[Treat-and-extend anti-angiogenic protocol in clinical practice for patients with exudative age-related macular degeneration: Consensus of French experts]. / Consensus d'experts français sur la mise en œuvre pratique du régime Treat-and-Extend par anti-angiogéniques chez les patients atteints de DMLA exsudative.

Optimizing treatment regimens for anti-angiogenic drugs is now a major issue in the management of patients with exudative AMD. The evolution of these approaches has led retinologists to favor so-called proactive administration regimens, such as Treat-and-Extend (T&E), which make it possible to anticipate recurrence and to plan intravitreal injections of anti-angiogenic drugs in advance. Nevertheless, a real need to standardize the application of this regimen has been identified. This article proposes a consensus based on the Delphi methodology, which might provide a guide for ophthalmologists to manage patients with exudative AMD using the T&E protocol. While some aspects remain debated to date, this article provides elements to guide the implementation of T&E. The experts recommend that a loading dose of 3 monthly injections should be administered before starting T&E. They also recommend adjusting the reinjection intervals by±2 weeks in a standardized fashion. The intervals are then decreased in the presence of anatomical and/or functional deterioration, maintained when the interval of recurrence is identified, and increased when anatomical and/or functional improvement is observed. A maximum interval between 3 and 4 months is recommended by the experts, with maintenance of the maximum interval for 1 year before considering a possible exit from the T&E protocol. In the event of a significant decrease in visual acuity related to the disease along with significant anatomical degradation, it is recommended to restart monthly injections. In the case of bilateral disease, when synchronized timing of injections for both eyes is desired, the experts recommend using the shorter of the two intervals.

[Dexamethasone intravitreal implant (Ozurdex) in patients with diabetic macular edema: Real life safety and efficacy]. / Implant de dexaméthasone (Ozurdex) dans l'œdème maculaire diabétique : efficacité, et sécurité d'utilisation en vraie vie.

PURPOSE: The goal of this study was to investigate the safety and efficacy of the intravitreal dexamethasone implant (DI) for patients with diabetic macular edema (DME) in real life. METHODS: We conducted a monocentric retrospective analysis of the change in visual acuity and central macular thickness (CMT) after intravitreal injection of the DI at peak efficacy (2 months after injection) as well as the timing of reinjections and complications in patients with a loss of vision due to DME. RESULTS: Forty eyes of 33 patients were included, with a mean follow-up of 12.6 months. Thirty percent of the eyes experienced an increase in best corrected visual acuity (BCVA)>15 letters at peak efficacy (P<0.05) after each ID injection. Treatment-naive patients had a sustained response after Ozurdex injection, with better visual acuity at 3 months (P=0.02) and 4 months (P=0.04) than non-naïve patients and better visual acuity at 6 months despite identical baseline visual acuity (P<0.05). Anatomical efficacy was good, with approximately 60% of patients with CMT<300 microns at peak efficacy after each injection of ID. Thirty percent of eyes demonstrated ocular hypertension (OHT)>25mmHg at peak efficacy, and 12.5% of eyes required cataract surgery during follow-up. CONCLUSION: The DI has good functional and anatomic efficacy in these patients, with a good safety profile. Treatment-naïve patients with more recent DME had a more sustained increase in visual acuity after the injections and better visual recovery at 6 months. This encourages us to initiate DI therapy early if there is no response to anti-vascular endothelial growth factor (anti-VEGF) treatment.

Approche diagnostique et thérapeutique de la vasculopathie polypoïdale choroïdienne. Recommandations de la Fédération France Macula.

PURPOSE: To update the medical literature on the diagnostic and therapeutic approach to polypoidal choroidal vasculopathy (PCV) and to propose a treatment algorithm in agreement with French market approval, supported by the France Macula Federation (FFM). METHODS: Literature review and expert opinion. RESULTS: The diagnosis of PCV is based on multimodal imaging, including indocyanine green angiography (ICGA), which is considered the gold standard for the diagnosis of PCV. Regarding the therapeutic management of PCV, the FFM recommends treating PCV first-line either by monotherapy with intra-vitreal anti-vascular endothelial growth factor (anti-VEGF) injections, or by a combined treatment of photodynamic therapy (PDT) with Verteporfin and intra-vitreal anti-VEGF injections, depending on the location of the PCV.

