Multimodal Evaluation of Patients with Acute Posterior Multifocal Placoid Pigment Epitheliopathy and Serpiginous Choroiditis

Purpose: To evaluate retinal and choroidal changes in patients with non-granulomatous choroiditis using the multimodality imaging (MMI).

Methods: Eight eyes of four patients were analyzed. Three patients (six eyes) were diagnosed with serpiginous choroiditis (SC) and one patient (two eyes) with acute posterior multifocal placoid pigment epitheliopathy (APMPPE). The patients were imaged on the same day using the RTVue Avanti XR instrument OCT/OCTA (Optovue Inc, Fremont, CA), Heidelberg Retina Angiograph 2 FAF and FA (Heidelberg Engineering, Germany), and TRC50DXi Topcon FP (Topcon Medical Systems, Oakland, NJ).

Results: OCT angiography (OCTA) showed hypoperfusion in all the cases, reperfusion in choriocapillaris in two eyes after treatment and identified a choroidal neovascularization (CNV), which was not detected on the fluorescein angiography (FA).

Conclusions: OCTA may be an effective noninvasive image modality to follow up these patients and may provide further information to help us to understand the pathophysiology and complications of these diseases.     

Multimodal Imaging in Ocular Tuberculosis

Intraocular tuberculosis presents a diagnostic challenge because of its protean clinical manifestations. Thus, it becomes imperative to distinguish chorioretinal inflammation due to tuberculosis from other infectious as well as non-infectious posterior uveitis since the clinical manifestations of these entities may be quite similar. With advancing technology, a number of novel imaging modalities are available today that enable in vivo near-histologic assessment of the chorioretinal tissue, greatly aiding the clinician in establishing a diagnosis and monitoring the therapeutic response of tubercular lesions. Techniques such as ultra-wide field fundus photography, fluorescein and indocyanine green angiography, optical coherence tomography and most recently, optical coherence tomography angiography, provide valuable information that helps in advancing our knowledge regarding the pathogenesis and natural history of the disease. The index review describes how these techniques supplement each other, and highlights the relevance of multimodal imaging in the management of intraocular tuberculosis.     

Clinical profile,multimodal imaging,and treatment response in macular serpiginous choroiditis

Purpose:To describe the clinical profile, multimodal imaging, and treatment response in macular serpiginous choroiditis (MSC).Methods:Clinical records of 16 eyes (14 patients) with MSC presenting to a tertiary eye care institute between 2015 and 2019 were analyzed retrospectively.Results:Mean age of 14 patients presenting with MSC was 33 ± 13 yrs with 64% males and 36% females. Mean visual acuity of the eyes with MSC at presentation was 0.43 ± 0.46 (logMAR) improving to 0.16 ± 0.28 (logMAR) at final visit. Thirteen eyes (81.3%) had active lesion at presentation. Mantoux test was positive in seven patients (50%) and QuantiFERON TB gold test positive in 10 patients (71%). HRCT chest showed latent tuberculosis in seven patients (50%). All patients underwent multimodal imaging. All patients received oral steroids as treatment therapy; 11 patients also received immunosuppressives, nine patients received additional anti-tubercular therapy (ATT). Mean duration of follow-up for the patients was 18 ± 10 months. A total of eight (50%) eyes had recurrence of lesions after an average duration of 14 ± 14 (3-36) months and were restarted on the treatment as per the requirement. At final follow-up, all eyes showed a good response to treatment and had healed lesions. Comparing the final BCVA to the initial BCVA, 38% (n = 6) showed improvement, 56% (n = 9) remained stable, and 6% (n = 1) eyes worsened at the final follow-up.Conclusion:Clinical profile and presentation of MSC is similar to that of CSC, and combination treatment with intravenous methyl prednisolone (IVMP), steroids, immunosuppressives, and ATT can salvage vision. A high suspicion of associated tuberculosis in endemic regions should be kept in mind.     

