Retinal fluorescein and indocyanine green angiography and spectral-domain optical coherence tomography findings in acute retinal pigment epitheliitis

Revisiting acute retinal pigment epitheliitis (Krill disease)

We reevaluate acute retinal pigment epitheliitis (ARPE) first described by Krill and Deutman in 1972, integrating a meticulous literature review with advanced multimodal imaging analyses. Our review included 98 eyes from 86 published cases diagnosed with ARPE. We scrutinized ARPE's clinical presentations, variability, and imaging characteristics, revealing that a large majority (90 %) of cases previously diagnosed as ARPE align more closely with other retinal disorders based on modern diagnostic criteria and imaging techniques. Only a small fraction (5 eyes) did not fit into any known categories, casting doubt on ARPE's distinct existence. This underscores the critical role of multimodal imaging in redefining our understanding of macular diseases and challenges the historical classification of ARPE as a unique clinical entity.

Acute retinal pigment epitheliitis during treatment of hyperprolactinaemia

BACKGROUND

Acute retinal pigment epitheliitis (ARPE) is a rare, idiopathic and self-limiting disease. The article aims to present ARPE in a patient using D2 dopamine receptor agonists for the treatment of hyperprolactinemia.

CASE PRESENTATION

A 28-year-old female during hyperprolactinaemia treatment suffered from a dyschromatopsia and a central visual field defect in the left eye. She noticed a deterioration of vision and discontinued the cabergoline administration. The woman had not been diagnosed with other chronic conditions and exhibited no symptoms of infection. Upon admission, the patient was subjected to a test for COVID-19, which was negative. The ophthalmological examination revealed a decrease in visual acuity to distance in the left eye, which amounted to 18/20 on the Snellen chart. A central scotoma was noted on the Amsler chart and a loss of pigment epithelium was visible on the fundus of the left eye. Fluorescein angiography showed a discrete window defect in the left one, with no signs of leakage. Optical coherence tomography (OCT) scans of the maculae revealed a characteristic change in the photoreceptor layer and retinal pigment epithelium (RPE) in the fovea in the left eye. The electrophysiological tests revealed decreased function of cells in macular region. A magnetic resonance imaging (MRI) of the head and orbits demonstrated an asymmetric pituitary gland without chiasm compression and discrete signal enhancement from the left optic nerve. The patient underwent observation during hospitalisation. She reported improved colour vision and a decreased scotoma in the centre of her visual field. In regular outpatient follow-ups, successive improvements in visual acuity, as well as a decreased RPE damage and outer photoreceptor layer loss during an OCT test were observed.

CONCLUSIONS

A case of ARPE is reported in a patient taking medications for hyperprolactinemia. The role of dopamine receptor antagonists in the photoreceptor function and causation of ARPE needs further evaluation.

A Long Term Recurrent Case of Acute Retinal Pigment Epithelitis

PURPOSE

To describe the case of a young adult who developed two episodes of Acute Retinal Pigment Epithelitis (ARPE) in the same eye 7 years apart, describing retinal morphologic changes using SD-OCT scan.

OBSERVATIONS

ARPE is an acute, self-limiting macular disorder characterized by a stippled dark macular lesion surrounded by a hypopigmented halo under fundus examination, corresponding to a foveal disruption of the outer retinal layers and an hyperreflective lesion under SD-OCT scan. Despite ARPE lesions usually appearing to be situated within the macula, a diffuse involvement of the RPE has been suggested1. SD-OCT scan in our patient showed multiple focal lesions involving the whole posterior pole of the affected eye.

CONCLUSIONS AND IMPORTANCE

We report the first case where a diffuse involvement of the RPE in the disease is supported by an OCT finding and the case with the longest period between two recurrent self-limited episodes described so far.

Acute retinal pigment epitheliitis (ARPE). A case report

A 35-year-old woman arrived in the emergency department due to loss of vision in the left eye. She had a subfoveal yellowish-looking lesion that, on optical coherence tomography (OCT), corresponded to a hyper-reflective lesion from the external nuclear layer to the retinal pigment epithelium. The lesion was reabsorbed at 6 weeks, leaving a discontinuity in the photoreceptor and retinal pigment epithelium lines. The patient was diagnosed with acute retinal pigmentary epitheliitis (ARPE). ARPE is a self-limiting disease with a good prognosis. Emphasis is placed on the importance of a correct diagnosis using funduscopy, OCT, and fluorescent angiography, in order to avoid unnecessary treatments.

