[Vascular factors in glaucoma]. / Facteurs vasculaires du glaucome.

The exact pathophysiology of glaucoma is not fully understood. Understanding of the vascular pathophysiology of glaucoma requires: knowing the techniques for measuring ocular blood flow and characterizing the topography of vascular disease and the mechanisms involved in this neuropathy. A decreased mean ocular perfusion pressure and a loss of vascular autoregulation are implicated in glaucomatous disease. Early decrease in ocular blood flow has been identified in primary open-angle glaucoma and normal pressure glaucoma, contributing to the progression of optic neuropathy. The vascular damage associated with glaucoma is present in various vascular territories within the eye (from the ophthalmic artery to the retina) and is characterized by a decrease in basal blood flow associated with a dysfunction of vasoregulation.

Correlation between clinical data and antibiotic resistance in coagulase-negative Staphylococcus species isolated from 68 patients with acute post-cataract endophthalmitis.

Coagulase-negative staphylococci (CNS) cause the majority of post-cataract endophthalmitis, which can lead to anatomical and/or functional loss of the eye. This study reports the antibiotic susceptibilities of CNS isolates associated with acute post-cataract endophthalmitis cases and correlates antibiotic resistance with severity and outcome of infection in these patients. Clinical data (initial ocular examination, final prognosis, antibiotic treatment) and the antibiotic susceptibilities of the isolated CNS strains were obtained from 68 patients with post-surgical endophthalmitis recruited during a 7-year period by the FRench Institutional ENDophthalmitis Study (FRIENDS) group. The CNS strains displayed 100% susceptibility to vancomycin, 70% to fluoroquinolones, 83% to fosfomycin, 46% to imipenem and 18% to piperacillin. The most effective antibiotic combinations were fosfomycin plus a fluoroquinolone and imipenem plus a fluoroquinolone, which were considered adequate in 80% and 58% of patients, respectively. Methicillin resistance was significantly associated with older age (p 0.001), diabetes mellitus (p 0.004), absence of fundus visibility (p 0.06), and poor visual prognosis (p 0.03). Resistance to fluoroquinolones was significantly associated with absence of fundus visibility (p 0.05) and diabetes mellitus (p 0.02). This large prospective study demonstrates that methicillin resistance and, to a lesser extent, fluoroquinolone resistance in CNS strains causing postoperative endophthalmitis are both prevalent in France and associated with a poorer visual prognosis. These results emphasize the need for an effective surveillance of this antibiotic resistance and the development of new diagnostic tools for rapid detection for early optimization of antibiotic therapy in endophthalmitis patients.

Intravitreal dexamethasone implant versus anti-VEGF injection for treatment-naïve patients with retinal vein occlusion and macular edema: a 12-month follow-up study.

PURPOSE: The objective of his study was to compare the visual and anatomical outcomes in treatment-naïve patients with macular edema secondary to retinal vein occlusion after intravitreal injections of dexamethasone implants (DEX) and anti-VEGF. METHODS: One hundred two patients (64 in the anti-VEGF group, 38 in the DEX group) without previous treatment were included in this multi-center retrospective study and evaluated at baseline and 1, 3, 6, and 12 months after the onset of treatment. Patients were defined as "good responders" if central macular thickness (CMT) was less than or equal to 250 µm in TD-OCT or 300 µm in SD-OCT after the injections. RESULTS: At month 3 (n = 102), BCVA had increased significantly, by 0.1 ± 0.3 logMAR in the anti-VEGF group (p = 0.04) and 0.4 ± 0.4 logMAR in the DEX group (p < 0.001); the difference between the two groups was statistically significant (p = 0.007). CMT decreased significantly, by 138 ± 201 µm (-19 %, p < 0.001) in the anti-VEGF group and 163 ± 243 µm (-21 %, p < 0.001) in the DEX group. After 3 months, five patients (13 %) in the DEX group and 20 (31 %) in the anti-VEGF group (p < 0.001) changed treatment. Among the 77 patients who did not switch from their initial treatment, no significant functional or anatomical difference between the two groups was observed at months 6 and 12. Elevation of intraocular pressure > 21 mmHg was more frequent in the DEX group (21 %) than in the anti-VEGF group (3 %, p = 0.008). CONCLUSIONS: Visual acuity recovery was better in the DEX group than in the anti-VEGF group at month 3, but with no difference in CMT. In patients who did not change treatment, the long-term anatomical and visual outcome was similar between the DEX and anti-VEGF groups.

