[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.

Benefits of Ophdiat, a telemedical network to screen for diabetic retinopathy: a retrospective study in five reference hospital centres.

AIM: One objective of Ophdiat, a telemedical network using digital non-mydriatic cameras in Ile-de-France, is to develop a comprehensive screening programme that provides access to annual fundus examinations to all diabetic patients. The aim of this study was to evaluate the benefits of this programme in a hospital setting. METHODS: A retrospective analysis of 500 case reports of diabetic patients hospitalized before and after Ophdiat setup was performed in five reference hospital centres. At each centre, 100 case reports (50 before, 50 after) of patients aged greater than 18 years, hospitalized for their annual check-up, with no known diabetic retinopathy (DR) before hospitalization and with the last fundus examination performed greater than 11 months previously, were randomly selected. The primary endpoint was the proportion of patients whose fundus examinations were performed during hospitalization; secondary endpoints were the number of cases of DR found and the time taken by ophthalmologists to make the diagnosis. RESULTS: The mean proportion of patients with fundus examinations was 50.4% and 72.4% before and after, respectively, Ophdiat (P<0.01). The prevalence of DR was 11.1% before and 12.7% after (not significant). The mean time taken by an ophthalmologist per diagnosis of DR was 0.90 half-day before and 0.32 half-day after Ophdiat. CONCLUSION: This evaluation shows that Ophdiat, combined with the availability of modern and effective devices, has improved DR screening in diabetology departments in hospitals. Additional human resources would certainly ensure more effective use of the system.

Relationship between visual outcomes and retinal fluid resorption in patients with diabetic macular edema treated with ranibizumab.

PURPOSE: We assessed the relationship between visual acuity (VA) recovery and a qualitative criterion - complete retinal fluid resorption (CRFR) - among patients treated with ranibizumab for diabetic macular edema (DME) METHODS: All consecutive diabetic patients with central DME received a loading dose of 3 monthly injections of ranibizumab 0.5mg, followed by retreatments on an as-needed basis as determined by monthly follow-up. Patients were divided into 3 groups: CRFR (defined as a CRT <300µm and restoration of the foveolar pit) with BCVA≤70 letters (group 1: G1), CRFR with BCVA>70 letters (20/40) (G2), and persistent retinal fluid throughout the follow-up (G3). RESULTS: Forty eyes were included. Mean baseline VA was 48.7 letters and no patient had VA>70 letters. Twenty-four (60%) eyes achieved CRFR: 12 (30%) in G1 and 12 (30%) in G2. In 16 patients (40%), the efficacy of the treatment was partial without CRFR (G3). At the time of the initial CRFR, VA was 57.4 letters in G1 (min-max: 30-65) and 77.5 letters in G2 (71-85). In G3, maximal VA during follow-up was 55 letters (25-70) and no patient achieved a VA >70 letters. CONCLUSIONS: In this study, CRFR was required but not sufficient to achieve a VA>70 letters.

[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.

[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.

Impact of lens thickness on complications of hypermature cataract surgery: A prospective study.

PURPOSE: To assess the correlation between lens thickness (LT) measured by ultrasonography and duration of surgery as well as complications. SETTING: The study was conducted in a hospital in the Parisian suburb of Bobigny, France. DESIGN: A prospective and monocentric study was conducted. All patients undergoing surgery for hypermature cataract between January 2013 and March 2014 were included. METHODS: Morphological features, including LT, axial length, anterior chamber depth and vitreous length were assessed using A-scan ultrasonography. The other parameters assessed were the duration of surgery, occurrence of complications during surgery, visual acuity (VA) and corneal edema score one week after surgery. RESULTS: Thirty eyes of 29 patients were included. Mean LT was 4.11±0.64mm (median: 3.89mm). Mean surgery duration was 24.2±8.7min. Three patients experienced complications during surgery: 2 capsular breaks and 1 posterior lens dislocation. At one week, the mean decimal VA was 0.49±0.34 and the mean corneal edema score was 0.76±1.09. The Pearson correlation coefficient was r=0.27 (P>0.05) between LT and surgery duration while it was r=-0.53 (P=0.01) between VA and LT. No correlation was found for the other parameters studied. DISCUSSION: In this study, the linear correlation between LT and the surgery duration was low. The visual recovery at day 7 appeared inversely correlated with the LT. CONCLUSIONS: LT did not seem to be a marker for longer surgery duration but appeared related to the visual recovery at one week.

