Ultra-Widefield Fluorescein Angiography in Intermediate Uveitis

Purpose: To examine associations between pattern of vascular leakage on ultrawide-field fluorescein angiography (UWFFA) and visual acuity, cystoid macular edema (CME), and inflammatory activity in intermediate uveitis.

Methods: Single center cross-sectional, retrospective review of medical records, spectral domain optical coherence tomography (SD-OCT) and angiographic images of intermediate uveitis patients who underwent UWFFA over a 12-month period.

Results: Forty-one eyes from 24 patients were included. Twelve eyes (29%) exhibited peripheral leakage, 26 eyes (64%) had diffuse leakage and three eyes (7%) had no leakage. Diffuse leakage was associated with 0.2 logMAR worse visual acuity than peripheral leakage (p = 0.02). There was no statistically significant difference in the odds of having CME when diffuse leakage was compared to peripheral leakage.

Conclusion: UWFFA identifies retinal vascular pathology in intermediate uveitis not present on clinical examination. Diffuse retinal vascular leakage was associated with worse visual acuity when compared to peripheral and no leakage patterns.     

Discrepancy in Fluorescein Angiography and Optical Coherence Tomography Findings of Macular Edema in Intermediate Uveitis

Purpose: To assess discrepancies between fluorescein angiography (FA) and optical coherence tomography (OCT) findings for macular edema (ME) in intermediate uveitis, and investigate treatment response differences corresponding to the discrepant patterns.

Methods: Discrepant results for ME detection between FA and OCT were evaluated. After 6 months, differences in treatment responses were analyzed.

Results: Discrepant findings for ME were found in 21 (44%) of 48 eyes. The best-corrected visual acuity significantly improved after treatment in the concordant group but not in the discrepant groups. Central retinal thickness significantly decreased after treatment in the FA+/OCT+ and FA?/OCT+ groups but not in the FA+/OCT? group. Disease duration was significantly longer in the FA+/OCT? group than in the other groups.

Conclusions: Discrepancies in FA and OCT findings for ME were common in patients with intermediate uveitis. Our results suggest that treatment outcomes may differ according to the discrepant patterns.     

Peripheral Vessel Leakage (PVL): A New Angiographic Finding in Diabetic Retinopathy Identified with Ultra Wide-Field Fluorescein Angiography

Purpose: To characterize the relationship between peripheral vessel leakage and other angiographic features of diabetic retinopathy.

Design: Retrospective, consecutive case series.

Methods: Consecutive ultra wide-field angiographs obtained at a single institution for diabetic retinopathy were graded for angiographic characteristics including macular edema, retinal neovascularization, retinal vascular perfusion abnormalities, and retinal vascular staining and leakage.

Results: Angiographic characteristics of 264 eyes of 143 patients were evaluated. Findings included focal and diffuse angiographic macular edema (150/264, 57%), neovascularization (107/264, 41%), late peripheral vascular leakage (PVL) (107/264, 41%), and peripheral non-perfusion (142/264, 54%). Amongst all subjects untreated peripheral non-perfusion was associated with anterior neovascularization (78% vs. 48%, p?=?0.0001, Fisher exact test) and posterior neovascularization (78% vs. 43%, p?<?0.0001), but not with macular edema (p?=?0.71). PVL was associated with peripheral non-perfusion (78% vs. 38%, p?<?0.0001) and posterior neovascularization (53% vs. 35%, p?=?0.01), but not with macular edema (p?=?0.449). However, focal macular edema was strongly associated with PVL (33% vs. 13%, p?=?0.008) in eyes without peripheral non-perfusion. Amongst untreated eyes with non-proliferative retinopathy and macular edema, there was a trend for association between macular edema and peripheral non-perfusion (p?=?0.065).

Conclusion: Untreated peripheral non-perfusion and late peripheral vascular leakage detected using ultra wide-field FA are associated with neovascularization in diabetic retinopathy. PVL may be associated with focal diabetic macular leakage in this cohort.     

