[Eye and Behçet's disease]. / Œil et maladie de Behçet.

Behçet's disease is a chronic multisystem disorder characterized by relapsing inflammation for which the underlying histopathology is an occlusive vasculitis. The disease has a high prevalence in the Mediterranean region, Far and Middle Eastern countries. It is clinically characterized by oral and genital ulcerations, ocular inflammatory involvement, skin lesions, vascular involvement and numerous other systemic manifestations. Uveitis is by far the most common ocular manifestation of Behçet's disease. It typically presents in the form of relapsing-remitting panuveitis with retinal vasculitis that may result in severe visual loss. Management of Behçet's uveitis relies on corticosteroid therapy, conventional immunosuppressive drugs and biological agents and requires a close collaboration between ophthalmologist and internist. A better understanding of the auto-inflammatory process and of the role of cytokines implicated in the pathogenesis of Behçet's disease will enable researchers to develop more specific and effective therapy.

Eye and Behçet's disease.

Behçet's disease is a chronic multisystem disorder characterized by relapsing inflammation for which the underlying histopathology is an occlusive vasculitis. The disease has a high prevalence in the Mediterranean region, Far and Middle Eastern countries. It is clinically characterized by oral and genital ulcerations, ocular inflammatory involvement, skin lesions, vascular involvement and numerous other systemic manifestations. Uveitis is by far the most common ocular manifestation of Behçet's disease. It typically presents in the form of relapsing-remitting panuveitis with retinal vasculitis that may result in severe visual loss. Management of Behçet's uveitis relies on corticosteroid therapy, conventional immunosuppressive drugs and biological agents and requires a close collaboration between ophthalmologist and internist. A better understanding of auto-inflammatory process and of the role of cytokines implicated in the pathogenesis of Behçet's disease will enable researchers to develop more specific and effective therapy.

[Idiopathic orbital inflammatory syndrome: Report of 24 cases]. / Syndrome d'inflammation orbitaire idiopathique : à propos de 24 cas.

BACKGROUND: Idiopathic orbital inflammatory syndrome (IOIS) is an inflammatory condition of unknown etiology. The inflammation may affect all the structures within the orbit (anterior, diffuse, apical, myositic, dacryoadenitis) and corresponds to uniquely orbital inflammation without an identifiable local cause or systemic disease. The goal of this study is to describe the clinical and radiographic characteristics of IOIS and discuss the role of orbital biopsy in this condition. PATIENTS AND METHODS: This is a retrospective review of the charts of 24 patients diagnosed with IOIS at Fattouma Bourguiba hospital, Monastir, Tunisia, from January 2007 to December 2015. This study included all patients with IOIS and a minimum follow-up of six months. All patients had a complete ophthalmological examination and orbital and head CT scan and/or MRI. A work-up was performed in all cases to rule out local causes and systemic disease. Only 11 patients underwent biopsy. The diagnosis of the clinical entity IOIS was made according to the Rootman criteria. Oral steroids were the first line therapy. A bolus of intravenous methylprednisolone was administered first in vision-threatening cases. Response to treatment was defined as disappearance of signs and symptoms of IOIS. RESULTS: Orbital pain was the most common symptom (62.5%), followed by proptosis and decreased vision (37.5% each). Best-corrected visual acuity (BCVA) was greater than 5/10 in 70.7% of patients. Lacrimal gland enlargement was observed in 3 patients. Oculomotor disorders were present in 70% of cases and 20.8% of patients had compressive optic neuropathy. Orbital imaging showed, in most cases, oculomotor muscle inflammation (87.5%) involving particularly the superior rectus muscle (54.2%) and inflammation of orbital fat (66.7%). Fifty percent had myositic inflammation. Biopsy was performed in 11 patients, showing nonspecific inflammation (n=10) and the sclerosing form (n=1). A total of 83.3% of patients received oral corticosteroids for a mean duration of 5.5 months. CONCLUSION: IOIS is a diagnosis of exclusion, based on history, clinical course, response to steroid therapy, laboratory tests, or even biopsy in selected cases. Orbital imaging provides valuable clues for diagnosis of IOIS and for identification of affected structures. Prolonged steroid therapy is necessary as IOIS classically responds to steroids; nevertheless, partial recovery or relapses often occur.

Epidemiological, clinical and laboratory features of murine typhus in central Tunisia.