[Early efficacy of dexamethasone implant (OZURDEX®) in diabetic macular edema: Real life study]. / Efficacité précoce de l'implant de dexaméthasone (OZURDEX®) évaluée en vraie vie dans le traitement de l'œdème maculaire diabétique.

PURPOSE: To assess early efficacy of dexamethasone intravitreal implant 0.7mg (OZURDEX®) at the time of peak efficacy (2 months after injection) in patients with decreased visual acuity secondary to diabetic macular edema (DME). MATERIALS AND METHODS: Retrospective monocentric study. Inclusion criteria were best-corrected visual acuity (BCVA)≤70 letters (20/40) due to DME and central retinal thickness (CRT)≥300 microns (Cirrus 2, Carl Zeiss Meditec, Inc, Dublin). Enrolled patients could be treatment naive or not (after failure of laser photocoagulation and/or anti-VEGF therapy). Follow-up was at least 6 months. Our primary endpoint was BCVA gain at M2 after injection. Secondary endpoints were best-corrected visual acuity at 2 and 4 months, central retinal thickness at 2 and 4 months, mean interval between 2 injections, and adverse events. RESULT: Nineteen eyes of 19 patients were included in this study. The mean age was 67.45 years, sex ratio was 2.17 men/women, and the patients were all type 2 diabetics. Three of 19 patients were treatment naive for anti-VEGF intravitreal injection, and 52.3% were pseudophakic (10/19 patients). The mean gain of BCVA at M2 was +7.7 letters. The mean BCVA was 51.1 ETDRS letters at baseline and 58.8 at M2. Mean CRT was 568.9µm at baseline and 291.2µm at M2. Treatment with dexamethasone implant was mainly a second-line treatment after failure of other treatments (macular laser photocoagulation and/or intravitreal injection of anti-VEGF). Three patients were naive of anti-VEGF treatment. Intraocular pressure≥25mmHg was found in 2 patients, and controlled medically. No glaucoma surgery was performed. CONCLUSION: The dexamethasone implant (OZURDEX®) allows an anatomical and functional improvement in patients suffering from vision loss due to DME. In this series, the implant was well tolerated.

Treatment patterns of ranibizumab intravitreal injection and dexamethasone intravitreal implant for retinal vein occlusion in the USA.

PurposeRanibizumab, an anti-vascular endothelial growth factor, and dexamethasone, a corticosteroid, have been shown to be effective in treating macular oedema secondary to retinal vein occlusion (RVO) (central RVO (CRVO) and branch RVO (BRVO)). Their real-world usage, however, has yet to be compared. We therefore evaluated ophthalmology visits for both drugs using US patient-level data.MethodsThe IMS Health Real-World Data Medical Claims database was used to identify treatment-naive patients receiving ranibizumab intravitreal injections or dexamethasone intravitreal implants between June 2010 and February 2014 who had 12 months of follow-up data. The primary outcome measure was the mean number of all ophthalmology visits for the two drugs in patients with CRVO and BRVO. Secondary outcome measures included a comparison of treatment visits, non-treatment visits, and time intervals between visits.ResultsOverall, 2822 patients received ranibizumab injections (CRVO, 1178; BRVO, 1644) and 365 received dexamethasone implants (CRVO, 191; BRVO, 174). The mean number (SD) of all ophthalmology visits was higher for patients receiving ranibizumab injections than for those receiving dexamethasone implants (CRVO: 7.2 (3.6) vs 6.2 (3.1), P<0.001; BRVO: 7.1 (3.4) vs 6.3 (3.1), P=0.016).ConclusionsPatients with RVO receiving ranibizumab injections had a mean of approximately one more visit to their ophthalmologist in the first 12 months of treatment than those treated with dexamethasone implants. The visit burden is therefore not substantially different and physicians should focus on the clinical benefits of these drugs when evaluating treatment options for RVO.

[French practice patterns in the management of diabetic macular edema]. / Étude des pratiques françaises dans la prise en charge de l'œdème maculaire diabétique.

