Update of choroidal imaging techniques: Past, present and future | Archivos de la Sociedad Española de Oftalmología (English Edition)

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The choroids are a highly vascularized and pigmented tissue located between the retina and the sclera&#46; The term originates in the Greek words &#8220;form&#8221; and &#8220;membrane&#8221;&#46; With a few exceptions and in contrast with the retina&#44; the choroids have not been extensively studied until relatively recently&#46; The main explanation could be that the choroids have always been a challenge for researchers&#46; From postmortem anatomopathological samples it is known that the choroids measure 0&#46;22<span class="elsevierStyleHsp" style=""></span>mm in the posterior pole and between 0&#46;1 and 0&#46;15<span class="elsevierStyleHsp" style=""></span>mm in the anterior zone&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">1</span></a> However&#44; the development of optical coherence tomography &#40;OCT&#41; and imaging techniques related to this technology has enabled the recovery of lost time in said research&#46; At present&#44; the choroids are one of the most popular subjects in research journals related to ophthalmology&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Ultrasonography</span><p id="par0010" class="elsevierStylePara elsevierViewall">In 1956&#44; ultrasonic &#40;US&#41; techniques were utilized for the first time for diagnosing ocular diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">2</span></a> Some researchers utilized the intensity modulation techniques &#40;mode B&#41; that required immersing eyes in water while obtaining an acoustic tomography of the eye through scanning of a crystal in front of the structure being examined&#46; Others utilized amplitude&#8211;time &#40;mode A&#41; where the <span class="elsevierStyleItalic">x</span> axis of the screen constitutes the time coordinate and the <span class="elsevierStyleItalic">y</span> axis represents the eco-amplitude coordinate&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Despite the fact that normal choroids could not be measured and that some authors stated that lesions under 4&#46;0<span class="elsevierStyleHsp" style=""></span>mm high could not be entirely evaluated&#44;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">4</span></a> choroidal melanoma and retina detachment could be identified in cases where they penetrated the vitreous cavity at least between 1&#46;5 and 2&#46;0<span class="elsevierStyleHsp" style=""></span>mm&#46; Coagulated subretinal blood was a difficult differential diagnostic at the time&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Contact ultrasound probes were introduced in the 1970s with continuous evolutions and sensitivity increases&#46; In the past two decades&#44; the digital technology revolution has brought about changes in exploration techniques and data storage as well as vast improvements in image quality &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Choroidal melanoma is the most common malign intraocular tumor and&#44; despite the appearance of new imaging techniques&#44; echography still maintains its usefulness&#46; Before the appearance of the latter technique&#44; melanoma could only be suspected when observing a mass through a transparent medium and&#44; even when the mass was visible&#44; the diagnostic was not entirely apparent&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">6</span></a> However&#44; in the presence of opaque medium&#44; US becomes very useful&#46; Ultrasound choroidal mass patterns remain crucial to establish an adequate differential diagnostic&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Angiography</span><p id="par0030" class="elsevierStylePara elsevierViewall">Fluorescein angiography &#40;FAG&#41; and indocyanine green angiography &#40;IGA&#41; has been applied for decades to obtain useful clinic information about the retina and the choroids&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">7&#44;8</span></a> FAG was developed in the 1960s for analyzing choroidal tumors&#44;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">9&#44;10</span></a> and was used mainly to study the retinal vasculature&#46; Some of the first authors to use this contrast studied choroidal circulation in the first angiogram phases or through retinal atrophy areas in which choroidal vessels were easier to identify&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">8&#44;9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Meanwhile&#44; indocyanine was the first dye utilized in the photographic industry and it was first applied to clinical environments in 1972 when Flower tried to describe and capture choroidal vascularization in Images&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">7</span></a> Indocyanine is a lipophilic and hydrophilic substance with high capacity of bonding to plasmatic proteins &#40;up to 98&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">11</span></a> These proteins have greater molecular weights and albumin which gives indocyanine lower vascular permeability and penetration in tissues&#46; This is what differentiates indocyanine from fluorescein and enables more in-depth study of choroidal vascularization&#46; Indocyanine is metabolized by the liver and excreted through the biliary route&#46; It is injected through the intravenous route at concentrations of 5<span