Fundus autofluorescence in patients with pseudoxanthoma elasticum

The role of multimodal imaging in characterization and monitoring of choroidal neovascularization secondary to angioid streaks

BACKGROUND

To characterize and monitor choroidal neovascularisation (CNV) secondary to angioid streaks (AS) using multimodal imaging and to compare the results with conventional fluorescein angiography (FA).

METHODS

A total of 11 eyes with CNV secondary to AS were included in this retrospective study. Multimodal morphological and functional assessment, including spectral-domain optical coherence tomography (SD-OCT), spectral-domain optical coherence tomography angiography (SD-OCTA), and fundus autofluorescence (FAF), were used to assess for evidence of CNV activity and compared with conventional FA. Morphological features of CNV were analyzed and treatment was continuously monitored using SD-OCT and SD-OCTA.

RESULTS

Our results showed that SD-OCTA provided reliable results for the detection of secondary CNV in AS that were comparable to conventional FA. With SD-OCTA, a total of 13 CNVs were detected in 11 eyes and analyzed by means of outer retinal choriocapillaris depth (ORCC) segmentation and the corresponding B-scans. Twelve of the 13 CNVs were classified as active and therefore required treatment. For treatment monitoring during intravitreal therapy (IVT), SD-OCTA was found to be a valuable diagnostic tool over a mean follow-up of 76 weeks.

CONCLUSIONS

Our study demonstrates that SD-OCTA can be routinely used to identify ill-defined CNV without dye-based angiography, especially in cases of CNV secondary to AS, where Bruch's membrane (BM) defects limit the diagnostic value of FA. Our results showed that non-invasive multimodal imaging facilitates sufficient CNV monitoring and treatment guidance. Further studies are warranted to provide more evidence in this rare retinal disease.

Angioid Streaks Remain a Challenge in Diagnosis, Management, and Treatment

Aim: Angioid streaks (ASs) are a rare retinal condition and compromise visual acuity when complicated with choroidal neovascularization (CNV). They represent crack-like dehiscences at the level of the Bruch's membrane. This objective narrative review aims to provide an overview of pathophysiology, current treatment modalities, and future perspectives on this condition. Materials and Methods: A literature search was performed using "PubMed", "Web of Science", "Scopus", "ScienceDirect", "Google Scholar", "medRxiv", and "bioRxiv." Results: ASs may be idiopathic, but they are also associated with systemic conditions, such as pseudoxanthoma elasticum, hereditary hemoglobinopathies, or Paget's disease. Currently, the main treatment is the use of anti-vascular endothelial growth factors (anti-VEGF) to treat secondary CNV, which is the major complication observed in this condition. If CNV is detected and treated promptly, patients with ASs have a good chance of maintaining functional vision. Other treatment modalities have been tried but have shown limited benefit and, therefore, have not managed to be more widely accepted. Conclusion: In summary, although there is no definitive cure yet, the use of anti-VEGF treatment for secondary CNV has provided the opportunity to maintain functional vision in individuals with AS, provided that CNV is detected and treated early.

Subretinal autofluorescent deposits: A review and proposal for clinical classification

Subretinal autofluorescent deposits (SADs) may be found in the posterior pole, associated with very various conditions. These disorders usually present a typical pattern of autofluorescent lesions seen on short-wavelength fundus autofluorescence. We describe SADs according to their putative pathophysiological origin and also according to their clinical pattern, i.e., number, shape, and usual location. Five main putative pathophysiological origins of SADs were identified in disorders associated with an intrinsic impairment of phagocytosis and protein transportation, with excess of retinal pigment epithelium phagocytic capacity, with direct or indirect retinal pigment epithelium injury, and/or disorders associated with long-standing serous retinal detachment with mechanical separation between the retinal pigment epithelium and the photoreceptor outer segments. Clinically, however, they could be classified into eight subclasses of SADs, as observed on fundus autofluorescence as follows: single vitelliform macular lesion, multiple roundish or vitelliform lesions, multiple peripapillary lesions, flecked lesions, leopard-spot lesions, macular patterned lesions, patterned lesions located in the same area as the causal disorder, or nonpatterned lesions. Thus, if multimodal imaging may be required to diagnose the cause of SADs, the proposed classification based on noninvasive, widely available short-wavelength fundus autofluorescence could guide clinicians in making their diagnosis decision tree before considering the use of more invasive tools.

Incidence and Risk Factors of Visual Impairment in Patients with Angioid Streaks and Macular Neovascularization

OBJECTIVE

To estimate the incidence and risk factors of visual impairment and complications in eyes with macular neovascularization (MNV) because of angioid streaks (ASs).

DESIGN

Longitudinal multicenter retrospective cohort study.

SUBJECTS

Patients with AS-associated MNV treated with anti-VEGF agents and a follow-up of > 3 months.

METHODS

Clinical and MNV characteristics were collected at baseline. Visual acuity (VA) values and the presence of atrophy or fibrosis were collected at each visit.

MAIN OUTCOME MEASURES

Rate of VA change over time and associated factors; the incidence rate of moderate-to-severe visual impairment (MSVI) and blindness and hazard ratio (HR) of candidate risk factors for MSVI; the incidence rate of fibrosis and macular atrophy.

