Optical Coherence Tomography Angiography Compared with Multimodal Imaging for Diagnosing Neovascular Central Serous Chorioretinopathy

Quantitative assessment of intervortex anastomosis in central serous chorioretinopathy and fellow eyes: Does the size of anastomotic vessels matter for the diagnosis?

PURPOSE

To evaluate the frequency and size of intervortex anastomosis at the posterior pole on en-face spectral domain optical coherence tomography (SD-OCT) images in central serous chorioretinopathy (CSC) cases and their fellow eyes and its associations with choroidal morphology.

METHODS

Sixty-five treatment-naive eyes of 65 patients with CSC, 65 fellow eyes, and 55 eyes of healthy age-matched participants were included. The presence of intervortex anastomosis at the watershed zone and asymmetry of the choroidal vessels between the superior and inferior macula were evaluated using 6 × 6 mm en-face SD-OCT. The diameter of the widest Haller vessel and the diameter of the widest anastomotic Haller vessel passing through the watershed zone were measured on en-face SD-OCT images. The choroidal vascularity index (CVI) was assessed using ImageJ software.

RESULTS

Intervortex vein anastomosis on the horizontal watershed zone was detected in 75.4% diseased eyes, 61.5% in fellow eyes, and 36.4% in healthy age-matched controls (p < 0.001). The mean CVI was significantly higher in both diseased (74.3 ± 2.3%) and fellow (73.8 ± 2.2%) eyes of CSC cases than in healthy controls (72.5 ± 2.3%) (p = 0.002, p = 0.013, respectively). In the cases with intervortex vein anastomosis, the diameter of the widest anastomotic Haller vessel passing through the watershed zone was 0.40 ± 0.10 mm in diseased eyes, 0.35 ± 0.11 mm in fellow eyes, and 0.30 ± 0.09 mm in healthy age-matched controls (p = 0.001).

CONCLUSIONS

Intervortex anastomosis might be seen as a variation in normal eyes, however, its frequency and the size of anastomotic vessels are significant higher in not only CSC but also in fellow eyes.

Improved accuracy of spectral-domain optical coherence tomography and optical coherence tomography angiography for monitoring myopic macular neovascularisation activity

BACKGROUND/AIMS

To evaluate the diagnostic accuracy of spectral-domain optical coherence tomography (SD OCT) combined with OCT angiography (OCTA) for myopic myopic macular neovascularisation (MNV) activity.

METHODS

Both eyes of patients with myopic MNV diagnosed with fluorescein angiography (FA), SD OCT and OCTA were assessed by unmasked investigators. The images were deidentified and randomised before graded by masked investigators, who determined the presence of active myopic MNV by using SD OCT together with OCTA without FA and by FA alone, respectively. The findings of masked investigators were compared with unmasked investigators.

RESULTS

213 eyes of 110 patients comprising 499 imaging episodes were eligible for grading. For diagnosing new-onset myopic MNV without FA, combined use of SD OCT and OCTA had a sensitivity of 0.94, specificity of 0.84 and area under the curve (AUC) of 0.92. FA had a sensitivity of 0.52 (p<0.01), specificity of 0.80 (p=0.38) and AUC of 0.66 (p<0.01). For recurrent myopic MNV, the combination of SD OCT and OCTA had a sensitivity of 0.98, specificity of 0.78 and AUC of 0.88. FA had a sensitivity of 0.50 (p=0.04), specificity of 0.76 (p=0.85) and AUC of 0.63 (p=0.01). Myopic traction maculopathy was more frequently associated with recurrent myopic MNV (p<0.01).

CONCLUSION

SD OCT with dense volumetric scan was highly sensitive for diagnosing myopic MNV. The addition of OCTA improved the diagnostic specificity without FA. Monitoring of the longitudinal changes on SD OCT and judicious use of FA is a reliable surveillance strategy for myopic MNV.

Multimodal Imaging Based Predictors for the Development of Choroidal Neovascularization in Patients with Central Serous Chorioretinopathy

This study evaluated predictors for choroidal neovascularization (CNV) associated with central serous chorioretinopathy (CSCR) based on multimodal imaging. A retrospective multicenter chart review was conducted on 134 eyes of 132 consecutive patients with CSCR. Eyes were classified as per the multimodal imaging-based classification of CSCR at baseline into simple/complex CSCR and primary episode/recurrent/resolved CSCR. Baseline characteristics of CNV and predictors were evaluated with ANOVA. In 134 eyes with CSCR, 32.8% had CNV (n = 44) with 72.7% having complex CSCR (n = 32), 22.7% having simple (n = 10) and 4.5% having atypical (n = 2). Primary CSCR with CNV were older (58 vs. 47, p = 0.00003), with worse visual acuity (0.56 vs. 0.75, p = 0.01) and of longer duration (median 7 vs. 1, p = 0.0002) than those without CNV. Similarly, recurrent CSCR with CNV were older (61 vs. 52, p = 0.004) than those without CNV. Patients with complex CSCR were 2.72 times more likely to have CNV than patients with simple CSCR. In conclusion, CNV associated with CSCR was more likely in complex CSCR and older age of presentation. Both primary and recurrent CSCR are implicated in CNV development. Patients with complex CSCR were 2.72 times more likely to have CNV than patients with simple CSCR. Multimodal imaging-based classification of CSCR supports detailed analysis of associated CNV.