[Managing antithrombotic therapy in vitreoretinal surgery]. / Comment gérer les antithrombotiques en chirurgie vitréorétinienne ?

Given the growing number of patients on antithrombotic therapy we are increasingly confronted with the management of this therapy before, during and after vitreoretinal surgery. In the absence of a consensus, the decision to withdraw antithrombotic therapy is based on the cardiovascular thromboembolism risk versus the theoretical risk of bleeding if the antithrombotic treatment is continued. As suggested by the literature, antiplatelet therapy (acetylsalicylic acid or clopidogrel) may be safely continued for vitreoretinal surgery, including retinal detachment repair. However, the risk/benefit ratio for patients being treated with two antiplatelet therapies is unknown. It appears that an International Normalized Ratio (INR) less than 3 for patients treated with anticoagulant therapy does not increase the perioperative risk of ocular bleeding. This risk has not been evaluated in patients treated by new antithrombotic therapies (prasugrel, ticagrelor as antiplatelet medication, or dabigatran, rivaroxaban, apixaban as anticoagulant therapy), and there is a need to study it further.

[Ocular syphilis]. / Atteinte oculaire de la syphilis.

Syphilis is a sexually transmitted disease caused by Treponema pallidum. Previously known as the "great imitator", this disease can have numerous and complex manifestations. The ophthalmologist should suspect the diagnosis in patients with uveitis or optic neuropathy and high-risk sexual behavior and/or another sexually transmitted disease (such as HIV) or those presenting with posterior placoid chorioretinitis or necrotising retinitis. Ocular involvement in acquired syphilis is rare, tending to occur during the secondary and tertiary stages of the disease. Syphilis may affect all the structures of the eye, but uveitis (accounting for 1-5% of the uveitis in a tertiary referral center) is the most common ocular finding. Granulomatous or non-granulomatous iridocyclitis (71%), panuveitis, posterior uveitis (8%) and keratouveitis (8%) are often described. In the secondary stage, the meninges and the central nervous system can be affected, sometimes with no symptoms, which justifies performing lumbar puncture in patients with uveitis and/or optic neuropathy. The diagnosis of ocular syphilis requires screening with a non-treponemal serology and confirmation with a treponemal-specific test. Parenterally administered penicillin G is considered first-line therapy for all stages of ocular syphilis. Systemic corticosteroids are an appropriate adjunct treatment for posterior uveitis, scleritis and optic neuritis if ocular inflammation is severe. Prolonged follow-up is necessary because of the possibility of relapse of the disease. With proper diagnosis and prompt antibiotic treatment, the majority of cases of ocular syphilis can be cured.

FRIENDS Group: clinical and microbiological characteristics of post-filtering surgery endophthalmitis.

PURPOSE: To study the clinical and microbiological characteristics as well as the prognostic factors for post-filtering surgery endophthalmitis. METHODS: Twenty-three eyes were included in the study in four tertiary centres between 2004 and 2010. The clinical and microbiological data were collected prospectively (minimum follow-up, 6 months). Microbiological diagnosis was based on conventional cultures and panbacterial PCR (16SrDNA amplification and sequencing). RESULTS: The onset of endophthalmitis was early (<6 weeks) in 22 % of the cases and delayed in 78 %. Elevated intraocular pressure and hypopyon were more frequent in delayed than in early presentations (p = 0.04). By combining the results of culture and panbacterial PCR, a bacterial species could be identified in 73.9 % of the cases, including 56.5 % of commensal species of the digestive tract such as Moraxella spp., oropharyngeal streptococci and Enterococcus faecalis. Good final visual acuity (VA ≥ 20/40) was correlated with initial VA greater than light perception (p = 0.05). Poor final VA (≤20/400) was correlated with a higher virulence of the infecting bacterial species (p = 0.006), and was noted in all patients with early-onset endophthalmitis. CONCLUSION: Acute early- or delayed-onset post-filtering surgery endophthalmitis is frequently caused by bacteria of the digestive tract (e.g., Streptococcus and Enterococcus spp.). The combination of conventional cultures and panbacterial PCR allowed us to identify the causative microorganism in three-quarters of the cases, i.e., 21 % more cases than through culture alone. Despite adequate antibiotic and surgical treatment, the anatomical and visual prognosis remains poor.

