Serial Spectral-Domain Optical Coherence Tomography Findings in Acute Retinal Pigment Epitheliitis and the Correlation to Visual Acuity

Revisiting acute retinal pigment epitheliitis (Krill disease)

We reevaluate acute retinal pigment epitheliitis (ARPE) first described by Krill and Deutman in 1972, integrating a meticulous literature review with advanced multimodal imaging analyses. Our review included 98 eyes from 86 published cases diagnosed with ARPE. We scrutinized ARPE's clinical presentations, variability, and imaging characteristics, revealing that a large majority (90 %) of cases previously diagnosed as ARPE align more closely with other retinal disorders based on modern diagnostic criteria and imaging techniques. Only a small fraction (5 eyes) did not fit into any known categories, casting doubt on ARPE's distinct existence. This underscores the critical role of multimodal imaging in redefining our understanding of macular diseases and challenges the historical classification of ARPE as a unique clinical entity.

Multicolor imaging: Current clinical applications

Multicolor (MC) imaging is an innovative pseudocolor fundus imaging modality based on confocal scanning laser ophthalmoscopy. It effectively scans the retina at different depths to create a composite image. The green reflectance image depicts the middle retinal while blue reflectance image provides images of the retinal surface. The infrared reflectance image depicts retinal structures at the level of outer retina and choroid. We systematically analyze published case reports, case series, and original articles on MC imaging where it has helped in discovering additional clinical features of retinal diseases not readily apparent on conventional color fundus photography and played a role in monitoring the response to treatment.

Acute retinal pigment epitheliitis during treatment of hyperprolactinaemia

BACKGROUND

Acute retinal pigment epitheliitis (ARPE) is a rare, idiopathic and self-limiting disease. The article aims to present ARPE in a patient using D2 dopamine receptor agonists for the treatment of hyperprolactinemia.

CASE PRESENTATION

A 28-year-old female during hyperprolactinaemia treatment suffered from a dyschromatopsia and a central visual field defect in the left eye. She noticed a deterioration of vision and discontinued the cabergoline administration. The woman had not been diagnosed with other chronic conditions and exhibited no symptoms of infection. Upon admission, the patient was subjected to a test for COVID-19, which was negative. The ophthalmological examination revealed a decrease in visual acuity to distance in the left eye, which amounted to 18/20 on the Snellen chart. A central scotoma was noted on the Amsler chart and a loss of pigment epithelium was visible on the fundus of the left eye. Fluorescein angiography showed a discrete window defect in the left one, with no signs of leakage. Optical coherence tomography (OCT) scans of the maculae revealed a characteristic change in the photoreceptor layer and retinal pigment epithelium (RPE) in the fovea in the left eye. The electrophysiological tests revealed decreased function of cells in macular region. A magnetic resonance imaging (MRI) of the head and orbits demonstrated an asymmetric pituitary gland without chiasm compression and discrete signal enhancement from the left optic nerve. The patient underwent observation during hospitalisation. She reported improved colour vision and a decreased scotoma in the centre of her visual field. In regular outpatient follow-ups, successive improvements in visual acuity, as well as a decreased RPE damage and outer photoreceptor layer loss during an OCT test were observed.

CONCLUSIONS

A case of ARPE is reported in a patient taking medications for hyperprolactinemia. The role of dopamine receptor antagonists in the photoreceptor function and causation of ARPE needs further evaluation.

A Long Term Recurrent Case of Acute Retinal Pigment Epithelitis

PURPOSE

To describe the case of a young adult who developed two episodes of Acute Retinal Pigment Epithelitis (ARPE) in the same eye 7 years apart, describing retinal morphologic changes using SD-OCT scan.

OBSERVATIONS

ARPE is an acute, self-limiting macular disorder characterized by a stippled dark macular lesion surrounded by a hypopigmented halo under fundus examination, corresponding to a foveal disruption of the outer retinal layers and an hyperreflective lesion under SD-OCT scan. Despite ARPE lesions usually appearing to be situated within the macula, a diffuse involvement of the RPE has been suggested1. SD-OCT scan in our patient showed multiple focal lesions involving the whole posterior pole of the affected eye.

