[Contribution of technological aids to the extraction of orbital foreign bodies]

BACKGROUND

Removal of orbital foreign bodies is a surgical challenge. The purpose of this study is to report our experience in the removal of orbital foreign bodies and to evaluate the usefulness of various technological aids in their removal.

MATERIALS AND METHODS

We conducted a single-center retrospective study at Nice University Hospital (France) from January 2017 to December 2023. All patients undergoing surgery for an orbital foreign body during the study period were included. Data recorded included the nature of the orbital foreign body, its size, location, surgical route, outcome (success, partial success, failure), and technological aids used (intraoperative navigation, intraoperative imaging scope, orbital magnet). Concurrently, we designed a dedicated orbital magnet, which was tested in the anatomy laboratory and in two of our patients.

RESULTS

Six patients, all young men, were included during the study period. Removal was successful, partially successful, or unsuccessful in one-third of cases, respectively. Failure was associated with orbital foreign bodies located in the intraconal or posterior orbital space. Preoperatively, the use of a "low-artifact" scanner allowed us to better determine the exact size and shape of the orbital foreign body. Intraoperative navigation was not accurate enough, due to the mobility of the orbital bodies within the orbital fat. In our experience, intraoperative scope imaging was more accurate. The use of a dedicated orbital magnet was successfully tested in the anatomy laboratory and allowed the removal of a small orbital foreign body in one of our patients. Intraoperative surgical videos are provided.

CONCLUSION

Vegetal orbital foreign bodies must be systematically removed. Removal of non-vegetal orbital foreign bodies should be considered on a case-by-case basis based on their size, best assessed using a "low artifact" scanner, their location, and their intrinsic ferromagnetism. Intraoperative navigation does not appear useful, while intraoperative scope imaging does. A dedicated orbital magnet might be helpful in removing ferromagnetic orbital foreign bodies. However, an orbital magnet may be ineffective in removing intraorbital bullets, since they are made primarily of an alloy of copper and lead.

Clinical features, diagnosis, treatment, and course of ocular sarcoidosis with or without uveitis: A retrospective, comparative study

OBJECTIVE

To evaluate and compare characteristics, diagnosis, treatment, visual prognosis, and course between ocular sarcoidosis with or without uveitis in a population in Southern France.

METHODS

We retrospectively analyzed data from patients with ocular sarcoidosis in a tertiary eye care center in Nice from January 2003 to December 2021. The inclusion criterion was biopsy-proven ocular sarcoidosis according to IWOS criteria as the first clinical manifestation of sarcoidosis.

RESULTS

A total of 25 patients were included. Twenty patients had uveitis (70% panuveitis, 20% intermediate uveitis, and 10% anterior uveitis) and five patients had non-uveitic ocular sarcoidosis (one patient with dacryoadenitis, one patient with orbital granuloma, two patients with palpebral granuloma, and one patient with episcleritis). Only the cases with uveitis had bilateral involvement (85% of cases). There was no significant difference in ethnicity, biopsy diagnosis, systemic manifestations, or treatment between the two groups. Final visual outcomes remained good for both groups, with 96% of patients with BCVA>20/50, with no significant difference. Patients with non-uveitic sarcoidosis experienced less recurrence on treatment (P=0.042) and more remission (P=0.038) than patients with uveitis. Eighty percent of patients with uveitis had at least three suggestive clinical intraocular signs meeting IWOS criteria.

CONCLUSION

In this population in Southern France, uveitis was the most common presentation of ocular sarcoidosis. The type of ocular sarcoidosis does not appear to be correlated with the type of systemic manifestations, use of systemic therapy, or visual prognosis, but patients with non-uveitic ocular sarcoidosis appear to have a better course with fewer recurrences on treatment and more remission than patients with uveitic ocular sarcoidosis.

