Behçet's disease uveitis.

Uveitis in Behçet's disease (BD) is frequent (40% of cases) and is a major cause of morbidity. The age of onset of uveitis is between 20 and 30 years. Ocular involvement includes anterior, posterior or panuveitis. It is non-granulomatous. Uveitis may be the first sign of the disease in 20% of cases or it may appear 2 or 3 years after the first symptoms. Panuveitis is the most common presentation and is more commonly found in men. Bilateralisation usually occurs on average 2 years after the first symptoms. The estimated risk of blindness at 5 years is 10-15%. BD uveitis has several ophthalmological features that distinguish it from other uveitis. The main goals in the management of patients are the rapid resolution of intraocular inflammation, prevention of recurrent attacks, achievement of complete remission, and preservation of vision. Biologic therapies have changed the management of intraocular inflammation. The aim of this review is to provide an update previous article by our team on pathogenesis, diagnostic approaches, identification of factors associated with relapse and the therapeutic strategy of BD uveitis.

[Intraocular pressure elevation and intravitreal steroid implant injection: State of the art in 2023. Recommendations of the French Glaucoma Society and French Ophthalmology Society [French version]]. / Hypertonie oculaire et injection intravitréenne d'implant de corticoïde, état de l'art en 2023. Recommandations françaises SFG/SFO [version française].

These are the recommendations of French glaucoma and retina experts on the management of ocular hypertension (OHT) observed in 1/3 of cases after intravitreal steroid implant injections. They are an update to the recommendations first published in 2017. There are two implants on the French market: the dexamethasone (DEXi) and fluocinolone acetonide (FAci) implants. It is important to know the pressure status before injecting a patient with a steroid implant. Monitoring of the IOP adapted to the specific drug is necessary throughout follow-up and reinjections. Real-life studies have made it possible to optimize the management algorithm by significantly increasing the safety of use of these implants. A corticosteroid test with DEXi is necessary before switching to FAci to optimize the pressure tolerance of the latter. In addition to topical glaucoma medications, SLT laser can be considered in the therapeutic arsenal for the management of steroid-induced OHT and future injections.

Ocular hypertension and intravitreal steroids injections, update in 2023. French guidelines of the French glaucoma society and the French ophthalmology society.

These guidelines are a consensus of French glaucoma and retina experts on the management of ocular hypertension (OHT) observed in a third of the cases after corticosteroid implant intravitreal injections. They update the first guidelines published in 2017. Two implants are marketed in France: the dexamethasone implant (DEXi) and the fluocinolone acetonide implant (FAci). It is essential to assess the pressure status before injecting a patient with a corticosteroid implant. A molecule-specific monitoring of the intraocular pressure is needed throughout the follow-up and at the time of reinjections. Real-life studies have allowed optimizing the management algorithm by significantly increasing the safety of these implants. Corticosteroid testing with DEXi should be performed before switching to FAci to optimize pressure tolerance of FAci. Beyond topical hypotensive treatments, selective laser trabeculoplasty may be considered in the therapeutic arsenal for the management of steroid-induced OHT and subsequent injections.

French recommendations for the management of non-infectious chronic uveitis.

This French National Diagnostic and Care Protocol (NDPC) includes both pediatric and adult patients with non-infectious chronic uveitis (NICU) or non-infectious recurrent uveitis (NIRU). NICU is defined as uveitis that persists for at least 3 months or with frequent relapses occurring less than 3 months after cessation of treatment. NIRU is repeated episodes of uveitis separated by periods of inactivity of at least 3 months in the absence of treatment. Some of these NICU and NIRU are isolated. Others are associated with diseases that may affect various organs, such as uveitis associated with certain types of juvenile idiopathic arthritis, adult spondyloarthropathies or systemic diseases in children and adults such as Behçet's disease, granulomatoses or multiple sclerosis. The differential diagnoses of pseudo-uveitis, sometimes related to neoplasia, and uveitis of infectious origin are discussed, as well as the different forms of uveitis according to their main anatomical location (anterior, intermediate, posterior or panuveitis). We also describe the symptoms, known physiopathological mechanisms, useful complementary ophthalmological and extra-ophthalmological examinations, therapeutic management, monitoring and useful information on the risks associated with the disease or treatment. Finally, this protocol presents more general information on the care pathway, the professionals involved, patient associations, adaptations in the school or professional environment and other measures that may be implemented to manage the repercussions of these chronic diseases. Because local or systemic corticosteroids are usually necessary, these treatments and the risks associated with their prolonged use are the subject of particular attention and specific recommendations. The same information is provided for systemic immunomodulatory treatments, immunosuppressive drugs, sometimes including anti-TNFα antibodies or other biotherapies. Certain particularly important recommendations for patient management are highlighted in summary tables.

