Excimer laser programming of refractive astigmatism vs. anterior corneal astigmatism in the case of ocular residual astigmatism (ORA).

PURPOSE: To determine whether manifest refractive astigmatism (RA) or anterior corneal astigmatism (CA) is the best value for excimer laser programming in cases of ocular residual astigmatism (ORA). PATIENTS AND METHODS: Patients who had undergone LASIK surgery with a disagreement between manifest refractive and corneal cylinder (ocular residual astigmatism ORA)>0.75 D were included retrospectively in this study. We calculated target induced astigmatism vector (TIA), surgically induced astigmatism vector (SIA), difference vector between the astigmatism correction programmed in the excimer laser and refractive astigmatism (DVRA), difference vector between the astigmatism correction programmed in the excimer laser and corneal astigmatism (DVCA) and difference vector between TIA and SIA (DV), by the Alpins method. Vectorial differences between DV and DVRA, and between DV and DVCA, were then calculated to determine whether RA or CA was closest to the ideal cylinder for laser programming. RESULTS: Of a total of 104 eyes undergoing LASIK, 22 eyes of 12 patients (21.1%) had an ORA>0.75 D and were included. Mean ORA was 0.9±0.2 D and mean postoperative subjective cylinder was 0.45 D. The DV-DVRA difference vector was 0.57±0.2 D, and the DV-DVCA difference vector was 0.86±0.4 D (P=0.02). RA was closer than CA to the ideal astigmatism correction. CONCLUSION: In cases of discrepancy between manifest astigmatism and corneal astigmatism, correction of manifest refractive astigmatism seems to give a better refractive result.

[In vivo confocal microscopy evaluation of corneal changes induced after LASIK using the IntraLase femtosecond laser technique]. / Evaluation en microscopie confocale des modifications morphologiques cornéennes induites après LASIK et découpe du volet stromal par laser femtoseconde IntraLase.

PURPOSE: To assess stromal modifications occurring after IntraLase femtosecond laser for laser in situ keratomileusis (LASIK) using the Heidelberg retina tomograph II/Rostock cornea module. MATERIAL AND METHODS: Twelve eyes from six patients were examined using the Heidelberg retina tomograph II cornea module after IntraLase femtosecond laser: ten eyes were examined at 1 week and 2 months after laser surgery, including four eyes examined at day 1, and two eyes examined at day 2. Morphological modifications of the corneal stroma, flap interface, and flap margin were evaluated at these different times and compared with the mechanical microkeratome interfaces of five patients (ten eyes), using the same technique at the same periods after the surgical intervention. RESULTS: Evaluations at days 1 and 7 showed simultaneous depletion and activation of keratocytes on both sides of the interface. We also observed some brightly reflecting particles together with scattered, less bright dots, from day 7 and increasing after 2 months. Some clinically visible deposits at the level of the interface were observed at the periphery of the flap at day 1 and could represent cell-degradation products. With confocal microscopy, they appeared as homogeneous reflective deposits with a larger size than that of particles; they had decreased at month 2. The flap margin appeared microscopically as a very clear-cut edge, including epithelial cells, while those performed with a mechanical microkeratome appeared more like a poorly limited fibrotic scar. We also observed a secondary fibrotic reaction at month 2, adjacent to the still well-defined IntraLase flap edge. CONCLUSION: This study showed substantial morphological similarity between the interfaces obtained with femtosecond laser and mechanical microkeratome. The discovery of brightly reflecting particles in the IntraLase interface goes against the hypothesis of the metallic origin of these deposits. The flap margin microscopically looked extremely well delimited, but seemed to provoke an adjacent secondary fibrotic reaction, both microscopically and macroscopically, greater at 2 months than after a mechanical microkeratome cut.

[Postoperative endophthalmitis: 2000-2002 results in the XV-XX National Ophthalmologic Hospital]. / Infections nosocomiales endoculaires au CHNO des XV-XX de 2000 à 2002.

