CLINICAL SCIENCES
Treatment of Retinal Angiomatous Proliferation in Age-Related Macular Degeneration
A Series of104Cases of Retinal Angiomatous Proliferation
Ferdinando Bottoni,MD;Amedeo Massacesi,MD;Mario Cigada,MD;Francesco Viola,MD;
Ilenia Musicco,MD;Giovanni Staurenghi,MD
Objective:To report the management of retinal angio-matous proliferation(RAP),a recently described intrareti-nal neovascular lesion occurring in age-related macular degeneration.
Methods:This was a retrospective review of consecutive patientswithage-relatedmaculardegenerationwhounder-wenttreatmentofRAPfromJanuary1,2000,throughJanu-ary31,2003.Inclusion criteria were age55years or older, signs of age-related macular degeneration,and diagnosis of RAPbasedondynamicindocyaninegreenangiography.Base-line angiograms were reviewed and RAP was classified into the following3stages:stage1,intraretinal neovasculariza-tion,earlystage;stage2,subretinalneovascularization,middle stage;and stage3,choroidal neovascularization,late stage. Treatmentandconcomitanttreatmentresultswereassessed separately for each RAP stage.The clinical data were statis-tically analyzed(?2test and analysis of variance)for2main outcomemeasures—completeobliterationofthelesionand final visual acuity.
Results:Eighty-onepatients(99eyes)with104RAPswere identified.Forty-two lesions were at stage1,42at stage 2,and20at stage3.The following5treatments were per-formed:direct laser photocoagulation of the vascular le-sion,laser photocoagulation of the feeder retinal arteri-ole,scatter“gridlike”laser photocoagulation,photody-
namictherapy,https://www.doczj.com/doc/9b3665902.html,plete
obliteration of RAP was achieved in about24(57.1%)of
the stage1lesions(direct laser photocoagulation of the
vascular lesion,73%success rate;photodynamic therapy,
45%),11(26.2%)of the stage2lesions(scatter gridlike
laser photocoagulation,38%success rate;direct laser pho-
tocoagulation of the vascular lesion,17%),and only3
(15.0%)of stage3lesions(P=.001).Predictive factors with
a significant effect on final visual acuity were initial visual
acuity(P=.003)and early lesion stage(P=.04).Best final
visual acuity was0.41(mean,direct laser photocoagula-
tion of the vascular lesion in stage1)and0.39(mean,pho-
todynamic therapy in stage1),with a mean decrease of
2.5and3lines from baseline,respectively. Conclusions:Treatment of RAP remains difficult.Early detection of the lesion and subsequent direct conven-
tional laser photocoagulation seems to be associated with
better anatomical and functional outcome.Once the vas-
cular complex is well established,anatomical closure is
rarely achieved.Further study is warranted to assess the
long-term efficacy and the need for re-treatment. Arch Ophthalmol.2005;123:1644-1650
R ETINAL VASCULAR ANOMALOUS
complex and retinalchoroidal
anastomosis are terms that
havebeenusedinterchange-
ably in the past decade to identify a peculiar vascular abnormality of themaculainage-relatedmaculardegenera-tion(AMD).1-5Itwasoriginallysuggestedthat in advanced AMD proliferation of the reti-nal capillaries could eventually lead to in-traretinalneovascularizationwithnoconnec-tions to the choroidal vasculature.1,3 Advances in fundus imaging and recent histopathologic correlations have increased ourknowledgeoftheretinalvascularanoma-lous complex and have validated the origi-nal assumption of Hartnett et al.1,3Dynamic indocyanine green angiograms(ICGA) showed retinal arteries feeding and retinal veinsdrainingthevascularcomplexinmore than90%ofcasesofretinalvascularanoma-lous complex.6,7Intraretinal and subretinal neovascularizationbutnotchoroidalneovas-cularization(CNV)werethemostconsistent
findingsofthehistopathologicworkofLafaut et al.8Yannuzzi et al9revisited this subject inanextensivearticleontheselesions,which supportedtheoriginalconceptofretinalan-giomatousproliferation,thussuggestingthe acronym RAP as the best representative de-scription of the disease.
