[Dexamethasone intravitreal implant (Ozurdex) in patients with diabetic macular edema: Real life safety and efficacy]

PURPOSE

The goal of this study was to investigate the safety and efficacy of the intravitreal dexamethasone implant (DI) for patients with diabetic macular edema (DME) in real life.

METHODS

We conducted a monocentric retrospective analysis of the change in visual acuity and central macular thickness (CMT) after intravitreal injection of the DI at peak efficacy (2 months after injection) as well as the timing of reinjections and complications in patients with a loss of vision due to DME.

RESULTS

Forty eyes of 33 patients were included, with a mean follow-up of 12.6 months. Thirty percent of the eyes experienced an increase in best corrected visual acuity (BCVA)>15 letters at peak efficacy (P<0.05) after each ID injection. Treatment-naive patients had a sustained response after Ozurdex injection, with better visual acuity at 3 months (P=0.02) and 4 months (P=0.04) than non-naïve patients and better visual acuity at 6 months despite identical baseline visual acuity (P<0.05). Anatomical efficacy was good, with approximately 60% of patients with CMT<300 microns at peak efficacy after each injection of ID. Thirty percent of eyes demonstrated ocular hypertension (OHT)>25mmHg at peak efficacy, and 12.5% of eyes required cataract surgery during follow-up.

CONCLUSION

The DI has good functional and anatomic efficacy in these patients, with a good safety profile. Treatment-naïve patients with more recent DME had a more sustained increase in visual acuity after the injections and better visual recovery at 6 months. This encourages us to initiate DI therapy early if there is no response to anti-vascular endothelial growth factor (anti-VEGF) treatment.

Relationship between visual outcomes and retinal fluid resorption in patients with diabetic macular edema treated with ranibizumab

PURPOSE

We assessed the relationship between visual acuity (VA) recovery and a qualitative criterion - complete retinal fluid resorption (CRFR) - among patients treated with ranibizumab for diabetic macular edema (DME) METHODS: All consecutive diabetic patients with central DME received a loading dose of 3 monthly injections of ranibizumab 0.5mg, followed by retreatments on an as-needed basis as determined by monthly follow-up. Patients were divided into 3 groups: CRFR (defined as a CRT <300μm and restoration of the foveolar pit) with BCVA≤70 letters (group 1: G1), CRFR with BCVA>70 letters (20/40) (G2), and persistent retinal fluid throughout the follow-up (G3).

RESULTS

Forty eyes were included. Mean baseline VA was 48.7 letters and no patient had VA>70 letters. Twenty-four (60%) eyes achieved CRFR: 12 (30%) in G1 and 12 (30%) in G2. In 16 patients (40%), the efficacy of the treatment was partial without CRFR (G3). At the time of the initial CRFR, VA was 57.4 letters in G1 (min-max: 30-65) and 77.5 letters in G2 (71-85). In G3, maximal VA during follow-up was 55 letters (25-70) and no patient achieved a VA >70 letters.

CONCLUSIONS

In this study, CRFR was required but not sufficient to achieve a VA>70 letters.

Sustained intraocular pressure elevation in eyes treated with intravitreal injections of anti-vascular endothelial growth factor for diabetic macular edema in a real-life setting

PURPOSE

The aim of this study was to investigate the sustained intraocular pressure (IOP) elevation after repeated anti-VEGF intravitreal injections (IVI) in patients with diabetic macular edema (DME).

METHODS

A retrospective study included 140 eyes without prior glaucoma, treated with at least three anti-VEGF injections for DME between 2012 and 2016. IOP elevation was defined by an increase above baseline IOP by ≥6 mmHg. Baseline IOP was defined as the mean of IOP values before treatment initiation. Three groups were differentiated: group 1 without IOP elevation, groups 2 and 3 with IOP elevation and IOP <21 mmHg (group 2) and ≥21 mmHg (group 3). Rate and several risk factors of IOP elevation were assessed and compared between the three groups.

