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Dat DT, Hien NDTN, Quan NN, Tung MQ, Tam HC, Hung BV. Current Trends in Clinical Characteristics, Diagnosis, and Treatment of Polypoidal Choroidal Vasculopathy: A Perspective from Vietnam. J Clin Med 2022; 11:jcm11164678. [PMID: 36012915 PMCID: PMC9410352 DOI: 10.3390/jcm11164678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/29/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022] Open
Abstract
Polypoidal choroidal vasculopathy (PCV) is a common choroidal disease in the Asian population including Vietnam and is characterized by subretinal red-orange nodules, pigmented epithelium detachment, and massive subretinal hemorrhage. The recent focus on PCV in Vietnam can be attributed to advancements in PCV diagnosis and treatment. However, there is a scarcity of published literature and clinical data on PCV in the Vietnamese population, highlighting a key knowledge gap in this region. In order to address this gap, we gathered the opinions of experienced clinicians and retinal experts in Vietnam and reviewed available medical literature with the aim of: (i) providing an overview of PCV in the Vietnamese population—in terms of epidemiology, clinical characteristics, and management; (ii) tailoring international/national guidelines for the diagnosis and management of PCV, in line with available resources and medical equipment in Vietnam; and (iii) identifying gaps in clinical data in order to guide future PCV research in Vietnam and other countries with similar clinical conditions. The present review will enable healthcare providers and researchers to gain insight into current clinical practices and the limitations of PCV management in Vietnam and provide optimal and effective solutions.
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Affiliation(s)
- Dang Tran Dat
- Outpatient Department, Vietnam National Eye Hospital, 85 Ba Trieu, Nguyen Du Ward, Hai Ba Trung District, Hanoi 100000, Vietnam
- Correspondence: ; Tel.: +84-903-555-986
| | - Nguyen Do Thi Ngoc Hien
- Department of Ophthalmology, Hanoi Medical University, 1 Ton That Tung Street, Hanoi 100000, Vietnam
| | - Nguyen Nhu Quan
- Phuong Dong International Eye Center, 71 Ngo Thoi Nhiem Street, District 3, Ho Chi Minh City 700000, Vietnam
| | - Mai Quoc Tung
- Department of Ophthalmology, Hanoi Medical University, 1 Ton That Tung Street, Hanoi 100000, Vietnam
| | - Hoang Chi Tam
- Ophthalmology and Refractive Surgery Department, FV Hospital, 6 Nguyen Luong Bang Street, Phu My Hung, District 7, Ho Chi Minh City 700000, Vietnam
| | - Bui Viet Hung
- Vitreoretial Department, Vietnam National Eye Hospital, 85 Ba Trieu, Nguyen Du Ward, Hai Ba Trung District, Hanoi 100000, Vietnam
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Wang W, Li X, Xu Z, Yu W, Zhao J, Ding D, Chen Y. Learning Two-Stream CNN for Multi-Modal Age-related Macular Degeneration Categorization. IEEE J Biomed Health Inform 2022; 26:4111-4122. [PMID: 35503853 DOI: 10.1109/jbhi.2022.3171523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This paper tackles automated categorization of Age-related Macular Degeneration (AMD), a common macular disease among people over 50. Previous research efforts mainly focus on AMD categorization with a single-modal input, let it be a color fundus photograph (CFP) or an OCT B-scan image. By contrast, we consider AMD categorization given a multi-modal input, a direction that is clinically meaningful yet mostly unexplored. Contrary to the prior art that takes a traditional approach of feature extraction plus classifier training that cannot be jointly optimized, we opt for end-to-end multi-modal Convolutional Neural Networks (MM-CNN). Our MM-CNN is instantiated by a two-stream CNN, with spatially-invariant fusion to combine information from the CFP and OCT streams. In order to visually interpret the contribution of the individual modalities to the final prediction, we extend the class activation mapping (CAM) technique to the multi-modal scenario. For effective training of MM-CNN, we develop two data augmentation methods. One is GAN-based CFP/OCT image synthesis, with our novel use of CAMs as conditional input of a high-resolution image-to-image translation GAN. The other method is Loose Pairing, which pairs a CFP image and an OCT image on the basis of their classes instead of eye identities. Experiments on a clinical dataset consisting of 1,094 CFP images and 1,289 OCT images acquired from 1,093 distinct eyes show that the proposed solution obtains better F1 and Accuracy than multiple baselines for multi-modal AMD categorization. Code and data are available at https://github.com/li-xirong/mmc-amd.
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Lee J, Kim YN, Kim JG. Monthly Alternating Injections of Aflibercept and Bevacizumab for Neovascular Age-Related Macular Degeneration. J Clin Med 2022; 11:jcm11061543. [PMID: 35329868 PMCID: PMC8950741 DOI: 10.3390/jcm11061543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/03/2022] [Accepted: 03/07/2022] [Indexed: 12/27/2022] Open
Abstract
We investigated the efficacy of monthly alternating injections of aflibercept and bevacizumab (MAAB) for maintenance treatment in patients with neovascular age-related macular degeneration (AMD) who showed improvement with the initial monthly injections but presented with rapid worsening after conversion to bimonthly injections. We included 72 patients with neovascular AMD who showed improvement with loading injections of aflibercept. For maintenance treatment, bevacizumab was administered every alternate month between the bimonthly aflibercept injections in 24 (33.3%) eyes showing worsening (MAAB group). The other eyes were treated with aflibercept (BiA group) bimonthly. Baseline low retinal thickness, thick choroid, and presence of intraretinal fluid were associated with worsening after extending the injection intervals. Visual improvement was lower in the MAAB group than in the BiA group, but the final visual outcomes were comparable. Additional bevacizumab stabilized the early fluctuation of retinal thickness, thus maintaining long-term visual stability without increasing the risk of geographic atrophy or disciform scar until the second year. Previously treated eyes or those with polypoidal choroidal vasculopathy responded less to the initial loading doses and showed worsening under the bimonthly regimen. MAAB was effective in preventing anatomical and functional deterioration when bimonthly aflibercept proved insufficient for the maintenance treatment of neovascular AMD.
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Visual acuity outcomes of anti-VEGF treatment for neovascular age-related macular degeneration in clinical trials. Jpn J Ophthalmol 2021; 65:741-760. [PMID: 34491474 DOI: 10.1007/s10384-021-00869-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/05/2021] [Indexed: 12/26/2022]
Abstract
Anti-VEGF treatment for neovascular age-related macular degeneration (nAMD) has been evaluated in clinical trials. To select the best anti-VEGF drug and the best treatment regimen for nAMD, a thorough understanding of the characteristics of each anti-VEGF drug and treatment regimen is essential. In this review, we summarized visual acuity (VA) changes in 30 previous clinical trials of anti-VEGF treatment for nAMD. In most studies, ranibizumab, aflibercept, and brolucizumab improved the VA by 6 to 12 letters from the baseline VA of 50-65 letters and maintained the VA improvement regardless of the treatment regimen; the VA improved from 0.2-0.4 to 0.3-0.7 in Snellen equivalents. The improvement was rapid during the first month and became slower after the second injection, and 60% to 90% of the VA improvement was attained within the first 3 months. The upper limit of the VA improvement should be determined according to eyes with nAMD themselves, not according to anti-VEGF drugs or treatment regimens. Since a fixed regimen can result in overtreatment, whilst a pro re nata regimen can result in insufficient treatment, a treat-and-extend regimen would be optimal to treat nAMD. Insufficient treatment fails to improve VA to the upper limit and/or to maintain the improved VA, whereas overtreatment can cause macular atrophy. One study reported no difference in the risk of macular atrophy between ranibizumab and aflibercept, whilst many studies have suggested that aflibercept causes more choroidal thinning, one of the risk factors for macular atrophy, than does ranibizumab. Further evaluation of drugs and regimens should be performed from the viewpoint of complications and minimum number of injections required to improve and maintain VA.
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Shen M, Bo Q, Song M, Jiang X, Yehoshua Z, Gregori G, Sun X, Wang F, Rosenfeld PJ. Replacement of polyps with type 1 macular neovascularization in polypoidal choroidal vasculopathy imaged with swept source OCT angiography. Am J Ophthalmol Case Rep 2021; 22:101057. [PMID: 33796797 PMCID: PMC7995480 DOI: 10.1016/j.ajoc.2021.101057] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/25/2020] [Accepted: 02/21/2021] [Indexed: 02/08/2023] Open
Abstract
Purpose To investigate the morphological changes of polyps in eyes with polypoidal choroidal vasculopathy (PCV) after treatment with vascular endothelial growth factor (VEGF) inhibitors using swept source optical coherence tomography angiography (SS-OCTA). Observations Following anti-VEGF therapy, polyps were found to evolve into typical type 1 macular neovascularization (MNV) in five eyes. In all of these five eyes, a polypoidal lesion was detected adjacent to a serous or hemorrhagic retinal pigment epithelial detachment (PED). Conclusions and importance Polypoidal lesions in PCV can evolve into typical type 1 MNV. This morphological evolution suggests that these polyps are clusters of tangled vessels that can proliferate into a more typical neovascular pattern, and this evolution may be facilitated by being adjacent to a PED. Since this morphological appearance could be associated with a better prognosis, SS-OCTA might be helpful in identifying cases of transformed polyps that may be associated with a decreased risk for vision loss.
