Macular Microstructures and Prognostic Factors in Myopic Subretinal Hemorrhages

CENTRAL BOUQUET HEMORRHAGE: Clinical and Multimodal Imaging Features

PURPOSE

To describe the clinical characteristics, multimodal imaging features, and anatomic basis of a distinctive pattern of deep retinal hemorrhages located in the central fovea, a presentation referred to as "central bouquet hemorrhage."

METHODS

Retrospective, observational, multicenter case series of eyes with central bouquet hemorrhage. Multimodal imaging features were reviewed and analyzed.

RESULTS

Ten eyes from 10 patients (4 women and 6 men), with a mean age of 55.6 ± 21.7 years (range 25-84 years) were included. Underlying etiologies were neovascular age-related macular degeneration (40%), lacquer cracks in pathological myopia (30%), macular telangiectasia Type 2 (10%), proliferative diabetic retinopathy (10%), and ocular trauma associated with angioid streaks (10%). On ophthalmoscopy, all eyes with central bouquet hemorrhage displayed a deep retinal hemorrhage with round margins in the central fovea and associated with petaloid hemorrhages radiating in the surrounding Henle fiber layer. Cross-sectional optical coherence tomography showed a well-delineated round hyperreflective lesion involving the central foveal Henle fiber layer/outer nuclear layer in all cases. Accompanying hyperreflective hemorrhages tracking along the obliquely oriented Henle fiber layer were present in all eyes. Resolution occurred in all patients, either spontaneously (30%) or after treatment with intravitreal anti-vascular endothelial growth factor injections (70%), and was associated with partial visual acuity improvement (from 20/113 to 20/36).

CONCLUSION

"Central bouquet hemorrhage" is a novel descriptive term describing a characteristic round pattern of intraretinal blood in the fovea associated with Henle fiber layer hemorrhage and encountered in a spectrum of macular disease.

Central Bouquet Hemorrhages in Pathologic Myopia: Clinical Characteristics and Prognostic Relevance

PURPOSE

To compare the clinical implications of central bouquet hemorrhages (CBHs) to primarily subretinal hemorrhages, both occurring in the setting of pathologic myopia with lacquer crack formation.

DESIGN

Multicenter retrospective cohort study.

PARTICIPANTS

Twenty-five eyes (11 primarily subretinal hemorrhages and 14 CBH) were monitored over a median of 35 (interquartile range [IQR], 9.50-54) months.

MAIN OUTCOMES MEASURES

Comprehensive ophthalmic examinations and OCT were reviewed. The study employed linear mixed-effects models to compare the impact of CBH versus primarily subretinal hemorrhages on baseline visual acuity (VA), rate of VA improvement, and final VA, adjusting for the follow-up period. Times of hemorrhages reabsorbtion and rate of ellipsoid zone (EZ) layer disruption on OCT were recorded.

RESULTS

Eyes with CBH exhibited significantly worse baseline VA (0.93 ± 0.45 logarithm of the minimum angle of resolution [logMAR]; 20/160 Snellen vs. 0.36 ± 0.26 logMAR [20/50 Snellen], P < 0.001), a slower rate of VA improvement (P = 0.04), and a trend toward worse final VA (0.48 ± 0.47 logMAR [20/60 Snellen] vs. 0.16 ± 0.16 logMAR [20/30 Snellen], P = 0.06) compared with eyes with primarily subretinal hemorrhages. The CBH group experienced longer median reabsorption times (10 [IQR, 4.6-23.3] months vs. 2.3 [IQR, 2-3.2] months), and a higher prevalence of EZ layer disruption (86% vs. 0%), than the group with primarily subretinal hemorrhages. Central bouquet hemorrhage reabsorption was followed by the appearance of vertical hyperreflective lines in the central fovea in 67% of eyes, persisting for up to 6 years of follow-up.

