Comparison of the effect of ranibizumab and verteporfin for polypoidal choroidal vasculopathy: 12-month LAPTOP study results

Evaluating photodynamic therapy versus brolucizumab as a second-line treatment for polypoidal choroidal vasculopathy

BACKGROUND

To compare the one-year outcomes between intravitreal brolucizumab (IVBr) monotherapy and photodynamic therapy (PDT) as a second-line treatment in patients with polypoidal choroidal vasculopathy (PCV) who did not respond to first-line therapy.

METHODS

This case-control study included eyes with PCV that do not respond to aflibercept or ranibizumab. The patients were retrospectively registered. We compared outcomes, including best-corrected visual acuity (BCVA), anatomical results, and the need for additional treatments, between IVBr and a combination therapy using PDT as second-line treatments for refractory PCV, after adjusting for potential confounders. We analyzed E-values to evaluate the robustness of the results against unmeasured confounders.

RESULTS

Twenty-two eyes received IVBr, and twenty-four underwent PDT. No apparent differences were observed in BCVA and central macular thickness (CMT) changes from baseline between the groups (IVBr vs. PDT: BCVA, 0.01 ± 0.47 logMAR vs. 0.04 ± 0.18 logMAR, P-value = 0.756; CMT: - 36.3 ± 99.4 μm vs. - 114.7 ± 181.4 μm, P-value = 0.146). Only in the PDT group, five eyes (20.8%) did not require additional treatment after the second-line treatment, the adjusted odds ratio indicating no further treatment needed was 11.98 (95% confidence interval: 1.42-2070.07, P-value = 0.019). The E-value for the adjusted odds ratio was 23.44.

CONCLUSIONS

Both second-line treatments for PCV exhibited similar visual and anatomical outcomes. Only in the PDT-treated eyes were there some patients who did not require further treatment after second-line therapy.

Efficacy and safety of anti-vascular endothelial growth agents for the treatment of polypoidal choroidal vasculopathy: A systematic review and meta-analysis

There remains limited agreement regarding the efficacy and safety of different antivascular endothelial growth factor (anti-VEGF) agents for the management of polypoidal choroidal vasculopathy (PCV). Our meta-analysis compares different anti-VEGF agents for PCV treatment. Ovid MEDLINE, EMBASE, and Cochrane Library were systematically searched from January 2000 to July 2022. We included articles comparing the efficacy and safety of different anti-VEGF agents, specifically bevacizumab (BEV), ranibizumab (RAN), aflibercept AFL), and brolucizumab (BRO), for patients with PCV. 10,440 studies were identified, 122 underwent full-text review, and seven were included. One study was a randomized trial, and six were observational studies. Ranibizumab and aflibercept were associated with a similar best-corrected visual acuity (BCVA) at the last visit in three observational studies (P = 0.10), similar retinal thickness at the last visit in two observational studies (P = 0.85). One observational study comparing BEV versus RAN found comparable outcomes for final BCVA, retinal thickness, and polyp regression. One randomized trial on BRO versus AFL found comparable outcomes for improvement in BCVA, while anatomical outcomes favored BRO. The available evidence suggests that final BCVA is comparable across different anti-VEGF agents, however, further investigation is warranted due to paucity of evidence.

Recent Advances in Imaging Polypoidal Choroidal Vasculopathy with Swept-Source Optical Coherence Tomography Angiography

The gold standard for polypoidal choroidal vasculopathy (PCV) diagnosis is indocyanine green angiography (ICGA), but optical coherence tomography angiography (OCTA) has shown promise for PCV imaging in recent years. However, earlier generations of OCTA technology lacked the diagnostic efficacy to replace ICGA. Swept-source optical coherence tomography angiography (SS-OCTA), the latest generation of OCTA technology, has significantly improved penetrating ability, scanning speed, scanning range, and overall image quality compared with earlier generations of OCTA. SS-OCTA reveals a "tangled vasculature" pattern of polypoidal lesions (PLs), providing evidence that they are neovascular rather than aneurysmal structures. New choroidal biomarkers, such as the choriocapillaris flow void (FV), have been identified to explain the development of PCV lesions. Although no direct comparison between SS-OCTA and previous OCTA generations in terms of diagnostic capability has been performed, SS-OCTA has shown several advantages in differential diagnosis and monitoring early reactivation for PCV. These improvements make SS-OCTA a valuable tool for PCV diagnosis and follow-up, and it may become more important for this disease in the future. This review summarized recent advances in PCV morphology and structure, as well as the possible pathogenesis based on SS-OCTA findings. The value of SS-OCTA for PCV management is discussed, along with remaining issues, to provide an updated understanding of PCV and OCTA-guided management.

Polypoidal Choroidal Vasculopathy: Updates on Risk Factors, Diagnosis, and Treatments

There have been recent advances in basic research and clinical studies in polypoidal choroidal vasculopathy (PCV). A recent, large-scale, population-based study found systemic factors, such as male gender and smoking, were associated with PCV, and a recent systematic review reported plasma C-reactive protein, a systemic biomarker, was associated with PCV. Growing evidence points to an association between pachydrusen, recently proposed extracellular deposits associated with the thick choroid, and the risk of development of PCV. Many recent studies on diagnosis of PCV have focused on applying criteria from noninvasive multimodal retinal imaging without requirement of indocyanine green angiography. There have been attempts to develop deep learning models, a recent subset of artificial intelligence, for detecting PCV from different types of retinal imaging modality. Some of these deep learning models were found to have high performance when they were trained and tested on color retinal images with corresponding images from optical coherence tomography. The treatment of PCV is either a combination therapy using verteporfin photodynamic therapy and anti-vascular endothelial growth factor (VEGF), or anti-VEGF monotherapy, often used with a treat-and-extend regimen. New anti-VEGF agents may provide more durable treatment with similar efficacy, compared with existing anti-VEGF agents. It is not known if they can induce greater closure of polypoidal lesions, in which case, combination therapy may still be a mainstay. Recent evidence supports long-term follow-up of patients with PCV after treatment for early detection of recurrence, particularly in patients with incomplete closure of polypoidal lesions.

Joint multimodal deep learning-based automatic segmentation of ICGA and OCT images for assessment of PCV biomarkers

Purpose

To develop a fully-automatic hybrid algorithm to jointly segment and quantify biomarkers of polypoidal choroidal vasculopathy (PCV) on indocyanine green angiography (ICGA) and spectral domain-OCT (SD-OCT) images.

Design

Evaluation of diagnostic test or technology.

Participants

Seventy-two participants with PCV enrolled in clinical studies at Singapore National Eye Center.

Methods

The dataset consisted of 2-dimensional (2-D) ICGA and 3-dimensional (3-D) SD-OCT images which were spatially registered and manually segmented by clinicians. A deep learning-based hybrid algorithm called PCV-Net was developed for automatic joint segmentation of biomarkers. The PCV-Net consisted of a 2-D segmentation branch for ICGA and 3-D segmentation branch for SD-OCT. We developed fusion attention modules to connect the 2-D and 3-D branches for effective use of the spatial correspondence between the imaging modalities by sharing learned features. We also used self-supervised pretraining and ensembling to further enhance the performance of the algorithm without the need for additional datasets. We compared the proposed PCV-Net to several alternative model variants.

Main Outcome Measures

The PCV-Net was evaluated based on the Dice similarity coefficient (DSC) of the segmentations and the Pearson's correlation and absolute difference of the clinical measurements obtained from the segmentations. Manual grading was used as the gold standard.

Results

The PCV-Net showed good performance compared to manual grading and alternative model variants based on both quantitative and qualitative analyses. Compared to the baseline variant, PCV-Net improved the DSC by 0.04 to 0.43 across the different biomarkers, increased the correlations, and decreased the absolute differences of clinical measurements of interest. Specifically, the largest average (mean ± standard error) DSC improvement was for intraretinal fluid, from 0.02 ± 0.00 (baseline variant) to 0.45 ± 0.06 (PCV-Net). In general, improving trends were observed across the model variants as more technical specifications were added, demonstrating the importance of each aspect of the proposed method.

