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Herbort, C.P.; Takeuchi, M.; Papasavvas, I.; Tugal-Tutkun, I.; Hedayatfar, A.; Usui, Y.; Ozdal, P.C.; Urzua, C.A. Optical Coherence Tomography Angiography in Uveitis. Encyclopedia. Available online: https://encyclopedia.pub/entry/41679 (accessed on 08 July 2025).
Herbort CP, Takeuchi M, Papasavvas I, Tugal-Tutkun I, Hedayatfar A, Usui Y, et al. Optical Coherence Tomography Angiography in Uveitis. Encyclopedia. Available at: https://encyclopedia.pub/entry/41679. Accessed July 08, 2025.
Herbort, Carl P., Masaru Takeuchi, Ioannis Papasavvas, Ilknur Tugal-Tutkun, Alireza Hedayatfar, Yoshihiko Usui, Pinar C. Ozdal, Cristhian A. Urzua. "Optical Coherence Tomography Angiography in Uveitis" Encyclopedia, https://encyclopedia.pub/entry/41679 (accessed July 08, 2025).
Herbort, C.P., Takeuchi, M., Papasavvas, I., Tugal-Tutkun, I., Hedayatfar, A., Usui, Y., Ozdal, P.C., & Urzua, C.A. (2023, February 26). Optical Coherence Tomography Angiography in Uveitis. In Encyclopedia. https://encyclopedia.pub/entry/41679
Herbort, Carl P., et al. "Optical Coherence Tomography Angiography in Uveitis." Encyclopedia. Web. 26 February, 2023.
Optical Coherence Tomography Angiography in Uveitis
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This entry is adapted from the peer-reviewed paper 10.3390/diagnostics13040601

The global and precise follow-up of uveitis has become possible with the availability of dual fluorescein (FA) and indocyanine green angiography (ICGA) since the mid-1990s. Progressively, additional non-invasive imaging methods have emerged, bringing value-added precision to the imaging appraisal of uveitis, including, among others, optical coherence tomography (OCT), enhanced-depth imaging OCT (EDI-OCT) and blue light fundus autofluorescence (BAF). More recently, another complementary imaging method, OCT-angiography (OCT-A), further allowed retinal and choroidal circulation to be imaged without the need for dye injection. Promoting the possibility that non-invasive OCT-A can substitute the invasive dye methods is deleterious, giving the elusive impression that dye methods are no longer inevitable for evaluating uveitis patients. Nevertheless, OCT-A is a precious tool in uveitis research.

optical coherence tomography angiography (OCT-A) dual fluorescein angiography (FA) and indocyanine green angiography (ICGA) posterior uveitis

1. Optical Coherence Tomography Angiography (OCT-A)

Unlike the other complementary imaging modalities, which were clearly contributive to the evaluation of certain ocular structures in uveitis entities, but were never considered nor pretended to replace the dye angiographic methods, OCT-A was put forward as being able to be a non-invasive method that could replace classical angiographic dye methods.
OCT-A is an evolution of OCT technology. It uses multiple scans per second to detect differences between the images, and especially the movement of red blood cells, in order to provide anatomic information about the scanned area. The images are firstly captured in a 3D motive, which is reconstructed and presented to the clinician as 2D cross sectional and en face scans [1]. As the capture of images is essential to the quality of the provided information, motion artifacts due to movement of the patient, or mirroring of the superficial vessel to lower structures were the major problems of the OCT-A. Moreover, common clinical features of patients with uveitis, such as subretinal fluid (in particular in VKH), may be acting as significant cofounders, since the fluid itself may decrease the decorrelation signal detected by the OCT-A machine [2]. New software such as the projection artifact removal OCT-A (PAROCTA) helped with the decrease in motion artifacts [3]. The limited field of view was another major disadvantage when the exam was compared to dye exams. Furthermore, new devices such as the Xephilio are promising a wider field of view, which would extend to 20 × 23 mm [4]. The presentation of the retinal vasculature and choriocapillaris without the use of a dye was a revolution which led to theories that OCT-A could replace the dye exams. Even though its use in everyday routine practice is of limited value after other multimodal investigations have been performed (see below), it was the origin of remarkable research data in numerous studies.
Although OCT-A is a very high-quality research tool, its ability to replace dye angiography in current uveitis practice was recently questioned by a group [5]. This motivated people to verify whether there was sufficient evidence in the literature to support these points (possible exclusive use of OCT-A and possible substitution to dye methods) or not, or whether a supposition of over-estimation of practical use of OCT-A, only based on cases so far, was supported by more sound proof in a literature search.
As a result, the purpose was to use pioneering pragmatism, perform a literature search and analyze the aims and outcomes of OCT-A studies in uveitis, and then to list its most useful applications and analyze the arguments, if any, claiming or suggesting its effectiveness for global routine evaluation and follow-up of posterior uveitis as a substitute for dye angiographic methods.

