Remodeling of macular vortex veins in pachychoroid neovasculopathy

Scleral Thickness in Simple Versus Complex Central Serous Chorioretinopathy

PURPOSE

To evaluate the association between scleral thickness and a newly developed multimodal imaging-based classification of central serous chorioretinopathy (CSC).

DESIGN

Retrospective, cross-sectional study.

METHODS

This study included 217 eyes of 217 patients classified as simple or complex CSC based on the established protocols. Clinical and anatomical factors were compared between the 2 types. The scleral thickness was measured at 4 locations using anterior-segment optical coherence tomography.

RESULTS

Of the 217 eyes, 167 were classified as simple CSC and 50 as complex CSC. The complex CSC group showed older age (P = .011), higher male ratio (P = .001), more bilateral involvement (P < .001), poorer visual acuity (P < .001), greater subfoveal choroidal thickness (P = .025), and higher frequency of loculation of fluid (P < .001) and ciliochoroidal effusion (P < .001) than the simple CSC group. The complex CSC group had significantly greater scleral thicknesses in the superior, temporal, inferior, and nasal directions (all P < .001) than the simple CSC group. Multivariable analysis revealed that older age (odds ratio [OR] 1.054, 95% confidence interval [CI] 1.013-1.097, P < .001), male sex (OR 10.445, 95% CI 1.151-94.778, P < .001), bilateral involvement (OR 7.641, 95% CI 3.316-17.607, P < .001), and the mean value of scleral thicknesses in 4 directions (OR 1.022, 95% CI 1.012-1.032, P < .001) were significantly associated with the complex CSC.

CONCLUSIONS

Older age, male sex, bilateral involvement, and thick sclera were associated with the complex CSC. Scleral thickness seemed to determine the clinical manifestations of CSC.

Vortex Veins in Eyes With Pachychoroid Spectrum Disorders Evaluated by the Adjusted Reverse 3-Dimensional Projection Model

Purpose

To compare the distribution of vortex vein ampulla (VVA) between pachychoroid spectrum disorder (PSD) and controls.

Design

A single-center, case-control study.

Participants

This study included 75 PSD, 35 fellow, and 65 control eyes.

Methods

We quantified VVA distribution using a 3-dimensional reverse projection model corrected for image distortion. We investigated the distribution of major drainage veins (MDV), in which macular Haller's vessels directly influx.

Main Outcome Measures

The mean distances from the optic disc to VVAs and the mean angles between VVAs and the fovea-disc line.

Results

The PSD group had significantly fewer VVA in infranasal sector (PSD, fellow, control; 1.6 ± 0.6, 1.8 ± 0.6, 1.9 ± 0.6, respectively, P = 0.026). In supralateral sector, for PSD, fellows, and controls, the mean distances from the optic disc to VVAs were 14.1 ± 1.0 mm, 14.1 ± 1.1 mm, and 13.6 ± 1.4 mm, respectively, and were significantly farther in PSD than in controls (P = 0.023). The mean angles between VVAs and the fovea-disc line were 64.8 ± 5.9°, 66.4 ± 6.4°, and 61.7 ± 6.4°, respectively, and were significantly higher in PSD and fellows than in controls (P = 0.008). The mean distances from the optic disc to MDV in supratemporal sector were 14.1 ± 1.2 and 13.7 ± 1.2 in eyes whose Haller's vessels extended beyond the fovea-disc line (asymmetry), and those that did not, respectively, with the asymmetric eyes significantly farther (P = 0.016).

Conclusions

The VVA position in supralateral sector was farther and higher in PSD than in controls, suggesting that the distribution of VVA may be associated with the development of PSD.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Attenuation of irradiated choroid and its regional vortex veins in central serous chorioretinopathy after photodynamic therapy

We retrospectively studied 12 eyes of 12 patients with central serous chorioretinopathy (CSC) to investigate choroidal thickness changes following half-fluence photodynamic therapy (PDT) using widefield choroidal thickness maps obtained by optical coherence tomography (OCT). Additionally, we assessed the relationship between choroidal thickness changes and the regional vortex veins as visualized on widefield en face OCT of the choroid. Pre-treatment en face images of the choroidal vasculature were superimposed on subtracted choroidal thickness maps before and 3 months after half-fluence PDT. The choroidal thickness decreased mainly in the irradiated macular area and in the region of vortex veins which function as drainage for the macula in all eyes. Eleven eyes (91.7%) showed choroidal thinning in the nasal area which overlapped with the nasal vortex vein distribution. Moreover, in 10 (90.9%) of those eyes, we observed intervortex venous anastomosis across the vertical watershed zone. Quantitative analysis revealed that the reduction in choroidal thickness was most pronounced in the macular area. Furthermore, the choroidal thickness reduction in the area with macular drainage vortex veins was significantly greater than that in the area without such vortex veins. These results suggest that half-fluence PDT might decrease choroidal thickness due to choriocapillaris occlusion in the irradiated macula, possibly leading to diminished venous drainage from the macula to regional vortex veins. Moreover, venous blood flow through the anastomotic vessels from the macular drainage vortex veins into the nasal vortex veins might be reduced post-treatment.

Choroidal features in non-neovascular and neovascular pachychoroid diseases

PURPOSE

To evaluate choroidal findings on multimodal imaging in eyes within pachychoroid spectrum diseases and to compare quantitative and qualitative choroidal features between non-neovascular (NNV-PDS) and neovascular (NV-PDS) pachychoroid diseases.

METHODS

Retrospective cross-sectional study comparing between NV-PDS and NNV-PDS. All patients underwent multimodal imaging including infracyanine green angiography (IFCGA) and swept source optical coherence tomography (OCT) and angiography (OCT-A). The following parameters were analyzed: subfoveal choroidal thickness (SFCT), choroidal vascular index (CVI), presence of pachyvessels and choroidal vascular interconnections (CVIC), presence of choroidal neovascularization and choriocapillaris density.

RESULTS

Of the 87 eyes included in the study, 63 eyes (73%) had NNV-PDS and 24 eyes (27%) had NV-PDS. Mean SFCT and CVI were significantly higher in NNV-PDS group (p = 0.01; p = 0.022). Pachyvessels were more diffusely distributed in NNV-PD group and more focally distributed in NV-PDS group (p = 0.029). CVIC were more frequently noted in NV-PDS group (p = 0.024). A higher CVI was associated to a thicker choroid (p < 0.001), with significant negative correlations between the presence of CVIC and both SFCT (p = 0.015) and CVI (p = 0.002). We also observed a lower choriocapillaris vascular density and higher number of choriocapillaris flow voids in eyes with NNV-PDS (p = 0.24; p = 0.61).

CONCLUSION

NNV-PDS eyes had a significantly thicker SFCT, higher CVI and a lower rate of detected CVIC than eyes with NV-PDS. These highlighted choroidal vascular changes might lead to a better understanding of pachychoroid disease pathophysiology. More frequently observed in NV-PDS group, CVIC are believed to assess the development of vortex vein anastomoses as a remodelling process for vascular decongestion.

Choroidal Vein Alterations in Pachychoroid Disease With Choroidal Vascular Hyperpermeability: Evaluated by Wide-Field Indocyanine Green Angiography

Purpose

The purpose of this study was to investigate choroidal vein (ChV) morphological features in pachychoroid disease (PCD) with choroidal vascular hyperpermeability (CVH).

Methods

This retrospective study assessed subfoveal choroidal thickness (SFCT) and CVH area numbers and locations of recruited patients with PCD using multimodal images. ChV alteration patterns, including fusiform, bulbosity, sausaging, confluence, and anastomoses, as well as asymmetric ChVs, dominant ChVs, and non-dominant ChVs, were evaluated using wide-field indocyanine green angiograms.

Results

Of 68 PCD eyes from 35 patients (mean age: 46.16 ± 6.28 years, 71.4% men), 2.9% had uncomplicated pachychoroid, 32.4% had pachychoroid pigment epitheliopathy (PPE), 55.9% central serous chorioretinopathy (CSC), and 8.8% pachychoroid neovasculopathy (PNV). Mean SFCT was 468.65 ± 131.40 µm. Among 419 CVH areas, ChV fusiform, ChV bulbosity, and ChV sausaging accounted for 35.8%, 35.1%, and 29.1%, respectively; 21.2% had ChV confluence and 11.9% had ChV anastomoses. At CVH areas, 13.1% had retinal pigment epithelium (RPE) leakage. ChV fusiform is steadily declining (37.4%, 36.8%, and 22.9%, respectively), and ChV sausaging, ChV anastomoses, and ChV confluence are increased gradually in the PPE, CSC, and PNV groups (21.4%, 30.0%, and 37.1%; 11.4%, 11.1%, and 20.0%; and 19.8%, 20.9%, and 28.6%, respectively). Dominant ChVs had higher CVH area numbers than non-dominant ChVs in the PPE and CSC groups (P = 0.010, P = 0.001).

Conclusions

Different patterns of ChV alterations, including the newly identified ChV confluence, are commonly present at CVH areas in PCD. The CVH areas in PCD eyes are primarily located within the dominant ChVs. These findings provide crucial evidence for advancing our understanding of the underlying mechanisms of PCD pathogenesis.