Conclusion

The PCV-Net has the potential to aid clinicians in disease assessment and research to improve clinical understanding and management of PCV.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Progression of Polypoidal Lesions Associated with Exudative Recurrence in Polypoidal Choroidal Vasculopathy

PURPOSE

To investigate the characteristics of the branching vascular network (BVN) and polypoidal lesions in polypoidal choroidal vasculopathy (PCV) to determine near-term indicators that may predict exudative recurrence.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients with PCV receiving anti-vascular endothelial growth factor (VEGF) monotherapy or anti-VEGF plus photodynamic therapy were followed for at least 1 year using swept-source OCT angiography (SS-OCTA) imaging.

METHODS

Patients were divided into 2 groups based on whether exudative recurrence occurred during follow-up. Multiple parameters were collected and compared between the 2 groups, such as age, gender, visual acuity, number of polypoidal lesions, lesion area at the first SS-OCTA visit, and total lesion area change from the first SS-OCTA visit to the last SS-OCTA visit. To evaluate the association between SS-OCTA imaging-based risk factors and the exudative recurrences, imaging features associated with PCV such as BVN growth and polypoidal lesion progression (enlargement, new appearance, and reappearance) at each follow-up visit were analyzed. The time intervals from the nonexudative visit with lesion progression to the corresponding exudative recurrence visit were documented to explore their association with exudative recurrences. Cox regression and logistic regression analyses were used.

MAIN OUTCOME MEASURES

Association between BVN growth and polypoidal lesion progression with exudative recurrence.

RESULTS

Thirty-one eyes of 31 patients (61% men) were included. Sixteen eyes had no recurrence of exudation, and 15 eyes had recurrence during follow-up. The average follow-up duration was 20.55 ± 6.86 months (range, 12-36 months). Overall, the recurrence group had worse best-corrected visual acuity (P = 0.019) and a greater increase in lesion area (P = 0.010). Logistical regression analysis showed that polypoidal lesion progression, including new appearance, enlargement, and reappearance of polypoidal lesions, was associated with exudative recurrences within 3 months (odds ratio, 26.67, 95% confidence interval, 3.77-188.54, P = 0.001).

CONCLUSIONS

Growth of nonexudative BVN and progression of polypoidal lesions were found to be lesion characteristics associated with exudative recurrences, and progression of polypoidal lesions might serve as a stand-alone indicator for the near-term onset of exudation. In PCV, more frequent follow-up visits are recommended when polypoidal lesions show progression.

Comparison of 3-year outcomes of photodynamic therapy combined with intravitreal ranibizumab or aflibercept for polypoidal choroidal vasculopathy in a European cohort

PURPOSE

Combined use of photodynamic therapy (PDT) with intravitreal anti-vascular endothelial growth factors (anti-VEGF) agents, such as ranibizumab (IVR) or aflibercept (IVA), has been shown to be effective for treating polypoidal choroidal vasculopathy (PCV). However, it is currently not well established which anti-VEGF agent provides superior outcomes for performing combination therapy. The present study compares the visual outcomes and re-treatment burden of combination therapy of PDT with either IVR or IVA in a European cohort of patients with PCV.

METHODS

A retrospective analysis was done on PCV patients who had received combination therapy of PDT with either IVR or IVA. The demographic characteristics, visual outcome, and anti-VEGF re-treatment exposures were analysed and compared.

RESULTS

A total of forty-four eyes (n = 11 male, 25%) were included in the analysis: 7 patients received IVR, 19 started with IVR but switched to IVA (IVS), and 18 received IVA, in combination with PDT. The BCVA improved in all three groups at 6-, 12-, 18-, 24-, 30-, and 36-month follow-ups after PDT, although the improvement was not statistically significant in the IVR group. The number of intravitreal anti-VEGF injections required/year after PDT was significantly fewer than before PDT. Significantly less eyes in the IVS group attained a good visual acuity of more than 70 ETDRS letters at the final visit.

CONCLUSION

Both IVR and IVA combined with PDT were effective treatments for the European cohort of patients with PCV. In eyes refractory to IVR, performing PDT promptly may be more beneficial than switching to IVA.

Optical Coherence Tomography Features for Identifying Posttreatment Complete Polypoidal Regression in Polypoidal Choroidal Vasculopathy

PURPOSE

To determine accuracy and relative risk (RR) of posttreatment optical coherence tomography (OCT) features in identifying complete or incomplete polypoidal regression in polypoidal choroidal vasculopathy (PCV).

DESIGN

Validity analysis.

METHODS

Treatment-naive PCV eyes undergoing OCT and indocyanine green angiography (ICGA) at baseline and posttreatment were included. Two graders confirmed diagnosis and identified posttreatment complete or incomplete regression on ICGA. Two other graders classified OCT characteristics of pigment epithelial detachment (PED) (polypoidal lesion) based on 5 prespecified features: "A," no PED; "B," PED with internal homogeneous reflectivity with predominant "BUN" (blended retinal pigment epithelium with underlying structure) sign; "C," PED with internal homogeneous reflectivity with minimal "BUN"; "D," heterogeneous PED; and "E," PED with hyporeflectivity.

RESULTS

Among 130 polypoidal lesions (65 pretreatment and 65 posttreatment) of 39 PCV eyes (39 patients; 54% female; mean age±SD: 64.6±8.2), all pretreatment lesions showed feature D on OCT. Posttreatment lesions with complete regression (31 lesions) showed OCT features A, B, C, D, and E in 32%, 45%, 13%, 10%, and 0%, respectively. Posttreatment lesions with incomplete regression (34 lesions) showed OCT features A, B, C, D, and E in 0%, 6%, 15%, 79%, and 0%, respectively. Presence of either feature A or B had highest accuracy (86%; 95% confidence interval: 75%-93%); 77% sensitivity; 94% specificity; RR 5.0 (3.5-7.1, P<0.001) for complete regression. Presence of feature D had highest accuracy (85%; 95% confidence interval: 74%-92%); 79% sensitivity; 90% specificity; RR 4.6 (3.0-6.9, P<0.001) for incomplete regression.

CONCLUSIONS

Without ICGA, OCT features could provide high accuracy in identifying posttreatment complete or incomplete polypoidal regression in PCV.

Current Trends in Clinical Characteristics, Diagnosis, and Treatment of Polypoidal Choroidal Vasculopathy: A Perspective from Vietnam

Polypoidal choroidal vasculopathy (PCV) is a common choroidal disease in the Asian population including Vietnam and is characterized by subretinal red-orange nodules, pigmented epithelium detachment, and massive subretinal hemorrhage. The recent focus on PCV in Vietnam can be attributed to advancements in PCV diagnosis and treatment. However, there is a scarcity of published literature and clinical data on PCV in the Vietnamese population, highlighting a key knowledge gap in this region. In order to address this gap, we gathered the opinions of experienced clinicians and retinal experts in Vietnam and reviewed available medical literature with the aim of: (i) providing an overview of PCV in the Vietnamese population—in terms of epidemiology, clinical characteristics, and management; (ii) tailoring international/national guidelines for the diagnosis and management of PCV, in line with available resources and medical equipment in Vietnam; and (iii) identifying gaps in clinical data in order to guide future PCV research in Vietnam and other countries with similar clinical conditions. The present review will enable healthcare providers and researchers to gain insight into current clinical practices and the limitations of PCV management in Vietnam and provide optimal and effective solutions.

