Analyzing Relative Flow Speeds in Diabetic Retinopathy Using Variable Interscan Time Analysis OCT Angiography.

PURPOSE: Further insight into the flow characteristics of the vascular features associated with diabetic retinopathy (DR) may improve assessment and treatment of disease progression. The variable interscan time analysis (VISTA) algorithm is an extension of OCT angiography (OCTA) that detects relative blood flow speeds, which then can be depicted on a color-coded map. This study used VISTA to analyze relative blood flow speeds in the microvascular changes associated with DR. DESIGN: Cross-sectional study. PARTICIPANTS: Thirteen patients with varying severities of DR treated at New England Eye Center, Boston, Massachusetts. METHODS: OCT angiography images centered at the fovea were obtained on a prototype swept-source OCT device, and the VISTA algorithm was applied to visualize relative blood flow speeds. MAIN OUTCOME MEASURES: Descriptive flow analysis of the retinal vascular features of DR was conducted on the VISTA-generated images. RESULTS: Twenty-six eyes were included in this study. Of these, 3 eyes had mild nonproliferative DR (NPDR), 6 eyes had moderate NPDR, 4 eyes had severe NPDR, 9 eyes had proliferative DR, and 4 eyes were normal controls. Microaneurysms, intraretinal microvascular abnormalities (IRMAs), and neovascularization appeared to originate from areas of relatively slow blood flow speeds. Microaneurysms showed relatively slower flow, IRMAs showed turbulent, intermediate to slow flow, and venous beading and looping presented with relatively high flow speeds that tapered progressively. Neovascularization of venous origin demonstrated slower flow speeds, whereas that of arterial origin showed relatively high flow speeds. Additionally, increased disease severity was associated with globally slower flow speeds, with particularly slower flow around the foveal avascular zone. CONCLUSIONS: The VISTA algorithm seems to be a useful extension of OCTA that overcomes some of the limitations of normal gray-scale OCTA. It seems to have some potential in providing relevant insight into the pathogenesis of the microvascular changes associated with DR. These findings may assist in improving our understanding of the pathogenic changes that take place in DR.

Repeatability of binarization thresholding methods for optical coherence tomography angiography image quantification.

Binarization is a critical step in analysis of retinal optical coherence tomography angiography (OCTA) images, but the repeatability of metrics produced from various binarization methods has not been fully assessed. This study set out to examine the repeatability of OCTA quantification metrics produced using different binarization thresholding methods, all of which have been applied in previous studies, across multiple devices and plexuses. Successive 3 × 3 mm foveal OCTA images of 13 healthy eyes were obtained on three different devices. For each image, contrast adjustments, 3 image processing techniques (linear registration, histogram normalization, and contrast-limited adaptive histogram equalization), and 11 binarization thresholding methods were independently applied. Vessel area density (VAD) and vessel length were calculated for retinal vascular images. Choriocapillaris (CC) images were quantified for VAD and flow deficit metrics. Repeatability, measured using the intra-class correlation coefficient, was inconsistent and generally not high (ICC < 0.8) across binarization thresholds, devices, and plexuses. In retinal vascular images, local thresholds tended to incorrectly binarize the foveal avascular zone as white (i.e., wrongly indicating flow). No image processing technique analyzed consistently resulted in highly repeatable metrics. Across contrast changes, retinal vascular images showed the lowest repeatability and CC images showed the highest.

Morphological changes in intraretinal microvascular abnormalities after anti-VEGF therapy visualized on optical coherence tomography angiography.

