Examining the choroid in ocular inflammation: a focus on enhanced depth imaging

Choroidal and Retinal Thicknesses in Healthy Eyes Measured with Ultra-Wide-Field Optical Coherence Tomography

Ultra-wide-field optical coherence tomography (UWF-OCT) has been recently introduced into clinical ophthalmological practice. To date, there are few data on the reference values of the retinal thickness (RT) and choroidal thickness (CT) measured with this technique. This study aimed to analyze the variance in RT and CT in the healthy eyes of white Caucasian patients with UWF-OCT tests performed with the largest available scan size of 23 × 20 mm. The data were analyzed with reference to the patients' age and gender and the axial length of the eyeball. The results of UWF-OCT scanning enabled us to visualize the shape of the retina and choroid in a large portion of the eyeball. Both anatomical entities became significantly thinner at the periphery. The peripheral CT was greater in the upper and temporal sectors; the RT was higher in the nasal compared to the temporal sectors. Both the choroid and retina showed a reduced thickness with age; however, the CT and RT did not show a statistically significant correlation with the axial length after adjusting for age and gender. Age-related variations in thickness were especially prominent in the choroid. The CT in UWF-OCT testing was significantly greater in females, while the RT was greater in males. UWF-OCT testing provides additional information on the anatomical structure of the retina and choroid compared to standard-field OCT.

The role of inflammation in central serous chorioretinopathy: From mechanisms to therapeutic prospects

Central serous chorioretinopathy (CSC) is a leading cause of permanent vision loss, ranking fourth among macular diseases, trailing only age-related macular degeneration, diabetic retinopathy, and retinal vein obstruction. While mounting evidence implicates inflammation as a pivotal factor in the onset and advancement of CSC, the specific pathophysiological process and molecular mechanisms underlying inflammation remain incompletely understood. A complex network of cytokines, chemokines, and adhesion molecules interplay to trigger inflammatory and pathological cascades, highlighting the need for a comprehensive comprehension of the inflammation-related mechanisms behind CSC progression. In this piece, we examine the existing comprehension of CSC's pathology and pathogenesis. Additionally, we present an overview of the mechanisms underlying the onset and progression of CSC inflammation, followed by a thorough analysis and discussion of the potential of targeted inflammatory intervention for both preventing and treating CSC.

Choroidal and central macular thickness before and after treatment in post fever retinitis

PURPOSE

To study the choroidal thickness (CT) and central macular thickness (CMT) in post-fever retinitis (PFR) and their correlation with visual acuity and treatment.

METHODS

A retrospective, observational study of patients presenting with PFR from 2013 to 2021 and with spectral domain optical coherence tomography (SD-OCT) (Heidelberg®, SpectralisTM, Heidelberg, Germany) images were included. The CT and CMT were measured at presentation and at the final visit. The CT was measured subfoveally and at points 2000 µm superior, inferior, medial, and lateral from the fovea using the caliper tool.

RESULTS

Seventy-nine eyes of 65 patients were included for this study. The mean age was 39.03 (±16.00) years with female preponderance of 53.84% (n = 35). Mean follow-up duration was 30 days. Mean CT at presentation and at follow-up was 254.12 µm and 241.51 µm, respectively. CT was decreased in majority of the eyes 67.1% (n = 53) from their baseline value. Mean CMTs at presentation and final visit were 454.8 µm and 223.7 µm, respectively. Best corrected visual acuity had a positive correlation with CMT (r = 0.340; P = 0.002) and negligible correlation with CT. A significant decrease in the mean CT was noted in patients who received doxycycline either alone or in combination with a steroid as compared to those who did not receive any treatment (P < 0.001). The significance of which is unknown presently.

CONCLUSION

CMT has a greater role in determining the final visual outcome than CT. CT can be reduced post-treatment with no effect on vision.

Insights into the diagnosis and management of sarcoid uveitis: A review

Sarcoidosis is a leading cause of non-infectious uveitis that commonly affects middle-aged individuals and has a female preponderance. The disease demonstrates age, sex and ethnic differences in clinical manifestations. A diagnosis of sarcoidosis is made based on a compatible clinical presentation, supporting investigations and histologic evidence of non-caseating granulomas, although biopsy is not always possible. Multimodal imaging with widefield fundus photography, optical coherence tomography and angiography can help in the diagnosis of sarcoid uveitis and in the monitoring of treatment response. Corticosteroid remains the mainstay of treatment; chronic inflammation requires steroid-sparing immunosuppression. Features on multimodal imaging such as vascular leakage may provide prognostic indicators of outcome. Female gender, prolonged and severe uveitis, and posterior involving uveitis are associated with poorer visual outcomes.

Comparison of the Choroid in Primary Open Angle and Angle Closure Glaucoma Using Optical Coherence Tomography

PRCIS

The current study highlights distinct choroidal alterations in primary open angle (POAG) and primary angle closure (PACG) glaucomas, underscoring the potential of the Choroidal Vascularity Index (CVI) as a valuable indicator for understanding glaucoma pathogenesis.

PURPOSE

To evaluate choroidal structural changes in patients with POAG and PACG and healthy controls utilizing the CVI and subfoveal choroidal thickness by enhanced depth imaging optical coherence tomography.

METHODS

This study was cross-sectional. A total of 171 eyes of 171 subjects, comprising 69 eyes with untreated POAG, 58 eyes with untreated PACG, and 44 healthy eyes, were enrolled in this study. Subfoveal choroidal thickness, luminal area (LA), stromal area (SA), and total choroidal area were measured on enhanced depth imaging-optical coherence tomography scans. The CVI parameter is calculated as the proportion of LA to the total choroidal area.

