Association of lesion size and visual prognosis to polypoidal choroidal vasculopathy

Efficacy of Brolucizumab in Polyp Regression of Treatment-Naive Polypoidal Choroidal Vasculopathy and Its Effect on 1-Year Treatment Outcome

PURPOSE

To evaluate the efficacy of intravitreal brolucizumab in polyp regression of treatment-naive polypoidal choroidal vasculopathy (PCV) patients and its effect on 1-year treatment outcome.

METHODS

Medical records of 31 treatment-naive PCV patients, who received three monthly intravitreal brolucizumab injections followed by as-needed injections for at least a year, were retrospectively reviewed. Visual and anatomical outcomes were evaluated at 3, 6, and 12 months. Complete polyp regression rate and percentage change of vascular lesion and polyp area were evaluated after three monthly injections of brolucizumab. The effect of complete polyp regression and the impact of vascular lesion and polyp reduction rate on 1-year treatment outcome were also evaluated.

RESULTS

In terms of visual outcome, best-corrected visual acuity significantly improved after 12-month follow-up (p < 0.001). In terms of anatomical outcome, central macular thickness (CMT) and central choroidal thickness significantly decreased after 12-month follow-up (p < 0.001). Complete polyp regression was observed in 23 patients (74.2%) after three monthly injections. Group with complete polyp regression had a higher rate of achieving dry macula at 3 months (p = 0.026) and fewer number of injections (p < 0.001) compared to the group without complete polyp regression. Higher polyp reduction rate was significantly associated with higher CMT change from baseline at 3 months (p = 0.048) while higher vascular lesion reduction rate was significantly associated with higher CMT change from baseline at 12 months (p = 0.031) and fewer number of injections (p = 0.012).

CONCLUSIONS

Intravitreal brolucizumab injection effectively improved visual and anatomical outcomes and achieved significant polyp regression in treatment-naive PCV patients. Complete polyp regression and the reduction rate of vascular lesion size and polyp size after loading injection significantly influence the treatment outcome of PCV patients. However, careful monitoring and preoperative warning is warranted due to occurrence of brolucizumab-related IOI.

Etiological Factors and Visual Outcomes of Dense Vitreous Hemorrhage in Patients Aged 80 years and above over the Past Decade in a Tertiary General Hospital

This study aimed to investigate the main etiological factors and visual outcomes in patients with dense vitreous hemorrhage (DVH) aged ≥80 years. We retrospectively included patients with DVH aged ≥80 years who were admitted to our ophthalmology department between January 1, 2010, and December 31, 2019. All patients underwent pars plana vitrectomy (PPV). Data regarding demographic characteristics; preoperative and postoperative best-corrected visual acuity (BCVA), intraocular pressure (IOP), and ophthalmic B-scan ultrasonography findings; intraoperative conditions; and postoperative complications were collected and analyzed. A total of 44 patients (44 eyes) were enrolled, with a median age of 82 years; among them, 25 patients (56.82%) were men. The median preoperative BCVA was 2.3 (1.1-3.0). The main etiological factors included retinal vein occlusion (RVO) (20 eyes, 45.45%), polypoidal choroidal vasculopathy (PCV) (15 eyes, 34.09%), proliferative diabetic retinopathy (PDR) (7 eyes, 15.90%), retinal arterial macroaneurysm (RAM) (1 eye, 2.27%), and posterior vitreous detachment (PVD) (1 eye, 2.27%). The median final BCVA was 1.92 (0.5-2.6). There was a significant postoperative improvement in the BCVA; moreover, branch RVO (BRVO) had a better postoperative visual prognosis than central RVO (CRVO), PCV, and PDR (P < 0.05). The final postoperative BCVA was significantly better when the initial BCVA was above hand motion (HM) than when it was HM or lower (P < 0.05). Our findings indicate that RVO, PCV, and PDR were the main causes of DVH. Microinvasive PPV is a safe and effective method that can clarify diagnosis and improve BCVA. Patients with BRVO and preoperative BCVA > HM may have a relatively good visual prognosis. For patients aged ≥80 years who have an appropriate general condition, PPV can be timely performed to treat DVH.

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.

Recurrence and visual prognostic factors of polypoidal choroidal vasculopathy: 5-year results

This retrospective study aimed to evaluate the factors affecting recurrence and visual prognosis in patients with treatment-naïve subfoveal polypoidal choroidal vasculopathy (PCV). Patients who had received three consecutive intravitreal injections of ranibizumab or aflibercept and had reached remission were enrolled. They were divided into a group without recurrence (group 1, 26 eyes) and a group with recurrence (group 2, 121 eyes) and followed up for at least 5 years. Patients in group 2 received additional treatment for worsening. Logistic regression analysis revealed that a young age of onset (P = 0.001), high choroidal vascularity index (CVI; P = 0.019), and presence of choroidal vascular hyperpermeability (CVH; P = 0.037) were associated with a low risk of recurrence. Multiple regression analysis revealed that recurrence (P = 0.001), greatest linear dimension (P = 0.003), and polyp configuration (single or cluster; P = 0.043) were associated with final visual acuity. Patients without recurrence had a lower age of onset and higher CVI than those with recurrence, and they tended to have CVH. In addition, patients with recurrence, large lesion, and cluster polyps had worse final visual acuity than those without these factors. CVI and CVH may be used to predict recurrence of PCV.

Association between Vortex Vein Engorgement and Treatment Outcomes of Intravitreal Aflibercept for Polypoidal Choroidal Vasculopathy

Purpose: To investigate the influence of the number of engorged vortex veins on treatment outcomes in eyes with treatment-naïve polypoidal choroidal vasculopathy (PCV) undergoing intravitreal aflibercept monotherapy.Methods: The medical charts of 65 patients with PCV who underwent intravitreal aflibercept injection were reviewed retrospectively. The number of quadrants of vortex vein engorgement was evaluated in the middle phase of ultra-widefield indocyanine green angiography, which was classified as extended engorgement if the dilated choroidal vessels expanded the macula. Associations between treatment outcomes with age, subfoveal choroidal thickness (SFCT), central retinal thickness, and vortex vein engorgement were investigated using univariate and multivariate analyses.Results: There were no significant differences in best-corrected visual acuity (BCVA), SFCT, and central retinal thickness at baseline and 12 months, according to the number of vortex vein engorgement. However, an increase in the number of vortex vein engorgement extending to the macula was associated with a thick SFCT (p = 0.038), a greater number of injections (p = 0.041), low BCVA at 12 months (p = 0.038), and a less dry macula at 12 months (p = 0.026). In the multivariate analysis, the number of quadrants with vortex vein engorgement extending to the macula was significantly associated with BCVA changes at 12 months, total number of injections, and a dry macula at 12 months (p = 0.030, p = 0.030, p = 0.020, respectively).Conclusions: More quadrants with vortex vein engorgement extending to the macula in PCV was associated with unfavorable visual outcomes, a less dry macula at 12 months, and a greater number of injections at 1 year after intravitreal aflibercept injection. Clinicians should keep in mind that vortex vein engorgement extending to the macula may be a new biomarker in predicting treatment outcomes in PCV.

