Amputation-free survival in the long-term follow-up and gender-related characteristics in patients revascularized for critical limb ischemia.

OBJECTIVE: Patients with Critical Limb Ischemia (CLI) present a high risk of cardiovascular events and death. Revascularization is the cornerstone of therapy to relieve ischemic pain and prevent limb loss. Literature data suggest that women tend to present with worse outcomes after revascularization. The aim of the present study is to determine amputation-free survival in a long-term follow-up in women and men following endovascular revascularization procedure for CLI. METHODS: From November 2013 to December 2020, 357 consecutive patients were retrospectively included. Clinical and biological parameters were recorded at baseline before endovascular revascularization. During follow-up until February 2023, overall survival and amputation-free survival (freedom from major amputation) were analysed using the Kaplan-Meier method. Univariate and multivariate analyses were performed to study the parameters associated with amputation-free survival. A P<0.05 was considered as statistically significant. RESULTS: A total of 357 consecutive patients were included, 189 men and 168 women with CLI, with a mean age of 78.6±12 years. Treated hypertension (79%), diabetes mellitus (48%), coronary artery disease (39%) and protein malnutrition (61%) were the most prevalent comorbidities. Women were older than men with a mean age of 82.4±11.4 years (versus 75.4±11 years in men) and presented more frequently with protein malnutrition (70% of women). Prevalence of diabetes, tobacco use and history of coronary heart disease were significantly higher in men. During the 10-year follow-up period, 241 patients had died (68%) and 38 (11%) underwent major amputation, of whom 22 patients were still alive on February 2023. Median survival was 35.5 months [IQR: 29.5; 43] in the overall population, 38.5 [32; 50.4] months in women and 33.5 months [24.7; 43.5] in men. No gender-related differences were noted according to peri-procedural complications, survival probability and amputation-free survival. In multivariate analysis for amputation-free survival, age, previous coronary heart disease, C-reactive protein level, left ventricular ejection fraction (LVEF)<60% and albumin level<35g/L were correlated with poor outcome. In particular, protein malnutrition, as a treatable risk factor, appears significantly correlated with poor outcome in both men and women (HR=2.50 [1.16;5.38], P=0.0196 in men; HR=1.77 [1.00;3.13], P=0.049 in women). CONCLUSION: The present results highlight that mortality in patients after endovascular revascularization remains high with a mortality rate of 28% at 1 year, 40% at 2 years and 51% at 3 years. Women represented a distinct population, almost 10-year older than their male counterparts, with more prevalent protein malnutrition. However, no gender-related difference was noted according to amputation-free survival on the long-term follow-up. Associated risk factors are mainly age, a history of coronary heart disease, pre-procedural inflammatory syndrome and protein malnutrition. Correction of malnutrition could have the potential to improve functional and general long-term prognosis in patients with CLI together with optimal medical and interventional management.

[Pretibial myxedema after Graves' disease: A differential diagnosis of lymphedema]. / Myxœdème prétibial pseudo-tumoral après une maladie de Basedow : un diagnostic différentiel du lymphœdème.

INTRODUCTION: Pretibial myxedema is a rare manifestation of Graves' disease, and pseudotumoral forms may be confused with lower limb lymphedema. OBSERVATIONS: We reported 3 cases of pretibial myxedema in 2 women and 1 man, aged 72, 66, and 49 years, treated for Graves' disease 3, 25 and 32 years previously. Two patients were active smokers. Lymphedema diagnosis of the lower limbs was suspected in the presence of bilateral pseudotumoral lesions of the feet, toes and ankles and the presence of a Stemmer's sign (skin thickening at the base of the 2nd toe, pathognomonic of lymphedema). Lymphoscintigraphy in one case was normal, not confirming lymphedema. CONCLUSION: Pretibial pseudotumoral myxedema is a differential diagnosis of lower limb lymphedema. This diagnosis is confirmed by questioning the patient about preexisting Graves' disease, the underlying etiology, to decide the appropriate treatment and to encourage cessation of smoking, which is a risk factor for pretibial myxedema.

[Real life retrospective study of 98 eyes treated with intravitreal dexamethasone or anti-VEGF injections for macular edema due to diabetes or retinal vein occlusion]. / Étude rétrospective de vraie vie de patients traités par injections intra-vitréennes de dexaméthasone ou d'anti-VEGF pour œdèmes maculaires diabétiques ou secondaires à une occlusion veineuse rétinienne : à propos de 98 yeux.

