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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_103_библиотеки_им_акад_М_И_Перельмана
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Fig. 28.10 OCT illustrating pathologies related to the
vitreoretinal interface. (a) Horizontal OCT of vitreomacular adhesion and (b) vitreomacular traction. (c) A horizontal OCT scan shows a thin hyperreective membrane
suggestive of ERM distorting the normal foveal depression. The outer nuclear layer appears stretched. All retinal
layers can be delineated. (d) A horizontal OCT shows
ERM causing alteration of the normal foveal architecture
and ectopic inner foveal layers. Also, the retinal layers
cannot be delineated. (e) A horizontal OCT scan of a
lamellar macular hole shows an irregular foveal contour
with loss of foveal tissue. Schitic cavities between the
outer nuclear and outer plexiform layers and the inner retinal layers can be seen. The photoreceptor layer appears
intact. (f) Horizontal OCT shows partial posterior vitreous
detachment, with the vitreous cortex still attached to the
optic disc margins. A full-thickness defect can be seen in
the neurosensory retina with cystic spaces in the outer and
inner nuclear layers
28.4.1 Epiretinal Membrane
On OCT, the epiretinal membrane (ERM) is seen
as a discrete, irregular, hyperreective line above
the inner retinal surface, usually associated with
wrinkling of the retina and hyporeective spaces
between the ERM and ILM.It can be classied into
[21] stage 1, where the ERM causes negligible anatomic disruption; stage 2, where the ERM causes
stretching of ONL, but all layers can be identied;
stage 3, where the ERM is associated with an ectopic inner foveal layer (EIFL), and stage 4 ERM
when there is signicant retinal thickening, presence of EIFL, and disrupted retinal layers [Fig.
28.10c, d]. On OCTA, the size of the FAZ may be
reduced. Also, an increase in foveal vessel density
(VD) and a decrease in parafoveal VD at the level
of SCP and DCP can be seen.
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28.4.2 Lamellar Macular Hole
A lamellar macular hole (LMH) is a defect in the
inner fovea with or without actual loss of tissue
[Fig. 28.10e]. It can be classied into tractional
and degenerative subtypes [22]. Pre-retinal tissue
can be seen in both subtypes. In tractional LMH,
ERM is seen as a thin, irregular, hyperreective
layer attached intermittently to the retina, and in
degenerative LMH, epiretinal proliferation, a
thick, homogenous material of medium reectivity, is seen. On OCTA analysis, a higher foveal
VD and lower parafoveal VD are seen at the SCP
and DCP level in tractional LMH cases. In degenerative LMH, a lower parafoveal VD can be seen
in both SCP and DCP, with no signicant difference noted for foveal VD.
28.4.3 Full-Thickness Macular Hole
On OCT, a full-thickness macular hole (FTMH)
can be seen as a full-thickness foveal lesion interrupting all macular layers [Fig. 28.10f]. It can be
classied based on its size into small (≤250μm),
medium (>250 μm but ≤400 μm), and large
(≥400μm) [20]. Other features that can be seen
on OCT include ERM, IRF, and SRF.Following
surgery, various closure patterns can be noted on
OCT, such as the U, V, and W patterns of closure,
and type 0, 1, and 2, and round or linear closure
patterns [23].
On OCTA, “vascular sliding” can be seen at
the border of the cystoid cavities in FTMH; this
suggests the preservation of the microvasculature
surrounding the cystoid spaces. Also, following
surgery, a decrease in FAZ area and an increase in
foveal vessel density and choriocapillaris network are noted.
28.5 Myopia-Related Retinal
Diseases
28.5.1 Myopic Macular Degeneration
The META-PM (META-analysis for Pathologic
Myopia) study group proposed the classication
of myopic macular degeneration (MMD) based
on fundus photographs that included atrophic
alterations in the macula along with “plus
lesions” that included lacquer cracks, Fuchs spot,
and myopic choroidal neovascularization
(mCNV). Correlation with OCT shows the presence of choroidal thinning with intact RPE in diffuse atrophy and the absence of both RPE and
choroid in patchy atrophy [24]. The SFCT (subfoveal choroidal thickness) decreases with worsening MMD. Wong et al. [25] observed that
choroidal thinning plays a more crucial role than
scleral thinning in the progression of MMD.BM
defects also contribute to the progression to macular atrophy.
