CNV Secondary to Laser

A history of prior macular laser would be essential.

Idiopathic

A diagnosis of exclusion in which CNV is present in the absence of any other fundus abnormalities [58].

Summary

AMD is a complex disorder with an extensive differential diagnosis. Using a good clinical exam, history taking, and ancillary testing, the physician can navigate properly to obtain the proper diagnosis. Conditions with similar appearances must be excluded as the treatment and/or prognosis may vary considerably. As our understanding of the disease process improves, we hope an international system of classification will be adopted so clinical trials can be properly compared.

References

1.Kahn HA, Leibowitz HM, Ganley JP, Kini MM, Colton T, Nickerson RS, et al. The Framingham Eye Study II. Association of ophthalmic pathology with single variables previously measured in the Framingham Heart Study. Am J Epidemiol. 1977; 106(1):33–41.

2.Gass JDM. Pathogenesis of disciform detachment of the neuroepithelium. II. Idiopathic central serous choroidopathy. Am J Ophthalmol. 1960;63:587–615.

3.Russell SR, Mullins RF, et al. Location, substructure, and composition of basal laminar drusen compared with drusen associated with age-related macular degeneration. Am J Ophthalmol. 2000;129:205–14.

4.Abdelsalam A, Del Priore L, Zarbin MA. Drusen in age-related macular degeneration: pathogenesis, natural course, and laser photocoagulation-induced regression. Surv Ophthalmol. 1999;44(1):1–29. Review.

5.Gass JD. Drusen and disciform macular detachment and degeneration. Arch Ophthalmol. 1973;90(3):206–17.

6.Green WR, McDonnell PJ, Yeo JH. Pathologic features of senile macular degeneration. Ophthalmology. 1985;92(5):615–27.

7.Sarks SH. Council lecture. Drusen and their relationshiptosenilemaculardegeneration.AustJOphthalmol. 1980;8(2):117–30.

8.Holz FG, Wolfensberger TJ, Piguet B, GrossJendroska M, Wells JA, Minassian DC, et al. Bilateral macular drusen in age-related macular degeneration.

Prognosis and risk factors. Ophthalmology. 1994; 101(9):1522–8.

9.Spraul CW, Grossniklaus HE. Characteristics of Drusen and Bruch’s membrane in postmortem eyes

with age-related macular degeneration. Arch Ophthalmol. 1997;115(2):267–73.

10. Gass JD. Stereoscopic atlas of macular disease: diagnosis and treatment. 4th ed. St. Louis: Mosby; 1997.

11. Lim JI. Age-related macular degeneration. New York: Marcel Dekkar, Inc.; 2002.

12. Klein R, Klein BE, Jensen SC, Meuer SM. The fiveyear incidence and progression of age-related maculopathy: the Beaver Dam Eye Study. Ophthalmology. 1997;104(1):7–21.

13. Klein ML, Mauldin WM, Stoumbos VD. Heredity and age-related macular degeneration. Observations in monozygotic twins. Arch Ophthalmol. 1994; 112(7):932–7.

14. Macular Photocoagulation Study Group. Risk factors for choroidal neovascularization in the second eye of patients with juxtafoveal or subfoveal choroidal neovascularization secondary to age-related macular degeneration. Arch Ophthalmol. 1997;115(6):741–7.

15.Ferris 3rd FL, Fine SL, Hyman L. Age-related macular degeneration and blindness due to neovascular maculopathy. Arch Ophthalmol. 1984;102(11):1640–2.

16. Sunness JS, Gonzalez-Baron J, Applegate CA, Bressler NM, Tian Y, Hawkins B, et al. Enlargement of atrophy and visual acuity loss in the geographic atrophy form of age-related macular degeneration. Ophthalmology. 1999;106(9):1768–79.

17. Macular Photocoagulation Study Group. Five-year follow-up of fellow eyes of patients with age-related macular degeneration and unilateral extrafoveal choroidal neovascularization. Arch Ophthalmol. 1993;111(9):1189–99.

