SUBCLINICAL MACULAR CHANGES AND DISEASE LATERALITY IN PEDIATRIC COATS DISEASE DETERMINED BY QUANTITATIVE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

Repeatability and reproducibility of quantitative OCT angiography measurements from table-top and portable Flex Spectralis devices

PURPOSE

The recent development of a portable investigational handheld OCT-angiography (OCTA) device has allowed for expansion of imaging into the operating room (OR) in addition to standard in-clinic imaging. The aim of this study was to assess intravisit repeatability and intervisit reproducibility of retinal microvasculature measures and central retinal thickness for in-clinic table-top and portable OR compatible OCTA devices.

METHODS

Repeated 10 × 10 OCTA images were acquired in 20 healthy adult participants on two separate visit days using Spectralis spectral-domain OCTA table-top and investigational armature suspended Flex systems. Intravisit and intervisit intraclass correlation coefficients and average absolute percent difference were calculated for quantitative microvasculature measures and CRT.

RESULTS

120 OCTA images were acquired from 20 subjects (n = 20, mean age 26.7 ± 1.61 years, range 24-30 years) with both devices across two separate imaging days. FAZ and CRT measurements had near complete intravisit and intervisit agreement with ICCs between .97 and 1 for both table-top (FAZ ICC .97, .97; CRT ICC .98-1, .98-.99) and Flex (FAZ ICC .97, .95; CRT ICC .99-1, .98-.99) devices. Vessel density measures demonstrated greater variance with only fair to strong agreement (ICC .32-.75) and average absolute percent differences ranging from 2.96 to 6.63%.

CONCLUSION

FAZ and CRT measures for both devices demonstrated high repeatability and reproducibility; retinal vessel density measures demonstrated less. Differences of less than 7% for retinal microvasculature measurements across time and devices are most likely attributable to expectable variance between repeat scans.

ABNORMALITIES IN THE RETINAL CAPILLARY PLEXUSES IN COATS DISEASE IN ADULTHOOD ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

PURPOSE

To describe and quantify the abnormalities of the retinal capillary plexuses using optical coherence tomography angiography in Coats disease.

METHODS

Retrospective study. Eleven eyes of 11 patients with Coats disease (9 men and two women aged 32-80 years) compared with nine fellow eyes and 11 healthy control eyes. Horizontal bands of contiguous 3 × 3 mm optical coherence tomography angiograms of the superficial vascular plexus and deep capillary complex were acquired from the optic disk to 6 mm temporal to the fovea, through areas with telangiectasia visible on fluorescein angiography in 9 cases.

RESULTS

The vascular density was significantly decreased in both plexuses in eyes with Coats disease compared with normal and fellow eyes within the 6 mm temporal to the fovea (superficial vascular plexus: 21.5 vs. 29.4%, P = 0.00004 and vs. 30.3%, P = 0.00008; deep capillary complex, 16.5 vs. 23.9%, P = 0.00004 and vs. 24.7%, P = 0.00008, respectively). The fractal dimension was also significantly decreased in eyes with Coats disease (superficial vascular plexus: 1.796 vs. 1.848 P = 0.001 and vs. 1.833, P = 0.003; deep capillary complex: 1.762 vs. 1.853, P = 0.003 and vs. 1.838, P = 0.004, respectively).

CONCLUSION

Retinal plexuses' vascular density was decreased in Coats disease, including in areas with no visible telangiectasia.

FURTHER EVIDENCE AGAINST BILATERAL MANIFESTATION OF COATS DISEASE IN OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY OF THE MACULA

PURPOSE

Recent studies have questioned the traditional view, which regards Coats disease as a strictly unilateral entity. Applying optical coherence tomography angiography, this prospective, monocentric study investigates quantitative capillary changes of the macula associated with Coats disease.

METHODS

Twenty-four eyes (4 untreated, 8 pre-treated) of 12 patients with stage 2 Coats disease (age range: 9-61 years) and 15 eyes of healthy, age-matched controls from the University of Muenster Medical Center, Germany received macular optical coherence tomography angiography measurements of the superficial, deep, and choriocapillary capillary plexus. Flow density and parameters related to the foveal avascular zone were compared between Coats eyes and fellow eyes, and between fellow eyes and control eyes. Additional subanalyses investigated changes based on disease stage.