CONCLUSIONS

Central bouquet hemorrhage signifies a distinct condition in pathologic myopia, characterized by worse visual outcomes, prolonged structural impact, and possible irreversible damage, compared with primarily subretinal hemorrhages. Central bouquet hemorrhage regression should be taken into account in the differential diagnosis of vertical hyperreflective lesions in the central fovea on OCT in eyes with pathologic myopia.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

'Structural OCT changes distinguishing between myopic macular haemorrhages due to choroidal neovascularization and spontaneous Bruch's membrane rupture: the "myopic 2 binary reflective sign"

OBJECTIVE

To evaluate the sensitivity and specificity of structural optical coherence tomography (OCT) in comparison to fluorescein angiography (FA) and OCT angiography (OCTA) in discerning between macular haemorrhages (MH) due to myopic choroidal neovascularization (m-CNV) and idiopathic macular haemorrhage (IMH) in myopic patients and to suggest a new OCT biomarker to discern these two entities.

METHODS AND ANALYSIS

In this longitudinal retrospective study, patients affected by MH and pathological myopia were included. All patients underwent OCTA and FA to discern bleeding from m-CNV or IMH. Furthermore, all patients underwent a structural OCT and 2 expert graders evaluated the presence of the myopic 2 binary reflective sign as a biomarker to discern between IMH and bleeding from m-CNV.

RESULTS

Forty-seven eyes of 47 patients were enrolled. By means of angiographic examinations, 34 out of 47 eyes with MH (57%) were diagnosed as m-CNV, whereas 13 eyes (43%) as IMH. Using structural OCT, the graders identified the presence of the myopic 2 binary reflective sign in 13 out of 13 eyes with IMH. In 33 out of 34 cases with m-CNV, the 2 graders established the absence of the sign. This accounted for 100% of sensibility and 97% of specificity of structural OCT in discerning between MH from m-CNV and IMH.

CONCLUSION

Structural OCT can discern with good reliability between IMH and bleeding from m-CNV based on the presence/ absence of the myopic 2 binary reflective sign. This could be of paramount relevance in the clinical setting for the diagnosis and treatment of HM patients.

ARTIFICIAL INTELLIGENCE'S ROLE IN DIFFERENTIATING THE ORIGIN FOR SUBRETINAL BLEEDING IN PATHOLOGIC MYOPIA

PURPOSE

To identify salient imaging features to support human-based differential diagnosis between subretinal hemorrhage (SH) due to choroidal neovascularization (CNV) onset and SH without CNV (simple bleeding [SB]) in pathologic myopia eyes using a machine learning (ML)-based step-wise approach.

METHODS

Four different methods for feature extraction were applied: GradCAM visualization, reverse engineering, image processing, and human graders' measurements. GradCAM was performed on a deep learning model derived from Inception-ResNet-v2 trained with OCT B-scan images. Reverse engineering consisted of merging U-Net architecture with a deconvolutional network. Image processing consisted of the application of a local adaptive threshold. Available OCT B-scan images were divided in two groups: the first group was classified by graders before knowing the results of feature extraction and the second (different images) was classified after familiarization with the results of feature extraction.

RESULTS

Forty-seven and 37 eyes were included in the CNV group and the simple bleeding group, respectively. Choroidal neovascularization eyes showed higher baseline central macular thickness ( P = 0.036). Image processing evidenced in CNV eyes an inhomogeneity of the subretinal material and an interruption of the Bruch membrane at the margins of the SH area. Graders' classification performance improved from an accuracy of 76.9% without guidance to 83.3% with the guidance of the three methods ( P  = 0.02). Deep learning accuracy in the task was 86.0%.

CONCLUSION

Artificial intelligence helps identifying imaging biomarkers suggestive of CNV in the context of SH in myopia, improving human ability to perform differential diagnosis on unprocessed baseline OCT B-scan images. Deep learning can accurately distinguish between the two causes of SH.

Prediction of the short-term efficacy of anti-VEGF therapy for neovascular age-related macular degeneration using optical coherence tomography angiography

Background

To evaluate whether the specific choroidal neovascularization (CNV) characteristics measured using optical coherence tomography angiography (OCTA) can predict the 6-month prognosis of neovascular age-related macular degeneration (nAMD) after anti-vascular endothelial growth factor (anti-VEGF) therapy.

