[Anterior chamber migration of Supramid tube from short Krupin valves after more than 13 years of implantation. Two case reports]. / Luxation intracamérulaire du tube en Supramid de valves de Krupin courtes plus de 13 ans après leur implantation. A propos de deux cas.

INTRODUCTION: In 2004, the authors had to remove two short Krupin valves because the Supramid tube of these valves implanted 13 years previously had migrated into the anterior chamber. CASE REPORT: The first case was treated in April 2004, the second in November 2004. These valves had been implanted in January 1991 and August 1983 respectively; both because of insufficient, intense general and local medical treatments for vascular glaucoma: post-traumatic for one and neovascular glaucoma after central retinal vein occlusion for the other. RESULTS: In 2004 in each case, the authors performed the extraction, with Healon, of the Supramid tube that had migrated into the anterior chamber and the dissection of the previous scleral flap, which allowed them to uncover and extract the Silastic scleral tube whose split distal end continued to allow seepage of aqueous humour. The two lateral Supramid arms used to stitch the valve were also removed. The two valves were replaced with a Molteno glaucoma drainage implant. Follow-up was simple. DISCUSSION: Since February 1981, several Krupin valves, first short, then long, were placed in the Ophthalmic Ward of the Villeneuve St Georges Hospital in France. The authors discuss their structure and evolution. The design of these valves, at first made of two different materials (an intracameral Supramid tube followed by a intrascleral Silastic tube) evolved toward a draining tube made from the same material for its entire length, preventing the disconnection of the two tubes. A literature review retraces the history of the device and the modifications over time. CONCLUSION: These old Krupin valves have stabilized the IOP for several years in numerous glaucoma patients who did not respond to intense medical treatments. Their dual-material concept was redesigned in favor of a single tube that could no longer become a mobile intraocular foreign body.

[Recurrent acute Enterococcal faecalis endophthalmitis following cataract surgery: a case report with a favorable outcome]. / Endophtalmie aiguë récurrente à Enterococcus faecalis après chirurgie de la cataracte: un cas à évolution favorable.

INTRODUCTION: Enterococcal faecalis endophthalmitis is an acute type of endophthalmitis that is exceptional because it is rare, can be recurrent, and has a poor functional prognosis. OBSERVATION: We report a case of recurrent Enterococcus faecalis endophthalmitis after cataract surgery on a 76-year-old woman. After four acute infectious episodes over a few months, this patient recovered without ablation of the IOL. After the classic intravitreous and general antibiotic injections, the treatment required posterior vitrectomy with posterior capsulorrhexis. Only this surgery enabled the cleansing of the vitreous cavity by removing the germs present in the intravitreous abscesses. Despite the responsible germ's virulence, the visual recovery at 7/10 P2 remained stable 2 years after these recurrent infectious episodes. DISCUSSION: As far as we know, this is the only published case of Enterococcus faecalis endophthalmitis that was cured without ablation of the IOL. A review of the literature shows the rarity of acute Enterococcus faecalis endophthalmitis, characterized by recurrences and a poor visual prognosis. The microbiologic and therapeutic particularities of Enterococcus faecalis endophthalmitis are discussed with the objective of elaborating a therapeutic protocol combining antibiotic therapy, corticotherapy, vitrectomy, and posterior capsulorrhexis while leaving the IOL in place. CONCLUSION: Enterococcus faecalis endophthalmitis is an ophthalmologic emergency, which requires not only a rapid intervention, but also close follow-up to detect recurrences early and perform vitrectomy and posterior capsulorrhexis with as little delay as possible.

[Monitoring, reporting, and preventing nosocomial infections in ophthalmology. Creation of the National Endophthalmitis Observation Database (ONDE)]. / Surveillance, signalement et prévention des infections nosocomiales en ophtalmologie. Création de l'Observatoire National Des Endophtalmies (ONDE).