[Observational study of QuantiFERON® management for ocular tuberculosis diagnosis: Analysis of 244 consecutive tests]. / Étude observationnelle de l'usage du QuantiFERON® pour le diagnostic de tuberculose oculaire, basée sur 244 tests consécutifs.

INTRODUCTION: Ocular tuberculosis (TB) diagnosisremains difficult and quantiferon (QFT) contribution needs still yet to be specified, despite its generalization in France. The purpose of this observational study is to assess in which ocular inflammation (OI) presentation QFT is prescribed and to evaluate the added value of new QuantiFERON®-TB Gold Plus (QFT-Plus) test for diagnosis ocular TB diagnosis. PATIENTS AND METHODS: Monocentric, observational study, carried out in an ophthalmology department over a period of 5 months. Inclusion criteria were defined as an existence of an OI for which a QFT-Plus test was part of the etiological investigations. Of the 316 consecutive files, 72 were excluded (indeterminate test, prescription before anti-TNFα or immunosuppressant initiation, missing data, wrong indication) and 244 were selected and divided into two groups: group one (anterior uveitis/episcleritis, n=129) and group two (intermediate/posterior uveitis/optic neuritis/ocular myositis, n=115). All positive QFT patients underwent an etiological investigation including thoracic imaging. RESULTS: Forty-five patients, aged 52±12 years, had positive QFT (18.5%), including 18 patients for group 1 and 27 for group 2. Living in TB-endemic area, TB exposure and chest imaging abnormalities were identified in 70%, 27% and 22% of cases, respectively. OI was chronic in 36% of cases (group one, 4/18; group two, 12/27). None of the 18 patients, in group 1, received anti-tuberculosis treatment (ATT) or experienced a relapse during one-year follow-up. Four QFT+ patients, from group 2 (15%) had another associated disease explaining their uveitis. Among the 23 other patients without identified etiology, 13 had at least one relevant ophthalmological signs predictive of TB uveitis (posterior synechiae, retinal vasculitis and/or choroidal granuloma) (59%). Eleven patients received a 6-month ATT trial. Radiological abnormalities and granulomas at angiography were significantly more frequent among treated patients (p=0.03 and 0.001, respectively). A full OI recovery was observed for 8 patients (73%), considered ex-post as ocular TB. Nine patients in group 2 received rifampicin/isoniazid dual therapy for 3 months, but no conclusion could be drawn as to the benefit of such prescription on OI. QFT rate comparison, according to CD4 stimulation by ESAT-6/CFP-10 peptides or by CD4/CD8 co-stimulation, was comparable and found only 4 cases of discrepancy (1.6%). None of these 4 cases had ocular TB diagnosis. CONCLUSION: Positive QFT frequency among patients consulting for posterior OI remains high. In this study, radiological abnormalities and granulomas at angiography seemed to be more closely related to clinician decision for starting ATT trial in QFT+ patients, which was effective in 73% of cases. QFT-Plus does not seem more relevant than QFT-TB in exploring an OI. Prospective studies are necessary to codify QFT management in the etiological assessment of OI and clearly define ATT trial indications as well as their modalities.

Safe short circuit in cataract surgery: Incidence and risk factors for intraoperative medical action.

