Vincent Gualino

Retinal pigment epitheliopathy, macular telangiectasis, and intraretinal crystal deposits in HIV-positive patients receiving ritonavir.

Purpose: The purpose of this study was to describe the occurrence of a retinal pigment epitheliopathy associated with macular telangiectasis and intraretinal crystal deposits in three human immunodeficiency virus-positive patients receiving long-term ritonavir as part of highly active antiretroviral therapy. Methods: The patients records were reviewed. Results: The CD4 T-cell counts at presentation were 163 cells per microliter, 464 cells per microliter, and 349 cells per microliter, and viral loads were undetectable in all patients. None of the patients had a concurrent AIDS-defining illness. Other significant medical history included hyperlipidemia in one patient and a remote history of lymphoma and tuberculosis in a second patient. Initial visual acuity ranged from 20/32 to 20/400, with a median of 20/150. Anterior segment examination and intraocular pressures were normal in all eyes. Posterior segment examination revealed bilateral macular retinal pigment epitheliopathy with intraretinal crystalline deposits. No hemorrhage or cotton wool spots were seen consistent with human immunodeficiency virus retinopathy, and there was no evidence of previous or active cystomegalovirus retinitis. Fluorescein angiography revealed parafoveal telangiectasis with late leakage in two of the three patients. Optical coherence tomography showed thickening of the macula in three eyes and inner foveal cysts in two eyes. Autofluorescence performed on one patient revealed complete loss of normal retinal pigment epithelium autofluorescence corresponding to the area of retinal pigment epitheliopathy bilaterally. The only medicine common to all 3 patients was ritonavir, and the duration of ritonavir therapy before presentation was 19 months in one patient, 30 months in the second patient, and 5 years in the third patient. Conclusion: Retinal changes characterized by retinal pigment epitheliopathy, parafoveal telangiectasias, and intraretinal crystal deposits occurred in three human immunodeficiency virus-positive patients on long-term ritonavir as part of highly active antiretroviral therapy.

LONG-TERM EVOLUTION OF DOME-SHAPED MACULA: Increased Macular Bulge is Associated With Extended Macular Atrophy.

Purpose: Dome-shaped macula (DSM) may cause impaired vision. This study analyzed the long-term evolution of DSM, most particularly macular changes: serous retinal detachment, retinal pigment epithelium atrophy, and DSM bulge increase. Methods: Twenty-nine eyes presenting with DSM were retrospectively studied. Clinical data, color photographs, fluorescein angiographs, and optical coherence tomography examinations were reviewed. Patients were followed up from 6 months to 111 months (mean, 37.89 months). The height of the macular bulge, the size of retinal pigment epithelium macular atrophy, and serous retinal detachment progression were studied. Other macular changes were noted. Results: Mean vision remained stable. Dome-shaped macula height increased significantly from 338.9 &mgr;m to 364.3 &mgr;m (P = 0.007). Serous retinal detachment was present initially in 15 of 29 eyes; it increased in 4 cases and resolved spontaneously in 7. Macular retinal pigment epithelium atrophy correlated with the bulge height (P = 0.015), and it enlarged during follow-up (1.12 vs. 1.34, P = 0.04). Other macular anomalies were present initially or appeared during follow-up: macular pucker, choroidal neovascularization (CNV), subretinal pigmentary clumps, and flat irregular pigmented epithelium detachment. A few treatments were proven in serous retinal detachment cases but were ineffective in restoring vision. Conclusion: In DSM, vision may be stable for years while macular changes progress: the macular bulge increases as does retinal pigment epithelium atrophy.

Macular Choroidal Thickness in Myopic Eyes with and without a Dome-Shaped Macula: A Case-Control Study

Background and Objective: Dome-shaped macula (DSM) has recently been described with myopic staphyloma, which may cause decreased vision. The purpose of this study was to evaluate the choroidal thickness of eyes with and eyes without DSM. Methods: A total of 26 eyes with DSM were paired based on axial length with 26 eyes without DSM. All patients underwent spectral-domain OCT examination using the 7-line EDI (enhanced depth imaging) protocol. The mean choroidal thickness was measured using Early Treatment Diabetic Retinopathy Study (ETDRS) grid areas. Results: Both nasal choroidal thickness and temporal choroidal thickness were significantly thinner in the DSM group (120.43 vs. 159.46 µm, p = 0.035, and 142.17 vs. 187.23 µm, p = 0.021, respectively). However, the mean central choroidal thickness did not differ (152.61 vs. 175.96 µm, p = 0.20). The ratio between central and peripheral choroidal thickness was very significantly elevated with DSM (1.18 ± 0.12 vs. 0.99 ± 0.09, p < 0.0001). Conclusion: Choroidal thickness decreases at the periphery but not in the macular area with DSM. DSM seems not to be due to an inward protrusion of the globe but due to macular anatomical preservation in a growing staphyloma.

Understanding the determinants of myopic choroidal neovascularization and response to treatment.