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Affiliation(s)
- Mengxi Shen
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Qiyu Bo
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Minlu Song
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoshuang Jiang
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA.,Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China
| | - Zohar Yehoshua
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Giovanni Gregori
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Xiaodong Sun
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,National Clinical Research Center for Eye Diseases, China.,Shanghai Key Laboratory of Ocular Fundus Diseases, China.,Shanghai Engineering Center for Visual Science and Photomedicine, China.,Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, China
| | - Fenghua Wang
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,National Clinical Research Center for Eye Diseases, China.,Shanghai Key Laboratory of Ocular Fundus Diseases, China.,Shanghai Engineering Center for Visual Science and Photomedicine, China.,Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, China
| | - Philip J Rosenfeld
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
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Timing of Complete Polypoidal Regression after Intravitreous Aflibercept Treatments in Polypoidal Choroidal Vasculopathy. Ophthalmol Retina 2021; 6:21-28. [PMID: 33781929 DOI: 10.1016/j.oret.2021.03.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 02/19/2021] [Accepted: 03/23/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE To understand timing of complete polypoidal regression on indocyanine green angiography (ICGA) after aflibercept injections for polypoidal choroidal vasculopathy (PCV). DESIGN Multicenter prospective study. PARTICIPANTS Adults with treatment-naïve PCV. METHODS After institutional review board approval, participants were enrolled and followed up for 1 year, from Apr 1, 2016, through Dec 30, 2018, at 2 university-based centers in Thailand. Diagnosis of PCV was based on the Efficacy and Safety of Verteporfin Photodynamic Therapy in Combination with Ranibizumab or Alone versus Ranibizumab Monotherapy in Patients with Symptomatic Macular Polypoidal Choroidal Vasculopathy criteria. Eligible eyes received fixed-dose aflibercept injections (3 monthly then every 8 weeks), or monthly if fluid persisted on OCT. Photodynamic therapy (PDT) was administered when fluid persisted despite 6 consecutive injections. Indocyanine green angiography was performed at baseline and then every 8 weeks. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was administered at baseline, 6 months, and 1 year. Two retina specialists reviewed posttreatment ICGA, categorized into: complete regression (complete disappearance of polypoidal lesions), partial regression (reduced in size or number), or no regression. Disagreements were resolved through open adjudication. MAIN OUTCOME MEASURES Timing of complete regression over 1 year. RESULTS Final analysis included 40 eyes (39 participants; 100% Thai, 59% women; mean age±standard deviation, 64 ± 8.3 years). At baseline, 90% had 5 or more polypoidal lesions. Ninety-five percent received aflibercept monotherapy, and 5% received rescue PDT per protocol. Polypoidal statuses at 1 year were 55% complete, 40% partial, and 5% no regression. Cumulative rates of complete regression at 2, 4, 6, and 12 months were 28%, 33%, 43%, and 55%. Of 22 eyes with complete regression at 1 year, complete regression was identified first at 2, 4, 6, 8, 10, 12 months in 50%, 9%, 18%, 5%, 9%, and 9%, respectively. Cumulative rates of complete regression among these eyes at 2, 6, and 12 months were 50%, 77%, and 100%, respectively. Median duration of complete regression was 3 months (interquartile range, 2-6 months). Median visual acuity improved from 20/125 (Snellen equivalent) to 20/50; median NEI VFQ-25 scores improved from 80 to 93 from baseline to 1 year. CONCLUSIONS Complete polypoidal regression could occur as early as 2 months after aflibercept injections. Most PCV eyes with complete polypoidal regression at 1 year already showed complete regression within the first 6 months. These findings support consideration of aflibercept for PCV to achieve both anatomic and visual outcomes.
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Montero Hernández J, Remolí Sargues L, Monferrer Adsuara C, Castro Navarro V, Navarro Palop C, Cervera Taulet E. Two-year results of a treat and extend regimen with aflibercept in Caucasian patients with aneurysmal type 1 neovascularization. Eur J Ophthalmol 2021; 32:377-384. [PMID: 33706554 DOI: 10.1177/11206721211001313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION There are a few reports investigating the treatment of aneurysmal type 1 neovascularization (AT1) in Caucasian patients. The aim of this study is to evaluate the 2-year results of a treat and extend regimen with aflibercept in Caucasian patients with AT1. METHODS We conducted an observational retrospective study in 28 eyes of 26 patients with naïve AT1 treated with a treat an extend regimen of intravitreal aflibercept. Best corrected visual acuity (BCVA), central macular thickness (CMT), pigment epithelium detachment (PED) height, presence of dry macula, and regression rate of polypoidal lesions were assessed at baseline and at 12 and 24 months. RESULTS BCVA was significantly increased by 9.03 ± 16 letters (p < 0.01) and 9.2 ± 16.87 letters (p < 0.01) after the 12 and 24 months follow-up. A significant decrease of CMT was found at 12 and 24 months (p < 0.01). Nevertheless, significant changes in PED height were not observed (0.1 < p > 0.05). At 12 and 24 months of follow-up, dry macula was achieved in a total of 10 eyes (35.71%) and 15 eyes (53.57%). The regression rate of polypoidal lesions was 25% (7 eyes) and 35.71% (10 eyes) after 12 and 24 months. The mean number of intravitreal injections was 7.81 ± 3.20 the first year and 6.11 ± 3.49 the second year. CONCLUSION To the best of our knowledge, treat and extend regimen with intravitreal aflibercept in Caucasian patients may be effective for improving BCVA, CMT, wet macula, and regression rate of polypoidal lesions.
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Affiliation(s)
- Javier Montero Hernández
- Servicio de Oftalmología, Department of Ophthalmology, Consorcio Hospital General Universitario of Valencia, Valencia, Spain
| | - Lidia Remolí Sargues
- Servicio de Oftalmología, Department of Ophthalmology, Consorcio Hospital General Universitario of Valencia, Valencia, Spain
| | - Clara Monferrer Adsuara
- Servicio de Oftalmología, Department of Ophthalmology, Consorcio Hospital General Universitario of Valencia, Valencia, Spain
| | - Verónica Castro Navarro
- Servicio de Oftalmología, Department of Ophthalmology, Consorcio Hospital General Universitario of Valencia, Valencia, Spain
| | - Catalina Navarro Palop
- Servicio de Oftalmología, Department of Ophthalmology, Consorcio Hospital General Universitario of Valencia, Valencia, Spain
| | - Enrique Cervera Taulet
- Servicio de Oftalmología, Department of Ophthalmology, Consorcio Hospital General Universitario of Valencia, Valencia, Spain
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Choo HG, Lee JH, Oh HS, Kim SH, You YS, Kwon OW. One-year outcomes of fixed-dosing Aflibercept therapy for pre treated and naive polypoidal choroidal vasculopathy patient. BMC Ophthalmol 2021; 21:94. [PMID: 33602156 PMCID: PMC7890830 DOI: 10.1186/s12886-021-01829-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 01/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Polypoidal choroidal vasculopathy (PCV) is a type of age-related macular degeneration that can cause permanent vision loss. The purpose of this paper was to report the one-year outcomes of fixed-dosing aflibercept therapy for the treatment of PCV. METHODS This was a prospective, single-arm, interventional case series study of 25 PCV patients; 12 pre-treated and 13 treatment-naïve patients. The patients were treated and monitored for 12 months. Each patient was administered with an aflibercept (2.0 mg) injection every month for the first 3 months (the loading phase), and thereafter, once every 2 months. At every follow-up visit, best-corrected visual acuity (BCVA) test, fundus examination, and optical coherence tomography for measuring the central subfield macular thickness (CSMT) were performed. Fluorescein and indocyanine green angiography were conducted at baseline and at 4 and 12 months. RESULTS After 12 months of aflibercept therapy, the mean BCVA of the patients significantly improved from 65.48 letters at baseline to 69.91 letters (p=0.001), and the CSMT significantly decreased from 406.92 um at baseline to 276.12 um (p< 0.001). Additionally, ten patients (40%) showed complete polyp regression. The treatment-naïve patients showed a statistically significant improvement in BCVA from 66.58 letters at baseline to 76.36 letters at 12 months, and a significant decrease in CSMT, from 462 to 243 um. In the pre-treated group, there was no change in BCVA (64.46 letters), and the decrease in CSMT from 356.08 to 303.69 um was not statistically significant. CONCLUSIONS The fixed-dosing aflibercept regimen is effective for treating patients with PCV and is more effective in treatment-naïve patients than in pre-treated patients. TRIAL REGISTRATION Clinical Research Information Service (CRiS), Republic of Korea. Identifer: KCT0005798, Registered: Jan 20, 2021. Retrospectively registered, URL: https://cris.nih.go.kr/cris/en/search/search_result_st01.jsp?seq=18546.
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Affiliation(s)
- Hun Gu Choo
- Department of Ophthalmology, Wonju College of Medicine - Yonsei University, Wonju, Republic of Korea
| | - Jin Hae Lee
- Department of Ophthalmology, First St. Marys Eye Clinic, Seoul, Republic of Korea
| | - Hyun Sub Oh
- Department of Ophthalmology, Nune Eye Hospital, Noon Bldg 404, Seonreung-ro Gangnam-gu, 06198, Seoul, Republic of Korea
| | - Soon Hyun Kim
- Department of Ophthalmology, Nune Eye Hospital, Noon Bldg 404, Seonreung-ro Gangnam-gu, 06198, Seoul, Republic of Korea
| | - Yong Sung You
- Department of Ophthalmology, Nune Eye Hospital, Noon Bldg 404, Seonreung-ro Gangnam-gu, 06198, Seoul, Republic of Korea
| | - Oh Woong Kwon
- Department of Ophthalmology, Nune Eye Hospital, Noon Bldg 404, Seonreung-ro Gangnam-gu, 06198, Seoul, Republic of Korea.
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Systematic review with network meta-analysis of antivascular endothelial growth factor use in managing polypoidal choroidal vasculopathy. Sci Rep 2021; 11:2735. [PMID: 33531615 PMCID: PMC7854625 DOI: 10.1038/s41598-021-82316-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/19/2021] [Indexed: 12/02/2022] Open
Abstract
Polypoidal choroidal vasculopathy (PCV) is a vision-threatening disease common in Asian populations. However, the optimal treatment for PCV remains under debate. We searched the databases with optimal searching strategy. The study included randomized clinical trials and prospective studies that recruited patients with active PCV who had received interventions, including PDT, anti-VEGF, or a combination of PDT and anti-VEGF. The Grading of Recommendations Assessment, Development, and Evaluation methodology was used for rating the quality of evidence. Our study included 11 studies involving 1277 patients. The network meta-analysis of RCTs revealed the anti-VEGF group, early combination group, and late combination group had significant BCVA changes compared with the PDT group. Early combination therapy led to a significant decrease in CRT compared with PDT, anti-VEGF, and late combination therapy. Additionally, the early combination group had a significantly higher complete polyp regression rate than the anti-VEGF group. No significant differences were detected in the analysis of the number of anti-VEGF injections and safety profile. This network meta-analysis revealed that early combination therapy exhibited better efficacy related to anatomical outcomes than other therapies. Nonetheless, no significant differences related to BCVA change could be detected between anti-VEGF and late combination therapy.
