Choroidal thickness changes after intravitreal ranibizumab and photodynamic therapy in recurrent polypoidal choroidal vasculopathy

Relationship between Pachychoroid and Polypoidal Choroidal Vasculopathy

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

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

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

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

Anti-VEGF treatment for neovascular age-related macular degeneration (nAMD) has been evaluated in clinical trials. To select the best anti-VEGF drug and the best treatment regimen for nAMD, a thorough understanding of the characteristics of each anti-VEGF drug and treatment regimen is essential. In this review, we summarized visual acuity (VA) changes in 30 previous clinical trials of anti-VEGF treatment for nAMD. In most studies, ranibizumab, aflibercept, and brolucizumab improved the VA by 6 to 12 letters from the baseline VA of 50-65 letters and maintained the VA improvement regardless of the treatment regimen; the VA improved from 0.2-0.4 to 0.3-0.7 in Snellen equivalents. The improvement was rapid during the first month and became slower after the second injection, and 60% to 90% of the VA improvement was attained within the first 3 months. The upper limit of the VA improvement should be determined according to eyes with nAMD themselves, not according to anti-VEGF drugs or treatment regimens. Since a fixed regimen can result in overtreatment, whilst a pro re nata regimen can result in insufficient treatment, a treat-and-extend regimen would be optimal to treat nAMD. Insufficient treatment fails to improve VA to the upper limit and/or to maintain the improved VA, whereas overtreatment can cause macular atrophy. One study reported no difference in the risk of macular atrophy between ranibizumab and aflibercept, whilst many studies have suggested that aflibercept causes more choroidal thinning, one of the risk factors for macular atrophy, than does ranibizumab. Further evaluation of drugs and regimens should be performed from the viewpoint of complications and minimum number of injections required to improve and maintain VA.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Central Serous Chorioretinopathy in Elderly Patients Mimicking Occult Neovascular Age-Related Macular Degeneration

Purpose

To describe elderly patients with central serous chorioretinopathy (CSCR) mimicking occult neovascular age-related macular degeneration (nAMD).

Materials and Methods

The records of 522 patients with initial diagnoses of nAMD over one year were reviewed to determine characteristics meeting diagnostic criteria for CSCR with three or more months of follow-up. Patients were evaluated by clinical examination, fluorescein angiography (FA) and optical coherence tomography (OCT). At the time of initial evaluation, patients were either monitored, treated with anti-VEGF therapy or with combination anti-VEGF and photodynamic therapy (PDT). When no response to anti-vascular endothelial growth factor (anti-VEGF) treatment was observed, the diagnosis of CSCR was favored and patients were observed with close follow-up. The Student’s t-test was used for statistical analysis; a p-value < 0.05 was considered statistically significant.

Results

Eleven elderly patients met diagnostic criteria for CSCR among 522 patients initially diagnosed with nAMD. Average age was 75.9 years, and average follow-up was 16.9 months. Average presenting visual acuity was 20/50+2 (67.9 ± 5.9 ETDRS letters), and choroidal thickness was 232.0 ± 69.4 µm. After observation or treatment, the average vision improved to 20/40+ (70.5 ± 7.8 ETDRS letters, p=0.289). When intravitreal bevacizumab was given, no changes were observed for patients’ neurosensory retinal detachments (NSRD). When NSRD changes were observed, they likewise did not correlate to the timing of anti-VEGF treatment. For patients who were monitored alone, one patient lost one line of vision, one gained one line, one gained two lines, and one gained three lines. One patient subsequently developed a choroidal neovascular membrane (CNVM) during initial follow-up with visual improvement after anti-VEGF treatment. Four patients developed CNVM overall with long term follow-up.

Conclusion

CSCR in elderly patients can mimic occult CNVM, especially on FA. In this group, many patients were monitored without treatment, which typically resulted in stable or improved vision. Careful monitoring is required because of possible development of CNVM.

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.

Initial treatment for polypoidal choroidal vasculopathy: Ranibizumab combined with photodynamic therapy or fixed-dosing aflibercept monotherapy

PURPOSE

To compare the 2-year outcomes of combination therapy using intravitreal ranibizumab and photodynamic therapy with those of fixed-dosing intravitreal aflibercept monotherapy as initial treatment for treatment-naïve polypoidal choroidal vasculopathy.

