Feeder vessel photocoagulation of subfoveal choroidal neovascularization secondary to age-related macular degeneration

OCTA-guided navigated laser therapy for advanced macula neovascularization secondary to age related macular degeneration

INTRODUCTION

To evaluate the effects of the Navilas system guided by optical coherence tomography angiography for advanced macular neovascularization (MNV) secondary to age-related macular degeneration (AMD).

METHODS

Prospective case-series including nine eyes presenting with advanced MNV with persistence of exudative signs, no longer responding to anti-VEGF therapy, best-corrected visual acuity at least of 1.3 logMar. All patients were treated with Navilas guided by overlaid optical coherence tomography angiography (OCTA) images at the site of branching large neovascular trunks.

RESULTS

Occlusion of large neovascular trunks successfully occurred in all nine included patients. OCTA analysis revealed, at 1 month follow up, MNV total area decreasing from 6.2 ± 3.1 to 2.6 ± 3.4 mm². At 6 months follow up, mean MNV area was 3.3 ± 3.4 mm² (p = 0.008).

CONCLUSION

This preliminary study showed that Navilas treatment guided by OCTA may represent an attractive therapeutic option in advanced neovascular lesions secondary to AMD.

Optical coherence tomography angiography markers associated with treatment response in neovascular age-related macular degeneration

PURPOSE

To investigate whether qualitative and quantitative features of choroidal neovascular membranes are associated with anti-vascular endothelial growth factor treatment response in patients with neovascular age-related macular degeneration.

METHODS

A total of 41 eyes were included in this cross-sectional observational study and divided into "good responders" and "poor responders" based on the long-term functional changes, frequency of recurrent choroidal neovascular activity, and injection need. Enface optical coherence tomography angiography images were obtained and qualitative features of choroidal neovascular membranes were described based on vessel network density. Then, quantitative measurements including vessel area, vessel length, junction density, and lacunarity were calculated using validated software (ImageJ and AngioTool). Chi-square tests, t-test, or Mann-Whitney U tests were used for group comparisons, and intraclass correlation coefficients were calculated for reliability assessment of quantitative analyses.

RESULTS

Twenty-two eyes treated by a median of 9 (3-24) anti-vascular endothelial growth factor injections at a median follow-up of 41 (12-89) months were categorized as good responders, 19 treated by a median of 26 (11-46) injections at a median follow-up of 44.5 (12-84) months as poor responders. Good responder group mostly had loose network (45.5%), and poor responders mostly had dense network (47.7%). The difference was not statistically significant (p = 0.25). The size of the lesion was 2.7 times greater at baseline (p = 0.04) and 1.7 times greater at final examination in the poor responder group (p = 0.04). Lacunarity index, showing lesion heterogeneity, was higher in good responders (p = 0.018) than poor responders. Other quantitative vascular features did not significantly differ between the groups (p > 0.05).

CONCLUSION

Long-term remodeling of chronically treated choroidal neovascular may be non-invasively and reproducibly investigated using optical coherence tomography angiography. Quantitative analysis and lacunarity index, in particular, may be used as a measure of vessel maturation and guide treatment strategies in neovascular age-related macular degeneration.

The Comparison of Morphologic Characteristics of Type 1 and Type 2 Choroidal Neovascularization in Eyes with Neovascular Age-Related Macular Degeneration using Optical Coherence Tomography Angiography

PURPOSE

The purpose of this study was to use optical coherence tomography angiography (OCTA) to compare the morphology characteristics of type 1 and 2 choroidal neovascularization (CNV) in neovascular age-related macular degeneration (nAMD) patients.

MATERIALS AND METHODS

This is a retrospective, observational study of 51 eyes with nAMD using OCTA from July 2016 through March 2017.

RESULTS

In total, 51 eyes of 50 patients were included in the analysis. According to the anatomical classification based on OCT, 27 eyes (53%) were diagnosed with type 1 CNV, and 24 eyes (47%) were type 2 CNV. Type 2 CNV was characterized by smaller flow area, smaller greatest vascular caliber (GVC), smaller greatest linear dimension (GLD), and shorter duration of disease. The duration of disease only correlated with GVC (p = 0.026) in multivariate linear regression results. Meanwhile, GLD correlated with GVC and flow area whereas GVC was not associated with flow area.

CONCLUSION

This study demonstrated that type 2 CNV was characterized by shorter duration of disease, smaller GVC, smaller GLD, and smaller flow area compared with type 1 CNV. Additionally, we showed that the duration of the disease correlated with GVC of the CNV.

The role of fundus autofluorescence imaging in the study of the course of posterior uveitis disorders

BACKGROUND

To evaluate the correlation of fundus autofluorescence (FAF) with indocyanine green angiography (ICGA) in patients with various posterior uveitis disorders.

METHODS

Interventional case series including 23 eyes of 15 patients with diagnosis of a specific type of retinochoroiditis, such as acute posterior multifocal placoid pigment epitheliopathy (APMPPE), serpiginous-like choroiditis, multifocal choroiditis (MFC), Harada disease, and syphilitic retinochoroiditis. Also, some cases with undefined retinochoroiditis were included. FAF and ICGA were performed and correlated at baseline and during follow-up after treatment.

RESULTS

In ICGA, early hypofluorescence was found to be the hallmark of acute choroidal inflammation, resolving in later stages and remaining in the late phase in areas with retinal pigment epithelium (RPE) damage. Poorly defined hyperautofluorescent areas correlated with acute choroidal lesions. Hypoautofluorescent delineation suggested the initiation of RPE healing processes, correlating well with the late phase of ICGA and delineating the RPE damage. Early hyperautofluorescence with late hypofluorescence in ICGA indicated the presence of primary RPE involvement.

CONCLUSION

FAF contributes to the interpretation of RPE disease and may be a useful tool for the follow-up of progressive inflammatory disorders. Comparative evaluation of FAF and ICGA allows a characterization of the sequence of inflammatory events and the level of tissue affected.

Unusual Loop-Like Vessel Formation After Intravitreal Ranibizumab Injections in AMD

The authors observed an unusual closed loop-like vessel formation in the macula and describe its regression caused by the heterogenous treatment effects of intravitreal ranibizumab injections in an eye with exudative age-related macular degeneration associated with multiple retinochoroidal anastomoses.

