Multilayered Exudative Bacillary Layer Detachment in Active Choroidal Neovascularization: A New Optical Coherence Tomography Sign.

In this article, we present three cases diagnosed with active choroidal neovascularization (CNV): two cases diagnosed with neovascular age-related macular degeneration (nAMD), and one case with myopic CNV in an elderly eye that presented a characteristic and unique optical coherence tomography (OCT) sign consisting of well-defined, circular-shaped multiple concentric layers of alternating iso-hyperreflective material located between the external limiting membrane and outer photoreceptor layers, which seems to be a multilayered bacillary layer detachment (BALAD). Multilayered exudative BALAD in active CNV may be a new and characteristic OCT sign. [Ophthalmic Surg Lasers Imaging Retina 2024;55:92-94.].

Astigmatism Influences Quantitative and Qualitative Analysis in Optical Coherence Tomography Angiography Imaging.

Purpose: The purpose of this paper was to study the influence of astigmatism in optical coherence tomography angiography (OCTA) images in a quantitative and qualitative analysis. Methods: This was a prospective, cross-sectional study. We included 110 eyes of 110 patients: 20 eyes without astigmatism and 90 eyes with astigmatism ≥0.5 diopters (D). We performed a macula centered OCTA as a reference image. In patients without astigmatism, registered follow-up scans were performed after induction of -1 and -2 D astigmatism. In patients with astigmatism, we performed the follow-up scan after astigmatism correction. We used a set of cylindrical lenses attached to the camera head of the SPECTRALIS (Heidelberg Engineering, Heidelberg, Germany). A quantitative and qualitative analysis of the superficial vascular complex (SVC) and deep vascular complex (DVC) was performed. The main outcome measures were vessel density (VD), image quality, and the presence of artifacts. Results: Mean VD of the SVC was significantly higher in the reference images compared with the images after induction of -2 D. Differences with -1 D were nonsignificant. Higher degrees of astigmatisms had higher VD dropout (0.012-0.02 per diopter in SVC). Astigmatism axis showed no relevance in our cohort. Image quality assessed by two independent observers was graded as higher in images without astigmatism. Defocus and attenuation were more prevalent in images with astigmatism. Conclusions: Astigmatism of -2 D affects quantification of VD in OCTA images, mainly affecting the SVC, as well as the subjective quality assessment. Correction of this refractive error might be necessary for an accurate quantitative assessment of OCTA images. Translational Relevance: Correcting astigmatism of 2 D or greater appears to be necessary when analyzing OCTA images.

Optical coherence tomography biomarkers in early and intermediate age-related macular degeneration: A clinical guide.

Advanced forms of age-related macular degeneration (AMD), characterised by atrophic and neovascular changes, are a leading cause of vision loss in the elderly population worldwide. Prior to the development of advanced AMD, a myriad of risk factors from the early and intermediate stages of AMD have been published in the scientific literature over the last years. The ability to precisely recognise structural and anatomical changes in the ageing macula, altogether with the understanding of the individual risk implications of each one of them is key for an accurate and personalised diagnostic assessment. The present review aims to summarise updated evidence of the relative risk conferred by diverse macular signs, commonly seen on optical coherence tomography, in terms of progression to geographic atrophy or macular neovascularization. This information may also serve as a basis for tailored follow-up monitoring visits.

CENTRAL BOUQUET HEMORRHAGE: Clinical and Multimodal Imaging Features.

PURPOSE: To describe the clinical characteristics, multimodal imaging features, and anatomic basis of a distinctive pattern of deep retinal hemorrhages located in the central fovea, a presentation referred to as "central bouquet hemorrhage." METHODS: Retrospective, observational, multicenter case series of eyes with central bouquet hemorrhage. Multimodal imaging features were reviewed and analyzed. RESULTS: Ten eyes from 10 patients (4 women and 6 men), with a mean age of 55.6 ± 21.7 years (range 25-84 years) were included. Underlying etiologies were neovascular age-related macular degeneration (40%), lacquer cracks in pathological myopia (30%), macular telangiectasia Type 2 (10%), proliferative diabetic retinopathy (10%), and ocular trauma associated with angioid streaks (10%). On ophthalmoscopy, all eyes with central bouquet hemorrhage displayed a deep retinal hemorrhage with round margins in the central fovea and associated with petaloid hemorrhages radiating in the surrounding Henle fiber layer. Cross-sectional optical coherence tomography showed a well-delineated round hyperreflective lesion involving the central foveal Henle fiber layer/outer nuclear layer in all cases. Accompanying hyperreflective hemorrhages tracking along the obliquely oriented Henle fiber layer were present in all eyes. Resolution occurred in all patients, either spontaneously (30%) or after treatment with intravitreal anti-vascular endothelial growth factor injections (70%), and was associated with partial visual acuity improvement (from 20/113 to 20/36). CONCLUSION: "Central bouquet hemorrhage" is a novel descriptive term describing a characteristic round pattern of intraretinal blood in the fovea associated with Henle fiber layer hemorrhage and encountered in a spectrum of macular disease.

