Identification of hyperreflective foci in angioid streaks

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

En-Face Optical Coherence Tomography Is Useful for Assessing Striated Lesions in Angioid Streaks: A Case Report

Angioid streaks are mainly characterized by radially striated lesions around the optical disc and result in severe vision loss when choroidal neovascularization (CNV) develops at the macula. The prediction of visual prognosis in cases with angioid streaks remains an unsolved problem. In this study, we report the usefulness of en-face optical coherence tomography (OCT) to assess the bilateral striated lesions in angioid streaks. A 59-year-old female who was previously diagnosed with angioid streaks complained of decreased visual acuity in her left eye. However, on en-face OCT, the striated lesions in the right eye with better vision were shown as thicker continuous lesions than those in the left eye. Twenty-four months after the initial visit, her right visual acuity was worse than her left. En-face OCT showed fine-striated lesions extending from those thicker lesions to the macular area in the right eye. The thicker striated lesions observed at the initial visit may be a risk factor for future CNV development and vision loss. The evaluation of lesion size using en-face OCT may be useful for predicting the visual prognosis in angioid streaks.

HYPERREFLECTIVE FOCI PRECEDE MACULAR NEOVASCULARIZATION FORMATION IN ANGIOID STREAKS

PURPOSE

To describe the steps leading to the development and progression of macular neovascularization (MNV) in angioid streaks.

METHODS

The study was designed as retrospective, longitudinal case series. Patients with angioid streaks were investigated by means of multimodal imaging, including fundus autofluorescence and structural optical coherence tomography. Main outcome measures were hyperreflective foci and MNV progression steps.

RESULTS

Overall, 40 eyes (20 patients) affected by angioid streaks were evaluated. Over the follow-up, five eyes of five patients developed MNV. The mean follow-up was of 1.6 years. The mean number of anti-vascular endothelial growth factor injections was 4.35 ± 1.4. Mean best-corrected visual acuity was 0.53 ± 0.38 LogMAR at the MNV onset, improving to 0.42 ± 0.40 LogMAR at the end of the follow-up ( P > 0.05). Intraretinal hyperreflective foci onset and coalescence represented the first alterations occurring before the onset of the MNV. Anti-vascular endothelial growth factor treatment was associated with exudation relapsing and remitting, with still present intraretinal hyperreflective foci and pigment accumulation. The longitudinal analysis of our cohort of eyes outlined the event timeline: 1.2 months to find concentrated hyperreflective foci, 4.5 months to observe pigment organization through the outer nuclear layer, and 1.5 years to detect MNV.

CONCLUSION

Hyperreflective foci formation, concentration, and migration represent early alterations occurring before the onset of the MNV in angioid streaks.

The Efficacy of Anti-VEGF Therapy for Putative or Visible CNV in Central Serous Chorioretinopathy by Optical Coherence Tomography Angiography

Purpose

To investigate the effect and underlying mechanism of intravitreal antivascular endothelial growth factor (VEGF) in patients with putative or visible choroidal neovascularization (CNV) secondary to central serous chorioretinopathy (CSCR) with optical coherence tomography angiography (OCTA).

Methods

In a retrospective cohort study, 16 eyes of 15 treatment-naïve CSCR patients were included and divided into two groups: a putative CNV group with nonhomogenous hyperreflectivity in the slab of choriocapillaris and a visible CNV group with obvious tangled vascular network in the slab of choriocapillaris in OCTA. Patients were recorded with best-corrected visual acuity (BCVA). The parameters, evaluated by OCTA, included central macular thickness (CMT), the height of subretinal fluid (SRF), the number of hyperreflective foci (HRF), and the area of putative or visible CNV.

Results

Compared with the baseline, visual acuity was improved significantly at the last follow-up, and CMT and the height of SRF were decreased significantly (P < 0.0001). The number of HRF was also declined in the outer retina and the choriocapillaris layer (P=0.0343). Although the visible CNV area in the eyes represented virtually unchanged during anti-VEGF treatment (P=0.4015), the area of putative CNV displayed an obvious reduction (P=0.0081).

