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Pigment epithelial detachment (PED)

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Diagnosing PED with OCT
Types of PED
PED on OCT report
Optometric approach to PED

Publicado en: Salud y medicina
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Pigment epithelial detachment (PED)

  1. 1. Pigment epithelial detachment (PED) Mohammad Riyaj Ali MSc Optometry
  2. 2. PED • Retinal pigment epithelial detachments (PEDs) are structural splitting within the inner aspect of Bruch’s membrane separating the RPE from the remaining Bruch’s membrane • It means that there is fluid beneath the retinal pigment epithelium (RPE) which is the layer of cells beneath the retina. PED has many causes but the most common are age-related macular degeneration and central serous choroidopathy
  3. 3. • PED can occur associated with multiple ocular and infrequently also primarily non-ocular pathologies. They can be sub-divided into drusenoid, serous, serous-vascularized and fibrovascular PED. Most commonly PED is found in age-related macular degeneration. • The space created by this separation is occupied by blood, serous exudate, drusenoid material, fibrovascular tissue or a combination
  4. 4. What causes pigment epithelial detachment? • Pigment epithelial detachment (PED) is a pathological process in which the retinal pigment epithelium separates from the underlying Bruch's membrane due to the presence of blood, serous exudate, drusen, or a neovascular membrane
  5. 5. Here are the different types of PED: •with CSCR (not ARMD) •serous (avascular) PED, not CSR (dry ARMD) •drusenoid PED (a dry ARMD, Adult Bests) •vascularised PED ( type 1 of wet ARMD) •haemorrhagic PED (a type of wet ARMD,) •PED as part of PCV (a type of wet ARMD)
  6. 6. • Serous PED is defined as an area of sharply demarcated, dome-shaped serouselevation of the retinal pigment epithelium (RPE). The histopathology of serous PED is consistent with the detachment of the RPE basement membrane, along with the overlying RPE from the remaining Bruch's membrane due to accumulation of fluid(1).
  7. 7. The PED is a dome of fluid under the pigment layer of the retina. there is a 'PED' only, no leak 'PED', with a leak under the retina (shown here) or in the retina
  8. 8. • Drusenoid PED was defined as ½ disc diameter (DD) of confluent soft drusen under the centre of the macula. All patients underwent visual acuity measurement, biomicroscopic fundus examination, stereoscopic colour photograph, and fluorescein and indocyanine green angiography.
  9. 9. • The classification of PEDs in AMD can be divided based on their contents. Categories include drusenoid, serous, vascularized, or mixed components. Drusenoid PEDs are seen mostly in nonneovascular or dry AMD. Serous PEDs are typically associated with the neovascular or wet form of AMD, but their natural history is relatively more favorable. Vascularized PEDs associated with Type 1 (sub- RPE) neovascularization and wet AMD, in contrast, have a greater risk of vision loss. In eyes with AMD, it is not uncommon to see more than one type of PED.
  10. 10. • PEDs are present in several chorioretinal diseases including Vogt-Koyanagi-Harada (VKH) Syndrome, Idiopathic Central Serous Chorioretinopathy (CSC) small multifocal idiopathic PEDs, Polypoidal Choroidal Vasculopathy (PCV), and Exudative/Non- Exudative Age-Related Macular Degeneration (AMD).
  11. 11. • Pathophysiology • The retinal pigment epithelium (RPE) monolayer, extending from the optic disk margin uninterrupted through to the ciliary body epithelium, is bounded by the apical surface of the retina and on its basal surface by the collagenous layer of Bruch’s membrane. • The forces maintaining normal adhesion between the RPE and Bruch’s membrane are not well understood. Under normal conditions, there exists a net bulk flow of fluid towards the choroid from the vitreous, with its generation dependent upon hydrostatic and osmotic forces within the two bodies. Both the RPE and the retina produce resistance to this fluid flow. The RPE has greater resistance due to its limited hydraulic conductivity, subsequently, a vector force is generated pushing it against Bruch’s membrane. The attachment of the RPE basement membrane to Bruch’s membrane is possibly supplemented by regions of hemidesmosomes containing fine filaments of laminin, proteoglycans and collagen types IV and V. • Age-related deposition of lipids, such as cholesterol esters, triglycerides, and fatty acids in Bruch's membrane may change its permeability altering retinochoroidal flow.Fluid may accumulate in the sub- RPE space, unable to pass through Bruch membrane, resulting in RPE elevation.
