Unilateral choroidal excavation in the macula detected by spectral-domain optical coherence tomography

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.

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.

DEVELOPMENT OF FOCAL CHOROIDAL EXCAVATION IN A CASE OF IDIOPATHIC CHOROIDAL NEOVASCULAR MEMBRANE

PURPOSE

The purpose of this study was to demonstrate the evolution of focal choroidal excavation in a 17-year-old girl on treatment for a choroidal neovascular membrane over a 6-year follow-up.

METHODS

Review of medical and imaging records of a 17-year-old girl who presented with a choroidal neovascular membrane in her left eye treated with multiple intravitreal antivascular endothelial growth factor injections over a period of 6 years.

RESULTS

The patient developed recurrent episodes of subretinal hemorrhage that were treated with antivascular endothelial growth factor injections. Over the follow-up period, swept source optical coherence tomography through the lesion revealed progressive reduction in size of the choroidal neovascular membrane complex with the development of acquired focal choroidal excavation.

Primary and secondary focal choroidal excavation morphologic phenotypes, associated ocular disorders and prognostic implications

AIMS

To characterise and classify the morphological, clinical and tomographic characteristics of focal choroidal excavation (FCE) lesions to determine their prognostic implications.

METHODS

36 eyes with FCE (32 patients) underwent multimodal imaging, including spectral domain optical coherence tomography and fundus autofluorescence. FCE lesions were classified into three subtypes: (1) type 1: myopic (central choroidal thickness: <100 µm), (2) type 2: suspected congenital (central choroidal thickness: 100-200 µm, without associated chorioretinal pathology) and (3) type 3: secondary or acquired (central choroidal thickness: >200 µm, with associated chorioretinal pathology).

RESULTS

80.6% of eyes were followed longitudinally (26.8±18.8 months). There were 9 type 1 FCEs (myopic), 8 type 2 FCEs (U-shaped, congenital) and 19 type 3 FCEs (V-shaped, secondary). Type 2 FCEs trended towards larger maximum widths (p=0.0563). Type 3 FCEs were associated with central serous chorioretinopathy or pachyvessels (47.4%), but were also seen in pattern dystrophy, geographic atrophy, inactive choroiditis, torpedo maculopathy and adult-onset vitelliform dystrophy. Choroidal neovascular membranes (CNVMs) were more prevalent in type 3 FCE (41.2% compared with 11.1% for type 1 FCE, p=0.251, and 0% for type 2 FCE, p=0.043).

CONCLUSIONS

The FCE types, stratified by central choroidal thickness, demonstrated distinct morphological characteristics and associated findings. The classification scheme held prognostic implications as type 3 FCE with V shapes were associated with other chorioretinal conditions and were more likely to develop CNVM.

Focal Choroidal Excavation: Epidemiology, Clinical Characteristics and Multimodal Imaging Findings

BACKGROUND

Focal choroidal excavation (FCE) is one of the pachychoroid spectrum diseases. It may be an isolated lesion or associated with other ophthalmological disorders. The aim of the study was to present the epidemiology, clinical features and multimodal imaging findings in FCE.

METHODS

This is a case series of 14 consecutive patients with a diagnosis of FCE, confirmed by multimodal imaging, from a review of the 5076 optical coherence tomography (OCT) scans in 2538 patients. Choroidal thickness (CT) was measured under the fovea and in the area of maximum choroidal thickening in the affected eye and under the fovea in the fellow eye.

RESULTS

The mean age of the subjects was 40 ± 13.58 years. FCE occurred unilaterally and was an isolated lesion in all cases. The fellow eye did not show any macular pathology in all patients. Twelve eyes presented conforming FCEs and two non-conforming FCEs. In 79% of cases, FCE was subfoveal. The mean maximum CT was 390 μm in the affected eye with the presence of pachyvessels. A total of 13 patients were asymptomatic, while one patient reported a visual disturbance due to neovascularization secondary to FCE. Of all the multimodal imaging techniques, optical coherence tomography (OCT) provided the most important data in the diagnosis of FCE.

CONCLUSIONS

Our study confirmed that FCE is a rare ocular condition, but it may be more common in Caucasian population than previously known. Multimodal imaging methods, mainly OCT, are crucial in FCE diagnostics. Further studies are needed to expand the available knowledge about its etiology and clinical course.

[Effects of systemic drugs on the development of drug-induced retinopathy]

This article reviews information on possible adverse events occurring in the organ of vision - in particular, the retina - after using systemic drugs, discusses the drugs that lead to drug-induced retinopathy most often, and describes histomorphological changes and modern understanding of the pathogenesis of damage to retinal structures.

Correlation of features on OCT with visual acuity and Gass lesion type in Best vitelliform macular dystrophy

OBJECTIVE

To correlate structural features seen on optical coherence tomography (OCT) with best-corrected visual acuity (BCVA) and Gass lesion type in patients with Best vitelliform macular dystrophy (BVMD).

METHODS AND ANALYSIS

This is a retrospective case series of consecutive patients with molecularly confirmed BEST1-associated BVMD. OCT scans were reviewed for lesion status and presence of subretinal pillar, focal choroidal excavation (FCE), intraretinal fluid or atrophy. Available OCT angiography images were used to evaluate for the presence of choroidal neovascularisation (CNV). These features were then correlated with BCVA and Gass lesion type.

