The RAP study, report 3: Discoloration of the macular region in patients with macular neovascularization type 3

Abstract

Background/Aims To explore whether the existence and pattern of distribution of macular haemorrhage or exudate can be valuable diagnostic markers for macular neovascularization type 3 (MNV3) in patients with neovascular age‐related macular degeneration. Methods Eighty‐three eyes of 83 consecutive treatment naïve patients with stage 3 MNV3 were enrolled. The diagnosis was based on fluorescein angiography (FA) and optical coherence tomography (OCT). Subretinal and intraretinal haemorrhage and dense exudates were evaluated on colour fundus photography. Fluorescein angiography (FA) images and OCT scans were used to identify the axial location of the haemorrhage. 83 patients with MNV1 and 83 with MNV2 were included as two control groups. Results In the MNV3 group, 62 (75%) eyes had intraretinal haemorrhage and 52 (63%) had dense exudates. 73 (88%) eyes had intraretinal haemorrhage and/or dense exudates. 41 (49%) had both pathologies. The intraretinal haemorrhage was flame shaped over the lesion and punctate or semi‐punctate further away from it and directed to the fovea. No subretinal haemorrhage was noticed. In the MNV1 and MNV2 groups, 11 (13%) and 24 (29%) eyes had subretinal haemorrhage or dense exudates, respectively. No intraretinal haemorrhage was seen in the two control groups. The prevalence of exudates and haemorrhage (irrespective of its location) was greater in MNV3 than in MNV1 or 2 (p < 0.0001). Conclusion The existence and pattern of distribution of intraretinal haemorrhage is pathognomonic of MNV3. It makes (alone or with dense exudates) the diagnose MNV3 possible using fundoscopy or colour fundus photo and without further diagnostic expenditure.

The RAP study, report 4: morphological and topographical characteristics of multifocal macular neovascularization type 3

“…In case of uncertainty of the exact axial location of a hemorrhage, it was verified as homogenous hyperreflective material which commonly causes underlying shadows on the corresponding OCT (Fig. 2) [15]. We also verified the presence of laminated hyperreflective material (onion sign) as a mark of extensive lipid deposition in the sub-PED space on OCT [16].…”

“…An explanation for the high percentage of intraretinal hemorrhage could be its natural course from the angiogenic network which grows vertically deep into the retina before it extends horizontally within the subretinal space. Therefore, such fragile vertical neovessels are less capable to stretch and tend to bleed as a result from the inevitable swelling of the intraretinal retina [15]. The high presence of intraretinal cysts in all eyes with MNV3 compared to those with other types supports this explanation of the mechanism [13].…”

“…1 and 2). Also, the existence of intraretinal hemorrhage as small splinter-shaped or focal intraretinal hemorrhage on CFP was explored [15]. In case of uncertainty of the exact axial location of a hemorrhage, it was verified as homogenous hyperreflective material which commonly causes underlying shadows on the corresponding OCT (Fig.…”

Correspondence

“…4,5 (c) Quantitative: The number of cysts (IRF) grows consistently with the progression of the lesion from Stages 1 to 3 as presented in the classification of Su et al 2 Thus, it would be needed to quantify the amount of IRF in both groups for a fair IRF comparison.(d) Morphological: Type 3 is frequently accompanied by intracystic and inner retinal hemorrhage in contrast to Types 1 and 2. 4 This complication induces a toxic and inflammatory retinal damage, which also correlates with the progression of the disease from Stages 1 to 3.SRF: At Stage 3, the pigment epithelium detachment is mainly subfoveal 6 and the overlying SRF is situated, as the authors mentioned in the discussion, at the boundary of the pigment epithelium detachment, i.e., extrafoveal, 2 and is therefore not related to the decrease in visual acuity noticed at this advanced stage. In addition, SRF in treatment-naïve Type 3 lesions, in contrast to SRF in Type 1 or 2, is never accompanied by subretinal hemorrhage, which enhances the damage of the photoreceptors causing severe visual loss.…”

“…2,3 Thus, IRF emerging from the lesion is extrafoveal at first, whereas at Stage 3, when the lesion is established (Group B), IRF extends preferentially to the center causing subfoveal edema and a massive loss of vision consequently. 4…”