Enhanced depth imaging optical coherence tomography in patients with different phases of Behcet's panuveitis

OPTICAL COHERENCE TOMOGRAPHY CHARACTERISTICS OVER TIME IN BEHÇET'S UVEITIS

PURPOSE

To analyze the characteristics of macular optical coherence tomography in patients with Behçet's uveitis (BU).

METHODS

Retrospectively analyzing optical coherence tomography images and clinical data of patients with Behçet's uveitis who visited our hospital from January 2010 to July 2022.

RESULTS

One hundred and one patients (174 eyes) were included. We analyzed the development of optical coherence tomography changes in these patients and its relationship with acuity vision and found that cystic macular edema, hyperreflexive retinal spots, inner nuclear layer edema, and outer nuclear layer edema appeared at any time during the disease course. Epiretinal membranes appeared beginning 1 to 2 weeks after onset and worsened over time, and foveal atrophy occurred beginning at 2 to 4 weeks. Foveal atrophy, foveal layers disappear, ellipsoid zone (EZ) disruption, retinal pigment epithelium (RPE) disruption, RPE hyperreflection, and choroidal hyperreflection were correlated with visual acuity. Kaplan‒Meier survival analysis showed at 60 months of follow-up, and almost all patients with foveal atrophy, EZ disruption, RPE disruption, RPE hyperreflection, and choroidal hyperreflection had visual acuity less than logMAR 1.0. EZ disruption and RPE disruption were reversible with aggressive treatment from 4 to 12 months after onset, but was less recoverable after 2 years. In advanced stages, optical coherence tomography manifested as structural disturbances and atrophy of the macular area, highly reflective material deposition in the RPE layer, and a thick macular epimembrane.

CONCLUSION

Optical coherence tomography showed that severe lesions occurred in macula of patients with Behçet's uveitis in early stage. Aggressive treatment can partially reverse it.

Choroidal vascularity index and submacular choroidal thickness in patients with Behçet disease assessed with enhanced-depth OCT

PURPOSE

To investigate changes in the choroid using the choroidal vascularity index (CVI) and choroidal thickness (ChT) in patients with ocular (OBD) and non-ocular Behçet disease (non-ocular BD).

METHODS

Sixty-eight OBD patients, 40 non-ocular BD patients, and 40 healthy control subjects were included. ChT was measured using optical coherence tomography (OCT) in enhanced-depth imaging (EDI) mode (EDI-OCT; sub-foveal ChT at 1000 μm, nasal ChT at 1000 μm temporal ChT). The CVI value (%) was calculated by dividing the luminal area by the sub-foveal total choroidal area.

RESULTS

The mean sub-foveal ChT (297 ± 68 µm), nasal ChT (261 ± 66 µm), and temporal ChT (272 ± 68 µm) in eyes with OBD and the mean sub-foveal ChT (286 ± 31 µm), nasal ChT (266 ± 29 µm), and temporal ChT (269 ± 32 µm) in eyes with non-ocular BD were significantly decreased compared with those regions in healthy control subjects (333 ± 69, 301 ± 75, and 312 ± 70 µm, respectively). Additional subgroup analysis was performed for active OBD, inactive OBD, non-ocular BD, and the control group, and in pairwise comparisons, the CVI value was significantly decreased in both active (64.3 ± 3.1) and inactive OBD groups (64.2 ± 4.5) compared with healthy control subjects (67.2 ± 3.6; p = 0.026 and p < 0.001, respectively). There was no significant difference between non-ocular BD (65.9 ± 3.4) and control subjects (67.2 ± 3.6) for CVI measurements (p > 0.05).

CONCLUSIONS

Decreased CVI values in OBD suggest that uveitis affects the choroidal vasculature and that perfusion is affected by uveitis, whereas systemic inflammation in non-ocular BD does not affect them. In addition, the choroid in uveitis is affected by the chronicity of the disease rather than disease activity. ChT measurements and CVI values may be a novel and robust prognosticating biomarker to evaluate choroidal vasculature and to monitor disease progression in OBD patients because EDI-OCT is a non-invasive imaging modality. However, CVI does not seem to be a biomarker for monitoring of disease activity or treatment efficacy.