Central Serous Chorioretinopathy by Autofluorescence, Enface and SLO-Retromode Imaging

The aim of our study was to investigate the clinical features of central serous chorioretinopathy (CSC) with autofluorescence (AF), retromode (RM), and enface imaging. This retrospective study was conducted at Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome (Italy), between September and December 2022. Each patient underwent a complete ophthalmological examination, which included optical coherence tomography (OCT), enface image analysis, AF, and RM imaging. We further evaluated the presence and area of extension of serous retinal detachment and retinal pigment epithelium (RPE) atrophy through AF, RM, and enface imaging. We included 32 eyes from 27 patients (mean age: 52.7 ± 13.3 years). The median AF area was 19.5 mm² (IQR 6.1-29.3), while the median RM area was 12.3 mm² (IQR 8.1-30.8), and the median enface area was 9.3 mm² (IQR 4.8-18.6). RPE atrophy was diagnosed in 26 cases (81.3%) with RM imaging and in 75% of cases with AF. No difference emerged between AF and RM analysis in the detection of central serous detachment in CSC. However, RM imaging showed a high specificity (91.7%) and negative predictive value (84.6%) to detect RPE changes when compared to the AF standard-of-care technique. Thus, RM imaging could be considered an adjunctive imaging method in CSC.

Pachychoroid neovasculopathy has clinical properties that differ from conventional neovascular age-related macular degeneration

To determine the clinical properties of pachychoroid neovasculopathy (PNV) that differ from conventional neovascular age-related macular degeneration (nAMD) and suggest that they are different clinical entities. To accomplish this, we reviewed the medical records of 100 consecutive patients diagnosed with nAMD. All of the patients were Japanese, and their mean age was 75.5 years. There were 72 men and 28 women. For the bilateral cases, only the right eye was analyzed. An eye was diagnosed with PNV when a macular neovascularization (MNV) was detected just above the dilated choroidal vessels. The Indocyanine green angiographic (ICGA) and en face optical coherence tomographic (OCT) images were used to assess the vertical symmetry of the medium and large choroidal vessels. The subfoveal choroidal thickness (SCT) was also measured manually in the OCT images. After reclassification, there were 29 (29%) patients with typical nAMD (25 with type 1 MNV, 4 with type 2 MNV), 43 (43%) with PNV, 21 (21%) with polypoidal choroidal vasculopathy, and 7 (7%) with retinal angiomatous proliferation. Of the 43 PNV, 17 (39.5%) had polypoidal lesions and 26 (60.5%) had no polypoidal lesions. The percentage of eyes with vertical asymmetry of the medium and large choroidal vessels was significantly greater in the 35 PNV (81.4%) than in the 16 non-PNV (28.1%; P < 0.01) cases. The mean SCT was significantly thicker in the PNV eyes than in the non-PNV eyes (298 ± 96 μm vs. 228 ± 82 μm; P < 0.01). The response of PNV to anti-vascular endothelial growth factor treatments was better than that of non-PNV eyes [higher dry macula rate after the loading period (90.9% vs. 59.1%), fewer total number of injections (11.0 ± 2.9 vs. 13.4 ± 3.2), and longer treatment intervals for the anti-VEGF therapy (8.4 ± 3.1 vs. 13.4 ± 3.2 weeks) at 2 years (all P < 0.01)]. These differences in the morphology and response to anti-VEGF treatments suggest that PNV is a separate clinical entity to conventional nAMD.

QUANTITATIVE ANALYSIS OF CHOROIDAL MORPHOLOGY USING MULTIMODAL IMAGING IN ACUTE AND PERSISTENT CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To analyze quantitative differences in choroidal morphology between acute and persistent central serous chorioretinopathy using multimodal images.

METHODS

Ultra-widefield indocyanine green angiography (UWICGA) and optical coherence tomography images of 72 eyes of 72 patients with acute (32 eyes) and persistent (40 eyes) central serous chorioretinopathy were collected. Choroidal thickness, area, vessel density, symmetry, and intervortex anastomosis were assessed.

RESULTS

The choroidal area on optical coherence tomography B-scan images was smaller and the choroidal vessel density on UWICGA images was lower in the persistent group ( P < 0.001 and P = 0.028, respectively). Choroidal vessel density on UWICGA showed positive correlation with that of vortex ampullae (all P ≤ 0.046). The constitution of the intervortex anastomosis and dominant vessels in the macular area showed differences between the groups ( P = 0.014 and P = 0.010, respectively), with greater inferonasal vessel participation in the anastomosis and combined superotemporal and inferotemporal vessels as dominant vessels in the persistent groups.

CONCLUSION

Acute and persistent central serous chorioretinopathy differed in subfoveal choroidal area, choroidal vessel density, and intervortex anastomosis constitution on UWICGA images. Choroidal vessel density on UWICGA images correlated with that of vortex ampullae. These findings enhance our understanding of the pathophysiology of central serous chorioretinopathy subtypes.

COMPLEX HEMODYNAMICS OF INTERVORTEX VEIN ANASTOMOSES IN HIGHLY MYOPIC EYES

PURPOSE

To analyze the complex pattern of filling of the intervortex vein (IVV) anastomoses through large trunks in highly myopic eyes based on indocyanine green angiographic (ICGA) videos.

METHODS

The medical records of 1,060 consecutive highly myopic eyes that had undergone ICGA were studied. IVV anastomoses were identified in the ICGA images, and the ICGA images and videos were analyzed comprehensively to characterize their hemodynamic features.

RESULTS

Seven eyes with IVV anastomoses through large trunks were analyzed. In the ICGA videos of six eyes, laminar flow was observed in the IVV anastomotic vessels. The laminar flow started in the arterial phase in two eyes, with pulsatile fashion in 1 of them. The flow began in the early arteriovenous transition phase in four eyes. The laminar flow continued for a mean of 12.17 ± 3.06 seconds, and the remaining section was gradually filled slower than the surrounding veins. The anastomotic trunk for the remaining one eye was too narrow to be analyzed. Four eyes had longitudinal ICGA records, and two had significant attenuation and narrowing of the anastomotic vessels.

CONCLUSION

The very early filling of part of the IVV anastomoses suggests that arteriovenous anastomoses are involved in the IVV of highly myopic eyes. However, this suggestion needs further study. There may be similar pathogenesis for IVV anastomoses either in thick or thin sclera.

Scleral Thickness as a Risk Factor for Central Serous Chorioretinopathy and Pachychoroid Neovasculopathy

In the pathophysiology of central serous chorioretinopathy (CSC), scleral changes inducing increased venous outflow resistance are hypothesized to be involved. This work aims to investigate anterior scleral thickness (AST) as a risk factor for pachychoroid disorders. A randomized prospective case-control study was performed at the Ludwig Maximilians University, Department of Ophthalmology. In patients with CSC or pachychoroid neovasculopathy (PNV) and in an age- and refraction-matched control group, swept source optical coherence tomography (SS-OCT) was used to measure anterior scleral thickness (AST). Subfoveal choroidal thickness (SFCT) was assessed using enhanced depth imaging OCT (EDI-OCT). In total, 46 eyes of 46 patients were included in this study, with 23 eyes in the CSC/PNV and 23 eyes in the control group. A significantly higher AST was found in the CSC/PNV compared with the control group (403.5 ± 68.6 (278 to 619) vs. 362.5 ± 62.6 (218 to 498) µm; p = 0.028). Moreover, the CSC/PNV group showed a higher SFCT (392.8 ± 92.8 (191-523) vs. 330.95 ± 116.5 (167-609) µm, p = 0.004). Compared with the age- and refraction-matched controls, patients with CSC and PNV showed a significantly thicker anterior sclera. Scleral thickness might contribute to the venous overload hypothesized to induce pachychoroid phenotypes.

Clinical implications of choroidal vascular brightness using ultra-widefield indocyanine green angiography in polypoidal choroidal vasculopathy

Polypoidal choroidal vasculopathy (PCV) is characterized by choroidal vascular abnormalities including polypoidal lesion and branching vascular networks. Not only choroidal structural changes, but also choroidal hyperpermeability and congestion are also thought to be involved in pathogenesis of PCV. We investigated choroidal vascular brightness intensity (CVB) using ultra-widefield indocyanine green angiography (UWF-ICGA) images and analyzed its association with clinical features in patients with PCV. In this study, 33 eyes with PCV and 27 eyes of age-matched controls were included. CVB was measured by extracting the enhanced pixels of choroidal vessels after the reference brightness across the images was adjusted to be uniform. Associations between choroidal vascular features and the clinical features of PCV were also determined. The mean CVB was higher in PCV than control eyes, regardless of the segmented region (all p < 0.001). CVB was also higher at the posterior pole than at the periphery, and the inferior quadrants were brighter than the superior quadrants in both the PCV and control group (all p < 0.05). In affected eyes, CVB was higher than in unaffected fellow eyes at the posterior pole, whereas there was no difference at the periphery. Posterior pole CVB correlated significantly with subfoveal choroidal thickness (r = 0.502, p = 0.005), polyp number (r = 0.366 p = 0.030), and the greatest linear dimension (r = 0.680, p = 0.040). Greatest linear dimension was positively correlated with CVB at posterior pole (p = 0.040), whereas SFCT or CVD in all regions didn't show the significant correlation. The UWF ICGA results showed an increase in CVB at the inferior quadrants and posterior pole, suggesting venous outflow congestion in PCV eyes. CVB might provide more substantial information on the phenotype than other choroidal vascular features.

Pachychoroid Spectrum Disorders: An Updated Review

Pachychoroid disease spectrum is a recent term that has been associated with an increasing number of phenotypes. This review discusses updated findings for each of the typical pachychoroid entities (central serous chorioretinopathy, pachychoroid pigment epitheliopathy, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy, peripapillary pachychoroid syndrome, and focal choroidal excavation), as well as two relatively new additions (peripapillary pachychoroid neovasculopathy and peripheral exudative hemorrhagic chorioretinopathy). Here, we discuss the potential pathogenic mechanisms for these diseases and relevant imaging updates. Finally, we argue for a consistent classification scheme for these entities.

Quadrant laser photocoagulation trial to ameliorate choroidal congestion in central serous chorioretinopathy

PURPOSE

To investigate the efficacy and safety of quadrant laser photocoagulation to ameliorate the choroidal congestion in central serous choroidopathy (CSC).