RESULTS

Overall, 84 eyes of 66 patients (39 men, 58%) with a mean (standard deviation) age of 55.7 (13.8) years were followed for a mean (standard deviation) of 67.7 (48.5) months. The median number of anti-VEGF doses per eye was 13. The average rate (95% confidence interval [CI]) of visual loss was +0.04 (0.02-0.06) logarithm of the minimum angle of resolution/year (P < 0.001); the visual loss was faster in nonnaive eyes (P = 0.007) and those with better baseline VA (P < 0.001); it was slower in eyes with pattern dystrophy-like features (P = 0.04). The incidence rates (95% CI) of MSVI and blindness were 10.4 (6.88-15)/100-eye-years and 2.33 (1.12-4.29)/100-eye-years. A higher number of injections (HR [95% CI] = 0.45 [0.19-0.94] for receiving ≥ 13 injections vs. < 13; P = 0.03) was protective against MSVI. The incidence rates (95% CI) of fibrosis and macular atrophy were 24.1 (17.5-32.3)/100-eye-years and 14.3 (10.1-19.6)/100-eye-years.

CONCLUSIONS

Eyes with MNV-related AS had a high rate of visual impairment and propensity to macular fibrosis and atrophy. A higher number of injections yielded better chances of maintaining good VA, suggesting the need for intensive treatment.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

A Case Series of "Solitary Idiopathic Choroiditis" and Proposal of a Nomenclature Change to "Idiopathic Scleroma"

Objective

To define the characteristics of solitary idiopathic choroiditis (SIC) in a consecutive series of patients and propose a nomenclature change to idiopathic scleroma.

Materials and Methods

Electronic patient records were retrospectively interrogated to identify all patients diagnosed with SIC between 2002 and 2019 in a tertiary referral ophthalmic hospital in the United Kingdom.

Results

Thirty-four eyes of 34 patients were found to have SIC. The mean age at diagnosis was 48 years (range 24-78) and 23 patients (68%) were female. All lesions were located posterior to the equator, most frequently in the inferotemporal quadrant (13 eyes, 38%). The lesions had a mean largest basal diameter of 1.2 ± 0.4 disc diameters (range 0.5-2) and their distance to the optic disc had a mean of 1.2 ± 0.9 disc diameters (range 0-3.3). All lesions were intrascleral on enhanced depth imaging optical coherence tomography, demonstrating a hypo-reflective zone within the sclera, with an underlying hyper-reflective zone in some cases. No lesion enlarged or developed features consistent with active inflammation after a median follow-up time of 0.9 years (range 0-16.8).

Discussion/Conclusion

Optical coherence tomography shows SIC to be an intrascleral lesion. Furthermore, we found no evidence of any inflammatory component. A nomenclature change to idiopathic scleroma is appropriate to prevent unnecessary investigation.

Serous business: Delineating the broad spectrum of diseases with subretinal fluid in the macula

A wide range of ocular diseases can present with serous subretinal fluid in the macula and therefore clinically mimic central serous chorioretinopathy (CSC). In this manuscript, we categorise the diseases and conditions that are part of the differential diagnosis into 12 main pathogenic subgroups: neovascular diseases, vitelliform lesions, inflammatory diseases, ocular tumours, haematological malignancies, paraneoplastic syndromes, genetic diseases, ocular developmental anomalies, medication-related conditions and toxicity-related diseases, rhegmatogenous retinal detachment and tractional retinal detachment, retinal vascular diseases, and miscellaneous diseases. In addition, we describe 2 new clinical pictures associated with macular subretinal fluid accumulation, namely serous maculopathy with absence of retinal pigment epithelium (SMARPE) and serous maculopathy due to aspecific choroidopathy (SMACH). Differentiating between these various diseases and CSC can be challenging, and obtaining the correct diagnosis can have immediate therapeutic and prognostic consequences. Here, we describe the key differential diagnostic features of each disease within this clinical spectrum, including representative case examples. Moreover, we discuss the pathogenesis of each disease in order to facilitate the differentiation from typical CSC.

Age-related macular degeneration masqueraders: From the obvious to the obscure

Age-related macular degeneration (AMD) is one of the leading causes of blindness worldwide with increasing prevalence owing to increased life expectancy. Intravitreal injections of antivascular endothelial growth factor agents are commonly used in exudative AMD and oral antioxidant medication for nonexudative AMD; however, many disorders mimic exudative and nonexudative AMD, and misdiagnosis can seriously affect the management of these patients. We summarize the demographics and clinical and imaging characteristics of each of the conditions that masquerade as AMD. As some of the conditions have features of AMD, a short update on the classical features of AMD is also included.

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.

Hickam's Dictum: Pseudoxanthoma elasticum and Usher syndrome in a single patient

BACKGROUND

To report the case of a patient with two distinct genetic systemic diseases - pseudoxanthoma elasticum (PXE) and Usher syndrome - confirmed by genetic testing.

MATERIALS AND METHODS

Single Retrospective Case Report.

RESULTS

A 36-year-old woman presented with acute central vision loss of the left eye (OS). Fundus exam revealed choroidal neovascularization OS in the setting of angioid streaks secondary to an underlying diagnosis of PXE. Unexpectedly, she also exhibited peripheral bony spicules with significant visual field constriction. Physical exam revealed skin papules on her neck and hearing loss. The presence of angioid streaks and skin findings was compatible with PXE; the etiology of her pigmentary retinopathy and hearing loss was elucidated using genetic testing. The patient was found to be compound heterozygous for pathogenic variants in both the ABCC6 and USH2A genes, confirming the diagnosis of two rare disorders in a single patient.

CONCLUSIONS

PXE and Usher syndrome are rare systemic disorders that cause distinctive retinal abnormalities. This report highlights the importance of genetic testing in diagnosing uncommon hereditary retinal disorders and outlines the progression of disease over 6 years.

