[Effect of keratoplasty on the quality of life of keratoconus patients]. / Effet de la kératoplastie sur la qualité de vie des patients atteints de kératocône.

Corneal deformations caused by keratoconus produce high levels of optical aberration (OA). Despite appropriate optical correction, these alter the quality of vision and diminish the patient's quality of life, especially since the affected population is predominantly young and of working age. When thinning is too severe or corneal transparency too impaired, a corneal transplant may be considered. In this study, we compare the quality of life of patients with keratoconus in the early (stages 1 and 2) or advanced (stages 3 and 4) stages of the Krumeich classification, as well as patients who have had keratoconus treated by keratoplasty. Quality of life was assessed using the NEI-VFQ 25 questionnaire, the most widely used for keratoconus. An aberrometric examination (OQAS®; HD Analyser, Visiometrics, Terrassa, Spain) was also performed to assess patients' quality of vision. Our results show that keratoplasty provides an improvement in quality of life compared with advanced-stage keratoconus in the areas of distance (p=0.0083) and near vision (p=0.029) activities. This improvement also applies to Best-Corrected Visual Acuity (BCVA) (p=0.032) and transparency (OSI) (p=0.049). Our study shows that keratoplasty improves corneal transparency, and it is interesting to note that it improves patients' quality of life over the long term.

[Safety and efficiency of epithelium-off accelerated corneal cross-linking for progressive keratoconus in pediatric patients]. / Efficacité et tolérance du cross-linking cornéen épithélium-off accéléré dans le traitement du kératocône évolutif de l'enfant.

In adults, the management of keratoconus has evolved in recent years to achieve a well-codified treatment algorithm. The technique of cross-linking (CXL) has allowed us to stabilize the progression of keratoconus and has been largely developed. It is very effective, with few postoperative complications. Currently, there is no specific keratoconus management protocol for children. As we already know that keratoconus usually evolves more rapidly in children, we might consider whether a stabilizing treatment should be proposed as first-line therapy at the time of diagnosis. We carried out a retrospective study including patients less than 18 years of age with keratoconus who consulted the ophthalmology department at Edouard Herriot hospital in Lyon between 2013 and 2017. The main study parameter was whether or not CXL was performed. The other parameters were gender, age, ethnicity, eye rubbing, presence or absence of atopic disease, maximum keratometry (Kmax), minimal pachymetry, best corrected visual acuity (BCVA) and spherical equivalent. Forty-eight eyes of 34 patients were included. We found that two-thirds of the patients were Caucasian boys. Half of the patients had allergies, and over 60% of patients rubbed their eyes regularly. Only six percent of patients had a family history of keratoconus. The mean age of the patients was 14 (7-18) years at the time of diagnosis. Thirty-four eyes of 22 patients underwent CXL, for a total of 71% of our cohort. No postoperative complications occurred. After CXL, there was no significant difference in minimum pachymetry (455.6±37.25µm vs. 453.45±42.6µm after treatment (P=0.71)) or Kmax (50.23±7.17D vs. 50.99±7.01D after treatment (P=0.058)). There was a significant improvement in BCVA (from 0.30±0.3LogMar to 0.17±0.17LogMar after CXL (P=0.024)) and spherical equivalent (-1.91±2.1D to -2.54±1.89D after treatment (P=0.009)). The mean duration of follow-up was 32.2 months (12-59). CXL shows long-term disease stabilization in children with keratoconus. Nevertheless, this technique is indicated only for progressive keratoconus. Early diagnosis and management are essential in this population where the disease is rapidly changing. Treatment of atopy and performance of corneal topography when a child has irregular astigmatism should become automatic for early detection of this disease.

[Management of post-traumatic aphakia and aniridia: Retrospective study of 17 patients undergoing scleral-sutured artificial iris intraocular lens implantation. Management of aphakia-aniridia with scleral-sutured artificial iris intraocular lenses]. / Prise en charge de l'aphakie et de l'aniridie post-traumatiques. Étude rétrospective de 17 patients opérés d'implants intraoculaires suturés à la sclère à iris artificiel. Gestion de l'aphakie-aniridie par implants suturés à la sclère à iris artificiel.

