[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.

Refractive accuracy and visual outcomes after combined descemet membrane endothelial keratoplasty and cataract surgery: A French multicentric study.

PURPOSE: Descemet membrane endothelial keratoplasty (DMEK) combined with cataract extraction and intraocular lens insertion (new triple procedure) limits postoperative refractive errors. The objective of this study was to assess refractive accuracy after DMEK combined with cataract extraction and intraocular lens implantation. SETTING: Four university hospitals (Rouen, Paris, Reims, Grenoble). DESIGN: This retrospective multicenter study included patients with symptomatic corneal endothelial decompensation and cataract. METHODS: The primary outcome was the difference between the target spherical equivalent and postoperative refraction at months 2 and 6. Secondary outcomes were visual acuity, keratometry, pachymetry and endothelial cell density. RESULTS: A total of 130 eyes of 111 patients (mean age 66.2 years) were included (94% with Fuchs' endothelial dystrophy). For a mean refractive target set at -0.50 (±0.57) D, the mean (95% CI) refractive error was hyperopia of +0.49 (0.314; 0.664) D at 2 months and +0.46 (0.299; 0.619) D at 6 months. Best corrected distance visual acuity was improved in all patients: from 0.49 (±0.3) logMAR to 0.14 (±0.14) logMAR at 2 months and 0.05 (±0.1) logMAR at 6 months. Mean corneal thickness decreased from 621.6 (±37.6) µm to 515.2 (±42.6) µm at 2 months and 539.0 (±39.0) µm at 6 months. CONCLUSIONS: Good refractive accuracy was obtained after the new triple procedure with DMEK. Hyperopic shift is common after triple procedures, and its persistence should be evaluated in future studies in order to anticipate a change in its value to optimize intraocular lens power calculation.

[Small Incision Lenticule Extraction (SMILE) for correction of myopic astigmatism]. / Correction de l'astigmatisme myopique par ablation d'un lenticule réfractif intracornéen (SMILE).

PURPOSE: To study the efficacy, stability, safety and predictability of small incision lenticule extraction (SMILE) at 1 day and 3 months postoperatively for moderate and high myopic astigmatism. To describe a simple and convenient method for detection and manual compensation of cyclotorsion during the procedure. METHODS: In this retrospective study, a total of 164 eyes from 114 patients over 20 years of age with at least 1.5 diopters (D) of myopic astigmatism were treated by SMILE. Any cyclotorsion was manually compensated by gently rotating the cone to align the horizontal marks on the cornea to the 0° to 180° axis of the reticule after activating the suction. RESULTS: The mean preoperative spherical equivalent (SE) was -5.3±2.01 D, and the mean cylinder was -2.01±0.67 D. Three months after surgery, a total of 87% of eyes were within±0.50 D of attempted post-operative SE, and 98% of eyes were within±1.00 D. Overall, the predictability of cylinder correction was excellent, with 96.3% of eyes within±1.00 D of attempted post-operative cylinder. The mean postoperative cylinder at three months was -0.3±0.39 D. We noted a slight undercorrection with treatment of high cylinder. However, 82% of eyes achieved postoperative refractive astigmatism less than 0.5 D. 91% of eyes achieved uncorrected distance visual acuity (UDVA) equal to or better than 8/10. 22% of eyes gained one line of visual acuity. CONCLUSION: SMILE is a predictable and safe technique for the surgical correction of astigmatism. Manual compensation may be an effective approach to improve astigmatic outcomes of SMILE, especially in moderate and high astigmatism.

Diagnosis associated with Tau higher than 1200 pg/mL: Insights from the clinical and laboratory practice.

CONTEXT: Cerebrospinal fluid (CSF) biomarkers are valuable tools for the diagnosis of neurological diseases. We aimed to investigate within a retrospective multicentric study the final diagnosis associated with very high CSF Tau levels and to identify patterns of biomarkers that would differentiate them in clinical practice, to help clinical biologists into physicians' counseling. PATIENTS AND METHODS: Within the national multicentric network ePLM, we included 1743 patients from January 1, 2008, to December 31, 2013, with CSF biomarkers assayed by the same Innotest assays (protein Tau, phospho-Tau [pTau], and Aß 1-42). We identified 205 patients with protein Tau concentration higher than 1200 pg/mL and final diagnosis. RESULTS: Among those patients, 105 (51.2%) were suffering from Alzheimer's disease, 37 (18%) from sporadic Creuztfeldt-Jakob disease, and 63 (30.7%) from other neurological diseases including paraneoplastic/ central nervous system tumor, frontotemporal dementia, other diagnoses, amyloid angiopathy, Lewy body dementia, and infections of the central nervous system. Phospho-Tau, Aß1-42 and Aß1-42/pTau values differed significantly between the three groups of patients (p < .001). An Aß1-42/pTau ratio between 4.7 and 9.7 was suggestive of other neurological diseases (threshold in AD: 8.3). CSF 14-3-3 was useful to discriminate Alzheimer's disease from Creuztfeldt-Jakob disease in case of Aß1-42 concentrations <550 pg/mL or pTau>60 pg/mL. CONCLUSION: This work emphasizes the interest of a well-thought-out interpretation of CSF biomarkers in neurological diseases, particularly in the case of high Tau protein concentrations in the CSF.

