Maladie de Vogt Koyanagi Harada chez un jeune homme compliquée d’une réactivation de tuberculose et d’une vasculite occlusive rétinienne

Nous rapportons le cas d’un jeune homme de dix-sept ans présentant une baisse d’acuité visuelle bilatérale, une panuvéite, des décollements rétiniens exsudatifs et une infiltration choroïdienne diffuse. Le patient rapporte également des céphalées et otalgies. Sur base du fond d’œil, de la fluoangiographie, de l’angiographie au vert d’indocyanine et de la tomographie par cohérence optique, le diagnostic de maladie de Vogt Koyanagi Harada est posé. Le traitement par hautes doses de methylprednisolone et azathioprine montre une excellente réponse avec amélioration progressive de l’acuité visuelle et disparition du liquide sous-rétinien. Un mois après l’instauration du traitement, l’œil droit présente une vasculite rétinienne sectorielle avec subocclusion de la veine temporale inférieure et hémorragies sous-rétiniennes massives. Les tests de coagulation sanguine ainsi que les sérologies HIV et syphilis sont négatifs mais le QuantiFERON revient positif. Le pet-scan met en évidence des ganglions lymphatiques hyper métaboliques au niveau médiastinal et la biopsie confirme une tuberculose ganglionnaire active. Une thérapie antituberculeuse à base de rifampicine est initiée, entrainant une induction enzymatique du cytochrome p450 avec comme conséquence une baisse de l’efficacité des corticoïdes menant à une récidive de l’inflammation choroïdienne.[Vogt-Koyanagi-Harada disease in a young man, which was complicated by tuberculosis reactivation and occlusive retinal vasculitis] We report the case of a 17-year-old man presenting with bilateral visual loss, panuveitis, exudative retinal detachments, and diffuse choroidal infiltration. The patient also complained of headaches and ear pain. Based on the fundus image analysis, fluoangiography, indocyanine green angiography, and optical coherence tomography, Vogt-Koyagani-Harada disease was diagnosed. The patient received high-dose methylprednisolone along with azathioprine. He responded well to treatment with progressive visual improvement and subretinal fluid disappearance. One month later, his right eye exhibited a sectorial retinal vasculitis with inferotemporal vein branch occlusion and massive subretinal hemorrhages. Coagulation screening as well as HIV and syphilis serology were all negative; whereas QuantiFERON was positive. An 18F-FDG PET/CT revealed hypermetabolic mediastinal lymph nodes, and a biopsy confirmed active tuberculosis (TB) infection. Anti-TB quadritherapy was initiated, resulting in cytochrome P450 enzyme induction and lowered steroid treatment efficacy, with consecutive recurrence of choroidal inflammation

Hibernoma mimicking liposarcoma

A 26-year-old man was referred to the ophthalmology department with a 1-week history of blurred vision of the left eye; there was no pain or redness. Ophthalmological examination found unilateral choriocapillaropathy with optic nerve oedema. He was in a stable relationship and had not travelled abroad recently, nor had he been in contact with any animals or pets. He had a history of ulcerative colitis diagnosed 2 years earlier for which he was treated for 1 year with azathioprine and oral corticosteroids. Since then he had been totally asymptomatic. [...

Traitement de la dégénérescence maculaire liée à l'âge par injections intravitréennes de bevacizumab (Avastin): résultats à court-terme.

PURPOSE: To analyse short term visual outcomes and macular morphologic changes associated with intravitreal injection of bevacizumab (Avastin) therapy for subfoveal choroidal neovascularization (CNV) in age-related macular degeneration (AMD) METHOD: Retrospective study of 59 eyes. Each included eye received 3 intravitreal injections of 1.25 mg bevacizumab at 4 to 6-week intervals. Mean follow-up was 5.5 months (range 3 to 9). Best-corrected visual acuity, ophthalmoscopic examination, optic coherence tomography and fluorescein or green indocyanin angiography were performed before and routinely after the treatment. RESULTS: A total of 160 injections were performed with a mean value of 2.7 (1-6) per eye. Visual acuity improved at least two lines in 17% (10 eyes), worsened at least two lines in 14% (8 eyes) and was stabilized in 69% (41 eyes). Among that last group of 41 eyes, a significative reduction of macular thickness was observed in more than 39% (12 eyes) and a subjective improvement with less metamorphopsia and better visual comfort was noticed in 24% (10 eyes). No intraocular or systemic adverse effects were observed except a self-limited iritis in two cases. CONCLUSION: Intravitreal bevacizumab therapy resulted in visual and morphologic improvements in a significant number of cases of advanced AMD with CNV. Randomized studies and longer follow-up are needed to confirm these preliminary results

