Experimental studies of indocyanine green dye-enhanced photocoagulation of choroidal neovascularization feeder vessels

PURPOSE: To report a model of choroidal neovascularization feeder vessels that reconciles current histologic, angiographic, and clinical data, and to report experimental studies that investigate the potential of indocyanine-green-dye-enhanced photocoagulation to improve feeder-vessel treatment. METHODS: A model of choroidal neovascularization feeder vessels was conceived to account for current histologic and angiographic data. Based on that model, experimental studies of the efficacy of indocyanine green-dye-enhanced photocoagulation were performed, using pigmented rabbit eyes as a model system. A Zeiss fundus camera was modified to permit visualization of choroidal blood flow by high-speed indocyanine green angiography and to permit simultaneous delivery of 810-nm-wavelength diode laser photocoagulation pulses to specific choroidal vascular targets during indocyanine green-dye bolus transit. RESULTS: Choroidal neovascularization feeder vessels appear to originate in the Sattler layer (that is, that portion of the choroidal vasculature consisting of medium-diameter vessels) and enter the choriocapillaris in close proximity to the small capillary-like vessels that penetrate Bruch membrane and communicate with the choroidal neovascularization. The rabbit eye experiments demonstrated that the presence of high indocyanine green dye concentration in circulating blood enhances uptake of near-infrared laser energy (three eyes); injection of sequential indocyanine green dye boluses results in gradually decreased efficiency of dye-enhanced photocoagulation (two eyes); and by application of laser energy during the initial transit of small-volume, high-concentration indocyanine green dye boluses, dye-enhanced photocoagulation of large diameter choroidal arteries can be accomplished with relatively little concomitant retinal tissue damage (three eyes). CONCLUSIONS: Although future trials will be necessary to substantiate these initial findings in the clinical arena, it appears that the efficiency of choroidal neovascularization feeder-vessel photocoagulation may be enhanced, while minimizing concomitant damage to overlying retinal tissue, by delivery of 810-nm wavelength laser energy immediately upon arrival of a high-concentration indocyanine green dye bolus in a targeted feeder vessel. However, molecules of dye adhering to vessel walls or lying in tissue interstitial spaces appear to divert laser energy from the photocoagulation process, so efficiency of indocyanine green dye-enhanced photocoagulation gradually diminishes as the number of injected dye boluses increases.     

Management of peripheral polypoidal choroidal vasculopathy with intravitreal bevacizumab and indocyanine green angiography-guided laser photocoagulation

A 69-year-old lady presented with complaints of decreased vision in left eye since one month. Best Corrected Visual Acuity (BCVA) was 6/18 in that eye. Fundus examination revealed non-central geographic atrophy and soft drusens at macula in both eyes. Temporal periphery of left eye revealed subretinal exudates with altered sub-RPE hemorrhage mimicking peripheral exudative hemorrhagic chorioretinopathy (PEHCR). Fundus Fluorescein Angiogram showed window defects at macula and blocked fluorescence at temporal periphery in left eye. However, Indocyanine green angiography (ICGA) revealed active peripheral choroidal polyps. The patient was successfully treated with intravitreal bevacizumab and ICGA-guided laser photocoagulation. 27 months after laser treatment, BCVA improved to 6/9. Rationale of consecutive anti-vascular endothelial growth factor (VEGF) treatment followed by more definitive laser photocoagulation is that anti-VEGF aids in resolution of subretinal fluid, thus making the polyp more amenable to focal laser photocoagulation which stabilizes the choroidal vasculature and prevents further leakage.     

