Impact of a program to prevent incivility towards and assault of healthcare staff in an ophtalmological emergency unit: study protocol for the PREVURGO On/Off trial.

BACKGROUND: The emergency department has been identified as an area within the health care sector with the highest reports of violence. The best way to control violence is to prevent it before it becomes an issue. Ideally, to prevent violent episodes we should eliminate all triggers of frustration and violence. Our study aims to assess the impact of a quality improvement multi-faceted program aiming at preventing incivility and violence against healthcare professionals working at the ophthalmological emergency department of a teaching hospital. METHODS/DESIGN: This study is a single-center prospective, controlled time-series study with an alternate-month design. The prevention program is based on the successive implementation of five complementary interventions: a) an organizational approach with a standardized triage algorithm and patient waiting number screen, b) an environmental approach with clear signage of the premises, c) an educational approach with informational videos for patients and accompanying persons in waiting rooms, d) a human approach with a mediator in waiting rooms and e) a security approach with surveillance cameras linked to the hospital security. The primary outcome is the rate of incivility or violence by patients, or those accompanying them against healthcare staff. All patients admitted to the ophthalmological emergency department, and those accompanying them, will be enrolled. In all, 45,260 patients will be included in over a 24-month period. The unit analysis will be the patient admitted to the emergency department. Data analysis will be blinded to allocation, but due to the nature of the intervention, physicians and patients will not be blinded. DISCUSSION: The strengths of this study include the active solicitation of event reporting, that this is a prospective study and that the study enables assessment of each of the interventions that make up the program. The challenge lies in identifying effective interventions, adapting them to the context of care in an emergency department, and thoroughly assessing their efficacy with a high level of proof.The study has been registered as a cRCT at clinicaltrials.gov (identifier: NCT02015884).

Three cases of post-cataract surgery endophthalmitis due to Rhizobium (Agrobacterium) radiobacter.

We present three unrelated post-cataract surgery endophthalmitis cases caused by Rhizobium radiobacter, hospitalized in three different hospitals. Early diagnosis was obtained in two cases by bacterial DNA detection in vitreous samples. All patients recovered from infection, but pars plana vitrectomy was needed in two patients due to rapid clinical deterioration.

Refined flicker photometry technique to measure ocular lens density.

Many physiological and pathological conditions are associated with a change in the crystalline lens transmittance. Estimates of lens opacification, however, generally rely on subjective rather than objective measures in clinical practice. The goal of our study was to develop an improved psychophysical heterochromatic flicker photometry technique combined with existing mathematical models to evaluate the spectral transmittance of the human ocular media noninvasively. Our results show that it is possible to accurately estimate ocular media density in vivo in humans. Potential applications of our approach include basic research and clinical settings on visual and nonimage-forming visual systems.

Relationship between baseline clinical data and microbiologic spectrum in 100 patients with acute postcataract endophthalmitis.

PURPOSE: To correlate the initial ocular presentation with bacterial identification in 100 patients with acute postcataract endophthalmitis. METHODS: This was a prospective multicenter study. Demographic data, medical history, and the initial eye examination data were recorded on a standardized form. The relationship between bacterial identification and clinical factors at baseline was studied using univariate and multivariate analyses. RESULTS: One hundred patients were admitted to the hospital with a median delay of 6 days after cataract surgery. The main symptoms were loss of vision (94.9%) and pain (75.5%). Major clinical signs were hypopyon (72%), pupillary fibrin membrane (77.5%), and loss of fundus visibility (90%). Baseline factors significantly associated with microbiologic identification were as follows: diabetes mellitus, a shorter delay of onset, initial visual acuity limited to light perception, higher intraocular pressure, chemosis, pupillary fibrin membrane, loss of the red reflex, and reduced fundus visibility. As compared with other bacteria, the identification of Streptococcus species (n = 19) was more frequently associated with male gender, diabetes mellitus, initial visual acuity limited to light perception, and pain. The Staphylococcus aureus and Staphylococcus lugdunensis group (n = 14) differed from other coagulase-negative Staphylococcus groups (n = 33) in that those patients had greater hypopyon height. CONCLUSION: The baseline features of acute endophthalmitis after cataract surgery in the era of phacoemulsification are similar to those reported in the Endophthalmitis Vitrectomy Study 15 years ago and differ according to the bacterial species. The association between the clinical signs and the microbiologic identification suggests that initial characteristics other than visual acuity may be useful in identifying patients presumed to be infected with a virulent species.

