Dry Eye Disease in the Middle East and Northern Africa: A Position Paper on the Current State and Unmet Needs.

In the Middle East and Northern Africa (MENA), dry eye disease (DED) is often misdiagnosed or overlooked. This review summarizes a series of conversations with ophthalmologists in the region around a variety of climatic, lifestyle, and iatrogenic factors that contribute to specific features of DED in the MENA region. These considerations are further classified by patient lifestyle and surgical choices. All statements are based on discussions and formal voting to achieve consensus over three meetings. Overall, a deeper understanding of the disease characteristics of DED specific to MENA can better guide local eyecare practitioners on appropriate management and follow-up care. Additionally, population-based studies and patient and physician education on ocular surface diseases, together with the use of culturally appropriate and language-specific questionnaires can help ease the public health burden of DED in this region.

A Case of Painful Diplopia after COVID-19 Vaccination: Could It Be Tolosa-Hunt Syndrome?

Herein, we report a rare case of Tolosa-Hunt syndrome (THS) following coronavirus disease 2019 (COVID-19) vaccine administration. A 64-year-old patient presented with recurrent horizontal diplopia and ipsilateral orbital pain, 2 weeks after being administered the COVID-19 vaccination. A diagnosis of THS was based on the relevant criteria after ruling out the differential diagnoses. The clinical presentation improved with corticosteroid administration. THS must be recognized as a complication of COVID-19 vaccination. This association can be explained by an autoimmune response.

The contribution of simulation in training for pterygium surgery.

INTRODUCTION: Pterygium surgery is a closed globe surface surgery. Although it is perfectly standard and followed by excellent results, it is not exempt from the general rule that there is no surgery without risk. It therefore seems important to integrate simulation as a pedagogical tool for training ophthalmology residents in pterygium surgery. AIM: To evaluate the effectiveness of procedural simulation as a training tool for pterygium surgery. RESULTS: During the study period, eight residents participated in the three workshops. The global assessment of residents' knowledge showed a mean score of 3/5 [1.5/5-4/5] and 4.1/5 [3.25/5-5/5] before and after the training respectively. There was a significant negative correlation between the initial score on the pre-test and the improvement of this score on the post-test, with an r'=-0.87 and a p=0.005. We noted a significant improvement in the global performance score (p<0.001) and even a significant improvement in the specific performance score (p=0.02) between the 3 workshops. The average training satisfaction score was 13.87/16 [10/16-16/16]. We noted a significant positive correlation with r=0.838 and p=0.009 between knowledge improvement and learner satisfaction. CONCLUSION: The training of fundus examination using an ophthalmoscopic simulator can improve the skills and knowledge of ophthalmic learners. This type of training can be an innovative addition to traditional learning methods.

Case Report: an unusual orbital tumor.

Introduction Orbital lipoma is an extremely rare tumor, representing less than 1% of all orbital tumors. We review the literature and describe the presentation, the differential diagnosis and the management of this tumor. Case report We report the case of a 63-year-old patient who was referred for a diplopia with recent hemi-cranial headache. Physical examination showed no exophthalmos nor decrease in visual acuity. The patient complained of diplopia on elevation and oculomotricity examination showed limited elevation of the right eye. The Hess Lancaster test was in favor of a limited course of the right inferior rectus muscle. Magnetic resonance imaging revealed a fusiform tissue process in the right inferior rectus muscle with a fatty signal. A complete excision of the tumor was performed by a trasncunjonctival approach. Cytopathological examination was consistent with a pleomorphic lipoma. The postoperative period was uneventful. The definitive histopathologic diagnosis was a lipoma. The postoperative Magnetic resonance imaging showed the complete disappearance of the lesion. With 3 years of follow up, there is no sign of recurrence or ocular motility trouble. Conclusion: Lipomas are rare tumors in the orbit. The clinic is variable depending on the size and the site. The clinical diagnosis is difficult to make. Only histology allows the final diagnosis.

Case Report: Central retinal artery occlusion following sildenafil intake.

Purpose: To report a case of central retinal artery occlusion associated with sildenafil intake and briefly discuss its causative pathogenesis. Methods: A 50-year-old man with no premorbidities presented with symptoms of sudden severe visual field constriction in the left eye (LE). Best-corrected visual acuity in the LE was 20/25. Fundus examination and fluorescein angiography of the LE were suggestive of central retinal artery occlusion (CRAO) with cilioretinal artery sparing. Further investigation revealed that 100 mg of sildenafil had been taken for the first time three hours before the onset of symptoms. Results: The patient was treated promptly with intravenous acetazolamide, sublingual isosorbide dinitrate and ocular massage, but without visual recovery. No other associated systemic or local risk factors were found, and the case was classified as a potential complication of sildenafil. Conclusion: Although no direct link could be established, the aim of this report is to highlight the incidence and to consider this issue when evaluating any case of central retinal artery occlusion.

