Prognostic factors for visual recovery after successful large macular hole surgery using the inverted flap technique.

PURPOSE: The goal of our study is to describe the functional results and preoperative factors predicting visual recovery after successful inverted flap technique and closure of large full-thickness macular holes (FTMH) and to evaluate the correlations between microstructural foveal changes and final visual acuity. METHODS: Retrospective, descriptive, analytical study including 80 eyes of 78 patients with large FTMH; operated by inverted flap technique with successful closure of the macular hole after surgery. All eyes underwent a full preoperative ophthalmic examination and macular B-scan SD-OCT. We performed the classic inverted flap technique for all patients. Postoperatively, all patients were examined at 7 days, 1, 3, 6, 9 and 12 months after surgery. SD-OCT was performed for all patients on each follow-up. Preoperatively, best-corrected visual acuity (BCVA), FTMH size and basal hole diameter were the main outcome measures. Postoperatively, BCVA, macular thickness, integrity of the external limiting membrane (ELM) and ellipsoid zone (EZ) were recorded. RESULTS: Mean age was 62±8.42 years with female predominance. Mean size of the FTMH was 692.59µm, and mean basal hole diameter was 1436.06µm. Mean BCVA improved from 1.06±0.491 LogMAR preoperatively to 0.52±0.32 at 9 months following surgery (P<0.001). At 9 months, the ELM was absent, partial or fully restored in 6.67, 10 and 83.33% respectively. The EZ was absent, partial or fully restored in 6.67, 33 and 63.33% respectively. ELM regeneration always preceded EZ regeneration at every point of follow-up. Final BCVA was statistically correlated with initial hole size (P=0.006, OR=1.056; CI [1.016-1.098]) and mean symptom duration prior to surgery (P=0.001. OR=0.987; CI [0.976-0.998]). Analysis of the ROC curve demonstrated that a hole diameter>478.5µm and symptom duration>5 weeks were correlated with non-improvement of visual acuity, with 81.3% sensibility and 18.7% specificity. CONCLUSION: We report tomographic microstructural foveal changes and functional results following successful large idiopathic FTMH surgery using the classic inverted flap technique. Preoperative parameters such as initial FTMH diameter and mean symptom duration prior to surgery are crucial prognostic factors influencing final visual results.

Epidemiology and prognostic factors of open globe injuries in a Tunisian pediatric population.

INTRODUCTION: Childhood ocular trauma is a preventable cause of visual impairment and blindness worldwide. The purpose of our study was to determine demographic, etiologic, and clinical characteristics, visual outcome, and factors affecting visual prognosis in children with open globe injuries (OGI) and to analyze the predictive value of ocular trauma scoring systems for OGI in children. METHODS: We conducted a retrospective study enrolling 120 pediatric patients hospitalized for OGI from January 2010 to March 2017. Age, gender, date of trauma, time between trauma and presentation, place and circumstances of injury, etiology, visual acuity (VA), wound location and type of injury based on the Birmingham Eye Trauma Terminology, and the clinical signs were recorded. We recorded the number of surgical procedures performed, complications and visual outcomes. RESULTS: The mean age was 7.38 years. In all, 62.5% of the patients were male, and 37.5% were female. The gender ratio was observed to decrease with increasing age. The mean time interval between injury and consultation was 22.80±42.68hours. Injuries usually occurred at home (80%) followed by playgrounds and sports venues (8.3%), the street (6.7%) and school (5%). All of the OGI's were accidental, and the main context was play (70%). The most common traumas were penetrating injury (60.8%) and metal (30%) objects. Penetrating trauma accounted for 68.3% of cases, followed by rupture (27.5%) and intraocular foreign body (IOFB) (7.5%). Initial VA was<1/10 in 59.2% of cases, and the point of entry was the cornea in 65.8% of cases. Final VA was<1/10 in 39.69% of all cases. FVA was significantly correlated with BCVA prior to the surgery, mechanism of the trauma, wound location and size, and other associated lesions. The Ocular Trauma Score (OTS) and the Pediatric Ocular Trauma Score (POTS) were significantly correlated with final VA. CONCLUSION: OGI's in children occurs most frequently in school-age boys. Prognosis is determined by presenting visual acuity, trauma score, and wound severity and location.

[Proliferative diabetic retinopathy inauguring gestational diabetes]. / Une rétinopathie diabétique proliférante inaugurant un diabète gestationnel.