THE EFFECT OF INCREASING ACQUISITION SPEED ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IMAGES: A Qualitative and Quantitative Analysis.

PURPOSE: To evaluate the effect of two different A-scan rates on qualitative and quantitative parameters on optical coherence tomography angiography images in a clinical setting. METHODS: Subjects undergoing a comprehensive ophthalmic examination were scheduled for optical coherence tomography angiography imaging using a new SPECTRALIS device allowing for 85 and 125 kHz scan rate. Consecutive registered 20° × 20° optical coherence tomography angiography images using both speeds were acquired using the follow-up tool. The acquisition time and the quality values of each scan were extracted and analyzed. The image quality was also graded in pairs by two independent graders. RESULTS: Two-hundred and one eyes of 128 consecutive patients (67 males, 52.3%) were included. Mean acquisition time significantly decreased from 56.92 ± 24.6 seconds on the 85 kHz images to 39.39 ± 15.5 seconds on the 125 kHz images (P < 0.001). The percentage change in acquisition time showed a mean decrease of 28.47%. Mean Q value significantly decreased from 32.97 ± 2.8 dB on the 85 kHz images to 31.43 ± 2.6 dB on the 125 kHz images (P < 0.001). Overall, 92.5% of images were graded as equal or better at 125 kHz A-scan rate. CONCLUSION: The use of optical coherence tomography angiography in daily clinical practice may require higher A-scan rates for an optimal workflow. Increased speed may also reduce image sensitivity and thus image quality could be compromised. In this study, 125 kHz scan rate using SPECTRALIS showed significant benefit with reduction on the acquisition time and no clinically significant differences on image quality analysis. Further studies evaluating qualitative and quantitative data in specific retinal conditions and using other devices are required to confirm these results.

Retinal neurodegeneration in age-related macular degeneration.

Age-related macular degeneration (AMD) is a complex and multifactorial disease characterized by the damage of the unit comprised of the photoreceptors, retinal pigment epithelium (RPE), Bruch's membrane, and choriocapillaris. Although the outer retina appears to be mainly affected in this disorder, several evidences exhibit that also the inner retina may be impaired. In this review we will provide a description of the prominent histologic and imaging findings suggesting an inner retinal loss in these eyes. In details, structural optical coherence tomography (OCT) technology proved either the inner and outer retina is impacted by AMD and that these two impairments are associated. Therefore, the purpose of this review is to provide a description of the role of neurodegeneration in AMD in order to better understand the relationship between neuronal loss and the outer retinal damage in this disease.

Acute macular neuroretinopathy following Moderna COVID-19 vaccination.

PURPOSE: To describe the occurrence of an acute macular neuroretinopathy (AMN) after administration of a Moderna COVID-19 Vaccine. METHODS: Case report. RESULTS: A 23-year-old female presented bilateral visual loss one week after the first dose of COVID-19 vaccine. Fundus examination revealed the classic wedge-shaped lesions with petaloid configuration around both foveas. Hypo-reflective macular lesions are evident in the near-infrared reflectance image. The spectral-domain optical coherence tomography reveled hyperreflectivity of the outer nuclear and plexiform layers, attenuation of the ellipsoid zone and disruption of interdigitation zone corresponding to the lesions. CONCLUSIONS: Despite the large number of doses of COVID-19 vaccines administered worldwide, there are not many reported cases of AMN. Most of them occurred after viral vector vaccines. Described here is one of the few cases that observed a time period of several days after receiving the Moderna messenger RNA vaccine. It is not possible to establish causality although this suggests an inflammatory or autoimmune response to the vaccine.

