Pachyvitelliform maculopathy: an optical coherence tomography analysis of a novel entity

Clinical Characteristics and Progression of Pachychoroid Macular Atrophy in Central Serous Chorioretinopathy

PURPOSE

Macular atrophy (MA) is a late-stage complication often associated with age-related macular degeneration (AMD). However, it can also occur in pachychoroid diseases, including central serous chorioretinopathy (CSCR), called pachychoroid MA (pMA). This study aimed to investigate the characteristics and progression of pMA in CSCR.

DESIGN

Multicenter retrospective study as part of the Macula Society International CSCR Research Network (MICRoN).

PARTICIPANTS

Thirty-eight eyes of 32 patients.

METHODS

Demographic and imaging data were collected. Optical coherence tomography and fundus autofluorescence images were analyzed to identify pMA features, including complete retinal pigment epithelium and outer retinal atrophy, pachychoroid phenotype, and baseline CSCR characteristics. The study comprised 2 parts: (1) progression analysis, comparing time to pMA among OCT features in cases without baseline pMA; and (2) follow-up analysis, including patients with at least a 12-month interval between 2 visits showing pMA progression. Pachychoroid macular atrophy area, number, and location were manually measured using the HEYEX-2 platform and ImageJ.

MAIN OUTCOME MEASURES

Progression analysis: OCT features that contributed to faster development of pMA. Follow-up analysis: progression rate of pMA after square root transformation (SQRT) and features that contribute to faster progression in lesion size.

RESULTS

Among 1675 eyes with CSCR, the prevalence of pMA was 2.27% and the incidence of pMA was 0.89%. Eyes with intraretinal fluid (IRF) experienced faster time to development of pMA (31.34 ± 16.66 months) compared with those without IRF (64.13 ± 37.14 months, P = 0.039). The mean pMA area increased from 1.65 ± 2.09 mm2 to 3.08 ± 3.14 mm2, with a mean progression rate of 0.29 ± 0.28 mm2/year. Central pMA exhibited a faster progression rate than noncentral pMA (0.13 ± 0.078 mm2/year vs. 0.052 ± 0.055 mm2/year, P = 0.011). Larger baseline pMA area was significantly associated with quicker progression (r = 0.65, P ≤ 0.001). However, after SQRT of pMA area, no significant association with baseline area was found. There was significant reduction of central macular thickness (195.72 ± 96.58 to 153.64 ± 100.25 microns, P = 0.034) and subfoveal choroidal thickness (372.92 ± 83.84 to 342.8 ± 78.33 microns, P value = 0.029) at follow-up.

CONCLUSIONS

Pachychoroid MA in CSCR exhibits distinct characteristics compared with AMD-related geographic atrophy from established literature. It progresses at a slower rate, and larger lesions tend to advance more rapidly. Additionally, central pMA progresses faster than noncentral pMA. The presence of IRF during the disease course accelerates the progression of CSCR to pMA.

FINANCIAL DISCLOSURE(S)

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

Pachyvitelliform Maculopathy: Clinical Features and Natural History

PURPOSE

To evaluate the prevalence, clinical features, associated factors, and natural history of pachyvitelliform maculopathy (PVM) within the pachychoroid disease spectrum (PDS).

DESIGN

Retrospective cohort study.

SUBJECTS

Patients affected with PDS were evaluated at a single retina referral center between 2006 and 2024.

METHODS

Demographics, medical history, and imaging features were reviewed. Pachyvitelliform maculopathy was diagnosed based on the presence of acquired vitelliform lesions (AVLs), identified as hyperreflective material above the retinal pigment epithelium (RPE) band on spectral-domain OCT and corresponding hyperautofluorescence on fundus autofluorescence imaging. Acquired vitelliform lesions were tracked longitudinally using serial OCT.

MAIN OUTCOME MEASURES

Factors associated with AVL development were assessed using multivariable logistic regression. The hazard of AVL persistence was evaluated with Cox regression. Complication rates were reported as absolute prevalence, and visual acuity (VA) changes were analyzed longitudinally using repeated measures modeling.

