Ellipsoid Zone Defects in Retinal Vein Occlusion Correlates With Visual Acuity Prognosis: SCORE2 Report 14

Multimodal Imaging Analysis of Supra-retinal Pigment Epithelium Granular Deposits in Treatment-Naive Full-Thickness Macular Holes

PURPOSE

To describe the morphology and provide anatomical correlations of supra-retinal pigment epithelium (RPE) granular deposits in full-thickness macular holes (FTMHs).

DESIGN

Retrospective, observational, single-center study.

PARTICIPANTS

Patients with idiopathic FTMH presenting to the University of Florence Eye clinic.

METHODS

Thirty-six eyes of 34 patients with a diagnosis of treatment-naive FTMH, scheduled for surgery, underwent multimodal imaging including spectral-domain OCT (SD-OCT), en-face OCT, and adaptive optics ophthalmoscopy (AOO). Different methodologies were evaluated to determine the location and topographical correspondence of granulations. The total volume of supra-RPE granular deposits was correlated to the macular hole (MH) characteristics and SD-OCT markers of photoreceptor damage with Spearman correlation coefficient (CC).

MAIN OUTCOME MEASURES

Morphological correlations in FTMHs using SD-OCT and AOO.

RESULTS

Using AOO, supra-RPE granular deposits appeared as hyper-reflective structures, mostly found within the minimum linear diameter (MLD) (104 of 139 deposits, 74%). Different imaging techniques were equally effective in the topographical identification of supra-RPE granular deposits (P > 0.30). The total volume of supra-RPE granular deposits significantly increased with stages B and C of FTMH, inversely correlated to the corrected ellipsoid zone (EZ) reflectivity (CC = -0.62) and positively correlated to the length of the EZ defect (CC = +0.41) and MH diameter at the base (CC = +0.35) and MLD (CC = +0.42) (all P < 0.05).

CONCLUSIONS

Supra-RPE granular deposits can be identified accurately using AOO and en-face OCT. Characteristics using AOO and anatomical correlations at SD-OCT indicate supra-RPE granular deposits as signs of photoreceptor degeneration.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Photoreceptor assessment in age-related macular degeneration

Clinical trials investigating drugs for various stages of age-related macular degeneration (AMD) are actively underway and there is a strong interest in outcomes that demonstrate a structure-function-correlation. The ellipsoid zone (EZ), a crucial anatomical feature affected in this disease, has emerged as a strong contender. There is significant interest in evaluating EZ metrics on Optical Coherence Tomography (OCT), such as integrity and reflectivity, as disruption of this photoreceptor-rich layer may indicate disease progression. Loss of photoreceptor integrity in the junctional zone of geographic atrophy (GA) has been shown to exceed the areas of retinal pigment epithelial (RPE) atrophy, thus predicting future GA expansion. Furthermore, reduced visual acuity and retinal sensitivity have been correlated with loss of EZ integrity, underscoring a structure-function relationship. Photoreceptor integrity has also recently been acknowledged by the Food and Drug Administration (FDA), supporting its use as a primary endpoint in clinical trials investigating treatments for GA. However, the segmentation of this EZ still poses challenges. Continuous enhancements in OCT resolution and advancements in automated segmentation algorithms contribute to improved assessment of the EZ, strengthening its potential as an imaging biomarker for assessing photoreceptor function. It remains to be seen whether the EZ will serve as a surrogate marker for intermediate AMD. This article aims to provide an overview of the current understanding and knowledge of the EZ, while addressing ongoing challenges encountered in its assessment and interpretation.

Integrated Assessment of OCT, Multimodal Imaging, and Cytokine Markers for Predicting Treatment Responses in Retinal Vein Occlusion Associated Macular Edema: A Comparative Review of Anti-VEGF and Steroid Therapies