THE CHRYSANTHEMUM PHENOTYPE OF IDIOPATHIC MULTIFOCAL CHOROIDITIS.

PURPOSE: To describe the clinical characteristics and multimodal imaging features of a distinctive subtype of active idiopathic multifocal choroiditis (iMFC) lesions with grey-yellow chorioretinal lesions surrounded by smaller satellite dots, a presentation referred to as "chrysanthemum lesions." METHODS: Retrospective, observational, multicenter case series of eyes with active iMFC and chrysanthemum lesions. Multimodal imaging features were reviewed and presented. RESULTS: Twenty-five eyes from 20 patients (12 women and 8 men), with a mean age of 35.8 ± 17.0 years (range, 7-78 years) were included. Chrysanthemum lesions were equally located in the macula (48.0%) or the mid/far periphery (52.0%). The number of lesions per eye varied from 1 (16.0%) to more than 20 (56.0%). On optical coherence tomography, chrysanthemum lesions showed typical features of iMFC, including subretinal hyperreflective material splitting the retinal pigment epithelium/Bruch membrane. Chrysanthemum lesions were hypoautofluorescent on fundus autofluorescence imaging, hyperfluorescent on fluorescein angiography, hypofluorescent on indocyanine green angiography, and associated with choriocapillaris flow signal deficit on optical coherence tomography angiography. CONCLUSION: Active iMFC may present with findings resembling chrysanthemum lesions. The distinctive lesion morphology on ophthalmoscopic examination, the large number of lesions, and the high prevalence of exclusive midperipheral and far peripheral involvement may represent a distinctive phenotype of iMFC.

ADVANTAGES OF OPTICAL COHERENCE TOMOGRAPHY AS A HIGH DYNAMIC RANGE IMAGING MODALITY IN SUBRETINAL HYPERREFLECTIVE MATERIAL.

PURPOSE: To describe the utility of high dynamic range optical coherence tomography imaging to study subretinal hyperreflective material (SHRM) in patients with age-related macular degeneration. METHODS: Clinical information including visual acuity and optical coherence tomography images (Heidelberg Engineering GmbH, Heidelberg, Germany) of patients undergoing antiangiogenic treatment for neovascular age-related macular degeneration and showing SHRM at baseline were retrospectively reviewed. Contrast between strong signal structures (high dynamic range image) reclassifying SHRM as hyperreflective (HyperR), isoreflective, and hyporeflective was increased. The patients at baseline, 3, 6, and 12-months follow-up were evaluated. RESULTS: Forty-four eyes were classified as 15 HyperR (34.1%), 21 as isoreflective (47.7%), and eight as hyporeflective (18.2%). During follow-up, hyporeflective SHRM disappeared in all cases, isoreflective SHRM faded in 16 cases (76.2%); HyperR SHRM remained in all cases. Hyporreflective SHRM showed a greater visual acuity improvement than HyperR SHRM group ( P = 0.033). After 12-month follow-up, only the hyporeflective and isoreflective groups significantly reduced the presence of fluid in 37.5% ( P = 0.250) and 46.62% ( P = 0.006) of the patients, respectively; outer retinal layers were disrupted more frequently in the presence of HyperR SHRM (ellipsoid zone, P = 0.16; external limiting membrane, P = 0.007). CONCLUSION: Contrast-enhanced optical coherence tomography images enabled us to classify SHRM according to its reflectivity, showing groups with different disappearance rates, visual acuity improvement, and outer retinal layer disruption. This easy-to-access tool may be helpful as a prognostic factor in neovascular age-related macular degeneration cases.

Review for Diagnostics of the Year: Inflammatory Choroidal Neovascularization - Imaging Update.

Inflammatory choroidal neovascularization (iCNV) is a rare complication of uveitis but is a major cause of vision compromise in affected patients. Fluorescein angiography (FA) has been the gold standard for diagnosis. However, it is an invasive modality and when used alone, it might be difficult to distinguish iCNV from inflammatory lesions. Optical coherence tomography (OCT) is a noninvasive and rapid imaging modality that can provide additional features to diagnose iCNV. OCT angiography (OCTA) uses intrinsic motion contrast to visualize flow and is useful to distinguish iCNV from inflammatory lesions. However, its role in evaluating iCNV activity and treatment response is still unclear and more studies are required to reach consensus. In conclusion, the use of data from multimodal imaging is necessary to identify and promptly treat iCNV, thus preserving patient vision.

