Use of electronic devices by people attending vision rehabilitation services in Italy: A study based on the device and aids registry (D.A.Re)

PURPOSE

To investigate the characteristics of electronic device users, specifically smartphones and tablets, in the Device & Aids Register (D.A.Re), from several low-vision rehabilitation services in Italy.

METHODS

We collected general and clinical information about ocular and systemic diseases, visual function, reading speed and Instrumental Activities of Daily Living (IADL) questionnaire score. Technological details of each optical and electronic device, (including screen size, touch-screen and OCR functions, text-to-speech function) were also collected.

RESULTS

1218 patients (752 females and 466 males) were included in our analysis, mean age 71.5 (±18.8) years. Users of electronic aids (n.237) were slightly younger (67 vs 72 years, p < 0.001) than non-users (n.981), had a worse reading speed (38 vs 65 words/minute), critical print size (43 vs 28 print size, p < 0.001), poorer visual acuity (VA)(1.0 logMAR or less: 30% non-users vs 73% users, p < 0.001) and more commonly visual field restriction within 10° (23% vs 14%, p = 0.001). A similar proportion of users and non-users were retired (about 70%) and about 16-17% were employed. The use of portable electronic devices (5″or less, p < 0.001; 6″ to 18″ screen size, p = 0.017) was associated with better IADL scores, and the use of stand devices with worse IADL score (p < 0.001); Furthermore, using smartphones and tablets (193 subjects) was strongly associated with better IADL scores.

CONCLUSION

We found that using electronic devices, and especially smartphone and tablets, were associated with better vision-related quality of life in low-vision people attending rehabilitation services. While this association does not mean causality, these findings seemed robust to confounder adjustment.

Macular Neovascularization Secondary to Subclinical Angioid Streaks in Age-Related Macular Degeneration: Treatment Response to Anti-VEGF at 2-Year Follow-up

INTRODUCTION

To characterize the response to antivascular endothelial growth factor (VEGF) treatment of macular neovascularization (MNV) secondary to age-related macular degeneration (AMD) with subclinical angioid streaks (AS) during a 2-year follow-up.

METHODS

Retrospective, longitudinal, case-control, and multicentric study. Among a cohort of neovascular AMD population, we selected patients with subclinical AS and treatment-naïve MNV treated with anti-VEGF for a 2-year follow-up. An age- and sex-matched control group with treatment-naïve MNV secondary to AMD without subclinical AS was selected. Demographics and differences in treatment response (i.e., number of injections needed, anatomical and functional outcomes) between the two groups were analyzed.

RESULTS

Among 102 eyes of 102 patients with neovascular AMD, 34 eyes of 34 patients (82 ± 6 years old) were included in the subclinical AS group, whereas 68 eyes of 68 patients (81 ± 6 years old, p = 0.342) in the control group. All eyes with subclinical AS presented RPD compared to 56% of eyes without subclinical AS (p < 0.001). During the 2-year follow-up, eyes with subclinical AS needed more injections (10.6 ± 3.2 vs 8.3 ± 3.1 injections for eyes with and without subclinical AS, respectively, p < 0.001). Visual acuity (VA) decreased during the treatment (from 0.53 ± 0.37 at the baseline to 0.69 ± 0.45 LogMAR at 2-year follow-up, p = 0.044) in eyes with subclinical AS; no VA changes were observed in the control group (p = 0.798). RPE atrophy at the end of the 2-year follow-up affected 74% of cases with subclinical AS and 29% of cases of the control group (p < 0.001).

CONCLUSIONS

MNVs secondary to AMD with subclinical AS are characterized by worse functional and anatomical outcomes after 2-year anti-VEGF treatment compared to MNV secondary to AMD without subclinical AS, supporting the different pathophysiological mechanisms involved in this recently described AMD phenotype.

Deep learning for automatic prediction of early activation of treatment naïve non-exudative MNVs in AMD

BACKGROUND

Around 30% of non-exudative macular neovascularizations(NE-MNVs) exudate within 2 years from diagnosis in patients with age-related macular degeneration(AMD).The aim of the study is to develop a deep learning classifier based on optical coherence tomography(OCT) and OCT angiography(OCTA) to identify NE-MNVs at risk of exudation.

METHODS

AMD patients showing OCTA and fluorescein angiography (FA) documented NE-MNV with a 2-years minimum imaging follow-up were retrospectively selected. Patients showing OCT B-scan-documented MNV exudation within the first 2 years formed the EX-GROUP while the others formed QU-GROUP.ResNet-101, Inception-ResNet-v2 and DenseNet-201 were independently trained on OCTA and OCT B-scan images. Combinations of the 6 models were evaluated with major and soft voting techniques.

RESULTS

Eighty-nine (89) eyes of 89 patients with a follow-up of 5.7 ± 1.5 years were recruited(35 EX GROUP and 54 QU GROUP). Inception-ResNet-v2 was the best performing among the 3 single convolutional neural networks(CNNs).The major voting model resulting from the association of the 3 different CNNs resulted in improvement of performance both for OCTA and OCT B-scan (both significantly higher than human graders' performance). Soft voting model resulting from the combination of OCTA and OCT B-scan based major voting models showed a testing accuracy of 94.4%. Peripheral arcades and large vessels on OCTA enface imaging were more prevalent in QU GROUP.

CONCLUSIONS

Artificial intelligence shows high performances in identifications of NE-MNVs at risk for exudation within the first 2 years of follow up, allowing better customization of follow up timing and avoiding treatment delay. Better results are obtained with the combination of OCTA and OCT B-scan image analysis.

Phenotypic characterization of predictors for development and progression of geographic atrophy using optical coherence tomography

PURPOSE

To evaluate the impact of optical coherence tomography (OCT) phenotypes preceding atrophy related to age-related macular degeneration (AMD) on the progression of atrophic lesions.

METHODS

In this observational retrospective cohort study, a total of 70 eyes of 60 consecutive patients with intermediate AMD with a minimum follow-up of 24 months were included. The atrophy was quantified using fundus autofluorescence, also considering the directionality of atrophy as centrifugal and centripetal progression rates.Main outcome measures were geographic atrophy (GA) progression rate (mm2/year) and square root-transformation GA (mm2/year).

RESULTS

The best-fit model for GA (OR: 1.81, p<0.001) and square root-transformation GA (OR: 1.36, p<0.001) areas revealed that the main baseline predictor was the presence of an RPE-basal lamina-(BL)-Bruch's membrane (BrM) splitting. Large drusen at baseline appeared protective for the GA area lesion expansion over time (OR: 0.52, p<0.001) when considered with other confounders.

CONCLUSION

A thin RPE-BL-BrM splitting without evidence of neovascularization on OCT angiography likely represents an OCT signature for late basal laminar deposits. Identifying this phenotype can help identify individuals with a higher risk of rapid progression and atrophy expansion.

Use of the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) questionnaires for clinical decision-making and psychological referral in ophthalmic care: a multicentre observational study

OBJECTIVES

The aim of this study was to evaluate the influence of anxiety and depression on clinician decision-making in patients suffering from chronic eye disease in ophthalmological clinical practice.

DESIGN AND SETTING

This multicentre observational study, in collaboration with the WHO, included ophthalmologists and their patients affected by chronic eye disease. States of anxiety and depression were screened with specific questionnaires, the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), self-administered by patients before the visit. In the present analysis, we report data from three major eye care centres in Italy between 2021 and 2022.

PRIMARY AND SECONDARY OUTCOMES

To assess self-reported changes in ophthalmologists' clinical approach (communication style and their clinical-therapeutic strategies) and decisions after knowing questionnaire scores (primary aim), and to analyse the PHQ-9 and GAD-7 scores in patients with chronic eye diseases (secondary aim).

RESULTS

41 ophthalmologists and 359 patients were included. The results from PHQ-9 and GAD-7 scores showed critical depression and anxiety status scores (PHQ-9 ≥5 and GAD-7 ≥10) in 258 patients. In 74% of cases, no actions were taken by the ophthalmologists based on these scores; in 26% of cases, they changed their clinical approach; and in 14% of cases, they referred the patients for psychological/psychiatric evaluation.

CONCLUSIONS

States of anxiety and depression affect many patients with chronic eye conditions and need to be detected and managed early to improve patients' well-being. Providing ophthalmologists with knowledge of their patients' psychological conditions can change the clinical management and attitude towards referral for a psychological evaluation. Further studies are needed to expand our knowledge of how to raise awareness among ophthalmologists regarding multimorbidity of patients suffering from chronic eye diseases in order to achieve better clinical outcomes.

In vivo assessment of associations between photoreceptors structure and macular perfusion in type 1 diabetes

PURPOSE

To explore the potential relationships between macular vascular network and different adaptive optics (AO) metrics in patients with type 1 diabetes mellitus (DM1) with no signs (NoDR) or mild non-proliferative diabetic retinopathy (NPDR).

DESIGN

Observational cross-sectional study.