Bacterial contamination rate of the anterior chamber during cataract surgery using conventional culture and eubacterial PCR.

PURPOSE: To evaluate the incidence of anterior chamber bacterial contamination during phacoemulsification cataract surgery using eubacterial polymerase chain reaction and conventional cultures. METHODS: This prospective study included 30 eyes of 24 patients who had phacoemulsification with implantation of a foldable acrylic posterior chamber intraocular lens through a 3.2-mm clear corneal incision. Topical aminosid was administered 3 days before surgery. After povidone-iodine antisepsis, 2 intraoperative anterior chamber aspirates were obtained from each patient, the first taken upon entering the anterior chamber and the second at the conclusion of surgery after the suture. Broad-range eubacterial polymerase chain reaction amplification and conventional cultures were used to verify that aqueous humor did not contain any detectable bacteria at the beginning of the surgery and to evaluate the bacterial contamination rate of the anterior chamber at the end of it. No oral antibiotic prophylaxis was used. RESULTS AND CONCLUSIONS: No specimens (0%) aspirated on entry into the anterior chamber or obtained at the conclusion of surgery were positive for microorganisms on culture or eubacterial polymerase chain reaction. None of the eyes developed acute endophthalmitis. The incidence of anterior chamber bacterial contamination during phacoemulsification recovered in this study using eubacterial polymerase chain reaction and conventional culture was null (0%).

Specific PCR and Quantitative Real-Time PCR in Ocular Samples from Acute and Delayed-Onset Postoperative Endophthalmitis.

PURPOSE: Rapid identification of virulent pathogens is essential to strengthen the therapeutic strategy of acute endophthalmitis. OBJECTIVES: This study sought to compare the contribution of a combination of polymerase chain reaction (PCR)-based tests to culture methods, in patients with postoperative endophthalmitis. DESIGN: Prospective multicenter study diagnostic evaluation. METHODS: Setting: university referral centers. PARTICIPANTS: 153 consecutive patients presenting with acute or delayed-onset postoperative endophthalmitis, between 2008 and 2015. There were a total of 284 aqueous humor (AH) and/or vitreous fluid (VF) samples. Outcomes and measurements: microbiological tests of intraocular samples included bacterial culturing of pediatric blood culture bottles; 16SrDNA amplification and sequencing (panbacterial PCR) for detection and identification of all bacterial species; real-time PCR (qPCR) assays targeting the femA or lytA gene for detection of Staphylococcus aureus (S. aureus) or Streptococcus pneumoniae (S. pneumoniae), respectively; and a qPCR assay targeting the tuf gene for detection and quantification of Staphylococcus epidermidis (S. epidermidis). RESULTS: At the time of admission, the rate of detection of microorganisms by PCR-based tests was not significantly different than that by culturing (38% versus 30% in AH samples [n = 69]; 66% versus 63% in VF samples [n = 82], respectively). In contrast, after 1 intravitreal injection (IVI) of antibiotics, the identification rate by PCR-based tests was higher than that in VF by culturing (62% vs 48%, respectively; n = 94; P = 0.05). Bacteria were identified in 70% of patients, with a predominance of Gram-positive bacteria (93%). Specific qPCR tests targeting S. aureus and S. pneumoniae did not provide additional diagnoses but provided earlier results. The S. epidermidis load in vitreous at the time of patients' admission was higher in cases of final visual acuity (VA) of <20/40 (127,118 ± 125,848 DNA copies/mL) in patients with a VA of ≥20/40 (40350,000 ± 46,912 DNA copies/mL; P = 0.09). No significant changes in S. epidermidis load was found after one IVI. CONCLUSIONS: Patients with acute or delayed-onset endophthalmitis should benefit from microbiological identification in vitreous samples by combined analysis using bacterial cultures in pediatric blood culture bottles and panbacterial PCR. The last test was more effective than cultures in vitreous samples collected after an IVI of antibiotics. The qPCR tests targeting S. aureus and S. pneumoniae gave earlier results than culture and panbacterial PCR but did not provide additional diagnoses. As for S. epidermidis infections, determination of bacterial load using the qPCR test targeting the tuf gene could help evaluation of the visual prognosis of patients. Its role in the follow-up of patients after antibiotic treatment needs further investigation.

