Pathologic Basis of Diseaseby Stanley L. Robbins is really the fourth edition of hisPathology. Appropriate updating and addition enhance the otherwise identical format, sequence, writing, and illustrations. So many medical students have benefited from this source that it may be the best known general book in the field. I recommend it even more now. Like his former texts, this will be enjoyed for its readability. He clearly lays out a great deal of information. When he includes minutiae, the reasons are clear and one feels that all the material is pertinent. Robbins keeps the whole field in perspective—that is, he does not dwell so long or so heavily on pathologic anatomy or pathogenesis as to tempt the reader to overlook clinical presentation or prognosis. A great strength of the subject of pathology is that it bonds strongly with many other medical sciences and specialties and thus occupies the

Pathologic Basis of Disease

PURPOSE\nTo measure macular choroidal thickness in normal eyes at different points using enhanced depth imaging (EDI) optical coherence tomography (OCT) and to evaluate the association of choroidal thickness and age.\n\n\nDESIGN\nRetrospective, observational case series.\n\n\nMETHODS\nEDI OCT images were obtained in patients without significant retinal or choroidal pathologic features. The images were obtained by positioning a spectral-domain OCT device close enough to the eye to acquire an inverted image. Seven sections were obtained within a 5 x 30-degree area centered at the fovea, with 100 scans averaged for each section. The choroid was measured from the outer border of the retinal pigment epithelium to the inner scleral border at 500-microm intervals of a horizontal section from 3 mm temporal to the fovea to 3 mm nasal to the fovea. Statistical analysis was performed to evaluate variations of choroidal thickness at each location and to correlate choroidal thickness and patient age.\n\n\nRESULTS\nThe mean age of the 30 patients (54 eyes) was 50.4 years (range, 19 to 85 years), and 14 patients (46.7%) were female. The choroid was thickest underneath the fovea (mean, 287 microm; standard deviation, +/- 76 microm). Choroidal thickness decreased rapidly in the nasal direction and averaged 145 microm (+/- 57 microm) at 3 mm nasal to the fovea. Increasing age was correlated significantly with decreasing choroidal thickness at all points measured. Regression analysis suggested that the subfoveal choroidal thickness decreased by 15.6 microm for each decade of life.\n\n\nCONCLUSIONS\nChoroidal thickness seems to vary topographically within the posterior pole. The thickness of the choroid showed a negative correlation with age. The decrease in the thickness of the choroid may play a role in the pathophysiologic features of various age-related ocular conditions.

Enhanced Depth Imaging Optical Coherence Tomography of the Choroid in Normal Eyes

https://bjo.bmj.com/content/bjophthalmol/62/3/196.1.full.pdf

Stereoscopic Atlas of Macular Diseases, Diagnosis and Treatment

Recent improvements in ophthalmic imaging have led to the identification of a thickened choroid or pachychoroid to be associated with a number of retinal diseases. The number of conditions linked to this phenotype has continued to widen with specific endophenotypes found within the pachychoroid spectrum. The spectrum includes choroidal features such as focal or diffuse choroidal thickening and thinning of the overlying inner choroid, and choroidal hyperpermeability as demonstrated by indocyanine green angiography. In addition, these diseases are associated with overlying retinal pigmentary changes and retinal pigment epithelial dysfunction and may also be associated with choroidal neovascularization. This article provides a comprehensive review of the literature looking at diseases currently described within the pachychoroid spectrum including central serous chorioretinopathy, pachychoroid pigment epitheliopathy, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy/aneurysmal type 1 neovascularization, peripapillary pachychoroid disease and focal choroidal excavation. We particularly focus on clinical imaging, genetics and pathological findings in these conditions with the aim of updating evidence suggesting a common aetiology between diseases within the pachychoroid spectrum.

Pachychoroid spectrum disease.

To study focal choroidal excavations in patients with Best vitelliform dystrophy using optical coherence tomography and their topographical relation with fibrotic pillars. This is a retrospective cross-sectional study of consecutive patients diagnosed with Best vitelliform dystrophy at a tertiary eye care center. Records of patients with Best vitelliform dystrophy were reviewed for best-corrected visual acuity, color fundus photographs, shortwave autofluorescence, optical coherence tomography, and electrooculogram with special emphasis on the presence of focal choroidal excavation (FCE) and fibrotic pillar. Main outcome measure was to study the fibrotic pillar in relation to the FCE. Thirty-eight eyes of 19 patients with mean age of 34.6 years were enrolled in the study. FCE was seen in eight eyes of six patients. Two patients had bilateral FCE and all the FCEs were located in the area of vitelliform lesion. Six out of eight eyes with FCE were in vitelliruptive stage of disease; one was in pseudohypopyon stage and one in atrophic stage. A fibrotic pillar was seen lying directly above the FCE in seven eyes. In one eye, hyper-reflective material not amounting to fibrotic pillar was seen lying above the FCE. A focal choroidal excavation in the setting of Best vitelliform dystrophy is seen predominantly in the vitelliruptive stage of the disease. Fibrotic pillars appear to play a role in the formation of these FCEs.

Fibrotic pillar leads to focal choroidal excavation in Best vitelliform dystrophy.