Clinical features and prognosis of polypoidal choroidal vasculopathy with different morphologies of branching vascular network on optical coherence tomography angiography

This study highlights the clinical features and treatment response of polypoidal choroidal vasculopathy (PCV) among three different branching vascular network (BVN) morphologies in optical coherence tomography angiography (OCTA), and further correlates the BVN features with those under fluorescent angiography (FA) and indocyanine green angiography (ICGA). In total, we reviewed 70 eyes with PCV followed up for > 12 months. OCTA, ICGA and FA images were obtained at baseline and post-treatments. BVN was assessed using OCTA and divided into three types by a previously described BVN classification: type 1 (trunk), type 2 (glomeruli), and type 3 (stick). At baseline, type 1 BVN had the poorest vision and thinnest subfoveal choroidal thickness (SFCT), whereas type 3 had the best vision and thickest SFCT. The aforementioned trend sustained after treatments. Each BVN morphology in OCTA showed typical features in FA + ICGA and encompassed significant correlation (p = 0.004). In conclusion, OCTA is an innovative imaging tool for the detection and classification of BVN in PCV. Furthermore, OCTA has advantages of being noninvasive and free of systemic toxicities. The BVN can be divided into three types based on morphological characteristics in OCTA, which play crucial roles in clinical presentations and treatment outcomes.

Comparative analysis of polypoidal choroidal vasculopathy with and without hemorrhage treated by anti-VEGF monotherapy

PURPOSE

Visual function and treatment response after anti-vascular endothelial growth factor monotherapy were compared between polypoidal choroidal vasculopathy (PCV) with and without hemorrhage.

METHODS

We conducted a retrospective, observational study (mean, 26 months) for 49 eyes of 49 treatment-naive patients with PCV. Patients were classified into PCV with hemorrhage (26 eyes) or without hemorrhage (23 eyes). PCV with massive hemorrhage subgroup has four or more disc-hemorrhagic areas and included five eyes.

RESULTS

There were no significant differences in patient age, sex, systolic blood pressure, diastolic blood pressure, presence of choroidal vascular hyperpermeability, number of polyps, maximum polyp size, lesion area, and presence of pigment epithelium detachment (PED) between the two groups. Except for the course of PCV-related hemorrhage, treatment number and its response were similar between the groups. Best-corrected visual acuity at the last visit in PCV with hemorrhage was 0.33 ± 0.51 logMAR (20/41) comparable with 0.28 ± 0.41 logMAR (20/38) without hemorrhage at the last visit (p = 0.944). Maximum polyp size in massive hemorrhagic PCV was significantly larger (314.6 ± 111.4 μm) than that of small hemorrhagic PCV (229.0 ± 119.1 μm; p = 0.037). All PCV with massive hemorrhage was accompanied by large hemorrhagic PED.

CONCLUSION

There were no significant differences in the baseline characteristics, treatment intervention, or suppression of disease activity between PCV with and without hemorrhage. Final visual acuity of PCV did not differ with or without hemorrhage. Development of massive hemorrhaging in PCV may be associated with both large polyps and hemorrhagic PED.

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.

Long-Term Outcomes of Switching from Fixed-Dose to As-Needed Regimen for Treating Submacular Hemorrhage Secondary to Polypoidal Choroidal Vasculopathy

Background: The aim of this study was to evaluate outcomes in patients with submacular hemorrhage secondary to polypoidal choroidal vasculopathy (PCV) after switching treatment from a fixed-dose to an as-needed regimen. Methods: This retrospective study included 19 patients with submacular hemorrhage secondary to PCV who were treated with fixed-dose intravitreal aflibercept during the first 56 weeks. After 56 weeks, the treatment regimen was switched to an as-needed regimen. The incidence and timing of lesion reactivation during the as-needed phase were evaluated. The best-corrected visual acuity (BCVA) at baseline (beginning of the regimen) and the final follow-up were compared. Multivariate analysis was performed to determine the factors associated with lesion reactivation. Results: During the mean follow-up period of 27 ± 7.3 months, lesion reactivation was noted in 10 patients (52.6%; mean time period: 12.2 ± 9.1 months) in the as-needed phase. Reactivations were treated with anti-vascular endothelial growth factor (VEGF) injections (mean, 4.1 ± 2.6). The mean logarithm of the minimum angle of resolution (logMAR) BCVA was 0.26 ± 0.34 at baseline and 0.31 ± 0.38 at final follow-up (p = 0.212). Deterioration of ≥0.2 logMAR BCVA was noted in two patients (10.5%). In multivariate analysis, large lesion size was closely associated with a high risk of lesion reactivation (p = 0.009). Conclusion: Visual acuity was relatively stable after switching from a fixed-dose to an as-needed regimen, with no definite visual deterioration in the majority of patients. We conclude that patients with large lesions should be carefully monitored when switching to an as-needed regimen.

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.

Latest Developments in Polypoidal Choroidal Vasculopathy: Epidemiology, Etiology, Diagnosis, and Treatment

Polypoidal choroidal vasculopathy (PCV) is a condition characterized by multiple, recurrent, serosanguineous pigment epithelial detachments, and neurosensory retinal detachments due to abnormal aneurysmal neovascular lesions. It is generally considered as a variant of neovascular age-related macular degeneration, but there are some differences between the clinical presentation, natural history, and treatment response between patients with PCV and typical neovascular age-related macular degeneration patients. Over the past decade, new research and technological advancements have greatly improved our understanding of the PCV disease process and the management of PCV. This review aims to summarize the recent research findings to highlight the epidemiology, pathogenesis, genetics, the application of various diagnostic tools for PCV, and the available treatment options for PCV.

Effectiveness of polypoidal lesion-selective photodynamic therapy with intravitreal antivascular endothelial growth factor for polypoidal choroidal vasculopathy

PURPOSE

To evaluate the 24-month effectiveness of polypoidal lesion-selective photodynamic therapy (PDT) combined with antivascular endothelial growth factor (VEGF) therapy for polypoidal choroidal vasculopathy (PCV) with branching vascular networks (BVNs) involving the fovea with 1 or more polyps.

STUDY DESIGN

A retrospective case series.

PATIENTS AND METHODS

Twenty-six eyes from 25 PCV patients treated with polypoidal lesion-selective PDT combined with aflibercept were included in the study. The main outcome measure was change in best-corrected visual acuity (BCVA), and the secondary outcome measures were changes in central retinal thickness and subfoveal choroidal thickness on optical coherence tomography (OCT), status of exudation at 24 months, and number of additional treatments.

RESULTS

Fourteen eyes of 14 patients showed treatment-naïve PCV, and 12 eyes of 11 patients were switched from anti-VEGF monotherapy. The baseline mean logMAR BCVA was 0.43, and this had increased significantly, by 0.31, at 24 months (P = .034). The mean central retinal thickness (CRT) and central choroidal thickness (CCT) were significantly lower at all time points than those at baseline. The mean number of additional injections of aflibercept was 3.1 (range, 0-9), and that of additional PDT treatments was 0.5 (range, 0-2).

CONCLUSION

Polypoidal lesion-selective PDT with aflibercept was effective for relatively large, fovea-involved PCV, with significant visual improvement at 24 months.

Five-year outcomes of photodynamic therapy combined with intravitreal injection of ranibizumab or aflibercept for polypoidal choroidal vasculopathy

We report 5-year visual and anatomical outcomes after combination therapy of photodynamic therapy (PDT) and intravitreal injection of ranibizumab or aflibercept for polypoidal choroidal vasculopathy (PCV) and predictive factors for visual outcomes at 5-year and time to recurrence. Medical charts were retrospectively reviewed for 43 consecutive eyes with PCV treated with combination therapy of PDT and intravitreal injection of ranibizumab(n = 13) or aflibercept(n = 30) and completed 5-year follow-up. The variants of ARMS2 A69S and CFH I62V were genotyped using TaqMan assay. Best corrected visual acuity (BCVA) significantly improved at 5-year (P = 0.01) with 20% reduction of subfoveal choroidal thickness irrespective of presence or absence of recurrence. Visual improvement was associated with baseline shorter greatest linear dimension (GLD) (P = 1.0×10-4). Mean time to recurrence was 28.6±23.1 months (95% CI: 21.5-35.7, Median:18.0) and time to recurrence was associated with G allele (protective allele) of ARMS2 A69S and GLD (P = 4.0×10-4 and 1.0×10-2, respectively). Multiple regression analysis revealed that time to recurrence extended by 15.5 months when the G allele of ARMS2 A69S increased by one allele (TT: 15.7±17.0, TG: 30.8±23.5, GG: 41.1±22.6 months). The combination therapy resulted in a favorable visual outcome for PCV during 5-year follow-up.

