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Krivosic V, Zureik A, Tadayoni R, Gaudric A. FROM OUTER RETINAL NEOVACULARIZATION TO EXUDATIVE SUBRETINAL NEOVASCULARIZATION IN MACULAR TELANGIECTASIA TYPE 2. Retina 2024; 44:1217-1223. [PMID: 38900579 DOI: 10.1097/iae.0000000000004079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
PURPOSE To describe the progression from outer retinal neovascularization (ORNV) to exudative subretinal new vessels (SRNVs) in idiopathic macular telangiectasia type 2. METHODS A total of 135 patients (270 eyes) imaged with optical coherence tomography angiography were included. MAIN OUTCOME MEASURES Ellipsoid zone loss, outer retinal hyperreflectivity, ORNV, and SRNVs. Outer retinal neovascularization was defined as a flow signal passing through the outer plexiform layer, with or without vertical linear outer retinal hyperreflectivity on the optical coherence tomography B-scan. Subretinal new vessels were defined as an abnormal capillary network with a peripheral anastomotic arcade seen on en face optical coherence tomography angiography and a convex hyperreflectivity at the retinal pigment epithelium. RESULTS Subretinal new vessels were observed in 38/270 eyes (14%). Subretinal new vessels were at a fibrotic stage in 24/38 eyes and at an exudative stage in 6/38 eyes, and a progression from ORNV to SRNVs was documented in 8/38 eyes. All cases showed an ellipsoid zone loss. In seven eyes (2.5%), SRNVs were also associated with subepithelial neovascularization. No retinochoroidal anastomosis was detected. The visual acuity dropped when SRNVs were present. CONCLUSION In this case series, SRNVs were found in 14% of eyes. In all cases, they were associated with an ellipsoid zone loss and with outer retinal hyperreflectivity. A progression from ORNV to SRNVs was observed.
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Affiliation(s)
- Valérie Krivosic
- Ophthalmology Department, AP-HP, Hôpital Lariboisière, Université Paris Cité, Paris, France; and
- Centre de Référence des maladies Vasculaires rares du Cerveau et de l'Œil (CERVCO), Hôpital Lariboisière, APHP, Paris, France
| | - Abir Zureik
- Ophthalmology Department, AP-HP, Hôpital Lariboisière, Université Paris Cité, Paris, France; and
- Centre de Référence des maladies Vasculaires rares du Cerveau et de l'Œil (CERVCO), Hôpital Lariboisière, APHP, Paris, France
| | - Ramin Tadayoni
- Ophthalmology Department, AP-HP, Hôpital Lariboisière, Université Paris Cité, Paris, France; and
- Centre de Référence des maladies Vasculaires rares du Cerveau et de l'Œil (CERVCO), Hôpital Lariboisière, APHP, Paris, France
| | - Alain Gaudric
- Ophthalmology Department, AP-HP, Hôpital Lariboisière, Université Paris Cité, Paris, France; and
- Centre de Référence des maladies Vasculaires rares du Cerveau et de l'Œil (CERVCO), Hôpital Lariboisière, APHP, Paris, France
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Yasvoina M, Yang Q, Woods SM, Heeren T, Comer GM, A Egan C, Fruttiger M. Intraretinal pigmented cells in retinal degenerative disease. Br J Ophthalmol 2023; 107:1736-1743. [PMID: 35301216 DOI: 10.1136/bjophthalmol-2021-320392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 02/28/2022] [Indexed: 11/04/2022]
Abstract
PURPOSE Invasion of pigmented cells into the retina occurs in retinal degenerative diseases, such as macular telangiectasia type 2 (MacTel) and retinitis pigmentosa (RP). These intraretinal pigmented cells may be derived from the retinal pigment epithelium (RPE), but differences and similarities between intraretinal pigmented cells and RPE have so far not been well characterised.Clinicopathologic case report. METHOD Here, we compared intraretinal pigment cells with RPE cells by immunohistochemistry. Immunohistological stains for classic RPE markers (RPE65, CRALBP and KRT18) and blood vessel markers (lectin and collagen 4) were done on sections from postmortem eye tissue from two MacTel donors, an RP donor and a control donor. MAIN OUTCOME MEASURES Presence of specific immunohistochemistry markers on intraretinal pigmented and RPE cells. RESULTS We found that intraretinal pigmented cells did not express RPE65 and CRALBP, with a small subset expressing them weakly. However, they all expressed KRT18, which was also present in normal RPE cells. Interestingly, we also found clusters of KRT18-positive cells in the retina that were not pigmented. CONCLUSIONS Our findings suggest that RPE cells invading the retina dedifferentiate (losing classic RPE markers) and can be pigmented or unpigmented. Therefore, the number of RPE cells invading the retina in retinal degenerative disease may be underappreciated by funduscopy.
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Affiliation(s)
- Marina Yasvoina
- UCL Institute of Ophthalmology, University College London, London, UK
| | - Qian Yang
- UCL Institute of Ophthalmology, University College London, London, UK
| | - Sasha M Woods
- UCL Institute of Ophthalmology, University College London, London, UK
| | - Tjebo Heeren
- Moorfields Eye Hospital, NHS Foundation Trust, London, UK
| | - Grant M Comer
- W.K. Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Marcus Fruttiger
- UCL Institute of Ophthalmology, University College London, London, UK
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Schmetterer L, Scholl H, Garhöfer G, Janeschitz-Kriegl L, Corvi F, Sadda SR, Medeiros FA. Endpoints for clinical trials in ophthalmology. Prog Retin Eye Res 2023; 97:101160. [PMID: 36599784 DOI: 10.1016/j.preteyeres.2022.101160] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 12/22/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023]
Abstract
With the identification of novel targets, the number of interventional clinical trials in ophthalmology has increased. Visual acuity has for a long time been considered the gold standard endpoint for clinical trials, but in the recent years it became evident that other endpoints are required for many indications including geographic atrophy and inherited retinal disease. In glaucoma the currently available drugs were approved based on their IOP lowering capacity. Some recent findings do, however, indicate that at the same level of IOP reduction, not all drugs have the same effect on visual field progression. For neuroprotection trials in glaucoma, novel surrogate endpoints are required, which may either include functional or structural parameters or a combination of both. A number of potential surrogate endpoints for ophthalmology clinical trials have been identified, but their validation is complicated and requires solid scientific evidence. In this article we summarize candidates for clinical endpoints in ophthalmology with a focus on retinal disease and glaucoma. Functional and structural biomarkers, as well as quality of life measures are discussed, and their potential to serve as endpoints in pivotal trials is critically evaluated.
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Affiliation(s)
- Leopold Schmetterer
- Singapore Eye Research Institute, Singapore; SERI-NTU Advanced Ocular Engineering (STANCE), Singapore; Academic Clinical Program, Duke-NUS Medical School, Singapore; School of Chemistry, Chemical Engineering and Biotechnology, Nanyang Technological University, Singapore; Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria; Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria; Institute of Molecular and Clinical Ophthalmology, Basel, Switzerland.
| | - Hendrik Scholl
- Institute of Molecular and Clinical Ophthalmology, Basel, Switzerland; Department of Ophthalmology, University of Basel, Basel, Switzerland
| | - Gerhard Garhöfer
- Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria
| | - Lucas Janeschitz-Kriegl
- Institute of Molecular and Clinical Ophthalmology, Basel, Switzerland; Department of Ophthalmology, University of Basel, Basel, Switzerland
| | - Federico Corvi
- Eye Clinic, Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Italy
| | - SriniVas R Sadda
- Doheny Eye Institute, Los Angeles, CA, USA; Department of Ophthalmology, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Felipe A Medeiros
- Vision, Imaging and Performance Laboratory, Department of Ophthalmology, Duke Eye Center, Duke University, Durham, NC, USA
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Chandran K, Giridhar A, Gopalakrishnan M, Sivaprasad S. Relation of interdigitation zone changes and right-angle vessels in Macular Telangiectasia Type-2 (MacTel). Eye (Lond) 2023; 37:2977-2986. [PMID: 36841866 PMCID: PMC10516857 DOI: 10.1038/s41433-023-02453-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 01/05/2023] [Accepted: 02/13/2023] [Indexed: 02/27/2023] Open
Abstract
BACKGROUND To study the relation between interdigitation zone (IDZ) and right-angle vessel (RAV) in Macular Telangiectasia Type-2 (MacTel). METHODS A total of 43 eyes of 38 patients with presence of definite RAV on colour fundus photograph (Gass and Blodi-only stage-3) were confirmed on multimodal imaging. The relation of IDZ changes and associated ellipsoid zone (EZ) alterations on spectral-domain optical coherence tomography (OCT) with RAV were studied at baseline and these OCT changes were followed up in 15 eyes over a mean of 3.86 years. RESULTS A total of 58 RAVs were found in the 43 eyes and 53/58 (91.3%) RAVs were associated with IDZ alterations in 39 eyes. On follow-up, IDZ attenuation progressed to IDZ loss and subsequent EZ attenuation and loss. A pre-existing IDZ loss was associated with subsequent EZ defect (P = 0.002). In 36 eyes that had OCT angiography, eyes with RAV showed deep capillary plexus telangiectasia in all 36 (100%) eyes and 32/36 (89%) eyes showed IDZ changes with or without EZ loss. CONCLUSIONS IDZ attenuation and/or loss are associated with RAV and may serve as predictor of EZ loss in MacTel.
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Affiliation(s)
- Kiran Chandran
- Department of Vitreoretinal Services, Giridhar Eye Institute, Cochin, Kerala, India
- SSM Eye Research Foundation, Giridhar Eye Institute, Cochin, Kerala, India
| | - Anantharaman Giridhar
- Department of Vitreoretinal Services, Giridhar Eye Institute, Cochin, Kerala, India.
