Visual function and course of basal laminar drusen combined with vitelliform macular detachment

Cuticular Drusen in Age-Related Macular Degeneration: Association with Progression and Impact on Visual Sensitivity

PURPOSE

To determine the prognostic significance and impact on visual function of the cuticular drusen phenotype in a cohort with intermediate age-related macular degeneration (AMD).

DESIGN

Longitudinal observational study.

PARTICIPANTS

Participants aged 50 years or older, with bilateral large conventional drusen, without late AMD.

METHODS

Multimodal imaging (MMI) and microperimetry were performed at baseline, and then every 6 months for up to 3 years. Eyes were graded for the MMI-presence of cuticular drusen at baseline. Color fundus photographs were used to grade for the presence of pigmentary abnormalities. Optical coherence tomography (OCT) scans were used to calculate drusen volume. The association between cuticular drusen and progression to MMI-defined late AMD (including OCT signs of atrophy), as well as the impact on visual sensitivity were examined, with and without adjustment for the confounders of baseline age, pigmentary abnormalities and drusen volume.

MAIN OUTCOME MEASURES

Time to develop MMI-defined late AMD and change in mean visual sensitivity.

RESULTS

280 eyes from 140 participants were included, with 70 eyes from 35 (25%) individuals having cuticular drusen at baseline. Cuticular drusen were not significantly associated with an increased rate of progression to late AMD, with and without adjustment for confounders (P ≥ 0.784 for both). In an adjusted model, cuticular drusen were not associated with lower baseline visual sensitivity (P = 0.758) or with a faster rate of visual sensitivity decline (P = 0.196).

CONCLUSIONS

In a cohort with bilateral large conventional drusen, individuals with the cuticular drusen phenotype neither had a higher, nor lower, risk of developing late AMD over 3 years, and were not associated with a difference in rate of visual sensitivity decline compared to those without this phenotype. As such, individuals with this phenotype currently warrant similar monitoring strategies to those with conventional drusen.

Localised relative scotoma in cuticular drusen

PURPOSE

To investigate retinal sensitivity changes in eyes with pure cuticular drusen.

METHODS

Multimodal imaging and microperimetry (37-loci grid) data were examined retrospectively to evaluate functional changes in eyes with pure cuticular drusen. Mean sensitivity in the cuticular drusen cohort was compared to age-matched normals. An age- and loci-specific normative reference was created to analyse localised sensitivity deviation.

RESULTS

The mean number loci with relative scotoma in the cuticular drusen cohort (n = 27, mean [SD] age: 48.5 [12.4] years) referenced to normal eyes (n = 80, 53.5 [14.6] years) was 5.5 (95% confidence interval 3.0 to 8.1). However, mean sensitivity was not statistically different to the age-matched normal cohort (95% CI, - 2.3 to + 3.4 dB). The 37-loci grid was stratified into three rings of the approximately same number of loci, and the percentage of cuticular drusen eyes with pointwise deviation was significantly lower in the inner compared to the middle ring (12.3 [5.3]% vs. 17.3 [5.1]%, p < 0.05).

CONCLUSIONS

Eyes with cuticular drusen demonstrated relative scotoma, but mean sensitivity was not affected. Pointwise sensitivity provides a more robust measure of retinal sensitivity than mean sensitivity in cuticular drusen and should be assessed both in the clinic and in future clinical trials.

Clinical Manifestations of Cuticular Drusen: Current Perspectives

Cuticular drusen are part of the spectrum of age-related macular degeneration (AMD) with particular clinical and multimodal imaging characteristics. This drusen subpopulation shares several high-risk single nucleotide polymorphisms with AMD. Despite this feature, they can manifest at a relatively young age, presenting with a female preponderance. Multimodal imaging is essential for characterizing such lesions, using a combination of color fundus photographs, optical coherence tomography (OCT), fluorescein angiography (FA), and fundus autofluorescence (FAF). The classic starry-sky pattern visible on FA and the typical central hypoautofluorescent lesion with hyperautofluorescent rim on FAF is considered the result of a central retinal pigment epithelium (RPE) erosion from these triangular elevations of the RPE-basal lamina. This finding may also be responsible for the typical choroidal hypertransmission appreciated through OCT. The clinical course of cuticular drusen may be relatively benign at early stages, with small drusen presenting at a young age. However, the presence of clinical phenotypes characterized by diffuse involvement and/or accompanying large drusen in patients older than 60 years may confer a significant risk for either macular neovascularization or geographic atrophy.