Dynamic changes in choroidal conditions during anti-vascular endothelial growth factor therapy in polypoidal choroidal vasculopathy

We defined the relationships between initial choroidal conditions and their dynamics and exudative changes during anti-vascular endothelial growth factor (anti-VEGF) therapy in polypoidal choroidal vasculopathy (PCV). One hundred treatment-naïve eyes of 100 patients with PCV treated for 24 months at Keio University Hospital with intravitreal ranibizumab or aflibercept monotherapy (three injections and PRN thereafter) were retrospectively analyzed. Wet macula risk after three induction injections, which affected visual prognosis, was predicted by initial pachyvessels in the choroid (foveal greatest vertical choroidal vessel diameter [CVD] ≥180 μm) and pachychoroid (central choroidal thickness [CCT] ≥220 μm) recorded by optical coherence tomography. The risk for recurrent exudative change was greater in the pachyvessel groups irrespective of presence or absence of pachychoroid. Mean CVD and CCT decreased with anti-VEGF therapy when achieving a dry macula, suggesting that exudative changes are regulated by VEGF. Mean CVD and CCT at remission were greater in patients with initial pachyvessels and pachychoroid than in those without; the basal levels of CVD and CCT most likely represent VEGF-unrelated conditions. CVD increase preceded CCT increase and recurrent exudative changes, suggesting that the VEGF-related CVD increase may regulate CCT and exudative change; and that CVD may be a biomarker of exudative change.

Therapeutic effects of ranibizumab in patients with polypoidal choroidal vasculopathy

Background

There is no consensus on the optimal initial treatment for polypoidal choroidal vasculopathy (PCV). Our study aimed to report the efficacy of repeated injections of intravitreal ranibizumab with or without photodynamic therapy for the treatment of PCV and to determine the possible factors predictive of visual outcomes.

Methods

The results of the initial treatment of 40 patients with PCV with 3 monthly injections of ranibizumab were retrospectively reviewed. We compared the results in terms of the best corrected visual acuity (BCVA), the central retinal thickness (CRT), the number of injections, the regression rates of polyps and the rates of the reduction of subretinal fluid.

Results

At the 3-month follow-up, the mean BCVA was significantly increased by 7.3 ± 12.4 letters compared to baseline (p < 0.01). At the 12-month follow-up, the mean BCVA was increased by 3.4 ± 15.4 letters compared to baseline, and there was no significant difference (p > 0.05). The mean CRT at the 12-month follow-up was 593.58 ± 243.64 μm, with an average decrease of 101.55 ± 256.07 μm compared to baseline (p < 0.01). Fifteen eyes (18.8%) showed the complete regression of polyps, and 22 eyes (27.5%) showed a reduction in polyps. The baseline VA, the reduction in subretinal fluids and the greatest lesion diameter were significant independent factors that were predictive of improved VA at the final follow-up.

Conclusions

Three monthly injections of ranibizumab as an initial treatment could significantly improve VA in PCV patients in the short term. At 12 months postinjection, ranibizumab treatment could stabilize VA in most PCV patients. The baseline VA, the reduction in subretinal fluids and the greatest lesion diameter were predictive factors for the relative improvement of VA at the final follow-up.

Intravitreal aflibercept for active polypoidal choroidal vasculopathy without active polyps

The purpose of this study was to evaluate the efficacy of intravitreal aflibercept for active polypoidal choroidal vasculopathy (PCV) without active polyps and to identify prognostic factors. We enrolled 40 eyes from 40 patients who manifested PCV with exudation but without active polyps after prior treatment with photodynamic therapy (PDT) and/or anti-vascular endothelial growth factor (VEGF) other than aflibercept. Participants were initially given three consecutive intravitreal injections of aflibercept at 1-month intervals, followed by injections every 2 months in the maintenance phase. Spectral-domain optical coherence tomographic and indocyanine green angiographic features were assessed to determine associations between anatomical parameters and visual outcomes 14 months later. Mean visual acuity improved from 61.5 ± 11.1 letters at baseline to 68.1 ± 13.6 letters at 14 months (P = 0.001). Better vision and a smaller branching vascular network at baseline and 1 month after three monthly injections (visit 4) were associated with better final vision (P < 0.001). The presence of an inner retinal cyst at visit 4 was significantly related to worse final vision (P = 0.011). Intravitreal aflibercept improved the visual and anatomical outcomes of PCV with exudation from BVN after pre-treatment with PDT and/or anti-VEGF other than aflibercept. Better vision, smaller lesion size, and absence of an inner retinal cyst after induction therapy may predict better visual outcome.

Five-year visual outcomes after anti-VEGF therapy with or without photodynamic therapy for polypoidal choroidal vasculopathy

BACKGROUND/AIMS

To evaluate the 5-year visual and anatomical outcomes after anti-vascular endothelial growth factor (VEGF) therapy alone or in combination with photodynamic therapy (PDT), followed by pro re nata (PRN) anti-VEGF therapy with or without PDT, for polypoidal choroidal vasculopathy (PCV).

METHODS

This retrospective, observational study included 61 consecutive patients with treatment-naïve symptomatic PCV who were followed for 5 years. Twenty eyes (20 patients) initially received PDT and intravitreal injection of ranibizumab (IVR), followed by a PRN regimen of anti-VEGF therapy with or without PDT (combination group), while 41 eyes (41 patients) initially received only IVR every 3 months, followed by a PRN regimen of anti-VEGF monotherapy (IVR group). Macular atrophy including the fovea was confirmed using colour fundus photography and spectral-domain optical coherence tomography.

RESULTS

In both groups, the visual acuity (VA) at 1 year was better than the baseline VA, whereas the 3-year, 4-year and 5-year VA values were similar to the baseline VA. There was no significant difference in the 5-year VA, 5-year central retinal thickness and incidence of macular atrophy between the two groups (p=0.63, 0.72 and 0.06, respectively). In the combination group, the 5-year VA was correlated with the 5-year incidence of macular atrophy (p=0.02, r=0.51).

CONCLUSIONS

A PRN regimen for PCV may have a limited effect for the long-term maintenance of improved VA. Macular atrophy may occur more frequently with combination therapy and is possibly associated with the 5-year VA. Thus, combination therapy should be carefully selected for patients susceptible to macular atrophy.

CHOROIDAL THICKNESS AS A PROGNOSTIC FACTOR OF PHOTODYNAMIC THERAPY WITH AFLIBERCEPT OR RANIBIZUMAB FOR POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To investigate factors associated with visual improvement and retreatment 12 months after a combination therapy of intravitreal injection of ranibizumab or aflibercept followed by photodynamic therapy for polypoidal choroidal vasculopathy.

METHODS

Changes in the best-corrected visual acuity and the subfoveal thickness of the retina and choroid were studied in 56 consecutive eyes with polypoidal choroidal vasculopathy treated initially with a combination therapy of either intravitreal ranibizumab injection (n = 23) or intravitreal aflibercept injection (n = 33) followed by photodynamic therapy. Factors associated with visual improvement and retreatment were investigated.

