Protocolo Clínico e Diretrizes Terapêuticas da Degeneração Macular Relacionada à Idade (forma neovascular) / Clinical Protocol and Therapeutic Guidelines of macular degeneration related to age (neovascular form)

CONTEXTO: Os PCDT são documentos que visam garantir o melhor cuidado de saúde diante do contexto brasileiro e dos recursos disponíveis no SUS. Podem ser utilizados como materiais educativos aos profissionais de saúde, auxílio administrativo aos gestores, regulamentação da conduta assistencial perante o Poder Judiciário e explicitação de direitos aos usuários do SUS. Os PCDT são os documentos oficiais do SUS que estabelecem critérios para o diagnóstico de uma doença ou agravo à saúde; tratamento preconizado, com os medicamentos e demais produtos apropriados, quando couber; posologias recomendadas; mecanismos de controle clínico; e acompanhamento e verificação dos resultados terapêuticos a serem seguidos pelos gestores do SUS. Os PCDT devem incluir recomendações de condutas, medicamentos ou produtos para as diferentes fases evolutivas da doença ou do agravo à saúde de que se tratam, bem como aqueles indicados em casos de perda de eficácia e de surgimento de intolerância ou reação adversa relevante,

Punctate inner choroidopathy with atypical presentation / Coroidopatia interna ponteada de apresentação atípica

ABSTRACT We report a case of a young Caucasian female presenting with sudden decrease of vision in the left eye, metamorphopsia, and nasal scotoma. Past medical history revealed a diagnosis of myasthenia gravis, which was currently treated with azathioprine, pyridostigmine, and prednisone. Ophthalmological examination showed fundus with clear vitreous and yellow-white lesions that were isolated and perimacular in the right eye, multiple and confluent in the macula, and punctate in periphery in the left eye. Laboratory workup ruled out the presence of infectious and inflammatory diseases. Fundus autofluorescence disclosed hypoautoflurescence with hyperfluorescent margins corresponding to the lesions observed in both eyes and the angiogram revealed hyperfluorescence since early phases without late leakage. Spectral-domain optical coherence tomography showed areas of intermittent retinal pigment epithelium elevations and disruption of the ellipsoid zone. She was diagnosed with punctate inner choroidopathy and then treated with an increased dose of daily prednisone, which resulted in progressive improvement of her visual acuity and anatomical status.(AU)

RESUMO Relato de caso de mulher jovem, caucasiana, com súbita diminuição de acuidade visual de olho esquerdo, metamorfopsia e escotoma nasal. Apresentava diagnóstico de Miastenia gravis, em tratamento com Azatioprina, Piridostigmina e Prednisona. Fundo de olho demonstrava vítreo límpido e lesões amarelo-esbranquiçadas, perimaculares e isoladas em olho direito, múltiplas e confluentes em mácula e pontilhadas em periferia no olho esquerdo. Exames laboratoriais descartaram doenças infecciosas e inflamatórias. Auto-fluorescência revelou lesões hipoautofluorescentes com margens hiperfluorescentes correspondentes às observadas em ambos os olhos, enquanto angiofluoresceinografia mostrou hiperfluorescência desde as fases iniciais sem vazamento tardio. Tomografia de coerência óptica de domínio espectral revelou áreas de elevações intermitentes do epitélio pigmentar da retina e interrupção da zona elipsóide correspondente. Definiu-se como diagnóstico a coroidopatia interna ponteada, sendo instituído aumento na dose diária de Prednisona, com melhoria progressiva da acuidade visual e do aspecto de fundo de olho da paciente.(AU)

Initial Experience with Exoscopic-Based Intraoperative Indocyanine Green Fluorescence Video Angiography in Cerebrovascular Surgery: A Preliminary Case Series Showing Feasibility, Safety, and Next-Generation Handheld Form-Factor.

