Spark ImageWise – 46

Subretinal hyper-reflective material in AMD

Dr. Ravi Daberao, Dr. Sarang Lambat, Dr. Prabhat Nangia, Dr. Vinay Nangia 
Suraj Eye Institute, 559, New Colony, Sadar, Nagpur- 440001.

Case Description
A male, 77 years of age presented to us with complaints of gradual diminution of vision in both eyes since a month. It was gradual, worsening, and not associated with any pain or redness. He had a history of diabetes mellitus, hypertension, and ischemic heart disease since past 15 years. Best-corrected visual acuity was 6/18, N 12 in right eye and 6/60, N36 in the left eye. Slit lamp examination showed pseudophakia in right eye and immature cataract in left eye. Intra-ocular pressure was 14 mmHg in both eyes. 

Fig.1: Right eye fundus showed clear media, a dull foveal reflex with a streak of blood (blue arrow) and asteroid hyalosis (black arrow).

Fig.2: Left eye fundus showed hazy media due to cataract with disc appearing normal.
Fig. 3 & 4: Right eye fundus fluorescein angiography (FFA) showed early hyper fluorescence (yellow arrow) (Fig.3) followed by an increase in hyper fluorescence in the late phase suggestive of an active CNVM (yellow arrow) (Fig.4).

He was diagnosed as active CNVM in right eye. We advised monthly doses of intravitreal anti-VEGF injections in right eye. Patient underwent serial OCT scans after each dose of Anti-VEGF injection.He was diagnosed as active CNVM in right eye. We advised monthly doses of intravitreal anti-VEGF injections in right eye. Patient underwent serial OCT scans after each dose of Anti-VEGF injection.

Fig. 5: Right eye SD-OCT Horizontal line scan showed hypo-reflectivity suggestive of sub retinal fluid (red arrow) and subretinal hyperreflective material (SHRM) (yellow arrow) between neurosensory retina and retinal pigment epithelium (RPE). Height of subretinal hyperreflective material was 205 microns. Asteroid hyalosis was also seen (white arrow). An undulated RPE is seen nasal to the SHRM suggestive of a possible RPE tear (blue arrow)  with some SHRM reaching underneath.
Fig.6A and 6B: Right eye SD-OCT Horizontal line scan showed reduction in subretinal fluid (red arrow) and subretinal hyperreflective material (SHRM) (yellow arrow). Height of subretinal hyperreflective material was 108 microns (Fig.6A) and 206 microns (Fig.6B). 
Fig. 7A, 7B and 7C: Right eye SD-OCT Horizontal line scan showed increase in subretinal hyperreflective material (SHRM) between neurosensory retina and RPE. Height of SHRM was 338 microns (Fig.7A), 390 microns (Fig.7B) and 364 microns (Fig.7C). As the height of SHRM increased at further follow ups the visual acuity showed a decreasing trend. 
Fig.8 A and 8 B: Right eye SD-OCT Horizontal line scan showed a decrease in size of subretinal hyperreflective material (SHRM) (yellow arrow). The height of subretinal hyperreflective material was 266 microns (Fig.8 A) and 228 microns (Fig.8 B) respectively. There is a presence of fibrosis (blue arrow) nasal to SHRM (Fig.8B)

Discussion 

Our patient presented with a classical type 2 CNVM (Fig.3 and Fig.4) with subretinal hyperreflective material (Fig.5). He received monthly doses of anti-VEGF injections in the right eye. After 4 doses of anti-VEGF therapy, there was a reduction in size of SHRM. But eventually, it increased at further follow-up for a few months till 7 doses of anti-VEGF were complete. This increase in SHRM led to a reduction in visual acuity. We continued giving anti-VEGF which finally led to shrinkage of SHRM, which again helped in restoration of vision which was stabilized to 6/18 at last follow up. Patient was lost to follow up.

Subretinal hyperreflective material (SHRM) is one of the newer biomarkers described in AMD. This SD‑OCT feature is identified as hyperreflective material located between neurosensory retina and retinal pigment epithelium (RPE). Fluid, fibrin, blood, scar or the fibrovascular tissue itself can constitute an SHRM and it may change with time and with anti-VEGF therapy. It has been suggested that lesion size correlates with VA, and SHRM decreases in size with anti‑VEGF therapy. Anti‑VEGF therapy reduces vascular fluid leakage which leads to shrinkage of size of SHRM. When the treatment continues over time and the relative amount of SHRM fluid declines, there maybe an increased fibrotic component, rendering anti‑VEGF therapy less effective in reducing SHRM thickness. It has been described that both VA and SHRM dimensions such as height, width and area correlate with each other.

In our patient the size of SHRM increased along the course of treatment after an initial decrease, as the patient missed his follow up for almost 6 months. This happened as the CNVM got reactivated in absence of anti-VEGF therapy during this period.

Furthermore, ellipsoid zone (EZ) loss was noted more often in eyes with underlying foveal SHRM compared with eyes without foveal SHRM which has a direct impact on the final visual acuity.

It may be important to know the morphological features of SHRM and their functional consequences which will enable the treating physician to tailor treatment to provide adequate disease control, minimize recurrence and neurosensory damage.

ReadWise:

1. Willoughby AS, Ying GS, Toth CA, Maguire MG, Burns RE, Grunwald JE, Daniel E, Jaffe GJ, Williams DF, Beardsley S, Bennett S. Subretinal hyperreflective material in the comparison of age-related macular degeneration treatments trials. Ophthalmology. 2015 Sep 1;122(9):1846-53.  
https://doi.org/10.1016/j.ophtha.2015.05.042

2. Alex D, Giridhar A, Gopalakrishnan M, Indurkhya S, Madan S. Subretinal hyperreflective material morphology in neovascular age-related macular degeneration: A case control study. Indian Journal of Ophthalmology. 2021 Jul;69(7):1862. 10.4103/ijo.IJO_3156_20

Dr. Sarang Lambat
MS, FRF
Consultant
Vitreoretinal services
Suraj Eye Institute
Nagpur
Email – education@surajeye.org

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