Publications by authors named "Sarah Mrejen"

82 Publications

Review of the Current Literature and Our Experience on the Value of OCT-angiography in White Dot Syndromes.

Ocul Immunol Inflamm 2021 Feb 22:1-15. Epub 2021 Feb 22.

DHU Sight Restore, Centre Hospitalier National Des Quinze-Vingts, Paris, France.

Purpose: To describe the application of OCT-A in various posterior uveitis disorders in our experience and to compare it with the available literature.

Methods: Eighteen eyes with the diagnoses of multifocal choroiditis (MFC), multifocal placoid pigment epitheliopathy (APMPPE), multiple evanescent white dot syndrome (MEWDS), tuberculous serpiginous-like choroiditis (SLC), serpiginous choroiditis (SC), and birdshot chorioretinopathy (BSCR) were studied.

Results: We found flow void of the choriocapillaris in patients with APMPPE, SC, MFC, BSCR, and in SLC. In contrast, perfusion of the choriocapillaris seemed normal in patients with MEWDS.

Conclusions: We confirmed that OCT-A contributes new information on the physiopathology of white dot syndromes and inflammatory chorioretinopathies, notably on whether or not the choriocapillaris is involved. Comparing the OCT-A features allowed us to suggest that both APMPPE and SLC might be part of the same spectrum of inflammatory disease with primary involvement at the level of the choriocapillaris and secondary RPE damage.
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http://dx.doi.org/10.1080/09273948.2020.1837185DOI Listing
February 2021

Outer Foveal Microdefects.

Ophthalmol Retina 2020 Sep 30. Epub 2020 Sep 30.

Ophthalmology Center for Imaging and Laser, Paris, France; Department of Ophthalmology, AP-HP, Lariboisière Hospital, University of Paris, Paris, France.

Purpose: To report a spectral-domain (SD) OCT clinical sign, outer foveal microdefect (OFMD), corresponding to a focal disruption of the foveal photoreceptors in association with various macular conditions.

Design: Retrospective cohort study.

Participants: Forty-five patients with OFMD.

Methods: All patients were imaged with color photography and SD OCT, and some were imaged with autofluorescence imaging, fluorescein angiography, indocyanine green angiography, or a combination thereof. Patient demographics, OFMD imaging, courses, and outcomes were analyzed retrospectively.

Main Outcome Measures: Demographics, conditions associated with OFMD, and diameter of OFMD.

Results: Fifty-one eyes of 45 patients (15 men and 30 women; age range, 10-88 years) were included. Symptoms included central scotoma, metamorphopsia, and mild to moderate visual loss. Outer foveal microdefects were observed in association with various macular conditions: presumed posterior vitreous detachment, vitreomacular interface changes, or both (24 eyes); sequelae of macular edema (3 eyes); blunt trauma (2 eyes); retinal phototoxicity resulting from laser or solar maculopathy (5 eyes); and macular telangiectasia type 2 (2 eyes). An improvement with a reduction in OFMD diameter was documented in 9 of 14 eyes that could be followed up.

Conclusions: We suggest renaming the condition outer foveal microdefect instead of macular microhole, which is usually associated with a vitreomacular disorder. The pattern indeed also was observed in traumatic or degenerative conditions. We assumed that various injuries led to changes in foveal morphologic features and that a full recovery of the foveal architecture could be altered, especially in eyes with findings suggestive of the pachychoroid spectrum of disorders.
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http://dx.doi.org/10.1016/j.oret.2020.09.018DOI Listing
September 2020

Reply.

Retina 2021 02;41(2):e22-e23

Ophthalmology Center for Imaging and Laser, Paris, France.

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http://dx.doi.org/10.1097/IAE.0000000000002935DOI Listing
February 2021

Reply.

Retina 2021 02;41(2):e19-e20

Ophthalmology Center for Imaging and Laser, Paris, France.

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http://dx.doi.org/10.1097/IAE.0000000000002928DOI Listing
February 2021

Expectations and fears of patients with diabetes and macular edema treated by intravitreal injections.

Acta Diabetol 2020 Sep 9;57(9):1081-1091. Epub 2020 Apr 9.

Ophthalmology Department, Hôpital Avicenne and University Paris 13, Bobigny, Paris, France.

Aims: Clinical outcomes of diabetic macular edema (DME) have been widely described, but data on diabetic retinopathy perceptions by diabetes patients are limited. The aim of this survey was to explore the lived experience, knowledge, fears and expectations about disease, and treatment in patients with diabetes and macular edema treated with intravitreal injections (IVTI) and to characterize patient profiles.

Methods: Cross-sectional survey including a preliminary qualitative phase (20 patients with DME, treated or treatment-naive, 5 female and 15 male, age 36-74 years) followed by a quantitative survey (116 patients treated with IVTI for DME). Data ASKIA Analyze (version 5.3.3.5) was used for descriptive statistics, and R software (version 3.4.1) for multiple correspondence analysis.

Results: The qualitative phase identified the wording used by patients and information helpful to propose modalities of response in the quantitative phase. In the quantitative survey (116 patients, mean age 66.6 years), most patients were treated with anti-vascular endothelial growth factor. Overall, 71.9% reported that the disease negatively affected their daily activities and 33.1% considered that regular visits to the ophthalmologist were disrupting their life. Treatment expectations differed significantly between patients in terms of disease experience (visit and injection schedules), fears and feelings, and relationship with physicians, allowing three patient profiles to be identified: "Worried" patients (n = 45) felt isolated and were worried about the need for repeated treatment and possible side effects. They were mainly active men aged < 60 with type I diabetes (T1D) and DME diagnosed for > 2 years; "Curious" patients (n = 21) experienced insufficient support and requested more information on their disease and existing treatments. They were mainly single women aged 60-69 years; "Passive" patients (n = 50) felt sufficiently informed by their ophthalmologist and were not concerned by DME. They were older (mean age: 70 years) and mainly type 2 diabetic men.

