Efficacy of treat-and-extend regimen with aflibercept for pachychoroid neovasculopathy and Type 1 neovascular age-related macular degeneration

Three-year outcome of photodynamic therapy combined with VEGF inhibitor for pachychoroid neovasculopathy

BACKGROUND

Long-term results of photodynamic therapy (PDT) combined with vascular endothelial growth factor (VEGF) inhibitors for pachychoroid neovasculopathy (PNV) are not yet clear.

METHODS

This study is a retrospective, observational case series. We retrospectively examined untreated PNV cases (22 cases, 22 eyes, mean age of 71.0 years) who underwent PDT therapy in combination with VEGF inhibitors followed by additional treatments with pro re nata protocol. Visual acuity, number of treatments, and time to recurrence were examined. In addition, foveal choroidal thickness and choroidal vascularity index (CVI) were evaluated in 13 of 22 patients who were followed up with SpectralisOCTR from baseline.

RESULTS

Fifteen (68%) cases had polyps at baseline. LogMAR visual acuity averaged 0.24 ± 0.20 (range, - 0.079 to 0.82) at baseline and significantly improved after 1, 2, and 3 years (p = 0. 004, 0.0003, 0.002, respectively). Fourteen patients (64%) recurred, with an average time to recurrence of 1.8 ± 0.9 years. Foveal choroidal thickness decreased significantly after 1 year (average from 326 μm to 263 μm) and remained unchanged up to 3 years (255 μm). CVI also decreased after 1 year (average from 0.62 to 0.61) and remained unchanged until 3 years later (0.60).

CONCLUSIONS

We examined the 3-year course of PDT in combination with the VEGF inhibitor for untreated PNV. Visual acuity was improved, foveal choroidal thickness and CVI were decreased after 3 years.

Clinical Characteristics of Punctate Hyperfluorescence Spots in the Fellow Eye of Patients with Unilateral Macular Neovascularization with No Drusen

Objectives: To assess the clinical characteristics of patients with macular neovascularization (MNV) with no drusen in the fellow eye, we investigated the incidence of MNV in fellow eyes and the outcomes of intravitreal aflibercept (IVA) monotherapy in MNV eyes of patients with unilateral MNV with a punctate hyperfluorescence spot (PHS) in the fellow eye. Methods: We retrospectively studied 58 treatment-naïve patients with unilateral MNV with no drusen in the fellow eye. Patients were classified into a PHS group (n = 29) or no-PHS group (n = 29) based on the presence of PHS. We evaluated the incidence of MNV in the fellow eye, and the retreatment rate after initiation of three monthly aflibercept injections over one year. Results: Fellow eyes in the PHS group had a thicker choroid (p < 0.05) and higher prevalence of pachychoroid pigment epitheliopathy (PPE) (p < 0.001). MNV eyes in the PHS group had a thicker choroid (p = 0.09). The PHS group had a lower retreatment rate (p < 0.05) and required fewer injections (p < 0.05) than the no-PHS group. MNV developed in one eye in both the PHS and no-PHS groups, and both cases occurred in areas of hypofluorescence on indocyanine green angiography within the PPE area before the onset of MNV. Conclusions: The PHS group frequently exhibited pachychoroid disease characteristics and responded better to IVA monotherapy than the no-PHS group. These groups may represent distinct populations of patients with unilateral MNV with no drusen in the fellow eye.

ENLARGEMENT OF CHOROIDAL NEOVASCULARIZATION BEFORE RECURRENCE AFTER PHOTODYNAMIC THERAPY FOR PACHYCHOROID NEOVASCULOPATHY

PURPOSE

To investigate predictors of recurrent exudation in choroidal neovascularization (CNV) of pachychoroid neovasculopathy after photodynamic therapy (PDT).

METHODS

Consecutive, treatment-naïve, symptomatic patients with pachychoroid neovasculopathy with subfoveal retinal fluid treated with PDT and followed for 18 months were studied retrospectively. Choroidal neovascularization areas were calculated from optical coherence tomography angiography images obtained at various time points after the initial PDT.

RESULTS

In 52 eyes, the subfoveal retinal fluid resolved completely three months after PDT; in 23 (44%) eyes, exudation recurred during the 18-month follow-up period. In 29 eyes with no recurrence, the mean baseline square root of the CNV area of 1.91 mm (95% CI, 0.27) decreased significantly ( P = 0.006) to 1.47 mm (95% CI, 0.16) at three months after PDT and decreased further until 12 months after PDT (mean, 1.26 mm; 95% CI, P < 0.001) and was maintained thereafter. In 23 eyes with a recurrence, the square root of the CNV area enlarged significantly ( P = 0.028) from 1.43 mm (95% CI, 0.21) at examination three months before the recurrence to 1.73 mm (95% CI, 0.18) at recurrence.

CONCLUSION

Choroidal neovascularization enlargement during the follow-up period after PDT for pachychoroid neovasculopathy may predict recurrence.

Retinal and choroidal changes after anti-VEGF therapy in neovascular-AMD patients: A systematic review and meta-analysis of SD-OCT studies

BACKGROUND

In recent years, the progress made in the field of optical coherence tomography has helped to understand the changes in eye layers in patients with exudative age-related macular degeneration (nAMD). Early diagnosis of nAMD, a leading cause of irreversible vision impairment, is helpful. Therefore, we performed a meta-analysis on OCT measurement alterations before and after anti-VEGF therapy in patients with nAMD and controls.

METHOD

We systematically searched Scopus, PubMed, Cochrane, and Web of Science to find articles that measured choroidal and retinal layer changes after anti-VEGF therapy in nAMD Patients. We chose either a fixed-effects or random-effects model based on the assessed heterogeneity level to perform a meta-analysis. In addition, we conducted meta-regression, subgroup analyses, publication bias, and quality assessment for included studies.

RESULTS

Thirteen studies were included in the meta-analysis, with 733 total participants. Foveal thickness and subfoveal choroidal thickness (CT) decreased significantly in the first 3 years after injections, except for subfoveal CT in the third year after injection. It also showed that CT at 1500 µm temporal and nasal to the fovea did not significantly change.

CONCLUSION

Our results showed anti-VEGF treatment for nAMD patients was associated with a significant reduction in foveal thickness and subfoveal CT in the first 2 years after treatment. Our analysis did not reveal any correlation between changes in foveal thickness and subfoveal CT with best-corrected visual acuity or other factors.

Clinical Characteristics of Unilateral Macular Neovascularization Patients with Pachydrusen in the Fellow Eye

Background/Objectives: To approach the clinical properties of pachydrusen that differ from conventional drusen, we investigated the incidence of macular neovascularization (MNV) in fellow eyes and the treatment outcomes of intravitreal aflibercept (IVA) in MNV eyes of unilateral MNV patients with pachydrusen in the fellow eye. Methods: We retrospectively studied 261 consecutive patients with treatment-naïve unilateral MNV. Patients were classified into four groups according to the type of drusen in the fellow eye: the pachydrusen group (n = 49), the soft drusen group (n = 63), the subretinal drusenoid deposit (SDD) group (n = 24), and the no drusen group (n = 125). The development of the MNV in the fellow eye was evaluated for five years, and the retreatment proportion after three monthly aflibercept injections was evaluated for one year. Results: The choroidal thickness in the fellow eyes and MNV eyes was the greatest in the pachydrusen group (all p < 0.001). The 5-year incidence of MNV in the pachydrusen group was similar to that in the soft drusen group and no drusen group. The pachydrusen group had a lower retreatment rate than the other groups did (pachydrusen group: 46.4%; soft drusen group: 78.1%; SDDs: 87.5%; no drusen group: 83.3%). Conclusions: Unilateral MNV patients with pachydrusen in the fellow eye had a lower retreatment rate (46.4%/1 year); therefore, aflibercept monotherapy using the PRN regimen is one of the preferred treatment methods for MNV patients with pachydrusen in the fellow eye.

Intravitreal anti-vascular endothelial growth factor and combined photodynamic therapy for pachychoroid neovasculopathy: long-term treatment outcomes

PURPOSE

To examine the long-term visual outcomes after initial treatment with combined photodynamic therapy (PDT) or aflibercept treat-and-extend (TAE) monotherapy in patients with pachychoroid neovasculopathy (PNV).

METHODS

Patients diagnosed with PNV, initially treated with PDT combined with anti-vascular endothelial growth factor (VEGF) or intravitreal aflibercept (IVA) monotherapy in the TAE protocol and followed up for at least 6 months, were included in the study. Medical records were retrospectively reviewed. Survival analysis was performed, in which deterioration in logMAR visual acuity by 0.1 or 0.3 is defined as "death." The annual number of treatments was also analyzed. Sub-analysis was performed on 33 patients diagnosed with PNV without polypoidal lesions.

RESULTS

This study included 46 patients (23 in the initial combined PDT group and 23 in the IVA TAE group). Mean age, sex, mean baseline logMAR visual acuity, or duration of observation (3.6 ± 3.2 years vs. 3.1 ± 1.9 years) in both groups were comparable. As for visual outcome, no significant differences were found in survival analysis based on worsening of 0.1 or 0.3 logMAR (3-year survival; 26% vs. 26%, 91% vs. 90%, respectively). Meanwhile, the additional number of anti-VEGF injections per year was significantly lower in the initial combined PDT group than in the IVA TAE group (1.0 ± 1.3 vs. 4.1 ± 1.5, p < 0.0001). No significant differences were found in the number of additional PDTs per year (0.07 ± 0.20 vs. 0.02 ± 0.09, p = 0.27). Similar results were found in a sub-analysis of 33 patients without polyps.