Ocular fluorophotometric and angiographic findings in toxemia of pregnancy.

Ocular fluorophotometry was performed in 24 patients with hypertension due to toxemia of pregnancy and in ten normal subjects. Patients showing features of accelerated hypertension in the fundus (eg, hemorrhage, cotton-wool spots, and disc edema) were excluded from the study. Fluorescein concentrations in the aqueous and posterior vitreous increased significantly in toxemic patients compared with those in normal subjects; the blood-aqueous barrier was disrupted earlier than the blood-retinal barrier. Nevertheless, these barriers were only disrupted when the arterial diameter was altered. Ocular fluorometric abnormalities disappeared after delivery in all but two cases.

Case-control study of the risk factors for age related macular degeneration. France-DMLA Study Group.

AIM: A case-control study was initiated to determine the risk factors for the development of age related macular degeneration (AMD). METHODS: Study participants, who were all white, aged 50-85 years, and were recruited from private ophthalmology practices. Each practitioner enrolled patients with bilateral AMD, who were then matched with controls for sex and age. Environmental factors and systemic and ocular histories were screened. All patients had bilateral red-free fundus photographs and fluorescein angiography. Photographs were classified into pigment epithelium alterations, drusen, geographic atrophy, and exudative AMD. Statistical analysis included the identification of risk factors for AMD. A multivariate analysis was performed at the end of the study. Analysis included the entire study population and was carried out for each stage of AMD. RESULTS: 1844 controls were compared with 1844 patients with AMD. Mean age was 71 years for controls and 72 for cases. Logistic regression identified six major risk factors for AMD (whole population): arterial hypertension (odds ratio (OR) = 1.28), coronary disease (OR = 1.31), hyperopia (OR = 1.33), light coloured irises (OR = 1.22), and lens opacities or previous cataract surgery (OR = 1.55). The significance of vascular risk factors was increased for late stages of AMD, especially the atrophic forms (coronary disease, OR = 3.19). CONCLUSIONS: This large case-control study confirms some of the risk factors previously identified and may contribute to the determination of methods for prevention of AMD.

Aqueous flare induced by heparin-surface-modified poly(methyl methacrylate) and acrylic lenses implanted through the same-size incision in patients with diabetes.

PURPOSE: To compare the degree of blood-aqueous barrier (BAB) breakdown in eyes of diabetic patients after phacoemulsification and implantation of heparin-surface-modified poly(methyl methacrylate) (PMMA) or soft hydrophobic acrylic intraocular lenses (IOLs) performed using the same technique with the same incision size to determine the influence of the IOLs on postoperative inflammation independent of other surgical factors. SETTING: Department of Ophthalmology, University of Paris XIII, Bobigny, France. METHODS: In a prospective study, 44 eyes of 31 diabetic patients with or without mild to moderate diabetic retinopathy were randomly assigned to receive an HSM PMMA IOL (22 eyes) or a soft hydrophobic acrylic IOL (22 eyes) after standardized phacoemulsification surgery. Both types of IOLs had a 6.0 mm optic, were inserted unfolded, and were placed in the bag through a calibrated 6.0 mm superior scleral incision. Anterior chamber flare was measured preoperatively and 1, 7, 30, and 240 days postoperatively using the Kowa 500 laser flare meter. RESULTS: The mean flare value was higher on the first postoperative day in both groups. There were no statistically significant between-group differences in flare scores or clinical parameters preoperatively or at any postoperative visit. CONCLUSIONS: No significant difference was observed in inflammation between eyes having HSM PMMA IOL implantation or those having soft hydrophobic acrylic IOL implantation through the same-size incision. This indicates that hydrophobic acrylic and HSM PMMA materials induce the same degree of BAB breakdown after phacoemulsification in eyes of diabetic patients.