2. Number of Articles (2016–2022)

One hundred and forty-four articles including the aforementioned search terms were identified. Case report articles were excluded, leaving 114 articles. It is found that 4 articles were published in 2016, 17 in 2017, 14 in 2018, 21 in 2019, 14 in 2020, 18 in 2021 and 26 before the end of August 2022. After having been more or less constant from 2017 until 2021, there was a substantial increase in articles in 2022. Of the articles, 7 were mainly technical informative or consensus-based definition or standardization articles [4][5][6][7][8][9][10][11][12], 92 were research articles and 15 were review articles or articles directly comparing OCT-A to dye methods.

3. Clinical Research Articles

The search yielded 92 research articles on different disease conditions and different localizations of structures. Of these articles, 32 concerned retinal circulation, 45 concerned choroidal circulation and 14 explored both retinal and choroidal circulation. Nineteen articles concerned the investigation of inflammatory choroidal neovascularization (CNV). Most articles indicated the adjunctive value rather than the exclusive use of OCT-A, but the positive contribution was the fact that evolution of CNV could be followed with reduced necessity of dye injection during treatment [13][14][15]. One article rated the detection of CNV by OCT-A as high as 76.9% compared to dye angiography [16]. Two articles focused on the fact that OCT-A was useful to distinguish CNV from inflammatory lesions [17][18]. Two articles found that OCT-A was insufficient to distinguish active from inactive CNV [19], and should, therefore, be used as part of multimodal imaging [20]. One article stated that OCT-A was not sufficient to replace dye angiography [21].
The most frequently analyzed conditions were the choriocapillaritis entities, including SC, TB-related or not, MFC/PIC, MEWDS and APMPPE (N = 35), Behçet’s disease (N= 15) and VKH disease (N = 8). This classification gives an idea for which diseases OCT-A is probably going to be most useful when it is integrated into the multimodal imaging investigation.