Case Report: Purtscher-like retinopathy in a patient with lung adenocarcinoma.

This case report describes an unreported case of  Purtscher-like retinopathy in a patient with pulmonary adenocarcinoma. A 39-year-old man was hospitalized for exploration of a hemoptysis and bilateral blurry vision. Fundoscopic examination showed multiple areas of retinal whitening in the peripapillary area. A chest computed tomography scan then showed a ground glass opacity in the right upper lobe associated to a hilar lymphadenopathy. A thoracotomy and lung biopsy were performed concluding with the diagnosis of lung adenocarcinoma. The patient was treated with high-dose corticosteroids and received Taxol-Carboplatin chemotherapy with good visual outcomes. The article discusses furthermore the importance of including pulmonary adenocarcinoma to the list of systemic conditions for Purtscher-like retinopathy.

Heterozygous factor V Leiden mutation manifesting with combined central retinal vein occlusion, cilioretinal artery occlusion, branch retinal artery occlusion, and anterior ischaemic optic neuropathy: a case report.

BACKGROUND: Our purpose was to describe a patient who developed combined central retinal vein occlusion (CRVO), cilioretinal artery occlusion, branch retinal artery occlusion (BRAO), and anterior ischaemic optic neuropathy (AION) followed by CRVO in the second eye because of the heterozygous factor V Leiden (FVL) mutation. CASE PRESENTATION: A 39-year-old female with a history of recurrent pregnancy losses presented with acute blurred vision in the right eye (RE), with visual acuity limited to counting fingers. She was diagnosed with combined impending CRVO, cilioretinal artery occlusion, BRAO, and AION. The results of thrombophilia testing, not including the FVL mutation, were negative. Retinal atrophy with vascular attenuation and optic disc pallor developed after resolution of acute retinal findings. Nine months after initial presentation, the patient developed an impending CRVO in the left eye (LE), with a secondary progression to a complete CRVO causing a decrease in best corrected visual acuity (BCVA) to 20/40. The patient was determined to be heterozygous for the FVL mutation. She subsequently was treated with acenocoumarol. At the last follow-up visit, the BCVA was 20/400 in the RE and 20/20 in the LE, and there was a complete resolution of the acute CRVO findings in the LE. CONCLUSION: Our case shows that the heterozygous FVL mutation may manifest with combined retinal vascular occlusion involving multiple sites in both eyes. Early recognition of such an inherited thrombophilic disorder is important because it implies the need for long-term anticoagulative therapy to reduce the patient's risk of recurrent, sight-threatening and life-threatening thrombotic events.

Case Report: Optical coherence tomography angiography findings in radiation retinopathy.

We reported the observation of a 31-year-old female followed for a nasopharyngeal carcinoma since 2009, treated by locoregional radiotherapy, with a cumulative dose of 75 Gray. The patient presented with a progressive decline in bilateral vision. Ophthalmologic examination revealed bilateral dry eye, posterior subcapsular cataract, radiation retinopathy, and optic neuropathy. The patient presented all ocular complications of radiotherapy. The most severe was radiation retinopathy. Performing optic coherence tomography angiography (OCT-A) earlier could have speeded up the diagnosis and led to a better prognosis. The OCT-A showed more pronounced macular edema in the right eye, and revealed enlargement of the central avascular zone and loss of the deep and superficial retinal vascular network. The patient received three consecutive monthly intravitreal injections of anti-vascular endothelial growth factor. Yet, we noted a non-improved visual acuity. The aim of this case report was to present the contribution of OCT-A in the diagnosis of radiation maculopathy and attribute these changes to ischemia at the level of the retinal vascular network.

Graves' Orbitopathy: Report of 82 cases.

