[Dry eye and qualitative tear alteration in essential blepharospasm]. / Sécheresse oculaire et altération qualitative des larmes dans le blépharospasme essentiel.

PURPOSE: We aimed to analyze the tears of patients with Benin Essential Blepharospasm (BEB) to explore possible corneo-conjunctival mechanisms for photophobia, tear deficiency and ocular pain. METHODS: Using an observational cohort of 42 patients diagnosed with BEB, we performed Schirmer's testing, measurement of tear film pH, tear film protein electrophoresis and conjunctival impression cytology. RESULTS: Schirmer's testing showed dry eye (8.4±9.7mm) with 71.3% eyes having a Schirmer's score<10mm. Surprisingly, the pH was basic (8.4±0.4) and was improved in patients receiving the standard treatment of quarterly botulinum toxin injections (8.32±0.36 for treated patients vs. 8.74±0.53 for untreated patients; P=0.045). Together, tear protein electrophoresis and conjunctival impression cytology showed conjunctival inflammation associated with BEB. CONCLUSION: For the first time, this study emphasizes corneo-conjunctival mechanisms to explain the photophobia, dry eye and pain in Benign Essential Blepharospasm. While encouraging, complementary studies remain necessary to evaluate the effect of correcting tear film pH and inflammation on the quality of life of blepharospasm patients.

Tear osmolarity, dry eye syndrome, blepharospasm and botulinum neurotoxin.

PURPOSE: To assess the severity of dry eye disease in patients with blepharospasm (BEB) before (control) and after injection of botulinum neurotoxin A (BoNT/A). DESIGN: Cross-sectional study. METHODS: Patients with clinically diagnosed BEB and no known history of dry eye syndrome prior to the onset of the disease, before (controls) or after injection with one of the three available types of BoNT/A: onabotulinumtoxinA (Botox®; Allergan, Irvine, CA, USA), abobotulinumtoxinA (Dysport®; Beaufour Ipsen Pharma SAS, Paris, France) or incobotulinumtoxinA (Xeomin®; Merz Pharma GmbH, Frankfurt, Germany) every 3 months. Tear osmolarity and Schirmer's I-test were measured at the first visit for non-treated BEB patients as controls and 3 months after BoNT/A injection. RESULTS: The study consisted of 101 BEB patients (86 females, 15 males) with a mean age of 67 years (range 30-86 years). Seventeen patients were untreated, 26 treated with onabotulinumtoxinA, 23 treated with abobotulinumtoxinA and 35 treated with incobotulinumtoxinA. Post-injection mean tear osmolarity was not significantly higher among patients treated with onabotulinumtoxinA, abobotulinumtoxinA, or incobotulinumtoxinA (P=0.65, P=0.92, and P=0.15, respectively), compared to controls, remaining less than 308 mosm/mL. Mean Schirmer's I-test results remained under 5mm and did not vary between the four groups. CONCLUSIONS: The results clearly demonstrate that reduced tear secretion appears to be present in BEB patients even prior to treatment. This decreased lacrimal secretion was not correlated with hyperosmolarity. Clinicians should proactively treat dry eye syndrome in conjunction with management of the blepharospasm.

Self-representation in Kleine-Levin syndrome: a single case fMRI study.

Kleine-Levin syndrome (KLS) is characterized by recurrent episodes of hypersomnia, compulsive hyperphagia, disinhibition, hypersexuality and self modifications. To investigate the Self, we used afunctional magnetic resonance imaging paradigm evaluating Self-reference processing (SRP) and Self-reference effect (SRE) in a17-year-old male adolescent at the end of an episode. We observed enhanced activations in right hemisphere and posterior areas- associated with physical Self representations- during the SRP condition, while during the SRE condition, enhanced activations in bilateral but prevailing left frontal areas- associated with the conceptual Self. These results suggest amodified Self during aKLS episode being more physically grounded.

[Secondary blepharospasm, analysis and pathophysiology of blepharospasm. French translation of the article]. / Blépharospasmes secondaires, analyse et réflexion sur la physio-pathogénie du blépharospasme.

