A pilot study of digital indocyanine green videoangiography for recurrent occult choroidal neovascularization in age-related macular degeneration

Indocyanine Green Videoangiography: Current Status

Indocyanine-green (ICG) angiography has experienced a rejuvenated interest in the past few years because of improvements in technological systems. After three years of experience with evolving digital technology, we have reviewed our experience to provide an update on potential applications in a variety of choroidopathies.

Based on 3,000 cases studied with ICG angiography, we evaluated the diagnostic value of the procedure in choroidal abnormalities including ischemic, tumor, idiopathic, inflammatory, and neovascularized diseases.

ICG angiography is still of limited clinical value in ischemic diseases because of a relatively poor imaging potential for the choriocapillaris. The procedure has not yet provided information which is of significant value in the evaluation and management of choroidal tumors. Valuable information has been provided on the fundamental pathogenesis of certain idiopathic diseases. Preliminary experience in inflammatory diseases is very promising. A genuine advance in imaging of “occult”-choroidal neovascularization has been provided by the diagnostic technique. Improved delineation of these vessels offers opportunities for ICG-guided laser treatment.

Effect of ranibizumab on high-speed indocyanine green angiography and minimum intensity projection optical coherence tomography findings in neovascular age-related macular degeneration

PURPOSE

The purpose of this 1-year prospective study was to investigate how induction/pro re nata ranibizumab intravitreal treatment of eyes with neovascular age-related macular degeneration affects the anatomy of choroidal neovascularization (CNV) and the overlying outer retinal tissue.

METHODS

High-speed indocyanine green (HS-ICG) angiography measurements provided quantification of the CNV size in 60 patients followed for 1 year. Minimum intensity projection optical coherence tomography (MinIP OCT), a novel algorithm assessing minimum optical intensity between the internal limiting membrane and retinal pigment epithelium, measured the area of outer retinal disruption overlying the CNV. Fluorescein angiography was also assessed to evaluate late retinal leakage.

RESULTS

After 1 year, the mean area of CNV measured with indocyanine green angiography decreased by 5.8%. The mean area of MinIP OCT of outer retinal disruption overlying the CNV decreased by 4.2%. Mean area of fluorescein angiography leakage decreased by 6.3%. Both the area of outer retinal disruption measured with MinIP OCT and the area of leakage on fluorescein angiography typically exceeded the area of CNV on indocyanine green angiography at baseline and 1 year.

CONCLUSION

Choroidal neovascularization treated with induction/pro re nata intravitreal ranibizumab for 1 year essentially remained static. Minimum intensity projection optical coherence tomography suggests that the area of outer retinal disruption overlying the CNV may be greater than the CNV itself and often correlates with the leakage area on fluorescein angiography. Additionally, there was minimal change in the area of outer retinal disruption on MinIP OCT even when fluid resolved. Measurements of the extent of CNV lesions based on indocyanine green angiography and MinIP OCT may provide useful outcome variables to help assess the CNV complex longitudinally and warrant further validation.

Indocyanine green angiography in posterior uveitis

Literature review for indocyanine green angiography and evaluate the role of indocyanine green angiogram (ICGA) in patients with posterior uveitis seen at a tertiary referral eye care centre. Detailed review of the literature on ICGA was performed. Retrospective review of medical records of patients with posterior uveitis and dual fundus and ICGA was done after institutional board approval. Eighteen patients (26 eyes) had serpiginous choroiditis out of which 12 patients had active choroiditis and six patients had healed choroiditis, six patients (12 eyes) had ampiginous choroiditis, six patients (12 eyes) had acute multifocal posterior placoid pigment epitheliopathy, eight patients (10 eyes) had multifocal choroiditis, four patients (eight eyes) had presumed ocular histoplasmosis syndrome, four patients (eight eyes) had presumed tuberculous choroiditis, two patients (four eyes) had multiple evanescent white dot syndrome and two patients (four eyes) had Vogt Koyanagi Harada (VKH) syndrome. The most characteristic feature noted on ICGA was the presence of different patterns of hypofluorescent dark spots, which were present at different stages of the angiogram. ICGA provides the clinician with a powerful adjunctive tool in choroidal inflammatory disorders. It is not meant to replace already proven modalities such as the fluorescein angiography, but it can provide additional information that is useful in establishing a more definitive diagnosis in inflammatory chorioretinal diseases associated with multiple spots. It still needs to be determined if ICGA can prove to be a follow up parameter to evaluate disease progression.

