Imaging of chorioretinal anastomoses in vascularized retinal pigment epithelium detachments

Retinal angiomatous proliferation: clinical characteristics and treatment options

BACKGROUND

A new form of exudative age-related macular degeneration (ARMD), retinal angiomatous proliferation (RAP), has been described in which neovascularization begins in the deep retina, extends through the subretinal space, and eventually communicates with choroidal neovascularization.

METHODS

Case series.

RESULTS

Common clinical features of RAP include small multiple intra-retinal hemorrhages, intra-retinal edema, vascularized pigment epithelial detachments (PEDs), and retinal choroidal anastomosis (RCA). Fluorescein angiography (FA) reveals ill-defined, occult choroidal neovascularization. Indocyanine green (ICG) angiography is useful in early stages because 'hot spots' can be detected before clinical or FA characteristics are present. Optical coherence tomography (OCT) is useful in illustrating some of the clinical and FA characteristics. The use of photodynamic therapy (POT), combined with intravitreal triamcinolone injection, was successful in stabilizing the RAP lesion in one case discussed in this report.

CONCLUSIONS

Retinal angiomatous proliferation is a newly recognized entity of exudative age-related macular degeneration with its own set of clinical, FA, ICG angiography, and OCT features. Experimental treatments such as the use of PDT combined with intravitreal triamcinolone injection demonstrate potential success with this entity. The biggest hope appears to be anti-angiogenic factors currently in clinical trials for the treatment of exudative ARMD.

Photodynamic therapy for age-related macular degeneration in a clinical setting: visual results and angiographic patterns

PURPOSE

To evaluate the visual outcome of patients with subfoveal choroidal neovascularization due to age-related macular degeneration, who received photodynamic therapy (PTD) in a clinical setting and to identify potential predictive visual and angiographic factors.

DESIGN

Interventional case series.

METHODS

The study included 74 patients with subfoveal choroidal neovascularization who underwent PDT from January 2000 to March 2001 and completed at least 1 year follow-up. All patients received verteporfin PDT and were followed clinically, with fluorescein angiography (74 eyes), and with indocyanine green angiography (65 eyes). A review of the medical records and angiograms was performed.

RESULTS

Mean follow-up was 15.6 months. Patients received a mean of 3.4 treatments per year. Sixty-six percent lost less than 3 Snellen lines of visual acuity. Three patients (4%) experienced profound visual acuity loss to finger counting. Final visual acuity was positively correlated with lesion size and visual acuity at presentation. Visual outcome was worse in the presence of cystoid macular edema. On indocyanine green angiography, a round hypofluorescent spot was seen at the site of the PDT, with maintenance of medium and large choroidal vessels.

CONCLUSION

Smaller lesion size and better visual acuity at presentation were good predictive signs, whereas cystoid macular edema was found to be a poor prognostic sign for visual outcome following PDT.

Focal Inner Retinal Hemorrhages in Patients with Drusen

PURPOSE

To present evidence that superficial retinal hemorrhage in the macula of patients with age-related macular degeneration (ARMD) may be an early sign of occult chorioretinal anastomosis (OCRA) and type 1 occult choroidal neovascularization (OCNV).

METHODS

Retrospective follow-up study of 16 patients presenting with a small focal area of superficial retinal hemorrhages and drusen in the juxtafoveolar area in 24 eyes.

RESULTS

OCRA and OCNV occurred in an older subset of patients with ARMD (mean age, 75 years). Of 22 eyes with the early stages of chorioretinal anastomosis (CRA), 18 had evidence of a piggyback neovascular complex, with the smaller subsensory retinal type 2 complex lying anterior to the larger subretinal pigment epithelial type 1 complex. At initial presentation, three patients had OCRA and OCNV bilaterally, and three patients had large disciform cicatricial lesions with overt CRA in the fellow eye. Nine patients had one or more laser photocoagulation treatments for early stages of CRA. Only one patient maintained visual acuity of better than 20/200 for >1 year. At the last follow-up, 24 of 26 eyes with CRA had visual acuity of 20/200 or less.

CONCLUSION

Superficial retinal hemorrhage in the paracentral area of patients with drusen is the earliest sign of OCRA and OCNV. Fluorescein angiography and indocyanine green angiography are important in detecting the dual nature of the subretinal neovascular network. Photocoagulation and photodynamic treatment is usually unsuccessful in preserving central vision.

