P. Fournié

384 - Kératite à Nocardia abscessus : à propos d’un cas.

Objectif Rapporter un cas de keratite a Nocardia abscess . Materiels et Methodes Cas clinique. Observation Une nocardiose corneenne a ete diagnostiquee sur des cultures realisees a partir de grattages corneens dans un cadre de keratite traumatique vegetale. L’identification d’espece abscessus ( Nocardia asteroides ) a ete realisee par l’observatoire des nocardioses de Lyon. Une reponse corneenne a ete obtenue par un traitement antibiotique adapte a l’antibiogramme par voie locale (gentamicine fortifiee et cefazoline fortifiee) et par voie generale (doxycycline). Un rebond a l’arret du traitement a 3 mois a necessite la reintroduction des antibiotiques pour une duree prolongee de 9 mois avec persistance d’une cicatrice corneenne. Discussion La nocardiose est due a une bacterie Gram positif, aerobie stricte et acido-alcoolo resistante. L’identification bacteriologique se fait par l’observation de pseudo-mycelium Gram positif et des hyphes acido-alcoolo resistants. Nocardia asteroides est l’espece pathogene la plus frequente chez l’homme. Il s’agit d’une bacterie tellurique ubiquitaire dont la porte d’entree chez l’homme est le plus souvent respiratoire. Des cas de keratite a Nocardia asteroides ont ete rapportes apres un traumatisme local tellurique mais egalement chirurgical apres LASIK. La sensibilite aux antibiotiques des bacteries du genre nocardia est a determiner pour chaque espece. La duree de l’antibiotherapie doit etre prolongee de 3 a 12 mois selon la gravite de l’infection avec un risque de rechute a l’arret precoce des antibiotiques ou lors de l’introduction de corticoides locaux. Conclusion La nocardiose corneenne est rare. L’identification du genre nocardia et de l’espece ainsi que la determination de l’antibiogramme sont importants pour adapter un traitement qui sera toujours de longue duree.

[Corneal collagen cross-linking with ultraviolet-A light and riboflavin for the treatment of progressive keratoconus].

INTRODUCTION The aim of the present study was to evaluate the clinical usefulness of riboflavin- and ultraviolet-A (UV-A)-induced collagen cross-linking (CXL) on progressive keratoconus. PATIENTS AND METHODS Twenty eyes of 20 patients with progressive keratoconus were included in a prospective, nonrandomized pilot study. The preoperative progression of keratoconus was documented by an increase in maximum keratometry (Kmax) on serial corneal topographies. Preoperative corneal thickness was at least 400 microm. The postoperative progression of keratoconus was evaluated from corneal topography, best-corrected visual acuity (BCVA) testing, and corneal biomechanical properties assessed with the Ocular Response Analyzer (ORA). The follow-up time was between 3 and 18 months. RESULTS The steepening decreased significantly by 1.68+/-2.18 diopters (D) in the first year (p<0.05). The Kmax value decreased in 66% of eyes and remained stable in 17% (within+/-0.50 D). The mean preoperative BCVA was 0.49+/-0.22. Six months after the CXL treatment, the mean BCVA was 0.63+/-0.23 (p<0.05) and improved at least one line in 56.25% of eyes. The ORA values remained stable over the entire follow-up period. DISCUSSION Extensive experimental study showed a significant increase in corneal rigidity after riboflavin/UV-A-induced CXL. CONCLUSION Preliminary results on the clinical effects of riboflavin/UV-A-induced CXL are encouraging in reducing the progression of keratoconus. Long-term results are necessary to evaluate the duration of the stiffening effect.

Kératoplastie lamellaire antérieure profonde dans le traitement chirurgical du kératocône. recul de plus d’un an