Retinal vein occlusion (RVO) is a significant cause of vision loss, characterized by the occlusion of retinal veins, leading to conditions such as central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO). Macular edema (ME), a prevalent consequence of RVO, is the primary cause of vision impairment in affected patients. Anti-VEGF agents have become the standard treatment, showing efficacy in improving visual acuity (VA) and reducing ME. However, a subset of patients exhibit a suboptimal response to anti-VEGF therapy, necessitating alternative treatments. Corticosteroids, which address inflammatory pathways implicated in ME, have shown promise, particularly in cases resistant to anti-VEGF. This review aims to identify biomarkers that predict treatment response to corticosteroids in RVO-associated ME, utilizing multimodal imaging and cytokine assessments. Baseline imaging, including SD-OCT and OCT-A, is essential for evaluating biomarkers like hyperreflective foci (HRF), serous retinal detachment (SRF), and central retinal thickness (CRT). Elevated cytokine levels, such as IL-6 and MCP-1, correlate with ME severity and poor anti-VEGF response. Early identification of these biomarkers can guide timely transitions to corticosteroid therapy, potentially enhancing treatment outcomes. The practical conclusion of this review is that integrating biomarker assessment into clinical practice enables personalized treatment decisions, allowing for earlier and more effective management of RVO-associated ME by transitioning patients to corticosteroid therapy when anti-VEGF agents are insufficient. Advanced diagnostics and machine learning may further refine personalized treatment strategies, improving the management of RVO-associated ME.

Artificial intelligence in individualized retinal disease management

Owing to the rapid development of modern computer technologies, artificial intelligence (AI) has emerged as an essential instrument for intelligent analysis across a range of fields. AI has been proven to be highly effective in ophthalmology, where it is frequently used for identifying, diagnosing, and typing retinal diseases. An increasing number of researchers have begun to comprehensively map patients' retinal diseases using AI, which has made individualized clinical prediction and treatment possible. These include prognostic improvement, risk prediction, progression assessment, and interventional therapies for retinal diseases. Researchers have used a range of input data methods to increase the accuracy and dependability of the results, including the use of tabular, textual, or image-based input data. They also combined the analyses of multiple types of input data. To give ophthalmologists access to precise, individualized, and high-quality treatment strategies that will further optimize treatment outcomes, this review summarizes the latest findings in AI research related to the prediction and guidance of clinical diagnosis and treatment of retinal diseases.

Evaluation of Anatomical and Tomographic Biomarkers as Predictive Visual Acuity Factors in Eyes with Retinal Vein Occlusion Treated with Dexamethasone Implant

Background: This prospective study evaluated the impact of anatomical and tomographic biomarkers on clinical outcomes of intravitreal dexamethasone implants in patients with macular edema secondary to retinal vein occlusion (RVO). Methods: The study included 46 patients (28 with branch RVO (BRVO) and 18 with central RVO (CRVO)). Best corrected visual acuity (BCVA) significantly improved from a mean baseline of 0.817 ± 0.220 logMAR to 0.663 ± 0.267 logMAR at six months and 0.639 ± 0.321 logMAR at twelve months (p < 0.05). Central retinal thickness (CRT) showed a significant reduction from 666.2 ± 212.2 µm to 471.1 ± 215.6 µm at six months and 467 ± 175.7 µm at twelve months (p < 0.05). No significant differences were found in OCT biomarkers between baseline and follow-ups. Results: The study analysed improvements in visual acuity relative to baseline biomarkers. At six months, ellipsoid zone disruption (EZD) was significant for all subgroups. Disorganization of retinal inner layers (DRIL), external limiting membrane (ELM) disruption, macular ischemia (MI), CRT, and BRVO showed significance for any improvement, while DRIL and ELM were significant for changes greater than 0.3 logMAR (p < 0.05). At twelve months, EZD remained significant for all subgroups. ELM, MI, CRT, and BRVO were significant for any improvement, while MI and BRVO were significant for changes greater than 0.3 logMAR (p < 0.05). Hyperreflective foci were not statistically significant at either time point (p > 0.05). Conclusions: The regression model suggested that MI and CRVO could be negative predictive factors for visual outcomes, while ELM and EZD were associated with BCVA improvement one-year post-treatment.

Month 60 Imaging Findings and Relationship to Treatment Outcomes Following Anti-VEGF Therapy for Macular Edema Due to Central or Hemi-Retinal Vein Occlusion

PURPOSE

To evaluate imaging findings from SCORE2 participants through 60 months, to describe the degree of resolution or progression of these variables, and to correlate changes in these imaging findings to treatment outcomes such as visual acuity and the number of treatments administered.

