The significance of external limiting membrane status for visual acuity in age-related macular degeneration

Subretinal hyperreflective material in retinal and chorioretinal disorders: A comprehensive review

Subretinal hyperreflective material (SHRM) is a common and remarkable optical coherence tomography (OCT) biomarker whose importance is emerging in several retinal and chorioretinal diseases, including age-related macular degeneration, central serous chorioretinopathy, polypoidal choroidal vasculopathy, pathologic myopia, posterior uveitis, vitelliform lesions and macular dystrophies, and rarer disorders. Multimodal imaging, also thanks to the introduction of OCT angiography, allowed a deeper characterisation of SHRM components and its morphological changes after treatment, suggesting its usefulness in clinical practice. We discuss and summarize the nature, multimodal imaging characteristics, and prognostic and predictive significance of SHRM in the different retinal and choroidal disorders in which it has been described.

Long-term predictors of anti-VEGF treatment response in patients with neovascularization secondary to CSCR: a longitudinal study

PURPOSE

To identify the baseline predictors of anti-VEGF treatment response at 3 years in patients affected by choroidal neovascularization (CNV) secondary to central serous chorioretinopathy (CSCR).

METHODS

In this retrospective longitudinal study, medical records of patients diagnosed with CNV secondary to CSCR and treated using anti-VEGF injections between April 2015 and May 2020 were reviewed. The potential qualitative and quantitative predictors of treatment response were identified or measured based on the multimodal imaging examination available for each patient at the baseline, including structural OCT, fluorescein angiography (FA), indocyanine green angiography (ICGA), and OCT-angiography (OCT-A). Univariate and multivariate analyses were performed.

RESULTS

Twenty-nine eyes from 29 patients affected by CNV complicating CSCR were included in the study. At the end of the 3-year follow-up, the mean BCVA was 20/50 Snellen equivalent (0.38 ± 0.36 LogMAR), and no significant difference with baseline BCVA (0.37 ± 0.29 LogMAR) was found (p = 0.9). Twenty out of 29 eyes (69%) had active lesions at the end of the follow-up. At multivariate analysis, none of the included features was independently associated with the 3-year BCVA outcome. Pigment epithelium detachment (PED) height (ß = 0.017, p = 0.028) and outer limiting membrane (OLM) preservation at the fovea (ß = -5.637, p = 0.026) were independently associated with the CNV activity at 3 years.

CONCLUSION

PED height and OLM obliteration at the fovea might be considered baseline predictors of lesion activity at 3-year follow-up in patients with CNV secondary to CSCR treated with anti-VEGF therapy.

A nationwide survey of hydroxychloroquine retinopathy presenting to the hospital eye service in the United Kingdom

BACKGROUND

The risk of developing hydroxychloroquine retinopathy is considered sufficient to justify national monitoring programmes. There are an estimated 71,144-77,170 long-term hydroxychloroquine users in the UK. However, the number of patients diagnosed with retinopathy is unknown. This study aimed to identify the number of cases and clinical characteristics of hydroxychloroquine retinopathy diagnosed annually in hospital eye services across the UK.

METHODS

A nationwide, prospective case ascertainment study was undertaken using the British Ophthalmological Surveillance Unit, which sends approximately 1420 reporting cards to UK Ophthalmologists monthly. The case definition was two abnormal tests suggestive of hydroxychloroquine retinopathy. Demographic and clinical data relating to hydroxychloroquine use and retinopathy were collected from identified cases using a standardised questionnaire over a 1-year period (2018-2019).

RESULTS

Sixty-six cases of hydroxychloroquine retinopathy were reported, and 46 questionnaires were received (73% response rate). Twenty-four incident cases of hydroxychloroquine retinopathy were identified (24-43 cases following adjustment). The median duration of drug therapy was 19 years (range: 4-50 years, IQR: 14.5-23 years). Fourteen patients were asymptomatic, and 9 symptomatic at diagnosis. A trend towards a lower mean deviation on visual field testing was observed in the symptomatic group (-11.55 dB versus -6.9 dB; P = 0.15).

CONCLUSION

Between 1 in 1655 and 3215 (0.03-0.06%) long-term hydroxychloroquine users were diagnosed with retinopathy over the study period. We estimate that monitoring was available for 1.9-3.8% of long-term users, accounting for a lower than expected incidence. The high proportion of symptomatic retinopathy at diagnosis underlines the importance of monitoring to detect pre-symptomatic disease.

INVESTIGATION OF INCIDENCE AND CAUSES OF ACUTE VISION LOSS DURING ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION DURING A FOUR-YEAR FOLLOW-UP

PURPOSE

To investigate the incidence, risk factors, and outcomes of patients with age-related macular degeneration who experienced acute vision loss despite periodic injections of anti-vascular endothelial growth factor treatment for 4 years.

METHODS

This retrospective cohort study included patients who were diagnosed with treatment-naive neovascular age-related macular degeneration and completed a 4-year follow-up. The incidence and risk factors for the occurrence of three or more lines of visual loss at every checkup were investigated.

RESULTS

The analysis included 76 eyes of 76 patients. Acute vision loss occurred in 30 eyes (39.5%) over 4 years. Lower baseline best-corrected visual acuity and disrupted ellipsoid zone were independent predictors of vision loss occurrence. Although the causes and timing of visual acuity loss varied, retinal pigment epithelium tears were observed only in the first year. Most patients (86.7%) who experienced vision loss recovered their vision to pre-loss levels at least once; however, the final best-corrected visual acuity was worse than that in the group that did not experience acute vision loss.

CONCLUSION

Approximately half of the patients with age-related macular degeneration experienced acute vision loss during a 4-year follow-up, despite continuous anti-vascular endothelial growth factor treatment. Most patients recovered from vision losses temporarily; however, they experienced worse visual outcomes subsequently.

Changes in the Hyperreflective Bands of Outer Retinal Layers after Idiopathic Epiretinal Membrane Surgical Removal

Purpose: The purpose of this study was to describe the relationship between the outer retinal hyperreflective bands and visual acuity recovery after idiopathic epiretinal macular membrane (ERM) surgical removal.Methods: A prospective longitudinal non-comparative study was conducted that included a total of 68 patients with idiopathic ERM, who underwent consecutive 23 G pars plana vitrectomy (PPV) at San Juan University Hospital (Alicante, Spain) from January 2019 to January 2021. All patients underwent a complete preoperative standard ophthalmic examination, including measurement of best corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT) examination. This protocol was repeated at 1 and 3 months after surgery.Results: Mean preoperative decimal BCVA was 0.30 ± 0.13 and disruption of the first, second, third and fourth outer retinal hyperreflective bands was observed by SD-OCT in 9 (27.9%), 27 (39.7%), 33 (48.5%) and 17 patients (25%), respectively. BCVA improved after ERM peeling at 1 and 3 months in all patients, regardless of the presence of disruption in any hyperreflective band. Significantly larger improvement of BCVA was found at 3 months after surgery in patients not showing disruption of hyperreflective bands 1 and 4 (p = 0.048 and 0.001, respectively).Conclusions: The integrity of the outer retinal hyperreflective bands by SD-OCT in patients with idiopathic ERM is a valuable tool to determine the visual prognosis of the surgical treatment of this condition. A successful recovery of hyperreflective bands 1 and 4 with ERM surgery may be a potential biomarker of the visual improvement achieved due to their important anatomical relation with cone photoreceptors at the foveal level.

Changes in foveal photoreceptor integrity after idiopathic epiretinal membrane surgery and its relationship with visual outcomes

PURPOSE

To investigate the changes in the external limiting membrane (ELM), ellipsoid zone (EZ), and interdigitation zone (IZ) integrity and their relationship with visual outcomes after idiopathic epiretinal membranes peeling.

METHODS

Clinical records of 150 eyes from 144 consecutive patients who underwent vitrectomy were reviewed. The status of IZ, EZ, and ELM was assessed by spectral-domain optical coherence tomography at baseline and 1, 4, 10, and 24 months postoperatively.

RESULTS

Sixty-one eyes presented with photoreceptor layer disruption preoperatively, and IZ disruption (40.7%) was the primary type. The best-corrected visual acuity (BCVA) in the photoreceptor disruption group was significantly lower than that in the intact group at baseline and the final follow-up. Of them, ELM + EZ + IZ disruption showed the worst BCVA (P = 0.001). After surgery, 62 eyes were observed with disruption aggravated. EZ + IZ disruption (51.0%) was the most frequent type at 1 month postoperatively. The eyes with longer symptom duration, better BCVA, earlier stage, thinner CFT at baseline, and combined cataract surgery more tended to be observed with photoreceptor damage progressed after surgery (P < 0.05). There was no significant difference in the final BCVA between the eyes with and without damage progressed (P = 0.332). Finally, 28.1% of the eyes recovered photoreceptor continuity. The eyes with foveal photoreceptor integrity restored had better BCVA than those remaining discontinuous (P < 0.001).