But Cette etude permet d’evaluer les resultats de la keratoplastie lamellaire anterieure profonde (KLAP) par dissection a l’air ou par visco-dissection dans le traitement chirurgical du keratocone comme alternative a la keratoplastie transfixiante. Materiels et methodes Des patients presentant un keratocone avec une intolerance aux lentilles de contact ont ete operes par KLAP entre fevrier 2001 et septembre 2002 dans le cadre d’une etude prospective monocentrique non comparative. La dissection lamellaire profonde a ete realisee soit par injection d’air dans la cornee de facon a obtenir un emphyseme corneen stromal, soit par injection de materiel visco-elastique. Cette derniere permettait de separer la membrane de Descemet du stroma profond en se servant de l’interface air-endothelium. L’humeur aqueuse avait ete prealablement remplacee par de l’air en chambre anterieure pour visualiser la surface corneenne posterieure. Un greffon allogenique de pleine epaisseur debarrasse de son endothelio-Descemet etait suture dans le lit corneen receveur. Resultats Quinze yeux de quinze patients (âge moyen : 41,2 ans) ont subi une KLAP. L’acuite visuelle moyenne pre-operatoire etait de 0,11 ± 0,06. A 1 an, la meilleure acuite visuelle moyenne corrigee etait de 0,47 ± 0,16 (p 2 alors qu’elle etait de 2 604 ± 235/mm 2 a un mois pre-operatoire (perte cellulaire de 22,5 %, p > 0,05). Une perforation per operatoire de la membrane de Descemet est survenue dans 5 cas (33,3 %). Deux cas ont ete convertis en keratoplastie transfixiante. Il n’y a pas eu de rejet endothelial. Conclusion Dans cette serie, la KLAP semble etre une procedure interessante dans le traitement du keratocone avec des resultats refractifs encourageants, une absence de decompensation endotheliale primaire du greffon et une absence de rejet de greffe endothelial. La KLAP est une alternative interessante a la keratoplastie transfixiante meme si elle est de realisation plus difficile.

Efficacité réfractive et tolérance de l’implant phaque myopique souple à fixation irienne Artiflex® dans la correction chirurgicale de la myopie forte : résultats à deux ans

Introduction Nous avons evalue l’efficacite refractive et la securite d’un nouvel implant phaque souple de chambre anterieure utilisee pour la correction chirurgicale de la myopie forte. Materiel et methodes Nous avons mene une etude prospective monocentrique portant sur l’efficacite refractive et la tolerance d’un implant phaque souple fixe a l’iris — Artiflex® —, dans le traitement de la myopie forte moderee, comprise entre − 8 et − 14 D. Vingt-cinq yeux de 25 patients ont recu un PIOL Artiflex® sans complication. Tous les patients ont ete suivis pendant 2 ans. La cible refractive fixee etait l’emmetropie. Les criteres d’inclusion etaient une myopie comprise entre − 8 et − 14 D et stable depuis 2 ans, une intolerance aux lentilles de contact, un cylindre inferieur a 1,5 D, une profondeur de chambre anterieure superieure a 3 mm et un comptage cellulaire endothelial central superieur a 2 200 cellules/mm2. Resultats L’equivalent spherique preoperatoire etait de − 9,70 ± 2,37 D. A 2 ans, l’equivalent spherique postoperatoire etait de − 1,07 ± 0,84 D. La valeur de l’astigmatisme chirurgical induit etait de 0,42 D × 67,4. Le pourcentage d’yeux avec une acuite visuelle sans correction (AVSC) superieure ou egale a 0,5 et 0,8 etait respectivement de 66,6 % et 33,3 %. Aucune complication operatoire n’a ete constatee. Le comptage endothelial a 2 ans etait de 2 267 ± 352 cellules/mm2. La qualite de vision objective et subjective etait importante, avec un taux de satisfaction du patient eleve. Discussion L’efficacite refractive de ce nouvel implant phaque est satisfaisante. La tolerance endotheliale de l’implant Artiflex® semble comparable a d’autres implants phaques de reference. Conclusion L’implant Artiflex® constitue une nouvelle alternative chirurgicale fiable dans la correction phaque de la myopie forte en raison des resultats refractifs excellents, de la recuperation visuelle rapide et de la qualite de vision elevee. Son injection au travers d’une incision de 3 mm permet de reduire l’astigmatisme induit et ainsi d’augmenter l’acuite visuelle sans correction postoperatoire.

Upregulation of Bone Morphogenetic Protein-1/Mammalian Tolloid and Procollagen C-Proteinase Enhancer-1 in Corneal Scarring