Body mass index as a discriminant function among health-related variables and risk factors.

A group of 206 subjects (30-55 years) were studied with the objective of quantifying the relationships between fitness indicators (relative body weight (BMI), aerobic power, muscular endurance), health indicators and risk factors, (appraised age, cost of health services consumed, blood pressure (SBP and DBP), blood lipids (CHO and HDL), cigarette smoking). BMI was significantly correlated with the risk indicators in the male sample (.302 less than or equal to r less than or equal to .364) and in the female sample (.217 less than or equal to r less than or equal to .521). All coefficients were in the direction of the established biological assumption as concerns hazards to health. The discriminant analysis revealed that in the total group of men, 77% (p less than or equal to .001) of the subjects could be classified either in high or low BMI (greater than Q75 or less than or equal to Q25) on the basis of the scores in SBP, HDL, HDL/CHO. In the subgroup of women greater than or equal to 40 years, statistically significant classification occurred in 100% of the cases (p less than or equal to .001) on the basis of DBP, CHO, HDL/CHO, NCIG. The results indicate that BMI is a fitness determinant which is valid, convenient and easy to use in the detection of unfavorable health indices and when clinical intervention is justified.

[Treatment of diabetic retinopathy by laser photocoagulation (author's transl)]. / Traitement de la rétinopathie diabétique par photocoagulation au laser.

Recent advances in our knowledge concerning spontaneous changes in diabetic retinopathy, and improved classification of clinical forms due to fluorescein angiography, have established precise indications for the use of the laser for retinal photocoagulation in diabetic retinopathy. Controlled, randomized, multicentre studies have conclusively demonstrated the value of the techniques used and results obtained: indirect photocoagulation of the ischaemic zones (pan-retinal photocoagulation) can now effectively preserve the future vision of patients with preproliferating of proliferating retinopathy. The value of photocoagulation in the fight against diabetic oedematous maculopathy appears to be less conclusive, though early elective therapy for juxtafoveolar microvascular lesions appears to be a significant advance.

[Cystoid macular edema and cytomegalovirus retinitis in AIDS patients treated with antiretroviral triple therapy]. / Oedème maculaire cystoïde et rétinite à cytomégalovirus chez des patients HIV traités par trithérapie antirétrovirale.

AIM OF THE STUDY: This study evaluated cystoid macular edema (CME) occurring during inactive cytomegalovirus (CMV) retinitis, in AIDS patients treated with highly active antiretroviral therapy (HAART) and without anti CMV treatment for 10 patients. PATIENTS AND METHODS: 12 patients were followed over 24 months. Assessment was carried out on visual acuity, biomicroscopy, fundus photographs every month, angiography for each patient, CD4 cell count and plasmatic viral load. RESULTS: 7 patients presented CME in association with chronic uveitis, large CMV retinitis scars and posterior pole involvement. CONCLUSION: CME is a new complication of CMV retinitis occurring in patients treated with HAART.

[Hypertensive retinopathy]. / La rétinopathie hypertensive.

Retinal blood vessels differ from most other vessels in the body (with the exception of those in the brain) in two important respects. The first is the presence of blood-retinal barriers, best illustrated by fluorescein angiography. The second important difference is that retinal vessels do not have sympathetic innervation and blood flow is modulated by autoregulation mechanisms. In 1939 Keith, Wagener and Barker proposed a classification system for hypertensive retinopathy which was innovative and of prognostic importance at that time. However, the different features of hypertensive and arteriosclerotic vasculopathies are not adequately distinguished by this classification system. Clinical features of accelerated hypertension are retinal haemorrhages, cotton wool-spots, hard exudates, papilloedema and increased vascular permeability. These must be differentiated from features associated with arteriosclerosis which are arteriovenous crossing changes and arterial constriction. The advantages of the Hogan classification system, based up on histopathologic and pathogenetic considerations are discussed. Other retinal vascular diseases associated with hypertension are also mentioned. Such as toxaemia of pregnancy, arterial macroaneurysm and anterior ischaemic optic neuropathy. Retinal branch vein occlusion is rather associated with arteriosclerosis than with hypertension.

