Clinical and Multimodal Imaging Clues in Differentiating Between Tuberculomas and Sarcoid Choroidal Granulomas

Quantitative and comparative analysis of thermography parameters in posterior scleritis, choroiditis, and controls

PURPOSE

To compare various ocular thermography parameters in posterior scleritis (PS), choroiditis (choroidal granuloma [CG], Vogt-Koyanagi-Harada [VKH] syndrome), central serous chorioretinopathy (CSCR), and healthy controls.

METHODS

This retrospective, observational, comparative study evaluated cases undergoing ocular thermography between April 2017 and October 2023. The study groups included cases of PS, CG, and VKH, while the control group comprised CSCR cases and healthy individuals. Various thermography parameters were assessed, which were as follows: Ocular surface temperature (OST), central corneal temperature (CCT), average scleral temperature (ST), nasal scleral temperature (nST), temperature difference between both the eyes (∆t), and difference between scleral and corneal temperatures (ST - CCT, nST - CCT).

RESULTS

It was found that ∆t was significantly higher in the PS group compared to the CG ( P = 0.005), CSCR ( P = 0.0001), and control groups (dilated control: P =0.006, undilated control: P = 0.0001). ST - CCT and nST - CCT were significantly higher in the undilated control and CSCR groups and significantly lower in the PS group. ST - CCT and nST - CCT showed less difference in the affected eyes compared to contralateral healthy eyes of PS and CG cases. OST, CCT, ST, and nST displayed statistically insignificant differences across all groups.

CONCLUSION

It is advisable to focus on temperature differences between the affected and healthy eyes, or the difference between the central corneal and scleral temperature of the affected eye, utilizing parameters such as ∆t, ST - CCT, and nST - CCT. These composite parameters offer a more effective approach than individual measurements like OST, CCT, ST, and nST. Thermography can serve as a screening tool to suspect and differentiate PS.

Choroidal and Retinal Thicknesses in Healthy Eyes Measured with Ultra-Wide-Field Optical Coherence Tomography

Ultra-wide-field optical coherence tomography (UWF-OCT) has been recently introduced into clinical ophthalmological practice. To date, there are few data on the reference values of the retinal thickness (RT) and choroidal thickness (CT) measured with this technique. This study aimed to analyze the variance in RT and CT in the healthy eyes of white Caucasian patients with UWF-OCT tests performed with the largest available scan size of 23 × 20 mm. The data were analyzed with reference to the patients' age and gender and the axial length of the eyeball. The results of UWF-OCT scanning enabled us to visualize the shape of the retina and choroid in a large portion of the eyeball. Both anatomical entities became significantly thinner at the periphery. The peripheral CT was greater in the upper and temporal sectors; the RT was higher in the nasal compared to the temporal sectors. Both the choroid and retina showed a reduced thickness with age; however, the CT and RT did not show a statistically significant correlation with the axial length after adjusting for age and gender. Age-related variations in thickness were especially prominent in the choroid. The CT in UWF-OCT testing was significantly greater in females, while the RT was greater in males. UWF-OCT testing provides additional information on the anatomical structure of the retina and choroid compared to standard-field OCT.

Insights into the diagnosis and management of sarcoid uveitis: A review

Sarcoidosis is a leading cause of non-infectious uveitis that commonly affects middle-aged individuals and has a female preponderance. The disease demonstrates age, sex and ethnic differences in clinical manifestations. A diagnosis of sarcoidosis is made based on a compatible clinical presentation, supporting investigations and histologic evidence of non-caseating granulomas, although biopsy is not always possible. Multimodal imaging with widefield fundus photography, optical coherence tomography and angiography can help in the diagnosis of sarcoid uveitis and in the monitoring of treatment response. Corticosteroid remains the mainstay of treatment; chronic inflammation requires steroid-sparing immunosuppression. Features on multimodal imaging such as vascular leakage may provide prognostic indicators of outcome. Female gender, prolonged and severe uveitis, and posterior involving uveitis are associated with poorer visual outcomes.

Wide Field Optical Coherence Tomography and Optical Coherence Tomography Angiography in Uveitis

BACKGROUND

We review the current literature on the use of wide-field optical coherence tomography (OCT) and wide-field optical coherence tomography angiography (OCTA) in different uveitic phenotypes as well as various sequelae of uveitis and discuss the limitations of this evolving technology.

MAIN BODY

Current consensus guidelines on nomenclature in wide-field OCT and OCTA are described. The specific utility of wide-field OCT and OCTA in assessment of the retina and choroid using different en-face and cross-sectional slabs in various inflammatory diseases is reviewed. Furthermore, we discuss widefield OCT and OCTA in assessment of retinal ischemia and its limitations in assessing retinal vascular leakage.

