Filler-induced blindness "seen" by ophthalmologists: Case presentation and treatment algorithm.

PURPOSE: Filler-induced blindness (FIB) is the most threatening complication following periocular injection. To date, no standard of care has been established. The goal of this study is to report a new case of FIB with partial visual recovery and present our personalized algorithm for treatment based on fluorescein angiography findings. MATERIALS AND METHODS: Case report with 24 months follow-up and treatment algorithm. RESULTS: Our patient experienced complete vision loss to no light perception following forehead lipofilling. Retinal angiography identified a posterior ciliary artery occlusion. Antiplatelet medication, steroids and intraocular pressure lowering medications were administrated, followed by hyperbaric oxygen treatment (HBOT). Visual acuity improved to +0.8 logMar. The HBOT treatment was monitored by fluorescein angiogram. Based on this case and on the ophthalmic literature on retinal and ciliary artery occlusion, we established a personalized FIB protocol guided by fluorescein angiography. CONCLUSION: Although prevention remains the best treatment, all physicians should be prepared to manage FIB. Prompt management at the office guided by written protocols, as well as emergency kits, are essential. In referral centers, personalized treatment should be undertaken based on fluorescein angiography findings.

Eye amputation following lifitegrast treatment for ocular graft-versus-host disease: First case report.

Graft-versus-host disease (GVHD) is a common complication in patients undergoing allogeneic stem cell transplantation for acute myeloblastic leukemia that could be very difficult to treat. Lifitegrast 5% (Xiidra@, Novartis), a new immunosuppressive eye drop, was recently approved by the FDA for the treatment of severe dry eye and is currently under review by the European Medicines Agency. In France, lifitegrast has been approved by the French authorities for temporary use in refractory dry eye syndrome resistant to tear substitutes and topical cyclosporine. To date, serious complications have been reported only exceptionally. In this article, we report the case of a 65-year-old patient with a medical history of acute myeloid leukemia (AML) diagnosed in 2015 who received a first matched related donor transplant. In 2019, this patient developed chronic GVH involving the skin, oral mucosa and eye. Despite taking topical and systemic medications for 3 months, the patient did not report relief of ocular symptoms. Therefore, lifitegrast was prescribed. To our knowledge, we report the first case of corneal perforation in which evisceration was required following treatment with topical lifitegrast for chronic GVH. In the case presented here, it can be assumed that the underlying mechanisms leading to corneal perforation are multifactorial. Using drug accountability criteria, lifitegrast appears to be strongly associated with the development of bacterial keratitis and corneal perforation.

Prevalence of burnout, depression and job satisfaction among French senior and resident radiation oncologists.

PURPOSE: Cancer caregivers are at high risk of burn-out, with potential severe consequences on professionals' health and on patients' care. We have investigated the prevalence of burn-out and its impact in terms of psychological morbidity among French radiation oncologists. METHODS AND MATERIALS: An anonymous online questionnaire was advertised in all French senior radiation oncologists and residents, including demographical data, job-related stress factors, drug use, the Maslach Burn-out Inventory (MBI) and the General Health Questionnaire (GHQ-12). RESULTS: The response rates were 37% (76 out of 204) for radiation oncologists and 22% (166 out of 751) for residents. Sixty-four (84%) radiation oncology residents and 104 (63%) radiation oncologists met criteria for moderate/severe burn-out (odd ratio 2.1 [95% confidence interval 1.0-4.8], P=0.03). Radiation oncology residents were more prone to depersonalization (P<0.001) and lower personal accomplishment (P<0.001). Burn-out was more frequent in radiation oncologists working for public facilities. Symptoms of depression (GHQ-12≥4) were reported by 42% of residents and 36% of radiation oncologists (P=0.40). Psychological morbidity, suicidal ideation and anxiolytic consumption were more frequent in burnt out responders. CONCLUSION: Our figures are in the highest range of published data. Active screening and prevention of burn-out should be implemented and particularly aimed at radiation oncology residents.

