Intravitreal triamcinolone acetonide combined with subthreshold grid laser treatment for macular oedema in branch retinal vein occlusion: a pilot study.

BACKGROUND: To compare the effectiveness of subthreshold grid laser treatment (SGLT) with infrared micropulse diode laser alone or in combination with intravitreal triamcinolone injection (SGLT-IVTJ) for the treatment of macular oedema (MO) secondary to branch retinal vein occlusion (BRVO). METHODS: Pilot randomised clinical trial including 24 patients (24 eyes) who were randomised either to the SGLT (13 eyes) or to SGLT-IVTJ (11 eyes). Complete ophthalmic examinations, including Early Treatment of Diabetic Retinopathy Study visual acuity, OCT and fluorescein angiography, were performed at the moment of the study entry and at 3-month intervals, with a planned follow-up of 12 months. Main outcome measures were the decrease in mean foveal thickness (MFT) on OCT, and the proportion of eyes that gained at least 10 letters (approximately two or more lines of visual acuity gain) at the 12-month examination. Secondary outcomes were the decrease in mean total macular volume on OCT, and the timing of MO resolution. RESULTS: The change in MFT from the initial values was statistically significant for the SGLT-IVTJ from the 3-month examination and for the SGLP from the 6-month examination (p<0.001). At the 12-month evaluation, 10 patients of the SGLT-IVTJ group (91%) and eight of the SGLT group (62%) gained at least 10 letters (two lines) in visual acuity. The mean number of lines gained was 3.4 and 1.3 in the SGLT-IVTJ and in the SGLT group, respectively. CONCLUSIONS: The combined SGLT-IVT treatment of MO secondary to BRVO allows a significant visual acuity improvement, when compared with simple grid laser treatment.

The spectrum of iris angiography abnormalities in pseudoexfoliation syndrome.

PURPOSE: To analyse the spectrum of angiographic features in patients monolaterally or bilaterally affected by pseudoexfoliation syndrome (PES), with and without glaucoma, and to evaluate the sensibility and specificity of these features in the diagnosis of glaucoma. METHODS: Sixty-eight patients affected by PES and 20 healthy subjects underwent iris fluorescein angiography (IFA) and iris indocyanine green angiography (IICGA). Angiographic features analysed were hypoperfusion, microneovascularizations, and anastomotic vessels. RESULTS: There was no statistically significant difference among unaffected, unilaterally affected, and bilaterally affected eyes. Patients affected by PES glaucoma showed a statistically significant difference with respect to the other groups for most of the variables. The results of qualitative variables revealed a gradual increase of the vascular involvement in the different groups. Peripupillary tufts, stromal tufts, and radial arterioles showed the best sensibility and specificity values on IFA, whereas radial arterioles and plexuses showed the highest sensibility and specificity values on IICGA. Considering all the parameters, the results were not associated with large effects on the post-test probability of disease. The values of likelihood ratio indicated that none of the examined variables was sufficiently able to discriminate patients affected by PSE glaucoma from the overall group. CONCLUSIONS: Patients clinically affected only monolaterally by PES show microvascular changes, which are similar in both eyes. Glaucoma PES represents a more advanced stage of the disease, with more pronounced alterations, even though no typical microvascular pattern can be identified by iris angiography.

Angiographic features after photodynamic therapy for choroidal neovascularisation in age related macular degeneration and pathological myopia.

AIM: To describe the angiographic features after photodynamic therapy (PDT) with verteporfin in choroidal neovascularisation (CNV) associated both with age related macular degeneration (AMD) and pathological myopia (PM). METHODS: 36 patients affected by subfoveal CNV in AMD and 25 patients with subfoveal CNV in PM underwent an ophthalmological examination including fluorescein angiography (FA) and indocyanine green angiography (ICGA) using the IMAGEnet System. Post-PDT examinations were performed 7, 30, and 90 days later. RESULTS: The typical angiographic aspect after PDT for AMD related CNV was a round hypofluorescence visible both on FA and on ICGA, which included both CNV and the surrounding tissues and corresponded to the area exposed to laser light. In PM the CNV appeared hypofluorescent during the early phases and gradually became hyperfluorescent during the late phases on FA, whereas on ICGA it was detectable in its whole extension as a hyperfluorescent lesion since the early phases. Differently from AMD, there was no round hypofluorescence surrounding the CNV on FA or on ICGA. Moreover, five patients in the AMD group showed hot spots on ICGA, which spontaneously disappeared during the follow up. Classic and occult components of the AMD related CNV revealed a different angiographic response to PDT, showing with the latter only a partial closure 1 week after PDT followed by a complete reopening at the first month in 100% of cases. CONCLUSION: The post-PDT hypofluorescence typical of AMD related CNV, especially visible on FA, might be secondary to a combination of choriocapillary occlusion and masking effect due to swelling of retinal pigment epithelium cells. Hot spots in the AMD affected patients could be interpreted as the expression of a non-thermal choroidal vasculitis secondary to PDT.

