[Intravitreal bevacizumab in AMD complicated by submacular hemorrhage]. / Injections intravitréennes de bevacizumab dans les hémorragies sous maculaires compliquant la DMLA.

PURPOSE: To evaluate functional and anatomic results of intravitreal bevacizumab as monotherapy at 12 and 24 months in patients with neovascular age-related macular degeneration (AMD) complicated by large submacular hemorrhage. METHODS: Retrospective analysis of a total of 21 patients (22 eyes) with large submacular hemorrhage secondary to age-related macular degeneration between May 2008 and December 2011. Patients were treated with three monthly intravitreal bevacizumab injections (1.25mg/0.05 mL) at a four to six week interval and then PRN. Retreatment was based on the presence of hemorrhage on fundus examination or signs of activity on optical coherence tomography. Changes from baseline best corrected visual acuity (BCVA) scores, central retinal thickness, volume of hemorrhage and number of injections were analyzed. RESULTS: The mean patient age was 72 years (range, 60-89 years). All patients completed at least 12 months of follow-up, and 17 patients fulfilled 24 months. The size of hemorrhage varied from 3 to 9 disc areas with a mean duration of 12.8 days. At baseline, mean initial BCVA was 20/400 (1.3 LogMAR) and improved to 20/160 at 12 months (P<0.001) and 20/164 at 24 months (P<0.001). Mean central retinal thickness decreased significantly from 550 µm to 255 µm at 24 months (P<0.001). The mean number of injections was 3.87 during the first 12 months. No case of recurrent bleeding was detected during the second year. CONCLUSION: Intravitreal bevacizumab may be a beneficial approach for the management of large submacular hemorrhage secondary to AMD.

[Neuro-ophthalmic adverse effects of metronidazole treatment in children: Two case studies]. / Effets secondaires neuro-ophtalmologiques du traitement par métronidazole chez l'enfant : à propos de deux cas.

PURPOSE: To report the onset of neuro-ophthalmological adverse effects in two children treated with metronidazole for amoebic dysentery. OBSERVATIONS: A 6-year-old child and his 8-year-old sister presented with sudden bilateral vision loss and diplopia associated with intense headache and vomiting. The medical history revealed amoebic dysentery 3 weeks before treated orally with metronidazole for 2 weeks. The ophthalmic examination was similar in the two children and revealed visual acuity of 3/10 bilaterally, binocular diplopia, normal oculomotor function, quiet anterior segment, altered afferent pupil light reflex associated with normal fundus examination, and most particularly absence of optic disc edema. The kinetic visual field showed restriction of isopters and blind spot enlargement and the Lancaster test showed discrete paresis of the lateral rectus muscle of the left eye. Orbitocranial computed tomography and magnetic resonance imaging were normal and visual evoked potential results were compatible with optic neuropathy. Clinical progression consisted in spontaneous resolution of general symptoms, total regression of diplopia, improvement of visual acuity, and normalization of visual evoked potentials after treatment interruption. Regression of symptomatology after interruption of the treatment allowed us to retain the toxic origin. CONCLUSION: Metronidazole may have neuro-ophthalmological side effects. These complications are rare but can be severe and are reversible after treatment interruption. Regular follow-up is necessary in children receiving this treatment.

[Choroidal thickness assessment with SD-OCT in high myopia with dome-shaped macula]. / Épaisseur choroïdienne fovéolaire au SD-OCT dans la myopie forte avec macula bombée.

PURPOSE: To measure macular choroidal thickness (CT) using spectral-domain optical coherence tomography (SD-OCT) in highly myopic eyes with dome-shaped macula (DSM), and to investigate whether the choroid is thicker in these eyes compared to highly myopic eyes without MB. PATIENTS AND METHODS: A cross-sectional study of 200 eyes was performed between January 2010 and June 2012. Twenty-four highly myopic eyes (12%) had a dome-shaped macula. All patients underwent a complete ophthalmological examination, SD-OCT (TOPCON 2000), and B-scan ultrasonography. OCT scans were analyzed in 7 sections, and subfoveal CT was measured manually between the Bruch's membrane and the internal aspect of the sclera. The 20 eyes with isolated dome-shaped macular were paired by age and axial length (AL) with 20 eyes without macular involvement. RESULTS: In the subgroup with isolated MB, the mean subfoveal CT was 101.86 µm (± 21.35 µm). A statistically significant negative correlation was found between CT and AL (r=-0.623, P=0.0001). The regression equation demonstrated a decrease of 8.3 µm per mm of AL. In the subgroup without MB, matched with the subgroup with MB by age (P=0.591), and AL (P=0.815), the mean subfoveal CT was 89.54 µm (± 20.12 µm). The comparison between the two subgroups found a statistically significant difference in subfoveal CT (P<10-4). CONCLUSIONS: In our study, choroidal thickness is increased in highly myopic eyes with dome-shaped macula compared to highly myopic eyes without dome-shaped macula. These findings suggest that abnormalities of the choroid may play a role in the pathogenesis of dome-shaped macula.

