Ocular sequelae of epidermal necrolysis: French national audit of practices, literature review and proposed management

Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are serious and rare diseases, most often drug-induced, and their incidence has been estimated at 6 cases/million/year in France. SJS and TEN belong to the same spectrum of disease known as epidermal necrolysis (EN). They are characterized by more or less extensive epidermal detachment, associated with mucous membrane involvement, and may be complicated during the acute phase by fatal multiorgan failure. SJS and TEN can lead to severe ophthalmologic sequelae. There are no recommendations for ocular management during the chronic phase. We conducted a national audit of current practice in the 11 sites of the French reference center for toxic bullous dermatoses and a review of the literature to establish therapeutic consensus guidelines. Ophthalmologists and dermatologists from the French reference center for epidermal necrolysis were asked to complete a questionnaire on management practices in the chronic phase of SJS/TEN. The survey focused on the presence of a referent ophthalmologist at the center, the use of local treatments (artificial tears, corticosteroid eye drops, antibiotic-corticosteroids, antiseptics, vitamin A ointment (VA), cyclosporine, tacrolimus), the management of trichiatic eyelashes, meibomian dysfunction, symblepharons, and corneal neovascularization, as well as the contactologic solutions implemented. Eleven ophthalmologists and 9 dermatologists from 9 of the 11 centers responded to the questionnaire. Based on questionnaire results, 10/11 ophthalmologists systematically prescribed preservative-free artificial tears, and 11/11 administered VA. Antiseptic or antibiotic eye drops or antibiotic-corticosteroid eye drops were recommended as needed by 8/11 and 7/11 ophthalmologists, respectively. In case of chronic inflammation, topical cyclosporine was consistently proposed by 11/11 ophthalmologists. The removal of trichiatic eyelashes was mainly performed by 10/11 ophthalmologists. Patients were referred to a reference center for fitting of scleral lenses (10/10,100%). Based on this practice audit and literature review, we propose an evaluation form to facilitate ophthalmic data collection in the chronic phase of EN and we also propose an algorithm for the ophthalmologic management of ocular sequelae.

[Anatomic-functional correlations in birdshot chorioretinopathy: An observational single-center prospective study]

INTRODUCTION

The purpose of this study was to identify anatomic-functional correlations in patients with Birdshot chorioretinopathy in order to better understand the mechanisms of visual loss.

MATERIALS AND METHODS

We conducted a single-center observational prospective study at the Nantes University Medical Center including all patients followed for Birdshot chorioretinopathy between January 2019 and July 2019. The parameters studied were visual acuity, microperimetry, standard automated perimetry, SD-OCT, EDI-OCT, OCT-A, RNFL-OCT, wide-field fundus photographs, and fluorescein and ICG angiography.

RESULTS

Forty-four eyes were studied. A significant correlation was found between visual acuity and retinal thickness (P=0.002, r=0.44), but not choroidal thickness (P=0.16). A significant correlation was also observed between retinal sensitivity and total macular thickness (P<0.001, r=0.68) as well as inner retinal thickness (P<0.001, r=0.65), while the correlation was weaker with choroidal thickness (P=0.03, r=0.32). There was a weak correlation between retinal sensitivity and superficial capillary density (P=0.02, r=0.42) as well as deep capillary density (P=0.02, r=0.41). The peripheral hypo-autofluorescent zones correspond to the visual field defects, but these defects are larger than the hypo-autofluorescent zones. Patients with paracentral or peripheral field defects had a history of vasculitis more often than hypo-ICG spots.

DISCUSSION

We found significant correlations between functional parameters such as visual acuity and retinal sensitivity and retinal anatomic parameters, particularly the inner retina, while there was no correlation shown with choroidal anatomic parameters.

CONCLUSION

The main results of our study suggest a retinal rather than choroidal origin of the degradation of visual function in birdshot chorioretinopathy.

[Impact of prematurity on the optic nerve]

INTRODUCTION

Thanks to the progress made in the past few years in pediatric intensive care as well as the increased survival of preterm infants, the consequences of premature birth are increasingly well documented. With regard to ophthalmologic complications, retinopathy of prematurity is well described, but the optic nerve may also be affected. The goal of this study is to compare the optic nerves of preterm infants as a function of their gestational period with a control group of the same age.

MATERIALS AND METHODS

We conducted a case-control study pairing a full-term infant with each preterm infant. Inclusion criteria were: any child from 5- to 10-years-old, separated into three sub-groups according to their degree of prematurity. Variables were: cup/disc ratio, ocular biometry, intraocular pressure and RNFL thickness.