PURPOSE: To localize the brain structures involved in blepharospasm. MATERIALS AND METHODS: This is a retrospective consecutive series of brain MRI's of patients with secondary blepharospasm whose immediate past medical history included cerebrovascular accident or head trauma. RESULTS: Six patients, including 4 with CVA with ischemic or hemorrhagic lesions of the thalamus and caudate nuclei and 2 with head trauma with contusive sequellae to the tectal plate and frontal cortical and cerebellar atrophy. CONCLUSION: According to the literature, brain lesions associated with blepharospasm involve mainly the thalamus, head of the caudate nucleus, corpus striatum, globus pallidus, internal capsule, cerebral cortex and cerebellum. This study demonstrates that blepharospasm is associated with a lesion of a complex neural network - cortex-thalamus-globus pallidus-cortex - and does not correspond to a single, unique lesion. This network is connected with ascending and descending sensory-motor pathways and motor nuclei.

[Hemifacial spasm. Etiology and management]. / Spasmes hémifaciaux. Étiologies et conduite à tenir.

INTRODUCTION: Hemifacial spasm (HFS) is an involuntary contracture of the facial muscles innervated by the ipsilateral facial nerve. We studied the etiology of these HFS. MATERIALS AND METHODS: This retrospective study included 233 patients with HFS who came to the ophthalmologist for quarterly botulinum neurotoxin A injection. Of these, we analyzed the 198 patients for whom MRI scans were performed. We recorded patient clinical data and clarified the etiology of their HFS. RESULTS: The 198 patients (62.6% women) had a mean age of 55.7±14years. An etiology was found in 52.5% of cases. In 34.5% of HFS, MRI revealed vascular compression where the facial nerve emerged from the brainstem. We specify the arteries involved. Brain tumors accounted for 1.5% of cases. MRI was normal in 64.5% of cases. In these secondary cases of HFS, we found 8.5% peripheral facial palsy, 4% post-traumatic HFS and 4% secondary to an eye injury. Stress was found in 17% of patients. DISCUSSION AND CONCLUSION: This study illustrates the need for MRI with attention to the posterior fossa in the work-up of HFS in order to identify primary HFS associated with vascular compression of the facial nerve and to rule out a rare but serious posterior fossa tumor. The treatment of HFS is based on quarterly injections of botulinum neurotoxin/A (NTBo/A), the three brands of which have market approval. The injection pattern and frequency is customized according to the results. In cases of insufficient response to injections of NTBo/A, neurosurgical microvascular decompression may be considered for cases of primary HFS.

Secondary blepharospasm, analysis and pathophysiology of blepharospasm.

PURPOSE: To localize the brain structures involved in blepharospasm. MATERIALS AND METHODS: This is a retrospective consecutive series of brain MRI's of patients with secondary blepharospasm whose immediate past medical history included cerebrovascular accident or head trauma. RESULTS: Six patients, including 4 with CVA with ischemic or hemorrhagic lesions of the thalamus and caudate nuclei and 2 with head trauma with contusive sequellae to the tectal plate and frontal cortical and cerebellar atrophy. CONCLUSION: According to the literature, brain lesions associated with blepharospasm involve mainly the thalamus, head of the caudate nucleus, corpus striatum, globus pallidus, internal capsule, cerebral cortex and cerebellum. This study demonstrates that blepharospasm is associated with a lesion of a complex neural network - cortex-thalamus-globus pallidus-cortex - and does not correspond to a single, unique lesion. This network is connected with ascending and descending sensory-motor pathways and motor nuclei.

[Blepharospasm, dry eye and extractable nuclear antigen antibodies (French translation of the article)]. / Blépharospasme, sécheresse oculaire et anticorps anti-nucléaires solubles.

PURPOSE: The goal of this study is to determine a link between benign essential blepharospasm and Sjogren's syndrome by analyzing the presence of extractable nuclear antigens in this population. METHODS: Seventy-two patients with benign essential blepharospasm (BEB) were included in this study. We eliminated patients with hemifacial spasm or blepharospasm secondary to corneal pathology. We collected the values of the Schirmer I test and the results of the anti-SSA and anti-SSB antibodies. RESULTS: Our study included 72 patients (144 eyes) whose 62 women (86.1%). Mean age was 74.3 years±10.73. Average Schirmer I test was 3.14mm±4.00mm. Five women (8% of this female population) had positive anti-SSA and SSB antibodies. Their mean age was 65.66 years±13.24 whereas the negative antibody patients had an average age of 75.42±9.27. There was no significant difference between their Schimer I test and the Schirmer I of negative antibody population. CONCLUSION: This study illustrates the possible association between the presence of Sjögren's syndrome and the occurrence of a BEB justifying the search for anti-SSA and anti SSB in blepharospasm patients.

Impact of the SARS-CoV-2 epidemic on private ENT consulting practice during the first month of lockdown in Réunion Island in 2020.

