STELLATE NONHEREDITARY IDIOPATHIC FOVEOMACULAR RETINOSCHISIS IN A PATIENT WITH MACULAR TELANGIECTASIA TYPE 2

PURPOSE

To present a case of unilateral stellate nonhereditary idiopathic foveomacular retinoschisis in a patient with macular telangiectasia (MacTel) Type 2.

METHODS

Single-patient case report.

RESULTS

A 61-year-old female white patient was referred to our clinic with metamorphopsia and reduction of visual acuity over a period of 2 months on her right eye. Ocular findings in her right eye included reduced best-corrected visual acuity of 20/63 Snellen, foveomacular retinoschisis with extension to the lower middle periphery, central elevation of the neurosensory retina, and macular telangiectasia (MacTel) Type 2. Other causes of foveomacular retinoschisis, such as glaucoma, myopic degeneration, optic or scleral pit, X-linked juvenile retinoschisis, degenerative retinoschisis, and vitreomacular traction, were ruled out. The patient had no history of niacin or taxane medication, which may cause rather similar appearing cases of cystoid macular edema without leakage in fluorescein angiography. Because of the unilateral presentation, uneventful medical history, female sex, and the absence of known hereditary diseases or retinal pathologies in the patient's family history, hereditary predisposition appears to be highly unlikely.

CONCLUSION

To our knowledge, this is the first reported case of stellate nonhereditary idiopathic foveomacular retinoschisis in combination with MacTel Type 2. Whether or not MacTel Type 2 plays a role in the development of stellate nonhereditary idiopathic foveomacular retinoschisis or has an impact on its clinical course requires further investigation. Furthermore, we suggest a significant involvement of Henle fiber layer in the process of intraretinal expansion in optical coherence tomography, in accordance with the most recent published nomenclature.

Refractory adult Coats disease treated with dexamethasone intravitreal implant: A case report

INTRODUCTION

Coats disease is a sporadic, retinal vascular abnormality, causing blindness. Several interventional methods, including laser photocoagulation, have been proposed; however, the use of intravitreal dexamethasone in refractory Coats disease is not well described.

PATIENT CONCERNS

A 38-year-old man presented with a painless reduction in visual acuity in his right eye, commencing 15 days prior to initial assessment.

DIAGNOSIS

Clinical manifestations and multimodal imaging indicated Coats disease.

INTERVENTIONS

Retinal laser photocoagulation was performed in the nonperfused areas, 15 months later, the exudative retinal detachment, and macular edema remained, the patient was then treated with an intravitreal slow-release dexamethasone implant.

OUTCOMES

The exudative retinal detachment and macular edema had resolved, and the BCVA had also improved.

CONCLUSION

Dexamethasone intravitreal implantation was effective in treating refractory Coats disease.

Visual outcomes after treatment in pediatric patients with Coats' disease

OBJECTIVE

To report visual outcomes for children with Coats' disease after treatment.

DESIGN

Retrospective case series.

PARTICIPANTS

Pediatric patients with Coats' disease treated between 2000 and 2018 at a tertiary care pediatric hospital.

METHODS

Review of medical records. The primary outcome was visual acuity at final follow-up. Anatomical outcomes, retreatment, and risk factors for a poor outcome were also assessed.

RESULTS

There were 30 patients with Coats' disease. All cases were unilateral, and 28 (93%) were male. At presentation, 14 (47%) had stage 2 disease (retinal exudates) and 16 (53%) had stage 3 disease (subtotal or total exudative retinal detachment). All patients underwent laser photocoagulation and (or) cryopexy as primary treatment, combined with antivascular endothelial growth factor injection in 7 patients, posterior sclerotomy in 5 patients, and pars plana vitrectomy in 1 patient. Retreatment was required in 16 (53%) patients. After a median follow-up of 3.8 years, visual acuity was 20/50 or better in 6 patients (20%), 20/60 to 20/150 in 3 (10%), 20/200 to counting fingers in 8 (23%), and hand motion or worse in 14 (47%). Greater severity of disease at presentation was significantly associated with a poor visual outcome (p = 0.0001). In terms of complications, 7 (23%) eyes developed cataracts and 2 (7%) progressed to phthisis bulbi, but no patients required enucleation.

