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Purpose: Retentional pigment epithelial detachment (PED) associated with age-related scattered hypofluorescent spots on late-phase indocyanine green angiography (ASHS-LIA) is hypothesized to be caused by Bruch membrane's lipid barrier. This study aimed to report the natural course of retentional PED and evaluate the relationship between retentional PED evolution and ASHS-LIA., Methods: Patients with treatment-naïve retentional PED were enrolled and observed every 3 months for at least 12 months. Treatment was not performed except for secondary macular neovascularization., Results: In 55 studied eyes with a median follow-up of 18.0 (range: 12-36) months, 87.3% (48/55) of the retentional PEDs persisted, 7.3% (4/55) resolved, and 5.5% (3/55) progressed to polypoidal choroidal vasculopathy. The mean PED area significantly increased during the follow-up ( P < 0.001) and with the ASHS-LIA grade at each follow-up point (all P <0.05), especially during the first 6 months before approaching the edge of confluent ASHS-LIA. Persistent PEDs were mostly stable (52.1%) or enlarged (45.8%) but reduced in only 1 case (2.1%) because of retinal pigment epithelium microrip at the edge of PED. The persistent PEDs were all within the ASHS-LIA region, especially the macular confluence region. The resolved PEDs all had grade 1 ASHS-LIA and resolved after gradual expansion of PED beyond the confluent ASHS-LIA region. Pigment epithelial detachments that progressed to macular neovascularization all had confluent grade 2 or 3 ASHS-LIA. Retinal pigment epithelium microrips or apertures within PED did not affect the progression of the PED., Conclusion: The natural course of retentional PED is closely related to the features of ASHS-LIA and supports its lipid-barrier hypothesis.

Purpose: To report eight cases of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) or persistent placoid maculopathy (PPM) initially masquerading as age-related macular degeneration in elderly individuals., Methods: APMPPE or PPM eyes in patients above age 55 years with macular retinal pigment epithelium disruption including drusenoid lesions on macular examination and/or with multimodal imaging were included. At least one method of multimodal imaging including fluorescein angiography (FA), indocyanine green angiography, optical coherence tomography (OCT), and OCT angiography (OCTA) was performed in all eyes for diagnosis and to monitor for macular neovascularization., Results: Eight elderly male patients presented with vision loss and were all initially diagnosed with non-neovascular or neovascular age-related macular degeneration. With the aid of multimodal retinal imaging, a final diagnosis of either APMPPE or PPM was rendered. With FA and indocyanine green angiography, choroidal hypoperfusion was detected in all but one eye. With OCT, the angular sign of Henle fiber layer hyperreflectivity was identified in >50% of eyes. With OCTA, inner choroidal flow deficits were detected in all eyes. Macular neovascularization requiring anti-vascular endothelial growth factor injection therapy complicated three of eight cases., Conclusion: Both APMPPE and PPM may develop in elderly individuals and may masquerade as age-related macular degeneration on presentation. Multimodal imaging including FA, indocyanine green angiography, and OCTA are important diagnostic modalities to assess for inner choroidal hypoperfusion to arrive at an accurate diagnosis and to detect macular neovascularization, which frequently complicates APMPPE and PPM. In these patients, serial anti-vascular endothelial growth factor intravitreal injections are essential in treating macular neovascularization and in preventing significant vision loss.

Purpose: To investigate the imaging and clinical features of polypoidal choroidal vasculopathy (PCV) with pulsation., Methods: The PCV eyes were classified into pulsatile and nonpulsatile PCV groups according to the pulsation on indocyanine green angiography. Imaging features including the dye filling time of the polyp and clinical features were compared., Results: A total of 75 eyes were classified into the pulsatile PCV (30 eyes) and the nonpulsatile PCV (45 eyes) groups. The initial filling time and complete filling time of the polyp of the pulsatile PCV group (2.59 ± 0.93 and 8.33 ± 3.42 seconds) were shorter than those of the nonpulsatile PCV group (4.11 ± 1.87 and 10.63 ± 3.81 seconds, P < 0.001 and P = 0.010, respectively). The pigment epithelial detachment height of the pulsatile PCV group (414.90 ± 377.15 µ m) was greater than that of the nonpulsatile PCV group (247.81 ± 164.07 µ m, P = 0.030). The pulsatile PCV group showed a higher prevalence of subretinal hemorrhage (43.33%) after intravitreal injection than the nonpulsatile PCV group (13.95%, P = 0.005) during 12 months. The mean number of injections during 12 months of the pulsatile PCV group (5.48 ± 1.46) was greater than that of the nonpulsatile PCV group (4.09 ± 1.21, P < 0.001)., Conclusion: Eyes with pulsatile PCV showed shorter filling time of the polyp, greater pigment epithelial detachment height, higher prevalence of subretinal hemorrhage, and more intravitreal injection numbers during 12 months. These might suggest that PCV has distinct imaging and clinical features according to the polyp pulsation.

Purpose: To explore the condition of fellow eyes of patients with macular neovascularization Type 3 (MNV3) and to verify whether the retinal-choroidal anastomosis (RCA) develops equally in all MNV types., Methods: The contralateral eyes of 94 patients with MNV3, 96 patients with MNV1, and 96 patients with MNV2 were included. Multimodal imaging was performed. The MNV3 stage including the development of fibrosis and RCA over 24 months was determined., Results: In the contralateral eyes of patients of the solitary (one lesion) MNV3 group, 32 eyes (42.1%) showed early/intermediate age-related macular degeneration, 25 eyes (33%) showed MNV3, and 11 eyes (14.5%) experienced fibrosis, of which 4 eyes (5.2%) had a RCA, 7 eyes (9.2%) had atrophy after resolved MNV3, and 1 eye (1.3%) developed MNV1. In the multifocal (more than one lesion) MNV3 group, 2 eyes (11.1%) showed early/intermediate age-related macular degeneration, 9 eyes (50%) showed 15 MNV3 lesions, and 4 eyes (22.2%) showed fibrosis, of which 2 eyes (11.1%) manifested with a RCA and 3 eyes (16.7%) showed atrophy after resolved MNV3. The number of eyes with a RCA accounted for 40% of all eyes with fibrosis. The count of simultaneous bilateral multifocal MNV3 was 5 (55.6%). In the MNV1 and MNV2 groups, no eye developed a RCA. The incidence of RCAs in the scarred eyes in MNV3 was significantly higher (P < 0.0001)., Conclusion: Retinal-choroidal anastomosis is an exclusive clinical feature of MNV3. The development of the multifocal MNV3 is usually bilateral and simultaneous. The occurrence of fibrosis in MNV3 has decreased dramatically after the introduction of the antiangiogenic therapy., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Opthalmic Communications Society, Inc.)

Purpose: To evaluate the mean change in visual acuity at 52 weeks in patients with idiopathic choroidal neovascularization treated with aflibercept., Methods: We conducted a prospective noncomparative open-label Phase-II trial. The dosage regimen evaluated in this study was structured into two periods: (1) from inclusion to 20 weeks: a treat-and-extend period composed of three mandatory intravitreal injections, and complementary intravitreal injections performed if needed; (2) from 21 weeks to 52 weeks: a pro re nata period composed of intravitreal injections performed only if needed., Results: A total of 19 patients were included, and 16 completed the 52-week study. At baseline, the mean best corrected visual acuity was 66.56 (±20.72) letters (≈20/50 Snellen equivalent), and the mean central retinal thickness was 376.74 µm (±93.77). At 52 weeks, the mean change in the best-corrected visual acuity was +19.50 (±19.36) letters [95% confidence interval = +9.18 to +29.82]. None of the patients included lost ≥15 letters at 24 weeks or 52 weeks. The mean change in central retinal thickness was -96.78 µm (±104.29) at 24 weeks and -86.22 µm (±112.27) at 52 weeks. The mean number of intravitreal injections was 5.4 (±3.0) at 52-weeks. No ocular serious adverse events related to the treatment were reported., Conclusion: The present analysis shows clinically significant functional and anatomical treatment effect of aflibercept in case of idiopathic choroidal neovascularization. The treat-and-extend regimen proposed after the first injection seems adequate to treat most neovessels.

