Choroidal Caverns: A Previously Unreported Optical Coherence Tomography Finding in Best Vitelliform Dystrophy

Subretinal hyporeflective globule: A novel OCT finding in central serous chorioretinopathy

PURPOSE

To describe the subretinal hyporeflective globule in cases of central serous chorioretinopathy (CSC).

METHODS

A retrospective analysis of consecutive cases of CSC presenting to a tertiary eye care center in eastern India was conducted. Subretinal hyporeflective globules were identified as small globular lesions below the external limiting membrane/ellipsoid zone, but above the RPE layer. They had a hyperreflective border with a hyporeflective core and a clear posterior tail of hyper-transmission.

RESULTS

The present study analyzed 137 eyes of 137 patients. Eighty (58.4%) eyes had acute disease at presentation, 48 (35%) eyes had chronic disease, and eight (5.8%) eyes had resolved CSC. Subretinal hyporeflective globules were seen in 27 (21.8%) eyes, of which choroidal caverns were seen in seven (5.1%) eyes. Twenty-five eyes with chronic CSC and only two eyes with acute CSC had subretinal hyporeflective globules. Three eyes with resolved CSC had subretinal hyporeflective globules.

CONCLUSION

We describe subretinal hyporeflective globule as a novel optical coherence tomography (OCT) finding in cases of CSC and describe its clinical correlates.

Presence of Choroidal Caverns in Patients with Posterior and Panuveitis

Choroidal caverns (CCs) have been described in association with age-related macular degeneration and pachychoroid disease. However, it is unknown if caverns are found in patients with chronic non-infectious uveitis (NIU). Herein, we evaluated patients with NIU who had optical coherence tomography and indocyanine green angiography for CCs. Clinical and demographic characteristics were extracted from the chart review. Univariate and multivariate mixed-effects logistical models were used to assess the association between clinical and demographic factors and the presence of CCs. One hundred thirty-five patients (251 eyes) met the inclusion criteria: 1 eye had anterior uveitis, 5 had intermediate uveitis, 194 had posterior uveitis, and 51 had panuveitis. The prevalence of CCs was 10%. CCs were only observed in patients with posterior and panuveitis, with a prevalence of 10.8% and 7.8%, respectively. Multifocal choroiditis (MFC) was the type of uveitis where CCs were most frequently observed, with 40% of eyes with MFC having CCs. In addition, male sex (p = 0.024) was associated with CCs. There was no significant difference in the degree of intraocular inflammation or mean subfoveal choroidal thickness between CC+ and CC- eyes. This is the first study to describe CCs in uveitis. Overall, these findings suggest that caverns may be a sequela of structural and/or vascular perturbations in the choroid from uveitis.

Characteristics and Classification of Choroidal Caverns in Patients with Various Retinal and Chorioretinal Diseases

PURPOSE

To investigate the features of choroidal caverns in diverse retinal diseases with swept-source optical coherence tomography (SS-OCT).

METHODS

Subjects with normal eyes, retinitis pigmentosa (RP), wet age-related macular degeneration (wAMD), acute central serous chorioretinopathy (CSC), or chronic CSC were enrolled. The characteristics of choroidal caverns were evaluated with SS-OCT. The prevalence of choroidal caverns in retinal diseases and the correlations between the number, width and depth of choroidal caverns with the thickness of choroid were analyzed.

RESULTS

Among 315 eyes of 220 subjects, choroidal caverns were found in 110 eyes (34.9%). Choroidal caverns were divided into two categories based on their location and size. Type I was small and usually lobulated, presented in the choroidal capillary and Sattler's layers. Type II was larger, usually isolated, and presented in the Sattler's and Haller's layers. The prevalence of type I in subjects with normal eyes, RP, wAMD, acute CSC, or chronic CSC was 17.4%, 19.6%, 1.6%, 32.8%, and 85.2%, respectively, while that of type II was 0%, 0%, 21.3%, 13.8%, and 53.7%, respectively. The number, width, and thickness of type II choroidal caverns correlated positively with macular choroidal thickness.

CONCLUSIONS

Choroidal caverns could be divided into two categories. Type II choroidal caverns appeared associated with the pachychoroid spectrum and RPE atrophic diseases.

Bilateral choroidal caverns in a child with pachychoroid and anxious personality

Purpose

To report a case of a 7-year-old male patient with bilateral choroidal caverns (CC) and pachychoroid.

Observations

During the Italian COVID-19 lockdown, a 7-year old boy presented with bilateral vision decline that had started two weeks before. Structural optical coherence tomography revealed pachychoroid and CC bilaterally. Other ocular examinations were negative. The patient had an apprehensive personality and symptoms quickly resolved when he was provided with non-prescription glasses; his visual disturbances were thus considered to be functional and factitious.

Conclusions and Importance

Our patient's symptoms remind us that the distress imposed upon psychologically frail subjects by the COVID-19 pandemic may have multifaceted manifestations. The discovery of CC in a pediatric patient with healthy eyes presents us with new questions about the processes of degeneration thought to be the cause for CC. Further studies are needed to estimate the prevalence of CC in the general adult and pediatric populations, as well as in patients with chorioretinal diseases.

Choroidal Caverns in Stargardt Disease

Purpose

To report choroidal caverns in patients affected by recessive Stargardt disease (STGD1) and to investigate its clinical features.

Methods

Retrospective analysis of STGD1 patients recruited at the Regional Reference Center for Hereditary Retinal Degenerations at the Eye Clinic in Florence from 2012 to 2017. Patients included in the study underwent a complete ophthalmic examination including best-corrected visual acuity, color fundus photography, fundus autofluorescence, optical coherence tomography (OCT) and OCT angiography.

