Placoid lesions of the retina: progress in multimodal imaging and clinical perspective

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.

Fractal Changes of the Retinal Microvasculature in Syphilitic Uveitis

PURPOSE

To quantify chorioretinal microvascular damage and recovery post-treatment in patients with acute syphilitic posterior placoid chorioretinitis (ASPPC) using fractal dimension (FD).

METHODS

Retrospective cohort study of patients with serologically confirmed syphilitic uveitis. We obtained optical coherence tomography angiography (OCTA) scans at baseline and follow-up after intravenous penicillin treatment and computed FD of the superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillaris (CC) using ImageJ.

RESULTS

We enrolled seven patients with ASPPC (11 eyes), and 17 control subjects (34 eyes). Pre-treatment averages of FD-SCP, FD-DCP, and FD-CC were: 1.672 (±0.115), 1.638 (±0.097), and 1.72 (±0.137); post-treatment: 1.760 (±0.071), 1.764 (±0.043), and 1.898 (±0.047). After treatment FD-CC increased in all 11 eyes with an average of 0.163 (p = 0.003); FD-DCP increased in 10 (91%) eyes with an average of 0.126 (p = 0.003); and FD-SCP increased in seven (64%) eyes with an average of 0.089 (p = 0.059). Compared to the post-treatment FD values in the syphilitic group, controls had similar FD-SCP (p = 0.266), FD-DCP (p = 0.078), and FD-CC (p = 0.449).

CONCLUSIONS

CC and DCP are mostly affected in ASPPC with minimal changes in the SCP. All vascular layers FD recovered after completing antibiotic treatment.

Tubercular Serpiginous-Like Choroiditis in Patients with Negative TB-Immunoreactivity Tests

BACKGROUND

Serpiginous-like choroiditis (SLC) denotes ocular tuberculosis (TB), in the presence of positive tuberculin skin test (TST) or interferon gamma release assay (IGRA).

METHODS

Retrospective review of SLC patients from a TB-endemic country, with negative TST and IGRA tests, but responsive to anti-TB therapy.

RESULTS

Fifteen patients (13 bilateral) with active SLC  were included.   Eleven (73.3%) patients had received corticosteroids ± immunosuppressive therapy prior to presentation. Chest radiographic abnormalities were found in four (26.7%) patients. We treated all patients with a combination of anti-TB therapy (ATT) and corticosteroids. Paradoxical worsening was noted in nine (60%) patients, complete resolution of lesions in 12 (80%), persistent inflammation (post-ATT) in one, while two were yet to complete ATT. None had recurrence after complete resolution of lesions (median follow-up of 71 weeks [range 15-676 weeks]).

CONCLUSIONS

TB-SLC may present with negative TST and IGRA tests but may still have clinical appearance, and treatment response, like test-positive disease.

Acute and Chronic Manifestations of Sympathetic Ophthalmia on Multimodal Imaging

PURPOSE

To report the clinical and multimodal imaging features of sympathetic ophthalmia in the acute and chronic phases.

METHODS

Retrospective cohort study of consecutive patients with sympathetic ophthalmia seen at a tertiary referral center. Charts, imaging studies, and histopathological specimens were reviewed. The clinical features and multimodal imaging in the sympathizing eye were analyzed by sorting features into those seen in the acute and chronic phase.

RESULTS

Ten patients were included in the analysis and all of them had previous ocular trauma or complicated retinal detachment. In the acute phase, 70% had anterior uveitis, 70% had vitritis, and 100% had active posterior uveitis; posterior uveitis included multifocal choroiditis (80%), optic disc swelling (40%), multiple serous retinal detachments (20%), MEWDS-like findings (10%), and retinal vasculitis with chorioretinitis (10%). In the chronic phase, posterior manifestations included widespread patches of chorioretinal atrophy in the mid- and far-periphery (80%), peripapillary subretinal fibrosis (50%), and nummular perivascular atrophy (50%).

CONCLUSIONS

Sympathetic ophthalmia shows different posterior segment manifestations in the acute and chronic phase. Active sympathetic ophthalmia should be ruled out in eyes with a MEWDS-like presentation or rapidly progressing chorioretinitis, and history of trauma in the fellow eye. Peripapillary subretinal fibrosis and perivascular nummular atrophy may be useful features to suspect SO once acute inflammation has resolved.