RESULTS

IOP elevation occurred in ten eyes (7.1%). IOP was <21 mmHg in six eyes and ≥21 mmHg in four eyes. Statistically significant associations were found between IOP elevation and the number of injections, and HbA1c level. Two patients required local hypotonic treatment.

CONCLUSIONS

In a real-life setting, we confirmed in eyes with center-involved DME without prior glaucoma or IOP elevation that repeated anti-VEGF IVI may increase the risk of sustained IOP elevation in about 7% of eyes.

[French practice patterns in the management of diabetic macular edema]

PURPOSE

To assess French practice patterns in the treatment of diabetic macular edema (DME).

METHODS

A 31-item survey investigating practice patterns in the diagnosis and management of DME was e-mailed in March 2015 to retina specialist members of the French-speaking Retina Specialist Society. During this time frame, only ranibizumab was reimbursed for this indication. For each question concerning the choice of treatments, respondents were asked to assume that all treatments having market approval were also reimbursed. Answers were analyzed anonymously by Evalandgo software.

RESULTS

Ninety-five specialists answered the survey. Two thirds of them initiated an intravitreal treatment for DME for a loss of vision greater than 0.5 (Monoyer scale). The three determining factors for treatment choice were potential VA improvement, expected retinal anatomic improvement, and patient availability for monthly follow-up. For central DME in phakic or pseudophakic eyes, the first choice of intravitreal (IVT) treatment was ranibizumab, even assuming that all drugs approved by French authorities (HAS) were reimbursed by the health care system. Eighty-five percent of retinal specialists propose bilateral intravitreal injections the same day for the same patient.

CONCLUSION

Most of the specialists initiate DME treatment for a VA>0.5 in France. Eighty-five percent of them perform bilateral intravitreal injections on the same day in the case of bilateral DME.

[Impact of cataract surgery on central macular thickness in diabetic patients without diabetic retinopathy]

PURPOSE

To determine whether cataract surgery increases macular thickness in diabetic patients without preoperative retinopathy or macular edema.

PATIENTS AND METHODS

In a prospective, non-controlled study, we compared preoperative macular thickness as measured by OCT to that measured 3 and 6 months after cataract surgery.

RESULTS

Thirty-six eyes of 21 patients (ten men and 11 women) were included in the study from November 2008 to May 2009. Mean foveolar thickness measured preoperatively was 198 μm (± 18.5 μm) compared with 202 μm (±17.2 μm) 3 months postoperatively and 212 μm (± 18.9 μm) 6 months postoperatively.

DISCUSSION

In our study, we do not show a significant increase in central foveolar thickness 3 months after cataract surgery; however, we do measure a significant increase at 6 months. This increase in thickness is similar to that found in the literature after cataract surgery in a non-diabetic population.

CONCLUSION

Cataract surgery in diabetic patients without preoperative retinopathy does not appear to induce significant macular thickening compared to non-diabetic patients. The period prior to any diabetic retinopathy or maculopathy seems to be the most amenable to cataract surgery when necessary.

[OCT measurement of the impact of Nd:YAG laser capsulotomy on foveal thickness]

INTRODUCTION

Posterior capsular opacification is the commonest complication of cataract surgery. It is treated with Nd:YAG laser capsulotomy. However, after treatment, cases of cystoid macular edema have been reported. The purpose of this study was to measure the foveal thickness change after Nd:YAG capsulotomy using optical coherence tomography (OCT) in order to clarify the physiopathology of this edema.

PATIENTS AND METHODS

A prospective, single-center study was conducted on patients who underwent Nd:YAG laser capsulotomy between May 2008 and November 2009. All patients received the same drug protocol after Nd:YAG capsulotomy (acetazolamide, apraclonidine, and rimexolone). Demographic parameters (age, sex, and medical history), clinical features (visual acuity, intraocular pressure) before and after Nd:YAG laser, and laser complications were analyzed. Central foveal thickness was measured by OCT (Stratus OCT 3, Zeiss). Data were collected before Nd:YAG laser capsulotomy and 1 week, 1 month, and 3 months after capsulotomy. The preoperative and postoperative thicknesses were compared. We used a Student t-test for statistical analysis.

