Fundus Autouorescence in Polypoidal Choroidal Vasculopathy

Tetsuya Yamagishi, MD,* Hideki Koizumi, MD, PhD,* Taizo Yamazaki, MD, Shigeru Kinoshita, MD, PhD
Purpose: To investigate and compare the characteristics of fundus autouorescence (FAF) in polypoidal choroidal vasculopathy (PCV) with those in typical neovascular age-related macular degeneration (AMD). Design: Retrospective, observational, consecutive case series. Participants: Ninety-two patients with PCV (92 affected eyes and 86 unaffected fellow eyes) and 31 patients with typical neovascular occult AMD with no classic choroidal neovascularization (31 affected eyes and 24 unaffected fellow eyes). Methods: All study eyes underwent FAF photography with a fundus camera based system. The incidence and distribution of hypoautouorescence, that is, the manifestation of retinal pigment epithelium (RPE) damages, were evaluated. Main Outcome Measures: The characteristic FAF ndings in PCV. Results: In the affected eyes with PCV, the sites of the neovascular lesions showed 2 distinct FAF patterns: (1) the conuent hypoautouorescence at the polypoidal lesions and (2) the granular hypoautouorescence at the branching choroidal vascular networks. The conuent hypoautouorescence, most of which was surrounded by a hyperautouorescent ring, was seen in 74 eyes (80.4%) with PCV but was seen in no eyes with typical neovascular AMD (P 0.001). The granular hypoautouorescence was seen in 91 eyes (98.9%) with PCV and 27 eyes (87.1%) with typical neovascular AMD (P 0.014). In addition, the eyes with PCV more frequently showed hypoautouorescence outside the macular area than those with typical neovascular AMD (P 0.021). In the unaffected fellow eyes, the hypoautouorescence was more frequently observed in patients with PCV than in those with typical neovascular AMD, inside the macular area and in the entire FAF image (P 0.012, P 0.003, respectively). Conclusions: In eyes with PCV, the polypoidal lesions and the branching choroidal vascular networks appeared to affect the RPE and induce peculiar FAF ndings. When compared with the patients with typical neovascular AMD, widespread RPE damage was more frequently observed in the patients with PCV, both in the affected eyes and in the unaffected fellow eyes. Financial Disclosure(s): The authors have no proprietary or commercial interest in any materials discussed in this article. Ophthalmology 2012;119:1650 1657 2012 by the American Academy of Ophthalmology.

Neovascular age-related macular degeneration (AMD) is one of the leading causes of legal blindness in developed and developing countries.1 However, the clinical characteristics of neovascular AMD are diverse and vary among populations. Polypoidal choroidal vasculopathy (PCV) is generally considered to be a subtype of neovascular AMD and is characterized by peculiar orange-reddish polypoidal lesions beneath the retinal pigment epithelium (RPE).2 Other clinical manifestations of PCV include multiple, recurrent serosanguineous detachments of the RPE and neurosensory retina secondary to leakage and bleeding from the neovascular lesions. Indocyanine green angiography (ICGA) allows for the visualization of the branching choroidal vascular networks that terminate in polypoidal dilations, and these 2 components are known to be characteristic ndings in PCV.3 Polypoidal choroidal vasculopathy is common in the Asian population compared with the Caucasian population.4 9 Although the precise pathogenesis of PCV remains controversial, it is important to clinically differentiate between PCV and typical neovascular AMD, because these 2 entities reportedly show different natural courses and responses to treatments.10

Fundus autouorescence (FAF) photography is used to visualize lipofuscin, which accumulates in RPE and provides information about RPE metabolism and function. Previous reports on FAF ndings in neovascular AMD1113 have provided information regarding the RPE integrity in relation to choroidal neovascularization (CNV). However, and to the best of our knowledge, no previous report has focused specically on the FAF ndings in PCV. The current study investigated and compared the characteristics of FAF in PCV with those in typical neovascular AMD to gain new insights into the pathologic differences between these 2 disease entities.