Methods

Patients with type 1, type 2, or mixed-type neovascularization (NV) were prospectively included. Participants underwent an initial loading phase of three consecutive monthly intravitreal injections of Conbercept (0.5 mg) and were switched to a pro re nata (PRN) treatment strategy. OCTA images were evaluated for eyes that underwent follow-up assessments for more than 6 months. CNV lesions were manually segmented, and the CNV area, vessel area, greatest vascular caliber (GVC), and greatest linear dimension (GLD) were compared between responders and non-responders. Two masked graders independently measured the above-mentioned parameters using OCTA, and consistency was assessed using the intraclass correlation coefficient (ICC) values. Multiple logistic regression analysis was performed to evaluate the effect of a 3-month change in the CNV area, GLD, and GVC on the 6-month response to anti-VEGF agents.

Results

Among the 60 eyes of 60 patients with nAMD, 39 were responders and 21 were non-responders. The proportion of CNV types was significantly different between responders and non-responders (P = 0.009). Patients with type 2 or mixed NV seemed more likely to respond to the treatment (28.2% vs. 0.0%, and 30.8% vs. 23.8%, respectively). The change in GVC showed a significant difference between responders (− 4.98 ± 17.17 μm) and non-responders (11.01 ± 14.10 μm) after three monthly intravitreal anti-VEGF injections. Multiple logistic regression analysis showed that only the change in GVC remained significant after controlling for baseline GVC, injection number, and CNV type (adjusted OR = 1.083; P = 0.008).

Conclusions

Type 2 and mixed-type NV were significantly associated with a better response to anti-VEGF therapy. Changes in GVC after 3 months of treatment were significantly associated with a response to anti-VEGF therapy at 6 months.

IMI Pathologic Myopia

Pathologic myopia is a major cause of visual impairment worldwide. Pathologic myopia is distinctly different from high myopia. High myopia is a high degree of myopic refractive error, whereas pathologic myopia is defined by a presence of typical complications in the fundus (posterior staphyloma or myopic maculopathy equal to or more serious than diffuse choroidal atrophy). Pathologic myopia often occurs in eyes with high myopia, however its complications especially posterior staphyloma can also occur in eyes without high myopia.

Owing to a recent advance in ocular imaging, an objective and accurate diagnosis of pathologic myopia has become possible. Especially, optical coherence tomography has revealed novel lesions like dome-shaped macula and myopic traction maculopathy. Wide-field optical coherence tomography has succeeded in visualizing the entire extent of large staphylomas. The effectiveness of new therapies for complications have been shown, such as anti-VEGF therapies for myopic macular neovascularization and vitreoretinal surgery for myopic traction maculopathy.

Myopia, especially childhood myopia, has been increasing rapidly in the world. In parallel with an increase in myopia, the prevalence of high myopia has also been increasing. However, it remains unclear whether or not pathologic myopia will increase in parallel with an increase of myopia itself. In addition, it has remained unclear whether genes responsible for pathologic myopia are the same as those for myopia in general, or whether pathologic myopia is genetically different from other myopia.