Genetic heterogeneity in Malattia Leventinese.

Malattia Leventinese (ML) is a dominant macular dystrophy characterized by drusen at the posterior pole. ML has been associated with a single mutation (R345W) in the EGF-containing fibulin-like extracellular matrix protein 1 (EFEMP-1) gene, but also the EFEMP-2 gene, known to share genetic homology with EFEMP-1, is considered a candidate gene for this genetic disorder. We have characterized clinically and genetically seven members of a three-generation family affected by ML. Results showed that five family members were clinically affected but the DNA sequencing failed to reveal the typical R345W mutation. Furthermore, the linkage analysis to EFEMP-1 (using polymorphic markers D2S337 and D2S2368) and to EFEMP-2 (using D11S987 and D11S1314 markers) gave negative results. Therefore, our results suggest EFEMP-1 or EFEMP-2 genes cannot be excluded as being responsible for ML but other genes have to be considered in the pathogenesis of the disease.

Occult choroidal neovascularization in adult-onset foveomacular vitelliform dystrophy.

AIMS: To report 6 cases in which indocyanine green angiography (ICGA) failed to convert occult choroidal neovascularization (CNV) into well-defined CNV in adult-onset foveomacular vitelliform dystrophy (AOFVD). METHODS: Patients with AOFVD observed from 1993 to 1999 were prospectively followed up. Whenever the development of CNV was suspected, ICGA was performed to detect the precise location and extension of CNV by means of the IMAGEnet System. RESULTS: Six out of 51 patients (11.7%) developed CNV during the follow-up. The CNV was of the occult type, with an associated detachment of the pigment epithelium in 1 eye. On ICGA, a large hyperfluorescent lesion appeared after about 10 min, irregularly increasing with time, without a clear visualization of site and extension of CNV. CONCLUSIONS: In AOFVD, ICGA may fail to convert occult CNV into well-defined CNV, which is amenable to laser treatment, since hyperfluorescence caused by the probably vitelliform material binding to the ICG molecule and the CNV-induced hyperfluorescence cannot be angiographically distinguished from each other.

Acute posterior multifocal placoid pigment epitheliopathy and ulcerative colitis: a possible association.

PURPOSE: To report a case of Acute Posterior Multifocal Placoid Pigment Epitheliopathy (APMPPE) in the course of Ulcerative Colitis (UC). METHODS: A complete ophthalmologic evaluation, including fluorescein and indocyanine green angiography, was performed. RESULTS: A patient with exacerbation of UC was referred to our department for sudden visual loss in RE. Ophthalmoscopy disclosed multifocal yellow-white placoid lesions typical of APMPPE in RE. There were no lesions in the fellow eye. On fluorescein angiography (FA), the active lesions showed early hypofluorescence, followed by late staining. Indocyanine green angiography (ICGA) revealed early and late hypofluorescence corresponding to the lesions observed clinically, and late anular staining surrounding a hypofluorescent lesion at the posterior pole. On LE ICGA revealed lesions not detected with ophthalmoscopy and FA. After corticosteroid therapy the lesions healed. CONCLUSION: Ulcerative Colitis may be responsible for the onset of AMPPPE by an immunological mechanism of delayed type hypersensitivity reaction.

A pilot study of ICG-guided laser photocoagulation for occult choroidal neovascularization presenting as a focal spot in age-related macular degeneration.

PURPOSE: To evaluate the effect of indocyanine green angiography (ICG)-guided laser photocoagulation in eyes with age-related macular degeneration (AMD) and occult choroidal neovascularization (O-CNV), appearing as a well-defined focal spot on ICG. METHODS: Eyes with extrafoveal or juxtafoveal focal spot on ICG, either without PED (Group A) or with PED (Group B) at baseline, were selected. The hyperfluorescent area was photocoagulated by krypton red laser within 24 hours from diagnosis on ICG guide. At 1, 3, 6, 9 and 12 months from treatment, all eyes underwent clinical examination, FA and ICG. Parameters as best corrected visual acuity (BCVA), CNV closure and recurrence onset were analyzed. RESULTS: 53 eyes were enrolled in Group A and 33 in Group B. After 1 year from treatment, a stabilized (+/-1 Snellen line) or improved (2 or more Snellen lines) visual acuity was measured in 37 eyes (43%), 32 in Group A and 5 in Group B. After 1 year, a complete resolution of exudative signs was achieved with one or more laser sessions in 41 eyes (48%), 34 in Group A and 7 in Group B. After 1 year, 50 eyes (58%) had one or more episodes of recurrent CNV, appearing in 51% of eyes of Group A and in 70% of eyes of Group B. Most of the recurrences (86%) occurred during the first trimester after photocoagulation. CONCLUSIONS: ICG-guided laser photocoagulation for O-CNV appearing as a focal spot produced encouraging anatomical and functional outcome in eyes without PED at presentation. When focal CNV is associated with a PED, our treatment technique produced disappointing results.