18. Bressler NM, Frost LA, Bressler SB, Murphy RP, Fine SL. Natural course of poorly defined choroidal neovascularization associated with macular degeneration. Arch Ophthalmol. 1988;106(11):1537–42.

19. Bird AC, Bressler NM, Bressler SB, et al. An international classification and grading system for age-related maculopathy and age-related macular degeneration. Surv Ophthalmol. 1995;39:367–74.

20. Klein R, Klein BE, Linton KL. Prevalence of agerelated maculopathy. The Beaver Dam Eye Study. Ophthalmology. 1992;99(6):933–43.

21. The Age-Related Eye Disease Study Research Group. The Age-Related Eye Disease Study system for classifying age-related macular degeneration from stereoscopic color fundus photographs: the Age-Related Eye Disease Study Report Number 6. Am J Ophthalmol. 2001;132:668–81.

22. Jager RD, Mieler WF, Mille JW. Age-related macular degeneration. N Engl J Med. 2008;358:2606–17.

23. Green WR, Gass JDM. Senile disciform degeneration of the macula. Arch Ophthalmol. 1971;100:487–94.

24. Green WR, Enger C. Age-related macular degeneration histopathologic studies: the 1992 Lorenz E. Zimmerman lecture. Ophthalmology. 1993;100: 1519–35.

25. Yannuzzi LA, Negrao S, Iida T, et al. Retinal angiomatous proliferation in age-related macular degeneration. Retina. 2001;21:416–34.

26. Borrillo JL, Sivalingam A, Martidis A, et al. Surgical ablation of retinal angiomatous proliferation. Arch Ophthalmol. 2003;121:558–61.

27. Fernandes LH, Freund KB, Yannuzzi LA, et al. The nature of focal areas of hyperfluorescence or hot spots imaged with indocyanine green angiography. Retina. 2002;22:557–68.

28. Stern RM, Zakov N, Zegarra H, et al. Multiple recurrent serous sanguineous retinal pigment epithelial detachments in black women. Am J Ophthalmol. 1985;100:560–9.

29. Yannuzzi LA, Sorenson J, Spaide RF, et al. Idiopathic polypoidal choroidal vasculopathy. Retina. 1990; 10:1–8.

30. Laude A, Cackett PD, Vithana EN, Yeo IY, Wong D, Koh AH, et al. Polypoidal choroidal vasculopathy and neovascular age-related macular degeneration: same or different disease? Prog Retin Eye Res. 2010;29(1):19–29. 2009 Oct 23.

31. Yannuzzi LA, Ciardella AP, Spaide RF, et al. The expanding clinical spectrum of idiopathic polypoidal vasculopathy. Arch Ophthalmol. 1997;115:478–85.

32. Perkovich PT, Zakov N, Berlin LA, et al. An update on multiple recurrent serosanguineous retinal pigment epithelium detachments in black women. Retina. 1990;10:18–26.

33. Lafaut BA, Leyes AM, Snyders B, et al. Polypoidal choroidal vasculopathy in Caucasians. Graefes Arch Clin Exp Ophthalmol. 2000;238:752–9.

34. Uyama M, Wada M, Nagai Y, et al. Polypoidal choroidal vasculopathy: natural history. Am J Ophthalmol. 2002;133:639–48.

35. Japanese Study Group of Polypoidal Choroidal Vasculopathy. Criteria for diagnosis of polypoidal choroidal vasculopathy. Nippon Ganka Gakkai Zasshi. 2005;109:417–27.

36. Chan WM, Lam DS, Lai TY, Liu DT, Li KK, Yao Y, et al. Photodynamic therapy with verteporfin for symptomatic polypoidal choroidal vasculopathy: oneyearresultsofaprospectivecaseseries.Ophthalmology. 2004;111:1576–84.

37. Sunness JS, Rubin GS, Applegate CA, Bressler NM, Marsh MJ, Hawkins BS, et al. Visual function abnormalities and prognosis in eyes with age-related geographic atrophy of the macula and good visual acuity. Ophthalmology. 1997;104(10):1677–91.