RECURRENT ACUTE RETINAL PIGMENT EPITHELIITIS: SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY AND OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FEATURES

PURPOSE

To describe an atypical case of acute retinal pigment epitheliitis including spectral domain optical coherence tomography (OCT) and OCT angiography features.

METHODS

We report a 41-year-old woman with 3 episodes of acute retinal pigment epitheliitis over a 3-year period. Spectral domain OCT and OCT angiography images were acquired with Cirrus 5,000 spectral domain OCT.

RESULTS

Although acute retinal pigment epitheliitis is described as a benign, self-limited pathology, as this case shows, recurrences are possible. OCT angiography shows a choriocapillaris alteration and further recovery during the acute episodes.

CONCLUSION

Acute retinal pigment epitheliitis can present as a recurrent disease.

Acute retinal pigment epitheliitis (ARPE). A case report

A 35-year-old woman arrived in the emergency department due to loss of vision in the left eye. She had a subfoveal yellowish-looking lesion that, on optical coherence tomography (OCT), corresponded to a hyper-reflective lesion from the external nuclear layer to the retinal pigment epithelium. The lesion was reabsorbed at 6 weeks, leaving a discontinuity in the photoreceptor and retinal pigment epithelium lines. The patient was diagnosed with acute retinal pigmentary epitheliitis (ARPE). ARPE is a self-limiting disease with a good prognosis. Emphasis is placed on the importance of a correct diagnosis using funduscopy, OCT, and fluorescent angiography, in order to avoid unnecessary treatments.

MULTICOLOR IMAGING IN A CASE OF ACUTE RETINAL PIGMENT EPITHELIITIS

PURPOSE

To describe multicolor imaging findings in a case of acute retinal pigment epitheliitis.

SETTING

Vitreoretinal department of a tertiary care center in Eastern India.

METHODS

A 28-year-old lady presented with acute vision loss in the right eye since 3 days. Left eye examination was unremarkable. Best-corrected visual acuity in the right eye was 20/40. Anterior segment examination revealed clear lens with no evidence of inflammation. There were no vitreous cells. Fundus examination of the right eye revealed a round orange lesion surrounded by a hypopigmented halo in the fovea with multiple tiny hypopigmented lesions temporal to the fovea. Fundus autofluorescence imaging of the right eye showed hyperautofluorescent lesions temporal to the fovea corresponding to the hypopigmented lesions seen temporal to the fovea. Spectral domain optical coherence tomography of the right eye revealed subfoveal hyperreflective lesion in the outer retina with disruption of the ellipsoid zone and interdigitation zone with a linear extension upward. Multicolor composite image of the right eye revealed the foveal lesion as circular red patch with an inferior orange extension. The infrared reflectance image revealed hyperreflective area corresponding to the foveal lesion. The blue and green reflectance images were unremarkable. The patient reported an upper respiratory tract infection 7 days before the visual loss. A diagnosis of acute retinal pigment epitheliitis was made based on history, clinical and imaging findings.

CONCLUSION

This is the first description of multicolor imaging signature of acute retinal pigment epitheliitis lesion in published literature. It seems to be a promising noninvasive imaging modality with a potential to replace color fundus photography.

RBC-Derived Optical Nanoparticles Remain Stable After a Freeze-Thaw Cycle

Nanosized carriers engineered from red blood cells (RBCs) provide a means for delivering various cargos, including drugs, biologics, and imaging agents. We have engineered nanosized particles from RBCs, doped with the near-infrared (NIR) fluorochrome, indocyanine green (ICG). An important issue related to clinical translation of RBC-derived nanocarriers, including these NIR nanoparticles, is their stability postfabrication. Freezing may provide a method for long-term storage of these and other RBC-derived nanoparticles. Herein, we have investigated the physical and optical stability of these particles in response to a single freeze-thaw cycle. Nanoparticles were frozen to -20 °C, stored frozen for up to 8 weeks, and then thawed at room temperature. Our results show that the hydrodynamic diameter, zeta potential, optical density, and NIR fluorescence emission of these nanoparticles are retained following the freeze-thaw cycle. The ability of these nanoparticles in NIR fluorescence imaging of ovarian cancer cells, as well as their biodistribution in reticuloendothelial organs of healthy Swiss Webster mice after the freeze-thaw cycle is similar to that for freshly prepared nanoparticles. These results indicate that a single cycle of freezing the RBC-derived nanoparticles to -20 °C followed by thawing at room temperature is an effective method to retain the physical and optical characteristics of the nanoparticles, and their interactions with biological systems without the need for use of cryoprotectants.