CONCLUSIONS

The visual prognosis for children with Coats' disease remains poor, particularly in patients with more severe disease at presentation. The risk of severe complications and enucleation is low after treatment.

Estimating Retinal Sensitivity Using Optical Coherence Tomography With Deep-Learning Algorithms in Macular Telangiectasia Type 2

IMPORTANCE

As currently used, microperimetry is a burdensome clinical testing modality for testing retinal sensitivity requiring long testing times and trained technicians.

OBJECTIVE

To create a deep-learning network that could directly estimate function from structure de novo to provide an en face high-resolution map of estimated retinal sensitivity.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional imaging study using data collected between January 1, 2016, and November 30, 2017, from the Natural History Observation and Registry of macular telangiectasia type 2 (MacTel) evaluated 38 participants with confirmed MacTel from 2 centers.

MAIN OUTCOMES AND MEASURES

Mean absolute error of estimated compared with observed retinal sensitivity. Observed retinal sensitivity was obtained with fundus-controlled perimetry (microperimetry). Estimates of retinal sensitivity were made with deep-learning models that learned on superpositions of high-resolution optical coherence tomography (OCT) scans and microperimetry results. Those predictions were used to create high-density en face sensitivity maps of the macula. Training, validation, and test sets were segregated at the patient level.

RESULTS

A total of 2499 microperimetry sensitivities were mapped onto 1708 OCT B-scans from 63 eyes of 38 patients (mean [SD] age, 74.3 [9.7] years; 15 men [39.5%]). The numbers of examples for our algorithm were 67 899 (103 053 after data augmentation) for training, 1695 for validation, and 1212 for testing. Mean absolute error results were 4.51 dB (95% CI, 4.36-4.65 dB) when using linear regression and 3.66 dB (95% CI, 3.53-3.78 dB) when using the LeNet model. Using a 49.9 million-variable deep-learning model, a mean absolute error of 3.36 dB (95% CI, 3.25-3.48 dB) of retinal sensitivity for validation and test was achieved. Correlation showed a high degree of agreement (Pearson correlation r = 0.78). By paired Wilcoxon rank sum test, our model significantly outperformed these 2 baseline models (P < .001).

CONCLUSIONS AND RELEVANCE

High-resolution en face maps of estimated retinal sensitivities were created in eyes with MacTel. The maps were of unequalled resolution compared with microperimetry and were able to correctly delineate functionally healthy and impaired retina. This model may be useful to monitor structural and functional disease progression and has potential as an objective surrogate outcome measure in investigational trials.

Long-Term Follow-Up of an Atypical Case of Idiopathic Macular Telangiectasia

The authors present a 6-year follow-up of an atypical case of idiopathic macular telangiectasia (IMT) type 1 in a 67-year-old man treated with intravitreal injections of anti-vascular endothelial growth factor (VEGF) and subthreshold micropulse yellow laser. In this case, the authors detected a bilateral idiopathic macular telangiectasia. The right eye was characterized by a severe cystoid macular edema, whereas in the left eye, small cysts with small pseudovitelliform macular lesion were detected. Anti-VEGF intravitreal injections were performed in absence of functional or anatomical results in the right eye. After a single subthreshold micropulse yellow laser treatment, the authors reported an important reduction of intraretinal cysts with the restoration of the foveal depression in the right eye. During the follow-up, the left eye remained stable. To the authors' knowledge, this is the first reported case of macular telangiectasia with a such long optical coherence tomography follow-up treated using micropulse yellow laser. The follow-up examination is fundamental to disentangle atypical cases, especially in these conditions in which there is an overlap of different clinical elements. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e278-e283.].

Treatment of Macular Telangiectasia Type 2 With Carotenoid Supplements Containing Meso-Zeaxanthin: A Pilot Study

BACKGROUND AND OBJECTIVE

To assess the outcomes of patients with macular telangiectasia type 2 (MacTel 2) in response to lutein (L), meso-zeaxanthin (M), and zeaxanthin (Z) supplements (LMZ3).

