Clinical and Spectral-Domain Optical Coherence Tomography Findings in Patients with Focal Choroidal Excavation

Visual functions and multimodal imaging of patients with idiopathic focal choroidal excavation

This study aimed to evaluate visual function and perform multimodal imaging on patients with focal choroidal excavation without any chorioretinal disease (idiopathic focal choroidal excavation [iFCE]). Seventeen eyes of 15 patients with iFCE (8 men, 7 women; mean ± standard deviation age, 56.0 ± 10.8 years) were assessed for visual function including visual acuity, metamorphopsia, aniseikonia, and retinal sensitivity. Multimodal imaging included optical coherence tomography (OCT), fundus autofluorescence (FAF), and OCT angiography. This study found that the maximum width and depth of the excavation were 597 ± 330 (238-1809) µm and 123 ± 45 (66-231) µm, respectively, and that FAF showed normal or hypoautofluorescence corresponding to iFCE. The fundus examination findings were stable during the follow-up period (96 ± 48 months). None of the eyes showed any abnormalities in central retinal sensitivity or aniseikonia. Metamorphopsia was detected using Amsler grid testing and M-CHARTS in two eyes. Therefore, this study is the first to quantitatively and qualitatively study metamorphopsia of patients with iFCE. Our results showed that most patients with iFCE did not have visual impairments, despite the presence of morphological changes in the outer retina and choroid.

Long-term follow-up demonstrates change in conformation shape of the focal choroidal excavation lesions

PURPOSE

This study aims to present long-term observation of 5 eyes with focal choroidal excavation (FCE), focusing on morphological changes in conformity of the lesion.

METHODS

A retrospective case series was conducted, including 5 eyes of 5 patients with FCE. The study utilized multimodal imaging including color fundus photography, optical coherence tomography (OCT), enhanced depth imaging OCT (EDI-OCT), fundus fluorescein angiography (FFA), fundus autofluorescence (FAF), red free imaging, and OCT angiography.

RESULTS

The mean age at diagnosis was 51 ± 10.65 years, with a mean follow-up period 37 ± 13.59 months. All cases were unilateral, with 1 presenting FCE as an isolated lesion, and one patient exhibiting 2 FCEs in one eye. The mean choroidal thickness measured by EDI-OCT was 268.2 ± 63.39 μm in the affected eye. One patient displayed choroidal thickening and pachyvessels. Of the 5 eyes, one had conforming and 4 non-conforming FCE. We observed a conversion in conformity in all patients, with 4 cases transitioning from non-conforming FCE to conforming type (3 spontaneously, 1 treatment-induced). In conforming FCE, a hyporeflective space appeared twice between neuroretina and retinal pigment epithelium with spontaneous regression.

CONCLUSION

We observed change in shape from the conforming to non-conforming FCE and vice versa in all patients. We consider this small change in the hyporeflective space as non-pathologic and clinically insignificant.

CHOROIDAL VASCULARITY AND VISUAL OUTCOMES IN MACULA-OFF RHEGMATOGENOUS RETINAL DETACHMENT

PURPOSE

To investigate the association between visual outcomes and choroidal changes in patients with macula-off rhegmatogenous retinal detachment.

METHODS

This study retrospectively reviewed 63 eyes of patients with macula-off rhegmatogenous retinal detachment who underwent vitrectomy. Their fellow eyes were analyzed as a control group. The choroidal vascularity index (CVI), ellipsoid zone/external limiting membrane integrity, central foveal thickness, and subfoveal choroidal thickness were documented and analyzed. Linear regression analyses were performed to identify factors affecting the final best-corrected visual acuity.

RESULTS

Eyes with rhegmatogenous retinal detachment showed increased CVI (68.8 ± 4.1) compared with the control group (66.1 ± 8.8, P = 0.028). Multivariate linear regression analysis revealed that patients with a poor final best-corrected visual acuity had a longer detachment duration ( P = 0.002), worse baseline best-corrected visual acuity ( P = 0.034), thinner central foveal thickness ( P = 0.005), and greater CVI ( P = 0.001) and were more likely to be tamponated with silicone oil ( P = 0.001). Choroidal vascularity index was particularly increased in eyes with poor ellipsoid zone/external limiting membrane integrity, prolonged detachment duration, thin central foveal thickness, and worse best-corrected visual acuity.

CONCLUSION

Increased CVI could indicate poor visual outcomes in patients with macula-off rhegmatogenous retinal detachment. Choroidal remodeling could be associated with the disruption of the ellipsoid zone/external limiting membrane integrity.

DEVELOPMENT OF FOCAL CHOROIDAL EXCAVATION AFTER ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

The purpose of this study was to describe a case of polypoidal choroidal vasculopathy, showing a newly developed focal choroidal excavation during a 4-year follow-up period with multiple intravitreal antivascular endothelial growth factor injections.

METHODS

This study was a case report.

RESULTS

A 64-year-old man was referred for treatment of age-related macular degeneration in his left eye. His corrected visual acuity at initial presentation was 20/20 in both the right and left eye. Optical coherence tomography of the left eye revealed a steep retinal pigment epithelial detachment and subretinal fluid, and indocyanine green angiography confirmed a polypoidal lesion, leading to the diagnosis of polypoidal choroidal vasculopathy with pachychoroid features. Thereafter, antivascular endothelial growth factor intravitreal injections were continued on a pro re nata basis. Two years after the initial presentation, the sharp pigment epithelial detachment began to shrink, and a novel focal choroidal excavation gradually emerged surrounding the pigment epithelial detachment with an inner choroidal layer attenuation.