[Blue light and intraocular lenses (IOLs): Beliefs and realities]

The first intraocular lenses (IOLs) used for cataract surgery transmitted both ultraviolet (UV) radiation and visible light to the retina. Colorless UV-blocking IOLs were introduced and rapidly adopted in the 1980s. Yellow-tinted blue-blocking (also known as blue-filtering) IOLs were marketed in the early 1990s. Blue-blocking IOLs were intended to simulate age-related crystalline lens yellowing to reduce the cyanopsia that some patients experienced after cataract surgery. When blue-filtering IOLs were introduced in North America, however, blue-blocking chromophores were advocated as a way to protect patients from age-related macular degeneration (AMD) despite the lack of evidence that normal environmental light exposure causes AMD. The "blue light hazard" is a term that describes the experimental finding that acute, abnormally intense light exposures are potentially more phototoxic to the retina when short rather than long wavelengths are used. Thus, in brief exposures to intense light sources such as welding arcs, ultraviolet radiation is more hazardous than blue light, which is more hazardous than longer wavelength green or red light. International commissions have cautioned that the blue light hazard does not apply to normal indoor or outdoor light exposures. Nonetheless, the hazard is used for commercial purposes to suggest misleadingly that ambient environmental light can cause acute retinal phototoxicity and increase the risk of AMD. Very large epidemiological studies show that blue-blocking IOLs do not reduce the risk or progression of AMD. Additionally, blue-filtering IOLs or spectacles cannot decrease glare disability, because they decrease image and glare illuminance in the same proportion. Blue light is essential for older adults' scotopic photoreception needed to reduce the risk of nighttime falling and related injuries. It is also critical for circadian photoreception that is essential for good health, sleep and cognitive performance. Unfortunately, age-related pupillary miosis, retinal rod and ganglion cell photoreceptor degeneration and decreased outdoor activity all reduce the amount of healthful blue light available to older adults. Blue-restricting IOLs further reduce the available blue light at a time when older adults need it most. Patients and ophthalmologists are exposed to hypothesis-based advertisements for blue-filtering optical devices that suppress short wavelength light critical for vision in dim lighting and for good physical and mental health. Spectacle and intraocular lens selections should be based on scientific fact, not conjecture. Ideal IOLs should improve photoreception rather than limit it permanently. Practice efficiency, surgical convenience and physician-manufacturer relationships may eliminate a patient's opportunity to choose between colorless blue-transmitting IOLs and yellow-tinted, blue-restricting IOLs. Cataract surgeons ultimately determine whether their patients have the opportunity to make an informed choice about their future photoreception.

Can 18F-FDG PET/CT findings be used to predict orbital tumor histology?

PURPOSE

To investigate whether 18F-FDG PET/CT might be useful to predict the histology of various orbital tumors based on the maximum standard uptake value (SUVmax) and the OMSUV (orbital max SUV)/MLSUV (mean liver SUV) ratio.

PATIENTS AND METHODS

A retrospective single-center study was conducted between May 2019 and December 2020. Patients with an orbital mass who underwent preoperative 18F-FDG PET/CT followed by an orbital biopsy were included. Tumor histology was classified as follows: orbital inflammation, solid tumor, low-grade lymphoid tumor, and high-grade lymphoid tumor. Orbital tumors were also classified as indolent or aggressive. Data recorded included the orbital SUVmax, OMSUV/MLSUV ratio and additional extra-orbital SUV sites.

RESULTS

Forty-five patients (24 men) were included. There were 15 (33.3%), 14 (31.1%), 9 (20%), and 7 (15.5%) cases of orbital inflammation, solid tumor, low-grade lymphoid tumor, and high-grade lymphoid tumor, respectively. No correlation was found between the OMSUV/MLSUV ratio and orbital SUVmax and tumor histology (Z = -0.77, Z = -0.6, Z = -1.6, and Z = 0.94, all P > 0.05, respectively). No correlation was found between the OMSUV/MLSUV ratio (Z = -1.42, P > 0.05) and orbital SUVmax (Z = -0.82, P > 0.05) and tumor aggressiveness (indolent versus aggressive). Subgroup analyses showed that SUVmax was predictive of lymphoma aggressiveness (P = 0.05) and was able to distinguish orbital cancers (all lymphomas+solid tumors) from benign tumors (P = 0.02).

CONCLUSION

18F-FDG PET/CT could not be used to predict the underlying orbital tumor histology. However, more aggressive tumors, especially high-grade lymphomas and cancers, tended to have a higher orbital SUVmax compared to indolent lesions.

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.

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.