Cataract surgery has become the most frequent surgical procedure performed every year in Western countries. Perioperative patient circuit has to be adapted to the important medical needs and progress. Hence, a secure short circuit (SSC) for surgeries of the anterior segment of the eye under topical anaesthesia was created. Patients included in the circuit are selected first by surgeons and answer a medical questionnaire, they do not have any preoperative evaluation by anaesthesiologist, are monitored during surgery by the surgical team and in case of problem an intraoperative medical action (IMA) can be performed. We conducted a retrospective observational incidence study of the occurrence of the IMA, followed by a case control study. The primary outcome was to identify risk factors of IMA among the patients' medical history. Out of 2744 screened patients, 1592 patients were included during the period of November 2015 to November 2017. The rate of IMA was 5%, 81% of them presenting with intraoperative high blood pressure (HBP). In the case control study part, stepwise regression analysis revealed that a history of HBP and insulin-dependent diabetes (IDD) was significantly correlated with IMA (respectively, adjusted odds ratio 1.7, P=0.005 and 2.6, P=0.002). The low incidence of IMA showed that the SSC is a safe tool thanks to a selection and an optimised and secure pathway. A history of HBP and IDD was significantly associated with the occurrence of IMA. Therefore, an optimisation of the perioperative period would be beneficial in these cases.

[Acute visual loss related to sphenoid meningioma]. / Troubles visuels aigus associés aux méningiomes sphénoïdaux.

Meningiomas represent about 20% of intracranial tumors. Involvement of the medial sphenoid wing includes anterior clinoid, cavernous sinus and superior orbital fissure meningiomas. Due to the proximity of these tumors to the optic nerve, typically progressive unilateral vision loss, over several months to years, is the classic clinical presentation. We report three cases of acute monocular vision loss, two transient and one permanent, ipsilateral to a sphenoid meningioma. Ophthalmological involvement with sphenoid meningiomas is most often chronic, due to interruption of axoplasmic flow and demyelination of the optic nerve by local compression. However, vascular involvement with ischemia of the optic nerve or transient low blood flow secondary to compression of the carotid branches vascularizing these structures is another possible mechanism. In our series, two patients had amaurosis fugax, and one patient had sudden, persistent visual loss in relation to acute anterior ischemic optic neuropathy on the side of the meningioma. The mean age of patients with acute visual manifestations was 62 years. These ischemic and non-compressive visual symptoms, ipsilateral to sphenoid meningiomas, are difficult to interpret. Whether these temporary visual disturbances of vascular origin should be considered an early sign of future severe or permanent visual impairment when no optic nerve compression is observed is not certain. The place of these acute visual disturbances in the therapeutic decision, particularly surgical, remains to be defined. Larger multicentric prospective studies are needed to better understand the role of local circulatory factors attributable to meningioma in the occurrence of these acute visual signs.

INFLIXIMAB and ADALIMUMAB in Uveitic Macular Edema.

PURPOSE: To compare the efficacy of infliximab and adalimumab in patients with refractory uveitis-related macular edema (ME). METHODS: A retrospective study was conducted in all patients with refractory uveitis-related ME treated with infliximab or adalimumab in Pitié-Salpêtrière hospital between January 1, 2006 and January 1, 2016. All patients underwent a complete ophthalmologic examination, OCT and retinal angiography at baseline, and 6 (M6) and 24 months (M24) after treatment initiation. Main outcome was a decrease in central foveal thickness (CFT) on OCT. RESULTS: Twenty-five patients were included: 12 treated with adalimumab and 13 treated with infliximab. The median baseline CFT was 381 µm (Q1 = 254; Q3 = 470) in the adalimumab group and 469 µm (307; 539) in the infliximab group. At M6, 6/12 adalimumab-treated patients (50%) and 8/13 infliximab-treated patients (61%) were responders. The median CFT decrease from baseline was 61 µm (17-136) and 66 µm (-59-119) respectively at M6 and M24 in the adalimumab group versus 92 µm (9-165) and 52 µm (33-130) respectively at M6 and M24 in the infliximab group (all p > 0.05). CONCLUSION: No significant difference in efficacy was observed between infliximab and adalimumab at M6 and M24.

[Bilateral uveitis associated with nivolumab therapy]. / Uvéite bilatérale associée à un traitement par nivolumab.

