[Blue light and intraocular lenses (IOLs): Beliefs and realities]. / Lumière bleue et implants intraoculaires : croyances et réalités.

The first intraocular lenses (IOLs) used for cataract surgery transmitted both ultraviolet (UV) radiation and visible light to the retina. Colorless UV-blocking IOLs were introduced and rapidly adopted in the 1980s. Yellow-tinted blue-blocking (also known as blue-filtering) IOLs were marketed in the early 1990s. Blue-blocking IOLs were intended to simulate age-related crystalline lens yellowing to reduce the cyanopsia that some patients experienced after cataract surgery. When blue-filtering IOLs were introduced in North America, however, blue-blocking chromophores were advocated as a way to protect patients from age-related macular degeneration (AMD) despite the lack of evidence that normal environmental light exposure causes AMD. The "blue light hazard" is a term that describes the experimental finding that acute, abnormally intense light exposures are potentially more phototoxic to the retina when short rather than long wavelengths are used. Thus, in brief exposures to intense light sources such as welding arcs, ultraviolet radiation is more hazardous than blue light, which is more hazardous than longer wavelength green or red light. International commissions have cautioned that the blue light hazard does not apply to normal indoor or outdoor light exposures. Nonetheless, the hazard is used for commercial purposes to suggest misleadingly that ambient environmental light can cause acute retinal phototoxicity and increase the risk of AMD. Very large epidemiological studies show that blue-blocking IOLs do not reduce the risk or progression of AMD. Additionally, blue-filtering IOLs or spectacles cannot decrease glare disability, because they decrease image and glare illuminance in the same proportion. Blue light is essential for older adults' scotopic photoreception needed to reduce the risk of nighttime falling and related injuries. It is also critical for circadian photoreception that is essential for good health, sleep and cognitive performance. Unfortunately, age-related pupillary miosis, retinal rod and ganglion cell photoreceptor degeneration and decreased outdoor activity all reduce the amount of healthful blue light available to older adults. Blue-restricting IOLs further reduce the available blue light at a time when older adults need it most. Patients and ophthalmologists are exposed to hypothesis-based advertisements for blue-filtering optical devices that suppress short wavelength light critical for vision in dim lighting and for good physical and mental health. Spectacle and intraocular lens selections should be based on scientific fact, not conjecture. Ideal IOLs should improve photoreception rather than limit it permanently. Practice efficiency, surgical convenience and physician-manufacturer relationships may eliminate a patient's opportunity to choose between colorless blue-transmitting IOLs and yellow-tinted, blue-restricting IOLs. Cataract surgeons ultimately determine whether their patients have the opportunity to make an informed choice about their future photoreception.

[Subfoveal posterior ciliary arteries: Multimodal imaging and classification based on choroidal elevation]. / Artères ciliaires postérieures sous-maculaires : imagerie multimodale et classification basée sur l'importance du soulèvement choroïdien.

PURPOSE: To characterize the magnitude and consequences for interpretation of macular elevations associated with short posterior ciliary arteries (SPCA) extending to the fovea. METHODS: Retrospective study of 96 eyes of 138 patients who underwent multimodal imaging (color photographs, SD-OCT with OCT-angiography analysis, fluorescein angiography [FA] and indocyanine green angiography [ICG]) over a two-year period. The authors selected patients with a focal choroidal elevation (FCE) associated with a SPCA extending to the fovea. FCEs were classified according to their magnitude as "Low" (<50µm), "Medium" (50µm to 100µm) and "High" (>100µm). RESULTS: Ten patients aged 80.10±11.82 years had a FCE associated with a macular SPCA. The patients were followed for advanced AMD with neovascularization (2 cases), advanced AMD with geographic atrophy (3 cases), intermediate AMD (1 case) ; one patient was followed for diabetes ; three patients had no identified retinal pathology. The FCE associated with the SPCAs was Low (3 cases), Medium (2 cases), High (3 cases). In 2 cases, the FCE was limited to an unmeasurable choroidal fold. The interpretation associated with these FCEs was not always related to the magnitude of the elevation. CONCLUSION: Our observations show the value of multimodal imaging in the identification of SPCA extending to the fovea, sometimes associated with a macular FCE. In some cases, the signs associated with FCE interfered with the monitoring of the condition for which the patient was being followed. Identifying these FCEs and grading their amplitude is relevant, as they should not be confused with pathological structures.

[Epigenetics and myopia: Mechanisms and therapeutic targets]. / Épigénétique et myopie : mécanismes et perspectives thérapeutiques.

