ASSOCIATION BETWEEN CHOROIDAL CAVERNS AND CHOROIDAL VASCULAR HYPERPERMEABILITY IN EYES WITH PACHYCHOROID DISEASES

Choroidal Vascular Changes on Ultrawidefield Indocyanine Green Angiography in Central Serous Chorioretinopathy: CERTAIN Study Report 1

PURPOSE

Choroidal venous overload was recently suggested to be a pathogenetic factor in central serous chorioretinopathy (CSC). Manifestations of venous overload on ultrawidefield indocyanine green angiography (UWF ICGA) include asymmetric arterial choroidal filling (AACF), enlarged choroidal vessels ("pachyvessels"), and asymmetric venous drainage (AVD) leading to choroidal intervortex venous anastomoses (CVAs) accompanied by choroidal vascular hyperpermeability (CVH). The purpose of the current study is to assess the presence of these signs of venous overload in a large cohort of CSC patients.

DESIGN

Monocentric retrospective cohort study.

PARTICIPANTS

Consecutive CSC patients seen at a large tertiary referral center.

METHODS

For the CERTAIN study, patients underwent a standardized imaging protocol including UWF ICGA. Features of choroidal venous overload were graded for each eye individually by 2 independent graders and, in case of disagreement, by a third grader.

MAIN OUTCOME MEASURES

Presence of AAFC, pachyvessels, AVD, CVA, and CVH.

RESULTS

In total, 178 eyes of 91 patients were included in this study. Mean patient age was 47.6 (± 12.0) years and 75 patients (82%) were male. The 116 eyes (65%) that showed subretinal fluid were considered affected (bilateral disease in 29 patients). In affected eyes, AACF was present in 62 eyes (85% of gradable eyes), pachyvessels in 102 eyes (88%), AVD in 81 eyes (74%), CVA in 107 eyes (94%), and CVH in 100% of affected eyes. For fellow eyes, prevalence of pachyvessels (94%), AVD (67%), and CVA (90%) was similar to affected eyes, whereas CVH was present in 85% of fellow eyes. Intergrader agreement was excellent for CVH (94%), and 74%-82% for all other criteria. Patients with pachyvessels and AVD in 1 eye were more likely to also show the same characteristic in the fellow eye (odds ratios 22.2 and 9.9, P < 0.01).

CONCLUSIONS

Signs of venous overload are seen in the vast majority of CSC patients, both in affected and unaffected eyes. Although pachyvessels, AVD, and CVA are observed frequently, CVH was observed in all affected eyes, showed excellent intergrader reliability, and is diagnostic for CSC. This supports the concept of choroidal venous overload as a major factor in CSC pathogenesis.

FINANCIAL DISCLOSURE(S)

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

Choroidal features in non-neovascular and neovascular pachychoroid diseases

PURPOSE

To evaluate choroidal findings on multimodal imaging in eyes within pachychoroid spectrum diseases and to compare quantitative and qualitative choroidal features between non-neovascular (NNV-PDS) and neovascular (NV-PDS) pachychoroid diseases.

METHODS

Retrospective cross-sectional study comparing between NV-PDS and NNV-PDS. All patients underwent multimodal imaging including infracyanine green angiography (IFCGA) and swept source optical coherence tomography (OCT) and angiography (OCT-A). The following parameters were analyzed: subfoveal choroidal thickness (SFCT), choroidal vascular index (CVI), presence of pachyvessels and choroidal vascular interconnections (CVIC), presence of choroidal neovascularization and choriocapillaris density.

RESULTS

Of the 87 eyes included in the study, 63 eyes (73%) had NNV-PDS and 24 eyes (27%) had NV-PDS. Mean SFCT and CVI were significantly higher in NNV-PDS group (p = 0.01; p = 0.022). Pachyvessels were more diffusely distributed in NNV-PD group and more focally distributed in NV-PDS group (p = 0.029). CVIC were more frequently noted in NV-PDS group (p = 0.024). A higher CVI was associated to a thicker choroid (p < 0.001), with significant negative correlations between the presence of CVIC and both SFCT (p = 0.015) and CVI (p = 0.002). We also observed a lower choriocapillaris vascular density and higher number of choriocapillaris flow voids in eyes with NNV-PDS (p = 0.24; p = 0.61).

CONCLUSION

NNV-PDS eyes had a significantly thicker SFCT, higher CVI and a lower rate of detected CVIC than eyes with NV-PDS. These highlighted choroidal vascular changes might lead to a better understanding of pachychoroid disease pathophysiology. More frequently observed in NV-PDS group, CVIC are believed to assess the development of vortex vein anastomoses as a remodelling process for vascular decongestion.

Choroidal Changes in Rhesus Macaques in Aging and Age-Related Drusen

Purpose

Choroidal vascular changes occur with normal aging and age-related macular degeneration (AMD). Here, we evaluate choroidal thickness and vascularity in aged rhesus macaques to better understand the choroid's role in this nonhuman primate model of AMD.

Methods

We analyzed optical coherence tomography (OCT) images of 244 eyes from 122 rhesus macaques (aged 4-32 years) to measure choroidal thickness (CT) and choroidal vascularity index (CVI). Drusen number, size, and volume were measured by semiautomated annotation and segmentation of OCT images. We performed regression analyses to determine any association of CT or CVI with age, sex, and axial length and to determine if the presence and volume of soft drusen impacted these choroidal parameters.

Results

In rhesus macaques, subfoveal CT decreased with age at 3.2 µm/y (R2 = 0.481, P < 0.001), while CVI decreased at 0.66% per year (R2 = 0.257, P < 0.001). Eyes with soft drusen exhibited thicker choroid (179.9 ± 17.5 µm vs. 162.0 ± 27.9 µm, P < 0.001) and higher CVI (0.612 ± 0.051 vs. 0.577 ± 0.093, P = 0.005) than age-matched control animals. Neither CT or CVI appeared to be associated with drusen number, size, or volume in this cohort. However, some drusen in macaques were associated with underlying choroidal vessel enlargement resembling pachydrusen in human patients with AMD.

Conclusions

Changes in the choroidal vasculature in rhesus macaques resemble choroidal changes in human aging, but eyes with drusen exhibit choroidal thickening, increased vascularity, and phenotypic characteristics of pachydrusen observed in some patients with AMD.

Interleukin-6 in retinal diseases: From pathogenesis to therapy

Interleukin-6 (IL-6) is a pleiotropic cytokine that participates in immunomodulation, inflammation, increases vascular permeability, hematopoiesis, and stimulates cell proliferation, among other biological processes. It exerts effects primarily through the classic and trans-signaling pathways. Many studies have demonstrated that IL-6 plays a critical role in the development of retinal diseases including diabetic retinopathy, uveitis, age-related macular degeneration, glaucoma, retinal vein occlusion, central serous chorioretinopathy and proliferative vitreoretinopathy. Thus, the progressive development of drugs targeting IL-6 and IL-6 receptor may play a role in the treatment of multiple retinal diseases. In this article, we comprehensively review the IL-6's biological functions of and its mechanisms in the pathogenesis of various retinal diseases. Furthermore, we summarize the drugs targeting IL-6 and its receptor and prospect their potential application in retinal diseases, hoping to provide new ideas for the treatment of retinal diseases.

