Neovascular Maculopathy after Laser Retinal Rejuvenation Therapy in a Young Myopic Patient: A Case Report

Resident Perspectives

Editor, Occult choroidal neovascularization (CNV) with pigment epithelium detachment (PED) in age-related macular degeneration (AMD) is generally associated with poor visual prognosis. Most physicians agree that further treatment modalities are required to treat these lesions, although photodynamic therapy with verteporfin should be avoided for the risk of retinal pigment epithelium tears (Axer-Siegel et al. 2004). Intravitreal bevacizumab is safe and effective in the treatment of exudative AMD in the short-term. Its results have been characterized by improvement in visual acuity (VA), decreased retinal thickness by optical coherence tomography (OCT) and no significant ocular or systemic side-effects (Rosenfeld et al. 2005; Avery et al. 2006). A 58-year-old man was referred for evaluation of progressive visual loss in the right eye (OD) of 30 days' duration. Visual acuity was 20/80. Funduscopy revealed PED in the juxtafoveal inferotemporal macula surrounded by hard exudates and inferior subretinal haemorrhage. Scattered drusen were seen in the posterior pole in both eyes. Fluorescein angiography showed early hyperfluorescence and pooling under the pigment epithelium in the inferotemporal macula, blocked choroidal fluorescence inferior to it, and stippled fluorescence and late leakage in the superior and nasal macular regions (Fig. 1). Optical coherence tomography disclosed inferotemporal PED and mild thickening of the overlying neurosensory retina (Fig. 2). The potential risks and benefits, as well as the off-label use of the drug, were discussed with the patient, after which 1.25 mg (0.05 ml) bevacizumab was injected intravitreally in an outpatient setting as previously described (Avery et al. 2006). One month later, VA was unchanged and partial resolution of the PED was noted on OCT images. Intravitreal bevacizumab was then re-injected OD. Seven days after the procedure, VA was 20/50. Fluorescein angiography showed late staining in the macular region and OCT depicted abnormal hyperreflectivity and thickening at the level of the retinal pigment epithelium−choriocapillaris band, consistent with early fibrosis (Fig. 3). Six weeks later, the picture was unchanged. Initial presentation. (A) Red-free photography of the right eye (OD) revealing pigment epithelium detachment in the juxtafoveal inferotemporal macula surrounded by hard exudates and inferior subretinal haemorrhage, as well as scattered drusen. (B) Late-phase fluorescein angiography frame OD showing pooling of the dye under the pigment epithelium in the inferotemporal macula, inferior blocked choroidal fluorescence, as well as stippled fluorescence and late leakage in the superior and nasal macular region. Initial presentation. (A) Horizontal cross-sectional image by optical coherence tomography (OCT). (B) Vertical cross-sectional image by OCT. An inferotemporal PED with mild thickening of the overlying neurosensory retina was noted. Visual acuity was 20/80. Seven days after the second intravitreal bevacizumab injection. (A) Horizontal cross-sectional image by optical coherence tomography (OCT). (B) Vertical cross-sectional image by OCT. Abnormal hyperreflectivity and thickening at the level of the retinal pigment epithelium−choriocapillaris band was seen in the subfoveal region, consistent with early fibrosis. Visual acuity was 20/50. Intravitreal bevacizumab injection was associated with both visual and anatomic improvement, as revealed by the lack of angiographic leakage, as well as tomographic resolution of the PED. Two intravitreal injections of the drug administered 1 month apart led to rapid and successful control of the disease. Thus, intravitreal bevacizumab may be beneficial to patients with occult CNV and PED in AMD and should be investigated further.

