IMAGING OF PIGMENT EPITHELIAL DETACHMENTS WITH OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

Acute Submacular Hemorrhage Resulting from Neovascular Age-Related Macular Degeneration in a Monocular Patient

Purpose: To present the management and outcomes of a case of acute submacular hemorrhage due to neovascular age-related macular degeneration (nAMD). Methods: A single case was retrospectively evaluated. Results: A 79-year-old man with a history of submacular hemorrhage from nAMD and persistent disease activity in the left eye presented with acute submacular hemorrhage in his better-seeing right eye, which was previously closely monitored for an extrafoveal serous pigment epithelial detachment without exudation. The patient received intravitreal antivascular endothelial growth factor (anti-VEGF) and subsequently had pars plana vitrectomy with subretinal tissue plasminogen activator and gas tamponade. After 5 days of face-down positioning, the hemorrhage was successfully displaced from the fovea. Recurrent disease activity 2 weeks postoperatively prompted intensive biweekly anti-VEGF therapy. By postoperative month 5, the patient's visual acuity improved from 20/400 to 20/70 OD. Conclusions: This case highlights the importance of close monitoring of patients with nAMD exhibiting aggressive disease as well as the efficacy of prompt surgical intervention and increased anti-VEGF frequency for large submacular hemorrhages.

Multimodal imaging in early onset non-neovascular pigment epithelial detachments

PURPOSE

To describe multimodal imaging of two cases of bilateral non-vascularized pigment epithelial detachments (PED) in young patients with a long-term follow-up.

METHODS

A complete ophthalmological examination was performed at each follow-up visit including best corrected visual acuity (BCVA), intraocular pressure, slit lamp examination, spectral domain optical coherence tomography (SD-OCT), fluorescein and indocyanine green angiography, OCT angiography.

RESULTS

Multimodal imaging of two women presenting avascular PED, aged 43 and 57, respectively, was described. In both patients, SD-OCT revealed a high central macular hyporeflective elevation corresponding with PED. Both patients showed a choroidal layer thicker than 420 μm. Fluorescein and indocyanine green angiography didn't show any choroidal neovascularization either at early or late frames. Cross-sectional and en face optical coherence tomography angiography (OCTA) didn't show any flow beneath the PED. During the follow up period one eye showed a retinal pigment epithelium tear and all eyes showed the presence of apical sub-retinal fluid and hyperreflective material on the top of the PED. None of the two patients showed any sign of atrophy during the follow-up period.

CONCLUSION

The peculiar characteristics of the presented cases suggest that specific pathogenetic mechanisms, not necessarily related to age related macular degeneration, may play a key role in the development of these lesions. Whether early onset of such drusenoid PED is a specific entity resulting from a genetic deficit of lipid transporters in the RPE is unknown. Further genetic and metabolic studies should be conducted.

Optical Coherence Tomography Angiography Characteristics of Polypoidal Lesions in Caucasians

Purpose

The aim of the study is to analyze the swept source-optical coherence tomography angiography (SS-OCTA) characteristics of polypoidal lesions in Caucasian patients.

Methods

In this retrospective observational case series, 43 polypoidal lesions in 32 eyes of 32 patients were diagnosed using indocyanine green angiography (ICGA) and compared to SS-OCTA at a tertiary medical retina center (Clinic Landstraße, Vienna Healthcare Group, Austria) between June 2017 and March 2020. Vascularity was identified by color-coded B-scan SS-OCTA while morphology was described as revealed by en face SS-OCTA after alignment with ICGA-confirmed findings.

Results

In total, SS-OCTA detected all polypoidal lesions, as identified by ICGA. On B-scan SS-OCTA, circumscribed flow was detected in 33 (76.7%) polypoidal lesions and diffuse flow in 10 (23.3%) lesions. On en face SS-OCTA, polypoidal lesions appeared morphologically as 19 tangled vessel balls (44.2%), 6 tangled vessel balls next to dilated vessels (13.9%), 8 vascular dilatations (18.6%), and 8 ill-defined vascular networks (18.6%), leaving 2 lesions (4.6%) undetected. Circumscribed flow was significantly associated with tangled vessel balls (p = 0.005).

