Epiretinal Neovascularization

Vitreomacular interface abnormalities in type 2 macular telangiectasia (MacTel)

PURPOSE

To describe the different types of vitreomacular interface abnormalities (VMIA) seen on optical coherence tomography (OCT) in type 2 macular telangiectasia (MacTel) and explain the possible reasons for its development.

METHODS

In this retrospective cross-sectional study, type 2 MacTel eyes with macular volumetric OCT imaging protocol were included to identify different types of VMIA such as abnormal PVD, vitreomacular traction (VMT), ERM, and lamellar and full-thickness macular hole. The VMIA findings were then correlated with different MacTel disease stages and visual acuity.

RESULTS

One thousand forty-three OCTs of 332 type 2 MacTel eyes from 169 patients at different visits were examined. VMIA was detected in 709 (68%) of those OCT scans in 216 (65%) eyes. There were 273 (39%), 31 (4%), 89 (13%), 7 (1%), and 381 (54%) OCT scans with vitreomacular adhesion, VMT, ERM, and inner and outer lamellar macular holes discovered respectively. VMIA eyes had a high frequency of abnormal PVD (p = 0.001) and retinal pigment clumps (RPCs) [p = 0.032]. Eyes with abnormal PVD (p = 0.034) and RPC (p = 0.000) had a higher rate of ERM development. RPC was linked to an increased risk of developing ERM (odd ratio 2.472; 95% CI 1.488-4.052). RPC and ERM contributed significantly to poor visual acuity (0.661 ± 0.416, 20/92).

CONCLUSION

OCT reveals a high frequency of VMIA in advanced type 2 MacTel eyes. RPC could be responsible for the development of anomalous PVD, as well as subsequent VMIAs and ERM. Additional work is required to examine the long-term changes and surgical outcomes of these eyes.

Sight threatening diabetic retinopathy in patients with macular telangiectasia type 2

PURPOSE

Although diabetes is highly prevalent in patients with MacTel, progression to severe non-proliferative (NPDR) and proliferative diabetic retinopathy (PDR) is rarely reported. We report multimodal imaging features of sight-threatening diabetic retinopathy (STDR) in eyes with macular telangiectasia type 2 (MacTel).

METHODS

Retrospective case series of seven participants of the MacTel Study at the Moorfields Eye Hospital NHS Foundation Trust study site and one patient from the Institute of Retina and Vitreous of Londrina, Brazil. Sight threatening diabetic retinopathy was defined as severe NPDR, PDR or diabetic macular edema.

RESULTS

We report imaging features of 16 eyes of eight patients (7/8, 87.5% female) with diagnoses of MacTel and type 2 diabetes mellitus with STDR. Mean (SD) age was 56 (8.3) years. Patients were followed-up for a mean time of 9.1 (4.7) years. A total of 10/16 (62.5%) eyes showed PDR and 2/16 (12.5%) eyes presented a macular epiretinal neovascularization.

CONCLUSIONS

People with diabetes mellitus and MacTel may not be protected from STDR as previously reported. Although the two diseases rarely co-exist, regular monitoring for diabetic retinopathy progression is recommended according to baseline retinopathy severity grades in line with established international guidelines. The presence of MacTel may not modify extended screening intervals, but there is no current evidence. The limited case series in the literature support treatment for complications and should follow the standard of care for either condition. Due to dual pathology, reactivation may be difficult to diagnose on standard imaging and multimodal imaging is recommended.

Epiretinal neovascular membrane in Macular Telangiectasia type 2: Multimodal imaging diagnosis

PURPOSE

To characterize an epiretinal neovascular membrane (ERNM) through multimodal imaging in the context of a patient with Macular Telangiectasia type 2 (MacTel) and ipsilateral concomitant ocular ischemic syndrome (OIS).

METHODS

Case report, with ultra-wide field (UWF) retinography, fluorescein angiography (FA), swept source optical coherence tomography (ss-OCT), and OCT-angiography (OCTA). Written informed consent for patient information and images to be published was provided by the patient. Approval from the Research Ethics Committee of the Hospital was obtained for publication.

