Pneumothorax in a young man with anorexia nervosa.

Primary spontaneous pneumothorax (PSP) is defined as a pneumothorax that occurs in the absence of an external cause in an individual without underlying generalized lung disease. A number of factors are important and should be carefully considered in the pathogenesis of PSP. This is the first case report of a PSP in a severely malnourished adolescent male with anorexia nervosa (AN) who was involved in excessive physical activity. Clinicians caring for adolescents with AN and vigorous exercise need to be aware of the risk factors associated with the development of a PSP. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:895-898).

Surgical management of orbital implant exposures after evisceration or enucleation: Retrospective study - Limoges University Hospital.

INTRODUCTION: Implant exposure is the most frequent complication after evisceration or enucleation, and multiple surgical techniques for the management of orbital implant exposure. The goal of our study is to investigate the success rate and risk factors for failure of various surgical procedures. METHODS: This was a retrospective study performed at the University Hospital of Limoges. We collected data from the files of every patient operated on for implant exposure between January 2005 and December 2020. The main criterion was the percentage of success for each procedure. Secondary objectives were to identify risk factors for failure of Müller's muscle flaps and to determine the incidence of post-enucleation socket syndrome depending on whether the orbital implant was maintained. RESULTS: Fifty-one patients were included: 26 patients who underwent Müller's muscle flap, 16 dermis-fat graft, 3 conjunctival flap, 2 amniotic membrane graft, 1 temporalis fascia graft, 1 buccal mucosa graft, 1 implant rotation, and 1 implant exchange. The dermis-fat grafts were more successful (87.5%) than the Müller's muscle flaps (52.2%) (P=0.0213). The study highlighted the importance of good vascularization of the implant (OR=32.00, P-value=0.0245) for the success of Müller's muscle flaps, and we found no statistically significant difference between the patients who maintained their implants and those who did not (P=0.3865) with regard to the incidence of post-enucleation socket syndrome. CONCLUSION: Müller's muscle flap may remain a reasonable option in the management of medium-sized implant exposures of well-vascularized implants confirmed on MRI in patients with no systemic healing disorders. Dermis-fat graft remains the option of choice in other cases, especially in large exposures or complicated orbits.

[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.

[The ground visual field assessment, using two methods, compared with Goldmann perimetry]. / Évaluation du champ visuel au sol, selon deux méthodes, comparée avec le champ visuel de Goldmann. Validation de l'évaluation du champ visuel au sol.

In visual rehabilitation, ground visual field assessment (GVFA) makes it possible to assess the size of scotomas in connection with locomotion and to restore the width of the patient's visual field (VF). The information obtained by these tests has never been compared with Goldmann testing. The purpose of this study was to assess the reproducibility of VF measurement under different conditions (Goldmann perimetry, manual and automated GVFA). Ten patients (51.4±14.0 years, 4 men and 6 women) with tunnel fields inferior or equal to the central 25°, performed three different versions of a binocular VF assessment: Goldmann perimetry, manual GVFA, and automated GVFA. The two versions of the GVFA were performed at 1m then 5m from the patient on the ground, and finally 5m away from the patient at eye level, facing the patient. The main outcome was the total perceived surface for each test. The reproducibility of the measurement was average or good for the test at 1m (ICC=0.685 to 0.866). Conversely, it was very poor between the tests at 5m, except for the automated and manual GVFA at 5m on the ground (ICC=0.888). This study shows good reproducibility of the GVFA measurements at 1m with less reproducibility at 5m, which can be explained by difficulties in the execution of the GVFA. Among the tests, the automated GVFA appears to be more reliable than the manual GVFA and is preferred by patients.

Direct genotyping of Toxoplasma gondii in ocular fluid samples from 20 patients with ocular toxoplasmosis: predominance of type II in France.

We report the direct genotyping analysis of Toxoplasma gondii in ocular samples collected from 20 patients, as well as associated clinical and epidemiological data. This work was aimed at better understanding the impact of genotypes of Toxoplasma gondii strains on toxoplasmic retinochoroiditis. For this purpose, we studied the aqueous humor (AH) or vitreous humor (VH) of 20 patients presenting with ocular toxoplasmosis (OT) in 2 hospitals in France. Genetic characterization was obtained with microsatellite markers in a multiplex PCR assay. In contrast to the results of previous studies, we found no association between atypical Toxoplasma gondii genotypes and the occurrence of OT. Considering the local epidemiological data, our OT patients seemed to be infected more frequently by ordinary type II strains found in the environment. In conclusion, direct genotyping of Toxoplasma gondii strains from aqueous or vitreous humor showed a predominance of the type II genotype in ocular toxoplasmosis; this may be due to a high exposure rate of this genotype in humans.

