Optical coherence tomographic features of macular telangiectasia type 2: Korean Macular Telangiectasia Type 2 Study-Report No. 1

Phenomenology of spontaneous closure in degenerative and mixed type lamellar macular hole

PURPOSE

To the describe OCT imaging characteristics of a cohort of patients showing spontaneously closing degenerative or mixed type lamellar macular holes (LMH) and to compare them to the ones of a sex and age matched group showing stable lesions.

METHODS

Patients diagnosed with degenerative and mixed type LMHs showing OCT-documented spontaneous anatomical closure were retrospectively selected from 3 specialized retina centres. An equal number of age and sex matching subjects were randomly selected among patients with anatomically stable lesions.

RESULTS

Eleven (11) spontaneously closing (SC group) and 11 stable (ST group) degenerative LMH with a mean follow up of 4 years were recruited. Hyperreflective inner border (HIB) and linear hyperreflectivity in the outer plexiform layer (LHOP) at baseline were significantly more prevalent in SC group in processed images (respectively p = 0.007 and p = 0.003). A borderline significance in lamellar hole associated epiretinal proliferation (LHEP) at last follow up was detected (p = 0.085). As for mixed type LMH, 10 patients for SC group and 10 for ST group were recruited. LHOP at baseline in processed images was significantly more prevalent in SC group (p = 0.005).

CONCLUSIONS

Spontaneously closing LMHs show higher prevalence of HIB and LHOP at the beginning of the closing process, a difference which is enhanced by image processing. These signs might be a signal of microglial and Muller cells coordinated activation.

Longitudinal anatomical and visual outcome of macular telangiectasia type 2 in Asian patients

Limited information regarding the anatomical and visual prognosis of macular telangiectasia (MacTel) type 2 in the Asian population is currently available. Herein, we conducted a retrospective longitudinal analysis of Japanese patients diagnosed with MacTel type 2. Disease progression was evaluated using the Simple MacTel Classification developed by Chew EY et al. in 2023, and its association with visual changes was analyzed. Sixteen eyes of eight Japanese patients were included in the study, with an average follow-up period of 8.2 ± 3.9 years (range, 2.2-14.0). At the initial visit, 7 (44%) and 5 (31%) eyes were classified as Grade 2 (central ellipsoid zone break) and Grade 3 (noncentral pigment), respectively. The proportion of eyes that progressed by 1 or 2-steps in grade after 1, 3, 5, 8, and 12 years was 0%, 14%, 43%, 70%, and 100%, or 0%, 7%, 7%, 30%, and 75%, respectively. The visual acuity significantly deteriorated during the follow-up period, particularly in the two eyes with full-thickness macular holes (FTMH). Three out of 7 patients exhibited low serum serine concentrations, although no apparent correlation with anatomical or visual outcomes was observed. Overall, this cohort demonstrated chronic disease progression, both anatomically and functionally, in eyes with MacTel type 2, with FTMH potentially associated with greater visual loss.

Early Optical Coherence Tomography Biomarkers for Selected Retinal Diseases-A Review

Optical coherence tomography (OCT) is a non-invasive, easily accessible imaging technique that enables diagnosing several retinal diseases at various stages of development. This review discusses early OCT findings as non-invasive imaging biomarkers for predicting the future development of selected retinal diseases, with emphasis on age-related macular degeneration, macular telangiectasia, and drug-induced maculopathies. Practitioners, by being able to predict the development of many conditions and start treatment at the earliest stage, may thus achieve better treatment outcomes.

Characteristics of retinal pigment clumps in Type 2 macular telangiectasia (MacTel)

OBJECTIVE

To assess the relationship of retinal pigment clump (RPC) size and its location with visual acuity and retinal neovascularisation in eyes with type 2 macular telangiectasia (MacTel).

METHODS

In this cross-sectional study, eyes diagnosed with type 2 MacTel showing RPC were included. Area occupied by pigment was measured on the multicolour image using the area tool on the Spectralis, Heidelberg machine. Pigment location within retinal layers was noted with OCT. Analysis was performed to identify factors associated with poor vision and proliferative disease.