RESULTS

Best-corrected visual acuity significantly improved with significant reduction in central macular thickness and subfoveal choroidal thickness at all points irrespective of treatment modalities (P < 0.001). Better best-corrected visual acuity and improvement of best-corrected visual acuity at 12 months were associated with baseline greater subfoveal choroidal thickness (P = 0.028 and P = 0.028) and baseline smaller greatest linear dimension (P = 0.0077 and P = 0.0077). Retreatment during 12-month follow-up was associated with baseline lesser subfoveal choroidal thickness (P = 0.036).

CONCLUSION

Irrespective of treatment modalities, the visual outcome at 12 months is favorable in eyes with polypoidal choroidal vasculopathy treated by photodynamic therapy combined with intravitreal ranibizumab or aflibercept. Baseline greater subfoveal choroidal thickness was associated with a better visual outcome and with reduction in the need for retreatment.

A 5-year multicenter prospective cohort study on the long-term visual prognosis and predictive factors for visual outcome in Japanese patients with age-related macular degeneration: the AMD2000 study

PURPOSE

In this study (AMD2000), we aimed to determine the visual prognosis of Japanese patients with age-related macular degeneration (AMD).

METHODS

This was a multicenter prospective observational cohort study. In total, 460 patients with AMD were recruited from April 2006 to March 2009 from 18 clinical trial sites in Japan. They were followed up for 5 years, as they continued to receive medical treatment.

RESULTS

Of the 409 study eyes followed up for at least 1 year, 243 eyes (59.4%) were treated with photodynamic therapy (PDT) using verteporfin, and 58 eyes (14.2%) were treated with intravitreal injections of antivascular endothelial growth factor agents as the initial treatment. The mean best-corrected visual acuities (BCVA) for typical AMD (tAMD; 0.688 ± 0.498) and polypoidal choroidal vasculopathy (PCV; 0.451 ± 0.395) were significantly less at 2 years (tAMD, 0.779 ± 0.632, P < 0.05; PCV, 0.534 ± 0.618, P < 0.05) and at 5 years (AMD, 0.873 ± 0.718, P < 0.05; PCV, 0.635 ± 0.668, P < 0.05) than at baseline. In eyes with tAMD, absence of blocked fluorescence was associated with 5-year maintenance of the baseline BCVA. Regarding PCV, the presence of polypoidal lesions and cystoid macular edema as well as the lesion size was associated with 5-year maintenance of the baseline BCVA. In some patients, the diagnosis changed: of the 192 eyes initially diagnosed with typical AMD, 19 were newly diagnosed with PCV during follow-up.

CONCLUSION

Maintaining the baseline BCVA over the long term is difficult in Japanese eyes with wet AMD.

Proteolytic Degradation and Inflammation Play Critical Roles in Polypoidal Choroidal Vasculopathy

Polypoidal choroidal vasculopathy (PCV) is a common subtype of wet age-related macular degeneration in Asian populations, whereas choroidal neovascularization is the typical subtype in Western populations. The cause of PCV is unknown. By comparing the phenotype of a PCV mouse model expressing protease high temperature requirement factor A1 (HTRA1) in retinal pigment epithelium with transgenic mice expressing the inactive HTRA1S328A, we showed that HTRA1-mediated degradation of elastin in choroidal vessels is critical for the development of PCV, which exhibited destructive extracellular matrix remodeling and vascular smooth muscle cell loss. Compared with weak PCV, severe PCV exhibited prominent immune complex deposition, complement activation, and infiltration of inflammatory cells, suggesting inflammation plays a key role in PCV progression. More important, we validated these findings in human PCV specimens. Intravitreal delivery of an HTRA1 inhibitor (DPMFKLboroV) was effective (36% lesion reduction; P = 0.009) in preventing PCV initiation but ineffective in treating existing lesions. Anti-inflammatory glucocorticoid was effective in preventing PCV progression but ineffective in preventing PCV initiation. These results suggest that PCV pathogenesis occurs through two stages. The initiation stage is mediated by proteolytic degradation of extracellular matrix proteins attributable to increased HTRA1 activity, whereas the progression stage is driven by inflammatory cascades. This study provides a basis for understanding the differences between PCV and choroidal neovascularization, and helps guide the design of effective therapies for PCV.

Comparison of two-year outcomes after photodynamic therapy with ranibizumab or aflibercept for polypoidal choroidal vasculopathy

Photodynamic therapy (PDT) combined with intravitreal anti-vascular endothelial growth factor (VEGF) agents is currently the first-line treatment for polypoidal choroidal vasculopathy (PCV), along with anti-VEGF monotherapy. In this study, 100 eyes with treatment-naïve PCV were initially treated with PDT combined with intravitreal ranibizumab (IVR; n = 57) or aflibercept (IVA; n = 43). We compared two-year outcomes between these two groups and investigated factors associated with visual improvement and retreatment over 24 months. Best-corrected visual acuity (BCVA) was significantly improved in both groups (P < 0.001) at 24 months. Multiple regression analysis revealed that visual improvement at 24 months was associated with female (P = 0.030), worse baseline BCVA (P = 3.0 × 10⁻⁶), smaller greatest linear dimension (GLD; P = 2.0 × 10⁻⁴), and treatment with IVA rather than IVR (P = 0.016). Multiple logistic regression analysis revealed that absence of retreatment was associated with younger age (P = 2.2 × 10⁻⁴), female (P = 1.2 × 10⁻³), and the non-risk variants of ARMS2 A69S (P = 6.0 × 10⁻⁴). Although there were no significant differences in the retreatment rate between the two groups, PDT/IVA may be superior to PDT/IVR in terms of visual improvement at 24 months.

Polypoidal Choroidal Vasculopathy with Feeder Vessels: Characteristics, Fellow Eye Findings, and Long-term Treatment Outcomes

PURPOSE

To evaluate the long-term outcomes of anti-vascular endothelial growth factor (VEGF) therapy for polypoidal choroidal vasculopathy (PCV) with feeder vessels and to investigate fellow-eye findings.

METHODS

This retrospective observational study included 14 eyes with treatment-naïve PCV accompanied by feeder vessels that were treated with anti-VEGF monotherapy. The best-corrected visual acuity (BCVA) at baseline was compared with that at the last follow-up. The fellow-eye indocyanine green angiography findings were also analyzed.

RESULTS

The mean follow-up period was 28.1 ± 19.2 months (range, 12 to 60 months). During the follow-up period, 5.9 ± 2.5 anti-VEGF injections were administered. The logarithm of the minimal angle of resolution (logMAR) BCVAs at the time of diagnosis, at 3 months, and at the last follow-up were 0.81 ± 0.49, 0.55 ± 0.44, and 0.71 ± 0.54, respectively. Although the BCVA at the last follow-up was not different from the baseline value (p=0.809), an improvement of ≥0.2 logMAR BCVA was observed in seven eyes (50.0%). In 11 eyes that underwent bilateral indocyanine green angiography at diagnosis, PCV, branching vascular networks, and late geographic hyperfluorescence were noted in two (18.2%), five (45.4%), and three (27.3%) fellow eyes, respectively. During the follow-up period, the development of polypoidal lesions in the fellow eye was observed in three patients.

CONCLUSIONS

In this study, long-term improvement in BCVA was noted in 50% of the included patients who received anti-VEGF monotherapy. A relatively high incidence of pathological findings in the fellow eye and bilateral involvement suggest the need for bilateral examinations.

Quantitative Changes in Pigment Epithelial Detachment Area and Volume Predict Retreatment in Polypoidal Choroidal Vasculopathy

PURPOSE

To determine if changes in pigment epithelial detachment (PED) area and volume predict retreatment in polypoidal choroidal vasculopathy (PCV).