SUBRETINAL LIPID GLOBULES AN EARLY BIOMARKER OF MACULAR NEOVASCULARIZATION IN EYES WITH INTERMEDIATE AGE-RELATED MACULAR DEGENERATION

PURPOSE

To explore the association between subretinal lipid globules (SLGs) detected in eyes with intermediate age-related macular degeneration with the presence of nonexudative macular neovascularization.

METHODS

This was a retrospective analysis of 113 consecutive patients with bilateral intermediate age-related macular degeneration (226 eyes) followed for a least 6 months. All eyes underwent multimodal imaging with fundus autofluorescence, spectral-domain optical coherence tomography, and optical coherence tomography angiography. Subretinal lipid globules were identified on spectral-domain optical coherence tomography as round hyporeflective lesions measuring 31 to 157 µ m located between the ellipsoid zone and the retinal pigment epithelium/Bruch membrane complex. Nonexudative macular neovascularization was detected with optical coherence tomography angiography. The features of NE-MNV lesions detected in eyes with SLGs were compared with those in eyes without SLGs.

RESULTS

Subretinal lipid globules were identified in 15 eyes of which 14 eyes (93.3%) demonstrated NE-MNV on optical coherence tomography angiography. In the remaining 98 eyes without SLGs, 18 (18.4%) displayed NE-AMD on optical coherence tomography angiography. The macular neovascularization area was larger in the SLG subgroup (+0.38 vs. +0.21 mm 2 , P = 0.008) and showed faster horizontal growth (+727 µ m, CI 95% 250.4, 1,205.4) than MNV in eyes without SLGs (+64.9 µ m, CI 95%, 24.3, 154) on optical coherence tomography B-scans. After a mean of 11.6 months, the conversion rate to exudative MNV was similar between eyes with SLGs and those without SLGs [8/26 (38.5%) versus 3/13 (27.3%), P = 0.56)].

CONCLUSION

The detection of SLGs in eyes with intermediate age-related macular degeneration was strongly correlated with the presence of NE-MNV. Although these MNV lesions were larger and grew faster than NE-MNV detected in eyes lacking SLGs, the rates of conversion to exudative MNV appeared similar.

Presence of Choroidal Caverns in Patients with Posterior and Panuveitis

Choroidal caverns (CCs) have been described in association with age-related macular degeneration and pachychoroid disease. However, it is unknown if caverns are found in patients with chronic non-infectious uveitis (NIU). Herein, we evaluated patients with NIU who had optical coherence tomography and indocyanine green angiography for CCs. Clinical and demographic characteristics were extracted from the chart review. Univariate and multivariate mixed-effects logistical models were used to assess the association between clinical and demographic factors and the presence of CCs. One hundred thirty-five patients (251 eyes) met the inclusion criteria: 1 eye had anterior uveitis, 5 had intermediate uveitis, 194 had posterior uveitis, and 51 had panuveitis. The prevalence of CCs was 10%. CCs were only observed in patients with posterior and panuveitis, with a prevalence of 10.8% and 7.8%, respectively. Multifocal choroiditis (MFC) was the type of uveitis where CCs were most frequently observed, with 40% of eyes with MFC having CCs. In addition, male sex (p = 0.024) was associated with CCs. There was no significant difference in the degree of intraocular inflammation or mean subfoveal choroidal thickness between CC+ and CC- eyes. This is the first study to describe CCs in uveitis. Overall, these findings suggest that caverns may be a sequela of structural and/or vascular perturbations in the choroid from uveitis.

Characteristics and Classification of Choroidal Caverns in Patients with Various Retinal and Chorioretinal Diseases

PURPOSE

To investigate the features of choroidal caverns in diverse retinal diseases with swept-source optical coherence tomography (SS-OCT).

METHODS

Subjects with normal eyes, retinitis pigmentosa (RP), wet age-related macular degeneration (wAMD), acute central serous chorioretinopathy (CSC), or chronic CSC were enrolled. The characteristics of choroidal caverns were evaluated with SS-OCT. The prevalence of choroidal caverns in retinal diseases and the correlations between the number, width and depth of choroidal caverns with the thickness of choroid were analyzed.

RESULTS

Among 315 eyes of 220 subjects, choroidal caverns were found in 110 eyes (34.9%). Choroidal caverns were divided into two categories based on their location and size. Type I was small and usually lobulated, presented in the choroidal capillary and Sattler's layers. Type II was larger, usually isolated, and presented in the Sattler's and Haller's layers. The prevalence of type I in subjects with normal eyes, RP, wAMD, acute CSC, or chronic CSC was 17.4%, 19.6%, 1.6%, 32.8%, and 85.2%, respectively, while that of type II was 0%, 0%, 21.3%, 13.8%, and 53.7%, respectively. The number, width, and thickness of type II choroidal caverns correlated positively with macular choroidal thickness.

CONCLUSIONS

Choroidal caverns could be divided into two categories. Type II choroidal caverns appeared associated with the pachychoroid spectrum and RPE atrophic diseases.

Hyper- and hypo-perfusion of choriocapillaris in the eyes with pachychoroid pigment epitheliopathy

PURPOSE

To evaluate the changes in choriocapillaris vessel density (VD) in eyes with pachychoroid pigment epitheliopathy (PPE) using swept-source optical coherence tomography (OCT) angiography (OCTA).

METHODS

This study included 83 eyes with PPE and 42 control eyes. We collected OCT and OCTA parameters, including central point thickness, subfoveal choroidal thickness (SFChT), and choriocapillaris VD of the fovea (CC fovea) and parafovea. The parafoveal area was divided into superior, nasal, inferior, and temporal choriocapillaris areas. Maximum (CC max) and minimum (CC min) choriocapillaris VD were defined as the highest and lowest values among the four parafoveal subfield VDs, respectively. We analyzed the average choriocapillaris VD, CC max, CC min, CC fovea, and the difference between CC max and CC min (CC delta) individually and compared all the parameters between PPE and control eyes.

RESULTS

CC max (56.0% ± 1.7%) was significantly higher and CC min (50.9% ± 2.0%) significantly lower in eyes with PPE than in control eyes (CC max, 55.3% ± 1.0%, P = 0.006; CC min, 51.5% ± 1.3%, P = 0.046). The CC delta value (5.0% ± 2.1%) and SFChT (389.9 ± 129.9 μm) were also significantly higher in eyes with PPE than in the control group (3.7% ± 1.5%, P < 0.001; 268.2 ± 102.2 μm, P < 0.001; respectively).

CONCLUSIONS

Choriocapillaris VD showed higher variability (hyperperfusion and hypoperfusion) in eyes with PPE than in control eyes. Choriocapillaris hypoperfusion may precede the development of PPE; however, choriocapillaris hyperperfusion is associated with projection artifacts.

