[Validation of the French version of the health-related quality of life questionnaire for adult strabismus (AS-20)]. / Validation de la version française d'un questionnaire de qualité de vie de l'adulte strabique (AS-20).

INTRODUCTION: A growing number of articles have shown the negative impact of strabismus on self image, relationships with others and professional life. The AS-20 is a standardized questionnaire in English measuring the psychosocial impact of strabismus in adults. The goal of this study is to validate the AS-20 in the French language. PARTICIPANTS: Three hundred and ninety one patients took part in the study: 131 had strabismus (group 1), 128 other ocular diseases (group 2) and 132 "normal" patients (group 3). RESULTS: The AS-20 scale showed good psychometrical properties in 2 or 4 dimensions: internal consistency was very good (Cronbach's alpha coefficient>0.9 in all dimensions and overall) and the reproducibility was satisfactory (intra class coefficient>0.7). The comparison of the scores in the 2 dimension scale showed significant differences between the groups (P<0.001): lower score in strabismus (63.9±18.3) than in other ocular diseases (73.5±17.8) and normal group (89.4±12.0) (divergent validity). The 4 dimension psychometric analysis was performed by removing 2 items and grouping the 18 others in 4 groups. It confirmed the divergent and convergent validity, internal consistency and reproducibility of the scale. The results of the confirmatory factor analysis were better with the 4 dimension scale than the 2 dimension scale (adjustment coefficients>0.9). CONCLUSION: We now have access to a health related questionnaire in French to quantify the impact of strabismus on quality of life and measure the results of treatment.

[Trabeculotomy as first-line surgical treatment in pediatric glaucoma: surgical and visual outcomes from a 7-year retrospective study]. / Trabéculotomie de première intention dans le glaucome de l'enfant: devenir chirurgical et visuel sur une étude rétrospective de 7 ans.

INTRODUCTION: Intraocular pressure and visual outcomes in primary pediatric glaucoma treated with trabeculotomy. MATERIALS ET METHODS: All children undergoing trabeculotomy as first-line surgical treatment between January 2002 and January 2012 were included in a retrospective monocentric study. We report initial clinical features, surgical complications, ophthalmological outcome and clinical progression. RESULTS: Twenty-nine eyes of 16 children met the inclusion criteria and were treated with trabeculotomy as first-line treatment (mean age: 6 months). Median follow-up was 7 years. No major perioperative complications occurred, but minor complications were observed in 11 eyes. Mean pre-operative and initial post-operative intraocular pressures were 25.4 and 9.1mmHg respectively, thus a decrease of 16.3 points (63%). Overall surgical success rate was 89% at first follow-up, 72% at one year and 64% on last follow-up. A mean intraocular pressure of 15mmHg on no medications was achieved for two-thirds of eyes. After 7 years of follow-up, over 50% of eyes did not require a 2nd surgery. Visual acuity was at least 20/30 for 62% of eyes (83% for eyes requiring only trabeculotomy). DISCUSSION AND CONCLUSION: Trabeculotomy as first-line treatment of primary juvenile glaucoma is a safe and effective surgery in about two-thirds of cases. It allows pressure control and satisfactory visual outcome in the majority of children.

[Amblyopia treatment of unilateral and bilateral cataract with visual acuity result]. / Traitement de l'amblyopie des cataractes unilatérales et bilatérales avec résultats en termes d'acuité visuelle.

Treatment strategies of congenital cataract provide evidence of recent improvement in the visual prognosis. This trend is likely to be accounted for by a combination of improved management of amblyopia occurring in parallel with advances in surgical techniques, instrumentation, and materials. Compliance with occlusion is the factor most strongly associated with visual outcome: to support, to encourage, to comfort, to explain, to require (demand) to put in front of the responsibilities, here are the other missions of the therapist which are not less important than the surgical gesture. Progress, in this "educational" care of the visual function remains to make but the way is drawn.

[Study of optic nerve head-fovea angle with retinophotography in congenital fourth nerve palsy]. / Etude des rapports papille-fovéa par rétinophotographie chez des patients atteints d'un déficit congénital de l'oblique supérieur.