RESULTS

95 eyes from 48 patients (mean age 38.9 years, range 4-87) were included. The presence of a pillar (24.2%), FCE (20.0%) and atrophy (7.4%) were associated with poor BCVA (p<0.05). Gass lesion type 1 eyes were correlated with good BCVA (LogMAR <0.4) whereas type 5 eyes had poor BCVA (LogMAR >0.4). Among 65 eyes with longitudinal data (mean follow-up 5.1 years), 7 eyes (10.8%) reverted from higher to lower Gass lesion type; of these, 4 eyes (57.1%) had CNV responsive to intravitreal anti-vascular endothelial growth factor treatment.

CONCLUSION

OCT-based structural features are readily identifiable in patients with BVMD and have prognostic importance due to their correlation with BCVA.

Pachychoroid disease spectrum: review article

PURPOSE

The aim of this article is to do a comprehensive literature review about the current understandings of the pachychoroid disease spectrum, describing its multimodal imaging analysis, pathophysiology, differential diagnosis, and current types of management.

METHODS

This comprehensive literature review was performed based on a search on the PubMed database, of relevant pachychoroid published papers according to our current knowledge.

DISCUSSION

The pachychoroid disease spectrum, according to some authors, includes the following: pachychoroid pigment epitheliopathy (PPE), central serous chorioretinopathy (CSC), pachychoroid neovasculopathy (PNV), polypoidal choroidal vasculopathy (PCV)/aneurysmal type 1 neovascularization (AT1), and more recently focal choroidal excavation (FCE) and peripapillary pachychoroid syndrome (PPS). Each one of these entities will be described and discussed in this article.

CONCLUSION

Significant advances in multimodal imaging have enabled a better understanding of the typical choroidal changes in pachychoroid disease spectrum. The clinical knowledge and managing options about this disease significantly increased in the last years. However, it is still unclear why some eyes with typical pachychoroid disease phenotype show no evidence of RPE damage and subretinal fluid (uncomplicated pachychoroid) while others present progressive tissue damage, neovascularization, and atrophy.

CONVERSION OF FOCAL CHOROIDAL EXCAVATION WITH THE ONSET OF CENTRAL SEROUS CHORIORETINOPATHY: REPORT OF 2 CASES AND REVIEW OF THE LITERATURE

PURPOSE

To describe two cases of focal choroidal excavation (FCE) conversion in patients with central serous chorioretinopathy.

METHODS

Case report and literature review of cases of FCE conversion.

RESULTS

A 35-year-old asymptomatic pregnant patient was found to have conforming FCE on spectral domain optical coherence tomography of the right eye during hydroxychloroquine screening. Three months later, she presented with decreased vision in the right eye and subretinal fluid in both eyes secondary to central serous chorioretinopathy. Spectral domain optical coherence tomography revealed that her FCE had changed to nonconforming type. A 40-year-old male patient was found to have nonconforming FCE and subretinal fluid in his right eye on spectral domain optical coherence tomography. On follow-up, spectral domain optical coherence tomography demonstrated resolution of subretinal fluid and conversion of nonconforming FCE to conforming type. Literature review showed that most cases of FCE remain stable over time. Conversion from nonconforming FCE to conforming type has been described after photodynamic therapy or anti-vascular endothelial growth factor therapy. Conversion from conforming to nonconforming type has been described in 2 cases that developed subretinal fluid in the setting of acute central serous chorioretinopathy.

CONCLUSION

Our cases and literature review suggest that nonconforming FCE is the result of persistent subretinal fluid. Further studies are necessary to determine whether symptomatic nonconforming SRF needs treatment to reduce subretinal fluid.

Choroidal Cavitary Disorders

The structure and functions of the choroid have been long acknowledged but the pathophysiology behind various anomalies has been difficult to understand until the advent of optical coherence tomography (OCT). With OCT imaging, choroidal cavitations appear as optically empty spaces between the outer retinal and choroidal layers with attenuation or loss of outer retinal layers. Choroidal cavitations are found in the posterior pole and seen in conditions such as pathologic myopia, north carolina macular dystrophy (NCMD), focal choroidal excavation (FCE), and torpedo maculopathy (TM). To date, these disorders have not been linked. A commonality they all share is malformation of the RPE-photoreceptor-choroid complex. The following report describes the differences and similarities of choroidal cavitation amongst the different retinal disorders and emphasizes the importance of multimodal imaging in the detection and management of potential complications.

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.

Focal Choroidal Excavation in a Case of Choroidal Osteoma Associated with Choroidal Neovascularization

Purpose

To report a case of choroidal osteoma associated with reactivation of choroidal neovascularization (CNV) and development of focal choroidal excavation (FCE).

Case Report

A 34-year-old woman with choroidal osteoma complicated by CNV in the right eye for two years presented with deterioration of visual acuity in her right eye. A small retinal hemorrhage accompanied by subretinal fluid (SRF) was seen in the macular area of the right eye. Optical coherence tomography (OCT) showed that the inner retina was intact, and the outer retinal layers had outward displacement. SRF and a wedge-shaped choroidal depression were also seen. This choroidal excavation was not present on previous OCT images. The integrity of the inner retinal layers was maintained, and an optically clear space was present between the neurosensory retina and the retinal pigment epithelium.

Conclusion

Choroidal osteoma can be complicated by CNV and FCE could occur as a consequence. Again, FCE can lead to CNV development. This cascade can deteriorate vision and sometime lead to permanent visual loss.

