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Berkowitz ST, Lam S, Sternberg P, Patel SN, Finn AP. Time-driven Activity-based Costing Analysis of Fluorescein Angiography. Ophthalmol Retina 2023; 7:804-810. [PMID: 37244412 DOI: 10.1016/j.oret.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/23/2023] [Accepted: 05/19/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE To use electronic health record (EHR) time logs and time-driven activity-based costing (TDABC) to calculate the complete cost profile of office-based fluorescein angiography (FA). DESIGN Economic analysis. SUBJECTS Patients undergoing routine FA (Current Procedural Terminology [CPT] 92235) at Vanderbilt Eye Institute in fiscal year 2022. METHODS Process flow mapping for routine FA was used to define the care episode after manual observation. Deidentified time logs were sourced from the EHR and all manually validated to calculate durations for each stage. The cost of materials was calculated from internal financial figures. Cost per minute for space, equipment, and personnel were based on internal figures. Published fluorescein costs were used for base-case analysis with scenario analysis based on a range of internal figures from pharmacy quotes. These inputs were used for a TDABC analysis. MAIN OUTCOME MEASURES Time-driven activity-based costing of FA episode of care. Secondary scenario analyses focus on breakeven scenarios for key inputs, including medication costs RESULTS: Cost analysis of office-based FA resulted in an average total cost of $152.95 (nominal) per interpreted study per patient, which was $36.52 more than the maximum Medicare reimbursement for CPT 92235 in Mac Locality for Tennessee 10312 for fiscal year 2022 ($116.43; $76.11 [technical component] and $40.33 [physician component]). The negative contribution margin is strongly influenced by the cost of fluorescein, which comprises 39.8% of the episode costs, excluding overhead. CONCLUSIONS The current analysis here shows that the recently increased cost of fluorescein has driven up the cost of office-based FA relative to the current maximum allowable Medicare reimbursement, leading to a negative contribution margin and financial loss. Given conservative cost estimates here, it is unlikely for profitability to be achieved without changes in the cost of fluorescein or increased reimbursement. These results may be informative for policy discussion regarding appropriate reimbursement for codes using injectable fluorescein. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Sean T Berkowitz
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shravika Lam
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Paul Sternberg
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shriji N Patel
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Avni P Finn
- Department of Ophthalmology, Vanderbilt University Medical Center, Nashville, Tennessee.
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Fayed AE, Baddar D, Estawro RG, Gerges TK. Masking of macular neovascular membranes by subretinal hyperreflective material on optical coherence tomography angiography. Eur J Ophthalmol 2022; 32:3547-3555. [PMID: 35243925 DOI: 10.1177/11206721221085396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this study was to determine whether subretinal hyperreflective material (SHRM) may mask the detection of macular neovascular membranes (MNV) on optical coherence tomography angiography (OCTA). METHODS In this observational study, eyes with active neovascular age-related macular degeneration (nAMD), co-existing SHRM & intraretinal or subretinal fluid or hemorrhage on structural OCT, underwent OCTA & fundus fluorescein angiography (FFA) imaging. 6 × 6 mm choriocapillaris and outer retinal slabs on OCTA were examined to determine the presence of MNV underneath the SHRM. The corresponding area on FFA was used as a reference arm to confirm activity. RESULTS Thirty eyes of thirty patients with SHRM and active nAMD were recruited. All eyes failed to show a MNV in the choriocapillaris & avascular slabs of the OCTA underneath the SHRM, but showed active hyperfluorescent MNVs that increased in size and intensity in the late stages of FFA. In one eye, parts of a MNV under the SHRM were undetectable due to signal attenuation, while parts extending beyond the SHRM were detected on the choriocapillaris en face slab with flow on the B scan. CONCLUSIONS SHRM may act as a reflecting surface that limits the passage of light waves in OCTA, creating areas of signal attenuation and diminishing its ability to detect underlying MNVs.
