[Alphacor keratoprosthesis: device, surgical technique and clinical outcomes]. / La kératoprothèse Alphacor : dispositif, technique chirurgicale et résultats cliniques.

PURPOSE: Clinical evaluation of Alphacor keratoprosthesis in patients at high risk of corneal allograft rejection. DESIGN: Retrospective case series. PATIENTS AND METHODS: Alphacor implantation was performed via a two-step procedure with intrastromal insertion followed by secondary exposure of the optic after 6 months. Visual acuity and occurrence of postoperative complications were evaluated. RESULTS: Fourteen eyes of 14 patients underwent Alphacor keratoprosthesis implantation. Mean follow-up was 15.6 ± 5.6 months (from 2 to 24 months). Postoperative mean visual acuity gain was 2.5 ± 3.1 lines (from 0 to +11 lines). Visual acuity was superior or equal to 20/200 in 21% of cases. Seven cases of stromal melt (50%) occurred, of which one case (7.1%) experienced spontaneous extrusion of the implant, three cases (21.4%) required tectonic penetrating keratoplasty, and three patients underwent lamellar keratoplasty on top of the implant. Three cases (21.4%) of retroprosthetic membrane were observed and successfully managed. One patient (7.1%) developed late endophthalmitis. CONCLUSION: Alphacor is an alternative to corneal allograft in cases of corneal blindness at high risk of allograft failure. Throughout the preoperative evaluation, it is imperative to take into account the limitations of this keratoprosthesis in terms of indications, and additional studies are necessary in order to determine and refine the optimal surgical technique for implantation as well as the efficacy of postoperative treatments.

[Kyrieleis arteritis: report of two cases and literature review]. / Artérite de Kyrieleis : présentation de deux cas et revue de la littérature.

We report the cases of two patients presenting with unilateral Kyrieleis arteritis complicating severe posterior uveitis, one secondary to toxoplasmosis and the other in the context of Behçet's disease. The treatment response was favorable with complete visual recovery in both cases. Kyrieleis arteritis has been described since 1933, but its pathogenesis is still unknown. However, it appears to be more of a periarteritis than an actual arteritis. It is classically associated with posterior uveitis without a direct correlation with disease severity.

[New therapeutic approach of keratoconus with intracorneal ring segments aided by femtosecond laser (Tecnolas Perfect Vision): indications, operating technique and results]. / Nouvelle approche thérapeutique du kératocône par segments d'anneaux intracornéens assistés par laser femtoseconde (Tecnolas Perfect Vision) : indications, technique opératoire et résultats.

OBJECTIVE: To assess the results of intracorneal ring segment implantation assisted by the Tecnolas Perfect Vision(®) femtosecond laser (Heidelberg, Germany). SETTINGS: Retrospective observational study. METHODS: The patients were operated on with the Tecnolas Perfect Vision(®) femtosecond laser. The following parameters were evaluated before and after surgery: uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), corneal topography, wavefront analysis, and central corneal thickness. The Wilcoxon test was used for statistical analysis. RESULTS: Seventeen eyes of 15 patients were included. The mean follow-up was 6.9±0.71 months. Significant improvement of UCVA and BCVA was observed in 82.35% (P=0.027) and 94.12% (P=0.003) of the eyes, respectively. The subjective refraction showed a significant decrease of the sphere from -10.29±5.54 to -6.5±5.03D (P=0.002). The subjective cylinder significantly decreased from 5.43±3.20 to 3.69±2.30D (P=0.026). The SAI also decreased significantly (P=0.011). CONCLUSION: Femtosecond-assisted intracorneal ring segment implantation is an effective treatment for corneal ectasia. Further studies are needed to improve surgical parameters and outcomes.

[Optical coherence tomography in following up papilledema in idiopathic intracranial hypertension treated with lateral sinus stent placement]. / Évolution en tomographie par cohérence optique de l'œdème papillaire dans l'hypertension intracrânienne idiopathique traitée par mise en place de stent endosinusien du sinus latéral.