INTRODUCTION: Graves' disease (GD) is a common autoimmune disorder. Graves'orbitopathy (GO) is its most common extrathyroidal manifestation. It is rare but may reveal the disease. AIM: To describe the demographic, clinical and therapeutic features of GO. METHODS: We carried out a retrospective and descriptive analysis of 82 patients with GO. This study was conducted in Ophthalmology and Endocrinology departments of Taher Sfar University Hospital in Mahdia, between January 2010 and December 2017. GD patients diagnosed with GO were included. RESULTS: The mean age was 36.17 years ± 12.81. Patients aged 19-40 years had the highest rate of GO. The male-to-female ratio was 0.49. Family history of autoimmune thyroid disease was present in 15% and associated autoimmune disease in 4% of cases. Smoking was seen in 71% of patients. The onset of GO was simultaneous with onset of GD in 45%, before in 21% and after the onset of GD in 34% of cases. GO was bilateral in 76% of patients. The most common ocular symptoms were prominent eyes (55% of patients), ocular pain (11%) and diplopia (41%). Proptosis and upper eyelid retraction were the most common clinical signs (93% and 90% respectively). Dysthyroid optic neuropathy was present in one eye, keratitis in one eye and glaucoma in five eyes. Severe disease was noted in 11% and active disease was present in 7% of patients. CT-scan and magnetic resonance imaging scan (MRI) were performed in 48% and 42% of cases respectively. Proptosis was the most common radiological sign. Thyroid dysfunction was managed with anti-thyroid medication only (59%), thyroxine replacement (37%), radioactive iodine (35%) and thyroidectomy (6%). 20% of patients received corticosteroids. One patient required immunosuppressive therapy. CONCLUSION: GO is a complex disease, which is associated with impaired quality of life and can potentially result in sight-threatening complications. Appropriate diagnosis, convenient therapy and a regular follow-up are necessary to improve results and avoid the aesthetic and functional sequelae.

The contribution of simulation in training for funduscopic examination.

INTRODUCTION: Simulation is emerging as an essential part of health sciences training programs as it provides safer patient care by reducing the risk of error. In the healthcare environment, simulation continues to spread in emergency specialties, but it is still underdeveloped in ophthalmology and there is a shortage of publications on this subject in Tunisia. OBJECTIVE: To evaluate the effectiveness of procedural simulation as a teaching tool for funduscopic examination training. Methods and population studied: This was a prospective study including students who underwent procedural simulation training sessions during their ophthalmology internship. The included students were assessed at the initiation and end of each session by a pre-test and post-test. The procedure for performing the funduscopic examination was evaluated by a specific performance score.  Student satisfaction was assessed at the end of each session. RESULTS: During the study period, four groups of 12 students were included, for a total of 48 participants spread over 4 simulation sessions. Simulation training improved post-test.  assessment scores with an overall median delta of +4.00. It also provided specific skills for performing the funduscopic examination, with an overall median specific performance score of 5.5/8 (5/8 to 7/8). The majority of students were satisfied upon completion of the simulation session. CONCLUSION: The training of fundus examination using an ophthalmoscopic simulator can improve the skills and knowledge of ophthalmic learners. This type of training can be an innovative addition to traditional learning.

Improvement in ocular symptoms and signs in patients with Demodex anterior blepharitis using a novel terpinen-4-ol (2.5%) and hyaluronic acid (0.2%) cleansing wipe.

Purpose: To evaluate the clinical improvement in ocular symptoms and signs in patients suffering from Demodex anterior blepharitis after using a novel cleansing wipe impregnated with 2.5% terpinen-4-ol and 0.2% hyaluronic acid. Study design: This was an exploratory, multicenter, open, randomized, two-parallel group comparative study. Methods: Forty-eight patients with Demodex anterior blepharitis were randomly assigned to apply the sterile wipe T1172 (Blephademodex®), either once daily (n=24, Group 1) or twice daily (n=24, Group 2) for 29 days. Overall ocular discomfort and other individual symptoms were measured using a 0-10 numeric rating scale at Day 8 and Day 29. Ocular signs, including eyelid margin hyperemia and number of cylindrical dandruff, were examined at slit lamp. Overall treatment performance by investigator, patient satisfaction and tolerance were evaluated with questionnaires. Results: Overall ocular discomfort was significantly reduced from baseline (p<0.0001) in both groups at Day 8 (-3.6±0.3 in Group 1 and -4.0±0.4 in Group 2) and Day 29 (-5.7±0.4 and -6.8±0.7, respectively), with no difference between groups (D8: p=0.718; D29: p=0.505). Each ocular symptom associated with Demodex blepharitis was improved in both groups. Eyelid margin hyperemia was significantly reduced at Day 8 (-0.7±0.7; p<0.001) and Day 29 (-1.1±0.7; p<0.0001) in Group 1. Similar results were observed in Group 2 (Day 8: p<0.001; Day 29: p<0.0001). Total disappearance of cylindrical dandruff was reported in 30.4% of patients in Group 1 and 43.5% in Group 2. Improvements in other ocular signs were observed in both groups. The product was well tolerated. All patients were satisfied or very satisfied and would continue using it. Conclusion: Daily eyelid hygiene using this cleansing wipe impregnated with 2.5% terpinen-4-ol and 0.2% hyaluronic acid during a 4-week period led to a rapid and marked reduction in ocular symptoms and signs associated with Demodex anterior blepharitis and was well tolerated.