Clinical Profile,Ultra-Wide-Field Fluorescence Angiography Findings,and Long-Term Prognosis of Uveitis in Tubulointerstitial Nephritis and Uveitis Syndrome at One Tertiary Medical Institute in China

Purpose: To analyze the clinical features and long-term prognosis of uveitis in tubulointerstitial nephritis and uveitis (TINU) syndrome in a cohort of Chinese patients.

Methods: A total of 32 patients with TINU syndrome between 2000 - 2016 were analyzed retrospectively.

Results: Mild anterior inflammation was observed in all cases. Ultra-wide-field fluorescence angiography (UWFA) was conducted on 13 patients, and peripheral vascular leakage was observed in 22/26 eyes (84.62%) compared with active anterior chamber inflammation in 13/26 eyes (50%). Three patients received increased corticosteroid dosage therapy on their first episode of uveitis guided by UWFA had stopped steroids without recurrence.

Conclusion: The uveitis in TINU syndrome was mild. Corticosteroids were efficient in most cases, but a slower tapering and long-term treatment were required. UWFA is sensitive in detecting the activity of uveitis and might be useful in monitoring disease progression. Complete withdrawal of medication was difficult to achieve in some cases.     

Epidemiology of Macular Edema in Uveitis

Purpose: To describe the epidemiology of macular edema (ME) in patients with uveitis.

Methods: Review of articles listed on PubMed pertaining to uveitic ME.

Results: Reported rates of uveitic ME ranging from 20% to 70%, depending on the ancillary tests used (fundus examination, fluorescein angiography, optical coherence tomography). Macular edema might develop due to uveitis itself, or occur as an adverse effect of drugs taken for different diseases. It is more frequently observed in adults than in children, in chronic uveitis, and in intermediate uveitis. Males with ankylosing spondylitis are more prone to develop ME than females. Three patterns of uveitic ME are observed, either isolated or in combination: cystoid ME, the most frequently encountered pattern seen in up to 80% of cases, diffuse ME and serous retinal detachment.

Conclusion: Older age, chronicity of uveitis and intermediate uveitis are risk factors for the development of ME in patients with uveitis.     

Intravitreal Dexamethasone Implant for the Treatment of Macular Edema in Chronic Non-infectious Uveitis

Purpose: To report observations on the single and repeat use of the dexamethasone (DEX) intravitreal implant (Ozurdex; Allergan, Inc, Irvine, CA) for the treatment of macular edema in patients with non-infectious posterior segment uveitis.

Methods: A chart review of 15 consecutive patients (25 eyes) was conducted. The primary outcome measure of the first and subsequent implants was central retinal thickness (CRT) on spectral-domain optical coherence tomography (sdOCT). Secondary outcomes were best-corrected visual acuity (BCVA), time to repeat implant, and adverse events. Multilevel mixed-effects linear regression was used to determine the effect of the DEX implant compared with baseline. The Kaplan–Meier estimator was used to examine survival from relapse.

Results: A total of 35 implants on 25 eyes of 15 patients were included in the analysis. Of these, 91.4% (32 of 35 eyes) had a reduction in CRT and 80% (20 of 25 eyes) had improved BCVA. After the first DEX implant, CRT decreased from 590 µm (SE: 28 µm) at baseline to 370 µm (SE: 31 µm) at 3 months (p < 0.001). The logMAR VA was 0.614 (SE: 0.089) at baseline and improved to 0.35 (SE: 0.10, p = 0.002), reaching a statistically significant difference at 3 months. A repeat implant led to VA improvement of –0.184 logMAR (SE: 0.171 logMAR) and CRT reduction of –291 µm (SE: 74 µm). There was no significant difference in effect between the first repeat implant and the initial implant. Kaplan–Meier estimates of treatment success were 72% between 3 and 6 months.

Conclusions: The DEX implant is an effective adjunct treatment to systemic corticosteroid or immunomodulatory therapy. Additional research is required to determine the efficacy of DEX implant as monotherapy for controlling chronic uveitic macular edema.     

