New Study Develops Multimodal Imaging Guidelines for Choroiditis

A task force recently published consensus-based imaging recommendations for two forms of noninfectious multifocal choroiditis—punctate inner choroiditis and multifocal choroiditis with panuveitis. OCT proved most useful for identifying active inflammatory markers such as subretinal hyperreflective material and disruptions in the ellipsoid zone, while FAF and OCT were both recommended for monitoring disease recurrence. Late-phase ICGA was particularly noted for its effectiveness in visualizing deeper choroidal lesions not easily appreciable on color fundus photos or FAF. Photo: Gangaputra S, et al. Am J Ophthalmol. April 25, 2025. Click image to enlarge. Punctate inner choroiditis (PIC) and multifocal choroiditis with panuveitis (MFCPU) are known for their complex diagnostic challenges due to ambiguous symptomatology. While Standardization of Uveitis Nomenclature (SUN) classification criteria exists for each condition, these guidelines lack explicit multimodal imaging biomarkers specific to PIC and MFCPU. Thus, an international task force recently commenced to develop imaging- and consensus-based criteria to enhance the SUN classification framework and reduce variability in the interpretation of imaging findings. Their recommendations, outlined below, were recently published in American Journal of Ophthalmology.The study used a structured method known as Nominal Group Technique for reaching group consensus. First, group members independently generated ideas about the key imaging characteristics useful for diagnosing and monitoring MFCPU and PIC. Each member presented an idea until all relevant imaging modalities and criteria, along with their advantages and feasibility, were discussed. Next, members voted on the importance of each imaging modality and diagnostic criterion based on severity, prevalence and clinical importance. To build the consensus, the strategies that received the highest amount of votes were selected, refined and developed into comprehensive guidelines.The results from the group consensus highlighted several key findings regarding the use of specific imaging modalities for diagnosing and managing MFCPU and PIC:Optical coherence tomography (OCT): This imaging modality was identified as the preferred tool for detecting active lesions, particularly useful in visualizing subretinal hyperreflective material and disruptions in the ellipsoid zone. OCT was underscored for its ability to differentiate between active and inactive disease stages, which is crucial for determining the appropriate treatment and management approach.Fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA): These modalities were considered valuable for their roles in detecting vascular changes and perfusion abnormalities. ICGA was particularly noted for its effectiveness in visualizing deeper choroidal lesions that are not apparent in OCT and fundus autofluorescence.Fundus autofluorescence (FAF): This modality was appreciated for its utility in tracing disease progression over time, providing a unique perspective on the metabolic activity of the retinal and choroidal tissues affected by the disease. The researchers summarized in their paper that the committee’s consensus “emphasizes the essential role of OCT as the primary imaging modality for assessing disease activity due to its reliability in visualizing inflammatory markers such as subretinal hyperreflective material, inflammatory pigment epithelial detachment and ellipsoid zone disruptions.” OCT angiography also “holds particular value for the noninvasive detection of CNV, necessitating confirmation through OCT to guide treatment decisions,” they added. Furthermore, the taskforce underscored the important role of ultrawidefield FAF and late-phase ICGA “for monitoring lesion reactivation, particularly in the peripheral retina where changes may not be evident through standard imaging or clinical examination.”The study group argues that integrating these newly refined imaging recommendations into clinical practice “could foster consistency in diagnosing, assessing disease activity and determining the treatment response, ultimately enhancing patient outcomes.”Click here for the journal source. Gangaputra S, Agarwal A, Ossewaarde-van Norel J, et al. Evidence and consensus-based imaging guidelines in multifocal choroiditis with panuveitis and punctate inner choroiditis - multimodal imaging in uveitis (MUV) taskforce report 5. Am J Ophthalmol. April 25, 2025. [Epub ahead of print].