Chieko Shiragami

Risk factors for diabetic choroidopathy in patients with diabetic retinopathy

AbstractPurpose. To identify risk factors for diabetic choroidopathy in patients with type 2 diabetes. Methods. Forty-five consecutive patients with diabetic retinopathy underwent simultaneous indocyanine green angiography (ICG) and fluorescein angiography using a double detector and confocal scanning laser ophthalmoscopy in both eyes. Choroidal vascular abnormalities were evaluated by comparing the angiographic findings derived from the two methods. We analyzed the association between the presence of abnormal choroidal lesions evident on ICG angiography and several risk factors. Results. Choroidal abnormalities evident on ICG angiography but not on fluorescein angiography included hypofluorescent spots in 72 eyes (80%) of 40 patients (89%), small hyperfluorescent spots in 61 eyes (68%) of 35 patients (78%), and large hyperfluorescent spots in 32 eyes (36%) of 21 patients (47%). The severity of diabetic retinopathy was significantly associated with the presence of hypofluorescent spots (P=0.002, Cochran–Armitage test) in both eyes and with the small hyperfluorescent spots in the right eyes (P=0.047, Cochran–Armitage test). Glycosylated hemoglobin levels were significantly associated with the large hyperfluorescent spots in the right eyes (P=0.003, Fishers exact probability test), and the treatment regimen was significantly associated with the small hyperfluorescent spots in the left eyes (P=0.048, chi-square test). Conclusion. These data suggest that risk factors influencing the prevalence of diabetic choroidopathy in patients with type 2 diabetes mellitus may include severity of diabetic retinopathy, degree of diabetic control and treatment regimen.

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.

Unintentional Displacement of the Retina after Standard Vitrectomy for Rhegmatogenous Retinal Detachment

OBJECTIVE To study unintentional displacement of the retina after standard vitrectomy for rhegmatogenous retinal detachment (RRD). DESIGN Prospective interventional case series. PARTICIPANTS Forty-three eyes of 43 consecutive patients with cystic RRD involving 1 or more quadrants underwent successful standard vitrectomy with 20% sulfur hexafluoride gas injection. Neither scleral buckling nor retinotomy was performed. METHODS Fundus autofluorescence (FAF) imaging was subsequently recorded to detect displacement of the retina using the Topcon TRC-50DX (Topcon, Tokyo, Japan) at 10 days and 1, 3, and 6 months postoperatively. Fluorescein angiography was also recorded using standard techniques for patients with abnormal FAF findings. Cyclotorsion and vertical deviation were measured postoperatively. MAIN OUTCOME MEASURES The proportion of eyes with postoperative retinal displacement detected by FAF imaging. RESULTS The mean age of these 43 patients was 60 years with a range of 39 to 77 years. Of the 43 eyes, retinal detachment involved 1 quadrant in 2 eyes, 2 quadrants in 31 eyes, 3 quadrants in 8 eyes, and 4 quadrants in 2 eyes. After complete reattachment of the retina, FAF photography demonstrated hyperfluorescent lines superiorly parallel to retinal vessels within the vascular arcade in 27 of the 43 eyes (62.8%). Fluorescein angiography did not demonstrate any abnormalities corresponding to the linear autofluorescence. This autofluorescence was hypothesized to originate from increased metabolic activity of the retinal pigment epithelium that had been preoperatively located under the major retinal vessels and was postoperatively exposed to light because of downward displacement of the retina. Of the 27 eyes with retinal displacement, 1 to 5 degrees of extorsion were seen in 16 eyes (59.3%), and 1 to 4 degrees of vertical deviation were seen in 13 eyes (48.1%). None of the 27 patients had diplopia or slant. The extent of retinal detachment (P = 0.019) and the macular status (on or off) (P = 0.016) were significantly associated with postoperative displacement of the retina. CONCLUSIONS In eyes with RRD treated with standard vitrectomy and gas injection, the retina may move downward after the surgery. If the extent of retinal detachment is large, or macular detachment is present, unintentional postoperative retinal translocation may easily occur. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

One-Year Results of Reduced-Fluence Photodynamic Therapy for Polypoidal Choroidal Vasculopathy

