M.sh) an animal model of metabolic syndrome and type 2 diabetes. The animals were divided into four groups. Two groups were fed a high fat diet (HFD) for 3 and 7 months, two other groups served as age-matched controls. Retinal function was assessed using full field electroretinogram (Ff-ERG). Retinal thickness and vasculature were examined by optical coherence tomography, eye fundus and fluorescein angiography. Immunohistochemistry was used to examine key proteins of glutamate metabolism and synaptic transmission. Diabetic animals exhibited significantly delayed scotopic and photopic ERG responses and decreases in scotopic and photopic a- and b-wave amplitudes at both time points. Furthermore, a decrease of the amplitude of the flicker response and variable changes in the scotopic and photopic oscillatory potentials was reported. A significant decrease in retinal thickness was observed. No evident change in the visual streak area and no sign of vascular abnormality was present; however, some exudates in the periphery were visible in 7 months diabetic animals. Imunohistochemistry detected a decrease in the expression of glutamate synthetase, vesicular glutamate transporter 1 and synaptophysin proteins. Results indicate that a significant retinal dysfunction was present in the HFD induced diabetes involving both rod and cone pathways and this dysfunction correlate well with the morphological abnormalities reported previously. Furthermore, neurodegeneration and abnormalities in retinal function occur before vascular alterations would be detectable in diabetic M.sh.

Purpose: To describe optical coherence tomography angiography (OCTA) findings in eyes with Behcet uveitis (BU) and to compare these findings with those of fluorescein angiography (FA). Methods: Prospective, comparative, cross-sectional study. Patients presenting with clinically active BU involving the posterior segment were evaluated using FA, spectral domain optical coherence tomography (SD-OCT), and OCTA. Optical coherence tomography angiograms were reviewed and analyzed. Foveal avascular zone areas and vessel densities were also reported. Results: Twenty-five patients (44 eyes) were included. Perifoveal microvascular changes were more frequently observed on OCTA than on FA (95.5 vs 59.1%; P < 0.001). Disruption of the perifoveal capillary arcade, areas of retinal capillary nonperfusion/hypoperfusion, and perifoveal capillary abnormalities, including rarefied, dilated, or shunting vessels were observed more frequently using OCTA than FA (40.9 vs 25%; P = 0.039, 86.4 vs 34.1%; P < 0.001, and 84.1 vs 36.4%; P < 0.001, respectively). Areas of retinal capillary nonperfusion/hypoperfusion were more frequently observed in the deep than in the superficial capillary plexus (81.8 vs 63.6%; P = 0.039). Capillary abnormalities and disorganization of the normal architecture of the capillary network were more frequent in the deep than in the superficial capillary plexus (P < 0.001). Foveal avascular zone area was not significantly larger in eyes with BU than in control group in both the superficial and the deep capillary plexuses (0.4 vs 0.34 mm; P = 0.23 and 0.72 vs 0.53 mm; P = 0.053, respectively). Capillary vessel density was significantly lower in eyes with BU than in control group in the deep capillary plexus (13.7 vs 17.2 mm 21; P = 0.004). Conclusion: OCTA allows better visualization and characterization of perifoveal microvascular changes than FA in eyes with active BU. The deep capillary plexus seemed to be more severely involved than the superficial capillary plexus.

The purpose of this study is to evaluate anterior chamber aqueous flare (ACAF) in Tunisian patients with pseudoexfoliation (PEX) syndrome with or without associated glaucoma. This is a prospective, cross-sectional, comparative study including 53 patients (88 eyes) with PEX syndrome, 48 patients with PEX glaucoma (86 eyes), and 53 healthy sex-and age-matched control subjects (106 eyes). All patients underwent a complete ophthalmic examination and laser flare photometry. Mean ACAF was significantly higher in the PEX syndrome group in comparison with the control group (17.96 ± 10.05 vs 7.06 ± 2.95 ph/ms; p = 10(-4)), in patients with PEX glaucoma compared to PEX syndrome without associated glaucoma (27.99 ± 15.45 vs 17.96 ± 10.05 ph/ms; p = 10(-4)), in the PEX glaucoma group in comparison with control group (27.99 ± 15.45 vs 7.06 ± 2.95 ph/ms; p = 10(-4)), and in patients with unilateral PEX syndrome in comparison with contralateral-unaffected eyes (25.72 ± 14.88 vs 8.58 ± 3.45 ph/ms; p = 0.000). For patients with PEX syndrome, a high ACAF might be a predictor for the development of glaucoma. Further investigations are needed to clarify the role of laser flare photometry in predicting the risk of glaucoma in patients with PEX syndrome.

