ANALYSIS OF THE NORMAL PERIPHERAL RETINAL VASCULAR PATTERN AND ITS CORRELATION WITH MICROVASCULAR ABNORMALITIES USING ULTRA-WIDEFIELD FLUORESCEIN ANGIOGRAPHY

RETINAL VASCULAR DISEASE IN LIMB-GIRDLE MUSCULAR DYSTROPHY

PURPOSE

To report bilateral retinal vascular occlusive disease in limb-girdle muscular dystrophy (LGMD).

METHODS

Case report.

RESULTS

A 34-year-old Asian woman was referred for evaluation and management of central retinal vein occlusion. Ultra-wide-field fluorescein angiography showed resolving initial peripheral retinal vein occlusion in one eye and peripheral venular segmental staining in the fellow asymmetric eye. Genetic testing established the diagnosis of LGMD.

CONCLUSION

Similar to other forms of muscular dystrophy, LGMD is caused by genetic abnormalities in sarcolemma proteins, a key structural component that connects the intracellular cytoskeleton of a myofiber to the extracellular matrix. Like other muscular dystrophies, LGMD may be associated with retinal vascular abnormalities noted. In this case, retinal vascular smooth muscle dysfunction was seen in LGMD, analogous to reported vascular abnormalities in other muscular dystrophies such as facioscapulohumeral dystrophy and Duchenne muscular dystrophy.

Vascular abnormalities in fellow eyes of patients with unilateral coats' disease

Coats' disease is an idiopathic retinal vascular disorder, known to usually occur unilaterally; however, recent studies have highlighted vascular abnormalities in the fellow unaffected eyes. This retrospective study investigated the peripheral vascular features and macular vascular structure of unaffected fellow eyes in patients with unilateral Coats' disease using multimodal imaging tools. We analysed images of patients, including bilateral ultra-widefield imaging, fluorescein angiography (FA), ultra-widefield FA, or standard fundus photography. Available bilateral optical coherence tomography angiography (OCT-A) images were used for macular vascular structure analysis. OCT-A parameters, including foveal avascular zone (FAZ), perfusion index, and vessel density (VD) in the superficial and deep capillary plexuses (SCP, DCP), were calculated using Image J software. The mean age at diagnosis was 34.5 ± 17.9 years. The mean final best-corrected visual acuity of the affected eyes was logMAR 0.78 ± 0.79, while that of the fellow eyes was logMAR 0.04 ± 0.12. Ten fellow eyes had microaneurysms (47.6%), two had tortuous vessel abnormalities (9.5%), and 11(52.4%) had abnormal vascular findings on FA. Although there was a trend towards larger DCP FAZ (1.201 ± 0.086 vs. 1.072 ± 0.226), and lower DCP VD (8.593 ± 1.583 vs. 10.827 ± 3.392) in the affected eyes as measured by the Cirrus machine, the difference was not statistically significant between affected and fellow eyes when measured using the Zeiss Cirrus machine (P = 0.686, P = 0.343, respectively). However, when measured with the Spectralis machine, DCP FAZ was larger in affected eyes (0.828 ± 0.426 vs. 0.254 ± 0.092, P = 0.002) and DCP VD was lower in affected eyes (6.901 ± 2.634 vs. 17.451 ± 7.207, P = 0.002) compared to the fellow eyes, while other parameters showed no significant variations. These findings indicate that there may be subtle vascular abnormalities primarily located in the peripheral regions of the unaffected fellow eyes in patients with unilateral Coats' disease, while the macular microvasculature remains unaffected.

Quantitative Analysis of Retinal Vasculature in Rhegmatogenous Retinal Detachment Based on Ultra-Widefield Fundus Imaging

Purpose

To quantitatively analyze retinal vascular morphological features, such as vascular density, caliber, and tortuosity, in rhegmatogenous retinal detachment (RRD).

Methods

A total of 244 patients with RRD and 400 healthy controls (HC) were included. Retinal fundus images were collected using OPTOS PLC Daytona P200T. Retinal images were divided into RRD and non-RRD regions of interest (ROIs). All visible retinal fundus vessels were then extracted mainly based on edge detection within ROI to form the whole-vascular image. Retinal vasculature parameters, such as vascular density, caliber, and tortuosity, were calculated.

