Wasim A. Samara

CORRELATION OF FOVEAL AVASCULAR ZONE SIZE WITH FOVEAL MORPHOLOGY IN NORMAL EYES USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY.

Purpose: To analyze the foveal avascular zone (FAZ) in normal eyes using optical coherence tomography angiography. Methods: Prospective noncomparative case series. The parafoveal region of 70 eyes from 67 healthy subjects was imaged using optical coherence tomography angiography to visualize the superficial and deep capillary plexuses and correlated with standard macular volume scans using spectral domain optical coherence tomography to determine foveal morphology. Results: In all 70 eyes imaged, 2 vascular plexuses could be detected within the retina: a superficial plexus within the ganglion cell layer and a deep plexus within the inner nuclear layer. A measurable FAZ was visualized in both plexuses in all imaged eyes. The FAZ area was variable in the study population with a mean of 0.266 mm2 ± 0.097 mm2 in the superficial plexus (range: 0.071 mm2–0.527 mm2) and a mean of 0.495 mm2 ± 0.227 mm2 in the deep plexus (range: 0.160 mm2–0.795 mm2). The FAZ area was significantly larger in the deep plexus (P < 0.0001) compared with superficial plexus. The FAZ area in both plexuses correlated inversely with central macular thickness and central macular volume (P < 0.0001). No significant correlation was found between superficial plexus FAZ area and age (P = 0.55) or sex (P = 0.34). In the same manner, no significant correlation was found between deep plexus FAZ area and age (P = 0.13) or sex (P = 0.13). Conclusion: Optical coherence tomography angiography provides a noninvasive method to visualize and measure the superficial and deep plexus FAZ in a normal population. The FAZ can vary in size and shape, with the FAZ area significantly larger in the deep compared with the superficial plexus. Both superficial and deep FAZ area correlate inversely with foveal thickness and volume.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY OF THE MACULA AFTER PLAQUE RADIOTHERAPY OF CHOROIDAL MELANOMA: Comparison of Irradiated Versus Nonirradiated Eyes in 65 Patients.

Purpose: To study radiation retinopathy after plaque radiotherapy of choroidal melanoma using optical coherence tomography angiography. Methods: Retrospective comparative analysis of 65 consecutive patients with choroidal melanoma, treated with standard dose I-125 plaque radiotherapy and imaged with optical coherence tomography angiography. A comparison of irradiated versus contralateral, nonirradiated (control) eyes was performed. Results: The mean patient age was 55 years. Underlying medical diseases included diabetes mellitus (4/65, 4%) or hypertension (25/65, 38%), but no patient demonstrated disease-related retinopathy. The mean pretreatment melanoma diameter was 11 mm and mean thickness was 5 mm. The mean radiation dose to the foveola was 5663 centiGray. At mean follow-up of 46 months after plaque radiotherapy, the most frequent qualitative finding on optical coherence tomography angiography (irradiated eye) was nonperfusion in the superficial capillary plexus (19/65, 29%) and deep capillary plexus (20/65, 31%), followed by loss of choriocapillaris within tumor margins (11/65, 17%). The quantitative findings revealed foveal avascular zone with significantly larger mean area (irradiated vs. nonirradiated eye) in the superficial plexus (0.961 vs. 0.280 mm2, P < 0.0001) and deep plexus (1.396 vs. 0.458 mm2, P < 0.0001), even in eyes without clinical evidence of radiation maculopathy (superficial 0.278 mm2, P = 0.03; deep 0.454 mm2, P = 0.02). Parafoveal capillary density (superficial and deep) was decreased in all irradiated eyes (P < 0.001). This difference was maintained after subgroup analysis of eyes with (P < 0.001) or without (P < 0.001) clinical evidence of radiation maculopathy. Mean logMAR visual acuity was significantly reduced in irradiated eyes (0.7 vs. 0.1 [Snellen equivalent 20/100 vs. 20/25], P < 0.001) and the reduced vision was significant even in eyes without clinical evidence of radiation maculopathy (0.4 vs. 0.1 [Snellen equivalent 20/50 vs. 20/25], P < 0.001). Conclusion: Optical coherence tomography angiography demonstrated significant enlargement of the foveal avascular zone and decreased parafoveal capillary density of both superficial and deep capillary plexuses in eyes after plaque radiotherapy of choroidal melanoma, even in eyes with no clinical evidence of radiation maculopathy.

IMAGE QUALITY AND ARTIFACTS ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY: Comparison of Pathologic and Paired Fellow Eyes in 65 Patients With Unilateral Choroidal Melanoma Treated With Plaque Radiotherapy.