The development of myopia is influenced by multiple environmental and genetic factors. A third component, epigenetics, may shed light on some of the relationships between environmental and genetic factors. Epigenetics is defined as the study of modulations of gene activity that can be transmitted over cell divisions without involving mutation of the DNA sequence. Methylation is one of the main mechanisms by which gene expression is decreased. In the context of myopia, the study of epigenetic mechanisms also contributes to the understanding of the involvement of candidate genetic variants. The analysis of metabolic and signalling pathways associated with ocular development enables discussion of the biological significance associated with these candidate genes. A better understanding of epigenetic mechanisms would allow individual risk estimations for myopia and probably targeting of therapeutic interventions at a population level. Measuring the level of DNA methylation at candidate gene sites could be used to monitor the effectiveness of myopia prevention measures such as reducing near work and increasing outdoor activity. More specifically, one could consider activating the methylation of myopia promoter genes or, on the contrary, inhibiting the methylation of myopia repressor genes. Finally, the control of metabolic and signalling pathways could be considered by targeting, for example, the regulation of the G protein signalling pathway (RGS 2) with the expression of the adenosine A2a receptor (AdoRs).

[Toxoplasmosis and behavioural changes (French translation of the article)]. / Toxoplasmose et modifications du comportement humain.

Nearly one-third of the planet's population is affected by T. gondii infection. In ophthalmology, toxoplasmosis is even considered to be the most common cause of posterior uveitis of infectious origin. Humans are only an intermediate host, and T. gondii needs to infect cats for its sexual reproduction. All the elements increasing the risk of predation by the definitive host are then favourable to the parasite. Numerous experimental animal model studies have shown that T. gondii infection is associated with predatory risk behaviours such as an attraction of infected mice to cat urine. Infection with the parasite is associated with a demethylation of the promoters of certain genes in the cerebral amygdala of the intermediate hosts, modifying dopaminergic circuits associated with fear. Similarly, T. gondii has been linked to behavioural changes in humans. Toxoplasma infection is classically associated with the frequency of schizophrenia, suicide attempts or "road rage." A more recent study shows that toxoplasma infection prevalence was a consistent, positive predictor of entrepreneurial activity. Fear of failure would be less important in infected individuals, who are more willing than others to start their own business. These elements shed interesting light on behaviours and their possible relationship with toxoplasmosis, which is generally considered benign in adults.

Toxoplasmosis and behavioural changes.

Nearly one-third of the planet's population is affected by Toxoplasma gondii infection. In ophthalmology, toxoplasmosis is even considered to be the most common cause of posterior uveitis of infectious origin. Humans are only an intermediate host and T. gondii needs to infect cats for its sexual reproduction. All the elements increasing the risk of predation by the definitive host are then favourable to the parasite. Numerous experimental animal model studies have shown that T. gondii infection is associated with predatory risk behaviours such as an attraction of infected mice to cat urine. Infection with the parasite is associated with a demethylation of the promoters of certain genes in the cerebral amygdala of the intermediate hosts, modifying dopaminergic circuits associated with fear. Similarly, T. gondii has been linked to behavioural changes in humans. Toxoplasma infection is classically associated with the frequency of schizophrenia, suicide attempts or "road rage". A more recent study shows that toxoplasma infection prevalence was a consistent, positive predictor of entrepreneurial activity. Fear of failure would be less important in infected individuals, who are more willing than others to start their own business. These elements shed interesting light on behaviours and their possible relationship with toxoplasmosis, which is generally considered benign in adults.

Geographic Atrophy and micronutritional supplements: A complex relationship.

In 2019, the Age-Related Eye Disease Study (AREDS) remains the basis for micronutritional supplement guidelines aiming to slow the progression of Age-Related Macular Degeneration (AMD) and reduce the risk of neovascularization. However, for Geographic Atrophy (GA) patients specifically, there seem to be more arguments for prescribing micronutritional supplements for the prevention of neovascular complications than to slow the progression of the atrophy. The AREDS report 8 showed a significant decrease in AMD progression over a five-year follow-up associated with a formulation containing antioxidants and zinc. It is noteworthy that the protective effect that was demonstrated was mainly related to the risk of a neovascularization and that the AREDS did not really demonstrate a protective effect that would slow the progression of GA. The 2013 AREDS II results have led to a change in the AREDS formulation. Nevertheless, the replacement of beta-carotene by lutein and zeaxanthine and the addition of Omega-3 did not add any further evidence for a protective effect on GA. Furthermore, the AREDS study used color photographs rather than fundus autofluorescence or OCT to assess the presence or the evolution of patches of atrophy. Over the last 10 years, it has been shown that OCT is far more accurate than color photographs to measure the size of the atrophic areas and to evaluate the extent of alterations in the chorioretinal layers. While lack of evidence of a protective effect of the AREDS formulation for GA is not a proof of the absence of effect, many publications seem to have taken the results of the AREDS in such a global way that the lack of evidence concerning GA seems to have been ignored. Micronutrition supplements are well prescribed for AMD patients, and the key factor for adherence is explanation to the patient. So far, it appears worth explaining to GA patients that prescription of the AREDS formulation is mainly aimed at reducing the risk of neovascularization.

