AMD Prechoroidal Cleft

This 80YO female presented with counting-fingers vision in her left eye from treatment-naive neovascular AMD (nAMD).

Triton color photography shows a few retinal hemorrhages and more peripheral large drusen. Swept-source OCT shows a shallow irregular RPE detachment with underlying type 1 macular neovascularization (MNV). A hyporeflective prechoroidal cleft is noted below the MNV and subretinal hyperreflective material (SRHM) above. There is shallow outer retinal fluid above the SRHM. Subretinal fluid is seen on either side of the MNV. Intravitreal Avastin therapy was begun.

Learning Points:
Our patient’s OCT includes numerous findings of active MNV, including SRHM, prechoroidal cleft, and subretinal and intraretinal fluid.

SHRM is an OCT finding that is invisible clinically. This material, located between the neurosensory retina and retinal pigment epithelium (RPE), is thought to consist of fluid, fibrin, blood, and other fibrovascular tissues. SHRM is a biomarker of active disease that decreases with successful anti-VEGF therapy (Willoughby et al, Ophthalmology 2015;122:1846-1853). Persistent SHRM is associated with an increased incidence of scar formation and worse vision.

A prechoroidal cleft is a hyporeflective space between the RPE and Bruch’s membrane. It is seen in up to 20% of treated eyes with nAMD, particularly with type 3 neovascularization (intraretinal MNV) and polypoidal choroidal vasculopathy. They are usually associated with worse visual acuity due to potential complications, including RPE tears and subretinal hemorrhages (Kim et al, Retina 2017;37:2047-2055).

This 84 YO female with macular degeneration presented with acute vision loss of counting fingers vision in her right eye from neovascular AMD (nAMD).

Fundus photography shows a large central subretinal hemorrhage. Swept-source OCT shows the hyperreflective subretinal blood, which shadows the underlying choroid. Sub-RPE blood vs a type-1 (located beneath the RPE) macular neovascularization (MNV) overlies a prechoroidal cleft.

Anti-VEGF therapy was begun.

Learning Points:

A prechoroidal cleft is a hyporeflective space between the RPE and Bruch’s membrane. These are seen in up to about 20% of treated eyes with nAMD, particularly with type 3 neovascularization (intraretinal MNV) and polypoidal choroidal vasculopathy.

They are usually associated with worse visual acuity due to potential complications including RPE tear and subretinal hemorrhages (Kim et al, Retina 2017;37:2047-2055).

This 87YO patient presented with vision of 20/200 OD and counting finger vision OS from bilateral active neovascular AMD (nAMD).

The right macula has a few dots of central and superior macular blood. OCT scanning shows a type 1 macular neovascularization (MNV, located below the RPE) adherent to an overlying RPE detachment. A prechoroidal cleft separates the MNV from the underlying choroid. Subretinal hyperreflective material (SRHM) lies above the RPE detachment (orange arrow). Intraretinal fluid is noted nasally with trace subretinal fluid on either side of the RPE detachment.

The left macula has faint subfoveal fibrosis with some scattered more inferior subretinal blood. OCT scanning shows a type 2 MNV (located above the RPE), which is tethered to the overlying edematous retina. Bacillary layer detachments are noted nasal and temporal to the MNV.

Learning Points:

A prechoroidal cleft is a hyporeflective space between the RPE and Bruch’s membrane. These are seen in up to about 20% of treated eyes with nAMD, particularly with type 3 neovascularization (intraretinal MNV) and polypoidal choroidal vasculopathy.

They are usually associated with worse visual acuity due to potential complications, including RPE tear and subretinal hemorrhages (Kim et al, Retina 2017;37:2047-2055).

SHRM is an OCT finding that is invisible clinically. This material, located between the neurosensory retina and retinal pigment epithelium (RPE), is thought to consist of fluid, fibrin, blood, and other fibrovascular tissues.

SHRM is a biomarker of active disease that decreases with successful anti-VEGF therapy (Willoughby et al., Ophthalmology 2015;122:1846-1853). Persistent SHRM is associated with an increased incidence of scar formation and worse VA.

Bacillary layer (cone and rod inner and outer segments) detachment appears as a unique dome-shaped collection of intraretinal fluid from photoreceptor splitting. These detachments can be observed in an increasing number of conditions, most classically Vogt-Koyanagi-Harada disease (Cicinelli et al, Ophthalmology Retina 2020;4:454-456).

This 82YO female was maintaining 20/40 vision in her left eye with intravitreal Eylea every 8 weeks for neovascular AMD. She was then lost to follow-up, with new blood and 20/50 vision.

Swept source OCT shows new subretinal fluid. The hyperreflective sub-RPE type 1 macular neovascularization is elevated above a hyporeflective prechoroidal cleft.

Fortunately, vision returned to 20/30, with complete resolution of all exudative findings, following 3-monthly Eylea injections.

Learning Points:
A prechoroidal cleft is a hyporeflective space between the RPE and Bruch’s membrane. These are seen in up to about 20% of treated eyes with wet AMD, particularly with type 3 neovascularization and polypoidal choroidal vasculopathy. They are usually associated with worse visual acuity due to potential complications, including RPE tear and subretinal hemorrhages.

For a more detailed discussion of prechoroidal clefts, see Kim et al Retina 2017;37:2047-2055.

This patient’s vision remained 20/100 one month following vitrectomy with subretinal tissue plasminogen activator.

Surgery accomplished its goal of displacing most of the subfoveal blood, which is variably red and devitalized (yellow).

OCT shows the remaining subretinal hyperreflective blood, the causative sub-RPE type 1 macular neovascularization, and a subfoveal prechoroidal cleft.

Learning Points:
A prechoroidal cleft is a hyporeflective space between the RPE and Bruch’s membrane.

These are seen in up to about 20% of treated eyes with wet AMD, particularly with type 3 neovascularization and polypoidal choroidal vasculopathy.

They are usually associated with worse visual acuity due to potential complications, including RPE tear and subretinal hemorrhages.

For a more detailed discussion of prechoroidal clefts, see Kim et al Retina 2017;37;2047-2055.