CONCLUSION

Multiple antivascular endothelial growth factor injections for polypoidal choroidal vasculopathy resulted in atrophy of the polypoidal lesion and a decrease in the blood flow in the adjacent inner choroidal vasculature, leading to the formation of a novel focal choroidal excavation.

DEVELOPMENT OF FOCAL CHOROIDAL EXCAVATION IN A CASE OF IDIOPATHIC CHOROIDAL NEOVASCULAR MEMBRANE

PURPOSE

The purpose of this study was to demonstrate the evolution of focal choroidal excavation in a 17-year-old girl on treatment for a choroidal neovascular membrane over a 6-year follow-up.

METHODS

Review of medical and imaging records of a 17-year-old girl who presented with a choroidal neovascular membrane in her left eye treated with multiple intravitreal antivascular endothelial growth factor injections over a period of 6 years.

RESULTS

The patient developed recurrent episodes of subretinal hemorrhage that were treated with antivascular endothelial growth factor injections. Over the follow-up period, swept source optical coherence tomography through the lesion revealed progressive reduction in size of the choroidal neovascular membrane complex with the development of acquired focal choroidal excavation.

Acquired Focal Choroidal Excavation Secondary to Pachychoroid Choroidal Neovascular Membrane After Central Serous Chorioretinopathy

Purpose: To report a case of acquired conforming-type focal choroidal excavation (FCE) secondary to a pachychoroid choroidal neovascular membrane (CNVM) triggered by central serous chorioretinopathy (CSCR). Methods: A case and its findings were analyzed. Results: A 54-year-old Asian man who had spontaneous resolution of CSCR in the right eye presented with a pachychoroid CNVM and FCE 1 year after the initial CSCR diagnosis. Intravitreal antivascular endothelial growth factor injections were initiated, and the subretinal fluid and intraretinal hemorrhage resolved. The patient was followed for FCE progression for 3 years. Conclusions: Acquired FCE can occur secondary to CSCR and pachychoroid CNVM. The pathogenesis may be focal choroidal ischemia, choroidal vascular collapse, and fibrosis leading to choroidal excavation. This case highlights the progression of the spectrum of pachychoroid disorders from CSCR, pachychoroid CNVM, and subsequent acquired confirming-type FCE. Further research is needed to assess other diseases leading to acquired FCE and to determine the underlying mechanism.

Primary and secondary focal choroidal excavation morphologic phenotypes, associated ocular disorders and prognostic implications

AIMS

To characterise and classify the morphological, clinical and tomographic characteristics of focal choroidal excavation (FCE) lesions to determine their prognostic implications.

METHODS

36 eyes with FCE (32 patients) underwent multimodal imaging, including spectral domain optical coherence tomography and fundus autofluorescence. FCE lesions were classified into three subtypes: (1) type 1: myopic (central choroidal thickness: <100 µm), (2) type 2: suspected congenital (central choroidal thickness: 100-200 µm, without associated chorioretinal pathology) and (3) type 3: secondary or acquired (central choroidal thickness: >200 µm, with associated chorioretinal pathology).

RESULTS

80.6% of eyes were followed longitudinally (26.8±18.8 months). There were 9 type 1 FCEs (myopic), 8 type 2 FCEs (U-shaped, congenital) and 19 type 3 FCEs (V-shaped, secondary). Type 2 FCEs trended towards larger maximum widths (p=0.0563). Type 3 FCEs were associated with central serous chorioretinopathy or pachyvessels (47.4%), but were also seen in pattern dystrophy, geographic atrophy, inactive choroiditis, torpedo maculopathy and adult-onset vitelliform dystrophy. Choroidal neovascular membranes (CNVMs) were more prevalent in type 3 FCE (41.2% compared with 11.1% for type 1 FCE, p=0.251, and 0% for type 2 FCE, p=0.043).

CONCLUSIONS

The FCE types, stratified by central choroidal thickness, demonstrated distinct morphological characteristics and associated findings. The classification scheme held prognostic implications as type 3 FCE with V shapes were associated with other chorioretinal conditions and were more likely to develop CNVM.

CORRELATION BETWEEN FOCAL CHOROIDAL EXCAVATION AND UNDERLYING RETINOCHOROIDAL DISEASE: A Pathological Hypothesis From Clinical Observation

PURPOSE

To evaluate focal choroidal excavation (FCE) in eyes with various diseases using multimodal imaging modalities and to investigate the correlation of FCE and underlying chorioretinal diseases.

METHODS

This retrospective observational study included 62 eyes from 56 patients who were identified by optical coherence tomography as having FCE. All included patients underwent comprehensive clinical examinations and multimodal imaging to identify and detect the characteristics of FCE and its correlation with underlying chorioretinal diseases.

RESULTS

All included patients were of Chinese descent, and the median age at diagnosis was 43 years (range: 15-66). Seventy-three FCEs appeared in these included eyes. Most FCEs were formed at sites with anatomical changes caused by various chorioretinal diseases. Choroidal osteoma, punctate inner choroidopathy, and central serous chorioretinopathy were the most common etiologies of FCE. During follow-up, 14 eyes (22.58%) exhibited a pattern change and three eyes (4.84%) developed new-onset choroid neovascularization.

CONCLUSION

Focal choroidal excavation is a common sign found in a variety of chorioretinal diseases. Processes that involve impairment or tissue loss of the outer retina and inner choroid and disrupt the balance of intraocular pressure and choroidal pressure because of mechanical disturbance may play a role in FCE formation.

Complications, treatments, and visual prognosis of choroidal osteomas

PURPOSE

This study aims to report complications, treatments, and visual prognosis of choroidal osteoma.

