Longitudinal Development of Peripapillary Hyper-Reflective Ovoid Masslike Structures Suggests a Novel Pathological Pathway in Multiple Sclerosis

Characterization of Peripapillary Hyperreflective Ovoid Mass-like Structures in a Broad Spectrum of Neurologic Disorders

PURPOSE

Peripapillary hyperreflective ovoid mass-like structures (PHOMSs) have been identified in ophthalmic and neurologic diseases. Because PHOMSs were found more frequently in these cohorts compared with healthy control participants, it is assumed that the presence of PHOMSs reflects a secondary disease marker of unknown significance. The extent to which disease-specific differences are reflected in PHOMSs has not yet been investigated sufficiently.

DESIGN

Monocentric, retrospective study.

PARTICIPANTS

We analyzed a large cohort of people with a broad spectrum of neurologic disorders, including neuroimmunologic diseases (NIDs; n = 237), epilepsy (n = 153), movement disorders (MDs; n = 44), intracranial hypertension (IH; n = 13), and inborn errors of metabolism (n = 90).

METHODS

We analyzed the prevalence, location, volume, and intensity of PHOMSs. Peripapillary hyperreflective ovoid mass-like structure volumes were correlated with demographic and other OCT parameters.

MAIN OUTCOME MEASURES

Prevalence, location, volume, and intensity of PHOMSs.

RESULTS

We identified PHOMSs in 7% of the analyzed eyes. Peripapillary hyperreflective ovoid mass-like structures were detected in all cohorts, and their location was predominantly nasal. The median volume of all PHOMSs was 0.06 mm3. However, the median PHOMS volume was increased in those with IH compared with those with NID (P = 0.009), epilepsy (P = 0.038), or MDs (P = 0.027). The PHOMS volume correlated positively with the opening of the Bruch membrane and correlated negatively with the age of the cohort after the exclusion of patients with IH. Overall, PHOMS intensity was comparable with that of the optic nerve.

CONCLUSIONS

Because larger PHOMS volumes were found in individuals with IH, a mechanistic link to increased intracranial pressure can be assumed. It remains unclear whether this explanation also applies to individuals with other neurologic disorders with PHOMSs. Because PHOMSs have a relevant influence on OCT parameters, their presence also should be considered in nonophthalmic scientific studies in the future.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Peripapillary choroidal vascularity of paediatric myopic eyes with peripapillary hyperreflective ovoid mass-like structures

PURPOSE

To assess the peripapillary choroidal vasculature in paediatric myopic patients with and without peripapillary hyperreflective ovoid mass-like structures (PHOMS).

METHODS

This prospective study includes 60 eyes of 60 myopic (spherical equivalent [SE] <-1.00 dioptre [D]) patients with (n = 30) and without (n = 30) PHOMS (PHOMS [+] and PHOMS [-] groups, respectively), and 30 eyes of 30 age- and sex-matched emmetropic children (control group). Peripapillary choroidal parameters, including total choroidal (TCA), luminal (LA), and stromal areas (SA) and choroidal vascularity index (CVI) calculated from vertical and horizontal single-line enhanced depth imaging-optical coherence tomography scans centred on optic nerve head.

RESULTS

Peripapillary retinal nerve fibre layer thicknesses were not different between the groups (p > 0.05). In the PHOMS (+) group, TCA, LA and SA were lower, and CVI was higher in all quadrants compared to the control (p < 0.05). However, only the mean TCA and LA in the inferior and nasal quadrants and the mean SA in the nasal quadrant were lower in PHOMS (+) than in PHOMS (-) (p < 0.05). In the PHOMS (-) group, higher CVI was observed in all quadrants except temporal compared to the control group. Although the mean CVI of the PHOMS (+) group was also higher than in the PHOMS (-) group, this difference was not statistically significant.

CONCLUSION

This study indicates that choroidal parameters differ in paediatric myopic patients with PHOMS. Further studies with larger sample sizes are needed to understand the details of choroidal parameters in eyes with PHOMS.

Prevalence and Clinical Associations of Peripapillary Hyperreflective Ovoid Mass-like Structures in Craniosynostosis

BACKGROUND

Patients with craniosynostosis are at high risk of developing elevated intracranial pressure (ICP) causing papilledema and secondary optic atrophy. Diagnosing and monitoring optic neuropathy is challenging because of multiple causes of vision loss including exposure keratopathy, amblyopia, and cognitive delays that limit examination. Peripapillary hyperreflective ovoid mass-like structures (PHOMS) are an optical coherence tomography (OCT) finding reported in association with papilledema and optic neuropathy. We investigated the prevalence of PHOMS in patients with syndromic craniosynostosis and the relationship with known risk factors of optic neuropathy.

METHODS

This was a cross-sectional retrospective study was performed at Boston Children's Hospital and included 118 eyes (60 patients) with syndromic craniosynostosis that had at least one good quality optic nerve OCT volumetry scan between January 2010 and December 2023. Testing was reviewed by 2 neuro-ophthalmologists to determine the presence of PHOMS. Information collected included demographics, and clinical course including possible Chiari malformation, obstructive sleep apnea (OSA), history of elevated ICP, best-corrected visual acuity (VA), spherical equivalent (SE), retinal nerve fiber layer thickness, macular ganglion cell layer volume, and funduscopic examination. Our primary outcome measure was presence of PHOMS, and secondary outcome measure was the relationship between clinical characteristics and the presence of PHOMS.

