We provide an overview of current macular imaging techniques and identify and describe biomarkers that may be of use in the routine management of macular diseases, particularly exudative age-related macular degeneration (AMD). This perspective includes sections on macular imaging techniques including optical coherence tomography (OCT) and OCT angiography (OCTA), classification of exudative AMD, and biomarkers in structural OCT and OCTA. Fluorescein angiography remains a vital tool for assessing the activity of neovascular lesions, while indocyanine green angiography is the preferred option for choroidal vessel imaging in neovascular AMD. OCT provides a non-invasive three-dimensional visualization of retinal architecture in vivo and is useful in the diagnosis of many imaging biomarkers of AMD-related neovascular lesions, including lesion activity. OCTA is a recent advance in OCT technology that allows accurate visualization of retinal and choroidal vascular flow. OCT and OCTA have led to an updated classification of exudative AMD lesions and provide several biomarkers that help to establish a diagnosis and the disease activity status of neovascular lesions. Individualization of therapy guided by OCT and OCTA biomarkers has the potential to further improve visual outcomes in exudative AMD. Moving forwards, integration of technologically-advanced imaging equipment with AI software will help ophthalmologists to provide patients with the best possible care.
Keywords: Artificial Intelligence; Biomarkers; Exudative age-related macular degeneration; Imaging; Optical Coherence Tomography; Optical Coherence Tomography Angiography.
Purpose: To describe a case of macular intraretinal microvascular abnormality (IRMA) detected with Optical Coherence Tomography Angiography (OCTA) and to show its remodeling and vascular density changes after panretinal photocoagulation (PRP) during an 18-month follow-up.
Methods: Case report.
Results: A 22-year-old female patient with proliferative diabetic retinopathy was found to have a small hyperreflective formation with posterior shadow cone and signal flow, located at the temporal margin of the fovea avascular zone (FAZ), identified as macular IRMA with OCTA. Her best-corrected-visual acuity was 20/20. Four months later the macular IRMA was larger and, in its context, there was also an increase in the flow area in B-scan. The patient underwent PRP and after 18 months we observed a regression of macular IRMA and an increase in the superficial capillary plexus vessel density in all sectors in comparison to baseline.
Conclusion: OCTA is a non-invasive tool that recognize macular IRMA in diabetic retinopathy patient and it could be helpful to follow their qualitative and quantitative vascular evolution over time.
Keywords: Macular IRMA; OCTA; panretinal photocoagulation; vessel density.
Background: Many neurologic complications have been described after severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) including atypical cases of optic neuritis (ON), positive to myelin oligodendrocyte glycoprotein (MOG) IgG.
Objective: To report a case of MOG-IgG-associated ON and discuss why SARS-CoV-2 infection could be a potential trigger.
Methods: Retrospective single case report.
Results: We report a case of ON with positive MOG-IgG developed 15 days after presentation of SARS-CoV-2 infection.
Conclusion: This report suggests that SARS-CoV-2 infection may have triggered autoantibodies production against MOG leading to ON.
Keywords: immunology < IMMUNOLOGY; infections disease/aids < NEURO OPHTHALMOLOGY; neuro imaging < NEURO OPHTHALMOLOGY; optic neuritis < NEURO OPHTHALMOLOGY; optic neuropathy < NEURO OPHTHALMOLOGY.
Background and Objectives: The aim of this study was to investigate the impact of oral administration of the combination of astaxanthin (AXT), lutein, folic acid, vitamin D3, and bromelain with antioxidants on choroidal blood flow in patients with age-related intermediate macular degeneration (AMD). Materials and Methods: Patients affected by intermediate AMD and treated with daily oral nutritional supplement with AXT, bromelain, vitamin D3, folic acid, lutein, and antioxidants for a period of at least 6 months were included in this retrospective study. A control group homogenous for age and sex was also included in the analysis. All participants underwent a complete ophthalmologic examination, spectral domain optical coherence tomography (SD-OCT), and optical coherence tomography angiography (OCTA) evaluation. Outcome measures were choroidal thickness (CHT) and choriocapillary vessel density (CCVD) after six months of AXT assumption. Results: CCVD values showed statistically significant difference between cases and controls at baseline (p < 0.001) and in the cases during follow-up (p < 0.001). The CHT measurements showed statistically significant difference between cases and controls (p = 0.002) and in the cases during follow-up (p < 0.001). Conclusions: The combined use of structural OCT and OCTA allows for a detailed analysis in vivo of perfusion parameters of the choriocapillaris and choroid and evaluation of changes of choroidal blood flow after oral nutritional supplements that affect blood flow velocity.
