Faculty Bibliography

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

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 disposable 19-gauge ophthalmic endoscope has been developed for imaging and treatment during vitreoretinal surgery whenever standard microscopic visualization is limited or impossible. The endoscopic system is adaptable to many standard light sources and standard video imaging or storage equipment. Preliminary clinical experience has demonstrated the usefulness and practical application of this new instrument

Indocyanine-green (ICG) angiography has experienced a rejuvenated interest in the past few years because of improvements in technological systems. After three years of experience with evolving digital technology, we have reviewed our experience to provide an update on potential applications in a variety of choroidopathies. Based on 3,000 cases studied with ICG angiography, we evaluated the diagnostic value of the procedure in choroidal abnormalities including ischemic, tumor, idiopathic, inflammatory, and neovascularized diseases. ICG angiography is still of limited clinical value in ischemic diseases because of a relatively poor imaging potential for the choriocapillaris. The procedure has not yet provided information which is of significant value in the evaluation and management of choroidal tumors. Valuable information has been provided on the fundamental pathogenesis of certain idiopathic diseases. Preliminary experience in inflammatory diseases is very promising. A genuine advance in imaging of 'occult'-choroidal neovascularization has been provided by the diagnostic technique. Improved delineation of these vessels offers opportunities for ICG-guided laser treatment

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

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