[Using the superficial temporal fascia flap in orbital surgery]. / Utilisation du lambeau de fascia temporalis superficialis en chirurgie orbitaire.

The superficial temporal fascia flap gives a fine malleable well vascularized tissue and can be used as a pedicled or a free flap to cover large areas of loss of substance. Its dissection needs a period of training. Its use in orbital surgery is rare. However when it is about an anophthalmic socket following radiotherapy with orbital retraction syndrome, it provides tissue of good quality. This could allow later reconstruction by mucous grafts. When used on cavities of exenteration it allows fast re-epithelialisation even post-radiotherapy, while allowing the monitoring of the cavity and in particular the early detection of any tumor recurrence. Its use is advantageous in unfavorable conditions especially after radiotherapy.

[Comparison of available clinical and imaging tools to assess good positioning of a fluocinolone acetonide implant (Iluvien®) in the vitreous cavity after injection]. / Comparaison des moyens clinique et d'imagerie disponibles en pratique clinique pour objectiver la présence de l'implant d'acétonide de fluocinolone (Iluvien®) dans la cavité vitréenne après injection.

INTRODUCTION: Sustained-release corticosteroid implants are injected into the vitreous cavity using preloaded pens. The fluocinolone (FAc) implant is approximately half the size of the dexamethasone implant (Dex-I). It is simply introduced in the vitreous base rather than propelled into the vitreous cavity as is Dex-I. Verification of its positioning after injection is thus difficult by indirect ophthalmoscopy. The goal of our study is to compare the performance of available clinical and imaging tools to confirm the presence of the FAc in the vitreous cavity following injection. METHODS: Twelve eyes of 12 consecutive patients were included in a retrospective, single-center, observational study carried out at the Bordeaux University Hospital, France. All patients were injected with the FAc after pupil dilation, and presence of the implant was immediately checked by indirect biomicroscopy, wide-field retinography (Clarus®, Carl-Zeiss-Meditec, Dublin, CA, USA) and ultra-wide-field retinography (California®, Optos, Edinburgh, United-Kingdom). Seven days later, a B-mode ultrasonography (10MHz, AVISO, Quantel-medical, France) and an UBM ultrasonography (50MHz, AVISO, Quantel-medical, France) were performed. RESULTS: Indirect biomicroscopy and wide-field retinography detected 4/12 implants (33.3%). Ultra-wide-field retinophotography detected 6/12 implants (50%). All the implants seen using indirect biomicroscopy and wide-field retinography were also visualized with ultra-wide-field. B-mode ultrasonography showed 5/12 implants (41.6%) and UBM 9/12 implants (75%). Finally, one implant dislocated into the anterior chamber and was seen in the iridocorneal angle on gonioscopy. CONCLUSION: Objective confirmation of the proper positioning of the FAc implant in the vitreous cavity is mandatory. If both indirect ophthalmoscopy and anterior examination fail to detect it, ultra-wide field retinography along with UBM ultrasonography, if necessary, appear to be the two best imaging modalities to use.

Choroidal granulomas due to Bartonella henselae infection: A case series.

PURPOSE: To report a case series of 3 patients with choroidal granulomas due to Bartonella henselae infection in order to raise awareness about this etiology in the differential diagnosis of choroidal granulomas. METHODS, PATIENTS: A retrospective case series of patients with choroidal granulomas due to Bartonella henselae infection who consulted between 2018 and 2020. Data were collected from the medical records (demographics, visual acuity (VA), laboratory tests, treatment, imaging). RESULTS: Patients were a 48-year old man, a 14-year old girl and a 31-year old man. They all had a choroidal granuloma seen on optical coherence tomography (OCT) and angiography. The laboratory work-up revealed a positive serology for Bartonella henselae in all patients. CONCLUSION: On multimodal imaging choroidal granulomas in B Henselae appeared as single or multiple, uni or bilateral round yellowish lesions. Fluorescein and indocyanine green angiography of the granuloma showed respectively a late staining and a hypofluorescence. On EDI-OCT choroidal granuloma appeared as a round hyporeflective lesion in the choroid with a retinal elevation. The exclusion of other diagnosis, the natural course and the serology must lead the ophthalmologist to evoke the diagnosis.