class="elsevierStyleHsp" style=""></span>mg&#47;ml&#46; To capture its circulation&#44; excitation and barrier filters are necessary with peaks of 805 and 835<span class="elsevierStyleHsp" style=""></span>nm&#44; respectively&#46; In general&#44; images are taken between 8 and 10 and 40<span class="elsevierStyleHsp" style=""></span>min after injecting the dye&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">12</span></a> Subsequent studies demonstrated that earlier IGA stages could be useful for identifying the feeder vessels of the choroidal neovascularization complexes &#40;CNV&#41; in order to facilitate focalized treatments therein &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">13</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">In fact&#44; age-related macular degeneration &#40;AMD&#41; was the focus of the vast majority of studies utilizing IGA&#44; but it was also useful for researching the physiology of some chorioretinal inflammatory alterations as well as in anterior segments diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The best way to visualize choroidal neovascularization is by means of IGA&#44; without being limited to cases where retina pigment epithelium &#40;RPE&#41; and choriocapillary atrophy areas can be found&#44; as is the case for FAG&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">14</span></a> Taking into account that the choroids is a 3-dimensional tissue and sets the images are reproduced in two dimensions&#44; it is important to have sufficient knowledge of choroidal anatomy to enable a precise interpretation of the angiograph&#46; Normal anatomical variations of blood drainage&#44; among others&#44; exhibit asymmetric patterns in up to 50&#37; of patients&#44; with preference for one of the vortex veins&#44; which could lead to erroneous interpretations &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">15</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">IGA is particularly useful for detecting recurrent CNV in difficult cases such as pigment epithelium detachments or areas adjacent to laser scars&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">16&#44;17</span></a> It is more precise than FAG for locating CNV below subretinal hemorrhages or sub-RPE due to the greater penetration capacity of infrared light&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">18</span></a> IGA has become the most useful tool for identifying macular&#44; extramacular of peripapillary polyps&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">11</span></a> It is also utilized for locating leak points in the choroids or dilated choroidal vessels in patients with central serous choroidopathy&#46;<a class="elsevierStyleCrossRefs" href="#bib0460"><span class="elsevierStyleSup">19&#44;20</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Optical coherence tomography</span><p id="par0055" class="elsevierStylePara elsevierViewall">The development of OCT brought about a significant progress in choroidal imaging as it provides greater resolution and depth with very short capture times&#46;<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">21&#44;22</span></a> This technology began its development in the 80s&#44; providing images similar to mode A echographies&#46; Transversal images in two dimensions were developed in 1992&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">22</span></a> The first retina scanners for in vivo humans were released in 1993&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">23</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Time domain OCT &#40;TD-OCT&#41; became available initially for studying the posterior pole but&#44; due to poor penetration under the RPE and low resolution&#44; could not be utilized to generate images of the choroids&#46; In 2006&#44; spectral domain OCT &#40;SD-OCT&#41; became available with several improvements such as the option of combining multiple images of the same point in order to reduce noise and improve end results&#44; or the <span class="elsevierStyleItalic">eye-tracking</span> software which made sure that the images were obtained in the same exact location in different explorations&#46; However&#44; despite the obvious advantages over TD-OCT&#44; signal distortions and attenuations due to the presence of pigmented tissue or medium opacity hindered optimum quality images of the choroids in the majority of cases&#46; Later on&#44; Spaide published the first articles reporting the new enhanced-depth imaging OCT &#40;EDI-OCT&#41; that provided consistent visualization of the choroids in most eyes and enabled reproducible and precise thickness measurements&#46;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">24&#8211;26</span></a> The most recent techniques for OCT images utilized a longer wave length with higher penetration&#44; i&#46;e&#46; <span class="elsevierStyleItalic">swept-source</span> OCT &#40;SS-OCT&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">27&#8211;29</span></a> According to some publications&#44; the choroidal thickness can be measured reliably with this device in up to 100&#37; of patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">30&#44;31</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Retinal vessels appear as hyper-reflective in OCT images&#44; while choroidal vessels are hyporeflective&#46; This difference seems to be related to the speed of blood cells passing through the vessels of each tissue&#46; The rate of blood flow