Focal laser ablation of retinal angiomatous proliferation

PURPOSE: To evaluate the feasibility of focal laser ablation of retinal angiomatous proliferation (RAP) identified with clinical examination and high-speed indocyanine green (ICG) imaging in patients with age-related macular degeneration. METHODS: In this retrospective, interventional case series, 16 consecutive eyes of 15 patients with macular degeneration and leakage from a stage I or II RAP lesion were identified. RAP lesions were identified using clinical examination and high-speed ICG imaging. High-speed ICG imaging was used to identify the intraretinal component of the lesion. RAP lesions were treated with a 100- to 200-mum green or yellow wavelength laser spot that was applied to completely ablate the intraretinal component of the lesion. In eyes with stage II lesions, the subretinal component of the lesion was not treated. Early Treatment of Diabetic Retinopathy Study visual acuity, optical coherence tomography retinal thickness, angiographic leakage, and progression of the angiomatous process shown by ICG imaging were evaluated preoperatively and postoperatively. RESULTS: Sixteen eyes underwent successful ablation of the RAP lesions with an average of 1.9 treatment sessions. At a mean follow-up of 15.5 months, 94% of eyes had stable or improved visual acuity. Only 6% of eyes had a loss of >or=3 lines of visual acuity. The average visual acuity at the last follow-up was 20/45 in the stage I lesion group and 20/160 in the stage II lesion group. Of the patients, 87.5% had a reduction in retinal edema and subretinal fluid, with 69% of patients having complete resolution of retinal edema and subretinal fluid; 14% of patients had progression to retinal choroidal anastomoses. No treatment complications were encountered. CONCLUSION: Focal laser photocoagulation of RAP lesions appears to be feasible. This treatment appears to be a safe method of managing the leakage from RAP. Treatment of solely the intraretinal component of the lesion may be adequate to control leakage. Treatment may allow the angiomatous process to be arrested, resulting in stabilization of visual acuity. Visual acuity results appear to be better for patients with early stage lesions.     

Optical coherence tomography (OCT) angiomatous prolifieration (RAP) in retinal

PURPOSE: To verify the utility of optical coherence tomography (OCT) for diagnosing retinal angiomatous proliferations (RAP) in patients with exudative age-related macular degeneration (AMD). METHODS: Multiple cross-sections were taken with OCT from 41 eyes of 39 consecutive patients with AMD and RAP. The presence and the location of the angiomatous complexes had already been documented by fluorescein angiography (FA) and high-speed confocal indocyanine green videoangiography (ICGA). RESULTS: RAP was detectable by OCT scans in all 41 eyes, appearing as a focal hyper-reflecting area in the neuroretinal layers; it was frequently located close to the inner surface of the retinal pigment epithelium (29 eyes [70. 7%]). All eyes had either no or only a low-reflecting OCTsignal surrounding the RAP, caused by serous intraretinal edema. Only 13 eyes (31.7%), however, had large serous retinal detachment (SRD). OCT detected pigment epithelium detachment in 31 eyes (75.6%), but none had underlying choroidal neovascularization. CONCLUSIONS: OCT findings confirm the intraretinal localization of the RAP which are always associated with impressive exudative phenomena. OCT is therefore a useful diagnostic tool, adding information to FA and high-speed ICGA.     

Recurrence after surgical ablation for retinal angiomatous proliferation

PURPOSE: To report the frequency of recurrence of retinal angiomatous proliferation (RAP) lesions after surgical ablation. METHODS: Seven eyes of seven consecutive patients with stage II RAP underwent surgical ablation of retinal feeder and draining vessels of RAP lesions. These eyes were examined with visual acuity testing, biomicroscopic slit-lamp fundus examination, fluorescein and indocyanine green angiographies, and optical coherence tomography before and after surgery. RESULTS: Between 2 months and 13 months after surgical ablation, all 7 eyes (100%) had lesion recurrence with exudative and/or hemorrhagic manifestations such as macular edema, serous detachment of the sensory retina, or pigment epithelial detachment. Retinal feeding and draining vessels were recanalized (six eyes) or newly developed (one eye) in communication with recurrent intraretinal neovascularization. CONCLUSIONS: After surgical ablation for stage II RAP, all seven eyes had recurrence of the RAP lesions. This treatment may be ineffective for RAP. Further study of this surgical technique is necessary before recommending it for the treatment of RAP.     