Conclusions: Patients with diabetes and macular edema treated with IVTI form a heterogeneous group regarding fears and expectations. Different patient profiles were identified and need to be confirmed in larger studies. A better understanding of psychological profiles may optimize compliance of diabetic patients.
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http://dx.doi.org/10.1007/s00592-020-01513-9DOI Listing
September 2020

INTRARETINAL HYPERREFLECTIVE LINES.

Retina 2021 Jan;41(1):82-92

Department of Ophthalmology, University of Paris Est, Creteil, France.

Purpose: To report intraretinal hyperreflective lines related to various macular conditions.

Methods: All cases were imaged with color photographs, autofluorescence images, and spectral-domain optical coherence tomography, some with fluorescein and/or indocyanine green angiography. Demographic data, imaging, course and outcome were retrospectively analyzed.

Results: Forty-nine eyes of 43 patients (16 men and 27 women) were included. Hyperreflective vertical lines (38 eyes) or curvilinear lines along the Henle fiber layer (11 eyes) were present in association with various macular conditions: adult vitelliform dystrophy or pattern dystrophy (24 eyes) frequently associated with an epiretinal membrane (six eyes) and/or thick choroid (nine eyes), age-related maculopathy or macular degeneration (nine eyes), partial resorption of subretinal or intraretinal hemorrhages (five eyes), idiopathic macular microhole (two eyes), vitreomacular traction (three eyes), multiple evanescent white dot syndrome (three eyes), fundus flavimaculatus (two eyes), and pachychoroid pigment epitheliopathy (one eye). The lines fully vanished in cases of hemorrhages, multiple evanescent white dot syndrome or resolution of vitreomacular traction, but usually persisted with gradual thinning in the other conditions.

Conclusion: The present series showed that intraretinal hyperreflective lines could occur in various inflammatory, degenerative, or tractional conditions. They could reflect a previously unrecognized reaction to various photoreceptor, Müller cell, and/or retinal pigment epithelium damage.
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http://dx.doi.org/10.1097/IAE.0000000000002806DOI Listing
January 2021

Topographic Variations of Choroidal Thickness in Healthy Eyes on Swept-Source Optical Coherence Tomography.

Invest Ophthalmol Vis Sci 2020 03;61(3):38

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Purpose: To assess topographic variations of choroidal thickness (CT) in the fovea and beyond in healthy eyes.

Methods: This cross-sectional study included healthy subjects ≤ 55 years of age with axial lengths (22-26 mm) and refractive error margins (-4D, +4D) in normal ranges. Images were acquired using swept-source optical coherence tomography angiography (OCT-A). Corneal thickness (CT) maps from 12 × 12-mm radial scans and 9 × 9-mm OCT-A B-scans were analyzed.

Results: The study included 64 eyes of 33 subjects (mean age, 37 years). Mean CT was >300 µm in all locations except the nasal outer macula. The subfoveal CT was >395 µm in 30% of cases; in 38.7% of cases, >50% of the CT map was thicker than 395 µm. The mean thickest choroidal point was 395.2 µm (range, 164-548 µm), located superior and temporal to the macula in 72.2% of cases and subfoveally in 1.8% of cases. The CT pattern was symmetrical (58%) or asymmetrical (42%) along a horizontal axis correlating with choroidal vein distribution. Half of the asymmetrical patterns were thicker in the inferior quadrants, with an oblique temporal watershed of venous drainage, and the other half were thicker superiorly. The mean vascularity index was ∼75% regardless of the mean CT.

Conclusions: One-third of healthy eyes of patients younger than age 55 had a thick choroid (>395 µm). In these normal eyes, the thickest choroidal point was not subfoveal, CT symmetry above and below the fovea depended on choroidal vein distribution, and choroidal vascularity index was independent from CT. No patients demonstrated fundus autofluorescence abnormalities, and the choriocapillaris remained visible even in thick choroids. These features could be interesting when differentiating normal versus pathological states.
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http://dx.doi.org/10.1167/iovs.61.3.38DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7401446PMC
March 2020

ATTENUATION OUTER RETINAL BANDS ON OPTICAL COHERENCE TOMOGRAPHY FOLLOWING MACULAR EDEMA: A Possible Manifestation of Photoreceptor Misalignment.

Retina 2020 Nov;40(11):2232-2239

Department of Ophthalmology, PARIS Group, Quinze-Vingts Hospital, INSERM-DGOS Clinical Investigation Center, Paris, France.

Purpose: Macular edema is a common retinal disease which may leave important anatomical and functional sequelaes. Directional fundus imaging consists of comparing on- and off-axis images to reveal angle-dependent reflectance properties of fundus structures, which may be related to misaligned photoreceptors. Here, we analyzed directional optical coherence tomography (OCT) and flood-illumination adaptive optics ophthalmoscopy images to detect evidence of misaligned photoreceptors following macular edema.

Methods: Transversal, observational study. Nine patients having recovered a normal macular profile after macular edema due to retinal vein occlusion were included. For each patient, a reference OCT scan (i.e., with the incident beam normal to the fovea) was acquired, and off-axis scans were then acquired by laterally shifting the entry pupil. In addition, in four of these eyes, directional adaptive optics ophthalmoscopy documented the directional variations of cone metrics.

Results: Included patients comprised two women and seven men (age range, 19-76 years). Reference OCT scans showed patchy attenuation of the cone outer segment tips and to a lesser extent of the inner segment/outer segment lines in all, but two eyes; these. Increased intensity of the cone outer segment tips and inner segment/outer segment lines could be observed on off-axis scans. Accordingly, fusion images showed 66% average reduction of the length of cone outer segment tips attenuation. In two cases, although reference scans showed continuity of outer bands, focal attenuation was evidenced in off-axis images. Directional adaptive optics ophthalmoscopy imaging showed a strong directional variability of cone counts in these areas, ranging from near absence to roughly two-third of reference values. In each case, directional variations of cone counts paralleled those of the reflectance of outer bands.

