Pierre-Yves Robert

Intracameral cefuroxime injection at the end of cataract surgery to reduce the incidence of endophthalmitis: French study

PURPOSE: To determine whether an intracameral injection of cefuroxime at the end of cataract surgery decreases the incidence of postoperative endophthalmitis. SETTING: Dupuytren Hospital, Ophthalmology Department, Limoges, France. DESIGN: Clinical trials. METHODS: Patients having cataract surgery between April 2003 and June 2008 were included in a survey of operative‐site infection. Intracameral cefuroxime injections started in June 2006. Preoperative data (beta‐lactam allergy, a history of endophthalmitis, age, sex), intraoperative data (use of trypan blue, use of capsular ring or iris retractors, surgical time, senior or junior surgeon, corticosteroid injection, iris retractors), and the incidence of postoperative infections at 8 days and 1 month were prospectively collected. RESULTS: During the inclusion period, 5115 patients had cataract surgery; 2289 received cefuroxime and 2826 did not. The incidence of endophthalmitis was 35 (1.238%) of 2826 patients without intracameral cefuroxime and 1 (0.044%) of 2289 patients with intracameral cefuroxime; the difference was statistically significant (P<.0001). No intraoperative factor was significantly associated with postoperative infection. No allergic reaction was reported. CONCLUSION: Intracameral cefuroxime injection at the end of cataract surgery was safe and significantly decreased the incidence of endophthalmitis. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Comparative Review of Topical Ophthalmic Antibacterial Preparations

The choice of an antibacterial is based on considerations of pharmacodynamic, pharmacokinetic and bacteriological characteristics, risk of selecting resistant mutants, and cost. In this article we review 16 commercially available ophthalmic antibacterial preparations.Fusidic acid and bacitracin are selective for Gram-positive bacteria whereas polymyxin B targets Gram-negative species. Aminoglycosides and quinolones are broad spectrum antibacterials. The widespread use of an antibacterial increases risks of selecting resistance to it. Acquired resistance is well documented for fusidic acid and rifamycin, and newly described for quinolones.The bioavailability of an antibacterial agent depends on the target bacterial species, the site of infection and the integrity of the haemato-aqueous barrier. Some agents (fusidic acid, quinolones) penetrate the cornea, passing into the anterior chamber of normal eyes at therapeutic concentrations, whereas others (polymixin B, bacitracin) have no penetrating powers and remain at the surface of the eye.Toxicity is mostly manifested by allergic reactions to excipients or active ingredients in topical antibacterial preparations. A few cases of haematological toxicity have brought suspicion on topical chloramphenicol, but the link has yet to be proven. Erythromycin and polymyxin B are probably okay to use as topical applications in pregnant women and nursing mothers.Costs of treatment must be evaluated as a whole (regimen, drug associations). Prices for a bottle of eyedrops may vary 3-fold. The cheapest drugs include chloramphenicol, polymyxin B and gentamicin, the most expensive being fusidic acid and the quinolones.

Treatment of ocular cicatricial pemphigoid with the tumour necrosis factor alpha antagonist etanercept.

Sir, Cicatricial pemphigoid (CP) is a rare autoimmune subepithelial blistering disease that predominantly affects the mucous membranes with scarring (1). The disease is characterized by the involvement of muco-cutaneous sites, among them ocular invo-lvement, which can lead to blindness. Mild forms of the disease may be controlled by anti-inflammatory drugs, such as dapsone, whereas severe forms, and particularly ocular involvement, usually require the use of immunosuppressive therapies (2). As tumour necrosis factor (TNF)-α plays a role in the fibrosing process, its targeting strategies are promising in the management of ocular CP. Here we report a case of ocular CP treated successfully with the TNF-α antagonist etanercept.

Decrease of intraocular pressure after fat-removal orbital decompression in Graves disease.

Purpose: To address the efficacy of fat-removal orbital decompression to reduce intraocular pressure in patients with Graves disease. Methods: This cohort study included 64 eyes of 39 patients with Graves disease. Thirteen men and 36 women, with a mean age of 52.5 years (range, 27 to 80 years), underwent fat-removal orbital decompression. Intraocular pressure (applanation) and proptosis (Hertel exophthalmometry) were prospectively investigated before surgery and 1 week and 6 months after surgery. Results: The volume of resected fat was 6.4 ± 4.5 (3 to 12) ml. The intraocular pressure in primary position decreased from 19.3 ± 4.4 mm Hg to 17.0 ± 2.9 mm Hg at 1 week (p < 0.001) and 15.9 ± 3.7 mm Hg at 6 months (p < 0.001). Mean proptosis dropped from 24.3 ± 2.5 mm before surgery to 19.9 ± 3.0 mm at 1 week (p < 0.01), and 19.9 ± 3.1 mm at 6 months (p < 0.01). Intraocular pressure decrease neither correlated to the volume of resected fat nor to proptosis reduction. Conclusions: Fat removal reduces intraocular pressure in patients with Graves disease, with no correlation to the volume of resected fat.