PURPOSE To report 1-year results of reduced-fluence photodynamic therapy (PDT) for polypoidal choroidal vasculopathy (PCV) in Japanese patients. DESIGN Prospective interventional case series. METHODS In the present study, 28 treatment-naïve eyes of 28 consecutive patients underwent PDT with a reduced laser fluence of 25 J/cm(2). Patients were followed up at baseline and 1 week and 3, 6, 9, and 12 months after PDT. Choroidal perfusion changes were evaluated by indocyanine green angiography (ICGA) and leakage from PCV lesions and exudative changes by fluorescein angiography and optical coherence tomography. Treatment safety was assessed according to visual acuity (VA) and adverse events. The best-corrected VA (BCVA) obtained by Landolt ring tests was converted into the logarithm of the minimal angle of resolution (logMAR). RESULTS At baseline, the mean logMAR BCVA was 0.45 (geometric mean: 7/20). At 12 months, the mean logMAR BCVA significantly improved to 0.29 (geometric mean: 10/20) (P = 0.0001). The logMAR BCVA was stable or improved by >or=0.2 in 26 eyes (93%) at 1-year follow-up. In 10 eyes with VA better than 20/40 at baseline, the mean logMAR BCVA was significantly improved compared with baseline at 12 months. Although 16 of 28 eyes (57%) showed mild to moderate nonperfusion of choriocapillaris in early ICGA at 1 week, 27 eyes (96%) showed recovery to pretreatment levels at 3 months. Mean number of treatment sessions during the 12 months was 1.3. No severe side effects related to treatment were encountered. CONCLUSIONS Reduced-fluence PDT is an effective treatment for PCV and could improve vision even in eyes with VA better than 20/40.

Recurrence after surgical ablation for retinal angiomatous proliferation.

Purpose: To report the frequency of recurrence of retinal angiomatous proliferation (RAP) lesions after surgical ablation. Methods: Seven eyes of seven consecutive patients with stage II RAP underwent surgical ablation of retinal feeder and draining vessels of RAP lesions. These eyes were examined with visual acuity testing, biomicroscopic slit-lamp fundus examination, fluorescein and indocyanine green angiographies, and optical coherence tomography before and after surgery. Results: Between 2 months and 13 months after surgical ablation, all 7 eyes (100%) had lesion recurrence with exudative and/or hemorrhagic manifestations such as macular edema, serous detachment of the sensory retina, or pigment epithelial detachment. Retinal feeding and draining vessels were recanalized (six eyes) or newly developed (one eye) in communication with recurrent intraretinal neovascularization. Conclusions: After surgical ablation for stage II RAP, all seven eyes had recurrence of the RAP lesions. This treatment may be ineffective for RAP. Further study of this surgical technique is necessary before recommending it for the treatment of RAP.

Relationship between progression of visual field damage and choroidal thickness in eyes with normal‐tension glaucoma

Background:  To measure choroidal thickness in normal eyes and in patients with normal‐tension glaucoma using enhanced depth imaging optical coherence tomography and evaluate the association between choroidal thickness and progression of visual field damage.

Transplanted and repopulated retinal pigment epithelial cells on damaged Bruch's membrane in rabbits

AIMS The authors studied how artificially damaged Bruch’s membrane influenced growth and differentiation of transplanted embryonic retinal pigment epithelial (RPE) cells and of host RPE cells in rabbits. METHODS Embryonic RPE cells obtained from pigmented rabbits were transplanted into the subretinal space of adult albino rabbits. The host RPE was removed with a silicone cannula, and Bruch’s membrane was damaged by scratching with a microhooked 27 gauge needle under the detached retina in closed vitrectomy. The transplantation sites were examined 3, 7, and 14 days after surgery by light and electron microscopy. RESULTS Varying degrees of damage in Bruch’s membrane were observed. Pigmented and hypopigmented RPE cells showed a normal polarity and tight junctions were seen at the sites of mild to moderate damage 3–7 days after the surgery. In contrast, fibroblast-like cells with no such features of RPE cells formed multiple layers at the sites of severe damage involving the full thickness of Bruch’s membrane and the choriocapillaris even 14 days after the surgery. Without transplantation, host RPE cells repopulated the damaged areas in the same way as transplanted RPE cells. CONCLUSIONS Transplanted embryonic RPE cells as well as host RPE cells grew and differentiated on the moderately damaged Bruch’s membrane, while the severely damaged Bruch’s membrane did not allow differentiation of RPE cells although these cells could grow and cover the damaged areas.