SEROUS MACULAR DETACHMENT IN BEST DISEASE: A Masquerade Syndrome

PURPOSE

To describe the clinical and multimodal imaging findings of a series of cases of serous macular detachment (SMD) caused by Best disease (BD) masquerading as neovascular age-related macular degeneration or central serous chorioretinopathy that were inappropriately treated with intravitreal anti-vascular endothelial growth factor or laser therapy. This study will also present data to support age-related progressive choroidal thickening in BD patients, which may play a role in the development of SMD in this population.

METHODS

Clinical examination and multimodal imaging findings, including color fundus photography, spectral-domain optical coherence tomography, fundus autofluorescence, fluorescein angiography, and optical coherence tomography-angiography, were reviewed and analyzed. Subfoveal choroidal thickness was also formally measured, and an age-related choroidal thickness analysis was performed and compared with a normal population.

RESULTS

Twenty-six eyes of 13 patients (5 women) were included. Median age was 44 years. Nine patients presented with a history of SMD and subretinal fluid recalcitrant to various therapies, including intravitreal anti-vascular endothelial growth factor injections and photodynamic therapy. Best disease was subsequently diagnosed genetically in six patients and by detailed family history in seven. Mean logarithm of the minimum angle of resolution best-corrected visual acuity for all 26 eyes at last follow-up was +0.36 (Snellen equivalent of 20/46). Subfoveal choroidal thickness positively correlated with age for our cohort, increasing linearly at a rate of 25.6 µm per decade (R = 0.64; P < 0.001). Choroidal neovascularization was identified in four eyes on optical coherence tomography angiography, but these eyes did not respond to anti-vascular endothelial growth factor treatment.

CONCLUSION

The diagnosis of BD should be considered in patients presenting with SMD and recalcitrant subretinal fluid masquerading as neovascular age-related macular degeneration or chronic central serous chorioretinopathy to avoid unnecessary treatment procedures. The positive correlation of subfoveal choroidal thickness with age in BD patients may be a factor in the pathogenesis and development of SMD in this population. Recognizing the multimodal imaging features of SMD associated with BD, described in detail in this study, will guide practitioners to the accurate diagnosis of BD and reduce the risk of unnecessary intraocular procedures with potential complications.

Clear subretinal fluid in a case of non-neovascular early-onset drusen: Swept-source imaging evaluation

A 50-year-old male presented with recent metamorphopsia in the right eye. Fundus examination revealed bilateral multiple cuticular drusen along with few large colloid drusen (phenotype 3 cuticular drusen). No vitelliform material was evident in the macula in either eye. Fluorescein angiography (FA), indocyanine green angiography (ICGA) did not demonstrate a macular neovascularization (MNV) in either eye. Swept-source optical coherence tomography (SS-OCT) revealed sub-retinal pigment epithelial (RPE) drusen and a clear space beneath the inter-digitation zone and above the RPE-Bruch's complex. SS-OCTA did not reveal MNV in either eye. The patient was kept under observation, and follow-up at 3 months did not reveal any structural change. Among patients with early-onset drusen, vitelliform detachments may occur due to accumulation of yellow pseudo-vitelliform material. However, serous detachments with an "optically clear" subretinal space can occur by the same mechanism without MNV. Such patients do not merit therapy with anti-vascular endothelial growth factor agents.