BACKGROUND: Native vessel patency and residual lesion are primary sources of morbidity in cerebrovascular surgery (CVS) that require real-time visualization to inform surgical judgment, as is available in endovascular procedures. Micro Doppler and microscopy-based indocyanine green (ICG) fluorescence are promising evolutions compared with intraoperative angiography (IA), and digital subtraction angiography (DSA) remains the gold standard. Exoscopic visualization in CVS is emerging; however, the feasibility of exoscopic-based ICG (ICG-E) for CVS has not yet been reported. To objective of the study was to provide initial experience with ICG-E video angiography in CVS. METHODS: Retrospective study in which 2 ICG-E form-factors (exoscopic-coupled or self-contained handheld imager) were used to determine native vessel patency and residual and compared with DSA. RESULTS: Eleven patients (8 aneurysms, 3 arteriovenous malformations [AVMs]) were included. ICG-E was feasible in all, providing real-time information leading to operative decisions affecting surgical judgment. For aneurysms, discordance of IA with ICG-E and DSA was 12%. In 1 patient, IA showed non-flow-restrictive branch stenosis; however, both ICG and DSA showed patency. All AVMs were fully obliterated, with 100% concordance among all modalities. ICG averaged 4.2 mg dose/run (1-4 doses/case); 1.25 mg was the lowest dose allowing visualization with no advantage with escalating dosages. There were no intraoperative/perioperative complications. CONCLUSIONS: In this preliminary study, ICG-E was safe and feasible, providing real-time visualization informing surgical decision making. The last 4 cases (2 aneurysms and 2 AVMs) evolved toward a portable handheld device, a readily accessible real-time modality providing contextual anatomic and flow visualization. Larger studies are needed to assess broader safety, dose escalation, and efficacy.

Microvascular Retinal and Choroidal Changes in Retinal Vein Occlusion Analyzed by Two Different Optical Coherence Tomography Angiography Devices.

PURPOSE: To investigate retinal and choroidal microvascular changes and structural choroidal involvement in retinal vein occlusion (RVO). METHODS: Retrospective analysis of treatment-naïve macular edema secondary to RVO, studied by optical coherence tomography (OCT) and OCT angiography (OCTA), before and after the loading phase of intravitreal injections of ranibizumab (IVR-LP). OCTA was performed using two different devices: AngioVue RTVue XR Avanti (spectral-domain OCTA) and Zeiss PLEX® Elite 9000 (swept-source OCTA). RESULTS: 30 eyes of 30 consecutive patients (17 branch and 13 central RVO) were included. Central macular thickness and subfoveal choroidal thickness (SCT) were significantly reduced after IVR-LP (p < 0.001 and p = 0.046, respectively). 23 eyes were eligible for OCTA analysis. Baseline vessel density (VD) in deep capillary plexus (DCP) was significantly reduced in RVO eyes compared with fellow eyes (p = 0.03 and p = 0.002 for PLEX® Elite and AngioVue, respectively). After IVR-LP, no significant VD changes in any vascular layer was found. PLEX® Elite VD analysis showed significant differences in DCP between ischemic versus non-is-chemic eyes (p = 0.011). CONCLUSION: OCTA suggests a retinal vascular impairment of DCP but no involvement of choroid in RVO eyes. A greater baseline SCT could be due to a choroidal exudation. OCTA imaged with PLEX® Elite allowed to differentiate ischemic and non-ischemic patients at baseline.

Intraoperative Fluorescence Cerebral Angiography by Laser Surgical Microscopy: Comparison With Xenon Microscopy and Simultaneous Observation of Cerebral Blood Flow and Surrounding Structures.

