Long-Term Results of Combined Trabeculotomy Trabeculectomy in Primary Congenital Glaucoma.

PRCIS: Primary congenital glaucoma (PCG) in Tunisian children seems to be characterized by a high prevalence of inherited and advanced forms of the disease. Primary combined trabeculotomy trabeculectomy (CTT) allowed satisfactory long-term intraocular pressure (IOP) control and reasonable visual outcome. PURPOSE: To report the long-term outcome of CTT as the initial glaucoma surgery in children with PCG. METHODS: Retrospective analysis of children who underwent primary CTT for PCG between January 2010 and December 2019. The main outcome measures were IOP reduction, corneal clarity, complications, refractive errors, and visual acuity (VA). Success was defined as IOP <16 mm Hg without (complete) or with (qualified) antiglaucoma medication. The WHO criteria of vision loss were used to categorize visual impairment (VI). RESULTS: Of 62 patients, 98 eyes were enrolled. At the last follow-up, the mean IOP was reduced from 22.7 ± 4.0 mm Hg to 9.7 ± 3.9 mm Hg ( P < 0.0001). The complete success rate was 91.6%, 88.4%, 84.7%, 71.6%, 59.7%, and 54.3%, at the first, second, fourth, sixth, eighth, and tenth year, respectively. Follow-up averaged 42.1 ± 28.4 months. Preoperatively, 72 eyes (73.5%) had significant corneal edema versus 11 eyes (11.2%) at the end of the follow-up ( P < 0.0001). Endophthalmitis was encountered in one eye. Myopia was the most common refractive error (80.6%). Data on Snellen VA were available for 53.2% of the patients; 33.3% achieved a VA ≥6/12, 21.2% had mild VI, 9.1% had moderate VI, 21.2% had severe VI, and 15.2% were blind. The failure rate was statistically correlated to the early disease onset (<3 mo) and to preoperative corneal edema ( P = 0.022 and P = 0.037, respectively). CONCLUSION: Primary CTT seems to be a good procedure in a population with advanced PCG at presentation, problematic follow-up visits, and limited resources.

Autologous retinal graft for the management of large macular holes associated with retinal detachment.

To present the efficacy of autologous neurosensory retinal transplantation in macular holes surgery with rhegmatogenous retinal detachment. Eleven eyes of 11 patients with rhegmatogenous retinal detachment associated to a large macular hole were enrolled between January 2019 and January 2021 in the Department A of the Hedi Rais Institute of Ophthalmology (Tunis, Tunisia). All patients underwent a 23 G pars plana vitrectomy. An autologous neurosensory retinal patch was placed inside the macular hole. Long-acting silicone tamponade was carried out. Clinical features of the macular area, best-corrected visual acuity (BCVA), fundus examination, and SD-OCT were recorded before surgery, at 1- and 3-month follow-up after surgery. The mean age of our population was 56.6 ± 10.33 years old, ranged from 45 to 76 years old. Final retinal reattachment was achieved clinically in all eyes. The Spectral domain-Optical Coherence Tomography (SD-OCT) follow-up showed the macular hole closure. The retinal patch was demonstrated by OCT at each control. BCVA improved from 1.52 ± 0.23 Logarithm of the Minimum Angle of Resolution (LogMAR) to 0.89 ± 0.16 LogMAR 3 months after surgery (p= 0.014). No adverse events were registered during the study. Autologous neurosensory retinal transplantation has been efficient to treat macular hole associated to rhegmatogenous retinal detachment. Further multicentric studies with a large number of patients are needed to establish the results of this technique in complex cases.

[Orbital cellulitis: diagnostic, therapeutic and prognostic approach in a reference center in Tunis, Tunisia (a retrospective study of 109 cases)]. / Les cellulites orbitaires: approche diagnostique, thérapeutique et pronostique dans un centre de référence à Tunis, Tunisie (une étude rétrospective sur 109 cas).