ICG Angiography-Guided Photodynamic Therapy for Large Pigment Epithelial Detachments in Age-Related Macular Degeneration

BACKGROUND AND OBJECTIVE

To evaluate the role of photodynamic therapy (PDT) in the management of vascularized pigment epithelial detachment in age-related macular degeneration (AMD) when the pigment epithelial detachment is the predominant component of the neovascular complex.

PATIENTS AND METHODS

Seventeen eyes of 17 patients underwent indocyanine green angiography-guided PDT and had at least 6 months of follow-up. Data retrieved included visual acuity and angiographic features prior to the treatment, number of PDT sessions, visual acuity, angiographic outcomes at the end of the follow-up, length of follow-up, and status of the fellow eye. in the series, with an average age of 77 years and a mean follow-up time of 11 months. Six (35%) of the patients lost less than 3 lines of visual acuity, 6 (35%) lost between 3 and 6 lines, and 5 (30%) lost 6 or more lines. Angiographic outcomes were categorized as failures in 14 (82%) of the treated eyes and successful in 3 (17%) eyes.

CONCLUSIONS

In 82% of the eyes, PDT failed to flatten the pigment epithelial detachment or prevent growth of the choroidal neovascular membrane. Visual acuity outcomes correlated poorly with angiographic outcomes. PDT does not seem to improve the prognosis of eyes with large pigment epithelial detachments in AMD.

Angiographic pattern of recurrent choroidal neovascularization in age-related macular degeneration

PURPOSE

To evaluate the angiographic characteristics of recurrent choroidal neovascularization (R-CNV) in age-related macular degeneration (AMD).

METHODS

A prospective investigation on 107 consecutive patients with exudative AMD and CNV not involving the fovea was conducted. Fluorescein angiography (FA) and indocyanine green angiography (ICGA) were planned before krypton laser treatment, and after 3 weeks, 2, 3, 4, 6, 9, 12, 18, and 24 months from photocoagulation. Laser treatment was FA-guided in eyes with classic CNV, and ICGA-guided in eyes with occult CNV on FA.

RESULTS

At baseline on FA, 23.3% had classic CNV, whereas, 76.6% showed occult CNV. On ICGA, CNV assumed a focal and a plaque pattern in 81.3 and 18.6% of cases, respectively. Overall, post-laser CNVs occurred in 56 eyes. FA identified well-defined and ill-defined R-CNV in 25 and 75% of cases, respectively. ICGA identified three different R-CNV patterns: focal, annular, and plaque. Focal R-CNV was defined as a single dot-like hyperfluorescence, which was detected in 69.6% of cases, with subfoveal location in half of them. Annular R-CNV was identified by a hyperfluorescent lesion, partially or completely encircling treated area, which was visible in 19.6% of cases, all with subfoveal involvement. Plaque R-CNV was defined as a hyperfluorescent lesion larger than 1 disc diameter in size, and was seen in 10.7% of cases, all with subfoveal location.

CONCLUSIONS

ICGA is able to improve R-CNV visualization identifying three different R-CNV patterns. Focal R-CNV is the most frequent pattern and can be re-treated in half of the cases.

A pilot study of ICG-guided laser photocoagulation for occult choroidal neovascularization presenting as a focal spot in age-related macular degeneration

PURPOSE

To evaluate the effect of indocyanine green angiography (ICG)-guided laser photocoagulation in eyes with age-related macular degeneration (AMD) and occult choroidal neovascularization (O-CNV), appearing as a well-defined focal spot on ICG.

METHODS

Eyes with extrafoveal or juxtafoveal focal spot on ICG, either without PED (Group A) or with PED (Group B) at baseline, were selected. The hyperfluorescent area was photocoagulated by krypton red laser within 24 hours from diagnosis on ICG guide. At 1, 3, 6, 9 and 12 months from treatment, all eyes underwent clinical examination, FA and ICG. Parameters as best corrected visual acuity (BCVA), CNV closure and recurrence onset were analyzed.

RESULTS

53 eyes were enrolled in Group A and 33 in Group B. After 1 year from treatment, a stabilized (+/-1 Snellen line) or improved (2 or more Snellen lines) visual acuity was measured in 37 eyes (43%), 32 in Group A and 5 in Group B. After 1 year, a complete resolution of exudative signs was achieved with one or more laser sessions in 41 eyes (48%), 34 in Group A and 7 in Group B. After 1 year, 50 eyes (58%) had one or more episodes of recurrent CNV, appearing in 51% of eyes of Group A and in 70% of eyes of Group B. Most of the recurrences (86%) occurred during the first trimester after photocoagulation.

