CORRELATION BETWEEN FOCAL CHOROIDAL EXCAVATION AND UNDERLYING RETINOCHOROIDAL DISEASE: A Pathological Hypothesis From Clinical Observation

Optical Coherence Tomography Angiography in Macular Neovascularization Secondary to Focal Choroidal Excavation

Purpose: To highlight the use of multimodal imaging for detecting and monitoring macular neovascularization (MNV) in the presence of focal choroidal excavation. Methods: A case and its findings were analyzed. Results: Spectral-domain optical coherence tomography (OCT) and OCT angiography (OCTA) were performed in a 30-year-old Asian woman with metamorphopsia in the left eye. Imaging showed striking MNV secondary to focal choroidal excavation, and an impressive response to antivascular endothelial growth factor therapy was seen throughout the follow-up. Conclusions: OCTA is a noninvasive, useful imaging modality for diagnosing and monitoring patients with MNV secondary to focal choroidal excavation.

Focal choroidal excavation: Review and updated pathogenesis

Focal choroidal excavation is a morphological abnormality that has been recognized with the widespread application of optical coherent tomography. It can exist alone or in combination with or secondary to other chorioretinopathies, so investigators have applied many classification methods, but its pathogenesis is currently not completely understood. We summarize the latest progress in focal choroidal excavation and offer a rethinking of its pathogenesis.

Visual functions and multimodal imaging of patients with idiopathic focal choroidal excavation

This study aimed to evaluate visual function and perform multimodal imaging on patients with focal choroidal excavation without any chorioretinal disease (idiopathic focal choroidal excavation [iFCE]). Seventeen eyes of 15 patients with iFCE (8 men, 7 women; mean ± standard deviation age, 56.0 ± 10.8 years) were assessed for visual function including visual acuity, metamorphopsia, aniseikonia, and retinal sensitivity. Multimodal imaging included optical coherence tomography (OCT), fundus autofluorescence (FAF), and OCT angiography. This study found that the maximum width and depth of the excavation were 597 ± 330 (238-1809) µm and 123 ± 45 (66-231) µm, respectively, and that FAF showed normal or hypoautofluorescence corresponding to iFCE. The fundus examination findings were stable during the follow-up period (96 ± 48 months). None of the eyes showed any abnormalities in central retinal sensitivity or aniseikonia. Metamorphopsia was detected using Amsler grid testing and M-CHARTS in two eyes. Therefore, this study is the first to quantitatively and qualitatively study metamorphopsia of patients with iFCE. Our results showed that most patients with iFCE did not have visual impairments, despite the presence of morphological changes in the outer retina and choroid.

Long-term follow-up demonstrates change in conformation shape of the focal choroidal excavation lesions

PURPOSE

This study aims to present long-term observation of 5 eyes with focal choroidal excavation (FCE), focusing on morphological changes in conformity of the lesion.

METHODS

A retrospective case series was conducted, including 5 eyes of 5 patients with FCE. The study utilized multimodal imaging including color fundus photography, optical coherence tomography (OCT), enhanced depth imaging OCT (EDI-OCT), fundus fluorescein angiography (FFA), fundus autofluorescence (FAF), red free imaging, and OCT angiography.

RESULTS

The mean age at diagnosis was 51 ± 10.65 years, with a mean follow-up period 37 ± 13.59 months. All cases were unilateral, with 1 presenting FCE as an isolated lesion, and one patient exhibiting 2 FCEs in one eye. The mean choroidal thickness measured by EDI-OCT was 268.2 ± 63.39 μm in the affected eye. One patient displayed choroidal thickening and pachyvessels. Of the 5 eyes, one had conforming and 4 non-conforming FCE. We observed a conversion in conformity in all patients, with 4 cases transitioning from non-conforming FCE to conforming type (3 spontaneously, 1 treatment-induced). In conforming FCE, a hyporeflective space appeared twice between neuroretina and retinal pigment epithelium with spontaneous regression.

CONCLUSION

We observed change in shape from the conforming to non-conforming FCE and vice versa in all patients. We consider this small change in the hyporeflective space as non-pathologic and clinically insignificant.

The multimodal imaging features and outcomes of multifocal choroiditis/punctate inner choroidopathy lesion with multiple evanescent white dot syndrome-like features: a retrospective study

BACKGROUND

Multiple evanescent white dot syndrome (MEWDS)-like features is a rare condition triggered by a macular disease or iatrogenic injury, exhibiting MEWDS changes in the fundus. This study aims to describe the multimodal imaging features and outcomes of multifocal choroiditis/punctate inner choroidopathy (MFC/PIC) lesions with MEWDS-like features.

METHODS

Six cases were studied retrospectively. All cases were given regional and oral corticosteroids.

RESULTS

All cases showed an isolated juxtafoveal yellowish-white MFC/PIC lesion with disruption of RPE-Bruch's membrane-choriocapillaris complex (RPE-BM-CC), subretinal hyperreflective materials and choroidal thickening on optical coherence tomography. Two weeks after presentation, the grayish-white dots disappeared spontaneously and the corticosteroids were given. After four weeks, the ellipsoid zone (EZ) around the lesion and hyper-autofluorescence resolved. After 13 weeks, five cases showed shrinkage of the juxtafoveal lesion and restoration of foveal EZ. After six months, the juxtafoveal lesion became pigmented. Only one case developed type 2 choroidal neovascularization.