RESULTS

Thirty-seven preterm infants and 37 controls were included in the study. The mean age at the time of inclusion was 7.05 years for the preterm group and 7.19 years for the control group. No significant difference was observed in axial length or spherical equivalent (P=0.31 and P=0.98, respectively). No significant difference was observed in pachymetry or intraocular pressure (P=0.28 and P=0.22, respectively). We observed a significant increase of 0.1 in the cup/disc ratio of the preterm group compared to the control group (P<0.05). The preterm group cup/disc ratio was 0.36 versus 0.27 for the control group. No significant difference was observed in the 7 quadrants of RNFL between the two groups. However, when comparing infants born before 28 weeks gestation with the control group, we observed a mean decrease of 14.5 microns in the superior temporal sector (P=0.04), a 9 micron decrease in the global thickness G (P=0.03) and a 12.7 micron decrease in the nasal sector (P=0.01).

CONCLUSIONS

In the case of the studied children (aged 5 to 10), the reduced RNFL fiber thickness is a phenomenon dependent essentially on the stage of prematurity. It would be useful to follow these preterm populations over the long term and to compare them to a matched control group to be able to obtain functional results.

[Vision screening for children: Recommended practices from AFSOP]

In light of the international literature, a workgroup of experts from the AFSOP met in February 2019 to formulate updated recommendations for visual screening in children. An ophthalmologic examination during the first month of life is recommended for children at risk of developing infantile organic amblyopia. An ophthalmologic examination including cycloplegic refraction between 12 and 15 months of age is recommended for children at risk of developing functional amblyopia. At any age, a prompt ophthalmologic examination is recommended for a child suspected of functional or organic ocular pathology. In children without risk factors or warning signs, a systematic orthoptic screening examination is recommended during the third year of life, including a monocular visual acuity test, a cover-test and a refraction by photoscreener. The child is referred to the ophthalmologist only in the case of an abnormal screening result, according to the following criteria: visual acuity <5/10, or >1 difference between eyes, abnormal cover test, photodetection refraction values <-3D or>+2.5D for the sphere,>1.5D for astigmatism and>1D for anisometropia. Finally, we review normal childhood refractive errors as a function of age as well as the correct use of photo screening devices.

Management of ocular involvement in the acute phase of Stevens-Johnson syndrome and toxic epidermal necrolysis: french national audit of practices, literature review, and consensus agreement

Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) can lead to severe ophthalmologic sequelae. The main risk factor is the severity of the initial ocular involvement. There are no recommendations for ocular management during acute phase.

We conducted a national audit of current practice in the 11 sites of the French reference center for toxic bullous dermatoses and a review of the literature to establish therapeutic consensus guidelines. We sent a questionnaire on ocular management practices in SJS/ TEN during acute phase to ophthalmologists and dermatologists. The survey focused on ophthalmologist opinion, pseudomembrane removal, topical ocular treatment (i.e. corticosteroids, antibiotics, antiseptics, artificial tear eye drops, vitamin A ointment application), amniotic membrane transplantation, symblepharon ring use, and systemic corticosteroid therapy for ophthalmologic indication. Nine of 11 centers responded. All requested prompt ophthalmologist consultation. The majority performed pseudomembrane removal, used artificial tears, and vitamin A ointment (8/9, 90%). Combined antibiotic-corticosteroid or corticosteroid eye drops were used in 6 centers (67%), antibiotics alone and antiseptics in 3 centers (33%). Symblepharon ring was used in 5 centers (55%) if necessary. Amniotic membrane transplantation was never performed systematically and only according to the clinical course. Systemic corticosteroid therapy was occasionally used (3/9, 33%) and discussed on a case-by-case basis.

The literature about ocular management practice in SJS/ TEN during acute phase is relatively poor. The role of specific treatments such as local or systemic corticosteroid therapy is not consensual. The use of preservatives, often present in eye drops and deleterious to the ocular surface, is to be restricted. Early amniotic membrane transplantation seems to be promising.