Retinal dysfunction parallels morphologic alterations and precede clinically detectable vascular alterations in Meriones shawi, a model of type 2 diabetes.

Diabetic retinopathy is a major cause of reduced visual acuity and acquired blindness. The aim of this work was to analyze functional and vascular changes in diabetic Meriones shawi (M.sh) an animal model of metabolic syndrome and type 2 diabetes. The animals were divided into four groups. Two groups were fed a high fat diet (HFD) for 3 and 7 months, two other groups served as age-matched controls. Retinal function was assessed using full field electroretinogram (Ff-ERG). Retinal thickness and vasculature were examined by optical coherence tomography, eye fundus and fluorescein angiography. Immunohistochemistry was used to examine key proteins of glutamate metabolism and synaptic transmission. Diabetic animals exhibited significantly delayed scotopic and photopic ERG responses and decreases in scotopic and photopic a- and b-wave amplitudes at both time points. Furthermore, a decrease of the amplitude of the flicker response and variable changes in the scotopic and photopic oscillatory potentials was reported. A significant decrease in retinal thickness was observed. No evident change in the visual streak area and no sign of vascular abnormality was present; however, some exudates in the periphery were visible in 7 months diabetic animals. Imunohistochemistry detected a decrease in the expression of glutamate synthetase, vesicular glutamate transporter 1 and synaptophysin proteins. Results indicate that a significant retinal dysfunction was present in the HFD induced diabetes involving both rod and cone pathways and this dysfunction correlate well with the morphological abnormalities reported previously. Furthermore, neurodegeneration and abnormalities in retinal function occur before vascular alterations would be detectable in diabetic M.sh.

Electroretinographic evidence suggesting that the type 2 diabetic retinopathy of the sand rat Psammomys obesus is comparable to that of humans.

PURPOSE: Type 2 diabetic retinopathy is the main cause of acquired blindness in adults. The aim of this work was to examine the retinal function of the sand rat Psammomys obesus as an animal model of diet-induced type 2 diabetes when subjected to a hypercaloric regimen. MATERIALS AND METHODS: Hyperglycemia was induced in Psammomys obesus by high caloric diet (4 kcal/g). The visual function of control (n = 7) and diabetic (n = 7) adult rodents were followed up during 28 consecutive weeks with full-field electroretinogram(ERG) recordings evoked to flashes of white light according to the standard protocol of the International Society for Clinical Electrophysiology of Vision protocol (ISCEV). RESULTS: Twenty-eight weeks following the induction of diabetes, results revealed significantly reduced and delayed photopic and scotopic ERG responses in diabetic rats compared to control rats. More specifically, we noted a significant decrease in the amplitude of the dark-adapted 0.01ERG (62%), a- and b-wave amplitudes of the dark-adapted 3.0 ERG (33.6%, 55.1%) and the four major oscillatory potentials components (OP1-OP4) (39.0%, 75.2%, 54.8% and 53.7% respectively). In photopic conditions, diabetic rats showed a significant decrease in a- and b-wave (30.4%, 43.4%), photopic negative response (55.3%), 30 Hz flicker (63.7%), OP1-OP4(51.6%, 61.8%, 68.3% and 47.5% respectively) and S-cone (34.7%). Significantly delayed implicit times were observed for all ERG components in the diabetic animals. Results obtained are comparable to those characterizing the retinal function of patients affected with advanced stage of diabetic retinopathy. CONCLUSION: Psammomys obesus is a useful translational model to study the pathophysiology of diabetic retinopathy in order to explore new therapeutic avenues in human patients.

Bilateral acute angle-closure glaucoma following tramadol subcutaneous administration.

