Maddalena Quaranta

Indocyanine Green Angiography of Drusen

PURPOSE To analyze the indocyanine green angiographic findings of drusen in the early stages of age-related macular degeneration. METHODS Sixty-nine eyes of 53 consecutive patients with drusen but without exudative complications of age-related macular degeneration were studied. Drusen were classified into four groups: hard drusen, drusen derived from clusters of hard drusen (hard cluster-derived drusen and soft cluster-derived drusen), membranous drusen, and regressing drusen. An additional category was constituted by reticular pseudodrusen that could be associated with drusen of either the inner or outer macula. Results of contact lens biomicroscopy and fluorescein angiography were compared with findings on indocyanine green angiography. RESULTS Hard drusen, either isolated hard drusen or hard cluster-derived drusen, were hyperfluorescent during indocyanine green angiography; in contrast, all sizes of soft drusen derived from clusters of hard drusen were hypofluorescent throughout the angiogram. Membranous drusen, visible on biomicroscopy and fluorescein angiography, were not visible during indocyanine green angiography. Regressing drusen may have showed hyperfluorescence at the early stages of indocyanine green angiography, but associated calcium and pigmentation were hypofluorescent. Reticular pseudodrusen were visible on red-free photographs; on midphase and late-phase indocyanine green angiography using the scanning laser ophthalmoscope only, reticular pseudodrusen were seen as a pattern of hypofluorescent dots. CONCLUSION The indocyanine green angiographic findings add to and support the clinicopathologic classification of drusen. Indocyanine green angiography may help to distinguish the different types of drusen and may thus be of use in evaluating the risk of progressive age-related macular degeneration in patients with drusen.

Exudative idiopathic polypoidal choroidal vasculopathy and photodynamic therapy with verteporfin

PURPOSE To report two cases of exudative idiopathic polypoidal choroidal vasculopathy treated by photodynamic therapy with verteporfin. DESIGN Interventional case reports. METHODS Two patients, a man aged 58 years and a woman aged 57 years, with recent visual impairment in the right eye (OD) (both eyes best-corrected visual acuity: 10/50 and Pelli-Robson contrast sensitivity 1.35 and 1.20) and angiographically proved subfoveal idiopathic polypoidal choroidal vasculopathy were treated with photodynamic therapy using verteporfin (Visudyne; Novartis SA, Rueil Malmaison, France). Functional and angiographic outcomes were assessed 6 weeks and 3, 6, and 12 months after treatment. RESULTS In Patient 1, 3 months after treatment, best-corrected visual acuity and contrast sensitivity improved (10/16 and 1.50) and then remained stable throughout the 12 months after treatment. In Patient 2, 6 weeks after treatment, vision and contrast sensitivity were 10/20 and 1.35; and at 3 months, were improved and stabilized at 10/12.5 and 1.50. Angiographically, photodynamic therapy with verteporfin was associated with nonperfusion and occlusion of the exudative polypoidal dilations. No acute recurrence was noted during the follow-up period. CONCLUSION In subfoveal exudative idiopathic polypoidal choroidal vasculopathy, photodynamic therapy with verteporfin may be associated with beneficial functional results.

Indocyanine Green Angiographic Features of Pathologic Myopia

PURPOSE To analyze indocyanine green angiographic findings of pathologic myopia and compare them with those of fluorescein angiography, with particular reference to the usefulness of indocyanine green angiography in the management of neovascular complications. METHODS Thirty-two consecutive patients (52 eyes) with pathologic myopia underwent a complete ophthalmologic examination including fluorescein and indocyanine green angiography. RESULTS Retrobulbar arteries and veins were visualized solely on indocyanine green angiography in 33 (63%) of 52 eyes. Choroidal arteries appeared attenuated and reduced in number. In the area of staphyloma, choroidal veins were less numerous, and in all eyes an absence of the normal choroidal flush caused by the choriocapillaris filling was observed. Subretinal and retinal hemorrhages were present in 28 (54%) of 52 eyes. Choroidal neovascularization was diagnosed in 16 eyes on fluorescein angiography and in 18 eyes on indocyanine green angiography. In seven eyes, indocyanine green angiography disclosed lacquer cracks (without choroidal neovascularization), appearing in the late phases as hypofluorescent lines, as the probable cause of the subretinal and retinal hemorrhages. In only one eye did indocyanine green angiography fail to disclose choroidal neovascularization detectable on fluorescein angiography. In two eyes, neither dye could clarify the origin of the hemorrhages. CONCLUSIONS Indocyanine green angiography allows identification of retrobulbar arteries and veins, and analysis of the altered choroidal vasculature. Moreover, indocyanine green angiography is a useful diagnostic tool to differentiate lacquer cracks from choroidal neovascularization in retinal and subretinal hemorrhages.

