Alessandro Invernizzi

Choroidal granulomas visualized by enhanced depth imaging optical coherence tomography.

Purpose: To assess the visualization of choroidal granulomas (CG) by enhanced depth imaging optical coherence tomography (EDI-OCT) and to describe their EDI-OCT characteristics. Methods: Combined indocyanine green (ICG) angiography and EDI-OCT images of 44 CG (sarcoid, tubercular, or Vogt–Koyanagi–Harada related) were reviewed. By ICG angiography, CG were classified as full thickness or partial thickness and as small or large. Two independent operators evaluated EDI-OCT scans over granulomas to record their characteristics (full thickness/partial thickness, shape, reflectivity, internal pattern, margins, and shadowing/increased transmission effect). The agreement between ICG angiography and EDI-OCT, the interobserver agreement, and the correlations between EDI-OCT features and lesion size or disease were studied. Results: Enhanced depth imaging optical coherence tomography could visualize 100% of CG detected on ICG. Lesions resulted full thickness in 90.9% and 77.3% of the cases on ICG angiography and EDI-OCT, respectively (K = 0.5). All CG were more homogeneous and showed increased transmission of the optical coherence tomography signal as compared with the surrounding choroid. Choroidal granulomas angiographic size influenced lesions characteristics on EDI-OCT. Large granulomas were more likely to be full thickness, round shaped, with defined margins, lower reflective than the surrounding structures, and with internal homogenous pattern. The type of disease significantly influenced CG shape and pattern. Most of tubercular-related lesions showed lobulated shape and nonhomogeneous internal pattern. Conclusion: Enhanced depth imaging optical coherence tomography is suitable to visualize CG and to describe their characteristics. Choroidal granulomas size and disease influence lesions appearance on EDI-OCT. Increased transmission effect could be helpful for CG identification.

Choroidal Findings in Dome-Shaped Macula in Highly Myopic Eyes: A Longitudinal Study

PURPOSE To describe choroidal findings in dome-shaped macula associated with high myopia using fluorescein angiography (FA), indocyanine green angiography (ICGA), and spectral-domain optical coherence tomography (SD OCT), and to elucidate the mechanism and natural course of serous retinal detachment (RD) associated with dome-shaped macula. DESIGN Retrospective, observational case series. METHODS We reviewed longitudinal imaging results of 52 highly myopic eyes with dome-shaped macula. Changes on FA and ICGA were assessed. Retinal, choroidal, and scleral thicknesses and bulge height were measured on SD OCT. RESULTS Serous RD was the most common abnormality associated with dome-shaped macula, detected by SD OCT in 44% of the cases with no associated choroidal neovascularization. Significant differences in the proportion of eyes with pinpoint leakage on FA (P < .001), punctate hypercyanescence on ICGA (P < .001), and pigment epithelium detachment on SD OCT (P < .001) were noted inside the inward bulge of the staphyloma between eyes with and without serous RD. Serous RD was not associated with hyperpermeability areas on ICGA. Eyes with serous RD had thicker choroid (P = .004) and tended to have thicker sclera (P = .067) and greater bulge height (P = .079). Choroidal thickness, scleral thickness, and bulge height were positively correlated (P < .01). All eyes presented a fluctuating course of serous RD during follow-up. Worsening of serous RD was associated with appearance of new punctate hypercyanescent spots on ICGA and leaking points on FA (P < .001 and P = .016, respectively). CONCLUSION Serous RD in dome-shaped macula was likely caused by choroidal vascular changes, similar to central serous chorioretinopathy, but specifically confined in the inward bulge of the staphyloma and secondary to excessive scleral thickening. Serous retinal detachment showed fluctuating changes over time, with alternating active and inactive stages. Angiographic findings in dome-shaped macula suggest the choroid as a target for possible treatment strategies.