Temperature Distribution During ICG-Dye-Enhanced Laser Photocoagulation of Feeder Vessels in Treatment of AMD-Related Choroidal Neovascularization

Laser photocoagulation of the feeder vessels of age-related macula degeneration-related choroidal neovascularization (CNV) membranes is a compelling treatment modality, one important reason being that the treatment site is removed from the fovea in cases of sub- or juxtafoveal CNV. To enhance the energy absorption in a target feeder vessel, an indocyanine green dye bolus is injected intravenously, and the 805nm wavelength diode laser beam is applied when the dye bolus transits the feeder vessel; this tends to reduce concomitant damage to adjacent tissue. A 3D theoretical simulation, using the Pennes bioheat equation, was performed to study the temperature distribution in the choroidal feeder vessel and its vicinity during laser photocoagulation. The results indicate that temperature elevation in the target feeder vessel increases by 20% in dye-enhanced photocoagulation, compared to just photocoagulation alone. The dye bolus not only increases the laser energy absorption in the feeder vessel but also shifts the epicenter of maximum temperature away from the sensitive sensory retina and retinal pigment epithelial layers and toward the feeder vessel. Two dominant factors in temperature elevation of the feeder vessel are location of the feeder vessel and blood flow velocity through it. Feeder vessel temperature elevation becomes smaller as distance between it and the choriocapillaris layer increases. The cooling effect of blood flow through the feeder vessel can reduce the temperature elevation by up to 21% of the maximum that could be produced. Calculations were also performed to examine the effect of the size of the laser spot. To achieve the same temperature elevation in the feeder vessel when the laser spot diameter is doubled, the laser power level has to be increased by only 60%. In addition, our results have suggested that more studies are needed to measure the constants in the Arrhenius integral for assessing thermal damage in various tissues.

Age-related macular degeneration and recent developments: new hope for old eyes?

Age-related macular degeneration (AMD) is the commonest cause of blindness in the population over 60 years of age and accounts for over 50% of those registered blind in the UK. The incidence is increasing and as older generations live longer a growing number of patients will be affected in the future. Affected patients lose central vision, important in all aspects of everyday life. This review outlines risk factors for AMD, clinical features, treatment and management strategies for patients, families and physicians caring for those with AMD. Recent trials are included along with practical clinical advice. While there is no curative treatment at present, intervention can reduce the risk of developing AMD and limit disease progression if it occurs. These modalities are discussed here. As new discoveries in the field of genetics and novel therapies emerge, a brighter future seems certain for the ageing population.

New therapies for neovascular age-related macular degeneration: critical appraisal of the current evidence

During the past 20 years, several multicentre clinical trials have investigated different therapies for neovascular age-related macular degeneration (AMD). These landmark studies have provided the scientific community with powerful data regarding the ability of laser photocoagulation, verteporfin therapy, pegaptanib sodium and submacular surgery to treat particular choroidal neovascular lesion types. Accurate interpretation of data from these trials is essential to enable clinicians to make informed decisions about therapeutic interventions. Furthermore, several new treatment options are likely to become available in the next few years and clinicians will have to decide how effective these therapies may be, and how (or if) they should be used in clinical practice. It is therefore timely to review the strengths and weaknesses of the body of evidence for the currently available therapeutic options for patients with choroidal neovascularization due to AMD. Evaluation of the quality of reporting in past clinical trials will also enable critical review of new studies that will be published in the future. This review summarizes the design, reporting and results of key randomized clinical trials, in addition to evaluating the available evidence for new therapies and identifying the important issues that need to be considered when evaluating their efficacy.

Phase I clinical trial results of verteporfin enhanced feeder vessel therapy in subfoveal choroidal neovascularisation in age related macular degeneration

AIMS

To investigate the safety and effectiveness of extrafoveal photodynamic therapy (PDT) occlusion of feeder vessels (FVs) in patients with subfoveal choroidal neovascularisation (CNV) as a result of age related macular degeneration.

METHODS

FVs were identified using dynamic fluorescein and indocyanine green angiography with scanning laser ophthalmoscope. The standard doses of verteporfin and laser wavelength were used. The light dose was escalated by increasing the duration of the light dose so the light regimen was 50 J/cm2 for patients 1 and 2; 100 J/cm2 for patients 3, 4, 5; 125 J/cm2 for patients 6 and 7; and 150 J/cm2 for patients 8 and 9. Patients were examined at weeks 1, 4, and 12.

RESULTS

The mean improvement on EDTRS chart 3 months after treatment was an increase of 2.1 lines (p = 0.07). Closure of the FV was achieved angiographically in three eyes at various light doses, in three eyes the FV was hypoperfused, and in three eyes the vessels were were neither closed nor hypoperfused. At the last follow up all FVs were reperfused. There was no evidence of retinal damage.

CONCLUSION

Verteporfin enhanced FV therapy does not cause subfoveal retinal damage and may have potential to improve central vision in subfoveal CNV caused by exudative macular degeneration. It is not recommended as a monotherapy for CNV.

Improved visualisation of choroidal neovascularisation by scanning laser ophthalmoscope using image averaging

AIMS

To improve visualisation of angiographic features in patients with age related macular degeneration associated with choroidal neovascularisation (CNV) and related complications. To evaluate if image averaging can achieve this goal.

METHODS

27 eyes of 20 sequential patients with age related macular degeneration over a 3 month period were studied. Indocyanine green angiograms (ICGA), fluorescein angiograms (FA), and oral fluorescein angiograms were recorded with a confocal scanning laser ophthalmoscope. Software was used to average multiple images from a 10-20 image series (over 0.5-1.0 seconds). Image quality was assessed by two masked observers and graded on a scale of 0-3. A more quantifiable grading method was devised by adding a variable amount of Gaussian noise to the improved image until the original and image averaged image appeared equal.

RESULTS

Masked review showed mild to strong improvement of visualisation of structures including borders of CNV. Improvement varied depending on the type and phase of the angiogram. Improvement was highest in late phase FA, mid and late phase ICGA, and all phases of oral FA.

CONCLUSION

Image averaging using software based algorithms improves the quality of angiographic images, particularly late ICGA images and oral FAs. This method may assist in the visualisation of choroidal neovascularisation in age related macular degeneration.