Focal choroidal excavation: review of literature

Focal choroidal excavation (FCE) is defined as an area of concavity in choroid detected on optical coherence tomography. These are mostly present in macular region without evidence of accompanying scleral ectasia or posterior staphyloma. Though initially considered to be congenital, increasing number of cases have been identified in association with other choroidal pathologies such as central serous choroidopathy, choroidal neovascularisation, polypoidal choroidal vasculopathy, choroiditis, choroidal tumours. In this review article, we aim to elaborate on the morphology, pathogenesis and differential diagnosis of FCE and specifically discuss the spectrum of diseases with known association along with the impact of their treatment on FCE

Large choroidal excavation in myopic macular degeneration: A case report

PURPOSE

To report the morphological and clinical features of a case of myopic macular degeneration with large choroidal excavation.

METHODS

A myopic patient underwent multimodal imaging, including optical coherence tomography and fluorescein angiography, over a 8-year follow-up.

RESULTS

A choroidal excavation was found in left eye, superior to the fovea. The excavation started as a focal choroidal excavation (FCE) and got deeper and larger during the 8-years-long follow-up, thus resulting in a large choroidal excavation (LCE).

CONCLUSIONS

LCE may be the evolution of FCE in highly myopic eyes, further studies are needed to describe the natural history of choroidal excavations in degenerative myopia.

Bilateral focal choroidal excavations in a patient with Stargardt disease and ocular toxoplasmosis

INTRODUCTION

Focal choroidal excavation (FCE) is a concavity of the choroid detected on optical coherence tomography (OCT). It is usually idiopathic and the affected eyes are otherwise healthy with near-normal overlying retinal architecture and good visual acuity.

PURPOSE

To report a case of bilateral conforming FCE in the setting of Stargardt disease and inactive ocular toxoplasmosis.

CASE REPORT

A 20-year-old man with known history of Stargardt disease, healed toxoplasmosis, and high myopia presented to our ophthalmology department for follow-up examination and was found with bilateral FCEs not present in any of his previous examinations.

CONCLUSION

FCEs have been reported in the literature in otherwise healthy eyes as well as a broad spectrum of ocular diseases. The case herein reported Stargardt disease, toxoplasmosis, and high myopia all could potentially contribute to the pathogenesis of these findings. Further studies are needed to define etiologies as well as clinical significance and course of FCEs.

Tomographic characteristics of focal choroidal excavation and its association with retinal disorders

PURPOSE

To evaluate the morphological, clinical, and tomographic characteristics of focal choroidal excavation in the context of concomitant retinal pathologies.

METHODS

This case series included 13 eyes of 13 patients with focal choroidal excavation diagnosed by spectral-domain optical coherence tomography. Morphologic characteristics of excavation and quantitative thicknesses of retinal layers and choroid were analyzed in excavation area, area adjacent to excavation, and fellow eye without focal choroidal excavation by spectral-domain optical coherence tomography.

RESULTS

At the initial examinations, one eye had a history of blunt trauma, three eyes were diagnosed with choroidal neovascularization, one with choroidal osteoma, one with angioid streaks, one with retinal detachment, one with diabetic macular edema, one with optic pit, one with torpedo maculopathy, and the rest three with idiopathic focal choroidal excavation. The mean choroidal thickness in the area of focal choroidal excavation was statistically significantly thinner compared to in the area adjacent to focal choroidal excavation and fellow eye (p < 0.001) and total average outer nuclear layer thickness was statistically significantly thicker in the area of excavation compared with fellow eye (p = 0.007).

CONCLUSION

This study confirmed the presence of focal choroidal excavation in various ocular diseases and the evaluation of focal choroidal excavation using the spectral-domain optical coherence tomography demonstrated choroidal thinning and outer nuclear layer thickening in the area of the excavation.

Focal Choroidal Excavation and Central Serous Chorioretinopathy Following Choroidal Neovascularization: A Longitudinal Case Study

Purpose:

This report describes the development of focal choroidal excavation (FCE) and recurrent central serous chorioretinopathy (CSCR) following the treatment of choroidal neovascularization (CNV) years earlier.

Methods:

A case report is presented.

Results:

A 30-year-old man previously treated for an active CNV returned several years later with subacute metamorphopsia. Optical coherence tomography and angiography demonstrated no recurrence of the CNV but instead found an FCE and associated CSCR in its place.

Conclusion:

Longitudinal follow-up with multimodal imaging demonstrated FCE with recurrent CSCR as possible sequelae of treated CNV.

Bilateral Multiple Focal Choroidal Excavations in a Patient with Paroxysmal Nocturnal Hemoglobinuria (PNH)

Focal choroidal excavation (FCE) is an unusual configuration characterized by focal thinning and pitting of the choroid in the absence of staphyloma or scleral ectasia. The etiology and clinical implications of FCE are currently unknown. We report a case of bilateral multiple FCEs in a patient with a long history of paroxysmal nocturnal hemoglobinuria (PNH). Focal choriocapillaris thinning and hyperreflectivity of the adjacent outer nuclear layer were revealed by spectral domain optical coherence tomography, which suggests the occlusion of the choriocapillaries and secondary degeneration of the above photoreceptors. We hypothesize that thrombophilia in the condition of PNH played an important role in the formation of FCE. Although there is no histopathological evidence to support the association between the choroid changes and PNH, this case may offer new clues as for the etiology of FCE.