METHODS

We retrospectively reviewed 63 eyes of 61 patients with treatment-naïve polypoidal choroidal vasculopathy who had undergone at least 24 months of follow-up. In total, 43 eyes underwent intravitreal ranibizumab-photodynamic therapy combination therapy and 20 eyes underwent fixed-dosing intravitreal aflibercept monotherapy. Visual outcomes and the number of treatments were compared between the two groups.

RESULTS

The mean logarithm of minimal angle of resolution best-corrected visual acuity significantly improved from 0.48 ± 0.41 at baseline to 0.30 ± 0.47 at 24 months in the intravitreal ranibizumab-photodynamic therapy group (p = .0002) and from 0.30 ± 0.18 at baseline to 0.16 ± 0.18 at 24 months in the intravitreal aflibercept group (p = .004), with no significant intergroup differences. The mean number of intravitreal ranibizumab or intravitreal aflibercept injections over 24 months was 5.7 ± 4.5 in the intravitreal ranibizumab-photodynamic therapy group and 12.2 ± 3.8 in the intravitreal aflibercept group (p < .0001).

CONCLUSION

The intravitreal ranibizumab-photodynamic therapy combination therapy was noninferior to fixed-dosing intravitreal aflibercept monotherapy in improving visual acuity and required fewer injections.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Characterizing Branching Vascular Network Morphology in Polypoidal Choroidal Vasculopathy by Optical Coherence Tomography Angiography

This study analyze the morphological characteristics of branching vascular networks (BVN) in polypoidal choroidal vasculopathy (PCV) using optical coherence tomography angiography (OCTA), and correlate imaging characteristics with clinical presentations. We presented a retrospective observational case series for fifty cases of PCV confirmed by indocyanine green angiography. Macular OCTA were done by the AngioVue. The PCV cases were classified by distinct morphologic patterns of BVN by two retina specialists and clinical features were analyzed. The sensitivity of polyp detection by OCTA was 86% after manual segmentation and that of BVN was 90%. Three distinct morphologic patterns of BVN were identified. (1) The “Trunk” pattern (47%) exhibited major vessel trunk with features including presence of drusens, thin choroid, and larger BVN area. (2) The “Glomeruli” pattern (33%) showed anastomotic vascular network without major trunk. (3) The “Stick” pattern (20%) had localized BVN and the thickest choroid. Subtypes 2 and 3 held higher recurrence rate. In conclusions, the precise visualization of BVN on OCTA supported that OCTA might be a noninvasive tool to study the morphology of BVN in PCV, which exhibits three different morphological types. Identifying the morphology of BVN has the potential to prognosticate outcomes in PCV patients.

Increased choroidal thickness: a new feature to monitor age-related macular degeneration recurrence

PURPOSE

The main objective of this study was to assess choroidal thickness (CT) changes during an exudative recurrence of age-related macular degeneration (AMD).

METHODS

A real-life prospective non-interventional 9-month study was conducted in two centers in consecutive patients with exudative AMD between November 2016 and July 2017. CT was measured manually in both eyes based on enhanced-depth imaging spectral-domain optical coherence tomography at different follow-up visits scheduled in the morning.

RESULTS

A total of 134 patients were included. Ninety-five patients presented at least one episode, defined by a follow-up visit under controlled condition (dry retina) followed by a visit for exudative recurrence. A total of 119 episodes were analyzed. The mean CT change in the treated eye was + 8.45 ± 13.52 μm (p < 0.001) and + 5.62 ± 14.77 μm (p = 0.009) respectively in the subfoveal area and nasal area. No significant change in CT was observed in the fellow eye. No significant association between CT changes and treatment, number of intravitreal injections, and blood pressure was observed.

CONCLUSION

CT increased in case of exudative recurrence of neovascular AMD. The increase was mild but significant. Thus, CT could be used as a monitoring criterion, like the central retinal thickness, in AMD management.

Choroidal morphology and short-term outcomes of combination photodynamic therapy in polypoidal choroidal vasculopathy

PURPOSE

To investigate outcomes of combined photodynamic therapy (PDT) and intravitreal bevacizumab in association with choroidal morphology in polypoidal choroidal vasculopathy (PCV).

METHOD

Eighty-six PCV eyes (83 patients) treated with PDT in combination with intravitreal bevacizumab and followed for 1 year were evaluated. Choroidal morphological features including subfoveal choroidal thicknesses, diameter of pachyvessel, and choroidal vascularity were analyzed for association with responsiveness and recurrence.

