PMC8077444_01
a Multimodal imaging at presentation: infrared photography with hemorrhage ( ) next to minor dots ( ) and bright spots (*). b Blue-peak FAF separating blood ( ) from SRF ( ) and a SD-OCT with vitreous cells ( ); SRF mixed with subretinal hyperreflective material (*). c Early FA angiography of a subretinal CNV ( ) besides ill-defined hyperfluorescence ( ) and a SD-OCT with a RPE defect ( ) due to a neovascular breakthrough. d Early indocyanine green angiography with the CNV ( ) besides hypocyanescent dots ( ) corresponding to defects of the RPE ( ) in the SD-OCT. e Dense CNV with capillaries ( ) and a feeder trunk ( ) in a SS-OCTA image and its corresponding outer retina segmentation. FAF, fundus autofluorescence; SRF, subretinal fluid; SD-OCT, spectral domain-optical coherence tomography; FA, fluorescein; CNV, choroidal neovascularization; RPE, retinal pigment epithelium; SS-OCTA, swept source-optical coherence tomography angiography.
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F1
The funduscopic appearance revealed several central bright dots next to submacular hemorrhage with minimal vitreous inflammation only in her right eye (Fig. 1a). Fundus autofluorescence set the hemorrhage apart from subretinal fluid (SRF) (Fig. 1b). FA showed early leakage consistent with CNV type 2 (Fig. 1c). Early indocyanine green angiography identified a subfoveal choroidal neovascular network and several well-circumscribed dots of hypocyanesence suggesting a deeper choroidal origin of the lesions (Fig. 1d). SS-OCTA 4.5 x 4.5 mm isolated a dense vascular network with numerous capillary branches and anastomoses (Fig. 1e).
a Follow-up 1 month later after 1 IVR and systemic corticosteroids infrared photography with resolution of subfoveal hemorrhage ( ), demarcated dots ( ), and spots (*) in the posterior pole. b FAF with an almost normal hypo-FAF of the foveal depression ( ) next to a circumscribed hyper-FAF plaque consistent with the SD-OCT demonstrating prominent subretinal hyperreflective material (*) and neither SRF nor intravitreal inflammation. c Glomerular loops ( ) with filamentous feeder vessels ( ) in the SS-OCTA of an outer retina segmentation encompassing the whole lesion. IVR, intravitreal ranibizumab; SRF, subretinal fluid; FAF, fundus autofluorescence; SD-OCT, spectral domain-optical coherence tomography; SS-OCTA, swept source-optical coherence tomography angiography.
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F2
A complete resolution of blood was observed biomicroscopically and of SRF in the structural SD-OCT 1 month later (Fig. 2a, b), while downsizing of the CNV area and a reduction of vessel density could be displayed in SS-OCTA en face scans (Fig. 2c).
a Follow-up comparing functional SS-OCTA en face scans with structural SD-OCT B-scans over time. b Second IVR based on small vessels at the tip of the CNV ( ) 1 month after initial presentation. c Low flow in the feeder trunks ( ) and no flow (*) in the neovascular network 1 week later. d Recirculation of the pre-existing CNV with regression of vessel termini as compared to image A after another month. e Third IVR based on new vessel formation and increased vessel density ( ). f Fourth IVR due to ongoing neovascular growth ( ) besides white band artefacts (*). g Regression of the network 1 month later. h Fifth IVR due to new capillaries at the lesion border similar to image D and as opposed to image F ( ). Numerous new branches ( ) led to the sixth IVR No sign of ongoing new vessel growth 1 month (i), 6 months (j), and 11 months (k) after the last IVR. l No well-defined neovascular growth 33 months after initial presentation. SS-OCTA, swept source-optical coherence tomography angiography; SD-OCT, spectral domain-optical coherence tomography; IVR, intravitreal ranibizumab; CNV, choroidal neovascularization.
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F3
A total of 6 IVR were administered based on the growth or regression of new vessels at the border of the CNV lesion (Fig. 3a-h). At the last follow-up, best-corrected visual acuity was 20/20 Sn while SS-OCTA en face scans showed hyperdense vessel formation pointing toward the foveal umbo, suggesting either non- or very slow lesion progression (Fig. 3i-l).