[Macular choroidal thickness assessment with SD-OCT in high myopia with or without choroidal neovascularization]. / Épaisseur choroïdienne fovéolaire au SD-OCT dans la myopie forte avec ou sans néovaisseaux choroïdiens.

PURPOSE: To measure macular choroidal thickness (CT) using spectral-domain optical coherence tomography (SD-OCT) in eyes with myopic macular choroidal neovascularization (CNV), and to compare choroidal thickness in these eyes with highly myopic eyes without CNV. PATIENTS AND METHODS: Sixty-four eyes with myopic CNV matched with 64 highly myopic eyes without CNV by age and axial length (AL) were examined between January 2010 and November 2011. OCT scans were performed with spectral-domain OCT (TOPCON OCT 2000). The reference position was changed from the vitreous to the choroid. OCT scan patterns consisted of seven sections; the subfoveal CT was measured manually between Bruch's membrane and the internal portion of the sclera in eyes with CNV and from the pigment epithelium to the scleral interface in eyes without CNV. RESULTS: In the subgroup with CNV, the mean subfoveal CT was 51.71 µm ± 17.35. A statistically significant negative correlation was found between CT and AL (r=-0.615, P=0.0001). Regression analysis demonstrated a decrease of 8.4 µm per mm of AL. In the subgroup without CNV, matched with the CNV subgroup by age (P=0.597), and AL (P=0.813), the mean subfoveal CT was 93.35 µm ± 34.81 µm. The difference between the two subgroups was statistically significant (P<10(-4)). DISCUSSION: Macular choroidal thickness is reduced in high myopia, especially when complicated by CNV. It has not yet been shown that choroidal thinning may be a risk factor for choroidal neovascularization, but our results may suggest that macular choroidal thinning may lead to hypoxic retinal changes resulting in secretion of VEGF and thus CNV. CONCLUSION: Macular choroidal thinning observed in high myopia with CNV. These findings may suggest that choroidal changes may play a role in the pathogenesis of choroidal neovascularization.

[Management of rhegmatogenous retinal detachment with unseen breaks: about 50 cases]. / Prise en charge des decollements de retine rhegmatogenes sans dechirure visible: a propos de 50 cas.

PURPOSE: To evaluate the clinical and therapeutic characteristics of rhegmatogenous retinal detachment (RRD) with unseen retinal breaks. PATIENTS AND METHODS: Retrospective study 50 eyes (50 patients) with RRD with unseen retinal breaks in the pre and intraoperative examination. These patients were treated between 2005 and 2010 by vitrectomy or scleral buckling. Retinal breaks were meticulously sought by indentation of the vitreous base. The subretinal fluid was drained by a peripheral retinotomy when a vitrectomy was needed and puncture ab externo when a scleral buckling was performed. RESULTS: A retinal detachment with unseen retinal breaks accounted for 15% of all RRD operated during this 5-year duration period (2005 - 2010). The average age of our patients was 57 years.Ten were myopic (20%) and 27 (54%) pseudophakic, with inferior RRD in 60% of the cases cases while advanced vitreoretinal proliferation (PVR) greater or equal to stage C in was present in 72%. Primary vitrectomy was performed in 46 cases. Retinal reattachment rate was achieved after a single procedure in 41 eyes (82%). Among them, 40 were operated by vitrectomy and one eye by scleral buckling. The recurrence rate was significantly higher in patients operated by scleral buckling (75%) than by vitrectomy (15%). CONCLUSION: RRD with unseen retinal breaks are often seen inferiorly and have a chronic evolution (60%). They concern pseudophakic patients in the majority of the cases. Their poor prognosis and high recurrence rate also appear to be related to an advanced PVR (72%). The good results of primary vitrectomy should be confirmed by randomized studies, especially in phakic eyes.

[Prevalence and risk factors of age-related macular degeneration (AMD) in a Tunisian hospital population]. / Prévalence et facteurs de risque de la dégénérescence maculaire liée à l'âge (DMLA) dans une population hospitalière tunisienne.