INTRODUCTION: Diabetic retinopathy is one of the diabetic microangiopathy complications generally occurring after insulin-dependent diabetes has evolved for a few years. OBSERVATION: We report a 24-year-old pregnant woman with severe proliferative diabetic retinopathy discovered at the time of the gestational diabetes diagnosis. Argon laser photocoagulation of retinal ischemic territories was initiated. The disease progressed to vitreous haemorrhage in the right eye. DISCUSSION: Proliferative diabetic retinopathy is exceptionally present at the time of the gestational diabetes. We did not find any similar case in the literature. CONCLUSION: Fundus examination seems necessary at the onset of gestational diabetes. It can prevent blindness in young women.

[The virological and epidemiological aspects of human adenoviral conjunctivitis in Tunisia]. / Aspects épidémiologiques et virologiques de la conjonctivite à adénovirus en Tunisie.

Human adenoviruses (HAdV) are the main cause of viral conjunctivitis. In Tunisia and North Africa more generally, there is no regular nationwide surveillance program that monitors viruses causing conjunctivitis and keratoconjunctivitis. In this study, we report the results of HAdV screening in conjunctival samples collected for over 14 years in Tunisia. A total of 282 conjunctival samples received between 2000 and 2013 were investigated. Detection and identification of genotype were performed by PCR-sequencing at the hexon gene; 64.5% of samples (n=182) revealed positive by PCR detection without correlation noted between infection, age, sex, social class or clinical manifestations of viral conjunctivitis. HAdV-D8 was the largely predominant genotype in Tunisia, representing 81.3% of all isolates, and was detected continuously from 2000 to 2013. Minor co-circulating genotypes were also identified - HAdV-E4, HAdV-B3, B55 and HAdV-B7 - accounting for 10.7%, 4.9%, 1.9% and 0.9% of isolates, respectively. In conclusion, this work reports epidemiological data on adenoviral conjunctivitis from a region where such information is very scarce and contributes to a better knowledge of the worldwide distribution of causative genotypes. It also presents an approach for the identification of circulating HAdV in the country and demonstrates the importance of molecular tools for both detection and identification of genotypes, which allow rapid virological investigation, especially during epidemics.

[Macula analysis by spectral domain OCT in rhegmatogenous retinal detachment surgery]. / Analyse de la macula par OCT spectral domain dans la chirurgie du décollement de rétine rhegmatogène.

INTRODUCTION: Despite surgical reattachment of retinal layers, postoperative functional outcomes after rhegmatogenous retinal detachment (RRD) may be limited. This can be explained by microstructural changes in the macula inherent to the pathology itself as well as the surgery. PURPOSE: To evaluate the various changes in the macula by OCT pre- and postoperatively, and correlate them with functional and clinical outcomes in patients with RRD. To establish pre- and postoperative prognostic factors. METHODS: This was a prospective study of 50 eyes of 50 patients operated for RDD. Each patient underwent a complete clinical examination and macular OCT using the Heidelberg Spectralis; preoperatively and then successively at 7 days, 1 month, 3 months and 6 months after RRD surgery. RESULTS: Preoperative tomographic results revealed an average height of submacular fluid of 742 ± 345 µm. Ninety-six percent of patients exhibited thickening of photoreceptor outer segments (PROS), 62% an outer layer undulation, 60% cystic cavities in the outer and/or inner nuclear layers (ONL, INL), 36% disruptions of the external limiting membrane (ELM) and 64% disruption of the IS/OS junction. Postoperatively, 24% of patients had persistent submacular fluid. The average thickness of the central fovea, the ONL, the IS/OS junction and the PROS were 172 ± 51.3 µm, 88.4 ± 30.9 µm, 11.36 ± 5.4 µm and 19.54 ± 13.1 µm respectively. Postoperative disruptions of the ELM, the IS/OS junction and Verhoeff's membrane (VM) were present in 24%, 60% and 82% of patients respectively. The preoperative tomographic risk factors for poor visual outcome were: submacular fluid height > 800 µm (P<0.001), disruptions of the MLE and/or IS/OS junction (P<0.001), as well as cystic cavities in the ENL and/or INL (P=0.002). Postoperative risk factors were: thinning of the fovea (≤ 250 µm), central fovea (≤ 160 µm), ONL (≤ 90 µm), IS/OS junction (≤ 10 µm) and PROS (≤ 18 µm) layers (P<0.001), as well as a discontinuous or absent appearance of the ELM (P<0.001), IS/OS junction (P<0.001) and VM (P=0.006). CONCLUSION: Spectral domain OCT allows detection of specific microscopic, quasi-histologic macular changes in rhegmatogenous retinal detachment. These anomalies could be predictive of final postoperative visual outcome.

[Microbiological profile of endophthalmitis in a referral centre in Tunisia]. / Profil microbiologique des endophtalmies aiguës dans un centre de référence en Tunisie.

