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Review
. 2023 Dec 10;13(24):3635.
doi: 10.3390/diagnostics13243635.

Recent Advances in Imaging Macular Atrophy for Late-Stage Age-Related Macular Degeneration

Anny M S Cheng  1   2   3 , Kakarla V Chalam  4 , Vikram S Brar  5 , David T Y Yang  6 , Jineel Bhatt  2 , Raphael G Banoub  1   2 , Shailesh K Gupta  1   2
Affiliations
Review

Recent Advances in Imaging Macular Atrophy for Late-Stage Age-Related Macular Degeneration

Anny M S Cheng et al. Diagnostics (Basel). .

Abstract

Age-related macular degeneration (AMD) is a leading cause of blindness worldwide. In late-stage AMD, geographic atrophy (GA) of dry AMD or choroidal neovascularization (CNV) of neovascular AMD eventually results in macular atrophy (MA), leading to significant visual loss. Despite the development of innovative therapies, there are currently no established effective treatments for MA. As a result, early detection of MA is critical in identifying later central macular involvement throughout time. Accurate and early diagnosis is achieved through a combination of clinical examination and imaging techniques. Our review of the literature depicts advances in retinal imaging to identify biomarkers of progression and risk factors for late AMD. Imaging methods like fundus photography; dye-based angiography; fundus autofluorescence (FAF); near-infrared reflectance (NIR); optical coherence tomography (OCT); and optical coherence tomography angiography (OCTA) can be used to detect and monitor the progression of retinal atrophy. These evolving diverse imaging modalities optimize detection of pathologic anatomy and measurement of visual function; they may also contribute to the understanding of underlying mechanistic pathways, particularly the underlying MA changes in late AMD.

Keywords: age-related macular degeneration; confocal scanning laser ophthalmoscope; fundus autofluorescence; macular atrophy; microperimetry; multifocal electroretinogram; optical coherence tomography; optical coherence tomography angiography.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Images of geographic atrophy (GA) with dry age-related macular degeneration (AMD). (A) Color fundus photography (CFP) shows multifocal retinal atrophy, and drusen without clear delineation of atrophic lesion boundaries. (B) Ultra-widefield scanning laser ophthalmoscopy shows GA in the presence of dry AMD. (C) Atrophic patches in fluorescein angiography (FA) appear as well-demarcated, hyperfluorescent areas due to enhanced visualization of choroidal fluorescence caused by the loss of RPE cells (window defect), which would normally diminish the transmission of fluorescein fluorescence. (D) Fundus autofluorescence (FAF) shows focal areas of hypoautofluorescence, indicating photoreceptor photopigment loss, and hyperautofluorescence, corresponding to varying degrees of RPE atrophy. (E) Near-infrared reflectance (NIR) image with relatively nonspecific reflectivity. NIR has a higher sensitivity for detecting refractile drusen as glistening dots (arrow) that are undetectable using FAF. (F) Scan position as indicated by bold green arrow line in SD OCT corresponding to (G) incomplete RPE and outer retinal atrophy (iRORA) at fovea, with hypertransmission under a region of absent RPE and outer retinal bands, as well as an undiscerned outer nuclear layer (arrow). Parafoveal region shows an elevated drusenoid pigment epithelial detachment (PED) (asterisk). The retinal pigment epithelium (RPE) with a focal thickening at the apex (reticular pseudodrusen, RPD), corresponding to hypertransmission in the choroid (arrowhead). RPD, as a major risk factor for progression to late AMD, is overlooked with standard CFP. (H) Optical coherence tomography angiography (OCTA) with reduced choriocapillaris identified via an en face slab.
Figure 2
Figure 2
Images of macular atrophy (MA) with neovascular age-related macular degeneration (nAMD). (A) Color fundus photography (CFP) shows large area of coalesced retinal atrophy with sparse areas of intact RPE without delineation of atrophic lesion boundaries. (B) Ultra-widefield scanning laser ophthalmoscopy shows MA in the presence of nAMD. (C) Atrophic patches in fluorescein angiography (FA) appear as demarcated hyperfluorescent areas, whereas (D) in indocyanine green angiography (ICG-A), they appear as minimally discernable hypofluorescent areas. (E) Fundus autofluorescence (FAF) shows a demarcated region hypoautofluorescence surrounded by a rim of weak hyperautofluorescence. (F) Atrophic patches, including some that are undetectable usingFAF, are discernable using near-infrared reflectance (NIR). (G) Spectral-domain optical coherence tomography (SD-OCT) scan position as indicated by bold green arrow line with corresponding scan in the (right panel) that shows disrupted inner and outer retinal bands with region of complete retinal pigment epithelium atrophy (cRORA) (asterisk) with intraretinal fluid (arrow). (H) Optical coherence tomography angiography (OCTA) with reduced choriocapillaris (right panel), deep (middle panel), and superficial retinal plexus (left panel) identified via an en face slab.
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