Ординатура / Офтальмология / Английские материалы / Optical Coherence Tomography in Age-Related Macular Degeneration_Coscas_2009

Clinical Signs

A 67-year-old woman was followed for recently decompensated wet AMD of the left eye.

The visual acuity in the left eye was slightly decreased with poorly-defined symptoms. The fellow eye (right eye) was asymptomatic with satisfactory visual acuity.

VA RE: 20/32 - VA LE: 20/50.

Fluorescein angiography (Figures 42d and e)

▬In the early phases, dotted hyper-fluorescence visible against the dark background of the inferior 2/3 of the lesion.

▬Gradual appearance of a circular macular zone of hy- per-fluorescence with slight fluorescein leakage and numerous pinpoint leaks, partially masked by xanthophyll pigment in the superior part of the macula.

SLO-ICG angiography (Figures 42e and f)

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Biomicroscopic Examination

Presence of a central translucent serous elevation extending temporally over about 2 DD with no hemorrhage or lipid exudates. A small number of perifoveal soft drusen were observed in the right eye.

Autofluorescence

A perimacular hyper-fluorescent halo was visible, predominantly in the temporal and inferior sectors with alteration of xanthophyll pigment in the same region (Figures 42a-c).

a): Early phase: vast zone of central macular hypo-fluo- rescence, masking the choroidal vessels with no detectable neovascular membrane.

b): Late phase: the well-delineated zone of hyper-fluo- rescence was confirmed, suggesting a vascularized PED comprising an area of moderate, cloudy hyper-fluores- cence with no well-defined neovascular membrane.

Suggested Diagnosis:

Round, clearly demarcated, vascularized pigment epi-

thelium detachment with hyper-fluorescence suggestive

of occult CNV. Recently developed lesion without fibrosis.

Stratus* horizontal section

The exudative reaction was essentially visualized posterior to the RPE.

The RPE was raised to form a prominent bullous cavity with almost completely optically empty contents and slight shadowing, leaving Bruch’s membrane visible.

On either side of this bullous cavity, the RPE was separated from Bruch’s membrane with a flat, partially organized and moderately reflective (false green color) detachment, suggesting the presence of fibrovascular tissue

Anterior to the RPE

There were no signs of SRF and only minimal intraretinal fluid on either side of the bullous PED (Figure 43a).

Stratus* vertical section

The appearance was essentially the same, suggesting a regular, dome-shaped vascularized PED with a rounded shape in all directions (Figure 43b).

The response to treatment by monthly intravitreous injections of anti-VEGF (Lucentis*) was monitored with visual acuity, OCT, fluorescein angiography, and ICG angiography.

Visual acuity improved to 20/40 after the first injection and this immediate response was accentuated and then maintained throughout the 2 years of follow-up. Each injection was decided according to the clinical presentation (Figure 44).

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OCT

At the First Follow-up Examination

The pigment epithelium detachment was considerably flattened. The RPE was still separated from Bruch’s membrane, but this elevation was much less marked.

The PED cavity was globally hypo-reflective, except in the periphery which remained moderately reflective.

The PED had a wavy surface, but the RPE itself had a regular appearance with no thickness variations.

Anterior to the RPE, retinal thickness was almost normal, but the retina remained raised with loss of the foveal depression (Figures 44a and b).

The first signs of improvement were observed after the first injection and were subsequently confirmed. Repeated IVT injections were performed due to persistence

At this Stage

This case of occult choroidal neovascularization was associated with a prominent, dome-shaped, mostly se-

rous (no detectable neovascular membrane) bullous

PED. It was identified and treated at a relatively early stage with marked intraretinal fluid but no hemorrhage.

The response to treatment was immediately favorable, but persistence of the PED justified repeated intravitreous injections until stabilization, obtained after the third or fourth injection.

of the PED but were suspended after the fourth injection due to nonresponse.

Subsequent examinations performed every 3 months, demonstrated remarkably stable features with good visual comfort and few changes on OCT: the flat, wavy PED persisted. Outer retinal layers gradually became more distinct (Figure 44c).

At the last Examination

The IS/OS interface was constantly visible with slight subfoveal thickening. The external limiting membrane was visible, linear, and continuous. The outer nuclear layer became regular with a homogeneous thickness. The foveal depression became visible with an almost normal profile (Figure 44d).

Angiography

The global appearance was favorable with marked regression of the lesions but without complete resolution of the angiographic abnormalities.

On fluorescein angiography, the zone of hyper-fluores- cence decreased gradually at each examination, but persisted in the inferior temporal zone.

SLO-ICG angiography did not reveal any abnormal neovascular membranes, but the dark PED persisted on all examinations, confirmed with persistence of the PED on SD-OCT (Figure 44).

Treatment was then suspended with follow-up

every 3 months for 2 years.

At the last examination, retinal morphology was

almost normal despite persistence of a relatively flat PED with no intraretinal fluid and no marked altera-

tions of the outer retinal layers.

The prognosis was good in this case, but follow-up every 3 months and then every 6 months remained essential.

ICG

Æ IVT 4

ICG

Stabilization

ICG

Stabilization

ICG

Clinical Signs

A 70-year-old woman presented with a few soft drusen in her right eye that were confluent in some areas, with almost normal visual acuity (20/32) (Figure 45).

Initially followed during the last several years for wet AMD in the left eye, she had developed a vascularized PED and had stabilized with visual acuity of 20/100.

Six months later, visual acuity in her right eye declined to 20/50 and remained at 20/100 in her left eye. Major clini-

8cal changes were noted in her right eye.

