[Dupilumab-related blepharoconjunctivitis: Recommendations of the CEDRE group. Atopic dermatitis, conjunctivitis and dupilumab: Which management approach?] / Blépharo-conjonctivites sous dupilumab : recommandations du groupe CEDRE. Dermatite atopique, conjonctivites et dupilumab : quelle prise en charge ?

Dupilumab is a recombinant monoclonal IgG4 type antibody which inhibits IL4 and IL13 signaling. It is indicated in moderate to severe atopic dermatitis (AD) in adults and adolescents over 12 years of age. Its side effects include conjunctivitis and blepharoconjunctivitis, affecting between 4.7% and 28% of patients depending on the study. The incidence of conjunctivitis in patients treated with dupilumab for AD appears to be higher than placebo in clinical studies. This increase was not observed in patients treated with dupilumab for asthma or sinonasal polyposis. The risk factors for conjunctivitis in patients with AD are disease severity, pre-existence of conjunctivitis and low concentrations of dupilumab, but the pathophysiology of this disease is poorly understood. A literature search carried out in April and May 2020 showed an increase in the number of publications on the subject, but there are currently no official joint dermatologist-ophthalmologist recommendations for prevention and management. The objective of this article is to provide an overview of the status of this subject, to address the main questions raised by this type of conjunctivitis and to suggest a course of action for starting and continuing treatment with dupilumab in patients with AD, according to the recommendations of the French Ophthalmologist/Dermatologist group CEDRE.

[Outcomes of cataract surgery in patients with Fuchs endothelial corneal dystrophy]. / Chirurgie de cataracte seule chez le patient porteur d'une dystrophie endothéliale de Fuchs.

PURPOSE: While endothelial keratoplasty has become the standard treatment for Fuchs dystrophy, the strategy for first-line surgery in patients with associated cataract is still debated. The purpose of this study was to evaluate the surgical outcomes of eyes with Fuchs endothelial corneal dystrophy (FECD) undergoing phacoemulsification alone, to ascertain preoperative factors that predict the need for endothelial keratoplasty (EK). METHODS: Single-center retrospective study. Cataract surgery alone was performed in 64 eyes of 50 patients with FECD. This decision was made if the patient did not have morning blur, the central corneal thickness (CCT) was below 630 microns, and endothelial cells were visible in the periphery. RESULTS: Mean follow-up was 21 months (range 5-55 months). The mean preoperative CCT was 571±43µm. 6 months after surgery, it was 584±52µm (P=0.12). During follow-up, 14 eyes (22%) required an EK because of poor visual outcome after cataract surgery alone. Mean pre-operative CCT of these eyes (595±23µm) was significantly higher than eyes that did not require EK during follow-up (564±45µm, P=0.022). Over 570 microns, 34% of eyes required an endothelial keratoplasty after the cataract surgery alone. CONCLUSIONS: CCT below 630µm associated with the absence of morning blur are preoperative criteria allowing 78.1% eyes with FECD to obtain good visual outcomes after cataract surgery alone. In these eyes, EK can therefore be avoided while ensuring good results.

[Panorama of limbal alterations (French translation of the article)]. / Panorama des altérations limbiques cornéennes.

The corneal limbus is a privileged region on the border between two quite different microenvironments, where corneal epithelial stem cells, numerous melanocytes, and antigen-presenting cells are all concentrated within a richly vascularized and innervated stroma. This situation within the ocular surface confers on it the key functions of barrier, epithelial renewal and defense of the cornea. As an immunological crossroads and since the corneoscleral limbus is directly exposed to external insults such as caustic agents, ultraviolet radiation, microbial agents, and allergens, it is the potential site of many tumoral, degenerative or inflammatory pathologies and may progress under certain conditions to limbal stem cell deficiency.

[Severe color change in corneal tattoos: Report of 3 cases (French translation of the article)]. / Modification majeure de la couleur des tatouages cornéens à propos de 3 cas.

INTRODUCTION: Corneal tattooing is a noninvasive technique which appears relatively well-tolerated in the medium term. We report the cases of 3 patients with a significant change in the color of their tattoos performed over 5 years previously. PATIENTS AND METHODS: Three patients with a history of intracorneal tattooing several years previously were studied because of a significant change from their initial color. Each patient's file was reviewed with analysis of slit lamp photographs, OCT and specular microscopy. RESULTS: All three patients experienced a significant color change in their tattoos between 5 and 6 years after surgery. The color had changed to golden-brown. DISCUSSION: Retrospective analysis of the components of the tattoo ink found the presence of iron in the black pigment. We believe that pigments composed of iron oxide are transformed into golden-brown ferric iron oxide in the presence of oxygen in the aqueous environment. The presence of moderate corneal edema in these three cases of multioperated patients could explain, in these specific cases, the occurrence of oxidation typically not described. CONCLUSION: Corneal tattooing remains a simple and very interesting technique when partial or total absence of iris causes significant photophobia. However, the significant changes in color that we report more than 5 years later suggest omitting iron from the dyes used for the cornea and limiting its use in cases of limited endothelial prognosis. A long-term evaluation of corneal tattoos appears necessary.

