HYPERREFLECTIVE FOCI PRECEDE MACULAR NEOVASCULARIZATION FORMATION IN ANGIOID STREAKS

Clinical and Imaging Biomarkers Associated with Outer Retinal Atrophy Onset in Exudative Age-Related Macular Degeneration: A Real-Word Prospective Study

INTRODUCTION

Macular neovascularization (MNV) secondary to age-related macular degeneration (AMD) is well managed by anti-vascular endothelial growth factor (anti-VEGF) intravitreal injections. However, outer retinal atrophy represents an unavoidable occurrence detected during follow-up. Several imaging metrics have been proposed as clinically relevant in stratifying the risk of onset of outer retinal atrophy. The main goal of this study is to evaluate the impact of noninvasive imaging metrics on the assessment of outer retinal atrophy onset in a large cohort of eyes with neovascular AMD managed in a real-world setting.

METHODS

This study was a prospective, observational, case series. We included patients affected by newly diagnosed neovascular AMD, requiring anti-VEGF intravitreal injections. We collected clinical and imaging data, with a planned follow-up of 24 months. The multimodal imaging protocol included optical coherence tomography, optical coherence tomography angiography, and fundus autofluorescence. We collected noninvasive imaging metrics and we assessed the relationship with the morphological and functional outcome evaluated at 12-month and 24-month time points.

RESULTS

We included 370 eyes of 370 patients with exudative AMD (210 male; mean age 79 ± 8 years). MNV were classified as follows: type 1, 198 (54%); type 2, 89 (24%); polypoidal choroidal vasculopathy, 29 (7%); and type 3, 54 (15%). A total of 120 out of 370 eyes (33%) showed complete outer retinal atrophy at the end of the 2-year follow-up. The presence of intraretinal fluid, thinning of the Sattler choroidal layer, late anti-VEGF switch, the overall number of anti-VEGF injections, and the perfusion characteristics of the MNV were found to be the most relevant factors associated with the onset of outer retinal atrophy. The other collected metrics were found to be less clinically relevant, also showing no cumulative effect in the multivariate analysis (p > 0.05).

CONCLUSIONS

We identified imaging metrics significantly associated with the 2-year risk onset of outer retinal atrophy. These metrics might pave the way for the development of future customized anti-VEGF treatment strategies.

Hyper-reflective vitreous spots in central retinal artery occlusion: An unusual finding in two cases

PURPOSE

To present two consecutive cases of Central Retinal Artery Occlusion (CRAO) with unusual Optical Coherence Tomography (OCT) presentation of Hyperreflective Spots (HRS) in the posterior vitreous.

CASE REPORT

The first patient was a 59 years-old male who developed CRAO in the post-operative period after aortic valve replacement. OCT scans revealed the presence of many HRS in the posterior vitreous, remarkably decreased in number at two months follow-up. The second patient was a 74-year-old male who developed CRAO after arterial chemoembolization for recurrent hepatocellular carcinoma. OCT scans showed again the presence of hyperreflective spots in the posterior vitreous and their reduction at two months follow-up with inner retinal atrophy as the final outcome in both cases.

CONCLUSIONS

HRS in the posterior vitreous have been described in inflammatory eye conditions such as uveitis, diabetic macular edema, post cataract surgery, and considered a clinical sign of inflammation. To our knowledge, the combination of CRAO and HRS has not been previously reported. The number of HRS seems to decrease over time, suggesting a role for inflammatory response in the acute stage of CRAO. A similar pathogenic process is known to occur during cerebral ischemia, where the inflammatory response may exacerbate brain injury and post-ischemic damage.

The Role of Inflammation in Age-Related Macular Degeneration: Updates and Possible Therapeutic Approaches

Age-related macular degeneration (AMD) is a common retinal disease characterized by complex pathogenesis and extremely heterogeneous characteristics. Both in "dry" and "wet" AMD forms, the inflammation has a central role to promote the degenerative process and to stimulate the onset of complications. AMD is characterized by several proinflammatory stimuli, cells and mediators involved, and metabolic pathways. Nowadays, inflammatory biomarkers may be unveiled and analyzed by means of several techniques, including laboratory approaches, histology, immunohistochemistry, and noninvasive multimodal retinal imaging. These methodologies allowed to perform remarkable steps forward for understanding the role of inflammation in AMD pathogenesis, also offering new opportunities to optimize the diagnostic workup of the patients and to develop new treatments. The main goal of the present paper is to provide an updated scenario of the current knowledge regarding the role of inflammation in "dry" and "wet" AMD and to discuss new possible therapeutic strategies.

Quantitative approaches in multimodal fundus imaging: State of the art and future perspectives

When it first appeared, multimodal fundus imaging revolutionized the diagnostic workup and provided extremely useful new insights into the pathogenesis of fundus diseases. The recent addition of quantitative approaches has further expanded the amount of information that can be obtained. In spite of the growing interest in advanced quantitative metrics, the scientific community has not reached a stable consensus on repeatable, standardized quantitative techniques to process and analyze the images. Furthermore, imaging artifacts may considerably affect the processing and interpretation of quantitative data, potentially affecting their reliability. The aim of this survey is to provide a comprehensive summary of the main multimodal imaging techniques, covering their limitations as well as their strengths. We also offer a thorough analysis of current quantitative imaging metrics, looking into their technical features, limitations, and interpretation. In addition, we describe the main imaging artifacts and their potential impact on imaging quality and reliability. The prospect of increasing reliance on artificial intelligence-based analyses suggests there is a need to develop more sophisticated quantitative metrics and to improve imaging technologies, incorporating clear, standardized, post-processing procedures. These measures are becoming urgent if these analyses are to cross the threshold from a research context to real-life clinical practice.