[Treatment of age-related macular degeneration: Expert opinion and therapeutic algorithm]. / Traitement de la dégénérescence maculaire liée à l'âge : avis d'experts et algorithme thérapeutique.

UNLABELLED: Intravitreal injections (IVT) of aflibercept are indicated in France for the treatment of neovascular age-related macular degeneration (AMD). An induction phase consisting of 3 monthly IVTs followed by follow-up visits and IVTs every other month during the first year is recommended. However, it may be necessary to adjust this schedule for some patients who might benefit from a more tailored approach, namely a follow-up visit immediately after the induction phase. The goal was to develop a treatment algorithm that would reflect current clinical experience and the opinions of experts on neovascular AMD. METHODS: A group of retinologists took positions on therapeutic questions regarding management of AMD using a nominal group technique (NGT). The results were combined to create a treatment algorithm. RESULTS: Seventy-nine percent of experts considered that the approved schedule was efficacious when fluid was completely resorbed after the induction phase. Ninety-four percent of experts recommended, after a successful induction phase, a monthly follow-up visit for 3 to 6 months in order to determine the rhythm of recurrence for each patient. Ninety-six percent of experts recommended that persistent fluid after the induction phase, even if visual acuity is improved satisfactorily, should be a criterion for systematic retreatment. CONCLUSION: The proposed algorithm (expert opinion) after the first year of use of aflibercept in France captures the complexity of the clinical cases that exist in daily practice and the necessity for regular follow-ups.

[Impact of eating habits on macular pathology assessed by macular pigment optical density measure]. / Impact des habitudes nutritionnelles sur la pathologie maculaire évalué par mesure de la densité optique du pigment maculaire.

INTRODUCTION: Low levels of lutein and zeaxanthin in blood or food are associated with an increased risk of age-related macular degeneration (AMD). These molecules, provided by food, form the macular pigment. PATIENTS AND METHODS: Patients included in this pilot study where categorized into four groups : (1) < 50 years with drusen, (2) > or = 50 years without drusen, (3) > or = 50 years with drusen, and (4) > or = 50 years with drusen and neovascularization. During consultation, macular pigment optical density was measured and information on pathology and eating habits were collected. RESULTS: Assessment of macular pigment optical density considering eating habits and groups showed that it was lower in group 1 patients when they ate less than five portions of fruits and vegetables per day and less than two portions of cabbage, broccoli, pepper, corn, or spinach a week. In groups 3 and 4, food supplement intake was related to an increase in optical density. Food supplements were consumed by 58.5 % of patients in group 4. CONCLUSION: Analysis of mean optical density measured by the MPS 9000 QuantifEYE considering eating habits confirmed the impact of food supplement intake on optical density, especially in patients > or = 50 years with drusen and with or without neovascularization.

[Photodynamic therapy]. / Traitement photodynamique.

Photodynamic therapy with Verteporfine (Visudyne Novartis Ophthalmics) achieves a photo occlusion of subfoveal choroidal neovascularization (CNV) resulting from age-related macular degeneration (AMD) in phase 1 and 2 studies. Thereafter, two international randomized clinical trials evaluated the product's efficacy in term of visual acuity. Eyes with neovascular lesions due to AMD of less than 5,400 micro, in size involving the fovea and presenting well-defined CNV on fluorescein angiography could be included when visual acuity was between 5 and 1/10. Six hundred and nine patients were subsequently randomized either to Verteporfine or to placebo (proportion 2:1). A follow-up of 3 months made it possible to consider retreatment when a fluorescein leakage was observed. Functional and angiographic results demonstrated the efficacy of PDT with Verteporfine in comparison with placebo at each examination during follow-up. A visual acuity decrease of less than 15 letters on ETDRS (or 3 lines or approximately 1.5/10) occured less frequently in the treated group with PDT (61% out of 402 treated eyes compared with 46% of 207 placebo eyes). Subgroup analysis of predominantly well-defined CNV (involving 50% or more of the total of the exsudative lesion) showed even more favourable effects (67% of treated eyes versus 39% of placebo eyes). Conversely, when well-defined CNV extended to a smaller area, the results were not significant. The most frequent side effect was Verteporfine extravasation at the injection site. As dynamic phototherapy with Verteporfine limits the decrease in visual acuity always occurring in the natural history of CNV caused by AMD, it is desirable that patients presenting subfoveal predominantly well-defined lesions benefit from this new treatment approach.

[New therapies for the treatment of age-related macular degeneration]. / Nouvelles thérapeutiques dans le traitement de la dégénérescence maculaire liée à l'âge.