Conclusion: After macular edema, focal attenuations of the inner segment/outer segment and of the cone outer segment tips lines may be present on OCT. These areas may show a strong directional variability by both OCT and adaptive optics ophthalmoscopy, suggesting that misaligned photoreceptor outer segments contribute to such features. The evaluation of outer retinal damage following macular edema should therefore take into account the optical Stiles-Crawford effect to disambiguate missing from misaligned cones.
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http://dx.doi.org/10.1097/IAE.0000000000002738DOI Listing
November 2020

Reply To: "Zicarelli F Et al. Multimodal Imaging of Multiple Evanescent White Dot Syndrome: A New Interpretation".

Ocul Immunol Inflamm 2019 Dec 18. Epub 2019 Dec 18.

Ophthalmology Department and Centre d'Imagerie et Laser, Hôpital des Quinze-Vingts, Paris, France.

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http://dx.doi.org/10.1080/09273948.2019.1691241DOI Listing
December 2019

CHORIORETINAL FOLDS IN PATIENTS WITH CENTRAL SEROUS CHORIORETINOPATHY.

Retin Cases Brief Rep 2019 Nov 15. Epub 2019 Nov 15.

Ophthalmology Center for Imaging and Laser, Paris, France.

Background And Purpose: To the best of our knowledge, there is no study of patients with central serous chorioretinopathy associated with chorioretinal folds, since a short mention in Gass' stereoscopic atlas. We report here six cases with this association.

Methods: Six patients with both conditions were examined in our institution and underwent fluorescein angiography and optical coherence tomography.

Results: Patients were 3 men and 3 women, aged 44 years to 82 years. All patients were hyperopic and two received corticosteroids. Fluorescein angiography showed pigmentary changes, diffuse leakage areas typical of chronic central serous chorioretinopathy, and chorioretinal folds mainly located in the upper temporal part of the fundus. Enhanced depth imaging optical coherence tomography was performed in 5 cases and revealed a thick choroid in all cases (mean subfoveal choroidal thickness: 381 µm, range: 280-510 µm).

Conclusion: Although possibly coincidental, the presence of chorioretinal folds in hyperopic central serous chorioretinopathy eyes could be due to the excessive thickness of the choroid in eyes with hyperopia related to short axial length.
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http://dx.doi.org/10.1097/ICB.0000000000000944DOI Listing
November 2019

NEW OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY FINDINGS ON AN INTRARETINAL VASCULAR PROCESS SECONDARY TO TOXOPLASMA RETINOCHOROIDITIS: 2 CASE REPORTS.

Retin Cases Brief Rep 2019 Sep 23. Epub 2019 Sep 23.

Quinze-Vingts National Eye Hospital, DHU Sight Restore, Paris, France.

Background/purpose: To determine which retinal layer is primarily involved in intraretinal vascular processes associated with Toxoplasma retinochoroiditis using multimodal imaging, including optical coherence tomography angiography (OCTA).

Methods: Toxoplasma retinal lesions were analyzed through multimodal imaging, including color fundus photographs, fluorescein angiography, indocyanine green angiography, spectral-domain OCT, and OCTA.

Results: Two patients with atypical features of Toxoplasma retinochoroiditis are described in the acute phase. The first patient presented with a primary episode of acute Toxoplasma retinitis associated with an intraretinal abnormal vascular process that was detected at the acute phase by indocyanine green angiography and was better delineated by OCTA. Seven months later, the intraretinal vascular process had fully resolved on OCTA imaging. The second patient presented with a recurrence of active Toxoplasma retinochoroiditis adjacent to a pre-existing pigmented scar. He had a similar abnormal intraretinal vascular process that was identified on both fluorescein angiography at the early phase and indocyanine green angiography, which was also confirmed by OCTA imaging.

Conclusion: We report a new finding associated with Toxoplasma chorioretinitis: an abnormal intraretinal vascular process that resolved without anti-vascular endothelial growth factor therapy but after toxoplasmosis treatment alone.
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http://dx.doi.org/10.1097/ICB.0000000000000926DOI Listing
September 2019

Outer Retinal Alterations Associated With Visual Outcomes in Best Vitelliform Macular Dystrophy.

Am J Ophthalmol 2019 12 26;208:429-437. Epub 2019 Aug 26.

Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Centre de Maladies Rares "dystrophies rétiniennes d'origine génétique," Département hospitalo-universitaire Sight Restore, Institut National de la Santé et de la Recherche Médicale, DHOS Centre d'Investigation Clinique 1423, Paris, France; Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, Centre National de la Recherche Scientifique, Institut de la Vision, Paris, France.

Purpose: To describe outer retinal structure in patients with Best vitelliform macular dystrophy (BVMD) using spectral-domain optical coherence tomography (OCT) and correlate these results with best-corrected visual acuity (BCVA) and patient age.

Design: Retrospective cross-sectional study.

Methods: Patients with molecularly confirmed BVMD were compared with normal control subjects (NCs). A complete clinical evaluation was performed, including BCVA, fundus photography, spectral-domain OCT, and fundus autofluorescence. Spectral-domain OCT images were analyzed to determine the stage of the lesion, the central macular thickness (CMT), the foveal outer nuclear layer (ONL) thickness, and tomographic structural changes.

Results: Forty-two patients with BVMD (42 eyes) with a molecular diagnosis and 42 NCs (42 eyes) were included. Clinical stages (Gass clinical classification) were distributed as follows: 4.8% for stage 1, 23.8% for stage 2, 16.6% for stage 3, 45.2% for stage 4, and 9.5% for stage 5. The presence of subretinal fluid and vitelliform material was noted in 76% and 79% of the BVMD eyes examined, respectively, and was not associated with BCVA modification (P = .758 and P = .968, respectively). The median ONL thickness was significantly lower compared with the NCs (P < .001). BCVA was significantly correlated with stage (R = 0.710; P < .01), age (R = 0.448; P < .01), CMT (R = -0.411; P < .01), and ONL thickness (R = -0.620; P < .01). The disruption of the external limiting membrane and the ellipsoid zone was associated with a decreased BCVA (P < .001 for both). Among the 32 eyes with subretinal detachment, photoreceptor outer segment length was significantly correlated with BCVA (R = -0.467; P < .01) and ONL thickness (R = 0.444; P = < .01).