RESULTS

This study included 69 patients with POAG with a mean age of 51.4 ± 13.3 years, 58 patients with PACG with a mean age of 57.0 ± 7.3 years, and 44 healthy subjects with a mean age of 51.11 ± 10.7 years. The CVI in the POAG and PACG groups was significantly lower than that in the control group ( P = 0.001 and P = 0.005, respectively); however, not significantly different between the two glaucoma groups ( P = 1.000). POAG eyes had significantly lower LA than PACG and controls ( P = 0.014 and P = 0.049, respectively), whereas PACG eyes had significantly greater SA than controls ( P = 0.041).

CONCLUSIONS

The CVI of POAG and PACG eyes was significantly lower than that of normal eyes. A reduced LA was observed mainly in eyes with POAG, and an increased SA was observed mainly in eyes with PACG. The role of the choroid may differ between POAG and PACG eyes.

Alteration of perivascular reflectivity on optical coherence tomography of branched retinal vein obstruction

This study aimed to evaluate perivascular reflectivity in patients with branched retinal vascular obstruction (BRVO) using en-face optical coherence tomography (OCT). The study retrospectively analyzed 45 patients with recurrent BRVO, 30 with indolent BRVO, and 45 age- and sex-matched controls. Using a 3.0 × 3.0-mm deep capillary plexus slab on macular scans, OCT angiography (OCTA) and structural en-face OCT scans were divided into four quadrants. Obstructive quadrants of OCTA scans were binarized using a threshold value of mean + 2 standard deviation. The selected area of high signal strength (HSS) was applied to the structural en-face OCT scans, and the corrected mean perivascular reflectivity was calculated as the mean reflectivity on the HSS area/overall en-face OCT mean reflectivity. The same procedure was performed in the quadrants of the matched controls. Regression analysis was conducted on several factors possibly associated with corrected perivascular reflectivity. The perivascular reflectivity in the obstructive BRVO quadrant was significantly higher than in the indolent BRVO and control quadrants (P = 0.009, P = 0.003). Both univariate and multivariate regression analyses showed a significant correlation between the average number of intravitreal injections (anti-vascular endothelial growth factor or dexamethasone implant) per year and refractive errors and image binarization threshold and perivascular reflectivity (P = 0.011, 0.013, < 0.001/univariate; 0.007, 0.041, 0.005/multivariate, respectively). En-face OCT scans of the deep capillary plexus slab revealed higher perivascular reflectivity in recurrent BRVO eyes than in indolent BRVO and control eyes. The results also indicate a remarkable correlation between perivascular reflectivity and the average number of intravitreal injections, suggesting a link to recurrence rates.

En-face optical coherence tomography hyperreflective foci of choriocapillaris in central serous chorioretinopathy

The purpose of this study is to evaluate choroidal hyperreflective foci (HRF) changes in central serous chorioretinopathy (CSC) on en-face optical coherence tomography (OCT). Retrospective analysis of 42 patients with unilateral CSC (84 eyes, including fellow eyes for controls) and 42 age- and sex-matched controls. With 4.5 × 4.5 mm macular scans, structural en-face OCT choriocapillaris (CC) slabs were used to calculate the density and number of HRF in acute CSC eyes with serous retinal detachment (SRD), resolved CSC eyes without SRD, unaffected fellow eyes, control eyes, and 1-year follow-up eyes. Based on the 2-disc diameter (3000 μm), the en-face OCT scan was divided into foveal and perifoveal lesion and analyzed to consider the impact of SRF in HRF measurement. Regression analyses were performed on the several factors with HRF number and density in the acute and resolved CSC eyes. The perifoveal density and number of CC HRF was significantly lower in the resolved CSC eyes when compared to the acute CSC eyes (P = 0.002, both), fellow eyes (P = 0.042/density, 0.028/number), and controls (P = 0.021/density, P = 0.003/number). There was no significant difference between the acute CSC eyes, fellow eyes, controls, and 1-year follow-up eyes. As subfoveal choroidal thickness decreased and choroidal vascularity (CVI) increased, the perifoveal density and number of HRF was measured higher with a significant correlation in univariate regression analysis of the acute and resolved CSC eyes (all, P < 0.05). The authors hypothesized that stromal edema induced by choroidal congestion and hyperpermeability has the greatest influence on HRF measurement, possibly affected by inflammatory cells and materials extravasation.

Analysis of choroidal thickness in juvenile systemic lupus erythematosus and its correlation with laboratory tests

BACKGROUND

The aim of this study is to investigate the alterations of choroidal thickness (CT) in juvenile systemic lupus erythematosus (JSLE) using enhanced depth imaging optical coherence tomography (EDI-OCT). We also aimed to assess whether CT parameters correlated with systemic health status in JSLE patients.

METHODS

JSLE patients and age- and sex-matched healthy subjects were recruited. A detailed ophthalmological examination was applied to all participants. CT measurements were acquired in the macular region using EDI-OCT. Moreover, a spectrum of laboratory tests was examined to evaluate the systemic conditions, and the Th1/Th2/Th17/Treg cytokine profiles in the peripheral blood were also analyzed in JSLE group.

RESULTS

A total of 45 JSLE patients with no visual impairment and 50 healthy individuals were enrolled in the study. CT values in the macular region were decreased in JSLE patients when compared with healthy controls, even adjusting for age, axial length and refraction. There were no significant correlations between CT and cumulative dose of hydroxychloroquine or duration of hydroxychloroquine use (all P > 0.05). The average macular, temporal and subfoveal CT in JSLE group was negatively correlated with IL-6 and IL-10 (all P < 0.05), but had no significant correlations with other laboratory results (all P > 0.05).

CONCLUSIONS

JSLE patients without ocular involvement may have significant variations in choroidal thickness at the macular area. Choroidal alterations might be associated with the systemic cytokine profiles in JSLE.

