[Long-term functional and anatomical effects after macular hole surgery with internal limiting membrane peeling]. / Effets à long terme du pelage de la membrane limitante interne sur la sensibilité et l'anatomie rétinienne lors de la chirurgie des trous maculaires.

INTRODUCTION: To study the functional and anatomical effects of internal limiting membrane (ILM) peeling in macular hole surgery with a minimum follow-up of 10 years. METHODS: Retrospective study of patients who underwent successful macular hole surgery prior to 2010. All patients underwent vitrectomy and ILM peeling after staining. Functional assessment included measurement of visual acuity and retinal sensitivity using microperimetry (NIDEK MP-3) as well as a subjective visual function questionnaire. Anatomical assessment was based on evaluation of the macular region and optic nerve using spectral domain optical coherence tomography (SD-OCT) with comparison to the fellow eye. RESULTS: Fourteen women and five men were included. Visual acuity of operated eyes (0.07±0.08logMar) was not significantly different from that of fellow eyes (0.04±0.08logMar) (P=0.10). The mean retinal sensitivity of the operated eyes was 25.1±1.9dB with no difference from the fellow eyes 25.2±1.6dB (P=0.82). However, 2 patients exhibited 2 relative scotomas >10dB. On questioning, 3/19 patients (16%) described a disturbing scotoma in monocular vision, while 11/19 (58%) described metamorphopsia, and 3 subjectively assessed their visual loss at more than 60%. The external limiting membrane was present and intact in all patients, and the ellipsoid zone was restored in 16/19 patients (84%). The cone interdigitation zone was intact in 9 patients, altered in one patient and not interpretable in 9 patients. Retinal optic nerve fiber layer thickness showed a moderate loss of fibers in the operated group 95.9±9.5 versus 101.5±10.9 (P=0.001) in the fellow eyes. The ganglionic complex thickness in the operated eyes (90.1±8.3) was not significantly different from that of fellow eyes (91.9±8.8) (P=0.37). CONCLUSION: ILM peeling in macular hole surgery induces anatomical changes in the inner layers of the retina, still visible on SD-OCT 10 years after the procedure. However, this remodeling of the inner layers does not appear to have significant deleterious effects on patients' retinal sensitivity or vision.

[Rhegmatogenous retinal detachment in young adults: Clinical characteristics and surgical outcomes]. / Décollement de rétine rhegmatogène chez l'adulte jeune : caractéristiques cliniques et résultats chirurgicaux.

PURPOSE: To report the causes, clinical features and surgical outcomes of retinal detachment (RD) in young adults. METHODS: Retrospective study of 111 eyes of 99 patients aged between 18 and 40 years, who underwent primary RD surgery between January 2011 and January 2019. All patients underwent either scleral buckling or pars plana vitrectomy. We analyzed the demographic data, characteristics of the RD, primary and final anatomic success rate and best-corrected visual acuity (BCVA) at the conclusion of follow-up. RESULTS: The mean age of the patients was 30.3±6.5 years. RD was more frequent in males, with a gender ratio of 1.8. The breaks were atrophic round holes or retinal dialysis in 49 (44.2%) cases and were associated with posterior vitreous detachment in 62 (55.8%) cases. The main etiologies were high myopia (45.0%) and trauma (9.0%). Retinal reattachment was achieved in 74 (66.5%) eyes overall with a single procedure and in 108 (97.2%) eyes with two or more procedures. The primary success rates were 69.6% (46/66 eyes) with scleral buckling and 62.2% (28/45 eyes) with vitrectomy. High myopia was a risk factor for surgical failure (P<0.01). The mean BCVA improved from 0.71±0.64 logMAR to 0.41±0.35 logMAR (P<0.01) CONCLUSION: RD in young adults differs from that in older adults in clinical features and etiology. The main causes are trauma and high myopia. The anatomic outcomes appear less favorable, with a primary reattachment rate of 66.5%. However, the functional prognosis remains satisfactory with an improvement of 3 lines of visual acuity.