Orbital cellulitis is a rare disease. Two anatomo-clinical forms can be distinguished: a preseptal "benign" form and a retroseptal "severe" form. The purpose of this study was to analyze the epidemiological, clinical, therapeutic and prognostic profile of orbital cellulitis in a third-line Hospital in Tunis, Tunisia. We conducted a retrospective study involving 109 patients hospitalized for orbital cellulitis. Two groups were distinguished: the retroseptal cellulitis group including 42 patients (38.5%) and the preseptal cellulitis group including 67 patients (61.5%). The average age of patients was 27.1 ± 34.8 years. The sex ratio M/F was 0.84 (45.9% of male patients). Acute sinusitis was the most frequently identified portal for retroseptal cellulitis entry (35.7%, n=15), while acute dacryocystitis was the most common cause of preseptal cellulitis (23.9%, n=16). Diabetes, non-functioning eye and prior use of non-steroidal anti-inflammatory drugs were associated with retroseptal cellulitis (p=0.007, p=0.022 and p=0.014 respectively). All patients received systemic antibiotic therapy. Ten patients (23.8%) of the retro-septal cellulitis group and 5 patients (7.46%) of the preseptal cellulitis group underwent surgery. Nine cases of blindness (8.2%), a case of septic shock and a case of death were reported. Poor prognostic factors were a time of consultation > 7 days (aOR = 4.277, 95% CI = 2.504-32.426, p = 0.006) and Chandler stage>III (aOR = 7.009, 95% CI = 1.69-51.839, p = 0.029). In developing countries and especially in Tunisia, orbital cellulitis can be sight threatening or even life-threatening. Early management could lead to a favorable outcome without sequelae.

Ophthalmic Manifestations of Newly Diagnosed Acute Leukemia Patients in a Tunisian Cohort.

Purpose: To describe ocular manifestations of acute leukemia in a Tunisian cohort and to assess the associations between ophthalmic findings and epidemiological, clinical, and biological features of the disease. Methods: A prospective study included patients newly diagnosed with acute leukemia referred to our clinics between January 2019 and July 2020. All patients underwent a complete ophthalmic evaluation and spectral-domain optical coherence tomography (SD-OCT) at presentation, then every two months during one year. We defined two groups: Group 1 included patients with leukemic ophthalmopathy and group 2 included patients with normal ophthalmic examination. Results: Forty-six patients were enrolled. The mean age of patients was 32.1±15.3 years. The sex ratio M/F was 1.55 (28 male patients and 18 females). Twenty-nine patients (63%) had acute myeloid leukemia (AML), and 17 (37%) had acute lymphoblastic leukemia (ALL). The average follow-up was 9.1 months (range: 3-12 months). We observed ophthalmic manifestations in 28 patients (61%). Among them, 17 (61%) had vision-threatening complications. The posterior segment was the most common site of ocular involvement (82% of group1). Primary leukemic infiltration (Disc edema, ptosis, exophthalmos) was present in 13 eyes (14.1%). Twenty-seven eyes (29.3%) had secondary involvement lesions (Subconjunctival hemorrhage, periorbital ecchymosis, retinal/sub-hyaloid hemorrhage, dilated/tortuous veins). Twenty-one eyes (22.8%) showed other ocular manifestations which etiopathogenesis is not yet fully understood (White-centred hemorrhages, cotton-wool spots, serous retinal detachment, hemorrhagic pigment epithelial detachment). Leukemic retinopathy was significantly more frequent in adults (23/39 and 1/7 in adult and pediatric groups, respectively; p=0.003). Patients suffering from AML were more likely to have secondary ocular involvement (20/29 and 7/17 in AML and ALL patients, respectively; p=0.047). Retinal hemorrhages were statistically associated with anemia and thrombocytopenia (p=0.041 and p=0.034; respectively). Conclusion: Leukemic ophthalmopathy seems to be frequent and may lead to severe visual impairment. An ophthalmic assessment complemented with SD-OCT has paramount importance in all newly diagnosed acute leukemic patients.

Clinical Features and Outcomes of Congenital Cataract Surgery with Primary Intraocular Lens Implantation in a Tunisian Cohort.

Purpose: To describe the clinical features of congenital cataract (CC) in a Tunisian cohort and to assess the surgical outcomes of primary intraocular lens implantation in two groups based on the age at surgery. Methods: This study was a prospective analysis of children under 5 years with CC that were operated between January 2015 and 2020. The surgery consisted of phacoaspiration with posterior capsulorhexis and primary implantation. Group 1 comprised children operated at <2 years of age and Group 2 comprised children operated between 2 and 5 years. Peri and postoperative surgical events as well as refractive and visual outcomes were compared between both the groups. Results: Fifty-five (84 eyes) infants were enrolled. Group 1 included 30 (48 eyes) children and Group 2 included 25 (36 eyes) patients. The mean follow-up was 27.60 ± 19.89 months. The mean delay between the diagnosis and the cataract surgery was 11.97 ± 13.84 months. Of 14 (16.7%) eyes with postoperative visual axis opacification (VAO), 9 (10.7%) eyes required pars plana membranectomy. The VAO was not statistically associated with the age at surgery (P = 0.112), but significantly correlated with sulcus implantation (P = 0.037). The final mean visual acuity was 0.51 logMAR and comparable between both the groups (P = 0.871). Poor visual outcome was significantly associated with low age at presentation (<6 months; P = 0.039), delay between the diagnosis and time of surgery (P = 0.001), preoperative nystagmus (P = 0.02), and poor parental compliance to amblyopia treatment (P = 0.009). Conclusions: Primary implantation seems to be safe and efficient. VAO appears to become an avoidable occurrence owing to better surgical techniques. Amblyopia remains the biggest barrier to final visual outcome.

