[Ocular tuberculosis]. / Tuberculose oculaire.

Despite extensive investigations, including the use of Interferon-gamma release assays (IGRA), the diagnosis of intraocular tuberculosis (TB) remains challenging. Ocular evidence of Mycobacterium tuberculosis in low endemic countries for TB is extremely rare, leading mostly to a TB-related ocular inflammation presumptive diagnosis. This present work aims: to highlights the main clinical patterns suggestive of ocular TB; and the latest recommended guidelines for diagnosing ocular TB to clarify interferon-gamma release assay (IGRA) contribution and accuracy to the management of intraocular TB and its diagnosis, in addition to other available diagnostic tools, such as tuberculin skin test, bacteriologic and histologic analysis from intra/extra ocular sample and radiographic investigations; to define the accuracy of these diagnostic tools according to the endemic TB prevalence; and finally to identify therapeutic strategies adapted to the main clinical presentations of ocular TB. Our review of the literature shows that management of suspected ocular TB differs significantly based on whether patients are from high or low TB prevalence countries since accuracy of chest X-ray, tuberculin skin test and IGRA is significantly different. Taking into account these discrepancies, distinct guidelines should be determined for managing patients with suspected ocular TB, taking into consideration home prevalence of TB-patients.

[Ocular manifestations in Behçet's disease]. / Les manifestations oculaires de la maladie de Behçet.

Ocular disease in Behçet's disease is frequent and may be associated with a poor functional prognosis. Uveitis is the most common ocular manifestation in Behçet's disease and represents a diagnostic criterion of the disease. The ocular involvement is inaugural of the disease in 20% of the cases or may develop 2 to 3 years after the beginning of the extraocular signs. The risk of blindness at 5 years is in the order of 15 to 25%, mainly due to macular involvement or retinal vasculitis. Uveitis may be anterior, intermediate, posterior or panuveitis. Anterior uveitis is rarely isolated and is frequently accompanied by posterior involvement. Anterior uveitis is always non granulomatous, sometimes associated with hypopion. Posterior involvement may include the presence of hyalitis, retinal vasculitis, mainly venous and often occlusive, macular edema, and/or foci of necrotizing retinitis. Behçet's disease is a chronic disorder, characterized by a relapsing and remitting course. Male patients with younger age at onset and severe lesions at presentation are at higher risk of severe visual loss over time. The main goals in the management of patients with Behçet's disease-associated uveitis are rapid suppression of intraocular inflammation, preservation of vision, and prevention of recurrences. The treatment is based on the use of systemic glucocorticosteroids and immunosuppressive agents. Posterior segment involvement requires the use of corticosteroids and immunosuppressants, primarily azathioprine. This treatment does not appear to be sufficient for severe uveitis with reduced visual acuity or retinal vasculitis that requires anti-TNF α or interferon α. Therapeutic strategies such as TNF-alpha blockers have dramatically improved the visual prognosis of patients with intraocular inflammation related to this chronic and potentially blinding condition.

[Management of orbital inflammation in internal medicine. Proposal for a diagnostic work-up]. / Orbitopathies inflammatoires. Que doit savoir l'interniste ?

Inflammatory orbitopathies relate to an inflammatory state originating within the orbit and its adnexes, except the inner ocular globe. Orbital inflammation (OI) may be either localized manifestation of a proven or like autoimmune disease, or local response from immune system against infectious, structural or tumoral antigens. We review the clinical manifestations of OI, which provide helpful clues to the diagnosis and describe the inflammatory, infectious and neoplastic conditions classically associated with OI. Autoimmune diseases are probably the most common causes of OI associated with a bilateral dacryoadenitis (e.g., sarcoidosis, granulomatosis with polyangiitis, IgG4-related disease). We focused on a major part of the IgG4-RD spectrum, the IgG4-related orbital disease which has been recently described and the idiopathic orbital inflammation syndrome that one should consider in patients 40 years of age or older with non specific inflammation OI on biopsy but without underlying local or systemic disease. An algorithm for the diagnostic approach of OI was proposed. If systemic explorations fail to diagnose an underlying disease, histopathologic control is required for distinguishing non-specific OI from other differential diagnosis, especially lymphoma. In the cases of pure myositic locations and posteriorly located tumours where biopsy could damage to the optic nerve, analysis of orbital lesions in T2W IRM sequence may be helpful to distinguish idiopathic OI (IOI) from lymphoma. When the diagnostic work-up fails, a corticosteroid trial could be used, but its beneficial effect has to be cautiously interpretated before definitively diagnosing IOI. Finally, treatments used in main infllammatory orbitopathies were also reviewed.