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Affiliation(s)
- Alaa E Fayed
- Department of Ophthalmology, Kasr Al-Ainy School of Medicine, 63527Cairo University, Giza, Egypt.,Watany Eye Hospital, Cairo, Egypt
| | - Dina Baddar
- Watany Eye Hospital, Cairo, Egypt.,155130Research Institute of Ophthalmology, Giza, Egypt
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FULL-THICKNESS MACULAR HOLE SIZE BY HYPERTRANSMISSION SIGNAL ON SPECTRAL-DOMAIN OPTICAL COHERENCE TOMOGRAPHY. Retina 2021; 41:2059-2065. [PMID: 33675334 DOI: 10.1097/iae.0000000000003163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To assess the full-thickness macular hole (FTMH) size using the choroidal hypertransmission signal on spectral-domain optical coherence tomography and to compare this method to the standard aperture measurement of the minimum aperture size at the level of the neurosensory retina. DESIGN Cross-sectional study of retrospective data. METHODS Eyes with FTMH imaged on spectral-domain optical coherence tomography were included. Two independent masked graders used the device's built-in caliper tool to measure the FTMH minimum aperture size at the level of the neurosensory retina and the size of the corresponding hypertransmission signal below the level of the retinal pigment epithelium/Bruch membrane complex. To assess the reproducibility of the hypertransmission measurement in tilted scans, two measurements were obtained and compared; the first was traced parallel to the retinal pigment epithelium (parallel hypertransmission), and the second was horizontal to the image frame (horizontal hypertransmission), both using Image J software. RESULTS A total of 31 eyes were enrolled. The mean FTMH minimum aperture size was smaller compared with both the choroidal parallel hypertransmission and horizontal hypertransmission measurements (mean ± SD: 335.7 ± 139.5 µm, 376.7 ± 150.6 µm, 375.1 ± 150.0 µm, respectively. P < 0.001 for both comparisons). CONCLUSION The proposed hypertransmission measurement is a feasible and reproducible alternative to assess FTMH size and could provide the basis for an automated FTMH measurement on cross-sectional spectral-domain optical coherence tomography scans, as presented in this study, or on the spectral-domain optical coherence tomography volumetric data set by using an en face projection.
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Anvari P, Ashrafkhorasani M, Habibi A, Falavarjani KG. Artifacts in Optical Coherence Tomography Angiography. J Ophthalmic Vis Res 2021; 16:271-286. [PMID: 34055264 PMCID: PMC8126744 DOI: 10.18502/jovr.v16i2.9091] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/05/2021] [Indexed: 01/10/2023] Open
Abstract
We performed a comprehensive search of the published literature in PubMed and Google Scholar to identify types, prevalence, etiology, clinical impact, and current methods for correction of various artifacts in optical coherence tomography angiography (OCTA) images. We found that the prevalence of OCTA image artifacts is fairly high. Artifacts associated with eye motion, misidentification of retinal layers, projections, and low optical coherence tomography signal are the most prevalent types. Artifacts in OCTA images are the major limitations of this diagnostic modality in clinical practice and identification of these artifacts and measures to mitigate them are essential for correct diagnosis and follow-up of patients.
