Florence Coscas

Choroidal changes associated with reticular pseudodrusen.

PURPOSE To analyze choroidal changes associated with reticular pseudodrusen by indocyanine green angiography (ICGA) and enhanced depth imaging spectral-domain optical coherence tomography (EDI SD-OCT). METHODS Twenty-two consecutive patients (22 eyes) with reticular pseudodrusen, and without medium/large drusen, underwent ICGA and EDI OCT. Twenty-one age- and sex-matched subjects (21 eyes) with early age-related macular degeneration (AMD), and without pseudodrusen, also underwent EDI OCT. RESULTS Mean age of patients with reticular pseudodrusen and with early AMD was 82.5 ± 0.9 and 79.3 ± 4.4 years of age, respectively (P = 0.9), and 59.0% and 76.2% were females, respectively (P = 0.7). On ICGA, reticular patterns appeared as hypofluorescent, not overlying the large choroidal vessels. Areas of iso/hyperfluorescence on ICGA, occurring adjacently to reticular patterns, appeared on OCT as subretinal deposits. The mean subfoveal choroidal thickness was significantly reduced in the group with reticular pseudodrusen compared with that in the control group (174.6 ± 10.1 and +241.4 ± 16.5, respectively; P < 0.001). At all measurement points, but the 3000 μm superior to the fovea, the choroidal thickness of eyes with reticular pseudodrusen appeared thinner than that of the control group. Interestingly, the choroid of eyes with reticular pseudodrusen appeared thicker at 3000 μm superior to the fovea compared with that at all other measurement points. CONCLUSIONS It was shown that the reticular patterns appeared as hypofluorescent lesions on ICGA, closely abutting, but not overlying the large choroidal vessels. In eyes with reticular pseudodrusen, EDI OCT revealed an overall thinned choroid.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY VERSUS TRADITIONAL MULTIMODAL IMAGING IN ASSESSING THE ACTIVITY OF EXUDATIVE AGE-RELATED MACULAR DEGENERATION: A New Diagnostic Challenge.

Purpose: To compare optical coherence tomography angiography (OCTA) with traditional multimodal imaging in patients with exudative age-related macular degeneration in terms of guiding the treatment decision. Methods: Prospective case series of 80 eyes of 73 consecutive patients with exudative age-related macular degeneration (39 women, mean age: 79.4 ± 5.3 years) diagnosed with different types of choroidal neovascularization (CNV) (58 Type I, 2 Type II, 6 mixed Type I and II, 3 retinal angiomatous proliferation, and 11 age-related macular degeneration-related polyps). The data obtained from traditional multimodal imaging, based on fluorescein angiography, indocyanine green angiography, and OCT were used to assess the need for treatment, those obtained from OCTA to identify two different patterns of CNV. Traditional multimodal imaging and OCTA findings were then compared with evaluate possible correspondence between treatment decision and CNV aspect on OCTA. Results: A CNV lesion was identified as Group A (requiring treatment) in 58 eyes (72.5%) in traditional multimodal imaging. On OCTA in 59 eyes (73.7%), the lesion was defined as Pattern I and the remaining 21 (26.3%) as Pattern II. There was 94.9% correspondence between the Pattern I CNV on OCTA and the cases Group A on conventional multimodal imaging. It was also computed 90.5% correspondence between Pattern II CNV on OCTA and the Group B (not requiring treatment) cases on conventional multimodal imaging. There was high (P < 0.05) interobserver agreement both for treatment decision in conventional multimodal and for Patterns (I or II) defining on OCTA imaging analysis. Conclusion: This study demonstrates a high level of correspondence, in patients with exudative age-related macular degeneration, between different CNV patterns identified on OCTA and treatment decisions established on conventional multimodal imaging. Although fluorescein angiography remains the gold standard for determining the presence of leakage, and OCT shows fluid accumulation and its variations, OCTA may now offer noninvasive monitoring of the CNV, aiding for each treatment decision during the follow-up.

Optical Coherence Tomography Angiography in Retinal Vein Occlusion: Evaluation of Superficial and Deep Capillary Plexa.

