Endoplasmic reticulum stress mediates resistance to BCL-2 inhibitor in uveal melanoma cells

To address unmet clinical need for uveal melanomas, we assessed the effects of BH3-mimetic molecules, the ABT family, known to exert pro-apoptotic activities in cancer cells. Our results uncovered that ABT-263 (Navitoclax), a potent and orally bioavailable BCL-2 family inhibitor, induced antiproliferative effects in metastatic human uveal melanoma cells through cell cycle arrest at the G0/G1 phase, loss of mitochondrial membrane potential, and subsequently apoptotic cell death monitored by caspase activation and poly-ADP ribose polymerase cleavage. ABT-263-mediated reduction in tumor growth was also observed in vivo. We observed in some cells that ABT-263 treatment mounted a pro-survival response through activation of the ER stress signaling pathway. Blocking the PERK signaling pathway increased the pro-apoptotic ABT-263 effect. We thus uncovered a resistance mechanism in uveal melanoma cells mediated by activation of endoplasmic reticulum stress pathway. Therefore, our study identifies ABT-263 as a valid therapeutic option for patients suffering from uveal melanoma.

Evaluating the cost-consequence of a standardized strategy for the etiological diagnosis of uveitis (ULISSE study)

MAIN OBJECTIVE

To prospectively assess the cost-consequence of a standardized diagnostic strategy as to compared to an open one for the etiological diagnosis of uveitis.

DESIGN

This was a prospective, non-inferiority, multicentre, randomized controlled trial.

METHODS

We included all consecutive patients with uveitis who had visited at least one of the Departments of Ophthalmology. In the standardized group, patients had a minimal work-up regardless of the type of uveitis (including evaluation of the CBC, ESR, C-reactive protein, tuberculin skin test, syphilis serology and chest X-ray). Depending on ophthalmological findings, further investigations could be performed. In the open strategy, ophthalmologists were free to order any kind of investigation. The main outcome was the mean cost per patient of each strategy.

RESULTS

903 uveitis patients were included from January, 2010 to May, 2013. The mean cost per patient of the standardized strategy was 182.97 euros [CI 95% (173.14; 192.80)], and the mean cost per patient of the open strategy was 251.75 euros [CI 95% (229.24; 274.25)]. Therefore, the mean cost per patient of the standardized strategy was significantly lower than the mean cost per patient of the open strategy (p<0.001). There were significantly fewer visits (p<0.001), fewer radiological procedures (p<0.004) and fewer laboratory investigations (p<0.001) in the standardized group.

CONCLUSION

A standardized strategy is a cost-saving approach for the etiological diagnosis of uveitis.

Comparison of two techniques used in routine care for the treatment of inflammatory macular oedema, subconjunctival triamcinolone injection and intravitreal dexamethasone implant: medical and economic importance of this randomized controlled trial

Background

Whether they are injected peri- or intraocularly, corticosteroids are still essential tools in the therapeutic arsenal for treating inflammatory macular oedema. A few years ago, however, only triamcinolone acetonide was available to ophthalmologists. While this compound was initially developed for rheumatological or dermatological use, it has been increasingly deployed in ophthalmology, despite still being off-label. In 2011, the system for delivery of dexamethasone from a biodegradable, injectable implant into the vitreous cavity obtained approval for use in inflammatory macular oedema. While the efficacy and safety of triamcinolone in macular oedema, including inflammatory oedema, have already been studied, there are currently no publications on subconjunctival triamcinolone injections, which are simple, effective and well tolerated. To date, the dexamethasone 700 μg implant has been authorized for the treatment of noninfectious intermediate and posterior uveitis, but there have been no studies to evaluate the efficacy and safety of the different peri- and intraocular strategies, including the treatment of inflammatory macular oedema.

