MULTIMODAL IMAGING OF TWO UNCONVENTIONAL CASES OF BARTONELLA NEURORETINITIS

PURPOSE

To report two cases of cat-scratch fever with atypical posterior segment manifestations.

METHODS

Two cases were retrospectively reviewed.

RESULTS

A 27-year-old woman presented with painless blurring of central vision in her left eye. Clinical examination revealed a small focal area of retinitis within the macula associated with a subtle macular star. Spectral-domain optical coherence tomography showed a hyper-reflective inner retinal lesion in addition to subretinal and intraretinal fluid as well as hyperreflective foci within the outer plexiform layer. Serology was positive for anti-B. henselae IgM (titer 1:32). A 34-year-old woman presented with painless loss of vision in both eyes associated with headaches and pain with extraocular movement. Spectral-domain optical coherence tomography depicted subretinal fluid, intraretinal fluid, and hyperreflective deposits within the outer plexiform layer. A focal collection of vitreous cell was observed overlying the optic nerve in the left eye. Bilateral disk leakage was identified on fluorescein angiography. Serology revealed high-titer anti-B. henselae antibodies (IgM titers 1:32, IgG titers 1:256).

CONCLUSION

Our cases highlight the necessity of recognizing more unusual posterior segment presentations of ocular bartonellosis. Multimodal retinal imaging including spectral-domain optical coherence tomography may help better characterize lesions.

MULTIMODAL IMAGING OF PHOTIC MACULOPATHY FROM ARC WELDING

PURPOSE

Photic retinal toxicity induced by exposure to arc welding can lead to irreversible vision loss. Serial multimodal imaging is characterized in a patient with outer retinal damage secondary to welder's maculopathy.

METHODS

A single case was retrospectively reviewed.

RESULTS

Spectral domain optical coherence tomography acutely revealed disruption of the ellipsoid zone, hyperreflective bands through the outer nuclear layer, and outer retinal cavitation consistent with phototoxicity. Subsequently, disruption and hypertrophy of the subfoveal retinal pigment epithelium developed. Autofluorescence depicted central hypoautofluorescence.

CONCLUSION

We report serial multimodal imaging in welder's maculopathy to better characterize the evolution of lesions. Multimodal imaging including spectral domain optical coherence tomography in arc welding phototoxicity may share features with other forms of phototoxicity such as hand-held laser maculopathy.

Retinal injury from handheld lasers: a review

Retinal photic injury induced by handheld lasers is a burgeoning public health concern due to the wider accessibility of high-powered devices. Retinal damage from thermal energy can cause potentially severe and permanent vision loss in children and young adults who are particularly vulnerable because of comorbid behavioral, learning, and psychiatric impairments. Understanding the spectrum of specific clinical and imaging features of such laser injuries aids in prompt and accurate diagnosis. Multimodal retinal imaging is important for the identification of the outer retinal abnormalities that characterize this condition. We reviewed 171 reported cases in the English and non-English language literature published from 1999, when handheld laser injury was first described, to December, 2018. Risk factors, demographic and clinical characteristics, as well as multimodal imaging findings, were collected and summarized. These findings both provide insights for public health awareness and guide areas of future investigation.

Long-term Visual Outcomes and Causes of Vision Loss in Chronic Central Serous Chorioretinopathy

PURPOSE

To evaluate the long-term visual outcomes and causes of vision loss in chronic central serous chorioretinopathy (CSC).

DESIGN

Retrospective, longitudinal study.

PARTICIPANTS

A total of 133 participants (217 eyes) with chronic CSC.

METHODS

A retrospective review of clinical and multimodal imaging data of patients with chronic CSC managed by 3 of the authors between May 1977 and March 2018. Multimodal imaging comprised color photography, fluorescein angiography, indocyanine green angiography, fundus autofluorescence (FAF), and OCT.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA) at the final visit; change in BCVA between first visit and 1-, 5-, and 10-year follow-up visits; and causes of vision loss at final visit.