DESIGN

Retrospective case-control study.

METHODS

PCV patients on pro re nata (PRN) anti-vascular endothelial growth factor (VEGF) therapy with >1 year follow-up at an academic retina service were included. Monthly anti-VEGF injections were given until a dry macula was achieved, and treatment deferred. Retreatment indication was recurrence of intraretinal or subretinal fluid or new hemorrhage. PED area and volume changes between visits with a dry macula ("D") and immediate preceding visits ("D-1") were analyzed with an automated optical coherence tomography-based software. Univariate and multivariate analyses were conducted to determine associations between changes in PED parameters and retreatment need at immediate subsequent visits ("D+1").

RESULTS

Twenty-two PCV patients (mean age 69.6 years) were included. Of 46 visits D, 11 (23.9%) were followed by retreatment at D+1. An increase in PED area (>0.43 mm²) and volume (>0.0245 mm³) from D-1 to D was associated with 18.2 (95% CI, 3.7-125.6; P < .001) and 101.9 (95% CI, 9.5-14 308.0; P < .001) higher retreatment odds at D+1, respectively. These associations remained significant after multivariate analyses adjusting for baseline PED area or volume, greatest linear dimension, and type of anti-VEGF agent.

CONCLUSION

In PCV on PRN anti-VEGF therapy, increases in PED area and volume at one visit, despite achievement of a dry macula, are associated with retreatment at the next visit. Retreatment criteria relying on intraretinal or subretinal fluid or new hemorrhages may be expanded to include PED changes. Studies are needed to determine if using PED parameters in treatment decisions reduces recurrences.

Distinct Responsiveness to Intravitreal Ranibizumab Therapy in Polypoidal Choroidal Vasculopathy With Single or Multiple Polyps

PURPOSE

To understand the prognosis of polypoidal choroidal vasculopathy (PCV) by evaluating the responsiveness to intravitreal ranibizumab (IVR) monotherapy according to the presence of a single or multiple polyps.

DESIGN

Retrospective case series.

METHODS

We included 48 treatment-naïve eyes of 48 patients who received IVR monotherapy at the Medical Retina Division Clinic, Keio University Hospital between March 2009 and January 2013 and attended the clinic for at least 12 months. All patients received 3 monthly IVR injections followed by pro re nata injections and were divided into single polyp and multiple polyps groups according to indocyanine green angiography and optical coherence tomography (OCT) findings. The outcome measures included changes in best-corrected visual acuity (BCVA) and OCT findings over 2 years after initial IVR.

RESULTS

At baseline, the multiple polyps group exhibited a poorer BCVA, larger greatest linear dimension, and higher prevalence of fibrovascular pigment epithelial detachment compared with the single polyp group. Over 2 years, the multiple polyps group showed no improvement in BCVA, although the central retinal thickness (CRT) decreased in both groups. The multiple polyps group exhibited a significantly greater CRT at 1 year and required more injections in the first year compared with the single polyp group; furthermore, it included a higher number of nonresponders judged either by BCVA or fundus findings at 1 year and fundus findings at 2 years.

CONCLUSIONS

We propose that the stratification of PCV lesions according to the presence of single or multiple polyps may be valuable to understand the prognosis.

Age-related macular degeneration and polypoidal choroidal vasculopathy in Asians

Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in elderly people globally. It is estimated that there will be more Asians with AMD than the rest of the world combined by 2050. In Asian populations, polypoidal choroidal vasculopathy (PCV) is a common subtype of exudative AMD, while choroidal neovascularization secondary to AMD (CNV-AMD) is the typical subtype in Western populations. The two subtypes share many common clinical features and risk factors, but also have different epidemiological and clinical characteristics, natural history and treatment outcomes that point to distinct pathophysiological processes. Recent research in the fields of genetics, proteomics and imaging has provided further clarification of differences between PCV and CNV-AMD. Importantly, these differences have manifested as disparity in response to intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) treatment between PCV and CNV-AMD, emphasizing the need for accurate diagnosis of PCV and in distinguishing PCV from CNV-AMD, particularly in Asian patients. Current clinical trials of intravitreal anti-VEGF therapy and photodynamic therapy will provide clearer perspectives of evidence-based management of PCV and may lead to paradigm shifts in therapeutic strategies away from those currently employed in the treatment of CNV-AMD. Further research is needed to clarify the relative contribution of specific pathways in inflammation, complement activation, extracellular matrix dysregulation, lipid metabolism and angiogenesis to the pathogenesis of PCV. Findings from this research, together with improved diagnostic technology and new therapeutics, will facilitate more optimal management of Asian AMD.

Systemic steroids as an aid to the management of Idiopathic Polypoidal Choroidal Vasculopathy (IPCV): A descriptive analysis

PURPOSE

To determine the role of systemic steroids in improving visual acuity, preventing recurrence and hastening pigment epithelial detachment resolution in IPCV patients.

METHODS

Retrospective computer assisted comparative case series of consecutive patients with documented IPCV who did and did not receive systemic steroids as part of their treatment regimen between 2007 and 2012. Patients who had systemic contraindication to steroid therapy were excluded from the steroid arm. Data collected included demographics, the best corrected visual acuity, details of the ocular and systemic exam, the treatment offered, the follow-up period and the final visual and anatomic outcomes. Outcome measures included the final BCVA, the time to resolution of the associated pigment epithelial detachment (PED, if present), the recurrence rate and the associated side effects, if any. Appropriate statistical analysis was done. Statistical significance: p < 0.05.

RESULTS

14 patients (14 eyes) had received systemic steroids in the stated period; these were compared with 26 consecutive patients (26 eyes) who did not. Mean age: 59.24 vs 62.38 years (A vs B). Mean baseline BCVA: 1.86 ± 1.24 logMAR vs 2.12 ± 1.48 logMAR (A vs B). 8 females in Group A and 14 in Group B. 11 patients in group A and 19 in group B had associated systemic hypertension. Therapy consisted of laser photocoagulation, anti-vascular endothelial growth factor therapy, photodynamic therapy or a combination of these. Mean follow-up: 43.21 ± 11.32 months (Group A) vs 48.24 ± 9.75 months (Group B). BCVA at three months was significantly better (0.84 ± 0.74 logMAR vs 1.16 ± 0.89 (p = 0.039). Final BCVA: 0.86 ± 0.78 logMAR (Group A) vs 1.29 ± 0.92 (Group B, p = 0.042). 7 patients in group A and 12 in Group B had a recurrence (insignificant difference). 1 patient in Group A and 7 in Group B had unresolved disease (persistent PED) at the end of follow-up (OR: 4.60; 95% CI 1.7-11.10).

CONCLUSION

Steroids appear to improve visual acuity and accelerate the resolution of the PEDs in patients with IPCV and large PEDs, but do not seem to influence recurrence.

Baseline polyp size as a potential predictive factor for recurrence of polypoidal choroidal vasculopathy

PURPOSE

To investigate the predictive factors for recurrence of polypoidal choroidal vasculopathy (PCV).

METHODS

The medical records of 78 consecutive patients (78 eyes) with treatment-naïve PCV who responded to first-line treatment and completed at least a 3-year follow-up after the first remission were retrospectively analyzed. In this comparative cohort study, baseline characteristics were compared between the patients who had at least one recurrence (the recurrence group) and those without recurrence (the non-recurrence group) during at least 3-year follow-up periods. In addition, possible predictive factors for recurrence of PCV were investigated by using Cox regression analysis.