OBJECTIVE: Murine typhus is an endemic zoonosis. It is difficult to diagnose because of its non-specific clinical manifestations. Our objective was to describe the epidemiological, clinical, laboratory, and treatment features of murine typhus. METHODS: We conducted a retrospective study of 73 adult patients hospitalized for murine typhus from 2006 to 2011. The diagnosis was confirmed by a single titer of IgM≥128 or by seroconversion to typhus group antigen identified by indirect fluorescent assay. RESULTS: The mean age of patients was 33.1 years (range, 13-68 years). Thirty-eight patients (52%) lived in rural or suburban areas; neither fleabites nor exposure to rats were reported. The most common clinical symptoms were: fever, headache, and myalgia. A maculopapular and non-confluent rash was observed in 47 patients (64.4%). No inoculation eschar was observed in any patient. Eight patients presented with interstitial pneumonia and two with lymphocytic meningitis. The diagnosis was confirmed by indirect fluorescence assay in every case. A single titer of IgM ≥ 128 was found in 62 (84.9%) cases. The other 11 cases were diagnosed by seroconversion. All patients were given antibiotics. Tetracyclines were prescribed in 57 cases (78%). The two patients presenting with meningitis were treated with fluoroquinolone. The outcome was favorable for all patients and no relapse was observed. CONCLUSION: The features of murine typhus are non-specific. The definitive diagnosis is based on serologic testing by indirect fluorescent assay. Cyclins were the most prescribed antibiotics.

Prevalence and causes of visual impairment in diabetic patients in Tunisia, North Africa.

PURPOSE: To investigate the prevalence and causes of blindness and partial sight among a population of Tunisian diabetic patients. METHODS: 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. RESULTS: 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 (P<0.001), duration of diabetes >10 years (P<0.001), body mass index >25 (P=0.014), hypertension (P<0.001), heart disease (P<0.001), peripheral neuropathy (P=0.03), vegetative neuropathy (P=0.002), macroalbuminuria (P<0.001), cataract (P<0.001), DR (P<0.001), diabetic macular edema (P<0.001), open angle glaucoma (P<0.001), intravitreal hemorrhage (P<0.001), rubeosis iridis (P<0.001), neovascular glaucoma (P<0.001), and tractional retinal detachment (P<0.001). CONCLUSION: 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.

[Treatment of rhegmatogenous retinal detachment by pneumatic retinopexy: a review of 50 patients]. / Traitement du décollement de rétine rhegmatogène par rétinopexie pneumatique: étude à propos de 50 cas.

PURPOSE: : To evaluate the effectiveness and safety of pneumatic retinopexy as an alternative technique for rhegmatogenous retinal detachment repair. MATERIAL AND METHODS: We conducted a review of 50 patients (50 eyes) who had undergone pneumatic retinopexy as the initial procedure for rhegmatogenous retinal detachment between January 2001 and March 2006. The mean follow-up period was 22 months (range, 6-57 months). RESULTS: Pneumatic retinopexy resulted in reattachment in 35 eyes (70%) with one procedure. The final reattachment rate, after revision, was 94% (47/50 eyes). In seven eyes (14%), the cause of failure was the presence of missed or new retinal breaks. There was no correlation between the initial reattachment rate and the size of detachment, the status of the macula at presentation, the number of retinal breaks, and the type of retinopexy (cryotherapy or laser photocoagulation). A two-line or more improvement in Snellen acuity was achieved in 24 of 35 eyes (68.6%). A postoperative visual acuity equal to or better than 4/10 was significantly correlated with time from first symptom to presentation less than 1 month (p=0.05), preoperative visual acuity equal to or better than 4/10 (p=0.02), and attached macula at presentation (p=0.03). CONCLUSION: Pneumatic retinopexy appears to be an effective procedure for the initial management of primary rhegmatogenous retinal detachments with superior retinal breaks and without proliferative vitreoretinopathy.

Ocular manifestations associated with murine typhus.

AIMS: To characterise and analyse ocular manifestations associated with acute murine typhus (MT), an infectious disease caused by Rickettsia typhi. METHODS: Nine consecutive patients (18 eyes) with serologically confirmed MT at the acute stage were enrolled in this prospective, non-comparative study. All patients underwent complete ophthalmic examination, including dilated biomicroscopic fundus examination, fundus photography, fluorescein angiography (FA) and indocyanine green (ICG) angiography. RESULTS: Of nine patients, eight (88.9%) had bilateral ocular involvement related to MT, with (n = 3) or without (n = 5) associated ocular symptoms. Findings included mild vitreous inflammation (10 eyes; 55.6%), white retinal lesions (nine eyes; 50%), retinal haemorrhages (four eyes; 22.2%), retinal vascular leakage (seven eyes; 38.9%), hypofluorescent choroidal dots on FA and/or ICG angiography (11 eyes; 61.1%), optic-disc swelling (two eyes; 11.1%), optic neuritis (one eye; 5.6%) and optic-disc staining (11 eyes; 61.1%). All ocular findings had a self-limited course. CONCLUSION: Ocular involvement is frequently observed in acute MT. A systematic fundus examination, complemented by angiography in selected cases, may be helpful in establishing an early clinical diagnosis of the disease while serological testing is pending.

Pattern of uveitis in a referral centre in Tunisia, North Africa.