Clinical manifestations of cuticular drusen in Korean patients

Cuticular drusen show some similarities to and differences from soft drusen in age-related macular degeneration (AMD) and might thus be a unique AMD subtype. Previous studies on cuticular drusen were performed mainly in white ethnic groups, but AMD shows ethnic differences. We investigated clinical manifestations of cuticular drusen in Korean patients to evaluate possible ethnic differences. Clinical records of Korean patients with cuticular drusen were retrospectively reviewed. Fundus distribution pattern, imaging features, and presence of large drusen, drusenoid pigment epithelial detachment (PED), and macular complications, including geographic atrophy (GA), choroidal neovascularization (CNV), and acquired vitelliform lesion (AVL), were assessed via multimodal imaging in 162 eyes with cuticular drusen (n = 81 patients; 67 females; mean age: 66.6 ± 9.1 years). Diffuse distribution was found in 61.7% and peripapillary involvement in 75.3% of eyes. Large drusen, drusenoid PED, GA, CNV, and AVL were observed in 59.3%, 26.5%, 18.5%, 3.7%, and 1.2% of eyes, respectively. The macular complication prevalence was similar between patients ≤ 60 and those > 60 years old. In Korean patients, cuticular drusen were less frequently associated with macular complications than in white patients, and the proportion of macular complications differed significantly, with AVL representing an uncommon complication.

CUTICULAR DRUSEN: Risk of Geographic Atrophy and Macular Neovascularization

PURPOSE

Cuticular drusen (CD) have been associated with manifestations of age-related macular degeneration such as atrophy and neovascularization in the macula. In this study, eyes with CD were followed and investigated for the estimated 5-year risk of progression to sequelae of age-related macular degeneration such as geographic atrophy (GA) and macular neovascularization (MNV).

METHODS

A consecutive series of patients with CD were followed for the development of GA and MNV. Whenever possible, they were also studied retrospectively. The patients with CD were categorized into three phenotypic groups. Phenotype 1: eyes had concentrated, densely populated CD in the macular and paramacular area, Phenotype 2: eyes showed scattered CD in the posterior fundus, and Phenotype 3: involved eyes with CD mixed with large drusen (>200 µm). The 5-year incidence of progression was then estimated using a Kaplan-Meier estimator.

RESULTS

A total of 63 eyes from 38 patients (35 women with a mean age at presentation of 58.9 ± 14.2 years) were studied and followed for a mean of 40 ± 18 months. Thirteen patients had single eyes with GA (84.5%; 11/13) or MNV (15.5%; 2/13) in one eye at presentation and were subsequently excluded. Geographic atrophy developed in 19.0% (12/63) of eyes and MNV in 4.8% (3/63) of eyes. The cumulative estimated 5-year risk of GA and MNV was 28.4% and 8.7%, respectively. The estimated 5-year incidence of MNV or GA was 12.6%, 50.0%, and 51.6% in Phenotype 1, Phenotype 2, and Phenotype 3, respectively (P = 0.0015, log-rank test). No difference in risk was found in the development of GA or MNV (P = 0.11) between the subgroup of patients presenting with GA or MNV in their fellow eye and those with both eyes included.

CONCLUSION

When patients with CD are followed longitudinally, there was a significant risk of progression to GA or MNV for Phenotype 2 and Phenotype 3. Patients with CD are commonly first diagnosed in the fifth decade of life, and there is a female predominance. Clinicians should use multimodal imaging to detect and be aware of the risk of progression to manifestations of GA and MNV. These risks of GA and MNV suggest that patients with CD may be part of the overall spectrum of age-related macular degeneration.

Mesopic and dark-adapted two-color fundus-controlled perimetry in patients with cuticular, reticular, and soft drusen

PURPOSE

To examine the feasibility and utility of dark-adapted two-color fundus-controlled perimetry (FCP) in patients with cuticular, reticular, and soft drusen, and to compare FCP data to microstructural spectral-domain optical coherence tomography (SD-OCT) data.

METHODS

Forty-four eyes (24 eyes of 24 patients with drusen, age 69.4 ± 12.6 years; 20 normal eyes of 16 subjects, 61.7 ± 12.4 years) underwent duplicate mesopic, dark-adapted cyan and dark-adapted red FCP within 14° of the central retina (total of 12 936 threshold tests) using the Scotopic Macular Integrity Assessment (S-MAIA, CenterVue, Padova, Italy) device. FCP data were registered to SD-OCT data to obtain outer nuclear layer, inner and outer photoreceptor segment, and retinal pigment epithelium drusen complex (RPEDC) thickness data spatially corresponding to the stimulus location and area (0.43°). Structure-function correlations were assessed using mixed-effects models.