Evaluating the cost-consequence of a standardized strategy for the etiological diagnosis of uveitis (ULISSE study).

MAIN OBJECTIVE: To prospectively assess the cost-consequence of a standardized diagnostic strategy as to compared to an open one for the etiological diagnosis of uveitis. DESIGN: This was a prospective, non-inferiority, multicentre, randomized controlled trial. METHODS: We included all consecutive patients with uveitis who had visited at least one of the Departments of Ophthalmology. In the standardized group, patients had a minimal work-up regardless of the type of uveitis (including evaluation of the CBC, ESR, C-reactive protein, tuberculin skin test, syphilis serology and chest X-ray). Depending on ophthalmological findings, further investigations could be performed. In the open strategy, ophthalmologists were free to order any kind of investigation. The main outcome was the mean cost per patient of each strategy. RESULTS: 903 uveitis patients were included from January, 2010 to May, 2013. The mean cost per patient of the standardized strategy was 182.97 euros [CI 95% (173.14; 192.80)], and the mean cost per patient of the open strategy was 251.75 euros [CI 95% (229.24; 274.25)]. Therefore, the mean cost per patient of the standardized strategy was significantly lower than the mean cost per patient of the open strategy (p<0.001). There were significantly fewer visits (p<0.001), fewer radiological procedures (p<0.004) and fewer laboratory investigations (p<0.001) in the standardized group. CONCLUSION: A standardized strategy is a cost-saving approach for the etiological diagnosis of uveitis.

Analysis of diluted vitreous samples from vitrectomy is useful in eyes with severe acute postoperative endophthalmitis.

PURPOSE: This study was designed to compare the diagnostic yield of microbiological analysis performed on diluted and undiluted vitreous samples from pars plana vitrectomy (PPV) in patients with acute postcataract endophthalmitis. DESIGN: Cohort study, evaluation of diagnostic test or technology. PARTICIPANTS: Patients with acute postcataract endophthalmitis (<6 weeks). METHODS: Undiluted and diluted vitreous samples were taken from 34 consecutive patients at the beginning of PPV as part of the multicenter prospective study of the French Institutional Endophthalmitis Study (FRIENDS) group. Vitrectomy was performed after 1 (n = 12) or 2 (n = 22) intravitreous antibiotic injections. McNemar's nonparametric test was used to compare culture and polymerase chain reaction (PCR) results between diluted and undiluted samples. MAIN OUTCOME MEASURES: Rate of positivity of conventional culture (brain heart infusion broth) and eubacterial PCR tests from undiluted and diluted vitreous samples. RESULTS: The microbiological analysis of both undiluted and diluted vitreous samples detected and identified a bacterial pathogen in 26 out of 34 cases (76.4%). The analysis of undiluted and diluted vitreous at the time of PPV, using eubacterial PCR and conventional culture, gave similar results (P = 0.99; McNemar test). However, eubacterial PCR was more sensitive than culture in detecting bacteria in vitreous at the time of PPV (76% vs 6%; P = 0.001; McNemar test). The difference in sensitivity between the 2 techniques was primarily associated with false-negative culture results for undiluted samples (2/3 of cases), mainly for coagulase-negative staphylococci. CONCLUSIONS: The microbiological results obtained combining PCR and culture techniques were similar for diluted vitreous and undiluted vitreous analysis. When eubacterial PCR is available, sampling diluted vitreous, an easier procedure, may replace sampling undiluted vitreous.

