Immunosuppressants and/or antivascular endothelial growth factor inhibitors in punctate inner choroidopathy? Follow-up results with optical coherence tomography angiography

Outcomes in PIC-Related CNV: Pooled Analysis of Individual Participant Data

Choroidal neovascularization (CNV) affects 64-75% of eyes with punctate inner choroidopathy (PIC). Although anti-VEGF agents are considered first-line therapy, there is controversy regarding other modalities, such as immunosuppression. We performed a systematic review of individual participant data (IPD) and generated a dataset of 278 eyes with PIC-related CNV from 45 studies. Forty-two percent presented with moderate visual loss (MVL) or worse. Four different treatment modalities (anti-VEGF, photodynamic therapy, local immunosuppression, and systemic immunosuppression) and most combinations among them were represented. Anti-VEGF injections decreased the likelihood of MVL (Odds Ratio 0.3, p = .027), an effect moderated by presenting visual acuity and patient age. Eyes receiving more than 3 injections were more likely to receive additional therapeutic modalities. Increasing number of modalities was associated with longer follow-up time and did not improve vision. The beneficial effect of anti-VEGF injections persisted when controlling for presenting visual acuity and follow-up time.

PREVALENCE AND CHARACTERISTICS OF MULTIFOCAL CHOROIDITIS/PUNCTATE INNER CHOROIDOPATHY IN PATHOLOGIC MYOPIA EYES WITH PATCHY ATROPHY

PURPOSE

To determine the prevalence and characteristics of multifocal choroiditis/punctate inner choroidopathy (MFC/PIC) in eyes with patchy atrophy because of pathologic myopia.

METHODS

Five hundred eyes of 253 patients with patchy atrophy were examined between 2014 and 2020 at the Advanced Clinical Center for Myopia. The main outcome measures included the prevalence and characteristics of active MFC/PIC lesions diagnosed by optical coherence tomography.

RESULTS

Fifty-five of the 500 eyes (11%) diagnosed with patchy atrophy had optical coherence tomography features of active MFC/PIC lesions, such as focal elevations of the retinal pigment epithelium filled with medium hyperreflectivity material, curvilinear scars (Schlaegel lines), and/or areas of outer retinal atrophy. At the time when the MFC/PIC was diagnosed, the mean age was 57.3 ± 12.0 years, and the mean axial length was 29.2 ± 1.8 mm. Macular neovascularization was found in 45 of eyes (81.8%) with MFC/PIC versus 151 eyes without such findings (33.9%; P < 0.001). In 25 of the 55 eyes (45.5%), active MFC/PIC lesions were found before the development of the patchy atrophy. The Bruch membrane defects were colocated with these lesions.

CONCLUSION

Active MFC/PIC lesions were identified in a minority of eyes with pathologic myopia, and a subset of these lesions were observed to progress to findings indistinguishable from myopic patchy atrophy. Evidence of MFC/PIC in eyes with pathologic myopia appeared to be a risk factor for the development of macular neovascularization.

Optical Coherence Tomography Findings of Underlying Choroidal Neovascularization in Punctate Inner Choroidopathy

Purpose: To analyze findings on optical coherence tomography (OCT) suggestive of choroidal neovascularization (CNV) in lesions of punctate inner choroidopathy (PIC).

Methods: In this multi-center retrospective study, clinical data of patients with PIC were retrospectively analyzed. Quantitative data (height, width, and volume of PIC lesions), and qualitative data (disruption of ellipsoid zone (EZ)/Bruch's membrane (BM), outer retinal fuzziness, and choroidal back-shadowing) were compared between CNV+ and CNV– groups using Mann–Whitney U-test and Fischer's exact test.

Results: In total, 35 eyes (29 patients; 21 women; mean age: 33.3 ± 6.5 years) were selected for analysis. Of the 35 PIC lesions studied, 17 had underlying CNV. Lesions with CNV+ had larger height, width, and volume (p < 0.001) and several distinctive features, such as disruption of EZ and BM, outer retinal fuzziness, and hypo-reflective back-shadowing (p < 0.001) compared with CNV—lesions.

Conclusions: Quantitative and qualitative OCT analysis can aid in the prediction of an underlying CNV in the eyes with PIC.

Classification Criteria for Punctate Inner Choroiditis

PURPOSE

The purpose of this study was to determine classification criteria for punctate inner choroiditis (PIC).

DESIGN

Machine learning of cases with PIC and 8 other posterior uveitides.

METHODS

Cases of posterior uveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on diagnosis by using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used in the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the posterior uveitides. The resulting criteria were evaluated in the validation set.

RESULTS

A total of 1,068 cases of posterior uveitides, including 144 cases of PIC, were evaluated by machine learning. Key criteria for PIC included: 1) "punctate"-appearing choroidal spots <250 µm in diameter; 2) absent to minimal anterior chamber and vitreous inflammation; and 3) involvement of the posterior pole with or without mid-periphery. Overall accuracy for posterior uveitides was 93.9% in the training set and 98.0% (95% confidence interval: 94.3-99.3) in the validation set. The misclassification rates for PIC were 15% in the training set and 9% in the validation set.

CONCLUSIONS

The criteria for PIC had a reasonably low misclassification rate and appeared to perform sufficiently well for use in clinical and translational research.