METHODS

Forty eyes of consecutive patients with DM1 (12 NoDR and 28 NPDR) and 10 healthy age-matched control subjects were included. All patients and controls were imaged using AO retinal camera and PLEX Elite 9000 optical coherence tomography (OCT) angiography (OCTA). The AO outcome measures to evaluate the cone photoreceptor mosaic characteristics were as follows: (1) Cone density (CD); (2) Linear Dispersion Index (LDi) and (3) Heterogeneity Packing Index (HPi). The OCTA outcome measures included: (1) superficial capillary plexus (SCP) perfusion density (PD); (2) deep capillary plexus (DCP) PD and (3) the choriocapillaris (CC) flow deficit percentage (FD%).

RESULTS

NPDR group exhibited a close relationship between cone metrics and CC FD. Notably, CC FD% increase along with LDi (p=0.035), while the increasing CC FD% were associated with reducing CD (p=0.042) and the HPi (p=0.017). Furthermore, the OCTA parameters, including PD SCP and DCP, showed a significant negative correlation with CD.

CONCLUSIONS

Our results demonstrated the relationship between macular perfusion at both retinal and choroidal levels and the cone mosaic in patients with DM1 interpolating swept-source-OCTA and AO metrics. In NPDR eyes, the photoreceptor damage was accompanied by CC insufficiency since the early stages of the disease.

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.

SUBRETINAL LIPID GLOBULES AN EARLY BIOMARKER OF MACULAR NEOVASCULARIZATION IN EYES WITH INTERMEDIATE AGE-RELATED MACULAR DEGENERATION

PURPOSE

To explore the association between subretinal lipid globules (SLGs) detected in eyes with intermediate age-related macular degeneration with the presence of nonexudative macular neovascularization.

METHODS

This was a retrospective analysis of 113 consecutive patients with bilateral intermediate age-related macular degeneration (226 eyes) followed for a least 6 months. All eyes underwent multimodal imaging with fundus autofluorescence, spectral-domain optical coherence tomography, and optical coherence tomography angiography. Subretinal lipid globules were identified on spectral-domain optical coherence tomography as round hyporeflective lesions measuring 31 to 157 µ m located between the ellipsoid zone and the retinal pigment epithelium/Bruch membrane complex. Nonexudative macular neovascularization was detected with optical coherence tomography angiography. The features of NE-MNV lesions detected in eyes with SLGs were compared with those in eyes without SLGs.

RESULTS

Subretinal lipid globules were identified in 15 eyes of which 14 eyes (93.3%) demonstrated NE-MNV on optical coherence tomography angiography. In the remaining 98 eyes without SLGs, 18 (18.4%) displayed NE-AMD on optical coherence tomography angiography. The macular neovascularization area was larger in the SLG subgroup (+0.38 vs. +0.21 mm 2 , P = 0.008) and showed faster horizontal growth (+727 µ m, CI 95% 250.4, 1,205.4) than MNV in eyes without SLGs (+64.9 µ m, CI 95%, 24.3, 154) on optical coherence tomography B-scans. After a mean of 11.6 months, the conversion rate to exudative MNV was similar between eyes with SLGs and those without SLGs [8/26 (38.5%) versus 3/13 (27.3%), P = 0.56)].

CONCLUSION

The detection of SLGs in eyes with intermediate age-related macular degeneration was strongly correlated with the presence of NE-MNV. Although these MNV lesions were larger and grew faster than NE-MNV detected in eyes lacking SLGs, the rates of conversion to exudative MNV appeared similar.

Progression Biomarkers of Microvascular and Photoreceptor Changes Upon Long-Term Evaluation in Type 1 Diabetes

Purpose

To assess demographic, metabolic, and imaging predictors influencing microvasculature and photoreceptors changes over a 4-year follow-up in type 1 diabetes mellitus (DM1).

Methods

This prospective cohort study enrolled patients with DM1 with mild non-proliferative diabetic retinopathy. Complete medical records, glycosylated hemoglobin (HbA1c), optical coherence tomography angiography, and adaptive optics were collected for the 4 years of follow-up. The main outcome measures included perfusion density at the superficial capillary plexus (SCP) and deep capillary plexus (DCP), choriocapillaris (CC) flow deficits (FDs, %), cone density, linear dispersion index (LDi), and heterogeneity packing index (HPi).

Results

The SCP presented a dichotomic perfusion trend, with increasing PD at 1 and 2 years and a subsequent decline (P < 0.001). DCP presented a similar trend in the first 2 years (P < 0.01) but not at the following time points, whereas CC FDs constantly increased over time (P < 0.01). The best-fitted model for the microvascular parameters demonstrated that the main factors affecting SCP included time (P < 0.001), duration of diabetes (P = 0.007), and HbA1c (P = 0.03), whereas the DCP was influenced by LDi modifications (P = 0.006). The LDi and HPi were mainly influenced by SCP and CC perfusion in the parafovea (P = 0.02).

Conclusions

This study demonstrated an initial vasodilatory phenomenon resulting from a compensatory mechanism from the superficial vasculature, followed by capillary dropout. Initially, it would seem that there was an adaptive response by the DCP to the needs of the photoreceptors. Although the SCP may initially support the DCP, when the microvascular damage becomes diffuse and involves the SCP and CC it directly affects photoreceptor integrity.

Prognostic Imaging Biomarkers in Diabetic Macular Edema Eyes Treated with Intravitreal Dexamethasone Implant

BACKGROUND

The aim was to evaluate predictive value of baseline optical coherence tomography (OCT) and OCT angiography (OCTA) parameters in diabetic macular edema (DME) treated with dexamethasone implant (DEXi).

METHODS

OCT and OCTA parameters were collected: central macular thickness (CMT), vitreomacular abnormalities (VMIAs), intraretinal and subretinal fluid (mixed DME pattern), hyper-reflective foci (HRF), microaneurysms (MAs) reflectivity, ellipsoid zone disruption, suspended scattering particles in motion (SSPiM), perfusion density (PD), vessel length density, and foveal avascular zone. Responders' (RES) and non-responders' (n-RES) eyes were classified considering morphological (CMT reduction ≥ 10%) and functional (BCVA change ≥ 5 ETDRS letters) changes after DEXi. Binary logistic regression OCT, OCTA, and OCT/OCTA-based models were developed.

RESULTS

Thirty-four DME eyes were enrolled (18 treatment-naïve). OCT-based model combining DME mixed pattern + MAs + HRF and OCTA-based model combining SSPiM and PD showed the best performance to correctly classify the morphological RES eyes. In the treatment-naïve eyes, VMIAs were included with a perfect fit for n-RES eyes.

CONCLUSION

The presence of DME mixed pattern, a high number of parafoveal HRF, hyper-reflective MAs, SSPiM in the outer nuclear layers, and high PD represent baseline predictive biomarkers for DEXi treatment responsiveness. The application of these models to treatment-naïve patients allowed a good identification of n-RES eyes.

Nascent Geographic Atrophy as a Predictor of Type 3 Macular Neovascularization Development

PURPOSE

To investigate the association of nascent geographic atrophy (GA) preceding the development of exudative type 3 macular neovascularization (MNV) in patients with age-related macular degeneration (AMD).

DESIGN

Retrospective longitudinal study.

PARTICIPANTS

Patients with AMD diagnosed with treatment-naive exudative type 3 MNV in 1 or both eyes were evaluated. Inclusion criteria included serial tracked structural OCT examinations for ≥ 2 years before the detection of exudative type 3 MNV.

METHODS

Clinical characteristics and retinal imaging, including structural OCT at baseline and at each follow-up examination, were analyzed. Eyes showing the presence of nascent GA during the follow-up were selected for analysis of prevalence, and clinical characteristics at the site of subsequent type 3 MNV development.

MAIN OUTCOME MEASURES

Description of the prevalence and clinical characteristics of nascent GA at the site of subsequent type 3 MNV development.

RESULTS

Overall, 97 eyes affected by type 3 MNV meeting inclusion criteria were analyzed. Of 97 eyes (71 patients), 22 eyes of 21 patients (mean age 82 ± 9 years) showed nascent GA preceding exudative type 3 MNV. The observed prevalence of nascent GA preceding exudative type 3 MNV was 22.7% (95% confidence interval, 14.4%-31.0%). Exudative type 3 MNV developed a mean of 9 ± 6 months after detection of nascent GA. The presence of reticular pseudodrusen in the study eye did not significantly influence the timing of exudative type 3 MNV development after the observation of nascent GA (P > 0.1 in all analyses). Reduced best-corrected visual acuity was recorded at the exudative type 3 stage in comparison with the nascent GA stage (P = 0.003).

