A Comparison Study of Polypoidal Choroidal Vasculopathy Imaged with Indocyanine Green Angiography and Swept-Source Optical Coherence Tomography Angiography

Slab-Specific Projection-Resolved Optical Coherence Tomography Angiography for Enhancing En Face Polyp Detection in Polypoidal Choroidal Vasculopathy

Purpose

A projection-resolved optical coherence tomography angiography (PR-OCTA) algorithm with slab-specific strategy was applied in polypoidal choroidal vasculopathy (PCV) to differentiate between polyp and branching vascular network (BVN) and improve polyp detection by en face OCTA.

Methods

Twenty-nine participants diagnosed with PCV by indocyanine green angiography (ICGA) and 30 participants diagnosed with typical neovascular age-related macular degeneration (nAMD) were enrolled. Polyps were classified into three categories after using the slab-specific PR algorithm. Type 1 polyps were considered in high-elevated pigment epithelial detachment (PED) and displayed in green. Type 2 polyps were considered in low-elevated PED and encoded in yellow, similar to BVN structures. Type 3 polyps were not able to be detected on OCTA. The algorithms were tested in the nAMD group to differentiate PCV and typical nAMD.

Results

With the algorithm, type 1 polyps were readily differentiated from BVN on en face OCTA. Polyp detection rate on en face OCTA only (type 1) was 68%, which was significantly improved from 30% when the algorithm was not used (P = 0.0001). To identify type 2 polyps, a combination of en face and cross-sectional OCTA images was needed and this resulted in a 91% polyp detection rate (types 1 and 2). The absence of luminal structure on OCT at the polyp site, small polyp size, and absence of halo on ICGA appeared to influence the polyp detection rate. When applying the algorithm to the nAMD group, 83% were correctly classified as typical nAMD (absence of type 1 polyps), whereas 17% showed false detection of polyps due to flow signals at the apices of large PEDs.

Conclusions

The slab-specific PR-OCTA with different color coding provides significant improvement in detecting polyp structures on en face OCTA, leading to rapid coronal visualization and diagnosis of PCV without the risk of dye injection.

Consensus and guidelines on diagnosis and management of polypoidal choroidal vasculopathy (PCV) from the Asia-Pacific Vitreo-retina Society (APVRS)

A panel of 21 international experts are formed by the Asia-Pacific Vitreo-retina Society to work out the consensus and guidelines on polypoidal choroidal vasculopathy (PCV). PCV is a common subtype of neovascular age-related macular degeneration and is more prevalent in Asian populations. Recent advancement in imaging technology allows greater understanding of the disease process of PCV. Furthermore, non-indocyanine green angiography features in optical coherence tomography angiography have been validated for PCV diagnosis and treatment response monitoring. Clinical trials provide new data on the safety and efficacy of various anti-vascular endothelial growth factor (anti-VEGF) agents as well as protocols that aim to improve the sustainability of treatments. In view of the myriads of emerging information, the panel gathered, reviewed, discussed, formulated and voted on the consensus and guidelines of PCV on four areas: 1) disease entity, 2) investigation and diagnosis, 3) treatment options, and 4) management protocol and future development in a five-point Likert scale (strongly agree, agree, neutral, disagree and strongly disagree). We proposed using a consensus score in which the maximum was 100. The summation of the respective "percentages" of experts voting for "agree" or "strongly agree" would be counted as the actual score. Consensus was achieved when the actual score of 75 or more was reached, which meant at least 75 % of the experts had voted for "strongly agree" or "agree" on the consensus statement concerned.

Rediscovering Age-Related Macular Degeneration with Swept-Source OCT Imaging: The 2022 Charles L. Schepens, MD, Lecture

PURPOSE

Swept-source OCT angiography (SS-OCTA) scans of eyes with age-related macular degeneration (AMD) were used to replace color, autofluorescence, infrared reflectance, and dye-based fundus angiographic imaging for the diagnosis and staging of AMD. Through the use of different algorithms with the SS-OCTA scans, both structural and angiographic information can be viewed and assessed using both cross sectional and en face imaging strategies.

DESIGN

Presented at the 2022 Charles L. Schepens, MD, Lecture at the American Academy of Ophthalmology Retina Subspecialty Day, Chicago, Illinois, on September 30, 2022.

PARTICIPANTS

Patients with AMD.

METHODS

Review of published literature and ongoing clinical research using SS-OCTA imaging in AMD.

MAIN OUTCOME MEASURES

Swept-source OCT angiography imaging of AMD at different stages of disease progression.