CONCLUSIONS AND IMPORTANCE

We report the first case where a diffuse involvement of the RPE in the disease is supported by an OCT finding and the case with the longest period between two recurrent self-limited episodes described so far.

ACUTE RETINAL PIGMENT EPITHELIITIS: ASSOCIATION WITH ACUTE COXSACKIE A VIRUS INFECTION

PURPOSE

The purpose of this study was to describe the occurrence of acute retinal pigment epitheliitis in association with serologic evidence of acute Coxsackie A virus infection.

METHODS

This study is a case report.

RESULTS

A 37-year-old man noted an acute onset of paracentral scotomas in his right eye correlating with stippled retinal pigment epithelial pigment alterations with whitish halos surrounding the fovea. Spectral domain optical coherence tomography revealed scattered distinct retinal pigment epithelial elevations in the paracentral macular region arranged in an annular fashion, with associated alterations in the interdigitation and ellipsoid zone layers anterior to the retinal pigment epithelial, characteristic of acute retinal pigment E. Suspicion of acute Coxsackie A virus in the patient because of the presence of simultaneous viral exanthematous illness in the patient's 1-year-old son prompted serologic testing for Coxsackie virus. Titers showed strongly positive IgM ("early") antibody for several Coxsackievirus A serotypes, including A16 (most commonly associated with hand-foot-mouth disease). Spontaneous regression of the anatomical and clinical findings occurred over the next month, with complete resolution noted 16 months later.

CONCLUSION

This is the first documented case of acute retinal pigment epitheliitis associated with evidence of acute Coxsackie A virus infection. Corroboration with serology in future cases would add to evidence that acute retinal pigment epitheliitis is part of the apparently expanding spectrum of recognized "Coxsackie retinopathies."

Foveal photoreceptor disruption in ocular diseases: An optical coherence tomography-based differential diagnosis

Fovea centralis, located at the center of the macula, is packed with cone photoreceptors and is responsible for central visual acuity. Isolated foveal photoreceptor disruption may occur in a variety of hereditary, degenerative, traumatic, and toxic chorioretinal diseases. These have been known previously by multiple synonyms including macular microhole, foveal spot, and outer foveal microdefects. A common clinical feature underlying these conditions is the presence of apparently normal fovea or subtle hypopigmented lesion at the foveal or juxtafoveal area. A detailed history along with high-resolution optical coherence tomography is often helpful to derive a conclusive diagnosis in majority of these cases. Focal photoreceptor disruption usually involves loss or rarefaction of ellipsoid/interdigitation zone, either in isolation or associated with external limiting membrane or retinal pigment epithelium disruption in the fovea. Vitreomacular interface (VMI) disorders including vitreomacular traction, posterior vitreous detachment, epiretinal membrane, and impending macular hole possibly remain the most common cause. Retinal dystrophies such as cone dystrophy, occult macular dystrophy, and achromatopsia may present with diminution of vision and normal appearing fundus in a younger age group. Other causes include photic retinopathy (e.g., from a history of sun gazing, or laser pointer exposure), blunt trauma, drug exposure (e.g., poppers maculopathy or tamoxifen retinopathy), and acute retinal pigment epitheliopathy (ARPE). Visual prognosis depends on the underlying etiology with complete recovery common in the subset of patients with VMI, and ARPE, whereas persistent outer retinal defects are the rule in other conditions. We discuss the differential diagnoses that lead to isolated foveal photoreceptor defects. Identifying and understanding the underlying disease processes that cause foveal photoreceptor disruption may help predict visual prognosis.

CLINICAL VARIANTS OF PRESUMED ACUTE FOVEALITIS

PURPOSE

To describe four eyes of three patients with presumed acute fovealitis to expand the clinical variants of this recently described disorder.

METHOD

The patients underwent a comprehensive ophthalmic examination, including multimodal imaging and electrophysiological tests.