PURPOSE: To evaluate the long-term outcomes of artificial iris intraocular lenses sutured to the sclera for managing traumatic aphakia and aniridia. METHODS: All consecutive cases receiving a Morcher® combination implant from June 2008 to February 2016 in Edouard-Herriot Hospital (Lyon, France) were included in this single-center retrospective study. Visual acuity, subjective degree of glare, quality of life and surgical complications were evaluated. RESULTS: Seventeen eyes of 17 patients were included, among which 82% were male. The mean age was 42 years. The injuries consisted of 23.5% contusion and 70.5% open globe injuries, of which 41% were globe ruptures. There was one postoperative case. A penetrating keratoplasty was performed at the same time for eight eyes. The mean follow-up was 32 months. Best-corrected visual acuity improved in 41.2%, remained the same in 17.6% and decreased in 41.2% of our cases. Distance vision averaged 1±0.25 line better and near vision 2.2±0.32 lines better when visual acuity was quantifiable before surgery. Glare improved in 80% of patients and remained stable in 20%, decreasing on average from 3.3/5 [min. 3-max. 4; SD: 0.48] before surgery to 1.9/5 [min. 0-max. 4; SD: 1.197] after surgery. Regarding the esthetic results, 78% of the patients declared themselves reasonably to very satisfied; 57% reported no limitation of activities of daily living, and 43% reported mild limitation. Ocular hypertension and glaucoma, found in 40% of eyes, were the main postoperative complications. CONCLUSION: Implantation of prosthetic iris device combined with an intraocular lens appears to be safe and effective in reducing glare disability and improving visual acuity. Close, long-term monitoring is essential for the success of this surgery.

[Clinical and paraclinical features of syphilitic uveitis]. / Caractéristiques cliniques et paracliniques des uvéites syphilitiques.

INTRODUCTION: Syphilis, caused by Treponema pallidum agent, results in polymorphic and non-specific ocular manifestations. Early diagnosis and institution of individualized treatment play a large role in the prognosis. The increase in syphilis over the past several years requires the ophthalmologist to consider this diagnosis in the setting of any intraocular inflammatory involvement. PURPOSE: To describe epidemiological, clinical and paraclinical features and natural history of syphilitic uveitis. MATERIALS AND METHODS: Retrospective, descriptive and non-comparative study of a series of patients hospitalized between 2007 and 2013 in our department of ophthalmology for management of ocular inflammation associated with a positive syphilitic serology. RESULTS: Thirteen patients of mean age 52.5 years ± 12.9 (33-82 years) were included. All were male and were followed for six months. Co-infection with human immunodeficiency virus (HIV) was present in four of them. Other risk factors discovered on history were unprotected sexual relations, multiple partners, homosexual relations, co-infection with another sexually transmitted disease (STD) or an occupational risk. Decreased visual acuity (VA) was present in all patients, with an average initial VA of 0.71 ± 0.81 LogMAR, i.e. 2/10. Involvement was bilateral in 38% (n=5) of cases. Papilledema was present in 10 patients. Seven patients exhibited vasculitis, 6 patients a necrotizing retinitis, 2 patients with placoid lesions, 7 patients with panuveitis and 2 patients with macular edema. We did not find any patients with isolated anterior uveitis. Three patients exhibited concomitant extraocular involvement with cutaneous palmoplantar lesions. Spectral domain optical coherence tomography (SD-OCT) found a fragmentation of the external limiting membrane and a disorganization of the ellipsoid line in two patients. Cerebrospinal fluid was studied for all patients. Eight of them exhibited lymphocytic meningitis, and we found the presence of anti-Treponema pallidum hemagglutination assay antibody (TPHA) in 9 patients and anti-veneral disease research laboratory antibody (VDRL) in 1 patient. Syphilis polymerase chain reaction (PCR) in the aqueous humor was positive in 50% (n=6) of studied cases and the PCR for Epstein Barr virus came back positive in four specimens out of eight. False positive reactions were observed for Lyme disease in eight patients. The four HIV-positive patients showed bilateral lesions more frequently, but less severe and with a favorable outcome. Antibiotic treatment with ceftriaxone (2 grams per day intramuscularly for 15 to 21 days) and local treatment (corticoids and mydriatics) in the case of inflammation of the anterior segment, allowed a regression of the inflammation in all of our patients as well as an improvement in VA (average final VA 0.09 ± 0.17 LogMAR, i.e. approximately 8/10). One Jarisch Herxheimer reaction occurred and was resolved with systemic corticosteroid therapy. A change in the retinal pigment epithelium was the main sequela in 44% of cases (n=8 eyes). CONCLUSION: Every structure of the eye may be involved with syphilis; therefore, syphilis must be systematically sought during the etiologic assessment of ocular inflammation even in the absence of historical risk factors. HIV-positive patients must be handled in the same way as immunocompetent patients. Collaboration with the internist is essential for the diagnosis, monitoring, and staging, especially in search of neurosyphilis. The clinical course is favorable with early treatment.

