1. 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

2. 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 2

3. Hard drusen
Soft drusen
Soft drusen
Geographic Atrophy
Choroidal New Vessels

4. LES 2 TYPES DE C Pre epithelial classic Sub epithelial occult
Choroidal New Vessels
LES 2 TYPES DE C
Pre epithelial classic
Sub epithelial occult

5. FA CLASSIFICATION Atrophy 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)

6. 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 6

7. ARM 7

8. Hard drusen
Soft drusen

9. AMD Exudative maculopathy Sub-epithelial occult CNV9

10. 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 10

11. Sub- epithelial occult CNV

12. Natural history:Clinical development of PED
Sub-epithelial occultCNV
Natural history:Clinical development of PED 12

13. Fibro vascular PED PED Occult
DEP très sombre, visible très tôt, à fort contraste,
partiellement envahi par une nappe de néovaisseaux sous épithéliaux
– à la phase tardive : hyperfluorescence irrégulière, en inféro temporo-maculaire
PED
Occult

14. Natural history Sub-epithelial CNV
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 14

15. AMD Exudative maculopathy Chorioretinal anastomosis or Type III15

16. 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

17. ICG

18. AMD Exudative maculopathy Idiopathic polypoidal vasculopathy18

19. Idiopathic polypoidal vasculopathy
Biomicroscopy 19 19

20. Idiopathic polypoidal vasculopathyFA
ICG

21. Idiopathic polypoidal vasculopathy21 21

22. ICG CLASSIFICATION Atrophy 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

23. 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 23

24. CIRRUS SD-OCT
SPECTRALIS SD-OCT
TOPCON SD-OCT
OCT 1
OCT 3
HR-OCT

25. Spectral OCT Analysis of the outer hyper-reflective layers
- external limiting membrane
- interface OS/IS
- RPE
- Bruch membrane
Interface
Bruch’s membrane
RPE
External limiting membrane
Outer nuclear layer
Outer segment
Inner segment
Spectral OCT

26. Eye tracking on graph

28. Sub- epithelial occult CNV
Network

29. Sub- epithelial occult CNV
Fovea
Junction OS/IS
Irregular, fragmented RPE

30. Sub- epithelial occult CNV
VA 20/50 P3

31. RPE detachment organized with discrete shadowing
Sub- epithelial occult CNV
Fovea
SRF
RPE
RPE detachment organized with discrete shadowing
SRF extensive
RPE thinned and irregular

32. Sub- epithelial occult CNV

33. Sub- epithelial occult CNV
Fovea
6 mm
RPE detachment
- Elevated RPE
with moderate reflectivity
no marked shadowing
Limited subfoveal SRF
small increase in retinal thickness
foveal flattening

34. PED with Spectral Domain OCTb
Serous PED
dépression fovéale
Fovea RD
DSR
DEP
PED
Occult
Fibro vascular PED

35. CRA with Spectral OCT FA Late ICG VA: 20/50 CRA Large Cysts
FA / OCT: Same aspect of Inner layer Intra-retinaIhemmoCG/ OCT:( More peripheral section) CRA with small PED
VA: 20/50 35

37. PCV with Spectral OCT
With SD-OCT, the RPE elevation due to the polyp becomes clearly distinguishable
The calipers help to localize the SRF, the PED and the polyp. 37

38. Visibility of Bruch’s membrane 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
OCT CLASSIFICATION

39. Evolution of imaging for neovascular AMD
Huang
OCT
Fluorescein
Angiography
Flower
Yannuzzi
ICG
Angiography
Drexler
Puliafito
SD-OCT
Coscas
Gass
1967
2000
Evolution of Therapy for Neovascular AMD
Over the years, treatment for neovascular AMD has evolved from approaches aimed at stabilizing vision to improving visual acuity.
Conventional therapies have important limitations, such as lack of specificity, associated retinal destruction, and failure to prevent new vessel formation. Newer treatment options address these limitations.
Results of VISION, MARINA, ANCHOR, and PIER have demonstrated that VEGF is a bona fide target of therapy, with activity across subtypes of subfoveal lesions. The introduction of anti-VEGF therapy has raised treatment goals and expectations.
Classic, Occult CNV, FV PED
Subepithelial CNV 39

40. Evolution of therapy for neovascular AMD
SST
Submacular surgery
Creteil
MPS reports
Laser photocoagulation
TAP
report
VIP
reports
VIM
PDT
with verteporfin
VISION
MARINA
ANCHOR
Anti-VEGF therapy
PIER
1980
2000
Evolution of Therapy for Neovascular AMD
Over the years, treatment for neovascular AMD has evolved from approaches aimed at stabilizing vision to improving visual acuity.
Conventional therapies have important limitations, such as lack of specificity, associated retinal destruction, and failure to prevent new vessel formation. Newer treatment options address these limitations.
Results of VISION, MARINA, ANCHOR, and PIER have demonstrated that VEGF is a bona fide target of therapy, with activity across subtypes of subfoveal lesions. The introduction of anti-VEGF therapy has raised treatment goals and expectations.
Halt progression
Improve vision
PDT = photodynamic therapy