CONCLUSION

ERM-induced photoreceptor disruption mainly manifests as IZ disruption and has a negative effect on BCVA, whereas surgery mainly causes EZ and IZ disruption, which does not have a significant impact on the final BCVA.

Hyperreflective Foci in Diabetic Macular Edema with Subretinal Fluid: Association with Visual Outcomes after Anti-VEGF Treatment

INTRODUCTION

Objectives of the study were to describe the hyperreflective foci (HRF) on optical coherence tomography angiography in diabetic macular edema (DME) with subretinal fluid (SRF) and explore the association of HRF in the outer retina with photoreceptor integrity and visual outcomes after anti-vascular endothelial growth factor (anti-VEGF) treatment.

METHODS

We retrospectively reviewed 46 eyes (36 patients) with DME treated with anti-VEGF drugs. The following parameters, including best-corrected visual acuity (BCVA), central macular thickness (CMT), the height of SRF, the number of HRF in the superficial capillary plexus, deep capillary plexus, and the outer retina, as well as the integrity of external limiting membrane (ELM) and ellipsoid zone (EZ), were evaluated and compared between the baseline and after 2 monthly injections of anti-VEGF drugs. The relationship between the HRF in the outer retina and the integrity of ELM and EZ, as well as BCVA, was analyzed.

RESULTS

BCVA was significantly improved in DME after anti-VEGF treatment; however, for the subgroup of DME patients with SRF, visual acuity remained unchanged after anti-VEGF treatment (p < 0.05 vs. p = 0.375). The number of HRF (p < 0.05), CMT (p < 0.001), and SRF height (p < 0.001) were significantly reduced, accompanied with partial restoration of ELM and EZ integrity after anti-VEGF injection. The HRF in the outer retina was correlated with the final ELM (p = 0.036) and EZ (p = 0.004) status. The final BCVA was significantly better in eyes with intact ELM (p = 0.002) and EZ at final visit (p < 0.001).

CONCLUSION

The number of HRF in outer retina was negatively associated with the microstructural restoration of ELM and EZ, as well as the visual outcome in DME patients with SRF after anti-VEGF treatment.

External Limiting Membrane Disruption Predicts Long-Term Outcome in Strict Treat-And-Extend Regimen in Neovascular Age-Related Macular Degeneration

The use of anti-vascular-endothelial growth factor agents for neovascular age-related macular degeneration (nAMD) in different treatment schemes is widely common in clinical practice. However, there is currently limited data on the long-term outcomes of a strict treat-and-extend regimen (TER) and imaging biomarkers to predict both functional outcome and the potential for a TER exit due to success. In this retrospective study we followed treatment-naïve subjects with nAMD starting treatment with either ranibizumab or aflibercept in a TER without loading dose but with predefined exit criteria for up to 8 years. We evaluated both the functional outcome and several spectral-domain optical coherence tomography parameters in a follow-up mode using a standardized protocol. Within the 211 eyes followed for a mean of 60.3 ± 20.9 months, follow-up adherence was high with major part of discontinuations of TER being due to success. Mean best-corrected visual acuity (BCVA) increased from initially 63.9 ± 15.5 ETDRS letters to 70.0 ± 14.7 after 1 year (+6.1 letters, p < 0.001) and to 68.5 ± 18.1 (+4.6 letters, p = 0.028) at 5 years. A worse BCVA (p = 0.001) and a better external limiting membrane (ELM) disruption score at baseline predicted (p = 0.019) BCVA gain at 5 years. The probability of reaching the exit criteria was significantly associated with a better ELM disruption score (p = 0.044) and the absence of a central pigment epithelial detachment (PED) (p = 0.05) at baseline. Significant visual gains were sustained in a long-term TER in a real-world setting. Integrity of ELM at baseline predicted BCVA gain at 5 years and the potential for TER exit due to success.

Baseline Optical Coherence Tomography Parameters That May Influence 6 Months Treatment Outcome of Polypoidal Choroidal Vasculopathy Eyes with Combination Therapy: A Short-Term Pilot Study

Although optical coherence tomography (OCT) parameters have assisted in the diagnosis of polypoidal choroidal vasculopathy (PCV), its potential to evaluate treatment outcomes has not been established. The purpose of this pilot study was to evaluate baseline OCT parameters that may influence treatment outcome in PCV eyes with combination therapy. In this single-centered, prospective study, patients were recruited with at least one treatment-naïve PCV eye and treated with combination therapy of intravitreal anti-vascular endothelial growth factor and photodynamic therapy. Best-corrected distance and near visual acuity (DVA and NVA), and contrast sensitivity (CS) were recorded at baseline and six months after treatment. OCT parameters were determined. Twenty-six eyes of 26 patients aged between 51 to 83 years were evaluated. In eyes that had disrupted external limiting membrane (ELM), photoreceptors inner and outer segment (IS-OS) junction at 1000 micron of fovea at baseline showed low mean visual functions after 6 months of treatment. Eyes with foveal sub-retinal fluid (SRF) and polyp at central 1000 micron of fovea at baseline showed significantly worse DVA and CS after six months. Thus, the presence of foveal SRF, foveal polyp, disrupted ELM, and IS-OS junction at baseline significantly influenced the six months' visual outcome in PCV eyes treated with combination therapy.

OPTICAL COHERENCE TOMOGRAPHY PREDICTORS OF SHORT-TERM VISUAL ACUITY IN EYES WITH MACULAR EDEMA SECONDARY TO RETINAL VEIN OCCLUSION TREATED WITH INTRAVITREAL CONBERCEPT

PURPOSE

To identify the spectral domain optical coherence tomography predictors of visual prognosis in retinal vein occlusion macular edema after intravitreal conbercept injection.

METHODS

Retrospective cohort study of 63 treatment-naive retinal vein occlusion macular edema eyes received pro re nata intravitreal conbercept with at least 3 months of follow-up. The best-corrected visual acuity (BCVA) and optical coherence tomography scans were recorded at baseline, 1 month, and 3 months after starting therapy. On spectral domain optical coherence tomography, the following lesions in the 1-mm-wide retinal area centered on the fovea: disorganization of the retinal inner layer extent, cysts, hyperreflective foci, microaneurysms, external limiting membrane or ellipsoid zone disruption, foveal bulge, and foveal depression were evaluated by masked graders. Regression analysis was used to determine independent predictors of BCVA at 1- and 3-month follow-up.

RESULTS

The thicker central subfield thickness, greater extent of external limiting membrane disruption, and presence of hyperreflective foci >20 at baseline were correlated with the worse baseline BCVA (all P < 0.05). The greater extent of external limiting membrane disruption and presence of hyperreflective foci >20 at baseline were associated with poorer BCVA during follow-up (all P < 0.05). The central subfield thickness and extent of ellipsoid zone disruption at baseline and their changes over time were correlated with the 3-month BCVA improvement (all P < 0.05). Furthermore, changes in the ellipsoid zone disruption extent or central subfield thickness after 1 month identified eyes with a high likelihood of subsequent BCVA improvement or decline.

CONCLUSION

The external limiting membrane status and hyperreflective foci >20 at baseline could be good predictors for short-term visual outcome, whereas the central subfield thickness and ellipsoid zone status at baseline and their changes over time may predict visual improvement in patients with retinal vein occlusion macular edema after intravitreal conbercept injection.

Effect of Dexamethasone Intravitreal Implant on Visual Acuity and Foveal Photoreceptor Integrity in Macular Edema Secondary to Retinal Vascular Disease

PURPOSE

The aim of this study was to evaluate the effect of the dexamethasone intravitreal (DEX) implant on the external limiting membrane (ELM) and ellipsoid zone (EZ) integrity in treatment-naïve patients with macular edema (ME) secondary to retinal vascular disease (RVD).

METHODS

This is a retrospective study conducted on patients with ME secondary to RVD, who underwent a DEX implant.

