[Recurrence of palpebral basal cell carcinoma according to histological margins]. / Récidive des carcinomes basocellulaires palpébraux selon les marges histologiques.

BACKGROUND: Basal cell carcinomas (BCCs) represent 90% of malignant tumors of the eyelids, which can be locally invasive and destructive. The observation of histological safety margins (MHS) allows for the prevention of recurrence while maintaining a fair compromise between aesthetics and functionality. However, to date, there is no consensus or national recommendations concerning the MHS to be observed according to the various histological subtypes of BCCs. METHODS: Through a retrospective analysis of patient records and corresponding excisional slides, we studied the 6-year recurrence rate of 98 patients who underwent surgery for palpebral BCC. RESULTS: MHS were mostly absent in the excisional specimens of recurrent BCCs and significantly more narrow than in non-recurrent BCCs, on average over 2mm. CONCLUSION: The results of our study suggest that an average MHS greater than 2mm prevents most recurrences.

[Management of ocular toxoplasmosis in France: Results of a modified Delphi study]. / Prise en charge de la toxoplasmose oculaire en France : résultats d'une étude Delphi modifiée.

OBJECTIVE: To evaluate diagnostic and therapeutic practices and then establish a consensus on the management of ocular toxoplasmosis in France through a Delphi study. MATERIALS AND METHODS: Twenty-three French experts in ocular toxoplasmosis were invited to respond to a modified Delphi study conducted online, in the form of two questionnaires, in an attempt to establish a consensus on the diagnosis and management of this pathology. The threshold for identical responses to reach consensus was set at 70 %. RESULTS: The responses of 19 experts out of the 23 selected were obtained on the first questionnaire and 16 experts on the second. The main elements agreed upon by the experts were to treat patients with a decrease in visual acuity or an infectious focus within the posterior pole, to treat peripheral lesions only in the presence of significant inflammation, the prescription of first-line treatment with pyrimethamine-azithromycin, the use of corticosteroid therapy after a period of 24 to 48hours, the prophylaxis of frequent recurrences (more than 2 episodes per year) with trimethoprim-sulfamethoxazole as well as the implementation of prophylactic treatment of recurrences in immunocompromised patients. On the other hand, no consensus emerged with regard to the examinations to be carried out for the etiological diagnosis (anterior chamber paracentesis, fluorescein angiography, serology, etc.), second-line treatment (in the case of failure of first-line treatment), or treatment of peripheral foci. CONCLUSION: This study lays the foundations for possible randomized scientific studies to be conducted to clarify the management of ocular toxoplasmosis, on the one hand to confirm consensual clinical practices and on the other hand to guide practices for which no formal consensus has been demonstrated.

[Acute macular neuroretinopathy: En face OCT description, case series]. / Neurorétinopathie maculaire aiguë : description et intérêt de l'OCT en face, série de cas.

Acute macular neuroretinopathy (AMN) is a rare disease characterized by involvement of the outer retinal layers of the macula. The diagnosis of AMN is based on multimodal imaging, combining infrared reflectance (IR) imaging and optical coherence tomography with B-scan analysis (OCT-B). The en face OCT is a tomographic image processing technique, integrating data from entire A-scans to create a frontal retinal image of the desired area. Structural en face OCT imaging appears to be effective in delineating AMN lesions, using segmentation between the outer plexiform line and the ellipsoid line. In the future, analysis of the various modalities of a single OCT acquisition may be sufficient to diagnose AMN.

Ex vivo porcine model for eye, eyelid, and orbit movement analysis of 4-mm ferromagnetic foreign bodies in MRI.