息肉样脉络膜血管病变静止性息肉样灶的吲哚青绿血管造影特征分析

目的 观察息肉样脉络膜血管病变(PCV)静止性息肉样灶的吲哚青绿血管造影(ICGA)特征.方法 回顾分析36例有静止性息肉样灶的PCV患者37只眼的临床资料.其中,11只眼随访了9～29个月,平均随访时间(12.3±5.5)个月.所有患眼均进行视力、眼压、裂隙灯显微镜、散瞳眼底检查,以及眼底彩色照相、荧光素眼底血管造影、ICGA检查.以ICGA检查早期发现囊袋样强荧光和晚期荧光渗漏或者着染者确定为活动性息肉样灶;ICGA检查发现囊袋样稍强荧光,晚期逐渐消退或者呈“冲刷”样表现者确定为静止性息肉样灶.以吲哚青绿开始注射至静止性息肉样灶开始显影的时间定为静止性息肉样灶的显影时间.根据临床和ICGA表现,将静止性息肉样灶分为无症状组、萎缩瘢痕组、结合组.对比观察各组的临床和影像特征以及随访观察眼底及病灶变化情况.结果 37只眼中,静止性息肉样灶的显影时间为8.2～27.0 min,平均显影时间(15.5±4.8) min.无症状组5只眼,占13.5％.眼底检查无出血、渗出、视网膜色素上皮脱离(PED)和(或)神经上皮脱离.ICGA检查有静止性息肉样灶显影.萎缩瘢痕组8只眼,占21.6％.眼底检查患眼黄斑区均有萎缩灶和(或)瘢痕灶,无出血、渗出、视网膜PED和(或)神经上皮脱离.ICGA检查显示其静止性息肉样灶位于萎缩灶或瘢痕灶边缘.结合组24只眼,占64.9％.眼底检查均无萎缩、瘢痕灶,其中10只眼有视网膜下出血,15只眼有视网膜渗出,10只眼有视网膜PED,4只眼有视网膜神经上皮脱离.ICGA检查显示静止性息肉样灶和活动性息肉样灶共存.随访的11只眼中,3只眼静止性息肉样灶完全消退,占27.3％;2只眼静止性息肉样灶部分消退,占18.2％;6只眼静止性息肉样灶无明显改变,占54.5％.结论 PCV的静止性息肉样灶主要在ICGA造影的中晚期显影,可出现于无症状眼、萎缩瘢痕眼以及与活动性息肉样灶共存眼等3种情况,其中与活动性息肉样灶共存是其主要形式.     

息肉状脉络膜血管病变的吲哚菁绿眼底血管造影分型研究

目的 分析黄斑区息肉状脉络膜血管病变(PCV)在吲哚菁绿眼底血管造影(ICGA)中的不同渗漏亚型及临床特点.方法 对经荧光素眼底血管造影(FFA)及ICGA确诊为PCV的137例144只患眼进行ICGA渗漏状态的分型及各型临床特点的分析.结果 在144只PCV患眼的ICGA中,110只眼出现晚期染料渗漏(渗漏型,76%).渗漏型又可分为三个亚型:息肉灶渗漏型(47只眼,42.7%)、异常分支状脉络膜血管渗漏型(14只眼,12.7%)和混合渗漏型(49只眼,44.5%).其他34只眼显示出晚期病灶的消退和(或)呈冲刷现象(消退型,24%).在渗漏型中,色素上皮脱离(PED)、最佳矫正视力(BCVA)<0.1及陈旧性视网膜下出血的比例分别为56.4%(62只眼),19.1%(21只眼)和4.6%(5只眼);消退型相应比例分别为8.8%(3只眼)、50%(17只眼)和38.2%(13只眼)(P<0.001),同时消退型的病程显著长于渗漏型(P<0.001).结论 在ICGA中可以观察PCV病灶的晚期渗漏及消退现象,其中以渗漏型居多.混合性渗漏是渗漏型中最常见的亚型.渗漏型多表现PED,较好的BCVA以及较短的病程,而消退型则更易表现视网膜下陈旧性出血、较差的BCVA以及较长的病程.这可能提示前者为活动性病灶或处于疾病的早期阶段,而后者则为静止性病灶或处于疾病的晚期阶段.     