[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.

[Intravitreal clindamycin injection in toxoplasma retinochoroiditis: About 9 cases in the ophthalmology department of the CHU de Bordeaux]. / Injection intravitréenne de clindamycine dans le traitement des rétinochoroïdites toxoplasmiques : à propos de 9 cas dans le service d'ophtalmologie du CHU de Bordeaux.

INTRODUCTION: Toxoplasma retinochoroiditis (TRC) is the main cause of posterior uveitis in immunocompetent patients. Several studies have shown safety and efficacy of treatment with intravitreal clindamycin injection in patients with contraindications, inadequate response or side effects with classic oral therapy. The goal of this study is to describe anatomic and functional results of local treatment with intravitreal clindamycin injection. MATERIALS AND METHODS: We performed an observational, retrospective, single-center study in the ophthalmology service of Bordeaux university medical center between December 2017 and January 2020 on management of toxoplasma retinochoroiditis by intravitreal clindamycin injection. We analyzed the efficacy of this treatment on improvement in visual acuity, decrease in size of the retinal lesion and decrease in macular thickness. RESULTS: A total of 10 eyes of 9 patients were injected. Only a single injection was required in 9 of the 10 cases. Injections demonstrated improvement in the 3 study criteria; visual acuity went from a mean of 1 LogMAR (1.07±0.77) pre-injection to 0.4 LogMAR (0.43±0.53) at 6 months, lesion size decreased by 51%, and macular thickness decreased by 78µm over the follow-up period. CONCLUSION: Intravitreal clindamycin injections are safe and effective for the treatment of TRC. They offer an alternative in patients with allergies, side effects or inadequate response to classic oral therapy.

[Long term outcomes of botulinum toxin injections in infantile esotropia]. / Évaluation a long terme de l'éfficacité de la toxine botulique dans l'ésotropie precoce.

PURPOSE: To evaluate long terms outcomes of botulinum toxin in infantile esotropia by measuring the amount of microtropia 24 months after injection. Secondary purpose was to identify predictive factors of microtropia. METHODS: A retrospective, single-center study was performed at the university medical center in Bordeaux between 2001 and 2018, including all patients with infantile esotropia greater than 20 D. All patients received 5 or 7,5 IU of botulinum toxin A in each medial rectus, once or twice depending on the angle of deviation after the first injection and after wearing full optical correction at least two months. We noted the angle at 1, 6, 12 and 24 months, the occurrence of any complications and the need for later strabismus surgery. The primary endpoint was the achievement of a microtropia less than 8 diopters (D) at 24 months post-injection. We evaluated the predictive factors for microtropia with a Fischer's test. RESULTS: We included 30 patients with esotropia greater than 20 D. The mean follow-up after injection was 48 months ±30. The mean age was 16.24 months (7-29 months) with a female predominance in the population (SR=0.43). The mean pre-injection deviation was 41.25±12.17 D. The majority of patients were mildly (40%) or moderately (40%) hyperopic. At 24 months, 46.7% microtropias were obtained (95% CI: 28.9%-64.5%). The change in mean angle at 1, 6, 12 and 24 months post-injection was -8.57±25.21 D; 14.48±13.40 D; 18.38±12.07 D and 21.23±14.97 D, respectively. No factors were predictive of microtropia. Of the 30 children, 3 had transient ptosis requiring strips and 12 showed an exotropia at 1 month. All complications were self-limited and without consequences. 3 children had a second injection of botulinum toxin, which in 2/3 of the cases resulted in a long-lasting microtropia. 26.7% (n=8) of the children underwent secondary surgery. Obtaining a microtropia 24 months after injection statistically significantly reduced the need for secondary strabismus surgery: 92.9% P=0.039% CI 95% (0.002; 1.0606). CONCLUSION: Botulinum toxin appears to be a less invasive and more conservative alternative to surgery in children with infantile esotropia. In 46.7% of cases, microtropia is achieved. An improvement was noted in 90% (n=27) of the children with a reduction of half (21.23 D) of the mean post-injection angle at 24 months. When effective, it significantly reduces the need for secondary surgery.