Multiple choroidal neovascularizations at the border of a myopic posterior macular staphyloma

Abstract · Background: In pathologic myopia, choroidal neovascularization (CNV) usually occurs in macular region and at the center of the macular staphyloma. CNV has been reported to occur at the borders of an inferior posterior staphyloma in the tilted disc syndrome. We present a case of multiple simultaneous CNVs located at the borders of a myopic macular staphyloma. · Methods: The clinical and angiographic records of a myopic patient who presented several areas of choroidal neovascularization were reviewed. · Results: On fundus examination, four gray lesions surrounded by subretinal hemorrhages and covered by a large serous retinal detachment were observed at the borders of a posterior staphyloma. Fluorescein angiography revealed that these four lesions were CNVs extending from the borders of the staphyloma to the macular region. As measured by B-scan ultrasonography, the staphyloma was 4 mm deep. · Conclusion: This case supports the hypothesis that the borders of staphylomas are sites at risk for the development of CNV in pathologic myopia.

Radiotherapy for isolated occult subfoveal neovascularisation in age related macular degeneration: a pilot study

BACKGROUND/AIMS Teletherapy has been proposed as a possible treatment for choroidal neovascular membranes (CNV), secondary to age related macular degeneration (AMD) not amenable to laser photocoagulation. The aim of this prospective study has been to investigate the effect of teletherapy on isolated occult choroidal neovascular membranes of subfoveal location. METHODS 28 AMD patients presenting with retrofoveal isolated occult CNV demonstrated by fluorescein angiography were treated by external beam radiation. A complete ophthalmological examination, fluorescein angiography, and indocyanine green angiography (ICG) were performed within 15 days before treatment and repeated at follow up. A total dose of 16 Gy was applied in four sessions of 4 Gy using a 4 MeV photon beam. Follow up ranged from 6 to 9 months (mean follow up 6.4 months). RESULTS Visual acuity was found to be stable in 68% of the cases. The decrease in visual acuity was of 3–6 lines in 18% and of more than 6 lines in 10% of the eyes at last examination. On fluorescein angiography the size of the lesion area was found to be stable in 67%, decreased in 13%, and increased in 20% of the cases. On ICG angiography the size of the CNV was stable in 93% and increased in 7% of the cases. All the eyes experiencing a visual acuity decrease showed either no change or an increase in size of the membrane on fluorescein angiography and/or on ICG. CONCLUSION According to this study with strict inclusion criteria, external beam radiotherapy seems to have a beneficial effect on the evolution of isolated occult subfoveal CNV.

Dietary, environmental, and genetic risk factors of Extensive Macular Atrophy with Pseudodrusen, a severe bilateral macular atrophy of middle-aged patients

EMAP (Extensive Macular Atrophy with Pseudodrusen) is a maculopathy we recently described that shares pseudodrusen and geographic atrophy with Age-related Macular Disease (AMD). EMAP differs from AMD by an earlier age of onset (50-55 years) and a characteristic natural history comprising a night blindness followed by a severe visual loss. In a prospective case-control study, ten referral centers included 115 EMAP (70 women, 45 men) patients and 345 matched controls to appraise dietary, environmental, and genetic risk factors. The incidence of EMAP (mean 2.95/1.106) was lower in Provence-Côte d’Azur with a Mediterranean diet (1.9/1.106), and higher in regions with intensive farming or industrialized activities (5 to 20/1.106). EMAP patients reported toxic exposure during professional activities (OR 2.29). The frequencies of common AMD complement factor risk alleles were comparable in EMAP. By contrast, only one EMAP patient had a rare AMD variant. This study suggests that EMAP could be a neurodegenerative disorder caused by lifelong toxic exposure and that it is associated with a chronic inflammation and abnormal complement pathway regulation. This leads to diffuse subretinal deposits with rod dysfunction and cone apoptosis around the age of 50 with characteristic extensive macular atrophy and paving stones in the far peripheral retina.

Isolated occult choroidal neovascularization: comparison between early and late phases of ICG angiography

Indocyanine (ICG) angiography is shown to be helpful in identifying choroidal new vessels when occult on fluorescein angiography1-5. Isolated occult choroidal neovascularization (CNV) or leakage of undetermined source (type II of the MPS classification) are not associated with serous haemorrhagic, or fibrovascular pigment epithelium detachment. On early phase ICG angiography, occult CNV may be converted into a well-defined net in about 40% of cases6,7. This conversion allows a good delination and definition of the limits of the neo vascular complex. This early net is more often identified using scanning laser ophthalmoscope technology while using infrared fundus cameras. The identification of isolated occult CNV is based on the visualization in the late phases of hyperfluorescent plaque with hyperfluorescence. The signification of this late staining plaque is still controversial.