Outer Plexiform Layer Elevations as a Marker for Prior Ocular Attacks in Patients With Behcet's Disease

Retinal Sublayer Analysis in Autoimmune Retinopathy and Identification of New Optical Coherence Tomography Phenotypes

PURPOSE

Autoimmune retinopathy (AIR) is a poorly characterized disease with a wide phenotypic spectrum, complicating investigations of its underlying pathophysiology. We sought to analyze optical coherence tomography (OCT) retinal thickness changes in AIR patients.

METHODS

A retrospective chart review from 2007 to 2017 was performed evaluating AIR patients at a single academic, tertiary referral center. OCT retinal sublayer analysis was performed, and paradoxical thickening phenotypes were reviewed.

RESULTS

Twenty-nine AIR patients with positive anti-retinal antibodies and OCT imaging were identified. Overall, AIR patients had thinner retinal sublayers compared to controls; however, 12 patients (41.4%) had paradoxical thickening of the outer plexiform layer (OPL). This revealed two distinct OCT phenotypes. No association was found between retinal sublayer thickness and specific antiretinal antibodies.

CONCLUSIONS

While the pathogenicity of antiretinal antibodies remains unclear, the OCT phenotypes observed underscore the potential for identifying clues in the underlying disease processes and clinical diagnosis.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY BIOMARKERS AND MICROPERIMETRY FEATURES IN BEHÇET'S UVEITIS

PURPOSE

To evaluate the parafoveal macular microvasculature and the macular function in patients with retinal vasculitis associated with Behçet's uveitis.

METHODS

In 14 patients with inactive Behçet's uveitis and 26 control individuals (13 with nonocular Behçet's syndrome and 13 healthy subjects), we analyzed the retinal nerve fiber layer, ganglion cell layer, full retinal thickness, foveal avascular zone area and sectorial parafoveal vascular density in the superficial vascular plexus, intermediate capillary plexus, and deep capillary plexus using SPECTRALIS optical coherence tomography (OCT) 2 and OCT angiography. Macular sensitivity was analyzed using an MP-3 microperimeter.

RESULTS

Eighteen eyes (78%) had a best-corrected visual acuity ≥ 20/25. Significant differences were found in Behçet's uveitis in comparison with the controls on the OCT and OCT angiography: 14.8%, 22.4%, and 14.9% ganglion cell layer thinning in the global, nasal, and inferior sectors, respectively; 6%, 13.2%, and 7.5% full retinal thickness thinning in the superior, nasal, and inferior sectors; and 16.8%, 14.9%, 23.6%, 15.8%, and 12.6% mean deep capillary plexus density reduction in the global, superior, nasal, inferior, and temporal sectors. Microperimetry data demonstrated significant mean reductions of 21% and 23.6% in central and average macular sensitivities and 28.8%, 40.4%, 27.7%, and 24.2% in the superior, nasal, inferior, and temporal sectors, respectively. Outer plexiform layer elevations were observed in Behçet's uveitis (69.6%).

CONCLUSION

Behçet's uveitis presented structural and functional macular damage despite good best-corrected visual acuity, mainly affecting the nasal sector and the deep capillary plexus. On OCT and OCT angiography, quantitative and qualitative changes can be valuable biomarkers of ocular involvement in Behçet's syndrome.

Stepwise approach for fundus imaging in the diagnosis and management of posterior uveitis

An array of retinochoroid imaging modalities aid in comprehensive evaluation of the immunopathological changes in the retina and choroid, forming the core component for the diagnosis and management of inflammatory disorders such as uveitis. The recent technological breakthroughs have led to the development of imaging platforms that can evaluate the layers of retina and choroid and the structural and functional alteration in these tissues. Ophthalmologists heavily rely on imaging modalities such as dye-based angiographies (fluorescein angiography and indocyanine green angiography), optical coherence tomography, fundus autofluorescence, as well as dye-less angiography such as optical coherence tomography angiograph,y for establishing a precise diagnosis and understanding the pathophysiology of the diseases. Furthermore, these tools are now being deployed with a 'multimodal' approach for swift and accurate diagnosis. In this comprehensive review, we outline the imaging platforms used for evaluation of posterior uveitis and discuss the organized, algorithmic approach for the assessment of the disorders. Additionally, we provide an insight into disease-specific characteristic pathological changes and the established strategies to rule out disorders with overlapping features on imaging.

Macular Cone Abnormalities in Behçet's Disease Detected by Adaptive Optics Scanning Light Ophthalmoscope

BACKGROUND AND OBJECTIVE

Investigations of morphological changes in photoreceptors in Behçet's disease (BD) using adaptive optics scanning light ophthalmoscope (AOSLO) are lacking. The authors aimed to evaluate macular cone density and regularity in BD patients with or without a history of uveitis with good visual acuity (VA).