PURPOSE: Prevention of nosocomial infection is a priority for the Infection Control Committee (ICC). Following their recommendations, the XV-XX National Ophthalmologic Hospital's ICC conducted a survey on cases of infection and we report these results for the 2000-2002 period. METHODS: During the 2000-2002 period, 21,384 programmed intraocular surgeries were done. Every day, a hygiene coordinator was informed of each bacterial or fungal laboratory test on intraocular samples and for all patients who were hospitalized for endophthalmitis. After data analysis with a referent ICC physician, resulting infection was declared postoperative nosocomial endophthalmitis. For these patients, prophylactic antibiotic use, the surgery report, and bacterial laboratory test results were reviewed. RESULTS: The overall 3-year incidence of suspected postoperative endophthalmitis after intraocular surgery was 2.0 per 1000 (42 cases). Confirmed microbiological growth was demonstrated in 19 cases (45%). For cataract surgery, the incidence was 1.0 per 1000 for acute-onset culture-proven postoperative endophthalmitis, 0.1 per 1000 for delayed culture-proven postoperative endophthalmitis, 2.1 per 1000 for acute-onset suspected postoperative endophthalmitis and 0.5 per 1000 for delayed suspected postoperative endophthalmitis. Gram-positive cocci were isolated in 77%. Twenty-one patients received systemic prophylactic antibiotics. Bacterial growth was positive in five of these 21 cases. For two cases, organisms were resistant to the prophylactic antibiotics used. CONCLUSION: Monitoring postoperative nosocomial infection is mandatory to detect incidence variation and evaluate infection control management. Prophylactic antibiotic efficacy remains to be evaluated.

[Femtosecond laser-assisted cataract surgery]. / Chirurgie de la cataracte assistée par laser.

Femtosecond laser-assisted cataract surgery is a major technological innovation. The femtosecond laser, during a pretreatment step, helps to prepare the patient's eye for the surgery proper by creating corneal incisions, anterior capsulotomy and lens fragmentation in an automated fashion. Thus, these steps can be performed with precision and reproducibility, and lens fragmentation reduces the amount of ultrasound required during surgery. Drawbacks of this technology are a longer operating time, a more demanding surgical procedure and a much higher cost for patients and surgical centers. New models of organization in the operating room, patient flow, and financial systems have to be designed to adapt this procedure to our practice. The benefits of this technology should make it an essential tool in the future, provided that cataract surgery can be reconsidered logistically and economically.

[Imaging of corneal dystrophies: Correlations between en face anterior segment OCT and in vivo confocal microscopy]. / Imagerie des dystrophies cornéennes : corrélations entre l'OCT en face de segment antérieur et la microscopie confocale in vivo.

PURPOSE: To evaluate the usefulness of en face Optical Coherence Tomography (OCT) for evaluation of corneal dystrophies and to describe correlations with in vivo confocal microscopy (IVCM). PATIENTS AND METHODS: Thirty-two eyes of 16 patients with 4 types of corneal dystrophies (epithelial basement membrane dystrophy, Fuchs dystrophy, Reis-Bücklers corneal dystrophy and Crocodile Shagreen dystrophy) were enrolled in this study. Axial and reconstructed en face scans were acquired using OCT. Images were then correlated to IVCM findings. RESULTS: En face OCT provided new insights into the structure, size and depth of corneal tissue alterations in various corneal dystrophies. OCT en face images were well correlated with IVCM features. Despite lower resolution than IVCM, en face OCT offers the advantages of being non-invasive and allowing the analysis of larger corneal areas. CONCLUSION: En face OCT provides useful new information in corneal dystrophies. This imaging technique will probably increase in popularity in the near future for the assessment of various anterior segment diseases.

Sub-Tenon's anaesthesia: an efficient and safe technique.

AIM: To evaluate sub-Tenon's anaesthesia as an alternative to peribulbar anaesthesia. METHODS: 109 consecutive patients listed for various eye operations (including cataract, trabeculectomy, and vitrectomy) under peribulbar anaesthesia were operated on under sub-Tenon's anaesthesia instead. After topical anaesthesia a buttonhole was fashioned through the conjunctiva and Tenon's capsule 10 mm posterior to the limbus. 1.5 ml of lignocaine 2% was then delivered to the posterior sub-Tenon's space using a blunt cannula. The surgical procedure was performed immediately after the completion of the anaesthetic procedure. Chemosis, conjunctival haemorrhage, degree of akinesia, and pain scoring were analysed. RESULTS: There were no anaesthesia related complications. The administration of the block was painless for 99.1% of the patients. In all, 97.3% reported no pain during surgery. There was no akinesia when assessed just after the completion of the block and akinesia was limited when assessed after surgery. Chemosis and conjunctival haemorrhage were frequent but caused no intraoperative problems. CONCLUSION: Sub-Tenon's anaesthesia is an efficient and safe anaesthetic technique. It is a good alternative to peribulbar anaesthesia.