Innovator Versus Biosimilar Ranibizumab in Polypoidal Choroidal Vasculopathy: Real-World Evidence

Introduction

To analyze the efficacy and safety profile of the intravitreal ranibizumab biosimilar molecule, Razumab^® (Intas Pharmaceuticals, Ahmedabad, India; BRm; Razumab^®) and the innovator ranibizumab drug (IRm; LUCENTIS^®) in Indian patients with polypoidal choroidal vasculopathy (PCV) under real-world conditions.

Methods

This was a retrospective study of treatment-naïve and previously treated PCV eyes undergoing intravitreal therapy with either BRm or IRm from January 2019 to September 2020 as three loading doses followed by a pro-re-nata (PRN) regimen. Changes in the best-corrected visual acuity (BCVA), subretinal fluid (SRF), intraretinal fluid (IRF), SRF height, and subfoveal choroidal thickness (SFCT) and the safety profiles were assessed at weeks 12, 24, and 52, respectively.

Results

A total of 22 eyes received IRm and 19 eyes underwent BRm therapy, respectively. Both the groups were comparable in age (P = 0.41) and gender distribution, although the BRm arm had significantly more eyes that were previously treated (P < 0.00001) with a greater median number of injections (P < 0.0001). At week 52, both groups had similar gains in visual acuity (P = 0.19), SRF resolution (P = 0.8), IRF resolution (P = 0.47), and SRF height (P = 0.71). The IRm eyes exhibited a significant improvement in BCVA (P = 0.001) at all visits with a greater mean number of injections (IRm: 5.41 ± 0.94; BRm: 4 ± 1.45; P = 0.0004), while the BRm eyes showed a similar increase in BCVA but did not reach statistical significance until week 52. The SFCT decreased significantly in the BRm arm at week 52 (P = 0.045). One eye (5.26%) in the BRm arm experienced mild anterior uveitis, which was treated with topical corticosteroids. In either arm, no other ocular or systemic adverse effects were observed.

Conclusions

Our real-world data demonstrated the ranibizumab biosimilar Razumab to have comparable visual acuity outcomes to the innovator ranibizumab molecule with an adequate safety profile in the management of PCV. Although these encouraging results support its use as a viable alternative to the innovator molecule, further prospective studies in a diverse patient population are needed to validate our findings.

Efficacy of Initial vs. Delayed Photodynamic Therapy in Combination With Conbercept for Polypoidal Choroidal Vasculopathy

Purpose

To compare the efficacy of initial vs. delayed photodynamic therapy (PDT) in combination with intravitreal injection of conbercept (IVC) for polypoidal choroidal vasculopathy (PCV).

Design

Multicenter, randomized, non-inferiority clinical trial.

Subjects

Naïve PCV patients.

Methods

Patients were randomized 1:1 into two groups: initial PDT with IVC and delayed PDT with IVC. At baseline, patients in the initial combination group were treated with PDT and IVC within 1 week, while patients in the delayed combination group were treated with IVC alone. PDT and IVC was given PRN during the follow-up in each group.

Main Outcome Measures

Non-inferiority of delayed PDT with IVC to initial PDT with IVC for mean change in best-corrected visual acuity from baseline to month 12 (95% CI of the difference entirely above −5 letters).

Results

Eighty-six patients were enrolled, with 43 in each group. At month 12, the change of BCVA in initial combination group was equivalent to that in the delayed combination group, with gains of 6.42 ± 1.89 and 7.49 ± 2.14 (mean ± standard error) letters, respectively [delayed group minus initial group: 1.07 letters; 95% confidence interval (CI): −4.62 to 6.76; P_{non−inferiority} = 0.0198]. The rates of complete polyp regression were 66.67 and 45.83% in the initial and delayed combination groups, respectively. The difference was not statistically significant (P = 0.386). The mean reductions of CRT were 204.77 ± 28.79 and 84.14 ± 30.62 μm in each group respectively. The difference was statistically significant (P = 0.005). In addition, the mean injection numbers were 3.47 ± 2.39 and 4.91 ± 2.65 in each group respectively. The differences were statistically significant (P = 0.010).

Conclusions

There was effective in both groups in patients with PCV. The initial combination group showed a more efficient decrease in CRT and polyp regression, along with fewer injections. However, the delayed combination group was non-inferior compared with the initial combination group in terms of the improvement of BCVA.

Trial Registration

https://ClinicalTrials.gov, Identifier: NCT02821520.

Evolving treatment paradigms for PCV

Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular AMD (nAMD) that accounts for a significant proportion of nAMD cases worldwide, and particularly in Asia. Contemporary PCV treatment strategies have closely followed those used in typical nAMD, though there are significant gaps in knowledge on PCV management and it remains unclear if these strategies are appropriate. Current clinical trial data suggest intravitreal anti-vascular endothelial growth factor (VEGF) therapy alone or in combination with photodynamic therapy is effective in managing haemorrhage and exudation in PCV, although the optimal treatment interval, including as-needed and treat-and-extend approaches, is unclear. Newer imaging modalities, including OCT angiography and high-resolution spectral domain OCT have enabled characterisation of unique PCV biomarkers that may provide guidance on how and when treatment and re-treatment should be initiated. Treatment burden for PCV is a major focus of future therapeutic research and several newly developed anti-VEGF agents, including brolucizumab, faricimab, and new modes of drug delivery like the port delivery system, offer hope for dramatically reduced treatment burden for PCV patients. Beyond anti-VEGF therapy, recent developments in our understanding of PCV pathophysiology, in particular the role of choroidal anatomy and lipid mediators in PCV pathogenesis, offer new treatment avenues that may become clinically relevant in the future. This article explores the current management of PCV and more recent approaches to PCV treatment based on an improved understanding of this unique disease process.

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.

Long-term outcomes of polypoidal choroidal vasculopathy in comparison with typical exudative age-related macular degeneration

PURPOSE

To compare long-term outcomes between typical exudative age-related macular degeneration (TexAMD) and polypoidal choroidal vasculopathy (PCV), and to investigate factors related to the outcomes.

METHODS

This retrospective study included 319 eyes (164 with TexAMD and 155 with PCV) treated with anti-vascular endothelial growth factor and followed more than 5 years. The primary outcome was visual acuity (VA) change from baseline to final visit. Linear regression analyses were used to determine factors associated with final VA.

RESULTS

Baseline logMAR VA was 0.7 ± 0.5 in the TexAMD group and 0.5 ± 0.4 in the PCV group (p < 0.001). After a mean follow-up of 9 years, final VA was also significantly worse in the TexAMD group than in the PCV group (0.9 ± 0.6 vs. 0.6 ± 0.5; p < 0.001). The PCV group showed longer maintenance of improved vision and later onset of significant visual decline than the TexAMD group. In multivariate analysis, loss to follow-up, worse baseline VA, macular atrophy, and subretinal fibrosis were significantly associated with poor final VA in both groups.

CONCLUSION

PCV eyes showed relatively favorable long-term visual outcome than TexAMD eyes. The results of this study emphasized the importance of compliance with treatment, along with other well-known prognostic factors.

REAL-WORLD EFFECTIVENESS AND SAFETY OF RANIBIZUMAB TREATMENT IN PATIENTS WITH AND WITHOUT POLYPOIDAL CHOROIDAL VASCULOPATHY: Twelve-Month Results From the LUMINOUS Study

Supplemental Digital Content is Available in the Text.

Twelve-month results from LUMINOUS support the use of ranibizumab as an effective first-line therapy for polypoidal choroidal vasculopathy. Higher baseline visual acuity and adequate injection frequency were associated with better visual acuity outcomes. No new safety signals were identified.

Purpose:

To evaluate the real-world effectiveness and safety of intravitreal ranibizumab 0.5 mg in treatment-naive patients with and without polypoidal choroidal vasculopathy (PCV).

Methods:

Assessment of neovascular age-related macular degeneration patients with or without PCV after 12 months of ranibizumab treatment during the LUMINOUS study. Outcome measures were visual acuity and central retinal thickness changes from baseline and the rate of ocular adverse events.