RESULTS

One-hundred eyes were included. Mean age was 70.3 ± 11.1 years. Mean ELM integrity significantly improved from 1,575.9 ± 285.9 μm at baseline to 1,711.7 ± 244.0 μm at month 3 (p < 0.0001). Similarly, there was a significant improvement in EZ integrity from baseline to month 3 (1,531.5 ± 317.1 vs. 1,694.3 ± 252.8 μm, respectively, p < 0.0001). At month 3, mean visual acuity (VA) gain was 9.9 ± 14.1 letters (p < 0.0001). Mean central retinal thickness (CRT) significantly decreased by -193.2 ± 185.7 μm from baseline to month 3 (p < 0.0001). Mean changes in VA and CRT were significantly correlated with baseline ELM integrity (p = 0.0065 and p = 0.0046, respectively) and EZ integrity (p = 0.0300 and p = 0.0035, respectively). At month 3, the proportion of eyes which had an intact ELM (mean difference 16.0%, 95% CI 5.4-26.4%, p = 0.0033) and EZ (mean difference 12.0%, 95% CI 1.8-22.1%, p = 0.0210) was significantly higher than at baseline.

CONCLUSIONS

DEX implant was able to significantly improve ELM and EZ integrity in naïve patients with ME.

The prognostic value of total macular external limiting membrane and ellipsoid zone damage for clinical outcome in treatment-resistant neovascular age-related macular degeneration

PURPOSE

To examine the prognostic value of the extent of damage to the ellipsoid zone (EZ) and external limiting membrane (ELM) in response to the treatment of age-related macular degeneration (AMD) eyes switched from ranibizumab to aflibercept.

METHODS

This is a retrospective study of patients with neovascular AMD resistant to ranibizumab defined as having persistent intra- or subretinal fluid on OCT scans despite at least 6-month treatment and switched to aflibercept. Clinical data was collected and quantitative measurements of the area of EZ and ELM damage were obtained, on en-face optical coherence tomography images, at the time of switch to aflibercept (baseline) and up to 6 months of follow-up.

RESULTS

The study included 71 eyes (52.1% right eye) of 71 patients. At baseline, there was a correlation between the size of the EZ and ELM damaged area and BCVA (R = -0.39, p = 0.001 and R = -0.47, p < 0.001, respectively). The EZ and ELM damaged areas maintained correlation with BCVA at 6 months (R = -0.28, p = 0.01 and R = -0.39, p = 0.001, respectively). Central retinal thickness did not correlate with BCVA at the time of switch (p = 0.38) or at 6 months (p = 0.36).

CONCLUSIONS

The extent of damage to the EZ and ELM correlates with BCVA following a switch in treatment.

Baseline visual acuity and interdigitation zone as predictors in idiopathic epiretinal membranes: A retrospective cohort study

OBJECTIVE

Determine which functional and anatomical characteristics may be predictors of final visual acuity in patients with idiopathic ERM (iERM) submitted to pars plana vitrectomy (PPV) with ERM and internal and internal limiting membrane (ILM) peeling.

DESIGN

Retrospective cohort study.

SUBJECTS

Patients with iERM submitted to PPV between 2016 and 2017.

METHODS

Data regarding the best-corrected visual acuity (BCVA) and the characteristics of the retinal layers observed in SD-OCT were collected preoperatively and until 12 months postoperatively. Central macular thickness (CMT), disorganization of the retinal inner layers (DRIL), outer nuclear layer (ONL) thickness, integrity of subfoveal external limiting membrane (ELM), ellipsoid zone (EZ), and interdigitation zone (IZ) were evaluated.

RESULTS

A total of 128 eyes with iERM from 121 patients were included. BCVA improved significantly (p < 0.001). Significant improvement of BCVA, CMT, DRIL, ONL, ELM, and EZ were obtained. The final IZ was not different from baseline until the end of the study. A significant correlation was observed between the baseline BCVA, EZ, IZ, and the postoperative BCVA (p < 0.001). However, only the baseline BCVA and the integrity of the subfoveal baseline IZ were predictive factors for final BCVA (p < 0.005 and p < 0.001, respectively).

CONCLUSION

PPV provides a significant improvement of BCVA and retinal anatomy recovery in iERM eyes. Baseline IZ didn't change during the 12 months following surgery. Baseline BCVA and subfoveal IZ at baseline were prognostic factors for the final BCVA.

Neurodegeneration, gliosis, and resolution of haemorrhage in neovascular age-related macular degeneration, a clinicopathologic correlation

BACKGROUND

To analyse cellular and spatiotemporal factors of neurodegeneration and gliosis in a patient with submacular haemorrhage (SMH) secondary to type 1 macular neovascularization in neovascular age-related macular degeneration (nAMD).

METHODS

This is a case study and clinicopathologic correlation of an 84-year-old white man with nAMD treated with antiangiogenic drugs and photodynamic therapy during a 6-year follow-up. Eyes were recovered for histology 8.23 h after death. In vivo multimodal imaging including optical coherence tomography (OCT) and en face modalities was compared with ex vivo OCT and high-resolution histologic images, using a custom image registration procedure. SMH components were defined (intraretinal, subretinal, sub-retinal pigment epithelium (RPE), and dehemoglobinized blood). Neurodegenerative changes in each of these areas were described. One anonymous donor eye with haemorrhagic nAMD was also reviewed as a comparator.

RESULTS

By in vivo OCT, progressive resolution of the haemorrhage and gradual transformation of sub-RPE fluid to fibrous hyperreflective tissue, progressive macular atrophy, and variation in external limiting membrane (ELM) visibility were observed. Histology showed intense photoreceptor loss with preservation and self-adhesion of macular Müller glia resulting in ELM condensation. The comparator eye exhibited shed cone inner segments among subretinal erythrocytes.

CONCLUSION

This is the most detailed clinicopathologic correlation of nAMD with SMH resolution to date, and the first in the OCT era. Our results reveal profound macular neurodegeneration and gliosis, signified by condensed ELM, soon after haemorrhage begins. Intensified OCT reflectivity of the ELM, an important retinal barrier, has potential as a biomarker for severe photoreceptor loss and gliosis.

Optical coherence tomographic comparison of naive macular edema due to ischemic and nonischemic retinal vein occlusion

PURPOSE

To examine the macular microstructure in macular edema (ME) due to retinal vein occlusion (RVO) in terms of ischemic or nonischemic type to determine whether and how ischemia affects macular microstructure.

METHODS

This retrospective, nonrandomized study included 75 newly diagnosed RVO cases (group 1: 55 nonischemic RVO cases and group 2: 20 ischemic RVO cases) with evidence of center-involving ME without any treatment. Quantitative measures on spectral-domain optical coherence tomography images were performed. Central subfield thickness (CST) was collected in the central 1 mm from the thickness map. The following items were evaluated in a 3-mm-wide area (perifoveal ETDRS circle) centered on the fovea: disorganization of the retinal inner layers (DRIL), disrupted external limiting membrane (ELM) and ellipsoid zone disruption (EZD). The microstructural changes were measured manually.

RESULTS

Baseline characteristics, such as age, sex, study eye, and RVO risk factors, were similar between the groups (P > 0.05). CST was 554.15 ± 191.45 µm for group 1 and 769.90 ± 290.00 µm for group 2 (P: 0.001). The extent of DRIL was 1864.09 ± 941.70 µm and 2447.25 ± 492.59 µm for groups 1 and 2, respectively (P: 0.010). The disrupted ELM length was 1700 (0-3000) µm for group 1 and 2725 (300-3000) µm for group 2 (P: 0.027). The EZD length was 1453.09 ± 870.38 µm for group 1 and 1846.00 ± 926.54 µm for group 2 (P: 0.093).

CONCLUSIONS

Ischemic RVOs cause greater macular edema and greater disruption in the macular microstructure compared to nonischemic RVOs, especially in terms of DRIL and ELM.

Spectral Domain Optical Coherence Tomography in Awake Rabbits Allows Identification of the Visual Streak, a Comparison with Histology

Purpose

To evaluate visual streak (VS) identification on spectral-domain optical coherence tomography (SD-OCT) scans in awake rabbits. To report thickness measurements in the VS and adjacent retina on OCT B-scans and histologic sections and to assess inter-method bias, precision and repeatability between OCT and histology.

Methods

Vertical SD-OCT B-scan images through the optic nerve head and VS were acquired from 16 awake, ophthalmologically healthy experimental rabbits. Scans were acquired from both eyes, which were later enucleated and processed for light microscopy. Inner retina, inner nuclear layer, outer nuclear layer, outer retina (OR) and photoreceptor outer segment (PROS) thickness were measured on OCT images and digitalized microscopy slides in- and outside of the VS, and compared using linear mixed effects models.

Results

Both SD-OCT and histology allowed retinal layer identification and measurement. On OCT, OR and PROS were thickest in the central VS and thinnest outside the VS. Histology mirrored OCT results for central outer retinal layers but shows discrepancies for other layers likely because of postmortem processing artifacts. The method comparison demonstrated better repeatability for OCT measurements compared with histology.