The purpose of this study is to compare the effect of topical diclofenac and topical dexamethasone on anterior chamber flare and postoperative pain following rhegmatogenous retinal detachment (RRD) surgery. This prospective study included 40 eyes of 40 patients treated for RRD. Twenty-eight patients underwent scleral buckling and 12 patients underwent 20-gauge pars plana vitrectomy (PPV). For each surgical procedure, patients were postoperatively randomly divided into two groups: the first group received topical dexamethasone phosphate 0.1 % four times daily for 28 days; the second group received topical diclofenac sodium 0.1 % three times daily for 28 days. The inflammatory reaction in the anterior chamber was measured with laser flare photometry preoperatively and 1, 7, 14, 28, and 90 days postoperatively. Pain level was evaluated with Scott's visual analog scale at day 1, 7, 14, and 28 postoperatively. For patients treated with scleral buckling, there was no significant difference between the two groups regarding mean aqueous flare at day 1 (p = 0.096), day 7 (p = 0.435), day 14 (p = 0.510), day 28 (p = 0.583), and day 90 (p = 0.423). The group who received diclofenac had significantly lower pain score at days 7, 14, and 28 (p = 0.048, p = 0.017, and p = 0.028, respectively). For patients treated with PPV, there was no significant difference between the two groups regarding mean aqueous flare at day 1 (p = 0.400), day 7 (p = 0.728), day 14 (p = 0.843), day 28 (p = 0.939), and day 90 (p = 0.568). Patients who received diclofenac had significantly lower pain score at days 7, 14, and 28 (p = 0.032, p = 0.030, and p = 0.023, respectively). Topical diclofenac seems to be as potent as topical dexamethasone in managing postoperative inflammatory response induced by surgery for RRD with better analgesic effect. Both of them are consequences of blood-aqueous barrier and blood-retinal barrier breakdown.

Background Cardiac and vascular involvement in Behçet disease (BD), also referred as vasculo BD, is frequent. We aimed to describe clinical characteristics, predictive factors and management of vasculo BD in the Tunisian context. Methods We retrospectively studied 213 records of all BD patients followed between January 2004 and May 2016 in the Internal Medicine Department and who fulfilled the ISGBD criteria. We described first clinical features of BD with cardiac and vascular involvement then predictive factors were studied in univariate then multivariate analysis. Results Among the 213 patients, 64 (30%) were diagnosed as having vasculo BD. The mean age at diagnosis was 31.5 years. About 81.25% of them were males and 18.75% females. Vascular involvement associated or not with cardiac involvement was found in 64 patients (30%). Deep venous thromboses are most common (62.5%) compared with superficial ones (23.4%), pulmonary arterial thrombosis (14.1%) or aneurysms (9.4%). Cardiac involvement is ranging from pericarditis (1.6%) to intra cardiac thrombosis (3.1%) and myocardial infarction (1.6%). Predictive factors associated with cardiac and vascular involvement in BD are male gender (OR = 3.043, 95% CI = 1.436–6.447, p = 0.004), erythema nodosum (OR = 4.134, 95% CI = 1.541–11.091, p = 0.005) and neurologic involvement (OR = 2.46, 95% CI = 1.02–5.89, p = 0.043). Conclusion Cardiac and vascular involvement in BD is frequent in the Tunisian context with a broad spectrum of manifestations ranging from vascular involvement to cardiac one. Male gender, patients with erythema nodosum or neurologic involvement are prone to develop cardiac or vascular features of BD needing therefore a close monitoring.

The purpose of this study was to determine final diagnosis of patients referred with a diagnosis of neuroretinitis. A retrospective study of 40 patients with optic disc oedema with macular star (ODOMS) referred with a diagnosis of neuroretinitis was conducted. The final diagnosis was neuroretinitis in 26 patients (65%), with most of these patients (96.1%) having unilateral involvement. Main underlying aetiologies included cat scratch disease (30.8%), rickettsiosis (19.2%), and idiopathic neuroretinitis (23.1%). The remaining 14 patients (35%) had ODOMS that had been mistaken for neuroretinitis. Of these patients, 42.8% were found to have a previously unknown malignant systemic hypertension in association with bilateral ODOMS. Neuroretinitis, usually unilateral, should be differentiated from other causes of unilateral or most often bilateral ODOMS that may masquerade as neuroretinitis, mainly malignant systemic hypertension. This is essential to avoid inappropriate work-up and management and subsequent potential visual or systemic morbidity.

To report optical coherence tomography angiography findings in a patient with rickettsial retinitis.A 29-year-old man complaining of acute blurring vision in the right eye associated with Rickettsia conorii infection underwent a comprehensive ocular examination, fluorescein angiography, spectral-domain optical coherence tomography, and swept-source optical coherence tomography angiography.Funduscopy showed two large areas of retinitis in the inferior macula along the distribution of the inferotemporal artery with associated retinal hemorrhages, retinal edema, and serous retinal detachment. Fluorescein angiography showed early hypofluorescence and late staining of white retinal lesions and associated adjacent retinal vascular leakage and optic disc hyperfluorescence. Optical coherence tomography angiography showed hypointense dark areas in the superficial capillary plexus and larger hypointense areas in the deep capillary plexus, outer retina, and choriocapillaris layer. The patient was treated with doxycycline and prednisone. Six weeks after presentation, retinal changes seen at the acute phase had resolved, leading to mild residual retinal pigment epithelial changes. Fluorescein angiography showed retinal capillary nonperfusion within areas of resolved retinitis. Spectral-domain optical coherence tomography findings included inner retinal atrophy, intraretinal cysts, and disruption of ellipsoid zone and interdigitation zone. Swept-source optical coherence tomography angiography showed well-delineated hypointense greyish areas of retinal capillary nonperfusion in both the superficial and deep capillary plexuses. Visual field testing revealed the presence of a corresponding paracentral defect.Optical coherence tomography angiography may be a valuable noninvasive imaging technique for detecting and analyzing occlusive complications associated with rickettsial retinitis.

