Fundus autofluorescence imaging of the white dot syndromes

Fundus Autofluorescence in Posterior and Panuveitis-An Under-Estimated Imaging Technique: A Review and Case Series

Fundus autofluorescence (FAF) is a prompt and non-invasive imaging modality helpful in detecting pathological abnormalities within the retina and the choroid. This narrative review and case series provides an overview on the current application of FAF in posterior and panuveitis. The literature was reviewed for articles on lesion characteristics on FAF of specific posterior and panuveitis entities as well as benefits and limitations of FAF for diagnosing and monitoring disease. FAF characteristics are described for non-infectious and infectious uveitis forms as well as masquerade syndromes. Dependent on the uveitis entity, FAF is of diagnostic value in detecting disease and following the clinical course. Currently available FAF modalities which differ in excitation wavelengths can provide different pathological insights depending on disease entity and activity. Further studies on the comparison of FAF modalities and their individual value for uveitis diagnosis and monitoring are warranted.

White Dot Syndromes: Report of Three Cases

Introduction

The term white dot syndromes has been used to refer conditions that differ in their morphology and prognosis. We report three cases of different pathologies encompassed within the white dot syndromes.

Case Presentations

Case 1: A 26-year-old female presented with scotoma in her right eye. Fundus examination revealed multiple white dots that demonstrated early hyperfluorescence with late staining on FA. OCT showed discontinuities in inner segment-outer segment junction associated with columnar-shaped outer retinal hyperreflective bands. AF revealed multiple hyperautofluorescent dots around the posterior pole, compatible with multiple evanescent white dot syndrome. The symptoms improved without treatment. Case 2: A 16-year-old male presented with retinal lesions compatible with punctate inner choroidopathy in his right eye. OCT showed lesion in the outer retinal layer. FAF revealed parafoveal hypoautofluorescent dots with early hyperfluorescence and late staining on FFA. After oral corticotherapy, they progress to atrophic scars. Case 3: A 65-year-old male presented with scotoma and decreased vision in his right eye. OCT showed hyperreflectivity in the outer layer that progresses to a large atrophic plaque with foveal affectation. FAF demonstrated hyperautofluorescent placoid lesion occupying macular area, compatible with acute posterior multifocal placoid pigment epitheliopathy. Retinal lesions improved with systemic corticosteroids.

Conclusion

The FAF pattern helps know the distribution of the lesions. It represents a noninvasive method that has been shown to be useful in the diagnosis and monitoring of white dot syndromes.

Fundus autofluorescence in uveitis: from pathogenesis to imaging interpretation

PURPOSE

This review aims to summarize the current fundus autofluorescence (FAF) ailment for diagnosis and follow-up of uveitis.

METHODS

A thorough literature search was performed in the PubMed database.

RESULTS

FAF maps the retinal pigment epithelium's (RPE) health. Therefore, several posterior infectious and non. This fast, easy-to-perform, noninvasive technique can detect and manage infectious uveitis.

CONCLUSIONS

FAF serves to understand pathophysiologic mechanisms of uveitis and is a valuable prognostic indicator of themselves.

Stepwise approach for fundus imaging in the diagnosis and management of posterior uveitis

An array of retinochoroid imaging modalities aid in comprehensive evaluation of the immunopathological changes in the retina and choroid, forming the core component for the diagnosis and management of inflammatory disorders such as uveitis. The recent technological breakthroughs have led to the development of imaging platforms that can evaluate the layers of retina and choroid and the structural and functional alteration in these tissues. Ophthalmologists heavily rely on imaging modalities such as dye-based angiographies (fluorescein angiography and indocyanine green angiography), optical coherence tomography, fundus autofluorescence, as well as dye-less angiography such as optical coherence tomography angiograph,y for establishing a precise diagnosis and understanding the pathophysiology of the diseases. Furthermore, these tools are now being deployed with a 'multimodal' approach for swift and accurate diagnosis. In this comprehensive review, we outline the imaging platforms used for evaluation of posterior uveitis and discuss the organized, algorithmic approach for the assessment of the disorders. Additionally, we provide an insight into disease-specific characteristic pathological changes and the established strategies to rule out disorders with overlapping features on imaging.

The Conundrum of Clinical Trials for the Uveitides: Appropriate Outcome Measures for One Treatment Used in Several Diseases

The uveitides consist of >30 diseases characterized by intraocular inflammation. Noninfectious intermediate, posterior, and panuveitides typically are treated with oral corticosteroids and immunosuppression, with a similar treatment approach for most diseases. Because these uveitides collectively are considered a rare disease, single-disease trials are difficult to impractical to recruit for, and most trials have included several different diseases for a given protocol treatment. However, measures of uveitis activity are disease specific, resulting in challenges for trial outcome measures. Several trials of investigational immunosuppressive drugs or biologic drugs have not demonstrated efficacy, but design problems with the outcome measures have limited the ability to interpret the results. Successful trials have included diseases for which a single uveitis activity measure suffices or a composite measure of uveitis activity is used. One potential solution to this problem is the use of a single, clinically relevant outcome, successful corticosteroid sparing, defined as inactive uveitis with a prednisone dose ≤7.5 mg/day coupled with disease-specific guidelines for determining inactive disease. The clinical relevance of this outcome is that active uveitis is associated with increased risks of visual impairment and blindness, and that prednisone doses ≤7.5 mg/day have a minimal risk of corticosteroid side effects. The consequence of this approach is that trial visits require a core set of measures for all participants and a disease-specific set of measures, both clinical and imaging, to assess uveitis activity. This approach is being used in the Adalimumab Versus Conventional Immunosuppression (ADVISE) Trial.