CONCLUSIONS

ICG-guided laser photocoagulation for O-CNV appearing as a focal spot produced encouraging anatomical and functional outcome in eyes without PED at presentation. When focal CNV is associated with a PED, our treatment technique produced disappointing results.

Indocyanine green angiography in chorioretinal diseases: indications and interpretation: an evidence-based update

TOPIC/PURPOSE: To assess the clinical usefulness and relevance of indocyanine green angiography (ICG) in the investigation of chorioretinal disorders and assess specifically in what conditions it may add useful information to that obtained using standard fluorescein angiography.

CLINICAL RELEVANCE

Many publications on ICG have appeared in recent years touting its use in ophthalmology. These publications have led to increasing use of this technique and to its application in numerous retinal diseases in which the fluorescein angiographic findings have been thoroughly described.

METHODS/LITERATURE REVIEWED

During this systematic literature review, we identified and reviewed a total of 376 articles, from among which we selected 92 that we considered most relevant to our purpose of evaluating published evidence as to the efficacy of ICG. We excluded many articles with weak study designs and those that simply duplicated previously published information. Our literature search used PubMed and was confined to articles in English or that included an English abstract.

RESULTS

Our systematic review suggests that ICG has relatively few specific indications for use as justified by previously published peer-reviewed studies. In keeping with the requirements for this Journal's evidence-based articles, we have divided our clinical recommendations for the use of ICG into three categories: (A) strongly recommended and supported by strong evidence; (B) recommended with moderately strong supporting evidence; (C) not recommended at present because supported only by anecdotal or group consensus evidence. We highly recommended ICG for (1) identification of polypoidal choroidal vasculopathy, (2) occult choroidal neovascularization, (3) neovascularization associated with pigment epithelial detachments, and (4) recurrent choroidal neovascular membranes. These are all conditions in which ICG contributes to the identification of lesions that may be treatable. We recommend ICG with some enthusiasm for identifying feeder vessels in age-related macular degeneration, choroidal neovascular membranes, chronic central serous retinopathy, multiple evanescent white dot syndrome, vasculitis, acute multifocal placoid pigment epitheliopathy, Vogt-Koyanagi-Harada syndrome, macular lesions associated with angioid streaks, and birdshot retinopathy. In all these conditions, ICG may help establish a diagnosis and provide some useful guidance for therapy. At present, we do not recommend ICG for scleritis and posterior scleritis, drusen differentiation, Behçet's disease, or sarcoidosis, because it has not been demonstrated to add useful clinical information.

CONCLUSIONS

ICG, although now a well established technique, has clear advantage over fluorescein angiography in relatively few chorioretinal disorders. It has, however, contributed to the understanding of pathologic processes in many ocular diseases. As yet, no published randomized controlled clinical trials show any benefit to the use of ICG in the management of any specific ocular disease.

Eligibility for treatment and angiographic features at the early stage of exudative age related macular degeneration

AIMS

To determine the eligibility for laser photocoagulation treatment or for photodynamic therapy (PDT) with verteporfin in eyes at the earliest stage (first month of symptoms) of exudative age related macular degeneration (AMD) based on fluorescein angiographic (FA) features; to evaluate the potential contribution of indocyanine green angiography (ICG-A) for occult choroidal neovascularisation (CNV) at this stage.

METHODS

Retrospective review of 252 consecutive patients (269 eyes) examined within the first month of symptoms of exudative AMD.

RESULTS

On FA, 97 eyes (36%) had classic CNV alone. Occult CNV associated with fibrovascular retinal pigment epithelium detachments (PEDs) was observed in 71 eyes (26%) and without fibrovascular PED in 101 eyes (38%). 91 eyes (34%) met the Macular Photocoagulation Study criteria for laser photocoagulation. 53 eyes (20%) met the Verteporfin In PDT (VIP) or Treatment of AMD with PDT (TAP) studies criteria. By ICG-A, occult CNV was visualised as focal spots in 49% of eyes examined within 15 days v 32% of eyes examined between 16 and 30 days after the onset of symptoms (p=0.07). 8.5% of late staining plaques disclosed in eyes examined within 15 days were combined with focal spots v 36% in eyes examined between 16 and 30 days (p<0.01).

