Interstitial keratitis diagnosis and treatment

Interstitial keratitis is a non-ulcerative, non-suppurative, more or less vascularized inflammation of the corneal stroma. The corneal lesions result from the host response to bacterial, viral (40% of cases) or parasitic antigens, or from an autoimmune response (1% of cases) without active corneal infection. The natural history of the disease is divided into two phases: acute and cicatricial. This type of keratitis is less common than ulcerative bacterial keratitis, but it is a non-negligible cause of visual loss. It is associated with systemic or infectious disease and requires early diagnosis and appropriate treatment to optimize visual prognosis and avoid other complications.

High-resolution imaging of photoreceptors in healthy human eyes using an adaptive optics retinal camera

PURPOSE

To determine the effects of age on perifoveal cone density in healthy subjects using adaptive optics.

METHODS

Healthy subjects of various ages were imaged using an adaptive optics retinal camera (RTX-1^® Imagine Eyes, Orsay, France). All patients underwent a comprehensive ophthalmologic examination and retinal imaging using spectral-domain optical coherence tomography (Spectralis^®, Heidelberg Engineering, Heidelberg, Germany). Cone density together with cone spacing and cone mosaic packing were measured in the nasal and temporal area 450 µm from the fovea. A multivariate analysis was performed to determine which of the following parameters were related to a decrease in cone density: age, axial length, central macular thickness, and retrofoveal choroidal thickness.

RESULTS

One hundred and sixty-seven eyes of 101 subjects aged 6-78 years were studied. Perifoveal cone density significantly decreased with age (R² = 0.17, p<0.01). Inversely, cone spacing increased with age (R²=0.18, p<0.01). There was no change in the cone packing mosaic (p>0.05). The mean coefficient of variation between fellow eyes was 3.9%. Age and axial length were related to a cone density decrease, while choroidal and retinal thicknesses did not affect cone metrics in healthy subjects.

CONCLUSIONS

A moderate perifoveal cone loss occurs with age. The precise consequences of these findings on visual function should be investigated. In addition to a better understanding of normal retinal anatomy, these results could act as a comparative database for further studies on normal and diseased retinas.

[Evaluation of coagulopathies and fibrinolytic abnormalities in central retinal vein occlusion in patients under 60 years of age]

PURPOSE

To investigate the association of thrombophilic and fibrinolytic factors with central retinal vein occlusion (CRVO) in patients under 60 years of age.

MATERIALS AND METHODS

A prospective, observational study of 21 patients with CRVO compared with an age- and sex-matched control group of 23 volunteers was performed. All participants were tested for: cholesterol, hypertension, factors VIII, IX, and XI, homocysteine, antiphospholipid antibodies, antithrombin III, proteins C and S, protein Z and protein Z antibodies, resistance to activated protein C, factor V Leiden mutation, prothrombin mutation, MTHFR genotypes, plasminogen activator inhibitor-1 (PAI-1) and tissue plasminogen activator (t-PA) polymorphisms.

RESULTS

There was a significantly higher rate of hyperhomocysteinemia (23.8% versus 0%, P=0.018) in CRVO patients. Increased level of factor VIII was more common in the CRVO group at diagnosis (23.8% versus 0%, P=0.018) but no significant difference was observed after one month (P=0.1). Hypercholesterolemia was more common in the CRVO group (42.8% versus 17.4%, P=0.09). Thirty-eight percent of patients with CRVO were hypertensive. Frequencies of other hypercoagulable states were rare. No significant differences were observed for hereditary fibrinolytic abnormalities.

DISCUSSION AND CONCLUSION

Among the coagulopathies studied, hyperhomocysteinemia appears to be a risk factor for central retinal vein occlusion in patients under 60 years of age. Conversely, polymorphisms of fibrinolytic factors do not appear to play a role in this population.

