COVID-19 pandemic and impact of universal face mask wear on ocular surface health and risk of infection.

Universal mask wear is an effective public health intervention to reduce SARS-Cov-2 transmission, especially in enclosed public spaces and healthcare environments. Concerns have been raised about possible transmission of the SARS-Cov-2 through ocular secretions, leading to enhanced protective measures during ophthalmic procedures. However, there is some evidence for air jets from the upper edge of the surgical mask to the ocular surface, especially when the mask is not well fit. Prolonged airflow towards the ocular surface during expiration may alter tear-film stability, leading to hyperosmolarity and ocular surface inflammation. This also raises the question of whether the ocular surface is contaminated with oral flora from airflow directed toward the eyes, thus increasing the risk of ocular infection. Herein we review the impact of patient face mask wear on the ocular surface, eyelids and risk of ocular infection, particularly during ocular surgery. There is some evidence for increased incidence of dry eye or eyelid disease during periods of mandatory face mask wear. While high daily exposure is consistent with a direct association, this should be mitigated by various cofounding factors which could also affect the ocular health during the COVID-19 pandemic. An increased risk of post-intravitreal injection endophthalmitis, possibly due to face mask wear by the patient, including culture-positive endophthalmitis, has been reported in one retrospective study. Several measures have been shown to prevent or limit the risk of developing dry eye disease or exacerbation, eyelid cyst, and ocular infection during intravitreal injections.

Conjunctival conveyance of SARS-CoV-2 in asymptomatic and non-severe symptomatic COVID-19 patients.

INTRODUCTION: The prevalence of ocular conveyance of SARS-CoV-2 has been well described for severe/hospitalized cases, but scarcely reported in asymptomatic and non-severe patients, who are unaware that they are carriers. MATERIAL & METHODS: This prospective cross-sectional study quantitatively evaluated SARS-CoV-2 shedding on the ocular surface (OS). Conjunctival testing was suggested to all hospital personnel being screened by nasopharyngeal (NP) SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR). Disease symptoms were evaluated using a standardized questionnaire and telephone follow-up 6±3 months later for disease evolution (recovery with/without severe disease). RESULTS: Four hundred and eighty seven patients were included. From 46 NP SARS-CoV-2-positive subjects (cycle threshold [CT]=24.2±7.1), 13% tested positive at the OS (CT=36.4±2.8). Most SARS-CoV-2-positive subjects were symptomatic (n=40, 87%), while 6 were asymptomatic (being tested as contact cases). Systemic symptoms were not significantly different in OS-positive vs OS-negative subjects, although headache tended to be more frequent in OS-positives (83% vs 54%, P=0.06). None of the OS-positive subjects reported ocular symptoms and none developed severe disease requiring hospitalization or oxygen therapy. CONCLUSION: SARS-CoV-2 shedding at the OS may occur in asymptomatic and non-severe COVID-19 individuals (including those absent of ocular symptoms). However, the high RT-PCR CT values attained may indicate a low risk of transmissibility via this route.

[Monkeypox: Important facts for the ophthalmologist]. / Variole du singe : les points importants pour l'ophtalmologiste.

The current monkeypox virus (MPXV) outbreak, raging since May 2022, is the largest ever observed on a world-wide scale. Despite previously being endemic in west and central Africa with a mortality rate of up to 10%, it remained a neglected tropical disease. Along with other recent pandemics gaining much attention, this MPXV outbreak has provided an opportunity to improve our understanding of its physiopathology and better define management strategies, particularly in patients with more serious disease. From the ophthalmologist's perspective, eyelid involvement and conjunctivitis or keratoconjunctivitis are frequently observed and may precede systemic signs or even remain the major site of involvement. While the course of MPXV keratoconjunctivitis is most often favorable, severe cases pose a functional threat, in particular for immunocompromised patients. This review provides an overview of MPXV pathophysiology, diagnosis and treatment, as well as considerations for prevention of transmission. During such an epidemic, the ophthalmologist can be the first to diagnose MPXV, treat the ocular involvement, and set up adequate preventative measures in collaboration with infectious disease specialists.

[Virological diagnosis of anterior herpetic ocular disease on tear sample: A simple and non-invasive technique]. / Diagnostic virologique des atteintes oculaires herpétiques antérieures sur prélèvement lacrymal : une technique simple et non invasive.