Keywords: astaxanthin; choroidal blood flow; intermediate AMD; optical coherence tomography angiography.
Purpose: To describe the anatomic and visual outcomes of eyes undergoing autologous iris transplantation for macular hole retinal detachment.
Methods: Seven consecutive patients with macular hole retinal detachment were enrolled in a single-arm prospective study. All patients underwent pars plana vitrectomy with autologous iris transplantation placed in the subretinal space as a plug to close the macular hole; in one case, a posterior retinal break was also closed with the same technique.
Results: Seven patients (2 males and 5 females) with a mean age of 69.14 ± 7.79 years (range 58-80 years) were followed up for a period of six months. The best-corrected visual acuity improved from 2.44 ± 0.48 logMAR (20/2000) preoperatively to 1.90 ± 0.26 logMAR (20/800) 6 months after surgery. Optical coherence tomography analysis showed retinal adhesion around the iris plug, and the retina remained dry in the follow-up period.
Conclusions: In this series of macular hole retinal detachments, autologous iris transplantation placed as a plug over the retinal pigment epithelium facing the macular hole opening or directly over the bare sclera achieved anatomical success with improvement in visual function.
Keywords: Iris pigment epithelium; macular hole; retinal detachment.
Purpose: To evaluate the incidence of neovascularization (NV) secondary to central serous chorioretinopathy (CSC)-a condition belonging to the spectrum of pachychoroid disorders by means of optical coherence tomography angiography.
Methods: One hundred and seventy five eyes with CSC were evaluated in this retrospective observational study. The eyes with acute or chronic CSC with no NV were included in Group 1, and those with NV were evaluated in Group 2. Only eyes that had undergone structural optical coherence tomography and optical coherence tomography angiography were included. Age, best-corrected visual acuity, and subfoveal choroidal thickness were evaluated in all eyes. In Group 2, the type and morphology of NV and the occurrence of exudation were considered.
Results: Of a total of 175 eyes with CSC, 86 had the acute form and 89 the chronic. Approximately 140 belonged to Group 1 (80%) and 35 to Group 2 (20%). Approximately 39.2% of all patient with chronic CSC developed NV. Mean age in Groups 1 and 2 was 53.3 years (±10.9) and 66.6 years (±10.2), respectively. Mean best-corrected visual acuity in Groups 1 and 2 was 45.7 (±11.7) and 30.9 (±17.9) early treatment diabetic retinopathy study letters, respectively. Mean CCT in Group 1 and 2 was 417.5 µm (±123) and 344.2 µm (±165.9), respectively. In Group 2, all patients had Type 1 NV (100%); 29 eyes (83%) had filamentous feature, and 6 eyes (17%) had irregular shape. Silent nonexudative NV was observed in 7 eyes (20%), all belonging to Group 2.
Conclusion: The use of optical coherence tomography angiography in everyday clinical practice allows for the accurate analysis of the chorioretinal vascular setting, with the identification of new vessels that could remain misdiagnosed.
Background: The purpose of this study was to describe early changes in the morphology of pigment epithelium detachments (PED) after an intravitreal injection of Brolucizumab into eyes with macular neovascularization secondary to exudative age-related macular degeneration (e-AMD).
Method: We included twelve eyes of 12 patients with PED secondary to e-AMD which were not responding to prior anti-VEGF treatments. An ophthalmic examination and an assessment of PED-horizontal maximal diameter (PED-HMD), PED-maximum high (PED-MH) and macular neovascularization (MNV) flow area (MNV-FA) by the means of structural optical coherence tomography (OCT) and OCT Angiography (OCT-A) were performed at baseline, as well as 1, 7, 14 and 30 days after the injection.
Results: The mean age of the population of study was 78.4 (SD ± 4.8). The mean number of previous Ranibizumab or Aflibercept injections was 13 (SD ± 8). At the last follow-up visit, the PED-HMD did not significantly change (p = 0.16; F(DF:1.94, 20,85) = 1.9), the PED-MH showed a significant reduction [p = 0.01; F(DF:1.31, 14.13) = 6.84.] and the MNV-FA did not significantly differ (p = 0.1; F(1.97, 21.67) = 2.54) from baseline. No signs of ocular inflammation were observed during follow-up.