RESULTS

Mean age at imaged OCT was 9.8 ± 5.2 years and 41/60 (68.3%) patients were female. The prevalence of PHOMS was 17/60 patients (28.3%) or 26/118 eyes (22.0%), higher than previously reported in children without craniosynostosis (P < 0.001). PHOMS were significantly associated with a history of elevated ICP (odds ratio [OR] 14.4, 95% CI: 1.9-111.0, P < 0.001) and with concurrent papilledema (OR 40.4, 95% CI: 6.6-248.0, P < 0.001). OSA, Chiari malformation, best-corrected VA, craniosynostosis variant, and SE were not independently associated with PHOMS.

CONCLUSIONS

Eyes in children with craniosynostosis had a higher prevalence of PHOMS than reported in children without craniosynostosis. PHOMS were significantly more common with a history of elevated ICP and with concurrent papilledema. PHOMS may serve as a clinically useful indicator of optic neuropathy, and of recurrence of papilledema in patients with craniosynostosis and in other populations characterized by multiple sources of vision loss and cognitive changes that limit evaluation.

Comparison of Ultrasound Characteristics of Peripapillary Hyperreflective Ovoid Mass-Like Structures (PHOMS) and Optic Disc Drusen in Children

BACKGROUND

In children, pseudopapilledema is frequently caused by peripapillary hyperreflective ovoid mass-like structures (PHOMS) or optic disc drusen (ODD). While enhanced depth imaging (EDI) OCT can identify both, lack of cooperation, especially from younger children due to the duration of testing, often necessitates the use of B-scan ultrasound (BSUS). This study investigated whether PHOMS are hyperreflective on BSUS and if BSUS can differentiate PHOMS from ODD.

METHODS

Pediatric patients referred by a neuro-ophthalmologist to the diagnostic ultrasound clinic for optic nerve head elevation between March 2019 and May 2021 were eligible. Subjects who underwent BSUS and EDI-OCT and were diagnosed with pseudopapilledema based on examination, imaging findings, stability on follow-up, and, in some cases, normal CSF opening pressure were included. ODD were identified on EDI-OCT as structures above the lamina cribrosa with a hyporeflective core and hyperreflective margin prominent superiorly. Hyperreflective horizontal lines (HHL) above the lamina cribrosa without ODD were identified. PHOMS were defined as ovoid, hyperreflective structures above Bruch's membrane external to the optic disc, with similar reflectivity to the retinal nerve fiber layer on OCT and upward deflection of other retinal layers. The BSUSs were read by a separate, masked evaluator who graded the size and reflectivity.

RESULTS

Two hundred thirty-nine eyes (120 patients; 58.3% female; mean age = 11.6 years) with pseudopapilledema were included. EDI-OCT mostly demonstrated PHOMS only (58.1%), followed by PHOMS and HHL (12.6%), and then PHOMS and ODD (11.7%). A combination of PHOMS, ODD, and HHL was found in 8.8%, 1.7% had HHL only, 0.8% had ODD and HHL, and 0.4% had ODD only. 5.9% of eyes were normal on OCT. On BSUS, 78.4% of eyes with only PHOMS demonstrated low or intermediate reflectivity, while 92.9% of eyes with both PHOMS and ODD demonstrated high reflectivity. When HHL was present with or without other findings, a majority demonstrated high reflectivity.

CONCLUSIONS

Though PHOMS are hyperreflective on BSUS, ODD are more highly reflective, which may allow clinicians to differentiate between the two if EDI-OCT is unavailable. Eyes with both PHOMS and HHL have similar characteristics to those with ODD, supporting current theories that these lines may be early indicators of evolving drusen.

Peripapillary hyperreflective ovoid mass-like structure (PHOMS): prevalence, risk factors, and development over time in Danish myopic children

BACKGROUND

On optical coherence tomography (OCT) scans of the optic nerve head, peripapillary hyperreflective ovoid mass-like structures (PHOMS) are sometimes seen as a sign of axonal distension. The phenomenon has been reported more frequently in myopic subjects. We investigated PHOMS-prevalence in a myopic pediatric cohort, associated risk factors, and PHOMS development over 18 months during low-dose atropine treatment.

METHODS

In this post hoc analysis of an investigator-initiated, placebo-controlled, randomized clinical trial, 97 6- to 12-year-old myopic participants were randomized to 0.1% atropine for 6 months, then 0.01% for 18 months (N = 33), 0.01% for 24 months (N = 32) or placebo for 24 months (N = 32). Primary outcome was presence of PHOMS. Secondary outcome was mean nasal PHOMS diameter measured on OCT B-scan. Outcomes were reported at baseline, 6, and 18 months. Logistic regression and linear mixed modelling were performed.

RESULTS

PHOMS were present in 26% of participants (n = 25), and 52% (n = 13) had bilateral presentation. Optic disk tilt (OR = 10.81; 95% CI, 3.58-32.58 [P < 0.001]) and longer axial length (AL) (OR = 2.06; 95% CI, 1.02-4.17 [P = 0.04]) increased the risk of having PHOMS. Greater increase in nasal peripapillary choroidal thickness over time was associated with smaller PHOMS diameter at 18 months (P = 0.05).

