Intracystic hyperreflective material in centre-involving diabetic macular oedema.

PURPOSE: To report evolution and predictive value of intracystic hyperreflective material (ICHRM) on optical coherence tomography (OCT) in centre-involving diabetic macular oedema (CI-DME). METHODS: Demographic and OCT features of patients with treatment-naïve CI-DME were analysed retrospectively. OCT parameters noted were macular oedema type, ICHRM presence, presence of hyperreflective spots, disorganised inner retinal layers and outer retinal layers integrity. Eyes were grouped into group 1 CI-DME without ICHRM and group 2 CI-DME with ICHRM. Univariate and multivariate linear regression analyses were done to study the correlation between various OCT features and final vision. RESULTS: In this study, 62 eyes of 50 patients were included in group 1 and 61 eyes of 51 patients in group 2. Mean presenting logMAR vision in groups 1 and 2 was 0.374 ± 0.346 and 0.523 ± 0.369 respectively. Poor final visual acuity was noted in CI-DME with ICHRM group (p = 0.015). On linear regression analysis, 3 OCT features, namely, ICHRM presence (p = 0.034), inner segment-outer segment layer disruption (p = 0.001) and ellipsoid zone defects (p = 0.003), were associated with poor final vision. More intravitreal anti-VEGF (2.98 vs 0.629) and steroid (1.51 vs 0.242) injections were required for macular oedema resolution in ICHRM group. CONCLUSION: This study is the first to assess the ICHRM on OCT as predictor for treatment outcome in DME eyes. We described its evolution during the DME management and its plausible influence on intravitreal therapy. We believe that this finding has the potential to become a novel biomarker for predicting the visual outcome in DME.

Impact of sub-foveal choroidal thickness on clinical features and long-term clinical outcomes in polypoidal choroidal vasculopathy.

PURPOSE: To study the clinical features and long-term clinical outcomes in polypoidal choroidal vasculopathy (PCV) in eyes with different sub-foveal choroidal thickness (SFCT). METHODS: In this retrospective, observational comparative study, treatment-naïve eyes diagnosed with PCV using the 'EVEREST-2' study criteria were included. The eyes were divided into three groups of thin, medium and thick choroids, based on the SFCT data of total study eyes. Demographic, clinical, imaging features and treatment outcomes between the 3 groups were compared. RESULTS: Sixty-three eyes in 63 patients were included. Right eye was involved in 39 (61%) cases and left eye in 24 (39%) cases. Mean age was 68.3 ± 6.82 years (range 54-85 years). Mean SFCT was 274 µm (median = 269 µm), and one standard deviation was 79.2 µm. Totally, 11, 43 and 9 eyes were included in the thin, medium and thick choroid groups, respectively. The mean SFCT was 161 ± 24.1 µm, 275 ± 39.6 µm and 412 ± 26.2 µm in the thin, medium and thick choroid groups, respectively. There was no statistically significant difference in the clinical and imaging features and treatment outcomes between eyes with thin, medium and thick SFCT. CONCLUSION: Eyes with PCV can have a choroid of varying thicknesses. Clinical, imaging and treatment responses were similar between the three sub-foveal choroidal thickness groups in this study. In future, more studies are required to evaluate the role of the choroidal thickness and its relationship to treatment in PCV.

Differences in the multicolour imaging features between the superficial and deep vascular occlusions.

Purpose To describe the multicolour imaging (MI) findings in superficial and deep vascular plexus occlusions. METHODS: In this retrospective observational study, patients diagnosed with central retinal artery and branch retinal artery occlusion, cotton-wool spot, paracentral acute middle maculopathy and acute macular neuroretinopathy between January 2018 and June 2019 were included. Colour fundus photograph, optical coherence tomography and MI of these patients were analysed. RESULTS: A total of 41 eyes of 40 patients were included in this study. In eyes with central retinal artery occlusion, MI showed white areas in the retina with orange foveal centre. In eyes with branch retinal artery occlusion, MI showed white area along the affected retinal quadrant without an orange foveal centre. In pure superficial vascular plexus occlusions as in cotton-wool spots, the lesion was identified on MI as a white lesion. On MI, paracentral acute middle maculopathy showed parafoveal white areas with orange foveal centre while acute macular neuroretinopathy on MI parafoveal greyish-white areas with normal foveal centre. CONCLUSION: En-face images using MI technology can provide yet another way to identify the level of retinal vasculature involvement which complements the existing gold standard of optical coherence tomography imaging.