[Study and prevention of contact lens-related microbial keratitis with a standardized questionnaire]

INTRODUCTION

microbial keratitis is a significant health concern for the one million wearers of contact lenses and their ophthalmologists, with some potentially modifiable risk factors. The number of risk factors for contact lens-related microbial keratitis has been described, but many of them still remain assumed or unknown.

PATIENTS AND METHODS

a multicenter prospective case-control study was conducted in 12 French university hospitals (Besançon, Bordeaux, Dijon, Fort-de-France, Grenoble, Limoges, Lyon, Nancy, Nantes, Paris, Marseille and Strasbourg) beginning in July 2007 on contact lens wearers presenting with microbial keratitis and on healthy contact lens wearers. Patients and healthy wearers were interviewed using a 51-item anonymous standardized questionnaire to determine subject demographics and contact lens wear history.

RESULTS

two hundred and fifty-six patients with microbial keratitis were included. One hundred and thirteen healthy contact lenses wearers were surveyed. Cosmetic contact lens wear highly increased the relative risk (RR) of microbial keratitis (RR, 16.5). Time since the last visit to an ophthalmologist longer than 1 year (RR, 3.4) or prescription by someone other than an ophthalmologist (RR, 7.6) also increased the risk of microbial keratitis. Education on lens care and handling was deficient (hand washing: RR, 2.2; rub and rinse: RR, 2.7).

DISCUSSION

a standardized questionnaire is a powerful tool to determine risk factors for contact lens-related microbial keratitis, but also to analyze individual mistakes in contact lenses use and care.

[Traumatic wound dehiscence after keratoplasty]

PURPOSE

To assess the patient characteristics, risk factors, and outcomes of penetrating keratoplasty wound dehiscence.

PATIENTS AND METHOD

Retrospective chart review of 11 eyes of 11 patients with corneal grafts who underwent repair of penetrating keratoplasty wound dehiscence from January 1986 to January 2006 in the Ophthalmology Department at the Besançon Minjoz Hospital (France).

RESULT

The mean time between penetrating keratoplasty and wound dehiscence was 3.3 years (range, 1-140 months). In all cases, dehiscence involved the junction between graft and host. The mean age at time of wound dehiscence was 47 years (range, 23-89 years). Falls were the most common mechanism of trauma, especially in the elderly population. There was a wide range of visual outcomes in the 11 patients, with six patients with best corrected visual acuity less than 1/20. There were no cases of endophthalmitis.

CONCLUSION

Patients with corneal transplants have a life-long risk for wound traumatic dehiscence. This complication may be reduced by the regular use of eye protection by all corneal transplantation patients.

Activité de greffe de cornée en France (1990-2005) : vers une stabilisation de la demande et de l’offre

OBJECTIVE

To evaluate changes in the balance between supply and demand for corneal grafts over the last 15 years in France in the light of the measures implemented and the 2005 national and regional audit.

MATERIALS AND METHODS

Corneal transplantation activities were estimated, mainly from a national prospective survey of ophthalmologists (1991-1994), annual surveys of ophthalmologists (1995-2000), tissue banks (1996-2005), and the national waiting list for surgery (since 2000).

RESULTS

In 2005, the main indicators available were consistent with a stabilization in the number of candidates added to the waiting list every year (4606 in 2005), accompanied by a large increase in the number of grafts procured (9264 in 2005). There was also a substantial increase in quality testing of these grafts, leading to a high rate of rejection (49.5% of the procured grafts). In addition, the number of grafts exported decreased to a very low level (213 in 2005). The percentage of malades registered on the waiting list who received grafts in the same year also increased (68.5% in 2005). Once the waiting list had been updated, 3016 malades remained on the list at the beginning of July 2006. The gap between supply and demand for corneal transplantation has therefore narrowed. Two actions made particularly large contributions to these changes: the creation in 2000 of 120 full-time staff positions in hospital coordination teams, which has had a major impact on procurement rates; and the organization of the tissue bank sector, making it possible to guarantee the quality and distribution of grafts.

