Incidence of outer retinal tubulation in ranibizumab-treated age-related macular degeneration

Persistent Placoid Maculopathy: Lichen-like Lesions Growing between Retinal Pigment Epithelium and Bruch's Membrane

PURPOSE

To report the novel imaging findings in persistent placoid maculopathy (PPM) from the first case series of Asian subjects.

DESIGN

Retrospective observational case series.

SUBJECTS

Patients with PPM from 2013 to 2023.

METHODS

Medical records and multimodal images from each visit were analyzed.

MAIN OUTCOME MEASURES

Imaging and follow-up findings.

RESULTS

Twenty-one eyes of 16 patients were included. Mean age was 61 (range, 48-84) years old. Five patients showed bilateral involvement. Persistent placoid maculopathy lesions were unremarkable on color fundus photography, autofluorescence, and fluorescein angiography. Hypofluorescent spots with a lichen-like appearance presented in all phases of indocyanine green angiography, which were most prominent in the late phase and presented in a fused (71%) or clustered (29%) pattern. The hypofluorescence correlated with the lesions between the retinal pigment epithelium (RPE) and Bruch's membrane (BM) with moderate reflectivity on OCT, and the thickness ranged from slit-like to mound-like. The intensity of hypofluorescence sometimes varied in the same eye and correlated with the thickness of sub-RPE lesions on OCT. No abnormal blood flow signals were detected in either the sub-RPE space or choriocapillaris slab of OCT angiography across the PPM lesions. Peripapillary (5 eyes, 24%) and extra posterior pole (2 eyes, 10%) involvements were seen, the former sparing the β zones of optic discs. Ten eyes of 7 patients were followed up (median, 26 months; range, 2-121 months). During follow-up, the lichen-like lesions spread and migrated slowly without changing the plane patterns of the first visit and were limited to sub-RPE growth. The fused lichen-like pattern sprawled around the enlarged base. The clustered lichen-like pattern gradually loosened. Ten eyes (48%, 9 eyes in the fused pattern, 1 eye in the clustered pattern) had secondary choroidal neovascularization (CNV) at the first visit, with type I (6 eyes, 5 of which were polypoidal choroidal vasculopathy) and type II (4 eyes). No new CNV developed during follow-up.

CONCLUSION

Persistent placoid maculopathy lesions were located in the sub-RPE space, as determined by multimodal imaging. Spreading and migration between the RPE and BM may account for their unique lichen-like appearance and progression pattern.

FINANCIAL DISCLOSURE(S)

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

CORRELATION OF OUTER RETINAL TUBULATIONS AND CHORIOCAPILLARIS FLOW SIGNAL DEFICITS SURROUNDING GEOGRAPHIC ATROPHY

PURPOSE

To evaluate and compare paralesional and perilesional choriocapillaris vascular impairment in eyes with geographic atrophy with and without outer retinal tubulations (ORT).

METHODS

Using swept-source optical coherence tomography angiography, 6 × 6 mm scans of eyes with geographic atrophy with and without ORT were acquired. Choriocapillaris en-face flow and structural images were binarized, before flow signal deficit (FD) analysis in the paraatrophy zone (a 500-µm-wide band adjacent to the geographic atrophy) and the periatrophy zone (a 500-µm-wide band adjacent to the latter).

RESULTS

Twenty-four eyes of 19 patients with ORT and 18 eyes of 15 patients without ORT were analyzed. With and without ORT, mean percental area of FD (%FD) was greater in para- than in periatrophy zone. The difference of %FD between para- and periatrophy zone (deltaFD) was lower in eyes with ORT (mean 1.8477%, 95% confidence interval 0.8607-2.8346) than without ORT (mean 4.0018%, 95% confidence interval 2.8622-5.1414).

CONCLUSION

In eyes with geographic atrophy caused by non-neovascular age-related macular degeneration, smaller reductions in FDs were found between the para- and periatrophy zone in eyes with ORT. In both cohorts, the paraatrophy zone had more FD than the periatrophy zone.