Recent Advances in Clinical Applications of Imaging in Retinal Diseases

Many diseases that cause visual impairment, as well as systemic conditions, manifest in the posterior segment of the eye. With the advent of high-speed, high-resolution, reliable, and noninvasive imaging techniques, ophthalmologists are becoming more dependent on ocular imaging for disease diagnosis, classification, and management in clinical practice. There are rapid advances on the indications of multimodal retinal imaging techniques, including the application of ultra-widefield fundus angiography, fundus autofluorescence, optical coherence tomography, as well as optical coherence tomography angiography. This review summarizes and highlights the clinical applications, latest indications, and interpretations of multimodal imaging in age-related macular degeneration, polypoidal choroidal vasculopathy, diabetic macular edema, central serous chorioretinopathy, diabetic retinopathy, retinal vein occlusion, and uveitis.

Central serous chorioretinopathy: A review

Central serous chorioretinopathy (CSC) is the fourth most common non-surgical retinopathy associated with fluid leakage. The pathogenesis is not yet completely understood, but changes in the choroid, sclera and RPE have been described associated with venous congestion of choroidal outflow. CSC can be categorised into acute, chronic, and recurrent subtypes with recent classifications of simple and complex based on the area of RPE change seen on fundus autofluorescence. A multimodal imaging approach is helpful in the diagnosis and management of CSC and secondary complications such as type 1 neovascularisation. Although spontaneous resolution with relatively good visual outcomes is common, treatment should be considered in patients with persistent or recurrent SRF. Treatment options include laser, systemic medications, intravitreal therapy, and surgery. Of these, argon laser for focal extramacular fluid leaks and photodynamic therapy of leakage identified by indocyanine-green angiography currently have the greatest supportive evidence.

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.

Individual vs. combined imaging modalities for diagnosing neovascular central serous chorioretinopathy

PURPOSE

To assess the diagnostic accuracy of individual and combined imaging modalities compared with multimodal imaging for the detection of choroidal neovascularization (CNV) in central serous chorioretinopathy (CSC).

METHODS

We analyzed patients with CSC with and without CNV who had indocyanine green angiography (ICGA), structural optical coherence tomography (OCT), and OCT angiography (OCTA) obtained on the same day. The presence of CNV was determined using multimodal imaging by a senior retina specialist (i.e., diagnostic reference). Individual and combined (i.e., ICGA + structural OCT) imaging modalities were then graded by two expert readers for the presence of CNV. Sensitivity, specificity, positive (PPV), and negative (NPV) predictive values were computed for individual and combined imaging modalities relative to the diagnostic reference.

RESULTS

CNV was detected in 17 eyes in 17 out of 33 CSC patients according to the reference standard. Using ICGA, the identification of CNV had a sensitivity of 66.7%, specificity of 66.7%, PPV of 70.6%, and NPV of 62.5%. Structural OCT had the following diagnostic accuracy values: 83.3% of sensitivity, 53.3% of specificity, 68.1% of PPV, and 72.7% of NPV. Using OCTA, CNV was graded to be present with a sensitivity of 77.8%, specificity of 86.7%, PPV of 87.5%, and NPV of 76.5%. The combination of ICGA and structural OCT granted the identification of CNV with a sensitivity of 83.3%, specificity of 86.7%, PPV of 88.2%, and NPV of 81.3%.

CONCLUSIONS

OCTA has an elevated diagnostic accuracy in identifying CSC-associated CNV, though a combination of ICGA and structural OCT has a comparable diagnostic efficiency.

Validation of central serous chorioretinopathy multimodal imaging-based classification system

PURPOSE

Validation of a recently described central serous chorioretinopathy (CSCR) classification system and assessment of levels of agreement among 10 retina physicians.

METHODS

This was a cross-sectional (inter-reader agreement) study. Ten retina physicians (assigned a role of masked grader) were provided with a comprehensive dataset of 61 eyes of 34 patients of presumed CSCR. Relevant clinical details and multimodal imaging (fundus autofluorescence, fluorescein and indocyanine green angiography, optical coherence tomography) of both involved and fellow eye were electronically shared. Later, only the fellow eye images were resent to understand the influence of affected eye on the grading of the fellow eye. Multiple inter-grader agreement using Fleiss Kappa was performed to determine the level of agreement among the 10 graders. p value of ≤ 0.05 was considered statistically significant.

RESULTS

Sixty-one eyes of 34 patients were evaluated. There was moderate agreement for major criteria with Fleiss Kappa value of 0.50 (p < 0.0001) with a single outlier observer. After excluding that observer, the Fleiss Kappa value increased to 0.57 (p < 0.0001) with statistically significant p values among all categories, i.e., simple CSC ([Formula: see text] = 0.575), complex CSC ([Formula: see text] = 0.621), and no CSC ([Formula: see text] = 0.452). Overall, moderate to substantial agreement was noted among the subtypes (primary, recurrent, and resolved). The influence of the affected eye on fellow eye grading was studied. The global Fleiss Kappa coefficient ([Formula: see text] = 0.642, p < 0.0001) showed substantial agreement when observers were aware of the affected eye grading. However, without prior available information on the affected eye, the inter-grader agreement was significantly lower (global [Formula: see text] = 0.255, p < 0.0001).

CONCLUSION

A fair-moderate inter-grader agreement among the masked graders suggests a need for further refinement of this novel classification system. Disease grading should include both eyes as lack of information on affected eye has a bearing on fellow eye grading and inter-grader agreement as shown by a significant difference in global [Formula: see text] values.