Objective To determine the organization of normal human choroidal arteries using a combination of laser Doppler holography (LDH) and OCT. Design Cross-sectional clinical study. Subjects One hundred thirty-two eyes of 74 healthy subjects. Methods By combining images from a prototypic LDH system and from OCT, we documented the 3-dimensional disposition of choroidal arteries from their emergence from ciliary arteries to precapillary arterioles. Main Outcome Measures Distribution, diameters, and pathways of choroidal arteries. Results A notable intereye variability in the disposition of arteries was found, in which dominant patterns were identified. A short ciliary artery emerging within 1000 μm from the fovea was identified in 63% of eyes, giving rise to a horizontal submacular artery (SMA; mean diameter 119.7 ± 24.9 μm) oriented temporally. The detection rate of an SMA was inversely correlated with choroidal thickness, that is, SMAs were more often identified in thinner choroids. Among cases with a detectable SMA, its diameter positively correlated with choroidal thickness (P < 0.003). Long posterior ciliary arteries were identified in 43% of eyes and emerged at a mean distance of 4820 ± 1567 μm temporal to the fovea (mean diameter 115 ± 41 μm). Paraoptic arteries radiated from the margins of the optic nerve head, some of which perfused the macula. Disseminated axially oriented arterioles perfusing precapillary arterioles were detected from first-order arteries. Conclusions Using a combination of LDH and OCT in healthy eyes, we identified recurrent organizational patterns of choroidal arteries in normal eyes, including SMAs, long posterior ciliary arteries, paraoptic arteries, and precapillary complexes. Characterizing the physiologic variants of the disposition of choroidal arteries helps to provide a reference framework that will enable the identification of disease-related changes. Financial Disclosure(s) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Purpose:To characterize structural phenotypes in intermediate and advanced non-neovascular age-related macular degeneration (AMD) using flood-illumination adaptive optics (FIAO) and to explore their relationship with established multimodal imaging biomarkers, including OCT-based atrophy classifications. Design:Prospective, cross-sectional observational study. Subjects:A total of 208 eyes from 117 patients (mean age 74 years; 63% female) with intermediate AMD (iAMD) or geographic atrophy (GA) were enrolled. Eligible participants had visual acuity ≥20/63, refractive error between -6 and +2 diopters, and sufficient media clarity for high-quality imaging. Methods:Participants underwent multimodal imaging, including color fundus photography, spectral-domain OCT, infrared reflectance, fundus autofluorescence, and FIAO. Structural phenotypes (drusen, subretinal drusenoid deposits, pigmentary changes, and GA margins) were assessed qualitatively across modalities. Flood-illumination adaptive optics features were compared with OCT-based atrophy classifications (incomplete and complete retinal pigment epithelium and outer retinal atrophy [iRORA and cRORA]) using descriptive analyses and cross-tabulation. Main Outcome Measures:Prevalence and multimodal characteristics of AMD structural phenotypes, and their correspondence with FIAO features. Results:Drusen and pigmentary abnormalities were detected in the majority of eyes across modalities, with variability in prevalence depending on imaging technique. Flood-illumination adaptive optics identified drusen in 70% of eyes revealing a consistent reflectivity pattern of hyperreflective borders and hyporeflective centers. Hyporeflective clumps corresponding to pigmentary changes were always observed on FIAO, frequently localizing to areas of atrophy or transition zones. Distinct FIAO-defined GA border phenotypes were observed, including well-demarcated and indistinct margins. In descriptive cross-tabulation, well-demarcated FIAO borders were more frequently associated with OCT-defined cRORA, whereas indistinct or hyporeflective margins were with iRORA. Conclusions:Flood-illumination adaptive optics provides high-resolution visualization of structural features in iAMD and GA, revealing distinct patterns of drusen, pigmentary changes, and atrophic margins. While certain FIAO features show qualitative correspondence with OCT-defined atrophy stages, these relationships remain descriptive. Further quantitative and longitudinal studies are needed to determine their clinical relevance and role in disease characterization. Financial Disclosures:Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Objective:To document the aspect, topography and morphometry of normal human choroidal arteries in the posterior pole by laser Doppler holography (LDH) and OCT. Design:Cross-sectional study. Subjects:Fifty-four eyes of 27 healthy subjects. Methods:A prototypic LDH system captured the laser Doppler shift of the choroidal circulation within the central 20°. Doppler shifts were filtered to extract high velocity vessels. Images of choroidal arteries identified by LDH were subsequently registered with en face and cross-sectional OCT images. Subsequently, the diameters of macular choroidal arteries and their correlation to central choroidal thickness was measured on OCT B-scans. Main Outcome Measures:Spatial disposition, distribution, and diameters of choroidal arteries. Results:Choroidal arteries were identified by LDH and OCT from their emergence from short posterior ciliary arteries (sPCAs), and could be traced to second and third divisions. In the 8 eyes that underwent LDH, 7 of 8 (88%) showed a horizontal first-order artery within 0.5 disc diameter from the fovea. OCT B-scans showed that first-order arteries were located along the sclera-choroid interface; around arteries, the choroidal tissue formed a pyramid-shaped avascular structure with a posterior base contiguous and isoreflective to the sclera. In a cohort of 49 eyes, the diameter of horizontal submacular arteries (average [± standard deviation] 136.3 μm [±47]; range, 70-209 μm) was weakly correlated to central choroidal thickness (P = 0.09). Conclusions:First-order choroidal arteries emerging from sPCAs are located along the sclerochoroidal interface and are surrounded by a pyramid-shaped avascular space, which contributes to differentiate them from veins. The majority of normal eye show a submacular first-order artery running horizontally toward the temporal periphery. These results will pave the way for a better knowledge of diseases affecting the choroidal circulation. Financial Disclosures:Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Objective To document the aspect, topography and morphometry of normal human choroidal arteries in the posterior pole by laser Doppler holography (LDH) and optical coherence tomography (OCT). Design Cross-sectional study. Subjects Fifty-four eyes of 27 healthy subjects. Methods A prototypic LDH system captured the laser Doppler shift of the choroidal circulation within the central 20°. Doppler shifts were filtered to extract high velocity vessels. Images of choroidal arteries identified by LDH were subsequently registered with en face and cross-sectional OCT images. Subsequently, the diameters of macular choroidal arteries and their correlation to central choroidal thickness was measured on OCT B scans. Main Outcome Measures Spatial disposition, distribution and diameters of choroidal arteries. Results Choroidal arteries were identified by LDH and OCT from their emergence from posterior ciliary arteries, and could be traced to second- and third divisions. In the 8 eyes that underwent LDH, 7/8 (88%) showed a horizontal first-order artery within 0.5 disc diameter from the fovea. OCT B-scans showed that first-order arteries were located along the sclera-choroid interface; around arteries, the choroidal tissue formed a pyramid-shaped avascular structure with a posterior base contiguous and isoreflective to the sclera. In a cohort of 54 eyes, the diameter of horizontal submacular arteries (average ±SD 136.3 μm (±47); range, 70-209μm) was weakly correlated to central choroidal thickness (p=0.09). Conclusion First-order choroidal arteries are located along the sclero-choroidal interface and are surrounded by a pyramid-shaped avascular space which contributes to differentiate them from veins. The majority of normal eye show a submacular first-order artery running horizontally toward the temporal periphery. These results will pave the way for a better knowledge of diseases affecting the choroidal circulation.