Impact of a comprehensive prevention programme aimed at reducing incivility and verbal violence against healthcare workers in a French ophthalmic emergency department: an interrupted time-series study.

OBJECTIVE AND SETTING: Primary prevention, comprising patient-oriented and environmental interventions, is considered to be one of the best ways to reduce violence in the emergency department (ED). We assessed the impact of a comprehensive prevention programme aimed at preventing incivility and verbal violence against healthcare professionals working in the ophthalmology ED (OED) of a university hospital. INTERVENTION: The programme was designed to address long waiting times and lack of information. It combined a computerised triage algorithm linked to a waiting room patient call system, signage to assist patients to navigate in the OED, educational messages broadcast in the waiting room, presence of a mediator and video surveillance. PARTICIPANTS: All patients admitted to the OED and those accompanying them. DESIGN: Single-centre prospective interrupted time-series study conducted over 18 months. PRIMARY OUTCOME: Violent acts self-reported by healthcare workers committed by patients or those accompanying them against healthcare workers. SECONDARY OUTCOMES: Waiting time and length of stay. RESULTS: There were a total of 22 107 admissions, including 272 (1.4%) with at least one act of violence reported by the healthcare workers. Almost all acts of violence were incivility or verbal harassment. The rate of violence significantly decreased from the pre-intervention to the intervention period (24.8, 95% CI 20.0 to 29.5, to 9.5, 95% CI 8.0 to 10.9, acts per 1000 admissions, p<0.001). An immediate 53% decrease in the violence rate (incidence rate ratio=0.47, 95% CI 0.27 to 0.82, p=0.0121) was observed in the first month of the intervention period, after implementation of the triage algorithm. CONCLUSION: A comprehensive prevention programme targeting patients and environment can reduce self-reported incivility and verbal violence against healthcare workers in an OED. TRIAL REGISTRATION NUMBER: NCT02015884.

Eubacterial PCR for bacterial detection and identification in 100 acute postcataract surgery endophthalmitis.

PURPOSE: To evaluate eubacterial PCR compared with conventional cultures for detection and identification of bacterial agents in ocular samples from patients with acute postcataract endophthalmitis. METHODS: Broad-range eubacterial PCR amplification was used, followed by direct DNA sequencing in ocular samples (aqueous humor, vitreous samples from tap or vitrectomy) from 100 consecutive patients presenting with acute postcataract endophthalmitis. Bacterial cultures were performed on the same ocular samples by using traditional methods (brain-heart infusion broth). RESULTS: At the time of admission, the detection rate was not significantly different between cultures and PCR (38.2% for cultures versus 34.6% for PCR in aqueous humor samples; 54% versus 57% in vitreous from a vitreous tap). In contrast, in the vitreous obtained from vitrectomy, after intravitreous injection of antibiotics, PCR detected bacteria in 70% of the cases, compared with 9% in cultures. By combining PCR and cultures, bacterial identification was obtained in 47% of aqueous humor samples at admission, in 68% of vitreous samples from a vitreous tap at admission, and in 72% of vitreous samples from pars plana vitrectomy. Gram-positive bacteria predominated (94.3%). The concordance between cultures and PCR was 100%. The contamination rate was 2%. CONCLUSIONS: Cultures and eubacterial PCR are complementary techniques for bacterial identification in eyes with acute postcataract endophthalmitis. PCR technique was needed for identification of the involved microbial pathogen in 25% of all the cases. Eubacterial PCR is more effective than cultures in detecting bacteria in vitreous samples from patients with previous intravitreous administration of antibiotics.