Methods

This protocol is therefore designed to compare the efficacy and safety of peri- and intraocular corticosteroid injections in the treatment of inflammatory macular oedema. In this ongoing study, 142 patients will be included, and the oedematous eye will be randomised to treatment with either subconjunctival triamcinolone injection or an intravitreal implant containing 700 μg dexamethasone. Follow-up is planned for 6 months with monthly visits. Each visit will include visual acuity measurement, a slit lamp examination, fundoscopy, intraocular pressure measurement, laser flare measurement (if available) and spectral domain optical coherence tomography.

Discussion

The results of this trial will have a real impact on public health if it is shown that a Kenacort retard® (i.e. triamcinolone) injection costing just €2.84 and performed in the physician’s office (with no additional overhead costs) is at least as effective as the dexamethasone 700 μg implant (Ozurdex®; costing approximately €960 with the injection performed in a dedicated room), with no increased side effects.

Trial registration

ClinicalTrials.gov, NCT02556424. Registered on 22 September 2015.

[Anatomical description of the retro-caruncular approach and its application in oculoplastics: A cadaveric study]

PURPOSE

To describe the anatomical landmarks of the retro-caruncular approach and its clinical applications based on a cadaveric study.

PATIENTS AND METHOD

A dissection of 8 orbits providing from 4 fresh cadavers was carried out at the anatomical laboratory of the University Hospital of Nice, France between October 2018 and January 2019.

RESULTS

Main anatomical relationships encountered are anteriorly the Duverney-Horner muscle and the lacrimal sac, posteriorly the anterior and posterior ethmoidal arteries, superiorly the pulley of the superior oblique muscle, inferiorly the lacrimonasal duct and the tendon of the inferior oblique muscle. The retro-caruncular approach allows a safe surgical access behind the lacrimal sac and Duverney-Horner muscle. Many oculoplastic surgical procedures can be performed through this approach: dacryocystorhinostomy, medial orbital fractures repair, "médial" orbital "décompression", biopsy of medial and extraconal tumours, medial periosteal fixation in third-nerve palsy.

CONCLUSION

The retro-caruncular approach is a safe procedure avoiding skin incision. It allows a wide surgical space even if it is reduced compared to a more conventional skin route. It requires a great anatomical knowledge and a longer surgical learning curve.

The Lens Opacities Classification System III Grading in Irradiated Uveal Melanomas to Characterize Proton Therapy-Induced Cataracts

PURPOSE

To evaluate the use of the Lens Opacities Classification System III grading (LOCS III) for the characterization of radiation-induced cataract, and to correlate the proton beam projection onto the lens with cataract location and grade as defined by the LOCS III.

DESIGN

Prospective, interventional case series.

METHODS

Fifty-two consecutive patients with cataract following proton therapy were included. All cataracts were graded using LOCS III. Relationships between proton beam and cataract subtypes, as well as between dose, proportion of lens irradiated, and extent of cataracts, were assessed.

RESULTS

Tumor diameter, volume, stage, and equatorial tumor location were associated with extent of posterior subcapsular cataracts (PSC) that were diagnosed at a median (interquartile range) 36 months (22;83) after treatment. In multivariate analysis, the tumor volume (P < .01) and an equatorial tumor location (P = .01) were risk factors for extensive PSC. Lens irradiation was avoided in 10 patients. In the remaining 42 patients (81%), the extent of PSC significantly correlated with the dose to the lens receiving 10, 26, and 47 Gy (P = .03, P = .03, and P = .04, respectively), the dose to the lens periphery receiving 10 and 26 Gy (P = .02 and P = .02, respectively), and the dose to the ciliary body receiving 10 and 26 Gy (P = .03 and P = .02, respectively). Nuclear color significantly correlated with the dose to the ciliary body receiving 10 Gy (P = .03) and 26 Gy (P = .02). After adjustment of the results on tumor volume and tumor location, the volume of lens receiving 10 Gy (P = .04) and 26 Gy (P = .03) remained significantly associated with the extent of PSC.

