[Evaluation of the efficacy of aflibercept's in the treatment of neovascular age-related macular degeneration in treatment-naive and switched patients. Report of 86 cases]. / Évaluation de l'efficacité de l'aflibercept comme traitement de la dégénérescence maculaire liée à l'âge exsudative chez des patients naïfs et « switchés ¼. À propos de 86 cas.

INTRODUCTION: AMD (age-related macular degeneration) is the leading cause of legal blindness after age 50 in developed countries. Anti-VEGF therapy by intravitreal injection has become the standard for the treatment of neovascular AMD. Ranibizumab is the most currently used, but the arrival of aflibercept on the market 1 year ago is changing clinical practices in France. METHODS: The objective of this study is to evaluate the efficacy of aflibercept in AMD. All patients with neovascular AMD undergoing IVT (intra-vitreal injection) of aflibercept were included. All patients had at baseline and on follow-up visits a measurement of best corrected visual acuity (ETDRS), a fundus examination and an OCT. For statistical analysis, we analyzed the data at 0, 3, 6 and 12 months. An induction phase was carried out for treatment-naive patients, and follow-up was performed according to the PRN method (Pro Re Nata). The total number of injections over the entire follow-up period was recorded. RESULTS: Ninety-six eyes were included, with 17 treatment-naive patients and 69 patients who had previously received ranibizumab. At 1 year, all patients had a mean improvement of 5.4 ETDRS letters (P=0.0026). The OCT data showed a rapid decline in retinal thickness, from baseline to the third month, of 143 microns on average (P=5.6×10(-15)); between the 3rd and 6th month, this was slower, with an average decrease of 4.6 microns, and between the 6th and the 12th month, the difference was significant, with an average decrease of 36 microns (P=0.003). The number of injections over one year was 5.7 on average. CONCLUSION: The efficacy of aflibercept with a PRN protocol provides interesting results, with an improvement in visual acuity and central retinal thickness in all treated groups, and with fewer injections than advocated.

[Secondary opacification of hydrophilic acrylic intraocular lenses: report of two cases]. / Opacification secondaire d'implants intraoculaires acryliques hydrophiles : à propos de deux cas.

PURPOSE: To describe two cases of secondary opacification of hydrophilic acrylic IOLs after vitreoretinal surgery. METHODS: Analysis of IOL deposits with anterior segment optical coherence tomography (OCT Visante(®)) and high-frequency ultrasound biomicroscopy (CineScan HF, Quantel Medical(®)) was carried out preoperatively. The explanted IOLs were analyzed with optical and electron microscopy, and energy dispersive spectrometry (EDS). RESULTS: In both patients, the deposits were located on the surface and within the implant and were composed of calcium phosphate crystals. Vitreoretinal surgery performed a few months prior to the secondary opacification was identified as a risk factor. CONCLUSION: When a patient presents with a secondary opacification of the IOL involving the visual axis, explantation is sometimes necessary, fortunately with typically good functional recovery in the postoperative period. While this complication is rare and the exact pathophysiology poorly understood, it must be considered in a pseudophakic patient with an unexplained decrease in visual acuity who has undergone more than one intraocular procedure.

[Role of intravitreal bevacizumab for resistant macular edema due to central retinal vein occlusion after failure of intravitreal triamcinolone acetonide]. / Intérêt du bevacizumab dans le traitement des occlusions de la veine centrale de la rétine après échec de la triamcinolone.

