Training in cataract surgery in Spain: analysis of the results of a survey of the European Board of Ophthalmology in a Spanish cohort.

INTRODUCTION: A survey conducted by the European Board of Ophthalmology (EBO) revealed significant differences in the surgical training of the ophthalmology residents in Europe, including a disparity between the sexes and a variation in the experience on cataract surgery (CC) between them. This study is about the Spanish sub-cohort of the survey, and its objective is to present and analyse the peculiarities of ophthalmology training in Spain within the European context, as well as discussing ways to harmonise and improve that training throughout the EU. METHODS: We analyse data of the Spanish participants in the EBO exams, defining subgroups by the Autonomous Communities existing in Spain. RESULTS: 93 of 135 requested participants (68.9%) responded. A 60.2% passed the EBO exam between 2021-2022, being mostly women (65.59%) aged 31 years old on average. The 91.4% were right-handed, coming from 13 of the 17 Spanish autonomous communities, although mostly from the Community of Valencia, Madrid and Catalonia. Respectively, 16.1%, 3.2% and 8.7% of the respondents said they have completed 10 or more training sessions on animal eyes, synthetic eyes and through the virtual reality simulator. This training was correlated with greater self-confidence in the management of a posterior capsular tear during surgery (p .025). All respondents manifested to have already performed stages of the CC. The average number of operations reported was 181.6 with regional disparities. A significant difference is observed between the sexes against women (-28.3%, p 0.03). DISCUSSION: Ophthalmologists in Spain, much more than other European countries, have greater opportunities for surgical training, with surgical procedures during the residency, that nearly triples those made by the others. Spanish women refer, like their European colleagues, to be in disadvantage in learning opportunities about cataract surgery. The Simulation Based Medical Education (SBME) allows to respond to the training deficit and complements the training on the patient. Although we demonstrate a significant correlation between the number of procedures carried out and self-confidence to operate simple cases, the SBME would be a complementary tool in self-confidence in front of a complication like capsular rupture. CONCLUSION: Spain massively adopts the model named by us "surgery for all", despite the underrepresentation of women in this area, emphasising a need for cultural change that the SBME could facilitate.

[A randomized study of subconjonctival bevacizumab (Avastin®) injection for corneal neovascularization]. / Étude randomisée de l'injection sous-conjonctivale de bévacizumab (Avastin®) dans la néo-vascularisation cornéenne.

PURPOSE: The goal of this phase III, comparative, multicentric, randomized, double-blinded clinical trial was to investigate the superiority of subconjunctival bevacizumab injections versus placebo in the treatment of corneal neovascularization. PATIENTS AND METHODS: We included 38 eyes (38 patients) with corneal neovascularization. Twenty patients received bevacizumab and 18 placebos. Patients received 3 monthly injections of either 5mg (0.2mL) bevacizumab or placebo. The main criteria of success was reduction of the surface area of corneal neovascularization after 3months (M3) versus baseline, as measured using semi-automatic analysis of color photographs. RESULTS: The percentage of neovascularized corneal surface decreased by -8.6%±32.8 with bevacizumab, versus -2.6%±20.8 with placebo (p=0.5284). Four patients were determined to be responders (reduction of more than 30%), 3 in the bevacizumab group and 1 in the placebo group, all with neovascularization of less than 1year duration. When restricting the analysis to neovascularization of less than 1 year duration, the difference approached the threshold for significance (-31.8%±42.4 in the bevacizumab group and -0.9%±23.1 in the placebo group) (p=0.0637), as well as the number of responders (3/6 in the bevacizumab group versus 1/10 in the placebo group) (p=0.1181). No serious adverse event was reported. CONCLUSION: This study shows the efficacy of subconjunctival bevacizumab injection in the reduction of neovascularized corneal surface area versus placebo, but only when the neovascularization has been present less than 1year. Nevertheless, the study did not attain the statistical power to pass the threshold of significance.

[Assessment method of cognitive load and stress inducer factors of surgeons and anesthetists in the operating room]. / Méthodes d'évaluation de la charge cognitive et des facteurs inducteurs de stress des chirurgiens et anesthésistes au bloc opératoire.

