High-speed, ultra-high-resolution optical coherence tomography of acute macular neuroretinopathy

Choroidal and Retinal Vascular Findings in Patients with COVID-19 Complicated with Pneumonia: Widefield Imaging

Purpose: The purpose of this study was to analyze choroidal and retinal vascular alterations of both the macula and midperiphery areas in patients hospitalized for COVID-19 infection complicated with pneumonia within 30 days from discharge. Methods: A total of 46 eyes of 23 subjects with a history of symptomatic COVID-19 infection and recent hospitalization for pneumonia were enrolled in this observational study. Patients had not been previously vaccinated against COVID-19. A group of patients homogenous for age and sex was enrolled as controls. Microvascular retinal and choroidal features of the enrolled patients were studied with widefield optical coherence tomography angiography (OCT-A). Perfusion parameters in terms of the vessel density (VD) of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) and the choroidal vascularity index (CVI) on enhanced depth imaging (EDI) mode OCT scans were analyzed. Results: Our cohort of patients showed a trend of reduction in VD, significantly in the SCP VD of the superior and inferior midperiphery sectors, whereas the CVI did not show significant differences between the cases and controls. Moreover, a positive correlation between CVI and vessel density in the deep capillary plexus in the macular area (VD-DCP-MAC) was found. Conclusion: The systemic disease due to COVID-19 can also involve the retina and choroid with multiple mechanisms: ischemic and inflammatory. Our study showed changes in perfusion occurring in the eyes of patients with a recent hospitalization for COVID-19 complicated with pneumonia and without any possible ocular effect due to the vaccines. There is still the need to better comprise how long COVID-19 actually affects vascular changes in the eye.

Tacrolimus Induced Thrombotic Microangiopathy (TMA) Presenting as Acute Macular Neuroretinopathy

This report highlights the association of tacrolimus use with acute macular neuroretinopathy (AMN). A 27-year-old woman, a known case of diffuse proliferative membranous glomerulonephritis, developed abnormal body movements, loss of consciousness, and blurring of vision in the left eye, after 3 months of starting tacrolimus. Blood investigations revealed anemia, thrombocytopenia, raised urea and creatinine levels, and raised LDH levels. A diagnosis of tacrolimus induced hemolytic uremic syndrome (HUS) with posterior reversible encephalopathy syndrome (PRES) was made. Ocular examination revealed a reddish-brown petaloid retinal lesion, which was better appreciated on red-free imaging as dark grey area pointing towards the fovea. OCT-A and SD-OCT revealed flow voids in deep retinal plexus, and disruption of ellipsoid and interdigitation zone, respectively, findings consistent with AMN. To the best of our knowledge, it is the first report of association of tacrolimus with AMN.

Deep Capillary Plexus Features in Acute Macular Neuroretinopathy: Novel Insights Based on the Anatomy of Henle Fiber Layer

PURPOSE

The purpose of this study was to identify a precise location of deep capillary plexus (DCP) injury in acute macular neuroretinopathy (AMN) lesions using multimodal imaging.

METHODS

En face structural optical coherence tomography (OCT) images were manually segmented to delineate outer retinal AMN lesions involving the ellipsoid zone and interdigitation zone. AMN lesion centroid was calculated, and image distortion was applied to correct for Henle fiber layer (HFL) length and orientation. The resulting image was registered with the corresponding en face OCT angiography (OCTA) image segmented at the DCP and structural OCT volume before grading for vascular and structural features, respectively.

RESULTS

Thirty-nine AMN lesions from 16 eyes (11 female patients, mean age 34 ± 4 years) were analyzed. After correcting for HFL anatomy, in 62% of AMN lesions, the centroid co-localized with a capillary vortex (pattern 1); flow defects were detected in 33% of lesions (pattern 2); and in 5% of lesions no specific pattern could be identified (pattern 3). The detection of a specific pattern increased after correcting the projection of AMN lesion for HFL anatomy (28% vs. 5%, P = 0.04). Outer nuclear layer thickness was lower in the centroid area in 10 (29%) AMN lesions from 6 patients, all corresponding to lesions fitting pattern 2 (r = 0.78, P < 0.001).