RESULTS

Within 3 years of the first remission, 50 eyes (64 %) showed at least one recurrence (mean 1.5; 1 to ∼2 times). There were no significant differences in the baseline characteristics between the recurrence group and the non-recurrence group. However, the largest polyp diameter was significantly different: the mean largest polyp diameter (524 ± 340 μm) was significantly larger in the recurrence group compared to that of the non-recurrence group (352 ± 173 μm; P = 0.038). Cox regression analysis showed that the largest polyp diameter at baseline significantly correlated with recurrence of PCV (B = 1.470, P = 0.015).

CONCLUSIONS

The largest polyp diameter at baseline may be predictive for PCV recurrence, as it was significantly larger in patients who had at least one recurrence.

Polypoidal Choroidal Vasculopathy in Asians

Age related macular degeneration (AMD) in Asians has been suggested to differ from their Western counterparts in terms of epidemiology, pathogenesis, clinical presentation and treatment. In particular, polypoidal choroidal vasculopathy (PCV) appears to be the predominant subtype of exudative AMD in Asian populations, in contrast to choroidal neovascularization secondary to AMD (CNV-AMD) in Western populations. Epidemiological data on PCV has been largely limited to hospital-based studies and there are currently no data on the incidence of PCV. Similarities and differences in risk factor profile between PCV and CNV-AMD point to some shared pathogenic mechanisms but also differential underlying mechanisms leading to the development of each phenotype. Serum biomarkers such as CRP, homocysteine and matrix metalloproteinases suggest underlying inflammation, atherosclerosis and deranged extracellular matrix metabolism as possible pathogenic mechanisms. In addition, recent advances in genome sequencing have revealed differences in genetic determinants of each subtype. While the standard of care for CNV-AMD is anti-vascular endothelial growth factor (VEGF) therapy, photodynamic therapy (PDT) has been the mainstay of treatment for PCV, although long-term visual prognosis remains unsatisfactory. The optimal treatment for PCV requires further clarification, particularly with different types of anti-VEGF agents and possible benefits of reduced fluence PDT.

The association of elastin gene variants with two angiographic subtypes of polypoidal choroidal vasculopathy

Objective

To compare the association of elastin (ELN) gene variants between two different angiographic phenotypes of polypoidal choroidal vasculopathy (PCV).

Methods

We included 411 treatment-naïve PCV patients and 350 controls in the present study. PCV was classified into two phenotypes (152 Type 1 and 259 Type 2) according to the presence or absence of feeding vessels found in indocyanine-green angiography. Single nucleotide polymorphisms (SNPs) in the ELN region including rs868005, rs884843, rs2301995, rs13239907 and rs2856728 were genotyped using TaqMan Genotyping Assays.

Results

In the allelic association analyses, rs868005 showed the strongest association with Type 2 PCV (allelic odds ratio 1.56; p = 7.4x10^-6), while no SNP was significantly associated with Type 1 PCV. Genotype association analyses revealed the significant association of rs868005 with Type 2 PCV in log additive model and predominant model (odds ratio 1.75; p = 1.5x10^-6 and odds ratio 1.60; p = 0.0044, respectively), but not with Type 1 PCV. These findings were further corroborated by another control group in the literature.

Conclusions

There may be significantly different associations in genetic variants of elastin between two angiographic phenotypes of PCV.

Outcome of polypoidal choroidal vasculopathy at 1 year by combined therapy of photodynamic therapy with ranibizumab and predictive factors governing the outcome

AIM

To report the visual outcome of polypoidal choroidal vasculopathy receiving combined treatment with photodynamic therapy using Visudyne and intravitreal ranibizumab injections, and to analyze the predictive factors of visual outcome at 1 year post treatment.

METHODS

Seventy-four consecutive patients with newly diagnosed polypoidal choroidal vasculopathy were treated with photodynamic therapy using Visudyne and three loading doses of intravitreal ranibizumab. The final visual outcome and polyp eradication rate at 1 year were reported. A stepwise regression model was used to estimate the baseline clinical factors predictive of better visual outcome and polyp eradication.

RESULTS

Visual acuities at 12-months follow-up improved significantly compared with baseline from 0.828 logMAR to 0.728 logMAR (P=0.026). The mean foveal thickness decreased from 380±175 to 278±117 μm. In all 29.7% of eyes improved at least by 0.3 logMAR, and 55.4% remained stable in visual acuity with less than 0.3 logMAR change. Overall, 85% of eyes achieved at least stable vision, 20.2% (15/74) cases achieved polyp eradication on angiogram, and 60.8% (45/74) achieved polyp size reduction on angiogram at 1 year. Regarding predictive factors, the baseline visual acuity (P=0.003), no foveal involvement by abnormal choroidal vasculature (P<0.0001), absence of hard exudates (0.001) or subretinal fluid (<0.0001) are important clinical factors affecting the final visual outcome.

CONCLUSIONS

Combination therapy with photodynamic therapy using Visudyne and three loading doses of intravitreal ranibizumab injections resulted in 85% success rate on visual stabilization and 81% success rate in polypoidal lesion control.

Management of significant reactivation of old disciform scars in wet age-related macular degeneration

BACKGROUND

Fibrotic disciform scars represent the end-stage of wet age-related macular degeneration (AMD) and ophthalmologists tend not to treat them. However, reactivation can occur resulting in further worsening of patients. The aim of this study is to describe the clinical outcomes of 10 patients with disciform scars from age-related macular degeneration (AMD) that have subsequently reactivated.

METHODS

Indocyanine green angiography (ICG) was used to identify the active areas and these "hot spots" (HS) that were subsequently treated with focal laser photocoagulation.

RESULTS

In 10 out of 11 patients with potential reactivation of an AMD scar, a treatable HS was found on the ICG at the border of the disciform scar. The identified HS was treated with focal laser photocoagulation. Post treatment these areas became inactive. However in 2 cases, reactivation occurred requiring retreatment a few months later.

CONCLUSIONS

AMD patients who are noted to have disciform scars that are increasing in size and signs of activation such as lipid exudation and subretinal haemorrhage should undergo ICG imaging to look for HS. These patients could benefit from focal laser to stabilize the disease and avoid complications and further peripheral visual loss. It is suspected that these patients may have the polypoidal subtype of AMD.

Associations of complement factor B and complement component 2 genotypes with subtypes of polypoidal choroidal vasculopathy

BACKGROUND

We previously reported on subtypes of polypoidal choroidal vasculopathy (PCV), and categorized PCV as polypoidal choroidal neovascularization (CNV) and typical PCV. The aim of this study was to clarify whether complement component 2 (C2) and complement factor B (CFB) genotypes are associated with subtypes of polypoidal choroidal vasculopathy, such as polypoidal CNV and typical PCV.

METHODS

First, we categorized 677 patients into typical age-related macular degeneration (tAMD; 250 patients), PCV (376) and retinal angiomatous proliferation (RAP; 51). Second, we categorized 282 patients with PCV as having polypoidal CNV (84 patients) or typical PCV (198) based on indocyanine green angiographic findings. In total, 274 subjects without AMD, such as PCV and CNV, served as controls. A SNP (rs547154) in the C2 gene and three SNPs (rs541862, rs2072633, rs4151667) in the CFB gene were genotyped, and case-control studies were performed in subjects with these PCV subtypes.

RESULTS

In tAMD, no SNPs were associated with allele distributions. In PCV, rs547154 and rs2072633 were associated with allele distributions. RAP was only associated with rs2072633. After logistic regression analysis with adjustment for confounding factors, tAMD, PCV and RAP were found to be associated with rs2072633.As to PCV subtypes, there were significant differences in the distributions of rs547154, rs541862 and rs2072633 in the case-control studies for polypoidal CNV, but not between the typical PCV and control groups. Logistic regression analysis with adjustment for confounding factors showed the distributions of rs547154, rs541862 and rs2072633 to differ significantly between the controls and polypoidal CNV cases and that these SNPs were protective. The A/A genotype of rs2072633 was significantly more common in the polypoidal CNV than in the typical PCV group (p = 0.03), even with adjustment for polyp number and greatest linear dimension.