INTRODUCTION: For many years, surgeons and anesthetists have recognized that stress can be present in their daily professional practice. The goal of this study was to identify tools for assessing stress and cognitive load in the operating room. MATERIAL AND METHODS: We conducted a literature review in the PubMed database of scientific articles published on the subject without date limit using the keywords anesthesia, surgery, surgeon, cognitive workload, definition, pathophysiology, physiological measurement, objective, subjective, stress. RESULTS: Nineteen articles were selected, focusing on cardiac surgery, gastrointestinal surgery, vascular surgery and urology. No publications concerning ophthalmology were found through the literature search. The means of measurement found were either subjective, such as questionnaires, or objective, such as the study of heart rate variability (HRV), reaction time, eye movements, electrical conductivity of the skin, biological markers and electroencephalogram. Of all these measurement tools, the NASA-TLX questionnaire, used in four articles, and the HRV study, used in eight articles, appear to be the most widely used and are strongly correlated with stress. CONCLUSION: The articles reviewed use only some of the available tools for assessment of stress and cognitive load. The main objective is to improve the quality of care and the quality of life of caregivers. It would be interesting to develop other methods to identify and better characterize the risk factors that increase stress and cognitive load.

[Ocular surface and outdoor air pollution: A systematic review]. / Surface oculaire et pollution environnementale extérieure : revue systématisée de la littérature.

INTRODUCTION: Air pollution has steadily increased for several decades, with widely studied effects on human health, including increased mortality, incidence of stroke, respiratory and allergic disease. However, the effects of pollution on the ocular surface, in direct contact with the outside world, have been less precisely studied. MATERIALS AND METHODS: We conducted a literature review of articles on the subject published from 1966 to October 2020. Among the 661 articles identified, 33 were retained. Ocular surface disease associated with pollution included non-specific conjunctivitis, dry eye disease, blepharitis, and allergic conjunctivitis. The studied pollutants were particulate matter less than 2.5µm and 10µm (PM2.5, PM10), ozone (O3), nitrogen dioxide (NO2), carbon monoxide (CO) and sulfur dioxide (SO2). Certain air quality parameters such as temperature and relative humidity were also studied. RESULTS: Among the markers of air pollution possibly associated with ophthalmic disease, NO2 and SO2 appear to be the most frequent and highly correlated. High temperatures and low humidity levels also appear to be aggravating factors for the ocular surface. However, due to the heterogeneity of the studies, the results must be interpreted with caution. Indeed, the methodology and the results of the various studies are sometimes contradictory. The inclusion of patients, the analysis of environmental data, and the correlation between these two elements indeed raise numerous methodological questions. CONCLUSION: Air pollution control would appear essential, as well as the development of new studies based on reliable methods of studying the environmental and its clinical effects.

[Management of ocular toxoplasmosis in France: Results of a modified Delphi study]. / Prise en charge de la toxoplasmose oculaire en France : résultats d'une étude Delphi modifiée.

OBJECTIVE: To evaluate diagnostic and therapeutic practices and then establish a consensus on the management of ocular toxoplasmosis in France through a Delphi study. MATERIALS AND METHODS: Twenty-three French experts in ocular toxoplasmosis were invited to respond to a modified Delphi study conducted online, in the form of two questionnaires, in an attempt to establish a consensus on the diagnosis and management of this pathology. The threshold for identical responses to reach consensus was set at 70 %. RESULTS: The responses of 19 experts out of the 23 selected were obtained on the first questionnaire and 16 experts on the second. The main elements agreed upon by the experts were to treat patients with a decrease in visual acuity or an infectious focus within the posterior pole, to treat peripheral lesions only in the presence of significant inflammation, the prescription of first-line treatment with pyrimethamine-azithromycin, the use of corticosteroid therapy after a period of 24 to 48hours, the prophylaxis of frequent recurrences (more than 2 episodes per year) with trimethoprim-sulfamethoxazole as well as the implementation of prophylactic treatment of recurrences in immunocompromised patients. On the other hand, no consensus emerged with regard to the examinations to be carried out for the etiological diagnosis (anterior chamber paracentesis, fluorescein angiography, serology, etc.), second-line treatment (in the case of failure of first-line treatment), or treatment of peripheral foci. CONCLUSION: This study lays the foundations for possible randomized scientific studies to be conducted to clarify the management of ocular toxoplasmosis, on the one hand to confirm consensual clinical practices and on the other hand to guide practices for which no formal consensus has been demonstrated.