Results:

At baseline, 572 and 5,644 patients were diagnosed with and without PCV, respectively. The mean visual acuity gain from baseline at Month 12 in the PCV and non-PCV groups was +5.0 and +3.0 letters, respectively; these gains were achieved with a mean of 4.4 and 5.1 ranibizumab injections. Eighty percent of PCV patients and 72.2% of non-PCV patients who had baseline visual acuity ≥73 letters maintained this level of vision at Month 12; 20.6% and 17.9% of patients with baseline visual acuity <73 letters achieved visual acuity ≥73 letters in these groups. Greater reductions in central retinal thickness from baseline were also observed for the PCV group versus the non-PCV group. The rate of serious ocular adverse events was 0.7% (PCV group) and 0.9% (non-PCV group).

Conclusion:

LUMINOUS confirms the effectiveness and safety of ranibizumab in treatment-naive patients with PCV.

Two different treatment regimens of ranibizumab 0.5 mg for neovascular age-related macular degeneration with or without polypoidal choroidal vasculopathy in Chinese patients: results from the Phase IV, randomized, DRAGON study

PURPOSE

To evaluate the efficacy and safety of monthly and pro re nata (PRN, guided by visual acuity stabilization and disease activity criteria) ranibizumab regimens in Chinese patients with neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV).

METHODS

This double-masked study randomized nAMD patients (1:1) to ranibizumab monthly from baseline to Month (M) 11 to a PRN regimen from M12 to M23 (monthly group, n = 167) versus ranibizumab three monthly doses followed by a PRN regimen up to M23 (PRN group, n = 166). Subgroups were assessed based on the presence/absence of PCV (indicated by indocyanine green angiography).

RESULTS

Of 334 randomized patients, 41.7% had PCV at baseline. Mean average best-corrected visual acuity (BCVA) change from M3 to M4 through M12 was 3.3 letters with monthly and 1.7 letters with PRN (mean difference: 1.6; 95% CI: -2.95, -0.20, primary end-point). Mean change in BCVA from baseline (monthly/PRN, 53.8/53.7) to M12 and M24 was 12.3 and 11.3 letters in monthly and 9.6 and 9.3 letters in PRN group. Corresponding values for patients with PCV/without PCV were 12.7/12.1 letters (M12) and 12.3/10.6 letters (M24) in monthly and 9.4/9.4 letters (M12) and 9.7/8.7 letters (M24) in PRN groups. The mean number of injections was 11.4 (monthly) and 8.2 (PRN) from Day 1 to M11 and 4.8 (monthly) and 5.0 (PRN) from M12 to M23. No new safety findings were reported.

CONCLUSIONS

The study results support the use of either ranibizumab monthly or PRN regimens in Chinese patients with nAMD, regardless of presence of PCV.

Comparison of the Efficacy of Three Loading Doses of Intravitreal Injection of Conbercept with Injection Combined with PDT for the Treatment of PCV

Purpose

To compare the efficacy between initial 3-monthly intravitreal conbercept monotherapy and combination intravitreal conbercept with photodynamic therapy (PDT) for polypoidal choroidal vasculopathy (PCV).

Methods

This is a retrospective, comparative study which involved 65 PCV eyes of 65 patients. According to the therapeutic regimen, the PCV patients were divided into two groups: 32 eyes with naive PCV received a PDT after the first intravitreal injection of conbercept (IVC) followed by pro re nata (prn) retreatment (combination group), and 33 eyes with naïve PCV received 3-monthly IVC monotherapy followed by prn regimen (IVC monotherapy group). All patients completed at least 6 months of monthly follow-up.

Results

At month 6, best-corrected visual acuity (BCVA) improved significantly (P < 0.05) in both groups compared with that at baseline; the mean changes of BCVA between the IVC monotherapy group and combination group have no significant difference (−0.22 ± 0.22 vs. −0.17 ± 0.22 LogMAR, P = 0.38). The central retinal thickness (CRT) decreased significantly in the two groups (P < 0.05), with no difference between the two groups (P = 0.24). The complete regression rate of polyps was 58.6% (17 out of 29 eyes) in the IVC monotherapy group and 80.65% (25 out of 31 eyes) in the combination group, respectively (P = 0.09, χ-squared test). The combination group required significantly fewer injections than the IVC monotherapy group (3.09 ± 0.89 vs. 3.67 ± 0.74, P = 0.006).

Conclusion

Conbercept monotherapy significantly improved visual acuity and effectively regressed polyps during 6-month follow-up time in the treatment of PCV.

Systematic review with network meta-analysis of antivascular endothelial growth factor use in managing polypoidal choroidal vasculopathy

Polypoidal choroidal vasculopathy (PCV) is a vision-threatening disease common in Asian populations. However, the optimal treatment for PCV remains under debate. We searched the databases with optimal searching strategy. The study included randomized clinical trials and prospective studies that recruited patients with active PCV who had received interventions, including PDT, anti-VEGF, or a combination of PDT and anti-VEGF. The Grading of Recommendations Assessment, Development, and Evaluation methodology was used for rating the quality of evidence. Our study included 11 studies involving 1277 patients. The network meta-analysis of RCTs revealed the anti-VEGF group, early combination group, and late combination group had significant BCVA changes compared with the PDT group. Early combination therapy led to a significant decrease in CRT compared with PDT, anti-VEGF, and late combination therapy. Additionally, the early combination group had a significantly higher complete polyp regression rate than the anti-VEGF group. No significant differences were detected in the analysis of the number of anti-VEGF injections and safety profile. This network meta-analysis revealed that early combination therapy exhibited better efficacy related to anatomical outcomes than other therapies. Nonetheless, no significant differences related to BCVA change could be detected between anti-VEGF and late combination therapy.

One-year Results of Aflibercept Treatment for Polypoidal Choroidal Vasculopathy with Good Visual Acuity

PURPOSE

To evaluate the one-year efficacy of intravitreal aflibercept injection in polypoidal choroidal vasculopathy (PCV) with best-corrected visual acuity (BCVA) of 20 / 40 or better.

METHODS

This was a multicenter retrospective study. The medical records of patients diagnosed with treatment-naïve PCV were retrospectively reviewed. Patients with an initial BCVA of 20 / 40 or better and who had undergone intravitreal aflibercept injection were included. Patients were treated with three consecutive monthly injections, followed by pro re nata regimen according to the clinician's discretion at variable interval visits. The proportions of eyes for which BCVA was maintained (≤ 0.2 logarithm of the minimum angle of resolution change) or improved at 12 months were evaluated. The changes of BCVA, central subfield macular thickness (CSMT), pigment epithelial detachment, and subretinal fluid also were assessed.

RESULTS

A total of 86 eyes were included. The mean number of injections for 12 months of treatment was 5.4 ± 1.7. BCVA was maintained or improved in 94.2% (81 / 86) of cases. Mean BCVA (logarithm of the minimum angle of resolution) had changed from the baseline (0.23 ± 0.09) at 3 months (0.21 ± 0.14), 6 months (0.24 ± 0.22), and 12 months (0.20 ± 0.18), but with no statistical significance. CSMT had improved significantly from the baseline (336.1 ± 97.3 μm) at 3 months (223.6 ± 47.22 μm), 6 months (239.6 ± 64.2 μm), and 12 months (223.8 ± 47.9 μm). Pigment epithelial detachment was observed in 93% of cases at the baseline, 72.1% at 3 months, and 69.8% at 12 months, showing a significant decrease at all observation points. Subretinal fluid was observed in 91.9% of cases at the baseline, 20.9% at 3 months, and 29.1% at 12 months, showing a significant decrease at all observation points.

CONCLUSIONS

In cases of PCV with good visual acuity, intravitreal aflibercept injections decreased CSMT and were effective in maintaining visual acuity.