RESULTS

Data from 6228 individual clinic visits were analyzed. Mean age of patients at the first visit was 60.7 years, and mean period of follow-up from first to last visit was 11.3 years. The cohort included 101 male patients (75.9%). At the final visit, 106 patients (79.7%) maintained driving-standard vision with BCVA of 20/40 or better in at least 1 eye, and 17 patients (12.8%) were legally blind with BCVA of 20/200 or worse in both eyes. Mean BCVA at first visit was not significantly different from mean BCVA at 1- or 5-year follow-up visits (both P ≥ 0.65) but was significantly better than the mean BCVA at the 10-year follow-up visit (P = 0.04). Seventy-nine percent of eyes with 20/40 or better vision at the first visit maintained the same level of vision at the 10-year follow-up visit. Ninety-two percent of eyes with 20/200 or worse vision at the first visit maintained the same level of vision at the 10-year follow-up visit. Cystoid macular degeneration, choroidal neovascularization (CNV), outer retinal disruption on OCT, and FAF changes were associated with poorer vision at the final visit (all P ≤ 0.001). Multivariable analysis revealed that greater age at first visit was associated with greater BCVA change at the 10-year follow-up visit (P = 0.001).

CONCLUSIONS

Chronic CSC can be a sight-threatening disease leading to legal blindness. Age at presentation and outer retinal changes on multimodal imaging were associated with long-term BCVA changes and may be predictors of long-term visual outcomes.

Comparative effectiveness and harms of intravitreal antivascular endothelial growth factor agents for three retinal conditions: a systematic review and meta-analysis

Intravitreal antivascular endothelial growth factor (VEGF) agents are widely used to treat ocular conditions but the benefits and harms of these treatments are uncertain. We conducted a systematic review to compare the effects of aflibercept, bevacizumab and ranibizumab on best-corrected visual acuity (BCVA) changes, quality of life and ocular or systemic adverse events in patients with neovascular age-related macular degeneration (NVAMD), diabetic macular oedema (DME) and central or branch retinal vein occlusion (RVO). We searched published and unpublished literature sources to February 2017 for randomised controlled trials and cohort or modelling studies reporting comparative costs in the USA. Two reviewers extracted data and graded the strength of the evidence using established methods. Of 17 included trials, none reported a clinically important difference (≥ 5 letters) in visual acuity gains between agents. Nine trials provide high-strength evidence of no difference between bevacizumab and ranibizumab for NVAMD. Three trials provide moderate-strength evidence of no difference between bevacizumab and ranibizumab for DME. There was low-strength evidence of similar effects between aflibercept and ranibizumab for NVAMD, aflibercept and bevacizumab for RVO and all three agents for DME. There was insufficient evidence to compare bevacizumab and ranibizumab for RVO. Rates of ocular adverse events were low, and systemic harms were generally similar between groups, although 1 DME trial reported more arterial thrombotic events with ranibizumab versus aflibercept. Overall, no agent had a clear advantage over another for effectiveness or safety. Aflibercept and ranibizumab were significantly less cost-effective than repackaged bevacizumab in two trials. Systematic review registration number: CRD42016034076.

Vision Loss from Choroidal and Pituitary Metastases Secondary to Renal Cell Carcinoma: A Case Report

A 62-year-old male with a history of metastatic clear cell renal cell carcinoma (ccRCC) presented with decreased vision to 20/50 in the left eye. Fundus examination revealed an elevated, amelanotic mass lesion in the superotemporal macula, without involvement of the central macula by subretinal fluid or tumour. Given incongruity between the fundus findings and the degree of visual impairment, visual field testing was obtained, revealing a bitemporal hemianopia. Magnetic resonance imaging demonstrated optic chiasm compression by a pituitary mass, which had previously been overlooked on computed tomography imaging. Biopsy confirmed metastatic ccRCC to the pituitary, which presented simultaneously with the presumed choroidal metastasis.

Tractional Abnormalities of the Central Foveal Bouquet in Epiretinal Membranes: Clinical Spectrum and Pathophysiological Perspectives

PURPOSE

To investigate the tractional alterations of the central bouquet (CB) in idiopathic epiretinal membranes (ERMs).

DESIGN

Retrospective, consecutive, observational case series.

METHODS

ERMs were classified according to a 4-stage grading system. The CB was defined as a circular area of approximately 100 μm composed of densely packed cones (and Müller cells) in the central fovea. Tractional abnormalities of the CB were identified with spectral-domain optical coherence tomography. Ex vivo histopathologic analysis was performed.