A common gesture with a rare but potentially severe complication: Re-expansion pulmonary edema following chest tube drainage.

BACKGROUND: Primary Spontaneous Pneumothorax (PSP) is usually considered as a benign pathology occurring in young people. In about half of cases, observation only is purposed. In case of intervention, chest tube drainage remains the preponderant strategy even if no studies conclude about superiority of drainage or aspiration. Re-expansion pulmonary edema (REPE) is a rare but potentially severe complication of chest tube drainage. Risk factors are not well identified, but REPE is more frequent for patients with diabetes, younger than 40 years, with large pneumothorax, lung collapse more than one week and fast re-expansion. CASE REPORT: We report a case of a 19-year old male presenting to the Emergency Department with a first episode of PSP. He was treated by chest tube drainage with immediate suction. He developed a REPE 3 hours after chest tube drainage with suction. Conservative management and oxygen therapy led to withdrawing the chest tube 9 days later. CONCLUSION: For the initial management of PSP, prevention of this complication is essential. In case of risk factors, prevention consist of absence of immediate suction after chest tube drainage and suction should be reserved in case of failure of initial treatment after 24 hours. Even if chest tube drainage is a common gesture, clinical presentation of REPE must alert physicians taking care of these patients.

How spontaneous pneumothorax is managed in emergency departments: a French multicentre descriptive study.

BACKGROUND: Management of spontaneous pneumothorax (SP) is still subject to debate. Although encouraging results of recent studies about outpatient management with chest drains fitted with a one-way valve, no data exist concerning application of this strategy in real life conditions. We assessed how SP are managed in Emergency departments (EDs), in particular the role of outpatient management, the types of interventions and the specialty of the physicians who perform these interventions. METHODS: From June 2009 to May 2013, all cases of spontaneous primary (PSP) and spontaneous secondary pneumothorax (SSP) from EDs of 14 hospitals in France were retrospectively included. First line treatment (observation, aspiration, thoracic drainage or surgery), type of management (admitted, discharged to home directly from the ED, outpatient management) and the specialty of the physicians were collected from the medical files of the ED. RESULTS: Among 1868 SP included, an outpatient management strategy was chosen in 179 PSP (10%) and 38 SSP (2%), mostly when no intervention was performed. Only 25 PSP (1%) were treated by aspiration and discharged to home after ED admission. Observation was the chosen strategy for 985 patients (53%). In 883 patients with an intervention (47%), it was performed by emergency physicians in 71% of cases and thoracic drainage was the most frequent choice (670 patients, 76%). CONCLUSIONS: Our study showed the low level of implementation of outpatient management for PS in France. Despite encouraging results of studies concerning outpatient management, chest tube drainage and hospitalization remain preponderant in the treatment of SP.

Epigenetics in Age-related Macular Degeneration (AMD).

Age-related Macular Degeneration (AMD) is a complex multifactorial condition involving multiple genetic, environmental and constitutional factors. Inflammation, oxidative stress and lipid metabolism seem to be the most important factors in the pathogenesis of the disease. The importance of genetic factors has mainly been revealed with the influence of histocompatibility complement factor H (CFH) variations and the ARSM2 susceptibility gene. Another component, epigenetics, could help to explain some of the relationships between environmental and genetic factors. Epigenetics is defined as the study of modulations of gene activity that can be transmitted over cell divisions without involving mutation of the DNA sequence. The molecules that are involved in these mechanisms are referred to as the epigenome. The mechanisms involve DNA methylation, histone modification, chromatin remodeling, and gene inhibition by non-coding RNA. Epigenetics could explain how the environment may induce relatively stable changes in traits or even diseases, possibly inheritable over several generations. Epigenetic traits established during development, and/or acquired under the influence of nutritional factors or other environmental factors, could influence the interactions between genes and the environment. Several authors have recently shown the influence of epigenetic factors in the pathogenesis of ocular diseases such as cataract, dry eye, glaucoma, diabetic retinopathy and more recently AMD. A better understanding of the involvement of genetic variants at risk, their relationship with epigenetics and environmental factors would certainly help to better assess the risk of developing AMD or better understand recent changes in the incidence of the disease.