Polypoidal choroidal vasculopathy: Angiographic characterization of the network vascular elements and a new treatment paradigm

Macular exudative manifestations secondary to choroidal neovascular lesions remain the leading cause of definitive visual impairment and legal blindness in the elderly. During the past decade, advances in ophthalmic imaging systems have enabled the recognition of presumed new distinct choroidal neovascular lesions that share some unique clinical and angiographic peculiarities as well as better comprehension of the pathophysiologic mechanisms related to such entities. Amongst presumed newer exudative maculopathies, polypoidal choroidal vasculopathy, which has been described as a distinct choroidal abnormality characterized by inner choroidal vascular network of vessels ending in polyp-like structures only identified on indocyanine green angiography and mostly affecting African-American and Asian descendents, has gained special interest from the ophthalmic community particularly because of its growing recognition among patients with clinical appearance of neovascular age-related macular degeneration. Thus far, however, the exact nature of the vascular structure of the polypoidal choroidal vasculopathy lesion remains unclear and data from recent studies have conflicted with the initial concept of a benign exudative maculopathy with long-term preservation of good vision. All together, such factors make difficult the establishment of an appropriate treatment, if any, for the entity. Herein, by using a modified technique of conventional indocyanine green angiography, we demonstrate new information about the morphologic characteristics, and to some extent the blood flow dynamics perfusion, of the polypoidal choroidal vasculopathy lesion. Our results suggest that the PCV lesion should be considered a variety of choroidal neovascularization rather than a distinct clinical entity, characterized by one single large neovascular complex presenting well-defined arterial neovascular vessels arising from one major "ingrowth site" and draining vessels that present aneurysm-like dilations corresponding to the polyp-like structures typically described for the entity. Finally, the visual acuity and angiographic findings observed after selective ingrowth site photothrombosis corroborate the existence of one major "ingrowth site" for the PCV neovascular complex and point toward a new treatment paradigm for this variety of choroidal neovascularization.

Prise en charge « basse vision » des patients atteints de DMLA avec néovaisseaux choroïdiens rétrofovéaux traités par PDT à la vertéporfine

PURPOSE

To demonstrate the rehabilitation benefit and immediate optical magnification and electronic equipment advantage in an age-related macular degeneration population with retrofoveal choroidal new-vessels treated by photodynamic therapy using Visudyne.

PATIENTS AND METHODS

Sixty seven consecutive patients with retrofoveal choroidal new-vessels treated by Photodynamic Therapy using Visudyne were referred to an orthoptist for low-vision rehabilitation. The criteria investigated for this study were: long distance visual acuity, reading ability, contrast sensitivity, (before treatment and during post-treatment examinations), and fixation localization and optical equipment model.

RESULTS

This study showed and studied visual acuity variations, mostly for patients with good visual acuity at inclusion. Contrast sensitivity stayed more or less the same. Retinal fixation was foveolar most of the time (68.7%). Optical or electronic devices for low-vision patients are numerous and video systems were the most currently used among our population. 62.7% des patients had low-vision rehabilitation with optic aids.

DISCUSSION AND CONCLUSION

This study threw light on patient optic aids which must be prescribed according to his needs and difficulties, without delay. This equipment will then be readapted at each stage of the patient evolution. PDT treatment gives an important role to low-vision rehabilitation associated with optic magnification aids.

Indocyanine green enhanced retinal vessel laser closure in rats: histologic and immunohistochemical observations

PURPOSE

Feeder vessel photocoagulation using both thermal and indocyanine green (ICG) enhanced applications as a treatment for choroidal neovascularization is under investigation. While closure of feeder vessels is achievable, reperfusion of these vessels occurs. The purpose of the following study was to compare, contrast anatomic, and immunohistochemical findings in rat retinal arterioles following attempts at vessel closure using either the diode (810 nm) laser alone or in conjunction with intravascular ICG.

METHODS

The retinal arterioles of adult Lewis or Brown Norway rats were treated with diode laser alone or immediately following intravenous injection with 75 mg ml(-1) ICG. Retinal vessel closure was determined by examination of retinal flatmounts following FITC-dextran or rhodamine-dextran perfusion. Anatomic changes were examined by electron microscopy and quantitative cellular changes were measured by perfusion with Hoechst 33342 nuclear staining. Recruited macrophages were detected by ED1 immunohistochemistry.

RESULTS

Treatment with diode laser alone resulted in partial retinal arteriolar closure seen only in pigmented animals. The use of adjuvant ICG achieved complete vessel closure in albino animals with reperfusion seen in all vessels by 7 days. Electron microscopy revealed an intraluminal clot only in ICG-enhanced diode laser treated animals, but with accompanying endothelial and perivascular cellular damage. Immunohistochemistry of the site of retinal arteriolar closure revealed a large increase in perivascular cellularity with an apparent influx of ED1 positive cells.

CONCLUSION

ICG-enhanced diode laser photocoagulation appears to be superior to diode treatment alone in achieving vessel closure, but is limited by clot resolution due to both excessive vascular damage and an accompanying inflammatory response. These results suggest that more durable feeder vessel closure rates may be achievable with either the use of accompanying anti-inflammatory therapies or with a less vascular damaging photoactivating dye.

Photodynamic therapy with verteporfin for symptomatic polypoidal choroidal vasculopathy: one-year results of a prospective case series

OBJECTIVE

To determine the efficacy of photodynamic therapy (PDT) with verteporfin as a treatment for symptomatic polypoidal choroidal vasculopathy (PCV).

DESIGN

Prospective consecutive, 2-centered, noncomparative interventional case series.

PARTICIPANTS

Twenty-one Asian patients with 22 eyes presenting with serosanguinous maculopathy due to PCV and an initial best-corrected visual acuity (BCVA) of 20/40 or worse were recruited prospectively. All patients had angiographic leakage seen on fluorescein angiograms (FAs) and features of PCV seen with indocyanine green (ICG) angiography.

METHODS

Intravenous infusion of verteporfin at a dose of 6 mg/m(2) of body surface area over 10 minutes was administered. Five minutes after the completion of infusion, a 689-nm laser was applied for 83 seconds, with a light dose of 50 J/cm(2). The laser spot size was chosen to cover the polyps and the surrounding abnormally dilated choroidal vessels shown on ICG angiography plus an extra 1000-microm margin. Photodynamic therapy retreatment was performed if leakage from the polyps was found on both repeat FAs and ICG angiography at regular 3-month follow-up intervals.

MAIN OUTCOME MEASURES

The proportion of eyes with stable or improved vision at a 1-year follow-up. Secondary outcome measures included change in mean BCVA and the changes in clinical and angiographic features in FAs and ICG angiography. The total number of PDT sessions and any complications were also recorded.