Stepwise approach for fundus imaging in the diagnosis and management of posterior uveitis

An array of retinochoroid imaging modalities aid in comprehensive evaluation of the immunopathological changes in the retina and choroid, forming the core component for the diagnosis and management of inflammatory disorders such as uveitis. The recent technological breakthroughs have led to the development of imaging platforms that can evaluate the layers of retina and choroid and the structural and functional alteration in these tissues. Ophthalmologists heavily rely on imaging modalities such as dye-based angiographies (fluorescein angiography and indocyanine green angiography), optical coherence tomography, fundus autofluorescence, as well as dye-less angiography such as optical coherence tomography angiograph,y for establishing a precise diagnosis and understanding the pathophysiology of the diseases. Furthermore, these tools are now being deployed with a 'multimodal' approach for swift and accurate diagnosis. In this comprehensive review, we outline the imaging platforms used for evaluation of posterior uveitis and discuss the organized, algorithmic approach for the assessment of the disorders. Additionally, we provide an insight into disease-specific characteristic pathological changes and the established strategies to rule out disorders with overlapping features on imaging.

Choroidal involvement in systemic vasculitis: a systematic review

Systemic vasculitides are a large group of heterogeneous diseases characterized by inflammatory destruction of blood vessels targeting diverse organs and tissues including the eye. As the most vascularized layer of the eye, the choroid is expected to be affected in multiple systemic rheumatologic diseases with vascular involvement. While there are plenty of studies investigating retinal vascular involvement, choroidal vascular involvement in systemic vasculitides has not been investigated in isolation. However, choroidal manifestations including thickness changes, choroidal vasculitis and ischemia may be the earliest diagnostic features of systemic vasculitic diseases. Thus, multimodal imaging of the choroid may help early detection of choroidal involvement which may also have prognostic implications in these life-threatening diseases. This article aimed to review involvement of the choroid in systemic vasculitic diseases.

Choroidal Imaging in uveitis: an update

An important goal of advancements in ocular imaging algorithms and devices has been to improve the image acquisition and resolution of deeper ocular tissues, namely the choroid and its vasculature that are otherwise inaccessible to direct clinical examination. These advancements have contributed to the understanding of the pathophysiology of a number of ocular inflammatory conditions. We focuse on the imaging characteristics of clinical conditions where imaging the choroid has improved or radically changed the understanding of the disease, has helped in differentiation of phenotypically similar but distinct lesions, and where imaging features have proven vital formonitoring disease activity. The last two decades have seen some major developments in ocular imaging relevant to uveitis. The current review addresses both the imaging characteristics and their interpretation on conventional modalities such as fundus photography, fluorescein angiography, indocyanine green angiography and fundus autofluorescence and the recent additions in the armamentarium including optical coherence tomography (OCT) with enhanced depth imaging, swept-source OCT, and OCT angiography.

Relationships of Rheumatoid Factor with Thickness of Retina and Choroid in Subjects without Ocular Symptoms Using Swept-Source Optical Coherence Tomography

Purpose

Researches have confirmed that the retinal and choroidal thickness in patients with autoimmune disease-associated uveitis displays significant changes. However, the relationships between rheumatoid factor (RF) and thickness of the retina and choroid in individuals without ocular manifestations remain unclear. The aim of this study is to assess the associations of RF with retinal and choroidal thickness.

Methods

The individuals enrolled in the cross-sectional research received full ocular examinations. The participants were classified as the RF (+) group (RF ≥ 15.0 IU/ml) and the RF (−) group (RF < 15.0 IU/ml) according to the serum RF titers. The thickness of the retina and choroid was measured by swept-source optical coherence tomography (SS-OCT).

Results

The study covered 65 right eyes of 65 individuals that are RF-positive and 130 right eyes of 130 age- and sex-matched individuals that are RF-negative. The RF (+) group showed decreased choroidal thickness that achieved statistical significance only in the outer inferior and outer temporal sectors, as compared to the RF (−) group. There was no statistically significant difference regarding the retinal thickness between the two groups. Pearson's correlation analysis revealed that the RF was significantly negatively related to the choroidal thickness in all areas. However, there was no significant correlation between the RF and the retinal thickness.

Conclusions

Serum RF titers are closely linked with choroidal thickness before the emergence of ocular symptoms. Research into the relationships may improve our understanding of the role of serum RF in the pathogenesis of uveitis.

