Adult vitelliform macular degeneration: a clinicopathological study

Risk Factors for Worsening Morphology and Visual Acuity in Eyes with Adult-Onset Foveomacular Vitelliform Dystrophy

PURPOSE

To explore clinical risk factors and OCT features associated with worse visual acuity (VA), progression of disease, choroidal neovascularization (CNV), and atrophy in eyes with adult-onset foveomacular vitelliform dystrophy (AOFVD).

DESIGN

Single-center, retrospective, observational cohort study.

PARTICIPANTS

Patients seen at Duke Eye Center between January 2012 and May 2023 with a diagnosis of AOFVD confirmed via OCT and fundus autofluorescence.

METHODS

Baseline and final-visit images from eyes with AOFVD were examined. Disease stage was assigned, and presence of atrophy or CNV was determined. Clinical and OCT features associated with progression to atrophy and CNV were determined using t tests and chi-square analysis. Correlation with lower VA was determined using linear regression.

MAIN OUTCOME MEASURES

Association of clinical characteristics and OCT features with worse VA, progression of disease, CNV, and atrophy as determined by independent t tests, chi-square analysis, and linear regression (P < 0.05).

RESULTS

One hundred one eyes (63 patients) met inclusion criteria for this study, with mean follow-up duration of 48 months (standard deviation, 31 months). Fifty-one percent of eyes progressed beyond baseline staging during follow-up; among baseline stage 1 eyes, incidence of atrophy was 0.068/person-year; incidence of CNV was 0.022/person-year. Risk factors for worse final VA were baseline presence of vitreomacular traction ([VMT], P = 0.006), ellipsoid zone attenuation (P = 0.02), and increased lesion height and width (P < 0.001). Predictors of progression include diabetes mellitus (P = 0.01), statin use (P = 0.03), presence of hyperreflective foci (P = 0.01), and increased lesion width and volume (P = 0.03 and P = 0.04, respectively). Predictors of atrophy include the baseline presence of VMT (P = 0.02), decreased choroidal thickness (P = 0.03), and greater maximal height, width, and volume of the lesion (P = 0.03, P = 0.02, and P = 0.009, respectively). Lower baseline VA (P = 0.03) and increased lesion volume (P = 0.04) were associated with CNV.

CONCLUSIONS

Clinical and OCT imaging features at baseline may prove useful in stratifying patient risk for progression, atrophy, CNV, and worse VA. Features such as statin use, diabetes, baseline VA, and laterality should be accounted for. OCT features, such as lesion size, VMT, ellipsoid zone attenuation, choroidal thickness, and hyperreflective foci, may impart greater risk of poor outcomes. Future prospective analysis accounting for the time to development of atrophy and CNV is needed.

FINANCIAL DISCLOSURES

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

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.

VITELLIFORM LESIONS ASSOCIATED WITH LEPTOCHOROID AND PSEUDODRUSEN

OBJECTIVE

To characterize clinical and prognostic implications of leptovitelliform maculopathy (LVM), a distinctive phenotype of vitelliform lesion characterized by the coexistence of subretinal drusenoid deposits (SDD) and leptochoroid.

DESIGN

Retrospective, cohort study.

SUBJECTS

The study compares patients affected by leptovitelliform maculopathy with cohorts displaying a similar phenotypic spectrum. This includes patients with acquired vitelliform lesions (AVL) and those with SDD alone.

METHODS

A total of 60 eyes of 60 patients were included, of whom 20 eyes had LVM, 20 eyes had AVL, and the remaining had SDD. Patients older than 50 years with complete medical records and multimodal imaging for at least 6 months of follow-up, including color fundus photograph (CFP) or MultiColor, optical coherence tomography (OCT), fundus autofluorescence (FAF), and OCT angiography (OCTA) were included.

MAIN OUTCOME MEASURES

Choroidal vascularity index (CVI); proportion of late-stage complications (macular neovascularization, atrophy).

RESULTS

The AVL subgroup exhibited a significantly higher CVI compared to both LVM (p<0.001) and SDD subgroups (p<0.001). The proportion of late-stage complications significantly differed among subgroups (χ2=7.5, p=0.02). Eyes with LVM presented the greatest proportion of complications (55%) after a mean of 29.3 months, while the remaining eyes presented a similar proportion of complications, including 20% in AVL after 27.6 months and 20% in SDD after 36.9 months. Kaplan-Meier estimates of survival demonstrated a significant difference in atrophy development between groups (p<0.001), with a median survival of 3.9 years for LVM and 7.1 years for controls. The presence of LVM correlated with a fourfold increase in the likelihood of developing complications.

CONCLUSIONS

Leptovitelliform maculopathy, characterized by the association of vitelliform lesions with SDD and leptochoroid, represents a distinct clinical phenotype in the broader spectrum of vitelliform lesions. The importance of a clinical distinction for these lesions is crucial due to a higher propensity for faster progression and an elevated rate of complications, particularly toward atrophic conversion.

LONG-TERM PRESERVATION OF VISUAL ACUITY AFTER RESORPTION OF ACQUIRED VITELLIFORM LESIONS IN AGE-RELATED MACULAR DEGENERATION

PURPOSE

To report the long-term (23 years) clinical and multimodal imaging features of acquired vitelliform lesions (AVLs) associated with nonneovascular age-related macular degeneration.

METHODS

Retrospective case report. Color and red-free fundus photographs, high-resolution optical coherence tomography, fluorescein and indocyanine green angiography, and optical coherence tomography-angiography were performed.

RESULTS

A 58-year-old man presented with bilateral AVLs in the setting of nonneovascular age-related macular degeneration. At baseline, his best-corrected visual acuity was 20/30 in his right eye and 20/20 in his left eye. Red-free fundus photographs showed AVLs with cuticular drusen in both eyes corresponding to a "stars-in-the-sky" pattern on fluorescein. Indocyanine green angiography showed no evidence of macular neovascularization. Throughout the 23-year follow-up, the patient reported consuming 20 mg/day of lutein supplement. At the end of follow-up, his best-corrected visual acuity was 20/20 in both eyes. Color fundus photographs showed resorption of the AVLs in both eyes and High-Res optical coherence tomography showed relative preservation of the outer retinal bands in the fovea. Optical coherence tomography-angiography confirmed the absence of macular neovascularization.

CONCLUSION

In nonneovascular age-related macular degeneration, spontaneous resorption of AVLs may be associated with long-term maintenance of visual acuity and relative preservation of the outer retinal morphology.

Topographic analysis of local OCT biomarkers which predict progression to atrophy in age-related macular degeneration

PURPOSE

To define optical coherence tomography (OCT) biomarkers that precede the development of complete retinal pigment epithelium and outer retinal atrophy (cRORA) at that location in eyes with age-related macular degeneration (AMD).

METHODS

In this retrospective case-control study, patients with dry AMD who had evidence of cRORA and OCT data available for 4 years (48 ± 4 months) prior to the first visit with evidence of cRORA were included. The visit 4 years prior to the development of cRORA was defined as the baseline visit, and the region on the OCT B-scans of future cRORA development was termed the case region. A region in the same eye at the same distance from the foveal center as the case region that did not progress to cRORA was selected as the control region. OCT B-scans at the baseline visit through both the case and control regions were evaluated for the presence of soft and cuticular drusen, drusen with hyporeflective cores (hcD), drusenoid pigment epithelial detachments (PED), subretinal drusenoid deposits (SDD), thick and thin double-layer signs (DLS), intraretinal hyperreflective foci (IHRF), and acquired vitelliform lesions (AVL).

RESULTS

A total of 57 eyes of 41 patients with dry AMD and evidence of cRORA were included. Mean time from the baseline visit to the first visit with cRORA was 44.7 ± 6.5 months. The presence of soft drusen, drusenoid PED, AVL, thin DLS, and IHRF at the baseline visit was all associated with a significantly increased risk of cRORA at that location. Multivariable logistic regression revealed that IHRF (OR, 8.559; p < 0.001), drusenoid PED (OR, 7.148; p = 0.001), and a thin DLS (OR, 3.483; p = 0.021) were independent predictors of development of cRORA at that location.

CONCLUSIONS

IHRF, drusenoid PED, and thin DLS are all local risk factors for the development of cRORA at that same location. These findings would support the inclusion of these features within a more granular staging system defining specific steps in the progression from early AMD to atrophy.

Acquired Vitelliform Lesions in Intermediate Age-Related Macular Degeneration: A Cross Sectional Study

PURPOSE

This study aims to define the characteristics of acquired vitelliform lesions (AVLs) in patients with intermediate age-related macular degeneration (iAMD).

DESIGN

Retrospective, observational, cross sectional study.

SUBJECTS

This study included 217 eyes with AVLs associated with iAMD, and an equivalent number of control patients.

