Postoperative outcomes for unilateral congenital trochlear nerve palsy: A retrospective cohort study.

PURPOSE: Congenital trochlear nerve palsy is the most common cause of vertical strabismus. The goal of this study was to investigate surgical outcomes after superior oblique tendon plication with or without inferior oblique recession in children and adults with unilateral congenital trochlear nerve palsy. METHODS: Data and outcomes were collected in patients with a diagnosis of unilateral congenital superior oblique palsy during a retrospective single-center study conducted at the University Hospital of Tours. A reproducible, standard ophthalmological and oculomotor examination was performed pre- and postoperatively at 1 year, including presence or absence of diplopia, vertical and horizontal deviations, and compensatory head posture. Surgical success, defined as an endpoint including absence of diplopia in primary position, absence of head tilt, and vertical deviation at distance fixation<5 prism diopters (PD), was analyzed. RESULTS: A total of fifty-seven patients (median [IQR] age of 11 years [5-42]) were analyzed. Patients experienced a significant reduction in vertical distance and near deviations (p<0.001), compensatory head tilt (p < 0.001), and diplopia after surgery (p < 0.001). Surgical success was higher in adults (17/24, 70.8%) than in children (15/33, 45.5%), although this did not reach statistical significance (p=0.0657). CONCLUSION: This study suggests that plication of the superior oblique muscle tendon, with or without recession of the inferior oblique muscle, can be effective in treating unilateral congenital trochlear nerve palsy. Further studies are necessary to compare surgical procedures and investigate their efficacy in adults compared to children in the short and long term.

Long-term ophthalmological outcomes in patients with anterior plagiocephaly managed with a fronto-orbital advancement procedure.

BACKGROUND: Anterior plagiocephaly results from early fusion of a unilateral coronal cranial suture, which affects 1/10,000 infants at birth and can be associated with ophthalmological complications. The study aimed to evaluate the frequency of oculomotor disorders and refractive errors in children with non-syndromic anterior plagiocephaly. METHODS: Patients with anterior plagiocephaly undergoing surgery using a fronto-orbital advancement technique were included in this retrospective study between 2011 and 2017. The following data were collected: cycloplegic refraction in diopters (D), best-corrected visual acuity, manifest strabismus in primary position, ocular motility, head tilt in primary position, slit-lamp and fundus examination. The refractive errors were determined by autorefraction after cycloplegia with cyclopentolate. RESULTS: Among the sixteen patients included, hyperopia >2.5D was found in 10 patients, astigmatism >1D in 10 patients and anisometropia >1D in 7 patients. Astigmatism was contralateral to the synostosis in 7 cases. In total, significant refractive errors were found in 92.9%. Amblyopia was found in 33.3% patients. Strabismus was found in 11 patients, most frequently combined horizontal and vertical, of which 4 required strabismus surgery. The most frequent vertical deviation was ipsilateral hypertropia in 54.5%. We found superior oblique muscle limitation in 3 patients. Optic disc pallor was found in 2 patients. CONCLUSION: In the years following fronto-orbital advancement for non-syndromic anterior plagiocephaly, refractive errors and oculomotor disorders are frequently encountered, mainly contralateral astigmatism and strabismus with both horizontal deviation and ispilateral hypertropia.

[Outcomes of partial vertical rectus transposition in acquired sixth nerve palsy]. / Efficacité de la transposition partielle des muscles droits verticaux dans les paralysies acquises du sixième nerf crânien.

PURPOSE: This study aimed to assess the outcomes of partial vertical rectus transposition (PVRT) in acquired sixth nerve palsy (SNP) on distance ocular deviation in primary position (PP), binocular diplopia in PP, head turn, and limitation of abduction. METHODS: This retrospective, single center study was conducted at the Regional University Medical Center of Tours between 2004 and 2019. All patients underwent comprehensive orthoptic and ophthalmic examination before and after surgery. Total success was defined as horizontal distance deviation in PP≤10 prism diopters (PD), absence of permanent diplopia in PP, head turn≤5 degrees and absence of any induced vertical deviation at last examination. RESULTS: Ten patients underwent PVRT with a median delay of 3.3 years (2.3 to 7.3) following the diagnosis of SNP. The median duration of postoperative follow-up was 13 months (3.25 to 25). Seven patients (70%) were considered a total success. The mean distance horizontal deviation in PP was reduced from 25.4±11.7 PD preoperatively to 9.2±11 PD postoperatively. Preoperatively, 10 patients did not cross midline in abduction, compared to 8 patients at the last follow-up examination. Postoperatively, 3 patients had permanent binocular diplopia in PP, and 2 patients had an anomalous head turn. CONCLUSION: Although further prospective investigations are needed, PVRT can be considered a safe and effective procedure for acquired SNP.