CONCLUSIONS

Early examination of eyes with exudative AMD would allow the treatment of 47% of eyes. 60% of eyes with subfoveal CNV would be eligible for PDT with verteporfin. Up to half of eyes with occult CNV would be converted by ICG-A into well delineated focal spots.

Fluorescence properties and metabolic features of indocyanine green (ICG) as related to angiography

Indocyanine green (ICG) is a fluorescent dye that has been used for the imaging of retinal and choroidal vasculatures for more than 30 years. Its high molecular weight, specific metabolic features, and its infrared spectra make the specificity of the images obtained with this dye in ophthalmology. The focus of this paper is to review the basic properties of ICG and to show how some clinical features related to basic properties also depend on the instrumentation used to perform ICG angiography. Indocyanine green has a complex molecular structure that leads to amphiphilic properties, that is, both hydrophilic and lipophilic properties. These properties explain that a specific interaction with phospholipids influences the emission spectrum and the fluorescence yield of ICG. The composition of cell membranes mainly composed of phospholipid bilayers is consistent with a binding and/or a diffusion of ICG molecules observed on angiograms. Likewise, ICG can bind to the lipid component of miliary drusen, explaining their hyperfluorescence. A knowledge of ICG basic properties and interactions may allow a better understanding of angiograms performed with this dye.

Retinal choroidal anastomoses and occult choroidal neovascularization in age-related macular degeneration

OBJECTIVE

This study was designed to identify the incidence of retinal choroidal anastomoses in patients with occult choroidal neovascularization (CNV) and focal hot spots on indocyanine green (ICG) angiography, to identify the clinical and angiographic features that would assist in their identification, and to determine if the presence of these anastomotic lesions affect the outcome of laser therapy.

DESIGN

Combined prospective and retrospective cross-sectional study.

PARTICIPANTS

One hundred fifty consecutive patients with newly diagnosed occult CNV secondary to exudative age-related macular degeneration and focal hot spots on ICG angiography were evaluated prospectively. In addition, a retrospective review was performed on 79 eyes previously reported to have undergone laser photocoagulation treatment with ICG guidance. METHODS AND TESTING: In all cases, stereo color and red-free photographs, and stereo fluorescein and digital ICG angiograms were obtained for evaluation.

MAIN OUTCOME MEASURES

Images obtained by all four techniques were evaluated for the presence of a retinal choroidal anastomosis. Associated clinical and angiographic findings were noted. In the retrospective review, the success rate of laser treatment was correlated with the presence or absence of a retinal choroidal anastomosis.

RESULTS

Of the 150 eyes evaluated prospectively, 31 (21%) were found to have a retinal choroidal anastomosis. Retinal choroidal anastomoses were found in 27% of patients with associated serous pigment epithelial detachment (PED), whereas 13% were found in those without an associated elevation of the retinal pigment epithelium. Seventy-one percent of eyes had multiple anastomotic connections. Ninety percent of eyes had at least one retinal vein involved in the anastomotic connection. Clinical evidence of preretinal and intraretinal hemorrhage and cystic edema coupled with angiographic evidence of intraretinal dye leakage were key features of retinal choroidal anastomoses. In the retrospective review, seven patients were found to have retinal choroidal anastomoses with associated serous PED and demonstrated a very low (14%) success rate for laser treatment.

CONCLUSIONS

Retinal choroidal anastomoses can present as a primary manifestation of the exudative process in age-related macular degeneration. They may be seen in eyes with and without detachment of the retinal pigment epithelium. Specific clinical and angiographic features have been identified that can aid in the diagnosis of these vascular anomalies. Their presence represents a poor prognostic sign for successful ICG-guided laser treatment.

Circumscribed choroidal hemangioma: characteristic features with indocyanine green videoangiography

OBJECTIVE

To determine the characteristic features of indocyanine green videoangiography (ICG-V) of circumscribed choroidal hemangioma.

DESIGN

Prospective, observational case series.

PARTICIPANTS

Twenty-five eyes of 25 consecutive patients with circumscribed choroidal hemangioma.

INTERVENTION

Indocyanine green videoangiography and intravenous fluorescein angiography (IVFA) were prospectively performed and reviewed. The specific features on ICG-V were compared with features of IVFA.

MAIN OUTCOME MEASURES

The behavior of circumscribed choroidal hemangioma cases was observed with ICG-V and IVFA.

