IMAGING OF VITELLIFORM MACULAR LESIONS USING POLARIZATION-SENSITIVE OPTICAL COHERENCE TOMOGRAPHY

Multimodal imaging analysis of autosomal recessive bestrophinopathy: Case series

RATIONALE

Autosomal recessive bestrophinopathy (ARB) is a subtype of bestrophinopathy caused by biallelic mutations of the BEST1 gene, which affect the retinal pigment epithelium (RPE). Studying RPE abnormalities through imaging is essential for understanding ARB. This case series involved the use of multimodal imaging techniques, namely autofluorescence (AF) imaging at 488 nm [short-wavelength AF] and 785 nm [near-infrared AF (NIR-AF)] and polarization-sensitive optical coherence tomography (PS-OCT), to investigate RPE changes in 2 siblings with ARB.

PATIENT CONCERNS

Two Japanese siblings (Case 1: male, followed for 20-23 years; Case 2: female, followed for 13-17 years) carried compound heterozygous mutations of the BEST1 gene.

DIAGNOSIS

Both siblings were diagnosed with ARB.

INTERVENTIONS AND OUTCOMES

Multimodal imaging techniques were used to evaluate RPE changes. Both siblings had funduscopic changes similar to those seen in the vitelliruptive stage of Best vitelliform macular dystrophy during the follow-up period. NIR-AF imaging showed hypo-AF of the entire macular lesion in both cases, and this hypo-AF remained stable over time. PS-OCT confirmed reduced RPE melanin content in these hypo-AF areas. Additionally, hyper-NIR-AF dots were observed within hypo-NIR-AF areas. Concomitant identification of focally thickened RPE melanin on PS-OCT imaging and hyper-AF on short-wavelength AF imaging at the sites containing hyper-NIR-AF dots indicated that the hyper-NIR-AF dots had originated from either stacked RPE cells or RPE dysmorphia.

LESSONS

We confirmed RPE abnormalities in ARB, including diffuse RPE melanin damage in the macula alongside evidence of RPE activity-related changes. This case series demonstrates that multimodal imaging, particularly NIR-AF and PS-OCT, provides detailed insights into RPE alterations in ARB.

Multimodal imaging in Best Vitelliform Macular Dystrophy: Literature review and novel insights

Best Vitelliform Macular Dystrophy (BVMD) is a dominantly inherited retinal disease caused by dominant variants in the BEST1 gene. The original classification of BVMD is based on biomicroscopy and color fundus photography (CFP); however, advancements in retinal imaging provided unique structural, vascular, and functional data and novel insights on disease pathogenesis. Quantitative fundus autofluorescence studies informed us that lipofuscin accumulation, the hallmark of BVMD, is unlikely to be a primary effect of the genetic defect. It could be due to a lack of apposition between photoreceptors and retinal pigment epithelium in the macula with subsequent accumulation of shed outer segments over time. Optical Coherence Tomography (OCT) and adaptive optics imaging revealed that vitelliform lesions are characterized by progressive changes in the cone mosaic corresponding to a thinning of the outer nuclear layer and then disruption of the ellipsoid zone, which are associated with a decreased sensitivity and visual acuity. Therefore, an OCT staging system based on lesion composition, thus reflecting disease evolution, has been recently developed. Lastly, the emerging role of OCT Angiography proved a greater prevalence of macular neovascularization, the majority of which are non-exudative and develop in late disease stages. In conclusion, effective diagnosis, staging, and clinical management of BVMD will likely require a deep understanding of the multimodal imaging features of this disease.

