Rocio Blanco-Garavito

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.

Genetic and environmental factors associated with reticular pseudodrusen in age-related macular degeneration.

Purpose: To analyze the genetic and environmental factors associated with reticular pseudodrusen (RPD) in age-related macular degeneration (AMD). Methods: In a large population, AMD patients (n = 519) with and without RPD were assessed with a standardized examination including infrared images and spectral domain optical coherence tomography scans. Three groups were defined: Group 1: AMD patients with RPD (n = 105); Group 2: AMD patients without RPD (n = 414); and Group 3: controls with no AMD and no RPD (n = 430). Four genes associated with AMD (CFH, ARMS2/HTRA1, C3, apolipoprotein E) and environmental factors were assessed between the 3 groups. Results: None of the environmental factors studied were more significantly associated to either Group 1 or Group 2. The odds ratios and 95% confidence intervals for individuals homozygous for the CFH risk allele were 4.0 (2.1–7.7) ([95% confidence interval: 2.1–7.7]; P < 0.0004) in Group 1 and 4.3 ([2.6–7.1]; P < 0.0004) in Group 2, compared with Group 3. The odds ratios for individuals homozygous for the ARMS2 risk allele for Groups 1 and 2 compared with Group 3 were 16.3 ([7.6–35.4]; P < 0.0004) and 11.9 ([6.3–22.3]; P < 0.0004), respectively. None of the genotypes studied were more significantly associated to Group 1 than Group 2. Conclusion: Genotypes known to be associated with AMD were similarly observed in patients with and without RPD.

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.

Appearance of medium–large drusen and reticular pseudodrusen on adaptive optics in age-related macular degeneration

Purpose To investigate the appearance of medium–large drusen and reticular pseudodrusen on adaptive optics (AO). Methods In 14 consecutive patients, AO infrared (IR) images were overlaid with confocal scanning-laser-ophthalmoscope IR reflectance images and IR-referenced spectral-domain optical coherence tomography. Results In eight eyes of six patients, a total of 19 images of medium–large drusen were investigated by AO imaging. En face AO revealed medium–large drusen as highly hyper-reflective round/oval lesions, always centred and/or surrounded by a continuous/discontinuous hyporeflectivity. Cone photoreceptors were detected overlying drusen, appearing either as continuous ‘bright’ hyper-reflective dots over a ‘dark’ hyporeflective background, or as continuous ‘dark’ hyporeflective dots over a ‘bright’ hyper-reflective background. In eight eyes from eight patients, a total of 14 images of pseudodrusen were investigated by AO imaging. En face AO revealed reticular pseudodrusen as isoreflective lesions, always surrounded by a continuous/discontinuous hyporeflectivity. Cone photoreceptors were detected overlying pseudodrusen as ‘bright’ hyper-reflective dots over either a hyporeflective or isoreflective background. No ‘dark’ hyporeflective dots were detected in eyes with reticular pseudodrusen only. Cone photoreceptors were counted on the border of the drusen and pseudodrusen, respectively, and in a visibly healthy zone in its absolute vicinity. A similar decrease in cone appearance was observed for drusen and pseudodrusen (15.7% vs 16.2%). Conclusions AO allows differences in reflectivity between medium–large drusen and reticular pseudodrusen to be appreciated. The cone mosaics may be detected as continuous ‘bright’ hyper-reflective dots overlying/on the border of drusen and pseudodrusen deposits, and possibly as continuous ‘dark’ hyporeflective dots overlying drusen only.

En face enhanced depth imaging optical coherence tomography features in adult onset foveomacular vitelliform dystrophy

BackgroundOur purpose was to describe the different morphological features in adult onset foveomacular vitelliform dystrophy (AOFVD), using en face enhanced depth imaging (EDI) spectral-domain optical coherence tomography (SD-OCT).MethodsThirty eyes of 22 consecutive patients presenting with diagnosis of AOFVD were enrolled. Diagnosis of AOFVD was concluded based on fundus examination, autofluorescence imaging, fluorescein angiography and SD-OCT. En face OCT imaging was obtained with the Spectralis EDI SD-OCT; 97 inverted sections (nine averaged B-scans per image) were acquired.ResultsOn en face OCT, vitelliform lesions appeared as regular concentric rings of different reflectivity. From the periphery to center of the ring, we observed: (1) the hypereflective ring representing the inner segment/ outer segment (IS/OS) junction, which was continuous in 23 out of 30 eyes, and (2) a well-detectable hyporeflective ring between the IS/OS junction and vitelliform material in 20 out of 30 eyes; the innermost composant of the lesion was hypereflective, and it corresponded to vitelliform material. In eight out of 30 eyes, a hyporeflective “croissant”-shaped lesion with inferior concavity in the upper part of the hyperreflective material was present. Hypereflective retinal pigment epithelium (RPE) elevations or bumps were detected in 25 out of 30 eyes. These areas of focal RPE thickening or bumps appeared to be intensely hypereflective on infrared reflectance imaging.ConclusionEn face imaging of the retina helps visualizing the distribution of vitelliform material in AOFVD. The sedimentation of vitelliform lesions is characterized by a upper “croissant”-shaped hypoflectivity. The bumps/thickening of RPE appeared as hypereflective lesions on IR imaging.