Uveitis Patterns and Severity: An Epidemiologic Study from a Tertiary Care Private Referral Center in Buenos Aires, Argentina

PURPOSE

To report uveitis' spectrum in a private practice cohort in the city of Buenos Aires, Argentina.

METHODS

Retrospective review at Instituto de la Visión (November 2011-October 2015). Standard demographics, ethnicity and Native American aboriginal ancestry were recorded.

RESULTS

Among 212 patients, median age 45 (6-97), 10% pediatric, 35% bilateral, 72% non-idiopathic, 36% infectious. Anterior uveitis presented in 50%, followed by posterior (32%), intermediate (9%) and panuveitis (8%). Frequent visits (≥ 6 per year) needed by 29%: posterior, non-idiopathic disease with 79% systemic immunosuppression requirement was their main presentation. Native American aboriginal ancestry was reported by 22.64% of the whole cohort and 37% of frequent visits' subgroup.

CONCLUSIONS

Unilateral, non-idiopathic, non-infectious anterior uveitis was the most frequent presentation, in agreement with reports coming from western developed cities. The multi-racial Argentinian population with specific Native American aboriginal ancestry might contribute to certain forms of posterior uveitis and their response to treatment.

Acute-onset Vogt-Koyanagi-Harada-like uveitis following Covid-19 inactivated virus vaccination

Purpose

We report a case of a 19-year-old male who presented with bilateral Vogt-Koyanagi-Harada (VKH)-like panuveitis following an injection of an inactivated Covid-19 vaccine.

Observations

A 19-year-old male was referred to our clinic with a 2-week history of blurred vision on both eyes and headaches, 12 hours following the administration of the first dose of an inactivated Covid-19 virus vaccine (Sinovac). He denied any past ocular or medical history. Clinical examination and multimodal imaging tests identified serous retinal detachment and choroidal thickening posteriorly and deep yellow foci in the far peripheral retina. Aqueous humor analysis ruled out viral and bacterial infection including Covid-19, but demonstrated an elevated interleukin-6 level. A workup ruled out systemic infection or autoimmune disease. Although the patient received a single positive T-SPOT result, no other clinical evidence supported active tuberculosis infection. Non-infectious panuveitis was diagnosed and treated with periocular steroids that quickly resolved the serous retinal detachment.

Conclusions and Importance

This is the first report of VKH-like uveitis following an inactivated Covid-19 vaccine, with aqueous humor analysis ruling out viral or bacterial infection and demonstrating an elevated interleukin-6 level. Though rare, VKH-like uveitis may be associated with administration of an inactivated Covid-19 vaccine.

Multimodal imaging supporting the pathophysiology of white dot syndromes

White dot syndromes (WDS) represent a heterogeneous group of inflammatory diseases, primarily affecting the outer retina, choriocapillaris and choroid. Recent advances in the field of ocular imaging and development of new technologies, including optical coherence tomography angiography (OCT-A), have allowed a better characterization of the morphology of these conditions. This review will analyse the WDS from an imaging-based perspective, providing a better understanding of the pathophysiology underlying these disorders.

HYPERAUTOFLUORESCENT SPOTS IN ACUTE OCULAR TOXOPLASMOSIS: A New Indicator of Outer Retinal Inflammation

PURPOSE

The aim of this study was to describe the fundus autofluorescence patterns in acute ocular toxoplasmosis (OT) and to correlate these findings with other imaging.

METHODS

A retrospective multicenter case series of 27 eyes from 27 patients with acute onset of posterior OT was conducted. Multimodal imaging including fundus autofluorescence was performed at diagnosis and during follow-up.

RESULTS

All OT lesions were hypoautofluorescent on fundus autofluorescence imaging. Fourteen patients (51.8%) also had hyperautofluorescent spots around the active foci that disappeared after retinal photobleaching. Although these spots were not seen on early phase of indocyanine green angiography, they become hypofluorescent in the late phase without choriocapillaris flow impairment on optical coherence tomography angiography. On B-scan spectral domain optical coherence tomography, spots corresponded to outer retinal alterations in all cases. All hyperautofluorescent spots disappeared during follow-up as acute OT resolved. Younger patients and those with more posterior inflammatory symptoms (vasculitis and/or papillitis) were more frequent with the presence of hyperautofluorescent spots.

CONCLUSION

Ocular toxoplasmosis may trigger a transient outer retinal disruption in eyes with marked inflammatory symptoms of the younger patients.