BACKGROUND: To report a case of bilateral acute angle closure-glaucoma following the use of subcutaneous Tramadol. CASE PRESENTATION: A 42-year-old healthy man with unremarkable past medical and ocular history, was admitted to the Orthopedic Department for surgical treatment of a bilateral open fracture of the femur following a road accident. Three hoursafterTramadolsubcutaneous injection, the patient complained of a bilateral acute painful visual loss with persistent vomiting. An ocular examination showed bilateral acute angle-closure-glaucoma. The patient was treated with topical anti-glaucoma therapy and intravenous Mannitol 20%.After resolution of ocular hypertension attack, NdYag laser peripheral iridotomy was performed on both eyes. After a follow-up period of 7 days visual acuity improved to 20/20 in both eyes and intraocular pressure returned to normal levels. CONCLUSIONS: This case highlights the risk of developing bilateral acute angle-closure glaucoma after Tramadol administration.

Anterior segment optical coherence tomography and retained vegetal intraocular foreign body masquerading as chronic anterior uveitis.

BACKGROUND: The purpose of this single case report was to report the use of anterior segment optical coherence tomography for the diagnosis and management of a retained vegetal intraocular foreign body. RESULTS: A 23-year-old otherwise healthy male presented with a progressive vision loss in the right eye (RE). He reported a mild ocular trauma with a tree leaf 1 year ago followed by recurrent episodes of redness and pain in the RE that partially resolved after a self-medication with topical steroids. Visual acuity of the RE was limited to light perception. Slit-lamp examination of the RE showed an iris granuloma with overlying exudate and associated anterior chamber inflammatory reaction. Film X-rays, contact B-scan ultrasonography, and CT scan showed no abnormalities. Anterior segment optical coherence tomography revealed an enclaved iris foreign body. The foreign body was removed after a short course of local antibio-corticosteroid therapy. This was followed 2 months later by cataract surgery with intraocular lens implantation, with subsequent improvement of visual acuity to 20/40. CONCLUSIONS: A missed intraocular foreign body can lead to sight-threatening complications. Anterior segment optical coherence tomography may be useful for detecting non-clinically evident intraocular foreign body involving the anterior segment masquerading as chronic anterior uveitis.

Characterizing the Retinal Function of Psammomys obesus: A Diurnal Rodent Model to Study Human Retinal Function.

PURPOSE: To compare the retinal function of a diurnal murid rodent, Psammomys obesus, with that of Wistar albino rat and human subjects. MATERIALS AND METHODS: Adult Psammomys obesus were captured and transferred to the animal facilities where they were maintained at 25°C with standard light/dark cycles and natural halophilic plants, rich in water and mineral salts. Standard full-field photopic and scotopic electroretinograms were obtained. RESULTS: The right eye of all animals displayed well detectable and reproducible scotopic and photopic electroretinogram (ERG) responses. Results were compared with those obtained from human subjects and Wistar rats. ERG measurement showed that the amplitudes of scotopic responses in Psammomys obesus are quite similar to those of human subjects. The amplitude of the photopic a-wave was comparable to that of humans and six times higher than that of the albino rat. The amplitudes of photopic b-wave, photopic oscillatory potentials (OPs), and 30 Hz flicker were all markedly larger in Psammomys obesus compared to those obtained from human subjects and Wistar rats. Furthermore, like the human photopic ERG, the photopic ERG of Psammomys obesus also includes prominent post b-wave components (i.e. i- and d-waves) while the ERG of Wistar rats does not. CONCLUSIONS: Our results suggest that the retinal function of Psammomys obesus, especially the cone-mediated function, shares several features with that of human subjects. We believe that Psammomys obesus represents an interesting alternative to study the structure and function of the normal and diseased retina in a human-like rodent model of retinal function.

A randomized, controlled study of the efficacy and safety of a new eyedrop formulation for moderate to severe dry eye syndrome.

PURPOSE: This study compared the efficacy and safety of hyaluronic acid (HA)-trehalose, a new eyedrop containing trehalose (a natural bioprotectant) and HA, to an established formulation containing only HA. METHODS: This was a phase III, randomized, active-controlled, investigator-masked, multicenter study in France and Tunisia. In all, 105 adult patients (≥18 years) with moderate to severe dry eye disease (DED) received either HA-trehalose (n = 52) or HA (n = 53) 3-6 times per day for 84 days. The primary efficacy variable was the Oxford grading score at day 35. A questionnaire on dry eye and symptoms, Schirmer test, tear break-up time, conjunctival hyperemia, and global performance were assessed as secondary efficacy criteria at baseline, day 35, and day 84. Safety assessments were standard. RESULTS: Noninferiority of HA-trehalose to HA for keratoconjunctivitis sicca assessed by Oxford grading score was demonstrated at day 35. For the secondary efficacy parameters, reductions in dry eye questionnaire classes of none or mild at day 84, dry eye symptoms of stinging, itching, and blurred vision at day 35, and investigator (days 35 and 84) and patient assessments (day 35) of global performance were significantly better for HA-trehalose. There were no clinically meaningful differences between groups for the other secondary criteria. Both treatments were well-tolerated, and there were fewer ocular symptoms upon instillation and fewer adverse events for HA-trehalose than for HA. CONCLUSIONS: Hyaluronic acid-trehalose is effective and safe, with better patient satisfaction, than existing HA-only eyedrops particularly from the first month of treatment, and offers a therapeutic advancement in the treatment of moderate to severe DED.

