Search

Purpose: The purpose of this study was to analyze the angiographic (confocal scanning laser ophthalmoscopy technology) and corresponding (eye-tracked) spectral-domain optical coherence tomography (SD-OCT) features and to propose a classification for the progressive phases establishing retinal-choroidal anastomosis (RCA)., Methods: We reviewed all consecutive eyes with RCA that underwent Heidelberg Retina Angiograph angiography and tracked Spectralis SD-OCT at the University Eye Clinic of Creteil between September 2007 and March 2009., Results: Twenty-six eyes of 23 patients (8 men and 15 women, aged 70-88 years) showing RCA naïve to any treatment were included for analysis. In 6 of 7 eyes showing a discrete focal hyperfluorescence (focal staining), the corresponding (eye-tracked) SD-OCT scan showed a focal retinal pigment epithelium (RPE) erosion ("erosion sign") over a small, localized RPE elevation (which appeared filled with a hyperreflective material); in 7 of 8 eyes showing a typical "hot spot" in the late angiographic frames (focal leakage) and absence of a serosanguineous pigment epithelium detachment, the corresponding (eye-tracked) SD-OCT scan showed a focal RPE break leaving 2 free RPE flaps ("flap sign") at the level of a small, localized RPE elevation. In 10 of 11 eyes showing a typical hot spot in the late angiographic frames and presence of a serosanguineous pigment epithelium detachment, the corresponding (eye-tracked) SD-OCT scan showed, at the level of a large serosanguineous RPE detachment, a focal funnel-shaped RPE joining (kissing) an inverted focal funnel-shaped inner neuroepithelium ("kissing sign")., Conclusion: An early neovascularization (a discrete focal hyperfluorescence) arising from the choroid initially simply erodes the basement membrane/RPE (erosion sign; Phase 1) and later breaks the basement membrane/RPE (flap sign), infiltrating first into the outer retina forming an early RCA (Phase 2, a typical hot spot without a serosanguineous pigment epithelium detachment) and later into the inner retina (kissing sign) forming an established RCA (Phase 3, a typical hot spot with a serosanguineous pigment epithelium detachment).

Purpose: To investigate the natural history and visual outcome in eyes with untreated retinal angiomatous proliferation, a neovascular form of age-related macular degeneration., Methods: Fourteen consecutive white patients (11 women, 78%; mean age, 74 years) with 16 eyes affected by retinal angiomatous proliferation were prospectively followed-up without treatment by means of complete ophthalmologic examinations at regular intervals, including best-corrected visual acuity and dynamic fluorescein and indocyanine green angiography using a scanning laser ophthalmoscope., Results: The patients were observed for a mean of 20 months (range, 6-44 months). Mean visual acuity in the eyes with retinal angiomatous proliferation was 0.48 at the initial examination, decreased to 0.23 after 6 months, and was 0.19 at the final examination, with a mean decrease of 6 lines from baseline. In 13 eyes (81%), visual acuity deteriorated by 2 Early Treatment Diabetic Retinopathy Study lines or worse by the time of the 6-month examination, and 31% of the patients had experienced severe loss of vision; the remaining 3 eyes (19%) showed a relatively stable clinical course and visual acuity. By the time of the final examination, visual acuity had decreased to 0.1 or worse in 11 eyes (69%), and 5 of the 14 patients (36%) were legally blind. At the final examination, 10 eyes (62%) showed a subretinal fibrosis and 9 (56%) showed a retinal choroidal anastomosis., Conclusion: Retinal angiomatous proliferation is a distinct form of neovascular age-related macular degeneration with high vasogenic potential, having its own clinical course and visual prognosis. The poor visual outcome is because of the exudative nature of the retinal angiomatous proliferation, and progression to poor vision is common and rapid (within 3 months in faster cases, and within 1 year in slower cases). The treatment options for this type of neovascular lesion should be planned bearing in mind its unfavorable natural history.