An Integrated eDiagnosis Approach (IeDA) versus standard IMCI for assessing and managing childhood illness in Burkina Faso: a stepped-wedge cluster randomised trial.

BACKGROUND: The Integrated eDiagnosis Approach (IeDA), centred on an electronic Clinical Decision Support System (eCDSS) developed in line with national Integrated Management of Childhood Illness (IMCI) guidelines, was implemented in primary health facilities of two regions of Burkina Faso. An evaluation was performed using a stepped-wedge cluster randomised design with the aim of determining whether the IeDA intervention increased Health Care Workers' (HCW) adherence to the IMCI guidelines. METHODS: Ten randomly selected facilities per district were visited at each step by two trained nurses: One observed under-five consultations and the second conducted a repeat consultation. The primary outcomes were: overall adherence to clinical assessment tasks; overall correct classification ignoring the severity of the classifications; and overall correct prescription according to HCWs' classifications. Statistical comparisons between trial arms were performed on cluster/step-level summaries. RESULTS: On average, 54 and 79% of clinical assessment tasks were observed to be completed by HCWs in the control and intervention districts respectively (cluster-level mean difference = 29.9%; P-value = 0.002). The proportion of children for whom the validation nurses and the HCWs recorded the same classifications (ignoring the severity) was 73 and 79% in the control and intervention districts respectively (cluster-level mean difference = 10.1%; P-value = 0.004). The proportion of children who received correct prescriptions in accordance with HCWs' classifications were similar across arms, 78% in the control arm and 77% in the intervention arm (cluster-level mean difference = - 1.1%; P-value = 0.788). CONCLUSION: The IeDA intervention improved substantially HCWs' adherence to IMCI's clinical assessment tasks, leading to some overall increase in correct classifications but to no overall improvement in correct prescriptions. The largest improvements tended to be observed for less common conditions. For more common conditions, HCWs in the control districts performed relatively well, thus limiting the scope to detect an overall impact. TRIAL REGISTRATION: ClinicalTrials.gov NCT02341469 ; First submitted August 272,014, posted January 19, 2015.

[Outcomes after medial rectus recession and lateral rectus plication for abducens nerve palsy: A retrospective study]. / Recul du droit médial et plicature du droit latéral pour les paralysies unilatérales du nerf abducens : une cohorte rétrospective.

BACKGROUND: Abducens nerve palsy (ANP) is the most common oculomotor palsy. This study aimed to evaluate the efficacy of medial rectus recession with lateral rectus plication in patients with unilateral acquired ANP and to describe the etiologies of this condition. METHODS: Thirty-one patients were included in this retrospective single-center study conducted between 2000 and 2019 at the university research hospital in Tours. The following data were collected before and after surgery: diplopia, oculomotor deviations, ocular motility, and head posturing. RESULTS: The mean age was 55.9±18.9 years and the mean postoperative follow-up was 11±4 months. Postoperatively, the patients had significant reduction in diplopia in primary position (P<0.001), in abduction of the affected eye (P<0.001) and in distance and near horizontal deviations (P<0.001). Abduction of the affected eye was significantly improved (P<0.001), but reduction in head posturing was insignificant (P=0.27). The etiologies were as follows: trauma (8 patients, 26%), neoplasm (6 patients, 16%), stroke-related (5 patients, 16%), compressive (5 patients, 16%), undetermined (5 patients, 16%) and inflammatory (2 patients, 6%). CONCLUSION: Medial rectus recession with lateral rectus plication is an effective procedure in reducing diplopia and ocular deviation in unilateral acquired ANP and may be used as a first-line intervention regardless of the initial ocular motility limitation in abduction. The causes are mainly traumatic but remain undetermined in one case out of six.

[Vision screening for children: Recommended practices from AFSOP]. / Le dépistage visuel chez l'enfant : les recommandations de l'Association Francophone de Strabologie et d'Ophtalmologie Pédiatrique (AFSOP).

In light of the international literature, a workgroup of experts from the AFSOP met in February 2019 to formulate updated recommendations for visual screening in children. An ophthalmologic examination during the first month of life is recommended for children at risk of developing infantile organic amblyopia. An ophthalmologic examination including cycloplegic refraction between 12 and 15 months of age is recommended for children at risk of developing functional amblyopia. At any age, a prompt ophthalmologic examination is recommended for a child suspected of functional or organic ocular pathology. In children without risk factors or warning signs, a systematic orthoptic screening examination is recommended during the third year of life, including a monocular visual acuity test, a cover-test and a refraction by photoscreener. The child is referred to the ophthalmologist only in the case of an abnormal screening result, according to the following criteria: visual acuity <5/10, or >1 difference between eyes, abnormal cover test, photodetection refraction values <-3D or>+2.5D for the sphere,>1.5D for astigmatism and>1D for anisometropia. Finally, we review normal childhood refractive errors as a function of age as well as the correct use of photo screening devices.

