Investigation of Choroidal Thickness and Choroidal Vascularity Index in Ocular Rosacea Patients According to Skin Subtypes

Pieklarz B., Gińdzieńska-Sieśkiewicz E., Zawadzka I., Bagrowska M., Daniluk J., Palewski M., Zonenberg A., Kowal-Bielecka O., Konopińska J., Dmuchowska D.A.

Abstract Purpose The aim of this study was to investigate choroidal parameters in patients with systemic sclerosis (SSc) using enhanced depth imaging spectral-domain optical coherence tomography (EDI-SD-OCT) and to determine their relationships with clinical variables and ocular features. Methods Thirty-three patients with SSc and 40 controls were enrolled. The groups did not differ with regard to age, sex, and axial length. The mean choroidal thickness and volume were obtained in each conventional Early Treatment of Diabetic Retinopathy Study grid subfield. The choroidal vascularity index (CVI), which provides a quantitative analysis of vasculature by calculating the proportion of the luminal area (LA) to the total choroidal area (TCA), was determined. Results Lower choroidal thickness and volume were observed in the SSc group. The CVI was significantly higher in SSc patients, whereas the TCA, LA, and stromal area were significantly lower in the SSc group; however, the significant difference of the stromal component was more pronounced than that of the luminal component. Regression analyses did not identify any clinical factors associated with the CVI (except Ca-blocker use), central macular thickness, or volume. No significant differences in choroidal parameters were found within the SSc subtypes (diffuse cutaneous systemic sclerosis (dcSSc) vs. limited cutaneous systemic sclerosis (lcSSc)), or between eyes stratified according to SSc pattern (early, active, or late) using nailfold capillaroscopy (p > 0.05 for all). Conclusion Our results, with notably higher CVI values, may shed new light on choroidal impairment in patients with SSc. Stromal involvement appeared to dominate the vascular component.

Soysal G.G., Berhuni M., Özer Özcan Z., Tıskaoğlu N.S., Kaçmaz Z.

To present the effects of vitamin D insufficiency on the choroidal vascularity index, central choroid and central macula.42 eyes of 42 patients with vitamin D insufficiency and 51 eyes of 51 age- and sex-matched healthy subjects were included in this retrospective, cross-sectional, and comparative study. The macular layer was examined using the retinal mapping mode of the spectral domain Optical coherence tomography (Optovue RTVue XR, Optovue Inc., Fremont, CA). Optical coherence tomography (OCT) images were taken in Enhanced Deep Imaging mode and transferred to Image J program. choroidal vascularity index (CVI) and subfoveal choroidal thickness (SFCT) measurements were evaluated.The mean age of volunteers was 35.4 ± 7.2 years. There was a significant difference in CVI values 67.75±2.4 in the patients with vitamin D insufficiency and 69.22±1.75 in the control group. The SCFT of patients with vitamin D insufficiency and control group were 295.25±42.3 and 335.71±11.6 (p = 0.001, p

Yesilirmak N., Bukan N., Kurt B., Yuzbasioglu S., Zhao M., Rodrigues-Braz D., Aktas A., Behar-Cohen F., Bourges J.

Patel N.V., Gupta N., Shetty R.

Rosacea is a chronic, inflammatory facial dermatosis commonly found in fair skin tone population. Recent studies have shown the increasing prevalence in the dark skin tone population as well. Ocular involvement is very common and can occur without cutaneous features. Common ocular features are chronic blepharoconjunctivitis with eyelid margin inflammation and meibomian gland dysfunction. Corneal complications include corneal vascularization, ulceration, scarring, and rarely, perforation. Diagnosis is largely based on clinical signs, although it is often delayed in the absence of cutaneous changes, particularly in children. The management ranges from local therapy to systemic treatment, depending on the severity of the disease. There is a positive association between demodicosis and rosacea; however, causality is always argued. In this review, we describe the epidemiology, clinical features, and treatment of rosacea and ocular rosacea.

Kaur G., Redd T.K., Seitzman G.D.