Age-related macular degeneration: etiology, pathogenesis, and therapeutic strategies

Age-related macular degeneration is the principal cause of registered legal blindness among those aged over 65 in the United States, western Europe, Australia, and Japan. Despite intensive research, the precise etiology of molecular events that underlie age-related macular degeneration is poorly understood. However, investigations on parallel fronts are addressing this prevalent public health problem. Sophisticated biochemical and biophysical techniques have refined our understanding of the pathobiology of drusen, geographic atrophy, and retinal pigment epithelial detachments. Epidemiological identification of risk factors has facilitated an intelligent search for underlying mechanisms and fueled clinical investigation of behavior modification. Gene searches have not only brought us to the cusp of identifying the culpable gene loci in age-related macular degeneration, but also localized genes responsible for other macular dystrophies. Recent and ongoing investigations, often cued by tumor biology, have revealed an important role for various growth factors, particularly in the neovascular form of the condition. Transgenic and knockout studies have provided important mechanistic insights into the development of choroidal neovascularization, the principal cause of vision loss in age-related macular degeneration. This in turn has culminated in preclinical and clinical trials of directed molecular interventions.

Fundus autofluorescence and age-related macular degeneration

PURPOSE

To evaluate the autofluorescence images of patients with nonexudative and the fellow eyes with exudative age-related macular degeneration (AMD).

DESIGN

Observational case series.

PARTICIPANTS

Fifty-four patients seen in the author's practice.

METHODS

A fundus camera-based system for autofluorescence photographs was used, and the wavelengths for the excitation (580 nm) and barrier (695 nm) filters were based on known transmission and autofluorescent characteristics of the ocular media. Patients were also photographed with red-free and infrared monochromatic imaging. The mean levels of autofluorescence were compared between patients without (group 1) and those with exudative AMD. Comparisons were made among patients with exudative AMD, examining the autofluorescence pattern in those without retinal vascular contribution to the exudative process (group 2) to those with retinal vascular contribution (group 3).

MAIN OUTCOME MEASURES

Mean amounts and patterns of autofluorescence.

RESULTS

A total of 54 patients was evaluated; 18 were in each group. The mean age was 75.4 years, and there was no difference in the mean ages among the groups (P = 0.16). There was no correlation of the autofluorescence measurements and the degree of nuclear sclerosis (P = 0.14). Patients with exudative AMD had more autofluorescence in the fellow eye than did eyes of patients without exudative AMD (P = 0.002). Patients in group 3 were more likely to have focal hyperpigmentation, particularly as imaged by infrared light (P = 0.015), and focal areas of intense autofluorescence (P = 0.001) than were patients in group 2.

CONCLUSIONS

By use of this method of autofluorescence imaging, it was determined that the fellow eyes of patients with exudative AMD had larger amounts of autofluorescence than did the eyes of patients without a history of exudative AMD. Patients with retinal vascular anastomosis to the vascular proliferation of exudative AMD were much more likely to have focal areas of intense autofluorescence in their fellow eye that corresponded, for the most part, with focal areas of hyperpigmentation best seen by infrared monochromatic fundus photography. Because the amount of fluorescence is directly related to the amount of lipofuscin, which in turn is related to the cumulative amount of oxidative damage, these findings suggest possible explanations for certain patterns of vessel growth seen in exudative AMD.

The nature of focal areas of hyperfluorescence or hot spots imaged with indocyanine green angiography

PURPOSE

To clarify the frequency and nature of ICG angiographic "hot spots" seen in patients with neovascular age-related macular degeneration (ARMD).

METHODS

A consecutive series of newly diagnosed patients with neovascular ARMD and fluorescein angiographic evidence of occult choroidal neovascularization (occult CNV) was imaged with ICG angiography. Eyes with ICG angiographic "hot spots" were identified and further classified. A hot spot was defined as any area of abnormal hyperfluorescence, in the mid to late stages of ICG angiography, measuring less than 1 disk area in size.

