Clinical Findings of Acquired Vitelliform Lesions Associated With Retinal Pigment Epithelial Detachments




Purpose


To study clinical findings associated with acquired vitelliform lesions in retinal pigment epithelial detachments (PEDs).


Design


Retrospective, interventional, consecutive case series.


Methods


We retrospectively reviewed 32 eyes of 24 patients (22 men, 2 women; age range [mean], 58-85 [73.7] years) with acquired vitelliform lesions.


Results


All eyes had acquired vitelliform lesions in the central macula associated with a serous PED at baseline. Of the 32 eyes, 30 (93.8%) were observed for 12 months, 26 (81.3%) for 24 months, and 17 (53.1%) for 36 months. The mean logarithm of the minimal angle of resolution best-corrected visual acuity (BCVA) levels were 0.19 at month 12, 0.28 at month 24, and 0.25 at month 36, none of which differed significantly from baseline. The mean changes in the BCVA were declines of 0.38, 1.29, and 1.21 lines at months 12, 24, and 36, respectively. Of 7 eyes treated with 3 consecutive monthly intravitreal injections of ranibizumab, the serous PEDs remained in all 7 eyes and the mean changes of BCVA were a decline of 2.40 lines 12 months after the first injection and a decline of 3.58 lines at the final visit. In the 24 untreated eyes, the mean change in the BCVA was a decline of 0.25 line at the final visit, which differed significantly ( P = .021) compared with that of the treated eyes at the final visit.


Conclusion


Intravitreal injections of ranibizumab were ineffective because of the absence of resolution of the PEDs and the declines in VA.


Gass first described adult vitelliform macular dystrophy as a peculiar macular dystrophy with bilateral and yellowish subretinal lesions. Yellowish and presumably subretinal material accumulates in various macular diseases such as adult-onset vitelliform macular dystrophy, basal laminar or cuticular drusen, pattern dystrophy, chronic central serous chorioretinopathy, macular vitreous traction, and age-related macular degeneration (AMD). Recently, this finding has been referred to as an acquired vitelliform lesion to avoid confusion with the terms vitelliform macular dystrophy and vitelliform macular degeneration. In eyes with acquired vitelliform lesions, subretinal fluid was reported in 19 of 90 eyes (21.1%), non-neovascular AMD was seen in 19 of 90 eyes (21.1%), and retinal pigment epithelial detachments (PED) were seen in 7 of 90 eyes (7.7%). However, no clinical findings have been reported in eyes with an acquired vitelliform lesion associated with a serous PED.


Choroidal neovascularization (CNV) secondary to exudative AMD is responsible for substantial visual loss. The presence of a serous PED in an eye with AMD is a risk factor for severe and irreversible visual loss. The prevalence of a vascularized PED (serous PED with CNV) accounts for 26%-31% of all newly diagnosed cases of exudative AMD. CNV complexes are composed of inflammatory cells and vascular endothelial growth factor (VEGF). Treatment with intravitreal ranibizumab (Lucentis; Genentech Inc, South San Francisco, California, USA) has become the standard therapy for AMD worldwide. However, photodynamic therapy (Visudyne; Novartis Pharma AG, Basel, Switzerland) and intravitreal ranibizumab in patients with acquired vitelliform lesions have not been efficacious.


The purpose of the current study was to report the clinical findings associated with acquired vitelliform lesions in PED.


Methods


We retrospectively analyzed 32 eyes of 24 patients with acquired vitelliform lesions. All patients underwent a routine follow-up examination at the Fukushima Medical University Hospital or the Vitreous-Retina-Macula Consultants of New York between May 2004 and December 2012. The institutional review board/ethics committee at the Fukushima Medical University and the Manhattan Eye, Ear, and Throat Hospital approved the retrospective chart review study and the retrospective comparative analysis performed in this study.


In the current study, baseline was defined as the period in which acquired vitelliform lesions were seen in the central macula associated with a serous PED. All patients underwent a complete examination including slit-lamp biomicroscopy with a contact lens and color or red-free fundus photography with a fundus camera (TRC-50 FA/IA/IMAGEnet H1024 system; Topcon, Tokyo, Japan). Fundus autofluorescence images were recorded with a Heidelberg Retina Angiograph 2 confocal scanning laser ophthalmoscope (Heidelberg Engineering, Heidelberg, Germany) with an excitation light with a wavelength of 488 nm (0.2 mW at the cornea) and a detection filter that transmitted light at wavelengths over 500 nm or a fundus camera (Topcon Medical System, Paramus, New Jersey, USA) with a bandpass filter for excitation light with a bandpass of 535-585 nm and a matched barrier filter with a bandpass of 605-715 nm. The retinal and choroidal images were obtained using spectral-domain optical coherence tomography (OCT) (Heidelberg Spectralis OCT; Heidelberg Engineering). In addition to conventional OCT scans, the choroid was imaged using enhanced depth imaging (EDI) by positioning the instrument sufficiently close to the eye to obtain an inverted image. Fluorescein angiography (FA) or indocyanine green angiography (ICGA) was performed when CNV was suspected.


