panoramic optical coherence tomography angiography
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1856 Indian Journal of Ophthalmology Volume 66 Issue 12
Declaration of patient consentThe authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorshipNil.
Conflicts of interestThere are no conflicts of interest.
Figure 3: (a) B scan optical coherence tomography with flow function of optical coherence tomography angiography shows localized elevation of the posterior hyaloid due to the growth of neovascularisation (arrow) with increased blood flow (red dots). (b) Post‑laser section through same area shows thinning of retinal layers with decrease in proliferative vascular thickness (arrow) and significantly decreased blood flow (much fewer red dots in elevated tissue post‑laser therapy)
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Cite this article as: Mehrotra N, Nagpal M, Khandelwal J, Juneja R. Panoramic optical coherence tomography angiography features in acute zonal occult outer retinopathy. Indian J Ophthalmol 2018;66:1856-8.
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
For reprints contact: [email protected]
Department of Vitreo‑Retina, Retina Foundation, Near Shahibag Underbridge, Shahibag, Ahmedabad, Gujarat, India
Correspondence to: Dr. Navneet Mehrotra, Department of Vitreo‑Retina, Retina Foundation, Near Shahibag Underbridge, Shahibag, Ahmedabad ‑ 380 004, Gujarat, India. E‑mail: [email protected]
Manuscript received: 07.06.18; Revision accepted: 20.08.18
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DOI:10.4103/ijo.IJO_826_18
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P a n o r a m i c o p t i c a l c o h e r e n c e tomography angiography features in acute zonal occult outer retinopathy
Navneet Mehrotra, Manish Nagpal, Jayesh Khandelwal, Rakesh Juneja
Key words: Acute zonal occult outer ret inopathy, autofluorescence, optical coherence tomography angiography, panorama, trizonal
AZOOR (acute zonal occult outer retinopathy) is a rare retinal disorder presenting with sudden onset scotoma and photopsia.[1] The pathognomic feature for diagnosing AZOOR is the presence of “trizonal pattern” on fundus autofluorescence (FAF). [2] We present a 36‑year‑old male complained of scotoma and photopsia since 1 month in both eyes, more predominantly in left eye. On examination, best‑corrected visual acuity was 20/20 OU (both eyes). Dilated fundus examination OU showed orange‑yellow‑colored demarcation line in the peripapillary area [Fig. 1a]. FAF imaging OU revealed corresponding abnormal area of speckled hyperautofluorescence around an area of hypoautofluorescence in the peripapillary area [Fig. 1b]. Spectral domain optical
Figure 4: (a) Optical coherence tomography angiography superficial plexus montage view post‑panretinal photocoagulation showing regression and pruning of neovascularisation (red circle). (b) Fundus fluorescein angiography SLO image (late arteriovenous phase) shows regression of neovascularisation (red circle) with adjacent panretinal photocoagulation scars
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December 2018 1857Photo Essay
coherence tomography [Fig. 1c] showed disruption of ellipsoid zone nasal to fovea in OU and a small pigment epithelial detachment subfoveally in OS. Optical coherence tomography angiography panorama (OCTA‑P) images were obtained on the RS‑3000 Advance OCT (Nidek, Japan) covering an area of 12 × 9 mm equivalent to 40° × 30° field of view [Fig. 1d], which revealed at the watershed zone that there is increased decorrelation signal and it is more prominently seen at the level of avascular zone of retina along with the projection artifacts
of the superficial blood vessels that are encroaching on this level. Visual field examination [Fig. 1e] revealed enlarged blind spot OU more in OS.
OCT angiography (OCTA) is a functional extension of OCT that works on the principle of decorrelation.[3] Few studies have described the role of multimodal imaging in AZOOR.[4,5] But to the best of our knowledge, this is the first time in the literature that OCTA‑P features of AZOOR are shown. OCTA panorama centered on fovea with wider field of view can prove as a
Figure 1: (a) Color fundus photograph OU showing orange‑yellow colored demarcation zone in the peripapillary area bordering affected and unaffected retina. (b) Fundus autofluorescence image OU showing typical characteristic trizonal pattern of involvement OD acute zonal occult outer retinopathy lesion: Zone 1 is characterized by presence of normal autofluorescence in the area outside the demarcation line, zone 2 by speckled hyperautofluorescence within the acute zonal occult outer retinopathy lesion, and zone 3 by hypoautofluorescence corresponding to the development of choroidal atrophy. (c) Optical coherence tomography scan OU passing though macula shows that the integrity of the external limiting membrane, ellipsoid zone, and interdigitation zone is disrupted corresponding to area demarcated in red free and fundus autofluorescence images. (d) Optical coherence tomography angiography 12 × 9 panorama OU shows increased decorrelation signal at the deeper capillary plexus along with projection artifacts of the superficial capillary plexus. (e) Visual field examination revealed enlarged blind spot OU
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1858 Indian Journal of Ophthalmology Volume 66 Issue 12
potential imaging marker and can subserve as an additional tool to FAF to accurately diagnose and manage AZOOR.
