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Brief Report |

Dynamic Optical Coherence Tomography Capillaroscopy A New Imaging Tool in Autoimmune Connective Tissue Disease ONLINE FIRST

Hans Christian Ring, MD1,2; Lotte Themstrup, MD1,2; Christina Alette Banzhaf, MD3; Gregor B. E. Jemec, DMSc, MD1,2; Mette Mogensen, MD, PhD3
[+] Author Affiliations
1Department of Dermatology, Zealand University Hospital, Roskilde Denmark
2Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
3Department of Dermatology, Bispebjerg Hospital, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
JAMA Dermatol. Published online June 29, 2016. doi:10.1001/jamadermatol.2016.2027
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Importance  Vasculopathy characterized by functional and structural abnormalities of the microcirculation plays an important role in systemic sclerosis and dermatomyositis. Although there are several advantages in using capillaroscopy, the method does not offer insight on the skin architecture, flow status, or morphology of the deeper dermal vessels. Dynamic optical coherence tomography (D-OCT) is a recently developed OCT technique that enables detection of high-speed changes in back-scattered light caused by moving cells in vessels. The high resolution of OCT enables the detection of the papillary loops.

Objective  To explore the potential for OCT capillaroscopy of the nailfolds using D-OCT.

Design, Setting, and Participants  In this case series study of 4 participants, the nailfolds in 2 patients with systemic sclerosis, 1 patient with dermatomyositis, and a healthy volunteer were scanned using D-OCT. The included patients were all outpatients from the department of dermatology at Bispebjerg Hospital. Data were analyzed from November 2015 to February 2016.

Main Outcomes and Measures  Dynamic OCT capillaroscopy revealed a potential for imaging of the capillary morphology, the surrounding skin architecture, and flow status of the capillaries in the nailfold. Moreover, D-OCT quantified evident changes of the blood flow in normal nailfold capillaries after application of nitroglycerine and brimonidine.

Results  This case series included 4 adult women. The quantitative measurements of the blood flow in the D-OCT images of the healthy participant showed significant quantitative differences in blood flow before and after application of nitroglycerine (mean difference, 0.035; 95% CI, 0.008-0.061; P = .02) and brimonidine (mean difference, −0.015; 95% CI, −0.082 to −0.039; P < .001). In the dermatomyositis patient, the en face D-OCT images showed a striking detailed Y-shaped dilated capillary correlating with the clinical finding. In the 2 patients with systemic sclerosis, D-OCT depicted megacapillaries, as well as loss of capillaries. Moreover, cross-sectional OCT images demonstrated a characteristic loss of distinct dermo-epidermal junction and more compact dermis with loss of adnexal structures.

Conclusions and Relevance  Compared with conventional capillaroscopy, D-OCT offers second-to-none information on nailfold capillary morphology, overall skin architecture, as well as quantitative data on vascular abnormalities and blood flow in the nailfold in a single scan.

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Figure 1.
Case of Induced Blood Flow Changes in a Normal Skin Fold

All images are D-OCT images displayed in en face view at a depth of 0.5 mm below the skin surface. The image size is 36 mm2. The black asterisk marks the eponychium; the white asterisk marks the nail plate. A, D-OCT image of a healthy proximal nailfold (fourth finger, left hand) before application of nitroglycerin spray. The image shows an organized vascular pattern and a regular hairpin distribution of capillaries in the proximal nailfold. B, D-OCT image (fourth finger, left hand) 40 minutes after the application of nitroglycerine spray. The D-OCT image shows significantly enhanced blood flow as well as an increased number of visible capillaries in the proximal nailfold. C, D-OCT image of a healthy proximal nailfold (4th finger, right hand) before application of brimonidine 0.33% gel. The image shows the same normal characteristics as in image A. D, D-OCT image (fourth finger, right hand) 40 minutes after the application of brimonidine 0.33% gel. The D-OCT image shows a significantly decrease in blood flow and a reduced number of visible capillaries in the proximal nailfold. E, Nailfold capillaroscopy clinical photo of healthy nailfold before application of nitroglycerin/brimonidine. D-OCT indicates dynamic optical coherence tomography.

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Figure 2.
Case of a Severe Dermatomyositis and 2 Cases of SSc in 3 Middle-Aged Female Patients

All of the D-OCT images are displayed in en face view. The image size of the D-OCT images is 36 mm2. In all images the black asterisk marks the eponychium; the white asterisk marks the nail plate. The VivoSight scanner probe is equipped with a micro camera that provides real-time, color, magnified images of the skin-area being scanned. The clinical probe image is shown simultaneously with the vertical and en face OCT images. A light beam is projected on to the probe image showing exactly where the scanning is performed. A, D-OCT image of the nailfold in a patient with limited SSc showing a disorganized vascular pattern as well as a mega-capillary (marked by arrow). The lumen of the mega capillary appears hyporeflective probably because of stationary blood inside the mega-capillary with very little flow. B, Clinical probe image of the nailfold of a patient with dermatomyositis (case 2) showing dilated vessels and a y-shaped vessel formation (marked by arrow). C, D-OCT image of the corresponding nailfold as seen in image B. The D-OCT image reveals a striking y-shaped vessel formation and a general disorganized and dilated vessel formation as well as avascular areas in the proximal nailfold. D, Clinical photo of SSc patient nailfold (case 4) showing characteristic architectural disorganization and loss-of-capillaries. E, OCT image of scleroderma skin. The mild hyperkeratosis increases the signal from the thin epidermis. A small digital ulcer (arrowhead) creates a dark hole in the image center and necrosis in epidermis creates black round areas inside the skin (arrow). F, D-OCT image of the same nailfold as in image D, displaying irregular and disorganized vascular pattern (white arrow). Note the area without any capillaries indicating late stage loss-of-capillaries (blue arrowhead). D-OCT indicates Dynamic optical coherence tomography; OCT, optical coherence tomography; SSc, systemic sclerosis.

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