[Diagnostic vitrectomy in intraocular inflammations: A retrospective series]. / Vitrectomie diagnostique dans les inflammations intraoculaires : étude d'une série rétrospective.

PURPOSE: To determine the diagnostic and functional yield of vitrectomy in patients with uveitis of unknown origin. METHODS: A single-centered retrospective study was performed on patients who underwent a diagnostic vitrectomy for uveitis in the Department of Ophthalmology of the Nancy University Hospital from January 2011 to December 2016. Vitreous samples were analyzed in the cytology laboratory by cytological and immunohistochemical techniques, and in the microbiological laboratory by culture and bacterial, fungal and viral PCR, depending on clinical findings. Preoperative and one- and six-month postoperative visual acuity were collected and compared. RESULTS: Thirty-four patients (39 vitrectomies) were included. Vitreous testing led to a diagnosis in 14 out of 39 cases (36 %): 10 intraocular lymphoma, 2 amyloidosis, 1 CMV retinitis, and 1 choroidal metastasis of cutaneous melanoma with vitreous dissemination. Vitrectomy was negative in 20 patients. Visual acuity improved from 1.2±0.7 logMAR preoperatively to 0.8±0.7 logMAR at 1 month (p<0.001) and 0.9±0.8 logMAR at 6 months (p=0.054). CONCLUSION: In our study, diagnostic vitrectomy and vitreous fluid analysis were useful to diagnose uveitis of unknown origin, most of which were found to be intraocular lymphomas. Visual acuity improved for the majority of patients. Diagnostic vitrectomy with appropriate vitreous analysis related to clinical examination must be considered in the evaluation of uveitis of unknown origin.

[Evaluation by quality of life questionnaires in patients undergoing strabismus surgery in Graves' disease]. / Évaluation par questionnaires de l'amélioration de la qualité de vie des patients opérés de strabisme dans le cadre d'une maladie de Basedow.

PURPOSE: To evaluate the improvement in quality of life of patients operated within 6 months for strabismus in Graves' disease using a questionnaire. MATERIALS AND METHODS: A retrospective study was based on a cohort of patients undergoing strabismus surgery for Graves' disease at the Nancy university medical center between June 2015 and January 2017. A quality-of-life questionnaire composed of the functional GO QOL questionnaire plus 10 additional questions was given to patients. The questionnaires were completed by patients in consultation before surgery and then at six months postoperatively. A subgroup analysis was conducted to identify potential risk factors such as smoking, orbital decompression, duration of disease progression, number of surgeries, previous treatments or gender influences on the progression of the postoperative score. RESULTS: Thirty-three patients (15 men/18 women) underwent surgery, with mean age 56 years; 16 (48 %) were smokers, 24 (70 %) were operated for the first time for strabismus. 8 patients (24 %) had a history of surgical orbital decompression. The mean preoperative GO QOLf was 30 (±23.8), which increased to 72 (±29.6) postoperatively (P=0.004). All the answers to the questions proposed were improved by surgery. The most improved items were difficulty in extreme gaze+6.82 points (P=0.001) and going down stairs +6.81 (P=0.002). Smokers had a lower preoperative GO QOLf than non-smokers (25±22.84 vs. 34±24.55); the same was true for their postoperative improvement (35±34.5 points vs. 50±18.8, P=0.002). History of orbital decompression did not appear to influence quality of life (21±25.39 vs. 65±33.98); the same was true for previous corticosteroid or immunosuppressant treatment (28±23.52 vs. 67±28.24), respectively P=0.42; P=0.73. Gender did not appear to influence the results P=0.17. First-time strabismus surgery patients showed a tendency which was not significant toward better improvement after 2 or 3 surgeries (respectively 45 vs. 39 vs. 33) P=0.056. There was no correlation between the duration of the disease and the change in the GO QOLf (R=0.04). CONCLUSION: This study confirms that strabismus surgery significantly improves the quality of life of patients with Graves' ophthalmopathy. The GO QOLf demonstrates its effectiveness in highlighting this progression. Our ten additional questions proved to be very good tools for assessing this condition.