[Digital eye strain. Functional symptoms and binocular balance analysis in intensive digital users]. / Stress oculaire induit par les écrans. Analyses des symptômes fonctionnels et de l'équilibre binoculaire chez des utilisateurs intensifs.

INTRODUCTION: In almost 50 % of cases, acute or chronic screen exposure is accompanied by symptoms of dry eye or binocular imbalance, known as digital eye strain. This phenomenon is described relatively little in the literature. The goal of this study is to determinate the effects of screen exposure on subjective comfort and binocular balance. PATIENTS AND METHODS: This is a cross-sectional, prospective, monocentric pilot study conducted from August to October 2019. The first part of the study focused on disturbances induced by short-term screen exposure (comparison between morning and evening examinations) between a control group (less than 5hours a day) and an exposed group (more than 5hours a day). The second part investigates the consequences of chronic exposure (screen exposure greater than 5hours a day, 5 days a week for one year) excluding pre-presbyopic and presbyopic patients (over 35 years of age). The study parameters consisted of an ocular discomfort questionnaire and binocular function tests (refraction, phoria, near point of accommodation and convergence, fusional vergence (FV), and binocular amplitude facility (BAF)). RESULTS: Short exposure : 52 participants were included. No significant difference was found between the control group (n=24, mean exposure=2.6 hr) and the exposed group (n=28, mean exposure=6.1 hr) for any of the objective parameters. The ocular discomfort score was highest in the exposed group for the following parameters: near (p=0.04) and intermediate (p=0.02) blurred vision and light sensitivity (p=0.04). Chronic exposure: 35 participants were included. The exposed group (n=12, mean exposure=6.7 hr) showed a decrease in FV (p=0.045) and BAF (p=0.038) compared to the control group (n=23, mean exposure=2.1 hr). DISCUSSION: Binocular balance is disturbed by intensive and chronic use of screens. Special attention must therefore be paid to these patients.

[Digital eye strain. Symptoms, prevalence, pathophysiology, and management]. / Perturbations oculaires secondaires à l'utilisation de supports numériques. Symptômes, prévalence, physiopathologie et prise en charge.

The digital revolution, which has been underway since the 1980's, is disrupting our daily routines with an exponential increase in the use of screens, which has not been without consequence to our visual system. Digital eye strain (DES), or computer vision syndrome (CVS), includes all the visual symptoms secondary to the use of digital devices. DES is present in at least 50% of regular users of digital media and is defined by blurred vision, difficulty focusing, ocular irritation or burning, dry eye, visual fatigue, headaches and increased sensitivity to light. Exposure time, age, female gender, and work environment are the main factors increasing its prevalence. Its pathophysiology, still poorly understood, is felt to be multifactorial and includes disturbances in the accommodative-convergence balance and changes in the ocular surface. Regarding accommodation and convergence, the studies are mostly old and their results heterogeneous. Conversely, many studies have shown an increase in the prevalence of dry eye in screen users. Although the retinal toxicity of blue light has been proven in in vitro models, the low level of evidence in the available studies does not allow it to be clearly correlated with the symptoms of DES. The objective of this review is to condense the knowledge available in the literature on the symptoms, prevalence, pathophysiology and management of DES.

[Interest of environmental exposure chambers in the evaluation of allergic conjunctivitis]. / Intérêt des chambres d'exposition environnementale dans l'évaluation des conjonctivites allergiques.

Allergic conjunctivitis affects 15 to 20% of the general population. It is currently evaluated by the Conjunctival Provocation Test (CPT), which is considered as the gold standard. In the investigation of allergic rhinitis and asthma, environmental exposure chambers (EEC) are increasingly utilised. For allergic conjunctivitis, EEC might be a valid alternative to the CPT. However, evaluation of the allergen response in individual provocation tests or in EECs is still in discussion due to the multiplicity of symptom scores. Indeed, there are many scores used to evaluate allergic conjunctivitis. The main criteria used were described by Abelson in 1990 and include redness, itching, tearing, and swelling. In clinical studies, the specifically ocular score most used is the Total Ocular Symptom Score (TOSS). Few treatments have been evaluated by EEC, including cold compresses, epinastine and N-acetyl aspartyl glutamic acid. Moreover, early data shows good correlation between ocular symptoms induced in an EEC and those assessed during natural exposure. EEC might be a valid alternative to CPT and correlate with natural seasonal allergen exposure. Finally, EEC might be useful in other fields as well, such as in the study of dry eye disease.