CONCLUSIONS

PHOMS were common in our cohort of children with myopia. Longer AL increases the risk of, but not size of, PHOMS. The diameter of PHOMS seemed stable over time and unaffected by low-dose atropine.

Peripapillary Hyperreflective Ovoid Mass-Like Structures in Stickler Syndrome

PURPOSE

To report a previously undescribed finding of peripapillary hyperreflective ovoid mass-like structures (PHOMS) in Stickler syndrome.

DESIGN

Noncomparative case series.

SUBJECTS

Twenty-two eyes with anomalous optic disc from 11 Stickler syndrome patients were identified and imaged.

METHODS

Peripapillary hyperreflective ovoid mass-like structures were graded using enhanced-depth imaging OCT (EDI-OCT) according to the consensus recommendations of the Optic Disc Drusen Studies Consortium. All EDI-OCT scans were obtained using the Heidelberg Spectralis (Heidelberg Engineering) with a dense horizontal raster (15 × 10°, 97 sections) centered on the optic nerve head and graded by 2 independent assessors. In case of disagreement, the image was graded by a third assessor. The presence of any coexisting optic disc drusen was also assessed using EDI-OCT and autofluorescence.

MAIN OUTCOME MEASURES

The presence of PHOMS, clinical characteristics and genetic mutations.

RESULTS

A pilot sample of 22 eyes with phenotypic optic disc abnormalities from 11 Stickler syndrome patients were identified and imaged. Eight patients were female and 3 were male. The mean age was 31 years (13-58 years). Peripapillary hyperreflective ovoid mass-like structures were present in 91% (n = 20) of imaged eyes. Seventy percent (n = 14) were type 1 Stickler syndrome and 30% (n = 6) were type 2 Stickler syndrome. All eyes were myopic and the degree of myopia did not seem to affect whether or not PHOMS was present in this cohort. One eye with PHOMS had retinal detachment, and 77.3% (n = 17) of eyes had undergone 360o prophylactic retinopexy. Thirty-two percent (n = 7) of eyes with PHOMS were present in patients with coexisting hearing loss and 22.7% (n = 5) had orofacial manifestation of Stickler syndrome in the form of a cleft palate. Seventy-seven percent (n = 15) of eyes with PHOMS were present in patients who reported joint laxity or symptoms of arthritis. No coexisting optic disc drusen were identified and raised intracranial pressure was also excluded after neurological investigation.

CONCLUSIONS

These data suggest that PHOMS are a novel finding in Stickler syndrome patients and should be considered when evaluating the optic nerves of these patients.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Prevalence, time course, and visual impact of peripapillary hyperreflective ovoid mass-like structures (PHOMS) in pediatric patients with optic nerve pathologies

BACKGROUND

Peripapillary hyperreflective ovoid mass-like structures (PHOMS) are a recently defined optical coherence tomography (OCT) finding. The purpose of this study was to characterize the presence of PHOMS and their visual significance in pediatric patients with and without optic nerve pathologies.

METHODS

This retrospective study evaluated 400 patients (<18 years of age) including normal control subjects and patients with optic neuritis, papillitis, optic nerve head drusen (ONHD), and papilledema. Information on demographics, visual function, and structural parameters were obtained.

RESULTS

PHOMS were found in 7 of 258 normal control eyes (2.7%), 9 of 59 eyes with optic neuritis (15.3%), 58 of 76 eyes with ONHD (76.3%), 3 of 11 eyes with papillitis (27.3%), and 180 of 308 eyes with papilledema (58.4%). PHOMS were more prevalent in the papilledema (P < 0.001), ONHD (P < 0.001), and optic neuritis (P = 0.028) eyes than in control eyes. We identified 5 cases where PHOMS developed de novo. This occurred over an average of 2.3 years (range, 0.2-7.4 years). Sixteen cases of PHOMS resolved over an average of 1.1 years (range, 0.3-4.0 years). Cross-sectionally, PHOMS were not associated with visual acuity (P = 0.551), retinal nerve fiber layer thickness (P = 0.068), ganglion cell volume (P = 0.375), or visual field mean deviation (P = 0.795).

CONCLUSIONS

PHOMS are present in a majority of children with papilledema or ONHD. PHOMS are dynamic and may form de novo over time with optic nerve pathology and may resolve either through treatment or atrophy. There was no relationship between the presence of PHOMS and poor visual function in our study cohort.

Peripapillary hyperreflective ovoid mass-like structures: multimodal imaging and associated diseases

Growing evidence has demonstrated that peripapillary hyperreflective ovoid mass-like structures (PHOMS) are novel structures rather than a subtype of optic disc drusen. They correspond to the laterally bulging herniation of optic nerve fibers and are believed to be the marker of axoplasmic stasis. PHOMS present in a broad spectrum of diseases, including optic disc drusen, tilted disc syndrome, papilloedema, multiple sclerosis, non-arteritic anterior ischemic optic neuropathy, optic neuritis, Leber hereditary optic neuropathy, and so on. We focus on the multimodal imaging features, pathophysiological mechanisms of PHOMS, and their association with multiple diseases and healthy people in this review to deepen the ophthalmologists' understanding of PHOMS. Additionally, we provide some new directions for future research.