Panorama of limbal changes.

The corneal limbus is a privileged region on the border between two quite different microenvironments, where corneal epithelial stem cells, numerous melanocytes, and antigen-presenting cells are all concentrated within a richly vascularized and innervated stroma. This situation within the ocular surface confers on it the key functions of barrier, epithelial renewal and defense of the cornea. As an immunological crossroads and since the corneoscleral limbus is directly exposed to external insults such as caustic agents, ultraviolet radiation, microbial agents, and allergens, it is the potential site of many tumoral, degenerative or inflammatory pathologies and may progress under certain conditions to limbal stem cell deficiency.

Severe color change in corneal tattoos: Report of 3 cases.

INTRODUCTION: Corneal tattooing is a noninvasive technique which appears relatively well-tolerated in the medium term. We report the cases of 3 patients with a significant change in the color of their tattoos performed over 5 years previously. PATIENTS AND METHODS: Three patients with a history of intracorneal tattooing several years previously were studied because of a significant change from their initial color. Each patient's file was reviewed with analysis of slit lamp photographs, OCT and specular microscopy. RESULTS: All three patients experienced a significant color change in their tattoos between 5 and 6 years after surgery. The color had changed to golden-brown. DISCUSSION: Retrospective analysis of the components of the tattoo ink found the presence of iron in the black pigment. We believe that pigments composed of iron oxide are transformed into golden-brown ferric iron oxide in the presence of oxygen in the aqueous environment. The presence of moderate corneal edema in these three cases of multioperated patients could explain, in these specific cases, the occurrence of oxidation typically not described. CONCLUSION: Corneal tattooing remains a simple and very interesting technique when partial or total absence of iris causes significant photophobia. However, the significant changes in color that we report more than 5 years later suggest removing iron from the dyes used for the cornea and limiting its use in cases of limited endothelial prognosis. A long-term evaluation of corneal tattoos appears necessary.

[Anterior uveitis]. / Uvéites antérieures.

Anterior uveitis is the most common form of uveitis. There are several known and many possible etiologies for anterior uveitis. After examining the posterior segment and ruling out masquerade syndromes, the main step of etiologic diagnosis is clinical characterization. It is essential to establish unilateral versus bilateral involvement and presence or absence of granulomatous features. Subsequently, a work-up may be obtained which then helps to confirm diagnostic hypotheses based on the detailed history and clinical examination. The priority is to rule out an infection, although less frequent, before starting steroid therapy, adapted to the severity of the clinical picture. Finally, biologics have greatly changed the management and prevention of some forms of anterior uveitis, in particular uveitis associated with HLA-B27 and juvenile idiopathic arthritis-associated anterior uveitis.

Tocilizumab for the treatment of birdshot uveitis that failed interferon alpha and anti-tumor necrosis factor-alpha therapy: two cases report and literature review.

Biotherapies appear as potential drugs for the treatment of inflammatory noninfectious uveitis. In this report, we show that tocilizumab, an anti-IL-6 agent, greatly improved two patients with birdshot chorioretinopathy refractory to conventional immunosuppressive drugs, interferon α2a, and anti-TNFα agents. After a follow-up of 22 months, patients exhibited an improvement of both visual acuity and macular edema. A corticosteroid-sparing effect was achieved in both cases.

Anterior uveitis.

Anterior Uveitis is the most common form of uveitis. There are several known and many possible etiologies for anterior uveitis. After examining the posterior segment and ruling out masquerade syndromes, the main step of etiologic diagnosis is clinical characterization. It is essential to establish the presence or absence of unilateral versus bilateral and granulomatous features. Subsequently, a directed work-up may be obtained which then helps to confirm diagnostic hypotheses based on the detailed history and clinical examination. The priority is to rule out an infection. Treatments are adapted according to etiology and disease severity. Finally, biologics have greatly changed the management and prevention of some forms of anterior uveitis, in particular uveitis associated with HLA-B27 and juvenile idiopathic arthritis-associated anterior uveitis.

[Gas-permeable scleral lens for management of severe keratoconjunctivitis sicca secondary to chronic graft-versus-host disease]. / Traitement des sécheresses oculaires sévères secondaires à la maladie du greffon contre l'hôte chronique par lentilles sclérales perméables à l'oxygène.