Pattern dystrophy-like changes and coquille d'oeuf atrophy in elderly patients affected by pseudoxanthoma elasticum

PURPOSE

To evaluate the retinal features of elderly patients affected by pseudoxanthoma elasticum (PXE).

MATERIALS AND METHODS

This is a retrospective case series of 62 eyes of 31 elderly PXE patients (age > 50 years). Clinical data, ultra-widefield fundus imaging (color, red-free (RF), infra-red imaging (IR), fundus autofluorescence (FAF)), and OCT examinations were collected. Diagnosis was confirmed by genetic testing or skin biopsy.

RESULTS

Thirty-one patients (10 males and 21 females (mean age 61.3 years, range 50-74 years)) were included in our study. Visual acuity ranged from 20/20 Snellen equivalent to 20/200. The mean follow-up was 66.4 ± 20.7 months (range 10-88). Pattern dystrophy-like changes (PD) (52 eyes of 26 patients, 83.8%) and atrophy resembling the "diffuse trickling" pattern described in geographic atrophy were present in the majority of patients. Twenty-three eyes of 12 patients (67.6%) had peripapillary atrophy, 9 eyes of 5 patients (26.4%) macular atrophy, 6 eyes of 3 patients (17.6%) displayed posterior pole atrophy and in 6 eyes of 3 patients (17.6%), atrophy could be detected beyond the vascular arcades (mid-peripheral atrophy). End-stage atrophy covered the entire area indicated as "coquille d'oeuf" (eggshell). Choroidal neovascularization occurred in 49 eyes of 26 patients (94.2%) with PD and in 6 eyes of 3 patients (60%) without PD. Genetic examinations were available for 29 patients (29/31, 93.5%).

CONCLUSIONS

The elderly PXE patients were characterized by pattern dystrophy-like changes with more or less extensive atrophy, progressive over time, which in some cases affected the whole area of the coquille d'oeuf during the course of the disease.

Combined Administration of Preoperative Intravitreal and Intraoperative Subretinal Recombinant Tissue Plasminogen Activator in Acute Hemorrhagic Age-related Macular Degeneration

Purpose

To evaluate the efficacy of combining pre-operative intravitreal administration of recombinant tissue plasminogen activator (rTPA) followed by 23G pars plana vitrectomy with the subretinal administration of rTPA in the management of acute submacular hemorrhage (SMH) secondary to neovascular age-related macular degeneration (AMD).

Methods

This is a single-center case series report that included 14 patients with SMH secondary to neovascular AMD. All of them received preoperative intravitreal injection of 0.05 ml (50 µg) rTPA, followed on the next day by 23G pars plana vitrectomy with subretinal 0.1 ml (10 µg) rTPA administration and air tamponade.

Results

There was a significant (p=0.01) overall improvement in the visual acuity post-treatment (from 1.4±0.5 log MAR to 0.9±0.4). The mean overall change in the visual acuity post-treatment was 0.5±0.3 log MAR (mean % change=31.7±15.1). There was a significant (p=0.03) overall reduction in the central macular thickness post-treatment (896±608.1 µm to 497.2±196.0 µm). The mean overall change in the central macular thickness post-treatment was 398.8±458.1 µm (mean % change=38.1±18.1).

Conclusion

Combined treatment of 24 hours of preoperative administration of intravitreal rTPA followed the next day by vitrectomy and the administration of subretinal rTPA with air tamponade appeared to be effective as a prompt intervention in managing acute SMH secondary to neovascular AMD. However, similar studies with larger sample size and a control comparative group are warranted to further confirm these findings.

EYES WITH SUBRETINAL DRUSENOID DEPOSITS AND NO DRUSEN: Progression of Macular Findings

PURPOSE

To investigate the macular changes over time in eyes containing subretinal drusenoid deposits (also known as pseudodrusen) with no drusen >63 µm.

METHODS

A consecutive series of patients were examined with color fundus photography, optical coherence tomography, and autofluorescence imaging with fluorescein angiography used as necessary. Exclusionary criteria included macular neovascularization, history of retinal surgery, pseudoxanthoma elasticum, and drusen >63 µm.

RESULTS

There were 85 eyes of 54 patients. The mean age at baseline was 83.6 (±7.8) years, and there were 17 men. The mean follow-up was 5.0 (±2.9) years. At initial optical coherence tomography examination, 12 eyes had extrafoveal atrophy and 17 eyes had vitelliform deposits, which were yellowish white subretinal collections that showed intense hyperautofluorescence. During follow-up, 11 eyes lost vitelliform material. After the disappearance of small deposits, focal hyperpigmentation remained. Loss of larger deposits was associated with noteworthy sequela; six developed subfoveal atrophy and one macular neovascularization close to regressing vitelliform material. Subfoveal geographic atrophy developed in four other eyes without vitelliform material by extension from areas of extrafoveal atrophy. Macular neovascularization developed in seven eyes over follow-up. The CFH Y402H and ARMS2 A69S allele frequencies were 57% and 48.9%, respectively, which is similar to a group of age-related macular degeneration controls. One patient had a novel PRPH2 mutation, but did not have a vitelliform deposit; the remainder had a normal PRPH2 and BEST1 coding sequences.

CONCLUSION

Eyes with subretinal drusenoid deposits and no drusen >63 mm have significant risk for the development of both neovascularization and geographic atrophy, the fundamental components of late age-related macular degeneration. An intermediate step in some eyes was the development of a vitelliform deposit, an entity not traditionally associated with age-related macular degeneration, but in these patients, the material seemed to be an important component of the disease pathophysiology. This vitelliform deposit was not associated with genetic markers for pattern dystrophy or Best disease.