BACKGROUND: Laser surgical microscopes should enable uniform illumination of the operative field, and require less luminous energy compared with existing xenon surgical microscopes. OBJECTIVE: To examine the utility of laser illumination in fluorescence cerebral angiography. METHODS: Fluorescein sodium (fluorescein) was used as a fluorescent dye. We first compared the clarity of cerebral blood flow images collected by fluorescence angiography between the laser illumination and xenon illumination methods. We then assessed use of the laser illuminator for simultaneous observation of blood flow and surrounding structures during fluorescence angiography. Furthermore, the study was designed to evaluate usefulness of the thus determined excitation light in clinical cases. RESULTS: Fluorescence angiography using blue light laser for excitation provided higher clarity and contrast blood flow images compared with using blue light generated from a xenon lamp. Further, illumination with excitation light consisting of a combination of 3 types of laser (higher level of blue light, no green light, and lower level of red light) enabled both blood flow and surrounding structures to be observed through the microscope directly by the surgeon. CONCLUSION: Laser-illuminated fluorescence angiography provides high clarity and contrast images of cerebral blood flow. Further, a laser providing strong blue light and weak red light for excitation light enables simultaneous visual observation of fluorescent blood flow and surrounding structures by the surgeon using a surgical microscope. Overall, these data suggest that laser surgical microscopes are useful for both ordinary operative manipulations and fluorescence angiography.

Comparison of Zeiss Cirrus and Optovue RTVue OCT Angiography Systems: A Quantitative and Qualitative Approach Examining the Three Capillary Networks in Diabetic Retinopathy.

BACKGROUND AND OBJECTIVES: Construct a method for visualizing the middle capillary plexus (MCP) using Zeiss optical coherence tomography angiography (OCTA) and compare to established segmentation methods using the Optovue system. PATIENTS AND METHODS: Twenty eyes with diabetic retinopathy were imaged. Visualization of the MCP, image artifacts, preservation of pathological changes, foveal avascular zone (FAZ) area, and vessel length density (VLD) were compared between devices. RESULTS: The authors successfully segmented the superficial (SCP), MCP, and deep (DCP) capillary plexuses on both devices. More images artifacts were detected on Optovue. Microaneurysms and telangiectatic vessels were better visualized in the MCP on the Optovue. FAZ area showed a strong correlation between the two instruments (r2= 0.666; P < .0001). The SCP had lower VLD compared to the MCP and DCP on both devices. CONCLUSION: The authors provide an objective and consistent method for manual segmentation using Zeiss OCTA to visualize the three retinal capillary plexuses. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e198-e205.].

Quantitative Comparison of Retinal Vascular Features in Optical Coherence Tomography Angiography Images From Three Different Devices.

BACKGROUND AND OBJECTIVE: To compare optical coherence tomography angiography (OCTA) images from three different devices. PATIENTS AND METHODS: This was a prospective, observational, cross-sectional study. All eyes (n = 24) were imaged thrice each time with swept-source OCT (DRI OCT Triton Plus; Topcon, Tokyo, Japan), spectral-domain OCTA (AngioVue; Optovue, Fremont, CA), and SD-OCT Angioplex (Cirrus HD-OCT 5000; Carl Zeiss Meditec, Jena, Germany). Outcome measures were foveal avascular zone (FAZ) area, vessel density, spacing between large vessels (SLV), and spacing between small vessels (SSV). They were calculated using local fractal analyses and Frangi filter. RESULTS: The vascular parameters showed good to excellent repeatability (intraclass coefficient > 0.8) in the three devices. The FAZ area (P = .3) and vessel density of the superficial layer (P = .8) were similar between the devices. In the deep layer, vessel density was significantly higher (P = .02) with Angio-Vue images compared to those acquired using the other devices. However, SLV was significantly higher (P < .05) and SSV was significantly lower (P < .05) on Angioplex scans compared to other devices. Vessel parameters were significantly altered in Frangi-filtered images as compared to nonfiltered images. CONCLUSIONS: Vessel density showed good repeatability among the three devices, although there were differences in vessel parameters between the devices. Also, vessel parameters changed significantly after Frangi filtering. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:488-496.].

