The course of non-infectious uveitis in pregnancy: a retrospective study of 79 pregnancies.

PURPOSE: The study aims to describe the course and management of non-infectious uveitis during pregnancy and postpartum period in European populations. METHODS: A retrospective observational study in two tertiary centers in France was performed. Pregnant patients during the follow-up of a non-infectious uveitis as well as those with new-onset uveitis were included. The medical records were analyzed with a systematic collection of the characteristics of the uveitis, the treatment and evolution of the uveitis, and the course of the pregnancy including obstetric complications. RESULTS: Seventy-nine pregnancies in 59 women were included: 48 patients (68 pregnancies) were followed for uveitis and 11 had a new-onset uveitis diagnosis. Most patients had idiopathic uveitis (32.2%) or sarcoid uveitis (27.1%). Among the patients followed for uveitis at the time of conception, there were 18 relapses (26.5%) requiring treatment escalation. Relapses occurred mainly in the two first trimester (n = 12) or during the postpartum period (n = 5) and were significantly associated with an active uveitis at the time of conception (OR = 9.2, 95% CI [1.57-48.4], p = 0.01). The characteristics of the new-onset uveitis were similar to those already existing before pregnancy. Obstetric complications occurred in 25 pregnancies (31.6%), mainly gestational hypertension and gestational diabetes. CONCLUSION: The frequency of non-infectious uveitis relapses decreases as pregnancy progresses, in agreement with data from other non-European studies. However, multidisciplinary monitoring should be advised, especially to uncontrolled patients at the time of conception.

[Management of ocular toxoplasmosis in France: Results of a modified Delphi study]. / Prise en charge de la toxoplasmose oculaire en France : résultats d'une étude Delphi modifiée.

OBJECTIVE: To evaluate diagnostic and therapeutic practices and then establish a consensus on the management of ocular toxoplasmosis in France through a Delphi study. MATERIALS AND METHODS: Twenty-three French experts in ocular toxoplasmosis were invited to respond to a modified Delphi study conducted online, in the form of two questionnaires, in an attempt to establish a consensus on the diagnosis and management of this pathology. The threshold for identical responses to reach consensus was set at 70 %. RESULTS: The responses of 19 experts out of the 23 selected were obtained on the first questionnaire and 16 experts on the second. The main elements agreed upon by the experts were to treat patients with a decrease in visual acuity or an infectious focus within the posterior pole, to treat peripheral lesions only in the presence of significant inflammation, the prescription of first-line treatment with pyrimethamine-azithromycin, the use of corticosteroid therapy after a period of 24 to 48hours, the prophylaxis of frequent recurrences (more than 2 episodes per year) with trimethoprim-sulfamethoxazole as well as the implementation of prophylactic treatment of recurrences in immunocompromised patients. On the other hand, no consensus emerged with regard to the examinations to be carried out for the etiological diagnosis (anterior chamber paracentesis, fluorescein angiography, serology, etc.), second-line treatment (in the case of failure of first-line treatment), or treatment of peripheral foci. CONCLUSION: This study lays the foundations for possible randomized scientific studies to be conducted to clarify the management of ocular toxoplasmosis, on the one hand to confirm consensual clinical practices and on the other hand to guide practices for which no formal consensus has been demonstrated.

Prospective pilot study: efficacy of intravitreal dexamethasone and bevacizumab injections in the treatment of macular oedema associated with branch retinal vein occlusion.

BACKGROUND/AIMS: To compare the efficacy of intravitreal injections of dexamethasone implants (IVD) with those of bevacizumab (IVB) for the treatment of macular oedema associated with branch retinal vein occlusion. METHODS: A total of 19 patients (19 eyes) were included in this prospective pilot study. Initially, 8 eyes received three IVBs (group 1) and 11 received one IVD (group 2). All the patients underwent a 1-, 3-, 4- and 6-month follow-up visit. A repeated IVB (group 1) or IVD (group 2) was proposed at 4 months when necessary. RESULTS: The mean visual acuity was significantly better 1 month after treatment in group 2, while the mean central macular thickness was also significantly lower in group 2. However, there was no longer any difference between the two groups at 3, 4 and 6 months, neither in terms of visual acuity nor in terms of retinal thickness. More than three IVBs were needed in 3 of 10 patients in group 1 while two IVDs were required in 10 of 11 patients in group 2. CONCLUSION: There was no significant difference between the two treatment regimens at the 6-month follow-up visit. A more rapid functional and anatomical efficacy was noted with IVD during the first month; however, reinjection at 4 months seemed more frequent with IVD than with IVB treatment.