Multiple immune disorders after natalizumab discontinuation: After the CIRIS, the SIRIS?

Natalizumab (NTZ) is an effective treatment for patients with highly active relapsing remitting multiple sclerosis (MS). However, when the therapy must be interrupted, it is important to anticipate the withdrawal to avoid reactivation or disease rebound. Described here is the case of a 35-year-old woman, with a past history of beta thalassemia, bulimia and asthma, who was diagnosed with MS at age 26. She was treated initially with first-line subcutaneous (sc) immunomodulatory treatments. However, due to liver toxicity, interferon beta-1a sc was interrupted and replaced by glatiramer acetate treatment, which was well tolerated and used for several years. Unfortunately, disease progression with numerous relapses and contrast enhancement on brain MRI led to initiation of NTZ treatment. After more than 2 years of treatment, NTZ was interrupted because of pregnancy, and the patient was again put on glatiramer acetate. Eight weeks after interruption of NTZ therapy, the first signs of diabetes were observed, together with an increase in blood levels of hepatic enzymes, skin reactions such as angioedema and giant urticaria, and hypothyroidism requiring hormone supplementation. The patient delivered her baby without complications, and NTZ was reintroduced several months later. At the present time, the patient's hypothyroidism, diabetes and increased blood levels of hepatic enzymes persist, although no new skin reactions have been observed. Withdrawal of NTZ can not only lead to reactivation of the disease or its rebound, but also to autoimmune manifestations within the framework of immune reconstitution inflammatory syndrome (IRIS). This risk needs to be considered when therapy has to be interrupted, especially when a personal and/or familial past history of autoimmune disease is present.

Efficiency of auricular acupuncture in climacteric symptoms after cancer treatments.

OBJECTIVES: This paper aims to highlight the efficiency of auriculotherapy in the treatment of hot flushes, especially in cancer-related menopausal transition. METHODS: We used systematically collected data from patients in 2014 in a medical oncology practice. The treatment was made according to the guidelines of The Inter-University Diploma and the cartography of the World Health Organization; data on satisfaction were collected orally. RESULTS: In 2014, 49 patients, among whom 41 had cancer, were treated for hot flushes. Although it is not recommended to treat several symptoms during the same session, we dealt with 1.7 symptoms per session on average. Sixty-nine percent of the patients were satisfied. We lacked data for nine patients, who did not come to the minimal recommended number of treatments (three). Only one patient among those who did not observe any improvement received three treatments. CONCLUSIONS: Auricular acupuncture is a safe and cheap method to treat hot flushes. It has been effective in numerous and various cases, among which were patients who presented cancer-related menopausal symptoms. It may be applied for a large variety of other symptoms.

Propuesta de un método para la valoración médico legal del perjuicio estético por cicatrices / A proposal for a method of forensic medical evaluation of the aesthetic damage of scarring

Una de las principales actividades en el ámbito médico forense es la valoración del perjuicio estético. Son diferentes los métodos recogidos en la literatura para efectuar esta valoración, pero sólo tres son dirigidos exclusivamente al daño estético ocasionado por cicatrices. Proponemos en este trabajo un método para la valoración médico legal del perjuicio estético por cicatrices: inicialmente se valoran y puntúan tres parámetros: zona del cuerpo donde está la cicatriz, longitud en centímetros y distancia a la que se ve la cicatriz. Cada uno de estos parámetros se pondera de forma diferente en la valoración global del perjuicio estético. El resultado podrá incrementarse o reducirse en función del grado de deformidad y del color de la cicatriz, aplicando una tabla cruzada. La puntuación final (sobre 100) se puede dividir por dos para asimilarla al RD Legislativo 8/2004 que contiene el baremo, actualmente vigente para la valoración de secuelas de un accidente de tráfico (AU)

