[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.

[Proliferative vitreoretinopathy: prophylactic treatment]. / Prolifération vitréo-rétinienne: traitement préventif.

Proliferative vitreoretinopathy (PVR) is a complex process. It causes contractile fibrocellular membranes that may prevent retinal reattachment. PVR therefore remains one of the most severe complications of rhegmatogenous retinal detachment (RD), with an incidence of 5-11%, and is among the most frequent causes of surgical failure (50-75%). Its severity derives from the complexity of the surgery required to treat patients and from its uncertain anatomic and functional prognosis. The first step in preventing PVR is to identify patients at risk by means of clinical and/or biological factors such as the characteristics of retinal tears (large size, number) and detachment (preexisting PVR, extent), and the use of cryotherapy. Surgeons must therefore adapt their surgical approach to the risk of PVR. The study of animal models and the natural history of the condition in humans demonstrate the importance of early antiproliferative treatment in the early stage of the disease. Combining 5-fluoro-uracil and heparin in the vitrectomy infusion lowers the rate of postoperative PVR onset in patients with PVR risk factors. The evaluation of new molecules and new dosages will lead to a decisive step in the fight against PVR.

[Proliferative vitreoretinopathy: pathophysiology and clinical diagnosis]. / Prolifération vitréo-rétinienne : physiopathologie et diagnostic clinique.

Proliferative vitreoretinopathy (PVR) remains one of the most common causes of failed retinal detachment (RD) surgery. Many histological and clinical studies have highlighted the chain of events leading to PVR: cellular migration into the vitreous cavity, cellular differentiation, myofibroblast proliferation and activation, synthesis of extracellular matrix proteins, then contraction of preretinal tissues. The development of PVR can be explained schematically by cellular exposure to growth factors and cytokines (particularly retinal pigment epithelial cells and glial cells), in the context of break-down of the blood-retinal barrier (inflammation, choroidal detachment, iatrogenic effect of cryotherapy and surgery) and of cellular contact with the vitreous. Although the pathophysiology of PVR is now better understood, its severity remains an issue. A systematic search for preoperative PVR risk factors allows the most suitable therapeutic option to be chosen.

[Proliferative vitreoretinopathy: curative treatment]. / Prolifération vitréo-rétinienne : traitement curatif.

Proliferative vitreoretinopathy (PVR), which causes contractile fibrocellular membranes that may prevent retinal reattachment, remains one of the most severe complications of rhegmatogenous retinal detachment (RD), with an incidence of 5-11%, and one of the most frequent causes of surgical failure (50-75%). Its severity is due to the complexity of the surgery required to treat patients, and to its uncertain anatomic and functional prognosis. Curative treatment of PVR includes vitrectomy, sometimes associated with phacoemulsification or scleral buckling; systematic peeling of epiretinal membranes, occasionally retinectomy; and systematic retinopexy by endolaser photocoagulation. The current preferred internal tamponade is silicone oil. Silicone oils of various densities are undergoing comparative studies.

[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 .

Screening of diabetic retinopathy: effect of field number and mydriasis on sensitivity and specificity of digital fundus photography.

PURPOSE: To evaluate the sensitivity and specificity of one- and three-field, nonmydriatic and mydriatic, and 45 degrees digital colour photography compared with mydriatic indirect ophthalmoscopy for diabetic retinopathy (DR) screening. METHODS: A group of 79 patients (158 eyes) were included in this prospective study. Colour fundus photographs were taken with a Topcon TRC-NW6S digital camera, using four different techniques--single-field nonmydriatic; three-field nonmydriatic; single-field mydriatic; and three-field mydriatic--followed by dilated ophthalmoscopy. Two independent ophthalmologists classified blinded photographs according to the presence or absence of specific diabetic retinal findings. The sensitivity, specificity and agreement (kappa analyses) of the four methods were calculated for the presence or absence of DR and for all diabetic retinal findings. RESULTS: The sensitivity and specificity of digital photography compared with ophthalmoscopy for detection of DR were, respectively: 77 and 99% using single-field nonmydriatic; 92 and 97% using three-field nonmydriatic; 90 and 98% using single-field mydriatic; 97 and 98% using three-field mydriatic. The degrees of agreement for the four methods were 0.82, 0.90, 0.90 and 0.95, respectively. For specific retinal findings, sensitivity was greater for detection of hard exudates, nerve fibre layer haemorrhage and venous beading, and lower for detection of microaneurysms, dot-blot haemorrhage, cotton wool spots and intraretinal microvascular anomalies. CONCLUSION: The three-field strategy without pupil dilation represents a good compromise, with reasonable sensitivity and good comfort (short examination duration, able to drive after photography) favouring patient compliance with the screening programme.

[Diffuse diabetic macular edema surgery: prospective study of seven cases followed up with optical coherence tomography]. / Chirurgie de l'oedème maculaire chez le patient diabétique: étude prospective de 7 cas suivis en tomographie par cohérence optique.