RESULT

Total choroid, Haller's layer, and pachyvessel were thicker in responders (n = 70) compared with non-responders (n = 16) at baseline (298 vs. 227 μm, 213 vs. 144 μm, and 276 vs. 210 μm, respectively; all P ≤ 0.001). Choroidal vascularity was significantly higher (0.68 vs 0.60, P < 0.001) and choroidal hyperpermeability was more frequent in responders (44 vs 13%, P = 0.018). Significant thinning of total choroid was observed in both responders and non-responders at 3 months after combination PDT (both P < 0.05), but the reduction was greater in responders (- 33 μm vs. - 10 μm, P = 0.036). In recurrent eyes (n = 26), increase in pachyvessel diameter and choroidal vascularity was observed at recurrence.

CONCLUSION

Choroidal morphology including characteristic features of pachychoroid and high vascularity can serve as predictive factors for outcomes after combination PDT in eyes with PCV.

Subfoveal Choroidal Thickness in Eyes with Neovascular Age-Related Macular Degeneration Treated with Anti-Vascular Endothelial Growth Factor Agents

PURPOSE

We aimed to assess the subfoveal choroidal thickness (SFChT) and the effect of treatment with anti-vascular endothelial growth factor (anti-VEGF) agents on the SFChT in age-related macular degeneration (AMD) subtypes.

METHODS

We enrolled 128 eyes of 107 patients with neovascular AMD (60 women; 47 men; mean age, 73.6 ± 8.9 years), and prospectively evaluated the best-corrected visual acuity (BCVA) and SFChT at baseline and at 3, 6, and 12 months after treatment with anti-VEGF agents. Patients were assigned to the typical AMD, polypoidal choroidal vasculopathy (PCV), and retinal angiomatous proliferation (RAP) subgroups.

RESULTS

In total, 85 (66.4%), 31 (24.2%), and 12 (9.4%) eyes were assigned to the typical AMD, PCV, and RAP subgroups, respectively. The baseline mean BCVA was 0.75 ± 0.26, 0.72 ± 0.21, and 0.77 ± 0.24 logMAR in the typical AMD, PCV, and RAP subgroups, respectively (p = 0.774). The mean baseline SFChT was 203.20 ± 35.80, 271.80 ± 24.50, and 182.93 ± 31.31 µm, respectively (p < 0.001). Mean SFChT significantly decreased from baseline to 3, 6, and 12 months after treatment. The RAP subtype presented a significantly higher decrease in SFChT compared to the other subtypes (p = 0.01). The percentage reduction in SFChT was not significantly correlated with the number of injections (r = -0.02; p = 0.823). No association was observed between baseline SFChT and final visual acuity at 12 months (r = 0.0; p = 0.586).

CONCLUSIONS

SFChT was greatest in eyes with PCV and least in eyes with RAP. The reduction in SFChT after treatment was greater in the RAP cases. The decrease in SFChT after 12 months of anti-VEGF treatment was not associated with the number of injections and there was no correlation between the baseline SFChT and visual acuity in all AMD subtypes.

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.

Comparison of clinical features and 3-month treatment response among three different choroidal thickness groups in polypoidal choroidal vasculopathy

Eyes with polypoidal choroidal vasculopathy (PCV) were recently reported to have various choroidal thickness, and choroidal thickness might be associated with visual outcome in the treatment of many retinal disorders. The range of subfoveal choroidal thickness (SFCT), clinical features, and 3-month treatment response among three groups having different range of SFCT were investigated in PCV eyes. In 78 treatment-naïve eyes with PCV, SFCT was measured using optical coherence tomography. Eyes were classified into thin, medium, and thick groups, using mean and one standard deviation of SFCT. Clinical features and imaging findings were compared among the three groups. Some eyes were treated with three consecutive monthly injection of anti-vascular endothelial growth factor (VEGF) as an initial treatment. They were also classified into three thickness groups, and the short-term post-treatment improvement in visual acuity and central retinal thickness were compared among groups. The mean SFCT was 271.9 ± 135.6 μm. Twelve, 53, and 13 eyes were classified into thin (<136.3 μm), medium (136.3–407.5 μm), and thick (>407.5 μm) groups, respectively. The thin group showed older age, lower visual acuity, and a higher prevalence of fundus tessellation than the other two groups (P <0.05). In multiple linear regression analyses, baseline BCVA was correlated with baseline SFCT. Forty-six eyes completed three consecutive anti-VEGF treatments. The thin group showed no visual improvement after treatment (P = 0.141), unlike the other two groups showing visual improvement (P<0.05). Eyes with PCV have a broad range of SFCT, and PCV eyes with a thin choroid manifest worse visual function than eyes with a medium or thick choroid.