Coquille d'oeuf in young patients affected with Pseudoxantoma elasticum

Purpose: To evaluate the fundus phenotype of young patients affected with Pseudoxantoma Elasticum (PXE). Materials and Methods: Retrospective case series of five young PXE patients. Clinical data, ultra-widefield imaging (color, red-free (RF), choroidal (Ch) and fundus autofluorescence (FAF)) and OCT examination were collected. Diagnosis was confirmed by the characteristic histopathological abnormalities in skin biopsies and genetic testing results. Results: Five patients, 2 males and 3 females (mean age 16 years, range 12-20 years) were included in our study. The visual acuity was 20/20 in all subjects. Fundus evaluation revealed peau d'orange in all patients: multiple, yellowish/white round lesions, scattered from the posterior pole to the mid-peripheral retina of each eye. Ultra-wide field imaging allows us to capture and describe the entire area of coquille d'oeuf/peau d'orange in a single picture, facilitating their identification and discrimination. Angiod streaks were visible in both eyes of four patients. In one patient optic disc drusen were detected in both eyes. All patients presented comet lesions. Conclusions: PXE-related retinopathy findings: peau d'orange/coquille d'oeuf, angioid streaks, comet lesions and drusen of the optic disc were present early in PXE patients. The early detection of coquille d'oeuf/peau d'orange revealed a preferable area into midperiphery where Bruch's membrane will be more likely to be affected.

Retinal sensitivity in angioid streaks

PURPOSE

To investigate retinal sensitivity in eyes with angioid streaks (AS).

METHODS

This study was a retrospective observational case series. A total of 13 eyes from 9 patients with AS underwent ophthalmologic examination, including fundus autofluorescence (FAF), spectral domain optical tomography (SD-OCT), and microperimetry. Retinal pigment epithelium (RPE) atrophy was assessed using FAF. Outer retinal atrophy, more specifically, disruption of the ellipsoid zone, was evaluated using SD-OCT images. The association between retinal sensitivity, RPE atrophy or outer retinal atrophy, and patient demographic characteristics or ophthalmologic findings were investigated.

RESULTS

The mean area of outer retinal atrophy was 14.5 ± 12.9 mm², significantly larger than the mean area of RPE atrophy (9.0 ± 9.0 mm²; P = 0.0028). The average retinal sensitivity in the area of RPE atrophy was 2.4 ± 5.6 dB, that in the area of outer retinal atrophy outside RPE atrophy was 14.6 ± 7.5 dB, and that in the area without any atrophy was 25.6 ± 5.1 dB. Reticular pseudodrusen (RPD) was observed in 5 eyes. Eyes with RPD showed a greater extent of both outer retinal atrophy and RPE atrophy than those without RPD and a greater decrease in mean retinal sensitivity.

CONCLUSIONS

In eyes with AS, especially in those with RPD, large areas of outer retinal atrophy and RPE atrophy were observed, and the retinal sensitivity in the areas was correspondingly decreased.

Reticular Pseudodrusen and Thin Choroid Are Associated With Angioid Streaks

BACKGROUND AND OBJECTIVE

To report the association of angioid streaks in patients with Pseudoxanthoma elasticum (PXE) with reticular pseudodrusen (RPD), thin choroid, and retinal pigment epithelium (RPE) atrophy using swept-source optical coherence tomography (SS-OCT) and short-wave autofluorescence (SWAF).

PATIENTS AND METHODS

Retrospective cross-sectional study. Records of consecutive patients with angioid streaks due to PXE, who presented with a decrease of vision due to choroidal neovascularization (CNV), were reviewed for best-corrected visual acuity, color fundus photographs, SS-OCT, SWAF, and red-free images with special emphasis on presence or absence of RPD, subfoveal choroidal thickness (SFCT), and RPE atrophy.

RESULTS

Sixteen eyes of eight patients with a mean age of 45.5 years ± 9.4 years were enrolled in the study. RPD were seen in 10 of the 16 eyes and were seen commonly along the superotemporal quadrant. Mean subfoveal thickness in study eyes (175.7 μm ± 37.2 μm) was significantly reduced when compared to controls (286.4 μm ± 40.8 μm). The mean SFCT was similar between the eyes with and without CNV. Four eyes had RPE atrophy in the macular area, whereas four eyes had peripapillary RPE atrophy.

CONCLUSIONS

Angioid streaks in PXE are associated with RPD, thin choroid, and RPE atrophy. These features occur at a younger age as compared to age-related macular degeneration and appear to be interrelated because of single pathophysiological mechanism. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:402-408.].

CHORIOCAPILLARIS SIGNAL VOIDS IN MATERNALLY INHERITED DIABETES AND DEAFNESS AND IN PSEUDOXANTHOMA ELASTICUM

PURPOSE

To evaluate the pattern of choriocapillaris signal voids in maternally inherited diabetes and deafness and in pseudoxanthoma elasticum in eyes before the development of any geographic atrophy.

METHODS

The choriocapillaris under the central macula was imaged with the Optovue RTVue XR Avanti using a 10 μm slab thickness. Automatic local thresholding of the resultant raw data extracted areas of absent flow signal, called signal voids, and these were counted and logarithmically binned. The signal void patterns were analyzed in four eyes of two patients with maternally inherited diabetes and deafness and four eyes of three patients with pseudoxanthoma elasticum. None of the patients had geographic atrophy. These data were compared with 55 eyes of 38 healthy control subjects and analyzed with generalized estimating equations.

