PMC6332618_01
Multimodal assessment. a Color fundus photograph of hamartoma mass, 0.6 mm (H) x 0.5 mm (V) in diameter with yellowish superior border. b Autofluorescence filter signal blocked by the pigmented lesion. c Near-Infrared hyperreflectivity on the lesion. d Red free signal blocked by the pigment. e FA revealing hyperfluorescence feeder vessel and superior margin in the artery-venous phase. f Indocianine Green angiography picture depicts lesser cyanescence on superior boundary. g EDI-SBOCT demonstrating intrinsic hyperreflectivity in almost all foveal layers and shadowing posterior to it, involving the choriocapillaris. h SBOCT revealing detailed rounded hyperreflective vessels (red arrow) below the hyperreflective mass
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Fig1
Fundus examination OS (Fig. 1a) showed a juxtafoveolar pigmented, circumscribed lesion measuring 0.6 mm in horizontal basal diameter and 0.5 mm in vertical basal diameter. Near-infrared reflectance imaging (Fig. 1c) demonstrated intrinsic hyperreflectivity, whereas short-wavelength autofluorescence (Fig. 1b) and red-free filter photography (Fig. 1d) revealed blocked signal by the lesion. There was an outer retinal defect (Fig. 1g) on vertical section of EDI-SBOCT and of SBOCT (Figs. 1h, 5f on asterisk). The mass appeared as a highly reflective lesion with deep shadowing by SBOCT (Fig. 1g, h). Interestingly rounded reflective vessels on SBOCT imaging (Fig. 1h, red arrow) was correlated to the Fig. 2g (red arrow).
Comprehensive retinal feeding vessel evaluation. a Color fundus photograph showing feeder vessel sectioning (green arrow 1 and 2). g1, g2, SBOCT crossing the hyperfluorescent feeder vessel (red dashed lines). Intrinsic mild ring-shaped fluorescence is well noted (g, red arrow). b High view of feeder vessel toward to inferior pigmented lesion. c, d, early fluorescein and indocyanine phase respectively. e, f, late fluorescein and indocyanine phase respectively
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Fig2
There was a minimally dilated feeding retinal arteriole across the lesion splitting the mass into a bi-lobulated "butterfly" appearance (Fig. 2b). Fluorescein angiography (FA) revealed mild ring-shaped fluorescence (Fig. 2g, red arrow) of the lesion in the arteriovenous phase that persisted without leakage into the late phase. Also, the FA showed early fluorescence (Fig. 2c) and late stained fluorescence (Fig. 2e) in the superior border lesion corresponding to the yellowish lesion. Indocyanine green not revealed intralesional cyanescence, but only weak cyanescence on superior boundary (Fig. 2d-f). The feeder vessel was cross-sectioned by SBOCT scans on Fig. 2g1, g2 (red dashed line) in the inner retina layer. A barely visible venule drainage capillary was solely detectable on early vascular FA-transit (Fig. 2c). Measurements obtained in unaffected superior-nasal area of OD, OS and hamartoma area (OS, inferiorly) revealed mean cone densities of 7355 (Fig. 6E1), 7175 (Fig. 6F1), and 16,375 (Fig. 6G1) cones/mm2, respectively.
OCT-angiography imaging and fluorescein angiography correlation. OCTA pictures from a superficial capillary layer, b deep capillary layer, c outer nuclear layer and d choriocapillaris. e, f Magnified images (red dashed) focusing increased FAZ (white arrow) and presence feeder arteriole vessel (red head-arrow) paired to drainage venule vessel (blue head-arrow). g Related FA area (yellow lined demarcation) showing hyperfluorescent intralesional radial vascularization and stained feeder vessel (red head-arrow)
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Fig3
Subsequently, the OCT-A depicted superficial (Fig. 3a) and deep (Fig. 3b) capillary layer which were zoomed (Fig. 3e, f) and manually correlated to fluorescein angiography (Fig. 3g). Besides, the feeder vessel (Fig. 3e, f, red arrowhead) was evident a venule-drainage capillary (Fig. 3e, f, blue arrowhead) mainly at superficial capillary level (Fig. 3a, e). In addition, the foveal avascular zone (FAZ) was more easily estimated on OCT-A, and was found to be increased FAZ inferiorly to the pigmented lesion (Fig. 3e, f, white arrows). The outer nuclear layer (Fig. 3c) and choriocapillaris (Fig. 3d) layer segmentation showed an artefact dark image from the pigmented lesion, blocking the under visualization.