Different forms of optic neuropathy causing visual impairment of varying severity have been reported in association with a wide variety of infectious agents. Proper clinical diagnosis of any of these infectious conditions is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular findings. Diagnosis is confirmed by serologic testing and polymerase chain reaction in selected cases. Treatment of infectious optic neuropathies involves the use of specific anti-infectious drugs and corticosteroids to suppress the associated inflammatory reaction. The visual prognosis is generally good, but persistent severe vision loss with optic atrophy can occur. This review presents optic neuropathies caused by specific viral, bacterial, parasitic, and fungal diseases.

Rift Valley fever (RVF) is an emerging arthropod-borne zoonotic disease caused by RVF virus, which belongs to the Bunyaviridae family. RVF virus infection in humans usually causes a self-limiting acute and febrile illness but severe potentially lethal forms may develop. Macular or paramacular retinitis is the most common ocular complication of RVF. Other findings may include nongranulomatous anterior uveitis, retinal vasculitis, retinal hemorrhages, vitritis, and optic disc edema. Diagnosis is based on epidemiologic data, serologic testing and/or PCR. Ocular involvement is frequently associated with permanent visual loss. Treatment of RVF is entirely supportive and prevention is the mainstay of infection control.

Purpose: To describe the pattern of acute retinal necrosis (ARN) syndrome in a referral center in Tunisia.Methods: Retrospective review of the charts of 12 patients (12 eyes).Results: Necrotizing retinitis involved >50% of the retina in 33.3% of eyes. Polymerase chain reaction on aqueous humor sample identified herpes simplex virus-1 in 4 eyes (33.3%) and varicella zoster virus in 3 eyes (25%), and was negative in 5 eyes (41.7%). All patients received intravenous acyclovir, followed by oral antivirals. Follow-up ranged from 6 to 16 months. Retinal detachment (RD) occurred in 3 eyes (25%), but no patient developed bilateral ARN. Final visual acuity was 20/200 or worse in 7 eyes (58.3%). Delay in diagnosis (p = 0.015), macular involvement (p = 0.045), development of RD (p = 0.018), and 25–50% of retinal involvement (p = 0.045) were associated with a worse visual outcome.Conclusion: ARN carries poor visual prognosis in Tunisia.

Summary Primary congenital glaucoma (PCG) is responsible for a significant proportion of childhood blindness in Tunisia. Early prevention based on genetic diagnosis is therefore required. This study sought to determine the frequency of CYP1B1 (cytochrome P450, family 1, subfamily B, polypeptide 1) mutations in 18 PCG patients, recruited from Central and Southern of Tunisia. Genomic DNA was extracted and the coding regions of CYP1B1 were analysed by direct sequencing. A phylogenetic network of CYP1B1 haplotypes was drawn using the median-joining algorithm. Sequence analysis revealed a “tetra-allelic mutation” (two novel mutations, p.F231I and p.P437A in the homozygous state) in one patient. The healthy members of his family carried those variations on the same allele. Two previously described mutations p.G61E and c.535delG were also identified in the homozygous state in seven and two probands, respectively. Seven single-nucleotide polymorphisms were identified and used to generate haplotypes. Our results showed that the CYP1B1 mutations were present in 55% of Tunisian PCG patients’ alleles. Haplotype analysis allowed us to define the proto-haplotype and to confirm historical migratory flows. Establishment of PCG genetic aetiology in Tunisia will improve genetic diagnosis and counselling.

To investigate the prevalence and causes of blindness and partial sight among a population of Tunisian diabetic patients.A cross-sectional study of 2320 randomly identified patients with diabetes mellitus. Patient's characteristics as well as data from the last ophthalmic examination were reviewed.Of all patients examined, 60.2% were females and 39.8% were males. Mean age of patients was 54.5 years. Mean duration of diabetes was 7.6 years. Diabetic retinopathy (DR) was recorded in 26.3% of patients, and was proliferative in 3.4% of patients. The prevalence of visual impairment was 22.2%, with 4.4% patients legally blind and 17.8% partially sighted. Visual impairment was significantly associated with age ≥60 years (P0.001), duration of diabetes10 years (P0.001), body mass index25 (P=0.014), hypertension (P0.001), heart disease (P0.001), peripheral neuropathy (P=0.03), vegetative neuropathy (P=0.002), macroalbuminuria (P0.001), cataract (P0.001), DR (P0.001), diabetic macular edema (P0.001), open angle glaucoma (P0.001), intravitreal hemorrhage (P0.001), rubeosis iridis (P0.001), neovascular glaucoma (P0.001), and tractional retinal detachment (P0.001).The current report is the largest study of DR in North African region. It provides a baseline data against which future progress can be assessed. Screening and treatment can greatly reduce the incidence of visual impairment due to diabetes.

