Published in Retina

Exposing Hidden Lesions: A Case of Non-Exudative Occult CNV

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7 min read

Daniel Epshtein, OD, FAAO, joins Julie Rodman, OD, MSc, FAAO, to discuss a case report of a patient with non-exudative occult choroidal neovascularization (CNV).

Welcome back to Ready, Set, Retina! In this episode, Daniel Epshtein, OD, FAAO, sits down with Julie Rodman, OD, MSc, FAAO, to review a case report of a patient with non-exudative occult choroidal neovascularization (CNV).

What is non-exudative occult CNV?

CNV is characterized by the abnormal growth of vessels from the choroidal vasculature to the neurosensory retina through Bruch’s membrane that can result in exudation, hemorrhage, and fibrosis, damaging the outer retina and often resulting in vision loss.1,2 Of note, CNV is defined as occult or type 1 choroidal neovascularization when the neovascular membrane is located below the retinal pigment epithelium (RPE).1
In the past, fluorescein angiography (FA) was the gold standard for diagnosing CNV; however, occult or type 1 choroidal neovascularization resides below the RPE, and FA generally does a poor job of imaging at this level. The borders of these lesions are poorly demarcated and absent, which are the characteristic hyperfluorescent patterns that allow for diagnosis if leakage is not present in these occult lesions.2
With the advent of optical coherence tomography angiography (OCTA), eyecare practitioners (ECPs) now have the capability of imaging retinal and choroidal microcirculation noninvasively and identifying non-exudative neovascular membranes that would be otherwise invisible with FA. This is due to the unique ability of OCTA to segment the retinal and choroidal vasculature into layers or plexi, thereby providing visualization of the vasculature at any layer.1,3

Non-exudative occult CNV case report

A 70-year-old African American male returned to the clinic 1 month after a comprehensive eye examination because he was identified as a glaucoma suspect and required further testing.
The patient’s best-corrected visual acuity (BCVA) was 20/25 OD and OS. The patient had hypertension, diabetes mellitus (DM), and acid reflux, though his systemic conditions were well-controlled.
Figures 1 and 2 are fundus photographs of the right eye (OD) and left eye (OS), respectively, at the initial visit. Enlarged cupping can be appreciated, though both images are largely unremarkable for retinal pathology.
Baseline Fundus OD
Figure 1: Courtesy of Julie Rodman, OD, MSc, FAAO.
Baseline Fundus OS
Figure 2: Courtesy of Julie Rodman, OD, MSc, FAAO.

OCT imaging from the glaucoma workup

Dr. Rodman then ordered OCT ganglion cell complex (GCC) and retinal nerve fiber layer (RNFL) scans as part of the glaucoma workup.
Figures 3 and 4 show OCT GCC scans OS, and a slight disorganization of the outer retina and RPE (highlighted with the red arrows) can be visualized in both scans.
OCT GCC Scan 1
Figure 3: Courtesy of Julie Rodman, OD, MSc, FAAO.
OCT GCC Scan 2
Figure 4: Courtesy of Julie Rodman, OD, MSc, FAAO.

OCT angiography

While considering the potential cause of the lesion, Dr. Rodman decided that OCTA may help narrow down the list of possible etiologies.
Figure 5 shows the results from OCTA imaging. There is a neovascular membrane at the level of the choriocapillaris (highlighted with a red circle). The lower panel is for comparative purposes and shows normal angiography images of the various plexi.
OCTA Membrane
Figure 5: Courtesy of Julie Rodman, OD, MSc, FAAO.
Figure 6 is a closeup of the choroidal neovascular lesion found on OCTA.
OCTA CNV Closeup
Figure 6: Courtesy of Julie Rodman, OD, MSc, FAAO.

Follow-up

Dr. Rodman explained that she was surprised to have found a choroidal neovascular membrane, as this was her first time seeing a “dry” retina with a neovascular lesion—a departure from the typical findings associated with occult CNV from AMD.
The patient’s retinal specialist ultimately decided not to pursue further treatment because the neovascular membrane was non-exudative. As a result, she followed the patient and ordered periodic OCTA testing to monitor the CNV lesion.
Figure 6 is a multiscan view of OCTA imaging captured at follow-up visits. The CNV membrane appears to remain stable, with no signs of growth or exudation. From left to right, the OCTA images were captured on July 22, 2017, October 14, 2017, and January 13, 2018.
OCTA MultiScan View Membrane
Figure 7: Courtesy of Julie Rodman, OD, MSc, FAAO.