STUDY DESIGN

Historically controlled study.

METHODS

We prospectively studied 20 eyes with acute CSC in the quadrant laser group, in which laser photocoagulation was applied to the macular leakage point(s) as well as the quadrant of the fundus showing vortex vein dilatation. Central choroidal thickness (CCT), vertical diameter of dilated vortex vein, resolution rate of serous retinal detachment (SRD), and visual field were evaluated post-treatment. We also compared the results with those of 18 retrospectively analyzed eyes with acute CSC in an external control group, in which laser photocoagulation had been applied only to the macular leakage point(s).

RESULTS

In the quadrant laser group, 2 eyes were excluded from data analysis due to choroidal neovascularization (CNV). CCT was significantly reduced in both groups, but more significantly in the quadrant laser group. The vertical diameter of the dilated vortex vein was significantly decreased only in the quadrant laser group. The resolution rate of SRD was similar in the two groups. In the quadrant laser group, 8 eyes (44.4%) showed mild deterioration of the visual field, consistent with the area subjected to quadrant laser photocoagulation.

CONCLUSION

Quadrant laser photocoagulation can have limited efficacy for ameliorating vortex vein congestion in CSC. When laser photocoagulation to the macular area is combined with quadrant laser photocoagulation, attention must be paid to the possible development of CNV and visual field deterioration.

Retinal Pigment Epithelial Abnormality and Choroidal Large Vascular Flow Imbalance Are Associated with Choriocapillaris Flow Deficits in Age-Related Macular Degeneration in Fellow Eyes

Choriocapillaris flow deficits detected on optical coherence tomography angiographs were retrospectively analyzed. In 38 age-related macular degeneration (AMD) fellow eyes, without fundus findings (26 men, 71.7 ± 1.9 years old), and 22 control eyes (11 men, 69.4 ± 1.8), the choriocapillaris flow area (CCFA) ratio and coefficient of variation (CV) of the CCFA ratio (which represented the heterogeneity of the ratio), negatively and positively correlated with age (all p < 0.01), respectively. Moreover, the respective mean values were lower (p = 0.0031) and greater (p = 0.002) in AMD fellow eyes than in the control eyes. The high-risk condition of AMD fellow eyes was defined by a CCFA ratio <58.5%, and the CV of the CCFA ratio ≥0.165 (odds ratio (OR), 5.408; 95% confidence interval (CI): 1.117-21.118, p = 0.035, after adjusting for age and sex) was related to the presence of fundus autofluorescence abnormality (OR, 16.440; 95% CI, 1.262-214.240; p = 0.033) and asymmetrically dilated choroidal large vasculature (OR, 4.176; 95% CI, 1.057-16.503; p = 0.042), after adjusting for age and sex. The presence of fundus autofluorescence abnormality indicated a retinal pigment epithelium (RPE) abnormality. The RPE volume was reduced in the latter eye group, particularly in the thinner choroidal vasculature. In addition to aging, RPE abnormality and choroidal large vascular flow imbalances were associated with exacerbated heterogeneous choriocapillaris flow deficits in AMD fellow eyes without macular neovascularization.

Association of IL-4 with pachychoroid neovasculopathy

The purpose of this study was to identify the inflammatory cytokines that were associated with pachychoroid neovasculopathy (PNV). Seventy-five eyes of 75 patients with PNV, 145 eyes of 145 patients with neovascular age-related macular degeneration without pachyvessels, and 150 eyes of 150 normal subjects were examined for the levels of intraocular cytokines. In eyes with PNV, the levels of IL-1α, IL-1β, IL-2, IL-4, IL-10, and VEGF were significantly higher than that of the controls. Logistic regression analysis showed that the highest association with the pachyvessels was found for IL-4, IL-2, and IL-1α. In eyes with PNV, the levels of IL-4, IL-2, IL-5, IL-13, IL-1α, and IL-1β were significantly higher in eyes with both increased choroidal thickness and choroidal vessel diameter. The strongest correlation with the choroidal thickness and vessel diameter was observed for IL-4. In PNV eyes with polypoidal lesions, the levels of IL-4, IL-17, and TNFβ were significantly correlated with the number of polypoidal lesions. Of these cytokines, IL-4 was especially associated with the thickness of the choroidal vessels and the formation of polypoidal lesions. We conclude that IL-4 is most likely involved in establishing the clinical characteristics of PNV and polypoidal vascular remodeling.

Effect of photodynamic therapy on choroid of the medial area from optic disc in patients with central serous chorioretinopathy

PURPOSE

To explore the effect of photodynamic therapy (PDT) on the choroid of medial area from optic disc and factors correlated with treatment outcomes, we evaluated choroidal changes using ultra-widefield optical coherence tomography (UWF-OCT) after PDT for central serous chorioretinopathy (CSC).

METHODS

In this retrospective case-series, we included CSC patients who received a standard-dose of full-fluence PDT. UWF-OCT were examined at baseline and 3 months after treatment. We measured choroidal thickness (CT), classified into central, middle, and peripheral sectors. We examined CT changes after PDT by sectors and treatment outcome.

RESULTS

Twenty-two eyes of 21 patients (20 males; mean age 58.7 ± 12.3 years) were included. CT reduction after PDT was significant in all sectors, including peripheral areas: supratemporal, 330.5 ± 90.6 μm vs. 237.0 ± 53.2 μm; infratemporal, 240.0 ± 89.4 μm vs. 209.9 ± 55.1 μm; supranasal, 237.7 ± 59.8 vs 209.3 ± 69.3 μm; infranasal, 172.6 ± 47.2 μm vs. 155.1 ± 38.2 μm (P < 0.001, for all). In patients with retinal fluid resolution, despite no apparent difference in baseline CT, there was more significant reduction after PDT in supratemporal and supranasal peripheral sectors, compared with patients without resolution: supratemporal, 41.9 ± 30.3 μm vs. -1.6 ± 22.7 μm; supranasal, 24.7 ± 15.3 μm vs. 8.5 ± 3.6 μm (P < 0.019, for both).

CONCLUSIONS

Whole CT decreased after PDT, including in medial areas from optic disc. This may be associated with the treatment response of PDT for CSC.

A Comparative Study of Choroidal Vascular and Structural Characteristics of Typical Polypoidal Choroidal Vasculopathy and Polypoidal Choroidal Neovascularization: OCTA-Based Evaluation of Intervortex Venous Anastomosis

BACKGROUND

The aim of this study was to compare the choroidal characteristics of typical polypoidal choroidal vasculopathy (T-PCV) and polypoidal choroidal neovascularization (P-CNV) cases, and to investigate the presence of intervortex venous anastomoses in these PCV subtypes by using en face optical coherence tomography angiography (OCTA).

METHODS

A total of 35 eyes of 33 PCV cases were included. The PCV cases were divided into T-PCV and P-CNV groups. The choroidal vascularity index (CVI) was calculated. En face OCTA images were evaluated for the presence of intervortex venous anastomoses. The diameter of the largest anastomotic Haller vessel was measured.

RESULTS

T-PCV cases had significantly higher mean CVI values (73.9 ± 3.7 vs. 70.8 ± 4.5%) than P-CNV cases (p = 0.039). Intervortex venous anastomoses were observed in 85.7% of T-PCV eyes and in 91.7% of P-CNV eyes on en face OCTA (p = 1.000). In the cases with intervortex venous anastomosis, the mean diameter of the largest anastomotic vessel on en face OCTA was 341.2 ± 109.1 µm in the T-PCV and 280.4 ± 68.4 µm in the P-CNV group (p = 0.048).

CONCLUSIONS

The higher CVI value in T-PCV may be an important feature concerning the pathogenesis and classification of PCV. Although there was no difference between the two subtypes in terms of intervortex anastomosis, more dilated anastomotic vessels were observed in the T-PCV.

Choroidal arteriovenous anastomoses: a hypothesis for the pathogenesis of central serous chorioretinopathy and other pachychoroid disease spectrum abnormalities

The pachychoroid disease spectrum (PDS) includes several chorioretinal diseases that share specific choroidal abnormalities. Although their pathophysiological basis is poorly understood, diseases that are part of the PDS have been hypothesized to be the result of venous congestion. Within the PDS, central serous chorioretinopathy is the most common condition associated with vision loss, due to an accumulation of subretinal fluid in the macula. Central serous chorioretinopathy is characterized by distinct risk factors, most notably a high prevalence in males and exposure to corticosteroids. Interestingly, sex differences and corticosteroids are also strongly associated with specific types of arteriovenous anastomoses in the human body, including dural arteriovenous fistula and surgically created arteriovenous shunts. In this manuscript, we assess the potential of such arteriovenous anastomoses in the choroid as a causal mechanism of the PDS. We propose how this may provide a novel unifying concept on the pathophysiological basis of the PDS, and present cases in which this mechanism may play a role.

Choroidal morphologic features in central serous chorioretinopathy using ultra-widefield optical coherence tomography

PURPOSE

To analyze the choroidal morphological changes in central serous chorioretinopathy (CSC) using ultra-widefield (UWF)-optical coherence tomography (OCT).

METHODS

This single-center, case-control study included 65 CSC eyes (52 males; age, 55.6 ± 13.0 years) and 65 healthy eyes (50 males; age, 57.1 ± 17.9 years). UWF-OCT (viewing angle, 200°) with real-shape correction was used to create an automated choroidal thickness (CT) map. The CT map had three sub-areas: the central (0-30°), middle (30-60°), and peripheral areas (60-100°), and was divided by vertical and horizontal lines. Differences in the CT and the CT change rate (CTCR) from the central to peripheral areas were examined between the CSC and control groups after adjusting for subjects' demographic and clinical factors. Furthermore, we assessed the vortex veins dilation patterns (VVDP) in the macula and examined the CT and the CTCR differences between CSC patients and controls for each VVDP.