Longitudinal follow-up of vision in a neuromyelitis optica cohort.

BACKGROUND: Neuromyelitis optica (NMO) is an inflammatory disease associated with optic neuritis and myelitis. Recently, several studies showed that optical coherence tomography (OCT) could be an interesting method for the evaluation of disease severity; however, to date there are no studies with a longitudinal follow-up of visual function in NMO. The aim of this study was to assess the ability of OCT to evaluate the progression of visual dysfunction in NMO. PATIENTS AND METHODS: A group of 30 NMO patients (thus, 60 eyes), comprised of 20 women and 10 men with a mean age of 43.7 +/- 12.3 years, were prospectively evaluated clinically and by a whole neuro-ophthalmological work-up, including: visual acuity (VA), fundoscopy, visual evoked potential (VEP), visual field (VF) and optical coherence tomography (OCT). All patients were tested at baseline (after a mean disease duration of 6.1 years) and after a mean time of follow-up of 18 months (range: 12-36 months). RESULTS: Mean VA was similar at the two evaluation times (0.77 +/- 0.36 versus 0.77 +/- 0.35). The mean VF defect decreased slightly, but the difference was not significant (-5.9 +/- 1.3 dB versus -5.3 +/- 1.3 dB). In contrast, the mean retinal thickness seen on OCT decreased from 87.4 +/- 23.3 µm to 79.7 +/- 22.4 µm (p = 0.006). These modifications were only observed in eyes with a past or a recent history of optic neuritis (-15.1 µm; p < 0.001) and not in eyes without any history of optic neuritis (-2.4 µm; not significant). Also, they occurred independently of the occurrence of relapses (n = 13) and especially optic neuritis episodes; however, the number of optic neuritis episodes was low (n = 5). CONCLUSION: OCT seems to be a more sensitive test than VA or VF for monitoring ophthalmological function in NMO and it seems to be helpful for the detection of infra-clinical episodes in patients with a past history of optic neuritis. Our results suggest that this easily performed technique should be used in the follow-up of NMO, but complementary studies are warranted to confirm its interest at an individual level.

[Optic neuropathy and meningioma: a diagnostic trap]. / Méningiome et neuropathie optique : un piège diagnostique.

INTRODUCTION: Meningiomas are benign primary meningeal tumors. Their diagnosis may be incidental or in response to a work-up for neurological or ophthalmological symptoms. PATIENTS AND METHODS: The clinical course of five patients with ophthalmological symptoms leading to the diagnosis of meningioma is described. RESULTS: The case reports consist of five women (48 to 54 years old - mean 52 years at the onset of symptoms), all suffering from a progressive unilateral decrease in visual acuity with a normal initial fundus examination and ipsilateral visual field changes. Ancillary testing, in particular MRI and CT-scans, had to be repeated to make the diagnosis of meningioma, which was delayed from 18 months to 4 years. DISCUSSION: The clinical presentation of these five cases was that of a retrobulbar optic neuropathy, which biased the work-up towards an inflammatory disease of the central nervous system such as multiple sclerosis. However, the atypical character of the neuropathy, which did not respond to intravenous steroids, caused the diagnosis to be questioned and radiological examinations repeated. The iso-intense appearance of meningiomas on T1 MR imaging and only slightly hyperintense appearance on T2 may result in a diagnostic delay if the exam is not performed and interpreted by an experienced professional. Gadolinium contrast, fat suppression and centration on the anterior visual pathways are essential to a proper MRI examination. CONCLUSION: When confronted with a progressive, painless optic neuropathy unresponsive to steroid treatment, the diagnosis of meningioma of the anterior visual pathways must be considered. This diagnosis is enabled by a targeted MRI of the anterior visual pathways.

Intermediate uveitis, an ophthalmological manifestation of systemic disease.

PURPOSE: Intermediate uveitis is frequently indicative associated with systemic disease. In addition to the initial evaluation of the patient with intermediate uveitis, we sought to determine the role of longitudinal follow-up in improving the diagnosis of systemic disease associated with intermediate uveitis. METHOD: Retrospective analysis of a cohort of 51 patients with intermediate uveitis followed for 5 to 13 years. RESULTS: Upon initial evaluation, an underlying disease associated with the intermediate uveitis was found in nine out of the 51 patients. Among the remaining patients, after at least 5 years of follow-up, eight new associated diagnoses were revealed (primarily inflammatory diseases and cancers). CONCLUSION: These results suggest that the initial work-up of the patient with intermediate uveitis is not sufficiently sensitive and that careful follow-up of these patients considerably improves the diagnosis of associated disease.

