JOURNAL CLUB

JOURNAL- RETINA VOLUME 31/NUMBER 2/FEBRUARY 2011

SPEAKER- HIMADRI CHOUDHURY

TOPIC 1
IS INDOCYANINE GREEN ANGIOGRAPHY STILL RELEVANT? Salomon Y. Cohen MD Lise Dubois Gabriel Quentel MD Alain Gaudric MD (Editorial)

HISTORY
Introduced in 1970 for imaging choroidal circulation Technical limitations(b/h films, xenon flash lamps) 1990 development of digital angiography,high contrast monitors Scanning laser ophthalmoscopy(SLO) ICG used extensively to detect occult CNV complicating AMD

 Increasing number of CNV cases became eligible for laser photocoagulation Number of articles on ICG steadily decreased between 1995 and 2010

HISTORY(CONTD)

What are the indications of ICG A in the present clinical scenario?

AGE RELATED MACULAR DEGENERATION

Diagnosis fundus evaluation Classification fluorescein angiography, ICG angiography, OCT NON EXUDATIVE AMD ICG A improves classification of drusen Diagnosis of basal laminar drusen, subretinal deposits, reticular pseudodrusen

EXUDATIVE AMD
FA allows distinction between classic and occult CNV (major implications in 90s because only extrafoveal and juxta foveal classic cnv-eligible for laser photocoagulation) ICG A allowed visualisation of occult cnv ICG guided photocoagulation became standard care in wet AMD

Imaging of Retinal angiomatous proliferation became possible

Fluorescein angiogram shows a few areas of ill-defined leakage in this occult CNV. ICG angiography demonstrates clearly an arteriolized vascular complex. OCT shows intraretinal and subretinal fluid, retinal thickening, and RPE disruption.

 Verteporfin photodynamic therapy Required precise localisation of CNV ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR First therapy to improve mean visual acuity Radically different from laser/V-PDT Localisation of CNV not required Effective in both occult and classic CNV

 New developments of OCT include better visualisation of choroid, therefore invasive procedures avoided. Anti VEGF treatment protocol, imagery guided reinjections- decided on OCT findings OCT is also used for follow up, observation, duration till next visit.

Conditions associated with CNV

In pathologic myopia CNV associated with laquer cracks Imaging of angioid streaks However these conditions can also be easily diagnosed by fundus examination, OCT and FA

POLYPOIDAL CNV
Choroidal disease more frequent in asians and blacks. Characterised by inner choroidal vascular network of vessels ending in aneurysmal bulges or outward projections from normal surface. Associated with chronic, multiple, recurrent serosanguinous detachments of the RPE & neurosensory retina SD-OCT may be used but ICG A remains confirmatory

 ICG A is also necessary for the management of PCV Allows localisation of active PCV or hotspot Anti-VEGFs give varied results and V-PDT is the treatment of choice.

IDOPATHIC POLYPOIDAL CHOROIDAL VASCULOPATHY

Early-phase fluorescein angiogram shows areas of mottled hyperfluorescence. ICG angiogram better demonstrates polypoidal choroidal vasculopathy lesions.

CENTRAL SEROUS CHORIORETINOPATHY

Pathogenesis is still unclear. In 1980s-90s ICGA allowed detection of anomalies in choroidal circulation thus pointing towards a choroidal origin ICG A guided V-PDT may be considered as the treatment of choice for acute or chronic CSC with foveal involvement when laser cannot be used.

CSCR

In a patient having CSR, as compared to the FA picture, the ICG picture reveals multiple areas of leakage

CHOROIDAL TUMORS
Diagnosis is based on fundus examination, FA and USG ICG A is most useful in diagnosis of choroidal haemangioma The precise tumor delineation is very useful f or treatment by V-PDT or transpupillary thermotherapy Not mandatory for diagnosis and management of other choroidal tumors

Icg angiography showing choroidal haemangioma

INFLAMMATORY DISEASES
Multiple white dot syndrome Punctate inner choroidaopathy & multifocal choroiditis In Vogt-Koyanagi-Harada disease to distinguish between acute and chronic phase Birdshot chorioretinopathy

RETINAL DYSTROPHIES
Fundus flavimaculatus Juvenile X-linked retinoschisis Best disease MISCELLANEOUS Traumatic choroidopathy Choroidal ruptures RVO Vortex vein varix

CONCLUSION
Improvements in imaging and changes in the management of exudative AMD is the main reason why ICG A is less used today. ICG A still remains essential in the diagnosis and management of IPCV and choroidal haemangioma. Wherever V-PDT is considered.

TOPIC 2
CILIORETINAL ARTERIES IN DIABETIC EYES ARE ASSOCIATED WITH INCREASED RETINAL BLOOD FLOW VELOCITY AND OCCURRENCE OF DIABETIC MACULAR EDEMA Gennedy Landa MD Wendewessen Amde MD Yodit Haileselassie BA Richard B. Rosen MD RETINA 31:304-311, 2011

PURPOSE
To investigate the relationship between occurrence of cilioretinal arteries and macular oedema in diabetic eyes in terms of retinal blood flow using Retinal function imager(RFI) Other imaging techniques such as Fundus photography, fluorescein angiography, SD-OCT and SLO were also used. Additional purpose was to look for cilioretinalretinal collaterals using RFI

 Cilioretinal arteries(CilRA)- single/multiple Originate from short posterior ciliary arteries or directly from choroidal circulation Emerge at the temporal margin of the optic disc Demonstrated during choroidal flush phase of Fluorecein angiography Incidence varies from 6%-40%

RETINAL FUNCTION IMAGER

Newly introduced device allows detection of fine retinal vasculature and evaluation of blood flow velocities in these vessels Also capable of revealing collatarels RFI system consists of a standard fundus camera to which a customised stroboscopic flash lamps system and a fast digital camera have been fixed. RFI detects the motion of erythrocytes in small vessels using haemoglobin as an optical marker

RETINAL FUNCTION IMAGER

PATIENTS AND METHODS

Patients with diagnosis of diabetic retinopathy were included. All pts underwent fundus photography, FA, SD-OCT and imaging using RFI. The presence of CilRA was recognised using colour/red free fundus photographs, FA and RFI Two groups according to the presence(CilRA group) or absence(NoCilRA) of cilioretinal arteries were made

IMAGES OF PTS IN THE CilRA GROUP

RESULTS (CONTD)
Mean blood flow velocities in retinal arteries and veins were significantly higher in diabetic eyes with cilioretinal arteries(P=0.04& P=0.005) Mean blood flow velocity in cilioretinal arteries was significantly higher in comparison with the mean arterial blood velocity In the CilRA grp cilioretinal retinal collaterals were detcted in 27%(4 of 15 eyes) In the NoCilRA grp mean blood velocity in retinal veins was significantly higher in eyes with macular oedema

CONCLUSION
Using RFI in conjunction with other retinal imaging techniques the presence of cilioretinal artery in diabetic eyes was found to be associated with increased occurrence of diabetic macular oedema. Occurrence of cilioretinal-retinal collaterals was also noted; however the pathophysiologic sinificance of this finding requires further investigation.