Alterations in the choroidal thickness and retinal vascular caliber in keratoconus

PURPOSE

To compare the choroidal thickness (CT) and retinal vascular caliber in the differentiation of patients who have keratoconus (KC) from those of astigmatic and normal patients.

METHODS

This was a prospective, cross-sectional study. A total of 72 patients who had KC, 70 who had astigmatism, and 83 healthy control subjects were enrolled in this study. All the patients were examined using the Sirius topography system and spectral domain optical coherence tomography with enhanced depth imaging. Using the digital fundus photographs, the retinal vascular calibers were calculated. The measurements were also analyzed between the KC stages according to the Amsler-Krumeich classification.

RESULTS

The CT measurements were significantly higher in the KC group, when compared with the other 2 groups, in each location (P < 0.05). No statistically significant difference was observed with regards to the central retinal artery equivalent (CRAE) values (P = 0.959), while significant differences were noted in the central retinal vein equivalent (CRVE) among the groups (P = 0.011). Significant increases were noted in the CT as the stage of KC progressed, except at temporal 3000 µm (P = 0.603). No statistically significant difference was observed with regards to the CRAE among the stages (P = 0.901). However, the CRVE changes increased remarkably as the stages advanced (P < 0.001).

CONCLUSION

The patients who had KC seemed to have a thicker CT and higher CRVE values than the healthy individuals, and these differences were progressively increased as the stages of KC advanced. Reflecting the vascular effects of inflammation, the high CRVE supported theories based on the inflammatory component of KC.

Serial choriocapillaris flow changes in eyes with branched retinal vascular obstruction (BRVO)

PURPOSE

To evaluate the choriocapillaris (CC) flow changes in branched retinal vascular obstruction (BRVO) on optical coherence tomography angiography (OCTA).

METHODS

Retrospective analysis of 29 patients with unilateral BRVO (58 eyes, including unaffected fellow eyes for controls). 4.5 x 4.5 mm macular scans were divided into 4 quadrants. Serial analyses were conducted on CC flow voids of the opposite quadrant to the active occluded area in BRVO eyes. Each of the quadrants were also compared to the occluded quadrant of resolved eyes and the contralateral quadrant of fellow eyes by matched data analysis. A regression analysis was performed on the several parameters (Choroidal thickness; CT, Choroidal vascularity index; CVI, Central macular thickness; CMT, The number of intravitreal injections) and CC flow voids.

RESULTS

The CC flow void increased sequentially: The uninvolved quadrant of acute BRVO-affected eyes, that of resolved eyes after 3-month/1-year, the contralateral quadrant of fellow eye, the involved (occluded) quadrant of resolved eyes. There were significant correlations between initial CMT, the number of injections and the CC flow void of uninvolved quadrants (P = 0.025, 0.031, respectively), and between the involved (occluded) quadrants and fellow CT (P = 0.029).

CONCLUSION

CC flow void of uninvolved macular areas decreased significantly in eyes with acute BRVO, suggesting that CC changes were limited to the blocked area and a compensatory mechanism would work in surrounding areas.

Sarcoid Uveitis: An Intriguing Challenger

The purpose of our work is to describe the actual knowledge concerning etiopathogenesis, clinical manifestations, diagnostic procedures, complications and therapy of ocular sarcoidosis (OS). The study is based on a recent literature review and on the experience of our tertiary referral center. Data were retrospectively analyzed from the electronic medical records of 235 patients (461 eyes) suffering from a biopsy-proven ocular sarcoidosis. Middle-aged females presenting bilateral ocular involvement are mainly affected; eye involvement at onset is present in one-third of subjects. Uveitis subtype presentation ranges widely among different studies: panuveitis and multiple chorioretinal granulomas, retinal segmental vasculitis, intermediate uveitis and vitreitis, anterior uveitis with granulomatous mutton-fat keratic precipitates, iris nodules, and synechiae are the main ocular features. The most important complications are cataract, glaucoma, cystoid macular edema (CME), and epiretinal membrane. Therapy is based on the disease localization and the severity of systemic or ocular involvement. Local, intravitreal, or systemic steroids are the mainstay of treatment; refractory or partially responsive disease has to be treated with conventional and biologic immunosuppressants. In conclusion, we summarize the current knowledge and assessment of ophthalmological inflammatory manifestations (mainly uveitis) of OS, which permit an early diagnostic assay and a prompt treatment.

The Next Steps in Ocular Imaging in Uveitis

PURPOSE

To describe the future steps and advances in the field of ocular imaging in uveitis.

METHODS

Narrative review.

RESULTS

There have been numerous advances in the field of imaging in uveitis in the past decade. Advanced techniques of imaging of the vitreous, vitreo-retinal interface, retinochoroid, and the sclera can provide significant information that helps in understanding the disease pathogenesis and manifestations. Imaging also helps in establishing a diagnosis in challenging cases, along with the laboratory and other assays. Notable developments in ocular imaging include wide-field and ultra-wide field imaging (including angiographies), automated quantification of the retinochoroidal vasculature using optical coherence tomography (OCT) and OCT angiography, quantification of vitreous cells, and intraoperative use of imaging in uveitis, among others.

CONCLUSIONS

We have summarized several technological achievements in ocular imaging in the field of uveitis and provided insights into the potential future developments.

Quantitative Evaluation of Macular Vessel Density Measurement by Optical Coherence Tomography Angiography in Patients with Inactive Ocular Sarcoidosis

PURPOSE

To evaluate the macular vessel density (VD) in inactive ocular sarcoidosis (OS) and investigate the relationship between VD and both disease duration and visual acuity (VA).

METHODS

This cross-sectional study was performed at a tertiary hospital. The macular VDs of patients with OS were obtained using optical coherence tomography angiography and compared with healthy subjects.

