Educational Concerns About the Safety of Cataract Surgery During Residency: The E3CAPS Pedagogic Study.

INTRODUCTION: Cataract surgery is the most common surgical procedure performed in France. While the incidence of intraoperative complications affecting visual prognosis is extremely low, given the large number of patients operated on, the absolute number of patients affected by complications is quite high. Complication rates are significantly higher when ophthalmology residents (ORs) perform the surgery. Although lack of experience remains the main risk factor, sleep deprivation may adversely affect ORs' successful surgery rate. The value of the EyeSi® surgical simulator in initial training has been demonstrated to increase cataract surgery safety through the transfer of surgical skills from the simulator to the operating room. However, there is no consensus regarding how much training is needed before the first-time ORs are allowed to operate. There is also no scientific evidence that sleep deprivation is associated with a decrease in surgical performance. Establishing a validated protocol for cataract surgery training using the EyeSi surgical simulator (referred to further as the EyeSi) and identifying risk factors for intraoperative complications related to sleep deprivation will improve cataract surgery safety and lead to the reorganization of our healthcare systems. METHODS AND PLANNED OUTCOMES: This multi-centre educational cohort study will include two distinct axes which will both aim to reduce the risks of cataract surgery. Enrollment will include 16 first-year ORs for Axis 1 and 25 experienced residents for Axis 2, all from the University Hospitals of Nantes, Tours, Angers and Rennes. Axis 1 will focus on investigating the learning curve of first-year ORs using the EyeSi, following the training program recommended by the "College des Ophtalmologistes Universitaires de France" in order to set up a future "licence to operate." Axis 2 will evaluate the impact of sleep deprivation on the surgical performance of experienced ORs using the EyeSi. TRIAL REGISTRATION: ClinicalTrial.gov identifier: NCT05722080.

Fluocinolone Acetonide Implant Injected 1 Month after Dexamethasone Implant for Diabetic Macular Oedema: the ILUVI1MOIS Study.

INTRODUCTION: The aim of this study was to assess the efficacy and safety of fluocinolone acetonide implant (FAci) injected 1 month after the last dexamethasone intravitreal implant (DEXi) in chronic diabetic macular oedema (DME) patients. METHODS: Retrospective multicentric study conducted in pseudophakic patients with chronic DME frequently treated with dexamethasone intravitreal implant (DEXi; time to DME recurrence ≤ 6 months), receiving FAci 1 month after the last DEXi, with at least a 6-month follow-up. Best-corrected visual acuity (BCVA), central macular thickness (CMT) on optical coherence tomography, intraocular pressure (IOP) and additional treatments were assessed on the day of FAci injection (M0), 1 (M1) and 3 months (M3) later and then every 3 months. RESULTS: A total of 41 eyes from 34 patients were included. At M0, patients' mean age was 68.7 ± 9.8 years, the mean DME duration was 63.9 ± 22.9 months, the mean interval between two DEXi was 14.2 ± 3.3 weeks. M12 data were available for 71% of patients. At baseline, the mean BCVA, CMT and IOP were 63.2 ± 16.6 letters, 299.4 ± 103.3 µm, and 16.2 ± 4.5 mmHg, respectively, and remained stable during the follow-up. At M12, 14% of patients required additional intravitreal treatments. CONCLUSION: In pseudophakic patients with chronic DME showing good response to DEXi but requiring repeated injections every < 6 months, switching to FAci 1 month after the last DEXi was effective and safe. Further prospective randomized controlled studies are needed to confirm these findings, and to determine the best interval between the last DEXi and the first FAci.

[Management of binocular diplopia in the department of ophthalmic emergencies at the Regional University Hospital of Tours]. / Prise en charge des diplopies binoculaires aux urgences ophtalmologiques du Centre hospitalier régional universitaire de Tours.

