Indocyanine green (ICG) is a cyanine dye used in medical diagnostics. It is used for determining cardiac output, hepatic function, liver and gastric blood flow, and for ophthalmic and cerebral angiography. It has a peak spectral absorption at about 800 nm. These infrared frequencies penetrate retinal layers, allowing ICG angiography to image deeper patterns of circulation than fluorescein angiography. ICG binds tightly to plasma proteins and becomes confined to the vascular system. ICG has a half-life of 150 to 180 seconds and is removed from circulation exclusively by the liver to bile. ICG is a fluorescent dye which is used in medicine as an indicator substance (e.g. for photometric hepatic function diagnostics and fluorescence angiography) in cardiac, circulatory, hepatic and ophthalmic conditions. It is administered intravenously and, depending on liver performance, is eliminated from the body with a half-life of about 3 to 4 minutes. ICG sodium salt is normally available in powder form and can be dissolved in various solvents; 5% (< 5% depending on batch) sodium iodide is usually added to ensure better solubility. The sterile lyophilisate of a water-ICG solution is approved in many European countries and the United States under the names ICG-Pulsion and IC-Green as a diagnostic for intravenous use.
History ICG was developed in the Second World War as a dye in photography and tested in 1957 at the Mayo Clinic for use in human medicine by I.J. Fox. After being granted FDA approval in 1959, ICG was initially used primarily in hepatic function diagnostics and later in cardiology. In 1964, S. Schilling was able to determine renal blood flow using ICG. From 1969, ICG was also used in the research and diagnosis of subretinal processes in the eye (in the choroid). In the years since 1980, the development of new types of cameras and better film material or new photometric measuring devices has cleared away many technical difficulties. In the meantime, the use of ICG in medicine (and especially in fluorescent angiography in ophthalmology) has become established as standard. A distinction is therefore also made, when describing fluorescent angiography, between NA fluorescent angiography and ICGA / ICG fluorescent angiography. Around 3,000 scientific papers on ICG have now been published worldwide.
Optical properties The absorption and fluorescence spectrum of ICG is in the near infrared region. Both depend largely on the solvent used and the concentration. ICG absorbs mainly between 600 nm and 900 nm and emits fluorescence between 750 nm and 950 nm. The large overlapping of the absorption and fluorescence spectra leads to a marked reabsorption of the fluorescence by ICG itself. The fluorescence spectrum is very wide. Its maximum values are approx. 810 nm in water and approx. 830 nm in blood. For medical applications based on absorption, the maximum absorption at approx. 800 nm (in blood plasma at low concentrations) is important. In combination with fluorescence detection, lasers with a wavelength of around 780 nm are used. At this wavelength, it is still possible to detect the fluorescence of ICG by filtering out scattered light from the excitation beam.
Toxicity and side-effects
ICG is metabolized microsomally in the liver and only excreted via the liver and bile ducts; since it is not absorbed by the intestinal mucous membrane, the toxicity can be classified as low. Administration is not without risks during pregnancy. It has been known since September 2007 that ICG decomposes into toxic waste materials under the influence of UV light, creating a number of still unknown substances. A study published in February 2008, however, shows that ICG (the substance without UV effect) is basically, as such, of only minor toxicity. The intravenous LD50 values measured in animals are 60 mg/kg in mice and 87 mg/kg in rats. Occasionally – in one out of 42,000 cases – slight side-effects occur in humans such as sore throats and hot flushes. Effects such as anaphylactic shock, hypotension, tachycardia, dyspnea and urticaria only occurred in individual cases; the risk of severe side-effects rises in patients with chronic kidney impairment. The frequencies of mild, moderate and severe side-effects were only 0.15%, 0.2% and 0.05%; the rate of deaths is 1:333,333. For the competitor substance fluorescein, the proportion of people with side-effects is 4.8% and the death rate is 1:222,222.
Uses
Uses in ophthalmology
Indocyanine green angiography
Because the preparation contains sodium iodide, a test must be carried out for iodine intolerance. Because around 5% of iodide is added, the iodine content of a 25 mg ampoule is 0.93 mg. In comparison, preparations for a bone marrow CT (140 ml) contain 300 mg/ml and for a corona angiography (200 ml) 350 mg/ml of iodine. ICG has the ability to bind 98% to plasma proteins – 80% to globulins and 20% to alpha-lipoprotein and albumin – and thus, in comparison with fluorescein as a marker, has a lower leakage (slower emergence of dye from the vessels, extravasally). Because of the plasma protein binding, ICG stays for up to 20 to 30 minutes in the vessels (intravasally). When the eye is examined, it thus stays for a long time in tissues with a higher blood flow, such as the choroid and the blood vessels of the retina.
Capsulorhexis Capsulorhexis is a technique used to remove the lens capsule during cataract surgery. Various dyes are used to stain lens capsule during cataract surgery. In 1998, Horiguchi et al. first described the use of indocyanine green dye (0.5%) for capsular staining to assist cataract surgery. ICG-enhanced anterior and posterior capsulorhexis is useful in childhood cataract surgery. It may also use in adult cataract with no fundus glow. Although ICG is approved by the US FDA, there is still no approval for intraocular use of the dye.
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