Subretinal hyperreflective exudation associated with neovascular age-related macular degeneration.

PURPOSE: To describe the multimodal imaging findings of subretinal hyperreflective exudation (SHE) observed in association with choroidal neovascularization and to distinguish SHE from other forms of subretinal hyperreflective material (SHM) seen in patients with age-related macular degeneration and other macular disorders. METHODS: A retrospective study on 46 eyes of 42 patients with SHE associated with Types 1, 2, and 3 choroidal neovascularization secondary to neovascular age-related macular degeneration. Patients were examined using multimodal imaging, including color photography, near-infrared reflectance imaging, spectral domain optical coherence tomography, fluorescein angiography, fundus autofluorescence imaging, and indocyanine green angiography. Clinical and imaging characteristics were evaluated at baseline, after the initiation of intravitreal antivascular endothelial growth factor therapy, and during the resolution of SHE. RESULTS: Forty-five of the 46 eyes were treatment naive. The mean ± SD age at the first detection of SHE was 77.2 ± 10.1 years. The mean ± SD follow-up was 2.1 ± 0.6 years. Fluorescein angiography was performed in 42 eyes and demonstrated leakage and/or staining of underlying or adjacent choroidal neovascularization but not of the SHE itself in all eyes. On fluorescein angiography, SHE was transparent in 29 eyes and blocking in 7 eyes. In 32 eyes, SHE showed isoautofluorescence on fundus autofluorescence imaging, and in 8 eyes, SHE showed varying degrees of hyperautofluorescence. Indocyanine green angiography was performed in eight eyes and demonstrated hyperfluorescence of SHE in seven eyes. In eight eyes, SHE was the only evidence of neovascular activity. All eyes having follow-up (42 eyes) showed resolution of the subretinal material with partial or full reconstitution of the ellipsoid zone after a median of 2 injections range (1-16 injections). Subretinal hyperreflective exudation persisted for a median of 9 weeks (range, 4-60 weeks) after the initiation of treatment. The mean visual acuity before treatment was 0.619 (20/83), and it improved to 0.380 (20/48) (P = 0.03) after the resolution of SHE. CONCLUSION: Subretinal hyperreflective exudation differs from other types of SHM based on the findings from multimodal imaging. This novel type of SHM likely represents a sign of active neovascular age-related macular degeneration distinct from subretinal fluid, hemorrhage, neovascular tissue, lipid, pigment hyperplasia, subretinal fibrosis, and the SHM observed with acquired vitelliform lesions. Intravitreal antivascular endothelial growth factor agents can be used to successfully resolve SHE, often resulting in better visual outcomes in eyes manifesting this form of exudation.

The pearl necklace sign: a novel spectral domain optical coherence tomography finding in exudative macular disease.

PURPOSE: To report a novel spectral domain optical coherence tomography finding in exudative macular disease, called the pearl necklace sign. METHODS: A retrospective case series of 21 eyes (20 patients) with chronic exudative maculopathy resulting from age-related macular degeneration, diabetic macular edema, branch retinal vein occlusion, retinal arterial macroaneurysm, and Coats disease. Spectral domain optical coherence tomography images were carefully evaluated and correlated with color fundus photography, near-infrared reflectance, and fluorescein angiography. RESULTS: A unique spectral domain optical coherence tomography macular finding of hyperreflective dots in a contiguous ring around the inner wall of cystoid spaces in the outer plexiform layer of the retina that the authors refer to as the pearl necklace sign was seen in all patients. Visual acuity ranged from 20/30 to hand motions. The cystoid spaces and the hyperreflective dots resolved in certain cases after anti-vascular endothelial growth factor therapy and/or focal macular laser, but tended to recur. CONCLUSION: Because the pearl necklace configuration can be found adjacent to hard exudates in the outer plexiform layer, the authors speculate that the hyperreflective material is composed of lipoproteins or lipid-laden macrophages. This novel spectral domain optical coherence tomography sign gives further insight into the development and progression of hard lipoprotein exudates in exudative maculopathy.

Ultra-widefield imaging with autofluorescence and indocyanine green angiography in central serous chorioretinopathy.