RESULTS

CSC patients had greater CT than those of the controls in all sectors (CSC vs. controls, the peripheral area: supratemporal 284.4 ± 71.2 μm vs. 220.4 ± 71.2 μm, infratemporal 263.3 ± 69.2 μm vs. 195.3 ± 52.3 μm, supranasal 251.9 ± 70.3 μm vs. 189.5 ± 58.1 μm, infranasal 193.6 ± 71.2 μm vs. 146.3 ± 48.9 μm, P < 0.0001 for all sectors). The CTCR was apparently larger in CSC eyes than controls only for the upper-dominant type of VVDP (CSC patients vs. controls, supratemporal 32.1 ± 9.9% vs. 4.6 ± 23.1%, infratemporal 44.0 ± 11.2% vs. 25.6 ± 16.8%, supranasal 42.6 ± 9.8% vs. 22.2 ± 19.4%, infranasal 57.6 ± 41.2% vs. 41.2 ± 13.9%, P < 0.0001 for all sectors).

CONCLUSIONS

CSC has a thicker choroid, even in the peripheral areas, and the macular choroidal thickening was more severe in the upper-dominant type of VVDP. VVDP may affect the location of excessive fluid.

Quantitative analysis of choroidal vasculature in central serous chorioretinopathy using ultra-widefield swept-source optical coherence tomography angiography

We aimed to quantitatively compare the choroid blood flow and choroid thickness at the periphery among eyes with central serous chorioretinopathy (CSC), fellow eyes and healthy eyes using ultra-widefield swept-source optical coherence tomography angiography (UWF SS-OCTA). Retrospective analysis of 49 patients with CSC (98 eyes, including unaffected fellow eyes) and 49 age and sex matched controls were included. We obtained 3-dimensional data of vertical 20 mm × horizontal 24 mm × scan depth 6 mm, comprising 9 subfields (superotemporal, upper, superonasal, temporal, central, nasal, inferotemporal, lower, inferonasal regions). CSC eyes presented with greater density of large-vessel choroidal layer in all the 9 subfields compared with controls. Compared with normal eyes, CSC eyes had greater choroidal thickness (superotemporal, upper, superonasal, temporal, central, nasal, inferotemporal, and inferonasal subfields) and choroidal volume (superotemporal, upper, superonasal, temporal, central, and nasal subfields). Compared with control eyes, the choriocapillaris density in the superotemporal, inferotemporal and inferonasal subfields was greater in patients with CSC. Our study may provide further evidence for the congestion of vortex vein in the pathogenesis of CSC. UWF SS-OCTA can be used to evaluate the abnormalities of the choroidal structures even at the periphery in eyes with CSC.

Angiopoietin-1 Is Required for Vortex Vein and Choriocapillaris Development in Mice

BACKGROUND

The choroidal vasculature, including the choriocapillaris and vortex veins, is essential for providing nutrients to the metabolically demanding photoreceptors and retinal pigment epithelium. Choroidal vascular dysfunction leads to vision loss and is associated with age-related macular degeneration and the poorly understood pachychoroid diseases including central serous chorioretinopathy and polypoidal choroidal vasculopathy that are characterized by formation of dilated pachyvessels throughout the choroid.

METHODS

Using neural crest-specific Angpt1 knockout mice, we show that Angiopoietin 1, a ligand of the endothelial receptor TEK (also known as Tie2) is essential for choriocapillaris development and vortex vein patterning.

RESULTS

Lacking choroidal ANGPT1, neural crest-specific Angpt1 knockout eyes exhibited marked choriocapillaris attenuation and 50% reduction in number of vortex veins, with only 2 vortex veins present in the majority of eyes. Shortly after birth, dilated choroidal vessels resembling human pachyvessels were observed extending from the remaining vortex veins and displacing the choriocapillaris, leading to retinal pigment epithelium dysfunction and subretinal neovascularization similar to that seen in pachychoroid disease.

CONCLUSIONS

Together, these findings identify a new role for ANGPT1 in ocular vascular development and demonstrate a clear link between vortex vein dysfunction, pachyvessel formation, and disease.

Pathogenic Risk Factors and Associated Outcomes in the Bullous Variant of Central Serous Chorioretinopathy

PURPOSE

To compare the clinical features, treatments, and outcomes between bullous and chronic variants of central serous chorioretinopathy (CSC).

DESIGN

Retrospective, observational case series.

PARTICIPANTS

Sixty-two eyes of 44 patients with bullous-variant CSC (bvCSC) and 97 eyes of 85 patients with nonbullous CSC.

METHODS

We conducted a national survey between September 1, 2020, and March 31, 2021, of members of the Korean Retina Society and obtained data of patients with bvCSC from 11 retinal centers. A comparator group comprised consecutive chronic CSC patients without bullous detachment.

MAIN OUTCOME MEASURES

Baseline demographics and patient characteristics were compared between groups. Secondary outcomes included factors associated with visual prognosis within the bvCSC group.

RESULTS

Compared with the nonbullous CSC group, the bvCSC group presented at a younger age (49 vs. 52 years; P = 0.047) and with more bilateral involvement (41% vs. 14%; P < 0.001). Systemic corticosteroid use was more prevalent in the bvCSC group, both in terms of any exposure (50% vs. 20%; P = 0.001) and long-term exposure (36% vs. 9%; P <  0.001). The bvCSC group had distinct imaging features (all P < 0.05): retinal folding (64% vs. 1%), subretinal fibrin (75% vs. 13%), multiple retinal pigment epithelium tears (24% vs. 2%), and multifocal fluorescein leakages with terminal telangiectasia (36% vs. 1%). Although bvCSC patients had worse vision at diagnosis (20/80 vs. 20/44; P =  0.003), treatment response was more robust (fluid resolution by final follow-up, 84% vs. 68%; P = 0.034) even with conservative management, resulting in similar final vision (20/52 vs. 20/45; P =  0.52). History of kidney-related (odds ratio [OR] 5.4; 95% confidence interval [CI] 1.3-18.5; P =  0.045) and autoimmune/rheumatoid diseases (OR 25.4, 95% CI 2.8-195.0; P =  0.004) showed associations with the bvCSC group. Apart from vision at diagnosis (OR 0.1, 95% CI 0.05-0.36; P  <  0.001), a history of renal transplantation was most predictive of visual prognoses for bvCSC eyes (OR 0.2, 95% CI 0.04-0.75; P  =  0.020).

CONCLUSIONS

Bullous-variant CSC may be associated with pathogenic risk factors based on underlying medical conditions and systemic corticosteroid use. Poor vision at diagnosis and history of renal transplantation were associated with poor visual outcome.

Widefield Choroidal Thickness of Eyes with Central Serous Chorioretinopathy Examined by Swept-Source OCT

PURPOSE

To examine widefield (WF) changes in the choroidal thickness of eyes with central serous chorioretinopathy (CSC).

DESIGN

An observational study.

PARTICIPANTS

Twenty-two patients (20 men and 2 women) with treatment-naïve unilateral CSC and 28 normal eyes of 28 age-matched, healthy participants (21 men and 7 women).

METHODS

We performed enhanced depth imaging of swept-source (SS) OCT with a viewing angle of vertical 20 mm × horizontal 23 mm. Moreover, we developed a grid consisting of 9 subfields, with diameters of 3, 9, and 18 mm; the inner and outer rings were enclosed by circles with diameters of 3 and 9 mm and 9 and 18 mm, respectively, which were divided into 4 subfields-superotemporal, inferotemporal, superonasal, and inferonasal.

MAIN OUTCOME MEASURES

Widefield changes in choroidal thickness.

RESULTS

The mean duration from the presumed onset of CSC was 6.8 ± 3.1 months during the examination. Compared with that in normal eyes, the choroidal thickness in eyes of patients with CSC was significantly greater in all subfields (P < 0.020 for fellow eyes; P < 0.001 for eyes with CSC). Compared with that in fellow eyes, the choroidal thicknesses in eyes of patients with CSC were significantly greater, except for the outer superotemporal and inferonasal subfields (P < 0.001 for all inner subfields; P < 0.001 for the outer superonasal and inferotemporal subfields). In areas with dilated vortex veins, choroidal thickening was observed from the vicinity of the vortex vein ampulla to the macula along the course of the veins. Choroidal thickening on the dominant side was significantly greater than that on the nondominant side (P = 0.015 for the nasal subfield of the inner ring; P = 0.003 and P < 0.001 for the temporal subfields of the inner and outer rings, respectively).

CONCLUSIONS

Enhanced depth imaging of SS-OCT facilitated the analysis of WF changes in choroidal thickness in both healthy patients and patients with CSC. The local factors of the affected vortex vein and systemic risk factors may be involved in the pathogenesis of CSC.

En face ultra-widefield optical coherence tomography of the vortex vein system in central serous chorioretinopathy

PURPOSE

To investigate whether noninvasive en face ultrawidefield (UWF) OCT can demonstrate salient features of the choroidal vasculature in eyes with central serous chorioretinopathy (CSC).

DESIGN

Retrospective observational case series.

PARTICIPANTS

Patients diagnosed with CSC who underwent UWF indocyanine green angiography (ICGA) and widefield OCT imaging were included.

METHODS

Widefield OCT imaging was performed with a horizontal 23-mm × vertical 20-mm field of view of 5 visual fixations (1 central and 4 peripheral fixations) to compose structural en face UWF OCT montage images and UWF choroidal thickness maps. Automated image alignment was performed before grading.

MAIN OUTCOME MEASURES

A comparison of choroidal vascular findings seen with UWF ICGA and en face UWF OCT images, including size and distribution of choroidal venous drainage areas and identification of dilated choroidal veins (pachyvessels) crossing the physiologic choroidal watershed zones. The spatial correlation between choroidal vascular hyperpermeability on UWF ICGA images and areas of choroidal thickening on UWF choroidal thickness maps was determined.

