Wide-field swept source optical coherence tomography angiography for peripheral polyps in peripheral exudative hemorrhagic chorioretinopathy - A case report

Charu Gupta; Sandeep Kumar; Daraius Shroff; Stuti Astir; Cyrus Shroff

doi:10.4103/ijo.IJO_1292_21

CASE REPORT

Year : 2022 | Volume : 2 | Issue : 2 | Page : 454-457

Wide-field swept source optical coherence tomography angiography for peripheral polyps in peripheral exudative hemorrhagic chorioretinopathy - A case report

Charu Gupta, Sandeep Kumar, Daraius Shroff, Stuti Astir, Cyrus Shroff
Shroff Eye Centre, New Delhi, Delhi, India

Date of Submission	17-May-2021
Date of Acceptance	24-Sep-2021
Date of Web Publication	13-Apr-2022

Correspondence Address:
Charu Gupta
Shroff Eye Centre, A-9 Kailash Colony, New Delhi, Delhi - 110 048
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1292_21

Abstract

We depict the novel use of wide-field swept-source optical coherence tomography angiography (SSOCTA) to image and longitudinally follow peripheral polyps in peripheral exudative hemorrhagic chorioretinopathy (PEHCR). A 65-year-old man with hemorrhagic mounds in the temporal mid-periphery of his left eye underwent wide-field en face and cross-sectional SSOCTA at the baseline and 3 monthly with a total follow-up of 10 months. We were able to image the peripheral polyps and branching vascular network (BVN) on wide-field SSOCTA and document its response to treatment. The SSOCTA findings correlated well to the gold standard indocyanine green angiography (ICGA).

Keywords: Peripheral exudative hemorrhagic chorioretinopathy (PEHCR), peripheral polyp, swept-source optical coherence tomography angiography (SSOCTA), wide-field

How to cite this article:
Gupta C, Kumar S, Shroff D, Astir S, Shroff C. Wide-field swept source optical coherence tomography angiography for peripheral polyps in peripheral exudative hemorrhagic chorioretinopathy - A case report. Indian J Ophthalmol Case Rep 2022;2:454-7

How to cite this URL:
Gupta C, Kumar S, Shroff D, Astir S, Shroff C. Wide-field swept source optical coherence tomography angiography for peripheral polyps in peripheral exudative hemorrhagic chorioretinopathy - A case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2023 Jun 2];2:454-7. Available from: https://www.ijoreports.in/text.asp?2022/2/2/454/342875

Peripheral exudative hemorrhagic chorioretinopathy (PEHCR) is a rare peripheral chorioretinal degenerative disorder characterized by subretinal hemorrhage (SRH) and/or subretinal pigment epithelium (RPE) hemorrhage and/or exudation.^[1] Within the PEHCR, there is a subgroup of lesions caused by peripheral polypoidal choroidal vasculopathy (PCV).^[2] ICGA is the gold standard to diagnose and monitor polyps but has the disadvantage of being invasive and time-consuming. We report the effectiveness of wide-field SSOCTA to diagnose and follow-up peripheral polyps in a case of PEHCR.

Case Report

A 65-year-old gentleman presented with a large subretinal and sub-RPE hemorrhage involving the macula in the right eye (RE). The left eye (LE) showed a fine epiretinal membrane (ERM) at the macula and pigmentary changes in the superior and temporal mid-periphery. He did not recover any useful vision post-intervention in the RE. On follow-up, he complained of floaters in the LE. On examination, the best corrected visual acuity (BCVA) was 20/25 in the LE and a patch of subretinal and sub-RPE hemorrhage (8–10 DD) was observed in the temporal mid-periphery [Figure 1]a. The patient underwent multimodal imaging which included simultaneous fluorescein angiography and ICGA (Spectralis; Heidelberg Engineering, Inc). The ICGA showed a cluster of polyps in the temporal mid-periphery and a branching vascular network (BVN) below it [Figure 1]b and [Figure 2]a. The lesion was peripheral to a high-definition swept source optical coherence tomography (SSOCT) line scan (HD Spotlight 16 mm, PLEX Elite 9000; Carl Zeiss Meditec, Inc.) taken in primary gaze in the horizontal meridian. The SSOCT scan was repeated to capture the temporal mid-periphery and showed subretinal and sub-RPE hemorrhage [Figure 1]c. Wide-field 12 mm × 12 mm scan centered on the fovea and a temporal 12 mm × 12 mm scan were acquired on SSOCTA (PLEX Elite 9000; Carl Zeiss Meditec, Inc). A 6 mm × 6 mm scan centered on the lesion was obtained [Figure 2]. To study the lesion, complex the outer retina to choriocapillaris (ORCC) or the choriocapillaris (CC) segmentation strategy was used. The temporal 12 mm × 12 mm en face SSOCTA scan showed a cluster of dilated vascular networks [Figure 2]b each of which had a corresponding high-flow signal (green) on the cross-sectional SSOCTA scan [Figure 2]c. These networks with the flow signals were even better delineated on the 6 mm × 6 mm scan centered on the lesion [Figure 2]d and [Figure 2]e and corresponded accurately to the cluster of polyps seen on the ICGA. The BVN seen on the ICGA was also seen on the wide-field temporal SSOCTA [Figure 2]a and [Figure 2]b. Image J software was used to measure the area of BVN on the ICGA and OCTA. After correcting for the magnification factor, the area of BVN was 1.4 mm² on ICGA and 1.87 mm² on SSOCTA. The patient underwent intravitreal anti-VEGF injection followed by laser photocoagulation to the polyps in the LE.