[Treatment of exudative age-related macular degeneration: Consensus of French experts for first-line treatment selection and the importance of long-term risk/benefit ratio]

Choosing a first-line treatment to optimize long-term outcomes is a major challenge for treating patients with neovascular age-related macular degeneration (AMD). The development of several new molecules makes it critical to identify the relevant factors to consider so as to provide an optimal risk-benefit ratio when initiating a treatment in naïve patients with neovascular AMD. This paper proposes a consensus established with the Delphi method (which includes a gradation in a consensus based on an analysis of the convergence rate of answers) to provide criteria that guide the ophthalmologist's decision for treatment initiation and follow-up in neovascular AMD patients. Fourteen questions were submitted to 93 French retina experts. Thirteen (93%) of the questions reached a consensus (≥50% of answers consensual). The criteria recommended to take into account were both efficacy and onset of action of the molecules, their safety, and the ability to decrease injection frequency. The primary criterion of expected efficacy of a molecule is a combination of the gain in visual acuity and resorption of retinal fluid. With regard to safety, experts recommend tighter follow-up for molecules currently in development, and at every scheduled visit, patients should be screened to identify early any potential adverse effects such as intraocular inflammation, retinal vasculitis or vascular occlusion. Experts also emphasize the importance of the packaging of the biological, with a preference toward prefilled syringes. Injection frequency is a key factor, and the authors recommended aiming for a maximal injection interval of 12 to 16 weeks. The stability of that maximum interval is also an important factor to consider in treatment selection.

Eye amputation following lifitegrast treatment for ocular graft-versus-host disease: First case report

Graft-versus-host disease (GVHD) is a common complication in patients undergoing allogeneic stem cell transplantation for acute myeloblastic leukemia that could be very difficult to treat. Lifitegrast 5% (Xiidra@, Novartis), a new immunosuppressive eye drop, was recently approved by the FDA for the treatment of severe dry eye and is currently under review by the European Medicines Agency. In France, lifitegrast has been approved by the French authorities for temporary use in refractory dry eye syndrome resistant to tear substitutes and topical cyclosporine. To date, serious complications have been reported only exceptionally. In this article, we report the case of a 65-year-old patient with a medical history of acute myeloid leukemia (AML) diagnosed in 2015 who received a first matched related donor transplant. In 2019, this patient developed chronic GVH involving the skin, oral mucosa and eye. Despite taking topical and systemic medications for 3 months, the patient did not report relief of ocular symptoms. Therefore, lifitegrast was prescribed. To our knowledge, we report the first case of corneal perforation in which evisceration was required following treatment with topical lifitegrast for chronic GVH. In the case presented here, it can be assumed that the underlying mechanisms leading to corneal perforation are multifactorial. Using drug accountability criteria, lifitegrast appears to be strongly associated with the development of bacterial keratitis and corneal perforation.

[Treat-and-extend anti-angiogenic protocol in clinical practice for patients with exudative age-related macular degeneration: Consensus of French experts]

Optimizing treatment regimens for anti-angiogenic drugs is now a major issue in the management of patients with exudative AMD. The evolution of these approaches has led retinologists to favor so-called proactive administration regimens, such as Treat-and-Extend (T&E), which make it possible to anticipate recurrence and to plan intravitreal injections of anti-angiogenic drugs in advance. Nevertheless, a real need to standardize the application of this regimen has been identified. This article proposes a consensus based on the Delphi methodology, which might provide a guide for ophthalmologists to manage patients with exudative AMD using the T&E protocol. While some aspects remain debated to date, this article provides elements to guide the implementation of T&E. The experts recommend that a loading dose of 3 monthly injections should be administered before starting T&E. They also recommend adjusting the reinjection intervals by±2 weeks in a standardized fashion. The intervals are then decreased in the presence of anatomical and/or functional deterioration, maintained when the interval of recurrence is identified, and increased when anatomical and/or functional improvement is observed. A maximum interval between 3 and 4 months is recommended by the experts, with maintenance of the maximum interval for 1 year before considering a possible exit from the T&E protocol. In the event of a significant decrease in visual acuity related to the disease along with significant anatomical degradation, it is recommended to restart monthly injections. In the case of bilateral disease, when synchronized timing of injections for both eyes is desired, the experts recommend using the shorter of the two intervals.