[Course of cytomegalovirus retinitis in HIV positive patients treated with triple antiretroviral therapy]. / Evolution de la rétinite à cytomégalovirus chez des patients HIV sous trithérapie antirétrovirale.

PURPOSE: The recent developments of protease inhibitors raise big hopes for the fight against AIDS. Combined in a triple therapy with 2 nucleoside analogs, those molecules strongly inhibit human immunodeficiency virus (HIV) replication. Their biological and clinical efficacy for increasing CD4 cell count and survival time has been proved. We have followed evolution of Cytomegalovirus (CMV) retinitis in 12 patients treated by triple antiretroviral combination therapy since April 1996. PATIENTS AND METHODS: Twelve AIDS patients with CMV retinitis background and a treatment by triple therapy were followed in this prospective study. At the onset of combination therapy, retinitis was cicatricial in 10 patients and active in 2 patients. Mean CD4 cell count was 23 +/- 16 CD4/microL [4-50]. Follow-up included ophthalmoscopic examination every 2 weeks and fundus photographs every month. CD4 cell count was noted at each exam. RESULTS: The mean time follow-up after onset of combination therapy was 10.3 +/- 2.4 months [5-14]. Retinitis relapsed in 6 patients (50%) within the 3 first months, and with a CD4 cells count higher than 75/microL for 3 patients. Inflammation response was noted in 3 patients. There was no recurrence after the third month, except in 1 case at the 9th month. CD4 cell count was 122 +/- 41 CD4/microL [30-350] after 6 months. As retinal lesions were completely still for some patients, maintenance therapy was reduced, then even stopped. At the end of follow-up, maintenance therapy was stopped for 8 patients. For these patients, retinitis remained stable without maintenance therapy for a mean time of 4,5 months (10 months in 1 case). Recurrence occurred for only 1 patient after 9 months of triple therapy and 2 months without maintenance therapy. For the 11 remaining patients, retinitis remained stable for a mean total time of 9.5 +/- 2.5 months [4.5-12.5]. CONCLUSION: Those first results show that clinical and therapeutic history of CMV retinitis may be changing. There seems to be a restoration of immune defenses that allowed suppression of maintenance therapy for 8 out of 12 patients. Our results need to be confirmed by a longer follow-up and multicentric studies.

[Winer's cutaneous calcinosis. Apropos of a case with eyelid localization]. / Calcinose cutanée de Winer. A propos d'un cas dans sa localisation palpébrale.

A case of Winer's solitary cutaneous calcinosis is used as a basis for a literature review of this rare, benign dermatosis. Despite concordant clinical features diagnosis of this lesion is histologic. Normal blood biological values, a debated etiopathogenicity and the need to eliminate a collagen disease are important factors to bear in mind before making this diagnosis of such a cutaneous lesion, for which exeresis ensures a cure.

[Validity of prediction after standard implant and the implant calculated according to the SRK formula]. / Validité de prédiction après implant standard et implant calculé selon la formule SRK.

The purpose of this study is to appreciate post-operative ametropia in pseudophakic patients (EEC and posterior chamber IOL). Two groups were implanted either with a standard 21 D IOL (group 1) or after calculation of implant power according to the SRK formula (group 2). Results show residual refractive errors over 2 D in 7% of case in group 2 and 22.3% of case in group 1.

[Early limbal autograft after alkali burn of the ocular surface]. / Autogreffe de limbe précoce après brûlure alcaline de la surface oculaire.

Limbal autograft transplantation is recommended for treatment of limbal stem cell destruction and its complications. It is appropriate to restore corneal reepithelialization and arrest corneal vascularization and scarring. In unilateral alkali injury, limbal transplantation was first recommended for late management of corneal conjunctivalization. Our patient had severe ocular unilateral alkali injury. Early autologous limbal transplant was effective in restoring an excellent corneal surface and a good visual function.