- SSM Eye Research Foundation, Giridhar Eye Institute, Cochin, Kerala, India.
| | | | - Sobha Sivaprasad
- NIHR Biomedical Research Centre, Moorfields Eye Hospital, NHS Foundation Trust, London, UK
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Erol MK, Gedik B, Bozdogan YC, Ekinci R, Bulut M, Dogan B, Suren E, Akidan M. Evaluation of Optic Disc, Retinal Vascular Structures, and Acircularity Index in Patients with Idiopathic Macular Telangiectasia Type 2. Diagnostics (Basel) 2023; 13:3046. [PMID: 37835789 PMCID: PMC10572724 DOI: 10.3390/diagnostics13193046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/21/2023] [Accepted: 09/23/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND We aimed to compare the retinal, optic disc vascular density (ODVD) values, and acircularity index (AI) of patients with idiopathic macular telangiectasia type 2 (IMT) and healthy individuals using the optical coherence tomography angiography (OCTA) device. METHODS The study included 39 patients with IMT and 37 healthy controls. The OCTA findings of the patients and controls were examined. RESULTS The total, parafoveal and perifoveal vascular density of the superficial capillary plexus, choriocapillaris blood flow, inside-disc ODVD, retinal nerve fiber layer (RNFL), and retinal thicknesses were found to be statistically significantly lower, and the foveal avascular zone value was statistically significantly higher in the IMT group compared to the control group (p = 0.001, p = 0.01, p = 0.02, p = 0.01, p = 0.009, p = 0.002, p = 0.02, respectively). There was a statistically significant negative correlation between best-corrected visual acuity (BCVA) and AI (p = 0.02), and a statistically significant positive correlation between peripapillary vascular density and BCVA (p = 0.04). CONCLUSIONS We consider that the lower retinal, choriocapillaris, ODVD values, and retinal and RNFL thicknesses in the patients with IMT compared to the controls were due to vascular damage, remodeling, fibrosis, proliferation, and Müller cell damage. Ellipsoid zone defect, AI, and peripapillary vascular density are important indicators in the evaluation of visual acuity in these patients.
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Affiliation(s)
- Muhammet Kazim Erol
- Department of Ophthalmology, Antalya Education and Research Hospital, University of Health Sciences, 07100 Antalya, Turkey; (Y.C.B.); (R.E.); (M.B.); (B.D.); (E.S.)
| | - Birumut Gedik
- Department of Ophthalmology, Serik State Hospital, 07500 Antalya, Turkey;
| | - Yigit Caglar Bozdogan
- Department of Ophthalmology, Antalya Education and Research Hospital, University of Health Sciences, 07100 Antalya, Turkey; (Y.C.B.); (R.E.); (M.B.); (B.D.); (E.S.)
| | - Rojbin Ekinci
- Department of Ophthalmology, Antalya Education and Research Hospital, University of Health Sciences, 07100 Antalya, Turkey; (Y.C.B.); (R.E.); (M.B.); (B.D.); (E.S.)
| | - Mehmet Bulut
- Department of Ophthalmology, Antalya Education and Research Hospital, University of Health Sciences, 07100 Antalya, Turkey; (Y.C.B.); (R.E.); (M.B.); (B.D.); (E.S.)
| | - Berna Dogan
- Department of Ophthalmology, Antalya Education and Research Hospital, University of Health Sciences, 07100 Antalya, Turkey; (Y.C.B.); (R.E.); (M.B.); (B.D.); (E.S.)
| | - Elcin Suren
- Department of Ophthalmology, Antalya Education and Research Hospital, University of Health Sciences, 07100 Antalya, Turkey; (Y.C.B.); (R.E.); (M.B.); (B.D.); (E.S.)
| | - Melih Akidan
- Department of Ophthalmology, Kepez State Hospital, 07320 Antalya, Turkey;
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Goerdt L, Weinhold L, Isselmann B, Garcia JLR, Künzel SH, Schmid M, Holz FG, Tzaridis S, Thiele S. Relative Ellipsoid Zone Reflectivity in Macular Telangiectasia Type 2. Invest Ophthalmol Vis Sci 2023; 64:21. [PMID: 37462978 PMCID: PMC10362918 DOI: 10.1167/iovs.64.10.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023] Open
Abstract
Purpose The relative ellipsoid zone reflectivity (rEZR) has been proposed as an innovative biomarker for photoreceptor integrity. This study evaluates the rEZR in macular telangiectasia type 2 (MacTel) eyes of different disease stages. Methods The mean rEZR (ratio ellipsoid zone [EZ]/external limiting membrane [ELM] reflectivity [arbitrary units {AUs}], grey level range = 0-1) was analyzed for an entire spectral domain optical coherence tomography volume scan (global) and for each subfield of the Early Treatment Diabetic Retinopathy Study (ETDRS) grid (topographic) in patients with MacTel and controls. MacTel disease severity was classified according to Gass and Blodi. Results Linear mixed-model analysis of 145 eyes of 74 patients and 50 eyes of 25 controls revealed globally lower, yet not statistically significant, rEZR values in MacTel eyes. Topographically, most pronounced decreases were found in stages 3 and 4/5 for the temporal inner (coefficient estimates [CEs] = -25.4 [-38.2; -12.6] and -34.1 [-48.7; -19.6] AU, both: P < 0.001), the inferior inner (-29.9 [-44.6; -15.6] and -35.3 [-52.1; -18.5] AU, both: P < 0.001), the nasal inner (-21.5 [-35.52; -7.4] and -31.6 [-47.6; -15.6] AU, P = 0,003 and P < 0.001), and in the superior inner subfield of stage 4/5 (-25.0 [-42.0; -7.9] AU, P = 0.004). Conclusions The rEZR showed association with disease severity and the predilection area of MacTel. Given the current understanding of the pathophysiological concept of MacTel, these findings underscore the value of the rEZR as a potential novel biomarker for outer retinal integrity. Longitudinal studies are demanded to better characterize its value as a biomarker for early photoreceptor alterations and disease progression in MacTel.
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Affiliation(s)
- Lukas Goerdt
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Leonie Weinhold
- Institute for Medical Biometry, Informatics and Epidemiology, University of Bonn, Bonn, Germany
| | - Ben Isselmann
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | | | | | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, University of Bonn, Bonn, Germany
| | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | - Simone Tzaridis
- Department of Ophthalmology, University of Bonn, Bonn, Germany
- The Lowy Medical Research Institute, La Jolla, California, United States
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, California, United States
| | - Sarah Thiele
- Department of Ophthalmology, University of Bonn, Bonn, Germany
- Department of Ophthalmology, Gloucestershire Hospital NHS Foundation Trust, Cheltenham, United Kingdom
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OUTER FOVEAL DEFECTS IN TYPE-2 MACULAR TELANGIECTASIA. Retina 2023; 43:111-119. [PMID: 36542082 DOI: 10.1097/iae.0000000000003640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 09/24/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE To report characteristics of outer foveal defects (OFDs) in type-2 macular telangiectasia (MacTel) on spectral domain optical coherence tomography. METHODS This was a single-center observational study. From a registry of 745 patients with MacTel, patients with OFDs were characterized. All patients underwent multimodal imaging including color fundus photography, confocal blue reflectance, fundus autofluorescence, and spectral domain optical coherence tomography. Staging of eyes was done using the Gass and Blodi classification. Spectral domain optical coherence tomography characteristics in the central 1 mm of the macula in eyes with OFD are reported. RESULTS Outer foveal defect was observed in 21 eyes of 15/745 (2%) patients with MacTel. These defects were bilateral in 6/15 (40%) patients and seen in stage 2 MacTel eyes. In order of prevalence, foveal parameters seen in OFD included hyper-reflective dots in outer retina in 19/21 (90%), ellipsoid zone loss in 18/21 (86%) eyes, interdigitation zone loss in 17/21 (81%) eyes, outer retinal hyporeflective cavitation in 14 (67%) eyes, hyporeflective cavitation at foveal pit in 8 (38%) eyes, and loss of external limiting membrane in 1 (5%) eye. The mean baseline length of the foveal ellipsoid zone loss was 240.17 ± 117.249 µm. The mean baseline central subfield thickness was 155.43 ± 17.215 µm. A total of 8/11 eyes (73%) showed an increase in size of OFD on follow-up. CONCLUSION Outer foveal defect in MacTel eyes is characterized predominantly by foveal loss of ellipsoid zone and interdigitation zone with relative preservation of external limiting membrane.
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Venkatesh R, Reddy NG, Mishra P, Yadav NK, Chhablani J. Structural-vascular-functional correlation in type 2 non-proliferative macular telangiectasia. Int J Retina Vitreous 2022; 8:59. [PMID: 36028918 PMCID: PMC9419364 DOI: 10.1186/s40942-022-00410-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/11/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To correlate the structural-vascular-functional changes in type 2 non-proliferative macular telangiectasia (MacTel) using optical coherence tomography (OCT) angiography (OCTA). METHODS In this retrospective study, OCTA and enface OCT image analysis of eyes with confirmed diagnosis of non-proliferative type 2 MacTel was performed. The 'MacTel area' was calculated by marking the outer boundary of an area affected by MacTel on superficial (SCP) and deep capillary plexus (DCP) on OCTA images and photoreceptor layer (PRL) on enface OCT scan. At every follow-up OCTA scan visit, best-corrected visual acuity, MacTel area and stage of disease was documented. Analyses between disease stage, MacTel area and logMAR visual acuity was carried out. RESULTS In total, 38 single-visit OCTA scans of 22 patients were included. The mean age was 58.9 ± 10.98 years. An increase in disease severity stage correlated positively with MacTel area in SCP segmentations slab (r = 0.334; p = 0.04) and logMAR visual acuity (r = 0.338; p = 0.038). No correlation in the DCP area or PRL area (p > 0.05) was noted with disease stage. A statistically significant positive correlation was noted between the structural changes in PRL layer with vascular changes in SCP (p = 0.021) but not in DCP (p = 0.199). No correlation of visual acuity with changes in SCP, DCP or PRL was noted (p > 0.05). CONCLUSION OCTA is a useful adjunct for determining disease severity in type 2 non-proliferative MacTel by assessing the structural-vascular changes. Further longitudinal studies need to be considered in future for understanding the pathomechanism of retinal damage in type 2 MacTel.
