[Outpatient management without day 1 clinical follow-up of patients undergoing uncomplicated filtering surgery]. / Prise en charge ambulatoire sans contrôle clinique à j1 de patients opérés d'une chirurgie filtrante non compliquée en peropératoire.

INTRODUCTION: Although the general increase in ambulatory surgery allows for a 20% reduction in costs of hospitalization, the necessity of a day 1 postoperative visit remains the main problem for elderly patients or those who reside at considerable distance. For these reasons, in 2014, we decided to only see patients with uncomplicated filtering surgery at D5 and D21 and to replace the D1 visit with a telephone call. The primary goal of our study was to analyze a population of patients undergoing uncomplicated filtering surgery who were not seen at D1 and to describe the frequency of postoperative complications, intraocular pressure results and therapeutic management at D5 and D21. PATIENTS AND METHODS: This was a retrospective monocentric study in the department of ophthalmology. All patients (naïve of surgical treatment for glaucoma) underwent surgery for primary open-angle glaucoma in an ambulatory surgery unit between May 2014 and July 2016. A nurse made a phone call to the patients at day 1 and they responded to a standardized questionnaire. Depending upon their responses, the patients were seen quickly (<24hr) or on the systematic schedule at day 5 and day 21. RESULTS: One hundred and forty-four eyes (126 patients) were included in our study. The mean preoperative IOP was 20.4±6.4mmHg. After the phone call, only five patients were examined before the first planned follow-up at day 5. For 3 of them, the examination revealed the presence of a hyphema, and their topical medication was changed. The other two patients had no treatment modifications. At day 5, the mean IOP was 10.6±5.9mmHg. Thirty-two eyes (22.2%) required a change in their medication at day 5. The mean IOP at day 21 was 12.9±4.6mmHg. Our success rate (IOP<21mmHg with no topical medication) at day 21 was 95.6%. DISCUSSION: The guidelines for filtering glaucoma surgery recommend examining the patient at day 1 (or at least before day 3), day 8, day 15 and day 30 or more frequently according to the case. We replaced the day 1 visit with a telephone call. We did not note a substantial rate of complications due to the elimination of the D1 visit. The criteria of success of filtering glaucoma surgery vary in the literature, but our success rate at D21 seems to be similar that in the literature and may suggest that the day 1 visit is not necessary if the surgery for primary open angle glaucoma is uncomplicated.

Mydriasis revealing vascular and osteodural compression of the oculomotor nerve: An observational study on five cases.

PURPOSE: To describe a form of neurovascular compression of the third cranial nerve (CNIII) in idiopathic mydriasis, in which a neurovascular "conflict" exists between the oculomotor nerve, the posterior communicating artery and the clinoid process, using high-resolution magnetic resonance imaging (MRI) with fast imaging employing steady acquisition (FIESTA) sequences. METHODS: An 18-month prospective, observational and monocentric case series report was performed. MRI was performed on 5 consecutive patients with idiopathic, unilateral, persistent and nonreactive mydriasis (pure intrinsic palsy of the CNIII). Patients with diplopia, ptosis or ophthalmoplegia were excluded. Cerebral MRI focused on the CNIII pathway from the mesencephalon to the cavernous sinus entry, particularly on the cisternal segment: image acquisition was performed on a 3 Tesla MRI; the protocol included fast imaging employing steady acquisition (FIESTA) and three-dimension time of flight (3D TOF) sequences. RESULTS: All patients presented a neurovascular compression point, involving the CNIII clamped between a tortuous posterior communicating artery (PCoA) and the posterior clinoid process at the entrance of the cavernous sinus. No cases occurred in the root entry zone. There was no compression on the contralateral side. No tumors or aneurysms were found. Thus, the mydriasis was caused by CNIII compression. CONCLUSION: MRI, including FIESTA sequences, revealed a new type of neurovascular conflict between the CNIII, PCoA and posterior clinoid process in patients with incomplete oculomotor palsy. Non-aneurysmal CNIII compression should be considered as a differential diagnosis in the work-up of idiopathic mydriasis. The role of MRI in the work-up of anisocoria should be considered.