INTRODUCTION: Virological diagnosis of anterior ocular herpetic disease (AOHD) is essential for the management of these often-chronic pathologies that may require long-term therapy. PCR has become the gold standard, but the type of sampling (tears, corneal scraping, aqueous tap) has not been standardized. In this study, we studied the technique of tear sampling for the diagnosis of AOHD. MATERIALS AND METHOD: We retrospectively analyzed the medical files of patients with a positive tear sample (Schirmer strip) for herpes simplex 1 virus (HSV-1) in the Department of Ophthalmology of Paris-Saclay Bicêtre Hospital between January 2018 and December 2020. We studied the clinical and virological characteristics (viral loads) of these cases of proven AOHD. RESULTS: Thirty-six samples (33 patients) were included: 12 epithelial keratitis, 9 stromal HSK with ulceration, 5 uveitis, 4 stromal HSK without ulceration, 3 blepharitis, 1 endothelial HSK, 1 neurotrophic keratitis, and 1 conjunctivitis. The mean viral load was 3.9×105 copies/mL. Viral load was higher in cases of corneal ulceration (5.2×105±9.4×105 versus 1.2×102±1.7×102 copies/mL, P<1×10-4). There was no significant difference between primary episodes and relapses. CONCLUSION: Tear sampling using Schirmer strips is a simple, non-invasive method that can be useful for the virological diagnosis of various clinical forms of AOHD.

Association of Dry Eye with Laryngopharyngeal Reflux in Clinical Practice.

BACKGROUND: Dry eye disease (DED) is a common disorder, accounting for up to 35% of the general population. Therefore, we hypothesized that laryngopharyngeal reflux (LPR), inducing refluxate rising into airways, may involve the ocular surface and may either induce or worsen DED. AIM: To investigate the prevalence and relevance of suspected LPR in DED patients and subjects with refractive problems (RP) without DED, they were defined as non-dry eye group (NEG) in clinical practice. METHODS: This retrospective study included consecutive patients evaluated because of dry eye-like symptoms at eight tertiary ophthalmological clinics. Parameters included reflux symptom index (RSI), ocular surface disease index (OSDI), symptom assessment in dry eye (SANDE) for frequency and severity, Schirmer test, tear break-up time (BUT), and Oxford grading. RESULTS: The study included 245 subjects (72.5% females; mean age 56.3 years), 152 DED patients, and 93 sex- and age-matched NEG subjects. Pathological RSI (score>13) was detected in 80 subjects (32.6%); 68 (85%) with DED and 12 (15%) CG (OR = 8; p < .0001). In NEG, pathological RSI was associated with higher SANDE (Frequency and Severity), OSDI, and Schirmer scores (OR = 16.36; 14.51; 12.54; and 7.22, respectively. In DED patients, pathological RSI was associated with higher OSDI values (OR = 8.75). CONCLUSION: Patients with DED are at eight times higher risk for having pathological RSI than NEG patients. Moreover, pathological RSI was associated with more severe ocular symptoms both in DED and non-DED patients. The role of LPR in definite DED patients remains to be clarified, but this condition deserves to be investigated in managing patients with DED symptoms.

[Multimodal evaluation of the ocular surface using a the new Lacrydiag device]. / Place du NIBUT automatisé dans l'évaluation multimodale de la surface oculaire dans le syndrome sec avec le Lacrydiag.

INTRODUCTION: Dry eye disease is a very frequent condition with a significant impact on patients' quality of life. The most common clinical sign is fluorescein break up time (BUT). Recently, non-invasive measurement of BUT (NIBUT) by Placido disc analysis has been proposed to replace FBUT. We performed an automated NIBUT analysis using Lacrydiag and compared the values obtained with other typical dry eye criteria. METHODS AND MATERIALS: A retrospective study was carried out in the Bicêtre ophthalmology department from July 1 through October 30. Dry eye patients over 18 years of age with Oxford scores>1 and OSDI scores>22 were included. They underwent slit lamp examination to determine fluorescein BUT, Oxford and Arita MGD scores. On the same day, they were tested with the Lacrydiag to assess NIBUT, tear lake height and meibography. OSDI and Schirmer's testing were performed on the date of examination. In this study, only patients' right eyes were included. The correlation between NIBUT and OSDI, Schirmer's testing and tear lake height was analyzed by Pearson's test. The correlation between NIBUT and fluorescein BUT was analysed by both Pearson and Bland-Altman statistical tests. RESULTS: Thirty right eyes (21 women, 9 men) were included. The mean age was 62.3 years (SD 16.0), mean OSDI 49.4 (SD=20.1), mean Oxford score 3.33 (SD 2.1), mean NIBUT 6.91sec (SD 3.4), and mean FBUT 3.6sec (SD 1.8). The NIBUT and FBUT were significantly correlated (R=0.139; P=0.042), with an even more significant concordance (r=0.55; P=0.001) on Bland-Altman graphic analysis, but the mean NIBUT was 2.7 seconds higher than the FBUT (P=0.001 on Bland-Altman analysis). In addition, NIBUT was correlated with the Oxford score (R=0.156; P=0.031), but not with Schirmer I score (R=0.120; P=0.061), OSDI score (R=0.018; P=0.48), tear lake height (R=0.04; P=0.148), or Arita meibomian gland dysfunction score (R=0; P=0.933). CONCLUSION: NIBUT is a possible alternative to FBUT for the measurement of tear film stability, with the advantage of lack of dependence on the amount of fluorescein instilled. In addition, modern imaging methods allow for automated, and thus reproducible, measurement. However, its role in the diagnostic tool kit remains to be precisely defined, especially given its weak correlation with other markers of dry eye and its significant difference from FBUT. The definitive diagnosis of dry eye thus remains based on the combined analysis of signs and symptoms.