多模式成像在匍行性脉络膜炎中的应用进展

匍行性脉络膜炎(SC)是一种罕见的慢性特发性炎性疾病,主要侵犯视网膜色素上皮(RPE)和脉络膜毛细血管,以视盘周围青灰色或灰黄色的地图状病变为特征。病因不清,脉络膜毛细血管炎可能是其主要病理类型。根据眼底表现可分为视盘周围型、黄斑型、变异型SC。由于SC的临床表现丰富多样,且与急性后部多灶性鳞状色素上皮病变(APMPPE)、结核、视网膜弓形虫病和脉络膜缺血等表现类似,所以对不具有典型眼底改变的SC诊断仍然存在一定困难。随着科技的进步,像荧光素眼底血管造影、吲哚菁绿血管造影、眼底自身荧光及光相干断层扫描等多模式影像检查联合应用有助于SC的早期诊断、评估病变范围、活动性以及可能的并发症,且对于避免不必要的药物使用至关重要。     

Multimodal Imaging of the Normal Eye

Multimodal imaging is the concept of “bundling” images obtained from various imaging modalities, viz., fundus photograph, fundus autofluorescence imaging, infrared (IR) imaging, simultaneous fluorescein and indocyanine angiography, optical coherence tomography (OCT), and, more recently, OCT angiography. Each modality has its pros and cons as well as its limitations. Combination of multiple imaging techniques will overcome their individual weaknesses and give a comprehensive picture. Such approach helps in accurate localization of a lesion and understanding the pathology in posterior segment. It is important to know imaging of normal eye before one starts evaluating pathology.

This article describes multimodal imaging modalities in detail and discusses healthy eye features as seen on various imaging modalities mentioned above.     

Enhanced Depth Imaging by High-Resolution Spectral Domain Optical Coherence Tomography in Tubercular Multifocal Serpiginoid Choroiditis

Purpose: To report the choroidal changes by enhanced depth imaging optical coherence tomography (EDI-OCT) in tubercular multifocal serpiginoid choroiditis (MSC).

Methods: Prospective study of 20 patients (23 eyes) with active MSC who underwent simultaneous fundus autofluorescence and EDI-OCT imaging at regular visits.

Results: Eyes with acute lesions demonstrated diffuse choroidal thickening at presentation, which decreased significantly as the lesions healed. Additionally, the region of (thickened) choroid just beneath the active choroiditis lesion demonstrated a localized area of mixed reflectivity (a central hyperreflectivity surrounded by a zone of hyporeflectivity), suggesting choroidal involvement deeper to choriocapillaris. Once the lesions healed, the choroid under the scar showed a localized thinning, along with outer retinal layers loss.

Conclusion: EDI-OCT highlighted diffuse and localized choroidal structural changes in MSC as the lesions evolved from acute to healed stage, providing an adjunct to clinical examination for monitoring response to therapy.     

Assesment of fundus autofluorescence in serpiginous and serpiginous-like choroidopathy

AimsThe aim of this study was to correlate the activity status disclosed in fluorescein angiography (FA) and fundus autofluorescence (FAF) imaging, and the variations of FAF images in the evolution of serpiginous choroidopathy (SC) and serpiginous-like choroidopathy (SLC).MethodsProspective consecutive case series. Patients with SC or SLC were included from July 2009 to December 2010. All patients underwent FAF imaging (Spaide Autofluorescence Filters, Topcon TRC 50IX) and FA (Topcon TRC 50IX).ResultsTwelve patients (eight males, mean age 51.2 years) were included. Bilateral involvement in nine cases. Three different patterns of FAF images were present: active inflammation, transitional, and inactive inflammation.ConclusionFAF may be a useful tool for following patients with SC and SLC. It is possible to reserve other invasive techniques, such as FA, for cases with suspicious activity disclosed by FAF imaging.     

Optical Coherence Tomography Angiography Features of Paradoxical Worsening in Tubercular Multifocal Serpiginoid Choroiditis

Purpose: To describe optical coherence tomography angiography (OCTA) features of lesions of tubercular multifocal serpiginoid choroiditis (TB MSC) that developed paradoxical worsening (PW).

