Franck Fajnkuchen

Results of one-year's treatment with ranibizumab for exudative age-related macular degeneration in a clinical setting.

PURPOSE To evaluate the results of 1 year of treatment with intravitreal ranibizumab for exudative age-related macular degeneration (AMD) in a clinical setting. DESIGN Nonrandomized, single-center, retrospective, interventional case series. METHODS Retrospective analysis of consecutive charts and angiograms of patients with previously untreated exudative AMD, treated in one or both eyes with ranibizumab between January 2 and October 31, 2007. The following were recorded for each patient: age at presentation, gender, treated eye, type of choroidal neovascularization, visual acuity (VA) measured on an Early Treatment Diabetic Retinopathy Study chart at baseline and at 52 +/- 6 weeks, the number of performed intravitreal (IVT) injections, and follow-up examinations. RESULTS The 122 patients comprised 85 women (70%) and 37 men ranging in age from 56 to 91 years (mean +/- standard deviation, 78.3 +/- 7). In all, 124 eyes were treated on a pro re nata basis after 1 or 3 initial IVT injections. The mean number of IVT injections was 3.79 +/- 1.39 (range, 1 to 7). The mean number of follow-up visits was 8.07 +/- 1.44 (range, 4 to 12). Mean VA +/- standard deviation changed from 56.15 +/- 14 to 56.89 +/- 17 letters (VA gain, +0.7 letters). CONCLUSIONS The results showed that VA stabilized rather than improved and compared unfavorably with the gains found in randomized clinical trials and the Prospective Optical Coherence Tomography Imaging of Patients with Neovascular AMD Treated with intraOcular Ranibizumab (PrONTO) Study. However in this study, patients were examined less frequently and were treated far less frequently. The present results suggest that a long, regular follow-up is necessary for patients treated with ranibizumab to obtain and preserve significant visual gain, and not only to achieve visual stabilization.

Endophthalmitis After Intravitreal Injections: Incidence, Presentation, Management, and Visual Outcome

PURPOSE To report the incidence and characteristics of endophthalmitis after intravitreal injections of anti-vascular endothelial growth factor agents or corticosteroids and to describe the clinical and bacteriologic characteristics, management, and outcome of these eyes with acute endophthalmitis in France. DESIGN Retrospective, nationwide multicenter case series. METHODS From January 2, 2008 to June 30, 2013, a total of 316,576 intravitreal injections from 25 French ophthalmic centers were included. For each center, the number of intravitreal injections was determined using billing codes and the injection protocol was recorded. A registry and hospital records were reviewed to identify patients treated for endophthalmitis after injection during the same time period. The main outcome measures were the incidence of clinical endophthalmitis and visual acuity of endophthalmitis cases. RESULTS During the study period, 65 cases of presumed endophthalmitis were found, giving an overall incidence of 0.021% (2.1 in 10,000 injections) (95% confidence interval [CI], 0.016%-0.026%). The median number of days from injection to presentation was 4 [1-26] days. The most common symptom was vision loss. Bacterial identification was achieved in 43.4%. The most frequent pathogens were gram-positive bacteria (91.3%), including coagulase-negative Staphylococcus in 78.3%. Neither the interval between injection and presentation for endophthalmitis nor the clinical signs differentiated culture-positive from culture-negative cases. In multivariate analysis, the use of a disposable conjunctival mould assist device and the use of prophylaxis with an antibiotic or antiseptic were significantly associated with an increased incidence of endophthalmitis (P = .001). The majority of patients had worse visual acuity after 3 months of follow-up when compared with acuity before endophthalmitis. CONCLUSIONS The incidence of presumed endophthalmitis after intravitreal injections of anti-vascular endothelial growth factors or corticosteroids was low and the prognosis poor. Prevention and management remain challenging. It remains to be determined whether the findings of this study are relevant for other countries using different techniques for intravitreal injections.