MULTIMODAL IMAGING OF A CHOROIDAL NEVUS WITH CAVERNS IN THE SETTING OF PACHYCHOROID DISEASE

PURPOSE

To describe the multimodal imaging findings of extensive choroidal caverns within a choroidal nevus in an eye with pachychoroid spectrum disease.

METHODS

A 69-year-old woman was referred with a known history of branch retinal vein occlusion in the right eye and choroidal nevus in the left eye. Fundus examination of both eyes revealed subretinal yellow deposits, suggestive of pachydrusen. Retinal venous collaterals were noted in the temporal macular of the right eye. A lightly pigmented choroidal lesion with nearly confluent overlying drusen and retinal pigment epithelial alterations, consistent with chronic choroidal nevus, was noted in the macula of the left eye.

RESULTS

Optical coherence tomography B-scans revealed thickened choroid (pachychoroid) with subfoveal choroidal thickness of 504 µ m and 580 µ m with large hyporeflective spaces suggestive of pachyvessels in both eyes. In the region of the choroidal nevus, the choroidal vascular spaces appeared comparatively large and were classified as "caverns" measuring up to 480 µ m in diameter. Optical coherence tomography angiography and indocyanine green angiography demonstrated the absence of flow within the caverns. Indocyanine green angiography further illustrated choroidal vascular hyperpermeability with patchy hyperfluorescent areas in both eyes. Wide-field swept-source optical coherence tomography showed mild posterior scleral bowing, a feature occasionally documented with choroidal nevus, and highlighted greater hyporeflectivity and hypertransmission on optical coherence tomography within the caverns compared with the noncavernous choroidal vessels.

CONCLUSION

Choroidal caverns can occur within choroidal nevus in the setting of pachychoroid disease.

Choroidal Vasculature Changes in Age-Related Macular Degeneration: From a Molecular to a Clinical Perspective

The contribution of choroidal vasculature to the pathogenesis of age-related macular degeneration (AMD) has been long debated. The present narrative review aims to discuss the primary molecular and choroidal structural changes occurring with aging and AMD with a brief overview of the principal multimodal imaging modalities and techniques that enable the optimal in vivo visualization of choroidal modifications. The molecular aspects that target the choroid in AMD mainly involve human leukocyte antigen (HLA) expression, complement dysregulation, leukocyte interaction at Bruch’s membrane, and mast cell infiltration of the choroid. A mechanistic link between high-risk genetic loci for AMD and mast cell recruitment has also been recently demonstrated. Recent advances in multimodal imaging allow more detailed visualization of choroidal structure, identifying alterations that may expand our comprehension of aging and AMD development.

The Association Between Circulating Sex Hormones and Central Serous Chorioretinopathy: A Case-Control Study

Background

Central serous chorioretinopathy (CSC) is preferential cocurated in males, however the associations between sex hormones and CSC incidence or progression remains unclear. The sex hormone concentration assessments in CSC cases and healthy controls will update the knowledge in CSC management.

Methods

This case-control study included 59 CSC cases and 30 healthy controls, from January 2019 to December 2020. The CSC cases would be defined as spontaneous resolved if the subretinal fluid were absorbed within three months. The concentrations of total testosterone (TT), free testosterone (FT), estradiol (E2), sex hormone-binding globulin (SHBG), progesterone, leuteinizing hormone (LH) and dehydroepiandrosterone sulfate (DHEA-S) were detected in all the participants. The relationships between sex hormone concentrations and CSC-related characteristics were analyzed with Pearson correlation analyses.

Results

Significantly increased TT, FT, FT/E2 ratio, SHBG concentrations as well as decreased DHEA-S level were detected in non-resolved CSC group compared with the control group. Comparing with the resolved ones, it was found that TT, FT and SHBG concentrations were increased in the non-resolved CSC. A significant positive correlation between TT concentrations and CMT (R²=0.168, P=0.031) as well as SRF height (R²=0.146, P=0.045) were detected in the non-solved CSC group.

Conclusion

Different concentrations of TT, FT, FT/E2 ratio, DHEA-S and SHBG were detected in resolved and non-resolved CSC cases. Sex hormones were related to CSC symptom durations and related parameters.

Association between retinal sensitivity and the presence of quiescent choroidal neovascularization in pachychoroid diseases

This study was conducted to examine retinal sensitivity (RS) in eyes with pachychoroid diseases and to analyze its association with the presence or absence of quiescent choroidal neovascularization (CNV), that can be protective against retinal dysfunction or atrophy in other macular diseases such as age-related macular degeneration. A total of 12 eyes of 12 patients aged ≥45 years having the characteristic findings of central serous chorioretinopathy but not presenting any exudative changes were included in this study. Choroidal vascular hyper permeability (CVH) was identified by indocyanine green angiography, and the presence or absence of CNV was evaluated by optical coherence tomography angiography. RS at 68 points was examined by microperimetry. The average RS corresponding to within and outside CVH was compared. The association between the difference in RS and the presence or absence of CNV was also analyzed. CNV was detected in six eyes (50%). In eyes without CNV, the RS within CVH was similar compared with that outside CVH. However, in eyes with CNV, the RS within CVH was significantly decreased compared with that outside CVH. Multiple regression analysis revealed the presence of CNV as an independent factor associated with RS. In eyes with pachychoroid diseases, RS decreased within the CVH area under the coexistence of nonexudative CNV.

Imaging Characteristics of Neovascular and Atrophic Pachychoroidal Spectrum Diseases

Background

This study qualitatively and quantitatively compared imaging characteristics between neovascular and atrophic pachychoroid spectrum disease (PSD) by optical coherence tomography (OCT), and OCT angiography (OCTA).

Methods

The subtypes of PSD were identified by multi-modality imaging approaches. Subfoveal choroidal thickness (SFCT), choroidal vascular index (CVI), and vascular density of choroidal neovascularization (CNV) were measured.

Results

The CVI and SFCT of 174 PSD eyes were 67.6% ± 5.48% and 362.2 ± 131.88 μm, respectively. After adjustment for age, linear regression indicated that SFCT was positively associated with CVI (p &lt; 0.001), and patched hyper-reflective lesions in choriocapillaris layers (p = 0.009). Compared with neovascular PSD eyes, atrophic PSD eyes had similar patient age (57.1 ± 16.72 years, p = 0.639), SFCT (332.0 ± 111.00 μm, p = 0.51), and CVI (67.6% ± 3.94%, p = 0.527). There were no differences between polypoidal choroidal vasculopathy (PCV) eyes with aneurysmal polypoidal lesions and PCV eyes with tangled polypoidal lesions in terms of age, CVI, SFCT, vascular density, or the occurrence of double layer signs (DLSs, all p &gt; 0.05). Logistic regression indicated that age (p = 0.003), SFCT (p = 0.003), patched hyper-reflective lesions in choriocapillaris layers (p = 0.009), and DLSs (p &lt; 0.001) were predictive factors for CNV progression in PSD eyes (all p &lt; 0.05).