CONCLUSIONS

As nascent GA may precede the development of exudative type 3 MNV, the detection of nascent GA in eyes with AMD may warrant closer surveillance to identify early exudative type 3 MNV warranting treatment.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Towards a better understanding of non-exudative choroidal and macular neovascularization

Non-exudative macular and choroidal neovascularization (MNV and CNV) usually refers to the entity of treatment-naïve type 1 neovascularization in the absence of associated signs of exudation. Histopathological studies, dating back in the early 70s, identified the presence of non-exudative MNV, but the first clinical report of this finding was in the late 90s using indocyanine green angiography in eyes with age-related macular degeneration (AMD). With more advanced retinal imaging, there has been an ever increasing appreciation of non-exudative MNV associated with AMD and CNV with other macular disorders. However, consensus regarding the exact definition and the clinical management of this entity is lacking. Furthermore, there may be variation in the imaging features and clinical course suggesting that a spectrum of disease may exist. Herein, we review the large body of published work that has provided a better understanding of non-exudative MNV and CNV in the last decade. The prevalence, multimodal imaging features, clinical course, and response to treatment are discussed to elucidate further key insights about this entity. Based on these observations, this review also proposes a new theory about the origin and course of different sub-types of non-exudative MNV/CNV which can have different etiologies and pathways according to the clinical context of disease.

Ocular Biomarkers for Alzheimer Disease Dementia: An Umbrella Review of Systematic Reviews and Meta-analyses

Importance

Several ocular biomarkers have been proposed for the early detection of Alzheimer disease (AD) and mild cognitive impairment (MCI), particularly fundus photography, optical coherence tomography (OCT), and OCT angiography (OCTA).

Objective

To perform an umbrella review of systematic reviews to assess the diagnostic accuracy of ocular biomarkers for early diagnosis of Alzheimer disease.

Data Sources

MEDLINE, Embase, and PsycINFO were searched from January 2000 to November 2021. The references of included reviews were also searched.

Study Selection

Systematic reviews investigating the diagnostic accuracy of ocular biomarkers to detect AD and MCI, in secondary care or memory clinics, against established clinical criteria or clinical judgment.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline checklist was followed and the Risk Of Bias in Systematic reviews tool was used to assess review quality.

Main Outcomes and Measures

The prespecified outcome was the accuracy of ocular biomarkers for diagnosing AD and MCI. The area under the curve (AUC) was derived from standardized mean difference.

Results

From the 591 titles, 14 systematic reviews were included (median [range] number of studies in each review, 14 [5-126]). Only 4 reviews were at low risk of bias on all Risk of Bias in Systematic Reviews domains. The imaging-derived parameters with the most evidence for detecting AD compared with healthy controls were OCT peripapillary retinal nerve fiber layer thickness (38 studies including 1883 patients with AD and 2510 controls; AUC = 0.70; 95% CI, 0.53-0.79); OCTA foveal avascular zone (5 studies including 177 patients with AD and 371 controls; AUC = 0.73; 95% CI, 0.50-0.89); and saccadic eye movements prosaccade latency (30 studies including 651 patients with AD/MCI and 771 controls; AUC = 0.64; 95% CI, 0.58-0.69). Antisaccade error was investigated in fewer studies (12 studies including 424 patients with AD/MCI and 382 controls) and yielded the best accuracy (AUC = 0.79; 95% CI, 0.70-0.88).

Conclusions and Relevance

This umbrella review has highlighted limitations in design and reporting of the existing research on ocular biomarkers for diagnosing AD. Parameters with the best evidence showed poor to moderate diagnostic accuracy in cross-sectional studies. Future longitudinal studies should investigate whether changes in OCT and OCTA measurements over time can yield accurate predictions of AD onset.

Effect of intravitreal dexamethasone implant in treatment-naive and previously-treated patients with diabetic macular edema

PURPOSE

To document the effects of intravitreal dexamethasone implant on retinal microvasculature in patients with diabetic retinopathy complicated by center-involving macular edema.

METHODS

35 eyes of 35 patients affected by retinopathy due to type 2 diabetes (15 treatment-naïve and 20 previously treated) were included in this retrospective study with a follow-up of 4 months. Foveal avascular zone (FAZ) area and superficial capillary plexus (SCP) and deep capillary plexus (DCP) densities in the foveal and parafoveal areas were measured by optical coherence tomography angiography (OCTA) at baseline and 2 and 4 months post-injection. Intraocular pressure, morphological and functional parameters were evaluated.

RESULTS

a significant difference was found in both groups at 2 months after injection in terms of functional (BCVA, p < 0.05) and morphological (CMT, p < 0.05) parameters. During follow-up, FAZ area, SCP, and DCP in the foveal and parafoveal areas did not change significantly.

CONCLUSIONS

intravitreal dexamethasone implant is effective in the treatment of diabetic center-involving macular edema and was associated with significant improvements in BCVA and CMT at 2 months after injection. After a single dexamethasone implant injection, FAZ area and retinal vascular density does not show significant variations in both naive and non-naive DME patients subgroups.

Cortisol awake response imbalance as an indicator of acute central serous chorioretinopathy: Relationship with choriocapillaris and choroidal features

Purpose

The purpose of the present study was to measure in central serous chorioretinopathy (CSC) the salivary cortisol awake response (CAR) delta percentage (Δ%) variation, a distinct and robust indicator of cortisol rhythm during wakefulness, commonly proposed as a marker of hypothalamic-pituitary adrenal (HPA) axis activity, whose alteration is frequently associated with several adverse health outcomes.

Methods

In the present cross-sectional observational study, salivary CAR Δ% variation was assessed in 17 adult male subjects affected by acute naïve CSC and compared to 17 matched healthy controls. Choroid vasculature metrics were assessed in the study population by measuring the subfoveal choroidal thickness (FCT) and the choroidal vascularity index (CVI) by the imaging technique of enhanced-depth imaging spectral-domain optical coherence tomography (EDI-SD-OCT). Furthermore, flow signal void area features of the choriocapillaris were evaluated in the study population using OCT angiography (OCTA).

Results

Both the control and CSC groups showed a physiological cortisol increase that occurred during the first 30 min after awaking. However, CSC adult male patients showed remarkably blunted CAR Δ% variation in comparison with controls, which might reflect a CSC-related imbalance of HPA axis activity. Statistically significant correlations were shown by Pearson’s correlation test between salivary CAR Δ% and the selected choroidal and choriocapillaris imaging biomarkers (FCT, CVI, and flow signal void area) in the study population.

Conclusion

In conclusion, alterations of the CAR Δ% increase, associated with choroidal-retinal metrics, might provide a window into the physiopathology of acute CSC, suggesting a possible common factor to explain the association between stress and CSC.

Sub-retinal pigment epithelium tubules in non-neovascular age-related macular degeneration

To describe a novel optical coherence tomography (OCT) signature resembling sub-retinal pigment epithelium (RPE) tubules (SRT) in non-neovascular age-related macular degeneration (AMD). Patients suffering from non-neovascular AMD with complete medical records and multimodal imaging were retrospectively revised in three different tertiary care centers. Multimodal imaging included color fundus photograph, spectral-domain OCT (Spectralis, Heidelberg Engineering, Germany), fundus autofluorescence, OCT angiography (RTVue XR Avanti, Optovue, Inc., Fremont, CA). A total of 7 eyes of 7 patients with drusenoid pigment epithelium detachment (PED) were consecutively analyzed. The sub-RPE tubules appeared as ovoidal structures with a hyperreflective contour and hyporeflective interior appreciable in the sub-RPE-basal lamina (BL) space on OCT B-scan. The anatomical location of the sub-RPE formations was lying above the Bruch’s membrane in 5/7 cases (71.4%) or floating in the sub-RPE-BL space in 2/7 cases (28.6%). En-face OCTA revealed a curvilinear tubulation-like structure corresponding to SRT without flow signal. Sub-RPE tubules represent a newly identified OCT signature observed in eyes with drusenoid PED. The presumed origin may include a variant of calcified structure or alternatively activated RPE cells with some residual BL or basal laminar deposits attracted to BrM for craving oxygen.

Multimodal Study of PRPH2 Gene-Related Retinal Phenotypes

PRPH2 gene mutations are frequently found in inherited retinal dystrophies (IRD) and are associated with a wide spectrum of clinical phenotypes. We studied 28 subjects affected by IRD carrying pathogenic PRPH2 mutations, belonging to 11 unrelated families. Functional tests (best-corrected visual acuity measurement, chromatic test, visual field, full-field, 30 Hz flicker, and multifocal electroretinogram), morphological retino-choroidal imaging (optical coherence tomography, optical coherence tomography angiography, and fundus autofluorescence), and clinical data were collected and analyzed. Common primary complaints, with onset in their 40s, were visual acuity reduction and abnormal dark adaptation. Visual acuity ranged from light perception to 20/20 Snellen. Visual field peripheral constriction and central scotoma were found. Chromatic sense was reduced in one third of patients. Electrophysiological tests were abnormal in most of the patients. Choroidal neovascular lesions were detected in five patients. Three novel PRPH2 variants were found in four different families. Based on the present multimodal study, we identified seven distinct PRPH2 phenotypes in 11 unrelated families carrying either different mutations or the same mutation, both within the same family or among them. Fundus autofluorescence modality turned out to be the most adequate imaging method for early recognition of this dystrophy, and the optical coherence tomography angiography was highly informative to promptly detect choroidal neovascularization, even in the presence of the extensive chorioretinal atrophy phenotype.