RESULTS

Sixty-two eyes of 42 patients diagnosed with type 2 MacTel and RPC were included. The mean age was 64.31 ± 10.19 years. There were 13 (31%) males and 29 (69%) females in the study. 74% of patients were diabetics and the mean logMAR visual acuity of the participants was 0.619 ± 0.359. Univariate and multivariate binary logistic regression analysis identified female gender (p = 0.026), increasing RPC size (p = 0.008) and its presence above the outer plexiform layer (p = 0.006) to be associated with poor vision and proliferative disease in type 2 MacTel.

CONCLUSION

Our data identified female gender, larger pigment size and its location above the OPL to be associated with poor vision and proliferative disease. This data may be useful for further improving the current system for staging disease severity in type 2 MacTel.

OUTER FOVEAL DEFECTS IN TYPE-2 MACULAR TELANGIECTASIA

PURPOSE

To report characteristics of outer foveal defects (OFDs) in type-2 macular telangiectasia (MacTel) on spectral domain optical coherence tomography.

METHODS

This was a single-center observational study. From a registry of 745 patients with MacTel, patients with OFDs were characterized. All patients underwent multimodal imaging including color fundus photography, confocal blue reflectance, fundus autofluorescence, and spectral domain optical coherence tomography. Staging of eyes was done using the Gass and Blodi classification. Spectral domain optical coherence tomography characteristics in the central 1 mm of the macula in eyes with OFD are reported.

RESULTS

Outer foveal defect was observed in 21 eyes of 15/745 (2%) patients with MacTel. These defects were bilateral in 6/15 (40%) patients and seen in stage 2 MacTel eyes. In order of prevalence, foveal parameters seen in OFD included hyper-reflective dots in outer retina in 19/21 (90%), ellipsoid zone loss in 18/21 (86%) eyes, interdigitation zone loss in 17/21 (81%) eyes, outer retinal hyporeflective cavitation in 14 (67%) eyes, hyporeflective cavitation at foveal pit in 8 (38%) eyes, and loss of external limiting membrane in 1 (5%) eye. The mean baseline length of the foveal ellipsoid zone loss was 240.17 ± 117.249 µm. The mean baseline central subfield thickness was 155.43 ± 17.215 µm. A total of 8/11 eyes (73%) showed an increase in size of OFD on follow-up.

CONCLUSION

Outer foveal defect in MacTel eyes is characterized predominantly by foveal loss of ellipsoid zone and interdigitation zone with relative preservation of external limiting membrane.

Macular Telangiectasia Type 2: A Comprehensive Review

Macular telangiectasia Type 2 (MacTel) is a gradually progressive disease that affects the quality of life by impairing both distant and near vision. It had previously been considered a vascular condition, but recent evidence suggests a neurodegenerative etiology, with primary involvement of Muller cells. Retinal pigment epithelium (RPE) hyperplasia and subretinal neovascularization (SNV) are responsible for most of the vision loss in advanced cases. Neurotrophic factors in the non-proliferative phase and intravitreal anti-Vascular Endothelial growth factor (VEGF) in the proliferative phase have shown to retard the progression of the disease. This review will discuss the pathophysiology, clinical features, important diagnostic imaging studies and available treatment options for MacTel.

Is Type 2 Macular Telangiectasia a Bilateral and Symmetrical Disease Entity?

Purpose

To study the inter-eye asymmetry in cases diagnosed with type 2 macular telangiectasia (MacTel).

Methods

Herein, type 2 MacTel cases were staged as per Gass and Blodi classification with multiple imaging techniques. Based on disease stage symmetry, two groups identified. Group 1: Symmetrical stage and Group 2: Asymmetrical stage MacTel disease. Prevalence, demography, and clinical features of MacTel cases showing inter-eye asymmetry were analyzed.

Results

Two hundred and eighty eyes of 140 patients diagnosed clinically with type 2 MacTel (84-Group 1 and 56-Group 2) were evaluated. Eighty-nine (64%) were female, and the median age of the entire cohort was 62.5 years (inter-quartile range: 57.0-68.75). MacTel disease with asymmetric stage was seen in 56 (40%) of the 140 patients. At presentation, a two-stage difference was noted in 46% (n = 26) of the patients with asymmetrical MacTel disease. A 10% conversion from symmetrical to asymmetrical disease stage was noted at the final visit. Of the 280 eyes evaluated for type 2 MacTel disease, 12 (4%) eyes showed no findings suggestive of MacTel on clinical examination and fluorescein angiography, optical coherence tomography (OCT), and OCT angiography when available and were labeled as unilateral type 2 MacTel disease.

