Indocyanine Green Angiography in Classic Choroidal Neovascularization

doi:10.1016/S0021-5155(98)00010-0

Japanese Journal of Ophthalmology

Volume 42, Issue 4, July–August 1998, Pages 300-303

https://doi.org/10.1016/S0021-5155(98)00010-0 Get rights and content

Abstract

The indocyanine green (ICG) angiographic features of classic choroidal neovascularization (CNV) were evaluated in the 66 consecutive patients (70 eyes) by ICG angiography using the scanning laser ophthalmoscope. All patients had classic CNV documented by fluorescein angiography. Indocyanine green angiographic findings of classic CNV were as follows: Vessel architecture in 66% (46 of 70) of eyes, feeding vessels in 29% (20 of 70), and late hyperfluorescence in 93% (65 of 70) of eyes. Borders of classic CNV were found well-defined in 47% (33 of 70), and ill-defined in 49% (34 of 70) of eyes. In the remaining 4% (3 of 70) of eyes ICG angiography did not detect CNV. Our study indicates that fluorescein angiography remains the method of choice in the diagnosis of classic CNV. Indocyanine green angiography provides more information in the detection of feeding vessels of classic CNV.

Introduction

The Macular Photocoagulation Study Group has reported the beneficial effects of laser photocoagulation in the treatment of classic choroidal neovascularization (CNV).1, 2, 3 Detection of classic CNV is one of the most important criteria for laser treatment, and fluorescein angiography has been the method of choice for diagnosis. Recent advances in imaging technology have made indocyanine green (ICG) angiography a popular diagnostic tool in addition to fluorescein angiography.4, 5, 6, 7, 8, 9, 10, 11 Indocyanine green angiography, because of the biophysical properties of ICG dye, offers the theoretical advantage of better visualization of the choroidal vasculature. In the following study, we evaluated whether the ICG angiographic features of classic CNV would provide additional information that might help in diagnosis and treatment of CNV.

Section snippets

Materials and Methods

The study included 66 consecutive patients (70 eyes) examined at the University Eye Clinic of Tübingen between January 1993 and December 1994. Inclusion criteria were: (1) Clinical evidence of choroidal neovascularization and (2) presence of classic CNV based on fluorescein angiography. Exclusion criteria were: (1) Clinical and/or fluorescein angiographical evidence of occult CNV; (2) prior laser treatment of the CNV; (3) patients with ocular opacities that precluded the interpretation of

Results

Of the 66 patients, 36 were female (55%) and 30 were male (45%). The mean age of the patients was 64.5 years (range, 22–88 years). The etiology of CNV was age-related macular degeneration (AMD) in 51 eyes, idiopathic in 10, and myopia in 6 eyes. Presumed ocular histoplasmosis syndrome (POHS) was present in 3 eyes.

The borders of the CNV were well-defined by ICG angiography in 47% (33 of 70) of eyes, and ill-defined in 49% (34 of 70) of eyes Figure 1., Figure 2.. In 4% (3 of 70) of eyes, CNV

Discussion

Indocyanine green dye has its absorption and reflection peak in the near infrared spectrum. Secondly, it binds rapidly to 98% of the serum proteins.¹² These unique properties of ICG angiography are advantageous for better imaging of choroidal vasculature.

The high temporal resolution of SLO makes dynamic evaluation of choroidal circulation possible and contributes to the superiority of the SLO in comparison to other cameras. This is because the 780-nm infrared laser of the SLO is the most

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Cited by (13)