Results

For the absolute density, the mean rank (MR) value of normal controls was significantly higher than that in non-RRD (p < 0.001). A consistent tendency of significant vascular density was increased from non-RRD to RRD (p < 0.001). The average and median diameters of normal controls were both significantly larger than RRD (p < 0.001). The average and median diameters were also appeared significantly thinner in non-RRD. Unweighted and width-inversely-weighted vascular tortuosity in RRD and non-RRD comparison exhibited non-significant differences. All types of tortuosity calculated from HC were significantly larger (p < 0.001) in values compared to RRD. All types of tortuosity values of HC were significantly higher than non-RRD. Compared with non-RRD, RRD was significantly larger in area-weighted, length-weighted, and width-weighted vascular tortuosity.

Conclusions

This study showed that RRD affects both the quantity and morphology of retinal vasculature, such as RRD and non-RRD areas. Smaller average and medium vascular diameters and tortuosity values were found in RRD. However, the absolute vascular density, the average and median diameter, and tortuosity values were also reduced in non-RRD although the retina is still attached. This work indicates that RRD may affect the retinal vasculature beyond the detached retina.

Ultra-Widefield Imaging of Peripheral Vascular Abnormalities in Idiopathic Macular Telangiectasia Type 1

PURPOSE

This work reports unusual peripheral vascular anomalies on ultra-widefield angiography in a case of idiopathic macular telangiectasia (IMT) type 1.

METHODS

A case report is discussed.

RESULTS

A 51-year-old woman with a 6-year history of IMT type 1 presented with ongoing vision symptoms from persistent macular edema despite extended antivascular endothelial growth factor therapy. Examination and macular imaging findings were consistent with a diagnosis of IMT type 1, and ultra-widefield angiography additionally demonstrated nonperfusion, terminal vascular loops, and arteriovenous anastomosis without exudation or telangiectasis. The patient's condition remained stable after she elected observation.

CONCLUSION

While extrafoveal vascular anomalies are a known feature of IMT type 1, they commonly consist of peripheral telangiectasias and exudation. Describing new peripheral vascular abnormalities in IMT adds to our knowledge of this condition and could be of value for diagnosis, management, and further study.

Peripheral arterial filling time and peripheral retina fluorescence features in ultra-widefield angiography

AIM

To evaluate the peripheral arterial filling time (PAFT) and venous filling time (VFT) in eyes without known diseases that may influence filling process using ultra-widefield (UWF) fluorescein angiography (FA), and to review the peripheral retina fluorescence features.

METHODS

A total of 30 eyes of 30 patients were retrospectively reviewed in this observational study. UWF-FA was performed using Optos 200Tx. PAFT and VFT was recorded. The interval between the arterial or venous filling completion and the previous photo was documented. The appearance of the far peripheral retina was described as either granular background fluorescence or mottled fluorescent band or vascular leakage. Terminal vascular patterns was described as loop pattern or branching pattern. Microvascular abnormalities such as arteriovenous shunting, vessels crossing the horizontal raphe, right angle vessels, terminal networks, capillary nonperfusion, drusen or microaneurysms were evaluated.

RESULTS

The normal limits of PAFT was 3.397-8.984s and 4.399-11.753s for VFT. The appearance of the far peripheral retina, defined as granular background (63%), mottled fluorescence (20%), or vascular leakage (17%), was symmetrical between both eyes. Capillary nonperfusion (23%) and microaneurysms (40%) were more frequently found in eyes with loop pattern than in eyes with branching pattern. Other peripheral signs such as right-angle vessels (73%), and terminal networks (80%) were commonly seen on UWF-FA in the normal peripheral retina.

CONCLUSION

The main courses of retinal artery and vein filling time are overlapping with each other on UWF-FA. Notably, the arterial filling process is completed in the arteriovenous phase rather than the traditionally named arterial phase. There are various manifestations in the peripheral retina of normal eyes.

PERIPHERAL RETINAL ANGIOGRAPHIC FINDINGS IN MACULAR TELANGIECTASIS TYPE 2

PURPOSE

To evaluate the retinal periphery in patients with idiopathic juxtafoveal telangiectasis or macular telangiectasis Type 2 (MacTel2), using widefield fluorescein angiography.

METHODS

Single-center, retrospective, observational case series of 50 eyes of 50 patients with MacTel2 and 50 eyes of 50 age-matched controls.

