Optical Coherence Tomography Angiography Findings in Deficiency Optic Neuropathy.

A 44-year-old man was evaluated for bilateral progressive visual loss and diagnosed with vitamin B12 deficiency optic neuropathy. Optical Coherence Tomography Angiography features of optic nerve and macula showed a decrease in peripapillary and macular vessel density that correlated well with the areas of retinal nerve fibre layer thinning seen on OCT. Further studies are needed to evaluate the role of this new technology in the evaluation of toxic and metabolic optic neuropathy.

Intravitreal bevacizumab for extrafoveal choroidal neovascularization secondary to pathologic myopia.

PURPOSE: To assess the effects of intravitreal bevacizumab injections in the treatment of extrafoveal choroidal neovascularization (CNV) associated with pathologic myopia. METHODS: Patients diagnosed with pathologic myopia complicated by extrafoveal CNV were considered in this prospective, open-label interventional study. All patients underwent a complete ophthalmologic examination, including Early Treatment Early of Diabetic Retinopathy Study (ETDRS) visual acuity measurement, optical coherence tomography, and fluorescein angiography. The protocol treatment included a first injection, followed by repeated injections over a 24-month follow-up period on the basis of optical coherence tomography and angiographic features, monitored monthly. Primary outcomes were the mean changes in best-corrected visual acuity and the proportion of eyes gaining at least 15 letters at the 24-month examination. Secondary outcomes included central macular thickness, size of the CNV, and extension to the fovea. RESULTS: Fifteen patients were included in the study. Mean best-corrected visual acuity changed from 0.47 logarithm of the minimum angle of resolution (20/60 Snellen equivalent) at baseline to 0.22 logarithm of the minimum angle of resolution (20/30 Snellen equivalent) at the 24-month examination. An improvement of at least 3 ETDRS lines was achieved by 7 eyes (46.6%) at the 24-month examination. Mean central macular thickness changed from 313 µm to 254 µm at the 24-month examination (P = 0.008). Mean CNV size decreased from 348 µm2 to 251 µm2 at 24 months (P = 0.029). CONCLUSION: Intravitreal bevacizumab injection is a beneficial treatment for extrafoveal CNV associated with pathologic myopia.

PREDICTIVE ROLE OF SWEPT SOURCE OCT ANGIOGRAPHY IN RELAPSING VOGT-KOYANAGI-HARADA DISEASE.

PURPOSE: The purpose of this study was to describe the optical coherence tomography (OCT) angiography findings as a predictive role in the chronic relapsing stage of Vogt-Koyanagi-Harada disease and its comparison with other imaging modalities such as fluorescein angiography, indocyanine-green angiography, and spectral domain OCT. METHODS: A 37-year-old woman from Bangladesh was diagnosed with Vogt-Koyanagi-Harada disease. She was evaluated 8 months before for a routine examination when she was in clinical remission. Full ophthalmic evaluation with multimodal imaging and OCT angiography was performed. RESULTS: Ophthalmic evaluation was unremarkable. Spectral domain OCT disclosed increased choroidal thickness in both eyes while swept source OCT angiography imaging showed choroidal flow voids well-matching hypofluorescent round lesions found by indocyanine-green angiography. A week later the disease reactivated. CONCLUSION: Optical coherence tomography angiography may provide novel insights into inflammatory activity of the choroid and potentially have a predictive role in relapsing Vogt-Koyanagi-Harada disease.

Intravitreal ranibizumab versus bevacizumab for treatment of myopic choroidal neovascularization.

PURPOSE: To compare intravitreal bevacizumab (IVB) and intravitreal ranibizumab (IVR) in the treatment of subfoveal choroidal neovascularization associated with pathologic myopia. METHODS: Fifty-five patients fulfilling inclusion and exclusion criteria were randomized either to IVB or to IVR. After the first injection, re-treatments were performed on a pro re nata basis in monthly examinations over an 18-month follow-up. Primary outcome measures were the change in mean best-corrected visual acuity and the proportion of eyes improving in best-corrected visual acuity by >1 and >3 lines at the 18-month examination. RESULTS: Forty-eight eyes received the treatment and were subsequently included in the analysis. At the 18-month examination, a significant improvement of 1.7 lines and 1.8 lines compared with baseline were noticed in the IVR and IVB subgroups, respectively. The difference in the final mean best-corrected visual acuity between the groups was not significant. A 3-line gain or higher was noted in 30% of eyes in the IVR subgroup and 44% of eyes in the IVB subgroup. Although both groups attained a significant improvement in central macular thickness, the IVR subgroup achieved a faster central macular thickness reduction. A significantly lower number of injections were administered in the IVR subgroup (2.5) compared with the IVB subgroup (4.7; P < 0.001). CONCLUSION: Intravitreal ranibizumab and IVB are effective in the treatment of subfoveal myopic choroidal neovascularization. Intravitreal ranibizumab achieved greater efficacy than IVB in terms of the mean number of injections administered.