Biomicroscopic examination

A central, round, translucent, serous elevation measuring 1 DD with no hemorrhage was seen.

Autofluorescence: A small temporal macular hyper-fluo- rescent zone was present.

Fluorescein angiography (Figure 46a and b)

a) Early phase: temporal and extrafoveal zone of heterogeneous hyper-fluorescence.

b) Late phase: progressive pooling of fluorescein in the macular region and staining of the central PED cavity with no fluorescein leakage.

SLO-ICG angiography (Figures 46c and d)

c)Early phase: dark central macular hypo-fluorescence without evidence of a neovascular membrane.

d)Late phase: the hypo-fluorescence of the well-demar- cated PED persisted. An irregular area of moderate hy- per-fluorescence appeared in the periphery, at 7 o’clock, suggesting a limited zone of occult CNV.

Suggested Diagnosis:

Recent onset of a well-demarcated, round, vascularized

pigment epithelium detachment with a zone of occult

CNV at its inferior temporal edge.

Stratus* horizontal section

The RPE was elevated, forming a rounded and regular dome and delineating a bullous cavity with Bruch’s membrane underneath. There was also slight shadowing posteriorly.

A moderately reflective band (false green color) was visualized posterior to the PED. Further posteriorly, the cavity was optically empty, suggesting a space filled with serous fluid.

The PED displaced the neurosensory retina, causing loss of the foveal depression. The retina was slightly thickened and with a small cystoid space, but there was no disorganization of the retinal layers (Figure 46e).

Stratus* vertical section

The appearance was almost identical on the vertical section, suggesting that the lesion had a symmetrical rounded shape in all axes (Figure 46f).

The response to treatment by monthly intravitreous injections of anti-VEGF (Lucentis*) was monitored by visual acuity, OCT, fluorescein angiography, and ICG angiography.

Visual acuity improved immediately to 20/32 and then remained stable for the 15 months of follow-up. However, due to the subjective variations reported by the patient, maintenance injections were administered every 3 to 6 months according to imaging and clinical examination (Figure 47).

OCT

8At the First Follow-up Examination

The RPE remained regular with normal thickness and the PED cavity was still optically empty. The pigment epithelium detachment slightly decreased in size but with persistent loss of the foveal depression.

In contrast, the SRF over the dome of the PED deteriorated with marked alteration of the outer retinal layers.

The outer nuclear layer was displaced and relatively thinned (Figure 47a).

Intravitreal injections were repeated due to persistence of the SRF. They were suspended after the third injection due to partial improvement and good visual acuity.

Subsequent follow-up examinations, performed every 3 months, demonstrated remarkably stable features with good visual function and relatively constant OCT findings.

The less prominent and regular PED persisted. The outer layers were much more clearly visualized and regular

despite persistent thickening of the IS/OS interface and thinning of the outer nuclear layer (Figure 47b).

After the 12th month, a slight decline in visual acuity (20/40) was observed, in parallel with slight extension of the lesions and appearance of a moderately reflective band, just posterior to the RPE.

The outer retinal layers were not altered and the SRF had decreased, but changes of the outer segments were clearly visible (Figure 47c).

At the last Examination (15th Month)

The external limiting membrane was constantly visible. The IS/OS interface was visible, still thickened subfoveally, with numerous bright hyper-reflective spots and irregularities of outer segments. The foveal depression was again visible and with an almost normal profile (Figures 47d and e).

Angiography

The area of occult CNV markedly regressed with no visible neovascular membrane and an overall improved appearance

However, on both fluorescein angiography and SLO-ICG angiography, the PED became slightly larger and then stabilized. (Figure 47).

Figure 47e: Occult CNV after treatment. Enlarged image.

Clinical Signs

A 77-year-old woman was already followed for AMD and had been treated by PDT first in the right eye and then in the left eye, with temporary improvement.

She presented with recent loss of visual acuity in the left eye, which had been the better of the two eyes up until that point.

Fluorescein angiography (Figures 48a and b)

In early phases, a very large area of progressive hyperfluorescence with pinpoint leakage seen superiorly, inferiorly, and temporally, suggesting progressive filling of a vast PED with irregular margins. This hyper-fluorescence was heterogeneous with several temporal radial folds in the macula.

SLO-ICG angiography (Figures 48c and d):

VA RE: 20/160 - VA LE: 20/100.

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Biomicroscopic Examination

The first examination of the left eye showed a small paracentral hemorrhage, a more marked retinal detachment, and several radial folds in the temporal region.

Autofluorescence

A vast hyper-fluorescent halo was visible, occupying almost all of the posterior pole, but sparing the zone of xanthophyll pigment.

Early phase: vast hypo-fluorescent area measuring 3 DD with irregular margins, occasionally retracted.

Late phase: the well-delineated hypo-fluorescence of the PED was confirmed with a poorly visible, small neovascular membrane in the central region.

Suggested Diagnosis:

Irregular, partially retracted vascularized PED with radial

folds, invaded by a vast neovascular membrane.

Stratus* horizontal section

The RPE was markedly elevated, especially in the temporal macular region, with a moderately reflective cavity, allowing partial visualization of Bruch’s membrane. A hyperreflective band (green) was present in the foveal region.

Anterior to the RPE, a large hyper-reflective band was suggestive of fibrosis. All of the neurosensory retina was thickened with poor visibility of retinal layers (Figure 48e).

Stratus* vertical section

The section passing directly through the foveal region clearly visualized the central depression, despite the presence of cysts in the plexiform layers.

The RPE appeared to be more or less merged with a hyper-reflective zone that appeared to occupy almost all of the cavity of the flat vascularized PED (Figure 48f).