CONCLUSIONS

AMN lesions might be a result of DCP impairment at the level of the capillary vortex or draining venule. In eyes with AMN, the location of outer retinal changes associated with DCP ischemia appears to be influenced by the length and orientation of HFL.

Ocular Complications Following Vaccination for COVID-19: A One-Year Retrospective

Vaccination efforts as a mitigation strategy in the corona virus disease 2019 (COVID-19) pandemic are fully underway. A vital component of understanding the optimal clinical use of these vaccines is a thorough investigation of adverse events following vaccination. To date, some limited reports and reviews have discussed ocular adverse events following COVID-19 vaccination, but a systematic review detailing these reports with manifestations and clinical courses as well as proposed mechanisms has yet to be published. This comprehensive review one-year into vaccination efforts against COVID-19 is meant to furnish sound understanding for ophthalmologists and primary care physicians based on the existing body of clinical data. We discuss manifestations categorized into one of the following: eyelid, orbit, uveitis, retina, vascular, neuro-ophthalmology, ocular motility disorders, and other.

Maculopathy Masquerading as Migraine

We describe a case of a 23-year-old Caucasian woman with a background history of migraines who presented with bilateral paracentral scotomata. The ophthalmoscopy and MRI head were originally thought to be normal, and the scotomata were attributed to be of migrainous origin: a persistent negative aura. However, persistence of her symptoms prompted further specialist review 10 months later, at which time subtle bilateral perifoveal changes were noted, which had been apparent but overlooked at the initial assessment. Near-infrared reflectance imaging enabled better visualization of the lesions, which were apparent prior to any abnormalities on clinical examination. Spectral-domain optical coherence tomography revealed the early findings of hyperreflectivity in the outer nuclear and outer plexiform layers characteristic of acute macular neuroretinopathy. Our case aims to emphasize the importance of scrutinising ancillary tests of the macula in patients presenting with scotomata or atypical migraine symptoms, and to caution clinicians against diagnosing migraine with persistent negative aura without these investigations.

Bilateral Acute Macular Neuroretinopathy in a Young Patient: Imaging and Visual Field during Two-Year-Follow-Up

Acute macular neuroretinopathy (AMN) is a rare disorder. We report a case of bilateral AMN in a young female patient, without any risk factors. She referred a positive scotoma in both eyes after flu-like symptoms. Fundus examination revealed parafoveal dark-reddish oval lesions in both eyes. Therefore, we performed visual field, optical coherence tomography (OCT), fluorescein angiography (FA) and indocyanine green angiography (ICG) at baseline and several times during the two years of follow-up. The infrared (IR) imaging showed one rounded hyporeflective lesion in the left eye and two similar lesions in the right eye. The OCT demonstrated the characteristic alterations in the outer retina. The visual field also demonstrated scotomas corresponding with these lesions. The OCT and IR features disappeared at the end of the follow-up except for the left eye, which continued to have hyperreflective spots in the outer plexiform layer. The patient complained about a residual scotoma only in the left eye after two years. Our case shows a difference in disease progression in the two eyes of the same patient, suggesting that several mechanisms can be implicated in the pathology of AMN.

Occult Acute Macular Neuroretinopathy

A 19-year-old Caucasian woman developed an upper respiratory infection, took a cold formulation containing 5 mg of phenylephrine, and developed a very rare and unusual form of acute macular neuroretinopathy (AMN) that could not be detected on fundoscopic examination, visual fields, nor electrophysiological testing. Spectral-domain optical coherence tomography (SD-OCT) revealed a lesion limited to the fovea. This case illustrates the value of SD-OCT, in light of otherwise normal testing, in a variant of AMN the authors call "occult AMN".