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Affiliation(s)
- Ramesh Venkatesh
- Narayana Nethralaya, #121/C, 1st R Block, Chord Road, Rajaji Nagar, Bengaluru, 560010, Karnataka, India. .,Deptartment of Retina and Vitreous, Narayana Nethralaya, #121/C, 1st R Block, Chord Road, Rajaji Nagar, Bengaluru, 560010, Karnataka, India.
| | - Nikitha Gurram Reddy
- Narayana Nethralaya, #121/C, 1st R Block, Chord Road, Rajaji Nagar, Bengaluru, 560010, Karnataka, India
| | - Pranjal Mishra
- Narayana Nethralaya, #121/C, 1st R Block, Chord Road, Rajaji Nagar, Bengaluru, 560010, Karnataka, India
| | - Naresh Kumar Yadav
- Narayana Nethralaya, #121/C, 1st R Block, Chord Road, Rajaji Nagar, Bengaluru, 560010, Karnataka, India
| | - Jay Chhablani
- University of Pittsburgh School of Medicine, Medical Retina and Vitreoretinal Surgery, 203 Lothrop Street, Suite 800, Pittsburg, PA, 15213, USA
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Non-vasogenic cystoid maculopathies. Prog Retin Eye Res 2022; 91:101092. [PMID: 35927124 DOI: 10.1016/j.preteyeres.2022.101092] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 11/23/2022]
Abstract
Besides cystoid macular edema due to a blood-retinal barrier breakdown, another type of macular cystoid spaces referred to as non-vasogenic cystoid maculopathies (NVCM) may be detected on optical coherence tomography but not on fluorescein angiography. Various causes may disrupt retinal cell cohesion or impair retinal pigment epithelium (RPE) and Müller cell functions in the maintenance of retinal dehydration, resulting in cystoid spaces formation. Tractional causes include vitreomacular traction, epiretinal membranes and myopic foveoschisis. Surgical treatment does not always allow cystoid space resorption. In inherited retinal dystrophies, cystoid spaces may be part of the disease as in X-linked retinoschisis or enhanced S-cone syndrome, or occur occasionally as in bestrophinopathies, retinitis pigmentosa and allied diseases, congenital microphthalmia, choroideremia, gyrate atrophy and Bietti crystalline dystrophy. In macular telangiectasia type 2, cystoid spaces and cavitations do not depend on the fluid leakage from telangiectasia. Various causes affecting RPE function may result in NVCM such as chronic central serous chorioretinopathy and paraneoplastic syndromes. Non-exudative age macular degeneration may also be complicated by intraretinal cystoid spaces in the absence of fluorescein leakage. In these diseases, cystoid spaces occur in a context of retinal cell loss. Various causes of optic atrophy, including open-angle glaucoma, result in microcystoid spaces in the inner nuclear layer due to a retrograde transsynaptic degeneration. Lastly, drug toxicity may also induce cystoid maculopathy. Identifying NVCM on multimodal imaging, including fluorescein angiography if needed, allows guiding the diagnosis of the causative disease and choosing adequate treatment when available.
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One-year follow-up of optical coherence tomography angiography microvascular findings: macular telangiectasia type 2 versus tamoxifen retinopathy. Graefes Arch Clin Exp Ophthalmol 2022; 260:3479-3488. [PMID: 35536356 DOI: 10.1007/s00417-022-05695-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 04/15/2022] [Accepted: 04/30/2022] [Indexed: 11/04/2022] Open
Abstract
PURPOSE To compare microstructural and microvascular changes in eyes with macular telangiectasia type 2 (MacTel2) and in those with tamoxifen retinopathy (TR) at baseline and at the 1-year follow-up using optical coherence tomography (OCT) and OCT angiography (OCTA). METHODS We followed up patients diagnosed with MacTel2 or TR for at least 1 year. We included 17 patients with MacTel2 (31 eyes) and 15 with TR (25 eyes) who discontinued tamoxifen use after a TR diagnosis. We performed OCT and OCTA at baseline and after 1 year. RESULTS Patients with MacTel2 and TR showed intraretinal cavitation, ellipsoid zone (EZ) loss, and capillary telangiectasia in the superficial and deep plexuses. EZ disruption predominantly affected the temporal region in MacTel2 (32%) and was limited to the foveal center in TR (24%). Vascular density (VD) was significantly reduced within the deep temporal parafovea and superficial fovea in MacTel2 and TR eyes, respectively. After 1 year, the MacTel2 eyes showed enlarged EZ loss, proliferative vascular invasion, and increased VD (p = 0.021) in the temporal deep plexus compared with TR eyes. CONCLUSIONS After 1-year follow-up, the MacTel2 eyes showed proliferative vascular remodeling, particularly in the temporal parafovea of the deep plexus with EZ loss progression, whereas the TR eyes maintained their baseline capillary rarefaction.
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Foulsham W, Chien J, Lenis TL, Papakostas TD. Optical Coherence Tomography Angiography: Clinical Utility and Future Directions. JOURNAL OF VITREORETINAL DISEASES 2022; 6:229-242. [PMID: 37008547 PMCID: PMC9976135 DOI: 10.1177/24741264221080376] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Purpose This work aims to review the principles of optical coherence tomography angiography (OCTA), to survey its clinical utility, and to highlight the strengths of this technology as well as barriers to adoption. Methods A literature review with editorial discussion of the current applications for OCTA is presented. Results There have been recent advances in multiple domains in OCTA imaging, including devices, algorithms, and new observations pertaining to a range of pathologies. New devices have improved the scanning speed, signal-to-noise ratio, and spatial resolution and offer an increased field of view. New algorithms have been proposed to optimize image processing and reduce artifacts. Numerous studies employing OCTA have been published describing changes to the microvasculature in diabetic retinopathy, age-related macular degeneration, central serous chorioretinopathy, retinal vein occlusion, and uveitis. Conclusions OCTA provides noninvasive, high-resolution volumetric scans of the retinal and choroidal vasculature. OCTA can provide valuable data to augment traditional dye-based angiography in a range of chorioretinal diseases.
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Affiliation(s)
- William Foulsham
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - Jason Chien
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - Tamara Lee Lenis
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - Thanos D. Papakostas
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
- The Retina Institute, St Louis, MO, USA
- Thanos D. Papakostas, MD, The Retina Institute, 2201 S Brentwood Blvd, St Louis, MO 63144, USA.
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Pauleikhoff D, Pauleikhoff L, Chew EY. Imaging endpoints for clinical trials in MacTel type 2. Eye (Lond) 2022; 36:284-293. [PMID: 34389818 PMCID: PMC8807726 DOI: 10.1038/s41433-021-01723-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/15/2021] [Accepted: 07/26/2021] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Macular Telangiectasia type 2 (MacTel) is a bilateral neurodegenerative disease associated with dysfunction in the serine and lipid metabolism resulting in loss of Muller cells and photoreceptors. Typical structural changes include vascular abnormalities, loss of retinal transparency, redistribution of macular pigment and thinning of the central retina with photoreceptor loss. The presence and extent of photoreceptor loss, as visible on Optical Coherence Tomography (OCT) ("disease severity scale"), correlate with functional loss and the limitation of photoreceptor loss appears to be the most promising therapeutic approach. Ongoing clinical trials of ciliary neurotrophic factor (CNTF) implants for the treatment of MacTel are using this outcome to evaluate efficacy. An ideal outcome measure provides the ability to quantify the extent of the disease progression with precision and reproducibility. METHODS This review describes the changes and findings on different imaging techniques including fluorescein- and OCT angiography, blue light reflectance, 1- and 2-wavelength autofluorescence and OCT. RESULTS The possibilities of objective quantification of the severity of MacTel and correlation with functional characteristics such as best-corrected visual acuity (BCVA) and microperimetry and their applications as quantitative imaging endpoints for clinical treatment trials are discussed. OCT and especially en face OCT could be demonstrated as precise and reproducible methods to quantify the area of photoreceptor loss, which correlated highly significantly with functional loss in microperimetry. CONCLUSION The analysis of the area of photoreceptor loss on en face OCT is the most reliable imaging endpoint for treatment trials in MacTel. This method is already being used in ongoing randomized trials.
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Affiliation(s)
- Daniel Pauleikhoff
- Department of Ophthalmology, St. Franziskus Hospital Muenster, Münster, Germany.
| | | | - Emily Y Chew
- National Eye Institute, National Institutes of Health, Bethesda, MD, USA
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Ong JX, Zandi R, Fawzi AA. Early-stage macular telangiectasia type 2 vascular abnormalities are associated with interdigitation zone disruption. PLoS One 2021; 16:e0259811. [PMID: 34767582 PMCID: PMC8589180 DOI: 10.1371/journal.pone.0259811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/26/2021] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To investigate the relationship between disruption in different photoreceptor layers and deep capillary plexus (DCP) telangiectasias in eyes with macular telangiectasia type 2 (MacTel). METHODS 35 eyes (21 patients) with MacTel imaged with optical coherence tomography angiography (OCTA) were included. Circumscribed areas of DCP telangiectasia were traced from OCTA slabs and the corresponding spectral-domain OCT (SD-OCT) slabs were used to visualize the photoreceptor layer interdigitation zone (IZ) and ellipsoid zone (EZ). IZ attenuation, IZ loss, and EZ loss were graded by reviewing en face SD-OCT slabs for hypo-reflective areas and confirming their status on cross-sectional views. Total area of photoreceptor disruption and overlap with DCP telangiectasia were evaluated with respect to OCT-based MacTel stage. Longitudinal changes were evaluated in a subset of patients with follow-up imaging. RESULTS Overlap of DCP telangiectasia with IZ attenuation significantly decreased with MacTel severity, while overlap with IZ and EZ loss significantly increased. Overlap with IZ loss peaked in moderate MacTel (Stages 3-5). Longitudinal imaging showed that new EZ loss at 6 months was largely predicted by baseline IZ loss. CONCLUSIONS Worsening MacTel severity is characterized by greater overlap between DCP telangiectasia and zones of increasing severity of photoreceptor disruption, with EZ loss enlarging over time within areas of preexisting IZ disruption. We suggest that IZ disruption may indicate early photoreceptor dysfunction that eventually progresses to EZ loss, with IZ loss being a more reliable metric than IZ attenuation. Additional studies will be necessary to further explore long-term photoreceptor changes and evaluate their relationship with visual function in MacTel.
