Intraoperative iStent versus postoperative selective laser trabeculoplasty in early glaucoma patients undergoing cataract surgery: A retrospective comparative study

PURPOSE

To compare the efficacy and safety of iStent inject® versus 360° selective laser trabeculoplasty (SLT) in patients with early glaucoma undergoing cataract surgery.

METHODS

A retrospective non-randomized study was conducted in 73 eyes divided into two groups: cataract surgery+intraoperative iStent (n=40) versus cataract surgery+postoperative SLT at one month (n=33). The primary endpoint was intraocular pressure (IOP) lowering≥20% between baseline and 6 months postoperatively. The secondary endpoints were IOP lowering at 1, 6 and 12 months, and the mean number of IOP-lowering medications at 6 and 12 months.

RESULTS

The mean baseline IOP was 19.1 mmHg with no significant difference between groups. The mean baseline number of IOP-lowering medications was higher in the iStent group (n=1.95) compared to the SLT group (n=1.53; P=0.04). At 6 months, 18 (60%) patients in the SLT group and 20 (51%) patients in the iStent group achieved IOP lowering≥20% with no significant difference between groups (P=0.431). At 6 months, no difference in the mean number of IOP-lowering medications was found between groups (-0.92 and -0.89 in the iStent and SLT groups, respectively). Similar results were found at 12 months.

CONCLUSION

These results suggest similar safety and efficacy of intraoperative iStent and postoperative 360° SLT in lowering IOP and reducing glaucoma eye drops in early glaucoma patients undergoing cataract surgery. Treatment choice should be based on the ophthalmologist's experience and on the cost-benefit ratio.

[Review by the French Glaucoma Society on the roles of new surgical techniques in glaucoma]

The surgical management of glaucoma has been enriched in recent years by the arrival of new surgical techniques as a group known as MIGS (minimally invasive glaucoma surgery). The objective of these new techniques is to reduce intraocular pressure (IOP) while limiting the risk of complications of conventional filtering surgery and allowing faster visual recovery. MIGS can be classified into three main categories depending on the route used to promote the outflow of aqueous humor: the trabecular route, the suprachoroidal route and the subconjunctival route. MIGS using the subconjunctival route are also called minimally invasive bleb surgery (MIBS). These new techniques do not replace conventional filtering surgery, which remains the gold standard technique, but now offer new alternatives for the surgical management of glaucoma patients in combination with cataract surgery or as stand-alone procedures.

Predicted essential fatty acid intakes for a group of dairy cows also apply at individual animal level

The ruminant requirements for essential fatty acids (EFAs), particularly linoleic acid (LA) and alpha-linolenic acid (ALA), have not been fully determined, although evidence suggests that an adequate supply of polyunsaturated fatty acids (FAs) could improve immunity and reproduction in transition cows. In previous studies, we predicted EFA intake for a group of cows based on animal characteristics and milk EFA secretions. However, to support precision livestock feeding, we need to match the nutrient requirements and intakes of each cow as closely as possible. Our group-level predictions may not be accurate enough to estimate the EFA intake of an individual cow, due to inter-individual variations in EFA digestion and metabolism related to differences in feed intake, intake patterns, and the composition and functioning of the rumen microbiota. To address this issue, here we set out to establish specific equations that predict EFA intake for an individual cow based on the difference (i.e. the residuals) between observed EFA intake and the predicted EFA intake based on our group-level equations. We studied a database of individual dairy cows (26 experiments; 503 datapoints from three research teams) and we predicted the residuals from (1) dietary and animal-related factors (i.e. full predictions) and (2) animal-related factors only (i.e. field predictions), which are considered more field-amenable. The variance of predicted LA and log ALA intake was explained to 68% by observed LA intake and 66% by observed log ALA intake, respectively. The residuals of LA intake were predicted by dietary ALA content, total FA intake, BW, milk yield and fat content in full predictions, and by BW, feeding level, milk yield and fat content, and sum of milk C4:0 to C14:0 FA in field predictions. The log residuals of ALA intake were predicted by dietary NDF and total FA contents, NDF intake, BW, milk protein, LA and ALA contents, and fat yield in full predictions, and by BW, DM intake, milk LA and ALA contents, and fat yield in field predictions. The field predictions showed a moderate loss of accuracy compared to full predictions based on RMSE of prediction (from 38 to 54 g/d for LA and from 0.090 to 0.12 log (g/d) for ALA). This work is the first to predict the EFA intake of an individual cow based on previously established group-level predictions of EFA intake adjusted for dietary and animal-related factors.