[Orbital mantle cell lymphoma succesfully treated by Bcl-2 inhibitor: Report of a case]

Lymphoma is the most common orbital malignancy in adults. Among the types of lymphoma, mantle cell lymphoma is a particularly aggressive form, often discovered through systemic involvement, with a dismal prognosis due to frequent recurrences. It is secondary to a t (11 ; 14) (q13; q32) chromosomal translocation resulting in an anti-apoptotic signal via overexpression of Bcl-2. Treatment is based on R-CHOP poly-chemotherapy. We describe the case of a patient with an orbital recurrence of mantle cell lymphoma successfully treated with oral Bcl-2 inhibitor monotherapy. A 58-year-old man who was treated with R-CHOP 8 years ago for mantle cell lymphoma, in remission for 5 years, presented with progressive decreased visual acuity in the left eye, along with binocular diplopia. Clinical examination revealed a decrease in visual acuity in the left eye to 1/20 Parinaud 20 and a relative afferent pupillary defect on the left. External examination revealed a left cranial nerve VI palsy, 2mm of painless proptosis, and hypesthesia of the left V1 territory, leading to a diagnosis of left orbital apex syndrome. The disc and macular OCT were normal. The visual field showed enlargement of the left blind spot. An emergency CT scan and MRI revealed an apical extraconal tissue mass infiltrating the medial rectus muscle, extending to the superior orbital fissure, optic canal and left cavernous sinus, hyperintense on T2 weighted images and isointense on T1. The morphological appearance was strongly suggestive of an infiltrative lymphomatous process. An 18 FDG PET-scan identified the orbital lesion as well as enhancing lesions in the axilla and colon; given the clinical features and test results, the diagnosis of recurrent mantle cell lymphoma was made without biopsy. Treatment with Venetoclax (Bcl-2 inhibitor) was initiated. At one month of treatment, the orbital apex syndrome had entirely resolved, with visual acuity increased to 8/10 Parinaud 4 and a metabolic return to normal on PET scan. The PET scanner and clinical examination at 3 months were entirely normal. At the one-year follow-up visit, the patient was still on Venetoclax, the clinical examination was unchanged, and the PET-scan still showed a complete metabolic response.

Incidence of Orbital Exenteration: A Nationwide Study in France over the 2006-2017 Period

PURPOSE

Orbital exenteration is a radical and disfiguring surgery mainly performed for treating orbital malignancies. Recently, several studies found favorable results in terms of overall survival with eye-sparing surgeries combined with targeted therapies and/or radiotherapy. The aim of this study was to assess the incidence of orbital exenteration and its evolution in France between 2006 and 2017.

METHODS

A national observational cohort study was conducted in France between January 2006 and December 2017. Data were collected from the national PMSI (Programme de Médicalisation des Systèmes d'Information) database provided by the CNAM (Caisse Nationale de l'Assurance Maladie). All patients undergoing orbital exenteration over the study period in France were included.

RESULTS

One thousand and fifty-seven patients were included. The mean annual number of orbital exenterations was 88.1 (63-117), corresponding to a mean incidence of 0.1/100,000 inhabitants/year. A male predominance was noted (n = 626, 59.2%). Exenteration was mainly performed between 75 and 79 years. The underlying etiology was available for 821 patients (77.7%): malignancies were the most common (n = 755; 92.0%) followed by infectious diseases (n = 16; 1.9%). Over the study period, no statistical difference in the mean incidence of orbital exenteration was found (p = .132).

CONCLUSION

The mean annual incidence of orbital exenteration was 0.1/100,000 inhabitants in France and was not significantly modified during the study period.

[Anatomical description of the retro-caruncular approach and its application in oculoplastics: A cadaveric study]

PURPOSE

To describe the anatomical landmarks of the retro-caruncular approach and its clinical applications based on a cadaveric study.

PATIENTS AND METHOD

A dissection of 8 orbits providing from 4 fresh cadavers was carried out at the anatomical laboratory of the University Hospital of Nice, France between October 2018 and January 2019.

RESULTS

Main anatomical relationships encountered are anteriorly the Duverney-Horner muscle and the lacrimal sac, posteriorly the anterior and posterior ethmoidal arteries, superiorly the pulley of the superior oblique muscle, inferiorly the lacrimonasal duct and the tendon of the inferior oblique muscle. The retro-caruncular approach allows a safe surgical access behind the lacrimal sac and Duverney-Horner muscle. Many oculoplastic surgical procedures can be performed through this approach: dacryocystorhinostomy, medial orbital fractures repair, "médial" orbital "décompression", biopsy of medial and extraconal tumours, medial periosteal fixation in third-nerve palsy.