RESULTS

Mean deviation values for eyes with cuticular, soft, and reticular drusen were similar for mesopic (-2.1, -3.4, and -3.6 dB) and dark-adapted red (-1.4, -2.6, and -3.3 dB) FCP. For the dark-adapted cyan FCP (0.1, -1.9, and -5.0 dB) and for the cyan-red sensitivity difference (+1.0, +0.5, and -2.4 dB), the mean deviation values differed significantly in dependence of the predominant drusen type (one-way ANOVA; p < 0.05). RPEDC thickness was associated with reduction of mesopic sensitivity (-0.34 dB/10 µm RPEDC thickening; p < 0.001), dark-adapted cyan sensitivity (-0.11 dB/10 µm RPEDC thickening; p = 0.003), and dark-adapted red sensitivity (-0.26 dB/10 µm RPEDC thickening; p < 0.001).

CONCLUSIONS

In contrast to mesopic FCP, dark-adapted two-color FCP allowed for meaningful differential testing of rod and cone function in patients with drusen indicating predominant cone dysfunction in eyes with cuticular drusen and predominant rod dysfunction in eyes with reticular drusen. RPEDC thickness was the strongest predictor of the evaluated SD-OCT biomarkers for point-wise sensitivity.

Cuticular Drusen: Clinical Phenotypes and Natural History Defined Using Multimodal Imaging

PURPOSE

To define the range and life cycles of cuticular drusen phenotypes using multimodal imaging and to review the histologic characteristics of cuticular drusen.

DESIGN

Retrospective, observational cohort study and experimental laboratory study.

PARTICIPANTS

Two hundred forty eyes of 120 clinic patients with a cuticular drusen phenotype and 4 human donor eyes with cuticular drusen (n = 2), soft drusen (n = 1), and hard drusen (n = 1).

METHODS

We performed a retrospective review of clinical and multimodal imaging data of patients with a cuticular drusen phenotype. Patients had undergone imaging with various combinations of color photography, fluorescein angiography, indocyanine green angiography, near-infrared reflectance, fundus autofluorescence, high-resolution OCT, and ultrawide-field imaging. Human donor eyes underwent processing for high-resolution light and electron microscopy.

MAIN OUTCOME MEASURES

Appearance of cuticular drusen in multimodal imaging and the topography of a cuticular drusen distribution; age-dependent variations in cuticular drusen phenotypes, including the occurrence of retinal pigment epithelium (RPE) abnormalities, choroidal neovascularization, acquired vitelliform lesions (AVLs), and geographic atrophy (GA); and ultrastructural and staining characteristics of druse subtypes.

RESULTS

The mean age of patients at the first visit was 57.9±13.4 years. Drusen and RPE changes were seen in the peripheral retina, anterior to the vortex veins, in 21.8% of eyes. Of eyes with more than 5 years of follow-up, cuticular drusen disappeared from view in 58.3% of eyes, drusen coalescence was seen in 70.8% of eyes, and new RPE pigmentary changes developed in 56.2% of eyes. Retinal pigment epithelium abnormalities, AVLs, neovascularization, and GA occurred at a frequency of 47.5%, 24.2%, 12.5%, and 25%, respectively, and were significantly more common in patients older than 60 years of age (all P < 0.015). Occurrence of GA and neovascularization were important determinants of final visual acuity in eyes with the cuticular drusen phenotype (both P < 0.015). Small cuticular drusen typically demonstrated a homogenous ultrastructural appearance similar to hard drusen, whereas fragmentation of the central and basal contents was seen frequently in larger cuticular drusen.

CONCLUSIONS

Although the ultrastructural characteristics of cuticular drusen appear more similar to those of hard drusen, their lifecycle and macular complications are more comparable with those of soft drusen. Cuticular drusen phenotype may confer a unique risk for the development of GA and neovascularization.

CHOROIDAL THICKENING IN PATIENTS WITH CUTICULAR DRUSEN COMBINED WITH VITELLIFORM MACULAR DETACHMENT

PURPOSE

To analyze the subfoveal choroidal thickness (SFCT) in patients with cuticular drusen.

