[Indications for fluorescein angiography and optical coherence tomography angiography (OCTA) in medical retina: Changes from 2015 and 2018]. / Indications d'angiographie à la fluorescéine et d'OCT-angiographie en consultation de rétine médicale : comparaison entre 2015 et 2018.

INTRODUCTION: Non-invasive multimodal imaging, including optical coherence tomography angiography (OCTA), has demonstrated high sensitivity and specificity for the management of retinal diseases. Since the availability of OCTA in 2015, we have developed a policy of "as little fluorescein angiography as possible". In this study, we describe the rate of OCTA and fluorescein angiography (FA) performed and their indications. METHODS: Retrospective descriptive single-centre study. Chart review of patients examined for retinal disorders by one medical retina specialist between January 2015 and June 2018. RESULTS: 3487 patients were examined for a retinal disease. The charts of 651 of these patients (1170 eyes) were randomly selected for analysis (study group). The mean age in the study group was 72 years (60% female). Overall, OCTA and FA were performed in 49.4% and 6.5% of the studied eyes respectively. After the first year, the rate of FA decreased to 2%. The main indications for OCTA were age-related macular degeneration (AMD): 50%, central serous chorioretinopathy (CSC): 12% and retinal vascular occlusion: 10%. The most frequent indications for FA were AMD: 49%, diabetic retinopathy (DR): 18% and CSC: 14%. FA was performed in 16%, 11% and 10% of eyes diagnosed with DR, CSC and AMD respectively (P<0.05). CONCLUSION: In routine practice, OCTA was performed in half of the eyes examined for a retinal disorder. The overall rate of FA was 6.5% and dropped to 2% after the first year of OCTA use. DR was the main disorder still requiring FA.

[Qualitative and quantitative study of ophthalmologic consultation in France: A multicenter descriptive survey]. / Étude qualitative et quantitative de la consultation ophtalmologique en France : enquête multicentrique descriptive.

This study aimed to precisely map current ophthalmologic consultation in France through systematic data collection in one consultation day. Nine ophthalmologic centers participated in the survey, performing 1148 observations of patients aged from 2 to 102 years old, with a mean of 55.12years old and a male/female distribution of 43.8 %/56.2 %. In general, the patients came in either spontaneously (28.8 %) or for follow-up (59.6 %). Emergency consultations comprised 5.7 % of all cases. Comorbidities or major risk factors were found. Most the patients already wore visual correction (82.6 %), mainly glasses (77.3 %). At the end of the consultation, 48.2 % received a prescription for new optical correction. During the interview, 53.3 % of patients reported visual symptoms, most frequently blurriness, distortion or loss of vision. 25.3 % of the patients experienced ocular symptoms such as pain, watery eyes or itching. An ophthalmic disease was the reason for the consultation in 77.1 % of all cases. Its management included medicinal and/or surgical treatment (45.6 % and10.5 % respectively). The necessary tests were performed on site the same day and only 2.6 % of the patients were given a prescription for additional testing to be performed elsewhere in a referral center. From a qualitatively and quantitatively representative sample, this survey describes ophthalmologic consultation in France today in terms of age, male/female distribution, reason for the visit, the proportion of visual correction and other diseases, diagnosis and treatment.

[Extemporaneous withdrawal with a mini-spike filter: A low infection risk technique for drawing up bevacizumab for intravitreal injection]. / Prélèvement extemporané du bévacizumab avec un mini-spike pour les injections intravitréennes : une technique de déconditionnement à risque infectieux minime.

PURPOSE: To describe a technique for extemporaneously drawing up bevacizumab for intravitreal injection (IVT) and report the rate of post-injection endophthtalmitis. PATIENTS AND METHODS: Retrospective monocentric analysis (January 2010-December 2014) of all IVT of bevacizumab drawn up with the following technique: in the operating room (class ISO 7) through a mini-spike with an integrated bacteria retentive air filter. The surgeon was wearing sterile gloves and a mask. The assisting nurse wore a mask. The bevacizumab vial was discarded at the end of each session. RESULTS: Six thousand two hundred and thirty-six bevacizumab injections were performed. One case of endophthalmitis was noted (0.016%). During the same period, 4 cases of endophthalmitis were found after IVT of other drugs (4/32,992; 0.012%. P=0.8). CONCLUSION: Intravitreal injection of bevacizumab after extemporaneous withdrawal through a mini-spike filter is a simple and safe technique. The risk of postoperative endophthalmitis is very low. This simple technique facilitates access to compounded bevacizumab.

