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 choroidal anastomoses and occult choroidal neovascularization in age-related macular degeneration.

OBJECTIVE: This study was designed to identify the incidence of retinal choroidal anastomoses in patients with occult choroidal neovascularization (CNV) and focal hot spots on indocyanine green (ICG) angiography, to identify the clinical and angiographic features that would assist in their identification, and to determine if the presence of these anastomotic lesions affect the outcome of laser therapy. DESIGN: Combined prospective and retrospective cross-sectional study. PARTICIPANTS: One hundred fifty consecutive patients with newly diagnosed occult CNV secondary to exudative age-related macular degeneration and focal hot spots on ICG angiography were evaluated prospectively. In addition, a retrospective review was performed on 79 eyes previously reported to have undergone laser photocoagulation treatment with ICG guidance. METHODS AND TESTING: In all cases, stereo color and red-free photographs, and stereo fluorescein and digital ICG angiograms were obtained for evaluation. MAIN OUTCOME MEASURES: Images obtained by all four techniques were evaluated for the presence of a retinal choroidal anastomosis. Associated clinical and angiographic findings were noted. In the retrospective review, the success rate of laser treatment was correlated with the presence or absence of a retinal choroidal anastomosis. RESULTS: Of the 150 eyes evaluated prospectively, 31 (21%) were found to have a retinal choroidal anastomosis. Retinal choroidal anastomoses were found in 27% of patients with associated serous pigment epithelial detachment (PED), whereas 13% were found in those without an associated elevation of the retinal pigment epithelium. Seventy-one percent of eyes had multiple anastomotic connections. Ninety percent of eyes had at least one retinal vein involved in the anastomotic connection. Clinical evidence of preretinal and intraretinal hemorrhage and cystic edema coupled with angiographic evidence of intraretinal dye leakage were key features of retinal choroidal anastomoses. In the retrospective review, seven patients were found to have retinal choroidal anastomoses with associated serous PED and demonstrated a very low (14%) success rate for laser treatment. CONCLUSIONS: Retinal choroidal anastomoses can present as a primary manifestation of the exudative process in age-related macular degeneration. They may be seen in eyes with and without detachment of the retinal pigment epithelium. Specific clinical and angiographic features have been identified that can aid in the diagnosis of these vascular anomalies. Their presence represents a poor prognostic sign for successful ICG-guided laser treatment.

Polypoidal choroidal vasculopathy masquerading as central serous chorioretinopathy.

OBJECTIVE: To differentiate polypoidal choroidal vasculopathy (PCV) from central serous chorioretinopathy (CSC). DESIGN: A retrospective, observational case series. PARTICIPANTS: Thirteen patients originally diagnosed with CSC proved to have PCV after more extensive evaluation and follow-up. METHODS: A clinical and angiographic review of patients with manifestations of CSC, including macular detachment. MAIN OUTCOME MEASURES: Demographic data, funduscopic examination, and fluorescein and indocyanine green (ICG) angiographic findings. RESULTS: Thirteen patients initially suspected of having CSC were ultimately diagnosed as having PCV. These eyes had exudative macular detachments secondary to a small caliber, polypoidal choroidal vascular abnormality or so-called polypoidal choroidal neovascularization. The clinical manifestations in the fundus varied. They included multiple, variably sized serous pigment epithelial detachments, neurosensory retinal detachment, lipid deposition, patchy atrophy of the pigment epithelium and indistinct staining from decompensation of the posterior blood-retinal barrier on fluorescein angiography. In reality, the suspected PEDs proved to be polypoidal lesions of PCV when imaged with ICG angiography. CONCLUSIONS: The clinical diagnosis of CSC or PCV generally poses little challenge to the experienced retinal specialist. However, in CSC with persistent and/or recurrent exudation, a myriad of retinal pigment epithelial changes may evolve that make it difficult to differentiate these two entities. In such patients, ICG angiography is useful in differentiating CSC from PCV. An accurate clinical diagnosis is important since each of these entities, CSC and PCV, may differ in terms of their risk factors, natural course, and visual prognosis.

Polypoidal choroidal vasculopathy and neovascularized age-related macular degeneration.