PATIENTS AND METHODS

Thirteen patients diagnosed with MacTel 2 were started on lutein 10 mg, meso-zeaxanthin 10 mg, and zeaxanthin 2 mg and were followed-up for a mean period of 15.7 months ± 4.85 months.

RESULTS

Visual acuity improved in three patients (13%), and there was a reduction in the percentage of patients who had worsening vision (25% to 4%; P < .05). Optical coherence tomography changes showed a reduction in the number of cavitations and the largest diameter of the cavitation after the LMZ3 supplements were started. The largest diameter of photoreceptor disruption showed mild improvement in the first 6 months after LMZ3 supplements were started.

CONCLUSION

LMZ3 supplements may stabilize vision and improve the cavitations in patients with MacTel 2. Larger randomized, controlled studies are required to verify these pilot results. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:528-535.].

Macular Telangiectasia Type 1: Capillary Density and Microvascular Abnormalities Assessed by Optical Coherence Tomography Angiography

PURPOSE

To describe microvascular abnormalities and capillary density in macular telangiectasia type 1 (MT1) using optical coherence tomography angiography (OCTA), and correlate them with fluorescein angiography (FA).

DESIGN

Observational case series.

METHODS

Seven patients with MT1 and 12 age-matched controls were included. Focal microvascular dilations were identified on 3 × 3 mm OCTA and early-frame FA images. OCTA images were processed to determine the global capillary density after subtraction of larger vessels and cystoid edema cavities. Local capillary densities were calculated inside 100-μm circles around telangiectasias, projected over superficial (SCP) and deep capillary plexuses (DCP). They were compared to a random sample of 100-μm circles generated in each OCTA image. FA images were processed to measure mean perifoveal intercapillary areas (PIA), inversely reflecting capillary density.

RESULTS

In MT1 eyes, fewer telangiectasias were identified with OCTA than with FA (P = .016), exclusively localized in the DCP (P = .016). Rarefaction of both capillary plexus and abnormal microvascular morphology were better identified by OCTA than by FA. The global capillary density on OCTA was significantly lower in MT1 eyes than in fellow and control eyes, respectively: SCP, 0.347 vs 0.513 (P = .004) and 0.560 (P = .0005); DCP, 0.357 vs 0.682 (P = .016) and 0.672 (P = .0005). Capillary density was significantly reduced around telangiectasias in both SCP (P = .021) and DCP (P = .042). Capillary density of the SCP correlated inversely with the mean PIA on FA (r = -0.94, P = .017). LogMAR visual acuity was inversely correlated with SCP (r = -0.88, P = .012) and DCP capillary densities (r = -0.79, P = .048).

CONCLUSIONS

OCTA confirmed that global and focal capillary depletion is associated with MT1.

Ciliary neurotrophic factor for macular telangiectasia type 2: results from a phase 1 safety trial

PURPOSE

To evaluate the safety and tolerability of intraocular delivery of ciliary neurotrophic factor (CNTF) using an encapsulated cell implant for the treatment of macular telangiectasia type 2.

DESIGN

An open-label safety trial conducted in 2 centers enrolling 7 participants with macular telangiectasia type 2.

METHODS

The participant's more severely affected eye (worse baseline visual acuity) received the high-dose implant of CNTF. Patients were followed for a period of 36 months. The primary safety outcome was a change in the parameters of the electroretinogram (ERG). Secondary efficacy outcomes were changes in visual acuity, en face measurements of the optical coherence tomography of the disruption in the ellipsoid zone, and microperimetry when compared with baseline.

RESULTS

The ERG findings demonstrated a reduction in the amplitude of the scotopic b-wave in 4 participants 3 months after implantation (month 3). All parameters returned to baseline values by month 12 and remained so at month 36 with no clinical impact on dark adaptation. There was no change in visual acuity compared with baseline. The area of the defect as measured functionally by microperimetry and structurally by the en face OCT imaging of the ellipsoid zone loss appeared unchanged from baseline.

CONCLUSIONS

The intraocular delivery of CNTF in the encapsulated cell implant appeared to be safe and well tolerated in eyes with macular telangiectasia type 2. Further evaluation in a randomized controlled clinical trial is warranted to test for efficacy.