Retinal angiomatous proliferation may occur frequently,possibly representing one fourth of occult CNV detected at fluores-For editorial comment
see page1741
Author Affiliations: Department of Ophthalmology, San Giuseppe Hospital,Milan, Italy(Drs Bottoni,Massacesi, and Cigada);and the Institute of Ophthalmology,Spedali Civili,University of Brescia, Brescia,Italy(Drs Viola, Musicco,and Staurenghi).
cein angiography.6,10We lack information about the natu-ral course of RAP because these lesions have often been interpreted as occult CNV.However,it has been re-ported,3and it is also our experience,11that most pa-tients achieve final visual acuity (VA)of 20/200or worse because of a disciform scar.
The most appropriate treatment for these lesions is https://www.doczj.com/doc/9b3665902.html,ser photocoagulation has been suggested in a small series of RAP 3or in cases in which the presump-tive diagnosis was occult CNV with “hot spot.”4Inas-much as dynamic ICGA was not used routinely to evalu-ate eligible patients,the Treatment of Age-Related Macular Degeneration With Photodynamic Therapy (TAP)and Verteporfin in Photodynamic Therapy (VIP)trials 12-14could have also enrolled patients who likely had RAP and not CNV.Although we have no information from these clinical trials about the use of photodynamic therapy (PDT)for the treatment of RAP,it has been reported that PDT is of little benefit in these lesions.15We describe our experience with the treatment of 104RAPs in 81con-secutive patients (99eyes)with AMD.
METHODS
Weobtainedapprovaltoconductthisretrospectivestudyfromthe institutional review boards of the 2study centers.Medical records of all patients with AMD who underwent treatment of RAP at our institutions between January 1,2000,and January 31,2003were reviewed.
The inclusion criteria for diagnosis of RAP were age 55years or older;signs of AMD,including hard and soft drusen,mot-tling of the retinal pigment epithelium,and retinal pigment epi-thelium detachment and atrophy;diagnosis of RAP based on dynamic ICGA (temporal evidence of “dye filling of at least one retinal arteriole descending into the deep retinal space to a vascular communication and at least one draining retinal vein”).3(p2043)We excluded from the study patients with any con-dition other than AMD associated with CNV,such as degen-erative myopia,angioid streaks,infectious or inflammatory cho-rioretinal diseases,tumors,inherited disorders,or trauma.Each patient underwent a complete ocular examination when firstseenandduringfollow-up,includingslitlampbiomicroscopy,best-corrected VA at manifest refraction using a standard Snellen chart,fundus biomicroscopy (78-diopter [D]lens;Volk Optical Inc,Mentor,Ohio),andsimultaneousdynamicfluoresceinandICGA withascanninglaserophthalmoscope(HRAEngineering,Heidel-berg,Germany).The instrument was set at 6frames per second,andthedyesweregivenasanantecubitalinjectionofa2-mLmixed
solution of 2.5mL of 20%sodium fluorescein and 25mg of indo-cyaninegreen,followedbyasalinesolutionflush.Forconsistency,2of us (F.B.and G.S.)retrospectively reviewed all of the baseline angiogramsandclassifiedRAPinto3stages,accordingtoYannuzzi et al.9In brief,stage 1involved proliferation of intraretinal capil-laries originating from the deep retinal complex (intraretinal neo-vascularization,early stage;Figure 1).Stage 2was determined by growth of the retinal vessels into the subretinal space (subreti-nal neovascularization,middle stage;Figure 2).Stage 3occurred whenCNVcouldclearlybedeterminedangiographically(latestage;Figure 3).Stereoscopicviewingofselectedimageswasoftenused for classification.
Treatments differed according to RAP stage(Tables 1,2,and 3)and were chosen at the discretion of the treating oph-thalmologist.Data were collected about the 5types of treat-ment used:
1.Direct laser photocoagulation of the vascular lesion (LPhc;argon green,532frequency-doubled Nd:YAG lasers).The treat-ment was performed according to the Macular Photocoagula-tion Study parameters for classic extrafoveal CNV 16(Table 1and Table 2;Figure 1and Figure 2).
https://www.doczj.com/doc/9b3665902.html,ser photocoagulation of the feeder retinal arteriole (FVT;argon green,532frequency-doubled Nd:YAG lasers).Spots at least 50%larger than the feeder vessel,0.2-second to 0.5-second du-ration,were applied during multiple sessions,15days apart,to constrict or obliterate the feeder vessel (Tables 1through 3).