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Kwon JM, Pak KY, Lee JJ, Sagong M, Kim HW. One-year Results of Aflibercept Treatment for Polypoidal Choroidal Vasculopathy with Good Visual Acuity. KOREAN JOURNAL OF OPHTHALMOLOGY 2021; 35:26-36. [PMID: 33307629 PMCID: PMC7904418 DOI: 10.3341/kjo.2020.0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/06/2020] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To evaluate the one-year efficacy of intravitreal aflibercept injection in polypoidal choroidal vasculopathy (PCV) with best-corrected visual acuity (BCVA) of 20 / 40 or better. METHODS This was a multicenter retrospective study. The medical records of patients diagnosed with treatment-naïve PCV were retrospectively reviewed. Patients with an initial BCVA of 20 / 40 or better and who had undergone intravitreal aflibercept injection were included. Patients were treated with three consecutive monthly injections, followed by pro re nata regimen according to the clinician's discretion at variable interval visits. The proportions of eyes for which BCVA was maintained (≤ 0.2 logarithm of the minimum angle of resolution change) or improved at 12 months were evaluated. The changes of BCVA, central subfield macular thickness (CSMT), pigment epithelial detachment, and subretinal fluid also were assessed. RESULTS A total of 86 eyes were included. The mean number of injections for 12 months of treatment was 5.4 ± 1.7. BCVA was maintained or improved in 94.2% (81 / 86) of cases. Mean BCVA (logarithm of the minimum angle of resolution) had changed from the baseline (0.23 ± 0.09) at 3 months (0.21 ± 0.14), 6 months (0.24 ± 0.22), and 12 months (0.20 ± 0.18), but with no statistical significance. CSMT had improved significantly from the baseline (336.1 ± 97.3 μm) at 3 months (223.6 ± 47.22 μm), 6 months (239.6 ± 64.2 μm), and 12 months (223.8 ± 47.9 μm). Pigment epithelial detachment was observed in 93% of cases at the baseline, 72.1% at 3 months, and 69.8% at 12 months, showing a significant decrease at all observation points. Subretinal fluid was observed in 91.9% of cases at the baseline, 20.9% at 3 months, and 29.1% at 12 months, showing a significant decrease at all observation points. CONCLUSIONS In cases of PCV with good visual acuity, intravitreal aflibercept injections decreased CSMT and were effective in maintaining visual acuity.
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Affiliation(s)
- Ji Min Kwon
- Department of Ophthalmology, Haeundae Paik Hospital, Inje University College of Medicine, Busan,
Korea
| | - Kang Yeun Pak
- Department of Ophthalmology, Haeundae Paik Hospital, Inje University College of Medicine, Busan,
Korea
| | - Jae Jung Lee
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan,
Korea,Biomedical Research Institute, Pusan National University Hospital, Busan,
Korea
| | - Min Sagong
- Department of Ophthalmology, Yeungnam University College of Medicine, Daegu,
Korea
| | - Hyun Woong Kim
- Department of Ophthalmology, Haeundae Paik Hospital, Inje University College of Medicine, Busan,
Korea
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Ogura Y, Iida T, Lee WK, Cheung CMG, Mitchell P, Leal S, Schmelter T, Ishibashi T. Efficacy and safety of intravitreal aflibercept for polypoidal choroidal vasculopathy: 96-week outcomes in the Japanese subgroup of the PLANET study. Jpn J Ophthalmol 2021; 65:344-353. [PMID: 33474611 DOI: 10.1007/s10384-020-00805-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/31/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE To evaluate the efficacy and safety of intravitreal aflibercept (IVT-AFL) versus IVT-AFL plus rescue photodynamic therapy (IVT-AFL + rPDT) in the subgroup of Japanese patients with polypoidal choroidal vasculopathy (PCV) enrolled in the PLANET study. STUDY DESIGN A 96-week, double-masked, sham-controlled phase-3b/4 randomized clinical trial conducted at multiple centers from May 2014 to August 2016. PATIENTS AND METHODS Patients with PCV (BCVA 73-24 ETDRS letters [20/40-20/320 Snellen]) received 3 initial monthly doses of IVT-AFL 2 mg. At week 12, the patients were randomly assigned 1:1 to IVT-AFL + sham PDT or IVT-AFL + rPDT. Patients not requiring rescue received IVT-AFL every 8 weeks; those requiring rescue received IVT-AFL monthly plus sham/active PDT. Following week 52, the treatment intervals could be extended > 8 weeks. RESULTS The baseline demographics for the 159 Japanese patients were balanced. At week 96, the mean BCVA change was + 9.7 (IVT-AFL) versus + 9.5 letters (IVT-AFL + rPDT) (least-squares mean difference of - 0.3; 95% CI, - 3.7 to 3.1); the mean central subfield thickness reduction was - 148.0 µm versus - 145.9 µm. Overall, 17.1% of the patients required rescue PDT. At week 96, 25.0% (IVT-AFL) and 37.9% (IVT-AFL + rPDT) of the patients had complete polyp regression; 84.1% (IVT-AFL) and 88.4% (IVT-AFL + rPDT) of the patients had no evidence of active polyps. The mean number of injections (weeks 52-96) were 4.6 (IVT-AFL) and 4.5 (IVT-AFL + rPDT). Overall, 36.0% (IVT-AFL) and 33.8% (IVT-AFL + rPDT) of the patients experienced ocular treatment-emergent adverse events. CONCLUSION IVT-AFL monotherapy was efficacious for the treatment of Japanese patients with PCV, and the addition of rescue PDT did not show additional benefits.
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Affiliation(s)
- Yuichiro Ogura
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya, 467-8601, Japan.
| | - Tomohiro Iida
- Department of Ophthalmology, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Chui Ming Gemmy Cheung
- Singapore National Eye Centre and Singapore Eye Research Institute, Singapore, Singapore.,Duke-NUS, National University of Singapore, Singapore, Singapore
| | - Paul Mitchell
- University of Sydney, Westmead Institute for Medical Research, Sydney, Australia
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Tamachi T, Kohno T, Yamamoto M, Hirayama K, Kyo A, Ueda N, Hirabayashi M, Shiraki K, Honda S. One-Year Results of a Treat-and-Extend Regimen of Intravitreal Aflibercept for Polypoidal Choroidal Vasculopathy. Ophthalmol Ther 2020; 9:1069-1082. [PMID: 33058069 PMCID: PMC7708582 DOI: 10.1007/s40123-020-00312-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/03/2020] [Indexed: 11/06/2022] Open
Abstract
Introduction To evaluate 1-year outcomes of intravitreal aflibercept (IVA) using a treat-and-extend (TAE) regimen for polypoidal choroidal vasculopathy (PCV) and identify the factors for patients whose treatment intervals could be extended. Methods Fifty-one eyes of treatment-naïve PCV patients treated with IVA using a TAE regimen for at least 1 year were examined retrospectively. All patients received at least three IVA injections every 5 weeks, and the intervals were then extended by 2-week adjustments up to 13 weeks. When retinal exudation recurred, the patient was treated with the same regimen, but with a shortened interval of 5 weeks. The main outcome measures were changes in best-corrected visual acuity (BCVA) and central retinal thickness (CRT) as well as the treatment interval at 1 year. Results The mean logarithm of the minimum angle of resolution BCVA improved from 0.24 ± 0.32 at baseline to 0.18 ± 0.31 at 12 months (p = 0.048). The mean CRT decreased from 350.3 ± 147.7 µm at baseline to 215.3 ± 75.0 µm at 4 months (p < 0.001), after which it was maintained at this level. At 12 months, the administration interval was 5 weeks in eight eyes (15.7%), 7 weeks in six eyes (11.8%), 9 weeks in two eyes (3.9%), 11 weeks in four eyes (7.8%), and 13 weeks in 31 eyes (60.8%). Female sex, a thinner CRT at 6 months, and absence of polypoidal lesions at 12 months were significant factors related to patients whose treatment intervals could be extended without recurrence to 13 weeks. Conclusion IVA using a TAE regimen improved visual and anatomical outcomes in eyes with PCV at 1 year using a protocol to adjust the injection intervals specifically for each patient so as to obtain no retinal exudation.
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Affiliation(s)
- Tomoko Tamachi
- Department of Ophthalmology and Visual Sciences, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takeya Kohno
- Department of Ophthalmology and Visual Sciences, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Manabu Yamamoto
- Department of Ophthalmology and Visual Sciences, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kumiko Hirayama
- Department of Ophthalmology and Visual Sciences, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akika Kyo
- Department of Ophthalmology and Visual Sciences, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Nobuhiko Ueda
- Department of Ophthalmology and Visual Sciences, Osaka City University Graduate School of Medicine, Osaka, Japan
| | | | - Kunihiko Shiraki
- Department of Ophthalmology and Visual Sciences, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shigeru Honda
- Department of Ophthalmology and Visual Sciences, Osaka City University Graduate School of Medicine, Osaka, Japan
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The Efficacy of Conbercept in Polypoidal Choroidal Vasculopathy: A Systematic Review. J Ophthalmol 2020; 2020:4924053. [PMID: 32855818 PMCID: PMC7442996 DOI: 10.1155/2020/4924053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 11/17/2022] Open
Abstract
Methods Thirty studies with 1308 eyes were identified and included in this study. The primary outcome measures were best-corrected visual acuity (BCVA), and secondary outcomes were optical coherence tomography characteristics and polyp regression rates. The pooled results were calculated by the random-effect or fixed-effect model according to the heterogeneity of the data. Results Despite a large standard deviation in means (SMD) improvement for BCVA and central retinal thickness (CRT) in the conbercept group, there was no statistically significant difference in the other outcomes compared to ranibizumab and aflibercept. However, there was a greater polyp regression rate in the conbercept group at 12 months. Conclusions This systematic review indicates that conbercept may achieve similar BCVA and CRT improvements as ranibizumab and aflibercept, with a superior rate of polyp regression at 12 months.
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Liu H, Ma Y, Xu HC, Huang LY, Zhai LY, Zhang XR. Updates on the Management of Ocular Vasculopathies with VEGF Inhibitor Conbercept. Curr Eye Res 2020; 45:1467-1476. [PMID: 32631094 DOI: 10.1080/02713683.2020.1781193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Purpose: To provide a detailed review on the therapeutic efficacy of conbercept for the management of ocular vasculopathies. Methods: A comprehensive literature search of various electronic databases was performed. Results: Ocular vasculopathy is one of the major causes of visual impairment and blindness which includes a range of disorders. Vascular endothelial growth factor (VEGF) regulates angiogenesis, enhances vascular permeability, and drives the formation of neovascularization. Anti-VEGF therapy has been shown to prevent vision loss or potentially improve vision in patients with exudative or neovascular retinal disease. The most recent anti-VEGF drug in China is conbercept. In the USA and Europe, bevacizumab is the most recently approved anti-VEGF agent. Conclusions: Conbercept serves as another anti-VEGF option for patients with neovascular AMD and other retinal vascular disorders. There have not been many clinical trials that study conbercept as compared with other currently available anti-VEGF drugs. There is a need for large-scale, well-designed, randomized clinical trials to ensure its long-term safety and efficacy and to determine if it has any advantages over other anti-VEGF agents.