Comparison between 1-year outcomes of aflibercept with and without photodynamic therapy for polypoidal choroidal vasculopathy: Retrospective observation study

Polypoidal choroidal vasculopathy (PCV) is characterized by polyp-like choroidal neovascularization and a branching vascular network. Intravitreal aflibercept injection (IAI) or photodynamic therapy (PDT) is used for treatment. We retrospectively compared the 1-year outcomes of IAI monotherapy and its combination with initial PDT for PCV. Twelve eyes with naïve PCV received three IAIs and a single PDT after the first IAI and as needed injection (combination group); 11 eyes with naïve PCV received three IAIs and as needed injections (IAI group). Significant improvements in visual acuity after 2 months and in CRT after 1 month were maintained at 12 months in both groups (both P < 0.05); groups did not differ significantly at any time point. CCT significantly reduced after 3 and 12 months in the combination group (both P < 0.05) but not in the IAI group. A mean of 3.7 ± 0.9 and 5.6 ± 2.0 injections was administered to the combination and IAI groups, respectively (P = 0.013). Within a 1-year period, combination therapy was found to yield similar visual acuity and retinal structure improvements and maintenance as IAI monotherapy while requiring fewer IAIs.

SUBRETINAL FIBROSIS AFTER ANTIVASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN EYES WITH MYOPIC CHOROIDAL NEOVASCULARIZATION

PURPOSE

To assess the incidence and risk factors of subretinal fibrosis and their impact on visual outcome in eyes with myopic CNV.

METHODS

Medical records of 72 eyes treated with antivascular endothelial growth factor (anti-VEGF) therapy in a pro re nata regimen for myopic CNV that followed up for more than 1 year were retrospectively reviewed. The presence of subretinal fibrosis after anti-VEGF therapy was determined using both fundus photographs and optical coherence tomography. The incidence and risk factors of subretinal fibrosis were evaluated, and best-corrected visual acuity was compared between the eyes with and without subretinal fibrosis.

RESULTS

The incidences of subretinal fibrosis during the 1-year and whole follow-up period were 31.9% and 36.1%, respectively. Occurrence of subretinal fibrosis was associated with frequent CNV recurrence (P = 0.005) and poor baseline best-corrected visual acuity (P = 0.044) in a Cox proportional hazard model. Anatomically, the eyes with subretinal fibrosis showed more frequent progression of chorioretinal atrophy (95.7% vs. 71.4%, P = 0.027) and less frequent photoreceptor recovery (17.4% vs. 65.3%, P < 0.001) after anti-VEGF therapy. Occurrence of subretinal fibrosis was associated with poor vision at baseline (P = 0.011) and the final visit (P = 0.008) when compared with the findings in the nonoccurrence group.

CONCLUSION

Development of subretinal fibrosis after anti-VEGF therapy was common in eyes with myopic CNV and was associated with CNV recurrence. Myopic eyes with subretinal fibrosis show progressive chorioretinal atrophy and poor visual outcome.

CHOROIDAL STRUCTURE ALTERED BY DEGENERATION OF RETINA IN EYES WITH RETINITIS PIGMENTOSA

PURPOSE

To compare the structural characteristics of the choroid in the areas with greater retinal degeneration to the areas with less retinal degeneration in eyes with retinitis pigmentosa (RP).

METHODS

Patients with RP who had a hyperautofluorescent ring were studied. The choroidal images obtained by enhanced depth imaging optical coherence tomography located 7,500 μm from the optic disk in the horizontal plane were analyzed. The cross-sectional areas of the total, luminal, and stromal choroid were measured. The area within the hyperautofluorescent ring was defined as the "central choroid" with less retinal degeneration.

RESULTS

Thirty-seven eyes of 24 patients with RP were studied. The cross-sectional area of the total choroid was significantly smaller in the RP eyes than that in the control eyes (P < 0.01). The stromal areas of the choroid were not significantly different from the stromal areas of the controls. However, the luminal areas of the nasal and temporal choroid in the RP eyes were significantly smaller than that of the corresponding areas of the controls. The ratio of the luminal area to the total choroidal area in the central choroid was 68.0 ± 3.3% which was significantly larger than that of the nasal or the temporal choroid (P < 0.01).