RESULTS

The choriocapillaris images in maternally inherited diabetes and deafness and pseudoxanthoma elasticum show that the model of signal voids followed a power law distribution, but with a slope and offset much lower than the normal control group, adjusted for age (P < 0.001). The eyes in the disease group were much more likely to have signal voids greater than 40,000 μm.

CONCLUSION

Before the development of any overt geographic atrophy, patients with maternally inherited diabetes and deafness and pseudoxanthoma elasticum show pronounced abnormalities of choriocapillaris flow. Current clinical measures of retinal pigment epithelial health only look for areas of cell death, as in geographic atrophy. It is not possible to determine from current imaging if the choriocapillaris loss precedes potential loss of function of the retinal pigment epithelium, such as secretion of vascular endothelial growth factor.

Ultra-Widefield Imaging in Patients with Angioid Streaks Secondary to Pseudoxanthoma Elasticum

PURPOSE

To investigate the application of noninvasive ultra-widefield (UWF) imaging in patients with angioid streaks secondary to pseudoxanthoma elasticum (PXE) and to compare detected findings with those obtainable with 7 standard 30° fields (7SF) imaging.

DESIGN

Cross-sectional, observational study.

PARTICIPANTS

Forty eyes of 20 consecutive patients with angioid streaks secondary to PXE (8 women and 12 men; mean age, 56.9 ± 12.3 years).

METHODS

Consecutive patients with angioid streaks secondary to PXE seeking treatment between January and June 2016 at the Medical Retina & Imaging Unit of the Department of Ophthalmology, University Vita-Salute San Raffaele, underwent UWF imaging (California; Optos PLC, Dunfermline, UK). Ultra-widefield color images and fundus autofluorescence (FAF) were evaluated. Ultra-widefield findings then were compared with those obtainable with 7SF.

MAIN OUTCOME MEASURES

Types and location of retinal lesions secondary to PXE.

RESULTS

Peripheral lesions not entirely visible with 7SF were identified in 29 of 40 eyes (72.5%; P < 0.0001). These peripheral lesions included peau d'orange (52.5% of the eyes), coquille d'oeuf (52.5%), cracked eggshell (5.0%), comet lesions (27.5%), peripheral retinal degenerations (17.5%), parastreak atrophies (10.0%), and peripheral hemorrhage (5.0%). Furthermore, chorioretinal atrophies, drusen of the optic disc, cracked eggshell, pattern-like dystrophies, and retinal hemorrhages associated with angioid streaks were observed on digital color or FAF images, or both, and described.

CONCLUSIONS

Ultra-widefield imaging showed valuable usefulness in patients with angioid streaks by providing in a single image the entire spectrum of retinal alterations associated with PXE. Peripheral lesions often are present in patients with angioid streaks and may be missed with 7SF imaging. A careful examination of fundus periphery should be performed during screening and follow-up visits.

Peau d'orange and angioid streaks: manifestations of Bruch membrane pathology

PURPOSE

The aim of this study was to characterize peau d'orange and angioid streaks, characteristic findings in eyes of patients with pseudoxanthoma elasticum, by examining fundus photography and optical coherence tomography imaging.

METHODS

Color photographs were evaluated directly as were the component red and green channels. Optical coherence tomography images were evaluated for reflectivity pattern of the band corresponding to the retinal pigment epithelium-Bruch membrane complex.

RESULTS

Eighteen eyes of 9 patients with a mean age of 48.7 years (range, 31-61 years) were examined; 7 of them were women. Color photographs showed areas of yellowish opacification that obscured visualization of the underlying choroid. At the outer edges of this confluent area, opacification were nonconfluent changes with similar appearance and these regions were typical peau d'orange. Angioid streaks occurred within and extended up to the outer border of the confluent opacification. Underlying choroidal details could be seen through the regions of peau d'orange and through the gaps in angioid streaks. The red channel image showed increased reflectivity from the confluent deposit and improved visualization of the choroidal vasculature, except where the confluent opacification was located. Optical coherence tomography imaging showed increased reflectivity from the outer border of the retinal pigment epithelium-Bruch membrane complex.

CONCLUSION

The findings suggest that the confluent region is the relevant lesion, not the subconfluent zone known as peau d'orange. Imaging characteristics of the confluent area of opacity are consistent with diffuse infiltration with calcium, a chief histologic abnormality of pseudoxanthoma elasticum. The name coquille d'oeuf was suggested for the confluent area of opacity as a consequence.

Submacular hemorrhage in neovascular age-related macular degeneration: A synthesis of the literature

Large submacular hemorrhage, an uncommon manifestation of neovascular age-related macular degeneration, may also occur with idiopathic polypoidal choroidal vasculopathy. Submacular hemorrhage damages photoreceptors owing to iron toxicity, fibrin meshwork contraction, and reduced nutrient flux, with subsequent macular scarring. Clinical and experimental studies support prompt treatment, as tissue damage can occur within 24 hours. Without treatment the natural history is poor, with a mean final visual acuity (VA) of 20/1600. Reported treatments include retinal pigment epithelial patch, macular translocation, pneumatic displacement, intravitreal or subretinal tissue plasminogen activator, intravitreal anti-vascular endothelial growth factor (VEGF) drugs, and combinations thereof. In the absence of comparative studies, we combined eligible studies to assess the VA change before and after each treatment option. The greatest improvement occurred after combined pars plana vitrectomy, subretinal tissue plasminogen activator, intravitreal gas, and anti-vascular endothelial growth factor treatment, with VA improving from 20/1000 to 20/400. The best final VA occurred using combined intravitreal tissue plasminogen activator, gas, and anti-vascular endothelial growth factor therapy, with VA improving from 20/200 to 20/100. Both treatments had an acceptable safety profile, but most studies were small, and larger randomized controlled trials are needed to determine both safety and efficacy.

