Oudy Semoun

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 in Central Serous Chorioretinopathy

Purpose. To analyze optical coherence tomography angiography (OCTA) findings in eyes with central serous chorioretinopathy (CSC) and to compare them with those obtained with multimodal imaging. Methods. A series of consecutive patients diagnosed with CSC, underwent OCTA and multimodal imaging, including spectral domain OCT, fluorescein, and indocyanine green angiography. OCTA images were performed at three main depth intervals: automatically segmented outer retina, manually adjusted outer retina, and automatically segmented choriocapillaris. Results. Thirty-three eyes of 32 consecutive patients were analyzed. OCTA showed 3 main anomalies at the choriocapillaris: the presence of dark areas (19/33 eyes) which were frequently associated with serous retinal detachment, presence of dark spots (7/33 eyes) which were frequently associated with retinal pigment epithelium detachment, and presence of abnormal vessels (12/33 eyes) which were frequently, but not systematically, associated with choroidal neovascularization, as confirmed by multimodal imaging. Conclusions. OCTA revealed dark areas and dark spots, which were commonly observed. An abnormal choroidal pattern was also observed in one-third of cases, even when multimodal imaging did not evidence any choroidal neovascularization. Abnormal choroidal vessels should be interpreted with caution, and we could assume that this pathological choroidal vascular pattern observed in many CSC cases could be distinct from CNV.

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.

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.

INTRAVITREAL DEXAMETHASONE IMPLANT IN PATIENTS WITH RANIBIZUMAB PERSISTENT DIABETIC MACULAR EDEMA.

Purpose: To study the efficacy of intravitreal injection (IVI) of dexamethasone implant as second-line treatment in patients with resistant chronic diabetic macular edema nonresponsive to 6 monthly consecutive IVI of ranibizumab. Methods: A retrospective study was conducted over 9 months. Best-corrected visual acuity and central macular thickness were noted. Patients with best-corrected visual acuity ⩽20/40 using Snellen chart, central macular thickness ≥300 &mgr;m, and poor response to 6 monthly consecutive IVI of ranibizumab were included. Patients received IVI of dexamethasone implant and were examined at 1, 3, 6, and 9 months. Results: Thirteen eyes of 12 patients were included (6 men and 6 women; mean age, 64 ± 7.8 years). Best-corrected visual acuity increased by a mean of 5.58 letters at Month 1 (P = 0.017), 4.61 at Month 3 (P = 0.05), 4.61 at Month 6 (P = 0.042), and 5.77 at Month 9 (P = 0.017). Central macular thickness decreased from 594 &mgr;m to 402 &mgr;m at Month 1 (P = 0.0002), 428 &mgr;m at Month 3 (P = 0.002), 459 &mgr;m at Month 6 (P = 0.02), and 489 &mgr;m at Month 9 (P = 0.03). Mean number of dexamethasone IVI was 1.07. Two patients (15.3%) developed elevated intraocular pressure, and 1 patient was operated for cataract at 6 months (9% of phakic patients). Conclusion: Intravitreal injection of dexamethasone implant seems as an effective second-line treatment in diabetic macular edema persistent after 6 monthly consecutive intravitreal ranibizumab injections in real life.

Infrared features of classic choroidal neovascularisation in exudative age-related macular degeneration

Aim: Wet age-related macular degeneration (AMD) represents a heterogeneous group of phenotypes, all defined by fluorescein angiography features (FA). Imaging of wet AMD is extensively described in literature, including colour pictures, FA, indocyanine green angiography (ICG) and optical coherence tomography (OCT). The purpose of this study was to describe features of infrared (IR) pictures of a homogeneous subgroup of classic choroidal neovascularisation (CNV) associated with wet AMD, Methods: We analysed 22 eyes of 22 consecutive patients with classic CNV. All patients underwent a complete ophthalmological examination including colour fundus photography, infrared picture, fluorescein angiography, indocyanine green angiography and an optical coherence tomography. Results: Infrared pictures revealed a whitish ring surrounding the neovascular lesion in all eyes (22/22). The whitish ring corresponded in all cases to the borders of the CNV defined on the early phase of FA and ICG pictures. The ring had an “O-shape” in 15/22 cases (68%) and a “U-shape” in 7/22 cases (32%). Conclusion: Analysis of infrared pictures in classic CNV constantly revealed a whitish ring that is correlated to the limits of the lesion. IR picture is a non invasive imaging of the macula, but the specificity of the features needs to be investigated in further studies.