OBJECTIVES: To describe the etiologies of binocular diplopia for patients presenting to the ophthalmologic emergency department of the Regional University Center Hospital (CHRU) of Tours. METHODS: This is a retrospective study of the medical records of patients who presented with binocular diplopia in the ophthalmic emergency department of the CHRU of Tours between January 1st and December 31st, 2019. Binocular diplopia was classified as paralytic or non-paralytic according to the ocular motility examination. RESULTS: One hundred twelve patients were included. The median age was 61 years. Internal referral from other hospital services represented 44.6% of the patients. On ophthalmological examination, 73.2% had paralytic diplopia, 13.4% non-paralytic diplopia and 13.4% normal examination. Neuroimaging was performed in 88.3% of cases, with 75.7% of patients receiving it on the same day. Oculomotor nerve palsy was the most frequent cause of diplopia in 58.9%, the majority represented by abducens nerve palsy (60.6%). The most frequent etiology of binocular diplopia was ischemic, with microvascular damage in 26.8% of cases and stroke in 10.7% of cases. CONCLUSION: Among patients assessed in an ophthalmological emergency department setting, one in ten patients had stroke. It is essential to inform patients of the urgent nature of ophthalmological evaluation in the case of acute binocular diplopia. Urgent neurovascular management is also mandatory and should be based on the clinical description provided by the ophthalmologist. Neuroimaging should be performed as soon as possible, based on the ophthalmologic and neurological findings.

Long-term functional outcomes and vision-related quality of life after vitrectomy for epiretinal membrane: a prospective cohort study.

To investigate the long-term effect of unilateral idiopathic epiretinal membrane (uiERM) removal on monocular and binocular visual function, and on vision-related quality of life (VR-QoL). Prospective, single-center study. The following data were collected before and after surgery: distance monocular and binocular best-corrected visual acuity (BCVA), horizontal and vertical metamorphopsia, horizontal and vertical aniseikonia, stereoacuity and National Eye Institute Visual Function Questionnaire-25 item (NEI VFQ-25). Forty-two patients (mean age: 72.7 ± 7.4 years; 24 men) were included. At 6 months postoperatively, distance monocular BCVA (p < 0.001), horizontal metamorphopsia (p = 0.001) and the composite score of NEI VFQ-25 (p < 0.001) significantly improved, in comparison to baseline. At 2 years postoperatively, distance monocular (p < 0.001) and binocular (p = 0.01) BCVA, horizontal (p < 0.001) and vertical (p = 0.02) metamorphopsia, vertical aniseikonia (p = 0.01), stereoacuity (p < 0.001) and 3 subscales scores of the NEI VFQ-25 (p < 0.05) ("general vision", "mental health", "driving") significantly improved in comparison to baseline. Removal of uiERM improves VR-QoL and achieves good visual outcomes on both monocular and binocular visual parameters over long-term. Visual symptoms induced by macular contraction have different improvement kinetics after surgery. Stereopsis, the highest level of binocular vision, can be improved in some cases.

Calcium oxalate crystals retinopathy following domino liver transplant: A case report.

INTRODUCTION: Hyperoxaluria is a rare cause of hereditary crystalline retinopathy. We report the first case of acquired calcium oxalate crystalsretinopathy following domino liver transplantation (DLT). CLINICAL CASE: A 72-year-old patient was referred for bilateral visual impairment 9 months after DLT. Slit lamp examination was unremarkable. Fundus examination revealed calcium oxalate crystals accumulation within both retina. Owing to multi-organ failure, the patient underwent combined liver-kidney retransplantation. During the following two years, calcium oxalate crystals accumulation within the retina gradually decreased and visual acuity improved. Nevertheless, OCT-angiography revealed abnormalities in the inner and outer retinal vascular plexus (i.e. retinal vessels occlusion and dilatation). Visual field examination revealed bilateral constriction associated with decreased optic nerve fibre layer thickness suggesting optic nerve atrophy. CONCLUSION: This case highlights the need for ophthalmologists to consider the diagnosis of acquired hyperoxaluria in patients with progressive bilateral visual impairment following DLT, especially if the postoperative course is marked by renal failure. Moreover, even after liver-kidney transplantation with a conventional graft, visual function can remain impaired owing to maculopathy and optic atrophy.