Management of idiopathic retinal vasoproliferative tumors by slit-lamp laser or endolaser photocoagulation

PURPOSE

To report the efficacy of laser photocoagulation in treating idiopathic (primary) retinal vasoproliferative tumors.

DESIGN

Retrospective noncomparative interventional case series.

PATIENTS AND METHOD

Thirty eyes of 30 patients (22 women and 8 men) with retinal vasoproliferative tumors. Main outcome measures were best-corrected visual acuity (BCVA), presence of retinal hard exudates, retinal detachment (RD), cystoid macular edema (CME), and epiretinal membrane (ERM). Laser photocoagulation was performed at the slit lamp or during pars plana vitrectomy for telangiectasia visible at the retinal vasoproliferative tumors surface.

RESULTS

Fifteen eyes were treated with slit-lamp laser. Mean follow-up was 36.5 months (range 7 months to 11 years). Mean BCVA increased from 20/40 to 20/32 at the end of the follow-up. Hard exudates and CME regressed completely in 15 of 15 and 5 of 6 eyes, respectively. Fifteen eyes underwent vitrectomy owing to the presence of ERM (10 eyes), large exudative RD (4 eyes), or vitreous hemorrhage (1 eye). Mean follow-up was 24 months (9 months to 3.5 years). Mean BCVA increased from 20/125 to 20/40 at the end of the follow-up. No vision loss occurred. The retina reattached in all cases. Hard exudates regressed completely in 14 of 15 eyes and decreased significantly in 1. Postoperative complications were rhegmatogenous RD in 2 eyes, successfully reattached after additional surgery.

CONCLUSION

Selective laser photocoagulation of retinal telangiectasia at the retinal vasoproliferative tumors' surface induced the regression of retinal exudation. Slit-lamp laser photocoagulation was sufficient in half of the cases. In more severe conditions, direct endolaser photocoagulation of the telangiectasia was required.

Pars plana vitrectomy for treatment of advanced Coats' disease--presentation of a modified surgical technique and long-term follow-up

BACKGROUND

To present a modified surgical technique in the treatment of retinal detachment secondary to advanced Coats' disease in children, and report on long-term anatomical and functional outcome.

METHODS

We analysed an interventional case series of 13 patients (13 eyes) with advanced Coats' disease characterised by retinal detachment in addition to massive subretinal exudates and vascular malformation. The presented patients underwent pars plana vitrectomy (PPV), including a modified technique of exocryotherapy applied after fluid-air exchange in order to achieve complete treatment of the vascular changes, to reduce associated side-effects, and to avoid retinectomy and silicone oil tamponade.

RESULTS

Within a median follow-up period of 37 months (range: 18-66 months), no enucleation was necessary. Four eyes (31 %) did not need any further therapy, and in nine eyes (69 %) additional treatments were performed. Six patients (46 %) required revisional surgery with silicone oil tamponade. In ten eyes (77 %), the pathologic vessels and exudates finally regressed and the retina reattached. Visual acuity (VA) could be stabilized in the majority of patients: in three eyes (27 %) VA improved, in four eyes (36 %) VA remained stable, in four eyes (36 %) visual acuity (VA) deteriorated, and in two eyes VA could not be evaluated.

CONCLUSIONS

The presented modified technique allows for sufficient cryotherapy of vascular malformations, even in the presence of massive exudation, in a subset of patients with advanced Coats' disease, and thus may reduce surgery-related complications and improve the rehabilitation process of these young patients.

Combination treatment of pediatric coats' disease: a bicenter study in Taiwan

PURPOSE

To present the clinical outcome of different combination treatment modalities in pediatric Coats' disease in two Taiwan medical centers.

METHODS

A retrospective review of clinical records was done of pediatric patients with Coats' disease treated at National Taiwan University Hospital and Changhua Christian Hospital. Data regarding the age at the time of diagnosis, initial presentation, methods of treatment, visual and anatomic results, and complications were recorded. Changes in vision and retinal status with the different methods of treatment were specifically evaluated.