Regeneration of Photoreceptor Outer Segments After Scleral Buckling Surgery for Rhegmatogenous Retinal Detachment.

PURPOSE: To investigate the regeneration of the cone outer segments in eyes after surgery for fovea-off rhegmatogenous retinal detachment with an adaptive optics (AO) fundus camera and to correlate these findings with the findings of optical coherence tomography (OCT). DESIGN: Retrospective, observational case series. METHODS: Medical charts of 21 eyes of 21 patients who had undergone surgery for fovea-off rhegmatogenous retinal detachment were retrospectively studied. Cone mosaic images were obtained with an AO fundus camera. Cone packing density at 2 degrees from the fovea within the previously detached area was measured 6 and 12 months after surgery. Retinal thicknesses between the interdigitation zone and the retinal pigment epithelium (IZ-RPE) and between the ellipsoid zone and the retinal pigment epithelium (EZ-RPE) were measured in OCT images. RESULTS: Cone density 12 months after surgery was significantly increased from that at 6 months (P = .001), but was still significantly lower than that of normal fellow eyes (P < .001). IZ-RPE and EZ-RPE thickness significantly increased from 6 to 12 months (P = .045, P = .033, respectively), and these values were not significantly different from those of normal fellow eyes. Multivariate analysis showed that cone density at 12 months was significantly associated with IZ-RPE thickness (P = .002), and increases in cone packing density were significantly associated with increases in IZ-RPE thickness (P = .001). CONCLUSIONS: Recovery of cone packing density measured by AO was associated with structural recovery of the outer retina observed in OCT, suggesting regeneration of the photoreceptor outer segment after surgery.

High-Resolution Adaptive Optics Retinal Image Analysis at Early Stage Central Areolar Choroidal Dystrophy With PRPH2 Mutation.

BACKGROUND AND OBJECTIVE: To report the clinical features of Japanese patients at Stage 1 and 2 of central areolar choroidal dystrophy (CACD). PATIENTS AND METHODS: Five family members had comprehensive ophthalmic examinations including adaptive optics (AO) retinal imaging. Mutation analysis of the PRPH2 gene was performed by Sanger sequencing. The protocol conformed to the tenets of the Declaration of Helsinki and was approved by the institutional review board of The Jikei University School of Medicine. RESULTS: Four family members had a heterozygous PRPH2 mutation, p.R172Q; however, one member with a mutation did not show any ophthalmological abnormalities. Two patients had mild parafoveal retinal dystrophy and a reduction of cone density determined by AO analysis. CONCLUSION: The results indicate that the parafoveal cone photoreceptors can be affected even at the early stage of CACD. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:1115-1126.].

Diagnosis and Follow-Up of Nonexudative Choroidal Neovascularization With Multiple Optical Coherence Tomography Angiography Devices: A Case Report.

Nonexudative choroidal neovascularization (CNV) is a new phenomenon that has only recently been described in the literature with the advent of optical coherence tomography angiography (OCTA) imaging. The authors present a 1-year longitudinal follow-up of a nonexudative CNV lesion secondary to age-related macular degeneration. This report describes the appearance of the lesion on two commercially available spectral-domain OCTA devices and one prototype swept-source OCTA device. Management of these cases is still debatable. Watchful waiting with regular follow-up using serial OCTA to monitor disease progression has been valuable in this case. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:778-781.].

Adaptive Optics Imaging in Laser Pointer Maculopathy.

