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

One-Year Outcome of Combination Therapy with Full or Reduced Photodynamic Therapy and One Anti-Vascular Endothelial Growth Factor in Pachychoroid Neovasculopathy

This paper evaluates a one-year treatment outcome after full or reduced photodynamic therapy (PDT) and anti-vascular endothelial growth factor (VEGF) combination therapy for pachychoroid neovasculopathy (PNV). After the initial combination therapy, a total of 29 eyes from 29 patients (16 for full treatment and 13 for reduced treatment), exhibited reduced, central retinal thickness and central choroidal thickness, and the improvements were maintained for 1 year after the initial combination therapy. Twenty-two eyes (75.9%) required no additional treatments for 1 year. The recurrence rate was 31.3% in the full treatment and 15.4% in the reduced treatment, with no significant differences between them. One shot of anti-VEGF and full or reduced PDT combination therapy had similar efficacy in treating PNV. Further prospective, large-scale, and long-term studies are required to determine a better treatment for PNV.

Quantitative analysis of branching neovascular networks in polypoidal choroidal vasculopathy by optical coherence tomography angiography after photodynamic therapy and anti-vascular endothelial growth factor combination therapy

PURPOSE

To study serial changes in branching neovascular networks (BNN) by using optical coherence tomography angiography (OCTA) in patients with polypoidal choroidal vasculopathy (PCV) who underwent combined photodynamic therapy (PDT) and anti-vascular endothelial growth factor (anti-VEGF) therapy.

METHODS

In this retrospective study of 30 PCV patients who underwent combined therapy, OCTA images obtained at baseline and 1, 3, and 6 months after treatment were collected. The vessel area, vessel percentage area, average vessel length, and presence of polypoidal lesions on OCTA images as well as best-corrected visual acuity (BCVA), central retinal thickness (CRT), and central choroidal thickness (CCT) were recorded at each time point.

RESULTS

The BNN- and polypoidal lesion-detection rates on baseline OCTA images were 100% and 71%, respectively. The vessel area decreased during the first 3 months, and increased 6 months post-treatment, showing significant differences from baseline (p = 0.031). The vessel percentage area also reduced 1 and 3 months post-treatment (p = 0.025) and increased 6 months post-treatment. Continuous polypoidal lesion regression was observed from 1 to 3 and 6 months post-treatment (p = 0.031, p = 0.004, p = 0.002, respectively, in comparison with baseline). Patients with a decreasing vessel area over 6 months showed greater choroidal thickness than those with increasing vessel area (p = 0.004).

CONCLUSIONS

The BNN showed initial regression but were enlarged at 6 months after therapy. Patients showing continuous BNN regression showed a thicker choroid at baseline. This difference should be considered during treatment for PCV, and OCTA could be used for follow-up evaluations of PCV patients.

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.

Multicentre, randomised clinical trial comparing intravitreal aflibercept monotherapy versus aflibercept combined with reduced-fluence photodynamic therapy (RF-PDT) for the treatment of polypoidal choroidal vasculopathy

PURPOSE

To compare the efficacy and safety of intravitreal aflibercept (IVA) monotherapy versus aflibercept combined with reduced-fluence photodynamic therapy (RF-PDT) (IVA+RF-PDT) for the treatment of polypoidal choroidal vasculopathy (PCV).

METHODS AND ANALYSIS

Multicentred, double-masked, randomised controlled trial to compare the two treatment modalities. The primary outcome of the study is to compare the 52-week visual outcome of IVA versus IVA+RF PDT. One hundred and sixty treatment-naïve patients with macular PCV confirmed on indocyanine green angiography will be recruited from three centres in Singapore. Eligible patients will be randomised (1:1 ratio) into one of the following groups: IVA monotherapy group-aflibercept monotherapy with sham photodynamic therapy (n=80); combination group-aflibercept with RF-PDT (n=80). Following baseline visit, all patients will be monitored at 4 weekly intervals during which disease activity will be assessed based on best-corrected visual acuity (BCVA), ophthalmic examination findings, optical coherence tomography (OCT) and angiography where indicated. Eyes that meet protocol-specified retreatment criteria will receive IVA and sham/RF-PDT according to their randomisation group. Primary endpoint will be assessed as change in BCVA at week 52 from baseline. Secondary endpoints will include anatomical changes based on OCT and dye angiography as well as safety assessment. Additionally, we will be collecting optical coherence tomography angiography data prospectively for exploratory analysis.