Surgical management of a traumatic intralenticular abscess: a case report.

lntralenticular abscess is a very rare entity that has been described after penetrating trauma, intraocular surgery and metastatic spread. We report a case of intralenticular abscess treated surgically by phacoemulsification with good postoperative results. A 32-year-old patient presented with right eye redness and defective vision of 4 days following thorn injury. The visual acuity was limited to counting fingers. Anterior segment examination revealed healed lamellar corneal tear, 3+ cells in the anterior chamber, iris synechia and heterogeneous opacity of the crystalline lens. Vitreous and fundus were normal. Initially, we prescribed topic and systemic antimicrobial treatment. Lens extraction was performed 1 week later by phacoemulsification with primary intraocular lens implantation. The immediate postoperative recovery was uneventful. The visual acuity at last follow-up was 9/10. In the current case, lens extraction associated with systemic and local antimicrobial treatment allowed infection control and good visual outcome.

Case report: Severe presentation of a syndromic congenital bilateral upper eyelids eversion.

INTRODUCTION: and importance: Congenital upper eyelid eversion (CUEE) is a rare congenital condition characterized by everted upper eyelids with prominent chemosis. The authors present the first case of concurrent upper eyelids eversion, umbilical hernia, and clubfeet. CASE PRESENTATION: A four-hour-old newborn male presented with bilateral red upper eyelids swelling. Ophthalmic examination revealed bilateral upper eyelids eversion and severe bilateral chemosis. The further pediatric evaluation showed a painless reducible umbilical hernia and clubfeet. Treatment of the eyelids eversion was conservative, combining topical steroids, antibiotics and lubricants. Chemosis reduced progressively. We obtained a complete resolution on day 21. We referred the neonate to the pediatric surgery, and orthopedic department for umbilical hernia and clubfeet management. CLINICAL DISCUSSION: Most infants with CUEE may show excellent anatomic and functional results with conservative treatment if managed timely and promptly. CONCLUSION: The innocuous appearance of CUEE must not prevent clinicians from investigating possible systemic associations and initiating appropriate treatment.

Hyperbaric Oxygen Therapy for Mumps-Associated Outer Retinitis with Frosted Branch Angiitis.

PURPOSE: To describe a case of outer retinitis with frosted branch angiitis associated with mumps infection treated with hyperbaric oxygen (HBO) therapy. METHODS: Observational case report. CASE REPORT: A four-year-old boy with bilateral blindness was diagnosed with necrotizing outer retinitis with frosted branch angiitis associated with serologically confirmed mumps virus infection. He was treated with HBO therapy. Visual acuity subsequently improved to 20/40 in the right eye and to 20/320 in the left eye. Sequential follow-up optical coherence tomography examinations showed progressive recovery of the outer retinal layers in the right eye. CONCLUSION: HBO therapy appears to be a feasible and safe treatment that might improve the anatomical and functional outcome in patients with mumps retinitis.

Preoperative Intralesional Bevacizumab Injection in Primary Pterygium in Tunisian Patients: A Randomized Controlled Prospective Study.

Purpose: To assess the efficacy and safety of a single preoperative intralesional bevacizumab injection as an adjuvant treatment before primary pterygium surgery. Methods: We conducted a randomized controlled interventional study from January 2019 to December 2020. The study included a total of 60 patients (60 eyes) with primary pterygium. We defined two groups of 30 patients each. Group A received an intralesional injection of bevacizumab (Avastin), 1 month before surgery (lesion excision and conjunctival autograft). Group B (control) had only the surgical treatment. Patients were followed up 7 days (D7), 1 month (M1), 3 months (M3), and 6 months (M6) postoperatively. Pre-, per-, and postoperatively, photographs of the lesions were taken, as well as a histopathological examination. The main outcome measures were the change in functional discomfort following intralesional bevacizumab injection and pterygium recurrence. Recurrence was defined as fibrovascular tissue growth invading the cornea. Therapeutic success was defined as the absence of pterygium recurrence in M6. Results: The mean age of the 60 patients was 54.17 ± 10.53. After bevacizumab injection, the preoperative functional discomfort score decreased significantly (P = 0.048). There was a significant improvement in grade and color intensity (P = 0.001). We noted no local nor systemic complications after intralesional injection of bevacizumab. After pterygium excision, the success rate was statistically higher in Group A (P = 0.047). There was no significant difference in either final best-corrected spectral visual acuity or astigmatism between the two groups. We noted a statistically significant association between recurrence and color intensity (P = 0.046), vascular density (P = 0.049), and the degree of elastic tissue degeneration (P = 0.040). Conclusion: A single preoperative subconjunctival injection of bevacizumab 1 month before surgery decreases the vascularity of newly formed blood vessels and hence may reduce the recurrence rate.

