[Chronic central serous chorioretinopathy (cCSC): differential diagnosis to choroidal neovascularisation (CNV) secondary to age-related macular degeneration (AMD)]. / Chronische RCS (chronic Central Serous Chorioretinopathy cCSC) als Differenzialdiagnose der feuchten, altersbedingten Makuladegeneration (AMD).

Central neurosensory detachments (NSD) with time-dependent height constitute a disease called central serous chorioretinopathy (CSC), if not arising from uveitis, choroidal neovascularisations (CNV) or leaking retinal vessels. In 10 % of these patients, CSC develops into a chronic disease with recurrent NSD, atrophy of photoreceptors and severe drop in visual acuity. This review article summarises recent progress in understanding this disease and its appearance in funduscopy, FLA, ICG, OCT, autofluorescence as well as its progress, therapy and possible development into secondary CNV. The provided examples illustrate the progression of acute CSC into chronic CSC and with CNV over years. The different appearance of polypoidal choroidal vasculopathy (PCV) in ICG and some of the signs of atypical chronic CSC are discussed. To distinguish between cCSC and wet AMD--both exhibiting leakage in FLA--typical signs are helpful, e.g., "gravitational tracks", retinal precipitates and missing drusen. However, in small lesions, it may be difficult or almost impossible to ensure the correct diagnosis of the underlying disease. The same holds for occult and classic secondary CNV in cCSC vs. CNV in AMD, where photodynamic therapy (PDT) can be successful only in cCSC-CNV and in cCSC without CNV. Corticosteroids often lead to further impairment, even in cases of atypical cCSC, when frequently misdiagnosed as uveitis. As a duration of NSD of more than 4 months is suspected to induce an impairment of photoreceptors, regular examinations are necessary not only in chronic CSC but also after acute CSC (as this form can develop into chronic CSC), while effective therapies are available to resolve the NSD (PDT, anti-VEGF).

[Morphological features of myopic choroidal neovascularization: differences to neovascular age-related macular degeneration]. / Morphologische Charakteristika der myopen choroidalen Neovaskularisation: Unterschiede zur neovaskulären altersabhängigen Makuladegeneration.

Choroidal neovascularization due to pathological myopia (mCNV) differs in important characteristics from lesions seen in age-related macular degeneration (ARMD). Myopic CNV is associated with typical phenomena, such as lacquer cracks or patchy atrophy drusen or pigment epithelium detachment are rare occurrences. The dimensions of mCNV and the extent of leakage are substantially smaller. The heterogeneous combination of thinning and concomitant staphyloma often complicates the early detection of neovascular lesions. Diagnosis and evaluation of the clinical progress are only possible using the combination of different imaging modalities, e.g. funduscopy, fluorescein angiography (FLA) and spectral domain optical coherence tomography (SD-OCT). Special forms, such as periconal mCNV or dome-shaped variants exhibit a typical progression and response to therapy. In the course of the disease a progressive pigmentation and secondary atrophy occur and later, depigmentation of the mCNV complicates the demarcation of the original mCNV within the zone of atrophy. Extensive information and counselling seem to be mandatory in order to allow a better self-assessment. Sometimes, patients notice the first symptoms of recurrent mCNV activity before confirmation is possible by objective diagnostics.

[Spectral domain optical coherence tomography in the treatment of myopic choroidal neovascularization]. / Spectral-Domain-optische-Kohärenztomographie in der Behandlung der myopen choroidalen Neovaskularisationsmembran.

Spectral domain optical coherence tomography (SD-OCT) investigations provide additional information about the morphological characteristics of myopic choroidal neovascularization (mCNV). Reproducible measurements of intraretinal and subretinal fluid are of growing importance for an evaluation of progression. The non-invasive technique reduces the need for frequent fluorescence angiography after individual assessment. Appropriate correction of the reference arm is mandatory. Automatic adjustment of transversal measured values due to alterations in the paraxial field (depending on the axial length) has been implemented in a new device. Mirror artefacts and excess curvature can be avoided by reducing the length of the OCT cross-section (15°). New possibilities to record the choriocapillaris and choroid have expanded the knowledge of potential pathomechanisms and risk factors.

[Clinical relevance of a new digital integration method (DIM) for the precise integration of OCT and fluorescein angiography (FLA)]. / Die Bedeutung der digitalen Integrationsmethode (DIM) von OCT und FLA für die klinische Anwendung.