RESULTS

Forty-two eyes from 27 patients with CSC with a mean age of 56 ± 12 years (range, 31-77 years) were included. Quantitative measures of vortex vein drainage areas on en face UWF OCT images were significantly and positively correlated with those obtained with UWF ICGA (mean Pearson r = 0.825, P < 0.01). Identification of pachyvessels crossing the choroidal watershed zones showed an excellent correlation between UWF ICGA and en face UWF OCT images (mean Spearman ρ = 0.873, P < 0.01). In all cases, choroidal vascular hyperpermeability was observed on UWF ICGA spatially colocalized with areas of choroidal thickening on the UWF choroidal thickness map. Congestion within the entire drainage area of the dominant vortex systems was observed on UWF choroidal thickness maps.

CONCLUSIONS

In eyes with CSC, noninvasive en face UWF OCT imaging can show distinctive features of choroidal venous insufficiency previously identified with UWF ICGA. Ultrawidefield OCT choroidal thickness maps enable quantitative assessment of choroidal congestion.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Choriocapillaris flow deficit in a pachychoroid spectrum disease using en face optical coherence tomography angiography averaging

Purpose

To investigate the choriocapillaris changes associated with pachychoroid pigment epitheliopathy (PPE) in comparison with healthy eyes.

Methods

Nine 3 × 3 mm macular optical coherence tomography angiography images were acquired in patients with PPE and age-matched healthy participants. Multiple en face image averaging of the choriocapillaris was binarized for quantitative image analysis of the flow voids. In PPE eyes, we evaluated the presence of pachyvessels and the association between the location of the choriocapillaris flow deficit and pachyvessels.

Results

Thirty-two eyes with PPE and 30 eyes of healthy participants were included. In PPE eyes, the mean total area (1.16 ± 0.18 vs. 0.91 ± 0.16, p < 0.001) and average size of the flow voids (790 ± 144 vs. 520 ± 138; p < 0.001) were significantly larger than those in control eyes. Composite images of the choriocapillaris and choroid showed choriocapillaris flow deficits just above and outside the pachyvessels. The mean proportion of the flow void area overlying the pachyvessels against the whole flow void area of the choriocapillaris was 21.3% ± 10.2% (9.38%-44.42%) in PPE eyes.

Conclusions

In PPE eyes, the blood flow area of the choriocapillaris decreased diffusely within the macular area compared to control eyes, and the choriocapillaris flow deficit was not necessarily related to pachyvessel location.

Three-dimensional choroidal vascularity index in central serous chorioretinopathy using ultra-widefield swept-source optical coherence tomography angiography

Background

To map and compare the three-dimensional choroidal vascularity index (3D-CVI) in eyes with unilateral central serous chorioretinopathy (CSC), fellow eyes and control eyes using ultra-widefield swept source optical coherence tomography (UWF SS-OCTA).

Methods

In this prospective observational study, the 3D-CVIs were measured in 9 subfields or 1 × 1 mm grids by the UWF SS-OCTA with a viewing angle of horizontal 24 × vertical 20 mm. The proportions of vortex vein anastomoses and their corresponding CVI in the central regions were compared among the CSC, fellow and control eyes. Correlations of CVI and vascular density of the large choroidal vessel layer/choriocapillaris layer/choroidal thickness (CT) were also assessed.

Results

Thirty-two eyes in 32 patients with unilateral CSC and 32 normal eyes were included in the study. The mean CVI in the eyes with CSC was significantly greater than that in the fellow eyes of CSC and control eyes (41.99 ± 3.56% vs. 40.38 ± 3.855%, P = 0.003; 41.99 ± 3.56% vs. 38.93 ± 4.067%, P = 0.004, respectively). The CVIs in superotemporal, inferotemporal and inferonasal regions were significantly higher in CSC eyes than control eyes (P = 0.03, P = 0.02, P = 0.008). In CSC eyes, there was a linear positive correlation between 3D-CVI and vascular density of the large choroidal vessel layer and CT in all subfields. The proportion of vortex vein anastomoses in CSC was 25/32 (78.1%), and significantly higher in fellow and control eyes (P < 0.001). The average central CVI was significantly higher in CSC eyes with anastomoses than in CSC eyes without anastomoses (42.8 ± 5.1% vs. 38.4 ± 2.7%, P = 0.039). CVIs in superior, central, inferior, superonasal, nasal and inferonasal regions were significantly correlated with vortex vein anastomoses (P < 0.05), regardless of CSC, fellow or healthy eyes. In addition, whether there were vortex vein anastomoses, CVI in superotemporal region was significantly higher in eyes with CSC (P = 0.002) and fellow eyes (P = 0.014), compared to control eyes. No significant correlation was found between hypertension and CVIs in the three groups.

Conclusion

Remodeling of choroidal drainage routes by venous anastomosis between superior and inferior vortex veins may be common in CSC. The 3D-CVI could be a comprehensive parameter to evaluate the choroid vasculature and help understand the pathogenesis of pachychoroid spectrum disease.

Vortex vein congestion in the monkey eye: A possible animal model of pachychoroid

Purpose

To create vortex vein congestion in the monkey eye as a possible pachychoroid model.

Methods

We ligated superotemporal and inferotemporal vortex veins at the surface of the sclera in monkey eyes. Optical coherence tomography (OCT) and indocyanine green angiography (ICGA) were performed before and 2, 7, and 28 days after the vortex vein ligations to investigate changes in vortex vein morphology and alterations in choroidal blood flow.

Results

Before the vortex vein ligations, en face OCT and ICGA images showed well organized vortex veins as well as horizontal and vertical watershed zones. Two days after the vortex vein ligations, dilatation of the superotemporal and inferotemporal vortex veins as well as intervortex venous anastomoses were seen on en face OCT and ICGA images. B-mode OCT images showed choroidal thickening associated with dilatation of the outer choroidal vessels. Moreover, video ICGA revealed choriocapillaris filling delay and pulsatile flow in the dilated vortex veins. At 7 and 28 days after we ligated the vortex veins, these findings were reduced, except for the intervortex venous anastomoses.

Conclusions

We created a monkey model of vortex vein congestion by ligating two vortex veins. This animal model demonstrated pachychoroid-related findings, indicating that vortex vein congestion is involved in the pathogenesis of pachychoroid. However, remodeling of the choroidal drainage route via intervortex venous anastomosis appeared to compensate for the vortex vein congestion created in this model.

A Comparative Study of Short-Term Vascular and Stromal Alterations of the Choroid Following Half-Fluence Photodynamic Therapy in Pachychoroid Neovasculopathy and Chronic Central Serous Chorioretinopathy

Background: Central serous chorioretinopathy (CSCR) and pachychoroid neovasculopathy (PNV) are among the pachychoroid spectrum diseases (PSDs). Half-fluence photodynamic therapy (hf-PDT) is one of the effective treatment methods for both diseases. The aim of this study was to compare the effect of hf-PDT on the choroidal structure in CSCR and PNV. Methods: This study included 35 patients with chronic CSCR and 18 patients with PNV. The hf-PDT protocol was applied to all eyes. Before and 3 months after hf-PDT, enhanced-depth optical coherence tomography images were analyzed. The total choroidal area (CA), luminal area (LA), and stromal area (SA) were measured using ImageJ software. Results: Compared with baseline values, 3 months after hf-PDT, the mean CA reduced from 1.398 to 1.197 mm2 (p < 0.001) in the CSCR group and the total CA reduced from 1.050 to 1.000 mm2 (p < 0.021) in the PNV group. The mean percentage changes in CA, LA, and SA values were statistically higher in the chronic CSCR group (13.86%, 13.53%, and 14.11%, respectively) than those in the PNV group (4.61%, 4.02%, and 5.74%; p = 0.001, p = 0.002, and p = 0.031, respectively). Conclusion: CSCR and PNV are thought to be PSDs. However, they differ in choroidal morphological response after hf-PDT, which might be a result of the different structural components of the PNV lesions.

Relationship between Pachychoroid and Polypoidal Choroidal Vasculopathy

Previous clinical studies have suggested that pachychoroid can induce macular neovascularization (MNV) to develop pachychoroid neovasculopathy (PNV) and that PNV can progress to polypoidal choroidal vasculopathy (PCV). Recent studies based on the pachychoroid concept are now gradually revealing the true nature of, at least some part of, PCV. However, previous studies on PNV and/or PCV have used different frameworks for the classification of PNV, PCV, and neovascular age-related macular degeneration (nAMD). These have hampered the rapid overhaul of the understanding of PCV. Some investigators have assumed that all PCV is pachychoroid-driven whereas other investigators have classified PCV into “pachychoroid PCV” and “non-pachychoroid PCV”. Furthermore, since there is no consensus as to whether PNV includes PCV, some studies have included PCV with PNV, while other studies have excluded PCV from PNV. To address these gaps, we summarize previous studies on PCV and pachychoroid. Even before the proposal of the pachychoroid concept, previous studies had suggested that PCV could be divided into two subtypes, of which one was characterized by pachychoroid features. Previous studies had also provided keys to understand relationship between PCV and PNV. We here recommend a refined conceptual framework for future studies on PNV, PCV, and nAMD. Considering the current inconsistent understanding of PCV, we should be cautious about using the term PCV until we understand the true nature of PCV.