Ocular hypertension and intravitreal steroids injections, update in 2023. French guidelines of the French glaucoma society and the French ophthalmology society

These guidelines are a consensus of French glaucoma and retina experts on the management of ocular hypertension (OHT) observed in a third of the cases after corticosteroid implant intravitreal injections. They update the first guidelines published in 2017. Two implants are marketed in France: the dexamethasone implant (DEXi) and the fluocinolone acetonide implant (FAci). It is essential to assess the pressure status before injecting a patient with a corticosteroid implant. A molecule-specific monitoring of the intraocular pressure is needed throughout the follow-up and at the time of reinjections. Real-life studies have allowed optimizing the management algorithm by significantly increasing the safety of these implants. Corticosteroid testing with DEXi should be performed before switching to FAci to optimize pressure tolerance of FAci. Beyond topical hypotensive treatments, selective laser trabeculoplasty may be considered in the therapeutic arsenal for the management of steroid-induced OHT and subsequent injections.

[Intraocular pressure elevation and intravitreal steroid implant injection: State of the art in 2023. Recommendations of the French Glaucoma Society and French Ophthalmology Society [French version]]

These are the recommendations of French glaucoma and retina experts on the management of ocular hypertension (OHT) observed in 1/3 of cases after intravitreal steroid implant injections. They are an update to the recommendations first published in 2017. There are two implants on the French market: the dexamethasone (DEXi) and fluocinolone acetonide (FAci) implants. It is important to know the pressure status before injecting a patient with a steroid implant. Monitoring of the IOP adapted to the specific drug is necessary throughout follow-up and reinjections. Real-life studies have made it possible to optimize the management algorithm by significantly increasing the safety of use of these implants. A corticosteroid test with DEXi is necessary before switching to FAci to optimize the pressure tolerance of the latter. In addition to topical glaucoma medications, SLT laser can be considered in the therapeutic arsenal for the management of steroid-induced OHT and future injections.

Uveitis in children: Epidemiological, clinical and prognostic characteristics

PURPOSE

The purpose of this study is to describe the characteristics and prognostic factors of pediatric uveitis in a French university referral hospital.

METHODS

We performed a retrospective study of all cases of all pediatric uveitis seen at our institution over a 7-year period.

RESULTS

A total of 141 eyes of 86 children were included. The mean age was 10.7 years, and 61.6% were girls. The uveitis was bilateral in 64.0% of cases. Anterior uveitis (41.0%) and intermediate uveitis (32.0%) were the most frequent forms. The most frequent etiologies were idiopathic (27.9%), juvenile idiopathic arthritis (25.6%) and pars planitis (18.6%). During the follow-up period, systemic corticosteroids were received by 43.0% of children, immunosuppressive drugs by 31.4% and biological agents by 18.6%. At the final examination, complications were present in 67.0% of patients: 18.0% had cataracts, and 11.3% had intraocular hypertension. Posterior synechiae were present in 27.6% of eyes, optic disc edema in 10.5% and macular edema in 16.2%. At the last visit, visual acuity was better than 20/200 in 97.0% of cases. The presence of band keratopathy, cataract or glaucoma was an independent predictor of impaired visual outcomes at follow-up.

CONCLUSION

Juvenile idiopathic arthritis is one of the most frequent and severe pediatric uveitides. Close monitoring and early treatment could prevent complications.

Relevance of Brain MRI in Patients with Uveitis: Retrospective Cohort on 402 Patients

Aim: To assess the diagnostic value of brain magnetic resonance imaging (bMRI) for the etiological diagnosis of uveitis and to establish predictive factors associated with its advantageous use.Methods: Retrospective study on all patients with de novo uveitis who were referred to our tertiary hospital and who underwent a bMRI between 2003 and 2018.Results: bMRI was contributive in 19 out of 402 cases (5%), among patients with a contributive bMRI, 68% had neurological signs. Univariate analysis established that neurological signs (p < .001), granulomatous uveitis (p = .003), retinal vasculitis (p = .002), and intermediate uveitis (p < .001) were all significantly associated with a contributive bMRI. Multivariate analysis confirms the significant association of neurological signs (p < .001) and intermediate uveitis (p = .01).Conclusion: bMRI appears to be a relevant exam in specific cases; intermediate/posterior uveitis or panuveitis accompanied by neurological signs, retinal vasculitis, or in patients older than 40, to rule out an oculocerebral lymphoma.Abbreviations: ACE: Angiotensin-Converting Enzyme; bMRI: Magnetic Resonance Imaging; CBC: Complete Blood cell Count; BMRI: Brain Magnetic Resonance Imaging; CT: Computerized Tomography; MS: Multiple Sclerosis; NS: Neurological Signs; OCL: Oculocerebral Lymphoma; RIS: Radiologically Isolated Syndrome.

