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Subthreshold Exudative Choroidal Neovascularization Associated With Age-Related Macular Degeneration Identified by Optical Coherence Tomography Angiography.

ABSTRACT: Purpose:This article describes the clinical and multimodal imaging characteristics of subthreshold exudative choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD). Methods:Among 3773 patients with AMD, 8 eyes (6 patients) were identified with the clinical phenotype of interest. Dilated fundus examinations, color fundus photography, fluorescein angiography (FA), indocyanine green angiography (ICGA), optical coherence tomography (OCT), and OCT angiography (OCTA) were performed. Results:OCT typically showed a moderately reflective irregular pigment epithelial detachment with overlying subretinal fluid (SRF). Traditional FA did not show leakage and ICGA showed no definitive neovascular network or hot spots. However, OCTA clearly demonstrated a CNV within the pigment epithelial detachment. The majority of our cases (7 of 8) did not receive antivascular endothelial growth factor (anti-VEGF) injections, and visual acuity remained stable over the available follow-up period of I to 10 years. Conclusions:CNV is often associated with SRF and vision loss in AMD, usually requiring frequent anti-VEGF injections. OCTA allowed us to better identify CNV not readily detected on FA and ICGA. Although some have suggested early clinical intervention with anti-VEGF injections in any case with fluid and confirmed CNV on OCTA, we describe a subset of AMD patients with SRF who may be better managed by observation. These cases may represent a more indolent, mature, and stable vascular network.

SUBMITTER: Roh M

PROVIDER: S-EPMC7556719 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Subthreshold Exudative Choroidal Neovascularization Associated With Age-Related Macular Degeneration Identified by Optical Coherence Tomography Angiography.

Roh Miin M Miller Joan W JW Jeng-Miller Karen W KW Wang Jay C JC Laíns Inês I Silverman Rebecca F RF Loewenstein John I JI Husain Deeba D Vavvas Demetrios G DG Miller John B JB

Journal of vitreoretinal diseases 20200427 5

<h4>Purpose</h4>This article describes the clinical and multimodal imaging characteristics of subthreshold exudative choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD).<h4>Methods</h4>Among 3773 patients with AMD, 8 eyes (6 patients) were identified with the clinical phenotype of interest. Dilated fundus examinations, color fundus photography, fluorescein angiography (FA), indocyanine green angiography (ICGA), optical coherence tomography (OCT), and OCT ang ...[more]

PMID: 33062911

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Project description:PurposeTo detect and quantify choroidal neovascularization (CNV) in patients with age-related macular degeneration (AMD) using optical coherence tomography (OCT) angiography.DesignObservational, cross-sectional study.ParticipantsA total of 5 normal subjects and 5 subjects with neovascular AMD were included.MethodsA total of 5 eyes with neovascular AMD and 5 normal age-matched controls were scanned by a high-speed (100 000 A-scans/seconds) 1050-nm wavelength swept-source OCT. The macular angiography scan covered a 3 × 3-mm area and comprised 200 × 200 × 8 A-scans acquired in 3.5 seconds. Flow was detected using the split-spectrum amplitude-decorrelation angiography (SSADA) algorithm. Motion artifacts were removed by 3-dimensional (3D) orthogonal registration and merging of 4 scans. The 3D angiography was segmented into 3 layers: inner retina (to show retinal vasculature), outer retina (to identify CNV), and choroid. En face maximum projection was used to obtain 2-dimensional angiograms from the 3 layers. The CNV area and flow index were computed from the en face OCT angiogram of the outer retinal layer. Flow (decorrelation) and structural data were combined in composite color angiograms for both en face and cross-sectional views.Main outcome measuresThe CNV angiogram, CNV area, and CNV flow index.ResultsEn face OCT angiograms of CNV showed sizes and locations that were confirmed by fluorescein angiography (FA). Optical coherence tomography angiography provided more distinct vascular network patterns that were less obscured by subretinal hemorrhage. The en face angiograms also showed areas of reduced choroidal flow adjacent to the CNV in all cases and significantly reduced retinal flow in 1 case. Cross-sectional angiograms were used to visualize CNV location relative to the retinal pigment epithelium and Bruch's layer and classify type I and type II CNV. A feeder vessel could be identified in 1 case. Higher flow indexes were associated with larger CNV and type II CNV.ConclusionsOptical coherence tomography angiography provides depth-resolved information and detailed images of CNV in neovascular AMD. Quantitative information regarding CNV flow and area can be obtained. Further studies are needed to assess the role of quantitative OCT angiography in the evaluation and treatment of neovascular AMD.