Background: The purpose of the study was to ascertain the prevalence of retinal angiomatous proliferation (RAP) by means of dynamic indocyanine green angiography (d-ICGA) in patients with newly diagnosed fibrovascular pigment epithelium detachment (type 1) or late leakage of undetermined source (type 2) occult choroidal neovascularization (CNV) on fluorescein angiography., Methods: We carried out a review of digital fluorescein and ICG angiograms obtained by confocal scanning laser ophthalmoscope (HRA; Heidelberg Engineering GmbH, Dossenheim, Germany) in 253 consecutive patients (270 eyes) with a clinical diagnosis of type 1 or type 2 occult CNV on fluorescein angiography (1998 through 2003)., Results: Sixty eyes had type 1 and 210 eyes type 2 occult CNV on fluorescein angiography. Overall, 57 cases of RAP were identified in 54 eyes (20%) with d-ICGA. RAP was present in 6 out of 60 eyes with type 1 (10%) and in 51 out of 210 eyes with type 2 occult CNV (24%). Mean distance of the lesion from the fovea was 682 +/- 304 microm (mean +/- SD)., Conclusions: d-ICGA is invaluable for early diagnosis of RAP in exudative age-related macular degeneration (ARMD). In our series, up to one fourth of type 2 occult CNV were in fact RAP.

Purpose: To determine the percentage of Japanese patients with age-related macular degeneration (AMD) who are eligible for photodynamic therapy (PDT) with verteporfin who have either polypoidal choroidal vasculopathy (PCV) or choroidal neovascularization (CNV) with retinochoroidal anastomosis (RCA)., Methods: The medical charts of 82 consecutive patients (83 eyes) with subfoveal CNV due to AMD were reviewed. Initially, we determined which of these eyes were eligible for PDT by using the criteria reported by two large randomized control studies, that is, the Treatment of Age-related Macular Degeneration with Photodynamic Therapy (TAP) study and the Verteporfin in Photodynamic Therapy (VIP) study. Among the PDT-eligible patients, the percentage of eyes with PCV or CNV with RCA was determined by indocyanine green angiography (ICGA)., Results: In total, 36 eyes (43%) of the 83 eyes were PDT-eligible; 17 (20%) based on the TAP study criteria, and 19 (23%) based on the VIP study criteria. Among these PDT-eligible eyes, ICGA revealed that 12 (33%) had PCV and 2 (6%) had CNV with RCA., Conclusions: With ICGA, PCV or CNV with RCA were recognized in a substantial proportion of cases eligible for PDT based on the two clinical studies. Considering that the treatment efficacy of PDT for PCV or RCA has not been established, detection of PCV or RCA prior to PDT with ICGA is highly recommended., (Copyright (c) Japanese Ophthalmological Society 2006.)

Background: Retinal-choroidal anastomoses (RCA) are a common finding in advanced cases of age-related macular degeneration. These high-flow lesions are associated with extensive subretinal exudation. This study examines the role of high-energy, short-duration (micropulse) laser pulses in effectively closing these shunts and reducing subretinal fluid., Methods: Nineteen consecutive eyes with advanced age-related macular degeneration undergoing treatment of RCAs to reduce subretinal exudation in a referral-only retina practice were reviewed retrospectively. RCA were identified using high-speed indocyanine green angiography. RCA were closed using a high-energy, short-duration laser pulse technique. Outcome measures included visual acuity, resolution of subretinal fluid and persistence of RCA., Results: Nineteen eyes with RCA associated with macular degeneration were successfully treated. Mean baseline visual acuity was 20/140 (HM to 20/50). One hundred percent of eyes had subretinal exudation and 73% had subretinal fibrosis at the time initial treatment. At mean follow-up of 11.7 (2-23) months, patients had undergone an average of 3.52 (1-12) sessions of laser treatment. Average final visual acuity was 20/146 (CF to 20/40). Fifty-three percent of eyes had complete resolution of subretinal fluid. One hundred percent had subretinal fibrosis. Forty-three percent had complete closure of RCA. No significant complications were encountered., Conclusion: High-energy, short-duration laser appears to be a reproducible technique to obtain closure of RCA associated with advanced macular degeneration. It appears to be effective in reducing subretinal exudation associated with these lesions. The technique is associated with stabilization of visual acuity without significant risk of complication.