Topical versus peribulbar anesthesia in cataract surgery.

PURPOSE: To compare the use of topical anesthesia with that of peribulbar anesthesia in cataract surgery. SETTING: Quinze-Vingts Hospital, Paris, France. METHODS: This prospective study comprised 45 patients who had phacoemulsification and intraocular lens implantation in both eyes with 1 to 9 months between surgeries. Each patient had peribulbar anesthesia for one surgery and topical anesthesia for the other. The anesthesia method for the first eye was randomly selected. After surgery, patients were asked to rate their pain and whether they preferred one anesthesia technique over the other. RESULTS: When topical anesthesia was given, 82.2% of patients required no intravenous medications. Overall, 62.2% preferred topical over peribulbar anesthesia, with most patients citing the lack of periocular injection as the reason. CONCLUSION: Despite the increased technical difficulty, topical anesthesia proved an effective alternative to peribulbar anesthesia for cataract surgery that avoids the risks of periocular injection and reduces the need for intravenous medications.

Results of photorefractive keratectomy on 63 myopic eyes with six months minimum follow-up.

We present our experience with 63 myopic eyes that had photorefractive keratectomy with an excimer laser. Minimum follow-up was six months. Mean preoperative myopia was -3.98 diopters (D) (range: -9.00 D to 1.25 D) and mean preoperative uncorrected visual acuity, 20/220. The epithelium was removed and fixation accomplished with a suction ring. Photoablation was then performed on a 5.0 mm diameter optical zone. Mean postoperative myopia was -0.60 D (range: -6.35 D to +2.25 D) after six months. Mean uncorrected visual acuity was 20/30. All corneas had a subepithelial haze that decreased progressively. There were no major complications. Except in a few cases, predictability was satisfactory. Photorefractive keratectomy proved effective throughout the trial. We need to study more patients with a longer follow-up to determine the indications and applications of this technique.

Surgically induced astigmatism with superior and temporal incisions in cases of with-the-rule preoperative astigmatism.

PURPOSE: To evaluate surgically induced astigmatism (SIA), postoperative astigmatism, and uncorrected visual acuity (UCVA) after cataract surgery with superior corneal, superior scleral, and temporal corneal 4.0 mm sutureless incisions in cases of preoperative with-the-rule (WTR) astigmatism. SETTING: Hopital des Quinze-Vingts, Paris, France. METHODS: This prospective evaluation included patients having phacoemulsification with foldable lens implantation through a 4.0 mm incision. Patients with preoperative WTR astigmatism were randomly assigned to 1 of 3 incisions: superior corneal (Group 1), superior scleral (Group 2), or temporal corneal (Group 3). All patients had autokeratometry preoperatively and postoperatively (1 day, 1 week, 1 month, 1 year). Surgically induced astigmatism using the vector method, postoperative astigmatism, and UCVA (patients whose spherical equivalent was with +/- 1 diopter) were evaluated. RESULTS: Ninety patients were included in the study; there were 30 in each incision group. One year postoperatively, Group 1 had 1.52 diopters (D) of SIA and 1.36 D of postoperative astigmatism; 53.5% of patients had a UCVA of 20/32 or better, Group 2 had 0.69 D of SIA (P < .05) and 0.67 D of postoperative astigmatism (P < .05); 82.7% of patients had a UCVA of 20/32 or better (P < .05). Group 3 had 0.69 D (P > .05), 0.98 D (P < .05), and 79.3% (P > .05), respectively. CONCLUSIONS: In this study, the superior corneal incision produced significant SIA, leading to high postoperative astigmatism and poor UCVA. The scleral and temporal incisions produced minimal SIA and good UCVA.

[Value of corticoids in the treatment of postoperative endophthalmitis]. / Intérêt des corticoïdes dans le traitement de l'endophtalmie postopératoire.