CONCLUSION

In the treatment of PNV, regardless of the presence of polyps, the long-term visual outcomes were similar between the initial combined PDT and IVA TAE monotherapy. However, the annual number of anti-VEGF injections was lower in the initial combined PDT group than in the aflibercept TAE group, whereas that of PDT was comparable.

Pro re nata anti-VEGF treatment in pachychoroid neovasculopathy compared with age-related macular degeneration based on optical coherence tomography

PURPOSE

To compare anti-vascular endothelial growth factor (anti-VEGF) treatment in pachychoroid neovasculopathy (PNV) and age related macular degeneration (AMD).

METHODS

Cases having pro re nata (PRN) anti-VEGF treatment for choroidal neovascularization were reviewed and grouped as PNV and AMD. Groups were compared according to central foveal thickness (CFT), best corrected visual acuity (BCVA), and total injection over 12 months. The correlation of beginning choroidal thickness, CFT, and BCVA with final BCVA was analyzed.

RESULTS

Forty-seven PNV and 65 AMD cases were reviewed. Both the PNV group (p = 0.0001) and the AMD group (p = 0.003) had a significant improvement in BCVA and a significant decrease in CFT (p = 0.0001). However, BCVA was better at the 3-, 6-, and 12-month follow-up in PNV (p = 0.003, 0.002, 0.02). No significant CFT difference was observed between groups. The total number of injections was 5.7 ± 1.7 for PNV and 5.2 ± 1.5 for AMD (p = 0.09). Beginning BCVA was positively correlated with final BCVA in both groups.

CONCLUSION

The PRN treatment regimen was effective for PNV and AMD in terms of visual and anatomical outcomes. Visual response was better in PNV with PRN treatment with the same number of injections.

Long-term predictors of anti-VEGF treatment response in patients with neovascularization secondary to CSCR: a longitudinal study

PURPOSE

To identify the baseline predictors of anti-VEGF treatment response at 3 years in patients affected by choroidal neovascularization (CNV) secondary to central serous chorioretinopathy (CSCR).

METHODS

In this retrospective longitudinal study, medical records of patients diagnosed with CNV secondary to CSCR and treated using anti-VEGF injections between April 2015 and May 2020 were reviewed. The potential qualitative and quantitative predictors of treatment response were identified or measured based on the multimodal imaging examination available for each patient at the baseline, including structural OCT, fluorescein angiography (FA), indocyanine green angiography (ICGA), and OCT-angiography (OCT-A). Univariate and multivariate analyses were performed.

RESULTS

Twenty-nine eyes from 29 patients affected by CNV complicating CSCR were included in the study. At the end of the 3-year follow-up, the mean BCVA was 20/50 Snellen equivalent (0.38 ± 0.36 LogMAR), and no significant difference with baseline BCVA (0.37 ± 0.29 LogMAR) was found (p = 0.9). Twenty out of 29 eyes (69%) had active lesions at the end of the follow-up. At multivariate analysis, none of the included features was independently associated with the 3-year BCVA outcome. Pigment epithelium detachment (PED) height (ß = 0.017, p = 0.028) and outer limiting membrane (OLM) preservation at the fovea (ß = -5.637, p = 0.026) were independently associated with the CNV activity at 3 years.

CONCLUSION

PED height and OLM obliteration at the fovea might be considered baseline predictors of lesion activity at 3-year follow-up in patients with CNV secondary to CSCR treated with anti-VEGF therapy.

Predictive factors for outcomes of half-dose photodynamic therapy combined with aflibercept for pachychoroid neovasculopathy

PURPOSE

To assess the effects of half-dose photodynamic therapy (PDT) combined with an intravitreous aflibercept (IVA) injection for pachychoroid neovasculopathy (PNV) and its predictive factors.

METHODS

Clinical information of 43 patients (43 eyes) with PNV obtained before and 6 months after treatment with half-dose PDT combined with IVA was retrospectively analyzed. Patients were categorized into the sufficient (25 eyes, 58.1%) or insufficient (18 eyes, 41.9%) group based on resolution or persistence/recurrence of subretinal fluid (SRF), respectively, and clinical data were compared. Macular neovascularization (MNV) change was studied in 30 cases with available pre- and post-treatment optical coherence tomography angiography images.

RESULTS

The sufficient group included younger patients with better baseline best-corrected visual acuity (BCVA), more treatment-naïve eyes, and smaller MNV lesions at baseline than the insufficient group (all, P < 0.047). Complete SRF resolution was 81.8% in treatment-naïve eyes and only 33.3% in previously treated eyes. MNV expanded after half-dose PDT was combined with IVA regardless of the treatment outcome (P = 0.003).

CONCLUSION

Half-dose PDT combined with IVA was effective for PNV treatment, especially for younger patients with good baseline BCVA, treatment-naïve eyes, and small MNV sizes at baseline. MNV expanded after treatment regardless of the treatment outcomes.

Pachychoroid neovasculopathy has clinical properties that differ from conventional neovascular age-related macular degeneration

To determine the clinical properties of pachychoroid neovasculopathy (PNV) that differ from conventional neovascular age-related macular degeneration (nAMD) and suggest that they are different clinical entities. To accomplish this, we reviewed the medical records of 100 consecutive patients diagnosed with nAMD. All of the patients were Japanese, and their mean age was 75.5 years. There were 72 men and 28 women. For the bilateral cases, only the right eye was analyzed. An eye was diagnosed with PNV when a macular neovascularization (MNV) was detected just above the dilated choroidal vessels. The Indocyanine green angiographic (ICGA) and en face optical coherence tomographic (OCT) images were used to assess the vertical symmetry of the medium and large choroidal vessels. The subfoveal choroidal thickness (SCT) was also measured manually in the OCT images. After reclassification, there were 29 (29%) patients with typical nAMD (25 with type 1 MNV, 4 with type 2 MNV), 43 (43%) with PNV, 21 (21%) with polypoidal choroidal vasculopathy, and 7 (7%) with retinal angiomatous proliferation. Of the 43 PNV, 17 (39.5%) had polypoidal lesions and 26 (60.5%) had no polypoidal lesions. The percentage of eyes with vertical asymmetry of the medium and large choroidal vessels was significantly greater in the 35 PNV (81.4%) than in the 16 non-PNV (28.1%; P < 0.01) cases. The mean SCT was significantly thicker in the PNV eyes than in the non-PNV eyes (298 ± 96 μm vs. 228 ± 82 μm; P < 0.01). The response of PNV to anti-vascular endothelial growth factor treatments was better than that of non-PNV eyes [higher dry macula rate after the loading period (90.9% vs. 59.1%), fewer total number of injections (11.0 ± 2.9 vs. 13.4 ± 3.2), and longer treatment intervals for the anti-VEGF therapy (8.4 ± 3.1 vs. 13.4 ± 3.2 weeks) at 2 years (all P < 0.01)]. These differences in the morphology and response to anti-VEGF treatments suggest that PNV is a separate clinical entity to conventional nAMD.

Two-Year Results of a Treat and Extend Regimen with Aflibercept in Caucasian Patients with Pachychoroid Neovasculopathy

INTRODUCTION

There are few reports evaluating the treatment of pachychoroid neovasculopathy (PNV) in white patients. The purpose of this study is to analyze the results of a treat and extend regimen with aflibercept in white patients with PNV after 2 years of follow-up.

METHODS

We performed a retrospective study in 31 eyes of 26 patients with PNV treated with a treat an extend regimen of intravitreal aflibercept. The mean age was 63,84 ± 7.92 years. There were 9 males (35%) and 17 females (65%). Best-corrected visual acuity (BCVA), central macular thickness (CMT), choroidal subfoveal thickness (CST), choroidal thickness (CT) under type 1 choroidal neovascularization (CNV), pigment epithelium detachment (PED) height, and presence of subretinal fluid (SRF), intraretinal fluid (IRF) and wet macula, were evaluated at baseline and after 3, 6, 12, and 24 months.

RESULTS

BCVA remained stable during the follow-up (p 0.161). A significant diminution of CMT was found (p 0.001). Conversely, PED height diminution was not significative (p 0.260). CST and CT under type 1 CNV improved significantly during the follow-up (p 0.005 and 0.009, respectively). Also, wet macula improved after 24 months (p < .001). The average number of intravitreal injections was 12.34 ± 6.01.

CONCLUSION

Treat and extend regimen with intravitreal aflibercept in white patients with PNV may be effective for improving CMT, CST, CT under type 1 CNV and wet macula, and to stabilize vision, with a personalized regimen of intravitreal injections.

Choroidal Morphology on Ultra-Widefield Indocyanine Green Angiography and Response to Aflibercept in Pachychoroid Neovasculopathy

Purpose: This study assessed the relationship between the choroidal morphology and short-term response to aflibercept treatment in pachychoroid neovasculopathy (PNV). Methods: This was a retrospective case-control study. Ultra-widefield indocyanine green angiography (UWICGA) and optical coherence tomography (OCT) images of 90 PNV eyes of 90 patients treated with aflibercept were enrolled. Responsiveness to aflibercept was defined as a complete resolution of sub- or intra-retinal fluid after three loading doses (50 dry and 40 non-dry eyes). Subfoveal choroidal thickness (SFCT) was measured on OCT images, and choroidal vessel density (CVD), CVD asymmetry, intervortex anastomosis, and choroidal vascular hyperpermeability (CVH) were assessed on UWICGA images. Results: CVD on UWICGA differed between groups in terms of the total area (0.323 ± 0.034 in dry vs. 0.286 ± 0.038 in non-dry, p < 0.001) and area of each quadrant (superotemporal: 0.317 ± 0.040 vs. 0.283 ± 0.040, superonasal: 0.334 ± 0.040 vs. 0.293 ± 0.045, inferonasal: 0.306 ± 0.051 vs. 0.278 ± 0.052, inferotemporal: 0.334 ± 0.047 vs. 0.290 ± 0.046; all p ≤ 0.010). The CVH grade differed between groups (mean 1.480 ± 0.735 vs. 1.875 ± 0.822, p = 0.013). ST and IT intervortex anastomoses were common in the dry group, while SN, ST, and IT were most common in the non-dry group (p = 0.001). Conclusions: A poor short-term response to aflibercept treatment in PNV eyes was associated with a lower Haller vessel density, higher CVH grade, and intervortex anastomosis involving more quadrants on UWICGA.