PURPOSE: To describe the prevalence and the risk factors for the age related macular degeneration (AMD) in a Tunisian hospital population. PATIENTS AND METHODS: A total of 2204 subjects 50 years of age and older were enrolled in a prospective study conducted between august 2004 and February 2009. Medical history was reviewed. Subjects underwent a complete ophthalmic examination, including best corrected visual acuity and slit lamp biomicroscopy with fundus examination. Fundus photography and fluorescein angiography were performed if clinical features of AMD were observed on fundus examination. Cases were classified in early and late stages of AMD. RESULTS: The prevalence of late AMD was higher than early AMD. Significant risk factors are age, male gender, smoking, excessive sunlight exposure and poor consumption of fish. Cardiovascular disease, diabetes and dyslipimia were not significantly associated to a high prevalence of AMD. CONCLUSION: AMD is a multifactorial disease. In our Tunisian hospital population, the prevalence of AMD was higher than in the Europeen population. It can be explained by genetic differences or risk factors. Age, cigarette smoking and sunlight exposure were associated with increasing prevalence of AMD in Tunisia.

[Clinical characteristics and therapeutic challenges of retinal detachment in highly myopic eyes]. / Particularités cliniques et thérapeutiques du décollement de rétine du myope fort: à propos de 83 cas.

PURPOSE: To evaluate the clinical characteristics and therapeutic challenges of retinal detachment in highly myopic eyes. PATIENTS AND METHODS: We retrospectively reviewed the medical records of 83 eyes in 79 patients with high myopia (> 6.00 diopters or axial length > or = 26.00 mm) who underwent surgery for retinal detachment between 2001 and 2008. The surgical approaches depended on the type and location of the retinal break, the degree of myopia, and the grade of PVR. RESULTS: The mean age of patients (48 men and 31 women) was 53.9 years. Refractive error ranged from - 10 D to - 25 D (mean was - 14.0 D). The mean follow-up was 19.4 months. Peripheral or equatorial retinal tears were present in 52 cases (62.6%), a macular hole in 14 cases (16.8%), a giant retinal tear in 6 cases (7.2%), and posterior paravascular retinal tears in 11 cases (13.2%). Single-surgery anatomic success was achieved in 65 cases (78.3%), with 17 cases after scleral buckle surgery and 46 cases after pars plana vitrectomy. Final anatomic success was achieved in 76 cases (91.5%). Per and postoperative hemorrhagic complications occurred in 16 cases (19.2%). CONCLUSION: Retinal detachment is a serious complication of high myopia. It often occurs in young patients. Treatment is difficult due to anatomical and clinical conditions.

[Internal astigmatism with other ocular lesions]. / Astigmatisme interne et lésions oculaires associées.

Astigmatism is a refractive defect whose origin is not always purely corneal, and is sometimes the result of corneal, crystalline lens or mixte contributions. The aim of our study is to report, through two cases, ocular lesions associated with a lenticular astigmatism and their evolution after treatment. In the first observation, it is a 25-year-old patient with a unilateral extra corneal astigmatism within the framework of the "tilted disc syndrome" associated with bilateral myopia. This patient has received treatment by Lasik. The postoperative course was good with a decline of 5 ans. The second observation is that of a patient aged 35 years without having a general history with a posterior lenticonus associated with keratoconus responsible for a major mixed astigmatism. She received combined surgery: penetrating keratoplasty with lens extraction and implantation of an artificial lens. The evolution was good with good visual recovery. The balance of internal astigmatism must include the systematic achievement of a subjective and objective refraction under cycloplegia and corneal topography. The search for etiology is critical to screen for eye or general disease and guide the therapeutic strategy. Knowledge of the refractive power of the cornea and crystalline lens of astigmatism separately would be important for surgery refractive and crystalline lens surgery.

[Ophthalmologic manifestations of congenital rubella]. / Manifestations ophtalmologiques de la rubéole congénitale.

