Double-Layer Sign May Be Less Predictive of Macular Neovascularization Than Thought

Final Stage Of Senile Macular Degeneration: Macular Atrophy. Photograph Of The Back Of Eye. (Photo By BSIP/UIG Via Getty Images)
Although a significant association between the double-layer sign on OCT, and MNV exists, not all MNV manifests as a double-layer sign.

Eyes with a nonhomogeneous and hyperreflective space under an elevated retinal pigment epithelium (RPE) of any length or height is more predictive of macular neovascularization (MNV) than the “double-layer sign,” according to a study published in the American Journal of Ophthalmology. To confirm the MNV and initiate proper treatment in a timely manner, clinicians should evaluate these patients with optical coherence tomography angiography (OCT-A), or OCT.

The study reviewed the relationship between DLS and central serous chorioretinopathy (CSCR)-related MNV, as well as the diagnostic accuracy of DLS in the identification of MNV in CSCR cases, as confirmed by OCT-A. DLS was defined in the report as a shallow pigment epithelium with a length of at least 1000 µm and a maximum height of 150 µm.

The investigators took into account 163 eyes of 132 patients (mean age 55.2 years; 28.2% women).They found a higher RPE in 91% of eyes, with MNV, as confirmed by OCT-A, in 33% of eyes. DLS was observed in 58% of eyes. 

The investigators found that hyperreflectivity and nonhomogeneity of the sub-RPE space were independently correlated with MNV within the DLS. No other demographic or anatomical features were related to MNV.

DLS is related to the presence of neovascularization in several chorioretinal diseases such as CSCR, age-related macular degeneration (AMD), and polypoidal choroidal vasculopathy. Elevated RPE and DLS have been observed in neovascular AMD.

Even though older age is significantly associated with a higher risk of MNV, results reflecting an association with age fell short of significance in this study. Other research supports the association between older age and the risk of neovascularization beneath the elevated RPE.

Limitations include the retrospective and cross-sectional design. Another limitation was that OCT-A imaging is not routinely performed at the study center for all CSCR patients. Chronicity and treatment could have affected the morphology of MNV, DLS, or both.

Disclosure: One study author(s) declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Hagag AM, Rasheed R, Chandra S, et al. The diagnostic accuracy of double-layer sign in detection of macular neovascularization secondary to central serous chorioretinopathy. Am J Ophthalmol. Published online October 23, 2021. doi:10.1016/j.ajo.2021.10.021.