Acute macular neuroretinopathy associated with subclinical cytomegalovirus infection

PURPOSE

To report a case of bilateral acute macular neuroretinopathy (AMN) occurring in a 32-year-old woman, analyzed using the multimodal imaging technique.

CASE REPORT

A 32-year-old Caucasian woman presented with 20 days history of acute onset of blurred vision in the right eye. The best-corrected visual acuity (BCVA) was 0.8 and 1.0 in the right and left eyes, respectively. She reported a lower urinary tract infection associated with fever, 7 days before the onset of the ocular symptoms. Serological tests demonstrated the presence of IgM specific for cytomegalovirus (CMV), while all the other laboratory tests were negative. SD-OCT exhibited the disruption of the inner segment-outer segment junction, associated with hyper-reflectivity of a thickened outer plexiform layer overlying such area associated with thinning of the outer nuclear layer. The patient was diagnosed with AMN and received a corticosteroid treatment. During all the follow-up, OCT features did not change, although BCVA improved. Four months after the first visit, we found also in the left eye a subfoveal IS/OS disruption but differently from the right eye, in which the abnormalities persisted during all the follow-up visits, in the left one they disappeared only after a month. The IgM specific for the CMV remained positive during the whole follow-up.

CONCLUSIONS

To our knowledge, this is the first patient reported with a diagnosis of AMN associated with persisting presence of IgM specific for CMV.

Acute Macular Neuroretinopathy Following Non-Ocular Trauma: A Hypothesis Regarding Pathophysiologic Mechanism

BACKGROUND AND OBJECTIVE

To describe the imaging characteristics and clinical course of acute macular neuroretinopathy (AMN) following non-ocular trauma, and to hypothesize a pathophysiologic mechanism for this syndrome.

PATIENTS AND METHODS

The records of five patients who developed symptoms and findings suggestive of AMN following trauma to the face or chest were retrospectively reviewed. Optical coherence tomography (OCT), infrared reflectance, fundus autofluorescence, fluorescein and indocyanine green angiography, and multifocal electroretinography were evaluated.

RESULTS

Visual symptoms started immediately or very soon after non-ocular trauma, and scotomas persisted at last follow-up (2 weeks to 10 years after trauma). OCT imaging performed within days of the trauma demonstrated focal areas of hyper-reflectivity in the outer plexiform and outer nuclear layers with eventual thinning of the outer nuclear layer, as well as variable loss of the ellipsoid and interdigitation zones.

CONCLUSION

Acute ischemic injury caused by trauma-induced hypotension and/or catecholamine release and involving the deep retinal capillary plexus is the pathogenic mechanism that most plausibly explains trauma-associated AMN.

Functional and high-resolution retinal imaging monitoring photoreceptor damage in acute macular neuroretinopathy

BACKGROUND

To report functional and high-resolution retinal imaging abnormalities, including adaptive optics (AO) throughout the course of acute macular neuroretinopathy (AMNR).

METHODS

Two female patients (four eyes) with a diagnosis of AMNR were observed at the Clinical Investigation Center, CHNO des Quinze-Vingts, Paris, France. The patients underwent detailed ophthalmic examination including best-corrected visual acuity, slit-lamp examination, kinetic and static perimetry, full-field and multifocal electroretinogram, infrared reflectance, autofluorescence imaging and spectral-domain optical coherence tomography (SD-OCT) and AO fundus imaging at presentation and during follow-up.

RESULTS

Both cases showed concomitant loss of integrity of the outer retinal structures on SD-OCT, and marked abnormalities on AO imaging with disruption of the visibility of the cone mosaic. In the first case, photoreceptor damage was seen to progress during several weeks before healing. In both cases, there were persistent morphological abnormalities of photoreceptors 1 year after onset.

CONCLUSION

This study further highlights the value of AO fundus imaging to facilitate detection, mapping, and monitoring of damage to the cone outer segments during AMNR. In particular, residual damage to the cone mosaic can be precisely documented.