RESULTS

Volumetric SS-OCTA dense raster scans were used to diagnose and stage both exudative and nonexudative AMD. In eyes with nonexudative AMD, a single SS-OCTA scan was used to detect and measure structural features in the macula such as the area and volume of both typical soft drusen and calcified drusen, the presence and location of hyperreflective foci, the presence of reticular pseudodrusen, also known as subretinal drusenoid deposits, the thickness of the outer retinal layer, the presence and thickness of basal laminar deposits, the presence and area of persistent choroidal hypertransmission defects, and the presence of treatment-naïve nonexudative macular neovascularization. In eyes with exudative AMD, the same SS-OCTA scan pattern was used to detect and measure the presence of macular fluid, the presence and type of macular neovascularization, and the response of exudation to treatment with vascular endothelial growth factor inhibitors. In addition, the same scan pattern was used to quantitate choriocapillaris (CC) perfusion, CC thickness, choroidal thickness, and the vascularity of the choroid.

CONCLUSIONS

Compared with using several different instruments to perform multimodal imaging, a single SS-OCTA scan provides a convenient, comfortable, and comprehensive approach for obtaining qualitative and quantitative anatomic and angiographic information to monitor the onset, progression, and response to therapies in both nonexudative and exudative AMD.

FINANCIAL DISCLOSURE(S)

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

Imaging characterization of the fellow eye in patients with unilateral polypoidal choroidal vasculopathy

INTRODUCTION

New insights on polypoidal choroidal vasculopathy (PCV) have shed light regarding its pathophysiology and associations. However, PCV characterization is still incomplete in Caucasians, which is due to presumed lower prevalence in this population. Features typically associated with AMD such as drusen, retinal pigmentary changes or atrophy are seen in PCV, as precursors and in the fellow eye. Pachychoroid spectrum, predisposing to PCV, also presents with chronic changes in the retinal pigment epithelium (RPE), such as drusen-like deposits (DLD), and in the choroid. The purpose of this study is to perform a multimodal imaging characterization of unaffected fellow eyes in a sample of Caucasian patients with unilateral PCV.

METHODS

Multicenter retrospective cohort study with a sample of 55 unaffected fellow eyes from patients diagnosed with unilateral PCV confirmed by indocyanine green angiography. The sample was characterized in the baseline by color fundus photography, spectral domain optical coherence tomography (SD-OCT), fluorescein angiography and indocyanine green angiography. Morphological characteristics of both the retina and the choroid were evaluated. The SD-OCT of the last follow-up visit was also evaluated in order to exclude evolution to PCV or choroidal neovascularization. All images captured underwent evaluation by two independent graders. Informed consent was obtained from all participants.

RESULTS

Fifty-five patients (median age, 74 ± 15 years) were included. After 15.5 ± 6.4 months of follow-up, only one developed disease (1.9%). Soft and/or hard drusen were present in 60% and pachydrusen in 23.6%. Pachychoroid signs were present in 47.2%, the double-layer sign in 36.4%, disruption of the RPE changes in 16.4% and RPE atrophy in 10.9%. ICGA revealed choroidal vascular dilation in 63.6% and punctiform hyperfluorescence in 52.7%. Branching vascular networks were identified in only 1.9% of cases.

CONCLUSION

The identification of pachychoroid signs in the OCT and ICGA were present in over half of the cases and the presence of the double-layer sign in more than a third provide crucial insights for enhanced characterization of this pathology and deeper understanding of its pathogenesis. These findings contribute significantly to the current knowledge, offering valuable markers to discern various phases of the pathology's progression.

Diagnosing Polypoidal Choroidal Vasculopathy Using Color Fundus Photography, Optical Coherence Tomography, and Optical Coherence Tomography Angiography

PURPOSE

To compare the diagnostic accuracy of differentiating polypoidal choroidal vasculopathy (PCV) from exudative age-related macular degeneration (AMD), using color fundus photography (CFP), optical coherence tomography (OCT), and swept-source OCT angiography (SS-OCTA) without using indocyanine green angiography (ICGA).

METHODS

Treatment-naive eyes with exudative AMD that underwent CFP, OCT, SS-OCTA, and ICGA imaging before treatment were identified. Images of each patient were categorized into two sets (set A, CFP + OCT; set B, CFP + SS-OCTA). In set B, both the en face and cross-sectional B scans were analyzed. Each set was reviewed by two graders, and it was determined whether the presumed diagnosis was PCV. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) for the diagnosis of PCV were assessed for each set by comparing diagnoses that included ICGA. The number of polypoidal lesions in each set was calculated and compared to ICGA.