CONCLUSIONS

Proton dose correlated with the occurrence of PSC and nuclear color cataracts as defined by LOCS III grading. Better characterization of cataracts with the LOCS III after irradiation may help to further fill gaps in the current understanding of the mechanisms of radiation-induced cataracts.

Management of Invasive Squamous Cell Carcinomas of the Conjunctiva

PURPOSE

Ocular surface squamous neoplasia includes a spectrum of diseases from dysplasia to invasive squamous cell carcinoma (SCC) of the conjunctiva. Whether the degree of invasion influences outcomes is debated. We evaluated the outcomes and management of conjunctival carcinomas defined as ≤0.2 mm invasion of the chorion (microinvasive; miSCC) or over (SCC).

DESIGN

Retrospective case series.

METHODS

Clinical, tumor, and therapeutic characteristics and outcomes were collected for consecutive patients with histology-proven invasive conjunctival miSCC/SCC treated between 2002 and 2017.

RESULTS

Patients were 70% men, ≥70 years old (56%), with carcinomas of the bulbar conjunctiva (83.0%). Limbal, corneal, and/or scleral involvement were present in 70.4%, 42.6%, and 27.8%, respectively. Patient characteristics, tumor characteristics, and no-touch surgery rates were similar between the 39 SCC and 15 miSCC. However, mitomycin was performed in 93.3% and 20.5% of miSCC and SCC, respectively (P < .001). Proton therapy was performed in 0% and 92.0% of miSCC and SCC, respectively (P < .001). SCC received mitomycin in case of tumoral resection margins, respectively (P = .018). The 24-month incidence of local relapse was 14.8%, including 20% and 12% for miSCC and SCC, respectively (P = .079). Irradiation was the only prognostic factor associated with a lower risk for local relapse (hazard ratio [0.25]; P = .045). There were 2 cancer-related deaths (2%). Mild/moderate anterior segment complications occurred in one third of the patients.

CONCLUSIONS

miSCC had slightly worse relapse rates compared with SCC. Postoperative proton therapy, performed in SCC only, was associated with a lower risk for relapse.

Occurrence of Phosphenes in Patients Undergoing Proton Beam Therapy for Ocular Tumor

PURPOSE

Phosphenes are frequently reported by patients irradiated in the head and neck area. The aim of the present study was to characterize and investigate potential mechanisms of proton beam therapy (PBT)-induced phosphenes in a large population of patients undergoing PBT for ocular tumors.

DESIGN

Prospective cohort study.

METHODS

Consecutive patients who underwent PBT in a single center were included. Immediately after the first session, all patients completed a questionnaire collecting information about the presence of phosphenes as well as their color, shape, and duration. Patient, tumor and treatment characteristics (dose volume histograms) were also collected.

RESULTS

Among the 474 patients included, 62.8% reported phosphenes during the first session of PBT. Reported colors were mainly blue-violet (70.5%) and white (14.1%). The prevalence of phosphenes was higher in younger patients (P = .003); other patient or ocular characteristics were not associated with the occurrence of phosphenes. Irradiation of the macula (P < .001) and/or optic disc (P < .001) were significantly associated with the presence of phosphenes, whereas blue-violet color was only associated with young age and irradiation of macular area (P = .04). Pupillary constriction was reported for 57.1% of patients with phosphenes vs 18.5% of patients without (P < .001). Blue-violet phosphenes (P < .001) and irradiation of macula (P = .001) were statistically associated with pupillary constriction.

CONCLUSIONS

The present study reported a high rate of phosphenes in patients irradiated by PBT for ocular tumor. Their blue-violet color and their association with a pupillary constriction probably indicates the stimulation of S-cones and retinal ganglion cells that reflects the activation of the afferent visual pathway.