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Affiliation(s)
- Huan Liu
- Division of Ocular Injuries, Department of Ophthalmology, The Third Affiliated Hospital of Hebei Medical University , Shijiazhuang, Hebei, China.,Hebei OPO Eye Bank, The Third Affiliated Hospital of Hebei Medical University , Shijiazhuang, Hebei, China
| | - Yue Ma
- Division of Ocular Injuries, Department of Ophthalmology, The Third Affiliated Hospital of Hebei Medical University , Shijiazhuang, Hebei, China
| | - Hong-Chang Xu
- Division of Ocular Injuries, Department of Ophthalmology, The Third Affiliated Hospital of Hebei Medical University , Shijiazhuang, Hebei, China
| | - Li-Ying Huang
- Division of Ocular Injuries, Department of Ophthalmology, The Third Affiliated Hospital of Hebei Medical University , Shijiazhuang, Hebei, China
| | - Li-Ying Zhai
- Division of Ocular Injuries, Department of Ophthalmology, The Third Affiliated Hospital of Hebei Medical University , Shijiazhuang, Hebei, China.,Department of Ophthalmology, Cangzhou Central Hospital , Cangzhou, Hebei, China
| | - Xiao-Rong Zhang
- Division of Ocular Injuries, Department of Ophthalmology, The Third Affiliated Hospital of Hebei Medical University , Shijiazhuang, Hebei, China.,Hebei OPO Eye Bank, The Third Affiliated Hospital of Hebei Medical University , Shijiazhuang, Hebei, China
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15
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Polypoidal choroidal vasculopathy in Canada. Can J Ophthalmol 2020; 55:199-211. [DOI: 10.1016/j.jcjo.2019.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/06/2019] [Accepted: 10/15/2019] [Indexed: 11/19/2022]
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16
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Sørensen JØ, Subhi Y, Molbech CR, Krogh Nielsen M, Sørensen TL. Plasma Levels of Matrix Metalloprotease MMP-9 and Tissue Inhibitor TIMP-1 in Caucasian Patients with Polypoidal Choroidal Vasculopathy. Vision (Basel) 2020; 4:vision4020027. [PMID: 32429088 PMCID: PMC7356191 DOI: 10.3390/vision4020027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/08/2020] [Accepted: 05/13/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Matrix metalloproteinase 9 (MMP-9) and tissue inhibitor of metalloproteinases 1 (TIMP-1) are regulating enzymes of the extracellular matrix. A systemic imbalance of MMP-9 and TIMP-1, thought to reflect an imbalance of the extracellular matrix homeostasis, is previously associated with polypoidal choroidal vasculopathy (PCV) in Asian patients. Previous studies suggest inter-ethnical differences in the genetic background and etiology of PCV. To further explore this issue, we studied the plasma levels of MMP-9 and TIMP-1 in Caucasian patients with PCV and compared to healthy age-matched controls. METHODS For this prospective case-control study, 60 participants were recruited who were either patients with PCV (n = 26) or healthy controls (n = 34). All participants underwent detailed clinical examination. We sampled fresh venous blood, isolated plasma, and quantified plasma concentrations of the extracellular matrix regulators MMP-9 and TIMP-1 using electrochemiluminescence immunoassays. RESULTS Plasma levels of MMP-9 (p = 0.4), TIMP-1 (p = 0.9), and MMP-9/TIMP-1 ratio (p = 0.4) did not differ significantly between patients with PCV and healthy controls. No differences appeared after adjusting for influencing co-variates in multivariate analyses. CONCLUSION We demonstrate that Caucasian patients with PCV do not have altered levels of plasma MMP-9 or plasma TIMP-1. These findings suggest no strong evidence of a systemic imbalance of the extracellular matrix homeostasis in Caucasian patients with PCV. Our findings are in line with studies of other aspects of PCV that are also subject to significant inter-ethnical differences.
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Affiliation(s)
- Jakob Ø. Sørensen
- Clinical Eye Research Division, Department of Ophthalmology, Zealand University Hospital, Vestermarksvej 23, DK-4000 Roskilde, Denmark; (C.R.M.); (M.K.N.); (T.L.S.)
- Department of Ophthalmology, Rigshospitalet-Glostrup, DK-2600 Glostrup, Denmark
- Correspondence: (J.Ø.S.); (Y.S.); Tel.: +45-4732-3900 (Y.S.)
| | - Yousif Subhi
- Clinical Eye Research Division, Department of Ophthalmology, Zealand University Hospital, Vestermarksvej 23, DK-4000 Roskilde, Denmark; (C.R.M.); (M.K.N.); (T.L.S.)
- Department of Ophthalmology, Rigshospitalet-Glostrup, DK-2600 Glostrup, Denmark
- Correspondence: (J.Ø.S.); (Y.S.); Tel.: +45-4732-3900 (Y.S.)
| | - Christopher R. Molbech
- Clinical Eye Research Division, Department of Ophthalmology, Zealand University Hospital, Vestermarksvej 23, DK-4000 Roskilde, Denmark; (C.R.M.); (M.K.N.); (T.L.S.)
- Department of Ophthalmology, Rigshospitalet-Glostrup, DK-2600 Glostrup, Denmark
| | - Marie Krogh Nielsen
- Clinical Eye Research Division, Department of Ophthalmology, Zealand University Hospital, Vestermarksvej 23, DK-4000 Roskilde, Denmark; (C.R.M.); (M.K.N.); (T.L.S.)
- Department of Ophthalmology, Rigshospitalet-Glostrup, DK-2600 Glostrup, Denmark
| | - Torben L. Sørensen
- Clinical Eye Research Division, Department of Ophthalmology, Zealand University Hospital, Vestermarksvej 23, DK-4000 Roskilde, Denmark; (C.R.M.); (M.K.N.); (T.L.S.)
- Faculty of Health and Medical Science, University of Copenhagen, DK-2200 Copenhagen, Denmark
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17
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Changes in cone-driven functions after intravitreal aflibercept injections in patients with age-related macular degeneration. Doc Ophthalmol 2020; 141:137-147. [PMID: 32100141 DOI: 10.1007/s10633-020-09758-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 02/18/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE To determine the changes in the cone-driven functions in patients with age-related macular degeneration (AMD) treated with intravitreal aflibercept. METHODS We studied 44 eyes of 44 patients diagnosed with AMD whose mean age was 75 years. The contralateral unaffected eyes served as controls. All patients were initially treated with 3 consecutive monthly intravitreal aflibercept injections and thereafter with bimonthly injections for 12 months. Full-field cone electroretinograms (cone ERGs) were recorded at the baseline and at 3, 6, and 12 months after beginning the intravitreal aflibercept injections. The cone ERGs were elicited by red stimuli on a blue background. The focal macular ERGs (fmERGs) were elicited by 15 degrees white stimulus spot centered on the fovea. The amplitudes of the a- and b-waves, photopic negative response (PhNR), and sum of the oscillatory potentials (ΣOPs, sum of OP1-3 amplitudes) were analyzed. In addition, the implicit times of the a- and b-waves were also analyzed. RESULTS The amplitudes and implicit times of all components of the fmERGs were significantly improved compared to the baseline at 3 months after beginning the intravitreal aflibercept injections (P < 0.0005-0.05). The amplitudes of the a-waves and PhNRs were further increased during the maintenance phase (P < 0.005-0.01). On the other hand, the amplitudes of the full-field a-waves and PhNR of the cone ERGs were significantly reduced at 6 and 12 months compared to the baseline. CONCLUSIONS The macular function improved continuously during the maintenance phase of the intravitreal aflibercept injections. In contrast, the cone-driven functions of the more peripheral retina decreased with repeated injections suggesting adverse effects of the intravitreal aflibercept injections on the function of the more peripheral normal retina.
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18
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Lee WK, Iida T, Ogura Y, Chen SJ, Wong TY, Mitchell P, Cheung GCM, Zhang Z, Leal S, Ishibashi T. Efficacy and Safety of Intravitreal Aflibercept for Polypoidal Choroidal Vasculopathy in the PLANET Study: A Randomized Clinical Trial. JAMA Ophthalmol 2019; 136:786-793. [PMID: 29801063 DOI: 10.1001/jamaophthalmol.2018.1804] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Polypoidal choroidal vasculopathy (PCV) is common in Asian populations, but an optimal treatment approach remains to be confirmed. Objective To evaluate intravitreal aflibercept injection (IAI) in participants with PCV and compare IAI monotherapy with IAI plus rescue photodynamic therapy (PDT). Design, Setting, and Participants This 96-week, double-masked, sham-controlled phase 3b/4 randomized clinical trial was conducted at multiple centers in Australia, Germany, Hong Kong, Hungary, Japan, Singapore, South Korea, and Taiwan from May 2014 to August 2016, and included adults 50 years or older with symptomatic macular PCV and a best-corrected visual acuity of 73 to 24 Early Treatment Diabetic Retinopathy Study letters (20/40-20/320 Snellen equivalent). Interventions Participants received 2 mg of IAI at weeks 0, 4, and 8. At week 12, participants with a suboptimal response were randomized 1:1 to receive IAI plus sham PDT (IAI monotherapy) or a "rescue" of IAI plus rescue PDT (IAI/PDT). Participants who did not qualify for rescue received IAI every 8 weeks; those qualifying for rescue received IAI every 4 weeks plus sham/active PDT. When the rescue criteria were no longer met, injection intervals were gradually extended to 8 weeks. Main Outcomes and Measures Noninferiority of IAI monotherapy to IAI/PDT for mean change in best-corrected visual acuity from baseline to week 52 (95% CI of the difference entirely above -5 letters). Results Of the 318 participants, the mean (SD) age was 70.6 (8.2) years, 96 (30.2%) were women, and 152 (47.8%) were Japanese. Monotherapy with IAI was noninferior to IAI/PDT for the primary end point (+10.7 vs +10.8 letters, respectively; 95% CI, -2.9 to 1.6; P = .55), with few participants requiring rescue therapy (19 [12.1%] vs 23 [14.3%], respectively). Participants in both treatment groups had similar reductions in central subfield thickness from baseline to week 52 (-137.7 [IAI monotherapy] vs -143.5 μm [IAI/PDT]). At week 52, 49 (38.9%) and 60 participants (44.8%) had no polypoidal lesions observed on indocyanine green angiography in the IAI monotherapy and IAI/PDT groups, respectively. Furthermore, 116 (81.7%) and 136 (88.9%), respectively, had no polypoidal lesions with leakage. The most frequent ocular adverse events were conjunctival hemorrhage (IAI monotherapy, 8 [5.1%]) and dry eye (IAI/PDT, 9 [5.6%]). Conclusions and Relevance Improvement in visual and/or functional outcomes was achieved in more than 85% of participants who were treated with IAI monotherapy, with no signs of leakage from polypoidal lesions in more than 80%. As fewer than 15% met the criteria of a suboptimal response to receive PDT, the potential benefit of adding PDT cannot be determined. Trial Registration ClinicalTrials.gov Identifier: NCT02120950.