Occlusion of a Vortex Vein After Treatment With Half-Fluence Photodynamic Therapy Combined With Intravitreal Aflibercept Injection for Pachychoroid Neovasculopathy

Photodynamic therapy (PDT) is a treatment option for pachychoroid diseases such as central serous chorioretinopathy (CSC), pachychoroid neovasculopathy (PNV), polypoidal choroidal vasculopathy (PCV), and peripapillary pachychoroid syndrome (PPS). On the other hand, morphological changes of choroidal vessels in the irradiated field after PDT have also been discussed, with occlusion of choriocapillaris and stenosis of choroidal middle and large vessels being reported. Here, we report a case of vortex vein occlusion after half-fluence PDT (HF-PDT) combined with an anti-vascular endothelial growth factor (VEGF) agent for PNV. In this case, HF-PDT achieved complete occlusion of PNV; in addition, a vortex vein that flowed in PNV but was located outside the PDT irradiation field was fully occluded three months post-treatment. At the occluded site of the vortex vein, indocyanine green video angiography revealed pulsation downstream of the vortex vein. Such occlusion of a large vessel by HF-PDT has not been reported previously. Occlusion could be induced by two factors: the potentiality of PDT and risk factors for thromboembolism, such as older age, smoking, and arrhythmia. Further studies are required to determine the mechanisms of these large vessel occlusions.

Characterization of Choroidal Morphology and Vasculature in the Phenotype of Pachychoroid Diseases by Swept-Source OCT and OCTA

The objective of this study was to characterize the choroidal morphology and vasculature in pachychoroid diseases (PCD). A total of 49 eyes with polypoidal choroidal vasculopathy (PCV), 43 eyes with neovascular age-related macular degeneration (nAMD), and 50 eyes with central serous chorioretinopathy (CSC), along with 80 healthy eyes, were enrolled in this nested case-control study. The swept-source optical coherent tomography (OCT), OCT angiography, and En face images were quantitatively analyzed. Multivariate logistic regression models showed that older age and increased vessel density (VD) in the choriocapillaris (CC) layer were independent risk factors for both PCV (page < 0.001, pVD = 0.004), and nAMD (page < 0.001, pVD = 0.005). Decreased VD in the Sattler’s layer was an independent risk factor for PCV (p = 0.014). Increased VD in the Haller’s layer was an independent risk factor for CSC (p = 0.001). The proportion of the diffuse type of collateral circulation in the Sattler’ layer in CSC group was significantly higher than in the other three groups (p < 0.001). We concluded that the involvement of the blood flow in the CC, Haller’s, and Sattler’s layers are differently affected in CSC, nAMD, and PCV eyes, indicating the different pathological mechanism underlying the phenotype of PCD. The age-dependent establishment of collateral circulation in the Sattler’s layer may play a compensatory role regarding ischemic injury in the development of PCD.

A new insight into pachychoroid diseases: Remodeling of choroidal vasculature

Purpose

Pachychoroid spectrum diseases are regarded as being different manifestations of a common pathogenic process. We suggest that pachychoroid diseases are consequences of chronic vortex vein stasis.

Methods

We describe how we came to this conclusion based on our own recent reports as well as a search of the related literature.

Results

Central serous chorioretinopathy (CSC) is the first stage of pachychoroid spectrum diseases. CSC is caused by congestion of choroidal veins, which are branches of the vortex veins. The venous outflow tract of the choroid is divided into four quadrants, based on horizontal and vertical watershed zones, with one or two vortex veins in each quadrant being independently responsible for venous outflow. In acute CSC, vortex vein stasis frequently causes asymmetric dilatation of the vortex veins in the horizontal watershed. The area of geographic filling delay in the choriocapillaris coincides with the area of this asymmetrically dilated vortex veins. With chronic stasis of the vortex veins, venous anastomosis occurs in the watershed zone as a means of compensating for the stasis, and the choriocapillaris becomes occluded in the area of filling delay. The anastomotic vessels dilate, becoming often hyperpermeable, and are then recognizable as pachyvessels. With the development of choriocapillaris ischemia, choroidal neovascularization (CNV) occurs at the site of pachyvessels. This is termed pachychoroid neovasculopathy (PNV). Polypoidal choroidal vasculopathy is regarded as a variant of PNV.

Conclusions

Intervortex venous anastomosis is among the key factors underlying the development of pachychoroid diseases. Remodeling of the venous drainage route though the anastomosis across the watershed zones is apparently a common response to chronic vortex vein stasis.

Clinical characteristics and pachychoroid incidence in Japanese patients with neovascular age-related macular degeneration

The phenotypes of neovascular age-related macular degeneration (nAMD) are recognized as differing between Caucasian and Asian patients. Pachychoroid is thought to be more prevalent in Asians than in Caucasians, and may be involved in the development of nAMD in Asian patients. Therefore, we investigated the clinical characteristics and pachychoroid incidence in Japanese patients with nAMD. We retrospectively analyzed 385 eyes of 370 consecutive Japanese patients with treatment naïve nAMD. According to the nAMD nomenclature, type 1 macular neovascularization (MNV) was observed in 132 eyes (34.3%), polypoidal choroidal vasculopathy (PCV) in 137 (35.6%), mixed type 1 and type 2 MNV in 32 (8.3%), type 2 MNV in 43 (11.2%), and type 3 MNV in 41 (10.6%). Pachychoroid was seen in 58.3% of type 1 MNV, 75.2% of PCV, 34.4% of mixed type 1 and type 2 MNV, 14.0% of type 2 MNV, and 0% of type 3 MNV. Compared to nAMD patients without pachychoroid (188 eyes), those who had nAMD with pachychoroid (197 eyes) were significantly younger, had a higher proportion of males, greater central choroidal thickness, and a higher frequency of macular vortex vein anastomoses (all P < 0.001). Furthermore, drusen subtypes differed significantly between the two groups (P < 0.001). These results suggest that most Japanese nAMD patients might have type 1 MNV or PCV. Moreover, in approximately half of patients, nAMD might be associated with pachychoroid, and choroidal congestion may be involved in the development of MNV in these cases.

Ultra-Widefield Indocyanine Green Angiography Reveals Patterns of Choroidal Venous Insufficiency Influencing Pachychoroid Disease

Purpose

To compare patterns of choroidal venous drainage in eyes with pachychoroid disease to those of healthy subjects using ultra-widefield indocyanine green angiography (UWF ICGA).

Methods

Patients with pachychoroid disease and healthy controls were recruited at two referral centers. UWF ICGA images were used to evaluate the proportion of the postequatorial fundus drained by major vortex vein systems in each quadrant and to study the incidence and topography of choroidal vascular hyperpermeability (CVH) and intervortex venous anastomoses. Widefield swept-source optical coherence tomography (SS-OCT) was used to evaluate choroidal thickness at the posterior pole in eyes with pachychoroid disease.

Results

Fifty-two pachychoroid eyes and 26 healthy eyes were evaluated. Eyes with pachychoroid disease showed a significant within-subject variance in the proportion of the postequatorial fundus drained by each vortex vein system (range, 4.1%–48.1%; P < 0.0001) that was not seen in controls (range, 17.3%–31.7%; P = 0.11). CVH was present in all pachychoroid disease eyes and three of 26 controls. Intervortex venous anastomoses were present in 46 of 52 pachychoroid disease eyes and nine of 26 control eyes. Vortex vein systems with large drainage areas showed greater density of CVH spots. SS-OCT demonstrated asymmetric choroidal drainage in the macula of 59% of pachychoroid eyes. CVH and intervortex venous anastomoses were more prominent in areas showing maximal choroidal thickness.

Conclusions

In eyes with pachychoroid disease, imbalanced choroidal venous drainage with congestion of specific vortex vein systems may contribute to a state of choroidal venous insufficiency characterized by regional choroidal thickening, CVH and remodeling of venous drainage routes.

Analysis focusing on plasma von Willebrand factor in pachychoroid neovasculopathy and age-related macular degeneration

Pachychoroid neovasculopathy (PNV) is a new concept of macular disorder. Some cases diagnosed as age-related macular degeneration (AMD) have been re-diagnosed as PNV. However, the biological features of PNV are still uncertain. The purpose of this study was to compare PNV and AMD by analyses focusing on von Willebrand factor (VWF) and complement factor H (CFH). Ninety-seven patients who were previously diagnosed with treatment naïve AMD were enrolled in this study. They were re-classified as either PNV or AMD based on the clinical criteria and 33 patients were classified as PNV and 64 patients as AMD. We examined the clinical data, analyzed VWF multimer and two genetic polymorphisms (I62V and Y402H) in the CFH. PNV group was significantly younger than AMD group (P = 0.001). In both I62V and Y402H, there were no significant differences between PNV and AMD while the recessive homozygous (AA) was found only in PNV group in I62V. The presence of unusually large VWF multimers (UL-VWFMs) and subretinal hemorrhages were significantly higher in PNV than in AMD (P = 0.045, P = 0.020, respectively). Thus, the residual UL-VWFMs may result in platelet thrombosis and hemorrhages in the choriocapillaris of PNV. In conclusion, our results suggest the biological differences between PNV and AMD.

Pachychoroid disease and its association with retinal vein occlusion: a case-control study

The development of a retinal vein occlusion (RVO) is multifactorial. This study investigates pachychoroid as a risk factor for RVO or as an entity sharing common pathophysiology with RVO. A database screening at the University Eye Hospital, Ludwig-Maximilian University Munich, Germany was performed for patients diagnosed with central or branch RVO (CRVO/BRVO). In every patient a complete ophthalmologic examination was performed, including posterior segment enhanced depth spectral domain optical coherence tomography (EDI-SD-OCT). The SD-OCT scans of respective partner eyes without history of RVO were compared to an age- and refraction-matched, randomly recruited normal control group. In total, 312 eyes of 312 patients were included in this study, with 162 eyes in the RVO and 150 eyes in the control group. A significantly higher subfoveal choroidal thickness (SFCT) was found in the RVO (310.3 ± 72.5 (94 to 583) µm) as compared to the control group (237.0 ± 99.0 (62 to 498); p < 0.00001). Moreover, the RVO group showed a significantly higher prevalence of a symptomatic pachychoroid (22 vs. 9 eyes; odds ratio: 2.46; 95 CI: 1.10 to 5.53; p = 0.029). Since pachychoroid disease represents a bilateral entity, it might be a risk factor for RVO, or share risk factors with RVO.