OBJECTIVE: To determine the nature and frequency of polypoidal choroidal vasculopathy (PCV) in a series of patients suspected of having neovascularized age-related macular degeneration (AMD). METHODS: A prospective analysis of 167 consecutive, newly diagnosed patients aged 55 years or older with presumed neovascularized AMD was performed. All patients were examined with fundus biomicroscopy as well as fluorescein and indocyanine green angiography. RESULTS: Choroidal neovascularization secondary to AMD was diagnosed in 154 (92.2%) of 167 patients; 13 (7.8%) patients had PCV. The patients affected by PCV were younger than those with AMD (P = .01). Peripapillary choroidal neovascularization was seen in 3 (1.9%) of 154 patients with AMD and 3 (23.1%) of 13 patients with PCV (P = .006). Significant drusen were present in 63 (70%) of 90 fellow eyes with unilateral AMD compared with only 1 (16.7%) of 6 eyes with PCV (P = .02). Only 5 patients with AMD (3.2%) were nonwhite compared with 3 patients with PCV (23.1%) (P = .02). CONCLUSIONS: A measurable number of elderly patients with findings suggestive of neovascularized AMD and serosanguineous macular manifestations will instead have PCV. Polypoidal choroidal vasculopathy can occur in any sex or race, but is more commonly seen in the peripapillary area, without associated drusen, and in nonwhite patients. It is important to differentiate AMD from PCV because there are significant differences in the demographic risk profile, natural course, visual prognosis, and management of these patients.

Indocyanine-green videoangiography of drusen as a possible predictive indicator of exudative maculopathy.

OBJECTIVE: Recent studies have shown that indocyanine-green videoangiography (ICG-V) is useful to image occult choroidal neovascularization. The authors studied the ICG-V findings in fellow drusen eyes of patients with unilateral exudative age-related macular degeneration (AMD). The authors also studied the occurrence of exudative changes to determine whether ICG-V is useful in predicting future exudative changes in these eyes with only drusen. DESIGN: Cohort study. PARTICIPANTS: The authors studied 432 consecutive patients diagnosed with unilateral exudative AMD in whom the fellow eye had only drusen by clinical fundus examination and fluorescein angiography. All of these eyes had ICG-V performed. Follow-up data were obtained in all eyes with abnormal indocyanine-green (ICG) angiograms and randomly sampled ICG angiograms of normal eyes. MAIN OUTCOME MEASURES: The initial ICG findings were classified as showing normal or abnormal hyperfluorescence. Abnormal hyperfluorescence eyes were subdivided into focal spots (focal areas of hyperfluorescence < 1 disc area in size) and plaques (areas of hyperfluorescence > 1 disc area). The development of exudative changes in eyes with normal and abnormal hyperfluorescence was compared. RESULTS: Of the 432 fellow eyes, 386 (89%) eyes with drusen had a normal ICG-V study, whereas 46 (10 focal spots and 36 plaques) (11%) eyes had an abnormal ICG-V. Exudative changes occurred in 6 (10%) of 58 normal ICG eyes and 9 (24%) of 38 eyes with abnormal ICG findings during a mean follow-up period of 21.7 months. The difference between drusen eyes with normal ICG angiograms and those with plaques on ICG-V regarding future exudative changes (10% vs. 27%, respectively) was statistically significant (P = 0.038). CONCLUSIONS: Abnormal ICG findings were found in 11% of eyes with clinically and fluorescein angiographically nonsuspicious drusen. The subgroup of patients with plaques on ICG-V had a higher chance of having exudative changes develop. Indocyanine-green videoangiography may be a predictive indicator of future exudative changes in eyes with drusen. A much larger prospective study seems justified.

Digital subtraction indocyanine green angiography of occult choroidal neovascularization.

OBJECTIVE: This study aimed to use a new technique for ocular imaging, digital subtraction indocyanine green angiography (DS-ICGA), to evaluate patients with occult choroidal neovascularization (CNV). DESIGN: The design was a cross-sectional study of patients with occult CNV. PARTICIPANTS: A total of 31 eyes of 31 patients were studied. INTERVENTION: Digital subtraction of sequentially acquired indocyanine green angiographic frames was used to image the progression of the dye front in eyes with occult CNV. A method of pseudocolor imaging of the choroid was developed that allows differentiation and identification of underlying choroidal arteries and veins. RESULTS: The DS-ICGA of occult CNV showed consistent findings. Occult CNV was imaged with greater detail and in a shorter period of time than with conventional indocyanine green angiography. The fundus landmarks were retained with DS-ICGA much better than with conventional indocyanine green angiography. CONCLUSIONS: The DS-ICGA uses time to dissect the choroidal circulation. With DS-ICGA, occult CNV could be imaged more quickly and in greater detail than with conventional imaging techniques. The DS-ICGA may improve the authors ability to image, and subsequently treat, occult CNV.