The Role of Optical Coherence Tomography Angiography in the Diagnosis and Management of Acute Vogt–Koyanagi–Harada Disease

ABSTRACT Purpose: To report the imaging characteristics of acute Vogt–Koyanagi–Harada (VKH) disease using optical coherence tomography angiography (OCTA). Methods: In this prospective study, patients with acute VKH (n = 10; mean age: 30.5 ± 13.43 years) underwent multimodal imaging (baseline and follow-up) using fundus photography, fluorescein angiography (FA), indocyanine green angiography (ICGA), OCT, and OCTA. The OCTA images were analyzed to assess the retinochoroidal vasculature and compared with other imaging techniques. Results: During the active stage, all eyes showed multiple foci of choriocapillaris flow void that correlated with ICGA. These foci decreased in number and size after initiation of therapy. In one patient, flow void areas reappeared after cessation of therapy without any detectable change on ICGA. This patient soon developed clinical recurrence requiring re-initiation of immunosuppression. Conclusions: OCTA allows high-resolution imaging of inflammatory foci suggestive of choriocapillaris hypoperfusion in acute VKH disease non-invasively. OCTA may be very helpful in the follow-up of such patients.

Enhanced depth imaging optical coherence tomography features of choroidal osteoma.

Purpose: To describe the choroidal findings in eyes affected by choroidal osteoma imaged by enhanced depth imaging optical coherence tomography. Methods: Retrospective case series. Results: Seven eyes from five patients with choroidal osteoma were included in the study. Patients mean age of presentation was 26 years (median, 34; range, 6–37 years) and mean best-corrected visual acuity was 20/32 (median, 20/20; range, 20/20–20/200). Enhanced depth imaging optical coherence tomography examination revealed normal inner retina in all the cases and normal outer retina in three eyes. Abnormalities included irregularities in external limiting membrane (n = 2), myoid zone (n = 1), ellipsoid junction (n = 4), cone outer segments of photoreceptors (n = 5), and retinal pigment epithelium (n = 3). Choroidal analysis revealed thinned (n = 4) or non visible (n = 2) choriocapillaris, thinned (n = 3) or non visible (n = 4) medium vessels, and thinned large vessels layer (n = 4). The osteoma showed multiple intralesional layers (n = 5), a sponge-like appearance (n = 7), and intralesional vessels (n = 7). The sclero-choroidal junction was visible in all cases. Choroidal neovascularization was found in four eyes. Conclusion: Analysis of eyes affected by choroidal osteoma revealed a characteristic sponge-like tumor appearance with the presence of multiple intralesional layers. The lesion showed a typical transparency with visibility of sclero-choroidal junction in all cases.

ENHANCED DEPTH IMAGING OPTICAL COHERENCE TOMOGRAPHY FEATURES IN AREAS OF CHORIOCAPILLARIS HYPOPERFUSION

Purpose: To detect choriocapillaris changes by enhanced depth imaging optical coherence tomography (EDI-OCT) in areas of choriocapillaris hypoperfusion visualized on indocyanine green angiography. Methods: Combined indocyanine green angiography and EDI-OCT from patients diagnosed with inflammatory choriocapillaris hypoperfusion were retrospectively analyzed. The EDI-OCTs were compared with indocyanine green angiography to detect choriocapillaris changes suggestive of choriocapillaris hypoperfusion in both active stage (AS) and inactive stage of the disease. The EDI-OCT was graded by two independent observers for choriocapillaris pattern (normal/altered) and reflectivity (hyper/hypo/isoreflective) changes. Manual measurements of choriocapillaris thickness were obtained. Interobserver agreement was assessed using Cohens kappa, and differences in groups were assessed using McNemars test. Results: Forty-two lesions from 11 eyes (8 patients, 3 males) were analyzed. Three patients (4 eyes, 17 lesions) were diagnosed with serpiginous choroiditis, and 5 patients (7 eyes, 25 lesions) were diagnosed with acute posterior multifocal placoid pigmented epitheliopathy. All the lesions demonstrated choriocapillaris hyporeflectivity on EDI-OCT during AS and isoreflectivity during inactive stage. The characteristic choriocapillaris dotted pattern was absent during AS. Choriocapillaris thickness at the sites of hypoperfusion was significantly higher during AS (63.07 ± 16.47 &mgr;m) than in inactive stage (22.92 ± 7.65 &mgr;m) (P < 0.001). Disruption of retinal pigment epithelium during AS was strongly associated with choriocapillaris atrophy during follow-up (P < 0.001). Conclusion: The EDI-OCT shows characteristic choriocapillaris changes suggestive of choriocapillaris hypoperfusion that correlate with ischemia on indocyanine green angiography during both AS and inactive stage of the disease.