Conclusions

Increased OR and PROS thickness compared with the adjacent retina allowed identification of the VS on SD-OCT in awake rabbits. OCT allows measurements devoid of processing artifacts in contrast to histology.

Translational Relevance

SD-OCT is possible in awake rabbits. Easy and reliable identification of the VS may facilitate the positioning and use of rabbits as model species in human macular and generalized retinal disease research.

Solar maculopathy: prognosis over one year follow up

Background

To document the visual acuity, spectral domain optical coherence tomography (SD-OCT) findings and prognosis in10 eyes of 6 patients with foveal damage from solar retinopathy in 1 year.

Methods

This was a prospective, observational case series of patients presented by solar maculopathy at Ophthalmology department, Sohag University. All patients underwent visual acuity (VA) testing, refraction, dilated fundus examination fluorescein angiography (FA) and SD-OCT (spectral Domain ocular coherence Tomography) imaging and follow up for 1 year.

Results

The mean age was 16.5 years (range 9–27 years, both eyes are affected in 4 patients. The mean spherical equivalent (SE) was – 0.25 ± 0.50 D.

The visual acuity of the affected eyes ranged from 0.4 to 0.9 on presentation. At presentation Significant foveal pathology was identified on SD-OCT in 10 eyes, All eyes showed disruption of the photoreceptor ellipsoid zone and the interdigitation zone on SD-OCT, Follow up of the cases continued for 1 year.100% of cases showed improvement in VA: 20% eyes regained 1, 50% eyes with VA of 0.9; two eyes 20% 0.8 and one eyes (10%) with 0.4. The improvement began after 1 week and reached its maximum and became stationary after the 6th month of follow up, the outer retinal hole persist in OCT in 80% of cases.

Conclusion

Solar maculopathy has a good prognosis yet shows no improvement after 6 months. Young age might pose as a risk factor.

Sphingosine Kinase-1 Is Essential for Maintaining External/Outer Limiting Membrane and Associated Adherens Junctions in the Aging Retina

Sphingosine-1-phosphate (S1P) produced by sphingosine kinases (SPHK1 and SPHK2) is a signaling molecule involved in cell proliferation and formation of cellular junctions. In this study, we characterized the retinas of Sphk1 knockout (KO) mice by electron microscopy and immunocytochemistry. We also tested cultured Müller glia for their response to S1P. We found that S1P plays an important role in retinal and retinal pigment epithelial (RPE) structural integrity in aging mice. Ultrastructural analysis of Sphk1 KO mouse retinas aged to 15 months or raised with moderate light stress revealed a degenerated outer limiting membrane (OLM). This membrane is formed by adherens junctions between neighboring Müller glia and photoreceptor cells. We also show that Sphk1 KO mice have reduced retinal function in mice raised with moderate light stress. In vitro assays revealed that exogenous S1P modulated cytoskeletal rearrangement and increased N-cadherin production in human Müller glia cells. Aged mice also had morphological degeneration of the RPE, as well as increased lipid storage vacuoles and undigested phagosomes reminiscent of RPE in age-related macular degeneration. These findings show that SPHK1 and S1P play a vital role in the structural maintenance of the mammalian retina and retinal pigmented epithelium by supporting the formation of adherens junctions.

Four-Year Outcome of Aflibercept for Neovascular Age-Related Macular Degeneration and polypoidal choroidal vasculopathy

Intravitreal injections of anti-vascular endothelial growth factor agents such as ranibizumab and aflibercept are the first-line treatment for neovascular age-related macular degeneration (AMD). However, data about long-term outcome in real-world clinical practice is scarce. We recruited 98 AMD patients and investigated four-year visual outcome. During the four years, 25 patients dropped out. The survivors received 7.0 ± 0.1 injections during the first year and 8.0 ± 7.4 injections in the following three years. The logarithm of minimum angle of resolution (logMAR) at baseline, year one, and year four was 0.28, 0.14 (P = 0.033), and 0.22 (P = 0.697), respectively. The gain of vision was not different among AMD subtypes (typical AMD, polypoidal choroidal vasculopathy, and retinal angiomatous proliferation; P = 0.513) Among the investigated factors, the presence of external limiting membrane (ELM), the absence of vitreoretinal adhesion, and thicker choroid at baseline were associated with better logMAR values at year four (coefficient beta = -0.388, 0.201, and -0.001; P = 7.34 × 10^-6; 0.01, and 0.028, respectively). In the present study, vision was retained at baseline level after the four-year treatment with aflibercept. The status of ELM, vitreoretinal adhesion, and choroidal thickness were predictive factors for final vision.

Biomarkers of optical coherence tomography in evaluating the treatment outcomes of neovascular age-related macular degeneration: a real-world study

This study evaluated the characteristic changes in optical coherence tomography (OCT) biomarkers in neovascular age-related macular degeneration (nAMD) treated with anti-vascular endothelial growth factor drugs and their relationship with visual outcomes at 1-year follow-up in a real-world setting. We retrospectively reviewed the medical records of 126 eyes with nAMD treated with either intravitreal ranibizumab or aflibercept, including ophthalmologic examinations and spectral-domain OCT at baseline and months 3, 6, and 12 after first injection. Treatment response of intraretinal cysts (IRCs), subretinal fluid (SRF), and pigment epithelial detachment (PED), and the correlation between best-corrected visual acuity (BCVA) changes and these OCT biomarkers were analyzed. After an average of 5.1 ± 1.5 injections, 33.3% of eyes with PED showed resolution at month 12, a significantly lower proportion than for IRCs (53.8%) or SRF (51.6%). BCVA improvement at 1 year was negatively associated with PED at baseline and with IRCs or PED at month 12. Persistence of IRCs at month 12 was associated with degeneration morphology of IRCs at baseline and non-resolved cysts at month 3 after loading. In conclusions, IRCs and PED are associated with poor visual improvement in nAMD in a real-world setting. Both IRCs and SRF responded better than PED to anti-VEGF therapy.

Long-term results of photodynamic therapy or ranibizumab for polypoidal choroidal vasculopathy in LAPTOP study

BACKGROUND/AIM

We previously reported that ranibizumab performed better on visual prognosis than photodynamic therapy (PDT) in a Ranibizumab (Lucentis) And Photodynamic Therapy On Polypoidal choroidal vasculopathy (LAPTOP) study. To determine if the first-choice treatment, either PDT or intravitreal ranibizumab, has a long-term effect in patients with polypoidal choroidal vasculopathy (PCV).

METHODS

We reviewed medical records of patientsrandomised to either PDT (29 eyes) or ranibizumab (27 eyes) from July 2009 to June 2011 in LAPTOP study. Retreatment or switching to other treatments were at the investigator's discretion after release from the 2-year LAPTOP study up to 5years. We evaluated visual acuity (VA), continuity of initial treatment, percentage of dry macula achievement and macular atrophy at 5 years.

RESULTS

The logarithm of minimal angle of resolution VA was 0.56 in the PDT and 0.44 in the ranibizumab groups at baseline (p=0.101) and was 0.55 and 0.28 at 5years, respectively (p<0.05). More than 70% of the patients converted to aflibercept in following years. Achievement percentages of dry macula were 74% (PDT) and 63% (ranibizumab) at 5years, and macular atrophy was detected in 78% (PDT) and 60% (ranibizumab) with a mean area of 7.7 and 3.5 mm², respectively (p=0.155).

CONCLUSIONS

The better VA in the initial ranibizumab group compared with the PDT group at 2 years was retained at the 5-year follow-up.

Shortest Distance From Fovea to Subfoveal Hemorrhage Border Is Important in Patients With Neovascular Age-related Macular Degeneration

PURPOSE

To identify factors influencing visual outcome in patients with neovascular age-related macular degeneration (NVAMD) and subfoveal hemorrhage (SFH) treated with anti-vascular endothelial growth factor (VEGF) agents.

DESIGN

Retrospective case series.

METHODS

Anti-VEGF-treated eyes with SFH > 1 disc area (DA) were identified (n = 16) and changes in visual acuity (VA) and central subfield thickness (CST) from baseline to last follow-up, along with SFH area, thickness, minimum distance from fovea to SFH border, and time to resolution, were determined.