Superficial Temporal Muscle Fascia Grafting: Successful Transplant of Surgical-induced Necrotizing Scleritis.

To report the case of a surgical-induced necrotizing scleritis (SINS) following vitreoretinal surgery for rhegmatogenous retinal detachment, successfully managed by superficial muscle temporal fascia grafting. An 18-year-old teenager, with a history of a 23G vitrectomy with silicone oil tamponade for rhegmatogenous retinal detachment of the left eye, presented with intense left ocular pain, decreased visual acuity to counting fingers and eye redness. Split lamp examination showed: Conjunctival infiltration with silicone oil, circumferential sclera thinning with ectasia of the underling uvea. The fundus examination showed an attached retina. Necrotizing scleritis was the retained diagnosis. SINS was the final diagnosis. An immunosuppressive therapy was started. Superficial muscle temporal fascia grafting was performed to cover the necrotizing sclera. The patient did well postoperatively without sclera thinning or ectasia and the fascia grafting still intact without retraction after 6 months of follow-up. This is the first case in the literature that used the superficial temporal muscle fascia as a graft for sclera reinforcement in SINS. We propose new support to reinforce the deficient sclera. This graft must be associated with prompt immunosuppressive therapy at high doses.

Cyclosporin A eye drop and subepithelial adenoviral keratoconjunctivitis infiltrates.

INTRODUCTION: The adenoviral keratoconjunctivitis infiltrates may be a source of significant visual impairment justifying the use of various therapeutic means. AIM: Evaluate the efficiency and safety of use of cyclosporine A 0,5% eye drop in the treatment of subepithelial infiltrates. METHODS: It was a prospective study of 37 eyes of 22 patients with adenoviral keratoconjunctivitis with subepithelial infiltrates treated with cyclosporine A 0,5% eye drop. Cyclosporine A 0,5% was prepared from the injectable form of cyclosporine (Sandimmun®) and artificial tears. The cyclosporine A 0,5% was first administered at 4 drops per day for 15 days, then at a rate of 2 drops per day for a variable period ranging from 15 days to 6 months. The use of this molecule has been motivated by the presence of a persistent dazzlement, by visual acuity under 6/10 or an astigmatism superior to 1 diopter. RESULTS: At the end of follow, dazzlement disappeared in all patients; the final average visual acuity was 8/10 and corneal astigmatism average was of 0.75 diopter. The slit lamp examination showed a marked decrease in the number and density of subepithelial infiltrates from the 15th day. A 29-year-old patient, however, presented some intercostal vesicles due to zonal recrudescence but with spontaneous and quick resolve in the same time of taking topical cyclosporine. No local complications were observed in our patients. The average follow-up was 13 months. CONCLUSION: Topical cyclosporine A is an effective and well-tolerated alternative to corticosteroids in the subepithelial infiltrates occurring as sequelae of adenoviral keratoconjunctivitis.

[Epidemiological aspects of malignant melanoma of the uvea in Tunisia]. / Aspects épidémiologiques du melanoma malin de l'uvée en Tunisie.

BACKGROUND: to assess clinical factors that may influence the prognosis of malignant melanoma of the uvea METHODS: We conducted a retrospective study from January 1990 to December 2013, involving 80 patients suffering from malignant melanoma of the uvea. We determined the location, the size, the tumor thickness, the clinicopathological aspect, the degree of pigmentation of the uveal melanoma, and associated signs Results: Factors significantly associated with poor prognosis were: a tumor location (p = 0.01), the infiltrative or fungus aspect (p = 0.001), a diameter equal to or larger than 10 mm (p = 0.003), the thickness greater than or equal to 5 mm (p = 10-3), achromatic or hyperpigmented melanomas (p = 0.02) and retinal detachment (p = 10-3). CONCLUSION: Clinical prognostic factors are important to know because they determine the evolutionary profile and the metastatic potential of the uveal melanoma.

[Results of congenital cataract surgery using 2,2 microincision in children before the age of 5 years]. / Résultats de la chirurgie de la cataracte congénitale par micro-incision cornéenne de 2,2 chez les enfants de moins de 5 ans.

