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RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2015 VOLUME 35 NUMBER 3
Patrícia Correa de Mello, MD Patricia Berensztejn, MD Oswaldo Ferreira Moura Brasil, MD Instituto Brasileiro de Oftalmologia (IBOL), Rio de Janeiro, Brasil None of the authors have any financial/conflicting interests to disclose. References 1. Hoang QV, Cunningham ET, Sorenson JA, Freund KB. THE “PITCHFORK sign” a distinctive optical coherence tomography finding in inflammatory choroidal neovascularization. Retina 2013;33:1049–1055. 2. Gass JD, Guerry RK, Jack RL, Harris G. Choroidal osteoma. Arch Ophthalmol 1978;96:428–435. 3. Foster BS, Fernandez-Suntay JP, Dryja TP, et al. Clinicopathologic reports, case reports, and small case series: surgical removal and histopathologic findings of a subfoveal neovascular membrane associated with choroidal osteoma. Arch Ophthalmol 2003;121:273–276.
may also indicate some degree of inflammation occurring in this neovascular process. Quan V. Hoang, MD, PhD* K. Bailey Freund, MD*†‡§ *Department of Ophthalmology, Columbia University College of Physicians and Surgeons New York, New York †Vitreous Retina Macula Consultants of New York New York, New York ‡LuEsther T. Mertz Retinal Research Center Manhattan Eye, Ear, and Throat Institute New York New York §Department of Ophthalmology, New York University Medical Center, New York, New York K. B. Freund is a consultant to Regeneron, Genentech, Bayer HealthCare, ThromboGenics, Ohr Pharmaceutical, and Heidelberg Engineering (honorarium for each). The other author has no conflicting interests to disclose. References
Reply To the Editor: We appreciate the opportunity to further discuss our recent report on the “Pitchfork Sign,” a distinctive optical coherence tomography finding in inflammatory choroidal neovascularization (CNV),1 in particular, to respond to the interest and letter from Dr. de Mello et al, who noted similar hyperreflective finger-like projections from Type 2 neovascularization in the setting of choroidal osteoma. The main purpose of our original article1 was to describe an optical coherence tomography finding that would be helpful in distinguishing cases of multifocal choroiditis/punctate inflammatory choroidopathy–related CNV from idiopathic or myopic CNV where the diagnosis was uncertain. In a report by de Mello et al, there is an obvious predisposing risk factor for CNV; therefore, although the presence of this optical coherence tomography finding is interesting, it is of less clinical relevance. Of interest, the patient in their report is a young female, similar to all four of the cases in our series. As these authors mention, there may be an inflammatory component to osteoma2; therefore, inflammation could be playing a role in this form of CNV. Although we agree that the CNV in the case by de Mello et al appears to be Type 2 neovascularization, it is a bit unusual in that Type 2 neovascularization in age-related macular degeneration tends to appear as a thin flat layer of tissue above the retinal pigment epithelium, whereas the CNV membrane in this case appears more similar to a mass of tissue. Perhaps, this optical coherence tomography finding
1. Hoang QV, Cunningham ET, Sorenson JA, Freund KB. The “pitchfork sign” a distinctive optical coherence tomography finding in inflammatory choroidal neovascularization. Retina 2013;33:1049–1055. 2. Gass JD, Guerry RK, Jack RL, Harris G. Choroidal osteoma. Arch Ophthalmol 1978;96:428–435.
