Shoji Kishi

Patterns of Diabetic macular edema with Optical coherence tomography

PURPOSE We report cross-sectional images of diabetic macular edema and correlation between tomographic features and visual acuity with best correction by means of optical coherence tomography. METHOD In a prospective study, optical coherence tomography was performed in 59 eyes of 42 patients with diabetic macular edema and in 10 eyes of 10 normal control subjects. RESULTS Optical coherence tomography showed three patterns of structural changes in diabetic macular edema: sponge-like retinal swelling (52 [88%] of 59 eyes), cystoid macular edema (28 [47%] of 59 eyes), and serous retinal detachment (9 [15%] of 59 eyes). Some eyes had more than one pathologic change. Retinal swelling was more pronounced in the outer rather than the inner retinal layers. Cystoid macular edema was located mainly in the outer retinal layers. In eyes with long-standing cystoid macular edema, cystoid spaces had fused, resulting in a large cystoid cavity involving almost the entire retinal layer. Hard exudates were seen as highly reflective areas located in the outer retinal layers. The retinal thickness at the central fovea and the visual acuity with best correction showed an intermediate negative correlation in eyes without cystoid macular edema (correlation coefficient: -0.61, P < .01). CONCLUSIONS Diabetic macular edema involved three structural changes, including sponge-like retinal swelling (88%), cystoid macular edema (47%), and serous retinal detachment (15%). Visual acuity with best correction moderately correlated with retinal thickness regardless of the different tomographic features.

Evaluation of central serous chorioretinopathy with optical coherence tomography

PURPOSE To evaluate central serous chorioretinopathy with optical coherence tomography during the acute phase and after resolution of the acute phase. METHODS In a prospective study, 23 consecutive eyes of 23 patients (19 men, four women; mean age +/- SD, 46.0+/-8.1 years; range, 29 to 60 years) with central serous chorioretinopathy were examined with optical coherence tomography during the acute phase and after resolution of the retinal detachment. After the initial examination, the patients were reexamined for 3 to 6 months (mean, 4.7+/-1.1 months). Cross-sectional retinal images through the center of the fovea were obtained from all eyes by optical coherence tomography. The retinal thickness at the center of the fovea was measured. The difference between the retinal thickness during the acute phase and after resolution of the retinal detachment was statistically analyzed using the Wilcoxon test. We also examined a grayish-white lesion that corresponded to the leakage point in fluorescein angiography in four eyes. RESULTS In the acute phase, neurosensory retina was thickened within the area of serous retinal detachment in all 23 eyes. The detached retina was thicker than the reattached retina after resolution of the retinal detachment in all eyes. The retinal thickness at the center of the fovea during the acute phase (range, 157 to 236 microm; mean +/- SD, 196.9+/-22.6 microm) was significantly thickened compared with that after resolution (range, 105 to 152 microm; mean +/- SD, 124.8+/-10.7 microm; P<.0001, Wilcoxon test). In the acute phase, areas of low reflectivity localized within the detached retina were observed in 18 of the 23 eyes. In the area of the grayish-white lesion, optical coherence tomography showed a moderately reflective mass bridging the detached neurosensory retina and retinal pigment epithelium in the four eyes; the outer layer of the detached retina was more highly reflective in these eyes. The retinal pigment epithelium was focally detached beneath the subretinal reflective mass in three of the four eyes. CONCLUSIONS In all eyes studied, neurosensory retina was thickened within the area of serous retinal detachment in the acute phase of central serous chorioretinopathy. The grayish-white lesion seems to be a fibrinous exudate that accumulates in the subretinal space and infiltrates into the outer retina.

Persistent and bilateral choroidal vascular abnormalities in central serous chorioretinopathy.

BACKGROUND To clarify the role of choroidal vascular abnormalities in central serous chorioretinopathy (CSC) in active stage, remission, and recurrence. METHODS Indocyanine green angiography and fluorescein angiography were performed in 105 eyes (104 patients) with active CSC. Forty-six patients were followed up for 6 to 48 months (mean +/- standard deviation, 22.5 +/- 8.9 months) with repeated angiography (mean +/- standard deviation, 3.5 +/- 1.5 times). Indocyanine green angiography and fluorescein angiography also were performed during remission in all 46 eyes with CSC and during recurrent CSC in 6 eyes. Unaffected fellow eyes underwent angiographic examinations in all patients. RESULTS In active CSC, indocyanine green angiography showed a choroidal filling delay (71%), venous dilation (61%), and focal choroidal hyperfluorescence (96%) surrounding leakage from the retinal pigment epithelium. Focal choroidal hyperfluorescence was present in unaffected areas of affected eyes (55%). The choroidal venous dilation (36%) and choroidal hyperfluorescence (62%) were noted even in unaffected fellow eyes. These choroidal abnormalities persisted during remission after leakage ceased throughout the follow-up period. In the six patients with recurrent CSC, new leakage developed in the areas of persistent choroidal hyperfluorescence. Central serous chorioretinopathy developed in the unaffected fellow eye in one of these six patients. CONCLUSION Choroidal vascular abnormalities persist in both eyes even after leakage from the retinal pigment epithelium ceases. Central serous chorioretinopathy may recur in areas of choroidal vascular abnormalities.