Dilated choroidal vascular channels in pachychoroid neovasculopathy

BACKGROUND

To elucidate the pattern of the choroidal vasculature in exudative pachychoroid neovasculopathy (PNV) and its correlation with the clinical course and treatment outcomes.

METHODS

The retrospective study included consecutive patients in National Taiwan University Hospital between 2014 and 2020 who fulfilled the criteria for exudative PNV defined as active type 1 macular neovascularization (MNV) on optical coherence tomography angiography (OCTA) and with leakage on fluorescein angiography (FA) or indocyanine green angiography (ICGA) associated with pachychoroid features. The corrected distance visual acuity (CDVA), FA, ICGA, and OCT images obtained by Optovue (Optovue Inc, Freemont CA, USA) spectral domain OCT were evaluated at baseline and various time points during the 12-month treatment period. The correlations between the choroidal vascular patterns, specifically those with or without dilated choroidal vascular channels (DCVC) revealed by ICGA, and baseline characteristics and treatment outcomes were evaluated using multiple regression models.

RESULTS

The study enrolled 34 eyes of 31 patients. The average age was 59.0 ± 9.3 years, and 20 participants were men. ICGA revealed DCVCs in 21 eyes, while the remaining 13 eyes did not have DCVCs. At baseline, DCVC group was older (p = 0.03) and had a longer duration of visual symptoms (p = 0.02), with a higher vessel density (defined as the percentage of the measured area occupied by flow area) of MNV (p = 0.04), higher proportion of ellipsoid zone disruption (p = 0.01), and poorer CDVA (p = 0.03). After the 12-month treatment period, the frequency of requirement of anti-VEGF injections (p < 0.01) was higher, and the risk for CDVA <20/40 was higher (adjusted OR: 5.29, 95% CI: 1.24-22.48, p = 0.02) in eyes with DCVCs.

CONCLUSIONS

For PNV, eyes with DCVCs were associated with higher vessel density of macular neovascularization and poorer CDVA at baseline, and had poorer visual and anatomical outcomes although more anti-VEGF injections were given.

Towards a better understanding of non-exudative choroidal and macular neovascularization

Non-exudative macular and choroidal neovascularization (MNV and CNV) usually refers to the entity of treatment-naïve type 1 neovascularization in the absence of associated signs of exudation. Histopathological studies, dating back in the early 70s, identified the presence of non-exudative MNV, but the first clinical report of this finding was in the late 90s using indocyanine green angiography in eyes with age-related macular degeneration (AMD). With more advanced retinal imaging, there has been an ever increasing appreciation of non-exudative MNV associated with AMD and CNV with other macular disorders. However, consensus regarding the exact definition and the clinical management of this entity is lacking. Furthermore, there may be variation in the imaging features and clinical course suggesting that a spectrum of disease may exist. Herein, we review the large body of published work that has provided a better understanding of non-exudative MNV and CNV in the last decade. The prevalence, multimodal imaging features, clinical course, and response to treatment are discussed to elucidate further key insights about this entity. Based on these observations, this review also proposes a new theory about the origin and course of different sub-types of non-exudative MNV/CNV which can have different etiologies and pathways according to the clinical context of disease.

Relationship between Pachychoroid and Polypoidal Choroidal Vasculopathy

Previous clinical studies have suggested that pachychoroid can induce macular neovascularization (MNV) to develop pachychoroid neovasculopathy (PNV) and that PNV can progress to polypoidal choroidal vasculopathy (PCV). Recent studies based on the pachychoroid concept are now gradually revealing the true nature of, at least some part of, PCV. However, previous studies on PNV and/or PCV have used different frameworks for the classification of PNV, PCV, and neovascular age-related macular degeneration (nAMD). These have hampered the rapid overhaul of the understanding of PCV. Some investigators have assumed that all PCV is pachychoroid-driven whereas other investigators have classified PCV into “pachychoroid PCV” and “non-pachychoroid PCV”. Furthermore, since there is no consensus as to whether PNV includes PCV, some studies have included PCV with PNV, while other studies have excluded PCV from PNV. To address these gaps, we summarize previous studies on PCV and pachychoroid. Even before the proposal of the pachychoroid concept, previous studies had suggested that PCV could be divided into two subtypes, of which one was characterized by pachychoroid features. Previous studies had also provided keys to understand relationship between PCV and PNV. We here recommend a refined conceptual framework for future studies on PNV, PCV, and nAMD. Considering the current inconsistent understanding of PCV, we should be cautious about using the term PCV until we understand the true nature of PCV.

Occlusion of a Vortex Vein After Treatment With Half-Fluence Photodynamic Therapy Combined With Intravitreal Aflibercept Injection for Pachychoroid Neovasculopathy

Photodynamic therapy (PDT) is a treatment option for pachychoroid diseases such as central serous chorioretinopathy (CSC), pachychoroid neovasculopathy (PNV), polypoidal choroidal vasculopathy (PCV), and peripapillary pachychoroid syndrome (PPS). On the other hand, morphological changes of choroidal vessels in the irradiated field after PDT have also been discussed, with occlusion of choriocapillaris and stenosis of choroidal middle and large vessels being reported. Here, we report a case of vortex vein occlusion after half-fluence PDT (HF-PDT) combined with an anti-vascular endothelial growth factor (VEGF) agent for PNV. In this case, HF-PDT achieved complete occlusion of PNV; in addition, a vortex vein that flowed in PNV but was located outside the PDT irradiation field was fully occluded three months post-treatment. At the occluded site of the vortex vein, indocyanine green video angiography revealed pulsation downstream of the vortex vein. Such occlusion of a large vessel by HF-PDT has not been reported previously. Occlusion could be induced by two factors: the potentiality of PDT and risk factors for thromboembolism, such as older age, smoking, and arrhythmia. Further studies are required to determine the mechanisms of these large vessel occlusions.

Long term results of three anti-vascular endothelial growth factor agents in pachychoroid neovasculopathy

PURPOSE

To assess morphological changes and visual results in eyes with pachychoroid neovasculopathy (PNV) that underwent different intravitreal anti-vascular endothelial growth factor (VEGF) agents.

MATERIALS AND METHODS

This is a retrospective, observational, comparative study included 76 PNV eyes in 76 patients that were allocated to 3 groups according to monotherapy injection procedure, as follows: the intravitreal bevacizumab (IVB) group, intravitreal ranibizumab (IVR) group, and intravitreal aflibercept (IVA) group. Central macular thickness (CMT), best-corrected visual acuity (BCVA), and subfoveal choroidal thickness (SFCT) were measured at baseline, after treatment 1^st month, 3^rd month, 6^th month, and 12^th month, and at the final post-treatment examination.

RESULTS

Mean age of the patients was 57.31 ± 5.91 years (range: 34-67 years). Mean duration of follow-up was 31.50 ± 12.91 months (range: 13-60 months). The IVB group included 30 eyes, the IVR group included 22 eyes, and the IVA group included 24 eyes. There weren't any significant differences in BCVA changes between the groups at any post-baseline measurement time point. Although CMT did not change significantly in the IVB group from baseline to final follow-up visit (baseline: 376.33 ± 86.31µm; final visit: 340.80 ± 122.70 µm) (p = 0.172), CMT did change significantly in the IVA group (baseline: 383.41 ± 131.83 µm; final visit: 297.33 ± 103.81 µm) (p = 0.029) and IVR group (baseline: 379.18 ± 97.93 µm; final visit: 335.72 ± 111.45 µm) (p = 0.041). SFCT decreased significantly in the IVR and IVA groups (p = 0.015 and p < 0.001, respectively). The mean number of injections was 12.06 ± 4.72 (range: 6-20) in the IVB group, 11.81 ± 3.31(range: 7-17) in the IVR group, and 7.16 ± 3.15 (range: 4-13) in the IVA group (p = 0.004).

CONCLUSION

All 3 anti-VEGFs were effective in terms of visual results in patients with PNV. Patients treated with IVA required fewer injections than those treated with IVB or IVR. Furthermore, IVR and IVA treatment significantly decreased SFCT, whereas IVB did not.