Purpose: To study image quality and artifacts seen on optical coherence tomography angiography (OCTA). Methods: Sixty-five consecutive patients with unilateral posterior uveal melanoma treated with plaque radiotherapy had OCTA during follow-up. Optical coherence tomography angiography was performed on both the affected and fellow eye. Signal strength and frequency of image artifacts on en face images were compared between affected and fellow eyes. Results: A total of 130 eyes in 65 patients were analyzed, the mean age at time of OCTA was 55 years (median: 56, range: 12–81 years), and 39 (39/65, 60%) were female. Majority of tumors were located in the choroid (62/65, 95%) and extramacular (55/65, 85%). The mean distance to the foveola was 4 mm (median: 3, range: 0–18 mm) and optic nerve was 4 mm (median: 4, range: 0–16 mm). Optical coherence tomography angiography was performed at a mean 46 months after plaque radiotherapy. Most patients had a history of radiation maculopathy or papillopathy in the treated eye at the time of OCTA (46/65, 71%). Overall, 95 eyes (95/130, 73%) had at least one significant artifact on OCTA. The most common major artifacts were loss of focus (71/130, 55%), broad (>5 pixels width and >4 lines) blink lines (48/130, 37%), motion artifact (34/130, 26%), specular dot (33/130, 25%), and edge duplication (10/130, 8%). Statistically, eyes treated with plaque radiotherapy (affected vs. fellow eye) were more likely to have at least one major OCTA artifact (92 vs. 54%, P < 0.001) and, specifically, loss of focus was more frequent (78 vs. 31%, P < 0.001). Multivariate analysis found decreased visual acuity significantly associated with higher incidence of broad blink lines (P = 0.0166) and loss of signal (P < 0.0001), whereas male sex was associated with increased loss of signal (P = 0.0015), and distance to the foveola was related to edge duplication (P = 0.0119). Conclusion: Image artifacts on OCTA are commonly encountered and appear to be more frequent in eyes with pathology and poor visual acuity. Recognition of these artifacts might help improve image interpretation and decision making.

VARIABILITY IN FOVEAL AVASCULAR ZONE AND CAPILLARY DENSITY USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY MACHINES IN HEALTHY EYES.

Purpose: To evaluate the variability in foveal avascular zone (FAZ) and capillary density measurements on optical coherence tomography angiography using Optovue RTVue XR Avanti (OA) (Optovue) and Zeiss Cirrus HD-OCT 5000 (ZC) (Carl Zeiss Meditec). Methods: In this prospective, comparative case series, parafoveal (3 × 3 mm) optical coherence tomography angiography scans were obtained on healthy volunteers using both the Avanti and Cirrus. The FAZ area and capillary density at the level of both the superficial and deep capillary plexus were measured automatically using the built-in ReVue software (Optovue) with the Avanti as well as manually using ImageJ (National Institutes of Health) with both machines. Results: There were 50 eyes in 25 healthy volunteers included in the analysis. Mean subject age was 33 years and there were 14 women (56%). On optical coherence tomography, mean central macular thickness was significantly greater on OA (259.1 &mgr;m) than ZC (257.6 &mgr;m, P = 0.0228). On optical coherence tomography angiography, mean superficial and deep plexus FAZ measured 0.2855 mm2 and 0.3465 mm2 on Avanti automated (A-A), 0.2739 mm2 and 0.3637 mm2 on Avanti manual (A-M), and 0.2657 mm2 and 0.3993 mm2 on Cirrus manual (C-M), respectively. There were no statistically significant differences in superficial plexus FAZ measurements between the A-A and A-M (P = 0.4019) or A-A and C-M (P = 0.1336). The A-M measured significantly larger than C-M (P = 0.0396). Deep plexus FAZ measurements were similar on A-A and A-M (P = 0.6299), but both were significantly less compared with C-M (P < 0.0001 for A-A vs. C-M, P = 0.0184 for A-M vs. C-M). Mean superficial and deep plexus capillary densities were 53.6% and 59.3% on A-A, 48.1% and 47.7% on A-M, and 52.5% and 48.1% on C-M, respectively. Superficial plexus capillary density measurements were statistically similar on A-A and C-M (P = 0.0623), but both were significantly higher than A-M (P < 0.0001 for A-A vs. A-M, P < 0.0001 for A-M vs. C-M). However, deep plexus capillary density measurements on A-A were significantly higher than A-M (P < 0.0001) and C-M (P < 0.0001), but A-M and C-M measurements were similar (P = 0.5986). There was no significant difference in all parameters measured in both eyes of one subject using any of the three measuring techniques. Conclusion: While measurements taken with the same machine and technique are consistent and reliable between fellow eyes, significant variability exists in FAZ and capillary density measurements among different machines and techniques. Comparison of measurements across machines and techniques should be considered with caution.