[Assessing the feasibility and the acceptability of outpatient retinal detachment surgery]. / Évaluation de la faisabilité et de l'acceptabilité de la prise en charge en ambulatoire des patients opérés de décollement de rétine.

PURPOSE: To assess the feasibility and acceptability of outpatient care for patients undergoing surgery for retinal detachment. PATIENTS AND METHODS: Patients successively undergoing retinal detachment surgery between January and November 2012 were prospectively included. Patient age, distance from home, type of detachment, surgical technique, postoperative intravenous medications if applicable, pain as evaluated on the visual analogue scale (VAS), slit lamp findings on the day of surgery (D0) and the next day (D1), the presence of another person in the home, comprehension of instructions, the patient's physical abilities and adherence to outpatient treatment were recorded. RESULTS: Forty-six surgeries on 17 women and 28 men, including 2 one-eyed patients, with a mean age of 62 years (±16.6; 19-95), were studied. The mean distance from home was 78km (±108; 1-490 km). The surgery was performed ab-interno in 44 cases (40 transconjunctival, 4 cases of disinsertion with placement of a buckle) and ab-externo in 2 cases; under general anesthesia in 40 cases and local/regional anesthesia in 6 cases. Five cases were recurrent detachments, lensectomy was performed in 6 cases, internal gas tamponade was performed in the majority of cases (4 with silicone oil and 1 without tamponade). Functional signs were absent or limited to simple discomfort in 95.7% of cases on D0 as well as D1. The mean VAS at D0 was very low, described as 0.32/10 (0-8) and 0.63/10 (0-5) at D1. Two patients vomited on D0 and one on D1. Mean intraocular pressure was 12.8mmHg (±4.4; 4-24) at D0 and 17.6mmHg (±6.3; 8-34) at D1. The retina was visible in 91.3% of cases on D0 and 89.1% of cases on D1. Sleepiness was present in 3 cases (6.5%) at the D0 exam, and returning home was impossible without assistance from a third party in 4 cases (8.7%) (this incapacity was permanent or related to the patient's one-eyed status in all cases). The instructions for proper positioning were assimilated by all patients on D0, and no intravenous treatment was necessary after awakening. A companion was present at home in 78.3% (n=36) of cases; 87% (n=40) of the patients felt they could return home on D0 had it been necessary, with an early return home even desired by 32.6% (n=15) of the patients. DISCUSSION: The changes in surgical management of retinal detachment patients and the appearance in France of a specific fee schedule now make it possible to consider ambulatory treatment of patients with retinal detachment. CONCLUSION: Outpatient management of retinal detachment patients appears perfectly feasible and acceptable according to this study.