Dark and white lesions observed in central serous chorioretinopathy on optical coherence tomography angiography.

PURPOSE: To describe abnormal dark (hyposignal) and white (hypersignal) lesions observed on optical coherence tomography angiography in central serous chorioretinopathy. METHODS: Prospective, multicenter, and descriptive study including patients with active or quiescent central serous chorioretinopathy. All patients had undergone a complete ophthalmic examination. RESULTS: Abnormal dark lesions were detected as "dark spots" and "dark areas" on optical coherence tomography angiography. A "dark spot" could correspond to six different abnormalities: pigment epithelium detachment, subretinal deposit, "Lucency" within surrounding subretinal fibrin, choroidal cavitation, choroidal excavation, and choroidal fluid. A "dark area" could be related to a serous retinal detachment or choriocapillary compression. Abnormal white lesions were also detected: A "white spot" could correspond with the leaking point on fluorescein angiography or with hyper-reflective dots; A "white filamentous pattern" at the Brüch's membrane level corresponded to abnormal choroidal neovascular vessels. CONCLUSION: A semiology is described using optical coherence tomography angiography in central serous chorioretinopathy as abnormal dark and white lesions. Multimodal imaging is mandatory in addition to optical coherence tomography angiography to diagnose non-neovascular retinal and choroidal central serous chorioretinopathy lesions. However, optical coherence tomography angiography alone is helpful in detecting choroidal neovascular membrane in central serous chorioretinopathy.

Contribution of diagnostic tests for the etiological assessment of uveitis, data from the ULISSE study (Uveitis: Clinical and medicoeconomic evaluation of a standardized strategy of the etiological diagnosis).

PURPOSE: ULISSE is the only study that prospectively assessed the efficiency of a standardized strategy, compared to an open strategy for the etiologic diagnosis of uveitis. Our aim was to evaluate the diagnostic yield of the tests prescribed in the ULISSE study to clarify their relevance. METHODS: ULISSE is a non-inferiority, prospective, multicenter and cluster randomized study. The standardized strategy is a two-steps strategy: in the first step, common standard tests were performed, and in the second step, tests were guided by the clinical and anatomic type of uveitis. We reported the relevance of the diagnostic tests used in the standardized strategy, as well as the profitability of the tests that were prescribed to more than twenty patients in each group. Based on diagnostic criteria, either an ophthalmologist, or an internist, established the profitability of a test by considering whether the test lead to a diagnosis or not. RESULTS: Among the 676 patients included (standardized 303; open 373), a diagnosis was made for 152 (50.4%) in the standardized group and 203 (54.4%) in the open group. The most common entities were HLA-B27 associated uveitis (22%), spondyloarthritis (11%), sarcoidosis (18%), tuberculosis (10.7%) and herpes virus infections (8.5%). Among the first step's systematic tests, tuberculin skin test was the most contributive investigation (17.1%), followed by chest X-ray (8.4%), C reactive protein and ESR (6.6% and 5.1%), complete blood count (2.2%) and VDRL (2.0%). The second step's most often contributive tests were: HLA B27 (56.3%), chest-CT (30.3%) and angiotensin converting enzyme (ACE) (16.5%). HLA B27 and ACE were significantly more contributive in the standardized group than in the open group. Immunological tests were never contributive. Among the free investigations, or among the investigations guided by clinical or paraclinical findings, the most often contributive tests were: Quantiferon® (24%), electrophoresis of serum protein (7.8%) and sacroiliac imagery (46.4%). Intracellular serologies (1.7%), serum calcium (2.1%) and hepatic tests (3.3%) were exceptionally contributive. Among the third intention tests, labial salivary gland biopsies were contributive in 17.9% of cases, but the profitability of other invasive investigations (anterior chamber tap, vitrectomy, bronchoscopy and lumbar puncture) or specialized imagery (18F-FDG PET, Brain MRI) could not be determined since these test were rarely performed. CONCLUSION: Only a few diagnostic tests are useful for the etiological assessment of uveitis. They are often cheap, simple, more often guided by the clinical findings, and lead to an etiological diagnosis in most patients. On the other hand, some tests are never or exceptionally contributive, such as immunological tests or intracellular serologies. Further studies are required to evaluate the profitability of third intention imagery and invasive investigations.