Purpose: To analyze the nature of multiple evanescent white dot syndrome (MEWDS) and differentiate an idiopathic or primary form of MEWDS from a secondary form that is seen in association with other clinical conditions affecting the posterior segment of the eye., Methods: Clinical and multimodal imaging findings including color fundus photography, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, spectral-domain optical coherence tomography, and optical coherence tomography angiography of patients with secondary MEWDS are presented., Results: Twenty consecutive patients with secondary MEWDS were evaluated. Fifteen patients were female. Most were young adults aged between 20 to 40 years with myopia (less than -6 diopters). Pathologic conditions associated with the secondary MEWDS reaction were high myopia (greater than -6 diopters) in two eyes, previous vitreoretinal surgery for rhegmatogenous retinal detachment in 2 eyes, and manifestations of multifocal choroiditis in 18 eyes. In all eyes, the MEWDS lesions followed a course of progression and resolution independent from the underlying condition., Conclusion: Secondary MEWDS seems to be an epiphenomenon ("EpiMEWDS") that may be seen in association with clinical manifestations disruptive to the choriocapillaris-Bruch membrane-retinal pigment epithelium complex.

Purpose: To investigate the correlation between choroidal vascularity index and the enlargement of geographic atrophy (GA) lesion secondary to age-related macular degeneration during the 2-year follow-up., Methods: In this longitudinal observational study, 26 eyes (26 patients, mean age 75.7 ± 8.8 years) affected by GA were included. Choroidal vascularity index was calculated in the subfoveal 3000-µm area. The main outcome measure included correlation analysis between baseline choroidal vascularity index and the rate of GA enlargement., Results: During the 2-year follow-up, the mean GA area increased from 6.99 ± 5.28 mm2 to 10.69 ± 6.61 mm2(P < 0.001), accounting for a growth rate of 0.35 ± 0.20 and 0.31 ± 0.17 mm/year after the square root transformation in the first and second year of follow-up, respectively. Stromal choroidal area significantly decreased during the 2-year follow-up (P = 0.002). Interestingly, there was a significant correlation between the baseline choroidal vascularity index and the rate of GA enlargement (r=-0.432, P = 0.027) and between stromal choroidal area and the rate of GA enlargement (r = 0.422, P = 0.032). No other significant relationship was disclosed among choroidal parameters with the rate of GA enlargement., Conclusion: Choroidal vascularity index impairment is strictly related to the rate of GA enlargement during the 1-year and 2-year follow-up in patients affected by GA. For this reason, choroidal vascularity index could be considered a predictor of GA progression in the clinical setting, and it could be considered as a new potential biomarker in the efficacy evaluation of new GA interventions.

Purpose: To increase insight into the myopic presentation of central serous chorioretinopathy (CSC) by comparing a large group of myopic patients with CSC with reference groups with only one of the diagnoses., Methods: Myopic patients with CSC (spherical equivalent ≤-3D, n = 46), emmetropic patients with CSC (spherical equivalent -0.5 to 0.5 D, n = 83), and myopic, non-CSC patients (n = 50) were included in this multicenter cross-sectional study. Disease characteristics and imaging parameters, such as subfoveal choroidal thickness and indocyanine green angiography patterns, were compared between cases and reference groups., Results: In myopic patients with CSC, median subfoveal choroidal thickness (286 µm [IQR 226-372 µm]) was significantly thicker than subfoveal choroidal thickness in myopic, non-CSC patients (200 µm [IQR 152-228 µm], P < 0.001) but thinner than emmetropic patients with CSC (452 µm [IQR 342-538 µm], P < 0.001). They also had pachyvessels in 70% of the eyes comparable with emmetropic CSC (76%, P = 0.70). Choroidal hyperpermeability was frequently present on indocyanine green angiography in both myopic and emmetropic CSC eyes. Need for treatment, treatment success, and recurrence rate were not significantly different between CSC groups., Conclusion: Myopic CSC presents with similar imaging and clinical characteristics as emmetropic CSC, apart from their thinner choroids. Keeping in mind the structural changes of myopia, other imaging characteristics could aid the diagnostic process., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Opthalmic Communications Society, Inc.)

Purpose: To evaluate the regression of prechoroidal cleft, its influence on visual outcomes, and differences in visual outcomes between neovascular age-related macular degeneration and polypoidal choroidal vasculopathy., Methods: This retrospective study included 61 patients exhibiting prechoroidal cleft who were treated with antivascular endothelial growth factors. The patients were divided into two groups according to the following categories: 1) regression of prechoroidal cleft: regression group versus nonregression group and 2) type of neovascularization: neovascular age-related macular degeneration group versus polypoidal choroidal vasculopathy group. Changes in the visual acuity during the follow-up period were also compared between the two groups., Results: During the 52.4 ± 17.4-month follow-up period, regression of prechoroidal cleft was noted in 17 patients (27.9%) at a mean of 25.7 ± 18.3 months after the first identification. The degree of the logarithm of the minimum angle of resolution of visual deterioration was greater in the nonregression group (0.59 ± 0.56, n = 17) than that in the regression group (0.25 ± 0.61, n = 44) (P = 0.007) and in the neovascular age-related macular degeneration group (0.56 ± 0.61, n = 51) than that in the polypoidal choroidal vasculopathy group (0.18 ± 0.33, n = 10) (P = 0.034)., Conclusion: Approximately 27.9% of prechoroidal cleft cases eventually regressed, in conjunction with relatively favorable visual outcomes. Considering the poor visual prognosis in neovascular age-related macular degeneration accompanied by prechoroidal cleft, more caution is required for this condition.

Purpose: To determine structural predictors of treatment response in neovascular age-related macular degeneration analyzing optical coherence tomography (OCT)-related biomarkers., Methods: A retrospective review of patients undergoing treatment for neovascular age-related macular degeneration at a tertiary institute was performed at presentation. High-intensity regimen included eyes on long-term anti-vascular endothelial growth factor treatment with the inability to extend beyond a month without a relapse and needed double the dose of medication (n = 25). Low-intensity regimen had eyes that went into long-term remission after at least three injections and remained dry for more than a year until the last visit (n = 20). Multimodal imaging including fluorescein angiogram, OCT, and comprehensive ocular evaluation were done. Choroidal vascularity index, total choroidal area, luminal area, subfoveal choroidal thickness, choriocapillaris thickness and Haller and Sattler layer thickness were analyzed for statistical significance., Results: The groups had no significant difference at baseline in age, gender, incidence of reticular pseudodrusen, polypoidal choroidal vasculopathy feature on OCT, type of choroidal neovascular membrane, and geographic atrophy. Multinomial logistic regression revealed that thicker subfoveal choroidal thickness and larger total choroidal area were the significant predictors of poor response to anti-vascular endothelial growth factor treatment (E = 0.02; P = 0.02; E = 1.82; P = 0.0075)., Conclusion: Thicker subfoveal choroidal thickness and higher total choroidal area are useful variables to predict a poor treatment response.

Purpose: To compare the effects of half-dose photodynamic therapy (PDT) and high-density subthreshold micropulse laser on choroidal dysfunction evaluated by degree and extent of hyperfluorescence on indocyanine green angiography (ICGA) in chronic central serous chorioretinopathy., Methods: Data from the multicenter, randomized, controlled PLACE trial were used in this study. Hyperfluorescent and hypofluorescent areas on ICGA, their association with subretinal fluid and visual function were assessed., Results: In total, 146 patients were included (72 in the PDT and 74 in the high-density subthreshold micropulse laser treatment arm). A significantly greater decrease in the size of hyperfluorescent areas on ICGA at first visit after treatment was seen after PDT compared with high-density subthreshold micropulse laser (mean, -1.41 ± 2.40 mm2 vs. -0.04 ± 0.73 mm2, respectively; P < 0.001). A reduction in the degree of hyperfluorescence on ICGA decreased the odds of having persistent subretinal fluid on optical coherence tomography at first visit after treatment (B = 0.295; P = 0.019). There were no significant differences in best-corrected visual acuity and retinal sensitivity between the subgroup with novel hypofluorescence (n = 20, 28%) on ICGA at first visit post PDT, compared with the subgroup without novel hypofluorescence on ICGA after PDT., Conclusion: Choroidal abnormalities in chronic central serous chorioretinopathy can be effectively treated by ICGA-guided half-dose PDT but not with high-density subthreshold micropulse laser application.