Conclusion

This study highlights the importance of a multimodal imaging approach, including SS-OCTA, for the evaluation of polypoidal lesions. Our findings suggest a morphological heterogeneity of vascular patterns in Caucasian patients with polypoidal lesions, as pictured by SS-OCTA.

Undetectable Macular Neovascularization on OCT Angiography in Age Related Macular Degeneration: Comparison between Different Devices

Background and Objectives: The aim of this study was to report the characteristics of macular neovascularization (MNV) with undetectable flow on optical coherence tomography angiography (OCTA) in neovascular age related macular degeneration (nAMD), and compare them with the characteristics of detectable MNV. Materials and Methods: Patients with a diagnosis of nAMD who underwent dye imaging and OCTA in the same day were included and divided into two groups: undetectable and detectable flow on OCTA. Three OCTA devices were used, two with spectral-domain technology (AngioVue, RTVue 100xAvanti, Optovue, Freemont, CA, USA and Heidelberg OCT2 Beta Angiography Module, Heidelberg Engineering, Germany) and one swept-source OCTA (PlexElite 9000; Carl Zeiss Meditec, Inc., Dublin, CA, USA). We studied the demographics, neovascularization characteristics, and OCTA device and acquisition characteristics for both groups. Results: A global comparison between Group 1 and Group 2 was made, followed by an analysis of variables associated with (un)detectability for each OCTA device. A total of 108 eyes were included: 90 in the detectable group (Group 1) and 18 in the undetectable group (Group 2), corresponding to a global sensitivity of OCTA for the detection of MNV of 83.49%. There was a statistically significant difference between the two groups regarding MNV type (p = 0.02) and PED height (p = 0.017). For the three devices, detection sensitivity with automatic segmentation was significantly lower than with manual segmentation. For Heidelberg, PED Height and scan quality explained 68.3% of the undetectability. For AngioVue, PED Height and absence of hemorrhage explained 67.9% of undetectability. Conclusions: In this study, we found a global sensitivity of 83.49% for the three OCTA devices combined, with a range from 55.5% to 96.26% depending on the segmentation and OCTA device. This means that undetectable/undetected MNV can represent up to 45% of the examinations, eventually misdiagnosing choroidal neovascularization for 1 out every 2 patients.

Small dome-shaped pigment epithelium detachment in polypoidal choroidal vasculopathy: an under-recognized sign of polypoidal lesions on optical coherence tomography?

PURPOSE

To evaluate the diagnostic accuracy of spectral-domain optical coherence tomography (SD-OCT) and swept-source optical coherence tomographic angiography (SS-OCTA) to identify polypoidal lesions in serous or serosanguinous maculopathy.

MATERIALS AND METHODS

A retrospective review of patients presenting pigment epithelial detachments (PEDs) with the diagnosis of polypoidal choroidal vasculopathy (PCV), neovascular age-related macular degeneration (nAMD), and central serous chorioretinopathy (CSC), all of which underwent SD-OCT, SS-OCTA, and indocyanine green angiography (ICGA). Typical features of polypoidal lesions on SD-OCT included sharply peaked PED, notched PED, and hyperreflective ring underneath PED. SS-OCTA feature was vascularized PEDs on cross-sectional images corresponding to cluster-like structures on en face images. The parameters of PEDs were measured for analysis.

RESULTS

Of 72 eyes, 30 had PCV, 22 had nAMD, and 20 had CSC. A total of 128 localized PEDs were detected on SD-OCT. Typical features on SD-OCT had a high specificity (94.0%) but a limited sensitivity (73.8%). SS-OCTA features provided a higher sensitivity (96.7%). PEDs of the polypoidal lesions unrecognized by SD-OCT were dome-shaped, with smaller ratio of height to base diameter and less area, and almost had heterogeneous internal reflectivity and a connected double-layer sign. Some lesions misidentified by SS-OCTA developed into ICGA-proven polypoidal lesions at follow-up visits.

