POS0825 CLINICAL CHARACTERISTICS AND TREATMENT MANAGEMENT OF NON-INFECTIOUS SCLERITIS WITH CORTICOSTEROID-SPARING THERAPY. A RETROSPECTIVE STUDY FROM A TERTIARY EYE CARE CENTER

Background

Non-infectious scleritis refers to a rare and sight-threatening scleral inflammation. An association with an underlying systemic disease is noted in 30% to 40% of cases. Their management may require the use of nonsteroidal anti-inflammatory drugs, oral corticosteroids, and sometimes steroid-sparing immunosuppressive agents. Because of the low incidence and prevalence of scleritis, treatment guidelines are currently not available.

Objectives

We analyzed in a retrospective observational study patients with scleritis referred to the Foundation Rothschild Hospital (Paris) from March 2011 to June 2021.

Methods

Characteristics, visual outcomes, ocular complications, associations with systemic diseases and efficacy of treatment were assessed in patients with non-infectious scleritis who needed steroid-sparing immunosuppressive agents.

Results

Among 731 patients diagnosed with scleritis, 54 patients (71 eyes, 7%) were treated by steroid-sparing immunosuppressive agents. Mean follow up was 111.9 ± 84.5 weeks. Mean age was 48.4 years ± 18.3, and 31 patients (57%) were female. Scleritis was anterior in 51 eyes (72 %), including 25 (35%) with diffuse scleritis, 24 (34%) with nodular scleritis and 2 (3%) with necrotizing scleritis. Scleritis was posterior in 20 eyes (28%). Bilateral involvement was noted in 17 patients (32 %). Ocular complications were observed in 52 eyes (73 %): scleral thinning in 25 eyes (35%), anterior uveitis in 24 eyes (34 %), loss of vision in 20 eyes (28%), posterior segment ocular complications in 18 eyes (25%), ocular hypertension in 17 eyes (24%) and corneal involvement in 16 eyes (23%). An underlying systemic disease was identified in 28 patients (52 %), and scleritis was the first manifestation of the systemic disease in 17 out of 28 patients. Rheumatoid arthritis was the most frequently identified disease (n=12), followed by granulomatosis with polyangiitis (n=8) and relapsing polychondritis (n=4). All patients received at least one immunosuppressive agent. Corticosteroid sparing with a daily dose ≤ 5 mg of prednisone was achieved in 85% of patients. Conventional immunosuppressive agents were used as the first steroid-sparing agent in 38 patients (70%) (methotrexate n=33, azathioprine n=4, mycofenolate mofetil (MMF) n=1) and as second steroid-sparing agent in 1 patient (MMF). This treatment led to control scleral inflammation in 23 (59%) patients after a mean delay of 10.0 ± 6.0 weeks. Biologic therapy was used in 33 (61%) patients (TNF alpha inhibitor n=17, IL6-R inhibitor n=7, anti-CD20 n=9), and as the first steroid-sparing agent in 16 (30%) (TNF alpha inhibitor n=4, IL6-R inhibitor n=4, anti-CD20 n=8). This treatment led to control scleral inflammation after a mean delay of 4,9 ± 3,7 weeks in 29 patients (87.9%).

Conclusion

Scleritis is a severe ocular inflammatory disease that requires repeated and thorough ophthalmologic and general examinations given the high frequency of complications and the possibility of an underlying systemic disease. This study reports real-life experience in management of non-infectious scleritis. Biological therapies seemed to be associated with a better outcome and a quicker reponse than conventional immunosuppressive agents. Further studies are warranted to develop specific guidelines

Disclosure of Interests

None declared

[Efficacy and tolerance of Latanoprost given as a first intention in the treatment of primitive open angle glaucoma in African melanoderm]

OBJECTIVE

To assess the reduction in IOP and ocular symptoms in patients newly diagnosed with POAG and treated with latanoprost as monotherapy.

PATIENTS AND METHOD

A multicentric, cross-sectional, descriptive study was conducted. We included adults newly diagnosed with POAG. All patients received one drop of preserved latanoprost 0.005% in each eye every night for 12 weeks. Changes in IOP and ophthalmic signs and symptoms were assessed during and at the end of treatment.

RESULTS

A total of 524 patients were included, with a participation rate of 93% at 12 weeks. The mean age was 52.79±17.33 years, and the sex ratio M/F was 1.39. At inclusion, the mean IOP was 21.68±9.72mmHg. After 2 weeks of treatment, the mean IOP was 15.49±5.81mmHg, for a reduction of 28.55%. After 12 weeks of treatment, the mean IOP was 13.16±3.54mmHg, for a reduction of 39.30%. The main symptom recorded was a gritty foreign body sensation, the frequency of which was 4.72% at W2 and 2.45% at W12. The main sign was hyperemia (4.33% at W2 and 1.84% at W12).