Aligning scan locations from consecutive spectral-domain optical coherence tomography examinations: a comparison among different strategies.

PURPOSE We compared intrasession repeatability values produced by different spectral-domain optical coherence tomography (SD-OCT) instruments when measuring macular retinal thickness from consecutive examinations. METHODS A total of 40 eyes from 23 healthy subjects and 47 eyes from 42 patients with macular edema were enrolled in the study. Subjects underwent two consecutive SD-OCT examinations using three instruments: spectralis HRA+OCT, Cirrus, and RS 3000. For the second SD-OCT examination, the scan location was aligned to the baseline exam using different strategies: RS 3000 eye-tracking (pre-acquisition), Spectralis follow-up (during acquisition), Cirrus fovea finding (postacquisition), and Cirrus macular change analysis (postacquisition). Macular retinal thickness values from the consecutive examinations were evaluated to assess repeatability of the measurements. RESULTS In healthy subjects all of the strategies used for scan location alignment for the second examination provided good repeatability. For instance, intraclass correlation coefficients (ICC) from the central subfield were between 0.88 (RS 3000 eye-tracking) and 0.99 (Spectralis follow-up). In subjects affected by macular edema, the results were excellent. Cirrus macular change analysis and Spectralis follow-up produced ICC values equaled 1.00 in the central subfield. Cirrus fovea finding and RS 3000 eye-tracking produced slightly lower ICC values (0.98 and 0.99, respectively) in the central subfield. CONCLUSIONS All of the strategies for aligning consecutive SD-OCT scan locations produced repeatable retinal thickness values. The best results were obtained using the Spectralis with follow-up and Cirrus with macular change analysis.

Searching for viral antibodies and genome in intraocular fluids of patients with Fuchs uveitis and non-infectious uveitis

BackgroundTo characterise the polyspecific intraocular antibody synthesis in aqueous humor of patients with Fuchs uveitis and other types of non-infectious uveitis.MethodsAqueous and serum samples collected from 24 patients with Fuchs uveitis, 21 patients with non-infectious uveitis, and 27 healthy subjects undergoing elective cataract surgery (control group) were analysed. In addition, vitreous samples, collected from seven uveitis patients (five Fuchs and two panuveitis) during retinal surgery, were examined. Specific immunoglobulin G antibodies against cytomegalovirus (CMV), rubella virus, herpes simplex virus (HSV), and varicella zoster virus (VZV) were investigated, and Goldmann–Witmer coefficients (GWCs) were calculated. Real-time PCR was performed to detect viral genome for HSV, VZV, and CMV, while nested PCR was conducted to detect rubella RNA.ResultsNone of the control samples tested positive for any of the viral antibodies investigated. Intraocular antibody production was found in eight samples of patients affected by Fuchs uveitis (6/8 positive for rubella virus and 2/8 positive for herpes virus). Among patients with non-infectious uveitis, three tested positive for intraocular antibody production (one RV, one HSV and one for VZV). PCR was positive for RV in two patients with Fuchs uveitis, in three patients with non-infectious uveitis (one for RV and two for HSV), and in three control subjects (one for CMV and one for HSV).ConclusionsOur series confirmed the presence of specific viral antibodies, especially against rubella virus, in the subgroup of patients affected by Fuchs uveitis, suggesting that this virus may be responsible for this chronic inflammatory condition. Rubella virus is probably the main causative agent of Fuchs uveitis, but other viruses may also be involved in the pathogenesis of this disease.

