Loss of Foveal Cone Structure Precedes Loss of Visual Acuity in Patients With Rod-Cone Degeneration

Purpose

To assess the relationship between cone spacing and visual acuity in eyes with rod-cone degeneration (RCD) followed longitudinally.

Methods

High-resolution images of the retina were obtained using adaptive optics scanning laser ophthalmoscopy from 13 eyes of nine RCD patients and 13 eyes of eight healthy subjects at two sessions separated by 10 or more months (mean 765 days, range 311-1935 days). Cone spacing Z-score measured as close as possible (average <0.25°) to the preferred retinal locus was compared with visual acuity (letters read on the Early Treatment of Diabetic Retinopathy Study [ETDRS] chart and logMAR) and foveal sensitivity.

Results

Cone spacing was significantly correlated with ETDRS letters read (ρ = -0.47, 95%CI -0.67 to -0.24), logMAR (ρ = 0.46, 95%CI 0.24 to 0.66), and foveal sensitivity (ρ = -0.30, 95%CI -0.52 to -0.018). There was a small but significant increase in mean cone spacing Z-score during follow-up of +0.97 (95%CI 0.57 to 1.4) in RCD patients, but not in healthy eyes, and there was no significant change in any measure of visual acuity.

Conclusions

Cone spacing was correlated with visual acuity and foveal sensitivity. In RCD patients, cone spacing increased during follow-up, while visual acuity did not change significantly. Cone spacing Z-score may be a more sensitive measure of cone loss at the fovea than visual acuity in patients with RCD.

Displacement of the Foveal Retinal Layers After Macular Hole Surgery Assessed Using En Face Optical Coherence Tomography Images

BACKGROUND AND OBJECTIVE

To investigate the displacement of foveal retinal layers in surgically closed macular holes (MHs) after removal of the internal limiting membrane (ILM).

PATIENTS AND METHODS

Medical records of 26 consecutive patients who underwent vitrectomy and removal of the ILM for idiopathic MH were retrospectively reviewed. En face optical coherence tomography images were exported at the level of the choroid, ellipsoid zone (EZ), and inner plexiform layer (IPL) at baseline and at 1, 3, and 6 months. The foveal center of the EZ and IPL was marked in the choroid en face image. The choroidal images were overlapped to match the vasculature in each patient, and the postoperative displacement of the foveal center was compared to baseline.

RESULTS

The center of the EZ and IPL was displaced significantly toward the disc during the first 3 months. The mean horizontal displacement at 1, 3, and 6 months was 52.7 μm, 112.5 μm, and 115.4 μm, respectively, for the EZ and 75.2 μm, 117.1 μm, and 136.5 μm, respectively, for the IPL. The location of the foveal center was significantly correlated between the EZ and the IPL (P ≤ .016).

CONCLUSIONS

The fovea was displaced nasally and slightly inferiorly after removal of the ILM. The displacement of the photoreceptor and inner retinal layers was concurrent. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:414-422.].

Comparison of foveal avascular zone between optical coherence tomography angiography and fluorescein angiography in patients with retinal vein occlusion

OBJECTIVE

To compare area of foveal avascular zone (FAZ) in different retinal vascular layers in optical coherence tomography angiography (OCTA) and fluorescein angiography (FA) in patients with retinal vein occlusion (RVO).

DESIGN AND METHODS

Prospective cross-sectional comparative study in 47 eyes of 47 patients. FA was recorded with the Zeiss FF450plusIR camera and OCTA was obtained with the Zeiss Cirrus 5000 equipped with the AngioPlex module. Area of FAZ was graded by two independent investigators and calculated with Adobe Photoshop. Analysis for the total study population as well as subgroup analysis for branch retinal vein occlusion (BRVO), central retinal vein occlusion (CRVO) and patients with and without macular edema (ME) was performed.

RESULTS

For all patients, FAZ was 0.449 mm2 in FA, 0.496 mm2 in OCTA superficial capillary layer (SCL) and 3.168 in OCTA deep capillary layer (DCL). In patients without ME FAZ was 0.288 mm2 in FA, 0.342 mm2 in OCTA SCL and 1.384 mm2 in OCTA DCL. FAZ area measurement in patients with ME revealed 0.482 mm2 in FA, 0.527 mm2 in OCTA SCL and 3.554 mm2 in OCTA DCL.

CONCLUSIONS

Especially the SCL of OCTA shows a good agreement to FA in measurement of FAZ in all patients with low limits of variation in patients without ME. There were no considerable differences in BRVO and CRVO. OCTA could replace FA in FAZ area measurement in patients with RVO, especially in those without ME, achieving similar measurements whilst being non-invasive.

Correlation of Outer Retinal Degeneration and Choriocapillaris Loss in Stargardt Disease Using En Face Optical Coherence Tomography and Optical Coherence Tomography Angiography

PURPOSE

This study measured and correlated degeneration of the junction between the inner and outer segments (IS/OS), the retinal pigment epithelium (RPE), and the choriocapillaris (CC) in Stargardt disease (STGD).