PURPOSE: To describe the spectrum of ultra-widefield autofluorescence (AF) and indocyanine green (ICG) angiographic findings in central serous chorioretinopathy (CSC). DESIGN: Retrospective observational case series. METHODS: In 37 patients, 65 eyes with CSC from 2 vitreoretinal clinical practices were imaged using ultra-widefield AF and 24 of these eyes with ultra-widefield ICG angiography. Images were correlated with clinical findings and spectral-domain optical coherence tomography (OCT). RESULTS: In 37 (57%) eyes, a variety of altered AF patterns, including gravitational tracts, extended beyond the posterior 50 degrees of retina. Hyper-AF corresponded to areas of subretinal fluid (SRF) on spectral-domain OCT and was found to persist in 44 (70%) eyes for up to 8 years despite resolution of SRF. These areas corresponded to outer retinal atrophy with viable retinal pigment epithelium (RPE) on spectral-domain OCT and may be explained by the unmasking of normal background RPE AF. Ultra-widefield ICG angiography revealed dilated choroidal vessels and choroidal hyperpermeability in areas corresponding to altered AF on ultra-widefield AF in all 24 eyes. In 20 (83.3%) eyes, dilated vessels were observed in association with 1 or more congested vortex veins ampullas, suggesting that outflow congestion may be a contributing factor to the pathogenesis of CSC. CONCLUSIONS: Ultra-widefield AF and ICG angiography in CSC revealed more widespread disease in a single image than with standard field imaging and may be useful for identifying peripheral areas of previous or ongoing SRF and choroidal hyperpermeability that can assist in the diagnosis of CSC, surveillance of recurrent disease and treatment of active disease.

Cyclo-oxygenase inhibitors in the treatment of chronic non-infectious, non-necrotizing scleritis and episcleritis.

PURPOSE: To evaluate the use of selective vs. non-selective cyclo-oxygenase inhibitors (COXIs) for the treatment of chronic non-infectious, non-necrotizing scleritis and episcleritis. METHODS: Sixty-nine patients with scleritis and episcleritis treated for ≥2 months with COXIs were included. Outcome measures were rates of inflammation control, corticosteroid sparing, and COXI discontinuation, as well as side effects. RESULTS: Initial inflammation control was achieved in 78-81% of scleritis patients and 73-80% episcleritis patients on COXIs (p > .05). Rates of steroid sparing after 4-24 months of consecutive treatment were similar. Gastrointestinal side effects were observed in 1 (2.7%) patient on selective vs. 3 (9.4%) patients on non-selective COXIs (p = .33). Overall discontinuation rate was 6/37 (16%) for selective vs. 7/32 (22%) for non-selective COXIs (p = .76). CONCLUSIONS: Selective vs. non-selective COXIs were equally efficacious for the treatment of chronic non-infectious, non-necrotizing scleritis and episcleritis. Prospective studies to elucidate potential differences in side effect profiles may be warranted.

Corneal thickness changes after corneal collagen crosslinking for keratoconus and corneal ectasia: one-year results.

PURPOSE: To determine the changes in corneal thickness over time after corneal collagen crosslinking (CXL) for keratoconus and corneal ectasia. SETTING: Cornea and refractive surgery subspecialty practice. DESIGN: Prospective randomized controlled clinical trial. METHODS: Corneal thickness at the apex, thinnest point, and pupil center were measured using Scheimpflug imaging (Pentacam) at baseline and 1, 3, 6, and 12 months after CXL. The treatment group was compared with both a sham-procedure control group and a fellow-eye control group. Associations with clinical outcomes (uncorrected and corrected distance visual acuities and maximum keratometry) were analyzed. RESULTS: The study comprised 82 eyes, 54 with keratoconus and 28 with ectasia after laser in situ keratomileusis. The mean preoperative thinnest pachymetry was 440.7 µm ± 52.9 (SD). After CXL, the cornea thinned at 1 month (mean change -23.8 ± 28.7 µm; P<.001) and from 1 to 3 months (mean change -7.2 ± 20.1 µm, P=.002), followed by a recovery of the corneal thickness between 3 months and 6 months (mean +20.5 ± 20.4 µm; P<.001). At 1 year, apex and pupil-center thicknesses returned to baseline (P=.11 and P=.06, respectively); however, the thinnest pachymetry remained slightly decreased from baseline to 12 months (mean change -6.6 ± 22.4 µm; P=.01). The recovery of corneal thickness was more rapid in ectasia than in keratoconus. There was no association between the degree of corneal thinning at 3 months and clinical outcomes after CXL. CONCLUSIONS: After CXL, the cornea thins and then recovers toward baseline thickness. The cause and implications of corneal thickness changes after CXL remain to be elucidated. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosure is found in the footnotes.