Management of ocular rosacea is challenged by the limited evidence-based systemic treatment guidelines and lack of elucidated mechanisms of treatment efficacy.We conducted an online survey of clinicians who regularly treat ocular rosacea to elicit their opinions on treatment algorithms and understanding of the treatment's primary mechanism of action. Descriptive statistics and univariate comparisons were reported.One hundred thirty-two participants completed the online survey. Of the 132 respondents, 74% were cornea specialists. Most respondents (85%) favored systemic tetracyclines over macrolides. Providers' specialty training did not significantly influence preference between tetracyclines and macrolides for ocular rosacea management. Among tetracycline prescribers, there was no consensus regarding initial dosage and duration prescribing patterns. Most macrolide prescribers (88%) initiated a 3-week course of 1 gram of azithromycin weekly. Long-term management strategy for treatment-responsive patients varied: 46% preferred to half the initial dose, 29% discontinued pharmacotherapy, and 16% chronically pulse-dosed patients. Most tetracycline prescribers (90%) and macrolide prescribers (73%) postulate their chosen agents' primary mechanism of effect for ocular rosacea is anti-inflammatory. However, there was no consensus in identifying anti-inflammatory doses of either drug class. Furthermore, there is discordance between prescribers' intended mechanistic effect with the selection of initial dosages for both tetracycline and macrolides for ocular rosacea.Among clinicians who commonly treat ocular rosacea, there is significant community equipoise regarding which dose of tetracycline is best for initial systemic treatment of this disease. In addition, a consensus understanding regarding mechanism of action of this treatment is lacking.

Kongwattananon W., Kumar A., Oyeniran E., Sen H.N., Kodati S.

To investigate the longitudinal changes in choroidal vascularity index (CVI) in eyes with active and quiescent intermediate uveitis using enhanced depth imaging optical coherence tomography (EDI-OCT).EDI-OCT images of eyes with active and quiescent intermediate uveitis were retrospectively reviewed and binarized using ImageJ software. Choroidal parameters including CVI, total choroidal area (TCA), luminal area (LA), stromal area (SA), and subfoveal choroidal thickness (SCT) were measured and compared between baseline and follow-up visits among eyes with active and quiescent intermediate uveitis.Thirty-eight eyes from 21 patients with active intermediate uveitis and 30 eyes from 17 patients with quiescent intermediate uveitis were included. CVI in eyes with active intermediate uveitis significantly increased from baseline (66.50% ± 3.40%) with resolution of inflammation on follow-up (68.82% ± 3.90%; P < 0.001). In eyes with quiescent intermediate uveitis at baseline eyes, CVI did not significantly change after follow-up (66.34% ± 3.19% to 66.25% ± 3.13%; P = 0.850).CVI significantly increased when active inflammation in intermediate uveitis resolved while CVI remained unchanged at follow-up in quiescent intermediate uveitis.CVI may be a useful noninvasive tool to monitor treatment response in intermediate uveitis. Our findings also highlight the involvement of choroidal vasculature in uveitic eyes without any clinical evidence of choroiditis.

Şahin T., Öztekin A., Cevher S.

This study aims to compare the choroidal thickness (CT) of patients with rosacea with healthy individuals.This study was conducted with 42 patients with Papulopustular Rosacea (PPR), 38 patients with Erythematotelangiectatic Rosacea (ETR), and gender and age-matched 37 healthy individuals in the control group. CT measurements were done using the spectral-domain optical coherence tomography.Choroidal thickness means were measured as 352 ± 78 μm, 331 ± 67 μm, and 346 ± 83 μm at the subfoveal region; 323 ± 72.3 μm, 303.5 ± 68.4 μm, and 314 ± 80.3 μm at 1000 μm nasal; and 325.2 ± 71 μm, 304.4 ± 52.2 μm, and 309 ± 67 μm at 1000 μm temporal in the PPR, ETR, and control groups, respectively (p > 0.05).Although rosacea is a common chronic skin disease that could have systemic findings, CT is not affected by this disease.

Aşıkgarip N., Temel E., Kıvrak A., Örnek K.

Purpose: To assess the impact of systemic hypertension on the choroidal structure and choroidal vascularity index (CVI). Methods: This prospective cross-sectional study comprised 50 eyes of 50 treatment-naive hypertensive patients and 50 eyes of 50 healthy subjects. Choroidal thickness (CT) was measured in the subfoveal region, 1500 µm nasal to the fovea, and 1500 µm temporal to the fovea. Binarization of the enhanced depth-optical coherence tomography images was performed with Image-J software. The CT, choroidal area (CA), luminal area (LA), and CVI were compared statistically. Results: The mean subfoveal, nasal, and temporal CT were decreased in the patient group (p 0.003, 0.026, and 0.001, respectively). The mean CA, LA, and CVI were decreased in the patient group in comparison to controls ( p = 0.047, 0.009, and 0.016 respectively). The correlation between the subfoveal CT and systolic blood pressure was significant ( r = −0.450, p < 0.001). There was a significant correlation between the systolic blood pressure and CVI ( r = −0.401, p < 0.001). Conclusion: The significant decrease in the structural parameters and CVI show that choroid is affected in patients with treatment-naive hypertension.

Ozcelik-Kose A., Balci S., Turan-Vural E.