Pathophysiology of central serous chorioretinopathy: a literature review with quality assessment

The pathogenesis of central serous chorioretinopathy (CSCR), a pachychoroid disease, is poorly understood. While choroid hyperpermeability and retinal pigment epithelium dysfunction are cornerstones for developing CSCR, the mechanisms at the retinal, vascular, retinal pigment epithelium, and cellular level continue to be an enigma. A few preclinical studies and the development of small-sized, poorly controlled clinical trials have resulted in limited insight into the disease mechanism. Effective treatments for CSCR are still lacking as current trials have produced inconsistent results for functional and structural gains. Thus, critically evaluating the literature to explore disease mechanisms and provide an up-to-date understanding of pathophysiology can provide valuable information and avenues to new treatments. In this study, a comprehensive summary of the mechanistic insight into CSCR is presented while highlighting the shortcomings of current literature. The mechanism was divided into seven sub-categories including mechanical obstruction, inflammation, oxidative stress, paracrine factors, autonomic dysfunction, mineralocorticoid receptors activation, and medications. We implemented validated tools like the JBI and CAMARADES to objectively analyze the quality of both clinical and preclinical studies, respectively. Overall, our analysis of the literature showed that no single mechanism was populated with a large number of sufficiently sized and good-quality studies. However, compiling these studies gave hints not only to CSCR pathogenesis but also pachychoroid disease in general while providing suggestions for future exploration.

Visual Outcome and Treatment Frequency of Anti-VEGF Therapy Using the Treat-and-Extend and Treatment Cessation Regimen for Exudative Age-Related Macular Degeneration and Pachychoroid Neovasculopathy

Purpose

To report the results of anti-vascular endothelial growth factor (VEGF) therapy using treat-and-extend (TAE) and treatment cessation regimens for exudative age-related macular degeneration (AMD) and pachychoroid neovasculopathy (PN).

Methods

We retrospectively studied 101 treatment-naïve eyes of 101 patients with exudative AMD and PN that underwent anti-VEGF therapy using TAE and treatment cessation regimen with a follow-up period of ≥12 months. Best-corrected visual acuity (BCVA), treatment frequency, and number of eyes with successful treatment cessation were measured. Successful treatment cessation was defined as dry macula retention without treatment for >16 weeks after the last injections. Factors related to the successful treatment cessation were evaluated.

Results

BCVA was maintained at the last visit with a mean follow-up period of 49.9 ± 26.9 months. The injection number decreased from 6.8 ± 2.31 at the first year to 3.7 ± 3.64 at the fifth year. At the last visit, 48 (47.5%) eyes were being treated at an interval of ≥12 weeks or were under treatment cessation. Successful treatment cessation during the follow-up period and at the last visit were achieved in 56 (55.4%) and 27 (26.7%) eyes, with a median treatment-free period of 66 and 126 weeks, respectively. Good early treatment response and a small recurrence number were associated with successful treatment cessation at the last visit.

Conclusion

Patients with good early response to treatment and fewer recurrences may achieve treatment cessation. This information could help physicians predict the achievement of treatment cessation for a considerable period.

Cytokine profiles of macular neovascularization in the elderly based on a classification from a pachychoroid/drusen perspective

PURPOSE

To classify macular neovascularization (MNV) based on pachychoroid and drusen features and to examine the aqueous humor cytokine signatures of each group.

METHODS

In total, 106 consecutive eyes with treatment-naïve MNV and 104 control eyes were examined. The aqueous humor concentrations of 15 cytokines were compared among the MNV groups classified based on the presence of drusen and/or pachychoroid features. Multidimensional scaling analysis was used to visualize the similarity level of the MNV subtypes according to their cytokine profiles.

RESULTS

Thirty-one, 18, 43, and 10 eyes were classified into the pachychoroid-associated, drusen-associated, pachychoroid/drusen-associated, and non-drusen/non-pachychoroid MNV groups, respectively. Compared with the control group, cytokines were differently upregulated among the MNV groups. CRP and CXCL12 were significantly upregulated in all MNV groups, whereas CXCL13 and IL-8 were significantly upregulated in three MNV groups, excluding the non-pachychoroid/non-drusen-associated MNV group. Ang-2 was significantly upregulated in three MNV groups except the drusen-associated MNV group. PlGF was significantly upregulated in the pachychoroid-associated and drusen-associated MNV groups. CCL-2 was significantly upregulated in the pachychoroid-associated and pachychoroid/drusen-associated MNV groups. VEGF was downregulated in the pachychoroid-associated and drusen-associated MNV groups, respectively. Multidimensional scaling analysis showed a distinct cytokine profile for each MNV group.

CONCLUSION

All MNV groups showed distinct cytokine profiles. Eyes with "neovascular age-related macular degeneration with drusen and concomitant pachychoroid" may share a similar etiology to those with "pachychoroid neovasculopathy" and "choroidal neovascularization with drusen," but have a distinct etiology to those without these. These findings suggest the importance of evaluating drusen and the choroid during the diagnosis of neovascular age-related macular degeneration.

Pachychoroid disease spectrum: review article

PURPOSE

The aim of this article is to do a comprehensive literature review about the current understandings of the pachychoroid disease spectrum, describing its multimodal imaging analysis, pathophysiology, differential diagnosis, and current types of management.

METHODS

This comprehensive literature review was performed based on a search on the PubMed database, of relevant pachychoroid published papers according to our current knowledge.

DISCUSSION

The pachychoroid disease spectrum, according to some authors, includes the following: pachychoroid pigment epitheliopathy (PPE), central serous chorioretinopathy (CSC), pachychoroid neovasculopathy (PNV), polypoidal choroidal vasculopathy (PCV)/aneurysmal type 1 neovascularization (AT1), and more recently focal choroidal excavation (FCE) and peripapillary pachychoroid syndrome (PPS). Each one of these entities will be described and discussed in this article.

CONCLUSION

Significant advances in multimodal imaging have enabled a better understanding of the typical choroidal changes in pachychoroid disease spectrum. The clinical knowledge and managing options about this disease significantly increased in the last years. However, it is still unclear why some eyes with typical pachychoroid disease phenotype show no evidence of RPE damage and subretinal fluid (uncomplicated pachychoroid) while others present progressive tissue damage, neovascularization, and atrophy.

Visual and anatomical outcomes associated with treat-and-extend administration of intravitreal aflibercept for neovascular age-related macular degeneration

Purpose

To investigate the visual and anatomical outcomes associated with treat-and-extend (TAE) regimen of intravitreal (IVT) aflibercept in eyes with treatment naïve neovascular age-related macular degeneration (nvAMD).

Methods

A retrospective chart review of eyes that underwent IVT aflibercept injections for nvAMD between May 2014 and March 2018 was performed. The primary outcome was the change in best corrected visual acuity (BCVA) at 12 months. Secondary outcomes included the change in central retinal thickness (CRT), subretinal fluid (SRF) and intraretinal fluid (IRF).

Results

Data from 213 eyes of 213 patients (138 female, 65%) met the inclusion criteria. The mean (SD) age of the patients was 80.4 (±  9.2) years. The mean baseline BCVA (0.92  ±  0.50 logMAR, improved by 0.20 (±  0.40) logMAR units at 12 months (p  <  0.001). Seventy-two (34%) eyes gained  ≥  0.3 logMAR and 47 (22%) eyes achieved BCVA  ≤  0.3 logMAR at 12 months. Baseline BCVA, patient age, and the number of aflibercept injections received were predictors of the change in BCVA at 12 months. Mean CRT improved from 347 (±  117) µm at baseline to 246 (±  55) µm at 12 months (p  <  0.001). The percentage of eyes with SRF and IRF on SD-OCT declined from 63 to 21% and from 60 to 26% at 12 months, respectively.

Conclusion

A TAE regimen of IVT aflibercept in treatment naïve nvAMD is associated with good visual and anatomical outcomes in routine clinical practice. Resolution of exudation occurred in about half of nvAMD cases at 12 months. Individualized administration of IVT aflibercept may reduce injection burden.

Visual acuity outcomes of anti-VEGF treatment for neovascular age-related macular degeneration in clinical trials

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.

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.

A comparative study of type 1 neovascularization: Neovascular age-related macular degeneration versus pachychoroid neovasculopathy

PURPOSE

This study aimed to compare type 1 choroidal neovascularization (CNV) characteristics in eyes with pachychoroid neovasculopathy (PNV) and neovascular age-related macular degeneration (nAMD) using optical coherence tomography angiography (OCTA).

METHODS

Treatment naive 23 eyes of 23 patients with PNV and 24 eyes of 24 patients with nAMD were evaluated. The height of pigment epithelial detachment (PED) and the central macular thickness were determined. OCTA sensitivity, CNV area, morphological patterns, and retinal superficial capillary plexus vessel density (SCP-VD) values were compared. The frequency of quiescent CNV, subretinal hyperreflective exudation (SHE), subretinal/intraretinal fluid, serous PED, double-layer sign (DLS), and pachyvessels were noted.

RESULTS

CNV was detected on OCTA in 83.3% of nAMD eyes and 91.3% of PNV eyes (p = 0.66). Indistinct pattern was more common (74% vs 50%) and the CNV area (mm²) was smaller in PNV (0.77 ± 0.54 vs 1.57 ± 1.43) but did not reach significant levels (p = 0.27 and 0.33 respectively). SCP-VD was similar between the groups (p = 0.38). Statistically significant differences were found between groups in age and subfoveal choroidal thickness (p < 0.05). DLS and pachyvessels were found to be more frequently in PNV (p < 0.05). However, both groups had similar rates of quiescent CNV, SHE, subretinal/intraretinal fluid, and serous PED (p > 0.05).

CONCLUSION

Morphological features, area, and activation findings of type 1 CNV may play a limited role in differentiating nAMD and PNV cases.

