Macular Choroidal Thickness and Volume in Eyes With  Angioid Streaks Measured by Swept Source Optical               Cohere...
tions, in most of these studies the choroidal thickness was         CNV (Group 2), eyes with CNV secondary to angioidmeasu...
TABLE 1. Characteristics of Eyes and Mean Choroidal Thickness and Volume Obtained by Swept Source Optical                 ...
Macular Choroidal Thickness and Volume in Eyes With Angioid Streaks Measured by Swept Source OCT
Macular Choroidal Thickness and Volume in Eyes With Angioid Streaks Measured by Swept Source OCT
Macular Choroidal Thickness and Volume in Eyes With Angioid Streaks Measured by Swept Source OCT
Macular Choroidal Thickness and Volume in Eyes With Angioid Streaks Measured by Swept Source OCT
Macular Choroidal Thickness and Volume in Eyes With Angioid Streaks Measured by Swept Source OCT
Macular Choroidal Thickness and Volume in Eyes With Angioid Streaks Measured by Swept Source OCT
Macular Choroidal Thickness and Volume in Eyes With Angioid Streaks Measured by Swept Source OCT
Macular Choroidal Thickness and Volume in Eyes With Angioid Streaks Measured by Swept Source OCT
Macular Choroidal Thickness and Volume in Eyes With Angioid Streaks Measured by Swept Source OCT
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Macular Choroidal Thickness and Volume in Eyes With Angioid Streaks Measured by Swept Source OCT

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Macular Choroidal Thickness
Angioid Streaks Measured
Swept Source
Optical coherence tomography

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Macular Choroidal Thickness and Volume in Eyes With Angioid Streaks Measured by Swept Source OCT

  1. 1. Macular Choroidal Thickness and Volume in Eyes With Angioid Streaks Measured by Swept Source Optical Coherence Tomography ABDALLAH A. ELLABBAN, AKITAKA TSUJIKAWA, AKIKO MATSUMOTO, KEN OGINO, MASANORI HANGAI, SOTARO OOTO, KENJI YAMASHIRO, MASAHIRO AKIBA, AND NAGAHISA YOSHIMURA P● PURPOSE: To study the mean choroidal thickness and SEUDOXANTHOMA ELASTICUM IS A RARE MULTISYS-volume of the macula in eyes with angioid streaks using tem disorder associated with a mutation in theswept source optical coherence tomography (OCT) in ABCC6 gene.1 Pseudoxanthoma elasticum causesthe 1050-nm wavelength range. progressive fragmentation and calcification of elastic fibers● DESIGN: Prospective case series. in connective tissue, resulting in pathologic changes that● METHODS: The macular area of 39 eyes of 23 patients are most pronounced in the dermis, blood vessels, andwith angioid streaks and of 20 normal eyes of 20 matched Bruch membrane.2 Characteristic fundus changes of pseu-controls (Group 1) was studied with a swept source OCT doxanthoma elasticum are peau d’orange, areas of chori-prototype system. Eyes with angioid streaks were classi- oretinal atrophy, and angioid streaks.3,4 Angioid streaksfied into 1 of 4 groups: those without choroidal neovas- are irregular crack-like dehiscences in the Bruch mem-cularization (CNV) (Group 2); those with CNV that brane that often allow the ingrowth of choroidal neovas-had no history of treatment (Group 3); those with CNV cularization (CNV) through Bruch membrane defects.3,4that had previously received only anti–vascular endothe- CNV secondary to angioid streaks occurs in 72% to 86% oflial growth factor treatments (Group 4); and those with eyes, is bilateral in more than 70% of cases, and oftenCNV that had previously received photodynamic therapy occurs at a younger age than does the CNV of age-related(Group 5). Using a raster scan protocol with 512 ؋ 128 macular degeneration (AMD). Because CNV secondary toA-scans, we produced a macular choroidal thickness map angioid streaks is often refractory to treatment, it leads in(6 ؋ 6 mm2). many cases to poor vision if the CNV involves the macular● RESULTS: There were no significant differences in age, area.5–9axial length, or