En Face Optical Coherence Tomography in Diagnosis of Persistent Subretinal Fluid & Outer Retinal Folds after Rhegmatogenous Retinal Detachment Repair

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Purpose To evaluate the role of en face optical coherence tomography (OCT) as a diagnostic tool for the detection of persistent subretinal fluid (PSRF) and outer retinal folds (ORF) following successful rhegmatogenous retinal detachment (RRD) repair. Design Observational post hoc analysis of two prospective surgical trials. Participants All patients with gradable (signal strength ≥ 5 and no segmentation error) 6x6 mm macular cube scans using spectral-domain OCT (SD-OCT) (Carl Zeiss Meditec, Jena, Germany) obtained between 1 and 2 months postoperatively were included in this study. Methods Scans were assessed for the presence or absence of PSRF or ORFs using en face OCT and cross-sectional B scans by two masked graders with any disagreements adjudicated by the third senior masked grader. Main Outcome Measure Sensitivity, specificity and predictive accuracy {using area under curve (AUC)} of en face OCT in comparison to cross-sectional OCT as the gold standard Results Two hu...

The OCT angular sign of Henle fiber layer (HFL) hyperreflectivity (ASHH) and the pathoanatomy of the HFL in macular disease

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The Henle fiber layer (HFL) is comprised of bundles of unmyelinated photoreceptor axons intermingled with outer Müller cell processes. The photoreceptor axons extend from the cell bodies located in the outer nuclear layer and radially project toward the outer plexiform layer, the inner third of which includes the synaptic junctional complexes and the outer two-thirds of which includes the HFL. The oblique path of the HFL provides unique structural and reflectance properties and this radial anatomy is highlighted in many macular disorders including those with macular star exudation and HFL hemorrhage. Recent investigations using multimodal imaging techniques, especially cross sectional and en face optical coherence tomography (OCT), have provided new perspectives regarding HFL disruption in retinal diseases. The aim of this review is to highlight the pathoanatomy and multimodal imaging, especially OCT, associated with HFL disruption that is present in various macular diseases. A...

Recommendations for OCTA reporting in retinal vascular disease: A Delphi approach by International Experts

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Purpose: To develop a consensus nomenclature for reporting optical coherence tomography angiography (OCTA) findings in retinal vascular disease (e.g., diabetic retinopathy, retinal vein occlusion) by international experts. Design: Delphi-based survey SUBJECTS, PARTICIPANTS AND/OR CONTROLS: Twenty-five retinal vascular disease and OCTA imaging experts METHODS, INTERVENTION, OR TESTING: A Delphi method of consensus development was used, comprising two rounds of online questionnaires, followed by a face-to-face meeting conducted virtually. Twenty-five experts in retinal vascular disease and retinal OCTA imaging were selected to constitute the OCTA Nomenclature in Delphi Study Group for retinal vascular disease. The four main areas of consensus were: definition of parameters of "widefield (WF)" OCTA, measurement of decreased vascular flow on conventional and WF-OCTA, nomenclature of OCTA findings, and OCTA in retinal vascular disease management and staging. The study endpoint was define...

En Face Optical Coherence Tomography Imaging of Foveal Dots in Eyes With Posterior Vitreous Detachment or Internal Limiting Membrane Peeling

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Purpose: To analyze the morphology of foveal hyperreflective dots (HRD) identified with en face optical coherence tomography (OCT) and evaluate the effects of internal limiting membrane (ILM) peeling and posterior vitreous detachment (PVD) on the number of these lesions. Methods: Retrospective cross-sectional study of patients with OCT angiography and en face OCT. Using en face OCT, superficial HRD lying on the foveal floor were measured and quantitated in eyes with ILM peel and in the fellow nonsurgical eyes. Eyes with foveal PVD were also compared to fellow eyes without foveal PVD. High-magnification en face OCT was also performed to better understand the morphology of HRD in the fovea. Results: Eyes that underwent ILM peel (n = 10) displayed fewer HRD (P = 0.012) compared to control fellow nonoperated eyes. In eyes with foveal PVD, the mean number of HRD was numerically greater, but without statistical significance, compared to the contralateral eye without foveal PVD. High-magni...

Longitudinal assessment of type 3 macular neovascularization using three-dimensional volume-rendering optical coherence tomography angiography

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Objective: To investigate the evolution of treatment-naive type 3 macular neovascularization (MNV) undergoing anti-vascular endothelial growth factor (VEGF) treatment through volume rendered three-dimensional (3D) optical coherence tomography angiography (OCTA). Design: Retrospective observational study. Participants: Patients with type 3 MNV and age-related macular degeneration (AMD). Methods: Included subjects had three loading injections of an anti-VEGF agent. The OCTA volume data at baseline and follow-up were processed with a previously published algorithm in order to obtain a volume-rendered representation of type 3 MNV. Progressive changes in type 3 lesions were analyzed via 3D OCTA volume rendering. Results: A total of 14 treatment-naive eyes with type 3 MNV from 11 AMD patients (7 females) were included. At both baseline and follow-up visits, a type 3 MNV complex was identifiable. Each complex was composed of a mean number of 2.5 ± 0.7 vascular branches at baseline a...

