Introduction
The choriocapillaris (CC) is a few-µm-thin layer of capillaries of relatively large diameter located in the inner aspect of the choroid below the retinal pigmented epithelium (RPE) [
1]. Changes in CC blood flow are known to occur physiologically with increasing age and are associated with a variety of chorioretinal diseases such as age-related macular degeneration (AMD) and central serous chorioretinopathy (CSC). While conventional imaging techniques such as fluorescein and indocyanine green angiography can only partially depict the CC, optical coherence tomography angiography (OCTA) enables us to assess and quantify the CC blood flow [
2]. Briefly, OCTA technology employs motion contrast to image blood flow and thereby vessels through different segmented areas in the eye, thus eliminating the need for intravascular dyes. Since this technology’s introduction in 2014 [
3], OCTA has developed rapidly and there are currently several generations of OCTA from different companies available. In the older-generation units, light is emitted by a spectral domain OCT (SD-OCT) with a wavelength of nearly 840 nm near the infrared range. The newer generations, on the other hand, apply swept-source OCT (SS-OCT) technology, which uses a longer wavelength of nearly 1050 nm (compared to 840 nm in SD-OCT) and a higher scan speed of 100,000 A-scans/s (compared to 68,000 A-scans/s). Thus, it allows deeper penetration into the tissue of 3 mm (compared to 2 mm), with the compromise of a slightly lower axial resolution of 6,3 µm (compared to 5 µm, personal communication with Zeiss).
Since OCTA is a light source-dependent technology, artifacts are very common and can lead to incorrect interpretations of OCTA images. They can arise from intrinsic characteristics of the eye, eye movements, OCTA image acquisition, image processing and display strategies [
4]. In particular, shadow artifacts represent an important category of artifacts that can appear as a weakened signal behind an absorbing or scattering opacity or obstruction. Examples of shadow-causing artifacts are attenuated OCTA signals from the retinal vasculature behind media opacity [
5] or retinal bleeding or a decreased OCTA signal from the CC caused by subretinal bleeding [
6] or drusen [
4]. Another potential artifact source is the presence of subretinal fluid (SRF), a common hallmark of various chorioretinal diseases [
7]. SRF can appear in neovascular eye disease such as age-related or myopic macular degeneration, in RPE atrophy, such as in geographic atrophy in AMD, or in exudative disease of the CC such as choroidal tumor or pachychoroidal disease, including CSC [
8].
While several studies have compared SD-OCTA and SS-OCTA in healthy patients [
9,
10] and chorioretinal diseases [
11], none has explicitly investigated the effects of SRF on the CC OCTA signal in both devices. Since SS-OCTA allows deeper light penetration and improved visualization of OCTA flow in deeper tissue [
9], scattering and absorption caused by SRF might be reduced.
The aim of this study was therefore to compare the OCTA signal from the CC in health and disease and to investigate the effects of SRF on the CC OCTA signal with SD-OCTA and SS-OCTA. We demonstrate that SRF is an important shadow-causing artifact source in CC assessment that can be mitigated but not entirely eliminated when employing SS-OCTA.
Patients and methods
Study design
This was a prospective, observational, single-center, case-control study approved by our local ethics committee and adhering to the tenets of the Declaration of Helsinki.
Study population
A total of 23 participants were included in this study. Ten patients (ten eyes) had acute CCS with SRF and three patients (three eyes) had retinal detachment (RD) with partial macular involvement. Ten age-matched healthy controls (10 eyes) with a visual acuity of at least 20/20 and no signs of chorioretinal pathology served as controls. All participants were examined in the Eye Center, University of Freiburg between June 2017 and August 2018. Patients presenting concomitant maculopathy, such as AMD, diabetic retinopathy, or other maculopathies were excluded. Patient characteristics such as gender, date of birth, preexisting conditions, initial diagnosis, prior treatment modalities and symptom duration were documented.
Imaging and image analysis
OCTA images were taken with commercially available OCTA systems: the Zeiss Cirrus 5000 AngioPlex® and Zeiss PLEX Elite 9000®. Zeiss Cirrus 5000 AngioPlex® uses full spectrum spectral domain (SD-OCT) with a light source wavelength of 840 nm, an A-scan rate of 68,000 A-scans per second and an A-scan depth of 2.0 mm in tissue (1024 pixels). Zeiss PLEX Elite 9000® uses full spectrum swept source (SS-OCT) with a light source wavelength of 1050 nm, an A-scan rate of 100,000 A-scans per second and an A-scan depth of 3.0 mm in tissue (1536 pixels). Both OCTA-systems use the Optical Microangiography (OMAG®) algorithm to decorrelate signal detection. A real-time image-stabilizer (FastTracTM) ensured a minimum of movement artifacts. Furthermore, a built-in software was used to eliminate positive artifacts created from the superficial vascular layers. Each patient underwent a 6 × 6 mm2 volume scan of the CC layer. A 20 µm slab between 29 µm and 49 µm below the inner RPE was manually selected for each patient.
