Corneal neurotization in the management of neurotrophic keratopathy: A review of the literature.

Neurotrophic keratopathy (NK) is a rare degenerative disease in which damage to the corneal nerves leads to corneal hypoesthesia or anesthesia. Neurotrophic corneal ulcers are notoriously difficult to treat and can lead to blindness. Corneal neurotization (CN) is a recent surgical technique aimed at restoring corneal sensation and may offer a definitive treatment in the wake of NK. Herein, we review the surgical techniques utilized in direct and indirect CN. Technical considerations, outcomes, current limitations and future perspectives are also discussed. This article highlights the key points of this promising procedure and biological aspects that will help provide the best treatment options for patients with severe NK.

[Regression and ablation profiles in corneal refractive surgery]. / Régression et profils d'ablation en chirurgie réfractive cornéenne.

Regression after corneal refractive surgery is a complex phenomenon which seems inevitable. The choice of surgical technique has very little influence on regression for low myopia or myopic astigmatism. However, LASIK and SMILE are the two techniques of choice in the correction of high myopia. LASIK is also better for the correction of hyperopia, hyperopic astigmatism and mixed astigmatism. Intraoperatively, the choice of a wide optical zone and adherence to a thick residual stromal bed provide stability. Regression may also be reduced by modulating anti-inflammatory therapy, treating dry eye, and using mitomycin C in PKR. In all cases, obtaining keratometry during patient follow-up helps to identify the cause of the regression. The objective of this review is to synthesize recent data from the literature on regression in refractive surgery as a function of the ablation profiles used.

[Intracorneal ring segments in keratoconus management]. / Les anneaux intra-cornéens dans la prise en charge du kératocône.

Intracorneal ring segments (ICRS), used in the management of keratoconus since the 2000s, have enjoyed significant technological development. Various types of ICRS exist, whose arc length, thickness, and diameter can be chosen according to the desired effect on the spherical equivalent, keratometry and asphericity. Individualized implantation strategies, based on each patient's topographic and tomographic pattern, are constantly evolving. The surgical procedure is standardized, and complications remain very rare. Combined procedures (corneal collagen cross-linking and refractive photokeratectomy±topo-guided, phakic and pseudophakic intraocular lenses) are increasingly used and require a good knowledge of the effect of ICRS alone on the keratoconic cornea. The objective of this review is to summarize clinical practices used in the visual rehabilitation of keratoconic patients using the ICRS+- combined procedures.

[Excimer laser in keratoconus management]. / Le laser excimer dans la prise en charge du kératocône.

Visual rehabilitation in keratoconus is a challenge, notably because of the significant irregular astigmatism and optical aberrations that it induces. Many surgical techniques have been developed in addition to, or in the case of failure of, spectacles and rigid gas permeable contact lenses: intracorneal ring segments, intraocular lenses, excimer laser and, as a last resort, keratoplasty. Excimer laser photoablates the cornea, allowing remodeling of its surface. There are various treatment modes (wavefront-optimized, wavefront-guided and topography-guided), allowing performance of a customized treatment if needed. Its use in keratoconus has been described since the 2000s, alone or in combination with other procedures. For example, the combination of photoablation and corneal cross linking, a technique that increases corneal rigidity and in so doing can slow or even stop the progression of keratoconus, proved its efficacy and safety in many studies, and various protocols have been described. A triple procedure, including intracorneal ring segments, excimer laser and cross linking, has also given some very promising results in progressive keratoconus, providing a significative improvement in visual acuity and topographic data. The combination of excimer laser and intraocular lenses remains a poorly explored lead that might provide some satisfactory results. The objective of this review is to summarize the recent data on excimer laser in keratoconus management.

Corneal crosslinking in keratoconus management.

Since two decades, corneal crosslinking (CXL) has been proposed as the sole therapeutic option to halt progression of keratoconus or other ectatic diseases. CXL aims at stiffening the cornea using a combination of ultraviolet-A light and a chromophore (vitamin B2, riboflavin), and has been proposed in various indications, from progressive ectatic diseases to corneal infection. Despite being in clinical use for many years, many controversies and discrepancies exist towards CXL procedure and its exact role is still under debate. We report an up-to-date review of the state of the art of CXL and describe the basic principles, the different existing CXL techniques reporting basic and clinical evidence, as well as the new perspectives and the possible future developments of the procedure.