The ratio of choroidal neovascularization (CNV) and pigment epithelium detachment (PED) represents an important parameter regarding the risk of developing atear of the retinal pigment epithelium (RPE) in patients with vascularized PED due to age-related macular degeneration (AMD). Within the framework of the RECOVER study a total of 29treatment-naive patients with vascularized PED underwent fluorescein angiography (FA), indocyanine green angiography (ICGA) and optical coherence tomography (OCT) volume scans. The CNV-PED ratio was evaluated retrospectively by two independent graders in three ways: 1) manually based on the en face image of the FA late phase and 2) manually based on the en face image of the ICGA late phase. 3) In every OCT scan encompassing the PED, the area between the RPE and Bruch's membrane and the CNV area was measured and multiplied by the distance between OCT scans in order to determine volumetric data of CNV, PED and the serous cavity. The FA and ICGA showed amean serous area of 6.14± 4.21 mm2 (ICGA 5.94± 4.13 mm2), amean CNV area of 3.25± 1.79 mm2 (ICGA 2.84± 1.68 mm2) and amean PED area of 9.39± 4.27 mm2 (ICGA 8.79± 4.23 mm2) resulting in amean two-dimensional morphological ratio of 0.35± 0.21 (ICGA 0.32± 0.22). The volumetric measurement revealed amean CNV volume of 0.63± 0.67 mm3, amean serous volume of 3.61± 3.83 mm3 and amean total PED volume of 4.25± 3.68 mm3. The mean three-dimensional morphological ratio was 0.15± 0.29. The difference between the two-dimensional ratios of FA (p< 0.0001) and ICGA (p= 0.0004) was significant compared to the three-dimensional OCT ratio. Assessment of the CNV-PED ratio using volumetric OCT measurements is an additional tool to the en face modalities FA and ICGA. This seems to be clinically relevant regarding the risk stratification of RPE tear development in PED patients and for the planning of the treatment regimen.

Dear Editor, Central serous chorioretinopathy (CSCR) is characterized by the development of serous retinal detachment in the macula and is mainly diagnosed by fluorescein angiography that shows one or multiple areas of leakage from the retinal pigment epithelium (RPE) seen as “expanding dot” or “smoke stack” sign.[12] The RPE defect corresponding to the dominant hyperfluorescence in the fluorescein angiogram, is believed to be the cause for serous leakage of fluid into the subretinal space and is seen as a pigment epithelium detachment (PED) on time domain Stratus Optical coherence tomography (OCT).[3] We present a case of CSCR where the spectral domain high-definition (HD) Cirrus OCT (Carl Zeiss Meditec) could diagnose subclinical CSCR before the development of the expanding dot sign on fluorescein angiography. A 40-year-old man was seen with complaints of blurred vision in his left eye with a visual acuity of 20/30 and was diagnosed to be suffering from CSCR in this eye. His right eye was asymptomatic with a visual acuity of 20/20. On fluorescein angiography, multiple areas of hyperfluorescence were seen that were diagnosed as PED. No expanding dot sign was seen at this stage in the right eye [Fig. 1] while the left eye showed multiple hyperfluroscence with late leakage [Fig. 2]. Analysis of the single-layer RPE showed elevations in the corresponding areas [Fig. 3]. A raster line scan of the right eye showed PED with serous retinal detachment [Fig. 4]. Similarly, the left eye showed PED with a serous retinal detachment [Fig. 2]. The patient was under regular follow-up for next few months. Three months later, the patient complained of blurred vision in his right eye (20/30) that now showed an expanding dot sign on fluorescein angiography [Fig. 5]. Repeat analysis of the single RPE layer now showed increased irregularity with bumps in the superior half [Fig. 5].Figure 1: (a and b) Fundus and red-free photograph of the right eye showing mottled appearance superotemporal to the fovea. (c and d) Angiogram during transit and late phase showing hyperfluorescence suggestive of pigment epithelium detachment (arrows). Additionally, an area of punctate hyperfluorescence (solid arrow) is shown with an absence of smoke stack or subretinal fluidFigure 2: (a and b) Fundus photograph and angiogram of left eye showing pigmentry changes and yellowish precipitate, mottled appearance supero-temporal to fovea showing hyperfluorescence (arrows). (c) Additionally, showing multiple areas of pinpoint hyperfluorescence (d). OCT of left eye showing pigment epithelium detachment and subretinal fluidFigure 3: Single layer retinal pigment epithelium scan of right eye on Macular Cube 512 × 128 Combo shows pigment epithelium detachment s (arrows). In addition, the superior part of retinal pigment epithelium layer shows uneven surface with bumps. The inset shows fundus image with scan cube overlayFigure 4: Raster Line scan of right eye passing above the fovea shows pigment epithelium detachment (black arrows), with subretinal fluid (arrowhead). Red arrows demarcate external limiting membrane while yellow arrows shows outer photoreceptor layer. Inset shows OCT slice showing the presence of subretinal fluid (solid arrow)Figure 5: (a and b) Same eye(right eye) 3 months later shows expanding dot sign on fluorescein angiography (arrows). (c). Single layer RPE scan shows more uneven and bumpy surface compared to previous scan in Figure 2. (d). Raster Line scan right eye shows pigment epithelium detachment with subretinal fluidThe diagnosis of CSCR is mainly clinical, aided by fluorescein angiography and OCT. Fluorescein angiography classically shows the leakage of dye from the choroid through a focal RPE defect and its pooling in the subretinal space in acute CSCR. OCT is traditionally used to quantify the amount and extent of the subretinal fluid, demonstrate thickening of the neural retina and is commonly used for monitoring during the follow-up and also for diagnosing the changes in the neurosensory retina that can cause permanent impairment in vision in such eyes.[34] Recently, 3D high-speed OCT has shown to facilitate the understanding of pathophysiologic changes in CSCR.[5] However, this case illustrates that spectral domain HD OCT could pick up the presence of the subretinal fluid and RPE changes even before they could manifest angiographically in CSCR. This indeed may be a better tool for monitoring the asymptomatic eye for the detection of early changes and may obviate the need for fluorescein angiography in selected cases. However, this is only a case report and a larger study is required.