RESULTS

From 2005 through 2011, 10 eyes of 9 patients were treated under the diagnosis of Coats' disease. The clinical manifestations varied from localized vascular abnormalities with subretinal fluid and hard exudates to extensive detachment with massive exudates and retinal hemorrhage. The main treatment modalities include argon laser photocoagulation, micropulse laser, and cryotherapy. The adjunctive therapies included intravitreal triamcinolone, bevacizumab, and ranibizumab. The mean follow-up was 40.50 ± 20.52 months (range: 14 to 72 months). Best corrected visual acuity at last follow-up was light perception to 1.0 (20/20 Snellen). Anatomic improvement was achieved in 9 eyes (90%). Visual improvement was noted in 7 eyes (70%), visual stabilization in 2 eyes (20%), and visual deterioration in 1 eye (10%). Vitreous fibrosis evolving into tractional retinal detachment occurred in 1 patient receiving cryotherapy combined with intravitreal bevacizumab injections. No enucleation was ultimately necessary.

CONCLUSIONS

Pediatric Coats' disease varies greatly in severity. Carefully selected treatment modalities can improve most eyes with different conditions. Intravitreal anti-vascular endothelial growth factor agents may act as useful adjuncts to improve anatomic and functional outcome. Cryotherapy combined with the intravitreal bevacizumab injection in severe cases of exudative retinal detachment may carry the risk of vitreoretinal traction and tractional retinal detachment.

Ultra-widefield imaging for the management of pediatric retinal diseases

PURPOSE

To describe the utility of using ultra-widefield digital fundus photography and ultra-widefield fluorescein angiography (UWFA) in the pediatric patient population to evaluate peripheral retinal pathology and to manage Coats' disease and familial exudative vitreoretinopathy (FEVR).

METHODS

Retrospective review of pediatric retinal patients with FEVR or Coats' disease who underwent ultra-widefield fundus photography and UWFA.

RESULTS

Eight patients were included in this case series. Five patients had the clinical diagnosis of FEVR, and two eyes of two patients with FEVR received UWFA-guided laser photocoagulation. Three patients were diagnosed as having Coats' disease and received UWFA-guided laser photocoagulation.

CONCLUSIONS

Ultra-widefield fundus photography and UWFA can be used successfully as an outpatient procedure in the pediatric patient population without the necessity of examination under anesthesia and can aid the physician in the documentation and evaluation of peripheral retinal pathology. UWFA can also assist in directing laser photocoagulation in the treatment of pediatric retinal diseases.

[Analysis of changes of ultrasonic image and hemodynamics of retrobulbar blood vessels in Coats disease]

OBJECTIVE

To analyze the changes of color Doppler flow imaging (CDFI) and hemodynamics of retrobulbar blood vessels in Coats disease.

METHODS

It was a prospective and self-comparative study in which 18 cases (18 eyes) were included. Axial eye length was measured with A scan. Routine CDFI was performed in all cases. We examined ophthalmic arteries (OA), central retinal arteries (CRA) and posterior ciliary arteries (PCA) by CDFI, and recorded the peak systolic velocities (PSV), end diastolic velocities (EDV), time averaged maximum velocities (TAMX), pulsatility indexes (PI) and resistance indexes (RI) in all cases. Each hemodynamic parameter in the affected eye (21.36 ± 1.19) mm was compared with those in the contralateral normal eye (controls). T-test was used for the estimation of significance of the difference between the diseased and normal eyes.

RESULTS

The axial length in diseased eyes was significantly shorter than that of the controls (22.92 ± 1.09) mm (t = 3.617, P < 0.05). The changes of CDFI in diseased eyes included retinal detachment, retinal cyst, subretinal organization, etc. Vitreoretinal traction, intraocular ossification and calcification were uncommon. The PSV (6.96 ± 1.21) cm/s and EDV (1.99 ± 0.36) cm/s in the diseased eyes were significantly lower than the PSV (8.30 ± 1.46) cm/s and EDV (2.48 ± 0.47) cm/s in the control eyes (t = 2.995, 3.476;P < 0.05). No significance difference was present in other hemodynamic parameters between diseased and normal eyes.

CONCLUSIONS

Coats disease is a congenital disease that may influence the development of the eye. The ultrasonography is helpful for the diagnosis and differential diagnosis in Coats disease. Low perfusion of the central optic artery might exist in Coats disease. The hemodynamics changes in Coats disease require further studies.