Assessment of blepharospasm surgery using an improved disability scale: study of 138 patients.

Purpose: To assess a new scale for grading functional disability in a series of patients operated on for blepharospasm resistant to treatment by botulinum toxin (BT) injections. Methods: The bicentric study included 138 patients: 80 (58%) with essential blepharospasm; 46 (33%) with apraxia of eyelid opening; and 12 (9%) with intermediate forms. They had undergone orbicularis myectomy (92 cases, 67%), frontalis suspension (31 cases, 22%), or both (15 cases, 11%). Functional disability was assessed by using an original scale covering 6 daily life activities, each graded using 5 levels from 0 (no disability) to 4 (activity impossible). The score obtained was related to the total of activities actually performed to produce a functional disability score (FDS) from 0 to 100. Each patient’s FDS was prospectively determined, before surgery and 3 months after surgery (M3). In patients who, after surgery, required a further course of BT injections, the FDS was assessed immediately before the third injection. Results: The mean FDS fell significantly, from 78 ± 15 (standard deviation) before surgery to 45 ± 21 at M3 (p < 0.01%), whatever the clinical form of essential blepharospasm or surgical procedure. The mean postoperative FDS was significantly lower in the 62 patients (45%) weaned off BT than in the unweaned group, respectively (31 ± 17 versus 56 ± 18; p < 0.01). In the latter group, the mean FDS after BT reinjection (34 ± 19) fell to a level comparable with that of the weaned patients. Conclusions: This accurate, easy-to-use scale makes it possible to quantify in patients with blepharospasm functional improvement as the result of surgery and, where applicable, of BT reinjection.

Internal and external contamination of donor corneas before in situ excision: bacterial risk factors in 93 donors

Abstract. Background: Most studies of corneal donor contamination concentrate on postenucleation contamination of the eyeball. The purpose of the present study was to evaluate the relative contamination of in situ excised corneal tissue and relevance to final success or rejection by recipients of the corneal grafts. Methods: Ninety-three donors underwent anterior chamber puncture (ACP) and corneal epithelium scarification (CS) before and after disinfection with 5% povidone-iodine. Following in situ excision, corneas were preserved in culture medium at +35°C. Morphological and bacteriological assessment was carried out after culture, and recipients were followed up over a 2-year period. Results: Samples taken by ACP, CS before disinfection, CS after disinfection and a culture medium sample were contaminated by bacteria in, respectively, 8 (8.6%), 23 (24.7%) 4 (4.3%) and 5 (5.4%) donors. Contamination of aqueous humor was significantly associated with age, death-to-sample time and premortem systemic infection. Contamination of epithelium significantly increased culture medium contamination. Conclusion: External bacteria on donor cornea are mainly skin bacteria (especially Staphylococcus) and can be partially eliminated by a povidone-iodine wash. Internal bacteria are mainly gut bacteria and may be due to perimortem bacteriemia. However, bacterial infection at the time of death appears to have no effect on the incidence of endophthalmitis in recipients and should no longer prevent use of such corneal tissue in grafts.

Specific antibody production in herpes keratitis: intraocular inflammation and corneal neovascularisation as predicting factors.

PurposeThe purpose of the study is to investigate whether analysis of specific antibody synthesis can aid the diagnosis of herpes keratitis.MethodsAqueous humor was collected from 39 patients with presumed recurrent herpes keratitis, including 23 consulting for keratitis and 16 patients scheduled for penetrating keratoplasty. Local antibody production was ascertained by analysis of paired aqueous humor/serum samples, using a modified micro-ELISA technique.ResultsLocal production of antibodies was found in 32 patients (82%): anti-herpes simplex virus (HSV) antibodies in 26 (67%) and anti-varicella zoster virus (VZV) antibodies in 11 (28%). Twenty of 23 patients with active keratitis (87%), and 12 of 16 undergoing keratoplasty (75%), tested positive. Five patients had local production of both anti-HSV and anti-VZV antibodies, whereas seven patients tested negative. Local antibody production was significantly associated with intraocular inflammation (P<0.05), corneal neovascularisation (P<0.05), and positive response to anti-viral treatment (P<0.05). No complications were encountered in sampling aqueous humor.ConclusionsAssessment of local anti-HSV and -VZV antibody production is a safe and reliable diagnostic procedure for recurrent herpes keratitis. It might be particularly helpful in patients presenting with intraocular inflammation and neovascularisation since it discriminates between herpes and non-herpes pathologies and may therefore be useful for preventive and therapeutic strategies.