4. Review Articles

Fifteen review articles were reviews or touched upon the comparison of OCT-A and dye angiographic methods and directly or indirectly hinted at the possibility of OCT-A replacing dye angiographic methods, but failed to prove such a paradigm.
Herbort and al. concluded that the claim of OCT-A to possibly replace classical dye angiographic methods for routine follow-up and management of posterior uveitis was largely overrated [22]. Similarly, Pichi and Hay declared that “OCT-A data and results were of limited utility to the ophthalmologists who are looking to apply OCTA in their everyday uveitis clinic” [23]. On the other hand, this outlined most of the inflammatory situations where OCT-A represented a precious adjunct to classical angiographic investigation. The authors further put forward that OCT-A could replace ICGA in detecting choroidal granulomas, a statement which should be considered cautiously for everyday clinical practice while taking into account the still-limited field of view of routinely used instruments. Since its availability, probably because of the high technicity of the OCT-A method, the unsubstantiated notion that OCT-A could replace the global use of dye methods in uveitis has been circulating and up in the air. This speculation was the origin of several articles attempting to support such a postulate. This approach stands out in a recent article by multiple authors entitled “Experts opinion: OCTA vs. FFA/ICG in uveitis-which will survive?” [24]. Even though the conclusion was not in favor of OCT-A, multiplying such articles tends to falsely strengthen the idea of a possible replacement of dye angiographic methods. Furthermore, it is not suitable to oppose these two methods, as in reality, they are complementary. Another article attempted to compare ICGA and OCT-A in choroiditis, with the aim to show that the latter was able to replace the former method [25]. Indeed, beyond the articles merely hinting that OCT-A represented more than just a complementary imaging modality such as OCT, EDI-OCT and FAF, some articles attempted to indicate that OCT-A was able to replace classical angiographic modalities in the appraisal and monitoring of uveitis [23][25]. Although this was not the official purpose of their article, Tian et al. [25], by trying to imply that OCT-A could possibly be compared to ICGA in posterior uveitis and putting them on an equal footing, precisely leads the reader to believe that one method could replace the other [25]. Besides the many drawbacks of OCT-A mentioned by the article itself, the article was characterized by several flaws. The authors considered the terms of uveitis and choroiditis as equivalent. Indeed, it is well-known that ICGA merely gives information on the choroid and not on other structures, and these terms are not equivalent. To declare that “posterior uveitis is also termed choroiditis” is a blatant misconception. Therefore, the inclusion of Behçet’s uveitis cases in their collective is not justified, as it is a purely retinal disease and does not present choroidal ICGA lesions. As far as technical matters are concerned, OCT-A montage was used to obtain a wider field of vision. A disadvantage of a montage is the presence of artifacts including, but not limited to, displacement, shadowing and vessel displacement. These can decrease the quality of the images and, as a consequence, the quality of the diagnosis and follow-up. On the contrary, ICGA covers a greater field of view with a better quality of imaging without the need of a montage. Additionally, a single ICGA time frame was used for comparison to OCT-A. It is well-known that ICGA is a dynamic exam which can provide information throughout the intermediate and late phases about the localization of the inflammation (choriocapillaris, full stroma of choroid or part of the choroidal stroma). According to the results of their study, in 64% of cases where hypofluorescence was shown on ICGA, OCT-A was unable to demonstrate these areas as they were outside the field of vision. OCT-A also failed to show which mechanism was at the origin of drop-out areas, choriocapillaritis or stromal choroiditis, which a dynamic analysis of ICGA frames is able to demonstrate. In conclusion, Tian et al. presented a case series of patients with posterior uveitis (in fact, choroiditis) where ICGA was superior to OCT-A in analyzing choroidal inflammation, failing to put forward OCT-A as a credible alternative to ICGA. At this time and with the current OCT-A technology routinely available to eye centers, ICGA remains the gold standard exam in the diagnosis and follow-up of choroidal inflammation. An article on the use of OCT-A in “so-called” white dot syndromes insisted on the complimentary information obtained with this imaging modality without claiming that it could replace classical dye-based angiography [26]. In their article, Invernizzi et al. stressed the importance of a multimodal approach to imaging of choroiditis, including ICGA and OCT angiography without establishing a hierarchy or precedence of one modality over the other [27]. Tranos et al. also compared OCT-A to FA and ICGA. Like many other review articles, it described the aspects of uveitis in which OCT-A was useful and pointed out the many complementary advantages it represented in addition to FA/ICGA, without going as far as to consider it as a possible exclusive angiographic modality [28]. Similarly to other reviews, Dingerkus et al. exposed situations where OCT-A was especially useful [29]. However, like all other reviews, their conclusion, considering the precious information yielded by OCT-A, was that “it should be used as a complementary modality rather than as an exclusive tool”. An earlier review by Invernizzi et al. insisted on the fact that OCT/OCT-A are “becoming more essential in the management of uveitis”; however, they did not put them in perspective with dye angiographic methods and refrained from any statement on the possibility that they might replace the latter [30]. The most complete and technically detailed review of OCT-A was published in 2018 by Spaide et al. [1]. As far as uveitis is concerned, the article addresses mainly general vasculitis aspects, not going into illustrations of practical disease. At this early stage of development, the authors state that “none of the older imaging modalities can be replaced by OCT-A at present”. Kashani et al. laid down the foundations and arguments of the situations where classical dye methods or OCT-A were more appropriate to be used in uveitis, a topic which will be discussed in another section of this analysis [31]. These authors mainly discussed the advantages of OCT-A in retinal/macular inflammatory diseases. In the comprehensive early review of Pichi et al. on OCT-A in uveitis, its applications in uveitic conditions are illustrated, but the authors conclude that “in its current state, OCTA serves as a useful adjunct to traditional angiographic techniques, since multimodal image analysis is still necessary to confirm pathological findings in uveitis” [32]. In this almost exhaustive group of review articles analyzing OCT-A starting in 2017, no article whatsoever claims nor hints that OCT-A is in a position to replace conventional dye angiographic methods. It must be considered, like OCT, EDI-OCT and BAF, as an adjunct/complementary imaging method, to be integrated in the multi-modal imaging of uveitis, although it is of high technical value.