ETHICS AND DISSEMINATION

This study will be conducted in accordance with the ethical principles that have their origin in the Declaration of Helsinki and that are consistent with the ICH E6 guidelines of Good Clinical Practice and the applicable regulatory requirements. Approval from the SingHealth Centralised Institutional Review Board has been sought prior to commencement of the study.

TRIAL REGISTRATION NUMBER

NCT03941587.

The polyp regression rate and treatment prognosis of different interventions for polypoidal choroidal vasculopathy: a systematic review and meta-analysis

PURPOSE

To estimate the polyp regression rate and treatment prognosis of different interventions for polypoidal choroidal vasculopathy (PCV) and clarify its baseline characteristics.

METHODS

The PubMed, EMBASE, and Ovid were searched up to January 2020 to identify related studies. R software version 3.6.3 was used to perform the statistical analyses. Results in proportion with 95% confidence interval (CI) were calculated by means of the Freeman-Tukey variant of arcsine square transformation. Chi-squared test and I² statistics were used to evaluate the statistical heterogeneity. Sensitivity analysis and subgroup analyses were performed to identify the source of heterogeneity.

RESULTS

This meta-analysis included 104 studies with 5816 patients. The pooling results indicated the general rate of complete polyp regression at post-treatment 12 months was 64% (95% CI [57~71%]), 89% (95% CI [81~95%]) for photodynamic therapy (PDT) monotherapy, 78% (95% CI [68~86%]) for PDT plus anti-vascular endothelial growth factor (anti-VEGF), and 42% (95% CI [35~49%]) for anti-VEGF monotherapy; PDT plus anti-VEGF showed the best efficacy in visual improvement and achieved the highest rate of dry macula (91%, 95% CI [78~99%]), while anti-VEGF monotherapy achieved the lowest polyp recurrence rate (14%, 95% CI [8~20%]); PDT monotherapy showed the best efficacy in pigment epithelial detachment regression (66%, 95% CI [58~83%]). Additionally, the baseline characteristics of PCV were also well described.

CONCLUSION

PDT plus anti-VEGF is still valuable for the management of PCV; it could achieve not only satisfactory anatomical outcomes like dry macula rate and polyp regression rate but also ideal visual prognosis like BCVA improvement.

Idiopathic polypoidal choroidal vasculopathy: a review of literature with clinical update on current management practices

PURPOSE

Polypoidal choroidal vasculopathy is a major cause of visual disability in a vast majority of Asian population due to exudative maculopathy. Although it is a distinctive disease entity with characteristic pathophysiology, genetics, immunology and clinical features, but it is still misdiagnosed as neovascular age related macular degeneration as both the diseases are a part of pachychoroid spectrum and have some similar features. Also, there are varied options for the management of this disease, but there are no clear recommendations. So, a detailed review of the literature has been done along with special attention to the recent therapeutic advances to help the readers get a better understanding of the disease and its current management practices.

METHOD

Detailed review of literature regarding polypoidal choroidal vasculopathy was done. The disease pathophysiology, genetics, risk factors, diagnostic modalities along with current treatment guidelines were extensively studied and compiled.

RESULT

A comprehensive clinical update on polypoidal choroidal vasculopathy was compiled with special emphasis on the recent diagnostic modalities and treatment guidelines.

CONCLUSION

Polypoidal choroidal vasculopathy is a distinct clinical entity which can be diagnosed based on indocyanine green angiography and optical coherence tomography. Treatment includes various options like photodynamic therapy, anti VEGF agents and thermal laser ablation. A review of literature has been done and recent diagnostic modalities with management practices have been compiled for the better understanding of the disease.

Early changes of vascular lesions and responses to combined photodynamic therapy in patients with polypoidal choroidal vasculopathy

PURPOSE

To evaluate early changes of vascular lesions and their associations with the early responses to combined photodynamic therapy (PDT) in eyes with polypoidal choroidal vasculopathy (PCV).