METHODS

We retrospectively reviewed electronic medical records and multimodal images of 41 patients with choroidal osteoma.

RESULTS

Visually significant complications included choroidal neovascularization (CNV) in 21 (47.7%) eyes and subretinal fluid (SRF) without CNV in 14 (31.8%) eyes. The most common treatment was intravitreal anti-vascular endothelial growth factor (VEGF) injection: 13 (61.9%) eyes with CNV received an average of 6.3 injections, and 6 (42.9%) eyes with SRF but without CNV received 1.8 injections. As the first-line treatment, intravitreal anti-VEGF injection induced complete or partial remission in 93.4% of eyes with CNV and 57.1% of eyes with SRF. The probability of legally low vision estimated at 3 and at 5 years was 29.1% and 34.2%, respectively. The presence of CNV and outer retinal tubulation (ORT) was independent risk factors for vision loss (adjusted odds ratio, 8.08 and 6.94, respectively).

CONCLUSIONS

The development of CNV and ORT was strong risk factors for visual impairment. Due to the frequent recurrence of complications and poor visual prognosis, regular check-ups and appropriate treatment choices are warranted.

Case Report: Use of Multimodal Imaging to Document a Rare Complication of Torpedo Maculopathy

SIGNIFICANCE

This study demonstrates the importance of routine multimodal imaging for the diagnosis of choroidal neovascular membrane secondary to torpedo maculopathy.

CASE REPORT

A 63-year-old woman with a history of torpedo maculopathy presented with recent-onset symptoms of visual distortion in the right eye. Multimodal imaging modalities revealed the presence of a choroidal neovascular membrane. The choroidal neovascular membrane was treated, and the patient was subsequently followed up to monitor the retinal appearance over time. Significant structural restoration of the macular anatomy with overall functional improvement was seen.

CONCLUSIONS

Although torpedo maculopathy is often a benign diagnosis, complications such as choroidal neovascular membrane can occur. Choroidal neovascular membrane formation is well documented in younger patients with torpedo maculopathy; however, we present a rare case of choroidal neovascular membrane in an elderly individual. Multimodal imaging proved instrumental in the early detection and management of this infrequently reported complication.

Case Report: Focal Choroidal Excavation: Conversion from Conforming to Nonconforming in a Pregnant Female

SIGNIFICANCE

Although rarely seen, clinicians should closely monitor patients, especially pregnant patients with focal choroidal excavation (FCE), as it can convert between subtypes and has been linked to pachychoroidal disease and potential for vision loss.

PURPOSE

This study aimed to report a case of the conversion of conforming FCE to nonconforming FCE with spontaneous resolution in a pregnant female.

CASE REPORT

A 35-year-old Indian woman presented with a slightly decreased vision in the right eye. The patient was 3 months pregnant at this visit. Her ocular history included stable conforming FCE in both eyes that was diagnosed 1 year earlier. Retinal pigmentary changes were noted in both eyes and consistent with previous examinations as being conforming FCEs in both eyes. Optical coherence tomography through the pigmented changes revealed FCE in the right eye with overlying serous fluid, with the left eye showing stable conforming FCE. She was diagnosed with a nonconforming FCE in the right eye secondary to her pregnancy. She was monitored with subsequent visits showing spontaneous resolution of the fluid and conversion back to a conforming FCE.

CONCLUSIONS

This case highlights the conversion of a conforming FCE to a nonconforming FCE with spontaneous resolution in a pregnant female. Similarities are seen in terms of pathophysiology with central serous chorioretinopathy, a fellow pachychoroidal disease, which also has pregnancy as a risk factor. Risk factors in pregnant patients such as increased cortisol and increased ocular blood flow may play an important part in the pathophysiology of the conditions, as they both result in choroidal hyperpermeability. Frequent monitoring and follow-up times are suggested for the patients. Lifelong monitoring is also indicated, as reoccurrences have been reported. Further research is needed at this time to elucidate the exact etiology of FCE and conversions between conforming and nonconforming FCE.

CONVERSION OF FOCAL CHOROIDAL EXCAVATION WITH THE ONSET OF CENTRAL SEROUS CHORIORETINOPATHY: REPORT OF 2 CASES AND REVIEW OF THE LITERATURE

PURPOSE

To describe two cases of focal choroidal excavation (FCE) conversion in patients with central serous chorioretinopathy.

METHODS

Case report and literature review of cases of FCE conversion.

RESULTS

A 35-year-old asymptomatic pregnant patient was found to have conforming FCE on spectral domain optical coherence tomography of the right eye during hydroxychloroquine screening. Three months later, she presented with decreased vision in the right eye and subretinal fluid in both eyes secondary to central serous chorioretinopathy. Spectral domain optical coherence tomography revealed that her FCE had changed to nonconforming type. A 40-year-old male patient was found to have nonconforming FCE and subretinal fluid in his right eye on spectral domain optical coherence tomography. On follow-up, spectral domain optical coherence tomography demonstrated resolution of subretinal fluid and conversion of nonconforming FCE to conforming type. Literature review showed that most cases of FCE remain stable over time. Conversion from nonconforming FCE to conforming type has been described after photodynamic therapy or anti-vascular endothelial growth factor therapy. Conversion from conforming to nonconforming type has been described in 2 cases that developed subretinal fluid in the setting of acute central serous chorioretinopathy.

CONCLUSION

Our cases and literature review suggest that nonconforming FCE is the result of persistent subretinal fluid. Further studies are necessary to determine whether symptomatic nonconforming SRF needs treatment to reduce subretinal fluid.

