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Chin YYB, Yeo TH, Bakthavatsalu M, Zhou WT, Wagle AM, Gopal L, Lim TH. ACUTE ATYPICAL ENDOPHTHALMITIS FOLLOWING INTRAVITREAL SUSTAINED-RELEASE DEXAMETHASONE IMPLANT: A CASE SERIES. Retin Cases Brief Rep 2024; 18:155-158. [PMID: 36730427 PMCID: PMC10898540 DOI: 10.1097/icb.0000000000001369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 11/01/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE To present three cases of acute endophthalmitis following intravitreal sustained-release dexamethasone (Ozurdex) with atypical presentation and to discuss the management of these patients. METHODS A retrospective case series of three patients with endophthalmitis following intravitreal sustained-release dexamethasone (Ozurdex) implantation who presented between July 2020 and August 2020. RESULTS Two of three patients who were treated with topical steroid and antibiotic therapy alone showed favorable outcomes and were managed without the need for intravitreal antibiotics or implant removal. One patient who showed initial response to topical therapy subsequently required pars plana vitrectomy, implant removal, and a single empirical dose of intravitreal antibiotics and antifungal agent due to persistent inflammation. CONCLUSION Postintravitreal Ozurdex endophthalmitis, although a rare entity, can present with atypical features of a painless white eye and a delayed onset intraocular inflammation. Although all cases of endophthalmitis should be treated as infective until proven otherwise, it is fair to consider a trial of conservative treatment with topical steroids and antibiotics initially with close monitoring. In cases with poor response to topical therapy, pars planar vitrectomy and implant removal should be strongly considered.
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Affiliation(s)
- Yi Yao Brendan Chin
- Department of Ophthalmology and Visual Sciences, Khoo Teck Puat Hospital, Singapore
| | - Tun Hang Yeo
- Department of Ophthalmology and Visual Sciences, Khoo Teck Puat Hospital, Singapore
| | | | - Wen Ting Zhou
- Department of Ophthalmology and Visual Sciences, Khoo Teck Puat Hospital, Singapore
| | - Ajeet Madhav Wagle
- Department of Ophthalmology and Visual Sciences, Khoo Teck Puat Hospital, Singapore
- International Eye Cataract Retina Centre, Farrer Park Medical Centre, Singapore; and
| | - Lekha Gopal
- Department of Ophthalmology and Visual Sciences, Khoo Teck Puat Hospital, Singapore
| | - Tock Han Lim
- Department of Ophthalmology, Tan Tock Seng Hospital, Singapore
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Cruz-Iñigo YJ, Klein K, Reddy RK. CASE REPORT OF ABIOTROPHIA DEFECTIVA ENDOPHTHALMITIS AFTER REPEATED INJECTIONS OF DEXAMETHASONE INTRAVITREAL IMPLANT (OZURDEX). Retin Cases Brief Rep 2022; 16:170-173. [PMID: 31479011 DOI: 10.1097/icb.0000000000000925] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
PURPOSE To present a case of endophthalmitis caused by Abiotrophia defectiva after repeated injections of dexamethasone intravitreal implant (Ozurdex), in a patient already on systemic immunosuppressive therapy, and discuss the management of this challenging situation. METHODS Case report and review of literature. RESULTS A 70-year-old female patient with history of idiopathic pulmonary fibrosis presented for urgent evaluation due to left eye vision loss and mild discomfort 12 days after receiving her seventh dexamethasone implant injection. Ocular history was pertinent for recurrent macular edema resulting from a remote branch vein occlusion. Twelve days after her last injection, visual acuity decreased from 20/30 to counting fingers at 5 feet. Slit-lamp examination showed anterior chamber cell without fibrinoid membranes or hypopyon. Within hours, the patient's clinical appearance progressed. A vitreous tap followed by intravitreal injection of vancomycin (1 mg/0.1 mL) and ceftazidime (2.25 mg/0.1 mL) was performed. The culture from the vitreous sample revealed heavy growth of A. defectiva. Owing to limited improvement, patient was taken to the operating room, and the presence of a full-thickness scleral defect at the site of most recent dexamethasone implant injection was confirmed. Vitrectomy with removal of implant, closure of all sclerotomies, including nonhealing full-thickness scleral defect, and repeated intravitreal antibiotic injection were performed. At the 3-month follow-up, no inflammation was observed, but visual acuity remained poor. CONCLUSION Intravitreal dexamethasone implant-associated endophthalmitis in the setting of systemic immunosuppression is a rare and challenging situation. Both local and systemic immunosuppression may delay wound healing, predisposing to wound leakage and consequent endophthalmitis. Despite repeated intravitreal antimicrobial injection and vitrectomy with implant removal, A. defectiva endophthalmitis carried a poor visual outcome.
