IMAGING in AMD

From Fluorescein Angiography

To the Spectral Domain OCT

G. Soubrane, MD,PhD, FEBO, FARVODepartment of Ophthalmology

University Paris 12-Creteil, FRANCE

Diagnosis of CNV: Gold standard

Leakage through abnormal endothelium and CNVStaining 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

FLUORESCEIN ANGIOGRAPHY

Soft drusen

Geographic Atrophy Choroidal New Vessels

Hard drusen Soft drusen

• LES 2 TYPES DE C

Choroidal New Vessels

Pre epithelial classic Sub epithelial occult

• 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)

FA CLASSIFICATION

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

INDOCYANIN GREEN ANGIOGRAPHY

ARM

Hard drusen Soft drusen

AMD

Exudative maculopathy

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 occult CNV

Natural history:Clinical development of PED

Sub-epithelial occultCNV

PED

Occult

Fibro vascular PED

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

Natural historySub-epithelial CNV

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 vasculopathyBiomicroscopy

Idiopathic polypoidal vasculopathy

ICG

FA

Idiopathic polypoidal vasculopathy

• 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

ICG CLASSIFICATION

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

OPTICAL COHERENCE TOMOGRAPHY

CIRRUS SD-OCT SPECTRALIS SD-OCT

TOPCON SD-OCT

OCT 1 OCT 3HR-OCT

•

• Analysis of the outer hyper-reflective layers- external limiting membrane- interface OS/IS - RPE- Bruch membrane

Interface

Bruch’s membraneRPE

External limiting membrane

Outer nuclear layer

Outer segment

Inner segment

Spectral OCTSpectral OCT

Eye tracking on graph

Network

Sub- epithelial occult CNV

Sub- epithelial occult CNV

Irregular, fragmented RPE

FoveaJunction OS/IS

VA 20/50 P3

Sub- epithelial occult CNV

RPE detachment organized with discrete shadowing

SRF extensive

RPE thinned and irregular

RPE

SRF

Sub- epithelial occult CNV

Fovea

Sub- epithelial occult CNV

6 mm

- Elevated RPE with moderate reflectivity no marked shadowing-Limited subfoveal SRF small increase in retinal thickness foveal flattening

Sub- epithelial occult CNV

RPE detachment

Fovea

PED with Spectral Domain OCT

b

Serous PED

dépression fovéale

DEPDSR

Occult

Fovea

PED

RD

Fibro vascular PED

VA: 20/50

CRALarge Cysts

CRA with Spectral OCT

Late ICG

FA

PCV with Spectral OCT

• 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

OCT CLASSIFICATION

Evolution of imaging for neovascular AMD

Gass Flower Yannuzzi

ICGAngiography Huang

OCT

Subepithelial CNVClassic, Occult CNV, FV PED

Drexler

PuliafitoSD-OCT

Coscas

1967 2000 2006 - 2009

Fluorescein Angiography

Evolution of therapy for neovascular AMD

CreteilMPS reports

Laser photocoagulation

TAPreport

VIP reports

VIM

PDT with verteporfin SST

Submacular surgery

Improve visionHalt progression

VISION

MARINA ANCHORAnti-VEGF therapy

PIER

PDT = photodynamic therapy

1980 2000 2006 - 2009