CONCLUSION

A small dome-shaped PED with heterogeneous internal reflectivity and a connected double-layer sign on SD-OCT may suggest a polypoidal lesion of PCV. SS-OCTA may be a helpful tool to investigate preclinical PCV and observe the formation of polypoidal lesions.

The Diagnostic Capability of Swept Source OCT Angiography in Treatment-Naive Exudative Neovascular Age-Related Macular Degeneration

Purpose

To evaluate the capability of swept source-optical coherence tomography angiography (SS-OCTA) in the detection and localization of treatment-naive macular neovascularization (MNV) secondary to exudative neovascular age-related macular degeneration (nAMD).

Methods

In this prospective, observational case series, 158 eyes of 142 patients were diagnosed with exudative nAMD using fluorescein (FA) and indocyanine green angiography (ICGA) and evaluated by SS-OCTA in a tertiary retina center (Rudolf Foundation Hospital Vienna, Austria). The main outcome measure was the sensitivity of SS-OCTA compared to the standard multimodal imaging approach. Secondary outcome measure was the anatomic analysis of MNV in relation to the retinal pigment epithelium.

Results

En-face SS-OCTA confirmed a MNV in 126 eyes (sensitivity: 79.8%), leaving 32 eyes (20.2%) undetected. In 23 of these 32 eyes (71.9%), abnormal flow in cross-sectional SS-OCTA B-scans was identified, giving an overall SS-OCTA sensitivity of 94.3%. Eyes with a pigment epithelium detachment (PED) ≥ 300 μm had a smaller probability for correct MNV detection (p=0.015). Type 1 MNV showed a trend (p=0.051) towards smaller probability for the correct detection compared to all other subtypes. Other relevant factors for the nondetection of MNV in SS-OCTA were image artifacts present in 3 of 32 eyes (9.4%). SS-OCTA confirmed the anatomic localization of 93 in 126 MNVs as compared to FA (sensitivity: 73.8%). There was no influence of age, gender, pseudophakia, visual acuity, central foveal thickness, or subfoveal choroidal thickness on the detection rate of MNV.

Conclusions

SS-OCTA remains inferior to dye-based angiography in the detection rate of exudative nAMD consistent with type 1 MNV and a PED ≥300 µm. The capability to combine imaging modalities and distinguish the respective MNV subtype improves its diagnostic value.

Hyperreflective Foci, Optical Coherence Tomography Progression Indicators in Age-Related Macular Degeneration, Include Transdifferentiated Retinal Pigment Epithelium

Purpose

By optical coherence tomography (OCT) imaging, hyperreflective foci (HRF) indicate progression risk for advanced age-related macular degeneration (AMD) and are in part attributable to ectopic retinal pigment epithelium (RPE). We hypothesized that ectopic RPE are molecularly distinct from in-layer cells and that their cross-retinal course follows Müller glia.

Methods

In clinical OCT (61 eyes, 44 patients with AMD, 79.4 ± 7.7 years; 29 female; follow-up = 4.7 ± 0.9 years), one HRF type, RPE plume (n = 129 in 4 morphologies), was reviewed. Twenty eyes of 20 donors characterized by ex vivo OCT were analyzed by histology (normal, 4; early/intermediate AMD, 7; geographic atrophy, 6; neovascular AMD, 3). Cryosections were stained with antibodies to retinoid (RPE65, CRALPB) and immune (CD68, CD163) markers. In published RPE cellular phenotypes, red immunoreactivity was assessed semiquantitatively by one observer (none, some cells, all cells).

Results

Plume morphology evolved over time and many resolved (40%). Trajectories of RPE plume and cellular debris paralleled Müller glia, including near atrophy borders. RPE corresponding to HRF lost immunoreactivity for retinoid markers and gained immunoreactivity for immune markers. Aberrant immunoreactivity appeared in individual in-layer RPE cells and extended to all abnormal phenotypes. Müller glia remained CRALBP positive. Plume cells approached and contacted retinal capillaries.

