Mayer Srour

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.

Type 2 Neovascularization Secondary To Age-related Macular Degeneration Imaged By Optical Coherence Tomography Angiography

Purpose: Optical coherence tomography angiography is a novel and noninvasive technique for imaging retinal microvasculature by detecting changes in reflectivity that is related to blood flow. The purpose of this study was to describe Type 2 neovascularization characteristics in age-related macular degeneration using optical coherence tomography angiography. Methods: Fourteen eyes of 14 consecutive patients with Type 2 neovascularization were prospectively included. All patients underwent a complete ophthalmological examination, including color and infrared fundus photography, fluorescein and indocyanine green angiography, spectral domain optical coherence tomography angiography, and optical coherence tomography angiography. Results: In all cases, Type 2 lesions could be detected by optical coherence tomography angiography, presenting as a hyperflow lesion in the outer retina, with a glomerulus (4/14) or medusa shape (10/14), surrounded by a dark halo. The superficial layer and the deep retina showed no abnormal flow. Surprisingly, the Type 2 lesions could also be observed in the presumed choriocapillaris layer. These glomerulus- or medusa-shaped lesions were connected, in 10/14 eyes, to a thicker main branch, which seemed to continue deep into the choroidal layers. Conclusion: Optical coherence tomography angiography may be a new imaging method for the diagnosis of Type 2 neovascularization in clinical routine. However, the specificity of the features needs to be investigated in further studies.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FEATURES OF SUBRETINAL FIBROSIS IN AGE-RELATED MACULAR DEGENERATION.

Purpose: To report the imaging features of subretinal fibrosis secondary to exudative age-related macular degeneration (AMD) on optical coherence tomography angiography. Methods: All consecutive patients diagnosed with subretinal fibrosis complicating exudative AMD were imaged by color retinal photographs or multicolor imaging, fluorescein angiography, spectral domain optical coherence tomography, and optical coherence tomography angiography. Eyes with active exudative features observed during the last 6 months were compared with those without any sign of exudation >6 months. Results: Forty-nine eyes of 47 consecutive patients were included. A blood flow inside the fibrotic scar could be detected in 46 of 49 cases (93.8%). Three patterns of vascular networks could be distinguished, that were described as pruned vascular tree (26 of 49 eyes; 53.1%), tangled network (14 of 49; 28.6%), and/or vascular loop (25 of 49; 51.0%). Furthermore, 2 types of hyporeflective structures, large flow void, and/or dark halo were observed in 63% and in 65% of eyes, respectively. The observed patterns did not differ between eyes with active or inactive lesions. Conclusion: Optical coherence tomography angiography of subretinal fibrosis showed almost constantly a perfused, abnormal vascular network and collateral architectural changes in the outer retina and the choriocapillaris layer. These features were associated with both active and inactive fibrotic choroidal neovessels.

Comparison of macular choroidal thickness in adult onset foveomacular vitelliform dystrophy and age-related macular degeneration.

PURPOSE To compare macular choroidal thickness (MCT) in eyes with adult onset foveomacular vitelliform dystrophy (AOFVD) and eyes with AMD. METHODS Five groups of 38 eyes each were included in a prospective, observational, comparative study: AOFVD eyes with fluid accumulation; AOFVD fellow eyes without fluid (early stage); advanced exudative (wet) AMD; advanced dry AMD; and healthy normal eyes. All study eyes underwent a comprehensive ophthalmologic examination. Macular choroidal thickness was measured using enhanced depth imaging optical coherence tomography (EDI-OCT). RESULTS Subfoveal choroidal thickness (SFCT) in AOFVD with subretinal fluid (325.66 ± 85.98 μm) was significantly (P < 0.001) thicker compared with that in exudative AMD (158.55 ± 57.87 μm) and in dry AMD (157.53 ± 67.08 μm). Also, in AOFVD, the choroid was significantly (P = 0.001) thicker than that in the normal group (255.87 ± 87.46 μm). However, in AOFVD, there was no significant difference (P = 0.69) between the SFCT in the study eye and in the fellow eye (317.66 ± 90.04 μm). The choroidal thickness at each of the other 12 measured points showed similar results. CONCLUSIONS This study demonstrates choroidal thickening in AOFVD in contrast with the choroidal thinning observed in advanced AMD. These findings suggest that the pathogenic mechanisms in AOFVD are different from those in exudative AMD. Choroidal thickness measurement could help differentiate the challenging diagnosis between exudative AMD and the advanced stage of AOFVD (with fluid accumulation but without choroidal neovascularization).

Optical coherence tomography angiography characteristics of polypoidal choroidal vasculopathy.