Diabetic retinopathy in well-controlled type 2 diabetes: Role of glycaemic memory.

AIMS: As diabetic retinopathy (DR) can occur even in well-controlled patients with type 2 diabetes (T2D), our study sought to determine whether it might be related to 'glucose memory' by evaluating patients' HbA1c over previous years and their skin autofluorescence (SAF). METHODS: In 334 patients with T2D and HbA1c levels≤8%, their available values of HbA1c from previous years were collected, and their SAF measured by an advanced glycation end-product (AGE) reader. Binary logistic regression analysis was then used to correlate DR with previously recorded HbA1c levels and to SAF, with adjustment for DR risk factors [age, gender, BMI, duration of diabetes, arterial hypertension, diabetic kidney disease (DKD), blood lipid levels and statin treatment]. RESULTS: Our patients were mostly men (58.4%) aged 63±10years, with a duration of diabetes of 13±10years and HbA1c=7.1±0.7%. Of these patients, 84 (25.1%) had DR, which was associated with longer duration of diabetes and greater prevalence of DKD. A total of 605 HbA1c values from previous years were collected for time periods -4±3 months (n=255), -16±4months (n=152), -30±4months (n=93) and -62±26 months (n=105). After adjustment, the association between DR and having an HbA1c higher than the median was significant only for the oldest previous HbA1c values: OR=6.75, 95% CI: 1.90-23.90. Moreover, SAF values were higher in those with DR [2.95±0.67 arbitrary units (AU)] vs 2.65±0.65 AU with no DR (P<0.01) and were also associated with the oldest previous HbA1c values (P<0.01). CONCLUSION: Our study found that 25.1% of our well-controlled T2D patients had DR, which was related to both their HbA1c levels from 5years prior to study admission and their SAF values, a marker of glucose memory.

[Cataract surgery in children with non-infectious uveitis: Review of current practices in France]. / Chirurgie de la cataracte uvéitique non infectieuse de l'enfant : bilan des pratiques actuelles en France.

PURPOSE: To evaluate the medical-surgical management of cataract surgery in children with chronic uveitis in various French pediatric ophthalmology centers. MATERIALS AND METHODS: Two-part study: first, a descriptive observational segment on the evaluation of French practices. A questionnaire was sent to the various pediatric ophthalmologists in France. A second retrospective chart review, including children with non-infectious chronic uveitis who had cataract surgery in the pediatric ophthalmology department of Bordeaux University Hospital from 2008 to 2017. RESULTS: Twenty-one ophthalmologists responded to the questionnaire. Only 23.8% systematically initiated immunosuppressive drugs (aside from corticosteroids) before surgery. A total of 88.2% prescribed oral corticosteroid treatment preoperatively. Eleven surgeons administered intravenous corticosteroid boluses during the surgery, and primary lens implantation is the most common method used in 95.2%. A total of 76.2% initiated oral steroid therapy after surgery. Postoperatively, all surgeons started local therapy with high-dose corticosteroids. At one year, 100% achieved improvement of visual acuity greater than or equal to 2 lines. On our service, 10 eyes (7 children) underwent cataract surgery. Seven were treated with systemic immunosuppressive drugs (aside from corticosteroids) and 80% of cases received oral corticosteroid therapy a few days before surgery. An intravenous corticosteroid bolus was administered preoperatively in 8 cases, and primary lens implantation was performed in 100% of cases. Postoperatively, 5 children received oral corticosteroid treatment. All were treated with local high dose steroids. At one year, the mean best-corrected visual acuity was 0.18 LogMar (0-0.7, SD: 0.25). CONCLUSION: When performed with an aggressive anti-inflammatory protocol, cataract surgery leads to a good visual outcome in selected children with chronic uveitis.

Bilateral macular detachment caused by bilateral optic nerve malformation in a papillorenal syndrome due to a new PAX2 mutation.