Purpose: To describe the differential response of two distinct inflammatory signs occurring in eyes with punctate inner choroidopathy., Methods: Retrospective, observational case series using multimodal imaging., Results: Four eyes of 4 myopic female patients (mean age of 35 years, range 31-42 years) presenting with retinal manifestations of punctate inner choroidopathy. All study eyes had 2 distinct signs of active disease: 1) acute focal hyperreflective lesions splitting the retinal pigment epithelium/Bruch membrane complex on optical coherence tomography which appeared hypoautofluorescent on fundus autofluorescence and 2) more diffuse areas of outer retinal disruption limited to the ellipsoid zone and interdigitation zone on optical coherence tomography and corresponding to hyperautofluorescence on fundus autofluorescence. All patients were treated with oral prednisone and demonstrated prompt regression of the retinal pigment epithelium/Bruch membrane complex lesions with a concurrent, paradoxical centrifugal expansion of outer retinal disruption. The outer retinal disruption eventually resolved in all eyes (mean time of 6 weeks, range 4-10 weeks)., Conclusion: In patients with punctate inner choroidopathy, two distinct inflammatory signs observed with multimodal imaging display a differential response to systemic corticosteroids. Although focal inflammatory lesions splitting the retinal pigment epithelium/Bruch membrane complex seem to respond rapidly, the more diffuse, transient outer retinal disruption shows little response. This difference in treatment response may reflect different immunological phenomena with independent natural history.

Purpose: To analyze and describe serial follow-up of choriocapillaris alterations in tubercular serpiginouslike choroiditis (SLC) using optical coherence tomography angiography (OCTA) and to compare it with multimodal imaging., Methods: In this prospective cohort study, patients with active tubercular SLC underwent OCTA using Optovue RTVue XR Avanti and other imaging techniques including enhanced-depth imaging OCT (EDI-OCT) (Heidelberg Spectralis; Heidelberg Engineering, Heidelberg, Germany), fundus autofluorescence, fluorescein angiography, and indocyanine green angiography. Serial imaging was performed for a total follow-up of 3 months. Choriocapillaris alterations at the site of lesions were analyzed on OCTA imaging, and their mean lesion areas were calculated., Results: Twenty-six eyes (26 patients; 20 males; mean age: 32.68 ± 10.56 years) were included. Fourteen eyes had active multifocal lesions (n = 39), whereas 12 eyes had active placoid lesions (n = 12). At baseline, OCTA showed hyporeflective flow deficit lesions corresponding to the hypofluorescent lesions on indocyanine green angiography in all eyes. In the multifocal type of SLC, the mean lesion area decreased in all eyes compared with baseline, and lesions with a lesion area less than 0.1 mm2 on OCTA showed near-complete resolution with minimal choriocapillaris atrophy. In comparison, all eyes with a placoid type of SLC showed no significant reduction in the lesion area and showed extensive choriocapillaris atrophy., Conclusion: Optical coherence tomography angiography has the unique ability to demonstrate pathological flow impairment at the level of choriocapillaris in active tubercular SLC. Serial OCTA analysis reveals that large tubercular SLC lesions result in choriocapillaris atrophy as the lesions heal, whereas smaller multifocal lesions show resolution of choriocapillaris hypoperfusion with minimal atrophy.

Purpose: To describe retinal and choroidal vascular changes, and choroidal stroma variations occurring in focal choroidal excavation (FCE)., Methods: Study design was a cross-sectional case series. Consecutive patients affected by FCE and healthy controls were recruited. All patients underwent complete ophthalmologic assessment and multimodal imaging, including structural optical coherence tomography and optical coherence tomography angiography. Choroidal thickness and stromal index were calculated from structural optical coherence tomography images. Moreover, we measured vessel density values of the superficial capillary plexus, deep capillary plexus and choriocapillaris at the level of the macula., Results: Twenty-two patients (28 eyes; mean age 57.2 ± 16.4) and 28 control eyes (mean age of 56.5 ± 9.8) were included. Five patients (23%) were asymptomatic, whereas 17 patients (77%) complained of visual symptoms. FCE was associated with choroidal neovascularization in 10 eyes (35%). Choroidal stromal component was lower in FCE patients than controls, whereas choroidal thickness was unremarkable. Stromal index values calculated in the region proximal to the FCE was significantly lower than the values obtained from the external region. Deep capillary plexus vessel density was lower in FCE than controls. Choriocapillaris was altered in the region surrounding the FCE, whereas it was normal in the external region., Conclusion: Deep capillary plexus and choriocapillaris plexus were significantly altered in FCE patients. Moreover, choroidal stroma was significantly reduced in the areas closer to FCE compared to the surrounding choroid in patients, as well as compared to healthy controls, suggesting the hypothesis of weakening of the architectural support, creating a more friable point, which can favor FCE development.

Purpose: To examine the characteristics of polypoidal choroidal vasculopathy using B-scan optical coherence tomography angiography (OCTA), and determine the diagnostic criteria of polypoidal choroidal vasculopathy based on OCTA., Methods: This retrospective case series included patients diagnosed with treatment-naïve polypoidal choroidal vasculopathy who underwent indocyanine green angiography (ICGA) and swept-source OCTA at baseline. We compared the characteristics of the polyps detected using B-scan OCTA and ICGA. Then, the diagnostic concordance of each polypoidal lesion between ICGA and OCTA was evaluated., Results: Among 54 eyes of 52 patients, all 54 eyes showed flow signals indicating polyps on both ICGA and B-scan OCTA. All polyps on B-scan OCTA were detected as round/ring-like flow signals inside pigment epithelial detachments, incomplete round/ring-like flow signals overlaid with round/ring-like OCT structures inside pigment epithelial detachments, or flow signals adjacent to a pigment epithelial detachment notch. Using B-scan OCTA, 94.7% of the polypoidal lesions were detected by an independent evaluator with an overall accuracy of 92.6% for counting the polypoidal lesions per eye relative to ICGA and a Kappa value of 0.82., Conclusion: Polyp detection on B-scan OCTA demonstrates high accuracy and is comparable to that obtained on ICGA. B-scan OCTA could replace ICGA for the diagnosis of polypoidal choroidal vasculopathy.

Purpose: The aim of this study was to describe the fundus autofluorescence patterns in acute ocular toxoplasmosis (OT) and to correlate these findings with other imaging., Methods: A retrospective multicenter case series of 27 eyes from 27 patients with acute onset of posterior OT was conducted. Multimodal imaging including fundus autofluorescence was performed at diagnosis and during follow-up., Results: All OT lesions were hypoautofluorescent on fundus autofluorescence imaging. Fourteen patients (51.8%) also had hyperautofluorescent spots around the active foci that disappeared after retinal photobleaching. Although these spots were not seen on early phase of indocyanine green angiography, they become hypofluorescent in the late phase without choriocapillaris flow impairment on optical coherence tomography angiography. On B-scan spectral domain optical coherence tomography, spots corresponded to outer retinal alterations in all cases. All hyperautofluorescent spots disappeared during follow-up as acute OT resolved. Younger patients and those with more posterior inflammatory symptoms (vasculitis and/or papillitis) were more frequent with the presence of hyperautofluorescent spots., Conclusion: Ocular toxoplasmosis may trigger a transient outer retinal disruption in eyes with marked inflammatory symptoms of the younger patients.

Purpose: To determinate the variation in thickness of the individual choroidal layers in patients with central serous chorioretinopathy treated with half-fluence photodynamic therapy., Methods: Twenty-two eyes were evaluated with spectral-domain optical coherence tomography. The images were taken before photodynamic therapy, 3 months, and 6 months after the treatment. Two investigators performed these measurements: 1) choroidal thickness (CT), 2) Haller layer thickness, defined as the most external layer containing a 100-μm vessel, and 3) choriocapillaris + Sattler layer (C&S). Nine measurements were taken in the macular region., Results: Choroidal thickness before photodynamic therapy was 471.8 µm ± 145.8. The Haller layer was 358.4 µm ± 122.6, and C&S was 114.3 µm ± 27.8. At 3-month follow-up, CT was 441.1 µm ± 150.7, Haller layer 348.8 µm ± 127.6, and C&S 92.4 µm ± 27.9. At 6-month follow-up, CT was 420.4 µm ± 118.4, Haller layer 331.8 µm ± 97.2, and C&S 89.5 µm ± 28.0. Using a multilevel mixed-effects linear regression, CT was found to be reduced at both 3 months (P < 0.03) and at 6 months (P < 0.001), Haller layer showed no significant reduction at 3 months (P = 0.483) or at 6 months (P = 0.055), and C&S showed reduction at 3 months (P < 0.001) and at 6 months (P < 0.001). Fellow nonaffected eyes showed no statistical variation at 3-month and 6-month follow-up., Conclusion: Reduction in CT in patients affected by central serous chorioretinopathy after half-fluence photodynamic therapy occurs primarily in the choriocapillaris and medium diameter vessel layers of the choroid in a short- and medium-term follow-up.

