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PubMedDate not supplied

Pars plana vitrectomy for subfoveal macular hemorrhage and choroidal neovascular membranes.

1. Choroidal neovascular membranes (CNVM), the abnormal ingrowth of blood vessels from the choroid through Bruch's membrane, remain a major cause of treatable visual loss. 2. Laser photocoagulation is effective in destroying CNVM and preserving central vision in many affected patients. However, laser treatment of subfoveal CNVM irreversibly destroys foveal vision. 3. The utility of vitrectomy techniques for removal of subfoveal macular hemorrhage on CNVM remains unknown pending the results of a randomized, controlled prospective study. 4. Laser photocoagulation remains the treatment of choice for extra- and juxtafoveal CNVM caused by age-related macular degeneration (ARMD), ocular histoplasmosis and idiopathic causes, and for selected subfoveal CNVM caused by ARMD.

Choroid Diseases↗
PubMed1989

Foveal ablation for subfoveal choroidal neovascularization.

Untreated subfoveal choroidal neovascularization (SFCN) often progresses to destroy much central visual function. In this study, laser photocoagulation which included the entire foveal avascular zone was applied to SFCN in the second eye of 13 consecutive patients. Each patient had untreated SFCN in their first eye with visual acuity less than or equal to 20/400. Each second eye had SFCN of recent onset which was less than or equal to 1 disc diameter (DD) in size and visual acuity less than or equal to 20/200. In 10 of 13 (76.9%) treated eyes, SFCN was eliminated for 3 to 30 months. These eyes all retained strikingly better visual fields (Amsler or automated) than their fellow untreated eyes, markedly better subjective vision, and Snellen visual acuities of 20/70 to 20/400. Foveal photocoagulation may be useful in selected cases of SFCN with small neovascular nets and poor visual acuity.

Aged↗
PubMed1995

ICG-enhanced digital angiography and photocoagulation of choroidal neovascularization in age-related macular degeneration.

Choroidal neovascular membranes are often poorly defined on fluorescein angiography because of fluorescein leakage or blockage of hyperfluorescence by overlying hemorrhage, lipid, turbid fluid, or pigment. Indocyanine green (ICG) is a highly protein-bound dye in the near infrared portion of the spectrum. Therefore, ICG remained in and around the neovascular membrane and enhanced the visualization of certain membranes poorly defined with fluorescein. ICG penetrated through the overlying turbid tissue, and improved the visualization of the underlying choroidal neovascular membrane. Using an infrared angiography system, the authors obtained 21 ICG-angiograms with suspected choroidal neovascularization, and compared them to fluorescein angiograms. In 5 of the 21 eyes, occult choroidal neovascularization was well delineated on the ICG angiograms. In 2 eyes, we were able to detect a well-defined choroidal neovascular membrane underlying a subretinal hemorrhage. In 12 of the 21 eyes with choroidal neovascular membrane, we performed argon-green laser photocoagulation applying the overlay technique of the ICG angiogram to red-free photo or the early fluorescein angiogram, and evaluated the effect of full coverage laser treatment.

Choroid↗
PubMed1985

Indocyanine green angiography of choroidal neovascular membranes.

The choroidal circulation was studied in 27 eyes with choroidal neovascular diseases by means of fluorescein and indocyanine green (ICG) angiography. In 10 of the cases the disciform response was seen to be associated with either watershed zones of the choroidal circulation or with areas of choroidal circulatory disturbance. This is consistent with the theory that hypoxic regions of the choroid are the underlying cause of macular disciform response.

Adult↗
PubMed1981

Morphologic fluorescein angiographic, and light microscopic features of experimental choroidal neovascularization.

We induced choroidal neovascularization in the rhesus monkey by impoverishing the blood supply to the inner retina and producing defects in Bruch's membrane by photocoagulation. Fourteen of 46 eyes undergoing photocoagulation developed neovascular fronds which were identified and categorized by histopathologic examination and fluorescein angiography. All new vessels gained access to the retina through defects in Bruch's membrane at the site of photocoagulation marks. In eight eyes the new vessels remained localized to the immediate vicinity of photocoagulation marks. In four eyes neovascular fronds infiltrated the subretinal space for distances up to 6 disk diameters from the point of entry into the retina. In the two eyes choroidovitreal neovascular complexes developed but rapidly regressed shortly after gaining the vitreous cavity. Fluorescein angiography demonstrated that all neovascular fronds were grossly incompetent to dye but that formed feeding channels had some degree of integrity. Light microscopic studies showed the proliferating networks to be composed of capillaries with well-formed basement membranes and more mature vessels with the basic structure of choroidal arteries and veins.