LONGITUDINAL FOLLOW-UP OF CHOROIDAL GRANULOMAS USING ENHANCED DEPTH IMAGING OPTICAL COHERENCE TOMOGRAPHY

Purpose: To assess the ability of enhanced depth imaging optical coherence tomography (EDI-OCT) in detecting variations in the structure and size of choroidal granulomas in response to treatment and to compare these findings with indocyanine green angiography (ICGA). Methods: EDI-OCT and ICGA images of choroidal granulomas in eyes of patients diagnosed with tubercular or sarcoid uveitis were obtained at baseline and follow-up visits. Two independent masked observers analyzed the lesions to compare changes in their structural features such as shape, reflectivity, and margins, among others, through time. The size of each lesion was manually measured on EDI-OCT and ICGA images at all the visits. In addition, longitudinal assessment of choroidal area was performed on the EDI-OCT images during the course of follow-up. Results: Twenty-eight granulomas (16 tubercular and 12 sarcoid; 7 patients) were included in the study. Using EDI-OCT, significant decrease in the mean size of lesions could be appreciated after 1 month of treatment (0.29 mm2 at baseline vs. 0.18 mm2 at 1 month; P < 0.001). However, ICGA did not reveal significant decrease in lesion size at 1 month compared with baseline (0.94 vs. 0.76 mm2; P = 0.07). The granulomas followed a characteristic healing pattern in which the antero-posterior extent (depth) decreased first, followed by decrease in their lateral extent. Apart from size, the choroidal granulomas did not show significant changes in their morphological features on EDI-OCT with treatment. Conclusion: EDI-OCT may be more sensitive than ICGA in detecting early variations in the size of choroidal granulomas. Morphometric analyses of choroidal granulomas on EDI-OCT may be very useful in monitoring the response to treatment in patients with choroidal granulomas.

Optic nerve head tubercular granuloma successfully treated with anti-VEGF intravitreal injections in addition to systemic therapy

Purpose To describe a case of optic nerve head tubercular granuloma, unresponsive to conventional therapy (antitubercular drugs and systemic steroids), successfully treated with anti–vascular endothelial growth factor (VEGF) intravitreal injections in addition to systemic drugs. Methods Case report. Results A 44-year-old patient was referred to our clinic for progressive vision decrease in his left eye during the preceding 4 months. A large granuloma infiltrating optic nerve head was visible at funduscopic examination along with diffuse intraocular inflammation. Workup for granulomatous uveitis supported the diagnosis of presumed intraocular tuberculosis. However, the large granulomatous lesion did not show a good response to conventional therapy for tubercular uveitis (antitubercular drugs and systemic steroids). Anti-VEGF (bevacizumab) intravitreal injections were performed as an adjunct to the ongoing therapy. After 2 injections, the patient showed an almost complete regression of the lesion (demonstrated by optical coherence tomography) and a restoration of vision. Conclusions Anti-VEGF intravitreal injections should be considered in the treatment of large tubercular granulomatous lesions in addition to conventional systemic therapy. Optical coherence tomography could be a suitable tool for studying and following optic nerve head granulomas.

Retrobulbar Structure Visualization With Enhanced Depth Imaging Optical Coherence Tomography

PURPOSE To assess enhanced depth imaging optical coherence tomography (EDI-OCT) visualization of deep posterior pole structures and retrobulbar tissues in myopic eyes and evaluate ocular structural elements that influence this capability. METHODS Thirty consecutive myopic eyes (>-6 diopters) from 21 patients were enrolled. Exclusion criteria included any pathological condition affecting the posterior pole. Patients underwent biometry to assess axial length, and irises were classified as darkly or lightly pigmented. EDI-OCT scans were obtained by spectral-domain OCT to image posterior pole and retrobulbar structures. Choroidal thickness was measured manually, and for eyes in which the sclera was fully visible, scleral thickness was also measured manually. The influence of central retinal thickness, axial length, refractive error, mean choroidal thickness, mean scleral thickness, and iris pigmentation on EDI-OCT visualization of structures beyond the choroid was tested. RESULTS Choroidal thickness was measurable in all eyes. In 11 of 30 eyes, the sclera was not completely visible (group 1). In 19 eyes, the full scleral thickness was measurable (group 2). In seven of the group 2 eyes, the full sclera was the deepest structure detected. In the remaining 11 eyes, deeper structures were visible. Choroidal thickness was the only parameter that correlated with the ability to visualize the full sclera (P < 0.001) and deeper structures (P = 0.044). CONCLUSIONS The full thickness of the choroid was visualized by EDI-OCT in all eyes. Full thicknesses of the sclera and retrobulbar structures were not always visible. Choroidal thickness was the only parameter that significantly correlated with EDI-OCT visualization of deeper structures.