Subclinical ocular inflammation in patients with recurrent aphthous stomatitis

OBJECTIVE

Recurrent aphthous stomatitis (RAS) is the major finding of Behçet's disease as well as an inflammatory disease. We compared the choroidal thickness (CT) in patients with RAS with healthy volunteers.

METHODS

Patients with RAS (n = 34) and age- and sex-matched controls (n = 34) were evaluated using spectral-domain optical coherence tomography (OCT). CT measurements were executed at 3 different points (subfoveal, nasal, and temporal). Laboratory parameters were determined for patients and controls.

RESULTS

The mean subfoveal CT in the RAS and control groups were 356.7 ± 91.7 μm and 326.3 ± 86.6 μm, respectively. The RAS group demonstrated significantly higher subfoveal CT than the control group (p = 0.008).

CONCLUSION

This was the first reported study demonstrating a significantly higher subfoveal CT in patients with RAS. Further studies investigating the risk for subclinical ocular inflammation in this patient population are warranted.

Geographical variations in ocular and extra-ocular manifestations in Behçet's disease

OBJECTIVE

Behçet's disease (BD) is a rare vasculitis that results in multi-organ inflammatory disease. At-risk populations are most prevalent in the Middle East and East Asia. Clinical data on BD in Western countries, especially in the United States, are scarce. We have compared clinical patterning of BD vasculitis in two geographically defined patient cohorts in the Western United States and Iran.

METHODS

Comparative analysis of a retrospective cohort of 56 patients with BD evaluated at Stanford University Hospital between 2000 and 2016 and a cohort of 163 patients from the BD Registry at Tehran University of Medical Sciences. Clinical, demographic, laboratory, and treatment data were available. Comparisons were performed using descriptive statistics, Student's t-test, and χ²-test.

RESULTS

The Stanford patients with BD were significantly younger at disease onset, had a higher proportion of females, and had longer disease duration than Iranian patients with BD. Genital ulcers, skin, joint, neurological, vascular, cardiopulmonary manifestations were all significantly more common in the Stanford cohort and 38% of Stanford patients had four or more organ systems involved compared with approximately 10% of Iranian patients. In contrast, Stanford patients had fewer ocular lesions (Stanford 21.4% vs. Iran 53.4% p<0.05), with the biggest difference seen for retinal vasculitis.

CONCLUSION

Patients with BD from the Western US have a more severe disease course when compared to Iranian patients with BD, as demonstrated by earlier onset and a higher rate of multi-organ involvement. The high risk of Iranian patients with BD developing vasculitis of ocular structures suggests distinct pathomechanisms driving ocular versus extra-ocular BD.

Choroidal and retinal thickness in systemic autoimmune and inflammatory diseases: A review

To identify the risk of relapse and subclinical inflammatory stages of systemic autoimmune diseases, new tools are needed. In the recent years, choroidal thickness and retinal thickness measured with ocular coherence tomography (OCT) have been proposed as an inflammatory marker for different systemic diseases, especially for conditions with a vascular component. Our aim in this article is to review the literature regarding the role of choroidal and retinal thickness as a potential inflammatory marker in systemic autoimmune and inflammatory diseases measured by OCT. Current literature suggests that the choroid of patients thickens in active phases of inflammatory diseases with vascular involvement. This pattern is observed in lupus, systemic sclerosis, Behçet disease, spondylitis, and familial Mediterranean fever. Choroidal thickness may decrease with biological treatments, along with systemic inflammation. Repeated flares and long-term disease, however, may thin the choroid, as a result of prolonged insult to the microvasculature and subsequent atrophy. Less is known about the effect of these diseases on retinal thickness. In summary, choroidal and retinal thickness measured by OCT may be promising markers for inflammation in systemic autoimmune and inflammatory diseases; however, more studies are warranted before generalizing choroidal thickness measurements by OCT as a marker for disease activity. The role of retinal thickness is more unclear due to a lack of studies in this field.