Animals↗
PubMed1992

Surgical management of subfoveal choroidal neovascularization.

BACKGROUND: Subfoveal choroidal neovascularization (CNV) usually is associated with a poor visual prognosis. Laser photocoagulation of certain subfoveal membranes secondary to age-related macular degeneration (ARMD) appears preferable to observation based on recent Macular Photocoagulation Study (MPS) findings but is associated with decreased vision. The authors explored the use of vitreoretinal surgical techniques as an alternative method of eradicating subfoveal CNV. METHODS: After vitrectomy, a small retinotomy technique was used to extract or disconnect from the choroidal circulation subfoveal CNV in 58 eyes. There were 33 eyes with ARMD, 20 eyes with presumed ocular histoplasmosis, and 5 eyes with miscellaneous etiologies. Five eyes also received subfoveal RPE patches. RESULTS: With limited follow-up, significant improvement in vision (defined as 2 Snellen lines) was achieved in 7 of 22 eyes with ARMD CNV removal (1 eye 20/20), 0 of 4 eyes with ARMD CNV removal and RPE patches, and 1 of 7 eyes with ARMD CNV disconnection. Significant improvement was achieved in 6 of 16 eyes with presumed ocular histoplasmosis removal and 0 of 4 eyes with presumed ocular histoplasmosis CNV disconnection. In 5 eyes with miscellaneous CNV, 2 improved (20/20 and 20/40). CNV recurred in 29%. CONCLUSIONS: Some patients with subfoveal CNV appear to benefit from surgical removal. Only rarely do eyes with ARMD improve. Longer-term follow-up and refined case selection are required before this approach can be widely recommended.

Aged↗
PubMed1994

Digital indocyanine-green videoangiography of occult choroidal neovascularization.

BACKGROUND: Occult choroidal neovascularization (CNV) secondary to age-related macular degeneration occurs in the majority of patients with exudative maculopathy. Since occult CNV cannot be imaged clearly by fluorescein angiography, this condition is untreatable. The authors performed digital indocyanine-green videoangiography (ICG-V) on 657 consecutive eyes with occult CNV by fluorescein angiography to determine if this technique could be useful in enhancing the imaging of the neovascularization, and thus increasing treatment eligibility. MATERIALS AND METHODS: Six hundred fifty-seven consecutive eyes with occult CNV were studied. The fluorescein and ICG angiograms were compared, and the percentage of patients potentially eligible for laser therapy based on ICG findings was calculated. RESULTS: Of 413 eyes with occult CNV without pigment epithelial detachments, focal areas of neovascularization were noted in 89 (22%). Overall, 142 (34.3%) eyes had lesions that were potentially treatable by laser photocoagulation based on additional information provided by ICG-V. Of the 235 eyes with occult CNV and vascularized pigment epithelial detachments, 98 (42%) were eligible for laser therapy based on ICG-V findings. The authors calculate that ICG-V enhances the treatment eligibility by approximately one third. CONCLUSIONS: In diagnosing occult CNV, ICG-V is an important adjunctive technique to fluorescein angiography. This technique is especially useful in delineating occult neovascularization, neovascularization with overlying subretinal hemorrhage or serosanguineous fluid, and neovascularization associated with pigment epithelial detachments. The authors currently suggest that ICG-V be performed in eyes in which well-delineated neovascularization cannot be identified by fluorescein angiography. Based on their preliminary study, it can be expected that one in three patients with occult CNV potentially will be eligible for laser photocoagulation based on ICG-V. Further studies are necessary to confirm these findings.

Aged↗
PubMed2000

[Micro-perimetric documentation of retinal function in photodynamic therapy of choroid neovascularizations].