Optical Coherence Tomography Angiography in Chiasmitis.

A 29-year-old girl presented complaining of acute bilateral visual loss associated with mild headache and retrobulbar pain. She was diagnosed with chiasmal optic neuritis caused by multiple sclerosis. Her visual acuity and visual field defect promptly improved after steroid therapy. However optical coherence tomography angiography showed a progressive reduction of superficial capillary plexus density of the retina and optic nerve consistent with the progressive impairment of the retinal ganglionar cell layer. Contrary to chiasmal compression, in chiasmal optic neuritis, the superficial capillary plexus density reduction is diffuse and does not reflect the peculiar anatomy of the chiasm.

Intravitreal bevacizumab therapy on an as-per-needed basis in subfoveal choroidal neovascularization secondary to pathological myopia: 2-year outcomes of a prospective case series.

PURPOSE: To evaluate the effects of intravitreal bevacizumab in the treatment of subfoveal choroidal neovascularization (CNV) related to pathological myopia. METHODS: Thirty eyes with treatment-naive CNV were included. Best-corrected visual acuity on Early Treatment Diabetic Retinopathy Study chart, optical coherence tomography (OCT), and fluorescein angiography assessment was performed at baseline and thereafter monthly for more than 24 months. Intravitreal bevacizumab on an as-per-needed basis was administered if either persistent intraretinal/subretinal fluid was detected on OCT or the presence of leakage was noted on fluorescein angiography. Primary outcome measures included the change in mean best-corrected visual acuity and the proportion of eyes improving by three lines or greater. Secondary outcome measures included the change in mean central macular thickness on OCT. The proportion of eyes with resolution of intraretinal/subretinal fluid on OCT and leakage on fluorescein angiography over the follow-up was also noted. RESULTS: Mean best-corrected visual acuity improved from 54.8 ± 14.8 (Early Treatment Diabetic Retinopathy Study letters ± SD) to 59.03 ± 17.0 at 3 months, subsequently stabilizing to 58.63 ± 18.52 at 12 months and 59.25 ± 20 at 24 months. A statistically significant difference was detected only at the 1-month examination. Best-corrected visual acuity at 24 months showed a 3-line improvement in 36.6% of cases and at least a 1-line increment in 43.3% of cases. Mean central macular thickness showed no significant reduction from baseline (216.8 ± 86 µm) up to the end of 24 months (205 ± 77.8 µm). At the last visit, a complete CNV closure was obtained in 93% of cases while intraretinal/subretinal fluid was detected on OCT in 13% of cases. The mean number of intravitreal bevacizumab injections was 4.73 (range, 1-10) at the end of 12 months and 5.9 (range, 1-13) at the end of the 24 months. CONCLUSION: Intravitreal bevacizumab injection for myopic subfoveal CNV administered on an as-per-needed basis over 24 months of follow-up achieved stabilization of vision with >90% CNV closure rate.

Swept-source optical coherence tomography angiography vitreo-retinal segmentation in proliferative diabetic retinopathy.