PURPOSE: To investigate the microbiological profile of acute postoperative endophthalmitis in a referral center in Tunisia and to assess the antibiotic sensitivity of the organisms. PATIENTS AND METHODS: This is a retrospective study over a period of eleven years, conducted on patients hospitalized with acute infectious postoperative endophthalmitis. Cultures were performed on aqueous (93%) and vitreous specimens (68%) obtained at presentation. Each sample underwent direct examination, culture and antibiotic susceptibilities. RESULTS: The number of acute postoperative endophthalmitis cases identified during the study period was 308. Organisms were found in 43% of samples (endophthalmitis was bacterial in 39.5%, fungal in 0.9% and polymicrobial in 2.6%). Cultures grew primarily Staphylococcus epidermidis in 31.4% of cases, Streptococcus pneumoniae in 22.7% of cases and Staphylococcus aureus in 12.7% of cases. Gram-positive cocci are more sensitive to vancomycin and Gram-negative bacilli are more susceptible to ofloxacin and ciprofloxacin. CONCLUSION: In our study, microbiological samples were positive in 43% and coagulase-negative Gram-positive cocci are the most common organisms. However, antibiotic resistance has been increasing over the years.

[Prognosis of primary malignant tumors of the conjunctiva]. / Le pronostic des tumeurs malignes primitives de la conjonctive.

PURPOSE: To discuss possible factors that could influence the prognosis of primary malignant conjunctival tumors. PATIENTS AND METHODS: We retrospectively analyzed medical records of 79 patients followed for primary malignant conjunctival tumors between January 1997 and July 2011. RESULTS: The mean age at the time of diagnosis was 61.1 years; male/female ratio was 2.59. The mean tumor size was 13.9 mm. The histological type was invasive squamous cell carcinoma in 43 cases (54.4%), epithelial dysplasia in 11 cases (13.9%), carcinoma in situ in 7 cases, conjunctival malignant melanoma in 5 cases, conjunctival lymphoma in 4 cases and other rare tumors in 9 cases. We performed an excisional biopsy with a safety margin in 89.8% of cases, associated with cryotherapy in 46.6% of cases. Enucleation was performed in two cases and orbital exenteration in 5 cases. We noted tumor recurrence in 33.3% of patients after an average period of 9.5 months. Radiation therapy was indicated in 44 cases (55.7%). The mean follow-up of our patients was 42 months. Tumor recurrences were statistically associated with a history of xeroderma pigmentosum (P=0.012), a diagnostic delay more than 11 months (P=0.001), caruncular location (P=0.004), tumor size greater than 10mm (P=0.044), scleral extension (P=0.011), initial treatment limited to excisional biopsy (P=0.033) and histopathologic involvement of the margin of the tumor resection (P=0.008). CONCLUSION: A better understanding of the prognostic factors of primary malignant conjunctival tumors is essential for management and may improve the prognosis of these tumors.

[Ocular contusions and giant retinal tears]. / Contusions oculaires et déchirures géantes.

PURPOSE: Analysis of the clinical and therapeutic results of giant retinal tears after ocular blunt trauma. PATIENTS AND METHODS: We performed a retrospective review of nine patients with giant retinal tears associated to retinal detachment after ocular blunt trauma. The traumatic giant retinal tear was a peripheral break of 90 degrees or greater. Seven patients had myopia. Primary management of retinal detachment included, scleral buckling and external drainage of subretinal fluid, in 2 cases. Vitrectomy with fluid-silicone oil exchange was used in 7 cases and perfluorodecalin in 3 cases. RESULTS: Our results indicate that myopia was the principal risk factor of blunt trauma retinal tears, which appear even when the contusion was not too violent or indirect. Successful results were not obtained with episcleral surgery alone (2 cases). With primar vitrectomy, the success rate was 57%. The overall success rate was 66.6% with an average acuity of 2/10. CONCLUSION: High myopia is the principal risk factor of giant retinal tear after blunt ocular trauma. The prognosis of this retinal detachment depends on the grade of proliferative vitreoretinopathy.

[Retinal detachment and posterior lens luxation. Value of liquid perfluorocarbons]. / Décollement rétinien et luxation postérieure du cristallin. Intérêt des perfluorocarbones liquides.

PURPOSE: The purpose of this study is to review the benefits of perfluorocarbon liquids in the surgical treatment of retinal detachment with posterior lens dislocation. METHODS: Three cases of retinal detachment occurring in the presence of a posteriorly dislocated intraocular lens were managed with vitrectomy, fluid perfluorocarbon, scleral buckling and silicone oil injection. The dislocated lens were removed by anterior approach. RESULTS: In all cases a successful retinal reattachment was obtained after one or two surgical procedures.

[The visual field of patients with pseudophakia using kinetic and automated perimetry]. / Etude du champ visuel du pseudophaque en périmétrie cinétique et automatisée.