DESIGN

Prospective cross-sectional study.

METHODS

This study was conducted at the Casey Eye Institute. A total of 23 patients with STGD were enrolled and underwent optical coherence tomography angiography (OCTA). Scans were centered on the fovea. OCT slab projections and en face boundary maps were used to create masks to measure total IS/OS loss or RPE atrophy as well as regions of isolated IS/OS loss, isolated RPE atrophy, and matched IS/OS and RPE degeneration or intact IS/OS junction and RPE. CC vascular density (CCVD) was quantified from the CC angiogram. Outcomes included the area of loss, and the CCVD of degeneration in different areas was quantified and correlated.

RESULTS

The total area of IS/OS loss was strongly correlated with the total area of RPE atrophy (r = 0.96; P < 0.0001) by a 1.6:1 ratio (r² = 0.90). CCVD within regions of matched degeneration (85.6% ± 2.7%; P < 0.0001), isolated IS/OS junction loss (93.6% ± 1.0%; P = 0.0011), and isolated RPE atrophy (94.1% ± 1.1%; P = 0.0065) were all significantly lower than normal (99.0% ± 0.17%). There was a trend for CCVD within intact areas (97.6% ± 0.38%) to decline as the area diminished (r = 0.68).

CONCLUSIONS

Photoreceptor and RPE degeneration exhibited a strong relationship wherein the IS/OS loss was 1.6-fold greater than that of RPE atrophy, supporting the theory that photoreceptor degeneration precedes RPE in STGD. Both the photoreceptors and the RPE degeneration contributed synergistically to CCVD attenuation, but extralesional CCVD also tended to be abnormal. The findings and techniques in this study may be of utility in developing endpoints for clinical trials.

RESOLUTION OF FOVEAL CYST AFTER THE RELEASE OF VITREOMACULAR ATTACHMENT IN EYE WITH MACULAR TELANGIECTASIA TYPE 2

PURPOSE

To report a case of macular telangiectasia Type 2 that showed a resolution of a foveal cystic change accompanying the release of vitreomacular attachment.

METHODS

Retrospective chart review.

REPORT OF THE CASE

A 75-year-old man presented with a bilateral decrease in visual acuity and metamorphopsia. At the initial visit, the left eye demonstrated a hyporeflective foveal cyst and a perifoveal vitreous detachment on optical coherence tomography. The characteristic clinical findings were consistent with the diagnosis of macular telangiectasia Type 2. Fifteen months later, the patient returned with a remission of the metamorphopsia in the left eye. The left eye had a vitreous detachment from the macula, and the hyporeflective foveal cyst was completely resolved.

CONCLUSION

At least in some cases, vitreous traction or attachment may play a role in the morphologic changes seen in macular telangiectasia Type 2.

Current Outcomes of Anti-VEGF Therapy in the Treatment of Macular Edema Secondary to Central Retinal Vein Occlusions: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the current anti-vascular endothelial growth factor (anti-VEGF) treatments for macular edema due to central retinal vein occlusions.

METHODS

PubMed, EMBASE, the Cochrane Library were systematically searched for studies between January 2013 and July 2018. Reference lists of published articles were searched and if necessary, authors were contacted to provide additional data. Meta-analysis was performed using Comprehensive Meta-analysis software. The best-corrected visual acuity (BCVA), central foveal thickness (CFT), injection frequency, and adverse events were evaluated.

RESULTS

Seventeen studies involving 1070 eyes were included in the meta-analysis. The mean differences in 12-month changes in BCVA and CFT were 14.4 ETDRS letters (P < 0.001) and -289.2 μm (P < 0.001), respectively. Visual acuity gains were maintained at 24 months (14.2 letters, P < 0.001) and CFT continued to reduce (-327.45 μm, P < 0.001). The incidence of severe adverse events was low and similar across all anti-VEGF therapies. Prospective studies administered a greater number of injections compared with retrospective studies, being 6.6 and 4.4 injections, respectively over 12 months (P < 0.001).

CONCLUSIONS

Intravitreal treatment with anti-VEGF agents demonstrated significant anatomical and functional gains in treating macular edema due to central retinal vein occlusions.

Impact and Implication of Fovea-Involving Intraretinal Hemorrhage after Acute Branch Retinal Vein Occlusion

PURPOSE

To compare clinical outcomes in patients with branch retinal vein occlusion (BRVO) with (group A) or without (group B) fovea-involving intraretinal hemorrhage (IRH).

DESIGN

Retrospective cohort study.

PARTICIPANTS

All patients diagnosed with acute, treatment-naive BRVO seen by the Duke Eye Center Retina Service from January 1, 2009, through June 30, 2017 who had treatment-naive BRVO with disease onset <3 months before presentation, macular involvement, spectral-domain OCT and color fundus photographs at presentation, and >12 months offollow-up.