Purpose: Choroidal neovascularization (CNV) is a common complication of patients affected by age-related macular degeneration, showing a highly variable visual outcome. The main aim of the study was, at baseline, to perform a quantitative optical coherence tomography angiography assessment of CNV secondary to age-related macular degeneration and to assess posttreatment outcomes., Methods: Seventy-eight naïve age-related macular degeneration-related CNV patients (39 men, mean age 78 ± 8 years) were recruited and underwent complete ophthalmologic evaluation and multimodal imaging. Several OCT and optical coherence tomography angiography parameters were collected, including vessel tortuosity and vessel dispersion (VDisp), measured for each segmented CNV. All patients underwent anti-vascular endothelial growth factor PRN treatment. Vessel tortuosity and VDisp values of CNVs were tested at baseline to establish a cutoff able to distinguish clinically different patient subgroups., Results: Mean best-corrected visual acuity was 0.49 ± 0.57 (20/62) at baseline, improving to 0.31 ± 0.29 (20/41) at the 1-year follow-up (P < 0.01), with a mean number of 6.4 ± 1.9 injections. Our cohort included the following CNV types: occult (45 eyes; 58%), classic (14 eyes; 18%), and mixed (19 eyes; 24%). Observing optical coherence tomography angiography parameters, classic, mixed, and occult CNV revealed significantly different values of VDisp, with classic forms showing the highest values and the occult CNVs showing the lowest (P < 0.01); mixed forms displayed intermediate VDisp values. The ROC analysis revealed that a CNV vessel tortuosity cut-off of 8.40, calculated at baseline, enabled two patient subgroups differing significantly in visual outcomes after anti-vascular endothelial growth factor treatment to be distinguished., Conclusion: A baseline quantitative optical coherence tomography angiography-based parameter could provide information regarding both clinical and functional outcomes after anti-vascular endothelial growth factor treatment in age-related macular degeneration-related CNV.

Purpose: To explore the regional distribution of macular neovascularization type 3 (MNV3)., Methods: Seventy-eight eyes of 78 patients were reviewed. We defined the location of each lesion after applying a modified ETDRS grid and the incidence of simultaneous MNV1 or 2. Also, we investigated the distribution of MNV3 at the outline of the foveal avascular zone and when the diameter of foveal avascular zone was less than 325 µm., Results: The distribution of MNV3 was 4 lesions (5%) from the center to 500 µm, 72 (92%) from 500 µm to 1500 µm, and 2 (3%) from 1,500 µm to 3000 µm. The distribution in respect of the ETDRS fields was 7 (9%) nasal, 16 (20%) superior, 32 (40%) temporal, and 23 (31%) inferior. No additional MNV1 or 2 were found elsewhere. Most lesions tended to distribute along straight bands radiating from the perifoveal area, mainly in the temporal half (72%). None of the cases had MNV3 at the boundary of the foveal avascular zone. Only five cases had foveal avascular zone diameter of less than 325 µm, the closest lesion was 425 µm away from the center., Conclusion: MNV3 lesions are most likely neither symmetrical nor uniformly distributed. They have a higher affinity to distribute radially in the temporal perifoveal area.

Purpose: In 2012, four patients with multiple asymptomatic, indolent, unilateral, choroidal lesions were described. We suspected benign-behaving lymphocytes infiltrating the choroid. This article expands the number of patients and duration of follow-up and speculates further on the etiology. Although histopathologic confirmation of these lesions is still unknown, the natural course of these patients is excellent and should be distinguished from aggressive choroidal lymphoma., Methods: To qualify for the study, the patients had to meet the following criteria: 1) Patients collected had asymptomatic choroidal infiltrates as demonstrated in the figures; 2) absence of vitreous cells; 3) no evidence of concomitant systemic malignancy; 4) no systemic inflammatory diseases, including sarcoidosis; 5) no birdshot chorioretinopathy; 6) no conjunctival or orbital lesions; and 7) advanced multimodal imaging and clinical follow-up were performed., Results: There were 11 eyes of 11 patients seen. Follow-up ranged from 4 months to 12 years and 1 month (mean 50.2 months; median 24 months). Systemic workup was unrevealing. No patients in this cohort developed systemic, conjunctival, orbital, or vitreoretinal lymphoma or inflammatory disease. No patients developed symptoms or vision loss., Conclusion: This entity is an indolent choroidal infiltrative disease. It resembles some cases of choroidal lymphoma and may represent an indolent lymphocytic infiltrate.

Purpose: To compare area measurements between swept source optical coherence tomography angiography (SSOCTA), fluorescein angiography (FA), and indocyanine green angiography (ICGA) after applying a novel deep-learning-assisted algorithm for accurate image registration., Methods: We applied an algorithm for the segmentation of blood vessels in FA, ICGA, and SSOCTA images of 24 eyes with treatment-naive neovascular age-related macular degeneration. We trained a model based on U-Net and Mask R-CNN for each imaging modality using vessel annotations and junctions to estimate scaling, translation, and rotation. For fine-tuning of the registration, vessels and the elastix framework were used. Area, perimeter, and circularity measurements were performed manually using ImageJ., Results: Choroidal neovascularization lesion size, perimeter, and circularity delineations showed no significant difference between SSOCTA and ICGA (all P > 0.05). Choroidal neovascularization area showed excellent correlation between SSOCTA and ICGA (r = 0.992) and a Bland-Altman bias of -0.10 ± 0.24 mm. There was no significant difference in foveal avascular zone size between SSOCTA and FA (P = 0.96) and an extremely small bias of 0.0004 ± 0.04 mm and excellent correlation (r = 0.933). Foveal avascular zone perimeter was not significantly different, but foveal avascular zone circularity was significantly different (P = 0.047), indicating that some small cavities or gaps may be missed leading to higher circularity values representing a more round-shaped foveal avascular zone in FA., Conclusion: We found no statistically significant differences between SSOCTA and FA and ICGA area measurements in patients with treatment-naive neovascular age-related macular degeneration after applying a deep-learning-assisted approach for image registration. These findings encourage a paradigm shift to using SSOCTA as a first-line diagnostic tool in neovascular age-related macular degeneration.

Purpose: To assess clinical characteristics and visual outcome in chronic central serous chorioretinopathy patients with posterior cystoid retinal degeneration (PCRD)., Methods: Patients' medical records were reviewed retrospectively in 62 cases (83 eyes, mean age = 59 years, 88% male). Data were collected at central serous chorioretinopathy diagnosis, at PCRD manifestation, and at final visit. All treatment modalities were reviewed. Main outcome measures were treatment efficacy in achieving PCRD resolution, and final best-corrected visual acuity., Results: In 63 eyes (76%), subretinal fluid was present at first PCRD manifestation, whereas fluorescein angiography showed active focal or diffuse leakage in 65 eyes (78%). Seventy-six eyes (81%) received treatment, and PCRD had resolved completely in 31 eyes (37%) at the final visit. Photodynamic therapy was most successful in achieving a complete PCRD resolution. Best-corrected visual acuity did not improve, even after complete PCRD resolution (mean baseline best corrected visual acuity = 69 ± 19, and mean final best corrected visual acuity = 67 ± 20 ETDRS letters [20/40 and 20/50 in Snellen equivalent respectively], P = 0.354)., Conclusion: Posterior cystoid retinal degeneration is a relatively common finding in chronic central serous chorioretinopathy, which is often accompanied by active subretinal fluid leakage. Treatment may be beneficial to stop the subretinal fluid leakage component, but is less likely to result in a complete PCRD resolution and/or a best-corrected visual acuity improvement.