RESULTS

Stable or improved vision was achieved in 21 (95%) of the 22 eyes at the 1-year follow-up. Ten (45%) eyes had a moderate gain in vision (improved by > or =3 lines), whereas 1 (5%) eye suffered a moderate visual loss (decrease by > or =3 lines). The mean BCVA improved from a logarithm of the minimum angle of resolution(logMAR) of 0.73 to 0.60, an equivalent of 1.3 lines of improvement. The change in logMAR BCVA at 12 months was statistically significant (Wilcoxon signed-ranks test, P = 0.009). Complete absence of leakage in FAs and total regression of the polyps in ICG angiography were observed in 20 (91%) and 21 (95%) eyes, respectively. Severe loss of vision due to massive subretinal hemorrhage occurred in 1 eye; otherwise, there were no other serious treatment-related adverse events.

CONCLUSIONS

The 1-year results of PDT in treating PCV of the macular type with serosanguinous presentations are encouraging. Further studies with longer follow-up and randomized controlled trials are warranted to assess the long-term safety and efficacy of PDT relative to observation or other treatment modalities.

Fluorescein angiography-guided indocyanine green angiography for the detection of feeder vessels in subfoveal choroidal neovascularization

AIMS

To compare the newly devised fluorescein angiography (FA) - guided indocyanine green angiography (ICGA) with conventional ICGA for detecting feeder vessels in subfoveal choroidal neovascularization (CNV).

METHODS

The detection of feeder vessels was attempted in 86 AMD patients with subfoveal CNV: 44 (age 70.4+/-4.5 years) underwent conventional ICGA (control group) and 42 (age 70.9+/-4.0 years) underwent an FA-guided ICGA (FA-guided group) using a double-detector scanning laser ophthalmoscope (SLO). In the control group, indocyanine green (ICG) was injected simultaneously with fluorescein. The patients were instructed to gaze forward localizing the fovea at the centre. In the FA-guided group, fluorescein sodium was injected a few minutes prior to ICG, and the patients were instructed to fixate in the appropriate direction by referring to the ongoing FA on the monitoring screen. In both groups, a 20 degrees visual angle was used to capture good images of feeder vessels in ICGA and, in case ICGA missed the first images of the entire CNV filling, an additional injection of ICG was given in the late phase to record the choroidal filling again. The overall detection rate, single-injection detection rate, double-injection rate and examination time were analysed using Fisher's direct exact probability test or Mann-Whitney's U-test.

RESULTS

There was no significant difference in the overall detection of feeder vessels between the two groups (50% in the control group and 52.3% in the FA-guided group; P=0.49 with Fisher's direct exact probability test). However, in the FA-guided group, the single injection detection rate was significantly higher (45.1 and 15.9%, respectively; P<0.001 with Fisher's direct exact probability test); significantly less double injections were required (7.1 and 50%, respectively; P=0.003 with Fisher's direct exact probability test); and significantly shorter examination times were needed (9.6+/-3.7 and 14.1+/-6.8 min, respectively; P=0.02 with Mann-Whitney's U-test).

CONCLUSION

FA-guided ICGA is effective for detecting feeder vessels of subfoveal CNV, minimizing the amount of ICG injected and the examination time compared to conventional ICGA.

Asymmetry of choroidal venous vascular patterns in the human eye

PURPOSE

To describe the angioarchitecture of choroidal veins in normal subjects using indocyanine green (ICG) angiography.

DESIGN

Consecutive observational case series.

PARTICIPANTS

Thirty-six eyes of 33 healthy volunteers ranging in age from 21 to 81 years (50.0+/-18.2 [mean +/- standard deviation]).

METHODS

Indocyanine green angiography was performed with a modified Topcon fundus ICG camera. Montage images were obtained during the venous phase of the ICG angiogram.

MAIN OUTCOME MEASURES

Indocyanine green angiographic montage images covering all areas of the observable fundus.

RESULTS

Eighteen of 36 eyes examined (50%) showed asymmetry of choroidal venous vascular patterns consistent with a preferential route of choroidal venous drainage of the macular region. Twelve of the 18 eyes with a preferred drainage route drained superotemporally; the remaining 6 eyes drained by either an inferotemporal or a superonasal route. A preferential choroidal venous drainage route in the macula was identified with equal frequency in young and old subjects. Of 36 eyes examined, 27 (75%) lacked ICG angiographic evidence of symmetric separation of outer choroidal veins.

CONCLUSIONS

There is ICG angiographic evidence of asymmetry of choroidal venous drainage in one half of normal individuals. The relative frequency of a resulting preferential drainage route in a group of normal subjects and the equal distribution in young and old subjects indicate that this finding is neither pathologic nor attributable to aging. There is also ICG angiographic evidence for a lack of symmetric separation in the outer choroidal venous system in the majority of normal human subjects tested, indicating that classic watershed zones may not be present or are less prominent in this portion of the choroidal vasculature.

[Visudyne photodynamic therapy and feeder vessel occlusion: rationale of a synergistic association and clinical options]

PURPOSE

Visudyne photodynamic therapy (PDT) has provided considerable improvement in patient care of subfoveal choroidal neovascularization (CNV). Patients tend to loose vision for a few months after the initial treatment, but the 4-year proven stability in vision most often provides an acceptable quality of life, sometimes with additional low vision rehabilitation. The initial visual acuity loss, borderline cost-effectiveness, and subgroups of patients not responding to PDT warrant improving the symptomatic treatment of subfoveal CNV. Today, the most tempting solution would be to combine PDT with an occlusion of the feeder vessel (FV).

METHODS

Two patients are described in whom the feeder vessel was occluded using modifications of the classic PDT treatment method. The FV was identified in both patients using fluorescein and indocyanine green angiographies at a recorded video rate using a modified scanning laser ophthalmoscope (Rodenstock SLO). The feeder vessel of the first patient was occluded by minimal photocoagulation immediately after a Visudyne PDT treatment in order to take advantage of the reduced blood flow within the feeder vessel. The second patient presenting a subfoveal FV was treated using a modified PDT treatment called feeder-vessel PDT. The photosensitizing agent was activated by a first classic spot covering the lesion, followed immediately by a small spot focused on the feeder vessel.

RESULTS

Both subfoveal CNVs were successfully and selectively occluded and some visual acuity was gained following the treatment.