Conclusions

Type 2 MacTel can show inter-eye disease stage asymmetry. Unilateral type 2 MacTel disease is a distinct stage in MacTel which would need further evaluation and consideration while staging.

Structural-vascular-functional correlation in type 2 non-proliferative macular telangiectasia

PURPOSE

To correlate the structural-vascular-functional changes in type 2 non-proliferative macular telangiectasia (MacTel) using optical coherence tomography (OCT) angiography (OCTA).

METHODS

In this retrospective study, OCTA and enface OCT image analysis of eyes with confirmed diagnosis of non-proliferative type 2 MacTel was performed. The 'MacTel area' was calculated by marking the outer boundary of an area affected by MacTel on superficial (SCP) and deep capillary plexus (DCP) on OCTA images and photoreceptor layer (PRL) on enface OCT scan. At every follow-up OCTA scan visit, best-corrected visual acuity, MacTel area and stage of disease was documented. Analyses between disease stage, MacTel area and logMAR visual acuity was carried out.

RESULTS

In total, 38 single-visit OCTA scans of 22 patients were included. The mean age was 58.9 ± 10.98 years. An increase in disease severity stage correlated positively with MacTel area in SCP segmentations slab (r = 0.334; p = 0.04) and logMAR visual acuity (r = 0.338; p = 0.038). No correlation in the DCP area or PRL area (p > 0.05) was noted with disease stage. A statistically significant positive correlation was noted between the structural changes in PRL layer with vascular changes in SCP (p = 0.021) but not in DCP (p = 0.199). No correlation of visual acuity with changes in SCP, DCP or PRL was noted (p > 0.05).

CONCLUSION

OCTA is a useful adjunct for determining disease severity in type 2 non-proliferative MacTel by assessing the structural-vascular changes. Further longitudinal studies need to be considered in future for understanding the pathomechanism of retinal damage in type 2 MacTel.

Use of OCT Angiography to Diagnose and Manage Atypical Presentations of Macular Telangiectasia Type 2

Macular telangiectasia Type 2 (MacTel) is a bilateral acquired retinal disease characterized by both vascular changes and atrophy of the retina. The purpose of this case series is to highlight the use of optical coherence tomography angiography (OCTA) as a non-invasive imaging modality to distinguish atypical MacTel from other macular conditions with similar presentations. We performed a retrospective review of patients referred to our academic retinal practice with unconfirmed or misdiagnosed MacTel between July 2017 and July 2021. Patients' OCTA imaging findings were reviewed to guide the appropriate diagnosis and management of atypical MacTel. Fifteen eyes from eight patients were included in this study. Six patients were referred with previous diagnoses of either full-thickness macular hole, lamellar hole, vitreomacular traction (VMT), postoperative cystoid macular edema (CME), or diabetic macular edema (DME). Two patients were referred to us to confirm the diagnosis of MacTel. OCTA revealed telangiectatic vessels in the temporal parafovea of all 15 eyes. OCTA also highlighted previously undiagnosed subretinal neovascularization (SRNV) in seven eyes. OCTA imaging is a valuable imaging modality to distinguish MacTel from other macular conditions, whose treatment courses vary substantially. Due to its ease of use, it holds immense potential in the future as treatments for non-proliferative MacTel emerge.

Spectral domain OCT features in type 2 macular telangiectasia (type 2 MacTel): its relevance with clinical staging and visual acuity

BACKGROUND

To report spectral domain optical coherence tomography (SDOCT) imaging findings in type 2 macular telangiectasia (MacTel) and correlate them with clinical stages and visual acuity.

METHODS

This retrospective, cross-sectional study included type 2 MacTel cases who underwent SDOCT imaging with Spectralis machine. Macular SDOCT images were analysed. Imaging features were tested for correlation with different clinicals stages and visual acuity.