Tactile sensitivity thresholds for the radial hemi-pulp of the index: A comparison between the Semmes-Weinstein and Cochet-Bonnet tests in 25 healthy subjects.

The purpose of this work was to determine whether the Cochet-Bonnet (CB) corneal sensitivity test has a lower cutaneous pulp sensitivity threshold than the Semmes-Weinstein (SW) monofilament test. Tactile sensitivity thresholds for the radial hemi-pulp of the index finger of 25 healthy adult subjects aged 30 years on average were measured using SW and CB esthesiometers. The sensitivity threshold of the radial hemi-pulp of the index was lower with the CB test than with the SW test. The sensitivity and specificity of the CB test on palm wounds still needs to be determined to rule out nerve damage.

[Fungal keratitis]. / Kératites fongiques.

Fungal keratitis, or keratomycoses, are corneal infections which must be considered in cases of corneal trauma, prior corneal surgery, chronic ocular surface disease, topical corticosteroids or contact lens wear. Filamentous fungi or yeasts may be involved. Presenting clinical features such as corneal infiltrates with feathery edges and/or raised surface, intact epithelium with deep stromal involvement, satellite lesions, endothelial plaques, lack of improvement with antibiotics and worsening with steroids are suggestive of fungal keratitis. Corneal scraping for laboratory examination is mandatory. Medical management with antifungal eye drops and systemic agents should be started as soon as possible. Surgical interventions are required in a significant number of cases to control the infection. The prognosis of fungal keratitis is worse than that of bacterial keratitis.

Fungal keratitis.

Fungal keratitis, or keratomycoses, are corneal infections which must be considered in cases of corneal trauma, prior corneal surgery, chronic ocular surface disease, topical corticosteroids or contact lens wear. Filamentous fungi or yeasts may be involved. Presenting clinical features such as corneal infiltrates with feathery edges and/or raised surface, intact epithelium with deep stromal involvement, satellite lesions, endothelial plaques, lack of improvement with antibiotics and worsening with steroids are suggestive of fungal keratitis. Corneal scraping for laboratory examination is mandatory. Medical management with antifungal eye drops and systemic agents should be started as soon as possible. Surgical interventions are required in a significant number of cases to control the infection. The prognosis of fungal keratitis is worse than that of bacterial keratitis.

[Scleritis and episcleritis]. / Sclérites et épisclérites.

Episcleritis is generally a benign disease with a self-limited course, while scleritis is a severe ocular condition due to a risk of impaired vision in one-fifth of patients and its association with systemic diseases in one third of them. Infectious scleritis, representing 8 % of the etiologies, is mainly of herpetic origin (varicella zoster and herpes simplex viruses). A systemic autoimmune disease is observed in roughly 30 % of scleritis patients: inflammatory rheumatisms (15 %), firstly rheumatoid polyarthritis, systemic vasculitides (8 %), mainly granulomatosis with polyangiitis (Wegener's) and polychondritis, and less often inflammatory bowel disease and systemic lupus erythematosus. Among the different types of scleritis, a clear distinction exists between necrotizing forms leading to decreased vision in 50 % of the cases and associated with systemic diseases in the vast majority, and non-necrotizing forms (either diffuse or nodular), with a better prognosis. However, recent publications show that necrotizing forms are much less frequent nowadays (around 5 % of the total), probably due to therapeutic innovations and progress made during the last 20 years. The medical management of scleritis requires collaboration between ophthalmologists and internists (or rheumatologists).

Species of Metarhizium anisopliae complex implicated in human infections: retrospective sequencing study.

OBJECTIVES: Fungi belonging to the Metarhizium anisopliae complex comprise ubiquitous arthropod pathogenic moulds used as mycopesticides. Rare cases of human infections due to M. anisopliae have been reported. We hypothesize misidentifications of fungal strains implicated in these cases or used in mycopesticides. METHODS: A review of the literature was conducted to identify previously published cases. We collected some of these previous described strains and reported new cases, and a French mycopesticide containing M. anisopliae. All identifications were performed based on elongation factor-1α gene sequencing. RESULTS: We report eight new cases of Metarhizium infection in humans (three from France and five from Australia). The strains isolated from these cases, and three others from already published cases and reported as M. anisopliae, were molecularly identified based on elongation factor-1α (Ef1-α) gene sequencing as follows: Metarhizium robertsii (six), Metarhizium guizhouense (three), Metarhizium brunneum (one) and Metarhizium pingshaense (one). CONCLUSIONS: In this study, we report new human cases of Metarhizium infections, and, based on Ef-1α gene sequencing, we demonstrate the misidentification of species in case reports. We also correct the species identification of a strain reported as M. anisopliae used in a commercially available mycopesticide. According to our results, none of the strains from the human infection reports reviewed belongs to the species M. anisopliae.

