Eric H. Souied

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN EARLY TYPE 3 NEOVASCULARIZATION.

Purpose: To report the imaging features of Type 3 neovascularization secondary to exudative age-related macular degeneration on optical coherence tomography angiography (OCTA). Methods: All consecutive treatment-naive patients diagnosed with early-stage Type 3 neovascularization underwent imaging by color retinal photographs or multicolor imaging, fluorescein angiography, indocyanine green angiography, spectral domain optical coherence tomography, and OCTA. The OCTA features were analyzed and correlated with the findings of conventional angiography and spectral domain optical coherence tomography. Results: A total of 18 treatment-naive eyes of 18 consecutive patients (13 females and 5 males; mean age 81.3 ± 6.0) were included in the analysis. Optical coherence tomography angiography showed lesions characterized by a retinal–retinal anastomosis that emerged from the deep capillary plexus, forming in all 18 eyes a clear tuft-shaped high-flow network in the outer retinal segmentation, finally abutting in the subretinal pigment epithelium space. In 15 of 18 eyes, in the choriocapillaris segmentation, there appeared a small clew-like lesion, which in 2 cases seemed connected with the choroid through a small caliber vessel. Conclusion: Optical coherence tomography angiography of treatment-naive Type 3 neovascularization showed almost constantly a high-flow, tuft-shaped abnormal outer retinal proliferation, frequently associated to a small clew-like lesion in the choriocapillaris layer.

Functional Characterization and Multimodal Imaging of Treatment-Naïve “Quiescent” Choroidal Neovascularization

PURPOSEnTo investigate the multimodal morphological and functional characteristics of treatment-naïve quiescent choroidal neovascularization (CNV) secondary to AMD.nnnMETHODSnEleven patients with treatment-naïve quiescent CNV that consecutively presented over a 6-month period, underwent multimodal morphological and functional assessment (including indocyanine green angiography [ICGA], spectral-domain optical coherence tomography [SD-OCT], microperimetry, and preferential hyperacuity perimeter [PHP]). For the purpose of this study, asymptomatic previously untreated CNVs showing absence of intraretinal/subretinal exudation in two consecutive visits (at least 6 months apart) were defined as treatment-naïve quiescent CNV.nnnRESULTSnEleven eyes of 11 patients (9 females; mean age 76.5 ± 8.5 years) were included. On fluorescein angiography (FA), quiescent CNVs appeared as late speckled hyperfluorescent lesions lacking well-demarcated borders. Mid-late phase ICGA allowed visualizing the hyperfluorescent quiescent CNV network and delineating the plaque. Mean lesion area (mid-late phase ICGA) appeared larger compared with earliest previous examination performed 23.8 ± 16.0 months before (3.24 ± 2.51 mm(2) vs. 3.52 ± 2.46 mm(2), respectively; P = 0.01). SD-OCT revealed, at the site of quiescent CNV, an irregularly slightly elevated RPE, without hyporeflective intraretinal/subretinal fluid, showing a major axis in the horizontal plane, which was characterized by collections of moderately reflective material in the sub-RPE space and clear visualization of the hyperreflective Bruchs membrane. Hypergeometric distribution revealed a significant correlation between microperimetry and PHP with respect to locations of affected areas (P = 0.001).nnnCONCLUSIONSnQuiescent CNVs are sub-RPE CNVs secondary to AMD, showing absence of intraretinal/subretinal exudation on repeated OCT. Quiescent CNVs enlarge over time and may contribute to local reduced retinal sensitivity and metamorphopsia.