Conclusions

Our study highlighted the similarities in SFCT and CVI between neovascular and atrophic PSD, both of which were late stage lesions. Besides, age, SFCT, patched hyper-reflective lesions in choriocapillaris layers, and DLSs were risk factors for CNV in PSD. Our results showed that atrophic PSD is an important change in the late stage of PSD disease, which is helpful for in-depth understanding of the pathological mechanism of PSD and corresponding intervention.

Bilateral choroidal caverns in a child with pachychoroid and anxious personality

Purpose

To report a case of a 7-year-old male patient with bilateral choroidal caverns (CC) and pachychoroid.

Observations

During the Italian COVID-19 lockdown, a 7-year old boy presented with bilateral vision decline that had started two weeks before. Structural optical coherence tomography revealed pachychoroid and CC bilaterally. Other ocular examinations were negative. The patient had an apprehensive personality and symptoms quickly resolved when he was provided with non-prescription glasses; his visual disturbances were thus considered to be functional and factitious.

Conclusions and Importance

Our patient's symptoms remind us that the distress imposed upon psychologically frail subjects by the COVID-19 pandemic may have multifaceted manifestations. The discovery of CC in a pediatric patient with healthy eyes presents us with new questions about the processes of degeneration thought to be the cause for CC. Further studies are needed to estimate the prevalence of CC in the general adult and pediatric populations, as well as in patients with chorioretinal diseases.

Choroidal imaging using optical coherence tomography: techniques and interpretations

The choroid is vascularized membranous tissue that supplies oxygen and nutrients to the photoreceptors and outer retina. Choroidal vessels underlying the retinal pigment epithelium are difficult to visualize by ophthalmoscopy and slit-lamp examinations. Optical coherence tomography (OCT) imaging made significant advancements in the last 2 decades; it allows visualization of the choroid and its vasculature. Enhanced-depth imaging techniques and swept-source OCT provide detailed choroidal images. A recent breakthrough, OCT angiography (OCTA), visualizes blood flow in the choriocapillaris. However, despite using OCTA, it is hard to visualize the choroidal vessel blood flow. In conventional structural OCT the choroidal vessel structure appears as a low-intensity objects. Image-processing techniques help obtain structural information about these vessels. Manual or automated segmentation of the choroid and binarization techniques enable evaluation of choroidal vessels. Viewing the three-dimensional choroidal vasculature is also possible using high-scan speed volumetric OCT. Unfortunately, although choroidal image analyses are possible using the images obtained by commercially available OCT, the built-in function that analyzes the choroidal vasculature may be insufficient to perform quantitative imaging analysis. Physicians must do that themselves. This review summarizes recent choroidal imaging processing techniques and explains the interpretation of the results for the benefit of imaging experts and ophthalmologists alike.

Choroidal Caverns in Stargardt Disease

Purpose

To report choroidal caverns in patients affected by recessive Stargardt disease (STGD1) and to investigate its clinical features.

Methods

Retrospective analysis of STGD1 patients recruited at the Regional Reference Center for Hereditary Retinal Degenerations at the Eye Clinic in Florence from 2012 to 2017. Patients included in the study underwent a complete ophthalmic examination including best-corrected visual acuity, color fundus photography, fundus autofluorescence, optical coherence tomography (OCT) and OCT angiography.

Results

Eighty-six patients (172 eyes) were included in the study. Twenty-three eyes (13.3%) of 21 patients presented choroidal caverns. The total number of detected choroidal caverns was 63. Choroidal caverns were only present in patients with stage III and IV STGD. Interestingly, patients with choroidal caverns presented larger macular atrophy (20.53 ± 16.9 mm² vs. 18.11 ± 20.39 mm²), worse visual acuity (1.03 ± 0.29 vs. 0.83 ± 0.26), and a thinner choroidal thickness (245.9 ± 88.7 vs. 266.0 ± 110.5 µm).

Conclusions

Choroidal caverns are present only in the advanced stage of STGD1, and a possible degenerative origin of the finding has been hypothesized.

Ultra-Widefield Indocyanine Green Angiography Reveals Patterns of Choroidal Venous Insufficiency Influencing Pachychoroid Disease

Purpose

To compare patterns of choroidal venous drainage in eyes with pachychoroid disease to those of healthy subjects using ultra-widefield indocyanine green angiography (UWF ICGA).

Methods

Patients with pachychoroid disease and healthy controls were recruited at two referral centers. UWF ICGA images were used to evaluate the proportion of the postequatorial fundus drained by major vortex vein systems in each quadrant and to study the incidence and topography of choroidal vascular hyperpermeability (CVH) and intervortex venous anastomoses. Widefield swept-source optical coherence tomography (SS-OCT) was used to evaluate choroidal thickness at the posterior pole in eyes with pachychoroid disease.

Results

Fifty-two pachychoroid eyes and 26 healthy eyes were evaluated. Eyes with pachychoroid disease showed a significant within-subject variance in the proportion of the postequatorial fundus drained by each vortex vein system (range, 4.1%–48.1%; P < 0.0001) that was not seen in controls (range, 17.3%–31.7%; P = 0.11). CVH was present in all pachychoroid disease eyes and three of 26 controls. Intervortex venous anastomoses were present in 46 of 52 pachychoroid disease eyes and nine of 26 control eyes. Vortex vein systems with large drainage areas showed greater density of CVH spots. SS-OCT demonstrated asymmetric choroidal drainage in the macula of 59% of pachychoroid eyes. CVH and intervortex venous anastomoses were more prominent in areas showing maximal choroidal thickness.

Conclusions

In eyes with pachychoroid disease, imbalanced choroidal venous drainage with congestion of specific vortex vein systems may contribute to a state of choroidal venous insufficiency characterized by regional choroidal thickening, CVH and remodeling of venous drainage routes.

Choroidal caverns in pachychoroid neovasculopathy

Background. Choroid plays an important role in the pathogenesis of retinal pathology. Choroidal cavern, a recently identifi ed fi nding of optical coherent tomography (OCT), has been described in some degenerative and atrophic forms of retinal pathology. In the literature, there are only a few studies of choroidal cavers in pachychoroid neovasculopathy, newly described form of age related macular degeneration.The aim: to perform a detailed analysis of choroidal structure on OCT scans of patients with pachychoroid neovasculopathy and to reveal the frequency of choroidal caverns identifi cation.Material and methods. The data of 30 patients (30 eyes) aged 64.4 ± 5.6 years with pachychoroid neovascularization were retrospectively analyzed. The patients underwent spectral OCT and OCT-angiography (OCTA) using a Spectralis device (Heidelberg Engineering, Germany). The protocol was “Posterior Pole”, consisting of 61 scans. To assess the structure of the choroid, an enhanced image depth (EDI) module was used. OCT angiography was performed with a scan area of 6 × 6 mm. These methods were compared to identify choroidal caverns.Results. On OCT subretinal type 1 neovascularization was revealed as a fl at detachment of the pigment epithelium and visualization of blood flow on OCTA in the lesion as angled vessels (21 eyes) or a seafan (9 eyes). On OCT-EDI scans, there was diffuse or local choroidal thickening of choroid with an increase in the vessels of the Haller’s layer and thinning of the choriocapillaries. Choroidal caverns appeared on OCT and en-face OCT as areas with low optical density, round or irregular, located in different layers of the chorioid, without hyperrefl ective boundaries. A typical sign of choroidal cavern is the tail of hypertransmission after the cavern toward the sclera. Choroidal caverns were found in 4 of 30 eyes (13.3 %) and were located both near the choroidal neovascularization lesion and beyond this area.Conclusion. The prevalence of choroidal cavities, a new choroidal biomarker, in pachychoroid neovasculopathy was 13.3 %. Identification of these changes is possible with the use of modern diagnostic techniques (OCT-EDI, OCTA and en-face OCT) that allow visualization the state of the choroid. The prognostic signifi cance of choroidal cavities requires further study.