METHODS

This study evaluated 19 eyes of 19 patients with PCV who underwent PDT combined with anti-vascular endothelial growth factor injections and were followed for 3 months. All subjects were examined 1 week and 1, 2, and 3 months after combined PDT. "Active" cases were defined as recurrence or persistence of serous retinal detachment or subretinal hemorrhage detected within 3 months. Branching vascular networks (BVNs) were evaluated by optical coherence tomography angiography (OCTA) and polyps by indocyanine-green angiography.

RESULTS

In total, 16%, 58%, 84%, and 89% of eyes displayed BVNs 1 week, 1, 2, and 3 months after PDT, respectively. BVNs were detected significantly more often 1 month after PDT in the "active" group than "inactive" group (89% vs. 30%, p = 0.020). There were significantly higher overall proportions of BVNs detected by OCTA in the "active" group than "inactive" group (p = 0.0058).

CONCLUSION

In most cases, BVNs disappeared once and gradually appeared again within 3 months. Detecting BVNs using OCTA from early phases could be a helpful biomarker to assess the early responses to PDT in eyes with PCV.

Efficacy and Safety of Intravitreal Aflibercept for Polypoidal Choroidal Vasculopathy in the PLANET Study: A Randomized Clinical Trial

Importance

Polypoidal choroidal vasculopathy (PCV) is common in Asian populations, but an optimal treatment approach remains to be confirmed.

Objective

To evaluate intravitreal aflibercept injection (IAI) in participants with PCV and compare IAI monotherapy with IAI plus rescue photodynamic therapy (PDT).

Design, Setting, and Participants

This 96-week, double-masked, sham-controlled phase 3b/4 randomized clinical trial was conducted at multiple centers in Australia, Germany, Hong Kong, Hungary, Japan, Singapore, South Korea, and Taiwan from May 2014 to August 2016, and included adults 50 years or older with symptomatic macular PCV and a best-corrected visual acuity of 73 to 24 Early Treatment Diabetic Retinopathy Study letters (20/40-20/320 Snellen equivalent).

Interventions

Participants received 2 mg of IAI at weeks 0, 4, and 8. At week 12, participants with a suboptimal response were randomized 1:1 to receive IAI plus sham PDT (IAI monotherapy) or a "rescue" of IAI plus rescue PDT (IAI/PDT). Participants who did not qualify for rescue received IAI every 8 weeks; those qualifying for rescue received IAI every 4 weeks plus sham/active PDT. When the rescue criteria were no longer met, injection intervals were gradually extended to 8 weeks.

Main Outcomes and Measures

Noninferiority of IAI monotherapy to IAI/PDT for mean change in best-corrected visual acuity from baseline to week 52 (95% CI of the difference entirely above -5 letters).

Results

Of the 318 participants, the mean (SD) age was 70.6 (8.2) years, 96 (30.2%) were women, and 152 (47.8%) were Japanese. Monotherapy with IAI was noninferior to IAI/PDT for the primary end point (+10.7 vs +10.8 letters, respectively; 95% CI, -2.9 to 1.6; P = .55), with few participants requiring rescue therapy (19 [12.1%] vs 23 [14.3%], respectively). Participants in both treatment groups had similar reductions in central subfield thickness from baseline to week 52 (-137.7 [IAI monotherapy] vs -143.5 μm [IAI/PDT]). At week 52, 49 (38.9%) and 60 participants (44.8%) had no polypoidal lesions observed on indocyanine green angiography in the IAI monotherapy and IAI/PDT groups, respectively. Furthermore, 116 (81.7%) and 136 (88.9%), respectively, had no polypoidal lesions with leakage. The most frequent ocular adverse events were conjunctival hemorrhage (IAI monotherapy, 8 [5.1%]) and dry eye (IAI/PDT, 9 [5.6%]).

Conclusions and Relevance

Improvement in visual and/or functional outcomes was achieved in more than 85% of participants who were treated with IAI monotherapy, with no signs of leakage from polypoidal lesions in more than 80%. As fewer than 15% met the criteria of a suboptimal response to receive PDT, the potential benefit of adding PDT cannot be determined.