A major hurdle to therapeutic development in cerebral small vessel diseases is the lack of in-vivo method that can be used repeatedly for evaluating directly cerebral microvessels. We hypothesised that Adaptive Optics (AO), which allows resolution images up to 1–2 μm/pixel at retinal level, could provide a biomarker for monitoring vascular changes in CADASIL, a genetic form of such condition. In 98 patients and 35 healthy individuals, the wall to lumen ratio (WLR), outer and inner diameter, wall thickness and wall cross-sectional area were measured in a parapapillary and/or paramacular retinal artery. The ratio of vessel diameters before and after light flicker stimulations was also calculated to measure vasoreactivity (VR). Multivariate mixed-model analysis showed that WLR was increased and associated with a larger wall thickness and smaller internal diameter of retinal arteries in patients. The difference was maximal at the youngest age and gradually reduced with aging. Average VR in patients was less than half of that of controls since the youngest age. Any robust association was found with clinical or imaging manifestations of the disease. Thus, AO enables the detection of early functional or structural vascular alterations in CADASIL but with no obvious link to the clinical or imaging severity.

To describe imaging characteristics of severe macular complications occurring in glaucoma and discuss available treatments. Retrospective case series of glaucomatous patients with macular retinoschisis (MR) and/or serous retinal detachment (SRD). Patients underwent a complete ophthalmological examination and multimodal imaging including retinography, SD-OCT, fluorescein and indocyanine green angiography (FA ICGA) and adaptive optics (AO). Ten eyes (8 patients) were included. Initial BCVA was 1.04 ± 1.12 logMAR and IOP was 24.0 ± 9.3mmHg. All eyes presented with MR while SRD was present in 5 eyes (5 patients), with a central macular thickness of 573 ± 152 μm. FA and ICGA allowed to exclude leakage in all cases. A focal lamina cribrosa defect (LCD) was found in four eyes (4 patients) using OCT, with AO providing en-face visualization of the defect in one eye. Outer retinal hole was present in 3 eyes (3 patients). No visual improvement or resolution of the macular retinoschisis was observed in eyes with medical or surgical IOP control (N = 9). Vitrectomy with internal membrane limiting peeling and gas tamponade was performed in one eye with good visual results. Multimodal high-resolution imaging is essential to diagnose severe macular complications associated with advanced glaucoma.