PURPOSE To evaluate the optical coherence tomography angiography (OCT angiography) appearance of the superficial and deep capillary plexa in eyes with retinal vein occlusion (RVO) and to compare these findings with those of fluorescein angiography (FA) and spectral-domain optical coherence tomography (SD OCT). DESIGN Retrospective observational case series. METHODS Patients presenting with RVO to Creteil University Eye Clinic were retrospectively evaluated. All patients had undergone a comprehensive ophthalmic examination including FA, SD OCT, and OCT angiography. RESULTS There were 54 (31 male, 57%) RVO patients with a mean age of 70 years. The perifoveal capillary arcade was visible in 52 of 54 eyes (96%) on OCT angiography and in 45 eyes (83%) on FA; this arcade was disrupted in 48 eyes (92%) and 39 eyes (72%) on OCT angiography and FA, respectively (P = .002). Perifoveal capillary arcade disruption was correlated with peripheral retinal ischemia (P = .025). Intraretinal cystoid spaces were observed in 34 eyes (68%) using FA, in 40 eyes (76%) using SD OCT, and in 49 eyes (90%) using OCT angiography (P = .008 for OCT angiography vs SD OCT and P = .001 for OCT angiography vs FA). Retinal capillary network abnormalities were observed in all patients in both superficial capillary plexus and deep capillary plexus on OCT angiography. Nonperfusion grayish areas were more frequent in the deep capillary plexus (43 eyes, 84%) than in the superficial capillary plexus (30 eyes, 59%, P < .001). CONCLUSION OCT angiography can simultaneously evaluate both macular perfusion and edema. For the first time, an imaging technique enables the evaluation of the deep capillary plexus, which appears to be more severely affected than the superficial capillary plexus in RVO.

Normative Data for Vascular Density in Superficial and Deep Capillary Plexuses of Healthy Adults Assessed by Optical Coherence Tomography Angiography.

PURPOSE To establish a normative database for vascular density (VD) and foveal avascular zone (FAZ) at the superficial (SCP) and deep capillary plexus (DCP) in healthy subjects with optical coherence tomography (OCT) angiography. METHODS The study was a retrospective chart review of healthy patients who had undergone OCT angiography imaging. A 3- × 3-mm area, centered on the fovea, was scanned for all the study eyes. The automated segmentation allowed separate analysis of the SCP, the DCP, and a comprehensive C-scan including both vascular layers. On the obtained images, VD and FAZ measurements were computed. Interobserver reproducibility and intraobserver repeatability were also assessed. RESULTS A total of 135 eyes of 70 subjects (51% male) were analyzed. The mean age was 48.3 ± 17.5. We divided patients into group 1, from 20 to 39 years of age; group 2, from 40 to 59 years; and group 3, age 60 years or older. At the level of the SCP, mean VD and mean FAZ ± SD were, respectively, 52.58 ± 3.22% and 0.28 ± 0.1 mm2. At the level of the DCP, mean VD and mean FAZ were 57.87 ± 2.82% and 0.37 ± 0.12 mm2, respectively. The mean VD was significantly higher (P < 0.05) in DCP compared with SCP in all Early Treatment Diabetic Retinopathy Study (ETDRS) sectors and in all age groups. Vascular density was higher in women than in men after 60 years (P < 0.01). After adjustment on the signal strength index (SSI), the mean VD remained directly correlated with the age range and sex. The mean FAZ area was lower in group 3 (P < 0.05). Interobserver reproducibility was 0.78 to 0.99 in SCP and 0.67 to 0.92 in DCP, and intraobserver repeatability was 0.64 to 0.93 in SCP and 0.63 to 0.87 in DCP. CONCLUSIONS Our study has provided, for the first time, age-related VD mapping data using OCT angiography in healthy subjects. The prototype software used in this study may help to improve the concept of VD grading with high inter- and intraexaminer repeatability and interexaminer reproducibility.

Analysis of progression of reticular pseudodrusen by spectral domain-optical coherence tomography.

PURPOSE To analyze reticular pseudodrusen progression using spectral domain-optical coherence tomography (SD-OCT). METHODS Thirty-three consecutive patients (48 eyes) underwent SD-OCT using the eye-tracked follow-up protocol 24 ± 2 months after baseline examination. Each pair of B-scans (only one per eye was evaluated among those showing pseudodrusen progression) was compared with respect to pseudodrusen appearance and retinal layer structure. Stage 1 pseudodrusen was defined as granular material between the RPE and the inner segment/outer segment (IS/OS), stage 2 as mounds of material sufficient to alter the contour of the IS/OS, stage 3 as thicker material adopting a conical appearance and breaking through the IS/OS, and stage 4 as fading of the material because of reabsorption and migration within the inner retinal layers. RESULTS A total of 78 pseudodrusen (detected on the 48 analyzed B-scans, and counting for a mean of 2.3 pseudodrusen per scan) showed progression over a mean of 23.9 ± 1.2 months. All 58 pseudodrusen (100%) graded as stage 1 at baseline examination progressed to stage 2. Thirteen of 16 pseudodrusen (81.3%) graded as stage 2 at baseline examination progressed to stage 3, and three (18.7%) progressed to stage 4. All four pseudodrusen (100%) graded as stage 3 at baseline examination progressed to stage 4. Among pseudodrusen that were stage 3 or 4 at follow-up (n = 20), 100% had IS/OS disruption whereas 12.1% (n = 7) had IS/OS disruption at stage 1 or 2 (n = 58) (OR, 1.736; 95% CI, 1.02-2.43). CONCLUSIONS The frequency of stage changes over time suggest that reticular pseudodrusen are dynamic pathologic structures.