Geographic chorioretinal atrophy in pseudoxanthoma elasticum

PURPOSE

To describe a series of patients with geographic atrophy independent of choroidal neovascularization (CNV) in pseudoxanthoma elasticum and to report progression over time.

DESIGN

Retrospective observational case series.

METHODS

Records of all Vanderbilt Eye Institute patients with pseudoxanthoma elasticum and at least 1 set of color fundus photographs were reviewed (41 eyes of 21 patients). Fluorescein angiography, fundus autofluorescence, and optical coherence tomography images were reviewed, when available. In patients with geographic atrophy and at least 1 year of follow-up, atrophy was measured using fundus photographs. Main outcome measures included incidence of geographic atrophy, progression over time, and macular features associated with development or progression of geographic atrophy.

RESULTS

Eight eyes (20%) of 5 patients had geographic atrophy independent of CNV. Progression was documented in 6 eyes of 4 patients followed for at least 1 year (mean 3.5 years). Mean initial and final area was 2.9 and 9.5 mm(2), respectively, and growth rate was 1.7 mm(2) per year. Of the 6 eyes, 3 had a final visual acuity of 20/20 and the other 3 ranged from 20/150 to 20/400. All 8 eyes had pattern dystrophy, and 5 had linear pigment deposits that appeared to predict development or growth of atrophy.

CONCLUSIONS

Isolated geographic atrophy independent of CNV can develop in pseudoxanthoma elasticum, causing significant vision loss. Linear pigmented pattern dystrophy appears to predate geographic atrophy. Progression is similar to age-related macular degeneration. Recognition of this feature is important, especially if therapies to slow or reverse geographic atrophy become available.

An update on the ocular phenotype in patients with pseudoxanthoma elasticum

Pseudoxanthoma elasticum (PXE) is an inherited multi-system disorder characterized by ectopic mineralization and fragmentation of elastic fibers in the skin, the elastic laminae of blood vessels and Bruch's membrane in the eye. Biallelic mutations in the ATP-binding cassette (ABC) transporter gene ABCC6 on chromosome 16 are responsible for the disease. The pathophysiology is incompletely understood. However, there is consent that a metabolic alteration leads to dysfunction in extracellular calcium homeostasis and subsequent calcification of connective tissues rich in elastic fibers. This review summarizes and aims at explaining the variety of phenotypic ocular findings in patients with PXE. Specialized imaging techniques including white light fundus photography, blue light autofluorescence, near-infrared confocal reflectance imaging, high resolution optical coherence tomography, fluorescein and indocyanine green (ICG) angiography have revealed characteristic lesions at the ocular fundus of PXE patients. These include the classic signs of angioid streaks, peau d'orange, comet lesions, and choroidal neovascularizations (CNVs), but also the more recently recognized features such as chorioretinal atrophy, subretinal fluid independent from CNV, pattern dystrophy-like changes, debris accumulation under the retinal pigment epithelium, reticular drusen and a decreased fluorescence on late phase ICG angiography.

Solitary idiopathic choroiditis: findings on enhanced depth imaging optical coherence tomography in 10 cases

OBJECTIVE

To describe the imaging characteristics of solitary idiopathic choroiditis (SIC).

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Ten eyes in 10 patients with SIC.

METHODS

Review of chart, fundus photography, ultrasonography, fundus autofluorescence (FAF), infrared reflectance (IR) imaging, and enhanced depth imaging optical coherence tomography (EDI OCT).

MAIN OUTCOME MEASURES

Scleral, choroidal, and retinal features of SIC as analyzed by EDI OCT.

RESULTS

The mean age at diagnosis was 47 years (range, 7-76 years). There were 4 male patients and 6 female patients. The mean best-corrected visual acuity was 20/25 (range, 20/20-20/150). The SIC lesions were postequatorial (n = 10), with a mean basal diameter of 2.6 mm (range, 1.0-4.0 mm), yellow hue (n = 10), and surrounding orange halo (n = 6). Ultrasonography revealed acoustic solidity (n = 10) with a mean thickness of 1.7 mm (range, 1.4-2.1 mm), FAF disclosed hyperautofluorescence (n = 9), and IR imaging displayed hyperreflectivity (n = 9). On EDI OCT, all 10 lesions were dome shaped with a smooth surface and arose with a gentle slope from the sclera. A more abruptly elevated volcanic configuration was seen in 2 lesions. The overlying choroid was thinned (mean thickness, 32 μm; range, 0-52 μm). The lesions were moderately reflective with an optically bright anterior band and deep shadowing (n = 8). The posterior margin of the lesion could be ascertained in only 1 case. By EDI OCT, the mean diameter was 2942 μm (range, 1887-3809 μm). In no case was there disturbance of the inner retina or subretinal fluid.

CONCLUSIONS

Solitary idiopathic choroiditis generally displays ultrasonographic solidity, hyperautofluorescence, and hyperreflectivity on IR imaging. On EDI OCT, the dome-shaped lesion arises from the sclera, outer choroid, or both and the overlying choroidal vasculature is thinned.