Non-arteritic anterior ischemic optic neuropathy after uneventful delivery in a healthy woman.

INTRODUCTION: Non-arteritic anterior ischemic optic neuropathy (NAION) is the most common cause of optic nerve swelling and optic neuropathy in adults over 50 years of age. It has been rarely reported during pregnancy, mostly related to systemic and ocular predisposing conditions. CASE REPORT: We report the case of a 44 years-old healthy female with no previous remarkable clinical history. She had in vitro fertilisation treatment to get pregnant. 18 days after uneventful cesarean section she referred sudden painless vision loss in her right eye (RE), denser inferiorly, with concurrent optic disc edema and relative afferent pupillary defect. Steroid intravenous treatment during the acute episode showed no improvement. Our patient showed normal magnetic resonance imaging (MRI), blood test, autoimmune disease biomarkers, infectious serology and inflammatory markers. She was diagnosed of RE NAION. After one year follow-up visual field defect remains stable. CONCLUSION: As far as we know this is the first report of NAION after in vitro fertilisation, uneventful pregnancy and cesarean section showing no systemic or ocular risk factors other than a small cup to disc ratio. Hemodynamic and hormonal changes during late pregnancy and uneventful cesarean section can trigger an episode of NAION in a healthy young woman.

Use of Artificial Tears in Patients Undergoing Treatment with Anti-VEGF Intravitreal Injections.

Purpose: To analyze the use of artificial tears in patients undergoing treatment with anti-vascular endothelial growth (anti-VEGF) intravitreal injections. Methods: Thirty-four eyes undergoing anti-VEGF treatment were analyzed. Each patient underwent a subjective and objective evaluation of the ocular surface, using the Ocular Surface Disease Index (OSDI), Dry Eye Questionnaire (DEQ)-5, tear meniscus height (TMH), first and average non-invasive Keratograph Break-Up Time (NIKBUT), bulbar conjunctival redness, meibography and the Vision Break-Up Time (VBUT). Patients attended 5 visits (days 0, 7, 30, 37, and 60). All patients continued with their intravitreal injection treatment during the study (days 0, 30, and 60). Patients did not receive any artificial tear treatment during the first month of the study, and at the baseline visit they were randomly assigned to one of two study groups to receive either the Systane Hydration or the Viscofresh 10mg/mL formulation. Patients were instructed to instill one drop of the assigned study treatment 3 times a day for 30 days during the second month of the study. Results: According to the Mixed Models for Repeated Measures analysis, there is not enough statistical evidence for any of the parameters examined to determine significant differences between being treated with artificial tears and not being treated (p > 0.05). There is, however, a tendency toward improved outcomes in some parameters when artificial tears were used. OSDI, DEQ-5, TMH, and meibography were not affected by either the type of artificial tear used or by the time (from day 30 to day 60; p > 0.05), but the NIKBUT and VBUT values increased over time during this period regardless of which treatment the patient was receiving. Conclusion: The use of artificial tears may help to keep the tear film stable Future studies with larger samples should be conducted to elucidate whether the tendency reported in our study becomes significant.

Atypical acute fovealitis in COVID-19 context.

Purpose: To describe the clinical and multimodal imaging findings, including optical coherence tomography (OCT), and OCT angiography (OCTA) in a case presenting with acute fovealitis after COVID-19 infection, and its differential diagnosis. Observations: A 39-year-old man presenting with acute central metamorphopsia in his right eye (OD) right after positive test for COVID-19 underwent comprehensive ophthalmic examination, including best corrected visual acuity (BCVA), color fundus (CF) examination, optical coherence tomography (OCT), OCT angiography (OCTA), fundus autofluorescence (FAF) and fluorescein angiography (FA). Baseline BCVA was 20/40 in his OD and fundus examination showed small inferior juxtafoveal hemorrhages with no other vascular abnormalities or peripheral changes. The OCT B-scans revealed a central focal defect of the ellipsoid and interdigitation zones associated with foveal and perifoveal columnar hyperreflectivities involving the photoreceptor layers, the external limiting membrane and outer nuclear layer up to the outer plexiform layer with preservation of the retinal pigment epithelium-Bruch's membrane complex. Both FAF and FA images were unremarkable. Over three months follow-up, the findings progressively resolved, and BCVA improved to 20/20. Conclusions and importance: The presence of hyperreflective material at the fovea in association with adjacent hemorrhages, the absence of alterations of the retinal pigment epithelium in OCT, OCTA, FAF and FA suggested the diagnosis of acute fovealitis in COVID-19 context. The presence of these findings highlights the importance of detailed ophthalmic evaluation in symptomatic patients with COVID-19 positive test.

