[Screening method for angle closure and angle closure glaucoma using scanning laser polarimeter GDxVCC and photodynamic gonioscopy in a darkened room. One-year outcomes of systematic peripheral iridotomy]. / Méthode de dépistage du glaucome chronique par fermeture de l'angle basée sur l'utilisation systématique du GDxVCC et de la gonioscopie photodynamique. Résultats à un an d'une iridotomie systématique.

INTRODUCTION: Angle closure glaucoma, a recognized major world health issue disproportionately affecting women and Asians, is not often considered in our European populations, normotensive subjects, myopic patients, or subjects with a deep anterior chamber. Early diagnosis is worthwhile, as laser peripheral iridotomy (LPI) is an effective one-step treatment of the causal mechanism. PATIENTS AND METHODS: We have performed a retrospective study of patients who underwent an LPI, the indication for which was based on "photodynamic" gonioscopy in a darkened room showing iridotrabecular contact in darkness. Such photodynamic gonioscopy was motivated by the presence of even minute defects in the nerve fiber layer as seen on the GDxVCC or the presence of a Van Herick sign (narrow limbal anterior chamber depth). RESULTS: One hundred and three eyes of 103 patients underwent LPI and a minimum 1-year follow-up (mean follow-up almost 2 years). Mean age was 63.7±11.8 years, and women accounted for 63.1% of cases. The vast majority (78.6%) of patients had neither glaucoma nor ocular hypertension. There were 60.1% hyperopes and 39.9% myopes. Over half (57%) had a deep or a very deep anterior chamber. After LPI, there was immediate deepening of the limbal depth of the anterior chamber in 100% of cases. The aqueous humor that flowed forward was almost always viscous-looking. After 1 year, the IOP was 1.3mm Hg±2.4 lower (P<.001) (t test). All patients who had experienced morning headaches (44% of patients) were relieved of this symptom. GDxVCC after 1 year was clearly improved in 18% of cases, slightly improved in 20%, stable in 50%, slightly worse in 11% of cases, and clearly worse in 1%. Cases treated at an earlier stage had a better improvement in GDxVCC. DISCUSSION: Our study shows frequent chronic angle closure in our European population even with deep anterior chambers. Absence of a Van Herick sign does not rule out angle closure at night. A photodynamic gonioscopy with the Goldmann three-lens mirror (to avoid unintentional indentation with the small diameter lenses in these normotensive eyes) should be performed in a darkened room. LPI is an effective one-step treatment of the underlying cause, that is particularly beneficial if performed early.

[Quality of life after Lasik: part I. Validation of the French translation of the NEI-RQL-42 scale]. / Qualité de vie après Lasik : partie I. Validation de la traduction française de l'échelle NEI-RQL-42.

INTRODUCTION: The objective of this study was to bring some validation elements to a French adaptation of an American refraction-related quality of life scale, as applied to a population of Lasik patients. METHODS: The NEI-RQL-42 scale was developed in 2003 in the United States. It comprises 42 questions and 13 scores exploring quality of vision, functional symptoms, influence of refraction on daily activities and psychological impact. The authors propose here a French adaptation and elements for its validation (internal consistency, discriminating validity and external validity). These were assessed through an observational cross-sectional study, performed in one center on all patients consecutively treated with Lasik between January and March 2008. RESULTS: The study sample (307 patients) has the expected characteristics of Lasik-treated patients. The French adaptation of the NEI-RQL-42 has a good internal consistency with Cronbach's coefficients greater or equal to 0.7 for 10 scores out of 12. The discriminating validity of the scale was shown though the reference groups techniques: quality of life is generally lower in severe hyperopes compared with non-severe myopes. The scale's external validity is confirmed by the comparison of its results to those of a satisfaction questionnaire that was simultaneously sent to patients. CONCLUSION: The results obtained are favorable arguments for the validity of the proposed French adaptation of the NEI-RQL-42. This is the first scale available in French to assess refraction-related quality of life.