Posterior staphyloma was classied based on
the area of ectasia, shape, margins, and characteristics of the optic disc and retinal vessels.
Posterior staphyloma can be observed as a protrusion of the wall of the eye. It can be clearly
dened on OCT, characterized by an outpouching area with a radius less than the surrounding
curvature of the wall of the eye. Other observations include inward protrusion of the sclera and
thinning of the choroid at the edge of the
staphyloma.
28.5.2 Myopic Choroidal
Neovascularization
One of the complications of high myopia is
mCNV (myopic choroidal neovascularization)
which can present as sudden, progressive deterioration of central vision if not promptly treated.
OCT is useful for detecting and guiding treatment with anti-VEGF (anti-vascular endothelial
growth factor) in mCNV (Fig. 28.11). Most
mCNVs are typically type 2 lesions that appear
as small, at, grayish lesions; these may be subfoveal, juxtafoveal, or extrafoveal inlocation. On
OCT, mCNV appears as a hyperreective mound
above the RPE. During the active phase, an
mCNV exhibits fuzzy edges on OCT, with variable amounts of SRF or IRF.The amount of retinal uid, in general, is less than that in nAMD
and has been attributed to less unhealthy RPE in
the myopic population. With treatment, the lesion
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Fig. 28.11 (a) Color fundus photo of a myopic patient
with a tessellated background, prominent choroidal vessels, and mCNV at the fovea. (b) Horizontal OCT scan
through the fovea of a myopic patient showing myopic
traction maculopathy. (c) OCTA of a myopic patient with
develops a hyperpigmented border and evolves
into a Fuchs spot in the scar stage. The corresponding OCT appears as an “encapsulated
lesion” with a well-dened, hyperreective outline and resolution of SRF/IRF. As mCNV
regresses, some eyes develop chorioretinal atrophy in the atrophic stage [25, 26]. On OCT, this
appears as an area of the outer retina and RPE
loss surrounding the mCNV. In the atrophic
stage, loss of choriocapillaris and RPE may eventually develop. On OCTA, an mCNV typically
appears as vascular nets located above the RPE,
in keeping with a type 2 NV [Fig. 28.11]. The
lesions were identied as a tight vascular net with
a perilesional halo and a visible core on OCTA is
considered as an important biomarker in determining the activity of mCNV. Branching with
mCNV showing a prominent network (green arrow). (d)
Horizontal OCT scan of a myopic patient with mCNV
showing subretinal hyperreective material and subretinal
uid (yellow arrow)
tiny vessels and anastomosis or loops is a sign of
neovascular activity. Although changes in shape,
size, and ow area in OCTA have been observed
with anti-VEGF treatment, there is no standard
method to repeatably quantify these parameters.
Flow signals may be detected even in treated
mCNVs without exudation.
28.5.3 Myopic Traction Maculopathy
Myopic traction maculopathy (MTM) results from
vitreomacular traction (VMT) in high myopia and
includes myopic foveoschisis, a macular hole with
or without RD.The increased rigidity of the retina
in the presence of posterior staphyloma contributes to the development of MTM.MTM occurs
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Fig. 28.12 (a–c)A case of MEWDS at presentation. (a)
Fundus autouorescence shows multiple punctate hyper
autouorescent lesions involving the macula. (b)
Structural en face OCT shows corresponding hyporeective lesions. (c) Structural OCT shows disruption of the
ELM and EZ.(d–f): Case of MEWDS following resolu-
more frequently in eyes with staphyloma than
those without. In addition to detecting MTM, OCT
can further delineate the severity of the condition
[Fig. 28.11]. Various systems have attempted to
classify MTM according to the extent of changes,
the level of disruption, and whether or not the
fovea is involved. The ATN classication includes
the atrophy, traction, and neovascularization components. The traction component was classied
based on the size of the macular retinoschisis into
absent, extrafoveal, foveal only, and foveal (but
not the entire macula), or foveal (entire macula).