[Spontaneous scleral rupture revealed by hypotony maculopathy]. / Rupture sclérale spontanée révélée par une maculopathie d'hypotonie.

Cases of a spontaneous scleral rupture are very uncommon. Their diagnosis can be challenging because the scleral lesion might be invisible on clinical examination. We describe herein one case revealed by hypotony maculopathy. A 30-year-old woman presented with severe visual loss in one eye caused by sudden hypotony. Funduscopy revealed a chorioretinal coloboma in the periphery of the retina associated with a hypotony maculopathy. Extensive work-up included optical coherence tomography (OCT), fluoroangiography, ultrasonography, and magnetic resonance imaging examinations. A search for infectious and inflammatory diseases was conducted. Inflammatory and infectious work-ups were not contributive. A surgical exploration was performed, which showed a spontaneous scleral perforation within the coloboma. A patch of polytetrafluoroethylene was sutured on the damaged sclera and air was injected into the vitreous cavity. Vision and ocular pressure were rapidly restored. Spontaneous scleral rupture cases associated with hypotony and visual loss are rare, with only a few cases reported in the literature. Hypotony maculopathy with sclerochoroidal lesion may be the cause of such cases. Excellent outcome can be obtained with surgical diagnosis and repair.

[Difficulties and reproducibility of radiological measurement of the proximal tibial axis according to Lévigne]. / Difficultés et reproductibilité de la mesure radiographique de l'axe épiphysaire proximal du tibia selon la technique de Lévigne.

PURPOSE OF THE STUDY: The angle between the anatomic axis of the tibia and the tangent to the superior borders of the tibial plateaus is, on average, tilted 3 degrees in the varus position. If there is no bone wear, this angle measures the constitutional epiphyseal axis of the proximal tibia. When degenerative joint disease modifies the aspect of the tibial plateaus, this angle measures the sum of the constitutional varus and the bone wear, without distinguishing between the two. It is known however that the respective contribution of these two deformations can have therapeutic implications, particularly when tibial osteotomy for valgus correction or implantation of a unicompartmental prosthesis is proposed. Lévigne proposed a radiographic measurement of the proximal tibial axis to distinguish between these two sources of tibial deformation. We studied the intra- and interobserver reproducibility of these measurements. MATERIAL AND METHODS: Fifty volunteers free of knee disease were chosen at random among a population of patients undergoing upper limb surgery. All patients provided their informed consent for participation in the study. Full-limb radiographs of one lower limb (chosen at random) were obtained using a standardized technique. The proximal tibial axis was measured according to the Lévigne technique using a manual goniometer graduated in degrees. One operator performed two series of measures independently on the same films. Two other operators performed a series of measurements on each film. The intra- and inter-observer reproducibility was determined with the interclass coefficient of correlation (rho). RESULTS: The proximal epiphyseal axis of the tibia could not be determined on 7 to 18 films, depending on the operator. All three operators were able to make the all measurements (four per film) for only 25 patients. The mean epiphyseal axis varied from 2.5 degrees to 4.7 degrees for the four series of measurements. Intra-observer reproducibility was considered good (rho=0.62). Inter-observer reproducibility was considered moderate (rho=0.41). DISCUSSION: The Lévigne technique is to our knowledge the only method described in the literature distinguishing the relative contribution of constitutional varus and bone wear of the proximal tibia. According to the advocates of this method, the angle between the epiphyseal axis linking the center of the tibial plateaus and the center of the proximal growth cartilage scare, and the anatomic axis of the tibia is a measurement of constitutional varus. The average is 3 degrees . The angle between a line perpendicular to the epiphyseal axis and the tangent of the superior borders of the tibial plateaus measures the deformation related to bone wear. In the present work, we found that this technique enables acceptable intra-observer reproducibility but that inter-observer reproducibility is low. The differences observed are certainly related to uncertain identification of the growth cartilage scar. This illustrates the difficulty in generalizing this technique for measuring healthy knees. Such difficulties would be even greater for degenerative knees. CONCLUSION: The Lévigne technique does not appear to be a reliable method for defining indications for different surgical procedures according to the morphology of the proximal tibia.