Choroidal neovascularization emerged right from the focal choroidal excavation in eyes with central serous chorioretinopathy post half-dose photodynamic therapy: a case report

BACKGROUND

Focal choroidal excavation (FCE) is a common concurrent disease with central serous chorioretinopathy (CSC) and choroidal neovascularization (CNV). Photodynamic therapy (PDT) was able to cease the course of CSC with efficacy and safety. To retrospectively observed and followed up a special course in eyes with CSC and concurrent FCE treated by a half-dose of PDT.

CASE PRESENTATION

In this case report analysis, two eyes with CSC and concurrent FCE treated with half-dose PDT, were followed up with monthly retinal fundus examinations. Best corrected visual acuity (BCVA) and ophthalmic fundus examination were examined, including fundus photos, optical coherence tomography (OCT) and angiography. In Case 1, a 46-year-old female has been diagnosed as CSC and concurrent FCE. The baseline BCVA was 10/20. After a half-dose of PDT, complete resolution of SRF was achieved at one-month with stable BCVA. At 3 months, the patient complained of obvious metamorphosis. Multimodal images confirmed the existence of CNV, derived from the FCE, inside the zone of PDT irradiation. The development of CNV stopped promptly 1 month post the injection of ranibizumab. In Case 2, a 39 year-old male was diagnosed as bilateral CSC. The BCVA was 8/20 (od), and 16/20 (os). The multimodal images showed classic CSC manifestation in left eye, but atypical manifestation in right eye with subtle SRF and FCE. Post half-dose treatment, the SRF in left eye completely resolved at three-months, and the BCVA improved to 24/20. However, a lesion of CNV grew in the FCE after 1 month in right eye, with decreased BCVA, 4/20. One month post-injection of ranibizumab, obvious regression was witnessed, with improved BCVA, 6/20. The CNV proceeded to be a scar 2 months after injection. The BCVA maintained at 8/20.

CONCLUSIONS

In this study, type II CNV was induced in two cases of CSC concurrent with FCE in 3 months post half-dose PDT. The CNV grew right from the FCE, inside the zone of PDT irradiation.

A CASE OF FULL-THICKNESS MACULAR HOLE IN EYE WITH FOCAL CHOROIDAL EXCAVATION

PURPOSE

To report an association between a Stage 4 full-thickness macular hole and focal choroidal excavation.

METHODS

Case report.

RESULTS

A 46-year-old male patient with high myopia was referred for macular hole surgery and found to have an associated focal choroidal excavation. The patient underwent uneventful combined procedure with closure of macular hole.

CONCLUSION

Successful macular hole surgery can be achieved even in the presence of focal choroidal excavation.

A Case of Focal Choroidal Excavation Development Associated with Multiple Evanescent White Dot Syndrome

Focal choroidal excavation (FCE) is described as an excavated lesion of the choroid that can be detected by optical coherence tomography (OCT). While the exact pathogenesis of FCE remains unclear, it has been proposed in some cases that there is an association with the inflammation in the outer retina. We present a case of FCE development that was detected by spectral domain OCT (SD-OCT) and found to be associated with multiple evanescent white dot syndrome (MEWDS). A 40-year-old Japanese woman was diagnosed with MEWDS based on multiple white dots observed from the posterior pole to the midperiphery, along with yellow granularity in the fovea. SD-OCT revealed separation between the retinal pigment epithelium (RPE) and Bruch's membrane (BM) and discontinuations of the ellipsoid zone, RPE, and BM. At 4 weeks after onset, several of the white dots disappeared, the yellow granularity in the fovea became small, and we detected nonconforming choroidal excavation under the central fovea. The choroidal excavation gradually deepened and changed to a conforming pattern. These findings suggest that the degree of the impairment caused by inflammation and the plasticity of the BM and RPE complex may be associated with different types of acquired FCE.

Multimodal imaging in choroidal osteoma

Purpose

To describe characteristics of choroidal osteomas (CO), using ocular ultrasound, fluorescein angiography, ultra-widefield retinal imaging, ultra-widefield autofluorescence, optical coherence tomography, enhanced-depth-imaging OCT, and OCT angiography (OCT-A).

Methods

Retrospective, observational case series study. Clinical records from patients with diagnosis of CO who underwent complete imaging evaluation were analyzed.

Results

Sixteen eyes from 11 patients were included. Mean patient age was 33.4 years (range 20–61), 72.7% were female, 100% were Hispanic, and 54.5% had unilateral CO. Median visual acuity was 20/150 (range 20/20–2000). CO was completely calcified in 25%, partially decalcified in 50%, and decalcified in 25%. Other features included choroidal neovascularization (18.75%), focal choroidal excavation (12.5%), choroidal depression associated to decalcification (18.75%), thinning of outer retina and photoreceptor layers over decalcified tumor (75%). Decreased fluorescence on FAF was observed in decalcified regions while relatively preserved fluorescence was observed in calcified regions.

Conclusions

Nowadays, diagnostic tests provide important information about each stage of choroidal osteoma. Progressive decalcification of the tumor might have a common pathogenic role for development of FCE or choroidal depression. OCT-A/FA proved to be valuable tools for detection of CNV in patients with CO.

FOCAL CHOROIDAL EXCAVATION AND ITS ASSOCIATION WITH PACHYCHOROID SPECTRUM DISORDERS: A Review of the Literature and Multimodal Imaging Findings

PURPOSE

To review the literature regarding focal choroidal excavation and show its association with pachychoroid features through case examples.