PURPOSE: To evaluate the efficacy of bevacizumab injection used secondarily in patients with macular edema due to central retinal vein occlusion after failure of intravitreal triamcinolone acetonide injection. PATIENTS AND METHODS: The present study represents a retrospective review of eight patients presenting with central retinal vein occlusion complicated by macular edema with central foveolar thickness greater than 350 µm by Cirrus-OCT, Zeiss. Between 4 and 6 months after the central vein occlusion, all patients initially underwent intravitreal triamcinolone acetonide injection (4 mg/0.1 ml). In the case of functional or anatomic failure, three monthly bevacizumab injections (1.25mg/0.05 ml) were administered. Prior to each injection, an ophthalmic examination was performed, documenting visual acuity (ETDRS), biomicroscopy, IOP and central foveolar thickness (OCT 3). RESULTS: After three intravitreal bevacizumab injections, we found no improvement in visual acuity (M0 = 45.56 ± 13 letters; M3 = 44.2 ± 8.6 letters), and no decrease in macular thickness (M0 = 559 µm ± 193; M3 = 543 µm ± 263). No intraocular pressure spikes or endophthalmitis were observed. DISCUSSION: The lack of anatomic and functional efficacy observed in our study does not appear to be related to the method, dosage or timing of injection, nor to the presence of subretinal macroaneurysms. It may be due to a cross-resistance to these two drugs. In any event, recent approval of ranibizumab and intraocular dexamethasone implants will likely change our therapeutic approach. CONCLUSION: In case of recalcitrant macular edema secondary to central vein occlusion after failed intravitreal triamcinolone acetonide injection, secondary intravitreal bevacizumab does not appear beneficial.

[Keratoplasty combined with cataract surgery]. / L'intervention combinée greffe-cataracte.

Corneal pathologies leading to keratoplasty are often associated with cataract and combined surgery is therefore mandatory. Triple procedure with penetrating keratoplasty and concurrent cataract extraction followed by intra ocular lens (IOL) implantation is usually the preferential choice because visual rehabilitation is theoretically more rapid. Surgeons have to be aware of surgical conditions during open-sky surgery because vitreous pressure is not counterbalanced by anterior chamber pressure. Today, many surgeons prefer non-simultaneous procedures with cataract surgery performed months after grafting because of the improvement in spherical refractive error. More recently, new triple procedures, Descemet's stripping automated keratoplasty and concurrent cataract surgery have gained popularity, especially in patients with Fuchs dystrophy associated with cataract. Surgery starts with phacoemulsification, followed by endothelium exchange through a 3 to 5 mm incision. Advantages against classic triple procedure are quick visual rehabilitation, fewer induced refractive errors, minimal postoperative discomfort and corneal integrity. Surgeons have to consider an eventual postoperative hyperopic shift secondary to corneal lenticule shape when choosing adequate intraocular lens.

[Subconjunctival bevacizumab for corneal neovascularization]. / Injections sous-conjonctivales de bévacizumab dans le traitement de la néovascularisation cornéenne.

PURPOSE: To assess efficacy and safety of subconjunctival bevacizumab in corneal neovascularization treatment. METHODS: The study was a prospective case series that included patients treated with subconjunctival bevacizumab injections for corneal neovascularization over a period of four months. A dose of 2.5 mg (0.1 mL) of bevacizumab (25 mg/mL) was injected into the subconjunctival area 1-2mm behind the limbus near the corneal neovascularization. The main outcome measures were visual acuity, corneal neovascularization, as well as local and general side effects. RESULTS: Thirteen eyes of 12 patients were included. The mean patient age was 44.2 years (range, 18-87 years). Patients received from two to four bevacizumab injections. The mean corneal neovascularization area decreased from 41.1 to 33.7 % at day 45 (p=0.0003) and to 33.9 % at day 120 (p=0.0013). Median visual acuity changed from 1.32 to 1.28 LogMAR on day 45 and to 1.25 LogMAR on day 120. Subconjunctival bevacizumab was well tolerated without general side effects. There was no significant change in intraocular pressure. An epithelial defect was described in three patients after initiation of bevacizumab therapy. CONCLUSIONS: Subconjunctival bevacizumab injections were effective and safe in reducing corneal neovascularization within the first four months. Meanwhile, improving vision may provide additional strategies.

[Stroke and iridodonesis revealing a homocystinuria caused by a compound heterozygous mutation of cystathionine beta-synthase]. / Infarctus cérébral et iridodonésis révélant une homocystinurie par mutation hétérozygote composite de la cystathionine bêta-synthase.

