Subfoveal choroidal thickness in polypoidal choroidal vasculopathy after switching to intravitreal aflibercept injection

Updated guidelines for the management of polypoidal choroidal vasculopathy: Recommendations from the Indian Polypoidal Choroidal Vasculopathy Panel and the Vitreoretinal Society of India

In Asians, polypoidal choroidal vasculopathy (PCV) is becoming more widely recognized as a significant cause of exudative maculopathy. The previous set of Indian guidelines on the management of PCV were published in 2018, with a literature search updated up to November 2015. As the treatment of PCV evolves, retinal physicians must constantly modify their current practice. The current guidelines are based on the most up-to-date information on PCV and are an update to the previous set of guidelines. These guidelines were developed by a panel of Indian retinal experts under the aegis of the Vitreoretinal Society of India (VRSI), based on a comprehensive search and assessment of literature up to September 2021. The final guidelines i) provide the updated nomenclature in PCV; ii) discusses the newer diagnostic imaging features of PCV, especially in the absence of indocyanine green angiography (ICGA); and iii) recommends the best possible therapeutic approach in the management of PCV, including the choice of anti-vascular endothelial growth factor (anti-VEGF) agents, treatment regimen, and the role of switching between the anti-VEGF agents. In the face of non-availability of photodynamic therapy (PDT) in India, we constructed practical recommendations on anti-VEGF monotherapy in PCV. The current updated recommendations would provide a broader framework to the treating retinal physician for the diagnosis and management of PCV for optimal therapeutic outcomes.

Subfoveal choroidal thickness after brolucizumab therapy for neovascular age-related macular degeneration: a short-term multicenter study

BACKGROUND/PURPOSE

Observation of choroidal thickness after anti-vascular endothelial growth factor (VEGF) therapy may be important for the ideal management of neovascular age-related macular degeneration (AMD). This study investigated changes in subfoveal choroidal thickness (SCT) during loading doses of intravitreal injections of brolucizumab in eyes with neovascular AMD.

METHODS

This study included 73 eyes of 72 patients with neovascular AMD at five university hospitals in Japan. All 73 eyes underwent three monthly 6.0 mg intravitreal injections of brolucizumab at baseline, 1 month, and 2 months. The SCT at 3 months was evaluated using optical coherence tomography.

RESULTS

The 73 eyes were classified into the treatment-naïve group (43 eyes) and the switched group (30 eyes) that were switched from other anti-VEGF treatments. After three intravitreal injections of brolucizumab, SCT significantly decreased from 236.5 ± 98.8 µm at baseline to 200.4 ± 98.3 µm at 3 months (percent of baseline 84.7%, P < 0.001) in the treatment-naïve group. In the switched group, SCT also significantly decreased from 229.0 ± 113.2 μm at baseline to 216.9 ± 110.2 μm at 3 months (percent of baseline 94.7%, P = 0.039), although the decrease was not as marked compared to that of the treatment-naïve group.

CONCLUSION

Intravitreal injections of brolucizumab for neovascular AMD significantly reduced the SCT in both the treatment-naïve and switched groups. Brolucizumab may cause significant anatomic changes in the choroid, particularly in treatment-naïve AMD eyes, possibly more than that previously reported for other anti-VEGF agents.

Pachychoroid spectrum disease

Recent improvements in ophthalmic imaging have led to the identification of a thickened choroid or pachychoroid to be associated with a number of retinal diseases. The number of conditions linked to this phenotype has continued to widen with specific endophenotypes found within the pachychoroid spectrum. The spectrum includes choroidal features such as focal or diffuse choroidal thickening and thinning of the overlying inner choroid, and choroidal hyperpermeability as demonstrated by indocyanine green angiography. In addition, these diseases are associated with overlying retinal pigmentary changes and retinal pigment epithelial dysfunction and may also be associated with choroidal neovascularization. This article provides a comprehensive review of the literature looking at diseases currently described within the pachychoroid spectrum including central serous chorioretinopathy, pachychoroid pigment epitheliopathy, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy/aneurysmal type 1 neovascularization, peripapillary pachychoroid disease and focal choroidal excavation. We particularly focus on clinical imaging, genetics and pathological findings in these conditions with the aim of updating evidence suggesting a common aetiology between diseases within the pachychoroid spectrum.

