Subretinal hyperreflective exudation associated with neovascular age-related macular degeneration

To describe the multimodal imaging findings of subretinal hyperreflective exudation (SHE) observed in association with choroidal neovascularization and to distinguish SHE from other forms of subretinal hyperreflective material (SHM) seen in patients with age-related macular degeneration and other macular disorders.

A retrospective study on 46 eyes of 42 patients with SHE associated with Types 1, 2, and 3 choroidal neovascularization secondary to neovascular age-related macular degeneration. Patients were examined using multimodal imaging, including color photography, near-infrared reflectance imaging, spectral domain optical coherence tomography, fluorescein angiography, fundus autofluorescence imaging, and indocyanine green angiography. Clinical and imaging characteristics were evaluated at baseline, after the initiation of intravitreal antivascular endothelial growth factor therapy, and during the resolution of SHE.

Forty-five of the 46 eyes were treatment naive. The mean ± SD age at the first detection of SHE was 77.2 ± 10.1 years. The mean ± SD follow-up was 2.1 ± 0.6 years. Fluorescein angiography was performed in 42 eyes and demonstrated leakage and/or staining of underlying or adjacent choroidal neovascularization but not of the SHE itself in all eyes. On fluorescein angiography, SHE was transparent in 29 eyes and blocking in 7 eyes. In 32 eyes, SHE showed isoautofluorescence on fundus autofluorescence imaging, and in 8 eyes, SHE showed varying degrees of hyperautofluorescence. Indocyanine green angiography was performed in eight eyes and demonstrated hyperfluorescence of SHE in seven eyes. In eight eyes, SHE was the only evidence of neovascular activity. All eyes having follow-up (42 eyes) showed resolution of the subretinal material with partial or full reconstitution of the ellipsoid zone after a median of 2 injections range (1-16 injections). Subretinal hyperreflective exudation persisted for a median of 9 weeks (range, 4-60 weeks) after the initiation of treatment. The mean visual acuity before treatment was 0.619 (20/83), and it improved to 0.380 (20/48) (P = 0.03) after the resolution of SHE.

Subretinal hyperreflective exudation differs from other types of SHM based on the findings from multimodal imaging. This novel type of SHM likely represents a sign of active neovascular age-related macular degeneration distinct from subretinal fluid, hemorrhage, neovascular tissue, lipid, pigment hyperplasia, subretinal fibrosis, and the SHM observed with acquired vitelliform lesions. Intravitreal antivascular endothelial growth factor agents can be used to successfully resolve SHE, often resulting in better visual outcomes in eyes manifesting this form of exudation.