Anouk Georges

Impact of reticular pseudodrusen on macular function.

Purpose: To investigate the impact of reticular pseudodrusen on macular function using microperimetry. Methods: Eighteen consecutive patients (18 eyes) with reticular pseudodrusen (Group 1), and without medium/large drusen, underwent microperimetry. Eighteen age-matched and sex-matched subjects (18 eyes) with typical drusen and without pseudodrusen (Group 2) also underwent microperimetry. Macular sensitivity was assessed by microperimetry and compared between the two Groups. Results: Mean age of patients with reticular pseudodrusen and with typical drusen was 77.3 ± 6.8 years and 75.0 ± 9.9 years, respectively (P = 0.4), and 61.1% and 61.1% were women, respectively. Mean best-corrected visual acuity was 0.14 ± 0.09 logarithm of the minimum angle of resolution and 0.13 ± 0.09 logarithm of the minimum angle of resolution (P = 0.8) in Group 1 and Group 2, respectively. Microperimetry revealed a significant difference in overall mean macular sensitivity (“square 7 × 7”; 49 points) between Group 1 and Group 2 (5.9 ± 1.7 dB vs. 8.8 ± 2.4 dB, P < 0.001). Both mean central macular sensitivity (“square 3 × 3”; 9 points) and mean peripheral macular microperimetric sensitivity (overall “square 7 × 7” − central “square 3 × 3”; 40 points) were significantly reduced in Group 1 compared with Group 2 (central macular sensitivity: 6.9 ± 1.7 dB vs. 8.9 ± 2.6 dB in Group 1 and Group 2, respectively; P = 0.01; peripheral macular sensitivity: 5.7 ± 1.8 dB vs. 8.7 ± 2.3 dB in Group 1 and Group 2, respectively; P < 0.001). In Group 1, mean peripheral sensitivity was reduced when compared with mean central sensitivity (5.7 ± 1.8 dB vs. 6.9 ± 1.7 dB, P = 0.01), whereas in Group 2, mean sensitivity was similar in both peripheral and central macula (8.7 ± 2.3 dB vs. 8.9 ± 2.6 dB, P = 0.4). Conclusion: Eyes with reticular pseudodrusen present a greater extent of reduced sensitivity than eyes with typical drusen.

WEDGE-SHAPED SUBRETINAL HYPOREFLECTIVITY IN GEOGRAPHIC ATROPHY.

Purpose: To describe wedge-shaped subretinal hyporeflectivity, a peculiar spectral domain optical coherence tomography finding in geographic atrophy (GA) areas of atrophic age-related macular degeneration. Methods: We reviewed the charts of consecutive patients with GA who presented between January 2012 and December 2013. A standardized imaging protocol was performed in all patients, which included blue fundus autofluorescence, and spectral domain optical coherence tomography. Results: Wedge-shaped subretinal hyporeflective lesions were found in 12 of 161 included eyes (11 of 94 consecutive patients, 6 males/5 females, mean age 79.6 ± 9.3 years). On spectral domain optical coherence tomography, regions immediately adjacent to the wedge-shaped subretinal hyporeflective lesions were characterized by absence of the hyporeflective outer nuclear layer, the hyperreflective external limiting membrane, the ellipsoid zone, the interdigitation zone, and the retinal pigment epithelium. On “en face” images, they appeared as round-oval hyporeflectivities delimited by hyperreflective borders, which we interpreted as the outer plexiform layer. Mean GA area was significantly larger in eyes with as compared with eyes without wedge-shaped subretinal hyporeflective lesions. Overall, the dimensions of the wedge-shaped subretinal hyporeflective lesions did not change after a mean of ∼15 months. Conclusion: Wedge-shaped subretinal hyporeflectivity, a previously unreported peculiar finding in GA areas of atrophic age-related macular degeneration eyes, appears delimited internally by the hyperreflective outer plexiform layer and externally by the hyperreflective Bruch membrane. These lesions, which are detected in eyes with large GA (even though stable over time), should be recognized and distinguished from subretinal fluid (and other exudative signs of age-related macular degeneration) because their presence should not require prompt treatment.

Appearance of medium–large drusen and reticular pseudodrusen on adaptive optics in age-related macular degeneration

