IMAGING in AMD
From Fluorescein Angiography
To the Spectral Domain OCT
G. Soubrane, MD,PhD, FEBO, FARVO
Department of Ophthalmology
University Paris 12-Creteil, FRANCE
FLUORESCEIN ANGIOGRAPHY
 Diagnosis of CNV: Gold standard
Leakage through abnormal endothelium and CNV
Staining of additional tissue or of RPE
Evaluation of inner (vessels) and outer (RPE)
retinal barriers
Diffusible molecule through choriocapillaris
Basis for staging of the disease
Age Related Maculopathy vs Age related Macular
Degeneration
Geographic Atrophy vs Choroidal New Vessels
Hard drusen
Soft drusen
Soft drusen
Geographic Atrophy
Choroidal New Vessels
Choroidal New Vessels
• LES 2 TYPES DE C
Pre epithelial classic
Sub epithelial occult
FA CLASSIFICATION
• Age Related Maculopathy (ARM)
RPE changes : hyper or hypopigmentation
Drusen : hard, soft, calcified, reticular pseudo-drusen
• Age related Macular Degeneration (AMD)
Atrophy
Choroidal new vessels (CNV) :
classic ,
occult (MPS type II),
PED serous, fibrovascular ( MPS type I)
INDOCYANIN GREEN ANGIOGRAPHY
Normal choroidal circulation
ARM : Distinction of various material
AMD : Dynamic visualisation of
– Abnormal network and new-vessels
Conversion of occult CNV into sub-epithelial CNV
Visualization of CNV inside a PED
Diagnosis of polypoidal vasculopathy and chorioretinal
anastomosis
ARM
Hard drusen
Soft drusen
AMD
Exudative maculopathy
Sub-epithelial occult CNV
Sub-epithelial occult CNV
Progressing sub-epithelial occult CNV:
AF
: discrete abnormalities without diffusion
ICG
: early filling of the central feeder vessel
perfusing a neovascular network
within a dark area
late staining of a persistent central plaque
Sub- epithelial occult CNV
Sub-epithelial occultCNV
Natural history:Clinical development of PED
Fibro vascular PED
PED
Occult
Sub-epithelial CNV
Natural history
Proliferation of pre-epithelial classic new vessels
In 42%, in 2 to 3 years
Angiographies : irreplaceable tools
AF : visualization of pre-epithelial classic new vessels
ICG : identification of sub-epithelial occult new vessels
AMD
Exudative maculopathy
Chorioretinal anastomosis or Type III
Chorioretinal anastomosis
• Severe form of neovascularization
• Frequency
15% of AMD (4.5% for Japanese*)
30% of vascularized PED
 Prognosis for second eye
* Am J Ophthalmol. 2007
AMD
Exudative maculopathy
Idiopathic polypoidal vasculopathy
Idiopathic polypoidal vasculopathy
Biomicroscopy
Idiopathic polypoidal vasculopathy
FA
ICG
Idiopathic polypoidal vasculopathy
ICG CLASSIFICATION
• Age Related Maculopathy (ARM)
RPE changes : hyper or hypopigmentation
Drusen : hard, soft, (reticular pseudo drusen)
• Age related Macular Degeneration (AMD)
Atrophy
Choroidal new vessels (CNV) :
Sub epithelial occult with RPE elevation
Vascularized PED
Ingrowth of classic pre epithelial
Fibrovascular PED
CRA, Polyps
OPTICAL COHERENCE TOMOGRAPHY
Direct and indirect symptoms
– Accumulation of fluid in all retinal layers
– Changes in the neurosensory retina
especially of the photoreceptors
– Irregularity or elevation of the RPE
– Quantification of the abnormalities :
retinal thickening or thinning
CIRRUS SD-OCT
SPECTRALIS SD-OCT
TOPCON SD-OCT
OCT 3
OCT 1
HR-OCT
Spectral OCT
•
• Analysis of the outer hyper-reflective layers
- external limiting membrane
- interface OS/IS
- RPE
- Bruch membrane
Outer nuclear layer
External limiting membrane
Inner segment
Interface
Outer segment
RPE
Bruch’s membrane
Eye tracking on graph
Sub- epithelial occult CNV
Network
Sub- epithelial occult CNV
Junction OS/IS
Fovea
Irregular, fragmented RPE
Sub- epithelial occult CNV
VA 20/50 P3
Sub- epithelial occult CNV
Fovea
SRF
RPE
RPE detachment organized with discrete shadowing
SRF extensive
RPE thinned and irregular
Sub- epithelial occult CNV
Sub- epithelial occult CNV
Fovea
RPE detachment
- Elevated RPE
with moderate reflectivity
no marked shadowing
-Limited subfoveal SRF
small increase in retinal thickness
foveal flattening
6 mm
PED with Spectral Domain OCT
Serous PED
dépression fovéale
Fovea
DSR
RD
DEP
PED
b
Fibro vascular PED
Occult
CRA with Spectral OCT
FA
Late ICG
Large Cysts
VA: 20/50
CRA
PCV with Spectral OCT
OCT CLASSIFICATION
• Fluid or not fluid
Early detection of fluid
Quantification of retinal thickness
Response to treatment
• Outer retinal layers
Visibility of Bruch’s membrane
IS-OS changes
Retinal atrophy
Beginning of choroidal analysis
• In the future Adaptive Optics
PED
Evolution of imaging for neovascular AMD
OCT
Fluorescein
Angiography
Gass
1967
ICG
Angiography
Flower Yannuzzi
2000
Classic, Occult CNV, FV PED
Huang
SD-OCT
Puliafito
Drexler
Coscas
2006 - 2009
Subepithelial CNV
Evolution of therapy for neovascular AMD
Laser
photocoagulation
Creteil
MPS reports
1980
Submacular
surgery
PDT
with verteporfin
TAP
VIP VIM
report reports
2000
Halt progression
PDT = photodynamic therapy
SST
Anti-VEGF therapy
MARINA ANCHOR
VISION
PIER
2006 - 2009
Improve vision