RESULTS

On ICG-V, earliest hyperfluorescence of circumscribed choroidal hemangioma was achieved at a mean of 27.6 seconds (range, 13-62 seconds), whereas maximum hyperfluorescence occurred at 222 seconds (range, 33-707 seconds). In the late frames, all eyes demonstrated a relative decrease in fluorescence, including 18 eyes (72%) that demonstrated "washout" of the dye. Other findings on ICG-V included intrinsic vessels in 19 eyes (76%), a late hyperfluorescent rim in 19 eyes (76%), and late frame hot spots in 14 eyes (56%). On IVFA, the earliest hyperfluorescence was achieved at a mean of 24 seconds (range, 10-66 seconds), whereas maximum hyperfluorescence occurred at a mean of 76.3 seconds (range, 21-720 seconds). Increasing hyperfluorescence in the late frames was found in all cases. Other findings included intrinsic vessels in 12 eyes (48%) and hot spots in the late frames in 9 eyes (36%).

CONCLUSIONS

Circumscribed choroidal hemangioma have specific characteristics on ICG-V that are not visualized with IVFA. We believe that ICG-V may become an important noninvasive tool for the diagnosis of choroidal hemangioma.

The present role of indocyanine green angiography in ophthalmology

Recent developments in the clinical application of indocyanine green angiography have mainly concerned refining its role as an adjunct to fluorescein angiography in detecting and guiding the treatment of choroidal neovascularization. We now have a better understanding of the different patterns of abnormal hyperfluorescence seen with indocyanine green angiography in eyes with both wet and dry forms of macular degeneration. In exudative cases, the success rate of laser treatment guided by indocyanine green angiographic findings can vary considerably, and it is now known which angiographic presentations are not as likely to benefit. In dry macular degeneration, indocyanine green angiography appears to add clinically useful information, such as helping to identify plaques in fellow eyes with choroidal neovasculrization or watershed zones that may be predictive of future exudative transformation. In certain circumstances, indocyanine green angiography can be valuable in detecting choroidal neovascularization in other macular diseases or in helping to diagnose other choroidal conditions, especially when the clinical presentation is atypical, such as central serous chorioretinopathy in elderly patients.

Clinical significance of postlaser indocyanine green angiographic hot spots in age-related macular degeneration

OBJECTIVE

To report the natural history and clinical significance of indocyanine green (ICG) angiographic hot spots in age-related macular degeneration (ARMD) after laser photocoagulation.

DESIGN

Retrospective noncomparative case series.

PARTICIPANTS

Two hundred thirty consecutive patients with exudative ARMD who underwent krypton laser treatment between March 1993 and December 1996.

INTERVENTION

Krypton laser photocoagulation was performed on all patients. Digital videoangiograms, including both fluorescein angiography and ICG angiography, were obtained at 2 weeks, 4 weeks, 6 weeks, and 3 months postlaser treatment on each patient and repeated if clinical changes were noted.

MAIN OUTCOME MEASURES

Detection by ICG of hyperfluorescent spots (hot spots) within the hypofluorescent laser-treated area.

RESULTS

Forty patients (18%) developed ICG hot spots 2 weeks after laser treatment. The hot spots disappeared spontaneously without recurrent choroidal neovascular (CNV) membrane in 31 patients (78%). Recurrent CNV was discovered at the hot spot in four patients and away from the hot spot in five patients.

CONCLUSION

The postlaser ICG angiographic hot spot is not rare. These spots tend to disappear spontaneously and do not necessarily represent a recurrent CNV. The presence of a hot spot on ICG angiography is not an indication for immediate laser retreatment.

Indocyanine green guided laser photocoagulation in patients with occult choroidal neovascularisation

AIMS

To determine whether indocyanine green (ICG) guided laser photocoagulation of occult choroidal neovascularisations (OCNV) is beneficial for patients with occult choroidal neovascularisation secondary to age related macular degeneration (AMD).

METHODS

A prospective pilot study was performed in 21 eyes with OCNV secondary to AMD that could be identified extrafoveolarly or juxtafoveolarly in an early ICG angiographic study. Laser photocoagulation was applied to the neovascular membrane identified in the early ICG angiographic study.

RESULTS

Visual acuity ranged from 20/400 to 20/20 (logMAR 0.54 (SD 0.29) before and hand movements and 20/30 (logMAR 0.81 (0.69)) at the last follow up after laser photocoagulation. During the follow up (30 (13) months) vision improved in four eyes (two lines), in seven eyes the initial visual acuity could be stabilised (two lines), in five eyes vision dropped moderately (three to five lines), and in five eyes vision decreased severely (six or more lines). Recurrences (seven patients) or persistent CNV (six patients) was observed in 13 patients.

