Takeya Kohno

Subtraction ICG angiography in Harada's disease.

BACKGROUND/AIM The significance of indocyanine green (ICG) angiography (ICGA) in Harada’s disease still awaits clarification in many respects. This study investigates the details of choroidal lesions observed in Harada’s disease by the subtraction method. METHODS Eight patients with Harada’s disease were followed with ICGA. ICG angiograms were obtained with a Topcon high resolution digital fundus camera and processed with a Topcon IMAGEnet computer system. Image subtraction was conducted for analysing serial angiograms taken at about 2 second intervals during the dye transit phase and those taken in the early and middle phases of angiography. RESULTS Standard ICG images of acute stage disease showed delayed choroidal filling in the early phase. Mid phase angiograms showed areas with bright fluorescence of variable intensity, indicating intrachoroidal ICG leakage. With image subtraction of angiograms with an interval of seconds the choroidal vessels could be imaged sequentially, with the choroidal arteries visualised first, followed by the definition of the choriocapillaris and then the choroidal veins. The choroidal veins with delayed filling were visualised as positive images in serial subtraction angiograms. Subtraction with an interval of minutes showed uneven background fluorescence and bright fluorescence corresponding to the areas of intrachoroidal ICG leakage. After the disease subsided with steroid therapy, angiography revealed an improvement in delayed choroidal filling. Image subtraction by the second allowed a clear visualisation of improved choroidal venous filling, while subtraction by the minute showed homogeneous background fluorescence, eliminating brighter areas. CONCLUSION Subtraction ICGA demonstrated that delayed filling of the choroidal veins of varying severity occurs in association with hyperpermeability of the choroidal vessels in the course of Harada’s disease.

Ultrasound biomicroscopic study of ciliary body changes in the post-treatment phase of Vogt-Koyanagi-Harada disease

Aims: To investigate the usefulness of ultrasound biomicroscopy for evaluating changes in the ciliary body in patients with Vogt-Koyanagi-Harada disease. Methods: Ultrasound biomicroscopy was used to evaluate 14 eyes of seven patients diagnosed with Vogt-Koyanagi-Harada disease. Cross sectional images of the ciliary body and thickness of the pars plana 3.0 mm posterior to the scleral spur were examined. Predicted thickness of the pars plana was obtained by multiple linear regression analysis of thickness in the acute phase and in the remission phase. Results: In the active phase, the cross sectional images showed a shallow anterior chamber in eight of the 14 eyes, ciliochoroidal detachment in five eyes, and a thickened ciliary body in all 14 eyes. Internal reflectivity of the ciliary stroma was low, with ciliary processes being unclear in 13 eyes. One month after steroid treatment, slit lamp examination findings were normal in 14 eyes. 10 eyes of five patients were examined by ultrasound biomicroscopy at this stage. Ciliochoroidal detachment was no longer seen in any eye. Internal reflection of the ciliary stroma became relatively homogeneous, and the ciliary processes were seen, though not clearly. However, the pars plana remained thickened. The actual thickness was greater at 1 month after steroid treatment than the predicted thickness for the remission phase. In the remission phase, the internal reflection was homogeneous and the ciliary processes were delineated clearly in all 14 eyes. Conclusion: Objective, quantitative evaluation of the ciliary body is possible with ultrasound biomicroscopy during the course of Vogt-Koyanagi-Harada disease. Ultrasound biomicroscopy is useful in determining disease activity in the anterior segment and in monitoring the clinical course, and it may improve evaluation of the efficacy of treatment.

Choroidopathy after blunt trauma to the eye: a fluorescein and indocyanine green angiographic study.

PURPOSE To describe the uses of fluorescein angiography and indocyanine green angiography in highlighting traumatic choroidopathy. METHODS In a prospective study, 21 patients (21 eyes) who presented with traumatic retinal opacity ophthalmoscopically underwent fluorescein angiography and indocyanine green angiography. With indocyanine green angiography, the subtraction method was used for detailed examination. RESULTS In 11 of 21 eyes, fluorescein angiography showed no abnormalities. On indocyanine green angiography, delayed filling in the choroid was found locally in nine of these 11 eyes. Delayed filling of the choroidal veins was clearly visualized by the subtraction method. In six eyes, intrachoroidal indocyanine green leakage around the choroidal vessels, including vortex veins, was found. In the remaining 10 of the 21 eyes, fluorescein angiography showed fluorescein leakage or a salt-and-pepper appearance in the region of retinal opacity. On indocyanine green angiography, a triangular-shaped area of delayed filling of the choroidal arteries was observed in four eyes. Delayed filling of the choroidal veins was visualized in all 10 eyes, intrachoroidal indocyanine green leakage was found in eight, and dilation and/or narrowing of the choroidal veins and changes in choroidal vasculature were visualized in five eyes. Furthermore, in regions with fluorescein leakage, indocyanine green leakage or hypofluorescence was observed, suggesting damage to the choriocapillaris. CONCLUSION Indocyanine green angiography allows the analysis of various degrees of choroidal vascular damage. Because the choroidal circulation nourishes the outer retinal layer, traumatic choroidopathy may play a role in the prognosis for visual recovery in eyes affected by contusion retinal opacities.