UTILITY OF EN FACE OPTICAL COHERENCE TOMOGRAPHY IN INTRAOCULAR LYMPHOMA.

PURPOSE: To report the en face optical coherence tomography (OCT) features of intraocular lymphoma. METHODS: Retrospective, observational case report. RESULTS: A 59-year-old man, a known case of primary testicular carcinoma, complained of right eye blurred vision since 1 week. He had previously undergone systemic intravenous chemotherapy (R-CHOP regimen), orchiectomy, and external beam radiotherapy for the primary malignancy. His right eye vision was 20/30, 6/6 reduced Snellen. The right eye anterior segment examination was normal. Fundus examination showed vitreous cells 1+ and a large, bumpy, subretinal dull-yellow lesion sparing the fovea with multiple discrete yellow retinal lesions at the posterior pole. Magnetic resonance imaging of the brain was normal. Multimodal imaging was used to document the clinical features. On the en face OCT, multiple hyperreflective lesions were identified on the superficial, deep, and outer retinal slabs of the scan corresponding to the vertical hyperreflective lesions extending from the retinal nerve fiber layer to the retinal pigment epithelium. The subretinal pigment epithelium lesion can be well delineated in the choriocapillaris segment. He was treated with multiple injections of intravitreal methotrexate 400 µg/0.1 mL along with systemic chemotherapy in conjunction with the oncologist. At the 6-month follow-up, fundus lesions had regressed. In addition, resolution of the lesions was noted on the OCT and en face OCT scans. CONCLUSION: En face OCT imaging can be considered for monitoring the therapeutic efficacy after intravitreal chemotherapy in intraocular lymphoma.

Association Between Sleep Apnea Risk Score and Retinal Microvasculature Using Optical Coherence Tomography Angiography.

PURPOSE: To investigate the retinal vessel changes at peripapillary and parafoveal regions using optical coherence tomography angiography in patients with varying obstructive sleep apnea syndrome (OSAS) risk, identified by the STOP-BANG questionnaire. DESIGN: Prospective, hospital-based cross-sectional study. METHODS: Participants were divided into 3 groups based on the OSAS risk score. Flow areas and vessel densities were calculated at peripapillary and parafoveal regions using optical coherence tomography angiography. Microvasculature changes between the 3 groups and correlation between OSAS risk score and vascular changes were calculated. RESULTS: Six hundred and six eyes of 303 patients were included in groups 1 (n = 96), 2 (n = 135), and 3 (n = 72). In patients with high OSAS risk, an increase in flow areas (P = .011) and vessel densities (P = .002) in superficial capillary plexus was noted. In contrast, flow areas (P = .003) and vessel densities (P < .000) in deep capillary plexus were reduced. Positive correlation was noted between sleep scores and vessel densities in superficial capillary plexus (P = .04). Negative correlation was noted between sleep scores and flow areas (P = .003) and vessel densities (P ≤ .001) in deep capillary plexus. CONCLUSION: The sleep apnea questionnaire is an easy method of identifying the disease severity stage, but polysomnography still remains the definitive gold standard. Optical coherence tomography angiography shows some associations with disease severity, but it cannot be used unambiguously to distinguish the severity of sleep apnea.

Optical coherence tomography angiography (OCTA) of retinal vasculature in patients with post fever retinitis: a qualitative and quantitative analysis.

