Successful management of dry eye disease with a new eye drop formulation combining hyaluronic acid, trehalose, and N-acetyl-aspartyl-glutamic acid (NAAGA).

PURPOSE: To assess the clinical efficacy and safety of T2769, a new preservative-free eye drop combining hyaluronic acid (HA), trehalose and N-acetyl-aspartyl-glutamic acid (NAAGA), in dry eye patients. PATIENTS AND METHODS: This was a multicenter, non-comparative, open-label study. After a run-in period with NaCl 0.9% solution, 62 patients with moderate-to-severe dry eye disease (DED) were included and treated with T2769, 3 to 6 times/day for 42 days. The primary efficacy endpoint was the change in global ocular symptomatology assessed on a visual analog scale between Day 1 (D1) and D42. Other efficacy endpoints included ocular surface disease index (OSDI), soothing sensation, individual dry eye symptoms, conjunctival hyperemia, global ocular staining, tear break-up time, Schirmer test, and global efficacy assessed by the investigator. Safety was assessed throughout the study. RESULTS: A marked reduction in ocular symptomatology was observed from D1 to D42 with a mean change of -55.9±23.1mm (P<0.001). This was accompanied by a mean change in OSDI score from baseline of -44.6±15.9 (P<0.001) and a substantial soothing sensation in 82.3% of patients. Clinically significant improvements were observed for all ocular symptoms (mainly burning/irritation, stinging/pain, feeling of ocular dryness, foreign body sensation, itching/pruritus). Conjunctival hyperemia significantly decreased in 96.8% of patients (56.5% displayed no conjunctival hyperemia at D42 versus 0% at baseline). All signs and symptoms improved by D14 and further improved at D42. Investigators assessed the ocular efficacy of T2769 as very satisfactory or satisfactory for 91.9% of patients at D42. T2769 was well tolerated, with no ocular adverse events and only a few ocular symptoms upon instillation. CONCLUSION: Management of moderate-to-severe DED patients with the new formulation T2769, combining NAAGA to HA and trehalose, led to rapid and significant improvements in dry eye signs and symptoms with good tolerability.

Outcomes of intermittent exotropia surgery.

PURPOSE: To study the epidemiological and clinical characteristics of intermittent exotropia and to describe our therapeutic choices as well as their results and prognostic factors. MATERIALS AND METHODS: This was a retrospective study including 57 cases of intermittent exotropia. All patients underwent a complete ophthalmological examination with a sensory-motor assessment. Surgery was performed by the same surgeon, and the vertical component was addressed surgically at the same time as the exotropia. Statistical analysis was performed using SPSS software version 21.0. RESULTS: Our patients were classified as basic exotropia in 46 cases (80.7%), divergence excess in eight cases (14.1%), and convergence insufficiency in three cases (5.2%). Amblyopia was found in 26% of cases. The preoperative maximum angle of deviation was 36.5DP±9.1DS and a vertical component was found in 16 patients (28%). The most common was V pattern (8 patients). The mean age at the time of surgery was 14.8 years old. After a single surgery, we obtained motor success in 78.9% of the patients. Three patients were re-operated, with an overall motor success of 84.2%. CONCLUSIONS: Motor and sensory success may be achieved in intermittent exotropia. Rigorous, early management is necessary, even if tropic episodes are still rare. The rate of early consultation among children is still low in our country; thus, a national strabismus screening program must be established to obtain the best results.

Outcomes of surgery in patients with sensory exotropia.

INTRODUCTION: Sensory exotropia is often due to profound amblyopia. Surgery essentially aims to improve aesthetic appearance and quality of life. Our goal was to discuss clinical features of sensory exotropia as well as surgical indications and outcomes. METHODS: Medical records of 43 patients who underwent sensory exotropia surgery were retrospectively reviewed. Each patient had an ophthalmological examination and a complete sensorimotor assessment. All surgeries were performed by the same surgeon. We studied the influence of certain prognostic factors on motility outcomes, such as age of onset of strabismus, gender, delay of surgical management, degree of amblyopia, angle of deviation, and amount of recession/resection. RESULTS: The mean follow-up was 2.3 years. All of our patients had severe amblyopia. An abnormal retinal correspondence with no fusion or stereopsis was noted in all subjects. The mean angle of deviation was 44.5 PD±12.4 SD preoperatively. The alignment success rate after a single procedure was 65.1%. Eight patients developed recurrent exotropia and were reoperated, with a final alignment success rate of 74.4%. CONCLUSIONS: Sensory exotropia is characterized by a large angle of deviation and an altered sensory status. The overall goal of surgery is to improve the patient's aesthetics and quality of life by treating the maximum angle of deviation. Surgical outcomes are often satisfactory for the patients, but certain complications may occur, such as diplopia, enopthalmos, and recurrences.