3.Scatter “gridlike”laser photocoagulation (GRID;argon green,532frequency-doubled Nd:YAG lasers).Scatter (GRID)burns consisted of light to moderately intense (gray)photoco-agulation burns of 0.1-second duration,100-μm spot size,spaced approximately 2burn widths from each other and applied for 3rows around a spared central area of 1500μm centered in the fovea (Tables 1through 3;Figure 3).
4.Photodynamic therapy.Photodynamic therapy with verte-porfin was used according to the recommended standard pro-cedure 12(Tables 1through 3;Figure 3).
5.Transpupillary thermotherapy (TTT;2consecutive spots of subthreshold 810-nm diode laser,3-mm and 1.2-mm spot size,400-mW and 200-mW intensity,respectively,1-minute exposure)(Tables 1through 3).17
The selected treatment and concomitant results (success or failure)were assessed separately for each RAP stage (ie,1through 3).The final VA and status of the eye were recorded as the date that the patient was last evaluated.Snellen VA was used for func-tional outcomes;it was converted to a logarithm of the mini-mal angle of resolution algorithm only to convert to a line score to record the number of lines gained or lost after treatment.Forthisstudy,oneRAPwasconsideredasonecase,andallRAPs per cases diagnosed at baseline were included and used for
data
Figure 1.Stage 1retinal angiomatous proliferation (RAP).Angiograms obtained at simultaneous dynamic fluorescein angiography (A)and indocyanine green angiography (B)in a 71-year-old man with decreased visual acuity (0.9)in the left eye for 3weeks.An extrafoveal RAP with 1feeding retinal arteriole and
1draining retinal vein is well outlined.Forty-six months after direct laser photocoagulation of the vascular lesion,dynamic fluorescein (C)and indocyanine green angiograms (D)confirmed complete obliteration of RAP (final visual acuity,0.8).
analyses.Clinical data were statistically analyzed(StatGraphics; Statistical Graphics Corp,StatPoint Inc,Herndon,Va)to obtain 2main outcomes—complete obliteration of the lesion and final VA.Theoccurrenceofobliterationinthedifferentstagesandamong the different treatments was compared using the?2test.An asso-ciation between pretreatment variables(initial VA and RAP stage) as well as treatment and final VA was examined using multifactor analysisofvariance.P?.05wasconsideredstatisticallysignificant.
RESULTS
One hundred four RAPs were diagnosed in81patients (99eyes)and were treated at the2study centers be-tween January1,2000,and January31,2003.Demo-graphic data and baseline characteristics are summa-rized in Table4.At baseline,63patients had only1RAP; multiple RAPs in the same eye were detected in5pa-tients and bilateral RAPs were present in17patients.
All patients underwent complete follow-up of at least6 months for analyses of the2outcome measures.Mean fol-low-up for RAP stage1was18months,for stage2was22 months,and for stage3was20months(P=.27).During follow-up,new RAPs developed in23(23%)of99eyes; 10RAPs were diagnosed in the fellow unaffected eye after a mean of18.3months from baseline(range,3-36months), and13new RAPs developed in the affected eye.
Tables1through3list the final outcomes for the3 stages of RAP.Overall,RAP was successfully obliterated in about24(57.1%)stage1lesions(intraretinal neovas-cularization,early stage),11(26.2%)stage2lesions(sub-retinal neovascularization,middle stage),and3(15%) stage3lesions(CNV,late stage;Figure4;?2=13.63; P=.001).Direct laser photocoagulation(22RAPs)and PDT(11RAPs)were the treatments most frequently per-formed in stage1(Table1).Well-developed RAPs(stage 2)were treated with all of the treatments examined,with the following frequency(Table2).Photodynamic therapy was the most frequently performed treatment in stage3 RAP,and GRID and FVT were used with the same fre-quency(Table3).