THE PROGNOSTIC SIGNIFICANCE OF ACUTE HENLE FIBER LAYER HYPERREFLECTIVITY IN PLACOID DISEASES

PURPOSE

To investigate the pathophysiology and prognostic significance of acute Henle fiber layer (HFL) hyperreflectivity in placoid diseases by examining its relationship with impaired choroidal flow and persistent photoreceptor disruption.

METHODS

Retrospective-prospective observational study on patients with placoid diseases. Indocyanine green angiography and optical coherence tomography were performed during the acute phase and follow-up. Impaired choroidal flow, HFL hyperreflectivity, and persistent ellipsoid zone disruption, their colocalization index, and their associations with initial and final visual acuity were explored.

RESULTS

Sixteen eyes from eight patients (mean age, 25.3 ± 6.44 years) were included (median follow-up, 13.5 months). Quantitative analysis revealed significant correlations between areas of impaired choroidal flow, HFL hyperreflectivity, and persistent ellipsoid zone disruption (correlation coefficients of 0.69, 0.63, and 0.46, respectively). Impaired choroidal flow area exceeded HFL hyperreflectivity (P = 0.002) and ellipsoid zone disruption (P = 0.003). A noteworthy 94% nonrandom overlap between HFL hyperreflectivity and ellipsoid zone disruption was observed. Worse initial visual acuity correlated with foveal involvement (P = 0.0002), thicker choroid (P = 0.001), larger impaired choroidal flow areas (P = 0.02), and thinner outer retina post lesion inactivation (P = 0.04).

CONCLUSION

Henle fiber layer hyperreflectivity predicted photoreceptor recovery potential in placoid diseases. If HFL hyperreflectivity corresponds to acute HFL damage, it may suggest more severe involvement of the entire photoreceptor length.

Clinical Characteristics and Visual Outcomes of Acute Syphilitic Posterior Placoid Chorioretinopathy

PURPOSE

To evaluate presenting features and visual outcomes in eyes with acute syphilitic posterior placoid chorioretinopathy (ASPPC).

DESIGN

Retrospective cohort study.

SUBJECTS

A total of 24 eyes of 17 adult patients with ASPPC.

METHODS

Chart review of patients with ASPPC who presented to the University of Michigan W. K. Kellogg Eye Center between January 1, 2012, and November 4, 2022. Demographic and clinical information, fundus photographs, fundus autofluorescence, and spectral-domain-OCT (SD-OCT) findings were reviewed.

MAIN OUTCOME MEASURES

Clinical characteristics and visual acuity (VA) on presentation and follow-up examination.

RESULTS

The median age was 46 (interquartile range [IQR], 38-51) years. At presentation, 20 (83.3%) eyes had subjectively decreased vision, with a median initial VA of 0.54 (IQR, 0.35-1.00) logarithm of the minimum angle of resolution (logMAR); at 45 days, median logMAR VA was 0.096 (IQR, 0.02-0.17). Initial VA was positively associated with posterior pole-sparing lesions (coefficient estimate [CE], -0.75; 95% confidence interval [CI], -1.38 to -0.12); P = 0.03), and negatively associated with ellipsoid zone (EZ) disruption (CE, 0.72; 95% CI, 0.03-1.42; P = 0.04), subfoveal EZ disruption (CE, 0.62; 95% CI, 0.02-1.23; P = 0.046), and initial hyperreflective foci on SD-OCT (CE, 0.66; 95% CI, 0.09-1.23; P = 0.03). Female eyes were more likely (hazard ratio [HR], 3.36; 95% CI, 1.07-10.6; P = 0.04), and eyes with optic nerve abnormality were less likely (HR, 0.34; 95% CI, 0.12-0.96; P = 0.04), to achieve a VA ≥ 20/40 (logMAR, 0.30).