[Triamcinolone-assisted vitrectomy in the treatment of recurrent retinal detachment due to myopic macular hole]. / Vitrectomie assistée par triamcinolone dans le traitement des récidives de décollement de rétine par trou maculaire du myope fort.

PURPOSE: To report the use of triamcinolone-assisted vitrectomy to assess the cause of vitrectomy failure in the treatment of retinal detachment due to myopic macular hole. OBSERVATIONS: We report the cases of three myopic patients presenting with recurrent retinal detachment due to macular hole after initial vitrectomy treatment with posterior vitreous detachment, a systematic attempt at membrane peeling, and gas injection (SF6). No retinal traction or tear other than the macular hole was observed. The recurrence of retinal detachment was treated with vitrectomy and intraoperative use of triamcinolone, which demonstrated persistent posterior hyaloid and thin and strongly adherent membrane remnants in each case. Anatomic success was obtained after peeling these structures. CONCLUSION: Intraoperative use of triamcinolone reduces the risk of overlooking hyaloid or membrane remnants during vitrectomy for the treatment of myopic retinal detachment. Transparent remnants of posterior hyaloid and membranes were visualized by triamcinolone-assisted vitrectomy. They could lead to traction on the retina and explain the failure of the initial vitrectomy. Anatomic success was obtained after peeling these structures.

[Efficiency of surgical treatment for chronic macular edema due to branch retinal vein occlusion]. / Efficacité du traitement chirurgical de l'oedème maculaire chronique secondaire à une occlusion de branche veineuse rétinienne.

INTRODUCTION: Internal limiting membrane peeling has recently given interesting results in the management of macular edema in diabetic patients, even in the absence of vitreomacular tractions. This study was conducted to evaluate the results of a surgical treatment for macular edema resulting from branch retinal vein occlusion. MATERIAL AND METHODS: A nonrandomized prospective study was conducted between March 2001 and April 2002 on 12 eyes of 12 consecutive patients with a visual acuity of 20/40 or less resulting from branch retinal vein occlusion with macular edema. Internal limiting membrane peeling associated with arteriovenous crossing sheathotomy was performed on six eyes and internal limiting membrane peeling alone was performed on six eyes. Patients were tested with ETDRS visual acuity, fluorescein angiography, automated perimetry, and OCT pre- and postoperatively (at 3 and 6 months). RESULTS: At 6 months, postoperative visual acuity was improved in all patients (mean VA=20/40; range, 20/125-20/20), with an average gain of three lines of vision (or 14 ETDRS points) (p=0.002). Fundus examination and fluorescein angiography results were improved in all patients. At 6 months, on automated field testing, the mean corrected defect improved from 3.4+/-0.9dB to 2.3+/-0.9dB (p=0.008). On OCT, mean foveal thickness decreased from 419+/-57 micro m to 233+/-10 micro m (p=0.02). No difference was noted between simple vitrectomy with internal limiting membrane peeling and arteriovenous crossing sheathotomy in terms of visual acuity (p=0.5), visual field (p=0.2), or foveal thickness (p=0.6) improvement. CONCLUSION: Our findings suggest that internal limiting membrane removal for macular edema may improve the functional prognosis in patients with branch retinal vein occlusion. Adventitial sheathotomy did not yield further functional benefits in these cases.

[Radial optic neurotomy for severe central retinal vein occlusion: preliminary results]. / Traitement des occlusions sévères de la veine centrale de la rétine par neurotomie optique radiaire. Résultats préliminaires.