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Affiliation(s)
- Pasha Anvari
- Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Ashrafkhorasani
- Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Abbas Habibi
- Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Khalil Ghasemi Falavarjani
- Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.,Stem Cell and Regenerative Medicine Research Center, Iran University of Medical Sciences, Tehran, Iran
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Hou KK, Au A, Kashani AH, Freund KB, Sadda SR, Sarraf D. Pseudoflow with OCT Angiography in Eyes with Hard Exudates and Macular Drusen. Transl Vis Sci Technol 2019; 8:50. [PMID: 31293805 PMCID: PMC6601711 DOI: 10.1167/tvst.8.3.50] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/21/2019] [Indexed: 01/04/2023] Open
Abstract
PURPOSE To analyze "pseudoflow," a false positive flow-artifact observed with optical coherence tomography angiography (OCTA) of stationary hyperreflective structures corresponding to hard exudates and macular drusen. METHODS Retrospective case series of patients with hard exudates (due to diabetic macular edema [DME] or retinal vein occlusion [RVO]) or macular drusen (due to nonneovascular, or dry, age-related macular degeneration [AMD]) studied with OCTA by using volume-based projection artifact removal (3D PAR). RESULTS OCTA of 20 eyes (10 DME/10 RVO) with hard exudates were analyzed. All eyes exhibited pseudoflow corresponding to hard exudates. Seven eyes concurrently demonstrated hard exudates without pseudoflow that were noted in areas lacking vascular flow in the overlying retina. Eight eyes exhibited suspended scattering particles in motion. In 26 of 30 eyes with nonneovascular AMD, pseudoflow associated with macular drusen of any type was noted. Two of 11 eyes with small drusen, 16 of 17 eyes with medium or large drusen, 5 of 5 eyes with drusenoid pigment epithelial detachment, 12 of 16 eyes with ribbon-like subretinal drusenoid deposits, and 13 of 17 eyes with dot-like SDD exhibited pseudoflow. CONCLUSIONS Pseudoflow due to projection artifact is common in eyes with hard exudates or macular drusen. 3D PAR reduces but does not eliminate pseudoflow, and pseudoflow may be detected within the foveal avascular zone, indicating that other factors, such as Z-axis micromotion, may also contribute to pseudoflow. TRANSLATIONAL RELEVANCE This study provides insight into the etiology of pseudoflow noted on OCTA and will guide more accurate clinical interpretation and investigation of OCTA images.
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Affiliation(s)
- Kirk K. Hou
- Department of Ophthalmology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Adrian Au
- Department of Ophthalmology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Amir H. Kashani
- Department of Ophthalmology, USC Roski Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - K. Bailey Freund
- Vitreous Retina Macula Consultants of New York, New York, NY, USA
,Department of Ophthalmology, New York University School of Medicine, New York, NY, USA
| | - Srinivas R. Sadda
- Department of Ophthalmology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
,Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, CA, USA
| | - David Sarraf
- Department of Ophthalmology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
,Retinal Disorders and Ophthalmic Genetics Division, Stein Eye Institute, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
,Greater Los Angeles VA Healthcare Center, Los Angeles, CA, USA
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Fayed AE, Fawzi AA. Projection resolved optical coherence tomography angiography to distinguish flow signal in retinal angiomatous proliferation from flow artifact. PLoS One 2019; 14:e0217109. [PMID: 31091288 PMCID: PMC6519823 DOI: 10.1371/journal.pone.0217109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 05/03/2019] [Indexed: 12/04/2022] Open
Abstract
Purpose To investigate whether hyperreflective foci (HRF) exhibit flow projection artifact on OCTA, and study the efficacy of commercial projection artifact removal software (PAR-OCTA, Optovue, Inc), and a custom projection resolved OCTA (PR-OCTA) in distinguishing artifacts from true flow in retinal angiomatous proliferation (RAP). Methods The study included five eyes with HRF representing pigment migration in dry age-related macular degeneration (AMD), five eyes with leaking treatment-naïve RAP, and ten eyes with diabetic hard exudates. We examined flow signal on OCTA cross-sections using PAR, and performed PR-OCTA to study the effect of increasingly stringent projection removal thresholds. Flow signal intensity was analyzed and quantified using imageJ (NIH, Bethesda, MD, USA), by calculating the percentage of red pixels (R) representing flow, compared to green (G) and blue (B) pixels. Results PAR-OCTA cross sections revealed persistent flow signal in all HRF, including RAP, hard exudates and pigment migration. In RAP, PR-OCTA detected intransigent flow, irrespective of the flow removal threshold. Mean R in the five RAP lesions remained higher than mean G and B at the most stringent PR-OCTA threshold (40.96% vs 29.52 and 29.52%, respectively), denoting persistence of flow. In contrast, increasing the PR-OCTA threshold in pigment migration and hard exudates removed the flow signal, with a statistically significant decrease in mean R with increasing threshold. (p = 0.017 and 0.0029, respectively) Conclusion Commercial PAR-OCTA is not completely effective at removing artifactual flow in hard exudates and HRF related to pigment migration. Custom built PR-OCTA, using a sliding scale of threshold, allowed us to distinguish true flow in RAP from artifactual flow in avascular HRF. Further studies are needed to validate the optimum threshold for projection artifact removal, which would preserve true flow in RAP and the small intraretinal capillaries.