CONCLUSION

This preliminary study of ICG guided laser photocoagulation of occult extrafoveal and juxtafoveal choroidal neovascularisations suggests that this technique may improve the visual prognosis of these patients. Further prospective controlled studies are necessary to confirm these data.

Laser treatment of feeder vessels in subfoveal choroidal neovascular membranes: a revisitation using dynamic indocyanine green angiography

OBJECTIVE

This study aimed to determine whether the indocyanine green angiography (ICGA)-guided laser treatment of feeder vessels (FVs) may be useful in the management of the subfoveal choroidal neovascular membranes (CNVM) in patients with age-related macular degeneration (ARMD).

DESIGN

Noncomparative case series.

PARTICIPANTS

The authors considered a series of 15 patients with subfoveal CNVM in whom feeder vessels could be clearly detected by means of dynamic ICGA but not necessarily with fluorescein angiography (FA). On the basis of the indications of the pilot study, the authors also studied a second series of 16 patients with FVs smaller than 85 microm.

INTERVENTION

Treatment of FV using argon green laser was performed. The ICGA was performed immediately after treatment, after 2, 7, 30 days, and then every 3 months, to assess FV closure. If an FV appeared to be still patent, it was immediately retreated and the follow-up was started again. The follow-up time ranged from 23 to 34 months for the pilot study and from 4 to 12 months for the second series.

MAIN OUTCOME MEASURES

The obliteration of the membrane and change in visual acuity from baseline were measured. The effect on the treatment of the number and width of the FVs, and the size and location of the membrane, also was evaluated.

RESULTS

In the pilot study, the CNVM was obliterated after the first treatment in only one patient, five patients needed more than one treatment, and obliteration failed in nine patients (40% success rate). The rate of success was affected by the width and number of the FVs. The success rate in the second series of 16 patients was higher (75%).

CONCLUSIONS

The success of the laser treatment of FVs depends on their width, length, and number. Dynamic ICGA, which detects smaller FVs and makes it possible to control the laser effect and initiate immediate retreatment in the case of incomplete FV closure, should be considered mandatory for this type of treatment; a comparable success rate would have been unlikely using the other currently available methods of treating subfoveal CNVMs.

Evaluating persistent and recurrent choroidal neovascularization. The role of indocyanine green angiography

OBJECTIVE

To evaluate the clinical utility of routinely using indocyanine green angiography (ICGA) with fluorescein angiography (FA) in detecting persistent or recurrent choroidal neovascularization (CNV).

DESIGN

Prospective, consecutive case series.

PARTICIPANTS

Twenty-four eyes of 21 patients with exudative age-related macular degeneration (AMD) that had conventional laser treatment for CNV were examined.

INTERVENTION

Fluorescein angiography and ICGA were performed together on all eligible eyes at the first post-treatment visit and all subsequent follow-up visits in which persistent or recurrent CNV was suspected clinically.

MAIN OUTCOME MEASURES

Choroidal neovascularization detection and delineation by each angiographic technique were measured.

RESULTS

Of the 54 FA-ICGA study pairs performed over a 20-month investigation period, FA showed well-defined, ill-defined, and no CNV in 10 (19%), 19 (35%), and 25 (46%) eyes, respectively. Indocyanine green angiography had a high concordance rate at 70% and 88% when persistent or recurrent CNV was well-defined and absent, respectively, on FA and rarely added additional, clinically useful information in these settings, particularly in the former presentation. Of the 29 eyes that showed some evidence of CNV by FA, the neovascular complex was ill-defined in 19 (66%) eyes. When CNV was ill-defined by FA, the corresponding ICGA showed well-defined CNV in 9 (47%) of 19 eyes, in 5 of which the CNV was nonsubfoveal in location.

CONCLUSIONS

Persistent or recurrent CNV in AMD was frequently ill-defined by FA. Indocyanine green angiography was a valuable adjunct to FA by better delineating CNV in this specific setting. However, ICGA was not useful when the post-treatment FA showed well-defined CNV. Furthermore, ICGA was not helpful when the first post-treatment FA was negative and there were no ophthalmoscopic signs of exudation.

Indocyanine green angiographic findings in fellow eyes of patients with unilateral occult neovascular age-related macular degeneration

PURPOSE

To determine the role of indocyanine green angiography (ICGA) in the prediction of the development of choroidal neovascularization (CNV).