CONCLUSIONS

PCV might be genetically divisible into polypoidal CNV and typical PCV. The C2 and CFB gene variants were shown to be associated with polypoidal CNV. Typical PCV was not associated with variants in these genes.

Visual outcomes of vitrectomy for polypoidal choroidal vasculopathy-related breakthrough vitreous haemorrhage

PURPOSE

To evaluate the long-term visual outcomes of pars plana vitrectomy (PPV) for polypoidal choroidal vasculopathy (PCV)-associated vitreous haemorrhage (VH).

METHOD

We retrospectively reviewed the records of patients with PCV-related VH who underwent PPV. The main outcome measures were best-corrected visual acuity (BCVA) and fundus findings at 3 months postoperatively and final visit.

RESULTS

Seventeen eyes of 17 patients with massive subretinal haemorrhage (16.7±7.1 disc size of mean subretinal haemorrhage area) were enrolled. The mean postoperative follow-up period was 25.2 months. Four eyes received intravitreal bevacizumab injections, and three eyes underwent photodynamic therapy before the onset of VH. The mean BCVA improved from logarithm of the minimum angle of resolution (LogMAR) of 2.63±0.57 preoperatively to 1.43±0.82 at final visit (P<0.001). Among the eyes with initial polyps at subfoveal or juxtafoveal area, 16.70% achieved final BCVA ≥20/400 (LogMAR 1.3), whereas 87.50% of eyes with initial polyps at extrafoveal area had final BCVA ≥20/400 (Fisher's exact test, P=0.026).

CONCLUSIONS

PCV with massive subretinal haemorrhage is at risk for breakthrough VH. The visual prognosis in eyes with PCV-related breakthrough VH is variable after vitrectomy. Initial polyps at the extrafoveal area led to better functional outcomes. Early vitrectomy may be beneficial for visual recovery after PCV-related VH.

Combined photodynamic therapy with intravitreal bevacizumab injections for polypoidal choroidal vasculopathy: long-term visual outcome

PURPOSE

To evaluate the long-term visual outcome after combination therapy of photodynamic therapy (PDT) with intravitreal bevacizumab injections for polypoidal choroidal vasculopathy (PCV).

DESIGN

Retrospective observational study.

METHODS

The medical records of 34 eyes (34 patients) with naïve PCV who were treated with combination therapy were analyzed. All patients completed at least 3 years of follow-up. All clinical data, including age, best-corrected visual acuity (BCVA, logarithm of the minimal angle of resolution [logMAR]), imaging data of fluorescein angiography, indocyanine green angiography, and optical coherence tomography, were investigated.

RESULTS

During a mean follow-up period of 46.8 ± 5.2 months, a mean of 1.4 ± 0.71 times of PDT and 9.2 ± 6.6 intravitreal bevacizumab injections were performed. During follow-up, 21 eyes (61.8%) showed at least 1 recurrence. Mean BCVA was 0.59 ± 0.35 logMAR (20/77 Snellen equivalent) at baseline and 0.39 ± 0.34 logMAR (20/49 Snellen equivalent) at 3 years (P = .004). At 3 years, 14 patients (41.2%) gained 0.3 logMAR or more BCVA and 4 patients (11.8%) lost 0.3 logMAR or more BCVA than baseline. Baseline polyp size (β = .551; P = .005) and location of polyps (β = -.400; P =.033) were significantly correlated with long-term visual outcome after combination therapy for PCV.

CONCLUSIONS

Combination therapy of PDT with intravitreal bevacizumab injections showed favorable visual outcomes, and significant visual improvement was maintained in PCV patients. A total of 88.2% of patients avoided visual loss at 3 years after treatments. Largest polyp size at baseline and location of polypoidal lesions were prognostic factors for long-term visual outcomes in these patients.

Effects of choroidal vascular hyperpermeability on anti-vascular endothelial growth factor treatment for polypoidal choroidal vasculopathy

PURPOSE

To evaluate the effect of choroidal vascular hyperpermeability, as determined using indocyanine green angiography (ICGA), on the outcome of anti-vascular endothelial growth factor (VEGF) treatment for polypoidal choroidal vasculopathy (PCV).

DESIGN

Retrospective comparative series.

METHODS

Based on the presence of choroidal vascular hyperpermeability on ICGA, 103 eyes (101 patients) with PCV were categorized into 2 subgroups: choroidal vascular hyperpermeability (+) group (41 eyes) and choroidal vascular hyperpermeability (-) group (62 eyes). All subjects were treatment naïve and treated by anti-VEGF with initial 3 loading injections per month, followed by an as-needed reinjection. Best-corrected visual acuity (BCVA) and central macular thickness after treatment were compared between the 2 groups at baseline and at 3, 6, 9, and 12 months.

RESULTS

At 12 months after treatment, mean BCVA was significantly improved from 0.68 logarithm of the minimal angle of resolution (logMAR) (20/95 Snellen equivalent) to 0.50 logMAR (20/63 Snellen equivalent) in the choroidal vascular hyperpermeability (-) group (P = .01); however, there was no significant improvement, from 0.79 logMAR (20/123 Snellen equivalent) to 0.74 logMAR (20/109 Snellen equivalent), in the choroidal vascular hyperpermeability (+) group. In paired comparisons of BCVA between baseline and each follow-up visit, the choroidal vascular hyperpermeability (-) group showed significant improvement of BCVA at every follow-up visit (P < .05); however, the choroidal vascular hyperpermeability (+) group did not show significant visual improvement after 9 months (P > .05).

CONCLUSIONS

The therapeutic response to anti-VEGF treatment for PCV in patients with choroidal vascular hyperpermeability decreased over time. Choroidal vascular hyperpermeability was associated with an inferior visual outcome after intravitreal anti-VEGF treatment for PCV.

Polypoidal choroidal vasculopathy: clinical features and genetic predisposition

Polypoidal choroidal vasculopathy (PCV) is currently recognized as a phenotype of age-related macular degeneration (AMD). PCV is believed to be a type of choroidal neovascularization, although some cases of PCV show a distinct vascular abnormality of the choroidal vessels. PCV often shows several unique clinical manifestations which are apparently different from typical neovascular AMD (tAMD). In addition, the natural course and response to treatment are often different between tAMD and PCV. Moreover, recent genetic studies suggested a possible difference in the genetic susceptibility to disease between tAMD and PCV, as well as the existence of heterogeneity among PCV cases. In viewing the accumulation of knowledge about PCV, we have summarized the recent literature regarding PCV in this review article to improve the understanding of this clinical entity including possible susceptibility genes. We will also discuss the optimal treatment strategies for PCV in accordance with the results of recent clinical and genetic studies.

Long-term visual outcome and prognostic factors after intravitreal ranibizumab injections for polypoidal choroidal vasculopathy

PURPOSE

To evaluate long-term visual outcome and investigate the prognostic factors after anti-vascular endothelial growth factor (VEGF) therapy for polypoidal choroidal vasculopathy (PCV).

DESIGN

Retrospective study.

METHODS

Analyses were done among 36 eyes (36 patients) with naïve PCV that were treated with intravitreal ranibizumab injections and completed at least 3-year follow-up. All clinical data, including baseline characteristics; imaging data from fluorescein angiography, indocyanine green angiography, and optical coherence tomography; presence of recurrence; and best-corrected visual acuity (BCVA) were investigated.