Patients and Methods

In the current study, FAF images of consecutive Japanese patients with newly diagnosed PCV who were seen in the outpatient clinic for macular diseases at Kyoto Prefectural University of Medicine between December 2008 and February 2011 were retrospectively reviewed. For the purpose of comparison, the FAF images of the patients with typical neovascular occult AMD with no classic CNV seen during the same period were also evaluated. Classic CNV was found to be mainly composed of subretinal brous
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tissue,14 resulting in possible blocked autouorescence, rather than the signs of RPE abnormalities.12 Therefore, the eyes diagnosed as having classic CNV on uorescein angiography (FA) were excluded from this study. In addition to the FAF photography, all patients underwent comprehensive ocular examinations including refraction testing, best-corrected visual acuity (BCVA) testing using Landolt C charts, examination by slit-lamp biomicroscopy with contact or noncontact lenses, color fundus photography, FA, ICGA, and optical coherence tomography (OCT) at the time of the initial diagnosis. Each diagnosis of PCV or typical neovascular AMD was based on the funduscopic and angiographic ndings by a researcher (H.K.). The diagnosis of PCV was based on ICGA, which demonstrates polypoidal structures at the border of the branching choroidal vascular networks.3 In some cases, subpigment epithelial orange-red protrusions were seen biomicroscopically, corresponding to the polypoidal lesions on ICGA. Typical neovascular AMD was characterized by exudative changes, and consistent CNV was revealed by FA and ICGA. When the experienced physician was unable to establish the denitive diagnosis of PCV or typical neovascular AMD, such confusing cases were excluded from this study. If a patient had bilateral active neovascular lesions, the right eye of that patient was chosen as the study eye. For the evaluation of FAF images, eyes with scar formation secondary to the neovascular lesions were excluded. Eyes with massive subretinal hemorrhage or subpigment epithelial hemorrhage that obscured the FAF ndings at the neovascular lesions were also excluded. Eyes with a spherical equivalent of 6 diopters or less or chorioretinal atrophic changes secondary to pathologic myopia and patients with other macular disorders, such as angioid streaks, central serous chorioretinopathy (CSC), and retinal angiomatous proliferation, were also excluded. Color fundus photography and FAF photography were performed with a commercially available fundus camera system (TRC-50DX, Topcon Corp, Tokyo, Japan) with a 50-degree eld of view. In the FAF mode, the device used blue light with an excitation lter centered at 560 nm (bandwidth, 535585 nm) and a barrier lter centered at 655 nm (bandwidth, 605705 nm). The fovea was centrally located in all FAF images. Fluorescein angiography and ICGA were performed with a confocal scanning laser ophthalmoscope (Heidelberg Retina Angiograph 2, Heidelberg Engineering, Heidelberg, Germany). The cross-sectional images of the macular area were obtained by spectral-domain OCT (3D-OCT 1000 Mark II, Topcon Corp). In our review of the published literature, we conducted a search of MEDLINE with PubMed. Search words included polypoidal choroidal vasculopathy, PCV, and autouorescence, and the results of our search informed us that the FAF ndings in PCV had not been reported. In this study, 2 researchers (T.Y. and T.Y.) who Table 1. Demographic Features of Patients with Polypoidal Choroidal Vasculopathy and Typical Neovascular Age-Related Macular Degeneration
PCV Group (n 92) Female (%) Age (yrs) SD Mean logMAR BCVA SD in the affected eyes 25 (27.2%) 74.67.6 0.520.39 AMD Group (n 31) 8 (29.0%) 75.410.0 0.530.31 P Value 1.00 0.65 0.89

Table 2. Hypoautouorescent Findings in the Affected Eyes

PCV Group AMD Group (n 92) (n 31) P Value Conuent hypoautouorescence at the neovascular lesion (%) Granular hypoautouorescence at the neovascular lesion (%) Hypoautouorescence outside the macular area (%) 74 (80.4%) 91 (98.9%) 39 (42.4%) 0 (0%) 27 (87.1%) 6 (19.4%) 0.0001* 0.014 0.021

AMD age-related macular degeneration; PCV polypoidal choroidal vasculopathy. *P 0.01; P 0.05.