Polymerase chain reaction identification in aqueous humor of patients with postoperative endophthalmitis.

PURPOSE: To identify bacterial agents in the aqueous humor of patients with postoperative endophthalmitis using eubacterial polymerase chain reaction (PCR) and conventional culture. SETTING: University Hospital of Lyon E. Herriot, Lyon, France. METHODS: Broad-range eubacterial PCR amplification followed by direct sequencing was used to identify microbial pathogens in ocular samples from 30 patients with acute or delayed-onset endophthalmitis, mainly after cataract surgery. Ocular samples included aqueous humor collected before the first intravitreal injection of antibiotics and vitreous samples collected at the time of the therapeutic pars plana vitrectomy. RESULTS: Cultures were positive in 32% of cases and PCR in 61% of cases with aqueous humor samples. When associated, culture and PCR of aqueous humor samples allowed for a microbiological diagnosis in 71% of cases. Microorganisms cultured by conventional techniques matched those identified by PCR. When applied on vitreous pretreated with intravitreal antibiotics, PCR increased the identification rate from 18% to 62%. CONCLUSIONS: Polymerase chain reaction assay of initial aqueous humor samples contributed to the diagnosis of endophthalmitis in 30% of cases. Previous use of intravitreal antibiotics did not seem to affect the ability to PCR-amplify DNA in the short term. Polymerase chain reaction-based technology was a useful adjunct to conventional culture because when used with aqueous humor samples only, the association of both techniques allowed for a microbiological diagnosis in 71% of cases of postoperative acute and delayed-onset endophthalmitis.

Longitudinal study of retinal status using optical coherence tomography after acute onset endophthalmitis following cataract surgery.

PURPOSE: To analyse the macula imaged with optical coherence tomography (OCT) in patients treated for acute postcataract endophthalmitis. METHODS: Patients presenting with acute postcataract endophthalmitis were included in this observational and multicentre study from January 2008 to December 2011. We recorded the following OCT data at the 3, 6 and 12-month visits: the central macular thickness, the perifoveal macular thickness, the central foveal point thickness and abnormalities of the outer retina, the macula and vitreoretinal interface. RESULTS: 46 patients were included in the OCT analysis. From month 3 to 12, epiretinal membrane (ERM) prevalence increased from 26% to 39%, vitreomacular traction prevalence decreased from 12% to 6%, non-tractional macular oedema (ME) prevalence varied between 7% and 13%. Only macular thinning remained stable at 10%. At month 12, a significant correlation was found between non-tractional ME and capsular rupture (at the time of cataract extraction, p=0.03). Eyes with an ERM exhibited increased central macular thickness (p=0.001) and lower visual acuity (VA) (p=0.02) at M12 in comparison to the group with normal macula. OCT analysis showed a significant association between ERM and the alteration of the ellipsoid band (p=0.02), as well as the external limiting membrane (ELM, p=0.07) at M12. CONCLUSIONS: ERM and ME were the main macular abnormalities diagnosed after 1 year of follow-up, associated with VA less than or equal to 20/40 in 50% of the cases. Ultrastructural abnormalities of the ELM and the ellipsoid band were frequently observed in those patients.

Randomized Controlled Trial Evaluating a Standardized Strategy for Uveitis Etiologic Diagnosis (ULISSE).