CONCLUSIONS

This study of patients with ASPPC showed that symptomatic eyes had an improvement from a median VA of 20/69 on presentation to a median VA of 20/25 at 45 days. Female sex and absence of optic nerve involvement were associated with higher probability of achieving ≥ 20/40. These findings provide refined guidance for counseling patients who present with decreased vision due to ASPPC.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Latest advances in white spot syndromes: New findings and interpretations

White spot syndromes (WSS) pose challenges in the field of ophthalmology, particularly in terms of accurate diagnosis and effective management. However, recent advancements in multimodal imaging (MMI) have significantly contributed to our understanding of WSS, allowing for improved characterization of these inflammatory chorioretinopathies. By employing various imaging modalities, including fundus fluorescein angiography, indocyanine green angiography, fundus autofluorescence, optical coherence tomography (OCT), ultra-widefield imaging, and OCT angiography, researchers and clinicians have gained valuable insights into the underlying pathophysiological changes and clinical progression of WSS. Furthermore, MMI has unveiled novel and atypical variants within the spectrum of WSS, expanding our knowledge in this field. Notably, the identification of secondary forms of WSS occurring concurrently with unrelated chorioretinal disorders has suggested a potential autoimmune mechanism underlying these conditions. The introduction of MMI has also facilitated a more comprehensive evaluation of previously ill-defined entities, such as acute zonal occult outer retinopathy, leading to improved diagnostic criteria and enhanced recognition of distinct features. This review paper provides a comprehensive overview of the latest advances and interpretations in WSS. By integrating MMI into the diagnosis and management of these conditions, this review aims to enhance patient outcomes and provide valuable insights into the complexities surrounding WSS.

Acute-Onset Retinal Conditions Mimicking Acute Optic Neuritis: Overview and Differential Diagnosis

Acute optic neuritis (AON) is a common cause of sudden visual loss in young patients. Because of the risk of demyelinating disease, patients affected by unilateral or bilateral optic neuritis should be evaluated and treated accordingly. Despite advancements in imaging of the brain and retina, misdiagnosis of AON is not uncommon. Indeed, some acute disorders of the retina have the potential to mimic AON and their prompt diagnosis may avoid unnecessary neurologic investigation, psychological stress to the patient, and delays in treatment. This review describes uncommon retinal disorders presenting with sudden-onset visual loss and absent or subtle funduscopic manifestation that can mimic AON. Multimodal retinal imaging is essential in detecting these conditions and in their differential diagnosis. It behooves neurologists and general ophthalmologists to be aware of these entities and be familiar with multimodal imaging of the retina.

THE CHRYSANTHEMUM PHENOTYPE OF IDIOPATHIC MULTIFOCAL CHOROIDITIS

PURPOSE

To describe the clinical characteristics and multimodal imaging features of a distinctive subtype of active idiopathic multifocal choroiditis (iMFC) lesions with grey-yellow chorioretinal lesions surrounded by smaller satellite dots, a presentation referred to as "chrysanthemum lesions."

METHODS

Retrospective, observational, multicenter case series of eyes with active iMFC and chrysanthemum lesions. Multimodal imaging features were reviewed and presented.

RESULTS

Twenty-five eyes from 20 patients (12 women and 8 men), with a mean age of 35.8 ± 17.0 years (range, 7-78 years) were included. Chrysanthemum lesions were equally located in the macula (48.0%) or the mid/far periphery (52.0%). The number of lesions per eye varied from 1 (16.0%) to more than 20 (56.0%). On optical coherence tomography, chrysanthemum lesions showed typical features of iMFC, including subretinal hyperreflective material splitting the retinal pigment epithelium/Bruch membrane. Chrysanthemum lesions were hypoautofluorescent on fundus autofluorescence imaging, hyperfluorescent on fluorescein angiography, hypofluorescent on indocyanine green angiography, and associated with choriocapillaris flow signal deficit on optical coherence tomography angiography.

CONCLUSION

Active iMFC may present with findings resembling chrysanthemum lesions. The distinctive lesion morphology on ophthalmoscopic examination, the large number of lesions, and the high prevalence of exclusive midperipheral and far peripheral involvement may represent a distinctive phenotype of iMFC.

Stepwise approach for fundus imaging in the diagnosis and management of posterior uveitis

An array of retinochoroid imaging modalities aid in comprehensive evaluation of the immunopathological changes in the retina and choroid, forming the core component for the diagnosis and management of inflammatory disorders such as uveitis. The recent technological breakthroughs have led to the development of imaging platforms that can evaluate the layers of retina and choroid and the structural and functional alteration in these tissues. Ophthalmologists heavily rely on imaging modalities such as dye-based angiographies (fluorescein angiography and indocyanine green angiography), optical coherence tomography, fundus autofluorescence, as well as dye-less angiography such as optical coherence tomography angiograph,y for establishing a precise diagnosis and understanding the pathophysiology of the diseases. Furthermore, these tools are now being deployed with a 'multimodal' approach for swift and accurate diagnosis. In this comprehensive review, we outline the imaging platforms used for evaluation of posterior uveitis and discuss the organized, algorithmic approach for the assessment of the disorders. Additionally, we provide an insight into disease-specific characteristic pathological changes and the established strategies to rule out disorders with overlapping features on imaging.