[Risk factors for contact lens-related microbial keratitis: A multicenter case-control study]. / Facteurs de risque de kératites infectieuses chez les porteurs de lentilles de contact, une étude cas-témoins.

PURPOSE: Currently, the most feared complication by ophthalmologists of contact lens (CL) wear is microbial keratitis (MK), even though its incidence remains low. It is also a significant financial burden for society. This study aimed to identify the risk factors for CL-related MK especially with regard to hygiene and pattern of use, in a large, prospective, multicenter, case-control study. METHODS: A multicenter retrospective case-control study was designed. The CL-related MK subpopulation (case) was compared with healthy CL wearers (control) using a 52-item anonymous questionnaire designed to determine subject demographics, lens wear history, lens type and disinfection solution, fitting, patient education, hygiene and maintenance of contact lenses, and patient history. Univariate logistic regression analysis was performed to compare both groups. RESULTS: The study included 497 cases and 364 controls. The risk factors associated with the greatest increased odds of CL-related MK were as follows: extended wear (OR=2.96 [1.65-5.33], P<0.001), occasional overnight lens use (OR=6.37 [4,55-8.90], P<0.001), fitting by an optician (OR=1.97 [1.38-2.83], P<0.001), absence of ophthalmologic exam (OR=6.56 [2-22], P<0.01) or no training in handling the contact lens (OR=4.47 [2.27-8.77], P<0.01), use of optician's disinfection solution (OR=5.55 [3.12-9.85], P<0.001), mixing solutions ("topping off") (OR=4.68 [2.73-8.04], P<0.001), no case replacement (OR=3.95 [2.28-6.82] P<0.01), no compliance with hygiene rules and smoking (OR=2.29 [1.67-3.14], P<0.01). The protective factors associated with the greatest reduction in OR were female gender (OR=0.49 [0.36-0.66], P<0.01), hypermetropia (OR=0.28 [0.16-0.48], P=0.01), rigid contact lens wear, fitting by an ophthalmologist, written and verbal instruction, and daily case maintenance. CONCLUSION: The knowledge of these risks factors incentivizes action at all levels to reduce the incidence of MK, from the prescriber to the patient, including the type of CL, case and contact lens solution.

[Evaluation of in vitro efficacy of combined riboflavin and ultraviolet-A (365 nm) for Acanthamoeba]. / Efficacité anti-amibienne in vitro de l'association riboflavine/UV-A.

INTRODUCTION: Acanthamoeba keratitis is a rare but serious disease and is particularly difficult to treat when the diagnosis is delayed, partly because of the limitations of current therapies. The purpose of our study is to evaluate the anti-amoebic effectiveness of riboflavin and UV-A on Acanthamoeba castellani. MATERIALS AND METHODS: We tested the effect of 0.02% chlorhexidine alone (C), the combination of riboflavin 1% and UV-A (UV-A+R), and the combination of the two treatments (R+C+UV-A) on cultures of vegetative and cystic forms of A. castellani. We conducted a parasite count under optical microscopy for each treated area at day 1, 4 and 8. RESULTS: There was a decrease in the number of cysts for all three treatments (C, UV-A+R, R+C+UV-A). This reduction was greater for the plates treated with R+UV-A (P <0.01 at D8) and those treated with C+R+UV-A (P<0.001 at D8) compared to those exposed to chlorhexidine alone (C). There was no decrease in the number of amoebic trophozoites for the three treatments (C, UV-A+R, R+C+UV-A), but encystment was observed. DISCUSSION: Given the in vitro efficacy of riboflavin combined with UV-A against cystic forms of A. castellani and excellent in vivo tolerance of the procedure, the treatment of acanthamoeba keratitis might be improved by this new therapeutic approach.