OBJECTIVE: To quantify the course of papilledema using the OCT 3 Stratus (Carl Zeiss Meditec, Dublin, CA, USA) after lateral sinus stent placement in patients with idiopathic intracranial hypertension (IIH). METHODS: Ten consecutive patients with a diagnosis of IIH underwent OCT examination before and after lateral sinus stenting, between March 2006 and April 2008, in Timone Hospital's Ophthalmology Department (Marseille, France). All patients had criteria for IIH (International Headache Society, 2004) and sinus abnormalities were diagnosed using three-dimensional rotational gadolinium-enhanced MR venography. In all cases, a direct retrograde cerebral venography with manometry was performed. We used the Cordis PRECISE® RX Nitinol Stent system (ref. 10136245-3, Johnson & Johnson), 30-40 mm in length and 8 mm in diameter, all placed by a single operator via a femoral venous puncture. For each eye, the mean retinal nerve fiber layer thickness was noted using the RNFL Thickness (3.4) strategy, before stenting, and three times after stent placement. The other parameters considered were age, sex, weight, height and body mass index. RESULTS: A significant decrease in retinal nerve fiber layer thickness was observed after stent placement. This parameter was considered normal 3 months after stent placement for eight of ten patients. CONCLUSION: Even though this pathology remains misunderstood, we observed a significant decrease in papilledema in IIH after lateral sinus stent placement, suggesting that high intracranial venous pressure could play a role in this pathology.

[New approach for determining the damage level of biological tissues using femtosecond laser: advantages and application to corneal surgery]. / Nouvelle approche de détermination du seuil d'endommagement de tissus biologiques par laser femtoseconde: intérêt et application à la chirurgie de la cornée.

INTRODUCTION: Optimization of femtosecond laser characteristics in corneal surgery is still needed to improve clinical results. In this study, we describe an original characterization technique able to measure laser damage of corneal tissues precisely and to provide complementary physical results on the laser-matter interaction. METHOD: A femtosecond laser was used to damage corneas not suitable for graft. The epithelium and the Bowman layer are exposed to a set of different single-shot fixed laser fluences. Optical microscopy can determine the probability of laser damage on the corneal surface. The high damage threshold (minimum fluence systematically damaging the cornea) roughly fixes the operating laser fluence conditions, while the low damage threshold sets the maximum laser fluence level preserving tissue integrity (safety level). RESULTS: We precisely evaluate the damage fluence threshold of a tissue, using a statistical approach coupled with optical microscopy analysis. This technique gives essential information on laser-tissue interaction with a high rate of confidence. For corneal epithelium and the Bowman layer, we determine the maximum laser fluence level preserving tissue integrity (safety level) and the minimum fluence level systematically damaging the tissue. High and low threshold fluences of epithelium and the Bowman layers are (5.6 ± 0.4 J/cm(2); 2.7 ± 0.1 J/cm(2)), and (7.1 ± 1.1 J/cm(2); 3.4 ± 0.1 J/cm(2)), respectively. CONCLUSION: These data constitute determinant parameters for clinical applications, since they determine a working window providing the minimal effective irradiation dose that is mandatory for the development of high-quality laser-cutting surgery processes with minimized side effects.

[Spectral-domain optical coherence tomography in anterior segment imaging: the 3rd dimension]. / Tomographie par cohérence optique en domaine spectral du segment antérieur: la 3e dimension.

PURPOSE: Anterior segment imaging using optical coherence tomography (OCT) time domain technology has been used for many years. When it appeared, it was a promising technique in the analysis of the anterior segment, making it possible to reach a definition of the ocular structures comparable with histology. Now with new-generation OCT, it is possible to perform high-definition and three-dimensional imaging. MATERIAL AND METHOD: A 3D OCT-1000 (Topcon, Tokyo, Japan) parameterized to obtain high-definition and 3D imaging of the iridocorneal structures. RESULTS: We present a collection of images obtained using this technique. DISCUSSION: Based on a very sophisticated tool for retinal and glaucoma imagery, it is now possible to obtain very-high-quality imaging of the anterior segment, which, with its great versatility, increases the value of acquiring this type of device. CONCLUSIONS: The potential of 3D OCT-1000, already a very good exam for the posterior segment, and the only one to perform anterior segment three-dimensional imaging in a single acquisition, should not be neglected.

