Chiara Giuffrè

Optical coherence tomography angiography of myopic choroidal neovascularisation

Background/aims To describe the morphological features of choroidal neovascularisation (CNV) and to report the ability of optical coherence tomography angiography (OCT-A) to detect the presence of myopic CNV by means of this new technique. Methods Myopic CNV cases were individuated from a pool of patients with pathological myopia consecutively presenting between October 2015 and March 2016. OCT-A images were assessed for classification of morphological features, and to estimate sensitivity and specificity. Results Thirty-six eyes of 28 consecutive patients with myopic CNV were included. In 4 out of 36 eyes it was not possible to classify the CNV ‘shape’, ‘core’, ‘margin’ and ‘appearance’ because the vascular network was not clearly visualised due to the poor quality of the examination. CNV shape on OCT-A was rated as circular in 9 eyes and irregular in 23 eyes. CNV core was visible in 11 eyes. CNV margin was considered as well defined in 16 eyes and poorly defined in 16 eyes. CNV appearance showed an ‘interlacing’ aspect in 16 eyes and a ‘tangled’ aspect in the other 16 eyes. A total of 11 CNVs were defined as active, 9 of which (81.8%) were interlacing, while a total of 21 were inactive, 14 of which (66.7%) were tangled. OCT-A sensitivity turned out to be 90.48% and specificity was 93.75%. Conclusions We describe the OCT-A features of myopic CNV secondary to pathological myopia and demonstrate its high sensitivity and specificity for neovascular detection. Qualitative evaluation of OCT-A characteristics may allow one to recognise different patterns, possibly corresponding to different degrees of neovascular activity.

Choroidal neovascularization and coincident perforating scleral vessels in pathologic myopia

Purpose To describe the coincidence of perforating scleral vessels and choroidal neovascularization (CNV) in pathologic myopia. Methods Medical records and multimodal imaging were reviewed from patients with CNV secondary to pathologic myopia who presented to the Medical Retina and Imaging Unit of San Raffaele Hospital in Milan between October 2015 and March 2016. Main outcomes were the prevalence of coincident perforating scleral vessels and overlying CNV and association between perforating scleral vessels and CNV position within the macula and neovascular activity. Results Forty-one eyes of 39 patients (6 male, 33 female, mean age 63.7 ± 14.1 years) with CNV secondary to pathologic myopia were included in the study. Scleral perforating vessels (average number of perforating vessels per eye 2.1 ± 1.0) were found in 29 out of 41 eyes (70.7%) at the site of CNV. There was no association between presence of perforating vessels and neovascular activity or CNV position. Conclusions Perforating scleral vessels are often coincident with myopic CNV. We hypothesize that scleral vessels located beneath myopic CNV can play a role in neovascular development.

Optical Coherence Tomography Angiography of Venous Loops in Diabetic Retinopathy

Venous loops are relatively rare manifestations of diabetic retinopathy. The authors describe a case characterized by the development of a venous loop during a 3-year period. Optical coherence tomography angiography (OCTA) revealed a hyperintense signal from the lesion, attesting an ordinary flow into the venous loop. OCTA also showed an area of capillary loss in proximity of the lesion, which is in agreement with the proposed pathogenesis for venous loops, developed to bypass an area of retinal vessels occlusion. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:518-520.].

Central Serous Chorioretinopathylike Mimicking Multifocal Vitelliform Macular Dystrophy: An Ocular Side Effect Of Mitogen/extracellular Signal-regulated Kinase Inhibitors.

Purpose: To describe a case of multiple detachments of the neurosensory retina mimicking multifocal vitelliform macular dystrophy after chemotherapy with mitogen/extracellular signal–regulated kinase inhibitor for metastatic ovarian cancer. Methods: Case report. Results: A 38-year-old woman presented to our clinic for eye examination before the initiation of chemotherapy with trametinib. One month after starting treatment, the patient complained of vision loss and metamorphopsia in both eyes. Best-corrected visual acuity decreased from 20/20 at baseline to 20/32 in both eyes, and fundus examination revealed multiple detachments of the neurosensory retina with vitelliformlike appearance, involving the central macula and the posterior pole with a circular distribution along the retinal vascular arcades. Spectral-domain optical coherence tomography showed widespread thickening of the interdigitation zone, particularly in areas with and without detachments, and also some hyporeflective fluid accumulating beneath the detached retina. Mitogen/extracellular signal–regulated kinase inhibitor therapy was discontinued, and after 1 week, best-corrected visual acuity recovered to 20/20 bilaterally, with complete resolution of the serous retinal detachments and normalization of interdigitation zone. Conclusion: The development of a central serous chorioretinopathylike retinopathy is a relatively common secondary event of mitogen/extracellular signal–regulated kinase inhibitors therapy, and typically, it resolves after the discontinuation of the treatment. Our case is peculiar in that the lesions were bilateral, involving the central macula and the posterior pole with a circular distribution along the retinal vascular arcades and in that the interdigitation zone showed a widespread thickening at spectral-domain optical coherence tomography, mimicking multifocal vitelliform macular dystrophy.