[Epithelial basement membrane dystrophy diagnosed following LASIK surgery]. / Dystrophie de Cogan révélée après chirurgie réfractive de type Lasik.

A 48-year-old woman with no significant past history underwent bilateral simultaneous laser in situ keratomileusis for correction of her myopia. On the tenth postoperative day, the patient complained of visual decrease and photophobia. Slit lamp exam showed corneal epithelial irregularities. Confocal microscopy was performed and revealed a characteristic appearance of epithelial basement membrane dystrophy (EBMD). The patient was successfully treated with artificial tears and autologous serum eyedrops. EBMD may be missed before LASIK surgery, even after a careful pre-operative examination. Exacerbation of EBMD after LASIK surgery is rare. It should be considered when unexplained corneal epithelial defects or irregularities occur following LASIK. Confocal microscopy is very useful to confirm the diagnosis.

[Role of in vivo confocal microscopy in irido-corneo-endothelial syndromes]. / Apport de la microscopie confocale in vivo dans les syndromes irido-cornéo-endothéliaux.

INTRODUCTION: In vivo confocal microscopy (IVCM) is an increasingly utilized tool in studying complex corneal and anterior segment pathologies. We illustrate the role of this imaging technique in the irido-corneo-endothelial (ICE) syndromes through a case report. CASE REPORT: A 47-year-old woman presented unilateral decreased vision associated with ocular hypertension and peripheral anterior synechiae. Slit lamp examination of the cornea was unremarkable but IVCM showed pleomorphism and polymegathism of the corneal endothelium and highly reflective nuclei resulting in an epithelial-like cell morphology. This appearance led to the diagnosis of ICE syndrome. DISCUSSION: Confocal microscopic findings in ICE syndromes are similar to histopathologic findings. This technique may be for a useful diagnostic adjunct in ICE syndromes by revealing specific characteristics, particularly in difficult diagnostic situations, such as when corneal edema impedes specular microscopy or when the iris fails to demonstrate pathognomonic anomalies.

[Is cheating with automatic perimetry possible?]. / Peut-on tricher en périmétrie automatique?

INTRODUCTION: Automatic perimetry examination requires the patient's cooperation, but the programs used check response validity. This study evaluated the possibility of patient cheating on this examination. MATERIALS AND METHOD: This study investigated 27 visual fields of automatic perimetry with patients who had no ophthalmological history. Each subject had to reproduce a visual field loss that was observed for 5 minutes (two diffuse losses, five fields reflecting hemianopsia, four reflecting quadranopsia, two tubular losses, five nasal steps, nine absolute and arciform losses). The 24-2 Fastpac of the Humphrey field analyzer and the G2 of the Octopus perimeter were used for this study. RESULTS: Simple deficits were easy to reproduce, but visual field defects are often deeper and simulated test results tend to be too perfect. On the other hand, complex defects such as arciform scotoma or nasal steps were more difficult to reproduce. Visual field defect simulations were exaggerated beyond what was reasonable. CONCLUSION: This study reports on whether it is possible to cheat with automatic perimetry. The different parameters analyzed by computer programs are not able to detect cheating patients.

[How patients react when glaucoma is diagnosed?]. / Comment les patients réagissent-ils à la découverte d'un glaucome?

PURPOSE: Evaluate the psychological consequences of announcing the diagnosis of glaucoma. MATERIALS AND METHODS: Two hundred patients completed a 20-item questionnaire designed to analyze the context in which glaucoma was discovered and the patients' reaction to this diagnosis. Behavioral modification in patients and their families are specified as well as their perception of the information received. COMMENTS: Most patients had open-angle glaucoma and showed either an anxious or a passive reaction to the announcement of the diagnosis. Severe anxiety led to prescription of minor tranquilizers or antidepressants in 11% of cases. Nearly half of the patients declared that they had modified their behavior after receiving the diagnosis, indicating a need to play an active role in disease management. A large majority of the patients were conscious of the risk of blindness related to glaucoma; however, they did not feel ill but rather handicapped . Most were dissatisfied with the information provided by their doctor and sought other sources of information. CONCLUSION: Announcing a diagnosis of glaucoma is a decisive step in the physician-patient relationship, known to be important in future treatment compliance. Better adapted information with regular reevaluation of the need for additional information is necessary. The psychological impact should be evaluated regularly in order to promote an active role on the part of the patient and avoid a decline in quality of life.