Purpose: To evaluate the association between treatment response and quantitative morphological changes in choroidal neovascularization and outer choroidal vessels using optical coherence tomography angiography (OCTA) and en face OCT in neovascular age-related macular degeneration (nAMD)., Methods: We retrospectively analyzed 75 eyes of typical nAMD patients and 53 polypoidal choroidal vasculopathy eyes of 124 patients with OCTA performed at least 6 months after initial antivascular endothelial growth factor treatment. Quantitative parameters, including vessel area, vessel diameter, branch vessel length, fractal dimension, and lacunarity were analyzed based on en face images of the choroidal neovascularization and choroidal vessel in Haller's layer. Parameters associated with loss of logarithm of the minimum angle of resolution visual acuity with the basis of 0.3 and the treatment interval (good vs. poor responder based on 12 weeks) were analyzed. Analyses were conducted for "before OCTA" (initial visit to OCTA) and "after OCTA" (OCTA to 6 months post-OCTA)., Results: In typical nAMD, visual acuity loss before OCTA was associated with a higher SD of choroidal neovascularization diameter and lower choroidal fractal dimension. Visual acuity loss after OCTA in typical nAMD was associated with higher lacunarity of the choroid. Poor responders before OCTA were not associated with any factor. Poor responders after OCTA were associated with a lower SD of outer choroidal vessel diameter in typical nAMD. In polypoidal choroidal vasculopathy, no factor was associated with clinical outcomes in either period., Conclusion: Quantitative analyses of choroidal neovascularization on OCTA and choroidal vessels on en face OCT provide information about treatment response, including changes in visual acuity and treatment interval, in nAMD.

Purpose: To investigate the differences in natural course, intravitreal bevacizumab injection (IVB) responsiveness, and optical coherence tomography angiography findings according to the type of pigment epithelial detachment (PED) in patients with central serous chorioretinopathy (CSC)., Methods: A retrospective review of angiographically proven CSC patients was conducted. Pigment epithelium detachment was classified as flat irregular or focal. To identify the natural course of CSC, we had observed whether subretinal fluid was improved without any treatment until symptom duration was >3 months. When CSC symptom duration was >3 months, IVB injection was performed. Symptom duration, central subfield thickness, subfoveal choroidal thickness, presence of subretinal fluid, natural course, optical coherence tomography angiography findings, and IVB responsiveness were compared between the PED types., Results: One hundred eyes were included (64 flat irregular PED vs. 34 focal PED). Flat irregular PED had a longer symptom duration than focal PED (7.20 ± 11.52 vs. 3.69 ± 3.98 months, P = 0.03). In untreated cases, the rate of complete resolution of subretinal fluid was significantly lower in flat irregular PED than in focal PED (34.78% vs. 65.22%, P = 0.017). In contrast to the natural course, responsiveness to IVB was significantly better in flat irregular PED (72.41% vs. 31.58%, P = 0.005). Optical coherence tomography angiography revealed more CNV in flat irregular PED (42.90% vs. 10.00%, P = 0.014). Subfoveal choroidal thickness in flat irregular PED was significantly thicker., Conclusion: In CSC patients with flat irregular PED, the natural course was poor, but treatment response to IVB was favorable. Flat irregular PED patients showed longer symptom duration and thicker subfoveal choroidal thickness than those with focal PED. Optical coherence tomography angiography revealed more choroidal neovascularization in flat irregular PED. These findings suggest that CSC with flat irregular PED could be considered a form of pachychoroid neovasculopathy.

Purpose: To compare the appearance and frequency of detection of common features in eyes with polypoidal choroidal vasculopathy using multicolor imaging (MC) or color fundus photography (CFP)., Methods: Thirty-eight eyes with indocyanine green angiography-proven polypoidal choroidal vasculopathy, imaged with both MC and CFP, were graded by three independent retinal specialists. The presence of five prespecified pathological features (blood, exudation, polypoidal lesions, pigment epithelial detachments, and atrophy) was graded on each modality independently. Multimodal imaging including optical coherence tomography, fluorescein, and indocyanine green angiography was used as the gold standard., Results: Overall, there was no statistically significant difference in the ability of MC imaging compared with CFP in detecting the pathological features. Polypoidal lesions appear as small, dark green, round lesions which have higher contrast on MC compared with a nodular orange appearance seen on CFP. Polypoidal lesions can be identified noninvasively using both MC and CFP in about half of the cases., Conclusion: There are differences in the appearance of polypoidal choroidal vasculopathy-associated features on MC compared with CFP. Both modalities are comparable for the detection of pathological features in eyes with polypoidal choroidal vasculopathy. MC imaging may be considered as an alternative to CFP.

Purpose: To describe the clinical and multimodal imaging findings of a series of cases of serous macular detachment (SMD) caused by Best disease (BD) masquerading as neovascular age-related macular degeneration or central serous chorioretinopathy that were inappropriately treated with intravitreal anti-vascular endothelial growth factor or laser therapy. This study will also present data to support age-related progressive choroidal thickening in BD patients, which may play a role in the development of SMD in this population., Methods: Clinical examination and multimodal imaging findings, including color fundus photography, spectral-domain optical coherence tomography, fundus autofluorescence, fluorescein angiography, and optical coherence tomography-angiography, were reviewed and analyzed. Subfoveal choroidal thickness was also formally measured, and an age-related choroidal thickness analysis was performed and compared with a normal population., Results: Twenty-six eyes of 13 patients (5 women) were included. Median age was 44 years. Nine patients presented with a history of SMD and subretinal fluid recalcitrant to various therapies, including intravitreal anti-vascular endothelial growth factor injections and photodynamic therapy. Best disease was subsequently diagnosed genetically in six patients and by detailed family history in seven. Mean logarithm of the minimum angle of resolution best-corrected visual acuity for all 26 eyes at last follow-up was +0.36 (Snellen equivalent of 20/46). Subfoveal choroidal thickness positively correlated with age for our cohort, increasing linearly at a rate of 25.6 µm per decade (R = 0.64; P < 0.001). Choroidal neovascularization was identified in four eyes on optical coherence tomography angiography, but these eyes did not respond to anti-vascular endothelial growth factor treatment., Conclusion: The diagnosis of BD should be considered in patients presenting with SMD and recalcitrant subretinal fluid masquerading as neovascular age-related macular degeneration or chronic central serous chorioretinopathy to avoid unnecessary treatment procedures. The positive correlation of subfoveal choroidal thickness with age in BD patients may be a factor in the pathogenesis and development of SMD in this population. Recognizing the multimodal imaging features of SMD associated with BD, described in detail in this study, will guide practitioners to the accurate diagnosis of BD and reduce the risk of unnecessary intraocular procedures with potential complications.

Purpose: To study B-scan flow overlay and en face flow optical coherence tomography angiography (OCT-A) images of Type 3 neovascularization (NV) and to characterize a staging system for Type 3 NV based on the OCT-A findings., Methods: We retrospectively collected data on consecutive treatment-naive eyes with Type 3 NV. All eyes underwent fluorescein angiography, indocyanine green angiography, structural spectral domain OCT, and OCT-A (AngioPlex). Localization and extension of abnormal flows detected by B-scan flow overlay and en face OCT-A images were assessed., Results: Of 24 eyes of 22 patients with Type 3 NV, B-scan flow overlay images showed that 4.2% had telangiectatic flow in the deep retinal layer without outer plexiform layer disruption (Stage 1), 8.3% had downward intraretinal flow and subretinal flow without retinal pigment epithelium disruption (Stage 2), and 87.5% had downward flow and retinal pigment epithelium disruption (Stage 3). Of the Stage 3 eyes, 95.2% showed flow signal penetrating at the site of the retinal pigment epithelium disruption on the B-scan flow overlay images., Conclusion: We showed the characteristics of Type 3 NV using B-scan flow overlay and en face OCT-A images. B-scan flow overlay OCT-A images seem useful to improve the detection and accurate diagnosis of Type 3 NV.