INTRODUCTION: Graft-versus-host disease is a major complication of allogeneic hematopoietic stem cell transplantation. Severe keratoconjunctivitis sicca is common in patients with chronic GVH disease. The goal of this study was to evaluate the safety and efficacy of a gas-permeable scleral lens in the management of severe dry eye disease associated with chronic GVH. PATIENTS AND METHODS: This is a retrospective study from June 2009 to November 2013. Patients fitted with scleral lenses for severe keratoconjunctivitis sicca associated with chronic GVH were included. The main outcomes measured were best-corrected visual acuity and quality of life (OSDI and NEI-VFQ25) composite scores before and six months after scleral lens fitting. RESULTS: Sixteen patients were included. The mean age was 52 years (19-69 years). Mean follow-up was 20 months (3-48 months). All patients reported improvement of their ocular symptoms. Best corrected visual acuity improved from 0.21 ± 0.26 to 0.1 ± 0.14 logMAR (P = 0.002), OSDI score improved from 92.1 ± 11.3 to 23.5 ± 11.2 (P = 0.002) and NEI-VFQ25 improved from 41.3 ± 7 to 83.1 ± 15.9 (P = 0.003), 6 months after scleral lens fitting. No serious adverse events, infectious, hypoxemic or allergic complications attributable to the scleral lens occurred. CONCLUSION: Gas-permeable scleral lens use appears to be safe and effective in patients with severe dry eye related to chronic GVH.

Efficacy and safety of pre-Descemet's membrane sutures for the management of acute corneal hydrops in keratoconus.

AIMS: The aim of this study was to assess the efficacy and safety of pre-Descemet's membrane (DM) sutures associated with intracameral air injection for management of acute corneal hydrops associated with keratoconus. METHODS: We carried out a retrospective interventional study of seven consecutive cases. Three to seven pre-DM sutures with 10-0 nylon were applied perpendicularly to the tear as close as possible to DM, under general anaesthesia. An air bubble was injected into the anterior chamber at the end of each procedure. RESULTS: Corneal oedema began to decrease from day 1 after surgery in all our patients. Best-corrected visual acuity progressed from 2.13 to 1.65 logMar (p=0.031) 1 month after surgery, and from 2.13 to 0.84 logMar (p=0.016) 2 months after surgery. The mean corneal thickness measured by anterior segment optical coherence tomography decreased from 1472 µm (range 689-2770 µm) on day 0 to 909 µm (range 484-1640 µm) on day 1 (p=0.016), 716 µm (range 484-1380 µm) on day 15 (p=0.016) and 528 µm (range 404-618 µm) 1 month after surgery. CONCLUSIONS: Our results suggest that intrastromal pre-DM sutures and intracameral air injection could promptly restore imperviousness of posterior stroma. This technique seems to be a safe and useful procedure to shorten acute corneal hydrops.

[Keratoplasty combined with cataract surgery]. / L'intervention combinée greffe-cataracte.

Corneal pathologies leading to keratoplasty are often associated with cataract and combined surgery is therefore mandatory. Triple procedure with penetrating keratoplasty and concurrent cataract extraction followed by intra ocular lens (IOL) implantation is usually the preferential choice because visual rehabilitation is theoretically more rapid. Surgeons have to be aware of surgical conditions during open-sky surgery because vitreous pressure is not counterbalanced by anterior chamber pressure. Today, many surgeons prefer non-simultaneous procedures with cataract surgery performed months after grafting because of the improvement in spherical refractive error. More recently, new triple procedures, Descemet's stripping automated keratoplasty and concurrent cataract surgery have gained popularity, especially in patients with Fuchs dystrophy associated with cataract. Surgery starts with phacoemulsification, followed by endothelium exchange through a 3 to 5 mm incision. Advantages against classic triple procedure are quick visual rehabilitation, fewer induced refractive errors, minimal postoperative discomfort and corneal integrity. Surgeons have to consider an eventual postoperative hyperopic shift secondary to corneal lenticule shape when choosing adequate intraocular lens.

[Conjunctival flap: Still a relevant procedure]. / Le recouvrement conjonctival : une technique toujours d'actualité.