[Epigenetics in age-related macular degeneration (AMD) - French translation of the article]. / Épigénétique et dégénérescence maculaire liée à l'âge (DMLA).

Age-related macular degeneration (AMD) is a complex multifactorial condition involving multiple genetic, environmental and constitutional factors. Inflammation, oxidative stress and lipid metabolism seem to be the most important factors in the pathogenesis of the disease. The importance of genetic factors has mainly been revealed with the influence of histocompatibility complement factor H (CFH) variations and the ARSM2 susceptibility gene. Another component, epigenetics, could help to explain some of the relationships between environmental and genetic factors. Epigenetics is defined as the study of modulations of gene activity that can be transmitted over cell divisions without involving mutation of the DNA sequence. The molecules that are involved in these mechanisms are referred to as the epigenome. The mechanisms involve DNA methylation, histone modification, chromatin remodeling, and gene inhibition by non-coding RNA. Epigenetics could explain how the environment may induce relatively stable changes in traits or even diseases, possibly inheritable over several generations. Epigenetic traits established during development, and/or acquired under the influence of nutritional factors or other environmental factors, could influence the interactions between genes and the environment. Several authors have recently shown the influence of epigenetic factors in the pathogenesis of ocular diseases such as cataract, dry eye, glaucoma, diabetic retinopathy and more recently AMD. A better understanding of the involvement of genetic variants at risk, their relationship with epigenetics and environmental factors would certainly help to better assess the risk of developing AMD or better understand recent changes in the incidence of the disease.

[A "fast track" to improve management of neovascular age related macular degeneration]. / Un « circuit court ¼ pour améliorer la prise en charge des patients atteints de dégénérescence maculaire liée à l'âge néovasculaire.

OBJECTIVE: To evaluate the role of a fast track for management of patients with neovascular age- related macular degeneration (nARMD) treated by intravitreal injection of anti-VEGF. PATIENTS: The records of 100 patients in the chronic maintenance phase of intravitreal anti-VEGF followed in the fast track and 63 patients followed in the standard protocol for at least 12 months were retrospectively analyzed. METHOD: Patients in the fast track underwent visual acuity (VA) testing by ETDRS, optical coherence tomography (OCT) and a physician assessment. The injection was performed the same day whenever possible. The primary endpoint to evaluate patient adherence was the time between the ideal date of visit or injection prescribed by the physician and the actual date of administration. RESULTS: The mean time between the ideal date of visit or injection prescribed by the physician and the actual date of administration was 4.1±7.5 days for the patients followed in the fast track and 5.6±18.7 days for the patients followed in the standard protocol. Mean VA remained stable for the patients followed in the fast track: 20/50 (20/800 to 20/20) at baseline vs. 20/50 (20/800 to 20/16) at the conclusion of follow-up. It dropped from 40/50 at baseline to 20/63 at the conclusion of follow-up for the patients followed in the standard protocol. CONCLUSION: In the context of a fast track, it was possible to improve the adherence of nARMD patients and maintain their VA gain or stabilization achieved after the induction phase.

Primary Spontaneous Pneumothorax Admitted in Emergency Unit: Does First Episode Differ from Recurrence? A Cross-Sectional Study.

Introduction. Management of primary spontaneous pneumothorax (PSP) consists of immediate resolution of pleural air, or observation, and prevention of recurrence. The risk factors for recurrence remain debated. Objectives. We aimed to describe and compare the characteristics of patients presenting a first episode of PSP to those of patients presenting a recurrent PSP, in order to identify factors potentially related to recurrence. Methods. We conducted a cross-sectional study including all admissions for PSP in the EDs of fourteen French public hospitals from 2009 to 2013. PSP were classified as a first episode if the patient had no previous history of pneumothorax and as recurrence if a previous episode of spontaneous pneumothorax was documented in the patient's medical records or if a recurrence was identified during the inclusion period. To identify factors potentially associated with recurrence of PSP, multilevel logistic models were fitted. Results. During the study period, 918 (61,6%) first episodes and 573 (38,4%) episodes of recurrent PSP were identified. Clinical presentation, age, gender, smoking habits, and use of cannabis were similar in both groups. No clinical factor associated with recurrence was identified by multivariate analysis. Conclusion. In this large multicenter study, no clinical factor associated with recurrence was highlighted.