Abnormal CC decorrelation signals were quantified using a custom image processing algorithm programmed with “R” (
www.r-project.org) as described previously [
8,
12‐
14]. Briefly, images were processed via a Gaussian blur and morphological
h-dome-operator, and the image’s average grayscale value was determined. The threshold for the color-coding was calculated for each OCTA image using the averaged grayscale value of all pixels (brightness of pixel) plus (increased flow, red pixels) or minus (decreased flow, green pixels) a constant and predefined threshold value. Before quantifying the pixel counts, shadowing artifacts of the inner retinal vessels were manually removed from each image. The pixel counts were used for statistical analyses of the CC signal’s homogeneity in SD-OCTA compared to SS-OCTA.
To analyze the influence of SRF on the OCTA CC signal, OCTA CC images were compared with the corresponding heatmap image provided by the OCTA devices. The area with a macular thickness exceeding 450 μm was defined as an area with significant SRF. Finally, the abnormal CC decorrelation signals were assessed in the area with or without SRF and statistically analyzed.
Statistical methods
Statistical analysis was performed using GraphPad Prism 6 (GraphPad Software, Inc., La Jolla, CA, USA). The Mann–Whitney U test was used to compare two groups.
Discussion
Understanding OCTA artifacts is essential to ensure accurate clinical evaluation. In this study, we describe the presence of SRF as an important shadow-causing artifact source when assessing the CC—one that can be mitigated but not completely eliminated when employing swept-source OCTA.
We show that SRF is associated with a disease-independent, reduced SD-OCTA signal from the CC by examining patients with acute CSC and RD. Our results are consistent with previous SD-OCTA studies describing a reduced CC flow signal in patients with CSC and SRF [
8,
12,
13,
15‐
17]. Similarly, numerous investigations have reported dark regions in OCTA CC scans, the so-called flow voids, in association with various chorioretinal diseases such as diabetic retinopathy [
18], age-related macular degeneration [
19] and CSC [
8,
17] suggesting that they represent potentially disease-relevant hypoperfusion in the CC. However, the comparison of SS-OCTA and SD-OCTA in our study suggests that detecting a reduced CC OCTA signal in the presence of SRF with SD-OCTA is at least partially artificial and may have been over-interpreted in the past. SS-OCTA led to a more homogeneous OCTA CC architecture in health and disease and to a decline in the diminished OCTA signal in the SRF range compared to SD-OCTA. This is attributable to the use of a longer wavelength, which reduces scattering and absorption caused by SRF, thus allowing deeper light penetration and improved visualization of OCTA flow in deeper tissue [
10,
20].
Several studies have been conducted comparing SD with SS-OCT imaging [
5,
10,
20,
21], all showing an advantage of SS-OCT when imaging beyond the retinal layers. Compared to the other mentioned studies, our study distinguishes between areas with and without SRF. We could therefore demonstrate that the OCTA signal strength in areas with SRF is reduced compared to areas without SRF in SD- and SS-OCTA, suggesting that SRF is a critical artifact source in CC imaging. Subretinal fluid, with its often protein-rich content, can lead to increased absorption or scattering of OCTA light, leading thus to reduced signal recognition by CC. This finding is supported by evidence from other imaging technologies such as fundus autofluorescence revealing reduced autofluorescence corresponding to the areas of SRF accumulation in 82.3% of patients with CSC [
22].
Interestingly, while SS-OCT can minimize the shadowing artifact caused by SRF, patients with acute CSC still exhibit a reduced OCTA flow signal in the CC. This can either be attributed to a diminished but persistent shadowing artifact or alternatively hypoperfusion of the CC in patients with CSC. The latter would be in line with studies demonstrating a reduced OCTA flow in patients with CSC [
8,
17,
23,
24]—potentially the result of low blood flow [
25,
26], defective CC endothelial cells [
27,
28] or a thinned CC being pushed upward by pachyvessels accompanied by enlarged vascular space in Haller’s layer [
17,
24,
29,
30]. Nicolò et al. [
31] examined quantitative changes in choroidal flow areas using SS-OCTA and reported on dark patterns in the choroid regardless of the amount of fluid in CSC or in fellow eyes—anomalies not observed in healthy eyes. Similarly, we recently demonstrated reduced OCTA signals in previous SRF areas in patients with inactive CSC indicating reduced CC blood flow in patients with CSC [
8]. Despite this evidence, it is currently not possible to state whether the reduced OCTA signal in patients with CSC is artificial or caused by disease-associated vascular changes. Further studies employing even better imaging modalities are warranted to elucidate this issue with confidence.
One of our study’s limitations is its small patient cohort. However, we consider it acceptable because of the robust signal strength when comparing SD- and SS-OCTA and the low interindividual standard deviation. Another limitation of our study is that we relied on the averaged pixel intensity of each image to determine increased and decreased flow changes within the same image, which may have caused some over- and underestimations of flow changes. Prospective longitudinal studies employing optimized image acquisition techniques less prone to artifact are therefore necessary to further validate our findings.
Taken together, our data provide evidence that the presence of SRF is an important shadowing artifact source for CC assessment that can be mitigated but not entirely eliminated when using SS-OCTA. SS-OCTA therefore appears to be superior to SD-OCTA for acquiring structural and flow information from deeper tissues such as the CC. Although SS-OCTA reduces the shadow artifacts caused by SRF, signal voids are still detected in CC from patients with CSC, which can be attributed to a reduced but persistent shadow artifact or hypoperfused CC. Further studies employing even better imaging technology and entailing OCTA follow-up of patients are needed to answer this question with certainty.
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