[Creation and evaluation of a triage survey for ophthalmology emergencies]. / Élaboration et évaluation d'un autoquestionnaire de triage pour les demandes de soins non programmés en ophtalmologie.

PURPOSE: The demand for eye care is growing continuously. We created a triage survey system, based on categories of severity, to optimize first line patient care in an ophthalmology emergency department. METHODS: This cross-sectional study was carried out from July 7th, 2021 to October 10th, 2021. During this period, a survey was taken by patients upon arrival to the emergency department. Patients completed the survey by ticking boxes that best fitted their situation. The survey classified patients into three categories of severity: GREEN, ORANGE and RED. A chart review was performed to record the final diagnoses. The severity of each diagnosis was rated according to the Base Score. This score was then compared to the level of severity as determined by our survey to calculate the agreement between the two methods. RESULTS: We collected 767 survey forms, with an 80% response rate. We noted 78 different diagnoses. We scored 564 patients as GREEN, 107 as ORANGE and 96 as RED. The sensitivity rates for the green, orange and red categories were 90%, 70% and 96% respectively. The specificity rates were 90% for the green category, 95% for orange and 94% for red, with good agreement (kappa coefficient=0.70). CONCLUSION: Our results suggest that a self-administered survey could be useful as a triage tool for common ocular emergencies. This survey could be performed better if complete by the patients with the assistance of emergency staff. Potentially helpful for high flow structures such as university-based hospitals, this triage survey might also help in comprehensive clinics or emergency departments.

[Dupilumab-related blepharoconjunctivitis: Recommendations of the CEDRE group. Atopic dermatitis, conjunctivitis and dupilumab: Which management approach?] / Blépharo-conjonctivites sous dupilumab : recommandations du groupe CEDRE. Dermatite atopique, conjonctivites et dupilumab : quelle prise en charge ?

Dupilumab is a recombinant monoclonal IgG4 type antibody which inhibits IL4 and IL13 signaling. It is indicated in moderate to severe atopic dermatitis (AD) in adults and adolescents over 12 years of age. Its side effects include conjunctivitis and blepharoconjunctivitis, affecting between 4.7% and 28% of patients depending on the study. The incidence of conjunctivitis in patients treated with dupilumab for AD appears to be higher than placebo in clinical studies. This increase was not observed in patients treated with dupilumab for asthma or sinonasal polyposis. The risk factors for conjunctivitis in patients with AD are disease severity, pre-existence of conjunctivitis and low concentrations of dupilumab, but the pathophysiology of this disease is poorly understood. A literature search carried out in April and May 2020 showed an increase in the number of publications on the subject, but there are currently no official joint dermatologist-ophthalmologist recommendations for prevention and management. The objective of this article is to provide an overview of the status of this subject, to address the main questions raised by this type of conjunctivitis and to suggest a course of action for starting and continuing treatment with dupilumab in patients with AD, according to the recommendations of the French Ophthalmologist/Dermatologist group CEDRE.

Posterior segment Intra-Ocular Implant (IOL) dislocation: Predisposing factors, surgical management, outcome analysis.

PURPOSE: To evaluate the predisposing factors, management and visual prognosis of intraocular Lens (IOL) dislocation into the posterior segment. METHODS: The cases of posterior IOL dislocation from January 2012 to May 2017 at 2 centers were reviewed. Only eyes with dislocations requiring IOL explantation or repositioning were included. Predisposing factors, interval between cataract surgery and IOL dislocation, circumstances of onset, management, and postoperative complications are reported. RESULTS: 72 eyes of 72 patients were included. The mean age was 67.6 years. 47 patients (68%) were men. The mean time interval from cataract surgery to IOL dislocation was significantly shorter in the out-of-the bag group than the in-the-bag IOL dislocation group (3.8 months vs 132 months, P=0.002). Predisposing factors for out-of-the-bag IOL dislocation were mainly capsular rupture and/or zonular dehiscence (83%) after complicated cataract surgery. The predisposing factors for in-the-bag IOL dislocation were high myopia (40%), pseudoexfoliation syndrome (40%), previous vitrectomy (38%), or Marfan syndrome (3%) with uneventful cataract surgery. The type of luxated implant was mainly a 3-piece foldable IOL (50%), followed by foldable one-piece IOL (28%) and a rigid one-piece IOL (17%). Most cases of posterior chamber IOL dislocation occurred spontaneously (80%) without a trigger event. Management consisted of a posterior approach in 24 cases (33%) or an anterior approach in 48 cases (67%), associated with IOL repositioning in 20 eyes (28%), and IOL replacement in 34 eyes (47%). Finally, 18 eyes (25%) were left aphakic. Postoperative complications occurred in 7 cases (9.7%). CONCLUSIONS: Predisposing factors and time from cataract surgery to IOL dislocation were different for out-of-the bag versus in-the-bag IOL dislocation. Management of IOL dislocation varied considerably, depending on surgeon preference and experience. Surgery for IOL dislocation significantly improved best corrected visual acuity and was associated with a low complication rate.