Conclusions

HRF are indicators not predictors of overall disease activity. Gain and loss of function starts with individual in-layer RPE cells and extends to all abnormal phenotypes. Evidence for RPE transdifferentiation, possibly due to ischemia, supports a proposed process of epithelial–mesenchyme transition. Data can propel new biomarkers and therapeutic strategies for AMD.

Biomarkers in Early Response to Brolucizumab on Pigment Epithelium Detachment Associated with Exudative Age-Related Macular Degeneration

Background: The purpose of this study was to describe early changes in the morphology of pigment epithelium detachments (PED) after an intravitreal injection of Brolucizumab into eyes with macular neovascularization secondary to exudative age-related macular degeneration (e-AMD). Method: We included twelve eyes of 12 patients with PED secondary to e-AMD which were not responding to prior anti-VEGF treatments. An ophthalmic examination and an assessment of PED-horizontal maximal diameter (PED-HMD), PED-maximum high (PED-MH) and macular neovascularization (MNV) flow area (MNV-FA) by the means of structural optical coherence tomography (OCT) and OCT Angiography (OCT-A) were performed at baseline, as well as 1, 7, 14 and 30 days after the injection. Results: The mean age of the population of study was 78.4 (SD ± 4.8). The mean number of previous Ranibizumab or Aflibercept injections was 13 (SD ± 8). At the last follow-up visit, the PED-HMD did not significantly change (p = 0.16; F(DF:1.94, 20,85) = 1.9), the PED-MH showed a significant reduction [p = 0.01; F(DF:1.31, 14.13) = 6.84.] and the MNV-FA did not significantly differ (p = 0.1; F(1.97, 21.67) = 2.54) from baseline. No signs of ocular inflammation were observed during follow-up. Conclusions: A single Brolucizumab injection was able to determine the short-term effects on PEDs’ anatomical features of eyes with an unresponsive e-AMD.

Retinal Pigment Epithelial Detachment in Age-Related Macular Degeneration

Retinal pigment epithelial detachment is defined as a separation of the retinal pigment epithelium from the inner collagenous layer of Bruch’s membrane. It is a common manifestation in both dry and wet types of age-related macular degeneration. This review aims to provide a comprehensive guide to the pathophysiology, clinical and imaging characteristics, natural course and treatment of the various types of pigment epithelial detachments in order to assist in diagnosis and management of this important feature of age-related macular degeneration.

Reliability and Reproducibility of Pigment Epithelial Detachment Volume Measurements in AMD Using a New Tool: ReVAnalyzer

BACKGROUND AND OBJECTIVE

To describe and present the reliability and reproducibility of a new software, Retinal Volume Analyzer (ReVAnalyzer), for pigment epithelium detachment (PED) volume quantification.

PATIENTS AND METHODS

This is a retrospective study including patients with PEDs secondary to exudative age-related macular degeneration (AMD). Macular volume scans on spectral-domain optical coherence tomography on enhanced depth imaging mode were performed in all eyes. Image batches were then exported in .xml format to the ReVAnalyzer software. A semiautomated PED volume measurement was performed by three independent readers (RBG, VC, OS) twice, at the beginning and end of a 15-day period. Bland-Altman assessment for agreement was used to compare intra- and interobserver observations.

RESULTS

Twenty eyes of 20 patients presenting with PED were analyzed. Bland-Altman analysis indicated a good agreement between inter- and intraobserver measurements. The intraclass correlation coefficient for intraobserver PED volume measurements and between the three observers (interobserver) was greater than 0.99, demonstrating high reproducibility and consistency of the methodology.

CONCLUSIONS

ReVAnalyzer is a reliable tool that can assist in the analysis of PED volume with high reproducibility. This type of specific retinal volume analysis can be of help for monitoring disease activity and therapeutic response in AMD. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e242-e249.].

Oct angiography compared to fluorescein angiography, indocyanine green angiography and optical coherence tomography in the detection of choroidal neovascularization in pigment epithelial detachment

PURPOSE

To evaluate the agreement between multimodal imaging-MI (fluorescein angiography, indocyanine green angiography, optical coherence tomography) and optical coherence tomography angiography (OCTA) in the detection of choroidal neovascularization (CNV) in patients with pigment epithelial detachment with subretinal/intraretinal fluid (PED+F) compared to patients with PED without subretinal/intraretinal fluid (PED-F).