Parolini etal. identied four retinal stages of MTM
that include inner/outer maculoschisis, predominantly outer maculoschisis, maculoschisismacular detachment, and macular detachment [26,
27]. The foveal stages include normal fovea, inner
lamellar macular hole, and full-thickness macular
hole. Wang etal. [28] described the imaging characteristics of MTM using OCTA that showed the
worse the BCVA, larger retinal volumes, and
larger subfoveal choroidal capillary vessel density
in retinoschisis.
tion. (d) Most of the initial hyper autouorescent lesions
have completely resolved, with a few foci of consolidated
hyper autouorescent lesions persisting. (e) Structural en
face OCT shows resolving lesions. (f) Structural OCT
shows restoration of the ELM and EZ
28.5.3.1 Technical Concerns
Increased axial length, exaggerated curvature
deformities, and imaging artifacts can make OCT
imaging challenging in highly myopic eyes [27,
29]. SS-OCT offers a higher signal-to-noise ratio,
deeper penetration, and longer scan length,
resulting in higher resolution in highly myopic
eyes than SD-OCT. Magnication correction
should be considered when evaluating retinal and
choriocapillaris blood ow quantication in
myopic eyes.
28.6 Uveitis
28.6.1 White Dot Syndromes
The white dot syndromes comprise a spectrum of
inammatory disorders affecting the retina,
including multiple evanescent white dot syndromes (MEWDS), punctate inner choroidopathy (PIC), and multifocal choroiditis (MFC).
These may range from self-limiting to recurrent
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Fig. 28.13 (a) Color fundus photograph of a case of mul-
tifocal choroiditis (b) OCT shows a dome-shaped hyperreective collection beneath the RPE, with loss of
uveitis. Involvement of the choroid and choriocapillaris have also been implicated.
On structural OCT, disruption or loss of EZ is
typically seen in MEWDS.These changes usually resolve within weeks, with reconstitution of
the EZ band and symptomatic recovery [28, 30].
Thickening of the subfoveal choroid has been
photoreceptors and choroidal hyper-transmissibility (c)
OCT shows disruption of the outer retina layers with choroidal hyper-transmission
retinal hyperreectivity (FORH), seen as hyperreective nger-like projections extending from
the RPE into the ONL with associated photoreceptor loss, with occasional extension till the
ILM.The OCTA evaluation shows the presence
of ow voids in choriocapillaris and also helps in
the detection of CNVM.
described, which suggests some choroidal
involvement. Diffuse hyporeective spots can be
seen on en face OCT segmented at the EZ, corresponding to the disrupted EZ seen on OCT B
scan [Fig. 28.12].
28.6.2 Sympathetic Ophthalmia
andVogt-Koyanagi-Harada
Disease
On OCT, acute MFC/PIC lesions are seen as
conical or dome-shaped collections in the subRPE space. Widespread loss of outer retinal
architecture and localized choroidal hyperreectivity below the sub-RPE material can also be
seen [Fig. 28.13] [29, 31]. Other features include
thinning of the choroid, occlusion of the choroidal vessels, and focal choroidal excavation.
Active disease can also present as foveal outer
Sympathetic ophthalmia (SO) and VogtKoyanagi- Harada disease (VKH) share similar
features in OCT. These include multiple serous
retinal detachments, bacillary layer detachment,
RPE folds, uctuations of the internal limiting
membrane, and subretinal and choroidal hyperreective dots. Choroidal analysis shows diffuse
choroidal thickening with loss of choroidal archi-
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tecture and increased CVI (choroidal vascularity
index) [Fig. 28.14] [30–33]. Dalen-Fuchs nodules are dome-shaped hyperreective, sub-RPE
lesions with associated disruption of the ellipsoid
zone and RPE.On OCTA, choriocapillaris ow
voids can be seen. With treatment, the neurosensory detachment resolves. Reduced choroidal
thickness is a useful measure to assess the
improvement of the underlying choroidal
inammation.
28.6.3 Non-infectious Retinitis
Retinal arteriolar and venous circulation can be
affected in Behcet’s disease. On OCT, supercial
retinal inltrates are seen as focal, hyperreective thickening of the retina with back-shadowing
Fig. 28.14 OCT of a patient with Vogt-Koyanagi-Harada
disease with increased central macular thickness, bacillary layer detachment, neurosensory layer detachment,
and increased choroidal thickness
[Fig. 28.15]. In the case of neuro retinitis, localized vitreous condensation over the inamed
optic disc can be seen, giving a “smoking volcano” appearance. An increase in CMT and macular volume can also be seen. Other features
include CME, ERM, serous RD, ELM, and EZ
disruption with OPL elevation, INL thinning,
VMA/VMT, LMH or FTMH, macular atrophy,
and scarring [32, 34]. On OCTA, there is an
increase in FAZ with hypo—or non-perfusion in
SCP and DCP.