Long-Term Bilateral Poorly Treated Acute Syphilitic Posterior Placoid Chorioretinitis Complicated with Choroidal Neovascularization: A Case Report

Purpose

To describe a case of long-term poorly treated bilateral acute syphilitic posterior placoid chorioretinitis (ASPPC) complicated with choroidal neovascularization, with a multimodal imaging approach.

Patients and Methods

Retrospective case report. Analysis of patient’s clinical data.

Case Report

A healthy 66-year-old man complained of decreased visual acuity in the right eye (RE). He had a past history of bilateral exudative maculopathy of unknown etiology, lasting for more than 10 years and leading to severe and irreversible vision loss on the left eye. The corrected distance visual acuity (CDVA) was 20/63 on the RE and <20/400 on the left eye (LE). On slit-lamp, no anterior chamber reaction was observed, a vitreous haze was present on the RE as well as large, bilateral yellowish lesions in the macula, with exuberant macular atrophy, particularly on the LE. These well-defined lesions were confined to the posterior pole. The spectral domain optical coherence tomography (SD-OCT) showed a flat retinal pigmented epithelium (RPE) detachment with hyperreflective material beneath the RPE and cystoid macular edema on the RE and an exuberant macular atrophy on the LE, with both eyes showing anomalous enlargement of choroidal vessels. The fluorescein angiography showed general hypofluorescence and indocyanine green angiography revealed a heterogeneous pattern. The OCT angiography (OCTA) of the RE demonstrated an anomalous vascular network related to the presence of choroidal neovascularization (CNV). An etiological study was performed and a positive treponemal test (TPHA) was found. The patient experienced visual acuity improvement to 20/25 after systemic treatment with Penicillin and anti-VEGF injections.

Conclusion

Clinical data and multimodal imaging information suggest that this case represents a complication of long-term untreated bilateral acute syphilitic posterior placoid chorioretinitis (ASPPC) with associated choroidal neovascularization. Once the RE presented signs of active disease, besides intravitreal anti-VEGF, treatment of the underlying disease was essential for visual recovery.

Adaptive Optics Imaging to Analyze the Photoreceptor Layer Reconstitution in Acute Syphilitic Posterior Placoid Chorioretinopathy

Acute posterior syphilitic placoid chorioretinopathy (ASPPC) is a rare ocular manifestation of syphilis characterized by outer retinal layers involvement and drop in visual acuity. The current work documents outer retinal layer involvement in this pathology and their reconstitution with treatment by means of adaptive optics (AO). Three eyes of two patients together with four controls eyes were included in the study. Patients underwent optical coherence tomography (OCT) and OCT angiography (OCTA) scan centered on fovea, where vessel density (VD) and vessel perfusion (VP) were calculated. AO images centered on fovea were acquired and cone density (CD) and cone spacing (CS) were measured and compared to control group. Multimodal imaging was performed at presentation, at 10 days, and at 2-month follow-up. All eyes improved in visual acuity, with reconstitution in outer retinal layers at 2-month follow-up. Overall choriocapillary layer VD and VP improved. AO imaging was able to identify outer retinal alterations at presentation and at follow-ups, with improvement in tissue architecture. CD and CS was respectively lower and greater than controls at all follow-ups and improved within patients at the 2-month follow-up. In conclusion, AO was able to document outer retinal alterations in ASPPC at presentation and improvement over the follow-up, representing a tool to study photoreceptor layer involvement in this pathology.

Case Report: Bilateral Choroidal Neovascular Membranes in a Patient With a Delayed Diagnosis of Acute Syphilitic Posterior Placoid Chorioretinopathy

We report the case of a 78-year old man with a delayed diagnosis of syphilis and an advanced phenotype of acute syphilitic posterior placoid chorioretinopathy after receiving 5 months of high dose steroids prior to anti-treponemal treatment. Bilateral choroidal neovascular membranes were present at the time of diagnosis and were successfully treated with intravitreal aflibercept, following completion of anti-treponemal therapy.