Morphological features of focal choroidal excavation and its association with macular pathology in Asian Indian eyes

Purpose

To study the characteristics of focal choroidal excavation (FCE) in Indian eyes based on spectral-domain optical coherence tomography (SD-OCT) findings and their association with macular pathologies.

Methods

Retrospective study of 26 patients diagnosed with FCE. All patients' clinical and imaging data were reviewed.

Results

There were eight females and 18 males aged between 24 and 85 years. FCE was noted in 31 eyes of 26 patients - unilateral in 21 and bilateral in 5. The conforming type was noted in 13 and nonconforming in 19 eyes. The location was extrafoveal in 16 and subfoveal in 15 eyes. The morphology was bowl-shaped in 24, cone-shaped in six eyes, and mixed type in one eye. Associated pathologies were central serous chorioretinopathy in nine eyes, choroidal neovascular membrane in seven eyes, Stargardt's disease in three eyes, Best disease in four eyes, other retinal dystrophies in two eyes, polypoidal choroidal vasculopathy and moderate non-proliferative diabetic retinopathy, each in one eye. The mean FCE width was 1667.2 ± 817.7 μ, mean depth was 95.7 ± 46.4 μ, and the mean choroidal thickness under the FCE was 234.8 ± 85.9 μ. No abnormal choroidal tissue was found under any FCE.

Conclusion

FCE is a relatively common entity and frequently associated with macular pathologies. The presence of an FCE did not alter the course or management of these conditions.

CHOROIDAL INFLAMMATION AND CHORIOCAPILLARIS ISCHEMIA IN FOCAL CHOROIDAL EXCAVATION IN COMPARISON TO PACHYCHOROID NEOVASCULOPATHY

PURPOSE

To investigate the choriocapillaris and choroidal characteristics of focal choroidal excavation (FCE) to establish pathomechanisms of the disease.

METHODS

Thirty eyes with FCE, 26 eyes with pachychoroid neovasculopathy (PNV), and 25 participants without any conditions (control group) were analyzed retrospectively. The thickness of both choriocapillaris equivalent and whole choroid was measured at three different points: under the lesion (excavation or neovascularization), in the normal retina, and in the fovea of fellow eye. Indocyanine green angiographic images were collected to confirm choriocapillaris ischemia and the presence of choroidal inflammation.

RESULTS

In both FCE and PNV, choriocapillaris-equivalent attenuation was observed under the lesion compared with other region of the retina (28.1 ± 11.3 μm vs. 69.4 ± 20.0 μm in FCE; 23.5 ± 9.7 μm vs. 62.3 ± 14.7 μm in PNV; both P < 0.001). We also observed focal thinning of the whole choroid under the lesion (149.7 ± 88.7 μm vs. 296.6 ± 83.2 μm; P < 0.001) in FCE but not in PNV. Pachyvessels distribution on optical coherence tomography and numerous dark areas on indocyanine green angiography implied that choroidal inflammation was related to the FCE occurrence.

CONCLUSION

Choriocapillaris ischemia was related to both FCE and PNV. The choroidal thinning under the excavation and adjacent pachyvessels observed in FCE suggested that focal inflammation and scarring may contribute to choriocapillaris ischemia and eventual retinal pigment epithelium retraction with dysfunction in the pathomechanism.

Focal choroidal excavation disappearing after successful treatment of type 2 choroidal neovascularization with intravitreal aflibercept

Purpose

To report a case with focal choroidal excavation (FCE) accompanied by type 2 choroidal neovascularization (CNV), in which the CNV was successfully treated with intravitreal aflibercept, after which the FCE was no longer detectable.

Observations

A conforming type of FCE was detected in the left eye of a 34-year-old Japanese man who visited our hospital for a second opinion regarding treatment for his right eye. Three months later, type 2 CNV developed in the region corresponding to the FCE in the left eye. After treatment with intravitreal aflibercept, the CNV disappeared, and FCE was no longer detected. No recurrence has been observed in the 12 months following the treatment.

Conclusions and Importance

Although the etiology of FCE has not been fully elucidated, we discussed the mechanisms underlying its occurrence, its association with CNV, and the disappearance of both conditions after treatment.

Choroidal Cavitary Disorders

The structure and functions of the choroid have been long acknowledged but the pathophysiology behind various anomalies has been difficult to understand until the advent of optical coherence tomography (OCT). With OCT imaging, choroidal cavitations appear as optically empty spaces between the outer retinal and choroidal layers with attenuation or loss of outer retinal layers. Choroidal cavitations are found in the posterior pole and seen in conditions such as pathologic myopia, north carolina macular dystrophy (NCMD), focal choroidal excavation (FCE), and torpedo maculopathy (TM). To date, these disorders have not been linked. A commonality they all share is malformation of the RPE-photoreceptor-choroid complex. The following report describes the differences and similarities of choroidal cavitation amongst the different retinal disorders and emphasizes the importance of multimodal imaging in the detection and management of potential complications.

Focal choroidal excavation: review of literature

Focal choroidal excavation (FCE) is defined as an area of concavity in choroid detected on optical coherence tomography. These are mostly present in macular region without evidence of accompanying scleral ectasia or posterior staphyloma. Though initially considered to be congenital, increasing number of cases have been identified in association with other choroidal pathologies such as central serous choroidopathy, choroidal neovascularisation, polypoidal choroidal vasculopathy, choroiditis, choroidal tumours. In this review article, we aim to elaborate on the morphology, pathogenesis and differential diagnosis of FCE and specifically discuss the spectrum of diseases with known association along with the impact of their treatment on FCE

Focal Choroidal Excavation and Central Serous Chorioretinopathy Following Choroidal Neovascularization: A Longitudinal Case Study

Purpose:

This report describes the development of focal choroidal excavation (FCE) and recurrent central serous chorioretinopathy (CSCR) following the treatment of choroidal neovascularization (CNV) years earlier.