Differences in cysts characteristics and related influence on the anatomical response after dexamethasone implant in diabetic macular oedema

PURPOSE

To assess the clinical significance of suspended scattering particles in motion (SSPiM) and different cystic phenotypes in diabetic macular oedema (DME) treated with dexamethasone implant (DEX-i).

METHODS

A retrospective review of type 2 diabetic patients with DME treated with a DEX-i was conducted. Swept-source optical coherence tomography angiography (OCTA, PLEX Elite 9000) with a 3-mm volume cube was performed. Regions of interest were delineated with Fiji software (version 2.1.0/1.53.c) in the superficial vascular complex (SVC) and deep capillary plexus (DCP) at baseline, 2- and 4-months after DEX-i. SSPiM was defined as regions of variable reflectivity with a decorrelation signal. Without a detectable decorrelation signal, its counterpart was addressed as 'corpuscular,' while hyporeflective cysts were optical empty without hyperreflective material enclosed.

RESULTS

After treatment, the hyporeflective component demonstrated substantial reabsorption in the SVC (-95.4% at 2- and -84.4% at 4-months, p < 0.01 both) and DVC (-84.4%, 2-months), with a less critical decrease of the corpuscular component in the SVC (2-months: -41.9%, p = 0.001 and 4 months: -1.8%, p = 0.73), and not significant in the DVC. SSPiM did not significantly change in the SVC and DVC neither at 2- and 4-months (p > 0.05, all).

CONCLUSIONS

After a single DEX-i, the clearance of different cystic phenotypes proceeds with resorption of hyporeflective, followed by corpuscular components. SSPiM demonstrated minimal response, indicating a severe BRB breakdown that may require repeated treatment to reach a satisfactory anatomical response.

Functional Correlates of Outer Retina Remodeling in Intermediate Age-Related Macular Degeneration Using Microperimetry

Purpose

To assess the effect of drusen morphometric changes and choroidal vascular modifications on retinal sensitivity (RS) evaluated through microperimetry in intermediate age-related macular degeneration (iAMD).

Methods

A retrospective review of 18 iAMD patients (18 eyes) with a 12-month follow-up was performed. Eye-tracked spectral-domain optical coherence tomography was obtained, with automatic segmentation of the outer retinal layer (ORL) delineating the drusen area from the external limiting membrane to Bruch's membrane and outer nuclear layer (ONL) thickness maps adjusted manually, as needed. Advanced retinal pigment epithelium analysis was also performed with a ZEISS PLEX Elite 900. Microperimetry obtained under mesopic conditions was overlaid with the corresponding thickness maps with Fiji software. The choroidal vascularity index (CVI) was calculated in the subfoveal b-scan and volumetric in the central 1-mm subfield.

Results

A reduced central ONL thickness was strongly associated with RS decline at the same region (r = 0.69, P = 0.002) and globally (r = 0.80, P < 0.001) at baseline, but also at 1 year in the central subfield (central: r = 0.70, P = 0.001). One-year subfoveal CVI variation, differently from volumetric CVI, directly influenced the central (r = 0.64, P = 0.004) and global RS (r = 0.59, P = 0.009), indicating that a CVI reduction negatively affected RS. A greater volumetric CVI within central 1-mm was associated with ORL thickening at 1 year (r = 0.61, P = 0.008).

Conclusions

Progressive degeneration of the ONL is related to irreversible photoreceptor dysfunction in iAMD. Likewise, choroidal vascular modifications are associated with a significant functional decline in the central region and diffusely.

Optical Coherence Tomography Angiography In Central Retinal Vein Occlusion: Macular Changes And Their Correlation With Peripheral Nonperfusion At Ultra-Widefield Fluorescein Angiography

INTRODUCTION

To investigate the correlation between ischemic index (ISI) measured on ultra-widefield (UWF) fluorescein angiography (FA) images and macular parameters obtained by optical coherence tomography angiography (OCT-A) in eyes affected by central retinal vein occlusion (CRVO).

METHODS

Retrospective study of data from 12 eyes affected by treatment-naïve CRVO. All patients underwent a comprehensive ocular examination including structural OCT, OCT-A, and UWF FA. Variables analyzed included best-corrected visual acuity (BCVA) measured with the ETDRS chart; foveal avascular zone (FAZ) area at full-thickness OCT-A angiogram; perfusion density (PD) in the superficial (SCP) and deep capillary plexus (DCP); ISI; and central macular thickness (CMT).

RESULTS

ISI showed a significant positive correlation with FAZ area (r=0.63, p=0.019) and a significant negative correlation with PD in the SCP (r=-0.62, p=0.022), PD in the DCP (r=-0.66, p=0.011), and BCVA (r=-0.75, p=0.002). FAZ area also negatively correlated to PD in the SCP (r=-0.75, p=0.002) and DCP (r=-0.64, p=0.016). BCVA positively correlated to PD in the SCP (r=0.67, p=0.009) and DCP (r=0.68, p=0.008), while a negative correlation was found with FAZ area (r=-0.65, p=0.013) and CMT (r=-0.70, p=0.006).

DISCUSSION/CONCLUSION

OCT-A macular parameters (namely, FAZ area and PD of SCP and DCP) significantly correlated with ISI, a quantitative way to assess peripheral retinal nonperfusion on UWF FA. Macular OCT-A analysis may help in assessing the need for additional UWF FA testing in eyes affected by CRVO.

Effectiveness of a Hydrophilic Curcumin-Based Formulation in Coadjuvating the Therapeutic Effect of Intravitreal Dexamethasone in Subjects With Diabetic Macular Edema

Purpose: This study evaluates if the addition of a curcumin formulation with a polyvinylpyrrolidone-hydrophilic carrier (CHC; Diabec^®, Alfa Intes, Italy) to intravitreal injections of dexamethasone (DEX-IVT) can affect the morphological retinal characteristics, extending the steroid re-treatment period in patients with diabetic macular edema (DME).

Methods: A randomized controlled clinical trial was carried out in DME patients, randomly assigned to receive DEX-IVT or DEX-IVT and a CHC. The evaluation of the mean difference of central retinal thickness (CRT) was the primary aim. Secondary aims were the evaluations of best-corrected visual acuity, differences in the predetermined retinal layer thickness, the number/time of re-treatment, and the assessment of safety.

Results: A total of 73 DME patients were included (35 in the control group and 38 in the combined therapy group). In both the control and combined therapy groups, the mean CRT change from T₀ to the 6 months’ evaluation was significant (p = 0.00). The mean CRT result was significantly different at month 4 (p = 0.01) between the control and combined therapy groups, with a greater reduction in the combined therapy group, in particular, in patients with ≤10 years of diabetes. A trend of CRT reduction in the combined therapy group has been observed also considering patients with subfoveal neuroretinal detachment. In addition, we observed that the reduction of inner retinal layer thickness was greater in the combination group, in comparison with controls.

Conclusion: The combination of a CHC to DEX-IVT is a promising therapeutic option in case of DME, in particular, for patients with early-stage diabetes and with an inflammatory phenotype. Further studies will be necessary to confirm these findings.

Relationship of Choroidal Vasculature and Choriocapillaris Flow With Alterations of Salivary α-Amylase Patterns in Central Serous Chorioretinopathy

Purpose

An abnormality in choroidal vasculature is a known factor in the pathogenesis of central serous chorioretinopathy (CSC), a chorioretinal disease affecting mostly middle-aged males. The purpose of the present study was to investigate the role of the autonomic nervous system (ANS) in the pathophysiology of CSC.

Methods

This was a cross-sectional observational study in which characteristic choroidal vasculature metrics were assessed by measuring the subfoveal choroidal thickness (FCT) and the choroidal vascularity index (CVI) using the imaging technique of enhanced-depth imaging spectral-domain optical coherence tomography (EDI-SD-OCT). Furthermore, flow signal void area features were also evaluated in the study population using OCT angiography (OCTA). Diurnal patterns of salivary α-amylase (a-AMY) production, proposed as a marker of autonomic activity, were assessed in an adult male study population affected by acute naïve CSC in comparison with matched healthy controls.

Results

Results include an overall higher diurnal output of salivary a-AMY production, which is in line with the phenomenon of a sympathetic “drive” playing a role in the pathophysiology of CSC, and a flattened diurnal percentage variation in α-AMY in CSC-affected subjects. Furthermore, Pearson's coefficient test revealed statistically significant correlations between salivary α-AMY diurnal percentage variation and selected choroidal imaging biomarkers (FCT, CVI, and flow signal void area). Finally, multiple linear regression analysis identified salivary α-AMY diurnal percentage production as the sole predictor of the CVI and flow signal void area in the study population.