BACKGROUND: To examine the baseline morphological characteristics and alterations in intraretinal microvascular abnormalities (IRMAs) in response to anti-vascular endothelial growth factor (anti-VEGF) treatment, documented by optical coherence tomography angiography (OCTA) in diabetic eyes. METHODS: In this retrospective study, IRMAs were evaluated with multimodal imaging (fundus photography, fluorescein angiography, OCTA) in treatment-naïve diabetic eyes before and after anti-VEGF treatment for diabetic macular edema (DME) and/or proliferative diabetic retinopathy (PDR) and compared to diabetic control eyes with similar diabetic retinopathy (DR) severity that did not receive anti-VEGF therapy. The morphological characteristics of IRMAs on enface OCTA imaging were graded by masked readers at baseline, then after anti-VEGF therapy in treated eyes or after observation in control eyes. Characterization of interval changes in an IRMA were based on the following parameters: branching, vessel caliber and area of adjacent capillary non-perfusion. RESULTS: The treated group included 45 IRMA foci from 15 eyes of 11 patients, while the control group included 27 IRMA foci from 15 eyes of 14 patients. Following anti-VEGF treatment, enface OCTA demonstrated that 14 foci of IRMA (31%) demonstrated regression with normalization of appearance of the capillary bed, 20 IRMAs (44%) remained unchanged, six IRMAs (13%) progressed with enlargement or development of new IRMAs and five IRMAs (11%) demonstrated complete obliteration defined as IRMA disappearance with advancing capillary drop-out. In the control group, 17 IRMA (63%) remained stable, 8 IRMAs (29.6%) progressed and 2 experienced total obliteration (7.4%). The difference in rank order between the two groups was statistically significant (p = 0.022). CONCLUSIONS: In eyes with DR status post anti-VEGF therapy, foci of IRMAs have a variable course demonstrating one of four possible outcomes: regression, stability, progression or complete obliteration. In contrast, none of the untreated control diabetic eyes demonstrated regression of IRMAs, consistent with known progression of DR severity in high risk eyes. Morphologic evaluation of IRMAs with OCTA may help to monitor changes in retinal blood flow as well as the response to anti-VEGF treatment.

Repeatability and reproducibility of vessel density measurements on optical coherence tomography angiography in diabetic retinopathy.

PURPOSE: Understanding the precision of measurements on and across optical coherence tomography angiography (OCTA) devices is critical for tracking meaningful change in disease. The purpose of this study is to investigate the repeatability and reproducibility of vessel area density and vessel skeleton density measurements from various commercial OCTA devices in diabetic eyes. METHODS: Patients were imaged three consecutive times each on three different OCTA devices. En face OCTA images of the superficial capillary plexus, deep capillary plexus, and full retinal layer were exported for analysis. Vessel area density and vessel skeleton density were calculated. The coefficient of repeatability (CoR) was calculated to assess the repeatability of these measurements, and linear mixed models were utilized to assess the reproducibility of these measurements. RESULTS: Forty-four eyes from 27 diabetic patients were imaged. Normalized CoR values ranged between 3.44 and 6.65% when calculated for vessel area density and between 1.35 and 23.39% when calculated for vessel skeleton density. When stratified by disease severity, the swept-source OCTA device consistently produced the smallest CoR values for vessel area density in the full retinal layer. Vessel area density measurements were repeatable across the two spectral-domain devices in the full retinal layer when all severities were combined, as well as in diabetic patients without retinopathy, mild nonproliferative diabetic retinopathy (NPDR), and moderate NPDR. CONCLUSION: Vessel area density measured in the full retinal layer may be a more precise measure than vessel skeleton density to follow diabetic retinopathy patients both on the same device and across devices.

Effects of enhanced depth imaging and en face averaging on optical coherence tomography angiography image quantification.

PURPOSE: To examine the effects of enhanced depth imaging (EDI) and en face averaging on global vascular measurements of optical coherence tomography angiography (OCTA) images. METHODS: All eyes were imaged with 3 mm × 3 mm fields centered at the fovea using the Carl Zeiss Cirrus 5000 spectral-domain OCTA, with and without EDI, and the Zeiss PLEX Elite 9000 swept-source OCTA. Vessel area density (VAD), vessel length (VL), and vessel diameter index (VDI) were calculated for the superficial capillary plexus (SCP) en face angiograms. For the choriocapillaris (CC), VAD and the number, total area, and average size of flow voids were calculated. These metrics were compared between SD- and SS-OCTA images, with and without en face averaging and EDI. RESULTS: Both averaging and EDI had a significant effect on quantitative metrics. EDI images trended toward a decrease in SCP VAD. In the CC, EDI decreased average flow void size. Averaging increased CC VAD while decreasing number of flow voids, total flow void area, and average flow void size. With both averaging and EDI, SD-OCTA was not able to visualize as many CC flow voids, particularly of a smaller size, compared with SS-OCTA. CONCLUSIONS: Averaging and EDI affect quantitative metrics from SCP and CC OCTA images. EDI resulted in a trend toward decreased VAD in SCP images. Averaging had a major effect on CC imaging. Even with the combination of EDI and en face averaging, SD-OCTA images do not appear to approximate SS-OCTA images in terms of quantitative metrics. This has implications for clinical and research use of SD-OCTA for retinal imaging.