METHODS

OCT scans were evaluated for qualitative and quantitative parameters at both the eye and lesion level. Eye-level parameters included the presence of: hyporeflective core drusen, intraretinal hyperreflective foci (IHRF), subretinal drusenoid deposits, macular pachyvessels, central retinal thickness, and central choroidal thickness. Lesion-level qualitative parameters included the presence of ellipsoid zone (EZ) and external limiting membrane disruption overlying the AVL, IHRF overlying the AVL, AVL overlying drusen, pachyvessels under the AVL, a solid core within AVL, and AVL location. Lesion-level quantitative characteristics included AVL height and width, AVL distance from the fovea, and sub-AVL choroidal thickness.

MAIN OUTCOME MEASURES

The primary outcomes assessed included the frequency of IHRF, the presence of macular pachyvessels, central choroidal thickness, and the dimensions (both height and width) of AVLs.

RESULTS

Comparing the AVL and control groups, the frequency of IHRF (AVL: 49.3% vs. control: 26.3%) and macular pachyvessels (37.3% vs. 6.9%) was significantly higher in the AVL case group, and the central choroidal thickness (256.8 ± 88 μm vs. 207.1± 45 μm) was thicker in the AVL group. Acquired vitelliform lesions located over drusen, with overlying IHRF, or situated subfoveally, and AVL lesions with EZ disruption were found to have a greater lesion height and width compared with AVL lesions lacking these characteristics (P value < 0.001 for all). Additionally, a significant negative correlation was observed between the distance from the fovea and AVL height (Spearman rho: -0.19, P = 0.002) and width (Spearman rho: -0.30, P = 0.001).

CONCLUSIONS

This study represents the largest reported cohort of AVL lesions associated with iAMD. Novel findings include the higher frequency of pachyvessels in addition to the presence of a thicker choroid in these eyes, as well as the greater height and width of AVL closer to the foveal center. These findings may offer insights into pathophysiologic mechanisms underlying the development of AVL.

FINANCIAL DISCLOSURE(S)

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

Predictive Factors Influencing the Evolution of Acquired Vitelliform Lesions in Intermediate Age-Related Macular Degeneration Eyes

PURPOSE

In this study, we identify risk factors that predict the progression of acquired vitelliform lesions (AVLs) over time.

DESIGN

Retrospective cohort study.

SUBJECTS

One hundred sixty-three eyes of 132 patients with a diagnosis of intermediate age-related macular degeneration (iAMD) with AVL.

METHODS

This retrospective study evaluated consecutive eyes with AMD from a retina clinic population and included 1181 patients and 2362 eyes. After excluding cases with associated geographic atrophy, macular neovascularization (MNV), vitreomacular traction, and those with <2 years of follow-up data, the final analysis cohort consisted of 163 eyes (132 patients) with ≥1 AVL. The first available visit in which an AVL was evident was considered the baseline visit, and follow-up data were collected from a visit 2 years (± 3 months) later. Progression outcomes at the follow-up visit were classified into 6 categories: resorbed, collapsed, MNV, stable, increasing, and decreasing. Subsequently, we analyzed the baseline characteristics for each category and calculated odds ratios (ORs) to predict these various outcomes.

MAIN OUTCOME MEASURES

The study focused on identifying predictive factors influencing the evolution of AVL in iAMD eyes.

RESULTS

In total, 163 eyes with AVL had follow-up data at 2 years. The collapsed group demonstrated a significantly greater baseline AVL height and width compared with other groups (P < 0.001). With regard to qualitative parameters, subretinal drusenoid deposits (SDDs) and intraretinal hyperreflective foci (IHRF) at the eye level, AVL located over drusen, and IHRF and external limiting membrane disruption over AVL were significantly more prevalent in the collapsed group compared with other groups (P < 0.05 for all comparisons). Odds ratios for progressing to atrophy after 2 years of follow-up, compared with the resorbed group, were significant for SDD (OR, 2.82; P = 0.048) and AVL height (OR, 1.016; P = 0.006).

CONCLUSIONS

The presence of SDDs and greater AVL height significantly increases the risk of developing atrophy at the location of AVL after 2 years of follow-up. These findings may be of value in risk prognostication and defining patient populations for inclusion in future early intervention trials aimed at preventing progression to atrophy.

FINANCIAL DISCLOSURES

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

Serous maculopathy with absence of retinal pigment epithelium (SMARPE) associated with large drusen

PURPOSE

To describe the association of serous maculopathy with absence of retinal pigment epithelium (SMARPE) and large drusen in patients with non-neovascular age-related macular degeneration (AMD).

METHODS

A retrospective study of ophthalmic examination and multimodal imaging data of individuals with SMARPE and large drusen observed over a period of 12-month was accomplished. SMARPE was defined as subretinal accumulation of fluid within the macular area due to retinal pigment epithelium (RPE) aperture. Large drusen were identified by the presence of sub-RPE deposits using multimodal imaging analysis (color fundus photography, fundus autofluorescence, and spectral-domain optical coherence tomography).

RESULTS

Twelve eyes of 7 white patients with a mean age of 77 years were observed to have SMARPE associated with large drusen. The median visual acuity was 20/100. Bilateral SMARPE lesions were observed in 71% of study patients. All SMARPE lesions were hypoautofluorescent, located in the subretinal space between the RPE and the ellipsoid zone, and presented as complete or incomplete RPE apertures associated with subretinal fluid. The SMARPE in this study had coincident multimodal imaging features as the SMARPE described in other reports in the literature.

CONCLUSIONS

Bilateral SMARPE can occur in association with typical AMD large drusen. Anomalisms resulting in drusen biogenesis or mechanisms that act alongside to these may be related to SMARPE development.

An unusual case of rapid resolution of bilateral vitelliform deposits after discontinuation of pentosan polysulfate sodium

Purpose

To report the structural and functional changes in a 67-year-old male with pentosan polysulfate sodium (PPS) maculopathy with a progressive resolution of bilateral vitelliform lesions after PPS cessation.

Observations

The patient was initially seen after taking daily PPS for over 26 years. Three months after discontinuing PPS, the bilateral vitelliform lesions identified on spectral-domain optical coherence tomography (SD-OCT) at initial consultation had completely resolved. Bilateral resolution of vitelliform lesions was associated with a decline in best-corrected visual acuity, and ellipsoid zone disruption on SD-OCT.

Conclusions and importance

Several PPS maculopathy phenotypes have been previously described including vitelliform lesions. Our case highlights that discontinuing PPS may lead to rapid resolution of vitelliform lesions in PPS maculopathy and may be associated with a rapid reduction in vision.

Adult-onset foveomacular vitelliform dystrophy: epidemiology, pathophysiology, imaging, and prognosis

Adult-onset foveomacular dystrophy (AOFVD) is a retinal pattern dystrophy that may affect up to 1 in 7,400 individuals. There is much that is unknown regarding this disease's epidemiology, risk factors for development, and rate of progression through its four stages. Advancements in retinal imaging over the past 15 years have enabled improved characterization of the different stages of AOFVD. These imaging advancements also offer new ways of differentiating AOFVD from phenotypically similar retinal diseases like age-related macular degeneration and Best disease. This review synthesizes the most recent discoveries regarding imaging correlates within AOFVD as well as risk factors for the development of AOFVD, complications of AOFVD, and treatment options. Our aim is to provide ophthalmologists a succinct resource so that they may offer clarity, guidance, and appropriate monitoring and treatments for their patients with suspected AOFVD.

Advanced ImageJ Analysis in Degenerative Acquired Vitelliform Lesions Using Techniques Based on Optical Coherence Tomography

Acquired vitelliform lesions (AVLs) are associated with a large spectrum of retinal diseases, among which is age-related macular degeneration (AMD). The purpose of this study was to characterize AVLs' evolution in AMD patients using optical coherence tomography (OCT) technology and ImageJ software. We measured AVLs' size and density and followed their impacts over surrounding retinal layers. Average retinal pigment epithelium (RPE) thickness in the central 1 mm quadrant (45.89 ± 27.84 µm vs. 15.57 ± 1.40 µm) was significantly increased, as opposed to the outer nuclear layer (ONL) thickness, which was decreased (77.94 ± 18.30 µm vs. 88.64 ± 7.65 µm) in the vitelliform group compared to the control group. We found a continuous external limiting membrane (ELM) in 55.5% of the eyes compared to a continuous ellipsoid zone (EZ) in 22.2% of the eyes in the vitelliform group. The difference between the mean AVLs' volume at baseline compared to the last visit for the nine eyes with ophthalmologic follow-up was not statistically significant (p = 0.725). The median follow-up duration was 11 months (range 5-56 months). Seven eyes (43.75%) were treated with intravitreal anti-vascular endothelium growth factor (anti-VEGF) agent injections, in which we noted a 6.43 ± 9 letter decrease in the best-corrected visual acuity (BCVA). The increased RPE thickness could suggest hyperplasia contrary to the decreased ONL, which could mirror the impact of the vitelliform lesion on photoreceptors (PR). Eyes that received anti-VEGF injections did not show signs of improvement regarding BCVA.