[Subretinal hemorrhage after intravitreal injection of anti-VEGF for age-related macular degeneration: a retrospective study]. / Hématomes maculaires après injections intravitréennes d'anti-VEGF pour dégénérescence maculaire liée à l'âge : série rétrospective.

INTRODUCTION: Prescription of anti-VEGF treatments have increased substantially over the past few years in treatment of wet age-related macular degeneration. We report the occurrence of macular hemorrhages after one year of use of anti-VEGF intravitreal injections, mainly for subfoveal choroidal neovascularization. MATERIAL AND METHODS: Four hundred forty five injections were given over one year (from 15 March 2007 to 15 March 2008), for age-related macular degeneration, retinal vascular occlusion, diabetic retinopathy, neovascular glaucoma, and idiopathic macular choroidal neovascularization; distributed as follows: 11.5% Bevacizumab, 18.6% Pegaptanib, 19.3% Triamcinolone, and 50.6% Ranibizumab. RESULTS: Six macular hemorrhages were observed, resulting in to a sharp decrease in visual acuity (20/400), with loss of five lines. All occurred after one injection of nonselective anti-VEGF (Ranibizumab) on already treated eyes (four previous injections on average, +/- photodynamic therapy). All were secondary to occult choroidal neovascularization or a large pigment epithelial detachment. Three patients presented a pigment epithelial tear. DISCUSSION: Anti-VEGF intravitreal injections can lead to pigment epithelial tears in case of large pigment epithelial detachment, especially with a small feeder vessel or with large occult choroidal neovascularization. The authors discuss the possible implications of anti-VEGF when macular hematoma occurs: retraction of choroidal neovascularization and alteration of physiological retinal vascularization. CONCLUSION: Macular hematoma affects visual prognosis in age-related macular degeneration. It may follow intravitreal anti-VEGF injection with large occult neovascularization, especially in previously treated eyes. Injection in large pigment epithelial detachment may cause a risk of epithelial tear. Other studies are necessary to evaluate the role of the nonselective anti-VEGF in the incidence of macular hematoma.

[Arcuate keratotomy for postkeratoplasty astigmatism by femtosecond laser]. / Incisions arciformes au laser femtoseconde pour correction de l'astigmatisme après kératoplastie transfixiante.

OBJECTIVE: Evaluation of the effectiveness of arcuate keratotomy performed with femtosecond laser for correction of postkeratoplasty astigmatism. METHODS: This retrospective clinical study included 11 eyes. All cases underwent arcuate keratotomy using femtosecond laser. Outcome measures included visual acuity and endothelial cell density as well as refractive, keratometric, and topographic astigmatism. The incision depth was also evaluated by OCT-3. RESULTS: With a mean follow-up of 7.4+/-6.7 months, uncorrected visual acuity was not modified and the mean best corrected visual acuity significantly improved from 1.68+/-1.59 lines (p=0.007). The mean preoperative refractive cylinder was 5.18+/-1.15D, decreasing to 3.41+/-1.93D (p=0.045) after laser-arcuate keratotomy. The reduction of preoperative keratometric (7.79+/-3.69D) and topographic (7.98+/-2.41D) astigmatism was higher, with a decrease to 4.81+/-2.52D (p=0.021) and 4.36+/-2.59D (p=0.005) postoperatively. Endothelial cell density was not modified after surgery. The difference between achieved and planned incision depth was -10.7+/-63.5mum. All cases were uncomplicated. DISCUSSION: Arcuate keratotomies performed with the femtosecond laser were effective in reducing postkeratoplasty astigmatism and has a number of advantages over conventional techniques. However, efficacy could be improved by a more accurate nomogram. CONCLUSION: Arcuate keratotomy performed with femtosecond laser is a relatively easy, safe, and effective means of treating postkeratoplasty astigmatism. Given our small sample, much larger series are needed to provide more confident estimates of astigmatism reduction proportions and to adjust correction parameters.

[A 3T fMRI study of cortical projection of visual scotomas: preliminary results]. / Etude en IRM fonctionnelle 3T de la projection corticale de scotomes rétiniens: résultats préliminaires.

