PMC:7190488 JSONTXT

{"target":"https://pubannotation.org/docs/sourcedb/PMC/sourceid/7190488","sourcedb":"PMC","sourceid":"7190488","source_url":"https://www.ncbi.nlm.nih.gov/pmc/7190488","text":"Conduite à tenir pour le suivi des patients atteints d’uvéite au cours de la pandémie Covid-19☆\nHow to approach follow-up of uveitis patients during the Covid-19 pandemic?\n\nL’uvéite touche une population d’âge variable avec un risque non négligeable de développer des formes graves du Covid-19. Le recours aux stéroïdes ou immunosuppresseurs mérite des précautions et une évaluation du bénéfice-risque.\n\nPrise en charge ambulatoire\n\nEn cas de premier épisode d’uvéite antérieure ou récidive aiguë\nAttention : Une consultation pour œil rouge peut correspondre à une conjonctivite Covid-19 et il est indispensable de porter des gants lors de l’examen de ces patients.\nLe fond d’œil est indispensable pour éliminer les causes infectieuses classiques pouvant imposer une hospitalisation.\nIl faut maintenir la consultation de contrôle à 48–72 heures (ou une semaine) puis la téléconsultation est à privilégier si amélioration.\nLa corticothérapie collyre n’est pas contre-indiquée, tout en favorisant une décroissance très lente de la corticothérapie afin d’éviter un rebond inflammatoire.\nEn l’absence de signe général, ou d’immunodépression, avec atteinte unilatérale et amélioration rapide : le bilan étiologique pourra être réalisé sans urgence dans le mois.\nSigne général, immunosuppression, atteinte bilatérale ou absence d’amélioration à 48 h : un bilan étiologique rapide est envisagé.\n\nEn cas d’uvéite antérieure suivie et traitée par collyres corticoïdes seuls\nSi l'uvéite est stabilisée : Pas de consultation. Ne pas procéder à la décroissance des corticoïdes topiques et garder le nombre minimal de gouttes ayant permis l’accalmie (si \u003c 5gtes/j de DXM). Si PIO limite (\u003e 20 mmHg) un hypotonisant prophylactique peut être proposé.\nSi l'uvéite est non contrôlée : consultation.\nEn cas d’uvéite ou sclérite suivie et traitée par corticoïdes systémiques et/ou immunosuppresseurs et/ou agents biologiques.\nSi uvéite chronique ou sclérite chronique ou stabilisées : Pas de consultation. Ne pas procéder à la décroissance des corticoïdes et garder la dose minimale ayant permis l’accalmie. En l’absence d’argument pour une infection par le SARS-CoV-2, ne pas différer l’administration des immunosuppresseurs ou biothérapies IV s’il n’est pas possible de traiter l’inflammation par voie sous cutanée ou orale. Les bilans sanguins de contrôle de la tolérance doivent être espacés si possible (si normalité sur les 2 derniers mois).\nSi uvéite/sclérite non contrôlée ou avec menace visuelle : Consultation. En l’absence d’argument pour une infection par le SARS-CoV-2, des traitements anti-infectieux ou bolus de méthylprednisolone peuvent être administrés en hospitalisation après avoir pesé la balance bénéfice/risque (monophtalme, atteinte maculaire sévère ou du nerf optique etc…). Dans les autres cas, les traitements stéroïdes locaux seront à privilégier pour permettre de différer le traitement systémique chez les patients Covid+.\n\nEn cas de kérato-uvéite herpétique ou rétinochoroïdite toxoplasmique\nPour le premier épisode : mise en route du traitement avec rythme de surveillance adapté au cas par cas et si possible sans corticothérapie associée. Prise en charge spécialisée si menace visuelle.\nInstaurer un suivi en téléconsultation pour modulation thérapeutique avec le cas échéant prise en charge spécialisée.\n\nLes injections intravitréennes\nLes IVT de corticoïdes pour œdème maculaire ou hyalite peuvent théoriquement être différées en l’absence de menace visuelle immédiate. Elles seront discutées si situation d’urgence chez un patient Covid+ contre-indiquant le traitement systémique. Privilégier les IVT aux injections sous-ténoniennes car la diffusion extraoculaire sanguine est quasi-nulle avec les premières.\nLes IVT d’anti VEGF pour néovascularisation choroïdienne inflammatoire doivent être maintenues. Comme pour la myopie forte un régime PRN est à privilégier. Si impossibilité d’examiner le patient avant IVT (pour limiter le risque de contracter le SARS-CoV-2), un régime fixe mensuel court (2 à 3 mois maximum) peut être choisi si une seule IVT n’induit pas d’amélioration visuelle notable.\n\nPrise en charge hospitalière\nUne prise en charge hospitalière est envisagée dans ces cas :• endothélite herpétique ou zona ophtalmique de l’immunodéprimé imposant un traitement antiviral IV ;\n• rétinites virales (aiguës) imposant des injections intravitréennes et IV d’antiviraux ;\n• uvéites bactériennes sévères ;\n• endophtalmies imposant des injections intravitréennes et IV d’antibiotiques ou d’antifongiques ;\n• uvéite postérieure ou panuvéite sévère avec AV \u003c 5/10, tyndall \u003e 3+, FO non accessible ou hyalite \u003e 2+, foyer ou nécrose rétinienne, menace maculaire ou papillaire ne pouvant pas bénéficier d’un traitement local.\n\nDans tous les cas\nL’évaluation du patient atteint d’uvéite est consommatrice d’examens (flare, angiographies, OCT). Il est demandé aux professionnels de ne les réaliser que si ces examens sont jugés indispensables.\nChez le patient supposé Covid-, il ne faut pas arrêter les traitements anti-infectieux, corticoïdes et/ou immunosuppresseurs et/ou biothérapies sous peine d’induire un rebond inflammatoire sévère à l’arrêt et donc un recours à des doses encore plus fortes de stéroïdes.\nSi fièvre, ou toux ou signes respiratoires chez un patient sous corticoïdes systémiques ou immunosuppresseurs ou agents biologiques : Consultation, prélèvement SARS-CoV-2 et arrêt transitoire des traitements immunosuppresseurs et/ou biologiques avec maintien d’une faible corticothérapie à discuter au cas par cas.\nEn cas d’uvéite nécessitant des corticoïdes et/ou des immunosuppresseurs et/ou des agents biologiques, il est préférable de retarder l’initiation du traitement systémique chez les patients à risque ou Covid+. En cas de menace visuelle directe, la voie locale doit être privilégiée.\n\nRappel aux patients\nIl est rappelé les règles ci-dessous aux patients :• respect des mesures barrières et de distanciation sociale ;\n• si fièvre \u003e 38°, prendre du paracétamol (maximum 3 g/j) mais éviter les AINS ;\n• si signes infectieux de virose (malaise, toux, anosmie, agueusie, myalgies, diarrhées, céphalée, et/ou de fièvre \u003e 38°), contacter le médecin référent ;\n• si oppression thoracique et/ou essoufflement associés aux signes infectieux : appeler le 15.\n\nDéclaration de liens d’intérêts\nLes auteurs déclarent ne pas avoir de liens d’intérêts.\n\n☆ La première publication par la Société française d’ophtalmologie, le 30 mars 2020, est à retrouver à l’adresse 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