Methods:

A case report is presented.

Results:

A 30-year-old man previously treated for an active CNV returned several years later with subacute metamorphopsia. Optical coherence tomography and angiography demonstrated no recurrence of the CNV but instead found an FCE and associated CSCR in its place.

Conclusion:

Longitudinal follow-up with multimodal imaging demonstrated FCE with recurrent CSCR as possible sequelae of treated CNV.

Bilateral Multiple Focal Choroidal Excavations in a Patient with Paroxysmal Nocturnal Hemoglobinuria (PNH)

Focal choroidal excavation (FCE) is an unusual configuration characterized by focal thinning and pitting of the choroid in the absence of staphyloma or scleral ectasia. The etiology and clinical implications of FCE are currently unknown. We report a case of bilateral multiple FCEs in a patient with a long history of paroxysmal nocturnal hemoglobinuria (PNH). Focal choriocapillaris thinning and hyperreflectivity of the adjacent outer nuclear layer were revealed by spectral domain optical coherence tomography, which suggests the occlusion of the choriocapillaries and secondary degeneration of the above photoreceptors. We hypothesize that thrombophilia in the condition of PNH played an important role in the formation of FCE. Although there is no histopathological evidence to support the association between the choroid changes and PNH, this case may offer new clues as for the etiology of FCE.

Development of focal choroidal excavation in non-neovascular age related macular degeneration with pachy-choroid features

Purpose

To present a documented case of development of focal choroidal excavation (FCE) in non-neovascular age related macular degeneration (AMD).

Methods

An 86-year-old female with pachy-choroid was followed clinically for non-neovascular AMD. Successive optical coherence tomography (OCT) scans were reviewed with tracking software.

Results

Over the course of follow-up development of a FCE adjacent to a pachy-vessel along with disappearance of the pachy-vessel was documented in OCT.

Conclusions

This case is a documented development of FCE in an eye with pachy-choroid features. The possible mechanism in this scenario may be thrombosis of pachy-vessels.

Focal choroidal excavation: Cause or effect?

We report the imaging characteristics of focal choroidal excavation (FCE) and associated choroidal neovascular membrane (CNVM) and interpret the probable etiopathogenesis of FCE through findings in four patients detected by spectral-domain optical coherence tomography (SD-OCT). FCE was found as an acquired entity in two of our cases subsequent to treatment of CNVM, whereas in the two other cases FCE was pre-existing. Furthermore, association of FCE with pachychoroid spectrum is reaffirmed through this case series.

Focal choroidal excavation complicated with choroidal neovascularization in young and middle aged patients

AIM

To investigate the clinical and optical coherence tomography (OCT) features of focal choroidal excavation (FCE) complicated with choroidal neovascularization (CNV) in young and middle aged patients.

METHODS

We performed a retrospective review of 26 patients with FCE accompanied by CNV. All patients underwent a complete ophthalmic examination. We analyzed the clinical characteristics of patients, focusing on the spectral-domain OCT features. All patients received intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents. And we assessed the changes of central retinal thickness and best-corrected visual acuity (BCVA) after anti-VEGF therapy.

RESULTS

The mean age of 26 patients was 35.5±7.3y (range, 21-48y). Of the 26 FCE lesions, 11 were located subfoveal, 6 were parafoveal, and 9 were extrafoveal. The mean FCE depth was 129.8±50.3 µm, and the mean width was 901.3±306.0 µm. The FCE depth was correlated positively with the width, but not correlated with age or refractive error. CNV was located within the excavation (19 eyes) or adjacent to the excavation (7 eyes). After anti-VEGF therapy, the central retinal thickness was significantly reduced and the BCVA was significantly improved. In the absorption process of subretinal fluid, we found that the fluid in the excavations needed to be absorbed at the last. A small amount of residual fluid could still be seen in a few deep excavations even after a long-term follow-up.

CONCLUSION

FCE may be an important reason to cause CNV. Especially in young patients with idiopathic CNV, we should pay attention to the use of OCT to check the presence of FCE. Anti-VEGF therapy is generally effective for CNV associated with FCE.

THE EXPANDING CLINICAL SPECTRUM OF CHOROIDAL EXCAVATION IN MACULAR DYSTROPHIES

PURPOSE

To assess the prevalence and the clinical course of focal choroidal excavation (FCE) in patients affected by macular dystrophies.

METHODS

Prospective case series. All the patients underwent a complete ophthalmologic examination, including best-corrected visual acuity and spectral domain optical coherence tomography. The presence of choroidal neovascularization (CNV) was assessed on the basis of the leakage detected on fluorescein angiography.

RESULTS

A total of 162 eyes from 81 patients with macular dystrophy were included in the study. FCE was diagnosed in seven eyes (4.3% of the eyes), including four eyes with Best vitelliform dystrophy, two eyes with pattern dystrophy associated with pseudoxanthoma elasticum, and one case of Stargardt disease. In eyes with FCE and macular dystrophy, the mean best-corrected visual acuity was 0.4 ± 0.1 logarithm of the minimum angle of resolution (approximately corresponding to 20/50 Snellen equivalent) at baseline and was stable to 0.41 ± 0.1 logarithm of the minimum angle of resolution (approximately corresponding to 20/50 Snellen equivalent) at the final visit. In four of these seven eyes, FCE was associated with a subfoveal CNV. The CNV was managed with one intravitreal anti-vascular endothelial growth factor injection, achieving the complete anatomical stabilization of the CNV and recovery of the best-corrected visual acuity.