Inclusion criteria were established at the funduscopic examination with the presence of an acquired vitelliform lesion in the macular region based on the presence of a well-circumscribed area of yellowish and presumably subretinal material detected in patients older than 40 years. We used the best-corrected visual acuity (BCVA) measured with a Japanese standard decimal visual acuity (VA) using Landolt ring eye chart or Snellen chart and calculated the mean BCVA using the logarithm of the minimal angle of resolution (logMAR) scale.


In patients with decreased VA compared to baseline, if patients desired treatment, we administered intravitreal ranibizumab injections. After the potential risks and benefits were explained in detail, all patients provided written informed consent. Intravitreal ranibizumab was injected 3.5-4.0 mm posterior to the corneal limbus into the vitreous cavity using a 30 gauge needle after topical anesthesia was applied.


Statistical analyses were performed using the Mann-Whitney U test to compare the VA outcomes. We used logMAR VA scores for statistical analysis.




Results


We evaluated 32 eyes of 24 patients (22 men, 2 women) with inclusion criteria over a follow-up period ranging from 0-103 months. Twenty-two patients were Japanese and 2 were white (age range, 58-85 years; mean ± standard deviation, 73.7 ± 6.6 years).


All eyes had an acquired vitelliform lesion in the central macula associated with a serous PED at baseline, which remained through the follow-up period ( Figures 1-9 ). In 11 of the 32 eyes (34.4%), although no acquired vitelliform lesions were seen during the first visit, they were observed during the follow-up period (range, 3-60 months; mean, 27 months).




Figure 1


Case 5. A 72-year-old man with an acquired vitelliform lesion with a pigment epithelial detachment (PED). At baseline, the best-corrected decimal visual acuity (VA) is 1.2 in the left eye. (Top left) A color photograph shows an acquired vitelliform lesion in the central macula associated with a serous PED (arrow). (Top right) A fluorescein angiography image shows hyperfluorescence without leakage. (Middle left) A late-phase indocyanine green angiography image shows no choroidal neovascularization. (Middle right) A fundus autofluorescence image shows blocked fluorescence corresponding to the fovea. (Bottom) Baseline horizontal (left) and vertical (right) spectral-domain optical coherence tomography images show hyperreflective material in the subretinal space (arrows).



Figure 2


Case 5. An acquired vitelliform lesion with a pigment epithelial detachment (PED) 30 months after baseline. The best-corrected decimal visual acuity (VA) decreased from 1.2 to 0.8 without treatment. (Top left) A color photograph shows an enlarged PED and an acquired vitelliform lesion (arrow). (Top right) A fluorescein angiography image shows an enlarged serous PED and hypofluorescence corresponding to the acquired vitelliform lesion (arrow). (Middle left) A corresponding late-phase indocyanine green angiography image shows no choroidal neovascularization. (Middle right) A fundus autofluorescence image shows hyperautofluorescence, corresponding to the yellowish material in the color photograph (arrow). (Bottom) Corresponding horizontal (left) and vertical (right) spectral-domain optical coherence tomography images show hyperreflective material beneath the inner segment/outer segment junction, subretinal fluid, and multiple thickenings or bumps in the retinal pigment epithelial band associated with a serous PED (arrows). Ranibizumab was administered.



Figure 3


Case 5. An acquired vitelliform lesion with a pigment epithelial detachment (PED) after 3 consecutive monthly intravitreal injections of ranibizumab (month 33). The best-corrected decimal visual acuity (VA) remains 0.8. (Top left) A color photograph shows a persistent acquired vitelliform lesion (arrow). (Top right) A fluorescein angiography image shows an unchanged serous PED and retinal pigment epithelial (RPE) tears (arrows). (Middle left) A corresponding late-phase indocyanine green angiography image shows no choroidal neovascularization. (Middle right) A corresponding fundus autofluorescence image shows hyperautofluorescence corresponding to the acquired vitelliform lesion and hypoautofluorescence corresponding to the RPE tear (arrows). (Bottom) Corresponding horizontal (left) and vertical (right) spectral-domain optical coherence tomography images show residual hyperreflective material (arrows). No additional treatment was performed.