Early onset of age-related changes in the retina of cystine/glutamate antiporter knockout mice

To determine the role of the cystine/glutamate antiporter on retinal structure and function, retinas of C57Bl/6J wild-type and xCT knockout mice, lacking the xCT subunit of the cystine/glutamate antiporter were examined from 6 weeks to 12 months of age. Fundoscopy, optical coherence tomography (OCT), and whole mount retinal autofluorescence imaging were used to visualise age-related retinal spots. Glial fibrillary acidic protein (GFAP) immunolabelling was used to assess retinal stress. Retinal function was evaluated using full-field and focal electroretinograms. Examinations revealed retinal spots in both wild-type and xCT knockout mice with the number of spots greater at 9 months in the knockout compared to wild-type. OCT confirmed these discrete spots were located at the retinal pigment epithelium (RPE)-photoreceptor junction and did not label with drusen markers. Whole mount lambda scans of the 9 month xCT knockout retinas revealed that the photoreceptor autofluorescence matched the spots, suggesting these spots were retinal debris. GFAP labelling was increased in knockout retinas compared to wild-type indicative of retinal stress, and the discrete spots were associated with migration of microglia/macrophages to the RPE-retina intersection. OCT revealed that the superior retina was thinner at 9 months in knockout compared to wild-type mice due to changes to the outer nuclear and photoreceptor layers. While global retinal function was not affected by loss of xCT, focal changes in retinal function were detected in areas where spots were present. Tother these results suggest that the xCT KO mice exhibit features of accelerated ageing and suggests that this mouse model may be useful for studying the underlying cellular pathways in retinal ageing.

Vitelliform maculopathy: Diverse etiologies originating from one common pathway

Vitelliform lesions (VLs) are associated with a wide array of macular disorders but are the result of one common pathway: retinal pigment epithelium (RPE) impairment and phagocytic dysfunction. VLs are defined by the accumulation of yellowish subretinal material. In the era of multimodal advanced retinal imaging, VLs can be further characterized by subretinal hyperreflectivity with optical coherence tomography and hyperautofluorescence with fundus autofluorescence. VLs can be the result of genetic or acquired retinal diseases. In younger patients, VLs usually occur in the setting of Best disease. Additional genetic causes of VL include pattern dystrophy or adult-onset vitelliform macular dystrophy. In older patients, acquired VLs can be associated with a broad spectrum of etiologies, including tractional, paraneoplastic, toxic, and degenerative disorders. The main cause of visual morbidity in eyes with VLs is the onset of macular atrophy and macular neovascularization. Histopathological studies have provided new insights into the location, nature, and lifecycle of the vitelliform material comprised of melanosomes, lipofuscin, melanolipofuscin, and outer segment debris located between the RPE and photoreceptor layer. Impaired phagocytosis by the RPE cells is the unifying pathway leading to VL development. We discuss and summarize the nature, pathogenesis, multimodal imaging characteristics, etiologies, and natural course of vitelliform maculopathies.

Choroidal structural features of acquired vitelliform lesions in non-exudative age-related macular degeneration

PURPOSE

To define the choroidal morphological characteristics of non-exudative age-related macular degeneration (AMD) cases associated with acquired vitelliform lesions (AVLs).

METHODS

This retrospective study included intermediate AMD patients with AVLs (Group1, 21eyes) and without AVLs (Group2, 21eyes). A healthy control group was (Group3, 23eyes) also included. Subfoveal choroidal thickness (SFCT), greatest basal diameter (GBD), and maximum height (MH) of the largest PED were measured on spectral domain optical coherence tomography. Internal reflectivity of PEDs and total choroidal area (TCA) were measured using ImageJ software. The TCA was binarized to the luminal area (LA) and stromal area. The choroidal vascularity index (CVI) was assessed.

RESULTS

The mean SFCT, TCA, and LA were higher in Group 1 (290.3 ± 86.8 μm, 0.840 ± 0.302 mm², 0.602 ± 0.227 mm²) than in Group 2 (215.6 ± 85.0 μm, 0.594 ± 0.183 mm², 0.429 ± 0.139 mm²) (p = 0.014, p = 0.017, p = 0.020, respectively). There was no significant difference in the CVI measurements between Group 1 and Group 2 (p = 1.000). The mean GBD and MH of the PED was higher in Group 1 (1443 ± 595 µm, 188 ± 86 µm) than in Group 2 (851 ± 368 µm, 119 ± 38 µm) (p = <0.001, p = 0.001, respectively). Internal PED reflectivity was significantly lower in Group 1 (0.44 ± 0.21) than in Group 2 (0.66 ± 0.17) (p = <0.001). Internal PED reflectivity showed negative correlation with GBD and MH of the PED in Group 1 (r = -0.587, p = 0.005; rho = -0.448, p = 0.042, respectively). In Group 2, internal PED reflectivity had a negative correlation with MH of the PED (rho = -0.511, p = 0.018).

CONCLUSION

Non-exudative AMD patients with AVLs are more prone to have a thick choroid and large hyporeflective PEDs as compared to the those without AVLs.

Evaluation of incidence of the adult-onset vitelliform macular dystrophy among patients in Far Eastern Federal District of Russia

BACKGROUND: Adult-onset vitelliform macular dystrophy is one of the pathologic conditions , which successfully masks as age-related macular degeneration. AIM: To assess the incidence of the adult-onset vitelliform macular dystrophy among patients of a major ophthalmological clinic in the Far Eastern Federal District of Russia. MATERIALS AND METHODS: We revealed the cases of adult-onset vitelliform macular dystrophy among 1000 patients aged 40 years and older who addressed for various ocular complaints. RESULTS: Adult-onset vitelliform macular dystrophy was found in 2 male patients aged 43 and 66 years. In the macular area of both eyes of the 1st patient, round yellow lesions in the foveola, local detachment of neuroepithelium, optically dense material deposits on the outer photoreceptor segments were detected (vitelliruptive stage of adult-onset vitelliform macular dystrophy). In the left eye of the 2nd patient, in the foveola, a single round yellow focus of 200 m was found, optically dense vitelliform material was detected between the pigment epithelium and neuroepithelium layers without any signs of choroidal neovascularization (vitelliform stage of adult-onset vitelliform macular dystrophy). CONCLUSIONS: The incidence of adult-onset vitelliform macular dystrophy among patients with various ocular conditions was 0.2%. Morphological changes in the macula consist in presence of deposits of vitelliform material, localized between the neuroepithelium and retinal pigment epithelium layers.

Longitudinal Analysis of a Resolving Foveomacular Vitelliform Lesion in ABCA4 Disease

PURPOSE

To describe the longitudinal progression and phenotypic association of bilateral foveomacular vitelliform lesions in the setting of ABCA4 disease.

DESIGN

Case report and cross-sectional cohort study.

PARTICIPANTS

Nineteen patients with confirmed ABCA4 disease exhibiting an optical gap phenotype.

METHODS

Multimodal retinal imaging across multiple visits included autofluorescence imaging, spectral-domain OCT (SD-OCT), and OCT angiography. Electro-oculogram (EOG) and full-field electroretinogram testing results were analyzed. Exome sequencing was performed for diagnostic confirmation and the verification of other variations.

MAIN OUTCOME MEASURES

Light-peak-to-dark-trough ratio (Arden ratio) on EOG; thickness and en face maps of various retinal layers on SD-OCT; area measurements on 488- and 787-nm autofluorescence images; and the presence of variation in vitelliform-associated genes identified using exome sequencing.

RESULTS

A 25-year-old White man presented with bilateral central vision loss due to foveal lesions consisting of vitelliform fluid. The result of EOG testing was inconsistent with bestrophinopathy (Arden ratio = 1.62), and no generalized rod or cone dysfunction was detected on full-field electroretinogram. Exome sequencing identified the pathogenic variants c.5882G>A (p.(Gly1961Glu)) and c.4139C>T (p.(Pro1380Leu)) in ABCA4 and no other vitelliform-associated genes. Significant thinning and abnormal reflectivity of photoreceptor-attributable layers as well as near-infrared autofluorescence abnormalities were found in lesion-adjacent areas. Complete resorption of the vitelliform fluid occurred after 30 months, after which the optical gap lesions exhibited an enlarged and "cavitated" appearance. Phenotypic screening for additional cases from a large ABCA4 disease database (n = 602) identified 18 additional patients at various stages of optical gap lesion formation, most of whom harbored the c.5882G>A (p.(Gly1961Glu)) variant (P < 0.001), although none had apparent vitelliform fluid. At least 5 of the 18 (31.6%) patients exhibited optical gap lesions with the distinct "cavitated" appearance, whereas the lesions remained unperturbed in the other patients over the course of examination.