METHODS

Retrospective study using a database of patients diagnosed with BRVO over an 8-year period. The presence of fovea-involving IRH was determined from baseline fundus photographs by human graders and confirmed with multimodal imaging. Presenting features, treatment patterns, and clinical outcomes were compared.

MAIN OUTCOME MEASURES

Visual acuity (VA), cystoid macular edema (CME), central subfield thickness (CST), and number of anti-vascular endothelial growth factor (VEGF) injections.

RESULTS

Of 172 patients with BRVO, 33 (19.2%) presented with fovea-involving IRH. At presentation, group A had worse VA (0.54±0.06 logMAR [Snellen equivalent, 20/69] vs. 0.34±0.03 logMAR [Snellen equivalent, 20/44]; P = 0.001), greater CST (523.8±32 μm vs. 345.9±11.8 μm; P < 0.001), were more likely to have CME (93.9% vs. 48.2%; P < 0.001), and received more anti-VEGF injections in the first year (4.50±3.43 vs. 1.89±3.26; P < 0.001) than group B. Final VA was worse in group A (0.57±0.12 logMAR [Snellen equivalent, 20/74] vs. 0.35±0.05 logMAR [Snellen equivalent, 20/45]; P = 0.05). More patients in group A had loss of >2 lines of VA (36.4% vs. 18.7%; P = 0.04) or >3 lines (27.3% vs. 10.8%; P = 0.05) at final follow-up. Group A was more likely to have CME (63.6% vs. 27.3%; P < 0.001) at final follow-up with greater treatment burden, yet experienced a greater decrease in CST (-197.8±45.3 μm vs. -51.7±14.7 μm; P = 0.005).

CONCLUSIONS

Acute BRVO presenting with fovea-involving IRH is associated with worse presenting features, greater treatment burden, and worse clinical outcomes despite current therapeutic interventions.

Comparative Study of 27-Gauge Versus 25-Gauge Vitrectomy With Air Tamponade in the Treatment of Myopic Foveoschisis

BACKGROUND AND OBJECTIVE

To compare the surgical outcome of 27-gauge pars plana vitrectomy (PPV) with 25-gauge PPV and evaluate the efficacy of air tamponade for the treatment of myopic foveoschisis (MF).

PATIENTS AND METHODS

Sixty eyes of 60 consecutive patients were recruited to undergo vitrectomy, internal limiting membrane (ILM) peeling, and air tamponade for treatment of MF. These eyes were divided into two groups: the 27-gauge group (n = 29) and the 25-gauge group (n = 31).

RESULTS

There were no significant differences in the mean operating time (P = .32), the mean time for vitrectomy (P = .20), and the suturing rate(P = .46) between the 27-gauge group and the 25-gauge group. At the final follow-up, anatomical resolution rate did not differ between the two groups (P = .65).

CONCLUSION

The 27-gauge vitrectomy system is as efficient and feasible as the 25-gauge system for the treatment of MF. Air tamponade can provide good postoperative anatomic resolution of MF. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e135-e142.].

Macular and Peripapillary Choroidal Thickness in Patients With Keratoconus

BACKGROUND AND OBJECTIVE

To investigate and compare macular and peripapillary choroidal thickness and profiles of patients with keratoconus and age-matched controls and correlate subfoveal choroidal thickness with keratoconus severity.

PATIENTS AND METHODS

This was a prospective, observational, cross-sectional study comprising 45 keratoconus patients and 56 healthy controls. Choroidal thicknesses at the fovea and at 750-μm intervals from the fovea to 1.5 mm in the nasal and temporal directions were measured by spectral-domain optical coherence tomography. Peripapillary choroidal thickness was measured at six segments along the circle scan.

RESULTS

Mean age did not differ between the patients with keratoconus and controls (24.5 ± 7.2 vs. 22.5 ± 7.4 years, P = .170). Mean subfoveal choroidal thickness was higher in the keratoconus group (427.48 μm ± 78.51 μm) than in controls (351.03 μm ± 99.08 μm; P < .001). Mean subfoveal choroidal thickness did not differ between mild and severe keratoconus (437.82 ± 53.4 vs. 418.87 ± 113.9 μm; P = .660). In the macular area, choroidal thickness was lower at 1.5 mm nasal to the fovea (P < .0001) in both groups. The choroid was thinner at 0.75 mm temporal to the fovea than under the fovea in the keratoconus group (P < .001). The peripapillary choroid was thinner in the inferonasal and inferotemporal segments than in the other segments in both groups (P < .001). The peripapillary choroid was thinner in the inferonasal segment than in the inferotemporal segment in the keratoconus group (P = .018).

CONCLUSION

Subfoveal choroidal thickening is observed in keratoconus eyes. The pathophysiological role of choroidal thickness variations should be considered in the natural history of keratoconus. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:664-673.].