RESULTS

A total of 94 eyes from 94 patients with AMD were included in the study, of which 66.0% were male, and the mean age was 71.8 ± 9.0 years. The PCV diagnosis rate using ICGA was 45.7%. The sensitivity was 0.88 for set A and 0.93 for set B, while the specificity was 0.94 for set A and 0.96 for set B. The AUC was 0.90 (95% confidence interval [CI], 0.83-0.97) for set A and 0.96 (95% CI, 0.90-1.00) for set B. Set A detected 1.28 ± 0.91 polypoidal lesions, while set B detected 1.47 ± 1.01; ICGA showed 1.51 ± 0.86.

CONCLUSIONS

This study highlights that, without using ICGA, both CFP combined with OCT and CFP combined with SS-OCTA demonstrate high sensitivity, specificity, and AUC in diagnosing PCV. It is evident that SS-OCTA contributes to enhancing sensitivity, specificity, and AUC for PCV diagnosis.

Advances in multi-modal non-invasive imaging techniques in the diagnosis and treatment of polypoidal choroidal vasculopathy

Polypoidal choroidal vasculopathy (PCV) is a disease characterized by subretinal pigment epithelium (RPE) orange-red polypoidal lesions and abnormal branching neovascular networks (BNNs). In recent years, various non-invasive imaging technologies have rapidly developed, especially the emergence of optical coherence tomography angiography (OCTA), multi-spectral imaging, and other technologies, which enable the observation of more features of PCV. In addition, these technologies are faster and less invasive compared to indocyanine green angiography (ICGA). Multi-modal imaging, which combined multiple imaging techniques, provides important references for the diagnosis and treatment of PCV with the assistance of regression models, deep learning, and other algorithms. In this study, we reviewed the non-invasive imaging techniques, multi-modal imaging diagnosis, and multi-scene therapeutic applications of PCV, with the aim of providing a reference for non-invasive multi-modal diagnosis and treatment of PCV.

Recent Advances in Imaging Polypoidal Choroidal Vasculopathy with Swept-Source Optical Coherence Tomography Angiography

The gold standard for polypoidal choroidal vasculopathy (PCV) diagnosis is indocyanine green angiography (ICGA), but optical coherence tomography angiography (OCTA) has shown promise for PCV imaging in recent years. However, earlier generations of OCTA technology lacked the diagnostic efficacy to replace ICGA. Swept-source optical coherence tomography angiography (SS-OCTA), the latest generation of OCTA technology, has significantly improved penetrating ability, scanning speed, scanning range, and overall image quality compared with earlier generations of OCTA. SS-OCTA reveals a "tangled vasculature" pattern of polypoidal lesions (PLs), providing evidence that they are neovascular rather than aneurysmal structures. New choroidal biomarkers, such as the choriocapillaris flow void (FV), have been identified to explain the development of PCV lesions. Although no direct comparison between SS-OCTA and previous OCTA generations in terms of diagnostic capability has been performed, SS-OCTA has shown several advantages in differential diagnosis and monitoring early reactivation for PCV. These improvements make SS-OCTA a valuable tool for PCV diagnosis and follow-up, and it may become more important for this disease in the future. This review summarized recent advances in PCV morphology and structure, as well as the possible pathogenesis based on SS-OCTA findings. The value of SS-OCTA for PCV management is discussed, along with remaining issues, to provide an updated understanding of PCV and OCTA-guided management.

Optical Coherence Tomography Angiography Characteristics of Polypoidal Lesions in Caucasians

Purpose

The aim of the study is to analyze the swept source-optical coherence tomography angiography (SS-OCTA) characteristics of polypoidal lesions in Caucasian patients.

Methods

In this retrospective observational case series, 43 polypoidal lesions in 32 eyes of 32 patients were diagnosed using indocyanine green angiography (ICGA) and compared to SS-OCTA at a tertiary medical retina center (Clinic Landstraße, Vienna Healthcare Group, Austria) between June 2017 and March 2020. Vascularity was identified by color-coded B-scan SS-OCTA while morphology was described as revealed by en face SS-OCTA after alignment with ICGA-confirmed findings.