CASE REPORT

Yearly follow up of a 51 year-old-female patient with advanced bilateral MacTel showed new punctate hemorrhages in all four quadrants of her right eye (OD). OCTA showed an ERNM in the superficial capillary plexus of the same eye and FA confirmed the ERNM and demonstrated peripheral ischemia. Carotid ultrasound was performed and complete right carotid artery occlusion was confirmed. These findings allowed the diagnosis of an ERNM associated with Mactel and OIS.

CONCLUSIONS

Interestingly, this case shows an ERNM diagnosed by multimodal imaging in a patient with advanced MacTel and a concomitant OIS. Mactel is a neurodegenerative disease which in its neovascular stage has been associated with macular neovascular membranes, but also ERNM have recently been described by OCTA.

Epiretinal membrane formation and optic disc vascularisation in type 2A macular telangiectasia (MacTel)

PURPOSE

To describe a rare clinical finding of epiretinal membrane (ERM) and abnormal optic disc vascularisation in type 2A macular telangiectasia (MacTel).

CASE DESCRIPTION

A 52-year-old asymptomatic healthy male was examined in the retina clinic. In both eyes, corrected visual acuity was 20/20, N6. Anterior segment examination and intraocular pressure were both normal in both eyes.

RESULTS

The right eye's dilated fundus examination revealed loss of retinal transparency and superficial intraretinal crystals. A thick ERM extending from the optic disc to the macula obscured the details of the underlying perifoveal region in the left eye fundus. The diagnosis of bilateral type 2 MacTel was confirmed by confocal blue reflectance imaging, fluorescein angiography (FA), and macular optical coherence tomography (OCT). The left eye macular OCT scan also revealed a thick ERM without causing significant retinal traction. Furthermore, FA of the left eye revealed early hyperfluorescence with intense late leakage at the inferior aspect of the optic disc, giving the impression of abnormal optic disc vascularisation. No other cause for the disc vascularisation could be identified. OCT scan through the area with the optic disc leakage revealed a tuft of irregular hyperreflective tissue lying over the ERM. OCT angiography imaging confirmed the vascularity within the tuft of hyperreflective tissue over the ERM. Over a two-year period, no changes in clinical or imaging features were observed.

CONCLUSION

In type 2A MacTel eyes, ERM formation and abnormal disc vascularisation are uncommon findings. More histopathologic research is needed to characterise these membranes.

A pilot optical coherence tomography angiography classification of retinal neovascularization in retinopathy of prematurity

Extraretinal neovascularization is a hallmark of treatment-requiring retinopathy of prematurity (ROP). Optical coherence tomography angiography (OCTA) offers vascular flow and depth information not available from indirect ophthalmoscopy and structural OCT, but OCTA is only commercially available as a tabletop device. In this study, we used an investigational handheld OCTA device to study the vascular flow in and around retinal neovascularization in seven preterm infants with treatment-requiring ROP and contrasted them to images of vascular flow in six infants of similar age without neovascular ROP. We showed stages of retinal neovascularization visible in preterm infants from 32 to 47 weeks postmenstrual age: Intraretinal neovascularization did not break through the internal limiting membrane; Subclinical neovascular buds arose from retinal vasculature with active flow through the internal limiting membrane; Flat neovascularization in aggressive ROP assumed a low-lying configuration compared to elevated extraretinal neovascular plaques; Regressed neovascularization following treatment exhibited decreased vascular flow within the preretinal tissue, but flow persisted in segments of retinal vessels elevated from their original intraretinal location. These findings enable a pilot classification of retinal neovascularization in eyes with ROP using OCTA, and may be helpful in detailed monitoring of disease progression, treatment response and predicting reactivation.

Multimodal imaging of epiretinal neovascularization associated with type 3 macular neovascularization

PURPOSE

To report a case of type 3 macular neovascularization presenting with an epiretinal neovascularization.

METHODS

Case report.

RESULTS

A 65-year-old gentleman presented with complaints of reduced vision in the left eye (LE) having a best corrected visual acuity (BCVA) of 20/200. Based on fundus examination and multimodal imaging findings he was diagnosed with type 3 macular neovascularization (MNV). An additional unusual finding was the presence of an epiretinal membrane (ERM) and epiretinal neovascularization (ERN), with the latter finding being confirmed on optical coherence tomography angiography (OCTA). He underwent three doses of intravitreal ranibizumab injection following which there was reduction in the epiretinal vascularity.