PURPOSE: Ferromagnetic foreign bodies (FFB) present during magnetic resonance imaging (MRI) explorations can lead to tissue injury due to movement, especially in and around the eyes. Ferromagnetic foreign bodies located in the intraocular area, eyelids, and orbit are thus prohibited from undergoing MRI. The aim of the study was to analyze movement of 4-mm ferromagnetic foreign bodies in MRI in the eye, eyelid, and orbit using computed tomography (CT) scan. METHOD: We developed a porcine model using 12 quarters of fresh porcine heads. Each porcine head included one whole orbit with the ocular globe, orbital fat, muscles, and eyelids. Four-millimeter FFB were implanted in the eye within 2 days post-slaughter, and images were acquired within 5 days post-slaughter. Four-millimeter FFB movement was analyzed after 1.5-Tesla (T) MRI. Four locations were tested: intravitreous, suprachoroidal, intraorbital fat, and intrapalpebral. Movement analysis was assessed using computed tomography (CT) scan. RESULTS: The intravitreous ferromagnetic ball moved 14.0 ± 8.8 mm (p < 0.01), the suprachoroidal ball moved 16.8 ± 5.4 mm (p < 0.01), the intraorbital fat ball moved 5.8 ± 0.9 mm (p > 0.05), and the intrapalpebral ball moved 2.0 ± 0.4 mm (p > 0.05). CONCLUSION: The ex vivo porcine model was able to study FFB movement. The 4-mm ferromagnetic balls moved in intravitreous and in suprachoroidal locations after MRI.

[Validation of an ophtalmology tele-expertise protocol in nursing homes]. / Validation d'un protocole de téléexpertise d'ophtalmologie en EHPAD.

INTRODUCTION: Assisted living residents are a fragile population with limited access to health care. In recent years, telemedicine has developed in several specialties, including ophthalmology. The main objective of our study is the validation of an ophthalmology telemedicine protocol in assisted living facilities. MATERIALS AND METHODS: This is a retrospective, multicentric, descriptive study including 4 assisted living facilities in the Rennes area. An ophthalmic technician examined residents for one half-day per week. The examination was performed directly in the patient's room, in bed or in a chair, with portable equipment. An ophthalmologist from our service interpreted the results remotely on a deferred basis within 7 days. Appropriate medical or surgical care was then offered to the patient depending on the diagnosis. RESULTS: We included 113 residents. A complete, interpretable examination was achieved in 84.1% of cases. One or more ophthalmic conditions were diagnosed in 57.5% of the residents. Of the residents who were then seen at the university medical center, 65% underwent a scheduled surgical procedure or laser. Visual acuity was significantly improved subsequent to the telemedicine encounter. DISCUSSION: The success rate of a complete, interpretable examination allows us to now validate our nursing home examination procedure. In addition to bringing a large amount of initially unknown information to the medical and paramedical staff of the structure, ophthalmology telemedicine allows for a significant improvement in visual acuity. CONCLUSION: This project validated the feasibility of ophthalmology telemedicine in an assisted living setting. This protocol may also be applicable to other health care settings (penitentiaries, mental health institutions, etc.).

[Clinical and paraclinical examination of non-traumatic optic neuropathy in the adult population]. / Examen clinique et paraclinique d'une neuropathie optique non traumatique de l'adulte.

Optic neuropathies (ON) occur in a variety of clinical presentations depending on their pattern of occurrence, their topography and the amount of functional visual impairment. Management of an ON requires a sequence of steps: confirm its existence (positive diagnosis): the diagnosis of ON is usually clinical and must be considered in the case of decreased visual acuity, change in color vision, visual field defect, relative afferent pupillary defect (RAPD), and absence of macular pathology; rule out differential diagnoses: determine the cause; etiologic diagnosis is sometimes complex and takes shape from clinical and paraclinical building blocks. The etiology may be vascular, inflammatory or demyelinating, infectious, toxic, vitamin-deficient, compressive (neoplastic or non-neoplastic), hereditary, congenital, traumatic or even pressure-related (glaucoma or advanced intracranial hypertension). Cerebral and orbital imaging with fine cuts of the optic nerves is often a mandatory examination, which is sometimes useful to repeat; identify therapeutic emergencies.

[Ocular hypertension and optic neuropathies secondary to dysthyroid orbitopathy: Review of the literature]. / Hypertonie intra-oculaire et neuropathies optiques secondaires à l'orbitopathie dysthyroïdienne : revue de la littérature.

Dysthyroidism, especially Graves' disease, causes potentially severe orbital disease. This is frequently accompanied by ocular hypertension stemming from multiple pathophysiological mechanisms. Adaptations in the technique of intraocular pressure measurement must occur, using portable equipment if necessary. Glaucomatous optic neuropathy secondary to dysthyroid orbitopathy is rare, and screening for signs of compressive optic neuropathy is essential in the case of visual field loss. In cases of secondary glaucomatous optic neuropathy, treatment of the intraocular pressure is based mainly on systemic corticosteroid therapy and topical medications as necessary.