CONCLUSION

Corneal procurement and transplantation activities seem to have reached equilibrium in France. A reliable estimation of demand, particularly at the regional level, has led the French agency in charge of tissue transplantation to modify the functioning of the national corneal transplant waiting list, with tissue banks now allowed access to declare transfers and the temporary registration of malades on the list to limit stagnation.

Carcinome adénoïde kystique de la glande lacrymale chez une enfant âgée de 14ans

The discovery of unilateral exophthalmia requires multidisciplinary care made all the more difficult in the case of a 14-year-old girl living in a tropical environment. The child, C.A., resident of the town of Djenné in Mali, was examined for nonpulsate, nonretractile, left lateral unilateral exophthalmia, painful upon palpation of a left upper-external mass under the orbital rim. The initial examination highlighted the existence of an intraorbital tumor with a moderate effect on visual function. In view of the slow and progressive development over 2 years, and with the assistance of an association, the child was transferred to a specialized medical structure where the tumorous nature was confirmed after surgical exeresis. The diagnosis was cylindroma, or adenoid cystic carcinoma. Neither chemotherapy nor radiation were used. At 15 months after surgery, the child showed no clinical sign of recurrence. Intraorbital tumors in children present diagnostic and therapeutic problems in countries with limited medical resources. Cylindromas or adenoid cystic carcinomas of the lachrymal gland are the second most common cause of epithelial tumors in this gland, which are characterized by a high degree of malignancy, a very high rate of recurrence, and a low survival rate at 5 years. In a tropical environment, diagnostic and therapeutic difficulties are compounded by limits to comprehensive care for the child.

Primary lymphoma of the lacrimal sac: an EORTC ophthalmic oncology task force study

AIM

To define the clinical and histopathological characteristics of primary lacrimal sac lymphoma in a predominantly white population.

METHODS

Specimens of lacrimal sac lymphoma and follow up data were solicited from members of the Ophthalmic Oncology Task Force of the European Organization for Research and Treatment of Cancer (EORTC) and the European Ophthalmic Pathology Society (EOPS). Specimens were stained with haematoxylin and eosin and an immunohistochemical panel against leucocyte antigens was applied. Diagnosis was reached by consensus of five experienced pathologists according to the World Health Organization classification system. The histopathological findings were correlated with the clinical data.

RESULTS

Of 15 primary lacrimal sac lymphomas, five (33%) were diffuse large B cell lymphoma (DLBCL), five (33%) were extranodal marginal zone B cell lymphoma of mucosa associated lymphoid tissue (MALT lymphoma), three were classified as "transitional MALT lymphoma," being in transition from MALT lymphoma to DLBCL, and two were unclassified B cell lymphomas. Nine of the patients were female, and the median age at the time of diagnosis was 71 years (range 45-95 years). The most frequent presenting symptoms were epiphora (85%), swelling in the region of the lacrimal sac (79%), and dacryocystitis (21%). All but one patient presented in stage I. Systemic spread occurred in three of nine patients (33%). The 5 year overall survival was 65%.

CONCLUSIONS

DLBCL and MALT lymphoma are equally common in the lacrimal sac in contrast with the remaining periorbital and/or orbital region where MALT lymphoma predominates.

[Quality of life after corneal transplantation: a retrospective study]

PURPOSE

To assess how clinical and social characteristics influence health-related quality of life among patients who have undergone corneal transplantation.

METHODS

Sixty-eight patients followed up for at least 1 year after corneal transplantation participated in this study. Data were collected on social status, systemic co-morbidities, ocular history, best corrected visual acuity, and a detailed ocular examination. Questionnaires that allowed calculation of VF14 and the SF36 scores were filled out for each participant interview. The associations between questionnaire outcomes and social status, ophthalmic status, and general health were evaluated using one-way analysis of variance and multiple stepwise linear regression.