Post fever retinitis is a heterogenous entity that is seen 2-4 weeks after a systemic febrile illness in an immunocompetent individual. It may occur following bacterial, viruses, or protozoal infection. Optical coherence angiography (OCTA) is a newer non-invasive modality that is an alternative to fundus fluorescein angiography to image the retinal microvasculature. We hereby describe the vascular changes during the acute phase of post fever retinitis on OCTA. Imaging on OCTA was done for all patients with post fever retinitis at presentation with 3 × 3 mm and 8 × 8 mm scans centred on the macula and corresponding enface optical coherence tomography (OCT) scans obtained. A qualitative and quantitative analysis was done for all images. 46 eyes of 33 patients were included in the study. Salient features noted were changes in the superficial (SCP) and deep capillary plexus (DCP) with capillary rarefaction and irregularity of larger vessels in the SCP. The DCP had more capillary rarefaction when compared to the SCP. The foveal avascular zone (FAZ) was altered with an irregular perifoveal network. Our series of post fever retinitis describes the salient vascular features on OCTA. Although the presumed aetiology was different in all our patients, they developed similar changes on OCTA. While OCTA is not useful if there is gross macular oedema, the altered FAZ can be indicative of macular ischemia.

Hyporeflective micro-elevations and irregularity of the ellipsoid layer: novel optical coherence tomography features in commotio retinae.

OBJECTIVE: To report on the anatomical changes at the macula in patients with commotio retinae (CR) and not accompanied by any other types of traumatic maculopathy. DESIGN: Retrospective, observational case series. PARTICIPANTS: In this study, individuals with history of blunt ocular trauma and having CR involving the macula without any other type of traumatic maculopathy were included. METHODS: Participants were evaluated with ophthalmic examination, visual acuity testing, and spectral domain optical coherence tomography (OCT) at presentation and further follow-up visits. RESULTS: On colour fundus photography, grey-white retinal discolouration was identified in all 16 patients and 1 patient had accompanying inferior vitreous hemorrhage. On OCT imaging, hyper-reflectivity of the ellipsoid zone (EZ) with disappearance of the thin hyporeflective optical space was noted in all 16 patients at presentation. One patient showed focal hyporeflective micro-elevation of the EZ (MEEZ) at presentation. Final follow-up visit ranged from 6 to 54 days (mean 19.5 days). Complete resolution of CR was noted in 14 eyes at the final visit. Focal hyporeflective MEEZ was noted in 11 eyes at the final follow-up visit. The number of eyes with irregular ellipsoid layer was 5 at the final follow-up visit. CONCLUSIONS: In eyes with CR involving the macula, 2 new OCT features were identified, namely, irregular ellipsoid layer and focal hyporeflective MEEZ. These OCT findings did not affect the vision. Further studies with histological evidence would be required in future to establish the pathogenesis of CR involving the macula.

Acute macular neuroretinopathy with coexistent central retinal vein occlusion as the presenting feature in intraocular tuberculosis.

AIM: To report a case of intraocular tuberculosis presenting as acute macular neuroretinopathy and central retinal vein occlusion. CASE DESCRIPTION: A 29-year-old man presented to the retina clinic with complaints of sudden blurring of vision in the left eye of 3 days duration. His visual acuity was 6/6 and 6/18 in the right and left eye, respectively. Fundus examination of the left eye showed features of central retinal vein occlusion. OCT showed features of type 2 acute macular neuroretinopathy (AMN) as well. Over a period of 2 weeks, the patient developed choroidal granulomas with overlying retinal elevation and peripapillary choroidal neovascular membrane and retinal granuloma. Mantoux test and HRCT chest confirmed the diagnosis of pulmonary tuberculosis. RESULTS: The patient was treated with a course of antitubercular therapy, oral corticosteroids and a single dose of intravitreal anti-vascular endothelial growth factor (1.25 mg/0.05 ml Bevacizumab, Roche Pharma) injection. After 6 months of therapy with ATT and tapering course of oral steroids, there was a complete resolution of all clinical signs including the choroidal granuloma with an improvement in visual acuity to 6/6. CONCLUSION: Acute macular neuroretinopathy can complicate intraocular TB. Tuberculosis should be kept as one of the differential diagnosis in patients with AMN. Prognosis is generally good in patients of ocular TB presenting with retinal vascular occlusions.

