Hagag, AM; Rasheed, R; Chandra, S; Jeffery, G; Sivaprasad, S; (2022) The Diagnostic Accuracy of Double-Layer Sign in Detection of Macular Neovascularization Secondary to Central Serous Chorioretinopathy. American Journal of Ophthalmology , 236 pp. 271-280. 10.1016/j.ajo.2021.10.021.

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Abstract

PURPOSE: To investigate the diagnostic value of elevated retinal pigment epithelium (RPE) and double-layer sign (DLS) in identifying macular neovascularization (MNV) secondary to central serous chorioretinopathy (CSCR). DESIGN: Retrospective, cross-sectional study. METHODS: Patients with CSCR underwent optical coherence tomography (OCT) and OCT angiography (OCT-A) scanning at Moorfields Eye Hospital. OCT scans were reviewed to identify the presence/absence of an RPE elevation. The maximum length and maximum height of the elevated RPE were measured. A minimum length of 1000 µm and a maximum height of 150 µm were used to define the "double-layer sign". Other qualitative anatomical features were also graded from OCT scans. OCT-A was examined to confirm the presence/absence of MNV. Binary logistic regression analyses were used to assess the association between OCT features and the detection of MNV on OCT-A. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to assess the diagnostic accuracy. RESULTS: One hundred and sixty-three eyes from 132 patients were included. Elevated RPE was detected in 148 eyes (91%). OCT-A-confirmed MNV was detected in 54 eyes (33%). The sensitivity and specificity of RPE elevation were 100% and 13.8%, respectively. DLS was identified in 95 eyes (58%). The sensitivity and specificity of DLS for detecting MNV were 87% and 56%, respectively. Hyper-reflectivity and non-homogeneity of the sub-RPE space were independently associated with MNV within the DLS (odds ratio, 17.7 and 14.8, p<0.001 and p=0.02, respectively). None of the other demographic or anatomical features associated with MNV. The presence of non-homogeneous hyper-reflective RPE elevation had a sensitivity and specificity of 98% and 67%, with PPV and NPV of 60% and 99%, respectively. CONCLUSIONS: Non-homogeneous and hyper-reflective space under an elevated RPE of any length or height indicates an eye with higher risk of MNV than DLS. OCT-A should at least be performed for these eyes to confirm the presence of MNV and treat accordingly.

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