CONCLUSION

The choroidal structure is differentially altered in eyes with RP. The changes in the choroid were dependent on whether they were located within the hyperautofluorescent or outside the hyperautofluorescent ring.

Short-term focal macular electroretinogram of eyes treated by aflibercept & photodynamic therapy for polypoidal choroidal vasculopathy

BACKGROUND

To compare short-term outcomes of intravitreal aflibercept injection (IAI) with or without initial photodynamic therapy (PDT) for polypoidal choroidal vasculopathy (PCV) using focal macular electroretinography (FMERG).

DESIGN

Observation case series.

METHODS

Twelve patients (6 males, 6 females; 12 eyes) with naïve PCV received 3 initial IAIs and a single session of PDT 3 days after the first IAI (combination group), and 13 patients (7 males, 6 females; 13 eyes) with naïve PCV received 3 initial IAIs only (IAI group) were retrospectively observed. Changes in visual acuity, central retinal thickness (CRT), central choroidal thickness (CCT), and FMERG parameters (FMERGs) were compared.

RESULTS

The combination group showed improved visual acuity after the second and third IAI (P = 0.040, 0.019, respectively); both groups showed reduced CRT after the first IAI (P < 0.01, each). Only the combination group showed reduced CCT after the third IAI (P = 0.031). The FMERGs of the IAI group showed improved amplitudes of a-waves after the third IAI (P = 0.026) and of b-waves after the first and third IAI (P = 0.034, < 0.01, respectively); the combination group did not show improvement. The implicit times of the a- and b-waves were not changed in either group.

CONCLUSIONS

Combination therapy and IAI monotherapy each improved visual acuity and retinal structure to a similar degree; combination therapy reduced choroidal thickness but did not improve FMERGs in the short term.

Subfoveal choroidal thickness changes after intravitreal bevacizumab injection for neovascular age-related macular degeneration and diabetic macular edema

The purpose of this study was to investigate the changes in subfoveal choroidal thickness (SFCT) after intravitreal injection of bevacizumab (IVB) for neovascular age-related macular degeneration (AMD) and diabetic macular edema (DME). This retrospective, consecutive, interventional case series study included 43 eyes [21 affected eyes with neovascular AMD (AMD group) and 22 affected eyes with DME (DME group)] which were treated with 1.25 mg/0.5 ml IVB and 43 untreated fellow eyes of 43 patients. SFCT was measured in all 86 eyes at baseline before IVB injection and at day 1, week 1, and month 1 after injection by use of enhanced depth imaging optical coherence tomography (EDI OCT). Central foveal thickness (CFT) and best-corrected visual acuity were analyzed at baseline and during follow-up visits. Main outcome measure was change in SFCT in 1 month after treatment. All 43 eyes treated with IVB showed a significant reduction in SFCT. Mean SFCT in treated eyes decreased from 237.1 ± 75.3 µm at baseline to 214.0 ± 65.7 µm at day 1, 205.4 ± 59.7 at week 1, and 222.7 ± 73.3 at month 1, whereas SFCT in fellow eyes changed from 228.4 ± 63.6 at baseline to 224.5 ± 68.5 at day 1, 220.4 ± 72.1 at week 1, and 226.9 ± 74.0 at month 1. SFCT demonstrated a similar trend toward decrease in both groups. CFT decreased significantly and visual acuity improved significantly. SFCT decreased significantly in AMD and DME eyes following injection. The decreasing effect of bevacizumab on choroidal thickness was highest at first week and continued to the end of first month after injection.

Choroidal Thickness Changes in Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy: A 12-Month Prospective Study

PURPOSE

To describe 12-month changes in choroidal thickness after anti-vascular endothelial growth factor (anti-VEGF) therapy for typical age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV).

DESIGN

Prospective, consecutive, noninterventional, longitudinal case series.

METHODS

This study included patients with typical AMD and PCV who received anti-VEGF therapy over a 12-month period. We used spectral-domain optical coherence tomography with enhanced depth imaging mode to measure choroidal thickness.