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Affiliation(s)
- Janice X. Ong
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Roya Zandi
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
| | - Amani A. Fawzi
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States of America
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Sánchez-Vicente JL, de Las Morenas-Iglesias J, González-Jáuregui-López B, Rueda-Rueda T, Espiñeira-Periñán Á, López-Herrero F. Idiopathic macular telangiectasia type 2, stage V or proliferative stage: Multimodal imaging. J Fr Ophtalmol 2021; 44:1447-1451. [PMID: 34420799 DOI: 10.1016/j.jfo.2021.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/31/2021] [Accepted: 02/10/2021] [Indexed: 10/20/2022]
Affiliation(s)
- J L Sánchez-Vicente
- Department of Ophthalmology. Virgen-del-Rocío University Hospital, avenue Manuel-Siurot, 41013 Seville, Spain
| | - J de Las Morenas-Iglesias
- Department of Ophthalmology. Virgen-del-Rocío University Hospital, avenue Manuel-Siurot, 41013 Seville, Spain
| | - B González-Jáuregui-López
- Department of Ophthalmology. Virgen-del-Rocío University Hospital, avenue Manuel-Siurot, 41013 Seville, Spain.
| | - T Rueda-Rueda
- Department of Ophthalmology. Virgen-del-Rocío University Hospital, avenue Manuel-Siurot, 41013 Seville, Spain
| | - Á Espiñeira-Periñán
- Department of Ophthalmology. Virgen-del-Rocío University Hospital, avenue Manuel-Siurot, 41013 Seville, Spain
| | - F López-Herrero
- Department of Ophthalmology. Virgen-del-Rocío University Hospital, avenue Manuel-Siurot, 41013 Seville, Spain
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15
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Sakti DH, Cornish EE, Mustafic N, Zaheer A, Retsas S, Rajagopalan S, Chung CW, Ewans L, McCluskey P, Nash BM, Jamieson RV, Grigg JR. MERTK retinopathy: biomarkers assessing vision loss. Ophthalmic Genet 2021; 42:706-716. [PMID: 34289798 DOI: 10.1080/13816810.2021.1955278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Mer tyrosine kinase-retinitis pigmentosa (MERTK-RP) causes a primary defect in the retinal pigment epithelium, which subsequently affects rod and cone photoreceptors. The study aims to identify the most appropriate MERTK-RP biomarkers to measure disease progression for deciding the optimum therapeutic trial intervention time. MATERIALS AND METHODS Patients' data from baseline (BL) and last follow-up (LFU) were reviewed. Best corrected visual acuity (BCVA), spectral domain-optical coherence tomography (SD-OCT), ultra-widefield fundus autofluorescence (UWF-FAF) patterns, kinetic perimetry (KP), and electroretinography (ERG) parameters were analyzed. RESULTS Five patients were included with the mean age of 17.7 ± 14.4 years old (6.7-42.3) at BL and mean BCVA follow-up of 8.4 ± 5.1 years. Mean BCVA at BL and LFU were 0.84 ± 0.86 LogMAR and 1.14 ± 0.86 LogMAR, respectively. The BCVA decline rate was 0.05 ± 0.03 LogMAR units/year. Ellipzoid zones (EZ) were measurable in eight eyes with mean BL length of 1293.75 ± 421.07 µm and reduction of 140.95 ± 69.28 µm/year and mean BL CMT of 174.2 ± 37.52 µm with the rate of 11.2 ± 12.77 µm declining/year. Full-field ERG (ffERG) and pattern ERG (pERG) were barely recordable. UWF-FAF showed central macular hyper-autofluorescence (hyperAF). KP (III4e and V4e) was normal in two eyes, restricted nasally in four eyes, superior wedge defect in two eyes and undetectable in two eyes. The four restricted nasally KPs became worse, while the others stayed almost unchanged. CONCLUSIONS This cohort showed early visual loss, moderately rapid EZ reduction and macular hyperAF. EZ, CMT, and BCVA were consistently reduced. Relative rapid decline in these biomarkers reflecting visual function suggests an early and narrow timespan for intervention.
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Affiliation(s)
- Dhimas H Sakti
- Save Sight Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Department of Ophthalmology, Faculty of Medicine, Public Health and Nursing; Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Elisa E Cornish
- Save Sight Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Eye Genetics Research Unit, Children's Medical Research Institute, the Children's Hospital at Westmead, Save Sight Institute, University of Sydney, Sydney, NSW, Australia
| | - Nina Mustafic
- Save Sight Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Afsah Zaheer
- Save Sight Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Stephanie Retsas
- Save Sight Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Sulekha Rajagopalan
- Department of Clinical Genetics, Liverpool Hospital, Liverpool BC, NSW, Australia
| | - Clara Wt Chung
- Department of Clinical Genetics, Liverpool Hospital, Liverpool BC, NSW, Australia.,School of Women's & Children's Health, University of NSW, Sydney, NSW, Australia
| | - Lisa Ewans
- Department of Clinical Genetics, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.,Faculty of Medicine and Health Central Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Peter McCluskey
- Save Sight Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Benjamin M Nash
- Eye Genetics Research Unit, Children's Medical Research Institute, the Children's Hospital at Westmead, Save Sight Institute, University of Sydney, Sydney, NSW, Australia.,Disciplines of Genomic Medicine & Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Sydney Genome Diagnostics, Western Sydney Genetics Program, the Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Robyn V Jamieson
- Save Sight Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Eye Genetics Research Unit, Children's Medical Research Institute, the Children's Hospital at Westmead, Save Sight Institute, University of Sydney, Sydney, NSW, Australia.,Disciplines of Genomic Medicine & Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Department of Clinical Genetics, Western Sydney Genetics Program, the Children's Hospital at Westmead, Sydney, NSW, Australia
| | - John R Grigg
- Save Sight Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Eye Genetics Research Unit, Children's Medical Research Institute, the Children's Hospital at Westmead, Save Sight Institute, University of Sydney, Sydney, NSW, Australia
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Bringmann A, Unterlauft JD, Barth T, Wiedemann R, Rehak M, Wiedemann P. Müller cells and astrocytes in tractional macular disorders. Prog Retin Eye Res 2021; 86:100977. [PMID: 34102317 DOI: 10.1016/j.preteyeres.2021.100977] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 02/04/2023]
Abstract
Tractional deformations of the fovea mainly arise from an anomalous posterior vitreous detachment and contraction of epiretinal membranes, and also occur in eyes with cystoid macular edema or high myopia. Traction to the fovea may cause partial- and full-thickness macular defects. Partial-thickness defects are foveal pseudocysts, macular pseudoholes, and tractional, degenerative, and outer lamellar holes. The morphology of the foveal defects can be partly explained by the shape of Müller cells and the location of tissue layer interfaces of low mechanical stability. Because Müller cells and astrocytes provide the structural scaffold of the fovea, they are active players in mediating tractional alterations of the fovea, in protecting the fovea from such alterations, and in the regeneration of the foveal structure. Tractional and degenerative lamellar holes are characterized by a disruption of the Müller cell cone in the foveola. After detachment or disruption of the cone, Müller cells of the foveal walls support the structural stability of the foveal center. After tractional elevation of the inner layers of the foveal walls, possibly resulting in foveoschisis, Müller cells transmit tractional forces from the inner to the outer retina leading to central photoreceptor layer defects and a detachment of the neuroretina from the retinal pigment epithelium. This mechanism plays a role in the widening of outer lameller and full-thickness macular holes, and contributes to visual impairment in eyes with macular disorders caused by conractile epiretinal membranes. Müller cells of the foveal walls may seal holes in the outer fovea and mediate the regeneration of the fovea after closure of full-thickness holes. The latter is mediated by the formation of temporary glial scars whereas persistent glial scars impede regular foveal regeneration. Further research is required to improve our understanding of the roles of glial cells in the pathogenesis and healing of tractional macular disorders.
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Affiliation(s)
- Andreas Bringmann
- Department of Ophthalmology and Eye Hospital, University of Leipzig, 04103, Leipzig, Germany.
| | - Jan Darius Unterlauft
- Department of Ophthalmology and Eye Hospital, University of Leipzig, 04103, Leipzig, Germany
| | - Thomas Barth
- Department of Ophthalmology and Eye Hospital, University of Leipzig, 04103, Leipzig, Germany
| | - Renate Wiedemann
- Department of Ophthalmology and Eye Hospital, University of Leipzig, 04103, Leipzig, Germany
| | - Matus Rehak
- Department of Ophthalmology and Eye Hospital, University of Leipzig, 04103, Leipzig, Germany
| | - Peter Wiedemann
- Department of Ophthalmology and Eye Hospital, University of Leipzig, 04103, Leipzig, Germany
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Cohen SY, Mrejen S, Nghiem-Buffet S, Dubois L, Fajnkuchen F, Gaudric A. Outer Foveal Microdefects. ACTA ACUST UNITED AC 2021; 5:553-561. [DOI: 10.1016/j.oret.2020.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/19/2020] [Accepted: 09/14/2020] [Indexed: 12/28/2022]
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18
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Krivosic V, Lavia C, Aubineau A, Tadayoni R, Gaudric A. OCT of Outer Retinal Hyperreflectivity, Neovascularization, and Pigment in Macular Telangiectasia Type 2. ACTA ACUST UNITED AC 2021; 5:562-570. [DOI: 10.1016/j.oret.2020.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/13/2020] [Accepted: 09/15/2020] [Indexed: 12/29/2022]
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Moussa M, Leila M, Moussa O. Multimodal imaging of macular telangiectasia type 2 in a pediatric patient. Am J Ophthalmol Case Rep 2021; 22:101082. [PMID: 33948521 PMCID: PMC8080470 DOI: 10.1016/j.ajoc.2021.101082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 02/23/2021] [Accepted: 03/29/2021] [Indexed: 10/27/2022] Open
Abstract
Purpose To describe findings of multimodal imaging in non-proliferative and proliferative stages of MacTel 2 in a pediatric patient, and results of aflibercept use for treating neovascularization secondary to MacTel 2. Methods Retrospective case report. Results An 11-year-old girl with no history of systemic disease. BCVA was 20/200 and 20/40 in the right and left eyes, respectively. FFA, SS-OCT and SS-OCTA revealed proliferative and non-proliferative stages of MacTel 2 in the right and left eyes, respectively. Intravitreal aflibercept (2mg/0.05mL) was started (PRN) in the right eye. The patient received 5 injections that led to involution of macular neovascularization and improvement of BCVA by 5 lines. BCVA in the left eye remained stable. Conclusion MacTel 2 can develop in an earlier age than previously reported. SS-OCTA is an effective alternative to conventional imaging in diagnosis and follow-up especially in pediatric patients. Intravitreal aflibercept is effective in treating proliferative MacTel 2.