PDT治疗前后脉络膜新生血管的光学相干断层扫描观察

目的利用光学相干断层扫描(OCT)观察光动力学治疗(PDT)黄斑脉络膜新生血管(CNV)前后CNV的组织形态变化,以评价PDT的疗效。方法回顾性分析从2004年5月至2005年6月在我院接受PDT治疗的各类CNV患者34例38眼,对治疗前后CNV的OCT形态特征进行评估和分类。结果PDT治疗后的OCT形态特征可分为5型。I型:急性炎症反应,有4眼,平均出现于PDT后26h;II型:黄斑中心凹结构基本恢复正常,视网膜下积液吸收,有38眼,平均出现于PDT后2.8w;III型:视网膜下积液重新出现伴纤维化,根据积液与纤维化程度又可分为IIIa/IIIb。IIIa:视网膜下积液为主,有8眼,平均出现时间为PDT后1.7m;IIIb:视网膜下纤维化30眼,平均出现时间PDT后1.9m;IV型:黄斑囊样水肿伴视网膜下纤维化有3眼,于PDT后平均4.9m出现。V型视网膜下纤维化伴萎缩有8眼,于PDT后平均8.1m出现。结论OCT可用于动态观察PDT后CNV的形态变化,根据分型可协助制订治疗方案,IIIa型代表CNV复发,可能需再次PDT治疗,而IIIb和IV型则可随访观察。     

Clinicopathological findings of retinal angiomatous proliferation

Background Neovascular membranes obtained from surgical excision of neovascularization for retinal angiomatous proliferation (RAP) were examined histopathologically in an attempt to elucidate the pathogenic mechanism of RAP. Methods Nine eyes of eight patients (mean age, 79±6 years) who underwent neovascularization excision were studied. Three eyes had stage II with RPE detachment, six had stage III. Immunohistochemical studies were performed to identify von Willebrand factor, vascular endothelial factor (VEGF), CD68 and hypoxia inducible factors (HIF-1 alpha and HIF-2 alpha). Results Multiple soft drusen were present in the macular area in all patients. In one stage II eye, we observed intraretinal neovascularization as a VEGF-positive mass, CD68-positive macrophage migration and HIF expression. In another stage II eye, neovascularization had extended above the RPE, while VEGF-positive fibroblasts were observed below the RPE. Therefore, in stage II, neither angiographic nor histopathological examinations identified choroidal neovascularization. In one phase III eye, angiography demonstrated choroidal neovascularization and chorioretinal anastomosis. Histopathologically, chorio-retinal communication was observed in the region where the RPE was destroyed, and VEGF-positive neovascularization was also seen below the RPE. Conclusions The findings of multiple drusen in elderly patients together with macrophage migration and HIF expression surrounding VEGF-positive retinal neovascularization suggest ischemic and inflammatory factors to be associated with the development and progression of RAP.     

旁中心凹渗出性血管异常复合体

旁中心凹渗出性血管异常复合体(PEVAC)是指相干光断层扫描(OCT)成像显示在旁中心凹视网膜表层或深层毛细血管网出现的大而孤立的动脉瘤样病灶,被确定为一种独立的新疾病。患者多为中老年人,不伴有视网膜血管病变,但可合并近视或年龄相关性黄斑变性等。若合并视网膜血管性疾病如糖尿病视网膜病变、视网膜静脉阻塞时,被称为PEVAC样病变。疾病早期无渗出,后期可有视网膜内渗出引起视物变形或视力下降。一些病例长期随访病灶无变化或自发消散。可能需要与3型视网膜新生血管(RAP)和Ⅰ型MacTel鉴别。抗血管内皮生长因子(VEGF)疗法无效。有用微脉冲激光等治疗改善的个案。推测此病与视网膜微血管周细胞变性有关。     