PURPOSE: Measurement of ocular torsion is an important element for analysis of certain oculomotor pathologies such as fourth nerve palsy. With nonmydriatic retinography, objective measurements of ocular torsion are now accessible in daily practice: the normal values in healthy subjects are known. We compared a population of subjects with fourth nerve palsy to a reference population. PATIENTS AND METHODS: Prospective study of 38 cases of congenital fourth nerve palsy, who had never undergone surgery. Each of these subjects had nonmydriatic retinography done according to a standardized protocol. The ocular torsion was measured using graphic software with consideration of reproducible anatomical marks. A statistical study determined the thresholds of significance. RESULTS: In this pathological population, the angle between the optic nerve head and fovea is organized in a Gaussian distribution but the values are different from those found with the same method in a population of healthy subjects (6.3 degrees +/-3.4) (t test, p<0.0001). Extorsion exists in paralytic eyes (mean, 10.7 degrees +/-3.8), as in the other eye (mean, 8.8 degrees +/-5.7). In addition, the study of the anatomical marks of the fundus (optic nerve head and the lower pole of the papilla) was shown to be reliable. DISCUSSION: This study confirms ocular torsion's variation in fourth nerve palsy. Extortion was found in both eyes. We demonstrated no relation between the severity of the extortion and the lateralization of the fixating eye. We confirmed the results of previous studies. CONCLUSION: This study confirms the relevance of the objective measures of the ocular torsion in a pathological situation. Simple anatomical marks of eye fundus provide a useful analysis of these clinical presentations.

[Orbital locations in Rosai-Dorfman disease: a series of three consecutive cases]. / Localisations orbitaires de la maladie de Rosai-Dorfman: série de trois cas consécutifs.

INTRODUCTION: Rosai-Dorfman disease (or sinus histiocytosis with massive lymphadenopathy) is a rare, benign entity, characterized by a histiocytic proliferative disorder that affects mainly the lymph node sinuses but also the lymphatics in extranodal manifestations. It affects mainly young men. The clinical syndrome consists of adenopathies, notably cervical, with fever and extranodal manifestations. Ophthalmological involvement is not frequent (10%), concerning above all the orbits, eyelids, and lacrimal glands, but cornea or uveal tissue can also be affected. Definitive diagnosis is anatomopathological, showing a histiocytic proliferation with lymphophagocytosis (emperipolesis) whose immunohistochemical analysis reveals CD68+ and PS100+. OBSERVATIONS: We describe a consecutive series of three cases seen in 2006 at the University Hospital of Nantes (France). One case presented an intraconical location with exophthalmos. The other two showed lacrimal fossa involvement. DISCUSSION: Our series, through the patients' mean age (61 years), symptom progression (from a few weeks to several years), clinical variability (several extranodal sites with no lymphadenopathy), and anatomopathological problems (especially extemporaneous analysis) shows the pathology's polymorphism as well as the diagnosis and therapeutic problems. CONCLUSION: A rare and unrecognized entity, Rosai-Dorfman disease can affect the entire ocular globe. Definitive diagnosis is only established by anatomopathological study. Although it is benign, ophthalmological involvement can cause severe damage, which requires efficacious treatment and a multidisciplinary approach.

[Study of the optic nerve head-fovea angle with retinophotography in healthy patients]. / Etude des rapports papille-fovéa par rétinophotographie chez le patient sain.

PURPOSE: The measurement of ocular torsion remains complicated and delicate when using subjective methods of measurement. Objective measures are now accessible in daily practice. This study determined the standards for ocular torsion in healthy patients with fundus photographs. MATERIALS AND METHODS: Prospective study on 150 patients divided into three different age groups: children (under 15 years); young adults (15-50 years); and adults (over 50 years). All patients included had a normal oculomotor examination and were close to emmetropia. The fundus photographs were taken using a standardized system. The results were analyzed with a graphic computer program and took into consideration reproducible anatomical models; a statistical study determined the thresholds of statistical significance. RESULTS: The optic nerve head-fovea angle followed a Gaussian distribution (mean, 6.3; standard deviation, 3.4). The measure was reproducible in a single patient through different successive examinations. There was no variation of this angle between the patients of different ages. Furthermore, in 87% of the patients, the fovea had a projection between the center and the lower edge of the optic nerve head, indicating that these anatomical models are reliable in a clinical evaluation of torsion. DISCUSSION: This study confirms the accuracy of the objective measurements of ocular torsion and validates the anatomical models proposed by the rare studies already published. CONCLUSIONS: The era of systematic ophthalmic photography is opening new perspectives in diagnosis now that the range in healthy patients has been determined, necessary before the disease could be analyzed. This validation of reliable and simple anatomical models should make this method easy to use in clinical and daily practice.