Angiographic lesion of polypoidal choroidal vasculopathy on indocyanine green and fluorescein angiography

BACKGROUND: Before treating polypoidal choroidal vasculopathy (PCV), the extent of the lesion should be determined, but the angiographic lesion size of PCV is sometimes different when comparing indocyanine green angiography (ICGA) and fluorescein angiography (FA). The purpose of this study was to evaluate angiographic findings and compare the lesion sizes of PCV on ICGA and FA using confocal scanning laser ophthalmoscopy (SLO) and fundus camera. METHODS: Thirty-seven eyes of 37 patients with PCV were examined by ICGA and FA using confocal SLO and a fundus camera, and the findings and the lesion sizes were compared during the early, mid, and late-phases of ICGA and FA. RESULTS: The polyps with abnormal vessel networks were depicted on ICGA in all eyes and the lesion showed classic-type leakage on FA in 15 eyes. Ten eyes with a pigment epithelial detachment (PED) had the maximal lesion size on FA because hyperfluorescent areas involving PED were determined as the lesions; although on ICGA, a PED distinguished from abnormal vessels was not included in the lesion. In 27 eyes without a PED, the early-phase of ICGA using confocal SLO showed the maximal lesion size in 24 eyes (89%) and the late-phase in three eyes (11%), and the maximal size on ICGA agreed on FA. While FA depicted the maximal lesion sizes in 24 eyes (89%), another three eyes showed the maximal lesion size on early-phase ICGA on confocal SLO. The maximal lesion size on ICGA using a fundus camera was smaller than when using confocal SLO in seven eyes (19%). CONCLUSIONS: The ICGA on confocal SLO could visualize the more detailed findings of the abnormal vasculature of PCV and the FA showed hyperfluorescent regions overlaying the lesions. To determine the maximal lesion size on angiograms, early-phase ICGA using confocal SLO and FA should be referred.     

Indocyanine green videoangiography in macular variant of idiopathic polypoidal choroidal vasculopathy

BACKGROUND: Fifty patients diagnosed with choroidal neovascularization in age-related macular degeneration were examined by indocyanine green videoangiography. Results were correlated with fundus photographs and fluorescein angiograms. Two patients were diagnosed with the macular variant of idiopathic polypoidal choroidal vasculopathy. CASES: Two middle-aged hypertensive women were diagnosed with macular idiopathic polypoidal choroidal vasculopathy. Throughout the follow-up period, both cases showed improved signs and symptoms without worsening of visual acuity, and despite the absence of definitive therapy. OBSERVATIONS: Indocyanine green videoangiography demonstrated the characteristic polypoidal lesions in idiopathic polypoidal choroidal vasculopathy better than fluorescein angiography, particularly when blood, exudates, or pigment epithelial detachments blocked visualization of the lesions. CONCLUSIONS: Incidence of idiopathic polypoidal choroidal vasculopathy may not be as low as reported, as its presentation mimics choroidal neovascularization in age-related macular degeneration. Differentiation can be made only through indocyanine green videoangiography. Conservative management may be beneficial, as visual prognosis is good.     

息肉状脉络膜血管病变在眼底FFA 与ICGA中特征分析

目的 探讨息肉状脉络膜血管病变(PCV)眼底荧光素血管造影(FFA)和吲哚青绿血管造影(ICGA)同步检查的影像学特征及其临床意义.方法 选取62例患者(75只眼)进行眼底彩色照相、FFA 和ICGA同步检查,对黄斑部视网膜下出血病灶其形态及特征做以对比分析.结果 FFA图像显示:PCV75只眼中斑块样视网膜下出血48只眼,占64.0%;伴浆液性视网膜色素上皮(RPED)脱离12只眼,占16.0%;出血性RPED8只眼,占10.7%;脉络膜血管网及息肉样结节7只眼,占9.4%,早期即出现荧光素渗漏并逐渐增强,CNV末端膨大处出现点状高荧光.ICGA图像显示:75只患眼中72只眼呈"蘑菇"状或"树枝"状异常扩张,其血管网末端多个息肉样膨大与彩色照相所见的结节样病变部位吻合.结论 FFA和ICGA同步检查,不但对PCV患者病灶其形态及特征作出对比分析,ICGA检查还能提高PCV视网膜下脉络膜新生血管膜(CNV)的检出率,同时提高PCV患者激光光凝的可能性,而FFA对评估PCV 视网膜下出血及出血性或浆液性视网膜色素上皮脱离、脉络膜血管网及息肉状结节则均有较好的效果.