Correspondence To the Editor: We congratulate Querques et al1 for their study entitled “Impact of intravitreal dexamethasone implant (Ozurdex) on macular morphology and function.” The authors investigated the relationship between the changes in macular morphology and function after intravitreal dexamethasone implant (Ozurdex) for central retinal vein occlusion. The study reports important results especially in terms of ocular electrophysiology and retinal morphology in macular edema due to central retinal vein occlusion. The authors reported that at 1 month, mean bestcorrected visual acuity, retinal sensitivity, multifocal electroretinography (mfERG), central macular thickness, and specific neurosensorial retinal measurements improved significantly. The authors found a significant negative correlation between retinal sensitivity and central macular thickness at 1 month and 3 months. The change in outer retinal thickness from baseline to Month 1 was positively related to mfERG N1R1 amplitude change, whereas change in central macular thickness was negatively correlated to mfERG P1R1 amplitude change. In a similar report, the authors found insignificant change in BCVA after intravitreal
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dexamethasone injection at the 1-month and 3-month examinations in central retinal vein occlusion patients.2 We believe that this difference is simply a result of increased patient number in this study. That makes the result of this study more valuable. In a previous study, we showed that the mfERG is not correlated with BCVA change after intravitreal triamcinolone acetonide injection in diffuse diabetic macular edema.3 At this point, we want to learn whether the baseline mfERG amplitudes can predict postinjection results such as postinjection BCVA. For this reason, we kindly ask the authors to perform a correlation analysis between the baseline mfERG amplitudes and the change in BCVA [(postinjection baseline)/baseline]. This statistics may clarify the value of baseline mfERG before the dexamethasone injection. Ümit Yolcu, MD* Ahmet Tas, MD† Abdullah Ilhan, MD‡ Salih Altun, MD§ Fatih C. Gundogan, MD§ *Ophthalmology Service, Sarikamis Military Hospital Kars, Turkey †Ophthalmology Service, Agri Military Hospital, Agri Turkey ‡Ophthalmology Service, Erzurum Military Hospital Erzurum, Turkey §Department of Ophthalmology, GATA Medical School, Ankara, Turkey None of the authors have any financial/conflicting interests to disclose. References 1. Querques G, Lattanzio R, Querques L, et al. Impact of intravitreal dexamethasone implant (Ozurdex) on macular morphology and function. Retina 2014;34:330–341. 2. Querques G, Cascavilla ML, Cavallero E, et al. Changes in macular function after ozurdex for retinal vein occlusion. Optom Vis Sci 2014;91:760–768. 3. Durukan AH, Memisoglu S, Gundogan FC. Is multifocal ERG a reliable index of macular function after triamcinolone acetonide injection in diffuse diabetic macular edema? Eur J Ophthalmol 2009;19:1017–1027.
Table 1. Correlation Analysis at Each Time Point Between Baseline Multifocal Electroretinography Amplitudes and Change in Best-Corrected Visual Acuity BCVA Change Amplitude, mV N1R1 Amplitude N1R2 Amplitude P1R1 Amplitude P1R2 Amplitude
R P R P R P R P
1 Month
3 Months
0.145 0.653 0.136 0.674 −0.163 0.613 −0.539 0.07
0.421 0.173 0.153 0.636 −0.121 0.707 0.017 0.958
R, Pearson correlation coefficient. BCVA change, best-corrected visual acuity change in 1 month and 3 months after intravitreal dexamethasone implant; N1R1 amplitude, first negative peak amplitude analyzed in ring 1; N1R2 amplitude, first negative peak amplitude analyzed in ring 2; P1R1 amplitude, first positive peak amplitude analyzed in ring 1; P1R2 amplitude, first positive peak amplitude analyzed in ring 2.
intravitreal dexamethasone implant (Ozurdex) for central retinal vein occlusion.1 In our study, we found significant correlations between several functional and morphological measures. However, as correctly pointed out by the authors, we did not report the correlations between baseline multifocal electroretinography amplitudes and best-corrected visual acuity change after treatment; indeed, this analysis, which was performed along with all other calculations, has been omitted because of the absence of significant correlations (Table 1). We thank the authors for giving us the opportunity to clarify this issue related to our article. Giuseppe Querques, MD, PhD Edoardo Cavallero, MD Francesco Bandello, MD, FEBO Department of Ophthalmology, University Vita-Salute, Scientific Institute San Raffaele, Milan, Italy None of the authors have any financial/conflicting interests to disclose.
Reply To the Editor: We thank Drs. Tas et al for their interest on our recent article describing the relationship between changes in macular morphology and function after
Reference 1. Querques G, Lattanzio R, Querques L, et al. Impact of intravitreal dexamethasone implant (Ozurdex) on macular morphology and function. Retina 2014;34:330–341.
RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES 2015 VOLUME 35 NUMBER 3
Patrícia Correa de Mello, MD Patricia Berensztejn, MD Oswaldo Ferreira Moura Brasil, MD Instituto Brasileiro de Oftalmologia (IBOL), Rio de Janeiro, Brasil None of the authors have any financial/conflicting interests to disclose. References 1. Hoang QV, Cunningham ET, Sorenson JA, Freund KB. THE “PITCHFORK sign” a distinctive optical coherence tomography finding in inflammatory choroidal neovascularization. Retina 2013;33:1049–1055. 2. Gass JD, Guerry RK, Jack RL, Harris G. Choroidal osteoma. Arch Ophthalmol 1978;96:428–435. 3. Foster BS, Fernandez-Suntay JP, Dryja TP, et al. Clinicopathologic reports, case reports, and small case series: surgical removal and histopathologic findings of a subfoveal neovascular membrane associated with choroidal osteoma. Arch Ophthalmol 2003;121:273–276.
may also indicate some degree of inflammation occurring in this neovascular process. Quan V. Hoang, MD, PhD* K. Bailey Freund, MD*†‡§ *Department of Ophthalmology, Columbia University College of Physicians and Surgeons New York, New York †Vitreous Retina Macula Consultants of New York New York, New York ‡LuEsther T. Mertz Retinal Research Center Manhattan Eye, Ear, and Throat Institute New York New York §Department of Ophthalmology, New York University Medical Center, New York, New York K. B. Freund is a consultant to Regeneron, Genentech, Bayer HealthCare, ThromboGenics, Ohr Pharmaceutical, and Heidelberg Engineering (honorarium for each). The other author has no conflicting interests to disclose. References
Reply To the Editor: We appreciate the opportunity to further discuss our recent report on the “Pitchfork Sign,” a distinctive optical coherence tomography finding in inflammatory choroidal neovascularization (CNV),1 in particular, to respond to the interest and letter from Dr. de Mello et al, who noted similar hyperreflective finger-like projections from Type 2 neovascularization in the setting of choroidal osteoma. The main purpose of our original article1 was to describe an optical coherence tomography finding that would be helpful in distinguishing cases of multifocal choroiditis/punctate inflammatory choroidopathy–related CNV from idiopathic or myopic CNV where the diagnosis was uncertain. In a report by de Mello et al, there is an obvious predisposing risk factor for CNV; therefore, although the presence of this optical coherence tomography finding is interesting, it is of less clinical relevance. Of interest, the patient in their report is a young female, similar to all four of the cases in our series. As these authors mention, there may be an inflammatory component to osteoma2; therefore, inflammation could be playing a role in this form of CNV. Although we agree that the CNV in the case by de Mello et al appears to be Type 2 neovascularization, it is a bit unusual in that Type 2 neovascularization in age-related macular degeneration tends to appear as a thin flat layer of tissue above the retinal pigment epithelium, whereas the CNV membrane in this case appears more similar to a mass of tissue. Perhaps, this optical coherence tomography finding
1. Hoang QV, Cunningham ET, Sorenson JA, Freund KB. The “pitchfork sign” a distinctive optical coherence tomography finding in inflammatory choroidal neovascularization. Retina 2013;33:1049–1055. 2. Gass JD, Guerry RK, Jack RL, Harris G. Choroidal osteoma. Arch Ophthalmol 1978;96:428–435.