Acute and Subacute Toxicity Profiles of the Methanol Extract of Lycopersicon esculentum L. Leaves (Tomato), a Botanical with Promising In Vitro Anticancer Potential.

Lycopersicon esculentum (tomato) is a plant widely used in Africa like food and to solve many health problems. The methanol crude extract of tomato recently demonstrated a good antiproliferative effect on many human cancer cell lines. The aim of this research was to evaluate the acute toxicity and subacute oral toxicity of methanolic extract from leaves of this plant. These toxicities were evaluated based on the OECD (Organization for Economic Cooperation and Development) guidelines. The assay of acute toxicity was performed using a total of 3 female rats, which received a single dose of 5000 mg/kg of methanolic extract via oral gavage. For the subacute toxicity study, 32 Wistar rats (males and females) were used. The groups were treated with three different doses of Lycopersicon esculentum methanolic extract (250, 500, and 1000 mg/kg b.w.) for 28 days and the control group received distilled water. The hematological, biochemical, and histopathological studies were performed after the sacrifice. Single dose of tomato extract caused no toxicity up to a dose of 5000 mg/kg body weight; hence, the median lethal dose (DL50) of leaves of this plant was greater than this value. However, lower toxic effects could be manifested in the long-term treatment at the highest dose (1000 mg/kg) because urea level and total serum proteins significantly increased at a dose of 1000 mg/kg with respect to control. The microscopic observation showed no remarkable pathological changes on all organs in the treated groups compared with the control groups of female and male rats. These results demonstrate that single dose of tomato extract leaves is relatively nontoxic at a dose of 5000 mg/kg b.w. and prolonged use of lower doses (250 and 500 mg/kg) of L. esculentum orally should be encouraged, whereas highest dose (1000 mg/kg) should be avoided.

Surgical outcomes after unilateral horizontal rectus surgery in children with infantile esotropia for the correction of A or V pattern.

PURPOSE: The management of A or V pattern deviation associated with esotropia can be challenging since the horizontal deviation changes with position of gaze. This study aimed to assess the effect of unilateral horizontal rectus surgery for the correction of horizontal deviation associated with A or V pattern in children with non-comitant infantile esotropia. METHODS: Twenty-seven children with infantile esotropia and A-V pattern, more than 10 and 15 prism diopters respectively, were included in this retrospective observational single-center study. Horizontal rectus surgery was performed on the most deviated eye under general anesthesia. The patients were divided into two groups: A pattern and V pattern. The outcome measures were change in the amount of pattern and rate of regression after surgery. The amount of pattern was characterized by the difference in esodeviation between upgaze and downgaze. RESULTS: Horizontal deviation at distance and near fixation decreased significantly (P<0.0001). Vertical gaze esotropia disparity decreased significantly (P=0.01 and P=0.0002 for A and V patterns respectively). A pattern esotropia was reported in only 2 (7%) cases after surgery compared to 9 (33%) before surgery. The number of subjects with V pattern esotropia decreased from 18 (67%) to 3 (11%) after surgery. CONCLUSIONS: The mechanisms involved in the pathophysiology of A and V patterns may not always be related to oblique muscle dysfunction. These findings suggest that unilateral horizontal rectus surgery may be an effective procedure to correct both horizontal deviation and A-V pattern in non-comitant infantile esotropia.

Reliability of objective ocular torsion assessment using fundus photography in infantile esotropia.

PURPOSE: To evaluate the interobserver reproducibility of objective ocular torsion measurements in infantile esotropia using fundus photography analysis. MATERIALS AND METHODS: This retrospective observational study was conducted in our ophthalmology department at the University Hospital in Tours from 2009 to 2015. OBJECTIVE: Ocular torsion was assessed using fundus photography and analysed on Adobe Photoshop software within a population of children with infantile esotropia. Two observers, an orthoptist and an ophthalmologist, carried out the evaluation separately. The interobserver agreement was calculated for quantitative measurement by the interclass correlation coefficient (ICC) and by Cohen's Kappa coefficient for qualitative assessment. RESULTS: A total of 200 eyes (100 subjects, mean age: 6.88 years) were assessed. Statistical analyses for quantitative measurements resulted in an ICC of 0.98 (95% CI, 0.97-0.99) for right eyes, 0.96 (95% CI, 0.95-0.97) for left eyes, 0.98 (CI 95%, 0.97-0.98) for pre- operative eyes and 0.96 (95% CI, 0.95-0.97) for postoperative eyes. The ICC calculated on all four hundred fundus photographs was 0.97 (95% CI, 0.97-0.98). The interobserver agreement for qualitative measurements resulted in a Kappa coefficient of 0.91 for right eyes, 0.85 for left eyes, 0.90 for preoperative eyes and 0.86 for postoperative eyes. The analysis of all four hundred eyes returned a Kappa coefficient of 0.88. CONCLUSIONS: Objective ocular torsion assessment using our procedure, whether by an orthoptist or ophthalmologist, is a reliable and reproducible method for the management of infantile esotropia.