Morphological Implications of Vascular Structures Not Visualized on Optical Coherence Tomography Angiography in Retinal Vein Occlusion

BACKGROUND AND OBJECTIVE

Advanced retinal imaging can improve understanding of retinal vein occlusion (RVO) pathology. The authors aimed to characterize the vascular pathology of RVO on en face optical coherence tomography (OCT) and OCT angiography (OCTA).

PATIENT AND METHODS

This was a cross-sectional study including 17 eyes with RVO. The authors identified discordance between vasculature on en face OCT and flow on OCTA, which was correlated with structural findings at the corresponding location on OCT B-scans.

RESULTS

Six eyes had vessels that were seen on OCT without flow on OCTA. The most clinically relevant finding was preserved inner retinal layers in areas where the en face OCT showed collaterals that appeared nonperfused on OCTA.

CONCLUSIONS

The authors' findings indicate that collaterals can appear on en face OCT without flow on OCTA in RVO and may be associated with relatively preserved inner retinal structures. Clinicians should consider multimodal imaging to evaluate RVO, including both OCT and OCTA. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:392-396.].

Macula Vessel Density and Foveal Avascular Zone Parameters in Exfoliation Glaucoma Compared to Primary Open-Angle Glaucoma

Purpose

The purpose of this study was to explore macula vessel density and foveal avascular zone (FAZ) parameters in exfoliation glaucoma (XFG) compared to primary open-angle glaucoma (POAG) using optical coherence tomography angiography (OCTA).

Methods

This was a cross-sectional observational study. Twenty-six XFG and 28 POAG patients with comparable visual field defects on Humphrey 24-2 and 10-2 perimetries were recruited. OCTA scans (3 × 3 mm) centered on the fovea were obtained. Built-in software was used to measure superficial capillary plexus (SCP) vessel density at different quadrants of the macula. Custom software was then used to create a full-thickness image. The FAZ was manually delineated, and large vessels were removed. Vessel density in eight concentric rings with increments of 200-μm diameters from the delineated FAZ was measured. FAZ parameters were calculated using the custom software.

Results

SCP density was significantly lower in the superior (mean difference [MD] = -4.32, 95% confidence interval [CI] = -7.02, -1.61, P = 0.003) and nasal (MD = -3.00, 95% CI = 05.22, -0.77, P = 0.010) quadrants in XFG versus POAG. SCP vessel density using the concentric ring approach revealed significantly decreased values at all eight rings in XFG versus POAG. In the full-thickness analysis, density was significantly less in the XFG group in all rings except the initial 200 μm. No significant differences existed in FAZ parameters between the groups.

Conclusions

Despite the presence of comparable central visual field defects, the macula vessel density was predominately lower in XFG compared with POAG in our sample of patients. Further studies are warranted to investigate the consistency of our results.

Comparison of effectiveness between complete internal limiting membrane peeling and internal limiting membrane peeling with preservation of the central fovea in combination with 25G vitrectomy for the treatment of high myopic foveoschisis

Vitrectomy combined with internal limiting membrane peeling (ILMP) treats high myopic foveoschisis with good results, but there is a risk of iatrogenic macular holes, which may be reduced by preserving the internal limiting membrane of the central fovea. This study compared complete ILMP with partial ILMP, both combined with 25G vitrectomy, for the treatment of high myopic foveoschisis.Thirty-three cases (33 eyes) of high myopic foveoschisis were retrospectively analyzed. They underwent 25G vitrectomy combined with C3F8 gas filling; Group A (20 patients, 20 eyes) underwent complete ILMP, while Group B (13 patients, 13 eyes) underwent partial ILMP to preserve the internal limiting membrane of the central fovea. Patients were followed up for 6 months and underwent best corrected visual acuity (BCVA), intraocular pressure, diopter, slit lamp microscopy, indirect ophthalmoscope, A-mode and/or B-mode ultrasound, and optical coherence tomography. Surgical complications were recorded.Up to the last follow-up, the BCVA improved and central fovea thickness (CFT) was lower compared with before surgery in both groups (All P < .05). There were no significant differences in BCVA and CFT at each time point between the groups (P > .05). Most of the postoperative retinas of the 2 groups were completely reattached, with disappearance of the macular retinoschisis cavity. Two patients in the Group A and none in the Group B developed a macular hole during follow-up (P = .508).The results did not support the superiority of partial ILMP over complete ILMP in reduced incidence of macular hole. Both methods had a similar curative effect.