BACKGROUND: We describe the establishment of a new digital integration method (DIM) for the anatomically precise and objective correlation of OCT and FLA. The aim of the study was to evaluate the clinical impact of DIM and deduce possible new knowledge in unclear angiographic findings. PATIENTS AND METHOD: DIM uses a newly developed software for the integration of OCT and FLA images of the same date. Corresponding vascular bifurcations and OCT scan position are marked in OCT and FLA images. Pathological areas in OCT or FLA can be marked and compared. A fundus enhancement system (FES) was developed for a better fundus image quality in OCT. Using a retinal tracking system (RTS) eye movements can be compensated. DIM was evaluated in 225 patients with macular diseases. RESULTS: Using FES, the DIM was successful in 95 % of the patients in contrast to 25 % without FES. Using the video system of RTS eye movement artefacts could be compensated in all patients. Cases with clear angiographic findings showed a high correspondence (66 %) with the OCT findings. A discrepancy between FLA and OCT findings was found in 33 %, especially in leakages of unknown origin. DIM was of high value in age-related macular degeneration (AMD), detecting a heterogeneous morphology of serous, solid RPE detachments, retinal cystoid formation and choroidal neovascularisation (CNV) and differentiating it in a precise topography. The lesion size of classic CNV with a hypofluorescent halo was in OCT always larger than in FLA. CONCLUSION: Through the correction of the eye movement artefacts by DIM and FES, a fundamental weak point in the previous OCT pictures is counterbalanced. Using DIM the OCT scan position for the follow-up can now be assessed in a safe and reliable manner which is mandatory for the evidence of OCT studies. The detection of precise morphology (serous RPE detachments) in angiographically unclear phenomena can lead to treatment consequences, e. g., avoiding contraindicated areas in photodynamic therapy. Using the new morphological information new knowledge is obtained on uncertain angiographic phenomena by this integration method (DIM).

Retinal pigment epithelial tears after single administration of intravitreal bevacizumab for neovascular age-related macular degeneration.

PURPOSE: To analyse retinal pigment epithelial (RPE) tears following single administration of intravitreal bevacizumab for neovascular age-related macular degeneration (AMD) during early follow-up. METHODS: Interventional, retrospective, non-comparative case series included 397 patients (409 eyes) of the 746 consecutive patients that met the eligibility criteria. Standardized visual acuity testing, fluorescein angiography, and optical coherence tomography were performed. Data collected included status of the fellow eye, previous treatment, subtypes of choroidal neovascularization (CNV), size and composition of the lesion. Multiple linear regression modelling was used to explore the effect of baseline parameters on the RPE tears. Primary end point was occurrence of RPE tears within 6 weeks after therapy. RESULTS: Fifteen of the 409 eyes (3.6%) developed RPE tear (95% confidence interval: 2.2-6.0, odds ratio: 26.3). The statistical modelling showed significant association between RPE tear and occult without classic CNV/predominantly haemorrhage vspredominantly/minimal classic CNV (P=0.019), as well as medium or large (>4 disc area) vssmall size of the total lesion (P=0.038). Previous treatment and status of the fellow eye did not statistically influence the risk of RPE tears. CONCLUSIONS: An RPE tear can develop in up to 3.6% of eyes with neovascular AMD following single administration of intravitreal bevacizumab in a short-term follow-up. Medium and large lesion size and occult without classic and predominantly haemorrhagic subtype of CNV were important predictive factors. Preoperative assessment of the lesion characteristics may help in identifying the risk of individual patients with neovascular AMD before intravitreal bevacizumab treatment.

Can the risk of retinal pigment epithelium tears after bevacizumab treatment be predicted? An optical coherence tomography study.

BACKGROUND: Retinal pigment epithelium (RPE) tears after bevacizumab treatment for neovascular age-related macular degeneration accompanied by a pigment epithelial detachment (PED) might be caused by stretching forces on the already weakened RPE. The purpose of this study was to evaluate whether simple measurements of optical coherence tomography (OCT) can predict the individual risk of an RPE tear in preoperative candidates. METHODS: A retrospective chart review study of 393 consecutive patients with neovascular age-related macular degeneration evaluated OCT images (Stratus-OCT Zeiss, Jena, Germany). The height of the PED, the central retinal thickness, and the maximum retinal thickness were determined by two independent observers and retrospectively analysed. RESULTS: Fifteen patients with an RPE tear had a significant higher PED than the remaining study population. In contrast, no correlation was seen with the central retinal thickness. In a linear regression model, the probability of an RPE tear exponentially increased in dependence of the extent of PED. CONCLUSION: The risk of an RPE tear can be estimated by simple measurement of the height of the PED on OCT.