Iris indocyanine green angiography in pseudoexfoliation syndrome and capsular glaucoma.

PURPOSE: The iris vasculature shows typical changes in pseudoexfoliation syndrome (PXS) revealed by iris fluorescein angiography (IFA), such as hypoperfusion, microneovascularisation, and anastomotic vessels. Iris indocyanine green angiography (IICGA) can visualize more precisely details of the iris vascular pattern, especially as regards hypoperfusion and capillary dilatations. The aim of the present study is to describe the angiographic features of PXS on IFA and IICGA, comparing eyes affected with those not affected by capsular glaucoma. METHODS: In a prospective study 42 consecutive patients affected by PXS underwent a complete ophthalmologic examination including IFA and IICGA. Thirty-two eyes were affected by capsular glaucoma. IICGA was performed using IMAGEnet System H1024. RESULTS: IFA can easily detect the microneovascularisation, whereas IICGA allows a better recognition of iris hypoperfusion and anastomotic vessels, and it can reveal iris pigment epithelium defects. While the degree of hypoperfusion was similar in the two subgroups, eyes affected by capsular glaucoma more frequently showed signs of both microneovascularisation (marked stromal tufts and marked plexi), and of anastomotic vessels (peripheral loop, lesser circle and oblique vessels), with statistically significant difference. A clear correlation between hypoperfusion, microneovascularisation, and anastomotic vessels as regards site and extent was not noticed. CONCLUSIONS: A different angiographic pattern can be detected in PXS eyes with capsular glaucoma in comparison with eyes without it. Further studies are needed to correlate angiographic features revealed by IFA and IICGA, with clinical features.

Hyperfluorescence associated with serous retinal pigment epithelial detachment on indocyanine green angiography.

PURPOSE: Indocyanine green angiography has been reported to improve detection and delineation of occult choroidal neovascularisation in serous pigment epithelium detachment in age-related macular degeneration. The study aims to evaluate the visual acuity results of eyes affected by serous pigment epithelium detachment in age-related macular degeneration, having had indocyanine green-directed laser photocoagulation, and to correlate them to the pattern of serous pigment epithelium detachment on indocyanine green angiography. METHODS: Thirty-four eyes of 31 patients affected by serous pigment epithelium detachment in age-related macular degeneration were prospectively considered. Each patient underwent an ophthalmological examination including fluorescein and indocyanine green angiography one day before, and 6 weeks, 3 months, 6 months, 9 months, 12 months and 24 months after krypton-laser treatment. The serous pigment epithelium detachment was classified in the late-phases angiograms as either hypofluorescent, isofluorescent or hyperfluorescent comparing the fluorescence of the serous pigment epithelium detachment with the choroidal background fluorescence. RESULTS: The indocyanine green-guided laser treatment was associated with a temporary stabilization and a long-term progressive reduction of visual acuity: after 24 months visual acuity improved in 2.9%, stabilized in 26.5% and worsened in 70.5% of cases. Serous pigment epithelium detachment presenting a pretreatment hyperfluorescence had a final visual acuity of 0.06, with subfoveal choroidal neovascularisation development in 100% of cases, whereas serous pigment epithelium detachment presenting a pretreatment hypofluorescence and isofluorescence showed a final visual acuity of 0.12, with subfoveal choroidal neovascularisation development in 43.5% of eyes, with statistically significant difference. CONCLUSION: Overall visual acuity decreases with time after indocyanine green-guided laser treatment of choroidal neovascularisation in serous pigment epithelium detachment, and serous pigment epithelium detachment becoming hyperfluorescent in the late-phases of indocyanine green angiography has the worst functional outcome.

Iris fluorescein angiography and iris indocyanine green videoangiography in pseudoexfoliation syndrome.

BACKGROUND: Precise evaluation of the iris vascular pattern in pseudoexfoliation syndrome (PXS) may be difficult with iris fluorescein angiography (IFA) because of the frequent presence of a heavily pigmented iris and conspicuous late leakage. However, iris indocyanine green videoangiography (IICGV) can precisely visualize details of the iris vascular pattern. This study analyzed the utility of IICGV in detecting microvascular changes in PXS and compared these findings with those of IFA. METHODS: Twenty-eight patients with PXS in both eyes underwent an ophthalmic examination including IFA and IICGV. IICGV was done with the IMAGEnet system H1024. RESULTS: IICGV gave better visualization of iris hypoperfusion and anastomotic vessels whereas iris microneovascularisation was far more clearly visible on IFA. IICGV also detected iris pigment epithelium defects. CONCLUSIONS: IICGV can be considered a useful tool for evaluation of the iris vascular pattern in PXS. Iris hypoperfusion did not appear to contribute to the development of iris microvascular changes.