Outer retinal tubulation formation and clinical course of advanced age-related macular degeneration

Outer retinal tubulations (ORT) are a relatively new finding characterizing outer retinal atrophy. The main aim of the present study was to describe ORT development in advanced age-related macular degeneration (AMD) and to assess its relationship with disease’s severity. Patients with advanced AMD characterized either by macular neovascularization or geographic atrophy, showing signs of outer retinal disruption or retinal pigment epithelium atrophy on structural optical coherence tomography (OCT) at the inclusion examination were prospectively recruited. All the patients underwent complete ophthalmologic evaluation, structural OCT scans and fundus autofluorescence imaging. The planned follow-up was of 3-years. Main outcome measures were ORT prevalence, mechanism of ORT formation, mean time needed for complete ORT formation, best-corrected visual acuity (BCVA), definitely decreased autofluorescence (DDAF) area, questionably decreased autofluorescence (QDAF) area, retinal layer thickness, foveal sparing, number of intravitreal injections. We also assessed the possible role of external limiting membrane (ELM) and Müller cells in ORT pathogenesis. Seventy eyes (70 patients) were included; 43 showed dry AMD evolving to geographic atrophy, while 27 displayed the features of wet AMD. Baseline BCVA was 0.5 ± 0.5 LogMAR, decreasing to 0.9 ± 0.5 LogMAR at the 3-year follow-up (p < 0.01). We detected completely formed ORT in 26/70 eyes (37%), subdivided as follows: 20 eyes (77%) wet AMD and 6 eyes (23%) dry AMD (p < 0.01). ORT took 18 ± 8 months (range 3–35 months) to develop fully. We described the steps leading to ORT development, characterized by progressive involvement of, and damage to the photoreceptors, the ELM and the RPE. Eyes displaying ORT were associated with a smaller QDAF area, less retinal layers damage and lower rate of foveal sparing than eyes free of ORT (p < 0.01). We also described pigment accumulations simulating ORT, which were detected in 16/70 eyes (23%), associated with a greater loss of foveal sparing, increased DDAF area and smaller QDAF area at the 3-year follow-up (p < 0.01). In conclusion, this study provided a description of the steps leading to ORT development in AMD. ELM and Müller cells showed a role in ORT pathogenesis. Furthermore, we described a subtype of pigment hypertrophy mimicking ORT, evaluating its clinical utility.

OCT Biomarkers in Neovascular Age-Related Macular Degeneration: A Narrative Review

Age-related macular degeneration (AMD) is the leading cause of legal blindness in elderly people. Neovascular AMD (nAMD) is responsible for the majority of cases of severe visual loss in eyes with AMD. Optical coherence tomography (OCT) is the most widely used technology for the diagnosis and follow-up of nAMD patients, which is widely used to study and guide the clinical approach, as well as to predict and evaluate treatment response. The aim of this review is to describe and analyze various structural OCT-based biomarkers, which have practical value during both initial assessment and treatment follow-up of nAMD patients. While central retinal thickness has been the most common and one of the first OCT identified biomarkers, today, other qualitative and quantitative biomarkers provide novel insight into disease activity and offer superior prognostic value and better guidance for tailored therapeutic management. The key importance of retinal fluid compartmentalization (intraretinal fluid, subretinal fluid, and subretinal pigment epithelium (RPE) fluid) will be discussed firstly. In the second part, the structural alterations of different retinal layers in various stages of the disease (photoreceptors layer integrity, hyperreflective dots, outer retinal tubulations, subretinal hyperreflective material, and retinal pigment epithelial tears) will be analyzed in detail. The last part of the review will focus on how alterations of the vitreoretinal interface (vitreomacular adhesion and traction) and of the choroid (sub-RPE hyperreflective columns, prechoroidal clefts, choroidal caverns, choroidal thickness and choroidal volume, and choroidal vascular index) interact with nAMD progression. OCT technology is evolving very quickly, and new retinal biomarkers are continuously described. This up-to-date review article provides a comprehensive description on how structural OCT-based biomarkers provide a valuable tool to monitor the progression of the disease and the treatment response in nAMD patients. Thus, in this perspective, clinicians will be able to allocate hospital resources in the best possible way and tailor treatment to the individual patient's needs.

Unique optical coherence tomographic features in age-related macular degeneration

Age-related macular degeneration is a major cause of blindness worldwide characterized by the presence of drusen and leading to retinal pigment epithelium and outer retinal changes in advanced stages. Approximately 10% of eyes with age-related macular degeneration develop neovascular complications and present with retinal or sub-retinal pigment epithelium exudation, hemorrhage, or both. Recent advances in imaging techniques, especially optical coherence tomography (OCT), help in early identification of disease and guide various treatment decisions; however, not all signs are suggestive of ongoing exudation or neovascular activity. Although uncommon, multiple OCT-based signs are reported that may be difficult to appreciate clinically. Prompt identification of these signs such as outer retinal tubulation, cystoid degeneration, or pseudocysts may avoid unnecessary interventions. Moreover, certain OCT-based features involving the choroid, such as prechoridal cleft and choroidal cavern, have also been found in eyes with age-related macular degeneration. We discuss these unique OCT-based signs, their pathogenesis, clinical relevance, and management.