Ambulatory cataract surgery centre without perioperative anaesthesia care: a prospective cohort study.

This study aims to evaluate the safety and patient satisfaction of a fast-track procedure for cataract surgery under topical anaesthesia without perioperative anaesthesia care. This is a prospective single-centre study including all cataract procedures in the Centre Ambulatoire de la Chirurgie de la Cataracte at the Hospital of Bourges between May and August 2018. Procedures were performed under topical anaesthesia without the presence of a nurse anaesthesiologist or anaesthesiologist, the patient had not fasted, and no peripheral venous line was placed. Only heart rate and oxygen saturation were monitored intraoperatively with pulse oximetry. Incidence and nature of intraoperative adverse events and surgical complications were recorded. Patient satisfaction was assessed using the Iowa Satisfaction with Anaesthesia Scale (ISAS). In total, 651 cataract surgeries were performed among which 614 (94.3%) were uneventful. Thirty (4.6%) intraoperative adverse events and 8 (1.2%) surgical complications were recorded. All surgeries were successfully completed. No medical emergency team intervention or hospital admittance was encountered. The mean ISAS score was 5.7/6, indicating high patient satisfaction. Cataract surgery in an ambulatory cataract surgery centre without perioperative anaesthesia care is a safe procedure with high patient satisfaction for screened patients. Anaesthesia ressources are scarce and may be more beneficial to more complex ophthalmic or non-ophthalmic surgeries.

Monocular and binocular visual parameters associated to vision-related quality of life in patients with epiretinal membrane: a prospective cohort.

PURPOSE: Binocular visual impairment related to unilateral idiopathic epiretinal membranes (uiERM) and its association with vision-related quality of life (VR-QoL) has not yet been investigated. This study aimed to explore binocular visual parameters (distance binocular best-corrected visual acuity (BCVA), aniseikonia, stereopsis) and VR-QoL in patients with uiERM. METHODS: We carried out a prospective single-centre cohort study. The following data were collected: VR-QoL (NEI VFQ-25), distance monocular and binocular BCVA, horizontal and vertical metamorphopsia (M-charts test), horizontal and vertical aniseikonia (NAT TEST) and stereoacuity (TNO test). Multiple linear regression analyses were performed to evaluate factors influencing VR-QoL. RESULTS: Forty-six patients with uiERM and visual complaints were included. Aniseikonia was found in 40 (80%) participants. Stereoacuity was poor (above 120 s of arc) in 46 (100%) participants. Distance monocular BCVA, horizontal metamorphopsia and horizontal aniseikonia were the factors associated with VR-QoL in patients with uiERM. CONCLUSIONS: In subjects presenting uiERM, aniseikonia is frequently found and stereopsis is constantly impaired. We advocate quantitative testing of metamorphopsia and aniseikonia in addition to BCVA for the assessment of global visual function. Further investigations are needed to evaluate the effect of vitrectomy on these parameters and VR-QoL. TRIAL REGISTRATION: EudraCT Number/ID RCB: 2016-A00252-49.

Ambulatory surgery centers: possible solution to improve cataract healthcare in medical deserts.

