[Assessment of ophthalmological surgical training in Île-de-France: Results of a survey on 89 residents]. / Formation chirurgicale en ophtalmologie en Île-de-France : résultats d'une enquête sur 89 internes.

OBJECTIVE: This study aims to evaluate surgical training in ophthalmology through feedback from residents. MATERIALS AND METHODS: An anonymous questionnaire was created, including 20 items which assessed the number of complete or partial surgical procedures performed during a semester, self-assessment of surgical skills, use of surgical simulators, an overall rating of the surgical training received and some suggestions to improve surgical training. It was sent by email to all residents in training in Île-de-France (DES Île-de-France and Inter-CHU), France. RESULTS: From October 23 to November 7, 2021, 89/137 residents responded to the questionnaire (65%). Since the beginning of their residency, ninety percent of the residents received training using simulators. Over 90% performed all of the technical steps of a "standard" cataract surgery at least once during the semester, and 60% 10 times or more. The least performed technical steps or procedures also received the lowest self-assessment: management of expulsive hemorrhage, open-globe or lacrimal laceration wound suturing, capsular tension ring injection, and intraocular lens explantation. Residents gave an overall average rating of 6.6/10 to their training and suggested some feedback on videos of resident surgeries (67%) and theoretical courses dealing with surgical techniques (61%). DISCUSSION: The increasing use of simulators should improve surgical training. Residents express the need for training regarding surgical complications and emergencies as well as improvement of their technical skills via improved feedback. CONCLUSION: Surgical teaching appears suitable for learning cataract surgery but seems less effective for the management of emergencies and intraoperative complications.

[Efficacy of intense pulsed light therapy in the treatment of Meibomian gland dysfunction-related severe dry eye]. / Efficacité de la lumière pulsée dans le traitement des sécheresses oculaires sévères par dysfonctionnement meibomien.

INTRODUCTION: Dry eye syndrome caused by Meibomian gland dysfunction (MGD) is a common disease in the general population and impairs quality of life. Intense Pulsed Light (IPL) has mainly been used in dermatology for the treatment of skin disorders, and more recently for MGD-related dry eye. The objective of our study is to evaluate the efficacy and tolerability of IPL with the E-Eye® device (E-Swin, Houdan, France) in severe MGD-related dry eye patients. MATERIALS AND METHODS: This non-comparative study included 20 patients with MGD-related dry eye with a Break-Up Time (BUT)<10seconds, dry eye symptoms >30mm on a Visual Analog Scale (VAS), and failure of lid hygiene and artificial tears. Treatment consisted of 3 sessions of IPL on D0, D15, and D45 (5 flashes of 13J/cm2 per eye). The following parameters were assessed at each visit and at D75 : symptoms graded with a VAS and the Standard Patient Assessment of Eye Dryness questionnaire (SPEED), BUT, corneal fluorescein staining, Meibomian gland expression score, meibography, tear film lipid layer thickness by interferometry and the ocular scattering index by double-pass aberrometry (OQAS). Statistical analysis was performed on the eye most affected at baseline. RESULTS: We included 40 eyes of 20 patients, 15 female and 5 male, mean age 47±15 years (24 to 74 years). The symptoms rated by VAS were severe, averaging 69±25mm. After treatment, there was a statistically significant decrease in symptoms, with a 14mm VAS decrease (55±29mm at D75 versus 69mm at D0, P=0.048) and SPEED score of 3.4 (19.0±6mm versus 22.4±4.6, P=0.03). The number of expressible Meibomian gland ducts increased significantly (from 5.9 to 8.1, P=0.04), lid redness decreased (from 1.4 to 0.6, P=NS) and BUT improved (from 4.2 to 5.9, P=NS). Other parameters remained unchanged. Three patients (15%) complained of transient ocular burning after each treatment. CONCLUSION: IPL appears to be effective in improving signs and symptoms in patients with severe MGD-related dry eye, with a good safety profile. Its exact mechanism of action remains to be elucidated.

[Efficacy and tolerance of Latanoprost given as a first intention in the treatment of primitive open angle glaucoma in African melanoderm]. / Efficacité et tolérance du Latanoprost donné en première intention dans le traitement du glaucome primitif a angle ouvert chez le mélanoderme africain.