RESULTS

At baseline, mean (± standard error of the mean) size and thickness of SFH were 14.9 ± 2.8 DA and 386.6 ± 46.9 μm, and mean Snellen VA and CST were 20/250 and 591.7 ± 57.0 μm. Median follow-up was 47.6 months. While more than 50% of patients had VA ≤ 20/200 at baseline and all time points through week 48, the percentage of patients with VA ≥ 20/50 increased to 30%-40% at months 6 and 12 and remained stable through month 48. Spearman rank correlation demonstrated 2 independent variables that correlated with good visual outcome, smaller area of SFH at baseline (r = -0.630; P = .009), and high frequency of anti-VEGF injections (r = 0.646; P = .007). In exceptional patients with good visual outcome despite large baseline SFH, shortest distance between the fovea and hemorrhage border significantly correlated with baseline VA (r = -0.503, P = .047) and final VA (r = -0.575, P = .02).

CONCLUSIONS

Patients with NVAMD and thick SFH, but short distance between fovea and uninvolved retina, can have good visual outcomes when given frequent anti-VEGF injections.

Predicting the visual acuity for retinal vein occlusion after ranibizumab therapy with an original ranking for macular microstructure

The study investigated predictive factors for best-corrected visual acuity (BCVA) after ranibizumab treatment in patients with macular edema (ME) associated with retinal vein occlusion (RVO) with an original ranking for the impairment of macular microstructure. In this retrospective study, 31 eyes of 31 patients with RVO received 3 monthly consecutive ranibizumab injections and another 3 months of follow-up. An original method was applied to rank the impairment of the external limiting membrane (ELM) and the ellipsoid zone (previously called the photoreceptor inner and outer segment junction, IS/OS) integrity on the baseline optical coherence tomography (OCT) images. Univariate and multivariate linear regression analyses were performed to assess the association between the baseline factors and post-treatment BCVA. ELM integrity and baseline BCVA were shown to be independent factors in the prediction of post-treatment BCVA. Comparison of post-treatment BCVA between original ELM ranks after adjusting for the baseline BCVA revealed the ELM integrity beneath the center of the fovea was important to post-treatment BCVA. ELM integrity in particular beneath the center of the fovea and baseline BCVA may be more useful than other factors in the prediction of visual function in patients with ME secondary to RVO after ranibizumab injections.

Association of Vascular Versus Avascular Subretinal Hyperreflective Material With Aflibercept Response in Age-related Macular Degeneration

PURPOSE

To investigate flow signal within subretinal hyperreflective material (SHRM) using optical coherence tomography angiography (OCTA) and its association with aflibercept treatment responses in treatment-naïve neovascular age-related macular degeneration (nAMD).

DESIGN

Prospective consecutive interventional case series.

METHODS

Forty-four eyes of 44 patients with treatment-naïve nAMD manifesting SHRM on OCT were studied. All patients underwent OCTA and received 3 monthly aflibercept injections. The intrinsic flow signals within SHRM were quantitatively analyzed using OCTA, and eyes were classified into the vascular and avascular SHRM groups.

RESULTS

Of 44 eyes, 21 (47.7%) and 23 (52.3%) showed vascular SHRM and avascular SHRM, respectively. Compared with eyes with avascular SHRM, eyes with vascular SHRM showed higher rates of external limiting membrane (ELM) disruption owing to SHRM (P = .015), classic choroidal neovascularization (CNV) (85.7% vs 26.1%, P = .87 × 10^-4), and intraretinal fluid (P = .008) at baseline. After 3 aflibercept injections, 38 eyes (86.4%) showed dry macula despite persistent SHRM in 24 eyes (54.5%). Compared with the eyes with resolved SHRM, those with persistent SHRM showed higher rate of vascular SHRM (75.0% vs 15.0%, P = .86 × 10^-4), classic CNV (P = .032), absence of polypoidal lesion (P = .020), ELM disruption owing to SHRM (P = .042), and intraretinal fluid (P = .008). Dry macula after loading injections was significantly associated with SHRM resolution (P = .025).

CONCLUSIONS

In nAMD, SHRM can be categorized as vascular and avascular by quantitative OCTA analysis. Vascular SHRM persisted after treatment and was associated with failure to achieve dry macula, suggesting that vascular SHRM is predictive of lower response to anti-VEGF therapy.

Correlation between retinal function and microstructural foveal changes in intermediate age related macular degeneration

PURPOSE

To assess foveal microstructural changes influencing retinal sensitivity (RS) and fixation stability using microperimeter MP-1 in intermediate age-related macular degeneration (AMD).

METHODS

In this cross-sectional study, 22 eyes of 22 patients (mean age: 75 ± 9.02 years) with intermediate AMD were enrolled. Retinal sensitivity and bivariate contour ellipse area (BCEA) were obtained by microperimetry MP-1 (Humphrey 10-2 68-loci grid) under mesopic conditions. Drusen type, drusenoid pigment epithelial detachment, hyperreflective foci (HF), integrity of external limiting membrane (ELM), inner ellipsoid zone (ISel), RPE/Bruch's membrane complex (RPE/B) and subfoveal choroidal thickness were analyzed in the foveal region and compared with RS and BCEA. Spearman's rank correlation coefficient was used to evaluate the relationship between variables. Logistic regression analysis was also used to assess morphological predictor influencing RS or BCEA.

RESULTS

RS was strongly and inversely related with the presence of HF (r = -0.66, P = 0.001), integrity of ELM (r = -0.70, P < 0.001), ellipsoid zone (r = -0.45, P = 0.03). Instead, BCEA is positively related to the ellipsoid zone integrity (r = 0.45, P = 0.03). Logistic regression analysis confirmed that disruption of ISel influenced fixation stability (ExpB: 9.69, P = 0.04) but not RS. Instead, the presence of HF and disruption of ELM predicted RS reduction (ExpB: 0.55, P = 0.02 and ExpB: 0.29, P = 0.04, respectively).

CONCLUSIONS

The integrity of ELM and the presence of HF are both predictors of RS. The ELM status may be considered a new biomarker of retinal function together with HF. Instead, the integrity of ISel band seems to be a more selective predictor of BCEA than RS.

Treat-and-extend approach with aflibercept: Effects on different subtypes of age-related choroidal neovascularisation

OBJECTIVE

To describe functional/morphological outcomes of treat-and-extend (TAE) with aflibercept in different subtypes of neovascularizations (CNV) secondary to exudative age-related macular degeneration (AMD).

METHODS

Retrospective study was conducted on 30 eyes of 30 patients treated with 2 mg-aflibercept according to a TAE protocol. Examinations included best corrected visual acuity (BCVA), number of injections, and visits needed. A quantitative/qualitative analysis was also performed with fluorescein angiography and spectral-domain optical coherence tomography (SD-OCT) at baseline, and at 3, 6, and 12 months.

RESULTS

BCVA significantly improved from 0.61±0.26 logMAR to 0.38±0.34 logMAR. Among the total AMD patients, type 1 CNV was diagnosed in 11 eyes (36%), type 2 CNV in 7 eyes (23%), mixed CNV in 5 eyes (16%), and type 3 CNV or retinal angiomatous proliferation (RAP) in 7 eyes (23%). The final mean number of injections was 7.5±1.65, 8.71±0.76, 7.4±0.89, 7.2±0.7, and number of visits 6.6±2.17, 7.89±1.46, 5.8±1.7, and 7.14±1.57, respectively in type 1, type 2, mixed, and type 3 or RAP. There was no difference between the different subtypes of CNV (P>.05).

CONCLUSIONS

Aflibercept in TAE is effective for all exudative-AMD subtypes. No significant differences in patient's visual gain, mean number of injections, or number of visits needed were found among the subtypes of CNV.

Macular Hole Surgery: The Healing Process of Outer Retinal Layers to Visual Acuity Recovery

Purpose

To evaluate optical coherence tomography (OCT) modifications of outer retinal layers as determinants for functional recovery after surgery for idiopathic macular hole (IMH).

Methods

This prospective study included 23 eyes of 23 consecutive patients who underwent vitreoretinal surgery for IMH. We excluded patients with other retinal diseases. Baseline and follow-up evaluations at months 3 and 6 included complete ophthalmologic and instrumental evaluations. Functional evaluation was performed by Best Corrected Visual Acuity (BCVA) and Amsler test. Morphologic evaluation was performed by spectral-domain 3D-OCT (Topcon, Tokyo, Japan) for a deep analysis of retinal layers as well as central retinal thickness evaluation. A standard 23-G or 25-G vitreoretinal surgery was performed, completed by posterior hyaloid and inner limiting membrane peeling by means of vital dyes and gas tamponade. Statistical analysis was performed on collected data.

Results

The mean BCVA increased significantly from 0.57 ± 0.25 logMAR at baseline to 0.34 ± 0.22 logMAR at month 6. Intraretinal layers modification showed a progressive recomposition of inner segment/outer segment layer in 91% of patients at month 6. Retinal layers recomposition showed a progressive increase in all patients during follow-up from the immediate postoperative control to the last 6-month visit.