within choroidal vessels is much higher than the flow rate in retinal vessels&#46; The production of OCT images is based on interferometry&#44; where a margin of interference is detected to generate signal intensity&#46; The high flow rate of blood cells diminishes the interference margin&#44; which means that no signal is observed within choroidal vessels&#46; On the other hand&#44; the flow rate of blood cells is relatively low in retinal vascular structures&#44; which makes the interference signal hyper-reflective&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The role of the choroids in several diseases has already been demonstrated&#46; This includes central serous choroidopathy &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">11&#44;32&#8211;34</span></a> AMD and polypoid choroidal vasculopathy &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">11&#44;34&#8211;37</span></a> myopia magna&#44;<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">38&#8211;41</span></a> posterior uveitis<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">11&#44;33&#44;34&#44;42&#44;43</span></a> and choroidal tumors &#40;<a class="elsevierStyleCrossRefs" href="#fig0030">Figs&#46; 6 and 7</a>&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">11&#44;44&#44;45</span></a> among others&#46; If in fact choroidal variations do play a role in retinal diseases&#44; the normal choroidal thickness profile and morphology should be known in order to identify variations as they appear&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Choroidal thickness</span><p id="par0075" class="elsevierStylePara elsevierViewall">Age-related thinning is a key factor to establish the role of the choroids in retinal diseases&#44; as demonstrated by several studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">26&#44;46&#8211;50</span></a> Margolis<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">26</span></a> studied a group of 54 eyes of 30 subjects of 52&#46;4 years of age with a mean spherical equivalent &#40;SE&#41; of &#8722;1&#46;3 diopters &#40;D&#41;&#44; and found a mean subfoveal choroidal thickness &#40;SFCT&#41; of 287<span class="elsevierStyleHsp" style=""></span>&#956;m&#46; These results are similar to those obtained by Flores-Moreno<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">41</span></a> and Manjunath&#44;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">49</span></a> who published a mean SFCT of 292<span class="elsevierStyleHsp" style=""></span>&#956;m in 96 eyes of 62 patients with a mean age of 62&#46;6 years&#44; and of 272<span class="elsevierStyleHsp" style=""></span>&#956;m in 34 eyes of patients with 51&#46;1 years de age&#44; respectively&#46; Xu described a mean SFCT of 266<span class="elsevierStyleHsp" style=""></span>&#956;m in the group of nondiabetic patients of his study &#40;1795 subjects&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">37</span></a> The choroids have also been studied with SS-OCT in pediatric patients and it was found to be thicker than in adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">30&#44;51</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The authors of this article have directed several studies on the topic utilizing SS-OCT technology&#46; A horizontal profile of the macula was created with manually measuring choroidal thickness of 276 eyes of 154 healthy patients between 3 and 95 years of age utilizing SS-OCT &#40;Topcon Corporation&#44; Tokio&#44; Japan&#41; in subfoveal localization&#44; with 5 additional determinations every 1000<span class="elsevierStyleHsp" style=""></span>&#956;m in the temporal direction &#40;T1&#44; T2&#44; T3&#44; T4 and T5&#41; plus 3 more in the nasal direction &#40;N1&#44; N2 and N3&#41; from the fovea &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46; The mean SFCT was 301&#46;8<span class="elsevierStyleHsp" style=""></span>&#956;m and the mean macular choroidal thickness &#40;MCT&#41; was 258&#46;6<span class="elsevierStyleHsp" style=""></span>&#956;m&#46; The sample was divided into five different age-based groups to verify the evolution of choroidal thickness&#46; Each group exhibited a choroidal thickness profile similar to the choroid&#44; which is thinner in the area nasally from the fovea&#44; thicker in the subfoveal position to progressively become thinner again toward the temporal sectors&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">52</span></a></p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Both MCT and SFCT exhibit a close correlation with age and both diminish as patient age increases&#44; with statistically significant differences between age groups&#46; It was demonstrated that this reduction was progressive up to age 40&#44; at which point the most significant variation occurs&#58; from 313&#46;9<span class="elsevierStyleHsp" style=""></span>&#956;m in the 21&#8211;40 age group down to 264&#46;6<span class="elsevierStyleHsp" style=""></span>&#956;m in the 41&#8211;60 age group&#46; Surprisingly&#44; from age 40 onwards &#40;41&#8211;60 vs &#62;60&#41; choroidal thickness differences were not statistically significant either in MCT or SFCT&#46; Similarly&#44; no statistically significant differences were found between males and females&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">52</span></a> Following linear regression models&#44; a mean reduction of 10<span class="elsevierStyleHsp" style=""></span>&#956;m in MCR per decade can be