Pachychoroid neovasculopathy in extramacular choroidal neovascularization

Abstract

Purpose: To review a series of extramacular choroidal neovascular membranes (CNVMs) in the context of their choroidal features, as determined by optical coherence tomography (OCT).

Methods: Patients with extramacular CNVMs were identified from a tertiary care center through a review of records. The charts and cases were reviewed using multimodal imaging including fundus photography, OCT, fluorescein angiography (FA), and indocyanine angio-graphy (ICG).

Results: Of six patients with extramacular CNVMs evaluated in this series, four patients (66.7%) exhibited pachychoroidopathy on OCT imaging under or adjacent to the extramacular CNVM. All four of these patients also exhibited pachychoroidopathy in the macular OCT distant from the CNVM.

Conclusion: Pachychoroidopathy is implicated in some cases of extramacular CNVMs. This represents the first report, to our knowledge, of pachychoroidopathy in extramacular CNVM.

Keywords: choroidal neovascularization; extramacular choroidal neovascularization; pachychoroid neovasculopathy; pachychoroidopathy; peripheral disciform lesions; polypoidal choroidal vasculopathy.

Figure 1

Case 1 ocular imaging. Notes: Color fundus photograph OD for case 1 reveals rare macular RPE changes and a superonasal peripapillary CNVM with exudation (A). EDI-OCT (B) of the macula OD reveals rare drusen and choroidal folds overlying thickened choroid with dilated choroidal vessels. EDI-OCT through the superonasal CNVM (C) reveals Type 1 CNVM overlying thickened choroid and dilated outer choroidal vessels. The dilated choroidal vessels are inwardly displaced and abutting the RPE. FA (D) 1 minute, 7 seconds; (E) 2 minutes, 53 seconds, reveals leakage suggestive of occult CNVM. Color fundus photo (F) revealed further increase in exudation, despite treatment with multiple anti-VEGF agents. Abbreviations: OD, oculus dexter (right eye); CNVM, choroidal neovascular membrane; EDI-OCT, enhanced-depth imaging optical coherence tomography; OCT, optical coherence tomography; RPE, retinal pigment epithelium; FA, fluorescein angiography; VEGF, vascular endothelial growth factor.

Figure 2

Case 2 ocular imaging. Notes: Color fundus photograph OS for case 2 reveals rare macular RPE changes, peripheral drusen, and a ring exudate superior to the disc (A). EDI-OCT of the macula OS reveals choroidal folds overlying thickened choroid with dilated outer choroidal vessels (B). FA (C, left panel) and ICG (C, right panel) reveal polypoidal CNVM in the area of exudation OS (C: 1 minute, 1 second), as well as polypoidal lesions in the peripapillary region OD (D: 3 minutes, 53 seconds; left panel, FA; right panel, ICG). EDI-OCT (E, right panel) through the CNVM OS (E, left panel; green arrow signifying location of corresponding EDI-OCT image) reveals thickened choroid and dilated outer choroidal vessels that are inwardly displaced and abutting the RPE. Abbreviations: OS, oculus sinister (left eye); OD, oculus dexter (right eye); RPE, retinal pigment epithelium; EDI-OCT, enhanced-depth imaging optical coherence tomography; FA, fluorescein angiography; ICG, indocyanine green angiography; CNVM, choroidal neovascular membrane.

Figure 3

Case 3 ocular imaging. Notes: Color fundus photograph OD for case 3 reveals temporal macular RPE changes and atrophy with an area of hemorrhage at the inferior border of the scar with associated exudation (A). EDI-OCT through the macula OD reveals temporal macular RPE changes and atrophy with underlying thickened choroid and dilated outer choroidal vessels (B). EDI-OCT through CNVM itself (C) reveals thick choroid and markedly dilated outer choroidal vessels which are inwardly displaced and abutting the RPE. Abbreviations: OD, oculus dexter (right eye); RPE, retinal pigment epithelium; EDI-OCT, enhanced-depth imaging optical coherence tomography; CNVM, choroidal neovascular membrane.

Figure 4

Case 4 ocular imaging. Notes: Color fundus photograph OD of case 4 reveals a peripapillary sub-RPE hemorrhage and incidentally noted inferior retinal detachment (A). EDI-OCT OD of the macula (B) and of the retina adjacent to the hemorrhagic PED (C) reveals thick choroid with dilated outer choroidal vessels. Abbreviations: OD, oculus dexter (right eye); RPE, retinal pigment epithelium; EDI-OCT, enhanced-depth imaging optical coherence tomography; PED, pigment epithelial detachment.

Figure 5

Case 5 ocular imaging. Notes: Color fundus photograph OD of case 5 reveals drusen and RPE changes with a hemorrhagic lesion in the far temporal periphery (A). EDI-OCT of the macula OD reveals RPE changes and a thin choroid (B). Abbreviations: OD, oculus dexter (right eye); RPE, retinal pigment epithelium; EDI-OCT, enhanced-depth imaging optical coherence tomography.

Figure 6

Case 6 ocular imaging. Notes: Color fundus photograph OS of case 6 reveals drusen and RPE changes, as well as a far peripheral elevated lesion (A). EDI-OCT of the central macula OS reveals RPE changes with choroidal thinning (B). Abbreviations: OS, oculus sinister (left eye); RPE, retinal pigment epithelium; EDI-OCT, enhanced-depth imaging optical coherence tomography.