CONCLUSION

Wide-field OCT and OCTA deliver more sensitive measures of inflammation. With continued advancement in both hardware technology and software processing, these modalities will allow for more accurate assessment of uveitis, better understanding of disease mechanisms, and precise monitoring of treatment response.

SARCOID GRANULOMA OF THE CHOROID AND CILIARY BODY IN 50 CASES

PURPOSE

To describe the clinical and imaging features of sarcoid granuloma of the choroid and ciliary body.

METHODS

Retrospective case series of patients with choroid and/or ciliary body sarcoid granuloma managed at the Ocular Oncology Service at Wills Eye Hospital.

RESULTS

The mean patient age at diagnosis was 51.0 years (54.1, 11.0-83.8 years). The mean logMAR visual acuity at presentation was 0.3 (0.2, 0.0-3.0) [Snellen equivalent 20/40 (20/30, HM-20/20)]. Clinical features included mean basal dimension of 5.2 mm (4.0, 0.3-20.0 mm) and thickness of 1.7 mm (1.8, 0.0-3.6 mm), yellow color (41, 82%), multifocality (18, 36%), and irregular vermiform margins (46, 92%). Related clinical features included inflammation of the anterior chamber (1, 2%), vitreous (5, 10%), and retina (5, 10%). Imaging features by optical coherence tomography of the choroid lesions (n = 49) demonstrated clear subretinal fluid (6, 12%), "dirty" subretinal fluid (14, 28%), cystoid macular edema (1, 2%), overlying retinal edema (6, 12%), and localized vitreous cellularity (1, 2%). Management included sub-Tenon's triamcinolone (11, 22%), intravitreal triamcinolone (3, 6%), systemic corticosteroids (19, 38%), or observation (26, 52%). Systemic sarcoidosis was present before ocular diagnosis (13, 26%), detected during ophthalmic care (4, 8%), detected after ocular diagnosis (3, 6%), or not found (30, 60%) over a mean follow-up of 13.7 months (6.9, 0.0-138.2).

CONCLUSION

Sarcoid granuloma of the choroid and/or ciliary body can manifest without anterior segment or vitreous/retina inflammation in many cases and reveal underlying systemic sarcoidosis in 40% of cases. A distinguishing feature of choroidal sarcoid granuloma was its vermiform margin.

Outcome Measures for Disease Monitoring in Intraocular Inflammatory and Infectious Diseases (OCTOMERIA): Understanding the Choroid in Uveitis with Optical Coherence Tomography (OCT)

PURPOSE

To compare imaging modalities for the choroid of the eye, and evaluate various choroidal changes in uveitides entities.

METHODS

A comprehensive systematic literature review was conducted looking at current imaging modalities available to assess choroid architecture and commonly used parameters available to qualify and quantify choroidal changes, before looking at specific uveitides entities with choroidal involvement which have been broadly separated into non-infectious and infectious in etiology.

RESULTS

We describe the various modalities currently available to evaluate the choroid of the eye such as Ultrasound B Scan, ICGA, and OCT. Choroidal changes in various ocular and systemic diseases such as Behcet's Disease, Sarcoidosis, Syphillis, Tuberculosis, and many more have been reported and published.

CONCLUSION

Multiple choroidal tomographic and angiotomographic findings have been demonstrated for evaluation in uveitis. These findings can manifest in multiple ocular and systemic diseases, and can be illustrated using the various imaging modalities at present. Future advancements in choroidal imaging would help to adapt these findings into parameters for clinical practice to properly evaluate these ocular and systemic diseases.

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.

Subretinal peripapillary biopsy-proven sarcoidosis: a case report

BACKGROUND

To report a case of a subretinal, unilateral, peripapillary granuloma that was diagnosed as sarcoidosis by a 27-gauge pars plana vitrectomy subretinal biopsy. Sarcoidosis is a chronic idiopathic granulomatous inflammatory disease, that has ocular involvement in 10-80% of patients. It is often mistaken for many other primary ocular diseases because the condition can involve any structure in or around the eye. Previous case reports of peripapillary sarcoidosis have either been limited to the choroid or presented with additional ocular and systemic signs, hence have not required an intraocular biopsy.

CASE PRESENTATION

A 54-year-old Filipino male presented with a 6-month history of painless blurred vision in his right eye. Fundus examination revealed a large white peripapillary lesion. Enhanced-depth imaging optical coherence tomography confirmed the subretinal location of the mass. Indocyanine green angiography demonstrated absolute hypofluorescent blockage with satellite lesions. A whole-body positron emission tomography scan demonstrated widespread lymphadenopathy, but investigations including an inguinal lymph node biopsy were inconclusive. Following growth of the peripapillary lesion and worsening vision, a 27-gauge pars plana vitrectomy subretinal biopsy was performed which confirmed sarcoidosis. He was treated with oral corticosteroids and transitioned to long term immunotherapy with methotrexate.

