[Update on recommendations for screening for hydroxychloroquine retinopathy]. / Mise à jour des recommandations sur la toxicité rétinienne des antipaludéens de synthèse.

INTRODUCTION: Recommendations for screening for chloroquine (CQ) and hydroxychloroquine (HCQ) retinopathy have recently been changed by the American Academy of Ophthalmology, taking into account new published data on toxicity prevalence, risk factors, location of onset in the retina and the efficacy of screening tests. METHODS: Literature review. RESULTS AND DISCUSSION: The risk of developing CQ or HCQ retinopathy depends on the daily dose and duration of treatment. At recommended doses, the risk is<1 % at 5 years, <2 % at 10years but increases to about 20 % after 20years of treatment. The maximum recommended daily dose is 5.0mg/kg for HCQ and 2.3mg/kg for CQ. The two main risk factors are the daily dose and duration of treatment. The presence of kidney failure and treatment with tamoxifen are also significant risk factors. A baseline examination should be performed at the initiation of treatment to rule out pre-existing maculopathy. The screening is then annual and starts from the 5th year of treatment. The two tests recommended for screening are the automated visual field and spectral domain OCT. Multifocal ERG and autofluorescence fundus imaging are only carried out secondarily to confirm the pathology.

[A "fast track" to improve management of neovascular age related macular degeneration]. / Un « circuit court ¼ pour améliorer la prise en charge des patients atteints de dégénérescence maculaire liée à l'âge néovasculaire.

OBJECTIVE: To evaluate the role of a fast track for management of patients with neovascular age- related macular degeneration (nARMD) treated by intravitreal injection of anti-VEGF. PATIENTS: The records of 100 patients in the chronic maintenance phase of intravitreal anti-VEGF followed in the fast track and 63 patients followed in the standard protocol for at least 12 months were retrospectively analyzed. METHOD: Patients in the fast track underwent visual acuity (VA) testing by ETDRS, optical coherence tomography (OCT) and a physician assessment. The injection was performed the same day whenever possible. The primary endpoint to evaluate patient adherence was the time between the ideal date of visit or injection prescribed by the physician and the actual date of administration. RESULTS: The mean time between the ideal date of visit or injection prescribed by the physician and the actual date of administration was 4.1±7.5 days for the patients followed in the fast track and 5.6±18.7 days for the patients followed in the standard protocol. Mean VA remained stable for the patients followed in the fast track: 20/50 (20/800 to 20/20) at baseline vs. 20/50 (20/800 to 20/16) at the conclusion of follow-up. It dropped from 40/50 at baseline to 20/63 at the conclusion of follow-up for the patients followed in the standard protocol. CONCLUSION: In the context of a fast track, it was possible to improve the adherence of nARMD patients and maintain their VA gain or stabilization achieved after the induction phase.

Occurrence rate of retinal detachment after small gauge vitrectomy for idiopathic epiretinal membrane.

PurposeTo assess the occurrence rate of retinal detachment (RD) after small gauge vitrectomy for idiopathic epiretinal membrane (ERM).Patients and methodsRetrospective observational case series. The records of consecutive patients operated on for idiopathic ERM using small gauge pars plana vitrectomy between August 2012 and December 2014 with at least a 1-year follow-up were reviewed. All patients were contacted by phone to assess the occurrence of RD during the post-operative follow-up. The main outcome was the occurrence of RD. Patients who underwent surgery for senile cataract over the same period with at least a 1-year follow-up were also contacted by phone for comparison.ResultsTwo hundred and sixteen eyes of 212 patients who had undergone ERM surgery were included, with a mean follow-up of 892±211 days (216-1238). RD occurred in two eyes (0.92%). Over the same period, two RD occurred in the 203 eyes (0.98%) of 157 patients operated on for senile cataract in our department.ConclusionsThe occurrence of RD after 25-gauge vitrectomy for idiopathic ERM was <1%. Using small gauge sutureless vitrectomy systems has improved the safety of ERM surgery, with a RD rate similar to that observed after cataract surgery.

[Epiretinal membranes]. / Les membranes épirétiniennes maculaires.