Conclusion: This study shows the correlation between BCVA, age, and spectral-domain OCT features in patients with BVMD. ONL thickness as well as photoreceptor outer segment length are relevant functional correlates and outcome measures to follow photoreceptor impairments and disease progression.
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http://dx.doi.org/10.1016/j.ajo.2019.08.011DOI Listing
December 2019

Reply.

Am J Ophthalmol 2019 07 10;203:120-121. Epub 2019 Jun 10.

Paris, France.

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http://dx.doi.org/10.1016/j.ajo.2019.02.021DOI Listing
July 2019

Long-term Visual Outcomes and Causes of Vision Loss in Chronic Central Serous Chorioretinopathy.

Ophthalmology 2019 04 17;126(4):576-588. Epub 2019 Jan 17.

Vitreous, Retina, Macula Consultants of New York, New York; LuEsther T. Mertz Retinal Research Center, Manhattan Eye, Ear, and Throat Hospital, New York, New York; Department of Ophthalmology, New York University School of Medicine, New York, New York.

Purpose: To evaluate the long-term visual outcomes and causes of vision loss in chronic central serous chorioretinopathy (CSC).

Design: Retrospective, longitudinal study.

Participants: A total of 133 participants (217 eyes) with chronic CSC.

Methods: A retrospective review of clinical and multimodal imaging data of patients with chronic CSC managed by 3 of the authors between May 1977 and March 2018. Multimodal imaging comprised color photography, fluorescein angiography, indocyanine green angiography, fundus autofluorescence (FAF), and OCT.

Main Outcome Measures: Best-corrected visual acuity (BCVA) at the final visit; change in BCVA between first visit and 1-, 5-, and 10-year follow-up visits; and causes of vision loss at final visit.

Results: Data from 6228 individual clinic visits were analyzed. Mean age of patients at the first visit was 60.7 years, and mean period of follow-up from first to last visit was 11.3 years. The cohort included 101 male patients (75.9%). At the final visit, 106 patients (79.7%) maintained driving-standard vision with BCVA of 20/40 or better in at least 1 eye, and 17 patients (12.8%) were legally blind with BCVA of 20/200 or worse in both eyes. Mean BCVA at first visit was not significantly different from mean BCVA at 1- or 5-year follow-up visits (both P ≥ 0.65) but was significantly better than the mean BCVA at the 10-year follow-up visit (P = 0.04). Seventy-nine percent of eyes with 20/40 or better vision at the first visit maintained the same level of vision at the 10-year follow-up visit. Ninety-two percent of eyes with 20/200 or worse vision at the first visit maintained the same level of vision at the 10-year follow-up visit. Cystoid macular degeneration, choroidal neovascularization (CNV), outer retinal disruption on OCT, and FAF changes were associated with poorer vision at the final visit (all P ≤ 0.001). Multivariable analysis revealed that greater age at first visit was associated with greater BCVA change at the 10-year follow-up visit (P = 0.001).

Conclusions: Chronic CSC can be a sight-threatening disease leading to legal blindness. Age at presentation and outer retinal changes on multimodal imaging were associated with long-term BCVA changes and may be predictors of long-term visual outcomes.
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http://dx.doi.org/10.1016/j.ophtha.2018.12.048DOI Listing
April 2019

INSIGHTS INTO PERIFOVEAL EXUDATIVE VASCULAR ANOMALOUS COMPLEX.

Retina 2020 Jan;40(1):80-86

Ophthalmology Center for Imaging and Laser, Paris, France; and.

Purpose: To report a series of eight patients with perifoveal exudative vascular anomalous complex imaged with optical coherence tomography angiography and the results of anti-vascular endothelial growth factor therapy or laser photocoagulation.

Methods: Retrospective analysis of demographic data, imaging including color pictures, spectral domain optical coherence tomography, and optical coherence tomography angiography, and fluorescein angiography, course, and outcome.

Results: Age at onset ranged from 45 to 84 years (mean ± SD: 68.6 ± 13.7). Five cases were initially misdiagnosed. The perifoveal exudative vascular anomalous complex lesion was unique in seven eyes and located predominantly in the superficial capillary plexus in two eyes, strictly in the deep capillary plexus in two eyes, but observed at the level of both plexi (3 eyes). One patient presented two lesions, one in the superficial capillary plexus and one in the deep capillary plexus. Capillary rarefaction was observed around the lesion in six eyes. Sustainable resolution of exudation could be achieved in 2 patients, one after 2 sessions of focal thermal laser photocoagulation and one after 13 intravitreal injections of anti-vascular endothelial growth factor.

Conclusion: The present series confirms that perifoveal exudative vascular anomalous complex corresponds to a new entity that differs from other conditions associated with capillary aneurysmal lesions. Visual improvement could be obtained after treatment with focal laser or intravitreal anti-vascular endothelial growth factor agents.
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http://dx.doi.org/10.1097/IAE.0000000000002435DOI Listing
January 2020

Vascular remodeling of choroidal neovascularization in older myopic patients treated with ranibizumab.

Graefes Arch Clin Exp Ophthalmol 2019 Mar 7;257(3):485-493. Epub 2018 Dec 7.

Department of Ophthalmology, Hôpital Avicenne, AP-HP and Paris 13 University, Bobigny, France.

Purpose: To investigate morphological changes in myopic choroidal neovascularization (mCNV) using optical coherence tomography-angiography (OCT-A) after treatment with ranibizumab.

Methods: Retrospective analysis of consecutive patients over a 24-month period. All treatment-naïve mCNV were imaged at baseline with color pictures, spectral-domain OCT and OCT-A, and fluorescein angiography in selected cases. CNV morphology was classified at baseline and at 6 months. The CNV lesion surface was also compared.