[Retinal OCT biomarkers and neurodegenerative diseases of the central nervous system beyond Alzheimer's disease]

BACKGROUND

Optical coherence tomography (OCT) biomarkers are increasingly used by neurologists, psychiatrists, and ophthalmologists for the diagnosis, prognosis, and follow-up of neurodegenerative diseases. Long-term data on OCT biomarkers of selected primary and secondary neurodegenerative diseases of the central nervous system (CNS), such as multiple sclerosis (MS) or Parkinson's disease, are already available in part. In addition, there are rare neurodegenerative diseases with early disease onset that may show OCT abnormalities.

METHODS

A literature review on the association of OCT biomarkers with neurodegenerative diseases of the CNS beyond Alzheimer's disease is presented. Parkinson's disease, MS, Friedreich's ataxia, Huntington's disease, spinocerebellar ataxia, and lysosomal storage diseases are addressed.

RESULTS

Relevant OCT biomarkers of neurodegenerative diseases are the macular ganglion cell inner plexiform layer (GCIPL) and the peripapillary retinal nerve fiber layer (pRNFL) thickness. Different sectors may be affected depending on the disease entity in addition to global pRFNL reduction. OCT‑angiography (OCT-A) is also increasingly used as a biomarker in neurodegenerative diseases.

CONCLUSION

Optical coherence tomography biomarkers are used in an interdisciplinary context. Retinal pathologies should be excluded by an ophthalmologist. While OCT biomarkers are increasingly used clinically in MS, the benefit in other neurodegenerative diseases, especially the rare ones, is less well documented. Further longitudinal studies are required.

Exploring Vitreous Haze as a Potential Biomarker for Accelerated Glymphatic Outflow and Neurodegeneration in Multiple Sclerosis: A Cross-Sectional Study

BACKGROUND

The glymphatic system removes neurodegenerative debris. The ocular glymphatic outflow is from the eye to the proximal optic nerve. In multiple sclerosis (MS), atrophy of the optic nerve increases the glymphatic outflow space. Here, we tested whether vitreous haze (VH) can provide novel insights into the relationship between neurodegeneration and the ocular glymphatic system in MS.

METHODS

This cross-sectional study comprised 315 persons with MS and 87 healthy controls (HCs). VH was quantified from optical coherence tomography (OCT) volume scans. Neurodegeneration was determined on three-dimensional T1 (3DT1) MRI, lesion detection on fluid-attenuated inversion (FLAIR), and layer thickness on OCT. Generalized estimating equations, corrected for age, were used to analyze associations between VH and metrics for neurodegeneration, demographics, and clinical scales. Group differences were determined between mild, moderate, and severe disability.

RESULTS

On the group level, VH scores were comparable between MS and control (p = 0.629). In MS, VH scores declined with disease duration (β = -0.009, p = 0.004) and age (β = -0.007, p = 0.001). There was no relation between VH scores and higher age in HCs. In MS patients, VH was related to normalized gray (NGMV, β = 0.001, p = 0.011) and white matter volume (NWMV, β = 0.001, p = 0.003), macular ganglion cell-inner plexiform layer thickness (mGCIPL, β = 0.006, p < 0.001), and peripapillary retinal nerve fiber layer thickness (pRNFL, β = 0.004, p = 0.008). VH was significantly lower in severe compared to mild disability (mean difference -28.86%, p = 0.058).

CONCLUSIONS

There is a correlation between VH on OCT and disease duration, more severe disability and lower brain volumes in MS. Biologically, these relationships suggest accelerated glymphatic clearance with disease-related atrophy.

Are PHOMS a clinical sign of optic neuritis?

PURPOSE

Assess the prevalence and evolution of PHOMS in optic neuritis.

METHODS

We analysed the medical files of 126 patients included in the OCTON cohort. Patients' medical files, digital retinal images and OCT examinations were reviewed, searching for optic nerve head oedema and PHOMS at the initial presentation and during the follow-up.

RESULTS

We included 102 patients in the final analysis. Twenty-nine (29) eyes had optic nerve head oedema at the initial presentation. PHOMS were found to be present in 8 eyes affected with optic neuritis. All cases of PHOMS were associated with optic nerve head oedema. All the PHOMS decreased in size and disappeared with the improvement of the oedema.

DISCUSSION

Our results show that PHOMS is not a common sign of optic neuritis. We didn't observe any case of PHOMS in the absence of optic nerve head oedema in eyes with optic neuritis. PHOMS seem to be a rare sign of optic neuritis associated to optic nerve head oedema, and they tend to disappear with the improvement of the optic nerve head oedema. We suggest that the presence of PHOMS in optic neuritis eyes with no optic nerve oedema should be a considered warning sign.