CONCLUSIONS

Multimodal imaging of this case highlights the presence of epiretinal neovascularization associated with type 3 MNV, which has not been reported previously.

Unraveling the mysteries of macular telangiectasia 2: the intersection of philanthropy, multimodal imaging and molecular genetics. The 2022 founders lecture of the pan American vitreoretinal society

PURPOSE

Offer a personal perspective on the scientific advances on macular telangiectasia type 2 (MacTel2) since the launch of the MacTel Project in 2005.

DESIGN

Literature review and personal perspective.

METHODS

Critical review of the peer-reviewed literature and personal perspective.

RESULTS

Generous financial support from the Lowy Medical Research Institute laid the foundations of the MacTel Project. MacTel Project investigators used state of the art multimodal retinal imaging and advanced modern biological methods to unravel many of the mysteries surrounding MacTel2. Major accomplishments includes elucidation of the pathogenic role that low serine levels, elevated 1-deoxysphingolipids and other mechanisms induce mitochondrial dysfunction which lead to Müller cell and photoreceptor degeneration; the use of objective measures of retinal structures such as the area of ellipsoid zone disruption as an outcome measure in clinical trials; the demonstration that the ciliary neurotrophic factor slows down retinal degeneration and the development of a new severity scale classification based on multimodal imaging findings.

CONCLUSIONS

MacTel2 is a predominantly metabolic disease characterized by defects in energy metabolism. Despite relatively good visual acuities, MacTel2 patients experience significant visual disability. The Mac Tel Project has been instrumental in advancing MacTel2 knowledge in the past two decades.

Clinical Use of Optical Coherence Tomography Angiography in Retinal Diseases

The advent of optical coherence tomography angiography (OCTA) is one of the cornerstones of fundus imaging. Essentially, its mechanism depends on the visualization of blood vessels by using the flow of erythrocytes as an intrinsic contrast agent. Although it has only recently come into clinical use, OCTA has become a non-invasive diagnostic tool for the diagnosis and follow-up of many retinal diseases, and the integration of OCTA in multimodal imaging has provided a better understanding of many retinal disorders. Here, we provide a detailed overview of the current applications of OCTA technology in the diagnosis and follow-up of various retinal disorders.

Epiretinal Membrane and Vitreomacular Traction Associated With Vasoproliferative Tumor in Macular Telangiectasia Type 2: A Case Report

We report a case of a 62-year-old man who presented with blurred and distorted vision in both eyes. Fundus examination revealed a fibrous band-like membrane emanating from the disc to the foveal center in the right eye, aneurysmal gray parafoveal lesions in both eyes, and an inferotemporal peripheral vascular tumor in the right eye. The presence of an epiretinal membrane with vitreomacular traction in this patient has led to the diagnosis of an incidental peripheral vascular tumor. To our knowledge, there are no reports describing an association between macular telangiectasia type 2 and epiretinal membrane formation with vitreomacular traction due to a vasoproliferative tumor.

Contributory factors for developing foveal neovascularization in proliferative diabetic retinopathy

Purpose

Foveal neovascularisation (NV) in proliferative diabetic retinopathy (PDR) is uncommon. The study aim is to analyse a series of cases of foveal NV in PDR and ascertain the factors leading to its development.

Methods

In this retrospective case-control study, optical coherence tomography (OCT) and OCT-angiography (OCTA) images of PDR cases with/without foveal NV diagnosed on fluorescein angiography were analysed.

Results

From 124 consecutive PDR eyes, foveal NV was identified in 12 (10%) eyes. Eyes with foveal NV showed thin choroid (p = 0.001), increased FAZ area and reduced vessel density at the macula compared to control group on OCT and OCTA. After regression analysis, an increased FAZ in the superficial capillary plexus slab (p = 0.002) was associated with foveal NV development.

Conclusion

Our case series suggest that foveal NV is an uncommon finding, occurring due to reduced choroidal and inner retinal perfusion at the macula. Further studies are required to assess the treatment outcomes in such eyes.