Syndrome pseudoexfoliatif et phakoexerèse : étude comparative à une population témoin

PURPOSE To determine the outcomes in cataract surgery by phacoemulsification in eyes with pseudoexfoliation syndrome (PEX) compared with eyes without this syndrome and to analyze the clinical features of pseudoexfoliation syndrome. PATIENTS AND METHODS A retrospective, single-center comparative study was conducted on patients who underwent cataract surgery between January 2006 and December 2008. Demographic parameters (age, sex, ethnicity, medical and ophthalmologic history), clinical features (visual acuity, pupil dilatation, intraocular pressure) before and after surgery, and surgery complications were analyzed and compared to a control group without PEX. RESULTS One hundred and four eyes of 81 patients were included in the study. The eyes were divided into two groups: 52 eyes with pseudoexfoliation syndrome (PEX) and 52 eyes without pseudoexfoliation (control group). The rate of surgical complications was not statistically different between the pseudoexfoliation and control groups. The mean preoperative and postoperative visual acuity were not statistically different between the two groups. The mean postoperative visual acuity was LogMAR 0,06 + or - 0,2 in the pseudoexfoliation group and LogMAR 0,03 + or - 0,06 in the control group. The mean follow-up was 1,4 + or - 1,3 months in the pseudoexfoliation group and 1 month in the control group. Pseudoexfoliation was bilateral in 72 % of cases. Open-angle glaucoma or ocular hypertension was associated in 21 cases (40 %) in the pseudoexfoliation group versus no open-angle glaucoma and five cases of ocular hypertension in the control group (10 %). Poor pupil dilatation was observed in 25 cases (48 %) in the pseudoexfoliation group and in two cases (4 %) in the control group. Phacoemulsification with IOL was the surgical technique in all the cases, with only one case of anterior chamber IOL in the pseudoexfoliation group. DISCUSSION Cataract surgery in PEX is known to be associated with more complications during surgery. Poor pupil dilatation is one of the most common problems in cataract surgery in eyes with PEX. Nevertheless, the cataract surgery in eyes with PEX syndrome is not associated with a higher rate of surgical complications in our study. However, PEX required optimized surgery. Pseudoexfoliation syndrome is most common in its bilateral presentation. It is associated with chronic secondary open-angle glaucoma. The best visual acuity after surgery was similar in the two groups, but PEX required more time to attain this maximal visual acuity. Coronary heart disease could occur more frequently in patients with PEX compared with subjects without PEX. CONCLUSION Pseudoexfoliation syndrome did not confer a statistically higher risk for surgical complications in eyes without marked phacodonesis or lens subluxation. Pseudoexfoliation syndrome did confer a higher risk for glaucoma and coronary ischemia.

Le syndrome de pseudo-exfoliation capsulaire dans la chirurgie de la cataracte. Étude rétrospective de 37 cas