Conclusions

Optical coherence tomography examination appears useful to investigate visual recovery after macular hole surgery. To ensure postsurgical functional increase, recomposition of all retinal layers, in particular in the outer retina, is mandatory. This process could be slow and not immediately observable during follow-up examinations.

LOSS OF EXTERNAL LIMITING MEMBRANE INTEGRITY PREDICTS PROGRESSION OF HYDROXYCHLOROQUINE RETINAL TOXICITY AFTER DRUG DISCONTINUATION

PURPOSE

To quantify external limiting membrane (ELM) disruption and photoreceptor volume over time, using spectral domain optical coherence tomography in eyes with hydroxychloroquine (HCQ) toxic effects after discontinuation.

METHODS

We performed a retrospective chart review of patients who were screened for toxic effects of HCQ between January 1, 2009 and August 31, 2014, and identified 10 patients diagnosed as having HCQ retinal toxic effects. Intact ELM and the Bruch membrane were manually traced using ImageJ software and their lengths from each scan of the spectral domain optical coherence tomography macular volume were summed. The ratio of intact ELM length/Bruch membrane length was calculated. We measured the two-dimensional photoreceptor area between the intact ELM and Bruch membrane in every cross-sectional B-scan. We calculated the total volume of photoreceptors in a volumetric OCT by multiplying photoreceptor area by the distance between B-scans.

RESULTS

Of the 10 patients (120 eyes), 1 eye was excluded because of the presence of vitreomacular traction. The mean cumulative dose of HCQ was 1,951 g (range, 584-3,650 g). The mean follow-up duration was 34.1 months (range, 11-64 months). Based on the extent of ELM integrity at diagnosis of HCQ toxicity, we classified eyes into 2 groups: 1) 12 eyes showed severe ELM disruption and 2) 7 eyes had intact ELM. All 19 eyes showed characteristic signs of HCQ toxicity on the visual field examination at the baseline. Seven of 12 eyes with ELM disruption showed progressive ELM changes, including 7 eyes that additionally developed progressive photoreceptor volume decline, whereas 5 eyes remained stable. All 7 eyes with intact ELM remained stable over time.

CONCLUSION

Intact ELM status at the time of HCQ discontinuation is a good prognostic sign, and ELM status may allow clinicians to predict patients at risk for progression of retinopathy. Quantitative measurements of ELM disruption and photoreceptors volume may provide an objective tool to monitor outer retinal changes due to HCQ.

Automated Quantitative Analysis of Retinal Microvasculature in Normal Eyes on Optical Coherence Tomography Angiography

PURPOSE

To describe a new automated quantitative technique for displaying and analyzing macular vascular perfusion using optical coherence tomography angiography (OCT-A) and to determine a normative data set, which might be used as reference in identifying progressive changes due to different retinal vascular diseases.

DESIGN

Reliability study.

METHODS

A retrospective review of 47 eyes of 47 consecutive healthy subjects imaged with a spectral-domain OCT-A device was performed in a single institution. Full-spectrum amplitude-decorrelation angiography generated OCT angiograms of the retinal superficial and deep capillary plexuses. A fully automated custom-built software was used to provide quantitative data on the foveal avascular zone (FAZ) features and the total vascular and avascular surfaces. A comparative analysis between central macular thickness (and volume) and FAZ metrics was performed. Repeatability and reproducibility were also assessed in order to establish the feasibility and reliability of the method.

RESULTS

The comparative analysis between the superficial capillary plexus and the deep capillary plexus revealed a statistically significant difference (P < .05) in terms of FAZ perimeter, surface, and major axis and a not statistically significant difference (P > .05) when considering total vascular and avascular surfaces. A linear correlation was demonstrated between central macular thickness (and volume) and the FAZ surface. Coefficients of repeatability and reproducibility were less than 0.4, thus demonstrating high intraobserver repeatability and interobserver reproducibility for all the examined data.

CONCLUSIONS

A quantitative approach on retinal vascular perfusion, which is visible on Spectralis OCT angiography, may offer an objective and reliable method for monitoring disease progression in several retinal vascular diseases.

MACULAR MICROSTRUCTURAL FEATURES IN CHILDREN WITH TILTED DISK SYNDROME EVALUATED BY SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY

PURPOSE

To assess macular microstructure in eyes with tilted disk syndrome (TDS) and determine the relationship between TDS foveal morphology and visual function.

METHODS

Twenty-six TDS eyes from 19 children (aged 5∼15 years) with a spherical equivalent refraction (SER) of -3.1 ± 1.3 diopter (D) and 28 control eyes from 14 children (aged 7∼12 years) with a SER of -3.0 ± 0.7 D were recruited. Horizontal and vertical optical coherence tomography scans through the fovea produced images that were segmented into eight intraretinal layers. Thicknesses of the total retina and each layer were measured at the foveal center and 12 other macular locations: 500 μm, 1,000 μm, and 1,500 μm along the horizontal and vertical meridians. The relationships between TDS best correct visual acuity (BCVA) and the presence of photoreceptor inner/outer segment (IS/OS) junction line, IS/OS foveal bulge, and cone outer segment tip (COST) line were evaluated.

RESULTS

The thickness of TDS central fovea, 218.94 ± 22.20 μm, was not significantly different from controls. The total retinal thickness in TDS eyes was thinner than controls at all peripheral locations (P < 0.05) except at 500 μm and 1,000 μm superiorly, and 1,500 μm temporally. Tilted disk syndrome intraretinal layer thicknesses in the nasal and inferior regions varied significantly from controls (P < 0.05). Only 80.7% and 23.1% of TDS eyes had a normal foveal bulge and continuous COST line, respectively, compared with 100% and 96.4% of controls. The BCVA of TDS eyes was similar whether or not the foveal bulge or COST line was abnormal.

CONCLUSION

Differences in intraretinal layer thickness may be correlated with defective vision.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY VERSUS TRADITIONAL MULTIMODAL IMAGING IN ASSESSING THE ACTIVITY OF EXUDATIVE AGE-RELATED MACULAR DEGENERATION: A New Diagnostic Challenge

PURPOSE

To compare optical coherence tomography angiography (OCTA) with traditional multimodal imaging in patients with exudative age-related macular degeneration in terms of guiding the treatment decision.

METHODS

Prospective case series of 80 eyes of 73 consecutive patients with exudative age-related macular degeneration (39 women, mean age: 79.4 ± 5.3 years) diagnosed with different types of choroidal neovascularization (CNV) (58 Type I, 2 Type II, 6 mixed Type I and II, 3 retinal angiomatous proliferation, and 11 age-related macular degeneration-related polyps). The data obtained from traditional multimodal imaging, based on fluorescein angiography, indocyanine green angiography, and OCT were used to assess the need for treatment, those obtained from OCTA to identify two different patterns of CNV. Traditional multimodal imaging and OCTA findings were then compared with evaluate possible correspondence between treatment decision and CNV aspect on OCTA.

RESULTS

A CNV lesion was identified as Group A (requiring treatment) in 58 eyes (72.5%) in traditional multimodal imaging. On OCTA in 59 eyes (73.7%), the lesion was defined as Pattern I and the remaining 21 (26.3%) as Pattern II. There was 94.9% correspondence between the Pattern I CNV on OCTA and the cases Group A on conventional multimodal imaging. It was also computed 90.5% correspondence between Pattern II CNV on OCTA and the Group B (not requiring treatment) cases on conventional multimodal imaging. There was high (P < 0.05) interobserver agreement both for treatment decision in conventional multimodal and for Patterns (I or II) defining on OCTA imaging analysis.

CONCLUSION

This study demonstrates a high level of correspondence, in patients with exudative age-related macular degeneration, between different CNV patterns identified on OCTA and treatment decisions established on conventional multimodal imaging. Although fluorescein angiography remains the gold standard for determining the presence of leakage, and OCT shows fluid accumulation and its variations, OCTA may now offer noninvasive monitoring of the CNV, aiding for each treatment decision during the follow-up.

Ellipsoid zone on optical coherence tomography: a review

Emergence of the high-resolution optical coherence tomography has allowed better delineation of retinal layers, and many of the anatomical correlations of these layers have now been agreed upon. However, some anatomical correlates still remain contentious, such as the second hyper-reflective band, which is now termed ellipsoid zone. Despite the lack of consensus of the actual origin of the ellipsoid zone, there has been much interest in evaluating its integrity and intensity in different disease processes. This review paper aims to provide an overview of the ellipsoid zone and its clinical and research applications.