[Micropulsed diode laser transscleral cyclophotocoagulation: An effective technique whose role remains to be defined]. / Cycloaffaiblisement au laser diode micropulsé : une technique efficace, mais dont la stratégie reste à définir.

Micropulse Transscleral Cyclophotocoagulation (MP-TSCP) is a recently developed cyclodestructive procedure less aggressive than conventional TSCP. In this study, we aimed to evaluate the safety and efficacy of MP-TSCP in a real-life setting. MATERIAL AND METHODS: We retrospectively included all MP-TSCP cases performed in the Bicêtre Hospital Ophthalmology department between January 2017 and September 2019. Intraocular pressure (IOP) and hypotensive medications were recorded preoperatively, at month 1, 3, 6 and at the conclusion of follow-up, as well as postoperative adverse events. Success was defined as an IOP between 6 and 21mmHg with a decrease of at least one medication or an IOP reduction>20%. RESULTS: Thirty eyes (28 patients) were included. Preoperative IOP was 27.2±10.6mmHg, with 3.5±0.6 hypotensive medications, the mean deviation on the Humphrey 24-2 visual field was -21.9±6.9dB, and 43% of eyes had a past history of filtering surgery. The mean follow-up was 13.5±8.1 months. Eleven patients (37%) had to be retreated with MP-TSCP during follow-up. At 3 and 6 months and at the conclusion of follow-up, the IOP was 18.3±7.3mmHg (-33%; P<0.0001), 22.5±11.8mmHg, (-17%; P=0.052), 22.7±12.0mmHg (-16,5%; P<0.050), respectively. The success rates were 57%, 50% et 53% at 3 months, 6 months and at the conclusion of follow-up, respectively. Severe adverse events included 3 cases of corneal ulcers and 2 cases of severe but transient ocular hypotony without visual impairment. CONCLUSION: MP-TSCP is an effective procedure for severe and/or refractory glaucoma, but retreatments are required in more than one-third of cases. Further studies are warranted to define factors predictive of success and indications for retreatment.

[Ocular manifestations of viral diseases]. / Atteintes ophtalmologiques des infections virales.

Viral infections may involve all ocular tissues and may have short and long-term sight-threatening consequences. Among them, ocular infections caused by herpesviruses are the most frequent. HSV-1 keratitis and kerato-uveitis affect approximately are the leading cause of infectious blindness in the Western world, mainly because of corneal opacification caused by recurrences. For this reason, they may warrant long-term antiviral prophylaxis. Herpes zoster ophthalmicus, accounts for 10 to 20% of all shingles locations and can be associated with severe ocular involvement (keratitis, kerato-uveitis) of which a quarter becomes chronic/recurrent. Post herpetic neuralgias in the trigeminal territory can be particularly debilitating. Necrotizing retinitis caused by herpesviruses (HSV, VZV, CMV) are seldom, but must be considered as absolute visual emergencies, requiring urgent intravenous and intravitreal antiviral treatment. Clinical pictures depend on the immune status of the host. Adenovirus are the most frequent cause of infectious conjunctivitis. These most often benign infections are highly contagious and may be complicated by visually disabling corneal lesions that may last over months or years. Some arboviruses may be associated with inflammatory ocular manifestations. Among them, congenital Zika infections may cause macular or optic atrophy. Conjunctivitis is frequent during the acute phase of Ebola virus disease. Up to 15% of survivors present with severe chronic inflammatory ocular conditions caused by viral persistence in uveal tissues. Finally, COVID-19-associated conjunctivitis can precede systemic disease, or even be the unique manifestation of the disease. Utmost caution must be taken because of viral shedding in tears.