Incidence of posterior capsular opacification requiring Nd:YAG capsulotomy after cataract surgery and implantation of enVista® MX60 IOL.

PURPOSE: To evaluate incidence of posterior capsule opacification requiring Nd:YAG capsulotomy over 3 years in a large series of eyes implanted with the enVista® MX60 Intraocular Lens (IOL). METHODS: A university-based, single-center, observational study of patients' medical records was conducted. Uneventful cataract surgery patients with in-the-bag implantations of the enVista® MX60 IOL with a minimum of 24 months follow-up were included in the study. Exclusion criteria were insufficient follow-up (<24 months), intraoperative complications and combined surgery. The primary outcome measure was rate of YAG laser capsulotomy, while secondary outcome measures were time to YAG laser capsulotomy and rate of glistenings. RESULTS: A total of 245 eyes of 143 patients received the MX60 IOL and were followed in the same center. Of these, 226 eyes were included in the study. Mean age was 80.7±8.3 years and M/F ratio was 42/101 (29.4/70.6%). The mean preoperative distance (logMAR) visual acuity was 0.67±0.5, while postoperatively it was 0.31±0.5 and 0.32±0.5 at the last visit. The Mean±SD follow-up time (min-max) was 35.2±7.2, (24-48.4) months. The incidence of Nd:YAG capsulotomy over 3 years was 5/226 (2.2%). Average time between surgery and Nd:YAG capsulotomy was 32.17 months. Univariate analysis of age, gender, presence of comorbidity and baseline visual acuity found no predictive factors for capsulotomy. No glistenings were reported at any postoperative visit. CONCLUSION: The three-year cumulative incidence of PCO requiring Nd:YAG laser capsulotomy was 2.2% for the enVista® MX-60 IOL, with no glistenings observed during follow-up. This low rate confirms the excellent safety profile of this IOL.

Two year outcome in treatment-naive patients with neovascular age-related macular degeneration (nAMD) using an individualized regimen of Aflibercept.

PURPOSE: To evaluate the 2 year visual and anatomical results of intravitreal aflibercept injection (IAI) in nAMD in treatment-naive eyes in real life using a flexible regimen combining a PRN and modified treat-and-extend (TAE) regimen. PATIENTS AND METHODS: This is a retrospective study including 48 eyes of 38 patients with nAMD treated with aflibercept as first line therapy. The modified T&E protocol consisted of a loading phase with 3 monthly IAI followed by an adaptation phase during which patients were monitored and treated as needed at the same visit from week 12 to week 32, then a T&E phase per se, for which the treatment interval was determined based on history of disease recurrence. RESULTS: A total of 48 eyes were included. Visual acuity at baseline was 57.3±16 letters. Visual gain was 6±12 letters at 1 year and 5.2±11 letters at 2 years. At the 2-year end point, 94.3% of eyes maintained visual acuity and 71.4% of eyes had ≥70 letters. Reduction of central macular thickness, macular volume and pigment epithelium detachment height was observed after the loading phase, at 1 and 2 years compared to baseline. Complete resolution of fluid was obtained in 78% of eyes after the loading phase, in 68% of eyes at 1 year and in 62.8% of eyes at 2 years. Subfoveal choroidal thickness remained stable during the study. The surface area of the neovascular lesion was reduced at 1 year. The mean number of IAI was 6 IVT (3-11) during the first year and 3.2 IVT (0-13) during the second year. CONCLUSION: Aflibercept is effective in real life in treatment-naive eyes at two years. A personalized regimen of IAI for neovascular AMD produced good functional and anatomical outcome over 2 years, with a lower number of injections than in the pivotal studies.

Visual exploration of objects and scenes in patients with age-related macular degeneration.

OBJECTIVE: Studies on people with age-related macular degeneration (AMD) have shown that they are able to detect briefly displayed objects and scenes with high accuracy (above 80%). However, in everyday life we explore our environment to search and to recognize objects. We assessed visual exploration in people with AMD during the identification of objects and scenes. METHOD: Twenty patients with AMD, fifteen age-matched and twelve young controls participated. We used colored photographs of isolated objects, natural scenes and objects in scenes, displayed centrally on a monitor. Participants were asked to name the objects and scenes. Ocular movements were recorded during the identification task. Scan paths, saccades, fixations, and accuracy were also recorded. RESULTS: People with AMD exhibited lower accuracy (by about 30%). Eye movement parameters were impaired with a larger number of saccades, shorter fixation durations and a larger scan path than controls. CONCLUSIONS: Our results are consistent with studies on artificial scotoma in normally sighted people showing that a central scotoma impairs oculomotricity. In contrast to detection tasks, people with central vision loss exhibit impaired performance in identification of objects and scenes (62 to 66%). Eye movement studies suggest that the lower accuracy in patients is likely due to the use of peripheral vision and instability of fixation.