Automatic segmentation of the foveal avascular zone in ophthalmological OCT-A images

Angiography by Optical Coherence Tomography (OCT-A) is a non-invasive retinal imaging modality of recent appearance that allows the visualization of the vascular structure at predefined depths based on the detection of the blood movement through the retinal vasculature. In this way, OCT-A images constitute a suitable scenario to analyze the retinal vascular properties of regions of interest as is the case of the macular area, measuring the characteristics of the foveal vascular and avascular zones. Extracted parameters of this region can be used as prognostic factors that determine if the patient suffers from certain pathologies (such as diabetic retinopathy or retinal vein occlusion, among others), indicating the associated pathological degree. The manual extraction of these biomedical parameters is a long, tedious and subjective process, introducing a significant intra and inter-expert variability, which penalizes the utility of the measurements. In addition, the absence of tools that automatically facilitate these calculations encourages the creation of computer-aided diagnosis frameworks that ease the doctor’s work, increasing their productivity and making viable the use of this type of vascular biomarkers. In this work we propose a fully automatic system that identifies and precisely segments the region of the foveal avascular zone (FAZ) using a novel ophthalmological image modality as is OCT-A. The system combines different image processing techniques to firstly identify the region where the FAZ is contained and, secondly, proceed with the extraction of its precise contour. The system was validated using a representative set of 213 healthy and diabetic OCT-A images, providing accurate results with the best correlation with the manual measurements of two experts clinician of 0.93 as well as a Jaccard’s index of 0.82 of the best experimental case in the experiments with healthy OCT-A images. The method also provided satisfactory results in diabetic OCT-A images, with a best correlation coefficient with the manual labeling of an expert clinician of 0.93 and a Jaccard’s index of 0.83. This tool provides an accurate FAZ measurement with the desired objectivity and reproducibility, being very useful for the analysis of relevant vascular diseases through the study of the retinal micro-circulation.

MULTIMODAL IMAGING DURING THE EVOLUTION OF BLOOD-BRAIN BARRIER DISRUPTION MACULOPATHY

PURPOSE

To highlight the course of blood-brain barrier disruption maculopathy in a patient with successfully managed relapsed central nervous system lymphoma.

METHODS

Case report with fundus autofluorescence and optical coherence tomography imaging, and literature review.

RESULTS

A 57-year-old patient diagnosed with central nervous system large B-cell lymphoma had a normal ophthalmic evaluation on his first visit. Subsequently, when his malignancy recurred locally, he was started on blood-brain barrier disruption therapy and intraarterial methotrexate. During the course of the therapy, he developed bilateral retinal pigment epithelial abnormalities located in the foveal and perifoveal zones. The changes were first mildly progressive and then marginally regressive in nature with minimal eventual loss of visual acuity to 20/32 and 20/25 in his right and left eye, respectively.

CONCLUSION

Maculopathy is a known complication in patients with central nervous system malignancies undergoing blood-brain barrier disruption. A detailed clinical evaluation using fundus autofluorescence and high-definition optical coherence tomography are informative in managing such patients.

The impact of central foveal thickness on the efficacy of subthreshold micropulse yellow laser photocoagulation in diabetic macular edema

To evaluate the efficacy of short-term subthreshold micropulse yellow laser photocoagulation (SMYLP) on eyes with diabetic macular edema (DME) with different central foveal thicknesses (CFT). Eighty eyes of 40 patients who had previously undergone ranibizumab treatment for DME and who subsequently had recurrent macular edema were included to the study. The study subjects were divided into four groups according to their initial CFT values (group 1, 250-300 μm; group 2, 301-400 μm; group 3, > 401 μm; group 4, 250-300 μm untreated control subjects). Patients were treated with SMYLP for one session and followed for 6 months. All patients underwent complete ophthalmologic evaluation. The alteration from baseline in CFT and the best corrected visual acuity (BCVA) were measured. Patients with a pretreatment CFT ≤ 300 μm experienced the statistically significant reduction in CFT and gain in BCVA at 2 months (p < 0.05), whereas patients with baseline CFT > 300 μm experienced no significant change (p > 0.05). Hyperautofluorescence lesions, that were not previously described, were detected in fundus autofluorescence imaging in the early period after SYMLP laser and these lesions were regressed with time. Our study indicates that the SYMLP provides a statistically significant improvement in BCVA and a reduction in CFT in the patients with a pretreatment CFT of 300 μm or less in DME and can be safe and effective in mild DME treatment.

Progression to Surgery for Patients With Idiopathic Epiretinal Membranes and Good Vision

BACKROUND AND OBJECTIVE

Patients with idiopathic epiretinal membranes (ERMs) and visual acuity of 20/40 or better are often monitored until vision or associated symptoms worsen to affect everyday living. This study looks at the rate of progression to surgery and the characteristics associated with progression.

PATIENTS AND METHODS

This study was a retrospective, consecutive case series of patients with newly diagnosed idiopathic ERMs who were referred to the Retina Service at the Ophthalmic Consultants of Boston between January 2009 and May 2015 with 20/40 or better visual acuity. Surgical membrane peel was typically offered when vision worsened to 20/50 or beyond and/or when patients could not tolerate symptoms attributable to the ERM. All eligible eyes were categorized by baseline optical coherence tomography (OCT) morphology into normal, mild or incomplete, or complete loss of foveal contour. Visual acuities were averaged through conversion to logMAR. Kaplan-Meier survival curves for progression to surgical membrane peel were calculated. The main outcome measure was progression to surgical intervention.

