[Late and sustained intraocular pressure elevation related to intravitreal anti-VEGF injections: Cases requiring filtering surgery (French translation of the article)]. / Hypertonie intraoculaire retardée liée aux injections intra-vitréennes répétées d'anti-VEGF : des cas nécessitant une chirurgie filtrante.

We report cases of delayed, sustained elevated intraocular pressure (IOP) associated with repeated intravitreal anti-VEGF injections (IVI), which ultimately resulted in the need for filtering surgery. Two of the three cases demonstrated severe IOP elevation despite maximal medical treatment following unilateral IVI and required urgent filtering surgery. Optic nerve involvement was severe in all three cases. These intravitreal injections were performed for exudative age-related macular degeneration (AMD), and the patients did not show any sign of glaucoma or ocular hypertension prior to the initiation of treatment. Elevated IOP secondary to intravitreal steroids is a well-known side effect, as is immediate transient IOP elevation associated with anti-VEGF injection. Late, sustained IOP elevation after repeated injections of anti-VEGF, described approximately ten years ago, is often underestimated. Its incidence is estimated between 2.1% and 13% according to studies and increases with the number of IVI (cumulative effect). The pathophysiologic process is becoming increasingly understood, and several risk factors for this chronic IOP elevation have been identified. Most often, it is a moderate IOP elevation for which topical monotherapy is sufficient, or sometimes two, three or four medications or even selective laser trabeculoplasty (SLT). However, filtering surgery may rarely be required. Our findings illustrate a little-described phenomenon: a sudden, severe, late IOP elevation in response to anti-VEGF by an "overflow" effect, requiring urgent filtering surgery.

Late and sustained intraocular pressure elevation related to intravitreal anti-VEGF injections: Cases requiring filtering surgery.

We report cases of delayed, sustained elevated intraocular pressure (IOP) associated with repeated intravitreal anti-VEGF injections (IVI), which ultimately resulted in the need for filtering surgery. Two of the three cases demonstrated severe IOP elevation despite maximal medical treatment following unilateral IVI and required urgent filtering surgery. Optic nerve involvement was severe in all three cases. These intravitreal injections were performed for exudative age-related macular degeneration (AMD), and the patients did not show any sign of glaucoma or ocular hypertension prior to the initiation of treatment. Elevated IOP secondary to intravitreal steroids is a well-known side effect, as is immediate transient IOP elevation associated with anti-VEGF injection. Late, sustained IOP elevation after repeated injections of anti-VEGF, described approximately ten years ago, is often underestimated. Its incidence is estimated between 2.1 % and 13 % according to studies and increases with the number of IVI (cumulative effect). The pathophysiologic process is becoming increasingly understood, and several risk factors for this chronic IOP elevation have been identified. Most often, it is a moderate IOP elevation for which topical monotherapy is sufficient, or sometimes two, three or four medications or even selective laser trabeculoplasty (SLT). However, filtering surgery may rarely be required. Our findings illustrate a little-described phenomenon: a sudden, severe, late IOP elevation in response to anti-VEGF by an "overflow" effect, requiring urgent filtering surgery.

[Is there a need for a therapeutic education with patients suffering with open-angle glaucoma? Preliminary inquiry regarding knowledge and patient adherence]. / Faut-il une éducation thérapeutique des patients atteints de glaucome à angle ouvert ? Enquête préliminaire des connaissances et de l'observance auprès des patients.

PURPOSE: To evaluate the knowledge and compliance of patients with open-angle glaucoma in order to propose an approach by therapeutic education, validated for other chronic pathologies. METHODS: A questionnaire-based interview of all patients in the waiting room of the glaucoma center is performed by the same health care professional. RESULTS: Out of 200 patients, 73% know they will need to be treated throughout their lives and 95% are aware of the risk of blindness in the absence of appropriate treatment. However, 16% respond that they can be cured, and 54% believe that treatment can save their eyesight. Knowledge increases with the length of follow-up of patients at the glaucoma center beyond one year, but the progress is still insufficient in their confidence that treatment can save their eyesight (36% to 57%), and in the decrease in the number of patients who forget their treatment (56% to 30%). CONCLUSION: Cognitive knowledge is insufficient to encourage the patient to comply with treatment. It is necessary to consider therapeutic patient education (TPE) techniques, such as described by WHO, in group and/or individual sessions, aimed at building the patient's confidence that treatment can delay the progression of the disease and blindness, strengthening his/her capacity to properly administer the eye drops, managing his/her treatment and coping with frequent side effects. Within this framework, our knowledge of the patients' representations of their glaucoma and its treatment must improve.