RESOLUTION OF A SUBFOVEAL CHOROIDAL CAVERN AFTER HALF-DOSE PHOTODYNAMIC THERAPY FOR CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To describe resolution of a subfoveal choroidal cavern after half-dose verteporfin photodynamic therapy for persistent central serous chorioretinopathy.

METHODS

Case report.

RESULTS

A 43-year-old man was referred for treatment of chorioretinopathy in his left eye. On presentation, swept-source optical coherence tomography demonstrated a serous retinal detachment and a 161-μm-thick subfoveal choroidal cavern showing a characteristic tail of hypertransmission extending posteriorly. Subfoveal choroidal thickness measured 456 μm in the affected eye. Complete resolution of subretinal fluid and the subfoveal choroidal cavern were observed 3 months after half-dose verteporfin photodynamic therapy. Twelve months after treatment, subfoveal choroidal thickness had decreased further to 276 μm, and visual acuity had improved to 20/15.

CONCLUSION

After half-dose verteporfin photodynamic therapy for chorioretinopathy, resolution of subretinal fluid was accompanied by resolution of a subfoveal choroidal cavern at 3 months and a 39.5% reduction in subfoveal choroidal thickness at 1 year.

COVID-19 Associated Choroidopathy

The aim of the study is to report on the indocyanine green angiography (ICGA) and OCT findings in patients hospitalized for severe COVID infection. In this observational prospective monocentric cohort study, we included patients hospitalized for severe COVID infection. The main outcomes were ICGA and OCT findings. A total of 14 patients with a mean age of 58.2 ± 11.4 years and a male predominance (9/14 patients; 64%) were included. The main ICGA findings included hypofluorescent spots in 19 eyes (68%), intervortex shunts in 10 eyes (36%), and characteristic "hemangioma-like" lesions in five eyes (18%). "Hemangioma-like" lesions were both unique and unilateral, and showed no washout on the late phase of the angiogram. The main OCT findings included focal choroidal thickening in seven eyes (25%), caverns in six eyes (21%) and paracentral acute middle maculopathy lesions in one eye (4%). All patients hospitalized for severe COVID infection had anomalies on ICGA and OCT. Lesions to both retinal and choroidal vasculature were found. These anomalies could be secondary to vascular involvement related directly or indirectly to the SARS-CoV2 virus.

Mid-Phase Hyperfluorescent Plaques Seen on Indocyanine Green Angiography in Patients with Central Serous Chorioretinopathy

(1) Indocyanine green angiography (ICG-A) shows the presence of mid-phase hyperfluorescent area in central serous chorioretinopathy (CSCR). However, their exact meaning remains uncertain. (2) The clinical and multimodal imaging findings of 100 patients (133 eyes) with CSCR, including the enhanced-depth-imaging OCT (EDI-OCT), blue-light fundus autofluorescence (BAF), fluorescein and indocyanine green angiography (FA and ICG-A) findings were reviewed. Mid-phase hyperfluorescent plaques (MPHP) were defined as fairly well circumscribed hyperfluorescent regions during the midphase of the ICG-A. The association between MPHP and other clinical/imaging parameters was assessed using a multiple logistic regression analysis. (3) MPHP were detected in 59.4% of eyes with CSCR. The chronic form of the disease, the presence of irregular pigment epithelium detachments (PED) and the retinal pigment epithelium (RPE) changes seen on FA were associated with the presence of MPHP in the multivariate analysis (p = 0.015; p = 0.018 and p = 0.002; respectively). OCT showed RPE bulges or PED in 98.7% of areas with MPHP and BAF showed changes in 57.3% of areas with MPHP. (4) MPHP were associated with a chronic form of CSCR and colocated with PED or RPE bulges. MPHP should be recognized as a sign of early RPE dysfunction before it is detected with BAF.

Pachychoroid Spectrum Disease: Underlying Pathology, Classification, and Phenotypes

PURPOSE

Pachychoroid spectrum disease encompasses a set of macular disorders secondary to an abnormally thick choroid. However, the pathological process underlying pachychoroid spectrum disease and its overlap with age-related macular degeneration (AMD) remain unclear. This review aimed to understand the underlying pathology, classification, and phenotypes of pachychoroid spectrum disease.

METHODS

This comprehensive literature review was performed based on a search of peer-reviewed published papers relevant to the current knowledge of pachychoroid disease spectrum.

RESULTS

Pachychoroid is primarily a bilateral phenomenon; the main pathological lesions include choriocapillaris attenuation and abnormally dilated pachyvessels. Chronic central serous chorioretinopathy (CSC) and pachychoroid neovasculopathy (PNV) show similar morphological changes and angiogenic cytokine levels. The subretinal fluid in PNV may not accurately indicate PNV activity. Besides, types 1 and 2 of choroidal neovascularization (CNV) may be involved in primary pachychoroidal disease. Both choroidal arteriosclerosis and higher hydrostatic pressure contribute to hyalinized choroidal arteries and aneurysmal dilatations, resulting in PNV progression to polypoidal choroidal vasculopathy (PCV). Thus, pachychoroid-related type 2 CNV and chronic CSC could be considered as PNV (IIIc) and as a precursor of PNV (IIIa), respectively. Tangled PCV on optical coherence tomography angiography that fails to develop aneurysms should be classified as a subtype of PNV or a forme fruste of PCV.

CONCLUSIONS

Multiple disorders of the pachychoroid spectrum are considered as a continuous disease process, ultimately stimulated by choroidal malfunction. PCV overlaps both AMD and pachychoroid disease, especially for thin-choroid and bilateral types. The terminology and classification of pachychoroid spectrum disease should be used cautiously.