[Angioid streaks]

Angioid streaks represent breaks in Bruch's membrane, appearing as dark or reddish radial streaks eminating from the optic disc. Usually asymptomatic, these streaks may develop neovascularisation and lead to a maculopathy with marked loss of vision. Some associations with systemic disease are classically described, especially pseudoxanthoma elasticum. This condition may involve cardiovascular complications. A mutation has been found in the ABCC6 gene, which encodes for a membrane transport protein involved in the synthesis of the extracellular matrix. Imaging allows for visualization of the extent of the streaks, and autofluorescence is particularly informative. Spectral domain OCT may also demonstrate early breaks in Bruch's membrane. Neovascular complications, previously responsible for inevitable visual impairment at some point after their occurrence, are now managed by intravitreal injections of anti-VEGFs with clear efficacity. The ophthalmologist must be aware of this condition, in order to guide the patient towards a systemic work-up if necessary, and also to insure quick and targeted treatment in the case of neovascular complications.

[Choroidal neovascularization secondary to pseudoxanthoma elasticum treated with ranibizumab: a report of 2 cases]

CASE REPORT

We report 2 cases of pseudoxanthoma elasticum with angioid streaks and choroidal neovascularization (CNV) in both eyes. Intravitreal ranibizumab (Lucentis) was administered with successful results in both cases.

DISCUSSION

CNV has been reported to occur in 72% to 86% of patients with angioid streaks. Although uncommon, the impact of CNV is important because it tends to affect people of working age. Based on the effectiveness of ranibizumab in other secondary CNVs, we decided to use it in our patients, observing the functional and anatomical improvement.

Multimodal fundus imaging of pseudoxanthoma elasticum

PURPOSE

To investigate spectral domain optical coherence tomography and autofluorescence findings in eyes with pseudoxanthoma elasticum.

METHODS

A retrospective analysis of visual acuity, spectral domain optical coherence tomography, and autofluorescence findings of consecutive patients with pseudoxanthoma elasticum was performed. The spectral domain optical coherence tomography was evaluated for retinal architecture, subretinal accumulations, and photoreceptor layer thickness. Autofluorescence and near-infrared reflectance images were reviewed for correlative findings.

RESULTS

There were 21 patients (42 eyes) with pseudoxanthoma elasticum with a mean age of 56.1 ± 12.4 years. Subretinal fluid was found in 14 eyes, 7 of which had no signs of choroidal neovascularization. In six of the seven eyes with a history of choroidal neovascularization controlled with antivascular endothelial growth factor injections, there were areas of subretinal fluid that were not contiguous with the choroidal neovascularization and did not seem responsive to antivascular endothelial growth factor injections. Two types of formed material were observed in the subretinal space and outer retina. The first was hypoautofluorescent deposits above the retinal pigment epithelium resembling subretinal drusenoid deposits (reticular pseudodrusen). The second was yellow to brown hyperautofluorescent aggregates in the subretinal space and outer retina similar to those seen in pattern dystrophies and was found in 19 eyes. There was an apparent association between the presence of subretinal fluid and pattern dystrophy-like findings.

CONCLUSION

Subretinal fluid in patients with pseudoxanthoma elasticum is not always indicative of active leakage from underlying choroidal neovascularization and can be resistant to antivascular endothelial growth factor injections. This fluid is associated with pattern dystrophy-like findings and may indicate abnormal retinal pigment epithelial function.

[Retinal autofluorescence imaging in patients with pseudoxanthoma elasticum]

PURPOSE

To evaluate the autofluorescence findings in patients diagnosed with pseudoxanthoma elasticum.

MATERIAL AND METHODS

A prospective study was conducted on 18 eyes of 9 patients who had ocular pathology andfollowed up in the pseudoxanthoma elasticum (PSX) unit of our hospital. We evaluated the best corrected visual acuity (BCVA), colour and autofluorescence photography (AF), and fluorescein angiography (FA) in patients with choroidal neovascularitation.

RESULTS

Of the 9 patients, 7 were women and 2 were men. The mean age was 40 +/- 14 years. The BCVA ranged from 1 to 0.01 (Mean 0.65 +/- 0.4). All patients showed PSX injuries. Angioid streaks (AS) 18 (100%), peau d'orange 16 (87.5%) and pigmented fibrotic plates 5 (31,5%). We observed different hypoautofluorescence patterns (RPE atrophy), of which 2 of them were AS patterns (irregular lines with hyperautofluorescence speckled in its interior and edges, or bands with lobulated lesions inside and hyperautofluorescence at the edges), and finally widespread areas of hypoautofluorescence, larger than observed by ophthalmoscope.

CONCLUSIONS

Autofluorescence in patients with PSX is an easy method to evaluate the initial level of ophthalmoscopic involvement and its subsequent progression. The extensive changes in the retinal pigment epithelium (RPE) suggests the important role of this in the physiopathology of the disease.

Fundus autofluorescence in Pseudoxanthoma elasticum

PURPOSE

Pseudoxanthoma elasticum (PXE) is an inherited multisystem disorder of the elastic tissue. Typical ocular manifestations include angioid streaks, peau d'orange, salmon spots, and choroidal neovascularization (CNV). Changes in Bruch membrane lead to progressive atrophy of the retinal pigment epithelium (RPE), secondary CNVs, and visual loss. The RPE-photoreceptor complex was studied in vivo using fundus autofluorescence (FAF) imaging.