Results

In total, SS-OCTA detected all polypoidal lesions, as identified by ICGA. On B-scan SS-OCTA, circumscribed flow was detected in 33 (76.7%) polypoidal lesions and diffuse flow in 10 (23.3%) lesions. On en face SS-OCTA, polypoidal lesions appeared morphologically as 19 tangled vessel balls (44.2%), 6 tangled vessel balls next to dilated vessels (13.9%), 8 vascular dilatations (18.6%), and 8 ill-defined vascular networks (18.6%), leaving 2 lesions (4.6%) undetected. Circumscribed flow was significantly associated with tangled vessel balls (p = 0.005).

Conclusion

This study highlights the importance of a multimodal imaging approach, including SS-OCTA, for the evaluation of polypoidal lesions. Our findings suggest a morphological heterogeneity of vascular patterns in Caucasian patients with polypoidal lesions, as pictured by SS-OCTA.

Advances in swept-source optical coherence tomography and optical coherence tomography angiography

Background

The fast development of swept-source optical coherence tomography (SS-OCT) and swept-source optical coherence tomography angiography (SS-OCTA) enables both anterior and posterior imaging of the eye. These techniques have evolved from a research tool to an essential clinical imaging modality.

Main text

The longer wavelength and faster speed of SS-OCT and SS-OCTA facilitate better visualization of structure and vasculature below pigmented tissue with a larger field of view of the posterior segment and 360-degree visualization of the anterior segment. In the past 10 years, algorithms dealing with OCT and OCTA data also vastly improved the image quality and enabled the automated quantification of OCT- and OCTA-derived metrics. This technology has enriched our current understanding of healthy and diseased eyes. Even though the high cost of the systems currently limited the widespread use of SS-OCT and SS-OCTA at the first beginning, the gap between research and clinic practice got obviously shortened in the past few years.

Conclusions

SS-OCT and SS-OCTA will continue to evolve rapidly, contributing to a paradigm shift toward more widespread adoption of new imaging technology in clinical practice.

Longitudinal Choriocapillaris Vascular Density Changes in Different Types of Primary Open-Angle Glaucoma

Purpose

To evaluate longitudinal changes in choriocapillaris perfusion in patients with glaucoma with four phenotypes of optic disc damage and to explore associated factors with decreased choriocapillaris vessel density (CVD).

Methods

This prospective longitudinal study included 96 eyes of 96 patients with primary open-angle glaucoma (POAG). Patients with POAG was differentiated into the optic disc phenotypes of focal ischemic type (FI), myopic type (MY), senile sclerotic type (SS), and generalized enlargement type (GE). Patients were followed up every three months. Simple linear regression was used to investigate the factors associated with a reduction in CVD.

Results

The median follow-up time was 2.5 years (range, 2.0-3.0 years). Choriocapillaris perfusion tended to decrease over time, with CVD decreasing significantly faster in the FI type than in the other three types (P < 0.001). The percentage decrease in the FI type was 7.85%, 10.89%, and 8.88% faster than MY, SS and GE, respectively, after correcting for age, gender, axial length, intraocular pressure, mean deviation, retinal nerve fiber layer (RNFL), and image quality score. In multivariate regression, decreased CVD was independently associated with the rate of RNFL thinning.

Conclusions

FI type had the fastest rate of CVD decline in the four phenotypes of optic disc damage, and decreased CVD was positively correlated with the rate of RNFL thinning.

Translational Relevance

The role of the choriocapillaris in the pathogenesis and therapeutic potential of glaucoma require further attention to facilitate better management of glaucoma patients.

Different Morphology of Branching Neovascular Network in Polypoidal Choroidal Vasculopathy: A Swept-Source Optical Coherence Tomography Angiography Study

Purpose: To evaluate the classification system of branching neovascular network (BNN) morphology in polypoidal choroidal vasculopathy (PCV) patients based on swept-source optical coherence tomography (SS-OCT) and swept-source optical coherence tomography angiography (SS-OCTA), and analyze the morphological features in each group as potential prognostic features. Methods: A total of 32 PCV eyes were included in this retrospective study. SS-OCT and SS-OCTA images of 6 mm × 6 mm centered on the foveal of each eye were analyzed. PCV cases were classified into three types ("trunk", "glomeruli", and "stick" type) based on the morphological features of BNN. OCT and OCTA features were compared among the three groups. The correlation of OCT/OCTA features with visual acuity at 12 months after anti-VEGF treatment was also analyzed. Results: Type 1 group had the largest BNN area and the largest numbers of polypoidal lesions. Type 2 group has the largest pigment epithelial detachment (PED) area, PED volume, subretinal fluid (SRF) area, and SRF volume. Type 3 group had better baseline BCVA, the smallest BNN area, the smallest PED size, and the smallest SRF size. Type 1 was also featured by a clear break on Bruch's membrane which corresponded to the origin of neovascular tissue. BCVA at 12 months was not significantly different among groups. Baseline BCVA and baseline central macular thickness were correlated with the final BCVA. Conclusions: The current classification system based on BNN morphology on SS-OCTA was highly applicable and revealed distinct characteristics in each group. The BNN type was not correlated with BCVA at 12 months after treatment.