Conclusion

Anti-VEGF is effective in treating CSCR coexisting putative or visible CNV. Early initiation of anti-VEGF therapy benefits CSCR patients with putative CNV detected by OCTA. Translational relevance nonhomogenous hyperreflectivity in the choriocapillaris layer in OCTA indicates putative CNV in patients with CSCR, implying early treatment with anti-VEGF.

The identification of activity of choroidal neovascularization complicating angioid streaks

OBJECTIVES

To inspect the inter-reader agreement of different diagnostic modalities in identifying choroidal neovascularization (CNV) activity secondary to angioid streaks (AS) and to analyze the prevalence of subretinal hyper-reflective material (SHRM) in active CNV.

METHODS

Retrospective study of patients with AS with active CNV; optical coherence tomography (OCT), OCT angiography (OCTA), fundus fluorescein angiography (FFA), and indocyanine green angiography (ICGA) from each patient were collected. Agreement between two readers using different diagnostic modalities is presented as free-marginal kappa (k) and 95% confidence interval (CI).

RESULTS

This study included 19 eyes of 12 patients with active CNV (5 naive and 14 previously treated). Agreement among readers on CNV activity was excellent for OCT (k =0.88; 95% CI 0.71-1.00), good for FFA (k = 0.70; 95% CI 0.46-0.94) and ICGA (k = 0.58; 95% CI 0.31-0.84), and poor using OCTA (k = 0.39; 95% CI 0.11-0.68). SHRM was the most common OCT finding associated with active CNV (100%); fuzzy borders were present in 53% of SHRM cases at baseline.

CONCLUSIONS

Identification of CNV activity in AS is challenging; OCT was the best modality to inspect active CNV. The identification of SHRM contributed to recognizing active CNV. Further studies are needed to assess the role of SHRM in anticipating prognosis and guiding treatment of CNV secondary to AS.

Choroidal Modifications Preceding the Onset of Macular Neovascularization in Age-Related Macular Degeneration

INTRODUCTION

Macular neovascularization (MNV) is a common complication of age-related macular degeneration (AMD). Although several biomarkers may help to estimate the risk of MNV onset, neovascular complication is difficult to predict. Previous studies showed that the quantitative assessment of choroidal and choriocapillaris changes is useful for the assessment of atrophy expansion. On the other hand, scant data are available regarding the role of this kind of assessment in the setting of MNV. The aim of the study is to analyze choroidal and choriocapillaris changes occurring before the onset of MNV in patients affected by AMD using quantitative optical coherence tomography (OCT) and OCT angiography (OCTA).

METHODS

The study was designed as a retrospective case series. Patients affected by AMD, categorized in eyes complicated by MNV and eyes not developing MNV, were retrospectively analyzed for 1 year of follow-up. Choroidal thickness (CT), Sattler layer thickness (SLT) and Haller layer thickness (HLT) were measured on OCT scans. Vessel density (VD) and choriocapillaris (CC) porosity were quantified on OCTA reconstructions. The main outcome measure was the relationship between choroidal and CC parameters, and MNV onset.

RESULTS

We included 50 eyes of 50 AMD patients (28 male; mean age 74 ± 5 years). Over the 1-year follow-up, 15/50 eyes developed MNV (9 type 1; 3 type 2; 3 mixed type 1-2). Mean best-corrected visual acuity (BCVA) was 0.15 ± 0.15 logMAR at baseline, remaining stable in eyes not developing MNV (0.15 ± 0.12 logMAR; p > 0.05), and worsening to 0.38 ± 0.20 logMAR in eyes developing MNV (p < 0.01). VD values were similar between eyes developing MNV and eyes not complicated by MNV at baseline, with significant worsening detected only in MNV eyes. CC porosity was significantly higher in MNV eyes already before the onset of MNV. Furthermore, SLT was significantly lower in eyes developing MNV. The onset of MNV was preceded by a significant increase in intraretinal hyperreflective foci, whereas choroidal hyperreflective foci showed no evident changes.

CONCLUSIONS

The degeneration of CC and the SLT thinning represent early an biomarker of MNV onset in AMD.

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

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