Current diagnosis and management strategies in pachychoroid spectrum of diseases (Review)

This review presents a systematic analysis of the literature regarding the pachychoroid disease spectrum nomenclature, diagnosis criteria and therapeutic options. Pachychoroid related diseases are a new concept, introduced into the ophthalmological nomenclature in 2013 and evolving both as concept and as classification since then. The six disorders included in this phenotype have some common characteristics (thick choroid, pachyvessels, attenuation of the choriocapillaris), but also show individual features. The classification of the pachychoroid spectrum was revised many times, with the recent addition of the focal choroidal excavation (FCE) and peripapillary pachychoroid syndrome (PPS). As the terminology is developing, so is the number of case reports and case series from the initial report in 2013 to 57 reports in 2019. This review takes into account both the current literature and the clinical experience of the authors, emphasizing the understanding of the pathogenesis and aiming to update the therapeutic options available.

Long-term switching between ranibizumab and aflibercept in neovascular age-related macular degeneration and polypoidal choroidal vasculopathy

PURPOSE

To investigate the rate and timing of switching between ranibizumab and aflibercept and to evaluate the difference in the switching rates among the different subtypes of neovascularization.

METHODS

This retrospective study included 386 patients (386 eyes) who had been diagnosed with neovascular age-related macular degeneration (AMD) or polypoidal choroidal vasculopathy (PCV) and treated with ranibizumab (ranibizumab group, n = 260) or aflibercept (aflibercept group, n = 126). The rate and timing of switching from ranibizumab to aflibercept or vice versa were evaluated. Within the ranibizumab and the aflibercept groups, the switching rates were compared among the 3 subtypes of neovascularization: PCV, type 1 or 2 neovascularization, and type 3 neovascularization.

RESULTS

During the mean 44.9 ± 15.9 months of follow-up period, switching rate was significantly higher in the ranibizumab group (28.8%, 75 patients) than in the aflibercept group (9.5%, 12 patients) (P < 0.001). No difference was observed in the mean duration between the diagnosis and switching among the ranibizumab (18.7 ± 14.6 months) and the aflibercept groups (14.8 ± 14.5 months) (P = 0.379). In the ranibizumab group, the switching rate was markedly higher in PCV (39.6%) than in type 1 or 2 neovascularization (17.6%) or in type 3 neovascularization (13.3%) (P < 0.001). In the aflibercept group, there was no significant difference in the switching rates among the subtypes of neovascularization (P = 0.811).

CONCLUSIONS

Although the timings of switching were similar, switching rate was higher in patients undergoing ranibizumab therapy than in those undergoing aflibercept therapy. The switching rate was especially higher in PCV patients undergoing ranibizumab therapy.

Long-Term Incidence and Growth of Chorioretinal Atrophy in Patients with Polypoidal Choroidal Vasculopathy

PURPOSE

To investigate the long-term incidence and growth rate of chorioretinal atrophy (CRA) in patients with polypoidal choroidal vasculopathy (PCV) and determine the associated risk factors.

METHODS

The medical records of 88 patients with unilateral symptomatic PCV who received anti-vascular endothelial growth factor (anti-VEGF) injections with or without photodynamic therapy (PDT) were analyzed retrospectively. Near-infrared fundus imaging and spectral domain optical coherence tomography were used to measure the CRA area and growth rate. Kaplan-Meier survival analysis was performed to estimate the CRA incidence. Logistic and linear regression analyses were used to investigate risk factors (e.g., age, frequency of abnormal OCT findings, PDT history, total injection number, and choroidal thickness) associated with the CRA incidence and growth rate, respectively.

RESULTS

The overall CRA incidence was 40.8% at 5 years. The absence of subretinal fluid, the presence of intraretinal fluid, and a thin choroid were significant risk factors for CRA occurrence with a history of PDT. Overall 5-year CRA growth rate was 0.69 mm2/year. Faster CRA growth was significantly related to the presence of subretinal hyperreflective material and thin choroid. PDT history was not significantly related to CRA growth.

CONCLUSIONS

Thin choroid may be a significant risk factor for long-term development and growth of CRA in eyes with PCV. Intraretinal fluid seems to promote the development of CRA, while subretinal fluid seems to be associated with CRA prevention. The history of PDT was significantly related to the occurrence of CRA, but not to the growth rate of CRA.

Running pattern of choroidal vessel in en face OCT images determined by machine learning-based quantitative method

PURPOSE

To evaluate the new method to quantitate the running pattern of the vessels in Haller's layer in en face optical coherence tomographic (OCT) images using the new algorithm.