[Ability of ophthalmic technicians to identify a normal ophthalmological examination]. / Capacité discriminative de la normalité de l'examen ophtalmologique par les orthoptistes.

INTRODUCTION: Ophthalmology care has been growing for several years. Since ophthalmic technicians have the opportunity to perform delegated procedures, it is important to evaluate their training. OBJECTIVE: To evaluate the ability of 3rd year ophthalmic technician students and graduates to assess the normality of an ophthalmological examination and to determine a proposed time delay for seeing an ophthalmologist. MATERIALS AND METHODS: One hundred records including ophthalmology examinations were shown to 8 ophthalmic technician students in their third year of study and to 3 graduated technicians. Three ophthalmologists determined the content of the files, the pathological nature or not of the case, as well as the proposed time for seeing an ophthalmologist. We calculated the sensitivity and specificity to recognize the normality of the case, as well as the concordance between the proposed time for seeing an ophthalmologist. RESULTS: For recognition of a normal case, the sensitivity was 80%, and the specificity was 83% in the group of technician students, and 81% versus 80% respectively in the group of graduated technicians. For the proposed time of consultation for seeing an ophthalmologist, the kappa agreement coefficient was 0.30 in the group of students and 0.41 in the group of graduates (low and moderate agreement respectively). CONCLUSION: The study showed a good ability of technicians to recognize the normality or not of clinical cases, but their ability to judge the appropriate timing of treatment by an ophthalmologist remains insufficient.

[Feedback on ophthalmologic telemedicine in a nursing home]. / La télé-ophtalmologie en EHPAD : retour d'expérience.

INTRODUCTION: Ophthalmologic care needings increase whereas the numbers of ophthalmologist decrease. Oldest people who are often vulnerable and dependent populations are particularly affected in difficulty to access to health services. To resolve the problem, the use of telemedicine in ophthalmology could be an alternative. MATERIALS AND METHODS: From June 2018 to November 2018, patients from Janzé Hospital (Ille et Vilaine) did an ophthalmologic teleconsultation during their stay. Teleconsultation was based on visual acuity, intraocular pressure measurement, wild-field retinophotography and optical coherence tomography performed by an orthoptist and a videoconference with an ophthalmologist. RESULTS: Sixty-seven patients underwent teleconsultation (60 % women, 40 % men). Mean age was 83 (standard deviation±8). Fifty-four percent (36) of consultations were complete. Retinophotography was missing in 45 % of cases (30) and optical coherence tomography in 53 % of cases (35). Ophtalmologic pathologies were detected in 37 patients (55 %) and we start medical care in 14 (38 %) of the patients. We gave glasses prescription to 45 % (30) of the patients. Eighteen percent (10) of the patients required a physical consultation. LogMar distance visual acuity was significantly improved from 0.67 (±0.76) to 0.52 (±0.72) (P<0.0001) and LogMar near visual acuity was significantly improved from 0.68 (±0.84) to 0.53 (±0.76) (P<0.0001). Low vision proportion was significantly decreased from 54 % to 39 % (P=0.02; OR=1.86; IC95 % [1.06-3.28]) after our intervention. DISCUSSION: This experiment gives the opportunity to old, vulnerable and dependent population that has no longer access to classical consultation to access eye care. At the same time, consultation informs the nursing home caregivers about the visual health status and provides environment improvement. CONCLUSION: Teleconsultation is an alternative to classical consultation especially in dependent population. This experiment could be a starting point to the development of this solution in social health-care institutions.

Feedback on ophthalmologic telemedicine in a nursing home.

