Characteristic Needle-Shaped Pattern Seen on OCT in a Patient with Ocular Amyloidosis

AN 82-YEAR-OLD WOMAN WITH RETINAL VASCULAR SHEATHING AND VITREOUS HEMORRHAGE

PURPOSE

This report describes a case of hereditary transthyretin amyloidosis in an 82-year-old woman who presented with bilateral retinal arteriolar vascular sheathing and vitreous hemorrhage in one eye.

METHODS

The patient underwent a full history, physical examination, genetic workup, and cardiac imaging to establish the diagnosis. Fundus photographs, optical coherence tomography, fluorescein angiography, and indocyanine green angiography were performed throughout the patient's treatment course.

RESULTS

Fundus examination demonstrated segmental sheathing of the retinal arterioles, telangiectasias, and intraretinal hemorrhages in both eyes without neovascularization. Fluorescein angiography revealed delayed filling of the nasal retinal arterioles in the right eye with severe temporal nonperfusion and areas hyperfluorescent segmental sheathing in both eyes. Ocular coherence tomography demonstrated retinal vessels with hyperreflective thickened walls. Cardiac amyloid nuclear scan was consistent with transthyretin-mediated amyloidosis amyloid heart disease, and genetic testing confirmed a heterozygous pathogenic transthyretin mutation: c.290 C>A (p.Ser97Tyr) also known as Ser77Tyr.

CONCLUSION

Amyloidosis should be considered in the differential of vasculitis and vitreous hemorrhage with or without significant vitreous opacities. Ophthalmologists aware of this diagnosis should complete a full review of systems with specific focus on cardiac history and symptoms of peripheral neuropathy when amyloidosis is in the differential.

Monitoring the Patient with Retinal Angiopathy Associated with Hereditary Transthyretin Amyloidosis: Current Perspectives

Retinal angiopathy associated with hereditary transthyretin amyloidosis (ATTRv), if untreated, may lead to irreversible vision loss. Our purpose was to systematically review the clinical and imaging features of retinal angiopathy associated with ATTRv and assemble a monitoring approach for these patients. All types of original research studies reporting clinical and imaging findings on retinal angiopathy associated with ATTRv were included. The most common clinical findings were tortuous retinal vessels, microaneurysms, retinal hemorrhages, sheathing of retinal vessels, whitish amyloid deposits along retinal arteries, obliteration of retinal vessels, vitreous hemorrhage, retinal and iris neovascularization. The most relevant imaging findings were hyperautofluorescence of perivessel amyloid deposits; delayed arterial filling, vascular leakage, and retinal ischemia on fluorescein angiography; late hypercyanescence along the choroidal arteries on indocyanine green angiography; perivascular hyperreflective material, needle-shaped deposits on the retinal surface and macular edema on optical coherence tomography (OCT) and attenuated retinal vascular network on OCT-angiography. ATTRv patients should be strictly followed to detect and treat retinal angiopathy, avoiding complications. Both panretinal photocoagulation and intravitreal anti-vascular endothelial growth factor have been used to treat retinal angiopathy in ATTRv. In an individual that presents with retinal angiopathy of unknown etiology, ATTRv should be considered as in the differential diagnosis, even out of the initial core countries. The prognostic value of subclinical findings, namely in OCT-A, is not yet established.

Case Report: Vitreous Amyloidosis Caused by a TTR Lys55Asn Mutation With Intraoperative Suprachoroidal Hemorrhage

We report a vitreous amyloidosis patient with white vitreous opacities (footplates) adhering to the posterior lens capsule. A positive Congo-red stain and transthyretin (TTR) Lys55Asn mutation confirmed the diagnosis of vitreous amyloidosis. Optical coherence tomography (OCT) revealed fern-like material adhering to the the posterior pole retinal surface in both eyes. Visual acuity significantly improved after the first vitrectomy, but vitreous opacities recurred 4 years later. The patient appeared to have aggravated sensorimotor neuropathy and severe autonomic dysfunction at the same time. He developed intraoperative suprachoroidal hemorrhage during the second vitrectomy.

Deposits on Retinal Surface Seen on OCT in Ocular Amyloidosis

PURPOSE

To investigate the tomographic features in patients with hereditary amyloidosis transthyretin (hATTR).

DESIGN

Retrospective case series and analysis of B-scan OCT images.

PARTICIPANTS

A total of 120 patients (240 eyes) diagnosed with hATTR.

METHODS

We performed a retrospective review of the treatment history and retrospective analysis of the OCT images of patients with hATTR. The parameters analyzed were the age at which the last OCT was performed, presence of ocular amyloidosis, history of pars plana vitrectomy (PPV), systemic treatment, and genetic mutations. Two independent evaluators evaluated the OCT images for characteristic needle-shaped pattern deposits on the retinal surface, and a third evaluator resolved any differences in their evaluations.

MAIN OUTCOME MEASURES

The frequency of characteristic needle-shaped deposits on the retinal surface seen on OCT.

RESULTS

The mean age at the time of the last OCT was 56.5 ± 14.9 years. Ninety-nine patients had gene encoding transthyretin (TTR) with the Val30Met mutation, and 21 patients had other mutations. Of 240 eyes, 128 had signs of ocular amyloidosis. Fifty of 73 eyes (68.5%) with a history of PPV for vitreous opacities exhibited characteristic deposits on OCT. Four of 31 eyes with vitreous opacity but without a history of PPV showed deposits on the retinal surface. No eyes without a history of vitreous opacities revealed the characteristic needle-shaped deposits.

CONCLUSIONS

Characteristic needle-shaped deposits on the retinal surface seen on OCT are significant because they are seen in most of the vitrectomized eyes presenting with ocular amyloidosis.