Myopic Simple Hemorrhage Presenting as Radial Hemorrhage in Henle's Fiber Layer

This case report describes a simple hemorrhage (SH) presenting as radial hemorrhage in Henle's fiber layer (HFL) in a patient with high myopia. A 26-year-old girl with high myopia was referred to our center for sudden onset of decreased vision and a central scotoma in the right eye (OD). Best corrected visual acuity (BCVA) was 20/100 OD. Fundus examination showed a stellate intraretinal hemorrhage in the fovea of the OD. The hemorrhage was organized in a peculiar petaloid pattern with feathery distal edges, suggesting localization within the radially oriented HFL. The presence of both choroidal neovascularization and microvascular abnormalities consistent with macular telangiectasia type 2 (MacTel 2) were excluded. Based on these findings, a diagnosis of myopic SH was made. At 4-month follow-up BCVA OD spontaneously improved to 20/40, without any treatment been ever administered to the patient. Spectral-domain optical coherence tomography OD showed reabsorption of the hemorrhage and almost complete restoration of the foveal architecture. The intraretinal location and spread of the hemorrhage into the HFL in our patient are an unusual presentation of SH, which vividly highlights the anatomy of the fovea. Since fibers in HFL are quite delicate and loosely arranged, this layer is very susceptible to deposition of transudates, exudates, hemorrhage, and other products. Radial hemorrhage in HFL has been originally reported in 4 patients as complication of MacTel 2. It has been previously postulated that it may represent a characteristic finding in MacTel 2 that may develop as a result of microvascular abnormalities of the deep retinal capillary plexus. On the contrary, our data suggest that radial hemorrhage in the HFL does not represent a characteristic finding of MacTel 2, but must rather be considered a non-specific sign with multiple possible etiologies.

Fish oil supplementation and repeated macular hemorrhage without choroidal neovascularization: A case report

Macular hemorrhage can occur spontaneously and repeatedly without choroidal neovascularization or other known lesions associated with myopia. We report a case of repeated myopic macular hemorrhage following fish oil supplementation. A 32-year-old male was referred with newly acquired paracentral scotoma in the left eye. Serial retinal imaging, including fundus photography, fluorescein angiography, and spectral-domain optical coherence tomography were performed. Fundus photography and fluorescein angiography showed a subtle red-colored lesion nasal to the fovea. Optical coherence tomography showed a dome shaped elevation in the ellipsoid zone and interdigitation zone in the left eye. No known ocular risk factors for macular hemorrhage, such as choroidal neovascularization, lacquer cracks, Fuch’s spot or choroid thinning or keratoconus were observed. After 2 months without any treatment, the left eye lesion disappeared. However 2 weeks later, another newly developed red-colored lesion close to the left fovea was observed. At that moment, the detailed medical history revealed that the patient had been regularly taking a high dose of commercially available fish oil supplement beginning one month before the first macular hemorrhage. After discontinuation of the fish oil, the second left hemorrhage resolved gradually over the following 8 weeks. No recurrent hemorrhages have been detected at the 12 months follow-up visits. Our observations suggest that the relative value of nutritional supplementation with high doses of fish oil should be cautioned in patients with repetitive retinal hemorrhage.

Natural course of the intraretinal hyperreflective sign after macular haemorrhage absorption in eyes with pathologic myopia

PURPOSE

We investigated the natural course of the intraretinal hyperreflective (IRH) sign after macular haemorrhage (MHE) absorption in eyes with pathologic myopia.

METHODS

This prospective observational cohort study evaluated 28 patients with pathologic myopia and MHE. The eyes were categorized into IRH and non-IRH sign groups according to IRH sign development. All eyes were evaluated; follow-up visits were scheduled at 1, 3, 6, 12 and 24 months after MHE absorption.

RESULTS

Of 28 patients (14 eyes each in the IRH and non-IRH groups), nine (32.1%) were men and 19 (67.9%) were women. The average age (mean ± SD) was 46.64 ± 11.92 versus 52.71 ± 12.19 years in the IRH and non-IRH groups. The IRH sign coincided with the MHE invasion site. The sign persisted for the entire follow-up period in all but two eyes, in which it disappeared at 12 and 24 months, respectively. Maximal MHE thickness was significantly greater in the IRH sign group (162.9 ± 67.84 versus 104.2 ± 32.34 μm, p = 0.013). The mean logarithm of the minimum angle of resolution visual acuity was significantly better in the non-IRH sign group at 12 (p = 0.029) and 24 (p = 0.033) months. The incidence of myopic traction maculopathies (MTM) was significantly higher in the IRH (57.1%) than in the non-IRH sign group (14.3%; p = 0.046).