Central serous chorioretinopathy: Professional repercussions among agents of the internal security forces.

PURPOSE: To describe the relationship between central serous chorioretinopathy (CSCR) and stress in addition to the transient and permanent professional repercussions of this condition among security forces agents. MATERIAL AND METHODS: This is a retrospective, descriptive study of 22 CSCR patients. All patients were interviewed to establish their job status, a stressful triggering event, the number of consultations, absenteeism, the duration of episodes, the number of days off, exemption from certain activities and professional reclassification. All of our patients underwent a complete ophthalmological examination and ancillary testing (OCT optical coherence tomography, fluorescein retinal angiography) to establish the positive diagnosis and to determine the clinical form. RESULTS: During their daily activity, all patients were armed and worked night security duty. They all reported a stressful event just before the onset of the disease. The average visual acuity was 4/10 P6 all forms combined; with a visual acuity between 1 and 2/10 for the chronic form. Visual impairment was associated with absenteeism (mean length of time off was 1.13 months per episode), exemptions from carrying arms or night duty in 36.36% of cases, with professional reclassification in 22.7% of patients. CONCLUSION: CSCR affects psychology and alters the quality of life of patients who are generally young and professionally active. This can interfere with work performance and cause temporary or permanent disability.

Oculomotor palsy in diabetics.

INTRODUCTION: Oculomotor palsy is one of the most frequent neuro-ophthalmologic complications of diabetic patients. It generates less interest in the literature than the other ocular manifestations. Our goal was to study the clinical, epidemiological, therapeutic and prognostic characteristics of oculomotor palsy in the diabetic. METHODS: This is a retrospective study of 24 diabetic patients with oculomotor palsy. The ophthalmological examination emphasized ocular motility. We performed an orthoptic assessment and a Hess-Lancaster test. Neuro-imaging was ordered in case of IIIrd and IVth nerve involvement, bilateral involvement, multiple ocular cranial nerve palsy or associated optic neuropathy. Treatment consisted of glucose management and alternating monocular occlusion or prisms for the diplopia. Data were entered and analyzed on SPSS 11.5 software. RESULTS: The mean age of the patients was 58.5±11.9 years. Binocular diplopia was the main symptom. The oculomotor palsy involved the VIth nerve in 50% of cases and was bilateral in two cases. Three patients also had an optic neuropathy. The mean duration of diabetes was 11.7±11 years; poorly controlled diabetes was found in 75% of cases and an association with diabetic retinopathy was noted in 56% of cases. CONCLUSIONS: Long-standing uncontrolled type 2 diabetes, hypertension, coronary artery disease, left ventricular hypertrophy, and elevated hematocrit are the most common risk factors. The VIth nerve is commonly involved. Certain characteristics of the pupillary light reflex can help to differentiate an ischemic insult from an aneurysmal injury to the IIIrd nerve.

[Neuropsychiatric side effects of antituberculosis agents]. / Les effets indésirables neuropsychiatriques des antituberculeux.