Evaluation of outer retinal tubulations in diabetic macular edema underwent anti-VEGF treatment

AIM

To investigate the incidence and subsequent changes of outer retinal tubulations (ORTs) in diabetic macular edema (DME) underwent anti-vascular endothelial growth factor (VEGF) therapy, and to assess the possibility of ORT as a biomarker of DME severity or response to anti-VEGF therapy.

METHODS

This retrospective and descriptive study included a total of 228 patients (435 eyes) with DME and treated with intravitreal anti-VEGF agents between March 2016 and January 2018. Patients were divided into 2 groups according to the presence of ORTs. High-resolution spectral-domain optical coherence tomography (SD-OCT) images acquired by vertical and horizontal scans and over consecutive visits were analyzed. The evolution of ORT over time, type of fluid and subfoveal photoreceptor integrity on OCT imaging was also assessed.

RESULTS

ORTs were identified in 108 eyes of 435 eyes with an overall incidence rate of 24.83% at baseline. ORTs were prone to locate adjacent to the lesions of exudation and/or cystoid edema and possibly situated in outer nuclear layer (ONL), outer plexiform layer (OPL) and/or inner nuclear layer (INL) in eyes with DME. The formation process of ORT led to focal downward displacement of OPL and INL toward RPE near the lesion. During the follow up, 45 eyes had steady ORTs and 63 eyes had dynamic variants in ORTs, including disappearance, reappearance, collapse, diminution, and enlargement. There were higher proportion of closed ORTs and fewer proportion of forming ORTs in eyes with steady ORTs, which showed a statistically significance when compared with eyes with variant ORTs (P=0.006, P=0.017, respectively). The eyes without ORTs had significantly better final best corrected visual acuity (BCVA) and more BCVA change than those eyes with ORTs in DME patients after anti-VEGF therapy (P=0.023, P=0.009, respectively). The disruption of subfoveal photoreceptor integrity in eyes with ORTs was more serious than that in eyes without ORTs (P=0.013). The proportion of stable vision in eyes with ORTs was significantly higher than that in eyes without ORTs, showing statistical significance (P=0.016). ORTs were associated with worse visual prognosis due to damage of the subfoveal photoreceptor integrity.

CONCLUSION

ORTs have a high incidence and changes over time in DME with anti-VEGF treatment and may be located at various retinal layers. Persistent ORT can be as a negative biomarker of outcome of DME.

The effect of ranibizumab and aflibercept treatment on the prevalence of outer retinal tubulation and its influence on retreatment in neovascular age-related macular degeneration

Background

We aimed to analyze the differences in the prevalence of outer retinal tubulation (ORT) in neovascular age-related macular degeneration (AMD) treated with anti-vascular endothelial growth factor (anti-VEGF) agents, either aflibercept or ranibizumab. Our further aim was to examine the changes in the frequency of injections of ranibizumab before and after ORT appearance.

Methods

Two hundred thirty six eyes of 230 patients were included in the study (184 eyes treated with ranibizumab by pro re nata regimen (PRN), 52 eyes with aflibercept bimonthly) and followed for 6–24 months. Using optical coherence tomography (OCT), the first appearance of ORT was documented, and fixed time point evaluations were also made every six months to determine the existence of ORT. The number of injections, the presence or absence of subretinal hyperreflective material (SHRM) at treatment initiation and visual acuity were also noted.

Results

The survival analysis with Cox proportional hazard model showed no significant difference between the ranibizumab and aflibercept groups in relation to the development of ORT (p = 0.79, hazard ratio 0.92). In the PRN treated ranibizumab group the number of injections showed significant decrease after ORT development (p = 0.004). When SHRM was present at treatment initiation the chance of developing ORT was 2.75 and 11.14 times higher in the ranibizumab and aflibercept groups, respectively.

Conclusions

The prevalence of ORT increased over time independently from the chosen anti-VEGF drug. Our results suggest that upon the appearance of ORT a decrease in retreatments can be expected.