Indocyanine Green Nanoparticles: Are They Compelling for Cancer Treatment?

Indocyanine green (ICG) is a Food and Drug Administration–approved near-infrared fluorescent dye, employed as an imaging agent for different clinical applications due to its attractive physicochemical properties, high sensitivity, and safety. However, free ICG suffers from some drawbacks, such as relatively short circulation half-life, concentration-dependent aggregation, and rapid clearance from the body, which would confine its feasible application in oncology. Here, we aim to discuss encapsulation of ICG within a nanoparticle formulation as a strategy to overcome some of its current limitations and to enlarge its possible applications in cancer diagnosis and treatment. Our purpose is to provide a short but exhaustive overview of clinical outcomes that these nanocomposites would provide, discussing opportunities, limitations, and possible impacts with regard to the main clinical needs in oncology.

Advances in image enhancement for sarcoma surgery

The recurrence rate of soft tissue and bone sarcomas strongly correlates to the status of the surgical margin after excision, yet excessive removal of tissue may lead to distinct, otherwise avoidable morbidity. Therefore, adequate margination of sarcomas both pre- and intra-operatively is a clinical necessity that has not yet fully been met. Current guidance for soft-tissue sarcomas recommends an ultrasound scan followed by magnetic resonance imaging (MRI). For bone sarcomas, two plane radiographs are required, followed similarly by an MRI scan. The introduction of more precise imaging modalities may reduce the morbidity associated with sarcoma surgery; the PET-CT and PET-MRI approaches in particular demonstrating high clinical efficacy. Despite advancements in the accuracy in pre-operative imaging, translation of an image to surgical margins is difficult, regularly resulting in wider resection margins than required. For soft tissue sarcomas there is currently no standard technique for image guided resections, while for bone sarcomas fluoroscopy may be used, however margins are not easily discernible during the surgical procedure. Near infra-red (NIR) fluorescence guided surgery offers an intra-operative modality through which complete tumour resection with adequate tumour-free margins may be achieved, while simultaneously minimising surgical morbidity. NIR imaging presents a potentially valuable adjunct to sarcoma surgery. Early reports indicate that it may be able to provide the surgeon with helpful information on anatomy, perfusion, lymphatic drainage, tumour margins and metastases. The use of NIR fluorochromes have also been demonstrated to be well tolerated by patients. However, prior to widespread implementation, studies related to cost-effectiveness and the development of protocols are essential. Nevertheless, NIR imaging may become ubiquitous in the future, carrying the potential to transform the surgical management of sarcoma.

Spectral-domain optical coherence tomography finding of acute retinal pigment epitheliitis

Acute retinal pigment epitheliitis (ARPE) is a rare, transient macular disorder affecting healthy young adults. We describe the morphologic appearance of the retina by spectral-domain optical coherence tomography (SD-OCT) and to evaluate both the anatomic changes and the functional visual acuity changes over time in the course of disease. A 35-year-old healthy male presented with 1-week history of sudden-onset bilateral central scotoma with blurry vision. He denied trauma, excessive sun exposure, or drug abuse history or alkyl nitrites before. The medical and ocular examinations were unremarkable. The best-corrected visual acuity (BCVA) was 20/200 (OU) at the initial visit. Slit-lamp examination result was normal. Fundus examination revealed subfoveal yellowish lesions with a halo-like pigment in both eyes. The SD-OCT imaging showed subtle disruption of the retinal pigment epithelium (RPE) and abnormal hyperreflectivity throughout the full thickness of the foveola in both eyes. Six weeks later, the BCVA improved to 20/30 (OU) without any treatment. Six months later, the BCVA observed deteriorated to 20/50 (OU). SD-OCT demonstrated ellipsoid zone and cone outer segment tips line defects at the fovea with sharply defined borders. One year later from the initial visit, the BCVA improved to 20/20 (OU), but persisted macular microhole presents on the SD-OCT. The patient was followed for 1 year without any treatment. Thereafter, we noted that in the case of poor initial visual acuity, external limiting membrane, or outer nuclear layer involvement, as determined by SD-OCT, at the baseline might need longer time for visual acuity. The natural course of ARPE may involve the demonstration of a minor outer retinal defect that is similar to a macular microhole. In ARPE, like SD-OCT findings, the location of the initial lesion is the photoreceptor outer segments. It is not just limited to the RPE.