CONCLUSION

The retro-caruncular approach is a safe procedure avoiding skin incision. It allows a wide surgical space even if it is reduced compared to a more conventional skin route. It requires a great anatomical knowledge and a longer surgical learning curve.

[Uveitis treated with biotherapy and/or DMARD: Analysis from the French Pharmacovigilance Study Base]

PURPOSE

To report the characteristics of uveitis cases occurring while on biologic therapy or disease-modifying antirheumatic drugs (DMARDs) reported to the French national pharmacovigilance database.

METHODS

All the uveitis cases occurring in patients with chronic rheumatologic diseases, chronic inflammatory intestinal diseases or connective tissue diseases, while treated with DMARDs and/or biologic therapies between 2000 and 2015 and reported to the French National Pharmacovigilance Database were collected.

RESULTS

During the study period, 32 cases of uveitis were reported (15 men, 17 women). Two patients were treated with one DMARD alone, 24 with biologic therapy alone, and six with both treatments. Anterior uveitis was diagnosed in 19 patients (8 cases were bilateral); intermediate uveitis was found (unilaterally) in one patient; posterior and diffuse uveitis occurred in 5 and 2 cases respectively. Five cases were inconclusive with regard to the anatomical type of uveitis. The uveitis was of infectious origin in 5 cases: 2 toxoplasmosis, 2 herpes virus and 1 tuberculosis. In the 27 other cases, it was not possible to state whether the uveitis was associated with the underlying disease (uncontrolled) or a side effect of the biologic/DMARD treatments. The occurrence of the uveitis led to 9 switches in biologic therapy and 13 discontinuations of treatment (8 complete discontinuations, 5 discontinuations only until uveitis remission was obtained). In 4 cases, the treatments were not modified. The database does not specify the ultimate course or rheumatologic disease activity at the time of the uveitis.

CONCLUSIONS

The presence of uveitis while on biologic therapy must not be taken to indicate a therapeutic failure, especially if the ocular manifestation is isolated. In the case of uveitis occurring in patients treated with biologic therapies and/or DMARDs, infectious complications should be ruled out.

[Oculoplastic complications of the excision of meningiomas with orbital extension]

INTRODUCTION

Meningiomas with orbital extension are the most frequent benign orbital tumors. The few studies available on the postoperative complications of their excision focus on the postoperative evolution of proptosis, visual acuity and visual field deficits. The goal of our study was to highlight the oculoplastic complications secondary to their excision.

MATERIAL AND METHOD

We identified all cases of meningiomas with orbital extension undergoing excision either neurosurgically or via an orbital approach in the ophthalmology and neurosurgery departments of Pasteur university medical center in Nice between February 2011 and January 2017. The data collection included the postoperative presence of proptosis, oculomotor disturbance, lid disorders, dry eye and trigeminal nerve damage.

RESULTS

Twenty-nine patients were included; 89.7 % were women. The mean age was 55 years. Postoperative complications included 25 % residual proptosis; 40.7 % oculomotor disturbance, 75 % of which regressed at least partially; 50 % ptosis, 21 % of which did not regress; 40 % dry eye; and in 21.4 % the trigeminal nerve was involved.

CONCLUSION

The management of meningiomas with orbital extension is difficult due to their anatomical location and requires joint neurosurgical and oculoplastic management. Sufficient follow-up is required before recommending surgery for oculomotor disturbances. The frequency of occurrence of ptosis with potential recommendation for surgery requires caution given the occurrence of trigeminal nerve involvement and dry eye syndrome.

[Systemic safety following intravitreal injections of anti-VEGF]

The goal of this manuscript is to assess data suggesting that intravitreal injection of anti-vascular endothelial growth factors (anti-VEGFs) could result in systemic adverse events (AEs). The class-specific systemic AEs should be similar to those encountered in cancer trials. The most frequent AE observed in oncology, hypertension and proteinuria, should thus be the most common expected in ophthalmology, but their severity should be lower because of the much lower doses of anti-VEGFs administered intravitreally. Such AEs have not been frequently reported in ophthalmology trials. In addition, pharmacokinetic and pharmacodynamic data describing systemic diffusion of anti-VEGFs should be interpreted with caution because of significant inconsistencies reported. Thus, safety data reported in ophthalmology trials and pharmacokinetic/pharmacodynamic data provide robust evidence that systemic events after intravitreal injection are very unlikely. Additional studies are needed to explore this issue further, as much remains to be understood about local and systemic side effects of anti-VEGFs.