PURPOSE: Photodynamic therapy provides occlusion of choroidal neovascularization by intravascular endothelial damage. The photodynamic approach offers the potential to occlude choroidal neovascularization selectively without altering adjacent sensory retina and therefore to preserve visual acuity. To determine the selectivity of photodynamic therapy photoreceptor function was measured by microperimetry allowing topic mapping of retinal function. METHODS: A Rodenstock scanning laser ophthalmoscope was used to document preservation of central visual fields before and after photodynamic therapy. Single photodynamic therapy without known efficient parameters was performed in 13 patients and repeated photodynamic therapy using optimised light doses was performed in 10 patients with subfoveal choroidal neovascularization using benzoporphyrin derivate (verteporfin). Intensity and dimension of central scotomas were measured, using a grading system of stimuli ranging from 0-32 dB. Areas of absolute and relative defect were defined and fixation localisation was monitored. Perimetric testing was done pre photodynamic therapy, one week, one month and three months post photodynamic therapy. RESULTS: Postoperative scotomas after single photodynamic therapy were smaller in 8%, identical in 61% and larger in 31% compared with preoperative findings. After repeated photodynamic therapy postoperative scotomas were smaller in 70%, identical in 30% and larger in no case. The observed increase was less than 25% of the original size. Postoperative defects were always significantly smaller than the entire size of the irradiated area. No new scotomas were found after photodynamic therapy. Angiographically visible occlusion post photodynamic therapy was in general larger than scotoma size. CONCLUSION: Documentation of the retinal function by microperimetry after photodynamic therapy of subfoveal choroidal neovascularization shows no new scotoma in the treated area. This can also be documented in the hypofluorescent area around the lesion one week after the treatment. After repeated treatment a reduced scotoma size due to choroidal neovascularization could be seen in 2/3 of the patients after 3 months. No initial vision loss as seen in conventional photocoagulation could be documented after photodynamic therapy.

Aged↗
PubMed2006

Prostate-specific membrane antigen is undetectable in choroidal neovascular membrane.

BACKGROUND: Choroidal neovascular membrane (CNVM) is one of the leading causes of severe visual loss and is often associated with age-related macular degeneration (AMD). Various modalities of treatment, including photocoagulation and surgery, are being considered as options, but with limited success. Prostate-specific membrane antigen (PSMA) is a type II membrane glycoprotein expressed in benign and malignant prostatic tissues, in some non-prostatic tissues, and in the endothelium of tumor-associated neovasculature of non-prostatic neoplasm. Some studies have suggested that the expression of PSMA is restricted to endothelium from tumor-associated neovasculature and might be stimulated by some tumor-secreted angiogenic factors. However, no previous study demonstrating PSMA expression in non-related tumor neovasculature, such as CNVM, has been performed to date. Furthermore, demonstration of PSMA expression in CNVM in AMD patients could reveal a novel target for antineovascular therapy. The purpose of this study was to evaluate the immunohistochemical expression of PSMA in CNVM from AMD. METHODS: Immunohistochemical analysis, with a standard avidin-biotin complex technique, was performed using an anti-PSMA mouse monoclonal antibody in 30 specimens of surgically excised CNVM from AMD patients. Antibody to an endothelial cell specific marker, factor VIII, was used to confirm the location of the endothelial cells. RESULTS: The angiogenic microvessels of the 30 cases demonstrated negative staining to PSMA while factor VIII was expressed in all cases. Seventy-five percent of the secretory-acinar epithelium of the prostatic hyperplasia specimen stained positive, confirming that the immunohistochemical technique was correctly performed. CONCLUSION: The absence of PSMA expression in non-tumoral neovasculature supports the theory, previously suggested, that endothelial cell PSMA expression may be stimulated by one or more tumor-secreted angiogenic factors. Angiogenesis is very important in neoplasia and the endothelial expression of PSMA in tumor-associated neovasculature may represent a target for antineovasculature-based therapy. The absence of PSMA expression in CNVM suggests that PSMA may not be a potential target for antineovasculature-based therapy.

Journal Article↗
PubMed2000

Optical coherence tomographic features of idiopathic submacular choroidal neovascularization.