METHODS

A retrospective and cross-sectional study. The en face image of top 25% slab of Haller's layer was analyzed. The vascular area in these images was calculated after binarization. Then, the vessels were thinned, and the total length of the vessels and the mean vessel diameter were calculated. Based on the angle of vessel running, "natural oblique vessel" was defined. The ratio of the natural oblique vessel to the whole vessels was defined as the "symmetry index". To examine the reproducibility of the software, the images obtained on two different examination dates of the same subject (25 eyes of 25 healthy subjects) were analyzed. Also, to compare the symmetry index and subjective evaluations, 180 eyes and 180 healthy subjects were analyzed. The subjective evaluations classified the images into 3 groups, the Symmetrical, Semi-symmetrical, and Asymmetrical types. Symmetry index was compared in each group.

RESULTS

The inter-measurement correlation coefficient (ICC) of the vessel area, vessel length, and vessel diameter were 0.955, 0.934, and 0.954, respectively. The ICC of the symmetry index was 0.926. The symmetry index of the Symmetrical type was 60.4 ± 7.2%, that of the Semi-symmetry type was 56.2 ± 4.6%, and that of the Asymmetry type was 52.6 ± 5.2%.

CONCLUSIONS

The present algorithm can analyze vessels in Haller's layer of the en face images of choroid in an objective manner with good repeatability.

Polypoidal choroidal vasculopathy: An update on current management and review of literature

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.

Kago-Eye2 software for semi-automated segmentation of subfoveal choroid of optical coherence tomographic images

PURPOSE

To determine the capabilities of the "Kago-Eye2" software to semi-automatically segment the choroid in the optical coherence tomographic (OCT) images.

STUDY DESIGN

A cross-sectional, prospective study of 44 healthy volunteers.

METHODS

The Kago-eye2 software was developed to detect the border between Choriocapillaris and Sattler's layer (C-S) and between Sattler's layer and Haller's layer (S-H). The intra- and inter-grader agreements were determined for the segmentations made with semi-automated and manual analysis using the Kago-Eye2 software. The inter-method agreements were determined for two independent graders.

RESULTS

Forty-four right eyes of 44 heathy volunteers (22 men) with a mean age of 35.0 ± 8.8 years were studied. The intra-grader agreement of the C-S border was 0.97 for grader 1 and 0.892 for grader 2 for the manual segmentation, and 0.908 for grader 1 and 0.842 for grader 2 for the Kago-Eye2 segmentation. For the S-H border, the intra-grader agreement was 0.96 for grader 1 and 0.981 for grader 2 for manual segmentation and 0.855 for grader 1 and 0.839 for grader 2 with the Kago-Eye2. For the C-S and S-H border, the inter-grader agreement was 0.548 and 0.902 for manual segmentation and 0.947 and 0.833 for the Kago-Eye2. The inter-method agreement was 0.565 for the C-S border and 0.759 for the S-H border.

CONCLUSION

The Kago-Eye2 software can segment the layers of the subfoveal choroid with good reproducibility and repeatability. We conclude that the Kago-Eye2 software can be used for semi-automatic segmentation of the choroidal layers.

Two-year outcome of treat-and-extend aflibercept after ranibizumab in age-related macular degeneration and polypoidal choroidal vasculopathy patients

Background

The purpose of the study was to evaluate the 2-year outcome and predictive factors of treat-and-extend aflibercept in patients with eyes affected by typical neovascular age-related macula degenelation (t-AMD) or polypoidal choroidal vasculopathy (PCV), who were switched from ranibizumab.

Patients and methods

The patients underwent three monthly aflibercept injections and subsequent administration following the treat-and-extend protocol. Sixty-two eyes of 62 patients were reviewed retrospectively. R statistical software was used for statistical analysis.

Results

Twenty-two eyes were t-AMD and the remaining 40 eyes were PCV. There was no significant difference in the logarithm of the minimal angle of resolution visual acuity (VA) between baseline and 2 years after switching to aflibercept (0.40 vs 0.40; P=0.99). Multivariate analyses suggested that the following factors were significantly correlated with better VA at 2 years after switching to aflibercept: patients with PCV, the absence of intraretinal fluid at baseline, and better VA at baseline.

Conclusion

In conclusion, VA was maintained and there was an anatomical improvement at 2 years in patients with t-AMD and PCV who were switched from ranibizumab to treat-and-extend aflibercept. PCV patients showed more favorable visual outcomes and less injections at 2 years compared to t-AMD patients. Intraretinal fluid and VA at baseline were predictors of VA at 2 years.

Choroidal structure as a biomarker for visual acuity in intravitreal aflibercept therapy for polypoidal choroidal vasculopathy

PURPOSE

To investigate the relationship between choroidal structure and visual acuity after intravitreal aflibercept therapy for polypoidal choroidal vasculopathy (PCV).

