[Development of a chatbot (conversational app) for cataract surgery patients]. / Développement d'un chatbot (agent conversationnel) pour les patients en parcours de chirurgie de la cataracte.

INTRODUCTION: The goal of this study was to create and promote a type of chatbot or conversational app, for patients who need cataract surgery and to evaluate its acceptability. METHODS: Multicentric prospective clinical study in two phases. Phase I : distribution of a questionnaire of 20 questions (evaluating patients' knowledge about cataracts and cataract surgery and their expectations in terms of patient education). Statistical analysis was performed through factorial analysis with factor rotation and Cronbach's alpha calculation. Phase II : creation of a chatbot with a repertoire of question-answer sets. An acceptability analysis was performed using a second questionnaire inspired by the « SUS Score ¼. RESULTS: One hundred and six initial questionnaires were collected. The patients were mostly women (56.6 %), aged 60 to 79 years (81 %), retired (77.4 %), with no high school diploma (33.0 %), had never used a chatbot before (95.3 %) and were accustomed to using a smartphone (66.0 %). Patients evaluated their knowledge about cataracts as insufficient (51.8 %) and felt the need to receive additional information (81.1 %). The comprehensibility score of the first questionnaire was 91 (middle school level). The baseline data of the chatbot was composed of 316 questions with a median comprehensibility score of 101 (middle school level). The first test of the chatbot included 18 patients. The median connection time was 4min and 40seconds (standard deviation 6.6). The median of number of questions asked for each connection was 6.5 (standard deviation 6.7). Acceptability was good, with a mean Sus Score of 78.6/100 (standard deviation 11.9). CONCLUSION: This study shows the importance of information for cataract surgery patients. The creation of a chatbot for patients undergoing cataract surgery appears to be relevant in achieving this goal.

[Setting up Objective Structured Clinical Examination (OSCE) in ophthalmology]. / Mise en place des examens cliniques objectifs structurés (ECOS) facultaires en ophtalmologie.

Obective Structured Clinical Examinations (OSCE) are a reproducible and objective way to evaluate medical students and have been used for many years in English-speaking countries, Canada and Switzerland. They evaluate candidates more on the basis of their practical skills, know-how and interpersonal skills than on their theoretical knowledge. From a nationally validated, limited list of typical clinical situations, stations are set up by the teaching team with standardized patients played by actors, designed to test a variety of problem solving, technical, diagnostic, therapeutic, communication, examination, and history taking skills, possibly with simulation tools. Setting up a station, as well as creating an OSCE cycle with several stations through which the candidates rotate, requires significant preparation prior to the examination: creating the station scenario with precise instruction sheets for the candidates, simulated patients and evaluators, multiple stages of proofreading, verifying the required equipment and adapting rating scales. OSCEs seek to evaluate students "objectively," as they are the only variable in this type of examination, in which the scripts, materials and rating scales have been standardized to limit subjectivity. This examination method is a flagship measure of the reform of the second cycle of French medical studies. OSCEs are now part of the testing modalities for the 2021-2022 academic year and will be integrated into the National Dematerialized Examination (NDE) starting in May 2023. They may also be useful in validating the achievements of students and residents in various stages of training, as well as in continuing medical education (CME). We present herein the key elements of these new evaluation tools and their practical applications in the evaluation of students in ophthalmology.

Intravitreal triamcinolone injections in non-arteritic anterior ischemic optic neuropathy - A retrospective report.