QUANTIFICATION OF RETINAL CAPILLARY NONPERFUSION IN DIABETICS USING WIDE-FIELD OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY.

PURPOSE: To combine advances in high-speed, wide-field optical coherence tomography angiography (OCTA) with image processing methods for semiautomatic quantitative analysis of capillary nonperfusion in patients with diabetic retinopathy (DR). METHODS: Sixty-eight diabetic patients (73 eyes), either without retinopathy or with different degrees of retinopathy, were prospectively recruited for volumetric swept-source OCTA imaging using 12 mm × 12 mm fields centered at the fovea. A custom, semiautomatic software algorithm was used to quantify areas of capillary nonperfusion. RESULTS: The mean percentage of nonperfused area was 0.1% (95% confidence interval: 0.0-0.4) in the eyes without DR; 2.1% (95% confidence interval: 1.2-3.7) in the nonproliferative DR eyes (mild, moderate, and severe), and 8.5% (95% confidence interval: 5.0-14.3) in the proliferative DR eyes. The percentage of nonperfused area increased in a statistically significant manner from eyes without DR, to eyes with nonproliferative DR, to eyes with proliferative DR. CONCLUSION: Capillary nonperfusion area in the posterior retina increases with increasing DR severity as measured by swept-source OCTA. Quantitative analysis of retinal nonperfusion on wide-field OCTA may be useful for early detection and monitoring of disease in patients with diabetes and DR.

DISTINGUISHING INTRARETINAL MICROVASCULAR ABNORMALITIES FROM RETINAL NEOVASCULARIZATION USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY.

PURPOSE: With the increasing prevalence of diabetes, fast, noninvasive identification of proliferative diabetic retinopathy (PDR) becomes essential. This study evaluated the utility of optical coherence tomography angiography (OCTA) to characterize intraretinal microvascular abnormalities (IRMA) and retinal neovascularization (NV). METHODS: Patients with severe non-PDR or PDR were imaged with fluorescein angiography and widefield swept-source OCTA (Zeiss Plex Elite 9000; Carl Zeiss Meditec, Dublin, CA). Regions suspicious for IRMA or retinal NV were identified and the OCTA, including flow overlay on the co-registered structural optical coherence tomography, and fluorescein angiography images were graded by two masked readers. RESULTS: Ninety-six foci of irregular vasculature were analyzed, comprised of 70 IRMA and 26 retinal NV lesions from 14 eyes. Compared with fluorescein angiography, OCTA with flow overlay demonstrated specificity of 99% and sensitivity of 92% in identifying IRMA and NV. Neovascularization differed from IRMA on OCTA by demonstrating supraretinal flow breaching the internal limiting membrane and posterior hyaloid (P < 0.001). Intraretinal microvascular abnormalities were distinguished from NV by outpouching of the internal limiting membrane (P = 0.035). Vascular flow was reduced in the presence of fibrosis. CONCLUSION: Optical coherence tomography angiography, through flow overlay, has utility to image and differentiate IRMA and NV, which are key features distinguishing severe non-PDR and PDR, respectively. Noninvasive widefield OCTA may be a useful tool to diagnose high-risk diabetic retinopathy eyes.

Retinal Nonperfusion Relationship to Arteries or Veins Observed on Widefield Optical Coherence Tomography Angiography in Diabetic Retinopathy.

Purpose: To evaluate whether retinal capillary nonperfusion is found predominantly adjacent to arteries or veins in eyes with diabetic retinopathy (DR). Methods: Sixty-three eyes from 44 patients with proliferative DR (PDR) or non-PDR (NPDR) were included. Images (12 × 12-mm) foveal-centered optical coherence tomography (OCT) angiography (OCTA) images were taken using the Zeiss Plex Elite 9000. In 37 eyes, widefield montages with five fixation points were also obtained. A semiautomatic algorithm that detects nonperfusion in full-retina OCT slabs was developed, and the percentages of capillary nonperfusion within the total image area were calculated. Retinal arteries and veins were manually traced. Based on the shortest distance, nonperfusion pixels were labeled as either arterial-side or venous-side. Arterial-adjacent and venous-adjacent nonperfusion and the A/V ratio (arterial-adjacent nonperfusion divided by venous-adjacent nonperfusion) were quantified. Results: Twenty-two eyes with moderate NPDR, 16 eyes with severe NPDR, and 25 eyes with PDR were scanned. Total nonperfusion area in PDR (median: 8.93%) was greater than in moderate NPDR (3.49%, P < 0.01). Arterial-adjacent nonperfusion was greater than venous-adjacent nonperfusion for all stages of DR (P < 0.001). The median A/V ratios were 1.93 in moderate NPDR, 1.84 in severe NPDR, and 1.78 in PDR. The A/V ratio was negatively correlated with the total nonperfusion area (r = -0.600, P < 0.0001). The results from the widefield montages showed similar patterns. Conclusions: OCTA images with arteries and veins traced allowed us to estimate the nonperfusion distribution. In DR, smaller nonperfusion tends to be arterial-adjacent, while larger nonperfusion tends toward veins.