CONCLUSION

Occlusion of the feeder vessel is an appealing clinical option that is complementary to Visudyne PDT. Both treatment methods presented here could provide additional options to close subfoveal CNV with an optimal efficacy-risk ratio.

Ophthalmic fundus imaging: today and beyond

PURPOSE

To review and update techniques of posterior segment ophthalmic fundus imaging.

DESIGN

Literature review and collective experience of the authors.

METHODS

This perspective includes sections on digital imaging, fundus autofluorescence, ultrasonography, angiography, and optical coherence tomography (OCT) -ophthalmoscopy written by leading clinicians and researchers in these areas.

RESULTS

Digital angiography has become the new standard in the ophthalmic community based upon improved technology which has enhanced resolution, processing time, and ease of image duplication, manipulation, and transmission. A relatively new imaging technique, fundus autofluorescence, highlights lipofuscin deposits and improves our understanding of the metabolic status of the retinal pigment epithelium. Diagnostic ultrasonography continues to be a major adjunct to ocular evaluation where advances now allow for exceptional versatility and portability. High speed angiographic techniques provide detailed visualization of choroidal perfusion which improves our understanding of both normal and pathologic vascular phenomenon. Advances in high-resolution OCT currently under development promise an even more detailed fundus representation. The integration of the scanning laser ophthalmoscope and OCT has produced a dynamic new instrument, the OCT ophthalmoscope, which simultaneously images the fundus in numerous ways with point to point correlation.

CONCLUSIONS

Ophthalmic imaging technology has revolutionized fundus examination. Currently available systems have contributed significantly to our understanding of the pathophysiology and treatment of various retinal diseases. Future advances promise near histologic resolution of retinal structures as well as real-time image manipulation and instantaneous transmission world-wide.

Thérapie photodynamique et DMLA : arguments pratiques sur la base de cas cliniques pour retraiter ou surveiller lors du suivi

Clinical and angiographic progression after photodynamic therapy (PDT) is usually slow, sometimes fluctuating and therefore difficult to evaluate. After several sessions of PDT, angiographic follow-up remains the basis for therapeutic management involving either a new PDT session or an alternative treatment. It remains difficult, however, to evaluate the activity and progression potential of the remaining neovessels. Imaging (angiography, optical coherence tomography) and functional data both contribute to the therapeutic decision. Certain patients require several sessions for a progressive reduction of the exudation. For others, the persistence of metamorphopsias and accentuation of the scotoma despite the treatment may entail alternative treatment. Thus, a perifoveal photocoagulation can be proposed to limit the extension of the scotoma if after a reasonable number of sessions, central visual acuity is not recovered; direct photocoagulation of a persistent active neovascular contingent, distant from the fixation zone (foveal or exenterated) can be proposed if it remains on the border of a stabilized lesion; the treatment of a feeder vessel can be proposed if it becomes visible and is associated with active neovessels with a persistent central serous detachment of the neuroretina. Lastly, performance status and patient wishes are important elements in the overall therapeutic project, especially if the eye involved is the second eye, in view of quickly initiating low-vision rehabilitation.

Current and Future Treatment Options for Nonexudative and Exudative Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is the leading cause of irreversible visual loss in the industrialised world. Although relatively simple to diagnose through direct visualisation augmented with rapid sequence fluorescein angiography, treatment has presented a far greater challenge because the true aetiology of AMD is largely unknown. Within the past decade, researchers have introduced many new, potentially promising treatment and prevention options in an attempt to minimise the damage imparted from AMD. They capitalise on many of the theoretical and known factors contributing to AMD progression. A high-dose of an orally administered combination of the antioxidants ascorbic acid (vitamin C), tocopherol (vitamin E) and beta-carotene, in addition to copper and zinc, is the only widely accepted preventive therapy. Thermal laser photocoagulation and verteporfin photodynamic therapy are the only standard treatment options available based on large scale, randomised, prospective, placebo-controlled trials; however, efficacy is limited and only a minority of patients who present with AMD are eligible for these treatments. Many other preventive and treatment options are in all phases of clinical studies and expected to change the entire approach to AMD management in the near future. For example, alternative antioxidants, drusen ablation, apheresis and HMG-CoA reductase inhibitors have shown promise in some studies by preventing or slowing the progression of certain forms of AMD. In addition, alternative photodynamic therapies, low-intensity laser, antiangiogenic medications, radiation treatment and surgery have demonstrated the ability, albeit to differing degrees, to inhibit or possibly even reverse the severe vision loss often associated with AMD characterised by choroidal neovascularisation.

Selective occlusion of subfoveal choroidal neovascularization in angioid streaks by using a new technique of ingrowth site treatment

PURPOSE

To evaluate the visual and angiographic effects, as well as optical coherence tomography (OCT) findings, after a new treatment-neovascular ingrowth-site photothrombosis-in patients with subfoveal choroidal neovascularization (CNV) secondary to angioid streaks.

DESIGN

Prospective noncomparative small case series.

PARTICIPANTS

Five eyes of 5 patients with angioid streaks in whom fluorescein and conventional indocyanine green (ICG) angiography clearly demonstrated distinct CNV vessels supplying the subfoveal neovascular complex.

INTERVENTION

All five eyes were submitted to ICG-mediated photothrombosis of the neovascular ingrowth site. This novel, laser/dye-mediated technique uses large-spot, lower-intensity 810-nm light for continuous application of laser energy to ICG concentrated in vascular lesions.

MAIN OUTCOME MEASURES

Visual outcome and the results of fluorescein angiography, ICG angiography, and OCT evaluation.

RESULTS

Fluorescein and conventional ICG angiography were sufficient to identify the CNV ingrowth site, which was juxtafoveal in 2 and extrafoveal in 3 of the 5 eyes in this series. Obliteration of the entire neovascular lesion was achieved in all patients within the first hour after ICG-mediated photothrombosis of the CNV ingrowth site. At 1 week, the mean change in best-corrected visual acuity from baseline was +3.2 (+/-1.4) lines. Twelve months after treatment, visual acuity improved by 3 or more lines in all patients, and decreased leakage of fluorescein from the CNV, as well as OCT evidence of reduced or resolved retinal edema, was seen at the last follow-up visit. Major complications, such as immediate severe visual loss and retinal vessel occlusion in the early posttreatment period, were not identified in the 5 patients submitted to the procedure.