Classification Criteria for Punctate Inner Choroiditis

PURPOSE

The purpose of this study was to determine classification criteria for punctate inner choroiditis (PIC).

DESIGN

Machine learning of cases with PIC and 8 other posterior uveitides.

METHODS

Cases of posterior uveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on diagnosis by using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used in the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the posterior uveitides. The resulting criteria were evaluated in the validation set.

RESULTS

A total of 1,068 cases of posterior uveitides, including 144 cases of PIC, were evaluated by machine learning. Key criteria for PIC included: 1) "punctate"-appearing choroidal spots <250 µm in diameter; 2) absent to minimal anterior chamber and vitreous inflammation; and 3) involvement of the posterior pole with or without mid-periphery. Overall accuracy for posterior uveitides was 93.9% in the training set and 98.0% (95% confidence interval: 94.3-99.3) in the validation set. The misclassification rates for PIC were 15% in the training set and 9% in the validation set.

CONCLUSIONS

The criteria for PIC had a reasonably low misclassification rate and appeared to perform sufficiently well for use in clinical and translational research.

Classification Criteria for Multifocal Choroiditis With Panuveitis

PURPOSE

To determine classification criteria for multifocal choroiditis with panuveitis (MFCPU).

DESIGN

Machine learning of cases with MFCPU and 8 other posterior uveitides.

METHODS

Cases of posterior uveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on diagnosis, using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used on the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the posterior uveitides. The resulting criteria were evaluated on the validation set.

RESULTS

One thousand sixty-eight cases of posterior uveitides, including 138 cases of MFCPU, were evaluated by machine learning. Key criteria for MFCPU included (1) multifocal choroiditis with the predominant lesions size >125 µm in diameter; (2) lesions outside the posterior pole (with or without posterior involvement); and either (3) punched-out atrophic chorioretinal scars or (4) more than minimal mild anterior chamber and/or vitreous inflammation. Overall accuracy for posterior uveitides was 93.9% in the training set and 98.0% (95% confidence interval 94.3, 99.3) in the validation set. The misclassification rates for MFCPU were 15% in the training set and 0% in the validation set.

CONCLUSIONS

The criteria for MFCPU had a reasonably low misclassification rate and seemed to perform sufficiently well for use in clinical and translational research.

Multimodal imaging in infectious and noninfectious intermediate, posterior and panuveitis

PURPOSE OF REVIEW

Given the heterogeneity of uveitis, markers of inflammation vary from patient to patient. Multimodal imaging has proven itself to be critical for accurate evaluation for disease activity and treatment response in uveitis.

RECENT FINDINGS

Ultra-widefield (UWF) fluorescein angiography and autofluorescence (AF) as well as optical coherence tomography angiography (OCTA) have provided insights into disease pathogenesis and monitoring not previously appreciated. In addition to structural retinal imaging, OCT can be used to assess the choroid, the posterior cortical vitreous and the retinal vasculature in eyes with uveitis.

SUMMARY

Multimodal ocular imaging in eyes with uveitis is critical for disease diagnosis and assessing response to treatment. UWF fluorescein angiography can detect retinal vasculitis even in the absence of overt vascular sheathing. UWF AF can help detect more chorioretinal lesions than clinically visible. OCT can be used to assess the posterior cortical vitreous, retina, large retinal vessels and choroid in uveitis. The use of multimodal imaging will likely be needed to determine clinical trial endpoints in studies evaluating therapeutics for uveitis.

An update on autoimmune retinopathy

Autoimmune retinopathy (AIR) refers to a group of rare autoimmune retinal degenerative diseases presumably caused by cross-reactivity of serum autoantibodies against retinal antigens. The pathogenesis of AIR remains largely presumptive and there are a significant number of antiretinal antibodies that have been detected in association with AIR. The diagnosis of AIR is largely based on the demonstration of antiretinal antibodies in the serum along with suggestive clinical features and ancillary investigations. A high index of suspicion along with early diagnosis and treatment may play a critical role to lower the risk of irreversible immunological damage to the retinal cells in these patients. A multi-disciplinary approach for complete management and evaluation is helpful in such conditions. Various therapeutic options have been described for the treatment of AIR, though there is no consensus on standard treatment protocol.

Propagation of structured light through tissue-mimicking phantoms

Optical interrogation of tissues is broadly considered in biomedical applications. Nevertheless, light scattering by tissue limits the resolution and accuracy achieved when investigating sub-surface tissue features. Light carrying optical angular momentum or complex polarization profiles, offers different propagation characteristics through scattering media compared to light with unstructured beam profiles. Here we discuss the behaviour of structured light scattered by tissue-mimicking phantoms. We study the spatial and the polarization profile of the scattered modes as a function of a range of optical parameters of the phantoms, with varying scattering and absorption coefficients and of different lengths. These results show the non-trivial trade-off between the advantages of structured light profiles and mode broadening, stimulating further investigations in this direction.