Assessment of Choroidal Topographic Changes by Swept Source Optical Coherence Tomography After Photodynamic Therapy for Central Serous Chorioretinopathy

PURPOSEnTo investigate the relationship between choroidal thickness and angiographic abnormalities in central serous chorioretinopathy (CSC) eyes by swept-source optical coherence tomography (swept-OCT), before and after half-fluence photodynamic therapy (PDT).nnnDESIGNnProspective interventional case series.nnnMETHODSnConsecutive patients presenting with treatment-naive active CSC underwent a complete ophthalmologic examination, including swept-OCT at study entry and at 7 days and 30 days after treatment with half-fluence PDT. The main outcome measures were changes in choroidal maps after PDT (mean ± SD) and the relationship between choroidal thickness and angiographic abnormalities.nnnRESULTSnOf 12 patients (2 females, 10 males; mean age, 55.6 ± 14.0 years), 12 eyes were included. At study entry, mean choroidal thickness measured in the center of the fovea was significantly thicker in the study eyes as compared to the fellow eyes (420.7 ± 107.5 μm vs 349.2 ± 109.7 μm, respectively; P = 0.016). Mean choroidal thickness in the center of the fovea significantly decreased in the study eyes at both 7 days (380.2 ± 113 μm; P = 0.005) and 30 days after PDT (362.3 ± 111 μm; P = 0.002). A similar significant choroidal thinning was recorded in each early treatment of diabetic retinopathy study (ETDRS) applied to 3D swept-OCT maps. At each time point, mean choroidal thickness was significantly thicker in sectors with than in sectors without angiographic abnormalities (421 ± 102.4 μm vs 397.6 ± 96.5 μm, P = 0.002 at study entry; 381.2 ± 106.6 μm vs 364 ± 101.2 μm, P = 0.01 at day 7; 366.3 ± 103.2 μm vs 347.2 ± 99.6 μm at day 30).nnnCONCLUSIONSnUsing swept-OCT, we demonstrated that in active CSC, choroidal thickness is increased to a greater extent in areas characterized by angiographic abnormalities. This increased choroidal thickness may persist even after PDT.

MultiColor imaging in the evaluation of geographic atrophy due to age-related macular degeneration

Purpose To compare different imaging modalities and to investigate the ability of MultiColor to evaluate geographic atrophy (GA) due to age-related macular degeneration (AMD). Methods Twenty-two consecutive patients with GA underwent MultiColor, colour fundus photography, blue fundus autofluorescence (FAF) (excitation=488u2005nm; emission >500u2005nm), near-infrared FAF (NIR-FAF) (excitation=787u2005nm; emission >800u2005nm) and spectral-domain optical coherence tomography (SD-OCT) (Spectralis HRA+OCT; Heidelberg Engineering) imaging. Two readers independently measured the size (area) and the width of GA (on horizontal SD-OCT scan cutting the fovea), and evaluated the foveal sparing in each examination. Results A total of 32 eyes (22 patients, mean age 79.2±8u2005years) with GA were included. Intragrader and intergrader agreement considering the evaluation of the size and width of GA was high for all the examinations. MultiColor and FAF showed the greatest intergrader agreement for GA area measurement (intraclass correlation (ICC)=0.990, 95% CI 0.980 to 0.995; ICC=0.998, 95% CI 0.996 to 0.999, respectively). SD-OCT showed the highest intergrader agreement of foveal involvement (k=1), followed by MultiColor and NIR-FAF (k=0.68). Conclusions We demonstrated that several different imaging modalities currently available in clinical practice are reliable for evaluating GA due to AMD. MultiColor is an excellent tool for the measurement of GA area and width, and for the detection of foveal sparing.

Assessment of Choroidal Topographic Changes by Swept-Source Optical Coherence Tomography After Intravitreal Ranibizumab for Exudative Age-Related Macular Degeneration