RESULTS

Deep whole image macular VD (WI-MVD), parafoveal, and perifoveal VDs were lower in OS group (p = .01, p = .01, p = .02, respectively). Negative correlation between disease duration and both superficial and deep WI-MVD, parafoveal, and perifoveal VDs was obtained (for all p < .05). There was a positive correlation between VA and superficial VD (p < .001, r = 0.848 for WI-MVD).

CONCLUSION

OS affects deep VD significantly. Changes in superficial VD affect VA more. Disease duration is an important factor affecting macular VD.

Quantitative analysis of choroidal blood flow parameters in optical coherence tomography and angiography in central serous chorioretinopathy

PURPOSE

To evaluate the choriocapillaris (CC) flow in central serous chorioretinopathy (CSC) and determine the relationship between CC flow void with the choroidal thickness (CT) and choroidal vascularity index (CVI).

METHODS

Retrospective analysis of 20 patients with CSC (40 eyes, including unaffected fellow eyes) and 20 age- and sex-matched controls. After compensation with optical coherence tomography (OCT) en-face structural image, the CC flow void (%) was measured using the phansalkar threshold with a window radius of 3 and 15 pixels. The mean CC flow voids of acute CSC, recovered-acute CSC, unaffected fellow, and control eyes were compared by matched data analysis. A regression analysis was performed on the choroidal parameters (CT and CVI) and CC flow voids.

RESULTS

The CC flow void had an increasing tendency in the following order: control, fellow, recovered-acute CSC, and acute CSC eyes. Acute/recovered comparison showed a significant P value (0.008) in the foveal lesion. Recovered/fellow and fellow/control presented significant P values regardless of location to fovea (all <0.05). There were significant positive correlations between CT and CC flow void (P < 0.05) in the acute CSC, recovered-acute CSC eyes.

CONCLUSION

The CC flow on OCT angiography decreased in acute CSC eyes, especially in the foveal lesion, with a published compensation method. The findings suggest that unmodulated choroidal blood flow contributed to partially reversible diminished CC flow.

Clinical and imaging features of sympathetic ophthalmia and efficacy of the current therapy

PURPOSE

The purpose of the study was to clarify the clinical and imaging features of sympathetic ophthalmia (SO) and evaluate the efficacy of the current therapy.

METHODS

The databases PubMed, EMBASE and Ovid up to January 2021 were searched to identify relevant studies. R software version 3.6.3 was used to perform the statistical analyses.

RESULTS

Thirty-two studies involving 1067 patients were finally included. Our study found SO was male-dominated, and more than half of SO patients aged 16 to 60 years old. Ocular trauma, surgical interventions and unknown events were estimated to be inciting events in 63%, 36% and 4% of SO patients. About 35% of the patients underwent baseline enucleation, and 45% took compelled enucleation during follow-up. The most common symptoms at the first presentation were decreased vision, followed by pain and redness. The most common signs were anterior chamber cells/flare, followed by vitritis, exudative retinal detachment and Dalen-Fuch nodules. Choroidal thickening was detected in 81% of SO patients by ocular ultrasound. The most common fluorescein fundus angiography signs were disc leakage. After corticosteroid therapy became the mainstay for SO, about 76% of SO patients could get inflammation well-controlled, while 24% of them might have recurrent inflammation. Around 72% of SO patients could achieve visual improvement, and more than half of them might have a best-corrected visual acuity of 20/50 or better.

CONCLUSION

SO is a complicated ocular disease with diverse clinical manifestations and imaging features. After proper anti-inflammation therapy, SO might not necessarily result in a poor prognosis.

Evaluation of eye involvement in paediatric celiac disease patients

BACKGROUND

The non-classic presentation of paediatric celiac disease (CeD) becomes increasingly common in daily practice, which requires an awareness of eye findings. The purpose of this study was to evaluate eye involvement and effect of gluten-free diet on ocular involvement in paediatric CeD patients by measuring the thicknesses of choroid and ganglion cell complex (GCC) composed of retinal nerve fibre layer, ganglion cell layer and inner plexiform layer using enhanced depth imaging optical coherence tomography.

METHODS

Forty-three CeD patients aged between four and 16 years (mean age: 9.9 ± 4.1, 12 boys and 31 girls) and 48 healthy children (mean age: 11.3 ± 4.1,17 boys and 31 girls) were compared. Following comprehensive eye examinations, thicknesses of choroid at three points and GCC layers (retinal nerve fibre layer at five points, ganglion cell layer and inner plexiform layer) were obtained using enhanced depth imaging optical coherence tomography. Measurement of thicknesses of choroid and GCC layers by a trained optical coherence tomography technician and an ophthalmologist who were not aware about group of children in paediatric CeD patients with 1 year gluten-free diet was carried out.

RESULTS

All layers of subfoveal, nasal and temporal choroid were significantly thinner in CeD than in the control group (P < .001, all, respectively). No significant difference was observed between the CeD and control groups in terms of GCC thicknesses (P > .05, all, respectively).

CONCLUSION

Paediatric CeD caused thinning of subfoveal, nasal and temporal areas of choroid, and this change is apparent even after 1 year gluten-free diet. This eye involvement should be more closely screened at diagnosis, and long-term clinical results of thin choroid should be determined. Thicknesses of GCC layers were not different in CeD group and may reveal the effect of diet or not involvement.

Role of the choroidal vascularity index in branch retinal vein occlusion (BRVO) with macular edema

Purpose

To assess choroidal vasculature changes in eyes with branch retinal vein occlusion (BRVO) and macular edema (ME) using the choroidal vascularity index (CVI) and evaluate the effectiveness of CVI as a prognostic biomarker.