High resolution Fourier-domain optical coherence tomography of retinal angiomatous proliferation

PURPOSE: To study the anatomic details of retinal angiomatous proliferation (RAP) in patients with age-related macular degeneration (AMD) using high-resolution Fourier-domain optical coherence tomography (Fd-OCT) and its three-dimensional reconstructions. METHODS: A Fd-OCT instrument was used to image five patients clinically diagnosed with RAP. A series of 100 raster-scanned B-scans centered over the macula was registered and rendered as a three-dimensional volume. These retinal structures were analyzed for anatomic details of the RAP lesions. RESULTS: The RAP lesion could be identified within the retina on Fd-OCT in all five cases. Fd-OCT images of the first four cases revealed areas of intraretinal neovascularization (IRN) in the deep retina adjacent to a pigment epithelial detachment (PED). There was neovascular proliferation anteriorly and posteriorly through a break in the retinal pigment epithelium (RPE). In three of the four cases, Bruch membrane remained intact. There was no identifiable choroidal neovascularization (CNV). The fifth case had both subretinal and sub-RPE neovascular membranes without a PED. CONCLUSION: Fd-OCT provides unprecedented in vivo detail of the anatomy of RAP lesions that nearly resembles histologic specimens. This study suggests that the initial neovascular process in RAP can originate either within the retina or in the sub-RPE space.     

Neovascularization Associated with Large Retinal Pigment Epithelial Detachment in Elderly Korean Patients: Subdivision According to Indocyanine Green Angiographic Features

PURPOSE: In Korean patients, to subdivide the neovascular forms of age-related macular degeneration (AMD) associated with large retinal pigment epithelial detachment (PED), according to the indocyanine green angiographic features. METHODS: Indocyanine green angiograms (ICGA) of 67 elderly patients (72 eyes) who presented with a PED of at least 1 disc diameter were evaluated retrospectively. RESULTS: Polypoidal choroidal vasculopathy (PCV) and typical choroidal neovascularization (CNV)-associated PEDs were identified in 18 eyes (25%) and 19 eyes (26%), respectively. In ten eyes (13.9%), the exact type of neovascularization, whether PCV or CNV, could not be determined. Pure serous PEDs were identified in seven eyes (10%). The remaining 18 eyes (25%) were classified as having retinal angiomatous proliferation (RAP)-associated PED based upon the angiographic findings of vascular connections between the retinal vasculature and the neovascular complex. CONCLUSIONS: Three subset groups of PCV, CNV, and RAP were present with similar frequency in neovascularized AMD with a large PED in these Korean patients. In particular, RAP, previously thought to be rare in Asian patients, was found to be present with considerable frequency.     

Retinal angiomatous proliferation: clinical characteristics and treatment options.

BACKGROUND: A new form of exudative age-related macular degeneration (ARMD), retinal angiomatous proliferation (RAP), has been described in which neovascularization begins in the deep retina, extends through the subretinal space, and eventually communicates with choroidal neovascularization. METHODS: Case series. RESULTS: Common clinical features of RAP include small multiple intra-retinal hemorrhages, intra-retinal edema, vascularized pigment epithelial detachments (PEDs), and retinal choroidal anastomosis (RCA). Fluorescein angiography (FA) reveals ill-defined, occult choroidal neovascularization. Indocyanine green (ICG) angiography is useful in early stages because 'hot spots' can be detected before clinical or FA characteristics are present. Optical coherence tomography (OCT) is useful in illustrating some of the clinical and FA characteristics. The use of photodynamic therapy (POT), combined with intravitreal triamcinolone injection, was successful in stabilizing the RAP lesion in one case discussed in this report. CONCLUSIONS: Retinal angiomatous proliferation is a newly recognized entity of exudative age-related macular degeneration with its own set of clinical, FA, ICG angiography, and OCT features. Experimental treatments such as the use of PDT combined with intravitreal triamcinolone injection demonstrate potential success with this entity. The biggest hope appears to be anti-angiogenic factors currently in clinical trials for the treatment of exudative ARMD.     