Declaration of patient consentThe authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorshipNil.
Conflicts of interestThere are no conflicts of interest.
References1. Gass JD, Agarwal A, Scott IU. Acute zonal occult outer
retinopathy: A long‑term follow‑up study. Am J Ophthalmol 2002;134:329‑39.
2. Tavallali A, Yannuzzi LA. Acute zonal occult outer retinopathy; revisited. J Ophthalmic Vis Res 2015;10:211‑3.
3. Nagpal M, Juneja R. Panoramic imaging with OCTA. Retina Today 2017;4:48‑52.
4. Mrejen S, Khan S, Gallego‑Pinazo R, Jampol LM, Yannuzzi LA. Acute zonal occult outer retinopathy: A classification based on multimodal imaging. JAMA Ophthalmol 2014; 132:1089‑98.
5. Duncker T, Lee W, Jiang F, Ramachandran R, Hood DC, Tsang SH, et al. Acute zonal occult outer retinopathy: Structural and functional analysis across the transition zone between healthy and diseased retina. Retina 2018;38:118‑27.
Cite this article as: Dogra M, Kumar N, Tigari B, Singh R. Multimodal imaging of acute zonal occult outer retinopathy in a Indian male. Indian J Ophthalmol 2018;66:1858-9.
This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
For reprints contact: [email protected]
Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Correspondence to: Dr. Mohit Dogra, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh ‑ 160 012, India. E‑mail: [email protected]
Manuscript received: 24.04.18; Revision accepted: 04.09.18
Access this article onlineQuick Response Code: Website:
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DOI:10.4103/ijo.IJO_570_18
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Multimodal imaging of acute zonal occult outer retinopathy in a Indian male
Mohit Dogra, Nitin Kumar, Basavraj Tigari, Ramandeep Singh
Key words: Acute zonal occult outer retinopathy, multimodal imaging, white dot syndrome
Case ReportA 24‑year‑old Indian male presented with a temporal field defect in his right eye (RE) since 1 month. There was no associated photopsia, redness, pain, and no preceding viral illness. Unaided visual acuity (UAVA) was 6/6 in both eyes (BE). Anterior segment examination, pupillary reflexes, and fundus examination of the left eye (LE) were unremarkable. Fundus examination of the RE revealed a hypopigmented amoeboid lesion in the peripapillary area extending upto the nasal margin of the fovea [Fig. 1]. RE
fundus autofluorescence (AF) showed stippled hypo‑ and hyper AF with a hyper AF transition zone between the involved and uninvolved retina [Fig. 2a]. Humphrey’s visual field (VF) testing revealed a temporal hemianopic defect in the RE [Fig. 2b]. Spectral domain optical coherence tomography showed absence of ellipsoid and interdigitation zones in the area of the lesion with normal inner retinal and choroidal architecture [Fig. 3a]. While fluorescein angiography showed transmission fluorescence [Fig. 3b]. Multimodal imaging (MMI) of the LE was normal. Clinical diagnosis of RE acute zonal occult outer retinopathy (AZOOR) was made and the patient was subjected to full‑field electroretinogram (ERG). RE ERG showed increased latency and significantly reduced amplitude of 30 Hz flicker response, suggestive of generalized cone dysfunction. The patient refused to take oral steroids, and at 6 months follow‑up, he was maintaining a UAVA of 6/6 with no change in MMI.
DiscussionAZOOR was first described by Donald Gass as acute onset VF defect with or without photopsias due to outer retinal dysfunction.[1] It is an idiopathic disorder whose demography, clinical features, and outcomes are different in Asians when compared with Caucasians.[2] Asian patients have lesser retinal pigment epithelium (RPE) atrophy, more chances of spontaneous resolution, and better visual acuities.[2,3] Most of the data on AZOOR in Asians are from China and Japan.[2,4] There is just one case report from India in which a polycythemia vera patient developed AZOOR‑like features.[5] About 76% of AZOOR patients have no findings on fundus examination at presentation; hence, MMI is invaluable to clinch
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