estimated &#40;1<span class="elsevierStyleHsp" style=""></span>&#956;m per year&#41; and of 8&#46;87<span class="elsevierStyleHsp" style=""></span>&#956;m SFCT per decade&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The above line of research led to the conclusion that both eyes do not appear to be exactly symmetrical&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">53</span></a> Mean nasal choroidal thickness &#40;the mean value of three measurements from the nasal area to the fovea&#41; was statistically thicker in the right eye than in the left one &#40;228 vs 212<span class="elsevierStyleHsp" style=""></span>&#956;m&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0002&#41;&#46; Chen also reported a tendency toward greater nasal choroidal thickness &#40;14<span class="elsevierStyleHsp" style=""></span>&#956;m&#41; in right eyes as well as thickness profiles that were very similar to those obtained by the present authors&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">54</span></a> It is difficult to explain consistent evidence that right eyes have thicker nasal choroids than left eyes in a healthy population&#46; One possibility is a difference of blood flow between both eyes due to the lack of anatomical symmetry in the aortic arch&#46; This asymmetry has been proposed to explain the differences in the incidence and prevalence of vascular diseases between right and left eyes in bacterial metastatic endophthalmitis<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">55</span></a> and retinal arterial occlusions&#46;<a class="elsevierStyleCrossRefs" href="#bib0645"><span class="elsevierStyleSup">56&#8211;59</span></a> Choroidal circulation is generated from the short posterior ciliary arteries that penetrated the sclera around the optic nerve in a number between 10 and 20&#46; Accordingly&#44; the nasal choroids &#40;between the fovea and the optic nerve&#41; are directly supplied by these short posterior ciliary arteries&#46; In addition&#44; said arteries are branches of the ophthalmic artery&#44; which in turn is a branch of the internal carotid artery and in turn from the common carotid artery&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">59</span></a> The right common carotid is a branch of the brachiocephalic trunk whereas the left carotid emerges directly from the aorta&#46; This could presumably be the cause of more direct blood flow for the right carotid artery&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">55</span></a> Taking into account that most of the choroidal structure is vascular tissue &#40;the mean vascular density in the external choroids is of 87&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">60</span></a> a supposedly greater blood flow in the right side would explain the greater thickness of the nasal choroids in the right eye&#44; as stated in the present study and as described previously by Chen&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">54</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Choroidal morphology</span><p id="par0100" class="elsevierStylePara elsevierViewall">The horizontal choroidal thickness profiles in the macular area has already been described in healthy patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">26&#44;30&#44;46&#8211;50&#44;52</span></a> The thickest point of the choroids is normally in the subfoveal region and diminishes gradually and progressively toward the temporal area and more abruptly toward the optic nerve&#44;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">52&#44;54</span></a> with a concave shape&#46; Adhi<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">61</span></a> described significant alterations in choroidal morphological characteristics in the majority of eyes with diabetic retinopathy &#40;DR&#41;&#46; Said author found an irregular inflection point in the temporal sclera-choroidal interface in 8 out of 9 eyes with nonproliferative DR &#40;89&#37;&#41;&#44; in 9 out of 10 eyes with proliferative DR &#40;90&#37;&#41; and in 13 out of 14 eyes with diabetic macular edema &#40;93&#37;&#41; compared with zero out of 24 healthy controls&#46; The presence of irregular contour in the temporal sclera-choroidal interface with focal thinning of the choroids has been detected in DR and in AMD&#46;<a class="elsevierStyleCrossRefs" href="#bib0670"><span class="elsevierStyleSup">61&#8211;63</span></a> Dolz-Marco<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">64</span></a> described a bilateral case of a focal inferotemporal scleral protuberance with a concave choroidal thinning surrounded by normal choroidal tissue&#46; The authors proposed the hypothesis that this finding could be related to the fact that the inferior oblique muscle compresses the choroids inwardly&#44; even though there is no capacity to studying the walls of the sclera because it is not entirely visible&#46;<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">64</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The present group of authors carried out a study in 276 eyes of 154 patients&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">65</span></a> In 87&#46;2&#37; of analyzed eyes&#44; a concave contour of the sclera-choroidal interface was found and an inflection in the temporal sclera choroidal interface was identified in 12&#46;8&#37; of eyes &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>&#41;&#46; All the irregularities or concave&#8211;convex&#8211;concave