Methods

35 patients with monocular BRVO and ME were analyzed retrospectively. Luminal and stromal areas in choroids of swept-source optical coherence tomography were calculated using the image binarization technique. The CVI was calculated as the ratio of the luminal to total choroidal area. The CVI of BRVO and ME eyes were compared with that of the unaffected fellow and post anti-vascular endothelial growth factor (VEGF) injected eyes. A regression analysis was performed on the choroidal parameters, logMAR visual acuity (VA) two years post disease onset and central macula thickness (CMT).

Results

The CVI of BRVO and ME eyes was significantly lower than the fellow and post-injected eyes (p<0.05). The regression analysis showed a strong association between two years after logMAR VA and the CVI of fellow eyes (R² = 0.433, p<0.001). Remarkable correlations were observed in the CVI and subfoveal choroidal thickness of BRVO and ME eyes (R² = 0.189, 0.155, respectively, p<0.05). The CMT of diseased eyes were also significantly associated with the CVI of unaffected fellow eyes (R² = 0.113, p<0.05).

Conclusions

The alteration of CVI in BRVO and ME suggests that choroidal vasculature might be affected by extracellular fluid shift and VEGF changes. The fellow eye CVI could be a useful supplementary prognostic biomarker.

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.

Multimodal Imaging in Ocular Sarcoidosis

Aim: Ocular sarcoidosis presents a diagnostic challenge because of its varied clinical presentations. It is important to distinguish sarcoidosis from other uveitis diseases. Multimodal imaging provides useful data to be introduced into clinical practice. Methods: This is a review article. Conclusions: This review article highlights the role of fundus fluorescein angiography (FA), indocyanine green angiography (ICG), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA) in the diagnosis and management of ocular sarcoidosis. This review article highlights the role of fundus fluorescein angiography (FA), indocyanine green angiography (ICG), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA) in the diagnosis and management of ocular sarcoidosis.

Initial-onset acute and chronic recurrent stages are two distinctive courses of Vogt-Koyanagi-Harada disease

PURPOSE

To describe distinctive stages of Vogt-Koyanagi-Harada (VKH) disease: initial-onset acute versus chronic recurrent disease.

METHODS

A comprehensive literature review regarding stages and clinical presentations of VKH disease was conducted.

RESULTS

Despite a list of signs that has been described as characteristic features of early or late phases of VKH disease, the current classification -developed by an international committee and published in 2001- does not consider a distinction regarding the time from onset of disease symptoms, and specific findings observed at certain time point from the symptoms presentation and outcomes related to the stage of VKH disease. In that sense, chronic recurrent VKH disease is more refractory to treatment and is associated with a higher rate of complications. Accordingly, this subset of VKH patients has poorer functional and anatomical outcomes than patients with an initial-onset acute disease.

CONCLUSIONS

An early clear distinction of VKH phenotype [Initial-onset acute versus chronic recurrent disease] should be considered in each clinical scenario, evaluating the delay in diagnosis and the clinical presentation, since it may help clinicians to perform a correct disease prognosis categorization and thus to make treatment decisions in terms of potential refractoriness or expected clinical outcomes.

Differentiating Multifocal Choroiditis and Punctate Inner Choroidopathy: A Cluster Analysis Approach

PURPOSE

To develop a robust approach to clinical phenotyping of multifocal choroiditis (MFC) and punctate inner choroidopathy (PIC).

DESIGN

Cross-sectional and longitudinal observational study.

METHODS

This multicenter study included sites in the United Kingdom and Israel. The study population included 343 eyes of 185 subjects with hospital record diagnoses of MFC or PIC. Eyes were observed over a period of 5 years for clinically relevant characteristics, including demographics and multimodal imaging features, by observers masked to the original diagnoses. Multivariate 2-step cluster analysis was used to identify clusters of eyes in the database with similar clinical phenotypes, which were then analyzed for between-group differences. The primary outcome measure was the difference between clinical phenotype clusters identified using clinical criteria from the multivariate cluster analysis.

RESULTS

Subjects ranged from 11 to 89 years of age, with a baseline best-corrected visual acuity of 2.3 to -0.2 logarithm of minimal angle of resolution. Eighty-two percent of eyes were from females, 74% were myopic with a refractive error of +3.00 to -17.00 diopters (spherical equivalent). Cluster analysis prioritized clinical criteria of chorioretinal lesion location and intraocular inflammation and identified 2 distinct phenotype clusters resembling the original descriptions of MFC and PIC. During the 5-year period of observation, the initial clinical diagnosis remained stable for most eyes and only 1 eye (0.3%) changed diagnosis from PIC to MFC because of newly developed peripheral lesions. There were significant between-group differences in clinical characteristics, for example, in choroidal neovascular membrane development and treatment received.

CONCLUSIONS

Cluster analysis of this large cohort of eyes identified peripheral lesions and intraocular inflammation as distinct clinical phenotypes of MFC and PIC. The initial diagnosis remained stable for most eyes. This methodology could be useful for future uveitis classification and management.

A rare entity: Sympathetic ophthalmia presumably after blunt trauma to the phthisical eye and optical coherence tomography angiography metrics to monitor response to treatment

A blunt trauma to a phthisical eye may elicit sympathetic ophthalmia. Non invasive imaging such as use of optical coherence tomography and angiography metrics of the retinal and choroidal vasculature can help monitor response to the treatment.

Increased Choroidal Thickness in Keratoconus Patients: Perspectives in the Disease Pathophysiology

Purpose

To analyze and compare choroidal thickness between keratoconus (KC) patients and age-matched non-KC subjects.