[Focus on Susac's syndrome. A pediatric case report]. / Mise au point sur le syndrome de Susac. À propos d'un cas pédiatrique.

INTRODUCTION: Susac's syndrome (SS) is a rare immune disorder. It combines encephalopathy, retinopathy and hearing loss. We report a new pediatric case, revealed by an occlusive retinal arteritis. CASE REPORT: A 12-year-old girl presented to the emergency room because of sudden onset of photopsias in her right temporal visual field. One year previously, she had developed an acute disseminated encephalomyelitis, resolving with steroids. Visual acuity was 10/10-P2 in both eyes. Fundus examination revealed a thin right inferior nasal artery. Fluorescein angiography revealed an occlusion of this artery and occlusive peripheral arterial vasculitis. An IV steroid bolus was administered urgently. Brain MRI showed high signal intensity abnormalities in the corpus callosum. The clinical triad was rapidly completed by a bilateral hearing loss. Intravenous immunoglobulins were initiated. The occurrence of contralateral occlusive retinal arteritis two months later led to treatment with cyclophosphamide. After 6 infusions, visual acuity was stable, but the visual field remained, and regression of the vasculitis remained incomplete. DISCUSSION: Three hundred cases of SS have been reported with predominance in young women. Pediatric cases are rare. Diagnosis is difficult, because the typical clinical triad is often incomplete. Occurrence of relapses is unpredictable. Visual prognosis depends on the location of the occluded retinal territories. Treatment, based on a combination of steroids, immunosuppressive and antiplatelet agents is not always able to prevent relapse, as in our case. CONCLUSION: Unpredictable progression of SS requires early diagnosis and treatment as well as close monitoring. It must always be considered in the case of any occlusive retinal arteritis, even in children.

[Simplified topical anesthesia protocol for ambulatory cataract surgery: safety and patient and surgeon satisfaction]. / Étude de satisfaction et de sécurité d'un protocole d'anesthésie simplifié pour la chirurgie de cataracte sous anesthésie topique.

BACKGROUND AND PURPOSE OF STUDY: The purpose of our study was to assess safety and efficacy of cataract surgery (CS) under topical anesthesia alone, i.e. without pre-anesthetic evaluation and without direct presence of an anesthesiologist. To this end we assessed the incidence of patients' preoperative anxiety, perioperative adverse events and patients' and surgeons' satisfaction. MATERIALS AND METHODS: Patients undergoing CS under topical anesthesia over a one-month period were included. An anesthesiologist and nurse anesthetist were present in the area and could intervene in case of an adverse event. Patients' anxiety was scored using the Amsterdam Preoperative Anxiety & Information Scale (APAIS), and their satisfaction with the Iowa Satisfaction with Anesthesia Scale (ISAS). Surgeons' satisfaction was scored with a VAS from 0 to 10 (0: surgery not possible & 10: excellent surgical conditions). RESULTS AND DISCUSSION: One hundred and twenty-four consecutive patients were included; mean age was 71 (±9.4) years. Mean APAIS I was 6.4/20 (±3.7). Mean APAIS II was 3.1 (±1.8). Mean ISAS score was 5.5/6 (±0.6), indicating high patient satisfaction. Surgeon satisfaction score was 8.9/10 (±1.7). Twenty-three adverse events occurred of which 16 required interventions by the anaesthesiologist or surgeon: 5 supplemental local or regional anaesthesia, 6 iv-analgesia, 5 management of hypertension. CONCLUSION: These preliminary data suggest that a simplified topical anesthesia protocol for ambulatory CS appears to be feasible and safe, as long as an anesthesia team is present in the area to intervene if needed.