Pachychoroid neovasculopathy: A comparative review on pathology, clinical features, and therapy

There have been major changes in our understanding of choroidal diseases in the last decade owing to multiple retinal and choroidal imaging related advances. A major conceptual pivot is establishment of pachychoroid and its spectrum of clinical disorders: pachychoroid pigment epitheliopathy, central serous chorioretinopathy, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy/aneurysmal type 1 neovascularization, peripapillary pachychoroid syndrome, and focal choroidal excavation. However, considerable overlaps in manifestations and therapeutics of these disorders make differentiation amongst them difficult. This review is focused on pathogenesis and clinical aspects of pachychoroid neovasculopathy (PNV). Since PNV was defined as a separate entity around 5 years ago, there have been numerous contrasting observations surrounding it. We review and summarize these studies, and also compare PNV with other disorders of the pachychoroid spectrum in detail. There are important differences between etiologies of neovascular age related macular degeneration and PNV. Yet the current treatment strategies for PNV have been extrapolated from the trials for the former. Future research needs to validate this assumption with long-term results.

Classification of Pachychoroid on Optical Coherence Tomographic En Face Images Using Deep Convolutional Neural Networks

Purpose

To study the efficacy of deep convolutional neural networks (DCNNs) to differentiate pachychoroid from nonpachychoroid on en face optical coherence tomography (OCT) images at the large choroidal vessel.

Methods

En face OCT images were collected from eyes with neovascular age-related macular degeneration, polypoidal choroidal vasculopathy, and central serous chorioretinopathy. All images were prelabeled pachychoroid or nonpachychoroid based on quantitative and qualitative criteria for choroidal morphology on multimodal imaging by two retina specialists. In total, 1188 nonpachychoroid and 884 pachychoroid images were used for training (80%) and validation (20%). Accuracy for identification of pachychoroid by DCNN models was analyzed. Trained models were tested on a test set containing 79 nonpachychoroid and 93 pachychoroid images.

Results

The accuracy on the validation set was 94.1%, 93.2%, 94.7%, and 94.4% in DenseNet, GoogLeNet, ResNet50, and Inception-v3, respectively. On a test set, each model demonstrated accuracy of 80.2%, 83.1%, 89.5%, and 90.1% and an F1 score of 0.782, 0.824, 0.904, and 0.901, respectively.

Conclusions

DCNN models could classify pachychoroid and nonpachychoroid with good performance on OCT en face images. Automated classification of pachychoroid will be useful for tailored treatment of individual patients with exudative maculopathy.

Translational Relevance

En face OCT images can be used by DCNN for classification of pachychoroid.

Vanishing pachy-choroid in pachychoroid neovasculopathy under long-term anti-vascular endothelial growth factor therapy

BACKGROUND

To investigate the diagnostic value of choroidal thickness in the definition of pachychoroid neovasculopathy (PNV), especially in eyes treated with anti-vascular endothelial growth factor (VEGF) therapy.

METHODS

Twenty-two consecutive eyes of 11 patients with uni- or bilateral PNV were analyzed. Anti-VEGF treatment was correlated with changes in choroidal thickness on enhanced depth imaging optical coherence tomography.

RESULTS

There were 14 eyes with PNV and 8 non-neovascular partner eyes. Mean age was 64.2 ± 4.0 (range: 60-72), total follow-up was 1.8 ± 0.4 (1-2) years. In PNV eyes, choroidal thickness at baseline was 400 ± 58 (269-485) μm. After two years and 13 anti-VEGF injections on average, a mean reduction of - 39 ± 10 (- 26 to - 56) % to final 241 ± 52 (162-327) μm was observed (p < 0.0001). Meanwhile, choroidal thickness in the partner eyes remained stable (p > 0.13 for all comparisons). A significant correlation of choroidal thinning and anti-VEGF injection rate was observed at year one (r = - 0.79; R2 = 0.63; p = 0.00073) and two (r = - 0.69; R2 = 0.48; p = 0.019). While 85.7% of PNV eyes exceeded a pachychoroid threshold of ≥350 μm at baseline, this figure dropped to 21.4% at year one and 0% at year two.

CONCLUSION

In PNV, choroidal thickness significantly decreases with anti-VEGF therapy, resembling a "vanishing pachy-choroid", and thus does not represent a valid long-term diagnostic criterium, especially when differentiating PNV from nAMD.

Long-term outcome of intravitreal anti-vascular endothelial growth factor treatment for pachychoroid neovasculopathy

To compare the long-term effectiveness of intravitreal anti-vascular endothelial growth factor (VEGF) treatment for pachychoroid neovasculopathy (PNV), polypoidal choroidal vasculopathy/aneurysmal type 1 neovascularization (PCV/AT1), and typical neovascular age-related macular degeneration (nAMD). Forty-one eyes with PNV, 68 eyes with PCV/AT1, and 56 eyes with typical nAMD were retrospectively included for analysis. All patients were treatment-naïve and received a three-monthly loading injection of anti-VEGF, followed by further injections, as required. The visual and anatomical outcomes after treatment were evaluated up to 36 months from baseline. No significant intergroup difference was found in terms of best-corrected visual acuity (BCVA) and changes in central foveal thickness at 12, 24, and 36 months after the baseline. In addition, no significant difference was found between the groups regarding the proportions of improved or worsened (increased or decreased more than 3-lines) visual acuity. However, the PNV group participants received significantly fewer anti-VEGF injections (11.7 ± 6.9) than those in the PCV/AT1 (12.4 ± 7.0; P = 0.031) and typical nAMD groups (13.2 ± 7.4; P = 0.016). The incidence of macular atrophy (MA) development was also significantly lower for the PNV (4/41 eyes, 9.8%) than the typical nAMD (15/56 eyes, 26.8%; P = 0.033) eyes. There was no significant difference between PNV, PCV/AT1, and typical nAMD regarding visual acuity improvement after anti-VEGF treatment over 36 months. However, the number of injections for PNV was significantly lower compared to that for PCV/AT1 and typical nAMD, and the incidence of MA development was significantly lower than in typical nAMD.

Two-Thirds Dose Photodynamic Therapy for Pachychoroid Neovasculopathy

Pachychoroid neovasculopathy (PNV) is treated with antivascular endothelial growth factor (VEGF) injection and photodynamic therapy (PDT), but no curative treatment has yet been established. We aimed to clarify the treatment results of a reduced dose of PDT for PNV. The subjects were 27 eyes of 27 patients (male:female = 20:7, mean age 58.9 years). PDT, at 2/3 of the conventional dose (2/3PDT), was administered once. The patients were then observed for one year. Eyes with polypoidal choroidal vasculopathy (PCV) were excluded. We investigated the associations among the central retinal thickness, choroidal thickness, and visual acuity changes before treatment and one, three, six and 12 months after PDT. When serous retinal detachment was increased or unchanged or new hemorrhages were observed, as compared with pretreatment findings, intravitreal injection of an anti-VEGF agent was performed. Visual acuity was significantly improved, as compared to before treatment, at three, six, and 12 months after 2/3PDT. Foveal retinal thickness was significantly decreased after versus before treatment in the 2/3PDT group (p < 0.001). Foveal choroidal thickness was also significantly reduced in the 2/3PDT group (p = 0.001). Additional intravitreal anti-VEGF agent injections were administered to three patients (11%), while 24 (89%) required no additional treatment during the one-year follow-up period. For PNV without polyps, 2/3PDT appears to be effective.

Clinical Characteristics of Neovascular Age-Related Macular Degeneration without Typical Drusen

Purpose

To evaluate the clinical characteristics of neovascular age-related macular degeneration (nAMD) patients without typical drusen.

Methods

We retrospectively studied 165 eyes in 165 patients with treatment-naïve nAMD, including typical AMD and polypoidal choroidal vasculopathy (PCV). According to the fellow eye condition, the patients were divided into nAMD with and without typical drusen groups. Eyes with soft drusen or subretinal drusenoid deposits were classified into the nAMD with the typical drusen group. Smoking status and diagnoses of hypertension and diabetes were identified from hospital records and patient recall. We assessed best-corrected visual acuity (BCVA), central retinal thickness (CRT) at the fovea, subfoveal choroidal thickness (SFCT), and the number of injections received.

Results

The nAMD without typical drusen group was significantly younger (77.9 ± 7.6 vs. 71.8 ± 8.3, P < 0.001) and had thicker SFCT at baseline (207.9 ± 99.5 vs. 260.1 ± 113.2 μm, P=0.007) and a higher proportion of PCV (30.6 vs. 63.1%, P < 0.001). The proportion of ever-smokers was significantly higher in the nAMD without typical drusen group (54.8 vs. 70.9%, P=0.036). There were no statistically significant differences in the proportion of patients with hypertension or diabetes; BCVA, CRT, or SFCT changes; or the number of injections between the nAMD with and without typical drusen groups.

Conclusion

The clinical features of patients in the nAMD without typical drusen group were almost identical to those of pachychoroid-driven choroidal neovascularization (CNV) patients. The nAMD without typical drusen group had a significantly higher proportion of ever-smokers than the nAMD with typical drusen group. Smoking could be a risk factor for the development of pachychoroid-driven CNV.

Effects of Intravitreous Aflibercept Injection in Pachychoroid Neovasculopathy: Comparison with Typical Neovascular Age-Related Macular Degeneration

Purpose

To compare the 12-month efficacy of intravitreous aflibercept (IVA) injection between eyes with pachychoroid neovasculopathy and neovascular age-related macular degeneration (AMD).

Methods

Retrospective, comparative case series analysis. Twenty-seven eyes with pachychoroid neovasculopathy and sixty-three eyes with neovascular AMD. All patients received three initial monthly, followed by bimonthly, IVA injections.