[Focus on clinical and pathological management of conjunctival melanocytic tumors]

Conjunctival-pigmented tumors are rare, but they are one of the most commonly encountered by the pathologist working with the department of ophthalmology. Nevus and melanoma can be encountered and have some histological difference compared to their cutaneous counterpart. Primary acquired melanosis (PAM) is a conjunctival specific entity. This clinical term includes several histological lesions ranging from benignity to melanoma precursor lesion. Histologic examination determines the therapy and the risk of progression to melanoma. We present here a histopathological, clinical and therapeutic synthesis of conjunctival-pigmented lesions, emphasizing the importance of a good understanding between clinicians and pathologists.

[Uveitis treated with biotherapy and/or DMARD: Analysis from the French Pharmacovigilance Study Base]

PURPOSE

To report the characteristics of uveitis cases occurring while on biologic therapy or disease-modifying antirheumatic drugs (DMARDs) reported to the French national pharmacovigilance database.

METHODS

All the uveitis cases occurring in patients with chronic rheumatologic diseases, chronic inflammatory intestinal diseases or connective tissue diseases, while treated with DMARDs and/or biologic therapies between 2000 and 2015 and reported to the French National Pharmacovigilance Database were collected.

RESULTS

During the study period, 32 cases of uveitis were reported (15 men, 17 women). Two patients were treated with one DMARD alone, 24 with biologic therapy alone, and six with both treatments. Anterior uveitis was diagnosed in 19 patients (8 cases were bilateral); intermediate uveitis was found (unilaterally) in one patient; posterior and diffuse uveitis occurred in 5 and 2 cases respectively. Five cases were inconclusive with regard to the anatomical type of uveitis. The uveitis was of infectious origin in 5 cases: 2 toxoplasmosis, 2 herpes virus and 1 tuberculosis. In the 27 other cases, it was not possible to state whether the uveitis was associated with the underlying disease (uncontrolled) or a side effect of the biologic/DMARD treatments. The occurrence of the uveitis led to 9 switches in biologic therapy and 13 discontinuations of treatment (8 complete discontinuations, 5 discontinuations only until uveitis remission was obtained). In 4 cases, the treatments were not modified. The database does not specify the ultimate course or rheumatologic disease activity at the time of the uveitis.

CONCLUSIONS

The presence of uveitis while on biologic therapy must not be taken to indicate a therapeutic failure, especially if the ocular manifestation is isolated. In the case of uveitis occurring in patients treated with biologic therapies and/or DMARDs, infectious complications should be ruled out.

[Oculoplastic complications of the excision of meningiomas with orbital extension]

INTRODUCTION

Meningiomas with orbital extension are the most frequent benign orbital tumors. The few studies available on the postoperative complications of their excision focus on the postoperative evolution of proptosis, visual acuity and visual field deficits. The goal of our study was to highlight the oculoplastic complications secondary to their excision.

MATERIAL AND METHOD

We identified all cases of meningiomas with orbital extension undergoing excision either neurosurgically or via an orbital approach in the ophthalmology and neurosurgery departments of Pasteur university medical center in Nice between February 2011 and January 2017. The data collection included the postoperative presence of proptosis, oculomotor disturbance, lid disorders, dry eye and trigeminal nerve damage.

RESULTS

Twenty-nine patients were included; 89.7 % were women. The mean age was 55 years. Postoperative complications included 25 % residual proptosis; 40.7 % oculomotor disturbance, 75 % of which regressed at least partially; 50 % ptosis, 21 % of which did not regress; 40 % dry eye; and in 21.4 % the trigeminal nerve was involved.

CONCLUSION

The management of meningiomas with orbital extension is difficult due to their anatomical location and requires joint neurosurgical and oculoplastic management. Sufficient follow-up is required before recommending surgery for oculomotor disturbances. The frequency of occurrence of ptosis with potential recommendation for surgery requires caution given the occurrence of trigeminal nerve involvement and dry eye syndrome.