RESULTS

In this study 263 eyes with ERMs were included. Mean follow-up was 21.2 ± 16.7 months. At baseline, tractional abnormalities of the CB were diagnosed in 58 out of 263 eyes (22%) and divided into 3 categories: cotton ball sign (defined as a fuzzy hyperreflective area between the ellipsoid zone and the interdigitation zone in the central fovea), foveolar detachment, and acquired vitelliform lesion. The presence of ectopic inner foveal layers was negatively correlated with the presence of CB tractional abnormalities (P = .002). Visual acuity was highest in association with the cotton ball sign and lowest in the acquired vitelliform lesion group. Sequential morphologic progression was identified in 7 eyes. Ex vivo histopathologic analysis illustrated characteristic staining patterns supporting a potential mechanism of traction by Müller cells in the CB.

CONCLUSIONS

The cotton ball sign, foveolar detachment, and acquired vitelliform lesion may comprise a continuum in the same clinical spectrum and may represent subsequent stages of CB abnormalities. Foveal Müller cells may play an integral role in the transmission of mechanical forces to the central foveal cones.

Projection-resolved optical coherence tomography angiography exhibiting early flow prior to clinically observed retinal angiomatous proliferation

Purpose

The purpose of this study is to analyze early retinal angiomatous proliferation (RAP) utilizing a novel imaging modality, Projection-Resolved Optical Coherence Tomography Angiography (PR-OCTA).

Observations

Five months prior to the diagnosis of a RAP lesion, cross-sectional PR-OCTA demonstrated flow in the outer retina contiguous with the deep retinal capillary plexus (DCP) and adjacent to a small pigment epithelial detachment. After development of a clinically visible RAP lesion, cross-sectional PR-OCTA demonstrated the RAP lesion connecting DCP and sub-retinal pigment epithelial neovascularization.

Conclusions & importance

This is the first report of PR-OCTA demonstrating abnormal flow in the outer retina prior to the development of a clinically detectable RAP lesion. PR-OCTA may be useful for surveillance and to help further characterize and stage RAP lesions.

Sensitivity and Specificity of OCT Angiography to Detect Choroidal Neovascularization

PURPOSE

To determine the sensitivity and specificity of optical coherence tomography angiography (OCTA) in the detection of choroidal neovascularization (CNV) in age-related macular degeneration (AMD).

DESIGN

Prospective case series.

SUBJECTS

Prospective series of seventy-two eyes were studied, which included eyes with treatment-naive CNV due to AMD, non-neovascular AMD, and normal controls.

METHODS

All eyes underwent OCTA with a spectral domain (SD) OCT (Optovue, Inc.). The 3D angiogram was segmented into separate en face views including the inner retinal angiogram, outer retinal angiogram, and choriocapillaris angiogram. Detection of abnormal flow in the outer retina served as candidate CNV with OCTA. Masked graders reviewed structural OCT alone, en face OCTA alone, and en face OCTA combined with cross-sectional OCTA for the presence of CNV.

MAIN OUTCOME MEASURE

The sensitivity and specificity of CNV detection compared to the gold standard of fluorescein angiography (FA) and OCT was determined for structural SD-OCT alone, en face OCTA alone, and with en face OCTA combined with cross-sectional OCTA.

RESULTS

Of 32 eyes with CNV, both graders identified 26 true positives with en face OCTA alone, resulting in a sensitivity of 81.3%. Four of the 6 false negatives had large subretinal hemorrhage (SRH) and sensitivity improved to 94% for both graders if eyes with SRH were excluded. The addition of cross-sectional OCTA along with en face OCTA improved the sensitivity to 100% for both graders. Structural OCT alone also had a sensitivity of 100%. The specificity of en face OCTA alone was 92.5% for grader A and 97.5% for grader B. The specificity of structural OCT alone was 97.5% for grader A and 85% for grader B. Cross-sectional OCTA combined with en face OCTA had a specificity of 97.5% for grader A and 100% for grader B.

CONCLUSIONS

Sensitivity and specificity for CNV detection with en face OCTA combined with cross-sectional OCTA approaches that of the gold standard of FA with OCT, and it is better than en face OCTA alone. Structural OCT alone has excellent sensitivity for CNV detection. False positives from structural OCT can be mitigated with the addition of flow information with OCTA.

Laser-Induced Photic Injury Phenocopies Macular Dystrophy

OBJECTIVE

To describe the phenotypes associated with laser-induced retinal damage in children.

METHODS

Five patients with maculopathy and reduced visual acuity associated with laser pointer use were evaluated. Best-corrected visual acuity, retinal structure, and function were monitored with color fundus, infrared (IR), and red-free images, fundus autofluorescence (AF), spectral domain-optical coherence tomography (SD-OCT), and full-field electroretinography (ERG).