BACKGROUND: Non-arteritic anterior ischemic optic neuropathy (NAION) is a common cause of vision loss but no treatment has demonstrated its efficiency. A preliminary study showed an improvement on the visual acuity (VA) in a group of patients who received intravitreal administration of triamcinolone acetonide (IVTA) versus a non-treated group. In the present series, the visual outcome of IVTA in NAION was evaluated on a larger group of patients. METHODS: This retrospective, unmasked and non-randomized study took place at Reims University Hospital between 2009 and 2017. The data of consecutive patients presenting with isolated optic disc edema characteristic of recent NAION (<1month of visual acuity loss) were included. After informed consent, a single intravitreal injection of filtrated 4mg/0.1mL triamcinolone acetonide were administered. Twenty-seven control patients chose not to be injected and therefore served as controls. LogMar visual acuity (VA), VA rating (VAR) (1 line=0.1LogMAR=5 VAR letters), retinal nerve fiber layer thickness assessed by OCT and static visual field were evaluated at presentation, after 7days, after 3months and after 6months. RESULTS: Sixty-eight patients with NAION were evaluated. Forty-one received IVTA, 29 were injected within 15days after the onset of symptoms and 12 after 15days. There was a higher proportion of patients improving VA of 2 lines or more (10 or more VAR letters) in the injected group (49%) compared with the non-injected group (11%, P=0.019). Among the patients injected before 15days, the proportion improving for 2 lines or more (55% vs. 11%, respectively, P=0.013) and for 3 lines or more (45% vs. 11%, respectively, P=0.035) were significantly higher than in the non-injected group. Also, comparing the VA at presentation with the VA after 6months in the injected eyes, it improved significantly (P=0.003) and also in the subgroup injected within 15days (P=0.0007) but not in the injected group after 15days (P=0.801). Visual field improvement was only observed in the subgroup of patients injected within 15days with a significant improvement of the mean deviation (dB) within 6months (P=0.015). CONCLUSIONS: This follow-up study confirms the results of the previous series displaying an apparent benefit of intravitreal steroids injected in the acute phase of NAION. Only patients receiving IVTA within 15days from onset of NAION have a significant improvement of VA and visual field during the follow-up period of 6months.

Cystic maculopathy of the inner nuclear layer in glaucoma patients.

PURPOSE: The study aimed to detect and describe glaucoma-related pseudocystic abnormalities at the internal nuclear layer (INL) of the macula using OCT, in relation with visual field defects and other clinical data. PATIENTS AND METHODS: Primary open-angle glaucoma patients presenting for a follow-up visit were consecutively included over 5 months and underwent clinical examination, OCT imaging, and central 10-2 visual field testing. OCT measures included the thickness of the peripapillary retinal nerve fiber layer (RNFL) and macular ganglion cell complex (GCC), together with an analysis of B-Scans and en-face images. All data provided by OCT were analyzed and compared with the visual field testing. RESULTS: Fourteen patients out of 216 showed pseudocysts in the INL of the macula. These cysts were hyporeflective, fusiform, and of variable size (15 to 25µm) and were always associated with a thinning of both the RNFL and GCC. En-face OCT showed evidence of a distribution of cysts in the macular region, based on the appearance of numerous, dense hyporeflective pits whose localization matched precisely with the vision loss as assessed by central 10-2 visual field testing. No other correlations were found. DISCUSSION: Pseudocysts of the internal nuclear layer of the macular region are found in some cases of chronic glaucoma. Their presence is always associated with a scotoma in the visual field and appear to constitute a marker for glaucoma progression. Glaucoma-related central pseudocysts could result from Müller cell changes, excitotoxicity, and/or trans-synaptic retrograde degeneration. The presence of pseudocysts could be a marker of a particular subpopulation whose features remain to be determined.

Refractive accuracy and visual outcomes after combined descemet membrane endothelial keratoplasty and cataract surgery: A French multicentric study.