Postoperative endophthalmitis, which has a dreadful reputation, needs early and aggressive treatment. Apart local and systemic antibiotic therapy, the place of corticosteroid treatment is still discussed. The authors retrospectively compared three groups of patients treated with appropriate antibiotics but with different corticosteroid. Group I received high dose corticosteroids early regimen, group II received delayed corticosteroids treatment and group III did not receive corticosteroids. Visual recovery as well as vitreous transparency better in group I.

[Interstitial tubulo-nephritis and uveitis (Nitu syndrome). Apropos of a case]. / Tubulo-néphrite interstitielle et uvéite (Nitu syndrome). A propos d'un cas.

Acute renal failure due to tubulo-interstitial nephritis developed in a 12 year old boy. It was accompanied by an inflammatory syndrome consisting of a markedly increased erythrocyte sedimentation rate and high levels of C. reactive protein and fibrin. The association of these anomalies with an uveitis are typical of the Tinu syndrome (tubulo-interstitial nephritis uveitis) first described by Dobrin and al. in 1975. The interest of this case lies in the observation of focal chorioretinitis, as yet never described. The possibility of toxoplasmosis is discussed; it could be a direct etiologic factor or could represent a concurrent phenomenon. However no evidence of toxoplasmic infection could be demonstrated in this case, nor in any case previously reported. Light microscopic examination of a renal biopsy reveals diffuse monocellular interstitial infiltration and epithelioid granulomas. In some cases, non-specific bone marrow and lymph node granulomas have been found. In the Tinu syndrome, the nephropathy is completely reversible, either spontaneously or following steroid treatment; this contrasts with the tendency towards relapse of the uveitis. The possible pathogenesis and the relationship with other idiopathic acute nephritis and uveitis are discussed. As in some previous publications, the presence of circulating immune complexes in our patient would suggest the involvement of the immune system. Temporary depression of cellular immunity was also observed in some cases. But the etiology and the pathogenesis of this syndrome are still unknown.

[Phacoemulsification and topical anesthesia. Apropos of 40 cases]. / Phacoemulsification et anesthesie topique. A propos de 40 cas.

BACKGROUND: To evaluate topical anaesthesia for cataract surgery. METHODS: Thirty-nine patients (40 eyes) underwent cataract surgery by phacoemulsification with topical anaesthesia consisting in instillations of tetracaine eyedrops. Thirty-four eyes were implanted with a foldable lens and 6 eyes received a PMMA lens. Final visual acuity (1 month minimum follow-up), patients reactions (sensibility, pain), anaesthetic and surgery difficulties were specially studied. RESULTS: Mean initial corrected visual acuity was 0.21. Mean final corrected visual acuity was 0.72; 90 % of the subjects experienced no pain. Implantation was the most sensitive moment. Eye mobility was not a problem except during capsulhorexis which had to be done with forceps. CONCLUSION: Simplicity of topical anaesthesia eliminates the complications of the other anaesthetic methods. It is necessary to have a close patient-surgeon relationship. Carefully chosen topical anaesthesia is an interesting alternative.

[Cataract and implantation in the vitrectomized eyes]. / Cataracte et implantation sur oeil vitrectomisé.

Cataract is a frequent complication of vitreous surgery after some months or years. In these cases cataract extraction is somewhat difficult. We performed cataract surgery with implantation in 38 eyes from 37 patients between 1986 and 1991. Twenty patients underwent vitreous or vitreoretinal surgery with or without internal tamponade by gas, 17 underwent silicone oil tamponade and silicone oil removal, prior to cataract surgery. Timing of surgery, number of surgical procedures and complications previous to cataract surgery are detailed in the paper. Cataract extraction was extracapsular in 7 cases, intracapsular in 6 cases; phako was performed in 24 cases and phacophagy in one case. A posterior IOL was inserted in 31 cases, an anterior chamber IOL in 7 cases. Anatomical and visual results were satisfying. Visual acuity improved postoperatively in 29 cases (up to 20/20 in 4 cases), was unchanged in 6 cases, decreased in 3 cases. Among these, loss of vision occurred in 5 cases due to retinal detachment or redetachment. For anatomical reasons, lack of vitreous support and the frequent zonular weakness of these eyes, account for surgical difficulties. Thus, phakoemulsification appears the best way to manage cataract in vitrectomized eyes.