METHODS

The clinical manifestations of focal choroidal excavation are illustrated with various imaging modalities inclusive of fundus photography, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, spectral domain optical coherence tomography (OCT), enhanced depth imaging OCT, and swept-source OCT.

RESULTS

Diffuse or focal areas of choroidal thickening with dilated choroidal vessels (pachyvessels) on OCT and choroidal hyperpermeability on indocyanine green angiography are present in many eyes with focal choroidal excavation. Clinical and imaging features of associated comorbidities including central serous chorioretinopathy and choroidal neovascularization are described.

CONCLUSION

Focal choroidal excavation appears to be a manifestation of pachychoroid spectrum disease associated with choroidal thickening and pachyvessels on structural OCT and choroidal hyperpermeability on indocyanine green angiography.

Focal choroidal excavation-morphological features and clinical correlation

PurposeTo describe and correlate the morphological and clinical features of focal choroidal excavation (FCE).MethodsThis is a consecutive case series from the review of the 4436 optical coherence tomography scans performed by Kowloon East Cluster Ophthalmic Service from 1 August 2014-31 January 2016. Statistical analysis was performed on SPSS 18.0 (SPSS, Chicago, IL, USA). A significance level of P<0.05 was taken.ResultsAll 16 patients with FCE had unilateral involvement. The mean age of diagnosis was 52.56±14.00. The mean greatest linear dimension (GLD) of FCE was 636.25±265.11 μm. The mean choroidal thickness was 183.63±52.39 μm. Fourteen FCEs (87.5%) were conforming and two were non-conforming (12.5%). In the eyes with FCE, concurrent macular pathology was present in four cases (25.0%). Tractional pathologies of macular pucker and macular scar corresponded to the two non-conforming FCEs in the series. Polypoidal choroidal vasculopathy (PCV) and lacquer crack had a close topographic relationship with the FCE. The mean GLD was significantly larger in eyes with concurrent macular pathology than those without (878.00 vs 555.67 μm, P=0.029). In the fellow eyes, concurrent macular pathology was present in 5 cases (31.3%): PCV in 3 cases and chronic central serous chorioretinopathy in 2 cases.ConclusionAs a significant proportion of FCE is associated with concurrent macular pathology in the involved or fellow eye, angiography for both eyes is recommended even for asymptomatic cases. The GLD of FCE may have clinical value in risk stratification.

Focal Choroidal Excavation in Retinal Dystrophies

AIM

To investigate the presence of focal choroidal excavation (FCE) in patients with retinitis pigmentosa (RP), Stargardt's disease (STGD), and Best disease in the Indian population.

METHODS

This retrospective consecutive case series included 309 eyes of 157 patients with RP (183 eyes), STGD (93 eyes), and Best disease (33 eyes) with good-quality, enhanced-depth spectral domain optical coherence tomography scans. Comprehensive ophthalmic examination data were collected. Characteristics of FCE, including location of FCE, type (conforming and non-conforming), maximal width, and depth, were noted.

RESULTS

FCE was found in 2 out of 33 (6%) eyes with Best disease and no FCE was found in eyes with RP or STGD. The location of the FCE was extrafoveal in both cases. The first case had non-conforming FCE while the second case had the conforming type and the FCE occurred in association with choroidal neovascularization in the second case. The first case maintained good visual acuity of 20/20 over the entire period of follow-up (14 months), while the second case had a visual acuity of 20/200 at the last follow-up (three years) due to scarred choroidal neovascular membranes. The FCE showed no change in both eyes over the entire duration of follow-up.

CONCLUSION

Focal choroidal excavation was found in 6% of eyes with Best disease, which remained stable throughout follow up. Eyes with RP and STGD did not have any FCE. Further studies are required to determine the role of vitelliform material in FCE development in Best disease.

Multimodal Imaging Evaluations of Focal Choroidal Excavations in Eyes with Central Serous Chorioretinopathy

Purpose. To investigate the prevalence and characteristics of focal choroidal excavation (FCE) concurrent with central serous chorioretinopathy (CSC) using multimodal imaging. Methods. This was a retrospective single-institution study. Clinical features and multimodal imaging findings were analyzed in eyes with CSC and FCEs, using imaging methods including optical coherence tomography (OCT), OCT angiography (OCTA), fluorescein angiography (FA), indocyanine green angiography (ICGA), fundus autofluorescence (FAF), and multispectral imaging. Results. Seventeen patients (4.8%) with 21 FCEs (19 eyes) were found among 351 consecutive Chinese patients with CSC. Chronic CSC represented 47.1% of those cases. Window defects in 12 lesions identified through FA and hypoautofluorescence in 13 lesions identified through FAF revealed retinal pigment epithelial attenuation. Choroidal hemodynamic disturbances characterized by localized filling defects at the excavation and circumferential hyperperfusion were validated by both ICGA and OCTA, which were similar to the angiographic features of normal chronic CSC. The hyperreflective tissue beneath FCE, observed on B-scan OCT, presented as intensive choroidal flow signals on OCTA. Conclusions. FCE is not uncommon in patients with CSC. Multimodal imaging suggested that the aberrant choroidal circulation might be a contribution factor for leakage from the dysfunctional retinal pigment epithelium at the area of excavation.

