[Creation and evaluation of a triage survey for ophthalmology emergencies]

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.

Multicenter prospective observational study of dupilumab-induced ocular events in atopic dermatitis patients

BACKGROUND

Although ocular adverse events are frequent in AD patients treated with dupilumab, their characterization remains limited due to a lack of prospective studies with a systematic ophthalmological examination.

OBJECTIVE

To examine the incidence, characteristics and risk factors of dupilumab-induced ocular adverse events.

METHODS

A prospective, multicenter, and real-life study in adult AD patients treated with dupilumab.

RESULTS

At baseline, 27 out of 181 patients (14.9%) had conjunctivitis. At week 16 (W16), 25 out of 27 had improved their conjunctivitis and 2 remained stable and 34 out of 181 patients (18.7%) had dupilumab-induced blepharoconjunctivitis: either de novo (n = 32) or worsening of underlying blepharoconjunctivitis (n = 2). Most events (27/34; 79.4%) were moderate. A multivariate analysis showed that head and neck AD (OR = 7.254; 95%CI [1.938-30.07]; p = 0.004), erythroderma (OR = 5.635; 95%CI [1.635-21.50]; p = 0.007) and the presence of dry eye syndrome at baseline (OR = 3.51; 95%CI [3.158-13.90]; p = 0.031) were independent factors associated with dupilumab-induced blepharoconjunctivitis.

LIMITATIONS

Our follow-up period was 16 weeks and some late-onset time effects may still occur.

CONCLUSION

This study showed that most dupilumab-induced blepharoconjunctivitis cases are de novo. AD severity and conjunctivitis at baseline were not found to be associated risk factors in this study.

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.

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.

[Screening for diabetic retinopathy using a three-field digital nonmydriatic fundus camera in the North of France]

PURPOSE

To evaluate screening for diabetic retinopathy, using three-field nonmydriatic fundus photography, combined with telemedicine, in two hospitals.

METHODS

Patients from the Endocrinology Department of Saint Philibert Hospital were screened consecutively from March 2007 to September 2008. Three 45 degrees digital images per eye examination were taken using a nonmydriatic fundus camera and sent by intranet to the Department of Ophthalmology of Saint Vincent de Paul Hospital for grading by two ophthalmologists.

RESULTS

A total of 1147 patients (52% males, 48% females) were screened. The mean age was 60 years (range, 19-92 years). Most patients had type 2 diabetes (n=1000; 90%). The mean HbA1c was 8%. Microalbuminuria was detected in 239 patients (20.8%). Of these 1147 patients, 521 (45%) said they had never had a fundus examination before. Fundus photography of at least one eye could not be graded in 160 patients (14%). Diabetic retinopathy was detected in 187 patients (19%). Suspected macular edema (hard exudates within one disc diameter of the macular center) was found in 38 patients (3.8%). Referral to an ophthalmologist was required in 347 patients (30%) for diabetic retinopathy and unreadable photographs. During the period of the study, 107 patients had both three-field nonmydriatic photography and dilated funduscopy, which was used as reference. Agreement between the two readers was 0.97.

CONCLUSIONS

Nonmydriatic photography combined with telemedicine is useful for screening for diabetic retinopathy and identifies patients requiring further complete eye examination. Good collaboration between the two centers is required to improve the follow-up after screening in the future.

[Screening for sickle cell disease retinopathy in the north of France]

OBJECTIVE

To study the frequency and the severity of retinopathy in adult patients with sickle cell disease in the north of France.

PATIENTS AND METHODS

Patients with sickle cell disease aged more than 18 years old were consecutively referred for screening of sickle cell retinopathy in the ophthalmology department from December 2005 to March 2008. Complete ophthalmologic examination with dilated funduscopy was performed in each patient. Fluorescein angiography was performed in cases with ischemic retinopathy. Goldberg and Penman classifications were used to grade retinopathy severity.

RESULTS

Fifty-five patients (100 eyes) were included (26 S/S, 9 S/C, 12 S/B, 3 S/S with hereditary persistence of fetal hemoglobin). Sickle cell retinopathy is more severe in patients with the S/C genotype than the S/S and S/B genotypes. Proliferative retinopathy is more common in S/C patients than S/S and S/B patients (S/C vs S/S, p=0.001; S/C vs SB, p=0.01). A qualitatively abnormal vascular border (type II) is also more frequent in S/C patients than S/S and S/B patients (S/C vs S/S, p=0.001; S/C vs SB, p=0.01). No proliferative retinopathy was found in patients with S/S and hereditary persistence of fetal hemoglobin syndrome.

CONCLUSIONS

Screening is useful to detect sickle cell retinopathy, particularly in the adult population, to prevent complications from proliferative retinopathy.

[Thickness of retinal nerve fiber layer and macular volume in children and adults with strabismic and anisometropic amblyopia]

PURPOSE

To compare the thickness of the retinal nerve fiber layer (RNFL) and the macular volume and of normal and amblyopic eyes between children and adults who had strabismic or anisometropic amblyopia.