One-year results of intravitreal conbercept in treatment-naïve subjects with polypoidal choroidal vasculopathy

PURPOSE

To evaluate the functional and structural outcomes of intravitreal conbercept monotherapy using a "3 + pro re nata (PRN)" regimen in treatment-naïve subjects with polypoidal choroidal vasculopathy (PCV) up to 12 months.

METHODS

Thirty subjects (30 eyes) with PCV participated in this interventional, retrospective study. All subjects received intravitreal injections of 0.5 mg (0.05 ml) conbercept using a "3 + PRN" regimen for 12 months. The changes in best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) parameters, polyp lesion area, and regression rate were evaluated at baseline, month 3, and month 12.

RESULTS

At the study end-point, BCVA improved significantly from 52.80 ± 17.17 ETDRS letters at baseline to 62.20 ± 18.96 letters (P < 0.001), with a mean gain of 9.40 ± 14.97 letters. The central retinal thickness (CRT) significantly reduced from 454.93 ± 147.31 μm at baseline to 308.73 ± 106.80 μm (P < 0.001) at end-point, and the total macular volume (TMV) decreased from 9.51 ± 1.04 mm³ at baseline to 8.32 ± 0.84 mm3 at end-point (P < 0.001). The mean volume of pigment epithelial detachment (PED) decreased from 0.73 ± 0.97 mm³ at baseline to 0.48 ± 0.71 mm³ (P < 0.05) at month 3. At month 12, the mean volume of PED was 0.57 ± 0.80 mm³ (P > 0.05 compared to baseline). After the 3-monthly loading injections, 6 eyes (20.0%) showed complete polyp regression, whereas a total of 19 eyes (63.5%) showed complete regression at month 12. The average injections given per subject were 7.70 ± 1.81.

CONCLUSION

Intravitreal conbercept using the "3 + PRN" regimen was effective in the treatment of PCV.

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.

Pachychoroid: current concepts on clinical features and pathogenesis

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Efficacy of Conbercept in Polypoidal Choroidal Vasculopathy: A Systematic Review

Methods

Thirty studies with 1308 eyes were identified and included in this study. The primary outcome measures were best-corrected visual acuity (BCVA), and secondary outcomes were optical coherence tomography characteristics and polyp regression rates. The pooled results were calculated by the random-effect or fixed-effect model according to the heterogeneity of the data.

Results

Despite a large standard deviation in means (SMD) improvement for BCVA and central retinal thickness (CRT) in the conbercept group, there was no statistically significant difference in the other outcomes compared to ranibizumab and aflibercept. However, there was a greater polyp regression rate in the conbercept group at 12 months.

Conclusions

This systematic review indicates that conbercept may achieve similar BCVA and CRT improvements as ranibizumab and aflibercept, with a superior rate of polyp regression at 12 months.

SHORT-TERM EFFICACY OF CONBERCEPT AND RANIBIZUMAB FOR POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To compare the 6-month efficacy of the intravitreal injection of conbercept or ranibizumab for patients with polypoidal choroidal vasculopathy (PCV).

METHODS

This is a retrospective case-control study involved 79 PCV eyes of 77 patients. The PCV eyes were treated with an intravitreal injection of either ranibizumab (n = 44) or conbercept (n = 35). Three monthly loading doses were injected and followed by retreatment as needed. The best-corrected visual acuity and angiographic characteristics were evaluated after 6 months.

RESULTS

The mean logarithm of the minimum angle of resolution best-corrected visual acuity had improved from 0.86 (Snellen equivalent, 20/145) at baseline to 0.70 (Snellen equivalent, 20/100) at 6 months in the conbercept group (P < 0.001), and from 0.74 (Snellen equivalent, 20/110) at baseline to 0.63 (Snellen equivalent, 20/85) at 6 months in the ranibizumab group (P = 0.032), respectively. The central foveal thickness was decreased from 407 ± 146 μm to 230 ± 71 μm in the conbercept group (P < 0.001), and from 394 ± 93 μm to 208 ± 56 μm in the ranibizumab group (P < 0.001). Polyps were completely regressed and in 21 (47.7%) eyes in the conbercept group at 6 months, significant higher than in 10 (28.6%) eyes in the ranibizumab group (P = 0.029).

CONCLUSION

Both conbercept and ranibizumab effectively increased the visual acuity and regressed the polyps of PCV eyes. No significant difference was found in the visual acuity improvement of the patients with PCV between the conbercept group and ranibizumab group at 6 months. However, conbercept was superior to ranibizumab monotherapy in the regression of polyps.

Comparison of one-year results of photodynamic therapy combined with ranibizumab or aflibercept for treating polypoidal choroidal vasculopathy

Purpose

To compare the 1-year visual outcomes and anatomical responses of patients who received photodynamic therapy (PDT) combined with intravitreal ranibizumab (IVR) injections with those of patients who received PDT combined with intravitreal aflibercept (IVA) injections for treating polypoidal choroidal vasculopathy (PCV).

Methods

We retrospectively studied all treatment-naïve patients with PCV who received PDT combined with either IVR or IVA. Best-corrected visual acuity (BCVA), central macular thickness (CMT), central choroidal thickness (CCT), the number of additional injections, and the presence of polypoidal lesions, as indicated by indocyanine green angiography (ICGA), during 1 year were evaluated.

Results

Forty-four eyes were assessed at the 1-year follow-up examination. Of these, 23 were treated with PDT combined with IVR (PDT/IVR group), and 21 were treated with PDT combined with IVA (PDT/IVA group). In both groups, BCVA was shown to be significantly improved 1 year after the initial treatment. CMT and CCT were also significantly decreased after 1 year. There were no significant differences in the changes in BCVA or CMT between the two groups. However, the change in CCT in the PDT/IVA group was significantly larger than that of the PDT/IVR group (P < 0.001). The mean number of additional injections was 0.78 ± 0.21 in the PDT/IVR group and 0.57 ± 0.21 in the PDT/IVA group with no significant difference between the two groups (P = 0.45). The polyp regression rate at 12 months was 78.2% in the PDT/IVR group and 78.9% in the PDT/IVA group with no significant difference between the two groups.

Conclusions

PDT combined with either IVR or IVA was well tolerated and appeared to improve both vision and anatomy in patients with PCV. PDT/IVA may have a more pronounced effect on macular choroidal thickness at 1-year follow-up.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Photodynamic Therapy for Chorioretinal Diseases: A Practical Approach

Photodynamic therapy (PDT) using verteporfin (Visudyne®; Bausch + Lomb) is a treatment that is widely used to elicit cell and tissue death. In ophthalmology, PDT targets choroidal vascular abnormalities and induces selective occlusion of vessels. PDT was originally used in combination with full-dose verteporfin to treat neovascular age-related macular degeneration. Since the introduction of treatment with vascular endothelial growth factor receptor inhibitors, the clinical targets of PDT have shifted to other chorioretinal conditions, such as central serous chorioretinopathy, polypoidal choroidal vasculopathy, and choroidal hemangioma. In recent years, clinical studies have facilitated the optimization of treatment outcomes through changes in protocols, including the introduction of reduced treatment settings, such as PDT with half-dose verteporfin and half-fluence PDT. Here, we review PDT and its use for chorioretinal diseases from a practical perspective.

Appearance of Polypoidal Lesions in Patients With Polypoidal Choroidal Vasculopathy Using Swept-Source Optical Coherence Tomographic Angiography

Importance

Polypoidal choroidal vasculopathy (PCV) is a major cause of visual loss worldwide, particularly in Asia, and the appropriate understanding of the structures in PCV previously described as polypoidal lesions is important for understanding their pathogenesis, diagnosis, and prognosis.

Objective

To report the morphologic characteristics of polypoidal lesions and their association with branching vascular networks (BVNs) in eyes with PCV using swept-source optical coherence tomographic angiography (SS-OCTA).

