Michelle C. Liang

Analysis of the thickness and vascular layers of the choroid in eyes with geographic atrophy using spectral-domain optical coherence tomography.

Purpose: To analyze the total choroidal thickness and thickness of the individual vascular layers of the choroid in eyes with geographic atrophy (GA), using spectral-domain optical coherence tomography. Methods: A cross-sectional retrospective review identified 17 patients with GA (17 eyes) and 14 age-matched healthy subjects (14 eyes), who underwent high-definition raster scanning at New England Eye Center, Boston, MA. Patients were diagnosed with GA based on clinical examination and investigations. Two independent raters evaluated the thickness and vascular layers of the choroid. Results: Mean choroidal thickness was significantly lower in eyes with GA when compared with age-matched healthy eyes (P < 0.0001). Subfoveal choroidal thickness in eyes with GA was significantly less when compared with healthy eyes (158.1 ± 23.65 &mgr;m versus 267.5 ± 19.27 &mgr;m, P = 0.001). Subfoveal large choroidal vessel layer thickness and medium choroidal vessel layer/choriocapillaris layer thickness were significantly reduced in eyes with GA when compared with healthy eyes (P = 0.001 and P < 0.0001, respectively). Conclusion: The choroid is significantly thinner in eyes with GA involving the fovea when compared with healthy eyes. Choroidal thinning in GA involves all its vascular layers. Further studies involving prospective correlation of choroidal vascular changes to the quantitative progression of GA is expected to provide further insight on the choroidal angiopathy associated with GA.

Subretinal Fluid Associated With MEK Inhibitor Use in the Treatment of Systemic Cancer.

IMPORTANCE The use of mitogen-activated protein kinase (MAPK) kinase (MEK) inhibitors has become more common in the treatment of systemic cancer. These agents have been associated with a central serous-like retinopathy in some patients. Recognition of such retinal findings and the relatively benign nature of these events is important to avoid unnecessary intervention, including the cessation of a potentially life-prolonging medication. OBJECTIVES To evaluate the presence and characteristics of subretinal fluid (SRF) associated with the use of MEK inhibitors in the treatment of systemic cancer and to correlate the presence of SRF with visual acuity and symptoms over time. DESIGN, SETTING, AND PARTICIPANTS Post hoc analysis was conducted of prospectively collected data from 51 patients with locally advanced or metastatic cancer undergoing treatment with the MEK inhibitor binimetinib in 1 of 4 clinical trials. All clinical trial participants underwent complete ophthalmic examination by retina specialists at a private practice in Boston, Massachusetts, and were monitored between February 29, 2012, and January 8, 2014. The examination included Snellen-measured visual acuity, dilated fundus examination, and spectral-domain optical coherence tomography at baseline, biweekly for 2 months, then monthly for the remainder of their trial participation. Post hoc design and data analysis were performed between December 1, 2013, and June 20, 2014. MAIN OUTCOMES AND MEASURES Visual symptoms, visual acuity, fundus appearance, and the presence and characteristics of SRF noted on optical coherence tomography. The characteristics of angiograms performed at the discretion of the treating physician were reviewed. RESULTS Of the 51 participants, 18 (35%) were men; the mean (SD) age was 60 (13) years (range, 32-87 years). Forty-six (90%) study participants developed SRF during the study period, with 9 (20%) experiencing symptoms at any point. The mean (SD) central retinal thickness of 39 study participants who developed SRF at the first visit increased from 280 (26) µm at baseline to 316 (43) µm at the first visit after starting binimetinib treatment (paired t test, P < .001). On examination, SRF appeared as elevated, yellow-orange pockets in the fovea and/or along the arcades. Corresponding optical coherence tomographic imaging revealed SRF beneath the interdigitation zone. The fovea was affected in 37 of 46 (80%) individuals; the location of SRF accumulation varied. Visual symptoms were mild and mainly transient, occurring in 9 participants with SRF (20%; 95% CI, 10%-33%). Only 2 participants (4%) were found to have SRF at the last study visit after discontinuation of treatment with binimetinib. Both had Snellen-measured visual acuity of 20/25 or better. CONCLUSIONS AND RELEVANCE The presence of SRF was common in study participants undergoing treatment with the MEK inhibitor binimetinib. Visual symptoms were mild and mainly transient. The presence of SRF did not lead to permanent ocular sequelae. Cessation of life-extending treatment with MEK inhibitors is not indicated when SRF is present.