Focal choroidal excavation (FCE) is an optical coherence tomographic finding detected in eyes with normal‐looking macula.2006 The aetiology and clinical course of focal choroidal excavation is stil...

https://onlinelibrary.wiley.com/doi/pdf/10.1111/cxo.12309

Bilateral focal choroidal excavation in cone dystrophy

Multifocal pattern dystrophy (MPD) simulating fundus flavimaculatus is characterized by yellowish flecks over posterior pole and extending beyond the arcades. With the progression of the disease, multiple chorioretinal atrophic patches develop over posterior pole.[1] Good vision is usually maintained till late-stage of the disease. Multimodal imaging features of MPD have not been reported in literature as yet. A 55-year-old male presented to us with gradual loss of vision in both eyes for last 6 months. The best corrected visual acuity was 20/30, N6 in both eyes. Fundus evaluation revealed multiple areas of chorioretinal atrophy over posterior pole along with flecks around vascular arcades. The fovea was spared [Fig. 1]. Infrared reflectance imaging showed hypoautofluroscence corresponding to the atrophic area [Fig. 2]. Fundus autofluorescence imaging showed hypoautofluorescence corresponding to the atrophic areas and hyperautofluorescence corresponding to flecks [Fig. 3]. Fundus fluorescence angiography at late phase showed diffuse transmission defects and staining of the atrophic area. There was no choroidal silence [Fig. 4]. Spectral domain optical coherence tomography (SDOCT) showed ovoid, moderate reflective deposits anterior to the ellipsoid zone and small schitic spaces in the inner retinal layers. Multiple hyperreflective dots were also seen in the inner choroid [Fig. 5].

Multimodal imaging in multifocal pattern dystrophy simulating fundus flavimaculatus

Background: Intact foveal bulge has been associated with good visual outcome in retinal diseases. The aim of this study was to study the variation in foveal bulge with age. Methods: It was an observational cross-sectional study conducted between October 2014 and December 2015. Totally, 101 eyes of 101 healthy volunteers were studied in a tertiary care center. All individuals had best corrected visual acuity of 20/20 or better. High myopia (>6 D), high hyperopia (>4 D), unstable fixation, media opacities and retinal disorder like diabetic retinopathy, retinal vein occlusion were the exclusion criteria. Spectral domain optical coherence tomography was used to identify foveal bulge. The height of foveal bulge was measured as the distance between inner border of retinal pigment epithelium and outer border of inner segment – outer segment line (ellipsoid zone) at fovea. Main outcome measures were a correlation between the height of the foveal bulge and age of the participants. Results: Foveal bulge was present in 61 (60.4%) and absent in 40 (39.6%) eyes. Mean age of patients with and without foveal bulge was 33.3 ± 16.2 years and 44.1 ± 20.5 years respectively (P = 0.02). Mean height of foveal bulge was 41.1 ± 6.4 μ (range: 23–51 μ). The height of the foveal bulge showed a negative correlation with the age of the participants (r = −0.15). Conclusion: Foveal bulge was more commonly seen in younger individuals and its height decreased with age. Age matching across groups should be undertaken in studies using foveal bulge as prognostic tool.

Age-related Changes in the Foveal Bulge in Healthy Eyes.

An anomalous choroidal excavation was first described by Jampol et al. in 2006 using time domain optical coherence tomography. In 2010, Wakabayashi et al. described a series of three patients with unilateral choroidal excavation having two distinct patterns. Margolis et al. first coined the term focal choroidal excavation (FCE) in 2011. Although thought to be mostly idiopathic, FCE has also been reported with central serous chorioretinopathy, choroidal neovascular membrane and idiopathic polypoidal choroidal vasculopathy. Isolated case reports of inflammatory choroidal pathologies, such as multiple evanescent white dot syndrome, Vogt Koyanagi Harada disease, multifocal choroiditis and punctate inner choroidopathy, have also shown association with FCE. To the best of our knowledge, there has been no case of FCE described in the Indian population. We present here a case of FCE in association with serpiginous choroiditis. CASE REPORT

https://www.onlinelibrary.wiley.com/doi/pdf/10.1111/cxo.12590

Forme fruste focal choroidal excavation in a case of serpiginous choroiditis.

PURPOSE To analyze the predictive ability of quantitative reduction in central foveal thickness (CFT) after the first antivascular endothelial growth factor (anti-VEGF) injection to assess final outcome in branch retinal vein occlusion (BRVO) patients. DESIGN A retrospective interventional consecutive case series. METHODS We retrospectively reviewed 60 treatment-naive BRVO patients. All the patients were treated with bevacizumab injection pro re nata. We measured the reduction in CFT 1 month after injection and at each visit along with other optical coherence tomography (OCT) features like external limiting membrane (ELM) integrity, ellipsoid zone (EZ) integrity, and foveal bulge (FB). RESULTS At final follow-up more patients in the >25% CFT reduction group had a better mean best-corrected visual acuity (BCVA) and dry macula as compared with the ≤25% group (0.25 logMAR vs 0.46 logMAR, P = 0.03; 28 eyes vs 9 eyes, P = 0.005). Based on the final visual outcome we divided patients into 2 groups: group 1, BCVA ≥ 20/40; group 2, BCVA <20/40. Analysis at 1 month after injection revealed the ELM was intact in 27 (73%) and 5 (21.7%), EZ was intact in 28 (75.7%) and 11 (47.8%), and FB was intact in 12 (32.4%) and 2 (8.7%) patients, respectively, in groups 1 and 2 (P = 0.001, 0.02, 0.03). CONCLUSIONS Patients who have more than a 25% reduction 1 month after the first anti-VEGF injection and a restored ELM, EZ, and FB have a significantly higher likelihood of achieving BCVA ≥20/40.

Quantitative Reduction in Central Foveal Thickness After First Anti-VEGF Injection as a Predictor of Final Outcome in BRVO Patients.

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