Comparison of wide-field swept source optical coherence tomography angiography and fundus autofluorescence in tubercular serpiginous-like choroiditis

Purpose:

To evaluate the potential clinical utility of wide-field swept source optical coherence tomography angiography (SS-OCTA) using a prototype device compared to a wide-field fundus autofluorescence (FAF) for analysis of the disease activity in eyes with tubercular serpiginous-like choroiditis (TBSLC).

Methods:

Using a prototype SS-OCTA device (PLEX Elite, Carl Zeiss Meditec, Dublin, CA), 17 eyes of 12 consecutive patients with TBSLC were imaged and multiple 12 mm × 12 mm OCTA scans were captured, which were montaged to create wide-field montage OCTA images scans. A wide- FAF (Eidon, CenterVue, Padova, Italy) was performed in the same sitting. Two masked graders independently analyzed OCTA and FAF images for the presence of choroidal lesions, recorded the number of lesions identifiable, and provided a subjective grading for the activity of individual lesion, which were then compared.

Results:

The total number of lesions identified on FAF were 282 (posterior pole lesions, n = 129 and peripheral lesions n = 153) and on wide-field SS-OCTA were 230 (posterior pole lesions, n = 108 and peripheral lesions n = 122). Active choroidal lesions were comparable on the two machines (n = 28 on FAF and n = 28 on SS-OCTA, respectively); whereas numerous healed lesions were identified on FAF (n = 219) as compared to SS-OCTA (n = 170). There was good correlation among the devices for healed lesions (Pearson correlation, r = 0.82) and active lesions (r = 0.88).

Conclusion:

There was good correlation between FAF and wide-field SS-OCTA for detection of disease activity in TBSLC; however, FAF depicted greater number of healed lesions compared to wide-field SS-OCTA.

Imaging in Tubercular Choroiditis: Current Concepts

PURPOSE

Ocular tuberculosis has protean clinical manifestations. Because of its varied clinical presentation, multimodal imaging is very important to characterize the disease activity, presence of inflammation, determining therapeutic response, and detection of complications.

METHODS

Narrative review.

RESULTS

In this review, various imaging modalities employed in the management of ocular tuberculosis including fluorescein angiography (FA), indocyanine green angiography (ICGA), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA) have been reviewed. Not only do these imaging tools complement each other in providing a comprehensive assessment of the pathology, they also help in gaining valuable insights regarding the evolution of the disease.

CONCLUSIONS

Fundus imaging plays a vital role in the diagnosis and management of patients with posterior uveitis due to tuberculosis. Fundus imaging may have a useful role in defining clinical endpoints for ocular tuberculosis in the future.

Fundus autofluorescence imaging

Fundus autofluorescence (FAF) imaging is an in vivo imaging method that allows for topographic mapping of naturally or pathologically occurring intrinsic fluorophores of the ocular fundus. The dominant sources are fluorophores accumulating as lipofuscin in lysosomal storage bodies in postmitotic retinal pigment epithelium cells as well as other fluorophores that may occur with disease in the outer retina and subretinal space. Photopigments of the photoreceptor outer segments as well as macular pigment and melanin at the fovea and parafovea may act as filters of the excitation light. FAF imaging has been shown to be useful with regard to understanding of pathophysiological mechanisms, diagnostics, phenotype-genotype correlation, identification of prognostic markers for disease progression, and novel outcome parameters to assess efficacy of interventional strategies in chorio-retinal diseases. More recently, the spectrum of FAF imaging has been expanded with increasing use of green in addition to blue FAF, introduction of spectrally-resolved FAF, near-infrared FAF, quantitative FAF imaging and fluorescence life time imaging (FLIO). This article gives an overview of basic principles, FAF findings in various retinal diseases and an update on recent developments.

Advances in imaging of uveitis

Advances in multimodal imaging have significantly contributed to the management of many uveitis diseases in recent years. The most significant developments include the use of optical coherence tomography to obtain a more accurate and reproducible assessment of ocular inflammation, the application of optical coherence tomography angiography in choroiditis and retinal vasculitis, new possibilities for studying vitritis with ultrawide field imaging, and the most recent applications of fundus autofluorescence in uveitis. In this review, we provide an overview of the most significant advances in multimodal imaging of uveitis achieved in recent years.

Optical coherence tomography angiography in uveitis

Before the introduction of optical coherence tomography angiography (OCTA) in the early 2000s, dye-based angiography was considered the “gold standard” for the diagnosis and monitoring of ocular inflammation. OCTA is a novel technique, which demonstrates capillary networks based on the amount of light returned from moving blood cells, providing further information on pathophysiological changes in uveitis.

The aim of this review is to describe the basic principles of OCTA and its application to ocular inflammatory disorders. It particularly emphasizes on its contribution not only in the diagnosis and management of the disease but also in the identification of possible complications, comparing it with fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA). Although the advent of OCTA has remarkably enhanced the assessment of uveitic entities, we highlight the need for further investigation in order to better understand its application to these conditions.