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Affiliation(s)
- Magdy Moussa
- Ophthalmology Department, Faculty of Medicine, Tanta University, El Bahr Street, Tanta Qism 2, Gharbia Governorate, Postal Code 31111, Tanta, Egypt.,MEDIC Eye Center, Tanta, Egypt
| | - Mahmoud Leila
- Retina Department, Research Institute of Ophthalmology, 2, Al-Ahram Street, Giza, Egypt
| | - Omar Moussa
- Ophthalmology Department, Faculty of Medicine, Kafr El Sheikh University, Mubarak Road, Qism Kafr El Sheikh, Kafr El Sheikh, Kafr El Sheikh Governorate, Egypt
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21
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CHARACTERIZING RETINAL-CHOROIDAL ANASTOMOSIS IN MACULAR TELANGIECTASIA TYPE 2 WITH OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY. Retina 2021; 40:92-98. [PMID: 31246676 DOI: 10.1097/iae.0000000000002619] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To characterize structural and angiographic findings in macular telangiectasia Type 2 (MacTel 2) and examine associations with visual acuity. METHODS MacTel 2 patients with complete ophthalmologic examination, including fundus photography, autofluorescence, spectral-domain optical coherence tomography, and projection-resolved optical coherence tomography angiography, were retrospectively evaluated. RESULTS There were 43 eyes of 22 patients with a mean age 63.9 (±10.3) years. Six patients had diabetes. Twenty-one eyes (48.8%) had retinal-choroidal anastomoses (RCAs) without any evidence of neovascularization extending laterally in a plane above or below the retinal pigment epithelium. None of the eyes had hemorrhage, lipid, or signs of subretinal exudation. When present, an average of 55 (±33.7) individual RCAs were clustered primarily in temporal juxtafoveal region of involved eyes. Right-angle veins were seen in all 21 eyes with RCAs, and hyperpigmentation was present in 18 (P < 0.001 for both). A conical collection of hyperreflective material spanning from Bruch membrane past external limiting membrane of ≥200-μm basal diameter was found in 21 eyes and labeled outer retinal hyperreflective lesion. Retinal-choroidal anastomoses occurred in clusters, often within the outer retinal hyperreflective lesion. This lesion colocalized with focal thinning of the outer nuclear layer and was surrounded by a larger defect in the ellipsoid zone. The presence of diabetes (P = 0.015), outer retinal hyperreflective lesion (P = 0.006), RCA (P = 0.005), and ellipsoid zone defect extent (P < 0.001) were associated with decreased visual acuity. CONCLUSION Retinal-choroidal anastomoses occur in eyes with MacTel 2 without signs of exudation. Retinal-choroidal anastomoses occur in numerous clusters particularly in the temporal juxtafoveal macula. Diabetes, ellipsoid zone defect extent, RCAs, and the outer retinal hyperreflective lesion predict poorer vision in MacTel 2.
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Mueller S, Gunnemann F, Rothaus K, Book M, Faatz H, Bird A, Pauleikhoff D. Incidence and phenotypical variation of outer retina-associated hyperreflectivity in macular telangiectasia type 2. Br J Ophthalmol 2021; 105:573-576. [PMID: 33414243 DOI: 10.1136/bjophthalmol-2020-317997] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/23/2020] [Accepted: 12/16/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Macular telangiectasia type 2 (MacTel) is a neurodegenerative disease resulting in photoreceptor loss. Optical coherence tomography (OCT) reveals outer retina-associated hyperreflectivity (ORaH) as part of this process. The purpose of this study was to describe the incidence and phenotypical variation of ORaH. METHODS Different parameters of ORaH were analysed: OCT characteristics (Spectralis SD-OCT), correlation with vascular changes (OCT angiography; OCTA 3×3 mm Optovue) and correlation with hyperpigmentation (autofluorescence/fundus images). ORaH was also evaluated regarding the grade of severity of photoreceptor loss (Disease Severity Scale). RESULTS Of 220 eyes with MacTel type 2, 106 demonstrated ORaH. On OCT, the size, the extension into the inner retina and the contact with retinal pigment epithelium (RPE) of the ORaH were variable. On OCTA neovascularisation (NV) in the outer retina (OR) was present at the location of the ORaH in 97.6%. Increasing size of NV correlated with progressive photoreceptor loss. In 86.6% with NV, the flow signals were visible between the OR and the choriocapillaris. In 85.7%, the ORaH was associated with hyperpigmentation on autofluorescence and fundus colour images. CONCLUSIONS The presence of ORaH is associated with increasing photoreceptor loss and disease severity. In these more advanced cases of the present study, a variable presentation of ORaH in respect to size and form was seen, but in most cases, ORaH was in contact to the RPE. Additionally, ORaH was associated with hyperpigmentation and OR NV on OCTA. These results are consistent with the concept of ORaH representing fibrovascular OR-NV with RPE proliferation after contact with the RPE.
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Affiliation(s)
- Stefanie Mueller
- Department of Ophthalmology, St. Franziskus Hospital, Münster, Germany
| | - Frederic Gunnemann
- Department of Ophthalmology, St. Franziskus Hospital, Münster, Germany.,Retinal Disorders and Ophthalmic Genetics, Jules Stein Eye Institute, Los Angeles, California, USA
| | - Kai Rothaus
- Department of Ophthalmology, St. Franziskus Hospital, Münster, Germany
| | - Marius Book
- Department of Ophthalmology, St. Franziskus Hospital, Münster, Germany
| | - Henrik Faatz
- Department of Ophthalmology, St. Franziskus Hospital, Münster, Germany
| | - Alan Bird
- Genetics, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Daniel Pauleikhoff
- Department of Ophthalmology, St. Franziskus Hospital, Münster, Germany .,Department of Ophthalmology, University of Duisburg-Essen Faculty of Medicine, Essen, Nordrhein-Westfalen, Germany
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Zandi R, Song J, Micevych PS, Fawzi AA. Topographic Relationship between Telangiectasia and Cone Mosaic Disruption in Macular Telangiectasia Type 2. J Clin Med 2020; 9:jcm9103149. [PMID: 33003381 PMCID: PMC7601362 DOI: 10.3390/jcm9103149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 09/23/2020] [Accepted: 09/27/2020] [Indexed: 12/25/2022] Open
Abstract
In this cross-sectional observational study, we investigated the relationship between photoreceptor layer disruption and telangiectasia in patients diagnosed with early stage macular telangiectasia type 2 (MacTel). A total of 31 eyes (17 patients) with MacTel were imaged with adaptive optics scanning laser ophthalmoscopy (AOSLO) and optical coherence tomography angiography (OCTA). Confocal AOSLO was used to visualize dark regions of nonwaveguiding outer segments, which we refer to as “photoreceptor lesions”. En-face OCTA images of the deep capillary plexus (DCP) were used in conjunction with confocal AOSLO to evaluate the topographic relationship between areas of capillary telangiectasias and photoreceptor lesions. Among seven eyes with early stage MacTel (stage 0–2 based on OCT), we identified ten photoreceptor lesions, all of which were located within parafoveal quadrants containing DCP telangiectasia on OCTA. Seven of the lesions corresponded to the intact ellipsoid zone on spectral-domain OCT (SD-OCT), and three of these also corresponded to the intact interdigitation zone. This work demonstrates a topographic relationship between AOSLO photoreceptor lesions and DCP telangiectasias, and it also suggests that these lesions with normal SD-OCT appearance may represent areas of photoreceptors at risk for dysfunction. Thus, confocal AOSLO may have a meaningful role in detecting early photoreceptor abnormalities in eyes with MacTel.
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Değirmenci MFK, Temel E, Yalçındağ FN. Quantitative Evaluation of the Retinal Vascular Parameters With OCTA in Patients With Behçet Disease Without Ocular Involvement. Ophthalmic Surg Lasers Imaging Retina 2020; 51:31-34. [PMID: 31935300 DOI: 10.3928/23258160-20191211-04] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 07/29/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVE To evaluate the optical coherence tomography angiography (OCTA) features of patients with Behçet disease (BD) without ocular involvement. PATIENTS AND METHODS Twenty-three patients with BD without ocular involvement and 29 healthy age/sex-matched control subjects were involved. The authors measured foveal avascular zone (FAZ) area, vessel density in the parafoveal region, and flow area (fovea-centered 3-mm radius area) in the superficial and deep capillary plexuses evaluated by OCTA. RESULTS FAZ area was significantly larger in eyes with BD in both the superficial and deep capillary plexuses (0.331 vs. 0.240 mm2 [P = .004] and 0.352 vs. 0.257 mm2 [P = .003], respectively). Although mean capillary vessel density in parafoveal region and mean flow area were lower in eyes with BD for both superficial and deep capillary plexuses, these findings were not statistically significant. CONCLUSION Microvascular changes in macular region can be identified in patients with BD without ocular manifestation. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:31-34.].
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Micevych PS, Soetikno BT, Fawzi AA. Perivenular Capillary Loss: An Early, Quantifiable Change in Macular Telangiectasia Type 2. Transl Vis Sci Technol 2020; 9:5. [PMID: 32818093 PMCID: PMC7396175 DOI: 10.1167/tvst.9.4.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/08/2019] [Indexed: 01/18/2023] Open
Abstract
Purpose To evaluate differences in parafoveal vascular density surrounding arterioles and venules in type 2 macular telangiectasia (MacTel). Methods Thirty-seven eyes (20 subjects) diagnosed with MacTel and 16 healthy eyes (10 subjects) were imaged with optical coherence tomography angiography between March 2016 and June 2019 in this single-center, observational, cross-sectional study. Arterioles and venules were manually identified, and perivascular density was generated using a custom MATLAB code. The primary outcome measure was the ratio of periarteriolar to perivenular vascular density (arteriovenous [A/V] capillary ratio) in the superficial and deep capillary plexuses across MacTel stages. The main secondary outcome measures were overall parafoveal vascular density (VD), periarteriolar VD, and perivenular VD. Results In the superficial capillary plexus (SCP), the A/V capillary ratio was significantly higher in MacTel subjects than controls (0.914 vs. 0.892; P = 0.0044). The greatest differences occurred between controls and nonproliferative MacTel subjects without optical coherence tomography evidence of disease (P = 0.0055). A/V capillary ratios progressed in a nonlinear fashion with MacTel severity, increasing from nonproliferative disease (0.912) to intraretinal proliferative disease (0.931), then decreasing in subretinal proliferative disease (0.905). Parafoveal VD in the SCP was lower in MacTel subjects than controls only in subretinal proliferative disease (P = 0.0130). Conclusions The A/V capillary ratio of the SCP is a quantifiable metric of vascular pathology in MacTel that occurs earlier than decline in parafoveal VD. Elevated A/V capillary ratios in MacTel are consistent with an early, disproportionately perivenular disruption in the SCP. Translational Relevance Findings inform MacTel pathogenesis through revealing early perivenular capillary loss and offer a new quantitative metric for earliest stage MacTel.