Changes in morphology and visual function over time in mouse models of retinal degeneration: an SD-OCT, histology, and electroretinography study

PURPOSE

To examine the long-term natural course of retinal degeneration in rd10 and rd12 mice using serial spectral-domain optical coherence tomography (SD-OCT), electroretinography/electroretinograms (ERGs), and histological analysis.

METHODS

Photoreceptor layer thickness and the ability to visualize photoreceptor ellipsoid zones were analyzed using SD-OCT images, and these images were compared with hematoxylin and eosin-stained sections and electron microscopy images. The a- and b-wave amplitudes of the ERGs were analyzed.

RESULTS

In rd10 mice, the photoreceptor layer thickness rapidly decreased, and the photoreceptor ellipsoid zone was visible on SD-OCT images in 89 and 43 % of eyes of 21 and 33-day-old mice, respectively. In rd12 mice, the photoreceptor layer gradually thinned, and the ellipsoid zone remained visible in 92 % of eyes at 19 months. Electron microscopy revealed that photoreceptor degeneration had occurred on the inner side of the outer nuclear layer in 21-day-old rd10 and 7-month-old rd12 mice, possibly due to autophagy mechanisms. Scotopic ERGs of rd10 mice showed a diminished response at 21 days; at 33 days, no response was detectable. In rd12 mice, scotopic ERGs were undetectable at 28 days (stimulus intensity 3.0 cds/m(2)). Photopic ERGs were nearly undetectable in 28-day-old rd10 mice, but a small b-wave was still recordable in 13-month-old rd12 mice.

CONCLUSIONS

Our results demonstrate that visual function deteriorated with photoreceptor degeneration within 1 month in rd10 mice. In rd12 mice, however, the process of visual function deterioration and photoreceptor degeneration was still in progress at 13 months of age.

Functional Visual Acuity in Age-Related Macular Degeneration

PURPOSE

We evaluated whether a functional visual acuity (FVA) system can detect subtle changes in central visual acuity that reflect pathological findings associated with age-related macular degeneration (AMD).

METHODS

Twenty-eight patients with unilateral AMD and logMAR monocular best corrected VA better than 0 in both eyes, as measured by conventional chart examination, were analyzed between November 2012 and April 2013. After measuring conventional VA, FVA, and contrast VA with best correction, routine eye examinations including spectral domain-optical coherence tomography were performed. Standard Schirmer test was performed, and corneal and lens densities were measured.

RESULTS

The FVA score (p < 0.001) and visual maintenance ratio (p < 0.001) measured by the FVA system, contrast VA (p < 0. 01), and conventional VA (p < 0.01) were significantly worse in the AMD-affected eyes than in the fellow eyes. No significant differences were observed in the anterior segment conditions. Forward stepwise regression analysis demonstrated that the length of interdigitation zone disruption, as visualized by optical coherence tomography imaging, correlated with the FVA score (p < 0.01) but not with any other parameters investigated.

CONCLUSIONS

The FVA system detects subtle changes in best corrected VA in AMD-affected eyes and reflects interdigitation zone disruption, an anatomical change in the retina recorded by optical coherence tomography. Further studies are required to understand the value of the FVA system in detecting subtle changes in AMD.

Correlation between foveal interdigitation zone band defect and visual acuity after surgery for macular pseudohole

PURPOSE

To determine the correlation between the integrity of the foveal microstructures and the best-corrected visual acuity (BCVA) after pars plana vitrectomy for a macular pseudohole.

METHODS

Thirty-one eyes of 31 patients with a macular pseudohole underwent vitrectomy with internal limiting membrane removal. The foveal area was examined by spectral domain optical coherence tomography preoperatively and postoperatively. The correlations between the BCVA and the lengths of the photoreceptor interdigitation zone (IZ), the ellipsoid zone, and the external limiting membrane band defects, and central foveal thickness were determined.

RESULTS

The BCVA improved significantly and the length of the IZ band defect decreased significantly after the surgery. Simple linear regression analyses showed that the BCVA was significantly correlated with the length of the IZ band defect preoperatively and also at 1 to 12 months postoperatively (P < 0.001 for all). The BCVA was not significantly correlated with the length of the ellipsoid zone, external limiting membrane band defect, and the central foveal thickness.

CONCLUSION

The significant correlation between the length of the foveal IZ band defect and the BCVA preoperatively and postoperatively indicates that the foveal IZ band is related to the visual recovery in patients with macular pseudohole.

SLO-Microperimetry in Wet Age-Related Macular Degeneration During Anti-VEGF Therapy

BACKGROUND AND OBJECTIVE

To evaluate the morphological and functional outcome of wet age-related macular degeneration (AMD) during antivascular endothelial growth factor therapy with bevacizumab using SLO microperimetry (SLO-MP) with eye tracking.

PATIENTS AND METHODS

First, reproducibility was tested over the choroidal neovascularization (CNV) in 21 eyes of 19 patients with wet AMD. Second, 21 eyes of 19 patients with active CNV were studied longitudinally during bevacizumab therapy. Best-corrected visual acuity, SLO-MP, spectral-domain optical coherence tomography and fluorescein angiography were performed.

RESULTS

There was good reproducibility with a concordance correlation coefficient of 0.85. In the longitudinal study, eyes with anatomical response demonstrated a significant increase of retinal sensitivity. Non-responders showed no change in SLO-MP. Retinal sensitivity at baseline had a significant predictive value for the change in retinal sensitivity during therapy with bevacizumab (P=.032).

CONCLUSION

SLO-MP is able to analyze retinal function overlying lesions in wet AMD and can be a useful tool to monitor therapy in patients with macular diseases.

Outer retinal tubulations response to anti-VEGF treatment

AIM

To review the longitudinal changes of outer retinal tubulations (ORTs) in wet age-related macular degeneration (AMD) and their response to anti-vascular endothelial growth factor (VEGF) therapy by spectral-domain optical coherence tomography (SD-OCT), and to correlate these observations with disease activity, presence or absence of fluid, and patients' demographics.

METHODS

Retrospective study of wet AMD eyes treated with anti-VEGF agents and showing ORTs on SD-OCT, and the patients' fellow eye with wet AMD but without ORTs.

RESULTS

Fifty-one wet AMD eyes from 31 patients diagnosed and treated for wet AMD were included in the review and analysis of data; 33 eyes showed ORTs at baseline, while 18 fellow eyes had no ORTs. During a median follow-up treatment period of 11 months, 23 eyes had stable ORTs and 10 eyes had ORT changes. Among the 10 eyes with ORTs changes, ORTs collapsed during anti-VEGF treatment in 5 eyes but then reappeared within 12 months after stopping treatment. In two eyes, ORTs increased in size during anti-VEGF treatment, while in two other eyes ORTs collapsed without any treatment. In a single eye, ORTs collapsed within 10 months of no treatment and did not reappear upon recurrence of fluid. Eyes with ORTs tended to have lower visual acuity than eyes with no ORTs due to greater disruption of the external limiting membrane in the fovea.

CONCLUSIONS

ORTs documented by SD-OCT may exhibit multiple types of longitudinal changes, such as collapse, recurrence or enlargement, which could be associated with anti-VEGF treatment or spontaneous. Some ORTs may have a vascular component or may be vascular in nature, considering their response to anti-VEGF treatment, while other ORTs are likely composed only of degenerating photoreceptor cells and may collapse independently from anti-VEGF treatments.

Spectral domain ocular coherence tomography findings pre- and post vitrectomy with fibrovascular membrane delamination for proliferative diabetic retinopathy

PurposeTo describe the intraretinal microstructure using serial spectral domain optical coherence tomography (SD-OCT) preceding and following pars plana vitrectomy and delamination of fibrovascular membranes in patients with proliferative diabetic retinopathy (PDR).MethodsThis retrospective, interventional case series includes 28 eyes. Outcome measures included LogMAR distance best-corrected visual acuity (BCVA), SD-OCT integrity of photoreceptor inner and outer segments junction (IS/OS), and integrity of external limiting membrane (ELM).ResultsPre-operative central macular thickness (CMT) was significantly correlated with the final post-operative LogMAR BCVA (Pearson's coefficient r=0.89; P=0.001). The eyes were categorised into three groups based on post-operative IS/OS integrity (group 0: IS/OS intact; group 1: IS/OS irregular but not completely disrupted; group 2: IS/OS completely disrupted). Mean BCVA improved significantly in group 0 (n=9) from 1.13±0.75 preoperatively to 0.34±0.21 (Student's t-test: P=0.06), in group 1 (n=10) the BCVA improved from 0.88±0.56 to 0.58±0.31 (Student's t-test: P=0.053) and in group 2 (n=9) the BCVA improved from 1.64±0.53 to 1.53±0.75 (Student's t-test: P=0.652).IS/OS integrity and ELM integrity at 3 months post operatively, were significantly and positively correlated with final BCVA (Pearson's coefficient: r=0.83, P<0.001 and r=0.72, P<0.001, respectively).ConclusionsPre-operative CMT and post-operative disruption of the IS/OS and ELM are useful prognostic indicators in fibrovascular delamination surgery for patients with PDR.