INTRODUCTION: The need for ophthalmologist appointments is increasing, while the number of practitioners is decreasing. Elderly patients, who may be dependent and isolated, are the most affected by this barrier to care. In order to get around this obstacle, telemedicine visits might be an alternative. MATERIALS AND METHODS: From June 2018 to November 2018, patients in the housing facility for dependent elderly individuals (EHPAD) at the Janzé (Ille-et-Vilaine) Medical Centre participated in an ophthalmology telemedicine visit during their stay. The telemedicine visit included measurement of visual acuity, intraocular pressure, wide field fundus photography, and optical coherence tomography (OCT) performed by a technician, and a videoconference with an ophthalmologist. RESULTS: Sixty-seven patients aged 83±8 years (60% women and 40% men) underwent a telemedicine visit. The visit was completed in 36 (54%) cases. The fundus photography was not performed in 30 (45%) cases, and the OCT was not performed in 35 (53%) cases. We diagnosed an ophthalmologic disease in 37 (55%) patients, with medical management having begun in 14 (38%) of them. A prescription for corrective lenses was given in 30 patients (45%). Following our visit, mean logMar visual acuity experienced a statistically significant improvement from 0.67 (±0.76) to 0.52 (±0.72) (P<0.0001) for distance vision and from 0.68 (±0.84) to 0.53 (±0.76) (P<0.0001) for near vision. Eighteen per cent of patients (10) required transportation to an in-person ophthalmologist visit for continued management. With regard to low vision, the proportion of low-vision eyes experienced a statistically significant decrease from 54% to 39% [P=0.02; OR=1.86; 95% CI (1.06-3.28)] following our visit. DISCUSSION: This experiment allowed an isolated, dependent patient population without access to classic office visits to gain access to clinical care. In addition to providing eye care to the patients, the visit increased awareness amongst the caregivers of the vision status of the residents, allowing them to adapt their environment accordingly. CONCLUSION: Telemedicine is an alternative to classic physician visits, particularly for very dependent, institutionalised patients. This experiment might serve as a point of departure for generalised adoption of these solutions within extended care facilities.

[Telemedicine monitoring for AMD patients]. / Suivi en télémédecine des patients atteints de DMLA.

INTRODUCTION: AMD follow-up is a public health issue in developed countries due to aging of the population and medical demographics. Telemedicine may be a means of improving follow-up. PURPOSE: To compare the agreement between telemedicine and in-person consultations in terms of indications for intravitreal injections in exudative AMD patients. MATERIALS AND METHODS: From January 2017 to April 2017, AMD patients followed on a PRN protocol at a single center, Rennes university medical center, were included. The telemedicine evaluation was read by two anonymous experts on the basis of the medical record including visual acuity and fundus photographs. The agreement between conventional follow-up and telemedicine in terms of indications for intravitreal injections, as well as interobserver agreement, were tested with the Cohen's kappa coefficient using SAS statistical software V9.4 (SAS Institute, Cary, NC). RESULTS: In total, 104 eyes corresponding to 57 consultations for 42 patients were analyzed. The mean age was 82.12 years (standard deviation±6.4). Recommendations for anti-VEGF were similar between the standard and telemedicine visits in 97 % of cases. The Kappa coefficient was 0.8861 [0.76; 1.00], P<0.0001 for agreement between telemedicine and in-person consultation. The Kappa coefficient was 0.8441 [0.70; 0.99], P<0.0001 for interobserver agreement. We observed 5 cases of disagreement between the two observers. DISCUSSION: The concordance was very good in our study. The few cases of disagreement resulted mainly from poorly interpretable examinations due to poor image quality, major macular changes in patients with a prior examination, and the fact that only a single cut was analyzed. CONCLUSION: AMD monitoring by telemedicine seems promising and reliable. This approach would allow better follow-up of patients with difficult access to care.

[Corneal topography in practice]. / Topographie cornéenne en pratique.

Corneal surface analysis is now more and more accurate. Corneal topography is a gold standard in corneal pathology follow-up: keratoconus, corneal grafts, orthokeratology. In refractive surgery, cornea ectasia post-Lasik must be avoided. Analyzing anterior and posterior surface can detect forme fruste keratoconus FFKC. Topography allows also better predictability of premium intraocular implants surgery. Topography is key examination and its interpretation is essential.

Corneal topography in clinical practice.

Developments in corneal topography allow for increasingly precise, detailed analysis of the corneal surface. This test is becoming indispensable in the treatment of complex corneas: keratoconus, corneal transplants, orthokeratology, etc. In refractive surgery, the combined analysis of the anterior and posterior cornea has permitted better screening for forme fruste keratoconus at risk for post-LASIK ectasia. Topography also assists in the calculation of premium intraocular lenses. Topography is an indispensable test for analyzing and following corneal disease.