METHODS

SCORE2 participants were followed for up to 60 months. Visual acuity, injection frequency and imaging tests color fundus photography (CFP), optical coherence tomography (OCT), and ultra-widefield fluorescein angiography [UWFA]) were performed throughout this period.

RESULTS

Less than 6% of eyes had subretinal fluid at month 60. Disorganization of the retinal inner layers (DRIL) was the most likely finding to persist, present in 96% of eyes at baseline and unchanged at 95% at month 60. For UWFA, at baseline, there was a mean of 5.0% non-perfusion area (95% CI: 3.3%-6.8%) in the NETWORC grid with little change to month 60. For the Early Treatment Diabetic Retinopathy Study (ETDRS) grid, at baseline, there was a mean of 2.3% non-perfusion area (95% CI: 0.7%-3.9%) with little change to month 60. There was no correlation between any of the imaging variables at baseline and change in visual acuity to month 60 or in the number of injections following the variable treatment timeframe (month 12 to month 60).

CONCLUSIONS

These analyses provide an anatomic explanation for persistent functional deficits many years following initial treatment. Clinical practice patterns should consider evaluation with these imaging tests to help explain persistent functional deficits in many eyes. Additionally, these 8 baseline imaging variables generally should not be relied on to predict visual acuity or intensity of treatment. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Foveal Thickness Fluctuations in Anti-VEGF Treatment for Central Retinal Vein Occlusion

Purpose

The aim of this study was to examine the effects of foveal thickness (FT) fluctuation (FTF) on 2-year visual and morphological outcomes of eyes with central retinal vein occlusion (CRVO) undergoing anti-VEGF treatment for recurrent macular edema (ME) based on a pro re nata regimen.

Design

Retrospective, observational case series.

Participants

We analyzed 141 treatment-naive patients (141 eyes) with CRVO-ME at a multicenter retinal practice.

Methods

We assessed FT using OCT at each study visit. Patients were divided into groups 0, 1, 2, and 3 according to increasing FTF.

Main Outcome Measures

We evaluated the logarithm of the minimal angle of resolution (logMAR) best-corrected visual acuity (BCVA), the length of the foveal ellipsoid zone (EZ) band defect measured using OCT, and the association of FTF with VA and EZ band defect length.

Results

The mean baseline logMAR BCVA and FT were 0.65 ± 0.52 (Snellen equivalent range: 20/20-20/2000) and 661.1 ± 257.4 μm, respectively. The mean number of anti-VEGF injections administered was 5.6 ± 3.6. At the final examination, the mean logMAR BCVA and FT values were significantly improved relative to the baseline values (both P < 0.01). During the observation, BCVA longitudinally improved in Groups 0 and 1, remained unchanged in Group 2, and worsened in Group 3. Likewise, the length of the foveal EZ band defect did not increase in Group 0; however, it gradually increased in Groups 1, 2, and 3. Foveal thickness fluctuation was significantly and positively associated with the logMAR BCVA and length of the foveal EZ band defect at the final examination (P < 0.01). The final logMAR BCVA of patients developing neovascular complications was 1.27 ± 0.72 (Snellen equivalent range: 20/50-counting fingers), which was significantly poorer than that of patients without complications (P < 0.001). There was no significant difference in the neovascular complication rate among the FTF groups (P = 0.106, Fisher exact test).

Conclusions

In eyes receiving anti-VEGF treatment for CRVO-ME, FTF can longitudinally impair the visual acuity and foveal photoreceptor status during the observation period, thus influencing the final outcomes. However, neovascular complications, which would also lead to a poor visual prognosis, may not be associated with FTF.

Financial Disclosures

The authors have no proprietary or commercial interest in any materials discussed in this article.

High Variation in Inner Retinal Reflectivity Predicts Poor Visual Outcome in Patients With Central Retinal Vein Occlusion: SCORE2 Report 21

Purpose

To assess the association of a novel spectral domain optical coherence tomography biomarker with 6-month visual acuity in in the Study of COmparative Treatments for REtinal Vein Occlusion 2.