CONCLUSIONS

Foveomacular vitelliform deposition is a mechanistically congruent but rare manifestation of ABCA4 disease. Specifically, this disease phenotype may be clinically associated with the c.5882G>A (p.(Gly1961Glu)) allele and optical gap lesions.

Multimodal Study of PRPH2 Gene-Related Retinal Phenotypes

PRPH2 gene mutations are frequently found in inherited retinal dystrophies (IRD) and are associated with a wide spectrum of clinical phenotypes. We studied 28 subjects affected by IRD carrying pathogenic PRPH2 mutations, belonging to 11 unrelated families. Functional tests (best-corrected visual acuity measurement, chromatic test, visual field, full-field, 30 Hz flicker, and multifocal electroretinogram), morphological retino-choroidal imaging (optical coherence tomography, optical coherence tomography angiography, and fundus autofluorescence), and clinical data were collected and analyzed. Common primary complaints, with onset in their 40s, were visual acuity reduction and abnormal dark adaptation. Visual acuity ranged from light perception to 20/20 Snellen. Visual field peripheral constriction and central scotoma were found. Chromatic sense was reduced in one third of patients. Electrophysiological tests were abnormal in most of the patients. Choroidal neovascular lesions were detected in five patients. Three novel PRPH2 variants were found in four different families. Based on the present multimodal study, we identified seven distinct PRPH2 phenotypes in 11 unrelated families carrying either different mutations or the same mutation, both within the same family or among them. Fundus autofluorescence modality turned out to be the most adequate imaging method for early recognition of this dystrophy, and the optical coherence tomography angiography was highly informative to promptly detect choroidal neovascularization, even in the presence of the extensive chorioretinal atrophy phenotype.

Multi-spectral imaging in adult-onset foveomacular vitelliform dystrophy: Report of two cases

Purpose

To describe the characteristic findings of non-invasive multi-spectral imaging (MSI) for adult-onset foveomacular vitelliform dystrophy (AFVD).

Observations

On examination of MSI, the characteristic performances of AFVD include the nodule-like high-reflecting lesions, the line-like low-reflecting lesions in the high-reflecting lesion, and the scattered high-reflecting and low-reflecting lesions around the nodule-like lesion. MSI has an advantage over color fundus photography (CFP) and fundus autofluorescence (FAF) in finding tiny lesions, which corresponded to drusenoid structures on optical coherence tomography (OCT). MSI showed different characteristics at different stages of AFVD, which may be instructive to the pathogenesis and progression of AFVD.

Conclusions and Importance

MSI is a promising diagnostic and follow-up tool that will provide additional information in fundus imaging for AFVD, and the changes on MSI is partially instructive to the pathogenesis and progression of AFVD.

Histology and Clinical Lifecycle of Acquired Vitelliform Lesion, a Pathway to Advanced Age-Related Macular Degeneration

PURPOSE

To evaluate hypotheses about the role of acquired vitelliform lesion (AVL) in age-related macular degeneration pathophysiology.

DESIGN

Laboratory histology study; retrospective, observational case series.

METHODS

Two donor eyes in a research archive with AVL and age-related macular degeneration were analyzed with light and electron microscopy for AVL content at locations matched to ex vivo B-scans. A retrospective, observational clinical cohort study of 42 eyes of 30 patients at 2 referral clinics determined the frequency of optical coherence tomography features stratified by AVL fate.

RESULTS

Histologic and clinical cases showed subretinal drusenoid deposit and drusen. Ultrastructural AVL components in 2 donor eyes included retinal pigment epithelium (RPE) organelles (3%-22% of volume), outer segments (2%-10%), lipid droplets (0.2%-12%), and a flocculent material (57%-59%). Of 48 AVLs (mean follow-up 46 ± 39 months), 50% collapsed to complete RPE and outer retinal atrophy, 38% were stable, 10% resorbed, and 2% developed neovascularization. The Early Treatment Diabetic Retinopathy Study grid central subfield contained 77% of AVLs. Hyperreflective foci, ellipsoid zone disruption, and hyperreflective thickening of the RPE-basal lamina-Bruch membrane band were common at maximum AVL expansion. Collapsing and noncollapsing AVLs had different growth rates (rapid vs slow, respectively).

CONCLUSIONS

AVL deposits contain unexpectedly low levels of RPE organelles and outer segments. Subfoveal predilection, reflectivity on optical coherence tomography, hyperautofluorescence, yellow color, and growth-regression phases suggest dysregulation of lipid transfer pathways specific to cone photoreceptors and supporting cells in formation of AVL deposit, analogous to drusen and subretinal drusenoid deposit. Prediction of AVL outcomes via growth rates should be confirmed in larger clinical studies.

Acquired Vitelliform Lesions - A Novel Finding in Eyes with Peripapillary Pachychoroid Syndrome

PURPOSE

To describe a novel finding of acquired vitelliform lesions (AVL) in eyes with peripapillary pachychoroid syndrome (PPS).

METHODS

A retrospective, multicenter, observational case series including seven patients with PPS and concomitant AVLs. Medical records and multimodal imaging findings were comprehensively reviewed.

RESULTS

Six of seven patients were male, with a mean age of 72.6 years. Mean baseline best corrected visual acuity (BCVA) was 0.11±0.07 (Snellen equivalent 20/25), and all patients presented with baseline BCVA of 20/30 or better. Mean follow-up time was 24.4 months (range 1-54 months). At last follow-up, BCVA was stable in 13/14 eyes, and deteriorated in one eye due to subfoveal atrophy.Fundus examination revealed peripapillary retinal pigment epithelium (RPE) alterations and pigment migration in all eyes. Fundus autofluorescence showed mottled hyper- and hypo-autofluorescence in the peripapillary region, as well as hypoautofluorescent lesions corresponding to the pigmentary changes. Optical coherence tomography showed nasal choroidal thickening, pachyvessels with overlying RPE irregularity. All eyes presented with peripapillary intraretinal fluid. Subretinal fluid was present in five eyes of three patients. AVLs were present in 11 eyes.

CONCLUSION

The novel association between PPS and AVL is characterized by the classic findings of both entities, and visual prognosis is accordingly good.

Acquired Vitelliform Macular Degeneration: Characteristics and Challenges of Managing Subretinal Fluid

Purpose

To highlight diagnostic challenges in patients with acquired vitelliform macular degeneration (AVMD) with subretinal fluid (SRF) and to examine the characteristics of image findings in patients with AVMD.

Methods

In this retrospective review, the electronic medical record of 22 eyes of 16 patients with AVMD was studied. The rates of SRF, drusen, pigment epithelial detachment (PED), and patient clinical information such as age, length of follow-up, and best-corrected visual acuity (BCVA) were assessed.

Results

The mean age at diagnosis with AVMD was 72 years with a mean follow-up time of 29 months. Median BCVA 20/33 at presentation and 20/33 at final follow-up. Drusen was found in 13 of 22 eyes (59.1%), PEDs in 4 of 22 eyes (18.2%), and SRF in 10 of 22 eyes (45.5%) at some point during their follow-up. Of the 10 eyes with SRF, 70% were center involving, and recurrence occurred in 40%, all in the same location as the initial presentation of SRF. Three eyes received an anti-vascular endothelial growth factor injection for SRF. In 66% of cases receiving an injection, the fluid later relapsed and remitted without further injections during the course of follow-up.

Conclusion

AVMD occurs in the same demographic as age-related macular degeneration (AMD) and has many common features. SRF in AVMD tends to be center involving and recurs usually in the same location as its origin. The use of anti-VEGF injections did not seem to improve SRF in contrast to the SRF seen in wet AMD. Proper differentiation of AVMD may prevent unnecessary long-term treatment with intravitreal anti-VEGF injections.

Progression of Subclinical Pachychoroid Neovasculopathy to an Active Neovascularization in the Presence of Acquired Vitelliform Lesions

We describe a unique case of bilateral acquired vitelliform lesions in a 67-year-old-female with pachychoroid associated with subretinal fluid in the right eye (OD) and a nonexudative choroidal neovascular membrane (CNVM) in the left eye (OS). Multimodal imaging performed at baseline and over the ensuing two years showed an increase in the OS vitelliform lesions with a concurrent transformation of quiescent CNVM to an exudative form. Further studies are warranted to gain better insight into the etiopathogenesis of these vitelliform lesions in pachychoroid and their potential role in instigating CNVM activation.