INTRODUCTION: Fighting against nosocomial infections (NI) is one of the missions of every healthcare institution (Decree No. 99-1034, 6 December 1999 and circular No. DGS-DHOS-2600-645, 29 December 2000). Setting up epidemiological surveillance for NI is an essential factor in preventing such infection as well as operation-site infections (OSI). It forms one of the priorities defined by the National Technical Committee for Nosocomial Infections (CTIN). In this context, the National Observation Endophthalmitis Database (ONDE) was born under the auspices of the Académie d'Ophtalmologie to coordinate epidemiological surveillance of OSI in ophthalmology, principally after cataract surgery. In addition, recent legislation (Decree No. 2001-671 of 26 July 2001 and circular No. DHOS/E2-DGS/SD/5C no 2001-383 of 30 July 2001) introduced the obligatory reporting of certain NI through the coordination centers to fight nosocomial infections (CCLIN) and to the DDASS, with the aim of alerting and assisting medical institutions. The interaction between these professional initiatives and regulatory obligations remains to be defined. MATERIALS AND METHODS: The ONDE project establishes surveillance of postoperative endophthalmitis by collecting information on cases of OSI and their circumstances of onset using a standardized, anonymous questionnaire. This questionnaire can be viewed online on the website . In conjunction, and as stipulated in Decree 671 dated 26.07.2001, it is essential to install the continuous reporting of endophthalmitis of infectious origin in every health care institution, thereby enabling transmission of these NI data in ophthalmology to various healthcare bodies (C-CLIN, DDASS, In Vs). This reporting does not replace the reporting obligations associated with safety monitoring. Patient information, another aspect of the regulatory device, is essential to the patient-healthcare professional confidence relationship. RESULTS: The creation of ONDE and an explanation of its objectives were announced by mail at the beginning of 2003 to all French ophthalmologists: 424 answers were received, 346 (82%) ophthalmologists stating that they were ready to take part in this project. Despite the length of the questionnaire, the project coordinators hoped to recover a sufficient number of observations, thereby repeating the success of the first prospective national survey piloted by GEEP in 1991. This project was presented to the Network for Advancing and Investigating the Surveillance of Nosocomial Infections (RAISIN), which is an association of CCLIN and the Institute for Health Monitoring. The ONDE process was received with interest and RAISIN offered its methodological support. The potential synergism between the ONDE work and that of other RAISIN studies was highlighted. The results of the surveillance network for OSI identified an ophthalmological infection rate in surgery in 2002 of 0.27 OSI per 100 operative procedures. The endophthalmitis reports received since 2001 make up 3% of the reports received at InVs, making this a warning event and justifying specific studies and the need for a case-control study to better understand the risk factors for this type of infection: ONDE will be associated with the RAISIN working group on this subject. DISCUSSION: Setting up a dialogue between ophthalmology professionals (surgeons, manufacturers of medical devices), and those in hygiene, and the surveillance of NI on regional and national scales, will help to increase the cooperation specifically required to introduce quality procedures and improve the understanding of the risk of infection in ophthalmology. Although sending data to ONDE cannot substitute for regulatory reporting, it will help to obtain additional information and to improve this knowledge. The American SENIC Project (Study of the Efficacy of Nosocomial Infection Control) in the 1970s found that the introduction of epidemiological surveillance could reduce NI by 30%. CONCLUSION: The need to regularly update epidemiological data on NI in ophthalmological surgery justifies this new effort required from the profession and will enable it to perform part of a permanent evaluation process for the multifactorial risk of infection. Ophthalmologists have long shown their involvement in mobilizing forces to fight infection.

[Pellet guns: a persistent threat to eyes]. / Armes à grenailles: une menace oculaire qui persiste.

Following a recent case of bilateral perforating ocular trauma by multiple pellets, the authors reviewed pellet traumatisms treated in the Emergency Department and operated on in the Ophthalmology Department of the Villeneuve-St-Georges Hospital over the past 15 years. At close range, pellet weapon shootings can generate lid, conjunctiva, and powder cornea tattoos; in these cases, the lesions are often unilateral. Shooting at longer range does not result in corneodermic tattoos, but because pellets scatter, binocular lesions frequently occur. The different lesions caused by these nonmagnetic foreign bodies are often very serious. An early, even very early, traumatic cataract is sometimes very difficult to treat in these polytraumatized eyes. The visual prognosis is more reserved, as the impact zones often involve the posterior pole and the macular area. The best recovered visual acuity is 30-35/20, with visual field alterations, but the injury to the eyeball by multiple pellets can generate globe atrophy. The authors stress the gravity of these ocular traumas, fortunately rarer but not completely eradicated since the law of May 6, 1995, which restricted the possession of these pellet guns.