Medical management of a subretinal Klebsiella pneumoniae abscess with excellent visual outcome without performing vitrectomy

OBJECTIVE

To report the case of a Klebsiella pneumoniae endogenous endophthalmitis (KPEE) of hepatic and urinary origin that was successfully treated with systemic antibiotherapy and 13 intravitreal antibiotics injections without performing a vitrectomy.

PATIENT AND METHOD

Case report of a 60-year-old man with a subretinal abscess in the left eye that developed 3 days after initial presentation for K. pneumoniae bacteremia, liver abscess and urinary tract infection.

RESULTS

Ophthalmic examination of the left eye showed anterior uveitis and a single subretinal abscess located in mid-peripheral temporal retina. BCVA dropped to 20/50. Follow-up was made with clinical examination and multimodal imaging (SD-OCT, FA, ICGA) with high field photographs. A total of 13 intravitreal injections (IVI) of ceftazidime were performed, and no vitrectomy was required. Ocular signs regressed and prognosis was excellent with 20/20 of final BCVA.

CONCLUSION

KPEE is a rare but severe condition with a typically poor ocular prognosis. When diagnosis is made early, subretinal abscess with partially conserved BCVA could be treated successfully with medical management that includes systemic antibiotics and repeated intravitreal injections without requiring vitrectomy.

Treatment patterns of ranibizumab intravitreal injection and dexamethasone intravitreal implant for retinal vein occlusion in the USA

Purpose

Ranibizumab, an anti-vascular endothelial growth factor, and dexamethasone, a corticosteroid, have been shown to be effective in treating macular oedema secondary to retinal vein occlusion (RVO) (central RVO (CRVO) and branch RVO (BRVO)). Their real-world usage, however, has yet to be compared. We therefore evaluated ophthalmology visits for both drugs using US patient-level data.

Methods

The IMS Health Real-World Data Medical Claims database was used to identify treatment-naive patients receiving ranibizumab intravitreal injections or dexamethasone intravitreal implants between June 2010 and February 2014 who had 12 months of follow-up data. The primary outcome measure was the mean number of all ophthalmology visits for the two drugs in patients with CRVO and BRVO. Secondary outcome measures included a comparison of treatment visits, non-treatment visits, and time intervals between visits.

Results

Overall, 2822 patients received ranibizumab injections (CRVO, 1178; BRVO, 1644) and 365 received dexamethasone implants (CRVO, 191; BRVO, 174). The mean number (SD) of all ophthalmology visits was higher for patients receiving ranibizumab injections than for those receiving dexamethasone implants (CRVO: 7.2 (3.6) vs 6.2 (3.1), P<0.001; BRVO: 7.1 (3.4) vs 6.3 (3.1), P=0.016).

Conclusions

Patients with RVO receiving ranibizumab injections had a mean of approximately one more visit to their ophthalmologist in the first 12 months of treatment than those treated with dexamethasone implants. The visit burden is therefore not substantially different and physicians should focus on the clinical benefits of these drugs when evaluating treatment options for RVO.

[Management algorithm of age-related macular degeneration with aflibercept: Real-life application]

Aflibercept is indicated in France for wet age-related macular degeneration (wAMD) since November 2013. Its official dosage consists in administrating one monthly intravitreal injection (IVT) during three months followed by one control visit and one IVT every two months the first year. In 2015, a group of French ophthalmologists, specialized in wAMD management, established a therapeutic algorithm to optimize naive patient management with aflibercept in order to obtain visual acuity gain. It indicates that official administration scheme is adapted for 80% of patients and that an adaptation of therapeutic scheme is needed for others. These experts recommended mostly the use of personalized proactive administration scheme. Since, aflibercept clinical use has significantly grown with interventional observational studies which results are now available. Use of aflibercept and of personalized proactive administration schemes allow in real-life obtaining important visual acuity gain, which is consistent with the established algorithm.