RESULTS

The mean best-corrected visual acuity (BCVA) was significantly better in the operated eye for keratoconus and dystrophies than for bullous keratopathy. There is a strong relationship between BCVA in the operated eye and the VF14 score (beta=8.45, p=0.005) and also between BCVA of the contralateral eye and the VF14 score (beta=19.91, p<0.0001). Correlations between VF14 and SF36 were all positive (range r=0.29-0.49, p<0.01).

CONCLUSION

This retrospective analysis provided strong evidence for the validity and reliability of the VF14 as an instrument for testing visual disabilities or satisfaction in patients who had corneal transplantation. Astigmatism or anisometropia did not affect VF14 and SF36 scores. The most important factors associated with the VF14 score and SF36 measures were the visual acuity of the operated eye as well as the contralateral one, including their physical function, vitality, and the patient's perception of mental and general health.

[The French national waiting list for keratoplasty created in 1999: patient registration, indications, characteristics, and turnover]

PURPOSE

To evaluate the French waiting list and the indications of registered patients, to compare the rates of registration, graft, and procurement between French regions.

METHODS

In France, each patient with an indication for penetrating keratoplasty should be registered on the waiting list with his or her clinical characteristics. Those registered during 2000 and 2001 were included in the study. Data on transplantation activity from the waiting list were compared to data collected by a questionnaire on graft and procurement activities completed each year by medical teams.

RESULTS

In 2000 and 2001, 6093 and 5505 waiting patients, respectively, were registered. For the same years, 3984 and 3457 keratoplasties were declared for the patients registered, but the questionnaires reported 4514 and 4388 grafts, respectively. The national registration rate was 96 per million population (pmp). The extreme values between regions ranged from 53 to 143 pmp. There was a significant correlation between regional procurement and transplantation rates (r=0.75, p=0.001) but not for registration and procurement rates, and not for registration and transplantation rates. The national registration rate was 27 pmp for pseudophakic and aphakic corneal edema, with extreme values of 12-64 pmp. The national registration rate was 24 pmp for keratoconus (11-37 pmp). A high patient turnover was observed between regions. Among the 11,598 patients registered, the most common indications were pseudophakic and aphakic corneal edema (27.7%), keratoconus (25.3%), and Fuchs'endothelial dystrophy (9.1%). Mean recipient age was 57+/-22 years (0-103 years). Among these patients, 14.1% had already received transplants at least once for the same eye (7.8% for keratoconus, 14.3% for pseudophakic and aphakic corneal edema, and 6.1% for Fuchs'dystrophy).

DISCUSSION

Ophthalmologists will be able to register their patients directly on the waiting list, which will improve data quality for transplantation notification. Regional policies should be developed to decrease the inequalities of graft shortages between regions.

Intracerebral alveolar echinococcosis

There are two species of the genus Echinococcus, Echinococcus multilocularis (also called alveolar hydatid) and Echinococcus granulosus, characterized by distinct growth features in humans. The main endemic regions for human alveolar echinococcosis (AE) caused by E. multilocularis are Central Europe, Russia, Turkey, Japan, China, eastern France and North America. Human echinococcosis is usually caused by an intrahepatic growth of parasitic larvae. Cerebral occurrence of E. multilocularis disease is rare, accounting for only 1% of cases, and is generally considered to be fatal. This report presents two cases of intracerebral E. multilocularis disease which occurred in two infected patients with AE pulmonary metastases. The anatomical and clinical features are discussed. Our retrospective survey would indicate that surgical treatment should be envisaged whenever possible.

[Fungal contamination detection in cornea preservation media]

PURPOSE

Fungi can cause major complications following corneal grafting. In this study we aimed to verify the efficiency of a fungal contamination detection protocol for human corneas in preservation before clinical use.

MATERIALS AND METHODS

The 12 most frequently found species of fungi responsible for keratitis and endophthalmitis were inoculated to preservation medium used by most French eye banks. A protocol used by several centers, including a daily visual control, was followed in order to check that it showed the presence of all microorganisms, particularly slow-growing filamentous fungi.