  12. 12. Clinical Exam • Often PEDs will transilluminate if they are filled predominantly with serous fluid when observed at the slit lamp. Pigment figures can also indicate chronicity of disease. Examination reveals a reticulated pattern of increased pigmentation extending radially over the PED, likely due to migration of RPE cells into the outer retinal space however it is unclear whether these carry a prognostic significance. • Drusenoid PED: Drusenoid PEDs appear as well-circumscribed yellow or yellow–white elevations of the RPE that are usually found within the macula. They may have scalloped borders and a slightly irregular surface. It is not uncommon to observe a speckled or stellate pattern of brown or gray pigmentation on their surface. • Serous PED: Serous PED appears as a distinct circular or oval-like detachment of the RPE. Clear or yellowish–orange in color, this dome-shaped elevation of the RPE has a sharply demarcated border. • Vascular PED: Gass reported that a flattened or notched border of the PED is a frequent and important sign of hidden associated CNV.[7] Other biomicroscopic findings suggestive of possible occult CNV association include yellow subretinal and intraretinal exudates that occur typically at the PED margins, subretinal hemorrhages at PED margins, sub-RPE blood which appears darker than subretinal blood with a fluid-level sign, irregular elevation of the PED because of organization in the lesser elevated area, and radial chorioretinal folds surrounding the PED caused by the contraction of Bruch membrane and the CNV.[
  13. 13. Optical coherence tomography • Drusenoid PED: Drusenoid PEDs usually show a smooth contour of the detached hyperreflective RPE band that may demonstrate an undulating appearance. The material beneath the RPE band typically exhibits a dense homogeneous appearance with moderate or high hyperreflectivity. Drusenoid PEDs are typically not associated with overlying subretinal or intraretinal fluid. • Serous PED: On OCT, serous PEDs appear as well-demarcated, abrupt elevations of the RPE with a homogenously hyporeflective sub-RPE space. Enhanced depth imaging (EDI) OCT is useful to determine whether serous PED is caused by AMD (normal subfoveal choroidal thickness) or by CSC (increased subfoveal choroidal thickness). [10] • Vascular PED: Optical coherence tomography allows better visualization of the exact relationship between neovascular membranes and PEDs. Enhanced depth imaging OCT enables better visualization of the contents of PEDs. Untreated PEDs demonstrate evidence of fibrovascular proliferation, often coursing along the back surface of the detached RPE.
  14. 14. Fundus autofluorescence imaging Drusenoid PED: Drusenoid PEDs may exhibit decreased FAF but typically they are isofluorescent or hyperautofluorescent.Drusenoid PEDs often show an evenly distributed, modest increase in the FAF signal surrounded by a well defined, hypoautofluorescent halo delineating the entire border of the lesion. Serous PED: Serous PEDs most often have an even distribution of hyperautofluorescence corresponding to the detachment and are surrounded by a hypoautofluorescent border. Vascular PED: Fundus autofluorescence imaging of vascularized PEDs has not been evaluated systematically in large series of patients. More work needs to be done to correlate the FAF pattern of PEDs and any associated CNV with findings obtained with FA and SD-OCT.
  15. 15. Fluorescein angiography Drusenoid PED: Drusenoid PEDs demonstrate faint hyperfluorescence in the early phase that increases throughout the transit stage of the study without late leakage. The correlation of FA findings with SD-OCT and occasionally ICGA may help differentiate drusenoid from vascularized PEDs. Serous PED: Serous PEDs demonstrate intense early hyperfluorescence and brisk, progressive pooling within the PED in a homogeneous and well-demarcated manner. Late staining of serous PEDs is typical and may make it difficult to differentiate these PEDs from those that are vascularized based on FA alone. In cases where there is suspicion of associated CNV, ICGA is a useful imaging modality. Vascular PED: From the analysis of fundus photographs of the macula and FA, the Macular Photocoagulation Study identified two main patterns of CNV: classic and occult. Classic CNV is characterized by a well-defined area of early typically lacy hyperfluorescence with progressive leakage in the late stages of the study. An additional fluorescein angiographic pattern of vascularized PEDs is a serous PED with a notch (e.g., kidney bean–shaped PED) or hot spot that may be referred to as a vascularized serous PED.