Macular edema associated with non-infectious uveitis: pathophysiology, etiology, prevalence, impact and management challenges

Macular edema (ME) is the most common sight-threatening complication in uveitis. The diagnostic and therapeutic management of the uveitic macular edema (UME) might be challenging due to the complex diagnostic workup and the difficulties physicians face to find the underlying cause, and due to its usually recurrent nature and the fact that it can be refractory to conventional treatment. Some of the mild cases can be treated with topical steroids, which can be combined with non-steroid anti-inflammatory drugs. However, immunomodulators such as methotrexate, tacrolimus, azathioprine, cyclosporine and mycophenolate mofetil together with anti-tumor necrosis factor-α (anti-TNF alpha) monoclonal antibodies such as adalimumab and infliximab, may be required to control the inflammation and the associated ME in refractory cases, or when an underlying disease is present. This review of the literature will focus mostly on the non-infectious UME.

Enigma of serpiginous choroiditis

Serpiginous choroiditis (SC) is an asymmetrically bilateral inflammation of the choroid that leads to loss of choriocapillaris atrophy or loss of overlying retinal pigment epithelium. Over the last few decades, SC has passed through a long evolution of nomenclature, etiologies and morphological variations. Initially diagnosed in patients with tuberculosis and syphilis, SC was predominantly considered as autoimmune process. With the advancement of molecular diagnosis, a new aspect of infectious subtypes of SC has emerged out. The terminologies such as serpiginous-like choroiditis (SLC) and multifocal serpiginoid choroiditis are now used to denote the subtypes of SC which are associated with infectious etiologies especially tuberculosis. In a country endemic for tuberculosis such as India, it is very important to differentiate between classic SC and SLC before initiating aggressive immunomodulatory therapy. Also, management of paradoxical worsening of the clinical condition with antitubercular treatment is another challenge in SLC and ophthalmologists should be aware of such situations. With advent of newer imaging modalities, monitoring the patient with choroiditis and identification of complications such as choroidal neovascular membrane have become much easier. This article aims to review the existing literature on SC with a special emphasis on management of SC and SLC.

Swept-Source OCT Angiography of Serpiginous Choroiditis

PURPOSE

To examine and quantify choriocapillaris lesions in active and quiescent serpiginous choroiditis (SC) using swept-source optical coherence tomography angiography (SS-OCTA) and en-face image analysis.

DESIGN

Prospective observational case series.

PARTICIPANTS

Patients with a clinical diagnosis of SC.

METHODS

A SS-OCTA prototype was used to image active and quiescent serpiginous lesions longitudinally before and after anti-inflammatory treatment. En-face slabs of choriocapillaris flow (CC-slab) or outer nuclear layer structure (ONL-slab) were generated from OCTA and OCT data, respectively.

MAIN OUTCOME MEASURES

Qualitative and quantitative analyses on lesion boundary and area using a semi-automated MATLAB algorithm. Lesions were also compared to traditional multimodal imaging.

RESULTS

Six eyes of three patients were imaged. Choroidal lesions were identified and analyzed in four of six eyes. Lesions with well-defined boundaries were identified in the CC-slab in areas of both active and inactive choroiditis. CC-slab lesion size and shape showed good correlation with lesions identified on indocyanine green angiography. CC-slab lesion area increased with disease activity and decreased with corticosteroid treatment. During active disease, the CC-slab lesion area was larger than both the ONL-slab and fundus autofluorescence lesion areas. Active CC-slab lesions not associated with corresponding abnormal autofluorescence resolved without clinical scarring after treatment. In inactive scars, the areas of retinal and choriocapillaris lesions were similar and did not change over time.

CONCLUSIONS

En-face analysis of SS-OCTA choriocapillaris flow voids provide a non-invasive method for the detection of lesions in patients with SC. The presence of lesions in the choriocapillaris in the absence of retinal pigment epithelium and outer retinal abnormalities supports the hypothesis that choriocapillaris is the primary site of pathology in SC, and may be a sensitive early sign of disease activity. We propose a simple grading system of SC lesions based on SS-OCTA and fundus autofluorescence findings. SS-OCTA is a promising non-invasive method for monitoring patients with SC.