Adaptive optics imaging of cone mosaic abnormalities in acute macular neuroretinopathy

BACKGROUND AND OBJECTIVE

To assess the cone photoreceptor mosaic in acute macular neuroretinopathy (AMN) using adaptive optics (AO) imaging.

PATIENTS AND METHODS

Four patients with AMN were evaluated retrospectively by near-infrared reflectance (IR) confocal scanning laser ophthalmoscopy (SLO), spectral-domain optical coherence tomography (SD-OCT), and a flood-illuminated retinal AO camera. Microperimetry was performed in one patient.

RESULTS

The cone photoreceptor density was decreased at the level of the AMN lesions. The cone mosaic disruption appeared heterogeneous and more widespread than the lesion detected in the IR-SLO and SD-OCT images. The areas of cone loss correlated with SD-OCT and microperimetry. After resolution of the AMN lesion on IR-SLO, there was incomplete recovery of the cone photoreceptor mosaic.

CONCLUSION

Cone photoreceptor damage and reconstitution were documented in vivo at the cellular level in AMN using AO imaging. AO imaging appeared more sensitive than combined IR-SLO and SD-OCT to detect and follow photoreceptor damage in patients with AMN.

Selective cone photoreceptor injury in acute macular neuroretinopathy

PURPOSE

To evaluate retinal structural and functional abnormalities in a patient with acute macular neuroretinopathy.

METHODS

An adaptive optics scanning light ophthalmoscope was used to image the photoreceptor mosaic and assess rod and cone structure. Spectral-domain optical coherence tomography was used to examine retinal lamination. Microperimetry was used to assess function across the macula.

RESULTS

Microperimetry showed reduced function of localized areas within retinal lesions corresponding to subjective scotomas. Spectral-domain optical coherence tomography imaging revealed attenuation of two outer retinal bands typically thought to reflect photoreceptor structure. Adaptive optics scanning light ophthalmoscope images of the photoreceptor mosaic revealed a heterogeneous presentation within these lesions. There were areas containing non-waveguiding cones and other areas of decreased cone density where the remaining rods had expanded to fill in the vacant space. Within these lesions, cone densities were shown to be significantly lower than eccentricity-matched areas of normal retina, as well as accepted histologic measurements. A 6-month follow-up revealed no change in rod or cone structure.

CONCLUSION

Imaging of acute macular neuroretinopathy using an adaptive optics scanning light ophthalmoscope shows a preferential disruption of cone photoreceptor structure within the region of decreased retinal sensitivity (as measured by microperimetry). Adaptive optics-based imaging tools provide a noninvasive way to assess photoreceptor structure at a level of detail that is not resolved by use of conventional spectral-domain optical coherence tomography or other clinical measures.

Acute macular neuroretinopathy in a 15-year-old boy: optical coherence tomography and visual acuity findings

PURPOSE

To report a case of acute macular neuroretinopathy (AMN) in a 15-year-old boy.

METHODS

Images were obtained with fundus photography and optical coherence tomography (OCT).

RESULTS

The patient complained of blurred vision and a small central scotoma in the left eye. Left visual acuity was 0.3. Fundus photographs revealed a small dark area in the fovea of the left eye. OCT showed attenuation of the photoreceptor inner segment (IS)/outer segment (OS) line and the OS/retinal pigment epithelium (RPE) line in the left eye. One week after the initial visit, left visual acuity had improved to 0.6, and there was partial recovery of the IS/OS line with focal thinning of the OS/RPE line. One month later, left visual acuity had improved to 0.8, and OCT showed complete restoration of the IS/OS line and the OS/RPE line.

CONCLUSIONS

To our knowledge, this is the youngest patient reported with a diagnosis of AMN. Changes in microstructural findings and visual acuity were analogous during recovery of AMN in our patient.

Spectral domain optical coherence tomography evolutive features in acute macular neuroretinopathy

PURPOSE

To demonstrate the usefulness of spectral domain optical coherence tomography (SD-OCT) in investigating the evolution of the retinal outer lesions seen in acute macular neuroretinopathy (AMN).