PURPOSE: To investigate the epidemiological impact of an ambulatory cataract surgery center providing a fast-track procedure without anesthetic evaluation on the access to cataract healthcare. SETTING: French nationwide study. DESIGN: Retrospective cross-sectional study. METHODS: The study included individuals undergoing cataract surgery from the French national administrative database of medical information. Data analyses focused on patients living in the Cher and neighboring areas. Epidemiological indicators of patient flow and healthcare efficiency were calculated. A medicoeconomic analysis was performed. RESULTS: Between 2012 and 2018, activity increased by +50.2% (3665 to 5506) interventions in the Cher area compared with a national increase of +22.7% (720 351/884 254), while maintaining a constant ophthalmologist workforce. The leakage ratio decreased by 5.9 points (26.3% to 20.4%), whereas the attractiveness and self-sufficiency ratios increased by 2.3 (8.6% to 10.9%) and 8.6 (80.6% to 89.2%) points, respectively. The age- and sex-standardized rate of healthcare utilization for cataract surgery increased by 4.3 points (11.6 to 15.9 cataract surgeries per 1000 inhabitants), making the Cher the second best French area in 2018 for the rate of cataract surgery despite ranking 96th of 109 French areas for ophthalmologist density. The cost of the cataract removal procedure was 523.99€ (666.22€ in the conventional operating room). CONCLUSIONS: An ambulatory cataract surgery center with a fast-track procedure could represent a solution in medical deserts to improve cataract healthcare without supplementary funding. Nonetheless, consulting activity should be optimized to detect eye disorders and schedule interventions.

Predictive values of initial semi-quantitative assessment of relative afferent pupillary defect for neovascularization in central retinal vein occlusion.

PURPOSE: To measure the predictive values of relative afferent pupillary defect (RAPD) assessed semi-quantitatively, and visual acuity (VA) at onset of central retinal vein occlusion (CRVO), for neovascularization. METHODS: Retrospective analysis of the TROXHEMO trial that included patients with CRVO within 30 days after the onset. Inclusion criteria were as follows: semi-quantitative RAPD assessment at diagnosis and/or at one month. RAPD was 'severe' if ≥ 0.9 log. Exclusion criteria were as follows: prophylactic panretinal photocoagulation (PRP) before neovascularization. RESULTS: Among the 119 patients enrolled in the main centre, 101 were analysed. 26 had a neovascular complication during the twelve months of follow-up: rubeosis (19), glaucoma (7) and posterior neovascularization (15). The mean time to onset of a neovascular complication was 4.7 months (1 to 12, median 3 months). All the patients who had a neovascular complication had RAPD at first examination or at one month (negative predictive value (NPV) = 100%) but the positive predictive value (PPV) was low (31%, 95% CI [21%; 42%]). The association 'severe RAPD or VA < 35 letters (ETDRS) at inclusion or at one month' was the best compromise between PPV (53%, [39%; 68%]) and NPV (96%, [92%; 100%]). CONCLUSION: To predict neovascularization, RAPD should be routinely evaluated with filters: the risk of neovascular complication is (a) almost nil if there is no RAPD, (b) very low if there is no severe RAPD and if VA is higher than 35 letters, and (c) higher than 50% if RAPD is ≥ 0.9 log or if VA is less than 35 letters.

Ophthalmological findings in children with autism spectrum disorder.

PURPOSE: Eye pathology could be related to atypical visual behaviours and impaired social communication through visual cues in children with autism spectrum disorder (ASD). The main purpose of this prospective study was to assess ophthalmological disorders in children with ASD and to investigate the relationships with intellectual disability (ID) and ASD severity. METHODS: In this prospective study, comprehensive ophthalmological and oculomotor examinations were performed. ASD severity and verbal and performance intelligence quotients were determined using adapted scales. These clinical data were compared between groups of children based on the presence or absence of ophthalmological disorders and the achievement or not of visual acuity (VA) testing by using non-parametric statistical tests. RESULTS: Amongst a sample of 51 children, ophthalmological disorders were found in 39% of cases, with 35% having significant refractive errors and 10% presenting with strabismus. Children with ASD and ophthalmological disorders had significantly lower verbal (29.8 ± 14.7 compared with 44.3 ± 21.5; p = 0.010) and performance quotients (57.8 ± 18.3 compared with 67.59 ± 20; p = 0.049) but no significant result was found between the presence of ophthalmological disorders and ASD severity, level of communication and social contact, or modulating behaviour when changes occur. Children who did not achieve monocular VA testing (39%) had significantly lower verbal (25.1 ± 9.7 compared with 46.1 ± 20.9; p < 0.001) and performance quotients (52.7 ± 17 compared with 69.8 ± 18.8; p = 0.001), also presented higher social interaction impairment (p = 0.002), and expressed more important behavioural signs (p = 0.007). CONCLUSIONS: Ophthalmological disorders are frequently found in children with ASD, especially in those with ID. Ophthalmologists and child psychiatrists should pay attention to perform ophthalmological examination in children with ASD since eye disorders might remain undetected. A comprehensive examination by a paediatric ophthalmologist would help to improve the individual clinical description and the global intervention. TRIAL REGISTRATION: Clinical trial registration number: NCT02444117.