Immunosuppression for the Uveitides

The uveitides are a collection of more than 30 diseases characterized by intraocular inflammation. Many cases of juvenile idiopathic arthritis-associated uveitis, many cases of intermediate uveitis, and most cases of posterior and panuveitides requiring treatment are treated with corticosteroids and immunosuppression. Disease-specific, time-updated modeling of clinical data for several uveitides suggests superior prevention of ocular complications and visual outcomes with immunosuppression. These studies also suggest that oral corticosteroids at doses low enough for safe long-term therapy (i.e., <7.5 mg/day) are ineffective, implying that immunosuppression should be part of the initial regimen. The Multicenter Uveitis Steroid Treatment (MUST) Trial and Follow-up Study was a randomized comparative effectiveness trial comparing systemic therapy with oral corticosteroids and immunosuppression with regional corticosteroid treatment. It demonstrated that, when used properly, oral corticosteroids and immunosuppression can be given safely for up to 7 years with no evident increased risk of systemic side effects compared with regional corticosteroid therapy, except for greater antibiotic use for infections. The Systemic Treatment for Eye Diseases (SITE) Cohort Study suggested long-term safety for this approach, when the immunosuppressive agents were antimetabolites or calcineurin inhibitors. Thus, oral corticosteroids and immunosuppression may be a preferred initial therapy for many noninfectious, intermediate, posterior, and panuveitides. Nonalkylating-agent immunosuppression has a low rate of sustained, drug-free remissions, <10%/year. Nonalkylating-agent immunosuppression for >3 years with control of the inflammation for >2 years is associated with a decreased risk of relapse after discontinuing immunosuppression. Alkylating agents can induce sustained drug-free remissions but likely increase the lifetime risk of cancer. Biologics, which target specific cytokines and pathways, hold promise for the future. Monoclonal antibodies directed against tumor necrosis factor (TNF)-α have been studied most often, and one, adalimumab, is U.S. Food and Drug Administration approved for the treatment of noninfectious, intermediate, posterior, and panuveitides.

Swept-source optical coherence tomography angiography in serpiginous choroiditis

Background/Aims

To analyse choroidal vascular density of affected and non-affected areas in active and inactive serpiginouschoroiditis (SC) by means of optical coherence tomography angiography (OCT-A).

Methods

In this cross-sectional and observational study, 22 eyes of 11 patients diagnosed with SC were included. All patients underwent blue-light fundus autofluorescence (spectralis Heidelberg retinalangiography+OCT) and swept-source OCT-A (AngioPlex Elite 9000 SS-OCT, Carl Zeiss Meditech) to analyse qualitative features and choroidal vessel density of areas considered affected, and the inner and the outer border of the lesions. Unaffected areas of otherwise healthy retina have also been studied.

Results

All inactive inflammatory lesions were characterised by atrophy of choriocapillaris with an impairment of its detectable flow and greater visibility of choroidal vessels. On the other hand, all active inflammatory lesions showed an area of complete absence of decorrelation signal. The pathological border was characterised by a statistically significant lower choroidal vessel density compared with both the outer border and the unaffected area (0.650±0.113 vs 0.698±0.112, (p<0.001)). Although not statistically significant, vessel density of the outer border of inactive lesions was lower than vessel density of unaffected areas (0.650±0.113 vs 0.698±0.112, p=0.441). Active inflammatory lesions showed an area of complete absence of decorrelation signal at the level of the choriocapillaris and whole choroid.

Conclusion

OCT-A represents a new imaging technique that provides useful information about the leading changes of choroidal vascular network in active and inactive lesions of SC.

Analysis of autofluorescence pattern in birdshot chorioretinopathy

PURPOSE

To characterize and correlate the different patterns of fundus autofluorescence (FAF) in patients with birdshot chorioretinopathy (BSCR), with functional and anatomical parameters.

METHODS

Twenty-one BSCR patients were prospectively studied in 2013 and 2014. Each patient underwent visual acuity (VA) and visual field (SITA standard 30.2) testing as well as fluorescein and indocyanine green angiography, spectral-domain optical coherence tomography (SD-OCT) B scan, enhanced depth imaging (EDI), and fundus autofluorescence (FAF) imaging. The disease was classified as active, chronic, or quiescent.

RESULTS

The patients' mean age was 60.3 ± 9.2 years and 60% were female. Disease duration was 5.7 ± 3.7 years. Autofluorescence imaging showed punctiform hyper-FAF spots in 23 out of the 29 eyes (79%), which was significantly associated with a greater visual field mean deviation (-7 ± 7 versus -3 ± 2 dB, p = 0.04). Hypo-FAF was defined as peripapillary (n = 25; 86.2%), macular (n = 10; 34.5%), lichenoid (n = 17; 58.6%), and/or diffuse (n = 13; 44.8%). Lichenoid hypo-FAF was significantly associated with worse VA (0.18 ± 0.24 vs. 0.05 ± 0.07 LogMAR, p = 0.04). Macular hypo-FAF was associated with a history of macular edema (62.5%; p = 0.06). Diffuse hypo-FAF was observed more frequently (p = 0.01) in chronic disease (66.7%) than in active (0%) or quiescent disease (27.3%).

CONCLUSIONS

Autofluorescence analysis in BRSC patients contributes to evaluating disease activity and could be useful to guide follow-up and treatment.

Multi-modal imaging and anatomic classification of the white dot syndromes

The white dot syndromes (WDS) are a diverse group of posterior uveitidies that share similar clinical findings but are unique from one another. Multimodal imaging has allowed us to better understand the morphology, the activity and age of lesions, and whether there is CNV associated with these different ocular pathologies. The “white dot syndromes” and their uveitic masqueraders can now be anatomically categorized based on lesion localization. The categories include local uveitic syndromes with choroidal pathology, systemic uveitic syndromes with choroidal pathology, and multifocal choroiditis with outer retinal/choriocapillaris pathology with uveitis and without uveitis. Neoplastic and infectious etiologies are also discussed given their ability to masquerade as WDS.