One of the main activities in the medical forensic area is the evaluation of aesthetic damage. There are different methods reported in the literature to perform this evaluation, but only three are intended solely for the aesthetic damage caused by scarring. We propose, in this paper, a method for evaluation the damage forensic aesthetic scars: initially three parameters are evaluated and given a numerical value: the area of the body, the length in cm and distance at which the scar is seen. Each of these parameters is pondered differently in the overall evaluation of aesthetic damage. The result may be increased or decreased depending on the degree of deformity and scar color, applying a crossed table. The final result (out of 100) can be divided by two to assimilate the RDL 8/2004 containing the scale, currently applicable to the assessment of the consequences of an accident (AU)

[Role of French teams in the development of clinical and translational research in radiation oncology]. / Implications récentes des équipes françaises en oncologie radiothérapie et radiobiologie clinique.

Many clinical studies have showed the key role of radiotherapy in anticancer treatment strategy. Radiations are delivered alone or in combination with systemic therapies. In recent years, the main goal of all clinical developments has focused on improving clinical benefit, with an increased tumour control and a higher normal tissue protection. This research was designed to reduce local recurrences, to increase recurrence-free or overall survival and to decrease acute and late effects. Technological and biological evolutions (or revolutions) accompanied clinicians to improve clinical benefit, namely with strong progress in radiology and better understanding of radiobiology, particularly at the molecular level. Differences in tumour and normal tissues radiosensitivity are nowadays integrated in daily clinical practice of radiation oncologists. The current report details the last 5-year developments of clinical and translational research in radiation oncology, especially the role of French teams in the development of personalized treatment.

[Hematological side effects of natalizumab: Correlation with clinical outcome]. / Anomalies hématologiques du natalizumab et sa signification clinique.

INTRODUCTION: Natalizumab (NTZ) is a monoclonal antibody used in a single-drug regimen to treat active relapsing remitting multiple sclerosis. Safety data collected during the AFFIRM pivotal study and post marketing cohorts reported infusion-related and allergic reactions, with development of persistent anti-NTZ antibodies in 6% of patients. Occurrence of hematological side effects (HSE), such as hyperlymphocytosis (HL) and hypereosinophilia (HEo) have been described. To our knowledge, there is no study assessing neither incidence of HSE, nor their correlation with clinical outcome. The objective is to evaluate prospectively the incidence of HSE of NTZ and to search for correlations with clinical outcome. METHODS: Clinical (EDSS, relapse, tolerance) and biological assessments were performed before the first infusion and every month during the follow-up in all patients treated with NTZ between 2007 and 2010. Before starting NTZ, data were collected on prior history of allergy and previous disease-modifying treatments (DMT). Statistical analysis was performed to search for correlations between the occurrence of HSE and clinical outcome. RESULTS: The series included 66 patients (sex ratio: 1/2.8) followed for up to 17 months. Mean age was 39 (±SD) years. Mean EDSS score was 3.2 (±SD). Fifty-six percent of patients had DMT history with beta interferons (41%), glatiramer acetate (6%) and immunosuppressive drugs (cyclophosphamide, mitoxantrone) (9%). Annualized relapse rate during follow-up was 0.41. Infusion-related reactions were noted in 10% of patients. Two patients had allergic reactions and had stopped their infusions. HL developed in 48% of patients and HEo in 20%. Regarding age and medical or therapeutic history, no predictive factor of HSE occurrence could be identified. Incidence of infusion-related side effects was higher in patients with HEo (38%) in comparison with patients without HEo (3.8%). Relapse rate during NTZ treatment was not significantly different between the different groups. CONCLUSION: This is the first prospective study assessing of HSE during NTZ treatment. There is a higher occurrence of intolerance reactions in patients with HEo.

[L-carnitine treatment and fish odor syndrome: an unwaited adverse effect]. / Traitement par L-carnitine et mauvaise odeur corporelle: un effet secondaire à connaître.