RESULTS

Flow density did not differ between fellow eyes of Coats disease patients and control eyes in any of the parameters investigated. Comparison of Coats eyes to their respective fellow eyes revealed Coats disease to be associated with lower flow density in superficial, deep, and choriocapillary capillary plexus regions, irrespective of disease stage (all P < 0.03). There were no noticeable differences regarding the size or symmetry of the foveal avascular zone.

CONCLUSION

In light of the recent discussion around the unilateral character of Coats disease, this trial provides evidence against a bilateral presentation of vascular changes in the macula.

Optical Coherence Tomography and Optical Coherence Tomography Angiography in Pediatric Retinal Diseases

Indirect ophthalmoscopy and handheld retinal imaging are the most common and traditional modalities for the evaluation and documentation of the pediatric fundus, especially for pre-verbal children. Optical coherence tomography (OCT) allows for in vivo visualization that resembles histology, and optical coherence tomography angiography (OCTA) allows for non-invasive depth-resolved imaging of the retinal vasculature. Both OCT and OCTA were extensively used and studied in adults, but not in children. The advent of prototype handheld OCT and OCTA have allowed for detailed imaging in younger infants and even neonates in the neonatal care intensive unit with retinopathy of prematurity (ROP). In this review, we discuss the use of OCTA and OCTA in various pediatric retinal diseases, including ROP, familial exudative vitreoretinopathy (FEVR), Coats disease and other less common diseases. For example, handheld portable OCT was shown to detect subclinical macular edema and incomplete foveal development in ROP, as well as subretinal exudation and fibrosis in Coats disease. Some challenges in the pediatric age group include the lack of a normative database and the difficulty in image registration for longitudinal comparison. We believe that technological improvements in the use of OCT and OCTA will improve our understanding and care of pediatric retina patients in the future.

EVIDENCE AGAINST A CONTRALATERAL COATS PHENOTYPE BY OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

PURPOSE

To evaluate the laterality of Coats disease by analyzing optical coherence tomography angiography features in affected, fellow, and control eyes.

METHODS

Patients with Coats disease who underwent optical coherence tomography angiography were retrospectively reviewed. Healthy eyes of age-matched patients served as controls. Automated optical coherence tomography angiography determination of foveal avascular zone size and vascular density of superficial capillary plexus and deep capillary plexus was recorded.

RESULTS

Thirty-four patients with Coats disease (13 with bilateral optical coherence tomography angiography) and 24 controls were included. The foveal avascular zone was larger in affected eyes compared with fellow eyes (P = 0.004). Vascular density was decreased in affected eyes compared with fellow eyes in the superficial capillary plexus and deep capillary plexus whole images (P = 0.047 and P = 0.007) and in the deep capillary plexus at the fovea (P = 0.001). Vascular density was significantly reduced only in the deep capillary plexus in Stage 1 or 2A patients but in both plexuses in patients with Stage 2B1. No differences were shown on foveal avascular zone and vascular density values between fellow eyes of patients with Coats disease and controls.

CONCLUSION

The foveal avascular zone is enlarged, and vascular density is decreased in affected eyes with Coats disease, but no differences are seen between fellow and control eyes, confirming the unilateral nature of the disease.

Updating Understanding of Macular Microvascular Abnormalities and Their Correlations With the Characteristics and Progression of Macular Edema or Exudation in Coats' Disease

Objective

To investigate the associations of macular microvascular abnormalities with the characteristics and progression of macular edema or exudation in Coats' disease, toward an updated understanding of possible risk factors for macular edema or exudation.

Methods

Twenty-six eyes (26 patients) with Coats' disease and macular edema or exudation underwent multimodal imaging and were followed for 18 months. The eyes were classified according to their outcomes (refractory or improved). Macular capillary affections were assessed by optical coherence tomography angiography (OCTA) and fluorescein angiography (FA). Histopathological analysis of the macular region of an additional enucleated eye was performed.