Pseudoexfoliation syndrome in cataract surgery. Retrospective study of 37 cases M. Streho, C. Rohart, B. Guigui, F. Fajnkuchen, G. Chaine Purpose: To analyze the clinical features of pseudoexfoliation syndrome and to determine complications in cataract surgery in eyes with pseudoexfoliation syndrome compared with eyes without this syndrome. Methods: A retrospective, single-center comparative study was conducted on patients who underwent cataract surgery between 2004 and 2006. Demographic parameters (age, sex, ethnicity, medical and ophthalmologic history), clinical features (visual acuity, pupil dilatation, intraocular pressure) before and after surgery, and surgical complications were analyzed and compared to a control group without pseudoexfoliation. Results: Seventy-four eyes of 71 patients were included in the study. The sex ratio of the pseudoexfoliation group was 1.26 with 19 males (56%) and 15 females (44%). Pseudoexfoliation was unilateral in 21 cases (61%). Open-angle glaucoma was associated in 11 cases (32%) in the pseudoexfoliation group versus two cases in the control group (5.4%). Poor pupil dilatation was observed in eight cases (24%) in the pseudoexfoliation group and in one case (2.7%) in the control group. Phacoemulsification with IOL was the surgical technique in all the cases with only one case (2.7%) of anterior chamber IOL in the pseudoexfoliation group. There was no significant difference in the surgical complications between the pseudoexfoliation and control group (5.4%). The mean preoperative intraocular pressure was 16±5 mmHg in the pseudoexfoliation group and 14±3 mmHg in the control group. The mean postoperative intraocular pressure at 1 month was 14±4 mmHg in the pseudoexfoliation group and 14±3 in the control group. The mean preoperative visual acuity was 1.0±0.7 LogMar in the pseudoexfoliation group and 0.7±0.5 LogMar in the control group. The mean postoperative visual acuity was 0.4±0.6 LogMar in the pseudoexfoliation group and 0.2±0.1 LogMar in the control group. The mean follow-up was 70 days in the pseudoexfoliation group and 30 days in the control group. Conclusion: Pseudoexfoliation syndrome is the most common in its unilateral presentation. It is frequently associated with chronic secondary open-angle glaucoma. Poor pupil dilatation is one of the most common problems faced by cataract surgeons. Nevertheless, pseudoexfoliation syndrome did not confer a statistically higher risk for surgical complication in eyes without marked phacodonesis or lens subluxation.

Atteintes ophtalmologiques de la sarcoïdose et des « sarcoid-like reaction » dans les déficits immunitaires. À propos de 4 cas

Ophthalmologic disease in sarcoid-like granulomatosis and true sarcoidosis in immunodeficiency. Four case reports C. Rohart, I. Badelon, F. Fajnkuchen, S. Nghiem-Buffet, G. Chaine Granulomatosis lesions occurring after diagnosis of primary or secondary immunodeficiency are not accidental and have been described in a small number of patients suffering from various diseases: common variable immunodeficiency (CVID), malignancy (lymphoma and solid tumors), and acquired immunodeficiency syndrome (AIDS). Two types of granulomatosis can appear: true sarcoidosis and sarcoid-like reaction. We report four patients, two with CVID and two with malignancy, in whom clinical granulomatosis appeared a few months to a few years after diagnosis of immunodeficiency. They developed noncaseating granulomas of the lung, spleen and liver associated with conjunctival granulomas and bilateral panuveitis. The granulomatous disorder was diagnosed after immunodeficiency on histopathological studies revealing noncaseating granulomas. Causation agents such as infectious organisms and environmental compounds were excluded. The relationship between sarcoid-like reaction, true sarcoidosis and immunodeficiency is discussed. The underlying pathophysiology responsible for the association between granuloma formation and immunodeficiency in the same patient remains obscure. It may be quite difficult to distinguish true sarcoidosis and sarcoid-like reaction. It is possible that these two entities are the clinical extremes of a common pathological process.

Functional and Anatomical Outcomes in Patients With Serous Retinal Detachment in Diabetic Macular Edema Treated With Ranibizumab

Purpose To assess the effect of serous retinal detachment (SRD) on functional and anatomical outcomes in ranibizumab-treated patients with diabetic macular edema (DME). Methods All consecutive ranibizumab-treated patients with SRD were included in this retrospective study. For each patient with SRD, a patient without SRD with the same baseline best-corrected visual acuity (BCVA) was randomly included for adjustment on their baseline BCVA. All patients with SRD were included in group 1 (G1) and those without SRD in G2. The primary endpoint was the mean change in BCVA between baseline and month 12 (M12). Secondary endpoints were the mean change in central retinal thickness (CRT) between baseline and M12, injection number, and proportion of patients who gained/lost ≥15 letters. Results Seventy-eight eyes were included, 39 in each group. Baseline BCVA was similar in both groups (45.2 and 45.3 letters). Mean change in BCVA between baseline and M12 was not statistically different: 11 ± 12 letters in G1 and 12 ± 13 letters in G2 (P = 0.78). Baseline CRT was 650 ± 130 μm in G1 and 480 ± 79 μm in G2. Mean change in CRT was -235 ± 170 μm in G1 and -130 ± 96 μm in G2 (P = 0.013). Patients received 5.2 and 5.5 injections in G1 and G2 (P = 0.46). In group 1, 38.5% and 2.6% of patients respectively gained and lost ≥15 letters versus 41% (P = 0.1) and 5.1% (P = 0.1) in G2. Conclusions Similar BCVA gains were observed regardless of the presence of SRD. The higher visual gain usually observed in DME with SRD could be associated with a lower baseline BCVA.