Multimodal Imaging in Pachychoroid Spectrum

Diagnostic investigation on pachychoroid spectrum disease (PSD) has been growing along with the rapid advancement of imaging technology. In optical coherence tomography (OCT)-based studies, choroidal thickness profile, luminal and stromal choroidal ratio, and abnormalities in the neurosensory retina have demonstrated various patterns in different clinical entities related to PSD. The emerging role of OCT angiography (OCTA) has been expanded to involve the quantitative analysis of the OCTA parameters in different clinical entities of PSD and to evaluate the choriocapillaris signal void and vessel density as indicators of choriocapillaris ischemia. OCTA has broadened our knowledge in characterization and assessment of both active and quiescent choroidal neovascularization and its association with treatment response. Recent studies using indocyanine green angiography (ICG) have focused on the evaluation of choroidal vascular hyperpermeability and its relationship with other pachychoroid related features. Ultrawidefield ICG enables observation and characterization of peripheral choroidal pathologies and their associations with macular abnormalities. Multicolor imaging is an emerging modality with the capability to demonstrate early abnormalities in PSD. We summarize all investigations reflecting the new insights into the application of multimodal imaging for PSD and focuses on novel findings observed in different clinical entities with each imaging modality.

Influence of Retinal Microsecond Pulse Laser Treatment in Central Serous Chorioretinopathy: A Short-Term Optical Coherence Tomography Angiography Study

Background: Central serous chorioretinopathy (CSC) is a common macular condition characterized by detachment of the neuroretina and is a frequent cause of central vision loss in adults. Among the various therapeutic strategies, subthreshold microsecond pulsed laser (SML) treatment has become a useful option. Despite the suggested involvement of choroidal circulatory disturbances in CSC, the effects of this treatment on macular microperfusion have not been fully evaluated yet. Herein, we report the impact of SML on retinal and choroidal microvascular flow using non-invasive optical coherence tomography (OCT) angiography (OCTA). Methods: In this study, CSC patients with persistent subretinal fluid (SRF) with or without secondary choroidal neovascularization (CNV) were included (referred to as the pachychoroid neovasculopathy (PNV) group and the CSC group, respectively). SML was conducted using a yellow (577 nm) laser with a duty cycle of 10%, spot size of 200 µm and duration of 200 ms. Best corrected visual acuity (BCVA) as well as OCT and OCTA images were evaluated at baseline and 4 weeks after SML. OCTA parameters of interest included full retinal perfusion (FRP), choriocapillaris perfusion (CCP), Sattler’s layer perfusion (SLP), and Haller’s layer perfusion (HLP), which were evaluated longitudinally and compared to unaffected fellow eyes. Results: 27 affected eyes and 17 fellow eyes from 27 patients were included. Before treatment, central retinal thickness (CRT) and subfoveal choroidal thickness (SFCT) of affected eyes were significantly larger than in fellow eyes. Four weeks after SML, CRT decreased significantly, whereas perfusion parameters did not change. In subgroup analyses, the CSC group showed a significant decrease in SFCT, whereas the PNV group did not despite the decrease in CRT. Conclusion: Our results suggest that the SML may affect the SFCT of the CSC, but not the PNV patients at least within four weeks following treatment. This effect seems to be independent of the change in choroidal perfusion measured with OCTA.

Venous overload choroidopathy: A hypothetical framework for central serous chorioretinopathy and allied disorders

In central serous chorioretinopathy (CSC), the macula is detached because of fluid leakage at the level of the retinal pigment epithelium. The fluid appears to originate from choroidal vascular hyperpermeability, but the etiology for the fluid is controversial. The choroidal vascular findings as elucidated by recent optical coherence tomography (OCT) and wide-field indocyanine green (ICG) angiographic evaluation show eyes with CSC have many of the same venous patterns that are found in eyes following occlusion of the vortex veins or carotid cavernous sinus fistulas (CCSF). The eyes show delayed choroidal filling, dilated veins, intervortex venous anastomoses, and choroidal vascular hyperpermeability. While patients with occlusion of the vortex veins or CCSF have extraocular abnormalities accounting for the venous outflow problems, eyes with CSC appear to have venous outflow abnormalities as an intrinsic phenomenon. Control of venous outflow from the eye involves a Starling resistor effect, which appears to be abnormal in CSC. Similar choroidal vascular abnormalities have been found in peripapillary pachychoroid syndrome. However, peripapillary pachychoroid syndrome has intervortex venous anastomoses located in the peripapillary region while in CSC these are seen to be located in the macular region. Spaceflight associated neuro-ocular syndrome appears to share many of the pathophysiologic problems of abnormal venous outflow from the choroid along with a host of associated abnormalities. These diseases vary according to their underlying etiologies but are linked by the venous decompensation in the choroid that leads to significant vision loss. Choroidal venous overload provides a unifying concept and theory for an improved understanding of the pathophysiology and classification of a group of diseases to a greater extent than previous proposals.

[Central serous chorioretinopathy]

Central serous chorioretinopathy (CSC) is the fourth most common disease of the macula after age-related macular degeneration, diabetic retinopathy and retinal vein occlusion and a cause of irreversible visual loss. This article gives an overview of the epidemiology, risk factors, pathophysiology, clinical presentation, multimodal imaging and discusses current therapeutic options for CSC.

Imbalance in the Levels of Angiogenic Factors in Patients with Acute and Chronic Central Serous Chorioretinopathy

BACKGROUND

The pathogenesis of central serous chorioretinopathy (CSC) remains a subject of intensive research. We aimed to determine correlations between plasma levels of selected angiogenic factors and different forms of CSC.

METHODS

Eighty patients were enrolled in the study including 30 with a chronic form of CSC, 30 with acute CSC, and 20 controls. Presence of active CSC was determined by fluorescein angiography (FA), indocyanine green angiography (ICGA), and swept-source optical coherence tomography (SS-OCT). Plasma concentrations of angiopoietin-1, endostatin, fibroblast growth factor, placental growth factor (PlGF), platelet-derived growth factor (PDGF-AA), thrombospondin-2, vascular endothelial growth factor (VEGF), VEGF-D, and pigment epithelium-derived factor were measured, and the results were compared between groups. Additionally, mean choroidal thickness (CT) was measured in all patients.

RESULTS

Levels of angiopoietin-1 (p = 0.008), PlGF (p = 0.045), and PDGF-AA (p = 0.033) differed significantly between the three groups. Compared with the controls, VEGF (p = 0.024), PlGF (p = 0.013), and PDGF-AA (p = 0.012) were downregulated in the whole CSC group, specifically PDGF-AA (p = 0.002) in acute CSC and angiopoietin-1 (p = 0.007) in chronic CSC. An inverse correlation between mean CT and VEGF levels was noted in CSC patients (rho = -0.27, p = 0.044).

CONCLUSIONS

Downregulated angiopoietin-1, VEGF, PDGF-AA, and PlGF levels may highlight the previously unknown role of the imbalanced levels of proangiogenic and antiangiogenic factors in the pathogenesis of CSC. Moreover, downregulated VEGF levels may suggest that choroidal neovascularization in CSC is associated with arteriogenesis rather than angiogenesis.

Altered plasma cytokine levels in acute and chronic central serous chorioretinopathy

PURPOSE

To evaluate plasma levels of selected cytokines and investigate their correlation with choroidal thickness (CT) in patients with acute and chronic central serous chorioretinopathy (CSC).