RESULTS

During mean follow-up of 42.58 ± 12.59 months, mean numbers of anti-VEGF injection were 11.45 ± 7.81. Twenty-four eyes (66.7%) showed at least 1 recurrence during follow-up. Mean baseline BCVA was 0.68 ± 0.43 logMAR (20/95 Snellen equivalent), and 0.78 ± 0.53 logMAR (20/120 Snellen equivalent) at 36 months (P = .307). Mean BCVA was significantly improved at 1 month (P = .018), and improvement was maintained until 12 months (P = .044), then deteriorated. Among baseline characteristics, greatest lesion diameter (B = 0.219, P = .001) and pigment epithelial detachment (B = 0.362, P = .025) were significantly correlated with long-term visual outcome. Recurrence during follow-up (B = 0.371, P = .024) was also significantly correlated with long-term visual outcome.

CONCLUSION

Significant visual improvement by anti-VEGF therapy was maintained during the first year of initial treatment; however, vision then deteriorated during long-term follow-up. Smaller lesion size, absence of pigment epithelial detachment at baseline, and no recurrence during follow-up were significantly correlated with better long-term visual outcome.

Indocyanine green angiographic and optical coherence tomographic findings support classification of polypoidal choroidal vasculopathy into two types

PURPOSE

We assessed the characteristic indocyanine green angiographic (ICGA) and spectral domain optical coherence tomographic (SD-OCT) findings of two types of polypoidal choroidal vasculopathy (PCV), distinguishable by different filling patterns on ICGA.

METHODS

Thirty-one eyes with PCV were classified into types 1 and 2 based on ICGA findings of either the presence or absence of both a feeder and a draining vessel. Characteristic ICGA findings were evaluated for each type of PCV. Spectral domain optical coherence tomographic images of the 31 eyes were also used to compare the two types of PCV.

RESULTS

Both a feeder and a draining vessel were observed in 13 eyes (type 1). Eighteen eyes had neither feeder nor draining vessels (type 2). In PCV type 1, a break in the highly reflective line thought to be Bruch's membrane was detected, corresponding to the feeder vessel in-growth site on SD-OCT. This line was straight. In PCV type 2, the highly reflective line exhibited irregular thickness and had highly reflective substances adhering to its lower portion. It curved downward and became increasingly obscure, ultimately disappearing at a point corresponding to the site at which network vessel filling began. The mean subfoveal choroidal thicknesses in eyes with PCV type 1 and PCV type 2 were 199 ± 65 and 288 ± 98 μm, respectively.

CONCLUSIONS

Our observations support the existence of two distinct types of PCV. The first type represents choroidal neovascularization, whilst the second type involves choroidal vasculature abnormalities.

Two-year results of photodynamic therapy with or without intravitreal ranibizumab for polypoidal choroidal vasculopathy

PURPOSE

To compare the 2-year outcomes of photodynamic therapy (PDT) with or without intravitreal ranibizumab (IVR) for polypoidal choroidal vasculopathy (PCV).

METHODS

Medical charts from 58 patients with PCV, who had been followed up for more than 2 years after initial treatment, were reviewed retrospectively. Visual outcomes were compared between 2 groups, consisting of 34 patients treated with PDT monotherapy without IVR and 24 with the combination of PDT and IVR, and the factors associated with the 2-year visual outcomes were investigated using multiple regression analysis.

RESULTS

In the PDT monotherapy group, the logarithm of the minimum angle of resolution (logMAR) of the best-corrected visual acuity (BCVA) improved significantly at 12 months (P=0.026), but was not significantly different from the initial logMAR BCVA at 24 months (P=0.21). By contrast, the logMAR BCVA improved significantly at 12 months and was maintained throughout the second 12-month period (P<0.001 at all time points) in the combined PDT group. Multiple regression analysis revealed that the initial BCVA (P<0.001), the greatest linear dimension of the initial PDT (P=0.006), and the combined PDT (P=0.039) were predictors of visual outcomes at 24 months.

CONCLUSIONS

Combined PDT with IVR is a better treatment modality compared with PDT monotherapy, and results in improvement of visual outcomes at 24 months after the initial treatment.

Relationship between clinical characteristics of polypoidal choroidal vasculopathy and choroidal vascular hyperpermeability

PURPOSE

To investigate the relationship between the clinical characteristics of polypoidal choroidal vasculopathy (PCV) and choroidal vascular hyperpermeability seen on indocyanine green angiography.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

We reviewed the medical records and the angiograms of 89 patients with PCV. The relationship between choroidal vascular hyperpermeability and background factors, associated clinical manifestations, and treatment responses to intravitreal injections of ranibizumab were evaluated.

RESULTS

Of the 89 patients with PCV, 31 patients (34.8%) demonstrated choroidal vascular hyperpermeability. The patients with choroidal vascular hyperpermeability more frequently showed bilateral neovascular membrane than those without choroidal vascular hyperpermeability (P=.009) and had a significant relationship with a history of central serous chorioretinopathy (CSC) (P=.01). Of the 98 eyes with treatment-naïve PCV, 34 eyes with choroidal vascular hyperpermeability demonstrated significantly greater subfoveal thickness than the 64 eyes without choroidal vascular hyperpermeability (P < .001). However, no significant relationship was found between choroidal vascular hyperpermeability and the other biomicroscopic and angiographic phenotypes of PCV. Three monthly intravitreal injections of ranibizumab were performed on 57 patients with treatment-naïve PCV, and the presence of choroidal vascular hyperpermeability was significantly related to the persistent retinal fluid 1 month after the third ranibizumab injection (P=.01).

CONCLUSIONS

The patients with PCV associated with choroidal vascular hyperpermeability more frequently demonstrated bilateral neovascular membrane, a history of CSC, a thickened choroid, and poor responses to intravitreal injections of ranibizumab than those without choroidal vascular hyperpermeability.

Responses to photodynamic therapy in patients with polypoidal choroidal vasculopathy consisting of polyps resembling grape clusters

PURPOSE

To investigate the responses to photodynamic therapy (PDT) in patients with polypoidal choroidal vasculopathy (PCV) that show large aneurysmal dilation with internal angio-architecture consisting of diverse patterns of curvilinear vessels and polyps resembling grape clusters.

DESIGN

Retrospective, interventional case series.

METHODS

Twenty-two eyes of 22 patients were included. All patients initially received PDT monotreatment. The main outcome measures were the rates of complete polyp regression on indocyanine green angiography and initial favorable responses observed clinically. Also, the rates of recurrent exudative changes were evaluated at the 2-year follow-up. We focused on changes in the vascular features and their clinical association.

RESULTS

Complete regression of polypoidal lesions was observed in 21 eyes (95%) after a mean of 1.7 PDTs. However, favorable clinical responses were achieved in only 9 eyes (41%), and 6 of them had recurrent exudation. Main vessels, previously consisting of the polypoidal lesion frame, persisted. Additionally, aberrant vessels with a thin radiating or tortuous configuration were observed in the area where large aneurysmal dilation was present. Leakage from this vascular complex or an expanded vascular complex was observed in a total of 14 eyes (64%) during the 2-year follow-up, contributing to persistent (8 eyes) or recurrent (6 eyes) exudation. This seemed to represent secondary choroidal neovascularization (CNV). In another 4 eyes (18%), fibrous changes developed immediately after PDT. Polyps recurred in 8 eyes (38%).

CONCLUSIONS

This PCV pattern frequently evolved into typical CNV after PDT, resulting in persistent or recurrent exudation despite the disappearance of polypoidal structures.