ADAPTIVE OPTICS IMAGING OF FOVEAL SPARING IN GEOGRAPHIC ATROPHY SECONDARY TO AGE-RELATED MACULAR DEGENERATION.

Background: To describe adaptive optics (AO) imaging of foveal sparing in geographic atrophy (GA) secondary to age-related macular degeneration. Methods: Flood-illumination AO infrared (IR) fundus images were obtained in four consecutive patients with GA using an AO retinal camera (rtx1; Imagine Eyes). Adaptive optics IR images were overlaid with confocal scanning laser ophthalmoscope near-IR autofluorescence images to allow direct correlation of en face AO features with areas of foveal sparing. Adaptive optics appearance of GA and foveal sparing, preservation of functional photoreceptors, and cone densities in areas of foveal sparing were investigated. Results: In 5 eyes of 4 patients (all female; mean age 74.2 ± 11.9 years), a total of 5 images, sized 4° × 4°, of foveal sparing visualized on confocal scanning laser ophthalmoscope near-IR autofluorescence were investigated by AO imaging. En face AO images revealed GA as regions of inhomogeneous hyperreflectivity with irregularly dispersed hyporeflective clumps. By direct comparison with adjacent regions of GA, foveal sparing appeared as well-demarcated areas of reduced reflectivity with less hyporeflective clumps (mean 14.2 vs. 3.2; P = 0.03). Of note, in these areas, en face AO IR images revealed cone photoreceptors as hyperreflective dots over the background reflectivity (mean cone density 3,271 ± 1,109 cones per square millimeter). Microperimetry demonstrated residual function in areas of foveal sparing detected by confocal scanning laser ophthalmoscope near-IR autofluorescence. Conclusion: Adaptive optics allows the appreciation of differences in reflectivity between regions of GA and foveal sparing. Preservation of functional cone photoreceptors was demonstrated on en face AO IR images in areas of foveal sparing detected by confocal scanning laser ophthalmoscope near-IR autofluorescence.

Visual acuity at presentation in the second eye versus first eye in patients with exudative age-related macular degeneration.

Purpose To assess the difference in best-corrected visual acuity (BCVA) at presentation between the first and second eye in patients with bilateral neovascular age-related macular degeneration (AMD). Methods We reviewed the charts of all patients who had a clinical examination for neovascular AMD at the University Eye Clinic of Creteil in January 2013. We retrospectively analyzed demographic and clinical data for 264 patients. Results In the fellow eye, choroidal neovascularization (CNV) developed in 75/264 patients (28.4%) with a time interval between the 2 events of 30.3 months (range 6-145). Data were available on 65 patients: 14/65 (21.5%) were asymptomatic, 24/65 (36.9%) had BCVA >20/40, whereas at the time of CNV diagnosis in the first eye, no patient was asymptomatic (p<0.0001), and 11/65 (16.9%) eyes had BCVA >20/40 (p<0.0001). The mean BCVA of the first affected eye was 0.68 (±0.41) logarithm of minimum angle of resolution (logMAR) and the mean BCVA for the second eye was 0.36 (±0.29) logMAR (p<0.0001). Conclusions The BCVA at the time of diagnosis of CNV was higher in the second eye than in the first affected eye. This was possibly due to several factors including systematic bilateral examination in follow-up of unilateral exudative AMD that allowed detection of 20% of cases.

Choroidal neovascularization associated with extensive macular atrophy with pseudodrusen-like appearance.

PURPOSE Extensive macular atrophy with pseudodrusen-like appearance (EMAP) is a recently described entity. We describe the first observations of choroidal neovascularization (CNV) associated with EMAP in 3 patients. METHODS Nineteen consecutive patients with EMAP were retrospectively investigated for the presence of CNV and treatment outcomes. Each patient underwent a complete ophthalmologic examination including color fundus photograpy, fluorescein angiography (FA), indocyanine green angiography (ICG) and spectral-domain optical coherence tomography (SD-OCT). RESULTS Retrospective analysis revealed choroidal neovascularization in 3 patients (4 eyes) out of 19 patients with EMAP. In these patients, laser photocoagulation or intravitreal injections of ranibizumab led to resolution of retinal exudation with limited functional improvement. CONCLUSION CNV is a possible complication of EMAP, a recently reported form of macular atrophy resembling geographic atrophy. Laser photocoagulation and anti-VEGF treatment appear to be two valuable therapeutic options.