PURPOSE: To identify a new cortical vitreous segmentation protocol for non invasive standardised investigation of Neovascularisation (NV) with detection of regression of NV activity in Proliferative Diabetic Retinopathy (PDR). DESIGN: Retrospective study. PARTICIPANTS: One hundred and eighty-six eyes of 93 consecutive diabetic patients (mean age: 52.6 ± 11.0 years) imaged using Topcon Triton® Swept-Source Optical Coherence Tomography Angiography (SS-OCTA) from June 2015 to January 2017. METHODS: Scans were performed through the macula, optic disc and areas of possible NV in mid-peripheral retina using 6 × 6 mm and/or 9 × 9 mm raster-patterns in three segmentation protocols: Vitreo-Retinal (VRS), Outer-Vitreous (OVS) and Core-Vitreous Segmentation (CVS). Any suspicion of PDR was confirmed in all patients by Heidelberg® Widefield-Fundus-Fluorescein-Angiography (WF-FFA) and/or Optos® Ultra-WF-FFA (UWF-FFA). Inter-observer reproducibility of NV diagnosis and agreement between SS-OCTA and UWF-FFA were assessed. Primary outcome was the identification of an effective and reproducible segmentation protocol. Secondary outcome was the identification of NV regression after treatment. RESULTS: Sensitivity-specificity reached, respectively, the value of 100 to 100 in detecting NVD, and 96.6 to 100 in detecting NVE in compared areas. SS-OCTA was able to confirm absence of blood flow within the residual NV plexus when using VRS protocol in 30 eyes in which regression of NV with absence of leakage was documented on FFA. CONCLUSION: Three segmentation protocols (VRS, OVS and CVS) with different but complementary characteristics, allowed a reproducible and standardised investigation of NVD and NVE. The proposed new SS-OCTA cortical vitreous segmentation protocols may be of value when identifying and assessing NV-activity (VRS, OVS and CVS) or NV-regression (VRS) in PDR and therefore, response to therapy.

Intraocular Tuberculosis: A Challenging Case Mimicking Wet Age-Related Macular Degeneration.

An otherwise healthy 72-year-old Chinese patient diagnosed with exudative age-related macular degeneration and decreased vision in left eye was fully investigated. The retrospective analysis of past multimodal imaging revealed bilateral severe choroidal neovascularization and choroiditis associated with a positive tuberculin skin testing and interferon-gamma release assay (QuantiFERON-TB Gold - Cellestis®, Chadstone, VIC, Australia) suggestive of latent ocular tuberculosis. The variable presentation and tests' results interpretation represent the greatest limitations in understanding and treating intraocular TB (IOTB). This may present without any other systemic symptoms, the intraocular tissues are of limited access to biopsies and other tests, including imaging and immunological tests, are of relative value. This case highlights how variable may be the presentation of IOTB, which can be easily misdiagnosed leading to a delayed treatment and worse prognosis.

Electronic retinal prosthesis for severe loss of vision in geographic atrophy in age-related macular degeneration: First-in-human use.

BACKGROUND: To date there are yet no available approved therapies for Geographic Atrophy (GA) secondary to age-related macular degeneration (AMD). METHODS: Single site, non-randomized safety and efficacy study presenting the preliminary results in a cohort of five late stage AMD (GA) patients successfully implanted with the Argus II Retinal Prosthesis System (Second Sight Medical Products Inc., Sylmar, CA, USA). Extensive fundus imaging including retinal photographs from which the GA area was measured. A combination of custom and traditional tests designed for very low vision subjects assessed visual function in study subjects. A Functional Low-Vision Observer Rated Assessment was carried out to evaluate the impact of the system on the subject's daily life. In addition, a study to evaluate structural characteristics of the visual cortex of the brain was performed in one subject using magnetic resonance imaging. RESULTS: Seven device-related adverse events were reported, four of which were classed as serious adverse events. Retinal detachment was reported in three patients and was successfully treated within 12 months of onset. Testing showed an improvement in visual function in three of five patients with the system turned on. Magnetic resonance imaging assessed in one patient after implantation indicates a selective increase in cortical myelin and thickness in visual brain regions 1 year post implantation. CONCLUSIONS: Epiretinal prostheses can successfully be implanted in those affected by GA secondary to late-stage AMD and can elicit visual percepts by electrical stimulation of residual neuroretinal elements and improve basic visual function in those affected.

Optical Coherence Tomography Angiography Findings in Optic Nerve Sheath Meningioma.

A 46-year-old female with a history of 5 months of progressive painless visual loss in the left eye was found to have an optic nerve sheath meningioma. Optical coherence tomography angiography showed a reduction in the superficial capillary plexus density consistent with her visual field defect and peripapillary retinal nerve fiber layer thinning. Moreover, abnormalities in the choriocapillaris were found in the affected eye compared to the fellow eye. Possible explanations for these findings are discussed. Further studies and a consistent number of cases are needed to correctly assess the impairment of ocular blood flow in optic nerve sheath meningioma.

