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Age-Related Choroidal Atrophy

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Age-Related Choroidal Atrophy ARTICLE IN PRESS Age-Related Choroidal Atrophy RICHARD F. SPAIDE ● PURPOSE: To report the clinical characteristics of a GE-RELATED MACULAR DEGENERATION (AMD) IS A newly defined entity, age-related choroidal atrophy. leading cause of vision loss in not only developed, 1–4 ● DESIGN: Retrospective, observational case series. A but also in developing countries. The initial ● METHODS: The choroidal thickness was measured in manifestations of the condition, drusen, focal hyperpig- images obtained by positioning a spectral-domain optical mentation, and focal hypopigmentation, are elements coherence tomography device close enough to the eye to defining the category early AMD. These findings precede acquire an inverted image. Seven sections each comprised the development of more visually significant forms of the -of 100 averaged scans were obtained within a 5 ؋ disease, either geographic atrophy or choroidal neovascu 5 15-degree or larger rectangle to encompass the macula larization (CNV), which are categorized as late AMD. and temporal juxtapapillary retina. The choroidal thick- Assessment of eyes for features of AMD is carried out ness of patients less than 125 ␮m in thickness were either by clinical examination or evaluation of fundus included, whereas eyes with myopia of 6 diopters or photographs. Formal studies depend on protocol evalua- tion of fundus photographs, and the protocols used are more, a history of uveitis, trauma, ionizing radiation, structured reproducible methods based, in part, on what photodynamic therapy, intravitreal corticosteroid injec- happens during careful clinical examination. The features tion, or tapetoretinal dystrophy were excluded. The and the methods used to grade them intend to classify and patients were evaluated for visual acuity, macular appear- discriminate accurately levels of severity of AMD plus ance, and the presence of glaucoma. other concurrent factors or diseases. The chosen features ● RESULTS: There were 28 eligible eyes of 17 patients expected for AMD and the confounding conditions are ؎ with a mean age 80.6 years (standard deviation, 7.3 based on established concepts of the pathophysiologic years). All eyes had a tessellated fundus appearance. The features of disease. For example, disturbances of the retinal ␮ mean subfoveal choroidal thickness was 69.8 m and pigment epithelium (RPE) occur commonly in AMD, and became even more attenuated nasally. Of the 18 eyes that these disturbances, according to the Wisconsin Age-Re- had no evidence of late age-related macular degeneration lated Maculopathy Grading System,5,6 a widely used pro- (AMD), the mean visual acuity was 20/40, there were tocol method of evaluating fundus photographs, can “lead pigmentary changes in the macula that arose in part from to deposition of granules or clumps of pigment in or the choroid potentially mimicking early AMD, and a beneath the retina.” The pigmentation grading system has rarefaction of the choroidal vessels under the macula. the implied assumption that pigmentary changes are at- Concurrent late AMD was found in the 10 remaining tributable to disturbances of the RPE.6 eyes. Glaucoma was present in 6 patients (35.3%), all of The retina, particularly the photoreceptor layer, has a whom had peripapillary atrophy. The choroid was seen to very high metabolic demand for oxygen, which is supplied become nearly obliterated before the demarcation of the by the underlying choroid, a structure with one of the ␤-zone of peripapillary atrophy. highest blood flow per gram of tissue in the body.7 The ● CONCLUSIONS: Age-related choroidal atrophy affects choroid is located behind the RPE and also is pigmented. older individuals in whom posterior pole abnormalities The pigmentation generally impedes visualization of the develop that may mimic and also be associated with full-thickness of the choroid by ophthalmoscopy, fundus findings typical for AMD. Patients with age-related photography, fluorescein angiography (FA), or conven- choroidal atrophy may be at higher risk for glaucoma. tional optical coherence tomography (OCT). As such, the (Am J Ophthalmol 2009;xx:xxx. © 2009 by Elsevier choroid is not frequently mentioned as participating in Inc. All rights reserved.) vision loss except for being the source of CNV. Recently, a method to obtain enhanced depth imaging (EDI) spec- tral-domain OCT has been developed that enables the cross-sectional structure and thickness of the choroid to be evaluated.8 EDI OCT was used to examine healthy eyes Accepted for publication Dec 4, 2008. From the Vitreous-Retina-Macula Consultants of New York and the with no visual problems attributable to the macula, and LuEsther T. Mertz Retinal Research Center, Manhattan Eye, Ear, and the choroid thickness was found to decrease approximately Throat Hospital, New York, New York. 16 ␮m per decade of life.9 The thinnest subfoveal choroi- Inquiries to Richard F. Spaide, the Vitreous-Retina-Macula Consult- ants of New York, 460 Park Avenue, 5th Floor, New York, NY 10022; dal thickness measured among that series of 54 eyes was e-mail: [email protected] 159 ␮m. However, because EDI OCT became available, a 0002-9394/09/$36.00 © 2009 BY ELSEVIER INC.ALL RIGHTS RESERVED. 