CONCLUSIONS

The clinical course of MEWDS-like manifestations is still evanescent in our cases. The yellowish-white juxtafoveal MFC/PIC lesions with disruption of RPE-BM-CC and choroidal thickening showed a well-controlled prognosis after corticosteroid treatment.

PUNCTATE INNER PACHYCHOROIDOPATHY: Demographic and Clinical Features of Inner Choroidal Inflammation in Eyes with Pachychoroid Disease

PURPOSE

To perform an unsupervised machine learning clustering of patients with punctate inner choroidopathy (PIC) and provide new insights into the significance of pachychoroid disease features in PIC eyes.

METHODS

Retrospective multicenter study, including 102 eyes from 82 patients diagnosed with PIC. Demographics, clinical data, and multimodal imaging, including fundus photography, optical coherence tomography, and indocyanine green angiography, were collected. Clusters of eyes were identified, and multilevel logistic regression analysis was performed to compare between-group differences.

RESULTS

Using 17 clinical features, two distinct clusters of patients with PIC were identified. Cluster 1 patients were characterized by older age, high myopia, myopic maculopathy features, thin choroids, multiple lesions, and a higher likelihood of developing patchy chorioretinal atrophy. Cluster 2 consisted of younger age, emmetropia or low myopia, thick choroids, choroidal vascular hyperpermeability on late-phase indocyanine green angiography, and high prevalence of focal choroidal excavation. These features exhibited significant differences ( P < 0.05) between the two clusters.

CONCLUSION

While PIC typically affects young myopic female patients with thin choroids, a subset of patients with PIC exhibits features associated with pachychoroid disease. Considering the potential influence of choroidal venous insufficiency on PIC manifestations and secondary complications, we propose the term "punctate inner pachychoroidopathy" to characterize this distinct subtype of PIC.

SOLITARY PUNCTATE CHORIORETINITIS: A Unique Subtype of Punctate Inner Choroidopathy

PURPOSE

To describe a case series of a special subtype of punctate inner choroidopathy with solitary lesions in the macular area and named solitary punctate chorioretinitis.

METHODS

This retrospective observational study clinically evaluated 12 eyes from 12 patients diagnosed as punctate inner choroidopathy with solitary lesions. Demographic data and multimodal imaging features were analyzed for the included patients.

RESULTS

All the included patients were Chinese and of Han ethnicity. The median age of the included patients was 29.5 years (range: 25-40 years). Most patients (11/12, 91.67%) were myopic, with median refraction errors of -4.4 diopters (D) (range: -8.5 to 0 D). Solitary chorioretinitis lesions were yellow‒white and appeared hyperfluorescent during the entire phase of fundus fluorescein angiography without leakage (9/12, 75%) and hypofluorescent on indocyanine green angiography (11/11, 100%). On spectral domain optical coherence tomography, active inflammatory lesions appeared as isolated, heterogeneous, moderately reflective material at the outer retina (10/12, 83.33%) in the fovea or parafoveal region with disruption of the outer retinal layers. When the inflammatory lesions regressed, the moderately reflective materials in the outer retina were absorbed or regressed with outer retinal tissue loss. Additional sequelae of lesion regression included focal choroidal excavation and intraretinal cystoid space. Secondary choroidal neovascularization was noticed in 2 eyes (2/12, 16.67%).

CONCLUSION

Solitary punctate chorioretinitis is a rare and unique subtype of punctate inner choroidopathy. Solitary punctate chorioretinitis may also be an unrecognized etiology of some forms of focal choroidal excavation and idiopathic choroidal neovascularization.

Pachychoroid Spectrum Disorders: An Updated Review

Pachychoroid disease spectrum is a recent term that has been associated with an increasing number of phenotypes. This review discusses updated findings for each of the typical pachychoroid entities (central serous chorioretinopathy, pachychoroid pigment epitheliopathy, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy, peripapillary pachychoroid syndrome, and focal choroidal excavation), as well as two relatively new additions (peripapillary pachychoroid neovasculopathy and peripheral exudative hemorrhagic chorioretinopathy). Here, we discuss the potential pathogenic mechanisms for these diseases and relevant imaging updates. Finally, we argue for a consistent classification scheme for these entities.

Clinical Observation of Choroidal Osteoma Using Swept-Source Optical Coherence Tomography and Optical Coherence Tomography Angiography

Choroidal neovascularization (CNV) secondary to choroidal osteoma (CO) can cause profound visual loss, but detecting CNV and the tumor’s feeder vessels using traditional fluorescent angiography imaging is challenging. Newly developed TowardPi swept-source optical coherence tomography (SS-OCT) and OCT angiography (SS-OCTA) enable ultra-high resolution, enhanced penetration with longer wavelength (1060 nm), a rapid scan rate (400 KHz), reduced loss of signal strength with increasing depth, and 120° angular widefield of fundus view, enabling a nearly histological description of the retina and choroid. We therefore used this SS-OCT and SS-OCTA platform to observe the intrinsic features of osteoma in 23 eyes of 21 patients. It was found that the borders of CO were clearly demarcated from the adjacent choroidal Sattler’s and Haller’s layers, while on a corresponding B-scan the blood flow of the CO was detected mainly within the choriocapillaries and partly within Sattler’s layer. The CNV was identified as numerous branching or radiating vessels connecting with intrinsic feeder vessels displaying various patterns including ginseng, instant noodle, growth ring, tangle, spider web, medusa, seafan, and irregular shape. Moreover, tumor-like tissues were found to grow above the disrupted Bruch’s membrane. SS-OCTA can be used to detect the tumor vasculature in CO.