  16. 16. Indocyanine green angiography Drusenoid PED: Using a confocal scanning laser ophthalmoscope (SLO) system and ICGA, the content of the drusenoid PED will block the fluorescence emitted from the underlying choroidal vasculature and, therefore, the PED will appear as a homogeneous hypofluorescent lesion during the early phase and remain hypofluorescent throughout the transit. Serous PED: With an infrared fundus camera, the ICGA reveals only variable, minimal blockage of normal choroidal vessels by the serous PEDs in the late phase. Using a confocal SLO system, the ICGA reveals hypofluorescence in both the early and the late phases of the ICGA study with complete blockage of the normal choroidal vasculature. Vascular PED:Vascularized PEDs may demonstrate either of two major findings with ICGA analysis. A focal bright area of well-defined hyperfluorescence less than 1 disk diameter in size referred to as a hot spot or focal CNV.
  17. 17. Absent reflectivity of underlying choroid green band due to shadowing effect of the blood beneath the RPE
  18. 18. PEDs appear as broad elevations of the RPE band relative to Bruch’s membrane . Fibrovascular PEDs may be accompanied by variable quantities of serous exudation and/or hemorrhage, with the slope of the PED varying according to fluid content (A, B). Using spectral domain OCT, many fibrovascular PEDs appear to be filled with solid layers of material of medium reflectivity, separated by hyporeflective clefts (B). Serous PEDs are seen on OCT as areas of smooth, sharply demarcated, domeshaped RPE elevation, typically overlying a homogenously hyporeflective space. Bruch’s membrane is often visible as a thin hyperreflective line at the outer aspect of the PED (C).
  19. 19. A: On optical coherence tomography (OCT) (Cirrus seen as dome-shaped elevations of the retinal pigment epith separating the RPE from the underlying Bruch’s membrane. (B be seen as discrete foci of hyperreflectivity with underlying s attached to areas of elevated RPE overlying drusen. Epir hyperreflective bands anterior to the inner retinal surface, wi
  20. 20. On OCT, fibrovascular tissue in the subretinal space often appears as an amorphous lesion of mediumto high- reflectivity above the RPE (A); with increased scarring, it may be seen as a more well-demarcated, highly hyperreflective lesion (B). Invasion of fibrovascular tissue is often accompanied by profuse leakage from its immature blood vessels that appears on OCT images as areas of hyporeflective space between the neurosensory retina and the RPE (Spectralis; Heidelberg Engineering)
  21. 21. On OCT, vitreomacular traction may be seen when a thickened, taut, posterior hyaloid causes deformation of the inner retinal surface, occasionally leading to formation of a full-thickness macular hole (A, B). Epiretinal membranes are often seen on OCT as hyperreflective bands anterior to the inner retinal surface, with distortion of the underlying anatomy (C) and pseudohole formation (D)
  22. 22. ears in the retinal pigment epithelium (RPE) are a well- described complication of neovascular AMD (A, B). On OCT, RPE tears are typically seen as an area of discontinuity in a large pigment epithelium detachment (PED) (Spectralis; Heidelberg Engineering) (C, D); with time, a disciform scar may form (E, F ).
  23. 23. Polypoidal choroidal vasculopathy (PCV) is associated with a branching vascular network and polypoidal lesions (A). On optical coherence tomography (OCT), branching vascular networks are associated with shallow elevations of the retinal pigment epithelium (RPE), while polypoidal lesions appear as sharper protuberances (Cirrus HD-OCT; Carl Zeiss Meditec) (B, C). As the exudative complications of these lesions evolve, large serosanguineous pigment epithelium detachments (PEDs) develop adjacent to the polypoidal bulges, creating a tomographic notch. With continued exudation, these polypoidal lesions remain adherent to the RPE and are lifted away from Bruch’s membrane (B).
  24. 24. OCT showing multiple PEDs as dome shaped elevations of the RPE with few intervening drusens seen as hyper reflective elevations.
  25. 25. Massive PED occupying the right macula (a) and two small PEDs in the left eye (b). Fluorescein angiography (c and d) show pooling with hypofluorescent streaks corresponding to altered pigmentation on the PED surface in the right eye (c). Spectral domain optical coherence tomography demonstrates serous PEDs (e and f); PED in the right eye had subretinal fluid at its apex with retinal pigment epithelium hyperplasia (arrow).
  26. 26. Treatment depends on the location, size and cause of the PED. Some PEDs can resolve spontaneously, but treatment may include drugs and/or laser.