Intravitreal Injection of Anti-VEGF Antibody Induces Glomerular Endothelial Cells Injury.

INTRODUCTION: Antiangiogenic agents that inhibit vascular endothelial growth factor have emerged as important tools in cancer therapy and ocular diseases. Their systemic use can induce renal limited microangiopathy. Local use of anti-VEGF agent is supposed to be safe. We report here a unique case of early endothelial cells injury induced by intravitreal injection of bevacizumab. CASE PRESENTATION: A 72-year-old man was addressed for acute kidney injury with proteinuria. He was under treatment with intravitreal injections of bevacizumab for glaucoma. Kidney biopsy was performed and electron microscopy showed signs of early stages of glomerular microangiopathy. Bevacizumab was discontinued resulting in the improvement of renal function and albuminuria. DISCUSSION: Bevacizumab, a humanized monoclonal antibody to VEGF is an approved therapy for metastatic cancer. Systemic adverse events including thrombotic microangiopathy have been mainly reported after its systemic injection. Podocytes produce VEGF that interacts with endothelial cells VEGF receptor-2 maintaining glomerular basement membrane integrity. Bevacizumab induce the detachment of endothelial cells from glomerular basement membrane leading to the proteinuria and renal function decline. Intravitreal bevacizumab is generally supposed to be safe. However, glomerular injury with microangiopathy features, even after intravitreal injection is possible. CONCLUSION: We report the electron microscopy evidence that intravitreal injection of anti-VEGF induces glomerular endothelial cells injury. Nephrologists and ophthalmologists should be aware of this complication.

[Ptosis associated with pachydermoperiostosis]. / Ptôsis associé à une pachydermopériostose.

INTRODUCTION: Pachydermoperiostosis or primary hypertrophic osteoarthropathy is a rare cause of ptosis. We report the case of a patient with pachydermoperiostosis and bilateral ptosis. The physiopathology and treatment of this ptosis are discussed. CASE REPORT: A 49-year-old patient was referred to our department with ptosis. He had pachydermia of the face, hands and the feet, digital clubbing and periostosis. Examination of the eyelids showed that palpebral apertures were reduced to less than 4mm bilaterally and that eyelids were markedly thickened. All theses features were consistent with the diagnosis of pachydermoperiostosis. Other secondary conditions were ruled out. Ptosis correction was performed by palpebral skin and orbicularis resection as well as tarsectomy. The aesthetic outcome was satisfactory. DISCUSSION: Pachydermoperiostosis is a rare inherited disease, characterized by pachydermia, digital clubbing and periotosis. Ptosis is the result of the palpebral hypertrophia. Excisions of skin, orbicularis muscle and tarsus often give good cosmetic outcomes. CONCLUSION: Pachydermoperiostosis is a rare cause of ptosis, which development is attributed to eyelid thickening. Surgical management has satisfactory cosmetic outcome.

[Senile scleral plaque associated with scleritis in a patient with rheumatoid arthritis]. / Plaque sclérale sénile associée à une sclérite chez un patient atteint d'une polyarthrite rhumatoïde.

Senile scleral plaque is an age-related, commonly asymptomatic hyaline degeneration of the sclera. We report a case of calcific scleral plaque associated with anterior scleritis in an elderly patient with rheumatoid arthritis. Response to anti-inflammatory treatment was favorable.

[Eyelid necrosis after injection of lidocaine with epinephrine]. / Nécrose cutanée palpébrale secondaire à une injection de xylocaïne adrénalinée.

Four patients (two women aged 50 and 67 years, a 36-year-old man, and a 5-year-old child) presented with necrosis of the eyelid after local anesthesia using 2% lidocaine with epinephrine. In three cases, the anesthesia was administered prior to suturing an eyelid laceration, and the necrosis involved the upper lid; in one case, the anesthesia was administered prior to temporal artery biopsy. Surgical debridement of the necrotic tissue was performed in all cases. Three patients developed a bacterial superinfection treated with systemic antibiotics with good results. Necrosis of the eyelid is a rare complication occurring after local anesthesia using lidocaine with epinephrine. Most dermatologists refrain from use of epinephrine with local anesthetics for digital blocks. Necrosis is due to prolonged vasoconstriction of arteries. It is observed especially commonly in patients at increased risk (arteritis, Raynaud's phenomenon and severe microvascular diseases). In the eyelid, few cases have been reported.

[Unilateral congenital ptosis with ipsilateral superior rectus muscle overaction]. / Ptosis congénital associé à une hyperaction du muscle droit supérieur.

Congenital ptosis may be frequently accompanied by weakness of the ipsilateral superior rectus muscle. We report a case of ptosis with ipsilateral superior rectus muscle overaction. The 45-year-old patient presented with unilateral congenital ptosis. Ipsilateral superior rectus muscle overaction was found in the upgaze, with an inferior sclera show. This can be found in 40% of congenital ptosis. The authors give two possible causes: either an exaggerated Bell reflex or misdirection innervations of the superior rectus muscle by the superior division of the oculomotor nerve, initially innervating the upper eyelid elevator muscle. Histological or electrophysiological studies can be useful to determine the physiopathology of this association.

[Oculopalpebral and facial synkinesis associated with ptosis: epidemiological, clinical, and therapeutic features]. / Les syncinésies oculo-facio-palpébrales associées au ptosis : aspects épidémiologiques, cliniques et thérapeutiques.

Synkinetic movements of the upper eyelids may be noted in association with movements of either extraocular muscles or other muscles of the face. Patients with oculopalpebral or facial-palpebral synkinesis may also have ptosis of the involved eyelid. The clinical and therapeutic features of this association are specific. We mainly distinguish two forms of synkinetic movements, characterized either by the elevation of the ptotic eyelid such as in Marcus Gunn phenomenon and in the Fuchs sign or by the falling of the upper lid such as in Marin Amat syndrome. Many surgical techniques have been used to correct the blepharoptosis and the synkinetic movement. Levator resection is often advocated for correction of blepharoptosis with a mild degree of synkinesis. However, when the ptosis is major, eyelid lag is a possible outcome. For moderate or major synkinesis, bilateral frontalis suspension with disinsertion of the levator has been suggested. This procedure generally provides satisfactory cosmetic results.