CORRELATION OF SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY AND CLINICAL ACTIVITY IN NEOVASCULAR AGE-RELATED MACULAR DEGENERATION.

Purpose: To characterize the features of choroidal neovascularization (CNV) in neovascular age-related macular degeneration with spectral domain optical coherence tomography angiography (OCTA) and to determine whether OCTA can be used to determine clinical activity of CNV. Methods: Observational, retrospective, consecutive case series. Results: Optical coherence tomography angiography revealed CNV in 28 eyes (62.2%) while 17 eyes (37.8%) did not demonstrate CNV vessels. Choroidal neovascularization was classified as well circumscribed in 12 eyes (42.8%) and poorly circumscribed in 16 eyes (57.2%). Twenty-two eyes with a CNV on OCTA were clinically active, whereas six eyes with visible CNV on OCTA were clinically inactive. Of the 17 eyes that did not have evidence of CNV on OCTA imaging, 14 were clinically inactive and 3 were clinically active. Presence of CNV on OCTA correlated with clinical activity and absence of CNV correlated with inactivity (P < 0.0001). Conclusion: Optical coherence tomography angiography is a noninvasive imaging technique that can be used to visualize blood flow comprising CNV. Optical coherence tomography angiography detects CNV vessels in some albeit not all eyes with neovascular age-related macular degeneration. Although the presence or absence of CNV vessels on OCTA highly correlated with clinical activity of CNV, the morphologic appearance of CNV on OCTA did not have significant correlation with clinical activity.

Optical Coherence Tomography Angiography of Mixed Neovascularizations in Age-Related Macular Degeneration

PURPOSE To describe the imaging of mixed neovascular age-related macular degeneration (AMD) using optical coherence tomography angiography (OCTA). METHODS Literature review and case series. RESULTS A review of mixed neovascularization in AMD is discussed, focusing on the different subtypes of neovascularization and the associated characteristics on imaging, including fluorescein angiography, optical coherence tomography, and OCTA. Three cases are presented. CONCLUSION OCTA is a method of identifying mixed neovascularization in AMD. Neovascular vessels can be seen on en face images of the retina, both below and above the retinal pigment epithelium, corresponding to different types of leakage observed on conventional angiography.

MICROBIOLOGIC SPECTRUM AND VISUAL OUTCOMES OF ACUTE-ONSET ENDOPHTHALMITIS UNDERGOING THERAPEUTIC PARS PLANA VITRECTOMY.

Purpose: To report the clinical presentation, microbiologic spectrum, and visual outcomes associated with acute-onset infectious endophthalmitis undergoing therapeutic pars plana vitrectomy. Methods: Multicenter interventional retrospective noncomparative consecutive case series. Billing records were reviewed to identify all charts for patients undergoing pars plana vitrectomy within 14 days of diagnosis of acute-onset infectious endophthalmitis over a 4-year period at 5 large tertiary referral retina practices. Statistical analysis was performed to assess for factors associated with visual outcomes. Results: Seventy patients were identified. The most common clinical setting was postcataract surgery (n = 20). Only 3 patients (4.3%) presented with 20/400 or better visual acuity (VA). Although most of the patients initially underwent vitreous tap and intravitreal antibiotic injection (n = 47, 67.1%), all patients eventually underwent pars plana vitrectomy within 14 days of presentation with 68.5% (48/70) of patients undergoing pars plana vitrectomy within 48 hours of presentation. Positive intraocular cultures were obtained in 56 patients (80%). The most common identified organism was Streptococcus sp (n = 19). Visual acuity at last follow-up was 20/400 or better in 19 patients (27.1%). Three patients underwent evisceration or enucleation (4.3%). Last recorded postoperative VA (mean LogMAR 1.99 ± 0.94, Snellen VA equivalent finger count) improved from presenting VA (mean LogMAR 2.37 ± 0.38, Snellen VA hand motions) (P ⩽ 0.001). There was no statistically significant correlation between the underlying etiology or the timing of surgery with this VA outcome. Conclusion: Although less than one-third of patients achieved 20/400 or better VA, this VA often improved significantly from presenting VA.