OBJECTIVE: To assess the reduction in IOP and ocular symptoms in patients newly diagnosed with POAG and treated with latanoprost as monotherapy. PATIENTS AND METHOD: A multicentric, cross-sectional, descriptive study was conducted. We included adults newly diagnosed with POAG. All patients received one drop of preserved latanoprost 0.005% in each eye every night for 12 weeks. Changes in IOP and ophthalmic signs and symptoms were assessed during and at the end of treatment. RESULTS: A total of 524 patients were included, with a participation rate of 93% at 12 weeks. The mean age was 52.79±17.33 years, and the sex ratio M/F was 1.39. At inclusion, the mean IOP was 21.68±9.72mmHg. After 2 weeks of treatment, the mean IOP was 15.49±5.81mmHg, for a reduction of 28.55%. After 12 weeks of treatment, the mean IOP was 13.16±3.54mmHg, for a reduction of 39.30%. The main symptom recorded was a gritty foreign body sensation, the frequency of which was 4.72% at W2 and 2.45% at W12. The main sign was hyperemia (4.33% at W2 and 1.84% at W12). CONCLUSION: Latanoprost given as first-line monotherapy in POAG in blacks considerably reduces IOP. The incidence of side effects remains low; it is higher at the start of treatment.

[Optic disc drusen or true papilledema?]. / Drusen de la tête du nerf optique ou oedème papillaire?

INTRODUCTION: Bilateral optic disc drusen can mimic papilledema, raising the question of intracranial hypertension and sometimes prompting unnecessary or invasive procedures. STATE OF THE ART AND PERSPECTIVES: Optic disc drusen are benign calcified masses, often visible within the optic nerve head. However, their clinical diagnosis can be more difficult at earlier stages of life, when they are buried within the optic nerve. Visual field loss can occur in patients with longstanding optic disc drusen. CONCLUSION: Ophthalmoscopy and B-scan ocular ultrasonography allow appropriate diagnosis of bilateral optic disc drusen mimicking papilledema. On rare occasions, optic disc drusen can be associated with ischemic complications, the other causes of drusen-related visual loss being exceptionally rare.

[Treatment of noninfectious intermediate uveitis, posterior uveitis, or panuveitis]. / Traitement des uvéites intermédiaires, postérieures et panuvéites non infectieuses.

Controlling long-term inflammation during non-infectious intermediate, posterior or panuveitis while limiting side effects remains challenging. There is no standardized pre-therapeutic evaluation providing diagnostic certainty, but some simple tests allow us to identifiy the main etiologies. The ophthalmologist identifies the type of uveitis, and the internist completes the investigations according to the ophthalmologist's findings. Fundus photographs, optical coherence tomography, and fluorescein and indocyanine green angiography should be considered during diagnosis and follow-up. Ocular complications of uveitis are numerous. They require close monitoring and specific medical and sometimes surgical management. The growing number of available drugs makes it possible to optimize the management of these conditions with varied etiologies and presentations. Currently, systemic corticosteroids remain the mainstay of therapy, and other alternatives are considered in the case of poor tolerance, steroid resistance or dependence. The choice of a systemic, periocular or intravitreal treatment depends on several factors: chronicity or recurrence of uveitis, duration, bilaterality, association with a systemic inflammatory disease, the presence of contraindications to certain treatments, and also socioeconomic constraints. It is of the utmost importance to find the best compromise allowing tight control of ocular inflammation by means of adapted systemic and/or local treatment while avoiding the main complications.

Microbiological efficacy of 3-day treatment with azithromycin 1.5% eye-drops for purulent bacterial conjunctivitis.

PURPOSE: Antibacterial efficacy of topically applied azithromycin 1.5% was compared with tobramycin 0.3% in a multicenter, randomized, investigator-masked study for the treatment of purulent bacterial conjunctivitis. METHODS: A total of 1043 adults and children received either azithromycin twice daily for 3 days (n=524) or tobramycin every 2 hours while awake for 2 days, then four times daily for 5 days (n=519). Conjunctival swabbing was taken at days 0, 3, and 9, using alginate swabs resuspended in a dissolution-transport medium, providing rapid and reproducible results. Cagle's criteria were used to define the pathogenicity level for each isolated bacterium. RESULTS: In the per-protocol set, the rate of bacteriologic resolution was 85.2% for azithromycin versus 83.8% for tobramycin on day 3, and 92.8% for azithromycin versus 94.6% for tobramycin on day 9. Azithromycin was demonstrated to be noninferior to tobramycin according to the 10% noninferiority margin. Although some bacteria were categorized as resistant to tested antibiotics, eradication was observed (for azithromycin: Acinetobacter, Enterobacteriaceae, Pseudomonas), highlighting the specific pharmacokinetics/pharmacodynamics of the ocular route. CONCLUSIONS: In total, topical therapy with azithromycin 1.5% administered only twice daily for 3 days effectively eradicates most pathogenic bacteria associated with bacterial conjunctivitis. These microbiologic results are in accordance with the observed clinical outcome. This new anti-infective product has the advantage of a short treatment course which could lead to an improvement in patient compliance.

Tear concentrations of azithromycin following topical administration of a single dose of azithromycin 0.5%, 1.0%, and 1.5% eyedrops (T1225) in healthy volunteers.