[Deep lamellar keratoplasty versus penetrating keratoplasty for keratoconus]. / Résultats de la kératoplastie lamellaire profonde pré-descemétique dans la prise en charge du kératocône chirurgical, en comparaison avec la kératoplastie transfixiante.

OBJECTIVE: To determine the advantages, safety, and accuracy of deep anterior lamellar keratoplasty (DLK) versus penetrating keratoplasty (PK) in terms of visual acuity, astigmatism, and endothelial preservation in corneal diseases with healthy endothelium. Of these candidates for keratoplasty, the study investigated keratoconus patients with no other ophthalmic abnormalities. MATERIALS AND METHODS: This comparative nonrandomized retrospective study investigated 22 patients with keratoconus requiring surgery, who underwent keratoplasty in the Nantes University Hospital between 1 June 2002 and 1 January 2004. Ten DLK, ten PK and two PK converted DLK cases were analyzed. Follow-up at 2 weeks and at 3, 6, 9, and 18 months is reported for visual acuity, astigmatism, pachymetry, specular microscopy, and intraocular pressure (IOP). Data are compared before and after surgery at each follow-up date. RESULTS: Preoperative visual acuity improved in both groups from 0.14+/-0.13 to 0.8+/-0.17 postoperatively. There was no significant difference between the two groups before and at each time after surgery for visual acuity and astigmatism (3.5+/-2 diopters in the PK group and 3+/-0.9 D in the DLK group). There was a statistical difference for IOP with two occurrences of increased IOP up to 30 mmHg in the PK group. Endothelial cell count analysis showed an immediate postoperative decrease of 10% in the DLK group (versus approximately 40% in the PK group), remaining rather stable the 1st year (-3.3%), although cell loss in the PK group declined up to 10% more at 18 months. DISCUSSION: With no statistical difference between the two groups for visual acuity and astigmatism, DLK is effective. It is safer than PK in terms of IOP disturbance (leading cause of graft failure) and endothelial cell loss. DLK converted into PK (16%) showed the same profile as first-intention PK. CONCLUSION: Despite very similar effectiveness, DLK in keratoconus surgery should be proposed rather than PK because it appears safer not only in the short term but also probably in the long term, with no risk of endothelial cell rejection.

[Amniotic membrane transplantation and limbic-conjunctival autograft for recurrent pterygium, either invasive or with optic axis involvement]. / Greffe de membrane amniotique avec greffe conjonctivo-limbique dans le traitement des ptérygions récidivants, invasifs ou intéressant l'axe optique.

OBJECTIVE: To evaluate amniotic membrane transplantation with limbic-conjunctival autograft during recurrent pterygium surgery in cases with a risk of stromal defect or with optic axis involvement, in order to limit the corneal defect in pterygium and preserve vision with moderate astigmatism. MATERIALS AND METHODS: Retrospective study of 50 cases. Three clinical aspects were encountered: A, recurrent pterygium after simple surgery (a corrected stromal defect)--six cases; B, primary pterygium at risk of stromal defect - five cases; C, primary pterygium with optic axis involvement--four cases. Each patient underwent ablative surgery followed by ocular surface rebuilding with limbic-conjunctival autograft combined with amniotic membrane graft on the corneal defect. Visual acuity and astigmatism were measured and compared before and after surgery. RESULTS: The mean follow-up was 13 months. At the end of the follow-up, the recurrence rate was 27% (four cases: two in A, two in B, and none in C). Mean visual acuity was improved from 0.7 to 0.8 postoperatively (p=0.041). Astigmatism changed slightly from 1.47 to 1.98 dioptres (p=0.155). DISCUSSION: For recurrent pterygium, with stromal defect or optic axis involvement, amniotic membrane transplantation and limbic-conjunctival autograft seems not to influence the recurrence rate. However, by limiting initial keratectomy, this surgical procedure only slightly modifies visual acuity and astigmatism in the cases where the two parameters are slightly affected. Failure can be easily managed with further surgery such as lamellar keratoplasty. CONCLUSION: Amniotic membrane transplantation and limbic-conjunctival autograft for recurrent pterygium or with optic axis involvement can be useful to integrate in the therapeutic arsenal of pterygium surgery.