AIM: We used functional magnetic resonance imaging (fMRI) to precisely measure both the localization and size of the cortical projections of artificial scotomas in healthy subjects as well as the size of a reversible retinal scotoma in a patient with central serous chorioretinopathy (CSCR). METHODS: Using a 3T MRI scanner, anatomical and functional data were acquired on two healthy subjects and a patient with CSCR. Retinotopic maps were first reconstructed using phase mapping techniques. Next, a block paradigm consisting of a grey background alternating with a full-field, flickering checkerboard was used to stimulate the complete central (19.5 degrees) visual field. A condition with artificial peri-foveal scotomas of different sizes and eccentricities was interleaved in healthy subjects. Differential maps were computed to obtain the cortical representation (size and location) of artificial scotomas. Full-field functional data were also acquired in the CSRC patient, at the acute stage and after recovery. RESULTS: Cortical projections of each scotoma were identified using differential maps and carefully characterized with quantitative analysis: the measured cortical positions of the inactivated cortical zones were compared with the known radius and eccentricity values in the scotomas in the visual field. We also compared the size of the inactivated cortical zones to the known size of scotomas. However, we found a consistent relationship between the size of the scotomas and their cortical projections, albeit with the absolute size smaller than expected from known cortical magnification factors. The cortical deactivation zone was also observed in the CRSC patient, which disappeared at recovery stage. CONCLUSIONS: Cortical retinotopic mapping can be performed successfully for both artificial and retinal scotomas. This study can serve as a basis for the future investigation of cortical plasticity in the visual cortex.

[Anterior segment analysis using OCT3]. / Méthodologie d'analyse du segment antérieur par OCT-3.

PURPOSE: Optical coherence tomography has been used for many years, in particular in the field of the retinal imaging, and is a promising technique in the analysis of the anterior segment, providing a similar resolution to histology for ocular tissue. MATERIAL AND METHODS: We present a collection of images obtained with the OCT3 (Carl Zeiss Meditec, Dublin, CA), with parameters set to obtain good-quality images of the iris and corneal structures. RESULTS: The OCT provides detailed analysis of the cornea, precise assessment of the dimensions and locations of corneal lesions - in the anterior-posterior plane as well as transversally or obliquely - with 10-microm precision, and the study of the iridocorneal angle and its dynamics. DISCUSSION: Using the highly precise OCT3 for retinal imaging, it is possible to obtain good-quality anterior segment imaging, which makes the device highly versatile and thus increases reasons for acquiring this type of apparatus. CONCLUSIONS: OCT3 users should not neglect this potential of the device, already in wide use for examining the retina.

[Retinotopic organization of the human visual cortex: a 3T fMRI study]. / Etude en IRM fonctionnelle 3T de l'organisation rétinotopique du cortex visuel.

UNLABELLED: INTRODUCTION. We used high-field (3T) functional magnetic resonance imaging (fMRI) to map the retinotopic organization of human cortical areas. METHODS: Retinotopic maps were reconstructed using existing mapping techniques. Stimuli were made of a rotating wedge stimulus, which provided angular coordinate maps, and an expanding or contracting ring, which provided eccentricity coordinate maps. Stimuli consisted of a grey background alternating with a flickering checkerboard. A Brucker 3T scanner equipped with a head coil and a custom optical system was used to acquire sets of echoplanar images of 20 occipital coronal slices within a RT of 2.111 ms and an 8 mm3 voxel resolution. Surface models of each subject's occipital lobes were constructed using the Brainvisa software from a sagittal T1-weighted image with a 1 mm3 voxel resolution. The cortical models were then inflated to obtain unfolded surfaces. Statistical analyses of the functional data were made under SPM99, and the response amplitudes were finally assigned to the cortical reconstructed surfaces. RESULTS: We identified boundaries between different early visual areas (V1, V2, V3) using eccentricity and polar angle retinotopic maps and detection of reversals in the representation of the polar angle. Both complete maps and reversals corresponding to the V1/V2 borders were clearly visible with a single recording session. Also, we were able to compare data from subjects across various fMRI acquisitions and found that there was a strong correlation between maps acquired at different sessions for the same subject. CONCLUSIONS: We developed a quick (<40 min) retinotopic cortical area mapping method at 3T, which makes it possible to study the cortical remapping in patients with retinal scotomas.