Optical Coherence Tomography Angiography of Pigmented Paravenous Retinochoroidal Atrophy

A 58-year-old man with bilateral pigmented paravenous retinochoroidal atrophy (PPRCA) associated with macular coloboma in the right eye underwent color fundus photography and fundus autofluorescence with the California ultra-widefield retinal imaging system (Optos, Dunfermline, UK), spectral-domain optical coherence tomography (SD-OCT) (Heidelberg Spectralis HRA + OCT; Heidelberg Engineering, Heidelberg, Germany), and en face OCT angiography (OCTA) (AngioPlex, Cirrus HD-OCT 5000; Carl Zeiss Meditec, Dublin, CA). The patient presented with a visual acuity of counting fingers in the right eye and 20/32 in the left eye. Fundus examination and SD-OCT showed typical PPRCA alterations in both eyes and a macular coloboma in the right eye. The OCTA showed relative sparing of the retinal capillary plexuses, with diffuse defects in the choriocapillaris. The authors concluded OCTA imaging of PPRCA suggests more insights of the pathogenesis of this disease, showing that the disease primarily affects the choroidal vascular network, with a relative sparing of the retinal vasculature. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:381-383.].

Swept-source optical coherence tomography angiography in serpiginous choroiditis

Background/Aims To analyse choroidal vascular density of affected and non-affected areas in active and inactive serpiginouschoroiditis (SC) by means of optical coherence tomography angiography (OCT-A). Methods In this cross-sectional and observational study, 22 eyes of 11 patients diagnosed with SC were included. All patients underwent blue-light fundus autofluorescence (spectralis Heidelberg retinalangiography+OCT) and swept-source OCT-A (AngioPlex Elite 9000 SS-OCT, Carl Zeiss Meditech) to analyse qualitative features and choroidal vessel density of areas considered affected, and the inner and the outer border of the lesions. Unaffected areas of otherwise healthy retina have also been studied. Results All inactive inflammatory lesions were characterised by atrophy of choriocapillaris with an impairment of its detectable flow and greater visibility of choroidal vessels. On the other hand, all active inflammatory lesions showed an area of complete absence of decorrelation signal. The pathological border was characterised by a statistically significant lower choroidal vessel density compared with both the outer border and the unaffected area (0.650±0.113 vs 0.698±0.112, (p<0.001)). Although not statistically significant, vessel density of the outer border of inactive lesions was lower than vessel density of unaffected areas (0.650±0.113 vs 0.698±0.112, p=0.441). Active inflammatory lesions showed an area of complete absence of decorrelation signal at the level of the choriocapillaris and whole choroid. Conclusion OCT-A represents a new imaging technique that provides useful information about the leading changes of choroidal vascular network in active and inactive lesions of SC.

Mineralocorticoid receptor antagonists in the treatment of central serous chorioretinopathy

ABSTRACT Introduction: Central serous chorioretinopathy (CSC) is one of the most common causes of central vision loss that primarily affects young adults. CSC is a multifactorial condition in which corticosteroids typically worsen the disease; this led to hypothesize the involvement of the mineralcorticoid receptor in its pathogenesis (due to the similar affinity of corticosteroids and aldosterone to this receptor). Area covered: Here, we perform a comprehensive literature review of all articles published in the English language, indexed on Pubmed, on the subject of ‘Mineralocorticoid receptor antagonists in the treatment of CSC.’ From these articles, the most salient disputes are presented. Expert commentary: Due to the lack of large randomized, controlled trials with long-term follow-up clearly demonstrating the positive effects of these treatments for CSC, no specific recommendation for the management of this disease has been defined yet. Despite lack of evidence level 1, mineralocorticoid receptor antagonists may represent an attractive therapeutic option for CSC. This review helps to clarity the efficacy and side effects of these drugs that maybe play an important role in treatment of CSC.