Design, Setting, and Participants

This cross-sectional observational study included 20 participants recruited from Shanghai General Hospital with a diagnosis of PCV based on the presence of focal hyperfluorescent spots on indocyanine green angiography (ICGA). Data were collected from December 1, 2017, to September 1, 2018, and analyzed from June 1 through September 30, 2018.

Main Outcomes and Measures

Polypoidal lesions in eyes with PCV were characterized using multimodal imaging that included fundus photography, fluorescein angiography, ICGA, SS-OCT, and SS-OCTA, and the images were anatomically aligned. Subfoveal choroidal thickness was manually measured as the distance between the Bruch membrane and the sclerochoroidal interface on the SS-OCT images.

Results

Of the 20 Asian patients, 5 (25%) were women and 15 (75%) were men. The mean (SD) age was 61.1 (7.6) years, and the mean (SD) logMAR visual acuity was 0.358 (0.294) (Snellen equivalent, 20/50 [20/40]). Twenty-three eyes underwent imaging and were diagnosed with PCV. Indocyanine green angiography identified 43 polypoidal lesions, and all corresponded to the structures that appeared as clusters of tangled vessels on SS-OCTA images. In addition, SS-OCTA detected 16 tangled vascular structures not seen on ICGA. Branching vascular networks were detected on SS-OCTA imaging in all eyes, but ICGA identified BVNs in only 17 of 23 eyes (74%). Of the 43 tangled vascular structures, 40 (93%) were located at the edge of a BVN and 3 (7%) were associated with type 2 neovascularization.

Conclusions and Relevance

In eyes with PCV undergoing SS-OCTA imaging, previously described polypoidal lesions may appear as tangled vascular structures associated with BVN or type 2 neovascularization. The identification of polypoidal lesions in patients with PCV as neovascular tangles rather than actual polypoidal lesions or aneurysmal dilatations may help facilitate understanding of their pathogenesis and response to treatment.

Six-Year Real-World Outcomes of Antivascular Endothelial Growth Factor Monotherapy and Combination Therapy for Various Subtypes of Polypoidal Choroidal Vasculopathy

The purpose of this study was to compare 6-year visual outcomes of antivascular endothelial growth factor (anti-VEGF) monotherapy and initial combination therapy of photodynamic therapy (PDT) and anti-VEGF therapy for polypoidal choroidal vasculopathy (PCV) in a Chinese population and to investigate imaging biomarkers associated with visual outcomes. Forty-eight treatment-naive PCV eyes of 46 patients were reviewed retrospectively, which underwent anti-VEGF monotherapy or initial combination therapy. PCV was classified into 2 subtypes. Mean best-corrected visual acuity (BCVA) using logarithm of minimal angle resolution and imaging morphological features was compared. No significant differences of mean BCVA changes were noticed between anti-VEGF monotherapy and combination therapy in either subtype 1 PCV or subtype 2 PCV during 6-year period (all P values >0.05). Compared with BCVA at baseline, the mean BCVA at 72 months deteriorated significantly in eyes with subtype 1 PCV (P < 0.001), while the mean BCVA at 72 months remained stable in eyes with subtype 2 PCV (P=0.941). In subtype 2 PCV eyes with continuous retina pigment epithelium, the mean changes of BCVA in eyes treated with anti-VEGF monotherapy were better than those in eyes treated with combination therapy (P=0.020). Anti-VEGF monotherapy and combination therapy for various subtypes of PCV had comparable long-term visual outcomes in most cases in real world. Imaging biomarkers which correlate with visual outcomes and treatment response should be included in the classification of PCV and validated in real world.

Optical Coherence Tomography-Based Deep-Learning Models for Classifying Normal and Age-Related Macular Degeneration and Exudative and Non-Exudative Age-Related Macular Degeneration Changes

INTRODUCTION

The use of optical coherence tomography (OCT) images is increasing in the medical treatment of age-related macular degeneration (AMD), and thus, the amount of data requiring analysis is increasing. Advances in machine-learning techniques may facilitate processing of large amounts of medical image data. Among deep-learning methods, convolution neural networks (CNNs) show superior image recognition ability. This study aimed to build deep-learning models that could distinguish AMD from healthy OCT scans and to distinguish AMD with and without exudative changes without using a segmentation algorithm.

METHODS

This was a cross-sectional observational clinical study. A total of 1621 spectral domain (SD)-OCT images of patients with AMD and a healthy control group were studied. The first CNN model was trained and validated using 1382 AMD images and 239 normal images. The second transfer-learning model was trained and validated with 721 AMD images with exudative changes and 661 AMD images without any exudate. The attention area of the CNN was described as a heat map by class activation mapping (CAM). In the second model, which classified images into AMD with or without exudative changes, we compared the learning stabilization of models using or not using transfer learning.

RESULTS

Using the first CNN model, we could classify AMD and normal OCT images with 100% sensitivity, 91.8% specificity, and 99.0% accuracy. In the second, transfer-learning model, we could classify AMD as having or not having exudative changes, with 98.4% sensitivity, 88.3% specificity, and 93.9% accuracy. CAM successfully described the heat-map area on the OCT images. Including the transfer-learning model in the second model resulted in faster stabilization than when the transfer-learning model was not included.

CONCLUSION

Two computational deep-learning models were developed and evaluated here; both models showed good performance. Automation of the interpretation process by using deep-learning models can save time and improve efficiency.

TRIAL REGISTRATION

No15073.

Five-year real-world outcomes of anti-vascular endothelial growth factor monotherapy versus combination therapy for polypoidal choroidal vasculopathy in a Chinese population: a retrospective study

Background

To evaluate 5-year outcomes of anti-vascular endothelial growth factor (VEGF) monotherapy and combination therapy of anti-VEGF agents and photodynamic therapy (PDT) for polypoidal choroidal vasculopathy (PCV) in a real-world Chinese population.

Methods

Retrospective study. Fifty-three eyes of 46 patients with subtype 1 and 2 PCV followed up for at least 60 months were grouped into three regimens: anti-VEGF monotherapy, PDT combining with anti-VEGF therapy initially, and PDT combining with deferred anti-VEGF therapy. Main outcome measure was best-corrected visual acuity (BCVA) using logarithm of minimal angle of resolution (logMAR).

Results

The mean BCVA of eyes with subtype 1 PCV (n = 28) deteriorated from 0.69 logMAR at baseline to 1.25 logMAR at months 60 (P = 0.001), while the mean BCVA of eyes with subtype 2 PCV (n = 25) sustained stable from 0.62 logMAR at baseline to 0.57 at months 60 (P = 0.654). No significant differences of visual outcomes were found between the 3 treatment regimens for subtype 1 PCV. Anti-VEGF monotherapy and initial combination treatment had better visual outcomes in eyes with subtype 2 PCV than deferred combination group during part of follow-up significantly. Initial combination group needed a less number of PDT than deferred combination group (P < 0.001).

Conclusions

Compared with subtype 1 PCV, subtype 2 PCV has a more favorable visual outcome in real world. All the regimens presented unfavorable visual outcomes for subtype 1 PCV. Anti-VEGF monotherapy and initial combination therapy should be superior to deferred combination therapy in the long-term management of subtype 2 PCV. Prospective randomized studies of larger size are needed to determine the long-term efficacy and safety of various treatment for PCV in real world.

Comparison of intravitreal ziv-aflibercept and bevacizumab monotherapy in treatment-naive polypoidal choroidal vasculopathy

Purpose:

To report the visual and anatomical outcomes of intravitreal ziv-aflibercept (IVZ) and bevacizumab (BVZ) monotherapy in treatment-naive polypoidal choroidal vasculopathy (PCV).