Communication de la SFOSyndrome pseudoexfoliatif et phakoexerèse : étude comparative à une population témoinPseudoexfoliation syndrome and phacoemulsification: Comparative study with a control population☆

PURPOSE To determine the outcomes in cataract surgery by phacoemulsification in eyes with pseudoexfoliation syndrome (PEX) compared with eyes without this syndrome and to analyze the clinical features of pseudoexfoliation syndrome. PATIENTS AND METHODS A retrospective, single-center comparative study was conducted on patients who underwent cataract surgery between January 2006 and December 2008. Demographic parameters (age, sex, ethnicity, medical and ophthalmologic history), clinical features (visual acuity, pupil dilatation, intraocular pressure) before and after surgery, and surgery complications were analyzed and compared to a control group without PEX. RESULTS One hundred and four eyes of 81 patients were included in the study. The eyes were divided into two groups: 52 eyes with pseudoexfoliation syndrome (PEX) and 52 eyes without pseudoexfoliation (control group). The rate of surgical complications was not statistically different between the pseudoexfoliation and control groups. The mean preoperative and postoperative visual acuity were not statistically different between the two groups. The mean postoperative visual acuity was LogMAR 0,06 + or - 0,2 in the pseudoexfoliation group and LogMAR 0,03 + or - 0,06 in the control group. The mean follow-up was 1,4 + or - 1,3 months in the pseudoexfoliation group and 1 month in the control group. Pseudoexfoliation was bilateral in 72 % of cases. Open-angle glaucoma or ocular hypertension was associated in 21 cases (40 %) in the pseudoexfoliation group versus no open-angle glaucoma and five cases of ocular hypertension in the control group (10 %). Poor pupil dilatation was observed in 25 cases (48 %) in the pseudoexfoliation group and in two cases (4 %) in the control group. Phacoemulsification with IOL was the surgical technique in all the cases, with only one case of anterior chamber IOL in the pseudoexfoliation group. DISCUSSION Cataract surgery in PEX is known to be associated with more complications during surgery. Poor pupil dilatation is one of the most common problems in cataract surgery in eyes with PEX. Nevertheless, the cataract surgery in eyes with PEX syndrome is not associated with a higher rate of surgical complications in our study. However, PEX required optimized surgery. Pseudoexfoliation syndrome is most common in its bilateral presentation. It is associated with chronic secondary open-angle glaucoma. The best visual acuity after surgery was similar in the two groups, but PEX required more time to attain this maximal visual acuity. Coronary heart disease could occur more frequently in patients with PEX compared with subjects without PEX. CONCLUSION Pseudoexfoliation syndrome did not confer a statistically higher risk for surgical complications in eyes without marked phacodonesis or lens subluxation. Pseudoexfoliation syndrome did confer a higher risk for glaucoma and coronary ischemia.

Outcomes after a 1-Year Treatment with Ranibizumab for Diabetic Macular Edema in a Clinical Setting