Results

Eighty-six patients (172 eyes) were included in the study. Twenty-three eyes (13.3%) of 21 patients presented choroidal caverns. The total number of detected choroidal caverns was 63. Choroidal caverns were only present in patients with stage III and IV STGD. Interestingly, patients with choroidal caverns presented larger macular atrophy (20.53 ± 16.9 mm² vs. 18.11 ± 20.39 mm²), worse visual acuity (1.03 ± 0.29 vs. 0.83 ± 0.26), and a thinner choroidal thickness (245.9 ± 88.7 vs. 266.0 ± 110.5 µm).

Conclusions

Choroidal caverns are present only in the advanced stage of STGD1, and a possible degenerative origin of the finding has been hypothesized.

Choroidal caverns in pachychoroid neovasculopathy

Background. Choroid plays an important role in the pathogenesis of retinal pathology. Choroidal cavern, a recently identifi ed fi nding of optical coherent tomography (OCT), has been described in some degenerative and atrophic forms of retinal pathology. In the literature, there are only a few studies of choroidal cavers in pachychoroid neovasculopathy, newly described form of age related macular degeneration.The aim: to perform a detailed analysis of choroidal structure on OCT scans of patients with pachychoroid neovasculopathy and to reveal the frequency of choroidal caverns identifi cation.Material and methods. The data of 30 patients (30 eyes) aged 64.4 ± 5.6 years with pachychoroid neovascularization were retrospectively analyzed. The patients underwent spectral OCT and OCT-angiography (OCTA) using a Spectralis device (Heidelberg Engineering, Germany). The protocol was “Posterior Pole”, consisting of 61 scans. To assess the structure of the choroid, an enhanced image depth (EDI) module was used. OCT angiography was performed with a scan area of 6 × 6 mm. These methods were compared to identify choroidal caverns.Results. On OCT subretinal type 1 neovascularization was revealed as a fl at detachment of the pigment epithelium and visualization of blood flow on OCTA in the lesion as angled vessels (21 eyes) or a seafan (9 eyes). On OCT-EDI scans, there was diffuse or local choroidal thickening of choroid with an increase in the vessels of the Haller’s layer and thinning of the choriocapillaries. Choroidal caverns appeared on OCT and en-face OCT as areas with low optical density, round or irregular, located in different layers of the chorioid, without hyperrefl ective boundaries. A typical sign of choroidal cavern is the tail of hypertransmission after the cavern toward the sclera. Choroidal caverns were found in 4 of 30 eyes (13.3 %) and were located both near the choroidal neovascularization lesion and beyond this area.Conclusion. The prevalence of choroidal cavities, a new choroidal biomarker, in pachychoroid neovasculopathy was 13.3 %. Identification of these changes is possible with the use of modern diagnostic techniques (OCT-EDI, OCTA and en-face OCT) that allow visualization the state of the choroid. The prognostic signifi cance of choroidal cavities requires further study.

COVID-19 Associated Choroidopathy

The aim of the study is to report on the indocyanine green angiography (ICGA) and OCT findings in patients hospitalized for severe COVID infection. In this observational prospective monocentric cohort study, we included patients hospitalized for severe COVID infection. The main outcomes were ICGA and OCT findings. A total of 14 patients with a mean age of 58.2 ± 11.4 years and a male predominance (9/14 patients; 64%) were included. The main ICGA findings included hypofluorescent spots in 19 eyes (68%), intervortex shunts in 10 eyes (36%), and characteristic "hemangioma-like" lesions in five eyes (18%). "Hemangioma-like" lesions were both unique and unilateral, and showed no washout on the late phase of the angiogram. The main OCT findings included focal choroidal thickening in seven eyes (25%), caverns in six eyes (21%) and paracentral acute middle maculopathy lesions in one eye (4%). All patients hospitalized for severe COVID infection had anomalies on ICGA and OCT. Lesions to both retinal and choroidal vasculature were found. These anomalies could be secondary to vascular involvement related directly or indirectly to the SARS-CoV2 virus.

Choroidal Rift: A New OCT Finding in Eyes with Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSC) is a complex and not entirely understood retinal disease. The aim of our research was to describe a novel optical coherence tomography (OCT) finding named “choroidal rift”, which may be identified in the choroid of eyes with CSC. We collected data from 357 patients (488 eyes) with CSC who had structural OCT and OCT angiography (OCTA) scans obtained. Choroidal rifts were identified as polygonal (and not round-shaped) hyporeflective lesions without hyperreflective margins. Choroidal rifts had to be characterized by a size superior to that of the largest choroidal vessel. Finally, hyporeflective lesions were graded as choroidal rifts only if these lesions had a main development perpendicular to the retinal pigment epithelium. OCT analysis allowed the identification of choroidal rifts in ten eyes from nine patients, all with chronic CSC, with an estimated prevalence rate of 2.1%. In three out of ten cases with choroidal rifts, these lesions spanned all the choroidal layers. In the remaining cases, choroidal rifts only partially spanned the choroidal thickness. In OCTA, choroidal rifts were characterized by the absence of flow. Combining structural OCT and OCTA information, we hypothesized that choroidal rifts may represent interruptions of the choroidal stroma in correspondence of fragile regions (in between expanded larger-sized choroidal vessels). Choroidal rift represents a novel OCT feature, which may characterize eyes with chronic CSC and may have a role in the development of irreversible chorio-retinal changes.

Choroidal cleft simulating choroidal caverns in neovascular age-related macular degeneration

The authors report a case of a female patient affected by neovascular age-related macular degeneration (AMD). In particular, multiple sub-retinal hyperreflective infiltrates were found on optical coherence tomography. Optical coherence tomography examination of her right eye displayed the presence of sub-retinal pigment epithelium hyporeflective spaces located beneath a hyperreflective fibrotic neovascularization. This case highlights the importance of differentiating choroidal clefts from choroidal caverns.