Prognostic Value of Hyperreflective Material on Visual Acuity in Treatment-Naïve BRVO.

BACKGROUND AND OBJECTIVE: To correlate between hyperreflective material (HRM) seen on optical coherence tomography (OCT) and visual outcomes in treatment-naïve acute branch retinal vein occlusion (BRVO). PATIENTS AND METHODS: Demographic and OCT features of patients with acute BRVO were analyzed retrospectively. OCT parameters noted were macular edema type, HRM presence and location, and outer retinal layer integrity. Eyes were separated into two groups: Group 1 (BRVO without HRM) and Group 2 (BRVO with HRM). RESULTS: Forty-seven eyes (67%) were included in Group 1 and 23 eyes (33%) were included in Group 2. Mean presenting logMAR visual acuity in Groups 1 and 2 was 0.521 ± 0.428 (mean Snellen equivalent = 20/66) and 0.627 ± 0.427 (mean Snellen equivalent = 20/85), respectively. Poor vision at final visit was noted in the BRVO with HRM group (P = .027). More intravitreal injections were required for macular edema resolution in the HRM group (4.83 vs. 2.67). CONCLUSIONS: Presence of HRM in BRVO is associated with poorer vision. It can be a useful prognostic biomarker. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:320-327.].

Variability in Imaging Findings in Choroidal Nevus Using Multicolor Imaging Vis-à-vis Color Fundus Photography.

PURPOSE: To describe the multicolor imaging (MCI) features in a series of patients diagnosed with a choroidal nevus and compare it vis-à-vis color fundus photography (CFP) in identifying the lesion. METHODS: In this retrospective, descriptive case series at a tertiary referral center in South India, all patients diagnosed with the choroidal nevus underwent CFP, optical coherence tomography, MCI, and infrared reflectance (IR) imaging. RESULTS: In this study, we found that on MCI, the choroidal nevus could be identified in only six of the 12 eyes. The lesions were seen as an area of hyperreflectance on IR image and orange-colored lesion on multicolor image. In one eye, there was a mixed pattern of hyper and hyporeflectance on IR imaging. The remaining five eyes with choroidal nevus lesions were not identified on MCI. CONCLUSION: The variable features of the choroidal nevus on MCI are most likely due to the variable melanin content within the nevus cells. Further studies are needed to validate these findings.

Relevance of Multicolor Imaging in Type 2 Macular Telangiectasia.

PURPOSE: To report the imaging characteristics of various clinical features in idiopathic macular telangiectasia (MacTel 2) on multicolor imaging (MCI) and compare its accuracy vis-à-vis color fundus photograph (CFP) and fluorescein angiography (FA). METHODS: In this retrospective observational study, 54 eyes of 27 patients with MacTel 2 were included after institutional review board approval. Multimodal imaging with CFP, optical coherence tomography (OCT), MCI, and FA was done. Images were analyzed to identify and describe the clinical findings in MacTel 2. Sensitivity, specificity, and positive and negative predictive values were computed for the various imaging modalities in MacTel 2. RESULTS: In this study, the MCI identified all the different clinical features of MacTel 2 in 100% of cases. The confocal blue reflectance (BR) image was more sensitive than CFP (100% vs. 96.3%) in identifying the loss of retinal transparency in MacTel 2. For other clinical features such as right-angled vessels, superficial retinal crystals, and retinal pigment epithelial hyperplasia/plaques, the sensitivity of BR, and green reflectance (GR) image, was comparable to that of CFP. Confocal infrared reflectance (IR) images showed poor sensitivity in identifying the non-proliferative features in MacTel 2 (P < 0.001). Loss of retinal transparency was not picked up on IR image. Other features such as right-angled vessels, superficial retinal crystals, and pigment plaques were seen in 20%, 4.6%, and 26.3% of cases, respectively. However, confocal IR images were superior to FA (100% vs. 47%) and CFP (100% vs. 15%) in identifying the extent and location of subretinal neovascular membrane. The confocal BR and GR images were unable to identify the choroidal neovascular membrane (P < 0.001). CONCLUSION: MCI is a useful and non-invasive imaging modality to identify the clinical features in MacTel 2. MCI can be used as a complementary imaging tool to CFP, FA, and OCT.