INTRODUCTION: A prospective study was performed in seven eyes of seven consecutive patients who had vitrectomy for diffuse diabetic macular edema (DME) with ILM premacular delamination as part of this treatment. PATIENTS AND METHODS: All patients had retinopathy and DME. Only one patient had previous grid photocoagulation. In all eyes, there was no ophthalmoscopic evidence of traction from the posterior hyaloid membrane or proliferative tissue, but all patients had no posterior vitreous separation. A clinical examination and optical coherence tomography (OCT) were performed in preoperative and postoperative surgery (1 and 6 months). Pars plana vitrectomy with separation of the posterior hyaloid was performed in seven cases. RESULTS: Only three patients had vitreomacular traction observed on OCT. Statistical analysis revealed a significant decrease in retinal thickness 6 months after surgery. Best corrected visual acuity improved in four patients. CONCLUSION: Vitreous surgery can improve the visual prognosis of some eyes with DME with or without posterior vitreous separation, whether combined or not with vitreomacular traction observed on OCT.

Survival after proton-beam irradiation of uveal melanomas.

PURPOSE: To evaluate the independent prognostic factors for survival, metastasis, local recurrence, and enucleation in patients who had undergone proton-beam therapy for posterior uveal melanomas. DESIGN: Interventional case series. METHODS: In this retrospective study, 224 consecutive incident cases were treated at the Biomedical Cyclotron Centre (Nice, France) from June 1991 to December 1997. Overall, metastasis-free, local recurrence-free, and enucleation-free survival rates were calculated according to the Kaplan-Meier method using the log-rank test. The multivariate prognostic analysis was performed using the Cox proportional hazards model. RESULTS: The 5-year overall survival rate was 78.1% (SE: 3.7%). A largest basal tumor diameter (LTD) below 10 mm and female sex were independently associated with a better prognosis. The 5-year metastasis-free survival rate was 75.6% (SE: 3.6%). Only an LTD above 10 mm and ciliary body involvement were independently associated with metastasis. Ten patients (4.5%) had a local recurrence, which was correlated with the risk of metastasis (P =.045). The 5-year enucleation-free survival rate was 69.6% (SE: 4.0%). Once again, an LTD below 10 mm and female sex were predictive of a better prognosis. CONCLUSION: Our results with proton-beam therapy correspond to those reported in the literature. This treatment strategy is safe and yields predictably good results. In addition to the two independent prognostic factors for survival and metastasis, namely LTD and ciliary body involvement, sex also had a significant impact in our case series, but the clinical relevance of this finding is unknown.

Survival, anatomic, and functional long-term results in choroidal and ciliary body melanoma after ruthenium brachytherapy (15 years' experience with beta-rays).

PURPOSE: To analyze survival, radiation-related complications, local recurrence, enucleation, and visual acuity after ruthenium-106 irradiation of malignant uveal melanoma. DESIGN: Retrospective study. METHODS: A total of 213 patients treated with ruthenium-106 brachytherapy between 1983 and 1995. End point rates were estimated by life tables, and prognostic factors by Cox proportional hazards regression. Main outcome measures were survival rate, radiation-related maculopathy, radiation-related vascular occlusion, local tumor recurrence, enucleation, and visual acuity (<20/100 at 3 years). RESULTS: At 5 and 10 years, survival was 82% (standard error [SE] 2.7%) and 72% (SE 3.4%), local recurrence 21.7% (SE 3.0%) and 24.3% (SE 3.2%), and enucleation 18.0% (SE 2.7%) and 19.2% (SE 2.8%), respectively. Sixty-one patients showed maculopathy (29%), 36 retinal vascular occlusion (17%), in 33 local recurrence (16%), and 38 enucleation (18%). Age and large tumor diameter were independently associated with survival (P <.0001 and P <.0075, respectively). Age below 40 and melanoma located posteriorly were significant risk factors for maculopathy (P <.0085 and P <.0004, respectively) and vascular occlusion (P <.0415 and P <.0114, respectively). Diameter and Bruch membrane rupture were significant predictors (P <.0032 and P <.0390, respectively) of local recurrence. Visual acuity <20/100 was observed in only 26 of 97 (27%) cases of anterior but 34 of 42 (81%) of posterior tumor (P <.001). CONCLUSION: Although percentage tumor recurrence was high, survival was comparable to series using other treatments. Radiation-related complication rates were acceptable, especially for anterior tumors. Ruthenium therapy can, therefore, be recommended for small and medium-sized tumors with anterior location.

[Ciliary body melanomas. Survival and prognostic aspects after brachytherapy or proton therapy]. / Mélanomes uvéaux impliquant le corps ciliaire. Analyse de la survie après protonthérapie ou bêta-curiethérapie par ruthénium-106. A propos de 106 cas.