Role of OCT Angiography in the Detection of Retinal Vascular and Macular Abnormalities in Subjects with Asteroid Hyalosis

Purpose: To study the role of Optical coherence tomography (OCT) Angiography (OCTA) in detecting retinal vascular and macular abnormalities as compared to Fundus Fluorescein Angiography (FFA) in subjects with Asteroid hyalosis (AH).

Methods: In a prospective study, patients with AH underwent OCTA and FFA. AH graded as Grade 1 in 8 (optic disc, second order vessels visible), Grade 2 in 4 (optic disc, first-order vessels visible), Grade 3 in 11 (hazy view of optic disc) and Grade 4 (no view of fundus) in 2 eyes.

Results: A total of 20 patients (25 eyes) with AH were included. In comparison to FFA, OCTA was able to similarly detect Diabetic Retinopathy changes such as Neovascularization, microaneurysms, capillary dropout, and foveal avascular zone extent in vascular occlusion in all grades of AH.

Conclusion: OCTA, a noninvasive imaging tool, could detect various retinal vascular and macular abnormalities in patients with all grades of AH in comparison to FFA.     

Causes of Visual Loss Associated with Uveitis in a Singapore Tertiary Eye Center

Purpose: To identify the causes of visual loss associated with uveitis and its risk factors.

Methods: Review of 359 patients attending a uveitis service.

Results: Anterior uveitis (n?=?229, 63.8%) was most common, followed by panuveitis (n?=?55, 15.3%). There were 82 infective cases with 29.3% associated with tuberculosis. Visual loss occurred in 100 (27.9%) patients, of which 27 (7.5%) had severe visual loss. The main causes of visual loss were cataract (26%) and glaucoma (12%). Cystoid macular edema (14.8%) accounted for severe visual loss. Panuveitis was predictive for visual loss (p?=?0.022, odds ratio (OR) 2.22) and severe visual loss (p?=?0.01, OR 3.47). Posterior uveitis (p?=?0.005, OR 5.01) and chronic uveitis (p?=?0.008, OR 3.83) also showed higher risk for severe visual loss.

Conclusion: With panuveitis being the second most common presentation, early specialist referral is essential in preventing visual loss.     

Fluorescein and OCT Angiography Features of Takayasu Disease

Purpose: Evaluate OCT (optical coherence tomography) angiography (OCTA) features in patients with Takayasau disease.

Methods: The OCTA was analyzed to evaluate perifoveal anastomatic capillary arcade disruption, microaneurysms. The foveal avascular zone (FAZ) was measured for superficial (SCP) and deep capillary plexus.

Results: There were 26 eyes included. In OCTA, 11 eyes presented ruptures of the perifoveal anastomotic capillary arcade in SCP. A total of 5 had microaneurysms. The average SCP FAZ was increased to 0.34 mm2 in Takayasu compared to 0.27 mm2 in control patients.

Conclusion: Fluorescein angiography is the gold standard to describe Takayasu retinopathy ischemic signs. Macular abnormalities are uncommon in Takayasu patients as retinopathy signs are mostly located in peripheral retina. This study reveals that most of our patients present an enlargement of the FAZ then highlights the relevance of OCTA to evaluate macular ischemia as a complement to usual retina global study in fluorescein angiography.     

Tracing Method in the Assessment of Retinal Capillary Blood Flow Velocity by Fluorescein Angiography with Scanning Laser Ophthalmoscope

Purpose

To evaluate the feasibility of a new method (the tracing method) for measuring perifoveal capillary blood flow velocity (BFV).

Methods

The BFV in the perifoveal capillaries was measured in 12 eyes of healthy subjects and 12 eyes of patients with clinically significant macular edema (CSME) by fluorescein angiography using a scanning laser ophthalmoscope by either the tracing method or the conventional method. A randomized crossover design was employed to assign the subjects to each method.