Identification and Characterization of Epivascular Glia using En Face OCT

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Purpose : To describe the clinical features of epivascular glia (EVG) using en face optical coherence tomography (OCT). Design : Retrospective cross-sectional study. Methods : Single institution en face OCT images were reviewed. Eyes displaying EVG were captured with manual internal limiting membrane segmentation and analysis with customized segmentation was performed. A random age- and gender-matched control group was selected to determine relative epiretinal membrane (ERM) prevalence. Results : Characteristic hyper-reflective internal limiting membrane (ILM) plaques with dendritic-like radiations were identified with en face OCT and displayed vascular predilection. 161 eyes with EVG (EVG group) and 2315 eyes without EVG (control group) were identified from a total cohort of 1298 patients (or 2476 eyes). The prevalence of EVG was 6.5% (161/2476) of eyes and 9.2% (119/1298) of patients in our cohort. Mean age was 79.3±10.7 years in the EVG group and 55.9±24.6 years in ...

Optical Coherence Tomography Angiography of the Choriocapillaris in Age-Related Macular Degeneration

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The advent of optical coherence tomography angiography (OCTA) has allowed for remarkable advancements in our understanding of the role of the choriocapillaris in age-related macular degeneration (AMD). As a relatively new imaging modality, techniques to analyze and quantify choriocapillaris images are still evolving. Quantification of the choriocapillaris requires careful consideration of many factors, including the type of OCTA device, segmentation of the choriocapillaris slab, image processing techniques, and thresholding method. OCTA imaging shows that the choriocapillaris is impaired in intermediate non-neovascular AMD, and the severity of impairment may predict the advancement of disease. In advanced atrophic AMD, the choriocapillaris is severely impaired underneath the area of geographic atrophy, and the level of impairment surrounding the lesion predicts the rate of atrophy enlargement. Macular neovascularization can be readily identified and classified using OCTA, but it is ...

Peripheral Optical Coherence Tomography Findings in a Choroideremia Carrier

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Purpose: To describe the peripheral optical coherence tomography (OCT) findings in a female choroideremia carrier. Methods: Case report. Patient: A 56 year-old woman was referred for visual disturbance complaining of some occasional photopsias and increasing difficulty with her vision at night in both eyes. Best-corrected visual acuity was 20/20 in the right eye and 20/150 in the left eye. Fundus examination revealed mildly tilted disks and peripapillary atrophy with subtle retinal pigment epithelial changes in the periphery. Results: Macular OCT in the right eye appeared unremarkable but the in the left eye there was diffuse ellipsoid zone (EZ) band disruption. Green-light fundus autofluorescence (FAF) revealed mottled areas of decreased AF in the mid and far periphery creating an irregular mosaic pattern. Peripheral OCT scans revealed more diffuse EZ alterations than were apparent on the FAF imaging. Genetic testing revealed a heterozygous pathogenic variant in the CHM gene (c.715...


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Purpose: To compare the anatomic results of optical coherence tomography angiography (OCTA)-guided half-dose photodynamic therapy (PDT) versus indocyanine green angiography (ICGA)-guided PDT in eyes with acute central serous chorioretinopathy. Methods: This study is a prospective, single-center, noninferiority, double-masked, randomized, controlled clinical trial. Fifty-one eyes of 45 patients with acute central serous chorioretinopathy were recruited, and randomized to an ICGA-guided group and an OCTA-guided group. The primary outcome measures were the rates of complete subretinal fluid (SRF) resolution at 1 month and 3 months. Results: Forty-six eyes of 40 patients finished the follow-up and were analyzed. In the OCTA-guided group, the SRF was completely resolved in 13 (56.5%) eyes within 1 month and in 21 (91.3%) eyes within 3 months. In the ICGA-guided group, the SRF was resolved in 16 (69.6%) of the eyes within 1 month and in 22 (95.7%) of the eyes by 3 months. Optical coherenc...

Optical coherence tomography angiography analysis of the retina in patients recovered from COVID-19: A case-control study

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Objective: To quantify the density of the macular microvasculature and the area of the foveal avascular zone (FAZ) in patients recovered from coronavirus disease 2019 (COVID-19) using optical coherence tomography angiography (OCTA) analysis. Methods: In a comparative cross-sectional, observational study, patients recovered from COVID-19 were included in this study. All included subjects exhibited a reverse transcription-polymerase chain reaction-confirmed diagnosis of COVID-19. Spectral domain macular OCTA was performed at least 2 weeks after recovery from systemic COVID-19. Vessel density (VD) of the superficial (SCP) and deep retinal capillary plexus (DCP) and the area of the FAZ were measured in COVID-19 recovered patients versus age-matched normal controls. Results: Thirty-one recovered COVID-19 patients and 23 healthy normal controls were studied. Mean quality scan index was 7.64 ± 0.66 in the COVID cases and 8.34 ± 0.71 in the normal controls (p = 0.001). Mean SC...