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Kavitha S, Tejaswini SU. Management of post glaucoma drainage device-related endophthalmitis: To retain or to remove? TNOA JOURNAL OF OPHTHALMIC SCIENCE AND RESEARCH 2021. [DOI: 10.4103/tjosr.tjosr_80_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Celik N, Khoramnia R, Auffarth GU, Sel S, Mayer CS. Complications of dexamethasone implants: risk factors, prevention, and clinical management. Int J Ophthalmol 2020; 13:1612-1620. [PMID: 33078113 DOI: 10.18240/ijo.2020.10.16] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 06/02/2020] [Indexed: 11/23/2022] Open
Abstract
AIM To evaluate major complications after intravitreal injection of dexamethasone implants (Ozurdex) and their clinical management. METHODS In a retrospective observational study between 2014 and 2016 at two university hospitals, we reviewed the clinical records of 1241 consecutive macular edema patients treated with the dexamethasone implant, and separated severe adverse events in the injection procedure from those that were post-injection complications. We evaluated the cause and the outcomes in each case. RESULTS In twenty-one procedures (1.69%) we noticed significant complications during and after intravitreal injection of the dexamethasone implant. Complications related to the injection procedure were in one case, that a second implant was injected by mistake in the same eye on the same day. In another case, the implant lodged in the sclera during retraction of the injector needle. Leaking scleral tunnel at the injection site led to hypotony in another case. There were 10 cases of post-injection displacement of the implant into the anterior chamber and one case with a migrated and trapped device between the intraocular lens and an artificial iris. Displacement typically occurred in patients with preexisting risk factors: eyes with complicated intraocular lens implantation, iris reconstruction or iris defects or pseudophakic eyes after vitrectomy were prone to develop this complication. Displacement led to secondary corneal decompensation with pseudohypopyon. One case developed an endophthalmitis, and we observed four cases of retinal detachment. Two eyes presented with long-lasting hypotony due to ciliary insufficiency. CONCLUSION Treatment with the dexamethasone implant may cause various expected or unexpected complications that may have serious consequences for the patient and require further surgery. To reduce complications, clinicians should evaluate certain risk factors before scheduling patients for dexamethasone implant treatment and use proper injection techniques.
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Affiliation(s)
- Nil Celik
- Department of Ophthalmology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Ramin Khoramnia
- Department of Ophthalmology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Gerd U Auffarth
- Department of Ophthalmology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Saadettin Sel
- Department of Ophthalmology, University Hospital of Heidelberg, Heidelberg 69120, Germany
| | - Christian S Mayer
- Department of Ophthalmology, University Hospital of Heidelberg, Heidelberg 69120, Germany
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Al Zamil W, Yassin SA. Acute Bacterial Endophthalmitis Following Dexamethasone Intravitreal Implant: A Case Report. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2019; 7:110-113. [PMID: 31080392 PMCID: PMC6503689 DOI: 10.4103/sjmms.sjmms_57_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 54-year-old male presented to our ophthalmology clinic with a diagnosis of the right central retinal vein occlusion with macular edema. The patient was treated with dexamethasone intravitreal implant. Three days after the implant insertion, the patient experienced pain, redness and blurred vision in the same eye. With a provisional diagnosis of acute endophthalmitis, a combination of ceftazidime 2.25 mg/0.1 ml and vancomycin 1 mg/0.1 ml was injected intravitreally. One week after the treatment, endophthalmitis signs and symptoms subsided. This report presents a case of endophthalmitis following dexamethasone intravitreal implant, with a favorable outcome after treatment with intravitreal antibiotic injection without removal of the implant.