OBJECTIVE: To analyze the impact of the first month of lockdown related to the 2020 SARS-Cov-2 epidemic on the consulting activity of private ENT physicians in Réunion Island. MATERIAL AND METHODS: A multicenter prospective study analyzed the consulting activity of 12 ENT physicians in full-time private practice. The main endpoints were the number, characteristics and conditions of consultations. Secondary endpoints comprised presenting symptoms, diagnosis, prescriptions, adverse effects, and progression of monthly consulting turnover. RESULTS: Six hundred and ninety three consultations were performed during the study period (Appendix 1), with 50% emergency consultations. In 57.9% were face-to-face, 28.4% by phone and 13.7% video. In face-to-face consultation, the physician wore gloves in 53.8% of cases and a mask in 92.2%: surgical mask in 71.6% of cases and FFP2 in 28.4%. The three most frequent symptoms (48.5% of cases) were otalgia, hearing impairment, and vertigo. The three most frequent diagnoses (60.6% of cases) were otitis, intra-auricular foreign body (including wax), and pharyngeal infection. The three most frequently prescribed complementary exams (74.3% of cases) were imaging, hearing work-up, and specialist opinion. The three most frequently prescribed treatments (52.7% of cases) were intra-auricular drops, oral antibiotics, and nasal spray. The incidence of adverse effects was 0.001%. None of the physicians or patients seemed to have been infected by Covid-19 during the study period. There was a 47.3-91% (median, 75.6%) drop in monthly consultation turnover. CONCLUSION: The present study underscored the availability and adaptability of ENT physicians in the Réunion Island in an epidemic context, although economic impact was detrimental.

Blepharospasm, dry eye and extractable nuclear antigen antibodies.

PURPOSE: To study whether there is an association between benign essential blepharospasm and Sjögren's syndrome by analyzing the presence of antibodies to extractable nuclear antigens in this population. METHODS: Seventy-two patients with benign essential blepharospasm (BEB) were included in this study. We excluded patients with hemifacial spasm or blepharospasm secondary to known corneal pathology. We recorded results of Schirmer I testing as well as levels of anti-SSA/Ro and anti-SSB/La antibodies. RESULTS: Our study included 72 patients (144 eyes), of which 62 (86.1%) were women. The mean age was 74.3±10.73 years. The mean Schirmer I test result was 3.14±4.00mm. Five women (8% of this female population) were found to have positive anti-SSA/Ro and anti-SSB/La antibodies. Their mean age was 65.66±13.24 years, while the mean age of the antibody-negative patients was 75.42±9.27 years. There was no statistically significant difference between the Schirmer I tests of the antibody positive and negative patients. CONCLUSION: This study demonstrates a possible association between Sjögren's syndrome and benign essential blepharospasm, justifying anti-SSA/Ro and anti-SSB/La testing in these patients.

Dry eye syndrome in benign essential blepharospasm.

PURPOSE: To determine the significance of dry eye syndrome in benign essential blepharospasm. DESIGN: Retrospective consecutive case series. PARTICIPANTS: One hundred and forty-four patients (288 eyes) with benign essential blepharospasm. METHODS: All subjects had Schirmer I tear tests. Those scores were analysed as a function of patient age, sex, and blepharospasm severity. MAIN OUTCOME MEASURES: Individual Schirmer-test scores in both eyes of all patients. RESULTS: A total of 144 eligible subjects (mean age±SD: 68.3±11.5 years; 76% females) were evaluated. Benign essential blepharospasm was significantly associated with female sex (P=0.0044). The mean Schirmer-test value was 5.9±7.5 (median: 2.5) mm; it was <15mm for 86.8% of the patients and <10mm for 75%, with no difference observed between men and women (P=0.27). Dry-eye syndrome severity was not correlated with age at diagnosis, for men (r=-0.22, P=0.22) or women (r=-0.067, P=0.49), or benign essential blepharospasm severity (P=0.15), but was strongly associated with benign essential blepharospasm independently of age, sex or blepharospasm intensity. CONCLUSION: Dry-eye syndrome and benign essential blepharospasm are strongly linked, independently of age, sex or BEB severity, and should be considered for the diagnosis of benign essential blepharospasm. The useful symptomatic treatment of dry eye will not cure the blepharospasm or the ocular pain, and specific treatment for blepharospasm is required, i.e., quarterly injections of botulinum toxin A into the orbicularis oculi muscle.

Botulinum neurotoxin A injection for the treatment of epiphora with patent lacrymal ducts.