Subretinal autofluorescent deposits: A review and proposal for clinical classification

Subretinal autofluorescent deposits (SADs) may be found in the posterior pole, associated with very various conditions. These disorders usually present a typical pattern of autofluorescent lesions seen on short-wavelength fundus autofluorescence. We describe SADs according to their putative pathophysiological origin and also according to their clinical pattern, i.e., number, shape, and usual location. Five main putative pathophysiological origins of SADs were identified in disorders associated with an intrinsic impairment of phagocytosis and protein transportation, with excess of retinal pigment epithelium phagocytic capacity, with direct or indirect retinal pigment epithelium injury, and/or disorders associated with long-standing serous retinal detachment with mechanical separation between the retinal pigment epithelium and the photoreceptor outer segments. Clinically, however, they could be classified into eight subclasses of SADs, as observed on fundus autofluorescence as follows: single vitelliform macular lesion, multiple roundish or vitelliform lesions, multiple peripapillary lesions, flecked lesions, leopard-spot lesions, macular patterned lesions, patterned lesions located in the same area as the causal disorder, or nonpatterned lesions. Thus, if multimodal imaging may be required to diagnose the cause of SADs, the proposed classification based on noninvasive, widely available short-wavelength fundus autofluorescence could guide clinicians in making their diagnosis decision tree before considering the use of more invasive tools.

Evaluation of incidence of the adult-onset vitelliform macular dystrophy among patients in Far Eastern Federal District of Russia

BACKGROUND: Adult-onset vitelliform macular dystrophy is one of the pathologic conditions , which successfully masks as age-related macular degeneration. AIM: To assess the incidence of the adult-onset vitelliform macular dystrophy among patients of a major ophthalmological clinic in the Far Eastern Federal District of Russia. MATERIALS AND METHODS: We revealed the cases of adult-onset vitelliform macular dystrophy among 1000 patients aged 40 years and older who addressed for various ocular complaints. RESULTS: Adult-onset vitelliform macular dystrophy was found in 2 male patients aged 43 and 66 years. In the macular area of both eyes of the 1st patient, round yellow lesions in the foveola, local detachment of neuroepithelium, optically dense material deposits on the outer photoreceptor segments were detected (vitelliruptive stage of adult-onset vitelliform macular dystrophy). In the left eye of the 2nd patient, in the foveola, a single round yellow focus of 200 m was found, optically dense vitelliform material was detected between the pigment epithelium and neuroepithelium layers without any signs of choroidal neovascularization (vitelliform stage of adult-onset vitelliform macular dystrophy). CONCLUSIONS: The incidence of adult-onset vitelliform macular dystrophy among patients with various ocular conditions was 0.2%. Morphological changes in the macula consist in presence of deposits of vitelliform material, localized between the neuroepithelium and retinal pigment epithelium layers.

A pathogenic in-frame deletion-insertion variant in BEST1 phenocopies Stargardt disease

Here, we describe affected members of a 2-generation family with a Stargardt disease-like phenotype caused by a 2-base pair deletion insertion, c.1014_1015delGAinsCT;p.(Trp338_Asn339delinsCysTyr), in BEST1. The variant was identified by whole-exome sequencing, and its pathogenicity was verified through chloride channel recording using WT and transfected mutant HEK293 cells. Clinical examination of both patients revealed similar phenotypes at 2 different disease stages that were attributable to differences in their age at presentation. Hyperautofluorescent flecks along the arcades were observed in the proband, while the affected mother exhibited more advanced retinal pigment epithelium (RPE) loss in the central macula. Full-field electroretinogram testing was unremarkable in the daughter; however, moderate attenuation of generalized cone function was detected in the mother. Results from electrooculogram testing in the daughter were consistent with widespread dysfunction of the RPE characteristic of Best disease. Whole-cell patch-clamp recordings revealed a statistically significant decrease in chloride conductance of the mutant compared with WT cells. This report on a mother and daughter with a BEST1 genotype that phenocopies Stargardt disease broadens the clinical spectrum of BEST1-associated retinopathy.

Anatomical and Functional Outcomes in Eyes with Idiopathic Macular Holes that Underwent Surgery Using the Inverted Internal Limiting Membrane (ILM) Flap Technique Versus the Conventional ILM Peeling Technique

INTRODUCTION

To evaluate the anatomical and functional outcomes of the inverted internal limiting membrane (ILM) flap technique (IFT) in macular holes (MHs), especially in MHs with a macular hole index (MHI) < 0.5.

METHODS

This was a retrospective comparative study. Patients with idiopathic MHs who underwent either the IFT or conventional ILM peeling (CP) were investigated. The main outcomes included the MH closure rate, best corrected visual acuity (BCVA), and recovery rates of the external limiting membrane (ELM) and ellipsoid zone (EZ) at 1, 3, and 6 months postoperatively.