PURPOSE: To prospectively assess the efficiency of a standardized diagnostic approach, compared to an open strategy, for the etiologic diagnosis of uveitis. DESIGN: Noninferiority, prospective, multicenter, clustered randomized controlled trial. METHODS: Consecutive patients with uveitis, who visited 1 of the participating departments of ophthalmology, were included. In the standardized group, all patients had a minimal evaluation regardless of the type of uveitis (complete blood count, erythrocyte sedimentation rate, C-reactive protein, tuberculin skin test, syphilis serology, and chest radiograph) followed by more complex investigations according to ophthalmologic findings. In the open group, the ophthalmologist could order any type of investigation. Main outcome was the percentage of etiologic diagnoses at 6 months. RESULTS: Nine hundred and three patients with uveitis were included from January 2010 to May 2013 and the per-protocol population comprised 676 patients (open 373; standardized 303). Mean age at diagnosis was 46 years. Anatomic distribution of uveitis was as follows: anterior (60.8% and 72.3%, P = .0017), intermediate (11.7% and 12.3%, P = .8028), posterior (17.8% and 8.2%, P = .0004), and panuveitis (15.3% and 15.2%, P = .9596). An etiologic diagnosis was established in 54.4% of cases in the open group and 49.5% in the standardized group (P = .2029). The difference between both strategies (standardized minus open) was -4.9% (95% CI [-12.5%; 2.6%]). There were more investigations in the open group than in the standardized group (5371 vs 3759, P < .0001). CONCLUSION: The standardized strategy appears to be an efficient diagnostic approach for the etiologic diagnosis of uveitis, although its noninferiority cannot be proved.

Polypoidal choroidal vasculopathy in tilted disk syndrome and high myopia with staphyloma.

PURPOSE: To describe polypoidal choroidal vasculopathy as a complication of tilted disk syndrome and high myopia with staphyloma. DESIGN: Retrospective interventional case series. METHODS: This report was a multicenter evaluation of six patients (eight eyes) with tilted disk syndrome or high myopia that was complicated by posterior staphyloma. Complete ophthalmic examination that included fluorescein angiography, optical coherence tomography (OCT), and indocyanine green angiography (ICG-A) was performed in all patients. RESULTS: All patients had macular abnormalities and visual loss. Fundus examination and fluorescein angiography showed typical features of tilted disk syndrome (five patients; six eyes) or high myopia (one patient; two eyes) with staphyloma that was associated with polypoidal choroidal vasculopathy. OCT and ICG-A confirmed the presence of polypoidal dilations in the choroid. Seven eyes were treated with laser photocoagulation or verteporfin-photodynamic therapy (V-PDT), although one eye did not require treatment. Visual acuity at the final visit had improved in three eyes, deteriorated in three eyes, and remained unchanged in two eyes. CONCLUSION: Polypoidal choroidal vasculopathy is a potential cause of visual loss in tilted disk syndrome and high myopia. We postulate that choroidal abnormalities at the border of staphylomas induce blood-flow disturbances that are similar to those disturbances that are observed in chronic central serous chorioretinopathy, which is another condition that occasionally is associated with polypoidal choroidal vasculopathy. The pathogenesis remains unclear, and further study is required to better understand the formation of choroidal polypoidal dilations in these conditions.

Heterochromatic Flicker Photometry for Objective Lens Density Quantification.