Figure 1: Composite of central and temporal fundus image of left eye at baseline (a) Color photograph shows subretinal and sub RPE haemorrhagic mound in the temporal mid periphery (white arrows). (b) ICGA shows blocked cyanescence due to the hemorrhage (white arrow heads), cluster of pinpoint hypercyanescent lesions (polyps) (yellow dotted circle) (c) High definition SSOCT showing subretinal (white arrow heads) and sub RPE hemorrhage (yellow arrow heads)

Click here to view

Figure 2: At baseline (a) ICGA showing a cluster of polyps (yellow dotted circle) and a BVN (red dotted circle) (b) Wide-field 12x12 en face SSOCTA showing BVN (red dotted circle) and polyps (yellow dotted circle) with corresponding (c) cross-sectional SSOCTA through the superior polyp (blue arrow head) showing a high flow signal (yellow arrow). (d) 6x6 en face SSOCTAA showing magnified view of the polyps (yellow dotted circle) with corresponding (e) cross-sectional SSOCTA through the inferior polyp (yellow arrow head) showing a high flow signal (yellow arrow) and neurosensory detachment (NSD) (white arrow).

Click here to view

Post-treatment fundus examination, SSOCT, and SSOCTA at 3 months, showed the resolution of the subretinal and sub-RPE hemorrhage. En face and cross-sectional SSOCTA showed obliteration of the cluster of dilated vascular networks and BVN and the flow signals corresponding to the polyps [Figure 3]A and [Figure 3]B. The patient was kept under observation.

Figure 3: Comparison of multimodal imaging (A) At baseline showing polyps (yellow dotted circle) and BVN (red dotted circle)(i) on wide-field SSOCTA, (ii) ICGA and (iii)corresponding cross sectional scan showing the high flow signal (yellow arrow) and NSD(white arrow). (B) at 3 months (i) showing the regressed polyps (yellow dotted circle) and BVN(red dotted circle) on the en face scan and (ii) flattening of PED, resolution of NSD and obliteration of the flow signal(yellow arrow) on the cross sectional scan. (C) At 10 months, showing regressed polyps (yellow dotted circle) and reactivation of the BVN (red dotted circle) (i) on wide-field SSOCTA, (ii) on ICGA and (iii) cross-sectional scan corresponding to the polyps showing no flow signal suggestive of polyp regression.

Click here to view

On examination 10 months post-treatment, the BCVA was 20/30. On fundus examination, fresh small subretinal and sub-RPE hemorrhagic patches were observed. Repeat wide-field SSOCTA showed reactivation of the BVN [Figure 3]C but there were no new or recurrent polyps observed on the en face and cross-sectional SSOCTA. Repeat ICGA confirmed the above findings. Intravitreal anti-VEGF was administered.

Discussion

The case report highlights the use of noninvasive SSOCTA to diagnose and follow-up peripheral polyps in PEHCR. Multimodal imaging, including ICGA, is important to diagnose PEHCR, characterize the lesions, and formulate a treatment plan.^[3],[4],[5] Both PCV and PEHCR are known to have a remitting-relapsing course.^[2] So, it would be helpful to have a wide-field noninvasive imaging modality in the armamentarium to regularly follow-up peripheral polyps in PEHCR patients.^[3],[4]

In our case report, we were able to image the PCV lesion complex in the temporal mid-periphery with a temporal 12 × 12 scan and to study further details of the lesion with a 6 × 6 scan centered on the lesion. The polyps were seen as a cluster of dilated vascular networks on the en face SSOCTA and each of these networks showed a corresponding high-flow signal on cross-sectional SSOCTA. Bo et al. have described a similar pattern of polypoidal lesions on OCTA.^[5] We were also able to identify a BVN below the cluster of polyps on en face SSOCTA. The PCV lesion complex on the SSOCTA correlated well with the ICGA. While the BVN was equally well delineated on ICGA and SSOCTA, the polyps were better visualized on ICGA compared to en face SSOCTA. However, the flow overlay on the cross-sectional SSOCTA helps to confirm the lesion.