Fundus autofluorescence applications in retinal imaging

Fundus autofluorescence (FAF) is a relatively new imaging technique that can be used to study retinal diseases. It provides information on retinal metabolism and health. Several different pathologies can be detected. Peculiar AF alterations can help the clinician to monitor disease progression and to better understand its pathogenesis. In the present article, we review FAF principles and clinical applications.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY AND WIDEFIELD FUNDUS AUTOFLUORESCENCE IN PUNCTATE INNER CHOROIDOPATHY

PURPOSE

To present the optical coherence tomography angiography and widefield fundus autofluorescence (FAF) imaging findings of a 34-year-old woman with punctate inner choroidopathy and Type 2 neovascularization.

METHODS

In the retrospective case report, optical coherence tomography angiography imaging was performed with the RTVue XR Avanti (Optovue Inc, Fremont, CA) platform, which uses split spectrum amplitude decorrelation angiography to detect flow.

PATIENTS

Single patient with the diagnosis of punctate inner choroidopathy.

RESULTS

Spectral domain optical coherence tomography of the macula showed an inactive submacular scar but optical coherence tomography angiography demonstrated the fine detailed structure of a Type 2 neovascular membrane. Peripheral FAF abnormalities were detected despite the notable absence of these lesions with clinical examination and color fundus photography. These FAF findings were important in guiding clinical follow-up and response to therapy. The FAF lesions resolved with normal follow-up and treatment with oral naproxen.

DISCUSSION

This is the first case report of optical coherence tomography angiography imaging of choroidal neovascularization associated with punctate inner choroidopathy and the first report of widefield FAF abnormalities in punctate inner choroidopathy. Optical coherence tomography angiography may provide a more noninvasive and sensitive imaging system for the evaluation of choroidal neovascularization than traditional fluorescein angiography and may provide a direct gauge of response to therapy. Widefield FAF may improve detection of inflammatory activity of retinal disease and monitoring of disease activity.

Spatial agreement between Goldmann visual field defects and fundus autofluorescence in patients with birdshot chorioretinopathy

BACKGROUND

The purpose of this paper is to study the spatial agreement between visual field defects and ultra-wide field (UWF) fundus autofluorescence (FAF) in patients with birdshot chorioretinopathy (BSCR). The study is a retrospective, cross-sectional analysis of a university uveitis practice. Eight (8) eyes of five (5) patients with BSCR were included. Inclusion criteria were ability to fixate reliably. Goldmann visual fields (GVF) and UWF FAF were obtained, digitalized, and standardized. Analysis was performed by measuring areas of overlap of hypo-autofluorescent FAF lesions and GVF scotomas within the central 60°. Overlap was calculated as a percentage of the total area of FAF and GVF, respectively. Average areas were also calculated.

RESULTS

The mean age of the subjects was 51 ± 12.28 years (range 38-69 years). 14 ± 23 % of the total lesion area identified as hypo-autofluorescent on FAF overlapped with scotoma. 28 ± 41 % of the GVF scotomas overlapped with hypo-autofluorescent FAF lesions. Average area of FAF hypo-autofluorescence was much larger (15.19 disc areas) than GVF (3.45 disc areas).

CONCLUSIONS

There appear to be larger total areas of hypo-autofluorescence on FAF than scotoma evidenced by GVF and only a small amount of overlap. The finding suggests that GVF is relatively insensitive to anatomic loss, which can be detected using FAF. Further studies are required to assess whether this finding holds true for automated white-on-white perimetry. In addition, more selective psychophysical stimuli may have higher sensitivity in detecting early functional loss that accompanies anatomic damage.

Parafoveal cone abnormalities and recovery on adaptive optics in posterior uveitis

Purpose

To determine if adaptive optics (AO) flood illumination imaging can detect subclinical changes in 4 cases of posterior uveitis affecting the outer retina.

Observations

In all 4 cases, the affected eye showed altered areas in the photoreceptor mosaic on AO that corresponded to changes on other imaging modalities. Abnormalities not apparent on other imaging modalities were also noted. In one case of multifocal choroiditis with acute outer retinal atrophy, AO revealed decreased visualization of photoreceptors in the unaffected eye that was not noted on spectral domain-optical coherence tomography. In the patient with multiple evanescent white dot syndrome, focal photoreceptor abnormalities were more apparent on AO compared to other imaging modalities, and these areas normalized on AO during follow-up. Five weeks after initiation of high dose prednisone and azathioprine in a patient with serpiginous choroidopathy, AO images showed recovery in apparent parafoveal cone density.

Conclusions and importance

AO detects subclinical changes in the photoreceptor layer in posterior uveitis that can recover over time. AO may be useful in following outer retinal inflammatory conditions.

OCT and Fundus Autofluorescence Enhances Visualization of White Dot Syndromes

PURPOSE

White dot syndromes (WDS) are a group of inflammatory conditions characterized by white lesions at the retina and choroid level. Detection and monitoring of these syndromes are currently hampered by the subtlety of these lesions, making them difficult to image using traditional clinical techniques. New imaging modalities such as optical coherence tomography (OCT) and fundus autofluorescence (FAF) offer new opportunities for clinicians to noninvasively image WDS.

