Morphological and Angiographic Peripheral Retinal Changes in Patients with Age-Related Macular Degeneration

Extensive macular atrophy with pseudodrusen-like appearance (EMAP) clinical characteristics, diagnostic criteria, and insights from allied inherited retinal diseases and age-related macular degeneration

Extensive macular atrophy with pseudodrusen-like appearance (EMAP) was first described in France in 2009 as a symmetric and rapidly progressive form of macular atrophy primarily affecting middle-aged individuals. Despite the recent identification of a significant number of cases in Italy and worldwide, EMAP remains an underrecognized condition. The clinical triad typical of EMAP consists of vertically oriented macular atrophy with multilobular borders, pseudodrusen-like deposits across the posterior pole and mid-periphery, and peripheral pavingstone degeneration. Nonetheless, recent research has portrayed EMAP as a highly stage-dependent condition, allowing the identification of novel disease hallmarks, including a diffuse separation between the Bruch's membrane and the retinal pigment epithelium, along with consistent sparing of a region temporal to the macula. Additionally, retinal electrophysiology is particularly useful in distinguishing EMAP from age-related macular degeneration (AMD). Supported by unpublished data from the largest EMAP cohorts worldwide, this review aims to provide a comprehensive and updated description of EMAP, now recognized as a severely blinding disease characterized by diffuse chorioretinal atrophy and photoreceptor dysfunction. Furthermore, we propose a set of diagnostic criteria that incorporate clinical, imaging, and functional tests, to facilitate the recognition of this clinical entity. Lastly, we aim to shed light on its pathogenesis by comparing it with AMD and monogenic retinal disorders exhibiting similar phenotypes.

Peripheral Retinal Involvement in Extensive Macular Atrophy with Pseudodrusen-Like Deposits

PURPOSE

To describe the alterations of the peripheral retina in extensive macular atrophy with pseudodrusen-like deposits (EMAP) by means of ultrawidefield fundus photography (UWFFP) and ultrawidefield fundus autofluorescence (UWF-FAF).

STUDY DESIGN

Prospective, observational case series.

PARTICIPANTS

Twenty-three patients affected by EMAP.

METHODS

Each patient underwent best-corrected visual acuity (BCVA) measurement, UWFFP, and UWF-FAF. The area of macular atrophy, as well as the pseudodrusen-like deposits and peripheral degeneration, were assessed using UWF images, at baseline and over the follow-up.

MAIN OUTCOME MEASURES

The assessment of the clinical patterns of both pseudodrusen-like deposits and peripheral retinal degeneration. Secondary outcomes included assessing macular atrophy by means of UWFFP and UWF-FAF, and tracking progression over the follow-up.

RESULTS

Twenty-three patients (46 eyes) were included, of whom 14 (60%) were female. Mean age was 59.0 ± 5 years. Mean BCVA at baseline was 0.4 ± 0.4, declining at a mean rate of 0.13 ± 0.21 logarithm of the minimum angle of resolution/year. Macular atrophy at baseline was 18.8 ± 14.2 mm2 on UWF-FAF, enlarging at a rate of 0.46 ± 0.28 mm/year, after the square root transformation. Pseudodrusen-like deposits were present in all cases at baseline, and their detection decreased over the follow-up. Three main types of peripheral degeneration were identified: retinal pigment epithelium alterations, pavingstone-like changes, and pigmented chorioretinal atrophy. Peripheral degeneration progressed in 29 eyes (63.0%), at a median rate of 0.7 (interquartile range, 0.4-1.2) sectors/year.

CONCLUSIONS

Extensive macular atrophy with pseudodrusen-like deposits is a complex disease involving not only the macula, but also the midperiphery and the periphery of the retina.

FINANCIAL DISCLOSURE(S)

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

Peripheral Retinal Degenerations and Idiopathic Epiretinal Membrane: Analysis with Ultra-Wide-Field Scanning Laser Ophthalmoscopy

BACKGROUND

The present study examined the relationships among retinal structure, peripheral retinal abnormalities, and epiretinal membrane (ERM) and explored the utility of ultra-wide-field laser scanning ophthalmoscopy in idiopathic ERM assessment.

METHODS

The study sample comprised 276 eyes of 276 patients. Ultra-wide field fundus imaging was performed without mydriasis using Optos California. Each patient underwent a Goldmann three-mirror contact lens fundus examination.

RESULTS

Ultra-wide field laser scanning ophthalmoscopy revealed peripheral retinal degeneration in 84 (54.54%) eyes in the ERM and in 28 (22.95%) eyes in the control group. Goldmann three-mirror contact lens examination revealed peripheral retinal degeneration in 96 (62.33%) eyes in the ERM group and 42 (34.42%) eyes in the control group. Ultra-wide field ophthalmoscopy enabled the detection of nearly 87% of all peripheral retinal lesions in patients with ERM, but it cannot replace fundus examination with a Goldmann triple mirror or ophthalmoscopy with scleral indentation.

CONCLUSIONS

In most patients, idiopathic ERM coexisted with changes in the peripheral retina. Some of these changes promote retinal detachment. Thus, surgeons should consider the risk of retinal tear during vitrectomy, which increases the scope of surgery and may adversely affect prognosis. Although ultra-wide field imaging is a valuable diagnostic method, it is not a substitute for Goldmann three-mirror contact lens fundus examination or ophthalmoscopy with scleral indentation.

Polypoidal choroidal vasculopathy in a patient with early-onset large colloid drusen

Purpose

To report a case of a 46-year-old patient affected by polypoidal choroidal vasculopathy (PCV) in large colloid drusen (LCD) and to show how switching to intravitreal injection of aflibercept could be considered as a useful treatment of PCV not responsive to other anti-vascular endothelial growth factor (VEGF) injections.

Observations

A 46-year-old woman was referred to our department with diagnosis of early-onset retinal drusen. Multimodal imaging confirmed the diagnosis of LCD in both eyes, complicated by suggestive PVC in the left eye. Due to the absence of anatomical improvement after 6 intravitreal injections of ranibizumab, the patient was switched and treated by a single injection of aflibercept, showing a complete anatomical and functional recovery.

Conclusions and Importance

This case suggests progressive development of PCV as a possible late evolution of degenerating LCD. In case of exudative complication, intravitreal aflibercept injection could be considered as a useful treatment, especially in patients who are not responsive to others anti-VEGF injections.