Wide-angle indocyanine green angiography.

BACKGROUND: Evaluation of the vasculature and blood flow in the fundus is limited by the small field of view of conventional fundus cameras. We sought to develop an easy method to image wide areas of the fundus. METHODS: Wide-angle contact fundus lenses with antireflective coatings in the infrared range were placed on the eye and indocyanine green angiography was done on the fundus through the contact lenses. More than 50 patients with varying fundus pathology have been examined. RESULTS: The angular field of view using this method can reach 160 degrees. Obtaining angiograms where the field of view extended anterior to the ora serrata was simplified, and studying the choroidal vasculature in detail was possible. In addition, imaging of entities such as peripheral choroidal neovascularization and choroidal tumors was enhanced with the present technique as compared with conventional techniques. CONCLUSIONS: Angiography through wide-angle fundus lenses is an easy and inexpensive method of visualizing large areas of the fundus. This technique may help improve our ability to image the angioarchitecture, hemodynamics, and pathologic changes in the retina and choroid.

Indocyanine green angiography of multifocal choroiditis.

PURPOSE: The purpose of the study is to determine indocyanine green (ICG) angiographic characteristics of patients with multifocal choroiditis (MC) and to identify features that may assist in the differentiation of MC from other ocular inflammatory diseases. METHODS: After complete ophthalmologic examination, fluorescein angiography and ICG angiography were performed in a series of 14 patients with MC. The ICG findings were then correlated with the clinical and fluorescein angiographic appearance of these patients to determine specific characteristics and distinguishing features of the entity. These findings then were compared with those of angiographic patterns observed in patients with ocular histoplasmosis syndrome to determine whether differentiating features could be identified. RESULTS: Fourteen (50%) of the 28 eyes were found to have large hypofluorescent spots in the posterior pole on ICG angiography, which, in most cases, did not correspond to clinically or fluorescein angiographically detectable lesions. Seventeen (61%) had smaller hypofluorescent lesions (approximately 50 pm in size) in the posterior pole on the ICG study. In seven eyes exhibiting enlarged blind spots on visual field testing, ICG angiography showed confluent hypofluorescence surrounding the optic nerve. The ICG angiogram was found useful in evaluating the natural course in two patients with MC as well as a response to oral prednisone therapy in four others. The ICG angiographic findings differed from those seen in patients with ocular histoplasmosis. CONCLUSIONS: Indocyanine green angiography can provide information that is not detectable by clinical or fluorescein angiographic examination in patients with MC. This information may prove useful in differentiating this condition from the ocular histoplasmosis syndrome, provide a better understanding of the natural course and progression of the disease, and provide a potential adjunct in the clinical evaluation of patients undergoing therapeutic regimens for active inflammatory lesions.

The expanding clinical spectrum of idiopathic polypoidal choroidal vasculopathy.

OBJECTIVE: To expand the clinical spectrum of idiopathic polypoidal choroidal vasculopathy based on historical cases and newly recognized observations. METHODS: A review of the previously reported 45 cases was carried out. An additional 20 cases were retrospectively reviewed to examine the clinical nature and course of idiopathic polypoidal choroidal vasculopathy. RESULTS: New observations on the clinical spectrum of idiopathic polypoidal choroidal vasculopathy were noted for demographic features, the nature and course of the vascular lesion, the possible association with intraocular inflammation, and the indocyanine green angiographic characteristics. CONCLUSIONS: Idiopathic polypoidal choroidal vasculopathy seems to be a distinct clinical entity that has a predilection for individuals of pigmented races. The disorder should be differentiated from typical choroidal neovascularization and other known choroidal degenerative, inflammatory, and ischemic disorders because of differences in clinical course and treatment.

Classification of choroidal neovascularization by digital indocyanine green videoangiography.