INTRODUCTION: Our main goals were to study the survival of patients with uveal melanomas involving the ciliary body 5 and 10 years after treatment and to review prognosis. MATERIAL AND METHODS: This study investigated 106 tumors (27 ciliary body melanomas and 79 choroidal-ciliary melanomas) of patients treated between June 1983 and April 1998. Seventy-two patients were treated with 106-ruthenium applicators and 34 were treated with proton therapy. Some large tumors or recurrences required a second treatment. The mean follow-up period was 91 months. RESULTS: The mean tumor sizes before treatment were 6,6mm for melanoma thickness and 10.3mm for mean largest basal melanoma diameters (LTD). Of the patients studied, 71% were still alive at 5 years, 35% had metastasis and 27.7% developed recurrences. Multivariate analysis showed that the risk factors for melanoma-related death were LTD greater than 13mm, presence of exudative retinal detachment, macroscopic iris root involvement at the time of diagnosis, and choroidal-ciliary location. DISCUSSION AND CONCLUSION: With 71% of patients still alive at 5 years, this review shows that melanomas involving the ciliary body do not seem less severe than more posterior uveal tumors. Because of size differences between ciliary body melanomas and choroidal-ciliary melanomas, we cannot come to the conclusion that choroidal-ciliary melanomas have a poorer prognosis than ciliary body melanomas. Largest tumor diameter over 13mm, presence of exudative retinal detachment, and macroscopic iris root involvement at the time of diagnosis are important risk factors for melanoma-related death, as shown by the multivariate analysis.

[Blindness after nitrous oxide anesthesia and internal gas tamponade]. / Cécité après une anesthésie comprenant du protoxyde d'azote en présence d'un tamponnement interne par gaz.

The authors describe the case of a patient with bilateral retinal detachment. Immediately after surgery for the second eye under general anesthesia with nitrous oxide, the patient reported severe visual loss in the first eye successfully treated surgically 2 weeks before, with a residual gas bubble (C3F8) of 50%. In this case, nitrous oxide had rapidly entered the gas bubble and induced a transient expansion of the gas tamponade with a dramatic increase in intraocular pressure. The consequence was a central retinal artery occlusion, which resulted in irreparable ischemic retinal damage and blindness, explaining the severe and sudden visual loss. Nitrous oxide is regularly used but contraindicated if intraocular gas is present, due to its potential threat to visual function. We suggest that patients anesthetized with nitrous oxide carry a card or a bracelet detailing the risks of intraocular gas tamponades combined with nitrous oxide and with travel to high altitudes. This would inform not only patients but also medical personnel caring for these patients.

[Sarcoid granuloma simulating amelanotic melanoma of the iris: a case report]. / Granulome sarcoïdosique simulant un mélanome achromique de l'iris.

We report the case of a unilateral vascular iris tumor in a 24-year-old patient. Clinically, the iris lesion appeared similar to amelanotic melanoma. A systemic work-up (initial check-up), including an angiotensin-converting enzyme determination, provided the diagnosis of sarcoid granuloma. A biopsy confirmation was not needed. We concluded that iris granuloma can be the only ocular manifestation of sarcoidosis and this context is likely to be confused with amelanotic melanoma and metastatic carcinoma.

[Conjunctival epithelial carcinoma in a 9-year-old child with xeroderma pigmentosum. Case report]. / Epithelioma conjonctival chez un enfant de neuf ans porteur d'un Xeroderma Pigmentosum. A propos d'un cas.

We report the case of a conjunctival tumor in a 9-year-old patient, suffering from Xeroderma Pigmentosum. Our patient presented a raspberry-colored conjunctival tumor. The tumor was resecked without any additional treatment. The histological study revealed squamous cell carcinoma. A suspicion of relapse appeared two months later of the same location and a new resection was performed. The initial checkup of this tumor was negative. In this disease, ocular localizations are frequent. The conjunctiva, the cornea, the eyelids and, into a lesser extent, the orbit can be involved. Basal cell carcinoma and squamous cell carcinoma are the most frequent tumors observed in Xeroderma Pigmentosum. Their treatment is mainly surgical.

[Primary ocular lymphoma manifesting as anterior uveitis. Apropos of a case]. / Lymphome oculaire primitif révélé par une uvéite antérieure. A propos d'un cas.

We report the case of a primitive ocular lymphoma occurring in a 48 year old patient. Non-Hodgkin's lymphomas are usually found in ocular localizations, and are often associated with a lymphomatous cerebral affection. The most frequent mode of presentation of these rare intra ocular tumors is usually posterior uveitis with chorioretinal lesions, and must be suspected for every long-standing chronic uveitis, especially posterior ones. The diagnosis can only be based on histological or cytological analysis. Our patient presented a primary ocular lymphoma which was initially revealed by an anterior uveitis and had evolved into a panuveitis that was resistant to treatment. The initial checkup of this uveitis remained negative and did not allow for an etiological diagnosis. The eye came less operational, hypertonic crisis became more frequent and controlled less and less by the treatment, therefore the patient had to be enucleated in order to establish a diagnosis and for therapeutic reasons. The histology revealed the existence of a NK lymphoma.