1 doi:10.1016/j.ajo.2008.12.010 ARTICLE IN PRESS subset of patients who were considered to have AMD and who had reported visual symptoms were found to have remarkably small choroidal thicknesses. Many of the eyes eventually were found to have no significant macular or RPE problems, although others were found to have con- current geographic atrophy and CNV. Because the finding FIGURE 1. Enhanced depth imaging (EDI) optical coherence of the markedly thin choroid was found in elderly people tomographic (OCT) scan of a normal eye. with visual symptoms that occurred relatively recently over the course of their lives, this finding was thought to be acquired; as such the entity was termed age-related choroidal be obtained from random sampling of a normal population. atrophy. The purpose of this study was to determine the Patients were included in this study if at least 1 eye had a features of age-related choroidal atrophy by cataloguing choroidal thickness of less than 125 ␮m. For the purposes the findings of a series of eyes with this condition. of illustration, the images were reinverted in Photoshop (Photoshop CS3; Adobe Systems Inc, San Jose, California, USA). The patients were evaluated with a comprehensive METHODS ophthalmoscopic examination including best-corrected Snellen visual acuity (VA) measurement, fundus photog- THIS WAS A RETROSPECTIVE STUDY OF PATIENTS WHO raphy, and fluorescein and indocyanine green angiography, underwent EDI OCT of the choroid in a private referral as indicated. Patients were excluded if they had any retinal practice during a 10-week period ending in August previous photodynamic therapy, intravitreal corticoster- 2008. The method of obtaining EDI OCT images has been oid injection, history of myopia of more than 6 diopters reported previously, as have the nomographic data. Con- spherical equivalent, amblyopia, proliferative retinopa- ventional spectral-domain OCT has limitations in imaging thies of any type, epiretinal membrane that caused distor- deeper structures in the fundus because of depth-depen- tion of the central macula, history of retinal detachment dent sensitivity decay related to decreasing sensitivity and (RD), uveitis, tapetoretinal dystrophy, ocular trauma, resolution with increasing displacement from zero-delay, ocular tumor, ionizing radiation, submacular surgery, diminished maximal dynamic range inherent in perform- transpupillary thermotherapy, focal laser, angioid streaks, ing the Fourier transform after analog-to-digital conver- use of any systemic or ocular corticosteroids, central serous sion, and wavelength-dependent light scattering and signal chorioretinopathy, or any retinovascular abnormalities. loss in the image path. EDI OCT is performed by placing The eyes were classified as having late AMD if they had the instrument close enough to the eye to obtain an signs of CNV or central geographic atrophy. Eyes with late inverted image. This image is averaged for 100 scans, AMD were entered into the dataset only if they had which in this study was obtained using the Heidelberg new-onset disease or if the fellow eye had no late AMD Spectralis (Heidelberg Engineering GmbH, Heidelberg, and a choroidal thickness of less than 125 ␮m. Peripapil- Germany) because of its automatic averaging and eye lary atrophy was graded as per the method outlined by 10 tracking features. Seven sections, each comprised of the Jonas and associates. (Peripapillary atrophy had been 100 averaged scans, was obtained in a 5 ϫ 30-degree rec- referred to as parapapillary atrophy in earlier publica- 10–15 tangle encompassing the macula and optic nerve or a tions. ) Peripapillary atrophy was considered to be 5 ϫ 15-degree rectangle centered on the macula.8 The present only if there was a ␤-zone of atrophy, which was resultant images were viewed and measured with the thought to represent full-thickness atrophy of the RPE and 15 contained Heidelberg Eye Explorer software (version choroid. VAs were converted to logarithm of the mini- 1.5.12.0; Heidelberg Engineering). The subfoveal choroid mum angle of resolution (logMAR) units before to any was measured from the outer portion of the hyperreflective calculations. line corresponding to the RPE to the inner surface of the sclera. In eyes with CNV, the subfoveal choroidal thick- ness was measured between the Bruch membrane, which RESULTS was visible in all such cases, and the inner portion of the sclera. The appearance of the choroid over the full-length THERE WERE 17 PATIENTS WITH A MEAN AGE 80.6 YEARS of the scan was inspected as well. (Ϯ 7.3 years). Of the potential 34 eyes, 6 were excluded In a previous study of the choroidal thickness, the mean because of past photodynamic therapy to the macula, subfoveal choroidal thickness was 287 ␮m Ϯ a standard amblyopia, trauma, or history of RD repair. A diagnosis of deviation of 75.7 ␮m.9 Two standard deviations less than glaucoma was present in 6 patients (35.3%).
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