PURPOSE To characterize the expression of the bone morphogenetic protein-1 (BMP-1)/tolloid-like proteinases (collectively called BTPs), which include BMP-1, mammalian tolloid (mTLD), and mammalian tolloid-like 1 (mTLL-1) and 2 (mTLL-2), as well as the associated proteins procollagen C-proteinase enhancers (PCPE-1 and -2), in corneal scarring. METHODS Using a mouse full-thickness corneal excision model, wound healing was followed for up to 28 days by transmission electron microscopy, immunohistology (BMP-1/mTLD and PCPE-1), and quantitative PCR (Q-PCR: collagen III, BMP-1/mTLD, mTLL-1, mTLL-2, PCPE-1, PCPE-2). Bone morphogenetic protein-1/mTLD and PCPE-1 were also immunolocalized in cases of human corneal scarring following injuries. RESULTS In the mouse model, throughout the follow-up period, there was a large increase in collagen III mRNA expression in the stroma. By transmission electron microscopy, there was marked cellular infiltration into the wound as well as disorganization of collagen fibrils, but no significant difference in fibril diameter. In control corneas, by Q-PCR, BMP-1/mTLD showed the highest expression, compared to low levels of mTLL-1 and undetectable levels of mTLL-2, in both epithelium and stroma. Following wounding, both BMP-1/mTLD and PCPE-1 mRNA and protein increased, while PCPE-2 mRNA decreased. Finally, by immunofluorescence, BMP-1/mTLD and PCPE-1 were strongly expressed in the scar region in both mouse and human corneas. CONCLUSIONS Bone morphogenetic protein-1/mTLD and PCPE-1 are upregulated in corneal scars. Both proteins may therefore contribute to the process of corneal scarring.

Kératites bactériennes sévères. Étude épidémiologique, clinique et microbiologique ☆

INTRODUCTION The aim of this study was to report the epidemiologic and microbiologic features and to define the risk factors of hospitalized cases of bacterial keratitis in the Toulouse University Hospital Center of Ophthalmology (France). METHODS This was a retrospective study including all cases of serious bacterial keratitis hospitalized between January 2006 and November 2007. Epidemiologic, microbiologic, and clinical factors such as age, reasons for hospitalization, visual loss, and risk factors were described. RESULTS Sixty-seven patients were hospitalized during this period, with a mean age of 46 years. The two most frequent clinical features for hospitalization were the area of stromal infiltrate (63%) and central corneal localization (61%). A local risk factor was identified in 92.5% of cases in decreasing order: contact lens wear (49%), keratopathy (16%), corneal injury (12%), and corneal surgery (7%). Sixteen percent had immunodeficiency from the most part because of diabetes and Gougerot-Sjögens syndrome. Bacterial samples were positive in 57% of cases. Gram-negative bacteria were often isolated (45%) among contact lens wearers. After 3 months, the final visual acuity improved in 85% of the eyes studied. DISCUSSION Contact lens wear, even if it was the leading risk factor of serious bacterial keratitis requiring hospitalization, was not a negative prognosis factor in our study. CONCLUSION Factors such as a low preoperative visual acuity, age, and the size of the initial infiltrate have a poor prognosis and immunodeficiency is the predisposing factor associated with the worst final visual acuity.

Kératite fongique à Scedosporium apiospermum

Introduction Nous rapportons un cas de keratite post-traumatique a Scedosporium apiospermum traite par voriconazole par voie topique et orale et keratoplastie therapeutique. Observation Un homme a ete admis pour un abces de la cornee de l’œil droit post-traumatique suite a un debroussaillage. L’evolution initiale sous collyres fortifies antibiotiques (vancomycine, gentamicine et cefazoline) et antifongiques par voie locale (amphotericine B collyre a 1 %) et par voie generale (itraconazole 200 mg/j per os ) a ete marquee par une aggravation locale. Les prelevements corneens associant ecouvillonnages et grattages ont mis en evidence une keratomycose a Scedosporium apiospermum , souche pou laquelle les principaux antifongiques ont montre des concentrations minimales inhibitrices (CMI) elevees alors que celle du voriconazole etait a 0,125 μg/mL. En raison d’un amincissement pre-perforatif et malgre l’efficacite therapeutique sous voriconazole collyre a 1 % toutes les heures associe a du voriconazole 400 mg per os , une greffe de cornee therapeutique a ete realisee. Les suites postoperatoires ont ete simples sans reprise evolutive de l’affection mycosique sous ciclosporine collyre 2 %, dexamethasone collyre et voriconazole par voies locale et generale. Conclusion Les keratites a Scedosporium apiospermum sont rares et de pronostic fonctionnel et anatomique souvent pejoratif en raison d’un retard diagnostique et d’une resistance aux antifongiques usuels. Le voriconazole est un antifongique triazole de deuxieme generation a large spectre. Sa preparation pour instillation topique, encore peu repandue, est aisee. Associee a une prise orale, l’instillation topique elargit l’utilisation du voriconazole au traitement de certaines keratomycoses rares et resistantes aux antifongiques usuels.

