Ординатура / Офтальмология / Английские материалы / Optical Coherence Tomography in Age-Related Macular Degeneration_Coscas_2009

Fluorescein Angiography

▬Heterogeneous hyper-fluorescence of all the raised region with progressive staining in certain areas.

▬Pooling of fluorescein in the juxtafoveal zone.

▬Cystoid spaces were stained in the late phases (Figure 10d and e).

SLO-ICG Angiography

a): Early phase, a small territory of hypo-fluorescence, with two small hot spots.

b): Late phase: the small PED was clearly visible and welldemarcated, but the contours were irregular with a crown of soft drusen.

The two hot spots in the PED were increasingly visible (Figure 10f and g).

Suggested Diagnosis:

Small polypoidal formations associated with a PED and

no detectable neovascular membrane.

Horizontal section

The RPE was irregular with several small thinned and thickened zones.

The RPE was separated from Bruch’s membrane with anterior protrusions corresponding to the two polypoidal formations

Posterior to the RPE, almost all of the heterogeneous PED cavity was optically empty.

Anterior to the RPE, an intense exudative reaction was observed with markedly increased retinal thickness and fluid infiltration between the outer retinal layers. A serous retinal detachment was demonstrated in the inferior and temporal macular region.

A large number of bright hyper-reflective spots were observed around the zones of intraretinal fluid and adjacent

to the polyps. The outer retinal layers and outer nuclear layer were no longer visible and were invaded by dense zones, bright hyper-reflective spots, and protruding polyps (Figure 11).

Vertical section

The vertical section through the largest polyp demonstrated similar features, with steeply sloped edges. Intraretinal fluid was increased with large central cysts and multiple cysts in the outer plexiform layer.

The polyp protruded as far as the outer plexiform layer. The outer nuclear layer was disorganized, irregular, and poorly-defined (Figure 11).

Treatment by monthly intravitreous injections of antiVEGF (Lucentis*) was continued for one year with fol- low-up by visual acuity, OCT, fluorescein angiography, and ICG angiography.

The response to treatment was encouraging although incomplete, and no recurrence was observed.

Visual acuity remained stable and relatively low at 20/160, despite improvement in subjective symptoms throughout follow-up.

OCT

▬ By the first follow-up examination, retinal thickness had considerably decreased, intraretinal fluid had almost completely disappeared, and the foveal depres-

sion was clearly visible.

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The outer plexiform layer was visible with normal thickness. Multiple small cysts and especially the large central cysts resolved over a period of several weeks.

The outer nuclear layer and external limiting membrane were again visible with only a small number of bright hyper-reflective spots.

Protrusion of the polyp was much less marked, although a persistent dense zone was present (Figure 12).

▬After the third injection, improvement continued with a normal appearance of all the retinal layers.

However, a small SRF with several dense spots on its edge and a localized hyper-reflective zone corresponding to

At this Stage

This case of polypoidal formations associated with oc-

cult neovascular membrane (transitional form or ac-

tive complications) was improved with treatment.

The polyps and the exudative and inflammatory reactions (intraretinal dense spots and zones) were rapidly and dramatically ameliorated.

This improvement was clearly demonstrated by Spectralis* OCT, particularly in the outer retinal layers.

the polyp anterior to the RPE were still present (Figure 12b).

▬After the fourth injection, the horizontal OCT section of the fovea showed a satisfactory appearance with a normal profile and resolution of the edema. There was a persistent subfoveal hyper-reflective zone, suggestive of fibrosis.

The vertical section confirmed almost complete resolution of the polyps and absence of intraretinal fluid with persistence of the juxtafoveal dense zone and localized loss of the external limiting membrane and IS/OS interface (Figure 13).

Visual acuity did not improve.

Fluorescein Angiography

The abnormal choroidal vascular network present on the first examination gradually decreased in terms of both surface area and perfusion.

This vascular network was virtually no longer visible on the last examination (Figures 12 and 13).

ICG Angiography

The choroidal vascular network, the polyps, and the PED progressively resolved with each successive examination and were no longer visible on the last examination (Figures 12 and 13).

The persistence and progression of limited but subfoveal fibrosis explained the absence of func-

tional improvement with only stabilization of visual

acuity.

The rapid resolution of the choroidal vascular abnormalities, polyps, and PED reflect the efficacy of treatment.

Long-term observation must be maintained as these lesions often recur.

FA

After IVT-1

FLUO

b

After IVT-3

FA

FA

a

b

ICG

After IVT-4

An 84-year-old man presented with progressive decline of visual acuity in the left eye, which was particularly worrying because it was his better eye. He had a central scotoma in the right eye for several years due to an extensive atrophic lesion.

VA RE: 20/80 - VA LE: 20/40.

of numerous, small zones of intense hyper-fluorescence, without fluorescein leakage.