RESULTS

From a total of 190 patients (220 eyes) with neovascular ARMD, 30 patients and 34 eyes (16%) with hot spots were identified. Hot spots were noted to be of three distinct patterns: polypoidal choroidal neovascularization (polypoidal CNV) in 21 of 34 eyes, or 62%; retinal angiomatous proliferation (RAP) in 11 of 34 eyes, or 30%; and focal occult CNV in 2 of 34 eyes, or 8%.

CONCLUSIONS

A focal area of intense hyperfluorescence or so-called hot spot seen on ICG angiography in neovascular ARMD is due to one of three possible forms of neovascularization: most frequently polypoidal CNV, less commonly RAP, and infrequently nonspecific, focal occult CNV. Since neovascular ARMD may be caused by different types of neovascularization, each with distinct clinical manifestations, natural course, visual prognosis, and response to treatment, it is important to identify the precise nature of hot spots to establish an accurate diagnosis and, when appropriate, a specific form of management.

Retinal angiopathy and polypoidal choroidal vasculopathy

PURPOSE

To describe the clinical and angiographic features of patients with polypoidal choroidal vasculopathy, exudative detachment of the macula, and an associated retinal microangiopathy.

METHODS

Case series.

RESULTS

Four patients with chronic exudative detachment of the macula with a variable degree of lipid deposition are described. The retina in the detached area, but not beyond, was noted to have a microangiopathy. There was capillary telangiectasia, microaneurysm formation, patchy nonperfusion, and intraretinal leakage. In each patient, there were no other retinal vascular changes in the fundus of either eye. The fluorescein angiogram showed subretinal leakage suspicious for occult choroidal neovascularization. The indocyanine green angiogram showed the presence of underlying polypoidal choroidal neovascularization, accounting for the exudative detachment. After photocoagulation, the retinal angiopathy improved, but not completely.

CONCLUSION

Retinal microangiopathy may occur in a chronic macular detachment secondary to polypoidal choroidal neovascularization. The development of these secondary retinal changes is not clearly understood; however, hypoxia from the chronic detachment, a neurotoxic effect from the lipid deposition, or a biochemically induced microvascular abnormality from secretion of vasogenic mediators are possible mechanisms. Indocyanine green angiography is helpful in making a definitive diagnosis. Clinicians should be aware that a retinal microangiopathy may occur in such eyes so that the proper diagnosis can be made and appropriate treatment administered.

Age-related macular degeneration: epidemiology and optimal treatment

Age-related macular degeneration (AMD) is a common macular disease affecting elderly people in the Western world. It is characterised by the appearance of drusen in the macula, accompanied by choroidal neovascularisation (CNV) or geographic atrophy. The disease is more common in Caucasian individuals than in pigmented races. In predominantly Caucasian populations, the age-standardised prevalence of AMD in at least one eye is 7760 cases per million. The age-standardised cumulated 1-year incidence of AMD in at least one eye is 1051 cases per million individuals. AMD is the most important single cause of blindness among Caucasian individuals in developed countries. Blindness resulting from AMD rarely occurs before age 70, and most cases occur after age 80. The age-standardised 1-year incidence of legal blindness resulting from AMD is 212 cases per million. Two-thirds of AMD cases have CNV (exudative cases); the remainder has only geographic atrophy. In cross-sectional population-based studies about 45% of eyes with AMD have visual acuity reduced to 20/200 or worse. This is true both for exudative AMD and pure geographic atrophy. Age and genetic predisposition are known risk factors for AMD. Smoking is probably also a risk factor. Preventive strategies using macular laser photocoagulation are under investigation, but their efficacy in preventing visual loss is as yet unproven. There is no treatment with proven efficacy for geographic atrophy. Optimal treatment for exudative AMD requires a fluorescein angiographic study and a physician capable of interpreting it. For CNV not involving the foveal centre, the only evidence-based treatment is laser photocoagulation. For AMD cases with subfoveal CNV, good visual acuity, and predominantly classic fluorescence pattern on fluorescein angiography, photodynamic therapy with verteporfin is the treatment of choice. Photodynamic therapy is also effective in eyes with pure occult CNV and evidence of recent disease progression. For new subfoveal CNV with poor vision and recurrent CNV, laser photocoagulation can be considered.

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.