Purpose of review Emergent and resurgent infectious diseases are major causes of systemic morbidity and death that are expanding worldwide mainly because of climate changes and globalization. Among them, specific diseases have been recently associated with ocular involvement. This review presents the ocular manifestations of selected emerging infectious diseases relevant to the ophthalmologist. Recent findings An array of ocular manifestations, involving mainly the posterior segment, have been recently described in association with specific arthropod vector-borne diseases including rickettsioses, West Nile virus, Rift Valley fever, Dengue fever, and Chikungunya. Influenza A (H1N1) virus has also been recently associated with ocular involvement. On the contrary, with advances in laboratory testing applied to ocular fluids, new infectious agents, mainly viruses, are increasingly being found to be associated with uveitis. Summary Emerging infectious diseases should be considered in the differential diagnosis of retinitis, chorioretinitis, retinal vasculitis, optic neuropathy, or any other ocular inflammatory condition in a patient living in or traveling back from a specific endemic area. On the contrary, ocular fluid sampling and analysis for specific new pathogens can be recommended in selected patients with uveitis of unexplained cause.

Purpose: To characterize and analyze ocular involvement associated with visual loss in a cohort of patients with rickettsial disease.Methods: Retrospective study of 16 eyes of 14 patients.Results: Mean initial visual acuity (VA) was 20/63 (range, 20/800–20/25). White retinal lesions infiltrating inner retina was the most common finding occurring in 14 eyes (87.5%). It was associated with a serous retinal detachment (SRD), accurately detectable by optical coherence tomography, in 11 eyes (78.6%). Other findings included optic neuropathy in 7 eyes (43.75%), cystoid macular edema in 1 eye (6.25%), branch retinal artery occlusion in 1 eye (6.25%), and choroidal neovascularization in 1 eye (6.25%). Thirteen patients were treated with a 2-week course of oral doxycycline 200 mg/day. Mean final VA was 20/40.Conclusions: Inner retinitis, associated with mild vitritis and SRD, and optic neuropathy are the most common vision-threatening ocular manifestations of rickettsial disease.

To report the results of multimodal imaging of acute outer retinitis associated to mumps infection. A patient with mumps-associated outer retinitis evaluated by color fundus photography, spectral domain optical coherence tomography (SD-OCT), optical coherence tomography angiography, fundus autofluorescence (FAF), fluorescein angiography (FA), and indocyanine green angiography (ICGA). We report a case of a 12-year-old boy who developed bilateral outer retinitis related to mumps. Ophthalmoscopy showed confluent areas of outer retinitis involving the posterior pole and the periphery with a centrifugal gyrate pattern. SD-OCT revealed a marked disorganization of the outer retinal layers with multiple highly reflective spicules. FA shows diffuse late hyperfluorescence with optic disk staining. ICGA shows macular and peripheral hyperfluorescent lesions with a geographical pattern in the late phases. The patient was treated with acyclovir and oral prednisone. Four weeks after presentation visual acuity remained unchanged, and retinal changes seen at the acute phase had resolved leading to extensive retinal atrophy and optic disk pallor. SD-OCT showed atrophy of the retinal pigment epithelial and outer retinal layers. FAF revealed scattered hyperautofluorescent lesions. Electrophysiology showed generalized retinal dysfunction. Mumps infection should be considered in the differential diagnosis of bilateral necrotizing outer retinitis in children and young adults. A multimodal imaging approach may help distinguish mumps-associated retinitis from other causes of viral retinitis and facilitate appropriate management.

Orbital infections (OI) are a serious disorder that may results in visual and systemic morbidity.To study epidemiologic data and outcome of OI in a tertiary eye care center.Retrospective study of 28 patients (28 eyes) with OI. All patients underwent detailed ophthalmic examination, otolaryngology examination, and cranio-orbital computed tomography scan. All patients received parenteral probabilistic antibiotic treatment then adapted depending on the sensitivity of antibiogram and clinical evolution, associated or not to corticosteroid treatment. The mean follow-up was 14 months.The mean age of our patients was 35.9 years. Fifteen patients (54%) were male. Of 28 cases, retroseptal cellulitis was the most common, noted in 67.8% of cases. subperiosteal or orbital abscess was recorded in 28.6% of the cases. Sinusitis was the most common etiology, found in 39.3% of cases. Treatment was based on empirical broad spectrum systemic antibiotics in all cases. Surgical management was performed in 39.3% of cases. Bacteriological samples were obtained for 28.5% of patients, with Staphylococcus aureus the most frequently isolated pathogen (5 cases; 62.5%). The evolution was favorable with complete resolution without sequelae in 92.8% of the cases and improvement of visual acuity in 82% of cases. Causes of poor visual outcome were corneal perforation, cataract and retinal detachment.In our series, OI affects children and young adults. Their prognosis is generally favorable provided rapid and appropriate management.