Detection of pachychoroid neovasculopathy with optical coherence tomography angiography versus dye angiography imaging

BACKGROUND

To investigate the sensitivity and specificity of optical coherence tomography angiography (OCTA) versus dye angiography for detecting pachychoroid neovasculopathy (PNV) and to determine the morphological factors that affect PNV detection.

METHODS

Patients with pachychoroid phenotype were prospectively enrolled and underwent multimodal imaging examinations during the same visit. The diagnostic accuracy of fundus fluorescein angiography (FFA), FFA combined with indocyanine green angiography (ICGA) and OCTA for PNV was evaluated using multimodal imaging as the reference. Multimodal parameters of PNV were qualitatively and quantitatively assessed.

RESULTS

PNV was detected in 58 eyes (46 patients) out of 340 pachychoroid eyes (201 patients) according to reference standard. Patients with PNV eyes were significantly older (54.6±7.56 vs. 48.2±9.1 years), were more likely to have a chronic central serous chorioretinopathy history (CSC) (93.1% vs. 12.4%) and had a worse visual acuity (0.30±0.22 vs. 0.58±0.30) than those without PNV eyes (all P<0.001). The sensitivity of FFA, FFA combined with ICGA, and OCTA in detecting PNV in patients with the pachychoroid phenotype was 67.2%, 63.8% and 98.3%, respectively, and the specificity was 87.2%, 96.8% and 100.0%, respectively. PNV not identified by dye angiography was more manifested as the absence of late plaque hypercyanescence on ICGA (P<0.001) and overall smaller capillaries without a distinct pattern (P=0.001), fewer core vessels (P=0.002) and smaller area (P=0.044).

CONCLUSIONS

OCTA showed superior detection rate and accuracy for identifying PNV over dye angiography. In case multimodal imaging is unavailable, OCTA can be an effective and noninvasive method for monitoring PNV and guiding treatment decisions.

Axial Length and Choriocapillaris Flow Deficits in Non-pathological High Myopia

PURPOSE

To examine the relationship between axial length (AL) and choriocapillaris (CC) flow deficits percentage (FD%) in non-pathological highly myopic eyes.

DESIGN

Prospective cross-sectional study.

METHODS

This study included Chinese patients with non-pathological high myopia, which was defined by an AL of > 26 mm and a META-PM classification grade of <2. Swept-source optical coherence tomography angiography was used to obtain 6 × 6 mm images of the macular CC. The CC FD% was measured in the fovea, parafovea, and perifovea subfields.

RESULTS

A total of 1017 individuals (1017 eyes) with a mean age of 35.95 ± 14.11 years were included. After adjusting for age, sex, intraocular pressure, body mass index, systolic blood pressure, and image quality score, the overall CC FD% increased by 0.27% (95% CI 0.02, 0.52; P = .034) for each mm increase in AL. Among subfields, longer AL was associated with a higher CC FD% in the perifovea (β = 0.53, 95% CI 0.30, 0.77; P < .001), and was not associated with a higher CC FD% in the parafovea (β = 0.08, 95% CI -0.26, 0.42; P = .652) and fovea (β = 0.001, 95% CI -0.50, 0.50; P = .999).

CONCLUSIONS

The CC FD% increased with a longer AL in high myopia in the perifovea region but not in the fovea and parafovea fields. These findings may be of interest in elucidating the etiology of myopic axial elongation.

Investigating the macular choriocapillaris in early primary open-angle glaucoma using swept-source optical coherence tomography angiography

Introduction

There has been a growing interest in the role of vascular factors in glaucoma. Studies have looked at the characteristics of macular choriocapillaris in patients with glaucoma but with conflicting results. Our study aims to use swept-source optical coherence tomography angiography (SS-OCTA) to evaluate macular choriocapillaris metrics in normal participants and compare them with patients with early primary open-angle glaucoma (POAG) (mean deviation better than −6dB).