RESULTS

Thirty eyes of 26 patients were analyzed. The mean foveal thickness was 209 ± 26 μm before capsulotomy, 213 ± 23 μm, 204 ± 19 μm, 213 ± 23 μm 1 week, 1 month, and 3 months, respectively, after capsulotomy. The foveal thickness did not significantly change during the first 3 months following laser treatment. No complications occurred.

DISCUSSION AND CONCLUSION

Macular cystoid edema was a classical complication after Nd:YAG capsulotomy. However, there was no significant increase of macular thickness shortly after Nd:YAG capsulotomy in our study.

[Value of first-day postoperative visit after cataract surgery]

INTRODUCTION

In France in 2009, newly operated patients after cataract surgery are usually seen by their surgeon the day after surgery (D1). The value of this day-after visit has been undergoing reassessment for some years, but this visit remains in widespread use in France. The aim of this study was to assess whether this visit changes patient management.

PATIENTS AND METHODS

One hundred three consecutive patients (106 eyes) undergoing cataract surgery by phacoemulsification were prospectively treated in our department (82% were outpatients). All intraoperative events were noted. The day after surgery, we monitored ocular tension, the anterior segment, and the fundus. Every change in the postoperative prescription compared with a standard prescription was noted.

RESULTS

Intraoperative complications occurred in eight cases. On D1, six patients had ocular hypertension that exceeded 24 mmHg, 14 had a corneal edema, six had corneal erosion, two had a Seidel, one had an anterior subluxation of the IOL, and one had retinal detachment. In 26 cases (24.5%), the prescription was changed compared to our standard prescription.

DISCUSSION

Several studies have shown that the day-after-surgery visit was not mandatory. The main objective of this visit is to check for ocular hypertension. More rarely, it can detect a Seidel in front of the wound, incorrect position of the IOL, retinal detachment, or other complications that may require surgery.

CONCLUSION

The day-after-surgery visit remains necessary after phacoemulsification because complications, sometimes unpredictable, can occur and compromise the result of surgery. This visit also has an educational value (to reiterate to the patients the symptoms that would require an emergency visit).

[Update on the genetics of age-related macular degeneration]

The relationship between genetics and age-related macular degeneration is well established. Heritability has been estimated to be up to 70%. Recent studies have identified several chromosomal regions that are likely to contain susceptibility loci. Common variations in three genes (CFH, LOC 387715 and C2-FB) strongly influence the risk of age-related macular degeneration. New findings in the field of the genetics of age-related macular degeneration are a starting point toward understanding the causes of AMD and for future therapeutic studies.

[Should patients with age-related macular degeneration have cataract surgery?]

PURPOSE

To study the progression of visual acuity (VA) and retinal abnormalities in patients with age-related macular degeneration (AMD) after cataract surgery.

METHODS

Forty eyes of 25 patients with AMD who had had cataract surgery were included in the study. They were divided up into two groups according to AMD stage: the first group with drusen and retinal pigmented epithelium abnormalities and the second in the severe stages of age-related macular degeneration with atrophy and neovascularization.

RESULTS

In the first group (15 eyes), we found an improvement in VA in 93.3% of the eyes. New manifestations of neovascularization appeared in only one eye (6.7%) 1 year after surgery. In the second group (25 eyes), we found atrophy in 80% of the eyes and neovascularization in 20% of the eyes before surgery. There was an improvement in VA after cataract surgery in 68% of the eyes, and in three eyes (17%) VA worsened.

