En Face OCT of Type 2 Neovascularization

A Reappraisal of the Pitchfork Sign

Falavarjani, Khalil Ghasemi MD
Au, Adrian MD
Anvari, Pasha MD
Molaei, Saber MD
Ghasemizadeh, Shahriar BS
Verma, Aditya MD
Tsui, Irena MD
Sadda, Srinivas MD
Sarraf, David MD

From the Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran (KGF, PA, SM, SG); Stein Eye Institute, David Geffen School of Medicine at University of California Los Angeles, Los Angeles (AA, IT, SS, DS); Doheny Eye Institute, University of California Los Angeles, Los Angeles (AV, SS); and Greater Los Angeles VA Healthcare Center, Los Angeles (DS).

Supported by Research To Prevent Blindness, New York (DS), and the Macula Foundation, New York (DS).

Dr. Sadda has received personal fees from Centervue, Optos, Allergan, Roche/Genentech, Amgen, Heidelberg, Novartis, and Bayer as well as grants from Zeiss outside the submitted work. Dr. Sarraf has received personal fees from Optovue, Amgen, Bayer, Genentech, and Novartis, as well as grants from Heidelberg, Regeneron, and Topcon outside the submitted work. The remaining authors report no relevant financial disclosures.

Address correspondence to David Sarraf, MD, 100 Stein Plaza, Los Angeles, CA 90095; email: [email protected], [email protected].

Received December 19, 2018

Accepted March 26, 2019

Ophthalmic Surgery, Lasers, and Imaging Retina 50(11):p 719-725, November 01, 2019. | DOI: 10.3928/23258160-20191031-07

BACKGROUND AND OBJECTIVES:

To describe a new en face optical coherence tomography (OCT) imaging feature of type 2 choroidal neovascularization (CNV) and illustrate the OCT angiographic (OCTA) findings in these eyes.

PATIENTS AND METHODS:

Multimodal images of patients with type 2 CNV who displayed the typical “pitchfork” sign with cross-sectional OCT were reviewed. Corresponding en face structural OCT and OCTA images were analyzed to correlate the finding before and after anti-vascular endothelial growth factor (VEGF) therapy.

RESULTS:

Five eyes of five patients, including two females and three males with a median age of 13 years (range: 8 years to 84 years), were studied. The etiology for type 2 CNV was laser-induced maculopathy in two eyes, idiopathic in two eyes, and age-related macular degeneration in one eye. None of the eyes had evidence of inflammatory ocular disease. En face OCT displayed a characteristic wreath-like pattern of hyperreflective spikes surrounding the type 2 neovascular membrane that originated from the ellipsoid zone and extended into the outer nuclear layer. Wreath-like spikes resolved with intravitreal anti-VEGF injection with good visual outcomes and transformation of the neovascular lesion from a type 2 to type 1 morphology.

CONCLUSIONS:

Type 2 CNV associated with the pitchfork sign with cross-sectional OCT displayed a characteristic wreath-like pattern of hyperreflective spikes with en face OCT that resolved with anti-VEGF therapy. This form of type 2 neovascularization may occur in eyes with different underlying etiologies and without signs of intraocular inflammation and is not limited to pediatric patients.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:719–725.]