Emergent and resurgent arthropod vector-borne diseases are major causes of systemic morbidity and death and expanding worldwide. Among them, viral and bacterial agents including West Nile virus, Dengue fever, Chikungunya, Rift Valley fever, and rickettsioses have been recently associated with an array of ocular manifestations. These include anterior uveitis, retinitis, chorioretinitis, retinal vasculitis and optic nerve involvement. Proper clinical diagnosis of any of these infectious diseases is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular involvement. The diagnosis is usually confirmed by the detection of a specific antibody in serum. Ocular involvement associated with emergent infections usually has a self-limited course, but it can result in persistent visual impairment. There is currently no proven specific treatment for arboviral diseases, and therapy is mostly supportive. Vaccination for humans against these viruses is still in the research phase. Doxycycline is the treatment of choice for rickettsial diseases. Prevention, including public measures to reduce the number of mosquitoes and personal protection, remains the mainstay for arthropod vector disease control. Influenza A (H1N1) virus was responsible for a pandemic human influenza in 2009, and was recently associated with various posterior segment changes.

Vogt–Koyanagi–Harada (VKH) disease is usually defined as a bilateral chronic granulomatous panuveitis that may be associated with CNS, auditory and integumentary manifestations. An autoimmune reaction against melanocyte antigens in genetically predisposed patients without history of ocular trauma is presumed to cause the disease. Features of ocular and extraocular involvement vary according to disease phase, and the condition can present with disease features limited to intraocular inflammation without associated systemic manifestations. Exudative retinal detachment is the most specific feature to acute VKH disease. Ancillary tests (mainly fluorescein angiography) may help in establishing the definitive diagnosis. On the other hand, sunset glow fundus is typical to chronic VKH disease. Complications are more likely to occur in the chronic recurrent phase. The mainstay of treatment for acute VKH relies on prompt systemic corticosteroid therapy initiated as a high dose and then tapered gradually. The durati...

The purpose of this study was to report a case of Parinaud's oculoglandular syndrome associated with subclinical Rickettsia conorii infection. We report a case of a 66-year-old male patient presented with unilateral persistent granulomatous conjunctivitis in the left eye and an ipsilateral preauricular lymphadenopathy without associated systemic features. Laboratory evaluation showed a positive indirect immunofluorescence antibody test for R. conorii. The patient received a 2-week course of oral doxycycline, with subsequent complete resolution of all his symptoms. Rickettsial disease should be considered in the differential diagnosis of oculoglandular syndrome with or without associated systemic symptoms in any patient living in or returning from a specific endemic area.

Purpose: To report 2 cases of branch retinal artery occlusion (BRAO) associated with Behcet disease (BD).Design: Small case series.Methods: Review of two patients’ charts, fluorescein angiography, and optical coherence tomography (OCT).Results: The authors report two young patients, diagnosed with BD, who developed decreased vision secondary to BRAO for the first patient and cilioretinal artery occlusion associated with branch retinal vein occlusion for the second patient. In the two cases, artery occlusion was associated with active intraocular inflammation.Conclusions: BRAO, with subsequent transient or permanent visual impairment, is an additional ocular complication of BD.

The purpose of this study was to describe the clinical and multimodal imaging findings in acute Vogt–Koyanagi–Harada (VKH) disease without clinically evident exudative retinal detachment (ERD). We retrospectively reviewed the charts of 18 patients (36 eyes), diagnosed with acute VKH disease without clinically evident ERD. All patients underwent complete ophthalmic examination, fundus photography, optical coherence tomography (OCT), B-scan ultrasonography, fluorescein angiography (FA), and indocyanine green angiography (ICGA). Of 18 patients, twelve (66.7 %) were female and 6 (33.3 %) were male. Mean age was 39 years (range, 23–60). Ten patients had been referred with an erroneous diagnosis of primary optic nerve disorder (8; 44.4 %) or isolated anterior uveitis (2; 11.1 %). Anterior chamber or vitreous inflammatory reaction was noted in 22 eyes (61.1 %), each. Fundus findings included optic disc swelling in 30 eyes (83.3 %), retinal striae in 20 eyes (55.5 %), and yellowish deep lesions in 3 eyes (8.3 %). OCT showed a shallow, localized subclinical ERD in 18 eyes (50 %), and retinal pigment epithelial folds in 23 eyes (63.9 %). B-scan ultrasonography showed diffuse, low- to medium-reflective choroidal thickening in all eyes. FA disclosed delayed choroidal perfusion in at least one eye of all patients (100 %), mild pinpoint leakage in 21 eyes (58.3 %), optic disc hyperfluorescence in 35 eyes (97.2 %) and choroidal folds in 13 eyes (36.1 %). ICGA findings included delayed choroidal perfusion in 24 eyes (66.7 %), decrease in the number of large choroidal vessels in 36 eyes (100 %), fuzzy choroidal vessels in 35 eyes (97.2 %), and hypofluorescent dark dots in 28 eyes (77.8 %). The association of bilateral optic disc edema with retinal striae and intraocular inflammatory reaction highly suggests acute VKH disease. A multimodal imaging approach including fundus photography, OCT, B-scan ultrasonography, FA, and ICGA provides important clues for the definite diagnosis and help differentiate VKH disease from primary optic nerve disorders.