PURPOSE: To evaluate long term outcomes of patients presenting with diabetic macular edema (DME) or edema secondary to a retinal vein occlusion (RVO). METHODS: This is a real world, retrospective, single-center study of 65 eyes of 47 patients treated for DME and 33 eyes of 33 patients with macular edema secondary to RVO between July 2012 and October 2018. The patients treated were treatment-naive and were followed for at least one year. We collected data such as visual acuity, central macular thickness, intravitreal injections (number/year, injection schedule, number of switches), number of visits and cases of vision loss. RESULTS: DME: the mean age at inclusion was 65.9years with 60.4% women, and the mean follow-up was 28.5months. The mean gain in visual acuity after 1year of follow-up was 6.4 ETDRS letters for patients treated with anti-VEGF and 2.6 letters for patients treated with dexamethasone. The average number of intravitreal injections of anti-VEGF was 5.6/year, compared to 2.9/year for dexamethasone. Fourteen patients initially treated with anti-VEGF were switched to dexamethasone. RVO: the mean age at inclusion was 68.8years with 54.5% women and a mean follow-up of 31.1months. The mean gain in visual acuity after 1year of follow-up was 26.7 ETDRS letters for patients treated with anti-VEGF and 7.0 letters for patients treated with dexamethasone. The average number of intravitreal injections of anti-VEGF was 5.8/year, compared to 2.4/year for dexamethasone. Five patients initially treated with anti-VEGF were switched to dexamethasone in the first year of follow-up. CONCLUSION: In this real-life retrospective study, we found good anatomical and functional results similar to those reported in other studies, remaining stable over time, for patients with DME or macular edema secondary to RVO.

[Neovascular recurrences in 42 treatment-naive eyes with neovascular age-related macular degeneration (AMD) followed for over 2 years]. / Étude des récidives exsudatives chez 42 yeux naïfs atteints de dégénérescence maculaire liée à l'âge suivis plus de 2 ans.

INTRODUCTION: The objective of this study was to analyze the reproducibility or variability of the time period to exudative recurrences in patients who were treated with intravitreal injections (IVT) of anti-VEGF (ranibizumab, aflibercept) for exudative age-related macular degeneration (AMD). The data studied included the number of recurrences per year, the time between the last IVT and the recurrence, fluctuation over time in the same patient, and changes in the therapeutic management of these exudative recurrences with regard to repeat induction therapy of three IVT, changes in monitoring protocols, and switches in anti-VEGF molecules. MATERIALS AND METHODS: We conducted a retrospective, single center, "real-life" study at the Nantes University Hospital, including 33 patients (42 eyes) between March 2012 and March 2017. These were IVT-naive patients, in whom anti-VEGF IVT treatment was initiated for management of exudative AMD, with a follow-up period of at least two consecutive years. The main outcome was the fluctuation in recurrences times for the same patient. RESULTS: Of the 33 patients included, 9 had bilateral involvement, for a total of 42 eyes. Twenty were women (60.6 %), the median age at inclusion was 78.5 years with a follow-up period of 3.7 years. The average time to recurrence was 11.6 weeks after the last IVT. The first recurrence occurred within 9.8 weeks after the last IVT. 12.3% of the eyes had consisent recurrence times, with fluctuations of less than 2 weeks between the various relapses over the two years of follow-up. a total of 7.1% of the eyes had no exudative recurrences during follow-up. The first exudative recurrence occurred at a mean of 38.2 weeks after diagnosis of the disease, or 37.2 weeks after the first IVT. 14.3% of the recurrences led to the administration of a repeat induction of three intravitreal anti-VEGF injections, 8.6% led to a change in anti-VEGF molecule, and 7.1% to a modification of the treatment protocol. DISCUSSION: The goal of this study was to analyze the variability of the time to exudative recurrence in patients treated with anti-VEGF IVT in the context of exudative AMD, because, since the advent of anti-VEGF IVT in 2007, few data have been available on long-term follow-up and fluctuations in recurrence times in patients who will receive treatment for several years. CONCLUSION: Recurrences times are not reproducible over follow-up, particularly in patients experience their first exudative recurrence beyond 8 weeks and in patients with multiple exudative recurrences.

[Anatomic-functional correlations in birdshot chorioretinopathy: An observational single-center prospective study]. / Corrélations anatomo-fonctionnelles dans la choriorétinopathie de Birdshot : étude prospective monocentrique observationnelle.