Figure 4


Case 5. An acquired vitelliform lesion with a pigment epithelial detachment, 6 months after intravitreal ranibizumab treatment (month 36). The best-corrected decimal visual acuity (VA) decreased from 1.2 at baseline to 0.5. (Top left) A color photograph shows that the acquired vitelliform lesion spread and shows a retinal pigment epithelium (RPE) tear. (Top right) A fundus autofluorescence image shows hyperautofluorescence corresponding to the acquired vitelliform lesion (arrow) and hypoautofluorescence corresponding to the RPE tear (arrow). (Bottom) Corresponding horizontal (left) and vertical (right) spectral-domain optical coherence tomography images show residual hyperreflective material (arrows).



Figure 5


Case 7. A 70-year-old man with an acquired vitelliform lesion with a pigment epithelial detachment (PED). At baseline, the best-corrected decimal visual acuity (VA) was 0.8 in the left eye. (Top left) A color photograph shows soft drusen and a PED. (Top right) A fluorescein angiography image shows hyperfluorescence without leakage corresponding to the serous PED. (Bottom left) A late-phase indocyanine green angiography image shows no choroidal neovascularization. (Bottom right) Baseline horizontal (top) and vertical (bottom) optical coherence tomography images show hyperreflective material in the subretinal space (arrows).



Figure 6


Case 7. An acquired vitelliform lesion with a pigment epithelial detachment (PED) 64 months after baseline. The best-corrected decimal visual acuity (VA) decreased from 0.8 to 0.4 without treatment. (Top left) A color photograph shows an enlarged PED and an acquired vitelliform lesion (arrows). (Top right) A fundus autofluorescence image shows small foci of increased autofluorescence signals corresponding to the acquired vitelliform lesion (arrows). (Middle left) A fluorescein angiography image shows enlargement of the serous PED and hypofluorescence corresponding to the acquired vitelliform lesion. (Middle right) A corresponding late-phase indocyanine green angiography image shows no choroidal neovascularization. (Bottom) A corresponding horizontal spectral-domain optical coherence tomography image shows hyperreflective material beneath the inner segment/outer segment junction, subretinal fluid, and multiple thickenings or bumps in the retinal pigment epithelial band associated with the serous PED (arrows). Ranibizumab was administered.



Figure 7


Case 7. An acquired vitelliform lesion with a pigment epithelial detachment (PED) after 3 consecutive monthly intravitreal injections of ranibizumab (month 67). The best-corrected decimal visual acuity (VA) remains 0.4. (Top left) A color photograph shows a persistent acquired vitelliform lesion. (Top right) A fundus autofluorescence image shows that the acquired vitelliform lesion remains. (Middle left) A fluorescein angiography image shows a serous PED and the remaining acquired vitelliform lesion. (Middle right) A late-phase indocyanine green angiography image shows no choroidal neovascularization. (Bottom) A corresponding horizontal spectral-domain optical coherence tomography image shows residual hyperreflective material (arrows). No additional treatment was administered.



Figure 8


Case 8. A 79-year-old woman with an acquired vitelliform lesion with a pigment epithelial detachment (PED). At baseline, the best-corrected decimal visual acuity (VA) is 0.4 in the right eye. (Top left) A color photograph shows an acquired vitelliform lesion in the central macula associated with a serous PED (arrow). (Top right) A fundus autofluorescence image shows small foci of increased autofluorescent signals corresponding to the acquired vitelliform lesion (arrow). (Middle left) A fluorescein angiography image shows a serous PED and no leakage. (Middle right) A corresponding late-phase indocyanine green angiography image shows no choroidal neovascularization. (Bottom) Baseline horizontal (left) and vertical (right) spectral-domain optical coherence tomography images show hyperreflective material in the subretinal space (arrows).



Figure 9


Case 8. An acquired vitelliform lesion with a pigment epithelial detachment (PED) 22 months after the baseline. The best-corrected decimal visual acuity (VA) has increased from 0.4 to 1.2 without treatment. (Top left) A color photograph shows that the PED resolved spontaneously and the acquired vitelliform lesion remains (arrow). (Top right) A fundus autofluorescence image shows that the acquired vitelliform lesion remains (arrows). (Bottom) Baseline horizontal (left) and vertical (right) spectral-domain optical coherence tomography images show flattening of the retinal pigment epithelium and residual hyperreflective material in the subretinal space (arrows).


In all eyes with an acquired vitelliform lesion associated with a PED at baseline, a yellowish lesion was seen in the central macula; OCT localized the yellowish lesion as the high reflective material in the subretinal space above the retinal pigment epithelial (RPE) layer ( Figures 1, 5, and 8 ). Fundus autofluorescence images showed small foci of increased autofluorescence signals corresponding to acquired vitelliform lesions. FA and ICGA were performed for 23 and 22 eyes, respectively. One eye had occult CNV with no classic component.