METHODS

A literature search was performed using a variety of WDS as the search terms. All articles from January 2004 to May 2014 were analyzed for clinical information regarding imaging of the diseases using OCT or FAF.

RESULTS

Current descriptions of OCT and FAF imaging of WDS are fragmented across case reports and small-scale studies. Assessing clinical presentation of WDS using OCT and FAF, however, is useful as the retinal layers affected in these syndromes are well characterized by these technologies. Furthermore, the new information revealed by OCT and FAF is helpful to elucidate the underlying mechanisms of these diseases in combination with known clinical and angiographic findings.

CONCLUSIONS

This review collates current literature and provides a succinct overview of the clinical presentation of WDS using OCT and FAF.

Fundus autofluorescence features in the inflammatory maculopathies

Purpose

To describe the fundus autofluorescence (FAF) features of the inflammatory maculopathies and develop a quantification method for FAF analysis.

Methods

This is a retrospective, consecutive case series of patients with inflammatory maculopathies from two tertiary centers. The clinical findings, demographics, and FAF imaging characteristics were reviewed. Foveal autofluorescence (AF) was analyzed. Median and standard deviation (SD) of foveal AF intensity were measured.

Results

Thirty eyes of 15 patients were evaluated with both qualitative and quantitative FAF analysis. In acute macular neuroretinopathy, the active phase showed foveal hypoautofluorescence, which became hypoautofluorescent with resolution. In acute posterior multifocal placoid pigment epitheliopathy, multiple lesions with hypoautofluorescent centers with hyperautofluorescent borders were observed in active disease and became hypoautofluorescent with disease convalescence. In multifocal choroiditis and punctate inner choroiditis, the active hyperautofluorescent lesions progressed to inactive, hypoautofluorescent scars. Active serpiginous choroiditis showed hyperautofluorescent borders adjacent to a helicoid-shaped, hypoautofluorescent scar. Active unilateral acute idiopathic maculopathy (UAIM) showed a complex pattern of hypo- and hyperautoflourescence in the macula. The median foveal AF was the greatest in acute macular neuroretinopathy and UAIM among the maculopathies, while the greatest SD of foveal AF intensity was observed in UAIM.

Conclusion

The active phase of the majority of inflammatory maculopathies was characterized by hyperautofluorescent lesions. Increased SD of foveal AF correlated with a mixture of hypo-and hyperautoflourescence. Median and SD may be useful metrics in foveal AF and quantifiable values that may be assessed over time as a disease process evolves. Improvements in quantification methods of FAF imaging may allow us to objectively evaluate posterior uveitis.

Fundus autofluorescence patterns in primary intraocular lymphoma

PURPOSE

To evaluate fundus autofluorescence (FAF) patterns in patients with primary intraocular (vitreoretinal) lymphoma.

METHODS

Records of all patients with primary intraocular lymphoma who underwent FAF imaging at the National Eye Institute were reviewed. Fundus autofluorescence patterns were evaluated with respect to clinical disease status and the findings on fluorescein angiography and spectral-domain optical coherence tomography.

RESULTS

There were 18 eyes (10 patients) with primary intraocular lymphoma that underwent FAF imaging. Abnormal autofluorescence in the form of granular hyperautofluorescence and hypoautofluorescence was seen in 11 eyes (61%), and blockage by mass lesion was seen in 2 eyes (11%). All eyes with granular pattern on FAF had active primary intraocular lymphoma at the time of imaging, but there were 5 eyes with unremarkable FAF, which were found to have active lymphoma. The most common pattern on fluorescein angiography was hypofluorescent round spots with a "leopard spot" appearance (43%). These hypofluorescent spots on fluorescein angiography correlated with hyperautofluorescent spots on FAF in 5 eyes (36%) (inversion of FAF). Nodular hyperreflective spots at the level of retinal pigment epithelium on optical coherence tomography were noted in 43% of eyes. The hyperautofluorescent spots on FAF correlated with nodular hyperreflective spots on optical coherence tomography in 6 eyes (43%).

CONCLUSION

Granularity on FAF was associated with active lymphoma in majority of the cases. An inversion of FAF (hyperautofluorescent spots on FAF corresponding to hypofluorescent spots on fluorescein angiography) was observed in less than half of the eyes.

Role of autofluorescence in inflammatory/infective diseases of the retina and choroid

Fundus autofluorescence (FAF) has recently emerged as a novel noninvasive imaging technique that uses the fluorescent properties of innate fluorophores accumulated in the retinal pigment epithelium (RPE) to assess the health and viability of the RPE/photoreceptor complex. Recent case reports suggest FAF as a promising tool for monitoring eyes with posterior uveitis helping to predict final visual outcome. In this paper we review the published literature on FAF in these disorders, specifically patterns in infectious and noninfectious uveitis, and illustrate some of these with short case histories.