Correlation between Visual Outcomes and Pre-Treatment Factors Including Hyperreflective Foci in Neovascular Age-Related Macular Degeneration

Hyung Woo Lee; Hyung Chan Kim

doi:10.3341/jkos.2015.56.8.1188

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Lee and Kim: Correlation between Visual Outcomes and Pre-Treatment Factors Including Hyperreflective Foci in Neovascular Age-Related Macular Degeneration

Original Article

J Korean Ophthalmol Soc 2015;56(8):1188-1194.

Published online: 29 August 2015

DOI: https://doi.org/10.3341/jkos.2015.56.8.1188

Correlation between Visual Outcomes and Pre-Treatment Factors Including Hyperreflective Foci in Neovascular Age-Related Macular Degeneration

Hyung Woo Lee, M.D., Hyung Chan Kim, M.D., PhD

Department of Ophthalmology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea

Address reprint requests to Hyung Chan Kim, MD, PhD Department of Ophthalmology, Konkuk University Medical Center, #120-1 Neungdong-ro, Gwangjin-gu, Seoul 143-729, Korea Tel: 82-2-2030-8180, Fax: 82-2-2030-5273 E-mail: eyekim@kuh.ac.kr

∗ This study was presented as a narration at the 111th Annual Meeting of the Korean Ophthalmological Society 2014.

Received 5 December 201413 April 2015 Accepted 4 June 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To investigate the correlation between hyperreflective foci (HF) on spectral domain optical coherence tomography (SD-OCT) at baseline and visual outcomes after intravitreal ranibizumab injection in neovascular age-related macular degener-ation (nAMD).

Methods

We retrospectively reviewed the medical records of 44 eyes of 44 nAMD patients. The number of HF was counted ac-cording to the location of HF on SD-OCT: neurosensory retinal layer, outer retinal layer, and subretinal layer. Statistical correla-tions among final visual acuity (VA) and pretreatment OCT parameters including number of HF, foveal thickness (FT), thickness of choroidal neovascularization (CNV), the status of external limiting membrane, and photoreceptor inner and outer segments (IS/OS) were evaluated.

Results

The number of HF was reduced in all retinal layers in nAMD patients after treatment. In multivariate regression analysis, final VA was associated with baseline VA, number of subretinal HF, and IS/OS disruption length ( p = 0.028, p = 0.046 and p = 0.009, respectively) in nAMD patients. The baseline number of subretinal HF was correlated with final FT and CNV thickness ( p = 0.002 and p = 0.009, respectively).

Conclusions

The baseline number of subretinal HF on SD-OCT might predict the final VA after intravitreal ranibizumab treat-ment in nAMD patients.

Keywords: Hyperreflective foci, Neovascular age-related macular degeneration, Ranibizumab, Spectral domain optical coher-ence tomography, Visual outcome

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Figure 1.

A 66-year-old male presented with neovascular age- related macular degeneration. (A) Fundus photography at ini-tial visit. Serous elevation is seen at the macula and yellowish fibrinous materials are seen at the parafoveal area. The visual acuity is 20/100. (B) Fundus photography at final visit. Serous elevation is resolved and yellowish fibrinous materials are much decreased. The visual acuity is 20/50. (C) Initial fluo-rescein angiography shows diffuse leakage around macula. (D) Initial indocyanine green angiography shows no definite polypoidal lesions. (E) Horizontal sectional image of optical coherence tomography (OCT) images at initial visit. The OCT shows sparse hyperreflective foci (red arrows) distribution in the inner, outer, and subretinal layers. Subretinal hyper-reflective foci are aggregated at the roof of the subretinal fluid (SRF). (F) Horizontal sectional image of OCT at final visit. Hyperreflective foci are almost resolved and just small amounts (red arrows) of hyperreflective foci remain at the in-ner retinal layer. SRF is also resolved.

Figure 2.

A 76-year-old male presented with neovascular age- related macular degeneration. (A) Fundus photography at ini-tial visit. Serous elevation at the macula is observed. Baseline visual acuity was 20/60. (B) Fundus photography at final visit. Serous elevation is decreased. (C) Initial fluorescein angiog-raphy shows multiple hyperfluorescene lesions around macula. (D) Initial indocyanine green angiography shows no definite polypoidal lesions. (E) Horizontal sectional image of spectral domain optical coherence tomography (SD-OCT) im-ages at initial visit. The image shows sparse hyperreflective foci (red arrows) distribution at all retinal layers, especially at the subretinal layer. (F) Horizontal sectional image of SD-OCT at final visit. Hyperreflective foci are reduced, but still present around the outer and subretinal layers (red ar-rows). Subretinal fluid has also resolved.