Conclusions

Autonomic nervous system dysregulation was highlighted in CSC patients.

Volume rendered 3D OCTA assessment of macular ischemia in patients with type 1 diabetes and without diabetic retinopathy

The aim of this study was to measure macular perfusion in patients with type 1 diabetes and no signs of diabetic retinopathy (DR) using volume rendered three-dimensional (3D) optical coherence tomography angiography (OCTA). We collected data from 35 patients with diabetes and no DR who had OCTA obtained. An additional control group of 35 eyes from 35 healthy subjects was included for comparison. OCTA volume data were processed with a previously presented algorithm in order to obtain the 3D vascular volume and 3D perfusion density. In order to weigh the contribution of different plexuses' impairment to volume rendered vascular perfusion, OCTA en face images were binarized in order to obtain two-dimensional (2D) perfusion density metrics. Mean ± SD age was 27.2 ± 10.2 years [range 19-64 years] in the diabetic group and 31.0 ± 11.4 years [range 19-61 years] in the control group (p = 0.145). The 3D vascular volume was 0.27 ± 0.05 mm³ in the diabetic group and 0.29 ± 0.04 mm³ in the control group (p = 0.020). The 3D perfusion density was 9.3 ± 1.6% and 10.3 ± 1.6% in diabetic patients and controls, respectively (p = 0.005). Using a 2D visualization, the perfusion density was lower in diabetic patients, but only at the deep vascular complex (DVC) level (38.9 ± 3.7% in diabetes and 41.0 ± 3.1% in controls, p = 0.001), while no differences were detected at the superficial capillary plexus (SCP) level (34.4 ± 3.1% and 34.3 ± 3.8% in the diabetic and healthy subjects, respectively, p = 0.899). In conclusion, eyes without signs of DR of patients with diabetes have a reduced volume rendered macular perfusion compared to control healthy eyes.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY ASSESSMENT OF THE DIABETIC MACULA: A Comparison Study Among Different Algorithms

PURPOSE

To assess the impact of histogram adjustments and binarization thresholding selection on quantitative measurements of diabetic macular ischemia using optical coherence tomography angiography (OCTA).

METHODS

Patients with diabetic retinopathy (DR) who had swept-source OCTA imaging obtained were enrolled. An additional group of 15 healthy control subjects was included for comparison. Previously used brightness/contrast changes and binarization thresholds were applied to original OCTA images to obtain and compare different binarized images. Qualitative and quantitative comparisons were performed.

RESULTS

Thirty patients with DR (30 eyes) were included in the analysis. Fifteen eyes displayed the presence of diabetic macular edema. Qualitative grading revealed that binarized images obtained using a global threshold had better quality compared with local or multistep thresholds. The "median" filter was most frequently graded as the histogram adjustment resulting in binarized images with best quality. In the quantitative analysis, local thresholds tended to generate higher values of measured metrics. Differences in OCTA metrics between global and local thresholds were associated with presence of diabetic macular edema and signal strength index value. In the comparison between healthy and DR eyes, differences in OCTA metrics were significantly affected by binarization threshold selection.

CONCLUSION

Quantitative OCTA parameters may be significantly influenced by strategies to quantify macular perfusion. Image quality and presence of macular edema can significantly impact OCTA-derived quantitative vascular measurements and differences between global and local binarization thresholds. These findings highlight the importance of consistent strategies to reliably generate quantitative OCTA metrics in patients with DR.

USING THREE-DIMENSIONAL OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY METRICS IMPROVES REPEATABILITY ON QUANTIFICATION OF ISCHEMIA IN EYES WITH DIABETIC MACULAR EDEMA

PURPOSE

Two-dimensional (2D) optical coherence tomography angiography (OCTA) is known to be prone to segmentation errors, especially in pathologic eyes. Therefore, our aim was to systematically compare intrasession repeatability between repeated scans for 2D and three-dimensional (3D) OCTA metrics in quantifying retinal perfusion in eyes with diabetic macular edema.

METHODS

Diabetic patients with diabetic retinopathy and diabetic macular edema who had two consecutive OCTA imaging scans obtained during the same visit were retrospectively included. A previously validated algorithm was applied to OCTA volume data to measure the 3D vascular volume and perfusion density. Optical coherence tomography angiography en face images were also processed to obtain 2D perfusion density metrics.

RESULTS

Twenty patients (20 eyes) with diabetic retinopathy and diabetic macular edema were included. The intraclass correlation coefficient ranged from 0.591 to 0.824 for 2D OCTA metrics and from 0.935 to 0.967 for 3D OCTA metrics. Therefore, compared with the 2D OCTA analysis, the intraclass correlation coefficients of the 3D OCTA analysis were higher (without overlapping of the 95% confidential intervals). Similarly, the coefficient of variation (ranging from 2.2 to 4.2 for 2D OCTA metrics and from 1.9 to 2.0 for 3D OCTA metrics) indicated that the 3D OCTA-based quantifications had the highest interscan intrasession agreements. Differences in interscan 2D OCTA metrics' values were associated with average macular volume.

CONCLUSION

Three-dimensional OCTA metrics have higher values of intrasession repeatability, as compared with 2D OCTA metrics. The latter finding seems to be related to the high rate of segmentation errors occurring in diabetic macular edema eyes.

Outer retina dysfunction and choriocapillaris impairment in type 1 diabetes

To study the outer retina morpho-functional characteristics and the choriocapillaris (CC) features in type 1 diabetic (T1D) patients, with and without signs of diabetic retinopathy (NPDR and NoDR). Twenty-five NPDR and 18 NoDR eyes were imaged by Optical Coherence Tomography Angiography. Ellipsoid zone (EZ) “normalized” reflectivity and CC perfusion density parameters, as flow deficits number (FDn), flow deficit average area (FDa) and flow deficit percentage (FD%), were analysed. Multifocal electroretinogram (mfERG) response amplitude densities (RADs) were measured. Mean EZ “normalized” reflectivity, CC FDn and FD% values, were similar (p > 0.05) in both groups, FDa was significant greater (p > 0.05) in NPDR compared with NoDR eyes. MfERG-RADs were similar in both groups. NPDR eyes showed a significant (p < 0.05) linear correlation between RADs and both, CC FDa and FD%. The EZ “normalized” reflectivity was negatively correlated with CC FD% in NoDR eyes. In NPDR T1D eyes a significant relationship between abnormal outer retina functional responses and CC impairment was observed, while in NoDR eyes the photoreceptor reflectivity was correlated to CC abnormalities. The outer retina dysfunction in NPDR correlated to CC drop-out let hypothesize that the outer retinal elements are functionally impaired in proportion to the CC vascular supply deficit.

Imaging Biomarkers of 1-Year Activity in Type 1 Macular Neovascularization

Purpose

The purpose of this study was to evaluate the predictive value of optical coherence tomography (OCT) and OCT angiography (OCTA) parameters at baseline on lesion's activity at the 1-year follow-up in type 1 macular neovascularizations (MNVs) treated with 1-year fixed regimen of intravitreal aflibercept injections (q8 IAIs).

Methods

All patients were imaged by structural OCT to evaluate central macular thickness (CMT), subretinal fluid (SRF), subretinal hyper-reflective material (SHRM), intraretinal fluid (IRF) and intraretinal hyper-reflective dots (HRDs), and by Swept-Source OCTA to measure baseline MNV area, perfusion density (PD), vessel length density (VLD), and vessel diameter index. At the end of q8 IAI, patients were classified in two groups: active-MNV (A-MNV) and inactive-MNV (I-MNV), considering the OCT signs of activity. Three binary logistic regression models were developed: (1) OCT-based, (2) OCTA-based, and (3) OCT/OCTA-based model.

Results

Thirty-one treatment-naïve type 1 MNVs were enrolled (13 A-MNV and 18 I-MNV). No differences were observed in baseline OCT and OCTA characteristics between A-MNV and I-MNV. Among the models developed, model 3 that combined OCT/OCTA parameters showed a performance of 87.5% and excellent sensitivity for A-MNV lesions (100%). By analyzing the model, the A-MNV group appears more likely to show at baseline SRF, greater CMT, wider MNV area, and lower PD and VLD compared to I-MNV.

Conclusions

Our study demonstrated that the combination of baseline OCT and OCTA parameters allowed to achieve a good models’ performance in the prediction of MNV activity permitting to correctly classifying the active lesions at the end of follow-up period, with excellent sensitivity.

Translational Relevance

OCT/OCTA could integrate statistical models potentially useful for artificial intelligence.

Characterisation of macular neovascularisation in geographic atrophy

AIM

To characterise macular neovascularisation (MNV) developing in eyes affected by geographic atrophy (GA).

METHODS

In this multicentric longitudinal study involving three retina referral centres, patients previously affected by GA who developed an active MNV were included. Patients were investigated using structural optical coherence tomography (OCT), fundus autofluorescence, OCT-angiography and dye angiographies. Patients were treated with ProReNata antivascular endothelial growth factor (VEGF) injections and were revaluated after treatment.