PURPOSE: The majority of patients with exudative maculopathy due to age-related macular degeneration present with poorly defined or occult choroidal neovascularization (CNV) that cannot be imaged adequately by fluorescein angiography. Digital indocyanine green (ICG) videoangiography is a new technique that allows enhanced imaging of these poorly defined or occult vessels. The authors studied 1000 consecutive cases of occult CNV using digital ICG angiography to describe the various types of neovascularization observed by this technique and to determine the frequency and natural history of the various lesions. MATERIALS AND METHODS: Digital ICG videoangiography was performed as described previously on 1000 consecutive eyes with occult CNV by fluorescein angiography. RESULTS: One thousand consecutive eyes with occult CNV by fluorescein angiography were imaged using digital ICG videoangiography. Three morphologic types of CNV were noted by ICG videoangiography, which included focal spots, plaques (well-defined or poorly defined), and combination lesions (in which both focal spots and plaques are noted). Combination lesions can be subdivided into marginal spots (focal spots at the edge of plaques of neovascularization), overlying spots (hot spots overlying plaques of neovascularization), or remote spots (a focal spot remote from a plaque of neovascularization). The relative frequency of these lesions was as follows: there were 283 cases (29%) of focal spots; 597 cases (61%) of plaques, consisting of 265 cases (27%) of well-defined plaques and 332 cases (34%) of poorly defined plaques; and 84 cases (8%) of combination lesions, consisting of 35 cases (3%) of marginal spots, 37 cases (4%) of overlying spots, and 12 cases (1%) of remote spots. In seven additional cases (1%), a mixture of the above lesions was noted. In 13 additional eyes (1%), no lesions were noted on the ICG angiogram. The studies of 16 eyes were unreadable or unobtainable. CONCLUSIONS: There are three types of CNV that can be observed by digital ICG videoangiography. Plaques are the most common type and have a poor natural history. Focal spots or hot spots are the next most frequently seen lesion and can potentially be treated by ICG-guided laser photocoagulation. Combination lesions, in which both focal spots and plaques are present, are rare. This study of 1000 consecutive cases of eyes with occult neovascularization that were imaged with digital ICG videoangiography serves to classify the various types of neovascularization observed by this technique. Digital ICG videoangiography is an important tool in better delineating eyes with occult CNV. Future studies are necessary to validate our findings.

Central serous chorioretinopathy in younger and older adults.

PURPOSE: The purpose of the study is to investigate the demographic characteristics and clinical findings of central serous chorioretinopathy (CSC). METHODS: This study examined a consecutive series of 130 patients with CSC seen over an 18-month period. RESULTS: The mean age of the patients when examined was 51 years, and the male-to-female ratio was 2.6:1.0. A total of 62 patients were older than 50 years of age when first examined. Although the patients shared some clinical and angiographic similarities, the older patients had a lower mean visual acuity and were more likely to have diffuse retinal pigment epitheliopathy, bilateral involvement, and secondary choroidal neovascularization than were the younger patients. With ophthalmoscopic and angiographic examination results, it was possible to differentiate CSC in older adults from choroidal neovascularization. CONCLUSION: This study expands the clinical concept of CSC. The male-to-female ratio was much lower, and the range of ages of the patients was much greater than in previous studies. Disease manifestations in older adults differed somewhat from those seen in younger adults. In older patients, CSC can be distinguished from other exudative maculopathies, particularly that of choroidal neovascularization secondary to age-related macular degeneration.

Indocyanine green-guided laser photocoagulation of focal spots at the edge of plaques of choroidal neovascularization.

OBJECTIVE: To determine whether indocyanine green-guided laser photocoagulation of focal spots at the edge of plaques of neovascularization is beneficial for patients with untreatable occult choroidal neovascularization by fluorescein imaging. PATIENTS: A pilot series of 23 eyes were identified that had untreatable occult choroidal neovascularization secondary to age-related macular degeneration with focal spots at the edge of a plaque of neovascularization on the indocyanine green study. After informed consent was obtained, indocyanine green-guided laser photocoagulation was applied solely to the focal spot at the edge of the plaque. RESULTS: Anatomical success with resolution of the exudative findings was noted in 15 (79%) of 19 eyes at 6 months, 13 (68%) of 19 eyes at 12 months, and six (37.5%) of 16 eyes at 24 months. The median follow-up period was 18 months (range, 3 to 44 months). Visual acuity was stabilized or improved in nine (69%) of 13 successfully treated eyes at 1 year. Of the successfully treated cases at 1 year, nine (69%) of 13 had a final visual acuity of 20/100 or better. CONCLUSIONS: Our preliminary study of indocyanine green-guided laser photocoagulation of focal spots at the edge of plaques of neovascularization suggests that this technique may improve the visual prognosis of these patients with presently untreatable disease. A prospective, randomized, controlled clinical trial is warranted to evaluate this treatment approach.

