Intravitreal dexamethasone implant versus anti-VEGF injection for treatment-naïve patients with retinal vein occlusion and macular edema: a 12-month follow-up study.

PURPOSE: The objective of his study was to compare the visual and anatomical outcomes in treatment-naïve patients with macular edema secondary to retinal vein occlusion after intravitreal injections of dexamethasone implants (DEX) and anti-VEGF. METHODS: One hundred two patients (64 in the anti-VEGF group, 38 in the DEX group) without previous treatment were included in this multi-center retrospective study and evaluated at baseline and 1, 3, 6, and 12 months after the onset of treatment. Patients were defined as "good responders" if central macular thickness (CMT) was less than or equal to 250 µm in TD-OCT or 300 µm in SD-OCT after the injections. RESULTS: At month 3 (n = 102), BCVA had increased significantly, by 0.1 ± 0.3 logMAR in the anti-VEGF group (p = 0.04) and 0.4 ± 0.4 logMAR in the DEX group (p < 0.001); the difference between the two groups was statistically significant (p = 0.007). CMT decreased significantly, by 138 ± 201 µm (-19 %, p < 0.001) in the anti-VEGF group and 163 ± 243 µm (-21 %, p < 0.001) in the DEX group. After 3 months, five patients (13 %) in the DEX group and 20 (31 %) in the anti-VEGF group (p < 0.001) changed treatment. Among the 77 patients who did not switch from their initial treatment, no significant functional or anatomical difference between the two groups was observed at months 6 and 12. Elevation of intraocular pressure > 21 mmHg was more frequent in the DEX group (21 %) than in the anti-VEGF group (3 %, p = 0.008). CONCLUSIONS: Visual acuity recovery was better in the DEX group than in the anti-VEGF group at month 3, but with no difference in CMT. In patients who did not change treatment, the long-term anatomical and visual outcome was similar between the DEX and anti-VEGF groups.

[Managing antithrombotic therapy in vitreoretinal surgery]. / Comment gérer les antithrombotiques en chirurgie vitréorétinienne ?

Given the growing number of patients on antithrombotic therapy we are increasingly confronted with the management of this therapy before, during and after vitreoretinal surgery. In the absence of a consensus, the decision to withdraw antithrombotic therapy is based on the cardiovascular thromboembolism risk versus the theoretical risk of bleeding if the antithrombotic treatment is continued. As suggested by the literature, antiplatelet therapy (acetylsalicylic acid or clopidogrel) may be safely continued for vitreoretinal surgery, including retinal detachment repair. However, the risk/benefit ratio for patients being treated with two antiplatelet therapies is unknown. It appears that an International Normalized Ratio (INR) less than 3 for patients treated with anticoagulant therapy does not increase the perioperative risk of ocular bleeding. This risk has not been evaluated in patients treated by new antithrombotic therapies (prasugrel, ticagrelor as antiplatelet medication, or dabigatran, rivaroxaban, apixaban as anticoagulant therapy), and there is a need to study it further.

[Ocular syphilis]. / Atteinte oculaire de la syphilis.

Syphilis is a sexually transmitted disease caused by Treponema pallidum. Previously known as the "great imitator", this disease can have numerous and complex manifestations. The ophthalmologist should suspect the diagnosis in patients with uveitis or optic neuropathy and high-risk sexual behavior and/or another sexually transmitted disease (such as HIV) or those presenting with posterior placoid chorioretinitis or necrotising retinitis. Ocular involvement in acquired syphilis is rare, tending to occur during the secondary and tertiary stages of the disease. Syphilis may affect all the structures of the eye, but uveitis (accounting for 1-5% of the uveitis in a tertiary referral center) is the most common ocular finding. Granulomatous or non-granulomatous iridocyclitis (71%), panuveitis, posterior uveitis (8%) and keratouveitis (8%) are often described. In the secondary stage, the meninges and the central nervous system can be affected, sometimes with no symptoms, which justifies performing lumbar puncture in patients with uveitis and/or optic neuropathy. The diagnosis of ocular syphilis requires screening with a non-treponemal serology and confirmation with a treponemal-specific test. Parenterally administered penicillin G is considered first-line therapy for all stages of ocular syphilis. Systemic corticosteroids are an appropriate adjunct treatment for posterior uveitis, scleritis and optic neuritis if ocular inflammation is severe. Prolonged follow-up is necessary because of the possibility of relapse of the disease. With proper diagnosis and prompt antibiotic treatment, the majority of cases of ocular syphilis can be cured.

