Management of Anti-vascular Endothelial Growth Factor Therapy
Figure 2: Chronic Central Serous Chorioretinopathy A
• C B B
On SD-OCT, there is always a typical appearance of type 2 AVL with pathognomonic abnormalities. These abnormalities are the imaging of the material resorption and the RPE hypertrophy reaction. Bruch’s membrane is always visible with a hyper-reflective focal thickening or bumps of the RPE band just above it. There is always a hyporeflective ‘empty’ space between the thickened RPE and the IS/OS junction of the photoreceptors. This pseudo-serous detachment probably corresponds to the dysfunction of the RPE. This appearance is often associated with small dots that are presumed to be macrophages.
Serous retinal detachments with analogous features can be seen in angioid streaks and central serous chorioretinopathy (CSC). In pseudo-xanthoma elasticum, one can frequently observe this kind of ‘vitelliform serous detachment’ attributed to RPE dysfunction and not to CNV diffusion.
C
• Type 3 – (see Figure 1E and F) type 3 AVL is less frequent, associated with pigment epithelial detachment (PED) and is mostly known as a non-neovascularised AMD. SD-OCT usually shows typical subretinal material with pseudo-serous detachment owing to RPE dysfunction. This serous detachment can be seen at the top of the PED or along the border of the detachment. FA and ICGA might be necessary to rule out occult CNV or polypoidal vasculopathy.
Spectral domain optical coherence tomography (SD-OCT) shows serous retinal fluid, focal thickening of the retinal pigment epithelium (RPE) and cystoid cavities (B). Enhanced depth imaging (EDI)-OCT demonstrates increased choroidal thickness (arrow) (C). Corresponding indocyanine green angiography (ICGA) demonstrates inner choroidal staining in the mid- stage of angiogram (A).
Figure 3: Retinal Pseudocysts A
AVL can therefore be confused with CNV. SD-OCT and FAF are the key examinations to avoid such diagnostic mistakes.
B
Pitfall 2 – Persistent Serous Detachment During Anti-Vascular Endothelial Growth Factor Treatment There are two main pitfalls in the case of persistent serous detachment during anti-VEGF treatment – general RPE dysfunction and polypoidal vasculopathy.
•
General RPE dysfunction. In some cases, after a period of active CNV treated with anti-VEGF injections, patients no longer complain of metamorphopsia. In biomicroscopy, no exudates or haemorrhages are present, but there is still a shallow serous detachment on SD-OCT.
Retinal pseudocysts (here after drusen resorption) (arrow) are located in the inner nuclear layer (A) above a hypoautofluorescent retinal pigment epithelium (RPE) atrophic area (B).
the RPE. This material is represented as a heterogenous reflective tissue between the RPE line and the inner segment–outer segment (IS/OS) photoreceptor junction line. It is often useful to magnify the SD-OCT image so as to verify that the RPE band is intact and that the serous retinal detachment observed corresponds to material resorption.
EUROPEAN OPHTHALMIC REVIEW
Why do some cases present such a persistent retinal serous detachment? It is thought to be the result of dysfunction of the RPE pump. These cases need to be checked and retreated only if CNV signs recur.
Rarely, AMD is confused with chronic central serous chorioretinopathy (CSC; see Figure 2). FA and ICGA are necessary to arrive at the correct diagnosis. Enhanced depth imaging (EDI)-OCT allows for visualisation of increased choroidal thickness usually >500μm in depth in CSC.16
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Type 2 – multimodal imaging in eyes with AVL has identified a second distinct type of material within the subretinal space (see Figure 1C and D). In these cases, there are no exudative signs on colour fundus photographs. FAF mostly shows hypofluorescent areas surrounded by some hyper-reflective zones. As in the first type of AVL, FA shows at the AVL site hypofluorescent areas surrounded by hyperfluorescent areas leaking with pin points in the late phases. ICGA also shows hypofluorescent areas in the early phases and hypo- and hyperfluorescent areas without leakage in the late phases.
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