Outer Retinal Tubulation and Neovascular Age-Related Macular Degeneration: A Review of the Pathogenesis and Clinical Implications

Outer retinal tubulation (ORT) is a retinal finding that can mimic intraretinal fluid and has been identified with spectral-domain optical coherence tomography in patients with age-related macular degeneration (AMD). The purpose of this review is to summarize the findings related to the pathogenesis of ORT and its clinical implications. Studies reporting the pathogenesis and the clinical implications of ORT in patients with AMD were identified and summarized. A total of 18 studies were included in this review. The body of evidence to date regarding ORT in patients with AMD indicates that ORT is a structure associated with advanced macular diseases that does not require anti-vascular endothelial growth factor treatment. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:870-876.].

Incidence of outer retinal tubulation in eyes with choroidal neovascularization under intravitreal anti-vascular endothelial growth factor therapy in a Japanese population

Purpose

The purpose of this study was to investigate the occurrence of outer retinal tubulation (ORT) among patients with different types of choroidal neovascularization (CNV) over time.

Materials and methods

In this retrospective chart review, disease type was classified as typical age-related macular degeneration (t-AMD), polypoidal choroidal vasculopathy (PCV), retinal angiomatous proliferation (RAP), or myopic CNV (mCNV). Spectral domain-optical coherence tomography (SD-OCT) images were evaluated for the appearance of ORT and subretinal fibrosis and fluid. Furthermore, the association of the presence of ORT with clinical data and OCT findings was investigated.

Results

Among the 136 eyes studied, the overall rates of occurrence of ORT were 7.8%, 18.8%, and 31.6% after 12, 24, and 36 months from baseline, respectively. Among patients with t-AMD, RAP, and mCNV, the occurrence of ORT increased soon after the initial visit. In contrast, among patients with PCV, the occurrence of ORT increased slowly over time. Patients with and without ORT – ORT(+) and ORT(−) groups, respectively – differed significantly in terms of sex ratio and presence of intraretinal fluid at the initial visit and presence of subretinal fibrosis at 3 years from baseline. The ORT(+) group exhibited lower visual acuity (VA; 0.67±0.43) than that of the ORT(−) group (0.41±0.36; P<0.001).

Conclusion

The occurrence of ORT tended to increase more slowly among eyes diagnosed with PCV than among eyes with other types of CNV.

The Evolution of Outer Retinal Tubulation, a Neurodegeneration and Gliosis Prominent in Macular Diseases

PURPOSE

To document outer retinal tubulation (ORT) formation in advanced retinal disorders.

DESIGN

Retrospective, observational study.

PARTICIPANTS

Consecutive cases with retinal diseases showing outer retinal disruption and atrophy of the retinal pigment epithelium (RPE) associated with ORT on spectral-domain (SD) optical coherence tomography (OCT) at the final available visit.

METHODS

Cross-sectional SD OCT scans showing ORT at the last available visit were compared with eye-tracked baseline scans. Only patients showing the formation of ORT over time with absence of ORT at baseline were analyzed.

MAIN OUTCOME MEASURES

Steps in ORT formation based on shapes of the external limiting membrane (ELM) descent (flat, curved, reflected, and scrolled) at the border of outer retinal and RPE atrophy, ORT characteristics (open, closed), and time between steps through a long-term follow-up.

RESULTS

From 170 eyes of 86 patients with ORT, 38 eyes of 30 patients (11 men, 19 women) with a mean age of 78.87 years (range, 56-96 years) met inclusion criteria. Of these 38 eyes, 23 (60%) had geographic atrophy secondary to age-related macular degeneration (AMD) and 2 eyes (5%) had geographic atrophy secondary to pattern dystrophy. Twelve eyes (32%) had neovascular AMD and 1 eye (3%) had neovascularization secondary to pseudoxanthoma elasticum, all showing similar ORT formative steps. Seventy-three different retinal areas (1434 cross-sectional images) were analyzed over a mean follow-up of 69.5 months (range, 21-93 months). At 73 borders, grading of eye-tracked follow-up SD OCT line scans showed a flat ELM descent at least once at 34 borders (47%), a curved ELM at 47 borders (64%), a reflected ELM at 37 borders (51%), and a scrolled ELM at 24 borders (33%). Of 81 ORTs, 73 (90%) were closed and 8 (10%) were open. The mean time for ORT formation was 14.9 months (range, 1.4-71.3 months).

CONCLUSIONS

We propose progressive steps in the development of ORT and analyze the time of progression between these steps. Analyzing the borders of atrophy to determine the origin of ORT provides new insights into the pathophysiology of advanced retinal disease highlighting a role for Müller cells and may inform future therapeutic strategies.