[Not Available]. / Épidémiologie descriptive de la brûlure dans un territoire de santé exemple du « territoire nord franche-comté ¼ durant l'année 2014.

This is an epidemiologic study of the need for Health Services for burns in the northern part of Franche Comté (north-east of France) along year 2014 (114 patients). Mean age was 26 years (8 month-81 years), one third of burns occurred in children below 15. Most burns take part in summer, around mealtime, in "school-free" days, at home and are scalds. Their surface is low (4,81%) and they are usually partial thickness ones. Patients are consulted in Emergency Department in 88,59% of the cases, and hospitalised thereafter in a Burns Unit (in Lyon more than Nancy or Metz) in 12,28%.

[Current uses and indications for indocyanine green angiography]. / Intérêt et indications actuelles de l'angiographie au vert d'indocyanine (ICG).

A full interpretation of indocyanine green angiography images involves not only optical issues but also pharmacokinetic and biochemical aspects. These issues may involve biochemical changes in the fluorescence yield and the affinity of the molecule for lipoproteins and phospholipids. For age related macular degeneration (AMD), the advent of photodynamic therapy and especially anti-VEGF drugs has increased the use of OCT in assessing treatment response and guiding retreatment. The ease and advantages of OCT have become increasingly associated with a decreasing interest in ICG angiography, which is becoming less well suited for the current management of AMD. An aging population, the efficacy of anti-VEGF drugs and the relative rarity of polypoidal choroidal vasculopathy (PCV) in Europe are factors contributing to our proportional increase in AMD patients. However, aside from AMD, the indications for ICG angiography remain little changed over the last decade: it remains important in diagnosing PCV and choroidal hemangiomas, since their prognosis and treatment are specific. Similarly, for certain inflammatory conditions such as Multiple Evanescent White Dot Syndrome (MEWDS) or Birdshot chorioretinitis, the value of ICG angiography remains significant. In addition, for the treatment of chronic Central Serous Chorioretinopathy, ICG angiography helps to find sites of leakage which otherwise might have been missed. The ICG angiographic appearance in this setting may also have prognostic value. Although the indications for ICG angiography are currently decreasing for AMD, these other conditions represent a large enough number of patients to justify the continued use of this original test, which remains complementary to other chorioretinal imaging techniques.

[Comparison of simple aspiration versus standard drainage in the treatment of large primary spontaneous pneumothorax]. / Comparaison de l'efficacité d'une exsufflation simple par rapport au drainage thoracique dans le traitement du pneumothorax spontané complet. Étude EXPRED: EXsufflation d'un PREmier pneumothorax versus Drainage.

BACKGROUND: Chest tube drainage is the standard treatment of a large spontaneous pneumothorax. Aspiration is an alternative technique that is simple and rapid to learn, and the success rate seems identical to chest tube drainage. Its widespread use justifies studies to define its place in the management strategy of spontaneous pneumothorax. METHODS: We propose a multicentre, prospective, randomized, open trial with two parallel groups. The main objective is to compare the therapeutic efficacy of a simple aspiration with chest tube drainage for a first large spontaneous pneumothorax. The hypothesis is that aspiration is not inferior to a chest drain in its immediate effect. The secondary objectives are to compare the therapeutic efficacy at 24h and at one-week, the relapse rate at one year, and the tolerance and complications. A comparison of both the medical and economic aspects will be made. With an α-risk of 0.05 and a ß-risk of 0.10, a proportion of failures of 30% expected in both groups and a target of non-inferiority of δ=0.15, the number of subjects to be included is 200 per group, totalling 400 in all. EXPECTED RESULTS: In the case of equivalence, this study should help to better define the place of aspiration compared to chest tube drainage in the management of spontaneous pneumothorax.

[Nutrition and age-related macular degeneration]. / Nutrition et dégénérescence maculaire liée à l'âge.

Age-related macular degeneration is a growing burden disease with a high prevalence in elderly: it is the first cause of blindness in developped countries. It is a multifactorial disease with genetic factors and nutritional factors. Carotenoids, lutein and zeaxanthin are components of macular pigment and they have a filter role for blue light and an antioxidant role. Other nutritional factors might play a role as antioxidants: zinc, selenium, vitamin E, vitamin C… which lead to the ARED Study. It is the only one study with proven positive effects on the disease progression (stages 3 and 4). A high glycemic index increases oxidative stress. Long chain omega-3 polyunsaturated fatty acids have a protective effect. Available data are presented and discussed. These are new preventive issues.