RESULTS

The study included 201 eyes from 170 patients; 29.8% had normal, 18.9% had mild loss, and 51.2% had complete loss of foveal contour on baseline OCT. Overall, 13% of eyes progressed to surgery at 7 years. However, only 5% of eyes with normal foveal contour progressed to surgery by 5.5 years, whereas 17% with incomplete and 16% with complete loss of foveal contour progressed to surgery at 6 and 7 years, respectively. Eyes with worse foveal contours progressed to surgery more rapidly.

CONCLUSION

A minority of patients with newly diagnosed ERMs who did not need surgical intervention progressed to needing surgery at 7 years with the rate and speed of progression dependent on baseline OCT morphology. These statistics can be useful in counseling patients who are deciding between watchful waiting and surgical intervention. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:S18-S22.].

Correlates of Good Vision in Eyes With Subfoveal Scars From Neovascular Age-Related Macular Degeneration

BACKGROUND AND OBJECTIVE

To compare subfoveal disciform scars with good and poor vision in patients with neovascular age-related macular degeneration (nAMD).

PATIENTS AND METHODS

A retrospective case-control study. Twenty-two eyes of 21 consecutively treated patients with nAMD with subfoveal disciform scar and best-corrected visual acuity (BCVA) of 20/63 or better at the final visit were included. Twenty-one eyes of 21 matched patients with disciform scar and final BCVA less than 20/63 served as controls.

RESULTS

Subretinal pigment epithelium scar location was more common in the good vision group than in the poor vision group (P < .001). The mean percent disruption of the ellipsoid and the external limiting membrane layers was significantly greater in poor vision eyes than in good vision eyes from scar formation and throughout follow-up (all P < .01).

CONCLUSION

Preserved photoreceptor layer correlated with good vision in patients with nAMD and subfoveal disciform scar. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:765-774.].

Surgical Repair of Traumatic Macular Holes With Extreme Macular Pathology Using an Internal Limiting Membrane Flap Technique

This report describes the use of inverted internal limiting membrane (ILM) flap technique as a treatment option for traumatic macular holes (MHs) with severe macular pathology. An interventional case series of two patients who experienced blunt trauma is reported. One patient developed two adjacent MHs and the second patient a MH with focal tissue avulsion in the fovea. Each patient underwent pars plana vitrectomy with ILM flap creation and intraocular gas tamponade. The ILM flap technique was successfully used for closure of MHs in one patient with a traumatic double MH and another patient with MH with foveal tissue avulsion. Visual acuity and symptoms improved in both patients. The ILM flap technique is a useful option for patients even with advanced pathologic findings subsequent to traumatic MH formation. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e143-e146.].

Dengue-Induced Inflammatory, Ischemic Foveolitis and Outer Maculopathy: A Swept-Source Imaging Evaluation

PURPOSE

Dengue maculopathy can present with a unique constellation of features resulting in significant central visual morbidity. We aim to describe various findings of dengue-induced inflammatory, ischemic foveolitis, and outer maculopathy (DIII-FOM) and assess the serial changes in vitreous inflammation, retinal structure, and vascularity using swept-source OCT (SS-OCT) and OCT angiography (OCTA).

DESIGN

Retrospective case series.

PARTICIPANTS

A total of 32 eyes (16 patients; 7 male) with dengue fever (positive serology for NS1 antigen) were enrolled in the study.

METHODS

In this study, serial assessments of ocular findings and imaging using fundus photography, SS-OCT, and SS-OCTA were performed. All the patients received 0.5 to 1 mg/kg/day oral prednisolone that was tapered over 4 to 6 weeks.

MAIN OUTCOME MEASURES

Outcome measures included functional change, that is, improvement in best-corrected visual acuity (BCVA), structural changes in the vitreous and retinal layers on SS-OCT, and retinal perfusion on OCTA.

RESULTS

The mean age of the patients was 29.17±10.91 years. Swept-source OCT showed vitreous cells (32 eyes; 100%), disruption of outer retinal layers (foveolitis) (24 eyes; 75%), and conical foveal elevation (22 eyes; 68.75%). After initiation of systemic corticosteroids, all the eyes showed resolution of vitreous cells and improvement in the integrity of retinal layers. Mean BCVA improved from an initial 0.80±0.33 logarithm of the minimum angle of resolution (logMAR) to 0.23±0.36 logMAR. Retinal plexus flow deficit (superficial plexus: 0.10±0.12 mm²; deep plexus: 0.29±0.13 mm²) persisted in all eyes and correlated well with initial BCVA (P < 0.05).