CONCLUSION

The IRH sign can develop after MHE in pathologic myopia and can remain stable long after MHE absorption; furthermore, it is predictive of future MTM.

Clinical features of simple hemorrhage and myopic choroidal neovascularization associated with lacquer cracks in pathologic myopia

PURPOSE

To investigate the clinical features of simple hemorrhage (SH) and myopic choroidal neovascularization (mCNV) lesions in pathologic myopia (PM) accompanied with lacquer cracks (LCs).

METHODS

Altogether 105 PM subjects were recruited with fifty-eight eyes categorized as group LC + SH and sixty eyes as group LC + mCNV. LCs were categorized into stellate and linear subtypes. Eye fundus photography, optical coherence tomography, fluorescein angiography, and indocyanine green angiography were performed. Clinical demographic data, PM maculopathy, peripapillary atrophy, and macular choroidal thickness (mCT) were documented.

RESULTS

Significant differences in age, gender, BCVA, and PM atrophies were observed between LC + SH and LC + mCNV groups. The stellate LC was more common in elder subjects with more severe chorioretinal atrophy and thinner mCT compared with linear LCs (P < 0.05). The mCT in group LC + SH was significantly larger than group LC + CNV (P < 0.001), especially in temporal, inferior, and superior locations of macula. The mCT showed correlation with age (P < 0.001)with a decreasing rate of 0.696 μm/year.

CONCLUSIONS

SH tended to initially occur in younger subjects with linear LCs. mCNV was more common in elder subjects with severe chorioretinal atrophy. Stellate LCs were associated with the worse PM lesions.

Neurodegeneration, gliosis, and resolution of haemorrhage in neovascular age-related macular degeneration, a clinicopathologic correlation

BACKGROUND

To analyse cellular and spatiotemporal factors of neurodegeneration and gliosis in a patient with submacular haemorrhage (SMH) secondary to type 1 macular neovascularization in neovascular age-related macular degeneration (nAMD).

METHODS

This is a case study and clinicopathologic correlation of an 84-year-old white man with nAMD treated with antiangiogenic drugs and photodynamic therapy during a 6-year follow-up. Eyes were recovered for histology 8.23 h after death. In vivo multimodal imaging including optical coherence tomography (OCT) and en face modalities was compared with ex vivo OCT and high-resolution histologic images, using a custom image registration procedure. SMH components were defined (intraretinal, subretinal, sub-retinal pigment epithelium (RPE), and dehemoglobinized blood). Neurodegenerative changes in each of these areas were described. One anonymous donor eye with haemorrhagic nAMD was also reviewed as a comparator.

RESULTS

By in vivo OCT, progressive resolution of the haemorrhage and gradual transformation of sub-RPE fluid to fibrous hyperreflective tissue, progressive macular atrophy, and variation in external limiting membrane (ELM) visibility were observed. Histology showed intense photoreceptor loss with preservation and self-adhesion of macular Müller glia resulting in ELM condensation. The comparator eye exhibited shed cone inner segments among subretinal erythrocytes.

CONCLUSION

This is the most detailed clinicopathologic correlation of nAMD with SMH resolution to date, and the first in the OCT era. Our results reveal profound macular neurodegeneration and gliosis, signified by condensed ELM, soon after haemorrhage begins. Intensified OCT reflectivity of the ELM, an important retinal barrier, has potential as a biomarker for severe photoreceptor loss and gliosis.

Long-Term Natural Outcomes of Simple Hemorrhage Associated with Lacquer Crack in High Myopia: A Risk Factor for Myopic CNV?

Purpose

To investigate the relationship between simple hemorrhage (SH) associated with lacquer crack (LC) and myopic choroidal neovascularization (CNV) in high myopia.

Methods

A cross-sectional evaluation including best-corrected visual acuity (BCVA), axial length, refractive error, color fundus photography, and spectral domain optical coherence tomography (SD-OCT) was performed in patients diagnosed with high myopia and SH. Fundus fluorescein angiography and indocyanine green angiography were performed if the eye was suspected with CNV.

