American Society of Retina Specialists Clinical Practice Guidelines on Multimodal Imaging for Retinal Disease

Abstract

Purpose: Advancements in retinal imaging have augmented our understanding of the pathology and structure-function relationships of retinal disease. No single diagnostic test is sufficient; rather, diagnostic and management strategies increasingly involve the synthesis of multiple imaging modalities. Methods: This literature review and editorial offer practical clinical guidelines for how the retina specialist can use multimodal imaging to manage retinal conditions. Results: Various imaging modalities offer information on different aspects of retinal structure and function. For example, optical coherence tomography (OCT) and B-scan ultrasonography can provide insights into the microstructural anatomy; fluorescein angiography (FA), indocyanine green angiography (ICGA), and OCT angiography (OCTA) can reveal vascular integrity and perfusion status; and near-infrared reflectance and fundus autofluorescence (FAF) can characterize molecular components within tissues. Managing retinal vascular diseases often includes fundus photography, OCT, OCTA, and FA to evaluate for macular edema, retinal ischemia, and the secondary complications of neovascularization (NV). OCT and FAF play a key role in diagnosing and treating maculopathies. FA, OCTA, and ICGA can help identify macular NV, posterior uveitis, and choroidal venous insufficiency, which guides treatment strategies. Finally, OCT and B-scan ultrasonography can help with preoperative planning and prognostication in vitreoretinal surgical conditions. Conclusions: Today, the retina specialist has access to numerous retinal imaging modalities that can augment the clinical examination to help diagnose and manage retinal conditions. Understanding the capabilities and limitations of each modality is critical to maximizing its clinical utility.

Keywords: fluorescein angiography; fundus autofluorescence; fundus photography; indocyanine green angiography; macular degeneration; multimodal imaging; optical coherence tomography; optical coherence tomography angiography; posterior uveitis; retinal dystrophy; retinal vascular disease; ultra-widefield imaging; vitreoretinal surgery.

Figure 1.

Multimodal imaging of diabetic retinopathy (DR). (A) Ultra-widefield fluorescein angiography shows extensive peripheral nonperfusion (asterisks) and peripheral and disc neovascularization (red arrows) in proliferative DR. (B) Optical coherence tomography (OCT) angiography of the macular superficial capillary plexus shows an enlarged and irregular foveal avascular zone (red arrow) seen in diabetic macular ischemia. (C) OCT of diabetic macular edema with subretinal fluid (white arrow), intraretinal fluid (yellow arrow), and hyperreflective dots (red arrow). (Images courtesy of Yasha S. Modi, MD.)

Figure 2.

Multimodal imaging of paracentral acute middle maculopathy (PAMM). (A) Color fundus photograph of an eye with central retinal vein occlusion also shows patchy whitish parafoveal lesions deeper in the retina (red asterisks) that appear smoother in contour and grayer than cotton-wool spots. (B) En face optical coherence tomography (OCT) shows thickening of the superficial retina corresponding to the lesions (red asterisks) seen on the fundus photograph. (C) Cross-sectional OCT in PAMM shows placoid areas of hyperreflective bands (red arrow) and thickening of the inner nuclear layer. (D) En face OCT angiography of the macular superficial capillary plexus shows capillary nonperfusion in the PAMM lesions (red asterisks). (E) Structural OCT angiography segmenting the superficial capillary plexus shows flow voids in the PAMM lesions (red arrows). (Images courtesy of Peter Weseley, MD.)

Figure 3.

Multimodal imaging of hydroxychloroquine toxicity. (A) Fundus autofluorescence of the left eye with stippled hyperautofluorescence and hypoautofluorescence in the parafoveal region (red arrows). (B) Corresponding optical coherence tomography with extensive parafoveal ellipsoid zone loss and retinal pigment epithelial irregularity (red arrows) and a central preserved island of outer retinal structures subfoveally (red bracket). (C) 10-2 Humphrey visual field testing shows a dense paracentral scotoma resulting from the parafoveal photoreceptor disruption. (Images courtesy of Kenneth J. Wald, MD.)

Figure 4.

Multimodal imaging of non-neovascular age-related macular degeneration (AMD). (A) Color fundus photograph is notable for drusen and a central hypopigmented area with sharply defined borders revealing underlying choroidal vasculature indicative of geographic atrophy (GA) resulting from AMD. (B) Fundus autofluorescence shows darkly hypoautofluorescent lesions corresponding to retinal pigment epithelium (RPE) loss in GA and stippled autofluorescence from drusen. (C) Near-infrared reflectance imaging with hyperreflective lesions of GA corresponding to complete RPE and outer retinal atrophy with choroidal hypertransmission signal seen on OCT in panel F (red bracket). (D and E) Optical coherence tomography shows features predictive of AMD progression to GA, including reticular pseudodrusen (red arrows), subsidence of the outer nuclear layer (red asterisks), and hyperreflective foci (within red box). (Images courtesy of Joel A. Pearlman, MD, PhD.)

Figure 5.

Multimodal imaging of polypoidal choroidal vasculopathy. (A) Fluorescein angiography shows ill-defined late staining of a pigment epithelial defect (PED) and leakage in the central macula. (B) Corresponding indocyanine green angiography better highlights the focal hyperfluorescent spot of the polypoidal lesion (red arrow). (C) En face optical coherence tomography angiography (OCTA) of the macula shows a large choroidal neovascular network with a terminal aneurysmal dilation consistent with the polyp (red arrow). Corresponding OCT (D) and cross-sectional OCTA (E) with flow overlay through the polyp show a fibrovascular PED with flow through the hyperreflective lesions within the PED. (Images courtesy of Michael Engelbert, MD, PhD.)