METHODS

A 32-year-old woman presented with a 1-day history of paracentral dark spot in the left eye, preceded by a flulike illness. A full ophthalmologic examination, color vision, visual field examination, and conventional imaging of the retina were done. Scanning laser ophthalmoscopic infrared imaging and SD-OCT of the macular region were performed.

RESULTS

Best-corrected visual acuity was 20/20 in both eyes. Slit-lamp examination as well as retinal photographs were unrevealing. Scanning laser ophthalmoscopic infrared examination showed a dark, sharp, oval area in the macular region that corresponded to a rounded patch drawn by the patient on an Amsler grid. The SD-OCT showed focal highly reflective lesion of outer plexiform layer (OPL) extending to the outer nuclear layer. After recovery of the OPL, follow-up SD-OCT showed an associated disruption of the external limiting membrane and the retinal pigment epithelium inner band as well as thinning of the inner segment/outer segment junction. Retinal inner layers were otherwise normal.

CONCLUSIONS

Spectral domain optical coherence tomography is of particular interest in the diagnosis of AMN. It is also very useful in featuring the chronological events happening in the outer retina. As the lesions shown are confined to the outer layers, this condition should be called acute macular outer retinopathy rather than AMN.

Microperimetry and optical coherence tomography in acute macular neuroretinopathy

PURPOSE

To report optical coherence tomography and microperimetry findings in acute macular neuroretinopathy.

METHODS

Case report.

PATIENTS

A single patient with acute macular neuroretinopathy.

CONCLUSION

Scotomata reported by a patient with acute macular neuroretinopathy correspond with findings of disruption of the photoreceptor inner segment-outer segment junction on optical coherence tomography and congruent decreased retinal function demonstrated with microperimetry.

Infrared imaging and spectral-domain optical coherence tomography findings correlate with microperimetry in acute macular neuroretinopathy: a case report

INTRODUCTION

Spectral-domain optical coherence tomography findings in a patient with acute macular neuroretinopathy, and correlation with functional defects on microperimetry, are presented.

CASE PRESENTATION

A 25-year old Caucasian woman presented with bitemporal field defects following an upper respiratory tract infection. Her visual acuity was 20/20 in both eyes and a dilated fundus examination revealed bilateral hyperpigmentary changes in the papillomacular bundle. Our patient underwent further evaluation with spectral-domain optical coherence tomography, infrared and fundus autofluorescence imaging. Functional changes were assessed by microperimetry. Infrared imaging showed the classic wedge-shaped defects and spectral-domain optical coherence tomography exhibited changes at the inner segment-outer segment junction, with a thickened outer plexiform layer overlying these areas. Fluorescein and indocyanine green angiography did not demonstrate any perfusion defects or any other abnormality. Microperimetry demonstrated focal elevation in threshold correlating with the wedge-shaped defects in both eyes.

CONCLUSION

Spectral-domain optical coherence tomography findings provide new evidence of the involvement of the outer plexiform layer of the retina in acute macular neuroretinopathy.

Outer retinal abnormalities in acute macular neuroretinopathy

PURPOSE

To investigate the spectral-domain optical coherence tomography findings in four cases of acute macular neuroretinopathy and identify features that may differentiate acute macular neuroretinopathy from similar conditions in the acute zonal occult outer retinopathy complex.

METHODS

Patients with acute macular neuroretinopathy underwent complete periodic examinations, including ophthalmoscopy, color photography and autofluorescence photography, visual field testing, and spectral-domain optical coherence tomography. Abnormalities as seen by multimodal imaging were documented and evaluated during follow-up.

