Purpose To analyze microvascular and structural changes in radiation maculopathy and their influence on visual acuity (VA), using optical coherence tomography (OCT) and OCT angiography (OCTA). Methods This was a retrospective analysis of consecutive patients with radiation maculopathy, 12 months or more after proton-beam irradiation for uveal melanoma, imaged with fluorescein angiography, OCT, and OCTA. Clinical parameters potentially affecting VA were recorded, including OCTA-derived metrics: foveal avascular zone (FAZ) area, vascular density, and local fractal dimension of the superficial (SCP) and deep capillary plexuses (DCP). Nonirradiated fellow eyes served as controls. Results Ninety-three patients were included. FAZ was larger, while SCP/DCP capillary density and local fractal dimension were lower in the 35 irradiated than in the 35 fellow eyes (P < 0.0001). Microvascular alterations graded on fluorescein angiography (minimally damaged/disrupted/disorganized) were correlated to FAZ area and SCP/DCP density on OCTA (P < 0.01). By univariate analysis, worse VA was associated to macular detachment at presentation (P = 0.024), total macular irradiation (P = 0.0008), higher central macular thickness (CMT) (P = 0.019), higher absolute CMT variation (P < 0.0001), cystoid edema (P = 0.030), ellipsoid zone disruption (P = 0.002), larger FAZ (P < 0.0001), lower SCP (P = 0.001) and DCP capillary density (P < 0.0001), and lower SCP (P = 0.009) and DCP local fractal dimension (P < 0.0001). Two multivariate models with either capillary density or fractal dimension as covariate showed that younger age (P = 0.014/0.017), ellipsoid zone disruption (P = 0.034/0.019), larger FAZ (P = 0.0006/0.002), and lower DCP density (P = 0.008) or DCP fractal dimension (P = 0.012), respectively, were associated with worse VA. Conclusions VA of eyes with radiation maculopathy is influenced by structural and microvascular factors identified with OCTA, including FAZ area and DCP integrity.