Choroidal features in flat irregular pigment epithelial detachment associated with Chronic central serous chorioretinopathy: Avascular versus vascularized

PURPOSE

To investigate the differences in the choroidal biomarkers between two forms of flat irregular pigment epithelial detachment (FIPED): avascular (aFIPED) and vascularized (vFIPED) in eyes with chronic central serous chorioretinopathy (CSC).

MATERIALS AND METHODS

Enhanced depth imaging optical coherence tomography (EDI-OCT) was done in eyes with FIPED correlated to chronic CSC, fellow eyes, and also in healthy eyes from gender- and age-matched subjects. Eyes with FIPED were classified into two subgroups based on optical coherence tomography angiography (OCTA) findings: vFIPED and aFIPED. Different choroidal biomarkers such as subfoveal choroidal thickness (SFCT), total choroidal area (TCA), and choroidal vascular index (CVI) were compared between the groups.

RESULTS

Forty-four eyes from 42 patients with chronic CSC and FIPED along with 40 eyes from 20 healthy subjects were included. OCTA identified vascularization in 14 eyes in the FIPED group (31.8%). Mean SFCT was higher in the FIPED group compared to two other groups (p = 0.005). In comparison to patients with aFIPED, patients with vFIPED had lower SFCT (p = 0.003) and higher CVI (p = 0.020) based on multivariate analysis.

CONCLUSIONS

It seems that measurement of CVI along with SFCT may help to differentiate aFIPED from vFIPED in patients with CSC. Further longitudinal studies would be required to confirm the clinical significance of these findings.

Vortex Vein Imaging: What Can It Tell Us?

This review article summarizes the patho-anatomy of the vortex veins, the major drainage channels for the choroid, and describes the various pathways of diseases associated with vortex vein abnormalities. This report also details the technical advancements to image the vortex veins, such as ultra-widefield indocyanine green angiography, which are critical to elucidate the importance of the vortices in various retino-choroidal disorders. Future applications of these advanced imaging systems to better understand the role of the vortex veins in health and disease are also discussed.

Chronic choriocapillaris ischemia in dilated vortex vein region in pachychoroid neovasculopathy

We evaluated choroidal congestion using multimodal imaging in pachychoroid neovasculopathy (PNV). In a retrospective case series of 100 eyes of 99 treatment-naïve PNV patients, their clinical records were reviewed and the corresponding multimodal imaging studies were analyzed. We assessed areas of choriocapillaris filling delay which overlapped with dilated outer choroidal vessels, choroidal neovascularization (CNV), and retinal pigment epithelium (RPE) atrophy. The study subjects were 78 men (78.8%) and 21 women (21.2%). The mean patient age was 67.5 ± 10.5 years. On indocyanine green angiography, all eyes showed choriocapillaris filling delay in the early phase. Dilated outer choroidal vessels were demonstrated in all eyes by en face optical coherence tomography. The areas of choriocapillaris filling delay overlapped extensively with that of dilated outer choroidal vessels. All eyes showed CNV localized within the sites of choriocapillaris filling delay. RPE atrophy was noted in 71 eyes (71.0%), and 68 of these (95.8%) had RPE atrophy within the areas showing choriocapillaris filling delay. These findings indicate that chronic choriocapillaris ischemia secondary to vortex vein congestion may lead to CNV development as well as RPE atrophy in eyes with PNV.

Pachychoroid Spectrum Disease: Underlying Pathology, Classification, and Phenotypes

PURPOSE

Pachychoroid spectrum disease encompasses a set of macular disorders secondary to an abnormally thick choroid. However, the pathological process underlying pachychoroid spectrum disease and its overlap with age-related macular degeneration (AMD) remain unclear. This review aimed to understand the underlying pathology, classification, and phenotypes of pachychoroid spectrum disease.

METHODS

This comprehensive literature review was performed based on a search of peer-reviewed published papers relevant to the current knowledge of pachychoroid disease spectrum.

RESULTS

Pachychoroid is primarily a bilateral phenomenon; the main pathological lesions include choriocapillaris attenuation and abnormally dilated pachyvessels. Chronic central serous chorioretinopathy (CSC) and pachychoroid neovasculopathy (PNV) show similar morphological changes and angiogenic cytokine levels. The subretinal fluid in PNV may not accurately indicate PNV activity. Besides, types 1 and 2 of choroidal neovascularization (CNV) may be involved in primary pachychoroidal disease. Both choroidal arteriosclerosis and higher hydrostatic pressure contribute to hyalinized choroidal arteries and aneurysmal dilatations, resulting in PNV progression to polypoidal choroidal vasculopathy (PCV). Thus, pachychoroid-related type 2 CNV and chronic CSC could be considered as PNV (IIIc) and as a precursor of PNV (IIIa), respectively. Tangled PCV on optical coherence tomography angiography that fails to develop aneurysms should be classified as a subtype of PNV or a forme fruste of PCV.

CONCLUSIONS

Multiple disorders of the pachychoroid spectrum are considered as a continuous disease process, ultimately stimulated by choroidal malfunction. PCV overlaps both AMD and pachychoroid disease, especially for thin-choroid and bilateral types. The terminology and classification of pachychoroid spectrum disease should be used cautiously.

Multimodal Imaging in Pachychoroid Spectrum

Diagnostic investigation on pachychoroid spectrum disease (PSD) has been growing along with the rapid advancement of imaging technology. In optical coherence tomography (OCT)-based studies, choroidal thickness profile, luminal and stromal choroidal ratio, and abnormalities in the neurosensory retina have demonstrated various patterns in different clinical entities related to PSD. The emerging role of OCT angiography (OCTA) has been expanded to involve the quantitative analysis of the OCTA parameters in different clinical entities of PSD and to evaluate the choriocapillaris signal void and vessel density as indicators of choriocapillaris ischemia. OCTA has broadened our knowledge in characterization and assessment of both active and quiescent choroidal neovascularization and its association with treatment response. Recent studies using indocyanine green angiography (ICG) have focused on the evaluation of choroidal vascular hyperpermeability and its relationship with other pachychoroid related features. Ultrawidefield ICG enables observation and characterization of peripheral choroidal pathologies and their associations with macular abnormalities. Multicolor imaging is an emerging modality with the capability to demonstrate early abnormalities in PSD. We summarize all investigations reflecting the new insights into the application of multimodal imaging for PSD and focuses on novel findings observed in different clinical entities with each imaging modality.

Pulsation of anastomotic vortex veins in pachychoroid spectrum diseases

Accumulating evidence points to pachychoroid possibly being caused by vortex vein congestion which results in remodeling of choroidal drainage routes via intervortex vein anastomosis. This hypothesis prompted us to investigate vortex vein hemodynamics by studying videos of indocyanine green angiography (ICGA) in a retrospective case series of 295 eyes with pachychoroid spectrum diseases. In the early phase of the video-ICGA, pulsatile vortex venous flow was observed in 76 eyes (25.8%) at the vortex veins connected with anastomosis between superior and inferior vortex veins. The patients with pulsatile vortex venous flow were significantly older than those without pulsatile vortex venous flow (67.8 ± 13.2 vs. 63.9 ± 14.5 years, P < 0.05). Pulsatile vortex venous flow was 1.84 times more common in the inferior quadrants than in the superior quadrants. Interestingly, 14 of 76 eyes (18.4%) with pulsatile vortex venous flow showed retrograde pulsatile blood flow in the vortex veins. This retrograde pulsatile blood flow was 2.50 times more common in the inferior than in the superior quadrants. These findings indicate altered vortex vein hemodynamics due to vortex vein congestion in pachychoroid spectrum diseases.

Vanishing pachy-choroid in pachychoroid neovasculopathy under long-term anti-vascular endothelial growth factor therapy

BACKGROUND

To investigate the diagnostic value of choroidal thickness in the definition of pachychoroid neovasculopathy (PNV), especially in eyes treated with anti-vascular endothelial growth factor (VEGF) therapy.

METHODS

Twenty-two consecutive eyes of 11 patients with uni- or bilateral PNV were analyzed. Anti-VEGF treatment was correlated with changes in choroidal thickness on enhanced depth imaging optical coherence tomography.

RESULTS

There were 14 eyes with PNV and 8 non-neovascular partner eyes. Mean age was 64.2 ± 4.0 (range: 60-72), total follow-up was 1.8 ± 0.4 (1-2) years. In PNV eyes, choroidal thickness at baseline was 400 ± 58 (269-485) μm. After two years and 13 anti-VEGF injections on average, a mean reduction of - 39 ± 10 (- 26 to - 56) % to final 241 ± 52 (162-327) μm was observed (p < 0.0001). Meanwhile, choroidal thickness in the partner eyes remained stable (p > 0.13 for all comparisons). A significant correlation of choroidal thinning and anti-VEGF injection rate was observed at year one (r = - 0.79; R2 = 0.63; p = 0.00073) and two (r = - 0.69; R2 = 0.48; p = 0.019). While 85.7% of PNV eyes exceeded a pachychoroid threshold of ≥350 μm at baseline, this figure dropped to 21.4% at year one and 0% at year two.

CONCLUSION

In PNV, choroidal thickness significantly decreases with anti-VEGF therapy, resembling a "vanishing pachy-choroid", and thus does not represent a valid long-term diagnostic criterium, especially when differentiating PNV from nAMD.