Mydriasis revealing vascular and osteodural compression of the oculomotor nerve: An observational study on five cases.

PURPOSE: To describe a form of neurovascular compression of the third cranial nerve (CNIII) in idiopathic mydriasis, in which a neurovascular "conflict" exists between the oculomotor nerve, the posterior communicating artery and the clinoid process, using high-resolution magnetic resonance imaging (MRI) with fast imaging employing steady acquisition (FIESTA) sequences. METHODS: An 18-month prospective, observational and monocentric case series report was performed. MRI was performed on 5 consecutive patients with idiopathic, unilateral, persistent and nonreactive mydriasis (pure intrinsic palsy of the CNIII). Patients with diplopia, ptosis or ophthalmoplegia were excluded. Cerebral MRI focused on the CNIII pathway from the mesencephalon to the cavernous sinus entry, particularly on the cisternal segment: image acquisition was performed on a 3 Tesla MRI; the protocol included fast imaging employing steady acquisition (FIESTA) and three-dimension time of flight (3D TOF) sequences. RESULTS: All patients presented a neurovascular compression point, involving the CNIII clamped between a tortuous posterior communicating artery (PCoA) and the posterior clinoid process at the entrance of the cavernous sinus. No cases occurred in the root entry zone. There was no compression on the contralateral side. No tumors or aneurysms were found. Thus, the mydriasis was caused by CNIII compression. CONCLUSION: MRI, including FIESTA sequences, revealed a new type of neurovascular conflict between the CNIII, PCoA and posterior clinoid process in patients with incomplete oculomotor palsy. Non-aneurysmal CNIII compression should be considered as a differential diagnosis in the work-up of idiopathic mydriasis. The role of MRI in the work-up of anisocoria should be considered.

[Impact of training conferences on medical student's performance for the French National Ranking Examination in Lorraine University. The ETIMCEL experimental study]. / ÉTude de l'IMpact de Conférences sur la réussite aux ECN en Lorraine. Étude interventionnelle ETIMCEL.

PURPOSE: To describe factors associated with a better rank, and to assess the impact of training conferences on medical student's performance for the French National Ranking Examination (FNRE) in Lorraine University, France in 2012. METHODS: Between October 2011 and May 2012, assistant professors of the faculty of medicine of Nancy, France, organized a cycle of 15 conferences combining clinical cases theoretical training and student peer assessment. Data were recorded with a self-administered questionnaire in January 2012 to collect potential confounders. RESULTS: Among 287 students enrolled in the last year of medical school in 2011-2012 in Lorraine University, 195 (67.9%) of them registered to the cycle of conferences. Among the potential prognostic factors assessed, not repeating the first year of medical curriculum (P=0.013), the number of courses validated at the first session during the second part of the medical curriculum (P=0.002), absence of difficulties experienced in the fifth and sixth year (P=0.032) and a desired ranking among the best (P=0.011) were independently associated with a better rank at the FNRE. Regular participation in conferences was significantly and independently associated with a higher ranking (mean gain for the participation in 13 or more conferences: 873; mean gain by conference: 63). CONCLUSION: Regular participation in conferences provided by assistant professors and based on clinical cases theoretical training and student peer assessment was significantly associated with a higher ranking to the FNRE in Lorraine University in 2012.

[Simplified topical anesthesia protocol for ambulatory cataract surgery: safety and patient and surgeon satisfaction]. / Étude de satisfaction et de sécurité d'un protocole d'anesthésie simplifié pour la chirurgie de cataracte sous anesthésie topique.

