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.     

Surgical ablation of retinal angiomatous proliferation

Age-related macular degeneration (AMD) remains the leading cause of visual loss in adults older than 65 years. Retinal angiomatous proliferation (RAP) is a newly recognized manifestation of exudative AMD that has a poor natural history and demonstrated resistance to treatment with conventional laser photocoagulation. A novel surgical technique has been developed in this pilot series that shows promise in the treatment of this subtype of neovascular lesions. Through specific surgical lysis of the feeding arteriole and draining venule of an RAP lesion, improvement in visual acuity has been noted. This has been correlated with resolution of intraretinal edema and flattening of associated pigment epithelial detachment, which was confirmed by fluorescein angiography, optical coherence tomography, and high-speed indocyanine green angiography.     

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.     

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.     

Intravitreal triamcinolone and laser photocoagulation for retinal angiomatous proliferation

BACKGROUND: Recently, the entity of retinal angiomatous proliferation (RAP) as a subtype of exudative age-related macular degeneration was described, but no treatment options have been established as yet. The only two therapeutic modalities being discussed are surgical lysis of the feeding arteriole and draining venule, and the use of photodynamic therapy combined with intravitreal triamcinolone injection. AIM: To examine focal laser treatment of early extrafoveal intraretinal neovascularisation of RAP. METHODS: Prospective case series. We included 13 consecutive patients with an extrafoveal RAP stage I lesion. All patients underwent a complete ophthalmic examination, including fluorescein angiography and optical coherence tomography (OCT) III before treatment and at 2 weeks, 1, 2 and 4 months afterwards. In cases with marked macular oedema (>350 mum retinal thickening in OCT III, r = 12), intravitreal injection of 4 mg triamcinolone was given before focal laser treatment to reduce the oedema. RESULTS: This case series indicates anatomical improvement or stabilisation in patients with an extrafoveal RAP lesion after treatment. Initial visual acuity ranged from 0.1 to 0.6 on the Snellen chart. By calculating logarithmic values, visual acuity was seen to be improved in five cases (2 to 5 log lines), deteriorated in four cases (-2 to 5 log lines) and stabilised in four cases (-1 to +1 log line change). Exudation on fluorescein angiography was stopped in 11 cases. CONCLUSIONS: This preliminary case series suggests laser photocoagulation combined with prior intravitreal triamcinolone injection as a viable treatment option for RAP stage I. In cases with marked macular oedema, intravitreal triamcinolone injection improved visual acuity. For long-term stabilisation, additional laser treatment is mandatory. These preliminary results warrant a more detailed prospective clinical trial.     

Macular degeneration related to age and cystoid macular edema. Apropos of 95 cases (100 eyes)

The leakage from the new vessels, responsible for the exudative form of age-related macular degeneration (ARMD), produces retinal detachment, haemorrhages, exudates and intraretinal cystoid macular edema (CME). In a retrospective study of 100 eyes, we assessed the prognostic value of cystoid macular degeneration of the inner retina. It was nos specifically linked to: 1 - the duration of the neovascular involvement; 2 - the extent of the neovascular membrane; 3 - the location of the new vessels; 4 - the type of the new vessels; definite (48 eyes) or occult (19 eyes), or advanced and fibrous lesions (21 eyes). However, cystoid macular edema was initially associated to legal blindness in 46% of eyes. Active SNV associated with CME were retrofoveal in 83% of the eyes. But biomicroscopical evidence of CME requires fluorescein angiography to identify the new vessels still amenable to laser photocoagulation. After a follow-up period ranging from 30 days to 6 years (mean 15 months), 69% of eyes were legally blind although 41 eyes were treated with laser photocoagulation (focal or perifoveolar). Thus, functional prognosis in ARMD is not uniquely and directly correlated with the presence of cystoid macular edema in ARMD.     

Combined surgical ablation and intravitreal triamcinolone acetonide for retinal angiomatous proliferation