The authors report multimodal imaging including adaptive optics scanning laser ophthalmoscopy (AOSLO) (Apaeros retinal image system AOSLO prototype; Boston Micromachines Corporation, Boston, MA) in a case of previously diagnosed unilateral acute idiopathic maculopathy (UAIM) that demonstrated features of laser pointer maculopathy. The authors also show the adaptive optics images of a laser pointer maculopathy case previously reported. A 15-year-old girl was referred for the evaluation of a maculopathy suspected to be UAIM. The authors reviewed the patient's history and obtained fluorescein angiography, autofluorescence, optical coherence tomography, infrared reflectance, and AOSLO. The time course of disease and clinical examination did not fit with UAIM, but the linear pattern of lesions was suspicious for self-inflicted laser pointer injury. This was confirmed on subsequent questioning of the patient. The presence of linear lesions in the macula that are best highlighted with multimodal imaging techniques should alert the physician to the possibility of laser pointer injury. AOSLO further characterizes photoreceptor damage in this condition. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:782-785.].

Murine fundus fluorescein angiography: An alternative approach using a handheld camera.

In today's modern pharmacologic approach to treating sight-threatening retinal vascular disorders, there is an increasing demand for a compact, mobile, lightweight and cost-effective fluorescein fundus camera to document the effects of antiangiogenic drugs on laser-induced choroidal neovascularization (CNV) in mice and other experimental animals. We have adapted the use of the Kowa Genesis Df Camera to perform Fundus Fluorescein Angiography (FFA) in mice. The 1 kg, 28 cm high camera has built-in barrier and exciter filters to allow digital FFA recording to a Compact Flash memory card. Furthermore, this handheld unit has a steady Indirect Lens Holder that firmly attaches to the main unit, that securely holds a 90 diopter lens in position, in order to facilitate appropriate focus and stability, for photographing the delicate central murine fundus. This easily portable fundus fluorescein camera can effectively record exceptional central retinal vascular detail in murine laser-induced CNV, while readily allowing the investigator to adjust the camera's position according to the variable head and eye movements that can randomly occur while the mouse is optimally anesthetized. This movable image recording device, with efficiencies of space, time, cost, energy and personnel, has enabled us to accurately document the alterations in the central choroidal and retinal vasculature following induction of CNV, implemented by argon-green laser photocoagulation and disruption of Bruch's Membrane, in the experimental murine model of exudative macular degeneration.

SPY technology as an adjunctive measure for lower extremity perfusion.

OBJECTIVE: Lack of a reliable outcome measure often leads to excessive or insufficient interventions for critical limb ischemia (CLI). SPY technology (Novadaq Technologies Inc, Bonita Springs, Fla), widely adapted by plastic and general surgeons, uses laser-assisted fluorescence angiography (LAFA) to assess tissue perfusion. We sought to determine the role of SPY as an alternative, perhaps more reliable outcome measure for vascular interventions. METHODS: All patients undergoing elective or urgent revascularization for claudication and CLI were prospectively recruited from June 2012 to August 2014. LAFA using SPY technology was performed before and after revascularization procedures under a standard Institutional Review Board-approved protocol. Quantitative measures of perfusion at plantar surfaces were analyzed and compared with ankle-brachial index. RESULTS: A total of 93 patients with claudication or CLI underwent LAFA before and after a revascularization procedure in the study period. The mean preoperative ankle-brachial index increased from 0.60 to 0.84 (P < .001) after a revascularization procedure. Plantar perfusion as measured by LAFA also improved significantly after intervention. Ingress, defined as the rate at which fluorescence intensity increases on the plantar surface during LAFA, increased from 7.1 to 12.4 units/s (P < .001). Peak perfusion, defined as the difference between the baseline and the peak of fluorescence intensity, increased from 97.1 and 143.9 units (P < .001). Egress, defined as the rate at which intensity diminishes after reaching peak perfusion, increased from 1.0 to 1.9 units/s (P = .035). Procedure-related digital embolization was also observed in several patients despite lack of an angiographic finding. CONCLUSIONS: This is the largest prospective study evaluating SPY technology in peripheral vascular interventions. Our study shows that SPY is a valuable tool in visualizing real-time procedural outcomes and providing additionally useful information on regional tissue perfusion. Further investigation is warranted to standardize outpatient use and to determine threshold values that predict wound healing.