[Surgery for idiopathic and secondary epiretinal membranes: functional results and complications]. / Chirurgie de membranes épirétiniennes idiopathiques et secondaires. Résultats fonctionnels et complications.

PURPOSE: To evaluate visual outcome after epiretinal membrane surgery. MATERIAL: and method: Retrospective study of 50 consecutive epiretinal membranes (ERM) (23 idiopathic and 27 secondary) with 12 to 42-month follow-up (mean 24 months). Functional evaluations were performed before and after surgery according to the idiopathic or secondary nature of the epiretinal membranes. RESULTS: For idiopathic ERM, vision improved by more than two lines in 43% of the eyes (33% after ERM surgery alone and 55% after ERM followed by cataract surgery) with final visual acuity of 4/10 for 66% of the patients (58% and 82% respectively); there was visual degradation for the two ERM on highly myopic eyes. For the secondary ERM, vision improved by more than 2 lines for 41% of the eyes and final visual acuity of 4/10 for 33% of the patients; visual degradation for almost all ERM secondary to uveitis was associated with preoperative cystoid macular edema. CONCLUSION: After surgery for idiopathic or secondary ERM, visual acuity is good with the exception of the idiopathic ERM on highly myopic eyes and of the uveitic ERM with preoperative cystoid macular edema. Progression of cataract often perturbs visual outcome analysis.

[Non-immunologic factors of failure of penetrating keratoplasties. Prospective study of 119 corneal grafts at the Nantes Hospital Center in 1995]. / Facteurs non immunologiques d'échec des kératoplasties perforantes. Etude prospective de 119 greffes de cornée au CHU de Nantes sur l'année 1995.

PURPOSE: A single-center prospective study was carried out in Nantes to evaluate corneal graft outcome, while immunosuppressive treatment was used topically or systemically, during the first year. METHODS: A cohort of 119 patients underwent penetrating keratoplasty between 1-1-95 and 31-XII-95. Systematic standardized exams were performed at 15 days, 1 month, 4 months, 6 months and 1 year. Grafts were obtained from organo-cultured corneas at +31 degrees C. Intraveinous methyl prednisolone was given at the time of the surgery in most cases (82%). Corticosteroid eye drops are used in all cases and systemic Cyclosporin A was given for high-risk rejection keratoplasties (29.5%). RESULTS: The clear graft rate at 1 year is 97% for keratoconus, 87.8% for bullous dystrophies and 80.7% for regrafts. The leading causes of graft failure are: graft rejection (25%), endothelial consequences of a non controlled elevated intra ocular pressure (25%) and ocular surface disorders (16%). Prevalence and management of elevated IOP (from 8% to 20%) and ocular surface disorders (from 18% to 43%) are reported over one year. CONCLUSION: This study points out the great frequency of elevated-IOP-related disorders and ocular surface diseases in corneal graft outcome. They must be tracked down and uncompromisingly treated before and after transplantation.

A novel method for controlling the quantity of mitomycin-C applied during filtering surgery for glaucoma.