Comparison of Intravitreal Triamcinolone Acetonide With Photodynamic Therapy and Intravitreal Bevacizumab with Photodynamic Therapy for Retinal Angiomatous Proliferation

PURPOSE To compare the efficacy of combined therapy with intravitreal triamcinolone (IVTA) and photodynamic therapy (PDT; IVTA plus PDT) with intravitreal bevacizumab (IVB) and PDT (IVB plus PDT) for patients with retinal angiomatous proliferation (RAP). DESIGN Retrospective, observational case series. METHODS We retrospectively reviewed 25 treatment-naïve eyes of 22 Japanese patients (11 men, 11 women) with retinal angiomatous proliferation. Twelve eyes of 11 patients were treated with combined therapy of IVTA plus PDT from September 1, 2004, through July 31, 2006. Thirteen eyes of 11 patients were treated with combined therapy of IVB plus PDT from February 1, 2007, through January 31, 2008. RESULTS In 12 eyes treated with IVTA plus PDT, the mean best-corrected visual acuity (BCVA) levels at baseline and 12 months were 0.29 and 0.13, respectively. A significant (P < .05) decline in the mean BCVA from baseline was observed at 12 months. In 13 eyes treated with IVB plus PDT, the mean BCVA levels at baseline and 12 months were 0.25 and 0.37. A significant (P < .05) improvement in the mean BCVA from baseline was observed. At 12 months, the difference in BCVA between the 2 groups was significant (P < .05). The mean numbers of treatments at 12 months in the IVTA plus PDT group and the IVB plus PDT group were 2.7 and 1.6, respectively. The difference between the 2 treatments reached significance (P < .05). No complications developed. CONCLUSIONS Compared with IVTA plus PDT, IVB plus PDT was significantly more effective in maintaining and improving visual acuity and in reducing the number of treatment for patients with retinal angiomatous proliferation.

Morphologic and functional advantages of macular hole surgery with brilliant blue G-assisted internal limiting membrane peeling.

Morphologic and Functional Advantages of Macular Hole Surgery with Brilliant Blue G–Assisted Internal Limiting Membrane Peeling Removal of the internal limiting membrane (ILM) is an effective additional treatment in macular hole (MH) surgery. The transparency of the ILM requires high skill to peel the membrane. In 2000, a technique using indocyanine green (ICG) to stain and peel the ILM was reported. However, some investigators have reported retinal toxicity of the residual ICG. Other investigators have shown the toxicity of ICG to the retinal pigment epithelium in vitro and in vivo. These reports indicate that surgeons have to be very careful not to allow ICG to remain subretinally at the end of MH surgery because it can cause postoperative complications such as retinal pigment epithelial changes and subsequent visual field loss. In 2006, Enaida et al initially reported that brilliant blue G (BBG) stains the ILM while having low retinal toxicity in their morphologic study using electron microscopy. In rapid succession, they also reported the clinical possibility of using BBG for ILM staining and peeling in MH and epiretinal membrane cases with no adverse events. Compared with ICG, the toxicity of BBG to cultured retinal ganglion cells was significantly lower based on evaluation of retinal ganglion cell apoptosis. Ueno et al injected ICG and BBG in clinical concentrations into the subretinal space of rats. They found that ICG caused retinal degeneration and retinal pigment epithelium cell atrophy, while BBG had no detectable toxic effects. After confirmation of the safety of BBG, Cervera et al reported their experience with ILM peeling using BBG and concluded that dyeing with BBG appeared to be an interesting alternative to ICG. Much improvement in the resolution of optical coherence tomography has enabled us to observe microstructure of the macula in MHs before and after surgery. Recent studies have revealed the correlation between visual recovery and the presence of the inner and outer segments of the photoreceptor (IS/OS) junction after MH surgery. The IS/OS junction can be observed in the normal eye as the continuous line located in the outer retina. Another investigator has reported the importance of the external limiting membrane (ELM) compared with the IS/OS in visual recovery after MH surgery. Thus, continuity of the IS/OS junction and the ELM has been well known as an important factor for postoperative recovery of visual acuity. In the present study, the results, including macular microstructure and visual acuity, of MH surgery using BBG and ICG were compared.

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.