[Treatment of diabetic cystoid macular edema by argon laser photocoagulation]. / Traitement de l'oedème maculaire cystoïde diabétique par photocoagulation au laser à argon.

Diabetic maculopathy remains the main cause of poor visual acuity in diabetic retinopathy either proliferative or non proliferative. Although photocoagulation in the macular area is known to be effective in treatment of exudates, results in treatment of cystoid macular edema (CME) are still questionable. 36 eyes with diabetic CME and non ischaemic capillary bed were treated with argon laser photocoagulation in the macular area. Two groups of patients were studied. Group I consisted of 16 eyes with CME and with circinate exudates in the paramacular area. Mild argon burns (50-200) were applied on the microvascular abnormalities and on the pigment epithelium in the center of the circinate exudates. The macula (1500 of diameter) was not treated in this group. As expected, results on the exudates rings were good. CME disappeared in 43% of the cases, and regressed in 23% of the cases. Nevertheless 3 years after treatment the mean visual acuity was found to be slightly worse than before the treatment. Group II consisted of 20 eyes with CME, exudates were absent or scattered. Mild argon burns were applied on the area of macular cysts avoiding only the foveal avascular zone (500 of diameter). Exudates when present disappeared in all cases. CME disappeared in 80% of the cases and regressed in 15% of the cases. Three years after treatment mean visual acuity remained identical. Extensive review of the literature concerning the treatment of diabetic maculopathy shows a wide range of techniques and evaluation procedures. We propose the following method of treatment: when exudate rings are present with CME, treatment should be aimed first towards focal microvascular abnormalities avoiding the macular area. When exudates are absent or in cases of unchanged CME after extramacular photocoagulation, treatment should be aimed towards the microcystic area avoiding the foveal avascular zone, if visual acuity is less than 0,5.

[Candida chorioretinitis in drug addicts. Apropos of 2 cases]. / Choriorétinite candidosique chez les toxicomanes. A propos de 2 cas.

We report two cases of candidal chorioretinitis occurring to two friends who abused of intravenous crack using the same syringe . An endophthalmitis "a minima" due to a therapeutic delay arose in one patient, when a rare spontaneous healing happened to the second patient. In both cases, an epiretinal membrane is noted after the lesions scarred. Ocular candidal infection is a typical complication occurring to intravenous drug addicts. The visual prognosis depends not only on early diagnosis and treatment, but also on a strict follow-up because late complications are frequent in spite of the healing of initial lesions.

[Photocoagulation with the argon laser in cystoid macular edema in retinal venous occlusions. Apropos of 68 cases]. / Photocoagulation au laser à argon dans l'oedème maculaire cystoïde des occlusions veineuses rétiniennes. A propos de 68 cas.

Sixty-eight consecutive eyes with cystoid macular edema due to venous occlusion were treated by grid laser photocoagulation. The diagnosis of cystoid macular edema was based on both the biomicroscopic and angiographic findings. The treatment was applied with blue-green or green argon laser. The criteria for treatment were the presence of cystoid macular edema, visual acuity of 0.5 or less and duration of the venous occlusion for more than 6 months. The technique of treatment included direct photocoagulation of certain microaneurysms and of collateral dilatations exhibiting fluorescein leakage in the macular area, followed by grid photocoagulation applied to the area of cystoid edema. No laser burn was placed within 300 microns of the center of the macula. The patients were followed for periods of 6 to 24 months with a mean follow-up of 15 months. Forty-five eyes presented with a branch vein occlusion. Photocoagulation resulted in the decrease or disappearance of macular edema in 42 of these eyes (93%) and the improvement of visual acuity by 0.2 or more in 12 (27%). Twenty-three eyes presented central vein occlusion. In these cases, photocoagulation resulted in the decrease or disappearance of macular edema in 20 eyes (87%), and visual acuity improved by 0.2 or more in 4 (17%). These results indicate that grid laser photocoagulation is an effective method, reducing persistent cystoid macular edema due to venous occlusion. However, visual results were better in the branch vein occlusions than in the central vein occlusions.