Purpose: To analyze the baseline findings predictive of the size and type of the late exudative age-related macular degeneration (AMD) lesions., Design: Observational case series., Methods: Retrospective study., Setting: University clinic referral practice., Study Population: The records of 167 consecutive patients initially diagnosed with recent choroidal neovascularization (CNV) related to AMD were analyzed 4.8 to 9.2 (mean 6.8) years after baseline. Of 121 patients still living, 74 attended the reexamination. After exclusions, data from 61 patients were analyzed., Observation Procedures: From the fundus photographs and fluorescein angiographic images taken at baseline and at follow-up the size and components of AMD lesion were measured. The presence of hemorrhage, pigment epithelial detachment (PED), classic CNV, laser treatment, and involvement of the fellow eye were recorded at baseline., Main Outcome Measures: Lesion size, increase in lesion size, persistent exudative process, subretinal fibrosis, and chorioretinal anastomosis at the follow-up examination., Results: Large lesion (P <.001) and CNV (P =.003) sizes, and the presence of occult, no classic CNV (P =.013) at baseline predict a large lesion at follow-up. Other factors predicting a large lesion were subfoveal (P =.019) and bilateral lesions (P =.017) and the presence of hemorrhage (P =.012) at baseline. A large (P =.040) and bilateral lesion (P =.040) and hemorrhage (P =.011) at baseline were correlated with subretinal fibrosis at follow-up. Occult lesions (P =.002) at baseline were correlated with chorioretinal anastomosis at follow-up., Conclusion: The type and size of the late AMD lesion can partly be predicted from baseline characteristics.

Objective: To identify the angiographic features of retinal choroidal anastomoses (RCAs) in patients with newly diagnosed occult choroidal neovascularization (CNV) in the setting of age-related macular degeneration (AMD) and to determine the sequence of flow between the RCA and the CNV., Design: Retrospective cross-sectional study., Participants: The angiograms of 205 eyes of 153 consecutive patients with occult CNV on fluorescein angiography (FA) and focal hot spots on indocyanine green angiography (ICGA) were evaluated retrospectively. METHODS OF TESTING: Red-free photographs and sequential digital fluorescein and indocyanine green angiograms obtained by confocal scanning laser ophthalmoscope (the Heidelberg Retina Angiograph; Heidelberg Engineering GmbH, Dossenheim, Germany)., Main Outcome Measures: The angiograms were evaluated for the presence of RCA. The following angiographic characteristics were recorded: number and type of anastomoses, location, distance from fovea, area of CNV, presence of pigment epithelium detachment (PED), cystoid macular edema on FA, and intraretinal leakage on ICGA. The direction of flow between the RCA and the CNV was identified by analyzing high-speed angiograms., Results: Retinal choroidal anastomoses were identified in 57 eyes (28%), in 49 of 154 eyes with PED (32%), and in 8 of 51 eyes without PED (16%). Of 109 anastomoses, 70% were venous and 30% were arterial. Ninety-six percent of the eyes had at least one venous anastomosis, 49% of the eyes had an arterial anastomosis, and 46% of the eyes had both. Cystoid macular edema was seen on FA in 37 eyes (65%), and intraretinal indocyanine green leakage was noted in 52 eyes (91%). Twenty-two eyes that underwent high-speed ICGA were analyzed for the direction of flow. All 15 eyes having arterial and venous anastomoses demonstrated a filling pattern from the retinal arteriole to the CNV, followed by the retinal venule. Seven eyes with venous RCA showed flow sequence from the CNV to the collecting retinal venule., Conclusions: Our study supports the presence of RCA in the early stages of acute exudative AMD with occult CNV, mainly with serous PED. High-speed angiography helps to identify the filling sequence of the RCA and the CNV, and therefore may guide the clinician in planning treatment strategies.

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.

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.