PURPOSE: Neovascular age-related macular degeneration (ARMD) with retinal angiomatous proliferation (RAP) has a poor natural history and the efficacy of any treatment has not yet been established. The authors describe a combined surgical treatment. METHODS: A 76-year-old woman presented with a best-corrected visual acuity (BCVA) of 20/600 in the right eye and macula with stage 3 RAP as identified by fluorescein angiography (FA), indocyanine green angiography (ICGA), and optical coherence tomography (OCT). After a standard three-port pars plana core vitrectomy (PPV), endodiathermy of the arteriolar and venous feeder vessels of each lesion was performed, intraretinal RAP feeder vessels were cut with manual vertical intraocular scissors, and 0.1 mL of triamcinolone acetonide (TAAC) was injected intravitreally. At 1 and 4 weeks and at the sixth month, the patient underwent a complete eye examination, FA, ICGA, and OCT to assess outcomes and complications. RESULTS: Six months later, BCVA was stable at 20/300, intraocular pressure was 15 mmHg, anterior segment and vitreous cavity were clear without evidence of TAAC granules, and retina was attached. FA and ICGA showed a complete occlusion of the RAP and absence of leakage or ischemia and OCT demonstrated decreased macular thickness with resolution of both intraretinal edema and pigment epithelium detachment, and the restoration of the normal macular profile. At the end of follow-up, the authors did not observe any ocular or systemic complication. CONCLUSIONS: Surgical approach to RAP stage 3 with intravitreal injection of 4 mg of TAAC was safe and anatomically effective.     

Photodynamic therapy for retinal angiomatous proliferations and pigment epithelium detachment

PURPOSE: To evaluate results of photodynamic therapy (PDT) with verteporfin for subfoveal neovascular age-related macular degeneration (ARMD) with retinal angiomatous proliferation (RAP) and pigment epithelial detachment (PED). DESIGN: Interventional case series. METHODS: Thirteen eyes (11 stage 2 and 2 stage 3 RAP) underwent PDT. Best-corrected visual acuity (BCVA), fluorescein and indocyanine-green angiography were performed to evaluate the outcome. RESULTS: After 13.5 +/- 2.5 months and 1.7 +/- 0.4 treatments, mean BCVA decreased from 20/73 to 20/174 (P = .04). Occlusion of RAP and flattening of PED was observed in three eyes, and persistence of PED in six. Two eyes deteriorated to disciform lesions, one developed hemorrhagic PED, and one evolved toward stage 3 RAP. Three eyes, with PED exceeding 50% of the entire lesion, developed retinal pigment epithelium tear. CONCLUSIONS: PDT might prove effective for neovascular ARMD with RAP and small PED, whereas it might cause acute retinal pigment epithelium tear for RAP with PED exceeding 50% of the lesion.     

玻璃体腔注射TA联合激光治疗非缺血型CRVO继发黄斑水肿

目的:评价玻璃体腔注射曲安奈德(intravitreal triamcinolo-ne acetonide,IVTA)联合激光治疗非缺血型视网膜中央静脉阻塞继发黄斑水肿的临床效果。方法:将非缺血型视网膜中央静脉阻塞继发黄斑水肿56眼随机分为两组:IVTA联合532半导体激光黄斑部光凝(治疗组)30眼,单独行532半导体激光黄斑部光凝治疗(对照组)26眼。每组在治疗前后查最佳矫正视力、眼压、眼底荧光血管造影(fluorescein fundus angiography,FFA)了解黄斑部荧光渗漏情况、光学相干断层扫描(optic coher-ent tomography,OCT)测量黄斑区视网膜厚度变化。治疗组为先行黄斑格栅样光凝,2wk后进行IVTA4mg。结果:治疗后3mo时,在治疗组中,23眼(77%)视力提高,7眼(23%)视力不变;FFA示黄斑部荧光渗漏明显减轻;黄斑中心凹平均厚度为(170±32)μm。在对照组中,15眼(58%)视力提高,11眼(42%)视力不变;FFA示黄斑部荧光渗漏减轻;黄斑中心凹平均厚度为(223±57)μm。两组视力变化及黄斑中心凹平均厚度改变比较差异有统计学意义(χ2=4.20,χ2=5.13,P<0.01)。结论:IVTA联合激光治疗非缺血型视网膜中央静脉阻塞继发黄斑水肿效果较好。     

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.     

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.     

Systemic bevacizumab for retinal angiomatous proliferation associated with retinal pigment epithelial detachment

PURPOSE: To report the off-label use of systemic bevacizumab in a patient with stage 3 retinal angiomatous proliferation (RAP) associated with a vascularized pigmented epithelium detachment (PED). METHODS: Interventional case report. RESULTS: The patient was treated with systemic bevacizumab after obtaining fully informed consent. At 3 months post-treatment, the authors observed an improvement of one line (seven letters) in visual acuity and total regression of the PED on ocular coherence tomography. No adverse effects were observed. CONCLUSIONS: Systemic bevacizumab therapy appears to be safe and effective in the treatment of RAP associated with PED during this short follow-up period of 3 months. The authors recommend a large trial with long-term follow-up to confirm the promising results and evaluate the occurrence of adverse effects associated with systemic bevacizumab.     