The nature of focal areas of hyperfluorescence or hot spots imaged with indocyanine green angiography

PURPOSE: To clarify the frequency and nature of ICG angiographic "hot spots" seen in patients with neovascular age-related macular degeneration (ARMD). METHODS: A consecutive series of newly diagnosed patients with neovascular ARMD and fluorescein angiographic evidence of occult choroidal neovascularization (occult CNV) was imaged with ICG angiography. Eyes with ICG angiographic "hot spots" were identified and further classified. A hot spot was defined as any area of abnormal hyperfluorescence, in the mid to late stages of ICG angiography, measuring less than 1 disk area in size. RESULTS: From a total of 190 patients (220 eyes) with neovascular ARMD, 30 patients and 34 eyes (16%) with hot spots were identified. Hot spots were noted to be of three distinct patterns: polypoidal choroidal neovascularization (polypoidal CNV) in 21 of 34 eyes, or 62%; retinal angiomatous proliferation (RAP) in 11 of 34 eyes, or 30%; and focal occult CNV in 2 of 34 eyes, or 8%. CONCLUSIONS: A focal area of intense hyperfluorescence or so-called hot spot seen on ICG angiography in neovascular ARMD is due to one of three possible forms of neovascularization: most frequently polypoidal CNV, less commonly RAP, and infrequently nonspecific, focal occult CNV. Since neovascular ARMD may be caused by different types of neovascularization, each with distinct clinical manifestations, natural course, visual prognosis, and response to treatment, it is important to identify the precise nature of hot spots to establish an accurate diagnosis and, when appropriate, a specific form of management.     

Pigment epithelial detachments with retinal vascular anomalous complex in age-related macular degeneration

PURPOSE: To analyze and compare the angiographic features of retinal vascular anomalous complex (RVAC) in patients with a vascularized pigment epithelial detachment (PED) secondary to age-related macular degeneration. METHODS: Retrospective evaluation of fluorescein and indocyanine green angiographies of 180 patients with occult choroidal neovascularization and PED. RESULTS: On indocyanine green angiography (ICGA), RVAC demonstrated as a focal hyperfluorescence in connection with retinal choroidal anastomosis was identified in 12 of the 180 eyes (6.7%) with a vascularized PED. In comparison, fluorescein angiography revealed RVAC in 6 of the 12 eyes. Associated clinical and angiographic features were intraretinal hemorrhage in all 12 eyes, cystoid macular edema in 6 eyes and preretinal hemorrhage in 4 eyes. CONCLUSIONS: RVAC is better delineated on ICGA than on fluorescein angiography. In clinically suspected cases with a vascularized PED in connection with intraretinal hemorrhage and/or cystoid macular edema, ICGA should be performed to enhance management considerations.     

Immediate indocyanine green angiography and optical coherence tomography evaluation after photodynamic therapy for subfoveal choroidal neovascularization

PURPOSE: To better understand the mechanisms of action of photodynamic therapy (PDT) with verteporfin for subfoveal choroidal neovascularization (CNV), the authors evaluated the retinal and choroidal response immediately after treatment with serial optical coherence tomography (OCT) and indocyanine green angiography (ICGA). METHODS: This study was a prospective, noncomparative case series. PDT was performed on nine eyes of nine consecutive patients who presented with subfoveal CNV due to age-related macular degeneration, and serial evaluation with OCT as well as ICGA was performed at 20-minute intervals for the first 2 hours and then at 1 week, 1 month, and 3 months. RESULTS: In the first 2 hours after PDT, OCT showed an increase in the thickness of the retina in the treatment area due to fluid leakage from the neovascular complex as confirmed by ICGA. At 1 week, marked reduction of intraretinal/subretinal fluid was observed in all patients. Neovascular complex nonperfusion by ICGA was associated with some degree of choroidal hypoperfusion in the treatment area. Return of the foveal contour by OCT was optimal after 1 month of treatment. At 3 months, choroidal reperfusion by ICGA and recurrent intraretinal/subretinal fluid by OCT were observed. CONCLUSIONS: Serial OCT and ICGA evaluation after PDT suggests that the initial successful CNV nonperfusion as shown by fluorescein angiography at 1 week occurs by means of selective PDT damage to the lesion and/or reduced choroidal blood flow in the treatment area, thereby decreasing intraretinal/subretinal fluid and facilitating restoration of the retinal architecture.     