Iridodonesis or tremulous iris is a clinical sign of ectopia lentis which is frequently associated with homocystinuria. We present a forty-two-year-old woman victim of a left middle cerebral artery ischemic stroke. The clinical examination found bilateral iridodonesis and laboratory tests showed an increased level of serum homocysteine and homocystinuria. Homocystinuria was caused by a compound heterozygous I278T and D444N mutation of cystathionine beta-synthase (CBS) gene and also a C667T heterozygous polymorphism of methylene-tetrahydrofolate-reductase gene. This case was atypical because of the incomplete phenotype, development of complications in adulthood and the association of a rare compound heterozygous mutation of the CBS gene.

Results of surgery on macular holes that develop after rhegmatogenous retinal detachment.

AIMS: To evaluate the characterics and surgical prognosis of macular holes that develop after rhegmatogenous retinal detachment repair. DESIGN: Retrospective, interventional, consecutive case series. METHODS: The case records of nine patients who developed a new full-thickness macular hole after prior RD repair were reviewed over 6 years. Optical coherence tomography (OCT) confirmed these holes. They were offered surgical repair with a median follow-up of 13.3 months (1-63 months). Main outcomes included preoperative vitreo-macular status, OCT evaluation and postoperative visual acuity. RESULTS: 1007 eyes underwent surgery for prior retinal detachment between August 1999 and September 2005. Nine eyes developed a full-thickness macular hole (prevalence 0.9%): five developed after scleral buckling surgery, one after pneumatic retinopexy and three after primary vitrectomy. The mean time to macular hole diagnosis after RD was 2.9 months (0.5-18). All patients underwent macular hole surgery by the same surgeon. At 1 month, macular hole repair was noticed in eight eyes. In this group, visual acuity at a median of 11.9 months of follow-up was 20/125 (20/400 - 20/63). Three eyes had an improvement of more than three Snellen lines. CONCLUSIONS: Macular holes developing after RD repair is a rare complication (less than 1%). Its physiopathological mechanisms are not well known. Conventional macular hole surgery including pars plana vitrectomy, inconstant internal limiting membrane delamination and long-acting gas tamponade seems to achieve to macular reattachment (89%). The visual outcome seems conditioned by the macular status noticed during the RD.

[Surgical results of retinal detachment with unseen retinal breaks]. / Résultats chirurgicaux des décollements de rétine sans déhiscence visible.

BACKGROUND: The treatment of retinal detachment (RD) with unseen breaks has not been clearly defined. The aim of this study was to evaluate surgical results of these RDs using two different techniques. PATIENTS AND METHODS: We conducted a retrospective study including consecutively operated RDs in our department between 2001 and 2006. Twenty-two RDs were identified. In eight eyes (36.4%), conventional scleral buckling was performed (with or without subretinal fluid drainage). In 14 eyes (63.6%), vitrectomy associated with cryopexy or endolaser impact was performed. Circumferential buckling was achieved in ten cases. RESULTS: These operated patients account for 2.5% of the RDs followed up in our department between January 2001 and June 2006 (887 patients). The eyes were predominantly pseudophakic (86.4%), with inferior RD (59.1%). The patients had described functional signs for a mean of 56 days (2-240 days). Sixteen eyes (73%) were reattached after the primary procedure. The primary reattachment rates at 1 month were 37.5% in the scleral buckling group versus 86.4% in the vitrectomized group. The final retinal reattachment rate was 86.4%. CONCLUSIONS: In our study, the situation where breaks are unseen during retinal detachment surgery is uncommon (2.5%), occurring most often with inferior retinal detachment in pseudophakic eyes. This seems to indicate better retina reattachment after vitrectomy associated with a circumferential buckling in first intention. However, a study including a larger number of patients would be necessary to confirm our results.

Systolodiastolic variations of blood flow during central retinal vein occlusion: exploration by dynamic angiography.