Purpose: To describe the incidence, clinical features, and long-term outcomes of photodynamic therapy (PDT)-induced acute exudative maculopathy (PAEM) in patients who underwent PDT for various indications., Methods: This retrospective observational case series included all cases who developed massive serofibrinous macular exudation within a week after PDT. Medical records of patients with post-PDT exudative events were reviewed for relevant data and imaging abstraction including optical coherence tomography and indocyanine green angiography features and were subjected to analysis., Results: The incidence rate of PAEM was 4.52%, being noted in 8 eyes (out of 177 PDT sessions in 155 eyes) with a mean age of 70.25 ± 6.65 years. Pre-PDT factors commonly associated with PAEM included age ≥65 years (87.5%), clinical diagnosis of polypoidal choroidal vasculopathy (75%), spot size ≥3,500 µm (100%), best-corrected visual acuity of 20/40 or better (87.5%), low-fluence PDT (87.5%), and the first exposure to PDT (75%). Photodynamic therapy-induced acute exudative maculopathy was noted at a mean interval of 2.9 ± 1.7 days (2-7 days) after PDT. Photodynamic therapy-induced acute exudative maculopathy resulted in significant decrease in mean best-corrected visual acuity from logMAR 0.29 ± 0.21 (approximate Snellen equivalent 20/39) to logMAR 0.91 ± 0.37 (approximate Snellen equivalent 20/163) [P = 0.0018], and significant increase in mean central macular thickness from 228.1 ± 71.8 µm to 481.4 ± 154.8 µm (P = 0.0029). Photodynamic therapy-induced acute exudative maculopathy resolved to baseline or even better tomographic status at a mean interval of 4.6 ± 1.2 weeks, resulting in complete visual recovery compared with baseline. During mean follow-up of 77.8 ± 46.4 weeks after PDT, no activity was noted for a mean duration of 26.3 ± 42.5 weeks after resolution. At final visit, mean best-corrected visual acuity and central macular thickness was logMAR 0.49 ± 0.28 (approximate Snellen equivalent 20/62) and 153.6 ± 40.0 µm, respectively, with underlying pathology being stable in 50% of the eyes., Conclusion: Photodynamic therapy-induced acute exudative maculopathy is an uncommon complication with self-resolving course and favorable prognosis. Patients undergoing PDT should be warned of the possibility of PAEM. The factors frequently associated with PAEM include elderly age (>65 years), clinical diagnosis of polypoidal choroidal vasculopathy, larger spot size (≥3,500 µm), pre-PDT best-corrected visual acuity of 20/40 or better, low-fluence PDT, and the first exposure to PDT.

Purpose: To evaluate 5-year functional outcomes involving the inner retina after epiretinal membrane (ERM) surgery., Methods: The study eye (SE) and fellow eye (FE) of 20 patients undergoing ERM surgery were examined preoperatively and at 3, 12, 24, 36, 48, and 60 months postoperatively. Retinal nerve fiber layer and ganglion cell-inner plexiform layer (GC-IPL) thicknesses were analyzed using spectral domain optical coherence tomography. Humphrey visual field mean deviation, pattern SD, and qualitative changes were assessed and compared over time., Results: Mean GC-IPL thickness in SEs was less than that of FEs at all time points with progressive thinning in SEs after ERM surgery. There was significant thinning of the superotemporal GC-IPL in SEs as compared to FEs at 3 months and 60 months (P < 0.05). Humphrey visual field mean deviation was greater in SEs as compared to FEs but statistically significant only at 0, 12, and 24 months (P < 0.05). Pattern SD increased from baseline in SEs but remained near baseline in FEs., Conclusion: Surgical eyes after ERM surgery demonstrated progressive thinning of the GC-IPL and transient worsening trends in Humphrey visual field mean deviation and pattern SD as compared to controls after ERM surgery.

Purpose: To investigate genetic associations in white patients with acute central serous chorioretinopathy (aCSC) and to assess genetic differences between aCSC and chronic CSC (cCSC)., Methods: A total of 135 aCSC patients, 272 cCSC patients, and 1,385 control individuals were included. Eight single nucleotide polymorphisms were genotyped for ARMS2 (rs10490924), CFH (rs800292, rs1061170, rs1065489, rs1329428, rs2284664, rs3753394), and NR3C2 (rs2070951). Also, C4B gene copy numbers were analyzed., Results: Three single nucleotide polymorphisms in the CFH gene were significantly associated with aCSC: rs800292 (P = 0.003, odds ratio = 1.53 [95% confidence interval = 1.15-2.03]), rs1061170 (P = 0.002, odds ratio = 0.64 [95% confidence interval = 0.48-0.86]), and rs1329428 (P = 5.87 × 10, odds ratio = 1.83 [95% confidence interval = 1.40-2.38]). A significant difference was found in the distribution of C4B gene copy numbers in aCSC patients compared with controls (P = 0.0042). No differences could be found among the selected variants between aCSC and cCSC patients., Conclusion: Three variants in the CFH gene and copy number variations in C4B were found to be significantly associated with the risk of aCSC development. Despite the differences in clinical presentation, acute and chronic CSC may share a similar genetic predisposition based on our present analysis. Other genetic and/or nongenetic risk factors may be more influential in the differentiation toward an acute or a chronic phenotype of CSC.

Purpose: To describe the imaging features of choroidal melanoma using swept-source optical coherence tomography angiography (SS-OCT-A) and to evaluate its ability to display tumor intrinsic vasculature., Methods: Consecutive patients diagnosed with choroidal melanoma underwent a complete ophthalmic evaluation, including best-corrected visual acuity, color fundus photography, B-scan ultrasound, fluorescein angiography, indocyanine green angiography, and SS-OCT-A (PLEX Elite 9000; Carl Zeiss Meditec, Inc, Dublin, CA)., Results: Twenty-two eyes of 22 consecutive patients were included in the study; 11 cases (50%) were treatment naive. Three lesions (14%) were located at the macula, 14 (63%) between the macula and equator, and 5 (23%) between the equator and the ora serrata. The mean tumor base and thickness were, respectively, 10.3 mm (range 5-15 mm) and 4.3 mm (range 1.5-8.9 mm). Seventeen lesions (77%) were dome shaped, whereas 5 (23%) had a mushroom configuration. Thirteen lesions (59%) were pigmented, 5 (23%) partially pigmented, and 4 (18%) amelanotic. An exudative retinal detachment was documented in 13 eyes (59%). Fluorescein angiography and indocyanine green angiography were performed in 20 patients and disclosed intrinsic microvasculature of the tumor, respectively, in 4 (20%) and 20 (100%) cases. Swept-source optical coherence tomography angiography was performed in 22 eyes and detected microvasculature of choroidal melanoma in all cases. Specifically, intrinsic vasculature could be recognized in 14 eyes (64%) using the automated choroid segmentation, 16 eyes (73%) using the automated whole eye segmentation, and in 22 eyes (100%) with fine manual adjustments of segmentation lines., Conclusion: Swept-source optical coherence tomography angiography represents a valid imaging technique to evaluate patients affected by choroidal melanomas. In our series, SS-OCT-A disclosed the intrinsic microvasculature of the tumor in all cases despite their size, location, and history of previous treatments.

Purpose: To study optical coherence tomography angiography (OCTA) and multimodal imaging features of Type 1 inflammatory choroidal neovascularization (CNV) in tubercular serpiginous-like choroiditis and response to anti-vascular endothelial growth factor therapy., Methods: In this study, multimodal imaging was performed using OCTA, enhanced-depth imaging optical coherence tomography, fluorescein angiography, and indocyanine green angiography. Correlation of OCTA with other imaging modalities in the detection of CNV was performed. The changes in CNV configuration after anti-vascular endothelial growth factor therapy were assessed., Results: In this study, nine eyes (8 patients; 5 females; mean age: 32.5 ± 11.57 years) with diagnosis of tubercular serpiginous-like choroiditis were included. All the eyes had presence of low-lying pigment epithelial detachments on enhanced-depth imaging optical coherence tomography. Using OCTA, it was possible to detect Type 1 CNV in all eyes. Type 1 CNV networks comprised fine anastomotic network of vessels, some of which had a hairpin loop configuration. After anti-vascular endothelial growth factor therapy, there was a decrease in branching and anastomosis. The visual acuity significantly improved from 0.49 ± 0.26 (20/60 Snellen equivalent) at baseline to 0.26 ± 0.17 (20/36 Snellen equivalent) (P = 0.03) in all eyes., Conclusion: Type 1 CNV can occur among patients with tubercular serpiginous-like choroiditis, leading to significant visual loss even in the healed stages of the disease. Optical coherence tomography angiography can help in the detection of Type 1 CNV where conventional multimodal imaging, including fluorescein angiography and OCT, fails to make a definitive diagnosis and thereby guide the initiation of anti-vascular endothelial growth factor therapy.