Idiopathic epiretinal membranes represent a common condition, and are present in approximately 10% of people over the age of 70 years. They are idiopathic in 80% of cases, or may be secondary to various conditions such as a prior retinal detachment, or vascular or inflammatory retinal diseases. The main symptoms are visual loss and metamorphopsia. The diagnosis of epiretinal membrane is currently facilitated by OCT, which provides prognostic and therapeutic decision-making assistance. Surgery for epiretinal membranes is currently well codified through sutureless vitrectomy and dyes. Dissection of the membrane (with or without associated peeling of the internal limiting membrane) ensures good anatomical and functional results, while being relatively minimally invasive.

Multi detector computed tomography (MDCT) for the diagnosis of early complications after pancreas transplantation.

PURPOSE: Solitary Pancreas (SPT) and simultaneous kidney-pancreas (SPKT) transplants carry a high risk of surgical complications that may lead to the loss of the pancreas graft and impact later kidney function. The purpose of this study was to investigate the role of MDCT in the diagnosis of early complications and its impact on kidney function. METHODS: All patients receiving SPT or SPKT over 5 years were retrospectively included. Complications that occurred within the first 15 days were registered and MDCT data analyzed. Data regarding donor, transplant, and recipient characteristics as well as transplantation procedures were analyzed according to the occurrence of early complications. Kidney function at day 3 following MDCT was evaluated. RESULTS: One hundred and forty-one patients were included (85 men, 56 women; mean age 40.1 years, SD 7.7) with 119 SPKT and 22 SPT. Sixty-four complications were registered in 50 patients. Partial (P-) or complete venous thrombosis (C-VT) occurred in 12.1 % (n = 17), arterial thrombosis (AT) in 1.4 % (n = 2), and hemorrhage in 8.5 % (n = 12) of all patients. For venous thrombosis, the predominant risk factor was body mass index (BMI) for either recipients (P < 0.05) or donors (P < 0.01). Median time for venous thrombosis diagnosis with MDCT was 4 days. Kidney function was not altered following MDCT. Fourteen pancreatectomies were necessary. All patients with C-VT and AT had to undergo graftectomy. CONCLUSION: Vascular complications occurred early following grafting. Systematic early-enhanced MDCT at day 2-3 should be adequate to detect early thrombosis, especially if risk factors have been identified, without induced kidney function alteration.

A solid pancreatic mass: tumour or inflammation?

The prognosis for pancreatic cancer is poor, and early diagnosis is essential for surgical management. By comparison with its classic form, the presence of acute or chronic inflammatory signs will hinder its detection and delay its diagnosis. The atypical forms of acute pancreatitis need to be known in order to detect patients who require additional morphological investigations to search for an underlying tumour. In contrast, pseudotumoral forms of inflammation (chronic pancreatitis, cystic dystrophy in heterotopic pancreas, autoimmune pancreatitis) may simulate a cancer, and make up 5-10% of the surgical procedures for suspected cancer. Faced with these pseudotumoral masses, interpretation relies on various differentiating signs and advances in imaging.

FDG-PET in the evaluation of myeloma in 2012.

Multiple myeloma (MM) is a malignant haematological disease characterised by clonal proliferation of malignant plasma cells in the bone marrow. MM is expressed by diffuse infiltration of the bone marrow, focal bone lesions and extra-medullary lesions. Conventional staging follows the Salmon and Durie classification, which was recently revised (Salmon and Durie plus) to include MRI and FDG-PET examinations. FDG-PET is being evaluated for initial staging and therapeutic monitoring and its place still needs to be validated, particularly in comparison with MRI of the pelvis and spine, the reference examination for diagnosis, which is systematically combined with X-rays of the skeleton. Certain recent data in the literature suggest that FDG-PET provides better staging of the disease at the time of diagnosis than MRI, and that the examination has considerable prognostic value when it normalises after the initial courses of chemotherapy and at the end of treatment. As for the evaluation of lymphomas, the interpretation criteria should be standardised.

Hypoglycaemia is associated with the absence of a decrease in diurnal macular thickness in patients with diabetic macular oedema.