forms with &#8805;1 inflection points were found in the temporal area of the macular choroidal thickness profile&#46; The authors only found one inflection point in all eyes&#44; with a median distance to the fovea of 4&#46;427&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>627&#46;9<span class="elsevierStyleHsp" style=""></span>&#956;m &#40;range from 2531 to 5492&#41;&#44; in all cases located in the temporal area&#46; The mean choroidal thickness at the inflection point was 372&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>76&#46;8<span class="elsevierStyleHsp" style=""></span>&#956;m &#40;range from 168 to 538&#41;&#46; No changes were found in the retinal profile in any case&#46; The mean age of patients with temporal inflection was 16<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19 vs 36<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>25 years in the group with concave contour &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#59; <span class="elsevierStyleItalic">t</span> for Student for nonpaired data&#41;&#46; No additional anomalies were found in the ocular fundus examination that could justify said thickening in the present series of patients with temporal inflection&#46; SS-OCT analysis did not detect any alteration in the choroids of these patients apart from said inflection point&#46; On the other hand&#44; an image was identified that could represent the upper edge of the insertion of the inferior oblique muscle in the sclera&#44; together with a thin hyporeflective line parallel to the limits of the sclerochoroidal junction that could fit in with the intra-scleral portion of the long temporal posterior ciliary artery&#46;</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Anatomopathological studies of the posterior part of the globe and its vascular and muscular structure in relation to the sclera demonstrates that the anterior and superior limits of the posterior insertion of the inferior oblique muscle coincide with the horizontal meridian at 5&#46;7<span class="elsevierStyleHsp" style=""></span>mm from the fovea&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">66</span></a> The mean distance from the inflection points to the fovea was 4&#46;427<span class="elsevierStyleHsp" style=""></span>&#956;m in the authors&#8217; series&#44; always located in the temporal part of the fovea&#46; This led the authors to believe that the presence of the inflection point is probably related to the insertion of the inferior oblique muscle&#46; Traction applied on the sclera by the tendon could cause its separation from the wall and produce its deformation with the ensuing thickening of the choroids&#46; On the basis of the anatomical descriptions of the area&#44;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">66</span></a> the parallel hyporeflective line at this level could correspond to the intra-scleral portion of the long temporal posterior ciliary artery&#46; The fact that this finding is more frequent in young and healthy individuals&#44; particularly under age 15&#44; could be explained by less scleral rigidity at earlier ages<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">67</span></a> that could facilitate the deformation induced by the traction of the inferior oblique muscle tendon&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Optical coherence tomography in face&#47;angiography with optical coherence tomography</span><p id="par0120" class="elsevierStylePara elsevierViewall">Latest improvements in OCT technology enabled the acquisition of multiple B-scans that generate high resolution images&#46; The <span class="elsevierStyleItalic">in face</span> OCT mode was released recently as a new imaging technique that provides a new way to visualize the posterior pole&#46; Whereas the new C-scans provide a coronal plane of the posterior pole&#44; the <span class="elsevierStyleItalic">in face</span> technology generates an artificial flattening of posterior pole tissue utilizing the selected layer &#40;usually the RPE&#41; as reference&#44; allowing navigation through different layers at the same time that image depth is modified&#46;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">68</span></a> In this way&#44; OCT <span class="elsevierStyleItalic">in face</span> allows a new vision of the choriocapillary and the Sattler and Haller layers without the need to apply indocyanine contrast &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 10</a>&#41;&#46;</p><elsevierMultimedia ident="fig0050"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">OCT B-scans and the <span class="elsevierStyleItalic">in face</span> images show choroidal vessels as hyporeflective against its surroundings&#44;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">69</span></a> but not all dark images are actually choroidal vessels because retinal vessel shadows could produce images that induce to errors&#46; Background images are recorded at the same time in the majority of current devices&#44; which allows the viewer to differentiate one from the other&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">70</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">While OCT <span class="elsevierStyleItalic">in face</span> enables the visualization of normal choroidal vascularization&#44; OCT angiography &#40;the latest development in the OCT field&#41; provides good images of retinal vessels and neovascular complexes without the need of applying