BACKGROUND: Thanks to the recent advances of the microsurgical techniques, the results of the congenital cataract surgery in children less than 5 years old have considerably improved. However, the age of implantation and the intraocular lens power calculation remain subjects of controversies. AIM: To evaluate the results of 2.2 mm micro-incision congenital cataract surgery in children less than five years old. METHODS: Forty seven consecutive eyes of 26 children who had dense congenital cataract surgery were included in this retrospective study. All children had had the same surgical procedure: anterior approach through 2.2 mm corneal tunnel, posterior capsulorhexis associated to anterior vitrectomy and a primary foldable intraocular lens implantation. The final evaluation was at the same time anatomical and functional depending on the children age. RESULTS: The median patient age of the children was of 23 months (6 to 54 months) and the sex ratio was 1.36 (15 boys / 11 girls). The cataract was bilateral in 77.7 % of the cases (21/27 children). The intraocular lens was implanted in the capsular bag in 93.6 % of the cases (44/47 eyes) and in the sulcus in 6.3 % of the cases (3/47 eyes). The postoperative complications were mild: inflammatory reaction limited to the anterior chamber in 17 % of the cases (8/47 eyes), opacification of the visual axis with a reproliferation of the epithelial cells behind the implant was observed in 4.25 % of the eyes (2/47 eyes). We noted no case of intraocular lens decentration or secondary glaucoma. The study of the refraction at last follow up showed a sphere average of 2.73 ± 1.21 diopters and mean astigmatism of 1.51 ± 0.82 diopters. The median best corrected distance visual acuity, evaluated in 12 children, was 5.2/10 ranging from 1/10 to 10/10. The amblyopia was also noted to 12/26 children (46.1 %). Among these children, 11/12 (91.6%) had a delay of surgery and 5/12 (41.6 %) had an unilateral cataract. CONCLUSION: Currently the anatomical prognosis of the congenital cataract surgery in children less than 5 years old is getting closer to that of the adult. However, the functional prognosis remains still unpredictable depending mainly on the deadline of surgery which remains very late in our series. Thanks to the improvement of the surgical techniques using microincision in cataract surgery and the new generation of foldable implants, the anatomical and functional prognosis of the congenital cataract have significantly improved.

[Keratomycosis in the area of Tunis: epidemiological data, diagnostic and therapeutic modalities]. / Les kératites fongiques dans la région de Tunis: caractéristiques épidémiologiques, modalités diagnostiques et thérapeutiques.

Fungal keratitis is a serious disease involving the visual prognosis. This pathology is not well known in Tunisia. The aim of our study is to determine epidemiological data and clinical and mycological characteristics of fungal keratitis in the area of Tunis (North of Tunisia) and discuss its therapeutic modalities. This is a retrospective study including 19 cases of fungal keratitis collected over a period of 11 years (January 1998-December 2008). The diagnosis of keratomycosis was based on clinical and mycological data. Mycological examination interested corneal scraping including direct examination and culture. The cases of fungal keratitis concerned 13 men and 6 women with a mean age of 48.7 years. The most common risk factors was corneal trauma (47.4%). The mean delay between the first ophthalmic signs and consultation was 17.7 days. Most frequently fungal isolated fungi were Candida albicans (6 cases), followed by Aspergillus spp (5 cases) and Fusarium spp (4 cases). All patients received topical and systemical antifungal therapy. The evolution was favourable in six cases. Three patients retained corneal scars. The surgery was necessary in 7 cases, consisting of a penetrating keratoplasty (5 cases), an enucleating (1 case) and amniotic membrane transplantation (1 case). In conclusion, despite the improvement of diagnosis and treatment of fungal keratitis, its prognosis remains pejorative. This prognosis depends on early diagnosis and choice of antifungal therapy.

[Acanthamoeba keratitis: diagnosis to consider]. / La kératite amibienne: il faut y penser.

INTRODUCTION: Acanthamoeba keratitis is a rare but severe disease that can cause blindness. The objective of this study is to call attention to its severity and conditions of development and to emphasize the importance of early treatment. CASE REPORT: We report a case of a 27-year-old woman. After wearing soft contact lenses for a month, she consulted for redness, pain and poor visual acuity in her left eye. The ophthalmological examination showed an epithelial corneal abscess measuring 2 mm in diameter in the left eye and very tiny epithelial corneal abscesses in the right eye. Microscopic examination and culture of samples from the contact lenses and the contact lens solution found Acanthamoeba spp. Rapid anti-amoeba treatment led to disappearance of the corneal abscesses and improvement of her vision. CONCLUSION: This case confirmed that the prognosis of Acanthamoeba keratitis depends on rapid diagnosis and early treatment.