Abstract：

Objective To observe on fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA) in polypoidal choroidal vasculopathy (PCV), and sync examine of its image features and clinical meaning. Methods Sixty-two patients (75 eyes) applied fundus camera, FFA and ICGA synchronous examination, do comparison analysis in macular sub-retinal hemorrhage shape and area. Results FFA image in 75 PCV patients showed 48 eyes (64.0%) with plaque sub-retinal hemorrhage, 12 eyes (16.0%) accompanied with retinal pigment epithelial detachments (RPED), 8 eyes (10.7%) with bleeding RPED, 7 eyes (9.4%) with choroid blood vessel net and polypoidal node of early stage flouresence leakage. ICGA showed that 75 eyes had abnormal choroid blood vessel net extension, 72 with "mushroom" shape or "tree-branch" shape with more polypoidal enlarge in the end which was the same as seen under ophthalmoscope. Conclusions It proves that FFA and ICGA synchronous examination, not only can be used for PCV patients' tissue shape and area comparison analysis, but also improves the finding rate of the choroidal neovascularization (CNV) in PCV, increases the feasibility of photocoagulation to PCV. FFA gives good result to evaluate PCV sub-retinal hemorrhage.     

特发性息肉样脉络膜血管病变的治疗进展

特发性息肉样脉络膜血管病变(idiopathic polypoidal choroidal vasculopathy,IPCV),简称息肉样脉络膜血管病变(polypoidal choroidal vasculopathy,PCV),为新近认识的一种以眼底后部脉络膜血管局限性膨隆,呈息肉状改变,伴复发性出血,并有浆液性或出血性色素上皮脱离.近年随着新的诊断技术的出现,对PCV有了进一步了解,治疗方面也相应出现了不少进展.本文对PCV在治疗方面的进展进行综述.     

A study of laser photocoagulation for polypoidal choroidal vasculopathy

PURPOSE: To evaluate the efficacy of laser photocoagulation for polypoidal choroidal vasculopathy (PCV) involving the macula. METHODS: The records of 38 patients (47 eyes) undergoing laser photocoagulation for PCV causing serosanguineous detachment involving the fovea were reviewed and the results were evaluated. Ten eyes underwent photocoagulation to induce a fusion scar covering whole lesions consisting of both abnormal vessels and polypoidal lesions. Thirty-seven eyes underwent photocoagulation for only polypoidal lesions. When serosanguineous detachment recurred, additional photocoagulation was performed, targeting the causative lesions. Photocoagulation was performed with an argon dye laser or multicolor krypton laser. Final visual acuity, macular changes at the final visit, and the number of photocoagulations were evaluated. Follow-up period after the first photocoagulation was at least 1 year. RESULTS: Of the 10 eyes undergoing photocoagulation of whole lesions, 9 showed absorption of exudate and/or blood after one photocoagulation, and maintained or improved visual acuity. Of the 37 eyes undergoing laser photocoagulation of only polypoidal lesions, 20 (54%) showed decreased visual acuity because of recurrent or persistent exudation and/or classic choroidal neovascularization or, alternatively, because of atrophy at the fovea; 32 of the 37 eyes had undergone photocoagulation at least twice or more. CONCLUSION: Photocoagulation is recommended only for whole lesions.     

Optical coherence tomography of idiopathic polypoidal choroidal vasculopathy

PURPOSE: To document and study the cross-sectional structures of polypoidal elements using optical coherence tomography in eyes with idiopathic polypoidal choroidal vasculopathy. METHODS: Optical coherence tomography images of two eyes with idiopathic polypoidal choroidal vasculopathy were correlated with slit-lamp biomicroscopic findings, fundus photographs, fluorescein angiograms, and indocyanine green angiograms. RESULTS: Cross-sectional optical coherence tomographic images of retinochoroidal structures showed prominent anterior protrusion of the orange subretinal mass corresponding to the polypoidal structure in the indocyanine green angiogram. Hemorrhagic detachment of the retinal pigment epithelium was contiguous with the cone-shaped nodule beneath the retinal pigment epithelium in one eye, and an apparent discontinuity was observed in the highly reflective layer that delineates the polypoidal structure. CONCLUSIONS: Some of the polypoidal structures in eyes with idiopathic polypoidal choroidal vasculopathy are anteriorly protruding lesions in the inner choroid that may cause serosanguineous detachment of the retinal pigment epithelium through damage of the overlying Bruch membrane, retinal pigment epithelium, and the adhesion between them. Cross-sectional optical coherence tomographic images may increase understanding of the pathophysiology of idiopathic polypoidal choroidal vasculopathy.     