RESULTS

Of the 163 patients, 77 had typical AMD and 86 had PCV. Patients with PCV were younger (67.6 vs 72.5 years, P < .01) and received fewer anti-VEGF injections (3.9 vs 5.6, P = .02) than patients with typical AMD. Baseline subfoveal choroidal thickness was not significantly different between PCV and typical AMD eyes, and was thicker in the study eye compared to fellow eye in the typical AMD group (223.1 vs 208.8 μm, P < .01). Subfoveal choroidal thickness decreased significantly in both typical AMD (213.7 μm to 190.3 μm, P < .001) and PCV (240.8 μm to 213.4 μm, P < .01) eyes, but no significant change was noted in fellow unaffected eyes. Reduction in choroidal thickness was associated with elevated C-reactive protein (odds ratio [OR]: 1.4, P = .04) and smoking (OR: 7.6, P = .03) at baseline, but not with age, refractive error, diagnosis of typical AMD or PCV, number or type of anti-VEGF injections, PDT therapy, or baseline choroidal thickness.

CONCLUSIONS

A significant reduction in subfoveal choroidal thickness was noted after anti-VEGF therapy in typical AMD and PCV. Choroidal thickness changes were similar despite differences in number of anti-VEGF treatment.

Punctate hyperfluorescent spots associated with polypoidal choroidal vasculopathy on indocyanine green angiography

BACKGROUND AND OBJECTIVE

To evaluate punctate hyperfluorescent spots on indocyanine green angiography (ICGA) in eyes with polypoidal choroidal vasculopathy (PCV).

PATIENTS AND METHODS

Retrospective observation case series of 88 eyes of 81 patients (63 men and 18 women) analyzing fundus photography, fluorescein angiography, ICGA, and spectral-domain optical coherence tomography (OCT) findings at baseline.

RESULTS

Seven patients (9%) had bilateral PCV lesions. Mean age was 68.44 ± 5.94 years (range: 45 to 86 years). Macular-type PCV was found in 72 eyes (81.8%), peripapillary-type PCV in 12 eyes (13.6%), and combined-type PCV in four eyes (4.5%). Choroidal vascular hyperpermeability was observed in 38 eyes (43.2%), and punctate hyperfluorescent spots on ICGA in 47 eyes (53.4%). ICGA of unaffected fellow eyes of 74 patients with unilateral PCV revealed choroidal hyperpermeability in 23 eyes (31.1%) and punctate hyperfluorescent spots in 38 eyes (51.4%). Presence of punctate hyperfluorescent spots was significantly associated with choroidal vascular hyperpermeability (P < .001).

CONCLUSION

Punctate hyperfluorescent spots were frequently observed in eyes with PCV in late-phase ICGA, as previously described in eyes with central serous chorioretinopathy, which may represent leakage from punctate hyperpermeable inner choroid spots or late staining of forme fruste drusen or drusen-like subretinal pigment epithelium deposits associated with choroidal hyperpermeability.

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

PURPOSE

To investigate the changes in subfoveal thickness after switching to intravitreal aflibercept injection for polypoidal choroidal vasculopathy (PCV).

METHODS

We retrospectively reviewed 66 eyes of 65 PCV patients (mean age 75.7 years) which were refractory to ranibizumab. The choroidal thickness was measured by optical coherence tomography (OCT) using an enhanced depth imaging technique. Intravitreal aflibercept (2 mg/0.05 ml) was administered with three consecutive monthly injections as a loading dose, followed by further injections bimonthly (every two months).

RESULTS

The mean subfoveal choroidal thickness significantly decreased from 203 μm at baseline to 171 μm at month 6 (P < 0.0001). The mean logMAR best-corrected visual acuity levels significantly improved from 0.40 at baseline to 0.33 at 6 months (P < 0.001). The central retinal thickness significantly decreased from 249 μm at baseline to 161 μm at 6 months (P < 0.0001). At month 6, 41 (62.1%) eyes had dry macula by OCT. Of 46 eyes with polypoidal lesions at baseline, complete regression of polypoidal lesions was achieved in 26 (56.5%) eyes at 3 months.

CONCLUSIONS

The choroidal thickness in PCV eyes significantly decreased after switching to intravitreal aflibercept injection. Aflibercept may help prevent choroidal neovascularization near or under the retinal pigment epithelium, which might help achieve greater occlusion of polypoidal lesions compared with ranibizumab.

Association between choroidal thickness and the response to intravitreal ranibizumab injection in age-related macular degeneration

PURPOSE

To investigate the relationship between the choroidal thicknesses of eyes of patients with age-related macular degeneration (AMD) and the outcomes of intravitreal ranibizumab injection.

