Kiriko Hirooka

Choroidal thickening prior to anterior recurrence in patients with Vogt–Koyanagi–Harada disease

Aim To assess choroidal thickness changes associated with anterior segment recurrences in patients with Vogt–Koyanagi–Harada (VKH) disease using enhanced depth imaging optical coherence tomography (EDI-OCT). Methods EDI-OCT images were obtained periodically from 11 patients with VKH disease (22 eyes) who were followed-up due to anterior segment recurrences. Subfoveal choroidal thickness (SCT) values at the following stages were evaluated: (1) during the remission phase, (2) 1 month before detecting the anterior recurrence, (3) during the anterior recurrence and (4) after systemic prednisolone (PSL) treatment leading to remission. In comparison with SCT values in remission as baseline, the changing ratios of SCT were statistically analysed at subsequent three stages. Results The average of the SCT changing ratios compared with the remission phase significantly increased to 1.45±0.11 during anterior segment recurrences (p=0.00044) lacking any funduscopic signs of posterior involvement. Interestingly, the average SCT ratio 1 month before detecting the recurrence had already increased to 1.30±0.08 (p=0.002). After the PSL treatment, the ratio of SCT recovered to 0.95±0.03, which was equivalent to the remission level. However, in patients with their remission SCT values less than 240 µm, the SCT ratio did not increase significantly at any time points evaluated. Conclusions The choroid in eyes with VKH disease thickened in association with the anterior segment recurrence, and this thickening was observed prior to the recurrence. EDI-OCT may be useful for detecting latent choroidal inflammation in VKH disease, whereas it may not for patients with the relatively thin choroid. Trial registration number The trial registration number of the internal review board of Hokkaido University Hospital is 014-0384.

Pulse Waveform Changes in Macular Choroidal Hemodynamics With Regression of Acute Central Serous Chorioretinopathy.

PURPOSE To quantitatively evaluate the pulse waveform changes in macular choroidal blood flow by using laser speckle flowgraphy (LSFG) with regression of acute central serous chorioretinopathy (CSC). METHODS This retrospective observational case series included 20 eyes of 20 patients with acute CSC. Laser speckle flowgraphy was performed at baseline and after 6 months. On the LSFG monochrome map, automatically divided 5 × 5 grid segments within the macula were classified into predominantly delayed filling (PDF) or minimally or no delayed filling (MDF) areas according to the degree of choroidal filling delay on early-phase indocyanine green angiography. The average mean blur rate (MBR) and the pulse waveform parameters, including the skew and blowout time (BOT), were compared between the total PDF and MDF areas during follow-up. RESULTS The average MBR significantly decreased in both PDF (P = 0.005) and MDF (P < 0.001) areas during follow-up; in both areas, the skew decreased (P < 0.001 and P = 0.006, respectively) and BOT increased (P < 0.001 for each), showing significant reduction in vascular resistance at 6 months. The degree of the changes in the skew and BOT was significantly larger (P = 0.02 and P < 0.001, respectively) in the PDF area than in the MDF area. CONCLUSIONS Changes in the skew and BOT, indices for vascular resistance, confirmed the involvement of circulatory disturbance at the acute stage of CSC. The present findings suggested that the pathogenesis of CSC stems from imbalanced distribution of choroidal blood flow due to augmented vascular resistance.

Changes in Inner and Outer Retinal Layer Thicknesses after Vitrectomy for Idiopathic Macular Hole: Implications for Visual Prognosis

Purpose To investigate sequential post-operative thickness changes in inner and outer retinal layers in eyes with an idiopathic macular hole (MH). Methods Retrospective case series. Twenty-four eyes of 23 patients who had received pars plana vitrectomy (PPV) for the closure of MH were included in the study. Spectral domain optical coherence tomography C-scan was used to automatically measure the mean thickness of the inner and outer retinal layers pre-operatively and up to 6 months following surgery. The photoreceptor outer segment (PROS) length was measured manually and was used to assess its relationship with best-corrected visual acuity (BCVA). Results Compared with the pre-operative thickness, the inner layers significantly thinned during follow-up (P = 0.02), particularly in the parafoveal (P = 0.01), but not perifoveal, area. The post-operative inner layer thinning ranged from the ganglion cell layer to the inner plexiform layer (P = 0.002), whereas the nerve fiber layer was unaltered. Outer layer thickness was significantly greater post-operatively (P = 0.002), and especially the PROS lengthened not only in the fovea but also in the parafovea (P < 0.001). Six months after surgery, BCVA was significantly correlated exclusively with the elongated foveal PROS (R = 0.42, P = 0.03), but not with any of the other thickness parameters examined. Conclusions Following PPV for MH, retinal inner layers other than the nerve fiber layer thinned, suggestive of subclinical thickening in the inner layers where no cyst was evident pre-operatively. In contrast, retinal outer layer thickness significantly increased, potentially as a result of PROS elongation linking tightly with favorable visual prognosis in MH eyes.