PURPOSEnTo investigate choroidal topographic changes by swept-source optical coherence tomography (Swept-OCT) in patients undergoing intravitreal injections of anti-vascular endothelial growth factor (VEGF) for exudative age-related macular degeneration (AMD).nnnDESIGNnProspective interventional study.nnnMETHODSnConsecutive patients with unilateral treatment-naïve exudative AMD were entered into the study over 6 months. Changes in choroidal thickness after intravitreal ranibizumab injections, overall in the macula and in neovascular and non-neovascular areas, from baseline to month 3 (loading phase) and month 6 (pro re nata phase), were investigated by means of Swept-OCT maps.nnnRESULTSnForty-one eyes of 41 patients (mean age: 79.4 ± 7.3 years) were analyzed. Choroidal thickness at study entry was significantly thicker in the study eyes as compared to fellow eyes (P < .05). Analysis of sectorial choroidal thickness over time in study eyes revealed a significant reduction in both neovascular and non-neovascular areas from baseline to month 3 and month 6 (P < .0001 for all). Central choroidal thickness revealed significant variation between treated and fellow eyes from baseline to month 3 (P = .017) and month 6 (P = .045). The visual gain was significantly higher (P = .02) in patients with a larger choroidal thickness reduction (≥29 μm, n = 11) vs the others (n = 30).nnnCONCLUSIONSnThe thinning of the macular choroid (affected or not by choroidal neovascularization), along with the significantly thicker choroid in exudative AMD eyes before treatment initiation compared to fellow eyes, allows the hypothesis that anti-VEGF treatment may favorably influence the choroidal exudation by reducing choroidal vascular hyperpermeability.

Treatment-Naïve Quiescent Choroidal Neovascularization in Geographic Atrophy Secondary to Nonexudative Age-Related Macular Degeneration

PURPOSEnTo describe the characteristics and natural history of quiescent choroidal neovascularization (CNV) in geographic atrophy (GA) secondary to nonexudative age-related macular degeneration (AMD) through multimodal imaging.nnnDESIGNnRetrospective observational case series.nnnMETHODSnPatients diagnosed with quiescent CNV were analyzed in 2 high-volume referral centers. Imaging features obtained using fluorescein angiography (FA), indocyanine green angiography (ICGA), structural optical coherence tomography (OCT), and OCT angiography (OCT-A) were noted at first presentation and during the study period.nnnRESULTSnNineteen eyes of 19 patients were included. Mean (+SD) follow-up was 45.7 ± 14.7xa0months. Quiescent CNV appeared as an ill-defined hyperfluorescent lesion without leakage or pooling of dye in the late phase of FA. On ICGA, quiescent CNV appeared as a distinct area of hyperfluorescence (vascular network) in early to intermediate frames and as a hyperfluorescent plaque in the late frame (late plaque). OCT-A revealed a flow signal beneath the small irregular elevation of the retinal pigment epithelium at the site of the quiescent CNV visualized by structural OCT. During the study period, 5 of the 19 CNV patients developed exudation. The remainder showed specific alterations in both structural OCT and OCT-A imaging. At last follow-up, 92% of the quiescent CNV seemed to cover the area spared from atrophy.nnnCONCLUSIONSnThe characteristics of the quiescent CNVs were very similar to those already described for intermediate AMD, although they had several specific features in the context of GA.

DOUBLE RETINAL PIGMENT EPITHELIUM TEARS IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION.

Purpose: To describe the occurrence and treatment outcomes of double retinal pigment epithelium (RPE) tears in neovascular age-related macular degeneration and to elucidate the mechanism of tear development by means of multimodal imaging analysis. Methods: Fundus autofluorescence, spectral-domain optical coherence tomography, fluorescein angiography, and indocyanine green angiography were retrospectively studied before and after the occurrence of first and second RPE tears and at the final visit. Results: Twelve eyes of 10 patients that developed double RPE tears, either simultaneously (6 eyes) or at variable intervals after repeated intravitreal anti–vascular endothelial growth factor administration (6 eyes), were included. First RPE tears developed after a mean of 4.5 ± 2.7 anti–vascular endothelial growth factor injections; second RPE tears developed after a mean of 7.1 ± 5.2 anti–vascular endothelial growth factor injections. Mean best-corrected visual acuity was 20/63 at baseline evaluation, 20/76 after occurrence of first tear, 20/90 after occurrence of second tear, and 20/95 at final visit (P > 0.05 for all). Multimodal imaging revealed in all cases a Type 1 neovascular lesion adherent to the posterior surface of the RPE and spanning a significant portion of the pigment epithelium detachment with variable orientation; after development of double tears, the RPE seemed retracted on both borders of the neovascular network. Conclusion: Double RPE tears may occur on opposite sides of a vascularized pigment epithelium detachment, in eyes with neovascular age-related macular degeneration after anti–vascular endothelial growth factor therapy, because of neovascular contraction of a Type 1 neovascular complex, adherent to the posterior surface of the RPE and spanning a significant portion of the pigment epithelium detachment area.