[Air bags and eye injuries: chemical burns and major traumatic ocular lesions--a case study]. / Air bags--sécurité vitale et risques oculaires: brûlures alcalines et lésions traumatiques profondes. A propos d'un cas.

The authors report a case of bilateral eye lesions with extended visual sequelae after the inflation of a driver's airbag during a head-on collision. The superficial facial lesions were accompanied by bilateral eye lesions, reaching both the anterior and posterior segments. Bilateral periorbital palpebral hematomas; voluminous bipalpebral edema combined with severe -conjunctival edema, corneal erosions, and edema; bilateral hyphema; pupillary changes with multiple iris sphincter breaks and weak pupillary light reflex only on the right eye; retrocession of the iridocorneal angle; and on fundus examination both retinas had posterior and peripheral hemorrhages and Berlin retinal edema. Five years after the trauma and 4 years after posttraumatic surgery for cataract that had progressively appeared on the left eye, the visual acuity is 25/20 in both eyes notwithstanding a small paracentral scotoma related to a break in the Bruch membrane. A review of the literature shows several types of ophthalmological lesions related to the airbag mechanism, which after combustion of an alkaline powder inflates at a very high speed, resulting in a risk of corneal-conjunctive-palpebral alkaline burns added to an eye contusion, which may be responsible for severe lesions. The American studies distinguish three factors affecting the seriousness of these airbag accidents: (a) wearing glasses, (b) position and size of the driver, and (c) inflation force of the airbag. Wearing a seatbelt is mandatory to minimize the violence of the oculofacial impact. After facial trauma from an airbag, an ophthalmological examination is necessary to assess of the chemical burns of the tissues exposed to the alkaline powder and possible major ocular lesions.

[Bacterial contamination: epidemiology in cataract surgery]. / Epidémiologie de la contamination bactérienne oculaire en chirurgie de la cataracte.

PURPOSE: To evaluate anterior chamber (AC) bacterial contamination at the end of cataract surgery in a large series of patients, to determine the influence of operative technique on ocular contamination. METHODS: Retrospective study of 2,624 patients undergoing cataract extraction, 354 extracapsular cataract extraction (ECCE) and 2,270 phacoemulsification. Anterior chamber aspirates were performed on completion of surgery for microbiological studies. RESULTS: One hundred and thirty two patients (5%) had culture-positive anterior chamber aspirates. Coagulase-negative Staphylococcus, Propionibacterium sp. and Corynebacterium sp. were the most commonly isolated organisms. The AC contamination rates during ECCE (5.6%) and phacoemulsification (4.7%) were not statistically different. There was a statistically significantly higher risk of AC contamination in eyes receiving an intraocular lens (IOL) with polypropylene haptics (9.9%) than in eyes receiving the same IOL with polymethylmethacrylate haptics (4.4%). CONCLUSION: Surgical technique had no statistically significant effect on ocular contamination. Polypropylene haptics IOLs were associated with a higher risk of bacterial contamination.

[Idiopathic polypoidal vasculopathy: 2 case reports]. / Vasculopathie polypoïdale idiopathique.

Idiopathic polypoidal choroidal vasculopathy (IPVC), is a particular vascular abnormality of the inner choroid, composed of 2 components, a network of branching vessels of variable dimension, terminating in an aneurysm-like enlargement with sometimes episodic serosanguineous detachment of the retinal pigment epithelium and neurosensory retina. We report two cases of female patients with a peripapillary location of IPVC. None of the eyes had any drusen characteristic of age-related macular degeneration.

[Capsulorhexis staining by trypan bleu in mature cataract surgery]. / Utilisation du bleu trypan pour la réalisation du capsulorhexis dans la chirurgie de la cataracte blanche.

BACKGROUND: Capsulorrhexis may be hazardous in the absence of the red fundus reflex. Anterior capsule trypan blue staining enabled to perform the capsulorrhexis and safe phacoemulsification. MATERIAL AND METHODS: Twenty patients with mature cataract were enrolled in the study and opereted on after injection of trypan blue in the anterior chamber. RESULTS: Circular capsulorrhexis was performed in all cases followed by phacoemulsification and in-the-bag IOL implantation. In two cases hard nuclei required a manual extracapsular technique. No operative complications, and no residual of coloration was noted the day after the operation. With a follow-up of 2 to 12 months, no complications appeared (cornea, capsulorrhexis, IOP). CONCLUSION: In mature cataracts, with no red fundus reflex, capsulorrhexis can be done by anterior capsule staining.