METHODS

Retrospective, monocentric, study of consecutive patients examined with enhanced depth imaging spectral domain optical coherence tomography (EDI SD-OCT, Cirrus, Zeiss) between 2009 and 2014 in a tertiary care center. Measurements of the height of the subfoveal vitelliform detachment and SFCT were manually performed.

RESULTS

Thirteen patients, 3 men and 10 women, aged from 35 to 73 (mean: 53.6 years) were selected. For the 24 eyes without macular atrophy at first visit, SFCT ranged from 195 to 559 µm (mean ± SD = 317.5 ± 93). The SFCT was significantly thicker in 12 eyes with vitelliform macular detachment at presentation (369 ± 96, median = 368.5) than in 12 eyes without (266 ± 58, median = 257.5) (P = 0.007), whereas the 2 groups did not differ in age (P = 0.35) or refractive error (P = 0.56). No correlation was observed between SFCT and the height of the foveal detachment. For 10 eyes followed up longer than 24 months (mean: 38.9 months), the SFCT significantly decreased over time, from 375 ± 96 (median = 368.5) to 303 ± 138 (median = 319) µm (P = 0.022).

CONCLUSION

Eyes with cuticular drusen combined with vitelliform macular detachment present with choroidal thickening, suggesting that the choroidal vasculature may play a role in the occurrence of macular detachments in patients with cuticular drusen. The life cycle of these vitelliform lesions evolves from translucent subretinal fluid to the accumulation of yellowish material eventually resolving and leading to atrophy with marked and rapid thinning of the choroid.

Retinal angiomatous proliferation in an eye with cuticular drusen

Purpose

To report the presence of retinal angiomatous proliferation (RAP) in an eye with cuticular drusen detected by fluorescein and indocyanine green angiography by confocal scanning laser ophthalmoscopy and by spectral-domain optical coherence tomography (SD-OCT).

Methods

Case report of a 65-year-old Japanese woman with cuticular drusen.

Results

At her first ophthalmic examination, her visual acuity was 20/20 in both eyes. An ophthalmoscopy showed many small subretinal pigment epithelial deposits in both eyes. These deposits had a ‘saw-tooth pattern’ in the SD-OCT images. During the follow-up examination, retinal hemorrhages were observed, and fluorescein angiography showed a ‘stars-in-the-sky’ appearance and intraretinal neovascularization. The patient was diagnosed with cuticular drusen associated with RAP.

Conclusion

We suggest that the cuticular drusen were associated with RAP, so periodic follow-up examinations are needed for patients with cuticular drusen for the early detection and treatment of RAP.

Multimodal imaging of adult-onset foveomacular vitelliform dystrophy

Adult-onset foveomacular vitelliform dystrophy (AOFVD) is a clinically heterogeneous maculopathy that may mimic other conditions and be difficult to diagnose. It is characterized by late onset, slow progression and high variability in morphologic and functional alterations. Diagnostic evaluation should include careful ophthalmoscopy and imaging studies. The typical ophthalmoscopic findings are bilateral, asymmetric, foveal or perifoveal, yellow, solitary, round to oval elevated subretinal lesions, often with central pigmentation. The lesions characteristically demonstrate increased autofluorescence and hypofluorescent lesions surrounded by irregular annular hyperfluorescence on fluorescein angiography. Optical coherence tomography studies demonstrate homogenous or heterogeneous hyperreflective material between the retinal pigment epithelium and the neurosensory retina. The visual prognosis is generally favorable, but visual loss can occur from chorioretinal atrophy and choroidal neovascularization.

Spectral domain optical coherence tomography characteristics of cuticular drusen

PURPOSE

To evaluate the appearance of cuticular drusen with spectral domain optical coherence tomography.

METHODS

Eyes of patients with cuticular drusen were imaged using a prototype spectral domain optical coherence tomography instrument with 5-microm axial resolution. Thickness maps were obtained after automated segmentation of the internal limiting membrane and retinal pigment epithelium layers using a proprietary algorithm. The volume of subretinal fluid (SRF) was calculated using a manual segmentation technique that involved drawing boundaries around the SRF. The repeatability of these measurements was tested by comparing the volume measurements from multiple scans performed on the same day in four eyes of three patients.