Time profile of viral DNA in aqueous humor samples of patients treated for varicella-zoster virus acute retinal necrosis by use of quantitative real-time PCR.

The objective of this study was to evaluate the kinetics of varicella-zoster virus (VZV) loads using quantitative PCR (qPCR) in patients treated for acute retinal necrosis (ARN). Six patients (52 ± 13 years old) with ARN syndrome were consecutively studied. Aqueous humor (AH) was sampled from both eyes of all patients for qPCR evaluation. The patients were treated with intravenous acyclovir and intravitreal injections of antiviral drugs. The mean follow-up time was 17.6 ± 16.4 months. Main outcome measures were the numbers of viral genome copies in the AH, assessed using real-time qPCR with hydrolysis probe technology with a threshold of detection of 200 copies/ml. Two main portions of the viral load curves were observed for each patient: a plateau phase (27.8 ± 24.9 days) and a decrease in the number of viral genome copies. The mean baseline viral load was 3.4 × 10(7) ± 4.45 × 10(7) copies/ml (6 × 10(6) to 1.2 × 10(8) copies/ml). The viral load decreased according to a logarithmic model, with a 50% reduction obtained in 3 ± 0.7 days. There was a significant viral load (>102 copies/ml) at 50 days after the onset of treatment, despite antiviral drugs. qPCR use demonstrated reproducible VZV DNA kinetics with a two-phase evolution: a plateau followed by a logarithmic decrease. These data suggest that high-dosage antiviral therapy administered for the conventional 10-day duration is insufficient for most patients. This series of patients responded with a similar decrease in viral load once treatment was initiated, and the data from these patients may be used to predict the responses of future patients.

Surgical removal of subfoveal choroidal neovascularization in pathologic myopia: a 12-year follow-up study.

The purpose of this study was to review the 12-year visual outcomes of patients who underwent surgical removal for subfoveal choroidal neovascularization (CNV) attributable to pathologic myopia. This retrospective study included 14 patients, with a mean age of 45.8 years, high myopia (>6 D) and classic subfoveal CNV. They were treated with pars plana vitrectomy and surgical removal of CNV. All patients were followed up every 3 months for 2 years, with visual acuity (VA), fundus examination, and fluorescein angiography and then every year for 5 years. Ten patients underwent a final visit with VA and fundus examination after a minimum 12-year follow-up. The main outcome measurement was VA and the secondary outcome measurement was the lesion size. After 12 years of follow-up, the mean VA did not significantly change over time, with a mean gain of 0.22 logMAR at 1 year, and 0.18, 0.12 and 0.05 at 2, 5 and 12 years, respectively. The anatomical evolution was characterized by a significant enlargement of the lesion size at 5 years. This study showed that final VA after surgical treatment with 12 years of follow-up was poor, due to the significant CNV scar enlargement over time. These results should prompt a prospective randomized study of other medical treatments, particularly anti-vascular endothelial growth factor therapy.

Risks of non-lethal weapon use: case studies of three French victims of stinger grenades.

The development of non-lethal weapons started in the 1960s. In France, they have been used by the police for about 10 years. We relate the cases of three French women, victims of stinger grenades, non-lethal weapons recently adopted by the French law enforcement to distract and disperse crowds. The three victims presented serious injuries requiring emergency surgical care. One lost her eye. Based on these cases, we discuss the lethal character of these weapons and propose measures to be taken to prevent their dramatic consequences. Although the danger is obviously less than for firearms, stinger grenades are nonetheless potentially lethal and cause serious physical injuries.