Geographic atrophy (GA), the late stage of age-related macular degeneration, is a major cause of visual disability whose pathophysiology remains largely unknown. Modern fundus imaging and histology revealed the complexity of the cellular changes that accompanies atrophy. Documenting the activity of the disease in the margins of atrophy, where the transition from health to disease occurs, would contribute to a better understanding of the progression of GA. Time-lapse imaging facilitates the identification of structural continuities in changing environments. In this retrospective pilot study, we documented the long-term changes in atrophy margins by time-lapse imaging of infrared scanning laser ophthalmoscopy (SLO) and optical coherence tomography (OCT) images in 6 cases of GA covering a mean period of 32.8 months (range, 18–72). The mean interval between imaging sessions was 2.4 months (range, 1.4–3.8). By viewing time-lapse sequences we observed extensive changes in the pattern of marginal hyperreflective spots, which associated fragmentation, increase and/or disappearance. Over the entire span of the follow-up, the most striking changes were those affecting hyperreflective spots closest to margins of atrophy, on the non-atrophic side of the retina; a continuum between the successive positions of some of the hyperreflective spots was detected, both by SLO and OCT. This continuum in their successive positions resulted in a subjective impression of a centrifugal motion of hyperreflective spots ahead of atrophy progression. Such mobilization of hyperreflective spots was detected up to several hundred microns away from atrophic borders. Such process is likely to reflect the inflammatory and degenerative process underlying GA progression and hence deserves further investigations. These results highlight the interest of multimodal time-lapse imaging to document cell-scale dynamics during progression of GA. Clinical Trial Registration clinicaltrials.gov, identifier: NCT04128150 and NCT04129021.

Purpose:Drusen are dynamic sub-RPE deposits that are risk factors for late-stage age-related macular degeneration (AMD). Here we show a new imaging method using flood-illumination adaptive optics (FIAO) that reveal drusen with high contrast and resolution. Methods:A fovea-centered 4° × 4° FIAO image and eight surrounding images with gaze displaced by ±2° vertically and horizontally were acquired. Clinical color fundus and spectral-domain optical coherence tomography were acquired for clinical grading and comparison. Custom software registered overlapping FIAO images and fused the data statistically to generate a fovea-centered 4° × 4° gaze-dependent image. Our dataset included 15 controls (aged 31-72) and 182 eyes from 104 AMD patients (aged 56-92), graded as either normal aging (n = 7), and early (n = 12), intermediate (n = 108) and late AMD (n = 42); 27 had subretinal drusenoid deposits (SDDs), and 83 were imaged longitudinally. Results:No gaze varying structures were detected in young eyes. In aging eyes with no evidence of age-related changes, putative drusen <20 µm in diameter were visible. Gaze-dependent images revealed more drusen and many smaller drusen than visible in color fundus images. Longitudinal images showed expansion and fusion of drusen. SDDs were lower contrast, and RPE atrophy did not yield a consistent signal. Conclusions:Gaze-dependent imaging in a commercially available FIAO fundus camera combined with image registration and postprocessing permits visualization of drusen and their progression with high contrast and resolution. Translational Relevance:This new technique offers promise as a robust and sensitive method to detect, map, quantify, and monitor the dynamics of drusen in aging and AMD.

Purpose: To monitor perivascular sheathing during the course of retinal vasculitis by flood illumination adaptive optics ophthalmoscopy (AOO).Methods: Perivenous sheathing and venous diameters were quantitatively analyzed by semi-automatic segmentation of AOO images in 12 eyes of treatment-naive patients with retinal vasculitis.Results: The width of venous sheathing ranged from 45 to 225 µm (mean 101.0 µm ± 54.3). In 10 cases, the underlying vein showed focal narrowing (mean ± SD 14% ± 10). Focal narrowing of arteries was also present in one eye. At presentation, width of sheathing and vessel diameters were not correlated with fluorescein leakage. During follow-up, 5 eyes showed an increase in vein diameter or resolution of narrowing and in 10 eyes a thinning of vascular sheathing was observed (p= .003).Conclusions: Perivenous sheathing may be quantitatively analyzed and monitored by AOO. AOO may therefore contribute to monitor vascular sheathing during posterior uveitis.