Subthreshold laser therapy with a standardized macular treatment pattern in chronic central serous chorioretinopathy

Purpose

There is an ongoing controversial debate about the effectiveness of laser treatments in chronic central serous chorioretinopathy (cCSC). We performed a prospective non-randomized interventional study to learn about the effects of a subthreshold laser treatment (Topcon Endpoint Management™, Topcon Healthcare Inc., Tokyo, Japan) in patients with cCSC.

Methods

Patients with cCSC and a minimum symptom duration of 4 months were included and treated with a standardized laser pattern covering the macular area. Retreatment was performed every 3 months if persistent subretinal fluid was observed. The primary endpoint was resolution of subretinal fluid at 6 months. Further outcome parameters included best corrected visual acuity, microperimetry, central macular and subfoveal choroidal thickness.

Results

A total of 42 eyes of 39 patients were included. Mean patient age was 48 ± 10.6 years (range 25–67). Mean symptomatic time before inclusion into the study was 134 ± 133.4 weeks (16–518). Before inclusion, 78.6% of the patients had failed to resolve subretinal fluid under mineralocorticoid receptor antagonists and 14.3% had a recurrence after half-dose photodynamic therapy. Complete resolution of subretinal fluid was observed in 42.9% at 6 months and in 53.8% at 12 months after baseline. Central retinal thickness decreased from 398 ± 135 µm to 291 ± 68 µm (p < 0.001), subfoveal choroidal thickness changed slightly (430 ± 116 µm to 419 ± 113 µm, p = 0.026), microperimetry-derived macular function improved by 19.1 ± 4.7 dB to 21.3 ± 4.8 dB (p = 0.008) and mean BCVA improved by 4.9 ± 8.6 ETDRS letters (p < 0.001).

Conclusion

The results show that the investigated laser treatment is effective in reducing subretinal fluid and leads to an improvement of functional parameters.

Venous overload choroidopathy: A hypothetical framework for central serous chorioretinopathy and allied disorders

In central serous chorioretinopathy (CSC), the macula is detached because of fluid leakage at the level of the retinal pigment epithelium. The fluid appears to originate from choroidal vascular hyperpermeability, but the etiology for the fluid is controversial. The choroidal vascular findings as elucidated by recent optical coherence tomography (OCT) and wide-field indocyanine green (ICG) angiographic evaluation show eyes with CSC have many of the same venous patterns that are found in eyes following occlusion of the vortex veins or carotid cavernous sinus fistulas (CCSF). The eyes show delayed choroidal filling, dilated veins, intervortex venous anastomoses, and choroidal vascular hyperpermeability. While patients with occlusion of the vortex veins or CCSF have extraocular abnormalities accounting for the venous outflow problems, eyes with CSC appear to have venous outflow abnormalities as an intrinsic phenomenon. Control of venous outflow from the eye involves a Starling resistor effect, which appears to be abnormal in CSC. Similar choroidal vascular abnormalities have been found in peripapillary pachychoroid syndrome. However, peripapillary pachychoroid syndrome has intervortex venous anastomoses located in the peripapillary region while in CSC these are seen to be located in the macular region. Spaceflight associated neuro-ocular syndrome appears to share many of the pathophysiologic problems of abnormal venous outflow from the choroid along with a host of associated abnormalities. These diseases vary according to their underlying etiologies but are linked by the venous decompensation in the choroid that leads to significant vision loss. Choroidal venous overload provides a unifying concept and theory for an improved understanding of the pathophysiology and classification of a group of diseases to a greater extent than previous proposals.

ROLE OF DILATED SUBFOVEAL CHOROIDAL VEINS IN EYES WITH MYOPIC MACULAR NEOVASCULARIZATION

PURPOSE

To investigate the dilated choroidal veins (DCVs) at or around myopic macular neovascularizations (MNVs) and to determine whether there is a hemodynamic relationship between them.

METHODS

Fifty-eight eyes of 57 patients with myopic MNVs were examined. Dilated choroidal veins were defined as choroidal veins whose diameter was 2X larger than adjacent veins. Indocyanine green angiography and swept-source optical coherence tomography images were reviewed to detect DCVs that crossed the subfoveal area. The filling sequence of the DCVs and MNVs was determined.

RESULTS

Patients' mean age was 71.4 ± 10.6 years. The mean axial length was 29.3 ± 1.8 mm. Dilated choroidal veins below or around the MNV were found in 17 eyes (29.3%). Emissaries of the short posterior ciliary arteries were seen at or around MNVs in 8 of the 17 eyes. In these eyes, the short posterior ciliary artery was filled first or almost simultaneously with the filling of the MNV, followed by a laminar filling of the DCVs. In one eye, afferent arterioles from the short posterior ciliary arteries and efferent venules connected to DCVs were seen.

CONCLUSION

Dilated choroidal veins are present below or around MNVs in about 30% of eyes with myopic MNVs. Our findings suggest that an MNV might be a vascular unit consisting of short posterior ciliary arteries, afferent arterioles, efferent venules, and DCVs.

INTERVORTEX VENOUS ANASTOMOSIS IN Pachychoroid-RELATED DISORDERS

PURPOSE

To evaluate the choroidal vascular patterns of patients with pachychoroid-related diseases in eyes images with wide-field indocyanine green angiography.

METHODS

Retrospective study of wide-field indocyanine green angiographic images of patients with pachychoroid, peripapillary pachychoroid syndrome, central serous chorioretinopathy, and pachychoroid-associated neovascularization that were evaluated for anastomoses between vortex vein systems, which are ordinarily separated by a watershed zone.

RESULTS

There were 21 subjects with a mean age of 57.4 years and 15 were male. Among the 42 eyes evaluated, central serous chorioretinopathy was found in 24 eyes (57.1%), peripapillary pachychoroid syndrome in 5 (11.9%), pachychoroid associated neovascularization in 7 (16.7%), and pachychoroid in 6 (14.3%). Every eye showed anastomosis between the superonasal, superotemporal, and inferotemporal vortex vein systems. The inferonasal vortex vein system was less likely to demonstrate anastomosis except for peripapillary pachychoroid syndrome, which showed anastomosis in all eyes. The anastomotic connections were prominent in the central macula in the central serous chorioretinopathy and pachychoroid-associated neovascularization cases, and around the nerve in the peripapillary pachychoroid syndrome cases. Although the large choroidal veins were particularly prominent in the neovascular cases, the number was fewer in the macular region than in other pachychoroid-related diseases in this series. Compared with a control group of nine eyes, the inferotemporal-superotemporal-superonasal anastomotic connections were more common in the case group (P < 0.001) and inferonasal quadrant (P = 0.023 right eye; P = 0.01, left eye).

CONCLUSION

Intervortex venous anastomosis is common in pachychoroid, central serous chorioretinopathy, peripapillary pachychoroid syndrome, and pachychoroid-associated neovascularization. This finding has important implications concerning pathogenesis and classification of disease.

A comparative study on the choroidal vascularity index and the determination of cut-off values in the pachychoroid spectrum diseases

PURPOSE

To determine the cut-off levels for choroidal thickness and choroidal vascularity index (CVI) to differentiate among pachychoroid spectrum diseases.

STUDY DESIGN

A retrospective comparative study METHODS: A total of 143 eyes were included. Of these 29 had uncomplicated pachychoroid (UCP), 29 had pachychoroid pigment epitheliopathy (PPE), 25 had pachychoroid neovasculopathy (PNV), 30 had central serous chorioretinopathy (CSC), and 30 had polypoidal choroidal vasculopathy (PCV). The choroidal areas were measured with ImageJ software. The CVI, the proportion of the luminal area to the total choroidal area, was assessed.

RESULTS

The cut-off points of central choroidal thickness were determined as 360 µm for the PPE and PCV group pair (p < 0.001), 422 µm for the PNV and CSC group pair (p = 0.026), 271 µm for the PNV and PCV group pair (p < 0.001), and 341 µm for the CSC and PCV group pair (p < 0.001). The cut-off points of CVI were 72.7 for the PPE and PCV group pair (p < 0.001), 74.7 for the PNV and CSC group pair (p = 0.005), 72.6 for the PNV and PCV group pair (p = 0.001), and 73.6 for the CSC and PCV group pair (p < 0.001).

CONCLUSION

Pachychoroid spectrum may be composed of a combination of distinct choroidal diseases with different vascular and structural characteristics.

Variation of vortex veins at the horizontal watershed in normal eyes

PURPOSE

To assess the vascular pattern of choroidal vortex veins at the horizontal watershed zone in normal eyes using optical coherence tomography (OCT).

METHODS

We retrospectively studied 207 normal eyes of 207 patients whose fellow eyes were diagnosed with unilateral retinal diseases without choroidal involvement. Venous anastomosis between the superior and inferior vortex veins and deviation of the horizontal watershed zone were evaluated using 12 × 12-mm en face OCT images. Central choroidal thickness (CCT) was measured on B-mode OCT images.

RESULTS

Vortex vein anastomosis was observed in 92 eyes (44.4%) at the horizontal watershed zone. Superior or inferior deviation of the horizontal watershed was ascertained in 69 eyes (33.3%). The frequency of the anastomosis and deviation did not differ significantly between age groups (P = 0.56 and 0.96, respectively). Mean CCT of all eyes was 221 ± 80 μm. CCT was significantly greater in eyes with anastomosis than in those without (233 ± 73 μm vs 210 ± 83 μm, P < 0.05). However, CCT did not differ significantly between eyes with and without deviation of the horizontal watershed zone (223 ± 74 μm vs 219 ± 82 μm).

CONCLUSIONS

Venous anastomosis at the horizontal watershed zone as well as superior or inferior deviation of the zone were frequently observed in normal eyes. CCT was greater in eyes with than in those without anastomosis, suggesting subclinical vortex vein congestion.