PURPOSE: Papillorenal syndrome is an autosomal dominant entity due to PAX2 gene mutation, involving optic nerve and renal malformations. METHODS: The authors report a 19-year-old man with bilateral macular detachment associated with optic nerve pit in one eye and morning glory syndrome in the other eye. The patient underwent three-port pars plana vitrectomy, endolaser photocoagulation, and C3F8 gas tamponade in his best eye. A medical history of vesicoureteric reflux and kidney hypoplasia led to genetic analysis. RESULTS: Molecular genetic PAX2 analysis revealed a novel nondescribed mutation in exon 3. One year postoperatively, ophthalmologic outcomes were satisfactory with complete flattening of the retina and improvement of the best-corrected visual acuity to 11/10. CONCLUSIONS: PAX2 is involved in the optic vesicles, genital tracts, kidney, and central nervous system embryogenic development. The association of optic nerve and renal malformations should lead to the suspicion of papillorenal syndrome with PAX2 mutation.

[Role of en face OCT in the diagnosis of syphilitic placoid chorioretinitis]. / Apport de l'OCT en face dans le diagnostic de la syphilis phacoïde oculaire.

INTRODUCTION: This is a retrospective case series of three patients presenting with syphilitic chorioretinitis. The diagnosis of syphilis rests on the ophthalmologic clinical exam as well as serologic confirmation. We studied the en face and SD-OCT images upon first consultation and after one month of antibiotic treatment with penicillin G. RESULTS: Four eyes of three male patients between 40 and 60 years of age all diagnosed with syphilitic placoid chorioretinitis were studied by en face OCT. Visual acuities upon initial presentation were unrecordable. On all the en face OCT examinations of the three patients, numerous small hyperreflective oval lesions were observed within the ellipsoid line and the retinal pigment epithelium around the macula. These lesions corresponded to small elevated nodules in the retinal pigment epithelium and interruptions in the ellipsoid line observed on SD-OCT. One month after treatment for neurosyphilis, the visual acuity had improved, and the outer retinal lesions had partially reversed in these eyes. CONCLUSIONS: We documented the characteristic lesions of syphilitic placoid chorioretinitis by en face OCT. En face OCT allows a more precise approach to the outer retina for diagnosis and follow-up as well as in understanding the pathophysiology of the disease.

[Refractive outcomes and precision in toric intraocular lens alignment using an automated alignment system]. / Résultats réfractifs et évaluation de la précision du positionnement des implants toriques à l'aide d'un système d'alignement automatisé.

PURPOSE: To compare precision in toric intraocular lens (TIOL) alignment and refractive outcomes between an intraoperative automated digital marker system and the conventional manual-ink marking. MATERIALS AND METHODS: Prospective single center study including consecutive patients undergoing uneventful cataract surgery with corneal astigmatism greater than 1 diopter. Total corneal astigmatism was measured using a placido-dual Scheimpflug system (GalileiG4®, Ziemer). Acrysof® SN6AT (Alcon) TIOL's were implanted, and patients were divided into 2 groups, the digital group (Verion®, Alcon) and the ink-marking group (Pendular marker, AMO). Mean error in TIOL axis, visual acuity and residual astigmatism were analyzed at 3 days, one month and 6 months after surgery. RESULTS: In total, 45 eyes of 30 patients were included (n=25 digital group, n=20 ink-marking group). The mean preoperative total corneal astigmatism was 1.71±0.53 diopters. At one month, there was a significantly lower mean average error in TIOL axis in the digital group compared to the ink-marking group (2.6±2.3° and 6.4±2.8° respectively, P=0.009). At 6months, these results remained statistically significant. Mean residual astigmatism was 0.7±0.4 diopters at one month, without significant difference between the two groups (P=0.9). The rate of misalignment less than or equal to 5° was 86 % (n=25) in the digital group and 63 % (n=20) in the ink-marking group (P=0.05). CONCLUSION: Intraoperative digital marker system is associated with better TIOL alignment accuracy and better reproducibility than the manual ink-marking method.

Screening for retinopathy of prematurity by telemedicine in a tertiary level neonatal intensive care unit in France: Review of a six-year period.