Prevalence and clinical correlates of focal choroidal excavation in eyes with age-related macular degeneration, polypoidal choroidal vasculopathy and central serous chorioretinopathy

PURPOSE

To describe the prevalence and clinical characteristics of focal choroidal excavation (FCE) in patients with exudative maculopathy due to age-related macular degeneration with choroidal neovascularisation (AMD-CNV), polypoidal choroidal vasculopathy (PCV) and central serous chorioretinopathy (CSC).

METHODS

Three hundred and forty-three patients (343 presenting eyes and 255 fellow unaffected eyes) from consecutive patients presenting with untreated AMD-CNV, PCV or CSC are prospectively recruited. Two independent retinal specialists masked to the clinical diagnosis graded the presence of FCE by examining the findings from spectral-domain optical coherence tomography (SD-OCT). The frequency and clinical characteristics of FCE in each of the three clinical diagnosis groups were compared.

RESULTS

The diagnosis in the presenting eye was AMD-CNV in 92 patients, PCV in 149 patients, retinal angiomatous proliferation (RAP) in 3 patients and CSC in 99 patients; 255 fellow eyes free of clinical diseases were also graded. The prevalence of FCE was 2.3% (total 14 eyes; 10 presenting eyes, 4 fellow eyes) out of 598 eyes examined. In presenting eyes, FCE was most prevalent in PCV (6.0%), followed by AMD-CNV (1.0%) and CSC (0%), p=0.02. In fellow eyes, the prevalence of FCE was 2.9%, 0% and 1.2% in patients with PCV, AMD-CNV and CSC, respectively. Eyes with FCE had a significantly longer axial length (24.93±1.65 mm vs 23.49±1.10 mm, p<0.001), but otherwise, all other characteristics were similar.

CONCLUSIONS

FCE is more common in PCV than AMD-CNV and CSC. Disturbance in the choroid/retinal pigment epithelium/Bruch membrane interface affected by FCE may be linked to the pathogenesis of PCV and AMD-CNV.

Various SD-OCT features of focal choroidal excavations

PURPOSE

To describe the clinical and spectral domain optical coherence tomography (OCT) features of two cases of focal choroidal excavation (FCE) and to review relevant literature to increase awareness and understanding of this rare condition.

CASE REPORT

Spectral domain OCT, enhanced depth imaging, and fundus autofluorescence (short wavelength and near infrared) were used to study two cases of FCE. Both patients were asymptomatic and maintained good vision at 6 months follow-up despite one case showing progression from a conforming- to a nonconforming-type FCE. At both lesion sites, the sclerochoroidal junction was unaltered, and the overlying retinal layers (retinal nerve fiber layer to outer plexiform layer) also remained intact. Enhanced depth imaging revealed an absence or compression of outer choroidal layers beneath the excavation and the presence of abnormally large choroidal vessels adjacent to the excavation. The near-infrared autofluorescence showed improved ability to highlight the FCE lesion compared with traditional short-wavelength autofluorescence.

CONCLUSIONS

Focal choroidal excavation is a rare, often asymptomatic macular condition. It appears on funduscopic examination as retinal pigment epithelial abnormalities, but its true structure is revealed with OCT. Certain spectral domain OCT imaging modalities, such as enhanced depth imaging and short and near-infrared autofluorescence, are helpful to monitor these lesions and to better understand its pathophysiology as it relates to choroidal vascular abnormalities.

Focal choroidal excavation: a preliminary interpretation based on clinic and review

AIM

To describe the clinical and imaging characteristics associated with focal choroidal excavation (FCE), analyze the possible complication, and interpret its probable etiopathogenesis.

METHODS

Retrospective descriptive case series of 37 eyes of 32 patients with FCE. Findings of spectral-domain optical coherence tomography (SD-OCT), fluorescein angiography, indocyanine green angiography, and clinical features were analyzed.

RESULTS

All patients were Chinese. Five patients (15.6%) were bilaterally involved. Patients' ages ranged from 7 to 66y. Refractive error ranged between +2.0 D and -11.0 D. Mean best-corrected visual acuity was 0.6 (range, 0.1 to 1.2). Fundus examinations exhibited mild-moderate localized pigmentary disturbances in the corresponding area of 17 eyes. Fluorescein angiography performed in 18 patients showed varying degrees of hyperfluorescence and hypofluorescence related to a range of retinal pigment epithelium (RPE) alterations. Indocyanine green angiography performed in 7 patients showed hypofluorescence at the excavation. SD-OCT demonstrated choroidal excavation in all 37 eyes. Twenty-nine eyes showed a single lesion of FCE, and three eyes showed 2-3 separated lesions. Fifteen eyes showed separation between the photoreceptor tips and RPE consistent with nonconforming FCE. Central serous chorioretinopathy (CSC, n=1) and choroidal neovascularization (CNV, n=1) developed during follow-up.

CONCLUSION

FCE could be interpreted as congenital focal choroidal dysplasia involving the RPE, choriocapillaris, and photoreceptor associated with the faulty anatomy. The abnormal anatomy of FCE was similar to anatomy at risk of CSC and CNV.

Focal Choroidal Excavation in Best Vitelliform Macular Dystrophy: Case Report

Focal choroidal excavation (FCE) was first reported as a choroidal posteriorly excavated zone without any scleral change. Choroidal excavation also divided into conforming and nonconforming type. Numerous reports demonstrated association between FCE and other disease such as choroidal neovascularization and central serous choroidoretinopathy. Here, we report a rare case of FCE in a patient with Best disease. The patient was diagnosed by spectoral domain optical coherence tomography (SD-OCT). To the best of our knowledge, our patient is the second report of choroidal excavation in Best vitelliform macular dystrophy.

