Luigi Borgia

CENTRAL SEROUS CHORIORETINOPATHY AND INDOCYANINE GREEN ANGIOGRAPHY

Background: Because of limitations in imaging through the retinal pigment epithelium (RPE), fluorescein angiography has not been able to characterize the choroidal abnormalities that are thought to be causative factors in central serous chorioretinopathy (CSC). Methods: Digital indocyanine green (ICG) videoangiography and fluorescein angiography were performed in 34 consecutive patients with various forms of CSC to investigate choroidal abnormalities. Results: The ICG videoangiographic studies revealed choroidal staining in association with active, spontaneously resolved, and previously photocoagulated pigment epithelial leaks documented with fluorescein angiography. In the space of a few minutes, the dye progressively spread outward from the region of choroidal staining. Conclusion: Localized hyperpermeability of the choriocapillaris, probably associated with segmental choroidal hyperperfusion, may be a causative factor of characteristic RPE and neurosensory retinal exudative changes in CSC.

Indocyanine green angiographic findings in central serous chorioretinopathy

The purpose of this study is to better characterise, on the basis of a large number of cases and follow-up evaluations, choroidal abnormalities recently observed with indocyanine green (ICG) angiography in central serous chorioretinopathy (CSC). Digital ICG videoan-giography was performed in 145 patients with active or inactive, acute or chronic CSC. Forty-eight patients were re-examined in a follow-up period of 6-22 months (mean 10 months). Areas of choroidal leakage attributable to hyperpermeability of the choriocapillaris were found in 98.6% of patients in association with active or resolved pigment epithelial leaks and pigment epithelial detachments. Diffusion of ICG into the choroid was characterised by rapid centrifugal spreading of the dye with a wash-out pattern which was particularly evident in areas corresponding to pigment epithelial detachments. In patients with a long-standing disease, when choroidal hyperfluorescence faded, hypofluorescent spots became increasingly evident revealing pigment epithelial alterations not shown by fluorescein angiography. Areas of choroidal leakage remained unchanged in each patient during the followup period, even when subretinal exudation resolved either spontaneously or after photocoagulation. In 5 eyes we observed the appearance of leakage points on pre-existing areas of choroidal leakage. Zonal hyperpermeability of the choriocapillaris characterises all the evolutional stages of CSC and seems to be the primary alteration of this disease. When it corresponds to pigment epithelial detachments choriocapillaris hypermeability is probably associated with local hyperperfusion.

Indocyanine green angiography of circumscribed choroidal hemangiomas.

Background Indocyanine green (ICG) angiography performed with the modern high resolution digital systems already has improved our knowledge of several chorioretinal disorders. It could provide new information on circumscribed choroidal hemangiomas. Methods Twelve consecutive patients with circumscribed choroidal hemangioma underwent both fluorescein angiography and ICG angiography with a digital high resolution system. In each patient, two ICG angiograms were taken—with normal and with artificially increased intraocular pressure. The latter method allowed analysis of the vascular connections of the tumor with the adjacent choroid during the induced slowdown of blood flow. Results With ICG, the authors obtained a clear delineation of the choroidal hemangiomas. In all cases, the lesion was better defined on the ICG than on the fluorescein angiogram. Nutrient and draining vessels of the tumors were identified. Nutrient vessels were represented by short posterior ciliary arteries in five eyes with severe exudative syndrome, and by ramifications of choroidal arteries in the other cases. Further special ICG findings were apparent choroidal ischemia downstream from the tumor (9 eyes), and clearing of the dye with a “washout” phenomenon. Conclusion Indocyanine green angiography can be helpful in the clinical evaluation of circumscribed choroidal hemangiomas. The blood supply to these tumors is provided directly by short posterior ciliary arteries or by ramifications of choroidal arteries. An adjacent compromised choroidal perfusion may be present.

Intravitreal triamcinolone acetonide as primary treatment for diffuse diabetic macular edema: a prospective noncomparative interventional case series.