Results

The number of capillaries recognized by the tracing method in healthy subjects and in patients with CSME was significantly higher than that recognized with the conventional method (P = 0.0134 and P = 0.0108, respectively). The number of fluorescent dots detected by the tracing method in healthy subjects and in patients with CSME was also significantly higher than that detected with the conventional method (P = 0.0002 and P = 0.0137, respectively). Accurate detection of the movement of fluorescent dots and analysis of BFV were possible with the tracing method. The BFV varied within each perifoveal capillary, and the mean BFV also varied according to capillary location in the macula.

Conclusion

The new tracing method is useful for analyzing the retinal capillary BFV in healthy subjects and in patients with CSME. Jpn J Ophthalmol 2006;50:25–32 © Japanese Ophthalmological Society 2006     

Optical Coherence Tomography for Classification and Clinical Evaluation of Macular Edema in Patients with Uveitis

Purpose: To study use of optical coherence tomography (OCT) for macular edema in uveitis. Methods: In total, 44 patients with uveitis and macular edema underwent OCT. Data obtained were correlated with anatomic type, duration of uveitis, and visual acuity (VA). Results: Both cystoid macular edema (CME) and diffuse macular edema (DME) correlate negatively with VA, although statistically CME showed stronger correlation (p = .02). Also CME had higher mean foveal thickness than DME (p < .01). Negative correlation between foveal thickness and VA (p < .05) was observed. CME correlates with uveitis duration (p < .01). Conclusions: CME and macular thickening correlate with VA reduction and uveitis duration.     

Fluorescein leakage of the optic disc in glaucomatous optic neuropathy

Purpose To identify and quantify the role of capillary leakage of the optic nerve head in digital fluorescein angiography in normal subjects and patients with open-angle glaucoma.Methods We conducted a prospective cross-sectional study in the Department of Ophthalmology of the Technical University of Aachen. Thirty patients with primary open-angle glaucoma (POAG) and 30 healthy age-matched subjects were included. Fluorescein angiograms were performed using the scanning laser ophthalmoscope. The fluorescence of the optic nerve head and the surrounding retina (ratio of leakage) was measured using digital imaging analysis in the late phases of the angiogram (9–10 min).Results The ratio of optic nerve head fluorescence to retinal reference loci was significantly increased (p=0.01) in patients with glaucoma (POAG, 1.38±0.34) compared with normal subjects (1.20±0.19). Intraocular pressure (p=0.0001), visual field indices (mean deviation, p<0.0001; pattern standard deviation, p<0.0001; corrected pattern standard deviation, p<0.0001), and cup to disc ratios (p=0.02) differed significantly between the groups. Age and systolic and diastolic blood pressure showed no significant differences between groups.Conclusion Fluorescein angiography revealed significantly increased vascular leakage of glaucomatous optic nerve heads. An endothelial disruption and fluorescein leakage might be the result of mechanical stress at the level of the lamina cribrosa and/or a sign of ischemic damage. This measurement approach might enable us to judge the severity of optic nerve head leakage, and it is a potential way to evaluate therapeutic regimens.     

Retinal Complications of Juvenile Idiopathic Arthritis-related Uveitis: A Microperimetry and Optical Coherence Tomography Study

Purpose: To evaluate ocular complications of juvenile idiopathic arthritis (JIA)-related uveitis; to study macular morphology and sensitivity.

Methods: Retrospective chart review of 67 patients. Fourteen consecutive patients (24 eyes) observed from January to December 2008 were submitted to optical coherence tomography study (OCT) and microperimetry MP-1 examination.

Results: Most frequent complications were posterior synechiae (63.0%), band keratopathy (53.9%), and cataract (31.8%). Posterior complications were documented in 37.0% of eyes: 13.8% macular edema, 12.0% papillitis, 6.8% epiretinal membranes, 2.5% retinal vasculitis, 1.7% retinal detachment. At OCT examination 25.0% of eyes presented macular edema; macular sensitivity by MP-1 was ≤16.5 dB in 25.0% of eyes.

