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Nesper, Peter L., BA*; Lutty, Gerard A., PhD; Fawzi, Amani A., MD*

doi: 10.1097/IAE.0000000000001863
Original Study

Purpose: To present a postprocessing approach in optical coherence tomography angiography (OCTA) to facilitate the visualization and interpretation of lesions in age-related macular degeneration with coexisting atrophy and choroidal neovascularization (CNV).

Methods: This retrospective study included 32 eyes of 26 patients with atrophy and treated CNV and 8 eyes with treatment-naive geographic atrophy. En face optical coherence tomography slabs highlighting atrophy were pseudocolored and merged with the corresponding OCTA. Cross-sectional optical coherence tomography and postprocessed OCTA were analyzed to identify CNV and normal choroidal vessels in relationship to the atrophy. We correlate the OCTA findings with those in a donor eye with treatment-naive geographic atrophy studied with transmission electronic microscopy.

Results: Medium-sized choroidal vessels were displaced anteriorly in areas of atrophy in all 40 eyes (100%), visualized in the choriocapillaris slab in all eyes, and in the outer retinal slab in 30 of 40 eyes (75.0%). Cross-sectional OCTA was used to confirm the presence of CNV. Postprocessing successfully highlighted the CNV and distinguished it from choroidal vessels in atrophy. Donor eye transmission electronic microscopy confirmed the anterior displacement of medium-sized choroidal vessels in geographic atrophy.

Conclusion: The anterior displacement of larger choroidal vessels in atrophy requires clinician vigilance to avoid misinterpreting these vessels as CNV on en face OCTA. Our proposed postprocessing approach offers a potential solution to facilitate the interpretation of en face OCTA in these cases. In the absence of other tools, clinicians are encouraged to rely on the location of flow relative to Bruch membrane on cross-sectional OCTA flow images.

Anterior displacement of residual choroidal vessels underlying retinal pigment epithelial atrophy can simulate choroidal neovascularization on en face optical coherence tomography angiography, complicating the interpretation of these angiograms. The authors demonstrate a clinical and software approach to distinguish between neovascularization and residual (displaced) choroidal vasculature. This article highlights important considerations when using optical coherence tomography angiography in eyes with coexisting atrophy and neovascularization in age-related macular degeneration.

*Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; and

Wilmer Ophthalmological Institute, Johns Hopkins Hospital, Baltimore, Maryland.

Reprint requests: Amani A. Fawzi, MD, Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, 645 N. Michigan Avenue, Suite 440, Chicago, IL 60611; e-mail:

Supported in part by NIH grants EY021470 (A.A.F.), EY016151 (G.A.L.), and EY01765 (Wilmer) and research instrument support by OptoVue, Inc. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

None of the authors has any conflicting interests to disclose.

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© 2018 by Ophthalmic Communications Society, Inc.