Sudden Visual Loss after Cardiac Resynchronization Therapy Device Implantation

Purpose To report a case of sudden decrease in visual acuity possibly due to a cardiogenic embolism in a patient who underwent cardiac resynchronization therapy (CRT) device implantation. Methods A 62-year-old man with severe left ventricular systolic dysfunction and a left bundle branch block was referred to our department because of a sudden decrease in visual acuity. Nine days earlier, he had undergone cardiac transapical implantation of a CRT device, which was followed, 2 days later, by an inflammatory reaction. The patient underwent several general and ophthalmologic examinations, including multimodal imaging. Results At presentation, right eye (RE) best-corrected visual acuity (BCVA) was counting fingers and RE pupil was hyporeactive. Fundus examination revealed white-centered hemorrhagic dots suggestive of Roth spots. Fluorescein angiography showed delay in vascular perfusion during early stage, late hyperfluorescence of the macula and optic disk, and peripheral perivascular leakage. The first visual field test showed complete loss of vision RE and a normal left eye. Due to suspected giant cell arteritis, temporal artery biopsy was performed. Thirty minutes after the procedure, an ischemic stroke with right hemisyndrome and aphasia occurred. The RE BCVA worsened to hands motion. Four months later, RE BCVA did not improve, despite improvement in fluorescein angiography inflammatory sign. Conclusions We report a possible cardiogenic embolism secondary to undiagnosed infective endocarditis causing monocular visual loss after CRT device implantation. It remains unclear how the embolus caused severe functional damage without altering the retinal anatomical structure.

Persistent subretinal fluid mimicking central serous retinopathy after scleral buckling surgery: possible vortex vein compression role.

Purpose To describe the case of a woman who developed persistent subretinal fluid in the macular region after the placement of encircling band for retinal detachment surgery, possibly due to vortex vein compression. Methods Case report. Results A 66-year-old woman diagnosed with central serous retinopathy presented with poor vision and metamorphopsia in the left eye (LE). Her visual acuity had deteriorated to 20/100 in LE after retinal detachment surgery with scleral buckling 8 months before. Multimodal imaging including fundus autofluorescence and fluorescein angiography disclosed a gravitational hyperfluorescent area involving the macular region that appeared to originate from the superotemporal quadrant in correspondence with the buckling. This area corresponded to a serous retinal detachment on structural spectral-domain optical coherence tomography (SD-OCT). Interestingly, on indocyanine green angiography, the encircling band of the scleral buckling appeared located at the emergence of the superotemporal vortex vein. Based on these findings, the patient was diagnosed with gravitational serous retinal detachment secondary to vortex vein compression. Successful rapid visual recovery and decrease of retinal fluid on SD-OCT was achieved with prompt surgery of scleral buckling removal, confirming the diagnosis. Conclusions Choroidal veins can be obliterated during retinal detachment surgery, especially when retinal breaks are posterior to the equator. Indocyanine green angiography is the gold standard to study choroidal circulation and in our case allowed us to visualize the compression of the superotemporal vortex vein at the site of scleral buckling.

Multimodal imaging in a patient with traumatic choroidal ruptures.

Purpose To describe the case and the follow-up of a traumatic choroidal rupture characterized by means of multimodal imaging including color fundus photographs, infrared reflectance, blue autofluorescence, swept-source optical coherence tomography, fluorescein angiography (FA), indocyanine green angiography (ICGA), and optical coherence tomography angiography (OCT-A). Methods Case report. Results A 17-year-old boy was referred to our clinic complaining of reduction in visual acuity in the right eye (RE) after a blunt ocular trauma during a soccer match. Dilated fundus examination of RE showed 2 peripapillary choroidal ruptures located temporally and inferiorly to the optic disc. Among different imaging tools useful in the diagnosis and study of choroidal ruptures, particular attention must be paid to OCT-A, which showed the lesions as breaks in the choriocapillaris plexus with a hypointense appearance due to the lack of substance. Moreover, along the break it was possible to see the projection of the underlying choroidal vasculature, which appeared hyperintense. The retinal vascular plexa were spared. Conclusions All patients presenting with blunt ocular trauma should undergo fundus examination to exclude damage to the optic nerve, retina, and choroid, and need close follow-up to avoid the development of secondary complications such as choroidal neovascularization. Optical coherence tomography angiography might add relevant information in the global evaluation and follow-up of choroidal ruptures in a noninvasive fashion, and could replace other invasive modalities such as FA or ICGA.