CONCLUSIONS

The pathophysiology of dengue maculopathy involves both ischemic and inflammatory components. Early institution of corticosteroid therapy may help in resolution of the inflammation-driven vitreoretinal alterations, but ischemia of the deep retinal plexuses may persist and may be the cause of permanent structural and functional changes.

Correlation between redefined optical coherence tomography parameters and best-corrected visual acuity in non-resolving central serous chorioretinopathy treated with half-dose photodynamic therapy

Purpose

To assess parameters on optical coherence tomography (OCT), and their correlation with best-corrected visual acuity (BCVA) in patients with non-resolving central serous chorioretinopathy (CSC).

Methods

For 25 non-resolving CSC patients treated with photodynamic therapy (PDT), the thickness of retinal layers was assessed on the foveal spectral-domain (SD) OCT scan. Evaluated OCT parameters included the central retinal thickness (CRT), defined as the internal limiting membrane (ILM) to ellipsoid zone (EZ) distance, and the second band thickness (SBT), defined as the EZ to hyperreflective subretinal accumulation distance. Integrity of the external limiting membrane (ELM) and the EZ bands was also determined. These parameters, along with BCVA and CRT measured automatically by SD-OCT device software were obtained before PDT, after PDT, and at final visit. After Bonferroni correction, a p-value <0.007 was considered statistically significant.

Results

Twenty-five patients could be included at last visit before PDT and first visit after PDT. At final visit, 24 patients could be included, since 1 patients was lost to follow-up. Mean CRT was 112 μm at last visit before PDT, 118 μm at first visit after PDT (p = 0.030), and 127 μm at final visit (p<0.001compared to baseline). Mean SBT was 74 μm, 26 μm (p<0.001 compared to baseline), and 21 μm (p<0.001 compared to baseline), respectively. Mean BCVA in Early Treatment of Diabetic Retinopathy Study letters was 79 at baseline, 85 at first visit after PDT (p = 0.005 compared to baseline), and 87 at final visit (p = 0.001 compared to baseline). BCVA had an estimated correlation of β = 0.103 (p = 0.114) with CRT, β = -0.051 (p = 0.014) with SBT, β = 0.615 (p = 0.600) with the integrity of the ELM, and β = 4.917 with the integrity of the EZ (p = 0.001).

Conclusions

In non-resolving CSC patients treated with half-dose PDT, the CRT increased at final visit in comparison to the last visit before PDT. The continuity of the EZ on SD-OCT was positively correlated with BCVA. We propose that the distance between ILM and EZ should be used as a reliable CRT measurement in non-resolving CSC patients treated with half-dose PDT.

Visual Acuity Change Over 24 Months and Its Association With Foveal Phenotype and Genotype in Individuals With Stargardt Disease: ProgStar Study Report No. 10

Importance

Limited data from prospective studies are available to understand the natural history of ABCA4-related Stargardt disease (STGD1). Such data are important for determining appropriate outcome measures for future STGD1 trials.

Objective

To estimate the rate of loss of best-corrected visual acuity (BCVA) during 2 years and to estimate the associations of BCVA loss with foveal phenotype and genotype in patients with STGD1.

Design, Setting, and Participants

This multicenter prospective cohort study included 259 participants (489 study eyes) with molecularly confirmed STGD1 who were 6 years or older. The participants were enrolled at 9 centers in the United States and Europe and were followed up every 6 months for 2 years.

Exposures

Baseline BCVA and presence and type of foveal lesion (determined via fundus autofluorescence images) and genotype (classified into 4 groups based on the number and pathogenicity of ABCA4 mutations).

Main Outcomes and Measures

Rate of BCVA change per year.

Results

The mean (SD) age was 33 (15) years. Of 259 the participants, 141 (54%) were female, and 222 (85%) were white. The overall rate of BCVA loss was 0.55 (95% CI, 0.20-0.90) letters per year during the 2 years. Eyes with baseline BCVA worse than 20/200 showed an improvement of 0.65 (95% CI, 0.1-1.2) letters per year. At baseline, the mean BCVA for eyes without foveal lesion was 20/32, and their BCVA change rate over time was 0.1 (95% CI, -1.2 to 1.35) letters per year (P = .89). Eyes with a foveal lesion but having BCVA of 20/70 or better at baseline lost BCVA at a rate of 3 (95% CI, 1.5-4.4) letters per year (P < .001). Genotype was neither associated with baseline BCVA nor with the rate of BCVA change during the follow-up.

Conclusions and Relevance

A clinically small BCVA loss was observed during 2 years, and the change rate varied depending on baseline BCVA. Eyes without lesion in the fovea had better BCVA at baseline and showed minimal change of BCVA throughout 2 years. Eyes with no or modest acuity impairment but with a foveal lesion at baseline had the fastest loss rate. For trials of STGD1 with 2 years of duration, it may be difficult to show efficacy using BCVA as an end point owing to its slow rate of change over this time.