Conclusions: Visual prognosis is good despite ocular complications. Incidence of macular edema seems to be higher when using OCT. Microperimetry may represent a useful tool in detecting alteration in retinal sensitivity that may supplement visual acuity in the follow-up of macular edema.     

The Pros and Cons of Intravitreal Triamcinolone Injections for Uveitis and Inflammatory Cystoid Macular Edema

Intravitreal triamcinolone acetonide (IVTA) injections are gaining in popularity and are regularly administered nowadays for various ocular diseases. This paper presents a literature review on the use, efficacy, and complications of IVTA application in non-infectious uveitis and inflammatory cystoid macular edema (CME). In addition, we describe the experiences of our own institute. IVTA applications brought about a quick improvement in vision in the majority of cases. Drawbacks included the temporary duration of the effect with the need for repeated injections which re-exposed patients to the risk of complications. The risk of bacterial endophthalmitis was 0.5% and was further influenced by the specific IVTA preparation. Based on the literature review, we chose ready-for-use IVTA injections prepared by our pharmacy department, in which 90% of the toxic additives were removed and the dispensed dose of triamcinolone acetonide was validated to diminish the risk of endophthalmitis. Elevated intraocular pressure (IOP) was seen in 30–43% of the eyes and cataract developed in 29% of the eyes of patients, who were usually of advanced age. In conclusion, the rapid effect of IVTA might be of value in severe presentations of non-infectious uveitis and CME and might shorten the time interval needed for the improvement.     

Clinical Profile of HLA B-27-Associated Uveitis Patients in a Tertiary Care Eye Hospital in Eastern India

Purpose: To analyse clinical profile of the patients with HLA B 27- associated uveitis in a tertiary care eye hospital in Eastern India Method: Retrospective analysis of 61 eyes of 43 patients with HLA B27- associated uveitis between 2015 and 2016. Result: We observed a male predominance (67%), and more unilateral involvement (58%) in our patients. The mean age of presentation was 44.7 ±11.7 years. Significant vitritis and macular edema were noted in 14 and 7 eyes respectively. In addition to topical therapy, oral steroid was required in 49% patients and 58% patients were treated with methotrexate. Five patients (12%) required biologicals. There was improvement in BCVA at final follow-up (p<0.001). Conclusion: Compared to the existing literature, the current study observed relatively high age of presentation and frequent posterior segment involvement with less systemic association.     

Fluorescein Angiography Findings in Eyes With Lamellar Macular Hole and Epiretinal Membrane Foveoschisis

PurposeThe purpose of this paper was to study fluorescein angiography (FA) findings in eyes with lamellar macular hole (LMH), and epiretinal membrane (ERM) foveoschisis.MethodsIn this prospective, observational case series, 46 eyes of patients affected by either LMH or ERM foveoschisis were examined using optical coherence tomography (OCT) and FA. All patients underwent a comprehensive ophthalmological examination and a general workup to exclude uveitis. Main outcome measures were: presence of FA abnormalities, measurements of the areas of vascular leakage, and intensity of pixels in the vitreous.ResultsTwenty-four (52.2%) eyes with LMH and 22 (47.8%) with ERM foveoschisis were studied. Overall, FA abnormalities were found in 20 (83.3%) eyes with LMH and 18 (81.8%) with ERM foveoschisis. The median areas of posterior pole and peripheral leakage were 7.52 vs. 1.07 mm² (P = 0.03) and 21.8 vs. 3.74 mm² (P = 0.02) in the LMH and ERM foveoschisis group, respectively. Disk hyperfluorescence was found in 8 and 4 eyes and perivascular leak in 10 and 4 eyes with LMH and ERM foveoschisis, respectively. OCT-derived measurements of vitreous intensity did not differ between the two groups, and the investigational workup for uveitis was negative in all patients.ConclusionsDiscrete areas of central and peripheral leakage are commonly found in eyes with LMH and ERM foveoschisis, whereas perivascular leak and hyperfluorescence of the disc are less frequently observed. These findings suggest that breakdown of the retinal blood barrier, involving the posterior pole and the periphery, is frequently associated with these two vitreoretinal disorders.     