[Surgical management of strabismus in dysthyroid orbitopathy: A retrospective single-center study of 32 cases]. / Prise en charge chirurgicale des strabismes compliquant une orbitopathie dysthyroïdienne : étude rétrospective monocentrique d'une série de 32 cas.

INTRODUCTION: Thyroid-related immune orbitopathy often results in a restrictive strabismus. We report our experience of surgical management in these cases. PATIENTS AND METHODS: We present a retrospective case series conducted on 32 patients, operated between 2008 and 2017. Strabismus surgery was proposed in the postinflammatory stage with stable clinical findings for at least 6 months. It was performed under general anesthesia by recessions of restrictive muscles using a fixed suture technique. Outcomes were graded as excellent, good or poor, according to the presence or absence of diplopia in primary or reading positions, and according to whether prism prescription was necessary. RESULTS: The study included 32 patients (21 women, 11 men) with a mean age of 53 years. Average follow-up was 9.6 months. Eight patients developed diplopia after orbital decompression. Fifteen patients had vertical surgery, 8 horizontal surgery, 9 mixed surgery. A mean of 1.31 surgeries (range 1-3) were performed. After all surgeries, 28 patients (87.5 %) had an excellent outcome, 4 (12.5 %) had a good outcome, and none had a poor outcome. There was a significant improvement in stereoscopic acuity (P<0.01), but not motility. Among the 8 patients who developed diplopia after orbital decompression, a clinically acceptable final outcome was achieved after only one surgery. CONCLUSION: Strabismus surgery using conventional non-adjustable sutures provides excellent ocular alignment and relief from diplopia in the majority of patients with dysthyroid strabismus. The reoperation rate is similar to other techniques, such adjustable suture and intraoperative relaxed muscle technique.

[Multimodal imaging in primary intraocular lymphoma]. / L'imagerie multimodale du lymphome oculo-cérébral.

INTRODUCTION: Vitreoretinal lymphoma is a serious disease with highly varied clinical presentations. The goal of this work is to identify the various presentations (clinical, imaging) in order to improve screening for this disease. MATERIALS AND METHOD: We collected data of patients followed on our service for vitreoretinal lymphoma. The fundus exam, autofluorescence and angiography data were classified in order to identify signs, which might lead to earlier diagnosis of lymphoma. RESULTS: The diagnosis of vitreoretinal lymphoma was confirmed by vitrectomy or cerebral biopsy for 12 patients (8 women and 4 men). Three clinical presentations were identified: no retinal involvement (2 patients), retinal infiltrate (4 patients) or acute retinal necrosis (3 patients). One patient had no imaging (deceased before it could be obtained), and two patients had uninterpretable imaging. CONCLUSION: Vitreoretinal lymphoma remains a rare and under-diagnosed disease. The prognosis is related to early diagnosis. Multimodal imaging can help to diagnose early vitreoretinal lymphoma in some cases.

[Systemic conditions associated with central and branch retinal artery occlusions]. / Apports du bilan étiologique des occlusions de l'artère centrale de la rétine et de ses branches et conséquences thérapeutiques.

INTRODUCTION: Retinal artery occlusions (RAO) are severe conditions threatening vision, affecting the subsequent mortality of these patients. PATIENTS AND METHODS: We retrospectively reviewed the work-up performed in all patients diagnosed with retinal artery occlusions evaluated in two university hospitals in France (Tours and Angers). RESULTS: A total of 131 patients (131 eyes) with RAO were included, with a mean age of 69.5years and male predominance (64 %). Central retinal artery occlusion (CRAO) resulted in poor initial visual acuity (90 % less than count fingers), whereas those with branch retinal artery occlusion (BRAO) had better visual acuity (63.6 % better than 20/40). Systemic arterial hypertension (HTN) was the most common associated risk factor. Carotid stenosis was found in 50 % of cases, leading to endarterectomy in nine patients (6.9 %), while an underlying cardiac cause was implicated in 14 % of cases. Giant cell arteritis was diagnosed in five patients (3.8 %). DISCUSSION: Work-up of RAO may detect treatable cardiovascular and systemic conditions, allowing prevention of further ocular recurrence or stroke. CONCLUSION: Etiologic work-up of retinal arterial occlusion can diagnose potentially treatable underlying systemic conditions, such as giant cell arteritis, cardiac conditions and extracranial cerebrovascular disease. Giant cell arteritis has to be ruled out at the acute phase, while the role and timing of semi-urgent testing (supra-aortic Doppler echography, echocardiography, electrocardiography, lab work-up) or delayed testing (transesophageal echocardiography, brain imaging) have yet to be determined.