RESULTS

212 eyes of 108 type 2 MacTel patients were included. Hyperreflective middle retinal layer (87%) was the most frequently detected abnormality. This was followed by inner retinal cavities (49%), outward bending of inner retinal layers (35%), retinal pigment clumps (35%) and foveal contour irregularity (31%). Hyperreflective middle retinal layers (p < 0.001), inner (p = 0.032) and outer retinal (p = 0.002) cavities and internal limiting membrane drape (p = 0.031) were associated with poor vision in non-proliferative group and presence of retinal pigment clumps (p = 0.002), subretinal fluid (p = 0.037) and foveal contour irregularity (p < 0.001) were associated with poor vision in proliferative group.

CONCLUSION

The described SDOCT features are practical for the diagnosis and staging in type 2 MacTel. Presence of hyperreflective middle retinal layers, hyporeflective inner and outer retinal cavities and internal limiting membrane drape were associated with poor vision in the non-proliferative group while retinal pigment clumps and subretinal neovascular membrane were associated with proliferative group and poor vision. Further long-term studies are required to describe the progressive and sequential changes on SDOCT.

Visual function correlates with foveal slope, retinal and choroidal thickness on optical coherence tomography in type 2 Macular Telangiectasia

PURPOSE

To correlate the foveal slope angle (FSA), retinal (RT) and choroidal (CT) thickness measured using optical coherence tomography (OCT) across different stages of type 2 macular telangiectasia (MacTel) with best-corrected visual acuity (BCVA).

METHODS

A cross-sectional study of 182 gradable quality macular OCT images of 49 patients with type 2 MacTel was carried out. RT was measured on the Spectralis OCT machine from ETDRS (Early Treatment Diabetic Retinopathy Study) retinal thickness map and later used for calculating FSA. RT and CT were measured at 500-µm intervals up to 1500 µm from foveal centre manually. The change in RT, CT and FSA across five stages of type 2 MacTel was assessed. The measurements were correlated with BCVA.

RESULTS

The FSA, RT and CT were calculated quadrantwise and stagewise. The FSA and RT showed a significant negative correlation with disease stage and BCVA (p < .05) in all four quadrants. No significant correlation was noted between CT and BCVA. Multivariate linear regression analysis identified the temporal FSA to correlate best with BCVA.

CONCLUSION

BCVA correlates best with temporal FSA. Smaller the temporal FSA, poorer the vision.

Functional relevance of macular telangiectasia (MacTel) area on multicolour imaging in type 2 MacTel

PURPOSE

To analyse the correlation between area of macular telangiectasia (MacTel) involvement on multicolour (MC) imaging, disease stages and visual acuity in type 2 MacTel.

METHODS

In this retrospective analysis of MC images, confirmed cases of type 2 MacTel were graded into different disease stages as per Gass and Blodi and Yannuzzi et al classification systems. The 'MacTel area' was calculated by marking the outer boundary of an area with abnormally increased reflectivity to confocal blue wavelength light. At every follow-up visit, best-corrected visual acuity, MacTel area and stage of disease on the MC image was documented. Analyses between disease stage, MacTel area and visual acuity was carried out.

RESULTS

In total, 92 eyes of 49 patients were included in the study. The mean age was 59.6 ± 8.96 years. About 182 high-quality gradable MC images were available for analysis. There was a statistically significant difference in the visual acuity (p < 0.001) and area of involvement (p < 0.001) in the non-proliferative and proliferative type 2 MacTel groups. An increase in disease severity stage statistically correlated positively with Mactel area (r = 0.544; p < 0.001) and logMAR visual acuity (r = 0.329; p < 0.001). Over time, there was a significant increase in area of MacTel involvement (p = 0.012) with an associated decrease in the visual acuity (p = 0.023).

CONCLUSION

The MacTel area measured on MC imaging showed a strong positive correlation with disease stage and a negative correlation with visual acuity. This could serve as a useful biomarker in clinical trials and understanding the natural history of the disease.