Treatment of serous pigment epithelium detachment with subthreshold micropulse diode laser photocoagulation: a case report.

PURPOSE: To propose a possible treatment for symptomatic serous pigment epithelium detachment (SPED) in the setting of dry age-related macular degeneration. METHODS: A 60-year-old woman presented with a SPED, subfoveal in location, enlarging in size and with gradually worsening vision over 1 year of follow-up, without any evidence of choroidal neovascular membrane or neurosensory detachment until it was treated with subthreshold micropulse laser. RESULTS: The last follow-up showed complete resolution of the SPED with restoration of visual function. CONCLUSIONS: Subthreshold micropulse laser could serve as a useful therapeutic modality for the treatment of symptomatic SPED.

Optical Coherence Tomography in a Cohort of Genetically Defined Hereditary Spastic Paraplegia: A Brief Research Report.

Introduction: In-vivo objective documentation of pathological changes in neurodegenerative disease is a major aim to possibly improve our ability to monitor disease progression and response to treatment. Temporal thinning of the retinal nerve fiber layer (RNFL) thickness shown by spectral domain optical coherence tomography (SD-OCT) has been reported in association with the complex forms in hereditary spastic paraplegia (HSP). We performed an assessment of the RNFL thickness in a group of HSP patients, including a longitudinal follow-up in a subgroup. Our aim was to measure and compare the changes and correlate them to clinical progression. Materials and Methods: Twenty-three HSP patients were recruited and studied with the SD-OCT including papillary and macular scan by Spectralis. The clinical severity was assessed using the Spastic Paraplegia Rating Scale. Results: Thinning of the superior, nasal and inferior quadrants bilaterally were observed compared to the normative data in both pure and complicated forms, that were clearly pathological only in a proportion of cases. Thinning correlated with age and disease duration, but not with clinical severity. The longitudinal study (n = 9) showed no significant change compared to the baseline data for the period of observation (mean 10.7 months). Conclusions: RFNL is frequently thinned in HSP with no specific recognizable pattern of quadrants involved and SPG types. The small sample size and the short follow-up time showed no clear progression. Although SD-OCT appraisal of RFNL deserves to be explored in neurodegenerative conditions, it might not be suitable for use as a biomarker in HSP as it appears not to be specific to this condition and can be a feature of aging.

The effect of bevacizumab before vitrectomy for diabetic tractional retinal detachment demonstrated on optical coherence tomography angiography.

PURPOSE: To demonstrate the effect of intravitreal bevacizumab (IVB) on the size and vascularity of the fibro-vascular complex with the optical coherence tomography angiography (OCTA) before pars plana vitrectomy (PPV). METHODS: Observational case series of three eyes with active diabetic fibro-vascular complex and tractional retinal detachment (TRD) who underwent IVB (1.25 mg/0.05 ml) two days before proceeding to PPV. OCTA was carried out prior to IVB, two days after IVB and six weeks after PPV. RESULTS: OCTA showed a reduction in the size and calibre of the diabetic fibro-vascular complex two days after IVB in all the cases. Consequently, there was less traumatic dissection of the fibro-vascular membranes during PPV and thus reduced chances of intraoperative and postoperative vitreous cavity bleeding. One case showed mild hemorrhage in the posterior vitreous on the second day post-injection which implies the increased traction caused by IVB. CONCLUSIONS: In this case series, we have used OCTA to demonstrate how IVB is highly effective in reducing the vascularity of diabetic fibro-vascular membranes. This finding also suggests that the use of IVB before PPV in the management of diabetic TRD could also be much shorter than the advocated standard practice of one week in most institutions.

Live porcine thirty days delayed recovery surgery: Qualitative findings with the hypersonic vitrectomy.