Peripapillary hyper-reflective ovoid mass-like structures (PHOMS): clinical significance, associations, and prognostic implications in ophthalmic conditions

Pioneering advancements in optical coherence tomography (OCT) have facilitated the discernment of peripapillary hyper-reflective ovoid mass-like structures (PHOMS), prevalent neuro-ophthalmological findings associated with an array of ophthalmic conditions, such as optic disc drusen (ODD), papilledema, myopic/tilted optic discs, non-arteritic anterior ischemic optic neuropathy (NA-AION), and optic neuritis. Despite an expanding corpus of research, numerous inquiries persist concerning their clinical significance, correlations with ocular afflictions, and prognostic implications. This comprehensive review endeavors to impart an in-depth comprehension of PHOMS, encompassing facets like conceptualization, detection, pathogenesis, and associations with diverse ophthalmic conditions. Furthermore, we underscore several unresolved quandaries and suggest prospective avenues for future exploration.

Clinical review of retinotopy

Two observations made 29 years apart are the cornerstones of this review on the contributions of Dr Gordon T. Plant to understanding pathology affecting the optic nerve. The first observation laid the anatomical basis in 1990 for the interpretation of optical coherence tomography (OCT) findings in 2009. Retinal OCT offers clinicians detailed in vivo structural imaging of individual retinal layers. This has led to novel observations which were impossible to make using ophthalmoscopy. The technique also helps to re-introduce the anatomically grounded concept of retinotopy to clinical practise. This review employs illustrations of the anatomical basis for retinotopy through detailed translational histological studies and multimodal brain-eye imaging studies. The paths of the prelaminar and postlaminar axons forming the optic nerve and their postsynaptic path from the dorsal lateral geniculate nucleus to the primary visual cortex in humans are described. With the mapped neuroanatomy in mind we use OCT-MRI pairings to discuss the patterns of neurodegeneration in eye and brain that are a consequence of the hard wired retinotopy: anterograde and retrograde axonal degeneration which can, within the visual system, propagate trans-synaptically. The technical advances of OCT and MRI for the first time enable us to trace axonal degeneration through the entire visual system at spectacular resolution. In conclusion, the neuroanatomical insights provided by the combination of OCT and MRI allows us to separate incidental findings from sinister pathology and provides new opportunities to tailor and monitor novel neuroprotective strategies.

Peripapillary hyper-reflective ovoid mass-like structures (PHOMS) in AQP4-IgG-positive neuromyelitis optica spectrum disease (NMOSD) and MOG-IgG-associated disease (MOGAD)

BACKGROUND

Peripapillary hyperreflective ovoid mass-like structures (PHOMS) have recently been described as new optical coherence tomography (OCT) marker. It is not yet clear whether the occurrence of PHOMS is disease-specific or disease-spanning. PHOMS have been described in 16-18% of patients with multiple sclerosis (MS). Currently, no data on the prevalence of PHOMS in other demyelinating diseases including aquaporine-4-IgG-positive neuromyelitis optica spectrum disease (AQP4 + NMOSD) or myelin oligodendrocyte glycoprotein-IgG-associated disease (MOGAD) are reported.

METHODS

We performed a cross-sectional, retrospective spectral domain OCT study evaluating the frequency of PHOMS in AQP4 + NMOSD (n = 47) and MOGAD (n = 44) patients. To test the association with retinal neuroaxonal damage, we compared demographic and clinical data as well as retinal layer thicknesses between eyes with vs. eyes without PHOMS.

RESULTS

PHOMS were detected in 17% of AQP4 + NMOSD and 14% of MOGAD patients. Intra-cohort analysis revealed that AQP4 + NMOSD patients with PHOMS were significantly older [mean (years): 57.5 vs. 50.0; p value = 0.04]. We found no association of PHOMS with retinal neuroaxonal degeneration. In addition, in subjects with only one eye affected by PHOMS compared with the unaffected fellow eye, no differences in retinal parameters were observed (n = 4).

CONCLUSIONS

In summary, we found PHOMS in 17% of AQP4 + NMOSD and 14% of MOGAD patients. This is comparable to the prevalence of published MS PHOMS data. Therefore, a disease-specific occurrence of PHOMS is unlikely. Interestingly, PHOMS do not seem to depend on retinal neuroaxonal degeneration.

The Acute Optic Neuritis Network (ACON): Study protocol of a non-interventional prospective multicenter study on diagnosis and treatment of acute optic neuritis

Optic neuritis (ON) often occurs at the presentation of multiple sclerosis (MS), neuromyelitis optica spectrum disorders (NMOSD), and myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD). The recommended treatment of high-dose corticosteroids for ON is based on a North American study population, which did not address treatment timing or antibody serostatus. The Acute Optic Neuritis Network (ACON) presents a global, prospective, observational study protocol primarily designed to investigate the effect of time to high-dose corticosteroid treatment on 6-month visual outcomes in ON. Patients presenting within 30 days of the inaugural ON will be enrolled. For the primary analysis, patients will subsequently be assigned into the MS-ON group, the aquapotin-4-IgG positive ON (AQP4-IgG+ON) group or the MOG-IgG positive ON (MOG-IgG+ON) group and then further sub-stratified according to the number of days from the onset of visual loss to high-dose corticosteroids (days-to-Rx). The primary outcome measure will be high-contrast best-corrected visual acuity (HC-BCVA) at 6 months. In addition, multimodal data will be collected in subjects with any ON (CIS-ON, MS-ON, AQP4-IgG+ON or MOG-IgG+ON, and seronegative non-MS-ON), excluding infectious and granulomatous ON. Secondary outcomes include low-contrast best-corrected visual acuity (LC-BCVA), optical coherence tomography (OCT), magnetic resonance imaging (MRI) measurements, serum and cerebrospinal fluid (CSF) biomarkers (AQP4-IgG and MOG-IgG levels, neurofilament, and glial fibrillary protein), and patient reported outcome measures (headache, visual function in daily routine, depression, and quality of life questionnaires) at presentation at 6-month and 12-month follow-up visits. Data will be collected from 28 academic hospitals from Africa, Asia, the Middle East, Europe, North America, South America, and Australia. Planned recruitment consists of 100 MS-ON, 50 AQP4-IgG+ON, and 50 MOG-IgG+ON. This prospective, multimodal data collection will assess the potential value of early high-dose corticosteroid treatment, investigate the interrelations between functional impairments and structural changes, and evaluate the diagnostic yield of laboratory biomarkers. This analysis has the ability to substantially improve treatment strategies and the accuracy of diagnostic stratification in acute demyelinating ON.