Benefits of a 14-year surgical site infections active surveillance programme in a French teaching hospital.

BACKGROUND: Surgical site infections (SSIs) are the second most common healthcare-associated infection. Active SSI surveillance can help inform preventative measures and assess the impact of these measures. AIM: We aimed to describe the evolution in trends over 14 years of prospective active SSI surveillance and implementations of SSI prevention measures in a French Teaching Hospital. METHODS: We monitored and included in the study all surgical procedures performed from 2003 to 2016 in eight surgical units. The semi-automated surveillance method consisted of weekly collection of SSI declaration forms (pre-filled with patient and procedure administrative data and microbiology laboratory data), filled-in by surgeons and then monitored by the infection control practitioners. FINDINGS: A total of 181,746 procedures were included in our analysis and 3270 SSIs recorded (global SSI rate 1.8%). The SSI rate decreased significantly from 3.0% in 2003 to 1.1% in 2016. This decrease was mainly in superficial SSIs and high infectious risk procedures. Higher SSI rates were observed for procedures associated with the usual risk factors. During this 14-year period, several evolutions in surgical practices occurred that might have contributed to this decrease. CONCLUSIONS: With an overall decrease in SSI rate throughout the surveillance, our results revealed the benefits of an active and comprehensive hospital SSI surveillance programme for understanding the SSI rate trends, analysing local risk factors and assessing the effectiveness of prevention strategies. These findings also highlighted the importance of the collaboration between surgeons and infection control practitioners.

[Congenital nasolacrymal duct obstruction: pulled monocanalicular intubation (Monoka) versus pushed monocanalicular intubation (Masterka)]. / Imperméabilité lacrymonasale simple de l'enfant : comparaison entre une intubation monocanaliculaire « tirée ¼ type Monoka versus intubation monocanaliculaire « poussée ¼ type Masterka.

INTRODUCTION: The primary cause of congenital epiphora, congenital nasolacrymal duct obstruction (CNLDO) affects 5 to 20% of newborns. In children over 12 months, it is currently recommended to treat with primary probing and intubation of the nasolacrymal duct under general anesthesia. The purpose of this study is to compare "pulled" monocanalicular intubation (Monoka) versus "pushed" monocanalicular intubation (Masterka). METHODS: This retrospective study included 73 children between 2014 and 2017 who presented with CNLDO with membranous (mucosal) obstruction. All procedures were performed under general anesthesia with endotracheal intubation. Children with CNLDO underwent either monocanalicular silicone intubation (Monoka) with classic nasal recovery or pushed monocanalicular intubation (Masterka) inserted via the canthus. Treatment success was defined as complete resolution of epiphora at two months after the procedure. RESULTS: Surgical outcomes were assessed in 53 eyes with Monoka and 20 eyes with Masterka intubation. The mean age at treatment was 25 months (range, 12-69 months) for the two groups. Treatment success was achieved in 19 of 20 eyes (95.0%) in the Masterka group compared with 50 of 53 eyes (94.0%) in the Monoka group. A tube loss occured in 14% of cases in both groups. CONCLUSION: In children over 12 months of age, the Masterka "pushed" monocanalicular intubation technique is an effective treatment for congenital nasolacrymal duct obstruction.

The use of anterior segment optical coherence tomography in evaluation of punctal stenosis.