Acute retinal pigment epithelial tear in the untreated fellow eye following repeated bevacizumab (Avastin™) injections

Ranibizumab Combined With Low-Dose Sorafenib for Exudative Age-Related Macular Degeneration

Imaging in vitreoretinal diagnostics

Predictors of AMD Treatment Response

We aimed to compare fluorescein angiography (FA)-based classification of macular neovascularisation (MNV) with optical coherence tomography (OCT)-based classification, as well as examine differences in retinal fluid among OCT MNV types. We analyzed baseline FA and OCT images from 704 eyes of neovascular AMD patients across two multicenter trials, with grading conducted at the Vienna Reading Center. Using a validated AI tool (RetInSight Fluid Monitor Version 2), we localized and quantified retinal fluid. Kappa coefficients for agreement between FA and OCT MNV types were 0.58 [0.52; 0.64] (type 1/occult), 0.46 [0.38; 0.55] (type 2/classic), and 0.53 [0.44; 0.62] (type 3/RAP). Significant differences in the volumes of intraretinal fluid (IRF), subretinal fluid (SRF), and pigment epithelial detachment (PED) were noted among MNV types (p < 0.0001). Pairwise comparisons revealed significant differences in IRF volumes across all lesion types except type 2 versus mixed type, in SRF between type 3 and other types, and in PED between type 2 and other lesions. In conclusion, there was moderate agreement between FA and OCT classifications, and notable differences in fluid distribution among OCT types, suggesting potential for AI-guided MNV recognition in clinical settings.

To correlate optical coherence tomography (OCT) with angiographic signs of choroidal neovascularization (CNV) in retinal pigment epithelial detachment (PED) associated with age-related macular degeneration (ARMD). Prospectively, the authors performed OCT in 35 eyes of 35 patients (30 men and 5 women with a mean age of 71.6 years [range, 56-76 years]) with ARMD. All 35 eyes had CNV in the area of PED or adjacent to it, which was shown by fluorescein or indocyanine green angiography. Cross-sectional images were obtained by the OCT scanning line through the CNV and PED. In 10 (56%) of 18 eyes in which the CNV was at the margin of the PED, a small PED was adjacent to the central, dome-shaped PED. There was a notch between the central and small mounds of PED. In 13 (76%) of 17 eyes in which the CNV was within the PED, a notch was seen in the dome-shaped PED, resulting in a contour with 2 mounds. One of the 2 mounds contained a highly reflective mass immediately beneath the detached retinal pigment epithelium in 8 (62%) of the 13 eyes. A tomographic notch in the PED may be diagnostically important as an indication of CNV beneath the detached retinal pigment epithelium in eyes with ARMD.

Optical Coherence Tomography Identification of Occult Choroidal Neovascularization in Age-related Macular Degeneration

Relationship Between Optical Coherence Tomography Retinal Parameters and Visual Acuity in Neovascular Age-Related Macular Degeneration