[Prospective study of 34 retinal detachments associated with giant retinal tear]. / Etude prospective de 34 décollements de rétine par déchirure géante.

PURPOSE: To report the anatomical and functional outcomes of vitrectomy with silicone oil tamponade in the treatment of retinal detachment associated with giant retinal tears due to various factors. METHODS: We prospectively followed 34 eyes of 33 patients with giant retinal tear. That underwent vitrectomy, injection of perfluorocarbon liquids and silicone oil tamponade. Scleral buckle was associated with vitrectomy in cases of inferior giant retinal tear; 26,5 % and 11,8 %, respectively, demonstrated pseudophakia and aphakia. Seven eyes (20,5 %) had a history of trauma (blunt injuries in four and a penetrating injury in three) and, 14 eyes (41,2 %) had severe myopia. One patient developed a bilateral giant retinal tear during the follow-up. RESULTS: Retinal attachment was obtained in 33 (97 %) of 34 eyes, with a mean follow-up of 14,5+/-6 months. Retinal detachment reoccurred in four eyes (11,6 %) under silicone oil, in one eye (2,9 %) during the silicone removal, and in two eyes (5,8 %) after silicone removal and cataract surgery. Silicone oil was removed from all eyes (4,3+/-1 months). The most frequent postoperative complication was cataract in ten of 18 phakic eyes (55,5 %). Functional success with visual acuity 0,4 or better was obtained in 18 cases (52,96 %). CONCLUSION: Pars plana vitrectomy with silicone oil tamponade proved to be highly effective in giant retinal tears in terms of the anatomical and functional results. The analysis of recurrent retinal detachment allowed us to refine the technique and to suggest scleral buckle in one case of inferior retinal tear with laser over 360 degrees .

Effects of photodynamic therapy on subfoveal blood flow in neovascular age-related macular degeneration patients.

AIM: To assess the short-term changes in choroidal blood flow (ChBF) after photodynamic therapy (PDT) in patients with neovascular age-related macular degeneration (AMD). METHODS: Fourteen patients with exudative AMD were included after a complete ophthalmological examination, fluorescein and indocyanine green angiography and optical coherence tomography. Subfoveal ChBF was assessed using laser Doppler flowmetry (LDF) in both treated (n=14) and nontreated contralateral (n=8) eyes, 1 h and 1 week after PDT. Ocular perfusion pressure was calculated. RESULTS: The detection sensitivity of the LDF measurements at 2-min intervals before PDT in treated eyes was 7.4% for volume, 6.3% for velocity, and 10.4% for ChBF. The initial mean visual acuity was 0.68+/-0.3 logMar. Macular thickness at baseline as measured by OCT3 was at median (interquartile range), 326.5 microm (188-367). At 1 h and 7 days after PDT, a significant increase in velocity (15.8 and 24.4%, respectively) and a significant decrease in volume (11 and 17.9%, respectively) were noted in treated eyes. Choroidal blood flow and ocular perfusion pressure (OPP) remained similar during follow-up. No significant change in flow parameters was reported in untreated eyes. CONCLUSION: The LDF technique provides feasible and reliable measurements of blood flow parameters before and after PDT in a selective population of patients with exudative AMD. The prognostic value of these early blood flow parameter changes also needs to be assessed.

[Frosted-branch angiitis revealing Behçet's disease]. / Angéite givrée révélatrice d'une maladie de Behçet.

A 30-year-old man with a history of skin and recurrent oral ulceration over 1 year developed loss of visual acuity in the right eye. The diagnosis of acute frosted branch angiitis was based on retinal vasculitis associated with retinal edema and hemorrhages, confirmed using fluorescein angiography (venous leakage and extensive staining of the vein walls). General examination revealed pseudofolliculitis and recurrent oral ulcers. The diagnosis of Behçet's disease was based on the international criteria. The patient was treated with prednisolone and colchicine, which were effective with a normalization of the fundus 1 month later. The initial presentation of Behçet's disease as frosted branch angiitis is exceptional, the main differential diagnosis being herpetic infections, which must be ruled out.