refractive error among the 5 groups. Recently, the choroid, which is a structure with one ofMean choroidal thickness of the macula in Group 2 the highest blood flows in the body,10 has been reported to(218.9 ؎ 46.8 ␮m) was as great as that in Group 1 be involved in the pathogenesis of various ocular diseases,(218.8 ؎ 69.2 ␮m). However, the macular choroidal including AMD,11 polypoidal choroidal vasculopathy,12thickness in Group 3 (119.7 ؎ 49.2 ␮m), Group 4 central serous chorioretinopathy,13 Vogt-Koyanagi-Harada(140.1 ؎ 64.9 ␮m), and Group 5 (144.0 ؎ 52.6 ␮m) disease,14 and myopic chorioretinal degeneration.15 Inwas significantly less than that of Group 1 (P < .05). angioid streaks, although the Bruch membrane is thoughtThere were no statistical differences between Groups 3 to be most affected, previous reports have suggested thatthrough 5. In each group, the choroid of the nasal the choroid is also involved in the pathogenesis of CNV.3,4quadrant was significantly thinner compared to that in Today, optical coherence tomography (OCT) is used toother quadrants (P < .05).● CONCLUSIONS: The choroid in eyes with angioid measure retinal thickness and to detect morphologic changes in various retinal diseases. However, commerciallystreaks without CNV was as thick as that in normal available OCT equipment visualizes the entire choroidcontrols, but was significantly thinner in eyes with only in eyes with high myopia because of low penetrationangioid streaks that had developed CNV. (Am J Oph-thalmol 2012;153:1133–1143. © 2012 by Elsevier Inc. and high backscattering at the level of the retinal pigmentAll rights reserved.) epithelium (RPE).16,17 So, to date, little in vivo informa- tion is available on the choroidal changes associated with Supplemental Material available at AJO.com. angioid streaks.Accepted for publication Dec 29, 2011. Since Spaide and associates16 introduced enhanced From the Department of Ophthalmology and Visual Sciences, KyotoUniversity Graduate School of Medicine, Kyoto, Japan (A.A.E., A.T., depth imaging OCT based on spectral-domain OCT tech-A.M., K.O., M.H., S.O., K.Y., N.Y.); and Topcon Corporation, Tokyo, nology, many investigators have studied the choroidalJapan (A.M., M.A.). thickness in eyes with various pathologies.11,14,15,18 –25 Inquiries to Akitaka Tsujikawa, Department of Ophthalmology andVisual Sciences, Kyoto University Graduate School of Medicine, Sakyo- Although normal choroidal thickness in the macula variesku, Kyoto 606-8507, Japan; e-mail: tujikawa@kuhp.kyoto-u.ac.jp with region and can vary even more in pathologic condi-0002-9394/$36.00 © 2012 BY ELSEVIER INC. ALL RIGHTS RESERVED. 1133doi:10.1016/j.ajo.2011.12.013
  2. 2. tions, in most of these studies the choroidal thickness was CNV (Group 2), eyes with CNV secondary to angioidmeasured at the foveal center or, sometimes, at several streaks that had no history of treatments (Group 3), eyesmeasurement points.11,14,15,18 –25 This is because enhanced with CNV secondary to angioid streaks that had previouslydepth imaging requires the averaging of 50 to 100 B-scans received only anti–vascular endothelial growth factorof an identical location of interest,16 hindering us from (VEGF) treatments with no history of photodynamichigh-density scanning. With the advances in OCT tech- therapy (PDT) (Group 4), and eyes with CNV secondarynology, the recent generation has used swept source laser to angioid streaks that did have a history of PDT (Grouptechnology, which has the advantage of a high-speed 5). Data obtained from the 4 groups with angioid streaksscanning rate and low-sensitivity roll-off vs depth com- were compared with data obtained from 20 healthy eyespared to spectral-domain OCT.26 –34 With the use of a (20 subjects) of controls, matched for age, axial length,light source at the 1-␮m wavelength region, swept source and refractive error (Group 1).36 Exclusion criteria forOCT allows