PURPOSE: To describe the results of radial optic neurotomy for the treatment of severe central retinal vein occlusion. PATIENTS AND METHODS: Prospective noncomparative single-center study. Analysis of ten eyes of ten consecutive patients whose visual acuity was 0.1 or less. They underwent fluorescein angiography, visual field testing by automated perimetry, and macular thickness analysis by optical coherence tomography preoperatively at 3 months and at 6 months postoperatively. RESULTS: Mean visual acuity on an ETDRS chart increased from 30+/-12 points preoperatively to 42+/-15 points at the 3-month visit, (p=0.03), and mean macular thickness decreased from 580+/-150 micro m to 361+/-52 micro m (p=0.04). All patients had clinical improvement as determined by fundus examination and fluorescein angiography. An improvement in the central visual field was observed in all eyes. Mean visual acuity of the five patients followed-up for 6 months was 52.8+/-20 points. No visual loss was observed. None of the patients underwent laser photocoagulation or has presented with neovascularization so far. Optociliary veins developed in three eyes and a retinochoroidal anastomosis within the disk incision was observed in two eyes. CONCLUSION: These preliminary results are encouraging when compared to the reported natural progression of severe central retinal vein occlusion. A bypass of the site of occlusion is a possible mechanism for radial optic neurotomy. A randomized study should be conducted to assess the efficacy of radial optic neurotomy and determine the best candidates for surgery.

Juxtapapillary subretinal pigment epithelial polypoid pseudocysts associated with unilateral tilted optic disc: case report with clinicopathologic correlation.

OBJECTIVE: To describe the unique preoperative appearance, successful postoperative clinical course, and histopathologic features of a cluster of progressively enlarging pseudocysts that arose at the temporal margin of a unilateral tilted optic disc. STUDY DESIGN: Case report. METHODS: Clinical observation, color fundus photography, fluorescein angiography, and optical coherence tomography, as well as routine histologic and immunohistochemical studies of tissue removed by subretinal surgery. RESULTS: Subretinal surgical excision of the lesions resulted in retinal reattachment with improved postoperative visual acuity. Histologic examination disclosed a cluster of fluid-filled polypoid pseudocysts lined by small vessels of choroidal origin lying beneath the basement membrane of the overlying retinal pigment epithelium (RPE). CONCLUSIONS: We postulate that buds of small vessels of choroidal origin grew through or around the edge of Bruch's membrane at the temporal margin of the tilted optic disc and then passed under the juxtapapillary RPE. Ensuing leakage of proteinaceous fluid from these vessels eventuated in formation of a cluster of polypoid pseudocysts and subsequent localized papillomacular retinal separation with visual loss. The lesions were amenable to subretinal surgical removal with restoration of visual acuity.

[Clinical features of gliomas of the chiasma. A retrospective study of a series of 18 patients]. / Particularités cliniques des gliomes du chiasma. Etude rétrospective sur une série de 18 patients.

Eighteen patients with a glioma of the chiasma were managed between 1980 and 1994. A retrospective analysis of this series showed that the most frequent functional ophthalmological signs were visual loss, nystagmus, or strabismus. Funduscopic examination was abnormal in 65%, mostly with optic atrophy. Other exams (visual field and electrophysiology) were inadequate for diagnosis. Our series demonstrated that early diagnosis of involvement of the chiasma could improve functional prognosis as rapid management can improve prognosis.

[Facial hemangioma associated with arterial anomalies, coarctation of the aorta, and eye abnormalities: PHACES syndrome]. / Hémangiome facial associé à des anomalies artérielles et oculaires et à une coarctation de l'aorte : syndrome PHACES.

BACKGROUND: Hemangiomas are frequent in childhood. Their association with dysmorphic anomalies is rare. Recently, the acronym "PHACES syndrome" was proposed to emphasize the association of Posterior fossa malformations, Hemangiomas, Arterial anomalies, Coarctation of the aorta and cardiac defects, Eye abnormalities, and Sternal malformations. CASE REPORT: A female child, 3 months old, had a large facial hemangioma. The physical examination was normal otherwise. A choroidal hemangioma and a papillary abnormality, causing amblyopia, were detected. The brain magnetic resonance imaging was normal. A subglottic hemangioma was found at endoscopy. At the age of 16 months, physical examination disclosed a heart murmur and coarctation of the aorta was detected. Moreover, the cardiac angiography showed diffuse arterial lesions. Strict surveillance was decided as there were no manifestations. DISCUSSION: Different abnormalities have been described to be associated with large facial hemangiomas. Frieden has grouped these abnormalities under the acronym PHACES. She described 43 hemangiomas and found 74 p. 100 Dandy Walker malformations and other posterior fossa malformations, 41 p. 100 arterial anomalies, 26 p. 100 cardiac or aortic malformations, 23 p. 100 ophthalmologic abnormalities. There is a high risk for the hemangiomas to develop in an airway localization. The prevalence of facial hemangiomas associated with other malformations is, to our knowledge, not known. In our department, 56 children were treated with corticosteroid therapy for severe facial hemangioma. 11 p. 100 had a cerebral abnormality. There were no cases with cardiac malformation or dysmorphism. PHACES syndrome is very rare but easy to remember. Thus in patients presenting a large facial hemangioma, it is important to conduct an attentive neurological examination completed by brain imaging and an extensive cardiovascular exploration. Special attention should be given to the ophthalmologic and sternal examinations as well as the search for hemangiomas in an airway localization.