Structural Endpoints and Outcome Measures in Uveitis

Most uveitis entities are rare diseases but, taken together, are responsible for 5-10% of worldwide visual impairment which largely affects persons of working age. As with many rare diseases, there is a lack of high-level evidence regarding its clinical management, partly due to a dearth of reliable and objective quantitative endpoints for clinical trials. This review provides an overview of available structural outcome measures for uveitis disease activity and damage in an anatomical order from the anterior to the posterior segment of the eye. While there is a multitude of available structural outcome measures, not all might qualify as endpoints for clinical uveitis trials, and thorough testing of applicability is warranted. Furthermore, a consensus on endpoint definition, standardization, and "core outcomes" is required. As stipulated by regulatory agencies, endpoints should be precisely defined, clinically important, internally consistent, reliable, responsive to treatment, and relevant for the respective subtype of uveitis. Out of all modalities used for assessment of the reviewed structural outcome measures, optical coherence tomography, color fundus photography, fundus autofluorescence, and fluorescein/indocyanine green angiography represent current "core modalities" for reliable and objective quantification of uveitis outcome measures, based on their practical availability and the evidence provided so far.

Swept Source-Optical Coherence Tomography Angiography for Management of Secondary Choroidal Neovascularization in Punctate Inner Choroidopathy

The purpose was to demonstrate the diagnostic and therapeutic feasibility of swept source-optical coherence tomography angiography (SS-OCTA) by picturing neovascular changes secondary to a rare white dot syndrome following long-term intravitreal ranibizumab (IVR). A 28-year-old Caucasian myopic female presented with visual loss in her right eye only. The clinical examination and multimodal imaging including spectral domain (SD)-OCT, blue-peak autofluorescence, fluorescein, and indocyanine green angiography (HRA Spectralis, Heidelberg Engineering; Heidelberg, Germany) as well as SS-OCTA (DRI Triton, Topcon; Tokyo, Japan) led to the diagnosis of idiopathic punctate inner choroidopathy with secondary subfoveal choroidal neovascularization (CNV). In addition to oral corticosteroids, a pro re nata regimen with IVR was initiated and guided by repeated SD-OCT and SS-OCTA. Six IVR were administered based on functional SS-OCTA en face scans illustrating vessel transformation and downsizing of the CNV area while SD-OCT B-scans were inconclusive as indirect signs of activity were absent throughout the follow-up period. SS-OCTA provided new possibilities for monitoring vessel development. IVR was managed based on vessel density as displayed by SS-OCTA.

Patchy hyperautofluorescence as a predictive factor for the recurrence of punctate inner choroidopathy

PURPOSE

To investigate baseline clinical and imaging factors that may correlate with risk of recurrence of punctate inner choroidopathy (PIC).

METHODS

In this retrospective observational study, charts and multimodal imaging of forty-five patients diagnosed with PIC during the active inflammatory phase were reviewed. MMI examinations, including fundus photography, shortwave fundus autofluorescence(SW-FAF), fluorescein angiography(FFA), indocyanine green angiography(ICGA), and spectral domain optical coherence tomography(SD-OCT_), were conducted to diagnose PIC, and MMI parameters at baseline were assessed as potential biomarkers indicating the recurrence of inflammation. Statistical analysis was performed to determine the clinical and imaging factors associated with recurrence of PIC.

RESULTS

Among the 45 recruited patients, 18 (40 %) had at least one episode of recurrence during a mean follow-up period of 23.66 ± 12.65 months (range, 12-50 months). Best corrected visual acuity (BCVA) at the final visit during the follow-up was significantly different between the recurrence and nonrecurrence groups. Patchy hyperautofluorescence at baseline appeared in 77.78 % of the patients with recurrence, and the incidence of patchy hyperautofluorescence was significantly different between the patients with recurrence and those without recurrence (P＜0.001).

CONCLUSIONS

Recurrence is not rare among PIC patients and leads to a worse visual acuity outcome. Patchy hyperautofluorescence at baseline is a risk factor for recurrence of PIC. Patchy hyperautofluorescent areas in PIC patients may indicate a need for close follow-up even though PIC-related inflammation regresses.

[White dot syndromes : Principles, diagnostics, and treatment]

The white dot syndromes include a group of diseases which are characterized by multiple yellowish-white foci in the outer retina, retinal pigment epithelium, and choroid. For clinicians and researchers alike they present significant diagnostic and therapeutic challenges. White dot syndromes include primary inflammatory choriocapillaropathies, such as acute posterior multifocal placoid pigment epitheliopathy (APMPPE)/acute multifocal ischemic choriocapillaropathy (AMIC), multiple evanescent white dot syndrome (MEWDS)/acute idiopathic blind spot enlargement (AIBSE), multifocal choroiditis (MFC), punctate inner choroidopathy (PIC), serpiginous choroiditis (SC), acute zonal occult outer retinopathy (AZOOR), and acute macular neuroretinopathy (AMN). Among the primary stromal choroiditis is birdshot retinochoroidopathy (BSRC); however, the pathogenesis of these disorders is largely unknown. Immunological reactions to previous viral infections with a genetic disposition seem to be a common denominator.