AIM: Spontaneous diurnal variations measured by optical coherence tomography (OCT) have been reported in diabetic macular oedema (DME) together with a daytime decrease in central macular thickness (CMT). For this reason, this study aimed to investigate the influence of acute glucose and blood pressure changes on daytime variations in CMT in patients with DME. METHODS: In this prospective observational study of type 1 (n=4) and type 2 (n=18) diabetic patients with DME, OCT scans, capillary blood glucose, and systolic and diastolic blood pressure measurements were performed at 9 a.m., 12 a.m., 3 p.m., 6 p.m. and again at 9 a.m. the day after. At the same time, the study protocol included simultaneous ambulatory blood pressure and glucose monitoring over a 24-h period. Hypoglycaemic episodes, defined as glucose values<60mg/dL, were also recorded. RESULTS: CMT decreased consistently between 9 a.m. and 6 p.m. in 10 patients (from 374±82µm to 337±72µm; P=0.01) and increased or remained steady in 12 others (from 383±136µm to 390±149µm; P=0.58), with a significant difference in CMT absolute change between the two groups (P<0.001). In the study population as a whole, the lower the mean diurnal blood glucose, the smaller the decrease in CMT during the day (P=0.027). Also, eight (67%) of the 12 patients with a flat CMT profile experienced a diurnal hypoglycaemic event whereas none of those with a CMT decrease had hypoglycaemia (P=0.002). CONCLUSION: Hypoglycaemic events may explain the lack of diurnal CMT decrease in diabetic patients with DME. However, further studies need to be conducted to evaluate whether having no diurnal CMT decrease is associated with a poorer visual prognosis and whether it can be modified by better glucose control.

Staging and monitoring in the treatment of lymphomas.

Lymphoma staging systematically includes a CT scan of the cervical, thoracic and abdominopelvic regions. PET is indicated in diffuse large B cell lymphomas (DLBCL) and Hodgkin's disease. Evaluation of the response to treatment is based on Cheson's 1999 morphological criteria, which have been replaced by the 2007 IWC criteria, which combine morphological and metabolic responses. CT and FDG-PET are complementary in characterizing residual masses: if negative, a PET scan indicates the absence of residual disease, if positive; it directs a CT-guided biopsy to obtain the histological evidence. Monitoring clinical features and laboratory values is primordial following treatment. Imaging is performed as a second intention for investigating a relapse, if necessary associated with a PET scan. Multimodal imaging implies multidisciplinary consultation between haematologists, imaging specialists and histopathologists.

The role of FDG-PET scanning in assessing lymphoma in 2012.

Positron emission tomography (PET) has a proven role in the assessment diffuse large B-cell lymphoma (DLBCL) and Hodgkin's lymphoma (HL). The clinical impact of PET carried out at the end of the patient's course of treatment is undeniable and recommendations must be followed in the interpretation of these examinations. PET is highly recommended as part of the initial investigations of these diseases because it can be used as a reference for the interpretation at treatment completion and allows disease spread to be assessed with greater sensitivity and specificity than when computed tomography (CT) is used. It seems to be certain that PET is useful for interim examinations too, in terms of assessing prognosis in DLBCL and HL, although its impact in terms of early changes to treatment is still to be determined. The criteria for interpreting the results of these early assessments are still evolving and the annual meetings in Menton, France, of groups of experts are leading towards a uniform interpretation method. In other types of lymphoma, PET can be useful for confirming local disease staging, especially in follicular lymphoma, and for guiding biopsy in patients with low-grade lymphoma that is suspicious for transformation into more aggressive disease. Several studies are in agreement that PET is valuable for assessing prognosis at treatment completion in FL and mantle cell lymphoma, but prospective studies are needed for this new indication to be validated.

[Corneal imaging]. / Imagerie de la cornée.

Initially developed for research purposes, several imaging techniques of the cornea are now available in clinical practice brought by technological advances that have improved resolution but have also simplified their use. In vivo confocal microscopy (IVCM) provides images with a resolution approaching one micron and permitting a histological-like in vivo imaging of the cornea. In parallel, Ocular Coherence Tomography (OCT) imaging techniques have been also developed and offers today macroscopic images of anterior segment tissues and of the cornea in particular. Numerous corneal diseases as well as corneal surgical procedures could have a benefit from these new imaging techniques of the anterior segment of the eye.

AME position statement on adrenal incidentaloma.