RESULTS

Thirty-seven eyes in the MacTel2 group (74%) showed peripheral capillary nonperfusion or dropout, compared with 37 eyes in the control group (74%, P = 1.0). Morphologically, the MacTel2 group trended toward having a higher proportion of pruning-type capillary dropout (44%) compared with controls (28%), but this was not statistically significant (P = 0.12). Patients with MacTel2 had a higher incidence of microaneurysms compared with controls (MacTel2 56%; controls 42%; P = 0.048), independent of age or systemic risk factors. There was no difference in the incidence of venous-venous shunts (MacTel2 10%; controls 10%; P = 1.0), arteriovenous shunts (MacTel2 14%; controls 18%; P = 0.60), venous tortuosity (MacTel2 60%; controls 66%; P = 0.58), or arterial tortuosity (MacTel2 54%; controls 68%; P = 0.20), which was mild in most cases.

CONCLUSION

We note a high incidence of peripheral vascular and retinal findings in both patients with MacTel2 and age-matched controls, using widefield fluorescein angiography. Patients with MacTel2 had significantly more microaneurysms, independent of age or other systemic risk factors.

Peripheral Leakage on Ultra-Widefield Fluorescein Angiography in Patients With Inherited Retinal Degeneration

Purpose:

This report illustrates that peripheral vascular leakage on ultra-widefield fluorescein angiography (FA) can occur in patients with inherited retinal degeneration (IRD) without evidence of a separate cause of leakage.

Methods:

We searched the electronic medical records of the Massachusetts Eye and Ear Infirmary from 2010 to 2019 for patients with an IRD diagnosis and examination with an ultra-widefield FA. Images from FAs were evaluated in masked fashion by 2 retina specialists. Documentation of an evaluation for alternative causes of vascular leakage was recorded, as well as results from electroretinography, Goldmann perimetry, and genetic testing.

Results:

A total of 305 patients with an IRD diagnosis and FA procedure code were identified. Of these, 26 patients had both a clinical diagnosis of IRD and ultra-widefield FA on detailed medical-record review. Three patients had FA to evaluate a Coats-like response and were excluded. Of the remaining 23, 4 patients (17%) had significant peripheral leakage on FA. Of these, 1 had pericentral retinitis pigmentosa (for which the genetic cause of disease was undefined), 1 had Refsum disease with confirmed biallelic PHYH mutations, 1 had a CRB1-associated macular dystrophy, and 1 had CERKL-associated macular dystrophy. There was no evidence of ocular inflammation from history, examination, or laboratory testing to account for the FA findings. Of the 19 patients without significant leakage, 4 had minimal leakage and 15 had no peripheral leakage.

Conclusions:

Peripheral retinal vascular leakage can be seen on ultra-widefield FA in patients with IRD that is likely due to the IRD disease process itself rather than to an additional, distinct eye condition.

Preliminary study of ultra-widefield peripheral retinal angiographic patterns in children and its association to the perinatal condition

This preliminary study analyzed the peripheral retinal vascular pattern in children, using ultra-widefield fluorescein angiography, and its association with perinatal conditions. Retrospective review was conducted examining the fluorescein angiographic findings of children with amblyopia (January 2017 to December 2018). We categorized the peripheral vascular patterns into two groups: loop and branching patterns. We investigated differences in these patterns, according to the perinatal condition. Thirty children (9.27 ± 3.41 years old; 47.67% male) were included. An equal number of children had the loop or branching pattern (15:15). The gestational age (GA) in the loop group was significantly shorter than the branching group (32.92 ± 5.62 vs. 36.67 ± 5.63 weeks, p = 0.04). The birth weight of the loop group was significantly lower than the branching group (2.00 ± 1.03 vs. 2.72 ± 0.93 kg, p = 0.03). Gender, age, delivery-type, and visual acuity, were not different between the groups. Lower birth weight and shorter GA were observed in children with the loop pattern. The difference in peripheral retinal vascular patterns, according to birth weight and GA, might be due to the development of immature retinal vessels at birth.

Observation of the far peripheral retina of normal eyes by ultra-wide field fluorescein angiography

PURPOSE

The appearance of the far peripheral retina in normal eyes was observed using an Optos ultra-wide field fluorescein angiography imaging system.

METHODS

A cross-sectional study of ultra-wide field pseudocolor and angiography images obtained using the Optos 200Tx. Four different non-vascular and six vascular-associated fluorescence features in far peripheral retina were analyzed.

