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Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 204-205

Rapid evolution of an inflammatory choroidal neovascularization: Predictors of progression on swept-source optical coherence tomography angiography


Advanced Eye Center, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Date of Submission27-Jun-2020
Date of Acceptance24-Sep-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Dr. Vishali Gupta
Advanced Eye Center, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2046_20

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  Abstract 


Keywords: Choroidal neovascularization, i-CNV, OCT, optical coherence tomography angiography, swept-source, syphilis


How to cite this article:
Agarwal A, Arora A, Aggarwal K, Gupta V. Rapid evolution of an inflammatory choroidal neovascularization: Predictors of progression on swept-source optical coherence tomography angiography. Indian J Ophthalmol Case Rep 2021;1:204-5

How to cite this URL:
Agarwal A, Arora A, Aggarwal K, Gupta V. Rapid evolution of an inflammatory choroidal neovascularization: Predictors of progression on swept-source optical coherence tomography angiography. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jun 14];1:204-5. Available from: https://www.ijoreports.in/text.asp?2021/1/2/204/312352




  Case Report Top


A 31-year-old Asian Indian male presented with complaints of decreased vision in his right eye (RE) for the past 10 days. His dilated fundus examination 2 months prior to the present complaints did not reveal any abnormality. Best-corrected visual acuity (BCVA) in RE was 20/40 and 20/20 in the left eye. Slit-lamp biomicroscopy did not reveal anterior chamber cells/flare or vitreous cells in either eye. Fundus examination revealed a large (approximately 5–6 disc diameter) yellowish outer retinal lesion with fuzzy margins and surrounding edema temporal to the macula [Figure 1]. Swept-source optical coherence tomography (SS-OCT) (DRI OCT Triton®, Topcon medical systems Inc., Oakland, NJ, USA) revealed subretinal hyper-reflective material with disruption of the ellipsoid and myoid zone, interdigitation line, and the retinal pigment epithelium.[1] There was absence of intra- or subretinal fluid. SS-OCTA encompassing the lesion revealed an inflammatory choroidal neovascularization (i-CNV) temporal to the fovea [Figure 1]. The CNV lesion had multiple branching pattern with peripheral capillary loops and a distinct perilesional hyporeflective area (halo).
Figure 1: Shows fundus photograph of the patient with human immunodeficiency virus (HIV) and syphilis coinfection with a large temporal macular outer retinal lesion (a). The lesion was yellowish and had an active, fuzzy edges with surrounding edema. There was mild exudation along the lesion inferiorly. Swept-source optical coherence tomography (SS-OCT) line-scan through the macula showed presence of subretinal hyper-reflective material (SHRM) temporal to the foveal dip and intraretinal hyper-reflective dots (yellow dashed square) (b) There was no intra- or subretinal fluid. SS-OCTA showed a large neovascular network underneath the SHRM. There was a surrounding hyporeflective halo around the choroidal neovascularization (CNV) (yellow asterisk), and significant branching and anastomosis within the CNV (white arrowhead). The feeder choroidal vessel was also seen (white arrow) giving it a sea-fan appearance (c)

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The patient was tested positive for human immunodeficiency virus (HIV-1) and syphilis.[2] He was started on highly active antiretroviral therapy along with oral sulfamethoxazole and trimethoprim (800 mg + 160 mg), and 1 gm/day intravenous ceftriaxone.

A week later, there was no change in the lesion on SS-OCT and no change in the CNV on SS-OCTA. It was deemed appropriate to keep the patient under close follow-up and review fundus imaging using OCT and OCTA. However, 2 weeks later, he experienced deterioration of BCVA to 20/100 (from 20/40 at presentation). A small area of retinal hemorrhage was seen temporal to the fovea. SS-OCT revealed an increase in the outer retinal lesion along with subretinal fluid. SS-OCTA revealed a mild increase in the size of the CNV [Figure 2]. The patient was given intravitreal ranibizumab (0.5 mg/0.05 mL). Two weeks after the injection, the SS-OCTA showed a small reduction in the size of the i-CNV [Figure 3].
Figure 2: Follow-up imaging of the patient after 1 week of initial presentation showed a small area of retinal hemorrhage just inferotemporal to the foveal center (white arrow) (a). The inflammatory lesion itself had started to show regression and had less opaque edges. The swept-source optical coherence tomography (SS-OCT) imaging showed an increase in the size of the subretinal hyper-reflective material (SHRM) and appearance of subretinal fluid (b). Follow-up SS-OCTA showed an increase in the size and complexity of branching of the choroidal neovascularization (white arrowhead) and persistence of the perilesional halo (yellow asterisk) (c). The figure shows central dark areas due to motion artifacts at the time of image acquisition

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Figure 3: Fundus imaging performed at 2 weeks after the intravitreal injection (3 weeks after initial presentation) showed an increase in the size of the retinal hemorrhage compared to previous visit (white arrow) (a). The outer retinal lesion had become more granular and less opacified signifying healing pattern. The swept-source optical coherence tomography (SS-OCT) imaging showed reduction in the amount of subretinal fluid and persistence of the subretinal hyper-reflective material (SHRM) (b). There was a reduction in the size of the choroidal neovascular network on SS-OCTA (white arrowhead) (c). The perilesional halo (yellow asterisk) was still persistent

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  Discussion Top


Using OCTA, it is now possible to detect presence of i-CNV non-invasively. This tool also helps in differentiating inflammatory lesions in uveitis from CNV by determining the presence of a network of vessels, and flow signals on cross-sectional B-scan.[3],[4] In our case, SS-OCTA imaging clearly identified a neovascular network with a “dark perilesional halo” in the outer retina, which within 2 weeks showed an increase in size with appearance of subretinal fluid. It has been hypothesized that such a “dark halo” may signify outer retinal ischemia leading to development of the CNV. Our case highlights that certain features on SS-OCTA such as complex tiny vessel branching, peripheral arcades at vessel termini, and perilesional “dark haloes” may signify an active i-CNV, similar to an active AMD-related CNV, meriting early follow-up or institution of therapy with anti-VEGF injections. Further studies with prospective design and large sample size are warranted.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dansingani KK, Tan ACS, Gilani F, Phasukkijwatana N, Novais E, Querques L, et al. Subretinal hyperreflective material imaged with optical coherence tomography angiography. Am J Ophthalmol. 2016;169:235-48.  Back to cited text no. 1
    
2.
Hughes EH, Guzowski M, Simunovic MP, Hunyor AP, McCluskey P. Syphilitic retinitis and uveitis in HIV-positive adults. Clin Experiment Ophthalmol 2010;38:851-6.  Back to cited text no. 2
    
3.
Coscas F, Cabral D, Pereira T, Geraldes C, Narotamo H, Miere A, et al. Quantitative optical coherence tomography angiography biomarkers for neovascular age-related macular degeneration in remission. PLoS One 2018;13:e0205513.  Back to cited text no. 3
    
4.
Rispoli M, Savastano MC, Lumbroso B. Quantitative vascular density changes in choriocapillaris around CNV after Anti-VEGF treatment: Dark halo. Ophthalmic Surg Lasers Imaging Retina 2018;49:918-24.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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