CONCLUSION

Focal choroidal excavation can be infrequently encountered in patients with macular dystrophies. The presence of CNV may complicate FCE in these patients, and anti-vascular endothelial growth factor seems to be an effective treatment with no progression of FCE over time.

Focal Choroidal Excavation Following Blunt Trauma

The authors report a case of nonconforming focal choroidal excavation (FCE) identified in an eye following blunt, nonperforating trauma to the globe. Multimodal imaging was undertaken including color fundus photographs, enhanced depth imaging optical coherence tomography, fluorescein angiography, and fundus autofluorescence. This shows that FCE may result from blunt ocular trauma. The authors hypothesize that loss of structural support provided by an intact Bruch's membrane may be a key factor in precipitating the specific morphological changes associated with FCE occurring in a range of clinical settings. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:187-190.].

Development of Secondary Choroidal Neovascularization in Focal Choroidal Excavation of Punctate Inner Choroidopathy

Purpose: To elaborate a case of focal choroidal excavation (FCE) in punctate inner choroidopathy (PIC) complicated by secondary choroidal neovascularization (CNV) based on multimodal imaging findings.Methods: In this retrospective case report, multimodal imaging including near-infrared reflectance, blue peak autofluorescence, spectral domain-optical coherence tomography (OCT), fluorescein and indocyanine green angiography (Heidelberg Engineering GmbH, Germany), and swept source-OCT angiography (SS-OCTA; Topcon Corporation, Japan) was performed.Patients: A 27-year-old moderate myopic woman presented with inactive CNV of unknown origin in her left eye, which had been previously treated with intravitreal anti-vascular endothelial growth factor.Results: Multimodal imaging revealed PIC as the causative disease and systemic corticosteroids were administered. Similar complaints 13 months later showed new CNV formation at the already documented FCE. No sign of PIC could be detected at follow-up.Conclusion: This well-documented case highlighted FCE as the preferential location for CNV development in PIC with multimodal imaging emphasizing a chorioretinal entity.Summary: This case report demonstrated the clinical course of focal choroidal excavation in a patient initially diagnosed with punctate inner choroidopathy complicated by choroidal neovascularization and its treatment response, well documented by multimodal imaging including optical coherence tomography angiography.

A CASE OF FULL-THICKNESS MACULAR HOLE IN EYE WITH FOCAL CHOROIDAL EXCAVATION

PURPOSE

To report an association between a Stage 4 full-thickness macular hole and focal choroidal excavation.

METHODS

Case report.

RESULTS

A 46-year-old male patient with high myopia was referred for macular hole surgery and found to have an associated focal choroidal excavation. The patient underwent uneventful combined procedure with closure of macular hole.

CONCLUSION

Successful macular hole surgery can be achieved even in the presence of focal choroidal excavation.

Fibrotic pillar leads to focal choroidal excavation in Best vitelliform dystrophy

PURPOSE

To study focal choroidal excavations in patients with Best vitelliform dystrophy using optical coherence tomography and their topographical relation with fibrotic pillars.

METHODS

This is a retrospective cross-sectional study of consecutive patients diagnosed with Best vitelliform dystrophy at a tertiary eye care center. Records of patients with Best vitelliform dystrophy were reviewed for best-corrected visual acuity, color fundus photographs, shortwave autofluorescence, optical coherence tomography, and electrooculogram with special emphasis on the presence of focal choroidal excavation (FCE) and fibrotic pillar. Main outcome measure was to study the fibrotic pillar in relation to the FCE.

RESULTS

Thirty-eight eyes of 19 patients with mean age of 34.6 years were enrolled in the study. FCE was seen in eight eyes of six patients. Two patients had bilateral FCE and all the FCEs were located in the area of vitelliform lesion. Six out of eight eyes with FCE were in vitelliruptive stage of disease; one was in pseudohypopyon stage and one in atrophic stage. A fibrotic pillar was seen lying directly above the FCE in seven eyes. In one eye, hyper-reflective material not amounting to fibrotic pillar was seen lying above the FCE.

CONCLUSION

A focal choroidal excavation in the setting of Best vitelliform dystrophy is seen predominantly in the vitelliruptive stage of the disease. Fibrotic pillars appear to play a role in the formation of these FCEs.

Focal choroidal excavaction associated with idiopathic choroidal neovascularization

CASE REPORT

The case is presented of a 45 year-old man with a focal choroidal excavation associated with choroidal neovascularisation not included in the area of excavation. Clinical features were analysed using retinography, fluorescein angiography, optical coherence tomography, and optical coherence tomography angiography. The patient was treated with 3 intravitreal injections of bevacizumab, with a good response.

DISCUSSION

Focal choroidal excavation can be associated with choroidal neovascularization not included in the area of excavation. Multimodal imaging provides a complete description of clinical features, before and after treatment.

Optical coherence tomography: A guide to interpretation of common macular diseases

Optical coherence tomography is a quick, non invasive and reproducible imaging tool for macular lesions and has become an essential part of retina practice. This review address the common protocols for imaging the macula, basics of image interpretation, features of common macular disorders with clues to differentiate mimickers and an introduction to choroidal imaging. It includes case examples and also a practical algorithm for interpretation.

