BACKGROUND: Indocyanine green fluorescence angiography, a validated noninvasive imaging technique, is used to assess tissue vascularization. Here, we report three infant patients who underwent intraoperative indocyanine green fluorescence angiography and suffered from postoperative complications caused by the lack of weak fluorescent intestinal resection and assessed residual intestinal perfusion.
METHODS: We observed the clinical characteristics and operative findings of patients treated from January 2022 to December 2022. Indocyanine green (0.5 mg/kg) was intravenously injected. The first patient was a 29-day-old girl with surgical necrotizing enterocolitis who underwent intraoperative indocyanine green fluorescence angiography at the first- and second-look operations. The proximal jejunum was difficult to diagnose to detect blood flow during the second-look operation. The second patient was a 32-day-old boy with surgical necrotizing enterocolitis. A part of the antimesenteric mucosa of the patient that exhibited weak fluorescence was preserved; however, it formed postoperative hematomas. The third patient was a 30-day-old boy with midgut volvulus. Weak fluorescence in the intestinal wall was observed 5 cm of the small intestine from the ileocecal valve was preserved, but it formed a stricture, and the patient underwent ileocecal resection after 30 days.
CONCLUSIONS: Weak fluorescence in the intestine in infants by performing indocyanine green fluorescence angiography is associated with a high risk of non-recovering ischemic lesions and postoperative complications.

The identification and evaluation of leaking areas in FA pictures are essential steps in the diagnostic process as well as the treatment and management of a variety of choroidal and retinal illnesses. We reported a case of rhegmatogenous retinal detachment in a seven-year-old boy with positive leakage on FA, which confused the presentation. A thorough contact lens examination and scleral indentation are mandatory to reach the diagnosis easily.

BACKGROUND: To report a rare case of acute posterior multifocal placoid pigment epitheliopathy (APMPPE) with a combination of serous retinal detachment, papilledema, and retinal vasculitis.
METHODS: A 19-year-old male complained of floaters in both eyes with decreased vision for 4 days. The best corrected visual acuity of the right eye and the left eye were 1.1 and 0.9 (logMAR), respectively. In both eyes, inflammatory cells can be seen suspended within the vitreous, multiple yellow/white lesions can be seen near the macula, and retinal neuroepithelial detachment. Swelling of the optic disc with blurring of the disc margins, in the left eye. Optical coherence tomography (OCT): showed retinal detachment in both eyes. The patient received oral prednisone treatment. 1 week later, OCT showed absorption of subretinal fluid in the macula of both eyes his binocular vision improved to 0.1 (logMAR). During the subsequent 28-month follow-up, fundus fluorescein angiography and OCT revealed extensive and progressive pigment epithelial atrophy in both eyes, and abnormal retinal vascular perfusion in the right eye due to persistent retinal vasculitis. Although the patient\'s binocular visual acuity remained at 0.1 (logMAR).
CONCLUSIONS: In the present case of APMPPE with a combination of serous retinal detachment, papilledema, and retinal vasculitis, through the multimodal imaging, further confirming that the lesions were located in the choroid, while the pigment epithelial lesions were secondary changes.

BACKGROUND: Polycythemia vera (PV) is a myeloproliferative neoplasm with increased hemoglobin, hematocrit, platelet count and leukocytosis, resulting in increased blood viscosity. PV which is initially presenting with ocular symptoms is rare, but irreversible retinal vessel occlusions leading to the diagnosis of PV have been described in literature.
METHODS: We describe a patient with PV, initially presenting with attacks of monocular temporary loss of vision due to intermittent retinal artery occlusions of different retinal arteries. The patient was immediately treated with phlebotomy and the impaired arterial retinal perfusion could be restored without permanent retinal ischemia. We were able to document these transient arterial occlusions with fundus photography as well as fluorescein angiography. To the best of our knowledge, a case like this has never been documented before.
CONCLUSIONS: This report is pertinent, in order to raise awareness among clinicians for polycythemia vera, as it can in fact be used as a differential diagnosis for patients with retinal artery occlusion. We would like to stress that early therapy might reverse the vessel complications.