PATIENTS AND METHODS

The authors included 16 patients (29 eyes) with BD and 12 healthy volunteers (12 eyes) as controls. All subjects had VA of 20/20 or higher. Subjects underwent AOSLO to evaluate the photoreceptor status including cone density (numbers/mm²) and proportion of hexagonal Voronoi domains.

RESULTS

Hyporeflective patches that were not detected in color fundus photograph or optical coherence tomography were observed by AOSLO in BD patients both with and without past uveitis history; these were not detected in the control group. Cone density was significantly reduced in BD patients with a history of uveitis compared to controls (P = .002). The proportion of hexagonal Voronoi domains was significantly reduced in BD eyes both with and without history of uveitis relative to controls (P < .001).

CONCLUSION

Macular photoreceptor damage was observed in BD patients with and without a history of uveitis. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:218-225.].

Old and New Challenges in Uveitis Associated with Behçet's Disease

Behçet’s disease (BD) is a systemic vasculitis disease of unknown origin occurring in young people, which can be venous, arterial or both, classically occlusive. Ocular involvement is particularly frequent and severe; vascular occlusion secondary to retinal vasculitis may lead to rapid and severe loss of vision. Biologics have transformed the management of intraocular inflammation. However, the diagnosis of BD is still a major challenge. In the absence of a reliable biological marker, diagnosis is based on clinical diagnostic criteria and may be delayed after the appearance of the onset sign. However, therapeutic management of BD needs to be introduced early in order to control inflammation, to preserve visual function and to limit irreversible structural damage. The aim of this review is to provide current data on how innovations in clinical evaluation, investigations and treatments were able to improve the prognosis of uveitis associated with BD.

Advances and potential new developments in imaging techniques for posterior uveitis. Part 1: noninvasive imaging methods

The aim of this review was to identify the imaging methods at our disposal to optimally manage posterior uveitis at the present time. The focus was put on methods that have become available since the 1990s, some 30 years after fluorescein angiography had revolutionized imaging of posterior uveitis in particular imaging of the retinal vascular structures in the 1960s. We have focussed our review on precise imaging methods that have been standardized and validated and can be used universally thanks to commercially produced and available instruments for the diagnosis and follow-up of posterior uveitis. The first part of this imaging review will deal with noninvasive imaging methods, focusing on fundus autofluorescence and optical coherence tomography as well as recent developments in imaging of the posterior segment.

Quantitative measurements with optical coherence tomography angiography in Behçet uveitis

PURPOSE

The aim of this study was to evaluate the quantitative measurements obtained by optical coherence tomography angiography in patients with Behçet uveitis.

METHODS

A total of 22 consecutive patients with Behçet uveitis and 19 age-matched healthy individuals were included in the study. Quantitative analysis of optical coherence tomography angiography images was performed. Comparisons between the patients and the control groups and correlation analysis between optical coherence tomography angiography results and age, visual acuity, duration of uveitis, central macular thickness, and fluorescein angiography scores in the patient group was performed.

RESULTS

The mean superficial foveal avascular zone area was 283.040 ± 113.003 µm² in the patient group and 254.268 ± 75.813 µm² in the control group (p = 0.821). The mean deep foveal avascular zone area was 317.657 ± 116.225 µm² in the patient group and 332.954 ± 94.783 µm² in the control group (p = 0.775). The foveal avascular zone area could not be calculated in eight eyes with macular atrophy in the patient group because of unclear foveal avascular zone borders. Both superficial and deep capillary vessel density in all regions were lower in the patient group than in the control. Superior, inferior, and temporal capillary vessel density were correlated with fluorescein angiography score (Pearson's r = -0.380, 0.392, and -0.384, p < 0.05 in superficial plexus; r = -0.357, -0.401, and -0.321, p < 0.05 in deep plexus, respectively). The foveal avascular zone area was correlated with central macular thickness in both superficial and deep plexus (r = -0.387 and -0.331, p < 0.05, respectively).

CONCLUSION

Recurrent uveitis attacks affecting the macula are associated with a decrease in capillary vessel density and expansion in the foveal avascular zone area in Behçet disease. The qualitative evaluation of the optical coherence tomography angiography findings may be more valuable in patients with macular atrophy.