PURPOSE: Descemet membrane endothelial keratoplasty (DMEK) combined with cataract extraction and intraocular lens insertion (new triple procedure) limits postoperative refractive errors. The objective of this study was to assess refractive accuracy after DMEK combined with cataract extraction and intraocular lens implantation. SETTING: Four university hospitals (Rouen, Paris, Reims, Grenoble). DESIGN: This retrospective multicenter study included patients with symptomatic corneal endothelial decompensation and cataract. METHODS: The primary outcome was the difference between the target spherical equivalent and postoperative refraction at months 2 and 6. Secondary outcomes were visual acuity, keratometry, pachymetry and endothelial cell density. RESULTS: A total of 130 eyes of 111 patients (mean age 66.2 years) were included (94% with Fuchs' endothelial dystrophy). For a mean refractive target set at -0.50 (±0.57) D, the mean (95% CI) refractive error was hyperopia of +0.49 (0.314; 0.664) D at 2 months and +0.46 (0.299; 0.619) D at 6 months. Best corrected distance visual acuity was improved in all patients: from 0.49 (±0.3) logMAR to 0.14 (±0.14) logMAR at 2 months and 0.05 (±0.1) logMAR at 6 months. Mean corneal thickness decreased from 621.6 (±37.6) µm to 515.2 (±42.6) µm at 2 months and 539.0 (±39.0) µm at 6 months. CONCLUSIONS: Good refractive accuracy was obtained after the new triple procedure with DMEK. Hyperopic shift is common after triple procedures, and its persistence should be evaluated in future studies in order to anticipate a change in its value to optimize intraocular lens power calculation.

[Retrospective evaluation of residencies in private ophthalmology practice from 2015 to 2018 in Champagne-Ardenne]. / Évaluation rétrospective de stages d'interne d'ophtalmologie en cabinet libéral de 2015 à 2018 en Champagne-Ardenne.

INTRODUCTION: Between 2010 and 2018, the quota for admission to ophthalmology residencies increased by 50 % (106 in 2010 vs 150 in 2018). In order to accommodate this increasing number of residents, the University Hospital of Reims formulated an agreement with the Regional Health Agency in May 2015 enabling certain ophthalmologists in the private sector to train a resident within their private practice for a semester. We will present the results of three and one half years of this experience. METHODS: Two retrospective questionnaires were created and completed. One was addressed to the host supervisor, the other to the resident. Their objective was to evaluate and standardize the experience from both points of view. The following aspects were explored: the extent to which the environment was welcoming, the resident's clinical ability and progress, the resident's surgical ability and progress, time-management, resident-patient relations and respective assessments. We also requested information on the number of residents hosted by each private practice as well as the positive and negative aspects of the internship for both the supervisor and the intern. RESULTS: Between May 2015 and October 2018 (seven semesters), 12 residents from the University Hospital of Reims did an internship with one of the six proposed private sector ophthalmologists in the Champagne-Ardennes region. The residents were between their second and eighth semesters of professional training. Seven residents did their first or second semester of ophthalmology training in a private practice. The survey results led to the conclusion of a positive experience for both trainer and trainee regarding the progress made by the resident, both clinically and surgically. CONCLUSION: Given the growing number of ophthalmology residents and the limits of the training capacity of hospital-based residencies, private sector internships with practitioners actively involved in teaching increase the training capacity for residents and complement the conventional hospital training.

[Tear film analysis and evaluation of optical quality: A review of the literature (French translation of the article)]. / Analyse du film lacrymal et évaluation de sa qualité optique : une revue de la littérature.

Dry eye is a complex multifactorial disease of the ocular surface and tears. It is associated with ocular surface symptoms and is one of the most common causes for ophthalmologic consultation. Despite their frequent use in clinical practice, the usual tests to evaluate dry eye and ocular surface disease-history of symptoms, tear break-up time (TBUT), Meibomian gland evaluation, corneal fluorescein staining, Schirmer test-have shown low reproducibility and reliability. In addition, subjective symptoms are often weakly or poorly correlated with objective signs. Since the tear film is the first system through which light must pass, the optical quality of the eye is highly dependent on the homogeneity of the tear film. Various investigative methods have been developed to evaluate both the structural and functional quality of the tear film, such as corneal topography, interferometry, tear meniscus measurement, evaporation rate, tear osmolarity and even aberrometry. Some are easily accessible to clinicians, while others remain in the field of clinical research. All of these tests provide a better understanding of the pathophysiology of the tear film. This review hopes to provide an overview of the existing tests and their role in evaluating the significance of the tear film in visual function.