RESULTS

Three female patients aged from 18 to 24 years presented sudden central visual disturbances in one or both eyes. The visual acuity ranged from 20/25 to 20/70 in the affected eyes. All of them showed a subtle yellowish lesion in the foveola. Fundus autofluorescence and fluorescein angiography were unremarkable. Optical coherence tomography disclosed focal disarrangement of the outer retinal layers restricted to the fovea and hyperreflective lesions above the external limiting membrane. Multifocal electroretinography responses were attenuated. The electrooculogram response was normal. All patients recovered normal visual acuity and the outer retinal layers.

CONCLUSION

Attenuated multifocal electroretinography foveal response and normal electrooculogram are newly described clinical findings in patients with acute fovealitis.

Atypical acute fovealitis in COVID-19 context

Purpose

To describe the clinical and multimodal imaging findings, including optical coherence tomography (OCT), and OCT angiography (OCTA) in a case presenting with acute fovealitis after COVID-19 infection, and its differential diagnosis.

Observations

A 39-year-old man presenting with acute central metamorphopsia in his right eye (OD) right after positive test for COVID-19 underwent comprehensive ophthalmic examination, including best corrected visual acuity (BCVA), color fundus (CF) examination, optical coherence tomography (OCT), OCT angiography (OCTA), fundus autofluorescence (FAF) and fluorescein angiography (FA). Baseline BCVA was 20/40 in his OD and fundus examination showed small inferior juxtafoveal hemorrhages with no other vascular abnormalities or peripheral changes. The OCT B-scans revealed a central focal defect of the ellipsoid and interdigitation zones associated with foveal and perifoveal columnar hyperreflectivities involving the photoreceptor layers, the external limiting membrane and outer nuclear layer up to the outer plexiform layer with preservation of the retinal pigment epithelium-Bruch's membrane complex. Both FAF and FA images were unremarkable. Over three months follow-up, the findings progressively resolved, and BCVA improved to 20/20.

Conclusions and importance

The presence of hyperreflective material at the fovea in association with adjacent hemorrhages, the absence of alterations of the retinal pigment epithelium in OCT, OCTA, FAF and FA suggested the diagnosis of acute fovealitis in COVID-19 context. The presence of these findings highlights the importance of detailed ophthalmic evaluation in symptomatic patients with COVID-19 positive test.

ACUTE FOVEALITIS

PURPOSE

To describe the clinical, optical coherence tomography (OCT), and OCT angiography findings of a patient with a foveal disturbance from the acute phase to the resolution of the visual disturbances.

METHOD

The patient had a comprehensive ophthalmic examination to include OCT and OCT angiography.

RESULTS

A 36-year-old man presented with decreased vision and distortion in the right eye. The right eye showed yellow-white punctate opacities in the central fovea. OCT showed numerous, well-defined, globular, aggregated, hyperreflective lesions that corresponded to the visible opacities along with a focal discontinuity of the outer retinal layers. Over 3 weeks, the patient's findings resolved, and the VA improved to 20/20. No abnormalities of the choriocapillaris flow were detected using OCT angiography. The lesion resolved without pigmentary change.

CONCLUSION

The configuration of the hyperreflective deposits, the lack of pigmentary change, and the absence of OCT angiographic findings of flow problems in the choriocapillaris argue against a primary retinal pigment epithelial or choriocapillaris abnormality as the fundamental cause of the disease. The name acute fovealitis is suggested.

Multimodal imaging of type 2 acute macular neuroretinopathy in a young woman

We report a case of type 2 acute macular neuroretinopathy (AMN) that occurred in an otherwise healthy 22-year-old white woman taking oral contraceptives and consuming large quantities of caffeinated coffee. The patient presented with a teardrop-shaped scotoma just inferior to her central vision in her left eye after a recent and significant increase in coffee consumption. A small extrafoveal retinal lesion was present superior to the fovea on pseudocolor fundus photography. Multimodal retinal imaging demonstrated focal disruption of the inner segment-outer segment junction of the photoreceptors with overlying hyperreflectivity at the level of the outer plexiform layer superior to the fovea, consistent with a diagnosis of type 2 AMN. Oral contraceptive use and high caffeine intake may be risk factors for the development of type 2 AMN.