28.6.4 Infectious Uveitis
28.6.4.1 Toxoplasmosis
The retinitis lesion in toxoplasma retinochoroiditis is seen as an area of increased intraretinal
reectivity and thickness with full-thickness disorganization of the retinal layers [Fig. 28.16].
Posterior hyaloid thickening or detachment may
also be seen overlying the lesion. Hyperreective
round-shaped deposits along the posterior hyaloid and hyperreective dots in the retro hyaloid
space are characteristic of the disease. The choroid is hyporeective below the lesion, and there
is diffuse thickening of the choroid with a
decrease in the number of hyperreective septa
corresponding to the walls of the choroidal ves-
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Fig. 28.15 (a) Color fundus photo of a case of Behcet’s
disease showing extensive sclerosed vessels and vitreous
hemorrhage. (b) Corresponding OCT macula shows
hyperreective lesions in the vitreous cavity suggestive of
vitreous hemorrhage, supercial retinal inltrates seen as
hyperreective lesions in the inner retina, epiretinal membrane, external limiting membrane, and ellipsoid zone
disruption
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Fig. 28.16 (a) Color fundus photograph showing a dis-
crete, well-dened yellowish lesion just temporal to the
fovea in a patient with toxoplasma retinochoroiditis. (b)
Horizontal OCT scan passing through the lesion showing
a full-thickness retinitis lesion
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Fig. 28.17 (a) Color fundus photograph of a patient with choroidal tuberculoma. (b) OCT macula of the patient shows
a full-thickness choroidal dome-shaped lesion, “contact sign,” and exudative retinal detachment
sels and loss of the dotted physiological pattern
of the choriocapillaris. OCTA shows reduced
SCP, DCP, and CC ow in the area corresponding
to the lesion. It is also useful to diagnose and
follow-up cases of CNVM [33, 35].
neurosensory retina, with surrounding
SRF.Tuberculous choroidal granulomas are seen
as full-thickness choroidal lesions with welldened margins, having a lobulated shape, nonhomogenous internal reectivity, and
hyporeective compared to the surrounding cho-
28.6.4.2 Tuberculosis
Ocular tuberculosis may present as choroidal
tubercles, granulomas, occlusive retinal vasculitis, multifocal serpiginoid, or serpiginous-like
choroiditis. On OCT, the tubercules are seen as a
single, rounded lesion having a hyporeective
core surrounded by a hyperreective area, in the
roid. It is characterized by a “contact sign,” a
localized area of adhesion between the RPEchoriocapillaris layer and the neurosensory retina, surrounded by exudative retinal detachment
[Fig. 28.17]. In tubercular serpiginous-like choroiditis, the OCT features include ELM and EZ
disruption, hyperreective material over the RPE
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extending towards the inner retina, RPE elevations, increased choroidal thickness, and choroidal hyperreective dots. OCTA shows
choriocapillaris ow void during the active stage
and vascular tufts and tangled vessels in the inner
ment, atrophy or loss, drusen, and choriocapillaris thinning overlying the drusen. On OCTA,
there is fading of the normal homogenous vascular mosaic in CC slab corresponding to the area
of the naevus [36, 38].
choroid in the healing stage [34–37].
28.7.2 Choroidal Melanoma
28.7 Retinal andChoroidal
Tumors
28.7.1 Choroidal Nevus
Choroidal nevus can be seen as a hyperreective
lesion within the choroid with back-shadowing.
They may be at or associated with mild elevation of the overlying retina [Fig. 28.18a, b].