FRIENDS Group: clinical and microbiological characteristics of post-filtering surgery endophthalmitis.

PURPOSE: To study the clinical and microbiological characteristics as well as the prognostic factors for post-filtering surgery endophthalmitis. METHODS: Twenty-three eyes were included in the study in four tertiary centres between 2004 and 2010. The clinical and microbiological data were collected prospectively (minimum follow-up, 6 months). Microbiological diagnosis was based on conventional cultures and panbacterial PCR (16SrDNA amplification and sequencing). RESULTS: The onset of endophthalmitis was early (<6 weeks) in 22 % of the cases and delayed in 78 %. Elevated intraocular pressure and hypopyon were more frequent in delayed than in early presentations (p = 0.04). By combining the results of culture and panbacterial PCR, a bacterial species could be identified in 73.9 % of the cases, including 56.5 % of commensal species of the digestive tract such as Moraxella spp., oropharyngeal streptococci and Enterococcus faecalis. Good final visual acuity (VA ≥ 20/40) was correlated with initial VA greater than light perception (p = 0.05). Poor final VA (≤20/400) was correlated with a higher virulence of the infecting bacterial species (p = 0.006), and was noted in all patients with early-onset endophthalmitis. CONCLUSION: Acute early- or delayed-onset post-filtering surgery endophthalmitis is frequently caused by bacteria of the digestive tract (e.g., Streptococcus and Enterococcus spp.). The combination of conventional cultures and panbacterial PCR allowed us to identify the causative microorganism in three-quarters of the cases, i.e., 21 % more cases than through culture alone. Despite adequate antibiotic and surgical treatment, the anatomical and visual prognosis remains poor.

Risks of non-lethal weapon use: case studies of three French victims of stinger grenades.

The development of non-lethal weapons started in the 1960s. In France, they have been used by the police for about 10 years. We relate the cases of three French women, victims of stinger grenades, non-lethal weapons recently adopted by the French law enforcement to distract and disperse crowds. The three victims presented serious injuries requiring emergency surgical care. One lost her eye. Based on these cases, we discuss the lethal character of these weapons and propose measures to be taken to prevent their dramatic consequences. Although the danger is obviously less than for firearms, stinger grenades are nonetheless potentially lethal and cause serious physical injuries.

[Prospective study of 34 retinal detachments associated with giant retinal tear]. / Etude prospective de 34 décollements de rétine par déchirure géante.

PURPOSE: To report the anatomical and functional outcomes of vitrectomy with silicone oil tamponade in the treatment of retinal detachment associated with giant retinal tears due to various factors. METHODS: We prospectively followed 34 eyes of 33 patients with giant retinal tear. That underwent vitrectomy, injection of perfluorocarbon liquids and silicone oil tamponade. Scleral buckle was associated with vitrectomy in cases of inferior giant retinal tear; 26,5 % and 11,8 %, respectively, demonstrated pseudophakia and aphakia. Seven eyes (20,5 %) had a history of trauma (blunt injuries in four and a penetrating injury in three) and, 14 eyes (41,2 %) had severe myopia. One patient developed a bilateral giant retinal tear during the follow-up. RESULTS: Retinal attachment was obtained in 33 (97 %) of 34 eyes, with a mean follow-up of 14,5+/-6 months. Retinal detachment reoccurred in four eyes (11,6 %) under silicone oil, in one eye (2,9 %) during the silicone removal, and in two eyes (5,8 %) after silicone removal and cataract surgery. Silicone oil was removed from all eyes (4,3+/-1 months). The most frequent postoperative complication was cataract in ten of 18 phakic eyes (55,5 %). Functional success with visual acuity 0,4 or better was obtained in 18 cases (52,96 %). CONCLUSION: Pars plana vitrectomy with silicone oil tamponade proved to be highly effective in giant retinal tears in terms of the anatomical and functional results. The analysis of recurrent retinal detachment allowed us to refine the technique and to suggest scleral buckle in one case of inferior retinal tear with laser over 360 degrees .