Purpose The pathophysiologic pathways that govern the development of choroidal neovascularization (CNV) are complex. Patchy atrophy and lacquer cracks are known to be major anatomic risk factors for the development of myopic CNV, but they are not alone and much remains to be understood about other factors that influence development. In addition, a greater understanding of the modifiable and nonmodifiable factors that influence outcome, resolution, and recurrence after intravitreal injection of anti-vascular endothelial growth factor (VEGF) could lead to more personalized treatment algorithms that integrate parameters other than the presence of CNV itself and could help improve clinical outcomes and reduce recurrence. Methods We reviewed recently published data on risk factors for CNV and predictors of response to anti-VEGF treatments. In particular, data pertaining to age, sex, genetic predisposition, baseline visual acuity, axial length, staphyloma, lacquer cracks, atrophic lesions, choroidal thickness or choroidal thinning, characteristics of CNV such as duration, localization, and size of CNV, and treatment considerations such as choice of treatment, loading doses, and combination treatments were reviewed. Results Our analysis showed that the body of evidence is incomplete. Conclusions Additional studies are required to identify high-risk patients and to develop personalized therapeutic approaches.

Epiretinal Membrane in Dome-Shaped Macula Complicated with Serous Retinal Detachment: Transient Efficacy of Surgery

Dome-shaped macula (DSM) is an entity recently described as a convex anterior protrusion of the macular area within a posterior myopic staphyloma. Specific complications were associated with DSM, like serous retinal detachment (SRD). We describe a woman presenting with a decreased vision at 20/50. SD-OCT scans were performed, showing a macular bulge. SRD was present and an epiretinal membrane could also be observed. Fluorescein angiography and indocyanin green angiography did not show any leakage nor choroidal neovascularization. Epiretinal membrane peeling was performed, and 3 months after surgery, SRD completely disappeared. However, SRD reappeared 1 year after surgery and enlarged within 2 years following surgery. In conclusion, two mechanisms could be considered for physiopathology of SRD: first, the epiretinal membrane may have exerted traction on the macular retina, second, vitreous body might constitute a tank for cytokines and/or other factors, triggering subretinal fluid accumulation, leading to SRD.

457 Ostéome choroïdien bilatéral avec néo vaisseaux choroïdiens traités par Bevacizumab

Introduction Nous rapportons le cas d’un patient de 17 ans d’origine antillaise presentant un osteome choroidien bilateral decouvert lors de l’apparition brutale de neo vaisseaux choroidiens des deux cotes. Materiels et Methodes L’acuite visuelle initiale etait de 5/10 P6 a droite et de 1/20 P14 a gauche. Une seule injection intra vitreenne de Bevacizumab a ete realisee aux deux yeux. Resultats Ces injections ont permis une amelioration anatomique et fonctionnelle importante. Il n’y a pas de rechute apres 6 mois de suivi. L’acuite visuelle est remontee a 10/10 P2 a droite et a 7/10 P2 a gauche. Discussion Les neo vaisseaux choroidiens sont une complication frequente des osteomes. 47 % des patients presentent cette complication apres 10 ans de suivi. Les osteomes ne sont bilateraux que dans 25 % des cas. Une neo vascularisation choroidienne bilaterale simultanee est exceptionnelle. Le Bevacizumab montre ici, comme dans d’autres cas de neo vascularisation choroidienne du sujet jeune, son efficacite avec une injection unique. Conclusion La neo vascularisation choroidienne est une complication non specifique qui emaille l’evolution des osteomes choroidiens et entraine une perte de vision prematuree. Un traitement intra-oculaire anti angiogenique se revele extremement efficace pour faire regresser de facon durable les neo vaisseaux, permettant une amelioration visuelle malgre la presence de l’osteome.

154 Autofluorescence du fond d’œil après chirurgie de décollement de rétine : étude descriptive

Objectif Comparer la fonction maculaire apres une chirurgie de decollement de retine avec des cliches en autofluorescence du fond d’œil. Materiels et Methodes Vingt-quatre patients ayant eu une chirurgie avec succes de decollement de retine ont ete suivis pendant 6 mois dans une etude prospective controlee. Les explorations ont ete realisees a 6 semaines et a 24 semaines. Une acuite visuelle ETDRS, des cliches en autofluorescences bilateraux, un OCT et une microperimetrie ont ete realises a chaque controle. Nous rapportons les resultats preliminaires. Resultats Dix-huit patients avaient un decollement de retine macula off et 6 patients macula on. A 6 semaines, 5 patients sur 24 (21 %) avaient un cliche en autofluorescence anormal. A 24 semaines, 6 patients sur 24 (25 %) avaient un cliche en autofluorescence anormal. Nous n’avons pas trouve de correlation statistiquement significative entre l’acuite visuelle et l’analyse des cliches en autofluorescence. Discussion Les decollements de retines entrainent, meme apres une chirurgie efficace, une recuperation visuelle le plus souvent incomplete et imprevisible. De nombreux mecanismes cellulaires peuvent expliquer des lesions irreversibles au niveau de la retine. Les cliches en autofluorescence apportent des informations supplementaires a la comprehension de certains processus, notamment au niveau de la dispersion du pigment maculaire. Conclusion Plus de 20 % des patients presentent une anomalie sur des cliches en autofluorescence apres une chirurgie de decollement de retine. De plus larges etudes pourront peut-etre identifier sur ces cliches des facteurs pronostiques precoces a une bonne recuperation visuelle.