Choroidal vascularity index in leptochoroid: A comparative analysis between reticular pseudodrusen and high myopia

LeptoVitelliform Maculopathy: delineating a distinct clinical entity from acquired vitelliform lesions

OBJECTIVES

To characterize acquired vitelliform lesions associated with leptochoroid (i.e., diffuse choroidal thinning) and reticular pseudodrusen (RPD) and compare this phenotype to the acquired vitelliform lesion (AVL) in the dystrophic spectrum.

METHODS

This retrospective, observational case-control study enrolled 56 patients (56 eyes) affected by vitelliform lesions (AVL), including 27 patients with AVL associated with RPD and leptochoroid (i.e., choroidal thinning) referred to as LeptoVitelliform Maculopathy (LVM), and 29 AVL patients without other funduscopic abnormalities. The main structural features analysed were the integrity of the external limiting membrane (ELM), ellipsoid zone (EZ), and retinal pigment epithelium (RPE), the presence of hyporeflective spaces, and hypertransmission. Choroidal vascular index (CVI) was calculated using ImageJ software.

RESULTS

Patients with LVM were 6.69 years older and presented smaller vitelliform lesions considering both vertical (P < 0.001) and horizontal diameters (P < 0.001) with a similar visual impairment compared to the AVL group (P = 0.27). The LVM subgroup showed a greater alteration of the ELM (p < 0.001) and choroidal hypertransmission (i = 0.007), accompanied by less frequent RPE bumps (P = 0.001) and hyporeflective spaces within the vitelliform material (P = 0.002). Furthermore, the LVM group presented a lower CVI with a significant attenuation on both the luminal and stromal compartments compared to AVL (P < 0.001, both).

CONCLUSIONS

The phenotypic combination of subretinal vitelliform lesion and RPD may delineate a distinct phenotype that shares with AVL only the presence of vitelliform material and a similar visual deterioration. The presented findings of LVM highlight significant structural and microvascular alterations that may hold prognostic relevance, warranting future longitudinal studies.

Pachy-Reticular Pseudodrusen

PURPOSE

To characterize the features of a peculiar association between reticular pseudodrusen (RPD) and pachychoroid (pachy-RPD) and to compare them with eyes affected by RPD and normal/leptochoroid.

DESIGN

Observational, retrospective, case-control study.

PARTICIPANTS

Among a cohort of patients with intermediate age-related macular degeneration (AMD), we selected eyes with RPD and pachychoroid (i.e., choroidal thickness of >50 μm). A control group of RPD eyes but without pachychoroid (i.e., a choroidal thickness of <250 μm) was included.

METHODS

Number and stages of RPD were evaluated in each ETDRS subfield. Furthermore, choroidal perfusion was investigated using the choroidal vascularity index (CVI), and choriocapillaris perfusion density (PD) on structural OCT and OCT angiography.

MAIN OUTCOME MEASURES

Description of the multimodal imaging features of pachy-RPD and differences with RPD associated with normal/leptochoroid.

RESULTS

Among 111 RPD eyes, 37 were included in the pachy-RPD group and 74 in the control group. Patients with pachy-RPD were significantly younger than patients with RPD and normal/leptochoroid (mean age, 75 ± 16 and 82 ± 7 years, respectively; P = 0.002). Total RPD number was comparable between the 2 groups (P = 0.220). However, pachy-RPD eyes showed a significantly higher number of stage 1 RPD in comparison to the controls (P < 0.001), and a lower number of stage 3 (P < 0.001) and stage 4 RPD (P = 0.052). The CVI and choriocapillaris PD were greater in pachy-RPD than in the control group (P < 0.001 and P= 0.010, respectively).

CONCLUSIONS

Pachy-RPD are characterized by a different distribution of RPD stages (i.e., more early stages and fewer advanced stages) in comparison to RPD with normal/leptochoroid. Furthermore, pachy-RPD eyes showed greater perfusion indices of the choroid. These features suggest that the presence of pachychoroid could be a protective factor in the RPD evolution to the advanced AMD forms.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

A Brazilian case of exudative perifoveal vascular anomalous complex responsive to aflibercept intravitreal injections

PURPOSE

To report a case of exudative perifoveal exudative vascular anomalous complex (ePVAC) in a Brazilian healthy patient that underwent a complete resolution after aflibercept intravitreal injections.

CASE DESCRIPTION

A 41-year-old healthy Brazilian man complained of acute central vision loss in his right eye (RE). Fundus examination showed a perifoveal hemorrhagic aneurysmal lesion, accompanied by several hard exudates in RE. On fluorescein angiography, these abnormalities showed a progressive hyperfluorescence with surrounding leakage. Optical coherence tomography (OCT) revealed a deep, perifoveal hyporeflective cystic space with a hyperreflective wall and hyperreflective material inside of fibrin-like aspect. Around this aneurism, intraretinal hyporeflective spaces suggestive of exudation were detected. Nor pathological flow signal, or telangiectatic dilations were evidenced on OCT-angiography. Therefore, a diagnosis of exudative ePVAC in RE was hypothesized. After an initial observation, the patient underwent three monthly aflibercept intravitreal injections (0.05 ml/2 mg), with a significative anatomical and functional improvement after two weeks from first dose. On last follow-up at five months from baseline, patient experienced no evidence of new exudation and a stable visual acuity.