Clinical application and technical standardization of indocyanine green (ICG) fluorescence imaging in pediatric minimally invasive surgery

PURPOSE

We reported our preliminary experience using ICG fluorescence in pediatric minimally invasive surgery (MIS) with the aim to standardize indications, dose, timing, and modality of administration of ICG according to different organs.

METHODS

ICG technology was adopted in 46 MIS procedures performed in our unit over the last 18 months: 30 left varicocele repairs; 5 cholecystectomies in obese adolescents; 3 tumor excisions; 3 nephrectomies; 2 partial nephrectomies; 3 lymphoma excisions. ICG solution was injected intravenously in all cases except for varicocelectomy in which it was injected into the testis. The ICG injection was performed intra-operatively in all cases except for cholecystectomy in which it was injected 18 h prior to the procedure.

RESULTS

All procedures were completed laparoscopically without conversions or intra-operative complications. No adverse or allergic reactions to ICG were reported.

CONCLUSION

Our preliminary experience showed that ICG fluorescence is a safe, useful, and versatile technique to adopt in pediatric MIS to achieve a better identification of anatomy and an easier surgical dissection or resection in challenging cases. Currently, the main indications are varicocelectomy, difficult cholecystectomy, tumor excision, nephrectomy, and partial nephrectomy. The main limitation is the needing of a special equipment to use ICG technology.

Multimodal imaging findings in 'hyper-early' stage MEWDS

OBJECTIVE

To describe a new stage of multiple evanescent white dot syndrome (MEWDS), occurring at a very early phase of the disease.

METHODS

Retrospective analysis of clinical, angiographic and tomographic findings in four patients with 'hyper-early' stage MEWDS.

RESULTS

In four patients seen within 1 week of the onset of symptoms, fundus analysis revealed macular granity and the classic yellow-white dots, some having no corresponding hyperautofluorescent pattern. Spectral-domain optical coherence tomography (SD-OCT) showed central foveal disruption of the ellipsoid zone (EZ) and interdigitation layer with a hyper-reflective dome-shaped lesion. In two patients, fluorescein angiography (FA) revealed an intermediate hypofluorescent perimacular halo, whereas late indocyanine green angiography (ICGA) showed a hyperfluorescent halo as well as the classic MEWDS features. After a few days, the EZ disruption appeared complete on OCT and fundus autofluorescence (FAF) in all patients. Visual acuity, OCT and FAF findings had fully recovered within 3 months.

CONCLUSIONS

We have shown a new feature of MEWDS on FAF, OCT, FA and ICGA, corresponding to a very early stage of the disease.

Feature space optical coherence tomography based micro-angiography

Current optical coherence tomography (OCT) based micro-angiography is prone to noise that arises from static background. This work presents a novel feature space based optical micro-angiography (OMAG) method (fsOMAG) that can effectively differentiate flow signal from static background in the feature space. fsOMAG consists of two steps. In the first step a classification map is generated that provides criterion for classification in the second step to extract functional blood flow from experimental data set. The performance of fsOMAG is examined through phantom experiments and in-vivo human retinal imaging, and compared with the existing OMAG. The results indicate its potential for clinical applications.

[Acute Retinal Pigment Epitheliitis: spectral-domain optical coherence tomography findings]

PURPOSE

Through a case presentation of Acute Retinal Pigment Epitheliitis (ARPE) we highlight the role of spectral-domain optical coherence tomography (SD-OCT) in the management of this rare entity.