RESULTS

Sixteen eyes from eight patients with cuticular drusen were scanned. Areas of decreased retinal thickness overlying drusen were best visualized using the three-dimensional retinal thickness map. The distribution and sawtooth pattern of cuticular drusen were best visualized using three-dimensional retinal pigment epithelium segmentation. Of the 16 eyes, 13 had SRF within the macula. In the eyes with macular SRF, characteristic excrescences were present along the outer retina and attenuation of the photoreceptor inner and outer segment boundary were observed in many areas. In areas where the retina was detached, the retinal pigment epithelium-Bruch's membrane complex appeared nodular or attenuated. The volumetric measurements of the SRF were performed using a manual segmentation with a 1.11% mean difference between repeated measurements on the same day (range, 0.47-1.68%; standard deviation, 0.55%).

CONCLUSION

The sawtooth pattern of drusen and the presence of excrescences along the detached outer retina are characteristic features of cuticular drusen that should be helpful in confirming the diagnosis of this condition. The volumetric analysis of the SRF is repeatable and may be useful in following the clinical course of these patients.

Extensive macular atrophy with pseudodrusen-like appearance: a new clinical entity

PURPOSE

To describe a previously unreported clinical entity of progressive extensive macular atrophy and pseudodrusen-like appearance in middle-aged patients.

DESIGN

Clinical, electrophysiologic, and molecular retrospective study.

METHODS

The database of an outpatient clinic unit for genetic sensory diseases was screened for patients older than 40 years with uncharacterized macular dystrophy. Patients with extensive macular atrophy and pseudodrusen-like appearance were included.

RESULTS

Eighteen patients of 45 records (40%) matched the inclusion criteria. Bilateral polycyclic well-delineated chorioretinal atrophy extending to the temporal vascular arcades, with a larger vertical axis and without sparing of the fovea featured the macular lesion. The pseudodrusen-like appearance was widespread throughout the posterior pole and the peripheral retina. In the extreme periphery, paving stone lesions were located mostly in the inferior quadrants. In contrast to age-related macular degeneration, a rapid progression of the atrophy was observed with an early involvement of the foveal zone, thus leading to a severe visual loss. All the patients except 2 were legally blind at the end of the follow-up. Unlike age-related macular degeneration, in none of these patients did choroidal neovascularization develop. In all patients, the scotopic and photopic electroretinography responses were reduced.

CONCLUSIONS

Extensive macular atrophy with pseudodrusen should be considered as a possible pattern of severe macular dystrophy occurring in the middle-aged adult.

Vitelliform macular detachment associated with Basal laminar drusen is unresponsive to vascular endothelial growth factor blockade

PURPOSE

To determine whether vascular endothelial growth factor (VEGF) mediates the leakage in basal laminar drusen (BLD)-associated vitelliform macular detachment (VMD) and whether VEGF blockade can improve visual function in affected eyes.

METHODS

Interventional case report.

PATIENT

A 46-year-old woman presented with decreased visual acuity in the right eye and BLD-associated VMD.

RESULTS

There was no improvement in visual acuity, fundus appearance, or findings of fluorescein angiography and optical coherence tomography after two intravitreal injections of anti-VEGF agents, suggesting that the exudation is not VEGF mediated.

CONCLUSION

Ophthalmologists should distinguish BLD-associated VMDs from age-related macular degeneration-associated choroidal neovascularization to avoid exposing patients to the risk of unnecessary intravitreal injections.

Pseudo-vitelliform macular detachment and cuticular drusen: exclusion of 6 candidate genes

PURPOSE

The etiology and genetic cause of pseudo-vitelliform macular detachment with cuticular drusen (PVMD/CD) are unknown; nor is it clear if this phenotype represents a separate disease entity, or is a sub-phenotype of disorders with overlapping clinical presentation. To answer this question, we screened a cohort of patients affected with PVMD/CD for variation in six plausible candidate genes (ABCA4, VMD2, TIMP-3, peripherin/RDS, fibulin 5 (FIBL5) and complement factor H (CFH)) associated with diseases of overlapping phenotypes.

METHODS

Twenty-eight patients, diagnosed with pseudo-vitelliform macular detachment and cuticular drusen, were evaluated by clinical examination, fundus photography, fluorescein angiography and autofluorescence imaging. DNA from all study subjects were screened for variants in the ABCA4, VMD2, TIMP-3, peripherin/RDS, FIBL5 and CFH genes by a combination of DHPLC, array screening and direct sequencing.