Macular Dystrophy with Bilateral Macular Telangiectasia Related to the CYP2U1 Pathogenic Variant Assessed with Multimodal Imaging Including OCT-Angiography

Purpose: We report the case of a neurologically asymptomatic young boy presenting with an unusual phenotype of CYP2U1 related macular dystrophy associating bilateral macular telangiectasia (MacTel) and fibrotic choroidal neovascularization (CNV), assessed with complete multimodal imaging including optical coherence tomography angiography (OCT-A). Case presentation: A twelve-year-old boy from a non-consanguineous family complained of bilateral progressive visual loss and photophobia. The best-corrected visual acuity was 2/10 on the right eye and 3/10 on the left eye. Fundus examination showed central pigmented fibrotic macular scar and yellowish punctuate deposits in both eyes. En face OCT-A detected typical macular telangiectasia (MacTel) in both eyes with dilated telangiectatic capillaries in the deep capillary plexus associated with vascular anomalies in the superficial and deep capillary plexus. Typical hypo-reflective cavities were observed within the inner foveal layers on structural OCT. En face OCT-A also confirmed the presence of bilateral inactive CNV within the fibrotic scars, showing high-flow vascular network at the level of the subretinal hyperreflective lesions. Whole exome sequencing identified a known homozygous pathogenic variant in CYP2U1 gene (c.1168C > T, p.Arg390*), which is a disease-causing mutation in autosomal recessive spastic paraplegia type 56 (SPG56). The neurological examination was normal, and electromyography and brain magnetic resonance imaging were unremarkable as well. Conclusion: Macular dystrophy can be the first manifestation in SPG56. A particular phenotype with MacTel was observed, and neovascular complications are possible. CYP2U1 should be included in the panels of genes tested for macular dystrophies, especially in the presence of MacTel and/or neurological manifestations.

Incidence and risk factors for macular atrophy in Acquired Vitelliform Lesions

PURPOSE

To study the time course to macular atrophy (MA) and associated risk factors in eyes with Acquired Vitelliform Lesions (AVL) as they vary between patients and between eyes of an individual.

DESIGN

Single centre, retrospective, observational cohort study.

SUBJECTS

Consecutive patients registered between Jan 2009 to Jan 2014 with first diagnosis of AVL confirmed by multimodal imaging were included. Eyes with baseline MA or choroidal neovascularization were excluded.

METHODS

Patient demographics were collected. Serial optical coherence tomography (OCT) scans and fundus autofluorescence (FAF) were graded and analysed. Turnbull's estimator was employed, and time censored at 5 years. Multivariable Weibull parametric proportional hazards models was used to assess association of risk factors with MA, following adjustment for age and gender. Hazard ratios are reported with 95% CI.

MAIN OUTCOME MEASURE

Time to the first OCT evidence of MA stratified by presenting visual acuity (VA) and AVL lesion subtypes. Secondary outcome included risk factors for incident MA.

RESULTS

A total of 237 eyes (132 patients) met the inclusion criteria. Incident MA was detected in 52/237 (21.9%) eyes by 5 years. Stratified by baseline VA, 40.3%eyes with VA≤ 70 letters developed atrophy within 5 years of first diagnosis in contrast to 10.3% eyes with VA>70 letters (p<0.001). Based on lesion type only 12.9% eyes with vitelliform lesion at baseline developed MA versus 39.8% and 44.2% eyes with pseudohypopyon or vitelliruptive lesion type respectively. In adjusted analysis, baseline factors associated with increased risk of MA included VA≤70 letters (HR 5.54; 95% CI 2.30-13.34), base width (HR 1.22; 95% CI 1.16-1.28), maximum height (HR 2.61; 95% CI 1.82-3.74), presence of SDD (HR 2.83; 95% CI 1.34 -5.96) and disrupted external limiting membrane (HR 2.81; 95% CI 1.34-5.86).

CONCLUSION

Baseline VA of 70 letters or less (Snellen ≤20/40) and pseudohypopyon or vitelliruptive lesion type attribute highest risk for MA. Other prognostic indicators for MA include baseline presence of SDD, disrupted ELM and larger lesion area.

SUBRETINAL DRUSENOID DEPOSIT IN AGE-RELATED MACULAR DEGENERATION: Histologic Insights Into Initiation, Progression to Atrophy, and Imaging

PURPOSE

To clarify the role of subretinal drusenoid deposits (SDD; pseudodrusen) in the progression of age-related macular degeneration through high-resolution histology.

METHODS

In 33 eyes of 32 donors (early age-related macular degeneration, n = 15; geographic atrophy, n = 9; neovascular age-related macular degeneration, n = 7; unremarkable, n = 2), and 2 eyes of 2 donors with in vivo multimodal imaging including optical coherence tomography, examples of SDD contacting photoreceptors were assessed.

RESULTS

Subretinal drusenoid deposits were granular extracellular deposits at the apical retinal pigment epithelium (RPE); the smallest were 4-µm wide. Outer segment (OS) fragments and RPE organelles appeared in some larger deposits. A continuum of photoreceptor degeneration included OS disruption, intrusion into inner segments, and disturbance of neurosensory retina. In a transition to outer retinal atrophy, SDD appeared to shrink, OS disappeared, inner segment shortened, and the outer nuclear layer thinned and became gliotic. Stage 1 SDD on optical coherence tomography correlated with displaced OS. Confluent and disintegrating Stage 2 to 3 SDD on optical coherence tomography and dot pseudodrusen by color fundus photography correlated with confluent deposits and ectopic RPE.

CONCLUSION

Subretinal drusenoid deposits may start at the RPE as granular, extracellular deposits. Photoreceptor OS, RPE organelles, and cell bodies may appear in some advanced deposits. A progression to atrophy associated with deposit diminution was confirmed. Findings support a biogenesis hypothesis of outer retinal lipid cycling.

Serous business: Delineating the broad spectrum of diseases with subretinal fluid in the macula

A wide range of ocular diseases can present with serous subretinal fluid in the macula and therefore clinically mimic central serous chorioretinopathy (CSC). In this manuscript, we categorise the diseases and conditions that are part of the differential diagnosis into 12 main pathogenic subgroups: neovascular diseases, vitelliform lesions, inflammatory diseases, ocular tumours, haematological malignancies, paraneoplastic syndromes, genetic diseases, ocular developmental anomalies, medication-related conditions and toxicity-related diseases, rhegmatogenous retinal detachment and tractional retinal detachment, retinal vascular diseases, and miscellaneous diseases. In addition, we describe 2 new clinical pictures associated with macular subretinal fluid accumulation, namely serous maculopathy with absence of retinal pigment epithelium (SMARPE) and serous maculopathy due to aspecific choroidopathy (SMACH). Differentiating between these various diseases and CSC can be challenging, and obtaining the correct diagnosis can have immediate therapeutic and prognostic consequences. Here, we describe the key differential diagnostic features of each disease within this clinical spectrum, including representative case examples. Moreover, we discuss the pathogenesis of each disease in order to facilitate the differentiation from typical CSC.

Drusenoid pigment epithelial detachment volume is associated with a decrease in best-corrected visual acuity and central retinal thickness: the Norwegian Pigment Epithelial Detachment Study (NORPED) report no. 1

PURPOSE

To investigate the association of drusenoid pigment epithelial detachment (DPED) volume and change in best-corrected visual acuity (BCVA) and central retinal thickness (CRT) during the growth phase of large DPEDs.

METHODS

Patients from an ongoing prospective observational study, the Norwegian Pigment Epithelial Detachment Study (NORPED), with 1 year of follow-up and DPEDs ≥1000 µm in diameter, examined with the Heidelberg Spectralis HRA-OCT were included. Patients with DPEDs in the regression phase were excluded. Multicolour, near-infrared reflectance, optical coherence tomography (OCT) and OCT angiography images were obtained every 6 months. Fluorescein angiography and indocyanine green angiography were performed at baseline and yearly to exclude choroidal neovascularization (CNV).

RESULTS

Forty-four patients and 66 eyes were included. In the statistical model for BCVA, every 1.0 mm³ increase in DPED volume led to a decrease in BCVA of 4.0 ETDRS letters (95% CI, -7.0 to -1.0, p = 0.008). A decrease in BCVA was significantly associated with older patient age, the presence of acquired vitelliform lesions and subfoveal location of the DPEDs. In the model for CRT, every 1.0 mm³ increase in DPED volume led to a decrease in CRT of 26.7 µm (95% CI, -44.4 to -9.0, p = 0.003). Two eyes had progression of geographic atrophy and none developed CNV.

CONCLUSION

The increasing volume of DPEDs during the growth phase is associated with a decrease in BCVA and CRT. The subfoveal location of DPEDs and the presence of acquired vitelliform lesions appear to be associated with a further reduction in BCVA.