Focal choroidal excavation in patients with central serous chorioretinopathy

PURPOSE

To evaluate the prevalence and clinical features of focal choroidal excavation (FCE) in patients presenting with central serous chorioretinopathy (CSC).

METHODS

This is a retrospective consecutive case series of consecutive patients with CSC who were referred for spectral domain optical coherence tomography (SD-OCT) between January 2010 and December 2011. Medical records were reviewed and clinical features including presence of FCE in SD-OCT, fluorescence angiography (FA), and indocyanine green angiography (ICGA) were studied.

RESULTS

Among the 116 CSC patients assessed, FCE was found in 11 eyes of 7 (6.0%) patients. FCE was associated with subretinal fluid in six eyes of six patients and serous pigment epithelial detachment in three eyes of two patients. The mean central subfield retinal thickness of CSC eyes with FCE was 283.7 μm, compared with 377.5 μm for CSC eyes without FCE (Mann-Whitney U-test, P=0.020). Five FCE eyes of five patients had focal leakage on FA. Choroidal hyperpermeability on ICGA was found in seven CSC eyes with FCE, with four eyes showing hypofluorescent spot corresponding to the FCE. After a mean follow-up of 16 months, visual acuity of all 11 eyes with FCE remained stable or improved at the last follow-up.

CONCLUSION

FCE is not an uncommon feature in patients with CSC and might be associated with choroidal hemodynamic disturbances.

A case of a vitreomacular traction-associated macular microhole in an eye with focal choroidal excavation

PURPOSE

It was the aim of this study to report a case of a vitreomacular traction-associated macular microhole (MMH) in an eye with focal choroidal excavation (FCE) detected by spectral-domain optical coherence tomography (SD-OCT).

PATIENTS AND METHODS

A 38-year-old Japanese female presented to our clinic complaining of metamorphopsia in her left eye. The patient then underwent SD-OCT as well as a routine ophthalmological examination. She had a previous history of a macular hole in her right eye that had been successfully treated by pars plana vitrectomy.

RESULTS

Upon initial examination, her best-corrected visual acuity was 20/25 in the left eye with a refractive error of -10.25 diopters. Examination by SD-OCT revealed an MMH with an outer retinal defect adjacent to the FCE. SD-OCT also revealed an intraretinal cystoid space in the macula with vitreous attachment around the foveal center.

CONCLUSIONS

The findings of this report show that variable changes are likely to be associated with FCE. However, the etiology of FCE has yet to be fully elucidated and careful observation is necessary in cases of FCE.

Population-based age group specific annual incidence rates of symptomatic age-related macular degeneration

Purpose

To study the population-based annual incidence rates of exudative, dry and all cases of symptomatic age-related macular degeneration (AMD) in different age and sex groups.

Methods.

This is a one year, prospective, population-based study on all consecutive new patients with AMD in the hospital district of Central Finland. The diagnosis was confirmed in all patients with slit lamp biomicroscopy, optical coherence tomography (OCT) using a Spectralis HRA + OCT device, and the Heidelberg Eye Explorer 1.6.2.0 program. Fluorescein angiograms were taken when needed.

Results.

The population-based annual incidence rates of all cases of symptomatic AMD increased from 0.03% (95% CI, 0.01-0.05%) in the age group 50-59 years to 0.82% (95% CI, 0.55-1.09%) in the age group 85-89 years and were 0.2% (95% CI, 0.17-0.24%) in exudative, 0.11% (95% CI, 0.09-0.14%) in dry, and 0.32% (95% CI, 0.28-0.36%) in all cases of AMD in the age group 60 years and older. During the next 20 years in Central Finland the population-based annual incidence rates can be estimated to increase to 0.27% (95% CI, 0.24-0.30%) in exudative, to 0.13% (95% CI, 0.11-0.15%) in dry, and to 0.41% (95% CI, 0.37-0.45%) in all cases of AMD in the age group 60 years and older. The population-based annual incidence of AMD did not show statistically significant differences between males and females (p>0.1).

Conclusion:

The population-based age-group specific annual incidence rates of symptomatic AMD of this study may help to plan health care provision for patients of AMD.

Clinical course of focal choroidal excavation in Vogt-Koyanagi-Harada disease

We describe focal choroidal excavation (FCE) in a case of Vogt–Koyanagi–Harada (VKH) disease and compare the findings with different chorioretinal conditions. A 55-year-old man was diagnosed with VKH based on panuveitis and exudative retinal detachments. Spectral-domain optical coherence tomography demonstrated a dome-shaped protrusion with a nonconforming pattern at the fovea, which had been detected as a conforming pattern 1 year before the onset. The FCE pattern returned into a conforming pattern following corticosteroid therapy. These findings suggest that the natively existent FCE could be affected by pathophysiological changes of VKH as well as other chorioretinal conditions.

Choroidal excavation in vogt-koyanagi-harada disease

Purpose

To report a case of choroidal excavation accompanied by Vogt-Koyanagi-Harada disease (VKH).

Methods

A 54-year-old Japanese woman who was complaining of bilateral blurring of vision associated with headache underwent optical coherence tomography (OCT), fluorescein angiography, and indocyanine green angiography as well as a routine ophthalmological examination.