Trial Registration

ClinicalTrials.gov Identifier: NCT02120950.

Polypoidal choroidal vasculopathy: a comprehensive clinical update

Polypoidal choroidal vasculopathy as a disease is yet to be comprehended completely. The clinical features consisting of huge serosanguineous retinal pigment epithelial and neurosensory layer detachments, although unique may closely mimick neovascular age-related macular degeneration and other counterparts. The investigative modalities starting from indocyanine angiography to optical coherence tomography angiography provide diagnostic challenges. The management strategies based on the available therapies are plenty and not vivid. A detailed review with clarifying images has been compiled with an aim to help the readers in getting a better understanding of the disease.

Pachychoroid disease

Pachychoroid is a relatively novel concept describing a phenotype characterized by attenuation of the choriocapillaris overlying dilated choroidal veins, and associated with progressive retinal pigment epithelium dysfunction and neovascularization. The emphasis in defining pachychoroid-related disorders has shifted away from simply an abnormally thick choroid (pachychoroid) toward a detailed morphological definition of a pathologic state (pachychoroid disease) with functional implications, which will be discussed in this review. Several clinical manifestations have been described to reside within the pachychoroid disease spectrum, including central serous chorioretinopathy, pachychoroid pigment epitheliopathy, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy/aneurysmal type 1 neovascularization, focal choroidal excavation, peripapillary pachychoroid syndrome. These conditions all exhibit the characteristic choroidal alterations and are believed to represent different manifestations of a common pathogenic process. This review is based on both the current literature and the clinical experience of our individual authors, with an emphasis on the clinical and imaging features, management considerations, as well as current understanding of pathogenesis of these disorders within the context of the recent findings related to pachychoroid disease.

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

Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular age-related macular degeneration (nAMD), commonly seen in the Asian population. It is dissimilar in epidemiology, genetic heterogeneity, pathogenesis, natural history, and response to treatment in comparison to nAMD. Confocal scanning laser ophthalmoscopy-based simultaneous fluorescein angiography and indocyanine green angiography, spectral-domain optical coherence tomography (OCT) with enhanced depth imaging, swept-source OCT, and OCT angiography have improved the ability to detect PCV, understand its pathology, and monitor treatment response. A plethora of literature has discussed the efficacy of photodynamic therapy, anti-vascular endothelial growth factor (VEGF) monotherapy, and combination of both, but only a few studies with higher level of evidence and limited follow-up duration are available. This review discusses the understanding of PCV with respect to epidemiology, pathogenesis, clinical features, natural history, imaging techniques, and various treatment options. Recent clinical trials (EVEREST-II and PLANET study) have emphasized that either anti-VEGF monotherapy or combination treatment is equally capable to strike a balance between polyp regression and stabilization of visual acuity. The recurrent nature of the disease, the development of macular atrophy, and the long-term poor visual prognosis despite treatment are concerns that open avenues for further research.

Complete regression of branching vascular network in polypoidal choroidal vasculopathy by ranibizumab and photodynamic therapy, two case reports

BACKGROUND

Polypoidal choroidal vasculopathy (PCV) consists of polyps that potentially cause massive subretinal hemorrhage and their branching vascular network (BVN) of feeder vessels. Although conventional indocyanine green angiography (IA) has shown anti-vascular endothelial growth factor (VEGF) agents and/or photodynamic therapy (PDT) to successfully induce polyp closure, the BVN appears resistant to these therapies and serves as the origin of recurrent active polyps. Recently introduced optical coherence tomography angiography (OCT-A) enables more frequent angiographic evaluation of polyps and the BVN than does conventional IA since it does not require intravenous fluorescent dye injection and is thus considered non-invasive.