METHODS

Twenty-two eyes of 15 patients were divided into two groups (PED+F and PED-F). All patients underwent MI and OCTA with manual and automatic segmentation. MI findings were compared to OCTA findings and then analysed.

RESULTS

In the PED+F group (10 eyes), all studied eyes demonstrated CNV in MI. In manual segmentation OCTA assessment, 9 of 10 eyes (90%) were detected with CNV. When evaluated by automatic segmentation, 8 of 10 eyes (80%) revealed the presence of CNV. In the PED-F (12 eyes) group, all eyes did not demonstrate CNV in MI and OCTA evaluations, either by manual or automatic segmentation. The agreement between MI and OCTA shows concordance (k: 0.908; 95% CI, 0.491-1.000); the evaluation of the agreement between the automatic and manual segmentation also shows concordance (k: 0.904; 95% CI, 0.488-1.000).

CONCLUSION

The solid agreement between the multimodal imaging regarding the ability of OCTA to identify possible initial CNV in a patient with PED-F was observed. Accuracy was 95.45%. In addition, the agreement between manual and automatic segmentation to identify CNV on OCTA was also shown.

Retinal pigment epithelium hyperplasia overlying pigment epithelial detachment in age-related macular degeneration can masquerade as neovascularization on optical coherence tomography angiography

Purpose

To report the image artifacts due to retinal pigment epithelium (RPE) hyperplasia overlying retinal pigment epithelial detachment (PED) in age-related macular degeneration (AMD), which can masquerade as neovascularization on optical coherence tomography angiography (OCTA).

Methods

A hospital-based, retrospective, and cross-sectional study. Twenty-two eyes from 16 patients with non-vascularized PED related to AMD were included in this study. All patients were examined by OCTA, spectral-domain optical coherence tomography, fluorescence angiography, and indocyanine green angiography. Vascular flow signals (VFS) on both the outer retinal slab of en face OCTA and cross-sectional OCTA and their correspondence with RPE hyperplasia were evaluated.

Results

Fifteen eyes (68.2%) showed VFS on both the outer retina slab of en face OCTA and cross-sectional OCTA, all corresponding to the RPE hyperplasia overlying PED. Among them, 12 eyes with lump RPE hyperplasia outside foveal avascular zone (FAZ) all showed obvious VFS on the outer retina slab of OCTA, and 3 eyes with scattered RPE hyperplasia outside FAZ showed VFS fragments. Of note, 4 eyes had accompanied RPE hyperplasia inside FAZ, and 7 eyes without RPE hyperplasia overlying PED showed no corresponding VFS on the outer retina slab of OCTA. Additionally, a round-like dark band at the edge of PED was observed in the outer retina slab on en face OCTA in 17 eyes (77.3%).

Conclusions

RPE hyperplasia overlying PED in AMD can masquerade as neovascularization on OCTA. To avoid misdiagnosis and unnecessary treatment, this RPE hyperplasia-related image artifact should be considered when interpreting OCTA images.

An update on inflammatory choroidal neovascularization: epidemiology, multimodal imaging, and management

Inflammatory choroidal neovascular membranes are challenging to diagnose and manage. A number of uveitic entities may be complicated by the development of choroidal neovascularization leading to a decrease in central visual acuity. In conditions such as punctate inner choroidopathy, development of choroidal neovascularization is extremely common and must be suspected in all cases. On the other hand, in patients with conditions such as serpiginous choroiditis, and multifocal choroiditis, it may be difficult to differentiate between inflammatory choroiditis lesions and choroidal neovascularization. Multimodal imaging analysis, including the recently introduced technology of optical coherence tomography angiography, greatly aid in the diagnosis and management of inflammatory choroidal neovascularization. Management of these neovascular membranes consists of anti-vascular growth factor agents, with or without concomitant anti-inflammatory and/or corticosteroid therapy.