OBJECTIVE: To assess currently available evidence on adrenal incidentaloma and provide recommendations for clinical practice. DESIGN: A panel of experts (appointed by the Italian Association of Clinical Endocrinologists (AME)) appraised the methodological quality of the relevant studies, summarized their results, and discussed the evidence reports to find consensus. RADIOLOGICAL ASSESSMENT: Unenhanced computed tomography (CT) is recommended as the initial test with the use of an attenuation value of ≤10 Hounsfield units (HU) to differentiate between adenomas and non-adenomas. For tumors with a higher baseline attenuation value, we suggest considering delayed contrast-enhanced CT studies. Positron emission tomography (PET) or PET/CT should be considered when CT is inconclusive, whereas fine needle aspiration biopsy may be used only in selected cases suspicious of metastases (after biochemical exclusion of pheochromocytoma). HORMONAL ASSESSMENT: Pheochromocytoma and excessive overt cortisol should be ruled out in all patients, whereas primary aldosteronism has to be considered in hypertensive and/or hypokalemic patients. The 1 mg overnight dexamethasone suppression test is the test recommended for screening of subclinical Cushing's syndrome (SCS) with a threshold at 138 nmol/l for considering this condition. A value of 50 nmol/l virtually excludes SCS with an area of uncertainty between 50 and 138 nmol/l. MANAGEMENT: Surgery is recommended for masses with suspicious radiological aspects and masses causing overt catecholamine or steroid excess. Data are insufficient to make firm recommendations for or against surgery in patients with SCS. However, adrenalectomy may be considered when an adequate medical therapy does not reach the treatment goals of associated diseases potentially linked to hypercortisolism.

[Unusual retinal abnormality: retinal hemorrhages related to scurvy]. / Une cause inhabituelle d'anomalies rétiniennes, hémorragies rétiniennes révélatrices de scorbut.

A diet restricted to rice and boiled fruit and vegetables leads to vitamin C deficiency. We describe the third case, to our knowledge, of retinal hemorrhages related to scurvy. Reduced bilateral visual acuity in a 50-year-old patient was associated with macrocytic anemia, denutrition, and cutaneous ecchymoses. Oral vitamin C treatment provided subjective clinical improvement and regression of the retinal hemorrhages on fundus examination, with no side effects. Vitamin C plays an important role in collagen stability in vascular and bone walls.

Automatic screening of age-related macular degeneration and retinal abnormalities.

We describe a novel approach for screening retinal imagery to detect evidence of abnormalities. In this paper, we focus our efforts on age-related macular degeneration (AMD), a pathology that may often go undetected in the early or intermediate stages, and can lead to a neovascular form often resulting in blindness, if untreated. Our strategy for retinal anomaly detection is to employ a single class classifier applied to fundus imagery. We use a multiresolution locally-adaptive scheme that identifies both normal and anomalous regions within the retina. We do this by using a hybrid parametric/non-parametric characterization of the support of the probability distribution of normal retinal tissue in color and intensity feature space. We apply this approach to screen for evidence of AMD on a dataset of 66 healthy and pathological cases and found a detection sensitivity and specificity of 95% and 96%.

[In vivo confocal microscopy: a new tool for the diagnosis of Acanthamoeba keratitis]. / Apport de la microscopie confocale in vivo au diagnostic des kératites amibiennes.

PURPOSE: To study the usefulness of in vivo confocal microscopy imaging for the diagnosis of Acanthamoeba keratitis. METHODS: A retrospective review of 50 cases of Acanthamoeba keratitis followed at the Quinze-Vingts National Ophthalmology Hospital from January 2005 to July 2008 was conducted. Gender, age, contact lens wear, best-corrected visual acuity before and after treatment, slit-lamp examination findings, corneal scrapings for biological analysis, and in vivo confocal microscopy images were analyzed. RESULTS: Nearly 82% of the cases of keratitis had a history of contact lens wear. Polymerase chain reaction (PCR) was positive for 40% of the samples. Heidelberg Retinal Tomograph II-Rostock Cornea Module (HRTII-RCM) examination detected images evoking Acanthamoeba cyst-like images in 84% of the cases. When the quality of biological samples was inadequate, the assessment of Acanthamoeba cysts using in vivo confocal microscopy made it possible to orient the diagnosis and to partially explain favorable progression under treatment. This technique showed images suggesting combined Acanthamoeba and fungal keratitis. CONCLUSION: HRTII-RCM in vivo confocal microscopy is a non invasive and rapid technique that may be helpful for the diagnosis of Acanthamoeba keratitis, especially when laboratory testing is not contributive and when Acanthamoeba keratitis is combined with a fungal infection.