Retinal and Choroidal Alterations in Heart Failure: A Systematic Review and Meta-analysis of OCT and OCT-A Findings...

Retina and choroid, given their high metabolic demands, are vulnerable to ischemic injury during the hemodynamic instability associated with heart failure (HF). Despite this, posterior segment ocular changes in HF remain understudied. This systematic review and meta-analysis consolidates optical coherence tomography (OCT) and OCT angiography (OCT-A) findings in HF.

We conducted a comprehensive search of Web of Science, PubMed/MEDLINE, and EMBASE on March 15, 2025. A random-effects meta-analysis of six studies was performed using Hedges' g to estimate effect sizes, with six additional studies included for qualitative synthesis (total n = 1139 eyes). The meta-analysis was limited to studies on heart failure with reduced ejection fraction (HFrEF), as this was the only heart failure subtype with sufficient data for quantitative analysis.

Key findings revealed significant reductions in parafoveal superficial capillary plexus vessel density (SCP VD) (Hedges' g = - 0.42, 95% CI - 0.78 to - 0.05, p = 0.03) and subfoveal choroidal thickness (Hedges' g = - 0.75, 95% CI - 1.31 to - 0.18, p = 0.01) in patients with HFrEF. Furthermore, severity-dependent thinning of retinal nerve fiber layer and significant correlations between whole macular vessel density and both left ventricular EF and New York Heart Association functional class emphasize the potential of these parameters in stratifying disease severity. Additionally, one study revealed thinning of ganglion cell-inner plexiform layer in patients with HF with preserved ejection fraction (HFpEF). Those with acute decompensated HF showed macular VD attenuation in superficial layers and decreased subfoveal choroidal thickness. Pediatric cases demonstrated central macular thinning, selective decreases in SCP VD, and choroidal thinning.

Collectively, OCT and OCT-A metrics provide useful information regarding systemic microvascular dysfunction, suggesting potential for disease detection and improved risk stratification. However, it is important to note that these findings are based on observational studies, which limits the ability to draw definitive causal conclusions. This highlights the need for prospective, longitudinal research to establish temporal relationships and validate these observations.