BACKGROUND/AIM: In patients with acute central retinal vein occlusion (CRVO), dynamic angiography may reveal the presence of pulsatile flow (termed here pulsatile venular outflow, PVO) within first order veins (that is, the large veins). The main goal of this study was to investigate the mechanism underlying PVO. METHODS: 10 patients with CRVO and PVO were included. Quantitative and qualitative analysis of venous flow on dynamic angiograms allowed the correlation, temporally, of second and first order vein flow on the one hand, and venous flow and systolic cycle on the other. RESULTS: Analysis of the time-velocity curve showed that (1) the onset of arterial systole preceded the onset of PVO by less than 0.08 seconds (n = 5); (2) PVO onset was simultaneous to the time of onset of minimal flow (Vmin) in first order veins (n = 10); (3) the time of onset of maximal flow (Vmax) in first order veins occurred 0.20-0.44 seconds after the onset of PVO (n = 6). CONCLUSIONS: During CRVO with severe reduction in blood flow, the presence of PVO is the result of the existence of a distinct haemodynamic regimen in first and second order veins. These data support the hypothesis that second order veins flow is synchronous with the arterial flow, while the delayed peak flow in first order veins may reflect the consequences of the delayed IOP curve and/or of intermittent venous compression.

[Comparison of two surgical techniques for the treatment of superior oblique palsy]. / Comparaison de deux techniques chirurgicales dans le traitement de la paralysie du muscle oblique supérieur.

AIM: To compare two surgical techniques for the treatment of superior oblique palsy. PATIENTS AND METHODS: Retrospective study involving 32 patients operated on at the Rouen Teaching Hospital for superior oblique palsy. Group 1 patients were treated by surgical reinforcement of the superior oblique muscle and group 2 patients were treated by surgical loosening (or weakening) of the antagonist muscles. One-year follow-up explored head tilt, diplopia, vertical deviation and cyclotorsion. RESULTS: Functional results (presence of diplopia or stiff neck) were positive in both groups but better in group 1. Only 12.5% of patients required a second operation. Cyclotorsion amounted to less than 2% in group 1 and was still greater than 8% in group 2; on the other hand, vertical deviation had improved more in group 2, where it decreased to 2.1 diopters versus 3.1 in group 1. DISCUSSION: and conclusion: Only reinforcing the superior oblique adequately corrects cyclotorsion, which is the main cause of asthenopia and diplopia, despite an often insufficient height correction that is otherwise clinically well tolerated. We suggest reinforcing the superior oblique as a first intent rather than weakening hyperactive muscles, and in case of excessive postoperative height, we would carry out additional treatment of one of the hyperactive muscles later.

Comparison after 10 years of two 100-patient cohorts operated on for eviscerations or enucleations.

PURPOSE: To compare the indications, surgical techniques, and operative outcome between two 100-patient populations operated on for evisceration or enucleation with a 10-year interval. METHODS: This retrospective study involved 100 patients operated on between 1987 and 1990 (Group 1) compared with another 100 patients operated on between 1996 and 2000 (Group 2). Group 1 included 64 males and 36 females, mean age 49 years; Group 2 included 60 males and 40 females, mean age 53. RESULTS: In Group 1, 19 eviscerations were performed, versus 55 in Group 2. In both groups, half of the indications for surgery were a painful blind eye. In Group 1, endophthalmia (23%) came second, whereas it was trauma (15%) in Group 2. Sixty-eight patients were implanted in Group 1 (silicone spheres 69%) versus 86 in Group 2 (hydroxyapatite spheres 69%). Twenty spheres (20%) were rejected in Group 1 versus 7% in Group 2. DISCUSSION AND CONCLUSIONS: The proportion of eviscerations increased in 10 years. The number of endophthalmitis-related operations decreased and trauma-related operations increased. The number of implantations increased with hydroxyapatite as the first choice material instead of silicone. This most likely contributed to reducing the number of rejections.