[Factors influencing early post surgical ocular hypertension after phacoemulsification]. / Les facteurs de l'hypertonie oculaire précoce après phacoémulsification.

PURPOSE: To evaluate factors influencing early post surgical ocular hypertension after phacoemulsification. METHODS: Records were collected for patients who had uncomplicated phacoemulsification with IOL implantation in the bag. Aspiration of the viscoelastic was performed at the conclusion of surgery. Patients with previous ocular surgery, high myopia, or glaucoma were excluded. Intraocular pressures were measured at six hours (+/-2) postoperatively. Following factors were analysed RESULTS: 26% of the patients had an ocular pressure equal or higher than 21 mmHg. Among the factors we analysed, pilocarpine injection was the only one to produce significant decrease in postoperative ocular pressure. COMMENTS: The acute postoperative IOP increase following phacoemulsification is presumably the result of trabecular obstruction by viscoelastic material. However it can occur despite meticulous evacuation of viscoelastic, which could be dependent upon the material's viscosity, and IOL material and design. Postoperative ocular hypertension is not related to ultrasonic duration. Intracameral injection of pilocarpine significantly reduces the incidence of postoperative intraocular pressure increase. CONCLUSION: Early postoperative ocular hypertension can be observed with different kinds of viscoelastics and IOL. Meticulous evacuation of viscoelastic from anterior chamber, although necessary does not always prevent this early complication. Intracameral injection of pilocarpine can reduce its incidence.

[Infectious complications of cataract surgery: revisiting acute endophthalmitis]. / Complications infectieuses de la chirurgie de la cataracte. L'endophtalmie aigüe en questions.

We reviewed management procedures for endophthalmitis on the basis of epidemiological, clinical, microbiological and experimental data, mainly obtained from two prospective multi-center studies in France (Groupement d'Etudes Epidémiologiques et Prophylactiques, GEEP) and the American Endophthalmitis Vitrectomy Study (EVS). We analyzed medical history of the patient, recent history involving the eye, and examination and laboratory findings to search for a better treatment protocol for each patient and to assess evidence-based prophylaxis for cataract surgery.

[Intraocular contamination during cataract surgery according to surgical technique and type of implant]. / Contamination intra-oculaire au cours de la chirurgie de la cataracte selon la technique et l'implant utilisés.

PURPOSE: To determine wether the cataract extraction method and intraocular lens material affect bacterial contamination of the eye during surgery. METHODS: This retrospective study evaluated microbial contamination of the anterior chamber fluid in three group of patients. Group 1: extracapsular extraction and PMMA lens (354 cases). Group 2: phacoemulsification and PMMA lens (474 cases). Group 3: phacoemulsification and silicone lens with PMMA haptic (264 cases). RESULTS: Microbial contamination rate was in group 1: 5.65%, in group 2: 4.75%, and in group 3: 4.54%. The difference was not statistically significant (chi: 0.321). All contaminants were Gram positive. CONCLUSION: Bacterial contamination rate of the anterior chamber is similar during extracapsular extraction and phacoemulsification, and is not modified when using PMMA or silicone lens.

[Results of a National survey on antibiotic prophylaxis and antisepsis in cataract surgery]. / Résultats d'une enquête nationale concernant l'antibioprophylaxie et l'antisepsie dans la chirurgie de la cataracte.

PURPOSE: We present the results of a national survey carried out in 1997 among French ophthalmologists on prophylactic antibiotic and antiseptic therapy in cataract surgery. METHOD: Among the 6050 questionnaires sent by post, 1082 answers recorded between January and February 1997. RESULTS: The results give precise details on French surgeons attitude as regards prophylactic antibiotics for: topical, subconjunctival, intra-ocular and systemic administration. CONCLUSION: This kind of study is frequent in English-speaking countries and is useful to help our profession to formulate important current questions and to collect answers.

Vancomycin prophylaxis and intraocular contamination during cataract surgery.