Purpose To evaluate the efficacy and safety of one intravitreal injection of 25 mg of triamcinolone acetonide as primary treatment for diffuse diabetic macular edema. Methods Intravitreal triamcinolone acetonide injection was performed in 30 eyes with previously untreated diabetic macular edema. The main outcome measures were logMAR visual acuity (VA) and central macular thickness (CMT) at 1, 3, and 6 months. A secondary outcome was intraocular pressure progression. Results Visual acuity results for 30 eyes that had a follow-up of at least 6 months are presented. Twenty of them were followed up to 10.1 ±2.38 months. Preoperatively, VA was 0.54±0.27. At 1, 3, and 6 months follow-up, VA was 0.44±0.29 (p=0.001), 0.43±0.28 (p=0.001), and 0.45±0.29 (p=0.006), respectively. Preoperatively, CMT was 417.3±143.5 μm. At 1, 3, and 6 months follow-up, CMT was 277.3 +74.0 μm (p<0.0001), 279.6±94.4 μm (p<0.0001), and 297.07±114.87 μm (p=0.002), respectively. For the 20 eyes with a follow-up of 10.1±2.38 months, VA was 0.5±0.25 and 0.50±0.32 at baseline and at the last follow-up visit, respectively (p>0.05). Preoperatively, intraocular pressue (IOP) was 15.13±1.48 mmHg. IOP was 18.26±2.71 mmHg, 20.07±4.27 mmHg, and 20.4±6.18 mmHg, at 1, 3, and 6 months, respectively (p<0.0001). Four eyes underwent uncomplicated filtrating surgery for intractable glaucoma. Conclusions Intravitreal triamcinolone as primary treatment effectively increases VA and reduces CMT due to diffuse diabetic macular edema. Longer follow-up and randomized clinical trial are war ranted. Safety results highlight the need to further study the relationship between triamcinolone and intraocular pressure.

Hyperautofluorescence in Outer Retinal Layers Thinning

Purpose. To evaluate if paracentral hyperautofluorescence (HAF) retinal regions, which can be occasionally found and analyzed by optical coherence tomography (OCT), were related to retinal layer changes and to detect which layer was involved. Methods. This is a cross-sectional and retrospective study. 648 OCT files were revised. OCTs that showed a paracentral HAF area by using the fundus autofluorescence imaging in Heidelberg Spectralis (Heidelberg Engineering, Germany) were selected. Then retinal layer morphology was analyzed observing OCT scans and a retinal thickness was measured. Results. 31 patients were selected: 20 patients had chronic serous epitheliopathy (CSE), 8 patients had resolved central serous chorioretinopathy (CSC), and 3 patients wet age related macular degeneration (ARMD). The HAF zones corresponded to areas of thickness reduction of the external hyporeflective band. In all these areas the retinal pigment epithelium was not atrophic and the neuroepithelium was more or less dystrophic. In particular the retinal thickness was 264 um, 232 um, and 243 um in wet ARMD, CSE, and CSC, respectively; the reduction was significant (P < 0.01) compared to the same area of the other eye. Discussion. The presence of HAF imaging might be mostly due to a “window effect” rather than an accumulation of lipofuscin.

Clinical assessment of retinal changes by spectral-domain OCT.

Purpose To evaluate optical coherence tomography changes in patients with retinal thinning at the posterior pole. Methods In this cross-sectional and retrospective study, 648 files were reviewed, and 67 patients were selected. Optical coherence tomography images that showed an area with a retinal thickness reduction at the macular region by using the Asymmetry Analysis Map in Heidelberg Spectralis were selected. The presence of hemisphere asymmetry in the same eye and asymmetry between the paired eyes were calculated and used for the analysis. Retinal thickness was measured in 3 different retinal areas (squares): (1) the area (square) involved by the pathology (IA), (2) the specular area (square) in the opposite hemifield (SA), and (3) the corresponding IA in the contralateral eye (CIA) (area used to recruit the patients). Retinal layer morphology was analyzed observing the Spectralis screen. Results The thickness of the IA was 235.54 ± 39.95 μm (mean ± standard deviation), while it was 269.84 ± 36.16 μm and 293.81 ± 37.52 μm for SA and CIA, respectively. Conclusions Different retinal layers could be involved in reduction of the retinal thickness: a reduction of the inner layers was related to disease in which ciliary or retinal arterial vessel flow was involved, while a reduction of the outer retinal layer was related to pathologies related to choroidal flow diseases.

