Benefits and Limitations of OCT-A in the Diagnosis and Follow-Up of Posterior Intraocular Inflammation in Current Clinical Practice: A Valuable Tool or a Deceiver?

Abstract

Purpose: Optical coherence tomography angiography (OCT-A) has been applied to uveitis and intraocular inflammation since its availability after 2014. The imaging of retinal and choroidal vascularization without the use of dyes was a major development and represented a potentially valuable tool in ocular research. In addition to such use, OCT-A is often put forward as being able to potentially replace invasive methods needing dye injection, such as fluorescein angiography (FA) and indocyanine green angiography (ICGA). The aim of this review was to establish whether OCT-A was sufficiently useful in everyday routine clinical practice to monitor disease evolution and to perform treatment adjustments to the extent that it could reliably replace the standard dye methods. Methods: Selective literature review and analysis of own data and experience. Results: OCT-A is a technologically high-grade imaging modality allowing to analyze retinal circulation in inflammatory diseases of the posterior pole with a high sensitivity useful for research purposes. However, there is no evidence that it reaches equal effectiveness in the routine management of posterior uveitis involving the retina. OCT-A is unable to show leakage. In choriocapillaritis involving pre-capillary vessels, it shows capillary drop-out but does not seem to have an advantage over ICGA except that it can be repeated easily, not being invasive, and so allows a closer follow-up. It is, however, less useful in end-choriocapillary non-perfusion, such as in MEWDS. For choroidal stromal inflammation, OCT-A is ill-suited as it only shows inconsistent secondary circulatory changes produced by choroidal foci. OCT-A seems to be useful in the diagnosis and follow-up of inflammatory chorioneovascularisation (iCNV), although dye exams are more precise in showing the activity of the iCNV. Conclusion: In summary, OCT-A is a very sensitive modality for the retinal circulation in uveitis for research purposes; it is sometimes useful for close follow of choriocapillary drop-out but not in end-capillary non-perfusion. Its use for monitoring purposes in stromal choroiditis, however, is questionable. Its claim to possibly replace classical angiographic work-up for the practical management of posterior uveitis is largely overrated.

Optical coherence tomography angiography (OCTA): A review of the current literature

“…However, a study by Herbort et al highlights the limitations of OCTA in the diagnosis and follow-up of posterior intraocular inflammation, and suggests that it should be used in combination with other imaging modalities and clinical examination. The study also suggests that the interpretation of OCTA images requires a high level of expertise, and that false positive and false negative results can occur if the images are not properly interpreted (24).…”

Review on imaging methods in non-infectious posterior uveitis, principles, relevance, and practical clinical applications to disease entities

“…Thanks to a semiquantitative angiographic scoring system the proportion of inflammatory involvement in both structures can be calculated. [7,26] The proportion of respective involvement can be very different from one case to another as shown in figures 24 Figure 23. Extreme sensitivity and global information on whole fundus involvement given by ICGA.…”

“…The limited field of view in commercially available instruments is a major disadvantage, as is the case for OCT, when compared to dye exams. The presentation of the retinal vasculature and choriocapillaris without the use of a dye was a revolution which led to theories that OCT-A could replace the dye exams which is absolutely not the case [24,25], but nevertheless stimulated the publication of articles attempting to oppose the two methodologies [26,27]. Indeed, OCT-A is of limited practical value in everyday routine clinical practice with limited valueadded information after other multimodal investigations have been performed [28].…”

Optical coherence tomography angiography: a review of the current literature

“…The study also showed that OCTA was able to detect inflammation in areas that were not visible on clinical examination, suggesting that it may be able to identify early stages of inflammation. 43 It should be noted that a study by Herbort et al 44 highlighted the limitations of OCTA in the diagnosis and follow-up of posterior intraocular inflammation, and the findings suggested that it should be used in combination with other imaging modalities and clinical examination. The study also suggested that the interpretation of OCTA images requires a high level of expertise and that false-positive and false-negative results can occur if the images are not properly interpreted.…”

“…The study also suggested that the interpretation of OCTA images requires a high level of expertise and that false-positive and false-negative results can occur if the images are not properly interpreted. 44 …”