PURPOSE: To clarify the morphologic features of idiopathic submacular choroidal neovascularization using optical coherence tomography. METHODS: Using optical coherence tomography, we prospectively examined 17 consecutive eyes (17 patients; eight men, nine women; mean age +/- SD, 36.0 +/- 9.3 years) with idiopathic submacular choroidal neovascularization. During the follow-up period (mean +/- SD, 7.5 +/- 3.8 months), we repeated optical coherence tomography in 15 eyes; optical coherence tomography was performed only at the initial examination in two eyes that underwent submacular surgery. RESULTS: Choroidal neovascularization was observed in the subsensory retinal space anterior to the retinal pigment epithelium as a highly or moderately reflective mass, which protruded from the retinal pigment epithelium in 13 of 17 eyes (protruding type). In four eyes, choroidal neovascularization was a highly reflective fusiform mass at the level of the retinal pigment epithelium and choriocapillaris (fusiform type). During the follow-up period, choroidal neovascularization regressed and the protruding mass became a highly reflective fusiform mass in 10 of 11 eyes with the protruding type that underwent repeated examination. In three of the 10 eyes, during 5 to 10 months from initial examination, the choroidal neovascularization was exacerbated and it again protruded into the subsensory retinal space anterior to the retinal pigment epithelium. Four eyes with the fusiform type remained the same throughout the follow-up period. The overlying retina was thickened and had low reflectivity in all 17 eyes at the initial examination. Optical coherence tomography identified subretinal fluid in only 11 of the 13 eyes with protruding type choroidal neovascularization. CONCLUSIONS: Optical coherence tomography confirmed subsensory retinal location of idiopathic submacular choroidal neovascularization anterior to the retinal pigment epithelium. Protruding choroidal neovascularization transforms to fusiform tissue at the level of the retinal pigment epithelium during the process of regression. Sensory retinal edema was always associated with choroidal neovascularization.

Adult↗
PubMed1998

Indocyanine green angiographic features of idiopathic submacular choroidal neovascularization.

PURPOSE: To clarify the indocyanine green angiographic features of idiopathic submacular choroidal neovascularization. METHODS: We performed fluorescein and indocyanine green angiography in 16 eyes of 16 patients (nine men, seven women; mean age +/- SD, 35.6 +/- 6.9 years; range, 24 to 48 years) with idiopathic submacular choroidal neovascularization. During the mean follow-up of 11.4 +/- 7.9 months (range, 1 to 28 months), angiography was repeated (mean, 2.6 +/- 0.5 times; range, 2 to 3 times) in 12 eyes and performed only once in four eyes. RESULTS: In the early phase of indocyanine green angiography, a network of choroidal neovascularization was observed in 11 of the 16 eyes with well-defined choroidal neovascularization seen by fluorescein angiography. Choroidal hyperfluorescent areas were noted in 10 of the 16 eyes in the late-phase angiography. Three of the 10 eyes showed focal dilatation of choroidal veins within the hyperfluorescent areas. Choroidal neovascular membrane was located within the hyperfluorescent areas in eight of the 10 eyes with choroidal hyperfluorescent areas. A dark rim surrounding choroidal neovascularization was observed in 13 of the 16 eyes at the initial examination. Indocyanine green angiography was repeated in nine of the 13 eyes and in the other three eyes without dark rim initially. During the follow-up period, the dark rim became prominent in eight of the nine eyes and developed in one eye without dark rim initially. Choroidal neovascular membrane regressed in these nine eyes. Choroidal neovascularization remained active or enlarged in three eyes in which the dark rim was stationary or invisible. CONCLUSIONS: The dark rim surrounding the choroidal neovascularization in indocyanine green angiograms appeared to reflect regression of idiopathic choroidal neovascularization. Choroidal vascular abnormalities such as hyperfluorescent areas or focal venous dilatation seem to be the background lesion predisposing to the choroidal neovascularization.

Adult↗
PubMed1996

Etiology of choroidal neovascularization in young patients.