Results

OCTA revealed telangiectasia in the deep capillary plexus (DCP) in 76.9% and the superficial capillary plexus (SCP) in 34.6% of 26 eyes with macular edema or exudation of Coats' disease, exceeding the rate detected by FA (21.4%). Eyes with intraretinal cystoid spaces/exudates of the macula presented higher presence of telangiectasia in the SCP (57.1% with vs. 8.3% without, X2 = 6.801, P = 0.009) and DCP (92.9 with vs. 58.3% without, X2 = 4.338, P = 0.037). The parafoveal vessel densities (VDs) and fractal dimension in the SCP and DCP were lower in affected eyes than in contralateral eyes (all P < 0.001). The VD in SCP (P = 0.009) and DCP (P = 0.010) were lower in refractory group than in improved group. Dilated capillaries with incomplete vessel walls and adjacent inflammatory cells were detected in the neuroretina of the macula in histopathological specimen.

Conclusions

Macular capillary abnormalities, including telangiectasia and VD loss, were positively detected in eyes with macular edema or exudation of Coats' disease. Intraretinal cystoid spaces/exudates of the macula, rather than subretinal exudates, may be related to macular telangiectasia. VD losses in the SCP and DCP may be risk factors for refractory macular edema or exudation.

Optical Coherence Tomography Angiography in Pediatric Retinal Disorders

Purpose:

The rapid and noninvasive nature of optical coherence tomography angiography (OCTA) makes it a potentially valuable tool for imaging the retina in children. With the optimization of tabletop systems and the development of experimental handheld OCTA devices, there is expanded potential for OCTA in the clinic and the operating room. This article reviews the utility of OCTA in some of the most common pediatric retinal disorders.

Methods:

A thorough computerized PubMed search was performed to review relevant published journal articles to contextualize and identify the role of OCTA in common retinal disorders with vascular involvement affecting children. Pertinent results and findings from original investigations and case reports were summarized.

Results:

The ability to quickly collect both qualitative and quantitative information about retinal microvasculature, in both the clinic and operating room settings, with OCTA, has led to the uncovering of microvascular features and morphologic changes in many pediatric retinal disorders such as Coats Disease, familial exudative vitreoretinopathy, incontinentia pigmenti, sickle cell retinopathy, Stargardt Disease, X-linked juvenile retinoschisis, retinopathy of prematurity, diabetic retinopathy in type 1 diabetes, pediatric retinal tumors, and choroidal neovascularization.

Conclusions:

OCTA is a relevant tool to aid early detection, guide intervention, monitor treatment response, and understand pathogenesis in a number of pediatric retinal disorders.

Multimodal imaging of unusual macular macroaneurysm rupture after navigated retinal laser in a patient with adult onset Coats disease

Purpose

To report the uncommon rupture of a macular macroaneurysm (MAR) during navigated retinal laser (Navilas®) focal treatment in a patient with adult onset Coats disease.

Observation

A 30-year-old man consulted for progressive decrease of vision in his right eye from one week. Fundoscopy examination showed macular hard exudates, aneurysms, vascular telangiectasias in the temporal inferior quadrant consistent with an adult onset Coats disease (CD). Spectral domain optical coherence tomography (SD-OCT) and fluorescein angiography (FA) revealed macular edema, vessels abnormalities associate to non-perfused areas. Ultra-widefield optical coherence tomography angiography (UWF-OCTA) clearly showed the blood flow abnormalities in both superficial and deep capillary plexus. Focal laser photocoagulation of abnormal vessels by navigated retinal laser and intravitreal injections (IVT) of aflibercept, successfully resolved macular edema. During supplemental navigated focal laser treatment, a macular macroaneurysm rupture occurred, causing intravitreal hemorrhage with a self-limiting resolution in three months. Indeed, visual acuity progressively improved during follow-up and absence of macular edema was observed at 18 months.

Conclusion

Adult onset CD is a rare condition. Our patient presented an unusual intravitreal hemorrhagic complication due to a MAR rupture after focal navigated laser treatment. Despite this complication, early laser photocoagulation and IVT injections of anti-VEGF, successfully resolved macular edema. UWF-OCTA follow-up clearly showed abnormal vessels in both superficial capillary plexus (SCP) and deep capillary plexus (DCP) and successfully guided additional navigated focal laser treatment.

Optical coherence tomography angiography and multimodal imaging in the management of coats' disease

Purpose

To illustrate the spectrum of clinical and imaging features in patients with unilateral Coats' disease at baseline and in response to treatment with laser, intravitreal bevacizumab, and regional steroids.