[Persistence of the pupillary membrane. Apropos of 3 cases]. / Persistance de la membrane pupillaire. A propos de 3 cas.

Persistent pupillary membrane has in most cases no functional consequence. Nevertheless, a thick membrane involving visual axis sometimes requires surgical removal. We describe three cases of this surgery with pathologic examination and functional results.

[Deep sclerectomy in congenital glaucoma. Preliminary results]. / Sclérectomie profonde dans le glaucome congénital. Résultats préliminaires.

PURPOSE: Trabeculectomy is an efficient procedure for congenital glaucoma, but can lead to postoperative complications. These complications seem to be less frequent with deep sclerectomy. The aim of this study is to evaluate results of this surgical technique for congenital glaucoma. MATERIALS AND METHODS: Twelve eyes from eight patients (age 2 to 84 months) with congenital glaucoma underwent sclerectomy and were followed-up for 10 months postoperatively. Success criteria was intraocular pressure inferior to 16 mm Hg under general anaesthesia. RESULTS: No per or immediate postoperative complication was observed. For nine eyes (75%), intraocular pressure was controlled at final examination. For three eyes, postoperative intraocular pressure was elevated and one of them underwent re-operation. CONCLUSIONS: Success rate of sclerectomy for congenital glaucoma is equivalent to trabeculectomy. Absence of anterior chamber opening diminishes postoperative complications risk. Further study with longer follow-up is currently under evaluation.

Extensive brain calcification in two children with bilateral Coats' disease.

We report two children with bilateral Coats' disease associated with cerebral calcifications in the basal ganglia and deep white matter, asymptomatic at the time of their discovery. Cerebellar ataxia developed secondarily in one of them. Both children were born small for date and had febrile convulsive seizures. Three similar patients have been previously reported, two of them in the same sibship; the third reported patient died of aplastic anemia. Bilateral Coats' disease in children should prompt systematic CT scan in search of cerebral calcifications. If present, neurological and genetic prognosis should be cautious.

Ocular surface inflammatory changes induced by topical antiglaucoma drugs: human and animal studies.

OBJECTIVES: To investigate conjunctival and trabecular specimens from patients with glaucoma according to the duration and number of drugs received before filtration surgery, and to confirm, in a complementary experimental model, the role of preservative by comparing the effects of preserved and nonpreserved timolol. STUDY DESIGN: Experimental animal and human tissue study. PARTICIPANTS: Paired specimens of conjunctiva and trabeculum were taken from 61 patients undergoing trabeculectomy. Twenty-six patients were treated with 2 or more drugs for at least 1 year; 30 had received a beta-blocker for more than 1 year and 5 underwent primary surgery. A second study was performed in 25 rats receiving topical solutions in both eyes for 1 month. INTERVENTION: Immunohistochemistry was performed in all biopsy specimens using 12 different monoclonal antibodies. Ocular structures from rats treated for 1 month with preserved 0.5% timolol, nonpreserved 0.5% timolol, or 0.01% benzalkonium chloride were similarly investigated in an experimental study. MAIN OUTCOME MEASURES: Inflammatory cell infiltrates and fibroblasts were evaluated in biopsies, as well as in animal specimens, together with histologic changes induced by the drugs applied. RESULTS: Twenty-four of 26 conjunctivae and 21 of 24 trabecular pieces from multitreated patients were found to be abnormally infiltrated by cells expressing inflammatory or fibroblastic markers or both. Nineteen of 30 conjunctivae and 9 of 22 trabeculums in the monotherapy group and only 1 of 5 specimens from the primary surgery group were abnormal. In rats, preserved timolol and benzalkonium similarly showed infiltrates together with toxic histopathologic changes as compared to the nonpreserved timolol and control groups. CONCLUSIONS: These two combined studies confirmed histopathologic effects of antiglaucomatous drugs on the conjunctiva and showed similar effects in the trabecular meshwork. The experimental study showed that benzalkonium chloride is at least, to a large part, responsible for these toxic or immunoinflammatory effects or both on the ocular structures.