[Systemic safety following intravitreal injections of anti-VEGF]

The goal of this manuscript is to assess data suggesting that intravitreal injection of anti-vascular endothelial growth factors (anti-VEGFs) could result in systemic adverse events (AEs). The class-specific systemic AEs should be similar to those encountered in cancer trials. The most frequent AE observed in oncology, hypertension and proteinuria, should thus be the most common expected in ophthalmology, but their severity should be lower because of the much lower doses of anti-VEGFs administered intravitreally. Such AEs have not been frequently reported in ophthalmology trials. In addition, pharmacokinetic and pharmacodynamic data describing systemic diffusion of anti-VEGFs should be interpreted with caution because of significant inconsistencies reported. Thus, safety data reported in ophthalmology trials and pharmacokinetic/pharmacodynamic data provide robust evidence that systemic events after intravitreal injection are very unlikely. Additional studies are needed to explore this issue further, as much remains to be understood about local and systemic side effects of anti-VEGFs.

Medical management of a subretinal Klebsiella pneumoniae abscess with excellent visual outcome without performing vitrectomy

OBJECTIVE

To report the case of a Klebsiella pneumoniae endogenous endophthalmitis (KPEE) of hepatic and urinary origin that was successfully treated with systemic antibiotherapy and 13 intravitreal antibiotics injections without performing a vitrectomy.

PATIENT AND METHOD

Case report of a 60-year-old man with a subretinal abscess in the left eye that developed 3 days after initial presentation for K. pneumoniae bacteremia, liver abscess and urinary tract infection.

RESULTS

Ophthalmic examination of the left eye showed anterior uveitis and a single subretinal abscess located in mid-peripheral temporal retina. BCVA dropped to 20/50. Follow-up was made with clinical examination and multimodal imaging (SD-OCT, FA, ICGA) with high field photographs. A total of 13 intravitreal injections (IVI) of ceftazidime were performed, and no vitrectomy was required. Ocular signs regressed and prognosis was excellent with 20/20 of final BCVA.

CONCLUSION

KPEE is a rare but severe condition with a typically poor ocular prognosis. When diagnosis is made early, subretinal abscess with partially conserved BCVA could be treated successfully with medical management that includes systemic antibiotics and repeated intravitreal injections without requiring vitrectomy.

Mechanisms of phosphenes in irradiated patients

Anomalous visual perceptions have been reported in various diseases of the retina and visual pathways or can be experienced under specific conditions in healthy individuals. Phosphenes are perceptions of light in the absence of ambient light, occurring independently of the physiological and classical photonic stimulation of the retina. They are a frequent symptom in patients irradiated in the region of the central nervous system (CNS), head and neck and the eyes. Phosphenes have historically been attributed to complex physical phenomena such as Cherenkov radiation. While phosphenes are related to Cherenkov radiation under high energy photon/electron irradiation conditions, physical phenomena are unlikely to be responsible for light flashes at energies used for ocular proton therapy. Phosphenes may involve a direct role for ocular photoreceptors and possible interactions between cones and rods. Other mechanisms involving the retinal ganglion cells or ultraweak biophoton emission and rhodopsin bleaching after exposure to free radicals are also likely to be involved. Despite their frequency as shown in our preliminary observations, phosphenes have been underreported probably because their mechanism and impact are poorly understood. Recently, phosphenes have been used to restore the vision and whether they might predict vision loss after therapeutic irradiation is a current field of investigation. We have reviewed and also investigated here the mechanisms related to the occurrence of phosphenes in irradiated patients and especially in patients irradiated by proton therapy for ocular tumors.

Randomized Controlled Trial Evaluating a Standardized Strategy for Uveitis Etiologic Diagnosis (ULISSE)

PURPOSE

To prospectively assess the efficiency of a standardized diagnostic approach, compared to an open strategy, for the etiologic diagnosis of uveitis.

DESIGN

Noninferiority, prospective, multicenter, clustered randomized controlled trial.