[Early postoperative intraocular pressure after phacoemulsification: Normal patients versus glaucoma patients]. / Pression intraoculaire en postopératoire précoce de phakoémulsification chez le sujet normal et glaucomateux.

OBJECTIVE: To compare intraocular pressure (IOP) during the first month following cataract surgery among patients with primary open-angle glaucoma (POAG) and non-glaucomatous patients. MATERIALS AND METHODS: This longitudinal observational study included 19 glaucoma patients and 18 healthy patients scheduled for phacoemulsification with IOL implantation between December 2013 and April 2014. IOP was measured preoperatively, on the day of surgery (j0), the next day (j1), one week (j7) and one month after (M1). The usual antiglaucoma medications were continued without any modification compared to the preoperative medications. Oral treatment with a carbonic anhydrase inhibitor was initiated in the case of ocular hypertension above 30mmHg. RESULTS: IOP in glaucoma patients was 18.42 and 21.16mmHg respectively at j0 and j1 versus 12.94 and 13.78mmHg in non-glaucomatous patients. The difference was significant with P=0.05. There was also more ocular hypertension over 30mmHg in the POAG group (31.5% vs. none in the non-glaucomatous group, P<0.05). CONCLUSION: Glaucoma patients, even stabilized on topical medications, are more likely to experience IOP spikes immediately after uncomplicated cataract surgery. High risk patients should have closer monitoring with IOP measurement the day of or the day after surgery. Further studies are needed to evaluate the effectiveness of prophylactic anti-hypertensive treatment.

[Efficacy of intravitreal dexamethasone implants in macular edema excluding venous occlusions: results for a cohort of 80 patients]. / Efficacité des implants intravitréens de dexaméthasone dans l'œdème maculaire hors occlusions veineuses : résultats sur une cohorte de 80 patients.

INTRODUCTION: The intravitreal dexamethasone implant has shown efficacy in the treatment of macular edema (ME) arising after retinal venous occlusions (central or branch), and in the treatment of non-infectious uveitis. The purpose of this study was to evaluate the efficacy of this implant in the treatment of other diffuse macular edemas with an inflammatory mechanism. MATERIALS AND METHODS: We carried out a retrospective cohort study over 2 years: from January 2012 to December 2013, including all patients who received at least one injection of intravitreal dexamethasone implant, excluding venous occlusions and non-infectious uveitis. The primary study parameter was the progression of visual acuity. The study protocol had the approval of the institutional review board of the respective clinical ethics committees, and was conducted in accordance to the tenets of the Declaration of Helsinki. RESULTS: Eighty patients were included. Eighty-eight percent of patients were pseudophakic. The indications for treatment were: diabetic ME when anti-VEGF were ineffective (53%), ME after retinal detachment (RD) (22%), ME of Irvine-Gass syndrome (16%), ME after endophthalmitis (4%), macular telangiectasia (4%), ME secondary to retinitis pigmentosa (1%). The mean ETDRS visual acuity was 53.7 letters prior to injection, improving to 62.3 letters after injection (P<0.001). The average gain in visual acuity was 6.7 letters [4.53;8.84] (P<0.001) in patients treated for diabetic ME, 9.6 letters [6.1;13.1] (P<0.001) in patients with ME after RD, and 15.2 letters [10.25;20.28] (P<0.001) for Irvine-Gass syndrome. The mean duration of efficiency was 4.6 months, with a median of 3.8 months. CONCLUSION: The intravitreal dexamethasone implant appears to be an effective second-line treatment even in patients with diabetic ME after failure or in the case of contraindication of anti-VEGF. It is also effective and well tolerated in patients with ME after RD, as well as in patients with Irvine-Gass syndrome.

[Evaluation of preoperative anxiety in patients requiring glaucoma filtration surgery]. / Évaluation de l'anxiété préopératoire chez les patients nécessitant une chirurgie filtrante du glaucome.