RESULTS

Among 512 patients previously diagnosed with GA, 40 eyes of 40 patients (mean age 80.8±7.9 years, mean GA area 8.73±7.39 mm²) presented with treatment-naïve exudative MNV (accounting for an estimated prevalence of 7.81%; 5.49 to 10.13, 95% CIs) and thus were included in the analysis. 67.5% of MNVs were classified as type 2 MNV, 25% as type 1, 2.5% as type 3 and 5% as mixed phenotype. In 92.5% of cases, active MNV in GA showed subretinal hyperreflective material with or without evidence of subretinal/intraretinal hyporeflective exudation. During a mean follow-up of 28±25 months, patients were treated with 6.6±6.3 anti-VEGF injections, with 2.9±1.4 injections in the first year of treatment. No patient developed GA enlargement in the area of MNV.

CONCLUSIONS

MNVs in GA showed different features and therapeutic response in comparison to previously reported features of MNV in age-related macular degeneration (AMD) without GA. For these reasons, the combined phenotype (ie, GA with neovascular AMD) should be considered as a distinct entity in the research and clinical setting.

Treatment-naïve quiescent macular neovascularization secondary to AMD: The 2019 Young Investigator Lecture of Macula Society

PURPOSE

To analyze different clinical and anatomical features in treatment-naïve non-exudative macular neovascularizations (MNVs) secondary to age-related macular disease (AMD).

METHODS

In this retrospective longitudinal study with a minimum follow-up of 1 year, 31 eyes of 28 consecutive AMD patients (mean age 75 ± 9 years) with treatment-naïve non-exudative MNV were enrolled. Patients were divided in: short-term activated MNV group (exudation before 6-month) and quiescent MNV group (per definition no exudation during a minimum 6-month follow-up) showing no or late activation during follow-up (persistently quiescent and long-term activated MNV group, respectively).

RESULTS

During the follow-up (mean duration: 22 ± 9 months) four eyes (13%) showed exudation before 6-month follow-up (short-term activated MNV group), whereas 21 eyes (68%) did not develop signs of exudation (persistently quiescent group), and six eyes (19%) developed exudation after the minimum 6-month follow-up (long-term activated MNV group). Monthly MNV growth rate was significantly higher in the short-term activated MNV group (growth rate of 13.30%/month), vs persistently quiescent MNV group (0.64%/month, p < 0.001) and long-term activated quiescent MNV group (1.07%/month, p < 0.001). Furthermore, at the baseline, perfusion density of short-term activated MNV group was significantly greater in comparison to persistently quiescent MNV group (p = 0.001) and long-term activated MNV group (p = 0.106).

CONCLUSION

We reported two different patterns for subclinical MNVs: subclinical MNVs characterized by short-term activation which could represent simply a pre-exudative stage in the development of an ordinary type 1 MNV, and quiescent MNVs characterized by low rate of growth and possible long-term activation. Analysis of OCT-A features may predict short-term activation for subclinical MNV but no features could predict the long-term activation.

Guidelines on Optical Coherence Tomography Angiography Imaging: 2020 Focused Update

Optical coherence tomography angiography (OCTA) has significantly expanded our knowledge of the ocular vasculature. In this review, we provide a discussion of the fundamental principles of OCTA and the application of this imaging modality to study the retinal and choroidal vessels. These guidelines are focused on 2020, and include updates since the 2019 publication. Importantly, we will comment on recent findings on OCTA technology with a special focus on the three-dimensional (3D) OCTA visualization.

Macular Functional and Morphological Changes in Intermediate Age-Related Maculopathy

Purpose

The purpose of this study was to evaluate macular preganglionic function and to verify its relationship with retinal and choroidal morphology in patients with intermediate age-related macular degeneration (iAMD) patients.

Methods

All included patients performed multifocal electroretinogram (mfERG) for investigating on macular function from the central 15° of foveal eccentricity, spectral domain optical coherence tomography (SD-OCT) for studying retinal structure, enhanced depth imaging OCT (EDI-OCT) for the measure of choroidal vascularity index (CVI), and OCT-angiography (OCTA) for the evaluation of vessel density (VD) in the superficial and deep capillary plexus, and choriocapillaris (CC) layer.

Results

Twenty-seven patients with iAMD and 20 age-matched control eyes were analyzed. Significantly (P < 0.01) delayed and reduced mfERG responses in the central 0 to 2.5°, paracentral 2.5 to 5°, and overall 0 to 5° areas, as well as increased CVI values in both foveal (1 mm centered to the fovea) and fovea + parafovea areas (3 mm centered to the fovea), increased foveal and parafoveal (annular area of 1-3 mm centered to the fovea) retinal pigment epithelium thickness, and volume and parafoveal outer retinal volume were found in iAMD eyes as compared to controls. Moreover, iAMD eyes showed significantly (P < 0.01) reduced foveal and parafoveal OCTA-VD values in the CC layer when compared to controls. In the iAMD group, not significant (P > 0.01) correlations were found between morphological and functional parameters.

Conclusions

Our findings support a dysfunction of photoreceptors and bipolar cells in both foveal and parafoveal areas in the presence of outer retina, CC, and choroidal structural changes, however, not significantly correlated. The observed enlargement of luminal choroidal area (measured by CVI) is possibly compensatory to CC vascular insufficiency.

Profile of non-responder and late responder patients treated for diabetic macular edema: systemic and ocular factors

Diabetic macular edema (DME) treatment represents a challenge for the ophthalmologists, and several aspects of real treatment expectancy are still being discussed and not yet fully elucidated. A univocal definition of responsiveness to treatment has not been reached. How the clinicians can evaluate the therapeutic success? The evaluation of systemic and ocular factors should help in this complex management. The age influences the long-term outcomes, and the role of glycemic control is confounded by contrasting correlations between hemoglobin glycated A1c and DME. Long-term treatment success is influenced by baseline best-corrected visual acuity (BCVA), central macular thickness (CMT) and early BCVA response. Also baseline diabetic retinopathy severity scale score is useful to evaluate the chances of improvement before and during treatments. The time-switching was influenced by early BCVA response, however considering a delayed response in a percentage of patients. Several structural optical coherence tomography (OCT) findings could predict long-term success, as the presence of serous retinal detachment, hyperreflective retinal spots, the disruption of external limiting membrane and ellipsoid zone, the disorganization of inner retinal layers and continued increase in CMT were considered predictors of poor response to treatment. Foveal avascular zone enlargement, high number of microaneurysms (Mas), lower vessel density (VD) in deep capillary plexus and lower parafoveal VD in superficial capillary plexus were considered as OCT angiography biomarkers of poor responsiveness. The aim of this review is to report the factors that could influence the response to treatment of DME patients.

Diurnal trajectories of salivary cortisol and α-amylase and psychological profiles in patients with central serous chorioretinopathy

It has been hypothesized that the occurrence of central serous chorioretinopathy (CSC) might be associated with stress. Therefore, our purpose was to investigate the diurnal trajectories of salivary cortisol and α-amylase (α-Amy) - markers of hypothalamic-pituitary-adrenal (HPA) axis and sympathetic-adrenal-medullary (SAM) system activity, respectively - and psychological profiles in idiopathic acute CSC. This cross-sectional observational case-control study, which included self-reported psychometric questionnaires, was formally approved by the Ethics Committee. Written informed consent was obtained from all participants. Home diurnal saliva collection was scheduled at several timepoints: at awakening, 30 and 60 min later, and at approximately 13:00 h and 20:00 h. Twenty consecutive male subjects with first-episode CSC attending the outpatient clinic of the Retina Medical Service at the Bietti Foundation were enrolled in the study. Twenty age-matched subjects were recruited as controls. After their initial enrollment, 3 subjects per group were excluded. The production of cortisol and α-Amy and the scores on the negative subscale of the Positive/Negative Affect Schedule, the Daily Hassles and Stress Scale and the Beck Depression Inventory were higher in the CSC group than in the control group. To estimate the diurnal trends in the production of salivary cortisol and α-Amy, an equation was derived for each group of the study population. The equations describing the interpolated regression lines gave salivary cortisol and salivary α-Amy slopes that were determined to be significantly different by Student's t-test (cortisol: t = 3.533, p < .001; α-Amy: t = 2.382, p = .018). Furthermore, the area under the curve with respect to the ground (AUC_G) was calculated to summarize repeated salivary biomarker measurements from 07:00 h to 08:00 h for assessment of the cortisol awakening response (CAR) and the α-Amy awakening response (AR). The diurnal cortisol AUC_G and diurnal α-Amy AUC_G were calculated from 07:00 h to 20:00 h. The CAR AUC_G values of the CSC patients were significantly higher than those of the controls. No differences between the two groups were detected for the α-Amy AR AUC_G. The present study adds novel information to the growing body of data suggesting that abnormal diurnal activity of the HPA axis and the SAM system is associated with CSC in susceptible individuals, providing ophthalmologists with a new chronobiological approach for these patients.