Results: Twenty-nine patients with a mean age of 70.3 ± 10.1 years were included. They received a mean number of 2.65 injections over 6 months. Best-corrected visual acuity improved from 62.2 to 68.5 letters (p = 0.004), with regression of exudation in 24 eyes (82.7%). Baseline CNV was classified into tree-in-bud (16 eyes), medusa (9 eyes), or sea-fan (4 eyes) pattern. At 6 months, no abnormal blood flow was observed in CNV in 13 eyes. Eyes with complete regression or evolution towards an indistinct pattern showed more often a complete regression of exudation than eyes with unchanged pattern (p = 0.007). The mean CNV surface significantly decreased from 0.19 to 0.08 mm (p < 0.0001).

Conclusion: An unchanged pattern was more often associated with exudation persistence, while a complete regression or evolution towards indistinct pattern was always associated with vascular inactivity. However, variable changes in mCNV were observed after anti-VEGF. Thus, OCT-A could be more useful in the diagnosis than in the follow-up of mCNV.
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http://dx.doi.org/10.1007/s00417-018-04205-xDOI Listing
March 2019

Predictive Factors of Response to Mineralocorticoid Receptor Antagonists in Nonresolving Central Serous Chorioretinopathy.

Am J Ophthalmol 2019 02 9;198:80-87. Epub 2018 Oct 9.

Department of Ophthalmology, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France.

Purpose: To assess the efficacy and safety of mineralocorticoid receptor antagonists (MRAs) in the treatment of nonresolving central serous chorioretinopathy (CSC) and to identify factors that are predictive of treatment response.

Design: Retrospective, multicenter, noncomparative, interventional case series.

Methods: Clinical and imaging data from consecutive patients with nonresolving CSC treated with eplerenone or spironolactone for 3 to 6 months between 2012 and 2016 were reviewed. Outcome measures included the resolution of foveal subretinal detachment (SRD), changes in SRD height, central macular thickness, subfoveal choroidal thickness, best corrected visual acuity, and the occurrence of adverse events assessed at 3 and 6 months. The response to treatment was defined by a decrease by >50% in SRD height under treatment. Comparisons between responder and nonresponder groups were performed using univariate and multivariate regression analyses to identify factors that were predictive of treatment response.

Results: Fifty-nine patients (64 eyes) were included. The mean SRD height and central macular thickness significantly decreased while the mean best corrected visual acuity significantly improved at 3 and 6 months. The mean subfoveal choroidal thickness significantly decreased at 3 months. Among the 64 eyes included, 67.2% responded to treatment, among which 38.3% and 40.5% had a complete resolution of the foveal SRD at 3 and 6 months, respectively. Baseline subfoveal choroidal thickness was the only factor associated with a treatment response in the multivariate analysis.

Conclusion: Our study suggests that MRA could be a safe and effective treatment in patients with nonresolving CSC. MRA treatment is more effective in cases with a thicker baseline choroid.
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http://dx.doi.org/10.1016/j.ajo.2018.09.034DOI Listing
February 2019

CRYSTALLINE RETINOPATHY AND RETINAL VASCULOPATHY IN CALCIFIC UREMIC ARTERIOLOPATHY (CALCIPHYLAXIS).

Retin Cases Brief Rep 2018 Fall;12(4):331-335

Vitreous Retina Macula Consultants of New York, New York.

Purpose: To report the posterior segment and retinal vascular manifestations of calcific uremic arteriolopathy (calciphylaxis). Clinical findings are correlated with multimodal imaging results.

Methods: Observational case report.

Results: A 65-year-old white woman on hemodialysis was referred for assessment of poor vision bilaterally. Clinical examination demonstrated a crystalline retinopathy with stigma of previous retinal arterial occlusion. Fluorescein angiography revealed delayed retinal arterial filling bilaterally, sheathing of vessels, and peripheral nonperfusion. The crystals were hyperautofluorescent. Spectral domain and enhanced depth imaging optical coherence tomography localized the crystals within the retina with a predilection for the retinal arterial vasculature. The choriocapillaris was not involved. Two years prior, the patient developed necrotic skin lesions which were biopsied and confirmed the diagnosis of calciphylaxis.

Conclusion: Calcific uremic arteriolopathy is an extremely rare cause of thrombogenic microangiopathy in end-stage renal disease patients. Retinal arterial occlusion appears to be a rare but significant cause of visual loss in this disease and is likely to be consequent to crystalline deposition in the retinal vasculature.
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http://dx.doi.org/10.1097/ICB.0000000000000494DOI Listing
September 2018

Clinical course of acute zonal occult outer retinopathy complicated by choroidal neovascularization.

Int J Retina Vitreous 2018 29;4:32. Epub 2018 Aug 29.

Vitreous Retina Macula Consultants of New York, New York, USA.

Purpose: To report the clinical course and multimodal imaging features of acute zonal occult outer retinopathy (AZOOR) complicated by choroidal neovascularization (CNV) treated with anti-vascular endothelial growth factor (VEGF) treatment or photodynamic therapy (PDT).

Methods: Observational case series. Retrospective analysis of patients presenting to different institutions with evidence of AZOOR and neovascular lesions. Diagnosis of AZOOR was made on the basis of clinical presentation and multimodal imaging. All patients underwent a comprehensive ophthalmic evaluation and multimodal retinal imaging, including color fundus photos, fundus autofluorescence, fundus fluorescein angiography and spectral-domain optical coherence tomography.

Results: Four patients (three males, mean age 53.5 years) were included in the study. Mean follow-up was 5.1 years. Presentation of AZOOR was unilateral in two patients and bilateral in the remainder two patients. One of the patients presenting with unilateral AZOOR developed zonal lesions in the fellow eye during follow-up. All patients presented with unilateral type 2 (subretinal) CNV. Three patients underwent intravitreal anti-VEGF injections and one patient underwent a single PDT. Multimodal retinal imaging showed zonal or multizonal progression during treatment. After treatment, visual acuity and CNV stabilization was observed in all patients.

Conclusions: The presence of CNV expands the clinical spectrum of AZOOR. CNV complicating AZOOR may be effectively treated with intravitreal injections of anti-VEGF, despite progression of the zonal lesions. Further studies are required to define the role of treatment in the progression of the zonal lesions.
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http://dx.doi.org/10.1186/s40942-018-0134-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6114516PMC
August 2018

SENSITIVITY OF 840-nm SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN DETECTING TYPE 1 NEOVASCULARIZATION ACCORDING TO THE HEIGHT OF THE ASSOCIATED PIGMENT EPITHELIAL DETACHMENT.