Methods:

This was a retrospective case series of 16 eyes (8 eyes each in IVZ and BVZ groups). The study period was from January 2016 to March 2018. The inclusion criteria were treatment-naive PCV patients who were treated with either IVZ or BVZ monotherapy on pro re nata protocol and followed up monthly for 6 months. The change in best-corrected visual acuity (BCVA), central macular thickness (CMT), and pigment epithelial detachment (PED) height was measured at baseline and 6 months.

Results:

A total of 16 eyes were studied. IVZ group had an improvement in BCVA by 0.15 logarithm of minimum angle of resolution (logMAR; approximately 1.5 lines) at 6 months, whereas BVZ group had a reduction in BCVA by 0.21 logMAR (approximately 2 lines) (P = 0.027). Five patients and one patient in IVZ and BVZ groups, respectively, had ≥5 letters gain of BCVA. IVZ group had significant reduction in PED height (P = 0.048), whereas the change in CMT was not significant at 6 months (P = 0.681). The mean number of injections (2.87 ± 0.83 in IVZ and 2.25 ± 0.89 BVZ group; P = 0.168) and longest treatment-free interval (3.00 ± 2.20 months in IVZ and 2.12 ± 1.96 months in BVZ group; P = 0.41) were not significantly different.

Conclusion:

The visual and anatomical outcomes in terms of PED reduction in treatment-naive PCV patients were better in IVZ group compared with BVZ. IVZ monotherapy is a viable, cost-effective alternative in these patients with good safety profile.

Visual Prognosis in the Better-seeing Eyes of Patients with Unilateral Polypoidal Choroidal Vasculopathy

SIGNIFICANCE

In patients initially diagnosed as having unilateral polypoidal choroidal vasculopathy, the visual prognosis of the better-seeing eye is highly favorable. If patients are overly pessimistic regarding their vision in the future, physicians can encourage patients by informing them of the small possibility for visual deterioration in the better-seeing eye.

PURPOSE

The purpose of this study was to investigate the long-term changes in the visual acuity of the better-seeing eyes in patients with unilateral polypoidal choroidal vasculopathy.

METHODS

This retrospective, single-institution study was performed with 221 patients who were diagnosed as having unilateral polypoidal choroidal vasculopathy and who were treated with intravitreal anti-vascular endothelial growth factor. Only patients with an initially uninvolved eye best-corrected visual acuity (BCVA) of 20/40 or better and who were followed up for at least 24 months were included. The changes in the BCVAs of the initially involved and uninvolved eyes as well as the better-seeing eyes were measured. For patients with three or more lines of uninvolved eye visual deterioration, the cause for the visual deterioration was identified.

RESULTS

Patients were followed up for a mean of 43.1 ± 11.8 months after diagnosis. During the follow-up period, three or more lines of deterioration in the BCVA were noted in 61 initially involved eyes (27.6%) and 11 uninvolved eyes (4.9%). The reasons for uninvolved eye visual deterioration were neovascularization (n = 8), retinal vein occlusion (n = 2), and posterior capsule opacification (n = 1). At diagnosis, the BCVA of the better-seeing eye was 0.05 ± 0.08 (Snellen equivalents, 20/22). During the follow-up period, three or more lines of deterioration in the BCVA for the better-seeing eye were noted in eight patients (3.6%).

CONCLUSIONS

Visual acuity of the better-seeing eye over time remained stable in most patients who were initially diagnosed as having unilateral polypoidal choroidal vasculopathy. As a result, the visual prognosis of the better-seeing eye is highly favorable in this condition.

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.

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.

Current management strategy of polypoidal choroidal vasculopathy

Polypoidal choroidal vasculopathy (PCV) is a retinal disorder commonly found in Asians presenting as neovascular age-related macular degeneration and is characterized by serous macular detachment, serous or hemorrhagic pigment epithelial detachment, subretinal hemorrhage, and occasionally visible orange-red subretinal nodular lesions. PCV is diagnosed using indocyanine green angiography (ICGA), and the lesions appear as polypoidal aneurysmal vascular lesions with or without abnormal branching vascular network. Although ICGA remains the gold standard for the diagnosis of PCV, various imaging modalities have also facilitated the diagnosis and monitoring of PCV. Recent advances in imaging technology including the use of high resolution spectral domain optical coherence tomography (OCT) and OCT angiography have provided new insights on the pathogenesis of PCV, suggesting a link between PCV and pachychoroid spectrum of macular disorders. With the evolving understanding on the pathogenesis and clinical characteristics of PCV, different therapeutic options have been proposed. These include intravitreal anti-vascular endothelial growth factor (anti-VEGF) monotherapy, combination therapy with anti-VEGF and verteporfin photodynamic therapy, and thermal laser photocoagulation. In recent years, major multi-center randomized clinical trials such as EVEREST, EVEREST II, and PLANET studies have been conducted to compare the efficacy and safety of various treatment options for PCV. This review aims to summarize the results of recent literature, clinical trials and studies to provide an update on the management options of PCV. An overall management strategy for PCV will also be proposed.

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.

Polypoidal Choroidal Vasculopathy

Purpose of review

The aim of this review is to summarize developments in the treatment of active polypoidal choroidal vasculopathy (PCV). PCV is associated with a poor visual prognosis as a consequence the condition's hallmark polypoidal dilatation and a branching network resulting in recurrent hemorrhages and serous leakage.

Recent findings

Recent research has provided new insights into the pathogenesis of PCV. While still considered a subtype of age-related macular degeneration, suggestions that PCV belongs to a spectrum of conditions that present with a pachychoroid are increasingly well accepted. Treatment remains challenging. Combination therapy (photodynamic therapy (PDT) and intravitreal anti-vascular endothelial growth factor (VEGF)) is associated with higher polyp closure rate, but polyp closure rate has not been correlated with superior visual outcomes. Current data points to non-inferiority of anti-VEGF alone versus combined with PDT when final vision acuity is the study outcome.

Summary

PCV remains a clinical challenge. Classification and treatment of the condition continues to evolve. Combination therapy may not be superior to anti-VEGF treatment alone in terms of visual acuity outcome, however data on long-term recurrence should be compared in formulating preferred treatment plans.

One-year outcomes of intravitreal conbercept combined rescue therapy for polypoidal choroidal vasculopathy in a Chinese population: a real-life clinical data

AIM

To evaluate the real-life clinical outcomes of intravitreal injection of conbercept combined rescue therapy for polypoidal choroidal vasculopathy (PCV).

METHODS

This was an open label, single center, and interventional study. All enrolled patients were treated initially with three consecutive monthly intravitreal conbercept injections (0.5 mg). Additional conbercept injections were administered upon substantial polyp regression with improved visual acuity (VA). Eyes with partial or no polyp regression and poor VA were rescue treated with photodynamic therapy (PDT) for subfoveal polyps or thermal laser photocoagulation for extrafoveal polyps. Best-corrected visual acuity (BCVA), central foveal thickness (CFT) and polyp regression were observed as primary outcomes. Side effects were also collected during the follow-up period.

RESULTS

A total of 56 eyes (56 patients) with PCV were included. BCVA increased significantly from the baseline of 43.52±24.21 letters to 55.88±21.94 letters (P<0.001) at 12mo, while CFT decreased significantly from 457.41±207.86 µm to 247.98±127.08 µm (P<0.001). All patients showed polyp regression. Twenty-three eyes achieved complete polyp regression after the three initial injections, which increased to 44 eyes at 12mo. Seventeen eyes underwent rescue therapy, among which 2 eyes treated with PDT and 15 eyes treated with laser photocoagulation. A mean of 4.30±1.43 injections were given per eye. No intraocular inflammation, retinal or vitreous hemorrhage, or systemic complication occurred.

CONCLUSION

Conbercept is an effective and safe option for the treatment of PCV in Chinese population. The treatment regimen of three initial conbercept injections followed by additional injections or rescue therapies is efficacious for treating PCV.