PURPOSE: To evaluate the applicability of anterior segment optical coherence tomography (AS-OCT) for objective diagnosis of punctal stenosis. METHODS: We report the use of AS-OCT in 3 cases of epiphora related to punctal stenosis. We followed the methodology described in previous studies. The examination was performed by a single technician using a single Spectralis OCT with the AS-OCT module. Three patients with complaints of epiphora (mean age=80 years) were examined. The external punctal diameter was measured on both infrared (IR) and OCT images. The internal diameter was measured on OCT images at a depth of 500µm. The diagnosis was confirmed by clinical examination. RESULTS: The external punctal diameters were 159µm in the right eye (Cases 1 and 2) and 195µm in the left eye (case 2; mean: 171µm). All measurements were lower than cadaveric measurements (200-500µm), as well as previously described average diameters, thus confirming the diagnosis of punctal stenosis. The AS-OCT diameter correlated moderately with the punctal diameter estimate on the IR photos (mean: 183µm). In addition, the mean internal diameter of the punctum at 500µm (cases 1 and 2) was 58µm, which is consistent with the mean diameter at 500µm described in previous studies. Case 3 involved an 88-year-old man who complained of chronic epiphora. Slit lamp examination showed total punctal stenosis associated with cicatricial ectropion in the left eye due to a cutaneous tumor treated with radiotherapy. AS-OCT confirmed the presence of total punctual stenosis and the absence of associated canalicular stenosis. LIMITATIONS: Our study is obviously limited by its small study population. The decision to resort to surgery was made by 2 different surgeons. There was thus no homogeneity in terms of stenosis. There is difficulty in everting the lid without applying pressure to the globe or changing the punctal or canalicular morphology. This maneuver was difficult in the postoperative setting after ectropion repair. CONCLUSION: Our study shows that AS-OCT can be a rapid, non-invasive method in diagnosing punctal stenosis. Further studies are necessary to assess the use of AS-OCT in punctal stenosis.

Nephrocalcinosis in a young male with anorexia nervosa.

Nephrocalcinosis (NC) has been described as a long-term complication of anorexia nervosa (AN). This is the first report of this complication in an adolescent male patient. We describe the case of a 12-year-old male with AN who presented with acute food restriction and excessive exercising leading to three inpatient admissions. The patient experienced an isolated episode of dysuria and hematuria while on calcium and vitamin D supplementation. Investigations revealed hypophosphatemia, hypercalciuria and mild NC. Follow-up confirmed the presence of NC and possible nephrolithiasis (NL). We discuss the pathophysiology and risk factors of NC and NL in the context of an early presentation of AN. We suggest fluid intake should be liberalized under observation and calcium and vitamin D supplementation should be initiated with caution in patients presenting with AN and risk factors for NC and NL.

[Use of mitomycin C (MMC) for dacryocystorhinostomy interventions]. / Utilisation de la mitomycine C pour les interventions de la dacryocystorhinostomie.

Mitomycin C (MMC) has been described as having a positive effect in different types of dacryocystorhinostomy (DCR) surgery such as external DCR, endonasal and transcanalicular DCR. MMC, an antineoplastic antibiotic, acts as an alkylating agent by inhibiting DNA, RNA and protein synthesis. Topical use of MMC can modulate the scarring process, which is useful in glaucoma surgery and pterygium excision. In DCR, MMC is also useful because it reduces the scarring process and thus prevents the occlusion of the osteotomy site related to the fibroblast activity. An increase in the success rate for long-term results has been observed by different authors, resulting from a larger osteotomy size as well as a decrease in the density and cellularity of the mucosa. No complications have been seen with topical use of MMC.

[Rationale for a diagnostic approach in non-Graves' orbital inflammation--Report of 61 patients]. / Établissement d'un arbre décisionnel diagnostique dans les orbitopathies inflammatoires non basedowiennes chroniques--à propos de 61 patients.

INTRODUCTION: Orbital inflammatory syndromes include a wide variety of inflammatory intraorbital processes which are very different in terms of clinical presentation and prognosis. We currently prefer to differentiate so-called "specific" inflammations, for which an etiology is able to be identified, from idiopathic orbital inflammatory syndromes (IOIS), for which the etiology remains unknown and the histology is nonspecific. PURPOSE: To propose an efficient diagnostic approach for clinicians managing patients with non-Graves' orbital inflammations. MATERIALS AND METHODS: This is a retrospective and prospective study concerning 61 patients managed by the medical team for non-Graves' orbital inflammations between May, 1999 and May, 2013 in the ophthalmology departments of Nice and Limoges university hospitals in France. Seventeen specific inflammations, 19 orbital lymphomas and 25 idiopathic orbital inflammatory syndromes were included. Patients were divided into two groups. Thirty-six patients (group 1) underwent primary biopsy, while for the other 25 (group 2), therapy was begun empirically without biopsy. We could therefore compare both approaches in terms of diagnostic efficiency and time until identification of a specific etiology. RESULTS: Our statistical results show that an approach without primary biopsy leads to a number of specific diagnoses statistically much lower than that obtained by the approach with primary biopsy. Also, the risk of missing a specific inflammation (with as a consequence an inappropriate treatment and a risk of functional sequelae as well as a fatal risk of missing a lymphoproliferative pathology) is very clearly higher in the case of not performing primary biopsy. Finally, the average time elapsed between the initial consultation with the ophthalmologist and a specific diagnosis was one month in the case of the first approach, while this delay was almost three times higher with the second approach, with a mean of 2.91 months (P<0.01). DISCUSSION: Our study shows that biopsy should be the mainstay of diagnostic management. A trial of empiric treatment is only performed first in myositis or in locations where biopsy could jeopardize functional prognosis. It should only be done after biopsy in all other cases. Of course, in all cases of relapse or recurrence after treatment, biopsy should be performed or repeated. CONCLUSION: The diagnostic work-up of a patient with an orbital inflammatory process must of course include blood testing and orbital imaging, but also a systematic primary biopsy for histological examination in the vast majority of cases. It must be repeated at least in the case of any doubt about the diagnosis or in the case of any recurrence or resistance to treatment.