Importance Sensitive outcome measures for disease progression are needed for treatment trials of Stargardt disease. Objective To estimate the progression rate of atrophic lesions in the prospective Natural History of the Progression of Atrophy Secondary to Stargardt Disease (ProgStar) study over a 12-month period. Design, Setting, and Participants This multicenter prospective cohort study was conducted in an international selection of tertiary referral centers from October 21, 2013, to February 15, 2017. Patients who were affected by Stargardt disease, aged 6 years and older at baseline, and harboring disease-causing variants of the ABCA4 gene were enrolled at 9 centers in the United States, United Kingdom, and continental Europe. Data analysis occurred from November 2016 to January 2017. Exposures Autofluorescence images obtained with a standard protocol were sent to a central reading center, and areas of definitely decreased autofluorescence, questionably decreased autofluorescence, and the total combined area of decreased autofluorescence were outlined and quantified. Progression rates were estimated from linear mixed models with time as the independent variable. Main Outcomes and Measures Yearly rate of progression, using the growth of atrophic lesions measured by autofluorescence imaging. Results A total of 259 study participants (488 eyes; 230 individuals [88.8%] were examined in both eyes) were enrolled (mean [SD] age at first visit, 33.3 [15.1] years; 118 [54.4%] female). Gradable images were available for evaluation for 480 eyes at baseline and 454 eyes after 12 months. At baseline, definitely decreased autofluorescence was present in 306 eyes, and the mean (SD) lesion size was 3.93 (4.37) mm2. The mean total area of decreased autofluorescence at baseline was 4.07 (4.04) mm2. The estimated progression of definitely decreased autofluorescence was 0.76 (95% CI, 0.54-0.97) mm2 per year (P < .001), and the total area of both questionably and definitely decreased autofluorescence was 0.64 (95% CI, 0.50-0.78) mm2 per year (P < .001). Both progression rates depended on initial lesion size. Conclusions and Relevance In Stargardt disease, autofluorescence imaging may serve as a monitoring tool and definitely decreased autofluorescence and total area as outcome measures for interventional clinical trials that aim to slow disease progression. Rates of progression depended mainly on initial lesion size.

PURPOSE:The purpose of this study was to describe a previously unreported manifestation of the optical Stiles-Crawford effect (oSCE) in normal eyes.METHODS:In a cohort of 50 normal subjects, the directional reflectance of cones in the retinal periphery was explored by flood-illuminated adaptive optics (FIAO) and optical coherence tomography (OCT).RESULTS:In 32 eyes (64%), off-axis FIAO images of the retinal periphery (∼15-20° from the fovea) showed variably sized patches of hyporeflective dots (called here negative mosaic) coexisting with hyperreflective (positive) cones. In nine cases, shifting the entry pupil toward the optical axis restored the positive cone mosaic, with a point-by-point correspondence between positive and negative mosaics. Rods remained hyperreflective around negative and positive cones. These changes were paralleled by changes of the OCT reflectance of the cone outer segment tips and, to a lesser extent, of the inner/outer segment limit.CONCLUSIONS:By en face FIAO imaging of the retina, the contrast of cones over rods may be strongly dependent on the entry pupil to such an extent that their reflectance is lower than that of rods. We hypothesized that the negative cone mosaic aspect results from the differential Stiles-Crawford effect of cones and rods. Cone reflectance by en face FIAO parallels the reflectance from the cone outer segment tip line and to a lesser extent of the inner/outer segment limit by OCT. Taking this into account, the oSCE is of importance for the interpretation of high-resolution images of photoreceptors. (ClinicalTrials.gov number, NCT01546181.)

Background: In healthy fundi, glistening whitish dots (so-called Gunn's dots) can often be seen, especially in young subjects. They are commonly attributed to the reflectance of Muller cell's footplates. However, despite their potential interest as biomarkers of retinal diseases, Gunn's dots have received little attention in the scientific literature.Methods: Scanning laser ophthalmoscope reflectance imaging and adaptive optics infrared flood imaging were performed in 18 healthy subjects (age range, 18-58 years) to analyze the localization, density, and shape of Gunn's dots.Results: Gunn's dots were more easily observed in the midperipheral retina along temporal vessels, although in two subjects, they could be detected in the macula. The reflectance of Gunn's dots showed a strong directional variability, which paralleled that of the inner limiting membrane. The mean (+/- SD) diameter of Gunn's dots was 13.3 mu m (+/- 3.5). Their density peaked at similar to 120 per square millimeter and decreased with age to become barely detectable after 50 years.Conclusion: Gunn's dots are highly anisotropic structures close to the inner limiting membrane. Their density, size, and age-related decline are closer to the characteristics of hyalocytes than those of Muller cells. Further studies are necessary to progress in the determination of their origin and interest as biomarkers of retinal diseases.