Nonconforming Deep Focal Choroidal Excavation in a Patient With Choroidal Osteoma: A Diagnostic Dilemma

Evolution of an osteoma may result in neurosensory detachment, deossification, and choroidal neovascularization (CNV). The authors report a rare case of choroidal osteoma with CNV associated with a deep non-conforming focal choroidal excavation. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:944-947.].

A CASE OF NEUROFIBROMATOSIS TYPE 2 WITH UNUSUAL CLINICAL FEATURES

PURPOSE

To report a case of a neurofibromatosis Type 2 with unusual clinical features.

METHODS

Observational clinical case report.

RESULTS

A 22-year-old woman was referred with bilateral blurred vision and macular "scars." Ocular examination revealed bilateral posterior subcapsular and cortical cataract, optic disk swelling, hyperpigmented macular lesions, epiretinal membrane, and macular temporal dragging. Spectral-domain optical coherence tomographic imaging showed bilateral epiretinal membranes, peripapillary nerve fiber layer thickening, and vitreoretinal tractional bands. In the right eye, focal choroidal excavation was noted at the site of the macular lesion. In fluorescein angiography, mild vascular leakage, capillary nonperfusion, and ground glass hyperfluorescence was seen in temporal periphery of the right eye. Brain imaging showed intracranial calcification and vestibular schwannoma, which was removed by a neurosurgeon. A clinical diagnosis of neurofibromatosis Type 2 was made.

CONCLUSION

A case of neurofibromatosis Type 2 with some possibly novel or rare findings, namely, focal choroidal excavation, ash leaf spots, and intracranial calcifications was presented.

FOCAL CHOROIDAL EXCAVATION AND ITS ASSOCIATION WITH PACHYCHOROID SPECTRUM DISORDERS: A Review of the Literature and Multimodal Imaging Findings

PURPOSE

To review the literature regarding focal choroidal excavation and show its association with pachychoroid features through case examples.

METHODS

The clinical manifestations of focal choroidal excavation are illustrated with various imaging modalities inclusive of fundus photography, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, spectral domain optical coherence tomography (OCT), enhanced depth imaging OCT, and swept-source OCT.

RESULTS

Diffuse or focal areas of choroidal thickening with dilated choroidal vessels (pachyvessels) on OCT and choroidal hyperpermeability on indocyanine green angiography are present in many eyes with focal choroidal excavation. Clinical and imaging features of associated comorbidities including central serous chorioretinopathy and choroidal neovascularization are described.

CONCLUSION

Focal choroidal excavation appears to be a manifestation of pachychoroid spectrum disease associated with choroidal thickening and pachyvessels on structural OCT and choroidal hyperpermeability on indocyanine green angiography.

Focal choroidal excavation and a traumatic macular hole secondary to accidental Q-switched Nd:YAG laser

Today, the widespread use of laser instruments in various fields has resulted in many accidental retinal injuries. Here we describe a rare clinical case of full-thickness macular hole (MH) and focal choroidal excavation (FCE) caused by a 1064-nm Q-switched Nd:YAG laser. After pars plana vitrectomy and the following 14 months, consecutive optical coherence tomography imagings showed closure of the MH. Visual acuity improved even in the absence of the outer retina and in the presence of FCE. We speculate that different focusing effects of the unexpected Nd:YAG lasers which target different levels of retinal tissue generate diverse prognosis.

Optical Coherence Tomography Angiography Study of Choroidal Neovascularization Associated With Focal Choroidal Excavation

The authors report the use of optical coherence tomography angiography (OCTA) (DRI OCT Triton; Topcon, Tokyo, Japan) to localize, characterize, and confirm the presence of a choroidal neovascular membrane in a patient of focal choroidal excavation (FCE) with recent-onset metamorphopsia and visual blurring. En face OCTA images just above the level of the retinal pigment epithelium-Bruch's membrane complex typically showed the presence of a glomerulus-like neovascular network with an adjacent dark area suggestive of a Type 2 choroidal neovascularization (CNV). OCTA was found to be a very useful, noninvasive, and quick imaging modality to detect secondary CNV formation in a case of FCE. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:969-971.].

Focal choroidal excavation-morphological features and clinical correlation

PurposeTo describe and correlate the morphological and clinical features of focal choroidal excavation (FCE).MethodsThis is a consecutive case series from the review of the 4436 optical coherence tomography scans performed by Kowloon East Cluster Ophthalmic Service from 1 August 2014-31 January 2016. Statistical analysis was performed on SPSS 18.0 (SPSS, Chicago, IL, USA). A significance level of P<0.05 was taken.ResultsAll 16 patients with FCE had unilateral involvement. The mean age of diagnosis was 52.56±14.00. The mean greatest linear dimension (GLD) of FCE was 636.25±265.11 μm. The mean choroidal thickness was 183.63±52.39 μm. Fourteen FCEs (87.5%) were conforming and two were non-conforming (12.5%). In the eyes with FCE, concurrent macular pathology was present in four cases (25.0%). Tractional pathologies of macular pucker and macular scar corresponded to the two non-conforming FCEs in the series. Polypoidal choroidal vasculopathy (PCV) and lacquer crack had a close topographic relationship with the FCE. The mean GLD was significantly larger in eyes with concurrent macular pathology than those without (878.00 vs 555.67 μm, P=0.029). In the fellow eyes, concurrent macular pathology was present in 5 cases (31.3%): PCV in 3 cases and chronic central serous chorioretinopathy in 2 cases.ConclusionAs a significant proportion of FCE is associated with concurrent macular pathology in the involved or fellow eye, angiography for both eyes is recommended even for asymptomatic cases. The GLD of FCE may have clinical value in risk stratification.