[Femtosecond-assisted anterior lamellar keratoplasty]. / Kératoplastie lamellaire antérieure assistée par laser femtoseconde.

INTRODUCTION: Automated lamellar keratoplasty remains a challenging surgical technique because of surgical difficulties and is associated with a high rate of complications. The precision of the corneal cut at any corneal depth with the femtosecond laser is an important improvement in this technique. We report the first case of femtosecond-assisted anterior lamellar keratoplasty. MATERIAL AND METHODS: A 63-year-old woman with anterior stromal dystrophy underwent femtosecond laser-assisted ALTK on the left eye. A donor lenticula was prepared from a corneoscleral rim utilizing the Femtec 20/10 Perfectvision femtosecond laser device and an artificial anterior chamber (Moria, Antony, France). The anterior lamellar cut was also performed on the patient's eye with the femtosecond laser. RESULTS: Postoperative examinations showed a well-adapted graft with a clear interface. OCT III (Carl Zeiss Meditech, Dublin) measurements showed a corneal pachymetry of 713 microm associated with a regular posterior bed and a central thickness of 132 microm. DISCUSSION: Femtosecond laser corneal cutting may offer greater safety, reproducibility, predictability, and flexibility. The risks of irregular cutting and microperforation are reduced. A better graft congruence can limit the risk of secondary displacement and the smooth interface should improve visual results. CONCLUSION: Donor lenticulae and corneal cuttings performed with the Femtec 20/10 Perfectvision( femtosecond laser device can be used in the successful management of eyes requiring anterior lamellar keratoplasty. Further studies are needed to evaluate outcomes of this procedure.

[Internal carotid artery dissection on arterial fibromuscular dysplasia causing a central retinal artery occlusion: a case report]. / Oblitération de l'artère centrale de la rétine secondaire à une dissection de la carotide interne sur fibrodysplasie artérielle.

INTRODUCTION: We report a case of a 66-year-old woman presenting a central retinal artery occlusion with no cardiovascular risk factor, with assessment using supra-aortic artery ultrasonography showing total internal carotid artery thrombosis. OBSERVATION: When vascular thrombosis risk factors are absent, more in-depth assessment such as a supra-aortic artery angioscan can provide the diagnosis of arterial dissection on arterial fibromuscular dysplasia. CONCLUSION: Central retinal artery occlusion is a rare but severe pathology. Therefore it is very important not to neglect the etiological assessment, because it can be the revealing element of a severe pathology.

[Bilateral corneal endothelial decompensation after postsepticemia coma]. / Décompensation endothéliale bilatérale après coma post septicémie à staphylocoque.

We report a case of unexplained bilateral corneal endothelial decompensation after a coma. A 71-year-old man with no medical history presented with bilateral endothelial decompensation that required penetrating keratoplasty of the left eye combined with cataract surgery. This coma was caused by septicemia originally due to staphylococcus infection following catheter placement in preparation for a CT scan. Visual acuity of the left eye was 20/400 and 20/100 in the right eye when the patient awoke from the coma. After examination, we noted only stromal thickening and Descemet membrane folds causing corneal edema predominating OS. The rest of the exam was normal. Six months after surgery, visual acuity improved to 20/25. The most probable physiopathological mechanism of this decompensation is an iatrogenic complication from drugs administered during the patient's stay in intensive care (oxacillin), but we cannot rule out direct aggression of a bacterium or its toxin or the decompensation of a preexisting pathology.

Metabolic factors and the foveal avascular zone of the retina in diabetes mellitus.

AIM: To study the foveal avascular zone (FAZ) of the central retina in diabetic patients with retinopathy having undergone metabolic evaluation. METHODS: One hundred and ten digital fluorescein angiograms were chosen from our digital image bank after cross matching diabetic patient lists of the ophthalmology and endocrinology departments of our institution. The patients had undergone day visits with systemic, biological and ophthalmologic evaluation, including digital fluorescein angiography. RESULTS: Sex ratio was M 62/F 48. Average age was 52.4 years (+/- 13.8) with 44 type 1 diabetics and 66 type 2. Retinopathy was present in all patients (54 background (BDR), 30 pre-proliferative (PPDR), 26 proliferative (PDR)). Age was positively correlated with FAZ grade (47.3 years +/- 13.2 for normal FAZ, 53.8 years +/- 13.7 for abnormal FAZ, P=0.03). Lipid profile showed a protective tendency of the Apo A1 fraction of cholesterol on macular vascularization (1.7 gr./l in normal FAZ patients vs 1.43 gr./l in abnormal FAZ patients, P=0.004). Body mass index was negatively correlated with macular ischemia (28.11 if FAZ not severely altered, 25.97 if FAZ severely altered, P=0.03). CONCLUSIONS: We found possible relations between BMI and Apo A 1 cholesterol and macular vascularization which may warrant further investigation.