for a high-contrast, high-penetration image of these 20 controls included history or evidence of chori-the entire choroid. Based on these advantages, swept oretinal or vitreoretinal diseases, including AMD, diabeticsource OCT at a longer wavelength allows us to obtain a retinopathy, central serous chorioretinopathy, epiretinal3-dimensional (3D) high-contrast image of the choroid. membrane, and macular dystrophy, or a history of intraoc- In the study described herein, we scanned the macular ular surgery. Subjects with systemic diseases or conditionsarea of eyes with angioid streaks associated with pseudo- that might affect retinal or choroidal thickness were alsoxanthoma elasticum using swept source OCT at 1050 nm excluded.with a 3D raster scan protocol, and produced a choroidalthickness map of the macular area. By applying the grid ● SWEPT SOURCE OCT SYSTEM AND SCAN PROTOCOLS:used by the Early Treatment Diabetic Retinopathy Study The prototype swept source OCT system (Topcon Corp)(ETDRS) to this map, the mean choroidal thickness and used in the current study has been reported previously.36 Involume in each sector was measured and compared with brief, this swept source OCT system uses a light source ofthose of normal subjects. a wavelength-sweeping laser centered at 1050 nm with 100 000-Hz repetition rate. Axial and transverse resolutions were 8 ␮m and 20 ␮m in tissue, respectively. Swept source PATIENTS AND METHODS OCT imaging operated at the 1-␮m wavelength region was conducted at ϳ1 mW on the cornea, which is well belowTHIS PROSPECTIVE STUDY CONSISTED OF 39 EYES OF 23 the safe retinal exposure limit established by the Americanpatients with angioid streaks secondary to pseudoxan- National Standards Institute.thoma elasticum. The macular area of these 39 eyes was Swept source OCT examinations of the eligible subjectsexamined with a swept source OCT prototype system at were performed by trained examiners after pupil dilation.Kyoto University Hospital between September 2010 and A 3D imaging data set was acquired on each subject byNovember 2011. The diagnosis of pseudoxanthoma elasti- using a raster scan protocol of 512 (horizontal) ϫ 128cum was based on systemic manifestations, fundus exami- (vertical) A-scans per data set (total 65 536 axial scans/nation, and fluorescein angiography,35 and the diagnosis data set) in 0.8 seconds. Each 3D raster scan covered a 6 ϫwas confirmed by characteristic histopathologic abnormal- 6-mm2 area centered on the fovea, which was confirmed byities in a skin biopsy. internal fixation and by a fundus camera built into the All subjects underwent a thorough ocular examination, swept source OCT system. To reduce speckle noise, eachincluding autorefractometry (ARK1; Nidek, Gamagori, Ja- image was enhanced by weighted moving average of 3pan), best-corrected visual acuity measurement with a 5-me- consecutive original images.ter Landolt chart, axial length measurement using ocular In each subject, 50 averaged horizontal and vertical scanbiometry (IOLMaster; Carl Zeiss Meditec, Jena, Germany), images in 12-mm transverse scan length were obtained asslit-lamp examination, intraocular pressure measurement, well. The 50 single images, where each image consisted ofdilated color fundus photography (TRC50LX; Topcon 1024 A-scans, were registered and averaged by software toCorp, Tokyo, Japan), and prototype swept source OCT create an averaged single image. The vertical scan wasexamination. All eyes with angioid streaks underwent centered on the fovea while the horizontal scan wassimultaneous fluorescein angiography and indocyanine centered on the midpoint between the fovea and opticgreen angiography using Spectralis HRAϩOCT (Heidel- disc.berg Engineering, Heidelberg, Germany). Eyes with poorimages attributable to opaque media (eg, cataracts or ● CHOROIDAL THICKNESS AND VOLUME MEASURE-vitreous hemorrhage) or to unstable fixation were excluded MENT PROTOCOL: The choroidal thickness was measuredfrom the study. as the distance between the outer border of the RPE and Eligible eyes with angioid streaks were classified into 4 the chorioscleral border. In areas where the RPE wasgroups based on the presence of CNV and the previous defective, the Bruch membrane was considered as an innertreatment of the CNV: eyes with angioid streaks without border of the choroid. In each image of the 3D data set,1134 AMERICAN JOURNAL OF OPHTHALMOLOGY JUNE 2012