Economic burden of diabetes in France between 2012 and 2017 based on French national claim database

Background

The aim of this study is to assess the economic burden of diabetes in France based on a top-down allocation of health care expenditure, and to analyze structure and trends of expenditure between 2012 and 2017.

Methods

Using information about 57 millions of individuals from the general scheme insurance database (87% of the French population), we applied algorithms based on ICD-10 diagnoses, long-term diseases, and specific treatments. All reimbursed expenditure (drugs, medical visit and other ambulatory care, hospitalization, disability/sickness benefits) were extracted for each individual. A top-down method was used to allocate expenditure to diabetes. To analyze trends, we applied the same methodology from 2012 through 2017.

Results

In 2016 (results for 2017 will be available for the conference), among the 137 billion euros reimbursed, 6.8 billion (5%) were attributed to diabetes and 3.2 million people were concerned (5.5% of the population). Drugs represented the main expenditure item (31% of the average annual expenditure per patient related to diabetes), followed by nursing (18%) and medical devices (17.5%). From 2012 to 2016, the number of people with diabetes increased by 11.4% (+322 700) with an increase by 2.7%/year, the expenditure attributed to diabetes increased by 2.3%/year. The average expenditure per patient in 2016 was about €2150, slightly decreasing from 2012, mainly due to price controls on antidiabetics drugs which permits to limit expenditure growth.

Conclusions

Our study shows the high economic burden of diabetes in France with a detailed analysis of expenditures and their main drivers. With the arrival of innovation and predicted increase of the number of patients partly related to ageing process, control of expenditure must be a priority. The developed tool will help decision makers to monitor the burden of diabetes but also to provide stakeholders with a better understanding of trends and regulating actions.

Key messages

Diabetes represents a high proportion of healthcare expenditure in France. With the arrival of innovation and predicted increase of the number of patients partly related to ageing process, control of expenditure must be a priority.

[Performance of ultra-wide field retinophotography for screening of diabetic retinopathy]

INTRODUCTION

Early diagnosis of diabetic retinopathy is a public health issue. Fundus retinophotography (FRP) is widely used for the detection of the disease. Recently, ultra-wide field retinophotography (WFRP) device allows imaging of approximately 80% of the retinal surface in a single image. The goal of the present study was to evaluate the efficacy of WFRP in the diagnosis and gradation of diabetic retinopathy compared to the gold standard of FRP.

METHODS

The non-mydriatic Optos P200Tx was used for WFRP imaging. FRP in the 9 positions of gaze was then acquired with the Topcon TRC-NW6S after pupillary dilation. The processing time for each imaging modality was recorded.

RESULTS

One hundred and sixteen eyes of 58 patients were included in this study. Fourteen eyes were excluded from the analysis due to insufficient imaging quality. WFRP sensitivity was 96% and specificity was 92%. Only 6 eyes received a higher severity grade of diabetic retinopathy by WFRP compared to FRP. In these cases, when the WFRP was analyzed in the same field as the FRP, the severity grade was similar for 5 of the 6 eyes. The mean time of acquisition was significantly lower for WFRP compared to FRP.

CONCLUSION

WFRP is fast and effective in screening for diabetic retinopathy. The severity grade of the disease was similar to the gold standard of FRP in most cases. WFRP could thus be used in mass screening for diabetic retinopathy.

[Screening for reading difficulties in Parkinson's disease: An evaluation of the Alouette test]

INTRODUCTION

Reading disorders in Parkinson's disease (PD) are poorly evaluated due to the lack of validated tests to screen for them. They are often attributed to hand tremors associated with the disease. In this study, we evaluated the "alouette test" validated for dyslexia screening, in PD by comparing the results to healthy patients.

METHODS

The "alouette test" was conducted on a fixed surface to avoid errors related to tremor. A fixation and tracking test were then performed. All the tests were filmed to be analyzed later by 2 examiners blinded to the neurological diagnosis.

RESULTS

Thirty-eight patients were included, 19 with PD, and 19 healthy age-matched patients. PD patients read on average 250.9±13.7 words correctly vs. 260.3±2.7 words for healthy patients (P=0.008). This difference was greatest for the older patient subgroup (>65 years), who had the disease longer (P=0.014). Tracking and fixation tests were more impaired in PD patients compared to healthy patients.

CONCLUSION

This study highlighted many reading disorders in PD. The use of the "alouette test" which can easily be implemented in clinical practice, could help to diagnose these disorders. Better evaluation of these difficulties would allow for better medical care of these patients.