Indocyanine green videoangiography of older patients with central serous chorioretinopathy.

PURPOSE: The authors studied the indocyanine green (ICG) videoangiography findings of central serous chorioretinopathy (CSC) in older adults. BACKGROUND: Central serous chorioretinopathy in older adults may be confused with the exudative forms of age-related macular degeneration (AMD) because the two entities may have similar ophthalmoscopic and fluorescein angiographic findings. Because of its enhanced ability to image the choroidal circulation, ICG videoangiography has been used to describe certain choroidal vascular abnormalities in young adults with CSC, as well as older patients with choroidal neovascularization (CNV). The ICG videoangiography findings in CSC in older adults is largely unknown. METHODS: The authors performed ICG videoangiography on 36 patients aged 50 years or older with CSC to characterize their findings. RESULTS: The ICG videoangiography findings of the patients were consistent, revealing choroidal vascular hyperpermeability manifested by areas of hyperfluorescence that were first seen in the midphase of the angiogram. In the later phases of the angiogram, there were dispersion of the hyperfluorescence and a distinctive silhouetting of the larger choroidal vessels. CONCLUSIONS: Older patients with CSC have a unique temporal and topographic pattern of hyperpermeability that can help establish the proper diagnosis.

Indocyanine-green angiography.

Indocyanine-green angiography represents a major advance in imaging of the choroidal circulation. Recent technical innovations have permitted this diagnostic technique to find clinical application in many chorioretinal conditions. The indocyanine-green molecule has proven to be safe for human study. In age-related macular degeneration, indocyanine-green angiography may play an important role in the diagnosis of patients with occult choroidal neovascularization, leading to eventual increased efficacy with laser photocoagulation treatment. Histopathologic confirmation of a lesion noted by ICG angiography has been made. In multiple inflammatory conditions, as well as with central serous chorioretinopathy, distinct ICG patterns have emerged that may facilitate better understanding of the disease processes. With greater experience, ICG angiography may provide improved imaging, a better understanding of the pathogenesis, and new treatment approaches for various chorioretinal conditions.

Digital indocyanine-green videoangiography of occult choroidal neovascularization.

BACKGROUND: Occult choroidal neovascularization (CNV) secondary to age-related macular degeneration occurs in the majority of patients with exudative maculopathy. Since occult CNV cannot be imaged clearly by fluorescein angiography, this condition is untreatable. The authors performed digital indocyanine-green videoangiography (ICG-V) on 657 consecutive eyes with occult CNV by fluorescein angiography to determine if this technique could be useful in enhancing the imaging of the neovascularization, and thus increasing treatment eligibility. MATERIALS AND METHODS: Six hundred fifty-seven consecutive eyes with occult CNV were studied. The fluorescein and ICG angiograms were compared, and the percentage of patients potentially eligible for laser therapy based on ICG findings was calculated. RESULTS: Of 413 eyes with occult CNV without pigment epithelial detachments, focal areas of neovascularization were noted in 89 (22%). Overall, 142 (34.3%) eyes had lesions that were potentially treatable by laser photocoagulation based on additional information provided by ICG-V. Of the 235 eyes with occult CNV and vascularized pigment epithelial detachments, 98 (42%) were eligible for laser therapy based on ICG-V findings. The authors calculate that ICG-V enhances the treatment eligibility by approximately one third. CONCLUSIONS: In diagnosing occult CNV, ICG-V is an important adjunctive technique to fluorescein angiography. This technique is especially useful in delineating occult neovascularization, neovascularization with overlying subretinal hemorrhage or serosanguineous fluid, and neovascularization associated with pigment epithelial detachments. The authors currently suggest that ICG-V be performed in eyes in which well-delineated neovascularization cannot be identified by fluorescein angiography. Based on their preliminary study, it can be expected that one in three patients with occult CNV potentially will be eligible for laser photocoagulation based on ICG-V. Further studies are necessary to confirm these findings.

Digital indocyanine green videoangiography of central serous chorioretinopathy.