contrast&#46;<a class="elsevierStyleCrossRefs" href="#bib0720"><span class="elsevierStyleSup">71&#44;72</span></a> This new tool identifies vessels on the basis of variations between multiple consecutive B-scans&#46; Whereas retinal tissue is static&#44; blood is in permanent movement and the digital processing of these images eliminates all static tissue and shows an image of retinal vessel contents&#44; thus drawing out its profile&#46; The drawback is that it does not show vascular leak or exudation&#46;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">71</span></a> Jia<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">73</span></a> improved said technology introducing split-spectrum amplitude-decorrelation angiography &#40;SSADA&#41;&#46; This tool improves the signal&#47;noise ratio for detecting flow&#44; showing the microvascular mesh and automatically eliminating errors caused by movement &#40;<a class="elsevierStyleCrossRef" href="#fig0055">Fig&#46; 11</a>&#41;&#46;</p><elsevierMultimedia ident="fig0055"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">Recent developments in imaging techniques have given access to new knowledge about the choroids and&#44; even though there is still a lot to discover about their anatomy and characteristics&#44; new conclusions can still be reached&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">While contrast-based echography and angiography still have their indications and usefulness for the diagnosing and managing some diseases such as choroidal tumors or CNV&#44; it seems clear that OCT techniques and the latest breakthroughs are at the forefront of choroidal imaging techniques at this date&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Current OCT devices enable good visualization of the choroids in up to 100&#37; of cases in some series and allow a precise outline of the sclerochoroidal interface for exact and reliable thickness measurements&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Latest developments such as the <span class="elsevierStyleItalic">in face</span> images and OCT angiography provide a new way of studying retinal and choroidal circulation without the use of pigments and its risks&#46; However&#44; there is still a lot to learn about the interpretation of the images said technologies provide&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of interests</span><p id="par0180" class="elsevierStylePara elsevierViewall">Professor Jos&#233; Mar&#237;a Ruiz Moreno receives financial support as consultant to TOPCON&#46; None of the other authors of this study has any conflict of interests to declare&#46;</p></span></span>"
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          "titulo" => "Abstract"
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          "titulo" => "Introduction"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Ultrasonography"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Angiography"
        ]
        7 => array:3 [
          "identificador" => "sec0020"
          "titulo" => "Optical coherence tomography"
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            0 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Choroidal thickness"
            ]
            1 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Choroidal morphology"
            ]
          ]
        ]
        8 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Optical coherence tomography in face&#47;angiography with optical coherence tomography"
        ]
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          "identificador" => "sec0040"
          "titulo" => "Conclusions"
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          "titulo" => "Conflict of interests"
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          "titulo" => "References"
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    "fechaRecibido" => "2016-07-13"
    "fechaAceptado" => "2016-10-08"
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            0 => "Choroidal imaging techniques"
            1 => "Optical coherence tomography"
            2 => "OCT"
            3 => "Ultrasound"
            4 => "Angiography"
            5 => "En face optical coherence tomography"
            6 => "OCT angiography"
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            0 => "T&#233;cnicas de imagen coroidea"
            1 => "Tomograf&#237;a de coherencia &#243;ptica"
            2 => "OCT"
            3 => "Ultrasonograf&#237;a"
            4 => "Angiograf&#237;a"
            5 => "Tomograf&#237;a de coherencia &#243;ptica en face"
            6 => "Angiograf&#237;a OCT"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The choroid is the middle layer of the eye&#44; a very vascular and pigmented tissue&#44; with its role in several ophthalmological pathologies already having been clearly established&#46; But it was not until the last few years that we have been able to reliably and precisely measure and quantify its shape and thickness&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ultrasound technology and indocyanine green angiography were the first techniques used for the study of the choroid&#44; and they still maintain their use and clinical indications for the diagnosis and management of several pathologies&#46; But it was the advent of optical coherence tomography that was the greatest breakthrough in choroidal imaging&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In