Immune-related adverse events (IRAEs) are rare but serious adverse events that may be associated with inhibitors of few immune control points. The purpose here is to report the case of an inflammatory ocular disease, potentially linked to the immunity and use of nivolumab, a new immunological agent used for the treatment of a solid tumor. In spite of the involvement of this treatment in the onset of inflammation, we must always seek another cause. It is possible to continue this treatment by considering the benefit/risk balance for each patient. Close collaboration between oncologists and ophthalmologists is necessary in the diagnosis and rapid management of these IRAE ocular related to these new emerging therapies.

[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.

[Therapeutic strategy for the treatment of non-infectious uveitis proposed by an expert panel]. / Avis d'experts pour le traitement des uvéites non infectieuses.

Conventional immunosuppressive drugs, anti-TNF alpha and other biotherapies used in clinical practice are capable of controlling non-infectious anterior uveitis, posterior uveitis and panuveitis. The present work has been led by a multidisciplinary panel of experts, internists, rheumatologists and ophthalmologists and is based on a review of the literature. In case of corticodependency or sight-threatening disease, conventional immunosuppressive drugs (methotrexate, azathioprine and mycophenolate mofetil) and/or anti-TNF alpha (adalimumab, infliximab) are used to achieve and maintain remission. Interferon is an efficient immunomodulatory treatment, as a second-line therapy, for some therapeutic indications (refractory macular edema, Behçet's vascularitis). Other biologics, especially tocilizumab, are showing promising results. Local treatments (corticosteroids, sirolimus etc.) are adjuvant therapies in case of unilateral inflammatory relapse. Therapeutic response must be evaluated precisely by clinical examination and repeated complementary investigations (laser flare photometry, multimodal imaging, perimetry, electroretinography measures).

Bilateral uveitis associated with nivolumab therapy.

New anticancer therapies, immune pathway inhibitors, may cause immune-related adverse events (IRAE). Immune-related ocular toxicities are rare but are potentially serious adverse events. The purpose of this article is to report a case of ocular inflammatory involvement potentially related to the immune response and the use of nivolumab, a new immunologic agent used for the treatment of a solid tumor. Despite the implication of this therapy in the occurrence of inflammation, other causes must always be ruled out. It is possible to continue this therapy in consideration of the risk/benefit ratio for each patient. Close collaboration between oncologists and ophthalmologists is necessary in the diagnosis and timely management of IRAE related to these new emerging therapies.

[Uveitis: Diagnostic work-up. Recommendations from an expert committee]. / Prise en charge diagnostique des uvéites : recommandations d'un groupe d'experts.

INTRODUCTION: Diagnostic work-up of uveitis involves many uncertainties. Search for an etiology should take into account the epidemiology of uveitis and focus on the most severe diseases or those, which can be treated. This work was undertaken to establish recommendations for the diagnosis work-up of uveitis. METHODS: Recommendations were developed by a multidisciplinary panel of 15 experts, including internists, ophthalmologists and a rheumatologist and are based on a review of the literature with regard to effectiveness of investigations and the results of the ULISSE study, which is the first prospective study assessing the efficiency of a standardized strategy for the etiological diagnosis of uveitis. Children, immunocompromised patients, severe retinal vasculitis and specific ophthalmological entities are excluded from these recommendations. RESULTS: Investigations should be first guided by the history and physical examination. Serological screening for syphilis is the only test appropriate in all forms of uveitis. If no diagnosis is made after this stage, we propose investigations guided by the anatomic characteristics of uveitis. It includes HLA B27 testing (in unilateral acute anterior non-granulomatous uveitis), serum angiotensin converting enzyme, interferon-gamma release assay and chest CT (chronic uveitis), cerebral MRI and anterior chamber tap with IL10 analysis (intermediate or posterior uveitis in patients over 40 years). Investigations ordered in the absence of orientation are almost always unhelpful. CONCLUSIONS: We propose a strategy for the etiologic diagnosis of uveitis. The recommendations should be updated regularly. The efficiency of more invasive investigations has yet to be evaluated.