METHODS

We enrolled 30 patients with acute CSC, 30 patients with chronic CSC and 20 controls. Plasma concentrations of 12 cytokines, interleukins IL-8, IL-1β, IL-2, IL-4, IL-5, IL-6, IL-10 and IL-12 p70, granulocyte-macrophage colony-stimulating factor, interferon-γ, tumour necrosis factor-α (TNF-α) and vascular endothelial growth factor (VEGF), were measured using multiplex immunoassays. Differences in cytokine levels between groups were assessed. We also investigated correlations between cytokine levels and CT using swept-source optical coherence tomography, as well as an association between plasma cytokine profile and systemic hypertension.

RESULTS

We noted differences in IL-6 (p = 0.005), IL-10 (p = 0.03), IL-12 p70 (p = 0.028) and VEGF (p = 0.029) levels between groups. Pro-inflammatory IL-12 p70 and multidirectional IL-10 cytokines were upregulated, while pro-angiogenic VEGF was downregulated in chronic CSC as compared with controls (p = 0.005, p = 0.025 and p = 0.027, respectively). Interleukin-6 (IL-6) was upregulated in acute and chronic CSC (p = 0.030 and p = 0.005, respectively). Interleukin-5 (IL-5), IL-6 and IL-12 levels correlated with mean CT in acute CSC (p = 0.008, p = 0.003 and p = 0.044, respectively), while IL-8, IL-6 and TNF-α plasma levels correlated with hypertension in chronic CSC (p = 0.005, p = 0.033 and p = 0.001, respectively).

CONCLUSION

We provided new evidence for the possible role of plasma cytokines in the pathogenesis of CSC. Our results suggest that IL-6 may be important in the pathophysiology of acute and chronic CSC. The association between inflammatory response and hypertension in patients with CSC was also confirmed.

Multimodal Imaging Features and Clinical Relevance of Subretinal Lipid Globules

PURPOSE

To describe the presence of subretinal lipid globules (SLG), analyze the multimodal imaging features inherent in their optical properties, and provide a means to distinguish them from other retinal structures and clinical signs.

DESIGN

Retrospective cohort study.

METHODS

The clinical data and multimodal imaging features of 39 patients (49 eyes) showing SLG were evaluated. Patients underwent color fundus photography, near-infrared reflectance (NIR), spectral-domain (SD) and swept-source (SS) optical coherence tomography (OCT) and OCT angiography. In vitro phantom models were used to model OCT optical properties of water, mineral oil, and intralipid droplets and to investigate the optical mechanisms producing hypertransmission tails beneath SLG.

RESULTS

The SLG were not visible in color fundus photographs or in NIR images. With both SD- and SS-OCT B-scans, SLG appeared as 31-157 μm, round, hyporeflective structures demonstrating a characteristic hypertransmission tail previously described with lipid globules found in the choroid and in neovascular membranes. Similarly, with en face OCT, SLG appeared as small, round, hyporeflective structures. SLG were encountered most often in eyes with neovascular age-related macular degeneration (AMD) that had type 1 macular neovascularization (MNV) (91.1%). Of those eyes, 93.3% were receiving intravitreal antivascular endothelial growth factor (VEGF) therapy (median of 15 injections) with a mean follow-up of 52.6 months. The number of prior injections positively correlated with the number of SLG. The detection of MNV preceded the presence of SLG in 66.7% of cases. En face OCT showed that, in many eyes (49%), SLG appeared in clusters of >10. In 38.8% of eyes, SLG were found overlying type 1 MNV, and in 44.9% of eyes, often those with more numerous SLG, the SLG were located near the lesion border. In 2 eyes with AMD followed for nonexudative type 1 MNV, SLG were detected prior to the detection of other imaging signs of exudation. SLG were observed in several other exudative macular diseases. Phantom models demonstrated that the hypertransmission tail beneath SLG is related to a lensing effect produced by these hyporeflective spherical structures.

CONCLUSIONS

SLG are a newly recognized OCT feature frequently seen in eyes receiving intravitreal anti-VEGF therapy for type 1 MNV due to AMD. OCT B-scans show SLG as small, round, hyporeflective structures with a characteristic hypertransmission tail. This OCT signature is influenced by the OCT focal plane, and it relates to reduced signal attenuation through oil and a lensing effect created by a higher refractive index compared to surrounding tissue.

Focal choroidal excavation and giant choroidal cavern in an eye with pachychoroid

Focal choroidal excavation (FCE) is a localized excavation of the choroid, which can be diagnosed by enhanced depth optical coherence tomography (OCT). Choroidal caverns are focal cavitation areas in the choroid which appear hyporeflective on OCT. These are angular or round, empty spaces with posterior tail of hypertransmission. A 47-year-old female presented to us for a routine eye check-up. The best-corrected visual acuity was 20/20 in both the eyes. On fundus examination, a localized pigmented lesion was seen in the right eye inferior to the optic disc, while the fundus of the left eye was normal. Spectral-domain OCT scan through the lesion showed an FCE and a giant cavern with a posterior tail of hypertransmission. The diameter of the cavern was 977 μ ×264 μ, with a subfoveal choroidal thickness (SFCT) of 360 μ. The SFCT of the other eye was 300 μ. Coexistence of FCE and cavern in an eye with thickened choroid is not yet reported in the literature, and their coexistence provides possible insight into the formation of FCE and caverns in the setting of thickened choroid.

Response to photodynamic therapy combined with intravitreal aflibercept for polypoidal choroidal vasculopathy depending on fellow-eye condition:2-year results

We investigated whether response to photodynamic therapy (PDT) with intravitreal aflibercept injection (IAI) for polypoidal choroidal vasculopathy (PCV) differs depending on fellow eye condition. A retrospective review was conducted for consecutive 60 eyes with PCV treated with PDT combined with IAI as well as 2-years of follow-up data. Fellow eyes were divided into 4 groups; Group 0: no drusen, Group 1; pachydrusen, Group 2; soft drusen, Group 3: PCV/fibrovascular scarring. Best-corrected visual acuity improved at 24-months irrespective of groups and there were no significant differences in visual improvement among treated eyes among the 4 groups. Within 2-years, 35 (58.3%) required the retreatment. The need for retreatment including additional injection and the combination therapy was significantly less in Group 1(12.5%) compared to the others (P = 0.0038) and mean number of additional IAI was also less in Group 1 compared to the others (P = 0.017). The retreatment-free period from the initial combination therapy was longest in Group 1 (23.6±1.1 months) (P = 0.0055, Group 0: 19.1±6.9, Group 2: 12.8±7.9, Group 3: 11.5±9.9). The need for retreatment was significantly different according to fellow-eye condition. Among PCV patients, pachydrusen in fellow eyes appear to be a predictive characteristic for a decreased treatment burden at 2 years.