5. Significant Contribution of OCT-A to Uveitis

There is no doubt that OCT-A represents significant progress in the appraisal of uveitis, as evidenced by the many research articles published since the method became available. Researchers will refrain from citing again what has been extensively and repeatedly described. Many of these studies report new data which is still to be standardized in order to possibly be applied to everyday routine practice. Furthermore, the experiments were often performed on research instruments not readily available to general clinicians. Researchers will, therefore, focus on the major intakes immediately beneficial for the practitioner in the daily management of patients. When investigating this point, Researchers reviewed the utility of OCT-A in a specific center that uses a routinely available OCT-A instrument and evaluated, using pioneering pragmatism, the situations in which OCT-A provided further determining information to dye angiography, OCT, EDI-OCT and BAF data. Additionally, practical use reported in the literature was also considered. As a general rule, OCT-A was performed in most patients consulting for uveitis at presentation and for follow-up in the center. Within the 217 new uveitis cases seen from 2018 to 2022 in this center, 146 were examined with an Optovue instrument and 46 posterior uveitis cases were analyzed. Rare were the cases for which OCT-A was of crucial additional utility in the practical management of patients, so they will not be individually described hereafter. It did not provide diagnostic help in any patient after multimodal imaging was performed. It was useful for follow-up in two cases of APMPPE, showing the evolution of choriocapillary drop-out without the need to repeat ICGA. In five cases of inflammatory CNV due to MFC and APMPPE, it also helped with monitoring the evolution during treatment and allowed the researchers to reduce the number of dye angiographies performed.
The main situations where OCT-A was of determining utility in everyday practice from the literature were the rare inability to use fluorescein dye and the even rarer inability to use ICG because of allergic reactions. OCT-A was shown to be useful and to help in the detection of CNV, such as in MFC/PIC and other choriocapillaritis entities as well as its follow-up during treatment, but none of the articles recommended it for exclusive use. [13] One article clearly stated that OCT-A was not sufficient to replace dye angiography [21], and two articles indicated that OCT-A was unable to distinguish active from inactive CNV [19][20]. In predominantly retinal diseases, such as Behçet’s uveitis, OCT-A cannot be considered as essential in the diagnosis. However, analysis of macular microcirculation and its monitoring have shown to be useful to the clinician at times, although no standardization has been put forward so far [33]. The most useful application of OCT-A was for the group of choriocapillaritis diseases, including APMPPE, MFC and SC, and its utility resided mainly in the close follow-up it allowed, as no dye injection was needed [34]. As far as MEWDS is concerned, OCT-A was useless, as end-capillary low flow circulation is not identified by OCT-A. This was the origin of the erroneous thinking that there was an absence of choriocapillaris non-perfusion and, thus, an alleged intact choriocapillaris, as well as that MEWDS was supposedly a primary photoreceptoritis [35]. Although it was not included in the search terms, when trying to establish the essential, practical contributions of OCT-A, the article of Abucham-Neto et al. should be cited [36]. These authors indicate that OCT-A may better identify new vessels obscured by retinal hemorrhage, early peripapillary neovascular proliferation and telangiectasias.

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Subjects: Ophthalmology
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :
Carl P. Herbort
,
Masaru Takeuchi
,
Ioannis Papasavvas
,
Ilknur Tugal-Tutkun
,
Alireza Hedayatfar
,
Yoshihiko Usui
,
Pinar C. Ozdal
,
Cristhian A. Urzua
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Update Date: 27 Feb 2023
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