The use of a sponge impregnated with mitomycin-C is an increasingly common practice in glaucoma surgery. The appropriate antibiotic concentration and exposure time have been considered in the literature, but not the exact amount to be used or the size of the sponge. The purpose of this study was to estimate the quantity of mitomycin-C contained in sponges prepared by different surgeons as compared to that in applicators of the type used in Schirmer's test graduation (5 x 5 mm). Four surgeons each cut and prepared 10 sponges for intraoperative use according to their usual method. The same procedure was performed with 10 Schirmer's test graduations. Each sponge and each graduation was immersed in a solution of mitomycin-C 0.2 mg/ml, and the quantity of antibiotic (microg) in each was calculated as the difference between wet and dry weight. The mean quantity (+/- SEM) of mitomycin-C contained in cut sponges was 9.6 +/- 4.4 microg (range 1.9-17.3), and the differences between surgeons were statistically significant (p<0.0001). The mean quantity of antibiotic in Schirmer's test graduation was 1.7 +/- 0.3 microg (range 1.1-2.5), and the differences between surgeons were not statistically significant (p=0.79). The quantities of mitomycin-C contained in sponges prepared for glaucoma surgery differed for a given surgeon and between surgeons. Thus, variations in the doses applied to the sclera could account for certain complications due to mitomycin-C. The use of a Schirmer's test graduation improves predictability for the quantity of mitomycin-C applied to the sclera.

[Scale for evaluating desirable ametropia or eumetropia]. / Echelle d'évaluation de l'amétropie désirée ou eumétropie.

GOAL: The purpose of this study is to assess the degree of desirable ametropia in cataract surgery. MATERIAL AND METHODS: A scale for evaluation was created. It allows to measure the desired distance for a neat uncorrected vision (desired ametropia) after cataract surgery that presbyopic patients (monocular vision) would like to obtain. This scale helps to calculate the power of the intraocular lens to be implanted. The scale was shown to a series of 50 consecutive presbyopic patients. Refraction was the same in both eyes. The interest of patients in the evaluation of their desirable ametropia was measured on a scale from 0 to 5. RESULTS: Interest was good for 50% of patients (grade > or = 3). Mean distance desired by patients for a neat uncorrected vision was 1 meter. Preoperative myopia and hyperopia have no significantive influence upon the distance desired for a neat uncorrected vision. CONCLUSION: The choice of the power of the lens implanted during cataract surgery should take into account the patients' desires. An evaluation of the postoperative desirable ametropia should be systematic.

[Does the dosage of mitomycin-C applied during filtering surgery of glaucoma vary with the individual surgeon?]. / La quantité de mitomycine-C appliquée pendant la chirurgie filtrante du glaucome varie-t-elle selon le chirurgien?

PURPOSE: The purpose of this study was to estimate the quantity of mitomycin-C contained in sponges prepared by different surgeons as compared to that in applicators of the type used in Schirmer's test graduation (5 x 5 mm). MATERIALS AND METHODS: Four surgeons each cut and prepared 10 sponges for intraoperative use according to their usual method. The same procedure was performed with 10 Schirmer's test graduations. Each sponge and each graduation was immersed in a solution of mitomycin-C 0.2 mg/ml, and the quantity of antibiotic (microgram) in each was calculated as the difference between wet and dry weight. RESULTS: The mean quantity (+/-SEM) of mitomycin-C contained in cut sponges was 9.6 +/- 4.4 micrograms (range 1.9-17.3), and differences between surgeons were statistically significant (p < 0.0001). The mean quantity of antibiotic in Schirmer's test graduation was 1.7 +/- 0.3 micrograms (range 1.1-2.5), and the differences between surgeons were not statistically significant (p = 0.79). CONCLUSION: The quantities of mitomycin-C contained in sponges prepared for glaucoma surgery differed for a given surgeon and between surgeons. Thus, variations in the doses applied to the sclera could account for certain complications due to mitomycin-C. The use of a Schirmer's test graduation improves predictability for the quantity of mitomycin-C applied to the sclera.

[Epidemiological and clinical aspects of Stilling-Turk-Duane syndrome]. / Aspects épidémiologiques et cliniques du syndrome de Stilling-Turk-Duane.