AIM: To analyse the pattern of uveitis in a referral centre in Tunisia, North Africa. METHODS: The study included 472 patients with uveitis examined at the Department of Ophthalmology of Monastir (Tunisia) from January 1992 to August 2003. 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 three-mirror lens. Standard diagnostic criteria were employed for all syndromes or entities of uveitis. RESULTS: The mean age at onset of uveitis was 34 years. The male-to-female ratio was 1:1.1. Uveitis was unilateral in 282 patients (59.7%) and bilateral in 190 patients (40.3%). Anterior uveitis was most common (166 patients; 35.2%), followed by posterior uveitis (133 patients; 28.2%), panuveitis (100 patients; 21.2%), and intermediate uveitis (73 patients; 15.5%). A specific diagnosis was found in 306 patients (64.8%). The most common cause of anterior uveitis was herpetic uveitis (56 patients; 33.7%). Toxoplasmosis was the most frequent cause of posterior uveitis (51 patients; 38.3%). Intermediate uveitis was most commonly idiopathic (63 patients; 86.3%). Behçet's disease was the most common cause of panuveitis (36 patients; 36%), followed by Vogt-Koyanagi-Harada (VKH) disease (15 patients; 15%). A total of 16 patients (3.4%) suffered from blindness, and 59 (12.5%) from uniocular blindness. CONCLUSIONS: In a hospital population in Tunisia, the most common causes of uveitis were Behçet's disease, herpes simplex infection, toxoplasmosis, and VKH disease.

[Posterior scleritis: six case reports]. / Les sclérites postérieures: à propos de 6 cas.

PURPOSE: To study the clinical features, management guidelines, and the course of the disease in six patients with posterior scleritis. SUBJECTS AND METHODS: Six patients with posterior scleritis were enrolled in this retrospective study. All patients underwent a complete ophthalmic examination, fluorescein angiography, and B-scan ultrasonography. Systemic evaluation included physical examination and laboratory screening investigations. Medical management included systemic indomethacin (two cases), oral steroids (two cases), intravenous pulses of methylprednisolone followed by tapered oral steroids (two cases). One patient underwent immunosuppressive therapy (azathioprine) because of steroid dependence. RESULTS: The main presenting symptoms were pain (six cases) and decreased vision (four cases). Chorioretinal changes included chorioretinal folds (six cases), retinal folds (five cases), optic disc edema (five cases), serous retinal detachment (two cases), and a subretinal mass (one case). Ultrasonography disclosed sclerochoroidal thickening in all cases and retrobulbar edema in three cases. Systemic evaluation was unremarkable in five cases and revealed Behçet's disease in one case. All patients showed a good response to medical treatment. CONCLUSION: Posterior scleritis has protean manifestations and can be easily overlooked. This diagnosis must be considered in all inflammatory and painful ocular disorders with no obvious etiology. B-scan ultrasonography is the most useful diagnostic tool in such patients. The disease usually shows a good response to systemic anti-inflammatory therapy.

[Purtscher-like retinopathy in systemic lupus erythematosus. Two cases]. / Pseudorétinopathie de Purtscher révélant un lupus érythémateux disséminé

Purtscher-like retinopathy is a retinopathy with vascular manifestations resembling Purtscher's retinopathy associated with autoimmune disorders such as lupus erythematosus. We report two cases of blurred vision associated with multiple whitish patches scattered over the macular and peripapillary areas. In the absence of trauma, these symptoms led us to systemic lupus erythematosus. The diagnosis was confirmed by the immunological and biological examinations. A steroid treatment was given with poor visual response. Purtscher-like retinopathy is a rare complication of systemic lupus erythematosus and there is some controversy about its pathogenesis and its treatment.

[Effectiveness of conjunctival autograft transplantation in pterygium surgery]. / Apport de l'autogreffe conjonctivale dans la chirurgie du ptérygion.

INTRODUCTION: Pterygium is a fibrovascular overgrowth of bulbar cunjonctiva over the cornea and may produce visual impairment. Many surgical techniques and adjunctive therapies have been proposed but recurrence remains frequent. MATERIALS AND METHODS: We report a prospective study of 52 eyes treated by limbal conjunctival autograft for primary and recurrent pterygium. We compare our results with the technique of simple excision performed in 111 cases of pterygium (3 being a recurrent pterygium). RESULTS: The mean age of the patients was 45 years. 30 cases of pterygium were primary (57.7%) and 22 were recurrent (42.3%). After an average follow-up of 14 months, the incidence of recurrence was 10%. Only 2 of these recurrent cases of pterygium were primary. DISCUSSION: Conjunctival autograft is a simple, safe, and highly effective procedure for the treatment of pterygium. It reduces the rate of recurrence more than simple excision (55.9% after a follow-up of 1 year). CONCLUSION: The introduction of limbal conjunctival autograft for the treatment of pterygium meets three main goals: safety, good optical outcome and a lower rate of recurrence. This procedure could be accepted as a successful technique for cases with recurrent pterygium specially in younger patients and when the environment al factors lower the development of recurrent pterygium.