RESULTS

All five laser pointer injury patients had retinal lesions resembling a macular dystrophy (one bilateral and four unilateral). These lesions were irregular in shape but all had a characteristic dendritic appearance with linear streaks radiating from the lesion. Photoreceptor damage was present in all patients, but serial OCT monitoring showed that subsequent photoreceptor recovery occurred over time in the eyes of at least four patients. One patient also had bilateral pigment epithelial detachments (PED). Both hyper- and hypoautofluorecence were observed in the laser damage area.

CONCLUSIONS

In general, OCT and IR images are quite useful to diagnose laser damage, but AF is not as sensitive. Laser pointer damage in children can occasionally be misdiagnosed as a macular dystrophy disease, but the distinctive lesions and OCT features are helpful for differentiating laser damage from other conditions.

A Central Hyporeflective Subretinal Lucency Correlates With a Region of Focal Leakage on Fluorescein Angiography in Eyes With Central Serous Chorioretinopathy

BACKGROUND AND OBJECTIVE

To correlate the appearance of a hyporeflective lucency on spectral-domain optical coherence tomography (SD-OCT) with a focal leak on fluorescein angiography (FA) in eyes with central serous chorioretinopathy (CSC).

PATIENTS AND METHODS

Multimodal imaging of 18 patients with CSC who had hyperreflective fibrin surrounding a hyporeflective lucency on SD-OCT was analyzed to investigate any potential correlation with an active leak on FA. The lucent area was evaluated using en face imaging and followed for resolution of the active leak.

RESULTS

High-resolution SD-OCT images of the lucency were found to correlate with the active leak. In certain cases, the lucent area could be visualized as communicating with a defect in a pigment epithelial detachment. En face imaging of the lucency revealed a smoke-stack appearance, and resolution of the leak correlated with the disappearance of the lucency on SD-OCT.

CONCLUSION

Visualization of a lucency within surrounding fibrin may suggest an active leak. En face imaging of the lucency may provide insight into the pathophysiology of the smoke-stack leak on FA.

Multimodal imaging in a severe case of hydroxychloroquine toxicity

Retinal toxicity from hydroxychloroquine (HCQ) can be detected most readily on fundus autofluorescence, spectral-domain optical coherence tomography, and multifocal electroretinogram. The authors describe a case of a 60-year-old woman with a history of systemic lupus erythematosus undergoing HCQ treatment for 30 years who presented with visual loss over several years. Examination and multimodal imaging showed bilateral retinal pigment epithelium (RPE) changes in a bull's-eye distribution associated with cystoid macular edema. A novel imaging modality, multi-spectral imaging, appeared sensitive in detecting a bull's-eye pattern of RPE disturbance involving the entire macular region of both eyes. Cessation of drug was advised with close follow-up.

Paraneoplastic retinopathy associated with systemic follicular cell lymphoma

The authors describe two rare cases of autoimmune retinopathy associated with follicular cell lymphoma, including a 54-year-old man who experienced nyctalopia for 1 year (patient 1) and a 59-year-old man who had bilateral loss of central vision for 6 months (patient 2). Visual field testing of patient 1 revealed nonspecific defects, and multifocal electroretinogram (ERG) testing showed mildly subnormal amplitudes more pronounced in the left than the right eye. Serologic testing detected antibodies against a 47-kD protein, presumed to be alpha-enolase. Goldmann perimetry of patient 2 showed dense central scotomas, and a full-field ERG revealed reduced amplitudes of bright scotopic responses. Serological testing yielded anti-bipolar cell antibodies. A variable presentation of autoimmune retinopathy can occur in the setting of follicular cell lymphoma. Disparate serum autoantibodies may have mediated the pathogenesis of retinal degeneration in these two patients and could explain the difference in course and severity of retinopathy.

Retention of good visual acuity in eyes with neovascular age-related macular degeneration and chronic refractory subfoveal subretinal fluid

PURPOSE

To describe the clinical characteristics of a subset of eyes with neovascular age-related macular degeneration (NVAMD) receiving intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy which retain good visual acuity despite chronic, persistent subfoveal subretinal fluid (SRF).

DESIGN

Retrospective, observational case series.

METHODS

Study eyes were identified from a consecutive series of 186 patients treated with anti-VEGF therapy seen for regular follow-up over a 3-month period. The clinical histories of 10 eyes of 9 patients with NVAMD, chronic subfoveal SRF despite continuous anti-VEGF therapy, and good long-term visual acuity of 20/40 or greater were reviewed. Demographic factors, baseline and final visual acuity, neovascular lesion type, duration of persistent fluid, baseline and final subfoveal choroidal thickness, presence of geographic atrophy, and number of anti-VEGF injections were analyzed.