Optical coherence tomography of idiopathic polypoidal choroidal vasculopathy

PURPOSE: To characterize cross-sectional images of idiopathic polypoidal choroidal vasculopathy (PCV). METHODS: A cross-sectional and retrospective study was performed involving 28 eyes with PCV and 112 eyes with exudative age-related macular degeneration. The frequency and dimensions of the retinal pigment epithelial detachment (RPED) with attenuation of internal reflectivity on optical coherence tomographic (OCT) examination were compared in both diseases. RESULTS: OCT showed the RPED with attenuation of internal reflectivity corresponding to the polypoidal structure in the indocyanine green angiogram in 75% of eyes with PCV, which was significantly more frequent than in eyes with exudative age-related macular degeneration (3.6%). In lesions suspicious of exudative age-related macular degeneration or PCV, the RPED with attenuation of internal reflectivity on OCT images strongly supported PCV diagnosis with a sensitivity of 84% and a specificity of 94%. The base diameter (p=0.010) and base diameter times height (p=0.028) of RPED were smaller in PCV than in exudative age-related macular degeneration. CONCLUSIONS: An RPED with attenuation of internal reflectivity in OCT examination is a highly sensitive and specific finding which characterizes PCV. Recognition of this RPED appearance, as well as the evaluation of its size, aids in the diagnosis of PCV.     

Use of fluorescein and indocyanine green angiography in polypoidal choroidal vasculopathy patients following photodynamic therapy

Background: Exudative age-related macular degeneration (AMD) is a sight-threatening event in many elderly people. Some patients have a much better outcome in visual acuity (VA) than others after treatment with photodynamic therapy (PDT) with verteporfin. The combination of fluorescein angiography (FA) and indocyanine green (ICG) angiography using the Heidelberg Retina Angiograph II (HRA 2) should make a delineation of distinct pattern(s) possible in order to better select and assess therapy.Methods: This is a retrospective, case-control, single-centre study. We identified a total of 168 eyes of 168 patients from July 2003 to June 2006, including 30 eyes of 30 patients with better visual outcome, defined in this study as VA ≤0.48 logMAR (≥20/60 Snellen chart) at the end of the study. Best-corrected VA, maximal central retinal thickness as measured by optical coherence tomography, and results of the FA/ICG angiography using the HRA 2 were analyzed. In this article, we discuss patients with polypoidal choroidal vasculopathy (PCV) and their characteristics.Results: The average follow-up time was 15.3 months (range 4–28 months). Seventeen (57%) of the 30 patients with better visual outcome had PCV. All patients in the group with better visual outcome needed fewer PDT treatments compared with our control group of patients with an exudative AMD.Interpretation: Simultaneous FA/ICG angiography using the HRA 2 allowed delineation of a subgroup of patients with PCV who showed a better visual outcome compared with those with other types of exudative AMD, after treatment with PDT.     

Optical coherence tomographic findings of idiopathic polypoidal choroidal vasculopathy

BACKGROUND AND OBJECTIVE: To identify the histological level of abnormal vessels associated with idiopathic polypoidal choroidal vasculopathy (IPCV), we examined IPCV with Optical Coherence Tomography (OCT). PATIENTS AND METHODS: Fourteen patients diagnosed with IPCV were examined with Indocyanine green (ICG) angiography and OCT. RESULTS: ICG angiography demonstrated branching vascular networks with polypoidal dilatations at the terminals beneath the retinal pigment epithelium (RPE). OCT showed dome-like elevation of the RPE, and moderate reflex or nodular appearance were seen beneath the RPE. CONCLUSION: The abnormal vessel associated with IPCV is supposed to be choroidal neovascularization with polypoidal dilatations at the terminals between Bruch's membrane and RPE. We consider that this disease is a peculiar form of age-related macular degeneration.