Appearance of cysts and capillary non perfusion areas in diabetic macular edema using two different OCTA devices

The aim of this paper was to distinguish the appearance of cysts and non-perfusion areas (NPAs) in diabetic macular edema (DME) using two different Optical Coherence Tomography Angiography (OCTA) devices. In this study, patients underwent OCTA using the AngioVue XR Avanti Spectral Domain (SD) OCTA and the PLEX Elite 9000 Swept-Source (SS) OCTA. Foveal and extrafoveal regions of interest (ROI), defined as any area with an altered flow signal comparing to the surrounding retina, were selected in superficial and deep capillary plexus (SCP and DCP). ROI reflectivity were classified as hypo-reflective or hyper-reflective. Foveal ROI were analyzed to detect suspended scattering particles in motion (SSPiM). Thirty-seven DME eyes were included. A larger number of ROIs were found in SCP (55 vs 39) and DCP (60 vs 49) using PLEX Elite 9000 vs AngioVue. The majority of ROIs were hypo-reflective with both instruments, while slightly more hyper-reflective ROIs (grey) were detected with the PLEX Elite, more likely to be cysts. The hyporeflective ROIs could be NPAs or cysts with both devices. Moreover, PLEX Elite 9000 identified SSPiM in more foveal ROIs than the AngioVue in the SCP (p = 0.005) and in the DCP (p = 0.027). In conclusion, NPAs and cysts may show variable appearances using different OCTA devices. Hyperreflective ROIs generally correspond to cysts, hyporeflective ROIs can be either cysts or NPAs. The SS-OCTA seems to detect SSPiM more frequently than the SD-OCTA.

Pharmacotherapy of Central Serous Chorioretinopathy: A Review of the Current Treatments

BACKGROUND

Central serous chorioretinopathy (CSC) is the fourth most frequent retinal disorder in terms of prevalence. It typically occurs in young subjects and affects men more often than women. CSC is characterized by serous retinal detachment (SRD) involving mainly the macular area. The clinical course is usually selflimited, with spontaneous resolution within 3 months. The persistence of SRD or multiple relapse may result in a chronic form of CSC distinguished by permanent retinal pigment epithelium (RPE) and photoreceptor damage. As the pathogenetic mechanism of CSC primarily involves RPE and choroidal vascularization, the current therapeutic approaches aim to restore the normal functions of RPE and normal choroidal vascular permeability. In this review, the authors aim to summarize the current therapeutic approach to CSC.

METHODS

A comprehensive review of the literature was conducted in PubMed by searching for relevant studies on the current therapeutic options for CSC, including simple observation, conventional laser treatment, subthreshold laser treatment (SLT), photodynamic therapy (PDT) with verteporfin, treatment with mineralocorticoid receptor (MR) antagonists and treatment with anti-vascular endothelial growth factor drugs.

RESULTS

Since most cases resolve spontaneously, the most common initial CSC treatment is observation. Current evidence suggests that PDT and SLT are valuable in improving visual acuity, reducing subretinal fluid and maintaining long-term effectiveness. No clear evidence of efficacy has been achieved for anti-VEGF. MR antagonists might be a viable choice for the treatment of chronic CSC.

CONCLUSION

The pathophysiology of CSC remains poorly understood and as a consequence, the gold standard of care for CSC is yet to be defined. To date, PDT and SLT continue to offer good clinical outcomes. Positive preliminary results seem to emerge from the studies of MR antagonists.

Impact of Bleaching on Photoreceptors in Different Intermediate AMD Phenotypes

Purpose

To investigate photoreceptors' structural changes after photobleaching exposure in intermediate age-related macular degeneration (iAMD) eyes with and without reticular pseudodrusen (RPD).

Methods

In this prospective, cross-sectional study, were enrolled iAMD patients and healthy controls. Patients and controls underwent repeated imaging with spectral-domain optical coherence tomography (SD-OCT), at baseline and at three intervals after bleaching, during the subsequent recovery in darkness. Structural changes in photoreceptors were investigated in the foveal region and in four perifoveal areas.

Results

Twenty eyes of 20 iAMD patients (12 with RPD and 8 without RPD) and 15 age-matched healthy controls were enrolled. At baseline, the photoreceptor outer segment (OS) volume was significantly reduced in iAMD eyes with RPD compared with controls, in the foveal and perifoveal regions. In healthy subjects, a precocious increase in OS volume was observed after bleaching in the foveal region, and a rapid recovery to baseline values was recorded. In the perifoveal regions, an increase in OS volume was observed 10 minutes after light onset. In contrast, in iAMD subjects with RPD an altered response to photobleaching, in the foveal and superior and inferior perifoveal regions, was recorded.

Conclusions

Our imaging evidences support the hypothesis that dark adaptation is more altered in eyes with RPD. The structural modifications may explain the functional increased damage of the retinal pigment epithelium and photoreceptors reported in eyes with RPD.

Translational Relevance

OCT imaging may be used to assess dark adaptation in AMD eyes.

Correction to: Effects of Macuprev® Supplementation in Age-Related Macular Degeneration: A Double-Blind Randomized Morpho-Functional Study Along 6 Months of Follow-Up

The article ''Effects of Macuprev Supplementation in Age-Related Macular Degeneration: A Double-Blind Randomized Morpho-Functional Study Along 6 Months of FollowUp'', written by Mariacristina Parravano, Massimiliano Tedeschi, Daniela Manca, Eliana Costanzo, Antonio Di Renzo, Paola Giorno, Lucilla Barbano, Lucia Ziccardi, Monica Varano, Vincenzo Parisi was originally published electronically on the publisher's internet portal (currently SpringerLink) on June 25, 2019 without Open Access. The article has now been made Open Access.

Optical Coherence Tomography Parameters as Predictors of Treatment Response to Eplerenone in Central Serous Chorioretinopathy

Purpose: To present data on clinical response to eplerenone over a 1-year period in patients with central serous chorioretinopathy (CSC), and to evaluate optical coherence tomography (OCT) variables as predictors of treatment response at 3- and 12-month follow-up visits. Methods: Patients with acute or chronic CSC treated with eplerenone were retrospectively included. Clinical and imaging characteristics were recorded at baseline and at the 3-month and 12-month follow-up visits. Changes from baseline in quantitative measurements were calculated at each follow-up. Logistic regression analysis was computed to correlate clinical and OCT parameters at baseline with response to treatment at 3 and 12 months of follow-up. Results: A total of 50 eyes of 50 patients were included in the study. Mean ± SD best corrected visual acuity (BCVA) was 0.20 ± 0.14 Logarithm of the Minimum Angle of Resolution (LogMAR) at baseline and significantly improved at both the 3-month (0.12 ± 0.13 LogMAR, p < 0.0001) and 12-month (0.10 ± 0.12 LogMAR, p < 0.0001) follow-up visits. At the 3-month follow-up visit, 25 out of 50 eyes (50.0%) demonstrated macular complete subretinal fluid (SRF) resolution, while 13 eyes (26.0%) showed macular partial SRF resolution, and 12 eyes (24%) had neither partial nor complete macular SRF resolution. Among those patients with macular partial or complete SRF resolution at 3 months and thus not shifted to photodynamic therapy, 36 out of 38 cases had macular complete SRF resolution at the 12-month follow-up visit. There was a significant change from baseline at both follow-up visits in all anatomical OCT parameters (except for reduction in choroidal thickness that did not reach the statistical significance at the 12-month follow-up visit). Several OCT parameters at baseline were independently significant predictors for macular subretinal fluid complete resolution at 3 months, including (i) a thicker subfoveal choroidal thickness; (ii) a smaller subretinal fluid maximum diameter; (iii) a lower number of serous pigment epithelium detachments; and (iv) a lower number of intraretinal hyperreflective foci. Conclusion: Treatment with eplerenone in CSC patients is confirmed to be beneficial for both anatomical and functional outcomes. We identified attractive OCT metrics that could potentially be used as a tool to select patients who might mainly benefit from this treatment.

A Comparison Among Different Automatically Segmented Slabs to Assess Neovascular AMD using Swept Source OCT Angiography

Purpose

We systematically compare the intermodality and interreader agreement in age-related macular degeneration(AMD)-associated neovascularization assessment for optical coherence tomography angiography (OCTA) images obtained using different slabs.

Methods

We collected data from 48 patients (50 eyes) with type 1 or 2 neovascularization (NV) and AMD. Subjects were imaged with a swept source (SS)-OCTA system. For each eye, three OCTA en face images generated from three different slabs were exported: (1) the outer retina to choriocapillaris (ORCC) image, (2) the choriocapillaris (CC) image, and (3) the retinal pigment epithelium (RPE)-RPE fit image. Each image was graded by two readers to assess interreader variability and a single image for each modality was used to assess the intermodality variability.