Trial registration

ClinicalTrials.gov, identifier: NCT05605951.

Peripapillary hyperreflective ovoid mass-like structures: Multimodal imaging-A review

Peripapillary hyperreflective ovoid mass-like structures (PHOMS) are a laterally bulging herniation of distended axons into the peripapillary region above the level of Bruch's membrane opening. Increased use of enhanced depth imaging-optical coherence tomography (EDI-OCT) in our evaluation of the optic nerve head (ONH) and greater recognition of the vast range of optic nerve pathologies with which PHOMS is associated provides convincing evidence that PHOMS is not just buried optic disc drusen (ODD) as previously described. The frequent coexistence of PHOMS with ODD, papilloedema, anterior ischaemic optic neuropathy, tilted optic disc syndrome, inflammatory demyelinating disorders and other diseases associated with axoplasmic stasis provides insight into its underlying pathophysiology. The present review will discuss the role of key imaging modalities in the differential diagnosis of PHOMS, explore the current literature on the relationship between PHOMS and common neuro-ophthalmic conditions, and highlight the gaps in our knowledge, with respect to disease classification and prognosis, to pave the way for future directions of research.

An overview of peripapillary hyperreflective ovoid mass-like structures

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of the ophthalmic findings associated with peripapillary hyperreflective ovoid mass-like structures (PHOMS) in both adult and pediatric patients.

RECENT FINDINGS

PHOMS have recently been identified in a number of different ophthalmic disease entities ranging from nonpathologic to pathologic, including but not limited to anatomic abnormalities (tilting in myopia), optic nerve head drusen, optic disc edema from inflammation (optic neuritis, white dot syndromes), vascular insults (ischemic optic neuropathy, retinal vascular occlusion), and papilledema. The mechanism underlying the formation of PHOMS has not been fully elucidated although it has been hypothesized that PHOMS occur secondary to axoplasmic stasis from crowding at the optic nerve head.

SUMMARY

Although the clinical significance of the presence of PHOMS remains unclear, PHOMS are associated with several disease processes. Understanding the mechanism behind their formation and their impact on optic nerve head structure and visual function may be relevant in patients with optic nerve head pathology. The presence of PHOMS may also correlate with disease severity and duration. Future studies to evaluate whether the formation of PHOMS may be useful as an early indicator of disease or a prognostic tool are warranted.

Peripapillary hyperreflective ovoid masslike structures in a pediatric population referred for suspected papilledema

BACKGROUND

Peripapillary hyperreflective ovoid masslike structures (PHOMS) are now considered a common cause of pseudopapilledema in the pediatric population.

METHODS

The medical records of all patients ≤18 years of age with PHOMS, confirmed on optical coherence tomography, seen at single pediatric neuro-ophthalmology clinic between 2017 and 2021 were reviewed retrospectively.

RESULTS

A total of 47 patients (35 females), with median age of 12.7 years at initial visit, were included. Of these, 24 (51%) of patients were optometry referrals. Headache was a common symptom. PHOMS were present bilaterally in all patients and were 360° around the disk in 57 of 94 eyes (61%). Patients with elevated intracranial pressure were more likely to have a reduction in the size of PHOMS at follow-up (P = 0.0133). Of the 47, 40 (85%) had diagnostic neuroimaging as a part of their papilledema workup. The retinal nerve fiber layer was thicker in patients with concomitant papilledema rather than optic disk drusen (P = 0.002) and compared with patients with PHOMS alone (P = 0.00051).

CONCLUSIONS

Pediatric patients with PHOMS may be referred because their clinical appearance can be suggestive of papilledema. In our study cohort, PHOMS were bilateral and frequently occurred concurrently with other ophthalmic conditions.