[Frosted-branch angiitis revealing Behçet's disease]. / Angéite givrée révélatrice d'une maladie de Behçet.

A 30-year-old man with a history of skin and recurrent oral ulceration over 1 year developed loss of visual acuity in the right eye. The diagnosis of acute frosted branch angiitis was based on retinal vasculitis associated with retinal edema and hemorrhages, confirmed using fluorescein angiography (venous leakage and extensive staining of the vein walls). General examination revealed pseudofolliculitis and recurrent oral ulcers. The diagnosis of Behçet's disease was based on the international criteria. The patient was treated with prednisolone and colchicine, which were effective with a normalization of the fundus 1 month later. The initial presentation of Behçet's disease as frosted branch angiitis is exceptional, the main differential diagnosis being herpetic infections, which must be ruled out.

Acute postoperative endophthalmitis caused by Staphylococcus lugdunensis.

Acute postoperative endophthalmitis caused by Staphylococcus lugdunensis is infrequently reported in clinical studies. Five cases of acute postcataract surgery endophthalmitis caused by S. lugdunensis were taken from a multicenter prospective study conducted in four university-affiliated hospitals in France (2004 to 2005). These cases were characterized by severe ocular inflammation occurring with a mean delay of 7.6 days after cataract surgery, severe visual loss (hand motions or less in three cases), and dense infiltration of the vitreous. Each of these patients was initially treated by using a standard protocol with intravitreal (vancomycin and ceftazidime), systemic, and topical antibiotics. Given the severity of the endophthalmitis, even though bacteria were sensitive to intravitreal antibiotics, pars plana vitrectomy was needed in four cases. The final visual prognosis was complicated by severe retinal detachment in three cases. The microbiological diagnosis was reached by using conventional cultures with specific biochemical tests and eubacterial PCR amplification followed by direct sequencing.

[Ultrasound imaging in the management of endophthalmitis]. / Place de l'échographie dans la prise en charge des endophtalmies.

Endophthalmitis is a major complication of surgery or trauma that may need an echographic evaluation by a general ophthalmologist in emergency. Echography is also useful for the therapeutic management of endophthalmitis. This review gives a general view of ocular lesions seen in this context (hyalitis, choroidal or retinal detachment, lens dislocation, intraocular foreign body, cellulitis). We describe a practical chart to standardize the echographic evaluation at the initial examination and during the follow-up.

[Acute endophthalmitis: from bacteria to clinical settings]. / Endophtalmies aiguës : du germe à la clinique.

The clinical presentation of endophthalmitis depends on numerous factors, especially the bacteria involved, which determines the delay of infection, the amount of ocular inflammation, and the final prognosis. Results of epidemiological studies have provided a better understanding of the correlation between bacteria and clinical characteristics. Some clinical signs may help the clinician to suspect a virulent bacterium. Clinical and microbiological factors are essential to guide the therapeutic strategy in patients with acute endophthalmitis.

[Microbiological and clinical diagnosis of acute endophthalmitis]. / Diagnostic microbiologique des endophtalmies aiguës.

The microbiological study identifies the bacterial spectrum after surgery, in acute, delayed-onset, or chronic endophthalmitis. DNA amplification of eubacterium-specific sequences in DNA extracted from ocular samples is a new tool for the etiological diagnosis of endophthalmitis. The most successful way to identify bacteria in endophthalmitis is the association of conventional cultures and panbacterial PCR on vitreous samples. Both techniques are complementary. The efficacy of these new molecular techniques should modify our future therapeutic strategies.