Methods

In this prospective, observational, cross-sectional study, 104 normal controls (157 eyes) and 100 patients with POAG (144 eyes) underwent 3 mm × 3mm imaging of the macula using the Plex Elite 9000 (Zeiss Meditec, Dublin, CA, USA). Choriocapillaris OCTA images were extracted from the device’s built-in review software and were subsequently evaluated for the density and size of choriocapillaris flow deficits.

Results

After adjusting for confounding factors, the density of flow deficits was independently higher in those aged 53 years and above (P ≤ 0.024) whereas the average flow deficit size was significantly larger in those aged 69 years and above (95% CI = 12.39 to 72.91; P = 0.006) in both normal and POAG patients. There were no significant differences in the density of flow deficits (P = 0.453) and average flow deficit size (P = 0.637) between normal and POAG participants.

Conclusion

Our study found that macular choriocapillaris microvasculature on SS-OCTA is unaltered by subjects with POAG. This suggests that OCTA macular choriocapillaris may not be potentially helpful in differentiating early glaucoma from healthy eyes.

Updated guidelines for the management of polypoidal choroidal vasculopathy: Recommendations from the Indian Polypoidal Choroidal Vasculopathy Panel and the Vitreoretinal Society of India

In Asians, polypoidal choroidal vasculopathy (PCV) is becoming more widely recognized as a significant cause of exudative maculopathy. The previous set of Indian guidelines on the management of PCV were published in 2018, with a literature search updated up to November 2015. As the treatment of PCV evolves, retinal physicians must constantly modify their current practice. The current guidelines are based on the most up-to-date information on PCV and are an update to the previous set of guidelines. These guidelines were developed by a panel of Indian retinal experts under the aegis of the Vitreoretinal Society of India (VRSI), based on a comprehensive search and assessment of literature up to September 2021. The final guidelines i) provide the updated nomenclature in PCV; ii) discusses the newer diagnostic imaging features of PCV, especially in the absence of indocyanine green angiography (ICGA); and iii) recommends the best possible therapeutic approach in the management of PCV, including the choice of anti-vascular endothelial growth factor (anti-VEGF) agents, treatment regimen, and the role of switching between the anti-VEGF agents. In the face of non-availability of photodynamic therapy (PDT) in India, we constructed practical recommendations on anti-VEGF monotherapy in PCV. The current updated recommendations would provide a broader framework to the treating retinal physician for the diagnosis and management of PCV for optimal therapeutic outcomes.

ASSOCIATION OF FLOW SIGNALS WITHIN POLYPS ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY WITH TREATMENT RESPONSES AFTER COMBINATION THERAPY FOR POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To evaluate the changes of blood circulation within the polypoidal lesions by OCT angiography in eyes with polypoidal choroidal vasculopathy after combination therapy with aflibercept and photodynamic therapy.

METHODS

A total of 46 eyes from 46 patients who underwent the combination therapy for polypoidal choroidal vasculopathy were followed for more than 6 months. OCT angiography, covering an area 6 mm2 × 6 mm2 including the macula, were performed at baseline, 2 weeks, and 3 months and 6 months post-treatment.

RESULTS

The subretinal fluid resolved within 3 months after treatment in 44 eyes (95.7%), and 27 eyes (58.7%) showed no recurrence, with no additional treatment. Seventeen eyes (37.0%) showed recurrence, and two eyes (4.3%) showed poor response. On OCT angiography at 2 weeks after treatment, flow signals were detected in 3 of 27 eyes (11.1%) without recurrence and in 8 of 19 eyes (42.1%) with recurrence or poor responses. A detectable flow signal at 2 weeks was significantly associated with recurrence or poor response (P = 0.032).

CONCLUSION

Persistent flow signals within polyps on OCT angiography at 2 weeks after combination therapy suggest less effectiveness of the initial treatment.

Choriocapillaris Flow Deficits in Normal Chinese Imaged by Swept-Source Optical Coherence Tomographic Angiography

PURPOSE

To evaluate the ocular and systemic determinants of the choriocapillaris flow deficits percentage (CC FD%) in normal eyes.

DESIGN

Observational cross-sectional study.

METHODS

Healthy Chinese participants without ocular or systemic diseases underwent detailed ophthalmic evaluations, including swept-source optical coherence tomography angiography (SS-OCTA) with 6- × 6-mm macular choriocapillaris images. The CC FD% was assessed in circular regions with diameters of 1.0 and 5.0 mm, rings with 1.0- to 2.5-mm diameters, and rings with 2.5- to 5.0-mm diameters.