PATIENTS AND METHODS

Patients with unilateral amblyopia were consecutively included from June 2006 to June 2007. The macular volume and the RNFL thickness were measured using OCT and compared depending on the type of amblyopia, either strabismic or anisometropic, and the age of the patients, either children (3-10 years old) or adults (18 years old or older).

RESULTS

Fifty-six patients were included. In the child group (n=27), there was no significant difference in RNFL thickness and macular volume between amblyopic and normal eyes in both anisometropic and strabismic amblyopia. In the adult group (n=29), the RNFL was statistically thicker in amblyopic eyes only in the subgroup of anisometropic amblyopia (114+/-10.3mum in the amblyopic eyes versus 103+/-9.8mum in the normal eyes, p=0.02). No difference was found in RNFL thickness and macular volume in strabismic amblyopia. When anisometropic amblyopic eyes in children were compared to those of adults, the spherical equivalence was more positive (p=0.03) and RNFL was thicker (p=0.02) in the adult group, whereas visual acuity was not significantly different between the two groups. In strabismic amblyopia, no difference was found in spherical equivalence, RNFL thickness, and macular volume, whereas visual acuity was better in children's amblyopic eyes as compared to those of adults (p=0.05).

CONCLUSION

The difference in RNFL thickness is related to the difference of refraction between normal and amblyopic eyes, and between children and adults, independently of visual acuity and the mechanism of amblyopia.

Uveitic macular oedema: correlation between optical coherence tomography patterns with visual acuity and fluorescein angiography

AIMS

(1) To associate optical coherence tomography (OCT) patterns with particular fluorescein angiography (FA) findings in uveitis patients with macular oedema. (2) To investigate the correlation between tomographic features and visual acuity (VA). (3) To determine the impact of OCT patterns on visual improvement over time.

METHODS

129 eyes of 90 patients followed for uveitis with macular oedema and adequate media clarity were consecutively included from February to November 2004. We examined the relationship between VA, the fluorescein angiograms grading and central thickness.

RESULTS

Mean retinal thickness at the central fovea was 357 (SD 128) microm. The mean VA was 0.5 (logMAR). There was agreement between OCT and FA in 112 eyes (86.8%). In eight eyes (6.2%), serous retinal detachment (SRD) was detected on OCT but not on FA. Nine eyes (7%) had perifoveal leakage on FA without macular thickening on OCT. There were three patterns of macular oedema on OCT: diffuse macular oedema (DMO), cystoid macular oedema (CMO) and SRD. CMO was detected in 61 eyes (50.8%), and in 18 of these eyes (15%), CMO was associated with SRD. DMO was detected in 45 eyes (37.5%), and in eight (6.7%) of these eyes, DMO was associated with SRD. SRD without retinal thickening was present in 14 eyes (11%). Epiretinal membrane was detected by OCT in 27 eyes (21%). Six eyes demonstrated vitreomacular traction (4.7%). There was a correlation between VA and central thickness on OCT (r = 0.407, p = 0.000001). Correlation between VA and central thickness is significant in the group with CMO (r = 0.401, p = 0.001) but not significant in the group with DMO. Furthermore, vision recovery was observed in patients with CMO but was limited in patients with DMO. SRD did not have a significant impact on visual recovery, but its presence reduced the correlation between vision and central thickness.

CONCLUSION

OCT is effective in detection of macular oedema. It allows determination of the distribution of fluid and quantification of retinal thickness particularly in patients with CMO. In these patients, a potential for vision recovery was also identified. DMO was associated with a poor visual prognosis and a poor prognosis for vision recovery. SRD is associated with a high probability of vision recovery when observed alone or underlying CMO eyes. It should be substracted from the central thickness measurement when attempting to correlate central thickness with vision in patients with macular oedema in uveitis.

Maculopathy in uveitis of juvenile idiopathic arthritis: an optical coherence tomography study

AIM

The aim of this study was to examine the frequency and characteristics of macular lesions observed in juvenile idiopathic arthritis (JIA) uveitis, using optical coherence tomography (OCT).

METHODS

In this cross-sectional study, 38 consecutive patients were recruited from a tertiary referral center in uveitis. All eyes with JIA uveitis underwent complete ophthalmic examination including OCT 3. Exclusion criterion was the inability to obtain OCT scans. Flare and visual acuity were also analysed by using linear regression.

RESULTS

We analysed foveal thickness (FT) and central foveal thickness (CFT), using software mapping, to describe macular lesions in 61 eyes. Maculopathy was observed in 51 eyes (84%) compared with 12% in the literature (p<0.0001) and comprised four types: perifoveolar thickening in 45 eyes (74%), macular oedema in 29 eyes (48%), foveal detachment in 11 eyes (18%) and atrophic changes in six eyes (10%). Only four eyes did not demonstrate any lesion.

CONCLUSIONS

Among children with JIA uveitis, macular involvement is frequent and characterised by perifoveolar thickening and serous retinal detachment. OCT is a non-invasive instrument. It can easily identify this maculopathy, which could impair visual function, and require therapeutic intensification.

[Diagnostic and therapeutic management of Vogt-Koyanagi-Harada syndrome]

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.

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.

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.

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.