Comparison of Spectral Domain Optical Coherence Tomography (SD OCT) Findings with Laser Flare Photometry (LFP) Measurements in Behçet's Uveitis

Purpose: This study aims to compare the spectral domain optical coherence tomography (SD OCT) findings and laser flare photometry (LFP) measurements in Behçet's disease (BD).Methods: This study was composed of 4 groups as follows: "Group 1: Healthy volunteers, Group 2: Volunteers with BD and no eye involvement, Group 3: Patients with active uveitis with BD, Group 4: Patients with BD in quiescent phase of uveitis". Laser Flare Photometry (Kowa FM-600, Kowa Acculas, San Jose, CA, USA), SD-OCT and Enhanced Depth Imaging protocol (EDI) (Spectralis®, Heidelberg Engineering Inc., Heidelberg, Germany) and Fundus Florescein Angiography (FFA) (Heidelberg Retina Angiograph 2®; Heidelberg Engineering, Heidelberg, Germany) were performed for all patients.Results: Twenty-four eyes of 12 healthy volunteers (Group 1); 61 eyes without ocular involvement of 31 volunteers with BD (Group 2); 29 active uveitic eyes of 17 patients with BD (Group 3); 35 eyes with quiescent uveitis in 18 patients with BD (Group 4) participated in the evaluation. There was a significant difference between visual acuity, submacular choroidal thickness (SCT), and flare values comparison among the groups(p<0.001,p<0.002, and p<0.001). When compared considering the SCT, choroidal thickness in Group 3 was higher than in the eyes of Group 1 and Group 2 (p:0.005, p:0.006). Central macular thickness (CMT) and disease duration were negatively correlated (rho:-0.453, p<0.001), while CMT and flare values were positively correlated (rho:0.267,p:0.006).Conclusion: Flare is a reliable indicator of the inflammation in Behçet's uveitis. Its concurrent use with OCT to evaluate choroid and macula enables the assessment of inflammation.

The Evolution of Central Retinal and Choroidal Thickness in Acute Anterior Uveitic Patients with Spondyloarthropathy

Purpose

To describe and correlate the degree of anterior segment inflammation with central retinal and choroidal thickness throughout the treatment period (in the course of follow-up) in the eyes affected with acute anterior uveitis in the patients with seronegative spondyloarthropathy (subgroup: ankylosing spondylitis).

Methods

Thirty eyes of 30 consecutive Caucasian patients with HLA-B27-associated acute anterior uveitis were included in this study. The flare, AC cell number, and central retinal/choroidal thickness were determined at each visit by optical coherence tomography and laser flare photometry. Treatment consisted of topical corticosteroids. Statistical analysis was performed by MathWorks Matlab software.

Results

In the follow-up period, central retinal thickness was increased in the first 9-10 days and then decreased until stabilization (after 5-6 weeks). The flare and AC cell number decreased rapidly at the beginning of the treatment, in the first 10 days, and thereafter, slower decrease could be observed until complete resolution of inflammation. Statistically significant, positive correlation was found between initial laser flare value and maximal central retinal thickness (r=0.881, p < 0.001). Positive correlation between flare and retinal thickening was observable throughout the treatment period. Central choroidal thickness was decreased also significantly during the follow-up (p < 0.001).

Conclusions

The retina and choroid may play a biomarker function in the anterior segment inflammation of the eye in the patients with seronegative spondyloarthropathy.

The role of ophthalmic imaging in central nervous system degeneration in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is an autoimmune connective tissue disorder that can involve any organ system. Central nervous system involvement can be a severe life threatening complication, ultimately resulting in severe neurodegenerative changes. Magnetic resonance imaging suggests that neurodegeneration, which may have deleterious effects on brain function, may occur early in SLE and experimental models suggest that neuroprotection may be feasible and beneficial. The retina is an extension of the brain. Recent ophthalmic imaging technologies are capable of identifying early changes in retinal and choroidal morphology and circulation that may reflect CNS degeneration. However, their utility in monitoring CNS involvement in SLE has been poorly studied as these have only been performed in small cohorts, in a cross-sectional design, non-quantitatively and without correlation to disease activity. The authors aim to review the current understanding of neurodegeneration associated with SLE, with particular focus on the visual pathway. We describe the neuropathology of the visual system in SLE and the evidence for retinal and choroidal neurodegenerative and microvascular changes using optical coherence tomography technology. We aim to describe the potential role of optical imaging modalities in NPSLE diagnosis and their likely impact on the study of neuronal function.