Danielle L. Costa

Indocyanine green angiography-guided photodynamic therapy for treatment of chronic central serous chorioretinopathy: a pilot study.

BACKGROUND Most patients with central serous chorioretinopathy (CSC) have spontaneous resolution of exudative macular detachments and a good visual prognosis. Patients with CSC have a primary choroidal hyperpermeability problem evident as multifocal areas of hyperpermeability during indocyanine green (ICG) angiography. A small percentage of patients develop chronic or progressive disease with widespread decompensation of the retinal pigment epithelium and severe vision loss. There is no known treatment for this variant of the disorder. PURPOSE To study ICG-guided photodynamic therapy (PDT) with verteporfin as a potential treatment for patients with chronic CSC. METHODS Twenty eyes of 15 patients were studied with fluorescein angiography, optical coherence tomography, and ICG angiography to diagnose the maculopathy, monitor the detachments, and localize the choroidal hyperpermeability of the disorder. PDT with ICG guidance was applied to areas of choroidal hyperpermeability, and the patients were observed to determine the anatomic and functional outcomes. RESULTS Photodynamic therapy guided by ICG was associated with complete resolution of exudative macular detachments in 12 patients and incomplete resolution in the remaining eight eyes. The vision improved in six eyes and remained unchanged in 14 eyes during a mean follow-up of 6.8 months. Six weeks after treatment, the mean visual acuity improved by 0.55 lines, an amount that was marginally significant. There was a significant inverse correlation between the baseline visual acuity and the amount of improvement in acuity at 6 weeks. No patient had any treatment-related side effects. CONCLUSIONS Indocyanine green angiography-guided PDT with verteporfin seems to aid in the resolution of exudative detachments in patients with chronic CSC. This treatment was associated with a rapid reduction in subretinal fluid and improvement in visual acuity. Although the follow-up time and number of patients in this pilot study were limited, the encouraging results and lack of complications suggest that further study is indicated.

Multiple evanescent white dot syndrome in patients with multifocal choroiditis.

Background Controversy exists as to whether a common causal entity is responsible for multifocal choroiditis (MFC) and multiple evanescent white dot syndrome (MEWDS). It is commonly known that patients with MEWDS can later develop manifestations of MFC, but the reverse is rarely seen. Purpose To report cases of MEWDS in patients previously diagnosed with MFC. Design Retrospective case series. Participants Four female patients 29 to 34 years old. Methods The charts of four patients with acute unilateral onset of MEWDS and evidence of previous MFC were examined retrospectively. Main Outcome Measures Photographic and angiographic interpretation of fundus appearance. Results At the time of diagnosis with typical MEWDS, one patient had a documented previous episode of acute MFC; one patient had previous bilateral choroidal neovascularization associated with discrete, posterior atrophic scars; and two patients had peripheral discrete chorioretinal pigmented lesions and peripapillary atrophy. Conclusions MEWDS may occur after MFC. Now that both directions of disease progression, MFC to MEWDS and MEWDS to MFC, have been well documented, it is likely that there is a common host susceptibility between these two distinct clinical diseases, if not a common pathogenesis.

Photodynamic therapy and vitelliform lesions.

Purpose: To investigate the effect of photodynamic therapy (PDT) with verteporfin on patients with vitelliform lesions caused by cuticular drusen or adult-onset foveomacular vitelliform dystrophy (AOFVD). Design: Observational case series. Patients and Methods: Eight eyes of seven patients from two centers were examined prospectively. Each patient received PDT with verteporfin applied to the vitelliform lesions. Results: Photodynamic therapy did not significantly affect the median visual acuity outcome (20/50 before PDT and 20/66 after PDT) in all seven treated patients. Of note, however, were four eyes of four patients who experienced a severe decrease in visual acuity after PDT with verteporfin. The temporary relationship of the vision loss to the treatment suggests that this may represent an adverse effect from therapy. The fluorescein angiographic appearance was virtually unchanged in all treated patients, whereas indocyanine green angiography showed typical PDT-associated reduction of choroidal perfusion in the treatment area. Conclusion: Photodynamic therapy does not have a positive influence on the visual outcome in patients with vitelliform lesions and may have a negative impact on vision in some treated patients. It is important for physicians using PDT to exercise caution in distinguishing between choroidal neovascular membranes and vitelliform lesions because the outcome in this latter group may be worse with application of PDT than with the natural course.

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.

Retinal-choroidal indocyanine green dye clearance and liver dysfunction.

toms (mean, 18 months; range, 0–48 months). In fact, the authors go on to state that the finding of capillary nonperfusion along with exudative retinopathy are the “ two most visually threatening manifestations of this condition.” 5 Moreover, Gass7 describes capillary nonperfusion as one of the main features of this syndrome. We present an adult patient with IRVAN with unusual features. First, the patient is male, and 11 of the 16 previously described patients were female.1–6 Second, he is older, presenting first at 61 years of age, while the average age reported by Chang et al was 32 years. Third, he has had retention of good vision. Although most patients present with good vision, five of seven patients that were followed by Chang et al eventually lost vision in one or both eyes within an average of 3 years after the onset of symptoms. Lastly, although our patient’s symptoms have persisted for more than 4 years and while all other criteria for the diagnosis of IRVAN are present, he still does not have evidence of capillary nonperfusion. The most likely explanation for the lack of capillary nonperfusion is that the course of the disease in our patient is relatively early. However, compared to patients followed by Chang et al, patients with IRVAN usually manifest this feature of the disease by this time in the process. We believe that while patients with IRVAN suffer in part from a retinal microvascular disease process, similar to other clinical entities that progress to retinal neovascularization, such as diabetic retinopathy, some time is required before sufficient nonperfusion develops and leads to the onset of retinal neovascularization. Indeed, it is likely that the patient described herein will also develop such a problem in the future. Therefore, careful follow-up is still warranted. Nonetheless, the absence of capillary nonperfusion in an adult patient with IRVAN has not been previously reported and this case is unique in this regard.

Imaging the posterior segment in uveitis.

This article reviews established and newly developed posterior segment imaging techniques that may be helpful in the diagnosis and management of patients with uveitis. A brief description of various techniques is followed by a discussion of the situations in which these techniques might be useful in assessing the cause of vision loss, and the extent and activity of the inflammatory changes. The last section of the article describes selected uveitis syndromes wherein posterior segment imaging can reveal diagnostically characteristic, and in some instances pathognomonic, findings.

Multiplanar OCT/confocal ophthalmoscope in the clinic

This paper demonstrates the clinical application of a multiplanar imaging system, which simultaneously acquires en-face (C-scan) OCT and corresponding confocal ophthalmoscopic images along with cross-sectional (B-scan) OCT at cursor designated locations on the confocal image. Advantages of the simultaneous OCT/confocal acquisition as well as the challenges of interpreting the C-scan OCT images are discussed. Variations in tissue inclination with respect to th coherence wave surface alters the sampling of structures within the depth in the retina, producing novel slice orientations which are often challenging to interpret. We evaluate for the first time the utility of C-scan OCT for a variety of pathologies including exudative ARMD, macular hole, central serous retinopathy, diabetic retinopathy, polypoidal choroidal vasculopathy and macular pucker. Several remarkable observations of new aspects of clinical anatomy were noted. The versatility of selective capture of C-scan OCT images and B-scan OCT images at precise points on the confocal image affords the clinician a more complete and interactive tool for 3D imaging of retinal pathology.