[Endogenous bacterial and fungal endophthalmitis at Nice University Medical Center: A 15-year case review]

PURPOSE

To evaluate epidemiology, diagnostic and therapeutic management strategies and visual outcomes of cases of bacterial and fungal endogenous endophthalmitis managed in the Nice University Medical Center between January 2000 and June 2015.

METHODS

Three hundred twenty-three charts of patients with endophthalmitis treated at the Nice University Medical Center over this period were retrospectively reviewed to select the ones with endogenous endophthalmitis. Demographic characteristics, medical history, clinical presentation, diagnostic and therapeutic management, microbiology, and final outcomes were analyzed.

RESULTS

Twenty-two eyes of 20 patients were selected, constituting 6.20% of all cases of endophthalmitis. The mean age was 69years, and 75% of patients were male. The most common risk factors were diabetes, malignancies and cardiac diseases. Bacterial isolates were found in 16 cases (80%), fungal isolates in 3 (15%) and co-infection in 1 case. Gram-positive organisms accounted for 70.6% of cases (mostly Staphylococcus aureus [25%], Streptococcus agalactiae [25%] and Streptococcus pneumoniae [16.7%]). Candida albicans was the most common fungal organism. There was one bacterial and fungal co-infection. Two patients died, 4 eyes were enucleated or eviscerated (20%), and 4 patients (20%) attained a final visual acuity of 1/10 or better.

CONCLUSION

Endogenous endophthalmitis is a rare and serious condition with a poor prognosis. Gram-positive microorganisms, mostly S. aureus, were the main causative pathogens found.

[Treatment of postoperative cystoid macular edema (Irvine-Gass syndrome) with dexamethasone 0.7 mg intravitreal implant]

PURPOSE

To evaluate the efficacy of dexamethasone 0.7 mg intravitreal implant in patients with postoperative cystoid macular edema.

MATERIALS AND METHODS

Fourteen patients' charts with postoperative cystoid macular edema were retrospectively reviewed. The main outcome measures were best-corrected visual acuity (BCVA) and mean central retinal thickness (CRT).

RESULTS

Patients' mean age was 72.1 years old. Five patients were diabetic. All patients had previously been treated with non-steroidal anti-inflammatory drops. Four patients had received a previous treatment with intravitreal ranibizumab. The mean follow-up period was 8.7 months. Mean BCVA before intravitreal dexamethasone was 0.72 logMAR. After injection, it improved to 0.50 at month 1, was 0.47 at month 3, and 0.60 logMAR at month 12. The pre-injection mean CRT was 598 μm. It improved to 286 μm at month 1, 338 μm at month 3, and was 441 μm at month 12. Eight patients received 2 intravitreal injections of dexamethasone. Five patients presented with elevated intraocular pressure during follow-up, which was treated with drops.

CONCLUSIONS

Intravitreal dexamethasone injection improved visual acuity and macular thickness at month 1 and month 3 in patients with postoperative cystoid macular edema. A second injection was necessary after a mean period of 5 months.

[Complications of silicone oil tamponade]

Silicone oil tamponade is used for the management of complicated retinal detachment. Patients should be closely monitored as many complications may occur with intraocular silicone oil. Short-term complications include temporarily increased intraocular pressure and anterior segment inflammation. Long-term complications include cataract, emulsification, ocular hyper- or hypotension, keratopathy and retinal redetachment associated with proliferative vitreoretinopathy.

[Panuveitis associated with papillary carcinoma of the thyroid]

Ocular involvement secondary to thyroid carcinomas is uncommon. Uveal metastasis may occur. More rarely, they can be responsible for paraneoplastic syndromes. We report the case of a 64-year-old woman who presented with a severe bilateral panuveitis with venous vasculitis associated with hyperthyroidism from a multinodular goiter, complicated by papillary carcinoma. Systemic steroid therapy was initiated; ocular symptoms resolved completely after total thyroidectomy. Other causes of panuveitis with venous vasculitis were ruled out. This is the first reported case of panuveitis associated with papillary thyroid carcinoma. The occurrence of the ocular symptoms with hyperthyroidism and their remission after surgery supports the possibility that this association may not be coincidental. A paraneoplastic phenomenon is suspected.