Juvenile Xanthogranuloma Involving the Eye and Ocular Adnexa: Tumor Control, Visual Outcomes, and Globe Salvage in 30 Patients

PURPOSE To report clinical features and treatment outcomes of ocular juvenile xanthogranuloma (JXG). DESIGN Retrospective case series. PARTICIPANTS There were 32 tumors in 31 eyes of 30 patients with ocular JXG. METHODS Review of medical records. MAIN OUTCOME MEASURES Tumor control, intraocular pressure (IOP), and visual acuity. RESULTS The mean patient age at presentation was 51 months (median, 15 months; range, 1-443 months). Eye redness (12/30, 40%) and hyphema (4/30, 13%) were the most common presenting symptoms. Cutaneous JXG was concurrently present in 3 patients (3/30, 10%), and spinal JXG was present in 1 patient (1/30, 3%). The ocular tissue affected by JXG included the iris (21/31, 68%), conjunctiva (6/31, 19%), eyelid (2/31, 6%), choroid (2/31, 6%), and orbit (1/31, 3%). Those with iris JXG presented at a median age of 13 months compared with 30 months for those with conjunctival JXG. In the iris JXG group, mean IOP was 19 mmHg (median, 18 mmHg; range, 11-30 mmHg) and hyphema was noted in 8 eyes (8/21, 38%). The iris tumor was nodular (16/21, 76%) or diffuse (5/21, 24%). Fine-needle aspiration biopsy was used in 10 cases and confirmed JXG cytologically in all cases. The iris lesion was treated with topical (18/21, 86%) and/or periocular (4/21, 19%) corticosteroids. The eyelid, conjunctiva, and orbital JXG were treated with excisional biopsy in 5 patients (5/9, 56%), topical corticosteroids in 2 patients (2/9, 22%), and observation in 2 patients (2/9, 22%). Of 28 patients with a mean follow-up of 15 months (median, 6 months; range, 1-68 months), tumor regression was achieved in all cases, without recurrence. Two patients were lost to follow-up. Upon follow-up of the iris JXG group, visual acuity was stable or improved (18/19 patients, 95%) and IOP was controlled long-term without medication (14/21 patients, 74%). No eyes were managed with enucleation. CONCLUSIONS Ocular JXG preferentially affects the iris and is often isolated without cutaneous involvement. Iris JXG responds to topical or periocular corticosteroids, often with stabilization or improvement of vision and IOP.

Foveal microanatomy documented by SD-OCT following treatment of advanced retinoblastoma.

Progress in the treatment of retinoblastoma has greatly improved patient survival and globe salvage rates. The introduction of intraoperative spectral domain optical coherence tomography (OCT) allows visualization of foveal anatomy and microstructure to predict visual potential and facilitate planning for visual rehabilitation. Eyes with total retinal detachments secondary to exophytic retinoblastoma have OCT findings of absence or disruption of the external limiting membrane and ellipsoid layers. We document the evolution of foveal microanatomy reconstitution following the use of chemotherapy in a 1-year-old boy and illustrate the restoration of the external limiting membrane and ellipsoid layer, thus achieving normal foveal microanatomy.

PARAFOVEAL CAPILLARY DENSITY AFTER PLAQUE RADIOTHERAPY FOR CHOROIDAL MELANOMA: Analysis of Eyes Without Radiation Maculopathy.