Visualization of choroidal vasculature in pigmented mouse eyes from experimental models of AMD
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A variety of techniques exist to investigate retinal and choroidal vascular changes in experimental mouse models of human ocular diseases. While all have specific advantages, a method for evaluating the choroidal vasculature in pigmented mouse eyes has been more challenging especially for whole mount visualization and morphometric analysis. Here we report a simple, reliable technique involving bleaching pigment prior to immunostaining the vasculature in whole mounts of pigmented mouse choroids. Eyes from healthy adult pigmented C57BL/6J mice were used to establish the methodology. The retina and anterior segment were separated from the choroid. The choroid with retinal pigment epithelial cells (RPE) and sclera was soaked in 1% ethylenediaminetetraacetic acid (EDTA) to remove the RPE. Tissues were fixed in 2% paraformaldehyde (PFA) in phosphate-buffered saline (PBS). Choroids were subjected to melanin bleaching with 10% hydrogen peroxide (H₂O₂) at 55 °C for 90 min, washed in PBS and then immunostained with anti-podocalyxin antibody to label vascular endothelium followed by Cy3-AffiniPure donkey anti-goat IgG at 4 °C overnight. Images of immunostained bleached choroids were captured using a Zeiss 710 confocal microscope. In addition to control eyes, this method was used to analyze the choroids from subretinal sodium iodate (NaIO₃) RPE atrophy and laser-induced choroidal neovascularization (CNV) mouse models. The H₂O₂ pretreatment effectively bleached the melanin, resulting in a transparent choroid. Immunolabeling with podocalyxin antibody following bleaching provided excellent visualization of choroidal vasculature in the flat perspective. In control choroids, the choriocapillaris (CC) displayed different anatomical patterns in peripapillary (PP), mid peripheral (MP) and far peripheral (FP) choroid. Morphometric analysis of the vascular area (VA) revealed that the CC was most dense in the PP region (87.4 ± 4.3% VA) and least dense in FP (79.9 ± 6.7% VA). CC diameters also varied depending on location from 11.4 ± 1.97 mm in PP to 15.1 ± 3.15 mm in FP. In the NaIO₃-injected eyes, CC density was significantly reduced in the RPE atrophic regions (50.7 ± 5.8% VA in PP and 45.8 ± 6.17% VA in MP) compared to the far peripheral non-atrophic regions (82.8 ± 3.8% VA). CC diameters were significantly reduced in atrophic regions (6.35 ± 1.02 mm in PP and 6.5 ± 1.2 mm in MP) compared to non-atrophic regions (14.16 ± 2.12 mm). In the laser-induced CNV model, CNV area was 0.26 ± 0.09 mm² and luminal diameters of CNV vessels were 4.7 ± 0.9 mm. Immunostaining on bleached choroids with anti-podocalyxin antibody provides a simple and reliable tool for visualizing normal and pathologic choroidal vasculature in pigmented mouse eyes for quantitative morphometric analysis. This method will be beneficial for examining and evaluating the effects of various treatment modalities on the choroidal vasculature in mouse models of ocular diseases such as age-related macular degeneration, and degenerative genetic diseases.
Diagnostic evaluation of type 2 (classic) choroidal neovascularization: Optical coherence tomography, indocyanine green angiography, and fluorescein angiography
2011, American Journal of Ophthalmology
Citation Excerpt :
Each patient underwent a complete clinical examination that included slit-lamp biomicroscopy, fundus photography, FA, ICGA, and SD OCT. Type 2 CNV was defined as an area of choroidal hyperfluorescence with well-demarcated boundaries clearly discernible in the early phase of FA, with progressive leakage beyond the initial boundaries of the CNV9 and an area of early hypercyanescence without marked leakage activity on ICGA.10,11 Patients with neovascular maculopathy from pathologic myopia, angioid streaks, infectious inflammatory chorioretinal disease, tumors, hereditary disorders, or trauma were excluded.
To evaluate the diagnostic characteristics of type 2 (classic) choroidal neovascularizations secondary to age-related macular degeneration using spectral domain-optical coherence tomography (SD OCT), indocyanine green angiography (ICGA), and fluorescein angiography (FA).
Observational case series.
setting: Institutional. study population: Thirteen treatment-naïve eyes with type 2 choroidal neovascularization without an occult component. main outcome measures: Greatest horizontal dimension, based on the anatomic features of the neovascular complex by SD OCT (Spectralis; Heidelberg Engineering), ICGA, and FA; retinal leakage area in late-phase FA and ICGA; and the area of retinal edema in SD OCT. observation procedures: For direct comparison, ICGA and FA images were overlaid manually on infrared plus SD OCT images using VirtualDub and Paint.NET software. Greatest horizontal dimension was measured using Image J software (National Institutes of Health).