PURPOSE: Although several methods have been proposed to evaluate lens transmittance, to date there is no consensual in vivo approach in clinical practice. The aim of this study was to compare ocular lens density and transmittance measurements obtained by an improved psychophysical scotopic heterochromatic flicker photometry (sHFP) technique to the results obtained by three other measures: a psychophysical threshold technique, a Scheimpflug imaging technique, and a clinical assessment using a validated subjective scale. METHODS: Forty-three subjects (18 young, 9 middle aged, and 16 older) were included in the study. Individual lens densities were measured and transmittance curves were derived from sHFP indexes. Ocular lens densities were compared across methods by using linear regression analysis. RESULTS: The four approaches showed a quadratic increase in lens opacification with age. The sHFP technique revealed that transmittance decreased with age over the entire visual spectrum. This decrease was particularly pronounced between young and older participants in the short (53.03% decrease in the 400-500 nm range) wavelength regions of the light spectrum. Lens density derived from sHFP highly correlated with the values obtained with the other approaches. Compared to other objective measures, sHFP also showed the lowest variability and the best fit with a quadratic trend (r2 = 0.71) of lens density increase as a function of age. CONCLUSIONS: The sHFP technique offers a practical, reliable, and accurate method to measure lens density in vivo and predict lens transmittance over the visible spectrum. An accurate quantification of lens transmittance should be obtained in clinical practice, but also in research in visual and nonvisual photoreception.

Impacts of users' antisocial behaviors in an ophthalmologic emergency department--a qualitative study.

BACKGROUND: Health-care workers in emergency departments are frequently exposed to risk of antisocial behavior and violence (ABV) by users. Underreporting of ABV by health-care professionals has been identified. In order to understand this phenomenon, we explored the experience of ABV in 30 health workers in an ophthalmology emergency department in the Rhône-Alpes administrative region of France. METHODS: A grounded theory qualitative approach was followed. Data were collected from field observations, 30 semistructured individual interviews, violence report forms, and 364 patient satisfaction questionnaires. Qualitative thematic content analysis of the interviews was performed with qualitative data analysis software. RESULTS: Third-party antisocial behaviors and violence were an everyday occurrence, with varying levels of seriousness: impoliteness, vulgarity, nonrecognition, insults, verbal threats, and aggressive gestures. Health-care workers adopted various strategies to adapt to such violence: proactive and reactive attitudes and avoidance. Several organizational factors concerning the political and economic context, hospital work organization, and health workers' behavior were identified as potentially contributing to ABV. Excessive waiting times, lack of user information, and understaffing emerged as factors contributing to users' ABV. CONCLUSIONS: Antisocial behaviors by hospital users are underreported by professionals and under-recognized. They appear to be like continuous occupational exposure leading to delayed adverse consequences either on workers' health or motivation. However, violence in hospitals is not the result of only the action of users, and it may be related to work organization and workers' own behaviors. Only a grounded analysis of the causes of violence in the local work context can uncover relevant solutions.

Occurrence and risk factors for retinal detachment after pars plana vitrectomy in acute postcataract bacterial endophthalmitis.

BACKGROUND/AIMS: To report the incidence, risk factors and prognosis of retinal detachment (RD) in patients who had vitrectomy for acute bacterial endophthalmitis after cataract surgery. METHODS: 123 patients with acute postcataract endophthalmitis, consecutively treated with pars plana vitrectomy (PPV) were included by the French Institutional Endophthalmitis Study group, in a prospective multicentre cohort study. Risk factors of RD were analysed using logistic regression. RESULTS: At the 6-month follow-up, the rate of post-PPV RD was 13% (n=16). The risk factors of post-PPV RD were diabetes (OR=4.7 (1.4-15.4), p=0.01) and visualisation of retinal vasculitis on the posterior pole (OR=3.8 (1.1-13.9), p=0.03) at the time of PPV. Postoperative RD occurred in 56% (n=9) of cases in the first month, in 31% (n=5) in the second month and in 6% (n=1) in the third month, with a mean delay of 47±71 days after PPV. The macula was detached in 12 cases (75%) and proliferative vitreoretinopathy grade C was present in seven cases. Final successful reattachment of the retina was obtained in 60% (n=9/15) of cases, with one (7/9) or two surgeries (2/9). Final visual acuity after surgical repair was ≥20/40 in 19% of cases, compared with 43% in patients without RD (p=0.05). CONCLUSIONS: RD is a major and severe complication of PPV performed in patients with acute postcataract endophthalmitis. Retinal vasculitis is a major risk factor of RD after PPV. Anatomical and functional outcome remain poor.