HEADINGS: Retrospective longitudinal study to evaluate the efficacy of botulinum neurotoxin A (BoNT/A) therapy for epiphora with patent lacrimal ducts. BACKGROUND/PURPOSE: BoNT/A has been used since 2000 in axillary hyperhidrosis to reduce sweat secretion. Some isolated cases of hyperlacrimation or crocodile tear syndrome have been treated with BoNT/A on this basis. We report our experience in the treatment of tearing despite patent lacrimal ducts by BoNT/A injection into the lacrimal gland. METHODS: We reviewed qualitative and quantitative criteria to evaluate the degree of improvement of epiphora after BoNT/A injections in the palpebral lobe of the lacrimal gland in patients referred for epiphora despite patent lacrimal ducts between 2009 and 2016. Epiphora was graded using a functional questionnaire, Munk score and Schirmer test performed before and after the injections. Side effects were recorded. RESULTS: Sixty-five palpebral lacrimal glands of forty-two patients with epiphora despite patent lacrimal ducts, of mean age 65 years, sex ratio 0.8, were treated with BoNT/A (IncobotulinumtoxinA, XEOMIN®, MERZ Pharma France) from April 2009 to April 2016. The etiology of the epiphora was represented by 56 paroxysmal lacrimal hypersecretion, 2 crocodile tear syndrome and 7 facial palsies. No conventional medical or surgical treatment had been effective in these cases. The technique of injection, dilution and dosage of BoNT/A were specific. We re-injected 33/65 cases a second time upon patient request due to recurrence of epiphora, 16/65 cases three times, 8/65 cases four times, 6/65 cases five times and 3/65 six times. The Schirmer's test measured a decrease of lacrimal secretion in 51/65 glands (78%) after the first botulinum neurotoxin injection. Side effects were limited to ptosis in 2 cases (3%) and six patients (9%) with rapidly regressing diplopia. Two patients experienced immediate lacrimal gland hematoma (3%) with no sequelae. The authors describe the injection techniques, the dosage, the volume and concentration of BoNT/A. CONCLUSION: Patients with intractable epiphora despite patent lacrimal ducts can be effectively treated with BoNT/A (IncobotulinumtoxinA) injection into the palpebral lobe of the lacrimal gland. Most of the patients (80%) were very satisfied with few side effects (hematoma, ptosis or mild diplopia lasting from 3 days to 3 weeks). More studies are needed to delineate which types of epiphora can be treated with BoNT A.

Botulinum neurotoxin injection for the treatment of epiphora in nasolacrimal duct obstruction.

PURPOSE: Retrospective long-term study to evaluate the efficacy of botulinum neurotoxin A (BoNT/A) therapy for epiphora due to non-surgical nasolacrimal duct obstruction. INTRODUCTION: BoNT/A has been used successfully since 2000 in axillary hyperhidrosis to reduce secretory disorders. Some isolated cases of hyperlacrimation or crocodile tear syndrome have been treated on this basis. We used BoNT/A to decrease lacrimal secretion in cases of epiphora. METHODS: We reviewed the qualitative and quantitative degree of improvement of epiphora after botulinum neurotoxin injections in the palpebral lobe of the lacrimal gland, carried out in an ophthalmic centre between 2009 and 2016. Epiphora was graded using a questionnaire, Munk scores and Schirmer tests before and after injections. Severity of side effects was recorded. RESULTS: Twenty-seven palpebral lacrimal glands of twenty patients with epiphora, mean age 65±13, were treated with BoNT/A (Botox® or Xeomin®) from April 2009 to April 2016. The epiphora was induced by persistent nasolacrimal duct stenosis after surgical treatment. No conventional medical nor surgical treatment was effective at this time. The technique of injection, dilution and dosage were specific. We re-injected 14/27 cases on an as-needed basis, 7/27 cases three times, 3/27 cases four times, and 2/27 cases (same patient both glands) five times. The Schirmer test measured a decrease of lacrimal secretion in 24/27 (89%) lacrimal glands after neurotoxin injection. Side effects were ptosis in 4 cases and transient esotropia in 2 cases. The authors describe the injection techniques, the dosage, the volume and concentration of BoNT/A. CONCLUSION: Patients with epiphora can be treated effectively with BoNT/A to reduce lacrimal secretion of the principal lacrimal gland in its palpebral portion. Ninety percent of the patients were very satisfied, with few side effects (ptosis or mild diplopia lasting from 3 days to 3 weeks). More studies are needed to delineate which types of epiphora can be treated with BoNT/A.