this chapter&#44; the past&#44; current and future image modalities for the study of the choroid will be discussed&#44; with special focus on optical coherence tomography and its latest developments&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La coroides es la capa media del ojo&#44; un tejido muy vascularizado y pigmentado&#44; cuyo papel ya ha sido probado en numerosas enfermedades oft&#225;lmicas&#46; Pero no ha sido hasta los &#250;ltimos a&#241;os cuando hemos sido capaces de cuantificar y medir de una forma fiable&#44; precisa y reproducible su grosor y su forma&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las t&#233;cnicas de imagen basadas en ultrasonidos y la angiograf&#237;a con verde de indocianina fueron las primeras en ser utilizadas para el estudio de la coroides&#44; y a&#250;n mantienen su uso y sus indicaciones cl&#237;nicas para el diagn&#243;stico y manejo de algunas enfermedades oculares&#46; Pero fue la llegada de la tomograf&#237;a de coherencia &#243;ptica la que supuso el mayor avance en cuanto a la visualizaci&#243;n de la coroides se refiere&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">En esta revisi&#243;n se discutir&#225;n modalidades de imagen coroidea pasadas&#44; presentes y futuras&#44; con una especial atenci&#243;n sobre la tomograf&#237;a de coherencia &#243;ptica y su m&#225;s reciente desarrollo&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ruiz-Medrano J&#44; Flores-Moreno I&#44; Gutierrez-Bonet R&#44; Chhablani J&#44; Ruiz-Moreno JM&#46; Actualizaci&#243;n en t&#233;cnicas de imagen coroidea&#58; pasado&#44; presente y futuro&#46; Arch Soc Esp Oftalmol&#46; 2017&#59;92&#58;128&#8211;136&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Mode B echography of a normal eye&#46; The choroids and its thickness cannot be reliably and precisely measured&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Indocyanine green angiographic image of the left eye of a patient&#44; clearly showing the presence of neovascular membrane&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Broad field indocyanine green angiography of a healthy eye&#46; Due to higher molecular weight&#44; indocyanine shows lower vascular permeability&#44; which makes it the best choice for studying choroidal vasculature&#46; The image shows the vortex veins in the four quadrants&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Image taken with the <span class="elsevierStyleItalic">enhanced depth imaging</span> OCT technology&#44; showing significant thickening of the choroids in a male patient diagnosed with central serous chorioretinopathy&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Enhanced depth imaging</span> OCT even enables the visualization of vascular polyps in some cases of polypoid choroidal vasculopathy&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">OCT image with <span class="elsevierStyleItalic">swept-source</span> technology showing the presence of choroidal nevus&#44; the dimensions of which can be clearly seen due to the increased penetration provided by its larger wavelength&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">OCT choroidal hemangioma image with <span class="elsevierStyleItalic">swept-source</span> technology&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">OCT <span class="elsevierStyleItalic">swept-source</span>&#46; Example of choroidal thickness measurements from the posterior RPE edge to the choroids&#47;sclera intersection&#46;</p>"
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; Sclerochoroidal interface of healthy patients analyzed utilizing <span class="elsevierStyleItalic">swept-source</span> OCT&#46; Concave choroids&#58; the choroids grow consistently thinner toward the nasal and temporal sectors&#46; The white line represents the concave contour of the sclerochoroidal interface&#46; &#40;b&#41; Temporal sclerochoroidal inflection&#58; evidencing choroidal thickening &#40;inflection point&#41; in relation to the two adjacent points measured at both sides of the inflection point&#44; without other relevant findings in the choroids of an 8-year-old child&#46; The white line represents the sclerochoroidal interface&#44; with an arrow indicating the choroidal inflection&#46;</p>"
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">OCT <span class="elsevierStyleItalic">swept-source</span>&#46; <span class="elsevierStyleItalic">In face</span> examination identifying three different layers of the choroids&#58; &#40;a&#41; choriocapillary&#59; &#40;b&#41; median vessels layer&#59; &#40;c&#41; large vessels layer&#46; B-scans artificially &#8220;flatten out&#8221; at the selected level &#40;green line&#41;&#46; The yellow line shows the level of the choroids shown in the upper scan&#46;</p>"
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Swept-source</span> OCT provides good images of &#40;a&#41; retinal vessels and &#40;b&#41; choroidal neovascular complex vessels&#44; without requiring intravenous contrast in a patient exhibiting age-related macular degeneration&#46;</p>"
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
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                          "etal" => false
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                          ]
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
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                    ]
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