[Management of uveomeningitis in internal medicine: Proposal for a diagnostic work-up]. / Prise en charge diagnostique des uvéoméningites en médecine interne.

Uveomeningitis relates to an inflammatory state extending from iris and ciliary bodies to the choroid behind the eye. Because of a close contact between eye and brain, and barrier disruption, the inflammation can spread into the central nervous system (CNS). We review the clinical manifestations of uveitis, which are known to provide helpful clues to the diagnosis and describe the infectious, inflammatory, and neoplastic conditions classically associated with the uveomeningitis. Inflammatory or auto-immune diseases are probably the most common clinically recognized causes of uveomeningitis associated with a significant pleiocytosis. These entities often cause inflammation of various tissues in the body, including ocular structures and the meninges (i.e., sarcoidosis, Behçet's disease, and Vogt-Koyanagi-Harada syndrome). The association of an infectious uveitis with an acute or a chronic meningo-encephalitis is unusual but occasionally the eye examination may suggest an infectious etiology or even a specific organism responsible for an uveomeningitis. One should consider the diagnosis of primary ocular-CNS lymphoma in patients of 40 years of age or older with bilateral uveitis, especially with prominent vitritis, showing poor response to corticosteroid therapy. Finally, an algorithm for the diagnostic approach of uveomeningitis is proposed.

[Bilateral sequential central retinal vein occlusion associated with primary antiphospholipid syndrome]. / Bilatéralisation à distance d'une occlusion de la veine centrale de la rétine associée à un syndrome des anti-phospholipides primaire.

PURPOSE: Case report of a young female patient presenting with bilateral sequential central retinal vein occlusion associated with primary antiphospholipid syndrome (APS), which rapidly improved with systemic anticoagulation. CASE REPORT: A complete ophthalmologic examination and hematological evaluation were performed on an 18-year-old female patient presenting with unilateral decreased visual acuity in the left eye, secondary to a central retinal vein occlusion. Three years later, she experienced a central retinal vein occlusion of the right eye. Hematologic evaluation revealed primary antiphospholipid syndrome. The patient was treated with systemic anticoagulation. RESULTS: One month after the diagnosis and treatment of the central retinal vein occlusion in the left eye, the patient discontinued anticoagulant therapy, unfortunately resulting in severe visual loss. Three years later, upon recurrence in the fellow eye, systemic anticoagulation was reinstituted. Over 12 months follow-up, upon complete ophthalmologic examination, the patient showed normalization of all retinal signs. CONCLUSION: In the case of young patients with bilateral central retinal vein occlusions, hematologic evaluation should be performed so as to detect APS. Prompt, effective treatment is necessary to prevent further retinal damage. Recurrent thrombotic events may jeopardize anatomic and functional prognosis.

Azathioprine in severe uveitis of Behçet's disease.