RESULTS

The study included 830 individuals (mean ± SD age 58.66 ± 8.75 years). CC FD% (mean ± SD 22.05% ± 1.13%) was the lowest in the 2.5- to 5.0-mm ring, followed by the 1.0- to 2.5-mm ring, and highest in the 1.0-mm circle. In multivariable analysis, a higher CC FD% was associated with older age (β = 0.16 [95% confidence interval {CI}] 0.08-0.24, P < .001), higher intraocular pressure (β = 0.34 [95% CI 0.25-0.42], P < .001), higher serum concentrations of high-density lipoprotein cholesterol (β = 0.24 [95% CI 0.17-0.32], P < .001), and lower image quality score (β = -0.22 [95% CI -0.30 to -0.14], P < .001). CC FD% was also independent of axial length.

CONCLUSIONS

In healthy adult Chinese individuals, a higher CC FD% was associated with older age, higher intraocular pressure, and higher high-density lipoprotein cholesterol serum concentration. These factors may influence clinical assessments of the choriocapillaris. The lack of an association between CC FD% and axial length is consistent with similar findings for Bruch membrane thickness, macular retinal thickness, and macular retinal pigment epithelium cell density.

Short-Term Efficacy in Polypoidal Choroidal Vasculopathy Patients Treated With Intravitreal Aflibercept or Conbercept

Purpose

To compare the short-term efficacy in patients with polypoidal choroidal vasculopathy (PCV) treated using either aflibercept or conbercept.

Methods

This prospective study included 41 patients with treatment-naive PCV (42 eyes). All the patients were treated with either aflibercept or conbercept using an initial series of 3 monthly loading injections. Changes in the best-corrected logMAR visual acuity (BCVA) and anatomic outcomes were evaluated at 3 months.

Results

BCVA was improved with reduction in central choroidal thickness (CCT), central foveal thickness (CFT), and subretinal fluid (SRF) after 3 monthly loading injections in both aflibercept (IVA) and conbercept (IVC) groups. There was no significant difference in either visual or anatomic outcomes between the two groups after 3 months of treatment. However, compared with the IVC group, significantly higher BCVA improvement was observed in the patients in the IVA group with baseline BCVA better than 1. A visual outcome improved ≥3 lines in 13 patients in the IVA group (59%), and 9 patients in the IVC group (45%). A relatively high proportion of polyp regression was observed in the IVA group (63%) compared with the IVC group (55%) via OCTA.

Conclusions

Visual and anatomic outcomes were significantly improved in both IVA and IVC groups, but the results suggest a potentially superior short-term response in the IVA group.

Choroidal Changes in Eyes With Polypoidal Choroidal Vasculopathy After Anti-VEGF Therapy Imaged With Swept-Source OCT Angiography

Purpose

Swept-source optical coherence tomography angiography was used to investigate choroidal changes and their association with pigment epithelial detachments (PEDs) in eyes with polypoidal choroidal vasculopathy (PCV) after treatment with vascular endothelial growth factor (VEGF) inhibitors.

Methods

Patients with treatment-naïve PCV were included and underwent anti-VEGF therapy. Mean choroidal thickness (MCT), choroidal vascularity index (CVI), and PED volume measurements were obtained before and after treatment.

Results

Thirty-four treatment-naïve PCV eyes from 33 patients were included. The PED volume decreased after treatment (P < 0.05). The MCT decreased from 223.0 ± 79.6 µm at baseline to 210.9 ± 76.2 µm after treatment (P < 0.001). The CVI at baseline was 0.599 ± 0.024, and the CVI after treatment was 0.602 ± 0.023 (P = 0.16). There was a correlation between the decreased PED volumes and the decreased MCT measurements (r = 0.47; P = 0.006). Also, there was a correlation between the decreased PED volumes and the increased CVI measurements (r = −0.63; P < 0.001).

Conclusions

In treatment-naïve eyes with PCV, the decreases in PED volumes were correlated with the decrease in MCT and the increase in CVI measurements. We propose that, at baseline, the PCV lesions serve as high-volume arteriovenous shunts between choroidal arterial and venous circulation, causing transudation into the choroidal stroma. We propose that, after treatment, the blood flow through the vascular shunt is reduced, the excess stromal transudation is resorbed, and the exudation from the neovascular lesion is reduced, resulting in thinning of the choroid, resolution of the PEDs, and an increase in the CVI due to the resorption of excess choroidal transudation.