Results

Fundoscopy showed papilloedema and serous retinal detachment in both eyes. Fluorescein angiography detected bilateral multifocal leakage with pooling of dye in the subretinal space. Indocyanine green angiography showed patches of hyperfluorescence and hypofluorescent spots bilaterally. A diagnosis of VKH was reached soon afterwards. OCT of the left eye revealed the presence of a unilateral choroidal excavation under the fovea and subretinal fibrin over the site of the excavation. Treatment successfully resolved VKH symptoms with gradual resolution of subretinal fibrin and fluid; however, the choroidal excavation remained.

Conclusions

This case is the first report of choroidal excavation associated with VKH. Our results suggest that choroidal excavation can be induced by choroidal inflammation caused by VKH.

Evaluation of focal choroidal excavation in the macula using swept-source optical coherence tomography

PURPOSE

To evaluate imaging findings of patients with focal choroidal excavation (FCE) in the macula using swept-source optical coherence tomography (SS-OCT) and correlate it clinically.

METHODS

Prospective observational case series. Eleven consecutive patients (12 eyes) with FCE were described. Data on demographics and clinical presentation were collected and imaging findings (including color photography, fundus autofluorescence imaging, fluorescein angiography, indocyanine green angiography, spectral-domain optical coherence tomography, and SS-OCT) were analyzed.

RESULTS

The primary diagnosis was epiretinal membrane (two eyes), choroidal neovascularization (one eye), polypoidal choroidal vasculopathy (three eyes), central serous chorioretinopathy (one eye), and dry age-related macular degeneration (two eyes). Eleven out of 12 of the lesions were conforming. One presented with a non-conforming lesion that progressed to a conforming lesion. One eye had multiFCE and two had two overlapping choroidal excavations. Using the SS-OCT, we found the choroid to be thinned out at the area of FCE but sclera remained normal. The choroidal tissue beneath the FCE was abnormal, with high internal reflectivity and poor visualization of choroidal vessels. There was loss of contour of the outer choroidal boundary that appeared to be pulled inward by this abnormal choroidal tissue. A suprachoroidal space was noted beneath this choroidal tissue and the choroidal-scleral interface was smooth. Repeat SS-OCT 6 months after presentation showed the area of excavation to be stable in size.

CONCLUSION

FCE can be associated with epiretinal membrane, central serous chorioretinopathy, and age-related macular degeneration. The choroid was thinned out in the area of FCE.

Choroidal Excavation in Eye with Normal Tension Glaucoma

Purpose

To report the case of an eye with normal tension glaucoma and a choroidal excavation.

Methods

This is an observational case report.

Results

A 59-year-old woman with normal tension glaucoma had a choroidal excavation in the left eye. Her best-corrected visual acuity and intraocular pressure were within normal limits and had been stable for 5 years. Fundus examination showed a small white lesion inferior to the macula and a nerve fiber layer defect at the inferior edge of the optic disc. Humphrey Field Analyzer (HFA) showed visual field defects corresponding to the nerve fiber layer defect with C30-2, and a central scotoma superior to the macula with C10-2. Optical coherence tomography (OCT) showed a 150-µm deep choroidal excavation. Disruptions of the IS/OS line were detected only in the area inferior to the choroidal excavation. During the 5 months of follow-up, her best-corrected visual acuity remained at 1.0 and the IOP ranged from 12 to 14 mm Hg in the left eye. The fundus and OCT images did not deteriorate and the choroidal excavation did not enlarge.

Conclusions

The disruption of the inner/outer segment (IS/OS) line was detected only at the area surrounding the choroidal excavation. OCT examinations are useful in assessing the area of the residual IS/OS line, and HFA can be used to estimate the residual central visual field.

Clinical and optic coherence tomography findings of focal choroidal excavation in Chinese patients

Background

To describe the clinical and optical coherence tomography (OCT) features of focal choroidal excavation in Chinese patients.

Methods

Retrospectively, thirty-seven eyes (in 31 patients) that demonstrated focal choroidal excavation on spectral-domain OCT were collected. Their clinical characteristics and other features were also collected and analyzed.

Results

In total, 42 focal choroidal excavations were identified in 31 patients, including 25 unilateral and 6 bilateral (37 eyes). The abnormal changes in these eyes with choroidal excavation were more prominent at the outer part of the neuro-retina, the retinal pigment epithelium (RPE) and the choroid. The average transverse diameter and depth of the excavations were 670.8 μm and 106.9 μm, respectively. In addition to the conforming and nonconforming types, the excavations could also be classified into 2 types according to their shape: type 1 – small with a sharp, cut-down contour; and type 2 – slightly larger with a gradual edge. The transverse diameter/depth ratio of the two types were significantly different (type1: 4.57 ± 1.65, type 2: 10.0 ± 5.2; p = 0.000). Four central serous chorioretinopathy (CSCR) cases were confirmed by fluorescein angiography; in these cases, the retinal detachment was larger than the area of excavation, and the inner segment/outer segment (IS/OS) and external limiting membrane (ELM) were above those of the normal part. Concomitant CNV was also found in another 2 cases.

Conclusions

Focal choroidal excavation was not uncommon in Chinese patients. The choroid and the RPE at the excavation were impaired or vulnerable to other damage. Additionally, OCT might be useful in the differentiation between nonconforming excavations and ones with CSCR.