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Affiliation(s)
- Alaa E. Fayed
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
- Department of Ophthalmology, Kasr Al-Ainy School of Medicine, Cairo University, Cairo, Egypt
| | - Amani A. Fawzi
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
- * E-mail:
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Liu L, Jian Gao, Bao W, Hu C, Xu Y, Zhao B, Zheng J, Fan L, Sun Y. Analysis of Foveal Microvascular Abnormalities in Diabetic Retinopathy Using Optical Coherence Tomography Angiography with Projection Artifact Removal. J Ophthalmol 2018; 2018:3926745. [PMID: 30319818 PMCID: PMC6167569 DOI: 10.1155/2018/3926745] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/11/2018] [Accepted: 08/12/2018] [Indexed: 01/12/2023] Open
Abstract
PURPOSE To analyze foveal microvascular abnormalities in different stages of diabetic retinopathy (DR) using optical coherence tomography angiography (OCTA) with projection artifact removal (PAR). METHODS We analyzed 93 eyes of 59 patients with diabetes-31 with no DR (no DR), 34 with mild to moderate nonproliferative DR (mild DR), and 28 with severe nonproliferative DR to proliferative DR (severe DR)-and 31 age-matched healthy controls. Sections measuring 3 × 3 mm2 centered on the fovea were obtained using OCTA. The area, perimeter, and acircularity index (AI) of the foveal avascular zone (FAZ), vessel density within a 300 μm wide region of the FAZ (FD-300), and parafoveal vessel density in the superficial capillary plexus (SCP) and deep capillary plexus (DCP) were calculated using novel built-in software with PAR. RESULTS There was no statistically significant difference in the FAZ area (p=0.162). There was a statistically significant difference in the FAZ perimeter (p=0.010) and the AI (p < 0.001) between the four groups. There was a correlation between the AI and the increasing severity of DR (p=0.010). Statistically significant decreases of vessel density in the FD-300, SCP, and DCP were observed (all p < 0.001). There was a difference in parafoveal vessel density in the DCP between the healthy control eyes and the eyes with diabetes without DR (p=0.027). There was a significant correlation between vessel density and increasing severity of DR (p < 0.001). CONCLUSION Compared with the FAZ area, AI allows a more helpful quantitative assessment of the changes in the FAZ. Vessel density determined using OCTA with PAR might be a useful parameter indicating the progression of DR. Parafoveal vessel density in the DCP after PAR might be a potential early biomarker of DR before appearance of clinically evident retinopathy and needs further investigation.