Characterizing right-angled vessel in macular telangiectasia type 2 with structural optical coherence tomography

We investigated the structural findings on spectral-domain optical coherence tomography (SD-OCT) related to the presence of right-angled vessels (RAV) in patients with macular telangiectasia (MacTel) type 2 with severity 3 in Korea. A retrospective multicenter cross-sectional study was conducted in six tertiary hospitals in Korea; the study included 116 MacTel type 2 eyes with severity 3. The SD-OCT findings were compared between eyes with RAV on fundus photography or fluorescein angiography and those without RAV. Logistic regression was performed to determine factors associated with the presence of RAV. Fifty eyes presented with RAV and 61 eyes without RAV. More eyes presented with only inner retinal (IR) cavities on SD-OCT among eyes without RAV than among those with RAV (P < 0.001). However, eyes with RAV presented with IR disorganization, outer retinal (OR) cavity, and ellipsoid zone (EZ) disruption more frequently than eyes without RAV did (all P < 0.001). These SD-OCT findings were significantly associated with the presence of RAV. The presence of RAV was closely related to IR disorganization, OR cavities, and EZ disruption on SD-OCT. These findings suggest an advanced phase of MacTel type 2.

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.

Long-term Clinical Course of Korean Patients Diagnosed with Macular Telangiectasia Type 2

Purpose: To evaluate long-term visual prognosis and changes in the retinal microstructure in patients with macular telangiectasia type 2.Methods: Retrospective analysis of medical records were performed for 61 eyes (32 patients) diagnosed with macular telangiectasia type 2. The visual acuity at diagnosis was compared with that at the final visit. In addition, cases were classified into three grades based on optical coherence tomography (OCT) findings: grade 1, inner retinal cavities only; grade 2, outer retinal cavities with ellipsoid zone disruption; and grade 3, ellipsoid zone disruption with proliferation of retinal pigment epithelium. Change in the grade during the follow-up was verified. In addition, visual acuities were compared between eyes with and without a change in grade.Results: The mean follow-up period was 41.5 ± 33.2 months. Visual acuity had deteriorated significantly from the mean logarithm of the minimal angle of resolution 0.23 ± 0.26 at diagnosis to a mean of 0.31 ± 0.31 at the final visit (p < 0.001). When classified using OCT, 65.6%, 22.9%, and 11.5% were grades 1, 2, and 3, respectively, at diagnosis and 47.5%, 36.1%, and 16.4% at the final visit. Progression of grade was noted in 22.9%. A higher degree of visual deterioration was noted in eyes showing progression than in eyes without (p = 0.002).Conclusions: During the long-term follow-up period, visual deterioration was noted in patients with macular telangiectasia type 2. However, the degree of deterioration was not high. Progression in the disruption of the retinal microstructure was the likely cause of visual deterioration.

Demographic and Multimodal Imaging Features of Macular Telangiectasia Type 2: Korean Macular Telangiectasia Type 2 Study - Report No. 2

Purpose: To investigate the demographic and multimodal imaging features of macular telangiectasia (MacTel) type 2 in Korea and their relationship with visual acuity and the clinical stage.Methods: A retrospective multicentre cross-sectional study was conducted in six tertiary hospitals in Korea and the study included 84 patients. Demographic data and imaging data of fundus photography, fundus autofluorescence (FAF), confocal blue-light reflectance (CBR), fluorescein angiography (FAG), and optical coherence tomography (OCT) were collected.Results: The Korean patients with MacTel type 2 were predominantly female (75%), and the mean logMAR visual acuity was 0.282 ± 0.280 at initial presentation. Most commonly presented signs were the loss of retinal transparency in fundus photographs (68.3%); increased autofluorescence in FAF (83.6%); increased blue reflectance involving the centre in CBR (68.0%); telangiectatic vessels in FAG (88.2%); and hyporeflective cavities in OCT (77.7%). The eyes diagnosed in the first half of the study period (2009-2014) showed a tendency to be diagnosed at more advanced severe stages than those diagnosed in the second half of the study period (2015-2019), using new severity scales based on FAG, FAF and OCT findings.Conclusion: The clinical features of MacTel type 2 in Korean patients assessed by newer imaging modalities suggest that Korean patients and the Caucasian-dominant population show similar presentations. This study showed that MacTel type 2 can be diagnosed in the earlier phase of the disease by using new imaging modalities and through better understanding of the disease.