RESULTS

Among 986 eyes with PDS, 48 (5%) demonstrated PVM. Key associations included recurrent fluid episodes (odds ratio [OR], 2.87; P = 0.002), thinner outer nuclear layer (OR, 0.89; P = 0.03), and choroidal folds (OR, 3.39; P = 0.002). Subfoveal AVLs were most common, observed in 79% of cases. Acquired vitelliform lesion typically developed at the apex of the subfoveal serous cavity or along its lateral edges, beginning with ellipsoid zone thickening, followed by suspended hyperreflective material settling onto the RPE and forming deposits. These deposits consolidated over time, appearing as "pachydrusen" or resembling the "double-layer sign." Indocyanine green angiography highlighted localized choroidal vascular hyperpermeability at AVL sites. Subfoveal lesions, a thicker Haller's layer, and increased peripapillary choroidal thickness were associated with reduced AVL resolution (all P < 0.05). Lesion turnover was slow (median 50 months); complications, including neovascularization (6%) and atrophy (4%), were rare, and VA remained stable over 7 years (P = 0.07).

CONCLUSIONS

Pachyvitelliform maculopathy represents a distinct phenotype within PDS, characterized by prolonged lesion persistence, recurrent fluid, and a relatively benign visual prognosis. Structural choroidal changes and RPE dysfunction drive lesion formation and progression.

FINANCIAL DISCLOSURE(S)

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

Pachychoroid disease: review and update

The pachychoroid disease spectrum is a phenotype characterized by alterations in choroidal vasculature which result in outer retinal and choriocapillaris damage and visual loss. The presence of pachyvessels is one of the key features of the pachychoroid phenotype. Recent imaging studies suggest that pachyvessels may form because of choroidal venous congestion in one or more quadrants. The formation of intervortex anastomosis may function as a compensatory mechanism to dissipate the increased venous pressure, while outflow obstruction has been hypothesized to occur at the site of the vortex vein exiting the sclera. This review aims to summarize recent imaging findings and discuss evolution in the understanding of pathogenesis of the pachychoroid disease spectrum. We have summarized notable treatment trials in central serous chorioretinopathy and polypoidal choroidal vasculopathy and included an update of the current diagnostic and management strategies of the entities that are part of the pachychoroid disease spectrum.

Pathogenesis of Central Serous Chorioretinopathy and the Link Between Choroidal Hyperpermeability and Retinal Pigment Epithelium Pump Reversal

PURPOSE

To describe 6 cases of acute central serous chorioretinopathy (CSCR) and the response to laser treatment, focusing on the underlying pathogenic mechanism.

METHODS

Multimodal imaging from 6 eyes of 6 patients with acute and recurrent CSCR were reviewed, including fundus autofluorescence (FAF), fluorescein angiography (FA), indocyanine green angiography (ICGA), and optical coherence tomography (OCT) at baseline and after laser therapy.

RESULTS

In 3 of the 6 cases with acute CSCR, the hyporeflective lucency sign was identified with cross-sectional and en face OCT and co-localized with an intense active inkblot retinal pigment epithelium (RPE) leak on FA. The development of this sign was suggestive of active leakage into the subretinal space displacing overlying subretinal hyperreflective material (SHRM) and suggestive of a reversal of RPE pump function. All 6 cases were treated with focal laser to directly target the intense leakage points with remarkable resolution of the fluid due to destruction of the RPE cells mediating reversal of pump function.

CONCLUSIONS

Unlike chronic CSCR in which degenerative changes of the RPE lead to oozing of fluid into the subretinal space, in acute forms of CSCR including bullous CSCR, there are focal leaks of the RPE that actively drive fluid into the subretinal space suggestive of RPE pump reversal. We propose that pachychoroid disease causes increased hydrostatic pressure and increased resistance to the RPE pump, thereby triggering a reversal in pump function. Understanding this concept can have therapeutic implications.

Acquired Vitelliform Lesions in Intermediate Age-Related Macular Degeneration: A Cross Sectional Study

PURPOSE

This study aims to define the characteristics of acquired vitelliform lesions (AVLs) in patients with intermediate age-related macular degeneration (iAMD).

DESIGN

Retrospective, observational, cross sectional study.

SUBJECTS

This study included 217 eyes with AVLs associated with iAMD, and an equivalent number of control patients.