• Binarisation of the EDI-OCT images might be a useful technique to differentiate which layers of the choroid affected with the ocular diseases. • In patients with Fuchs uveitis syndrome vitreous condensation and chorioretinal scars are signs of involvement of the posterior segment. • We used new binarisation technique and demonstrated that structural changes in the luminal part of choroid in the affected eyes of these patients. This study aimed to investigate changes in the choroidal vascularity index (CVI) in eyes with Fuchs uveitis syndrome (FUS) and determine the effect of heterochromia on choroidal vascularity using binarisation of enhanced-depth imaging (EDI)-optical coherence tomography (OCT) images. The study included the affected eyes (FEs) and unaffected fellow eyes (NFEs) of 24 patients with unilateral FUS and the eyes of 30 healthy controls (HCs). The subfoveal total choroidal area (TCA) and the luminal area (LA) were determined by binarised EDI-OCT images using Image J software (National Institutes of Health, Bethesda, MD). The CVI value was calculated by dividing the LA value by the TCA value. The CVI values were significantly lower in FEs (58.8 ± 3.7 %) compared to NFEs (62.3 ± 3.9 %, p = 0.002) and HCs (61.1 ± 3.7 %, p = 0.008). The mean LA was significantly narrower in FEs than in NFEs (p = 0.047) and HCs (p = 0.001). Additionally, the mean CVI values were significantly lower in eyes with heterochromia compared to those without heterochromia (p = 0.024) in the affected eyes of patients with FUS. This study shows that there are significant quantitative structural changes, especially in the luminal part of the subfoveal choroid, in eyes with FUS. The choroid seems to be more affected in the presence of heterochromia. These findings might support posterior involvement and the chronicity of the disease.

Sekeryapan Gediz B., Ozturk M., Kilinc Hekimsoy H., Yuksel E.G., Ozdamar Erol Y.

To evaluate choroidal vascularity index (CVI) and to investigate the association of CVI with neutrophil-to-lymphocyte ratio (NLR) as an indicator of inflammation in obsessive-compulsive disorder (OCD).This prospective study included newly diagnosed OCD patients and healthy controls. All patients underwent EDI-OCT imaging to assess the subfoveal choroidal thickness (sCT) and peripapillary CT (pCT). CVI was defined as the ratio of luminal area to stromal area after binarization on EDI-OCT images.A total of 39 patients with OCD and 25 controls were included. The sCT, pCT, and CVI values were significantly higher in the OCD vs. control group (p˂0.05 for all). The NLR values were significantly higher in the OCD vs. control group (p = .007). A significant positive correlation was noted between CVI and NLR (p = .039).Our findings suggest that systemic inflammation may play a role in the pathogenesis of OCD.

BAYTAROĞLU A., KADAYIFÇILAR S., AĞIN A., DELİKTAŞ Ö., DEMİR S., BİLGİNER Y., KARAKAYA J., ÖZEN S., ELDEM B.

To assess EDI-OCT (enhanced depth imaging optical coherence tomography) of choroid for inflammatory signs in children with polyarteritis nodosa (PAN) and adenosine deaminase-2 deficiency (DADA-2). In this cross-sectional study conducted between June 2017 and September 2018, we evaluated children diagnosed with PAN (n = 11) and DADA-2 (n = 4) and an age- and sex-matched control group (n = 15). Demographic and laboratory data were retrospectively analyzed from patient charts. Disease activity was assessed using the pediatric vasculitis activity score (PVAS). Choroidal images were obtained with spectral domain-OCT to measure choroidal thickness (ChT) at 5 points (750 and 1500 μm from the foveal center in the temporal and nasal quadrants and beneath the fovea), and to calculate the total subfoveal choroidal area (TCA), luminal area (LA), stromal area (SA), and the choroidal vascularity index (CVI). The median (min-max) age was 8 (4–16) years in PAN patients, 6 (5–16) years in DADA-2 patients and 8 (8–10) years in control group at the OCT visit (p = 0.214). The ChT at 3 points and the TCA, LA, and SA were higher in children with both PAN and DADA-2 patients compared to those of the control group (p < 0.0001, p = 0.049, p = 0.007, p = 0.007, p = 0.006, p = 0.033, respectively). The CVI was similar in both groups. No association was observed between the OCT findings, PVAS, and the erythrocyte sedimentation rate, and serum leukocyte and C-reactive protein levels. Similar CVI scores were obtained from PAN and DADA2 patients under treatment and from healthy controls. Increased subfoveal ChT without any other signs of ocular involvement may suggest choroidal thickening as a sign of mild subclinical inflammation.