Volumetric Analysis of Vascularized Serous Pigment Epithelial Detachment Progression in Neovascular Age-Related Macular Degeneration Using Optical Coherence Tomography Angiography.

Purpose: To analyze the evolution of type 1 neovascularization associated with vascularized serous pigment epithelial detachment (vsPED) using three-dimensional, volumetric, en face optical coherence tomography angiography (OCTA). Methods: This was a retrospective case series from four tertiary medical centers. OCTA images were analyzed at baseline and at the 3-, 6-, 12-, 18-, and 24-month follow-up visit when available. Visual acuity, number of injections, PED maximal height and PED area and volume, and choroidal neovascularization (CNV) flow area and progression were determined at each visit. Qualitative and quantitative analysis of CNV progression (including CNV/PED flow area) and final PED morphology was performed to determine anatomic outcomes. Results: Twenty-four eyes in 22 patients were studied. Median follow-up was 20 months. Across all eyes, maximum PED height decreased from 395.5 to 369.5 µm while CNV/PED flow ratio increased from 27.3% to 40.2%. Median visual acuity was unchanged at 20/40. Final PED outcomes included filled fibrovascular versus persistent vsPED. Filled vsPEDs decreased in PED height and volume and displayed a multilayered morphology in contrast to persistent vsPEDs. Fibrovascular PEDs received on average seven less injections as compared to persistent vsPEDs. Conclusions: Three-dimensional, volumetric, en face OCTA analysis of vsPED progression illustrated two anatomic outcomes: filled, typically multilayered fibrovascular PED versus persistent vsPED. The filled multilayered PED displayed a reduction in PED height and volume, greater CNV/PED flow ratio, and fewer anti-VEGF injections versus the persistent vsPED and may represent a more stable anatomic outcome while the persistent vsPED may indicate a more unstable morphology.

Accuracy and Reliability in Differentiating Retinal Arteries and Veins Using Widefield En Face OCT Angiography.

PURPOSE: To evaluate the accuracy and reliability in differentiating retinal arteries from veins using widefield optical coherence tomography angiography (OCTA). METHODS: Ten healthy eyes and 12 eyes from diabetic patients were included. Foveal-centered swept-source OCTA images (12 × 12 mm) were obtained using the PLEX Elite 9000. Vessels were graded as arteries or veins by two independent, masked readers. Arteriovenous crossings were also evaluated in healthy eyes. The vessel identification gold standard was defined using color fundus photographs (CFP) for normal eyes and both CFP and fluorescein angiography for diabetic eyes. Grading accuracy was compared to the gold standard and reliability between readers assessed. RESULTS: The study evaluated 538 vessels (119 first order, 110 second, 309 third) in healthy eyes and 645 vessels (184 first order, 159 second, 302 third). In healthy eyes, the average accuracies identifying all, first-, second-, and third-order vessels were 98.61%, 99.16%, 100%, and 98.06%, respectively. Cohen's κ between graders in all vessels was 0.948. In diabetic eyes, the average accuracies identifying vessels were 96.90%, 99.46%, 97.77%, and 94.85%, respectively. Cohen's κ between graders for all vessels was 0.888. For crossing identification, the average accuracy and Cohen's κ were low (60.71% and 0.659, respectively). CONCLUSIONS: En face OCTA allows for accurate and reliable artery and vein identification; for small branches and crossings, identification by en face OCTA alone may be less accurate and reliable. TRANSLATIONAL RELEVANCE: Arteries and veins can be differentiated on OCTA, assisting in clinically identifying pathology as arterial or venous side.