Observations

Telangiectasias, macular exudates, and vascular leakage were present in all 3 patients included in this series. After treatment with laser and bevacizumab, OCT angiography findings included an anomalous foveal vascular loop and chorioretinal anastomoses. Choroidal flow voids appeared to improve after intravitreal bevaziumab and laser treatment in 2 patients with OCT angiography obtained at follow up. A-scan axial lengths in affected eyes were 1.5-1.8 mm smaller than fellow eyes.

Conclusions and importance

OCT angiography is a non-invasive tool that can be a useful adjunct to multimodal imaging studies in the management of Coats' disease. Improved vascular density following anti-VEGF injection suggests a possible role of the choroidal vasculature in this retinal vascular pathology.

Clinical features and prognostic factors in 71 eyes over 20 years from patients with Coats' disease in Korea

This retrospective study assesses the clinical features, treatment strategies, and long-term outcomes of patients with Coats’ disease in Korea. Multimodal imaging and medical records of consecutive patients treated between July 2000 and April 2020 at two tertiary centers were evaluated based on onset age (adult vs. childhood [< 18 years]). Factors associated with final visual acuity (VA) and risk of treatment failure were assessed. A total of 71 eyes of 67 patients were included, with subgrouping by onset age showing 45% childhood and 55% adult cases. Overall, Stage 2 disease was most common at presentation (76%), though childhood cases had more Stage 3b (22% vs. 3%, P = 0.02) and greater clock hours of retinal telangiectasia (7 vs. 5, P = 0.005). First-line treatment included laser (25%), combined laser/anti-VEGF (23%), cryotherapy (20%), surgery (16%), and anti-VEGF only (9%). Cryotherapy was associated with a higher risk for secondary interventions (OR 11.8, P < 0.001), required in 56% overall. Despite a 3-line VA decrease in 34% overall, adult cases had superior final VA (P = 0.037). Multivariable regression showed that the number of anti-VEGF injections performed during the initial treatment period was associated with a 9.4 letter improvement in vision (P = 0.041). We observed a higher proportion of adult-onset Coats’ disease than previously reported in other non-Asian populations. An aggressive treatment with the addition of anti-VEGF may yield the most favorable long-term visual outcomes.

Optical Coherence Tomography Angiography Findings After Intravitreal Ranibizumab in Patients With Coats Disease

The aim of this retrospective study was to describe the vascular features in eyes with Coats disease, using optical coherence tomography angiography (OCTA), at baseline and after 3 monthly intravitreal injections of ranibizumab. Fifteen eyes of 15 consecutive patients affected by Coats' disease were recruited in this study. All patients underwent the best-corrected visual acuity (BCVA) evaluation, fundus examination, fluorescein angiography (FA), indocyanine green angiography (ICGA), multicolor imaging, structural Spectral Domain (SD)-OCT and OCTA at baseline and 1 month after the third monthly ranibizumab injection (loading phase). Fifteen patients completed the study, of whom nine were males and six females. Mean age was 20.4 ± 2 years. BCVA was 0.46 ± 0.11 logMar and 0.47 ± 0.12 logMar at baseline and after treatment, respectively (p = 0.164). SD-OCT revealed no significant decrease in central macular thickness (486.33 μm ± 93.37 at baseline vs. 483.4 μm ± 80.97 after treatment; p = 0.915). The subretinal exudates persisted in macular region after intravitreal injections. OCTA showed a general vascular rarefaction in superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillary (CC) that did not change after loading phase. This study showed no functional and vascular improvement following 3 monthly ranibizumab injections. OCTA, non-invasive technique, could be useful during follow up of these patients and provide a better understand of pathogenesis of this disorder.

Vascular findings in primarily affected and fellow eyes of middle-aged patients with Coats' disease using multimodal imaging

AIMS

To investigate the retinal vascular structure and capillary anomalies of affected and fellow eyes of patients with unilateral Coats' disease using multimodal imaging.

METHODS

Clinical investigation of both eyes of each patient with diagnosed Coats' disease using ultra-widefield (UWF) fundus imaging, including UWF fluorescein angiography (UWFFA), spectral domain optical coherence tomography (OCT) and optical coherence tomography angiography (OCT-A).