[Statistical study of the results of radial keratotomy]. / Etude statistique des résultats de la kératotomie radiaire.

The statistical study of 384 R.K. performed by the same surgeon shows that in 82% of R.K., preoperative myopia was between -1.5 to -6 diopters and in 77.5% of R.K., postoperative refraction was between -1 to +1. The 90% confidence interval was between -2 to +1 for all preoperative myopias and was the best when preoperative myopia was between -0.5 to -3 diopters (-1 to +1 D). The study of the stability and security shows that this surgical technique is stable and gives a good security.

[Fifty-two cases of postoperative endophthalmitis treated with one protocol: anatomical and functional results]. / 52 cas d'endophtalmie post-opératoire traités par un protocole thérapeutique unique: résultats anatomiques et fonctionnels.

PURPOSE: To evaluate our management of postoperative endophthalmitis and compare our protocol to the Endophthalmitis Vitrectomy Study's (EVS) recommended protocol. PATIENTS AND METHODS: This study comprises 52 patients with postoperative endophthalmitis treated with the same protocol in 1996 and 1997. Patients were given an intravitreal injection of antibiotics (vancomycin-amikacin) and steroids (dexamethasone), systemic antibiotics (pefloxacin-piperracillin), and systemic steroids in bolus. Vitrectomy was not systematic. So as not to delay the treatment, cultures were obtained only from an anterior chamber paracentesis. RESULTS: Visual acuity was measurable in 86.5% of the patients, with 20/100 in 63.4% and 20/40 in 44.2%. Our results are similar to those of the EVS even when initial visual acuity was Light Perception. CONCLUSION: Our protocol is simple and easy to perform in all ophthalmology centers. It is based on intravitreal injection, which must be performed as quickly as possible.

[Clinical evaluation of the ocular safety of Amukine 0.06% solution for local application versus povidone iodine (Bétadine) 5% solution for ocular irrigation) in preoperative antisepsis]. / Evaluation clinique de la tolérance oculaire d'Amukine 0,06% solution pour application locale versus povidone iodée (Bétadine 5% solution pour irrigation oculaire) en antisepsie pré-opératoire.

INTRODUCTION: The aim of this monocentric, randomized, comparative, open study was to evaluate the safety of Amukine 0.06% solution (an isotonic hypochloride sodium solution) versus a 5% povidone iodine solution (Bétadine 5% solution for ocular irrigation) in antisepsis before cataract surgery. MATERIAL AND METHODS: One hundred and thirteen patients, aged between 49 and 90 years, were included and split, after randomization, into two groups: one testing Amukine 0.06%, the other testing a 5% povidone iodine solution. For each group, after local anesthesia, the antiseptic procedure consisted of an antisepsis of periocular teguments followed by an eye antisepsis through the instillation of two drops of the tested product in the conjunctival fornices. The safety evaluation was performed by grading superficial punctate keratitis 24 hours after surgery (slit lamp examination after fluorescein instillation). Conjunctival hyperemia scores by examination of the bulbar conjunctiva before the first instillation, immediately before surgery, and 24 hours after surgery were also compared. RESULTS: One hundred and seven reports were analyzed. Concerning the presence of corneal superficial punctate keratitis 24 hours after surgery, mean scores were not different (0.27 for the Amukine 0.06% group and 0.38 for the povidone iodine group; p=0.27 Mann Whitney test). The observations did not show a different progression of conjunctival hyperemia depending on the treatment group (p=0.65 (immediately after application) and p=0.52 (after 24 hours); Mann Whitney test). CONCLUSION: In this study, the ocular safety of Amukine 0.06% solution was not different from a 5% povidone iodine solution. Therefore, Amukine 0.06% is a new interesting approach to surgical antisepsis in ophthalmology and an alternative in case of iodine allergy.

Femtosecond and excimer laser-assisted endothelial keratoplasty (FELEK): a new technique of endothelial transplantation.