PURPOSE: To investigate the effect of vancomycin added to the intraocular irrigation solution to prevent anterior chamber contamination during phacoemulsification. SETTING: Centre Hospitalier, Villeneuve-Saint-Georges, France. METHODS: A group of 372 patients having cataract extraction by phacoemulsification was divided into two consecutive, nonrandomized groups. The first group (n = 190) was a control; there was no antibiotic in the irrigation solution. The second group (n = 182) received vancomycin in the irrigation solution. Intraocular fluid was aspirated at the end of surgery and injected into a blood culture bottle to evaluate bacterial contamination of the anterior chamber. RESULTS: There was no between-group difference in bacterial intraocular contamination. Eight samples in the first group were contaminated and nine in the second group. All contaminants were gram-positive vancomycin-sensitive organisms. CONCLUSIONS: Adding vancomycin to the intraocular irrigation solution during cataract surgery had no effect on the occurrence of intraocular contamination as evaluated by anterior chamber taps.

Ocular penetration kinetics of fosfomycin administered as a one-hour infusion.

The penetration of fosfomycin in aqueous humour was studied in 21 patients who were to undergo cataract surgery. All patients received 4 grams of fosfomycin as an infusion lasting one hour. Concentrations of the drug in aqueous humour were measured 1, 2, 4, 6 and 12 hours after the start of infusion. Drug concentrations in aqueous humour and serum were measured by HPCE (High Performance Capillary Electrophoresis). The aqueous humour concentration at one hour was 11.46 mg/l +/- 2.12. Peak concentration was 14.63 mg/l +/- 5.54, reached two hours after the infusion. Concentrations were high until 6 hours and remained significant at 12 hours. These results confirm the excellent diffusion of fosfomycin in aqueous humour, with high levels at 12 hours. They justify its use in intraocular infections, by infusions repeated every eight hours, to maintain concentrations above the MIC 90 for organisms usually susceptible to the drug.

[Interleukin-6 and other cytokines in the aqueous humor in uveitis and endophthalmitis]. / Interleukine-6 et autres cytokines dans l'humeur aqueuse au cours d'uvéites et d'endophtalmies.

We studied aqueous humour and serum level of 4 cytokines during uveitis and endophthalmitis: Interleukin 6, Gamma interferon, tumor necrosis factor and Granulocyte-macrophage colony stimulating factor. High levels of IL-6 were found in aqueous humour during ocular inflammation and infection. This elevation of IL-6 level was more constant and more important in the endophthalmitis group (mean level 2.992 pg/ml) than in the uveitis group (mean level 1.480 pg/ml). During endophthalmitis no evident relation was found between IL-6 level and clinical course or aspect, or bacteriological results of anterior chamber tapes. In the uveitis group, no relation was found between IL-6 level and clinical aspect or aetiology.

[Bacteriological study of the intraocular fluid at the end of cataract surgery]. / Etude bactériologique du liquide intra-oculaire en fin d'intervention de cataracte.

The authors studied bacterial contamination of the anterior chamber during extracapsular cataract extraction with intraocular lens implantation. A first study was conducted to determine the rate of contamination of anterior chamber aspirates, before surgery, in 46 patients undergoing cataract extraction. A second study concerned 200 patients undergoing extracapsular extraction with posterior chamber lens. Anterior chamber fluid was aspirated at the end of surgery, and inoculated into blood culture bottles. Bacteriological results were positive in 11 cases, and were compared with conjunctival smears. The way in which aqueous humor was aspirated and inoculated is described. The bacteriological method was tested with a small inoculum of bacteria. Bacteriological study of intraocular fluid at the end of cataract surgery might be useful in the diagnosis and treatment of postoperative endophthalmitis.

[Infectious endophthalmitis]. / Endophtalmies infectieuses.

Bacterial endophtalmitis is a disastrous postoperative complication of any intraocular surgery which can lead to blindness. With prompt endocular taps for appropiate laboratory investigations, the use of large spectrum antibiotics with good intraocular penetration, the intraocular injections of antibiotics, most of the eyes can be salvaged. Although it is unlikely that postoperative microbial endophthalmitis can be avoided entirely, all efforts should be made to reduce the incidence of this complication. Under this point of view, in addition to the available sterile techniques during the surgery, the topical and systemic antibiotic prophylaxis requires that carefully controlled studies be performed on very large numbers of patients to attain statistical validity.

[Bacterial endophthalmitis. Ophthalmological results of a national multicenter prospective survey]. / Endophtalmies bactériennes. Résultats ophtalmologiques d'une enquête prospective multicentrique nationale.