[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 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.

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.

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]. / 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.

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.

[Tetraspanins: a new target for antiangiogenic therapy?]. / Les tétraspanines : une nouvelle cible pour la thérapie anti-angiogénique ?

Inhibition of the vascular endothelial growth factor A or inhibition of its receptors are currently used for the treatment of cancer. However, the results are still modest, especially because of the multitude and redundancy of angiogenic factors. It can be hypothesized that therapies targeting directly endothelial cells themselves could be more effective. The tetraspanins are transmembrane molecules, which are devoid of intrinsic enzymatic activity but can associate with each other and with other molecules such as integrins or proteins of the immunoglobulin superfamily to form a network. The tetraspanins are present on the surface of endothelial cells and in vitro, inhibition of these molecules by antibodies or small interfering RNA suggests that tetraspanins play a role in angiogenesis. These preliminary data have been confirmed by the study of cancer xenografts in tetraspanin-deficient mice, which have a significant decrease in tumor size and tumor angiogenesis. In vivo, it has been shown that intravenous administration of a monoclonal antibody (ALB6) directed against CD9 decreases the tumor growth and angiogenesis and that intravitreal injection of a small interfering RNA decreasing CD9 significantly inhibits choroidal neovascularization induced by laser. Finally, anti-angiogenic effects and potent anti-tumor activity are observed by the intraperitoneal administration of GS-168AT2, a peptide derived from CD9-Partner 1, a molecule belonging to the immunoglobulin superfamily, which interacts strongly with the CD9 and CD81. These data suggest that the pharmacological modulation of the tetraspanin web could play a new promising anti-angiogenic strategy.

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.

[Secondary opacification of hydrophilic acrylic intraocular lenses: report of two cases]. / Opacification secondaire d'implants intraoculaires acryliques hydrophiles : à propos de deux cas.

PURPOSE: To describe two cases of secondary opacification of hydrophilic acrylic IOLs after vitreoretinal surgery. METHODS: Analysis of IOL deposits with anterior segment optical coherence tomography (OCT Visante(®)) and high-frequency ultrasound biomicroscopy (CineScan HF, Quantel Medical(®)) was carried out preoperatively. The explanted IOLs were analyzed with optical and electron microscopy, and energy dispersive spectrometry (EDS). RESULTS: In both patients, the deposits were located on the surface and within the implant and were composed of calcium phosphate crystals. Vitreoretinal surgery performed a few months prior to the secondary opacification was identified as a risk factor. CONCLUSION: When a patient presents with a secondary opacification of the IOL involving the visual axis, explantation is sometimes necessary, fortunately with typically good functional recovery in the postoperative period. While this complication is rare and the exact pathophysiology poorly understood, it must be considered in a pseudophakic patient with an unexplained decrease in visual acuity who has undergone more than one intraocular procedure.

[Role of intravitreal bevacizumab for resistant macular edema due to central retinal vein occlusion after failure of intravitreal triamcinolone acetonide]. / Intérêt du bevacizumab dans le traitement des occlusions de la veine centrale de la rétine après échec de la triamcinolone.

PURPOSE: To evaluate the efficacy of bevacizumab injection used secondarily in patients with macular edema due to central retinal vein occlusion after failure of intravitreal triamcinolone acetonide injection. PATIENTS AND METHODS: The present study represents a retrospective review of eight patients presenting with central retinal vein occlusion complicated by macular edema with central foveolar thickness greater than 350 µm by Cirrus-OCT, Zeiss. Between 4 and 6 months after the central vein occlusion, all patients initially underwent intravitreal triamcinolone acetonide injection (4 mg/0.1 ml). In the case of functional or anatomic failure, three monthly bevacizumab injections (1.25mg/0.05 ml) were administered. Prior to each injection, an ophthalmic examination was performed, documenting visual acuity (ETDRS), biomicroscopy, IOP and central foveolar thickness (OCT 3). RESULTS: After three intravitreal bevacizumab injections, we found no improvement in visual acuity (M0 = 45.56 ± 13 letters; M3 = 44.2 ± 8.6 letters), and no decrease in macular thickness (M0 = 559 µm ± 193; M3 = 543 µm ± 263). No intraocular pressure spikes or endophthalmitis were observed. DISCUSSION: The lack of anatomic and functional efficacy observed in our study does not appear to be related to the method, dosage or timing of injection, nor to the presence of subretinal macroaneurysms. It may be due to a cross-resistance to these two drugs. In any event, recent approval of ranibizumab and intraocular dexamethasone implants will likely change our therapeutic approach. CONCLUSION: In case of recalcitrant macular edema secondary to central vein occlusion after failed intravitreal triamcinolone acetonide injection, secondary intravitreal bevacizumab does not appear beneficial.

[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.