Inflammatory cytokines in vitreous fluid and serum of patients with diabetic vitreoretinopathy

To determine whether inflammatory cytokines are increased in proliferative diabetic retinopathy. We measured concentrations of interleukin-6, 8 (IL-6, 8) and tumor necrosis factor (TNF)-alpha by enzyme-linked immunosorbent assay (ELISA) in vitreous and serum from 47 patients with proliferative diabetic retinopathy and 21 patients with vitreous noninflammatory retinopathies. Vitreous concentration of IL-6 were 64.7+/-12.8 pg/ml in proliferative diabetic retinopathy, much greater (P<.005) than in noninflammatory retinopathy (2.8+/-4.5 pg/ml). Amounts of IL-8 in vitreous fluid also were greater in proliferative retinopathy than in noninflammatory retinopathy (34.0+/-11.5 vs. 6.1+/-2.0 pg/ml, P<.005). Concentrations of TNF-alpha in vitreous fluid were not statistically different in proliferative retinopathy from those in noninflammatory retinopathy. In sera, concentrations of IL-6 and IL-8 were not different between proliferative and noninflammatory retinopathy. However, serum TNF-alpha was much greater in proliferative retinopathy than in noninflammatory retinopathy (0.81+/-0.72 vs. 0.09+/-0.00 pg/ml, P<.001). Elevated TNF-alpha in serum then may be diagnostically useful in proliferative diabetic retinopathy. And inflammatory cytokines in vitreous may be pathogenically important in this concentration.

Tomographic assessment of vitreous surgery for diabetic macular edema

Abstract PURPOSE: To evaluate the retinal structure before and after vitrectomy for diabetic macular edema and to assess the correlation between thickness of neurosensory retina and best-corrected visual acuity. METHODS: Tomographic features of 13 eyes (nine patients) with diabetic macular edema were prospectively evaluated with optical coherence tomography before and after vitrectomy. The foveal thickness (the distance between the inner retinal surface and the retinal pigment epithelium) and the retinal thickness (thickness of neurosensory retina) were measured by optical coherence tomography preoperatively and postoperatively. The correlation of the best-corrected visual acuity with foveal and retinal thickness was determined. RESULTS: All 13 eyes had retinal swelling with low intraretinal reflectivity. In addition to retinal swelling, there were cystoid spaces in five (38%) of 13 eyes, a serous retinal detachment in three (23%), and both cystoid spaces and serous detachment in three (23%). Six months postoperatively, the mean foveal thickness significantly decreased from 630 ± 170 to 350 ± 120 μm (P CONCLUSIONS: Vitrectomy was generally effective in treatment of diabetic macular edema. Optical coherence tomography demonstrated the intraretinal changes of macular edema and the process of edema absorption. During the process of macular edema absorption, intraretinal fluid appeared to move into the subretinal space in some cases. Best-corrected visual acuity improvement was greater in eyes with less preoperative increase in thickness of neurosensory retina.

Vitreous cortex remnants at the fovea after spontaneous vitreous detachment

We performed a scanning electron microscopic observation of the posterior retinal surface of 59 autopsy eyes with spontaneous vitreous detachment. In 26 eyes (44%), there were remnants of the posterior vitreous membrane in the foveal area. These vitreous cortex remnants formed three basic patterns. They appeared either as disc-shaped collagenous membranes covering the fovea, as rings along the foveal margin, or forming a structure that resembles a cyst. Each of these patterns seemed to have a counterpart to various known clinical situations.These findings imply that remnants of the vitreous cortex membrane frequently remain attached to the fovea after apparent complete posterior vitreous detachment. The observed features would provide morphological basis for the interpretation of several clinical conditions that take place along the vitreoretinal interface at the fovea.