Project description:BackgroundOCT-A is a recent imaging technique allowing a non-invasive assessment of the retinal and choroidal microvasculature, providing valuable data for the diagnosis and monitoring of wet AMD. We aim to determine the diagnosis accuracy, describe the morphological features, and assess the clinical activity of MNV in wet AMD using OCT-A.Materials and methodsWe conducted a descriptive cross-sectional study over a 15-month period. We enrolled patients with treatment-naive and treated MNV secondary to wet AMD. Macular OCT-A images were obtained using a swept-source OCT-A device (Triton SS-OCT, Topcon, Tokyo, Japan). Morphologic characteristics and semi-automated measurements were analyzed on the en face projection OCT-Angiograms. For the qualitative analysis, determined the sensitivity of detection of the MNV using OCTA. When detected, we described its shape, branching pattern, anastomoses and loops, and vessel termination. We looked for the halo sign and the feeder vessel. We then defined the lesion's "pattern" reflecting its exudative activity. For the quantitative analysis, we measured the lesion's area in square millimeters, when its borders were clearly defined.Results70 eyes from 55 patients were enrolled in this study. Type 1 MNV was identified in 57,1% eyes, type 2 in 21,4%, mixed type 1 and2 in 1,4%, type 3 in 1,4% and unclassified fibrotic MNV in 18,6%. 55,7% were active and 44,3% were inactive. Sensitivity of detection was 85% for type 1 lesions, 100% for type 2, mixed and type 3 lesions, and 92% for unclassified fibrotic lesions. It was 84,6% for active lesions and 96,8% for inactive lesions. For each detected lesion, shape was well-defined (medusa, glomerulus, seafan), long liner vessels or ill-defined. Branching pattern was dense or loose. Anastomoses and vascular loops were numerous or few. Termination was in an anastomotic arcade or in a dead-tree aspect. Halo sign was present or absent and feeder vessel was detected or not. All types combined, 41,3% of the lesions were "pattern I" and 58,7% were pattern II. We reported a correlation rate of 84,8% between the lesion's activity on MI and « pattern I » on OCT-A, and of 96,6% between absence of activity signs on MI and « pattern II » on OCT-A The mean area of inactive lesions was slightly larger than that of active lesions with respective values of 3.86 mm2 and 2.92 mm2.ConclusionOCT-A is a non-invasive, safe, and reproducible retinal imaging technique with a high sensitivity of detection of MNV in AMD. It provides useful qualitative and quantitative data. The involvement of OCT-A in the treatment decision for MNV in AMD is linked to identifying the "pattern" of the lesion reflecting its active or inactive status.