INTRODUCTION: The purpose of this study was to identify anatomic-functional correlations in patients with Birdshot chorioretinopathy in order to better understand the mechanisms of visual loss. MATERIALS AND METHODS: We conducted a single-center observational prospective study at the Nantes University Medical Center including all patients followed for Birdshot chorioretinopathy between January 2019 and July 2019. The parameters studied were visual acuity, microperimetry, standard automated perimetry, SD-OCT, EDI-OCT, OCT-A, RNFL-OCT, wide-field fundus photographs, and fluorescein and ICG angiography. RESULTS: Forty-four eyes were studied. A significant correlation was found between visual acuity and retinal thickness (P=0.002, r=0.44), but not choroidal thickness (P=0.16). A significant correlation was also observed between retinal sensitivity and total macular thickness (P<0.001, r=0.68) as well as inner retinal thickness (P<0.001, r=0.65), while the correlation was weaker with choroidal thickness (P=0.03, r=0.32). There was a weak correlation between retinal sensitivity and superficial capillary density (P=0.02, r=0.42) as well as deep capillary density (P=0.02, r=0.41). The peripheral hypo-autofluorescent zones correspond to the visual field defects, but these defects are larger than the hypo-autofluorescent zones. Patients with paracentral or peripheral field defects had a history of vasculitis more often than hypo-ICG spots. DISCUSSION: We found significant correlations between functional parameters such as visual acuity and retinal sensitivity and retinal anatomic parameters, particularly the inner retina, while there was no correlation shown with choroidal anatomic parameters. CONCLUSION: The main results of our study suggest a retinal rather than choroidal origin of the degradation of visual function in birdshot chorioretinopathy.

[Evaluation of diabetic retinopathy screening using fundus photography: Evaluation and epidemiologic factors at Nantes university medical center]. / Dépistage de la rétinopathie diabétique par télétransmission de photographies du fond d'œil : évaluation et aspects épidémiologiques au CHU de Nantes.

INTRODUCTION: The goal of our study was to evaluate the results of screening for diabetic retinopathy using the non-mydriatic fundus camera combined with telemedicine in the university hospital of Nantes. PATIENTS AND METHODS: This is a retrospective study of all diabetic patients hospitalized in the endocrinology department between June and September 2016 inclusive. The photos were taken by a nurse if the patient had an indication for screening as determined by the attending physician. The ophthalmologist then provided a written interpretation of the photos on a consultant's sheet. Quality control with re-reading of a sample of the photos was performed. RESULTS: A total of 442 patients (48% females, 52% males) were studied. 227 patients (51.3%) had undergone an eye examination within the previous year. 160 patients (36.2%) were screened with fundus photography. Fundus photography of at least one eye could not be graded in 10 patients (6.3%). Diabetic retinopathy was detected in 27 patients (16.9%) and diabetic maculopathy in 5 patients. Longer duration of diabetes and the presence of microalbuminuria were significantly associated with incidence of retinopathy. The double reading of 26% of the photos found a 93% of concordance between the 2 readers. Referral to an ophthalmologist was required in 32 patients (20%), of whom 27 were rescheduled at the university hospital, for unreadable photographs, diabetic retinopathy or concomitant eye disease. 38.5% of rescheduled patients did not come to the appointment. CONCLUSION: Non-mydriatic fundus photography combined with telemedicine is attractive for diabetic retinopathy screening and identifies patients requiring further eye examination. In our study, it obviated the need for an ophthalmologic examination in 8 out of 10 cases. It is important to continue to educate patients about the necessity of regular eye examinations and post-screening follow-up.

[Retinal detachment surgery: Evaluation of the anatomical success and functional outcomes in a consecutive series of patients operated between 2011 and 2014 at Nantes University Medical Center]. / Chirurgie des décollements de rétine : évaluation du succès anatomique et du devenir fonctionnel sur une série consécutive de patients opérés entre 2011 et 2014 au CHU de Nantes.

OBJECTIVE: Evaluate the anatomical and functional outcomes of retinal detachment (RD) surgery from January 2011 to November 2014. MATERIALS AND METHODS: We conducted a retrospective study of 182 eyes of 175 patients with a minimum follow-up of 6 months, operated for RD at Nantes University Medical Center. It consists of 56 simple RDs and 126 complex RDs treated in first intention by Scleral Buckling (SB), vitrectomy or combined surgery. The analysis is based on anatomic reattachment at the end of a follow-up of at least 6 months after the first surgery and the progression of the best corrected visual acuity (BCVA). RESULTS: One hundred and seventy-two vitrectomies, 15 SB and 5 combined surgeries (vitrectomy+SB) were performed. The overall anatomical success rate after a single operation was 131 eyes (72 %). It increased to 163 eyes (90 %) at the end of the follow-up. Depending on the type of RD, anatomic success at 6 months after surgery was achieved for 47 simple RDs (84 %) and 84 complex RDs (67 %). At the end of the follow-up, after one or more operations, these rates increased to 53 simple RDs (95 %) and 110 complex RDs (87 %). For all RDs with an anatomically successful result, we observed a visual improvement≥2 lines in 45 % of cases and a postoperative BCVA≥5/10 in 40 % of cases. CONCLUSION: This study confirms the evolution toward vitrectomy surgery for retinal detachment. It finds anatomical and functional results consistent with the literature, with a percentage of approximately 5 % of RDs still not reattached in spite of several operations.