Effects of EGb761 and superoxide dismutase in an experimental model of retinopathy generated by intravitreal production of superoxide anion radical.

BACKGROUND: A study was carried out to investigate the effect of two antioxidants--Ginkgo biloba extract (EGb761) and superoxide dismutase (SOD)--in an experimental model of vitreoretinopathy obtained by direct production of oxygen free radicals in the vitreous cavity. METHODS: Twenty-eight pigmented rabbits were used. Vitreoretinopathy was induced by intravitreal injection of 50 microliters of a mixture composed of 40 nmol of xanthine and 0.001 IU of xanthine oxidase. Rabbits were randomly distributed into four groups: Group 1 (n = 8) did not receive any treatment and served as a positive control. Groups 2 (n = 8) and 3 (n = 8) received for 1 month EGb761 given orally at a dose of 100 mg/kg/day, respectively 1 day after and 1 week before induction of retinopathy. Group 4 (n = 4) was treated by three intramuscular injections of 15,000 IU/kg of SOD, 24 h before induction and 24 and 48 h thereafter. Clinical evaluations and electroretinograms (ERG) were repeatedly performed until the animals were killed at day 28. Histological examinations and immunohistological procedures were performed to ascertain the origin and characteristics of the cellular proliferation and to compare vitreoretinal structures in the four groups. RESULTS: Intravitreal injection of xanthine-xanthine oxidase produced a strong inflammatory response with vitreous infiltrates and epiretinal membrane formation, inconstantly associated with retinal detachment. ERG showed a decrease of the a-, b- and c-waves beginning within a few hours after injection. Histologic evaluation found an intravitreal and epiretinal infiltration by leukocytes and epithelial-derived cells, dense vitreoretinal membranes and retinal detachments with occasional neovascularization. In the treated groups (groups 2-4), all clinical, electric and histologic data were significantly improved compared to the control group. However, no difference could be found among the three treated groups. CONCLUSION: This study demonstrates the strong pathologic effects of free radical production on the retina and the close relationships between free radicals, inflammatory pathways and vitreoretinal proliferative disorders. It also confirms the pharmacological interest of prevention by antioxidants and free radical scavengers.

[Value of lacrymal IgE determination and conjunctival cytology in the diagnosis of chronic conjunctivitis]. / Intérêt du dosage des IgE lacrymales et des empreintes conjonctivales dans le diagnostic des conjonctivites chroniques.

PURPOSE: Chronic conjunctival inflammatory diseases may depend upon various strongly intricated mechanisms. Discriminating allergy from nonspecific inflammation has become of striking importance for diagnosis and treatment. We investigated conjunctival inflammatory response by comparing two objective biological tools, tear IgE detection and HLA DR expression by conjunctival epithelium, as indirect indicators of activation of the Th1 and Th2 subsets, respectively. METHODS: Sixty-eight patients (135 eyes) with chronic conjunctivitis underwent tear IgE dosage by an ELISA technique and quantification of HLA DR expression in impression cytology specimens. 34 had direct or indirect clinical indications of allergic mechanisms, 22 had chronic conjunctivitis without any sign of allergy, and 12 suffered from isolated nonallergic dry eyes. RESULTS: Patients clinically considered as allergic only showed positive IgE in 31 out pf 68 eyes (46 per cent), whereas 11/44 (25%) and 7/24 (29%) eyes with nonspecific conjunctivitis and dry eyes respectively were also positive. HLA DR positivity in epithelial cells was found in 18/61 (29.5%), 15/40 (37.5%) and 9/22 (41%) eyes, respectively. HLA DR expression by epithelial cells was negatively correlated with tear IgE, as most specimens positive to one criterion were negative to the other one (37 eyes DR+ IgE-, 35 eyes DR- IgE+, and 5 eyes DR+ IgE+; chi-square: p = 0.0001). CONCLUSION: As IgE synthesis and HLA DR induction may represent indirect indicators of the activation of the Th1 and Th2 subsets, association of these two simple tests could be interesting for the routine assessment of the mechanisms of inflammatory ocular surface diseases.