Methods

A cross-sectional, case-control study. One hundred and thirty-four keratoconic eyes and 78 control eyes, from individuals aged from 12 to 30 years old, were studied. Patients with KC followed in Corneal Department of Centro Hospitalar São João, Porto, Portugal, were identified and consecutively included between December 2017 and February 2018. A spectral-domain optical coherence tomography (OCT) using depth enhanced imaging was performed, and choroidal thickness in the center of the fovea and at 500 μm intervals along a horizontal section was measured and compared.

Results

The statistical analysis showed that keratoconic eyes present a thicker choroid in every measured location (p < 0.05). Mean subfoveal choroidal thickness (SFCT) values obtained were 375.86 ± 89.29 and 322.91 ± 85.14 in keratoconus and control groups, respectively (p < 0.001). In a multivariate analysis, SFCT was significantly associated with spherical equivalent (p=0.004) and the presence of keratoconus (p < 0.001), but not with age (p=0.167), gender (p=0.579), or best-corrected visual acuity (p=0.178). In a "fixed model," keratoconus patients were found to have a 67.55 μm (95% CI 36.61-98.49) thicker subfoveal choroid compared to controls.

Conclusion

Keratoconus patients seem to have a thicker choroid than healthy individuals. The exact pathophysiological mechanism resulting in a thicker choroid in KC patients is not known, but it could possibly be associated with inflammatory choroidal mechanisms.

Analysis in Choroidal Thickness in Patients with Graves' Ophthalmopathy Using Spectral-Domain Optical Coherence Tomography

Objectives

The objective of the study is to observe changes in choroidal thickness (CT) in patients with Graves' ophthalmopathy using spectral-domain optical coherence tomography (SD-OCT).

Methods

The right eyes of 36 patients (27 females and 9 males) with Graves' ophthalmopathy (GO) and those of 36 age-, gender-, and diopter-level-matched healthy participants were evaluated. The patients' data were obtained within 3 months after the onset of Graves' disease (GD). Thyroid hormone levels and thyroid-stimulating hormone receptor antibody (TRAb) levels were measured, and the degree of exophthalmos was measured in all patients. Activity is measured by the clinical activity score (CAS). A horizontal scan centered on the fovea was performed in all participants. Five points of choroidal thickness were measured at the fovea (SFCT) and at 1500 μm nasal (N1500), 3000 μm nasal (N3000), 1500 μm temporal (T1500), and 3000 μm temporal (T3000) to the fovea.

Results

The CT measurements obtained were (mean ± SD) 313.47 ± 100.32 μm, 279.22 ± 85.80 μm, 214.64 ± 75.52 μm, 313.19 ± 80.36 μm, and 298.14 ± 82.75 μm in patients with GO and were 256.33 ± 50.18 μm, 223.14 ± 59.61 μm, 176.69 ± 60.66 μm, 250.92 ± 52.184 μm, and 239.47 ± 60.35 μm in the control group at the foveal, N1500, N3000, T1500, and T3000 measurement points, respectively. The CT in GO patients was significantly increased at all the points compared with the control group (P < 0.05). There was no relationship between the CT and CAS, the degree of exophthalmos, triiodothyronine (T3), tetraiodothyronine (T4), thyroid-stimulating hormone (TSH), or TRAb levels in GO.

Conclusions

CT was found to be increased in GO patients and had poor relationship with CAS, exophthalmos, and thyroid function tests.

The Increment of Choroidal Thickness in Euthyroid Graves' Ophthalmopathy: Is It an Early Sign of Venous Congestion?

Objective

Clinical manifestations of Graves' ophthalmopathy (GO) are caused by the overcompression of orbital tissues within the restricted orbital bone cavity. Impaired ocular blood flow may disrupt the retinal microstructure and functions. In this study, we aimed to investigate the macular and choroidal thickness changes in GO compared with healthy subjects.

Materials and Methods

The study group comprised 50 adult patients with previously diagnosed Graves' disease with ophthalmopathy who were on antithyroid treatment. For the assessment of GO activity, the VISA (vision, inflammation, strabismus, and appearance) inflammatory score was used. When euthyroidism was achieved without side effects, the patients were referred to the ophthalmology clinic for spectral-domain optical coherence tomography (SD-OCT) evaluation.

Results

Subfoveal, mean, and temporal choroidal thicknesses were increased significantly in the study group according to the controls. The mean choroidal thickness was elevated.

Conclusions

This elevation is because of the intraorbital inflammation even in this nonsevere GO group. Choroidal thickness might be affected from the venous obstruction and congestion in patients with GO. The elevation of the choroidal thickness might be an early sign of venous congestion that occurs before the elevation of intraocular pressure.

Choroidal vascularity index in type-2 diabetes analyzed by swept-source optical coherence tomography

The relationships between changes in choroidal vasculature and the severity of diabetic retinopathy (DR) remain unclear. We assessed choroidal changes in diabetic patients by measuring choroidal vascularity index (CVI) in conjunction with DR stage. In this study, patients with diabetes and healthy controls were retrospectively analyzed. Subjects were divided into seven groups as follows: Healthy controls, no DR, mild/moderate non-proliferative DR (NPDR), severe NPDR, proliferative DR (PDR), panretinal photocoagulation-treated DR, and clinically significant macular edema. The mean CVI values in the above groups were 69.08, 67.07, 66.28, 66.20, 63.48, 65.38, and 66.28, respectively. The eyes of diabetic patients exhibited a significantly lower CVI value than those of healthy controls even without DR. The PDR group exhibited a significantly lower CVI value than the healthy control, no DR, and mild/moderate NPDR groups. Age, sex, disease duration, glycated hemoglobin, fasting blood sugar, or intraocular pressure had no correlation with CVI. In multivariate regression analysis, thicker subfoveal choroid and thinner central retina were significantly associated with higher CVI values. These findings carefully suggest that changes in choroidal vasculature could be the primary event in diabetes even where there is no DR.