Optical coherence tomography angiography analysis of macular vessel density before and after anti-VEGF therapy in eyes with diabetic retinopathy.

PURPOSE: To evaluate changes in macular vessel density following intravitreal anti-VEGF injection in patients with diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR). METHODS: In this retrospective case series, optical coherence tomography angiography (OCTA) images from 55 eyes of 35 patients with either DME (46 eyes) or PDR (9 eyes) were included. Macular capillary vessel density at the level of the superficial retinal capillary plexus (SCP), deep retinal capillary plexus (DCP) and total retinal capillary plexus (TCP) before and after anti-VEGF treatment was calculated. Longitudinal changes in vessel density following serial anti-VEGF treatment were analyzed in a subset of eyes. RESULTS: Vessel density in the SCP, DCP or TCP was not found to be significantly different after one, two or three intravitreal injections (p > 0.05 for all time points). Subgroup analysis revealed no significant change in the DME and PDR subgroups (all p > 0.05). Multivariate analysis revealed no effect of type of injected anti-VEGF agent or presence of previous treatment on VD measurements (all p > 0.05). There was no correlation between the anatomic response of DME to treatment and VD measurements. CONCLUSIONS: In this study, macular vessel density remained statistically unchanged following up to three intravitreal injections of any anti-VEGF agent. This indicates that there may not be an early effect of anti-VEGF treatment on macular vessel density and its effect on macular perfusion may not be a direct change in microvascular flow.

Early hydroxychloroquine retinopathy: optical coherence tomography abnormalities preceding Humphrey visual field defects.

BACKGROUND/AIMS: Hydroxychloroquine (HCQ) retinopathy may result in severe and irreversible vision loss, emphasising the importance of screening and early detection. The purpose of this study is to report the novel finding of early optical coherence tomography (OCT) abnormalities due to HCQ toxicity that may develop in the setting of normal Humphrey visual field (HVF) testing. METHODS: Data from patients with chronic HCQ exposure was obtained from seven tertiary care retina centres. Ten patients with HCQ-associated OCT abnormalities and normal HVF testing were identified. Detailed analysis of the OCT findings and ancillary tests including colour fundus photography, fundus autofluorescence, multifocal electroretinography and microperimetry was performed in these patients. RESULTS: Seventeen eyes from 10 patients illustrated abnormalities with OCT and normal HVF testing. These OCT alterations included (1) attenuation of the parafoveal ellipsoid zone and (2) loss of a clear continuous interdigitation zone. Several eyes progressed to advanced parafoveal outer retinal disruption and/or paracentral visual field defects. CONCLUSION: Patients with high risk HCQ exposure and normal HVF testing may develop subtle but characteristic OCT abnormalities. This novel finding indicates that, in some cases of early HCQ toxicity, structural alterations may precede functional impairment. It is therefore important to employ a screening approach that includes OCT to assess for these early findings. Ancillary testing should be considered in cases with suspicious OCT changes and normal HVFs.

VISUALIZATION OF CHOROIDAL NEOVASCULARIZATION USING TWO COMMERCIALLY AVAILABLE SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY DEVICES.

PURPOSE: To compare the sensitivity of detection and the measured size of choroidal neovascularization (CNV) on two commercially available spectral domain optical coherence tomography angiography (OCTA) devices, the Optovue RTVue XR Avanti with AngioVue and the Zeiss Cirrus HD-OCT with AngioPlex. METHODS: Patients with CNV lesions were imaged consecutively on both OCTA devices on the same day of their visit. 3 × 3 mm and 6 × 6 mm scans centered at the fovea were obtained. Two independent masked readers evaluated the OCTA images for CNV identification and its area measurements. RESULTS: No significant differences were observed between the 2 OCTA devices in CNV area measurements on their 3 × 3 mm and 6 × 6 mm scans. However, there was suboptimal performance of their automated segmentation algorithms as compared to manually adjusted segmentation for visualizing CNV lesions. CONCLUSION: There was no significant difference in the size of the CNV lesion as measured on either commercially available spectral domain OCTA device. Both devices were comparable in their detection of CNV lesions on manual adjustment of segmentation lines. However, their automated segmentation algorithms need improvement to allow for accurate measurement of CNV lesions for routine clinical application.