Age-related macular degeneration has a natural progression from the precursors (the drusen) towards atrophic or neovascular complications. Choroidal neovascularization is undoubtedly the aspect of the disease that benefits most from new therapeutical approaches. Destructive photocoagulation based on fluorescein angiography has demonstrated since 20 years its efficiency on choroidal neovascularization. The same approach based on indocyanine green (ICG) angiography would increase the number of patients available to therapy. Very recently photodynamic therapy has demonstrated its efficiency to stabilize visual acuity at least at two years in patients with choroidal new vessels predominantly well defined. Other treatment developments are considered, such as refinement of photocoagulation techniques or of surgery. Until now, none has demonstrated its efficiency although they raise justified hopes. The future approaches rely upon the progress of the research both in physiopathology of the disease and on the angiogenic process requiring a constant interaction with all thematics of research. Finally, palliative treatments will be required before heading up to a preventive treatment.

[Optical coherence tomography in the follow up of macular edema treatment in retinitis pigmentosa]. / Tomographie en cohérence optique pour le suivi du traitement de l'oedème maculaire au cours de la rétinopathie pigmentaire.

Macular edema is frequently responsible for loss of central vision in patients affected with retinitis pigmentosa (RP). This macular edema can be treated with acetazolamide. Our purpose was to evaluate optical coherence tomography (OCT) examination in the follow-up of macular edema in RP. In addition, we tried to evaluate the minimal efficient dose of acetazolamide, using means other than fundus examination or fluorescein angiography. We report the cases of 5 patients affected with typical retinitis pigmentosa and fundus appearance of macular edema. These patients received oral acetazolamide treatment (500 mg/d). The OCT examinations were performed before and during treatment, which allowed us to demonstrate, quantify and monitor the progression of macular edema during treatment. OCT appears to be a useful tool in the follow-up of patients affected with macular edema and RP. This noninvasive examination contributes to improving our strategy in treating patients.

Treatment of recent onset central retinal vein occlusion with intravitreal tissue plasminogen activator: a pilot study.

AIMS: To study the effects of intravitreal tissue plasminogen activator (tPA) in recent onset central retinal vein occlusion (CRVO). METHODS: 15 patients with recent onset CRVO (from 1-21 days' duration, mean 8 days) were given 75-100 microg of tPA intravitreally associate with low dose low molecular weight heparin. CRVO was perfused in nine patients and with mild ischaemia not exceeding 100 disc diameters in six patients. Follow up ranged from 5 to 21 months for 14 patients (mean 8 months). Visual acuity measurement, macular threshold (Humphrey perimeter), fluorescein angiography with the scanning laser ophthalmoscope with special emphasis on retinal circulation times, and retinal perfusion were performed at days 0, 1, and 8 and months 1, 3, and 6. RESULTS: Visual acuity was significantly improved on the first day after treatment in only one eye, and decreased transiently in six eyes (40%). Retinal blood velocity was not significantly modified by tPA injection. Retinal ischaemia developed in six eyes (43%), leading to panretinal photocoagulation in five eyes including one with rubeosis iridis. At the end of follow up, visual acuity had improved to 20/30 or better in five eyes (36%), including two with complete recovery; visual acuity was worse than 20/200 in three eyes (28%). No complication of tPA injection was observed. CONCLUSION: Intravitreal tPA treatment for CRVO appears to be simple and safe, but did not significantly modify the course of the occlusion in our patients immediately after treatment. Final visual outcome did not differ significantly from that observed in the natural course of the disease, but final visual acuity seemed to be slightly better. A randomised study is required to determine if intravitreal tPA actually improves visual outcome in CRVO.

[Sarcoid optic neuropathy]. / Neuropathie optique sarcoïdosique.

Sarcoidosis is a multisystem granulomatous disease mostly involving the chest. Sarcoid optic neuropathy is an uncommon but serious manifestation that requires long-term corticosteroid treatment. We report here the case of a 50-year-old black patient complaining of a recent blurred vision on his left eye. The ophthalmologic examination was normal. Goldmann visual field and visual evoked potentials confirmed the diagnosis of retrobulbar optic neuropathy. Sarcoidosis was presumed on a chest radiography and computed tomography and confirmed with a transbronchial biopsy. Symptoms disappeared with intravenous bolus of corticosteroids. Three months later, without treatment, a right inferior eyelid tumor was observed. Magnetic resonance imaging (RMI) showed two orbital masses and multiple meningeal lesions enhancing with contrast suggesting neurosarcoidosis which decreased with a long-term high-dose corticosteroid therapy (1 mg/kg/d). Optic neuropathy is a rare manifestation of neurosarcoidosis, mostly accompanied by optic-disc involvement with papillary lesions. Chest roentgenogram and computed tomography give a presumption of sarcoidosis. But biopsy is mandatory to confirm the diagnosis demonstrating the histologic lesion of a non caseating granulomatous. Corticosteroid therapy is dramatically efficient but sometimes several months treatment is required.