Iris arteriovenous communication: clinical and angiographic features.

BACKGROUND: Iris arteriovenous communication (IAVC) represents a quite rare congenital anomaly, consisting of abnormal vascular connection bypassing the iris capillary bed. The aim of the present study is to describe clinical and angiographic pattern of IAVC on iris fluorescein angiography (IFA) and on indocyanine green videoangiography (IICGV). METHODS: During a mean follow-up period of 33.5 months, eight patients affected by IAVC underwent at least three ophthalmological examinations completed by IFA and IICGV. RESULTS: IFA allows the detection of IAVC vascular structures, evidencing afferent and efferent branches, which show a rapid filling, without any evidence of leakage or iris hypoperfusion. IICGV shows more precisely the entire vascular pattern of IAVC, revealing also the presence of iris hypoperfusion in the sector in which the IAVC lay. One patient underwent cataract surgery; three months later, two neovascular tufts appeared in the hypoperfused area related to IAVC. In all other patients, periodical examinations did not reveal any clinical or angiographic changes. CONCLUSION: In IAVC, the clinical picture appears stable throughout the follow-up; both angiographic techniques seem able to precisely delineate the vascular pattern. Nevertheless, IICGV is superior in showing iris hypoperfusion surrounding the vascular abnormality. Particular care must be drawn to patients affected by IAVC who need cataract surgery.

Branch retinal vein occlusion and macroaneurysms.

BACKGROUND: Macroaneurysms can represent common consequences of branch retinal vein occlusion (BRVO). The aim of the present study is to evaluate the clinical and angiographic aspects of 31 cases of branch retinal vein occlusions (BRVO) in which retinal macroaneurysms developed, in an attempt to analyze their pathogenic features. METHODS: One hundred and sixty-one consecutive patients affected by BRVO were considered. Each patient underwent an opthalmological examination including fluorescein angiography, at an average interval of two months (range: 1-4 months) from the onset of the disease, with a mean follow-up of 43 months (range: 32-56 months). The macroaneurysms were subdivided according to size into small (from 100 to 149 microns), medium (from 150 to 249 microns), and large (greater than 250 microns), and according to origin into arterial, venous, capillary and collateral-associated. RESULTS: Thirty-one patients (19.3%) developed retinal macroaneurysms. The total number of detected macroaneurysms was 51; ten (19.6%) were large, 21 (41.2%) were of medium-size and 20 (39.2%) were small in dimension. Three lesions were of arterial origin, 22 were capillary and 26 were from collateral vessels. In 27 patients (87.1%) the lesions were located outside the macular region, and in 4 patients (12.9%) in the macular region. Patients with retinal macroaneurysms did not show a different prevalence of capillary non-perfusion when compared with others. With regard to the number of retinal venous collaterals patients with macroaneurysms developed fewer than other patients, and the difference was statistically significant (p < 0.001). CONCLUSION: The insufficient number of retinal venous collaterals can be considered the most contributory factor in the development of macroaneurysms secondary to BRVO.

Iris indocyanine green videoangiography in diabetic iridopathy.

AIMS/BACKGROUND: Iris fluorescein angiography (IFA) is not commonly used in clinical practice, although its value has been demonstrated especially in cases of diabetic disease. IFA is able to show neovascular tufts in order to guide the laser treatment, and it is highly recommended in diabetic patients who need cataract surgery or vitrectomy. Nevertheless, IFA fails to demonstrate the iris vascular pattern in heavily pigmented iris and conspicuous leakage cases. The aim of the study was to evaluate the feasibility of iris indocyanine green videoangiography (IICGV) and to correlate its findings with those of IFA in diabetic iridopathy. METHODS: Thirty six patients affected in varying degrees by diabetic retinopathy underwent an ophthalmic examination including retinal fluorescein angiography, IFA, and IICGV. IICGV was performed using IMAGEnet System H1024. RESULTS: The results demonstrated that IICGV allows precise visualisation of the iris vascular pattern, also in cases of heavily pigmented iris. CONCLUSIONS: Three main findings seemed to be evident: firstly, iris neovascularisations are detected with IFA far more easily than IICGV; secondly, capillary dilatations and iris hypoperfusion are identified far more clearly using IICGV; thirdly, there is no evident relation between capillary dilatation or iris hypoperfusion, and degree of diabetic retinopathy.