Aqueous angiopoietin-like levels correlate with optical coherence tomography angiography metrics in diabetic macular edema

AIM: To quantitatively detect aqueous levels of angiopoietin-like (ANGPTL)3, ANGPTL4, and ANGPTL6 and investigate their correlation with optical coherence tomography angiography (OCTA) findings in patients with diabetic macular edema (DME).METHODS: This cross-sectional study included 23 patients (27 eyes) with type 2 diabetes and 16 control subjects (20 eyes). All patients underwent OCTA imaging and ultra-wide field fundus photography. Diabetic patients were categorized into two groups according to the presence or absence of diabetic retinopathy (DME group, 14 patients, 16 eyes); and non-diabetic retinopathy (NDR) group, 9 patients, 11 eyes, respectively. Aqueous levels of ANGPTL3, ANGPTL4, and ANGPTL6 were assessed using suspension array technology, and foveal-centered 3×3 mm2 OCTA scans were automatically graded to determine the central, inner, and full vessel density (CVD, IVD, FVD); central, inner, and full perfusion density (CPD, IPD, FPD), foveal avascular zone (FAZ) area, FAZ perimeter, and FAZ circularity index (FAZ-CI) on superficial capillary plexuses. Additionally, central subfield thickness (CST), cube volume (CV), and cube average thickness (CAT) were measured in a model of macular cube 512×128.RESULTS: Aqueous ANGPTL3 levels were not significantly different among the three groups (P>0.05). ANGPTL4 levels were significantly higher in the DME group than the control and NDR groups (P<0.0001 and P<0.001), while ANGPTL6 levels were significantly higher in the DME group than the control group (P<0.05). In the whole cohort, the aqueous ANGPTL3 levels correlated negatively with the IVD, FVD, IPD, and FPD, and positively with the CV and CAT. The aqueous ANGPTL4 levels correlated negatively with the CVD, IVD, FVD, CPD, IPD, and FPD, and positively with the FAZ perimeter, CST, CV, and CAT. The aqueous ANGPTL6 levels correlated negatively with the IVD, FVD, IPD, FPD, FAZ-CI and positively with CST, CV, CAT.CONCLUSION: ANGPTL4 and ANGPTL6 may be associated with vascular leakage in DME and may represent good targets for DME therapy. In addition, OCTA metrics may be useful for evaluating macular ischemia in DME.     

葡萄膜炎性黄斑水肿对视功能的影响

目的:探讨葡萄膜炎性黄斑水肿对视力、视野损害的相关性.方法:此研究为单中心、回顾性的、对临床中发现的中间、后部或全葡萄膜炎治疗的特征性对照研究.葡萄膜炎性黄斑水肿患者132例248眼,接受视力、频域光学相干断层扫描、微视野检测.结果:葡萄膜炎性黄斑水肿与视力、视野的损害具有明显的相关性(P＜0.05).不同类型的黄斑水肿对应不同的视力损害:不伴有黄斑中心凹厚度增加的囊腔型可产生中等程度的视力损害,平均10个字母;不伴有囊腔而仅有黄斑中心凹厚度增加型可产生更大程度的视力损害,平均19个字母;而同时伴有囊腔、黄斑中心凹厚度增加的黄斑囊样水肿型可产生最大程度的视力损害,平均26个字母.入选的所有黄斑水肿都产生了不同程度的视野损害:与黄斑中心凹的的厚度密切相关,即厚度越大,视野损害的范围越广,差异具有统计学意义(P＜0.05),而与是否具有囊腔关系不大.结论:黄斑水肿对应的视功能损害提示我们在以后的葡萄膜炎治疗过程中,对黄斑水肿的治疗也应作为一个重要方面去关注;对葡萄膜炎性黄斑水肿的视功能损害评估,应该从视力和微视野两方面关注.