PURPOSE: To describe a new technique of endothelial keratoplasty (EK) that improves the quality of lamellar dissection of donor cornea. METHODS: We compared four techniques of donor cornea preparation for lamellar dissection on 8 donor corneas: mechanical dissection with a microkeratome, a single femtosecond laser lamellar cut, a double femtosecond laser lamellar cut and combined femtosecond laser lamellar dissection with excimer laser surface photoablation. The quality of the donor cornea interface was assessed and compared using scanning electron microscopy (SEM), and the most satisfactory technique was employed for EK on three patients. The postoperative anatomic results were analyzed with anterior segment spectral-domain optical coherence tomography (SD-OCT) and in vivo confocal microscopy (IVCM). RESULTS: The smoothest stromal interface was observed on SEM with the combined use of femtosecond laser dissection and excimer photoablation. The surgical procedures performed with donor cornea prepared by a combination of femtosecond and excimer lasers resulted in clear corneas after 1 month. SD-OCT showed good attachment of the endothelial graft and a hyperreflective interface. On IVCM, subepithelial haze, honeycomb-like activated keratocytes and needle-shaped particles were visible in the recipient corneal stroma as well as numerous hyperreflective particles on the donor-recipient interface. CONCLUSION: A new technique, femtosecond and excimer laser-assisted endothelial keratoplasty (FELEK), which refines the current limitations observed in Descemet-stripping automated endothelial keratoplasty (DSAEK), is described. Femtosecond laser dissection provides a thin and reproducible endothelial graft cut with a high level of safety and accuracy, while excimer photoablation yields a smooth, high-quality interface.

[Limbal relaxing incisions to correct preexisting astigmatism during cataract surgery]. / Kératotomies arciformes périphériques et correction de l'astigmatisme dans la chirurgie de la cataracte.

PURPOSE: To evaluate the effectiveness of limbal relaxing incisions for correcting significant preoperative astigmatism during cataract surgery. METHODS: In 32 patients (50 eyes) with preoperative keratometric astigmatism between 1.25 and 2.5 D, cataract surgery was combined with limbal relaxing incisions according to a modified Gills nomogram. RESULTS: The mean preoperative keratometric astigmatism was 1.6 (+/- 0.39) D. The mean preoperative manifest refraction was 1.26 ((+/- 0.39) D. The mean 1-month, 6-month and 3-year or more postoperative keratometric astigmatisms were 0.77 ((+/- 0.29), 0.84 ((+/- 0.5) and 0.86 ((+/- 0.32) D, respectively. The mean postoperative manifest refractions were 0.48 ((+/- 0.32), 0.55 ((+/- 0.29) and 0.54 ((+/- 0.29) D, respectively. Postoperative refractive astigmatisms were 0 or 0.25 D in 22% of the cases, 0.5 or 0.75 D in 64% and greater than 0.75 D in 14%. Conclusion.- Limbal relaxing incisions are an effective and simple approach to the correction of significant preoperative astigmatism during cataract surgery.

[Optical biometry of eyes corrected by phakic intraocular lenses]. / Biométrie optique des yeux avec implants phaques.

PURPOSE: The aim of this study was to determine whether eye length measurements obtained with the IOL Master (Zeiss Humphrey) before and after phakic IOL implantation would show any changes. METHODS: In a prospective study, we used the IOL Master to measure optical biometry in 25 myopic eyes of 15 patients before and after phakic IOL implantation (PRL, ICL, Artisan). The differences between both axial length measurements were calculated and compared using a nonparametric Wilcoxon test. RESULTS: The difference between the preoperative and postoperative measurements ranged from -0.16 mm to 0.06 mm and averaged -0.016 mm, which was not statistically significant (p=0.20). Both measurements correlated in a highly positive manner (r=0.999; p<0.0001). The reproducibility of the preoperative and postoperative axial length measurements was very high (coefficient of variation=0.09% and 0.07%, respectively). The precision was 26 microm for preoperative measurements and 19 microm for postoperative measurements. CONCLUSION: Our results showed that postoperative measurements of axial length are highly comparable to preoperative measurements and that optical biometry can achieve highly precise and reliable axial length measurements in eyes with phakic IOLs. This application becomes clinically relevant in evaluating eyes with phakic IOLs that might require cataract surgery. Hence, accurate axial length measurements in eyes with phakic IOLs will be extremely important when cataract occurs in these eyes and when the preoperative measurements are no longer available.