RESULTS

Every species was detected in a time from 2 to 4 days.

CONCLUSION

This microbiological contamination detection protocol of detection for human corneas in organ culture at +31 degrees C, seems to effectively detect the main agents responsible for fungal contamination.

Value of two mortality assessment techniques for organ cultured corneal endothelium: trypan blue versus TUNEL technique

BACKGROUND/AIM

It is known that trypan blue staining is not a good predictor of loss of corneal endothelial cells (ECs) during organ culture. As it is primarily an indicator of membrane integrity, it would also not be expected to identify ECs undergoing apoptosis. The aim of this study was to determine the ability of the in situ TdT dUTP mediated nick end labelling (TUNEL) technique to detect cell death in the corneal endothelium caused by apoptosis during organ culture, compared with conventional vital staining with trypan blue.

METHODS

31 human corneas were organ cultured at 31C for 3-35 days. Staurosporine was used to induce apoptosis in five control corneas. The endothelium was assessed by trypan blue and by the in situ TUNEL technique. The percentages of trypan and TUNEL positive ECs were compared. Their links with sex, donor age, time from donor death and organ culture, initial and final EC density and cell loss were studied.

RESULTS

TUNEL stained ECs were observed in all corneas. TUNEL positive ECs were mostly located either in corneal folds or at the periphery of corneal folds showing central shedding. The mean percentage of cell death at the end of storage, assessed by the trypan blue technique, was 1.47% (SD 2.63, range 0.03-12); assessed by the TUNEL technique it was 12.7% (SD 16.4 range 0.6-65.5). There was a significant correlation between the two techniques (r = 0.7, p<0.001). The percentage of TUNEL stained ECs was correlated negatively with EC density at the end of storage (r = -0.47, p <0.005) and positively with percentage EC loss during storage (r = 0.46, p < 0.05).

CONCLUSION

This study demonstrates that organ cultured corneas systematically carry non-viable ECs that are implicated in cell death by apoptosis and go undetected when trypan blue staining is used. Because the in situ TUNEL assay detects earlier events in the cell death process than does trypan blue, it should be used to quantify endothelial viability, especially for experiments with new storage media.

Cancer transmission through corneal transplantation

PURPOSE

A retrospective study to demonstrate the safety of corneas from donors affected by systemic malignancies in a view of keratoplasty.

METHODS

Using the data of the cancer registry department in a district of 500,000 residents, we analyzed retrospectively 143 patients followed up in the same region and transplanted between 1987 and 1995. We compared the incidence of cancer in recipients of cornea coming from donors with malignancies with recipients of cornea from donors without malignancies. The rate of cancer in this population was also compared with the incidence of cancer in the general population at the same age.

RESULTS

Eleven patients (7%) were excluded from the study, eight of them for the presence of cancer in their medical history before surgery and the three others because of lack of information about their follow-up after surgery. Forty patients received corneas from cancerous donors and 103 from donors without cancer. Six patients developed malignancies between 1 and 4 years after transplantation, and only one of them received a cornea from a donor with a systemic malignancy. This recipient developed a different type of cancer from that of the donor. The five other patients received corneas from donors without systemic malignancies. By comparing theses results, there was no relationship between the occurrence of malignancies and transplantation of corneas from cancerous donors (relative risk = 0.49, 95% confidence interval = 0.01-13.62).

CONCLUSION

There was no increased incidence of cancer in our patient population compared with reference population. Based on this study, there is no statistical or clinical evidence to suggest the transmission of cancer from donors with malignancies via corneal transplantation, according to the accepted criteria of donor selection.

[Procurement of corneas: analysis of inventory of hospital coordination. Prospective study at the Besançon Hospital University during the course of one year]

PURPOSE

To identify the obstacles contributing to the deficiency in supply of corneal donation. Quantitative and qualitative analysis of the collection and the distribution of corneas was performed by the staff of organ and tissue transplantation in the University Hospital of Besançon.