Results

In the assessment of type 1 NV, mean absolute interreader difference between measured NV areas was 0.19, 0.30, and 0.16 mm² for ORCC, CC, and RPE-RPE fit images, respectively. Similarly, the coefficient of repeatability (CR) and intraclass correlation coefficient (ICC) indicated that the RPE-RPE fit assessment was characterized by the highest interreader reproducibility. Type 1 NV size was 0.58 mm² (0.30–1.60 mm²) on ORCC images, 0.00 mm² (0.00–0.36 mm²) on CC images (P = 0.002 vs. ORCC), and 0.62 mm² (0.31–2.03 mm²) on RPE-RPE fit images (P < 0.0001 vs. CC, P = 0.041 vs. ORCC).

Conclusions

The RPE-RPE fit OCTA images have the highest interreader agreement and deliver larger measurements in type 1 lesions.

Translational Relevance

OCTA imaging may be used in ongoing trials of potential novel treatments for NV.

Microvascular Retinal and Choroidal Changes in Retinal Vein Occlusion Analyzed by Two Different Optical Coherence Tomography Angiography Devices

PURPOSE

To investigate retinal and choroidal microvascular changes and structural choroidal involvement in retinal vein occlusion (RVO).

METHODS

Retrospective analysis of treatment-naïve macular edema secondary to RVO, studied by optical coherence tomography (OCT) and OCT angiography (OCTA), before and after the loading phase of intravitreal injections of ranibizumab (IVR-LP). OCTA was performed using two different devices: AngioVue RTVue XR Avanti (spectral-domain OCTA) and Zeiss PLEX® Elite 9000 (swept-source OCTA).

RESULTS

30 eyes of 30 consecutive patients (17 branch and 13 central RVO) were included. Central macular thickness and subfoveal choroidal thickness (SCT) were significantly reduced after IVR-LP (p < 0.001 and p = 0.046, respectively). 23 eyes were eligible for OCTA analysis. Baseline vessel density (VD) in deep capillary plexus (DCP) was significantly reduced in RVO eyes compared with fellow eyes (p = 0.03 and p = 0.002 for PLEX® Elite and AngioVue, respectively). After IVR-LP, no significant VD changes in any vascular layer was found. PLEX® Elite VD analysis showed significant differences in DCP between ischemic versus non-is-chemic eyes (p = 0.011).

CONCLUSION

OCTA suggests a retinal vascular impairment of DCP but no involvement of choroid in RVO eyes. A greater baseline SCT could be due to a choroidal exudation. OCTA imaged with PLEX® Elite allowed to differentiate ischemic and non-ischemic patients at baseline.

Choroidal Caverns: A Novel Optical Coherence Tomography Finding in Geographic Atrophy

Purpose

To describe and interpret “choroidal caverns,” an unreported optical coherence tomography (OCT) finding in the choroid of patients with geographic atrophy (GA) secondary to atrophic AMD.

Methods

Retrospective analysis of patients with GA. Main outcomes measures included estimation of the prevalence of choroidal caverns, their localization and relation with retinal-choroidal structures by reviewing medical records and multimodal imaging.

Results

One hundred twenty consecutive patients (mean age 80.5 ± 8.61 years) were included. Among the 201 eyes with GA, 17 eyes of 15 patients presented choroidal caverns on OCT B-scan in GA areas (a total of 43 choroidal caverns, mean 2.5/eye, variably localized in the Sattler and Haller layers, with relative preservation of the choriocapillaris). This accounts for 12.5% estimated prevalence (6.5–18.5, 95% confidence interval [CI]) of choroidal caverns in GA areas of atrophic AMD patients. Choroidal caverns appeared on OCT (both B-scan and en face) as gaping hyporeflective cavities in the choroid, typically empty, angular, without hyperreflective borders, often with punctate/linear hyperreflectivities internally. Indocyanine angiography and OCT-Angiography confirmed that the areas occupied by these cavities do not represent perfused choroidal blood vessels.

Conclusions

Choroidal caverns represent a relatively infrequent peculiar finding in GA areas of atrophic AMD eyes. They appear as gaping angular hyporeflective cavities in areas devoid of choroidal vessels, often with punctate/linear hyperreflectivities internally. Choroidal caverns may possibly arise from nonperfused ghost vessels and persistence of stromal pillars where the vessels were originally situated.

Brain connectivity in patients with schizophrenia related to psychological stress

Introduction

It is commonly accepted that in most patients with schizophrenia external factors act on genetic predisposition to produce active psychotic symptoms. In fact, we showed that patients with schizophrenia have an abnormal brain activation and peripheral autonomic response to psychological stress. We sought to characterize the brain connectivity networks of such response in schizophrenia.

Methods

We studied the pattern of brain connectivity in relation to mental arithmetic stress paradigm in 21 patients and 21 healthy subjects aged 18 to 50 years, using 3T-fMRI. A period of 6 minutes of resting state acquisition (PRE) were followed by a block design with three 1-minute CONTROL task (one digit sum), 1-minute STRESS task (two digit subtraction) and 1-minute rest after task (POST). Pairwise Pearson correlations were calculated between 90 regions of interest. Data were analyzed with MATLAB and SPSS software.

Results

Patients with schizophrenia showed a lower connectivity network between fronto-temporal limbic areas compared with control subjects during control and stress task. Moreover, we observed a great variability of link density during resting state in patients but not in controls, and it diminishes in response to task.

Conclusions

Patients present abnormalities in networks related to stress response showing an alteration in fronto-temporal connectivity, and a poor and random modulation of these networks at rest. Current and previous findings suggest abnormal fronto-temporal connectivity that ultimately would lead to psychotic symptoms emergency in response to an environmental stressor and, even, could be related to hypervigilance and misattribution feeding into the paranoid cognition characteristic of patients with schizophrenia.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

RETINAL PIGMENT EPITHELIUM APERTURE: A Previously Unreported Finding in the Evolution of Avascular Pigment Epithelium Detachment

PURPOSE

To describe retinal pigment epithelium (RPE) aperture and to generate hypotheses about pathogenesis of this previously unreported finding in the evolution of avascular pigment epithelium detachment (PED) secondary to age-related macular degeneration.

METHODS

Medical records and multimodal imaging results from 10 patients with RPE apertures were reviewed between January 2009 and December 2014 by 2 institutions. Main outcome measures were analysis of RPE aperture imaging characteristics, including aperture areas and PED diameters, and their temporal course. Lesions preceding RPE aperture development were also evaluated.

RESULTS

Eleven RPE apertures were identified in 10 eyes of 10 patients (1 male, 9 females; mean age 73.1 ± 6.7 years) and included for analysis. The RPE apertures appeared as round discontinuities either at the apex or at the base of avascular PED. No rippling or retraction of the RPE was found at the sites of aperture. The RPE apertures enlarged homogeneously (mean round area of hypoautofluorescence significantly increased from 0.18 ± 0.13 to 0.93 ± 1.2; P = 0.005), and PED flattened (PED maximal height on spectral domain optical coherence significantly decreased from 445.2 ± 259 to 206.4 ± 218; P = 0.04) after a mean of 38.6 ± 16.3 months. Analysis of lesions preceding RPE apertures revealed areas of focal hyperautofluorescence at the site of development, in some cases appearing as drusenoid material connected with the base of avascular PED.

CONCLUSION

The RPE aperture represents a previously unreported possible evolution of avascular PED, which should be distinguished by typical RPE tears. Analysis of lesions preceding RPE apertures suggests focal atrophic progression of drusenoid material in its pathogenesis.

Hyperreflective Choroidal Vessels in Geographic Atrophy Secondary to Age-Related Macular Degeneration

BACKGROUND AND OBJECTIVE

To describe choroidal vessels in areas of geographic atrophy (GA) secondary to age-related macular degeneration that appear as hyperreflective choroidal vessels (HRCVs) on multicolor (MC) imaging.

PATIENTS AND METHODS

Retrospective case series of patients with GA. Multimodal imaging evaluation was performed.

RESULTS

HRCVs, which seem to be sclerotic on MC imaging, appeared as hyperautofluorescent on fundus autofluorescence, clearly distinguishable over the background of hypo-autofluorescence, and correlated with late-phase hypocyanescence areas on indocyanine green angiography. Average size of GA areas was significantly larger in eyes with (4.19 mm ± 0.83 mm) compared to eyes without (3.22 mm ± 1.05 mm) HRVCs (P = .0002). Similarly, mean choroidal thickness (CT) was significantly thinner in eyes with (78.5 µm ± 33.8 µm) compared to eyes without (155.4 µm ± 69.8 µm) HRVCs (P < .0001).

CONCLUSIONS

HRCVs are more clearly distinguishable than other choroidal vessels on MC imaging in GA. HRCV identification is more frequent in eyes with larger areas of atrophy and reduced CT, and thus possibly represent a maker of more advanced GA. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:1106-1114.].