INTRODUCTION: Levocarnitine treatment is usually well tolerated, with essentially dose-dependent diarrhea as the main induced adverse effect. CASE REPORT: We report a case of fish odor syndrome during levocarnitine treatment which resolved after levocarnitine discontinuation. CONCLUSION: This adverse effect seems to be correlated with excedent carnitine intake and might be expressed when the elimination pathway becomes saturated or in a situation of deficiency enzymatic metabolism.

[Bilateral optic neuropathy with loss of vision after an influenza vaccination in a patient suffering from mixed connective tissue disease]. / Névrite optique rétrobulbaire bilatérale cécitante après vaccination contre la grippe saisonnière chez une patiente présentant un syndrome de Sharp.

BACKGROUND: Optic neuropathy is a rare adverse reaction to vaccination. CASE REPORT: A 62-year-old-woman was hospitalized for bilateral optic neuropathy with loss of vision. The symptoms occurred 15 days after a seasonal influenza vaccination. Her past medical history included a mixed connective tissue disease with no immunosuppressive treatment for several years. Investigations did not reveal any obvious cause and the hypothesis of post-influenza vaccination bilateral optic neuropathy was retained although a complication of the connective tissue disease complication could not be ruled out. The patient was given intravenous methylprednisolone 1g daily. At a cumulative dose of 8 g, oral steroids were given and tapered off. DISCUSSION: Few similar case reports have been described in literature. The causal link between vaccination and optic neuropathy thus remains to be confirmed. Clinicians should however consider this etiology.

[Natalizumab (Tysabri) prescription practices of neurologists in southern France]. / Enquête auprès des neurologues sur les prescriptions de natalizumab en région Provence-Alpes-Côte-d'Azur.

INTRODUCTION: Tysabri is indicated as single-drug disease-modifying therapy in patients with highly active relapsing remitting multiple sclerosis (RRMS). Potential risk for opportunistic infection and especially for progressive multifocal leucoencephalopathy has implied specific guidelines for use. The purpose of this study was to ascertain the prescription practices of neurologists in southern France and to learn more about how the drug is used in clinical practice compared with management guidelines stated in the product's characteristics and national recommendations. METHODS: We developed a questionnaire which was sent to all neurologists practicing in our region, whether they had multiple sclerosis patients or not. Questions regarded demographic data (geography, practice in hospital or private office), current knowledge on natalizumab (mechanism of action, indications), monitoring of treated patients (pre-therapeutic and therapeutic check-up), rescue decisions and overall experience with using natalizumab. RESULTS: Two hundred fifty neurologists, practicing in eight administrative districts in our region, were contacted. Demographic data showed that most of them were prescribing Tysabri. Patients treated with Tysabri were mostly followed in teaching hospitals (79%). Concerning knowledge about natalizumab, neurologists applied the recommended check-up (73%) but most of them preferred prescribing Tysabri as a second line of treatment after IFN failure (66%). Inefficacy was mainly evaluated on clinical parameters (one or two relapses under treatment with sequels or EDSS progression in each answer); MRI was only useful to confirm clinical conclusions, but for the neurologists, gadolinium enhancement was required to confirm lack of efficacy. DISCUSSION: Results tended to show that, in clinical practice, despite some deviation from national guidelines, the recommended precautions are applied for the use of Tysabri. Neurologists considered that Tysabri is other immunosuppressant drugs used in RRMS. Further medical information might be useful to improve compliance with all of the recommended indications and standard practices for patient follow-up. CONCLUSION: This survey enabled an assessment of current knowledge about Tysabri as a treatment for RRMS patients and to learn more about how it was used in real life practice during its first year of marketing in France.

[A severe side effect of antitubercular therapy: pyrazinamide induced thrombocytopenia]. / Un effet indésirable grave du traitement antituberculeux: la thrombopénie au pyrazinamide.