Spontaneous retinal pigment epithelium tear in geographic atrophy

PURPOSEnTo report two cases of spontaneous retinal pigment epithelial (RPE) tears occurring in two patients affected with geographic atrophy (GA) due to non-exudative age-related macular degeneration (AMD).nnnCASE REPORTnTwo patients (a 79-year-old man and a 71-year-old woman) presented to our department with progressive visual loss. The man had a best-corrected visual acuity (BCVA) of 20/100 in the right eye (RE) and 20/50 in the left eye (LE); the woman had a BCVA of 20/200 in the RE and 20/160 in the LE. Upon complete ophthalmologic examination, revealing a large area of atrophy (>175 μm in diameter) along with pigmentary changes, calcified drusen and no choroidal neovascularization (CNV) in either eye, the patients were diagnosed with GA due to non-exudative AMD. Interestingly, the imaging modalities performed, including fluorescein angiography (FA), indocyanine green angiography (ICGA) and spectral-domain optical coherence tomography (SD-OCT), clearly highlighted the presence of spontaneous RPE tears in the context of non-exudative AMD, while in general, RPE tears are a well-recognized complication of exudative AMD.nnnCONCLUSIONSnTo our knowledge, this is the first description of spontaneous RPE tears as a possible complication of GA due to non-exudative AMD.

Clinical applications of optical coherence tomography angiography: What we have learnt in the first 3 years:

A review of the literature from 2014 to 2016 was conducted, focusing on the results of optical coherence tomography angiography in different chorioretinal diseases. In only 3u2009years, optical coherence tomography angiography has been shown to be an effective tool for diagnosing choroidal neovascularization complicating age-related macular degeneration, pathologic myopia, and inflammatory conditions. The technique has sometimes been considered superior to conventional multimodal imaging, for example, in choroidal neovascularization associated with chronic central serous chorioretinopathy or multifocal choroiditis. In retinal vascular diseases, optical coherence tomography angiography has helped to understand the condition described as paracentral acute middle maculopathy and has been considered highly effective for the analysis of retinal vascular macular changes secondary to retinal vein occlusion or macular telangiectasia. Changes in the foveal avascular zone, also reported in diabetic maculopathy, have been shown to occur before any angiographic signs. A reduction in capillary vascular density has been reported in the fovea of eyes with malignant melanoma, but not in eyes with choroidal nevus. However, optical coherence tomography angiography is a recent technique that probably needs refinements and further studies. Nevertheless, the first 3 years of optical coherence tomography angiography use suggest its clinical relevance and useful applications in daily clinical practice.

ACQUIRED VITELLIFORM DETACHMENT IN MULTIPLE MYELOMA.

Purpose: To report a case of subfoveal acquired vitelliform detachment in a patient with multiple myeloma. Methods: Case report. Results: A 65-year-old man was referred for treatment of a serous macular detachment considered to be caused from chronic central serous chorioretinopathy or adult pseudovitelliform macular dystrophy. His medical history revealed an untreated multiple myeloma. Systemic chemotherapy was undertaken and resulted in a rapid resolution of the detachment. Conclusion: Multiple myeloma may be considered as a possible cause of vitelliform macular detachment.