PURPOSE: To analyze the prevalence and risk factors for retinopathy of prematurity (ROP) and severe (treatment-requiring) ROP. METHODS: A retrospective study was conducted in a level III neonatal unit in Bordeaux, France, from 2009 to 2015. Four hundred and nineteen preterm infants who were screened for ROP exclusively by RetCam were included. RESULTS: ROP of any degree was diagnosed in 27.68% of infants. Stages 1, 2, 3 and 4 ROP was found in 44%, 46%, 9% and 1% of subjects, respectively. No stage 5 ROP was observed. 28/419 infants (6.6%) were treated exclusively with laser photocoagulation. No intravitreal anti-VEGF injections or surgical treatments were performed. No infants born at>31 weeks or with BW>1110g required ROP treatment. On multivariate analysis, risk factors for ROP development were low birth weight, low gestational age at birth, high duration of invasive mechanical ventilation, shock or use of vasopressors. On multivariate analysis, risk factors for severe, treatment-requiring ROP were male gender, gestational age≤27 weeks and Apgar score at 5minutes≤7. CONCLUSION: In our 6-year series, ROP was successfully identified on screening exclusively by telemedicine, and no surgical treatment was required. This study identifies known ROP risk factors, but the Apgar score at 5minutes as a risk factor for severe ROP requires further studies in order to be confirmed.

Types of choroidal neovascularisation in newly diagnosed exudative age-related macular degeneration.

AIM: To describe the types and location of choroidal neovascularisation (CNV) in exudative age-related macular degeneration (AMD), including vascularised pigment epithelial detatchments (PED), and most recently described subtypes, such as retinal choroidal anasmostosis, also termed "retinal angiomatous proliferation" (RAP). METHODS: Prospective multicentre consecutive descriptive case series. A total of 207 consecutive cases of newly diagnosed exudative AMD undergoing fluorescein angiography (FA) were recruited by 7 French referral hospital-based or private centres. Indocyanine green angiography (ICG) also was performed, when judged necessary by investigators. Types and location of CNV were classified by two independent experts and adjudicated by a third when discordant. RESULTS: All patients had FA, while ICG was performed in 50% of subjects. A total of 17.6% had classic CNV only, 5.4% and 8.3% had predominantly and minimally classic CNV, respectively. Occult CNV could be classified in occult CNV without PED (32.7%) and occult CNV with PED, ie, vascularised PED (23.9%). RAP was observed in 15.1% of cases, and accounted for 30% of vascularised PED. In 5.8% of the cases there was haemorrhagic AMD and 4.8% had fibrovascular scars. Lesions were mainly subfoveal (80%). Agreement between the centre's ophthalmologist and the final validated expert classification was moderate (kappa = 0.52 for location and 0.59 for type of lesion). CONCLUSION: This study confirms that newly diagnosed cases of exudative AMD are mainly occult and subfoveal. RAP appeared as a common lesion in patients with newly diagnosed exudative AMD.

OCT angiography of acute non-arteritic anterior ischemic optic neuropathy.

PURPOSE: To describe changes of the retinal peripapillary microvasculature on optical coherence tomography angiography (OCT-A) in non-arteritic anterior ischemic optic (NAION) neuropathy. METHODS: Observational study of 10 patients at the acute phase of NAION. OCT-A was performed using a 3mm×3mm square centered on the optic disc (Cirrus HD-OCT with Angioplex, Carl Zeiss Meditec, Dublin, CA). A qualitative comparison was made with the healthy fellow eye of each patient. All patients had a fluorescein angiography (HRA2, Heidelberg, Germany) and a visual field examination (Octopus 101®, Haag-Streit, USA). RESULTS: In the affected eyes, OCT-A showed clear modifications in the radial peripapillary network. In all these eyes, a focal disappearance of the superficial capillary radial pattern was present, twisted and irregular. In 8 eyes, there was also a lack of vascularization in some focal areas, appearing as dark areas. No correlation was found between the topography of the vascular alteration shown on OCT-A and visual field pattern defects. CONCLUSIONS: OCT-A is a new imaging technology able to demonstrate easily and safely the changes in the peripapillary capillary network during the acute phase of NAION. These changes are likely related to a decrease of the prelaminar optic nerve blood flow during the acute phase of NAION. Visual field defects are not correlated with OCT-A images, suggesting that they may be due mainly to disturbances in posterior ciliary artery blood flow.