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Affiliation(s)
- Won Ki Lee
- Department of Ophthalmology, Seoul St Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Tomohiro Iida
- Department of Ophthalmology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yuichiro Ogura
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shih-Jen Chen
- Department of Ophthalmology, Taipei Veterans General Hospital, School of Medicine, National Yang-Ming University Taipei, Taiwan
| | - Tien Yin Wong
- Singapore Eye Research Institute and National Eye Centre, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
| | - Paul Mitchell
- University of Sydney, Sydney, Australia (Westmead Institute for Medical Research)
| | - Gemmy Chui Ming Cheung
- Singapore Eye Research Institute and National Eye Centre, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore
| | | | | | - Tatsuro Ishibashi
- Department of Ophthalmology, Kyushu University Hospital, Fukuoka, Japan
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Yoneda A, Wakiyama H, Kurihara J, Kitaoka T. Initial treatment for polypoidal choroidal vasculopathy: Ranibizumab combined with photodynamic therapy or fixed-dosing aflibercept monotherapy. Eur J Ophthalmol 2019; 30:1473-1479. [PMID: 31476891 DOI: 10.1177/1120672119871886] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To compare the 2-year outcomes of combination therapy using intravitreal ranibizumab and photodynamic therapy with those of fixed-dosing intravitreal aflibercept monotherapy as initial treatment for treatment-naïve polypoidal choroidal vasculopathy. METHODS We retrospectively reviewed 63 eyes of 61 patients with treatment-naïve polypoidal choroidal vasculopathy who had undergone at least 24 months of follow-up. In total, 43 eyes underwent intravitreal ranibizumab-photodynamic therapy combination therapy and 20 eyes underwent fixed-dosing intravitreal aflibercept monotherapy. Visual outcomes and the number of treatments were compared between the two groups. RESULTS The mean logarithm of minimal angle of resolution best-corrected visual acuity significantly improved from 0.48 ± 0.41 at baseline to 0.30 ± 0.47 at 24 months in the intravitreal ranibizumab-photodynamic therapy group (p = .0002) and from 0.30 ± 0.18 at baseline to 0.16 ± 0.18 at 24 months in the intravitreal aflibercept group (p = .004), with no significant intergroup differences. The mean number of intravitreal ranibizumab or intravitreal aflibercept injections over 24 months was 5.7 ± 4.5 in the intravitreal ranibizumab-photodynamic therapy group and 12.2 ± 3.8 in the intravitreal aflibercept group (p < .0001). CONCLUSION The intravitreal ranibizumab-photodynamic therapy combination therapy was noninferior to fixed-dosing intravitreal aflibercept monotherapy in improving visual acuity and required fewer injections.
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Affiliation(s)
- Ai Yoneda
- Department of Ophthalmology, The Japanese Red Cross Nagasaki Genbaku Hospital, Nagasaki, Japan.,Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Harumi Wakiyama
- Department of Ophthalmology, The Japanese Red Cross Nagasaki Genbaku Hospital, Nagasaki, Japan.,Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Junko Kurihara
- Department of Ophthalmology, The Japanese Red Cross Nagasaki Genbaku Hospital, Nagasaki, Japan.,Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Takashi Kitaoka
- Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
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20
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Srour M, Sayag D, Nghiem-Buffet S, Arndt C, Creuzot-Garcher C, Souied E, Mauget-Faÿsse M. Approche diagnostique et thérapeutique de la vasculopathie polypoïdale choroïdienne. Recommandations de la Fédération France Macula. J Fr Ophtalmol 2019; 42:762-777. [DOI: 10.1016/j.jfo.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 04/25/2019] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
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21
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Wong TY, Ogura Y, Lee WK, Iida T, Chen SJ, Mitchell P, Gemmy Cheung CM, Zhang Z, Leal S, Ishibashi T. Efficacy and Safety of Intravitreal Aflibercept for Polypoidal Choroidal Vasculopathy: Two-Year Results of the Aflibercept in Polypoidal Choroidal Vasculopathy Study. Am J Ophthalmol 2019; 204:80-89. [PMID: 30849345 DOI: 10.1016/j.ajo.2019.02.027] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 01/03/2023]
Abstract
PURPOSE We sought to evaluate longer-term efficacy and safety of intravitreal aflibercept monotherapy (IAI) vs IAI plus rescue photodynamic therapy (rPDT) in patients with polypoidal choroidal vasculopathy (PCV). DESIGN This was a prospective multicenter, double-masked, sham-controlled randomized clinical study across 62 centers. METHODS In this phase 3b/4 study, patients with PCV with best-corrected visual acuity of 73-24 Early Treatment Diabetic Retinopathy Study letters (20/40-20/320 Snellen equivalent) received IAI 2 mg every 4 weeks until week 12, when they were randomized 1:1 to receive IAI or IAI plus rPDT if rescue criteria were met. Patients not requiring rescue received IAI every 8 weeks; those requiring rescue received IAI every 4 weeks plus sham/active PDT. At week 52 (the primary endpoint), IAI was noninferior to IAI plus rPDT. After week 52, treatment intervals could be extended beyond 8 weeks at the investigators' discretion. Noninferiority of IAI vs IAI plus rPDT for mean best-corrected visual acuity change from baseline to week 96 was evaluated. RESULTS Over 96 weeks, 54 patients (17.0%) met rescue criteria. At week 96, IAI was noninferior to IAI plus rPDT in terms of Early Treatment Diabetic Retinopathy Study letters gained (+10.7 vs +9.1, P = .48). Proportions of patients with complete polyp regression (33.1% vs 29.1%) or without active polyps (82.1% vs 85.6%) were similar. In year 2, the mean number of injections was 4.6 in both arms. No new safety signals were observed. CONCLUSION IAI monotherapy was noninferior to IAI with rescue PDT up to 96 weeks, and functional and anatomical improvements achieved at 52 weeks were maintained. Few patients required rescue PDT, which provided no additional visual benefit.
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Affiliation(s)
- Tien Yin Wong
- Singapore Eye Research Institute and Singapore National Eye Centre, Singapore; Duke-National University of Singapore Medical School, National University of Singapore, Singapore.
| | - Yuichiro Ogura
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Won Ki Lee
- Department of Ophthalmology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Tomohiro Iida
- Department of Ophthalmology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shih-Jen Chen
- Department of Ophthalmology, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University Taipei, Taiwan
| | - Paul Mitchell
- University of Sydney, Sydney, New South Wales, Australia (Westmead Institute for Medical Research)
| | - Chui Ming Gemmy Cheung
- Singapore Eye Research Institute and Singapore National Eye Centre, Singapore; Duke-National University of Singapore Medical School, National University of Singapore, Singapore
| | | | | | - Tatsuro Ishibashi
- Department of Ophthalmology, Kyushu University Hospital, Fukuoka, Japan
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INTRAVITREAL INJECTION OF AFLIBERCEPT IN PATIENTS WITH POLYPOIDAL CHOROIDAL VASCULOPATHY: A 3-YEAR FOLLOW-UP. Retina 2019; 38:2001-2009. [PMID: 28816730 DOI: 10.1097/iae.0000000000001818] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare the 3-year follow-up results of intravitreal injections of aflibercept between fixed dosing (FD) regimen and a pro re nata (PRN) regimen after three initial monthly doses for the treatment of polypoidal choroidal vasculopathy and to analyze factors influencing improvement in visual acuity. METHODS We retrospectively studied all treatment-naive patients with polypoidal choroidal vasculopathy who were scheduled to receive intravitreal aflibercept injections FD or PRN after induction treatment between March 2013 and May 2014. Best-corrected visual acuity was evaluated before treatment and at 4, 12, 24, and 36 months after initial treatment. Factors that influence improvement in visual acuity were also investigated. RESULTS Thirty-three eyes were assessed at the 3-year follow-up examination. Twenty-three eyes were treated with intravitreal aflibercept injections every 2 months for at least 1 year after three initial monthly doses (FD group), and 10 eyes were treated PRN after loading doses (PRN group). In the FD group, during the follow-up period from 1 to 3 years, quarterly dosing with capped PRN or a treat and extend regimen were selected. The mean number of administered intravitreal aflibercept was 15.3 ± 4.6 in the FD group and 9.0 ± 8.9 in the PRN group, with a significant difference between the two groups (P = 0.004). Significant improvement of the mean logarithm of the minimum angle of resolution values for best-corrected visual acuity was shown at 36 months, as compared to baseline values (P = 0.019). No significant difference in the improvement of best-corrected visual acuity between the two groups was observed at baseline or at 4, 12, 24, and 36 months after treatment (all P > 0.05), although there was a trend toward better results in the FD group. Multiple regression analysis showed that the FD group had better visual acuity at 36 months and greater improvement in visual acuity than the PRN group (P = 0.031 for both comparisons). CONCLUSION Intravitreal aflibercept was effective in improving the vision of patients with polypoidal choroidal vasculopathy, as evaluated at the 3-year follow-up. Fixed treatment might be an important factor influencing improvement in visual acuity.
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Kwon HJ, Lee JJ, Park SW, Byon IS, Lee JE. Enlargement of polypoidal choroidal vasculopathy lesion without exudative findings assessed in en face optical coherence tomography images. Graefes Arch Clin Exp Ophthalmol 2019; 257:1621-1629. [PMID: 31098753 DOI: 10.1007/s00417-019-04317-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/26/2019] [Accepted: 04/01/2019] [Indexed: 11/30/2022] Open
Abstract
PURPOSE This study aimed to investigate growth of polypoidal choroidal vasculopathy (PCV) without exudative findings assessed in en face optical coherence tomography (OCT) images and its clinical implications. METHODS Fifty patients who were diagnosed with PCV and had no disease activity after treatment with intravitreal anti-vascular endothelial growth factor (anti-VEGF) were included. Patients were followed up for at least 12 months. Measurement of best-corrected visual acuity and volume scan using swept-source OCT was performed at each visit. The neovascular area of PCV was assessed using en face OCT. Growth group comprised patients who showed increase in neovascular area in the en face images without exudative findings. The main outcome measure was relationship between growth of PCV and recurrence. RESULTS Among 50 eyes of 50 patients with average age of 68.5 ± 8.6 years, 25 (50%) eyes were included in the growth group. Exudative recurrence was noted more frequently in the growth group (18 eyes, 72%) than in the non-growth group (6 eyes, 24%, P = .002, odds ratio = 8.143). More injections were performed in the growth group (4.7 ± 2.1 vs. 1.9 ± 2.4, P = .002), but there was no difference in visual acuity at 1 year. After an exudative recurrence following the lesion growth, more frequent injections were required than before the recurrence to achieve no disease activity (P = .002). CONCLUSION PCV lesion growth without fluid preceded exudative recurrence and worsening of response to anti-VEGF treatment.