PURPOSE: To assess French practice patterns in the treatment of diabetic macular edema (DME). METHODS: A 31-item survey investigating practice patterns in the diagnosis and management of DME was e-mailed in March 2015 to retina specialist members of the French-speaking Retina Specialist Society. During this time frame, only ranibizumab was reimbursed for this indication. For each question concerning the choice of treatments, respondents were asked to assume that all treatments having market approval were also reimbursed. Answers were analyzed anonymously by Evalandgo software. RESULTS: Ninety-five specialists answered the survey. Two thirds of them initiated an intravitreal treatment for DME for a loss of vision greater than 0.5 (Monoyer scale). The three determining factors for treatment choice were potential VA improvement, expected retinal anatomic improvement, and patient availability for monthly follow-up. For central DME in phakic or pseudophakic eyes, the first choice of intravitreal (IVT) treatment was ranibizumab, even assuming that all drugs approved by French authorities (HAS) were reimbursed by the health care system. Eighty-five percent of retinal specialists propose bilateral intravitreal injections the same day for the same patient. CONCLUSION: Most of the specialists initiate DME treatment for a VA>0.5 in France. Eighty-five percent of them perform bilateral intravitreal injections on the same day in the case of bilateral DME.

[Management of macular edema secondary to retinal vein occlusion]. / Prise en charge de l'œdème maculaire secondaire à une occlusion veineuse rétinienne.

BACKGROUND: In recent years, intravitreal injections have added to the treatment modalities available for macular edema (ME) secondary to retinal vein occlusion (RVO). This article aims to provide an update regarding the management of ME secondary to RVO. METHODS: A work group met in order to analyze the literature available on Embase/PubMed, regarding treatments for venous occlusion that have received market approval and are reimbursed in France. In total, 33 articles were selected. Consensus within the group for recommendations was based on this data from the literature review and clinical experience and was reported in this article. RESULTS: The management of ME secondary to branch retinal vein occlusion (BRVO) or central vein occlusion of the retina (CRVO) differs on a number of points. Methods of best practice were discussed separately for BRVO and CRVO, taking into account various ocular and associated parameters. DISCUSSION: Ranibizumab and dexamethasone implant are the first-line treatments for visual impairment due to ME secondary to RVO. The choice of either of these drugs may take into account various ocular and extraocular parameters. A change of treatment to one or the other or to laser may also be considered during follow-up.

[Severity of diabetic macular edema (DME) in Seine St Denis among patients treated by anti-VEGF]. / Sévérité de l'œdème maculaire diabétique (OMD) en Seine-Saint-Denis chez des patients traités par anti-VEGF.

INTRODUCTION: DME is the main cause of loss of vision over the course of diabetes. DME incidence is correlated with diabetes duration, high glycemic levels, high blood pressure, and the severity of diabetic retinopathy. To prevent DME, patients need to have access to medical care. In this study, we sought to know whether DME was more severe in Seine-Saint-Denis, a French area, where the poverty is higher than in other french places, and where the number of physicians is lower. PATIENTS AND METHODS: We enrolled patients suffering from DME and treated by ranibizumab intravitreal injections between November 2012 and April 2013. In order to evaluate the severity of DME and the medical management of diabetes of these patients, we collected the following parameters: central macular thickness measured by SD-OCT, best corrected visual acuity, diabetic retinopathy severity, HbA1c, diabetes duration, type of diabetes, insulinotherapy, previous DME treatment and associated diseases. RESULTS: We included 25 type 2 diabetic patients (8 women and 17 men), the mean age was 64±8.1 years. Mean central macular thickness was 523±145µm. The best corrected visual acuity was 45 letters at baseline (counting fingers-70 letters). Twenty-two patients (88%) had a severe non-proliferative diabetic retinopathy or a proliferative diabetic retinopathy. Mean HbA1c was 7.8% (±2.3%). For 23 cases (92%), diabetes was associated with high blood pressure. Sixty-four percent were treated by insulin. Diabetes lasted for 13.1 years at baseline. DISCUSSION AND CONCLUSION: Diabetic patients, in this case series, had a more severe DME regarding macular thickness and visual acuity than patients from large randomized studies found in the literature. This severity could be due to a sub-optimal management of their diabetes. DME may become a tool to identify patients with a limited access to good medical cares.