UNLABELLED: Accurency of neurological or psychiatric complications secondary to the administration of antituberculosis may be at the origin of diagnosis and therapeutic problems. This work aims at studying the frequency of these manifestations, their clinical presentations and their therapeutic approach. PATIENTS AND METHODS: This retrospective study was carried on from January 1990 to June 2008 at Ibn Nafis Pulmonary Department of Abderrahmen Mami Hospital in Ariana. It dealt with 18 in-patients with a neurologic or a psychiatric complication due to antituberculous drugs. Peripheral neuropathy was noted in 6 patients (33%). One of them had a history of chronic alcoolism, another one had a history of diabetes mellitus and 2 other patients were more than 72 years old. We had definitively stopped isoniazide in 2 cases and decreased the dosage in 4 other patients. However, all patients received B6 vitamin. Convulsions occured in 2 women without any history of epileptic status. Anticonvulsivant treatment was prescribed and isoniazid definitively stopped. Hallucinosis was noted in 4 patients, with one having a history of chronic alcoolism. Isoniazide was stopped in all cases. Agressivity, insomnia and memory problems were noted in 6 patients. Isoniazid was interrupted in only one woman who had history of depression. In 5 other patients, anxiolytics were prescribed. Isoniazide was incrimined in all cases and evolution was favorable for the 18 patients. A close monitoring of patients on antituberculous treatment is required to detect the onset of any neuropsychiatric complications incriminating usually isoniazid. Definitive interruption or decrease of the dose of isoniazid depending of the acetylation test were necessary.

[Rare primary chest wall sarcoma: the synovialosarcoma]. / Sarcome primitif rare de la paroi thoracique: le synovialosarcome.

INTRODUCTION: Malignant primary tumours occurring in the thorax encompass a large group of tumours which may arise from the lung, mediastinal structures, the pleura or the chest wall. OBSERVATION: We report the case of a 37 year old patient, who presented with left sided chest pain. On clinical examination a right sided chest wall mass was identified. Chest X Ray showed a left sided upper mediastinal opacity, associated with a left sided pleural opacity. Thoracic CT scan revealed a large mass arising from the chest wall and infiltrating the mediastinum associated with a second chest wall mass at the level of the 8(th) and 9(th) right ribs. The biopsy of the chest wall mass revealed it to be a parietal synovialosarcoma. The patient responded to chemotherapy based on ifosfamid and doxorubicin as well as mediastino-pulmonary radiotherapy. There was an improvement in the patient's clinical and radiological state but the patient died by pulmonary embolism after the 3(rd) cause of treatment. CONCLUSION: Chest wall synovialosarcoma has a poor prognosis, however, its chemosensitivity means that treatment may initially be effective.

[Enigmatic evolution of an association of pulmonary tuberculosis and amyloidosis]. / Évolution énigmatique d'une association de tuberculose et d'amylose pulmonaire.

INTRODUCTION: Amyloidosis is characterized by tissue deposits of amyloid material. Secondary amyloidosis can occur as a sequel to pulmonary tuberculosis over a relatively long period. However, this was not the case with our patient. Subsequently we conducted a literature review to try to explain the unusual course of AL amyloidosis in our patient. CASE REPORT: A 36- year-old patient was admitted to our department for investigation of haemoptysis. A diagnosis of primary pulmonary tuberculosis was made and antituberculous treatment was started. On the second day of treatment, a haematoma appeared on the sole of the right foot, which spread down to the toes during the following days. Renal investigations showed a 24h proteinuria of 9 g/L and serum protein electrophoresis revealed an albumin level of 11.8 g/L. A diagnosis of nephrotic syndrome was made. A renal biopsy was indicated but this was not possible on account of a marked worsening of the patient's condition after 14 days of treatment. The patient's level of consciousness deteriorated and he was transferred to the intensive care unit for ventilation. He died 48 hours later. Post-mortem histological examination of pulmonary and cutaneous tissue revealed AL amyloid deposits. CONCLUSION: In view of the association of active pulmonary tuberculosis and a pulmonary localisation of amyloidosis, a causal relationship is not definite. Coexistence of active pulmonary tuberculosis and primary amyloidosis must also be considered, particularly as the immunohistochemical characterisation revealed AL amyloidosis.

[Hypersensitivity reactions to antituberculous therapy]. / Manifestations d'hypersensibilité aux antituberculeux.