METHODS

Consecutive patients with uveitis, who visited 1 of the participating departments of ophthalmology, were included. In the standardized group, all patients had a minimal evaluation regardless of the type of uveitis (complete blood count, erythrocyte sedimentation rate, C-reactive protein, tuberculin skin test, syphilis serology, and chest radiograph) followed by more complex investigations according to ophthalmologic findings. In the open group, the ophthalmologist could order any type of investigation. Main outcome was the percentage of etiologic diagnoses at 6 months.

RESULTS

Nine hundred and three patients with uveitis were included from January 2010 to May 2013 and the per-protocol population comprised 676 patients (open 373; standardized 303). Mean age at diagnosis was 46 years. Anatomic distribution of uveitis was as follows: anterior (60.8% and 72.3%, P = .0017), intermediate (11.7% and 12.3%, P = .8028), posterior (17.8% and 8.2%, P = .0004), and panuveitis (15.3% and 15.2%, P = .9596). An etiologic diagnosis was established in 54.4% of cases in the open group and 49.5% in the standardized group (P = .2029). The difference between both strategies (standardized minus open) was -4.9% (95% CI [-12.5%; 2.6%]). There were more investigations in the open group than in the standardized group (5371 vs 3759, P < .0001).

CONCLUSION

The standardized strategy appears to be an efficient diagnostic approach for the etiologic diagnosis of uveitis, although its noninferiority cannot be proved.

Treatment patterns of ranibizumab intravitreal injection and dexamethasone intravitreal implant for retinal vein occlusion in the USA

Purpose

Ranibizumab, an anti-vascular endothelial growth factor, and dexamethasone, a corticosteroid, have been shown to be effective in treating macular oedema secondary to retinal vein occlusion (RVO) (central RVO (CRVO) and branch RVO (BRVO)). Their real-world usage, however, has yet to be compared. We therefore evaluated ophthalmology visits for both drugs using US patient-level data.

Methods

The IMS Health Real-World Data Medical Claims database was used to identify treatment-naive patients receiving ranibizumab intravitreal injections or dexamethasone intravitreal implants between June 2010 and February 2014 who had 12 months of follow-up data. The primary outcome measure was the mean number of all ophthalmology visits for the two drugs in patients with CRVO and BRVO. Secondary outcome measures included a comparison of treatment visits, non-treatment visits, and time intervals between visits.

Results

Overall, 2822 patients received ranibizumab injections (CRVO, 1178; BRVO, 1644) and 365 received dexamethasone implants (CRVO, 191; BRVO, 174). The mean number (SD) of all ophthalmology visits was higher for patients receiving ranibizumab injections than for those receiving dexamethasone implants (CRVO: 7.2 (3.6) vs 6.2 (3.1), P<0.001; BRVO: 7.1 (3.4) vs 6.3 (3.1), P=0.016).

Conclusions

Patients with RVO receiving ranibizumab injections had a mean of approximately one more visit to their ophthalmologist in the first 12 months of treatment than those treated with dexamethasone implants. The visit burden is therefore not substantially different and physicians should focus on the clinical benefits of these drugs when evaluating treatment options for RVO.

[Management algorithm of age-related macular degeneration with aflibercept: Real-life application]

Aflibercept is indicated in France for wet age-related macular degeneration (wAMD) since November 2013. Its official dosage consists in administrating one monthly intravitreal injection (IVT) during three months followed by one control visit and one IVT every two months the first year. In 2015, a group of French ophthalmologists, specialized in wAMD management, established a therapeutic algorithm to optimize naive patient management with aflibercept in order to obtain visual acuity gain. It indicates that official administration scheme is adapted for 80% of patients and that an adaptation of therapeutic scheme is needed for others. These experts recommended mostly the use of personalized proactive administration scheme. Since, aflibercept clinical use has significantly grown with interventional observational studies which results are now available. Use of aflibercept and of personalized proactive administration schemes allow in real-life obtaining important visual acuity gain, which is consistent with the established algorithm.