Volumetric ellipsoid zone mapping for enhanced visualisation of outer retinal integrity with optical coherence tomography

Objective assessment of retinal layer integrity with optical coherence tomography (OCT) is currently limited. The ellipsoid zone (EZ) has been identified as an important feature on OCT that has critical prognostic value in macular disorders. In this report, we describe a novel assessment tool for EZ integrity that provides visual and quantitative assessment across an OCT data set. Using this algorithm, we describe the findings in multiple clinical examples, including normal controls, age-related macular degeneration, drug effects (eg, ocriplasmin, hydroxychloroquine) and effects of surgical manipulation (eg, following membrane peeling using intraoperative OCT). EZ mapping provides both en face visualisation of EZ integrity and EZ-retinal pigment epithelium height. Additionally, volumetric, area and linear measurements are feasible using this assessment tool.

Optical Coherence Tomographic Features and Visual Prognosis after Treatment for Idiopathic Choroidal Neovascularization

BACKGROUND

The aim of this study was to determine whether pretreatment spectral-domain optical coherence tomographic (SD-OCT) features are associated with visual prognosis after treatment for idiopathic subfoveal choroidal neovascularization (ISCNV) with intravitreal ranibizumab.

METHODS

We retrospectively evaluated SD-OCT images of eyes with ISCNV undergoing treatment with intravitreal ranibizumab with a mean follow-up of 7 months.

RESULTS

This study included 22 patients (22 eyes) with a mean age of 32.7 ± 8.1 years. In univariate analysis, better final visual acuity expressed in logMAR units was significantly associated with a lower amount of pretreatment ellipsoid zone defects (p = 0.03; standardized correlation coefficient β = 0.46) and a lower amount of pretreatment external limiting membrane (ELM) damage (p = 0.007; β = 0.56). All other SD-OCT parameters were not significantly associated with final visual acuity. A higher improvement in visual acuity was marginally significantly associated with larger pretreatment ellipsoid zone defects (p = 0.049; β = -0.43).

CONCLUSIONS

The integrity of the outer retinal layers at baseline, in particular of the ELM, is of importance in predicting the final visual outcome in patients undergoing intravitreal medical therapy for ISCNV.

Correlation of structure and function of the macula in patients with retinitis pigmentosa

PURPOSE

To correlate the structure of the macula, as measured by spectral-domain optical coherence tomography (SD-OCT) and function, as measured by microperimetry (MAIA) in patients with retinitis pigmentosa (RP) and relatively good visual acuity.

DESIGN

Prospective, cross-sectional, non-intervention study.

SUBJECTS

Patients with RP.

METHODS

Thirty patients with RP and good central visual acuity were identified. Each patient underwent SD-OCT of the macula and microperimetry. The images were overlaid using the custom-designed software. The retinal sensitivity by microperimetry was correlated with corresponding retinal thickness, as measured by the SD-OCT. ELM, COST, and IS/OS junction were scored as intact, disrupted, or absent.

MAIN OUTCOME MEASURES

Comparing the retinal sensitivity on the MAIA with various measurements on the SD-OCT.

RESULTS

The retinal sensitivity on the MAIA showed a significant correlation with total retinal thickness and outer retinal thickness on the SD-OCT. There was no association with either the inner retinal thickness or the choroidal thickness. ORT showed a statistically significant correlation with the anatomical classification of ELM (r=-0.76, P<0.001), IS/OS (r=-0.800, P<0.001), and COST (r=-0.733, P<0.001).

CONCLUSION

This study determined that there was a high correlation of the structure and function of the central macula in patients with RP. These studies are important to establish surrogate markers that can be used as end points for various tests in future therapeutic clinical trials.

One-year result of aflibercept treatment on age-related macular degeneration and predictive factors for visual outcome

PURPOSE

To investigate the efficacy of periodic injection of aflibercept in each subtype of age-related macular degeneration (AMD) and to explore the predictive factors for visual outcome in clinical settings.

DESIGN

Prospective nonrandomized interventional case series.

METHODS

Patients with AMD were recruited and were administered aflibercept injections once a month for 3 months followed by once every 2 months for 8 months. The logarithm of the minimal angle of resolution (logMAR) at 12 months and improvement of vision from baseline were compared among polypoidal choroidal vasculopathy (PCV), retinal angiomatous proliferation (RAP), and typical AMD. Regression rate of polypoidal lesions was assessed. We also performed regression analysis with logMAR at 12 months as the dependent variable.

RESULTS

The study sample consisted of 98 patients: 46 had typical AMD, 42 had PCV, and 10 had RAP. Mean logMAR improved from 0.36 to 0.21 in 12 months. While there was no difference in visual improvement between typical AMD and PCV, final logMAR was better in PCV (0.32 ± 0.09 vs 0.08 ± 0.04, P = .016). Thirty-nine PCV patients underwent follow-up angiography, and regression of polyps was observed in 27 cases (69.2%). Multiple regression analysis showed that the presence of external limiting membrane (ELM), smaller greatest linear dimension, and the presence of polypoidal lesion were associated with better visual outcome (R(2) = 0.53, P = 2.73 × 10(-14)).

CONCLUSIONS

Periodic injection of aflibercept is effective for PCV as well as for typical AMD. The statuses of ELM, greatest linear dimension, and polypoidal lesion are predictive for visual outcome.

Predictive factors for postoperative visual acuity in idiopathic epiretinal membrane: a systematic review

The aim of this study was to review the literature on predictive factors for postoperative visual acuity (VA) in surgery for idiopathic epiretinal membrane (ERM). A systematic review of the literature in the databases of PubMed and Embase was performed. The risk of bias was assessed based on predefined criteria and the results were summarized. In total, 1927 studies were retrieved of which 35 were potentially eligible. Nineteen studies were of adequate quality in terms of bias. Preoperative VA, central foveal thickness (CFT) and inner segment/outer segment (IS/OS) integrity on optical coherence tomography (OCT) were most extensively studied. Other preoperative factors studied were severity of metamorphopsia, several OCT parameters, fundus autofluorescence and multifocal electroretinogram. In the current literature, preoperative VA is the only variable consistently associated with postoperative VA. IS/OS integrity on OCT is probably associated, and the severity of metamorphopsia, cone outer segment tips integrity and fundus autofluorescence are possibly associated with postoperative VA. CFT is not associated with postoperative VA. Further studies with adequate methodological quality are needed to confirm these findings. Therefore, an overall prediction model, including different parameters, is still awaited.

Association between microperimetric parameters and optical coherent tomographic findings in various macular diseases

Purpose

To analyze the correlation between microperimetric parameters and optical coherent tomographic findings in the eyes of patients with macular diseases.

Methods

A total of 64 eyes were included in this retrospective cross-sectional study. Differences in the macular integrity index and microperimetric parameters were analyzed according to types of outer retinal band defects. Correlations between average threshold values and retinal thickness in the corresponding areas were analyzed. Finally, microperimetric parameters were compared between inner and outer retinal lesions.

Results

Measures of best-corrected visual acuity, macular integrity index, and average threshold values were significantly worse in eyes with defects in the ellipsoid portion of the photoreceptor inner segment (ISe), the cone outer segment tip (COST), and the external limiting membrane (ELM) than in eyes without ISe, COST, and ELM defects. Also, visual functionality is more significantly impacted by ELM defects than by other hyper-reflective band defects. There was a significant negative correlation between retinal thickness and the average threshold of the corresponding area in the Early Treatment Diabetic Retinopathy Study grid. Microperimetric parameters in the eyes of patients with inner retinal lesions were better than in the eyes of patients with outer retinal lesions.

Conclusions

The macular integrity index may be a useful factor for reflecting the functional aspects of macular diseases. Specifically, ELM, ISe, and COST defects are significantly associated with poor retinal sensitivity and macular integrity index values that suggest abnormalities. Among eyes with these particular defects, the visual functionality of patients is most sensitively impacted by ELM defects. This finding suggests that microperimetric parameters are sensitive and useful for evaluating functional abnormalities in the eyes of patients with macular disease, particularly in patients with outer retinal pathology.