Anti-retinal IgG antibodies in patients with early and advanced type 2 macular telangiectasia.

Type 2 idiopathic macular telangiectasia (MacTel-2) is a progressive adult-onset macular disease associated with bilateral perifoveal vascular changes, Muller cell degeneration and increased blood-retinal barrier permeability. The pathophysiological mechanisms of MacTel-2 remain unclear, however it was previously reported that anti-retinal antibodies in MacTel-2 patients are a significant feature of the disease. In this study, we aimed to compare the prevalence of anti-retinal antibodies in patients MacTel-2, healthy controls and patients with other retinal diseases. MacTel-2 patients diagnosed with multimodal imaging were enrolled and their disease severities were graded using spectral-domain optical coherence tomography. For comparison, patients with age-related macular degeneration (AMD), inherited retinal diseases (IRDs) or no retinal disease (healthy controls) were recruited as controls. Blood serum samples were screened for immunoglobulin G anti-retinal antibodies by western blotting, followed by densitometry analysis. Odds ratios (OR) with 95% confidence intervals (CI) were calculated and p < 0.05 considered statistically significant. Overall, anti-retinal antibody-positive cases were older (64 ± 15 vs 53 ± 17 years, p < 0.001) and females were more likely to develop anti-retinal antibodies (OR: 2.41, CI: 1.12-5.18). The frequency of anti-retinal antibody detection in MacTel-2 patients (n = 42, 36%) was not significantly different from healthy controls (n = 52, 25%) or IRD patients (n = 18, 25%) and the majority of MacTel-2 patients had no anti-retinal antibodies. In contrast, the frequency of anti-retinal antibody detection was significantly higher in patients with AMD (n = 15, 73%, p < 0.001). The lack of a greater anti-retinal antibody frequency or specificity in the MacTel-2 cohort suggests that antibody mediated immunological mechanisms may play a less significant role in MacTel-2 disease pathogenesis.

Five-year outcomes after intravitreal bevacizumab of treatment-naive eyes with macular edema secondary to CRVO in routine clinical practice: Results of the Pan-American Collaborative Retina Study (PACORES) group.

PURPOSE: The purpose of this study was to report the 5-year outcomes of treatment-naive eyes with cystoid macular edema secondary to central retinal vein occlusion treated with intravitreal bevacizumab in routine clinical practice. METHODS: We conducted multicenter retrospective non-comparative case series of 102 eyes. The main outcome measured was the change in best-corrected visual acuity (BCVA) at 5 years. Secondary outcomes included the number of injections and the change in CMT at 5 years. RESULTS: At 5 years, the mean BCVA improved from 1.22 ± 0.58 (Snellen 20/428) at baseline to 1.00 ± 0.68 logMAR (Snellen 20/200; p < 0.0001). At 5 years, 48 (47%) eyes had a gain of ≥ 3 lines, 41 (40.2%) eyes remained within 3 lines and 13 (12.7%) eyes had a loss of ≥ 3 lines of BCVA. The CMT improved from 740 ± 243 to 322 ± 179 µm (p < 0.0001). At 5 years, 59 (57.8%) eyes had a completely dry SD-OCT. Patients received a total of 10.6 ± 6.1 (range 6-27) injections. Baseline BCVA (p < 0.0001) and the duration of symptoms prior to initial anti-VEGF injection (p = 0.0274) were the only predictive factors for BCVA at 5 years. CONCLUSIONS: After 5 years with an average of 10.6 injections, there was a mean gain of 0.22 logMAR. In addition, more eyes achieved a BCVA of ≥ 20/40, gained ≥ 3 lines and less patients had a BCVA ≤ 20/200. Eyes with a better baseline BCVA and a shorter duration of symptoms were more likely to achieve better BCVA at 5 years.