[Teaching pediatrics to residents via conventional lectures in France: A national survey from students]. / Enseignement théorique du Diplôme d'études spécialisées de pédiatrie en France : évaluation nationale par les internes.

OBJECTIVE: To assess the point of view of young physicians training in pediatrics in France on their theoretical courses during residency. METHODS: A free-access electronic anonymous survey was sent three times by e-mail to the 1215 residents in pediatrics, from July to October 2015. RESULTS: Fifty-seven percent of French residents in pediatrics responded to the survey. It was established that they took part in six (range, 3-10) half-days of specific theoretical teaching in pediatrics from November 2014 to mid-April 2015. Only 54% participated in more than 75% of regional theoretical training. The main self-declared reason for their absence was that they could not leave their clinical activities. Fifty-three per cent of the residents took part in additional training, 45% of them because they found the primary theoretical training insufficient. The overall quality of the theoretical teaching was rated 5 (range, 3-7) out of 10. Eighty-five percent of residents expected to be evaluated on their knowledge during their residency. CONCLUSION: In pediatrics, additional training is individually undertaken because they deemed their initial training insufficient during their residency. An evaluation of knowledge is requested by residents. The reform of the national residency program must take into account these results in redesigning the theoretical training in pediatrics, integrating innovative teaching techniques to daily practice, for example.

[Cataract surgery among 50 Alzheimer's patient (55 eyes)]. / Chirurgie de la cataracte chez 50 patients Alzheimer (55 yeux).

OBJECTIVE: Cataract surgery for 50 Alzheimer patients (55 eyes). METHODS: Cinquante Alzheimer's patients with 0≤MMS≤25, with bilateral disabling cataracts were included for surgery. The surgical technique is analyzed. RESULTS AND CONCLUSION: The preoperative examination of Alzheimer's patients is time consuming and requires experience in this area, which is important to integrate into the practice of ophthalmology. The type of cataract is unusual, with a predilection for pseudoexfoliation syndrome and zonular fragility that has to be managed during surgery. The procedure may be performed under local anesthesia. Three months after surgery, Alzheimer's patients demonstrated improved visual acuity (P<0.001) with no worsening of their dementia.

[Neuropsychological benefit of cataract surgery among sight impaired Alzheimer's patient]. / Modifications des troubles du comportement après l'opération de la cataracte chez les patients Alzheimer.

PURPOSE: Evaluation of neuropsychological benefits of cataract surgery for 46 Alzheimer patients on the basis of neuropsychiatric index (NPI), as the principal criterion of analysis of the VIVA study. METHODS: Prospective, monocentric neuropsychiatric study, performed from 2005 to 2011. All Alzheimer's patients with 10

A biologically inspired meta-control navigation system for the Psikharpax rat robot.

A biologically inspired navigation system for the mobile rat-like robot named Psikharpax is presented, allowing for self-localization and autonomous navigation in an initially unknown environment. The ability of parts of the model (e.g. the strategy selection mechanism) to reproduce rat behavioral data in various maze tasks has been validated before in simulations. But the capacity of the model to work on a real robot platform had not been tested. This paper presents our work on the implementation on the Psikharpax robot of two independent navigation strategies (a place-based planning strategy and a cue-guided taxon strategy) and a strategy selection meta-controller. We show how our robot can memorize which was the optimal strategy in each situation, by means of a reinforcement learning algorithm. Moreover, a context detector enables the controller to quickly adapt to changes in the environment-recognized as new contexts-and to restore previously acquired strategy preferences when a previously experienced context is recognized. This produces adaptivity closer to rat behavioral performance and constitutes a computational proposition of the role of the rat prefrontal cortex in strategy shifting. Moreover, such a brain-inspired meta-controller may provide an advancement for learning architectures in robotics.

[Management of ear, nose, and throat diseases in district hospital centers in Madagascar]. / Prise en charge de la pathologie ORL dans les centres hospitaliers de district à Madagascar.

The purpose of this report is to describe the experience of a specialized medico-surgical ENT team sent to hospital centers in Atalaha and Tulear, Madagascar by a nonprofit organization called "Terre rouge" from the Reunion Island. In three separate short-term missions, a total of 93 patients received care. Discussion focuses on the particular pathological, cultural, and pedagogical features of the Island and on the resources that were deployed during the missions. Providing ENT care in district hospitals in Madagascar requires adaptation to the difficult climatic conditions, poor hospital facilities (infrastructure, equip ment, and personnel), and advanced stage of diseases. To ensure continuous access to ENT care, it will be necessary to provide practical and didactic training for healthcare personnel in the country.