CONCLUSIONS

Photothrombosis of the CNV ingrowth site by using lower-intensity light to direct laser energy continuously after IV ICG infusion is a safe and effective technique for rapid induction of CNV hypoperfusion in selected patients and is associated with considerable improvement in visual acuity and partial restoration of the retinal architecture up to 12 months after treatment.

Selective occlusion of subfoveal choroidal neovascularization in pathologic myopia using a new technique of ingrowth site treatment

PURPOSE

To evaluate the visual and angiographic effects as well as optical coherence tomography findings after a new technique of ingrowth site treatment of subfoveal choroidal neovascularization (CNV) secondary to pathologic myopia with the use of indocyanine green (ICG)-mediated photothrombosis.

DESIGN

Interventional, noncomparative case series.

METHOD

In the setting of a tertiary referral center, patients with pathologic myopia in whom fluorescein and conventional ICG angiography demonstrated distinct CNV vessels supplying the subfoveal neovascular complex were submitted to focal ingrowth site treatment using a new therapeutic modality termed ICG-mediated photothrombosis. Prospective evaluation including visual acuity assessment, fluorescein and ICG angiography, and optical coherence tomography (OCT) evaluation was performed at weeks 1, 12, 24, and 48 after treatment.

RESULTS

Six consecutive patients (six eyes) had treatment using a single session of ICG-mediated photothrombosis at the CNV ingrowth site. Obliteration of the entire neovascular complex was achieved immediately after treatment in all patients. At last follow-up, visual acuity improvement of 1 or more Early Treatment Diabetic Retinopathy Study lines was observed in five of six patients, and fluorescein angiography showed an absence (four eyes) or minimal leakage (two eyes) from CNV. Indocyanine green angiography demonstrated selective obliteration of the neovascular complex. Accordingly, reduction of retinal edema was observed in the OCT evaluation in all patients. There was no significant complication related to the procedure.

CONCLUSIONS

The use of lower irradiances of 810- nm continuous light application and intravenous ICG infusion for neovascular ingrowth site photothrombosis induced selective CNV hypoperfusion, as demonstrated by fluorescein and ICG angiography in patients with pathologic myopia. These findings were either consistent with the visual acuity improvement observed in five of six patients or with the partial restoration of the retinal architecture seen in OCT evaluation 12 months after treatment.

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.

Optimizing treatment of choroidal neovascularization feeder vessels associated with age-related macular degeneration

PURPOSE

To optimize the method of treating choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD).

DESIGN

Experimental study and interventional case series.

METHODS

The parameters associated with locating and then photocoagulating CNV feeder vessels were identified and optimized using published data and data derived from modeling the choroidal vasculature. Based on these optimized parameters, a prototype diagnostic/treatment system was designed that captures high-speed indocyanine green (ICG) angiogram images and facilitates analysis of the images by enhancing visualization of dye movement through CNV feeder vessels (FVs). The system also permits precise aiming and delivery of 810- nm wavelength photocoagulation laser energy to target FVs on a real-time ICG angiogram image of the choroidal vasculature. Target FVs are tracked by a joy-stick controlled laser aiming beam until an intravenously-injected high-concentration ICG dye bolus is observed to enter the target vessel, at which time the laser is fired. Proof of principle of the combined diagnosis/treatment system design for performing dye-enhanced photocoagulation (DEP) in the clinical setting and determination of the minimum DEP laser energy needed to close CNV FVs was made in 11 AMD patients requiring treatment of CNV, but for whom other treatment was not appropriate.

RESULTS

Using ICG-DEP, CNV feeder vessels were closed with single pulse laser energy, delivering as little as 0.6 to 1.8 J of energy to the fundus, producing no visible change in the fundus. Successful FV closure was usually indicated immediately by presence of incarcerated ICG dye in the vessel adjacent to the burn site. The prototype system proved relatively easy to operate. After acquiring and interpreting diagnostic angiograms and repositioning a patient in front of the device, feeder vessel DEP and treatment evaluation required 15 to 20 minutes.

CONCLUSIONS

Indocyanine green dye-enhanced photocoagulation of CNV feeder vessels, facilitated by use of a device that permits real-time visualization of the choroidal circulation while aiming the treatment laser beam, appears to minimize the amount of energy applied to the fundus and the volume of fundus tissue affected by treatment, compared with other treatment modalities. The combination diagnosis/treatment device should be useful in optimizing FV treatment and in refining and evaluating the efficacy of DEP in future clinical trials.

Clinical observations supporting a theoretical model of choriocapillaris blood flow in treatment of choroidal neovascularization associated with age-related macular degeneration

PURPOSE

To report clinical observations consistent with conclusions from a previous theoretical investigation indicating that photocoagulation of choroidal neovascularization (CNV) efferent vessels can be, in some instances, an effective treatment.

DESIGN

Interventional case series.

METHODS

In five eyes with age-related macular degeneration (five patients with mean age +/- SD of 65 +/- 11 years, range 55-79 years) requiring treatment of CNV. In each case, the appropriate treatment was location and photocoagulation of the CNV efferent vessels, since the afferent vessels were not identifiable or were located beneath the fovea. Targeted vessels were determined to be draining vessels by analysis of pretreatment high-speed indocyanine green (ICG) angiograms, and successful vessel closure by photocoagulation was demonstrated by posttreatment ICG angiograms. The eyes subsequently were followed from 2 to 12 months.

RESULTS

After photocoagulation of efferent vessels, CNV-related retinal edema was significantly reduced or resolved within 1 to 4 days. Visual acuity became stabilized in three eyes and improved in two eyes. In a few days, metamorphopsia disappeared in four of the eyes and was stable for a period longer than the duration of the associated efferent vessel closure. Initial efferent vessel closure by photocoagulation persisted on average for 7 to 15 days, after which additional treatment was required. It is significant that in no case did hemorrhage result from the photocoagulation treatment.

CONCLUSIONS

These observations are consistent with the earlier theoretical study prediction that photocoagulation of efferent CNV vessels can be effective in reducing CNV-associated edema. That no hemorrhage was induced by photocoagulation is consistent with the theoretical concept that there appears to be no direct hydrostatic connection between the CNV and its afferent vessels. Rather, that connection appears to be a functional one made through the choriocapillaris, which may dissipate excess CNV hydrostatic pressure produced by occlusion of a draining vessel. However, this finding is not intended to be a recommendation to attempt CNV efferent vessel photocoagulation.