At the late phase, fairly numerous punctate lesions were observed, suggesting small polyps (Figure 14d and e).

SLO-ICG Angiography

Early hyper-fluorescence of the entire posterior pole with a false image of central sparing (due to xanthophyll pigment). This irregular hyper-fluorescence was composed

a): Early phase: rapid filling of an abnormal network, initially in the superior nasal sector and then extending inferiorly.

b): Late phase: partial emptying of the superior part of the network, while the inferior part became increasingly visible and well-contrasted. This initially suggested occult choroidal neovascularization, but there was no leakage phenomenon (Figure 14f and g).

Suggested Diagnosis:

Vast abnormal choroidal network and numerous polyps

with a slowly progressive course causing limited leakage.

No detectable choroidal neovascularization.

Vertical section

The vast macular lesion detected on angiography was responsible for few signs on SD-OCT, essentially a moderate and flat PED, involving almost all of the fovea.

The RPE, separated from Bruch’s membrane except in the foveolar region, was irregular with thinner and thicker zones and numerous hyper-reflective dense spots. Numerous small prominences were also observed, probably corresponding to small polyps.

The outer retinal layers were altered: the IS/OS interface was thickened in the center and fragmented and was only partially visible.

The outer nuclear layer was severely altered with thinned zones and denser zones, mainly in the superior part, over a small zone of RPE atrophy.

Minimal intraretinal fluid was observed in the central region (Figure 15).

Treatment by monthly intravitreous injections of an- ti-VEGF (Lucentis*) was continued for 6 months with follow-up by visual acuity, OCT, fluorescein angiography, and ICG angiography.

Visual acuity improved to 20/32 after the first injection, then remained stable throughout follow-up with no subsequent improvement.

OCT

On the first follow-up examination

Retinal thickness was considerably decreased. Intraretinal fluid was decreased but was still present, and the foveal

depression remained clearly visible.

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Abnormalities of the outer layers had barely changed with persistence of the irregularities and minimal prominences of the RPE (Figure 16a).

After the second injection

Improvement continued with flattening of the PED and visibility of the external limiting membrane (Figure 16b).

After the third injection

The retinal profile became almost normal on the horizontal and vertical sections (Figure 16c and d).

The PED persisted over its entire surface, but was flat and barely visible, essentially marked by persistence of several

At this Stage

A relatively favorable response to treatment was observed in this case, comprising numerous small polyps (especially in the superior temporal sector) and a vast, juxtafoveal and interpapillomacular abnormal choroidal network.

The polyps and exudative and inflammatory reactions (intraretinal dense spots and zones) resolved rapidly. Polyps were barely detectable following treatment. Intraretinal fluid was no longer visible, and the PED had almost completely resolved.

small polyps. The external limiting membrane and IS/OS interface were clearly visualized.

Several persistent zones of thinning and hyper-reflectivity were observed in the outer nuclear layer over the residual polyps.

The inner retinal layers had a normal, well-organized appearance.

However, thickening of the inner limiting membrane was observed in the superior temporal sector, corresponding to relative RPE atrophy (Figure 16c).

Fluorescein Angiography

All of the abnormal vascular network remained visible with the same topography. The small polyps also remained visible, but their density and staining were markedly decreased.

No fluorescein leakage was observed (Figure 16).

ICG Angiography

Only the abnormal choroidal network remained visible, although the branches appear to be fewer and smaller with lower contrast, even in the late phase (Figure 16).

These results justified suspension of treatment after

the third injection.

However, the abnormal choroidal network still persisted, with a superior temporal zone of thinning and atrophy of the RPE.

The prognosis remained fairly reserved due to the persistence of this abnormal choroidal network, justifying 6-month or annual follow-up due to the risk of recurrence.

FA

a

After IVT-1

FA

b

After IVT-2

FA

c

d

After IVT-3

Idiopathic polypoidal choroidal vasculopathy, or PCV, is a particular entity, distinct from the usual definition of

AMD.

Polypoidal choroidal vasculopathy can be clearly distinguished from AMD by its polymorphic clinical features, the presence of extramacular lesions, onset at a younger age, and the absence of the usual precursor signs of AMD.

However, these two diseases share many features in common

The presence of multiple, recurrent serosanguinous pigment epithelium detachments is suggestive of AMD.

of these vessels appears to constitute a distinct entity.

As illustrated by this series of clinical cases, polypoidal ectasias can also be observed within very small choroidal vessels, almost at the level of capillaries. Polypoidal dilatations can also be observed in advanced forms of

AMD.

Transitional forms between initial PCV and subsequent development of occult choroidal neovascularization with hemorrhagic complications can also be observed.

It is still unclear at the present time whether these lesions are related or different manifestations of the same disease.

The frequency of these forms in Asian countries raises the question of a genetic predisposition. Recent genetic correlation studies advocate for a common genetic background.