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In Vivo Visualization of Large Choroidal Vessels Obliteration in Geographic Atrophy.

In late stages of nonexudative age-related macular degeneration, when retinal pigment epithelium and choriocapillaris atrophy occurs (i.e., GA), ICGA allows us to visualize choroidal vessels (CVs) and their modifications over time. An 85-year-old woman with GA secondary to age-related macular degeneration, never treated in her left eye, underwent fundus autofluorescence, spectral domain optical coherence tomography, and ICGA as a part of a routine clinical workup. Three years after first presentation, best-corrected visual acuity remained unchanged in her left eye. By comparing early-phase ICGA performed 3 years apart, thanks to enhanced visualization of dye filling of large CVs due to GA, we noticed disappearance of detectable flow (i.e., absence of dye) in 2 large CVs possibly due to lumen obliteration (Figure 1, A and B). Indocyanine green angiography also showed a dilation of the superior branch and increased flow, temporal to the fovea, with dilation of the smaller CV possibly secondary to reduced/absent flow in the 2 emissaries (Figure 1B). Vascular remodeling could also be due to the dilation of the superior vessel shunting the high flow and in the meantime resulting in decreased vascular flow of adjacent smallercaliber vessels. Simultaneous spectral domain optical coherence tomography and ICGA (early frames) (Figure 2, A and B) highlighted the disappearance of the 2 CVs and further slight choroidal thinning after 3 years (Figure 2B); no choroidal caverns were detected. On fundus autofluorescence, the extension of atrophic area was revealed 3 years later (Figure 3, A and B). Studies demonstrated that choriocapillaris breakdown may precede retinal degeneration in agerelated macular degeneration. Our current findings suggest that after RPE and choriocapillaris atrophy, further loss of CVs, including Sattler’s and Haller’s layers may occur in the evolution of GA. This case demonstrates in vivo the process of choroidal sclerosis and atrophy in age-related macular Fig. 1. Early-phase ICGA of the left eye showing enhanced visualization of dye filling of large choroidal vessels due to GA (A, white arrows). Three years later, ICGA shows disappearance of detectable flow (i.e., absence of dye) in 2 large choroidal vessels possibly due to lumen obliteration (B, white arrows). Note the dilation of the superior branch possibly secondary to reduced/absent flow in the 2 emissaries (B, arrowhead) and the increased flow temporal to the fovea with dilation of the smaller choroidal vessels (B, white square).