METHODS

We reviewed the ICG angiograms of 124 patients with newly diagnosed unilateral occult CNV secondary to age-related macular degeneration (AMD) in whom the fellow eye had only drusen by biomicroscopy and fluorescein angiography. Follow-up data of at least 12 months were obtained in all eyes.

RESULTS

113 fellow eyes had a normal ICG study, while 11 fellow eyes revealed plaque-like late hyperfluorescence. During an average follow-up time of 18.2 months exudative AMD developed in 7 of 11 eyes with late hyperfluorescence on ICGA and in 6 of 113 with a normal ICGA study.

CONCLUSION

ICGA may help to predict which fellow eyes are at higher risk of developing future exudative changes.

Indocyanine green angiography-guided photocoagulation of choroidal neovascularization associated with retinal pigment epithelial detachment

PURPOSE

To determine visual acuity outcome after indocyanine green angiography-guided laser photocoagulation of choroidal neovascularization associated with pigment epithelial detachment in eyes with age-related macular degeneration.

METHODS

We retrospectively reviewed pretreatment and posttreatment visual acuity after laser photocoagulation to well-demarcated hyperfluorescent areas seen with indocyanine green angiography adjacent to or within pigment epithelial detachments in 20 eyes of 20 patients with age-related macular degeneration and suspected choroidal neovascularization.

RESULTS

Visual acuity before and after laser photocoagulation was followed up for 3 to 24 months (median, 9 months). At 3 months after laser photocoagulation, visual acuity had improved 2 or more Snellen lines in two eyes (10%), worsened by 2 or more lines in 10 (50%), and remained unchanged in eight of 20 (40%). By 6 months after laser photocoagulation, visual acuity had improved by 2 or more lines in two eyes (12%), worsened by 2 or more lines in nine (53%), and remained unchanged in six of 17 (35%). At 9 months after laser photocoagulation, visual acuity had improved by 2 or more lines in one eye (9%), worsened by 2 or more lines in nine (82%), and remained unchanged in one of 11 (9%).

CONCLUSIONS

Indocyanine green angiography-guided laser photocoagulation may temporarily stabilize visual acuity in some eyes with choroidal neovascularization associated with pigment epithelial detachments, but final visual acuity decreases with time.

Indirect scatter laser photocoagulation to subfoveal choroidal neovascularization in age-related macular degeneration

BACKGROUND

Occult choroidal neovascularization (CNV), poorly defined on fluorescein angiography, is present in the majority of patients with exudative complications of age-related macular degeneration. For patients who present with this type of subfoveal CNV but who have useful visual acuity, no form of treatment is of proven benefit. Accordingly, a pilot randomized trial of indirect laser treatment was performed. The rationale of this treatment was to inhibit the CNV through laser-induced effects on the retinal pigment epithelium.

METHODS

Patients with occult subfoveal CNV without retinal pigment epithelial detachment and with visual acuity of 20/200 or better were randomized to treatment or control groups. A grid of laser burns was applied to the macula beyond the area of serous retinal detachment and of angiographically defined occult CNV.

RESULTS

After an average follow-up of 38 months, there was no difference in mean final visual acuity (0.12 treated, 0.14 control) or clinical outcome between treated and untreated groups. Fluorescein angiography showed gradual enlargement in the occult CNV in 58% of eyes in both groups. A decrease in visual acuity to worse than 20/200 (54% of treated, 50% of control eyes) was associated with ingrowth of well-delineated CNV (6 treated, 7 control eyes) or progression to a fibroglial or atrophic scar (11 treated, 8 control eyes).

CONCLUSIONS

No benefit was demonstrated for scatter photocoagulation of the macula in patients with age-related macular degeneration and occult subfoveal CNV with initially good visual acuity. There were, however, no complications related to treatment.

ICG videoangiography of occult choroidal neovascularization in age-related macular degeneration

Digital indocyanine green videoangiography has recently been reported to improve the imaging of occult choroidal neovascularization. In this study, 44 eyes with occult choroidal neovascularization in age-related macular degeneration were studied with fluorescein and indocyanine green videoangiography. On indocyanine green videoangiographic examination, 6 of the 44 eyes (13.6%) with occult choroidal neovascularization had vascularized pigment epithelial detachment and 27 (61.4%) had vascularized retinal pigment epithelium. In the remaining 11 (25%) eyes which had previous laser photocoagulation, indocyanine green videoangiography confirmed the presence of recurrence while fluorescein revealed no demonstrable neovascularization. The findings in our study indicate that patients with occult choroidal neovascularization have manifestations that are more clearly demonstrated with indocyanine green videoangiography and improved imaging of these abnormal vessels could potentially increase the number of patients eligible for photocoagulation treatment.