Retinal angiomatous proliferation in age-related macular degeneration

BACKGROUND

It is known that choroidal neovascularization (CNV) in age-related macular degeneration (ARMD) may erode through the retinal pigment epithelium, infiltrate the neurosensory retina, and communicate with the retinal circulation in what has been referred to as a retinal-choroidal anastomosis (RCA). This is extremely common in the end stage of disciform disease. In recent years, the reverse also seems to be possible, as angiomatous proliferation originates from the retina and extends posteriorly into the subretinal space, eventually communicating in some cases with choroidal new vessels. This form of neovascular ARMD, termed retinal angiomatous proliferation (RAP) in this article, can be confused with CNV.

PURPOSE

The purpose of this article is 1) to review the clinical and angiographic characteristics of a series of patients with RAP and 2) to propose a theoretical sequence of events that accounts for the neovascularized process.

METHODS

In this retrospective clinical and angiographic analysis, 143 eyes with RAP (108 patients) were reviewed and classified based on their vasogenic nature and course. Clinical biomicroscopic examination, fluorescein angiography, and indocyanine green angiography were used to evaluate patients.

RESULTS

The results of this series suggest that angiomatous proliferation within the retina is the first manifestation of the vasogenic process in this form of neovascular ARMD. Dilated retinal vessels and pre-, intra-, and subretinal hemorrhages and exudate evolve, surrounding the angiomatous proliferation as the process extends into the deep retina and subretinal space. One or more dilated compensatory retinal vessels perfuse and drain the neovascularization, sometimes forming a retinal-retinal anastomosis. Fluorescein angiography in these patients usually revealed indistinct staining simulating occult CNV. Indocyanine green angiography was useful to make an accurate diagnosis in most cases. It revealed a focal area of intense hyperfluorescence corresponding to the neovascularization ("hot spot") and other characteristic findings. Based on understanding of the nature and progression of the neovascularized process, patients with RAP were classified into three vasogenic stages. Stage I involved proliferation of intraretinal capillaries originating from the deep retinal complex (intraretinal neovascularization [IRN]). Stage II was determined by growth of the retinal vessels into the subretinal space (subretinal neovascularization [SRN]). Stage III occurred when CNV could clearly be determined clinically or angiographically. A vascularized pigment epithelial detachment and RCA were inconsistent features of this stage.

CONCLUSIONS

Retinal angiomatous proliferation appears to be a distinct subgroup of neovascular ARMD. It may present in one of three vasogenic stages: IRN, SRN, or CNV. Whereas ICG angiography is helpful in diagnosing RAP and in documenting the stage of the neovascularized process, it is frequently difficult to determine the precise nature and location of the new vessel formation. It is important for clinicians to recognize the vasogenic potential and the associated manifestations of this peculiar form of neovascular ARMD so that a proper diagnosis can be made, and when possible, an appropriate management administered.

Clinicopathological correlation of retinal pigment epithelial tears in exudative age related macular degeneration: pretear, tear, and scarred tear

AIMS

To analyse the histopathology of vascularised pigment epithelial detachments and tears of the retinal pigment epithelium (RPE) in age related macular degeneration (AMD).

METHODS

The light microscopic architecture of 10 surgically removed subretinal specimens-three vascularised pigment epithelial detachments, four recent tears, and three scarred tears as a manifestation of AMD-were studied and correlated with the angiographic findings.

RESULTS

Recent tears: a large fibrovascular membrane was found to be originally situated in Bruch's membrane. About half of the surface of the fibrovascular tissue was denuded of RPE and diffuse drusen. The RPE and diffuse drusen had retracted and rolled up, covering a neighbouring part of the intra-Bruch's fibrovascular membrane. The rolled up RPE and diffuse drusen were not interspersed with fibrovascular tissue but lay superficial to the intra-Bruch's fibrovascular membrane itself. Scarred tears: a collagen capsule surrounded the rolled up diffuse drusen and RPE. Fibrovascular tissue was found inside the rolled up material, predominantly at its choroidal side.

CONCLUSION

The area of choroidal neovascularisation associated with a vascularised pigment epithelial detachment and a tear of the RPE may be larger than was hitherto thought or indicated by fluorescein angiography. This neovascular tissue may be present within the bed of the RPE tear, as well as at the site of the scrolled up RPE.