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.

Toward a Specific Classification of Polypoidal Choroidal Vasculopathy: Idiopathic Disease or Subtype of Age-Related Macular Degeneration

PURPOSE To suggest a clinical distinction between idiopathic polypoidal choroidal vasculopathy (PCV) and secondary polyps associated with neovascular age-related macular degeneration (NV-AMD). METHODS The study was a retrospective case series of 52 eyes of 52 consecutive patients (31 females and 21 males) diagnosed with PCV. Initial diagnosis was based on scanning laser ophthalmoscope-indocyanine green angiography (SLO-ICGA) in association with fluorescein angiography (FA) and optical coherence tomography (OCT). All the data and images were analyzed in a masked fashion by four experienced examiners in two different sessions: the first, to classify patients into the two hypothesized groups (idiopathic polyps or NV-AMD-related polyps); the second, following a predetermined scheme, to describe objective features. The results obtained in each session underwent a cross multivariate analysis to identify statistically significant differences (P ≤ 0.05) between the two groups. RESULTS The two groups were clinically different on the basis of FA (leakage origin [P = 0.001] and presence of drusen [P = 0.001]), ICGA (evidence of choroidal neovascularization [CNV; P = 0.001] and/or branching vascular network [BVN; P = 0.001]), OCT imaging (type of pigmented epithelium detachment [P = 0.001], presence of BVN [P = 0.001], and subfoveal choroidal thickness [P = 0.001]). Further significant differences were observed according to the location of lesion (uni- or multifocal) (P = 0.001), type of CNV (P = 0.001), and best-corrected visual acuity (P = 0.001). CONCLUSIONS Our study demonstrated clinical and statistically significant differences between idiopathic PCV and NV-AMD-related polyps that could be considered as distinct entities. Although they share some similarities, mainly the sub-RPE location, the ability to identify a specific clinical pattern suggests a more specific therapeutic approach for these two entities.

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.

Gray Hyper-Reflective Subretinal Exudative Lesions in Exudative Age-Related Macular Degeneration

PURPOSE To investigate the effects of ranibizumab 0.5 mg on gray hyper-reflective subretinal lesions diagnosed by spectral-domain optical coherence tomography (SD OCT) in patients with exudative age-related macular degeneration (AMD). DESIGN Retrospective interventional study. METHODS Data from 28 consecutive patients affected with neovascular AMD that presented subretinal hyper-reflective lesions as visualized by SD OCT were collected. Gray hyper-reflective subretinal lesion characteristics were analyzed before and after intravitreal ranibizumab 0.5 mg injection. RESULTS Thirty eyes of 28 patients (5 male, 23 female, aged 57-91 years) were included. At study entry, gray lesion was associated with exudative features in 24 of 30 eyes (80%), including subretinal fluid (SRF) in 20 of 30 eyes (67%) and retinal cystoid spaces in 11 of 30 eyes (37%). Twenty-four eyes with exudative features at study entry received prompt treatment; 6 eyes without exudative features at study entry received deferred treatment (after 1 month observation), when exudative signs emerged (SRF in 3/6 eyes and retinal cystoid spaces in 5/6 eyes). Ninety-three percent of the gray lesions responded to ranibizumab treatment at 2 months and 77% at 6 months. Gray hyper-reflective subretinal lesion thickness was significantly reduced after treatment at both 2 months (from 482±116 μm to 367±102 μm, P<.0001) and 6 months (from 482±116 μm to 369±71 μm, P<.0001). CONCLUSION Our findings suggest that gray hyper-reflective subretinal lesions might be considered as a qualitative criterion for retreatment of exudative AMD. They may represent an early sign of active choroidal neovascularization, and should prompt to early treatment.