Managing patients with non-exudative choroidal neovascularization

Dr. Rodman noted that in the case of this patient, due to his demographic considerations and the absence of any classic AMD signs, she initially followed up with him every 4 to 6 months to monitor the CNV lesion. However, this timeline would be altered if the patient had AMD in either eye. She also indicated that she might opt to co-manage the patient with a retinal specialist if there were other ocular co-morbidities.
She added that the risk of non-exudative neovascularization converting to the exudative form of the disease is significantly higher when the fellow eye has pre-existing AMD or neovascularization.4 In addition, she mentioned that patients with intermediate AMD and/or geographic atrophy (GA) can also develop non-exudative neovascular membranes. However, studies are finding that these membranes may, in fact, have a protective effect in GA and represent vascular remodeling.4
Dr. Epshtein added that for a patient with AMD in one eye and non-exudative occult CNV in the other, he would choose to monitor them with both structural OCT and OCTA every 2 months initially, and then extend the follow-up period to every 3 to 4 months to monitor for exudation if no changes were seen during the initial period.
Further, in his clinical experience, a telltale sign that the membrane is likely to leak is if the lesion grows. Dr. Rodman noted that, based on her experience, lesions that remain stable for longer periods of time (i.e., 6 to 12 months) are at a lower risk of exudative conversion.

Conclusion

Non-exudative CNV is a relatively new clinical entity that is now being diagnosed more frequently due to the advent of OCTA imaging.3
This case report highlights how OCTA can identify retinal microvascular changes that may possibly go undetected with funduscopy and OCT imaging.
  1. Hoyos Dumar AT, Kim LA, Lee SY, et al. Choroidal neovascularization: OCT angiography findings. EyeWiki. Updated May 28, 2024. Accessed June 6, 2024. https://eyewiki.aao.org/Choroidal_Neovascularization:_OCT_Angiography_Findings.
  2. Bailey ST, Thaware O, Wang J, et al. Detection of non-exudative choroidal neovascularization and progression to exudative choroidal neovascularization using optical coherence tomography angiography. Ophthalmol Retina. 2019;3(8):629-636. doi:10.1016/j.oret.2019.03.008
  3. Lane M, Ferrara, Louzada RN, et al. Diagnosis and follow-up of nonexudative choroidal neovascularization with multiple optical coherence tomography angiography devices: A case report. Ophthalmic Surg Lasers Imaging Retina. 2016;47(8):778-781. doi:10.3928/23258160-20160808-13
  4. Laiginhas R, Yang J, Rosenfeld PJ, Falcão M. Non-exudative macular neovascularization – A systematic review of prevalence, natural history, and recent insights from OCT angiography. Ophthalmol Retina. 2020;4(7):651-661. doi:10.1016/j.oret.2020.02.016
Daniel Epshtein, OD, FAAO
About Daniel Epshtein, OD, FAAO

Dr. Daniel Epshtein is an assistant professor in the ophthalmology department of Mount Sinai Morningside in New York City. Previously, he held a position in a high-volume multispecialty ophthalmology practice where he supervised fourth-year optometry students as an adjunct assistant clinical professor of the SUNY College of Optometry. Dr. Epshtein’s research focuses on using the latest ophthalmic imaging technologies to elucidate ocular disease processes and to simplify equivocal clinical diagnoses. He developed and lectures in the perioperative care course at the SUNY College of Optometry. Dr. Epshtein writes and lectures on numerous topics including glaucoma, retinal disease, multimodal imaging, ocular surface disease, and perioperative care.

Daniel Epshtein, OD, FAAO
Julie Rodman, OD, MSc, FAAO
About Julie Rodman, OD, MSc, FAAO

Dr. Julie Rodman received her optometry degree from the New England College of Optometry, after which she went on to complete a residency in hospital-based optometry at the VAMC Brockton/West Roxbury, MA. Since completing her residency, Dr. Rodman has worked in various settings, including an ophthalmology private practice and an HMO-based practice. In 2014, Dr. Rodman received her Masters of Science in Clinical Vision Research from Nova Southeastern University. In February 2008, Dr. Rodman joined the Nova Southeastern faculty on a full-time basis as an Assistant Professor of Optometry and now holds the rank of Professor of Optometry.

Dr. Rodman has taught in the Optometry Theory and Methods Laboratory and currently serves as the Chief of the Broward Eye Care Institute in downtown Fort Lauderdale. She has been the recipient of numerous teaching awards, including the Golden Apple Award for Excellence in Clinical Precepting, and Preceptor of the Year. She has been recognized as Primary Care Optometry’s “Top 300 Innovators in Optometry”.

Dr. Rodman has authored multiple posters at the American Academy of Optometry, American Optometric Association, Association for Research in Vision and Ophthalmology (ARVO), Southeast Conference of Optometry (SECO), and Heart of America on various ocular disease topics. She became a Fellow of the American Academy of Optometry in 2007. She serves as a poster reviewer for the multi-media session at SECO and is a reviewer for multiple index medicus journals as well. Dr. Rodman is a member of the American Optometric Association, Florida Optometric Association and Optometric Retina Society. Dr. Rodman also sits on the Optovue Advisory Board where she serves as a lecturer and consultant. She holds her Oral Pharmaceuticals Certification and is Laser Certified as well. Her scholarly interests include retinal disease, optical coherence tomography, optical coherence tomography angiography and diseases of the vitreo-retinal interface. She was the principal investigator on a multi-center, nationwide investigation into the prevalence of Vitreomacular Adhesion in Patients 40 Years of Age and Older. She is also the author of a textbook titled “Optical Coherence Tomography Angiography: A Case Study Approach.”

Julie Rodman, OD, MSc, FAAO
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