ACUTE IDIOPATHIC MACULOPATHY: A Proposed Disease Staging Based on Multimodal Imaging

PURPOSE

To describe the clinical course and the multimodal imaging of acute idiopathic maculopathy.

METHODS

Medical records and multimodal imaging including color fundus photography, optical coherence tomography, and fundus autofluorescence were retrospectively reviewed. Recognition of the fundus autofluorescence patterns and their relationship with the disease duration, best-corrected visual acuity, and optical coherence tomography features represented the main outcome measures.

RESULTS

Seventeen eyes of 16 patients (7 women; mean age 29.9 years) with a mean follow-up of 23.9 months were included. The mean best-corrected visual acuity at presentation was 0.63 ± 0.54 logarithm of the minimum angle of resolution (Snellen equivalent, 20/85). All but one patient had the best-corrected visual acuity recovery to 20/20. Four sequential patterns of fundus autofluorescence corresponding to 4 proposed stages of disease were observed. Patterns 1 (central hypoautofluorescence with surrounding hyperautofluorescence) and 2 (stippled hyperautofluorescence and hypoautofluorescence) were found at presentation. Patterns 3 (central hyperautofluorescence surrounded by hypoautofluorescence) and 4 (hypoautofluorescence) were observed during the disease course and/or at the last follow-up visit. Duration of the disease was significantly different between patterns at baseline and last visit. Pattern 1 significantly related to the presence of subretinal detachment (Fisher's exact test; P =0.003) on optical coherence tomography in comparison with Pattern 2. Pattern 4 showed unique homogeneously decreased autofluorescence with corresponding attenuation of retinal pigment epithelium and restored outer retinal layers on optical coherence tomography.

CONCLUSION

A sequential disease staging based on multimodal imaging for acute idiopathic maculopathy is proposed. The recognition of the observed imaging patterns may help clinicians in the correct diagnosis and patient counseling.

RECURRENT ACUTE RETINAL PIGMENT EPITHELIITIS: SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY AND OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FEATURES

PURPOSE

To describe an atypical case of acute retinal pigment epitheliitis including spectral domain optical coherence tomography (OCT) and OCT angiography features.

METHODS

We report a 41-year-old woman with 3 episodes of acute retinal pigment epitheliitis over a 3-year period. Spectral domain OCT and OCT angiography images were acquired with Cirrus 5,000 spectral domain OCT.

RESULTS

Although acute retinal pigment epitheliitis is described as a benign, self-limited pathology, as this case shows, recurrences are possible. OCT angiography shows a choriocapillaris alteration and further recovery during the acute episodes.

CONCLUSION

Acute retinal pigment epitheliitis can present as a recurrent disease.

MULTICOLOR IMAGING IN A CASE OF ACUTE RETINAL PIGMENT EPITHELIITIS

PURPOSE

To describe multicolor imaging findings in a case of acute retinal pigment epitheliitis.

SETTING

Vitreoretinal department of a tertiary care center in Eastern India.

METHODS

A 28-year-old lady presented with acute vision loss in the right eye since 3 days. Left eye examination was unremarkable. Best-corrected visual acuity in the right eye was 20/40. Anterior segment examination revealed clear lens with no evidence of inflammation. There were no vitreous cells. Fundus examination of the right eye revealed a round orange lesion surrounded by a hypopigmented halo in the fovea with multiple tiny hypopigmented lesions temporal to the fovea. Fundus autofluorescence imaging of the right eye showed hyperautofluorescent lesions temporal to the fovea corresponding to the hypopigmented lesions seen temporal to the fovea. Spectral domain optical coherence tomography of the right eye revealed subfoveal hyperreflective lesion in the outer retina with disruption of the ellipsoid zone and interdigitation zone with a linear extension upward. Multicolor composite image of the right eye revealed the foveal lesion as circular red patch with an inferior orange extension. The infrared reflectance image revealed hyperreflective area corresponding to the foveal lesion. The blue and green reflectance images were unremarkable. The patient reported an upper respiratory tract infection 7 days before the visual loss. A diagnosis of acute retinal pigment epitheliitis was made based on history, clinical and imaging findings.