Enhanced-depth imaging optical coherence tomography and laser speckle flowgraphy in a patient with acute macular neuroretinopathy.

Acute macular neuroretinopathy (AMN) is a rare disease characterized by a wedge-shaped dark reddish-brown lesion at the macula. Spectral domain optical coherence tomography (OCT) images have shown that AMN lesions mainly affect the outer retina. AMN lesions can be visualized clearly using scanning laser ophthalmoscope (SLO) infrared imaging, a noninvasive technique used to characterize structural changes at the level of the retinal pigment epithelium–inner choroid layers. The data collected thus far suggest that AMN lesions typically extend from the outer retina to the inner choroid. In a recent study using SD-OCT, AMN was classified into type 1 or 2 by whether hyperreflective bands corresponding to the lesions were located above or below the outer plexiform layer. Type 2 appears to involve the outer retinal impairments but type 1 does not and was especially named as paracentral acute middle maculopathy. The mechanism was speculated to be the occlusion of the superficial (type 1) or deep (type 2) retinal capillary plexus. In the study, however, pathology regarding the choroid, which supplies the oxygen and nutrient to the photoreceptor, was not examined. Laser speckle flowgraphy (LSFG) can be used for noninvasive evaluation of circulation of ocular tissues and calculation of the mean blur rate (MBR), a quantitative index of relative blood flow velocity. Since the MBR originates mainly from the choroid, this value is associated with choroidal hemodynamics, particularly at the macula. LSFG is a suitable device to quantitatively monitor changes in ocular tissue circulation during the course of various diseases because it provides a relative value for the blood flow. We used LSFG to show that choroidal blood flow velocity decreased at the lesion site during the acute phase of AMN. This result suggests that impaired choroidal circulation is involved in the pathogenesis of AMN. Furthermore, we recently reported a case with the simultaneous onset of AMN and central retinal vein occlusion, suggesting that circulatory disorder concurrently occurred in retinal and choroidal vessels. However, few studies regarding morphology of the choroid in AMN patients have been reported. We examined changes in morphology and circulation in the choroid of an AMN patient using enhanced-depth imaging OCT (EDI-OCT) and LSFG. An 11-year-old girl reported a paracentral scotoma of the right eye, first noted 3 months prior to presentation at our clinic. The patient’s medical and family histories were unremarkable. The patient’s best-corrected visual acuity (BCVA) was 1.5 OU with mild hyperopia of the same degree. Slit-lamp examination revealed no abnormal findings OU. There were no abnormal funduscopic findings OS. Funduscopic examination revealed a petaloid dark reddish lesion at the upper edge of the fovea (Figure 1A). SLO infrared imaging showed a dark area corresponding to the site of the dark reddish lesion (Figure 1B). Fluorescein angiography (FA) revealed hypofluorescence from the initial phase

Retinal outer layer thickness increases with regression of multiple evanescent white dot syndrome and visual improvement positively correlates with photoreceptor outer segment length

Editor, M ultiple evanescent white dot syndrome (MEWDS) is a unilateral chorioretinal disease characterized by multiple small subretinal white dots extending from the posterior pole to the midperiphery (Jampol et al. 1984). Spectral-domain optical coherence tomography (SD-OCT) demonstrates impairments in outer retinal morphology that recover along with improvements in visual function (Li & Kishi 2009). However, little is known about how inner and outer retinal layer thicknesses change with regression of MEWDS or how this correlates with visual outcomes. Here we show, using SD-OCT, the time–course of changes in retinal layer thicknesses in MEWDS. This study included 8 eyes from 8 patients (1man and 7women;mean age, 31.6 13.6 years) with MEWDS. All enrolled cases were unilateral. Using the C-scanmode (6 9 6 mmmacular thickness map) of SD-OCT (RS-3000 or RS3000 Advance; NIDEK, Gamagori, Japan), the whole (the inner limiting membrane [ILM] to the retinal pigment epithelium [RPE]), inner (the ILMto the inner plexiform layer [IPL]) and outer (the outer nuclear layer to the RPE) retinal layer thicknesses were automatically measured at baseline and 1 and 3 months after baseline in MEWDS eyes and at baseline and 3 months in unaffected fellow eyes (Fig. 1A), as described previously (Hashimoto et al. 2014). Moreover, the inner retinal layer was divided into two layers (i.e. the ILM

Choroidal circulation impairment during the anterior recurrence of Vogt-Koyanagi-Harada disease confirmed with indocyanine green angiography and laser speckle flowgraphy.