To investigate the therapeutic effects of different treatments on serous pigment epithelium detachment (PED) in age-related macular degeneration (AMD). A total of 328 patients suffering from serous PED in AMD were retrospectively analysed. We treated only patients with documented visual deterioration: 86 patients with bevacizumab, 128 with ranibizumab, 60 with pegaptanib, and 54 with photodynamic therapy (PDT) combined with intravitreal triamcinolone acetonide (IVTA). Best-corrected vision was determined in the logarithm of the minimal angle of resolution (logMAR). We also analysed morphological findings such as full foveal thickness by optical coherence tomography (OCT), manually calculated height of PED as measured by OCT, and fluorescence angiography. The mean follow-up was 42.4 weeks. The best-corrected visual acuity of 0.78 logMAR before treatment could be improved by about 0.066 logMAR after treatment. Retinal thickness decreased in all patients with PED, in the mean by about 64.06 microm, and the mean value of the manually calculated height decreased by about 0.98 units. All functional and morphological results proved to be significantly better after injection of ranibizumab and bevacizumab than after pegaptanib and the combined treatment with PDT and IVTA. In all, 41 (12.5%) of our patients developed a tear of the retinal pigment epithelium (RPE). The therapeutic results were significantly better in patients treated with bevacizumab and ranibizumab than in those treated with pegaptanib or with a combination of PDT and IVTA. Even with treatment, tears of the RPE or only a partial flattening of the PED always indicated a worse prognosis in eyes with exudative AMD than in eyes with classic choroidal neovascularization.

Purpose To evaluate the functional, anatomical, vascular flow, effects of intravitreal Ranibizumab injections for retrofoveolar neovascular Pseudo vitelliform and/or Drusenoid pigment epithelium detachment (PED) Age Related Macular Degeneration (AMD), at 3 years 1/2 evolution.Methods 48 eyes of 40 patients, 15 men, 25 women, with neovascular Pseudo vitelliform(35 eyes) and/or Drusenoid PED (13eyes) AMD. Patients received intravitreous Ranibizumab, 3 times, every 4 weeks in an inductive treatment, the next injections (IVT), depending on the follow‐up results, were done by series of 3 IVT. First and 2 months’ interval follow‐up exam included ETDRS visual acuity (VA), complete ophthalmic examination, fluorescein and infracyanine (ICG) angiography, and optical coherence tomography (OCT).VA and OCT were done before each IVT.Results VA improved in 52% cases. Angiographic leakage disappeared in 78% cases, reduced about 75% in 40% cases. At ICG ,vascular flow, vessel’s diameter were 2/3 time less in 45% cases, low‐flow in 83% cases .Diffuse edema was normalized in 60% cases , pigment epithelial detachment(PED) was less dense in most of cases, by OCT. No ocular or systemic side effects observed.Better contrast Inductive treatment was sufficient in 24 cases, needed 2 IVT Series in 40% cases, failed in 1 case. In few cases, retinal and pigment epithelium atrophy was induced, Drusenoid PED disappeared.Discussion is open.Conclusion The results, with generally improved visual function, lack of fluorescein leakage, low neovascularisation’s flow in ICG, reduction of exudation on OCT, suggest Series of 3 Ranibizumab IVT Protocol seems effective, in those usually poor resort considered cases.

PurposeTo report the image artifacts due to retinal pigment epithelium (RPE) hyperplasia overlying retinal pigment epithelial detachment (PED) in age-related macular degeneration (AMD), which can masquerade as neovascularization on optical coherence tomography angiography (OCTA).MethodsA hospital-based, retrospective, and cross-sectional study. Twenty-two eyes from 16 patients with non-vascularized PED related to AMD were included in this study. All patients were examined by OCTA, spectral-domain optical coherence tomography, fluorescence angiography, and indocyanine green angiography. Vascular flow signals (VFS) on both the outer retinal slab of en face OCTA and cross-sectional OCTA and their correspondence with RPE hyperplasia were evaluated.ResultsFifteen eyes (68.2%) showed VFS on both the outer retina slab of en face OCTA and cross-sectional OCTA, all corresponding to the RPE hyperplasia overlying PED. Among them, 12 eyes with lump RPE hyperplasia outside foveal avascular zone (FAZ) all showed obvious VFS on the outer retina slab of OCTA, and 3 eyes with scattered RPE hyperplasia outside FAZ showed VFS fragments. Of note, 4 eyes had accompanied RPE hyperplasia inside FAZ, and 7 eyes without RPE hyperplasia overlying PED showed no corresponding VFS on the outer retina slab of OCTA. Additionally, a round-like dark band at the edge of PED was observed in the outer retina slab on en face OCTA in 17 eyes (77.3%).ConclusionsRPE hyperplasia overlying PED in AMD can masquerade as neovascularization on OCTA. To avoid misdiagnosis and unnecessary treatment, this RPE hyperplasia-related image artifact should be considered when interpreting OCTA images.