RESULTS

The average age of the 4 patients was 32 years (range, 28-34 years), and 2 had bilateral involvement. The follow-up ranged from 1 month to 5 months. In each patient, dark lobular areas seen by ophthalmoscopy corresponded to the measured visual field defect and what appeared to be a regional loss of outer segments of the photoreceptors. The outer segment defect resolved in two patients and improved in the other two during follow-up. All patients showed a colocalizing regional thinning of the outer nuclear layer, which did not change during the follow-up period. There were no associated abnormalities in the fundus appearance.

CONCLUSION

Acute macular neuroretinopathy causes reddish brown patches that are because of outer retinal damage as documented by spectral-domain optical coherence tomography. Unlike other entities in the acute zonal occult outer retinopathy complex, acute macular neuroretinopathy has no other synchronic ophthalmoscopically visible fundus abnormalities. These lesions may resolve over time, with restoration of the outermost retinal architecture, but persistent thinning of the overlying outer nuclear layer remained.

Reproducibility and comparison of retinal thickness and volume measurements in normal eyes determined with two different Cirrus OCT scanning protocols

PURPOSE

To assess reproducibility and compare raster scanning protocols of Cirrus high-definition optical coherence tomography (Carl Zeiss Meditec, Dublin, CA).

METHODS

Five hundred and twenty-eight computed tomography scans were performed in 17 healthy subjects. Four sessions were performed at each visit including two 200 × 200 and two 512 × 128 macular cube scans per session. The examined eye, observer, and order of scanning protocols in-between each session were randomly chosen. Reproducibility was described with intraclass correlation coefficients, coefficients of variance, intervisit, interrater, intersession intra-, and intersubject standard deviations.

RESULTS

Intraclass correlation coefficients ranged from 80.4% to 97.8% and the coefficients of variance from 0.7% to 2.3% for retinal volume and retinal thickness measurements. Intersubject, intervisit, interrater, intersession, and intrasubject standard deviations ranged from 0 μm to 18.54 μm. Differences in retinal thickness between protocols were small (range 3.55 ± 1.95 μm to 0.81 ± 0.59 μm) but significant for the central (P < 0.0001), the outer superior (P = 0.0036), temporal (P = 0.0026), and nasal subfield (P < 0.0001). Average difference of retinal volume between protocols was 0.05 ± 0.04 mm (P = 0.0001).

CONCLUSION

Both raster scanning protocols of the Cirrus optical coherence tomography showed excellent reproducibility of retinal thickness and volume measures. Significant differences between protocols for retinal thickness in four macula thickness map subfields and for retinal volume were found.

Acute macular neuroretinopathy: contribution of spectral-domain optical coherence tomography and multifocal ERG

BACKGROUND

Acute macular neuroretinopathy is a rare disease which occurs in young women and causes sudden paracentral scotoma and typical reddish-brown macular lesions.

MATERIAL AND METHODS

We report two cases of young women suffering from acute macular neuroretinopathy which we observed with spectral-domain Spectralis HRA-OCT and multifocal ERG at 3 and 7 months.

RESULTS

Imaging revealed an early hyper-reflectivity of the photoreceptor layer, which changed into hyporeflectivity in the first week and remained the same in the following months, whereas visual field improved.

CONCLUSIONS

Our findings show involvement primarly of the outer retina, and confirm OCT and mf ERG as important tools for diagnosis and follow-up of pathologic changes in AMNR, as other diagnostic tests often remain normal.

Visualization and follow-up of acute macular neuroretinopathy with the Spectralis HRA+OCT device

BACKGROUND

Acute macular neuroretinopathy (AMNR) is a rare disease entity, the diagnosis of which is frequently complicated by the subtlety of biomicroscopic findings.

METHODS

Two cases of AMNR are presented, in which the diagnosis and follow-up was enabled using the Spectralis HRA+OCT in the absence of clear biomicroscopic findings.

RESULTS

The typical lesions were visualized by hyporeflexion during infrared imaging and faded over time. With spectral domain optical coherence tomography, changes in the outer retina in the affected regions were documented, with no change over time.

CONCLUSION

The broader availability of this technology may enhance the diagnosis and follow-up of AMNR.