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Affiliation(s)
- Paul S Micevych
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Brian T Soetikno
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Amani A Fawzi
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Estawro RG, Embabi SN. Optical Coherence Tomography Angiography in Monitoring Proliferative Macular Telangiectasia Type 2 Treatment Response. Ophthalmic Surg Lasers Imaging Retina 2020; 50:485-491. [PMID: 31415694 DOI: 10.3928/23258160-20190806-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 01/17/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Difficulty exists in the follow-up of proliferative macular telangiectasia type 2 (MacTel 2) cases after anti-vascular endothelial growth factor (VEGF) treatment due to staining in fluorescein angiography (FA) and alteration in retinal layers by optical coherence tomography (OCT). Herein, the authors report three cases in which OCT angiography (OCTA) could resolve this issue. PATIENTS AND METHODS In this retrospective, observational case series, diagnosis of MacTel 2 was made based on clinical examination, FA, OCT, and OCTA at presentation. Regression of neovessels was monitored by OCT and OCTA. RESULTS OCTA could delineate neovessels before treatment in all cases and facilitate differentiation between active and regressed lesions after treatment. Simultaneous OCT images were less easily appreciated due to altered retinal structure secondary to degenerative nature of the disease. CONCLUSION OCTA could be the tool of choice to monitor neovascular response to anti-VEGF treatment in proliferative MacTel 2. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:485-491.].
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Overlap between telangiectasia and photoreceptor loss increases with progression of macular telangiectasia type 2. PLoS One 2019; 14:e0224393. [PMID: 31658282 PMCID: PMC6816569 DOI: 10.1371/journal.pone.0224393] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/11/2019] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To examine the topographical correlation between ellipsoid zone loss and telangiectasia in the deep capillary plexus in patients with macular telangiectasia type 2 (MacTel). METHODS 38 eyes (20 subjects) diagnosed with MacTel were imaged with OCTA between March 2016 and June 2019 in this single center, cross-sectional observational study. The en face OCTA and OCT were evaluated for areas of deep capillary plexus telangiectasia and ellipsoid zone loss, respectively, and their outlines were superimposed to study their overlap (mm2). The primary outcome was percentage of overlap and its relationship to MacTel stage. Secondary outcomes included the relationship between neovascularization and hyperreflective foci as well as correlations between ellipsoid zone loss, deep capillary plexus telangiectasia and visual acuity. RESULTS In nonproliferative MacTel stage, ellipsoid zone loss was localized to margins of telangiectatic areas (mean overlap = 15.2%). In proliferative stages, ellipsoid zone loss showed a higher degree of overlap with telangiectatic areas (mean overlap = 62.8%). Overlap increased with advancing MacTel stages, with an overall average of 45.3%. Overlap correlated highly with ellipsoid zone loss (r = 0.831; p<0.0001). Telangiectasia was present in all 38 eyes (range: 0.08mm2-0.99mm2), while ellipsoid zone loss was absent in 6 (range: 0.00-3.32mm2). Visual acuity correlated most strongly with ellipsoid zone loss (r = 0.569; p = 0.0002), followed by overlap (r = 0.544; p = 0.0004), and finally, telangiectasia (r = 0.404; p<0.0118). Presence of hyperreflective foci on OCT correlated with the presence and intraretinal location of neovascularization. CONCLUSIONS Ellipsoid zone loss occurs at the margins of deep capillary plexus telangiectasia in nonproliferative MacTel, with progressively increasing overlap as MacTel advances, peaking in proliferative disease. Deep capillary plexus telangiectasia and its overlap with ellipsoid zone loss are two promising markers of nonproliferative MacTel, while hyper-reflective foci are markers for proliferative MacTel.
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Demir ST, Güven D, Karatas ME, Dirim AB, Sendül SY, Ustaoglu M. Evaluation of 1-year follow-up results of macular telangiectasia type 2 cases by optical coherence tomography angiography. GMS OPHTHALMOLOGY CASES 2019; 9:Doc29. [PMID: 31531275 PMCID: PMC6734514 DOI: 10.3205/oc000118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The results of 1-year follow-up with optical coherence tomography angiography (OCTA) of 3 patients with macular telangiectasia type 2 (MacTel 2) were evaluated. The 3X3 mm OCTA imaging was performed in January 2017 and February 2018. The superficial and deep capillary plexus vascular density changes of the whole area, the parafoveal temporal and parafoveal nasal areas were examined. The mean whole, parafoveal temporal, and parafoveal nasal vessel densities at superficial capillary plexus were 51.31, 50.39, 54.57 at baseline and 49.93, 46.79, 51.83 at 1-year follow-up, respectively. The mean whole, parafoveal temporal and parafoveal nasal vessel densities at deep capillary plexus were 59.06, 59.05, 63.39 at baseline and 52.18, 54.68, 57.9 at 1-year follow-up, respectively. In this case series, it was shown quantitatively that vessel densities of MacTel2 patients markedly decreased over time, more pronounced in the deep capillary plexus.
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Affiliation(s)
- Semra Tiryaki Demir
- Department of Ophthalmology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Dilek Güven
- Department of Ophthalmology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Mehmet Egemen Karatas
- Department of Ophthalmology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Ayse Burcu Dirim
- Department of Ophthalmology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Selam Yekta Sendül
- Department of Ophthalmology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Melih Ustaoglu
- Department of Ophthalmology, Şişli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
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Progression of vascular changes in macular telangiectasia type 2: comparison between SD-OCT and OCT angiography. Graefes Arch Clin Exp Ophthalmol 2019; 257:1381-1392. [PMID: 31093765 DOI: 10.1007/s00417-019-04323-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 04/01/2019] [Accepted: 04/08/2019] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To investigate the different appearances of vascular changes in macular telangiectasia type 2 (MacTel) and to describe their possible progression, the vascular patterns in different retinal layers were analyzed with optical coherence tomography angiography (OCT-A) and the findings were correlated with a spectral-domain OCT (SD-OCT) disease severity scale based on the extent of ellipsoid zone (EZ) loss. METHODS Participants from the MacTel Study Group in Muenster and a healthy cohort were investigated with OCT-A using RTVue XR Avanti. After segmentation of the superficial capillary network, the deep capillary network, and the outer retina (OR), flow density was analyzed using Optovue software. Then, the images were exported using the software Fiji (National Institute of Mental Health, Bethesda, MD, USA) and analyzed with the automated MATLAB program (Mathworks, Version R2014b). Four parameters (total vessel length, number of vessel branches, number of vessel segments, and fractal dimension) were examined on the vascular skeletons (temporal, foveal, nasal, and total fields of the ETDRS grid). In addition, linear and area measurements of EZ loss were performed on SD-OCT volume scans. Progression characteristics and correlation between linear and area measurements were analyzed using linear mixed effects models. RESULTS Twenty eyes of healthy probands (20 OCT-A and 20 SD-OCT scans) and 122 eyes of 61 MacTel patients were included. In order to classify the severity of the disease, MacTel eyes were assigned to a SD-OCT "disease severity scale" (grade 1 = no EZ loss; grade 2 = EZ loss temporal to the fovea; grade 3 = EZ loss including the fovea and the region nasal to the fovea). Flow density and total vessel length showed only limited differences between healthy eyes and different grades of MacTel, but particularly the numbers of branches and vessel segments, as well as the fractal dimension values, demonstrated significant and progressive reduction in the superficial and deep capillary networks of the temporal, nasal, and total ETDRS fields. Moreover, the outer retina showed a progressive presence of hyperreflective material in SD-OCT grades 2 and 3 eyes with associated vascular patterns in the OR on OCT-A. CONCLUSIONS In SD-OCT, the severity of MacTel is characterized by progressive EZ loss, which may be used as a simple clinical "disease severity scale". In addition, OCT-A enables visualization and quantification of vascular patterns with mathematical methods. The morphological progression of the disease correlated significantly with progressive vascular changes, especially in respect of the numbers of branches and vessel segments as well as fractal dimension. This suggests that the severity of neurodegenerative and neurovascular changes develops in parallel and that the analysis and quantification of the vascular changes in the superficial and deep capillary networks may become an additional parameter for future treatment trials. Moreover, the significant association between hyperreflective material progressively visible on SD-OCT in the OR, which most often contains vessels in OCT-A, and advancing SD-OCT severity grades, as well as vascular changes in OCT-A, supports the concept of retinal neovascularization in the OR in patients with advanced MacTel.
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Strampe MR, Huckenpahler AL, Higgins BP, Tarima S, Visotcky A, Stepien KE, Kay CN, Carroll J. Intraobserver Repeatability and Interobserver Reproducibility of Ellipsoid Zone Measurements in Retinitis Pigmentosa. Transl Vis Sci Technol 2018; 7:13. [PMID: 29881650 PMCID: PMC5989764 DOI: 10.1167/tvst.7.3.13] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 04/12/2018] [Indexed: 12/29/2022] Open
Abstract
Purpose To examine repeatability and reproducibility of ellipsoid zone (EZ) width measurements in patients with retinitis pigmentosa (RP) using a longitudinal reflectivity profile (LRP) analysis. Methods We examined Bioptigen optical coherence tomography (OCT) scans from 48 subjects with RP or Usher syndrome. Nominal scan lengths were 6, 7, or 10 mm, and the lateral scale of each scan was calculated using axial length measurements. LRPs were generated from OCT line scans, and the peak corresponding to EZ was manually identified using ImageJ. The locations at which the EZ peak disappeared were used to calculate EZ width. Each scan was analyzed twice by each of two observers, who were masked to their previous measurements and those of the other observer. Results On average, horizontal width (HW) was significantly greater than vertical width (VW), and there was high interocular symmetry for both HW and VW. We observed excellent intraobserver repeatability with intraclass correlation coefficients (ICCs) ranging from 0.996 to 0.998 for HW and VW measurements. Interobserver reproducibility was also excellent for both HW (ICC = 0.989; 95% confidence interval [CI] = 0.983–0.995) and VW (ICC = 0.991; 95% CI = 0.985–0.996), with no significant bias observed between observers. Conclusions EZ width can be measured using LRPs with excellent repeatability and reproducibility. Our observation of greater HW than VW is consistent with previous observations in RP, though the reason for this anisotropy remains unclear. Translational Relevance We describe repeatability and reproducibility of a method for measuring EZ width in patients with RP or Usher syndrome. This approach could facilitate measurement of retinal band thickness and/or intensity.