Diode laser photocoagulation of choroidal neovascularization associated with retinal pigment epithelial detachment

AIMS/BACKGROUND

Association of choroidal neovascularization with pigment epithelial detachment is not an uncommon feature. Since this condition usually has a poor visual outcome, new treatments should be developed.

METHODS

We studied the anatomical and visual results of 11 eyes with this association as a manifestation of an Exudative Age Related Macular Degeneration which were treated with diode laser photocoagulation guided by indocyanine green angiography. The average follow up time was 25.5 months (from 12 to 48 months).

RESULTS

Complete closure with complete resolution of the exudates and flattening of the detachment was observed in five eyes (45%). Visual acuity in the final examination improved or remained stable in 6 cases (55%).

CONCLUSION

These results indicate that diode laser photocoagulation guided by indocyanine green angiography is at least as effective as conventional lasers with shorter wavelengths for treatment of vascularized pigment epithelial detachments in Age Related Macular Degeneration.

Clinicopathological correlation of deep retinal vascular anomalous complex in age related macular degeneration

AIMS

To analyse the histopathology of "deep retinal vascular anomalous complex" or "chorioretinal anastomosis".

METHODS

Six patients with a deep retinal vascular anomalous complex (age range 66-88 years) had fundus photography and fluorescein angiography not more than 14 days before foveal translocation surgery. Four patients were also documented with indocyanine green angiography. The surgical specimens were serially sectioned and stained in a stepped fashion with Masson trichrome, periodic acid Schiff, and phosphotungstic acid haematoxylin, a histochemical stain for fibrin.

RESULTS

A subretinal fibrovascular membrane was surrounded by a rim consisting of diffuse drusen (basal laminar deposits), retinal pigment epithelium, and amorphous, fibrinous material interspersed with remains of outer segments in all specimens. In two specimens vascular structures were identified that left the specimen towards the retina. Amorphous material with the remains of outer segments was not found on the retinal side of the fibrovascular tissue itself but in four specimens a small neuroretinal portion (outer nuclear layer) was adherent to the complex. In three specimens a thin fibrocellular membrane was seen at the choroidal side of the diffuse drusen.

CONCLUSION

Deep retinal vascular anomalous complex represents histologically neovascularisation growing out of the neuroretina, into the subretinal space, which mimics choroidal neovascularisation. The term therefore appears rightly chosen.

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.

Spatial extent of pigment epithelial detachments in age-related macular degeneration

OBJECTIVE

To quantify the spatial extent of pigment epithelial detachment (PED) associated with age-related macular degeneration (AMD) using a rapid, noninvasive method.

DESIGN

Prospective, cross-sectional study.

PARTICIPANTS

The authors tested 32 eyes of 21 patients (13 women and 8 men) with AMD 56 to 91 years of age (mean = 72.8 years). The authors retested seven eyes of six patients.

INTERVENTION

Three-dimensional imaging and quantification of PED were performed in each subject using confocal infrared imaging (790 nm) with a Topographic Scanning System (TopSS). The data consisted of a series of 32 images within a 3-mm-depth range requiring 0.9 second. Three-dimensional calculations were made from the series.

MAIN OUTCOME MEASURE

Height, diameter, area, volume, and slope of each PED were obtained with two calculation methods. The Ellipse Method used a graphics tool to draw elliptical borders circumscribing the region of interest in the image. The software automatically calculated the values for all parameters for the region inside the ellipse, with the retinal reference plane adjusted to match the height of the surrounding retina. The User-Defined Region Method differed in that the region of interest was drawn manually.

RESULTS

PEDs were easily detected in all patients using the TopSS. Maximum height of all PEDs above the reference plane ranged from 0.204 to 1.818 mm (mean = 0.57 mm). The diameter was 0.501 to 5.151 mm (mean = 2.711 mm), area was 0.179 to 20.402 mm2 (mean = 6.585 mm2), and volume was 0.012 to 13.981 mm3 (mean = 2.173 mm3). Intraobserver variability was low, with correlations between first and second measurements for the first visit ranging from r = 0.906 to 0.997 for slope and diameter, respectively.