  3. 3. TABLE 1. Characteristics of Eyes and Mean Choroidal Thickness and Volume Obtained by Swept Source Optical Coherence Tomography Group 3 Group 4 AS With CNV and AS With CNV and a Group 5 Group 1 Group 2 No History of History of Only AS With CNV and a Normal Eyes AS Without CNV Treatment Anti-VEGF Treatments History of PDT P Value Number of eyes 20 6 7 11 15 Sex (male/female) 10/10 4/2 4/3 8/3 8/7 Age (years) 67.4 Ϯ 13.2 66.0 Ϯ 6.8 65.1 Ϯ 7.1 65.6 Ϯ 7.8 66.7 Ϯ 9.9 .960 Axial length (mm) 23.5 Ϯ 1.3 23.3 Ϯ 1.0 23.6 Ϯ 1.1 23.9 Ϯ 1.5 23.4 Ϯ 1.8 .949 Refractive error (diopters) Ϫ0.51 Ϯ 2.96 0.01 Ϯ 1.02 0.11 Ϯ 1.93 Ϫ1.38 Ϯ 2.50 Ϫ2.20 Ϯ 1.90 .134 Visual acuity (logMAR) 0.01 Ϯ 0.21 Ϫ0.14 Ϯ 0.05 1.02 Ϯ 0.32a 0.45 Ϯ 0.61a 0.80 Ϯ 0.45a Ͻ.001 Foveal retinal thickness (␮m) 204.4 Ϯ 35.5 194.0 Ϯ 12.6 260.3 Ϯ 119.5 209.9 Ϯ 97.8 154.4 Ϯ 64.3 .027 Foveal choroidal thickness (␮m) 254.8 Ϯ 76.0 244.7 Ϯ 51.0 142.0 Ϯ 67.9a 144.0 Ϯ 79.8a 124.8 Ϯ 54.2a Ͻ.001 Mean choroidal thickness within a 238.7 Ϯ 75.0 239.0 Ϯ 45.4 117.4 Ϯ 55.9a 144.1 Ϯ 69.8a 130.5 Ϯ 52.8a Ͻ.001 circle of 1.0-mm diameter (␮m) Mean choroidal thickness within a 233.0 Ϯ 72.4 232.7 Ϯ 49.7 116.5 Ϯ 52.4a 139.0 Ϯ 68.9a 137.7 Ϯ 57.6a Ͻ.001 circle of 3.0-mm diameter (␮m) Mean choroidal thickness within a 218.8 Ϯ 69.2 218.9 Ϯ 46.8 119.7 Ϯ 49.2a 140.1 Ϯ 64.9b 144.0 Ϯ 52.6b Ͻ.001 circle of 6.0-mm diameter (␮m) Choroidal volume within a circle of 0.187 Ϯ 0.059 0.188 Ϯ 0.036 0.092 Ϯ 0.044a 0.113 Ϯ 0.056a 0.102 Ϯ 0.041a Ͻ.001 1.0-mm diameter (mm3) Choroidal volume within a circle of 1.646 Ϯ 0.512 1.644 Ϯ 0.351 0.823 Ϯ 0.370a 0.982 Ϯ 0.487a 0.973 Ϯ 0.407a Ͻ.001 3.0-mm diameter (mm3) Choroidal volume within a circle of 6.183 Ϯ 1.957 6.185 Ϯ 1.323 3.381 Ϯ 1.389a 3.959 Ϯ 1.853b 4.070 Ϯ 1.487b Ͻ.001 6.0-mm diameter (mm3) CNV (active/inactive) — — 4/3 5/6 1/14 Treatment Number of anti-VEGF treatments 0 0 0 3.4 Ϯ 2.1 3.1 Ϯ 3.9 Number of PDT treatments 0 0 0 0 2.9 Ϯ 1.9 AS ϭ angioid streaks; CNV ϭ choroidal neovascularization; logMAR ϭ logarithm of minimal angle of resolution; PDT ϭ photodynamic therapy; VEGF ϭ vascular endothelial growth factor. a P Ͻ .01, compared with Group 1. b P Ͻ .05, compared with Group 1.FIGURE 1. Images of a healthy subject obtained with swept source optical coherence tomography (OCT) at 1050 nm. (Left) A multi-averagedhorizontal OCT image of 12 mm in length was obtained by averaging 50 images, which consisted of 1024 A-scans. Fine structure from the innerlimiting membrane to the chorioscleral border is seen clearly beyond the vascular arcade. Regional changes in choroidal thickness are seen.(Middle and Right) In a raster scan protocol, 128 consecutive images, consisting of 512 A-scans, were obtained. To reduce speckle noise, eachimage was enhanced by weighted moving average of 3 consecutive original images. (Middle) Single OCT image acquired with a raster scanprotocol without weighted moving average. (Right) Single OCT image acquired with a raster scan protocol with weighted moving average.lines of both RPE and the chorioscleral border were mined the distance between these 2 lines. The measure-determined manually by a trained observer in a masked ment points per image consisted of 512 points with anfashion. Automated built-in calibration software deter- interval of ϳ12 ␮m. From the 128 images of each 3D dataVOL. 153, NO. 6 MACULAR CHOROIDAL THICKNESS IN ANGIOID STREAKS 1135

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