There was no significant difference in the oblitera-tion rate among the various treatments within each stage group of RAP.However,in stage1(Table1),LPhc of the vascular lesion achieved complete obliteration of RAP in 16(73%)of22cases after a mean follow-up of17.4 months(range,6-48months).All of the vascular com-plexes were extrafoveal at baseline and only1treatment session was necessary for complete closure(Figure1). Mean final VA was0.41(range,0.005-1.0),with a mean decrease of2.5lines from baseline.Ten(45%)of the pa-tients in this group maintained a final VA of0.5or bet-
A B C
D E F
Figure2.Stage2retinal angiomatous proliferation.Angiograms obtained with fluorescein(A)and indocyanine green(B)in a74-year-old woman with decreased visual acuity(0.2)in the left eye for2months.Dynamic indocyanine green angiogram revealed a well-developed extrafoveal retinal vascular anomalous complex with 1feeding retinal arteriole and more draining retinal veins,with telangiectatic capillaries in the surrounding https://www.doczj.com/doc/9b3665902.html,te fluorescein phases showed cystoid macular edema with a foveal macrocyst.Three months after direct laser photocoagulation of the vascular lesion(LPhc;argon green,532frequency-doubled Nd:YAG lasers), dynamic fluorescein(C)and indocyanine green(D)angiograms of the left eye showed complete obliteration of the vascular complex within the postlaser atrophic scar.There were transmission defects in the fovea and the surrounding area,but the cystoid macular edema and the macrocyst were completely reabsorbed.Visual acuity in the left eye remained stable(0.2)for13months.Twenty-two months after treatment,visual acuity decreased to0.06OS.Fluorescein and indocyanine angiograms demonstrated diffuse remodeling of the subfoveal choriocapillaris with massive cystoid macular edema(E)and a retinochoroidal anastomosis(F).
ter.The second most successful treatment was PDT,with a closure rate of 45%(5of 11RAPs)but functional re-sults similar to those in the LPhc group:the mean final
VA was 0.39(range,0.005-1.0),with a mean decrease of 3lines from baseline,and 5(45%)of the patients main-tained a final VA of 0.5or
better.
Figure 3.Stage 3retinal angiomatous proliferation.Simultaneous angiograms obtained with fluorescein (A)and indocyanine green (B and C)in an 80-year-old woman with decreased visual acuity (0.16)in the right eye for 4months.B and C,Indocyanine green angiograms revealed retinochoroidal anastomoses with an evident choroidal neovascular component.D,Twenty-two months after 1photodynamic therapy treatment and 1scatter “gridlike”laser photocoagulation treatment,fluorescein angiogram showed a still active disciform scar.Final visual acuity was 0.005OD.
Abbreviations:FVT,laser photocoagulation of feeder retinal arteriole;GRID,scatter “gridlike”laser photocoagulation;LPhc,direct laser photocoagulation of vascular lesion;PDT,photodynamic therapy;RAP ,retinal angiomatous proliferation;TTT,transpupillary thermotherapy.*Snellen chart.
Abbreviations:FVT,laser photocoagulation of feeder retinal arteriole;GRID,scatter “gridlike”laser photocoagulation;LPhc,direct laser photocoagulation of vascular lesion;PDT,photodynamic therapy;
RAP ,retinal angiomatous proliferation;TTT,transpupillary thermotherapy.*Snellen chart.
Abbreviations:FVT,laser photocoagulation of feeder retinal arteriole;GRID,scatter “gridlike”laser photocoagulation;LPhc,direct laser photocoagulation of vascular lesion;NA,not applicable;PDT,photodynamic therapy;RAP ,retinal angiomatous proliferation;TTT,transpupillary thermotherapy.*Snellen chart.
In stage2(Table2),complete closure of the vascular complex was achieved in2(17%)of12RAPs after LPhc treatment,compared with5(38%)in the GRID group and1(11%)in the PDT treatment groups(Figure2). Overall,the mean final VA was0.16,with a mean loss of 5lines at last follow-up examination.Only2patients had a final VA of0.5or better.
In stage3(Table3),the anatomical and functional re-sults were discouraging(Figure3).Overall,obliteration of RAP was achieved in3(15%)of20patients,and the mean final VA was poor(?0.1),with a mean loss of3.3lines at last follow-up examination.No patients had a final VA of 0.5or better.