[Treatment of macular edema: Comparison of efficacy and tolerability of subconjunctival triamcinolone injections, sub-tenon's triamcinolone injections and intravitreal dexamethasone implant]. / Traitement des œdèmes maculaires : comparaison de l'efficacité et de la tolérance des injections sous-conjonctivales de triamcinolone, des injections sous-ténoniennes de triamcinolone et des injections intra-vitréennes de l'implant de dexaméthasone.

The area of uveitis is related to numerous pathological entities. One of the main causes of decreased visual acuity in these patients is macular edema. One aspect of the treatment includes cortosteroids used peri- and intra-ocularly. MATERIALS AND METHODS: The goal of our work was to estimate the criteria of efficacy (on improvement in visual acuity and macular edema, as well as time to recurrence) and safety (on intraocular pressure and cataract) of these various routes of administration of corticosteroid after a single injection. We compared patients treated with Ozurdex® versus subconjonctival triamcinolone versus sub-tenon's triamcinolone. This is a retrospective study conducted in 2 tertiary centers, the university medical center of Nantes and La Pitié-Salpêtrière hospital from November, 2011 to November, 2013. RESULTS: At presentation, 25 % of the patients displayed VA better than 5/10. During follow-up, this proportion increased to 45 % at M1, 50 % at M3, 49 % at M6 and 48 % at the end of follow-up. There was no significant difference between the groups with respect to VA gain. The reductions in mean CMT compared with D0 were all statistically significant (improvement of one line in log-OCT). We observed an improvement in macular thickness of 88 % at M1, 86 % at M3, 61 % at M6 and 60 % at the end of follow-up, significant at each time, with no significant difference between the three groups. A comparison of time to anatomic vs. functional recurrence was performed, showing no difference. The largest increase in IOP was observed at M1, statistically different from the other time points. DISCUSSION: Intra- and periocular injections should be considered as an adjuvant therapy, since the majority of the conditions in question require systemic treatment. They allow for increased intravitreal concentrations with fewer systemic effects. CONCLUSION: We demonstrated neither any true superiority of any of the 3 treatments nor any difference in tolerability between the 3 groups.

[Optical coherence tomography and microperimetry after internal limiting membrane peeling for epiretinal membrane]. / Micropérimétrie et OCT en face après pelage de membrane limitante interne dans la chirurgie des membranes épimaculaires.

INTRODUCTION: To evaluate the anatomical and functional consequences of internal limiting membrane (ILM) peeling in epiretinal membrane (ERM) surgery. METHODS: Retrospective single-center study including consecutive patients operated on for idiopathic ERM. The integrity of the ILM was assessed by ILM Blue® staining after removal of the ERM: either the peeling was spontaneous (group 1) or a complementary peeling was required (group 2). Pre- and post-operatively (1 and 6 months), all patients were analyzed using visual acuity, SD-OCT (Spectralis HRA OCT, Heidelberg, Germany) and microperimetry (OPKO/OTI, Miami, USA). RESULTS: Twenty-one eyes of 21 patients were included: 12 "active ILM peelings" and 9 "spontaneous peelings". In both groups, visual acuity increased significantly after surgery. Microperimetry revealed more microscotomata at 1 and 6 months for active peeling (P<0.05). Their location corresponded more often to the site where the ERM or ILM was grasped, based on surgical videos (P<0.05), and with the appearance of inner retinal defects using en face OCT. DISCUSSION: ILM peeling is frequently performed to reduce ERM recurrence. Despite lack of effect on visual acuity, active ILM peeling increases the incidence of microscotomas related to the site where the ERM or ILM is grasped. CONCLUSION: Active ILM peeling may be responsible for postoperative visual discomfort related to microscopic trauma during peeling.

[Ophthalmologic adverse effects of systemic corticosteroids]. / Complications ophtalmologiques des corticoïdes systémiques.

The article reviews the ophthalmologic side effects of systemic corticosteroids. These side effects include involvement of both anterior (cataract, ocular hypertension) and posterior (serous central chorioretinopathy) segements of the eye. We review the clinical presentations and detail the advance in the knowledge still incomplete of the pathophysiological mechanisms involved in the occurrence of these complications. The clinical knowledge of the ophthalmologic side effects of systemic corticosteroids is essential to inform our patients, and prevent or detect these complications to treat them appropriately.

