PMC6925683_01
Regeneration of the ellipsoid zone in a patient with laser-induced maculopathy. (a) Fundus photography on day 1 after the accident showing small central lesion in both eyes of patient 1. (b) B-scan OCT images through the fovea of the right and left eye depicts a hyperreflective band reaching from the retinal pigment epithelium (RPE) to the outer plexiform layer extending slightly to the perifoveal region (assumingly following the Henle fibers) and a hyporeflective zone expanding from the ellipsoid zone (EZ) to the external limiting membrane (ELM) in both eyes on day 1. It also showed thickened subfoveal outer retinal layers and a hyporeflective zone expanding from the EZ to the ELM. These findings diminish over follow-up (day 11, 46, and 249). Last follow-up on day 249 showed only a distinct hyporeflective zone in the outer retinal layers, boarded by intact ELM and RPE layers. (c) En face OCT images on the level of the EZ demonstrating a regeneration of the EZ alterations over time in both eyes. Early images show a central hyporeflective oval zone surrounded by a distinct hyperreflective ring and again a faint, fuzzily bounded hyporeflective zone. Late images show a pronounced hyporeflective defect in the EZ, decreasing in size over follow-up. Note the inhomogeneous choroidal hypertransmission as an indirect sign of incomplete RPE and outer retina damage visible on days 11 and 46 in both eyes.
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Patient 1 (Figure 3) was a 23-year-old male who looked directly into a green laser pointer light with each eye individually, presumably out of curiosity. Dilated ophthalmoscopic examination showed a central yellow spot in both eyes (Figure 3(a)). ELM and RPE was noted. Early en face OCT on the level of the EZ showed a hyporeflective oval zone surrounded by an inner distinct hyperreflective ring and an outer faint hyporeflective zone (Figure 3(c)).
B-scan and en face OCT images of patient 2 and 3 (a and b) and multimodal imaging data including autofluorescence imaging (c), fluorescein (d) and indocyanine green (e) angiography of patient 2. (a) OCT B-scan on day 7 through the foveal center shows a lammelar hole reaching up to the outer nuclear layer; En face OCT shows an EZ alteration boarded by a hyperreflective ring; On day 166 (last follow-up) closure of the lamellar hole and near complete regeneration of the EZ. An inhomogeneous choroidal hypertransmission can be detected until the last follow-up (star). (b) B-scan OCT on day 4 through the foveal center demonstrates a typical hyperreflective band in the outer retina reaching from the RPE to the outer plexiform layer; there was no distinct hyporeflective zone and no thickening of the outer retinal layers. One month after the incident, B-scan showed a distinct hyporeflective defect in the ellipsoid zone (EZ), which persisted until last follow-up on day 431. En face OCT on day 4 shows a mild hyperreflective circle, partially surrounded by a scantly hyporeflective zone area; on day 431 a clearly demarcated EZ loss can be observed. (c) Autofluorescence (Heidelberg Spectralis HRA+OCT, excitation at 488nm, barrier filter wavelength of 500nm) showed a hyperautofluorescent zone at first presentation (seven days after the incidence) in the impact region (arrow). (d) Fluorescein angiography (ten minutes after injection) ten days after the incidence did not show any leakage or staining. (e) Indocyanine-green (ICG) angiography (ten minutes after injection) did show minimal irregular hyper- and hypocyanescence in the region of impact (arrowhead).
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Patient 2 was a 19-year-old woman who had looked directly into a laser show light projector of unknown strength on holidays abroad and experienced a small central scotoma in her right eye (Figure 4(a)). There was a small area of hyperautofluorescence at first presentation in the impact region (Figure 4(c)). Fluorescein angiography 10 days after the incident did not show any leakage or staining (Figure 4(d)). Indocyanine-green (ICG) angiography at the same time point did show minimal irregular hyper- and hypocyanescence in the region of impact in the late frames (Figure 4(e)). Patient 3 (Figure 4(b)) was a 38-year-old male who watched a solar eclipse without any protection, but he closed the eyes alternatively.
Fundus photography, B-scan, and en face OCT images of a patient with solar maculopathy. (a) Fundus photography on day 3 after the accident shows central pigment alterations in both eyes of patient 4. (b) B-scan OCT images through the fovea show disruption of the retinal pigment epithelium (RPE) and the ellipsoid zone (EZ) as well as a hyperreflective band reaching from the outer nuclear layer to the outer plexiform layer (whereas the external limiting membrane (ELM) seemed to be intact) in both eyes on day 3, diminishing in the follow-up images (days 10, 52 and 115), while presenting hyperreflective granular appearances at the level of the EZ. Last follow-up 452 days after the incidence showed a smaller, clearly delineated EZ alteration with persistent hyperreflective granular appearances boarded by intact ELM and RPE layers. (c) En face OCT at the level of the EZ on day 3 shows a hyporeflective defect surrounded by a hyperreflective ring in both eyes. On day 10, the hyporeflective defect expands to the region where the hyperreflective ring was seen and a central defect with granular appearances comes to light. Follow ups on days 52 and 115 show a regression of the granular appearing central defect. Last follow-up 452 days after the incidence shows a smaller, clearly delineated EZ loss suggesting a partial, centripetal regeneration of the EZ alteration over time in both eyes.
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Patient 4 (Figure 5) was a 41-year-old male with a history of schizophrenia which was currently treated with escitalopram, a selective serotonin reuptake inhibitor, not known to have any effect on phototoxicity. Dilated ophthalmoscopic examination showed a clearly yellow area at the fovea with a reddish centre in both eyes (Figure 5(a)). EZ and a wide hyperreflective band reaching from the outer nuclear layer to the outer plexiform layer (Figure 5(b)), similar to patient 1. En face OCT at the level of the EZ showed a hyporeflective defect surrounded by a hyperreflective ring (Figure 5(c)), which evolved into a central alteration with granular appearances and expanding in size before regressing to a clearly delineated EZ loss.