Methods

Spectral domain optical coherence tomography volume scans were evaluated for inner retinal hyperreflectivity, quantified by optical intensity ratio (OIR) and OIR variation. Baseline visual acuity letter score (VALS), baseline OCT biomarkers, and month 1 OIR were correlated with VALS at month 6. Regression trees, a machine learning technique yielding readily interpretable models, were used to assess for variable interaction.

Results

Only baseline VALS correlated positively with month 6 VALS in multivariate regression. Regression trees detected a novel functional and anatomical interaction in a subgroup. Among patients with a baseline VALS worse than 43, those with an OIR variation at month 1 of more than 0.09 had a mean of 13 fewer letters of vision at 6 months compared with patients with an OIR variation of 0.09 or less.

Conclusions

Baseline VALS was the strongest predictor of month 6 VALS. Regression tree analysis detected an interaction effect, in which higher OIR variation at month 1 predicted worse 6-month VALS in patients with low VALS at baseline. OIR variation may serve as a predictor for poor visual outcome despite treatment of macular edema secondary to retinal vein occlusion in patients with poor vision at baseline.

Translational Relevance

Pixel heterogeneity in three-dimensional OCT data may serve as measure of disruption of the retinal laminations, and this factor may carry visually prognostic value.

Binocular metamorphopsia in patients with branch retinal vein occlusion: a multi-center study

PURPOSE

The pathology of branch retinal vein occlusion (BRVO), a retinal circulatory disease, is related to monocular metamorphopsia-related vision impairment of the affected eyes, but the association of binocular metamorphopsia in such patients is unclear. This study aimed to examine the frequency of binocular metamorphopsia and its association with the clinical characteristics of patients with BRVO.

METHODS

A total of 87 patients who were treated for BRVO-associated macular edema (ME) were included in this study. At baseline and 1 and 3 months after the initiation of anti-vascular endothelial growth factor (VEGF) treatment, we quantified metamorphopsia in the affected eyes and binocular metamorphopsia using the M-CHARTS^® diagnostic tool.

RESULTS

At baseline, 53 and 7 patients had metamorphopsia in the affected eyes and binocular metamorphopsia, respectively. Although the visual acuity improved significantly after the initiation of anti-VEGF treatment, the mean M-CHARTS score in the affected eyes did not change from the baseline score. At 3 months, 9 patients showed binocular metamorphopsia; it was significantly associated with metamorphopsia in the affected eyes with a 95% confidence interval of 0.021-0.122 (β = 0.306, p = 0.006).

CONCLUSION

Metamorphopsia in the affected eyes can cause binocular metamorphopsia in patients with BRVO-ME.

Foveolar thickness as potential standardized structural outcome measurement in studies of Bietti crystalline dystrophy

Bietti crystalline dystrophy (BCD) is an ultra-rare orphan disorder that can lead to blindness. Because of the variable rates of progression of the disease, it is necessary to identify suitable outcome measurements for tracking progression in BCD. A retrospective analysis of patients with a clinical and genetic diagnosis of BCD was conducted. Four measurements of spectral domain-optical coherence tomography were compared to patients’ best corrected visual acuity. We observed that patients with higher measurements of foveolar thickness, choroidal thickness in the foveolar region, ellipsoid zone band length and the outer nuclear layer + area, had on average better visual acuity. Future studies are needed to validate the structural–functional correlations we observed in BCD and to propose a sensitive and clinically meaningful outcome measurement for tracking this rare, variable disease.

Structural-vascular-functional correlation in type 2 non-proliferative macular telangiectasia

PURPOSE

To correlate the structural-vascular-functional changes in type 2 non-proliferative macular telangiectasia (MacTel) using optical coherence tomography (OCT) angiography (OCTA).

METHODS

In this retrospective study, OCTA and enface OCT image analysis of eyes with confirmed diagnosis of non-proliferative type 2 MacTel was performed. The 'MacTel area' was calculated by marking the outer boundary of an area affected by MacTel on superficial (SCP) and deep capillary plexus (DCP) on OCTA images and photoreceptor layer (PRL) on enface OCT scan. At every follow-up OCTA scan visit, best-corrected visual acuity, MacTel area and stage of disease was documented. Analyses between disease stage, MacTel area and logMAR visual acuity was carried out.