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.

One-year real-world outcomes of ranibizumab 0.5 mg treatment in Taiwanese patients with polypoidal choroidal vasculopathy: a subgroup analysis of the REAL study

AIM

To assess the effectiveness and safety of ranibizumab 0.5 mg in Taiwanese patients with polypoidal choroidal vasculopathy (PCV) by performing a retrospective exploratory subgroup analysis of the REAL study.

METHODS

REAL was a 12-month, observational, prospective, non-interventional phase IV post-marketing surveillance study conducted at 9 centers in Taiwan. The study collected data as part of the routine patient visits from the medical records of patients with neovascular age-related macular degeneration treated with ranibizumab 0.5 mg according to local standard medical practice and local label and/or reimbursement guidelines. The presence of PCV at baseline was determined using indocyanine green angiography.

RESULTS

At baseline, PCV was diagnosed in 64 of the 303 enrolled patients (21.1%). Of these, 41 patients (64.1%) had received prior treatment; 15 (23.4%) patients had received ranibizumab. The intent-to-treat population included 58 patients; 47 (80%) who received ranibizumab and 11 (20%) who received ranibizumab plus photodynamic therapy (PDT; 9 patients received once, 2 patients received twice). Bevacizumab was used as a concomitant medication in a similar percentage of patients who received ranibizumab (43%, n=20) or ranibizumab plus PDT (45%, n=5). In patients who received ranibizumab, visual acuity (VA) at baseline was 50.1±12.9 Early Treatment Diabetic Retinopathy Study letters, and the gain at month 12 was 1.1±17.8 letters. In patients who received ranibizumab plus PDT, VA at baseline was 51.4±15.9 letters, and there was a marked gain in VA at month 12 (14.0±9.2 letters, P=0.0009). In the intent-to-treat population, the reduction in central retinal subfield thickness from baseline at month 12 was 69.6±122.6 µm (baseline: 310.8±109.8 µm, P=0.0004). The safety results were consistent with the well-characterized safety profile of ranibizumab.

CONCLUSION

In real-world settings, ranibizumab 0.5 mg treatment for 12mo results in maintenance of VA and reduction in central retinal subfield thickness in Taiwanese patients with PCV. Improvements in VA are observed in patients who received ranibizumab plus PDT. There are no new safety findings.

Polypoidal choroidal vasculopathy (PCV): the 4-year review of the real-life treatment experiences

Purpose

The purpose of this article was to study the real-life treatment results of polypoidal choroidal vasculopathy (PCV).

Design

This was a retrospective study.

Methods

Patients with presumed age-related macular degeneration were reviewed, and PCV diagnosis was made using the EVEREST study criteria. Outcomes were changes in visual acuity (VA) and central retinal thickness, time between treatments, follow-up time, and number of treatments.

Results

The prevalence of PCV was 30.8%. At the beginning, 195 eyes received monotherapy of anti-vascular endothelial growth factor (anti-VEGF) injections, either bevacizumab or ranibizumab, and only six eyes received the combination of anti-VEGF injection and photodynamic therapy (PDT) at the time of the first treatment. During the follow-up, some patients received “rescue or add-on” PDT when they had a poor response after anti-VEGF injections. After 4 years, the average number of injections was 8.25 and 9.15 for the anti-VEGF monotherapy and the combination groups, respectively. The average time between the first anti-VEGF injections and the first PDT was 21.4 months. The average VA in the anti-VEGF monotherapy group increased by 1.5 letters, whereas it decreased by 0.95 letters in the combination group (P=0.48).

Conclusion

The review demonstrated the same visual outcomes between the combination therapy of anti-VEGF injections and rescue or add-on PDT vs monotherapy anti-VEGF injections in PCV treatment. When compared with EVEREST II and Planet studies, the “initial” or “rescue or add-on PDT” might have different effects on the final visual outcomes.

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.

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

Background

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

Patients and methods

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

Results

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

Conclusion

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

Long-term results of photodynamic therapy or ranibizumab for polypoidal choroidal vasculopathy in LAPTOP study

BACKGROUND/AIM

We previously reported that ranibizumab performed better on visual prognosis than photodynamic therapy (PDT) in a Ranibizumab (Lucentis) And Photodynamic Therapy On Polypoidal choroidal vasculopathy (LAPTOP) study. To determine if the first-choice treatment, either PDT or intravitreal ranibizumab, has a long-term effect in patients with polypoidal choroidal vasculopathy (PCV).

METHODS

We reviewed medical records of patientsrandomised to either PDT (29 eyes) or ranibizumab (27 eyes) from July 2009 to June 2011 in LAPTOP study. Retreatment or switching to other treatments were at the investigator's discretion after release from the 2-year LAPTOP study up to 5years. We evaluated visual acuity (VA), continuity of initial treatment, percentage of dry macula achievement and macular atrophy at 5 years.

RESULTS

The logarithm of minimal angle of resolution VA was 0.56 in the PDT and 0.44 in the ranibizumab groups at baseline (p=0.101) and was 0.55 and 0.28 at 5years, respectively (p<0.05). More than 70% of the patients converted to aflibercept in following years. Achievement percentages of dry macula were 74% (PDT) and 63% (ranibizumab) at 5years, and macular atrophy was detected in 78% (PDT) and 60% (ranibizumab) with a mean area of 7.7 and 3.5 mm², respectively (p=0.155).

CONCLUSIONS

The better VA in the initial ranibizumab group compared with the PDT group at 2 years was retained at the 5-year follow-up.

Comparison of the effects of photodynamic therapy, intravitreal ranibizumab and combination for polypoidal choroidal vasculopathy under 1 + PRN regimen

Background

The optimal treatment for polypoidal choroidal vasculopathy (PCV) is still under debate. Little knowledge is known about the treatment effect of “1+pro re nata(PRN)” treatment regimen for PCV. The aim of this study was to compare the outcomes of photodynamic therapy (PDT), intravitreal ranibizumab injection (IVR) and combination therapy under the “1 + PRN” treatment regimen for PCV.

Methods

Fifty-seven eyes of 57 patients completed the 12 months’ follow-up in this prospective study. The patients in the PDT arm(n = 23), ranibizumab arm(n = 18), or combination arm(n = 16) underwent a session of PDT, IVR or combination of both at baseline followed by additional IVR as needed. Mean change of logarithm of the minimal angle of resolution (logMAR) visual acuity (VA), central foveal thickness (CFT) and the regression rate of polyps were evaluated. Cost-benefit analysis was also performed.

Results

At Month 12, the mean logMAR VA improved from 0.90 ± 0.52 to 0.75 ± 0.57 in the PDT group (P < 0.05), from 0.96 ± 0.58 to 0.77 ± 0.41 in the IVR group (P < 0.05), and from 0.94 ± 0.55 to 0.72 ± 0.44 in the combination group (P < 0.05), respectively. The CFT decreased from 478.04 ± 156.70 μm, 527.5 ± 195.90 μm, and 522.63 ± 288.40 μm at the baseline to 366.43 ± 148.28 μm, 373.17 ± 134.88 μm and 328.44 ± 103.25 in the PDT group (P < 0.05), IVR group (P < 0.01), and the combination group (P < 0.05), respectively. However, no statistical difference was found between groups (P > 0.05). PDT treatment (60.87%) was superior to the IVR therapy (22.22%) in achieving complete regression of polyps (P < 0.05). Cost-benefit analysis showed that IVR treatment cost the least money for improving per 0.1logMAR units and the combination therapy demanded the least money for reducing per 100 μm of CFT.

Conclusions

PDT, IVR and the combination therapy have similar efficacy in the VA improvement as well as the reduction of CFT under the “1 + PRN” treatment regimen.

Trial registration

Current Controlled Trials NCT03459144. Registered retrospectively on March 2, 2018.