CONCLUSION

Latanoprost given as first-line monotherapy in POAG in blacks considerably reduces IOP. The incidence of side effects remains low; it is higher at the start of treatment.

[Efficacy of intense pulsed light therapy in the treatment of Meibomian gland dysfunction-related severe dry eye]

INTRODUCTION

Dry eye syndrome caused by Meibomian gland dysfunction (MGD) is a common disease in the general population and impairs quality of life. Intense Pulsed Light (IPL) has mainly been used in dermatology for the treatment of skin disorders, and more recently for MGD-related dry eye. The objective of our study is to evaluate the efficacy and tolerability of IPL with the E-Eye® device (E-Swin, Houdan, France) in severe MGD-related dry eye patients.

MATERIALS AND METHODS

This non-comparative study included 20 patients with MGD-related dry eye with a Break-Up Time (BUT)<10seconds, dry eye symptoms >30mm on a Visual Analog Scale (VAS), and failure of lid hygiene and artificial tears. Treatment consisted of 3 sessions of IPL on D0, D15, and D45 (5 flashes of 13J/cm² per eye). The following parameters were assessed at each visit and at D75 : symptoms graded with a VAS and the Standard Patient Assessment of Eye Dryness questionnaire (SPEED), BUT, corneal fluorescein staining, Meibomian gland expression score, meibography, tear film lipid layer thickness by interferometry and the ocular scattering index by double-pass aberrometry (OQAS). Statistical analysis was performed on the eye most affected at baseline.

RESULTS

We included 40 eyes of 20 patients, 15 female and 5 male, mean age 47±15 years (24 to 74 years). The symptoms rated by VAS were severe, averaging 69±25mm. After treatment, there was a statistically significant decrease in symptoms, with a 14mm VAS decrease (55±29mm at D75 versus 69mm at D0, P=0.048) and SPEED score of 3.4 (19.0±6mm versus 22.4±4.6, P=0.03). The number of expressible Meibomian gland ducts increased significantly (from 5.9 to 8.1, P=0.04), lid redness decreased (from 1.4 to 0.6, P=NS) and BUT improved (from 4.2 to 5.9, P=NS). Other parameters remained unchanged. Three patients (15%) complained of transient ocular burning after each treatment.

CONCLUSION

IPL appears to be effective in improving signs and symptoms in patients with severe MGD-related dry eye, with a good safety profile. Its exact mechanism of action remains to be elucidated.

Tear Concentrations of Azithromycin following Topical Administration of a Single Dose of Azithromycin 0.5%, 1.0%, and 1.5% Eyedrops (T1225) in Healthy Volunteers

Purpose

To evaluate azithromycin tear concentrations after one drop of T1225 0.5%, 1.0%, and 1.5% eyedrops.

Methods

In this randomized, double-masked study, 91 healthy volunteers received one drop into each eye of T1225 0.5% (n=23), T1225 1.0% (n=38), or T1225 1.5% (n=38). Azithromycin tear concentrations were measured by HPLC-MS at seven time points for 24 hours. Tolerability was evaluated.

Results

T1225 1.0% and 1.5% had similar pharmacokinetic profiles. After a post-instillation peak (167 to 178 mg/L after 10 minutes), mean concentrations remained above 7 mg/L for 24 hours (except for T1225 1% at H24). A delayed increase of the azithromycin mean tear concentration might be explained by the known late azithromycin release from tissues after storage in cells. Areas under inhibitory curve (AUICs) of T1225 1.0% and 1.5% were higher than AUICs of T1225 0.5% and ranged between 47 and 90. The three T1225 concentrations were safe for the ocular surface.

Conclusions

Once daily instillation of T1225 1.0% and 1.5% was shown to reach an AUIC markedly above the required threshold for an antibacterial activity against Gram-positive bacteria (25–35). These results suggest that a BID instillation is more likely to ensure antimicrobial activity against Gram-negative bacteria (threshold >100).

[Prevention of post intravitreal injection endophthalmitis: is antibioprophylaxis indicated?]

Endophthalmitis remains the main complication of intravitreal injections, especially because their repetition multiplicates the risks. Surgical antisepsis is required for the prevention of endophthalmitis, but the benefit/risk ratio of topical antibioprophylaxis has never been demonstrated. In contrast, the selection of resistant bacteria appears to be exponential with the wider use of topical antibioprophylaxis. It seems that more and more operators stop using anibioprophylaxis, provided that the antisepsis is surgical and that the injection is performed in accordance with the rules of good practice.