[Quality of life after LASIK: part II. Quality of life and satisfaction of a population of patients treated with LASIK]. / Qualité de vie après LASIK : partie II. Qualité de vie et satisfaction d'une population de patients opérée par LASIK.

INTRODUCTION: The objective of this study was to assess the refraction-related quality of life and patients' satisfaction in a LASIK-treated sample. METHODS: The French adaptation of the NEI-RQL-42 scale and a satisfaction questionnaire were sent to all patients consecutively treated with LASIK (all ages, all indications) in a same center between January and March 2008. The 13 scores of the NEI-RQL-42 were described. The scores "satisfaction with correction" and "glare" have been further analyzed using multivariate logistic regression. Answers to the satisfaction questionnaire were also described. RESULTS: The study sample (307 patients) has the expected characteristics of LASIK-treated patients. Quality of life scores are generally high (>70/100), except for the "glare" (65/100) and "expectations" (42/100) scores. Most of the scores are higher in myopes than in hyperopes. A lower "satisfaction with correction" score was associated with hyperopia (P<0.001) and with a lower "glare" score. A lower "glare" score was associated with ametropia severity (P=0.002), secondary surgery (P=0.02) and to the use of a non-customized treatment (P=0.047). Satisfaction rate was 95%. CONCLUSIONS: Quality of life scores and satisfaction rate are high in this sample, and suggesting how the refractive results impact patients' lives. They also show the importance of glare and other visual symptoms.

[ISO 9001-2000 certification for refractive laser treatment]. / Certification ISO 9001-2000 des traitements réfractifs par laser cornéen.

PURPOSE: To obtain ISO 9001-2000 certification for laser corneal refractive treatment, never before sought in Europe. MATERIAL AND METHODS: The consulting firm Veritas led the certification process with the clinic's staff manager. This ISO norm is dedicated to the implementation of a quality management system. We assessed and optimized all necessary resources, evaluating customer satisfaction using patient and referring-physician surveys. We started quality rounds including surgeons, nurses, and technicians. Based on this preparation, we redefined and explained all processes including staff responsibilities and necessary resources in the quality manual. The procedure lasted 14 months with substantial involvement on the part of the management. RESULTS: Unconditional ISO 9001-2000 certification was granted by the independent audit firm, BVQI, in december 2003 for refractive laser treatment. CONCLUSION: The 2000 version of the new ISO 9001-2000 seeks to meet the demand for improving health care delivery in this field, most particularly by establishing a clear procedural orientation. Such certification enhances team work, stabilizes methodologies, and reinforces cohesion and self-audit. Patients notice that the center follows a consistent quality policy and are assured that the clinic respects rules and regulations. Certification is an advantageous alternative when accreditation cannot be considered. Our article discusses the steps taken in upper management, quality management, procedural guidance, as well as customer and staff counselling. It also discusses the project's cost/benefit ratio for the organization.

[Topical anesthesia for out-patient adult cataract surgery without an anesthesiologist]. / L'anesthésie topique en chirurgie de la cataracte ambulatoire de l'adulte sans anesthésiste présent.

To review the local anesthesia environment in France in adult out-patient cataract surgery. The author considers the presence or absence of an anesthesiologist in the operating room. The report shows that in many circumstances there is no need for an anesthesiologist if the following criteria are respected: the adult is fully informed, in rather good health, with no acute risk factors, and surgery is performed by a senior surgeon in a certified operating room. In France, a move toward more flexible regulations is expected, with a new cooperation between ophthalmologists and anesthesiologists that will lead to a new true risk/benefit/obligation ratio. Respect of the individual and safety remain crucial requirements making systematic generalizations impossible.

[Leber's optic neuropathy presenting as an alcohol- and tobacco-related optic neuropathy]. / Neuropathie optique de Leber se présentant comme une neuropathie optique alcoolo-tabagique.