MATERIALS AND METHODS

A 29-year-old woman presented for reduced visual acuity in the right eye occurring one week after a viral episode. Fundus examination showed zones of macular hyperpigmentation surrounded by yellowish hypopigmented haloes. Fluorescein angiography noted early hyperfluorescence of the hypopigmented lesions. ICG angiography revealed central hyperfluorescence surrounded by a hypofluorescent halo. SD-OCT showed a linear disruption between the photoreceptor inner/outer segments (IS/OS) and an accumulation of material in the photoreceptor outer segments and retinal pigment epithelium (RPE). Spontaneous normalization of visual acuity was noted after 10 weeks. SD-OCT revealed restored and continuous inner segment and outer segment layers and some persistent deposits in the photoreceptor layer.

RESULTS

SD-OCT findings suggest that the initial lesion in ARPE is located at the junction between the photoreceptor outer segments and the apical side of the RPE cells. It would correspond to an accumulation of photoreceptor outer segment debris secondary to RPE dysfunction, which can occur as a post-viral reaction.

CONCLUSION

SD-OCT provides very specific information about the topography of retinal lesions during ARPE, allowing a better understanding of its pathogenesis.

Acute retinal pigment epitheliitis: spectral domain optical coherence tomography, fluorescein angiography, and autofluorescence findings

A 17-year-old presented with central and paracentral scotomas in his right eye for one week. There was no remarkable medical or ocular history. Blood analyses were within normal range. At presentation both eyes' best-corrected visual acuities were 20/20. Slit-lamp examination result was normal. Fundus examination revealed yellow-white hypopigmented areas in the macula. Fluorescein angiography (FA) showed hypofluorescence surrounded by ring of hyperfluorescence. Fundus autofluorescence (FAF) was slightly increased. Spectral domain optical coherence tomography (SD-OCT) showed disruption of IS/OS junction with expansion of abnormal hyperreflectivity from retinal pigment epithelium to the outer nuclear layer (ONL). One month later fundus examination showed disappearance of the lesions. FA revealed transmission hyperfluorescence. FAF showed increased autofluorescence and pigment clumping. Hyperreflective band in SD-OCT disappeared. Loss of photoreceptor segment layers was observed in some of the macular lesions. The diagnosis of acute retinal pigment epitheliitis can be challenging after disappearance of fundus findings. FA, FAF, and SD-OCT are important tests for diagnosis after resolution of the disease.

Macular function and morphology in acute retinal pigment epithelitis

A 20-year-old man applied with vision loss in the left eye. Right eye examination was unremarkable. Best-corrected visual acuity (BCVA) in the left eye was 20/200. Fundus examination revealed a few yellow spots within a round-shaped macular lesion. Autofluorescence imaging showed hyperautofluorescence in the lesion. Central amplitudes in multifocal electroretinogram (mfERG) were depressed. The patient reported a rhinopharyngitis 7–10 days before the visual loss. The patient was diagnosed as acute retinal pigment epithelitis. BCVA improved gradually up to 20/20 in 4 weeks. mfERG amplitudes returned to normal. A slight pigmentary distortion was the only residual fundus finding.

Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery

Background

Recently major developments in video imaging have been achieved: among these, the use of high definition and 3D imaging systems, and more recently indocyanine green (ICG) fluorescence imaging are emerging as major contributions to intraoperative decision making during surgical procedures. The aim of this study was to present our experience with different laparoscopic procedures using ICG fluorescence imaging.

Patients and methods

108 ICG-enhanced fluorescence-guided laparoscopic procedures were performed: 52 laparoscopic cholecystectomies, 38 colorectal resections, 8 living-donor nephrectomies, 1 laparoscopic kidney autotransplantation, 3 inguino-iliac/obturator lymph node dissections for melanoma, and 6 miscellanea procedures. Visualization of structures was provided by a high definition stereoscopic camera connected to a 30° 10 mm scope equipped with a specific lens and light source emitting both visible and near infra-red (NIR) light (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany). After injection of ICG, the system projected high-resolution NIR real-time images of blood flow in vessels and organs as well as highlighted biliary excretion .