Congenital rubella is a rare and serious disease including auditory neurological, cardiac, urinary, and ocular abnormalities. The eye complaints are often congenital cataract, congenital glaucoma, microphthalmia, and oculomotor disorders. We report the case of a 6-year-old girl presenting with a unilateral congenital cataract associated with congenital rubella. She was referred for complaints of high myopia in her right eye. She had a family history of cardiac and urogenital malformations, and presented deafness at birth. The ophthalmologic examination showed a microcornea and a unilateral dense congenital cataract in the right eye. B-scan ophthalmic ultrasound revealed a posterior microphthalmos. The anterior segment examination of the left eye was normal. Funduscopy revealed a salt-and-pepper appearance. Laboratory tests revealed a positive serology, confirming the congenital rubella. Given her complaints of loss of visual acuity in the right eye, the patient was operated on with a phacoaspiration implant in the capsular bag. The postoperative course was uneventful. The prevention of congenital rubella is based on routine vaccination of children. The association of cataract, congenital heart defects, and deafness must be systematically investigated as it may be more serious in association with systemic manifestations.

Pediatric penetrating keratoplasty: indications and outcomes.

PURPOSE: This report evaluates patient characteristics, indications, and outcomes of pediatric keratoplasty, and identifies variables that help to predict poor surgical outcomes. METHODS: We undertook a retrospective review of all cases in our department of primary penetrating keratoplasty performed in children 14 years of age or younger between January 2003 and December 2009. RESULTS: Sixteen primary penetrating keratoplasties were performed during the study interval. Mean age was 11.2 years (3 to 14 years) and the gender ratio was 2. The mean duration of follow-up was 16 months (2 to 36 months).The surgical indications were acquired traumatic opacities in 6 cases, keratoconus in 5 cases, corneal perforation secondary to infectious keratitis in 3 cases, hereditary corneal dystrophy in 1 case, and acquired non-traumatic opacities secondary to congenital glaucoma in one case. The initial visual acuity was less than 1/20 in 68% of cases and the mean final visual acuity after 1 year was 2/10. The graft was clear in 52% of cases after 1 year of follow-up. Postoperative complications were graft failure (24%), ocular inflammation (5%), and ocular trauma (19%). CONCLUSION: Penetrating keratoplasty in children has been documented to have a higher rate of graft failure and a worse visual prognosis than adult keratoplasty. Poor prognosis outcomes were especially caused by noncooperation of parents and postoperative ocular trauma.

[Ocular lesions after bee sting of the cornea. A case report]. / Lésions oculaires par piqûre d'abeille. A propos d'un cas.

Bee stings of the cornea are rarely reported but can potentially cause serious ophthalmologic injuries. Locally, damage occurs through toxic and immunologic reactions and from the stinger retained in the cornea. Early recognition of the possible complications and appropriate treatment may help to prevent permanent loss of vision. Removal of a retained bee stinger remains controversial. We present a case of corneal bee sting with retained stinger apparatus and associated anterior uveitis and discuss the pathologic mechanisms of injury and evaluation of these uncommon presentations.

[Therapeutic penetrating keratoplasty: indications and results in Tunisia]. / Kératoplastie transfixiante à visée thérapeutique : indications et résultats en Tunisie.

PURPOSE: To report the experience of the Tunis Institute of Ophthalmology (Tunisia) in therapeutic penetrating keratoplasty. METHODS: We retrospectively analyzed 35 patients after therapeutic penetrating keratoplasty over a period of 6 years (between September 2002 and September 2008). RESULTS: The mean patient age was 49.3 years. Men outnumbered women by a ratio of 2.5 to 1. The mean follow-up was 13.5 months. Corneal diseases within a therapeutic penetrating keratoplasty were divided into infectious keratitis (21 eyes) and noninfectious diseases (14 eyes). Herpetic keratitis was the most common etiology (11 eyes). The anatomical success rate was 92.4%, with infection eradicated in 80% of cases. The graft clarity at the end of follow-up was 54.2%. Rejection was the leading cause of graft opacification (50%). Final visual acuity was better than 1/10 in 25.7% of patients. Recovery of useful vision was observed in 45.7% of patients. CONCLUSION: Therapeutic penetrating keratoplasty is a surgical technique that has proved its effectiveness in maintaining the integrity of the eyeball. The prognosis for this intervention would probably be better if it could be postponed.

[Therapeutic penetrating keratoplasty in herpes infected eye]. / Les keratoplasties transfixiantes therapeutiques dans les atteintes oculaires d'origine herpetique.