Under the aegis of the GEEP (Groupement d'Etudes Epidémiologiques et Prophylactiques) a prospective multicentre study concerning bacterial endophthalmitis was carried out over a period of one year long with the contribution of 64 metropolitan ophthalmologic hospital departments. During this survey 143 cases of post surgical endophthalmitis were recorded: 111 of them were secondary to elective surgery, 32 developed after a perforating eye injury. Twenty-four cases of endophthalmitis developed in the absence of surgery were therefore called "medical" endophthalmitis. The frequency of endophthalmitis after elective surgery was 0.32%, and 2.8% after penetrating eye injury. Intraocular samples were obtained in 61.5% of the cases of post surgical endophthalmitis. 53 bacteria were isolated from 50 cases of endophthalmitis. The bacterial nature of the endophthalmitis was proved in 35% of these cases of post surgical endophthalmitis. Bacteria isolated from these cases of post surgical endophthalmitis were gram positive in 86.7%, and gram negative in 13.3% of cases. 20 bacteria were isolated from pseudophakic eyes: 10 of them were Staphylococcus epidermidis. The visual prognosis of endophthalmitis depends on the strain: visual acuity was more than 1/10 in 68% of cases of Staphylococcus endophthalmitis infection, but in only in 7% of cases of Streptococcus endophthalmitis infection. Intraocular injections of antibiotics both in the anterior chamber and in the vitreous, and vitrectomy increased the quality of the visual result. Three months after post surgical endophthalmitis, 35% of those eyes who received systemic and periocular antibiotic therapy, combined with intraocular antibiotics, with or without vitrectomy, recovered a visual acuity of 4/10 or more, instead of only 18% in the group without any intraocular therapy.

[Chronic Corynebacterium endophthalmitis. Apropos of 3 cases]. / Endophtalmie chronique à Corynebacterium. A propos de 3 cas.

Only a few isolated cases of endophthalmitis have Corynebacterium been implicated as etiology. This diphtheroid, which has been considered for a long time as a nonpathogenic contaminant from the conjunctival flora, may produce systemic diseases usually in immuno-deficient patients. Keratitis and endophthalmitis cases have been reported in the literature. We report three cases of chronic endophthalmitis after extracapsular extraction with intraocular chamber posterior lens which are characterized by many subacute iridocyclitis and vitritis attacks treated by topical steroids. These endophthalmitis are characterized by decrease of visual acuity, hypopion, white plaque on posterior capsule and vitritis. In the first case, Corynebacterium has been isolated from the culture of vitreous and in the second and third cases from the culture of aqueous humor. These bacteria are often very slow growing, 8 to 14 days in the 3 cases. Colonies may not become visible on culture plates before one week or more. Corynebacterium grow well on ordinary media (blood and chocolate agar). The major difficulty is not to discard organism frequently considered contaminants. The treatment associated systemic antibiotherapy with steroids or not, central capsulotomy and vitrectomy with intraocular injection of antibiotic with or without steroids. Antibiotics sensitivities among diphteroids vary greatly. Quinolones, penicillins, vancomycin, cyclines and aminosides are often a good choice. However, individual sensitivities determined by the antibiogram must be used for an appropriate treatment.

[Diffusion of pefloxacin in the aqueous humor and crystalline lens after repeated oral administration in man]. / Diffusion oculaire dans l'humeur aqueuse et le cristallin de la péfloxacine après administration orale répétée chez l'homme.

The intraocular penetration of pefloxacin was evaluated in 38 patients undergoing extracapsular cataract extraction. Patients were treated for three days with 400 mg of pefloxacin every twelve hours (the first dose being 800 mg). The mean maximum concentration of pefloxacin reached six hours after the last dose in the aqueous humor was 7.69 +/- 3.50 mg/l and reached twelve hours after the last dose in the lens was 4.59 +/- 3.15 micrograms/g. Antibiotic levels were measured by high performance liquid chromatography. Several doses until plasma steady state were effective in obtaining a higher level than a single dose of 400 mg. The ratio between aqueous humor and serum concentrations ranged between 0.50 and 0.89 (mean 68%). These concentrations in aqueous humor were higher than the MIC90 of pefloxacin for most bacterial pathogens involved in endophthalmitis 24 hours after the last dose.