Optical coherence tomography angiography (OCTA) flow speed mapping technology for retinal diseases.

INTRODUCTION: Optical coherence tomography angiography (OCTA) is a noninvasive imaging modality for depth-resolved visualization of retinal vasculature. Angiographic data couples with structural data to generate a cube scan, from which en-face images of vasculature can be obtained at various axial positions. OCTA has expanded understanding of retinal vascular disorders and has primarily been used for qualitative analysis. AREAS COVERED: Recent studies have explored the quantitative properties of OCTA, which would allow for objective assessment and follow-up of retinal pathologies. Various quantitative metrics have been developed, such as foveal avascular zone area and vessel density. However, quantitative assessment of the characteristics of retinal blood flow remains limited, as OCTA provides an image depicting either the presence or absence of flow at a particular region without information of relative velocities. The development of variable interscan time analysis (VISTA) overcomes this limitation. The VISTA algorithm generates a color-coded map of relative blood flow speeds. VISTA has already demonstrated utility in furthering our understanding of various retinal pathologies, such as geographic atrophy, choroidal neovascularization, aneurysmal type 1 neovascularization, and diabetic retinopathy. EXPERT COMMENTARY: VISTA, an OCTA flow speed mapping technique, may have a role in developing the utility of OCTA as a screening tool.

Parafoveal Retinal Vessel Density Assessment by Optical Coherence Tomography Angiography in Healthy Eyes.

BACKGROUND AND OBJECTIVE: To assess variability in vessel density (VD) measurements across three optical coherence tomography angiography (OCTA) devices to identify a methodology that offers the least amount of variation in VD, and to assess the effect of averaging of multiple scans on VD variability. PATIENTS AND METHODS: Fifteen eyes of eight healthy individuals were imaged consecutively on three OCTA devices. Segmentations at the superficial, deep, and full retinal layers were generated. Repeat scans for each retinal layer were registered and averaged to generate one OCTA image. Two different automated thresholding techniques were used to calculate vessel area density (VAD) from binarized images and vessel skeleton density (VSD) from skeletonized images. Vessel length, a linear measure of the combined lengths of vessels, was calculated. Foveal avascular zone (FAZ) area was measured. RESULTS: All three OCTA devices were significantly different (P < .0001). This finding remained after averaging images (P < .0001). VSD was more repeatable within a device but less reproducible across devices. Conversely, VAD demonstrated less repeatability but greater reproducibility. Differences in VSD between devices were systematic and attributable to differences in resolution. Vessel length, unaffected by resolution, demonstrated no significant differences between the devices (P > .107). There was no significant difference in FAZ area across devices (P = .51). After averaging images, VD was significantly different from the single images for each device and plexus (P < .05) but remained within 1% of the value of a single scan. CONCLUSIONS: OCTA devices show variability in VD for healthy individuals. With greater repeatability, VSD appeared useful for following a patient on one device. VAD and vessel length seemed ideal for comparing vessel parameters between OCTA devices. After averaging multiple scans, VSD remained within 1% of a single scan, for which clinical significance remains to be determined. Caution is advised when comparing quantitative analyses across OCTA devices. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:S5-S17.].

Choriocapillaris changes in dry age-related macular degeneration and geographic atrophy: a review.

Age-related macular degeneration (AMD) is a leading cause of central vision loss worldwide. The progression of dry AMD from early to intermediate stages is primarily characterized by increasing drusen formation and adverse impact on outer retinal cells. Late stage AMD consists of either geographic atrophy (GA), the non-exudative (dry) AMD subtype, or choroidal neovascularization, the exudative (wet) AMD subtype. GA is characterized by outer retinal and choroidal atrophy, specifically the photoreceptor layer, RPE, and choriocapillaris. Much remains to be discovered regarding the pathogenesis of AMD progression and subsequent development of GA. As the functionality of all three layers is closely linked, the temporal sequence of events that end up in atrophy is important in the understanding of the pathogenic pathway of the disease. The advent of OCTA, and particularly of swept-source technology, has allowed for depth-resolved imaging of retinal vasculature and the choriocapillaris. With the use of OCTA, recent studies demonstrate that choriocapillaris flow alterations are closely associated with the development and progression of AMD. Such changes may even possibly offer predictive value in determining progression of GA. This article reviews studies demonstrating choriocapillaris changes in dry AMD and summarizes the existing literature on the potential role of the choriocapillaris as a key factor in the pathogenesis of AMD.