Histopathological effects of topical ophthalmic preservatives on rat corneoconjunctival surface.

PURPOSE: Long term use of topical drugs has clearly been shown to induce toxic immunopathological changes in the ocular surface. However, little is known concerning the respective roles of active compounds and preservatives. Benzalkonium chloride (BAC) is the most used preservative and its cytotoxicity is well known, but other preservatives have not yet been clearly evaluated. We thus performed a comparative study to investigate toxic side effects induced in the rat ocular surface by applications of various preservatives, with special attention to inflammatory infiltrates. METHODS: A total of 35 brown Norway rats were divided into seven groups of five each. They received, for one month, in both eyes, either 0.01% cetrimonium chloride, 0.01% benzalkonium chloride, 0.01% benzododecinium bromide, 0.004% thiomersal, 0.05% methyl parahydroxybenzoate or phosphate-buffered saline (PBS), the last group remaining untreated. Then, animals were sacrificed and eyes were processed for histological and immunological procedures with monoclonal antibodies to rat immunocompetent cells. RESULTS: When compared to controls, all preservative-treated eyes consistently showed corneal and conjunctival damage, including epithelial alterations, various degrees of keratinization and inflammatory infiltrates at the limbus and within the conjunctival stroma and epithelium. No difference was found between the five tested drugs. CONCLUSIONS: This study confirms that most preservatives used in ophthalmic eyedrops may similarly induce strong histopathological and inflammatory changes in the ocular surface after short term use. Although obtained in animal model, these results confirm strong toxic side effects in patients with preexisting ocular surface disorders and/or receiving topical drugs for long periods.

Expression of Fas-Fas ligand antigens and apoptotic marker APO2.7 by the human conjunctival epithelium. Positive correlation with class II HLA DR expression in inflammatory ocular surface disorders.

Fas antigen (CD95) is a membrane receptor that plays a major role in induction of apoptosis. In surface conjunctival epithelial cells the expressions of Fas, Fas ligand, the apoptotic marker APO2.7 and of HLA DR class II antigen, a membrane marker known to be expressed in inflammatory conditions were investigated. Impression cytology specimens were collected in 65 patients: 20 normal ones, 15 contact lens wearers, 20 receiving chronic topical antiglaucoma treatment and 10 with nonspecific chronic conjunctivitis. Cells were processed for flow cytometry, using monoclonal antibodies to Fas, Fas ligand, APO2.7, HLA DR antigens and a negative isotypic control. Percentages of positive cells were recorded and levels of fluorescence quantified using fluorescent beads at standardized fluorescence intensities. In addition, a human conjunctival cell line was incubated with anti-Fas stimulating antibodies in order to test Fas-induced apoptosis in vitro. Fas was found in all specimens in most of the conjunctival cells, but quantitation of levels of fluorescence showed a significantly higher expression in pathologic eyes than in normal ones. Fas ligand and APO2.7 were variably expressed by conjunctival cells, but in a significantly higher percentage of cells in pathological eyes than in normal ones. In these eyes a strong expression of HLA DR was also observed, whereas normal eyes showed lowest levels. Highly significant correlations were found between Fas, Fas ligand, APO2.7 and HLA DR levels. Anti-Fas antibodies in vitro induced strong apoptosis in epithelial cells as confirmed by APO2.7 expression and DAPI staining. This study confirms that conjunctival epithelial cells normally express Fas antigen, and more inconstantly its ligand, as do corneal ones or keratinocytes. Fluorescence quantitation by flow cytometry showed much higher expression in inflammatory eyes than in normal ones, and demonstrated a strong correlation between apoptotic and inflammatory pathways in the ocular surface.