[Efficacy and safety of long-acting carteolol 1% once daily. A double-masked, randomized study]. / Efficacité et tolérance du cartéolol 1% à libération prolongée une fois par jour. Etude randomisée en double insu.

PURPOSE: Carteolol is a beta-adrenoceptor antagonist with intrinsic sympathomimetic activity. Used topically to reduce intraocular pressure, it is typically applied twice daily. In an effort to provide a once-daily dosing regimen, carteolol was formulated with 1% alginic acid. Sodium alginate is a natural polymer product with bioadhesive properties providing increased corneal contact time and a better carteolol penetration through the cornea. The objective of this study was to evaluate the efficacy and safety of long-acting 1% carteolol alginate solution compared to standard 1% carteolol solution. METHODS: This was a double-masked, parallel group, multicentre study. Patients with ocular hypertension or open angle glaucoma (n=151) were randomly assigned to receive either 1% carteolol alginate once daily (AM) or standard 1% carteolol solution twice daily for 2 months. The masking was maintained through the use of a placebo in the evening for the alginate group. Entry into the study required unmedicated intraocular pressure (IOP) between 23 mmHg and 32 mmHg at 9 AM and 11 AM. Patients using ocular hypotensive medication were required to undergo a washout. All patients provided written informed consent. Excluded from the study were patients with angle closure, congenital, secondary glaucoma or advanced glaucoma; any intraocular infection or inflammation, ocular trauma, ocular surgery or laser trabeculoplasty within the previous 3 months; contraindications to the use of beta adrenoceptor antagonists; systemic medications likely to modify IOP prescribed or modified during the previous 3 months; ocular steroid use; contact lens wear; and pregnant and lactating women. Patients were evaluated at baseline, 15 and 60 days, with IOP measurements at 9 AM and 11 AM. At day 15 and day 60, IOP was measured just before instillation of medication (9 AM) and 2 hours after (11 AM). Slit lamp examinations were performed at each follow-up examination, together with measurement of heart rate and blood pressure (10 AM) and ocular tolerance after medication (11 AM). The primary efficacy criterion was the decrease in IOP from baseline at day 60 for each measurement at 9 AM and 11 AM. The study eye was the eye with the higher IOP at day 0 or, if equal, the right eye. RESULTS: Efficacy-of the 151 patients included in the study, 149 were evaluated (two patients were lost to follow-up after day 0): 74 in the alginate group and 75 in the standard group. Both treatment groups were comparable at day 0 except for sex, diastolic blood pressure, and IOP in the fellow eye. At 09.00 hours (presumed trough) on day 60, mean reductions from baseline in intraocular pressure were 6.32+/-2.87 and 5.67+/-3.30 mmHg for the alginate carteolol and standard groups, respectively. At 11.00 hours (presumed peak), mean reductions were 6.70+/-2.81 and 6.55+/-3.35 mmHg, respectively. At each evaluation time, the two unilateral t tests were highly significant (p<0.005), confirming the equivalence of both treatments. Conclusions were not modified taking into account sex and diastolic blood pressure. Safety- Slight decreases in heart rate and blood pressure means were observed in both groups at follow-up visits with no significant difference between groups. Subjective tolerance upon instillation was judged good or very good at day 60 by 100% of alginate patients and by 98.7% of standard patients. Transient discomfort (mainly stinging or burning sensation) was reported by approximately 4% - 6% of patients in each treatment group at each visit. A blurred vision sensation was reported by 2 out of 74 patients of the alginate group. Among the 17 reported adverse events, three were assessed as drug-related: one vertigo, one superficial punctate keratitis in the alginate group and one decrease in blood pressure in the standard group. No serious adverse events were reported. CONCLUSIONS: The new alginate formulation of long-acting carteolol 1% given once daily is as effective as standard 1% carteolol given twice daily, with no meaningful differences regarding safety. This efficacy wasy was verified at 9 AM (24 hours after the last drop of long-acting carteolol or 12 hours after that of standard carteolol) and at 11 AM (2 hours after the morning drop). The new alginate formulation of long-acting carteolol 1% given once a day is effective and well tolerated by glaucoma patients who require chronic treatment.