Correspondence To the Editor: We congratulate Querques et al1 for their study entitled “Impact of intravitreal dexamethasone implant (Ozurdex) on macular morphology and function.” The authors investigated the relationship between the changes in macular morphology and function after intravitreal dexamethasone implant (Ozurdex) for central retinal vein occlusion. The study reports important results especially in terms of ocular electrophysiology and retinal morphology in macular edema due to central retinal vein occlusion. The authors reported that at 1 month, mean bestcorrected visual acuity, retinal sensitivity, multifocal electroretinography (mfERG), central macular thickness, and specific neurosensorial retinal measurements improved significantly. The authors found a significant negative correlation between retinal sensitivity and central macular thickness at 1 month and 3 months. The change in outer retinal thickness from baseline to Month 1 was positively related to mfERG N1R1 amplitude change, whereas change in central macular thickness was negatively correlated to mfERG P1R1 amplitude change. In a similar report, the authors found insignificant change in BCVA after intravitreal
e25
Correspondence
dexamethasone injection at the 1-month and 3-month examinations in central retinal vein occlusion patients.2 We believe that this difference is simply a result of increased patient number in this study. That makes the result of this study more valuable. In a previous study, we showed that the mfERG is not correlated with BCVA change after intravitreal triamcinolone acetonide injection in diffuse diabetic macular edema.3 At this point, we want to learn whether the baseline mfERG amplitudes can predict postinjection results such as postinjection BCVA. For this reason, we kindly ask the authors to perform a correlation analysis between the baseline mfERG amplitudes and the change in BCVA [(postinjection baseline)/baseline]. This statistics may clarify the value of baseline mfERG before the dexamethasone injection. Ümit Yolcu, MD* Ahmet Tas, MD† Abdullah Ilhan, MD‡ Salih Altun, MD§ Fatih C. Gundogan, MD§ *Ophthalmology Service, Sarikamis Military Hospital Kars, Turkey †Ophthalmology Service, Agri Military Hospital, Agri Turkey ‡Ophthalmology Service, Erzurum Military Hospital Erzurum, Turkey §Department of Ophthalmology, GATA Medical School, Ankara, Turkey None of the authors have any financial/conflicting interests to disclose. References 1. Querques G, Lattanzio R, Querques L, et al. Impact of intravitreal dexamethasone implant (Ozurdex) on macular morphology and function. Retina 2014;34:330–341. 2. Querques G, Cascavilla ML, Cavallero E, et al. Changes in macular function after ozurdex for retinal vein occlusion. Optom Vis Sci 2014;91:760–768. 3. Durukan AH, Memisoglu S, Gundogan FC. Is multifocal ERG a reliable index of macular function after triamcinolone acetonide injection in diffuse diabetic macular edema? Eur J Ophthalmol 2009;19:1017–1027.
Table 1. Correlation Analysis at Each Time Point Between Baseline Multifocal Electroretinography Amplitudes and Change in Best-Corrected Visual Acuity BCVA Change Amplitude, mV N1R1 Amplitude N1R2 Amplitude P1R1 Amplitude P1R2 Amplitude
R P R P R P R P
1 Month
3 Months
0.145 0.653 0.136 0.674 −0.163 0.613 −0.539 0.07
0.421 0.173 0.153 0.636 −0.121 0.707 0.017 0.958
R, Pearson correlation coefficient. BCVA change, best-corrected visual acuity change in 1 month and 3 months after intravitreal dexamethasone implant; N1R1 amplitude, first negative peak amplitude analyzed in ring 1; N1R2 amplitude, first negative peak amplitude analyzed in ring 2; P1R1 amplitude, first positive peak amplitude analyzed in ring 1; P1R2 amplitude, first positive peak amplitude analyzed in ring 2.
intravitreal dexamethasone implant (Ozurdex) for central retinal vein occlusion.1 In our study, we found significant correlations between several functional and morphological measures. However, as correctly pointed out by the authors, we did not report the correlations between baseline multifocal electroretinography amplitudes and best-corrected visual acuity change after treatment; indeed, this analysis, which was performed along with all other calculations, has been omitted because of the absence of significant correlations (Table 1). We thank the authors for giving us the opportunity to clarify this issue related to our article. Giuseppe Querques, MD, PhD Edoardo Cavallero, MD Francesco Bandello, MD, FEBO Department of Ophthalmology, University Vita-Salute, Scientific Institute San Raffaele, Milan, Italy None of the authors have any financial/conflicting interests to disclose.
Reply To the Editor: We thank Drs. Tas et al for their interest on our recent article describing the relationship between changes in macular morphology and function after
Reference 1. Querques G, Lattanzio R, Querques L, et al. Impact of intravitreal dexamethasone implant (Ozurdex) on macular morphology and function. Retina 2014;34:330–341.