Intravitreal Ranibizumab and Bevacizumab in Combination with Full-Fluence Verteporfin Therapy and Dexamethasone for Exudative Age-Related Macular Degeneration

Purpose: To evaluate the efficacy and safety of triple therapy with intravitreal anti-vascular-endothelial-growth-factor (VEGF) antibody, dexamethasone and verteporfin photodynamic therapy (PDT) for exudative age-related macular degeneration (AMD). Methods: Retrospective, comparative, interventional study. Records of treatment-naïve patients who received intravitreal bevacizumab or ranibizumab in monotherapy or in combination with dexamethasone and full-fluence verteporfin PDT in triple therapy were reviewed. logMAR visual acuity, foveal thickness (FT) on optical coherence tomography, intraocular pressure and endophthalmitis occurrence were recorded. Results: Sixty-one eyes were included in the triple-therapy group, 40 eyes were included in the monotherapy group. The mean follow-up was 14.1 ± 3.4 months in the triple-therapy group and 16.3 ± 4.1 months in the monotherapy group. The triple-therapy group enjoyed a lower total number of treatments (1.92 ± 0.44 vs. 3.12 ± 0.37, p < 0.001) and a longer time before first retreatment (5.4 ± 3.3 vs. 3.6 ± 2.5 months, p = 0.001). A significant improvement of visual acuity and FT was present in both groups during the 12 months following first treatment. No adverse effects were observed. Conclusion: The combination of intravitreal bevacizumab or ranibizumabwith dexamethasone and full-fluence PDT for exudative AMD provided visual and anatomic improvement and a good safety profile. Triple therapy may reduce the number of retreatments when compared to anti-VEGF alone.

Effects of Subconjunctival Bevacizumab on Corneal Neovascularization : Results of a Prospective Study

Purpose: To evaluate the effect of subconjunctival bevacizumab injections in patients with corneal neovascularization resulting from different ocular surface disorders. Methods: Prospective case series. Twelve eyes of 11 patients with corneal neovascularization caused by different ocular surface disorders, such as healed corneal ulcers, long-standing chronic inflammatory diseases, and corneal ischemia secondary to burn, were included. All eyes received a single subconjunctival injection of 2.5 mg (0.1 mL) of bevacizumab. Morphological changes in neovascularization were evaluated during 3 months using slit-lamp biomicroscopy, corneal digital photography, and computer-assisted semiautomatic analysis of corneal neovascularization area. Results: Recession of corneal vessels was observed in all eyes at 1 week postinjection. The surface of the neovascular tree continued to decrease noticeably for 1 month and then increased again for the remainder of the follow-up period. The corneal neovascularization area amounted to 11.25 ± 4.49% of the corneal surface preinjection, compared with 8.44 ± 3.37% postinjection (P = 0.02), reflecting a mean decrease in corneal neovascularization of 25%. No local or systemic adverse events possibly related to subconjunctival bevacizumab injection were observed. Conclusions: Short-term results suggest that subconjunctival bevacizumab can be used safely and effectively for corneal neovascularization resulting from different ocular surface disorders, providing an additional strategy to improve success of corneal grafts.

Extraocular Muscle Involvement in Marginal Zone B-Cell Lymphomas of the Orbit

Introduction: Marginal zone B-cell lymphoma is the most frequent ocular adnexal lymphoma. It may involve the conjunctiva, lacrimal gland, eyelid, extraocular muscle, and orbital connective tissue. Extraocular muscle infiltration is rare. Methods: We report here a series of 5 patients presenting with extraocular muscle infiltration due to marginal zone B-cell lymphoma, extracted from a retrospective study of 39 patients with primitive ocular adnexal marginal zone B-cell lymphoma presenting within a 15-year period, from 1993 to 2007, at two university hospitals. Results: Out of 39 patients, two females and three males presented with extraocular muscle involvement (one levator muscle, one medial rectus muscle, one lateral rectus muscle, one inferior rectus muscle, and one inferior oblique muscle). In 4 cases, the right eye was involved. The median age of presentation was 60 years. Proptosis and diplopia were the main clinical signs. A mean duration of symptoms was 12 months before diagnosis was given. Three patients were stage IE at the diagnosis, according to Ann Arbor classification, and one was at stage IV. Three patients received radiotherapy and two received chemotherapy. Three patients underwent local relapses at a median time of 40 months. The patients with relapses were treated with chemotherapy alone in one case, radiotherapy alone in one case, and immunotherapy and chemotherapy in one case. The mean follow-up period was 54 months. Discussion: When compared to other locations of marginal zone B-cell lymphomas of the orbit, extraocular involvement occurred in younger patients and had similar prognosis. Conclusion: Extraocular muscle involvement is a rare location of marginal zone B-cell lymphoma that had to be known and can simulate thyroid orbitopathy.