were unfamiliar with the patients biomicroscopic and angiographic information specically evaluated the incidence and distribution of hypoautouorescence (i.e., the manifestations of RPE damage at various sites). With regard to the affected eyes, the incidence of hypoautouorescence at the neovascular lesions and outside the macular area was investigated. For the unaffected fellow eyes, the incidence of hypoautouorescence inside and outside the macular area was also assessed. The hypoautouorescence was classied into the following 2 patterns: (1) conuent hypoautouorescence and (2) granular hypoautouorescence. The conuent hypoautouorescence was dened as a manifestation of a homogeneous lack of autouorescence that was well demarcated and clearly distinguishable from the other adjacent lesions. The granular hypoautouorescence was dened as a heterogeneous mixed nding of the hypoautouorescence lesion at the various levels. Blocked autouorescence induced by other causes, such as subretinal hemorrhages, was not considered as a manifestation of RPE damage. The macular area was dened as a 6.0-mm diameter area around the foveola. The obtained data were analyzed as to the frequency and descriptive statistics. The BCVA measurements were converted to logarithm of the minimum angle of resolution units before analysis. Chi-square testing was used for categoric analysis. The Fisher exact test was used if the expected cell count was less than 5. Statistical analyses for the nonparametric data used the Mann Whitney U test. All statistical analyses were performed with StatView software version 5.0 (SAS Inc, Cary, NC). A P value less than 0.05 was considered statistically signicant for all tests, and all tests were 2-sided. The study protocol followed the tenets of the Declaration of Helsinki and was approved by the institutional review board of Kyoto Prefectural University of Medicine. Table 3. Hypoautouorescent Findings in the Unaffected Fellow Eyes
PCV Group (n 86) Hypoautouorescence in the entire image (%) Hypoautouorescence inside the macular area (%) Hypoautouorescence outside the macular area (%) 54 (62.8%) 50 (58.1%) 26 (30.2%) AMD Group (n 24) 7 (29.2%) 7 (29.2%) 3 (12.5%) P Value 0.003* 0.012 0.081

AMD age-related macular degeneration; BCVA best-corrected visual acuity; logMAR logarithm of minimum angle of resolution; PCV polypoidal choroidal vasculopathy; SD standard deviation.

AMD age-related macular degeneration; PCV polypoidal choroidal vasculopathy. *P 0.01. P 0.05.

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Figure 1.

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Figure 2.

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Figure 3.

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Results
Ninety-two patients with PCV (PCV group) and 31 patients with typical neovascular occult AMD with no classic CNV (AMD group) matched the inclusion criteria. There were no signicant differences in gender, age, or BCVA in the affected eyes between the PCV group and the AMD group (Table 1). Of the 92 patients in the PCV group, 6 patients had bilateral neovascular lesions. Of those 6 patients, 5 showed scar formation in the contralateral eye, and those 5 eyes were excluded from the FAF image evaluations. The other patient had active PCV lesions bilaterally, and the right eye was selected as the affected eye. Therefore, 92 eyes were evaluated as the affected eyes, and 86 eyes were evaluated as the unaffected fellow eyes. Of the 92 affected eyes, the neovascular lesion was located at the subfovea in 63 eyes, at the juxtafovea in 16 eyes, at the extrafovea in 7 eyes, and in the peripapillary area in 6 eyes. Of the 31 patients in the AMD group, 7 patients had bilateral CNV; however, all 7 patients showed brotic scar formation in the contralateral eye. Accordingly, 31 eyes were evaluated as the affected eyes, and 24 eyes were evaluated as the unaffected fellow eyes. Of the 31 affected eyes, the CNV was located at the subfovea in 25 eyes, at the juxtafovea in 4 eyes, and at the extrafovea in 2 eyes. The FAF ndings in the affected eyes are shown in Table 2. At the sites of the neovascular lesions, conuent hypoautouorescence (termed as punched-out lesion in this study) was observed in 80.4% of the eyes in the PCV group, yet was not observed in any of the eyes in the AMD group (P 0.001). All of the conuent hypoautouorescence observed in the PCV group corresponded to polypoidal lesions seen on ICGA. In addition, most of

the conuent hypoautouorescence was surrounded by a hyperautouorescent ring. The granular hypoautouorescence was observed in most of the PCV group (98.9%) at the branching choroidal vascular networks and in the AMD group (87.1%) at the CNV, yet it was signicantly more frequently observed in the PCV group (P 0.014). The hypoautouorescence outside the macular area was signicantly more frequently observed in the PCV group (42.4%) than in the AMD group (19.4%) (P 0.021). All of the hypoautouorescence observed outside the macular area appeared to be granular hypoautouorescence. The FAF ndings in the unaffected fellow eyes are shown in Table 3. The hypoautouorescence inside the macular area and in the entire FAF image was signicantly more frequently observed in the PCV group than in the AMD group (58.1% vs 29.2% [P 0.012] and 62.6% vs 29.2% [P 0.003], respectively). The hypoautouorescence outside the macular area was more frequently seen in the PCV group than in the AMD group, but the difference did not reach a signicant level (P 0.081). All of the hypoautouorescence in the unaffected fellow eyes was found to be granular hypoautouorescence. The representative cases are shown in Figures 1 to 3.