Ozer M.D., Batur M., Tekin S., Seven E., Kebapci F.

This study aimed to compare the choroidal vascularity index (CVI) of eyes having Fuchs’ uveitis syndrome (FUS) with healthy fellow eyes (N). This prospective, cross-sectional study included unilateral FUS cases and an age- and gender-matched healthy control group. Thirty-nine participants were included in the FUS group, and 24 age- and gender-matched individuals were randomly selected for the control group. Endothelial cell density (ECD) was measured using Tomey specular microscopy. Spectral-domain optical coherence tomography was used to acquire the choroidal images, and binarization was applied to the images. Two blinded investigators analyzed the CVI in both eyes of the FUS cases and the right eyes of the healthy control group. CVI was found to be significantly decreased in FUS (p < 0.001). Additionally, ECD had a strong positive correlation with CVI (r = 0.383, p = 0.008). CVI may provide information about the chronicity of the disease.

Steiner M., Esteban-Ortega M.D., Muñoz-Fernández S.

To identify the risk of relapse and subclinical inflammatory stages of systemic autoimmune diseases, new tools are needed. In the recent years, choroidal thickness and retinal thickness measured with ocular coherence tomography (OCT) have been proposed as an inflammatory marker for different systemic diseases, especially for conditions with a vascular component. Our aim in this article is to review the literature regarding the role of choroidal and retinal thickness as a potential inflammatory marker in systemic autoimmune and inflammatory diseases measured by OCT. Current literature suggests that the choroid of patients thickens in active phases of inflammatory diseases with vascular involvement. This pattern is observed in lupus, systemic sclerosis, Behçet disease, spondylitis, and familial Mediterranean fever. Choroidal thickness may decrease with biological treatments, along with systemic inflammation. Repeated flares and long-term disease, however, may thin the choroid, as a result of prolonged insult to the microvasculature and subsequent atrophy. Less is known about the effect of these diseases on retinal thickness. In summary, choroidal and retinal thickness measured by OCT may be promising markers for inflammation in systemic autoimmune and inflammatory diseases; however, more studies are warranted before generalizing choroidal thickness measurements by OCT as a marker for disease activity. The role of retinal thickness is more unclear due to a lack of studies in this field.

Kim M., Kim R.Y., Park Y.

Purpose: To assess choroidal thicknesses and choroidal vascularity index (CVI) in HLA-B27-associated uveitis.Methods: Medical records of 45 treatment-naive unilateral HLA-B27-associated uveitis patients presenting with first episode and with onset time of < 1-week were reviewed.Results: Mean choroidal thickness was 275.98 ± 71.62 in acute phase and 254.93 ± 73.48 after resolution (p = .003). Mean CVI was 34.75 ± 3.08 in acute phase and 33.56 ± 2.48 after resolution (p < .001). Interestingly, even in fellow eyes, there were relative retinal and choroidal thickening and relative choroidal vascular engorgement in acute phase, but these differences were not significant. Degree of anterior chamber inflammation was correlated with relative choroidal vascular engorgement (p = .001) and choroidal thickening (p = .044).Conclusion: Eyes with acute HLA-B27-associated uveitis exhibited choroidal thickening with increased choroidal vascularity that subsequently decreased after uveitis resolution. These were evident even in patients without posterior segment involvement.

Wei X., Mishra C., Kannan N.B., Holder G.E., Khandelwal N., Kim R., Agrawal R.

To assess choroidal structural changes in patients with retinal dystrophies using choroidal vascularity index (CVI), a novel optical coherence tomography (OCT) based tool.This retrospective study included 26 patients with retinal dystrophies (17 with retinitis pigmentosa, four with Stargardt disease, three with cone-rod dystrophy, one each with Best disease and Bietti crystalline dystrophy) and 32 healthy controls. Subfoveal OCT images were used for analysis. Mean CVI was compared between retinal dystrophy and control group, as well as among the retinal dystrophy subgroups.Mean CVI in eyes with retinal dystrophies was 52 ± 9% and it was significantly lower compared to that in normal eyes (70 ± 3%, p < 0.001). The differences among subgroups of retinal dystrophy were not statistically significant (p = 0.084). All types of retinal dystrophy were associated with lower CVI (all p < 0.001), after adjusting for age, gender, visual acuity and duration of symptoms. Older age was also shown to be independently associated with lower CVI (p = 0.012). Gender, visual acuity (VA) and duration of symptoms did not significantly affect CVI.Decreased choroidal vascularity was seen in eyes with retinal dystrophies. (CVI) may be a helpful tool in monitoring choroidal involvement in retinal dystrophies.

Avella M., Pellegrino I.