OBJECTIVE: To investigate the efficacy and tolerance of azathioprine in severe uveitis related to Behçet's disease (BD). METHODS: We reported 157 consecutive patients with severe uveitis (active posterior uveitis or panuveitis) fulfilling the international criteria for BD and treated with corticosteroids (0.5-1 mg/kg/day) and azathioprine (2.5 mg/kg/day). Long-term outcome and factors associated with complete remission were assessed. RESULTS: Mean±SD age at diagnosis was 29.9±10.1 years, with 71.3% men. At baseline, 59 patients (37.6%) had loss of useful vision, 54 (34.4%) had retinal vasculitis, 66 (42.0%) had panuveitis, and 132 (84.1%) had bilateral uveitis. Following azathioprine therapy, 81 patients (51.6%) were complete responders, 65 (41.4%) were partial responders, and 11 (7%) were nonresponders. The visual acuity significantly improved (P<0.001), and a significant decrease in the mean oral prednisone dosage (55.3 to 10.5 mg/day; P<0.001) was observed after therapy. Patients with retinal vasculitis (odds ratio [OR] 0.45 [95% confidence interval (95% CI) 0.2-0.9], P=0.02) and severe visual loss (OR 0.28 [95% CI 0.2-0.7], P<0.0001) at diagnosis were less likely to be complete responders. Azathioprine was well tolerated, with only 3 withdrawals due to hepatotoxic effects (n=2) and bacterial septicemia (n=1). CONCLUSION: Azathioprine represents an effective and safe therapy in patients with severe uveitis of BD.

[Ocular manifestations of Behçet's disease]. / Manifestations oculaires de la maladie de Behçet.

Eye involvement in Behçet's disease (BD) is frequent and an important cause of morbidity. The mean age at onset of uveitis is between 20 and 30 years in male and 30 years in female patients. Ocular involvement includes anterior, posterior or panuveitis. Uveitis may be the presenting manifestation of the disease in 20% of cases or may appear 2 or 3 years after the disease onset. The estimated risk of blindness at 5 years ranges from 15 to 25%. The main goals in the management of patients with BD uveitis are the rapid control of intraocular inflammation, the prevention of recurrent attacks, the achievement of complete remission, and preservation of vision. The medical treatment of patients with severe uveitis relies on the use of systemically administered drugs, including corticosteroids and cytotoxic agents. Anti-TNF agents and interferon-alpha seem to be efficient and well-tolerated alternative therapeutic options. Controlled clinical trials are mandatory to define the place of these new immunomodulatory agents in the therapeutic strategy, and especially their use as first-line therapy.

[Neoretinal antigen expression: a comparison of anatomical and clinical features of a murine uveoretinitis model]. / Expressions oculaires d'un néoantigène rétinien: confrontation anatomoclinique dans un nouveau modèle murin d'uvéorétinite.

PURPOSE: Uveitis is an inflammation involving the retina. The antigens targeted by the experimental models are located in the pigmentary epithelium-photoreceptor complex. To gain insights into the variations in topographic expression of the antigen in the retina, we studied a new mouse model. MATERIAL: and methods: Stable retinal expression of the influenza virus hemagglutinin (HA) was obtained after intravitreal or subretinal injection of recombinant adeno-associated virus carrying HA (AAV-HA). One month later, we transferred HA-specific T cells, followed by a subcutaneous immunization of the cognate antigen emulsified in CFA. The animals were clinically examined with a slit lamp biomicroscope. Infiltration of donor cells was detected by immunostaining on retina flatmounts with anti-Thy-1.1 antibody, and infiltrating cells were studied using FACS analysis. RESULTS: Whatever the location of the HA expression, intraocular inflammation was clinically and histologically detected in all animals, between 10 and 15 days after immunization with HA. Lesions were identified with histopathological analysis. The ocular infiltrate was mostly composed of macrophages and HA-specific T cells in different proportions. CONCLUSIONS: The topographic variations of targeted ocular antigens do not seem to modify the development of inflammatory reactions in our model. By targeting different antigen-presenting cells, ocular infiltrating cells are different.

[Multiple evanescent white dot syndrome and acute idiopathic blind spot enlargement: angiographic and electrophysiologic findings]. / Syndrome des taches blanches évanescentes et syndrome d'élargissement de la tache aveugle, confrontation électrophysiologique et angiographique.