Discussion
The results of this study demonstrated the characteristic FAF ndings of PCV in comparison with those of typical neovascular AMD. The PCV-associated neovascular lesions exhibited the combination of 2 distinct FAF patterns: conuent hypoautouorescence and granular hypoautouores-

4
Figure 1. A 75-year-old man with polypoidal choroidal vasculopathy (PCV). Biomicroscopic examination of the right eye (A) revealed irregular elevation of retinal pigment epithelium (RPE) with orange-reddish nodules, accompanied by multiple areas of subretinal hemorrhages. The left eye (B) showed mild RPE depigmentation in the macula. Optical coherence tomography along the white lines (A, B) showed subretinal uid accumulation and irregularly elevated RPE in the right eye (C) and no exudative changes in the left eye (D). Indocyanine green angiography of the right eye (E) revealed characteristic components of PCV consisting of the polypoidal structures (arrows) and the branching choroidal vascular networks (arrowheads), but no neovascular lesion was seen in the left eye (F). The fundus autouorescence (FAF) imaging of the right eye (G) demonstrated conuent hypoautouorescence (punched-out lesion) surrounded by hyperautouorescent rings (arrows) at the polypoidal lesions seen on indocyanine green angiography (ICGA) and granular hypoautouorescence at the branching choroidal vascular network (arrowheads). In addition, the granular hypoautouorescence was also seen outside the macular area (open arrowheads). Asterisks indicate blocked autouorescence induced by the subretinal hemorrhages. The FAF image of the left eye (H) showed granular hypoautouorescence inside (arrowheads) and outside (open arrowhead) the macular area.

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Figure 2. A 70-year-old man with polypoidal choroidal vasculopathy (PCV). Biomicroscopic examination demonstrated no notable nding in the right eye (A) and an orange-reddish lesion at the fovea in the left eye (B). Optical coherence tomography along the white lines (A, B) revealed no exudative ndings in the right eye (C) and a high protrusion of the retinal pigment epithelium (RPE) at the fovea accompanied by subretinal uid accumulation in the left eye (D). Indocyanine green angiography (ICGA) of the right eye (E) showed no neovascular lesion, whereas there were several polypoidal lesions (arrows) connected to the branching choroidal neovascular networks (arrowheads) in the left eye (F). Fundus autouorescence photography of the right eye (G) showed multifocal areas of the granular hypoautouorescence inside the macular area (arrowheads). The left eye (H) showed the conuent hypoautouorescence (punched-out lesion) surrounded by hyperautouorescent rings (arrows) at the polypoidal lesions seen on ICGA and the granular hypoautouorescence at the branching choroidal vascular networks (arrowheads). Note that the granular hypoautouorescence was also present outside the macular area (open arrowheads).

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Figure 3. A 61-year-old man with typical neovascular age-related macular degeneration (AMD). Fluorescein angiography of the right eye (A) showed no sign of neovascular AMD, whereas the left eye (B) showed occult AMD with no classic choroidal neovascularization (CNV). Indocyanine green angiography of the right eye (C) demonstrated no particular abnormalities, but the left eye (D) appeared to show the irregular hyperuorescence suggestive of CNV in the macula. Optical coherence tomography along the white lines (A, B) in the right eye (E) was normal, but the left eye (F) showed some hyperreectivity beneath the irregular pigment epithelial detachment accompanied by subretinal uid accumulation. Fundus autouorescence (FAF) photography of the patients right eye (G) demonstrated a normal FAF nding, whereas that of the left eye (H) showed continuous autouorescence in the macular area without evident hypoautouorescence.