Purpose To investigate the appearance of medium–large drusen and reticular pseudodrusen on adaptive optics (AO). Methods In 14 consecutive patients, AO infrared (IR) images were overlaid with confocal scanning-laser-ophthalmoscope IR reflectance images and IR-referenced spectral-domain optical coherence tomography. Results In eight eyes of six patients, a total of 19 images of medium–large drusen were investigated by AO imaging. En face AO revealed medium–large drusen as highly hyper-reflective round/oval lesions, always centred and/or surrounded by a continuous/discontinuous hyporeflectivity. Cone photoreceptors were detected overlying drusen, appearing either as continuous ‘bright’ hyper-reflective dots over a ‘dark’ hyporeflective background, or as continuous ‘dark’ hyporeflective dots over a ‘bright’ hyper-reflective background. In eight eyes from eight patients, a total of 14 images of pseudodrusen were investigated by AO imaging. En face AO revealed reticular pseudodrusen as isoreflective lesions, always surrounded by a continuous/discontinuous hyporeflectivity. Cone photoreceptors were detected overlying pseudodrusen as ‘bright’ hyper-reflective dots over either a hyporeflective or isoreflective background. No ‘dark’ hyporeflective dots were detected in eyes with reticular pseudodrusen only. Cone photoreceptors were counted on the border of the drusen and pseudodrusen, respectively, and in a visibly healthy zone in its absolute vicinity. A similar decrease in cone appearance was observed for drusen and pseudodrusen (15.7% vs 16.2%). Conclusions AO allows differences in reflectivity between medium–large drusen and reticular pseudodrusen to be appreciated. The cone mosaics may be detected as continuous ‘bright’ hyper-reflective dots overlying/on the border of drusen and pseudodrusen deposits, and possibly as continuous ‘dark’ hyporeflective dots overlying drusen only.

ADAPTIVE OPTICS IMAGING OF FOVEAL SPARING IN GEOGRAPHIC ATROPHY SECONDARY TO AGE-RELATED MACULAR DEGENERATION.

Background: To describe adaptive optics (AO) imaging of foveal sparing in geographic atrophy (GA) secondary to age-related macular degeneration. Methods: Flood-illumination AO infrared (IR) fundus images were obtained in four consecutive patients with GA using an AO retinal camera (rtx1; Imagine Eyes). Adaptive optics IR images were overlaid with confocal scanning laser ophthalmoscope near-IR autofluorescence images to allow direct correlation of en face AO features with areas of foveal sparing. Adaptive optics appearance of GA and foveal sparing, preservation of functional photoreceptors, and cone densities in areas of foveal sparing were investigated. Results: In 5 eyes of 4 patients (all female; mean age 74.2 ± 11.9 years), a total of 5 images, sized 4° × 4°, of foveal sparing visualized on confocal scanning laser ophthalmoscope near-IR autofluorescence were investigated by AO imaging. En face AO images revealed GA as regions of inhomogeneous hyperreflectivity with irregularly dispersed hyporeflective clumps. By direct comparison with adjacent regions of GA, foveal sparing appeared as well-demarcated areas of reduced reflectivity with less hyporeflective clumps (mean 14.2 vs. 3.2; P = 0.03). Of note, in these areas, en face AO IR images revealed cone photoreceptors as hyperreflective dots over the background reflectivity (mean cone density 3,271 ± 1,109 cones per square millimeter). Microperimetry demonstrated residual function in areas of foveal sparing detected by confocal scanning laser ophthalmoscope near-IR autofluorescence. Conclusion: Adaptive optics allows the appreciation of differences in reflectivity between regions of GA and foveal sparing. Preservation of functional cone photoreceptors was demonstrated on en face AO IR images in areas of foveal sparing detected by confocal scanning laser ophthalmoscope near-IR autofluorescence.

Pilot evaluation of short-term changes in macular pigment and retinal sensitivity in different phenotypes of early age-related macular degeneration after carotenoid supplementation

Purpose To investigate the response of carotenoid supplementation in different phenotypes of early age-related macular degeneration (AMD) by measuring macular pigment optical density (MPOD) and retinal sensitivity. Methods Consecutive patients with only medium/large drusen and only reticular pseudodrusen (RPD) and age-matched and sex-matched controls were enrolled. At baseline, participants underwent a complete ophthalmological examination including measurement of best-corrected visual acuity (BCVA), MPOD and retinal sensitivity. Patients were put on vitamin supplementation (lutein 10 mg/day, zeaxanthin 2 mg/day) and 3 months later underwent a repeated ophthalmological examination. Results Twenty patients with medium/large drusen, 19 with RPD and 15 control subjects were included. At baseline, in controls, mean MPOD and BCVA were significantly higher compared with RPD (p=0.001 and p=0.01) but similar to medium/large drusen (p=0.9 and p=0.4). Mean retinal sensitivity was significantly higher in controls compared with RPD and medium/large drusen (for all p<0.0001). After 3 months of carotenoid supplementation the mean MPOD significantly increased in RPD (p=0.002), thus showing no more difference compared with controls (p=0.3); no significant changes were found in mean retinal sensitivity and BCVA (p=0.3 and p=0.7). Medium/large drusen did not show significant changes on MPOD, retinal sensitivity and BCVA (p=0.5, p=0.7 and p=0.7, respectively). Conclusions Patients with early AMD, especially RPD phenotype, show lower macular sensitivity and MPOD than controls. After supplementation, MPOD significantly increased in RPD. These results suggest different pathophysiology for RPD as compared with medium/large drusen and may open new ways to identifying further therapeutic targets in this phenotype of early AMD.