Conduite automobile et aptitude visuelle chez 100 patients âgés de plus de 60 ans

OBJECTIVE: To evaluate visual capacity and automobile driving in a sample of individuals over 60 years of age based on the visual function criteria as defined in the 29 May 1997 French Journal Officiel. MATERIAL AND METHODS: Drivers over 60 years of age were included in a prospective monocentric epidemiological study between January and March 2005. Binocular visual acuity and monocular visual acuity were measured in subjects with their optical corrections. Binocular or monocular visual field was tested depending on visual acuity results. Etiologies of visual acuity loss and visual field impairment of each eye were recorded in patients who did not meet the required criteria. RESULTS: One hundred patients were included (mean age, 70.7 years +/- 7.12 years). Twenty-nine patients did not meet the required criteria (29%; 95% confidence interval=[20.1;37.9]). On these 29 patients, 20 (69%; 95% CI=[52.2;85.8]) were unfit for driving an automobile with potential reversibility, whereas nine (31%; 95% CI=[14.2;47.8]) were permanently unfit from a visual point of view. CONCLUSION: The frequency with which patients ignore their poor distance visual acuity and the possibility of reversing the problem make it clear that the ophthalmologist has a role to play in detecting and informing patients. Language: fr

Sphingosine-1 phosphate prevents ethanol-induced corneal epithelial apoptosis.

Background: Apoptosis is a programmed cell death in multicellular organisms, found in a wide variety of conditions, including inflammatory process, everywhere in the body, including the cornea and conjunctiva. Aim: To evaluate the effect of a new topical formulation of sphingosine-1 phosphate on preventing apoptosis of the corneal epithelium. Setting: Medical University. Materials and Methods: We tested several formulations suitable for topical application. Twenty-five rabbits were distributed among five groups. Group 1 comprised the controls. In Group 2, 20% ethanol was applied topically for 20 seconds; in Group 3, 50 μM topical sphingosine-1 phosphate was applied 2 hours prior to 20% ethanol application. In Group 4, 200 μM topical sphingosine-1 phosphate was applied 2 hours before the 20% ethanol application. In Group 5, only 200 μM topical sphingosine-1 phosphate was applied. Apoptosis was evaluated using the terminal deoxynucleotidyl transferase biotin-dUTP Nick End Labeling (TUNEL) assay. Pairwise comparisons were performed using t-tests with Scheffes correction. Data were analyzed using STATA 9.0 statistical software. Results: A suspension of sphingosine-1 phosphate in the presence of Montanox 80 was stable and could be formulated without sonication. Epithelial apoptosis was detected only in Groups 2 and 3. Conclusion: Sphingosine-1 phosphate can prevent ethanol-induced apoptosis in the corneal epithelium of rabbits.

Complications après Descemet stripping automated endothelial keratoplasty : étude monocentrique sur 32 yeux

OBJECTIVE To report complications during and after Descemet stripping automated endothelial keratoplasty (DSAEK) in 32 eyes at a single academic center with two techniques for delivering the endothelial corneal graft. PATIENTS AND METHODS Outcomes from a single center of 32 consecutives cases of DSAEK were analyzed prospectively. In the first 23 patients, the endothelial graft underwent single-fold delivery with forceps, and in the remaining nine patients, the graft was delivered with the Busin glide-based technique. The complications of DSAEK were noted from the intra- and postoperative periods. RESULTS Graft detachment was the most common type of complication encountered. In seven of 32 eyes (22%), graft detachments were observed. Three of the 32 eyes (9.5%) were considered to have failed DSAEK, meaning that persistent edema was present after DSAEK. One of the 32 eyes had a late corneal decompensation. Three eyes (9.5%) demonstrated graft rejection. Four eyes with detached grafts were successfully rebubbled after surgery. Two of the 32 eyes (6.2%) underwent repeat DSAEK and three eyes (9.5%) underwent penetrating keratoplasty. CONCLUSIONS DSAEK is becoming the preferred method for treating endothelial dysfunction because it maintains the structural integrity of the eye and provides rapid visual recovery with minimal refractive change. However, we experienced some complications. Graft detachment is the most common complication, but postoperative rebubbling allows for graft reattachment in most cases. Other common complications found in this series were graft failure and graft rejection.