Methods: In this prospective study, subjects with TB MSC who developed PW upon initiation of anti-tubercular therapy were included. Multimodal imaging was performed using OCTA, enhanced-depth imaging OCT, fluorescein angiography (FA), and indocyanine green angiography (ICGA). Morphologic changes in the retinochoroidal vasculature during progression of TB MSC were assessed on OCTA.

Results: Five subjects (4 males, 1 female) were included in the study. PW of the lesions was associated with increased areas of choriocapillaris flow void on en face OCTA in all eyes. The lesions showed partial healing in the center and continuous progression at the active edges. Two eyes showed development of vascular tufts on OCTA as the lesions progressed.

Conclusions: OCTA provides high-resolution imaging of progressive choriocapillaris hypoperfusion among TB MSC patients developing PW of the disease.     

Retinal and Choroidal Changes of Vitreoretinal Lymphoma from Active to Remission Phase after Intravitreal Rituximab

ABSTRACT

Purpose

To identify main qualitative and quantitative changes by spectral-domain optical coherence tomography (SD-OCT) in eyes with vitreoretinal lymphoma (VRL) shifting form active to remission phase, after intravitreal rituximab (IVR).     

Optical coherence tomography and autofluorescence findings in chronic phototoxic maculopathy secondary to snow-reflected solar radiation

A professional mountain trekker presented with gradual, moderate visual decline in one eye. The subnormal vision could not be explained by the examination of anterior and posterior segment of either eye, which was unremarkable. Optical coherence tomography and autofluorescence imaging revealed subtle defects in the outer retina, which correlated with the extent of visual disturbance. A novel presentation of retinal phototoxicity due to indirect solar radiation reflected from snow in inadequately protected eyes of a chronically exposed subject is reported.     

Multimodal Imaging in Retinal Vasculitis

Retinal vasculitis presents with inflammation involving the retinal vasculature as an isolated disease or in combination with other ocular or systemic conditions. This entity may be associated with a wide variety of clinical manifestations such as vascular sheathing, cotton-wool spots, retinal ischemia, and neovascularization. Often, retinal vasculitis and its complications lead to diagnostic challenges in identifying the exact etiology of the inflammation. Ancillary investigations such as fundus photography, fluorescein angiography, and more recently, adaptive optics imaging and optical coherence tomography angiography, may provide valuable information that help in establishing the exact diagnosis and initiation of appropriate therapy. In the index review, multimodal imaging features of retinal vasculitis are described. In addition, detection of vascular inflammation using novel noncontact imaging techniques has been highlighted.     

Multimodal Imaging in Birdshot Retinochoroiditis

Purpose: To describe retinal vascular changes in Birdshot Retinochoroiditis (BSRC) with multimodal imaging techniques and functional values.

Methods: In this single-center study, 64 eyes of 32 subjects with BSRC were classified according to disease activity and duration and underwent imaging with spectral domain optical coherence tomography, fluorescein angiography, indocyanine green angiography, fundus autofluorescence, and optical coherence tomography angiography (OCTA).

Results: Mean age of the patients was 60 years (range, 38–74). OCTA revealed capillary loops (58%), telangiectatic vessels (44%), increased intercapillary spaces (52%), altered vascular architecture (53%), and rarefication of C-scans (63%) in retinal layers. Increased rarefications of C-scans (p = 0.0056; p = 0.0046) and altered vascular architecture (p = 0.0120; p = 0.0243) in superficial and deep capillary layers were significantly correlated with disease activity.

Conclusion: OCTA adds new insights in a multimodal imaging approach of retinal vascular layer visualization in BSRC and may contribute to existing methods for diagnosing severity and potentially progression of the disease.     

Role of Ultra-Wide Field Imaging in the Management of Tubercular Posterior Uveitis

Purpose: To assess the utility of ultra-wide field (UWF) versus conventional fundus imaging in the management of tubercular (TB) posterior uveitis.

Methods: Twenty-two consecutive patients (33 eyes) diagnosed with TB posterior uveitis in a tertiary care center who underwent UWF fundus photography and fluorescein angiography (FA) between July 2014 and March 2015 were included. Complete clinical and imaging records of the patients were retrospectively reviewed. A circle simulating the central 75-degree field was drawn on UWF pseudocolor and fluorescein angiography images. Findings within the circle were compared with the information yielded by the complete image and its impact on patient management was noted.