Hyperreflective Dots: A New Spectral-Domain Optical Coherence Tomography Entity for Follow-Up and Prognosis in Exudative Age-Related Macular Degeneration

Purpose: Spectral-domain optical coherence tomography (SD-OCT) enables high-resolution analysis of retinal layers and previously unseen hyperreflective dots (HRD). HRD morphological characteristics, evolution, possible origin and prognostic value are discussed. Methods: We conducted a prospective study of 100 patients with exudative age-related macular degeneration (AMD), who were treated and followed up with monthly imaging examinations. Statistical correlations between visual acuity (VA) and pre-/post- treatment HRD characteristics were evaluated. Results: HRD were present in all cases, mainly in the outer retinal layers but also elsewhere. After treatment, HRD regressed in a few days, 1 month (p < 0.04) and 3 months (p < 0.01). Regression was evident in all VA and morphological subsets. Resolution was associated with better final VA (p < 0.001). Conclusions: Presence of initial/recurrent HRD, rapid treatment response and the growing role that early biological inflammatory reaction plays in AMD suggests HRD are activated microglia cells. The correlation between VA and HRD could make HRD a clinical marker for early decisions about treatment and retreatment.

Adult-onset foveomacular vitelliform dystrophy: a study by optical coherence tomography.

PURPOSE To evaluate the morphology of adult-onset foveomacular vitelliform dystrophy (AFVD) using optical coherence tomography (OCT) and to correlate the OCT findings with those of biomicroscopy and fluorescein angiography (FA). DESIGN Prospective observational case series. METHODS A complete ophthalmologic examination, including visual acuity, fundus biomicroscopy, FA, and OCT was performed in 21 eyes of 14 consecutive patients with AFVD. RESULTS Mean age at presentation was 64 years (range, 39 to 84 years), and best-corrected visual acuity ranged from 20/25 to 20/400 (median 20/50). Sixteen of 21 eyes (11 patients) exhibited late staining of lesions on FA. In these 16 eyes, OCT revealed that AFVD material consists of a hyperreflective structure located between the photoreceptor and the retinal pigment epithelium layers. The retinal pigment epithelium layer was linear and was not elevated, unlike what is observed in retinal pigment epithelium detachment. Five other eyes (x4 patients) without late staining in FA showed, by OCT, a hyperreflective area at the level of the retinal pigment epithelium band, with no material visible between the photoreceptor and retinal pigment epithelium layers. In all 21 eyes, the retina overlying the hyperreflective structure was raised by the pseudovitelliform material and was markedly thinned. CONCLUSIONS Optical coherence tomography is a noninvasive useful tool that provides new information on the morphology of AFVD. It demonstrates, better than biomicroscopy, the location of the yellowish material under the sensory retina but above the retinal pigment epithelium, corresponding angiographically to the late staining. The foveal thinning found by OCT in all cases probably explains the progressive visual loss and possible evolution toward a full-thickness macular hole.

Optical coherence tomography angiography during follow-up: qualitative and quantitative analysis of mixed type I and II choroidal neovascularization after vascular endothelial growth factor trap therapy.