Diagnosis and classification of optic neuritis

There is no consensus regarding the classification of optic neuritis, and precise diagnostic criteria are not available. This reality means that the diagnosis of disorders that have optic neuritis as the first manifestation can be challenging. Accurate diagnosis of optic neuritis at presentation can facilitate the timely treatment of individuals with multiple sclerosis, neuromyelitis optica spectrum disorder, or myelin oligodendrocyte glycoprotein antibody-associated disease. Epidemiological data show that, cumulatively, optic neuritis is most frequently caused by many conditions other than multiple sclerosis. Worldwide, the cause and management of optic neuritis varies with geographical location, treatment availability, and ethnic background. We have developed diagnostic criteria for optic neuritis and a classification of optic neuritis subgroups. Our diagnostic criteria are based on clinical features that permit a diagnosis of possible optic neuritis; further paraclinical tests, utilising brain, orbital, and retinal imaging, together with antibody and other protein biomarker data, can lead to a diagnosis of definite optic neuritis. Paraclinical tests can also be applied retrospectively on stored samples and historical brain or retinal scans, which will be useful for future validation studies. Our criteria have the potential to reduce the risk of misdiagnosis, provide information on optic neuritis disease course that can guide future treatment trial design, and enable physicians to judge the likelihood of a need for long-term pharmacological management, which might differ according to optic neuritis subgroups.

Retinal imaging with optical coherence tomography in multiple sclerosis: novel aspects

Optical coherence tomography (OCT) is of increasing interest in the clinical assessment of multiple sclerosis (MS) patients beyond the scope of clinical studies. In this narrative review, we discuss novel changes of OCT parameters during acute optic neuritis and the disease course of MS patients. OCT images document the changes of retinal layers during an episode of acute optic neuritis and can therefore provide valuable insights into the pathophysiology. Moreover, MS patients show progredient thinning of retinal layers throughout the disease. The thinning is accelerated through relapses as well as disease progression without relapse. The OCT parameters are also associated with clinical outcome parameters, including disability, cognitive function, and brain atrophy. The impact of disease-modifying therapies on OCT parameters is the subject of ongoing research and depends on the agent used. Additional data are still necessary before OCT parameters can be implemented in the clinical standard of care of MS patients.

Volumetric Measurement of Peripapillary Hyperreflective Ovoid Masslike Structures in Patients with Optic Disc Drusen

Purpose

To develop a method to determine the volume of peripapillary hyperreflective ovoid masslike structures (PHOMS) and to examine the correlation between PHOMS and anatomic optic nerve head characteristics in a large cohort of patients with optic disc drusen (ODD).

Design

Retrospective, observational study of patients with ODD.

Participants

Patients with ODD seen in a 3-year period.

Methods

We determined the prevalence of PHOMS. We then developed a method to calculate the volume of PHOMS and measured this in all patients where radial scans on OCT were available. We analyzed the correlation between PHOMS volume and patient age, size of Bruch's membrane opening (BMO), ODD visibility, and anatomic location of ODD in the optic nerve.

Main Outcome Measures

Prevalence and characteristics of PHOMS in patients with ODD.

Results

In 247 (77%) eyes with ODD, PHOMS were found. Among these, 80% were in the first decade of life, 87% were in the second decade, 89% were in the third decade, 85% were in the fourth decade, 74% were in the fifth decade, 73% were in the sixth decade, 58% were in the seventh decade, 40% were in the eighth decade, and 0% were in the ninth decade. The ophthalmoscopic visibility of ODD increased with age. The volume of PHOMS decreased with age, but with no correlation to the size of BMO. The median volume of PHOMS was 0.27 mm3 (interquartile range [IQR], 0.13-0.49 mm3). Predominantly, PHOMS were observed in the nasal peripapillary area (87.5% nasal, 78.5% superior, 67% inferior, and 63.5% temporal).

Conclusions

In patients with ODD, PHOMS are seen frequently, with the highest prevalence in younger individuals. The volume of PHOMS decreases with age, and PHOMS are seen more frequently in patients with superficial ODD.

Clinical and Multi-Mode Imaging Features of Eyes With Peripapillary Hyperreflective Ovoid Mass-Like Structures

Purpose

To observe and analyze the clinical and multi-mode imaging features of eyes with PHOMS, and to introduce two cases of PHOMS which underwent multi-mode imaging.

Methods

Retrospective clinical observational study. A total of 26 patients (37 eyes) with hyperreflective structures surrounded by hyporeflective edges around the optic discs who were examined and diagnosed at Shandong Eye Hospital between January 2019 and June 2021 were included in the study. Among these patients, 12 were male and 14 were female. Fifteen were monocular. The average age was 39 years. All patients underwent the following examinations: Best-corrected visual acuity (BCVA), intraocular pressure examinations, slit-lamp anterior segment examinations, indirect ophthalmoscopy, visual field examinations, fundus color photography, fundus autofluorescence (FAF), optical coherence tomography (OCT), and optical coherence tomography angiography (OCTA). Some of the patients were examined with fundus fluorescein angiography (FFA). Clinical data and imaging characteristics from the OCT, OCTA, and FFA were analyzed retrospectively.

Results

We found the hyperreflective structures surrounded by hyporeflective edges around the optic discs in 37 eyes. EDI-OCT results revealed hyperreflective structures surrounded by hyporeflective edges around the optic discs in all eyes. Typical hyperreflexia lesions occurred around the optic disc, located subretinally and above Bruch's membrane. OCTA revealed that the highly reflective perioptic material also had vascular structures.