Real-time fluorescence angiography by intra-arterial indocyanine green injection to identify obscure gastrointestinal bleeding territory: proof of concept in the porcine model.

BACKGROUND: Despite intensive preoperative localization workouts, intraoperative localization of the bleeding source in case of obscure gastrointestinal bleeding (OGIB) can be cumbersome and time-consuming. Our aim was to assess the feasibility of image-guided laparoscopic identification of the small bowel loop containing the bleeding source with and without near-infrared angiographic enhancement. MATERIALS AND METHODS: Angiography of superior mesenteric artery (SMA) branches was performed in 11 pigs using a right femoral artery approach, followed by a three-port laparoscopy, using a near-infrared-equipped laparoscope. Two pigs were used to identify the optimal intra-arterial indocyanine green (ICG) dose. Eight pigs were divided into two groups: ICG near-infrared angiography-assisted laparoscopy (n = 4) and fluoroscopic-assisted laparoscopy (n = 4). Finally, in one pig, a novel OGIB model was created and used to evaluate the ICG enhancement pattern in the presence of active bleeding. RESULTS: Mean time to identify the fluorescence signal from the small bowel segment fed by the catheterized SMA branch was 13.75 ± 7.8 s, which was statistically significantly shorter than the time required to identify the tip of the catheter by fluoroscopic guidance, i.e., 243.25 ± 107 s (p = 0.02). CONCLUSIONS: Near-infrared fluorescence angiography using intra-arterial ICG injection provides a fast image-guided intraoperative localization of the small bowel loop fed by the arterial territory identified as bleeding by digital subtraction angiography and could help target the bleeding source during OGIB surgery.

Development of and Clinical Experience with a Simple Device for Performing Intraoperative Fluorescein Fluorescence Cerebral Angiography: Technical Notes.

To perform intraoperative fluorescence angiography (FAG) under a microscope without an integrated FAG function with reasonable cost and sufficient quality for evaluation, we made a small and easy to use device for fluorescein FAG (FAG filter). We investigated the practical use of this FAG filter during aneurysm surgery, revascularization surgery, and brain tumor surgery. The FAG filter consists of two types of filters: an excitatory filter and a barrier filter. The excitatory filter excludes all wavelengths except for blue light and the barrier filter passes long waves except for blue light. By adding this FAG filter to a microscope without an integrated FAG function, light from the microscope illuminating the surgical field becomes blue, which is blocked by the barrier filter. We put the FAG filter on the objective lens of the operating microscope correctly and fluorescein sodium was injected intravenously or intra-arterially. Fluorescence (green light) from vessels in the surgical field and the dyed tumor were clearly observed through the microscope and recorded by a memory device. This method was easy and could be performed in a short time (about 10 seconds). Blood flow of small vessels deep in the surgical field could be observed. Blood flow stagnation could be evaluated. However, images from this method were inferior to those obtained by currently commercially available microscopes with an integrated FAG function. In brain tumor surgery, a stained tumor on the brain surface could be observed using this method. FAG could be performed with a microscope without an integrated FAG function easily with only this FAG filter.

Efficacy of intraoperative HyperEye Medical System angiography for coronary artery bypass grafting.

PURPOSE: When performing coronary artery bypass grafting, anastomotic insufficiency needs to be detected during surgery. We developed a novel indocyanine green angiography system, the HyperEye Medical System (HEMS), which enables color imaging of the bypass flow. This article described the accuracy of HEMS angiography for predicting graft patency. METHODS: A total of 144 grafts in 40 coronary artery bypass grafting patients were assessed by HEMS angiography, a transit time flowmeter (TTF) during surgery and fluoroscopic angiography 1 year after the operation. RESULTS: HEMS angiography showed normal flow in 133 grafts, but abnormal flow in 11. Fluoroscopic angiography showed that 130 of the 133 "normal" grafts were patent (negative predictive value: 97.7%) and that nine of the 11 "abnormal" grafts were occluded (positive predictive value: 81.8%). As a result, 134 grafts were assessed as normal and 10 as abnormal by TTF. Fluoroscopic angiography showed that 124 of these 134 grafts were patent (negative predictive value: 92.5%), whereas two of the 10 grafts were occluded (positive predictive value: 20.0%). For the 127 grafts with compatible results by the HEMS and TTF assessments, the positive and negative predictive values were 100 and 97.6%, respectively. CONCLUSION: HEMS angiography of a bypass graft may provide an accurate prediction of the graft patency after surgery.