CASE PRESENTATION

Case 1. A 70-year-old male with PCV in his left eye suffered from vision deterioration (20/40) due to persistent subretinal fluid despite 42 intravitreal injections of ranibizumab (IVRs) over 5 years and 7 months. PDT was performed as an adjunct therapy 3 days after the 43rd IVR. IA at 3 months after PDT showed successful polyp closure but persisting BVN. However, more frequent evaluation with OCT-A starting at 1 week after PDT demonstrated complete regression of both the BVN and polyp. OCT-A at every subsequent outpatient visit depicted gradual re-perfusion of the BVN and the restoration of most of its original network at 3 months, which was compatible with IA findings. Neither OCTA nor IA revealed polyp recurrence at 3 months. Case 2. A 65-year-old female suffering from left vision deterioration due to PCV underwent 5 intravitreal injections of aflibercept. Since her subretinal fluid persisted, the treatment was switched to a combination of IVR and PDT. OCT-A revealed marked regression of the BVN and polyp at 2 weeks, but the BVN had regained its original shape at 2 months without any sign of polyp recurrence.

CONCLUSIONS

Differently from previous observations obtained by IA alone, more frequent non-invasive OCT-A examination revealed complete but transient regression of the BVN just after combination therapy with IVR and PDT.

The Use of Vascular Endothelial Growth Factor Inhibitors and Complementary Treatment Options in Polypoidal Choroidal Vasculopathy: A Subtype of Neovascular Age-Related Macular Degeneration

Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular age-related macular degeneration (AMD; nAMD) which occurs more commonly in Asian populations as compared to Caucasians. PCV and nAMD share pathological mechanisms, including pathological expression of vascular endothelial growth factor (VEGF). The advent of anti-vascular endothelial growth factor (VEGF) revolutionized the treatment of nAMD. Despite being a subtype of nAMD, PCV responds less well to VEGF inhibitors; thus, photodynamic therapy (PDT) in combination with anti-VEGF treatment may be considered. This review aims to summarize the current evidence for the treatment of PCV, especially whether VEGF inhibitors should be used alone or in combination with PDT.

Submacular hemorrhage and grape-like polyp clusters: factors associated with reactivation of the lesion in polypoidal choroidal vasculopathy

PurposeThe purpose of this study is to investigate the factors associated with reactivation of the lesion during the first year in patients with polypoidal choroidal vasculopathy (PCV) treated with intravitreal ranibizumab.Patients and methodsThis retrospective observational study included 84 eyes diagnosed with PCV and treated with 3-monthly ranibizumab injections. Only those patients who exhibited complete resolution of fluid after initial treatment and were followed up at least 12 months were included. The baseline characteristics of the patients, including their age and sex, location of the polyps, greatest linear dimensions of the lesions, largest polyp diameter, choroidal vascular hyperpermeability, submacular hemorrhages ≥1 disc area in size, presence of grape-like polyp clusters, central foveal thickness, and best-corrected visual acuity were compared between patients with and without reactivation of the lesion.ResultsDuring the 12-month follow-up period, reactivation of the lesion was observed in 60 patients (71.4%). The first reactivation was noted at a mean duration of 3.9±1.7 months after the third ranibizumab injection. Cox regression analysis revealed that the absence of submacular hemorrhages ≥1 disc area (P=0.009), presence of grape-like polyp clusters (P=0.002), and greatest linear dimension of the lesions (P=0.019) were associated with reactivation of the lesion.ConclusionThe absence of submacular hemorrhages, presence of grape-like polyp clusters, and large lesion size at diagnosis were associated with a high risk of reactivation of PCV in patients treated with intravitreal ranibizumab. Patients exhibiting these characteristics may require close monitoring.

ANGIOGRAPHIC FINDINGS OF RANIBIZUMAB-RESISTANT POLYPOIDAL CHOROIDAL VASCULOPATHY AFTER SWITCHING TO A TREAT-AND-EXTEND REGIMEN WITH INTRAVITREAL AFLIBERCEPT

PURPOSE

The aim of this study was to study the angiopathic findings of ranibizumab-resistant polypoidal choroidal vasculopathy after switching to a treat-and-extend regimen with intravitreal aflibercept.

METHODS

The authors retrospectively reviewed 17 eyes of 17 Japanese patients with polypoidal choroidal vasculopathy (10 men and 7 women, age: 73.8 ± 7.4 years) who were treated with intravitreal aflibercept (2 mg/0.05 mL) injections from February 2013 to August 2014 at Tokyo University Hospital. All patients had switched to aflibercept because their polypoidal choroidal vasculopathy had been refractory to ranibizumab.