Purpose: The aim of this study was to assess the efficacy and safety of ranibizumab in patients with diabetic macular edema (DME). Methods: We conducted a retrospective analysis of consecutive patients with vision loss due to DME who were treated with ranibizumab. All patients received a loading dose of 3 monthly injections followed by re-treatments on an as-needed basis. The primary endpoint was the change in best-corrected visual acuity (BCVA) at 12 months. Secondary endpoints were the change in central retinal thickness (CRT) and the number of intravitreal injections (IVI) at 12 months. Results: One hundred and six eyes of 78 patients were included. BCVA changed from 48.3 (20/100) letters at baseline to 59.0 letters (20/63) at 12 months (p < 0.0001; mean gain: +10.7 letters), and 38% of the patients had a final BCVA >70 letters. CRT decreased from 519 µm at baseline to 355 µm at 12 months (p < 0.0001). The threshold of the first quartile of the baseline VA was 40 letters. Patients with a baseline VA >40 letters had a higher final VA of 66 ± 14 letters (20/50) versus 43 ± 18 letters (20/125) for patients with a baseline VA ≤40 letters (p < 0.0001). A mean number of 5.4 (3-10) IVI were administered. Conclusion: This study conducted in a clinical setting confirms the results of previous randomized trials. The final BCVA was mainly influenced by the baseline BCVA, which supports the utility of early DME treatment before patients experience a severe vision loss.

Intravitreal Ranibizumab and/or Dexamethasone Implant for Macular Edema Secondary to Retinal Vein Occlusion

Purpose: To investigate the outcome of intravitreal ranibizumab and/or dexamethasone implant treatment for treatment of macular edema (ME) secondary to central or branch retinal vein occlusion (CRVO or BRVO) in a clinical setting. Methods: Retrospective analysis of consecutive patients followed for at least 6 months. Data recorded included the type of occlusion, initial and final visual acuity, and number of injections. Results: Sixty-five patients were included, 26 had CRVO and 39 BRVO. Mean (±SD) follow-up duration was 16 (±7.7) months. Twenty-four (36.9%) patients received ranibizumab in monotherapy, 19 patients (29.3%) dexamethasone in monotherapy, and 22 patients (33.8%) received successively both treatments. In dexamethasone-treated patients, mean (±SD) visual acuity gain was 5.8 ± 10.7 letters for BRVO and 16.8 ± 15.6 letters for CRVO. In ranibizumab-treated patients, mean (±SD) visual acuity gain was 9.2 ± 10 letters for BRVO and 18.2 ± 20.5 letters for CRVO. Conclusion: Both intravitreal ranibizumab and dexamethasone intravitreal implant could be used as first-line therapy for patients with ME secondary to retinal vein occlusion.

Mesure par OCT de l’impact d’une capsulotomie au laser Nd:YAG sur l’épaisseur maculaire

INTRODUCTION Posterior capsular opacification is the commonest complication of cataract surgery. It is treated with Nd:YAG laser capsulotomy. However, after treatment, cases of cystoid macular edema have been reported. The purpose of this study was to measure the foveal thickness change after Nd:YAG capsulotomy using optical coherence tomography (OCT) in order to clarify the physiopathology of this edema. PATIENTS AND METHODS A prospective, single-center study was conducted on patients who underwent Nd:YAG laser capsulotomy between May 2008 and November 2009. All patients received the same drug protocol after Nd:YAG capsulotomy (acetazolamide, apraclonidine, and rimexolone). Demographic parameters (age, sex, and medical history), clinical features (visual acuity, intraocular pressure) before and after Nd:YAG laser, and laser complications were analyzed. Central foveal thickness was measured by OCT (Stratus OCT 3, Zeiss). Data were collected before Nd:YAG laser capsulotomy and 1 week, 1 month, and 3 months after capsulotomy. The preoperative and postoperative thicknesses were compared. We used a Student t-test for statistical analysis. RESULTS Thirty eyes of 26 patients were analyzed. The mean foveal thickness was 209 ± 26 μm before capsulotomy, 213 ± 23 μm, 204 ± 19 μm, 213 ± 23 μm 1 week, 1 month, and 3 months, respectively, after capsulotomy. The foveal thickness did not significantly change during the first 3 months following laser treatment. No complications occurred. DISCUSSION AND CONCLUSION Macular cystoid edema was a classical complication after Nd:YAG capsulotomy. However, there was no significant increase of macular thickness shortly after Nd:YAG capsulotomy in our study.