RESULTS

A total of 166 eyes in 83 patients met the inclusion criteria. The mean patient age was 40.78 ± 10.94 years (range: 20-65 years) with a female-to-male ratio of 0.98. Slight cataract were present in 64 eyes (38.55%), low to moderate myopia in 50 eyes (30.12%), and unspecified visual disturbances in 52 eyes (31.33%). Far peripheral retinas were found to have mottled florescent band in 42.17% eyes, ground glass hyperfluorescence in 84.34% eyes, granular hyperfluorescence in 12.65% eyes, local mottled fluorescence in 10.84% eyes, vascular anastomosis with a peripheral avascular area in 36.23% eyes, invisible capillary details in 50.67% eyes, vessels passing through the ora serrata in 16.98% eyes, late-phase slight leakage in 32.53% eyes, angiectasis in 18.67% eyes, and microaneurysm in 34.94% eyes.

CONCLUSION

Ultra-wide field fluorescein angiography revealed various fluorescence features in the periphery of normal eyes, providing a basis for interpreting normal and pathological changes in peripheral retina and an important reference for clinical work.

Multimodal Chorioretinal Imaging in Erdheim-Chester Disease

Purpose

To analyze the subclinical intraocular involvement using multimodal imaging approach in patients affected by Erdheim-Chester disease (ECD) without ocular symptoms.

Patients and Methods

In this prospective cross-sectional study, 18 eyes of 9 consecutive patients with ECD were enrolled. Each patient underwent comprehensive ocular examination and extensive multimodal chorioretinal imaging.

Results

None of the patients presented any evidence of chorioretinal localization of disease using multimodal imaging. One patient exhibited a choroidal nevus complicated by active polypoidal choroidal neovascularization. Subretinal hyperreflective material was seen in three eyes, mainly resembling acquired vitelliform lesion. One patient had an isolated intraretinal hemorrhage. Most patients exhibited peripheral vascular abnormalities (ie, microaneurysms, peripheral vascular leakage). Fundus autofluorescence showed faint hyperautofluorescence in eleven eyes.

Conclusion

Intraocular involvement is an extremely rare event of an extremely rare disease. In patients affected by ECD without ocular symptoms, advance multimodal imaging examinations did not show signs of subclinical chorioretinal involvement related to the disease.

Longitudinal Examination of Fellow-Eye Vascular Anomalies in Coats' Disease With Widefield Fluorescein Angiography: A Multicenter Study

BACKGROUND AND OBJECTIVE

Retinovascular anomalies in the fellow eyes of patients with Coats' disease have been described, but the clinical significance is unknown, as well as whether these lesions progress over time.

PATIENTS AND METHODS

This is an international, multicenter, retrospective, observational cohort study of fellow-eye abnormalities on widefield fluorescein angiography in patients with Coats' disease.

RESULTS

Three hundred fifty eyes of 175 patients with Coats' disease were analyzed. A total of 33 patients (18.8%) demonstrated abnormal fellow-eye findings: 14 (42.4%) telangiectasias, 18 (54.5%) aneurysms, six (18.2%) segmental non-perfusion, six (18.2%) leakage, and two (6.0%) vascular tortuosity. All eyes were asymptomatic, and none of the lesions progressed over time. There was no association between fellow-eye findings with severity of Coats' disease (P = .16), patient age (P = .16), or presence of systemic vascular disease (P = .16).

CONCLUSIONS

The vascular abnormalities in fellow eyes of patients with Coats' disease did not progress over time. Observation is a reasonable initial management strategy. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:221-227.].

Wide-field angiography in retinal vein occlusions

BACKGROUND

Retinal vein occlusion (RVO) is the second most common retinal vascular disease after diabetic retinopathy. It can result in significant visual loss from complications like macula edema, retinal and iris neovascularization, and vitreous hemorrhage. Recently, ultra-widefield imaging (UWF) has been developed for posterior pole visualization and has shown to be useful in the evaluation and treatment of RVO.

MAIN TEXT

Ultra-widefield imaging (UWF) imaging allows for visualization of the retina up to an angle of 200°. This is especially important in detecting peripheral retinal pathologies, especially in retinal conditions such as RVO, where the disease process affects the peripheral as well as central retina. In particular, retinal non-perfusion in RVO is a risk factor for neovascularization. Various techniques, such as ischemic index and stereographic projection, have been described to assess areas of ischemia on UWF images. Retinal non-perfusion has an impact on disease complications, such as macular edema, and retinal and iris neovascularization. Retinal non-perfusion also has implications on disease response, including visual acuity, reduction in retinal edema and treatment burden.

CONCLUSION

Ultra-widefield imaging (UWF) imaging plays an important role in the assessment and management of RVO, especially in measuring retinal non-perfusion in the peripheries.