Results: The clinical manifestations of posterior tubercular uveitis included retinal vasculitis (17 eyes), multifocal serpiginoid choroiditis (13 eyes), choroidal granulomas (2 eyes) and intermediate uveitis (1 eye). UWF imaging revealed additional capillary non-perfusion areas, neovascularization, active vasculitis, and peripheral choroiditis lesions in 30/33 eyes (90.9%), which influenced treatment decision in 15 eyes (45.5%).

Conclusions: UWF imaging is useful in the detection of peripheral pathologies in tubercular posterior uveitis that may influence management decisions, such as addition of immunosuppressive therapy or scatter laser photocoagulation.     

Unilateral Papillitis,the Tip of the Iceberg of Bilateral ICGA-detected Tuberculous Choroiditis

Purpose: To report the case of a patient who presented with unilateral papillitis that turned out to be the visible feature of bilateral tubercular choroiditis.

Design: Retrospective review of chart and clinical history of the patient.

Methods: Case report of a 54-year-old Hispanic woman with visual complaints and papillitis in the left eye.

Results: A complete and extended workup was negative and only indocyanine green angiography (ICGA) combined with a positive interferon gamma release assay (IGRA) pointed toward a diagnosis of bilateral tubercular choroiditis.

Conclusions: Without the help of ICGA the diagnosis of tuberculous choroiditis would have been missed.     

Multimodal imaging of experimental choroidal neovascularization

AIM: To compare choroidal neovascularization (CNV) lesion measurements obtained by in vivo imaging modalities, with whole mount histological preparations stained with isolectin GS-IB4, using a murine laser-induced CNV model. METHODS: B6N.Cg-Tg(Csf1r-EGFP)1Hume/J heterozygous adult mice were subjected to laser-induced CNV and were monitored by fluorescein angiography (FA), multicolor (MC) fundus imaging and optical coherence tomography angiography (OCTA) at day 14 after CNV induction. Choroidal-retinal pigment epithelium (RPE) whole mounts were prepared at the end of the experiment and were stained with isolectin GS-IB4. CNV areas were measured in all different imaging modalities at day 14 after CNV from three independent raters and were compared to choroidal-RPE whole mounts. Intraclass correlation coefficient (ICC) type 2 (2-way random model) and its 95% confidence intervals (CI) were calculated to measure the correlation between different raters'' measurements. Spearman''s rank correlation coefficient (Spearman''s r) was calculated for the comparison between FA, MC and OCTA data and histology data. RESULTS: FA (early and late) and MC correlates well with the CNV measurements ex vivo with FA having slightly better correlation than MC (FA early Spearman''s r=0.7642, FA late Spearman''s r=0.7097, and MC Spearman''s r=0.7418), while the interobserver reliability was good for both techniques (FA early ICC=0.976, FA late ICC=0.964, and MC ICC=0.846). In contrast, OCTA showed a poor correlation with ex vivo measurements (Spearman''s r=0.05716) and high variability between different raters (ICC=0.603). CONCLUSION: This study suggests that FA and MC imaging could be used for the evaluation of CNV areas in vivo while caution must be taken and comparison studies should be performed when OCTA is employed as a CNV monitoring tool in small rodents.     

Review for Diagnostics of the Year: Multimodal Imaging in Behçet Uveitis

Behçet disease is a chronic relapsing multisystem inflammatory disorder. Ocular involvement is characterized by a bilateral recurrent non-granulomatous panuveitis and retinal vasculitis. Posterior segment findings vary during the course of the disease, in parallel with the relapsing and remitting intraocular inflammation. Structural alterations occur with increased disease duration. Fluorescein angiography is the gold standard in revealing the extent and severity as well as the leaky and/or occlusive nature of retinal vasculitis. Multimodal imaging using color fundus photography, fluorescein angiography, and optical coherence tomography is essential in visualizing diagnostic features, detecting structural changes, and monitoring disease activity and response to treatment in patients with Behçet uveitis.