INTRODUCTION: Hypersensitivity reactions to antituberculous drugs pose both a diagnostic and a therapeutic problem. This work aims to study the frequency of allergic reactions to antituberculous drugs, their clinical presentations and the diagnostic approach required. PATIENTS AND METHODS: This retrospective study covered the period from January 1990 to June 2008 at the Ibn Nafis Pulmonary Department of Abderrahmen Mami Hospital in Ariana. It dealt with 30 in-patients who experienced an allergic reaction to antituberculous drugs. RESULTS: Cutaneous manifestations were the most frequent (80% of cases), predominantly urticarial. Thrombocytopenia was noted in two cases, anaphylactic shock in three cases, a systemic toxidermia in two cases and renal failure in one patient. Pyrazinamide was implicated in most cases (28%) when only one drug was considered to be responsible for the reaction. Interrupting either one drug or the whole treatment was necessary to define the cause of the reaction. The clinical evolution of hypersensitivity signs was favorable in all cases following definitive withdrawal of the responsible drug. Complete recovery from tuberculosis occurred in all cases. CONCLUSION: Close monitoring of patients on antituberculous treatment is required to detect the onset of any allergic reaction and ensure an adequate compliance with treatment.

[Tuberculosis in patients with asthma]. / Asthme et tuberculose: association bénéfique ou maléfique?

INTRODUCTION: The association of asthma and tuberculosis is rare but may raise particular issues around patient management. The aim of this study was to evaluate the clinical, therapeutic and progress of this association. PATIENTS AND METHODS: We describe a retrospective study, which included seven asthmatic patients hospitalized for pulmonary tuberculosis during the period between June 2001 and June 2006. RESULTS: Five men and two women were included. Mean age was 37 years. Two patients had mild asthma, four had moderate asthma and one had severe and corticosteroid-dependant asthma. Only four patients had controlled asthma when tuberculosis diagnosis was established. Asthma treatment was based on inhaled corticoids and long-acting beta-2-agonists. During antituberculosis treatment two patients developed near fatal asthma. Long-term stable asthma control was achieved over a time course of 3 to 8 years. CONCLUSION: The association of asthma and tuberculosis can lead to potential therapeutic difficulties because of pharmacologic interactions between antituberculosis therapies and treatments for asthma treatment. In addition asthma following treatment for tuberculosis appears to be well controlled.

[Pseudotumoral mediastinal amyloidosis]. / Amylose ganglionnaire médiastinale pseudotumorale.

PURPOSE: Amyloidosis involvement of mediastinal nodes is rare. Isolated pseudotumoral involvement without extra-thoracic disease is a diagnostic challenge and typically raises concern for underlying malignancy. We present 3 cases of pseudotumoral mediastinal amyloidosis. METHODS: We report the cases of 3 patients presenting with recent onset of respiratory symptoms. Bronchoscopy showed mucosal infiltration suspicious for lymphangitic spread of tumor. The patients underwent chest radiography complemented by CT of the chest and abdomen, and laboratory and immunological work-up. A diagnosis of pseudotumoral mediastinal amyloidosis was confirmed by mediastinoscopic biopsy in all cases. RESULTS: CT showed a pulmonary and mediastinal tumor process in 2 cases and pericarinal tumor in 1 case. Diffuse bronchial wall thickening was present in all cases. Review of biopsy material showed tracheobronchial amyloidosis in 1 case. Patient work-up showed no evidence of extra-thoracic amyloidosis. Rapid progression of bronchial obstruction was observed in 1 case. CONCLUSION: The imaging features of mediastinal amyloidosis are non-specific. Pseudotumoral involvement of mediastinal nodes associated with pulmonary amyloidosis accelerates the degree of airway obstruction.

[Effect of tobacco smoking on pulmonary tuberculosis]. / Effet du tabagisme sur la tuberculose pulmonaire.

Tobacco increases the risk of pulmonary infection, especially tuberculosis. We try by this study to analyse this action. It's a comparative study between two groups of patients hospitalized in our department between January 2006 and June 2008. The first group was made of 30 smokers patients hospitalized because of confirmed pulmonary tuberculosis. The second group consists of 30 non smokers patients and also hospitalized because of confirmed pulmonary tuberculosis. Delay of diagnosis was longer in the group of smokers (3, 1 +/- 3 months versus 2 +/- 1 month with p = 0.039). The most frequent symptoms in both groups were cough and loss of weight. The biological investigations showed a high level of white blood cells with predominance of neutrophil cells especially in smokers (p = 0.024). Chest X ray showed essentially nodules in both groups. These nodules were bilateral in smokers (P = 0.045). Evolution after antituberculosis treatment was favourable for all patients. A delay of recovery (time between symptoms and recovery) was longer in smokers than in non smoker patients (p = 0.043). Pulmonary Sequels such as dyspnoea (p = 0.016) and fibrosis (p = 0.041) were most frequent in smokers. No patients had tuberculosis relapse. Tobacco may delay the recovery of pulmonary tuberculosis and may induce pulmonary sequels in spite of correctly antituberculosis treatment.