Ocular involvement associated with Behcet disease is characterized by a relapsing remitting panuveitis with diffuse vitritis, retinal infiltrates, and occlusive vasculitis. Proper management relies on the early use of immunosuppressive drugs in combination with corticosteroids and administration of biologic agent in resistant and severe posterior segment involvement. VKH disease is a bilateral panuveitis that may be associated with extraocular manifestations. Exudative retinal detachment, associated with typical imaging findings, is the most specific feature to acute VKH disease. Sunset glow fundus is typical to chronic VKH disease. Complications are more likely to occur in the chronic recurrent phase. The mainstay of treatment for acute VKH disease relies on systemic corticosteroid therapy for at least 6 months. Immunosuppressive therapy is mainly used in chronic recurrent disease. Main ocular features of sarcoidosis include bilateral granulomatous anterior uveitis, vitritis with snowballs, multifocal chorioretinitis, and segmental periphlebitis. Diagnosis may be challenging in the absence of apparent systemic involvement. Treatment of sarcoidosis is based on corticosteroids and immunosuppressive agents, in severe cases.

International audience; Primary congenital glaucoma (PCG) is responsible for a significant proportion of childhood blindness in Tunisia. Early prevention based on genetic diagnosis is therefore required. This study sought to determine the frequency of CYP1B1 (cytochrome P450, family 1, subfamily B, polypeptide 1) mutations in 18 PCG patients, recruited from Central and Southern of Tunisia. Genomic DNA was extracted and the coding regions of CYP1B1 were analysed by direct sequencing. A phylogenetic network of CYP1B1 haplotypes was drawn using the median-joining algorithm. Sequence analysis revealed a "tetra-allelic mutation" (two novel mutations, p.F231I and p.P437A in the homozygous state) in one patient. The healthy members of his family carried those variations on the same allele. Two previously described mutations p.G61E and c.535delG were also identified in the homozygous state in seven and two probands, respectively. Seven single-nucleotide polymorphisms were identified and used to generate haplotypes. Our results showed that the CYP1B1 mutations were present in 55% of Tunisian PCG patients' alleles. Haplotype analysis allowed us to define the proto-haplotype and to confirm historical migratory flows. Establishment of PCG genetic aetiology in Tunisia will improve genetic diagnosis and counselling.

We report a case of a 14-year-old otherwise healthy patient who developed acute retinal periphlebitis mimicking frosted branch angiitis inferotemporally and associated exudative retinal detachment in the left eye following blunt trauma. Fluorescein angiography revealed delayed filling of inferotemporal branch retinal vein and late leakage of sheathed retinal venules, and late pooling in the area of exudative retinal detachment. Indocyanine green angiography showed a crescent-shaped hypofluorescent streak concentric to the optic disk inferiorly highly suggestive of choroidal rupture. The patient was treated with oral prednisone, with gradual tapering over a period of 15 days. One month after presentation, retinal vein sheathing and exudative retinal detachment had resolved, with the development of peripapillary subretinal fibrosis, macular atrophy, pseudomacular hole, and epiretinal membrane. The acute perivenular sheathing in our patient might be related to autoimmune-mediated reaction induced by retinal vascular damage caused by severe ocular trauma. Fluorescein angiography and indocyanine green angiography findings might suggest that the retinal detachment could be caused by leakage from choroid through Bruch’s membrane and retinal pigment epithelium rupture or by transient dysfunction of the outer or inner blood-retinal barrier.

Syphilis is a sexually transmitted infection caused by the spirochete Treponema pallidum. Left untreated, the disease progresses through four stages. Posterior segment involvement may occur at any stage of the disease and may include intermediate and posterior uveitis, chorioretinitis, retinitis, retinal vasculitis, and optic neuropathy. Diagnosis of syphilis is based on high level of clinical suspicion and supported by a combination of treponemal-specific and nontreponemal serological tests. All patients with newly diagnosed syphilis should be tested for coinfection with human immunodeficiency virus, as the risk factors are similar for both diseases. Patients with ocular syphilis should be treated as neurosyphilis with aqueous penicillin G or procaine penicillin G plus probenecid.

Rickettsioses are emergent and resurgent arthropod vector borne diseases due to obligate intracellular small gram-negative bacteria. Most of them are transmitted to humans by the bite of contaminated arthropods, such as ticks. Systemic disease typically consists of high fever, headache and skin rash, with or without «tache noire» (dark spot). Ocular involvement is common including conjunctivitis, keratitis, anterior uveitis, panuveitis, retinitis, retinal vascular changes, and optic nerve involvement. Proper clinical diagnosis of this infectious disease is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular involvement. The diagnosis is usually confirmed by detection of specific antibodies in serum. Ocular involvement associated with rickettsial infection usually has a selflimited course, but it can result in persistent visual impairment. Doxycycline is the treatment of choice for rickettsial diseases but prevention is the mainstay of rickettsial infection control.