[Dural carotid-cavernous fistulas: progression in therapeutic management from 1989 to 2004. A report of ten cases]. / Fistules carotido-caverneuses indirectes (durales): évolution de la prise en charge thérapeutique de 1989 à 2004. A propos de 10 cas.

INTRODUCTION: Dural carotid-cavernous fistulas are rare and require multidisciplinary management. Today there is no consensus on treatment, even though embolization is currently the first-line treatment. We present the cases of ten patients with a dural carotid-cavernous fistula diagnosed between 1989 and 2004 in order to compare the therapeutic choices used to treat dural carotid-cavernous fistulas in the late 1980s and mid-1990s to the therapeutic strategy currently favored. PATIENTS AND METHODS: The ten patients, with a mean age of 65.9 years, were seven women and three men. They had an ophthalmologic examination and the diagnosis was angiographically confirmed. Treatments were either noninvasive (such as decoagulation and/or carotid-jugular or ocular compression) or embolization. A combination of these different treatment modalities was provided for several patients. RESULTS: The main symptoms were arterialized conjunctival veins, proptosis, diminished visual acuity, chemosis, elevated intraocular pressure, and diplopia. Of the seven patients who only had noninvasive treatment (embolization not possible), three remained stable, three showed partial improvement, and the last one was clinically cured. As for the three patients treated with embolization (prior or not), this treatment led to a dramatic clinical improvement for one patient, a clinical cure for the second, and a complete cure in the remaining patient. CONCLUSION: Prior embolization when possible appears to be an effective and safe treatment for dural carotid-cavernous fistulas. Nonetheless, noninvasive treatment options, particularly compressions, remain an important therapeutic alternative.

[Prescribing fortified eye drops]. / Prescrire les collyres fortifiés.

Fortified preparations of ophthalmic antibiotics are made with commercially available antibiotics (parenteral or lyophilized preparations). These fortified eyedrops have two main advantages: the increase in the antibiotic concentration in the corneal stroma and the wide choice of available antibiotics. Fortified ophthalmic solutions are used in severe keratitis (large diameter, stroma infiltration, inflammation of the anterior chamber, old patient). The following associations are recommended: ticarcillin+gentamicin+vancomycin or cephazolin+amikacin since they provide a broad-spectrum antibiotic activity against the wide range of bacteria that may cause keratitis. The main toxicity of these preparations is the retardation effect of the epithelial-healing rate (aminoglycosides, vancomycin) and the corneal and conjunctival toxic effects (aminoglycosides). However, fortified antibiotic drops remain the standard therapy for severe bacterial keratitis, given their corneal penetration and the possibility of the synergic and combined effect of an antibiotic association.

Acute postoperative endophthalmitis caused by Staphylococcus lugdunensis.

Acute postoperative endophthalmitis caused by Staphylococcus lugdunensis is infrequently reported in clinical studies. Five cases of acute postcataract surgery endophthalmitis caused by S. lugdunensis were taken from a multicenter prospective study conducted in four university-affiliated hospitals in France (2004 to 2005). These cases were characterized by severe ocular inflammation occurring with a mean delay of 7.6 days after cataract surgery, severe visual loss (hand motions or less in three cases), and dense infiltration of the vitreous. Each of these patients was initially treated by using a standard protocol with intravitreal (vancomycin and ceftazidime), systemic, and topical antibiotics. Given the severity of the endophthalmitis, even though bacteria were sensitive to intravitreal antibiotics, pars plana vitrectomy was needed in four cases. The final visual prognosis was complicated by severe retinal detachment in three cases. The microbiological diagnosis was reached by using conventional cultures with specific biochemical tests and eubacterial PCR amplification followed by direct sequencing.

[Ultrasound imaging in the management of endophthalmitis]. / Place de l'échographie dans la prise en charge des endophtalmies.

Endophthalmitis is a major complication of surgery or trauma that may need an echographic evaluation by a general ophthalmologist in emergency. Echography is also useful for the therapeutic management of endophthalmitis. This review gives a general view of ocular lesions seen in this context (hyalitis, choroidal or retinal detachment, lens dislocation, intraocular foreign body, cellulitis). We describe a practical chart to standardize the echographic evaluation at the initial examination and during the follow-up.