Results

Twelve months after initial treatment, the mean best-corrected visual acuity (BCVA) had improved both in pachychoroid neovasculopathy (from 0.28 to 0.14 logMAR; P = 0.001) and neovascular AMD (from 0.40 to 0.29 logMAR; P < 0.001). Twelve months after initial treatment, eyes with pachychoroid neovasculopathy exhibited decreased mean central retinal thickness (CRT) and subfoveal choroidal thickness (both, P < 0.001) and presence of polyps (P = 0.039) and improved integrity of external limiting membrane (ELM) (P = 0.008) and ellipsoid zone band (P = 0.001). At the 12-month follow-up, 77% and 68% of eyes with pachychoroid neovasculopathy and neovascular AMD, respectively, exhibited dry macula (P = 0.30). Baseline CRT was correlated with 12-month BCVA in eyes with pachychoroid neovasculopathy (P = 0.02). In eyes with neovascular AMD, CRT (P = 0.005) and presence of intact ELM (P = 0.007) were significant predictors of 12-month BCVA.

Conclusion

Periodic IVA injection leads to anatomical and functional improvement in eyes with pachychoroid neovasculopathy and in eyes with neovascular AMD.

Classification of pachychoroid on optical coherence tomography using deep learning

PURPOSE

Pachychoroid is characterized by dilated Haller vessels and choriocapillaris attenuation that are seen on optical coherence tomography (OCT) B-scans. This study investigated the feasibility of using deep learning (DL) models to classify pachychoroid and non-pachychoroid eyes from OCT B-scan images.

METHODS

In total, 1898 OCT B-scan images were collected from eyes with macular diseases. Images were labeled as pachychoroid or non-pachychoroid based on strict quantitative and qualitative criteria for multimodal imaging analysis by two retina specialists. DL models were trained (80%) and validated (20%) using pretrained convolutional neural networks (CNNs). Model performance was assessed using an independent test set of 50 non-pachychoroid and 50 pachychoroid images.

RESULTS

The final accuracy of AlexNet and VGG-16 was 57.52% for both models. ResNet50, Inception-v3, Inception-ResNet-v2, and Xception showed a final accuracy of 96.31%, 95.25%, 93.40%, and 92.61%, respectively, for the validation set. These models demonstrated accuracy on an independent test set of 78.00%, 86.00%, 90.00%, and 92.00%, and an F1 score of 0.718, 0.841, 0.894, and 0.920, respectively.

CONCLUSION

DL models classified pachychoroid and non-pachychoroid images with good performance. Accurate classification can be achieved using CNN models with deep rather than shallow neural networks.

Efficacy of a novel personalised aflibercept monotherapy regimen based on polypoidal lesion closure in participants with polypoidal choroidal vasculopathy

PURPOSE

To compare the efficacy of aflibercept using a personalised versus fixed regimen in treatment-naïve participants with polypoidal choroidal vasculopathy (PCV).

DESIGN

A 52-week, randomised, open-label, non-inferiority, single-centre study that included participants with symptomatic PCV. Participants were randomised (3:1 ratio) to receive either personalised (n=40) or fixed 8-weekly treatment regimen (n=13). The personalised regimen allowed for either early treat and extend (T&E) after week 12 or late T&E with 3 additional 4-weekly aflibercept injections until week 24 in participants with residual polypoidal lesions (PL) on indocyanine green angiography (ICGA) at week 12.

MAIN OUTCOMES AND MEASURES

Non-inferiority of personalised to fixed regimen for mean change in best-corrected visual acuity (BCVA) from baseline to week 52 (non-inferiority margin: -5 letters). The key secondary outcomes include reduction in central subfield thickness (CSFT) on optical coherence tomography and the anatomical closure of PL on ICGA.

RESULTS

Of the 53 participants, the mean (SD) age was 69.2 (8.1) years, 19 (35.8 %) were male. Personalised group was non-inferior to fixed for the primary end point (+8.1 vs +7.9 letters at week 52, respectively; difference 0.16, 95% CI -2.8 to 2.4, p=0.79). There was greater reduction in mean CSFT (SD) in the personalised versus fixed group (-248.8 (169.9) vs -164.8 (148.9) µm, p=0.03). Closure of PL occurred in 21 (55.2%) and 5 (41.6%) of study eyes in personalised and fixed groups, respectively at week 52 (p=0.41).

CONCLUSIONS

Personalised regimen achieved non-inferior BCVA gain and numerically higher PL closure compared with fixed regimen.

TRIAL REGISTRATION NUMBER

NCT03117634.

One-year comparison of anti-vascular endothelial growth factor and half-dose photodynamic therapies for pachychoroid neovasculopathy

BACKGROUND

To compare 1-year outcomes between anti-vascular endothelial factor (VEGF) therapy and half-dose photodynamic therapy (PDT) for treatment-naive pachychoroid neovasculopathy (PNV) with subretinal fluid (SRF).

METHODS

Consecutive patients with treatment-naive PNV patients with SRF treated with intravitreal anti-VEGF injections or half-dose PDT followed by as-needed schedule with 1-year follow-up were studied retrospectively.

RESULTS

Eighty-two eyes of 82 patients were eligible: 50 eyes underwent anti-VEGF therapy and 32 eyes underwent half-dose PDT. SRF resolved in 41 (82%) of 50 eyes after initial three monthly injections and 31 (96.9%) of 32 eyes 3 months after initial PDT, and 43 (86%) eyes and 30 (94%) eyes 1 year after initial anti-VEGF injection and half-dose PDT, respectively. No significant differences were found in SRF resolution rates 3 months and 1 year after initial treatment between the two treatment groups. Best-corrected visual acuity (BCVA) improved significantly after initial three monthly injections (P = 0.025) and initial PDT (P = 0.022) compared with baseline; the improvements were maintained 1 year after initial treatment in the two treatment groups. No significant differences were found in BCVA between the two treatment groups at baseline and throughout the 1-year follow-up period. Mean (± standard error) numbers of intravitreal injections and PDT over 12 months were 3.7 ± 0.16 and 1.1 ± 0.06, respectively.

CONCLUSIONS

Both treatments are similarly effective on SRF resolution and VA improvement 1 year after the initial treatment. Half-dose PDT may be an option for treatment for PNV. Prospective studies are required to confirm these findings.

Choroidal congestion mouse model: Could it serve as a pachychoroid model?

Pachychoroid spectrum diseases have been described as a new clinical entity within the spectrum of macular disorders. “Pachychoroid” is defined as choroidal thickening associated with dilated outer choroidal vessels often showing retinal pigment epithelium (RPE) degeneration. Although various clinical studies on the pachychoroid spectrum diseases have been conducted, the pathophysiology of pachychoroid has yet to be fully elucidated. In this study, we attempted to establish a mouse model of pachychoroid. We sutured vortex veins in eyes of wild type mice to imitate the vortex vein congestion in pachychoroid spectrum diseases. Fundus photography and ultra-widefield indocyanine green angiography showed dilated vortex veins from the posterior pole to the ampulla in eyes after induction of choroidal congestion. Optical coherence tomography and tissue sections presented choroidal thickening with dilatation of choroidal vessels. The RPE-choroid/retina thickness ratios on the tissue sections in the treated day 1 and day 7 groups were significantly greater than that in the control group (0.19±0.03 and 0.16±0.01 vs. 0.12±0.02, P<0.05 each). Moreover, immunohistochemistry using RPE flatmount revealed focal RPE degeneration in the treated eyes. Furthermore, inflammatory response-related genes were upregulated in eyes with choroidal congestion induction, and macrophages migrated into the thickened choroid. These results indicated that vortex vein congestion triggered some pachychoroid features. Thus, we have established a choroidal congestion mouse model by suturing vortex veins, which would potentially be useful for investigating the pathophysiology of pachychoroid spectrum diseases.

Short-term effect of anti-VEGF for chronic central serous chorioretinopathy according to the presence of choroidal neovascularization using optical coherence tomography angiography

Purpose

To analyze the short-term therapeutic efficacy of intravitreal injection of bevacizumab (IVB) for chronic central serous chorioretinopathy (CSC) according to the presence of choroidal neovascularization (CNV) using optical coherence tomography angiography (OCTA).

Methods

A retrospective chart review was perfomed on cases of CSC with CNV (Group 1: n = 31) and an age-matched cases of CSC without CNV (Group 2: n = 30). The response to IVB was evaluated by changes in best-corrected visual acuity (BCVA), central macular thickness (CMT), choroidal thickness (CT), and pachyvessel diameter. Univariate and multivariate linear regression analyses were performed to identify factors associated with the visual outcome of chronic CSC with CNV after IVB.

Results

At baseline, the CT values differed significantly between Groups 1 and 2 (371.55 ± 67.09 vs. 417.33 ± 71.32 μm, p = 0.01). In Group 1, BCVA improved significantly (p < 0.001), and CMT (p < 0.001), CT (p = 0.001) and pachyvessel diameter (p = 0.045) decreased significantly, after IVB. In Group 2, only pachyvessel diameter (p = 0.001) was significantly smaller after IVB. Univariate analysis showed that the initial CT (B = 0.002, p = 0.026) and pachyvessel diameter (B = 0.002, p = 0.001) significantly affected visual outcome. In multivariate analysis, the initial pachyvessel diameter exhibited significant results (B = 0.002, p = 0.001).

Conclusions

IVB showed less effective short-term outcomes in chronic CSC patients without CNV than in patients with CNV. In chronic CSC with CNV, the short-term visual outcome after IVB was better in patients with a thinner choroid and smaller pachyvessels.

