Aniruddha Agarwal

State of science: Choroidal thickness and systemic health

The choroid is a highly vascular structure; therefore, a wide range of systemic conditions can affect it. Conversely, choroid health may also give us insight into systemic health. With the emergence of optical coherence tomography, there has been a surge in the research on choroidal thickness and factors affecting it. Studies regarding the effect of systemic health on the choroid have largely been in the form of cross-sectional, prospective, and case studies. We offer a summary of recent findings on the topic.

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 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.

Endogenous endophthalmitis: diagnosis, management, and prognosis

Endogenous endophthalmitis is an ophthalmic emergency that can have severe sight-threatening complications. It is often a diagnostic challenge because it can manifest at any age and is associated with a number of underlying predisposing factors. Microorganisms associated with this condition vary along a broad spectrum. Depending upon the severity of the disease, both medical and surgical interventions may be employed. Due to rarity of the disease, there are no guidelines in literature for optimal management of these patients. In this review, treatment guidelines based on clinical data and microorganism profile have been proposed.

What have we learnt about the management of diabetic macular edema in the antivascular endothelial growth factor and corticosteroid era

Purpose of review To summarize the outcomes of the use of antivascular endothelial growth factor (anti-VEGF) agents and corticosteroids on the treatment paradigm for diabetic macular edema (DME). Recent findings Favorable efficacy data along with acceptable long-term safety results of anti-VEGF agents have made them the standard first-line therapy in the management of DME. Level I evidence from large, multicenter clinical trials has established the beneficial role of anti-VEGF agents and intravitreal steroids. In addition, the role of anti-VEGF agents in the treatment of diabetic retinopathy has also been recently recognized. However, concerns such as suboptimal response, VEGF resistance, and long-term effects on retinal layers and vasculature have also been highlighted recently. Summary The use of anti-VEGF agents and corticosteroids has revolutionized the management of DME. Despite the advantages including ease of administration, low incidence of adverse events, and concomitant improvement in retinopathy status, limitations of this therapeutic approach have been recognized. The current review will focus on the lessons learnt in the management of DME in the anti-VEGF and steroid era.

NOVEL FINDINGS ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN PATIENTS WITH TUBERCULAR SERPIGINOUS-LIKE CHOROIDITIS

Purpose: To analyze and describe the imaging characteristics of tubercular serpiginous-like choroiditis using optical coherence tomography angiography (OCTA) and to compare these findings with multimodal imaging. Methods: In this prospective cross-sectional study, multimodal imaging was performed in subjects with tubercular serpiginous-like choroiditis using OCTA (Optovue RTVue XR Avanti), enhanced-depth imaging OCT (Heidelberg Spectralis), fundus autofluorescence, fluorescein angiography, and indocyanine green angiography. Distinct morphologic features of the retinochoroidal vasculature at the sites of choroiditis lesions were analyzed on OCTA imaging. Multimodal imaging analysis was performed to study the changes observed on OCTA. Results: Eighteen eyes (18 subjects, 16 males) were included in the study. The en face OCTA images demonstrated discrete areas of flow void beneath the retinal pigment epithelium–Bruch membrane layer suggestive of choriocapillaris hypoperfusion that corresponded well with indocyanine green angiography, especially in the chronic phase. Additional information such as areas of preserved choriocapillaris, vascular tufts, and tangled vessels were observed using OCTA among lesions in advanced stages of healing. Compared with indocyanine green angiography, the areas of choriocapillaris atrophy appeared better defined on OCTA and correlated well with enhanced-depth imaging OCT. Conclusion: The OCTA images provide high-resolution structural information of the retinochoroidal vasculature in tubercular serpiginous-like choroiditis. Morphologic information obtained from OCTA images correlates well with and supplements other imaging techniques such as indocyanine green angiography and enhanced-depth imaging OCT.

Optical coherence tomography angiography: a non-invasive tool to image end-arterial system

Optical coherence tomography angiography (OCTA) is a relatively novel technology for in vivo imaging of vascular network. It uses moving erythrocytes as contrasting mechanism and avoids the use of intravenous dyes. A depth-resolved 3-dimensional image set can be generated within seconds using the technique of OCTA. Therefore, it possesses a great potential for widespread application in ophthalmic angiography. Herein we discuss the most common technologies behind OCTA and the scope of future technical improvement. We provide a perspective on advantages and disadvantages of OCTA over conventional fluorescein angiography and indocyanine green angiography. Lastly, current literature on the clinical application of OCTA in common ocular diseases including neovascular age-related macular degeneration, diabetic retinopathy, retinal artery and vein occlusion, and glaucoma are reviewed.

Novel Therapies in Development for Diabetic Macular Edema.

Diabetic macular edema (DME) secondary to diabetic retinopathy (DR) is a major cause for functional visual loss in the developed world. Laser photocoagulation has been used for decades in the treatment of DME. However, the advent of anti-vascular endothelial growth factor (anti-VEGF) has revolutionized the treatment of DME. Three important anti-VEGF agents whose efficacy has been well established via phase III clinical trials include ranibizumab, bevacizumab, and aflibercept. However, even in the era of anti-VEGF therapies, there are some challenges that retina specialists have to confront in managing patients with DME. These include the need for frequent treatment and an unpredictable response to therapy. There is evidence to suggest that pathways other than the VEGF pathway may be playing a role in the development of DME. Thus, extensive research is focused on development of novel agents that target these pathways. This review focuses on novel therapeutic agents in development, which may be used as a monotherapy or in combination with anti-VEGF agents, for the management of DME in the future.

Management of neovascular age-related macular degeneration: current state-of-the-art care for optimizing visual outcomes and therapies in development

Contemporary management of neovascular age-related macular degeneration (AMD) has evolved significantly over the last few years. The goal of treatment is shifting from merely salvaging vision to maintaining a high quality of life. There have been significant breakthroughs in the identification of viable drug targets and gene therapies. Imaging tools with near-histological precision have enhanced our knowledge about pathophysiological mechanisms that play a role in vision loss due to AMD. Visual, social, and vocational rehabilitation are all important treatment goals. In this review, evidence from landmark clinical trials is summarized to elucidate the optimum modern-day management of neovascular AMD. Therapeutic strategies currently under development, such as gene therapy and personalized medicine, are also described.

Optical Coherence Tomography Angiography Features of Paradoxical Worsening in Tubercular Multifocal Serpiginoid Choroiditis

ABSTRACT Purpose: To describe optical coherence tomography angiography (OCTA) features of lesions of tubercular multifocal serpiginoid choroiditis (TB MSC) that developed paradoxical worsening (PW). Methods: In this prospective study, subjects with TB MSC who developed PW upon initiation of anti-tubercular therapy were included. Multimodal imaging was performed using OCTA, enhanced-depth imaging OCT, fluorescein angiography (FA), and indocyanine green angiography (ICGA). Morphologic changes in the retinochoroidal vasculature during progression of TB MSC were assessed on OCTA. Results: Five subjects (4 males, 1 female) were included in the study. PW of the lesions was associated with increased areas of choriocapillaris flow void on en face OCTA in all eyes. The lesions showed partial healing in the center and continuous progression at the active edges. Two eyes showed development of vascular tufts on OCTA as the lesions progressed. Conclusions: OCTA provides high-resolution imaging of progressive choriocapillaris hypoperfusion among TB MSC patients developing PW of the disease.