[Optic neuritis associated with infliximab]. / Névrite optique rétrobulbaire associée au traitement par infliximab.

Infliximab is a chimeric human-murine monoclonal antibody of the IgG1 type with a high affinity and specificity for tumor necrosis factor alpha (TNFalpha). Infliximab was used in Crohn disease, rheumatoid arthritis, spondyloarthropathy, juvenile idiopathic arthritis, Behcet's disease, Wegener's granulomatosis, HLA-B27-associated uveitis and chronic severe refractory uveitis. Reported adverse effects of this treatment were infections, development of antinuclear antibodies and anti double-stranded DNA, lymphomas, and exacerbation of demyelinating disease. We report a case of infliximab-associated optic neuritis with favorable outcome after systemic steroid treatment.

[Diagnostic and therapeutic management of Vogt-Koyanagi-Harada syndrome]. / Prise en charge diagnostique et thérapeutique du syndrome de Vogt-Koyanagi-Harada.

PURPOSE: To determine the most efficient diagnostic tools in Vogt-Koyanagi-Harada syndrome, taking into account the international diagnostic criteria, and to evaluate the therapeutic management of these patients. PATIENTS AND METHODS: This study examined patients with a suspicion of VKH syndrome who presented between January 2001 and March 2003, including ocular and extraocular evaluation of the disease at the time of diagnosis. Each patient was classified according to the 1978 international diagnostic criteria and the revised 2001 criteria. In most cases, intravenous steroid pulses were administered. Immunosuppressors were initiated when inflammation was not controlled with steroids. RESULTS: Twenty-two patients were included. The mean age was 33.5 years (range, 15-49 years). Posterior segment involvement, which was observed in 21 patients, depended on the stage of the disease. Anterior segment inflammation was associated in eleven cases. Neurologic symptoms, including meningitis, cerebrospinal fluid lymphocytic pleocytosis, tinnitus, or hearing loss were observed in 12 patients. Fourteen patients had dermatologic signs. Five patients who developed VKH syndrome did not meet the 1978 criteria, and three patients did not meet the 2001 revised criteria. In 19 cases, intraocular inflammation was controlled with corticosteroids. In three cases, corticosteroids could not be discontinued. These patients were treated with immunosuppressive molecules: azathioprine, cyclophosphamide, interferon alpha. At the end of the follow-up period, inflammation was controlled in all patients. DISCUSSION: Revision of the diagnostic criteria provides a more subtle diagnosis of VKH syndrome. However, it is difficult to consider the variability of clinical symptoms during the duration of disease. Corticosteroids must be used at appropriate dosages, followed by slow tapering over 6 months. This attitude seems to reduce the duration of ocular inflammation and decreases the frequency of recurrence. The use of immunomodulating drugs could be reduced by early and appropriate use of systemic steroids. Interferon alpha seems to be a promising alternative in corticoresistant or corticodependent forms of the disease, but further controlled studies are required.

Polymerase chain reaction analysis of aqueous humour samples in necrotising retinitis.

AIM: To evaluate the diagnostic value of polymerase chain reaction (PCR) performed on aqueous humour for the detection of viral DNA in patients with necrotising herpetic retinitis. METHODS: The clinical features and laboratory results of 22 patients (29 eyes) presenting with necrotising herpetic retinitis between March 1999 and June 2001 were reviewed retrospectively. Aqueous humour was obtained after anterior chamber paracentesis and PCR was performed in all cases. RESULTS: Viral DNA was detected in the aqueous humour of 19 patients (86.4%). Epstein-Barr virus (EBV) seroconversion was evidenced in one additional patient. In the acute retinal necrosis (ARN) group (n = 19), varicella zoster virus (VZV) DNA was identified in six patients, herpes simplex virus 1 (HSV-1) DNA in two patients, herpes simplex virus 2 (HSV-2) DNA in four patients, and cytomegalovirus (CMV) genome in four patients. In the progressive outer retinal necrosis (PORN) group (n = 3), VZV DNA was detected in all patients. No sample was positive for more than one virus. CONCLUSIONS: PCR analysis of aqueous humour in patients with clinical features of necrotising viral retinitis can provide specific aetiological orientation and the method appears to be safe and highly sensitive.