Antarctica eye study: a prospective study of the effects of overwintering on ocular parameters and visual function

BACKGROUND

In 2013 five polar explorers attempted to complete the first Trans-Antarctic Winter Traverse (TAWT). This study presents the ophthalmological findings for this group, who overwintered in Antarctica as part of the White Mars Human Science Protocol. Antarctic crews are exposed to extreme cold, chronic hypoxia and altered day-night cycles. Previous studies of Antarctic explorers have focused on the prolonged effect of ultraviolet radiation including the development of ultraviolet keratitis and accelerated cataract formation. This is the first study of its kind to investigate the effect of overwintering in Antarctica on the human eye.

METHODS

Pre and post-expedition clinical observations were made including visual acuity, contrast sensitivity, colour vision, auto-refraction, subjective refraction, retinal examination, retinal autofluoresence and retinal thickness, which were graded for comparison. During the expedition additional observations were made on a monthly basis including LogMAR visual acuity, autorefraction and intraocular pressure.

RESULTS

No significant differences between pre and post-expedition observations were found, including visual acuity, contrast sensitivity, colour vision, refraction, visual fields, intraocular pressure and retinal examination. There was a small but statistically significant decrease in retinal thickness across all regions of the retina, except for the macular and fovea, in all explorers. Intra-expedition observations remained within normal limits.

CONCLUSION

Reassuringly, the human eye remains largely unchanged by exposure to the extreme conditions encountered during the Antarctic winter, however, further research is needed to investigate changes in retinal thickness. This may have implications for scientists who spend prolonged periods of time in the polar regions, as well as those who have prolonged exposure to the extreme cold or chronic hypoxia in other settings.

Optical coherence tomography automated layer segmentation of macula after retinal detachment repair

Purpose

To investigate the thickness of retinal layers and association with final visual acuity using spectral-domain optical coherence tomography (SD-OCT) in macular area of macula-off rhegmatogenous retinal detachment (RRD) patients after a successful macular re-attachment.

Methods

In retrospective study, a total 24 eyes with macula-off RRD were enrolled. All patients underwent vitrectomy to repair RRD. Outer plexiform layer (OPL), outer nuclear layer (ONL), photoreceptor layer (PR), retinal pigment epithelium (RPE) thicknesses were measured by the Spectralis (Heidelberg Engineering, Heidelberg, Germany) SD-OCT with automated segmentation software. The relationship between the thicknesses of each retinal layer and postoperative logarithm of the minimum angle of resolution scale (LogMAR) visual acuity was analyzed.

Results

OPL and RPE thicknesses were not significantly different between the retinal detachment eyes and fellow eyes (P = 0.839, 0.999, respectively). The ONL and photoreceptor thickness were significantly thinner in the retinal detachment eyes (P <0.001 and 0.001, respectively). In the univariate regression analysis, preoperative best corrected visual acuity (BCVA), ONL thickness and photoreceptor thickness showed association with the postoperative BCVA (P = 0.003, <0.001 and 0.024, respectively). In final multiple linear regression model, ONL thickness was the only variable significantly associated with postoperative BCVA (P = 0.044).

Conclusions

Segmented ONL and photoreceptor thickness of retinal detachment eyes were significantly thinner than fellow eyes. Segmental analysis of the retinal layer in macular region may provide valuable information for evaluation RRD. And ONL thickness can be used as a potential biomarker to predict visual outcome after RRD repair.

Optical Coherence Tomography in Children With Microtropia

PURPOSE

To assess whether optical coherence tomography (OCT) could be useful for detecting and documenting fixation in patients with microtropia.

METHODS

Retinal fixation observation was performed using spectral-domain OCT on amblyopic children with microtropia. The position between the retinal fixation point and the anatomical fovea was measured, in microns, using the system software tools. Only patients with a high level of cooperation, OCT scan quality signal of 7 or better, and visual acuity of 0.70 logarithm of the minimum angle of resolution (logMAR) or worse in the amblyopic eye were included.

RESULTS

A total of 25 patients were included: 15 with microtropia (study group) and 10 without tropia and with foveal fixation and stereopsis (control group). In the study group, microtropia was previously diagnosed in 67% of cases through the cover test, and was predominantly in the left eye (73%). The average visual acuity of the sound eye was 0.03 decimal and 0.18 logMAR in the amblyopic eye. The microtropia was 3.73 ± 3.34 prism diopters and eccentric fixation (387 ± 199 µm) with OCT was observed in all cases except one. Eccentricity was predominantly in the superonasal quadrant (57%). Both eyes in the control group and the contralateral eyes of the study group showed foveal fixation.

CONCLUSIONS

OCT can play an important role in the diagnosis and measurement of eccentric fixation in eyes with microtropia, providing high sensitivity. [J Pediatr Ophthalmol Strabismus. 2018;55(3):171-177.].