CONCLUSION

This is the first description of multicolor imaging signature of acute retinal pigment epitheliitis lesion in published literature. It seems to be a promising noninvasive imaging modality with a potential to replace color fundus photography.

A Novel Approach to Quantitative Evaluation of Outer Retinal Lesions Via a New Parameter "Integral" in Spectral Domain Optical Coherence Tomography

Purpose

The purpose of this study was to design a new parameter "integral" to quantitatively evaluate the spatial cumulative reflectivity of the outer retinal layers in optical coherence tomography (OCT), and to investigate its role in the detection of outer retinal diseases.

Methods

This was a cross-sectional study. Fovea-centered line OCT scans were performed on 60 eyes of 60 healthy volunteers and 44 eyes of 44 patients diagnosed with outer retinal diseases. The integrals of the ellipsoid zone (EZ) and interdigitation zone (IZ) were measured by respectively accumulating the grayscale values of all the pixels within the EZ and IZ at specified locations on the scanning lines, and were then adjusted by calculating their percentages on the outer retina. The integrals of the EZ and IZ were compared between the two groups.

Results

The integrals of the EZ and IZ were stably and normally distributed in the healthy eyes, and were significantly lower in eyes with outer retinal lesions than in healthy ones (P < 0.05). Moreover, the integrals of the EZ and IZ were correlated with best corrected visual acuity (BCVA; adjusted R² = 0.620) and the presence of outer retinal lesions (Nagelkerke R² = 0.767). The area under the receiver operating characteristic (ROC) curve was 0.954 (95% confidence interval [CI] = 0.918-0.990) when the integral was selected as a diagnostic variable.

Conclusions

Obtained from this novel quantification method, the new parameter integral was comparable between different individuals and had the potential to detect outer retinal abnormalities in reflectivity through OCT.

Translational Relevance

Our work verified the feasibility of the new image analysis technique in the detection of the diseases affecting the outer retina.

Spectral-domain optical coherence tomography finding of acute retinal pigment epitheliitis

Acute retinal pigment epitheliitis (ARPE) is a rare, transient macular disorder affecting healthy young adults. We describe the morphologic appearance of the retina by spectral-domain optical coherence tomography (SD-OCT) and to evaluate both the anatomic changes and the functional visual acuity changes over time in the course of disease. A 35-year-old healthy male presented with 1-week history of sudden-onset bilateral central scotoma with blurry vision. He denied trauma, excessive sun exposure, or drug abuse history or alkyl nitrites before. The medical and ocular examinations were unremarkable. The best-corrected visual acuity (BCVA) was 20/200 (OU) at the initial visit. Slit-lamp examination result was normal. Fundus examination revealed subfoveal yellowish lesions with a halo-like pigment in both eyes. The SD-OCT imaging showed subtle disruption of the retinal pigment epithelium (RPE) and abnormal hyperreflectivity throughout the full thickness of the foveola in both eyes. Six weeks later, the BCVA improved to 20/30 (OU) without any treatment. Six months later, the BCVA observed deteriorated to 20/50 (OU). SD-OCT demonstrated ellipsoid zone and cone outer segment tips line defects at the fovea with sharply defined borders. One year later from the initial visit, the BCVA improved to 20/20 (OU), but persisted macular microhole presents on the SD-OCT. The patient was followed for 1 year without any treatment. Thereafter, we noted that in the case of poor initial visual acuity, external limiting membrane, or outer nuclear layer involvement, as determined by SD-OCT, at the baseline might need longer time for visual acuity. The natural course of ARPE may involve the demonstration of a minor outer retinal defect that is similar to a macular microhole. In ARPE, like SD-OCT findings, the location of the initial lesion is the photoreceptor outer segments. It is not just limited to the RPE.