Retina 2019 Oct;39(10):1973-1984

Ophthalmic Center for Imaging and Laser, Paris, France.

Purpose: To evaluate the ability of optical coherence tomography angiography (OCTA) to detect abnormal vascular blood flow in Type 1 neovascularization (NV) with or without significant pigment epithelial detachment (PED).

Methods: Consecutive age-related macular degeneration patients with either treatment-naive or anti-vascular endothelial growth factor-treated Type 1 NV were divided into 2 groups based on the PED height on structural OCT: greater than 250 μm (Group 1) versus less than 250 μm (Group 2). Two independent senior retina specialists analyzed the OCTA images (Zeiss Angioplex OCT, Carl Zeiss AG, Jena, Germany) using the automatic slabs alone (first reader) versus automatic and manual segmentation slabs (second reader).

Results: In Group 1, 15 men and 42 women, aged from 51 years to 97 years (mean: 87.5), were included. Optical coherence tomography angiography was able to show an abnormal blood flow suggestive of Type 1 NV in 23 (40.3%) of 57 eyes for the first reader and in 32 (56.1%) of 57 eyes for the second reader. In Group 2, 7 men and 30 women, aged from 60 years to 96 years (mean: 80.2), were included. The first and second readers were able to observe an image suggestive of Type 1 NV in 33/37 (89.2%) and 37/37 (100%) of eyes, respectively.

Conclusion: The ability of OCTA to detect an abnormal blood flow in Type 1 NV was found to highly depend on the height of the associated PED and the use of manual segmentation slabs. Our results suggest that automatic slabs of OCTA should be interpreted with caution for the diagnosis of vascularized PED. The diagnosis of Type 1 NV using OCTA requires the use of manual segmentation and a multimodal imaging approach, especially when the height of the associated PED is >250 μm.
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http://dx.doi.org/10.1097/IAE.0000000000002244DOI Listing
October 2019

Adaptive optics ophthalmoscopy: Application to age-related macular degeneration and vascular diseases.

Prog Retin Eye Res 2018 09 17;66:1-16. Epub 2018 Jul 17.

Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, INSERM-DHOS Clinical Investigation Center, 1423, Paris, France.

Adaptive optics (AO)-enhanced en face retinal imaging, termed here AO ophthalmoscopy (AOO) has reached a level of robustness which fuels its increasing use in research and clinical centers. Here we will review the contribution of clinical AOO to the understanding and monitoring of 1) age-related macular degeneration and 2) vascular diseases. The main contributions of AOO to the phenotyping of AMD are a better identification of drusen, a better delineation of the limits of atrophy, and the identification of novel features such as punctate hyperreflectivity and mobile melanin-containing clumps. Characterization of progression of atrophy is facilitated by time-lapse imaging. In vessels, AOO enables the observation and measurement of parietal structures and the observation of microscopic pathological features such as small hemorrhages and inflammatory cell accumulations.
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http://dx.doi.org/10.1016/j.preteyeres.2018.07.001DOI Listing
September 2018

Clinical applications of optical coherence tomography angiography: What we have learnt in the first 3 years.

Eur J Ophthalmol 2018 Sep 19;28(5):491-502. Epub 2018 Mar 19.

1 Ophthalmological Center for Imaging and Laser, Paris, France.

A review of the literature from 2014 to 2016 was conducted, focusing on the results of optical coherence tomography angiography in different chorioretinal diseases. In only 3 years, optical coherence tomography angiography has been shown to be an effective tool for diagnosing choroidal neovascularization complicating age-related macular degeneration, pathologic myopia, and inflammatory conditions. The technique has sometimes been considered superior to conventional multimodal imaging, for example, in choroidal neovascularization associated with chronic central serous chorioretinopathy or multifocal choroiditis. In retinal vascular diseases, optical coherence tomography angiography has helped to understand the condition described as paracentral acute middle maculopathy and has been considered highly effective for the analysis of retinal vascular macular changes secondary to retinal vein occlusion or macular telangiectasia. Changes in the foveal avascular zone, also reported in diabetic maculopathy, have been shown to occur before any angiographic signs. A reduction in capillary vascular density has been reported in the fovea of eyes with malignant melanoma, but not in eyes with choroidal nevus. However, optical coherence tomography angiography is a recent technique that probably needs refinements and further studies. Nevertheless, the first 3 years of optical coherence tomography angiography use suggest its clinical relevance and useful applications in daily clinical practice.
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http://dx.doi.org/10.1177/1120672117753704DOI Listing
September 2018

DIRECTIONAL VARIABILITY OF FUNDUS REFLECTANCE IN ACUTE MACULAR NEURORETINOPATHY: EVIDENCE FOR A CONTRIBUTION OF THE STILES-CRAWFORD EFFECT.

Retin Cases Brief Rep 2018 Fall;12 Suppl 1:S19-S24

Ophthalmology Department, Quinze-Vingts Hospital, DHU SightMaintain, INSERM-DHOS Clinical Investigation Center 1423, Paris, France.

Purpose: To document directional reflectivity of fundus lesions in a case of acute macular neuroretinopathy.

Methods: Case report. Clinical and imaging data from a patient with acute macular neuroretinopathy were reviewed. Imaging comprised infrared scanning laser ophthalmoscopy, optical coherence tomography and flood-illumination adaptive optics images acquired through different entry pupils in the cardinal directions (approximately 2° eccentricity).

Results: The patient reported acute bilateral paracentral scotoma revealing dark, wedge-shaped macular plaques which by optical coherence tomography were associated with focal loss of the visibility of the cone outer segment tip and inner/outer segment lines. Comparing scanning laser ophthalmoscopy images taken at different entry points in the pupil showed that macular plaques varied from hyporeflectance to isoreflectance. Cone counts by flood-illumination adaptive optics within plaques and optical coherence tomography features of the cone outer segment tip showed also a strong directional variability, peaking at near-normal values. Within each modality, fusion images showed that directional variability covered most of macular plaques.