Characteristic Findings of Optical Coherence Tomography in Retinal Angiomatous Proliferation

Purpose

To identify the unique pathologic findings of retinal angiomatous proliferation (RAP) in optical coherence tomography (OCT).

Methods

Retrospectively, 29 eyes of 25 patients with age-related macular degeneration and complicated RAP were analyzed. All 29 eyes had choroidal neovascularization (CNV) in the area of pigment epithelial detachment (PED) or adjacent to it, which was visible with fluorescein angiography or indocyanine green angiography. Cross-sectional images were obtained by OCT scanning through the CNV lesions.

Results

Six distinctive findings of OCT included drusen (100%), inner retinal cyst (80%), outer retinal cyst (68%), fibrovascular PED (84%), serous retinal detachment (40%), and PED (68%).

Conclusions

Through analysis of OCT findings, we revealed six different types of lesions distinctive of RAP which may provide helpful diagnostic information for subsequent treatment and predicting the prognosis of RAP.     

Retinal angiomatous proliferation in age-related macular degeneration

BACKGROUND: It is known that choroidal neovascularization (CNV) in age-related macular degeneration (ARMD) may erode through the retinal pigment epithelium, infiltrate the neurosensory retina, and communicate with the retinal circulation in what has been referred to as a retinal-choroidal anastomosis (RCA). This is extremely common in the end stage of disciform disease. In recent years, the reverse also seems to be possible, as angiomatous proliferation originates from the retina and extends posteriorly into the subretinal space, eventually communicating in some cases with choroidal new vessels. This form of neovascular ARMD, termed retinal angiomatous proliferation (RAP) in this article, can be confused with CNV. PURPOSE: The purpose of this article is 1) to review the clinical and angiographic characteristics of a series of patients with RAP and 2) to propose a theoretical sequence of events that accounts for the neovascularized process. METHODS: In this retrospective clinical and angiographic analysis, 143 eyes with RAP (108 patients) were reviewed and classified based on their vasogenic nature and course. Clinical biomicroscopic examination, fluorescein angiography, and indocyanine green angiography were used to evaluate patients. RESULTS: The results of this series suggest that angiomatous proliferation within the retina is the first manifestation of the vasogenic process in this form of neovascular ARMD. Dilated retinal vessels and pre-, intra-, and subretinal hemorrhages and exudate evolve, surrounding the angiomatous proliferation as the process extends into the deep retina and subretinal space. One or more dilated compensatory retinal vessels perfuse and drain the neovascularization, sometimes forming a retinal-retinal anastomosis. Fluorescein angiography in these patients usually revealed indistinct staining simulating occult CNV. Indocyanine green angiography was useful to make an accurate diagnosis in most cases. It revealed a focal area of intense hyperfluorescence corresponding to the neovascularization ("hot spot") and other characteristic findings. Based on understanding of the nature and progression of the neovascularized process, patients with RAP were classified into three vasogenic stages. Stage I involved proliferation of intraretinal capillaries originating from the deep retinal complex (intraretinal neovascularization [IRN]). Stage II was determined by growth of the retinal vessels into the subretinal space (subretinal neovascularization [SRN]). Stage III occurred when CNV could clearly be determined clinically or angiographically. A vascularized pigment epithelial detachment and RCA were inconsistent features of this stage. CONCLUSIONS: Retinal angiomatous proliferation appears to be a distinct subgroup of neovascular ARMD. It may present in one of three vasogenic stages: IRN, SRN, or CNV. Whereas ICG angiography is helpful in diagnosing RAP and in documenting the stage of the neovascularized process, it is frequently difficult to determine the precise nature and location of the new vessel formation. It is important for clinicians to recognize the vasogenic potential and the associated manifestations of this peculiar form of neovascular ARMD so that a proper diagnosis can be made, and when possible, an appropriate management administered.     