Safety of intravitreal injection of ranibizumab in early pregnancy: a series of three cases

PurposeRanibizumab is used in the treatment of choroidal neovascularization (CNV). Although systemic exposure to ranibizumab is low after ocular administration, its mechanism of action must be regarded as potentially teratogenic and embryo-fetotoxic. Women are advised to wait 3 months after the last dose of treatment with ranibizumab before conceiving. Little is known about the fetal side-effects of this drug.MethodsThree pregnant women were treated with ranibizumab. One patient had idiopathic CNV.ResultsAfter receiving injections at 10 and 21 weeks after her last menstrual period (LMP), she gave birth to a healthy child. The second patient had myopic choroidal neovascularization (mCNV) and was treated by a single injection at 17 weeks post LMP. She gave birth to a healthy child after an uneventful pregnancy. The third patient had CNV secondary to a punctuate inner choroiditis. The injection was performed at 8 weeks post LMP. This patient presented a cholestasis of pregnancy at 36 weeks post LMP and gave birth at 38 weeks post LMP to a child that did not present any malformations.ConclusionsThis case series describes three women who underwent intravitreal ranibizumab treatment during pregnancy without showing any obstetric, embryofetal or neonatal complications.

[Treatment of macular edema: Comparison of efficacy and tolerability of subconjunctival triamcinolone injections, sub-tenon's triamcinolone injections and intravitreal dexamethasone implant]

The area of uveitis is related to numerous pathological entities. One of the main causes of decreased visual acuity in these patients is macular edema. One aspect of the treatment includes cortosteroids used peri- and intra-ocularly.

MATERIALS AND METHODS

The goal of our work was to estimate the criteria of efficacy (on improvement in visual acuity and macular edema, as well as time to recurrence) and safety (on intraocular pressure and cataract) of these various routes of administration of corticosteroid after a single injection. We compared patients treated with Ozurdex^® versus subconjonctival triamcinolone versus sub-tenon's triamcinolone. This is a retrospective study conducted in 2 tertiary centers, the university medical center of Nantes and La Pitié-Salpêtrière hospital from November, 2011 to November, 2013.

RESULTS

At presentation, 25 % of the patients displayed VA better than 5/10. During follow-up, this proportion increased to 45 % at M1, 50 % at M3, 49 % at M6 and 48 % at the end of follow-up. There was no significant difference between the groups with respect to VA gain. The reductions in mean CMT compared with D0 were all statistically significant (improvement of one line in log-OCT). We observed an improvement in macular thickness of 88 % at M1, 86 % at M3, 61 % at M6 and 60 % at the end of follow-up, significant at each time, with no significant difference between the three groups. A comparison of time to anatomic vs. functional recurrence was performed, showing no difference. The largest increase in IOP was observed at M1, statistically different from the other time points.

DISCUSSION

Intra- and periocular injections should be considered as an adjuvant therapy, since the majority of the conditions in question require systemic treatment. They allow for increased intravitreal concentrations with fewer systemic effects.

CONCLUSION

We demonstrated neither any true superiority of any of the 3 treatments nor any difference in tolerability between the 3 groups.

[Ocular syphilis: A retrospective study of 27 cases in Nantes University Hospital (France) from 2000 to 2013]

INTRODUCTION

Syphilis may manifest as several distinct ophthalmological forms. The main objective of our study was to describe the diagnostic, therapeutic data and prognosis of ocular syphilis.

PATIENTS AND METHODS

We retrospectively analysed the cases of syphilitic uveitis diagnosed in the University Hospital of Nantes between 2000 and 2013.

RESULTS

Twenty-seven patients were included in our study. Their mean age was 53.1 years. Bilateral uveitis was the most frequent clinical presentation (67%). The average diagnostic delay after the first symptoms was 2.8 months. Three patients (11%) presented with an anterior uveitis and 24 (89%) with a posterior uveitis, panuveitis or papillitis. The most frequent clinical signs were papillar lesion (44%), multifocal choroiditis (33%) and chorio-retinitis (37%). Ninety-three percent of the patients were treated with benzathine penicillin intravenously, one patient was treated by intramuscular penicillin injections and another by ceftriaxone intramuscularly. Ocular manifestations alone were sufficient to make the diagnosis of syphilis in 25 patients (93%) and of HIV seroconversion in 3 patients (11%). Forty-one percent of the patients benefited from an adjuvant therapy with corticosteroids. The treatment allowed a visual improvement of -0.48 log MAR (P<0.0001) with an average reduction of retinal central thickness of 70.2 μm (P=0.33).

CONCLUSION

We did not find a significant difference neither in management nor in results between the HIV seropositive and HIV seronegative groups. Others studies remains controversial about this aspect. The increased frequency of ocular manifestation as well as the increase of syphilis makes systematic screening in uveitis of a great value.