Conclusions: A single Brolucizumab injection was able to determine the short-term effects on PEDs’ anatomical features of eyes with an unresponsive e-AMD.
Keywords: Brolucizumab; OCT angiography; age-related macular degeneration; exudative AMD; innovative biotechnologies; personalized medicine.
Purpose: To evaluate structural changes in response to antivascular endothelial growth factor (anti-VEGF) treatment in patients with long-term type 1 choroidal neovascularization (CNV) by optical coherence tomography (OCT) and OCT angiography (OCTA).
Method: This is a longitudinal study that involved a total of 51 eyes with type 1 CNV (35 female and 16 male eyes). Structural OCT and OCTA were performed on all the subjects. AngioVue OCTA (XR Avanti, Optovue, Inc., Fremont, CA) was used to obtain qualitative and quantitative information. All eyes were treated with an anti-VEGF ProReNata (PRN) approach and were followed for a mean of 38.9 months (SD ± 7.22). Best-corrected visual acuity (BCVA) was assessed at each follow-up timepoint.
Results: We observed two kinds of possible evolution of type 1 CNV: “positive evolution,” including stabilization in 20% of patients and chronicity in 35%, and “negative evolution,” in which fibrosis was shown in 18% of patients, chorioretinal atrophy in 25%, and hemorrhage or RPE tears in 2%. The mean BCVA at baseline was 33.67 ± 15.85 ETDRS letters; after 1 and 2 years, it was 31.61 ± 18.04 and 31.18 ± 18.58 ETDRS letters, respectively. The mean BCVA at the end of follow-up was 25.27 ± 20 ETDRS letters. The difference between the values at baseline and at the end of follow-up was not statistically significant (P = 0.06, r 2 = 0.10).
Conclusions: This study describes an in vivo structural long-term evolution of type 1 CNV by OCT and OCTA. Different possible CNV outcomes were observed. This study suggests that new retinal imaging techniques could be useful tools for assessing the potential retinal changes in the evolution of type 1 CNV to develop personalized medicine. Further studies using OCTA in the long term are needed to better understand why similarly treated type 1 CNV cases evolve differently and produce different results.
Purpose: To investigate the optical coherence tomography (OCT) en face reconstruction of the choroid in different phenotypes of non-neovascular age-related macular degeneration (AMD), to identify the relative distribution of the vascular patterns of the Haller’s layer in each AMD category.
Methods: Retrospective study enrolling consecutive patients with non-neovascular AMD. Patients were divided into the following: (1) those with reticular pseudodrusen (RPD); (2) those with small (< 63 μm) or medium-large drusen (63-124 μm); (3) those with geographic atrophy (GA). Qualitative analysis of the en face images provided by CIRRUS HD-OCT 5000 (Carl Zeiss Meditech, Inc., Dublin, USA) was performed, identifying five arrangements of Haller’s vessels: temporal herringbone, branched from below, laterally diagonal, double arcuate, and reticular. Choroidal thickness (CT) was measured from structural OCT. Healthy age-matched subjects were included as a control group.
Results: Fifty-eight eyes of 58 patients (20 eyes with RPD; 22 eyes with drusen; 16 eyes with GA) and 18 control eyes were enrolled. The laterally diagonal configuration was the most prevalent (40.0%) in the RPD group; the reticular pattern was the most frequent in the drusen group (50.0%); the double arcuate (62.5%) was the most recurrent pattern in patients with GA. In the control group, the temporal herringbone (38.9%) arrangement was the most represented. The CT associated with the temporal herringbone and reticular arrangement was significantly higher compared to the branched from below (p < 0.001), the laterally diagonal (p = 0.014), and the double arcuate pattern (p = 0.009).
Conclusion: Different phenotypes of non-neovascular AMD present a specific distribution of vascular arrangement on en face OCT. The temporal herringbone and the reticular pattern (the ones more associated in a physiological setting) disclosed a thicker choroid compared to the arrangements more represented in non-neovascular AMD-correlated phenotypes.
Keywords: Age-related macular degeneration; Choroidal patterns; Drusen; En face optical coherence tomography; Geographic atrophy; Reticular pseudodrusen.