PARS PLANA VITRECTOMY FOR LATE VITREORETINAL SEQUELAE OF INFECTIOUS ENDOPHTHALMITIS: Surgical Management and Outcomes

Purpose: To report the visual acuity outcomes after pars plana vitrectomy for delayed vitreoretinal sequelae of infectious endophthalmitis. All eyes were initially treated with intravitreal antibiotics (Abx). Methods: Multicenter, retrospective, consecutive case series. Results: Forty-two eyes met the study criteria. The mean follow-up was 48 weeks (SD ± 61.8). Mean interval from Abx to pars plana vitrectomy was 13 weeks (SD ± 14.3, range 2–70). Indications for pars plana vitrectomy included vitreous opacities (VO) (n = 22), epiretinal membrane (n = 9), and retinal detachment (n = 11). LogMAR visual acuity improved from 1.87 (Snellen equivalent: 20/1,482) preoperatively to 1.35 (Snellen equivalent: 20/447) at final evaluation (P < 0.001). LogMAR visual acuity improved significantly for patients with vitreous opacities (P < 0.01) and retinal detachment (P = 0.02) but not for patients with epiretinal membranes (P = 0.08). Conclusion: Patients with infectious endophthalmitis can gain vision if they have a pars plana vitrectomy for delayed sequelae such as vitreous opacities or for retinal detachment.

Progressive Outer Retinal Necrosis Secondary to Herpes Simplex Virus Type 2.

Progressive outer retinal necrosis is an aggressive form of necrotizing herpetic retinitis that presents in immunocompromised patients. It is usually secondary to varicella zoster virus or, rarely, herpes simplex virus type 1. The authors report a case of progressive outer retinal necrosis associated with herpes simplex virus type 2 in a patient with a history of congenital herpes. [Ophthalmic Surg Lasers Imaging Retina. 2014;45:xxx-xxx.].

Solid-appearing retinal cysts in diabetic macular edema: a novel optical coherence tomography finding.

PURPOSE To describe a novel finding of solid-appearing retinal cysts in patients with diabetic macular edema. METHODS Case series of four patients with diabetic retinopathy discovered to have solid-appearing retinal cysts on spectral-domain optical coherence tomography. RESULTS These cases demonstrate the presence of inner retinal hyporeflective cysts filled with an isoreflective substance on spectral-domain optical coherence tomography. These solid-appearing cysts arise from previously fluid-filled cysts and are not found in relation to intraretinal hemorrhage. Treatment with intravitreal anti-vascular endothelial growth factor agents did not seem to directly alter their natural course. CONCLUSION The authors report solid-appearing retinal cysts as a new optical coherence tomography finding in four patients with diabetic macular edema. The exact composition of this isoreflective material is unknown. The authors hypothesize that fibrin or other inflammatory by-products fill these spaces.

SPECTRAL DOMAIN-OPTICAL COHERENCE TOMOGRAPHY FINDINGS OF COMMOTIO RETINAE WITH ASSOCIATED SEROUS RETINAL DETACHMENT.

Purpose: To describe the appearance of a serous retinal detachment associated with commotio retinae on spectral domain optical coherence tomography. Methods: Case report. Results: This case demonstrates the rare presentation of subretinal fluid in commotio retinae. Characteristic outer retinal changes associated with commotio retinae were also seen. Treatment was deferred and the subretinal fluid resolved within 1 week. Conclusion: Commotio retinae is rarely associated with a serous retinal detachment. This presentation is important to identify as it can avoid unnecessary workup and treatment.

Retinoschisis and Outer Retinal Hole Formation in a Patient With Papillorenal Syndrome

This report describes a 19-year-old patient with the rare association of macular retinoschisis and outer retinal hole formation with papillorenal syndrome. Initially diagnosed with transplant-related central serous chorioretinopathy, she presented several years later with worsening vision and distortion in her right eye. On examination, she was found to have bilateral optic nerve dysplasia, bilateral macular and extramacular retinoschisis, and a serous retinal detachment with outer hole formation in the right eye. A history of prior renal transplantation due to poor kidney development led to the diagnosis of papillorenal syndrome.