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Affiliation(s)
- Margaret R Strampe
- Ophthalmology & Visual Sciences, Medical College of Wisconsin, Milwaukee, WI, USA.,University of Minnesota Medical School, Minneapolis, MN, USA
| | - Alison L Huckenpahler
- Cell Biology, Neurobiology, & Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Brian P Higgins
- Ophthalmology & Visual Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sergey Tarima
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alexis Visotcky
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kimberly E Stepien
- Ophthalmology & Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Joseph Carroll
- Ophthalmology & Visual Sciences, Medical College of Wisconsin, Milwaukee, WI, USA.,Cell Biology, Neurobiology, & Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
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Cohen SY, Miere A, Nghiem-Buffet S, Fajnkuchen F, Souied EH, Mrejen S. Clinical applications of optical coherence tomography angiography: What we have learnt in the first 3 years. Eur J Ophthalmol 2018; 28:491-502. [PMID: 29554812 DOI: 10.1177/1120672117753704] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
A review of the literature from 2014 to 2016 was conducted, focusing on the results of optical coherence tomography angiography in different chorioretinal diseases. In only 3 years, optical coherence tomography angiography has been shown to be an effective tool for diagnosing choroidal neovascularization complicating age-related macular degeneration, pathologic myopia, and inflammatory conditions. The technique has sometimes been considered superior to conventional multimodal imaging, for example, in choroidal neovascularization associated with chronic central serous chorioretinopathy or multifocal choroiditis. In retinal vascular diseases, optical coherence tomography angiography has helped to understand the condition described as paracentral acute middle maculopathy and has been considered highly effective for the analysis of retinal vascular macular changes secondary to retinal vein occlusion or macular telangiectasia. Changes in the foveal avascular zone, also reported in diabetic maculopathy, have been shown to occur before any angiographic signs. A reduction in capillary vascular density has been reported in the fovea of eyes with malignant melanoma, but not in eyes with choroidal nevus. However, optical coherence tomography angiography is a recent technique that probably needs refinements and further studies. Nevertheless, the first 3 years of optical coherence tomography angiography use suggest its clinical relevance and useful applications in daily clinical practice.
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Affiliation(s)
- Salomon Y Cohen
- 1 Ophthalmological Center for Imaging and Laser, Paris, France.,2 Department of Ophthalmology, University of Paris-Est, Creteil, France
| | - Alexandra Miere
- 2 Department of Ophthalmology, University of Paris-Est, Creteil, France
| | | | | | - Eric H Souied
- 2 Department of Ophthalmology, University of Paris-Est, Creteil, France
| | - Sarah Mrejen
- 1 Ophthalmological Center for Imaging and Laser, Paris, France
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VASCULAR DISTORTION AND DRAGGING RELATED TO APPARENT TISSUE CONTRACTION IN MACULAR TELANGIECTASIS TYPE 2. Retina 2018; 38 Suppl 1:S51-S60. [PMID: 28492432 DOI: 10.1097/iae.0000000000001694] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To examine the alterations in retinal vascular morphology over an extended follow-up in eyes with macular telangiectasis Type 2 (MacTel2). METHODS Eyes with high-quality digital photographs were evaluated. The geometric distortion in baseline images required to emulate the follow-up images was determined and vectors were made that represented the direction and magnitude of changes, to create a warp field. Optical coherence tomography and optical coherence tomography angiography evaluation of the retina was performed. RESULTS There were 7 eyes of 4 patients, who had a mean age of 70.25 years, which were followed for a mean of 8.8 years. The eyes showed increasing grayish opacification in the temporal macula with straightening and displacement of the macular vessels, even those in the nasal macula. The warp field vectors pointed to the temporal juxtafoveal macula. There was never any cavitation at the epicenter of the retinal distortion in any patient, although cavitations were found around this area. Optical coherence tomography imaging showed a circumscribed region of hyperreflectivity in the temporal macula. Optical coherence tomography angiography showed a deep angular condensed network of vessels within the hyperreflective region. One eye showed marked atrophic changes including full-thickness macular hole formation, but no increase in graying of the retina, loss of retinal laminations, pigmentary infiltration, or alteration in the retinal vessels. CONCLUSION Tissue contraction with retinal vascular displacement and contortion seem to be integral aspects of disease manifestation in MacTel2. The induced vascular changes may lead to secondary effects that increase morbidity in this disease.
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Mechanisms of macular edema: Beyond the surface. Prog Retin Eye Res 2017; 63:20-68. [PMID: 29126927 DOI: 10.1016/j.preteyeres.2017.10.006] [Citation(s) in RCA: 365] [Impact Index Per Article: 52.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 10/24/2017] [Accepted: 10/31/2017] [Indexed: 02/07/2023]
Abstract
Macular edema consists of intra- or subretinal fluid accumulation in the macular region. It occurs during the course of numerous retinal disorders and can cause severe impairment of central vision. Major causes of macular edema include diabetes, branch and central retinal vein occlusion, choroidal neovascularization, posterior uveitis, postoperative inflammation and central serous chorioretinopathy. The healthy retina is maintained in a relatively dehydrated, transparent state compatible with optimal light transmission by multiple active and passive systems. Fluid accumulation results from an imbalance between processes governing fluid entry and exit, and is driven by Starling equation when inner or outer blood-retinal barriers are disrupted. The multiple and intricate mechanisms involved in retinal hydro-ionic homeostasis, their molecular and cellular basis, and how their deregulation lead to retinal edema, are addressed in this review. Analyzing the distribution of junction proteins and water channels in the human macula, several hypotheses are raised to explain why edema forms specifically in the macular region. "Pure" clinical phenotypes of macular edema, that result presumably from a single causative mechanism, are detailed. Finally, diabetic macular edema is investigated, as a complex multifactorial pathogenic example. This comprehensive review on the current understanding of macular edema and its mechanisms opens perspectives to identify new preventive and therapeutic strategies for this sight-threatening condition.
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Study of foveal avascular zone by OCTA before and after idiopathic epiretinal membrane removal. SPEKTRUM DER AUGENHEILKUNDE 2017. [DOI: 10.1007/s00717-017-0375-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hagag AM, Gao SS, Jia Y, Huang D. Optical coherence tomography angiography: Technical principles and clinical applications in ophthalmology. Taiwan J Ophthalmol 2017; 7:115-129. [PMID: 28966909 PMCID: PMC5617355 DOI: 10.4103/tjo.tjo_31_17] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Optical coherence tomography angiography (OCTA) is a functional extension of OCT that provides information on retinal and choroidal circulations without the need for dye injections. With the recent development of high-speed OCT systems and efficient algorithms, OCTA has become clinically feasible. In this review article, we discuss the technical principles of OCTA, including image processing and artifacts, and its clinical applications in ophthalmology. We summarize recent studies which qualitatively or quantitatively assess disease presentation, progression, and/or response to treatment.
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Affiliation(s)
- Ahmed M Hagag
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, OR, USA
| | - Simon S Gao
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, OR, USA
| | - Yali Jia
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, OR, USA
| | - David Huang
- Department of Ophthalmology, Casey Eye Institute, Oregon Health and Science University, Portland, OR, USA
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VOLUME-RENDERED ANGIOGRAPHIC AND STRUCTURAL OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY OF MACULAR TELANGIECTASIA TYPE 2. Retina 2017; 37:424-435. [PMID: 27749698 DOI: 10.1097/iae.0000000000001344] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate multimodal imaging including volume-rendered angiographic and structural optical coherence tomography of macular telangiectasia Type 2 (MacTel2) for right-angle vein complexes, macular cavitations, and signs of deeper retinal vascular invasion. METHODS Retrospective review of imaging performed in a community-based retinal referral center. The eyes were scanned using optical coherence tomography using split-spectrum amplitude-decorrelation techniques to derive flow information. These data were extracted and used to create volume-rendered images of the retinal vasculature with integrated structural information derived from the component optical coherence tomographic images. RESULTS There were 24 eyes of 16 patients who had a mean age of 61.8 years. Right-angle veins seemed in association with vascular proliferation external to the deep vascular plexus. The origin of a right-angle vein was surrounded by a stellate arrangement of radiating retinal vessels apparently caused by contraction of surrounding tissue in the temporal macula. Cavitations were found in the fovea and varied in size and configuration from one examination to the next. Many smaller cavitations, called microcavitations, were seen in the surrounding macula. Vascular invasion occurred into the subretinal space. CONCLUSION There are contractile features of the tissue in the temporal macula and the number, size, and temporal variations in the cavitations have not been in not mentioned in previous published descriptions of MacTel2. Vascular invasion of deeper layers occurred in the temporal macula through the outer nuclear layer. Volume-rendered angiographic and structural optical coherence tomography offers unprecedented ability to examine the vascular interrelationships their associations with cavitations in the macula.
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Runkle AP, Kaiser PK, Srivastava SK, Schachat AP, Reese JL, Ehlers JP. OCT Angiography and Ellipsoid Zone Mapping of Macular Telangiectasia Type 2 From the AVATAR Study. Invest Ophthalmol Vis Sci 2017; 58:3683-3689. [PMID: 28727884 PMCID: PMC5518977 DOI: 10.1167/iovs.16-20976] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Purpose To evaluate alterations on optical coherence tomography angiography (OCT-A) and quantitatively assess alterations in the ellipsoid zone (EZ) in eyes with macular telangiectasia type 2 (MacTel type 2). Methods The Observational Assessment of Visualizing and Analyzing Vessels With Optical Coherence Tomography Angiography in Retinal Diseases study is an institutional review board-approved prospective, observational study investigating OCT-A in macular disease. Patients underwent spectral-domain (SD)-OCT and OCT-A imaging at a single visit. SD-OCT data were analyzed using a novel OCT EZ-mapping software to obtain linear, area, and volumetric measurements of the EZ-retinal pigment epithelium (RPE) complex across the macular cube. OCT-A retinal capillary density was measured using the Optovue Avanti split-spectrum amplitude-decorrelation angiography algorithm. EZ-RPE parameters were compared to age-matched, sex-matched controls. Results Fourteen eyes of seven patients (mean age, 59 ± 6.5 years) were analyzed. Mean visual acuity was 20/45 (range, 20/20–20/150). EZ-RPE central foveal mean thickness was 27.8 ± 6.7 μm, EZ-RPE central foveal thickness was 22.1 ± 21.6 μm, EZ-RPE central foveal area was 0.17 ± 0.04 mm2, and EZ-RPE central subfield volume was 0.017 ± 0.012 mm3. Each of these measurements was significantly inversely correlated with visual acuity (P < 0.02). In addition, all of these measurements were significantly reduced compared to controls (all P ≤ 0.005). OCT-A showed a reduced parafoveal vessel density of 50.8% temporally compared to 53.8% nasally (P = 0.01) in the superficial vascular plexus. In the deep vascular plexus, similar findings were noted with a parafoveal vessel density of 56.7% temporally and 58.8% nasally (P = 0.01). Conclusions Abnormalities in EZ-RPE thickness, area, and volume are correlated with visual acuity in MacTel type 2, and may provide quantitative markers to measure disease progression and treatment response. OCT-A was a useful adjunct for determining disease severity.