Mesalazine treatment causing resolution of intracranial hypertension secondary to ulcerative colitis: A case report.

RATIONALE: The association between intracranial hypertension (ICH) and ulcerative colitis (UC) is rare. We report the unusual case of a male patient with UC and ICH in whom both conditions resolved with mesalazine therapy. PATIENT CONCERNS: A 48-year-old Caucasian man presented to our department in June 2016 for decreased vision, transient visual obscuration, pulsatile tinnitus and headaches of 7 months duration. Bilateral optic disc swelling was found at fundus examination. Brain MRI excluded any brain tumor and lumbar puncture showed cerebrospinal fluid (CSF) opening pressure of 26 cm of water with normal CSF contents. DIAGNOSES: Idiopathic ICH was suspected. INTERVENTIONS: The patient was managed with oral acetazolamide. Headaches initially improved but the dosage could not be decreased under 750 mg a day without recurrence of the symptoms. Extensive review of systems showed that the patient had active UC. He was given oral mesalazine, 2000 mg a day. OUTCOMES: The symptoms of UC and ICH quickly resolved. Acetazolamide was progressively tapered over the course of the 9 subsequent months and the patient did not show any worsening of his symptoms or papilledema. LESSONS: UC should be added to the list of disorders associated with ICH. In case of atypical ICH with drug dependency, investigations should seek for UC. Treating efficiently UC with mesalazine may improve ICH, suggesting an underlying inflammatory process.

Objective ocular torsion outcomes after unilateral horizontal rectus surgery in infantile esotropia.

PURPOSE: To analyse objective ocular torsion among patients with infantile esotropia and to determine the effects of unilateral horizontal rectus surgery. METHODS: Sixty-eight patients (136 eyes) (range 4 to 16 years) who underwent unilateral horizontal rectus surgery for infantile esotropia participated in this retrospective single-centre study. Objective ocular torsion using fundus photography was assessed before surgery and 1 year later. We defined three groups of patients based on preoperative qualitative objective ocular torsion: physiological extorsion and pathological extorsion and intorsion. For each group, the disc-foveal angle was measured and analysed both before and after surgery. We looked for possible correlations between amount of esodeviation and disc-foveal angle size. RESULTS: Preoperatively, 28 (41%) patients had + 6.73 (± 2.66) degrees of physiological extorsion. Thirty-one (46%) patients had + 12.94 (± 3.67) degrees of pathological extorsion. Nine (13%) patients had - 1.99 (± 2.52) degrees of intorsion. After surgery, the number of subjects with physiological extorsion increased to 45 (66%). The number of patients with pathological extorsion decreased to 17 (25%) and the mean disc-foveal angle was significantly reduced by 1.80°. Six (9%) patients presented intorsion and the mean disc-foveal angle was significantly reduced by 2.28°. For the pathological extorsion group, the size of the disc-foveal angle before surgery was positively correlated to its reduction after surgery. Disc-foveal angle variation and distance esodeviation variation after surgery were positively correlated. CONCLUSIONS: These results highlight that pathological objective ocular torsion can be frequently found in infantile esotropia and is decreased after unilateral recession-plication surgery.