METHODS

We conducted a retrospective, single-centre and observational study including 18 eyes of 18 patients with PCV (73.8 ± 10.2 years of age) who were treated with three monthly intravitreal aflibercept injections followed by additional treatments in a treat-and-extend protocol. The cross-sectional images of the macula were obtained with enhanced depth imaging optical coherence tomography at baseline, at 3 months, and at 12 months. The choroidal layer was divided into luminal or stromal segments by applying binarization processing to calculate these areas. The relationships between age, spherical equivalent, best-corrected visual acuity (BCVA), baseline value, or changes in the luminal or the stromal areas, and the BCVA change at 12 months were analysed using multiple regression analyses and model selection procedures.

RESULTS

Both stromal and luminal areas were decreased at 3 and 12 months compared to baseline areas (5% and 9% at 3 months, 6% and 12% at 12 months, p < 0.0001, p < 0.0001, p < 0.0001 and p < 0.0001, respectively). Greater improvement of visual acuity (VA) at 12 months was significantly associated with younger age, greater spherical equivalent, worse baseline BCVA, greater baseline luminal area, and smaller baseline stromal area.

CONCLUSIONS

Choroidal structure might be useful as a new biomarker for potential Visual outcomes after intravitreal aflibercept therapy for PCV.

Switching between ranibizumab and aflibercept for the treatment of neovascular age-related macular degeneration

The introduction of antivascular endothelial growth factor agents such as ranibizumab and aflibercept has revolutionized the management of neovascular age-related macular degeneration. A number of randomized clinical trials have shown that ranibizumab and aflibercept produce similar efficacy and safety outcomes. Most of the switching studies published to date show that efficacy benefits are uncontrolled, retrospective trials with limitations in terms of their selection, monitoring, numbers, and assessment criteria. Based on the published literature to date, we propose arguments for and against switching antivascular endothelial growth factor agents, provide our own perspective on this topic, and suggest a focus for future research.

Semi-automated software to measure luminal and stromal areas of choroid in optical coherence tomographic images

PURPOSE

To determine the capabilities of "EyeGround" software in measuring the choroidal cross sectional areas in optical coherence tomographic (OCT) images.

STUDY DESIGN

Cross sectional, prospective study.

METHODS

The cross-sectional area of the subfoveal choroid within a 1500 µm diameter circle centered on the fovea was measured both with and without using the EyeGround software in the OCT images. The differences between the evaluation times and the results of the measurements were compared. The inter-rater, intra-rater, inter-method agreements were determined.

RESULTS

Fifty-one eyes of 51 healthy subjects were studied: 24 men and 27 women with an average age of 35.0 ± 8.8 years. The time for analyzing a single image was significantly shorter with the software at 3.2±1.1 min than without the software at 12.1±5.1 min (P <0.001). The inter-method correlation efficient for the measurements of the whole choroid was high [0.989, 95% CI (0.981-0.994)]. With the software, the inter-rater correlation efficient was significantly high [0.997, 95% CI (0.995-0.999)], and the intra-rater correlation efficient was also significantly high [0.999, 95% CI (0.999-1.0)].

CONCLUSION

The EyeGround software can measure the choroidal area in the OCT cross sectional images with good reproducibility and in a significantly shorter times. It can be a valuable tool for analyzing the choroid.

Polypoidal Choroidal Vasculopathy

PURPOSE OF REVIEW

The goal of this paper is to review the recent literature of polypoidal choroidal vasculopathy (PCV) and provide an update on the epidemiology, pathophysiology, clinical findings, and management.

RECENT FINDINGS

Although indocyanine-green angiography (ICGA) is still the gold standard for diagnosis of PCV, the use of en face optical coherence tomography (OCT) and OCT angiography are useful tools in the diagnosis of PCV. Studies demonstrate superior treatment outcomes with combination photodynamic therapy (PDT) and anti-vascular endothelial growth factor (VEGF) therapy.

SUMMARY

PCV is a disease most commonly in Asians and African-Americans and presents with an orange-red nodule in the macula or the peripapillary region. While ICGA remains the most accurate method to diagnose PCV, newer non-invasive imaging modalities (eg. OCT-A and en face OCT) can be used to identify PCV lesions. The combination of PDT and anti-VEGF therapy is superior to either monotherapy. Future studies of OCT modalities and other anti-VEGF agents will be important in guiding PCV diagnosis and management, respectively.