BACKGROUND AND PURPOSE OF STUDY: The purpose of our study was to assess safety and efficacy of cataract surgery (CS) under topical anesthesia alone, i.e. without pre-anesthetic evaluation and without direct presence of an anesthesiologist. To this end we assessed the incidence of patients' preoperative anxiety, perioperative adverse events and patients' and surgeons' satisfaction. MATERIALS AND METHODS: Patients undergoing CS under topical anesthesia over a one-month period were included. An anesthesiologist and nurse anesthetist were present in the area and could intervene in case of an adverse event. Patients' anxiety was scored using the Amsterdam Preoperative Anxiety & Information Scale (APAIS), and their satisfaction with the Iowa Satisfaction with Anesthesia Scale (ISAS). Surgeons' satisfaction was scored with a VAS from 0 to 10 (0: surgery not possible & 10: excellent surgical conditions). RESULTS AND DISCUSSION: One hundred and twenty-four consecutive patients were included; mean age was 71 (±9.4) years. Mean APAIS I was 6.4/20 (±3.7). Mean APAIS II was 3.1 (±1.8). Mean ISAS score was 5.5/6 (±0.6), indicating high patient satisfaction. Surgeon satisfaction score was 8.9/10 (±1.7). Twenty-three adverse events occurred of which 16 required interventions by the anaesthesiologist or surgeon: 5 supplemental local or regional anaesthesia, 6 iv-analgesia, 5 management of hypertension. CONCLUSION: These preliminary data suggest that a simplified topical anesthesia protocol for ambulatory CS appears to be feasible and safe, as long as an anesthesia team is present in the area to intervene if needed.

[Ultrasound biomicroscopy long-term study of filtering belbs]. / Analyse à long terme de la bulle de filtration après chirurgie de glaucome, par échographie ultrasonore.

PURPOSE: To study aspect of filtering blebs by Ultrasound Biomicroscopy (UBM) and to compare it to intraocular pressure (IOP), to type of surgery performed and to the measurement of the anterior chamber angle after glaucoma surgery. METHODS: An observational study, conducted between January and December 2010 on 46 eyes of 42 patients who underwent glaucoma surgery. 17 combined surgeries (14 non-penetrating deep sclerectomy (NPDS) with phacoemulsification and 3 trabeculectomy with phacoemulsification) and 29 filtering surgeries alone (16 NPDS and 13 trabeculectomy) were performed by the same surgeon with application of mitomycin C for 1.30 minutes during surgery. After surgery, IOP was controlled at day 5, day 30 and at UBM realisation. Filtering blebs were classified according to Yamamoto's study: functional blebs (L: Low-reflective) and non-functional blebs (H: High-reflective, E: Encapsulated and F: Flattened). RESULTS: Mean follow-up was 21 months (± 3.7). We noted a significant decrease in IOP, mean preoperative IOP 23.2mmHg (± 9.4), mean post operative IOP 14.7mmHg (± 3.3) (P<0.001). We identified 36 functional blebs (36L type) and 10 non-functional blebs (including 1 H, 7 F and 2 E). There was no significant morphological differences between filtering blebs after combined surgery and filtering surgery alone (P=0.072). We did not find any morphological difference between filtering blebs after trabeculectomy and NPSD (P=0.394). Blebs are significantly more functional with an IOP less or equal to 6mmHg after surgery (P=0.028). We didn't find any difference between efficacy of filtering blebs and depth of the anterior chamber angle. CONCLUSION: Our study reports 78% of functional blebs after glaucoma surgery (mean duration of 21 months). Type of surgery does not seem to interfere with the long-term morphological type of the bleb, however the immediate postoperative IOP less than or equal to 6mmHg is a factor of good prognosis. UBM appears to be an interesting tool for monitoring patients undergoing glaucoma surgery.

[Vincristine-induced unilateral ptosis: case report and review of the literature]. / Ptosis unilatéral induit par la vincristine : à propos d'un cas et revue de la littérature.

We report the case of a 31-month-old girl, treated by the ifosfamide-vincristine-actinomycin chemotherapy protocol for vaginal rhabdomyosarcoma, who developed a unilateral left ptosis on day 36 of chemotherapy, i.e. 7 days after the fifth vincristine dose (1.5mg/m(2) or 0.90 mg). The cumulative vincristine dose was thus 4.50mg. The remainder of the neurological and systemic examinations were unremarkable. Laboratory testing and thoracic-cervical-cranial CT were normal. Other causes of ptosis were excluded. The ptosis decreased a few days after the infusion of vincristine and re-increased just after a new dose. It finally resolved upon lowering the dose of vincristine. According to our observations, the role of vincristine in the pathogenesis of this ptosis appears "likely". In such cases, maintenance of treatment is possible with adjustment of vincristine doses, but requires regular follow-up.