CONCLUSIONS

Sarcoidosis can present in the subretinal space, around the optic nerve without other ocular findings.

Imaging-based Assessment of Choriocapillaris: A Comprehensive Review

PURPOSE

Over the past two decades, advancements in imaging modalities have significantly evolved the diagnosis and management of retinal diseases. Through these novel platforms, we have developed a deeper understanding of the anatomy of the choroidal vasculature and the choriocapillaris. The recently developed tools such as optical coherence tomography (OCT) and OCT angiography (OCTA) have helped elucidate the pathological mechanisms of several posterior segment diseases. In this review, we have explained the anatomy of the choriocapillaris and its close relationship to the outer retina and retinal pigment epithelium.

METHODS

A comprehensive search of medical literature was performed through the Medline/PubMed database using search terms: choriocapillaris, choroid, quantification, biomarkers, diabetic retinopathy, age-related macular degeneration, choroidal blood flow, mean blur rate, flow deficit, optical coherence tomography, optical coherence tomography angiography, fluorescein angiography, indocyanine green angiography, OCTA, Doppler imaging, uveitis, choroiditis, white dot syndrome, tubercular serpiginous-like choroiditis, choroidal granuloma, pachychoroid, toxoplasmosis, central serous chorioretinopathy, multifocal choroiditis, choroidal neovascularization, choroidal thickness, choroidal vascularity index, choroidal vascular density, and choroidal blood supply. The search terms were used either independently or combined with choriocapillaris/choroid.

RESULTS

The imaging techniques which are used to qualitatively and quantitatively analyze choriocapillaris are described. The pathological alterations in the choriocapillaris in an array of conditions such as diabetes mellitus, age-related macular degeneration, pachychoroid spectrum of diseases, and inflammatory disorders have been comprehensively reviewed. The future directions in the study of choriocapillaris have also been discussed.

CONCLUSION

The development of imaging tools such as OCT and OCTA has dramatically improved the assessment of choriocapillaris in health and disease. The choriocapillaris can be delineated from the stromal choroid using the OCT and quantified by manual or automated methods. However, these techniques have inherent limitations due to the lack of an anatomical distinction between the choriocapillaris and the stromal choroid, which can be overcome with the use of predefined segmentation slabs on OCT and OCTA. These segmentation slabs help in standardizing the choriocapillaris imaging and obtain repeatable measurements in various conditions such as diabetic retinopathy, age-related macular degeneration, pachychoroid spectrum, and ocular inflammations. Additionally, Doppler imaging has also been effectively used to evaluate the choroidal blood flow and quantifying the choriocapillaris and establishing its role in the pathogenesis of various retinochoroidal diseases. As tremendous technological advancements such as wide-field and ultra-wide field imaging take place, there will be a significant improvement in the ease and accuracy of quantifying the choriocapillaris.

The Role of Optical Coherence Tomography and Optical Coherence Tomography Angiography in the Differential Diagnosis of Posterior Uveitis

PURPOSE

Modalities such as optical coherence tomography (OCT) and OCT angiography (OCTA) have improved the diagnostic utility of fundus imaging in management of uveitis. The purpose of this study is to review role of OCT and OCTA in differential diagnosis of certain posterior uveitic entities.

METHODS

Narrative review.

RESULTS

In this review, we have comprehensively summarized the utility of OCT and OCTA in helping the clinician diagnose common but challenging inflammatory conditions including ocular toxoplasmosis, viral retinitis, and vitreoretinal lymphoma, among others. OCT and OCTA can also be used to assess the choriocapillaris involvement in conditions such as multiple evanescent white dot syndrome, and choroidal granulomas in tubercular and sarcoid uveitis.

CONCLUSIONS

Fundus imaging with OCT and OCTA has assumed a significant role in establishing the diagnosis in uveitis apart from microbiological and other laboratory analysis. Advantages such as rapidity and non-invasiveness make these imaging modalities very useful and convenient.

Optical Coherence Tomography Findings in Infectious Posterior Uveitis

PURPOSE

To describe and illustrate the main optical coherence tomography (OCT) findings of infectious uveitis.

METHODS

Narrative review.

RESULTS

Posterior segment OCT in patients with infectious uveitis reveals posterior hyaloid face precipitates, superficial retinal precipitates and infiltrates, foveolitis, retinitis, neuro-retinitis, choroidal granulomas, and choroiditis as main imaging biomarkers. Some of these features are specific to the underlying causing etiology and may support the diagnosis and the initiation of treatment. Some OCT features disappear completely with resolution; some others are associated with irreversible retinal damage.

CONCLUSIONS

OCT identifies different features of infectious uveitis into the vitreous, the retina, and the choroid. OCT characteristics, combined with other multimodal imaging features, are helpful in the differential diagnosis of infectious uveitis, the early detection of complications, and the assessment of the response to therapy.