Tear film analysis and evaluation of optical quality: A review of the literature.

Dry eye is a complex multifactorial disease of the ocular surface and tears. It is associated with ocular surface symptoms and is one of the most common causes for ophthalmologic consultation. Despite their frequent use in clinical practice, the usual tests to evaluate dry eye and ocular surface disease-history of symptoms, tear break-up time (TBUT), Meibomian gland evaluation, corneal fluorescein staining, Schirmer test-have shown low reproducibility and reliability. In addition, subjective symptoms are often weakly or poorly correlated with objective signs. Since the tear film is the first system through which light must pass, the optical quality of the eye is highly dependent on the homogeneity of the tear film. Various investigative methods have been developed to evaluate both the structural and functional quality of the tear film, such as corneal topography, interferometry, tear meniscus measurement, evaporation rate, tear osmolarity and even aberrometry. Some are easily accessible to clinicians, while others remain in the field of clinical research. All of these tests provide a better understanding of the pathophysiology of the tear film. This review hopes to provide an overview of the existing tests and their role in evaluating the significance of the tear film in visual function.

Blue light exposure in vitro causes toxicity to trigeminal neurons and glia through increased superoxide and hydrogen peroxide generation.

Today the noxiousness of blue light from natural and particularly artificial (fluorescent tubes, LED panels, visual displays) sources is actively discussed in the context of various ocular diseases. Many of them have an important neurologic component and are associated with ocular pain. This neuropathic signal is provided by nociceptive neurons from trigeminal ganglia. However, the phototoxicity of blue light on trigeminal neurons has not been explored so far. The aim of the present in vitro study was to investigate the cytotoxic impact of various wavebands of visible light (410-630 nm) on primary cell culture of mouse trigeminal neural and glial cells. Three-hour exposure to narrow wavebands of blue light centered at 410, 440 and 480 nm of average 1.1 mW/cm2 irradiance provoked cell death, altered cell morphology and induced oxidative stress and inflammation. These effects were not observed for other tested visible wavebands. We observed that neurons and glial cells processed the light signal in different manner, in terms of resulting superoxide and hydrogen peroxide generation, inflammatory biomarkers expression and phototoxic mitochondrial damage. We analyzed the pathways of photic signal reception, and we proposed that, in trigeminal cells, in addition to widely known mitochondria-mediated light absorption, light could be received by means of non-visual opsins, melanopsin (opn4) and neuropsin (opn5). We also investigated the mechanisms underlying the observed phototoxicity, further suggesting an important role of the endoplasmic reticulum in neuronal transmission of blue-light-toxic message. Taken together, our results give some insight into circuit of tangled pain and photosensitivity frequently observed in patients consulting for these ocular symptoms.

[SMILE (Small Incision Lenticule Extraction) among the corneal refractive surgeries in 2018 (French translation of the article)]. / Quelle place pour le SMILE (Small Incision Lenticule Extraction) dans la chirurgie réfractive cornéenne en 2018.

Refractive surgery is a field in constant evolution. In recent years, a new procedure has appeared under the name SMILE (Small Incision Lenticule Extraction). This technique, carried out solely with a femtosecond laser, should make it possible to better preserve corneal innervation and biomechanics. After a detailed review of the technique itself, we then focus on the scientific evidence for the safety and efficacy of SMILE and its current indications. Advantages of SMILE will be discussed in comparison to disadvantages of the conventional techniques, particularly concerning dry eye and the risk of corneal ectasia with LASIK. Lastly, the current limitations of SMILE (indications, retreatment) are discussed, and future applications are considered regarding improvements in the technique.

SMILE (Small Incision Lenticule Extraction) among the corneal refractive surgeries in 2018.