[Acute endophthalmitis: from bacteria to clinical settings]. / Endophtalmies aiguës : du germe à la clinique.

The clinical presentation of endophthalmitis depends on numerous factors, especially the bacteria involved, which determines the delay of infection, the amount of ocular inflammation, and the final prognosis. Results of epidemiological studies have provided a better understanding of the correlation between bacteria and clinical characteristics. Some clinical signs may help the clinician to suspect a virulent bacterium. Clinical and microbiological factors are essential to guide the therapeutic strategy in patients with acute endophthalmitis.

[Microbiological and clinical diagnosis of acute endophthalmitis]. / Diagnostic microbiologique des endophtalmies aiguës.

The microbiological study identifies the bacterial spectrum after surgery, in acute, delayed-onset, or chronic endophthalmitis. DNA amplification of eubacterium-specific sequences in DNA extracted from ocular samples is a new tool for the etiological diagnosis of endophthalmitis. The most successful way to identify bacteria in endophthalmitis is the association of conventional cultures and panbacterial PCR on vitreous samples. Both techniques are complementary. The efficacy of these new molecular techniques should modify our future therapeutic strategies.

[How to ensure that glaucoma is stable? Intraocular pressure]. / Comment s'assurer de la stabilité d'un glaucome? La pression intraoculaire.

In patients with open-angle glaucoma, intraocular pressure (IOP) obtained through treatment should guard against the progression of glaucoma damage. This depends on the initial state of intraocular pressure, but also on the stage of glaucoma, how fast the alterations are progressing, the patient's age and life expectancy, as well as the presence of other risk factors. To determine the ideal level of treated IOP, the term "target pressure" is often used. This term is very much open to criticism, however, because it calls on a static figure for what is highly variable biological information belonging to the body's biological rhythms. A large number of formulas are used to calculate this target pressure number, but all of them come up against the disadvantage of not taking into account the variations in IOP during the day/night cycle. Yet it is these very variations that can characterize the severity of the disease in terms of IOP. In a glaucoma patient, the IOP curve plotted over 24 h has higher IOP values during the day than at night, contrary to a healthy subject. Fluctuations of more than 10 mmHg are not rare during the day/night cycle, most often with many peaks, which are deleterious for retinal nerve fibers. These dynamic pressure parameters are essential both in determining the therapeutic strategy and in evaluating the effectiveness of treatment. In practice, with any case of open-angle glaucoma and before any treatment is given, a diurnal curve should be established. Six to eight measurements between 8 AM and 6 or 8 PM should be enough. They should be carefully combined with concomitant measures of systemic blood pressure. Once treatment has started, we suggest that a new diurnal curve be established 1 month and then 4 months after the beginning of treatment. The treatment will be modified if needed, based on IOP criteria established at 1 month, and on IOP, perimetric, and anatomic criteria determined again at 4 months. If the disease continues to worsen despite a satisfactory diurnal IOP, IOP should be measured over 24 h, associated with Holter monitoring, looking for an escape of pressure at night.

[Consequences of glaucoma on circadian and central visual systems]. / Impact de la pathologie glaucomateuse sur les voies visuelles centrales et les structures circadiennes.

Glaucoma is a chronic optic neuropathy leading to a degeneration of retinal ganglion cells. There is accumulating evidence that glaucomatous damage extends from retinal ganglion cells to vision centers in the brain. Degenerative changes are observed in magnocellular, parvocellular, and koniocellular pathways in the lateral geniculate nucleus, and these changes are related to intraocular pressure and the severity of optic nerve damage. In addition, recent studies show that there are also changes in the visual cortex in relation to varying degrees of retinal ganglion cell loss. In a rat model of glaucoma, we have recently demonstrated a reduction of retinal projections of retinal ganglion cells, not only on the visual system but also on the suprachiasmatic nucleus. Human studies suggest that the ganglion cell degeneration caused by glaucoma could lead to a lesion of the retinohypothalamic tract, which permits the synchronization of circadian rhythms.