CONCLUSION

In our study, patients with AMD improved VA and quality of life after cataract surgery. The same results of VA improvement after surgery can be found in the literature. However, no conclusions can be made concerning the progression of fundus lesions on a short term, though it seems that cataract surgery may accelerate the progression of AMD lesions 5 years after surgery.

Épithéliopathie en plaque et mauvais pronostic visuel : à propos d’un cas

We report a case of a fifty-year-old women suffering from acute multifocal posterior placoid pigment epitheliopathy (AMPPPE), very atypical in terms of clinical appearance and course. From this observation, we provide a progress report on the usual course of AMPPPE as well as atypical features of this affection through reports in the literature; finally we detail disorders ressembling both AMPPPE and serpiginous choroidopathy, the main differential diagnosis.

[Retinal arteritis in a case of sarcoidosis. A case report]

Retinal vasculitis is a common finding and occurs in 10% - 83% of patients with sarcoidosis. In most cases, there are bilateral, peripheral and nonischemic periphlebitis. In contrast, periarterial involvement is rarely observed. We report a case of retinal vasculitis associated with sarcoidosis and its differential diagnosis. Sarcoidosis should not be excluded in case of periarteritis.

[Peripheral retinal neovascularization and sarcoidosis: two case reports]

Peripheral retinal neovascularization occurs in approximately 10% of cases of sarcoidosis. Its pathogenesis is unknown, but it probably results from retinal ischemia and/or inflammation. In cases of peripheral retinal neovascularization associated with sarcoidosis, sickle cell disease should be considered, even if sarcoidosis is histologically proved: new vessels seen in sickle cell disease and sarcoidosis may have a very similar pattern. We present two cases with histologically proven sarcoidosis who developed peripheral neovascularization: the first one had no associated disease and new vessels were likely to be related to sarcoidosis; in the second case, hemoglobin electrophoresis revealed hemoglobin SC, and provided diagnosis of sickle cell hemoglobinopathy.

[Cataract in uveitis patients: extracapsular and intraocular posterior implantation results. A retrospective study of 14 eyes]

PURPOSE

Checking visual results and progression after cataract surgery in uveitis patients.

METHODS

Fourteen eyes of 13 patients were retrospectively studied after cataract extraction from December 1993 to April 1997. We describe the surgical procedure followed by the visual outcome of cataract surgery, complications, and treatment.

RESULTS

Specific uveitic syndromes were determined in eight patients. Fuchs' heterochromic iridocyclitis was the cause in three cases, ankylosing spondylitis in one case, sarcoidosis in two cases, toxoplasmosis in one case and Birdshot chorioretinopathy in one case. Phacoemulsification was performed in 10 eyes and a manual extracapsular procedure in four eyes. Posterior chamber implantation was performed in 13 cases. Final visual acuity improved in 64% cases, from 1 to 8 lines (average 3.5). Eight eyes had visual acuity worse than 5/10, attributed to posterior segment abnormalities, in particular macular edema, which is the main limiting factor of optimal visual recovery. Capsular opacification was the most frequent complication in the anterior segment. Endophthalmitis was described in one patient.

CONCLUSION

Visual results of cataract surgery depend on different uveitic entities and on posterior segment abnormalities. Results are generally successful when uveitis is not severe and the posterior segment can be carefully observed after cataract surgery. Extracapsular cataract extraction and posterior chamber implantation seem to be well tolerated if inflammation is perfectly under control before surgery.

[Retinal vascularization in sarcoidosis]

OBJECTIVES

To describe the characteristics of retinal vasculitis related to sarcoidosis, and to study the radio-clinical findings of sarcoidosis in case of retinal vasculitis.

METHODS

We performed a retrospective study on 33 cases of retinal vasculitis associated with sarcoidosis. Our patients had a complete ophthalmological examination and a systematic fluorescein angiography was performed. Recorded data included clinical, biological and radiological evaluation of sarcoidosis.