[Pseudoexfoliation syndrome and phacoemulsification: comparative study with a control population]. / Syndrome pseudoexfoliatif et phakoexerèse : étude comparative à une population témoin.

PURPOSE: To determine the outcomes in cataract surgery by phacoemulsification in eyes with pseudoexfoliation syndrome (PEX) compared with eyes without this syndrome and to analyze the clinical features of pseudoexfoliation syndrome. PATIENTS AND METHODS: A retrospective, single-center comparative study was conducted on patients who underwent cataract surgery between January 2006 and December 2008. Demographic parameters (age, sex, ethnicity, medical and ophthalmologic history), clinical features (visual acuity, pupil dilatation, intraocular pressure) before and after surgery, and surgery complications were analyzed and compared to a control group without PEX. RESULTS: One hundred and four eyes of 81 patients were included in the study. The eyes were divided into two groups: 52 eyes with pseudoexfoliation syndrome (PEX) and 52 eyes without pseudoexfoliation (control group). The rate of surgical complications was not statistically different between the pseudoexfoliation and control groups. The mean preoperative and postoperative visual acuity were not statistically different between the two groups. The mean postoperative visual acuity was LogMAR 0,06 + or - 0,2 in the pseudoexfoliation group and LogMAR 0,03 + or - 0,06 in the control group. The mean follow-up was 1,4 + or - 1,3 months in the pseudoexfoliation group and 1 month in the control group. Pseudoexfoliation was bilateral in 72 % of cases. Open-angle glaucoma or ocular hypertension was associated in 21 cases (40 %) in the pseudoexfoliation group versus no open-angle glaucoma and five cases of ocular hypertension in the control group (10 %). Poor pupil dilatation was observed in 25 cases (48 %) in the pseudoexfoliation group and in two cases (4 %) in the control group. Phacoemulsification with IOL was the surgical technique in all the cases, with only one case of anterior chamber IOL in the pseudoexfoliation group. DISCUSSION: Cataract surgery in PEX is known to be associated with more complications during surgery. Poor pupil dilatation is one of the most common problems in cataract surgery in eyes with PEX. Nevertheless, the cataract surgery in eyes with PEX syndrome is not associated with a higher rate of surgical complications in our study. However, PEX required optimized surgery. Pseudoexfoliation syndrome is most common in its bilateral presentation. It is associated with chronic secondary open-angle glaucoma. The best visual acuity after surgery was similar in the two groups, but PEX required more time to attain this maximal visual acuity. Coronary heart disease could occur more frequently in patients with PEX compared with subjects without PEX. CONCLUSION: Pseudoexfoliation syndrome did not confer a statistically higher risk for surgical complications in eyes without marked phacodonesis or lens subluxation. Pseudoexfoliation syndrome did confer a higher risk for glaucoma and coronary ischemia.

[Value of first-day postoperative visit after cataract surgery]. / Intérêt de la visite du J1 dans la chirurgie de la cataracte.

INTRODUCTION: In France in 2009, newly operated patients after cataract surgery are usually seen by their surgeon the day after surgery (D1). The value of this day-after visit has been undergoing reassessment for some years, but this visit remains in widespread use in France. The aim of this study was to assess whether this visit changes patient management. PATIENTS AND METHODS: One hundred three consecutive patients (106 eyes) undergoing cataract surgery by phacoemulsification were prospectively treated in our department (82% were outpatients). All intraoperative events were noted. The day after surgery, we monitored ocular tension, the anterior segment, and the fundus. Every change in the postoperative prescription compared with a standard prescription was noted. RESULTS: Intraoperative complications occurred in eight cases. On D1, six patients had ocular hypertension that exceeded 24 mmHg, 14 had a corneal edema, six had corneal erosion, two had a Seidel, one had an anterior subluxation of the IOL, and one had retinal detachment. In 26 cases (24.5%), the prescription was changed compared to our standard prescription. DISCUSSION: Several studies have shown that the day-after-surgery visit was not mandatory. The main objective of this visit is to check for ocular hypertension. More rarely, it can detect a Seidel in front of the wound, incorrect position of the IOL, retinal detachment, or other complications that may require surgery. CONCLUSION: The day-after-surgery visit remains necessary after phacoemulsification because complications, sometimes unpredictable, can occur and compromise the result of surgery. This visit also has an educational value (to reiterate to the patients the symptoms that would require an emergency visit).