Assessing bowel viability can be challenging during acute surgical procedures, especially regarding mesenteric ischaemia. Intraoperative fluorescence angiography (FA) may be a valuable tool for the surgeon to determine whether bowel resection is necessary and to define the most appropriate resection margins. The aim of this study is to report on FA use in the acute setting and to judge its impact on intraoperative decision making.
This is a multi-centre, retrospective case series of patients undergoing emergency abdominal surgery between February 2016 and 2021 in three general/colorectal units where intraoperative FA was performed to assess bowel viability. Primary endpoint was change of management after the FA assessment.
A total of 93 patients (50 males, 66.6 ± 19.2 years, ASA score ≥ III in 85%) were identified and studied. Initial surgical approach was laparotomy in 66 (71%) patients and laparoscopy in 27 (29% and seven, 26% conversions). The most common aetiologies were mesenteric ischaemia (n = 42, 45%) and adhesional/herniae-related strangulation (n = 41, 44%). In 50 patients a bowel resection was performed. Overall rates of anastomosis after resection, reoperation and 30-day mortality were 48% (n = 24/50, one leak), 12% and 18%, respectively. FA changed management in 27 (29%) patients. In four patients (4% overall), resection was avoided and in 21 (23%) extra bowel length was preserved (median 50 cm of bowel saved, IQR 28-98) although three patients developed further ischaemia. FA prompted extended resection (median of 20 cm, IQR 10-50 extra bowel) in six (6%) patients.
Intraoperative use of FA impacts surgical decisions regarding bowel resection for intestinal ischaemia, potentially enabling bowel preservation in approximately one out of four patients. Prospective studies are needed to optimize the best use of this technology for this indication and to determine standards for the interpretation of FA images and the potential subsequent need for second-look surgeries.

BACKGROUND: Skin metastasis from primary squamous cell carcinoma of the head and neck is rare . These metastatic lesions are usually detected by physical examination, ultrasound imaging, computed tomography, and positron emission tomography.. Recently, indocyanine green fluorescence angiography (ICG-FA) has been used to discover superficial tumors. However, the optimum timing of ICG injection and fluorescence patterns of skin tumors in ICG-FA are still unknown.
METHODS: We encountered a 60-year-old man with hypopharyngeal squamous cell carcinoma. The patient underwent concurrent chemotherapy, radiotherapy, and surgery. However, following these treatments, the patient developed two nodules in the skin of the right upper limb. Thus, the patient underwent ICG-FA. The two skin metastatic nodules showed different fluorescence patterns. One lesion showed high fluorescence intensity during ICG-FA. However, the fluorescence intensity of a small part of the other lesion exceeded that of the surrounding tissue only for a short time.
CONCLUSIONS: We suggest that ICG-FA is effective for detecting skin metastases, and with further studies on the various fluorescence patterns of skin tumors, this technique will become more efficient.

OBJECTIVE: To identify novel tumor-specific features of ossification by using multispectral imaging (MSI) in patients diagnosed with choroidal osteoma.
METHODS: Six eyes of 5 patients previously diagnosed with choroidal osteoma by ocular ultrasonography and orbital computerized tomography were observed with multispectral imaging (MSI). Traditional multimodal imaging, including color fundus photograph (CFP) and enhanced depth-imaging-optical coherence tomography (EDI-OCT), fundus autofluorescence (FAF), indocyanine green angiography/fundus fluorescein angiography (ICGA/FFA), was performed. Osseous features detected by MSI such as calcification and decalcification were characterized and compared with other imaging modalities.
RESULTS: In all 3 eyes with calcified choroidal osteoma (100%), MSI featured by the homogeneous reflectance in 550 nm but the beehive appearance in 600-680 nm and homogenous hyper-reflectance in 780-850 nm\', indicating the compact bone in the outer layers and bone trabecula in the middle layer (Sandwich sign). The pigmentary change showed high agreement between MSI and FAF. In other 3 eyes with extensive decalcification, MSI was able to differentiate the inactive portion of the osteoma from the decalcified area. The inactive portion was characterized by geographic hyper-reflective islands with higher reflectivity border (floating island sign). Decalcified portion was featured by increased definition and reflectivity from osteoma. Partial decalcification and total decalcification can be differentiated in one decalcifying eye (33.3%). MSI revealed better the presence and border of the osteoma compared with FFA, FAF and MC (100%) in all six eyes in our study.
CONCLUSIONS: MSI presented characteristic osseous-related features of choroidal osteoma, providing clear evidence for differentiating osteoblastic and osteoclastic regions and noncalcifying regions. It can contribute to en-face visualization of choroidal osteomas at different stages, providing new insight into the spectrum behavior of CO.