BACKGROUND: Choroidal neovascularization (CNV) is a common cause of legal blindness in developed countries. In patients younger than 50 years of age, CNV can be due to various causes, but to the authors' knowledge there has been no large epidemiologic study to compare the relative incidence of the various causes of CNV in this younger-aged group. METHODS: A retrospective study was performed of patients seen over a 30-month period to precisely define the relative incidence of the various etiologies of CNV in patients younger than 50 years of age who had been referred to a tertiary care ophthalmology department in western Europe. RESULTS: Clinical charts and angiograms of 363 patients were reviewed. The etiology of CNV was high myopia in 225 (62%) patients, pseudo-presumed ocular histoplasmosis syndrome in 42 (12%), angioid streaks in 17 (5%), and miscellaneous hereditary or traumatic or inflammatory disorders in 16 (4%). Choroidal neovascularization could not be related to any etiology in 63 (17%) patients, and was considered to be idiopathic lesions. Choroidal neovascularization was subfoveal in 62% of the patients due to myopia versus 30% to 36% in patients due to other etiologies. Laser photocoagulation was applied in the majority of patients due to all etiologies except myopia. CONCLUSION: These data provide the relative incidence of the various etiologies of CNV in young patients and emphasize the importance of myopia as an etiology of CNV in such patients. In addition, an apparent preferential localization of CNV to the subfoveal region in myopic eyes precludes its treatment with photocoagulation.

Adolescent↗
PubMed1994

Persistent and recurrent neovascularization after laser photocoagulation for subfoveal choroidal neovascularization of age-related macular degeneration. Macular Photocoagulation Study Group.

OBJECTIVE: To determine the incidence and visual impact of and risk factors for persistent and recurrent neovascularization after laser photocoagulation of subfoveal choroidal neovascularization (CNV) in patients with age-related macular degeneration. DESIGN, PATIENTS, AND METHODS: The records of 189 eyes in the Subfoveal New CNV Study and 100 eyes in the Subfoveal Recurrent CNV Study assigned to laser photocoagulation were examined. Persistent CNV (detected within 6 weeks of treatment) and recurrent CNV (detected after 6 weeks) were defined angiographically by fluorescein leakage from the periphery of the treatment scar. Incidence was estimated using survival analysis methods. RESULTS: In both studies, persistent CNV was observed in approximately 13% of the eyes, and recurrent CNV was estimated to have developed by 3 years in an additional 35% of the eyes. In the New CNV Study, by 3 years, 36% of the eyes with persistent CNV had lost 6 or more lines of visual acuity as had 19% of the eyes with recurrent CNV and 27% of the eyes without persistence or recurrence. The presence of neovascular maculopathy in the fellow eye was associated with an increased risk for persistence or recurrence in the study eye. In the New CNV Study, partial coverage of the lesion with heavy laser treatment and/or runoff was associated with increased risk for persistence; less extensive natural scarring of the lesion at study entry was associated with increased risk for recurrence. CONCLUSIONS: Close to half of the eyes treated for subfoveal CNV have persistent or recurrent CNV within 3 years. There is a strong association between neovascular maculopathy in the fellow eye and the inability of laser photocoagulation to permanently obliterate signs of CNV from the study eye. Within these two studies, there was little additional damage to visual function resulting from persistent or recurrent neovascularization. There appears to be no reason to deviate from the protocol goal of covering the entire neovascular complex when treating eyes with subfoveal CNV.

Aged↗
PubMed1993

Laser treatment of choroidal neovascularization in patients with angioid streaks.

The benefit of laser photocoagulation to choroidal neovascularization secondary to angioid streaks remains controversial. To further expand our knowledge, we reviewed the records of 20 patients (24 eyes) with classic (well-defined) choroidal neovascularization secondary to angioid streaks, who were treated with laser between 1982 and 1991 at the Retinal Vascular Center of the Wilmer Institute. The choroidal neovascularization was extrafoveal in 18 (75%), juxtafoveal in two, subfoveal in three, and indeterminate in one eye. Seventeen of the 24 fellow eyes (71%) had a disciform scar or choroidal neovascularization, or both. Follow-up ranged from three months to nine years (mean, 3.5 years; median, two years). Lines of visual acuity change averaged -2.5 at three, -2.6 at six, -2.4 at 12, and -4.8 lines at 24 months. Choroidal neovascularization persisted in five of 24 eyes and recurred in nine of the remaining 19 eyes at risk. When the fellow eye had choroidal neovascularization, scar, or both, at the time of treatment, the rate of persistence or recurrence was 65% vs 33% if the fellow eye had no choroidal neovascularization, scar, or both. An average of four lines of visual acuity was lost when fellow eyes had choroidal neovascularization, scar, or both, vs one line when the fellow eye had no choroidal neovascularization or scar. Laser photocoagulation of choroidal neovascularization in patients with angioid streaks can result in closure of the choroidal neovascularization and stabilization of visual acuity.