Multiple myeloma presenting with multiple thoracic manifestations.

Multiple myeloma is a malignant proliferation of plasma cells that affects mainly bone marrow but may also involve other organs as well. We report thoracic involvement in the form of left-sided pleural effusion, osseous lesions, bronchial infiltration, and mediastinal lymphadenopathy in a 61-year-old woman, non-smoker presented with chest pain, dyspnoea, cough and deterioration in general health over the preceding seven months. Immunoelectrophoresis and immunofixation showed raised kappa-light chain immunoglobulin G (IgG) in serum and pleural fluid. Bronchial and pleural biopsies documented myelomatous infiltration and bone marrow aspirate revealed extensive plasma cell infiltration. At eight months, following the fourth cycle of melphalan, endoxan and prednisone based chemotherapy, the patient died.

[Pleural empyema revealing osteopoikilosis]. / Pleurésie purulente révélatrice d'une ostéopoecilie.

INTRODUCTION: Osteopoikilosis is a rare, inherited and usually asymptomatic sclerosing bone dysplasia of unknown etiology which predominantly involves the appendicular and rarely the axial skeleton. CASE REPORT: We report the case of a 24 year old man who was hospitalized for pleural empyema and treated with antibiotics for six weeks in addition to pleural evacuation and physiotherapy. The diagnosis of osteopoikilosis associated with the pleural empyema was made on the radiological findings. In fact the chest X-Ray showed spherical areas of increased bone density in both humeral epiphyses. In order to explore these bone abnormalities further investigations were performed, including red and white blood cell counts, sedimentation rate and protein electrophoresis. There were no biological abnormalities. Radiography of the whole skeleton showed disseminated sclerotic lesions in the pelvis and the metacarpal and carpal bones of both hands. A neoplastic aetiology was excluded. In the light of these investigations, the diagnosis of osteopoikilosis was established. CONCLUSION: Widespread osteopoikilosis can be revealed on chest radiography.

[Hypophysial macroadenoma revealed by clinical symptoms simulating chronic glaucoma]. / Macroadénome hypophysaire révélé par un tableau clinique simulant un glaucome chronique.

INTRODUCTION: A large optic cup is a sign of glaucoma, although it has been reported in other optic neuropathies, particularly in compressive neuropathies. CASE REPORT: A 37-year-old man presented with a decrease in visual acuity for 2 months. Fundus biomicroscopic examination revealed a glaucoma-like bilateral and asymmetric large optic cup. Neuroradiological examination revealed an expansive mass in the sella turcica that was compressing the optic tract. CONCLUSIONS: Optic nerve compression can lead to perimetric alterations and optic disc anomalies such as those seen in normal-tension glaucoma. Age under 50 years, visual loss, and neuroretinal rim pallor may lead to a suspicion of compressive neuropathy.

[Retinal venous occlusion in Behçet disease]. / Occlusions veineuses rétiniennes et maladie de Behçet.

PURPOSE: The aim of our study is to report three cases of retinal venous occlusion in patients with Behçet disease and to discuss the physiopathology of this vascular accident. METHODS: In this retrospective study, out of a series of 32 patients suffering from Behçet disease, we report three cases of retinal venous occlusion. General and ophthalmologic features are described. Treatment strategy is detailed for each case. RESULTS: There were 2 cases of branch retinal venous occlusion and one case of central retinal venous occlusion. Relapses and retinal neovascularization were the most common complications. CONCLUSION: The retinal venous occlusion in Behçet's disease is a non-common but severe complication. Early and appropriate treatment is required to improve the functional prognosis.