RESULTS

In total, 38 single-visit OCTA scans of 22 patients were included. The mean age was 58.9 ± 10.98 years. An increase in disease severity stage correlated positively with MacTel area in SCP segmentations slab (r = 0.334; p = 0.04) and logMAR visual acuity (r = 0.338; p = 0.038). No correlation in the DCP area or PRL area (p > 0.05) was noted with disease stage. A statistically significant positive correlation was noted between the structural changes in PRL layer with vascular changes in SCP (p = 0.021) but not in DCP (p = 0.199). No correlation of visual acuity with changes in SCP, DCP or PRL was noted (p > 0.05).

CONCLUSION

OCTA is a useful adjunct for determining disease severity in type 2 non-proliferative MacTel by assessing the structural-vascular changes. Further longitudinal studies need to be considered in future for understanding the pathomechanism of retinal damage in type 2 MacTel.

The impact of laboratory findings and optical coherence tomography biomarkers on response to intravitreal anti-VEGF treatment in patients with retinal vein occlusion

AIMS

To investigate potential laboratory and imaging biomarkers as treatment response predictors to intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents in patients with retinal vein occlusion (RVO).

METHODS

Participants in this prospective study were 53 patients with treatment naïve macular edema secondary to RVO, treated with intravitreal anti-VEGF agents and followed-up for 12 months. At baseline, all participants underwent best-corrected visual acuity measurement, dilated fundoscopy, optical coherence tomography and fluorescein angiography (FFA), while full blood count and biochemical analysis of various parameters was also performed. At month 12, treatment response was examined and classified as "favorable" or "non-response". Potential associations between laboratory/imaging biomarkers and treatment response were assessed.

RESULTS

Univariate analysis showed that "favorable" response at month 12 after initiation of anti-VEGF treatment was correlated with baseline central subfield thickness (CST) < 464 μm (p < 0.001), absence of subretinal fluid (p = 0.004), absence of hyperreflective foci (HF) (p = 0.004), intact ellipsoid zone (EZ) and external limiting membrane (ELM) (p < 0.001 and p = 0.001, respectively), absence of epiretinal membrane (ERM) (p = 0.020) and absence of macular ischemia on FFA (p < 0.001), while increased monocytes-to-lymphocytes ratio was also associated with "favorable" treatment response (p = 0.010). All other laboratory parameters did not reach statistical significance. However, at the multivariate analysis, EZ and ELM status, HF, macular ischemia and monocytes-to-lymphocytes ratio were found to be independent predictors of treatment response.

CONCLUSIONS

Intact EZ and ELM, absence of HF, absence of macular ischemia and increased monocytes-to-lymphocytes ratio at baseline can predict "favorable" treatment response in patients with treatment naïve macular edema secondary to RVO.

SCORE2 Report 17: Macular thickness fluctuations in anti-VEGF-treated patients with central or hemiretinal vein occlusion

PURPOSE

To evaluate macular thickness fluctuations and their association with visual acuity outcome in eyes with macular edema (ME) secondary to central (CRVO) or hemiretinal vein occlusion (HRVO) treated initially with intravitreal aflibercept or bevacizumab.

METHODS

Post hoc analysis of 362 patients with ME secondary to CRVO or HRVO initially randomized to six monthly intravitreal injections of aflibercept or bevacizumab. Three spectral domain optical coherence tomography (SD-OCT) central subfield thickness (CST) fluctuation measures were investigated over Months 1-12: standard deviation (SD), number of turning points (T) for each participant, and a measure denoted as Zigzag reflecting the magnitude of alternating ups and downs in a participant's CST. Main outcome measure is Month 12 visual acuity letter score (VALS).

RESULTS

More fluctuations occurred in eyes randomized to bevacizumab than aflibercept: SD (59.98 vs 32.12; p < 0.0001), T (4.03 vs 3.53; p = 0.02) and Zigzag (24.91 vs 11.60; p = 0.0003). Month 12 VALS is significantly lower for the 4th (highest) quartile of the CST fluctuation measure than for the 1st (lowest) quartile for both SD (mean difference in VALS of 7.87; 95% confidence interval: 3.03, 12.70) and Zigzag (mean difference in VALS of 5.11; 95% confidence interval: 0.29, 9.93). SD and Zigzag quartiles were no longer significantly different after Month 1 VALS was added to the regression analysis.