Comparative Analysis of the Clinical Features and Long-Term Outcomes of Pachychoroid Neovasculopathy and Type 1 Neovascular Age-Related Macular Degeneration

Purpose. To evaluate the clinical characteristics and long-term prognosis of pachychoroid neovasculopathy (PCN) when compared with type 1 neovascular age-related macular degeneration (nAMD). Methods. We retrospectively analyzed 30 and 60 patients whose eyes were diagnosed as treatment-naïve PCN or type 1 nAMD, respectively. All subjects were followed up for 5 years. Baseline angiographic characteristics and long-term clinical outcomes were compared between the two groups. Results. PCN group consisted of patients of younger age and represented more choroidal vascular hyperpermeability, polypoidal lesion, and history of central serous chorioretinopathy (CSC) at the time of diagnosis (all $p$  < 0.01). During the 5-year follow-up period, individuals in the PCN group received significantly fewer injections and reported better visual acuity compared to individuals in the type 1 nAMD group. A progressive decrease in the subfoveal choroidal thickness was observed in the type 1 nAMD group, while the thick choroid was maintained in the PCN group during the 5-year follow-up period. Conclusions. PCN developed in younger patients with a higher propensity of forming polypoidal lesions and a history of CSC. Long-term outcomes revealed that PCN had a thicker choroid and better visual prognosis with fewer number of intravitreal injection than that of type 1 nAMD.

Four-year outcome of aflibercept administration using a treat-and-extend regimen in eyes with recurrent neovascular age-related macular degeneration

PURPOSE

To investigate the 4-year outcome of aflibercept treatment using a treat-and-extend (TAE) regimen for recurrent neovascular age-related macular degeneration (AMD).

STUDY DESIGN

Retrospective observational study.

METHODS

Data of eyes with recurrent AMD previously treated with anti-vascular endothelial growth factor agents or photodynamic therapy and had started aflibercept treatment using a TAE regimen for the first time were collected. Best-corrected visual acuity (BCVA), intervals of treatments, the presence of exudation, central foveal thickness (CFT), and central choroidal thickness (CCT) were analyzed.

RESULTS

Of 47 consecutive eyes, 30 of the 47 eyes completed a 4-year follow-up. The mean BCVA (logMAR) was sustained over the 4 years (0.37 at baseline, 0.36 at 1 year, 0.36 at 2 years, 0.41 at 3 years, and 0.43 at 4 years, P = 0.21). Of the 30 eyes that completed the follow-up, BCVA of two eyes deteriorated by 0.3 logMAR or more at 4 years. At 4 years, 67% of eyes had extended treatment intervals to > 8 weeks, and 47% of eyes had extended intervals to > 12 weeks. Exudative changes in the macula, seen in all eyes at baseline, were only seen in 50% of the eyes at 4 years. The mean CFT and CCT decreased significantly at 4 years from 332 μm to 248 μm and from 218 μm to 183 μm, respectively.

CONCLUSION

In clinical settings, aflibercept treatment using a TAE regimen may successfully maintain visual acuity for up to 4 years even in recurrent cases of AMD.

Deep phenotype unsupervised machine learning revealed the significance of pachychoroid features in etiology and visual prognosis of age-related macular degeneration

Unsupervised machine learning has received increased attention in clinical research because it allows researchers to identify novel and objective viewpoints for diseases with complex clinical characteristics. In this study, we applied a deep phenotyping method to classify Japanese patients with age-related macular degeneration (AMD), the leading cause of blindness in developed countries, showing high phenotypic heterogeneity. By applying unsupervised deep phenotype clustering, patients with AMD were classified into two groups. One of the groups had typical AMD features, whereas the other one showed the pachychoroid-related features that were recently identified as a potentially important factor in AMD pathogenesis. Based on these results, a scoring system for classification was established; a higher score was significantly associated with a rapid improvement in visual acuity after specific treatment. This needs to be validated in other datasets in the future. In conclusion, the current study demonstrates the usefulness of unsupervised classification and provides important knowledge for future AMD studies.

Pachychoroid: current concepts on clinical features and pathogenesis

PURPOSE

The term "pachychoroid" refers to a newly described phenotype in which functional and structural choroidal changes are thought to play a key pathogenic role in a spectrum of related retinal disorders. A more detailed understanding of how the choroid is involved within this spectrum and a better knowledge of the most relevant clinical signs of the pachychoroid phenotype are important to differentiate these disorders from other retinal conditions. Our objectives are to provide a literature review of pachychoroid and the commonalities that may be present across pathologies included in the spectrum, and to provide details on the examination, monitoring, and management of these disorders.

METHODS

We searched the PubMed web platform to identify relevant studies using the following keywords: pachychoroid, pachychoroid pigment epitheliopathy, pachychoroid neovasculopathy, aneurysmal type 1 neovascularization, focal choroidal excavation, peripapillary pachychoroid syndrome, vasculopathy pachysclera, pachychoroid geographic atrophy, and pachydrusen. We selected 157 publications and identified the most important features related to pachychoroid.

RESULTS

The presence of hypertrophic or congested vessels in the choroid, not thickened choroid per se, under an area of reduced or absent choriocapillaris in the posterior pole seems to be the most salient feature of pachychoroid. However, other qualitative/quantitative features are needed to differentiate the uncomplicated pachychoroid from the pathological pachychoroid clinical spectrum, which may be associated with exudation, neovascularization, and/or retinal pigment epithelium and photoreceptor atrophy.

CONCLUSIONS

The most salient feature of pachychoroid appears to be the presence of large vessels under an area of reduced or absent choriocapillaris. Knowledge of the features and pathogenesis of the different disorders in the pachychoroid spectrum may assist in the management of patients.

Characteristics of pachychoroid neovasculopathy

Recently, several research groups have reported a newly recognized clinical entity of choroidal neovascularization, termed pachychoroid neovasculopathy. However, its characteristics have yet to be well described. The purpose of this study was to investigate the clinical and genetic characteristics of pachychoroid neovasculopathy regardless of treatment modality. This study included 99 eyes of 99 patients with treatment-naïve pachychoroid neovasculopathy. Mean initial best-corrected visual acuity (BCVA) was 0.20 ± 0.32 logMAR, and did not change (P = 0.725) during follow-up period (mean ± SD, 37.0 ± 17.6 months). Subretinal hemorrhage (SRH) (≥ 4 disc areas in size) occurred in 20 eyes (20.2%) during follow-up. Age, initial BCVA, central retinal thickness, SRH (≥ 4 disc areas in size) and treatment (aflibercept monotherapy) were significantly associated with the final BCVA (P = 0.024, < 0.001, 0.031, < 0.001, and 0.029, respectively). Multiple regression analysis showed initial BCVA and presence of SRH to be significant predictors of final BCVA (both P < 0.001). Polypoidal lesions were more common in the SRH group than in the non-SRH group (85.0% vs 48.1%, P = 0.004). There was no significant difference in the frequency of the risk allele in ARMS2 A69S, CFH I62V, CFH Y402H between these groups (P = 0.42, 0.77, and 0.85, respectively). SRH (29.1% vs 9.1%, P = 0.014) and choroidal vascular hyperpermiability (65.5% vs 43.2%, P = 0.027) were seen more frequently in the polypoidal lesion (+) group than in the polypoidal lesion (−) group. There was considerable variation in lesion size and visual function in patients with pachychoroid neovasculopathy, and initial BCVA and presence of SRH at the initial visit or during the follow-up period were significant predictors of final BCVA.

Polypoidal Choroidal Vasculopathy: Consensus Nomenclature and Non-Indocyanine Green Angiograph Diagnostic Criteria from the Asia-Pacific Ocular Imaging Society PCV Workgroup

PURPOSE

To develop consensus terminology in the setting of polypoidal choroidal vasculopathy (PCV) and to develop and validate a set of diagnostic criteria not requiring indocyanine green angiography (ICGA) for differentiating PCV from typical neovascular age-related macular degeneration (nAMD) based on a combination of OCT and color fundus photography findings.

DESIGN

Evaluation of diagnostic test results.

PARTICIPANTS

Panel of retina specialists.

METHODS

As part of the Asia-Pacific Ocular Imaging Society, an international group of experts surveyed and discussed the published literature regarding the current nomenclature and lesion components for PCV, and proposed an updated consensus nomenclature that reflects our latest understanding based on imaging and histologic reports. The workgroup evaluated a set of diagnostic features based on OCT images and color fundus photographs for PCV that may distinguish it from typical nAMD and assessed the performance of individual and combinations of these non-ICGA features, aiming to propose a new set of diagnostic criteria that does not require the use of ICGA. The final recommendation was validated in 80 eyes from 2 additional cohorts.

MAIN OUTCOME MEASURES

Consensus nomenclature system for PCV lesion components and non-ICGA-based criteria to differentiate PCV from typical nAMD.

RESULTS

The workgroup recommended the terms polypoidal lesion and branching neovascular network for the 2 key lesion components in PCV. For the diagnosis of PCV, the combination of 3 OCT-based major criteria (sub-retinal pigment epithelium [RPE] ring-like lesion, en face OCT complex RPE elevation, and sharp-peaked PED) achieved an area under the receiver operating characteristic curve of 0.90. Validation of this new scheme in a separate subset 80 eyes achieved an accuracy of 82%.

CONCLUSIONS

We propose updated terminology for PCV lesion components that better reflects the nature of these lesions and is based on international consensus. A set of practical diagnostic criteria applied easily to spectral-domain OCT results can be used for diagnosing PCV with high accuracy in clinical settings in which ICGA is not performed routinely.

Long-term follow-up of quiescent choroidal neovascularisation associated with age-related macular degeneration or pachychoroid disease

AIMS

To evaluate the long-term progression of quiescent type 1 choroidal neovascularisation (CNV) associated with age-related macular degeneration (AMD) or with pachychoroid disease.