Parasitic and fungal infections of the eye are major, worldwide distributed causes of infectious posterior uveitis that may lead to blindness. The causative agents include several species of Protozoa and Helminths that have a natural predilection for the eye. These parasitic infections may be transmitted by vectors, food consumption, or acquired indirectly from the environment. Ocular involvement can be due to damage directly caused by the infectious pathogen, indirect pathology caused by toxic products, or the immune response incited by infections or ectopic parasitism. Epidemiologic data, clinical features, diagnostic tools, and management of the clinically important species of parasites involved in posterior uveitis including toxoplasmosis and toxocariasis are reviewed in this chapter. Presumed ocular histoplasmosis syndrome, which is considered to be of fungal origin, also will be discussed.

Infections of the eyelids include a wide variety of bacterial, viral, parasitic, and fungal diseases that may range from benign, self-limiting conditions to severe infections associated with ocular or systemic morbidity. Hordeolum, chalazion, and blepharitis are by far the most common bacterial infections encountered in clinical practice. They are diagnosed on the basis of typical clinical features, and their treatment is based on eyelid hygiene and local or systemic specific anti-infectious medication. Surgery may be needed for persistent chalazia. Eyelid infections caused by herpes simplex or Varicella-Zoster virus are also common. Numerous other infectious agents should be considered in the differential diagnosis of eyelid inflammation. Diagnostic clues for any eyelid infectious disease include epidemiological data, the patient’s history, the pattern of eyelid involvement, and associated ocular or systemic findings. Laboratory investigations, including culture, histopathology of biopsied lesions, or PCR, will help establish the definitive diagnosis in specific clinical situations.

The aim of this study was to evaluate and compare 10-MHz and 20-MHz ultrasonography in the assessment of patients with optic nerve head drusen (ONHD). The design of the study was prospective, comparative and cross-sectional. Ultrasonographic examination with a 10 and 20 MHz probe was performed in 45 eyes with suspected ONHD. The 20 MHz probe showed drusen in 43 eyes (95.5 %), while the 10 MHz probe revealed drusen in only 33 eyes (73.3 %, p = 0.0001). The 10 MHz probe showed surface drusen in 10 eyes (22.2 %), while the 20 MHz probe showed surface drusen in 14 eyes (31.1 %) (sensitivity 71.4 %; 95 % CI [47.6–95.1 %]). The 10 MHz probe showed buried drusen in 23 eyes (23.1 %), while the 20 MHz probe showed buried drusen in 29 eyes (64.4 %) (sensitivity 79.3 %; 95 % CI [56.6–86.2 %]). The sensitivity was 76.7 % with 10 MHz probe compared to a 20 MHz as gold standard. The use of 20 MHz probe increased the sensitivity of buried disc drusen by 1.5 times and surface disc drusen by nearly 2 times. Using the 10 MHz probe alone the false negative error rate was 83.3 %. The 20 MHz probe has shown itself to be an excellent method for the diagnosis of ONHD; it is more sensitive and reliable than 10 MHz probe and should be considered in the management of patients with clinical evidence of ONHD.

Behcet disease (BD) is a multisystem inflammatory disorder that is an important cause of morbidity worldwide. BD is most common along the ancient "Silk Road" route in the Far East and Mediterranean basin. The eye is the most commonly involved organ in BD patients.The prototypical form of involvement is a relapsing remitting panuveitis and retinal vasculitis. Less commonly, BD may present in the form of conjunctivitis, conjunctival ulcers, keratitis, episcleritis, scleritis, and extraocular muscle paralysis. Uveitis in BD carries significant implications for the patient, because it is a chronic recurrent disease characterized by explosive attacks of severe inflammation that may cause significant, cumulative damage to the intraocular structures. This review summarizes the epidemiology of systemic and ocular clinical features of BD with particular focus on risk factors, clinical characteristics, complications, and prognosis of BD-associated uveitis.

Purpose The purpose of this study is to assess macular involvement in patients with Behçet’s uveitis. Methods The study included 65 patients (120 eyes) with Behçet’s uveitis. All patients underwent detailed ophthalmic examination, including dilated biomicroscopic fundus examination, fundus photography, fluorescein angiography, and optical coherence tomography. Follow-up ranged from 6 to 46 months (mean 20 months). Results At initial examination, 29 eyes (24.1 %) had macular involvement including macular edema (16 eyes, 13.3 %), serous retinal detachment (SRD; five eyes, 4.1 %), active retinitis (three eyes, 2.5 %), macular hole (three eyes, 2.5 %), macular atrophy (two eyes, 1.6 %), macular ischemia (one eye, 0.8 %), epiretinal membrane (one eye, 0.8 %), branch retinal vein occlusion involving the macula (three eyes, 2.5 %), and branch retinal artery occlusion involving the macula (two eyes, 1.6 %). During follow-up, 22 eyes (18.3 %) developed macular complications including macular edema (ten eyes, 8.3 %), SRD (four eyes, 3.3 %), active retinitis (two eyes, 1.6 %), severe macular atrophy (two eyes, 1.6 %), macular ischemia (three eyes, 2.5 %), macular hole (one eye, 0.8 %), epiretinal membrane (two eyes, 1.6 %), and subretinal fibrosis (one eye, 0.8 %). Branch retinal vein occlusion involving the macula developed in two eyes (1.6 %). Final best corrected visual acuity in patients with macular involvement ranged from 20/400 to 20/25 (mean 20/80). Conclusions Macular edema and other vision-threatening macular complications are common in Behçet’s uveitis. Macular damage is often irreversible, causing permanent visual impairment. Early and appropriate treatment of Behçet’s uveitis is mandatory to reduce the risk of visual impairment due to macular involvement.