[Intravitreal injections: AFSSAPS guide to good practice]

Intravitreal injections are very commonly performed in the daily practice of Ophthalmology and become a leading procedure in the management of age-related macular degeneration, diabetic retinopathy, infectious endophthalmitis or retinitis, uveitis and retinal vein occlusions. Based on the comments of a group of experts, including ophthalmologists, pharmacists and hygienists, the French Agency for the Safety of Health Products (AFSSAPS) edited a guide to good practice of intravitreal injections, revisiting those previously published in 2006. The overall experience accumulated during time is a valuable source of information to determine the most appropriate protocol. Therefore, the simplification of the procedure is reasonably proposed even though safety remains a major issue, in order to avoid complications, especially infections.

[Efficacy assessment of azithromycin 1.5% eye drops versus tobramycin 0.3% on clinical signs of purulent bacterial conjunctivitis]

INTRODUCTION

Bacterial conjunctivitis is characterized by hyperemia and discharge of one or both eyes. These clinical signs appear quickly and are contagious. This study compares the clinical efficacy (signs and symptoms) and safety of azithromycin 1.5% eye drops with tobramycin 0.3%.

PATIENTS AND METHODS

This was a multicenter, randomized, investigator-masked study including 1,043 patients with purulent bacterial conjunctivitis. Patients received either azithromycin twice daily for 3 days or tobramycin, 1 drop every 2 hours for 2 days, then four times daily for 5 days. The primary variable was clinical cure at the test-of-cure (TOC) visit (D9) on the worst eye. The cure was defined as bulbar conjunctival injection and discharge scores of 0. Clinical signs were evaluated at D0, D3, and D9.

RESULTS

In the azithromycin group 87.8% of patients and in the tobramycin group 89.4% were clinically cured at D9. Clinical cure with azithromycin was not inferior to tobramycin at D9: discharge was absent in 96.3% of patients treated with azithromycin and 95.1% with tobramycin. Azithromycin was well tolerated.

CONCLUSIONS

Azithromycin 1.5% for 3 days (six drops) was as effective as tobramycin for 7 days (36 drops). Furthermore, patients on azithromycin presented earlier clinical cure on Day 3 than patients on tobramycin. Azyter, with its convenient dosing (bid for 3 days), is a step forward in the management of purulent bacterial conjunctivitis.

Microbiological efficacy of 3-day treatment with azithromycin 1.5% eye-drops for purulent bacterial conjunctivitis

PURPOSE

Antibacterial efficacy of topically applied azithromycin 1.5% was compared with tobramycin 0.3% in a multicenter, randomized, investigator-masked study for the treatment of purulent bacterial conjunctivitis.

METHODS

A total of 1043 adults and children received either azithromycin twice daily for 3 days (n=524) or tobramycin every 2 hours while awake for 2 days, then four times daily for 5 days (n=519). Conjunctival swabbing was taken at days 0, 3, and 9, using alginate swabs resuspended in a dissolution-transport medium, providing rapid and reproducible results. Cagle's criteria were used to define the pathogenicity level for each isolated bacterium.

RESULTS

In the per-protocol set, the rate of bacteriologic resolution was 85.2% for azithromycin versus 83.8% for tobramycin on day 3, and 92.8% for azithromycin versus 94.6% for tobramycin on day 9. Azithromycin was demonstrated to be noninferior to tobramycin according to the 10% noninferiority margin. Although some bacteria were categorized as resistant to tested antibiotics, eradication was observed (for azithromycin: Acinetobacter, Enterobacteriaceae, Pseudomonas), highlighting the specific pharmacokinetics/pharmacodynamics of the ocular route.

CONCLUSIONS

In total, topical therapy with azithromycin 1.5% administered only twice daily for 3 days effectively eradicates most pathogenic bacteria associated with bacterial conjunctivitis. These microbiologic results are in accordance with the observed clinical outcome. This new anti-infective product has the advantage of a short treatment course which could lead to an improvement in patient compliance.

[Increasing compliance in glaucoma patients through education ]

Compliance is a major issue in glaucoma, a chronic and asymptomatic disease. The management of the disease by the patient himself is a key point in the prognosis of glaucoma. Ophthalmologists can increase glaucoma patient compliance through education and medicopsychological assistance.