The authors report a case of a 70-year-old man presenting a recent unilateral decrease in visual acuity, appearing in a context of alcohol and tobacco intoxication. Diagnosis of Leber's optic neuropathy was evoked after elimination of other causes of a visual acuity decrease such as giant cell arteritis and compressive or inflammatory optic neuropathy. The authors emphasize that Leber's optic neuropathy must be evoked in a recent decrease in visual acuity, even if it appears in an unusual context.

Macular hemorrhage after laser in situ keratomileusis for high myopia.

We describe 2 women with high myopia of -12.0 and -18.0 diopters who presented with myopic macular hemorrhages 1 and 4 days, respectively, after being treated by laser in situ keratomileusis (LASIK). One hemorrhage was related to a pre-existing choroidal neovascularization and the other to the presence of lacquer cracks. The hemorrhages resolved but resulted in a permanent decrease in vision. A careful fundus examination should be conducted before performing LASIK in highly myopic patients. In cases of similar macular pathology, fluorescein angiography should be done before LASIK.

Vitrectomy with endoscopy for management of retained lens fragments and/or posteriorly dislocated intraocular lens.

PURPOSE: To evaluate the advantages of vitrectomy combined with endoscopy for the management of retained lens fragments and/or posteriorly dislocated intraocular lens (IOL). METHODS: A consecutive series of 30 eyes with these complications treated by this technique was reviewed retrospectively. An endoscopic probe which incorporates a video channel, a fibreoptic light source, and a diode laser was used for visualization. Lens material or the IOL was extracted through the corneal wound in 18 eyes (60%). They were either aspired or grasped or lifted using perfluorocarbon liquids (PFCL), under endoscopic control. In 9 eyes (30%) pars plana phakoemulsification was performed. PFCL was used in 11 eyes (36.6%). In 16 eyes (53.3%) an IOL was sutured in the ciliary sulcus. RESULTS: Final visual acuity was > or = 20/40 in 19 eyes (63.3%), > or = 20/30 in 15 eyes (50%). Intraoperative breaks occurred early in the series in two eyes (in one case from use of the endoprobe, in the other from pars plana phakoemulsification). Poor final acuity was related to proliferative vitreoretinopathy, which developed in both cases with an intraoperative iatrogenic retinal break, senile macular degeneration, myopia and amblyopia, cystoid macular oedema, corneal oedema and high astigmatism. CONCLUSION: We found that endoscopy facilitated the management of these complications of cataract surgery once the peculiar difficulties of the technique (absence of stereoscopy, manipulation of the endoprobe, video monitor control) were mastered. Endoscopy facilitated and shortened localization of lens fragments embedded into the vitreous base for aspiration, grasping and phakoemulsification, enabled detection of small anterior retinal breaks, permitted resection of adhesions between anterior hyaloid, lens capsule and ciliary sulcus and facilitated PFCL manipulations, whatever the status of the anterior segment (corneal edema, myosis, synechiae, presence of IOL).

[Patient information and preoperative informed consent: comments on an experience]. / L'information du patient et le consentement écrit à l'opération: commentaires d'une expérience.

We gave consideration to the new legal obligation to a medical doctor to prove that he has given to a patient adequate information. 312 cases of cataract or glaucoma received written information about their disease and the risks of surgery. An informed consent regarding the operation and the post-opérative care were signed by all patients. Information cover surgical risks, sides effects, unpredictable events, care steps and all last minute protocol modifications. These documents were given when scheduling the surgery. No cancellation and no objection were noticed. The French Code Civil article 1315 was not dedicated to medical exercise but it concerns physicians. The way to give a proof is not clear. Nothing is asked in the by-laws and every medical doctor can choose the method he prefers. A signature is not an obligation and an informed consent is not an authorization. A discussion is opened to clear the best and safest recommendations to obtain a legal proof of information. Now, written texts seem to be the easiest procedure. Quality medical records and personal relation between patient and surgeon are of great importance to prevent patient unsatisfaction and disappointment.