METHODS

All cases of quiescent type 1 CNV with a minimum follow-up of 12 months seen at the Department of Ophthalmology of University Paris Est, Creteil and at the Centre Ophtalmologique de l'Odeon, Paris, between June 2009 and December 2018 were retrospectively reviewed. Optical coherence tomography angiography (OCT-A) of eyes not showing CNV activation during 24 months was evaluated for quantitative analyses of CNV status biomarkers (fractal dimension, lacunarity, vessel density, aspect ratio, CNV area).

RESULTS

A total of 67 eyes (65 patients, 43 females, mean age 76.63±9.7 years) with quiescent CNV and a mean follow-up of 49.56±27.3 (12-112) months were included. Of 28 eyes showing activation of quiescent CNV, 12 eyes with pachychoroid-associated CNV showed reduced visual loss (-3.28 ETDRS letters, p=0.7 vs -13.03 ETDRS letters, p=0.02), greater choroidal thinning (-59.5 µm, p=0.03 vs - 16.36 µm, p=0.3) and needed less antivascular endothelial growth factor intravitreal injections (IVI) (0.09 vs 0.21, p=0.01) than 16 eyes with AMD-associated CNV. CNV area was the only OCT-A biomarker to significantly change during 24 months in inactive quiescent CNV (+29.5%, p=0.01, in pachychoroid group and +27.1%, p=0.03, in the AMD group).

CONCLUSION

In the long-term follow-up, inactive quiescent CNV showed an increase of CNV area without significant changes of the other OCT-A biomarkers. Quiescent type 1 CNV undergoing activation showed greater response to IVI when associated to pachychoroid.

Pachychoroid neovasculopathy: a type-1 choroidal neovascularization belonging to the pachychoroid spectrum-pathogenesis, imaging and available treatment options

PURPOSE

The purpose of this paper is to provide a meaningful literature review about the epidemiology, pathogenesis, imaging and treatment of pachychoroid neovasculopathy (PNV).

METHODS

A computerized search from inception up to December 2019 of the online electronic database PubMed was performed using the following search string: "pachychoroid neovasculopathy". The reference list in each article was scanned for additional relevant publications.

RESULTS

PNV is a type-1 choroidal neovascularization, overlying focal areas of choroidal thickening and dilated choroidal vessels. It can develop in patients affected by pachychoroid pigment epitheliopathy or chronic central serous chorioretinopathy. The absence of drusen, the presence of pachydrusen, younger age of onset and choroidal thickening distinguish it from neovascular age-related macular degeneration (AMD). PNV incidence and prevalence data are lacking. Its pathophysiology is not fully understood, but angiogenic mechanisms involved in neovascular AMD may be different from those in PNV. Due to optical coherence tomography (OCT) improvements, PNV can be diagnosed more easily than before. In particular, PNV shows a shallow pigment epithelium detachment with an undulating retinal pigment epithelium over a subfoveal choroidal thickening, associated with vein enlargement in Haller's layer (named pachyvessels) and choriocapillaris thinning. On OCT angiography, PNV reveals tangled hyper-reflective filamentous neovessels in the choriocapillaris itself. The current first-line PNV treatment is intravitreal anti-VEGF (vascular endothelial growth factor) injections with a treat-and-extend regimen. In particular, aflibercept shows a higher rate of fluid absorption than others. In the case of fluid recurrence or persistence, photodynamic therapy is a valid alternative.

CONCLUSION

Ongoing research into pathophysiology and imaging improvements may be helpful in defining prognostic criteria and stratifying patient risk, allowing responsible monitoring and management of PNV.

Classification of pachychoroid disease on ultrawide-field indocyanine green angiography using auto-machine learning platform

AIMS

Automatic identification of pachychoroid maybe used as an adjunctive method to confirm the condition and be of help in treatment for macular diseases. This study investigated the feasibility of classifying pachychoroid disease on ultra-widefield indocyanine green angiography (UWF ICGA) images using an automated machine-learning platform.

METHODS

Two models were trained with a set including 783 UWF ICGA images of patients with pachychoroid (n=376) and non-pachychoroid (n=349) diseases using the AutoML Vision (Google). Pachychoroid was confirmed using quantitative and qualitative choroidal morphology on multimodal imaging by two retina specialists. Model 1 used the original and Model 2 used images of the left eye horizontally flipped to the orientation of the right eye to increase accuracy by equalising the mirror image of the right eye and left eye. The performances were compared with those of human experts.

RESULTS

In total, 284, 279 and 220 images of central serous chorioretinopathy, polypoidal choroidal vasculopathy and neovascular age-related maculopathy were included. The precision and recall were 87.84% and 87.84% for Model 1 and 89.19% and 89.19% for Model 2, which were comparable to the results of the retinal specialists (90.91% and 95.24%) and superior to those of ophthalmic residents (68.18% and 92.50%).

CONCLUSIONS

Auto machine-learning platform can be used in the classification of pachychoroid on UWF ICGA images after careful consideration for pachychoroid definition and limitation of the platform including unstable performance on the medical image.

Characteristics of Pachychoroid Diseases and Age-Related Macular Degeneration: Multimodal Imaging and Genetic Backgrounds

The emergence of pachychoroid disease is changing the concept of age-related macular degeneration (AMD). The concept of pachychoroid diseases was developed through clinical observation of multimodal images of eyes with AMD and central serous chorioretinopathy; however, recent genetic studies have provided a proof of concept for pachychoroid spectrum disease, which should be differentiated from drusen-driven AMD. The genetic confirmation of pachychoroid concept further provides novel viewpoints to decode previously reported findings, which facilitates an understanding of the true nature of pachychoroid diseases and AMD. The purpose of this review was to elucidate the relationship between pachychoroid diseases and AMD by interpreting previous findings on pachychoroid diseases and AMD from the novel viewpoints of genetic associations. We confirmed that previous genetic studies supported the concept of pachychoroid diseases. From a genetic viewpoint, the presence of thick choroid and the presence of choroidal vascular hyperpermeability were important characteristics of pachychoroid spectrum diseases. Previous studies have also suggested the classification of polypoidal choroidal vasculopathy (PCV) into two subtypes, pachychoroid neovasculopathy and drusen-driven PCV. Genetic viewpoints will be beneficial to rearrange subtypes of drusen-driven AMD and pachychoroid spectrum diseases. Further genetic studies are needed to investigate pachyvessels, pachydrusen and the significance of polypoidal lesions in pachychoroid neovasculopathy and drusen-driven AMD/PCV.

Comparison of different morphologies of choroidal neovascularization evaluated by ocular coherence tomography angiography in age-related macular degeneration

IMPORTANCE

The clinical implications of different morphologies of choroidal neovascularization (CNV), as evaluated by ocular coherence tomography angiography (OCTA) in neovascular age-related macular degeneration (nAMD), are lacking.

BACKGROUND

To describe the morphology of CNV in nAMD using OCTA, and to compare the visual prognosis and other structural OCT biomarkers between different morphologic patterns.

DESIGN

Retrospective cohort study.

PARTICIPANTS

One hundred and forty eyes with nAMD treated with anti-vascular endothelial growth factor (VEGF).

METHODS

Patients were examined using OCTA prior to and at 3, 6 and 12 months after receiving anti-VEGF therapy.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA) and morphologic retinal features.

RESULTS

Organized CNV was identified in 110/140 eyes (78.6%) using OCTA. These CNV complexes could be divided into three OCTA patterns: the 'medusa' pattern (n = 41), characterized by branching vessels radiating in all directions; the 'seafan' pattern (n = 43), characterized by branching vessels radiating to one side of the lesion; and the 'tangled' pattern (n = 26), characterized by globular entwined vessels without a main trunk. At baseline, the eyes with the tangled pattern were from younger patients (P = .031) with better BCVA (P = .007). There were also fewer intraretinal cysts (P = .021), less fibrovascular pigment epithelial detachment (P = .009), and more pachychoroid (P = .007) in eyes with the tangled pattern on OCT. At 12 months post-treatment, patients with the tangled CNV pattern also showed greater visual improvement than patients with the other two patterns (P = .049).

CONCLUSIONS AND RELEVANCE

Using OCTA, distinct morphologies of CNV in nAMD patients were identified. These different patterns might be useful predictors for the prognosis of nAMD patients after anti-VEGF therapy.

Treatment outcomes of pachychoroid neovasculopathy with photodynamic therapy and anti-vascular endothelial growth factor

Purpose:

To describe treatment outcomes of eyes with pachychoroid neovasculopathy (PNV) with PDT and anti-(vascular endothelial growth factor) VEGF therapy.

Methods:

Retrospective interventional case series. Records of six consecutive cases of PNV were reviewed. Four cases were treated with PDT+ inj ranibizumab. Two cases underwent only PDT. Final visual outcomes and functional outcome including macular status and choroidal thickness were assessed.

Results:

We analysed six eyes of six patients with PNV. There were four males and two females. Mean age of the patients was 56.5 years. Mean duration of follow up was 8.2 months. All patients received reduced fluence PDT. Four patients received ranibizumab along with PDT; mean BCVA at presentation was 0.41 log MAR units and mean BCVA at final follow up was 0.44 log MAR units. There was significant improvement at final follow up (P = 0.03). Mean subfoveal choroidal thickness (SFCT) at presentation was 445 microns and mean SFCT at final follow up was 293 microns. There was a significant reduction at final follow up (P = 0.02).

Conclusion:

PDT with or without ranibizumab appears to be an effective treatment modality for PNV.