Adult↗
PubMed2002

Blockade of nitric-oxide synthase reduces choroidal neovascularization.

Nitric oxide (NO) promotes retinal and choroidal neovascularization, although different isoforms of nitric-oxide synthetase (NOS) are critical in each. Deficiency of endothelial NOS (eNOS) suppresses retinal but not choroidal neovascularization, whereas deficiency of neuronal NOS (nNOS) or inducible NOS (iNOS) suppresses choroidal, but not retinal neovascularization. In this study, we investigated the effect of N(G)-monomethyl-L-arginine (L-NMMA), a nonspecific NOS inhibitor, in three models of ocular neovascularization. Oral administration of L-NMMA caused significant inhibition of choroidal neovascularization in mice with laser-induced rupture of Bruch's membrane and significantly inhibited subretinal neovascularization in transgenic mice with expression of vascular endothelial growth factor (VEGF) in photoreceptors (rho/VEGF mice) but did not inhibit retinal neovascularization in mice with ischemic retinopathy. By extensive mating among mice deficient in NOS isoforms, triple homozygous mutant mice deficient in all three NOS isoforms were produced. These mice had marked suppression of choroidal neovascularization at sites of rupture of Bruch's membrane and near-complete suppression of subretinal neovascularization in rho/VEGF mice but showed no difference in ischemia-induced retinal neovascularization compared with wild-type mice. These data indicate that NO is an important stimulator of choroidal neovascularization and that reduction of NO by pharmacologic or genetic means is a good treatment strategy. However, the situation is more complex for ischemia-induced retinal neovascularization for which NO produced in endothelial cells by eNOS is stimulatory, but NO produced in other retinal cells by iNOS and/or nNOS is inhibitory. Selective inhibitors of eNOS may be needed for treatment of retinal neovascularization.

Animals↗
PubMed1999

Dramatic inhibition of retinal and choroidal neovascularization by oral administration of a kinase inhibitor.

The most common cause of new blindness in young patients is retinal neovascularization, and in the elderly is choroidal neovascularization. Therefore, there has been a great deal of attention focused on the development of new treatments for these disease processes. Previous studies have demonstrated partial inhibition of retinal neovascularization in animal models using antagonists of vascular endothelial growth factor or other signaling molecules implicated in the angiogenesis cascade. These studies have indicated potential for drug treatment, but have left many questions unanswered. Is it possible to completely inhibit retinal neovascularization using drug treatment with a mode of administration that is feasible to use in patients? Do agents that inhibit retinal neovascularization have any effect on choroidal neovascularization? In this study, we demonstrate complete inhibition of retinal neovascularization in mice with oxygen-induced ischemic retinopathy by oral administration of a partially selective kinase inhibitor that blocks several members of the protein kinase C family, along with vascular endothelial growth factor and platelet-derived growth factor receptor tyrosine kinases. The drug also blocks normal vascularization of the retina during development but has no identifiable adverse effects on mature retinal vessels. In addition, the kinase inhibitor causes dramatic inhibition of choroidal neovascularization in a laser-induced murine model. These data provide proof of concept that pharmacological treatment is a viable approach for therapy of both retinal and choroidal neovascularization.

Administration, Oral↗
PubMed2004

Early neovascular bridging after photodynamic therapy of myopic choroidal neovascularization.

BACKGROUND: Photodynamic therapy is a relatively new modality for the treatment of subfoveal choroidal neovascularization (CNV). An unusual response to verteporfin therapy of myopic CNVs is reported. METHODS: Out of 187 CNVs secondary to pathologic myopia treated with photodynamic therapy, three eyes manifested two separate foci of CNV before treatment. The three eyes were treated with verteporfin therapy according to the standard protocol, using a single spot of light that covered both neovascular fronds. RESULTS: All the three eyes showed neovascular bridging of the two separate neovascular complexes 1 month after treatment. CONCLUSIONS: Eyes with multiple foci of myopic CNV may show unexpected outcomes after verteporfin therapy. Several factors, such as changes of the retinal pigment epithelium and choroidal vasculature involved in the treatment and enhanced expression of vascular endothelial growth factor, may play a role.

Choroidal Neovascularization↗