METHODS

OCT scans were evaluated for qualitative and quantitative parameters at both the eye and lesion level. Eye-level parameters included the presence of: hyporeflective core drusen, intraretinal hyperreflective foci (IHRF), subretinal drusenoid deposits, macular pachyvessels, central retinal thickness, and central choroidal thickness. Lesion-level qualitative parameters included the presence of ellipsoid zone (EZ) and external limiting membrane disruption overlying the AVL, IHRF overlying the AVL, AVL overlying drusen, pachyvessels under the AVL, a solid core within AVL, and AVL location. Lesion-level quantitative characteristics included AVL height and width, AVL distance from the fovea, and sub-AVL choroidal thickness.

MAIN OUTCOME MEASURES

The primary outcomes assessed included the frequency of IHRF, the presence of macular pachyvessels, central choroidal thickness, and the dimensions (both height and width) of AVLs.

RESULTS

Comparing the AVL and control groups, the frequency of IHRF (AVL: 49.3% vs. control: 26.3%) and macular pachyvessels (37.3% vs. 6.9%) was significantly higher in the AVL case group, and the central choroidal thickness (256.8 ± 88 μm vs. 207.1± 45 μm) was thicker in the AVL group. Acquired vitelliform lesions located over drusen, with overlying IHRF, or situated subfoveally, and AVL lesions with EZ disruption were found to have a greater lesion height and width compared with AVL lesions lacking these characteristics (P value < 0.001 for all). Additionally, a significant negative correlation was observed between the distance from the fovea and AVL height (Spearman rho: -0.19, P = 0.002) and width (Spearman rho: -0.30, P = 0.001).

CONCLUSIONS

This study represents the largest reported cohort of AVL lesions associated with iAMD. Novel findings include the higher frequency of pachyvessels in addition to the presence of a thicker choroid in these eyes, as well as the greater height and width of AVL closer to the foveal center. These findings may offer insights into pathophysiologic mechanisms underlying the development of AVL.

FINANCIAL DISCLOSURE(S)

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

Adult-Onset Foveomacular Vitelliform Dystrophy With Unilateral Presentation: A Case Series

Adult-onset foveomacular vitelliform dystrophy (AOFVD) is a rare condition affecting the macula that presents diagnostic and management challenges due to its varied manifestations and clinical overlap with other retinal disorders. As vitelliform lesions can occur in various conditions, such as Best disease and age-related macular degeneration, clinical presentation, multimodal imaging findings, and genetic testing can aid in accurate diagnosis. Although AOFVD typically affects both eyes, unilateral involvement can occur. This study presents four cases of unilateral AOFVD in female patients aged 43 to 66 years. Each patient was monitored for two years with fundoscopy and multimodal imaging, including color fundus photography, optical coherence tomography (OCT), OCT-angiography, fluorescein angiography, and fundus autofluorescence (FAF). All patients presented with a characterized solitary, subfoveal, yellow lesion on fundoscopy. FAF revealed intense hyperautofluorescence corresponding with the lesions. OCT revealed the accumulation of homogenous hyperreflective material between the retinal pigment epithelium and photoreceptors. No abnormal findings were observed in the fellow eyes. Subfoveal choroidal thickness was measured at 355 μm, 545 μm, 486 μm, and 669 μm in the affected eyes. While AOFVD typically manifests bilaterally, these cases demonstrate a unique unilateral presentation, highlighting the importance of comprehensive examination and differential diagnosis. Distinguishing cases with unilateral presentation from other conditions can be more challenging, so awareness of this unusual phenotype and its clinical characteristics must be raised. Choroidal thickness measurements provide additional insights into AOFVD pathophysiology, suggesting a potential association with the pachychoroid spectrum.

Adult-onset foveomacular vitelliform dystrophy: epidemiology, pathophysiology, imaging, and prognosis

Adult-onset foveomacular dystrophy (AOFVD) is a retinal pattern dystrophy that may affect up to 1 in 7,400 individuals. There is much that is unknown regarding this disease's epidemiology, risk factors for development, and rate of progression through its four stages. Advancements in retinal imaging over the past 15 years have enabled improved characterization of the different stages of AOFVD. These imaging advancements also offer new ways of differentiating AOFVD from phenotypically similar retinal diseases like age-related macular degeneration and Best disease. This review synthesizes the most recent discoveries regarding imaging correlates within AOFVD as well as risk factors for the development of AOFVD, complications of AOFVD, and treatment options. Our aim is to provide ophthalmologists a succinct resource so that they may offer clarity, guidance, and appropriate monitoring and treatments for their patients with suspected AOFVD.