Focal Choroidal Excavation

Focal choroidal excavation is a choroidal pit that can be detected by optical coherence tomography. Central serous chorioretinopathy, choroidal neovascularization and polypoidal choroidal vasculopathy are pathologies associated with focal choroidal excavation. In this article, we present the follow-up and treatment outcomes of three eyes of two patients with focal choroidal excavation.

Spectrally encoded common-path fiber-optic-based parallel optical coherence tomography

We demonstrate a fiber-optic-based parallel optical coherence tomography (OCT) using spectrally encoded extended illumination with a common-path handheld probe, where the flexibility and robustness of the system are significantly improved, which is critical in the clinical environment. To the best of our knowledge, we present the first parallel OCT based on fiber optics including a fiber coupler with a sensitivity of 94 dB, which is comparable to that of point-scanning OCT. We also investigated the effect of the phase stability of the fiber-based interferometry on the parallel OCT system by comparing the common-path OCT with two-arm OCT. Using the homemade common-path handheld probe based on a Mirau interferometer, the phase stability was 32 times better than that of the two-arm OCT. The axial resolution of the common-path OCT was measured as 5.1±0.3  μm. To demonstrate the in vivo imaging performance of the fiber-optic-based parallel OCT, human skin was imaged.

Focal Choroidal Excavation in Retinal Dystrophies

AIM

To investigate the presence of focal choroidal excavation (FCE) in patients with retinitis pigmentosa (RP), Stargardt's disease (STGD), and Best disease in the Indian population.

METHODS

This retrospective consecutive case series included 309 eyes of 157 patients with RP (183 eyes), STGD (93 eyes), and Best disease (33 eyes) with good-quality, enhanced-depth spectral domain optical coherence tomography scans. Comprehensive ophthalmic examination data were collected. Characteristics of FCE, including location of FCE, type (conforming and non-conforming), maximal width, and depth, were noted.

RESULTS

FCE was found in 2 out of 33 (6%) eyes with Best disease and no FCE was found in eyes with RP or STGD. The location of the FCE was extrafoveal in both cases. The first case had non-conforming FCE while the second case had the conforming type and the FCE occurred in association with choroidal neovascularization in the second case. The first case maintained good visual acuity of 20/20 over the entire period of follow-up (14 months), while the second case had a visual acuity of 20/200 at the last follow-up (three years) due to scarred choroidal neovascular membranes. The FCE showed no change in both eyes over the entire duration of follow-up.

CONCLUSION

Focal choroidal excavation was found in 6% of eyes with Best disease, which remained stable throughout follow up. Eyes with RP and STGD did not have any FCE. Further studies are required to determine the role of vitelliform material in FCE development in Best disease.

Another Form of Focal Choroidal Excavation Based on Multimodality Imaging

PURPOSE

To describe a peculiar choroidal entity using multimodality imaging and to further understand the relationship between focal choroidal excavation and central serous chorioretinopathy.

CASE REPORT

A peculiar entity was detected in both eyes of a 20-year-old male patient who was followed for more than 4 years; one perifoveal focal choroidal excavation and two extrafoveal focal choroidal excavations were noted in each eye. The bilateral perifoveal focal choroidal excavations exhibited progressive development with repeated interconversion between the nonconforming and conforming types. Dilated choroid blood vessels were detected by en face spectral-domain optical coherence tomography (SD-OCT). Although the ellipsoid zone and retinal pigment epithelium layer defect also involved the fovea, a visual acuity of 20/20 was maintained in both eyes, with neither metamorphopsia by Amsler grid nor abnormalities noted by multifocal electroretinogram. However, pigment epithelium detachment finally appeared in the right eye. The microperimetry test revealed reduced threshold sensitivity corresponding to the lesions, and near-infrared autofluorescence revealed increased hyperfluorescence at the latest visit.

CONCLUSIONS

Idiopathic focal choroidal excavation may convert to the structure of central serous chorioretinopathy alike, which likely indicates another rare condition of focal choroidal excavation or central serous chorioretinopathy. Wide- and deep-scanning modes should be routinely applied in OCT imaging to detect choroidal disorders.

Multimodal Imaging Evaluations of Focal Choroidal Excavations in Eyes with Central Serous Chorioretinopathy

Purpose. To investigate the prevalence and characteristics of focal choroidal excavation (FCE) concurrent with central serous chorioretinopathy (CSC) using multimodal imaging. Methods. This was a retrospective single-institution study. Clinical features and multimodal imaging findings were analyzed in eyes with CSC and FCEs, using imaging methods including optical coherence tomography (OCT), OCT angiography (OCTA), fluorescein angiography (FA), indocyanine green angiography (ICGA), fundus autofluorescence (FAF), and multispectral imaging. Results. Seventeen patients (4.8%) with 21 FCEs (19 eyes) were found among 351 consecutive Chinese patients with CSC. Chronic CSC represented 47.1% of those cases. Window defects in 12 lesions identified through FA and hypoautofluorescence in 13 lesions identified through FAF revealed retinal pigment epithelial attenuation. Choroidal hemodynamic disturbances characterized by localized filling defects at the excavation and circumferential hyperperfusion were validated by both ICGA and OCTA, which were similar to the angiographic features of normal chronic CSC. The hyperreflective tissue beneath FCE, observed on B-scan OCT, presented as intensive choroidal flow signals on OCTA. Conclusions. FCE is not uncommon in patients with CSC. Multimodal imaging suggested that the aberrant choroidal circulation might be a contribution factor for leakage from the dysfunctional retinal pigment epithelium at the area of excavation.