Accuracy of peripapillary versus macular vessel density in diagnosis of early to advanced primary open angle glaucoma

PURPOSE

To evaluate macular and peripapillary vessel density (mVD, pVD) using optical coherence tomography angiography (OCT-A) in healthy subjects, patients with ocular hypertension (OHT) and primary open-angle glaucoma (POAG) patients.

METHODS

In this prospective observational study, OCT-A images were obtained from 60 eyes of 36 healthy, ocular hypertension (OHT), preperimetric glaucoma (PPG), early glaucoma (EG) and moderate and advanced POAG subjects. Superficial mVD was acquired over a 6×6-mm cube centered on the foveal avascular zone and pVD over a 4.5×4.5-mm cube centered on the optic disc. Peripapillary retinal nerve fiber layer (pRNFL) and ganglion cell complex (GCC) thickness was calculated using spectral-domain OCT. Correlations between vascular, structural and Humphrey VF indices were evaluated (Spearman's rank correlation coefficient).

RESULTS

Median pVD and mVD in the PPG eyes were lower than in healthy eyes (51.87% and 47.23% versus 55.70% and 53.61%, respectively; P<0.001 and P=0.003), but higher than in mild glaucoma eyes (46.21% and 41.98%, P<0.001 compared to normal eyes) and moderate to advanced glaucoma eyes (37.45% and 39.89%, P<0.0001 compared to normal eyes). The highest correlations were found between structural parameters and pVD (r=0.87 and 0.86 for pRNFL and GCC, P<0.0001), followed by mVD (r=0.69 for both pRNFL and GCC, P<0.0001). Correlations with mean VF sensitivity were similar for pVD and mVD (r=0.61 and 0.56) and for GCC and pRNFL (r=0.60 and 0.52, P<0.0001 for all).

CONCLUSIONS

VD measured with OCT-A shows reduction in POAG. Detection of this damage differentiates PPG from normal and perimetric POAG eyes with a high correlation with structural parameters. Peripapillary VD accuracy is higher than mVD in detecting the disease. These results suggest that OCT-A could improve POAG diagnosis and understanding of the pathophysiologic mechanisms behind glaucoma.

Static Threshold Visual Field in Glaucoma with the Fastpac™ Algorithm of the Humphrey Field Analyser is the Gain in Examination Time Offset by Any Loss of Information?

A new algorithm (Fastpac™) has been designed to speed up full threshold tests with the Humphrey Field Analyser. We studied the utility of this algorithm by comparing central 24-2 threshold programs obtained with standard and Fastpac™ algorithms in 43 hypertensive or glaucomatous eyes. The Fastpac™ reduced testing time by 35% to 45%. In glaucomatous eyes, the time spared was inversely correlated with the degree of visual field impairment. Global indices were used to compare visual fields. Mean absolute differences in indices did not exceed 0.98 dB. Correlations between indices in glaucoma patients with standard and Fastpac™ strategy were respectively 0.99 and 0.98 for mean deviation and pattern standard deviation. The intra-test variability (short-term fluctuation) was slightly higher with Fastpac™ with a lower correlation between algorithms (r=0.62). The use of Fastpac™ achieves a mean time reduction of 40% and does not significantly modify global indices obtained with the Humphrey perimeter in hypertensive and glaucomatous eyes.

The Effects of Rimexolone 1% in Postoperative Inflammation after Cataract Extraction. A Double-Masked Placebo-Controlled Study

Aim

A multicentre, randomized, placebo-controlled double-masked study was conducted to assess the efficacy and safety of Rimexolone 1% eye drops in reducing inflammation after cataract surgery and intra-ocular lens implantation.

Methods

Rimexolone 1% (124 patients) or placebo (58 patients) was given, four times a day for 14 days starting 22-34 hours after surgery. All patients also received tobramycin 0.3% four times a day for 7 days. The clinical signs of ocular inflammation were recorded on days 1, 3, 8, 15 and 17 or 18.

Results

Rimexolone 1% markedly decreased the mean inflammation severity scores, and the sum of clinical assessments of cells and flare in the anterior chamber compared with placebo at each assessment. In addition, the percentage of patients with no anterior chamber inflammation was significantly higher with Rimexolone 1% than with the placebo at each assessment. All these results were statistically significant. Intra-ocular pressure did not rise after treatment with Rimexolone 1%.

Conclusions

The results suggest that Rimexolone 1% ophthalmic solution is an effective and safe steroidal anti-inflammatory agent for topical use following cataract surgery and intraocular lens implantation.

Herpes Simplex Virus Acute Retinal Necrosis during Pregnancy

Purpose

As pregnancy is liable to modify immune response, the authors explored the immune functions of a pregnant patient with acute retinal necrosis (ARN) to ascertain whether pregnancy may promote the onset of infection.