Multiple white evanescent white dot syndrome (MEWDS) and acute idiopathic blind spot syndrome enlargement (AIBSE) are two acute retinopathies occurring in young patients: improvement is the rule. The present review describes two cases: one case of MEWDS and one of AIBSE. We observed these patients from the acute phase until absolute recovery. Comparing these two reports, we noted differences in ophthalmoscopic, fluorescein angiographics, and multifocal electroretinographic (mERG) analysis, but common findings were observed in clinical presentation and indocyanine green imagery. The first and recent description of these two disorders dates from less than 25 years ago. Although the pathophysiology is still unknown, some authors suggest that these two syndromes could be two different expressions of the same disease, depending on the patient's sensitivity. In our two case reports, multifocal ERG anomalies were directly related to visual impairment and visual field alterations. MEWDS and AIBSE are two acute retinopathies that must be recognized, because of the spontaneous visual recovery that the patient needs to understand for a good follow-up.

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.

[Results of fine needle aspiration biopsy, frozen section diagnosis and definite histological results in thyroid pathology. Report of 163 cases]. / Analyse des résultats de la cytoponction, de l'examen histologique extemporané et définitif dans le traitement chirurgical de la pathologie thyroïdienne: à propos de 163 cas.

INTRODUCTION: In thyroid diseases, the place of fine needle aspiration biopsy still continues to be discussed: the sensibility and specificity vary greatly in the literature. Frozen section diagnosis is necessary to form a diagnostic strategy. The objective of this study was compare the results of fine needle aspiration biopsy, frozen section diagnosis, and definitive histologic results in a population of 163 patients and to draw conclusions about treatment. MATERIAL AND METHOD: From 1994 to 1999, 163 patients (132 females and, 31 males) undergoing thyroid surgery were included in this retrospective study, after a standard preoperative work-up. Those with a single palpable nodule and hypofixation on scintigraphy underwent fine needle aspiration before surgery. These results were compared with the definitive histologic results. RESULTS: A loboisthmectomy was performed in 88 cases (54%), a subtotal thyroidectomy in 34 cases (21%), and a total thyrodectomy in 41 cases (25%). In the latter group, an associated neck dissection was performed in 18 cases (11%); a frozen section diagnosis was obtained in all cases of thyroid nodules. This study demonstrated a single nodule in 97 cases (60%), multiple nodules in 27 cases (17%), multinodular goitre in 34 cases (21%), and 5 Basedow diseases (3%). Sixty-two cases (38%) of thyroid nodules underwent fine needle aspiration before surgery. In 25 cases (15%), definitive pathology showed a malignant lesion. The frozen section diagnosis had a sensitivity of 73% and a specificity of 99%, and the fine needle aspiration biopsy had a sensitivity of 40% and a specificity of 100%. CONCLUSION: The authors propose fine needle aspiration biopsy in the following cases: a single palpable nodule and hypofixation on scintigraphy or a surgical contra indication; and direct surgery in symptomatic thyroid disease or if there are one or several full nodules > 2 cm. In near future, these indications will be modified with the increasing reliability of fine needle aspiration biopsy.

Incidencia de infección congénita por citomegalovirus en recién nacidos de distinta condición socioeconómica / Incidence of congenital cytomegalovirus infection in newborns of different socioeconomic condition

Cytomegalovirus is the main agent of congenital viral infections. The aim of this study was to compare the incidence of congenital cytomegalovirus infection of 2 groups of newborns of differing socioeconomic status. Cytomegalovirus was isolated from urine or oropharyngeal secretions in 218 children born in a private clinic and 471 born in a public hospital. Positive viral isolates were confirmed with indirect immunofluorescence using monoclonal antibodies. Infection was detected in 12 children (1.82 percent), 4 coming from the private clinic (1.86 percent) and 8 coming from the public hospital (1.81 percent). Ninety two percent of onfected children were asymptomatic. Urine and oropharingeal secretion samples had the same yield for viral isolation. It is concluded that the incidence of congenital cytomegalovirus infection is similar to that described in developed countries