PURPOSE: To evaluate azithromycin tear concentrations after one drop of T1225 0.5%, 1.0%, and 1.5% eyedrops. METHODS: In this randomized, double-masked study, 91 healthy volunteers received one drop into each eye of T1225 0.5% (n=23), T1225 1.0% (n=38), or T1225 1.5% (n=38). Azithromycin tear concentrations were measured by HPLC-MS at seven time points for 24 hours. Tolerability was evaluated. RESULTS: T1225 1.0% and 1.5% had similar pharmacokinetic profiles. After a post-instillation peak (167 to 178 mg/L after 10 minutes), mean concentrations remained above 7 mg/L for 24 hours (except for T1225 1% at H24). A delayed increase of the azithromycin mean tear concentration might be explained by the known late azithromycin release from tissues after storage in cells. Areas under inhibitory curve (AUICs) of T1225 1.0% and 1.5% were higher than AUICs of T1225 0.5% and ranged between 47 and 90. The three T1225 concentrations were safe for the ocular surface. CONCLUSIONS: Once daily instillation of T1225 1.0% and 1.5% was shown to reach an AUIC markedly above the required threshold for an antibacterial activity against Gram-positive bacteria (25-35). These results suggest that a BID instillation is more likely to ensure antimicrobial activity against Gram-negative bacteria (threshold >100).

Ocular involvement in Epstein-Barr virus-associated T-cell lymphoma.

PURPOSE: To determine if serous retinal detachment may occur in a case of Epstein-Barr virus-associated T-cell lymphoma. METHODS: We examined a 51-year-old man who had recent loss of vision and poor general health. RESULTS: Ocular involvement consisted of bilateral serous retinal detachment and choroidal infiltrates. The diagnosis of lymphoma was made by liver biopsy. The course of the disease was fulminant. Postmortem histologic examination disclosed a massive infiltration of the choroid and hematopoietic organs by pleomorphic large T cells. Epstein-Barr virus was detected by in situ hybridization. CONCLUSION: Ocular involvement, including choroidal infiltrates and serous retinal detachment, may occur in Epstein-Barr virus-associated T-cell lymphoma.

Cytomegalovirus retinitis in HIV-infected patients with and without highly active antiretroviral therapy.

PURPOSE: To assess the impact of highly active antiretroviral therapy on the epidemiology of cytomegalovirus retinitis in patients infected with the human immunodeficiency virus (HIV). METHODS: In a study performed in a single center for infectious diseases, we compared the data collected in 1995 (without highly active antiretroviral therapy) with 1997 data (with highly active antiretroviral therapy). RESULTS: In a comparison of 1997 with 1995 data, the mean CD4+ cell count of patients with cytomegalovirus (CMV) retinitis was higher (169 +/- 150 CD4/microl vs 15 +/- 47 CD4/microl) (P = .05), and the relapses of CMV retinitis were less frequent (17% vs 36%) (P = .02). Newly diagnosed CMV retinitis decreased from 6.1% (59 of 952 patients) in 1995 to 1.2% (nine of 726 patients) in 1997 (P < .0001). In 1997, patients with newly diagnosed or relapsing CMV retinitis had a lower mean CD4+ (37 +/- 42) cell count than patients with no relapsing CMV retinitis (197 +/- 160) (P = .01). CONCLUSION: The incidence and recurrences of CMV retinitis decreased from 1995 to 1997, probably as a result of restored immunity while the patients were undergoing highly active antiretroviral therapy; however, the increasing frequency of HIV resistance to highly active antiretroviral therapy justifies close ocular follow-up.

AIDS related eye disease in Burundi, Africa.

AIMS: To determine the prevalence of ocular manifestations in AIDS patients hospitalised in Bujumbura, Burundi, according to their CD4+ lymphocyte count, serological status for CMV and VZV, and general health status. METHODS: Prospective study of 154 consecutive patients who underwent general and ophthalmological examinations, including dilated fundus examination. AIDS was diagnosed on the basis of Bangui criteria and HIV-1 seropositivity. CD4+ lymphocyte counts were determined by the Capcellia method. CMV and VZV antibodies were detected with ELISA methods. RESULTS: The mean age was 37 (SD 9) years and 65% of the patients were male. Active tuberculosis was the most frequent underlying disease (61%). Almost all the patients (99%) were seropositive for CMV and VZV. Among the 115 patients for whom CD4+ lymphocyte counts were available, 86 (75%) had more than 100 cells x 10(6)/l. Ocular involvement comprised 16 cases of microangiopathy, six of opalescence of the anterior chamber, five of retinal perivasculitis, two of zoster ophthalmicus, two of viral retinitis, and one of opalescence of the vitreous. CONCLUSION: In Africa, the prevalence of ocular involvement in HIV infection is far lower than in Europe and the United States, possibly because most African patients die before ocular opportunistic infections occur.

Epidemiological considerations about retinal opportunistic infections in HIV-infected patients in France.