Table 1.

Baseline characteristics of patients

No. of patients (eyes)	44 (44)
Male/female (%)	27 (61.4)/17 (38.6)
Age (years)	74.0 ± 8.9
Systemic disease
DM no. (%)	1 (2.3)
HTN no. (%)	14 (31.8)
Follow up period (months)	6.51 ± 1.95
No. of injections	3.41 ± 0.79
VA (log MAR) at baseline	0.74 ± 0.45

Values are presented as mean ± SD or n (%).

DM = diabetes mellitus; HTN = hypertension; VA = visual acuity; log MAR = logarithm of the minimum angle of resolution.

Table 2.

Parameters at baseline and final visit

	Baseline	Final	p-value
VA (log MAR)	0.74 ± 0.45	0.54 ± 0.38	0.001
No. of HF
HF inner^∗	3.27 ± 3.21	1.57 ± 2.10	<0.001
HF outer^†	2.93 ± 2.42	1.11 ± 1.51	<0.001
HF subretina^‡	4.98 ± 4.17	3.00 ± 4.46	0.003
HF total^§	11.18 ± 6.36	5.68 ± 5.87	<0.001
Thickness (μ m)
FT	428.84 ± 142.65	322.14 ± 136.76	<0.001
PED	33.18 ± 108.88	21.30 ± 81.04	0.441
CNV	97.16 ± 95.77	73.91 ± 91.97	0.030
IS/OS disruption length (μ m)	644.32 ± 591.72	579.55 ± 584.92	0.187
ELM disruption length (μ m)	461.36 ± 571.91	409.09 ± 567.67	0.239

Values are presented as mean ± SD. All analyses were performed by paired t-test.

VA = visual acuity; log MAR = logarithm of the minimum angle of resolution; HF = hyperreflective foci; FT = foveal thickness; PED = pigment epithelial detachment; CNV = choroidal neovascularization; IS/OS = photoreceptor inner segment and outer segment; ELM = external limiting membrane.

^∗ HF at inner retinal layer;

^† HF at outer retinal layer;

^‡ HF at subretinal layer;

^§ HF in total retinal layers

Table 3.

Regression analysis of baseline characteristics for final BCVA (log MAR)

	Univariate		Multivariate^∗
	Standardized coefficient beta	p-value	Standardized coefficient beta	p-value
Age (years)	0.224	0.144	-	-
Gender	0.124	0.424	-	-
DM	-0.151	0.327	-	-
HTN	0.044	0.776	-	-
No. of injections	-0.065	0.676	-	-
Initial VA (log MAR)	0.576	<0.001	0.317	0.028
No. of HF
HF inner^†	0.205	0.183	-	-
HF outer^‡	0.021	0.894	-	-
HF subretina^§	0.389	0.009	0.254	0.046
HF total^∏	0.366	0.014	-	-
Thickness (μ m)
FT	0.079	0.610	-	-
PED	0.275	0.071	-	-
CNV	0.193	0.210	-	-
IS/OS disruption length (μ m)	0.527	<0.001	0.362	0.009
ELM disruption length (μ m)	0.389	0.009	-	-

BCVA = best corrected visual acuity; log MAR = logarithm of the minimum angle of resolution; DM = diabetes mellitus; HTN = hypertension; VA = visual acuity; HF = hyperreflective foci; FT = foveal thickness; PED = pigment epithelial detachment; CNV = choroidal neovascularization; IS/OS = photoreceptor inner segment and outer segment; ELM = external limiting membrane.

^∗ Multivariate linear regression analysis with backward elimination (R²: 0.473);

^† HF at inner retinal layer;

^‡ HF at outer retinal layer;

^§ HF at subretinal layer;

^∏ HF in total retinal layers.

Table 4.

Final clinical parameters associated with baseline number of subretnal hyperreflective foci

	r^∗	p-value
Final VA (log MAR)	0.389	0.009
Thickness (μ m)
FT	0.452	0.002
PED	0.023	0.881
CNV	0.390	0.009
IS/OS disruption length (μ m)	0.138	0.371
ELM disruption length (μ m)	0.149	0.333

VA = visual acuity; log MAR = logarithm of the minimum angle of resolution; FT = foveal thickness; PED = pigment epithelial detachment; CNV = choroidal neovascularization; IS/OS = photoreceptor inner segment and outer segment; ELM = external limiting membrane.

^∗ Pearson's correlation coefficient.

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