RESULTS

The mean logMAR best-corrected visual acuity at baseline and after 12 months of therapy was 0.30 ± 0.29 (Snellen equivalent: 20/40) and 0.17 ± 0.26 (20/30) (paired t-test P < 0.001). Visual acuity remained stable in 5 cases (29%), deteriorated in 3 (18%), and improved in 9 (53%). Branching vascular networks persisted in all 17 eyes but shrank in 15 (88%). The mean lesion diameter was 3329 ± 1261 μm at baseline and 3180 ± 1247 μm after 12 months (P = 0.0002).

CONCLUSION

A treat-and-extend regimen with intravitreal aflibercept for ranibizumab-resistant patients resulted in branching vascular network shrinkage over a 1-year period.

Intravitreal Anti-vascular Endothelial Growth Factor for Treating Polypoidal Choroidal Vasculopathy with Grape-like Polyp Clusters

Purpose

To evaluate 12-month outcomes of anti-vascular endothelial growth factor (VEGF) therapy for polypoidal choroidal vasculopathy (PCV) with grape-like polyp clusters.

Methods

This retrospective observational study included 23 eyes of 23 patients who were newly diagnosed with PCV with grape-like polyp clusters, and who were subsequently treated with anti-VEGF monotherapy. The study compares the best-corrected visual acuity (BCVA) of the patients at diagnosis, at 3 months, and at 12 months after diagnosis. In addition, 12-month changes in BCVA values were compared between cases with subfoveal or juxtafoveal polyps and cases with extrafoveal polyps.

Results

The baseline, 3-month, and 12-month logarithm of the minimal angle of resolution BCVA was 0.62 ± 0.35, 0.50 ± 0.43, and 0.58 ± 0.48, respectively. Compared to the baseline, patient BCVA was not significantly different at 12 months after diagnosis (p = 0.764). Six eyes (26.1%) gained ≥0.2 logarithm of the minimal angle of resolution BCVA. In cases with subfoveal or juxtafoveal polyps, BCVA values at baseline and at 12 months after diagnosis were 0.66 ± 0.37 and 0.69 ± 0.53, respectively. In cases with extrafoveal polyps, the values were 0.54 ± 0.33 and 0.37 ± 0.31, respectively. Changes in BCVA values were significantly different between the two groups (p = 0.023).

Conclusions

Although anti-VEGF therapy has favorable short-term efficacy for treating PCV with grape-like polyp clusters, long-term visual improvements are generally limited in the majority of afflicted eyes. The presence of subfoveal or juxtafoveal polyps may suggest unfavorable treatment outcomes.

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.

1-year results of combined half-dose photodynamic therapy and ranibizumab for polypoidal choroidal vasculopathy

Background

To evaluate the efficacy and safety of half-dose photodynamic therapy (PDT combined with ranibizumab for polypoidal choroidal vasculopathy (PCV). PCV is commonly treated with a combination of anti-vascular endothelial growth factor and standard-dose photodynamic therapy (PDT). Choroidal ischemia and visual loss can be resulted from the standard-dose PDT. Half-dose PDT has proved to produce similar results and safety profile in treating central serous chorioretinopathy. Half-dose PDT may offer an alternative for PCV cases where the damage to choroidal vasculature maybe less. Here, we report the efficacy of treating PCV cases with combination of ranibizumab and half-dose PDT.

Methods

In this prospective, non-comparative, interventional case series, 19 treatment-naive eyes were treated with combined half-dose PDT and ranibizumab. All subjects were followed up for 12 months with measurement of best-corrected visual acuity (BCVA), central foveal thickness (CFT) by optical coherence tomography. Indocyanine green angiogram (ICG) was performed every 3-monthly, and subjects assessed in terms of polyp regression rates, changes in vision and central foveal thickness, need to repeat half-dose PDT. Subgroup analysis was performed based on ICG features.

Results

The mean logMAR BCVA improved from 0.64 at baseline to 0.41 at 12 months. The mean CFT improved from 459.6mum at baseline to 384.2mum at 12 months. The difference between baseline BCVA and CFT and that at 12 months were statistically significant (both P = 0.03). Polyp regression rate after one half-dose PDT was 42.1 %. This was 61.5 % in the polyp-only group, while that in the branching-vascular-network (BVN) group was 0 % (P = <0.01).