Atypical spherical deposition on vitreoretinal interface associated with toxoplasmic chorioretinitis

PURPOSE: To report the clinical and optical coherence tomography features of spherical deposits associated with recurrent toxoplasmic chorioretinitis. METHODS: Case report. RESULTS: Atypical, 100 microm to 150 microm, greyish deposits appeared along retinal arteries and veins as well as on the vitreoretinal interface in the macula of a 44-year-old Caucasian woman while she was being treated for recurrent toxoplasmic chorioretinitis with antiparasitic drugs and subconjunctival injection of betamethasone. They disappeared progressively with the systemic use of corticosteroids. Their clinical course was nicely documented by optical coherence tomography. CONCLUSIONS: Greyish spherical deposits on the vitreoretinal interface have been previously described as inflammatory reactions in asymptomatic human T-lymphotropic virus type I (HTLV-1) carriers and in patients with HTLV-1-associated uveitis. For the first time, optical coherence tomography (OCT) provided clinical correlation of this unusual presentation of toxoplasmic chorioretinitis

Hibernoma mimicking liposarcoma

A 26-year-old man was referred to the ophthalmology department with a 1-week history of blurred vision of the left eye; there was no pain or redness. Ophthalmological examination found unilateral choriocapillaropathy with optic nerve oedema. He was in a stable relationship and had not travelled abroad recently, nor had he been in contact with any animals or pets. He had a history of ulcerative colitis diagnosed 2 years earlier for which he was treated for 1 year with azathioprine and oral corticosteroids. Since then he had been totally asymptomatic. [...

Intravitreal Aflibercept Treatment Strategies in Routine Clinical Practice of Neovascular Age-Related Macular Degeneration in Belgium: A Retrospective Observational Study.

INTRODUCTION: STELLAR was a Belgian, multicentre, retrospective, observational chart review that described the utilization (number of injections and treatment regimen) and effectiveness of intravitreal aflibercept (IVT-AFL) in patients with anti-vascular endothelial growth factor (VEGF) treatment-naïve neovascular age-related macular degeneration (nAMD) during the first 12 months of IVT-AFL treatment. METHODS: Patients initiating IVT-AFL between July 2013 and July 2017 were included in STELLAR. Primary endpoints were number of visits and IVT-AFL injections, and number of patients who received ≥ 7 versus < 7 IVT-AFL injections during the first 12 months of treatment. RESULTS: A total of 337 patients completed ≥ 12 months of IVT-AFL treatment. The mean number of visits and mean number of injections during the first 12 months was 9.8 and 7.1 injections, respectively (64% received ≥ 7 injections). Overall, 96% of patients received ≥ 3 initial monthly injections. Of the 337 patients, 180 received VT-AFL as needed (pro re nata), 141 received it as treat-and-extend dosing and 16 received it as fixed dosing. The proportion of patients who received treat-and-extend dosing increased year-on-year. Mean best-corrected visual acuity (BCVA) (± standard deviation) was 61.6 (± 14.9) Early Treatment Diabetic Retinopathy Study (ETDRS) letters at baseline and improved by + 3.9 and + 5.7 ETDRS letters at 3 and 12 months, respectively. Mean BCVA improvement was numerically greater in patients who received ≥ 7 versus < 7 injections during the first 12 months 7 (+ 6.5 vs. + 4.4 ETDRS letters) and in patients who received ≥ 3 versus < 3 initial monthly injections (+ 5.2 vs. - 0.25 ETDRS letters [3 at months]; + 5.9 vs + 1.2 ETDRS letters [at 12 months]). No specific adverse events were reported. CONCLUSION: Most patients in this Belgian study received ≥ 7 IVT-AFL injections during a mean of 9.8 visits over the 12 months assessed. IVT-AFL was an effective treatment for nAMD in clinical practice, with numerically higher BCVA gains in patients receiving ≥ 7 versus < 7 injections over the first 12 months and ≥ 3 versus < 3 injections in the first 3 months