Effects of Age, Sex, and Axial Length on the Three-Dimensional Profile of Normal Macular Layer Structures

PURPOSE To identify sex-related differences and age-related changes in individual retinal layer thicknesses in a population of healthy eyes across the lifespan, using spectral domain optical coherence tomography (SD-OCT). METHODS In seven institutes in Japan, mean thicknesses of the retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), inner plexiform layer (IPL), inner nuclear layer (INL), outer plexiform layer (OPL), outer nuclear layer (ONL), photoreceptor inner segment (IS), and photoreceptor outer segment (OS) were measured using SD-OCT with a new automated segmentation protocol in 256 healthy subjects. RESULTS Interoperator coefficients of variability for measurements of each layer ranged from 0.012 to 0.038. The RNFL, GCL, IPL, and INL were thinnest in the foveal area, whereas the OPL+ONL and OS were thickest in this area. Mean thicknesses of the INL and the OPL+ONL were significantly greater in men (P = 0.002 and 0.001, respectively). However, mean RNFL thickness was greater in women (P = 0.006). Thicknesses of the RNFL, GCL, IPL, INL, and IS correlated negatively with age. Thickness of the OPL+ONL was not correlated with age, and thickness of the OS correlated positively with age. Inner retinal (RNFL+GCL+IPL) thickness over the whole macula correlated negatively with age (P < 0.001), but outer retinal (OPL+ONL+IS+OS) thickness did not. Thicknesses of layers did not correlate with axial length. CONCLUSIONS Macular layer thicknesses measured on SD-OCT images in healthy eyes showed significant variations by sex and age. These findings should inform macular layer thickness analyses in SD-OCT studies of retinal diseases and glaucoma.

Restored Photoreceptor Outer Segment and Visual Recovery After Macular Hole Closure

PURPOSE To evaluate restoration of the photoreceptor outer segment and visual outcomes in closed macular holes. DESIGN Retrospective case series. METHODS We retrospectively observed the reparative process of macular holes in 28 eyes one, three, and six months postoperatively using spectral-domain optical coherence tomography. We evaluated the reflective line at the junction between the photoreceptor inner and outer segment (IS/OS) and the best-corrected visual acuity (BCVA). RESULTS The outer photoreceptor layer showed a foveal detachment, a disrupted IS/OS line, or both one month postoperatively. No eye had a continuous IS/OS line. These abnormalities were gradually restored at various levels. At six months, nine eyes had a normal outer photoreceptor layer, four eyes outer foveal defects with a continuous IS/OS line, 12 eyes a disrupted IS/OS line, and three eyes outer foveal defects with a disrupted IS/OS line. The mean BCVAs were significantly (P = .017) lower in groups with a disrupted IS/OS line compared to groups with a continuous IS/OS line with or without outer foveal defects. CONCLUSIONS Macular hole closure is attained by bridge formation (foveal detachment) and the IS/OS line heals in varying degrees. The visual outcomes were significantly better in eyes with a continuous IS/OS line than in those with a disrupted IS/OS line.

Correlation between visual acuity and foveal microstructural changes in diabetic macular edema.

Purpose: The purpose of this study was to investigate the correlation between best-corrected visual acuity and foveal microstructural changes of the external limiting membrane and the junction between the inner and outer segments of the photoreceptors in diabetic macular edema. Methods: The authors performed spectral-domain optical coherence tomography in all eyes. The authors defined central subfield thickness as the average retinal thickness of the 1-mm central scanned area. The length of disruption of the external limiting membrane and the inner and outer segments of the photoreceptors in the fovea (1.8 mm in diameter) were measured and graded according to their length as follows: 1) >1.4 mm; 2) >0.4 mm but <1.4 mm; or 3) <0.4 mm. Results: The best-corrected visual acuity was strongly associated with the external limiting membrane (r = 0.66) and inner and outer segments of the photoreceptor (r = 0.68) scores, whereas best-corrected visual acuity was weakly and negatively correlated with central subfield thickness (r = −0.23). Conclusion: Spectral-domain optical coherence tomography showed that the integrity of the external limiting membrane and inner and outer segments of the photoreceptors was more strongly correlated with best-corrected visual acuity when compared with central subfield thickness in diabetic macular edema.

Tomographic features of branching vascular networks in polypoidal choroidal vasculopathy.

Purpose: To identify the tomographic features of the branching vascular networks in patients with polypoidal choroidal vasculopathy (PCV). Methods: We prospectively performed third-generation optical coherence tomography (OCT) and fluorescein angiography for 44 eyes of 42 patients (mean age ± SD, 67.1 ± 9.1 years) with PCV. All eyes had branching vascular networks and polypoidal lesions that were confirmed by indocyanine green angiography. Results: OCT showed double reflective layers that consisted of retinal pigment epithelium (RPE) and another highly reflective layer beneath the RPE (“double-layer sign”) in the area of the branching network vessels in 26 (59%) of 44 eyes. The remaining 18 eyes had no double-layer sign, but 17 (94%) of 18 eyes had a slightly elevated RPE. A serous retinal detachment was present in 23 (88%) of 26 eyes with a double-layer sign, while only 1 (6%) of 18 eyes without the sign had a serous retinal detachment. Conclusions: In PCV, the double-layer sign is seen frequently in the area of the network vessels, particularly in eyes with a serous retinal detachment. The sign may reflect fluid accumulation between RPE and Bruch membrane resulting from leakage from the network of abnormal vessels.