PURPOSE: Preoperative anxiety is often expressed by patients requiring filtration surgery for their glaucoma. So far, there has been no scale for screening this group of patients for preoperative anxiety. The Amsterdam Preoperative Anxiety and Information Scale (APAIS) is a self-evaluation questionnaire which has been used in specialties other than ophthalmology and which makes it possible to identify the adult patients with a high level of preoperative anxiety over an upcoming surgical procedure. The purpose of this study is to estimate the preoperative anxiety in glaucoma patients requiring filtration surgery. METHODS: We performed a prospective study of 36 adult patients with chronic glaucoma not responding to medical treatment and who were about to undergo filtration surgery (trabeculectomy or deep sclerectomy). The APAIS questionnaire was given to the patients after discussing the indication for surgery. A global anxiety score (ranging from 4 to 20) above 10 defined patients with a high level of preoperative anxiety. We attempted to identify among these patients the factors related to filtration surgery which caused them anxiety (lack of control of intraocular pressure, risk of blindness, presence of the filtering bleb). RESULTS: In our sample of patients, we found that glaucoma was a source of anxiety. That was also true for the surgical procedure, though most patients believe that once the decision had been made, their psychological status was not modified by the upcoming procedure. DISCUSSION: The patient-clinician relationship is important in any chronic disease, all the more so in glaucoma, since this disease remains asymptomatic for a long time. When filtration surgery is necessary, the patients are going to express less preoperative anxiety if they trust their physician and if individualized information has been given to them CONCLUSION: The French version of the APAIS is a quick scale, easily completed, that can be recommended for evaluating anxiety and patients' need for information prior to filtering surgery. It is usually easier for the surgeon to find ways to reduce the patient's anxiety if a relationship of trust has been established between the two.

[Critical reading of clinical trials]. / L'interprétation des essais cliniques.

Clinical trials are playing an increasingly crucial role in modern evidence based medicine, allowing for rigorous scientific evaluation of treatment strategies and validation of patient care. The results of clinical trials often form the rational basis from which physicians draw information used to adapt their therapeutic practices. Critical reading and analysis of trials involves the assessment of whether the available data provide enough credible evidence that the treatment will result in a clinically significant and relevant improvement. Evaluating the quality of a clinical trial is a process that draws upon sometimes complex methodological and statistical concepts, with which the reader should nonetheless be familiar in order to come to impartial conclusions regarding the raw data presented in the clinical trials. The goal of the current article is to review the methodological and statistical concepts required for the design and interpretation of clinical trials, so as to allow for a critical analysis of publications or presentations of clinical trials. The first section describes the major methodological principles of clinical trial design required for a rigorous evaluation of the treatment benefit, as well as the various pitfalls or biases that could lead to erroneous conclusions. The second section briefly describes the main statistical tests used in clinical trials, as well as certain situations that may increase the risk of false positive findings (type 1 error), such as multiple, subgroup, intermediate and non-inferiority analysis.

[Glaucoma and sleep apnea syndrome]. / Glaucomes et syndrome d'apnées du sommeil.

Glaucomatous optic neuropathy is multifactorial, with currently one known and modifiable risk factor, with good results on the prognosis and intraocular pressure. Nevertheless, some patients may experience progression of their neuropathy even though their intraocular pressure seems appropriately controlled. Vascular risk factors are hypothesized and researched. Obstructive sleep apnea syndrome (OSAS) could be considered one of these risk factors. Screening for this cardiovascular risk factor in glaucomatous patients presenting evocative signs, should be proposed.

Primary open angle glaucoma and snoring: prevalence of OSAS.

INTRODUCTION: Obstructive sleep apnea syndrome (OSAS) may be suspected at interview, notably in case of snoring. Various studies suggested a link between primary open angle glaucoma (POAG) and OSAS. The present study sought to determine OSAS prevalence in POAG associated with snoring. MATERIAL AND METHODS: Thirty-one snoring glaucomatous patients prospectively underwent simplified polysomnography. Ophthalmologic examination ruled out secondary glaucoma and assessed the glaucomatous neuropathy. RESULTS: 49% of the patients included were diagnosed with OSAS. Ophthalmologically, glaucoma showed no specific characteristics. CONCLUSION: Given the high-prevalence of OSAS in patients with POAG, presence of snoring should be explored at interview. Conversely, patients who snore should be asked whether they have POAG, and if so, should undergo all-night sleep recording to explore for OSAS.

[Contribution of GDx-VCC in ocular hypertensive patients: a complement to blue-on-yellow perimetry and FDT matrix?]. / Apport du GDx-VCC chez les patients hypertones oculaires : complémentarité avec la périmétrie bleu-jaune ou le FDT Matrix ?