Assessment of retinal vessel density in adult-onset foveomacular vitelliform dystrophy by optical coherence tomography angiography

BACKGROUND

To evaluate retinal thickness, area of foveal avascular zone (FAZ), flow area and flow density of choriocapillaris, vessel density of both superficial capillary plexus (SCP) and deep capillary plexus (DCP) of eyes with adult-onset foveomacular vitelliform dystrophy (AOFVD) using optical coherence tomography angiography (OCT-A) and compare the results with healthy controls.

METHODS

17 eyes of 14 patients diagnosed with AOFVD and 17 eyes of 17 healthy subjects were enrolled in this study. All patients underwent a complete ophthalmological examination and a 6 x 6 mm macular OCT-A scanning. Quantiative results of retinal thickness, retinal vessel density of SCP and DCP, FAZ area, flow area and flow density of choriocapillaris were analyzed.

RESULTS

No statistically significant differences were noted in the vessel density of the SCP, except for the parafoveal nasal sector (P = 0.048). Similarly, no statistically significant differences were observed in the vessel density of the DCP, except for the parafoveal (P = 0.037) and the parafoveal temporal (P = 0.048) sectors. The choriocapillaris flow area and the flow density were significantly lower in the patients with AOFVD than in the healthy controls (P = 0.001 for both). The mean FAZ area and the retinal thickness measurements were comparable in both groups.

CONCLUSIONS

Patients with AOFVD show vascular abnormalities that can be detected with OCT-A. OCT-A, as a noninvasive imaging modality, could provide a new perspective for understanding the pathophysiology of AOFVD and could also be useful in the follow-up of these patients and in the management of the disease progression.

Investigating the role of BEST1 and PRPH2 variants in the molecular aetiology of adult-onset vitelliform macular dystrophies

Objective: To determine the clinical relevance and frequency of BEST1 and PRPH2 mutations in a clinically diagnosed adult-onset vitelliform macular dystrophy (AVMD) group with Caucasian ethnicity. Methods: The study comprised 24 patients who had been diagnosed with AVMD via indirect fundus ophthalmoscopy and presented with a dome-shaped appearance between the retinal pigment epithelium and photoreceptors on their spectral-domain optical coherence tomography. They had lesion hyper- autofluorescence on their fundus autofluorescence images and were also investigated for BEST1 and PRPH2 mutations for a probable molecular aetiology. Results: No pathogenic or likely pathogenic mutation was detected in the BEST1 and PRPH2 genes of any of the clinically diagnosed AVDM patients. A heterozygous NM_000322.5:c.938C>T (p.Pro313Leu) variant of the PRPH2 gene was detected in 2 non-consanguineous patients. According to current guidelines, this variant was classified as a 'variant of uncertain significance'. Conclusion: In conclusion, AVMD is a genotypic and phenotypic heterogeneous disease. The genetic aetiology could not be explained by sequencing BEST1 and PRPH2 genes in the AVMD patients; however, the variant of PRPH2 could be a cause of predisposition relevant to the phenotype.

[Avascular retinal pigment epithelium detachments in age-related macular degeneration]

Retinal pigment epithelium detachment (PED) is a pathological condition in which retinal pigment epithelium is separated from the underlying Bruch's membrane due to the formation of a fibrovascular membrane, drusenoid material, accumulation of fluid and/or blood. Six types of RPE detachments have been determined: pseudovitelliform, detachments associated with drainage drusen, serous, vascular and hemorrhagic, as well as PED associated with vascular retinal anomaly. The drusenoid PED is always avascular, the drusenoid material is contained between the RPE and Bruch's membrane. It was first described by Casswell in 1985. Ophthalmoscopy of the fundus shows a yellow-white cellular structure in the subretinal space, sometimes containing a patch of pigment, with an uneven surface, clear boundaries and a wavy edge. Serous PED is larger in area and prominence than drusenoid, characterized by the presence of a hyporeflective area under the detached RPE, over the area of more than 50% of the total area of detachment. Ophthalmoscopy shows a transparent yellow lesion in the subretinal space, sometimes brown-tinted, with clear boundaries and dome-shaped prominence. True serous PED is avascular (combination of choroidal neovascularization and serous PED will be discussed in the article about vascularized PED).

Retinal pigment epithelium and age-related macular degeneration: A review of major disease mechanisms

Age‐related macular degeneration (AMD) is a progressive degenerative disease that is the leading cause of vision loss in the elderly population. Degeneration/dysregulation of the retinal pigment epithelium (RPE), a supportive monolayer of cells underlying the photoreceptors, is commonly seen in patients with AMD. While treatment exists for the neovascular/wet form of AMD, there is currently no cure for the non‐exudative/dry form of AMD, making it imperative to understand the pathogenesis of this disease. Although our understanding of the aetiology of AMD has increased over the years, the underlying disease mechanism has not yet been identified, mainly due to the multifactorial nature of this disease. Herein, we review some of the commonly proposed degeneration pathways of RPE cells and their role in the pathogenesis of AMD; including activation of the complement cascade, oxidative stress‐induced cell death mechanisms, dysfunctional mitochondria and the role of crystallins in AMD disease progression.

Bilateral Macular Holes in Adult Vitelliform Macular Dystrophy

Purpose:

This report describes a case of bilateral macular holes (MHs) in adult vitelliform macular dystrophy (AVMD).

Methods:

A retrospective case report of a patient with AVMD and sequential onset of bilateral MHs is presented.

Results:

Bilateral MHs were observed after vitreomacular traction was identified on optical coherence tomography. Holes in both eyes were repaired with pars plana vitrectomy (PPV) with C3F8 (perfluoropropane) gas tamponade; only the right eye underwent internal limiting membrane peeling. In the right eye, 2 PPVs were required for hole closure. In both eyes, long-term atrophy of the retina and retinal pigment epithelium was observed.

Conclusions:

MHs in AVMD may be preceded by vitreomacular traction. Surgical repair with PPV and gas tamponade was successful. Retinal and retinal pigment epithelium atrophy developed postoperatively, but the patient’s vision still improved.

IMAGING OF VITELLIFORM MACULAR LESIONS USING POLARIZATION-SENSITIVE OPTICAL COHERENCE TOMOGRAPHY

PURPOSE

To examine the involvement of the retinal pigment epithelium (RPE) in the presence of vitelliform macular lesions (VML) in Best vitelliform macular dystrophy (BVMD), autosomal recessive bestrophinopathy, and adult-onset vitelliform macular degeneration using polarization-sensitive optical coherence tomography (PS-OCT).

METHODS

A total of 35 eyes of 18 patients were imaged using a PS-OCT system and blue light fundus autofluorescence imaging. Pathogenic mutations in the BEST1 gene, 3 of which were new, were detected in all patients with BVMD and autosomal recessive bestrophinopathy.

RESULTS

Polarization-sensitive optical coherence tomography showed a characteristic pattern in all three diseases with nondepolarizing material in the subretinal space consistent with the yellowish VML seen on funduscopy with a visible RPE line below it. A focal RPE thickening was seen in 26 eyes under or at the edge of the VML. Retinal pigment epithelium thickness outside the VML was normal or mildly thinned in patients with BVMD and adult-onset vitelliform macular degeneration but was diffusely thinned or atrophic in patients with autosomal recessive bestrophinopathy. Patients with autosomal recessive bestrophinopathy showed sub-RPE fibrosis alongside the subretinal VML. Polarization-sensitive optical coherence tomography was more reliable in assessing the localization and the integrity of the RPE than spectral domain OCT alone. On spectral domain OCT, identification of the RPE was not possible in 19.4% of eyes. Polarization-sensitive optical coherence tomography allowed for definite identification of the location of VML in respect to the RPE in all eyes, since it provides a tissue-specific contrast.

CONCLUSION

Polarization-sensitive optical coherence tomography confirms in vivo the subretinal location of VML and is useful in the assessment of RPE integrity.

Study of vessel density in adult-onset foveomacular vitelliform dystrophy with optical coherence tomography angiography

BACKGROUND

To evaluate retinal and choriocapillaris (CC) vessel density in macular region in patients affected by adult-onset foveomacular vitelliform dystrophy (AOFVD) using optical coherence tomography angiography (OCTA) METHODS: A total forty-four right eyes of 44 AOFVD patients (20 females, 24 males, mean age 69.17 ± 11.57 years) divided in 3 stages (vitelliform, pseudohypopyon and vitelliruptive) and 60 normal right eyes of 60 controls (20 females, 40 males, mean age 66.04 ± 6.40 years) were included in this prospective study. We evaluated the vessel density of superficial capillary plexus (SCP), deep capillary plexus (DCP) and CC in different macular areas (whole image, parafovea and fovea). We also analyzed the subfoveal choroidal thickness (SFCT) with Enhanced Depth Image (EDI)-OCT.