The mean greatest horizontal dimension of the neovascular complex and the retinal leakage area consistently were smaller on ICGA compared with the area of retinal edema on SD OCT. According to FA, the greatest horizontal dimension of early, well-demarcated hyperfluorescence was significantly smaller than the neovascular complex on SD OCT. In addition, the greatest horizontal dimension of the retinal leakage area in late-phase FA consistently was smaller than the area of retinal edema on SD OCT.
In classic choroidal neovascularization, ICGA and FA seem to underestimate the extension of the neovascular complex and the associated retinal pathologic features compared with SD OCT imaging.
Indocyanine green angiography in chorioretinal diseases: Indications and interpretation: An evidence-based update
2003, Ophthalmology
To assess the clinical usefulness and relevance of indocyanine green angiography (ICG) in the investigation of chorioretinal disorders and assess specifically in what conditions it may add useful information to that obtained using standard fluorescein angiography.
Many publications on ICG have appeared in recent years touting its use in ophthalmology. These publications have led to increasing use of this technique and to its application in numerous retinal diseases in which the fluorescein angiographic findings have been thoroughly described.
During this systematic literature review, we identified and reviewed a total of 376 articles, from among which we selected 92 that we considered most relevant to our purpose of evaluating published evidence as to the efficacy of ICG. We excluded many articles with weak study designs and those that simply duplicated previously published information. Our literature search used PubMed and was confined to articles in English or that included an English abstract.
Our systematic review suggests that ICG has relatively few specific indications for use as justified by previously published peer-reviewed studies. In keeping with the requirements for this Journal’s evidence-based articles, we have divided our clinical recommendations for the use of ICG into three categories: (A) strongly recommended and supported by strong evidence; (B) recommended with moderately strong supporting evidence; (C) not recommended at present because supported only by anecdotal or group consensus evidence.
- A. We highly recommended ICG for (1) identification of polypoidal choroidal vasculopathy, (2) occult choroidal neovascularization, (3) neovascularization associated with pigment epithelial detachments, and (4) recurrent choroidal neovascular membranes. These are all conditions in which ICG contributes to the identification of lesions that may be treatable.
- B. We recommend ICG with some enthusiasm for identifying feeder vessels in age-related macular degeneration, choroidal neovascular membranes, chronic central serous retinopathy, multiple evanescent white dot syndrome, vasculitis, acute multifocal placoid pigment epitheliopathy, Vogt-Koyanagi-Harada syndrome, macular lesions associated with angioid streaks, and birdshot retinopathy. In all these conditions, ICG may help establish a diagnosis and provide some useful guidance for therapy.
- C. At present, we do not recommend ICG for scleritis and posterior scleritis, drusen differentiation, Behçet’s disease, or sarcoidosis, because it has not been demonstrated to add useful clinical information.
ICG, although now a well established technique, has clear advantage over fluorescein angiography in relatively few chorioretinal disorders. It has, however, contributed to the understanding of pathologic processes in many ocular diseases. As yet, no published randomized controlled clinical trials show any benefit to the use of ICG in the management of any specific ocular disease.
Indocyanine Green Angiography
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Optical coherence tomography angiography features of choroidal neovascularization secondary to angioid streaks
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^☆: This paper was presented at the Second International Symposium on Indocyanine Green Angiography, Nara, Japan, April 5, 1995.

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Indocyanine Green Angiography in Classic Choroidal Neovascularization☆

Abstract

Introduction

Section snippets

Materials and Methods

Results

Discussion

Ophthalmology

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Laser photocoagulation of subfoveal neovascular lesions in age-related macular degenerationresults of a randomized clinical trial

Arch Ophthalmol

Subfoveal neovascular lesions in age-related macular degenerationguidelines for evaluation and treatment in the Macular Photocoagulation Study

Arch Ophthalmol

Argon laser photocoagulation for neovascular maculopathyfive-year results from randomized clinical trials

Arch Ophthalmol

Ten year’s experience with choroidal angiography using indocyanine green dyea new routine examination or an epilogue?

Doc Ophthalmol

Indocyanine green videoangiography of choroidal neovascular membranes

Ophthalmologica