Project description:This study aimed to investigate the differences between images obtained by optical coherence tomography angiography (OCTA) with those from immunohistochemical labeling of laser-induced choroidal neovascularization (CNV) in a mouse model. CNV was induced by laser photocoagulation (GYC-2000, NIDEK; wavelength 532 nm) in the left eyes of 10 female C57BL/6J mice aged 6 weeks. The laser parameters included a 100-μm spot, 100-ms pulse duration and 200-mW incident power to rupture Bruch's membrane. OCT and OCTA CNV images were obtained using the RS-3000 Advance (NIDEK) 5 days post-laser photocoagulation. After OCTA imaging, the isolated choroid/retinal pigment epithelium complexes were fluorescently labeled with CD31 (an endothelial cell marker), platelet-derived growth factor receptor β (PDGFRβ, a pericyte-like scaffold marker), α-smooth muscle actin (α-SMA) and collagen I. Area measurements of the lesions obtained by enface OCTA were compared with immunolabeled CD31+ CNV lesions in choroid flat-mounts. We also examined structural correlations between the PDGFRβ+ pericyte-like scaffold and OCTA images. Laser-induced CNV was clearly detected by enface OCTA, appearing as a hyperflow lesion surrounded by a dark halo. Area measurements of the CNV lesion by immunolabeling were significantly larger than those obtained by enface OCTA (p = 0.006). The CNV lesion beneath the periphery of the pericyte-like scaffold was not clearly visible by enface OCTA due to the dark halo; however, the lesion was detectable as blood flow by cross-sectional OCTA and was also highly labeled by CD31. The periphery of the pericyte-like scaffold appeared to develop into subretinal fibrosis and this region was rich in myofibroblasts. Enface OCTA was unable to detect the entire area of laser-induced CNV in mice, with an undetectable portion located beneath the fibrotic periphery of the pericyte-like scaffold. Due to this OCTA fibrosis artifact, OCTA imaging has limited potential for accurately estimating CNV lesions.

Project description:ImportanceBy validating optical coherence tomography angiography (OCTA) in the analysis of type 3 macular neovascularization secondary to age-related macular degeneration, the overall value of clinical OCTA for disease observation, diagnosis, and staging is increased.ObjectiveTo assess the association of in vivo OCTA of type 3 macular neovascularization secondary to age-related macular degeneration with corresponding ex vivo histology.Design, setting, and participantsThis study included clinical imaging, laboratory microscopy, and eye-tracked clinicopathologic correlation of a single case from a community-based practice evaluated at a university-based research laboratory from 2014 to 2019.ExposuresInfrared reflectance and eye-tracked spectral-domain OCTA clinical imaging was correlated with ex vivo high-resolution histologic images of the preserved donor eye. Eye tracking, applied to the donor eye, enabled identification of histologic features corresponding with clinical OCTA signatures. Projection artifact removal based on 2-dimensional vessel-shape estimation and a Gaussian blur filter demonstrated a robust preservation of neovascular flow signal.Main outcomes and measuresHistology findings associated with clinical OCTA signatures. Three-dimensional view of neovascularization via video.ResultsA White woman in her 90s with type 3 neovascularization secondary to age-related macular degeneration was treated with 37 intravitreal injections of ranibizumab and aflibercept in the right eye. The index lesion displayed a drusenoid pigment epithelium detachment, characteristic of type 3 neovascularization. OCTA decorrelation signal in the index lesion corresponded in histology to a collagen-ensheathed vascular complex contacting basal laminar deposit that outlasted the retinal pigment epithelium. The subretinal pigment epithelium-basal laminar space contained calcified material and glial processes. No connection between the choriocapillaris and this space was observed. Video showed a columnar tangle of flow signal in the outer nuclear layer, with inflow and outflow vessels connecting to the superficial artery and vein.Conclusions and relevanceWhile this study presents only 1 case in which a vascular connection between subretinal pigment epithelium-basal laminar space and choriocapillaris was undetected, these results support the potential value of OCTA for diagnosis. OCTA decorrelation signal of type 3 neovascularization corresponded with intraretinal neovessels on histology. Projection artifact removal based on 2-dimensional vessel-shape estimation and Gaussian blur filter demonstrated their potential value for further use in OCTA decorrelation signal processing.

Dataset Information

Subthreshold Exudative Choroidal Neovascularization Associated With Age-Related Macular Degeneration Identified by Optical Coherence Tomography Angiography.

Publications

Subthreshold Exudative Choroidal Neovascularization Associated With Age-Related Macular Degeneration Identified by Optical Coherence Tomography Angiography.

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