The characteristics of choriocapillaris flow void in the unilateral polypoidal choroidal vasculopathy fellow eyes

To evaluate the morphological characteristics of flow void (FV) in the fellow eyes of the unilateral polypoidal choroidal vasculopathy (PCV). Fifty PCV fellow eyes (PCVF) and 31 age-matched normal ocular circulation controls were recruited in this retrospective study. The number of FV was analyzed according to the size in a centered 5 × 5 mm swept source optical coherence tomography angiography scans. We used indocyanine green angiography images to determine whether choroidal vascular hyperpermeability (CVH) has occurred. For the PCVF, the prevalence rate of CVH was 70% (35 of 50) The number of FVs was significantly lower in 400-25,000 μm2 (P = 0.005), 400-500 μm2 (P = 0.001), 525-625 μm2 (P = 0.001) and 650-750 μm2 (P = 0.018). compared to the controls. And showed no difference in size from 775 to 1125 μm2 between the two groups. The area under the receiver operating characteristic curve of PCVF with CVH and controls was 0.94 (95% CI 0.88-1.00) (P < 0.001). We found that the number of small FVs was significantly lower in the PCV fellow eyes than that in the eyes with control group.

Optical coherence tomography angiography analysis of aneurismal type 1 neovascularization in a cohort of white patients

INTRODUCTION

To evaluate the detection rate of aneurysmal type 1 neovascularization (AT1) in Caucasian patients using optical coherence tomography angiography (OCTA) and to describe OCTA characteristics of AT1 in a cohort of white patients.

METHODS

We conducted an observational retrospective study in 44 eyes of 43 patients with AT1. All patients underwent a complete ophthalmologic examination, including fundus imaging, indocyanine green angiography, optical coherence tomography, and OCTA. Branching vascular network (BVN) and polyp detection rates by OCTA were evaluated. Furthermore, we described BVN and polyp morphologies on en face OCTA and flow of polyps on B-scan OCTA.

RESULTS

En face OCTA revealed BVN in 84.09% of cases and polypoidal lesions in 86.36% of cases. B-scan OCTA showed BVN and polyps in 95.45% and 93.18% of the patients, respectively. "Trunk" BVNs (51.35%) and "ring" polyps (47.37%) were the most frequent morphologies observed in our cohort, and "patchy hyperflow" (80.49%) signal was the most common visualized in our patients. Regarding OCT parameters, CT under polyps was higher in patients with positive detection of polyps on B-scan OCTA.

CONCLUSION

OCTA is a possible diagnosis tool in Caucasian patients with AT1. To the best of our knowledge, this is the largest study performed in Caucasian patients regarding OCTA diagnostic abilities and features.

Applications of Multimodal Imaging in Central Serous Chorioretinopathy Evaluation

Central serous chorioretinopathy (CSCR) is a macular disease characterized by serous retinal detachment commonly involving the macular region. CSCR has a wide spectrum of clinical presentations. Although a significant proportion of CSCR cases are self-limiting, patients can suffer from persistent or recurrent disease, sometimes complicated with choroidal neovascularization, resulting in permanent visual loss. Multimodal imaging, including fluorescein angiography, indocyanine green angiography, fundus autofluorescence, and optical coherence tomography, has advanced the diagnosis and classification of CSCR cases. Evolution of new imaging techniques including optical coherence tomography angiography, wide-field imaging, and en face reconstruction imaging has also contributed to better understandings of the pathophysiology of CSCR. This review article summarizes the features of multimodal imaging for CSCR and discusses the application of such features in evaluating the disease.

Replacement of polyps with type 1 macular neovascularization in polypoidal choroidal vasculopathy imaged with swept source OCT angiography

Purpose

To investigate the morphological changes of polyps in eyes with polypoidal choroidal vasculopathy (PCV) after treatment with vascular endothelial growth factor (VEGF) inhibitors using swept source optical coherence tomography angiography (SS-OCTA).

Observations

Following anti-VEGF therapy, polyps were found to evolve into typical type 1 macular neovascularization (MNV) in five eyes. In all of these five eyes, a polypoidal lesion was detected adjacent to a serous or hemorrhagic retinal pigment epithelial detachment (PED).

Conclusions and importance

Polypoidal lesions in PCV can evolve into typical type 1 MNV. This morphological evolution suggests that these polyps are clusters of tangled vessels that can proliferate into a more typical neovascular pattern, and this evolution may be facilitated by being adjacent to a PED. Since this morphological appearance could be associated with a better prognosis, SS-OCTA might be helpful in identifying cases of transformed polyps that may be associated with a decreased risk for vision loss.