[Retinal vein occlusion: anti-VEGF treatments]. / Occlusions veineuses rétiniennes : traitements anti-VEGF.

To date, there is no consistently effective proven therapy for patients with macular edema resulting from central retinal vein occlusion. Grid laser treatment only showed visual acuity benefit in branch retinal vein occlusion. Other treatment like intravitreal triamcinolone acetonide demonstrated transient inconsistent benefit with potential complications. As retinal vein occlusion is associated with increased levels of Vascular Endothelial Growth Factor (VEGF), anti-VEGF therapy was proposed to be a promising strategy for retinal vein occlusion. We reviewed the current literature on this topic: case reports, non controlled and non randomized trials. Short term results are encouraging with visual acuity benefit associated with reduction of retinal central thickness but multiple injections seems to be necessary to achieve visual stabilization. Further randomized and controlled clinical trials are necessary to confirm the long term safety and efficacy of bevacizumab in the care of retinal vein occlusion edema treatment.

[Ophthalmologic disease in sarcoid-like granulomatosis and true sarcoidosis in immunodeficiency. Four case reports]. / Atteintes ophtalmologiques de la sarcoïdose et des "sarcoid-like reaction" dans les déficits immunitaires. A propos de 4 cas.

Granulomatosis lesions occurring after diagnosis of primary or secondary immunodeficiency are not accidental and have been described in a small number of patients suffering from various diseases: common variable immunodeficiency (CVID), malignancy (lymphoma and solid tumors), and acquired immunodeficiency syndrome (AIDS). Two types of granulomatosis can appear: true sarcoidosis and sarcoid-like reaction. We report four patients, two with CVID and two with malignancy, in whom clinical granulomatosis appeared a few months to a few years after diagnosis of immunodeficiency. They developed noncaseating granulomas of the lung, spleen and liver associated with conjunctival granulomas and bilateral panuveitis. The granulomatous disorder was diagnosed after immunodeficiency on histopathological studies revealing noncaseating granulomas. Causation agents such as infectious organisms and environmental compounds were excluded. The relationship between sarcoid-like reaction, true sarcoidosis and immunodeficiency is discussed. The underlying pathophysiology responsible for the association between granuloma formation and immunodeficiency in the same patient remains obscure. It may be quite difficult to distinguish true sarcoidosis and sarcoid-like reaction. It is possible that these two entities are the clinical extremes of a common pathological process.

[Cataract surgery and age-related maculopathy: benefits in terms of visual acuity and quality of life--a prospective study]. / Chirurgie de la cataracte et dégénérescence maculaire liée à l'âge: bénéfice en termes d'acuité visuelle et de qualité de vie--étude prospective.

PURPOSE: To assess the benefits of cataract surgery in patients with age-related macular degeneration (AMD) in terms of visual acuity and quality of life. PATIENTS AND METHODS: Forty-two eyes of 30 patients were included in this prospective study between October 2003 and January 2005. The eyes were divided into two groups: the first group (n=12) with geographic atrophy and neovascularization (late-stage AMD) and the second group (n=30) with drusen and retinal pigment epithelium abnormalities (early-stage AMD). Assessment included best corrected visual acuity (BCVA) and quality-of-life measures (VF-14 questionnaire) before surgery and BCVA and the VF-14 score after surgery. RESULTS: In the first group, there was no statistical difference but a trend toward improvement in BCVA (p>0.05). In terms of quality of life, there was a statistical difference between pre- and postoperative VF-14 (p=0.0078). In the second group, there was a statistical difference between pre- and postoperative BVCA (p<0.0001). In terms of quality of life, there was a statistical difference between pre- and postoperative VF-14 (p<0.0001). CONCLUSION: This study shows a benefit in terms of visual acuity and quality of life in the majority of patients with age-related maculopathy after cataract surgery, even in late-stage AMD. Indeed, we noted a marked improvement in visual acuity in cases of early-stage AMD and a slight improvement of visual acuity in late-stage AMD. Quality of life was improved at both stages. In conclusion, cataract surgery is justified in patients with AMD.