Advanced OCT Analysis of Biopsy-proven Vitreoretinal Lymphoma.

PURPOSE: Although diagnosing vitreoretinal lymphoma (VRL) can be challenging, early detection is critical for visual prognosis. We analyzed the spectrum of optical coherence tomography (OCT) findings in patients with biopsy-proven VRL and correlate these features with clinical parameters. DESIGN: This retrospective cross-sectional study was a multicenter chart review from 13 retina, uveitis, and ocular oncology clinics worldwide from 2008 to 2019. We included patients with a diagnosis of biopsy-proven VRL imaged with OCT at presentation. Ocular information, systemic information, and multimodal retinal imaging findings were collected and studied. The main outcome measure was the characteristics of VRL on OCT. RESULTS: A total of 182 eyes of 115 patients (63 women, mean age 65 years) were included in this study. The disease was bilateral in 81 patients (70%), and mean baseline visual acuity was 0.2 ± 0.89 logMAR (Snellen equivalent, 20/32). At baseline, 38 patients (33%) presented with isolated ocular involvement, 54 (45%) with associated central nervous system involvement, and 11 (10%) with other systemic lymphomatous involvement; an additional 12 patients (10%) presented with central nervous system and other systemic involvement. On OCT, tumor infiltration was identified in various retinal layers, including lesions in the subretinal pigment epithelium compartment (91% of eyes), the subretinal compartment (43% of eyes), and the intraretinal compartment (7% of eyes). OCT analysis of eyes with VRL identified 3 main regions of retinal infiltration. Subretinal pigment epithelium location, with or without subretinal infiltration, was the most common pattern of involvement and isolated intraretinal infiltration was the least.

Significance of Hyperreflective Foci as an Optical Coherence Tomography Biomarker in Retinal Diseases: Characterization and Clinical Implications.

Hyperreflective foci (HRF) is a term coined to depict hyperreflective dots or roundish lesions within retinal layers visualized through optical coherence tomography (OCT). Histopathological correlates of HRF are not univocal, spacing from migrating retinal pigment epithelium cells, lipid-laden macrophages, microglial cells, and extravasated proteinaceous or lipid material. Despite this, HRF can be considered OCT biomarkers for disease progression, treatment response, and prognosis in several retinal diseases, including diabetic macular edema, age-related macular degeneration (AMD), retinal vascular occlusions, and inherited retinal dystrophies. The structural features and topographic location of HRF guide the interpretation of their significance in different pathological conditions. The presence of HRF less than 30 µm with reflectivity comparable to the retinal nerve fiber layer in the absence of posterior shadowing in diabetic macular edema indicates an inflammatory phenotype with a better response to steroidal treatment. In AMD, HRF overlying drusen are associated with the development of macular neovascularization, while parafoveal drusen and HRF predispose to macular atrophy. Thus, HRF can be considered a key biomarker in several common retinal diseases. Their recognition and critical interpretation via multimodal imaging are vital to support clinical strategies and management.

Risk of Posterior Capsular Rupture during Phacoemulsification in Patients with the History of Anti-VEGF Intravitreal Injections: Results from the Pan-American Collaborative Retina Study (PACORES) Group.

PURPOSE: To assess the risk for capsular rupture during routine phacoemulsification in patients with a history of anti-VEGF injections and other possible risk modifiers such as treatment patterns, type of anti-VEGF agent, and experience of the surgeon, among others. METHODS: This study reviewed the medical records of 11,129 patients from 7 different hospitals in 5 countries. The study included 939 patients that underwent routine phacoemulsification and had a history of anti-VEGF therapy. We excluded patients with known risk factors for capsular rupture, as well as patients with a history of other retinal procedures. The study extracted data regarding general demographics, the number of previous injections, type of anti-VEGF agent, details of cataract surgery, and anti-VEGF treatment patterns. RESULTS: Overall prevalence of posterior capsular rupture: 7.45% (95% CI: 5.9-9.32%). The mean number of injections per patient was 3.37 ± 2.8. More than 50% of the patients received their last anti-VEGF injection within three months before cataract surgery. The complication rate during intravitreal injections was 1.07%. In the univariate analysis, the experience of the cataract surgeon (inexperience surgeons; OR: 2.93) and the history of prior anti-VEGF therapy (OR: 1.77) were significant risk indicators for PCR (p < 0.05). However, after controlling for age in the multivariate analysis, the trend did not reach a statistical significance. CONCLUSION: The risk for capsular rupture is higher in patients with a history of intravitreal anti-VEGF injections.