The potential of spectral domain optical coherence tomography imaging based retinal biomarkers

Background

Biomarker”, a merged word of “biological marker”, refers to a broad subcategory of medical signs that objectively indicate the state of health, and well-being of an individual. Biomarkers hold great promise for personalized medicine as information gained from diagnostic or progression markers can be used to tailor treatment to the individual for highly effective intervention in the disease process. Optical coherence tomography (OCT) has proved useful in identifying various biomarkers in ocular and systemic diseases.

Main body

Spectral domain optical coherence tomography imaging-based biomarkers provide a valuable tool for detecting the earlier stages of the disease, tracking progression, and monitoring treatment response. The aim of this review article is to analyze various OCT based imaging biomarkers and their potential to be considered as surrogate endpoints for diabetic retinopathy, age related macular degeneration, retinitis pigmentosa and vitreomacular interface disorder. These OCT based surrogate markers have been classified as retinal structural alterations (macular central subfield thickness and cube average thickness); retinal ultrastructural alterations (disruption of external limiting membrane and ellipsoid zone, thinning of retinal nerve fiber layer and ganglion cell layer); intraretinal microangiopathic changes; choroidal surrogate endpoints; and vitreoretinal interface endpoints.

Conclusion

OCT technology is changing very quickly and throughout this review there are some of the multiple possibilities that OCT based imaging biomarkers will be more useful in the near future for diagnosis, prognosticating disease progression and as endpoint in clinical trials.

Longitudinal change in choroidal thickness after trabeculectomy in primary open-angle glaucoma patients

PURPOSE

To investigate longitudinal changes in intraocular pressure (IOP), axial length (AL), and choroidal thickness (ChT) in primary open-angle glaucoma (POAG) eyes after trabeculectomy and to evaluate the parameters that might influence those changes.

METHODS

In this prospective observational study, we recruited 28 patients with POAG (28 eyes) scheduled for trabeculectomy. The average macular ChTs and foveal retinal thicknesses along 6-mm segments centered on the fovea were examined preoperatively and postoperatively (at 1, 3, and 6 months) using swept-source optical coherence tomography. The IOP, AL, and mean deviation (MD) of standard automated perimetry (SAP) were also analyzed as independent variables.

RESULTS

Results from 16 patients were included in the final analysis. A significant increase in ChT with respect to the preoperative value was observed at every postoperative stage (1 month, P < 0.001; 3 months, P < 0.001; 6 months, P = 0.011), whereas the retinal thickness showed no significant change over the study period. The ChT increase and IOP reduction were sustained throughout the 6-month period without further significant changes. Stepwise multivariate analyses showed significant correlations between the percentage decrease in IOP and the percentage increase in ChT at 1 and 6 months postoperatively. The percentage increase in ChT was also significantly correlated with a better MD of the SAP at 1 month (β = 0.01; P = 0.009).

CONCLUSIONS

The ChT increase following trabeculectomy was sustained at 1, 3, and 6 months postoperatively. The percentage increase in ChT was significantly correlated with the percentage change in IOP and (more weakly) with better SAP MD values.

Retreatment of polypoidal choroidal vasculopathy after photodynamic therapy combined with intravitreal ranibizumab

PURPOSE

To investigate the incidence, risk factors and effect on visual improvement of retreatment within 60 months after initial photodynamic therapy (PDT) combined with intravitreal ranibizumab (IVR) in eyes with treatment-naïve polypoidal choroidal vasculopathy (PCV).

METHODS

We retrospectively reviewed the medical records of 61 eyes from 60 patients with PCV, who were followed up for at least 12 months after undergoing combination therapy. Retreatment, including combination therapy or IVR alone, was administered if residual or recurrent exudative changes were present.

RESULTS

During the follow-up period (mean 44 ± 13 months, median 48 months), 46 eyes (75.4 %) underwent retreatment. Survival analysis revealed that the proportions of eyes that were retreatment-free were 59 % at the 12-month visit, 41 % at the 24 month, 31 % at the 36 month, and 20 % at the 60-month visit. The median retreatment-free period was 15.0 [95 % confidence interval (CI) 7.4-22.7] months, and the mean period was 24.9 (95 % CI 19.3-30.6) months. Cox regression analysis revealed that older age (P = 0.010, hazard ratio 1.06, CI 1.02-1.11) and male gender (P = 0.043, hazard ratio 2.41, CI 1.03-5.62) were associated with retreatment. Visual improvement was significantly better in eyes without retreatment compared with those with retreatment at the 12-, 24- and 48-month visits.

CONCLUSIONS

About 80 % of eyes with PCV require retreatment within 5 years after combination therapy with PDT and IVR. Retreatment is associated with older age and male gender and is related to reduced improvement of visual acuity.