Analysis of choroidal and central foveal thicknesses in acute anterior uveitis by enhanced-depth imaging optical coherence tomography

Background

Currently, there are a limited number of reports of structural changes in the retina and choroid in acute anterior uveitis (AAU). The aim of this study was to evaluate choroidal and central foveal thicknesses during episodes of AAU.

Methods

The medical records of 120 patients with AAU and 120 healthy subjects matched for age, sex, and spherical equivalent of refractive error were reviewed. Subjects were divided into group 1 (AAU-affected eyes), 2 (unaffected fellow eyes), and 3 (healthy control eyes).

Results

In the uveitis group, etiologic diagnoses included human leukocyte antigen (HLA)-B27-associated (n = 71) and idiopathic (n = 49) AAU. The mean subfoveal choroidal thicknesses (SFCTs) in groups 1–3 were 326.7 ± 64.2, 296.1 ± 66.6, and 294.9 ± 41.7 μm, respectively. The corresponding mean central foveal thicknesses (CFTs) were 273.5 ± 29.3, 264.4 ± 24.6, and 263.0 ± 30.8 μm, respectively. The AAU group exhibited a significantly greater SFCT than the control groups (P < .001). Relative to the control group, while eyes with idiopathic AAU exhibited a significantly greater CFT, those with HLA-B27-associated AAU exhibited no such significant difference. Anterior chamber cell grade was not associated with SFCT or CFT.

Conclusions

The SFCT increased significantly during AAU. This indicates the importance of OCT examination for detection of subclinical choroidal and retinal changes in all types of AAU.

Pearls and pitfalls of optical coherence tomography angiography in the multimodal evaluation of uveitis

BACKGROUND

Optical coherence tomography angiography (OCTA) employs a novel imaging algorithm that detects the amplitude or phase decorrelation of blood cell movement. It thus provides a flow map with depth-resolved visualization of the various vascular layers in the posterior pole of the eye including the retina capillary plexus and the choroid. In the past 3 years, the number of research papers on the subject of OCTA in retinal diseases has grown exponentially including important applications in the field of uveitis. While the study of OCTA in uveitic diseases has gained remarkable relevance worldwide, interpretation can be challenging, and many limitations exist in optimally using this advanced system in uveitic eyes. The aim of this review is to describe the many significant applications of OCTA in uveitis disorders and to outline the various limitations that can confound interpretation and support uveitis specialists in the integration of OCTA in the multimodal imaging approach to inflammatory diseases.

MAIN BODY

Unlike conventional angiography that can dynamically detect inflammation and leakage of dye from retinal vessels, OCTA provides other important biomarkers of inflammation. Detailed microvascular reconstruction of normal and abnormal blood vessels and quantitative evaluation are advantages of OCTA analysis. OCTA can therefore non-invasively detect choroidal neovascularization that may complicate inflammatory disorders, and with remarkable depth-resolved capability, OCTA can identify and quantitate flow loss as a manifestation of ischemia and/or inflammation. The areas of flow deficit on OCTA at the level of the inner choroid often co-localize with hypofluorescent lesions with indocyanine green angiography. These regions of presumed choriocapillaris ischemia may occur in placoid disorders. Space-occupying granulomas may occur in disorders such as sarcoid and may or may not co-localize with choriocapillaris ischemia on ICG angiography. Blocking or shadowing artifacts should be excluded when evaluating inner choroidal abnormalities with OCT angiography. Fundus autofluorescence may assess the metabolic function of the retinal pigment epithelium (RPE) and the viability of the overlying photoreceptors and thus the activity of inflammation associated with uveitic lesions. The photoreceptors are physiologically maintained by the diffusion of oxygen from the choriocapillaris below and, to a lesser extent, from the deep retinal capillary plexus above. The depth-resolved capability of OCTA may therefore provide additional significant microvascular information about these vascular layers that may be driving the development of hyper-autofluorescent RPE inflammation and photoreceptor loss.

CONCLUSIONS

The implementation of OCTA in the evaluation and management of uveitis disorders is being spurred by our greater knowledge and understanding of its application. In order to take full advantage of this exciting new imaging modality, however, uveitis specialists must understand the limitations of interpretation and potential artifact-related pitfalls in assessment and should continue to support evaluation with multimodal imaging to best optimize diagnoses and treatment of inflammatory diseases.

Evaluation of retrobulbar blood flow and choroidal thickness in patients with rheumatoid arthritis

PURPOSE

To evaluate whether retrobulbar blood flow and choroidal thickness (CT) are affected in patients with rheumatoid arthritis (RA), and the relationship between these values.

METHODS

We evaluated 40 eyes of 20 RA patients and 40 eyes of 20 healthy controls. The enhanced depth imaging optical coherence tomography, color Doppler imaging, was held. Statistical analysis was performed.

RESULTS

Peak systolic velocity (PSV) of ophthalmic (OA) and central retinal artery (CRA) were significantly higher in RA. No significant difference was observed when end-diastolic velocity (EDV) of OA and CRA was compared between the groups. The resistivity index (RI) of OA and CRA was higher in RA. Perifoveal/subfoveal CT was lower in RA. Negative correlation was detected between the RI of OA and the perifoveal CT, and a positive correlation was detected between RI of CRA and CT.

CONCLUSIONS

Ocular hemodynamics is effected by RA and can exaggerate ocular complications of various vascular diseases such as diabetes mellitus, hypertension, retinal vascular occlusions.