RESULTS

The mean age of patients was 78 years (range 55-91). The mean duration of persistent fluid was 5.2 years (range 1.3-11.0). Long-term visual acuities remained stable at 20/40 or better in all eyes. All eyes had type 1 (sub-retinal pigment epithelial) neovascularization. Average baseline subfoveal choroidal thickness was 285.3 μm and the average follow-up subfoveal choroidal thickness was 239.7 μm. No eyes had the presence of geographic atrophy. The mean number of injections was 36.5 (range 17-66).

CONCLUSION

Some eyes with type 1 neovascularization associated with chronic persistent subfoveal subretinal fluid despite continuous intravitreal anti-VEGF therapy may maintain good long-term visual outcomes. We hypothesize that type 1 neovascularization and greater subfoveal choroidal thickness may exert a protective effect on photoreceptor integrity. Further studies are necessary to assess long-term visual prognosis and predictive factors in patients with type 1 neovascularization leading to persistent subretinal fluid that is recalcitrant to anti-VEGF treatment.

Choroidal thickness in retinal pigment epithelial tear as measured by spectral domain optical coherence tomography

PURPOSE

To evaluate the choroidal thickness with spectral domain optical coherence tomography in subjects with retinal pigment epithelial (RPE) tear compared with the choroidal thickness of their fellow eye.

METHODS

For this cross-sectional investigation, seven eyes of seven patients with neovascular age-related macular degeneration and RPE tear in one eye imaged with spectral domain optical coherence tomography were identified. Choroidal thickness was measured from the posterior edge of the retinal pigment epithelium to the choroid/sclera junction at 500 μm intervals up to 2,500 μm temporal and nasal to the fovea in both the eye with the RPE tear and the eye with intact RPE. All measurements were performed by two independent observers and averaged for the purpose of the analysis. Measurements were compared using paired t-test.

RESULTS

The average age of patients was 79 years (range, 66-88 years). All subjects had dome-shaped pigment epithelial detachments before RPE tear and no dome-shaped pigment epithelial detachments in the unaffected eye. Average subfoveal choroidal thickness in the eye with the RPE tear was 154.9 ± 10.1 µm. Average subfoveal choroidal thickness in the eye with intact RPE was 212.9 ± 10.6 µm (P = 0.035).

CONCLUSION

There is a significant decrease in subfoveal choroidal thickness in the subjects with RPE tear compared with their fellow eye with intact RPE. It is unclear if this thinning is a consequence of or precedes the RPE tear. Further studies are necessary to prospectively follow choroidal thickness in subjects with dome-shaped pigment epithelial detachments.

Risk factors for progression of subclinical diabetic macular oedema

BACKGROUND/AIMS

[corrected] The purpose of this study was to determine the incidence of, and risk factors dictating, progression of subclinical macular oedema (SCME) to clinically significant macular oedema (CSME) in patients with diabetes.

METHODS

This was a retrospective, observational case-controlled study at the Veterans Administration (VA) Boston Healthcare System. The study group included subjects with central subfield macular thickness (CSMT) of 200-300 μm, measured by optical coherence tomography, compared with a control group with foveal thickness of <200 μm, matched for age, sex and duration of diabetes. Main outcomes measured were progression to CSME by clinical examination.

RESULTS

A total 124 eyes of 73 diabetic patients from the greater Boston area were included in this retrospective study. The study group comprised 52 eyes of 37 diabetic patients with SCME in one or both eyes. The control group included 72 eyes of 36 patients without macular oedema. Sixteen eyes of 13 subjects (35%) progressed to CSME in the study group, compared with six eyes of four subjects (11%) in the control group. Stepwise logistic regression analysis confirmed that prior history of CSME increased the risk of progression (OR 3.69, CI 1.10 to 12.31, p=0.03). Logistic regression analysis also depicted a 15% increase in odds of progression with each 10 μm increase in CSMT (OR 1.15, CI 1.03 to 1.28, p=0.01).

CONCLUSIONS

The results and statistical analyses of this retrospective study suggest that a significant number of patients with SCME ultimately progress to CSME compared with controls. A significant association with prior history of CSME, advancing age and graded increases in CSMT was found.