Choroidal Rift: A New OCT Finding in Eyes with Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSC) is a complex and not entirely understood retinal disease. The aim of our research was to describe a novel optical coherence tomography (OCT) finding named “choroidal rift”, which may be identified in the choroid of eyes with CSC. We collected data from 357 patients (488 eyes) with CSC who had structural OCT and OCT angiography (OCTA) scans obtained. Choroidal rifts were identified as polygonal (and not round-shaped) hyporeflective lesions without hyperreflective margins. Choroidal rifts had to be characterized by a size superior to that of the largest choroidal vessel. Finally, hyporeflective lesions were graded as choroidal rifts only if these lesions had a main development perpendicular to the retinal pigment epithelium. OCT analysis allowed the identification of choroidal rifts in ten eyes from nine patients, all with chronic CSC, with an estimated prevalence rate of 2.1%. In three out of ten cases with choroidal rifts, these lesions spanned all the choroidal layers. In the remaining cases, choroidal rifts only partially spanned the choroidal thickness. In OCTA, choroidal rifts were characterized by the absence of flow. Combining structural OCT and OCTA information, we hypothesized that choroidal rifts may represent interruptions of the choroidal stroma in correspondence of fragile regions (in between expanded larger-sized choroidal vessels). Choroidal rift represents a novel OCT feature, which may characterize eyes with chronic CSC and may have a role in the development of irreversible chorio-retinal changes.

Efficacy of mineralocorticoid receptor antagonist for central serous chorioretinopathy: a meta-analysis

PURPOSE

To evaluate the efficacy of mineralocorticoid receptor antagonist (MRA) for patients with central serous chorioretinopathy (CSCR).

METHODS

The Pubmed, Embase, and the Cochrane Central Register of Controlled Trials were comprehensively searched up to February 2020, to identify the studies comparing the efficacy of MRA with placebo/observation or photodynamic therapy (PDT) for CSCR. The primary outcomes were maximal subretinal fluid height and central macular thickness (CMT). The secondary outcomes included subfoveal choroidal thickness (SFCT) and best-corrected visual acuity (BCVA). Data of interest were extracted and analyzed by R version 3.6.0. The weighted mean difference and their 95% confidence intervals were used to assess the strength of the association.

RESULTS

Ten studies including 284 affected eyes were involved, with 168 undergoing MRA treatment, 60 taking placebo/observation, and 56 receiving PDT. The pooling results showed that MRA was significantly more effective in resolving maximal subretinal fluid height (P < 0.01) and diminishing CMT (P < 0.01) than placebo/observation, while PDT could achieve significantly better CMT reduction than MRA (P = 0.03). For BCVA improvement and SFCT reduction, no statistical difference was detected among the groups of MRA, observation, placebo, or PDT (P > 0.05).

CONCLUSION

MRA is an effective therapy for the management of CSCR, which is only slightly inferior to PDT in terms of CMT reduction. For patients who could not afford PDT, MRA could function as an alternative treatment with acceptable efficacy and safety.

Classification of pachychoroid disease on ultrawide-field indocyanine green angiography using auto-machine learning platform

AIMS

Automatic identification of pachychoroid maybe used as an adjunctive method to confirm the condition and be of help in treatment for macular diseases. This study investigated the feasibility of classifying pachychoroid disease on ultra-widefield indocyanine green angiography (UWF ICGA) images using an automated machine-learning platform.

METHODS

Two models were trained with a set including 783 UWF ICGA images of patients with pachychoroid (n=376) and non-pachychoroid (n=349) diseases using the AutoML Vision (Google). Pachychoroid was confirmed using quantitative and qualitative choroidal morphology on multimodal imaging by two retina specialists. Model 1 used the original and Model 2 used images of the left eye horizontally flipped to the orientation of the right eye to increase accuracy by equalising the mirror image of the right eye and left eye. The performances were compared with those of human experts.

RESULTS

In total, 284, 279 and 220 images of central serous chorioretinopathy, polypoidal choroidal vasculopathy and neovascular age-related maculopathy were included. The precision and recall were 87.84% and 87.84% for Model 1 and 89.19% and 89.19% for Model 2, which were comparable to the results of the retinal specialists (90.91% and 95.24%) and superior to those of ophthalmic residents (68.18% and 92.50%).

CONCLUSIONS

Auto machine-learning platform can be used in the classification of pachychoroid on UWF ICGA images after careful consideration for pachychoroid definition and limitation of the platform including unstable performance on the medical image.

The effect of hyperbaric oxygen therapy on retinal thickness and progression of retinopathy in patients with Type 2 diabetes: a prospective cohort study

Purpose: Evaluation of the effect of hyperbaric oxygen therapy (HBOT) on the progression of retinopathy, choroidal and retinal thickness in patients with type 2 diabetes mellitus (DM). Materials and methods: This prospective non-randomized cohort study consisted of 60 eyes of 30 patients who received 30 sessions of HBOT for a diabetic foot ulcer (DFU). The participants were divided into three groups; group 1: mild-moderate non-proliferative diabetic retinopathy (DRP) (n = 14), group 2: severe non-proliferative DRP (n = 20) and group 3: DRP without active proliferative findings with the applied laser for at least 2 years (n = 26). The cases were examined on base-line (measurement-1), after the 10th session of HBOT (Measurement-2), after the 20th session of HBOT (Measurement-3), after the 30th session of HBOT (Measurement-4), and after 10 days of the last session of HBOT (Measurement-5). The changes in central macular thickness (CMT; subfoveal point [CMT-SF], nasal point [CMT-N] and temporal point [CMT-T]), central choroidal thickness (CCT; subfoveal point [CCT-SF], nasal point [CCT-N] and temporal point [CCT-T]), and the stage of DRP were compared. Results: There was no significant difference between groups in terms of change ratio (CR%) in CMT-SF and CMT-N values. However, in Measurement-3, CR% in CMT-T was significantly higher in group 1 (p = 0.019). A significant increase in CMT-N and CMT-T parameters over time was observed in Group 1 (p < 0.05). There was a significant decrease in CCT-SF, CCT-N, and CCT-T values with time in each of the three groups (p < 0.05). At the end of HBOT, there was no progression or regression in the stage of DRP in any group. Conclusions: HBOT has both a thinning effect on the choroid layer in all three groups and a thickening effect on the macula in the mild-moderate non-proliferative diabetic eyes.

Choriocapillaris Flow Impairments in Association with Pachyvessel in Early Stages of Pachychoroid

To analyze features of the choriocapillaris in eyes with earlier stages of pachychoroid spectrum, this study included 46 eyes with PPE, 32 age-matched eyes with pachychoroid without epitheliopathy, and 30 normal controls. Macular 3 × 3 mm² angiographic images were obtained with swept-source optical coherence tomography. Vascular density and signal void area in the choriocapillaris were analyzed. Topographical correlation of signal voids with the dilated choroidal large vessel (pachyvessel) was assessed. Choriocapillaris vascular density was significantly lower in eyes with PPE compared with controls (p = 0.003). The number, the total area and the average size of signal voids was the highest in the PPE group followed by the pachychoroid without epitheliopathy and then controls (all p ≤ 0.001). 89.0% signal void area colocalized with pachyvessels. The average size of the signal void was higher if it was colocalized with pachyvessel (p < 0.001). In conclusion, the area of flow impairment in the choriocapillaris was increased in eyes with pachychoroid and even greater when epitheliopathy was present. Pachyvessel was associated with choriocapillaris flow impairment by location and size.