Orbital myositis revealing a vegetal intraorbital foreign body: a case report.

INTRODUCTION: Foreign intraorbital bodies are rare. Their clinical manifestation is usually late. CLINICAL CASE:     We report a case of 32 years-old man presenting an old vegetal foreign intraorbital body. The orbitotomy allowed its extraction with favorable result. DISCUSSION: Vegetal foreign intraorbital bodies have clinical aspects. The latency between the trauma and the onset of symptoms is variable. Radiological examination can identify exactly the size and location. Surgical removal is often necessary but can expose to major risks. CONCLUSION: The diagnosis of ignored intraorbital foreign body remains difficult. The management should be early in order to avoid severe functional consequences.

A 3-day regimen with azithromycin 1.5% eyedrops for the treatment of purulent bacterial conjunctivitis in children: efficacy on clinical signs and impact on the burden of illness.

PURPOSE: To compare the efficacy of azithromycin 1.5% versus tobramycin 0.3% eyedrops on clinical ocular signs and symptoms of bacterial conjunctivitis in children and to assess the parents' satisfaction regarding the dosing regimen. PATIENTS AND METHODS: An international, multicenter, randomized, investigator-masked, controlled clinical trial conducted in children (1 day to 18 years old) with bulbar conjunctival hyperemia and purulent discharge. Azithromycin 1.5% was administered as 1 drop twice daily for 3 days, and tobramycin 0.3% as 1 drop every 2 hours for 2 days, then 4 times daily for 5 days. RESULTS: A total of 286 patients (mean age: 3.2 years) were enrolled. In children with bacteriologically positive cultures (N=203), azithromycin produced a significantly greater improvement in conjunctival discharge (P<0.01) and a trend (P=0.054) toward improvement in conjunctival hyperemia at day 7 than did tobramycin. Complete resolution of conjunctival discharge was significantly more frequent at day 3 on azithromycin than tobramycin (P=0.005). More parents found azithromycin easier to use (in terms of treatment duration, total number of instillations, instilling drops during the day, and difficulty in performing daily activities) than tobramycin. CONCLUSION: The azithromycin 1.5% regimen produced a rapid resolution of cardinal signs of purulent bacterial conjunctivitis with a more convenient dosage regimen. Such improved convenience is likely to improve compliance and lessen the burden of illness for patients and carers.

Efficacy and safety of azithromycin 1.5% eye drops in paediatric population with purulent bacterial conjunctivitis.

OBJECTIVE: To determine the efficacy and safety of azithromycin 1.5% eye drops in a paediatric population with purulent bacterial conjunctivitis. PATIENTS AND METHODS: This was a multicentre, international, randomised, investigator-masked study in 286 children with purulent discharge and bulbar conjunctival injection. Patients received either azithromycin 1.5% eye drops (twice daily for 3 days) or tobramycin 0.3% eye drops (every 2 h for 2 days, then four times daily for 5 days). Clinical signs were evaluated on day (D) 0, 3 and 7, and cultures on D0 and D7. The primary variable was the clinical cure (absence of bulbar conjunctival injection and discharge) on D3 in the worse eye for patients with positive cultures on D0. RESULTS: 286 patients (mean age 3.2 years; range 1 day-17 years) were included; 203 had positive cultures on D0. Azithromycin was superior to tobramycin in clinical cure rate on D3 (47.1% vs 28.7%, p=0.013) and was non-inferior to tobramycin on D7 (89.2% vs 78.2%, respectively). Azithromycin treatment eradicated causative pathogens, including resistant species, with a similar resolution rate to tobramycin (89.8% vs 87.2%, respectively). These results were confirmed in a subgroup of patients younger than 24 months old. CONCLUSIONS: Azithromycin 1.5% eye drops provided a more rapid clinical cure than tobramycin 0.3% eye drops in the treatment of purulent bacterial conjunctivitis in children, with a more convenient twice-a-day dosing regimen.