RESULTS

All patients presented with cuticular drusen; pseudo-vitelliform detachment was seen in 21 cases, while atrophic changes following regression of the detachment were seen in the remaining 7 subjects. Visual acuity ranged from 20/20 to CF. The screening revealed an I32V mutation in peripherin/RDS in one patient and 2ABCA4 variants, T897I and G1961E, in 2 more patients. No amino acid-altering variants were detected in VMD2, TIMP-3, and FIBL5 genes. The frequency of the CFH Y402H variant in this cohort corresponded to that detected in the general population.

CONCLUSIONS

Screening of 6 candidate genes detected possibly disease-associated mutations in only 3/28 (10.7%) of patients presenting with PVMD/CD, eliminating these genes as causal for this phenotype.

PHOTODYNAMIC THERAPY AND VITELLIFORM LESIONS

PURPOSE

To investigate the effect of photodynamic therapy (PDT) with verteporfin on patients with vitelliform lesions caused by cuticular drusen or adult-onset foveomacular vitelliform dystrophy (AOFVD).

DESIGN

Observational case series.

PATIENTS AND METHODS

Eight eyes of seven patients from two centers were examined prospectively. Each patient received PDT with verteporfin applied to the vitelliform lesions.

RESULTS

Photodynamic therapy did not significantly affect the median visual acuity outcome (20/50 before PDT and 20/66 after PDT) in all seven treated patients. Of note, however, were four eyes of four patients who experienced a severe decrease in visual acuity after PDT with verteporfin. The temporary relationship of the vision loss to the treatment suggests that this may represent an adverse effect from therapy. The fluorescein angiographic appearance was virtually unchanged in all treated patients, whereas indocyanine green angiography showed typical PDT-associated reduction of choroidal perfusion in the treatment area.

CONCLUSION

Photodynamic therapy does not have a positive influence on the visual outcome in patients with vitelliform lesions and may have a negative impact on vision in some treated patients. It is important for physicians using PDT to exercise caution in distinguishing between choroidal neovascular membranes and vitelliform lesions because the outcome in this latter group may be worse with application of PDT than with the natural course.

Location, substructure, and composition of basal laminar drusen compared with drusen associated with aging and age-related macular degeneration

PURPOSE

To determine whether basal laminar drusen differ in their location, ultrastructure, or composition from drusen associated with aging and age-related macular degeneration.

METHODS

A paraffin-embedded block from an eye of a patient with basal laminar drusen was obtained. Sections were examined immunohistochemically using a battery of antibodies and lectins directed against drusen-associated proteins and glycoconjugates, respectively. Thin sections were examined by electron microscopy and compared with eyes with age-related macular degeneration.

RESULTS

Drusen in the eye with basal laminar drusen are located between the basal lamina of the retinal pigment epithelium and the inner collagenous layer of Bruch membrane, just as they are in age-related macular degeneration. Two distinct ultrastructural phenotypes are observed in the eye with basal laminar drusen; their substructure is indistinguishable from drusen phenotypes in age-related macular degeneration. Both basal laminar drusen and drusen associated with age-related macular degeneration are bound by the lectins Ricinis communis agglutinin and Arachis hypogea agglutinin (after neuraminidase digestion) and by antivitronectin, anti-HLA-DR, anti-serum amyloid P, and anti-C5 antibodies, but not by antibodies directed against basement membrane-associated heparan sulfate proteoglycan, laminin, fibrinogen, or collagen type IV.

CONCLUSIONS

These data support the notion that cuticular or basal laminar drusen are similar to, and perhaps indistinguishable from, drusen associated with age-related macular degeneration and are not nodular or diffuse thickenings of Bruch membrane, as previously suggested. Thus, we suggest basal laminar drusen is a misnomer. This clinical phenotype should be identified as "early adult onset, grouped drusen" or by the eponym "Gass syndrome." Features of basal laminar drusen, such as uniform drusen size, clustered distribution, and angiographic features, do not appear to be related to differences in drusen location, composition, or substructure.