[Viral cause and management of necrotizing herpetic retinopathies]. / Prise en charge diagnostique et thérapeutique des rétinites nécrosantes herpétiques.

PURPOSE: To study the viral cause and present the management of necrotizing herpetic retinopathies. METHODS: Charts of patients presenting with acute retinal necrosis (ARN) or progressive outer retinal necrosis (PORN) diagnosed between March 1997 and June 2001 were retrospectively reviewed. Intraocular specimens were obtained in 33 cases to determine the viral cause using polymerase chain reaction-based assays and/or detection of intraocular antibody production. RESULTS: The mean age was 43.4 Years. Herpesvirus genome was identified in 29 patients (80.5%). In the ARN group (32 patients, 38 eyes), herpes simplex virus (HSV) DNA was found in 11 patients (34.4%), varicella-zoster virus (VZV) in nine patients (28.1%), and cytomegalovirus (CMV) in four patients (12.5%). One patient (3.1%) presented an Epstein-Barr virus (EBV) infection. ARN was bilateral at initial examination in six patients and secondary bilateralization was observed in four patients. In the PORN group (four patients, eight eyes), the retinitis was bilateral and VZV DNA was detected in all cases. Two patients were treated with intravenous acyclovir, six with foscarnet alone, ten with intravenous foscarnet + acyclovir, 18 with intravenous foscarnet and intravitreous ganciclovir injections. Complications of necrotizing herpetic retinitis were cataract (26%), optic nerve atrophy (23.9%), and retinal detachment (17.4%). Final visual acuity was less or equal to 20/200 in 47.8% of cases. CONCLUSIONS: It is important to determine the specific viral etiology since progression and prognosis may be different in herpetic necrotizing retinitis caused by HSV, VZV, or CMV. Visual prognosis is improved by intensive antiviral therapy, but remains poor if complications occur.

[Perception of objects and scenes in age-related macular degeneration]. / La perception des objets et des scènes naturelles dans la dégénérescence maculaire liée à l'âge.

Vision related quality of life questionnaires suggest that patients with AMD exhibit difficulties in finding objects and in mobility. In the natural environment, objects seldom appear in isolation. They appear in a spatial context which may obscure them in part or place obstacles in the patient's path. Furthermore, the luminance of a natural scene varies as a function of the hour of the day and the light source, which can alter perception. This study aims to evaluate recognition of objects and natural scenes by patients with AMD, by using photographs of such scenes. Studies demonstrate that AMD patients are able to categorize scenes as nature scenes or urban scenes and to discriminate indoor from outdoor scenes with a high degree of precision. They detect objects better in isolation, in color, or against a white background than in their natural contexts. These patients encounter more difficulties than normally sighted individuals in detecting objects in a low-contrast, black-and-white scene. These results may have implications for rehabilitation, for layout of texts and magazines for the reading-impaired and for the rearrangement of the spatial environment of older AMD patients in order to facilitate mobility, finding objects and reducing the risk of falls.

Intravitreal ranibizumab injection for choroidal neovascularization in Strümpell-Lorrain Syndrome.

Strümpell-Lorrain syndrome, or hereditary spastic paraplegia is a genetic disease of the central nervous system affecting the spinal cord and cerebellum. It represents a clinically heterogenous group of neurodegenerative disorders characterized by progressive spasticity and hyperreflexia of the lower limbs. Ocular abnormalities include keratitis, macular pigmentary abnormalities, juxtafoveolar retinal telangiectasis and choroidal neovascularization. We report the first case of choroidal neovascularization associated with Strüpell-Lorrain syndrome treated successfully with intravitreal ranibizumab injection.

[Atrophic tamoxifen maculopathy]. / Maculopathie atrophique au tamoxifène.

Tamoxifen maculopathy is characterized by perifoveal white refractile deposits associated with pigmentary changes and cystoid macular edema. We report a case of atrophic maculopathy related to tamoxifen in a 70-year-old patient. Fundus examination showed refractile deposits in the macula predominantly in the left eye. Fundus autofluorescence demonstrated foveolar autofluorescence in both eyes. Fluorescein angiogram showed bilateral foveolar hyperfluorescence without leakage in the late phase. Optical coherence tomography disclosed an interruption of the photoreceptor layer in both eyes with a foveolar cystoid space. Multifocal electroretinogram showed bilateral alteration of the foveolar pic. The perifoveal foveolar cyst disappeared on OCT after discontinuation of tamoxifen. This case highlights the usefulness of optical coherence tomography and multifocal electroretinogram in the early diagnosis of atrophic form of tamoxifen maculopathy.