Conclusion: The characteristic fundus abnormalities of acute macular neuroretinopathy may show a strong directional variability. Our findings suggest that the Stiles-Crawford effect may be an important factor in signs and symptoms of acute macular neuroretinopathy.
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http://dx.doi.org/10.1097/ICB.0000000000000701DOI Listing
October 2018

Cuticular Drusen: Clinical Phenotypes and Natural History Defined Using Multimodal Imaging.

Ophthalmology 2018 01 28;125(1):100-118. Epub 2017 Sep 28.

LuEsther T. Mertz Retinal Research Center, Manhattan Eye, Ear and Throat Hospital, New York, New York; Vitreous Retina Macula Consultants of New York, New York, New York. Electronic address:

Purpose: To define the range and life cycles of cuticular drusen phenotypes using multimodal imaging and to review the histologic characteristics of cuticular drusen.

Design: Retrospective, observational cohort study and experimental laboratory study.

Participants: Two hundred forty eyes of 120 clinic patients with a cuticular drusen phenotype and 4 human donor eyes with cuticular drusen (n = 2), soft drusen (n = 1), and hard drusen (n = 1).

Methods: We performed a retrospective review of clinical and multimodal imaging data of patients with a cuticular drusen phenotype. Patients had undergone imaging with various combinations of color photography, fluorescein angiography, indocyanine green angiography, near-infrared reflectance, fundus autofluorescence, high-resolution OCT, and ultrawide-field imaging. Human donor eyes underwent processing for high-resolution light and electron microscopy.

Main Outcome Measures: Appearance of cuticular drusen in multimodal imaging and the topography of a cuticular drusen distribution; age-dependent variations in cuticular drusen phenotypes, including the occurrence of retinal pigment epithelium (RPE) abnormalities, choroidal neovascularization, acquired vitelliform lesions (AVLs), and geographic atrophy (GA); and ultrastructural and staining characteristics of druse subtypes.

Results: The mean age of patients at the first visit was 57.9±13.4 years. Drusen and RPE changes were seen in the peripheral retina, anterior to the vortex veins, in 21.8% of eyes. Of eyes with more than 5 years of follow-up, cuticular drusen disappeared from view in 58.3% of eyes, drusen coalescence was seen in 70.8% of eyes, and new RPE pigmentary changes developed in 56.2% of eyes. Retinal pigment epithelium abnormalities, AVLs, neovascularization, and GA occurred at a frequency of 47.5%, 24.2%, 12.5%, and 25%, respectively, and were significantly more common in patients older than 60 years of age (all P < 0.015). Occurrence of GA and neovascularization were important determinants of final visual acuity in eyes with the cuticular drusen phenotype (both P < 0.015). Small cuticular drusen typically demonstrated a homogenous ultrastructural appearance similar to hard drusen, whereas fragmentation of the central and basal contents was seen frequently in larger cuticular drusen.

Conclusions: Although the ultrastructural characteristics of cuticular drusen appear more similar to those of hard drusen, their lifecycle and macular complications are more comparable with those of soft drusen. Cuticular drusen phenotype may confer a unique risk for the development of GA and neovascularization.
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http://dx.doi.org/10.1016/j.ophtha.2017.08.033DOI Listing
January 2018

Atypical retinal pigment epithelial defects with retained photoreceptor layers: a so far disregarded finding in age related macular degeneration.

BMC Ophthalmol 2017 May 15;17(1):67. Epub 2017 May 15.

Department of Ophthalmology and Department of Clinical Research, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.

Background: To report patients with age-related macular degeneration and atypical central retinal pigment epithelium (RPE) defects not attributable to geographic atrophy (GA) or RPE-tears with overlying preserved photoreceptor layers.

Methods: Multimodal imaging case-series evaluating the course of atypical RPE- defects in patients with AMD using Color fundus images, Optical coherence tomography (OCT), OCT-Angiography, fundus autofluorescence (FAF) and fluorescein-angiography (FA).

Results: Ten patients were identified. Three patients had a prior RPE-rip and were excluded. Seven patients with a mean follow-up period of 47 ± 38 months after the occurrence of the RPE-defect were included (age range 71-87 years). Mean distance Best corrected visual acuity (BCVA) at initial presentation was 0.36 ± 0.29logMAR and at last follow-up visit 0.51 ± 0.43logMAR. Patients presented with clinically apparent GA on funduscopy and FAF, but preserved photoreceptor layers on optical coherence tomography (OCT). On FA there was early hyperfluorescence and late pooling visible. Over time, migration of RPE/drusenoid material right above the Bruch's membrane with concomitant decrease of hypoautofluorescence was detectable in 4 cases. An enlargement of the RPE-defect was apparent in the remaining 3 cases. The majority (n = 4) showed a drusenoid pigment epithelium detachment (PED) preceding the lesion.

Conclusions: Beside GA and characteristic RPE-tears, another atypical form of RPE-defect with overlying preserved photoreceptor layers are found in AMD. This so far disregarded subgroup of patients present with reasonable visual function and long-term survival of photoreceptors layers. Repair mechanisms such as ingrowth of RPE/drusenoid material and persistent subretinal fluid (SRF), but also a RPE-independent visual cycle for cone photopigment within the neurosensory retina may contribute to their favorable course.
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http://dx.doi.org/10.1186/s12886-017-0452-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5433076PMC
May 2017

Imaging of Exudative Age-Related Macular Degeneration: Toward a Shift in the Diagnostic Paradigm?

Retina 2017 09;37(9):1625-1629

*Ophthalmic Center for Imaging and Laser, Paris, France †Department of Ophthalmology, Paris-Est University, Creteil, France ‡Department of Ophthalmology, XV-XX Ophthalmology National Hospital Center, Paris, France.

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http://dx.doi.org/10.1097/IAE.0000000000001695DOI Listing
September 2017

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY TO DISTINGUISH CHOROIDAL NEOVASCULARIZATION FROM MACULAR INFLAMMATORY LESIONS IN MULTIFOCAL CHOROIDITIS.