Purpose: To report the optical coherence tomography angiography (OCT-A) findings in an exudative age-related macular degeneration (AMD) patient presenting mixed type I and II choroidal neovascularization (CNV) during follow-up after intravitreal vascular endothelial growth factor (VEGF) trap treatment. Methods: The clinical assessment included both traditional multimodal imaging, based on fluorescein angiography (FA), indocyanine green angiography (ICGA) and B-scan OCT, and OCT-A at baseline and follow-up. OCT-A images were obtained using a Spectralis OCT-A prototype able to acquire 70,000 A-scans per second, with a resolution of 7 µm axially and 14 µm laterally. An amplitude decorrelation algorithm developed by Heidelberg Engineering was applied to a volume scan, on a 15 × 5° area, which was composed of 131 B-scans (35 frames per scan) at a distance of 11 µm each. The borders of type I and type II CNV were manually outlined and then the areas were analyzed using the provided automated software before and after treatment. Results: The qualitative approach revealed a substantial decrease in the visibility of tiny branching vessels and anastomoses both in type I and type II components of the neovascular complex, associated with persistence of a clear hyperintense signal coming from the larger trunks, which remained well-perfused. Quantitative analysis confirmed a reduction of the lesion area after VEGF trap treatment: the type II component decreased from 0.25 to 0.19 mm2, while the type I component decreased from 2.03 to 1.80 mm2. Conclusions: Our study qualitatively and quantitatively demonstrated the response of a mixed type I-II CNV to intravitreal VEGF trap therapy. Although FA remains the gold standard for determining the presence of leakage and OCT easily shows fluid accumulation and its variations, OCT-A offers noninvasive monitoring of the retinal and choriocapillaris microvasculature in patients with CNV, aiding in diagnosis and treatment decisions during follow-up.

Endophthalmitis After Intravitreal Injections: Incidence, Presentation, Management, and Visual Outcome

PURPOSE To report the incidence and characteristics of endophthalmitis after intravitreal injections of anti-vascular endothelial growth factor agents or corticosteroids and to describe the clinical and bacteriologic characteristics, management, and outcome of these eyes with acute endophthalmitis in France. DESIGN Retrospective, nationwide multicenter case series. METHODS From January 2, 2008 to June 30, 2013, a total of 316,576 intravitreal injections from 25 French ophthalmic centers were included. For each center, the number of intravitreal injections was determined using billing codes and the injection protocol was recorded. A registry and hospital records were reviewed to identify patients treated for endophthalmitis after injection during the same time period. The main outcome measures were the incidence of clinical endophthalmitis and visual acuity of endophthalmitis cases. RESULTS During the study period, 65 cases of presumed endophthalmitis were found, giving an overall incidence of 0.021% (2.1 in 10,000 injections) (95% confidence interval [CI], 0.016%-0.026%). The median number of days from injection to presentation was 4 [1-26] days. The most common symptom was vision loss. Bacterial identification was achieved in 43.4%. The most frequent pathogens were gram-positive bacteria (91.3%), including coagulase-negative Staphylococcus in 78.3%. Neither the interval between injection and presentation for endophthalmitis nor the clinical signs differentiated culture-positive from culture-negative cases. In multivariate analysis, the use of a disposable conjunctival mould assist device and the use of prophylaxis with an antibiotic or antiseptic were significantly associated with an increased incidence of endophthalmitis (P = .001). The majority of patients had worse visual acuity after 3 months of follow-up when compared with acuity before endophthalmitis. CONCLUSIONS The incidence of presumed endophthalmitis after intravitreal injections of anti-vascular endothelial growth factors or corticosteroids was low and the prognosis poor. Prevention and management remain challenging. It remains to be determined whether the findings of this study are relevant for other countries using different techniques for intravitreal injections.

Comparison of Exudative Age-related Macular Degeneration Subtypes in Japanese and French Patients: Multicenter Diagnosis With Multimodal Imaging

PURPOSE To compare and analyze differences and similarities between Japanese and French patients in subtype diagnosis of exudative age-related macular degeneration (AMD) as determined by fundus photography (FP) and fluorescein angiography (FA), and a multimodal imaging involving FP, FA, indocyanine green angiography (ICGA), and optical coherence tomography (OCT). DESIGN Retrospective chart review. METHODS We determined the subtype diagnosis for 99 consecutive Japanese eyes and 94 consecutive French eyes with exudative AMD. The first-step diagnosis was made using FP and FA, while the second-step diagnosis was made using FP, FA/ICGA, and OCT. The diagnoses made by Japanese and French physicians were compared, and when the diagnoses differed, a third institute was consulted to arrive at a final consensus and diagnosis. RESULTS The first-step diagnosis showed 20%-30% disagreement against the final diagnosis, but the second-step diagnosis showed only 10% disagreement. Polypoidal choroidal vasculopathy (PCV) was observed more in Japanese patients (48%) than in French (9%), and the rate of PCV with type 1 or 2 choroidal neovascularization (CNV) was extremely low: 3% in Japanese and 0% in French. Type 1 CNV was found significantly more in French cases (53.3% vs 35.1%, P=.018), while the rate of eyes with type 2 CNV only or chorioretinal anastomosis was similar between populations. CONCLUSIONS Multimodality imaging significantly improved the sub-classification of AMD. There were significant differences between the 2 series in the proportions of type 1 CNV and PCV, while the proportions of type 2 CNV only and chorioretinal anastomosis were similar between groups.