[Surgery for choroidal subfoveal neovascularization in patients with severe myopia. Retrospective analysis of 17 patients]. / Chirurgie des néovaisseaux choroïdiens rétrofovéolaires du sujet myope fort.

UNLABELLED: Treatment of choroidal neovascularization in pathological myopia is still controversial. METHODS: A retrospective analysis of 17 patients with severe myopia (>-6) and subfoveal choroidal neovascularization who underwent surgical removal of choroidal neovascularization, was performed. The patient population consisted of 2 groups: 9 patients younger than 50 years and 8 patients older than 50 years. All the patients underwent vitrectomy with surgical removal of subfoveal choroidal neovascularization. RESULTS: We reviewed the postoperative clinical and angiographic findings. In group I, visual acuity improved in 4 eyes (44%), remained unchanged in 4 eyes (44%) and decreased in one eye. In group II, none of the patients had visual improvement, visual acuity remained unchanged in 6 eyes (71%), and decreased in 2 eyes. CONCLUSION: The visual outcomes in most patients in this series were better than their natural history. Surgical removal of subfoveal choroidal neovascularization associated with severe myopia may provide visual benefit in young patients. A prospective, randomized clinical trial is necessary to determine the place of this surgical procedure.

[Radiotherapy for age-related macular degeneration: risk factors of complications, prevention and treatment of side-effects]. / Radiothérapie dans la dégénérescence maculaire liée à l'âge: facteurs de risque de survenue des complications, prévention et traitement des effets secondaires.

PURPOSE: To analyze the retinal and choroidal side-effects of radiotherapy given for age-related macular degeneration (ARMD) and to describe the risk factors of these complications and their treatment. MATERIAL: and methods: Two hundred and ninety five eyes in 270 patients with ARMD were treated using radiotherapy. Nineteen patients had diabetes. The doses were as follows: 15 Gy or less (4 eyes); 16 Gy/4 fractions (113 eyes); 18 Gy/5 fractions (35 eyes); 20 Gy/5 fractions (123 eyes); 24 Gy/6 fractions (2 eyes); 28.8 Gy/8 fractions (17 eyes); more than 28.8 Gy (1 eye). Patients had a regular follow-up visit with visual acuity, contrast sensitivity evaluation, biomicroscopic fundus examination, fluorescein and ICG angiographies every six months over a mean period of 15 months. RESULTS: Radiation retinopathy was noted in 15 eyes, a bilateral neovascular glaucoma in one patient, ischemic optic neuropathy in 5 eyes, choroidal telangiectasiae in 19 eyes, venous occlusion in 2 eyes, oedematous retinopathy with major exudation (ORME) in 31 eyes, and choroidal hematoma in 8 eyes. Radiation retinopathy, choroidal telangiectasiae and ORME were related to radiation dose. Radiation retinopathy was more severe and more frequent in patients with diabetes. Choroidal telangiectasiae were diagnosed with ICG angiography and were treated early with laser. CONCLUSION: Radiotherapy for ARMD should not be done in patients with diabetes. Hypofractionation is not recommended. ICG angiography should be considered essential in the follow-up of patients treated with radiotherapy.

[Implantation of autologous chondrocytes for cartilagenous lesions in young patients. A study of 24 cases]. / Implantation de chondrocytes autologues pour lésions cartilagineuses du sujet jeune. Etude de 24 cas.