An association between initial VA(P=.003)as well as stage of RAP(P=.04)and final VA was established us-ing multifactor analysis of variance.In other words,eyes with higher VA and stage1RAP at baseline had better VA at the end of follow-up period(Figure5).Again, within each stage group of RAP,no association was found between a specific treatment method and better final VA.
COMMENT
Our data underline the importance of the early detec-tion of RAP,which can be successfully treated at early stages.The most appropriate treatment of RAP is un-known,mainly because of the diagnostic problems en-countered with these lesions when using conventional angiography.The technical gap was responsible for the lack of information on prevalence and natural history of the retinal vascular complex.We think that this form of neovascular AMD is not uncommon,possibly represent-ing as much as one fourth of occult or minimally classic CNV.6,10Although data on the natural history of RAP are missing,there is a general consensus toward a poor func-tional prognosis with these lesions,after progression to different stages and a resulting disciform scar.2-4,9,11 We reviewed the data for various treatments according tospecificclinicalcharacteristicsatbaseline(ie,RAPstage). The rationale for the treatments chosen at the discretion of thetreatingophthalmologistdeservessomeexplanation.The lackofinformationpublishedintheliteratureregardingthe treatment of RAP lesions prompted us to select5types of treatment.
Direct laser photocoagulation of the neovascular pro-cess is a standardized treatment for CNV.16RAP,being ini-tially by nature extrafoveal,may be a suitable indication for use of LPhc(Table1and Figure1).Photodynamic therapy has been recently proposed for treating classic or occult CNV,12-14thereby representing another reasonable treatment option(Tables1through3).It has been also re-cently reported that PDT is of little benefit in RAP.15How-ever,baseline VA was poor in that series(mean,20/126), suggesting an advanced stage of the lesions at baseline.
If we assume that RAPs are retinal angiomatous prolif-eration,then treating the feeder retinal arteriole of an an-giomatous proliferation has already been proposed,18with a valid scientific rationale(Tables1through3).GRID treat-ment for occult subfoveal CNV has been reported,with poor functional results.19In our series,we are possibly dealing with intraretinal neovascularization rather than CNV.3,8
Abbreviation:RAP,retinal angiomatous proliferation.
*Stage1involved proliferation of intraretinal capillaries originating from the deep retinal complex;stage2was determined by the growth of the retinal vessels
into the subretinal space;and stage3was occurred when choroidal neovascularization could clearly be
determined angiographically.
?Snellen chart.
Figure4.Obliteration rate in retinal angiomatous proliferation(RAP)stages 1through3(?2=13.6;P=.001).Figure5.Mean±Tukey Honestly Significant Difference intervals(95% confidence interval)for final visual acuity with various stages of retinal angiomatous proliferation(P=.04).Asterisk indicates the mean.
Although the exact pathogenesis of RAP has not been elucidated,advancedBruchmembranechanges,alwayspres-ent in patients with RAP,seem to be the common precur-sor.3One assumption is that in AMD thick deposits within Bruch membrane and loss of choroidal vessel may lead to less available oxygen.3Resultant hypoxia of the outer reti-nal layers may in turn up-regulate the release of angio-genic growth factor,such as vascular endothelial growth factor.20,21In transgenic mice,overexpression of the vas-cular endothelial growth factor causes new vessel prolif-eration originating from the deep retinal capillary plexus with extension into the subretinal space.In time,the neo-vascular lesion gradually enlarges and coalesces with other vascular complexes,22,23thereby resembling the clinico-pathologic changes of RAP in human eyes reported by oth-ers.3,6-9If hypoxia of the outer retinal layer has a role in the development of RAP,then scatter GRID laser photocoagu-lation of the macula has a rationale,either because it may enable the choriocapillaris to deliver oxygen to ischemic inner retina24or because removal of some of the photore-ceptors reduces the metabolic needs of the outer retina (Tables2through4).25,26
Transpupillary thermotherapy is being investigated as a possible treatment for“occult”subfoveal CNV.27The modified TTT technique used in our study(2consecu-tive,superimposed,subthreshold spots of3and1.2mm) is based on the thermotolerance mechanism of tissue hy-perthermia.28It has proved to be well tolerated by the retina and showed encouraging results in the treatment of stage2and3RAP(Tables2through4).17
The most significant finding of our study is that RAP of recent onset may be amenable to conventional ther-mal laser treatment.This is consistent with treatment sug-gestions of previous studies reporting on similar le-sions.3,4,9In our series,RAP at earlier stages showed better closure rates(Figure1;P=.001).In addition,2factors were significantly related to better final VA:initial VA (P=.003)and earlier stage of lesions(P=.04).