PURPOSE: To evaluate the evolution of the epidemiology of retinal opportunistic infections in HIV-infected patients from 1994 to 1997 and to assess the effect of HAART initiated in 1996. MATERIALS AND METHODS: Epidemiological prospective study using the data collected during ocular examinations of HIV-infected patients conducted in a single referral center specialized in HIV infection. RESULTS: From 1995 to 1997, the total number of examined HIV-infected patients and the incidence of retinitis related to CMV, VZV, tuberculosis, and toxoplasmosis decreased. The incidence of CMV retinitis, which was by far the most frequent ocular infection, fell from 6.2% to 1.2%. COMMENTS: The dramatic decrease in retinal opportunistic infections since 1996 may be related to the use of HAART. However, a close follow-up is still justified due to the increasing occurrence of resistance to protease inhibitors.

Uveitis in patients treated with intravenous cidofovir.

PURPOSE: To study the characteristics of uveitis occurring during intravenous cidofovir treatment for CMV retinitis in patients with AIDS. PATIENTS AND METHODS: We retrospectively studied ten cases (16 eyes) of uveitis in patients with CMV retinitis treated with intravenous cidofovir. All the patients had ophthalmologic examinations and, if required, fundus angiographies. The median follow-up was eight months. RESULTS: Uveitis occurred after a mean of 8.5 infusions of cidofovir (range 2-17). All ten patients were on protease inhibitors. The mean CD4+ cell count was 92 +/- 51/microl and the median viral load was 3.9 log. All the eyes with uveitis had healed CMV retinitis. The first examination of the involved eyes showed inflammation of the anterior chamber (100%), vitritis (50%), posterior synechiae (75%), and low intraocular pressure (94%). Uveitis did not relapse in the seven patients who stopped cidofovir, whereas it relapsed in two of the three patients who did not stop treatment. At the end of follow-up, permanent posterior synechiae were present in 69% of the involved eyes. COMMENTS: Cidofovir therapy necessitates slit-lamp surveillance, especially in patients on HAART. Cidofovir-related uveitis requires a local steroid treatment, but if possible, cidofovir should be withdrawn.

Management of silicone-induced cataract in AIDS patients treated for viral retinitis-associated retinal detachment.

BACKGROUND AND OBJECTIVE: To evaluate the outcome of cataract surgery for patients with acquired immunodeficiency syndrome (AIDS) who underwent vitrectomy and silicone tamponade for viral retinitis-associated retinal detachment. PATIENTS AND METHODS: The authors retrospectively reviewed the data of five AIDS patients (five eyes) who had cataract within a mean period of 4 months following vitrectomy and silicone oil tamponade for viral retinitis-associated retinal detachment. Phacoemulsification and implantation of a poly-methylmethacrylate posterior chamber intraocular lens were performed. The mean postoperative follow-up was 3 months. RESULTS: Neither silicone oil loss nor retinal redetachment were reported postoperatively. Visual acuity improved in two eyes and remained unchanged in one eye. Total blindness occurred in two eyes. CONCLUSION: Although cataract surgery in these eyes is a relative easy procedure and does not interfere with the retinal status, visual outcome remains poor because of possible postoperative optic atrophy.

[Cataract surgery and prostaglandin analogs? Yes, but under certain conditions]. / Chirurgie de la cataracte et analogues des prostaglandines? Oui, sous conditions...

Use of a prostaglandin analog in cataract surgery can cause cystoid macular edema in the pseudophakic patient, but this is a rare complication that resolves when treatment is stopped. However, in the surgical context, this type of eye drop should not be prescribed as first-line treatment and in any case it should be associated with nonsteroidal anti-inflammatory agents.

[Bioavailability of antiinflammatory drugs]. / Biodisponibilité des anti-inflammatoires.

Bioavailability is one of the major factors for therapeutic efficacy. The bioavailability of antiinflammatory drugs depends on the status of the eye (degree of inflammation, vitrectomy, aphakia) and on the drug (route of administration, regimen, concentration and presentation). The bioavailability of steroid drops increases with acetate compounds, frequency of administration, concentration and contact time. Peribulbar injections provide a long-delivery system but with a significant systemic diffusion. Intravitreal steroids have only a local effect due to the very low doses injected. The bioavailability of non steroidal antiinflammatory drugs is variable, but their effects are similar. Antimetabolites such as 5-fluorouracil or mitomycin C have short half-lives, but mitomycin C must be rinsed after use due to its toxicity.

[Unconventional transmissible agents]. / Agents transmissibles non conventionnels.

Ophthalmologists must take into account the possible emergence of unconventional transmissible agents in their daily practice. Official recommendations have been circulated; however, their routine application remains difficult, with technical and financial considerations limiting factors in the use of an ideal of one disposable medical device per patient. This review describes how these recommendations are followed and tries to provide insights into improving daily practice with these unconventional transmissible agents.