[Quantitative and spatial analysis in image processing: study of drusen distribution from the foveal center in age-related macular degeneration]. / Méthode d'analyse quantitative et spatiale dans le traitement d'image: étude de la distribution radiale des drüsen dans la dégénérescence maculaire liée à l'âge.

Angiofluorograms were obtained from 58 patients presenting posterior pole drusen due to age-related macular degeneration. These frames underwent image processing by morphological mathematics algorithms. The detection sensitivity of this algorithm is 78%. We present a quantitative and spatial analysis of drusen distribution from the foveal center in the form of a graph. This technique may allow for multi-date comparisons, by using a graphic representation of this risk factor for age-related macular degeneration.

Foveal avascular zone in diabetic retinopathy: quantitative vs qualitative assessment.

PURPOSE: To describe the relations between foveal avascular zone (FAZ) size and outline in patients presenting diabetic retinopathy. METHODS: 110 high-quality fluorescein angiograms from 110 diabetics were chosen from our digital retinal image databank. Patients with significant media opacities, macular scars, macular hard exsudates, high ametropia, and associated macular pathology were excluded. Both FAZ perimeter and surface area were measured with image analysis software. FAZ outline was graded according to ETDRS report Number 11 (from 0=normal to 4=capillary outline completely destroyed). Data were compared to that of 31 healthy controls. FAZ surface in diabetics was compared to that of controls and FAZ surface was compared to FAZ grade, FAZ perimeter and retinopathy stage in diabetics. Quantitative variables were compared using the U-test of Mann-Whitney or Kruskal-Wallis test and correlations between quantitative variables were estimated with the Spearmann coefficient. RESULTS: All patients presented diabetic retinopathy (54 BDR, 30 PPDR, 26 PDR). FAZ size was larger in diabetics than controls (P<0.001). In diabetics, FAZ size increased with FAZ grade (P

[Teaching phacosection in a tropical setting]. / Formation à la phacosection en milieu tropical.

PURPOSE: The aim of this study was to prospectively evaluate the training of a Malagasy ophthalmologist, already proficient in classic manual extracapsular cataract extraction (ECCE), in a small incision manual technique (phacosection). MATERIALS AND METHODS: Within the activity of the Sight First program to fight blindness in Madagascar, the ophthalmologist of Majunga recruited patients presenting total white cataracts. These patients were operated by phacosection using the local hospital's usual instrumentation along with two specific phacosection instruments and extra single-use material (a precalibrated 3.2 mm knife and viscoelastic products). Peribulbar anesthesia with eye pressure was provided. Postoperative follow-up (visual acuity and corneal status) was conducted on days 1, 7 and 30. RESULTS: Forty-four eyes were operated, the first seven by the instructor assisted by the local ophthalmologist, the next 36 by the local ophthalmologist assisted by the instructor. Five postoperative complications were noted: two cases of posterior capsular rupture (one during implantation) and three cases needing reoperation with aspiration of residual cortical masses. Induced astigmatism was low and visual rehabilitation was good, with all corneas clear at day 30. DISCUSSION: The results are quite acceptable given the training period, with only two marked complications (one not related to the operative technique) and good visual rehabilitation in less than 2 weeks. This small incision technique allowed reduction of induced astigmatism and risk-free management of total white cataracts (independent of operator). CONCLUSION: Small incision manual ECCE by phacosection is a safe, possible management option for difficult cataracts in a tropical setting with only a small increase in cost. Moreover, the training of an ophthalmologist mastering classic manual ECCE appears rapid and risk-free for patients.