[Demodex and ocular surface disease]. / Demodex et pathologies de la surface oculaire.

Demodex is a saprophytic mite of the ocular adnexa, which can in certain circumstances proliferate on the skin of the face and on the eyelid margins. It is involved in facial rosacea (especially in the papulopustular form) and in the development or aggravation of anterior and/or posterior blepharitis or even keratoconjunctivitis, often in association with cutaneous lesions ; the pathophysiology is often multifactorial. Symptoms are non-specific, but the presence of cylindrical sleeves on the eyelashes is very suggestive of infestation, and certain techniques of biomicroscopic examination or imaging, such as confocal microscopy in vivo, allow direct visualization of the parasite. Parasitological examination of the eyelashes can confirm the diagnosis and can be improved by good sampling technique. Eyelid hygiene and oil-based ointments are the cornerstone of treatment. New specific treatments, in particular topical treatments based on tea tree oil, ivermectin, as well as pulsed light therapy and micro-exfoliation of the eyelid margin, can help to reduce the parasitic load and improve symptoms.

Dry eye disease treatment: the role of tear substitutes, their future, and an updated classification.

OBJECTIVE: The aim of this review is to summarize the results of a consensus meeting held by a group of experts in dry eye disease (DED) to discuss the importance of tear substitutes in the treatment of DED. The meeting focused especially on the main characteristics of lacrimal substitutes, the development of in vitro models to investigate DED pathophysiology and treatment, the importance of conducting rigorous clinical trials, the requirements of the upcoming European Legislation on medical devices, the advances in the formulation of safer preservatives, the peculiarities of treatment in younger subjects, and the importance of an updated terminology for lacrimal substitutes. MATERIALS AND METHODS: A literature search was conducted using MEDLINE, with different combinations of pertinent keywords, depending on the subject under discussion, such as "dry eye disease"; "tear substitutes"; "in vitro models"; "ocular surface"; "clinical trials"; "European Regulation"; "preservatives" "younger patients". Also, each author included in the discussion selected articles from their personal library. Using a consensus-based method called nominal group technique to reach a conclusion and proposal for a new classification of eye drops used to improve the tear film and ocular surface epithelia, the experts also conducted a round table meeting. RESULTS: The new terms proposed by the authors are "wetting agents", "multiple-action tear substitutes" or "ocular surface modulators". The new classification is needed to distinguish eye drops used to improve the tear film and ocular surface epithelia, in line with the new definition of DED, which recognizes the loss of ocular homeostasis, and the creation of a vicious circle of chronic inflammation and ocular damage as fundamental aspects of DED pathophysiology. CONCLUSIONS: Although tear substitutes have been historically used to provide eye lubrication to the ocular surface, recent advances in the pathophysiology of dry eye disease (DED) clarified that treatment should not just focus on tear film quality or quantity, but address the loss of homeostasis of the ocular surface, blocking the vicious circle of chronic inflammation and ocular damage. Given the scant comparative evidence on tear substitutes currently on the market, further studies should focus on developing new agents, considering the advantages provided by in vitro models, importance of conducting rigorous clinical trials, availability of less harmful preservatives and obligations related to the new European legislation on medical devices. Based on the discussion of these topics, a group of experts held a consensus meeting to identify new and more appropriate terms for different tear substitutes. The proposed terms are wetting agents, multiple-action tear substitutes and ocular surface modulators. Regardless of the agent used, it is important to note that tear substitutes represent one of many options for DED treatment, which should not overlook the psychological aspects of the disease and the peculiarities of younger subjects, who seem to have a higher risk for DED, possibly related to digital devices excessive use.

[SARS-CoV-2, COVID-19 and the eye: An update on published data]. / SARS-CoV-2, COVID-19 et œil : le point sur les données publiées.

The COVID-19 pandemic has dramatically changed our daily lives as ophthalmologists. This general review firstly provides a better understanding of the virus responsible for the pandemic: the SARS-CoV-2, and the clinical manifestations of the COVID-19 disease. The second part is detailing the pathophysiology, clinical signs and challenges of ocular involvement, which seems rare and not functionally severe, but which may be a potential source of contamination. Finally, we discuss the preventive measures that need to be implemented in our daily practice to avoid any viral dissemination.