WRINKLED VASCULARIZED RETINAL PIGMENT EPITHELIUM DETACHMENT PROGNOSIS AFTER INTRAVITREAL ANTI-VEGF THERAPY

Background/Purpose: Neovascular age-related macular degeneration (nAMD) is frequently associated with vascularized pigment epithelial detachment (v-PED). We observed a peculiar characteristic of v-PED characterized by small lacy folds of the retinal pigment epithelium, appearing as a wrinkled PED (w-PED) on spectral domain optical coherence tomography (SD-OCT). Our purpose was to describe the visual prognosis and number of intravitreal injections in w-PED compared with non-w-PED. Methods: In this retrospective, case-control series, we reviewed retrospectively medical records of 52 eyes of 51 patients who were consecutively included between November 1 and 30, 2015 with a previous minimum 3-year follow-up. Inclusion criteria were: neovascular age-related macular degeneration, affected with w-PED. Baseline characteristics, best-corrected visual acuity (BVCA), number of intravitreal anti-vascular endothelial growth factor injections (anti-VEGF IVT) and maximal recurrence-free interval, that is, without intravitreal anti-vascular endothelial growth factor injection, were analyzed. A w-PED was defined as a v-PED ≥200 &mgr;m in height on SD-OCT imaging, presenting with at least 4 small lacy folds on the surface of the retinal pigment epithelium. Patients were compared with a control group, that is, patients harboring PED without wrinkle shape (non-w-PED). All patients had been treated by intravitreal anti-vascular endothelial growth factor injection of either ranibizumab (IVR) or aflibercept (IVA) using a pro re nata (PRN) protocol after three initial monthly treatments, with a minimum of follow-up of 3 years. Results: Two groups of patients were compared, w-PED (29 eyes, from 29 patients), and non-w-PED (23 eyes from 22 patients). In the w-PED group, mean BCVA evolved from 0.28 (±0.18) log MAR (20/40, range 20/25–20/63) at baseline, to 0.29 (±0.21) log MAR (20/40, range 20/25–20/63) at 1 year (P = 0.41), 0.34 (±0.26) log MAR (20/40, range 20/25–20/80) at 2 years (P = 0.49), 0.35 (±0.28) log MAR (20/40, range 20/25–20/80) at 3 years (P = 0.54). In the non-w-PED group, mean BCVA was 0.40 (±0.28) log MAR (20/50, range 20/25–20/100) at baseline and decreased to 0.48 (±0.46) log MAR (20/63, range 20/20–20/160) at 1 year (P = 0.19), 0.48 (±0.35) log MAR (20/63, range 20/25–20/125) at 2 years (P = 0.02), 0.60 (±0.38) log MAR (20/80, range 20/32–20/200) at 3 years (P = 0.002). In the w-PED group, the mean maximal documented recurrence-free interval was 7.87 (±2.94) months at Year 1, 13.5 (±7.52) at Year 2 and 14.78 (±10.70) at Year 3, versus 4.59 (±2.95) months at Year 1, 7.83 (±6.62) at Year 2, 8.57 (±11.18) at Year 3 in the non-w-PED group (P = 0.0004; 0.0101; 0.0168 respectively at Years 1, 2 and 3). Discussion: The evolution of v-PED after intravitreal anti-vascular endothelial growth factor injection is still difficult to predict despite intense clinical research in this topic. In our study, we noticed that w-PED might be a phenotypic prognosis factor for better visual acuity and longer maximal recurrence-free interval.

Influence of fasting followed by acute water ingestion on subfoveal choroidal thickness in eyes of healthy subjects

Purpose To investigate the influence of at least 12 hours of fasting followed by acute water ingestion on macular choroidal thickness in eyes of healthy subjects. Methods Prospective case series study including healthy volunteers from April 1, 2015 to May 31, 2015. Macular choroidal thickness was measured on enhanced depth imaging optical coherence tomography (EDI-OCT) and on swept-source (SS)-OCT after 12 hours of fasting, and 60 minutes after acute water ingestion (750 mL in 5 minutes). Results A total of 52 eyes of 26 healthy volunteers were included in this study. The mean age for participants was 32 years old. After 12 hours of fasting, the mean (±SD) subfoveal choroidal thickness was 335.43 (±104.82) μm on EDI-OCT and 286.16 (±80.32) μm on SS-OCT. The mean (±SD) subfoveal choroidal thickness after acute water intake was 352.32 (±120.36) μm and 290.5 (±85.86) μm, respectively. There was no significant difference between the mean subfoveal thickness at baseline and 60 minutes after acute water ingestion for any of the choroidal imaging techniques (p = 0.1386 for EDI-OCT and p = 0.0659 for SS-OCT). Conclusions These results suggest that choroidal circulation can physiologically quickly adapt to systemic vascular changes in healthy eyes. Choroidal thickness did not depend upon the hydration status for the subjects participating in this study.