METHODS

Medical records of all the deceased patients between the 8(th) of February 1998 and 28(th) of February 1999 were reviewed. In these medical records, we distinguished 2 groups

RESULTS

During the study period, 1044 patients died at Besançon University Hospital. 616 medical records were checked and 428 were not. Out of 616 checked medical records, we found 337 (54%) medical contraindications, 112 (18%) denied requests, 105 (17%) logistic problems and 62 (10%) procurements after consent. Out of 428 medical records unchecked, we found 215 (50%) medical contraindications, 199 (46%) potential donors and 14 (3,2%) logistic problems. The most important factor of non cornea procurement was medical contraindication. The unavailability of the transplant coordination ophthalmologists and logistic problems represented 30% of non procurement corneas. Relatives opposition was found only in 18% of cases.

CONCLUSION

This survey was an overview of the real condition of corneal donation in our institution. Caution regarding medical selecting donor corneal material should be used even if it represents the most important factor of non cornea procurement. To increase the supply of donor material, logistic and audibility of transplant coordination and surgeons should be improved.

[Difficult cornea procurement: causes and consequences of the exceptional situation in France]

Despite scientific advances, corneal grafting is still in a crucial situation in France in 1999. Over the last 3 years, the number of corneal grafts (2 903 in 1996, 3 213 in 1997, and 4 053 in 1998) has been insufficient to satisfy estimated needs (8 041 in 1996, 8 303 in 1997, 7 400 in 1998). The consequences are waiting lists, long time on waiting lists, and regional differences. This situation results more from difficulties in the cornea procurement system than from limited numbers of potential donors or restricted selection criteria. Progress will depend greatly on structural changes.

[French Directory of Eye Banks. Report on activities during 1993-1997]

PURPOSE

To describe the activity of the eye banks participating in the French Eye Bank Directory over the period 1993-1997.

METHODS

Since 1993, the eye banks have answered annually a questionnaire concerning technical aspects (procurement procedures, microbiological testing, tissue evaluation and preservation procedures) and activity (number of corneas processed, preserved and issued). Data from these banks were collected and presented in the Directory each year.

RESULTS

In 1997, a total of 2,432 eyes were processed. Most of the eye banks (84%) used organ culture as the storage method. Thirty percent of the processed corneas were not used for transplantation. The main reasons for discarding corneas were inadequate endothelium before preservation (15.5%) and positive serology (27%), contamination during preservation (4.6-7.2%), and inadequate endothelium after preservation.

CONCLUSION

Quality assurance, microbiological safety and tractability requirements are currently an integral part of the cornea transplantation circuit in France. Publication of eye bank activity has enabled and evaluation of the different procedures.

[Tetracaine versus diclofenac in the treatment of pain following refractive photokeratectomy]

PURPOSE

To compare the efficacy and safety of topical diclofenac and tetracaine in reducing ocular pain after photorefractive keratectomy.

SETTING

Ophthalmology Department, Minjoz Hospital, Besançon, France.

METHODS

Seventy-four patients were randomized to receive either tetracaine 1% or diclofenac 0.1% after undergoing PRK. Tetracaine was instilled at 30 minute intervals for 24 hours. Diclofenac was instilled four times a day for 3 days. All patients were allowed to use oral Diantalvic (paracetamol-noramidopyrine) as a rescue analgesic if the study medications failed to control the ocular pain. Visual analog pain charts were used to record pain levels every hour for 30 hours after surgery. A subjective questionnaire was to be completed by the patient to evaluate discomfort every day for 3 days. Computer analysis of photography performed at D0, D1, D3, was used to evaluate the rate of epithelial closure.

RESULTS

Women had significantly more pain. Patients in the diclofenac group had significantly less pain. No statistically significant difference was seen in the rate of epithelial closure.

CONCLUSION

Diclofenac is more effective than tetracaine to reduce ocular pain and functional symptoms.