[Current treatments for corneal neovascularization]. / Traitements actuels de la néovascularisation cornéenne.

The extension of blood vessels into the normally avascular stroma defines corneal neovascularization. Though this phenomenon, pathophysiological and clinical features are well characterized, therapeutic modalities have been hindered by a lack of safe, efficacious and non-controversial treatments. In this literature review, we focus on available therapeutic options in light of recent evidence provided by animal and clinical studies. First, this review will focus on pharmacological treatments that target angiogenesis. The low cost and market availability of bevacizumab make it the first anti-angiogenic therapy choice, and it has demonstrable efficacy in reducing corneal neovascularization when administered topically or subconjunctivally. However, novel anti-angiogenic molecules targeting the intracellular pathways of angiogenesis (siRNA, antisense oligonucleotides) provide a promising alternative. Laser therapy (direct photocoagulation or photo-dynamic therapy) and fine needle diathermy also find a place in the treatment of stabilized corneal neovascularization alone or in association with anti-angiogenic therapy. Additionally, ocular surface reconstruction using amniotic membrane graft or limbal stem cell transplantation is essential when corneal neovascularization is secondary to primary or acquired limbal deficiency.

Visual outcomes with flow-diverter stents covering the ophthalmic artery for treatment of internal carotid artery aneurysms.

BACKGROUND AND PURPOSE: Flow-diverting stents can be used to treat intracranial aneurysms that are not amenable to treatment with coils. We analyzed ophthalmic consequences due to coverage of the origin of the ophthalmic artery by flow-diverting stents for the treatment of internal carotid artery aneurysms. MATERIALS AND METHODS: From April 2009 to April 2013, the clinical and angiographic outcomes of all 28 patients treated for aneurysms with flow-diverting stents covering the origin of the ophthalmic artery were prospectively collected. The origin of the ophthalmic artery in relation to the target aneurysm was classified by using a 4-type classification. A complete ophthalmic examination was performed by a single ophthalmologist 48 hours before and 1 week after covering the ophthalmic artery. RESULTS: Ophthalmic artery patency was normal at the end of endovascular treatment in 24/28 cases (85.7%). With extensive ophthalmic examinations, 11 patients (39.3%) showed new ophthalmic complications. Patients with the ophthalmic artery originating from the aneurysm sac were at high risk for retinal emboli (4/5, 80%). Patients with the ophthalmic artery originating from the inner curve of the carotid siphon were at high risk for optic nerve ischemic atrophy (3/4, 75%). CONCLUSIONS: This prospective study shows that covering the ophthalmic artery with a flow-diverting stent is not without potential complications. Ophthalmic complications can occur but are often not diagnosed. The anatomic disposition of the ophthalmic artery in relation to the carotid siphon and aneurysm should be clearly understood because some configurations have a higher risk. When not required, covering of the ophthalmic artery by flow-diverting stents should be avoided.

Risk factors for visual loss in giant cell (temporal) arteritis: a prospective study of 174 patients.