Initial VA depends on the integrity of the macular pho-toreceptors and,therefore,on the duration of the dis-ease.The relationship between initial VA and stage of RAP and final VA is not surprising.Early treatment may lead to better anatomical and functional outcome.Of42RAPs at stage1,24(57.1%)were successfully obliterated (Table1and Figure4).The success rate decrease to26.2% (11of42lesions)at stage2(Table2and Figure4)and 15.0%(3of20lesions)at stage3(Table3and Figure4). The final VA was also significantly different among pa-tients with stage1RAP and stage2or3RAP(Figure5).
It seems that once the vascular complex is well established,anatomical closure is rarely achieved either with LPhc,FVT,PDT,TTT,or GRID.In addi-tion,new RAPs developed in almost one fourth of eyes during follow-up,either in the fellow eye or the same eye.Hence,early diagnosis is important.
With conventional angiography,images are usually captured at1frame per second.That makes virtually im-possible visualization of the progression of the dye through the vascular complex,even though images are taken at very early phases(Figure6).By contrast,with dy-
A B C
D E
https://www.doczj.com/doc/9b3665902.html,parison of dynamic(6frames per second)and conventional indocyanine green angiography of the same stage of retinal angiomatous proliferation (stage2).Feeding retinal arteriole(A),filling of the vascular lesion(B),and draining retinal vein(C)are all features visible in the dynamic sequences.
D and E,Progression of filling is lost in the first2images captured with a conventional digital system.
namic ICGA(up to12frames per second),the progres-sive filling of the lesion enables detection of very small and recent-onset RAP.That is possibly why in the series of Yannuzzi et al9the diagnosis of RAP was made at stage 1(intraretinal neovascularization)in only41%of the eyes and a retinal-retinal anastomosis was seen in stage1in only30%of the eyes.The higher sensitivity of high-speed dynamic angiography in the early diagnosis of RAP is also supported by the low prevalence of retinal pig-ment epithelial detachments,a late complication of RAP, recorded in our patients(12.5%).7
CONCLUSIONS
This retrospective review describes various treatment methods being used to treat RAP of varying levels of ac-tivity and duration.This study has many limitations.Its retrospective nature may lead to biased enrollment;this is why we classified patients as having either early or more advanced disease and we examined the various treat-ments separately within each group.The low cell counts in some subgroups in each stage could have been re-sponsible for the lack of association between a specific treatment and a better closure rate or final VA within the 3stages of RAP.Therefore,we do not know,for ex-ample,whether scatter GRID or TTT would be success-ful at earlier stages of RAP development.In addition,VA was measured using a Snellen chart,as opposed to the more standardized Early Treatment Diabetic Retinopa-thy Study chart,and duration of follow-up is short.
Nevertheless,RAP is becoming an important cause of neovascular AMD,and more cases will be diagnosed with the advent of dynamic ICGA.Treatment of these lesions remains a difficult problem to be solved.Our data cast light on the different treatments for the various stages of the vascular complexes.Despite several treatment op-tions,early intervention with direct conventional laser photocoagulation of an extrafoveal RAP is the only treat-ment advised for best long-term visual outcome.Fur-ther study is warranted to assess the long-term efficacy and the need for re-treatment.
Submitted for Publication:September16,2004;final re-vision received December13,2004;accepted December 15,2004.
Correspondence:Ferdinando Bottoni,MD,Depart-ment of Ophthalmology,San Guiseppe Hospital,Via An-drea Verga8,20144Milan,Italy(ferdinando.bottoni @fastwebnet.it).
Financial Disclosure:None.
Previous Presentation:This study was presented in part at the23rd meeting of the Club Jules Gonin;August31, 2002;Montreux,Switzerland,and at the annual meet-ing of the Association for Research in Vision and Oph-thalmology;April25,2004;Fort Lauderdale,Fla.
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