Purpose To analyse the morphological characteristics of polypoidal choroidal vasculopathy (PCV) on optical coherence tomography angiography (OCT-A). Methods Prospective study with consecutive patients affected with PCV were included. All patients underwent a complete ophthalmological examination including fundus photography, fluorescein angiography, indocyanine green angiography, spectral-domain OCT and OCT-A. Results Twelve eyes of 12 patients (mean age 72.6±10.5 years; 4 men and 8 women) were included for analysis. In all eyes (12/12) the segmentation of the choriocapillaris layer on OCT-A revealed the branching vascular network (BVN) as a hyperflow lesion. OCT-A segmentation of the choriocapillaris layer in correspondence of the polypoidal lesion showed in 3/12 eyes (25%) a hyperflow round structure, surrounded by a hypointense halo, and in 9/12 eyes (75%) a hypoflow round structure. Conclusions The OCT-A is a non-invasive imaging modality allowing the visualisation of different structures in PCV. The BVN is constantly clearly detected. The hypoflow round structure appearance of the polyp in OCT-A, is probably due to an unusual blood flow inside the polypoidal lesions, contrasting with the BVN. Further improvement in OCT-A knowledge will provide information on the specificity of the different intensity characteristics in PCV.

Restoration of Outer Retinal Layers After Aflibercept Therapy in Exudative AMD: Prognostic Value.

PURPOSE To evaluate the outer retinal layer (ellipsoid zone [EZ] and external limiting membrane [ELM]) changes following intravitreal aflibercept injections in eyes with treatment-naïve exudative age-related macular degeneration (eAMD) and to correlate these changes with fluid response and visual improvement. METHODS A retrospective case series of 50 treatment-naïve eAMD eyes followed-up for 18 months. All patients underwent regular comprehensive ophthalmic examinations. The presence of EZ disruption, ELM disruption, EZ swelling, subretinal hyper-reflective exudation (SHE), central macular thickness (CMT), cystoid spaces, subretinal fluid, and pigmented epithelium detachment were evaluated by two different retinal specialists at baseline and final visits, and correlated with best corrected visual acuity (BCVA) improvement. RESULTS At 18 months, BCVA, EZ disruption, ELM disruption, EZ swelling and SHE improved significantly (P = 0.001) at 18 months. Improvement of BCVA showed a statistically significant correlation with ELM restoration (P = 0.018), but not with EZ restoration (P = 0.581). Swelling of the EZ decreased from 72% of the cases at baseline to 30% in 18 months while SHE decreased from 52% to 6% in 18 months (P = 0.001). We observed a statistically significant (P = 0.001) reduction between the baseline and final value of CMT. CONCLUSIONS Aflibercept is safe and effective in treating exudative AMD with the restoration of the outer retinal layers. Restoration of the EZ is not statistically correlated with the final BCVA, even though persistent EZ changes could be associated with irreversible decrease in vision. On the contrary, the final status of the ELM is directly correlated with final BCVA. Also, baseline changes in outer retinal layers, especially the ELM, appear to predict photoreceptor restoration and final BCVA, and must be comprehensively analyzed to enable and determine a future prognosis.

Optical coherence tomography angiography in adult-onset foveomacular vitelliform dystrophy

Purpose To describe structural features of eyes with adult-onset foveomacular vitelliform dystrophy (AFVD) on optical coherence tomography angiography (OCT-A) and to evaluate the ability to detect the presence of choroidal neovascularisation (CNV). Methods Consecutive patients presenting at the University Eye Clinic of Creteil with diagnosis of AFVD were included. All patients underwent a complete ophthalmological examination, including fundus autofluorescence, fluorescein angiography, indocyanine green angiography, spectral domain optical coherence tomography and OCT-A by Optovue RTVue XR Avanti. Results Twenty-two eyes of 18 consecutive patients (8 women and 10 men; 68±12.8 years) were included. On OCT-A the presence of subretinal material leads to displacement of blood vessels at both the superficial and deep capillary plexuses of the retina. In one case, these vascular abnormalities were associated with long filamentous vessels running thorough the foveal avascular area. In all cases, a rarefaction of the choriocapillaris was also observed. In two eyes OCT-A distinctly disclosed the presence of a CNV secondary to AFVD while conventional imaging did not show clearly the neovascularisation due to masking effect of the subretinal vitelliform material. Conclusions In patients with AFVD, OCT-A showed vascular network rarefaction with less blood vessels at the superficial and deep capillary plexuses, and the choriocapillaris layer. These vascular abnormalities may play a role in the pathogenesis or simply represent a consequence of material accumulation and reabsorption in AFVD. In two cases, the conventional imaging did not show clearly the neovascularisation due to masking effect of the subretinal vitelliform material, while OCT-A showed distinctly the CNV.

Early spectral-domain optical coherence tomography findings in unilateral acute idiopathic maculopathy.