[Early antiexudative response--OCT monitoring after intravitreal bevacizumab injection]. / Früher antiexsudativer Effekt--OCT-Monitoring nach intravitrealer Bevacizumab-Applikation.

VEGF is more potent than histamine by a factor of 50,000 for inducing increased vessel permeability. Already in the first few minutes, hydraulic conductivity and diffusive permeability are significantly increased, followed by a longer-lasting, marked leakage over 20 h. Specific inhibition of the angiogenic, vasoactive, and permeability-inducing protein VEGF is now possible by new drugs, one of which is the first available (off-label) treatment in Germany for routine clinical use (Avastin). Retinal edema is composed of increased outflow of water and low molecular substances in the interstitial environment and is an important determinate of functional development in different ocular diseases. First experiences with the anti-hyperpermeability effect show early response and high potential in pathologic leakage. Future examinations have to assess when a permanent benefit can be achieved in respect to the other antiproliferative capabilities of the drug.

Verteporfin photodynamic therapy induced apoptosis in choroidal neovascular membranes.

AIM: To evaluate the impact of verteporfin photodynamic therapy (PDT) on the induction of apoptosis in choroidal neovascular membranes (CNV) secondary to age related macular degeneration. METHODS: Retrospective review of 22 surgically excised CNV. 12 of these patients had been treated with PDT 3-146 days previously. Apoptotic cells were detected with the TUNEL technique and compared to the expression of CD34 (endothelial cells, EC), CD105 (activated endothelial cells), Ki-67 (proliferation marker), and cytokeratin18 (retinal pigment epithelial cells, RPE). RESULTS: CNV excised 3 days after PDT were characterised both by collapsed and patent vessels. The EC displayed a statistical significant positive TUNEL reaction when compared to the remaining treated CNV (p < 0.001) and untreated CNV (P = 0.002). The proliferative activity was reduced. CNV excised 1-5 months after PDT displayed a patent vascularisation and high proliferative activity. All membranes either treated or untreated disclosed only sporadic TUNEL positive cells within the stroma and the RPE. CONCLUSIONS: Verteporfin PDT leads to selective and effective damage of EC within CNV. Both patent and occluded vessels were lined by apoptotic EC. This finding and the increased expression of proliferation marker at later time points suggest that revascularisation after PDT is caused by angiogenesis rather than recanalisation.

Clinicopathological findings of choroidal neovascularisation following verteporfin photodynamic therapy.

AIMS: To report the clinicopathologic findings of surgically excised choroidal neovascularisation (CNV) three days after verteporfin photodynamic therapy (PDT). METHODS: In three patients (three eyes) with age related macular degeneration, the CNV was surgically removed three days after PDT. The CNV specimens were examined by light microscopy. RESULTS: The patients had subfoveal classic CNV. Fluorescein angiography revealed non-perfusion of the CNV after PDT and before surgery in all eyes. The light microscopy of the CNV membranes showed swollen and damaged endothelium. Thrombus formation or vascular occlusion in the CNV vessels was not detected. CONCLUSION: PDT did not cause a thrombosis of the vessels within the CNV three days after PDT. Severe endothelial damage of the CNV was observed and is likely a primary effect of PDT. Non-perfusion of the CNV at this stage is possibly secondary to occlusion at a deeper level, namely the underlying feeding choroid.

Retinal pigment epithelial tear after photodynamic therapy for choroidal neovascularization.

PURPOSE: To report a case of retinal pigment epithelial tear after photodynamic therapy for choroidal neovascularization. METHODS: Case report. A 74-year-old woman with exudative age-related macular degeneration and classic subfoveal choroidal neovascularization RE underwent photodynamic therapy with verteporfin. RESULTS: Ophthalmoscopy and fluorescein angiography RE disclosed a retinal pigment epithelial tear in the area of photodynamic therapy. CONCLUSION: This case presents the first report of a retinal pigment epithelial tear after photodynamic therapy with verteporfin for subfoveal choroidal neovascularization in age-related macular degeneration.

[Clinical characteristics of idiopathic polypoidal choroid vasculopathy]. / Klinische Charakteristika der idiopathischen polipoiden choroidalen Vaskulopathie.