Open-source algorithm for automatic choroid segmentation of OCT volume reconstructions

The use of optical coherence tomography (OCT) to study ocular diseases associated with choroidal physiology is sharply limited by the lack of available automated segmentation tools. Current research largely relies on hand-traced, single B-Scan segmentations because commercially available programs require high quality images, and the existing implementations are closed, scarce and not freely available. We developed and implemented a robust algorithm for segmenting and quantifying the choroidal layer from 3-dimensional OCT reconstructions. Here, we describe the algorithm, validate and benchmark the results, and provide an open-source implementation under the General Public License for any researcher to use (https://www.mathworks.com/matlabcentral/fileexchange/61275-choroidsegmentation).

The Eye As a Biomarker for Alzheimer's Disease

Alzheimer's disease (AD) is a progressive neurodegenerative disorder resulting in dementia and eventual death. It is the leading cause of dementia and the number of cases are projected to rise in the next few decades. Pathological hallmarks of AD include the presence of hyperphosphorylated tau and amyloid protein deposition. Currently, these pathological biomarkers are detected either through cerebrospinal fluid analysis, brain imaging or post-mortem. Though effective, these methods are not widely available due to issues such as the difficulty in acquiring samples, lack of infrastructure or high cost. Given that the eye possesses clear optics and shares many neural and vascular similarities to the brain, it offers a direct window to cerebral pathology. These unique characteristics lend itself to being a relatively inexpensive biomarker for AD which carries the potential for wide implementation. The development of ocular biomarkers can have far implications in the discovery of treatments which can improve the quality of lives of patients. In this review, we consider the current evidence for ocular biomarkers in AD and explore potential future avenues of research in this area.

Choroidal Thickness in Patients with Graves' Ophthalmopathy

PURPOSE

The purpose of the study is to compare choroidal thickness (CT) in patients with active and inactive Graves' ophthalmopathy (GO) and that in healthy subjects by using spectral domain optical coherence tomography (SD-OCT).

METHODS

We conducted an observational, cross-sectional study of 28, 48, and 74 eyes of 14 patients with active GO (group 1), 24 patients with inactive GO (group 2), and 37 age-matched healthy subjects (group 3), respectively. Activity of GO was assessed by using initial clinical activity score (CAS). CT was measured by using SD-OCT. The differences in CT among the groups were compared, and the factors affecting subfoveal CT were analyzed.

RESULTS

The mean subfoveal CT was significantly greater in group 1 (395.84 ± 9.68 µm) than that in group 2 and group 3 (319.76 ± 7.07 µm and 314.22 ± 5.74 µm, respectively; p < 0.001) after adjusting for age, axial length, and intraocular pressure (IOP). Subfoveal CT was positively correlated with CAS (p < 0.001; r = 0.567). In multivariate analysis, thicker subfoveal CT was associated with younger age (p < 0.001; correlation coefficient B, -1.67; 95% CI, -2.57 to -0.78); disease activity (p < 0.001; correlation coefficient B, 95.28; 95% CI, 73.14-117.43); and lower IOP ((p < 0.001; correlation coefficient B, -4.09; 95% CI, -8.03 to -0.15).

CONCLUSIONS

To our knowledge, this is the first study showing that the mean subfoveal CT increases in patients with active GO. Subfoveal CT may be a useful parameter to monitor disease activity.

Ocular manifestations of Sturge-Weber syndrome: pathogenesis, diagnosis, and management

Sturge–Weber syndrome has been included in the group of phakomatoses that is characterized by hamartomas involving the brain, skin, and eyes. The characteristic facial port-wine stain, involving the first branch of the trigeminal nerve and the embryonic vasculature distribution in this area, leads to several ocular complications of the anterior segment and can involve the eyelids and conjunctiva. The posterior segment of the eyes is also affected with diffuse choroidal hemangiomas. However, the most frequent ocular comorbidity is glaucoma with a prevalence rate ranging from 30%–70%. Glaucoma is related to anterior chamber malformations, high episcleral venous pressure (EVP), and changes in ocular hemodynamics. Glaucoma can be diagnosed at birth, but the disease can also develop during childhood and in adults. The management of glaucoma in Sturge–Weber syndrome patients is particularly challenging because of early onset, frequently associated severe visual field impairment at the time of diagnosis, and unresponsiveness to standard treatment. Several surgical approaches have been proposed, but long-term prognosis for both intraocular pressure control and visual function remains unsatisfactory in these patients. Choroidal hemangiomas may also lead to visual impairment thorough exudative retinal detachment and macular edema. Treatment of exudative hemangioma complications is aimed at destructing the tumor or decreasing tumor leakage.

The suprachoroidal space: from potential space to a space with potential

Recent advances have made it possible to image the suprachoroidal space, and the understanding of its clinical applications is currently being greatly expanded. This opinion piece covers the advances in imaging techniques that enable the demonstration of the suprachoroidal space, and its implication in various retinal pathologies. It also reviews its potential uses as a route for drug delivery for the treatment of retinal diseases, and its use in innovative surgical techniques. Current research is leading the way for the suprachoroidal space to be an aspect of retinal disease diagnosis, monitoring, medical treatment, and surgical manipulation.

Uveitis and glaucoma: new insights in the pathogenesis and treatment

Glaucoma is a potentially blinding complication of uveitis, where intraocular inflammation, secondary corticosteroid response, and varying types and degrees of angle abnormalities contribute to its pathogenesis. Management of uveitic glaucoma remains challenging. Treatment is targeted at reducing the inflammation and lowering the intraocular pressure. Recent studies have highlighted the role of viruses, such as cytomegalovirus, herpes simplex virus, and more recently Ebola virus, in the pathogenesis of uveitic glaucoma. Antiviral therapy may be beneficial in eyes with detectable viral DNA. The success of glaucoma surgery is decreased in eyes with uveitic glaucoma, and surgical interventions are associated with a higher incidence of postoperative complications. Novel glaucoma surgical and laser treatments may improve the predictability of surgery for uveitic glaucoma, but these require further evaluation.