Fundus autofluorescence in patients with pseudoxanthoma elasticum.

Purpose: To characterize changes in fundus autofluorescence in patientswith pseudoxanthoma elasticum (PXE). Fundus autofluorescence intrinsicallyderives from lipofuscin, and the degree of autofluorescence is thought to indicatethe degree of retinal pigment epithelium (RPE) metabolic activity. Methods:Twelve eyes of 6 patients (2 men, 4 women) with PXE were studied with aconfocal scanning laser ophthalmoscope. Patient age ranged from 42 to 62years. The autofluorescence of abnormal retinal areas was compared digitallywith that of neighboring, presumed healthy control areas. When the averagegray level of a fundus region was 2 SDs above or below the average graylevel of a control area, autofluorescence of the fundus region was consideredabnormal. Results: In all 12 eyes, some segments of the angioid streaksshowed decreased fundus autofluorescence, and other segments of the streaksshowed normal autofluorescence. Areas of peripapillary chorioretinal atrophyseen in 2 eyes and of disciform scarring seen in 3 eyes showed decreasedautofluorescence. Solitary or multiple drusen-like spots showed increasedautofluorescence in all 12 eyes. Conclusion: Atrophic and degenerativeRPE regions showed decreased fundus autofluorescence in areas of chorioretinalatrophy and in some segments of the angioid streaks. Some drusen-like spotsshowed increased autofluorescence. The characteristic changes in autofluorescencethat we observed in PXE patients suggest that the content of the drusen-like substancediffers from that of senile drusen and that the drusen-like lesions are similar to thesub-RPE deposits seen in macular dystrophy.

Indocyanine green angiographic features of choroidal rupture and choroidal vascular injury after contusion ocular injury

PURPOSE To report features of choroidal rupture and choroidal vascular injury after contusion ocular injury on indocyanine green angiography. METHODS In a prospective study, nine patients (nine eyes) with choroidal rupture after ocular contusion underwent initial fluorescein angiography and indocyanine green angiography within 19 days after trauma. Eyes that had a distinct abnormality of the retinal pigment epithelium were excluded from this study. Subtraction indocyanine green angiography was also performed. Follow-up fluorescein angiographic and indocyanine green angiographic findings were also studied. RESULTS Initial ophthalmoscopic examination revealed subretinal hemorrhage in all nine eyes. In five of the nine eyes, choroidal rupture was not seen on initial ophthalmoscopic or fluorescein angiographic examination because it was hidden beneath the subretinal hemorrhage, but it was detected on subsequent examinations. In the remaining four eyes, choroidal rupture was observed by ophthalmoscopy at the time of initial examination, and these eyes exhibited hyperfluorescent streaks on fluorescein angiography in the region of the subretinal hemorrhage. On initial indocyanine green angiography of all nine eyes, observed hypofluorescent streaks became more obvious with time. For each eye, there were more hypofluorescent streaks on indocyanine green angiography than hyperfluorescent streaks on fluorescein angiography. In one eye, the location of indocyanine green leakage nearly coincided with the location of a hyperfluorescent streak on fluorescein angiography. In this case, crescentic streaks of hypofluorescence were seen on the temporal side of the subretinal hemorrhage on indocyanine green angiography, although choroidal rupture was not observed in that region by ophthalmoscopy or fluorescein angiography. In two of the nine eyes, indocyanine green angiography and the subtraction technique demonstrated disturbance of flow into choroidal vessels, especially at the choroidal rupture site. CONCLUSION After ocular contusion injury, various features of choroidal rupture and choroidal vascular injury were observed on indocyanine green angiography. This technique may contribute to the diagnosis of choroidal rupture and to the understanding of the clinical course after injury.

Computer assisted image analysis using the subtraction method in indocyanine green angiography

The choroidal vessels are three dimensionally distributed and very complex in their patterns. They often appear to be overlaid in indocyanine green (ICG) angiograms so it is harder to analyze ICG angiography than fluorescein angiography. When an earlier frame is subtracted from a later frame in a sequence of angiograms, the fluorescence which has increased during the time between the two frames can theoretically be demonstrated. We applied computer-assisted image subtraction methods in selected clinical cases of directly acquired digital ICG angiography to demonstrate how this method works. We used software already installed in an IMAGEnet computer system (Topcon) for image subtraction. We applied the subtraction technique in 18 cases with various diseases. When two images with a time difference of several seconds were subtracted, filling of the choriocapillaris, the neovascularization or the pathological vessels could be observed. When the images had a time difference of several minutes, intrachoroidal dye leakage could be seen more clearly. This method is very helpful for analyzing pathological changes in ICG angiography in clinical cases, when two images are selected appropriately.