视网膜血管瘤样增生的诊断与治疗

视网膜血管瘤样增生(retinal angiomatous proliferation,RAP)是湿性老年性黄斑变性(age-related macular degeneration,AMD)隐匿性新生血管的另一种病变形式,起源于黄斑旁视网膜深层毛细血管层,以多发性小灶状视网膜内出血、视网膜色素上皮脱离(pigment epithelial detachment,PED)、视网膜-脉络膜血管吻合(retinal-choroidal anastomosis,RCA)为特点,对视力损害严重。本文对近年来的有关文献进行复习,并就RAP的发病机制、临床分期、诊断特点、治疗及预后进行综述。     

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。     

Krypton red laser photocoagulation for branch retinal vein occlusion

Krypton red (647 nm) laser photocoagulation may offer distinct advantages in the treatment of branch retinal vein occlusion (BRVO), particularly in eyes with extensive intraretinal hemorrhage or in the presence of media opacities such as vitreous hemorrhage or cataract. Twenty-three eyes were followed for a minimum of 6 months (range, 6-38). Of 19 eyes treated for macular edema, 17 (89%) had complete resolution of their edema, one (5%) had reduction of its edema, and one (5%) was unchanged. Of five eyes treated for retinal neovascularization of the disc or retina, all eyes had complete elimination of neovascularization. The authors were unable to demonstrate any statistical correlation between final visual acuity and the following factors: duration of symptoms, cystoid macular edema (CME), degree of paramacular nonperfusion, and contiguous intraretinal hemorrhage extending into the foveal avascular zone (FAZ).     

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.     

Optical cross-sectional observation of resolved diabetic macular edema associated with vitreomacular separation

PURPOSE: To describe the resolution of cystoid macular edema associated with vitreomacular separation in a diabetic patient. METHODS: Case report. A 58-year-old man who had cataract surgery 3 years earlier developed diabetic macular edema after panretinal laser photocoagulation. For a detailed fundus examination, we performed neodymium: YAG (Nd:YAG) laser capsulotomy in the left eye as the initial management. RESULTS: Two days after the laser capsulotomy, fundus biomicroscopy and B-mode ultrasonography disclosed a vitreomacular separation in the left eye that was not detectable preoperatively. Optical coherence tomography through the macula disclosed a dramatic decrease in the size of intraretinal cystoid spaces with an improvement of visual acuity. Scanning retinal thickness analysis also confirmed the decrease of retinal thickness at the macula with the resolution of cystoid macular edema. CONCLUSION: Resolution of diabetic macular edema with subsequent visual recovery is potentially associated with the vitreomacular separation in a patient after Nd:YAG laser capsulotomy.     

Remodeling of the vascular channels in retinal angiomatous proliferations treated with intravitreal triamcinolone acetonide and photodynamic therapy

Background The objective was to describe the remodeling of the vascular channels in stage II retinal angiomatous proliferation (RAP) treated by intravitreal injections of triamcinolone acetonide (TA) and subsequent photodynamic therapy (PDT). Methods Stage II RAP secondary to age-related macular degeneration was documented by dynamic digital fluorescein and indocyanine green angiography in 3 consecutive patients (3 eyes). All eyes were treated with intravitreal injection of TA (4 mg, 0.1 ml) followed by PDT 5–10 days later. Results Indocyanine green angiography (ICGA) revealed a complete remodeling of the vascular structure of the three RAPs after treatment. The feeding retinal artery, which shunted a major part of the blood flow from the original arteriole toward the intraretinal neovascular complex before treatment, regained a normal appearance after treatment. With RAP closure, the blood flow was again directed through the original retinal arteriole, and the connection to the RAP was no longer visible. Conclusions Stage II RAPs are difficult lesions to treat. A real remodeling of the vascular lesion is achieved with the combined use of intravitreal TA and PDT. This finding corroborates the need for randomized clinical trials currently under way to evaluate this combination treatment in wet, age-related macular degeneration.     

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     

Intravitreal injection of bevacizumab (Avastin) for retinal angiomatous proliferation

CLINICAL CASE: An 81-year-old man presented with stage 2 retinal angiomatous proliferation (RAP) as identified by fluorescein angiography and optical coherence tomography (OCT), and was shown to have a visual acuity (VA) of 20/40. One week after an intravitreal injection of bevacizumab (1.25 mg) the VA improved to 20/25, and the OCT showed a reduction of both intraretinal edema and pigment epithelium detachment. Three months after the injection, no ocular complications were observed, VA was 20/20 and the OCT showed an almost normal macular contour. DISCUSSION: Intravitreal injection of bevacizumab may provide another treatment option for patients with RAP.