INTRODUCTION: Qualitatively assess the possible delayed structural, macroscopic and microscopic changes in the neuro-retina, retinal vasculature, retinal pigment epithelium (RPE) and optic nerve head (ONH) after pars plana vitrectomy (PPV) surgery using a new hypersonic vitrector (HV). MATERIALS AND METHODS: Eight live porcine eyes underwent PPV using either the HV or a conventional pneumatic guillotine vitrector (GV). The un-operated fellow eye from each pig was used as an external control. The pigs were post-operatively kept alive for 30 days before termination and enucleation of the eyes. Prior to enucleation, all eyes underwent examination of the lens and indirect ophthalmoscopy. Enucleated eyes were fixed in formalin, examined macroscopically and processed for histological assessment. Microscopic analysis included assessment of neuro-retina, retinal vasculature, RPE and ONH, as well as observation for any morphological intraocular changes. Comparison was made between: (1) treated and untreated areas of the same eye (internal control) (2) different areas within the same eye operated on using different vitrector settings (3) eyes operated on with the HV and GV (4) eyes receiving surgery and the fellow un-operated eye (external control, same pig). RESULTS: All lenses had remained clear at 30 days into the postoperative period. On indirect ophthalmoscopy, the retina had remained attached in all eyes with no visible changes to the neuro-retina, retinal vasculature, RPE or ONH. Two eyes showed localized RPE depigmentation secondary to previously documented intraoperative retinal touch. The Morphological changes in the retinal layers above depigmented RPE were no different from retinal change elsewhere. There were mild and similar microscopic changes observed in the neuro-retina, retinal vasculature, RPE or ONH associated with either the HV or GV PPVs. Preliminary histological findings revealed no significant differences between eyes operated on with the HV and those operated on the GV. DISCUSSION: At 30 days into the postoperative period, there seemed to be similar morphological changes attributable to the use of HV and GV. Therefore, the HV promises to be a new alternative to the currently commercially available GV for PPV.

Segmented swept source optical coherence tomography angiography assessment of the perifoveal vasculature in patients with X-linked juvenile retinoschisis: a serial case report.

PURPOSE: To describe perifoveal microvascular changes occurring in X-linked juvenile retinoschisis (XLRS) using swept source optical coherence tomography angiography (SS OCTA). PATIENTS AND METHODS: This is a serial case report of three patients. Retrospective data of patients affected by XLRS were collected. Structural optical coherence tomography (OCT) and color fundus photography (CFPh) were carried out with Topcon® OCT 2000 3D OCT as part of the standard care. Two patients were imaged on Topcon Atlantis® SS OCTA and one on Topcon Triton® SS OCTA. SS OCTA images were acquired using the 3 × 3 mm fovea-centered cubes scanning protocol. Analysis of both perifoveal superficial vascular plexus (pSVP) and perifoveal deep vascular plexus (pDVP) was performed by two observers after automated segmentation. RESULTS: Four eyes of three males (mean age 14 ± 3.8 years) were analyzed. All eyes showed foveoschisis on CFPh images. OCT B-scans of three eyes showed schistic cysts in the ganglion cell layer, inner nuclear layer (INL) and outer nuclear layer (ONL); in one eye, cysts were depicted in INL and ONL only. In two eyes, SS OCTA showed abnormal foveal avascular zone (FAZ) shape in the pSVP, and in the other two, FAZ shape was abnormal in both plexuses. In all eyes, retinal vascular abnormalities (ie, microvascular protrusions) were present in pDVP. CONCLUSION: SS OCTA can depict perifoveal microvascular changes in young patients affected by XLRS. In this study, the structural and vascular changes seem to be more evident in the pDVP and may represent a useful biomarker of prognosis.

Swept-Source Optical Coherence Tomography Angio™ (Topcon Corp, Japan): Technology Review.

Optical coherence tomography (OCT) angiography (OCTA) is a novel, noninvasive, three-dimensional imaging technique that allows for the visualization of intravascular flow in the microvasculature. Swept-source OCT technology utilizes longer-wavelength infrared light than conventional spectral-domain OCT. This enables improved penetration into tissue and imaging through optical opacities and is invisible to the subject. Topcon has recently developed an innovative OCTA algorithm, OCTARA (OCTA Ratio Analysis), which benefits from being paired with swept-source OCT. OCTARA aims to provide improved detection sensitivity of low blood flow and reduced motion artifacts without compromising axial resolution. In this chapter, we describe the implementation of OCTARA with swept-source OCT technology, the technical specifications of acquisition (e.g. the number of scans, area of examination field, etc.) along with the algorithm's function and principles for analysis of B-scan data to achieve angiographic visualization. Examples of OCTA scans performed using the OCTARA algorithm and a comparison of these scans with images obtained using other technologies are also presented.