Thinning and small holes at an impending tear of a retinal pigment epithelial detachment.

Abstract.Background: A tear of a retinal pigment epithelial detachment (PED) suddenly exposes a large area of bare Bruchs membrane. We report here the case of a patient whom we observed during the gradual, spontaneous development of a PED tear. Method: A 5.25-year case study of a 67-year-old woman with bilateral serous PEDs. Results: Retinal pigment epithelial (RPE) thinning or small holes were seen along the PED margin in both eyes. Fluorescein angiograms showed intense hyperfluorescence without leakage, and indocyanine green angiography showed choroidal vessels through regions of RPE thinning or small holes. Optical coherence tomographs showed an interruption of a hyperreflective band corresponding to retinal pigment epithelium. A typical tear of the PED ensued later. Conclusion: Multiple, small regions of RPE thinning or holes along the margin of PED can be a sign of an impending PED tear.

Age-related scattered hypofluorescent spots on late-phase indocyanine green angiograms

Purpose: Scattered hypofluorescent spots may be seen on indocyanine green (ICG) angiograms of regions that do not show abnormalities when viewed with an ophthalmoscope. Hypofluorescent spots are found in several pathologic conditions, typically in inflammatory diseases. In this report, we describe hypofluorescent spots in normal fundi and show that such spots can be age-related.Methods: Video-fundus camera ICG angiograms of 115 eyes of 109 patients aged 12 to 85 years with normal fundi or with only age-related maculopathy were reviewed. The relation between age and scattered hypofluorescent spots, and between age-related maculopathy and spots was examined utilising regression analysis.Results: Scattered hypofluorescent spots were seen throughout the posterior pole in 24 eyes of 23 patients and in a portion of the posterior pole in 30 eyes of 29 patients. The hypofluorescent spots were noted between 26 and 37 minutes after dye injection. Patient age ranged from 51 to 80 years, and regression analysis showed that the frequency of hypofluorescent spots increased significantly with aging (p < 0.05). However, age-related maculopathy did not show a significant relation to the spots.Conclusion: Scattered hypofluorescent spots seen in the posterior pole during the late-phase of ICG angiograms can apparently be due to aging of the fundus.

Indocyanine green angiography in choroidal osteoma.

A choroidal osteoma appears ophthalmoscopically as a yellow to orange choroidal mass which is irregular and slightly elevated and usually situated adjacent to the optic disc. Its diagnosis is essentially based on ophthalmoscopy, ultrasonography and computer tomodensitometry of the orbit, which shows a plaque-like lesion in the posterior pole with the density of normal bone. The osteoma is most commonly found in young women and is of unknown cause. The tumour is considered to be a choristoma, although it has not been fully established whether it is congenital. An osteoma consists of compact bone lying in the choroid. The intratrabecular spaces are filled with loose connective tissue containing blood vessels. Some vascular tufts may extend outside the tumour mass and lie external to Bruch’s membrane. These tufts must be differentiated from choroidal new vessels, a possible sight threatening complication of choroidal osteomas.

Sorsby fundus dystrophy without a mutation in the TIMP-3 gene.

AIMS To examine a large family with an autosomal dominant fundus dystrophy and to investigate whether or not mutations in TIMP-3 gene were involved. METHODS A large family of 58 individuals with an autosomal dominant fundus dystrophy was examined ophthalmologically. A DNA linkage analysis in the 22q12.1-q13.2 region was performed. The TIMP-3 gene was screened for mutations in all five exons. RESULTS In this large family 15 individuals were affected. All other individuals were found to be clinically unaffected. Pisciform flecks in the midperiphery and drusen-like deposits were the most typical ophthalmological finding in this family and were encountered from the fifth decade on. Chorioretinal atrophy and neovascularisation with disciform lesions characterised the disease from the sixth decade on. Linkage analysis using an affected only analysis, showed a maximum positive lod score of 3.94 at θ = 0.0 with marker D22S283. No mutations possibly causing Sorsby fundus dystrophy were found in either the exonic sequences, the promotor region, or the 3′UTR. CONCLUSION The family in this pedigree has an autosomal dominant fundus dystrophy, which is most probably Sorsby fundus dystrophy. Although, in the linkage analysis, significant positive lod scores were found with the region 22q12.1-q13.2, no causative mutations could be identified in the TIMP-3 gene.