Silent occult choroidal vascular abnormalities.

PURPOSE To describe clinically occult choroidal vascular abnormalities that can be revealed by indocyanine green (ICG) angiography. METHODS Out of approximately 2,700 patients who underwent ICG angiography, a lesion was incidentally observed in eight eyes of eight patients. In five patients, the ICG study included a second examination taken during artificially induced intraocular hypertension. Examinations were repeated in six patients over a follow-up period ranging from 4 months to 3 years. RESULTS On ICG angiogram, the choroidal vasculopathy appeared as a round-oval hyperfluorescent area 2-4 disk diameters in size that was located at the temporal vascular arcades in six eyes, at the inferomacular region in one eye, and above the optic disk in one eye. The lesions were not identifiable with funduscopic, fluorescein angiographic, or ultrasonographic examination. The lesions filled at the same time as the choroidal arteries and lost fluorescence in mid-late phase of the ICG angiogram. The ICG series taken during induced intraocular hypertension showed the hyperfluorescent areas originated from choroidal arterial abnormalities giving rise to confluent hyperfluorescent patches. Draining vessels connecting the choroidal vasculopathy with a vortex vein were evidenced in three eyes. A sector of apparent choroidal hypoperfusion downstream from the lesion was present in three eyes. During the follow-up period, the lesions remained occult and with an unchanged ICG angiographic pattern in all patients. CONCLUSION Some silent occult choroidal vascular abnormalities may be incidentally revealed by ICG angiography. These must be distinguished from ICG imaging of concomitant chorioretinal disorders.

Is Spectral-Domain Optical Coherence Tomography Always Able to Detect the Anti-Vascular Endothelial Growth Factor Action on Neovascular Membrane

Purpose: To show the presence of an active neovascular membrane in age-related macular degeneration even if optical coherence tomography (OCT) does not detect intra- or subretinal edema. Methods: This is a retrospective case report. During the follow-up after the intravitreal injection, 3 patients showed no intraretinal or subretinal edema by OCT; however, there was a progressive reduction in their visual acuity; thus, a fluorangiography (FA) examination was performed. Results: In these 3 cases, FA showed an active neovascular network. Conclusion: OCT could show a real reduction in the edema, but it is not always able to detect neovessel presence. Intravitreal injection could improve the vessel permeability without care and delete the neovascular network.

Follow-up evaluation of indocyanine green angiographic findings in central serous chorioretinopathy

Observations with indocyanine green (ICG) angiography by our group and other authors suggest a primary involvement of the choroid in central serous chorioretinopathy (CSC)1–3. The main result of our studies was the constant observation of areas of dye diffusion in the choroid in correspondence with the pigment epithelial alterations that characterize CSC3. We proposed zonal hyperpermeability of the choriocapillaris as the primary lesion in CSC, leading to degenerative alterations of the retinal pigment epithelium and passage of fluid in the subretinal space3.

Indocyanine green angiography of choroidal naevi and suspected melanomas

Current diagnosis of pigmented choroidal tumours is based on ophthalmoscopic evaluation, on standard fluorescein angiography and standardized A-scan echography1,2. Modern indocyanine green (ICG) angiography using high resolution digital imaging procedures, has to a great extent overcome the limits of fluorescein angiography in imaging of the choroidal vasculature3–7.