[Ultrasound biomicroscopy long-term study of filtering belbs]. / Analyse à long terme de la bulle de filtration après chirurgie de glaucome, par échographie ultrasonore.

PURPOSE: To study aspect of filtering blebs by Ultrasound Biomicroscopy (UBM) and to compare it to intraocular pressure (IOP), to type of surgery performed and to the measurement of the anterior chamber angle after glaucoma surgery. METHODS: An observational study, conducted between January and December 2010 on 46 eyes of 42 patients who underwent glaucoma surgery. 17 combined surgeries (14 non-penetrating deep sclerectomy (NPDS) with phacoemulsification and 3 trabeculectomy with phacoemulsification) and 29 filtering surgeries alone (16 NPDS and 13 trabeculectomy) were performed by the same surgeon with application of mitomycin C for 1.30 minutes during surgery. After surgery, IOP was controlled at day 5, day 30 and at UBM realisation. Filtering blebs were classified according to Yamamoto's study: functional blebs (L: Low-reflective) and non-functional blebs (H: High-reflective, E: Encapsulated and F: Flattened). RESULTS: Mean follow-up was 21 months (± 3.7). We noted a significant decrease in IOP, mean preoperative IOP 23.2mmHg (± 9.4), mean post operative IOP 14.7mmHg (± 3.3) (P<0.001). We identified 36 functional blebs (36L type) and 10 non-functional blebs (including 1 H, 7 F and 2 E). There was no significant morphological differences between filtering blebs after combined surgery and filtering surgery alone (P=0.072). We did not find any morphological difference between filtering blebs after trabeculectomy and NPSD (P=0.394). Blebs are significantly more functional with an IOP less or equal to 6mmHg after surgery (P=0.028). We didn't find any difference between efficacy of filtering blebs and depth of the anterior chamber angle. CONCLUSION: Our study reports 78% of functional blebs after glaucoma surgery (mean duration of 21 months). Type of surgery does not seem to interfere with the long-term morphological type of the bleb, however the immediate postoperative IOP less than or equal to 6mmHg is a factor of good prognosis. UBM appears to be an interesting tool for monitoring patients undergoing glaucoma surgery.

[Vincristine-induced unilateral ptosis: case report and review of the literature]. / Ptosis unilatéral induit par la vincristine : à propos d'un cas et revue de la littérature.

We report the case of a 31-month-old girl, treated by the ifosfamide-vincristine-actinomycin chemotherapy protocol for vaginal rhabdomyosarcoma, who developed a unilateral left ptosis on day 36 of chemotherapy, i.e. 7 days after the fifth vincristine dose (1.5mg/m(2) or 0.90 mg). The cumulative vincristine dose was thus 4.50mg. The remainder of the neurological and systemic examinations were unremarkable. Laboratory testing and thoracic-cervical-cranial CT were normal. Other causes of ptosis were excluded. The ptosis decreased a few days after the infusion of vincristine and re-increased just after a new dose. It finally resolved upon lowering the dose of vincristine. According to our observations, the role of vincristine in the pathogenesis of this ptosis appears "likely". In such cases, maintenance of treatment is possible with adjustment of vincristine doses, but requires regular follow-up.

Optic disc neovascularization revealing neurosyphilis.

PURPOSE: To report a case of neurosyphilis revealed by bilateral optic disc neovascularization. DESIGN: Case report. METHODS: A 39-year-old man presented with a 6-month history of progressive visual loss (20/25 RE, 20/1200 LE) and transient headaches. Fundus examination demonstrated a 1+ vitritis, mild macular edema and large optic disc neovascularization in both eyes. Serological tests for syphilis were positive. RESULTS: Specific antibiotics and systemic steroids were undertaken and complete regression of disc neovascularization was observed within 6 months. CONCLUSION: Optic disc neovascularization, which is a rare manifestation of chronic uveitis, may lead to the diagnosis of neurosyphilis and be successfully treated by specific antibiotic and steroid therapy.