STUDY AIM: The aim of this study was to describe the treatment of symptomatic knee cartilage defects on young active patients by autologous chondrocyte implantation and to report preliminary results in 24 patients. PATIENTS AND METHODS: Since April 1996, 24 selected patients underwent 25 implantations in five military hospitals. There were 19 men and five women (all of them practicing sports); mean age was 27. Lesions were localized on left (n = 13) and right (n = 12) aligned and stabilized knees. There were 12 isolated cartilage defects (eight OCD and four posttraumatic) and 13 associated with ligament lesions (n = 8) or multiple and severe lesions (n = 3 indication of salvage). Mean surface of cartilage defects was 6 cm2. Mean preoperative evolution was 11 months and stage was grade IV (Outerbridge) for all. The first step was arthroscopy for classification and biopsy. The second one was implantation after a 3-week delay (for the ex vivo culture) through arthrotomy, under a periosteal flap taken from tibia and sutured on the edges of the prepared defect. Weight bearing was allowed after the 6th week; MRI was performed at 6, 12, 18, 24 months. The follow up was evaluated with three scales: Lysholm 2, Tegner Activity, Cincinnati Knee Rating System. RESULTS: Postoperative complications included: algodystrophy (n = 2) and phlebitis (n = 1). Four patients were revised at 6 months, seven between 6 and 12 months, 11 after. The longest follow-up was 26 months. Results were poor in one patient (salvage). For the others, pain and swelling decreased after 6 months and disappeared after 12 months. CONCLUSION: Autologous chondrocyte implantation used in this senes and in a large international ongoing series seems to be the only procedure allowing a true long-term regeneration of cartilage defects. Some questions remain, on the biological level in relation with the use of some growth factors and the risk of chromosomic abnormalities, and on the economical level because of the high cost of this technique.

Schwannoma of the bulbar conjunctiva.

We describe a conjunctival tumor that occurred in the limbic region of the left eye in a 37-year-old man. The mass was located beneath the conjunctival epithelium. It consisted of a well-demarcated proliferation of fusiform cells arranged in bundles in a fibrous stroma. Tumor cells strongly expressed S-100 protein. On ultrastructural analysis, the tumor was composed of Schwann cells surrounded by a continuous basal lamina. These data led to the rare diagnosis of conjunctival schwannoma.

Comparative clinical trial of AMO Vitrax and Healon use in extracapsular cataract extraction.

This randomized, single-masked, multicenter clinical trial, comprising 95 patients enrolled at five sites, evaluated the performance of AMO Vitrax and Healon viscoelastic materials during cataract surgery. Patients were examined preoperatively and at one day, four days, one month, and three months postoperatively. The following measurements were recorded and analyzed: percentage of endothelial cell loss from preoperative to three months postoperative; change in intraocular pressure (IOP) from preoperative to 24 hours postoperatively; postoperative corrected visual acuity; subjective assessment of ability of viscoelastic to create and maintain tissue space; intraocular transparency; ease of evacuation. Three months postoperatively, endothelial cell loss was 4.9% (+/- 8.3%) for the AMO Vitrax group and 6.3% (+/- 10.5%) for the Healon group. One day postoperatively, IOP decreased by 1.6 mm Hg and increased by +1.1 mm Hg, respectively. Postoperative visual acuities were similar between the two groups at three months. Subjective assessment of transparency was higher for Healon. Assessment of tissue space maintenance was similar between the two materials. Healon was rated as slightly easier to evacuate.

[Vacuum mattress for positioning patients with severe kyphoscoliosis in eye surgery under loco-regional anesthesia]. / Le matelas coquille pour l'installation des patients atteints de cypho-scoliose sévère en chirurgie ophthalmologique sous anesthésie loco-régionale.

Severe kyphoscoliotic patients cannot be positioned in a safe way for eye surgery. We use a device created for prehospital care, vacuum mattress. This device allows a comfortable position for the patient and surgeon, leading to better loco-regional anaesthesia possibilities.

[Primary empty sella turcica syndrome]. / Syndrome de la selle turcique vide primaire.

Authors relate a typical case of primary empty sella turcica. Its physiopathogenesis is not yet well known, ophthalmological manifestations are non specific and variable, and authors point out difficulties in treatment.