METHODS

Forty-six patients (92 eyes) with PXE were investigated using digital fundus photography, fluorescein angiography (FA), and FAF imaging. The diagnosis was confirmed by multisystem clinical examination, mutation analysis of the ABCC6 gene, and skin biopsy.

RESULTS

The mean age of the patient cohort was 50 years (range, 13-74 years), and mean visual acuity was 20/125. Fundus changes typical for PXE were observed in all eyes. Angioid streaks were detected in all but six eyes. Peau d'orange was hardly detectable on FAF, whereas comet tail lesions were apparent. Retinal pigment epithelium atrophy typically was widespread and heterogeneous, located mostly adjacent to angioid streaks or CNVs. Pattern dystrophy-like changes were only found in patients with previous CNV formation in the same or the contralateral eye.

CONCLUSION

Abnormalities of the RPE-photoreceptor complex detected by FAF imaging were more diverse and widespread than expected from conventional fundus imaging. The exhibition of pattern dystrophy-like changes may be a transitional state toward a neovascular event in a subgroup of patients. The extensive alteration of the RPE suggests an important role of pathologic RPE changes in the evolution of visual loss in PXE.

Complementary angiographic and autofluorescence findings in pseudoxanthoma elasticum

Pseudoxanthoma elasticum (PXE) is a systemic disease with characteristic findings on fundus examination. The fundus findings may be difficult to detect with ophthalmoscopy. A case report is described as follows. A PXE patient had subtle retinal findings on fundoscopy that were more prominently seen using a combination of both fundus autofluorescence (FAF) imaging and indocyanine green (ICG) angiography. The fundus features visualized using each of these two modalities appeared different from each other. FAF imaging and ICG angiography may be able to more prominently detect pathology at the level of the retinal pigment epithelium and Bruch's membrane, respectively. The use of these imaging modalities together may be complementary and useful in the evaluation of patients with PXE.

Non-vascular vision loss in pseudoxanthoma elasticum

Pseudoxanthoma elasticum patients with angioid streaks are well-known to have acute vision loss due to choroidal bleeding. However, chronic vision loss due to macular atrophy is less well characterized. We describe a patient with sub-acute vision loss in one eye due to loss of macular retinal pigment epithelium function. Autofluorescence and pattern electroretinogram were useful adjuncts to help diagnose the source of her vision loss.

Fundus autofluorescence imaging: review and perspectives

Fundus autofluorescence (FAF) imaging is a novel imaging method that allows topographic mapping of lipofuscin distribution in the retinal pigment epithelium cell monolayer as well as of other fluorophores that may occur with disease in the outer retina and the subneurosensory space. Excessive accumulation of lipofuscin granules in the lysosomal compartment of retinal pigment epithelium cells represents a common downstream pathogenetic pathway in various hereditary and complex retinal diseases, including age-related macular degeneration. FAF imaging has been shown to be useful with regard to understanding of pathophysiologic mechanisms, diagnostics, phenotype-genotype correlation, identification of predictive markers for disease progression, and monitoring of novel therapies. FAF imaging gives information above and beyond that obtained by conventional imaging methods, such as fundus photography, fluorescein angiography, and optical coherence tomography. Its clinical value coupled with its simple, efficient, and noninvasive nature is increasingly appreciated. This review summarizes basic principles and FAF findings in various retinal diseases.

Advances in the diagnosis and immunotherapy for ocular inflammatory disease

Significant advances in the diagnosis and therapy for uveitis have been made to improve the quality of care for patients with ocular inflammatory diseases. While traditional ophthalmic examination techniques, fluorescein angiography, and optical coherence tomography continue to play a major role in the evaluation of patients with uveitis, the advent of spectral domain optical coherence tomography and fundus autofluorescence into clinical practice provides additional information about disease processes. Polymerase chain reaction and cytokine diagnostics have also continued to play a greater role in the evaluation of patients with inflammatory diseases. The biologic agents, a group of medications that targets cytokines and other soluble mediators of inflammation, have demonstrated promise in targeted immunotherapy for specific uveitic entities. Their ophthalmic indications have continued to expand, improving the therapeutic armentarium of uveitis specialists.

Fundus autofluorescence in choroidal melanocytic lesions

PURPOSE

To correlate fundus autofluorescence (FAF) patterns in choroidal melanocytic lesions with changes present on the surface of such lesions, including lipofuscin, hyperpigmentation, drusen, and fibrous metaplasia.

METHODS

Retrospective chart review for 23 consecutive patients with choroidal nevi and melanoma who underwent FAF photography. The correlation between increased FAF patterns and foci of lipofuscin, hyperpigmentation, drusen, or fibrous metaplasia was defined as complete correlation, partial correlation, or no correlation.

RESULTS

Lipofuscin was present in 13 tumors, hyperpigmentation was present in 9 tumors, drusen were present in 6 tumors, and fibrous metaplasia was present in 4 tumors. Complete correlation between increased FAF and lipofuscin was found in 8 tumors (61.5%); partial correlation, in 3 tumors (23.1%); and no correlation, in 2 tumors (15.4%). Complete correlation between hyperpigmentation and increased FAF was found in 5 tumors (55.6%); partial correlation, in 3 tumors (33.3%); and no correlation, in 1 tumor (11.1%). Partial correlation was found between drusen and increased FAF in 4 tumors. Partial correlation was found between fibrous metaplasia and increased FAF in three tumors.

CONCLUSION

Choroidal melanocytic lesions with overlying lipofuscin and hyperpigmentation are associated with increased FAF in approximately 90% of cases.