Purpose: To describe the clinical, optical coherence tomographic, and angiographic findings in patients with acute toxoplasmic retinochoroiditis (RC) associated with serous retinal detachment (SRD). Methods: The study included 60 eyes with acute toxoplasmic RC. Results: Of 60 eyes, 14 (23.3%) were found to have SRD. The SRD was visible on fundus examination in 6 cases and detectable only by optical coherence tomography (OCT) in the 8 remaining cases. It involved the fovea in 9 eyes. There was evidence of associated choroidal ischemia on fluorescein angiography and indocyanine green angiography in 5 eyes. Findings seen at the acute stage gradually resolved over a period of 2–6 weeks in all patients. Conclusions: SRD, accurately detected by OCT, is a common complication of acute toxoplasmic RC that should be considered as a potential cause of visual loss. Choroidal ischemia might contribute to the development of such complication.

To evaluate the efficacy and safety of supratarsal injection of triamcinolone acetonide in the treatment of refractory allergic keratoconjunctivitis in childhood. Thirty-five patients (70 eyes) with severe allergic keratoconjunctivitis were included in this study. Fifteen patients (42.8%) had atopic keratoconjunctivitis (AKC) and 20 (57.2%) had vernal keratoconjuncivitis (VKC). All patients underwent a bilateral supratarsal injection of 20 mg triamcinolone acetonide. Mean follow-up was 28 months (range 14–38). All patients showed a significant symptomatic improvement and partial resolution of clinical features of keratoconjunctivitis within the first 2 weeks. Corneal complications related to keratoconjunctivitis disappeared in all patients. One patient with VKC experienced ocular hypertension. No patient with AKC showed side-effects. Severe relapse of the disease was noted in 10% of eyes with VKC and in 6.7% of eyes with AKC after a mean follow-up of 9 and 11 months, respectively. Supratarsal injection of triamcinolone acetonide is effective and safe in patients with severe chronic allergic keratoconjunctivits to relieve severe inflammation associated with this disease.

Purpose: To identify factors associated with the development and severity of chorioretinitis (CR) in patients with West Nile virus (WNV) infection. Methods: Prospective study of 38 patients with WNV infection. Results: Simple analysis showed that diabetes (p = 0.027) and age older than 45 years (p = 0.03) were significantly associated with CR. When controlling for age, only association between diabetes and CR remains statistically significant. Diabetic patients' eyes were more likely to have macular involvement (p < 0.0001), 20 or more chorioretinal lesions (p < 0.001), and lesion size 500 μ m or more (p < 0.01). Conclusions: Diabetes was a risk factor for the development and severity of WNV-associated CR.

Purpose: To estimate prevalence and number of people visually impaired or blind due to cataract. Methods: Based on the Global Burden of Diseases Study 2010 and ongoing literature research, we examined how many people were affected by moderate to severe vision impairment (MSVI; presenting visual acuity

To analyze the pattern of childhood uveitis in a referral center in Tunisia, North Africa.The study included 64 patients with uveitis examined at the Department of Ophthalmology of Monastir (Tunisia) from January 1994 to July 2005. All patients had a comprehensive ocular and systemic history, including an extensive review of medical systems. Complete ophthalmic examination was performed in all cases, including best-corrected Snellen visual acuity, slit-lamp examination, applanation tonometry, and dilated fundus examination with 3-mirror lens. Standard diagnostic criteria were employed for all syndromes or entities of uveitis.The mean age at onset of uveitis was 12.4 years. The male-to-female ratio was 0.68. The process was unilateral in 51.6% of patients. Mean follow-up was 43.2 months. Anterior and intermediate uveitis each represented 31.25% of cases, posterior uveitis 20.3%, and panuveitis 17.2%. Noninfectious uveitis (75%) was the most frequent type of inflammation. Idiopathic uveitis was found in 50% of patients. Infectious uveitis was responsible for 25% of the cases, with toxoplasmosis (14.1%) being the most frequent cause. Twenty percent of the patients had systemic associations; juvenile idiopathic arthritis was found in 6.25%. Ocular complications occurred in 74.7% of affected eyes, of which the most common were posterior synechiae (28.4%), cataract (17.9%), cystoid macular edema (19%), and optic disc edema (32.6%). Fifty-seven affected eyes (60%) had a final visual acuity more than 20/40 and nine (9.5%) had a final visual acuity less than 20/200.In a hospital population in Tunisia, a specific cause of uveitis in children was found in half the patients. Idiopathic intermediate uveitis was the leading cause of uveitis in our study, followed by idiopathic anterior uveitis and toxoplasmosis. Uveitis associated with juvenile idiopathic arthritis was rare. Visual prognosis appeared to be good.