BACKGROUND: Originally, idiopathic polypoidal choroidal vasculopathy (IPCV) was thought to present as a bilateral disorder with peripapillary location of the polipoidal lesions in predominantly black patients. Until now, only a few patients have been described in Europe. MATERIALS AND METHODS: A retrospective study of the clinical spectrum of nine Caucasian patients with IPCV using standard clinical fluorescein and indocyanine green angiography (ICGA) techniques. RESULTS: ICGA demonstrated the typical vascular dilatations in the inner choroid in all patients. The polypoidal lesions were unilateral in six, bilateral in three patients, isolated in the macular in six and peripapillar in three patients. During the course of follow-up (range 6-92 months, mean 29.4 months) vitreous hemorrhage occurred in one eye, the polypoidal lesions spontaneously disappeared in three eyes and new lesions grew in two eyes. Laser photocoagulation was beneficial in three out of five treated eyes. CONCLUSION: The clinical manifestations of IPCV overlap with those of exudative age-related macular degeneration and central serous retinopathy. However, there are differences in the natural course, the visual prognosis and the response to laser treatment. ICGA is helpful to differentiate these entities.

Indocyanine green angiography in classic choroidal neovascularization.

The indocyanine green (ICG) angiographic features of classic choroidal neovascularization (CNV) were evaluated in the 66 consecutive patients (70 eyes) by ICG angiography using the scanning laser ophthalmoscope. All patients had classic CNV documented by fluorescein angiography. Indocyanine green angiographic findings of classic CNV were as follows: Vessel architecture in 66% (46 of 70) of eyes, feeding vessels in 29% (20 of 70), and late hyperfluorescence in 93% (65 of 70) of eyes. Borders of classic CNV were found well-defined in 47% (33 of 70), and ill-defined in 49% (34 of 70) of eyes. In the remaining 4% (3 of 70) of eyes ICG angiography did not detect CNV. Our study indicates that fluorescein angiography remains the method of choice in the diagnosis of classic CNV. Indocyanine green angiography provides more information in the detection of feeding vessels of classic CNV.

Detection of choroidal aneurysms with indocyanine green videoangiography.

BACKGROUND: Aneurysms of the choroidal vasculature have been described only in histopathological studies. METHODS: Indocyanine green videoangiograms obtained with the scanning laser ophthalmoscope from 32 patients with geographic atrophy were reviewed. RESULTS: In 8 of 32 patients indocyanine green videoangiography (ICGVA) showed hyperfluorescent aneurysms along choroidal arteries. The same aneurysmal formations were found in two of the eight patients on very early images of fluorescein videoangiography before dye leakage occurred. Seven of eight patients with choroidal aneurysms had a history of hypertension. CONCLUSIONS: ICGVA is a useful diagnostic tool in detecting choroidal aneurysms. Multiple mechanisms are probably involved in the pathogenesis of choroidal aneurysms, among them the higher hemodynamic stress in the macular region, hypertension and aging.

Indocyanine green videoangiography of occult choroidal neovascularization: a comparison of scanning laser ophthalmoscope with high-resolution digital fundus camera.

PURPOSE: To compare the indocyanine green (ICG) angiographic findings of occult choroidal neovascularization (O-CNV) taken by scanning laser ophthalmoscope and high-resolution digital fundus camera. METHODS: We examined 100 eyes of 100 consecutive patients with ICG angiographic evidence of CNV secondary to age-related macular degeneration. All patients were diagnosed with O-CNV based on fluorescein angiography. Indocyanine green videoangiography was carried out using the scanning laser ophthalmoscope and high-resolution digital fundus camera at the same session. RESULTS: Indocyanine green videoangiography revealed well-defined vessel structure of the O-CNV in 28% of eyes examined by scanning laser ophthalmoscope and in 8% of eyes examined by digital fundus camera. Well-defined focal spots were demonstrated in 37% of eyes examined by scanning laser ophthalmoscope and in 52% of eyes examined by digital fundus camera. Plaques (well-defined) were found in 13% and 35% of eyes examined by scanning laser ophthalmoscope and digital fundus camera, respectively. CONCLUSION: Indocyanine green videoangiography with scanning laser ophthalmoscopy seems to be superior to the digital fundus camera in delineation of the vessel architecture of O-CNV. Focal spots and plaques are best detected by digital fundus camera.