BASIS: In a retrospective study on 155 patients with Stilling-Turk-Duane's syndrome, we compare our results with those described in the literature. Particular focus was based on the different clinical entities observed. PATIENTS AND METHODS: Patients were selected from 8000 charts of cases of strabismus seen in the Ophthalmological Clinic of the CHU in Nantes between 1980 and 1995. An oculomotor assessment carried out for all of these patients allowed us to determine the clinical type according to Malbran's classification. Patients were classified on the basis of family history of oculomotor disorder and associated pathology. RESULTS: The incidence of this syndrome in the population of strabismic patients was 1.9%. The number of women affected was 83 (53.5%). The syndrome was unilateral in 121 cases (78.1%). The left eye (71.9%) was affected more frequently than the right. Clinical entities not described by Malbran's classification were found in 24% of cases. These were described and classified. The oculomotor disorder most frequently encountered was esotropia. The number of patients with a amblyopia was 51 cases (32.9%). The number of patients with a torticollis was 101 cases (65.1%). The number of cases with associated medical pathology was 38 (24.5%). This pathology was ocular in 17 cases (10,9%) and extra-ocular in 22 cases (14.2%). The number of patients with a family history of oculomotor disorder was 39 (22.2%) among which 9 (5.8%) had at least one family member with Stilling-Turk-Duane's syndrome. CONCLUSION: Data provided by this study allowed us to analyse the clinical and epidemiological features of the Stilling-Turk-Duane's syndrome. What is more, they allowed us to describe and classify clinical forms not described by Malbran's classification.

[Optico-geometric axes of the eye: application to the alpha angle and its representatives. Review of the literature]. / Les axes optico-géométriques du globe: applications à l'angle alpha et ses représentants. Synthèse de la littérature.

The different positions of the corneal reflex and the center of the pupil demonstrates the decentration of the ocular structures. The optic axis and the visual axis are different. They form a angle (defined as angle alpha) important for appreciation of strabismic deviation. This phenomenon is well-known since the nineteen century. This review discusses the different definitions of the optico-visual axes and angles (angle alpha, gamma, kappa, lambda). A possible clinical application is discussed.

[Medial rectus stretching test in recurrent esotropia]. / Le test d'élongation musculaire du droit interne dans les ésotropies récidivantes.

In oculomotor surgery, evaluation of muscle elongation is necessary before deciding on the operative plan. This is particularly important in recurrent esotropia where the motor problem is highly complex because of visco-elastic alterations caused by previous surgery. The study of a series of 132 cases of recurrent esotropia shows that weakening of the medial rectus almost always causes reduced muscle elongation, the extent of which is directly proportional to the amount of recession.

[A case of Tolosa Hunt syndrome]. / Un cas de syndrome de Tolosa Hunt.

The authors review the clinical signs, results of investigations and clinical course under treatment of the Tolosa-Hunt syndrome; they illustrate their case presentation with a complete sequence of the imaging and the clinical and radiological findings of a case which fits the classical description found in the literature. They insist on the term of syndrome rather than disease because of the obvious diversity of anomalies encountered in this condition.

[Monobloc PMMA lenses. Anteroposterior displacement of the implant as a function of the insertion diameter]. / Implants PMMA monobloc. Déplacement antéro-postérieur du corps en fonction du diamètre d'insertion.

Data concerning the biomechanical properties of IOL are rare. A systematic study of these properties was performed in the "laboratoire de Mécanique des Structures" at the "Ecole Centrale de Nantes". The results of the anteroposterior displacement of the optical part of eleven posterior chamber lenses (all PMMA) which were subjected to a diameter reduction, are reported. The deplacement of the implants was very slight and the position of the posterior side was relatively anterior whatever the diameter of insertion. The clinical implications, especially concerning the posterior capsule, are discussed.

[Differential photo-oculography of vertical and oblique movements]. / Photo-oculographie différentielle des mouvements verticaux et obliques.

Up to now EOG has been the only method used to record ocular movements in daily practice. However such a mean has various drawbacks and limits. It has two main gaps: firstly for vertical movements because the interference discharges related with palpebral movements and blinkings; on the other hand for oblique movements because the unequal transmission of EOG potential towards the orbital rim. The differential photo-oculography perfected by Charlier et Buquet has been fitted and now can be easily used in clinical conditions. With this optical method, it exists a direct relation between the gaze direction and video signals of the eye. The authors point out the reliability of its results not only for horizontal movements, but also for vertical and oblique movements. This method allows a relevant analysis of all kinetic parameters whatever the moving axis may be.