Purpose: This work aimed to describe the morphology of pigment epithelial detachment (PED) using optical coherence tomography angiography and to investigate its potential to detect choroidal neovascularization in various types of PEDs., Methods: In this retrospective study, 53 patients diagnosed with PED after undergoing both optical coherence tomography angiography (AngioPlex, CIRRUS HD-OCT) and spectral domain optical coherence tomography (Spectralis SD-OCT) were included., Results: Among the 53 eyes, flat vascularized PED (vPED) affected 21 eyes (40%), peaked vPED affected 10 eyes (19%), serous PED affected 12 eyes (23%), drusenoid PED affected 6 eyes (11%), and 4 eyes (7%) had multiple PED subtypes. The main underlying etiologies were pachychoroid spectrum disorder (30.2%), wet age-related macular degeneration (28.3%), central serous chorioretinopathy (18.9%), dry age-related macular degeneration (11.3%), and polypoidal choroidal vasculopathy (11.3%). Optical coherence tomography angiography identified neovascularization in 29 (94%) of the vPED eyes, 2 (17%) of the serous PED eyes, and all 4 (100%) mixed PED eyes., Conclusion: Optical coherence tomography angiography successfully identified neovascularization in both vPEDs and PEDs previously considered to be nonneovascular. However, structural OCT and blood flow analysis should be combined to interpret PED-associated neovascularization accurately in the clinic.

Purpose: This study analyzes a subset of patients with peripapillary polypoidal choroidal vasculopathy (PCV) to determine whether quantifiable pachychoroid features colocalize with disease foci., Methods: Patients with PCV diagnosed by indocyanine green angiography were identified for the analysis of medical records and multimodal imaging and classified as having peripapillary or macular PCV. The ratio of Haller layer thickness to total choroidal thickness was calculated at the fovea and at the site of dilated Haller vessels that showed spatial correlation with the origin of neovascularization. Choroidal thickness was measured horizontally across the fovea and circumferentially around the temporal side of the disk to study its relationship to neovascularization., Results: Three hundred and fourteen eyes of 299 patients with PCV were identified, of which 17 eyes (5%) had peripapillary disease. Although eyes with peripapillary PCV exhibited thinner subfoveal choroids than those with macular PCV, at the extrafoveal disease foci, choroidal thickness, Haller's layer thickness, and its ratio to total choroidal thickness were relatively high., Conclusion: Quantitative indices of choroidal structure previously identified in macular PCV performed consistently when applied to a peripapillary PCV cohort, thus supporting the hypothesis that inner choroidal thinning and Haller vessel enlargement are mechanistically relevant to these related entities.

Purpose: To evaluate treatment of circumscribed choroidal hemangioma by hyperfractionated proton beam therapy protocol (20 gray relative biological effectiveness in 8 fractions) on tumor control, attachment of retina and visual function., Methods: Retrospective review of patients treated between January 2010 and April 2015 with at least 6 months of follow-up., Results: Forty-three patients with exudative and symptomatic circumscribed choroidal hemangioma were included. Before treatment, 41 (95%) presented an exudative retinal detachment, median visual acuity was 20/63 and median tumor thickness was 3.3 mm. Mean follow-up was 26 months (7-62). At last follow-up, all patients presented regression of ultrasound tumor thickness and 23/43 (53.5%) a totally flat scar. The mean time to achieve a flat scar was 20 months. Retina was reattached in all patients except one with 9 months of follow-up. Visual acuity was improved or stabilized in 37 patients (86%) and final median visual acuity was 20/25. No patient presented radiation maculopathy or papillopathy., Conclusion: Proton beam therapy with a dose of 20 gray relative biological effectiveness delivered in 8 fractions provides excellent anatomical and functional results and are comparable with those obtained with the same dose delivered in 4 fractions. Longer follow-up is required to determine the long-term radiation sequelae.

Purpose: To investigate the prevalence of a newly defined drusen type, pachydrusen, soft drusen, and subretinal drusenoid deposits in eyes with polypoidal choroidal vasculopathy and fellow eyes and the relationship between each drusen type and the choroidal thickness, vascular morphology, and hyperpermeability., Methods: The 169 eyes of 90 patients with polypoidal choroidal vasculopathy were retrospectively reviewed. The prevalence of each drusen type was evaluated using color fundus photography and optical coherence tomography. The choroidal thickness and presence of pachyvessels on optical coherence tomography and choroidal vascular hyperpermeability on indocyanine green angiography were compared among the drusen groups., Results: Pachydrusen, soft drusen, and subretinal drusenoid deposits were found in 49.3%, 12.3%, and 6.9% in polypoidal choroidal vasculopathy eyes. The mean subfoveal choroidal thickness of the pachydrusen, soft drusen, and subretinal drusenoid deposit groups was 403.1, 184.4, and 176.4 µm. The pachydrusen group showed significantly thicker choroid than the others. The choroidal hyperpermeability was noticed at 41.7%, 0%, and 0% and the pachyvessel was observed at 80.6%, 44.4%, and 40% in pachydrusen, soft drusen, and subretinal drusenoid deposit groups, respectively., Conclusion: In patients with polypoidal choroidal vasculopathy, pachydrusen was prevalent and associated with thicker choroid. Polypoidal choroidal vasculopathy with pachydrusen was highly associated with choroidal vascular hyperpremeability and pachyvessel morphology than other types of drusen.

Purpose: Using optical coherence tomographic angiography (OCT-angiography), we examined the vasculature of the choriocapillaris in patients with central serous chorioretinopathy (CSC)., Methods: The prospective observational clinical study included patients with CSC defined by painless loss of central visual acuity and presence of a serous macular detachment as visualized by spectral-domain OCT. All eyes underwent OCT-angiography. Subfoveal choroidal thickness and choriocapillaris width were measured., Results: The study included 26 eyes of 21 patients with a mean age of 47.0 ± 7.9 years (range: 34-65 years). All 26 eyes showed an image pattern of high signal intensity, and 21 eyes additionally demonstrated dilated capillaries in the OCT-angio images. The areas showing abnormalities in the OCT-angiography were congruent with leaking areas in fluorescein angiography or areas with hyperpermeability in indocyanine green angiography. Among 16 patients with unilateral CSC, 1 patient showed a high intensity pattern in the OCT-angiogram in the contralateral, clinically unaffected eye. Parallel to thicker choroidal thickness measurements in affected eyes as compared with contralateral unaffected eyes in unilateral CSC, OCT-angiography revealed significantly thicker choriocapillaris measurements in the affected eyes. Conventional fluorescein angiography did not demonstrate leakage in 14 of 18 eyes with clinically diagnosed CSC., Conclusion: Optical coherence tomographic angiography showed an image pattern of high signal intensity in all eyes with CSC and dilated vessels in the choriocapillaris in most eyes with clinically diagnosed CSC. The results indicate that OCT-angiography may become a noninvasive valuable tool for the diagnosis of CSC in particular and for the diagnosis of macular disorders in general.

Purpose: To determine the long-term effect of internal limiting membrane with associated epiretinal membrane (ERM) peeling versus single peeling alone in terms of best-corrected visual acuity and anatomical outcomes on spectral-domain optical coherence tomography., Methods: This retrospective comparative cohort study of patients who had follow-up of >1 year and underwent surgery for ERM by a single surgeon (S.C.) from January 1, 2008 to December 31, 2012 compared cases in which the internal limiting membrane was stained with brilliant blue G to facilitate double peeling (n = 42) and single peeling (n = 43) of the ERM alone for up to 3 years of follow-up. For continuous variables, an independent two-tailed t-test was performed. For binary variables, the Fisher's exact test was performed. Statistical significance was defined as P < 0.05., Results: Eighty-five of 142 patients fit the inclusion criteria. At the last follow-up, the single-peeling group were more likely to have ERM remaining in the central fovea postoperatively (P = 0.0020, becoming significant by postoperative Year 1, P = 0.022) and less likely to develop inner retinal dimpling (P = 0.000, becoming significant by postoperative Month 3, P = 0.015). At 3 years, central foveal thickness had decreased in the single-peeling group by -136.9 µm and by -84.1 μm in the double-peeling group, which was not significantly different (P = 0.08). Mean best-corrected visual acuity improved in both the groups at all time points. There was no statistically significant difference between the 2 groups at 3 years (P = 0.44; single-peeling group, 0.32 ± 0.42, Snellen 20/42; double-peeling group, 0.23 ± 0.27, Snellen 20/34)., Conclusion: Brilliant blue G-assisted internal limiting membrane peeling for ERM results in a more thorough removal of residual ERM around the paracentral fovea. However, there is no difference in long-term best-corrected visual acuity at 3 years and a greater likelihood of inner retinal dimpling.

