Sir,
The retinochoroidal anastomosis represents a communication between the retinal and choroidal circulation and is described in a subset of patients with neovascular age-related macular degeneration (AMD).1
Case report
We present the spectral-domain optical coherence tomography (SD-OCT) features of an 83-year-old Caucasian lady with retinal angiomatous proliferation (RAP) in her right eye (OD). This was treated with intravitreal ranibizumab injections. SD-OCT imaging was performed using both a Topcon Medical Systems, Inc. (Oakland, NJ, USA) (3D OCT 1000) and a Heidelberg Engineering Spectralis Imaging System (Carlsbad, CA, USA). The acquired B-scan images were registered with color (Topcon) or near-infrared (Heidelberg) fundus imaging.
On initial presentation, the best-corrected visual acuity (BCVA) was 20/300 in the right eye (OD). Dilated fundus examination and fluorescein angiography (FA) OD findings demonstrated a RAP type of choroidal neovascularization (CNV; type III). This is a subgroup of neovascular AMD (Figure 1a–d).1 Serial SD-OCT B-scans revealed a pigment epithelial detachment (PED) with intra-retinal fluid and a high-reflective lesion in the inner retina corresponding to the intra-retinal hemorrhage seen on color photography OD (Figure 1e).2
After 18 months and seven intravitreal ranibizumab injections, the BCVA was 20/240 OD. There was no evidence of retinal fluid clinically or on SD-OCT evaluation. FA confirmed the inactive CNV with scar formation (Figure 2). Interestingly, further evaluation of the serial B-scans from dense raster scans revealed an optically empty curvilinear space seen vertically dipping from the inner-retinal surface into the PED OD (Figure 3). Furthermore, this observation on OCT B-scans co-localized with a branch retinal arteriole seen penetrating the scar tissue on near-infrared and color fundus images. This represents a retinochoroidal anastomosis (RCA).3
Comment
We report the detailed visualization of RCA on serial SD-OCT imaging. The visualization of the retinal arteriole noted on B-scan images is notably similar to the histology images presented by Green and Gass4 (case 5 of their series). Such an anastomoses can result from RAP or disciform scar formation.1, 3, 4 Identification of such an anastomoses by SD-OCT may guide treatment.
References
Yannuzzi LA, Negrão S, Iida T, Carvalho C, Rodriguez-Coleman H, Slakter J et al. Retinal angiomatous proliferation in age-related macular degeneration. Retina 2001; 21 (5): 416–434.
Troung SN, Alam S, Zawadzki RJ, Choi SS, Telander DG, Park SS et al. High resolution fourier-domain optical coherence tomography of retinal angiomatous proliferation. Retina 2007; 27 (7): 915–925.
Freund KB, Zweifel SA, Engelbert M . Do we need a new classification for choroidal neovascularization in age-related macular degeneration? Retina 2010; 30 (9): 1333–1349.
Green WR, Gass JDM . Senile disciform degeneration of the macula. Arch Ophthalmol 1971; 86: 487–494.
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Meeting presentation: Amsler Club Meeting, London, 29 September 2012.
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Pilli, S., O'Brien, C. & Lotery, A. Imaging retinochoroidal anastomosis via spectral-domain optical coherence tomography. Eye 27, 1105–1107 (2013). https://doi.org/10.1038/eye.2013.121
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DOI: https://doi.org/10.1038/eye.2013.121
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