CONCLUSIONS

Greater CST fluctuation as assessed by SD and Zigzag was negatively associated with Month 12 VALS. However, early post-treatment VALS is a stronger predictor of VALS outcomes than the CST fluctuation measures.

Biomarkers to Predict the Success of Treatment with the Intravitreal 0.19 mg Fluocinolone Acetonide Implant in Uveitic Macular Edema

To predict the need for additional local corticosteroids after receiving the 0.19 mg fluocinolone acetonide (FAc) implant in patients with macular edema secondary to non-infectious uveitis previously treated with local peribulbar corticosteroids. The number of corticosteroids required prior FAc, visual acuity, central retinal thickness, ellipsoid zone reflectivity ratio (EZR), and choroidal vascularity index (CVI) were compared between patients who did and did not require additional corticosteroids after FAc implantation. Pearson’s correlation coefficient (R) between putative predictors and the number of adjunctive corticosteroids after FAc implantation were measured; significant candidates were included in a generalized regression model. Patients who required additional corticosteroids after FAc had higher CVI and central retinal thickness as well as worse EZR at subsequent visits (p < 0.05). The number of corticosteroids required prior to FAc implantation (R: 0.49), CVI change from baseline to 6 months (R: −0.41), and central retinal thickness at baseline (R: −0.36) correlated to the number of additional corticosteroids (all p < 0.05). A higher number of corticosteroids per year before FAc implantation was predictive for an increase in corticosteroids required after FAc (odds ratio = 2.65), while a decrease in CVI from baseline to 6 months was inversely correlated (odds ratio = 0.82). Our results suggest that the more corticosteroids prior to FAc and the greater the short-term CVI reducing effect, the less is the chance to get additional corticosteroids after FAc.

Semi-Automated Quantification of Retinal and Choroidal Biomarkers in Retinal Vascular Diseases: Agreement of Spectral-Domain Optical Coherence Tomography with and without Enhanced Depth Imaging Mode

BACKGROUND

We compared with and without enhanced depth imaging mode (EDI) in semi-automated quantification of retinal and choroidal biomarkers in optical coherence tomography (OCT) in patients with diabetic retinopathy (DR) or retinal vein occlusion (RVO) complicated by macular edema. We chose to study three OCT biomarkers: the numbers of hyperreflective foci (HF), the ellipsoid zone reflectivity ratio (EZR) and the choroidal vascularity index (CVI), all known to be correlated with visual acuity changes or treatment outcomes.

METHODS

In a single examination, one eye of each patient (n = 60; diabetic retinopathy: n = 27, retinal vein occlusion: n = 33) underwent macular 870 nm spectral domain-OCT (SD-OCT) B-scans without and with EDI mode. Semi-automated quantification of HF, EZR and CVI was applied according to preexisting published protocols. Paired Student's t-test or Wilcoxon rank-sum test was used to test for differences in subgroups. Intraclass correlation coefficient (ICC) and Bland-Altman plots were applied to describe the agreement between quantification in EDI and conventional OCT mode. The effect of macular edema on semi-automated quantification was evaluated.

RESULTS

For the entire cohort, quantification of all three biomarkers was not significantly different in SD-OCT scans with and without EDI mode (p > 0.05). ICC was 0.78, 0.90 and 0.80 for HF, EZR and CVI. The presence of macular edema led to significant differences in the quantification of hyperreflective foci (without EDI: 80.00 ± 33.70, with EDI: 92.08 ± 38.11; mean difference: 12.09, p = 0.03), but not in the quantification of EZR and CVI (p > 0.05).

CONCLUSION

Quantification of EZR and CVI was comparable whether or not EDI mode was used. In conclusion, both retinal and choroidal biomarkers can be quantified from one single 870 nm SD-OCT EDI image.

Challenges Associated With Ellipsoid Zone Intensity Measurements Using Optical Coherence Tomography

Translational Relevance

Qualitative evaluation of the ellipsoid zone band on optical coherence tomography is a valuable clinical tool for assessing photoreceptor structure, though more quantitative metrics are emerging. Awareness of the challenges involved in interpreting quantitative metrics is important for their clinical translation.