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Affiliation(s)
- Han Jo Kwon
- Department of Ophthalmology, College of Medicine, Pusan National University, Yangsan, South Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Jae Jung Lee
- Department of Ophthalmology, College of Medicine, Pusan National University, Yangsan, South Korea.,Medical Research Institute, Pusan National University Hospital, 179 Gudeok-ro Seo-gu, Busan, 49241, South Korea
| | - Sung Who Park
- Department of Ophthalmology, College of Medicine, Pusan National University, Yangsan, South Korea.,Medical Research Institute, Pusan National University Hospital, 179 Gudeok-ro Seo-gu, Busan, 49241, South Korea
| | - Ik Soo Byon
- Department of Ophthalmology, College of Medicine, Pusan National University, Yangsan, South Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Ji Eun Lee
- Department of Ophthalmology, College of Medicine, Pusan National University, Yangsan, South Korea. .,Medical Research Institute, Pusan National University Hospital, 179 Gudeok-ro Seo-gu, Busan, 49241, South Korea.
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Calvo-Gonzalez C, Reche-Frutos J, Fernández-Vigo JI, Donate-López J, Serrano-García I, Fernández-Pérez C. Indocyanine green angiography findings in patients with neovascular age-related macular degeneration refractory to ranibizumab switched to aflibercept. Int Ophthalmol 2019; 39:2441-2448. [PMID: 30767090 DOI: 10.1007/s10792-019-01082-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/28/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To describe indocyanine green angiography (ICGA) and visual acuity (VA) results in patients with neovascular age-related macular degeneration (nAMD) refractory to ranibizumab switched to aflibercept. METHODS This study is a prospective interventional case series. Thirty-two eyes of 32 patients with nAMD showing a poor response after at least 24 months of ranibizumab were switched to aflibercept. Twenty eyes had type I choroidal neovascularization (CNV group), and 12 eyes had polypoidal choroidal vasculopathy (PCV group). After an initial loading dose of three monthly aflibercept injections, treatment was continued on a treat-and-extend basis. ICGA was performed just before the first aflibercept injection (baseline) and 12 and 24 months later. The variables recorded were: closure of polyps and lesion area, VA, number of aflibercept injections, dry macula, and pigment epithelium detachment. RESULTS The following means were recorded in the CNV and PCV groups, respectively: number of ranibizumab injections 20.4 ± 11.2 and 22.4 ± 12.9 (p = 0.740); baseline VA (before aflibercept) 73.2 ± 9.1 and 70.3 ± 13.7 letters (p = 0.654); and final VA 73.0 ± 7.6 and 69.3 ± 15.6 letters (p = 0.509). VA remained stable (p = 0.761 and 0.964) after 15.5 ± 3 and 15.1 ± 3.5 aflibercept injections (p = 0.244). At 24 months, dry macula was noted in 40 to 50% of the eyes (p = 0.620). Complete resolution of polyps was observed in 58% at 12 months and 92% at 24 months. CONCLUSIONS In patients with nAMD refractory to ranibizumab, aflibercept was effective at maintaining VA and closing numerous polyps. In half of the patients, dry macula was observed at 24 months.
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Affiliation(s)
- Cristina Calvo-Gonzalez
- Department of Ophthalmology, Hospital Universitario Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), c/Profesor Martin Lagos, 28040, Madrid, Spain.
| | - Juan Reche-Frutos
- Department of Ophthalmology, Hospital Universitario Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), c/Profesor Martin Lagos, 28040, Madrid, Spain
| | - José Ignacio Fernández-Vigo
- Department of Ophthalmology, Hospital Universitario Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), c/Profesor Martin Lagos, 28040, Madrid, Spain
| | - Juan Donate-López
- Department of Ophthalmology, Hospital Universitario Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), c/Profesor Martin Lagos, 28040, Madrid, Spain
| | - Irene Serrano-García
- Department of Preventive Medicine, Hospital Universitario Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Cristina Fernández-Pérez
- Department of Preventive Medicine, Hospital Universitario Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
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25
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Abstract
Polypoidal choroidal vasculopathy (PCV) is a retinal disorder commonly found in Asians presenting as neovascular age-related macular degeneration and is characterized by serous macular detachment, serous or hemorrhagic pigment epithelial detachment, subretinal hemorrhage, and occasionally visible orange-red subretinal nodular lesions. PCV is diagnosed using indocyanine green angiography (ICGA), and the lesions appear as polypoidal aneurysmal vascular lesions with or without abnormal branching vascular network. Although ICGA remains the gold standard for the diagnosis of PCV, various imaging modalities have also facilitated the diagnosis and monitoring of PCV. Recent advances in imaging technology including the use of high resolution spectral domain optical coherence tomography (OCT) and OCT angiography have provided new insights on the pathogenesis of PCV, suggesting a link between PCV and pachychoroid spectrum of macular disorders. With the evolving understanding on the pathogenesis and clinical characteristics of PCV, different therapeutic options have been proposed. These include intravitreal anti-vascular endothelial growth factor (anti-VEGF) monotherapy, combination therapy with anti-VEGF and verteporfin photodynamic therapy, and thermal laser photocoagulation. In recent years, major multi-center randomized clinical trials such as EVEREST, EVEREST II, and PLANET studies have been conducted to compare the efficacy and safety of various treatment options for PCV. This review aims to summarize the results of recent literature, clinical trials and studies to provide an update on the management options of PCV. An overall management strategy for PCV will also be proposed.
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Affiliation(s)
- Christine P S Ho
- Faculty of Medicine, The University of Hong Kong; 2010 Retina and Macula Centre, Kowloon, Hong Kong SAR
| | - Timothy Y Y Lai
- Department of Ophthalmology and Visual Sciences, Hong Kong Eye Hospital, The Chinese University of Hong Kong; 2010 Retina and Macula Centre, Kowloon, Hong Kong SAR
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26
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Palkar AH, Khetan V. Polypoidal choroidal vasculopathy: An update on current management and review of literature. Taiwan J Ophthalmol 2019; 9:72-92. [PMID: 31198666 PMCID: PMC6557071 DOI: 10.4103/tjo.tjo_35_18] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular age-related macular degeneration (nAMD), commonly seen in the Asian population. It is dissimilar in epidemiology, genetic heterogeneity, pathogenesis, natural history, and response to treatment in comparison to nAMD. Confocal scanning laser ophthalmoscopy-based simultaneous fluorescein angiography and indocyanine green angiography, spectral-domain optical coherence tomography (OCT) with enhanced depth imaging, swept-source OCT, and OCT angiography have improved the ability to detect PCV, understand its pathology, and monitor treatment response. A plethora of literature has discussed the efficacy of photodynamic therapy, anti-vascular endothelial growth factor (VEGF) monotherapy, and combination of both, but only a few studies with higher level of evidence and limited follow-up duration are available. This review discusses the understanding of PCV with respect to epidemiology, pathogenesis, clinical features, natural history, imaging techniques, and various treatment options. Recent clinical trials (EVEREST-II and PLANET study) have emphasized that either anti-VEGF monotherapy or combination treatment is equally capable to strike a balance between polyp regression and stabilization of visual acuity. The recurrent nature of the disease, the development of macular atrophy, and the long-term poor visual prognosis despite treatment are concerns that open avenues for further research.
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Affiliation(s)
- Amit Harishchandra Palkar
- Department of Vitreoretinal Services, Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Vikas Khetan
- Department of Vitreoretinal Services, Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
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27
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Iesato Y, Tanaka M, Murata M, Kitahara J, Hirano T, Kurenuma T, Yoshida N, Murata T. Complete regression of branching vascular network in polypoidal choroidal vasculopathy by ranibizumab and photodynamic therapy, two case reports. BMC Ophthalmol 2018; 18:284. [PMID: 30390650 PMCID: PMC6215629 DOI: 10.1186/s12886-018-0952-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 10/23/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Polypoidal choroidal vasculopathy (PCV) consists of polyps that potentially cause massive subretinal hemorrhage and their branching vascular network (BVN) of feeder vessels. Although conventional indocyanine green angiography (IA) has shown anti-vascular endothelial growth factor (VEGF) agents and/or photodynamic therapy (PDT) to successfully induce polyp closure, the BVN appears resistant to these therapies and serves as the origin of recurrent active polyps. Recently introduced optical coherence tomography angiography (OCT-A) enables more frequent angiographic evaluation of polyps and the BVN than does conventional IA since it does not require intravenous fluorescent dye injection and is thus considered non-invasive. CASE PRESENTATION Case 1. A 70-year-old male with PCV in his left eye suffered from vision deterioration (20/40) due to persistent subretinal fluid despite 42 intravitreal injections of ranibizumab (IVRs) over 5 years and 7 months. PDT was performed as an adjunct therapy 3 days after the 43rd IVR. IA at 3 months after PDT showed successful polyp closure but persisting BVN. However, more frequent evaluation with OCT-A starting at 1 week after PDT demonstrated complete regression of both the BVN and polyp. OCT-A at every subsequent outpatient visit depicted gradual re-perfusion of the BVN and the restoration of most of its original network at 3 months, which was compatible with IA findings. Neither OCTA nor IA revealed polyp recurrence at 3 months. Case 2. A 65-year-old female suffering from left vision deterioration due to PCV underwent 5 intravitreal injections of aflibercept. Since her subretinal fluid persisted, the treatment was switched to a combination of IVR and PDT. OCT-A revealed marked regression of the BVN and polyp at 2 weeks, but the BVN had regained its original shape at 2 months without any sign of polyp recurrence. CONCLUSIONS Differently from previous observations obtained by IA alone, more frequent non-invasive OCT-A examination revealed complete but transient regression of the BVN just after combination therapy with IVR and PDT.