Purpose: To evaluate the risk factors for retinal pigment epithelium (RPE) tears after intravitreal ranibizumab injections in neovascular age-related macular degeneration (nAMD) and to determine the efficacy of continued ranibizumab treatment after RPE tears., Methods: A total of 407 treatment-naïve eyes (377 patients) with nAMD were retrospectively included. All patients were treated with an initial series of 3 monthly loading injections, followed by further injections as required. Baseline characteristics and pigment epithelial detachment (PED) lesion features were evaluated as potential risk factors for RPE tear. The visual and anatomical outcomes after treatment during 12 months were also evaluated., Results: By 12 months, RPE tears developed in 32 eyes (7.9%). Pigment epithelial detachment height was associated with a higher risk of RPE tear (odds ratio [OR], 1.318; 95% confidence interval [CI], 1.217-2.031, P = 0.018). Fibrovascular PED compared with serous PED had a higher risk of developing tears (OR, 9.129; 95% CI, 6.228-32.124, P = 0.039), and typical nAMD (OR, 4.166; 95% CI, 2.030-14.913, P = 0.031) and retinal angiomatous proliferation (OR, 3.778; 95% CI, 2.185-9.277, P = 0.040) had a higher risk of developing tears compared with polypoidal choroidal vasculopathy. Mean best-corrected visual acuity (BCVA) of RPE tear patients showed no significant improvement after treatment at 12 months; however, patients with RPE tears without foveal involvement (19 eyes) showed significant BCVA improvement at 12 months (P = 0.034)., Conclusion: PED type and nAMD subtype are associated with the development of RPE tears after intravitreal ranibizumab injections. Continued ranibizumab therapy after RPE tear development can maintain visual acuity when the fovea is not involved.

Purpose: To detect choriocapillaris changes by enhanced depth imaging optical coherence tomography (EDI-OCT) in areas of choriocapillaris hypoperfusion visualized on indocyanine green angiography., Methods: Combined indocyanine green angiography and EDI-OCT from patients diagnosed with inflammatory choriocapillaris hypoperfusion were retrospectively analyzed. The EDI-OCTs were compared with indocyanine green angiography to detect choriocapillaris changes suggestive of choriocapillaris hypoperfusion in both active stage (AS) and inactive stage of the disease. The EDI-OCT was graded by two independent observers for choriocapillaris pattern (normal/altered) and reflectivity (hyper/hypo/isoreflective) changes. Manual measurements of choriocapillaris thickness were obtained. Interobserver agreement was assessed using Cohen's kappa, and differences in groups were assessed using McNemar's test., Results: Forty-two lesions from 11 eyes (8 patients, 3 males) were analyzed. Three patients (4 eyes, 17 lesions) were diagnosed with serpiginous choroiditis, and 5 patients (7 eyes, 25 lesions) were diagnosed with acute posterior multifocal placoid pigmented epitheliopathy. All the lesions demonstrated choriocapillaris hyporeflectivity on EDI-OCT during AS and isoreflectivity during inactive stage. The characteristic choriocapillaris dotted pattern was absent during AS. Choriocapillaris thickness at the sites of hypoperfusion was significantly higher during AS (63.07 ± 16.47 μm) than in inactive stage (22.92 ± 7.65 μm) (P < 0.001). Disruption of retinal pigment epithelium during AS was strongly associated with choriocapillaris atrophy during follow-up (P < 0.001)., Conclusion: The EDI-OCT shows characteristic choriocapillaris changes suggestive of choriocapillaris hypoperfusion that correlate with ischemia on indocyanine green angiography during both AS and inactive stage of the disease.

Purpose: To determine whether classical indocyanine green angiography lesions in patients with birdshot chorioretinitis can be used to monitor disease activity., Methods: A retrospective case series was performed on 26 eyes in 26 consecutive patients with birdshot chorioretinitis who had at least one indocyanine green angiography performed during disease activity and another during disease quiescence. Using Photoshop, the mean number, area, and area per spot on indocyanine green angiography were compared between disease activity and quiescence using a paired ratio test., Results: The mean total lesion number, area, and area per spot during disease activity were 75.27 spots, 24,525 pixels, and 364 pixels/spots, respectively. The mean total lesion number, area, and area per spot size during disease quiescence were 28.35 spots (P < 0.01), 7,411 pixels (P < 0.01), and 279 pixels/spot (P = 0.12), respectively., Conclusion: There was a statistically significant decrease in the mean total area and number of lesions between the time of disease activity and disease quiescence (P < 0.01). Our results suggest that indocyanine green angiography has a role not only in diagnosis but also in monitoring treatment effectiveness; lesions can be reversible with treatment and their reappearance may be an indicator of disease relapse.

Purpose: To describe changes in three-dimensional choroidal volume and thickness with full raster scans of enhanced depth imaging optical coherence tomography in patients with birdshot retinochoroidopathy., Methods: This prospective case series collected spectral domain optical coherence tomography images with the enhanced depth imaging technique from eight eyes of eight patients with birdshot retinochoroidopathy including four active patients (four eyes) and four quiet patients (four eyes). Fifty scans of each patient were manually segmented before automated built-in calibration software was used., Results: Of all active patients, there were no statistically significant differences in the total choroidal volume and mean central choroidal thickness between the active and inactive phase over 6 months of follow-up. Alterations in choroidal parameters were evident and consistent after amelioration of inflammation, whereas the retinal volume and thickness remained stable. Regarding the eight inactive eyes at 6 months, the mean total choroidal volume and mean central choroidal thickness were significantly less than historical controls (P = 0.03 and P < 0.001, respectively). Persistent suprachoroidal hyporeflective space in two patients was noted despite the fact that clinical inflammation completely subsided at 6 months., Conclusion: Choroidal volume and thickness changes were consistent with inflammation in patients with birdshot retinochoroidopathy. Patients with inactive birdshot retinochoroidopathy have significant reduction in choroidal volume and thickness than do normal patients.

Purpose: To investigate the clinical features and surgical outcomes in patients with epiretinal membrane-induced full-thickness macular holes (FTMHs)., Methods: Consecutive cases with epiretinal membrane-induced FTMH followed by a single surgeon were retrospectively reviewed (study group, 24 cases). The criteria of epiretinal membrane-induced FTMH selection were 1) documented lamellar macular hole before FTMH formation, 2) FTMH with lamellar hole-associated epiretinal proliferation at the hole edge, and 3) FTMH with wider inner opening and narrower base. Consecutively treated Stage 2 (Control A, 20 cases) and Stage 4 (Control B, 22 cases) MH patients served as controls. All patients were followed up for at least 12 months after treatment., Results: Patients in the study group were younger and had a higher rate of high myopia than Controls A and B. The average hole size (203.6 ± 104.9 μm) was similar to that in Control A group and smaller than that in Control B group; the postoperative visual improvement (2-3 lines in Early Treatment Diabetic Retinopathy Study) was lower than that in Control A and B groups. Similar results were found when excluding high myopia cases from the study group., Conclusion: Epiretinal membrane-induced FTMH has distinct features from the typical Stage 2 or 4 FTMH. Despite the small size, visual improvement is not as good as that in Stage 2 FTMH.

Purpose: To investigate subfoveal choroidal thickness and subanalyze Haller and Sattler layers in eyes with central serous chorioretinopathy (CSC), uninvolved fellow eyes, and eyes of healthy controls using enhanced depth imaging optical coherence tomography., Methods: Ocular findings and clinical features of 31 eyes with CSC, 24 fellow eyes and eyes of 30 healthy controls were analyzed retrospectively from October, 2014 to March, 2015. Subfoveal choroidal thickness was measured using enhanced depth imaging optical coherence tomography, and the thicknesses of Haller and Sattler layers were analyzed., Results: Mean subfoveal choroidal thickness and mean thickness of Haller layer were significantly greater in CSC than in fellow eyes (P = 0.043 and P = 0.036, respectively) and in normal control eyes (P < 0.001 each), and those of fellow eyes in CSC patients were significantly thicker than those in normal control eyes (P = 0.018 and P = 0.017, respectively). The thickness of Sattler layer did not differ significantly among these groups (P = 0.519)., Conclusion: Subfoveal choroidal thickness and the thickness of Haller layer were increased not only in affected but also in uninvolved fellow eyes of CSC patients. Nonvascular smooth muscle cells of the choroid may play a role in the pathophysiology of CSC, in response to increased sympathetic tone.