Cherchez la petite bête…

La fièvre boutonneuse méditerranéenne, est une rickettsiose endémique en Afrique sub-saharienne, en Asie du sud et dans le pourtour méditerranéen. Nous décrivons ici deux cas rencontrés à quelques jours d’intervalle dans nos unités de médecine interne, avec pour l’un deux une manifestation ophtalmologique plus inhabituelle[In search for the little beast ...] Mediterranean spotted fever is a rickettsial infection, endemic in sub-Saharan Africa, south Asia, and on the Mediterranean periphery. We herein report two cases, which were seen only a few days apart in our internal medicine units, with one of them bearing an uncommon ophthalmological presentation

Epidemiology, clinical presentation, treatment, and outcome of neurosarcoidosis: A mono-centric retrospective study and literature review.

Neurosarcoidosis is a rare granulomatous disorder, and treatment guidelines are mainly based on retrospective studies. This retrospective study was performed to provide a detailed description of the clinical characteristics and treatment outcomes of patients with neurosarcoidosis followed at Cliniques Universitaires Saint Luc in Belgium. The second objective of our study was to perform a comparative literature review of neurosarcoidosis, with a focus on treatment outcomes with the use of TNF-α antagonist. Among 180 patients with sarcoidosis followed in our hospital, 22 patients with neurosarcoidosis were included in the final analysis. Our literature research identified 776 articles of which 35 articles met our inclusion criteria, including 1,793 patients diagnosed with neurosarcoidosis. In our cohort, the majority of patients (86%) were diagnosed with systemic sarcoidosis which was similar to that reported in the literature (83%). Serum CRP and calcemia were elevated only in 33 and 18% of patients, respectively. Serum lysozyme and angiotensin-converting enzyme were elevated in 79 and 16% of patients, respectively. Lumbar puncture and CSF fluid analysis were performed in 15/22 patients and were abnormal in all patients. Brain MRI was performed in 21/22 patients and showed abnormalities in 16 patients consisting of parenchymal lesions in 63%, hypothalamic-pituitary axis lesions in 38%, and meningeal enhancement in 31%. In both cohort patients, methotrexate was the most frequently used treatment (>45% of cases) with a favorable outcome in an average of 50% of patients. A TNF-α antagonist was administered in 9% of patients in our cohort and in 27% of patients in the literature review. The proportion of favorable outcomes in literature research was significantly higher in patients treated with TNF-α antagonists compared to methotrexate ( < 0.0001), mycophenolate mofetil ( < 0.0001), or azathioprine ( < 0.0001). The results of our cohort and literature review confirm that neurosarcoidosis occurred most frequently in the context of systemic sarcoidosis. Methotrexate is the most frequent second-line therapy. The effectiveness of therapy with TNF-α antagonists is well-demonstrated and associated with a better outcome. Their earlier use during the disease course among aggressive and/or refractory neurosarcoidosis should be considered

Acute visual loss following dapsone-induced methemoglobinemia and hemolysis

Objective. While methemoglobinemia is a possible complication of chronic dapsone therapy or of acute overdose, serious adverse manifestations related to methemoglobin formation remain rare. We present an unusual case with severe ischemic retinal injury. Case report. A 30-year-old African woman presented with a sudden decrease of visual acuity secondary to retinal ischemia. She was chronically treated with dapsone (50 mg/day) for a dermatologic disease and denied any drug overdose. However, the determination of serum dapsone level on admission revealed a largely supratherapeutic concentration (20,044 μg/ml compared with 1-3.5 ± 0.5 μg/ml for therapeutic levels). The methemoglobin level at admission was 32% (sulfhemoglobin 1.2%), with hemoglobin level, 7.4 g/dl, schistocytes count, 2-5%, lactate dehydrogenase level, 580 IU/l, and haptoglobin level, &lt; 10 mg/dl. The patient had both alpha-thalassemia and sickle cell trait. She was treated with methylene blue, vitamin C, and exchange transfusion. There was no improvement in visual symptoms over time. Conclusions. In a patient with supratherapeutic serum levels of dapsone, the severity of visual injury was associated with dapsone-induced methemoglobinemia and hemolysis, and perhaps also with some hematologic predisposing factors