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Affiliation(s)
- Yasuhiro Iesato
- Department of Ophthalmology, School of Medicine, Shinshu University, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Masaaki Tanaka
- Department of Ophthalmology, School of Medicine, Shinshu University, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Masako Murata
- Department of Ophthalmology, Matsumoto Medical Center, Narional Hospital Organaization, 2-20-30 Murai-Minami, Matsumoto, Nagano, 390-8621, Japan
| | - Junya Kitahara
- Department of Ophthalmology, School of Medicine, Shinshu University, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Takao Hirano
- Department of Ophthalmology, School of Medicine, Shinshu University, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Taihei Kurenuma
- Department of Ophthalmology, School of Medicine, Shinshu University, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Noriko Yoshida
- Department of Ophthalmology, School of Medicine, Shinshu University, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Toshinori Murata
- Department of Ophthalmology, School of Medicine, Shinshu University, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
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Tick S, Cornut PL, De Bats F, Wolf B, Souied EH, Cohen SY. [Update from France Macula Federation: Treatment of Wet AMD]. J Fr Ophtalmol 2018; 41:862-867. [PMID: 30361178 DOI: 10.1016/j.jfo.2018.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 06/26/2018] [Accepted: 06/27/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE To update the recommendations of the France Macula Federation for treatment of wet age-related macular degeneration (AMD). METHODS Analysis of literature and expert opinion. RESULTS The FFM recommends initiating anti-VEGF therapy as soon as possible after diagnosis of exudative AMD. There has been no major change in the last several years concerning the procedure of intravitreal injection itself. However, the litigious points are discussed: simultaneous bilateral injection; antibiotic therapy; medico-legal aspects. All anti-VEGF strategies possess advantages and limitations. The strategy should be left to the ophthalmologists' preference. However, the chosen strategy should be explained to patients and strictly followed. CONCLUSION The treatment of wet-AMD is more precisely codified than before. However, various strategies still coexist.
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Affiliation(s)
- S Tick
- Centre hospitalier national d'ophtalmologie des XV-XX, 28, rue de Charenton, 75012 Paris, France; Centre ophtalmologique Vincennes, 17, bis rue des Meuniers, 94300 Vincennes, France
| | - P-L Cornut
- Centre pôle vision, clinique du Val d'Ouest, Croix rousse, 39, chemin de la Vernique, 69130 Écully, France
| | - F De Bats
- Centre pôle vision, clinique du Val d'Ouest, Croix rousse, 39, chemin de la Vernique, 69130 Écully, France; Hôpital de la Croix-Rousse, 103 grande rue de la Croix-Rousse, 69004 Lyon, France
| | - B Wolf
- Centre ophtalmologique de la maison rouge, 6, rue de l'Église, 67000 Strasbourg, France
| | - E H Souied
- Service d'ophtalmologie et université Paris Est, 61, avenue du Général de Gaulle, 94000 Créteil, France
| | - S Y Cohen
- Service d'ophtalmologie et université Paris Est, 61, avenue du Général de Gaulle, 94000 Créteil, France; Centre ophthalmologique d'imagerie et de laser, 11, rue Antoine Bourdelle, 75015 Paris, France.
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29
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Teo KYC, Gillies M, Fraser-Bell S. The Use of Vascular Endothelial Growth Factor Inhibitors and Complementary Treatment Options in Polypoidal Choroidal Vasculopathy: A Subtype of Neovascular Age-Related Macular Degeneration. Int J Mol Sci 2018; 19:ijms19092611. [PMID: 30177632 PMCID: PMC6165414 DOI: 10.3390/ijms19092611] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/17/2018] [Accepted: 08/27/2018] [Indexed: 02/04/2023] Open
Abstract
Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular age-related macular degeneration (AMD; nAMD) which occurs more commonly in Asian populations as compared to Caucasians. PCV and nAMD share pathological mechanisms, including pathological expression of vascular endothelial growth factor (VEGF). The advent of anti-vascular endothelial growth factor (VEGF) revolutionized the treatment of nAMD. Despite being a subtype of nAMD, PCV responds less well to VEGF inhibitors; thus, photodynamic therapy (PDT) in combination with anti-VEGF treatment may be considered. This review aims to summarize the current evidence for the treatment of PCV, especially whether VEGF inhibitors should be used alone or in combination with PDT.
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Affiliation(s)
- Kelvin Yi Chong Teo
- Singapore National Eye Centre, Singapore 168751, Singapore.
- Singapore Eye Research Institute, Singapore 169856, Singapore.
- Sydney Eye Hospital Foundation, Sydney Eye Hospital, Sydney 2000, Australia.
| | - Mark Gillies
- The Save Sight Institute, Sydney Medical School, University of Sydney, Sydney 2000, Australia.
| | - Samantha Fraser-Bell
- The Save Sight Institute, Sydney Medical School, University of Sydney, Sydney 2000, Australia.
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30
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Wolff B, Vasseur V, Cahuzac A, Coscas F, Castelnovo L, Favard C, Michel G, Français C, Salomon L, Mauget-Faÿsse M. Aflibercept Treatment in Polypoidal Choroidal Vasculopathy: Results of a Prospective Study in a Caucasian Population. Ophthalmologica 2018; 240:208-212. [PMID: 29804123 DOI: 10.1159/000488808] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 03/26/2018] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Polypoidal choroidal vasculopathy (PCV) is a choroidal pathology characterized by frequent occurrences of subretinal hemorrhages and resistance to monotherapies such as ranibizumab or bevacizumab intravitreal injections (IVT). The purpose of this study is to evaluate both the anatomical and functional efficacy of aflibercept IVT as a monotherapy in PCV in a Caucasian population. METHODS We conducted a prospective multicenter study in either treatment-naïve patients with PCV or PVC patients who had not been treated with anti-VEGF within the previous 3 months or with photodynamic therapy (PDT) within the previous 6 months. All patients had been treated with 3 initial monthly loading doses of aflibercept followed by a Q8 regimen for 28 weeks in total. All patients underwent a complete ophthalmic examination including the measurement of best-corrected visual acuity (BCVA) before each IVT and after 28 weeks as well as an optical coherent tomography (OCT) of the macula. At baseline and 28 weeks, the polypoidal dilations were analyzed with indocyanine green angiography. RESULTS Thirty-four eyes of 34 patients were included in this study. All patients were followed for 28 weeks and received 5 aflibercept IVT. The mean baseline BCVA was 55 letters. After 28 weeks, significant +13 letters in BCVA and a regression of exudative signs on OCT in all patients were observed. In 62% of the cases, polyp disappearance was observed on indocyanine green angiography. DISCUSSION In this study on a Caucasian population, we showed that aflibercept as a monotherapy provided both a significant visual gain and the regression of polypoidal dilations. Aflibercept use in monotherapy may contribute to reduce the hemorrhagic risk and atrophy linked to PDT.
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Affiliation(s)
| | - Vivien Vasseur
- Adolphe de Rothschild Foundation, CIC Department, Paris, France
| | - Armelle Cahuzac
- Adolphe de Rothschild Foundation, CIC Department, Paris, France
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31
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Medina-Baena M, Huertos-Carrillo MJ, Rodríguez L, García-Pulido JI, Cornejo-Castillo C, Calandria-Amiguetti JM. One-Year Outcome of Aflibercept and Photodynamic Therapy in a Caucasian Patient with Polypoidal Choroidal Vasculopathy Refractory to Ranibizumab and Photodynamic Therapy. Case Rep Ophthalmol 2018; 9:172-178. [PMID: 29681832 PMCID: PMC5903101 DOI: 10.1159/000487227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 01/25/2018] [Indexed: 11/19/2022] Open
Abstract
Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular age-related macular degeneration characterised by an abnormal branching vascular network with aneurysmal polypoidal choroidal vascular lesions. PCV is more prevalent in Asian populations than in Caucasians, which may explain its underdiagnosis in Western countries. Evidence regarding the efficacy of different anti-vascular endothelial growth factor (anti-VEGF) agents on PCV is scarce, with most of these studies being conducted in Asian treatment-naïve patients. Ranibizumab was the first anti-VEGF agent to demonstrate the superiority of a combination of photodynamic therapy (PDT) and anti-VEGF over PDT or anti-VEGF monotherapy for inducing polyp regression in Asian patients with PCV. The efficacy of other anti-VEGF agents has been less studied. Resistance to ranibizumab has been described. Aflibercept offers another mechanism of targeting choroidal neovascular lesions. A 75-year-old Caucasian woman presenting to our office was diagnosed with PCV using indocyanine green angiography. Combination therapy with a loading dose of 0.5 mg intravitreal ranibizumab followed by PDT at standard fluence at month 4 and a fourth dose of ranibizumab at month 5 yielded no visual or anatomic outcomes. Treatment was switched to intravitreal aflibercept at month 6 (3 monthly loading doses of 2.0 mg) followed by half-fluence PDT (month 9). Optical coherence tomography revealed remission of the anatomic lesions. Right-eye visual acuity increased to 0.6. Aflibercept injections were administered bimonthly afterwards. Follow-up during 1 year has shown functional and anatomic stability.
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Affiliation(s)
- Marta Medina-Baena
- Unidad de Retina y Vítreo, Hospital Universitario Puerto Real, Cádiz, Spain
| | | | - Laura Rodríguez
- Unidad de Retina y Vítreo, Hospital Universitario Puerta del Mar, Cádiz, Spain
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Peng Y, Zhang X, Li M, Liu B, Mi L, Zuo C, Wen F. Short-term efficacy of intravitreal conbercept in treatment-naive patients with polypoidal choroidal vasculopathy. DRUG DESIGN DEVELOPMENT AND THERAPY 2018; 12:339-345. [PMID: 29497280 PMCID: PMC5823069 DOI: 10.2147/dddt.s158368] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Introduction To evaluate the functional and morphological outcomes of intravitreal conbercept monotherapy in patients with polypoidal choroidal vasculopathy (PCV). Materials and methods In this retrospective, observational case series study, we reviewed medical records of 48 eyes (48 patients) with naive PCV that were treated with a series of 3 monthly intravitreal injections of 0.5 mg of conbercept followed by as-needed injections (3+pro re nata). All patients completed at least 6 months of monthly follow-up. Changes in the best-corrected visual acuity, optical coherence tomography, and indocyanine green angiography were retrospectively evaluated. Results At 6 months, the mean best-corrected visual acuity significantly improved from 0.89±0.35 (20/160 in Snellen equivalent) at baseline to 0.58±0.26 (Snellen equivalent of 20/80; P<0.001), and 60.42% (29/48) of eyes had an improvement of three lines of vision; the mean central retinal thickness significantly decreased from 333.56±171.04 μm at baseline to 187.65±54.46 μm (P<0.001), and 93.75% (45/48) achieved a dry macula. At 3 months, 6 of 32 eyes (18.75%) showed partial regression of branching vascular network, 14 of 32 (43.75%) patients showed complete resolution of polyps. The mean number of injections was 3.4±0.9 through 6 months. No conbercept-related systemic or ocular adverse effects were observed. Conclusion Intravitreal injection of conbercept using "3+pro re nata" regimen significantly improved visual acuity and anatomical outcomes in treatment-naive patients with PCV.