PURPOSE: To evaluate the technique of conjunctival flap for the treatment of ocular surface disorders. PATIENTS AND METHODS: This is a retrospective study. Forty-three eyes of 43 patients had undergone conjunctival flap surgery performed during a 5-year period at the Rouen University Hospital. Thirty-one patients were followed regularly and could thus be included in this study. The indications and complications experienced by patients undergoing partial or total conjunctival flap surgery were reviewed. RESULTS: The surgical indication was tectonic for 15 out of 31 patients (48.4%) including six corneal perforations, analgesic for nine out of 31 patients (29.0%) and aesthetic for 7 out of 31 patients (22.6%). All the operated patients experienced clinical improvement with a decrease in their pain or inflammation of the ocular surface, or an excellent cosmetic result. Complications were encountered in 6 eyes among the 31 patients (19.4%), and four required surgical revision. CONCLUSION: Conjunctival flap is an underutilized technique. Its primary indication is ocular surface disease in eyes with poor visual potential. It represents an interesting alternative to more mutilating surgeries.

[Subconjunctival bevacizumab for corneal neovascularization]. / Injections sous-conjonctivales de bévacizumab dans le traitement de la néovascularisation cornéenne.

PURPOSE: To assess efficacy and safety of subconjunctival bevacizumab in corneal neovascularization treatment. METHODS: The study was a prospective case series that included patients treated with subconjunctival bevacizumab injections for corneal neovascularization over a period of four months. A dose of 2.5 mg (0.1 mL) of bevacizumab (25 mg/mL) was injected into the subconjunctival area 1-2mm behind the limbus near the corneal neovascularization. The main outcome measures were visual acuity, corneal neovascularization, as well as local and general side effects. RESULTS: Thirteen eyes of 12 patients were included. The mean patient age was 44.2 years (range, 18-87 years). Patients received from two to four bevacizumab injections. The mean corneal neovascularization area decreased from 41.1 to 33.7 % at day 45 (p=0.0003) and to 33.9 % at day 120 (p=0.0013). Median visual acuity changed from 1.32 to 1.28 LogMAR on day 45 and to 1.25 LogMAR on day 120. Subconjunctival bevacizumab was well tolerated without general side effects. There was no significant change in intraocular pressure. An epithelial defect was described in three patients after initiation of bevacizumab therapy. CONCLUSIONS: Subconjunctival bevacizumab injections were effective and safe in reducing corneal neovascularization within the first four months. Meanwhile, improving vision may provide additional strategies.

[An update on the use of tissue adhesives in ophthalmology]. / Mise au point sur l'utilisation des colles tissulaires en ophtalmologie.

Tissue adhesives have a long history of use in almost all surgical disciplines, both as an alternative and a complement to sutures. Nevertheless, ophthalmologists have restricted knowledge of their potential applications; consequently, tissue adhesives have been underutilized so far. This review discusses the most relevant clinical and experimental advances in the use of tissue adhesives in ophthalmology and details the characteristics and properties of the glues. Among the currently available adhesives, synthetic glues are mainly represented by cyanoacrylates and biologic glues by fibrin-based adhesives. Cyanoacrylate-based glues are especially useful for treating perforated or preperforated corneal ulcers and performing temporary tarsorrhaphy. Fibrin-based glues have the largest field of application, as they can be used in corneal perforations and are being widely used in pterygium surgery and conjunctival surgery. We also reviewed other anecdotic applications of these adhesives. Novel biomaterials such as biodendrimers, polyethylene glycols, modified chondroitin sulfates, and acrylic copolymers show promising results in the experimental field, and one product has been on the market for a short period of time.

[Advantages of amniotic membrane transplantation in eye surface diseases]. / Intérêt des greffes de membranes amniotiques dans les pathologies oculaires de surface.

Amniotic membrane transplantation is now a widely adopted technique in the field of eye surface diseases. Depending on the indication, the amniotic membrane can be used as either a graft or a patch. When used as a graft, the amniotic membrane serves as a substrate for regrowth of deficient epithelium; the aim is to integrate this membrane. The basal membrane reinforces the adhesion and differentiation of the corneal epithelial cells, facilitates their migration, and prevents their apoptosis. When used as a patch, the amniotic membrane is sutured epithelium-down so as to maximize the concentration of biological factors delivered by this membrane: the membrane covers the diseased cornea and acts as a biological bandage and analgesic. The best indications for amniotic membrane grafts are acute chemical burns and trophic corneal ulcers refractory to all medical treatment. When these ulcers are perforated or in the early stages of perforation, it is best to use multiple layers of amniotic membrane, restoring the thickness of the cornea. In cases of confirmed limbal deficiency, amniotic membrane grafts may be a useful complement to the necessary limbal stem cell grafts. In the future, amniotic membranes will provide an indispensable support for the expansion of cultured stem cells. Amniotic membrane grafts may also be used to reconstruct the conjunctiva following the exeresis of symblepharons or conjunctival tumors. However, the use of this technique is currently limited to diseases with little inflammation and no extensive fibrosis.