INTRODUCTION: Evaluate the importance of GDx-VCC results compared with FDT Matrix and blue-on-yellow perimetry in a population of ocular hypertensive patients. METHODS: Prospective study including 135 eyes of 135 patients. All had normal standard achromatic perimetry and intraocular pressure greater than 21 mmHg without medication. They underwent short wavelength automated perimetry (SWAP) 24-2 FASTPAC, FDT Matrix 24-2 Threshold strategy, and retinal nerve fiber layer (RNFL) analysis with GDx-VCC. RESULTS: Fifty two patients had neither structural (GDx-VCC) nor functional (SWAP and Matrix) optic nerve injury. Eighty-three patients had preperimetric glaucoma (at least one of the tests showed pathologic results). We found isolated functional defects (38% cases), isolated structural lesions (31% cases), or mixed injury (31% cases). When GDx-VCC revealed structural damage, Matrix was abnormal in 30%, as was SWAP in 8% of cases. Both functional and structural evaluation revealed identical defects for 12% of patients. RNFL loss could be either diffused or compatible with typical glaucomatous topography. Most temporal damage was detected by FDT Matrix, whereas SWAP performed better for nasal defects. The results of GDx analyses correlated better with Matrix than with SWAP. CONCLUSION: When associated with automated perimetry, GDx-VCC is a valuable tool to evaluate optic nerve damage and detect preperimetric glaucoma. Clinical evaluation of the optic nerve head remains essential. We found a good correlation between visual field defects and structural injuries.

[Acute angle-closure glaucoma complicating an intravitreal injection of bevacizumab]. / Glaucome aigu par fermeture de l'angle compliquant une injection intravitréenne de bevacizumab.

INTRODUCTION: The use of anti-VEGF by intravitreal injection is being generalized, and the indications are multiplying. Ocular hypertension after injection can be a classic complication. CASE REPORT: We report the case of an acute angle-closure glaucoma that occurred immediately after an intravitreal injection of 0.05 ml of bevacizumab. The patient was suffering from intravitreal hemorrhage complicating retinal central venous occlusion. The treatment consisted of intravenous acetazolamide and mannitol, associated with a local treatment. DISCUSSION: Elevation of intraocular pressure is frequent a short time after an intravitreal injection. However, this complication is more often moderate and transient, and does not usually require an adapted treatment. The physiopathology remains unclear. To our knowledge the occurrence of acute angle-closure glaucoma following an intravitreal injection is exceptional.

[Rare complication in microspherophakia surgery: early capsular contraction]. / Complication rare de la chirurgie de la microsphérophakie : rétraction capsulaire précoce.

INTRODUCTION: Microspherophakia is characterized by a decreasing equatorial diameter of the crystalline lens and a relative spherical shape objectivized by an increase in the diameter of the anteroposterior axis. This rare abnormality, leading to severe glaucoma and lenticular myopia, can be sporadic or inherited. OBSERVATION: We report the case of an 18-year-old woman with a history of bilateral angle-closure glaucoma consulting for recurring painful episodes with no relief from medical treatment. The clinical examination showed idiopathic microspherophakia, confirmed by crystalline lens diameter measures with B-scan biometry, associated with secondary glaucoma due to pupillary blockage even though bilateral iridotomy was achieved. A lens extraction was performed with a bag implantation, with no complications. Seven days after surgery, visual acuity dropped to 10/10 with no refractive error, but a major capsular contraction and a superior haptic luxation were noted. After a new surgery to reposition the haptic, at the end of 3 months the visual acuity was 10/10 without refractive error or hypertony. CONCLUSION: This report is an example of a rare crystalline lens disease that required lens extraction. Postoperative complications raise the problem of implantation in this pathology because of the small capsular bag diameters and the high rate of bag contraction. Using a capsular tension ring may prevent this complication but a ring was not placed in this case because of a particular anatomic condition (small bag).

[Glaucoma and ultrasound biomicroscopy]. / Glaucomes et biomicroscopie ultrasonore.

Ultrasound biomicroscopy (UBM) can provide high-resolution images in the living human eye; this resolution has been compared to microscopic resolution. This system is particularly useful in studying the anterior segment and analyzing the different types of glaucoma. Anatomical aspects, physiopathological processes and surgical results in glaucoma could be evaluated with UBM. This exploration is also important in determining differential diagnosis, risk factors, and prognostic elements. In addition, using UBM after filtering surgery helps detect early complications and understand poor surgical outcome.