DISCUSSION

Placental growth factor (PlGF) may impact on pericytes' dropout, and thus on ePVAC development. In contrast to the other anti-VEGF drugs, aflibercept is the only molecule contrasting PlGF. Therefore, aflibercept would act on ePVAC not as an anti-VEGF drug, but rather as an anti-PlGF one.

CONCLUSION

This report encouraged the use of aflibercept as a therapeutic option for ePVAC. Further studies are required to confirm our result and the impact of PlGF on ePVAC pathogenesis.

Choroidal remodeling following different anti-VEGF therapies in neovascular AMD

The purpose of this study was to investigate choroidal morphology remodeling in AMD-associated type 1 macular neovascularization using two different anti-VEGF drugs. We registered 73 treatment-naïve eyes with a diagnosis of exudative AMD and type 1 MNV. Patients received 3 monthly intravitreal aflibercept (n = 36, aflibercept group [AG]) or brolucizumab (n = 37, brolucizumab group [BG]). Baseline best-corrected visual acuity (BCVA) and anatomical (structural optical coherence tomography) parameters were collected at "T1 control", before the loading phase (LP) of intravitreal injection, and at "T2 control", 1 month after the last injection. The main outcomes measured were choroidal vascularity index (CVI), sub-foveal choroidal thickness (SFCT), and central macular thickness (CMT). Our results displayed significant SFCT reduction in both groups between T1 and T2 (p < 0.05), We did not find choroidal vascularity modifications (p > 0.05) after the loading aflibercept injections. Moreover, only the BG displayed a significant choroidal remodeling (stromal choroidal area [SCA], total choroidal area [TCA] and CVI) at T2 (p < 0.05). In particular, a relevant stromal and total choroidal volume reduction was noted, accompanied by an increase in CVI. To conclude, the latter modifications of the choroidal morphology were found significant between two groups (p < 0.05). Our analysis showed a significant impact of brolucizumab on choroidal morphology in eyes affected by type 1 nAMD. This effect was found relevant when compared with aflibercept.

Short-Term Morphofunctional Changes in Previously Treated Neovascular AMD Eyes Switched to Brolucizumab

The purpose of the study is to explore the morphofunctional fluctuations in eyes treated for neovascular AMD (nAMD) when treatment is switched from aflibercept or ranibizumab to brolucizumab. A total of 31 eyes of 31 patients with nAMD with type 1 macular neovascularization (MNV) were included. All patients were imaged using spectral domain optical coherence tomography (SD-OCT). The OCT acquisition was performed at the following visits: (i) “T1 visit” corresponding to the last follow-up examination in which an intravitreal injection of aflibercept or ranibizumab was performed before switching to brolucizumab because of the lack of improvement and (ii) “T2 visit” corresponding to the examination performed 1 month after T1, the latter visit corresponding to the day when a switch to brolucizumab injection was performed, (iii) and 1 month after the latter injection “(T3)”. The main outcome measures were: (1) central macular thickness (CMT), (2) choroidal vascularity index (CVI), (3) subfoveal choroidal thickness (CT), and best-corrected visual acuity (BCVA). Functional outcome showed significant differences at each time. Mean ± SD BCVA was 0.43 ± 0.12 LogMAR at T1 and 0.56  ±  0.16 LogMAR at T2 (p = 0.038). A significant improvement in BCVA was displayed at T3 (0.34  ±  0.21 LogMAR) as compared with T2 (p  = 0.019). CMT analysis showed fluctuations three times. In detail, T2 displayed a thicker CMT in comparison with T1, although not statistically significant (p = 0.12). Contrariwise, T3 showed a thinner CMT in comparison with T2 (p = 0.002). Analyzing CVI among the three different times, the luminal choroidal area (LCA) and total choroidal area (TCA) showed significantly different values before and after switching to brolucizumab. T2 showed a significant reduction in both vessel lumen and total area compared with T1 (p = 0.032 and p  =  0.046, respectively). Moreover, T3 showed a greater value of both LCA and TCA in comparison with T2 (p = 0.008 and p  =  0.01, respectively). CT did not show significant differences at each time (p > 0.05). Our results reported early experiences on morphofunctional fluctuations in patients with nAMD who switched to brolucizumab. The anatomical impact of brolucizumab administration appears to result in choroidal vascular enlargement, accompanied by the resolution of subretinal fluid (SRF) and intraretinal fluid (IRF).