BACKGROUND: The pathogenesis of central serous chorioretinopathy (CSC) is poorly understood. Abnormalities in the choroidal circulation have been hypothesized to be causative factors. Fluorescein angiography has not been particularly useful in identifying specific choroidal defects in CSC, largely because of inherent limitations in imaging with this technique. Recent technologic advances in digital indocyanine green videoangiography allow enhanced imaging of the choroid and other subretinal structures in comparison with fluorescein angiography. METHODS: We performed digital indocyanine green videoangiography in 29 consecutive eyes with CSC and compared our results with clinical and fluorescein angiographic findings. RESULTS: Several newly recognized subretinal abnormalities in CSC were noted with digital indocyanine green videoangiography, including (1) presumed hyperpermeability of the choroidal circulation surrounding active retinal pigment epithelial leaks, (2) additional focal and multifocal areas of presumed choroidal hyperpermeability not associated with abnormalities detectable by fluorescein angiography or clinical examination, and (3) multiple presumed "occult" serous retinal pigment epithelial detachments with a characteristic indocyanine green videoangiographic pattern. CONCLUSION: We suggest that the pathogenesis of CSC may be due to a choroidal vascular hyperpermeability with and without associated active pigment epithelial leaks and multiple presumed "occult" serous retinal pigment epithelial detachments. Based on these findings, a hypothetical model can be constructed related to the pathogenesis of CSC, beginning with choroidal abnormalities that secondarily affect the retinal pigment epithelium and neurosensory retina.

A pilot study of indocyanine green videoangiography-guided laser photocoagulation of occult choroidal neovascularization in age-related macular degeneration.

PURPOSE: To evaluate the use of digital indocyanine green videoangiography in patients with clinical and fluorescein angiographic evidence of "occult" choroidal neovascularization in age-related macular degeneration and to investigate indocyanine green videoangiography-guided laser photocoagulation as a therapeutic approach. METHODS: Three hundred forty-seven consecutive patients with exudative age-related macular degeneration and symptoms and clinical manifestations of occult choroidal neovascularization were studied with indocyanine green videoangiography. Patients were selected for laser treatment, using conventional guidelines, when indocyanine green videoangiography demonstrated a well-delineated area of hyperfluorescence, presumed to be a focal area of choroidal neovascularization. RESULTS: Seventy-nine (23%) of 347 eyes were found to have a localized and definable lesion that was potentially amenable to laser photocoagulation therapy; 44 (56%) of these 79 treated eyes had complete resolution of their exudative manifestations. Visual acuity improvement was noted in 10 (13%) of 79 eyes, and stabilization of vision achieved in 42 eyes (53%). CONCLUSION: Laser photocoagulation treatment guided by indocyanine green videoangiography was shown to produce promising anatomical and visual improvement in a small number of patients with occult choroidal neovascularization secondary to age-related macular degeneration. This pilot study warrants further research to investigate the efficacy and safety of this form of treatment.

A pilot study of digital indocyanine green videoangiography for recurrent occult choroidal neovascularization in age-related macular degeneration.

PURPOSE: Digital indocyanine green videoangiography (ICG-V) was used to study recurrent choroidal neovascularization (CNV) in patients with the clinical and fluorescein angiographic findings indicative of ill-defined, or recurrent occult, CNV (RO-CNV). The use of ICG-V-guided laser caphotocoagulation as an alternative form of treatment was also investigated when a well-delineated area of CNV was imaged with this technique. METHODS: A consecutive series of 66 patients were studied who presented with exudative age-related macular degeneration and symptoms and clinical manifestations of recurrent CNV in which fluorescein angiography did not reveal classic, or well-defined, neovascularization. Patients were selected for laser treatment based on conventional guidelines if ICG-V imaged a well-delineated area of recurrent CNV. RESULTS: Indocyanine green videoangiography showed late staining that was consistent with recurrent CNV in 64 (97%) of these 66 patients with RO-CNV. Twenty-nine (44%) of the 66 were eligible for laser treatment, and 18 (62%) of these 29 patients experienced successful anatomic and visual results, which were defined as resolution of the exudative manifestations and improvement or stabilization (+/- 1 line on a Snellen chart) of vision. CONCLUSIONS: This pilot study suggests that ICG-V is of value in imaging patients with RO-CNV after laser photocoagulation for CNV secondary to age-related macular degeneration. Laser treatment of RO-CNV with ICG-V guidance may be successful both anatomically and functionally in a promising number of these otherwise untreatable cases. Further studies are necessary to validate these preliminary findings.