Fluorescence Angiography with Temporary Occlusion to Confirm the Distal Artery: Technical Notes.

Confirming the patency of the proximal parent and distal artery is necessary in cerebral aneurysm surgery. To understand the relationship between the parent and distal arteries of the aneurysm, the blood vessels running through the subarachnoid space should be extensively dissected, which is time consuming. To examine the efficacy of a temporary clip with indocyanine green (ICG) technique, in which the parent artery is temporarily occluded using a temporary clip, an ICG videoangiography (ICGVAG) is performed to clarify the relationship between the distal artery and the proximal parent artery. Three patients with a distal aneurysm. This technique was used to confirm the connection of the parent and the distal artery in distal aneurysms. With regard to middle cerebral artery (MCA), the procedure is conducted as follows. First, the M2 within the Sylvian fissure is investigated to ensure the absence of atherosclerosis and perforators and that this vessel could undergo occlusion by temporary clipping. The subarachnoid space surrounding the distal artery of the lesion site suspected of an existent aneurysm is dissected. The image range of the ICGVAG is set sufficiently wide to accommodate the possibility that the distal artery is not the artery that was anticipated. Subsequently, after the temporary clip occlusion is completed, the ICGVAG is recorded. In the three distal aneurysms, the relationship between the aneurysm, the distal artery, and the parent artery was confirmed. This method was useful, suggesting that unnecessary dissection in the subarachnoid space might be reduced.

Intraoperative free jejunum flap monitoring with indocyanine green near-infrared angiography.

The free jejunum flap technique has been regarded as the optimal approach during circumferential pharyngolaryngectomy reconstruction. Although classical patency tests are available, an intraoperative guarantee of the patency of anastomoses and microcirculations is inevitable. Indocyanine green near-infrared angiography (ICGA) was intraoperatively performed in six patients after reconstruction using the free jejunum flap. An adequate arterial as well as venous phase was observed. In addition to classical patency tests and doppler, we have successfully monitored the flap after total pharyngolalyngectomy intraoperatively using the ICGA. Our preliminary results implicate that this novel technique offers secure intraoperative monitoring of a free jejunum graft. This technique will provide us with advantages over regular patency test in selected cases.

Advantage of microscope integrated for both indocyanine green and fluorescein videoangiography on aneurysmal surgery: case report.

Neck clipping of a large middle cerebral artery aneurysm was performed using a newly developed surgical microscope integrated with modules for both indocyanine green (ICG) and fluorescein videoangiography. During surgery, ICG and fluorescein videoangiography by intra-arterial or intravenous injection were safely carried out without interrupting the surgical procedure. Based on the findings obtained from the case, we evaluated the differences between the dyes and the injection routes. With intra-arterial injection, fluorescein offered sharper contrast images and was better at depicting fine arteries than ICG. Patchy staining of vessel walls was observed in intravenous fluorescein videoangiography, while it was not evident in ICG. Intra-arterial injection method had a great advantage in the rapid clearance of the dyes, which allowed us to perform repeated videoangiography within a short period, and was useful in detecting incomplete clipping in this case; however, catheter insertion requires additional work and carries a potential risk. Use of a microscope integrated for both ICG and fluorescein videoangiography would be another method for repeated evaluation. Namely, alternate use of the dyes enables us to perform videoangiography in a short time even via intravenous injection.