Multimodal imaging in uveitis

1. MULTIMODAL
IMAGING IN
UVEITIS
P R E S E N T E R : D R . I D D I N D YA B AW E
M O D U L ATO R : D R . L U S O BYA R E B E C C A

2. COMMON IMAGING MODALITIES
• Colour fundus photography
• Angiography
• Fundus autoflorescence
• OCT and OCT-A

3. COLOUR FUNDUS IMAGING
• Documentation of visible disease
• Fast and non-invasive
• Each FOV has cons and pros: 30 deg, 50 deg
• SFBF photography:
Pros: cheap: iPhone 4 irradiance, 10X Keeler indirect; accessible… teaching, ROP, DR,
Remote locations
Cons: Narrow FOV, Confidentiality

4. QUANTITATIVE ANALYSIS OF COLOR
IMAGES IN UVEITIS
• In clinical trials: disease present vs absent; active vs quiescent
• In clinic: rarely quantitative, proxy for clinical documentation, huge data sets

5. DYE BASED ANGIOGRAPHY
• FLUORESCEIN ANGIOGRAPHY (FA)
• Evaluation of perfusion and blood ocular barrier: retinal vasculitis, retinochoroiditis,
papillitis, macular edema; neovascularization and non-perfusion
• Essential in posterior and panuveitis: extent of dz, activity,response to treatment,
complications
• Important in intermediate uveitis
• INDOCYANINE GREEN ANGIOGRAPHY (ICGA)
• Perfusion and inflammation:
-Pathology in the choriocapillaris and choroid
-Ischemia vs inflammatory blockage
• Adjunctive vs essential depending on diagnosis
• ICGA can detect subclinical dz in BSCR

6. GOALS OF REPLACING INVASIVE
ANGIOGRAPHY WITH OCT-A
• Retinal perfusion present
• Choriocapillaris perfusion present
• Choroidal stroma inflammation (present or absent)
• Fluorescein leakage absent

7. MULTIMODAL IMAGING TO IDENTIFY
THE LESION
• Dye-based angiography
-En-face view; but limited depth information
-OCT: Depth information, but anatomic relationships lost
• Solution:
Enface OCT:
• Depth information and anatomic relationships

8. FUNDUS AUTOFLUORESCENCE
• Many autofluorescence substances in the eye.
• Primary evaluation of lipofuscin in the eye.
• Increased lipofuscin means increased autofluorescence
• Hyper AF: sick RPE or degenerating PR
• Hypo-AF: dead RPE or blockage from the retina

9. MULTIPLE EVANESCENT WHITE DOTS
(MEWDS)
• Multimodal: spots and dots
• FA: Dye and leakage in ‘spots’
• FAF: Hyper-autofluorescence in the ‘spots’
• Flow: ICGA and SD-OCTA
• No flow abnormalities
• ‘Photoreceptor-tis’ causes ICGA blocking

10. MULTIFOCAL CHOROIDITIS (MFC) AND
PUNCTATE INNER CHOROIDOPATHY (PIC)
• Structural OCT:
• Active lesions:
-sub-RPE Hyper reflective material
-dehiscence of RPE
-Outer Retinal Hyperreflectivity
-Choroidal hyperreflectivity (increased
signal transmission)
• Quiescent lesions
-Resolved sub-RPE material
+/- flattening of RPE
Irregularity of outer retinal bands

11. MULTIMODAL IMAGING
• New lesions:
-Hypopigmented
-Domed/volcano lesion on OCT
-Hypo-AF
-FA Hyperfluorescence, ICGA
Hypocyanescence
-CNVM is a confounder
• Older lesions
-Hypo-AF
-Window defect on FA, ICGA
hypocyanescence
Combined disease activity; e.g mixed
PIC and MEWDS

12. ACUTE MULTIFOCAL PLACOID
PIGMENT EPITHELIOPATHY
• STRUCTURAL OCT
• Acute lesions:
• Hyperreflexivity ONL and ONL
• Elipsoid layer disruption
• RPE irregularity
• Subretinal fluid
• MULTIMODAL IMAGING
• Insult to the choriocapillaris
• 2nd RPE/Photoreceptor injury: Hypo-
AF, from PR edema
• +/- choriocapillris recovery:
+/- PR/RPE recovery: retinal thinning,
Hypo-AF from RPE damage

13. SERPIGINOUS CHORIORETINITIS
• Multimodal imaging:
• Active
• FA leakage, ICGA, Hypocyanescence
• Distint CC flow deficits
• Hyper-AF
• Outer retinal hyperreflectivity/loss
• Quiescent
• RPE and outer retinal atrophy
• Hypo-AF
• FA rim of hypofluorescence
• Permanent CC flow deficits on ICGA
and OCTA

14. MULTIMODAL IMAGING TO LOCALIZE
THE LESION: SUMMARY
• MEWDS: Photoreceptor/RPE
• CNVM: Subretinal/sub-RPE
• MCP/PIC: Outer retinal/RPE/CC
• AMPPE + Serpiginous: choriocapillaris
• Birdshot: located in the deeper stroma