Conclusion

EDI-OCT of PHOMS showed hyperreflective structures surrounded by hyporeflective edges around all of the optic discs. Infra-red photography showed temporal hyperreflexia. These characteristics can be seen in a variety of diseases and may be a relatively common feature revealed by EDI-OCT scanning. These characteristics may also be seen in elderly patients as well as children. PHOMS may be found in optic disc drusen (ODD), tilted disc syndrome (TDS), optic neuritis, ischemic optic neuropathy, and in white dot syndromes. Few patients may be developed into macular neovascularization (MNV). In order to improve the accuracy and robustness of the conclusions and provide better clinical guidance, we need to conduct more comprehensive research in the subsequent clinical work.

Upregulated Retinal Neurofilament Expression in Experimental Optic Neuritis

In optic neuritis (ON), transient thickening of the macular retinal nerve fibre layer (RNFL) can be observed. This optical coherence tomography-based observation is not understood. The axonal diameter correlates with the neurofilament (Nf) protein content, but there are no data on the retinal tissue concentration of Nfs. The myelin-oligodendrocyte-glycoprotein (MOG) induced experimental autoimmune encephalomyelitis (EAE) model was used to investigate the retinas of Brown Norway rats with (i) visual evoked potentials (VEP) confirmed ON, (ii) VEP confirmed absence of ON and (iii) control animals. Twenty retinas were collected from MOG-EAE and control rats 27 days after immunisation. Retinal tissue Nf concentrations per total protein (μg/mg) were significantly higher in MOG-EAE rats with ON (median 4.29, interquartile range [IQR] 3.41-5.97) compared with MOG-EAE rats without ON (1.14, IQR 1.10-1.67) or control rats (0.93, IQR 0.45-4.00). The data suggest that up-regulation of Nf expression in the retinal ganglion cells precedes development of RNFL atrophy and plausibly explains the transient increase of axonal diameter and RNFL thickening.

Peripapillary Hyper-reflective Ovoid Mass-like Structure (PHOMS): An Optical Coherence Tomography Marker of Axoplasmic Stasis in the Optic Nerve Head

BACKGROUND

With the development and widespread adoption of spectral-domain optical coherence tomography (OCT), peripapillary hyper-reflective ovoid mass-like structures (PHOMS) have become a frequent OCT finding in neuro-ophthalmic practice. Although originally assumed to represent a form of buried optic disc drusen (ODD), PHOMS differ from ODD in many important ways. The histopathological underpinnings of PHOMS are now becoming more clearly understood.

EVIDENCE ACQUISITION

Review of literature.

RESULTS

PHOMS can be broadly classified as disk edema-associated PHOMS, ODD-associated PHOMS, or anomalous disk-associated PHOMS. PHOMS are seen in many conditions, including papilledema, nonarteritic anterior ischemic optic neuropathy, central retinal vein occlusion, acute demyelinating optic neuritis, ODD, and tilted disks (myopic obliquely inserted disks) and in many cases resolve along with the underlying condition. The histopathological study of these diverse entities reveals the common feature of a bulge of optic nerve fibers herniating centrifugally over Bruch membrane opening into the peripapillary space, correlating exactly with the location, shape, and space-occupying nature of PHOMS on OCT. Because of the radial symmetry of these herniating optic nerve fibers, PHOMS are best thought of as a complete or partial torus (i.e., donut) in 3 dimensions.

CONCLUSIONS

PHOMS are a common but nonspecific OCT marker of axoplasmic stasis in the optic nerve head. They are not themselves ODD or ODD precursors, although they can be seen in association with ODD and a wide spectrum of other conditions. They do not exclude papilledema and often accompany it. The circumferential extent and characteristic 3D toroidal nature of a PHOMS are best appreciated by scrolling through consecutive OCT images.

Association of peripapillary hyper-reflective ovoid masslike structures and disease duration in primary progressive multiple sclerosis

BACKGROUND AND PURPOSE

Peripapillary hyper-reflective ovoid masslike structures (PHOMS) are a novel finding during retinal optical coherence tomography in patients with multiple sclerosis (MS). To date, there are no data on the occurrence of PHOMS in early MS. The aim of this study was to investigate the frequency of PHOMS in patients with first diagnosed early relapsing-remitting MS (RRMS) and to search for associations of PHOMS with disease patterns in different MS subtypes.

METHODS

This was a cross-sectional analysis in two different cohorts: cohort 1, consisting of early RRMS patients (n = 349); cohort 2, consisting of patients with primary progressive MS (PPMS) (n = 66) and RRMS (n = 65).

RESULTS

Peripapillary hyper-reflective ovoid masslike structures were detected in 18.3% of patients with early RRMS. The occurrence of PHOMS was not associated with age, disease duration and disability. Investigating clinical patterns and the occurrence of PHOMS (cohort 2), an association of PHOMS with higher Expanded Disability Status Scale measures (PHOMS 4.9, 3.7-6.1; no PHOMS 3.5, 3.0-5.3; p = 0.03) and longer disease durations (PHOMS 6.5 years, 1.9-11.0; no PHOMS 1.0 years, 0.0-4.0, p = 0.0007) was found in patients with PPMS but not RRMS. After p value adjustment, the disease duration appeared to be more relevant (β = 0.16, p = 0.06).

CONCLUSION

Peripapillary hyper-reflective ovoid masslike structures were found in 18% of patients with early MS. The presence of PHOMS might be associated with disease progression only in PPMS but not RRMS, suggesting that PHOMS might be embedded in neurodegenerative processes.