RESULTS

The vessel density of SCP and of DCP did not differ between patients and controls in all macular sectors. The vessel density of CC was lower in patients compared to controls but the difference turned out to be statistically significant only in foveal region (p < 0.001). We found that the foveal vessel density of the CC was lower in vitelliform stage and significantly increased in vitelliruptive stage (p = 0.031). At EDI-OCT, the SFCT revealed a statistically significant increase in patients compared to controls (p = 0.002) whereas it was similar in the different stages of this dystrophy (p = 0.276).

CONCLUSIONS

In vitelliform stage of AOFVD, OCTA and EDI-OCT can be useful to avoid mistakes of evaluation, due to the masking effect artifact. OCTA provides us a better understanding of the vascular role in the physiopathology of the macular diseases.

Spontaneous Closure of the Macular Hole in a Patient with Acquired Vitelliform Lesion

In this paper, we report an extremely rare case of spontaneous closure of a macular hole (MH) that developed in a patient in whom acquired vitelliform lesion (AVL) occurred after vitrectomy for atopic retinal detachment (ARD). A 32-year-old male developed ARD in both eyes, and retinal reattachment was achieved after vitrectomy. Five years after surgery, optical coherence tomography showed localized serous retinal detachment (SRD) and a granular lesion with a higher brightness in the subretinal fluid, thus leading to the diagnosis of AVL. One month later, an MH developed, and a follow-up examination performed 6 weeks later revealed that the MH had spontaneously closed and the SRD decreased. In the fovea, fluorescein angiography revealed a window defect due to atrophy of the retinal pigment epithelium (RPE). These findings in this present case suggest the possibility that RPE dysfunction was involved in the development of AVL and MH.

ADULT-ONSET FOVEOMACULAR VITELLIFORM DYSTROPHY EVALUATED BY MEANS OF OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY: A Comparison With Dry Age-Related Macular Degeneration and Healthy Eyes

PURPOSE

To investigate alterations of superficial and deep retinal vascular densities, as well as of choroidal thickness, in patients affected by adult-onset foveomacular vitelliform dystrophy (AOFVD).

METHODS

A total of 22 eyes (15 patients) affected by AOFVD were recruited in the study. Furthermore, 20 eyes of 20 healthy subjects and 20 eyes of 18 patients affected by intermediate dry age-related macular degeneration (AMD) were enrolled. All patients underwent a complete ophthalmologic examination, including optical coherence tomography angiography. Outcome measures were superficial vessel density, deep vessel density, and choroidal thickness.

RESULTS

Parafoveal superficial vessel density was increased in patients with AOFVD compared with the AMD group (50.6 ± 4.3% and 46.3 ± 4.3%, respectively, P = 0.016). Parafoveal deep vessel density was 57.9 ± 6.4% in patients with AOFVD, 52.2 ± 3.8% in patients with AMD, and 52.7 ± 6.0% in healthy controls (P = 0.006 and P = 0.035, respectively, after comparison with the AOFVD group).

CONCLUSION

We demonstrated that both superficial and deep vessel densities were significantly increased in patients with AOFVD, after the comparison with intermediate patients with AMD. These findings suggest that the pathogenic mechanisms in AOFVD are different from those in AMD and that optical coherence tomography angiography could be useful in differentiate early stages of these two diseases.

Subretinal drusenoid deposits AKA pseudodrusen

A distinction between conventional drusen and pseudodrusen was first made in 1990, and more recently knowledge of pseudodrusen, more accurately called subretinal drusenoid deposits (SDDs), has expanded. Pseudodrusen have a bluish-white appearance by biomicroscopy and color fundus photography. Using optical coherence tomography, pseudodrusen were found to be accumulations of material internal to the retinal pigment epithelium that could extend internally through the ellipsoid zone. These deposits are more commonly seen in older eyes with thinner choroids. Histologic evaluation of these deposits revealed aggregations of material in the subretinal space between photoreceptors and retinal pigment epithelium. SDDs contain some proteins in common with soft drusen but differ in lipid composition. Many studies reported that SDDs are strong independent risk factors for late age-related macular degeneration. Geographic atrophy and type 3 neovascularization are particularly associated with SDD. Unlike conventional drusen, eyes with SDD show slow dark adaptation and poor contrast sensitivity. Outer retinal atrophy develops in eyes with regression of SDD, a newly recognized form of late age-related macular degeneration. Advances in imaging technology have enabled many insights into this condition, including associated photoreceptor, retinal pigment epithelium, and underlying choroidal changes.

QUANTITATIVE ANALYSIS OF OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN ADULT-ONSET FOVEOMACULAR VITELLIFORM DYSTROPHY

PURPOSE

To quantify the foveal avascular zone area at superficial capillary plexus (SCP) and deep capillary plexus (DCP) and the global, parafoveal, and perifoveal vessel densities at SCP, DCP, and choriocapillaris using optical coherence tomography angiography in patients affected by adult-onset foveomacular vitelliform dystrophy (AOFVD).

METHODS

Twenty eyes of 20 consecutive patients (10 females, 50%) with AOFVD and 20 eyes of 20 healthy controls presenting at the Department of Ophthalmology of San Raffaele Hospital, Milan, Italy were enrolled. All patients underwent a complete ophthalmic examination, including 3-mm × 3-mm optical coherence tomography angiography centered on the macula. The vessel density was calculated in the three plexuses (i.e., SCP, DCP, and choriocapillaris) by mean of image binarization, and foveal avascular zone area was manually outlined at SCP and DCP with ImageJ software.

RESULTS

In the SCP, patients with AOFVD disclosed a significant reduction of global (P < 0.001), parafoveal (P = 0.0017), and perifoveal (P = 0.0019) vessel density. In the DCP, parafoveal vessel density was higher in patients with AOFVD (P = 0.0026), whereas no significant difference was appreciated for both the global image (P = 0.5) and the perifoveal area (P = 0.5). Patients with AOFVD showed less dense choriocapillaris (P = 0.012) and perifoveal circle (P = 0.0152), whereas no difference was observed in the perifoveal zone (P = 0.07). Foveal avascular zone area was significantly enlarged at the DCP (P = 0.0184), but not at the SCP.

CONCLUSION

Patients with AOFVD have quantitative vascular alterations in all vascular layers.

FUNDUS-WIDE SUBRETINAL AND PIGMENT EPITHELIAL ABNORMALITIES IN MACULAR TELANGIECTASIA TYPE 2

PURPOSE

Macular telangiectasia Type 2 (MacTel) causes glial and photoreceptor cell death in a small, oval patch in the central retina. Beyond this oval area, no disease manifestations have been described so far. Here, we describe a novel pathological aspect of MacTel in the retinal pigment epithelium (RPE) that is not restricted to the clinically affected area but covers the entire retina.

METHODS

We have studied postmortem eyes from four patients with MacTel by immunohistochemistry and electron microscopy.

RESULTS

We found cellular debris in the subretinal space (between photoreceptor outer segments and RPE), consisting mainly of outer segments and RPE components. In healthy eyes, the RPE normally phagocytoses the tips of the continuously growing outer segments, a process considered to be essential for photoreceptor survival. However, in the patients with MacTel, we found no evidence of ongoing outer segment phagocytosis, and the apical surface of the RPE appeared abnormal throughout most of the retina.

CONCLUSION

Reduced outer segment phagocytosis may explain the accumulating debris in the subretinal space but is a surprising finding because visual function in the peripheral retina is normal in patients with MacTel. Nevertheless, the subclinical pathology might induce a specific stress to which the central area is uniquely susceptible.

Microperimetric evaluation in patients with adult-onset foveomacular vitelliform dystrophy

Introduction:

To compare mean best-corrected visual acuity (BCVA), retinal sensitivity (RS), and bivariate contour ellipse area (BCEA) in patients with adult-onset foveomacular vitelliform dystrophy (AOFVD) and healthy subjects (HSs), reporting also functional disease-related changes in the different stages of the AOFVD disease.

Materials and Methods:

In this observational cross-sectional study, a total of 19 patients (30 eyes; 12 female and 7 male) with AOFVD were enrolled, and 30 patients (30 eyes; 16 female and 14 male) were recruited as age-matched control group (74.36 ± 9.17 years vs. 71.83 ± 6.99 years respectively, P = 0.11). All patients underwent a complete ophthalmologic examination, fundus autofluorescence and fluorescein angiography, spectral-domain optical coherence tomography and microperimetry (MP)-1 analysis. The data collection included mean BCVA, mean RS measured by means of MP-1, BCEA, and central retinal thickness.

Results:

All the functional parameters (BCVA, RS, and BCEA) were significantly worse in AOFVD group than HS. Subgroup analysis showed that the most significant functional changes, quantified by mean BCVA, RS, and BCEA, were in the atrophic stage (P = 0.03, P = 0.01, and P = 0.001, respectively). All the functional parameters were well correlated in the different stages.

Conclusions:

This study further confirms the good visual prognosis in the AOFVD eyes. Fixation stability measurement using BCEA demonstrates good evaluation of visual performance integrating traditional functional parameters. It may also serve for further rehabilitative purposes in atrophic eyes.