Photodynamic therapy increases the eligibility for feeder vessel treatment of choroidal neovascularization caused by age-related macular degeneration

PURPOSE

To report angiographic observations about feeder vessel identification after photodynamic therapy in patients with choroidal neovascularization caused by age-related macular degeneration.

DESIGN

Cohort study.

METHODS

We analyzed fluorescein and indocyanine green dynamic angiography in 156 eyes of 145 patients before and after photodynamic therapy to identify the feeder vessels of the choroidal neovascular membrane.

RESULTS

Before photodynamic therapy one or more feeder vessel could be detected in 35 (22.4%) out of 156 eyes with choroidal neovascularization. Three months after photodynamic therapy, a feeder vessel could be identified in 112 (84.2%) out of 133 eyes with persistent choroidal neovascularization. Among these, 16 eyes received direct laser photocoagulation of the feeder vessel and did not need any further photodynamic therapy.

CONCLUSION

Previous photodynamic therapy improves the detection of the feeder vessel of the choroidal neovascularization. A sequential combined therapy (photodynamic and feeder vessel treatment) could be considered as an alternative to multiple photodynamic treatments.

Photodynamic therapy with verteporfin in mallatia leventinese

OBJECTIVE

To describe a case of a patient with documented genetic mallatia leventinese who developed a classic choroidal neovascular membrane and underwent photodynamic therapy (PDT) with verteporfin (Visudyne; CIBA Vision Corp., Duluth, GA).

DESIGN

Interventional case report.

INTERVENTION

The patient underwent a complete ophthalmologic evaluation and fluorescein angiography. Photodynamic therapy with verteporfin was performed.

MAIN OUTCOME MEASURES

Clinical and angiographic records were analyzed for evidence of changes in visual acuity, clinically evident subretinal fluid and the extent of fluorescein leakage from choroidal neovascularization (CNV).

RESULTS

Three weeks after treatment, a fluorescein angiogram showed closure of the neovascular membrane, no evident subretinal fluid was seen, and visual acuity had improved from 20/60- to 20/40. Nine weeks after the application, fluorescein angiography demonstrated a microscopic hyperfluorescent spot at the site of the previously active CNV at which a small area of shallow subretinal fluid was observed, and visual acuity was 20/50. Thirty-four weeks after PDT, visual acuity was 20/60, subretinal fluid resolved, and fluorescein angiography did not show any further changes.

CONCLUSIONS

Photodynamic therapy with verteporfin may be considered as a possible treatment in patients with mallatia leventinese who develop classic CNV.

Theoretical investigation of the role of choriocapillaris blood flow in treatment of subfoveal choroidal neovascularization associated with age-related macular degeneration

PURPOSE

To investigate the relationship between choriocapillaris blood flow and blood flow through an overlying choroidal neovascularization, as it relates to photocoagulation-induced changes in the choriocapillaris circulation.

METHODS

A theoretical model that simulates the blood flow in the choriocapillaris and choroidal neovascularization of the human eye was developed, based on histologically determined vascular geometry and experimentally measured blood pressure gradients. The choriocapillaris blood pressure and blood flow were examined before and after simulated photocoagulation of various Sattler layer vessels entering the choriocapillaris in the vicinity of the choroidal neovascularization. (The Sattler layer is the inner layer of medium-sized choroidal vessels that includes both arterioles and venules that supply the choriocapillaris.)

RESULTS

The theoretical model showed that both partial and complete occlusion of either Sattler arteriole or venous vessels in the vicinity of the capillary-like vessels connecting a choroidal neovascularization to the underlying choriocapillaris results in significant choroidal neovascularization blood flow reduction. These theoretical results are similar to clinically observed changes induced by laser photocoagulation of feeder vessels. (In this discussion, the term "feeder vessels" refers to those vessels in an indocyanine green angiogram image that appear to supply blood to a choroidal neovascularization; these vessels appear to be Sattler layer vessels, rather than the histologically demonstrated short, capillary-like vessels that form choriocapillaris-choroidal neovascularization communications.)

CONCLUSIONS

Reduction of choriocapillaris blood flow underlying a choroidal neovascularization may be sufficient to reduce the blood flow rate in the choroidal neovascularization and thereby reduce the associated retinal edema. The results also suggest that reduction of choriocapillaris blood flow may be the common hemodynamic event associated with the successful application of several currently practiced methods of choroidal neovascularization treatment, including feeder vessel photocoagulation, photodynamic therapy, transpupillary thermotherapy, and prophylactic drusen photocoagulation. Ultimately, this model may be useful in determining optimal placement of laser photocoagulation burns to achieve a desirable perturbation in choroidal blood flow distribution and thereby reduce choroidal neovascularization blood flow to the extent necessary to obliterate associated retinal edema.

Scleral outfolding for macular translocation

PURPOSE

To report experimental study and clinical observation of scleral outfolding for macular translocation.

METHODS

In six human cadaver eyes, circumferential mattress sutures to create sclera infoldings were compared with radial-interrupted mattress sutures to create scleral outfoldings. In a 75-year-old man with macular degeneration and choroidal neovascular membrane, radial-interrupted mattress sutures were used for macular translocation.

RESULTS

In the human cadaver eyes, circumferential mattress sutures for scleral infolding created an average decrease in corresponding internal anteroposterior retinal contour of 0.36 mm. Radial-interrupted mattress sutures for scleral outfoldings created an average decrease in the corresponding internal anteroposterior retinal contour of 4. 61 mm. The statistical significance of the difference between infoldings of the sclera versus outfoldings of the sclera had a P value of.0001.

CONCLUSIONS

Initial experimental and clinical study suggests that radial-interrupted mattress sutures may generate more shortening of the internal scleral surface and greater macular translocation than circumferential mattress sutures. Additional studies are needed to evaluate the long-term effects of radial-interrupted mattress sutures and macular translocation for treatment of subfoveal choroidal neovascularization secondary to age-related macular degeneration.

Experimental studies of indocyanine green dye-enhanced photocoagulation of choroidal neovascularization feeder vessels

PURPOSE

To report a model of choroidal neovascularization feeder vessels that reconciles current histologic, angiographic, and clinical data, and to report experimental studies that investigate the potential of indocyanine-green-dye-enhanced photocoagulation to improve feeder-vessel treatment.