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Affiliation(s)
- Lun Liu
- Department of Epidemiology and Health Statistics, School of Public Health of Anhui Medical University, Hefei, Anhui, China
- Department of Ophthalmology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jian Gao
- Department of Ophthalmology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Weili Bao
- Department of Ophthalmology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Chengyang Hu
- Department of Epidemiology and Health Statistics, School of Public Health of Anhui Medical University, Hefei, Anhui, China
| | - Yajing Xu
- Department of Ophthalmology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Bingying Zhao
- Department of Ophthalmology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Jie Zheng
- Department of Ophthalmology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Lingling Fan
- Department of Ophthalmology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Yehuan Sun
- Department of Epidemiology and Health Statistics, School of Public Health of Anhui Medical University, Hefei, Anhui, China
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Prevalences of segmentation errors and motion artifacts in OCT-angiography differ among retinal diseases. Graefes Arch Clin Exp Ophthalmol 2018; 256:1807-1816. [PMID: 29982897 DOI: 10.1007/s00417-018-4053-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 06/12/2018] [Accepted: 06/18/2018] [Indexed: 10/28/2022] Open
Abstract
PURPOSE To assess the prevalences of segmentation errors and motion artifacts in optical coherence tomography angiography (OCT-A) in different retinal diseases METHODS: In a retrospective analysis, multimodal retinal imaging including OCT-A was performed in one eye of 57 healthy controls (50.96 ± 22.4 years) and 149 patients (66.42 ± 14.1 years) affected by different chorioretinal diseases: early/intermediate age-related macular degeneration (AMD; n = 26), neovascular AMD (nAMD; n = 22), geographic atrophy due to AMD (GA; n = 6), glaucoma (n = 28), central serous chorioretinopathy (CSC; n = 14), epiretinal membrane (EM; n = 26), retinal vein occlusion (RVO; n = 11), and retinitis pigmentosa (RP; n = 16). Central 3 × 3 mm2 OCT-A imaging was performed with active eye-tracking (AngioVue, Optovue). Best-corrected visual acuity (BCVA) and signal strength index (SSI) were recorded. Images were independently evaluated by two graders using the OCT-A motion artifact score (MAS; scores I-IV) as well as a newly introduced segmentation accuracy score (SAS; score I-IIB). RESULTS Mean SSI was 63.67 ± 9.2 showing a negative correlation with increasing age (rSp = - 0.42, p < 0.001, n = 206). In the healthy cohort, mean MAS was 1.45 ± 0.8 and segmentation was accurate (SAS I) in all eyes. In eyes with retinal pathologies, mean MAS was 2.1 ± 0.9 (p < 0.001). Lowest MAS was observed in GA (2.67 ± 0.5) and RVO (2.45 ± 1.1). Compared to an accurate segmentation in 100% in healthy subjects, 34.2% (n = 51) of all patients showed highest segmentation quality (p < 0.001). 63.8% showed segmentation errors in more than 5% of all single b-scans in one (SAS IIA, n = 58) or at least two (SAS IIB, n = 40) segmentation boundaries. Highest percentages of inaccurate segmentation (SAS IIA or IIB) were observed in the nAMD group (90.1%). The inner plexiform layer was the segmentation boundary most prone to inaccurate segmentation in all pathologies compared to the inner limiting membrane (ILM) and retinal pigment epithelium (RPE) segmentation layer. Incorrect ILM segmentation was only seen in patients with EM. CONCLUSIONS Prior to both qualitative and quantitative analysis, OCT-A images must be carefully reviewed as motion artifacts and segmentation errors in current OCT-A technology are frequent particularly in pathologically altered maculae.
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Choriocapillaris Vascular Density Changes in Patients with Drusen: Cross-Sectional Study Based on Optical Coherence Tomography Angiography Findings. Ophthalmol Ther 2018; 7:101-107. [PMID: 29383674 PMCID: PMC5997591 DOI: 10.1007/s40123-018-0119-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Indexed: 11/30/2022] Open
Abstract
Introduction The purpose of this study was to investigate the extent and morphology of the choriocapillaris’ density defect in patients with drusen in non-neovascular age-related macular degeneration (AMD). Methods Participants in this study were 36 patients with non-neovascular AMD and drusen. All patients underwent best-corrected visual acuity, slit-lamp examination, spectral domain-optical coherence tomography (SD-OCT), and optical coherence tomography angiography (OCTA). Results In all studied cases, the presence of drusen was associated with choriocapillaris’ reduced blood flow signal of different extent and severity. Three types of choriocapillaris’ non-perfusion were observed, along with an association between the size of drusen and the morphology of choriocapillaris’ density defect. Moreover, the extent of choriocapillaris’ density change has been related to ellipsoid zone disruption and therefore to visual impairment. Conclusions Our study showed that in patients with drusen due to non-neovascular AMD, there is choriocapillaris’ impairment of different morphology in OCTA, which is mainly related to the size and location of the drusen.
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