Results

Thirty-three eyes of 27 patients with SH were enrolled in the study. None of the eyes developed CNV at final examination following the occurrence of hemorrhage. Recurrent hemorrhage was observed in 36.5% of the eyes. Compared with the initial BCVA, the final BCVA was significantly improved (P < 0.001) and correlated with the integrity of the ellipsoid zone in SD-OCT. There was no significant difference in the final BCVA between group 1 (LC crossed the central fovea) and group 2 (no LC crossed the central fovea) (P = 0.299).

Conclusions

SH associated with LC is not a risk factor for the development of myopic CNV in patients with high myopia. LCs have little influence on the final BCVA unless the integrity of the ellipsoid zone in the central fovea is disrupted.

Multimodal imaging of linear lesions in the fundus of pathologic myopic eyes with macular lesions

PURPOSE

To detect, using multimodal imaging, lacquer cracks (LCs) and myopic stretch lines (MSLs) in pathologic myopic eyes with macular hemorrhage (MHE) and those without.

METHODS

We collected 18 consecutive pathologic myopic eyes (spherical equivalent ≤ -8.0 diopters) that had presented with linear, yellowish-white lesions in the macula. We categorized the eyes into either the MHE group or the non-MHE group. All underwent fluorescein angiography (FA), near infrared autofluorescence (NIA), indocyanine green angiography (ICGA), and spectral-domain optical coherence tomography (SD-OCT).

RESULTS

In all 18 eyes, the linear lesions were hyperfluorescent under NIA imaging, but hypofluorescent under ICGA. All ten eyes in the MHE group had LCs, and two had both LCs and MSLs. None of the eight eyes in the non-MHE group had LCs. Regarding proximity to the MHE, LCs tended to locate closer than MSLs. Incidental perforating scleral vessels were clearly visible on the tracked SD-OCT scanning line, joining the choroid beneath the border of MHE. Sample cases are illustrated using delicate photographs and explanations.

CONCLUSION

NIA imaging combined with SD-OCT and ICGA can detect and differentiate early the subtle difference between the two types of linear lesions in pathological myopic eyes. Notably, MSLs were not associated with MHEs or LCs in our consecutive series.

Diagnosis and treatment guideline for myopic choroidal neovascularization due to pathologic myopia

Pathologic myopia is a leading cause of visual impairment. Development of myopic choroidal neovascularization (CNV) is one of the most common complications that leads to central vision loss in patients with pathologic myopia. If left untreated, it can cause scarring with expanding macular atrophy leading to irreversible visual loss in a period as short as 5 years. Advancements in multimodal imaging technology have furthered our understanding of the condition; however, further studies are necessary to extend its utility in the diagnosis of myopic CNV. Intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy has become the standard-of-care and the recommended first-line treatment option for myopic CNV. Long-term studies have demonstrated that early treatment of confirmed myopic CNV cases with an intravitreal anti-VEGF agent is useful to avoid late-stage complications. This strategy has also been shown to achieve visual outcome improvements for up to 4 years and visual stabilization up to 6 years. This review article provides an overview of the current knowledge on myopic CNV and discusses recent updates in the diagnosis and management of the condition. Furthermore, treatment recommendations are provided based on the authors' expert opinions.

Photoreceptor inner segment ellipsoid band integrity on spectral domain optical coherence tomography

Spectral domain optical coherence tomography cross-sectional imaging of the macula has conventionally been resolved into four bands. However, some doubts were raised regarding authentication of the existence of these bands. Recently, a number of studies have suggested that the second band appeared to originate from the inner segment ellipsoids of the foveal cone photoreceptors, and therefore the previously called inner segment-outer segment junction is now referred to as inner segment ellipsoidband. Photoreceptor dysfunction may be a significant predictor of visual acuity in a spectrum of surgical and medical retinal diseases. This review aims to provide an overview and summarizes the role of the photoreceptor inner segment ellipsoid band in the management and prognostication of various vitreoretinal diseases.