OCT Angiography as an Interdisciplinary Diagnostic Tool for Systemic Diseases

In recent years, OCT angiography (OCT-A) has emerged as a well established imaging modality of the retina. This allows non-invasive visualisation of the retinal circulation at a micrometre scale in eye disorders and systemic diseases with potential ocular involvement. This review summarises the current state of this topic.

The preproliferative stage in type 2 macular telangiectasia (MacTel type 2)

PURPOSE

To study clinical and imaging features of various stages of macular telangiectasia (MacTel type 2).

METHODS

In this retrospective study, cases of MacTel type 2 with fluorescein angiography (FA), optical coherence tomography (OCT) and OCT-angiography (OCTA) imaging were included. Based on angiographic perifoveal fluorescence, two groups were formed: group 1: diffuse hyperfluoroscence and group 2: diffuse + focal hyperfluoroscence. Later, based on OCT features, group 2 was subdivided into group 2A: without SRNVM and group 2B: with SRNVM. Clinical, FA, OCT and OCTA features were analysed. Eyes showing conversion to the proliferative stage at final visit were noted.

RESULTS

Ninety-four eyes of 48 patients were included. Group 1 (n = 28) showed diffuse perifoveal hyperfluoroscence, hyperreflective middle retinal layers, absent SRNVM (p = 0.006) on OCT and dilated perifoveal capillaries in deep capillary plexus (DCP) on OCTA. Group 2A (n = 40) showed diffuse + focal perifoveal hyperfluoroscence, hyperreflective middle retinal layers (p = 0.001), hyporeflective outer retina cavities (p = 0.021), absent SRNVM with dilated and bunching perifoveal capillaries (p = 0.004) in DCP. Group 2B (n = 26) showed late diffuse + focal perifoveal hyperfluoroscence, foveal contour irregularity (p = 0.002), retinal pigment clumps (p = 0.015) and SRNVM on OCT with bunching of capillaries in DCP and vessels in outer retina (p = 0.002). Five eyes showed conversion to group 2B at final visit.

CONCLUSION

There exists a distinct disease stage called "preproliferative" MacTel type 2 showing clinical features of non-proliferative disease, diffuse + focal perifoveal hyperfluoroscence on FA, absent SRNVM on OCT and bunching perifoveal capillaries in DCP on OCTA. Its identification is important for suspecting proliferative disease, planning management and follow-up visit accordingly.

Morphological characteristics preceding exudative neovascularisation secondary to macular telangiectasia type 2

AIMS

To identify morphological characteristics preceding the development of exudative neovascularisation secondary to Macular Telangiectasia type 2 (MacTel) using multimodal retinal imaging.

METHODS

In this retrospective study, eyes with a minimum observation period of 6 months prior to the de novo diagnosis of an exudative neovascularisation secondary to MacTel were analysed. Morphological changes preceding the formation of neovascularisation were evaluated using colour fundus photography, infrared imaging, fluorescein angiography, macular pigment measurement and optical coherence tomography (OCT). OCT-angiography (OCT-A) images were additionally available in a subset of patients.

RESULTS

Twenty eyes from 20 patients were examined over a median period of 17 months (range: 6-100 months). Eyes were characterised by an accelerated progression of ellipsoid zone loss (median of 0.013 mm²/month), increased thickness of the temporal parafovea and hyper-reflective lesions on OCT. The latter underwent morphological changes preceding the development of exudative neovascularisation, including an increase in size and density, and expansion to outer retinal layers and the retinal pigment epithelium. All eyes showed a foveal depletion of macular pigment. On OCT-A, a focal increase in blood flow was observed at the level of the outer retina/choriocapillaris, and retinal-retinal and retinal-choroidal anastomoses preceded the formation of exudative neovascularisation.

CONCLUSIONS

Multimodal imaging allows the identification of prognostic morphological features preceding the formation of exudative neovascularisation in MacTel. Eyes exhibiting these characteristics should be monitored closely and patients should be alert for emergent symptoms in order to detect and treat neovascularisation early and, thereby, prevent irreversible visual loss.