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might suggest, at least in part, a common pathologic background between PCV and CSC. It still remains controversial as to whether PCV represents a subtype of neovascular AMD.10 However, the clinical discrimination between PCV and typical neovascular AMD is important, especially when considering the optimal treatment strategy, such as intravitreal injection of antivascular endothelial growth factor agents and photodynamic therapy. The FAF ndings shown in this current study, and as an adjunct to the other conventional imaging methods, may prove valuable for supporting more denite diagnoses of PCV or typical neovascular AMD. Furthermore, in future epidemiologic research, noninvasive and accurate classication of the subtypes of neovascular AMD might be possible by means of FAF photography, for example, in conjunction with higher-resolution OCT without FA and ICGA.

cence. The former was represented by well-demarcated areas of hypoautouorescence, most of which were surrounded by a hyperautouorescent ring, corresponding to the polypoidal lesions seen on ICGA images. This characteristic punched-out lesion pattern was observed in most of the eyes with PCV, yet not observed in the eyes with typical neovascular AMD. Thus, the conuent hypoautouorescence appeared to be peculiar to PCV, thus indicating that the polypoidal lesions might induce signicant damage to the RPE layers. Prominent anterior protrusions at the sites of the polypoidal lesions were observed by use of OCT,15 and those protrusions may cause marked mechanical stress on the overlying RPE layer. The sites of the branching choroidal vascular networks in PCV exhibited granular hypoautouorescence in all but 1 eye, somewhat more frequently than those of CNV in typical neovascular AMD. This nding suggests that the RPE layer might be affected not only by the polypoidal lesions but also by the branching choroidal vascular networks. In previous reports, there have been controversies with regard to the localization of the branching choroidal vascular networks. In some studies, the authors considered that they are located in the sub-RPE space, similar to CNV seen in typical neovascular AMD,16 whereas in other studies, it was theorized that they are in the choroid.17 The FAF manifestation might be consistent with the ndings shown on spectral-domain OCT images in which the branching choroidal vascular networks, as well as the polypoidal lesions, exist between the RPE and the Bruchs membrane and adhere to the back surface of the RPE layers.18 By using a time-domain OCT, Sato et al19 reported about the double layer sign corresponding to the branching choroidal vascular networks and demonstrated the uid accumulation between the RPE and the Bruchs membrane. Similar to the polypoidal lesions, the branching choroidal vascular networks seem to produce an exudative property and may produce a signicant hemodynamic effect on the RPE layer. In comparison with typical neovascular AMD, the hypoautouorescence in the macular area of the unaffected fellow eyes in this study was found to be more frequent in PCV. Ueta et al20 reported that RPE atrophy in the macular area was the prevailing feature of the unaffected fellow eyes of patients with PCV, consistent with the ndings of this present study. Moreover, in patients with PCV, the hypoautouorescence outside the macular area in the affected eyes and, although not statistically signicant, outside the macular area in the unaffected fellow eyes was more frequently observed than in patients with typical neovascular AMD. Such FAF ndings might suggest that PCV causes more widespread RPE damage than typical neovascular AMD. Sasahara et al21 reported that ICGA demonstrated the ndings of bilateral and multifocal choroidal vascular hyperpermeability more frequently in PCV than in typical neovascular AMD. Thus, subclinical stress induced by the hemodynamic changes in the choroid might be put on the RPE layer, resulting in the widespread hypoautouorescence in eyes with PCV, and even in the contralateral eyes. Similar widespread RPE changes, shown by hypoautouorescent ndings, are also known to appear in CSC,22 and

Study Limitations
The current study has major limitations inherent in any retrospective study and the limited number of cases. In addition, this study was only a cross-sectional study, and the longitudinal changes of FAF over time in a subject should be investigated in future studies. In this study, the evaluation of FAF images was qualitative, not quantitative. Furthermore, this study did not take into consideration the duration of symptoms in each patient, which might have an effect on the FAF ndings. In conclusion, despite these limitations, and to the best of our knowledge, this study is the rst to show the characteristics of FAF specic to PCV eyes and might shed some light on the pathophysiology. Both the polypoidal lesions and the branching choroidal vascular networks appeared to affect the RPE and resulted in peculiar FAF ndings. In comparison with typical neovascular AMD, the subclinical and widespread RPE damages were more frequent in PCV, both in the affected eyes and the unaffected fellow eyes. Fundus autouorescence imaging might prove to be helpful and clinically benecial as an adjunct tool in the diagnosis and management of PCV.