BACKGROUND: Disadvantages of bowel perfusion assessment with indocyanine green fluorescence angiography include the need for a fluorophore and the subjective nature of the assessment. This study was performed to evaluate the clinical efficacy of bowel perfusion assessment using laser speckle contrast imaging (LSCI) during laparoscopic colorectal surgery.
METHODS: The study population comprised the first 27 consecutive patients who underwent laparoscopic left-sided colorectal resection with intraoperative perfusion assessment using LSCI. The operative outcomes of these patients were compared with those of a matched group of patients without perfusion assessment. We analyzed the flux data expressed in laser speckle perfusion units.
RESULTS: After propensity score matching, we found no significant between-group differences in the patients\' characteristics with the exception of the cancer stage. No patients undergoing LSCI perfusion assessment developed anastomotic leakage, but five (18.5%) patients in the control group did, at a significantly higher rate in male patients (P = .042). There were no significant differences in other operative outcomes. The laser speckle perfusion unit values after ligating marginal vessels were significantly lower than before ligation (P < .01).
CONCLUSIONS: With respect to anastomotic leakage, LSCI may improve patient outcomes after colorectal surgery. This technique appears to be a superior tool with the advantages of measurement repeatability and quantitativity and no need for a fluorophore.

OBJECTIVE: An anastomotic leak in ileoanal pouch surgery may lead to pouch failure. Constructing a tension-free ileal pouch-anal anastomosis (IPAA) reduces this risk but can be technically challenging, balancing pouch vascularization with ileal mesenteric length and site of vessel ligation. Fluorescence angiography (FA) may help the clinician make a more balanced judgement.
METHODS: Thirty-two patients undergoing minimally invasive completion proctectomy with FA-guided IPAA at two academic centres were matched and compared on a 1:1 basis to a historical group undergoing the same procedure without the use of this technique.
RESULTS: Ligation of the ileocolic vessels was safely performed in 15/32 (47%) of FA patients compared with 5/32 (16%) of historical controls. One patient underwent intra-operative IPAA reconstruction after FA detected ischaemia. No anastomotic leak occurred with FA but there was only one in the historical controls (P = 0.31). The postoperative complication rate was similar between the two groups (P = 0.60).
CONCLUSIONS: FA is applicable to IPAA surgery and may help to reduce perfusion-related anastomotic leaks. A prospective randomized trial is warranted.

OBJECTIVE: Optimal perfusion of the gastric conduit during esophagectomy is elementary for the anastomotic healing since poor perfusion has been associated with increased morbidity due to anastomotic leaks. Until recently surgical experience was the main tool to assess the perfusion of the anastomosis. We hypothesized that anastomoses located in the zone of optimal ICG perfusion of the gastric conduit (\"optizone\") have a reduced anastomotic leakage rate after esophagectomy.
METHODS: Indocyanine green (ICG) fluorescence tissue angiography was used to evaluate the anastomotic perfusion in 35 patients undergoing esophagectomy with gastric conduit reconstruction. The transition point of the \"optizone\" to the malperfused area of the conduit was defined macroscopically and with the use of ICG angiography during the operation. The anastomosis was performed in the optizone whenever possible. The results of the ICG patients were retrospectively reviewed and compared with 55 patients previously operated without ICG angiography.
RESULTS: The visual assessment of the conduit perfusion concurred with the ICG angiography in 27 cases. In 8 cases (22.8%) the ICG angiography deviated from the visual aspect. One case of anastomotic leakage was observed in the group of patients in which the anastomosis could be performed in the optizone (1/33; 3%) compared with 10 cases in the control group (18%; p = 0.04). In two cases we had to perform the anastomosis in an area of compromised ICG perfusion. Both patients developed an anastomotic leakage.
CONCLUSIONS: ICG tissue angiography represents a feasible and reliable technical support in the evaluation of the anastomotic perfusion after esophagectomy. In this retrospective analysis we observed a significant decrease in anastomotic leakage rate when the anastomosis could be placed in the zone of good perfusion defined by ICG fluorescence. A prospective trial is needed in order to provide higher level evidence for the use of ICG fluorescence in reducing leakage rates after esophagectomy.