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Affiliation(s)
- Waseem Al Zamil
- Department of Ophthalmology, King Fahd Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Sanaa A Yassin
- Department of Ophthalmology, King Fahd Hospital of the University, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Acute Onset of Exogenous Endophthalmitis after Dexamethasone Implant Injection Treated without Implant Removal. Case Rep Ophthalmol Med 2018; 2018:4614802. [PMID: 30581640 PMCID: PMC6276387 DOI: 10.1155/2018/4614802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/27/2018] [Accepted: 09/17/2018] [Indexed: 11/21/2022] Open
Abstract
We present a case of acute endophthalmitis after intravitreal dexamethasone implant injection and discuss the management of this rare and challenging case in which the implant could not be removed. A 50-year-old woman with a history of branch retinal vein occlusion in the right eye was treated with intravitreal dexamethasone implant injection for macular oedema. Four days after injection, the patient was admitted to the department with acute pain, decreased vision, and redness. A diagnosis of acute post-intravitreal injection endophthalmitis was made. A 23-guage (23G) vitrectomy was performed immediately to remove the implant, and a vitreous tap for culture and polymerase chain reaction was acquired during the procedure. We were unable to remove the dexamethasone implant during the vitrectomy because of dense membrane formation. At the end of the procedure, we injected intravitreal antibiotics (vancomycin and amikacin), and the patient was treated with fortified topical antibiotics and steroids. At the time of writing, 5 years later, the patient retains a best corrected visual acuity of 10/10 (6/6) with dexamethasone implant therapy maintenance. Intravitreal dexamethasone implant-associated endophthalmitis is a rare and challenging condition. Immediate 23G pars plana vitrectomy, even without removal of the implant, can lead to favourable visual results.
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Sherman T, Raman V. Incomplete scleral penetration of dexamethasone (Ozurdex) intravitreal implant. BMJ Case Rep 2018; 11:11/1/e227055. [PMID: 30567246 DOI: 10.1136/bcr-2018-227055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Ozurdex (Allergan, Irvine, California, USA) is a biodegradable sustained release intravitreal implant containing 0.7 mg dexamethasone in a solid polymer drug delivery system. In the UK, it is approved for use in patients with macular oedema secondary to retinal vein occlusion, diabetic maculopathy and non-infectious uveitis. Although the implant is meant to be injected into the vitreous cavity, it can be inadvertently injected into the crystalline lens. This can also migrate into the anterior chamber, under altered anatomical conditions of the anterior segment. We report a case of incompletely penetrated dexamethasone implant, in a patient undergoing treatment for macular oedema secondary to retinal vein occlusion. The partially penetrated implant was managed conservatively with a good outcome.
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Affiliation(s)
- Thomas Sherman
- Royal Eye Infirmary, University hospitals of Plymouth NHS Trust, Plymouth, UK
| | - Vasant Raman
- Royal Eye Infirmary, University hospitals of Plymouth NHS Trust, Plymouth, UK
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Management of bacterial postoperative endophthalmitis and the role of vitrectomy. Surv Ophthalmol 2018; 63:677-693. [DOI: 10.1016/j.survophthal.2018.02.003] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 02/04/2018] [Accepted: 02/06/2018] [Indexed: 11/20/2022]
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Mahalingam P, Topiwalla TT, Ganesan G. Drug-resistant coagulase-negative staphylococcal endophthalmitis following dexamethasone intravitreal implant. Indian J Ophthalmol 2017; 65:634-636. [PMID: 28724830 PMCID: PMC5549425 DOI: 10.4103/ijo.ijo_810_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
A 60-year-old female came to our hospital with defective vision due to persistent diabetic macular edema and was treated with intravitreal ozurdex implant in the right eye. Three days later, the patient presented with diminution of vision, ocular pain, congestion, and hypopyon with no fundus view. B-scan ultrasonography showed vitritis, and diagnosis of endophthalmitis was made. Subsequently, 25-gauge pars plana vitrectomy was performed along with intravitreal vancomycin and amikacin and removal of implant. On culture, there was growth of coagulase-negative staphylococcus which was resistant to ofloxacin antibiotic. A week following treatment, there was significant improvement in the patient's sign and symptoms with improvement in vision. Our case demonstrated that acute endophthalmitis can occur following dexamethasone intravitreal implant.