References
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6. Yannuzzi LA, Wong DW, Sforzolini BS, et al. Polypoidal choroidal vasculopathy and neovascularized age-related macular degeneration. Arch Ophthalmol 1999;117:150310. 7. Uyama M, Matsubara T, Fukushima I, et al. Idiopathic polypoidal choroidal vasculopathy in Japanese patients. Arch Ophthalmol 1999;117:1035 42. 8. Liu Y, Wen F, Huang S, et al. Subtype lesions of neovascular age-related macular degeneration in Chinese patients. Graefes Arch Clin Exp Ophthalmol 2007;245:14415. 9. Maruko I, Iida T, Saito M, et al. Clinical characteristics of exudative age-related macular degeneration in Japanese patients. Am J Ophthalmol 2007;144:1522. 10. Laude A, Cackett PD, Vithana EN, et al. Polypoidal choroidal vasculopathy and neovascular age-related macular degeneration: same or different disease? Prog Retin Eye Res 2010;29:19 29. 11. Dandekar SS, Jenkins SA, Peto T, et al. Autouorescence imaging of choroidal neovascularization due to age-related macular degeneration. Arch Ophthalmol 2005;123:150713. 12. McBain VA, Townend J, Lois N. Fundus autouorescence in exudative age-related macular degeneration. Br J Ophthalmol 2007;91:491 6. 13. Vaclavik V, Vujosevic S, Dandekar SS, et al. Autouorescence imaging in age-related macular degeneration complicated by choroidal neovascularization: a prospective study. Ophthalmology 2008;115:342 6. 14. Lafaut BA, Bartz-Schmidt KU, Vanden Broecke C, et al. Clinicopathological correlation in exudative age related macular degeneration: histological differentiation between classic and occult choroidal neovascularisation. Br J Ophthalmol 2000;84:239 43. Iijima H, Iida T, Imai M, et al. Optical coherence tomography of orange-red subretinal lesions in eyes with idiopathic polypoidal choroidal vasculopathy. Am J Ophthalmol 2000;129: 21 6. Tateiwa H, Kuroiwa S, Gaun S, et al. Polypoidal choroidal vasculopathy with large vascular network. Graefes Arch Clin Exp Ophthalmol 2002;240:354 61. Iijima H, Imai M, Gohdo T, Tsukahara S. Optical coherence tomography of idiopathic polypoidal choroidal vasculopathy. Am J Ophthalmol 1999;127:3015. Ojima Y, Hangai M, Sakamoto A, et al. Improved visualization of polypoidal choroidal vasculopathy lesions using spectral-domain optical coherence tomography. Retina 2009;29:529. Sato T, Kishi S, Watanabe G, et al. Tomographic features of branching vascular networks in polypoidal choroidal vasculopathy. Retina 2007;27:589 94. Ueta T, Iriyama A, Francis J, et al. Development of typical age-related macular degeneration and polypoidal choroidal vasculopathy in fellow eyes of Japanese patients with exudative age-related macular degeneration. Am J Ophthalmol 2008;146:96 101. Sasahara M, Tsujikawa A, Musashi K, et al. Polypoidal choroidal vasculopathy with choroidal vascular hyperpermeability. Am J Ophthalmol 2006;142:6017. Imamura Y, Fujiwara T, Spaide RF. Fundus autouorescence and visual acuity in central serous chorioretinopathy. Ophthalmology 2011;118:700 5.

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16. 17. 18.

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Footnotes and Financial Disclosures

Originally received: November 18, 2011. Final revision: January 13, 2012. Accepted: February 9, 2012. Available online: April 17, 2012. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Supported in part by Grant No. 22791676 from the Ministry of Education, Culture, Sports, Science and Technology-Japan (Dr. Koizumi). Correspondence: Hideki Koizumi, MD, PhD, Department of Ophthalmology, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kamigyo-ku, Kyoto 6020841, Japan. E-mail: hidekoiz@koto.kpu-m.ac.jp. *Drs. Yamagishi and Koizumi contributed equally as corst authors.

Manuscript no. 2011-1661.

Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan. Presented in part at: the Association for Research in Vision and Ophthalmology Annual Meeting, May 2, 2011, Fort Lauderdale, Florida.

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