Optic disc neovascularization revealing neurosyphilis.

PURPOSE: To report a case of neurosyphilis revealed by bilateral optic disc neovascularization. DESIGN: Case report. METHODS: A 39-year-old man presented with a 6-month history of progressive visual loss (20/25 RE, 20/1200 LE) and transient headaches. Fundus examination demonstrated a 1+ vitritis, mild macular edema and large optic disc neovascularization in both eyes. Serological tests for syphilis were positive. RESULTS: Specific antibiotics and systemic steroids were undertaken and complete regression of disc neovascularization was observed within 6 months. CONCLUSION: Optic disc neovascularization, which is a rare manifestation of chronic uveitis, may lead to the diagnosis of neurosyphilis and be successfully treated by specific antibiotic and steroid therapy.

[Uveitis as a presenting manifestation of sarcoidosis: clinical characteritics of a series of 23 cases]. / Uvéites révélant une sarcoïdose : caractéristiques cliniques à propos de 23 cas.

PURPOSE: Uveitis may rarely reveal sarcoidosis in Caucasian patients. Our objective was to analyze the clinical manifestations, and the outcome in a group of patients in whom uveitis was the presenting manifestation of sarcoidosis. METHODS: Retrospective study including 23 patients (mean age: 50.3±14.5 years) diagnosed with sarcoidosis after an episode of uveitis. Granulomatous lesions were documented in 14 patients. RESULTS: Ophthalmological examination revealed anterior uveitis (n=5), intermediate uveitis (n=2), posterior uveitis (n=25) and panuveitis (n=11). Ocular inflammation was bilateral in 16 patients (69,6%), typical aspects of granulomatous uveitis were found in only 16 eyes over 39 (41%), posterior uveitis was found in 18 eyes (46.2%), with an averaged visual acuity of 5/10. Macular oedema was noted in five patients. Suggestive signs of ocular sarcoidosis were present in 43% of the patients. Stage 1 or 2 pulmonary involvement (n=22), musculoskeletal (22%), skin (13%), or spleen (9%) involvements were the most common findings. Oral corticosteroids were necessary in 91.3% of the patients, immunosuppressive agents in 26.1%, with a prolonged treatment greater than two years in 58%. The visual prognosis was good, with visual acuity greater than 6/10 in 96% of the cases if the ocular inflammation spared retina and choroid. However, a visual acuity less than 6/10 was observed in 44% of the cases when the posterior segment was involved. CONCLUSION: Sarcoidosis may be revealed by an intraocular inflammation, with typical patterns in only 43% of the cases. Sarcoidosis should therefore be included in the differential diagnosis of every uveitis. Oral corticosteroids are required in almost all cases, owing to ocular involvement rather than visceral involvement.

[Recurrent unilateral optic neuropathy associated with human immunodeficiency virus (HIV)]. / Neuropathie optique unilatérale récidivante liée au VIH.

HIV-related optic neuropathy is rare compared to optic neuropathies secondary to opportunistic infections in seropositive patients. We report the case of a 39-year-old HIV-positive woman referred for unilateral visual loss leading to the diagnosis of recurrent, unilateral, inflammatory optic neuropathy directly associated with HIV. Despite initial recovery after steroid treatment, she relapsed twice. Absence of any opportunist infections or toxic causes and presence of a very high viral load due to non-compliance with treatment led to the diagnosis of HIV-related optic neuropathy. Steroids and effective anti-retroviral treatment resulted in definitive and complete recovery. Inflammatory, degenerative and/or vascular mechanisms have been hypothesized to explain the occurrence of these rare HIV-related optic neuropathies. This diagnosis remains a diagnosis of exclusion to be considered in the work-up of seropositive patients with optic neuropathies.

["Teddy bear granuloma", a rare condition: a case report of a 3-year-old child]. / « Teddy bear granuloma ¼, une pathologie rare : à propos du cas d'un enfant de trois ans.