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Acute bacterial endophthalmitis following intravitreal dexamethasone implant: A case report and review of literature. Saudi J Ophthalmol 2017; 31:51-54. [PMID: 28337065 PMCID: PMC5352935 DOI: 10.1016/j.sjopt.2016.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 11/02/2016] [Accepted: 12/06/2016] [Indexed: 11/24/2022] Open
Abstract
Endophthalmitis following intravitreal dexamethasone (DEX) implant has been rarely reported. This report describes the case of a 70-year-old male who underwent intravitreal DEX implant injection under aseptic conditions, for diabetic macular edema. He developed a clinical picture suggestive of endophthalmitis within 2 weeks of the injection, and vitreous culture grew coagulase negative Staphylococcus. He was treated with intravitreal antibiotics followed by pars plana vitrectomy and removal of the implant. This was followed by resolution of the infection with a favorable final visual outcome. The challenges faced during surgical management of this case are discussed.
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Venkatesh P, Chawla R, Shah B, Garg SP. Surprises during intravitreal drug delivery-a report of three cases. Digit J Ophthalmol 2017; 23:33-35. [PMID: 28924419 DOI: 10.5693/djo.02.2016.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We describe 3 cases with unusual events during and after intravitreal injection of dexamethasone intravitreal implants and bevacizumab. In case 1, delayed release of the safety stop of a dexamethasone intravitreal implant injector led to impaction and retinal break formation. Timely recognition and laser treatment prevented further retinal complications. In case 2, reinjection of a second dexamethasone intravitreal implant from the same site as the first injection was noted to dislodge the remnant of the previous implant from the vitreous base. In case 3, translucent floating particles were noted in the vitreous after intravitreal injection of bevacizumab from ampules procured from our dispensing pharmacy.
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Affiliation(s)
- Pradeep Venkatesh
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Rohan Chawla
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Bhavin Shah
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Sat Pal Garg
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
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TWO CASES OF ACUTE ENDOPHTHALMITIS AFTER INTRAVITREAL DEXAMETHASONE IMPLANT INJECTION. Retin Cases Brief Rep 2017; 10:154-6. [PMID: 26426482 DOI: 10.1097/icb.0000000000000213] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To present two cases of acute endophthalmitis after intravitreal dexamethasone implant injection and discuss the management of intravitreal implant-associated endophthalmitis. METHODS Two patients, who underwent intravitreal dexamethasone implant injection for macular edema secondary to diabetic retinopathy in one and branch retinal vein occlusion in the other, were admitted with decreased vision, pain, and redness in their treated eyes, 3 days and 5 days after the injection, respectively. The clinical findings of both patients were consistent with acute endophthalmitis. RESULTS After obtaining aqueous and vitreous samples, the patients were treated with intravitreal antibiotic injection and topical fortified antibiotics. Both patients revealed favorable clinical response and functional vision was recovered. CONCLUSION Intravitreal dexamethasone implant-associated endophthalmitis is an uncommon and a challenging situation. Intravitreal antibiotics may lead to favorable visual outcomes without the need for a pars plana vitrectomy and implant removal in selected cases.