Retina 2018 Feb;38(2):299-309

Department of Ophthalmology, Intercity Hospital and University Paris Est, Créteil, France.

Purpose: To characterize the macular lesions in multifocal choroiditis using multimodal imaging (MMI) and to evaluate optical coherence tomography angiography (OCTA) in distinguishing neovascular from inflammatory lesions.

Methods: Retrospective review of medical records of consecutive patients diagnosed with multifocal choroiditis and macular involvement, between September 2014 and May 2016, were included. All patients underwent standard examination and MMI, including fundus color photography, fundus autofluorescence, fluorescein angiography, and spectral domain optical coherence tomography. They also underwent OCTA examination. Multimodal imaging and OCTA characteristics of inflammatory lesions and choroidal neovascularization (CNV) were compared.

Results: Eighteen eyes of 13 patients (11 females) were analyzed. The mean age was 42.9 ± 13.4 years. The lesions were first categorized as active or inactive CNV and active or inactive inflammatory lesions through conventional MMI. Using OCTA, an abnormal blood flow was observed in all active CNV (9/9) and most inactive CNV (5/6), but also in 2 of 14 lesions previously classified as active inflammatory lesions. On the contrary, no case of inactive inflammatory lesions showed abnormal blood flow. Therefore, the use of OCTA allowed a diagnosis of CNV that was not made through conventional MMI in 14% of cases of active inflammatory lesions.

Conclusion: The combined findings of conventional imaging and OCTA demonstrate distinctive features of inflammatory lesions and CNV in multifocal choroiditis, allowing an appropriate management of these sight-threatening lesions. However, OCTA alone did not distinguish between active and inactive CNVs and should be integrated into an MMI approach.
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http://dx.doi.org/10.1097/IAE.0000000000001617DOI Listing
February 2018

Retinitis Pigmentosa and Other Dystrophies.

Dev Ophthalmol 2017 28;58:191-201. Epub 2017 Mar 28.

Retinitis pigmentosa (RP) is a heterogeneous group of inherited retinal degenerations characterized by progressive degeneration of rod and cone cells that affects predominantly peripheral visual fields. Macular edema may cause additional central visual acuity decrease. Cystoid macular edema (CME) is one of the few treatable causes of visual loss in RP. The prevalence of CME in RP has been found to be between 10 and 20% on fluorescein angiography-based studies, and as high as 49% on reports based on optical coherence tomography. Macular edema can manifest at any stage of the disease and may be unilateral or bilateral. It can be found in any genetic form, but is more often associated with RP caused by CRB1 mutations. The origin of macular edema in RP patients still remains poorly understood. Some mechanisms have been suggested, including antiretinal antibodies (retinal, carbonic anhydrase, and enolase antibodies), vitreous traction, retinal pigment epithelium dysfunction, and Müller cell edema. There is no gold standard therapeutic strategy. Drug therapy is the primary treatment. Systemic carbonic anhydrase inhibitors, such as oral acetazolamide or topical dorzolamide, are still the mainstays of initial therapy. If CME is refractory to acetazolamide, intravitreal corticosteroid injections may be a therapeutic option. However, antivascular endothelium growth factor injections have limited effect and should be avoided. Vitrectomy has also been evaluated, but its exact role remains to be determined. The benefits of these therapies are variable among patients. The establishment of therapeutic approaches is limited by our poor understanding of the pathophysiology of CME in patients with RP. Autoimmune retinopathies (AIRs) are a group of rare diseases characterized by acute or subacute progressive vision loss and are thought to be mediated by autoantibodies specific to retinal antigens. The AIRs encompass paraneoplastic syndromes, such as cancer-associated retinopathy and melanoma-associated retinopathy, and a larger group of AIRs that have similar clinical and immunological findings but without underlying malignancy. These diseases may also be complicated by macular edema. RP is one of the most common forms of inherited retinal degeneration. It displays extensive clinical and genetic variations and leads to progressive blindness with variable onset.
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http://dx.doi.org/10.1159/000455281DOI Listing
August 2017

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY OF FLAT IRREGULAR PIGMENT EPITHELIUM DETACHMENT IN CHRONIC CENTRAL SEROUS CHORIORETINOPATHY.

Retina 2018 Mar;38(3):629-638

Department of Ophthalmology, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, AP-HP, Université Paris 7, Sorbonne Paris Cité, Paris, France.

Purpose: To assess the rate of choroidal neovascularization (CNV) detected by optical coherence tomography angiography (OCTA) in flat irregular pigment epithelium detachment (PED) in chronic central serous chorioretinopathy.

Methods: Data on all consecutive patients with chronic central serous chorioretinopathy who underwent OCTA over a 1-year period were reviewed. The presence of flat irregular PED, which was defined as an irregular elevation of the retinal pigment epithelium allowing the visualization of a distinct Bruch's membrane was assessed on high-resolution OCT B-scan. Clinical, multimodal imaging, and OCTA data were reviewed by two graders for the detection of CNV.

Results: Eighty-eight eyes of 61 patients with chronic central serous chorioretinopathy were included. Patient mean age (±SD) was 54.5 ± 12.2 years, and 78.7% were males. Mean subfoveal choroidal thickness (±SD) was 452.6 ± 145.6 μm. Flat irregular PEDs were detected in 59 eyes of 51 patients. OCTA detected the presence of CNV in flat irregular PEDs in 35.6% of cases. Conversely, using the combination of spectral domain optical coherence tomography angiography, fluorescein and indocyanine green angiography, CNV was detected in only 25% of flat irregular PEDs. All hyporeflective flat irregular PEDs on OCT were avascular on OCTA while they were at least partially hyperreflective when associated with CNV.

Conclusion: One-third of flat irregular PEDs in chronic central serous chorioretinopathy contained CNV. OCTA detected CNV more frequently than the other imaging modalities. Further longitudinal studies are needed to assess the indication of antivascular endothelial growth factor treatments in such cases.
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http://dx.doi.org/10.1097/IAE.0000000000001580DOI Listing
March 2018