Classification of choroidal neovascularization by digital indocyanine green videoangiography

PURPOSE

The majority of patients with exudative maculopathy due to age-related macular degeneration present with poorly defined or occult choroidal neovascularization (CNV) that cannot be imaged adequately by fluorescein angiography. Digital indocyanine green (ICG) videoangiography is a new technique that allows enhanced imaging of these poorly defined or occult vessels. The authors studied 1000 consecutive cases of occult CNV using digital ICG angiography to describe the various types of neovascularization observed by this technique and to determine the frequency and natural history of the various lesions.

MATERIALS AND METHODS

Digital ICG videoangiography was performed as described previously on 1000 consecutive eyes with occult CNV by fluorescein angiography.

RESULTS

One thousand consecutive eyes with occult CNV by fluorescein angiography were imaged using digital ICG videoangiography. Three morphologic types of CNV were noted by ICG videoangiography, which included focal spots, plaques (well-defined or poorly defined), and combination lesions (in which both focal spots and plaques are noted). Combination lesions can be subdivided into marginal spots (focal spots at the edge of plaques of neovascularization), overlying spots (hot spots overlying plaques of neovascularization), or remote spots (a focal spot remote from a plaque of neovascularization). The relative frequency of these lesions was as follows: there were 283 cases (29%) of focal spots; 597 cases (61%) of plaques, consisting of 265 cases (27%) of well-defined plaques and 332 cases (34%) of poorly defined plaques; and 84 cases (8%) of combination lesions, consisting of 35 cases (3%) of marginal spots, 37 cases (4%) of overlying spots, and 12 cases (1%) of remote spots. In seven additional cases (1%), a mixture of the above lesions was noted. In 13 additional eyes (1%), no lesions were noted on the ICG angiogram. The studies of 16 eyes were unreadable or unobtainable.

CONCLUSIONS

There are three types of CNV that can be observed by digital ICG videoangiography. Plaques are the most common type and have a poor natural history. Focal spots or hot spots are the next most frequently seen lesion and can potentially be treated by ICG-guided laser photocoagulation. Combination lesions, in which both focal spots and plaques are present, are rare. This study of 1000 consecutive cases of eyes with occult neovascularization that were imaged with digital ICG videoangiography serves to classify the various types of neovascularization observed by this technique. Digital ICG videoangiography is an important tool in better delineating eyes with occult CNV. Future studies are necessary to validate our findings.

Selective use of indocyanine green angiography for occult choroidal neovascularization

PURPOSE

Indocyanine green angiography is useful in situations where fluorescein angiography shows occult choroidal neovascularization or pigment epithelial detachment. We sought to determine how often the selective application of indocyanine green angiography results in useful information for eyes with occult choroidal neovascularization.

METHODS

We reviewed 153 consecutive indocyanine green angiograms and identified 77 in which corresponding fluorescein angiograms showed occult choroidal neovascularization or pigment epithelial detachment. We examined the indocyanine green angiograms to detect areas of hyperfluorescence and to classify the margins of hyperfluorescence as well demarcated or poorly demarcated.

RESULTS

Of 77 eyes, 42 (55%) eyes had occult choroidal neovascularization by fluorescein angiography, seven (9%) eyes had both classic and occult choroidal neovascularization by fluorescein angiography, and 28 (36%) eyes had pigment epithelial detachments. Of 42 eyes with occult choroidal neovascularization by fluorescein angiography, 21 (50%) had well-demarcated margins, 13 (31%) had poorly demarcated margins, and eight (19%) had no detectable hyperfluorescence by indocyanine green angiography. Of seven eyes with both classic and occult choroidal neovascularization by fluorescein angiography, two had both poorly demarcated and well-demarcated borders, two had only poorly demarcated borders, and three had well-demarcated borders by indocyanine green. The indocyanine green angiogram showed 23 (82%) of 28 pigment epithelial detachments to have well-demarcated borders of hyperfluorescence; 13 (57%) of 23 were treated.

CONCLUSION

Indocyanine green angiography adds clinically useful information to fluorescein angiography by demonstrating well-demarcated areas of hyperfluorescence in 50% of eyes selected because of diagnosis of occult choroidal neovascularization and in 82% of eyes selected because of pigment epithelial detachment.