38. Steinmetz RL, Haimovici R, Jubb C, Fitzke FW, Bird AC. Symptomatic abnormalities of dark adaptation in patients with age-related Bruch’s membrane change. Br J Ophthalmol. 1993;77(9):549–54.

39. Fine AM, Elman MJ, Ebert JE, Prestia PA, Starr JS, Fine SL. Earliest symptoms caused by neovascular membranes in the macula. Arch Ophthalmol. 1986;104(4):513–4.

40. Bressler NM, Munoz B, Maguire MG, Vitale SE, Schein OD, Taylor HR, et al. Five-year incidence and disappearance of drusen and retinal pigment epithelial

abnormalities. Waterman study. Arch Ophthalmol. 1995;113(3):301–8.

41. Sunness JS, Gonzalez-Baron J, Bressler NM, Hawkins B, Applegate CA. The development of choroidal neovascularization in eyes with the geographic atrophy form of age-related macular degeneration. Ophthalmology. 1999;106(5):910–9.

42. Yannuzzi LA, Shakin JL, Fisher YL, et al. Peripheral retinal detachments and retinal pigment epithelial atrophic tracts secondary to central serous pigment epitheliopathy. Ophthalmology. 1984;91:1554–72.

43. Spaide RF, Campeas L, Haas A, et al. Central serous chorioretinopathy in younger and older adults. Ophthalmology. 1996;103:2070–9; discussion 2079–80.

44. Spaide RF, Hall LS, Haas A, et al. Indocyanine green videoangiography of older patients with central serous chorioretinopathy. Retina. 1996;16:203–13.

45. Marmor MF. New hypotheses on the pathogenesis and treatment of serous retinal detachment. Graefes Arch Clin Exp Ophthalmol. 1988;226:548–52.

46. Tittl MK, Spaide RF, Wong D, et al. Systemic findings associated with central serous chorioretinopathy. Am J Ophthalmol. 1999;128:63–8.

47. Yoshida T, Ohno-Matsui K, Ohtake Y, et al. Myopic choroidal neovascularization: a 10-year follow-up. Ophthalmology. 2003;110(7):1297–305.

48. Johnson DA, Yannuzzi LA, Shakin JL, et al. Lacquer cracks following laser treatment of choroidal neovascularization in pathologic myopia. Retina. 1998;18: 118–24.

49. Armstrong JD, Meyer D, Xu S, et al. Long-term follow up of Stargardt’s disease and fundus flavimaculatus. Ophthalmology. 1998;105:448–58.

50. Weleber RG. Stargardt’s macular dystrophy. Arch Ophthalmol. 1994;112:752–4.

51. Marmor MF, Byers B. Pattern dystrophy of the pigment epithelium. Am J Ophthalmol. 1977;84:32–44.

52. Hsieh RC, Fine BS, Lyons JS. Patterned dystrophies of the retinal pigment epithelium. Arch Ophthalmol. 1977;95:429–35.

53. Patrinely JR, Lewis RA, Font RL. Foveomacular vitelliform dystrophy, adult type. A clinicopathologic study including electron microscopic observations. Ophthalmology. 1985;92:1712–8.

54. Jaffe GJ, Schatz H. Histopathologic features of adultonset foveomacular pigment epithelial dystrophy. Arch Ophthalmol. 1988;106:958–60.

55. Kim DD, Mieler WF, Wolf MD. Posterior segment changes in membranoproliferative glomerulonephritis. Am J Ophthalmol. 1992;114(5):593–9.

56. Clarkson JG, Altman RD. Angioid streaks. Surv Ophthalmol. 1982;26:235–46.

57. Lim JI, Bressler NM, Marsh MJ, et al. Laser treatment of choroidal neovascularization in patients with angioid streaks. Am J Ophthalmol. 1993;116: 414–23.