Retinal Angiomatous Proliferation in an Eye with Cuticular Drusen

Purpose

To report the presence of retinal angiomatous proliferation (RAP) in an eye with cuticular drusen detected by fluorescein and indocyanine green angiography by confocal scanning laser ophthalmoscopy and by spectral-domain optical coherence tomography (SD-OCT).

Methods

Case report of a 65-year-old Japanese woman with cuticular drusen.

Results

At her first ophthalmic examination, her visual acuity was 20/20 in both eyes. An ophthalmoscopy showed many small subretinal pigment epithelial deposits in both eyes. These deposits had a ‘saw-tooth pattern’ in the SD-OCT images. During the follow-up examination, retinal hemorrhages were observed, and fluorescein angiography showed a ‘stars-in-the-sky’ appearance and intraretinal neovascularization. The patient was diagnosed with cuticular drusen associated with RAP.

Conclusion

We suggest that the cuticular drusen were associated with RAP, so periodic follow-up examinations are needed for patients with cuticular drusen for the early detection and treatment of RAP.Key Words: Cuticular drusen, Basal laminar drusen, Retinal angiomatous proliferation, Spectral domain optical coherence tomography     

Focal inner retinal hemorrhages in patients with drusen: an early sign of occult choroidal neovascularization and chorioretinal anastomosis

PURPOSE: To present evidence that superficial retinal hemorrhage in the macula of patients with age-related macular degeneration (ARMD) may be an early sign of occult chorioretinal anastomosis (OCRA) and type 1 occult choroidal neovascularization (OCNV). METHODS: Retrospective follow-up study of 16 patients presenting with a small focal area of superficial retinal hemorrhages and drusen in the juxtafoveolar area in 24 eyes. RESULTS: OCRA and OCNV occurred in an older subset of patients with ARMD (mean age, 75 years). Of 22 eyes with the early stages of chorioretinal anastomosis (CRA), 18 had evidence of a piggyback neovascular complex, with the smaller subsensory retinal type 2 complex lying anterior to the larger subretinal pigment epithelial type 1 complex. At initial presentation, three patients had OCRA and OCNV bilaterally, and three patients had large disciform cicatricial lesions with overt CRA in the fellow eye. Nine patients had one or more laser photocoagulation treatments for early stages of CRA. Only one patient maintained visual acuity of better than 20/200 for >1 year. At the last follow-up, 24 of 26 eyes with CRA had visual acuity of 20/200 or less. CONCLUSION: Superficial retinal hemorrhage in the paracentral area of patients with drusen is the earliest sign of OCRA and OCNV. Fluorescein angiography and indocyanine green angiography are important in detecting the dual nature of the subretinal neovascular network. Photocoagulation and photodynamic treatment is usually unsuccessful in preserving central vision.     

One-year results of bevacizumab intravitreal and posterior sub-Tenon injection of triamcinolone acetonide with reduced laser fluence photodynamic therapy for retinal angiomatous proliferation

Purpose

Our aim was to study the efficacy of combined triple therapy with intravitreal bevacizumab injections (IVB), posterior sub-Tenon injection of triamcinolone acetonide (STTA), and reduced laser fluence photodynamic therapy (RFPDT) in Japanese patients with retinal angiomatous proliferation (RAP).

Design

This was a retrospective, observational, consecutive case series.