To assess choroidal inflammation‐related circulatory changes associated with the anterior recurrence of Vogt–Koyanagi–Harada (VKH) disease, using indocyanine green angiography (ICGA) and laser speckle flowgraphy (LSFG).

A patient with acute macular neuroretinopathy and central retinal vein occlusion

Purpose The precise mechanism causing acute macular neuroretinopathy (AMN) is still unknown. A recent report suggested that choroidal circulation impairment correlates with its pathogenesis. We report a rare case with simultaneous onset of AMN and central retinal vein occlusion (CRVO), which is a retinal circulation disorder Methods Case report. Results A 44-year-old woman complained of central visual loss of the left eye for the previous 2 weeks. The patient’s visual acuity was 0.5 in the left eye (OS). Fundoscopic examination revealed a wedge-shaped, dark reddish-brown lesion at the macula, and CRVO-like retinal hemorrhages OS. Fluorescein angiography revealed retinal vasculitis and hypofluorescence corresponding to the macular lesion. The patient’s scanning laser ophthalmoscopy infrared imaging result led to a diagnosis of AMN. Two weeks after corticosteroid pulse therapy, her visual acuity improved to 1.2 OS, with improvement of macular findings and Humphrey perimetry. When the dose of oral corticosteroid was decreased, the AMN lesion worsened, with recurrence of retinal hemorrhages. Visual functions improved again after an increased dose of corticosteroid. Conclusion These results suggest that circulatory disorders almost simultaneously occurred in choroidal and retinal vessels, resulting in the onset of both AMN and CRVO.

Improvements of visual function and outer retinal morphology following spontaneous regression of cancer in anti-recoverin cancer-associated retinopathy

Purpose To report an anti-recoverin antibody-positive cancer-associated retinopathy (anti-recoverin CAR) patient with remarkable improvements of visual function and outer retinal morphology following spontaneous regression of cancer. Observations A 65-year-old woman with small cell lung carcinoma developed progressive, bilateral vision loss with diffuse loss of the ellipsoid zone at the macula on optical coherence tomography and marked reduced responses of a- and b-waves on electroretinography. Western blot analysis led to a diagnosis of anti-recoverin CAR. The visual function and outer retinal morphology gradually improved following spontaneous regression of the cancer and the initiation of systemic corticosteroid. Subsequent intermittent chemotherapy and continuation of corticosteroid maintained reduction of the cancer and prevented the recurrence of CAR, with preservation of improvements of the visual function and macular outer retinal morphology. Conclusions and importance These results suggest that requirement for obtaining good visual prognosis in CAR patients is to make the cancer regress prior to falling into photoreceptor apotosis.

Early post-treatment choroidal thickness to alert sunset glow fundus in patients with Vogt-Koyanagi- Harada disease treated with systemic corticosteroids

Purpose To determine if early post-treatment central choroidal thickness (CCT) changes can predict sunset glow fundus (SGF) development in patients with Vogt-Koyanagi-Harada (VKH) disease treated using systemic corticosteroids. Methods This retrospective case series included 39 eyes of 21 treatment-naïve patients with acute VKH disease who could be followed up for more than 12 months after systemic corticosteroid therapy. The eyes were divided into two groups according to whether SGF was present or absent at 12 months (9 eyes of 5 patients versus 30 eyes of 16 patients, respectively). Using enhanced depth imaging optical coherence tomography, CCT values were measured before treatment, then at 1 week and 1 and 3 months after treatment in both groups and compared between the two groups. Results Development of SGF was found 4–11 months after treatment. Mean post-treatment CCT decreased significantly at all examinations compared with baseline in both groups, along with resolution of serous retinal detachment. One week after treatment, mean CCT was significantly higher in eyes with SGF than in those without (P = 0.024). SGF was present at 12 months in 9 of 22 eyes with CCT values > 410 μm at 1 week after starting treatment, in contrast with none of 17 eyes with CCT ≤ 410 μm at this time (P = 0.003). Conclusions The current study suggested the potential validity of early post-treatment CCT as a feasible index to alert future progression to SGF in patients with VKH disease treated using systemic corticosteroids.