PURPOSE: To report the clinical results, the postoperative course and the complications observed after therapeutic penetrating keratoplasty in herpetic keratitis. METHODS: Eleven eyes with herpetic keratitis (11 patients) that underwent therapeutic keratoplasty between September 2002 and September 2008 were included in this study. The eyes were evaluated retrospectively with respect to the anatomic success rate, the graft clarity, the visual prognosis and the postoperative complications. RESULTS: The mean follow-up was 13.7 months. Nine cases presented with corneal perforation and two cases with descemetocele. Anatomic repair was obtained in 11 eyes (100%). The graft transparency rate was 54.5%. A final visual acuity equal to or better than 1/10 was achieved in 45.45%. Major causes of failure of corneal graft included recurrent disease (n = 1), glaucoma (n = 1), graft rejection (n = 2) and early irreversible edema of the graft (n = 1). CONCLUSION: The prognosis of therapeutic penetrating keratoplasty in herpetic eye disease can only be improved with proper postoperative care and optimal management of immunologic and virologic complications.

Preoperative tissue Doppler imaging differentiates beneficial from detrimental left ventricular hypertrophy in patients with surgical aortic stenosis. A postoperative morbidity study.

BACKGROUND: In a pressure overloaded left ventricle, regional systolic function has often deteriorated despite normal ejection fraction. OBJECTIVE: To correlate regional systolic function obtained by tissue Doppler imaging (TDI) with improvement in functional status after aortic valve replacement in patients with aortic stenosis (AS). METHODS AND RESULTS: 24 hours before aortic valve replacement, 32 patients with severe AS underwent conventional and TDI echocardiography for systolic peak velocity, peak strain and peak strain rate measurement in the short-axis posterior wall. At follow-up, a composite end point of cardiovascular death, worsening of heart failure and limited exercise capacity was recorded. Before surgery, mean (SD) aortic valve area and pressure gradient were 0.69 (0.22) cm(2) and 50 (14) mm Hg, respectively. Ejection fraction was 61 (10)% and septal thickness was 15 (3) mm. Fourteen events were recorded but no cardiac death. By using the multivariate regression analysis, systolic peak strain rate (p = 0.003) was the strongest predictor of limited recovery after aortic valve replacement. The peak strain rate cut-off point was 2/s by receiver operating characteristic analysis. CONCLUSION: Irrespective of ejection fraction and thickness, strain rate is a determinant which predicts recovery after aortic valve replacement in patients with severe AS.

[Iridocyclitis in a patient with Behçet's disease and a familial form of retinitis pigmentosa]. / Iridocyclite chez une patiente atteinte d'une maladie de Behçet et d'une forme familiale de rétinopathie pigmentaire.

INTRODUCTION: Iridocyclitis associated with retinitis pigmentosa is rarely described in the medical literature. We report an unusual case of this association. OBSERVATION: A 55-year-old woman with a history of Behçet's disease presented with acute red and painful eyes and moderately blurred vision. Ophthalmologic examination concluded in bilateral acute hypertensive uveitis. Funduscopy and fundus fluorescein angiogram showed retinitis pigmentosa. The same fundus changes were found in the patient's siblings. Recurrences were frequent and topical steroids were always successful. CONCLUSION: This case is particular in its association of anterior uveitis as the exclusive manifestation of ocular Behçet's disease and familial retinitis pigmentosa.

[Severe microbial keratitis: report of 100 cases]. / Les abcès graves de la cornée: à propos de 100 cas.

PURPOSE: To study predisposing factors, clinical aspects, and microbiological diagnosis in severe microbial keratitis, and to discuss the therapy and visual outcome. MATERIAL: and methods: A prospective and retrospective study concerning patients presenting microbial keratitis hospitalized in department B of the Hedi Raies Ophthalmology Institute (Tunis, Tunisia), from August 1996 to November 2004. RESULTS: One hundred patients with microbial keratitis were hospitalized (45 females and 55 males; ranging in age from 11 to 87 years). The principal predisposing factors were ocular surface pathology (30%), ocular trauma (28%), prior ocular surgery (17%), and contact lens wear (8%). The corneal scraping culture was positive in 42% of cases, isolating Gram-positive bacteria (48.6%), Gram-negative bacteria (29.7%), and fungi (21.6%). The majority of our patients (93%) had broad-spectrum topical antibiotics with therapeutic success in 53.8% of cases. Systemic antifungal agents were indicated in 17 cases. Surgery was necessary in 25.8% of cases: therapeutic keratoplasty in five cases and deleted keratoplasty in nine cases. Final visual acuity was equal to or better than at admission in 81% of cases. Anatomic loss of the eye was observed in eight cases (evisceration, six cases; enucleation, two cases). CONCLUSION: microbial keratitis is a frequent and severe pathology that can lead to blindness. Only early and adapted management can improve the prognosis of severe microbial keratitis.