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Affiliation(s)
- Yuting Peng
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Xiongze Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Miaoling Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Bing Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Lan Mi
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Chengguo Zuo
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Feng Wen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
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33
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Gharehbagh SS, Subhi Y, Sørensen TL. Efficacy of aflibercept for polypoidal choroidal vasculopathy in Caucasians. Acta Ophthalmol 2018. [PMID: 28636275 DOI: 10.1111/aos.13461] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Sanaz Shoja Gharehbagh
- Clinical Eye Research Division; Department of Ophthalmology; Zealand University Hospital; Roskilde Denmark
| | - Yousif Subhi
- Clinical Eye Research Division; Department of Ophthalmology; Zealand University Hospital; Roskilde Denmark
- Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
| | - Torben Lykke Sørensen
- Clinical Eye Research Division; Department of Ophthalmology; Zealand University Hospital; Roskilde Denmark
- Faculty of Health and Medical Sciences; University of Copenhagen; Copenhagen Denmark
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Qian T, Li X, Zhao M, Xu X. Polypoidal choroidal vasculopathy treatment options: A meta-analysis. Eur J Clin Invest 2018; 48:e12840. [PMID: 28981139 PMCID: PMC5771464 DOI: 10.1111/eci.12840] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 10/01/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Combined treatment with intravitreal anti-vascular endothelial growth factor (anti-VEGF) and verteporfin photodynamic therapy (PDT) is widely used for patients with polypoidal choroidal vasculopathy (PCV), although clinical evidence regarding the therapeutic efficacy and safety of such treatment remains lacking. DESIGN/METHODS We performed a meta-analysis of previously reported studies comparing combination treatment, PDT monotherapy, and anti-VEGF monotherapy. Primary outcome measures included changes in best-corrected visual acuity (BCVA) and central retinal thickness (CRT). The proportion of patients with polyp regression was regarded as the secondary outcome measure. RESULTS Twenty studies (three RCTs and 19 retrospective studies) involving 1,178 patients with PCV were selected. Significant differences in the proportion of patients with polyps were observed between the PDT and anti-VEGF monotherapy groups at 3 and ≥6 months (P < .00001; and P = .0001, respectively). Significantly greater reductions in CRT were observed in the anti-VEGF than in the PDT group at the 3-month follow-up (P = .04). Significantly greater improvements in BCVA were observed in the combined therapy group than in the PDT monotherapy group at 3, 6, 12, and 24 months (P = .03; P = .005; P = .02; and P < .00001, respectively). Combined treatment also resulted in significantly greater improvements in BCVA than monotherapy with anti-VEGF at 6 and 24 months (P = .001; P < .00001, respectively), and significantly greater polyp regression than that observed following anti-VEGF treatment at 3 and ≥6 months (P < .00001; P < .0001, respectively). CONCLUSIONS Combined therapy involving anti-VEGF agents and PDT may be more effective in improving long-term outcomes for patients with PCV than monotherapy.
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Affiliation(s)
- Tianwei Qian
- Department of Ophthalmology, Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai General Hospital, Shanghai, China
| | - Xinxin Li
- Department of Ophthalmology, Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai General Hospital, Shanghai, China
| | - Mengya Zhao
- Department of Ophthalmology, Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai General Hospital, Shanghai, China
| | - Xun Xu
- Department of Ophthalmology, Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai General Hospital, Shanghai, China
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35
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Tan CS, Hariprasad SM, Lim LW. New Paradigms in Polypoidal Choroidal Vasculopathy Management: The Impact of Recent Multicenter, Randomized Clinical Trials. Ophthalmic Surg Lasers Imaging Retina 2018; 49:4-10. [PMID: 29304260 DOI: 10.3928/23258160-20171215-01] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Kumar S, Nakashizuka H, Jones A, Lambert A, Zhao X, Shen M, Parker M, Wang S, Berriochoa Z, Fnu A, VanBeuge S, Chévez-Barrios P, Tso M, Rainier J, Fu Y. Proteolytic Degradation and Inflammation Play Critical Roles in Polypoidal Choroidal Vasculopathy. THE AMERICAN JOURNAL OF PATHOLOGY 2017; 187:2841-2857. [PMID: 28941979 PMCID: PMC5718105 DOI: 10.1016/j.ajpath.2017.08.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/31/2017] [Accepted: 08/17/2017] [Indexed: 01/28/2023]
Abstract
Polypoidal choroidal vasculopathy (PCV) is a common subtype of wet age-related macular degeneration in Asian populations, whereas choroidal neovascularization is the typical subtype in Western populations. The cause of PCV is unknown. By comparing the phenotype of a PCV mouse model expressing protease high temperature requirement factor A1 (HTRA1) in retinal pigment epithelium with transgenic mice expressing the inactive HTRA1S328A, we showed that HTRA1-mediated degradation of elastin in choroidal vessels is critical for the development of PCV, which exhibited destructive extracellular matrix remodeling and vascular smooth muscle cell loss. Compared with weak PCV, severe PCV exhibited prominent immune complex deposition, complement activation, and infiltration of inflammatory cells, suggesting inflammation plays a key role in PCV progression. More important, we validated these findings in human PCV specimens. Intravitreal delivery of an HTRA1 inhibitor (DPMFKLboroV) was effective (36% lesion reduction; P = 0.009) in preventing PCV initiation but ineffective in treating existing lesions. Anti-inflammatory glucocorticoid was effective in preventing PCV progression but ineffective in preventing PCV initiation. These results suggest that PCV pathogenesis occurs through two stages. The initiation stage is mediated by proteolytic degradation of extracellular matrix proteins attributable to increased HTRA1 activity, whereas the progression stage is driven by inflammatory cascades. This study provides a basis for understanding the differences between PCV and choroidal neovascularization, and helps guide the design of effective therapies for PCV.
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Affiliation(s)
- Sandeep Kumar
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas
| | - Hiroyuki Nakashizuka
- Department of Visual Sciences, Nihon University School of Medicine, Tokyo, Japan
| | - Alex Jones
- Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, Utah
| | - Alyssia Lambert
- Department of Chemistry, University of Utah, Salt Lake City, Utah
| | - Xuchen Zhao
- Department of Chemistry, University of Utah, Salt Lake City, Utah
| | - Megan Shen
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas
| | - Mackenzie Parker
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas
| | - Shixian Wang
- Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, Utah
| | - Zachary Berriochoa
- Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, Utah
| | - Amrita Fnu
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas
| | - Stephanie VanBeuge
- Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, Utah
| | | | - Mark Tso
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jon Rainier
- Department of Chemistry, University of Utah, Salt Lake City, Utah
| | - Yingbin Fu
- Department of Ophthalmology, Baylor College of Medicine, Houston, Texas; Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, Utah.
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Muftuoglu IK, Tsai FF, Gaber R, Alam M, Meshi A, Freeman WR. High-frequency aflibercept injections in persistent neovascular age-related macular degeneration. Graefes Arch Clin Exp Ophthalmol 2016; 255:709-717. [PMID: 27878592 DOI: 10.1007/s00417-016-3547-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/25/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To report the 1-year outcomes of every-4-weeks (Q4W) as-needed aflibercept treatment in resistant neovascular age-related macular degeneration (nAMD) patients who had been treated and failed prior bevacizumab or ranibizumab injections, and who also responded poorly to every-8-weeks (Q8W) aflibercept treatment. METHODS Forty-three eyes of 39 patients with persistent nAMD despite monthly bevacizumab and/or ranibizumab injections and who were switched to Q8W 2-mg aflibercept injections, but showed persistence of fluid were included. Patients were treated with as-needed Q4W aflibercept injections with monthly monitoring. Maximum retinal thickness (MRT), central macular thickness (CMT), maximum pigment epithelial detachment height (PED) and best-corrected visual acuity (BCVA) were assessed and compared to baseline when high-frequency aflibercept was initiated. RESULTS A mean of 8 (interquartile range, 4-11) Q4W injections were given during the follow-up. MRT and CMT significantly decreased at all follow-up visits (p < 0.05); however, there was no significant change in maximum PED height (p > 0.05) at any visit. Mean BCVA was 0.38 ± 0.28 (logMAR) (≈20/63, Snellen) at baseline, and 0.4 ± 0.34 (logMAR) (≈20/76, Snellen) at 1 year (p = 0.76). Seventy-two percent of eyes maintained a final BCVA of 20/63 or better. Twelve eyes (28 %) had some subretinal scar tissue formation and 5 eyes (11.6 %) had evidence of atrophy at 1 year. CONCLUSION A stepwise algorithm with Q4W as-needed aflibercept treatment led to anatomic improvement in previously treated eyes which failed other therapies, including aflibercept every 8 weeks. Lack of visual improvement may be due to a ceiling effect as our eyes generally had good visual acuity.
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Affiliation(s)
- Ilkay Kilic Muftuoglu
- Department of Ophthalmology, Jacobs Retina Center at the Shiley Eye Institute, University of California San Diego, La Jolla, CA, USA.,Department of Ophthalmology, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Frank F Tsai
- Department of Ophthalmology, Jacobs Retina Center at the Shiley Eye Institute, University of California San Diego, La Jolla, CA, USA.,Sharp Rees-Stealy Medical Group Division of Ophthalmology, San Diego, CA, USA
| | - Raouf Gaber
- Department of Ophthalmology, Jacobs Retina Center at the Shiley Eye Institute, University of California San Diego, La Jolla, CA, USA
| | - Mostafa Alam
- Department of Ophthalmology, Jacobs Retina Center at the Shiley Eye Institute, University of California San Diego, La Jolla, CA, USA
| | - Amit Meshi
- Department of Ophthalmology, Jacobs Retina Center at the Shiley Eye Institute, University of California San Diego, La Jolla, CA, USA
| | - William R Freeman
- Department of Ophthalmology, Jacobs Retina Center at the Shiley Eye Institute, University of California San Diego, La Jolla, CA, USA. .,Jacobs Retina Center at the Shiley Eye Institute, University of California San Diego, 94093 Campus Point Drive, La Jolla, CA, 92037, USA.
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