Vinorelbine-induced regression of a choroidal metastasis from primary breast carcinoma.

BACKGROUND: Various therapeutic options exist to treat choroidal metastatic lesions. However, they are all associated with potential long-term adverse effects. This case report discusses a case of choroidal metastasis from primary breast carcinoma that regressed after single-agent chemotherapy. CASE PRESENTATION: We report a case of choroidal metastasis from estrogen receptor (ER) positive breast carcinoma that became resistant to endocrine therapy. The primary malignancy was treated with surgical resection and adjuvant chemoradiation, followed by hormone therapy with various agents in combination with kinase inhibitors for ER resistance. The choroidal metastatic lesion regressed after the initiation of vinorelbine. Vinorelbine is a cytotoxic vinca alkaloid with tolerable systemic adverse effects. CONCLUSIONS: This case report highlights the possible role of vinorelbine as a single chemotherapeutic agent for the conservative therapy of uveal metastasis from advanced breast carcinoma, irrespective of responsiveness to hormone therapy.

Use of OCTA, FA, and Ultra-Widefield Imaging in Quantifying Retinal Ischemia: A Review.

As ischemia remains a key prognostic factor in the management of various diseases including diabetic retinopathy, an increasing amount of research has been dedicated to its quantification as a potential biomarker. Advancements in the quantification of retinal ischemia have been made with the imaging modalities of fluorescein angiography (FA), ultra-widefield imaging (UWF), and optical coherence tomography angiography (OCTA), with each imaging modality offering certain benefits over the others. FA remains the gold standard in assessing the extent of ischemia. UWF imaging has allowed for the assessment of peripheral ischemia via FA. It is, however, OCTA that offers the best visualization of retinal vasculature with its noninvasive depth-resolved imaging and therefore has the potential to become a mainstay in the assessment of retinal ischemia. The primary purpose of this article is to review the use of FA, UWF, and OCTA to quantify retinal ischemia and the various methods described in the literature by which this is achieved.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY AFTER PHOTOCOAGULATION OF TYPE 2 NEOVASCULARIZATION.

PURPOSE: To illustrate errors in the automated segmentation image analysis of optical coherence tomography angiography after laser photocoagulation therapy for Type 2 neovascularization. METHODS: This case report describes a patient with extrafoveal Type 2 neovascularization treated with argon laser photocoagulation evaluated before and after treatment by optical coherence tomography angiography. RESULTS: Disrupted retinal layers after laser photocoagulation therapy lead to segmentation errors. CONCLUSION: Images of optical coherence tomography angiography are prone to degradation by artifacts in cases in which there is disruption of the retinal layers. Clinicians must be aware of these errors because they can be misinterpreted as active Type 2 neovascularization. Improvement in optical coherence tomography angiography image analysis to minimize automated segmentation errors needs to be further explored.

Optical coherence tomography angiography artifacts in retinal pigment epithelial detachment.

OBJECTIVE: To describe optical coherence tomography angiography (OCTA) reflectance artifacts secondary to retinal pigment epithelial detachment (RPED). DESIGN: Retrospective review. METHODS: Four eyes from 4 subjects were included. Three presented with RPED and 1 eye was a normal control. Two eyes diagnosed with RPED and the normal eye were evaluated using en face OCTA centred at the fovea acquired using the RTVue XR Avanti (Optovue Inc). In the third eye with RPED, OCTA imaging was performed using a CIRRUS 5000 prototype modified to do OCTA imaging on a spectral domain OCT platform provided by Carl Zeiss Meditec, Inc. The segmented OCTA angiograms were overlaid to determine if the flow patterns seen at the edge of the RPEDs were due to reflectance from the inner retinal vessels, also known as "decorrelation tails." RESULTS: OCTA projection artifacts were noted when segmentation lines intersected with the boundary of the RPED. The overlaid segmented OCTA from the 3 RPED eyes imaged using each system revealed the same vasculature pattern at the edges of the RPED as that of the inner retina, demonstrating the "decorrelation tails" artifact, which caused the RPED to appear as a bright ring on the segmented OCTA. CONCLUSIONS: OCTA images are susceptible to various known artifacts. This series describes the impact of the projection artifact seen at the edges of an RPED that simulates appearance of flow but is actually due to reflectance of the inner retinal vasculature on the RPED.