Methods

Fifteen consecutive RAP treatment-na?ve eyes were treated with triple therapy of IVB, STTA, and RFPDT (25?J/cm² of laser fluence). Whenever there was a recurrence of retinal–retinal anastomosis (RRA) or retinal–choroidal anastomosis (RCA) and marked leakage from subretinal neovascularization, the triple therapy was reapplied. When there were only intraretinal exudative and/or hemorrhagic changes without distinct RRA or RCA, IVB alone was applied.

Results

The mean logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) at baseline improved significantly (from 0.489 to 0.294 12 months) (paired t test, p?=?0.043). LogMAR BCVA at 12?months was stable or improved by ≥0.2 in 14 eyes (93.3?%). Mean number of triple therapy instituted during the 12-month study period was 1.2, and mean number of IVB treatments was 1.4.

Conclusion

Combined IVB, STTA, and RFPDT for RAP was effective in maintaining or improving VA at 1?year. In addition, the number of treatments could be markedly reduced.     

Optical coherence tomography of subfoveal choroidal neovascularization treated with transpupillary thermotherapy

Transpupillary thermotherapy (TTT) has been proposed as a new treatment modality for choroidal neovascularization (CNV). Most studies conducted show decreased exudation due to CNV and reduction of subretinal elevation. Optical coherence tomography (OCT) shows a dynamic sequence of changes early after treatment. Within 1 hour after TTT, OCT shows increased retinal thickness and intraretinal fluid with retinal elevation. One week after treatment, OCT shows decreased subretinal and intraretinal fluid and diminished retinal elevation. OCT can be a valuable method to assess the early effect of TTT. A placebo-controlled, multi-center trial (TTT4CNV) evaluating the long-term efficacy and visual implications of TTT in occult CNV is underway.     

Optical coherence tomography of subfoveal choroidal neovascularization treated with transpupillary thermotherapy

Transpupillary thermotherapy (TTT) has been proposed as a new treatment modality for choroidal neovascularization (CNV). Most studies conducted show decreased exudation due to CNV and reduction of subretinal elevation. Optical coherence tomography (OCT) shows a dynamic sequence of changes early after treatment. Within 1 hour after TTT, OCT shows increased retinal thickness and intraretinal fluid with retinal elevation. One week after treatment, OCT shows decreased subretinal and intraretinal fluid and diminished retinal elevation. OCT can be a valuable method to assess the early effect of TTT. A placebo-controlled, multi-center trial (TTT4CNV) evaluating the long-term efficacy and visual implications of TTT in occult CNV is underway.     

Nature and risk of neovascularization in the fellow eye of patients with unilateral retinal angiomatous proliferation

PURPOSE: To determine the nature and risk of neovascularization in the fellow eyes of patients with unilateral retinal angiomatous proliferation (RAP), a neovascular form of age-related macular degeneration (AMD). METHODS: A consecutive series of 52 patients diagnosed with unilateral RAP were studied retrospectively. Clinical biomicroscopic examination, fluorescein angiography, and indocyanine green angiography were used to evaluate all patients for the development of neovascular manifestations in the fellow eye. RESULTS: Neovascularization developed in the fellow eye in 52 patients over the follow-up period (range, 2-36 months). All patients developed neovascular manifestations of RAP in the fellow eye. Twenty-one patients (40%) developed a RAP lesion within 1 year; 29 (56%), within 2 years; and 52 (100%), within 3 years. At the time of diagnosis of neovascularization in the fellow eye, 8 patients (15%) had a stage I RAP lesion, 36 (70%) had a stage II RAP lesion, and 8 (15%) had a stage III RAP lesion. Other characteristic findings in these patients included the presence of preretinal, intraretinal, and subretinal hemorrhages in 49 patients (94%) and pigment epithelial detachments in 41 patients (79%). CONCLUSIONS: In patients diagnosed with unilateral RAP lesions, the form of neovascularization that develops in the fellow eye is virtually always RAP. The annual and accumulative risk of neovascularization in the fellow eye is higher in patients with RAP than in those with other forms of neovascular AMD. These new findings enhance our understanding of the clinical spectrum of RAP in terms of its natural course and visual prognosis and may possibly offer useful information to establish future treatment options.