Swept-Source Optical Coherence Tomography Angiography of Paediatric Macular Diseases.

PURPOSE: To describe the optical coherence tomography (OCT) angiography (OCTA) features of paediatric macular pathologies. METHODS: Retrospective serial case reports of patients who underwent routine clinical examination and OCTA of the posterior pole using both a DRI OCT Atlantis prototype and Triton Swept-Source OCT. When considered necessary, imaging was performed using Optos wide-field imaging or another non-invasive imaging system. The findings were compared with the current literature. RESULTS: Three cases with X-linked retinoschisis, 2 with epiretinal membrane, 1 with Best disease and 2 with Coats disease are fully illustrated. CONCLUSION: OCTA is an effective, non-invasive imaging technique that can offer additional information regarding the morphologies and vascular characteristics of macular lesions in paediatric ophthalmology. Because of the rarity and characteristics of many paediatric macular pathologies, further multi-centric research is required with regard to the utilisation and features of OCTA imaging.

New Findings in Diabetic Maculopathy and Proliferative Disease by Swept-Source Optical Coherence Tomography Angiography.

PURPOSE: To describe the optical coherence tomography (OCT) angiography (OCTA) features of diabetic retinopathy. METHODS: Retrospective serial case reports were examined of patients who underwent routine clinical examination and OCTA with both DRI OCT Atlantis prototype and Triton Swept-Source OCT of the posterior pole and mid-periphery. When considered necessary, fluorescein fundus angiography (FFA) with OPTOS California wide-field imaging was performed. The findings were compared with the current literature. RESULTS: Forty-three consecutive patients (86 eyes) were evaluated. Fourteen of these patients (28 eyes) underwent an additional FFA examination due to advanced retinopathy signs, such as diabetic macular edema, ischemia or neovascularization (NV). OCTA was able to detect the microvascular lesions observed on color fundus images in the whole sample. Thirty-six of the 86 eyes showed foveal avascular zone enlargement on OCTA. Microvascular lesions, diabetic macular edema, and NV of the optic disc observed on FFA were also detected on OCTA in all cases (28/28 eyes). Features of NV elsewhere were detected on FFA in 16/28 eyes. Ten of the 16 eyes had signs of NV within the 100 central degrees, and OCTA was able to detect these signs in 9 of the eyes. CONCLUSION: OCTA is an effective noninvasive imaging technique that can provide additional information regarding the localization and morphology of vascular lesions in all cases of NV of the optic disc and in more than half of cases of NV elsewhere, suggesting that it is a noninferior technique for the study of posterior pole alterations compared with FFA, which remains the gold standard and is fundamental for the study of the retinal periphery.

Subthreshold laser treatment versus threshold laser treatment for symptomatic retinal arterial macroaneurysm.

PURPOSE: This study was designed to compare the effects of subthreshold laser treatment (STLT) with threshold laser treatment (TLT) in patients affected by symptomatic retinal arterial macroaneurism (RAM). METHODS: Patients affected by symptomatic RAM, characterized by exudative manifestations involving the fovea and best-corrected visual acuity (BCVA) worse than 20/80 Snellen equivalent, were recruited. Patients were randomly assigned to STLT or TLT and regularly followed up for 12 months. Primary outcome measures were changes in central point thickness (CPT) at the end of the follow-up. Secondary outcome measures were changes in mean BCVA at the end of the follow-up and identification of postlaser alterations. RESULTS: In this single center, randomized, clinical trial, 12 patients were randomized to STLT and 13 to TLT. CPT in STLT was 332 µm at baseline and changed to 249 µm at the 12-month examination. CPT in TLT was 341 µm and reduced to 226 µm at the end of the follow-up. BCVA in STLT changed from 0.72 logMAR to 0.28 logMAR. BCVA in TLT changed from 0.76 logMAR to 0.26 logMAR. The statistical analyses revealed a significant difference comparing the baseline values for both CPT and BCVA in each subgroup from the third month (P < 0.001). No difference was found comparing the two subgroups at any point in time. Three eyes (23%) treated with TLT developed an epiretinal membrane with subjective metamorphopsia. CONCLUSIONS: This pilot randomized clinical trial shows that both STLT and TLT can achieve similar improvements in BCVA and CPT. The lower laser energy delivered by STLT can reduce the complication rate.