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Fassbender Adeniran JM, Jusufbegovic D, Schaal S. Common and Rare Ocular Side-effects of the Dexamethasone Implant. Ocul Immunol Inflamm 2016; 25:834-840. [DOI: 10.1080/09273948.2016.1184284] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Janelle M. Fassbender Adeniran
- Department of Ophthalmology and Visual Sciences, University of Louisville School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Denis Jusufbegovic
- Department of Ophthalmology and Visual Sciences, University of Louisville School of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Shlomit Schaal
- Department of Ophthalmology and Visual Sciences, University of Massachusetts School of Medicine, Worcester, Massachusetts, USA
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AlHadlaq A, AlMalki S, AlShahwan S. Late onset endophthalmitis associated with unexposed glaucoma valved drainage device. Saudi J Ophthalmol 2015; 30:125-7. [PMID: 27330390 PMCID: PMC4908096 DOI: 10.1016/j.sjopt.2015.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 12/20/2015] [Accepted: 12/20/2015] [Indexed: 11/28/2022] Open
Abstract
We report an extremely rare presentation of late-onset endophthalmitis in a young adult patient with an unexposed Ahmed tube implant. The implant was inserted 11 years prior to presentation. There was no history of trauma or any obvious exposure on clinical examination and the tube plate was filled with purulent material. After aqueous and vitreous tap, the patient underwent intracameral, intravitreal subconjunctival antibiotic injections and was started on systemic antibiotics with good response. Endophthalmitis associated with tube drainage device can present as late as 11 years and even without an unexposed tube.
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Affiliation(s)
- Abdulaziz AlHadlaq
- Glaucoma Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Salem AlMalki
- Anterior Segment Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Sami AlShahwan
- Glaucoma Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
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Bernard Y, Bonnin N, Farguette F, Chiambaretta F. [Tolerability and short-term efficacy of the Ozurdex® dexamethasone intravitreal implant for treatment of uveitic cystoid macular edema: A retrospective study of 52 injections performed at the Clermont-Ferrand teaching hospital]. J Fr Ophtalmol 2015; 39:1-4. [PMID: 26616298 DOI: 10.1016/j.jfo.2015.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 06/28/2015] [Accepted: 07/02/2015] [Indexed: 11/26/2022]
Abstract
Macular edema is the main cause of decreased visual acuity in uveitis and determines the visual prognosis. We retrospectively analyzed the tolerability and efficacy of the dexamethasone intravitreal implant in the management of uveitis. Twenty-five patients with uveitic cystoid macular edema were all treated with the Ozurdex(®) dexamethasone intravitreal implant from January 2012 to August 2014. The main outcome measures were visual acuity recovery, changes in macular thickness and resolution of the vitritis. Thirty-two eyes of 25 patients received 52 injections of Ozurdex(®). Both complete regression of the macular edema and resolution of the vitritis occurred in 100 % patients. Visual acuity improved in 62 % of patients: the mean reduction in macular thickness was 252 (±171μm); the mean time between injections was 6.7 (±3.8) months. Secondary ocular hypertension was seen in 33 % of patients. No patient required secondary surgery although a selective laser trabeculoplasty was required for one patient. The dexamethasone intravitreal implant Ozurdex(®) resulted in continuous and complete regression of uveitic cystoid macular edema. It allows evaluation of the potential visual recovery of treated eyes. The tolerability and duration of action provide a rationale for considering Ozurdex(®) as a first-line therapy for uveitis which remains uncontrolled despite optimal systemic treatment.
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Affiliation(s)
- Y Bernard
- Service de neuroradiologie, pôle radiologie, CHU de Clermont-Ferrand, EA 7281 R2D2, biochemistry laboratory, medicine faculty, Auvergne university, 63000 Clermont-Ferrand, France
| | - N Bonnin
- RMND-M2O pole, ophthalmology department, Clermont-Ferrand university hospital, 63000 Clermont-Ferrand, France; Service de neuroradiologie, pôle radiologie, CHU de Clermont-Ferrand, EA 7281 R2D2, biochemistry laboratory, medicine faculty, Auvergne university, 63000 Clermont-Ferrand, France.
| | - F Farguette
- Service de neuroradiologie, pôle radiologie, CHU de Clermont-Ferrand, EA 7281 R2D2, biochemistry laboratory, medicine faculty, Auvergne university, 63000 Clermont-Ferrand, France
| | - F Chiambaretta
- RMND-M2O pole, ophthalmology department, Clermont-Ferrand university hospital, 63000 Clermont-Ferrand, France; Service de neuroradiologie, pôle radiologie, CHU de Clermont-Ferrand, EA 7281 R2D2, biochemistry laboratory, medicine faculty, Auvergne university, 63000 Clermont-Ferrand, France
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