December 2014
Volume 55, Issue 12
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Letters to the Editor  |   December 2014
Association of Focal Choroidal Excavation With Age-Related Macular Degeneration
Author Notes
Investigative Ophthalmology & Visual Science December 2014, Vol.55, 8542. doi:10.1167/iovs.14-15804
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      Giuseppe Querques; Association of Focal Choroidal Excavation With Age-Related Macular Degeneration. Invest. Ophthalmol. Vis. Sci. 2014;55(12):8542. doi: 10.1167/iovs.14-15804.

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      © ARVO (1962-2015); The Authors (2016-present)

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I read with great interest the article by Kuroda et al.1 on the association of focal choroidal excavation (FCE) with age-related macular degeneration (AMD). Focal choroidal excavation is a recently reported clinical entity, first described by Jampol et al.,2 and has been suggested to form the basis of choroidal neovascularizations (CNVs). 
The authors hypothesized that FCE may be involved in the development of CNV associated with exudative AMD. Using swept-source optical coherence tomography (OCT) they examined the macular area in 243 consecutive eyes (217 patients) with exudative AMD to study the possible association with FCE. Overall, 15 FCEs were found in 12 eyes. 
I noted that the authors did not report the inclusion criteria (they only reported the exclusion criteria), neither specified which characteristics established the diagnosis of AMD. I also noted, that the cases provided to illustrate the FCEs miss the typical signs of AMD, including the visualization of drusen on fundus color pictures and fluorescein angiography frames, and the typical retinal pigment epithelium elevations on OCT (B-scans and three-dimensional image reconstructions). In addition, the OCT scans show a dilation of choroidal vessels and overall choroidal thickening, which is unusual for AMD.34 Dilation of choroidal vessels characterizes polypoidal choroidal vasculopathy (PCV) and central serous chorioretinopathy (CSC), both considered part of a pachychoroid-driven disease spectrum.5 The PCV is particularly frequent in Asians, and in the current series (all patients were Japanese) accounts for 8 of the 12 eyes. While PCV may represent a manifestation of long-standing CNVs in AMD, at least in Caucasian it is not considered in the spectrum of typical AMD. The PCV also may represent a manifestation of long-standing CSC. Moreover, CSC was shown to be associated with Type 1 neovascularization, which could lead to the misdiagnosis of exudative AMD.6 The association between PCV and FCEs has been reported previously.7,8 Similarly, the association between CSC and FCEs has been reported previously.9 
The authors highlight how the clinical characteristics of the CNVs reported in their series are different from those of typical exudative AMD, and that are rather similar to those of secondary CNV; indeed, this could be simply due to the fact that the series reported probably is not AMD. 
Before definitively stating that, at least in Asians, FCE is quite commonly associated with AMD (4.9% in the current series), the authors should provide clarifications regarding the criteria adopted to establish the diagnosis of AMD. 
References
Kuroda Y Tsujikawa A Ooto S Association of focal choroidal excavation with age-related macular degeneration. Invest Ophthalmol Vis Sci. 2014; 55: 6046–6054. [CrossRef] [PubMed]
Jampol LM Shankle J Schroeder R Tornambe P Spaide RF Hee MR. Diagnostic and therapeutic challenges. Retina. 2006; 26: 1072–1076. [CrossRef] [PubMed]
Spaide RF. Enhanced depth imaging optical coherence tomography of retinal pigment epithelial detachment in age-related macular degeneration. Am J Ophthalmol. 2009; 147: 644–652. [CrossRef] [PubMed]
Jirarattanasopa PI Ooto S Nakata I Choroidal thickness, vascular hyperpermeability, and complement factor H in age-related macular degeneration and polypoidal choroidal vasculopathy. Invest Ophthalmol Vis Sci. 2012; 53: 3663–3672. [CrossRef] [PubMed]
Warrow DJ Hoang QV Freund KB. Pachychoroid pigment epitheliopathy. Retina. 2013; 33: 1659–1672. [CrossRef] [PubMed]
Fung AT Yannuzzi LA Freund KB. Type 1 (sub-retinal pigment epithelial) neovascularization in central serous chorioretinopathy masquerading as neovascular age-related macular degeneration. Retina. 2012; 32: 1829–1837. [PubMed]
Kobayashi W Abe T Tamai H Nakazawa T. Choroidal excavation with polypoidal choroidal vasculopathy: a case report. Clin Ophthalmol. 2012; 6: 1373–1376. [CrossRef] [PubMed]
Lee JH Lee WK. Choroidal neovascularization associated with focal choroidal excavation. Am J Ophthalmol. 2014; 157: 710–718. [CrossRef] [PubMed]
Ellabban AA Tsujikawa A Ooto S Focal choroidal excavation in eyes with central serous chorioretinopathy. Am J Ophthalmol. 2013; 156: 673–683. [CrossRef] [PubMed]
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