Fundus autofluorescence applications in retinal imaging

Fundus autofluorescence (FAF) is a relatively new imaging technique that can be used to study retinal diseases. It provides information on retinal metabolism and health. Several different pathologies can be detected. Peculiar AF alterations can help the clinician to monitor disease progression and to better understand its pathogenesis. In the present article, we review FAF principles and clinical applications.

Clinical Characteristics, Choroidal Neovascularization, and Predictors of Visual Outcomes in Acquired Vitelliform Lesions

PURPOSE

To quantify the temporal properties of the acquired vitelliform lesion (AVL) life cycle, define the clinical characteristics of choroidal neovascularization (NV) in this setting, and determine the predictors of long-term visual outcomes.

DESIGN

Retrospective cohort study.

METHODS

Clinical and imaging data from 199 eyes of 124 consecutive patients with AVLs associated with age-related macular degeneration (AMD) and adult-onset foveomacular vitelliform dystrophy (AOFVD) were analyzed. Volumetric calculations of vitelliform material were determined using spectral-domain optical coherence tomography and the temporal properties of the AVL life cycle were quantified. The clinical characteristics of NV were assessed, as were the predictors of final best-corrected visual acuity (BCVA) and change in BCVA.

RESULTS

Mean age was 79.2 ± 12.1 years. AVLs grew and collapsed at approximately the same rate (P = .275). Fifteen eyes (7.5%) developed NV, of which all were type 1. In 13 of these eyes, NV occurred during the collapse phase of the AVL life cycle, after the peak AVL volume was reached. The risk of NV (P = .006) and the decline in BCVA (P = .001) were both significantly greater among eyes with AMD. Foveal atrophy was the characteristic most significantly associated with final BCVA and change in BCVA from baseline (both P < .0005). The development of NV was not predictive of long-term visual outcomes (all P = .216).

CONCLUSIONS

Complications associated with AVLs typically occur during the collapse phase of the AVL life cycle. Visual outcomes and risk of NV are related to the underlying disease associated with AVLs.

Focal Choroidal Excavation in Retinal Dystrophies

AIM

To investigate the presence of focal choroidal excavation (FCE) in patients with retinitis pigmentosa (RP), Stargardt's disease (STGD), and Best disease in the Indian population.

METHODS

This retrospective consecutive case series included 309 eyes of 157 patients with RP (183 eyes), STGD (93 eyes), and Best disease (33 eyes) with good-quality, enhanced-depth spectral domain optical coherence tomography scans. Comprehensive ophthalmic examination data were collected. Characteristics of FCE, including location of FCE, type (conforming and non-conforming), maximal width, and depth, were noted.

RESULTS

FCE was found in 2 out of 33 (6%) eyes with Best disease and no FCE was found in eyes with RP or STGD. The location of the FCE was extrafoveal in both cases. The first case had non-conforming FCE while the second case had the conforming type and the FCE occurred in association with choroidal neovascularization in the second case. The first case maintained good visual acuity of 20/20 over the entire period of follow-up (14 months), while the second case had a visual acuity of 20/200 at the last follow-up (three years) due to scarred choroidal neovascular membranes. The FCE showed no change in both eyes over the entire duration of follow-up.

CONCLUSION

Focal choroidal excavation was found in 6% of eyes with Best disease, which remained stable throughout follow up. Eyes with RP and STGD did not have any FCE. Further studies are required to determine the role of vitelliform material in FCE development in Best disease.

Clinical applications of fundus autofluorescence in retinal disease

Fundus autofluorescence (FAF) is a non-invasive retinal imaging modality used in clinical practice to provide a density map of lipofuscin, the predominant ocular fluorophore, in the retinal pigment epithelium. Multiple commercially available imaging systems, including the fundus camera, the confocal scanning laser ophthalmoscope, and the ultra-widefield imaging device, are available to the clinician. Each offers unique advantages for evaluating various retinal diseases. The clinical applications of FAF continue to expand. It is now an essential tool for evaluating age related macular degeneration, macular dystrophies, retinitis pigmentosa, white dot syndromes, retinal drug toxicities, and various other retinal disorders. FAF may detect abnormalities beyond those detected on funduscopic exam, fluorescein angiography, or optical coherence tomography, and can be used to elucidate disease pathogenesis, form genotype-phenotype correlations, diagnose and monitor disease, and evaluate novel therapies. Given its ease of use, non-invasive nature, and value in characterizing retinal disease, FAF enjoys increasing clinical relevance. This review summarizes common ocular fluorophores, imaging modalities, and FAF findings for a wide spectrum of retinal disorders.

Intraretinal Hyperreflective Foci in Acquired Vitelliform Lesions of the Macula: Clinical and Histologic Study

PURPOSE

To describe the natural course, visual outcomes, and anatomic changes and provide histologic correlates in eyes with intraretinal hyperreflective foci associated with acquired vitelliform lesions.

DESIGN

Retrospective cohort study and imaging-histology correlation in a single donor eye.

METHODS

participants: Patients with intraretinal hyperreflective foci and acquired vitelliform lesions from 2 tertiary referral centers were evaluated from January 2002 to January 2014.

MAIN OUTCOME MEASURES

The chronology of clinical and imaging features of retinal anatomic changes and the pattern of intraretinal hyperreflective foci migration were documented using spectral-domain optical coherence tomography (OCT). One donor eye with intraretinal hyperreflective foci was identified in a pathology archive by ex vivo OCT and was studied with high-resolution light and electron microscopic examination.

RESULTS

Intraretinal hyperreflective foci were associated with acquired vitelliform lesions in 25 of 254 eyes (9.8%) with a strong female preponderance (86% of patients). Focal disruptions to the ellipsoid zone and external limiting membrane overlying the acquired vitelliform lesions were observed prior to the occurrence of intraretinal hyperreflective foci in 75% of cases. Histologic evaluation showed that intraretinal hyperreflective foci represent cells of retinal pigment epithelium origin that are similar to those found in the vitelliform lesions themselves and contain lipofuscin granules, melanolipofuscin granules, and melanosomes. The occurrence of intraretinal hyperreflective foci was not a significant determinant of final visual acuity (P = .34), but development of outer retinal atrophy was (P = .003).

CONCLUSIONS

Intraretinal hyperreflective foci associated with acquired vitelliform lesions are of retinal pigment epithelium origin, and the natural course and functional changes are described.

Prevalence of Subretinal Drusenoid Deposits in Older Persons with and without Age-Related Macular Degeneration, by Multimodal Imaging

PURPOSE

To assess the prevalence of subretinal drusenoid deposits (SDD) in older adults with healthy maculas and early and intermediate age-related macular degeneration (AMD) using multimodal imaging.

DESIGN

Cross-sectional study.

PARTICIPANTS

A total of 651 subjects aged ≥60 years enrolled in the Alabama Study of Early Age-Related Macular Degeneration from primary care ophthalmology clinics.

METHODS

Subjects were imaged using spectral domain optical coherence tomography (SD OCT) of the macula and optic nerve head (ONH), infrared reflectance, fundus autofluorescence, and color fundus photographs (CFP). Eyes were assessed for AMD presence and severity using the Age-Related Eye Disease Study (AREDS) 9-step scale. Criteria for SDD presence were identification on ≥1 en face modality plus SD OCT or on ≥2 en face modalities if absent on SD OCT. Subretinal drusenoid deposits were considered present at the person level if present in 1 or both eyes.

MAIN OUTCOME MEASURES

Prevalence of SDD in participants with and without AMD.

RESULTS

Overall prevalence of SDD was 32% (197/611), with 62% (122/197) affected in both eyes. Persons with SDD were older than those without SDD (70.6 vs. 68.7 years, P = 0.0002). Prevalence of SDD was 23% in subjects without AMD and 52% in subjects with AMD (P < 0.0001). Among those with early and intermediate AMD, SDD prevalence was 49% and 79%, respectively. After age adjustment, those with SDD were 3.4 times more likely to have AMD than those without SDD (95% confidence interval, 2.3-4.9). By using CFP only for SDD detection per the AREDS protocol, prevalence of SDD was 2% (12/610). Of persons with SDD detected by SD OCT and confirmed by at least 1 en face modality, 47% (89/190) were detected exclusively on the ONH SD OCT volume.

CONCLUSIONS

Subretinal drusenoid deposits are present in approximately one quarter of older adults with healthy maculae and in more than half of persons with early to intermediate AMD, even by stringent criteria. The prevalence of SDD is strongly associated with AMD presence and severity and increases with age, and its retinal topography including peripapillary involvement resembles that of rod photoreceptors. Consensus on SDD detection methods is recommended to advance our knowledge of this lesion and its clinical and biologic significance.