The haematological side effects of antitubercular drugs are not well known. We report the observation of a patient who received Rifater for the treatment of pulmonary tuberculosis. After one month of treatment, he developed an acute pulmonary infection, with neutropenia (1218/microl) and thrombocytopenia (109,000/microl), requiring suspension of his antitubercular drugs. After the reintroduction of he again developed thrombocytopenia (6,000/microl) associated with bleeding and required treatment with intravenous immunoglobulin. The introduction of a combination of moxifloxacin, isoniazid, pyrazinamide, and ethambutol was followed by a new relapse of the thrombocytopenia. Responsibility of pyrazinamide was then suspected and later confirmed by the evolution of platelet levels after stopping and reintroducing this antibiotic. This is the third reported case of pyrazinamide induced thrombocytopenia, whose frequency is probably underestimated because of the use of compound treatment.

[Coordination of health vigilances: for a global management of hospital risks]. / La coordination des vigilances sanitaires : pour une gestion plus globale des risques hospitaliers.

The sanitary vigilances represent a permanent sanitary surveillance. They signal, enregister, treat and investigate the adverse events occurring through the use of health products. They assure the traceability of these health products and the management of the sanitary alerts. The sanitary vigilances are part of the sanitary security. They are optimized when coordinated and integrated to the global risk management process of the health care establishments.

[Topiramate and acute myopia with angle-closure glaucoma: case report and literature review]. / Topiramate et myopie avec crise aiguë de fermeture de l'angle irido-cornéen: cas clinique et revue de la littérature.

Topiramate, an antiepileptic medication, has been widely used since its recent indication for migraine prophylaxis. We report a case of bilateral angle-closure glaucoma and acute myopia in a 44-year-old woman on oral topiramate therapy initiation for migraine prophylaxis. Intraocular pressure was 31 mmHg right and 32 mmHg left, myopia was 4 diopters. Topiramate was interrupted and general and local hypotensive treatment begun and rapidly stopped after improvement. Iridotomy was also performed. Fifteen days later, complete resolution was observed on ophthalmologic examination: anterior chambers were deep, myopia fully regressed, intraocular pressure returned to normal, and the visual field was complete. This new case prompts discussion on current reports in the literature and French drug monitoring database cases in this context.

[Möbius syndrome: ocular and clinical manifestations]. / Syndrome de Möbius: manifestations ophtalmologiques et cliniques.

PURPOSE: To assess ocular and clinical manifestations in patients with Möbius syndrome. METHODS: Twenty-seven patients (26 infants and 1 adult) underwent prospective ophthalmic, clinical, neurological, otorhinological, orthopedic and electrophysiological assessment. Twenty-three patients underwent MRI and 20 patients genetic examination with karyotype. RESULTS: Three of 27 patients with cranial nerve palsies did not satisfy the criteria for Möbius syndrome. All 24 patients with Möbius syndrome had facial palsy. Nineteen patients (79.2%) had limited abduction. Eleven patients (45.9%) presented with esotropia, five patients (20.8%) presented with exotropia or hypertropia. Cranial nerve impairment of the Vth, IXth, XIth, and XIIth nerves was noted in 20 patients (83.4%). Other signs were general motor disability in 14 patients (58.2%), orthopedic abnormalities in eight patients (33.3%), and otorhinological abnormalities in six patients (25%). Electromyographic studies of facial muscles revealed neuromuscular changes in all cases. MRI findings showed hypoplasia of facial nerves in two patients (8.3%). Chromosomal abnormalities were not found. One patient presented an inherited inversion of the sixth chromosome. CONCLUSION: The diagnosis of Möbius syndrome may be difficult in some patients with atypical signs of facial diplegia and other cranial nerve palsies. When diagnosing Möbius syndrome, all ophthalmologic and clinical signs must be applied. Möbius syndrome is more than a cranial nerve or nuclear disorder. It is a syndrome of more complex lower brainstem involvement.