RESULTS

Forty-eight eyes of 48 patients who underwent the IFT (n = 29, Group A) or CP (n = 19, Group B) were included. The mean minimal diameter was 522.00 ± 208.08 µm. The closure rate was 100.0% in Group A and 94.7% in Group B (P = 0.396). The mean BCVA and EZ and ELM recovery rates improved significantly in both groups postoperatively. No significant differences in BCVA or the EZ or ELM recovery rates were found between the two groups. Of the 39 eyes whose MHI was < 0.5, 25 underwent the IFT, and 14 underwent CP. Comparing the results of the closure rate, BCVA and recovery rates of the EZ and ELM between groups were similar to those in 48 eyes.

CONCLUSION

Both the IFT and CP can achieve a high closure rate, with no significant difference in ordinary idiopathic MHs. The IFT does not seem to achieve better anatomical and functional outcomes than CP. The IFT should be used conservatively in ordinary non-refractory MH surgery.

[Large macular hole-Always a poor prognosis?]

Hintergrund

Alter, präoperativer Visus und Makulaforamengröße gelten als prognostische Marker für das postoperative Ergebnis bei Patienten mit durchgreifendem Makulaforamen (MF).

Ziel der Arbeit

Um den postoperativen Verlauf nach i‑ILM Peeling (inverted-Flap ILM-Peeling) mit konventionellem ILM-Peeling (k-ILM) zu vergleichen, wurde eine retrospektive Beobachtungsstudie durchgeführt. Patienten mit i‑ILM Peeling hatten dabei präoperativ ein statistisch signifikant größeres Makulaforamen.

Material und Methoden

Es wurden 45 konsekutive Patienten mit durchgreifendem Makulaforamen (MF) in 2 Gruppen (i-ILM vs. k‑ILM) eingeteilt und auf Unterschiede im postoperativen Visus (BCVA) und der Netzhautmorphologie hin untersucht. Die Integrität der äußeren Netzhautschichten, äußere limitierende Membran (ELM), ellipsoide Zone (EZ) und äußere Photorezeptoraußensegmente (OS), wurde postoperativ mittels SD-OCT (Spectral-Domain-OCT) analysiert.

Ergebnisse

Die präoperative Apertur in der i‑ILM Gruppe war signifikant größer (i-ILM = 408,4 µm, SD = 157,5 µm; k‑ILM = 287,4 µm, SD = 104,9 µm; p = 0,01). Der Ausgangsvisus sowie der postoperative Visus nach 1 Monat waren in der Gruppe mit k‑ILM-Peeling signifikant besser (p = 0,03 und p = 0,001). Der postoperative Visus nach mindestens 6 Monaten zeigte keinen signifikanten Unterschied zwischen den beiden Gruppen (p = 0,24). Die ELM zeigte als erste der äußeren Netzhautschichten eine Re-Integrität in beiden Gruppen.

Schlussfolgerung

Mithilfe der i‑ILM-Peeling-Technik erschien es in dieser konsekutiven Serie möglich zu sein, für Patienten mit großem durchgreifendem MF ein ähnliches postoperatives Visusergebnis zur erreichen wie für mittels k‑ILM-Peeling-Technik operierte Patienten mit kleinerem durchgreifendem MF.

Caring for Hereditary Childhood Retinal Blindness

Inherited retinal diseases (IRDs) are a major cause of incurable familial blindness in the Western world. In the pediatric population, IRDs are a major contributor to the 19 million children worldwide with visual impairment. Unfortunately, the road to the correct diagnosis is often complicated in the pediatric population, as typical diagnostic tools such as fundus examination, electrodiagnostic studies, and other imaging modalities may be difficult to perform in the pediatric patient. In this review, we describe the most significant IRDs with onset during the pediatric years (ie, before the age of 18). We describe the pathogenesis, clinical presentation, and potential treatment of these diseases. In addition, we advocate the use of a pedigree (family medical history), electroretinography, and genetic testing as the 3 most crucial tools for the correct diagnosis of IRDs in the pediatric population.