Evaluation of retinal vessel quantity within individual retinal structural layers using optical coherence tomography angiography

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Purpose To evaluate retinal vessel quantity within various retinal structural layers using optical coherence tomography angiography (OCTA). Methods In this IRB-approved study, 22 normal eyes (from 22 subjects) were imaged using the Spectralis OCT2, with a 15 × 15 degree OCTA scan centered on fovea and two additional 15 × 5 degree OCTA scans, displaced temporally and nasally by 15 degrees along the fovea-Bruch’s membrane opening (BMO) axis. Following projection artifact removal (PAR), vessel quantity (i.e., amount of flow signal) within each retinal nuclear and plexiform layer was assessed across the scan and was plotted as a vessel quantity profile over this fovea-BMO axis. Vessel quantity was correlated against the retinal layer thickness at the corresponding locations using the Spearman correlation. Results For the nerve fiber layer (NFL), the vessel quantity was highest nasally and declined towards the fovea and was near zero temporal to the fovea with or withou...

Pearls and Pitfalls of Optical Coherence Tomography Angiography Image Interpretation


The advent of optical coherence tomography angiography (OCTA), a relatively new tool to image the retinal and choroidal microvasculature with depth-resolved capability, has been met with great excitement by some ophthalmologists. This noninvasive technology is a potentially valuable instrument to differentiate flow impairment in the superficial vs deep retinal capillary plexus, and it can quantify nonperfusion in eyes with retinal vascular disease. Moreover, OCTA has advanced understanding of the microvascular morphology of choroidal neovascularization and has demonstrated its various growth patterns.  It also has highlighted the potential importance of inner choroidal flow impairments associated with the development and progression of various macular diseases, including placoid-associated disorders (eg, acute posterior multifocal placoid pigment epitheliopathy) and age-related macular degeneration, and has provided a quantitative tool to measure inner choroidal flow impairment...

En Face OCT of Type 2 Neovascularization:A Reappraisal of the Pitchfork Sign

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To describe a new en face optical coherence tomography (OCT) imaging feature of type 2 choroidal neovascularization (CNV) and illustrate the OCT angiographic (OCTA) findings in these eyes. PATIENTS AND METHODS: Multimodal images of patients with type 2 CNV who displayed the typical “pitchfork” sign with cross-sectional OCT were reviewed. Corresponding en face structural OCT and OCTA images were analyzed to correlate the finding before and after anti-vascular endothelial growth factor (VEGF) therapy. RESULTS: Five eyes of five patients, including two females and three males with a median age of 13 years (range: 8 years to 84 years), were studied. The etiology for type 2 CNV was laser-induced maculopathy in two eyes, idiopathic in two eyes, and age-related macular degeneration in one eye. None of the eyes had evidence of inflammatory ocular disease. En face OCT displayed a characteristic wreath-like pattern of hyperreflective spikes surrounding the type 2 neovascular membr...

Effect of Choroidal Vessel Density on the Ellipsoid Zone and Visual Function in Retinitis Pigmentosa Using Optical Coherence Tomography Angiography

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Purpose : We evaluate the effect of choroidal vessel density on the residual length of the ellipsoid zone (EZ) and visual function in patients with retinitis pigmentosa (RP) using optical coherence tomography angiography (OCTA). Methods : Fifty-three patients with RP ( n = 101 eyes) and 53 normal participants ( n = 76 eyes) were enrolled in this study. Patients with RP were assigned to three groups according to their best-corrected visual acuity (BCVA). All patients underwent ophthalmologic examinations, including BCVA, fundus examination performed with a slit-lamp using an indirect 90 diopter (D) lens, OCTA, full-field electroretinogram (ERG), and visual field. The choroidal vessel density in the choriocapillaris-Sattler's layer (D C-S ), Haller's layer (D H ), horizontal length of the ellipsoid (HEL), and vertical length of the ellipsoid (VEL) were assessed using OCTA and Adobe Photoshop CS3 extended software. Results : A significantly increasing impairment of choroidal vessel den...

Volumetric Analysis of Vascularized Serous Pigment Epithelial Detachment Progression in Neovascular Age-Related Macular Degeneration Using Optical Coherence Tomography Angiography

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Purpose : To analyze the evolution of type 1 neovascularization associated with vascularized serous pigment epithelial detachment (vsPED) using three-dimensional, volumetric, en face optical coherence tomography angiography (OCTA). Methods : This was a retrospective case series from four tertiary medical centers. OCTA images were analyzed at baseline and at the 3-, 6-, 12-, 18-, and 24-month follow-up visit when available. Visual acuity, number of injections, PED maximal height and PED area and volume, and choroidal neovascularization (CNV) flow area and progression were determined at each visit. Qualitative and quantitative analysis of CNV progression (including CNV/PED flow area) and final PED morphology was performed to determine anatomic outcomes. Results : Twenty-four eyes in 22 patients were studied. Median follow-up was 20 months. Across all eyes, maximum PED height decreased from 395.5 to 369.5 μm while CNV/PED flow ratio increased from 27.3% to 40.2%. Median visual acuit...


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