The natural history of the disease in the PEHCR due to PCV is favorable and most patients can be observed.^[1] However, when hemorrhage is progressive or macula threatening, treatment in the form of laser-based therapies and/or intravitreal anti-vascular endothelial growth factor therapy, and, in some situations, surgery is indicated.^[2],[6] Siebel et al. reported that there was an inability to restore visual acuity when administering intravitreal anti-VEGF in patients who already had macular involvement.^[7] Considering the unfortunate course of events in the other eye and the recent onset of subretinal and sub-RPE hemorrhage in the temporal quadrant in the LE, we decided to treat our patient. Combination therapy of intravitreal anti-VEGF with laser photocoagulation to the polyps was administered.^[8]

The previous studies have reported that patients with PEHCR need to be reviewed for retreatment in a manner similar to the patients with exudative AMD.^[7] Considering the relapsing-remitting course of the disease, we followed up our patient with serial SSOCTA. The regression of the polyps and BVN at the 3-month follow-up was well-documented and we were safely able to observe the lesion. The reactivation of the lesion which was suspected on clinical examination at the 10-month follow-up visit was confirmed on wide-field SSOCTA through the lesion. Wide-field en face SSOCTA showed reactivation of the BVN which was further confirmed on ICGA, the gold standard imaging modality for PCV.

The limitation of wide-field SSOCTA to image the peripheral lesion is the need for a cooperative patient. Another limitation is in the patients of PEHCR with large hemorrhagic mounds.

Conclusion

We found wide-field SSOCTA to be a useful imaging modality to diagnose and monitor the temporal changes in a peripheral PCV lesion. However, it cannot replace ICGA pre-treatment but it can decrease the need to repeat ICGA on follow-up and give an early indication of the recurrence of the PCV lesion.

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

1.	Shields CL, Salazar PF, Mashayekhi A, Shields JA. Peripheral exudative hemorrhagic chorioretinopathy simulating choroidal melanoma in 173 eyes. Ophthalmology 2009;116:529-35.
2.	Goldman DR, Freund KB, McCannel CA, Sarraf D. Peripheral polypoidal choroidal vasculopathy as a cause of peripheral exudative hemorrhagic chorioretinopathy: A report of 10 eyes. Retina 2013;33:48-55.
3.	Kumar V, Janakiraman D, Chandra P, Kumar A. Ultra-wide field imaging in peripheral exudative hemorrhagic chorioretinopathy (PEHCR). BMJ Case Rep 2015;2015:bcr2015213628. doi: 10.1136/bcr-2015-213628.
4.	Tsui I, Jain A, Shah S, Schwartz SD, McCannel TA. Ultra widefield imaging of peripheral exudative hemorrhagic chorioretinopathy. Semin Ophthalmol 2009;24:25-8.
5.	Bo Q, Yan Q, Shen M, Song M, Sun M, Yu Y, et al. Appearance of polypoidal lesions in patients with polypoidal choroidal vasculopathy using swept-source optical coherence tomographic angiography. JAMA Ophthalmol 2019;137:642-50.
6.	Vandefonteyne S, Caujolle JP, Rosier L, Conrath J, Quentel G, Tadayoni R, et al. Diagnosis and treatment of peripheral exudative hemorrhagic chorioretinopathy. Br J Ophthalmol 2020;104:874-8.
7.	Seibel I, Hager A, Duncker T, Riechardt AI, Nürnberg D, Klein JP, et al. Anti-VEGF therapy in symptomatic peripheral exudative hemorrhagic chorioretinopathy (PEHCR) involving the macula. Graefes Arch Clin Exp Ophthalmol 2016;254:653-9.
8.	Rishi P, Das A, Sarate P, Rishi E. Management of peripheral polypoidal choroidal vasculopathy with intravitreal bevacizumab and indocyanine green angiography-guided laser photocoagulation. Indian J Ophthalmol 2012;60:60-3. [PUBMED] [Full text]