Methods

Polymerase chain reaction (PCR) was used for the detection of herpes simplex virus (HSV) DNA in ocular, uterus cervix, and cerebrospinal fluid samples. Peripheral blood mononuclear cells were cultured for 72 hours with mitogens and cellular proliferation was assessed using (methyl-3H) thymidine incorporation. Flow cytometry was performed for T, B, and NK cell count using CD2, CD3, CD4, CD8 (T cells), CD19, CD20 (B cells), and a combination of CD3–CD16 and CD56 monoclonal antibodies (NK cells).

Results

Unilateral ARN, with a confluent peripheral necrotizing retinitis extending throughout the entire retina, was diagnosed clinically. The herpetic infection (herpes simplex virus 1) was confirmed using PCR of aqueous humor specimen. The immunologic study performed during and after pregnancy showed that T and B lymphocytes were quantitatively normal and responses to concanavalin A, phytohemagglutinin, and pokeweed mitogens were weaker during pregnancy.

Conclusions

A reduced response to mitogens, with postdelivery normalization, was noted in a pregnant woman with an ARN syndrome. Further studies are needed to explore the antigen-specific immune deviation in pregnant patients with ARN.

Treatment Carryover Impacts on Effectiveness of Intraocular Pressure Lowering Agents, Estimated by a Discrete Event Simulation Model

Purpose

To compare the effectiveness of two treatment sequences, latanoprost–latanoprost timolol fixed combination (L-LT) versus travoprost–travoprost timolol fixed combination (T-TT), in the treatment of open-angle glaucoma (OAG) or ocular hypertension (OHT).

Methods

A discrete event simulation (DES) model was constructed. Patients with either OAG or OHT were treated first-line with a prostaglandin, either latanoprost or travoprost. In case of treatment failure, patients were switched to the specific prostaglandin-timolol sequence LT or TT. Failure was defined as intraocular pressure higher than or equal to 18 mmHg at two visits. Time to failure was estimated from two randomized clinical trials. Log-rank tests were computed. Linear functions after log-log transformation were used to model time to failure. The time horizon of the model was 60 months. Outcomes included treatment failure and disease progression. Sensitivity analyses were performed.

Results

Latanoprost treatment resulted in more treatment failures than travoprost (p<0.01), and LT more than TT (p<0.01). At 60 months, the probability of starting a third treatment line was 39.2% with L-LT versus 29.9% with T-TT. On average, L-LT patients developed 0.55 new visual field defects versus 0.48 for T-TT patients. The probability of no disease progression at 60 months was 61.4% with L-LT and 65.5% with T-TT.

Conclusions

Based on randomized clinical trial results and using a DES model, the T-TT sequence was more effective at avoiding starting a third line treatment than the L-LT sequence. T-TT treated patients developed less glaucoma progression.

Anatomical and functional recurrence after dexamethasone intravitreal implants: a 6-month prospective study

PURPOSE

To evaluate the efficacy, safety, and delay of anatomical and functional recurrence after a first intravitreal injection of dexamethasone implant in eyes with cystoid macular edema (CME) secondary to retinal vein occlusion (RVO).

METHODS

A 6-month prospective, monocentric and noncomparative case-series of 26 eyes of 26 patients. Best-corrected visual acuity (BCVA) and central subfield thickness (CST) were measured at baseline and each visit at 1 week, and months 1, 2, 3, 4, 5, and 6 after a first treatment. Primary efficacy outcome was the proportion of eyes with a minimum three-line improvement from baseline BCVA at each visit and at 6 months. We also defined different patterns of recurrence: qualitative anatomical recurrence, quantitative anatomical recurrence and functional recurrence. A P-value <5% was considered statistically significant.

RESULTS

Mean population age was 69.3 years (SD=12.2; range=42-94 years). Mean ME duration before treatment was ~9.2 months (SD=11.43; range=0.4-40 months). Eighty eight percent of eyes achieved a three-line improvement from baseline at 2 months (P=0.02). The mean delay from baseline until qualitative anatomical, functional, or quantitative anatomical recurrence was 4.11 months (±0.86), 4.31 months (±1.33), and 4.40 months (±1.14), respectively. Qualitative anatomical recurrence occurred on average 14.4 days (SD=42.18) before a minimum of one-line BCVA impairment (functional recurrence).

CONCLUSION

Dexamethasone intravitreal treatment seems to be effective for ME after RVO even with long-duration ME or poor visual acuity before treatment. Other longer studies should assess the delay of recurrence after second and further treatments with DEX implants or combined therapies for ME after RVO.