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Affiliation(s)
- Anne P Runkle
- Ophthalmic Imaging Center, Cleveland Clinic, Cleveland, Ohio, United States 2Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Peter K Kaiser
- Ophthalmic Imaging Center, Cleveland Clinic, Cleveland, Ohio, United States 2Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Sunil K Srivastava
- Ophthalmic Imaging Center, Cleveland Clinic, Cleveland, Ohio, United States 2Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Andrew P Schachat
- Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Jamie L Reese
- Ophthalmic Imaging Center, Cleveland Clinic, Cleveland, Ohio, United States 2Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Justis P Ehlers
- Ophthalmic Imaging Center, Cleveland Clinic, Cleveland, Ohio, United States 2Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, United States
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Khan HA, Mehmood A, Khan QA, Iqbal F, Rasheed F, Khan N, Pizzimenti JJ. A major review of optical coherence tomography angiography. EXPERT REVIEW OF OPHTHALMOLOGY 2017. [DOI: 10.1080/17469899.2017.1356229] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Hashim Ali Khan
- Ophthalmology, SEHHAT Foundation Hospital, Main KKH, Danyore, Gilgit, Pakistan
| | - Asim Mehmood
- Ophthalmology, Multan Medical & Dental College, Multan, Pakistan
| | - Qaim Ali Khan
- Ophthalmology, Poonch Medical College, AJK, Pakistan
| | - Fatima Iqbal
- School of Optometry, The University of Faisalabad, Faisalabad, Pakistan
| | - Faisal Rasheed
- Ophthalmology, Sheikh Zayd Medical College, Rahim Yar Khan, Pakistan
| | - Naeemullah Khan
- Ophthalmology, SEHHAT Foundation Hospital, Main KKH, Danyore, Gilgit, Pakistan
| | - Joseph J. Pizzimenti
- Rosenberg School of Optometry, University of the Incarte Word, San Antonio, TX, USA
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Gao SS, Jia Y, Zhang M, Su JP, Liu G, Hwang TS, Bailey ST, Huang D. Optical Coherence Tomography Angiography. Invest Ophthalmol Vis Sci 2017; 57:OCT27-36. [PMID: 27409483 PMCID: PMC4968919 DOI: 10.1167/iovs.15-19043] [Citation(s) in RCA: 239] [Impact Index Per Article: 34.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Optical coherence tomography angiography (OCTA) is a noninvasive approach that can visualize blood vessels down to the capillary level. With the advent of high-speed OCT and efficient algorithms, practical OCTA of ocular circulation is now available to ophthalmologists. Clinical investigations that used OCTA have increased exponentially in the past few years. This review will cover the history of OCTA and survey its most important clinical applications. The salient problems in the interpretation and analysis of OCTA are described, and recent advances are highlighted.
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SUPERFICIAL FOVEAL AVASCULAR ZONE DETERMINED BY OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY BEFORE AND AFTER MACULAR HOLE SURGERY. Retina 2017; 37:444-450. [PMID: 28225721 DOI: 10.1097/iae.0000000000001205] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To determine the size of the superficial foveal avascular zone (FAZ) by optical coherence tomography angiography before and after surgery for an idiopathic macular hole. METHODS A retrospective, observational case series, in which 16 eyes of 16 patients with an idiopathic macular hole were studied. Pars plana vitrectomy was performed with internal limiting membrane peeling. The foveal retinal vasculature was examined by optical coherence tomography angiography, and the area of the superficial FAZ was determined before, and at 1 and 3 months after the surgery. The area of the macular hole was also measured in the en face optical coherence tomography images. The central foveal thickness was measured to determine the relationship between the size of the superficial FAZ and foveal shape. The unaffected fellow eyes were used as controls. RESULTS The mean age of the patients was 68.9 years. The average preoperative superficial FAZ area was 0.45 ± 0.14 mm, which was significantly reduced to 0.23 ± 0.08 mm at 1 month (P < 0.001) and 0.25 ± 0.08 mm at 3 months postoperatively (P < 0.001). The size was smaller than that of the control eyes (0.36 ± 0.12 mm, P = 0.003). There was a significant inverse correlation between the area of the postoperative superficial FAZ and the central foveal thickness (r = -0.589, P = 0.016). The correlations between the visual acuity and the area of the superficial FAZ at 1 and 3 months postoperatively were not significant (P = 0.369 and 0.285). CONCLUSION The significant decrease in the superficial FAZ after the macular hole surgery indicates that there was a centripetal movement of the foveal tissue postoperatively.
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Capuano V, Miere A, Amoroso F, Todisco L, Cohen SY, Souied E, Querques G. Uncommon retinal vascular diseases. EXPERT REVIEW OF OPHTHALMOLOGY 2016. [DOI: 10.1080/17469899.2016.1251315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lang SJ, Cakir B, Evers C, Ludwig F, Lange CA, Agostini HT. Value of Optical Coherence Tomography Angiography Imaging in Diagnosis and Treatment of Hemangioblastomas in von Hippel-Lindau Disease. Ophthalmic Surg Lasers Imaging Retina 2016; 47:935-946. [DOI: 10.3928/23258160-20161004-07] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/30/2016] [Indexed: 12/13/2022]
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Matet A, Daruich A, Dirani A, Ambresin A, Behar-Cohen F. Macular Telangiectasia Type 1: Capillary Density and Microvascular Abnormalities Assessed by Optical Coherence Tomography Angiography. Am J Ophthalmol 2016; 167:18-30. [PMID: 27084003 DOI: 10.1016/j.ajo.2016.04.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 03/31/2016] [Accepted: 04/03/2016] [Indexed: 01/19/2023]
Abstract
PURPOSE To describe microvascular abnormalities and capillary density in macular telangiectasia type 1 (MT1) using optical coherence tomography angiography (OCTA), and correlate them with fluorescein angiography (FA). DESIGN Observational case series. METHODS Seven patients with MT1 and 12 age-matched controls were included. Focal microvascular dilations were identified on 3 × 3 mm OCTA and early-frame FA images. OCTA images were processed to determine the global capillary density after subtraction of larger vessels and cystoid edema cavities. Local capillary densities were calculated inside 100-μm circles around telangiectasias, projected over superficial (SCP) and deep capillary plexuses (DCP). They were compared to a random sample of 100-μm circles generated in each OCTA image. FA images were processed to measure mean perifoveal intercapillary areas (PIA), inversely reflecting capillary density. RESULTS In MT1 eyes, fewer telangiectasias were identified with OCTA than with FA (P = .016), exclusively localized in the DCP (P = .016). Rarefaction of both capillary plexus and abnormal microvascular morphology were better identified by OCTA than by FA. The global capillary density on OCTA was significantly lower in MT1 eyes than in fellow and control eyes, respectively: SCP, 0.347 vs 0.513 (P = .004) and 0.560 (P = .0005); DCP, 0.357 vs 0.682 (P = .016) and 0.672 (P = .0005). Capillary density was significantly reduced around telangiectasias in both SCP (P = .021) and DCP (P = .042). Capillary density of the SCP correlated inversely with the mean PIA on FA (r = -0.94, P = .017). LogMAR visual acuity was inversely correlated with SCP (r = -0.88, P = .012) and DCP capillary densities (r = -0.79, P = .048). CONCLUSIONS OCTA confirmed that global and focal capillary depletion is associated with MT1.
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Affiliation(s)
- Alexandre Matet
- Department of Ophthalmology, University of Lausanne, Jules-Gonin Eye Hospital. Fondation Asile des Aveugles, Lausanne, Switzerland
| | - Alejandra Daruich
- Department of Ophthalmology, University of Lausanne, Jules-Gonin Eye Hospital. Fondation Asile des Aveugles, Lausanne, Switzerland
| | - Ali Dirani
- Department of Ophthalmology, University of Lausanne, Jules-Gonin Eye Hospital. Fondation Asile des Aveugles, Lausanne, Switzerland
| | - Aude Ambresin
- Department of Ophthalmology, University of Lausanne, Jules-Gonin Eye Hospital. Fondation Asile des Aveugles, Lausanne, Switzerland
| | - Francine Behar-Cohen
- Department of Ophthalmology, University of Lausanne, Jules-Gonin Eye Hospital. Fondation Asile des Aveugles, Lausanne, Switzerland; Inserm, U1138, Team 17, From Physiopathology of Ocular Diseases to Clinical Development, Université Paris Descartes Sorbonne Paris Cité, Centre de Recherche des Cordeliers, Paris, France.
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Morgan JIW. The fundus photo has met its match: optical coherence tomography and adaptive optics ophthalmoscopy are here to stay. Ophthalmic Physiol Opt 2016; 36:218-39. [PMID: 27112222 PMCID: PMC4963017 DOI: 10.1111/opo.12289] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 01/20/2016] [Indexed: 12/24/2022]
Abstract
PURPOSE Over the past 25 years, optical coherence tomography (OCT) and adaptive optics (AO) ophthalmoscopy have revolutionised our ability to non-invasively observe the living retina. The purpose of this review is to highlight the techniques and human clinical applications of recent advances in OCT and adaptive optics scanning laser/light ophthalmoscopy (AOSLO) ophthalmic imaging. RECENT FINDINGS Optical coherence tomography retinal and optic nerve head (ONH) imaging technology allows high resolution in the axial direction resulting in cross-sectional visualisation of retinal and ONH lamination. Complementary AO ophthalmoscopy gives high resolution in the transverse direction resulting in en face visualisation of retinal cell mosaics. Innovative detection schemes applied to OCT and AOSLO technologies (such as spectral domain OCT, OCT angiography, confocal and non-confocal AOSLO, fluorescence, and AO-OCT) have enabled high contrast between retinal and ONH structures in three dimensions and have allowed in vivo retinal imaging to approach that of histological quality. In addition, both OCT and AOSLO have shown the capability to detect retinal reflectance changes in response to visual stimuli, paving the way for future studies to investigate objective biomarkers of visual function at the cellular level. Increasingly, these imaging techniques are being applied to clinical studies of the normal and diseased visual system. SUMMARY Optical coherence tomography and AOSLO technologies are capable of elucidating the structure and function of the retina and ONH noninvasively with unprecedented resolution and contrast. The techniques have proven their worth in both basic science and clinical applications and each will continue to be utilised in future studies for many years to come.
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Affiliation(s)
- Jessica I W Morgan
- Department of Ophthalmology, Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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