Results

No intraoperataive or injection-related adverse effects were reported, and the biliary/vascular anatomy was always clearly identified. The imaging system provided invaluable information to conduct a safe cholecystectomy and ensure adequate vascular supply for colectomy, nephrectomy, or find lymph nodes. There were no bile duct injuries or anastomotic leaks.

Conclusions

In our experience, the ICG fluorescence imaging system seems to be simple, safe, and useful. The technique may well become a standard in the near future in view of its different diagnostic and oncological capabilities. Larger studies and more specific evaluations are needed to confirm its role and to address its disadvantages.

B-scan and "en-face" spectral-domain optical coherence tomography imaging for the diagnosis and followup of acute retinal pigment epitheliitis

Purpose. To report B-scan and “En-face” spectral-domain optical coherence tomography (SD-OCT) findings in acute retinal pigment epitheliitis (ARPE). Methods. Two patients (3 eyes) with ARPE were examined. Fluorescein and indocyanine green (ICGA) angiography, B-scan, and “En-face” SD-OCT were performed in each patient at initial and follow-up visits. Results. Both patients presented with acute onset of blurred vision, and one with bilateral involvement. B-can OCT revealed disruption of the macular retinal pigment epithelial (RPE) inner band layer and photoreceptors' inner and outer segment (IS-OS) junction. Hyperreflective dots were observed in the outer nuclear layer (ONL) above the RPE/IS-OS disruption. Just around these hyperreflective dots, slight thickening of the hyperreflective IS/OS junction was observed. During the late phase, indocyanine green angiography (ICGA) showed a macular cockade-like hyperfluorescent halo. “En-face” OCT showed the same cockade-like appearance with a hyporeflective center and a hyperreflective border matching the pattern observed on ICGA. At followup, as vision improved without treatment, B-scan OCT demonstrated progressive resolution of the hyperreflective and disrupted lesions; “en-face” OCT also showed disappearance of the macular cockade-like halo with a transient discrete hyperreflective macular star at the RPE level in one eye. Conclusion. “En-face” OCT associated with B-scan SD-OCT analysis appears to be very helpful in the diagnosis and followup of ARPE. The pathophysiology of ARPE remains complex and still poorly understood. These techniques help define the location and extent of structural damage occurring in this disease.

[Acute retinal pigment epitheliitis. Diagnosis using optical coherence tomography]

CASE REPORT

A 17 year-old female presented with a bilateral and acute visual loss. On ophthalmoscopic examination, there was a subfoveal deposit with a vitelliform appearance. Optical coherence tomography revealed a hyperreflective and homogeneous material located at the photoreceptor external segment layer. A month later, vision had spontaneously recovered and macular appearance was normalised. On tomography, the subretinal material had completely disappeared.

DISCUSSION

Acute retinal pigment epitheliitis is a rare condition that usually causes a transient visual loss, with a good prognosis in young subjects.

High-resolution optical coherence tomography findings in solar maculopathy and the differential diagnosis of outer retinal holes

PURPOSE

To characterize the morphology of outer retinal holes caused by solar maculopathy, using spectral-domain optical coherence tomography (SD-OCT).

DESIGN

This study is an observational case series.

METHODS

The SD-OCT findings of 3 patients (6 eyes) with chronic solar maculopathy are presented.

RESULTS

SD-OCT demonstrates a characteristic appearance of partial-thickness hole(s) in the outer retina at the fovea. In 3 of 6 eyes, there is 1 hole directly beneath the umbo. In the remaining 3 eyes, there are multifocal holes spread across the fovea. Holes in more restricted layers, as had been previously reported with time-domain OCT, were not seen. In addition, advanced visualization of SD-OCT data demonstrates a hyperreflective ring around the outer retinal hole.

CONCLUSIONS

SD-OCT can be used diagnose solar maculopathy. In patients with central scotomas, characteristic outer retinal hole(s) without inner retinal cystic changes may prompt the clinician to uncover an undisclosed history of sungazing. Similar OCT findings can be caused by welder's maculopathy, tamoxifen retinopathy, juxtafoveal macular telangiectasia, foveolar vitreomacular traction, or, rarely, a closed macular hole, achromatopsia, alkyl nitrite abuse, acute retinal pigment epitheliitis, or Stargardt disease.