58. Ho AC, Yannuzzi LA, Pisicano K, et al. The natural history of idiopathic subfoveal choroidal neovascularization. Ophthalmology. 1995;102:782–9.

Key Points

•Digital fundus cameras and confocal scanning laser ophthalmoscopes have increased the efficiency and resolution of fundus photography.

•Autofluorescent images yield information about the functional status of the outer retina and retinal pigment epithelium (RPE).

•Fluorescein angiography remains invaluable for studying retinal vascular anatomy and physiology in eyes with neovascular agerelated macular degeneration (AMD).

•Optical coherence tomography (OCT) permits visualization of the vitreoretinal interface, retina, RPE, and choroid, though the implementation of enhanced-depth imaging, in exquisite detail.

•Indocyanine green (ICG) angiography is useful for differentiating neovascular AMD from masquerading conditions.

Introduction

Advancements in fundus imaging technology have contributed immensely to our study and understanding of vitreoretinal disease. Monochromatic and color photography afford an

A. Chiang ( )

Retina Service, Wills Eye Institute/Mid-Atlantic Retina, 840 Walnut St., Suite 1020, Philadelphia, PA, USA e-mail: chiang.allen@gmail.com

increasingly efficient and reliable way to document fundus findings, having evolved from 35 mm film-based camera systems to high-resolution cameras based on either digital imaging sensors or scanning laser systems. Fluorescein angiography (FA) introduces an added dimension to fundus imaging, providing a means to assess the retinal vascular anatomy and physiology in a manner previously unattainable [1]. Similarly, indocyanine green (ICG) angiography enhances our ability to visualize and analyze the choroidal circulation [2]. In the presence of these dyes, information on other layers of the fundus, particularly the retinal pigment epithelium (RPE), can be obtained indirectly by assessing the degree of increased or decreased transmission of underlying choroidal fluorescence, amount of staining and leakage, and RPE contour via stereoscopic cues. Autofluorescence imaging [3], using several interconnected physiologic principles, provides a means to evaluate the RPE and outer retina on both an anatomic and a functional basis. Optical coherence tomography (OCT) allows ophthalmologists to visualize the vitreoretinal interface as well as the underlying architecture of the retina and the RPE in exquisite cross-sectional detail. Moreover, recent implementations of OCT have permitted improved visualization of the choroid in a number of conditions, including age-related macular degeneration (AMD). Although each of these imaging methods will be discussed individually, in clinical practice they are complementary and often employed simultaneously.

Fig. 4.1 Occult choroidal neovascularization. (a) Digital color fundus photograph from an eye with exudative age-related macular degeneration. (b) Digital red-free fundus photograph. Note that intraretinal hemorrhage is more clearly highlighted. (c) SLO infrared image

demonstrates the direction of subsequent OCT image. (d) Optical coherence tomography image. The retinal pigment epithelium (RPE) is elevated from Bruch’s membrane by a fibrovascular membrane. Shallow subretinal fluid is also evident

Color Photography

Originally, fundus cameras utilized 35 mm photographic film that required a chemical development process in order to reproduce the captured images. More recently, digital photography has supplanted film-based technology as charged coupled devices (CCDs), silicone microprocessors, and digital memory chips have become increasingly more affordable. While the spatial resolution of a film is similar to that of high quality scientific CCDs, other determinants of color image quality including color accuracy, noise, dynamic range, and sensitivity are generally superior with highresolution color CCDs. Digital images also have other significant advantages; they can instantly be

retaken if the initial image capture is of poor quality and they are easy to store, retrieve, and reproduce. Collectively, these attributes make high-resolution digital color photography an efficient and a practical way to record baseline and follow-up images of patients with AMD (Fig. 4.1a).

Monochromatic Photography

When film-based photography was prevalent, a green filter was commonly placed within the imaging light path of the fundus camera in order to produce “red-free” photographs. Green light is advantageous for highlighting small hemorrhages, which appear dark, and for improving the contrast of certain anatomic structures such as blood