METHODS

A model of choroidal neovascularization feeder vessels was conceived to account for current histologic and angiographic data. Based on that model, experimental studies of the efficacy of indocyanine green-dye-enhanced photocoagulation were performed, using pigmented rabbit eyes as a model system. A Zeiss fundus camera was modified to permit visualization of choroidal blood flow by high-speed indocyanine green angiography and to permit simultaneous delivery of 810-nm-wavelength diode laser photocoagulation pulses to specific choroidal vascular targets during indocyanine green-dye bolus transit.

RESULTS

Choroidal neovascularization feeder vessels appear to originate in the Sattler layer (that is, that portion of the choroidal vasculature consisting of medium-diameter vessels) and enter the choriocapillaris in close proximity to the small capillary-like vessels that penetrate Bruch membrane and communicate with the choroidal neovascularization. The rabbit eye experiments demonstrated that the presence of high indocyanine green dye concentration in circulating blood enhances uptake of near-infrared laser energy (three eyes); injection of sequential indocyanine green dye boluses results in gradually decreased efficiency of dye-enhanced photocoagulation (two eyes); and by application of laser energy during the initial transit of small-volume, high-concentration indocyanine green dye boluses, dye-enhanced photocoagulation of large diameter choroidal arteries can be accomplished with relatively little concomitant retinal tissue damage (three eyes).

CONCLUSIONS

Although future trials will be necessary to substantiate these initial findings in the clinical arena, it appears that the efficiency of choroidal neovascularization feeder-vessel photocoagulation may be enhanced, while minimizing concomitant damage to overlying retinal tissue, by delivery of 810-nm wavelength laser energy immediately upon arrival of a high-concentration indocyanine green dye bolus in a targeted feeder vessel. However, molecules of dye adhering to vessel walls or lying in tissue interstitial spaces appear to divert laser energy from the photocoagulation process, so efficiency of indocyanine green dye-enhanced photocoagulation gradually diminishes as the number of injected dye boluses increases.

Identification of ingrowth site of idiopathic subfoveal choroidal neovascularization by indocyanine green angiography

PURPOSE

This study aimed to determine whether indocyanine green (ICG) angiography is useful to identify the ingrowth site of idiopathic choroidal neovascularization (CNV), which can predict visual outcomes after surgical removal of idiopathic CNV.

DESIGN

Consecutive, observational case series.

PARTICIPANTS

Twenty-six patients with idiopathic subfoveal CNV, of whom six underwent submacular surgery.

INTERVENTION

Indocyanine green videoangiography with a scanning laser ophthalmoscope.

MAIN OUTCOME MEASURES

We studied ICG videoangiographic images of choroidal neovascular membranes from the early phase to the late phase with special attention to abnormal findings, which can indicate the ingrowth site of CNV.

RESULTS

Early ICG angiography demonstrated distinct neovascular vessels in 24 of the 26 patients (92%). Hypofluorescent rims continuously or intermittently surrounded neovascular membranes on late ICG angiograms in 21 of the 26 patients (81%). In 22 of the 26 patients (85%), ICG angiography demonstrated hypofluorescent areas within the CNV. These hypofluorescent areas frequently became ring shaped in the middle to late phase of the ICG angiography. In 14 of 16 patients (88%) with CNV larger than half a disc area, the filling of neovascular vessels appeared from the inside of the hypofluorescent areas and branched out toward the surrounding hyperfluorescent membrane in the early phase. In all six patients who underwent surgical removal of CNV, ICG videoangiography showed these hypofluorescent areas from which neovascular vessels emanated. Three of the four surgical patients, in whom hypofluorescent areas or central fluorescent areas surrounded by ring-shaped hypofluorescence were extrafoveal or juxtafoveal, had a best postoperative visual acuity of 20/60 or better. In contrast, both surgical patients with subfoveal hypofluorescent areas had a best postoperative visual acuity of 20/70 or worse.

CONCLUSIONS

Although further observations are needed, ICG angiography may be a useful adjunct in the identification of the ingrowth site of idiopathic CNV, which can predict visual outcomes after surgery.

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.

Indocyanine green angiography and retinal sensitivity after photodynamic therapy of subfoveal choroidal neovascularization

Photodynamic therapy (PDT) is currently being evaluated in clinical trials for the treatment of choroidal neovascularization (CNV). Preliminary results indicate that PDT achieves immediate absence of leakage from CNV while maintaining visual acuity. Indocyanine green angiography reveals a reduction in CNV size and a persistent decrease in leakage activity after PDT. PDT appears to be characteristically accompanied by choroidal perfusion changes that regularly resolve within 3 months. Microperimetry shows an improvement of the central visual field with a decrease in scotoma size and intensity. Repeated PDT applications do not cause additional damage to the treated area, but might further enhance the recovery of macular function. A placebo-controlled, multi-center trial (TAP trial) evaluating the benefit of repeated PDT treatments in 3-month intervals is currently underway.

Choroidal abnormalities in Behçet disease observed by simultaneous indocyanine green and fluorescein angiography with scanning laser ophthalmoscopy

OBJECTIVE

To examine choroidopathy in patients with Behçet disease.

DESIGN

Prospective clinical study.

PARTICIPANTS

Thirty-three patients (63 eyes) with Behçet disease.

INTERVENTION

Patients underwent simultaneous indocyanine green (ICG) and fluorescein angiography with a double detector of scanning laser ophthalmoscopy.

MAIN OUTCOME MEASURES

Angiographic findings recorded on videotapes were evaluated. The relation of angiographic findings with systemic activity and aqueous inflammation was also analyzed.

RESULTS

Fluorescein angiography showed leakage in varying degrees from retinal vessels in 30 patients (53 eyes, 84%). The ICG angiographic findings were choroidal vascular wall staining in 16 eyes (25%), hyperfluorescent spots in 42 eyes (66%) and hypofluorescent plaques in 22 eyes (35%), both of which were not evident with fluorescein, leakage from choroidal vessels in 3 eyes (5%), and irregular filling of choriocapillaris in 11 eyes (17%). These findings did not have a statistically significant correlation with the presence or absence of aqueous inflammation or oral aphthous ulcerations.

CONCLUSIONS

The patients with Behçet disease showed choroidal abnormalities, which could be revealed only by ICG angiography, but not with funduscopy or fluorescein angiography. Simultaneous ICG and fluorescein angiography would be useful for examining choroidal lesions in Behçet disease.