Sustained intraocular pressure elevation in eyes treated with intravitreal injections of anti-vascular endothelial growth factor for diabetic macular edema in a real-life setting.

PURPOSE: The aim of this study was to investigate the sustained intraocular pressure (IOP) elevation after repeated anti-VEGF intravitreal injections (IVI) in patients with diabetic macular edema (DME). METHODS: A retrospective study included 140 eyes without prior glaucoma, treated with at least three anti-VEGF injections for DME between 2012 and 2016. IOP elevation was defined by an increase above baseline IOP by ≥6 mmHg. Baseline IOP was defined as the mean of IOP values before treatment initiation. Three groups were differentiated: group 1 without IOP elevation, groups 2 and 3 with IOP elevation and IOP <21 mmHg (group 2) and ≥21 mmHg (group 3). Rate and several risk factors of IOP elevation were assessed and compared between the three groups. RESULTS: IOP elevation occurred in ten eyes (7.1%). IOP was <21 mmHg in six eyes and ≥21 mmHg in four eyes. Statistically significant associations were found between IOP elevation and the number of injections, and HbA1c level. Two patients required local hypotonic treatment. CONCLUSIONS: In a real-life setting, we confirmed in eyes with center-involved DME without prior glaucoma or IOP elevation that repeated anti-VEGF IVI may increase the risk of sustained IOP elevation in about 7% of eyes.

[Neuro-ophthalmological conditions: Study of the clinical care pathway]. / Les affections neuro-ophtalmologiques : étude du parcours de soins du patient.

INTRODUCTION: Neuro-ophthalmologic conditions require specialized multidisciplinary management, both medical and surgical, for patients affected by visual loss due to nervous system disease. The primary goal of this study is to define the specificity of neuro-ophthalmology within the realm of visual health. The secondary goal is to review clinical care pathways by studying the organization of management, in terms of accessibility to care and personalization of the care pathway. PATIENTS AND METHODS: A field study was carried out from February to June 2015, within the ophthalmology service of the Pitié-Salpêtrière University Medical Center in Paris. A 30-minute interview with the patient before or after his or her neuro-ophthalmology consultation was performed, so as to describe the clinical care pathway. The medical records of interviewed patients were also analyzed. RESULTS: Seventeen care pathways (10 women and 7 men) were reviewed. The mean age at appearance of visual involvement was 44.5 years (±8.4 years). If we exclude 3 patients over 66 years and retired, 35.71% were active, 35.71% were disabled, and 28.57% were on sick leave. Ten patients (58.82%) met the criteria for admission to long-term care. The first step had been carried out by local private practitioners. The first physician seen was the general medicine physician (59%), then the private ophthalmologist on an emergency basis (17%). On average, patients went through 8 steps during their care pathway (from 6 to 10 steps) and 14 medical departments were involved. The study showed collaboration with the other services of the University Hospital Department of Vision and Disabilities (notably with the Fondation Rothschild, the Quinze-Vingts National Ophthalmology Hospital and the Fondation Sainte-Marie). In addition to rehabilitation services, health care professionals participating in the outpatient care of the patients included an orthoptist (11.7%), a psychologist (11.7%), and an optician specializing in low vision for visual aids. And finally, patient support groups, AFM-Téléthon (myasthenia) and the ARIBa Association (visual disability) were solicited by 2 patients for their involvement. A disturbance in activities of daily living leading to disabilities with psychological repercussions was noted by a number of patients. The most frequent complaints involve mobility (29.41%) and reading (23.52%). In total, 77% of patients state that their well-being has been affected and they are disturbed by the progression of their disease. DISCUSSION AND CONCLUSIONS: The review of the clinical care pathway of patients affected by neuro-ophthalmological conditions shows that these pathologies are, on the one hand, often poorly understood, and on the other hand complex, leading to an often significant number of steps for the patient. This also emphasizes the necessity of a care network, specialized and structured to improve the efficiency of this management. Finally, these results demonstrate the existence of a very frequent disability, which may affect all aspects of the patients' lives, highlighting the importance of rehabilitation services and individuals participating in the follow-up of these patients beyond their acute care.