Fluid as a critical biomarker in neovascular age-related macular degeneration management: literature review and consensus recommendations.

Current guidelines on the management of patients with neovascular age-related macular degeneration (nAMD) lack clear recommendations on the interpretation of fluid as seen on optical coherence tomography (OCT) imaging and the incorporation of this information into an ongoing disease treatment strategy. Our objective was to review current guidelines and scientific evidence on the role of fluid as a biomarker in the management of nAMD, and develop a clinically oriented, practical algorithm for diagnosis and management based on a consensus of expert European retinal specialists. PubMed was searched for articles published since 2006 relating to the role of fluid in nAMD. A total of 654 publications were screened for relevance and 66 publications were included for review. Of these, 14 were treatment guidelines, consensus statements and systematic reviews or meta-analyses, in which OCT was consistently recommended as an important tool in the initial diagnosis and ongoing management of nAMD. However, few guidelines distinguished between types of fluid when providing recommendations. A total of 52 publications reported primary evidence from clinical trials, studies, and chart reviews. Observations from these were sometimes inconsistent, but trends were observed with regard to features reported as being predictive of visual outcomes. Based on these findings, diagnostic recommendations and a treatment algorithm based on a treat-and-extend (T&E) regimen were developed. These provide guidance on the diagnosis of nAMD as well as a simple treatment pathway based on the T&E regimen, with treatment decisions made according to the observations of fluid as a critical biomarker for disease activity.

Multimodal Imaging Features and Clinical Relevance of Subretinal Lipid Globules.

PURPOSE: To describe the presence of subretinal lipid globules (SLG), analyze the multimodal imaging features inherent in their optical properties, and provide a means to distinguish them from other retinal structures and clinical signs. DESIGN: Retrospective cohort study. METHODS: The clinical data and multimodal imaging features of 39 patients (49 eyes) showing SLG were evaluated. Patients underwent color fundus photography, near-infrared reflectance (NIR), spectral-domain (SD) and swept-source (SS) optical coherence tomography (OCT) and OCT angiography. In vitro phantom models were used to model OCT optical properties of water, mineral oil, and intralipid droplets and to investigate the optical mechanisms producing hypertransmission tails beneath SLG. RESULTS: The SLG were not visible in color fundus photographs or in NIR images. With both SD- and SS-OCT B-scans, SLG appeared as 31-157 µm, round, hyporeflective structures demonstrating a characteristic hypertransmission tail previously described with lipid globules found in the choroid and in neovascular membranes. Similarly, with en face OCT, SLG appeared as small, round, hyporeflective structures. SLG were encountered most often in eyes with neovascular age-related macular degeneration (AMD) that had type 1 macular neovascularization (MNV) (91.1%). Of those eyes, 93.3% were receiving intravitreal antivascular endothelial growth factor (VEGF) therapy (median of 15 injections) with a mean follow-up of 52.6 months. The number of prior injections positively correlated with the number of SLG. The detection of MNV preceded the presence of SLG in 66.7% of cases. En face OCT showed that, in many eyes (49%), SLG appeared in clusters of >10. In 38.8% of eyes, SLG were found overlying type 1 MNV, and in 44.9% of eyes, often those with more numerous SLG, the SLG were located near the lesion border. In 2 eyes with AMD followed for nonexudative type 1 MNV, SLG were detected prior to the detection of other imaging signs of exudation. SLG were observed in several other exudative macular diseases. Phantom models demonstrated that the hypertransmission tail beneath SLG is related to a lensing effect produced by these hyporeflective spherical structures. CONCLUSIONS: SLG are a newly recognized OCT feature frequently seen in eyes receiving intravitreal anti-VEGF therapy for type 1 MNV due to AMD. OCT B-scans show SLG as small, round, hyporeflective structures with a characteristic hypertransmission tail. This OCT signature is influenced by the OCT focal plane, and it relates to reduced signal attenuation through oil and a lensing effect created by a higher refractive index compared to surrounding tissue.