[Safety and efficacy of subconjunctival triamcinolone injections in the management of uveitic macular edema: retrospective study of thirty-one cases]

Triamcinolone acetonide (Kenacort) is a corticosteroid that can be administrated by subconjunctival injection, with an extended release for up to three months. Our retrospective study aims to analyze safety and efficacy of subconjunctival triamcinolone injections in the treatment of uveitic macular edema. We included 31 eyes of 30 patients, who had one or several injections. We studied the progression of visual acuity, central macular thickness by optical coherence tomography (OCT), intraocular pressure, and presence or absence of cataract, on the day of injection (T0), and at 1, 3, 6 and 12 months after injection. Twenty-one patients had only one injection; 10 patients had 2. The 12-month follow-up showed an improvement in visual acuity with an initial mean of 0.36 ± 0.27 logMAR to 0.23 ± 0.33 logMAR at 3 months of follow-up (P<0.0004), and to 0.24 ± 0.21 logMAR at 12 months (P=0.0371), for a two-line improvement. A decrease in mean central macular thickness was measured by OCT, from a mean of 444 ± 112 μm (0.24 ± 0.11 logSD-OCT) at T0 to 355 ± 103 μm (0.14 $ ± 0.10 logSD-OCT) at 3 months (P=0.0002). We did not find a significant increase in intraocular pressure, and we diagnosed one cataract during follow-up but this occurred in the uninjected eye as well. Subconjunctival injection of triamcinolone acetonide is a safe and effective treatment of macular edema related to uveitis. Initial clinical monitoring is necessary to detect iatrogenic events.

Biogenic volatile organic compounds (BVOCs) emissions from Abies alba in a French forest

Air quality studies need to be based on accurate and reliable data, particularly in the field of the emissions. Biogenic emissions from forests, crops, and grasslands are now considered as major compounds in photochemical processes. Unfortunately, depending on the type of vegetation, these emissions are not so often reliably defined. As an example, although the silver fir (Abies alba) is a very widespread conifer tree in the French and European areas, its standard emission rate is not available in the literature. This study investigates the isoprene and monoterpenes emission from A. alba in France measured during the fieldwork organised in the Fossé Rhénan, from May to June 2003. A dynamic cuvette method was used. Limonene was the predominant monoterpene emitted, followed by camphene, alpha-pinene and eucalyptol. No isoprene emission was detected. The four monoterpenes measured showed different behaviours according to micrometeorological conditions. In fact, emissions of limonene, alpha-pinene and camphene were temperature-dependant while eucalyptol emissions were temperature and light dependant. Biogenic volatile organic compounds emissions were modeled using information gathered during the field study. Emissions of the three monoterpenes previously quoted were achieved using the monoterpenes algorithm developed by Tingey et al. (1980) [Tingey D, Manning M, Grothaus L, Burns W. Influence of light and temperature on monoterpene emission rates from slash pine. Plant Physiol 1980;65: 797-801.] and the isoprene algorithm [Guenther, A., Monson, R., Fall, R., 1991. Isoprene and monoterpene emission rate variability: observations with eucalyptus and emission rate algorithm development. J Geophys Res 26A: 10799-10808.]; [Guenther, A., Zimmerman, P., Harley, P., Monson, R., Fall, R., 1993. Isoprene and monoterpene emission rate variability: model evaluation and sensitivity analysis. J Geophys Res 98D: 12609-12617.]) was used for the eucalyptol emission. With these methods, simulation results and observations agreed fairly well. The standard emission rate (303 K) and beta-coefficient averaged for limonene, camphene and alpha-pinene were respectively of 0.63 microg gdw-1 h-1 and 0.06 K-1. For eucalyptol, the standard emission rate (T=303 K and PAR=1000 micromol m-2 s-1) was 0.26 microg gdw-1 h-1. This classified A. alba as a weak monoterpenes emitter.

The use of a germene for the synthesis of esters of alpha-germyl-substituted alpha-amino acid and alpha-aminophosphonic acid

The first alpha-germyl-substituted alpha-amino ester and alpha-germyl-substituted alpha-aminophosphonic ester have been synthesized by a one-pot reaction between the germene Mes2Ge=CR2 (CR2 = fluorenylidene) and the iminoester or iminophosphonate Ph(H)C=NCH2-Y (Y = COOMe, P(O)(OEt)2).