OBJECTIVE: To determine the risk factors--especially the effects of thrombocytosis--for permanent visual loss in patients with temporal arteritis. METHODS: One hundred seventy-four patients with temporal arteritis (147 biopsy proven) were prospectively observed for the development of permanent visual loss. We used multivariate logistic regression analysis to determine which of 17 pretreatment characteristics were associated with visual loss. RESULTS: Visual ischemic manifestations occurred in 48 (28%) patients, including permanent visual loss in 23 (13%) patients. The independent predictors associated with an increased risk of permanent visual loss were a history of transient visual ischemic symptoms (odds ratio [OR] = 6.3; 95% confidence interval [CI]: 1.4 to 29; P = 0.02) and a higher platelet count (OR = 3.7 per SD; 95% CI: 1.8 to 7.9; P = 0.001). The presence of constitutional symptoms (OR = 0.14; 95% CI: 0.02 to 0.77, P = 0.01), polymyalgia rheumatica (OR = 0.04; 95% CI: 0.01 to 0.48, P = 0.02), and C-reactive protein level (OR = 0.35 per SD; 95% CI: 0.13 to 0.92, P = 0.03) were associated with a reduced risk. Upper limb artery involvement was excluded from the multivariate model, as no patients with that problem developed permanent visual loss. Of the 87 patients who presented with thrombocytosis (platelet count >400 x 10(9)/L), 32 (37%) developed ischemic visual symptoms, compared with 16 (18%) of those without thrombocytosis. CONCLUSIONS: An elevated platelet count is a risk factor for permanent visual loss in temporal arteritis. The finding of thrombocytosis in a patient with suspected temporal arteritis should emphasize the need for urgent treatment, with consideration of using inhibitors of platelet aggregation or anticoagulation therapy.

Comparative review of topical ophthalmic antibacterial preparations.

The choice of an antibacterial is based on considerations of pharmacodynamic, pharmacokinetic and bacteriological characteristics, risk of selecting resistant mutants, and cost. In this article we review 16 commercially available ophthalmic antibacterial preparations. Fusidic acid and bacitracin are selective for gram-positive bacteria whereas polymyxin B targets gram-negative species. Aminoglycosides and quinolones are broad spectrum antibacterials. The widespread use of an antibacterial increases risks of selecting resistance to it. Acquired resistance is well documented for fusidic acid and rifamycin, and newly described for quinolones. The bioavailability of an antibacterial agent depends on the target bacterial species, the site of infection and the integrity of the haemato-aqueous barrier. Some agents (fusidic acid, quinolones) penetrate the cornea, passing into the anterior chamber of normal eyes at therapeutic concentrations, whereas others (polymixin B, bacitracin) have no penetrating powers and remain at the surface of the eye. Toxicity is mostly manifested by allergic reactions to excipients or active ingredients in topical antibacterial preparations. A few cases of haematological toxicity have brought suspicion on topical chloramphenicol, but the link has yet to be proven. Erythromycin and polymyxin B are probably okay to use as topical applications in pregnant women and nursing mothers. Costs of treatment must be evaluated as a whole (regimen, drug associations). Prices for a bottle of eyedrops may vary 3-fold. The cheapest drugs include chloramphenicol, polymyxin B and gentamicin, the most expensive being fusidic acid and the quinolones.

Anterior chamber concentrations of vancomycin in the irrigating solution at the end of cataract surgery.

PURPOSE: To verify that therapeutic levels of vancomycin were present in the irrigating solution at the end of cataract surgery. SETTING: Service d'ophtalmologie, Université de Limoges, France. METHODS: An irrigating solution that contained 20 mg/L of vancomycin was used in 15 patients having phacoemulsification. Antibiotic concentrations in the phacoemulsification handpiece and in the aqueous humor were measured at the end of surgery. RESULTS: Passage through the phacoemulsifier did not affect antibiotic concentration. In the aqueous humor, after wound closure, the concentration constantly exceeded the minimal inhibitory concentration of the principal gram-positive bacteria responsible for human endophthalmitis. CONCLUSION: Vancomycin added to the irrigating solution used during cataract surgery was found in effective concentrations in the anterior chamber at the end of surgery.

Abnormalities of orbital volume.

New information on the physiopathology and treatment of orbital volumes pathologies is described: 1) In post-enucleation or evisceration socket syndrome placing of synthetic material (HA-TCP) directly in the intraconal orbital fat can correct most of the symptoms. However the best approach is to prevent orbital volume deficiencies during first surgery using an implant large enough to allow a future prosthesis of a volume less than 2 mL. New procedures for placing the implant after enucleation or evisceration are described. 2) In proptosis related to Graves' orbitopathy relative indications are given for orbital decompression by removal of fat or bone.