Conjunctival synthetic fiber granulomas, or "Teddy bear granulomas", are rare granulomatous responses to synthetic fabric fibers. We report the case of a 3-year-old boy with no prior infectious or traumatic history, brought in by his parents for an incidentally discovered conjunctival growth in his right eye. Slit lamp examination revealed a 10-mm growth in the inferior fornix surrounding a small greyish foreign body. Surgical excision and histopathology revealed granulomatous inflammatory cell response with foreign body giant cells surrounding exogenous material. This foreign material was birefringent in polarized light, very suggestive of synthetic fabric fibers, which permitted the diagnosis of Teddy bear granuloma. Synthetic fiber granulomas present in children as unilateral, more or less inflammatory growths in the inferior conjunctival fornix. Surgical excision with histopathology makes the diagnosis and effects the cure.

[Wolfram syndrome: clinical and genetic analysis in two sisters]. / Le syndrome de Wolfram : mise au point clinique et génétique à propos du cas de deux sœurs.

Wolfram syndrome is a severe genetic disorder defined by the association of diabetes mellitus, optic atrophy, deafness, and diabetes insipidus. Two sisters complained of progressive visual loss. Fundus examination evidenced optic atrophy. Their past medical history revealed diabetes mellitus and deafness since childhood. The association of these symptoms made the diagnosis of Wolfram syndrome possible. It was confirmed by molecular analysis, which evidenced composite WFS1 heterozygous mutations inherited from both their mother and father. Ophthalmologists should be aware of the possibility of Wolfram syndrome when diagnosing optic atrophy in diabetic children.

Intravascular lymphoma mimicking a Vogt-Koyanagi-Harada disease.

PURPOSE: To report a case of intravascular lymphoma (IVL) mimicking a Vogt-Koyanagi-Harada disease (VKH). DESIGN: Case report. METHODS: A 38-year-old man was referred for blurred vision, headache, and hearing loss. Examination demonstrated vitritis and subretinal detachments in each eye. Cerebral fluid analysis showed lymphocytic meningitis. Cerebral MRI was normal. A diagnosis of VKH disease was made. RESULTS: Steroid treatment was introduced, after which all symptoms disappeared. Six months later, the patient returned with paraplegia and confusion. Cerebral MRI revealed hypodense periventricular lesions. A stereotaxic biopsy confirmed the diagnosis of IVL. The patient died a few months later. CONCLUSION: IVL may have many revealing aspects, including ophthalmologic symptoms.

[A case report of frosted branch angiitis associated with aseptic meningitis in a young boy]. / Un cas d'angéite givrée associée à une méningite aseptique chez un jeune garçon.

We report on an 11-year-old boy with frosted branch angiitis in both eyes associated with aseptic meningitis. The patient presented after a severe decrease in vision in both eyes and a 40°C fever. The examination of the fundus of the eyes revealed a diffuse edema of the retina and diffuse bilateral vascular sheathing. The complementary examinations revealed aseptic meningitis. Neither infectious etiologies nor systemic diseases could be confirmed and an inflammatory digestive disease was suspected because of recent diarrhea events responsible for substantial weight loss. A systemic corticotherapy slowly improved the vision in both eyes. After 1 year of medication, visual recovery was full with no sequelae on fundus examination.

[Central retinal artery occlusion following coronary angiography: a case report]. / Occlusion de l'artère centrale de la rétine après une coronarographie : à propos d'une observation.

We report the case of a 74-year-old man referred in ophthalmology for acute central visual loss in his right eye 2 hours after a coronary angiography. Visual acuity was limited to light perception RE and 20/20 LE. Fundus examination revealed a central retinal artery occlusion with retinal edema and a cherry-red spot in the right eye. Fluorescein angiography confirmed that the central retinal artery was not filling. Despite selective ophthalmic artery fibrinolysis, visual acuity remained very low. Embolic occlusion is the most probable etiology in this complication. Central retinal artery occlusion is a serious but very rare complication of coronary angiography.