[Effectiveness of interferon alpha in the treatment of uveitis macular edema refractory to corticosteroid and/or immunosuppressive treatment]. / Efficacité de l'interféron alpha dans le traitement des oedèmes maculaires uvéitiques réfractaires au traitement corticoïde et/ou immunosupresseur.

INTRODUCTION: Macular edema is always a major complication in intermediate and/or posterior uveitis. Some of these macular edemas are refractory to steroid and/or immunosuppressive drugs. Interferon, a validated treatment for Behçet disease, has antiproliferative and immunoregulative properties that may be very valuable in uveitic edema refractory to steroid and/or immunosuppressive agents. Recent studies have brought out the value of interferon-alpha by demonstrating its low blood rate in affected patients. OBSERVATIONS: We describe a series of six consecutive uveitic macular edema, secondary to two birdshot retinochoroidopathy, and four cases of idiopathic uveitis treated with interferon-alpha. Our small case series showed a 189.7+/-67 mum decrease in mapping and an improvement in visual acuity of 0.35+/-0.21 LogMAR. DISCUSSION: Other publications have shown a remarkable efficacy on macular edema and visual acuity in less than 1 month of treatment. Our small case series found the same results as the other studies, despite a less aggressive therapeutic regimen. However, we also observed some well-known side effects, in particular depression. CONCLUSION: In our series of six consecutive cases of uveitic macular edema refractory to steroid or immunosuppressive drugs, alpha-interferon provided highly advantageous anatomical and functional results. The treatment modality must be specified, but it seems that a shorter duration and lower posologies might be as effective and lead to a lower rate of complications than the regimen currently proposed in the literature.

[Reasons for readmission to hospital after vitreoretinal surgery: 5-year retrospective follow-up]. / Suivi de cohorte rétrospectif sur 5 ans des motifs de ré-hospitalisation après chirurgie vitréo-rétinienne au centre hospitalier universitaire de Besançon.

INTRODUCTION: To study the etiologies and occurrence rate of readmissions after vitreoretinal surgery. PATIENTS AND METHODS: One hundred fifty-three eyes requiring vitreoretinal surgery in 2000 at the Besançon (France) University Hospital were retrospectively studied. The occurrence rate and etiologies of these readmissions and the time between surgery and readmission were analyzed from the patient files. RESULTS: The main indications for vitreoretinal surgery were retinal detachment, epiretinal membrane surgery, idiopathic macular holes, neovascular retrovascular membranes, and intravitreal hemorrhage. A total of 40.5% of the patients were readmitted. The major causes were redetachment and cataract for retinal detachment surgery and cataract for epiretinal membrane and macular hole surgeries. CONCLUSION: The results highlight the possibly iatrogenic association between anterior and posterior eye segment surgeries, in agreement with the literature.

[Study of pupillary motility after implantation of an iris claw lens (Artisan) in a phakic population with severe myopia]. / Etude de la motilité pupillaire chez le sujet phaque porteur d'un implant Artisan.

PURPOSE: To assess the effect of the Artisan lens on pupillary motility in a highly phakic myopic population. PATIENTS AND METHODS: Eleven patients (21 eyes) were enrolled in a nonrandomized prospective study between September 2002 and August 2003, with a 6- to 11-month follow-up. A portable Colvard pupillometer was used to measure pupil diameters before and after surgery under two different light conditions: one with scotopic surroundings with absolute darkness in the examination room and the other maximal simulated photopic surroundings, caused by the instillation of a pilocarpine 2% drug until a nonreactive myosis could be observed. Under such light conditions, both the horizontal and vertical pupil motion ranges were measured. Measures were then sorted into five temporal segments in order to have enough samples per temporal segment for a cohesive data analysis. Mean values and confidence intervals were then derived per temporal segment according to Student's law. Constraints on the pupil motion range were identified. RESULTS: After implantation of an Artisan lens, the pupil motion range was limited to both horizontal and vertical axes. For the horizontal axis, the motion range was 4.3+/-0.2mm (p=0.1) before claw implantation and was 2.7+/-0.5mm (p=0.1) 9 months after claw implantation. For the vertical axis, the motion range was 4.46+/-0.28mm before claw implantation and 3.08+/-0.89mm 9 months after claw implantation. CONCLUSIONS: The Artisan lens durably restrains the pupil in its motion range and introduces a noticeable oval deformation under extreme light condition variations. This side effect is, however, not visible under regular conditions but only in maximal photopic surroundings.