CONCLUSIONS

Three-dimensional analysis with the TopSS provides objective outcome measures not obtainable with typical clinical methods such as fundus photography and angiography. Height and volume are crucial in determining whether neovascularization is worsening or persistent after photocoagulation. More longitudinal data are needed to determine whether tomographic data reduce the need for angiography. Unique to scanning laser tomography, exudative features were imaged at different depths.

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.

Indocyanine green hyperfluorescence associated with serous retinal pigment epithelial detachment in age-related macular degeneration

PURPOSE

Indocyanine green (ICG) angiography may improve visualization of choroidal neovascularization (CNV) associated with serous retinal pigment epithelial detachment (RPED) in age-related macular degeneration (AMD). The features of ICG hyperfluorescence associated with serous RPED and therapeutic effect of ICG-directed laser photocoagulation in eyes with serous RPED is evaluated.

DESIGN

Retrospective review of all simultaneous fluorescein/ICG angiograms (n = 918) performed over an 18-month period to identify 44 eyes in 39 patients with serous RPED secondary to AMD on fluorescein angiography.

PARTICIPANTS

Thirty-nine patients with AMD, aged 53 to 89 years, participated.

INTERVENTION

Eyes were nonrandomly treated with ICG-directed laser photocoagulation or observation.

MAIN OUTCOME MEASURES

Characteristics of ICG hyperfluorescence associated with a serous RPED are reviewed. Final visual acuity and anatomic appearance of the serous RPED are given.

RESULTS

Twenty-three (52%) of the 44 eyes had an isolated serous RPED without obvious CNV, and 21 (48%) of the 44 eyes had a serous RPED associated with occult CNV on fluorescein angiography. Indocyanine green angiography demonstrated underlying CNV in 19 eyes (83%) with an isolated serous RPED and in all 21 eyes (100%) with serous RPED and occult CNV. The pattern of ICG hyperfluorescence revealed focal CNV in 15 eyes and plaque CNV in 4 eyes with an isolated serous RPED. In eyes with serous RPED and occult CNV, focal CNV and plaque CNV were noted with ICG in 8 and 13 eyes, respectively. No follow-up was available for two eyes. Twenty eyes were treated with ICG-directed laser photocoagulation. In these eyes, the visual acuity remained stable in 6 eyes (30%) and decreased in 14 eyes (70%). Twenty-two eyes were observed, and the visual acuity remained stable in 8 (36%), improved in 2 (9%), and decreased in 12 eyes (55%).

CONCLUSIONS

Although ICG angiography may enhance visualization of CNV associated with serous RPED in AMD, ICG-directed laser treatment did not appear to improve visual acuity when compared with observed eyes in this series.

Deep retinal vascular anomalous complexes in advanced age-related macular degeneration

PURPOSE

The authors describe the clinical characteristics of a group of patients with age-related macular degeneration (AMD), deep retinal vascular anomalous complexes (RVACs), advanced Bruch membrane changes, and severe visual loss. Based on clinical evaluation and imaging studies, the authors hypothesize the cause of such retinal vascular formations.

PATIENTS AND METHODS

The authors quantified an initial case series of 6 patients and expanded it to 11 patients (14 eyes) with AMD and RVACs diagnosed by fluorescein angiography or slit-lamp examination. Associated pigment epithelial detachments (PEDs) of 13 eyes are described. In addition to the clinical and fluorescein angiography descriptions, infrared imaging and indocyanine green angiography were used to characterize more recently described RVACs and fellow eyes.

RESULTS

Each study eye had a clearly defined anastomosis connecting the retinal circulation to a vascular complex in the deep retina. The RVACs associated with PEDs assumed a more central location than did typical choroidal neovascularization associated with PEDs. In seven eyes with RVACs, there were clinically recognizable retinovascular findings: intraretinal hemorrhages, telangiectasia, or microaneurysms. Legal blindness occurred in 9 of 11 patients.

CONCLUSION

These results indicate that retinovascular changes can be associated with nondisciform AMD. The authors speculate that neurodegenerative changes and hypoxia may lead to such changes, the RVAC being a more advanced finding. Closure of an RVAC with photocoagulation is difficult, perhaps because of its higher blood flow. The visual outcome is poor, not only because of the advanced state of the underlying AMD, but also because of the exudative nature of the RVAC.