Evaluation of outer retinal tubulations in eyes switched from intravitreal ranibizumab to aflibercept for treatment of exudative age-related macular degeneration

PURPOSE

To evaluate the changes of outer retinal tubulations (ORTs) as seen on spectral-domain optical coherence tomography (SD OCT) in eyes with neovascular age-related macular degeneration (AMD) where treatment was switched from intravitreal ranibizumab to intravitreal aflibercept.

METHODS

This was a prospective study of eyes diagnosed with neovascular AMD and previously treated with >6 intravitreal ranibizumab injections and switched to aflibercept, conducted at a single centre (Department of Ophthalmology at Pitié Salpetriere Hospital, Paris VI University) from January to July 2015. Before and after treatment was switched from ranibizumab to aflibercept, SD-OCT was used to evaluate the presence of ORTs. Additional assessments in this patient group included best-corrected visual acuity (BCVA), fluorescein angiography (FA), indocyanine green angiography (ICGA). Changes in pigment epithelium detachments (PED), presence of intraretinal cysts, and presence of subretinal fluid (SRF) were also noted.

RESULTS

Twenty-four eyes of 24 consecutive patients (15 female/nine male, mean age 70 years) diagnosed with neovascular AMD and previously treated with >6 intravitreal ranibizumab injections and switched to aflibercept were included in the analysis. After receiving aflibercept, patients were followed for a mean of 6.1 months. Prior to treatment switch, 97 % of eyes showed ORTs, while after treatment switch to aflibercept, at the end of the study period, 75 % had ORTs (p =  0.219). Changes in BCVA (LogMAR) were not statistically significant (1.16 ± 0.44 to 1.18 ± 1.06, p =  0.12), however, a significant reduction in central macular thickness (CMT) (from 406 μm ± 112 to 263 μm ± 68, p =  0.001), PED (from 70.8 % to 41.7 % , p =  0.016), presence of intraretinal cysts (from 83.3 % to 33.3 %, p =  0.002) and SRF (from 91.7 % to 25 %, p = 0.001 ) were noted.

CONCLUSION

After switching from ranibizumab treatment to aflibercept, ORTs remained present in 75 % of eyes, and significant reductions in CMT, PED, and SRF, and presence of intraretinal cysts were observed.

Prevalence of outer retinal tubulation in eyes with choroidal neovascularization

Background

Outer retinal tubulations (ORTs) are branching tubular structures located in the outer nuclear layer of the retina. The goal of this study is to determine the prevalence of ORTs observed in eyes with choroidal neovascularization (CNV) undergoing treatment with anti-angiogenic intravitreous injection (IVI) with anti-VEGF (vascular endothelial growth factor) at the Ophthalmology Department of a tertiary hospital in São Paulo, Brazil.

Methods

This is a descriptive study based on medical charts and Spectral-domain Optical Coherence Tomography (Sd-OCT) scans of 142 patients (158 eyes) treated between 2012 and 2014 with IVI of anti-VEGF for CNV. The patients’ data was analysed according to age, gender, pathology, presence of ORTs, and best corrected visual acuity (BCVA). Patients with and without ORTs were compared according to the last BCVA obtained using Chi square corrected by the Yates factor.

Results

ORTs were found in a total of 40 out of 158 eyes (25.31 %) with CNV; in 33 out of 119 eyes (27.7 %) with neovascular age-related macular disease (AMD); in 5 out of 8 eyes (62.5 %) with neovascular angioid streaks; and in 2 out of 12 eyes (16.67 %) with myopic neovascular membranes. Most patients with ORTs had BCVA worse than 20/200, significantly worse BCVA than patients without ORTs.

Conclusions

Recent studies have considered that the presence of ORTs is indicative of a photoreceptor degeneration process and may represent a final stage of multiple retinal degenerative pathologies. The prevalence of ORTs in eyes with CNV has not been well described, especially when considering the Brazilian population treated in a public health care system. In our study, ORTs were observed in only three different pathologies: neovascular AMD, neovascular angioid streaks and myopic neovascular membranes. The correct recognition of ORTs is fundamental for its differentiation from intraretinal cysts, for the latter is related to the activity of neovascular diseases, and usually guides anti-angiogenic therapy. We conclude that ORTs have a high prevalence in the population studied, and their correct identification presents relevant therapeutic implications.