To assess the current role of fluorescein angiography after the introduction of optical coherence tomography angiography in real-life clinical practice.
This was a multicentric retrospective observational study to evaluate the number of fluorescein angiography and optical coherence tomography angiography procedures performed by different devices from January 2013 to December 2018. The centers involved were Centro Italiano Macula (Rome), and ophthalmology departments of University “G. D’Annunzio” Chieti–Pescara (Chieti) and “Azienda Ospedaliero Universitaria Careggi” (Florence).
Out of 19,898 total fluorescein angiography procedures performed in the observation period, 3444 (17.3%) were in 2013, 3972 (19.9%) were in 2014, 3601 (18.1%) were in 2015, 3407 (17.2%) were in 2016, 3285 (16.5%) were in 2017, and 2189 (11%) were in 2018. Out of 7949 optical coherence tomography angiography procedures performed in the observation period, none were performed in 2013, 550 (6.9%) were in 2014, 908 (11.5%) were in 2015, 2098 (26.4%) were in 2016, 2090 (26.3%) were in 2017, and 2303 (28.9%) were in 2018.
Fluorescein angiography procedures were performed less often after the introduction of optical coherence tomography angiography technology. The ease, speed, and safety of the optical coherence tomography angiography procedure in everyday clinical practice have facilitated more optical coherence tomography angiography application compared to fluorescein angiography in recent years. In the future, we will probably evaluate the different pathologies that still need an evaluation by fluorescein angiography.
The authors have observed and quantified choriocapillaris vascular density changes (“dark halo”) around choroidal neovascularization (CNV) before and after anti-vascular endothelium growth factor (VEGF) injections by optical coherence tomography angiography (OCTA).
Forty-three flow density areas of 11 eyes with CNV were evaluated before and after treatment in this observational case series. Four cases were CNV type 1 and seven were CNV type 2. All the patients were evaluated by a spectral-domain OCT system. The scans were registered at baseline before injection, between 6 days and 14 days after injection, and monthly thereafter. The dark halo was automated assessed by Image J software.
The authors observed a fluctuation of the dark halo around the CNV, the dark halo being larger in 95.4% of the cases before treatment and decreasing after injection. Correspondingly, the mean CNV area decreased in 83.7% of the cases after injection. The mean CNV area before treatment was 0.44 mm2 (± 0.40 mm2) and 0.34 mm2 (± 0.29 mm2) after treatment. The dark halo mean area before treatment was 0.34 mm2 (± 0.27 mm2) and 0.25 mm2 (± 0.23 mm2) after treatment. CNV area and dark halo area reductions after injection were statistically significant (P < .001). CNV-to-halo ratio was statistically significant, decreasing after injection (P < .001).
OCTA is a noninvasive vascular imaging tool able to detect CNV flow and features. OCTA is also suitable to highlight choriocapillaris vascular density changes around neovascularization after treatment. The dark halo around CNV seen by OCTA showed a fluctuation after anti-VEGF treatment. These results might be useful in clinical practice. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:918-924.].
To describe and interpret the features of pachychoroid neovasculopathy (PNV) using optical coherence tomography angiography (OCTA) technique.
This is an observational case series of patients who presented with PNV. Best-corrected visual acuity (BCVA), anterior segment examination, dilated funduscopic examination, infrared and autofluorescence fundus images and spectral-domain optical coherence tomography (SD-OCT; B-scan, ‘en-face’ and OCTA) were carried out for all patients. Choroid thickness was measured using enhanced depth imaging (EDI) mode. Colour fundus photographs, fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA) were not performed systematically. Optical coherence tomography angiography (OCTA) features of PNV are described and interpreted.
Five eyes of five patients with a mean age of 62.2 years (range, 53-73 years) presenting with PNV were analysed. They all presented pachychoroid pigment epitheliopathy (PPE) with choroidal thickening and dilated choroidal vessels as seen with EDI-OCT. Fluorescein angiography (FFA) was performed in three patients showing multiple areas of retinal pigment epithelium atrophy and fundus lesions suggestive of chronic central serous chorioretinopathy. Indocyanine green angiography (ICGA) in one patient confirmed the presence of large choroidal veins and choroidal hyperpermeability seen beneath the area of the neovascular tissue. Two eyes had the appearance of polypoidal structures within the neovascular tissue, with the characteristic aspect of the polypoidal lesions on B-scan and ‘en-face’. Optical coherence tomography angiography (OCTA) showed the appearance of tangled filamentous vascular network in all eyes.