Unilateral acute idiopathic maculopathy (UAIM) is a rare disorder that affects young people presenting with an acute onset of unilateral central visual loss often associated with a prodromal flu-like illness. Coxsackievirus infection is considered as the cause of UAIM. The disease is characterized by a spontaneous recovery over several weeks. Previous spectral-domain optical coherence tomographic studies have reported abnormal heterogenous hyperreflective thickening at the level of the outer retina and retinal pigment epithelium in the foveal region during the acute phase. However, direct visualization of outer retina and retinal pigment epithelium edema has not been reported so far. Here, we report the very early macular changes in UAIM. A 30-year-old man clinically diagnosed with UAIM (previous flu-like symptoms and elevated coxsackievirus A16 antibody titers) underwent a complete ophthalmologic examination 3 hours after the onset of symptoms. Fundus biomicroscopy revealed a yellowish white lesion in the right macula (Figure 1A). Fluorescein angiography revealed late hyperfluorescence form the macular lesion (Figure 1B). Indocyanine green angiography revealed a persistent hypofluorescent lesion surrounded by a hyperfluorescent halo (Figure 1C). Spectral-domain optical coherence tomography (Spectralis HRA + OCT; Heidelberg Engineering, Heidelberg, Germany) performed at presentation showed the swelling of the outer retina with the inner segment/outer segment junction that appeared elevated and disrupted (Figure 1D). Spectral-domain optical coherence tomography also revealed hyperreflective exudation and a pocket of hyporeflective fluid in the subretinal space (Figure 1D). Enhanced depth imaging optical coherence tomography revealed a subfoveal thickened choroid (Figure 1, E and F). Three weeks later, visual symptoms spontaneously regressed, and spectraldomain optical coherence tomography showed resolution of the outer retina swellingand reabsorption of both the hyperreflective exudation and the pocket of hyporeflective fluid (Figure 2A). The inner segment/ outer segment junction elevation/disruption almost completely regressed and a thickening and slight elevation of the retinal pigment epithelium developed (Figure 2, A and B). To our knowledge, there are no other reports of the acute phase of UAIM showing the very early macular changes such as outer retina swelling and hyperreflective exudation with hyporeflective fluid in the subretinal space. These findings, together with the choroidal thickening, the inner segment/outer segment junction elevation, and disruption, suggest that the choroid might the primary originating anatomical site of the disease process.

En face enhanced depth imaging optical coherence tomography of polypoidal choroidal vasculopathy

Purpose To analyse retinal and choroidal changes associated with polypoidal choroidal vasculopathy (PCV) using en face spectral-domain optical coherence tomography (SD-OCT). Methods In this retrospective and descriptive study, we collected imaging of patients affected with PCV examined using enhanced depth imaging (EDI) SD-OCT, fluorescein and indocyanine green angiography for a qualitative analysis. The three-dimensional reconstruction of 197 transverse sections with EDI SD-OCT at 30 μm intervals provided a virtual macular brick through which 496 sections in the coronal plane resulted in a C-scan or en face OCT image. Results 30 eyes of 30 patients affected with PCV were studied. En face OCT revealed polyps as roundish structures visible deeper than pigment epithelium layer, attached to its posterior face, easily detected in all cases. Hyper-reflective dots were visible on en face OCT in all cases within the retinal layers, associated to a well-defined dark area suggesting serous exudation in 27 eyes. The abnormal choroidal network was identified in four eyes. At the Bruch membrane level, all polyps were associated with a localised back shadowing, and were no more visible at the choriocapillaris layer level. Large choroidal vessels were visible in all eyes, mainly at the polypoidal lesion periphery, not directly behind. Conclusions En face OCT imaging using SD-OCT is an easy, reproducible, non-invasive and effective tool to visualise and to understand retinal and choroidal changes PCV. It provides complementary morphological information, describes new semiological entities and might substitute other exams in the future, without dye injection.

Optical Coherence Tomography Angiography of Idiopathic Polypoidal Choroidal Vasculopathy.

PURPOSE To analyze the morphological characteristics of polypoidal choroidal vasculopathy (PCV) on optical coherence tomography angiography (OCT-A). METHODS Consecutive patients with PCV underwent complete ophthalmological examination, including fundus photography, fluorescein angiography, indocyanine green angiography, spectral-domain OCT and OCT-A. RESULTS Segmentation of the choriocapillaris layer on OCT-A revealed the branching vascular network as a hyper-flow lesion, and it revealed the polypoidal lesion as a hyper-flow round structure surrounded by a hypo-intense halo in some cases and as a hypo-flow round structure in most cases. CONCLUSION OCT-A is a noninvasive imaging modality that allows for the visualization of different structures in PCV. The branching vascular network is consistently and clearly detected. The hypo-flow round appearance of the polyps on OCT-A is probably due to unusual blood flow inside of the polypoidal lesions, in contrast with the branching vascular network. Further improvements in OCT-A knowledge will provide information on the specificity of the different intensity characteristics in PCV.