Associated features which can be imaged with
OCT in a case of choroidal nevus are IRF, SRF,
photoreceptor loss, EZ irregularity, RPE detach-
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On OCT imaging, the choroidal melanoma lesion
shows deep optical back-shadowing. Other features are SRF, subretinal lipofuscin deposition,
RPE atrophy, IRF, loss of ELM and EZ and irregularity of GC-IPL [Fig. 28.18c, b]. Shaggy photoreceptors have also been noted, which represent
edematous photoreceptors or macrophages with
lipofuscin on the posterior surface of the detached
retina [37, 39]. Vitreous seeding can be seen as
highly reective spheroidal bodies in the vitreous
cavity. Imaging with OCTA shows heteroge-
c
Fig. 28.18 Choroidal mass. (a) Color fundus photograph
showing a choroidal nevus. (b) An OCT scan passing
through the lesion shows a at hyperreective choroidal
lesion with back-shadowing (red arrow). (c) Color fundus
photograph showing an amelanotic choroidal melanoma
d
along the superotemporal arcade with subretinal uid
extending to the macula. (d) An OCT scan passing through
the lesion shows an elevated choroidal lesion with deep
optical shadowing with overlying subretinal uid, subretinal lipofuscin, RPE atrophy, and photoreceptor loss
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Fig. 28.19 (a) Color fundus photograph showing cir-
cumscribed choroidal hemangioma along the superotemporal arcade with subretinal uid extending to the macula.
(b) An OCT scan passing through the lesion shows a
Fig. 28.20 (a) SS-OCT scan of a patient with choroidal
osteoma showing well-dened choroidal lesion having an
intralesional sponge-like appearance. Overlying subretinal
hyperreective material and subretinal uid can also be
neously distributed small blood vessels and disorganized intratumoral vasculature.
28.7.3 Choroidal Hemangioma
smooth elevated choroidal lesion with dilated Haller and
Sattler choroidal vessels. There is overlying subretinal
uid and schitic cavities in the neurosensory retina
seen, which is suggestive of type-2 choroidal neovascular
membrane (CNVM). (b) Corresponding OCTA through
the outer retinal slab shows the presence of ne vascular
network conrming the presence of type-2 CNVM
signal void areas. Vessels at the SCP level have a
bag of worms appearance, whereas the deeper
choroidal vessels demonstrate a club-like appearance [38, 40].
On imaging with EDI-OCT, circumscribed cho-
28.7.4 Choroidal Osteoma
roidal hemangioma lesions are seen as a smooth,
gently sloping anterior contour and gradual choroidal expansion. The lumen of the choriocapillaris, Sattler’s, and Haller’s layers are expanded.
Also, there is partial optical shadowing deep to
the lesion, lipofuscin deposition, IRF, retinal
schisis, and SRF [Fig. 28.19]. On OCTA, choroidal vessels appear white with few intervening
With the help of EDI-OCT, an intralesional
sponge-like appearance can be seen in cases
of choroidal osteoma [Fig. 28.20]. Subtle horizontal hyperreflective lamellar lines representing the bone lamellae and horizontal or
vertical tubular channels possibly representing vessels may also be seen. There is marked
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Fig. 28.21 Hamartoma. (a) Color fundus photograph of the
left eye showing astrocytic hamartoma of the optic disc. (b)
Corresponding OCT passing through the lesion shows an
elevated dome-shaped lesion with intralesional calcications
thinning of the outer retinal layers with indistinct RPE in areas of the decalcified tumor.
On OCTA, blood flow is mainly detected
within the choriocapillaries layer and partly
within the Sattler’s layer. It is also useful in
diagnosing and monitoring associated with
choroidal neovascular membrane (CNVM)
[Fig. 28.20] [39, 41].
28.7.5 Hamartoma
28.7.5.1 Retinal Astrocytic
Hamartoma
Retinal astrocytic hamartoma is seen on OCT as
a dome/plateau-shaped lesion with the calcied
tumors showing high reectivity and backshadowing [Fig. 28.21a, b]. There is DRIL with a
gradual transition to the adjacent normal retina.
and back-shadowing. (c) Color fundus photograph of the right
eye showing combined hamartoma of the retina and retinal
pigment epithelium. (d) OCT of the same patient shows retinal traction and saw-tooth appearance of the inner retina
Other associated features noted include retinal
traction, discrete internal moth-eaten optically
empty spaces, adjacent retinal or macular edema,
and shallow elevation of the adjacent retina. On
OCTA, nely branching tumor vessels can be
seen in the supercial and deep retina. Also, the
outer retina and choriocapillaris layer show
hyporeective changes due to shadowing caused
by calcium or high blood ow within the lesion
[40, 42].
28.7.5.2 Combined Hamartoma
oftheRetina andRetinal
Pigment Epithelium
On OCT, focal vitreoretinal traction can be seen
and the inner retina shows a “saw-tooth” and
“omega sign” pattern [Fig. 28.21c, d]. On OCTA
evaluation, a ligree pattern of intratumoral vessels can be identied [41, 43].
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