The mean size of the PED in all eyes at baseline was 3.8 disc areas. In 10 of the 32 eyes (31.3%), the serous PED resolved spontaneously during the follow-up period ( Figure 9 ). At the final visit, the PED was unchanged in 13 eyes (40.6%), decreased in size in 4 eyes (12.5%), and enlarged in 4 eyes (12.5%) ( Figures 4 and 7 ). One eye (3.1%) was lost to follow-up and no data were available.


Twelve eyes underwent EDI-OCT, which showed that the choroidal thickness under the acquired vitelliform lesions was a mean of 290 ± 83 μm ( Table ).



Table

Acquired Vitelliform Lesions Associated With Retinal Pigment Epithelial Detachments


























































































































































































































































































































































































































































































































































Case Age (y) Sex Eye AVLs Duration From First Visit to Baseline (mo) Baseline
VA (logMAR) PED Choroidal Thickness Final Visit
Size (DA) Follow-up (mo) Treatment VA (logMAR) PED
1 81 M Left Yes 0 0.05 Serous 3.0 NA 65 No 0.10 Di
2 74 M Right Yes 3 0.30 Serous 13.5 NA 13 No 0.40 Di
3 Left Yes 3 0.15 Serous 4.7 NA 13 No 0.30 NC
4 78 M Right Yes 0 0.52 Serous 7.8 NA 53 No 0.22 Di
5 72 M Left Yes 0 −0.08 Serous 0.8 NA 66 IVR 0.30 Di
6 70 M Right Yes 59 −0.08 Serous 1.8 NA 44 No 0.10 NC
7 Left Yes 0 0.10 Serous 1.3 NA 103 IVR 0.70 Di
8 79 F Right Yes 0 0.40 Serous 4.2 NA 22 No −0.08 Di
9 79 M Right Yes 27 0.30 Serous 5.3 NA 22 IVR 0.70 NC
10 67 M Left Yes 0 0.00 Serous 3.1 NA 46 No −0.08 Di
11 71 M Left Yes 0 0.00 Serous 1.6 NA 52 No 0.00 Di
12 79 M Right Yes 0 0.10 Serous 3.9 NA 51 IVR 0.52 De
13 Left Yes 0 0.82 Serous 8.0 NA 51 No 1.22 De
14 58 F Right Yes 47 0.15 Serous 1.4 NA 35 No 0.22 En
15 74 M Right Yes 0 0.05 Serous 3.4 255 20 No 0.30 NC
16 Left Yes 0 0.00 Serous 5.6 120 20 No 0.22 NC
17 76 M Right Yes 15 0.15 Serous 1.9 397 26 No 0.22 En
18 Left Yes 0 0.22 Serous 5.9 378 41 IVR 1.15 En
19 73 M Right Yes 5 0.15 Serous 3.7 329 32 No 0.22 De
20 Left Yes 0 0.00 Serous 3.4 263 36 No 0.00 NC
21 67 M Right Yes 0 −0.08 Serous 1.8 220 37 No −0.08 En
22 71 M Right Yes 17 0.05 Serous 1.8 NA 44 No −0.08 Di
23 Left Yes 0 0.10 Serous 0.9 NA 61 No 0.15 Di
24 69 M Right Yes 31 0.15 Serous 0.9 NA 31 No 0.15 NC
25 Left Yes 31 0.15 Serous 1.3 NA 31 No 0.22 NC
26 81 M Right Yes 0 0.10 Serous 15.8 418 18 No 0.00 De
27 85 M Right Yes 0 0.15 Serous 2.3 281 24 No 0.05 NC
28 80 M Left Yes 0 0.22 Serous 1.5 277 18 IVR 0.05 NC
29 81 M Right Yes 0 0.15 Serous 4.2 245 11 IVR 0.10 NC
30 69 M Right Yes 60 −0.08 Serous 3.0 NA 6 No 0.00 NC
31 76 M Right Yes 0 0.30 Serous 1.6 NA 22 No 0.30 NC
32 61 M Left Yes 0 1.00 Serous 1.8 302 0 No 1.00 NA
Mean 73.7 0.18 3.8 34.8 0.27
SD 6.6 0.24 3.4 21.2 0.34

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Jan 8, 2017 | Posted by in OPHTHALMOLOGY | Comments Off on Clinical Findings of Acquired Vitelliform Lesions Associated With Retinal Pigment Epithelial Detachments
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