Inter-observer agreement and sensitivity of Optomap images for screening peripheral retinal lesions in patients undergoing refractive surgery.

PURPOSE: The aim of this study was to compute the sensitivity, specificity and inter-reader variability of ultra-widefield retinal imaging (Optomap 200Tx) for screening retinal lesions before myopic refractive surgery. METHODS: Two hundred and eight eyes of 109 consecutive refractive surgery candidates were included in this study. All subjects underwent Optomap 200Tx, mydriatic slit-lamp lens examination and dilated retinal examination with scleral indentation by a retinal specialist. Retinal findings by indirect dilated examination by retinal specialist was considered as the gold-standard. Sensitivity analyses for the readers were calculated between the Optomap images and the gold-standard retinal examination. RESULTS: Seventy-three of the 208 eyes (35.1%) had peripheral retinal lesions diagnosed by the retinal specialist on dilated fundus examination. Peripheral lesions were seen on the Optomap images in 111 (53.4%) eyes. Compared to the dilated retinal examination, the detection rate with the Optomap 200Tx was 78.1% and specificity rate was 60%. The accuracy rate between the 3 readers ranged from 72% to 87%. The highest accuracy was noted with the reader post 1 year of retinal training (86.54%). CONCLUSION: The Optomap 200Tx showed a high sensitivity and moderate specificity for identifying peripheral retinal lesions in eyes undergoing refractive surgery. The Optomap examination is a convenient, fast and feasible method for detecting the pathological fundus changes in myopic eyes. The reliability of the examination improves when the images are interpreted by a reader with prior retinal training.

Multicolour imaging in central serous chorioretinopathy.

BACKGROUND: Multicolour imaging (MI) is a novel, non-invasive retinal imaging technology. Its sensitivity for detecting the clinical features in central serous chorioretinopathy (CSCR) has not been previously described. The aim of this study is to evaluate the accuracy of MI compared to fluorescein angiography and colour fundus photography in CSCR, and to describe the imaging features of MI. METHODS: In this retrospective study at a tertiary referral centre, 63 consecutive eyes with CSCR (both acute and chronic) were included after obtaining permission from the institutional review board. Multimodal imaging with colour fundus photography, optical coherence tomography, MI and fluorescein angiography/indocyanine green angiography and near-infrared and blue wavelength autofluorescence was analysed to identify the clinical findings in CSCR. Sensitivity and specificity values were computed for the different clinical features for each imaging modality. RESULTS: On comparison with fluorescein angiography, MI was found to be more effective in identifying the extent of subretinal fluid (78 per cent versus 13 per cent). MI was equally capable in identifying pigment epithelium detachment (100 per cent versus 100 per cent) and retinal pigment epithelial changes (100 per cent versus 100 per cent). Focal leaks were identified in 84 per cent and 97 per cent of eyes using MI and fluorescein angiography imaging, respectively. The sensitivity of MI in identifying focal retinal pigment epithelial leaks was higher compared to near-infrared autofluorescence (84 per cent versus 34 per cent) and blue wavelength autofluorescence (84 per cent versus 18 per cent) imaging. CONCLUSION: MI is a useful, non-invasive imaging modality for detecting clinical features in CSCR. In the future, MI has the potential to substitute for fluorescein angiography and colour fundus photography as the imaging modality of choice.