En face OCT imaging. a ILM en face image showing hyper signal on pigmented lesion (white arrows). b IPL en face level showing deeper bright signal temporally. c, d RPE and choriocapillary en face level respectively, demonstrating the dark artefact secondary to optical transmission blocking by the hamartoma. e Horizontal OCT B-scan section showing the hiperreflective tissue on the superficial layers. A very small portion of the outer retina reflectivity may be seen between the two islands of the hamartomatous tissue (yellow arrow). f Vertical OCT B-scan section revealing hyperreflective pigmented portion and full thickness shadowing
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Fig4
Vertical and horizontal SBOCT sections (Fig. 4e, f) and en face imaging (Fig. 4a-d) were correlated. ILM en face image showed bright signal on the pigmented lesion (Fig. 4a) that correlated to the hyperreflective SBOCT within retinal inner layer (Fig. 4e, white arrow). In the IPL level (Fig. 4b) the en face image showed deeper bright signal temporally. Additionally, in the interior of the SBOCT shadowing region there was less reflectivity in the outer retina with external limiting membrane (ELM) layer and ellipsoid band absence and that could be related to the deep capillary shunt (Fig. 4e, yellow arrow). The RPE (Fig. 4c) and choriocapillaris (Fig. 4d) en face image demonstrating dark artefact, blocking the optical transmission.  
Sensitivity map and imaging correlating evaluation. a, b microperimetry from OS and OD respectively. c Apparent reduced retinal function near to the hamartoma (white dashed square). d Correlated hyposensitive area (orange and red asterisks) on yellowish color image as well as the fluorescent margin. e Related AO cell density hamartoma showing lack photoreceptor count on hyposensitive area (orange and red asterisks). f SBOCT evidencing absence of ellipsoid band and RPE interdigitations in the outer nuclear layer defected
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Fig5
A sensitivity map of OS (Fig. 5a, c) suggested reduced retinal function near the hamartoma area, conversely to the regular retinal function from sensitivity map of OD (Fig. 5b). Corresponding hyposensitivity areas (yellow and red asterisks) on yellowish color fundus (Fig. 5d1), hyperfluorescent on FA (Fig. 5d2), cell density absence (Fig. 5e) and SBOCT (Fig. 5f, black asterisk) were related. 
Adaptive optics imaging and AO system analysis. A, B color image focusing foveal zone (yellow dashed square). C, D showing adaptive optics en face image (1.2 mm x 1.2 mm) inward to 2-degree foveal center. E green dashed square of OD and F blue dashed square of OS uninvolved juxta-foveolar retina depicts 300 x 300 microm samples analysis for the cone cell density (parts E1 and F1), intercellular spacing (parts E2 and F2), and Voronoi polygon (parts E3 and F3). G orange dashed square of hamartoma region depicts 300 x 300 microm sample analysis for cone cell density (G1), intercellular spacing (G2), and Voronoi polygon (G3). (H1-3); entire hamartoma analysis (red dashed square)
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Fig6
The en face AO imaging inward to the macular 2-center degree (2 ) demonstrated an irregular reflective cell mosaic that became discontinuous with enlarged hyperreflective and hyporeflective polygonal shapes at the site of the lesion (Fig. 6D, red dashed square). High cone cell density was detected despite the tumor presence (Fig. 6D, orange dashed square). The unaffected matched superior nasal retina in both eyes within 2  on juxtafoveolar area revealed cone photoreceptors as continuous bright hyperreflective dots (Fig. 6C, green dashed square and D, blue dashed square). Representative 300 x 300 microm sampling windows from uninvolved (Fig. 6C, green dashed square and D, blue dashed area) and hamartoma (Fig. 6D, orange dashed square) areas were matched to spatial distribution inside 2  centered area and analyzed for standardized RTX 1 measurements which included intercellular spacing (normal range 15-20 microm), local cell density (normal range 20,000-30,000 cones/mm2), and number of neighboring cells (standardized value: approximately 6) using the AO software images to create color scale graphic representation. Measurements obtained in unaffected superior-nasal area of OD, OS and hamartoma area (OS, inferiorly) revealed mean cone densities of 7355 (Fig. 6E1), 7175 (Fig. 6F1), and 16,375 (Fig. 6G1) cones/mm2, respectively. Intercellular spacing was 11.98 (Fig. 6E2), 12.46 (Fig. 6F2) and 8.52 (Fig. 6G2) microm in the uninvolved superior-nasal area of OD, OS and hamartoma area respectively. Proportions of 6-sided Voronoi polygons were 33.8% (Fig. 6E3), 33.5% (Fig. 6F3) and 38.6% (Fig. 6G3) in the uninvolved superior-nasal area of OD, OS and hamartoma area respectively.