Les risques des anti-infectieux

The main risk of anti-infectious drugs is the selection of resistant microorganisms that might be a threat for the human community. It requires a justified prescription of every antibiotic and antiseptic product, including the topicals such as eye drops. The risk of toxicity is less important because it is well known, it is obvious when it occurs, and because it is an individual and nontransmissible risk.

Manifestations neuro-ophtalmologiques révélatrices d’une neuro-sarcoïdose

PURPOSE

To describe different forms of neuro-ophthalmologic onset of sarcoidosis: clinical signs, means of diagnosis, treatment, and progression.

PATIENTS AND METHODS

Retrospective study of 13 patients with neuro-ophthalmologic initial onset of sarcoidosis diagnosed in three departments between 1997 and 2003.

RESULTS

There were ten women and three men, with a mean age of 36 years. Six patients suffered from diplopia. In three cases, the cavernous sinus was involved; the three other patients with diplopia had meningoradiculitis. Nine patients had infiltration of the anterior visual pathway: the optic nerve was involved in five cases, the chiasm in two cases, and two patients had papilledema. Two patients also had both symptoms. The dosage of the angiotensin-converting enzyme level was evaluated in 11 patients and was elevated in six cases. Nine patients underwent a lumbar puncture; the cerebrospinal fluid protein was high in seven cases. Chest radiography and CT were abnormal in nine cases of 11. Ten patients had histological proof of sarcoidosis; the three others had enough evidence to support this diagnosis. All of them were treated with systemic corticosteroids. The diplopia improved for the six patients. Among the seven patients with optic nerve or chiasmal infiltration, one recovered completely, two were partially improved, and four remained stable.

CONCLUSIONS

Diplopia and anterior visual pathway abnormalities can be the manifestation of initial onset of sarcoidosis; therefore this diagnosis must be kept in mind when these frequent neuro-ophthalmologic signs are encountered. Complementary exams, mainly biopsy of the involved areas with histological analysis, are needed to confirm this diagnosis. Corticosteroid treatment is generally followed by improvement, but relapses may occur.

Description des pratiques pour la réalisation des injections intravitréennes

Drugs to treat retinal diseases are often injected intravitreally. This procedure can cause severe complications. We present ways to minimize the risk for complications. Rigorous preoperative antisepsis with povidone iodine, a sterile environment (using gloves and a mask for the injector, a lid speculum, and a drape on the eye to be injected), and immediate follow-up after injection are key issues of the injection technique.

Comparison of carteolol plasmatic levels after repeated instillations of long-acting and regular formulations of carteolol 2% in glaucoma patients

BACKGROUND

A new long-acting (LA) formulation of carteolol 2% instilled once daily has been shown to provide a therapeutic effect similar to that of the regular formulation of carteolol 2% instilled twice daily. This study was designed to test whether the new formulation reduces the systemic delivery of carteolol.

METHODS

In this double-masked, randomised, intra-subject comparative study, 23 patients with bilateral primary open-angle glaucoma or bilateral ocular hypertension received sequentially, according to the randomised order of administration, each of the 2 following treatments: carteolol 2% LA once daily for 2 months and carteolol 2% regular twice daily for 2 months. Treatments were instilled in both eyes throughout the study period. At the end of each period of treatment, blood samples were taken immediately before the last morning instillation (residual time), then 30 min, 1 h, 2 h and 4 h after this instillation in order to measure the carteolol plasma concentrations.

RESULTS

The mean values of maximal plasma concentration (C(max)), residual level and area under the curve obtained following carteolol 2% LA treatment were significantly lower than the values obtained after carteolol 2% regular treatment (mean+/-SD): C(max) (ng/ml): 1.72+/-0.85 versus 3.64+/-3.65; residual level (ng/ml): 0.70+/-0.58 versus 1.80+/-0.84; area under the curve (ng/mlxh): 5.50+/-2.66 versus 10.27+/-5.46. Regarding safety, two drug-related, non-serious adverse events were reported in the LA group: one case of moderate, superficial, punctate keratitis and one case of "bitter taste in the throat." Both treatments appeared to be well tolerated.

CONCLUSIONS

The data from this study showed that the systemic delivery of carteolol is lower for the once-daily LA formulation than for the regular twice-daily formulation. Consequently, long-acting carteolol eye-drops should reduce the risk of beta-blocking systemic side effects.

[Medical treatments and practices. Ascertaining maximal drug treatment]

Maximal drug treatment can be absolute, using all the combinations possible if no surgery can reasonably be undertaken, or relative, with surgery as the next step. The drug treatment is chosen in collaboration with the patient, who should always receive attentive explanations, detailing the prescription and adapting it to each situation so as to achieve maximum compliance.