Conclusion

Half-dose PDT combined with intravitreal ranibizumab was able to induce high polyp regression rate in PCV cases that had one single polyp.

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.

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.

Polypoidal choroidal vasculopathy exudation and hemorrhage: results of monthly ranibizumab therapy at one year

PURPOSE

To evaluate the efficacy and safety of monthly intravitreal injections of ranibizumab in patients with polypoidal choroidal vasculopathy (PCV) and active exudation or hemorrhage.

METHODS

A prospective, single practice, open label trial of monthly intravitreal ranibizumab (0.5 mg) injections for PCV in 13 eyes of 13 patients who completed the 1-year study. The primary outcome measure was stabilization of vision (loss of <15 ETDRS letters). Secondary outcome measures included incidence of ocular and systemic adverse events, changes in subretinal hemorrhage, central foveal thickness, and polypoidal complexes on indocyanine green angiography at 1 year.

RESULTS

No patient lost ≥ 15 letters in visual acuity at 1 year. Three patients (23%) gained ≥ 15 letters at 12 months. Subretinal hemorrhage resolved in 9/9 eyes (100%). Macular edema improved in 5/5 eyes (100%). Subretinal fluid completely resolved in 4/9 eyes (44%), decreased in 2/9 eyes (22%), and increased in 3/9 eyes (33%). Polypoidal complexes decreased in 5/13 eyes (38%).

CONCLUSION

Continuous monthly intravitreal ranibizumab decreases leakage and hemorrhage in eyes with exudative and hemorrhagic complications of PCV. Branching vascular networks persisted, and polypoidal complexes decreased in only 5/13 (38%) eyes with continuous antiangiogenic therapy at 1 year.

Long-term outcome of intravitreal ranibizumab treatment, compared with photodynamic therapy, in patients with polypoidal choroidal vasculopathy

PURPOSE

To evaluate the functional outcomes of patients with polypoidal choroidal vasculopathy (PCV) who underwent intravitreal ranibizumab (IVR) treatment, compared with photodynamic therapy (PDT), after at least 2 years.

METHODS

We retrospectively studied all the treatment-naïve patients with PCV who were scheduled to undergo IVR or PDT between August 2005 and June 2010. All the patients who had a 2-year or longer follow-up period were included in the study. The best-corrected visual acuity (BCVA) in the two groups was compared before treatment and at 3, 6, 12, 18 and 24 months after the initial treatment. The regression of the polyps was also assessed using indocyanine green angiography.

RESULTS

A total of 77 patients were included in this study. Thirty-three eyes were treated with IVR, and 44 eyes were treated with PDT. Although no significant differences between the two groups were observed at baseline or at 3, 6, and 12 months after treatment, a significantly better BCVA was seen in the IVR group, compared with the PDT group, at 18 and 24 months after treatment (P=0.035 and P=0.021, respectively). No significant difference in the rate of polyp regression was observed between the two groups (P=0.092).

CONCLUSION

IVR was well tolerated and maintained or improved the vision of patients with PCV, compared with PDT, as evaluated at 2-year follow-up examinations. PDT for the treatment of PCV might result in unfavorable outcomes, with no superiority to achieving the involution of polyps.

Asian Age-Related Macular Degeneration: Current Concepts and Gaps in Knowledge

Data on the epidemiology and treatment of age-related macular degeneration (AMD) in Asian populations have been scarce. Recently, significant advances in the current knowledge of AMD in Asia have been made, but deficiencies in important areas remain. Epidemiological data on AMD in those 80 years or older are lacking.There are also few incidence data on AMD or polypoidal choroidal vasculopathy (PCV), an important variant of AMD that seems to be more common in Asia. The risk factors for PCV have not been clearly defined to the extent that those for AMD have. No trials of nutritional supplementation for AMD prevention in Asia exist, and there is also a lack of long-term clinical trial data on combination therapy for PCV and indeed very few trial data on PCV. These represent opportunities for future research. With aging populations in Asia, increased data on the prevalence, risk factors, prevention, and treatment of AMD and PCV in Asian populations will be needed to formulate evidence-based public health and clinical guidelines.