Optical coherence tomography angiography (OCTA) is a safe, highly sensitive and specific examination for the detection of type 1 neovascularization associated with PPE. Features are characteristic of tangled filamentous vessels overlying a focal area of thickened choroid.
To compare the prevailing patterns of Haller vessel arrangements at the posterior pole between healthy eyes and those with central serous chorioretinopathy (CSC) using en face optical coherence tomography.
Eyes of normal subjects and patients with acute or chronic CSC underwent optical coherence tomography imaging (RTVue 100; Optovue Inc, Fremont, CA). En face sections at the level of the Haller layer were classified by two masked graders into five mutually exclusive morphologic categories (temporal herringbone, branched from below, laterally diagonal, double arcuate, and reticular). The relative prevalence of each Haller vessel arrangement pattern was determined for each phenotype.
Numbers of eyes examined were as follows: 154 eyes of 77 normal subjects; 41 eyes of 31 patients with acute CSC; and 39 eyes of 33 patients with chronic CSC. The mean age of participants was 44.4 ± 14.6 years for healthy subjects (M:F = 37:40), 48.5 ± 8.2 years (M:F = 24:7) for acute CSC, and 65.3 ± 13.1 years (M:F = 28:5) for chronic CSC. The relative prevalence of each Haller vessel arrangement pattern differed by phenotype. The temporal herringbone pattern was most prevalent in healthy eyes (49.2%), whereas a reticular pattern was most prevalent in eyes with acute and/or chronic CSC (combined, 48.8%).
A significant difference was observed in the prevalence of respective Haller vessel arrangement patterns between eyes of normal subjects and those of patients with either acute or chronic CSC. Although further study is needed to determine the mechanistic factors underlying these differences, and the hemodynamic implications, our data suggest that en face optical coherence tomography may find a formal role in choroidal disease classification.
Optovue AngioVue system technology for optical coherence tomography (OCT) angiography is based on the AngioVue Imaging System (Optovue, Inc., Freemont, CA), using split-spectrum amplitude-decorrelation angiography (SSADA) algorithm. This algorithm was developed to minimize scanning time. It detects motion in blood vessel lumen by measuring the variation in reflected OCT signal amplitude between consecutive cross-sectional scans. The novelty of SSADA lies in how the OCT signal is processed to enhance flow detection and reject axial bulk motion noise. Specifically, the algorithm splits the OCT image into different spectral bands, thus increasing the number of usable image frames. Each new frame has a lower axial resolution that is less susceptible to axial eye motion caused by blood pulsation. Optovue AngioVue system technology allows quantitative analysis. It provides numerical data about flow area and non-flow area. It can also generate a flow density map. These metrics may serve as biomarkers in diagnosis and for tracking disease progression or treatment response. Flow area: the software will calculate the drawn area and vessel area in mm(2). It allows for comparison of all measurements for a given participant. Non-flow area: the software shows the non-perfused areas by mouse click selection. Ischemic areas will be shown in yellow. These areas may be saved and matched with others in the study. Flow density tool is able to measure the percentage of vascular areas on en face angiograms. This analysis is based on an ETDRS grid centered on the macula as with the thickness map. This tool works both on inner and outer vascular plexus.
© 2016 S. Karger AG, Basel.
Study the choroidal neovascularization (CNV) morphological evolution after treatment using optical coherence tomography angiography (OCTA).
We used Optovue XR Avanti, with split-spectrum amplitude-decorrelation angiography algorithm.
OCT Angiography allows to recognize better the CNV type. In our series all our cases seem to follow a 45 to 60 days cycle, after intra vitreal injection. After each injection a pruning of smaller vessels is seen immediately (after 24 hours) that increases for 6 to 12 days when it reaches a maximum. It is followed by a reopening or new sprouting of the vessels 20 to 50 days later. The later cycles seem longer. Our results on early CNV evolution seem to confirm previous observations of CNV abnormalization and arterialization. Pruning the small peripheral branches seems to strengthen the trunk. In OCTA, closing terminal vessels (anti-VEGF effects) seems to cause an increased flow in trunk after the CNV reactivation.
© 2016 S. Karger AG, Basel.