RESULTS

We analysed 38 eyes of 19 patients with unilateral Coats' disease and found that all fellow eyes (19/19; 100%) revealed vascular alterations, detected by UWFFA, predominantly located in the temporal periphery. Thereby, 89% of the fellow eyes (17/19) presented capillary bed abnormalities, that did not exceed the capillary level; 58% (11/19) presented tortuous abnormalities and 26% (5/19) presented microaneurysmatic abnormalities, exceeding the capillary level. If primarily affected eyes presented central Coats' specific vascular abnormalities, fellow eyes revealed tortuous vascular abnormalities twice as often (78% (7/9) vs 40% (4/10); P=0.096). In primarily affected eyes, a tendency towards larger foveal avascular zones was revealed, compared to fellow eyes (0.28±0.16 mm² vs 0.20±0.10 mm²; P=0.123).

CONCLUSION

The use of modern multimodal imaging allows the detection of even subtle vascular changes in fellow eyes of patients with Coats' disease. Coats' disease appears to be a bilateral ocular disease with a predominant manifestation in one eye of the affected patients.

Foveal avascular zone and vessel density in children with attention deficit hyperactivity disorder

PURPOSE

To compare the retinal and choroidal microvasculature quantitatively via optical coherence angiography (OCTA) in children with attention deficit hyperactivity disorder (ADHD) who were under methylphenidate (MFD) treatment or newly diagnosed as ADHD and were not taking any medication.

METHODS

This was a cross-sectional, comparative, and observational study. The children who were between 6 and 17 years old and previously diagnosed as ADHD and were under MFD treatment or who were newly diagnosed as ADHD were included in the study. Optical coherence tomography angiography imaging was performed via OCT RT XR Avanti with AngioVue software (Optivue Inc, Freemont, CA). The main outcome measure of the study was OCTA parameters of the children with ADHD.

RESULTS

A total of 186 eyes of 186 patients were included in the study. There were 80 eyes in the control group (newly diagnosed) and 106 eyes in the treatment group (under MFD treatment). The mean duration of methylphenidate use in the treatment group was 33.9 ± 20.1 months (between 6 and 84 months). The choriocapillary flow area (p = 0.03), superficial parafoveal thickness (p = 0.01), and deep parafoveal thickness (p = 0.01) were statistically greater in the treatment group than the control group.

CONCLUSION

Most of the important OCTA parameters especially foveal avascular zone (FAZ) area and FAZ perimeter were similar in the two groups. There was a significant difference between the two groups in parafoveal thickness values which might point to a slight effect of MFD on retinal circulation.

Clinical validation of the RTVue optical coherence tomography angiography image quality indicators

IMPORTANCE

All automated image quality indicators for en face optical coherence tomography angiography (OCTA) images require gold standard validation for determining optimum thresholds.

BACKGROUND

A manual grading system (gold standard) for OCTA images was validated and compared to two automated image quality indicators: signal strength index (SSI) and scan quality index (SQI) generated by different software versions of the Optovue OCTA device.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

A total of 52 eyes of 52 healthy individual and 77 eyes of 51 patients with retinal vascular diseases.

METHODS

A total of 129 OCTA images of the superficial vascular plexus were graded manually by three independent examiners. Each image was assigned grades 1 to 4 (1-2, unacceptable; 3-4, acceptable) masked to the software-generated quality indicators.

MAIN OUTCOME MEASURES

Inter-grader agreement and comparison of the utility of SSI and SQI in discriminating between acceptable and unacceptable OCTA images.

RESULTS

There was a substantial agreement between the three graders (κ = 0.63). Mean SSI and SQI was significantly different between acceptable and unacceptable images (P < .001). SQI outperformed SSI in separating acceptable from unacceptable images (areas under the receiver operating characteristic curve: 0.87 vs 0.80) and the optimum cut-off was ≥7 for SQI and ≥70 for SSI for acceptable images. Up to 30% of images with quality indicators reaching the optimum SQI and SSI cut-off thresholds still had unacceptable quality on manual grading. Unacceptable images were found in 33% and 66% of healthy and diseased eyes, respectively.

CONCLUSIONS AND RELEVANCE

SQI is closely related to manual grading but we caution reliance on the optimized threshold to determine image quality. SQI is superior to SSI in discriminating between acceptable and unacceptable images.