Purpose: To study the parafoveal capillary density using optical coherence tomography angiography (OCTA) in eyes treated with plaque radiotherapy. Research Design: Retrospective comparative case series. Participants: Ten patients treated with plaque radiotherapy for choroidal melanoma without evident radiation maculopathy on ophthalmoscopy or optical coherence tomography were imaged with OCTA. Main Outcome Measure: Comparison of the parafoveal capillary density in the superficial and deep capillary plexuses in the irradiated versus fellow nonirradiated eye. Results: Overall, mean patient age was 55 years (median: 57, range: 45–65 years), and majority were white (9/10, 90%) and female (9/10, 90%). No patient had diabetes mellitus, and 2 (2/10, 20%) had controlled systemic hypertension. The melanoma was located in the choroid in all patients (10/10, 100%), with 2 (2/10, 20%) in the macular region. The mean largest basal diameter was 11 mm (12, 6–16 mm), and mean thickness was 5 mm (5, 2–10 mm). Mean radiation dose to the tumor apex was 72 Gy (median: 70 Gy, range: 70–85 Gy). Mean foveolar radiation dose was 53 Gy (median: 35 Gy, range: 14–110 Gy). Mean follow-up duration after plaque radiotherapy was 17 months (median: 16 months, range: 5–39 months). There was no ophthalmoscopic evidence of radiation maculopathy throughout the follow-up in every case. Optical coherence tomography demonstrated normal foveal contour without edema or subretinal fluid in every case. On OCTA, there was no significant difference in signal strength (P = 0.1151), central macular thickness (P = 0.9316), and foveal avascular zone area in the superficial (P = 0.1595), and deep (P = 0.1534) capillary plexuses between the irradiated versus fellow eyes. However, there was a statistically significant decrease in capillary density in the parafoveal superficial (P = 0.0005) and deep (P = 0.0067) plexuses in the irradiated eye. In addition, mean logMAR visual acuity was 0.2 (0.1, 0.0–0.5) (Snellen equivalent 20/32) in the irradiated eye and 0.0 (0.0, range: 0.0–0.1) (Snellen equivalent 20/20) in the fellow eye (P = 0.0252). Conclusion: Optical coherence tomography angiography allows qualitative and quantitative analysis of parafoveal capillary density. After plaque radiotherapy for choroidal melanoma, in eyes with normal macular features on ophthalmoscopy and optical coherence tomography, there is a statistically significant decrease in parafoveal capillary density and logMAR visual acuity in irradiated eyes compared with fellow eyes. These subclinical ischemic findings represent the commencement of radiation maculopathy.

COMBINED PARS PLANA VITRECTOMY AND SCLERAL FIXATION OF AN INTRAOCULAR LENS USING GORE-TEX SUTURE: One-Year Outcomes.

Purpose: To report the 1-year clinical outcomes of combined pars plana vitrectomy and ab externo scleral fixation of an intraocular lens using Gore-Tex suture. Methods: Retrospective, interventional case series. Outcome measures were change in visual acuity and occurrence of intraoperative and postoperative complications with minimum follow-up of 1 year. Results: Eighty-four eyes of 83 patients were identified. The mean best available visual acuity improved from 20/782 preoperatively to 20/65 postoperatively (P < 0.001). The mean follow-up was 598 ± 183 days (median 533 days, range 365–1,323 days). There were no intraoperative complications noted. A Bausch & Lomb Akreos AO60 intraocular lens was implanted in 77 eyes and an Alcon CZ70BD in 7 eyes. Postoperative complications included transient vitreous hemorrhage in six eyes (7.1%), cystoid macular edema in four eyes (4.8%), ocular hypertension in three eyes (3.6%), hyphema in two eyes (2.4%), and transient corneal edema in two eyes (2.4%). There were no cases of postoperative endophthalmitis, suture erosion/breakage, hypotony, retinal detachment, suprachoroidal hemorrhage, choroidal detachment, uveitis–glaucoma–hyphema syndrome, or persistent postoperative inflammation during the follow-up period. Conclusion: Combined pars plana vitrectomy and ab externo scleral fixation of an intraocular lens with Gore-Tex suture was well tolerated at a minimum of 1-year follow-up. No suture-related complications were encountered.

Detection of Minimally Visible Recurrent Retinoblastoma by Hand-held Spectral-Domain Optical Coherence Tomography

A 2-month-old male infant with bilateral familial retinoblastoma was treated with intravenous chemotherapy and focal adjuvant therapy. At 5 months of follow-up, fundus examination and ultrasonography disclosed no recurrence; however, hand-held spectral-domain optical coherence tomography (SD-OCT) demonstrated subclinical recurrence within a previous regression scar. Subsequent treatment led to flat scar. Hand-held SD-OCT can be a useful tool for detection of subclinical recurrent retinoblastoma. [J Pediatr Ophthalmol Strabismus. 2017;54:e6-e8.].

Conjunctival Melanoma with Intraocular Extension.

Originally received: March 14, 2015. Final revision: July 20, 2015. Accepted: July 29, 2015. Available online: September 1, 2015. Manuscript no. 2015-432. 1 Department of Ophthalmology, National Yang-Ming University Hospital, Yilan, Taiwan. 2 National Yang-Ming University School of Medicine, Taipei, Taiwan. 3 Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan. 4 Institute of Pharmacology, National Yang-Ming University, Taipei, Taiwan. 5 Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan. 6 Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. 7 Department of Medical Research and Education, Taipei Veterans General Hospital, Taipei, Taiwan. 8 Department of Radiology, National Yang-Ming University Hospital, Yilan, Taiwan. 9 Healthcare and Management Center, Taipei Veterans General Hospital, Taipei, Taiwan. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.