METHODS

We reviewed the medical records of 141 consecutive eyes (80 with typical neovascular AMD and 61 with polypoidal choroidal vasculopathy [PCV]) treated by intravitreal ranibizumab and 121 normal control eyes matched in terms of age and spherical equivalent (SE). Eyes of patients were divided into three subgroups with thin, medium and thick choroids. We investigated the relationships between choroidal thickness and treatment outcomes of intravitreal ranibizumab.

RESULTS

In eyes with typical neovascular AMD, thin choroids were associated with older age (linear regression; p < 0.0001) and larger choroidal neovascularization (CNV) lesions (p = 0.049). Patients with thin choroids had a higher prevalence of intra-/subretinal fluid (generalized estimated equation; thin versus medium p < 0.0001; thin versus thick p = 0.003), and less visual gain from baseline to 12 months after treatment, than did other subgroups (linear mixed model; thin versus medium p < 0.0001; thin versus thick p = 0.023). PCV eyes with thick choroids more often had retinal fluid, and eyes with thin choroids experienced more frequent resolution of retinal fluid, from baseline to 12 months after treatment (thick versus medium p < 0.0001, thick versus thin p < 0.0001, thin versus medium p = 0.001). No intergroup difference in post-treatment functional outcome was noted in eyes with PCV (p = 0.584).

CONCLUSIONS

Subfoveal choroidal thickness was associated with functional and anatomical outcomes after intravitreal ranibizumab injection in eyes with typical neovascular AMD and PCV.

Short-term changes in choroidal thickness after aflibercept therapy for neovascular age-related macular degeneration

PURPOSE

To investigate changes in choroidal thickness after aflibercept therapy for neovascular age-related macular degeneration (AMD).

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

This study included 102 eyes of 102 patients with treatment-naïve neovascular AMD. All 102 eyes underwent 3 consecutive monthly 2.0 mg intravitreal aflibercept injections at baseline, 1 month, and 2 months. Choroidal thickness during 3 months were evaluated using either swept-source optical coherence tomography (OCT) or enhanced-depth imaging OCT.

RESULTS

Of the 102 eyes, 46 eyes (45.1%) were diagnosed as typical neovascular AMD and 56 eyes (54.9%) as polypoidal choroidal vasculopathy. After intravitreal aflibercept injections, the mean subfoveal choroidal thickness decreased from 252.0 ± 99.7 μm at baseline to 217.9 ± 95.6 μm at 3 months (P < .0001; percentage change from baseline, 86.5%). Mean choroidal thickness measured at 3 mm from the foveal center in the superior, inferior, temporal, and nasal directions also decreased significantly from 258.7 ± 85.9 μm to 236.4 ± 84.6 μm, 229.9 ± 93.0 μm to 208.6 ± 86.5 μm, 237.4 ± 86.5 μm to 214.6 ± 79.5 μm, and 183.7 ± 97.0 μm to 162.3 ± 90.6 μm, respectively (P < .0001 for all directions). Both subtypes of neovascular AMD demonstrated a similar trend toward decreasing choroidal thickness during the follow-up period.

CONCLUSIONS

Choroidal thickness significantly decreased not only at the foveal center but also in the entire macula after 3 monthly intravitreal aflibercept injections for neovascular AMD.

The Effect of Systemic Tamsulosin Hydrochloride on Choroidal Thickness Measured by Enhanced Depth Imaging Spectral Domain Optical Coherence Tomography

BACKGROUND

To evaluate the effects of selective α1A-adrenoceptor antagonist tamsulosin hydrochloride on choroidal thickness using enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT).

METHODS

This is a prospective observational study including 29 eyes of 29 patients with newly diagnosed benign prostatic hyperplasia. Choroidal thickness and retrobulbar ocular blood flow measurements were performed at baseline and after 3 months of treatment. Results were analyzed by the masked observer.

RESULTS

The mean subfoveal choroidal thickness (275.8-291.9 µm) and thicknesses 750 µm nasal (257.9-270.4 µm) and 750 µm temporal (262.4-277.0 µm) to the fovea were significantly increased after 3 months of treatment (p < 0.001). No statistically significant change was found in retrobulbar ocular blood flow.

CONCLUSIONS

Tamsulosin causes a significant increase in EDI-OCT-based choroidal thickness measurements. This increase might be associated with choroidal vasodilation in consequence of blockade of sympathetic α1A-adrenoceptors, which is critical for the maintenance of vascular tone and resistance in the choroidal vascular architecture. This should be kept in mind when choroidal disease and its response to treatment are followed by EDI-OCT imaging.