One of the major benefits of pseudophakia is to maintain a good visual field. Visual field was therefore studied in 40 pseudophakic eyes using: 1. kinetic perimetry according to Goldmann using 3 tests: I1, I2, I4; 2. Automated perimetry. Insertion of a posterior chamber intraocular lens was performed in 85% of cases whereas the remaining 15% received an anterior chamber intraocular lens. Visual acuity was > 5/10 P2-P4 in all patients. The results showed a 15% reduction in the visual field compared to normal values. This reduction was concentric and harmonious but was more marked in internal isopters. This reduction was less marked with posterior chamber intraocular lenses. On the other hand, automated perimetry showed that global retinal sensitivity was decreased in pseudophakia, and this deficiency was more pronounced in the periphery.

[Results of trabeculectomy in congenital glaucoma]. / Résultats de la trabéculectomie au cours du glaucome congénital.

Congenital glaucoma has a very serious prognosis. It represents the first cause of blindness in Tunisian children. Trabeculectomy introduced by Cairns in 1968, was initially proposed as second-line treatment in congenital glaucoma surgery. It has now become more frequently used as first-line treatment in this indication. We have already used this technique directly in 35 children suffering from congenital glaucoma with a total of 54 eyes. Forty four eyes underwent a single operation, ten eyes underwent two to four trabeculectomies. Then study of these cases with a mean follow up of 24 months shows an overall success rate of 64% after one trabeculectomy, with or without additional medical treatment. The study of tonometric diagrams shows that the successful results obtained after 3 months persisted in the long term. Trabeculectomy gives better results in congenital glaucoma with intraocular pressure greater than 40 mmHg. Repeated operations are sometimes necessary. In these cases, postoperative subconjunctival 5 fluorouracil (SFU) did not improve the surgical outcome.

[Epidemiologic study of strabismic amblyopia in Tunisia]. / Etude épidémiologique de l'amblyopie strabique en Tunisie.

The authors study 202 strabismus cases and evaluate the strabismic epidemiology of Tunisia: 58% of squint children have amblyopia. The low vision is important, and getting worse with age. The treatment is simple, consisting of occlusion of the good eye, but it become longer and more difficult after six years. The best results are obtained in the first four years. Good cooperation from the parents is required. The authors insist on the necessity of early detection through testing, the prevention of recurrence and, above all, on preventing the advent of amblyopia as soon as strabismus appears.

[Intraorbital dermoid cyst. Apropos of a case]. / Kyste dermoïde intra-orbitaire. A propos d'un cas.

Orbital dermoid cyst represents 3 to 4% of all primary orbital tumours. The intraorbital location is relatively rare. We report the case of a 9 year-old male child with an orbital dermoid cyst, who presented with progressive right proptosis, which had developed 3 months earlier. Visual acuity, ocular motility and funduscopic examination were normal. Imaging aspects (ultrasonography and computed tomography) have revealed an extraconical orbital, hypodense, well limited tumor, without bone destruction and no enhancement located at the postero-external side of the orbit. The tumors was extirpated surgically via a superior approach. Histopathology confirmed the diagnosis of dermoid cyst.

[Etiologies and risk factors of endophthalmitis]. / Etiologies et facteurs de risque des endophtalmies.

Endophthalmitis is a serious disease with multiple aetiologies. Its development seems to be dependent upon various risk factors. Among 99 cases of endophthalmitis, 79% were secondary to intraocular surgery especially cataract surgery and perforating ocular trauma. To identify risk factors of post-cataract surgery endophthalmitis, we performed a case-control study: 55 cases and 269 controls were used. Five risk factors were identified: duration of the operative procedure longer than 60 min, suture dehiscence, persistence of lens mass, traumatic cataract and left eye operated. The importance of prevention of endophthalmitis by avoiding such risk factors is raised.

[Developmental aspects of diabetic retinopathy during pregnancy]. / Aspects évolutifs de la rétinopathie diabétique pendant la grossesse.

The course of diabetic retinopathy (DR) was studied in 93 pregnant patients. Results were compared with data from 98 diabetic non pregnant women. Worsening of initial retinal lesions was observed in 16% of the pregnant group whereas only 6% of the control group showed a similar aggravation. The difference between the two groups was statistically significant (p < 0.05). Argon laser panretinal photocoagulation of pre-proliferative and proliferative DR resulted in no subsequent DR-induced complications. On the other hand, the risk of appearance of DR and/or its worsening during pregnancy depends on initial network but mostly on the duration of diabetes mellitus. In conclusion, regular ophthalmologic examination of diabetic patients especially during pregnancy seems crucial for the early screening of any worsening. Furthermore, the importance of pregnancy planning is emphasized.