RESULTS

Retinal vasculitis were and remained asymptomatic in almost a third of the patients (n = 10). In 11 patients (33%) a decreased visual acuity of more than 3 lines was observed. Periphlebitis was observed in all cases, and 75.7% were of non ischemic forms. Thirty patients out of 33 (90.9%) were treated with systemic steroids in whom 17 were treated for ophthalmological reasons. The presence of anterior or posterior uveitis, more than one attack of vasculitis, and significant hyalitis were statistically associated with visual acuity decrease. Ninety percent of patients regained their initial visual acuity, only three patients at the end of the medical follow-up remained with a visual acuity below or equal to 2/10. Thirty one patients (91%) presented with mediastinal and pulmonary signs concordant with sarcoidosis on chest x-rays. Extrapulmonary localisations were common in case of retinal vasculitis (91% of patients).

CONCLUSION

Retinal vasculitis associated with sarcoidosis are often asymptomatic. In most cases, there are bilateral, non ischaemic periphlebitis. They seem to have a relatively better prognosis than in other etiologies of vasculitis and they are part of an evolutive multisystemic sarcoidosis. Most of the time treatment with systemic steroids was indicated for ophthalmological or extra ophthalmological reasons.

[Factors influencing early post surgical ocular hypertension after phacoemulsification]

PURPOSE

To evaluate factors influencing early post surgical ocular hypertension after phacoemulsification.

METHODS

Records were collected for patients who had uncomplicated phacoemulsification with IOL implantation in the bag. Aspiration of the viscoelastic was performed at the conclusion of surgery. Patients with previous ocular surgery, high myopia, or glaucoma were excluded. Intraocular pressures were measured at six hours (+/-2) postoperatively. Following factors were analysed

RESULTS

26% of the patients had an ocular pressure equal or higher than 21 mmHg. Among the factors we analysed, pilocarpine injection was the only one to produce significant decrease in postoperative ocular pressure.

COMMENTS

The acute postoperative IOP increase following phacoemulsification is presumably the result of trabecular obstruction by viscoelastic material. However it can occur despite meticulous evacuation of viscoelastic, which could be dependent upon the material's viscosity, and IOL material and design. Postoperative ocular hypertension is not related to ultrasonic duration. Intracameral injection of pilocarpine significantly reduces the incidence of postoperative intraocular pressure increase.

CONCLUSION

Early postoperative ocular hypertension can be observed with different kinds of viscoelastics and IOL. Meticulous evacuation of viscoelastic from anterior chamber, although necessary does not always prevent this early complication. Intracameral injection of pilocarpine can reduce its incidence.

[Candida chorioretinitis in drug addicts. Apropos of 2 cases]

We report two cases of candidal chorioretinitis occurring to two friends who abused of intravenous crack using the same syringe . An endophthalmitis "a minima" due to a therapeutic delay arose in one patient, when a rare spontaneous healing happened to the second patient. In both cases, an epiretinal membrane is noted after the lesions scarred. Ocular candidal infection is a typical complication occurring to intravenous drug addicts. The visual prognosis depends not only on early diagnosis and treatment, but also on a strict follow-up because late complications are frequent in spite of the healing of initial lesions.

[Choroidal metastases of a bronchial carcinoid tumor. Review of cases in the literature. A case report]

Carcinoid tumors are rare tumors with low malignancy. They are most often located in the digestive system and the bronchial tree. They metastasize to the lymph nodes, liver, bones and very rarely to the eye. Choroidal metastases almost always originate from the bronchial tree. Inversely, most orbital metastases originate in the digestive tract. Sometimes they have an orange color useful for diagnosis. We report the case of a woman who developed a bronchogenic carcinoid tumor at the age of 18, and presented five years later with bilateral and multifocal choroidal metastases. There was no other metastatic site. She has been treated with photocoagulation and cryotherapy. From the 25 previously reported cases, one can summarize that these specific metastasis grow slowly and allow good long-term survival.