An Algorithm for the Diagnosis of Behçet Disease Uveitis in Adults

Purpose: To develop an algorithm for the diagnosis of Behçet's disease (BD) uveitis based on ocular findings.Methods: Following an initial survey among uveitis experts, we collected multi-center retrospective data on 211 patients with BD uveitis and 207 patients with other uveitides, and identified ocular findings with a high diagnostic odds ratio (DOR). Subsequently, we collected multi-center prospective data on 127 patients with BD uveitis and 322 controls and developed a diagnostic algorithm using Classification and Regression Tree (CART) analysis and expert opinion.Results: We identified 10 items with DOR >5. The items that provided the highest accuracy in CART analysis included superficial retinal infiltrate, signs of occlusive retinal vasculitis, and diffuse retinal capillary leakage as well as the absence of granulomatous anterior uveitis or choroiditis in patients with vitritis.Conclusion: This study provides a diagnostic tree for BD uveitis that needs to be validated in future studies.

Prevalence of resolved paracentral acute middle maculopathy lesions in fellow eyes of patients with unilateral retinal vein occlusion

PURPOSE

To study the prevalence of resolved paracentral acute middle maculopathy (PAMM) lesions in fellow eyes of patients with unilateral retinal vein occlusion (RVO) and eyes of healthy individuals.

METHODS

This case-control observational study took place in a referral university medical centre. Forty-five (17 males, 28 females, 64.7 ± 10.8 years) patients with branch retinal vein occlusion (BRVO), 21 (17 males, 4 females, 68.8 ± 11.2 years) patients with central retinal vein occlusion (CRVO) and 57 healthy individuals (25 males, 32 females, 67.4 ± 10.5 years) were included. Presence of resolved PAMM lesions was evaluated by reviewing cross-sectional scans of 8-mm optical coherence tomography angiography protocol. Resolved PAMM lesion was defined as inner nuclear layer thinning with outer plexiform layer elevation.

RESULTS

Resolved PAMM lesions were found in 32/45 (71.1%) and 15/21 (71.4%) of BRVO and CRVO patients, respectively. In healthy volunteers, resolved PAMM lesions were found in 11/57 (19.3%) individuals with bilateral involvement in 8 individuals (72.7%). RVO patients demonstrated the presence of resolved PAMM lesions in fellow eye significantly more frequently than healthy individuals (odds ratio (OR) 10.6, p < 0.001, 95% CI 4.5-24.6). OR for the presence of large resolved PAMM lesions in BRVO patients and CRVO patients versus healthy individual was 12.1 (p = 0.02, 95% CI 1.5-100.9) and 22.4 (p = 0.005, 95% CI 2.5-200.6), respectively.

CONCLUSION

Resolved PAMM lesions defined as inner nuclear layer thinning associated with outer plexiform layer elevation are highly prevalent in fellow eyes of patients with unilateral RVO. Resolved PAMM lesions may have an association with RVO.

Prolonged Cone b-Wave on Electroretinography Is Associated with Severity of Inflammation in Noninfectious Uveitis

PURPOSE

This study sought to investigate retinal function in patients with noninfectious uveitis by using full-field electroretinography (ERG) and correlate the ERG to disease duration and severity of inflammation.

DESIGN

Prospective cohort study.

METHODS

Patients (n = 200) with noninfectious uveitis and a disease duration of <1 year (group A [n = 80]) and those with a disease duration of >5 years (group B [n = 120]) were included. ERGs of the total 355 uveitis eyes were measured according to an extended International Society for Clinical Electrophysiology of Vision protocol. ERG abnormalities were related to demographics and uveitis characteristics, including anatomical classification, duration of uveitis, severity of inflammation, best corrected visual acuity (BCVA), cystoid macular edema (CME), and the highest fluorescein angiography (FA) score during the course of the disease.

RESULTS

ERGs showed abnormalities in 235 eyes (66.2%). The most frequent and pronounced ERG abnormality was a prolonged implicit time of the cone b-wave (151 eyes [42.5%]), which was associated with vitritis (P = .005); cells in the anterior chamber (P = .007); the highest fluorescein angiography score (P = .011); age (P < 0.001); and pupil diameter (P < 0.001). BCVA was relatively good (0.05 logMAR [interquartile range {IQR}, 0.011, 0.22]) and not associated with this ERG abnormality. There were no differences between the ERG abnormalities in group A and those in group B and no significant associations between ERG abnormalities and anatomical classification or specific diagnoses.

CONCLUSIONS

ERG results are frequently affected in cases of noninfectious uveitis of all anatomic subtypes, including anterior uveitis without apparent inflammation of the posterior segment. ERG abnormalities appear to be associated with the severity of inflammation from both the present and the past and therefore may be seen even when signs of retinal inflammation have disappeared.