Refractive surgery is a field in constant evolution. In recent years, a new procedure has appeared under the name SMILE (SMall Incision Lenticule Extraction). This technique, carried out solely with a femtosecond laser, should make it possible to better preserve corneal innervation and biomechanics. After a detailed review of the technique itself, we then focus on the scientific evidence for the safety and efficacy of SMILE and its current indications. Advantages of SMILE will be discussed in comparison to the conventional techniques, particularly concerning dry eye and the risk of corneal ectasia related to LASIK. Lastly, the current limitations of SMILE (indications, retreatment) are discussed, and future applications are considered regarding new improvements in the technique.

[Is Holladay 2 formula acurate enough for calculating intraocular lens power in non-standard eyes?] / Intérêt de la formule Holladay 2 dans le calcul de la puissance de l'implant intraoculaire pour les yeux de biométrie hors normes.

PURPOSE: To evaluate the benefit of the Holladay 2 formula versus the 3rd generation formulae in calculating the IOL power in eyes with non-standard axial length or keratometry before cataract surgery. PATIENTS: Retrospectiv study from January to December 2015. The inclusion critaeria were axial length (AL) <22mm or >26mm, or average keratometry <42 D or >46 D, dividing the patients in 4 groups respectively. The 7 parameters required to calculate the Holladay 2 formula were collected. The final refractive result was turned into spherical equivalent to calculate the optimal power retrospectively. Then, the results obtained using the other formulae were compared with the optimal IOL power. RESULTS: One hundred and twenty-six eyes operated by two surgeons were included. In the high AL group (n=32), the SRK/T was the most accurate formula; regarding the low AL group (n=36), the Hoffer Q and Holladay 2 formulae performed better; for the steep cornea group (n=27), the Hoffer Q, Haigis, Holladay 1 and 2 formulae were not different; last, the Holladay 1 and 2 were more accurate in the flat cornea group (n=33). CONCLUSION: In our study, the Holladay 2 formula does not seem to be better than the others for calculating IOL power in non-standard eyes. Preoperative eye features in such non-standard cases should be taken into account before the surgery to choose the more suitable formula.

[A new classification for meibomian gland diseases with in vivo confocal microscopy]. / Une nouvelle classification des dysfonctionnements meibomiens en microscopie confocale in vivo.

INTRODUCTION: Meibomian gland dysfunction (MGD) is a frequent disorder often associated with dry eye disease. Slit-lamp examination with digital expression of the tarsal Meibomian glands allows examination of the contents of the distal Meibomian gland and the meatus. However, the Meibomian epithelium, interglandular space and proximal secretions cannot be clinically assessed. In vivo confocal microscopy (IVCM) is a rapid and non-invasive imaging technique that provides high-resolution images of the ocular surface and eyelids. The primary objective of the present study was to establish a classification of MGD with IVCM. Secondary objectives were to evaluate this scoring system by analyzing the correlation with OSDI, infrared (IR) meibography and Demodex infestation. MATERIAL AND METHODS: Forty-six dry eye patients (Ocular Surface Disease Index [OSDI] >13) associated with MGD were enrolled. Ten healthy subjects without dry eye disease or blepharitis were also included as controls. An OSDI questionnaire, clinical examination, IVCM and infrared meibography of the lower lid were performed in all subjects by the same examiner. RESULTS: A new MGD score was established based on IVCM findings: the first stage was Meibomian obstruction with a clear epithelium, the second stage was an inflammatory state with Meibomian gland obstruction, epithelial and interglandular inflammation, and the last stage was glandular fibrosis. This score was significantly correlated with the meiboscore obtained with infrared meibography (correlation coefficient 0.47, CI95% [0.22-0.66]). CONCLUSION: IVCM of the Meibomian gland complex complements the clinical examination by determining the stage of dysfunction and may help clinicians evaluate and treat MGD.