Prognostic factors for combined ranibizumab and prompt verteporfin photodynamic therapy for polypoidal choroidal vasculopathy

Impact of Photodynamic Therapy Combined with Anti-VEGF vs. Anti-VEGF Monotherapy on Choriocapillaris Vessel Density in Polypoidal Choroidal Vasculopathy

PURPOSE

To compare the choriocapillaris vessel density between intravitreal ranibizumab (Lucentis) (IVR) plus photodynamic therapy (PDT) and intravitreal aflibercept (Eylea) (IVA) monotherapy in patients experiencing polypoidal choroidal vasculopathy (PCV).

DESIGN

An observational, prospective cohort study SUBJECTS: Adults with treatment-naïve PCV INTERVENTION: IVR plus PDT or IVA monotherapy MAIN OUTCOME MEASURES: After propensity-score (PS) matching, study outcomes were compared at 1 month after the final treatment. The primary outcome was a choriocapillaris vessel density, recognized by optical coherence tomography angiography (OCTA). The secondary outcomes included best corrected visual acuity (BCVA), presence of retinal hemorrhage, central macular thickness (CMT) and subfoveal choroidal thickness (SFCT), assessed by optical coherence tomography (OCT).

RESULTS

Initially, 23 patients receiving IVR plus PDT, and 75 patients receiving IVA monotherapy were included. After PS-matching, 19 eyes of 19 patients receiving IVR plus PDT and 38 eyes of 38 patients receiving IVA monotherapy were analyzed. A significantly lower choriocapillaris vessel density in the IVR plus PDT group than the IVA monotherapy group (41.9% vs. 52.2%, p= 0.009) was demonstrated. The similarity of the BCVA, occurrence and severity of retinal hemorrhage, CMT, and SFCT between two treatment groups was exhibited.

CONCLUSIONS

The choriocapillaris vessel density was significantly reduced in PCV patients treated with IVR plus PDT compared to those receiving IVA monotherapy.

Fluid Biomarkers in Optical Coherence Tomography for Visual Outcome in Polypoidal Choroidal Vasculopathy

Purpose: To investigate the associations between fluid accumulation at different levels in the retina and visual outcome in polypoidal choroidal vasculopathy (PCV). Design: A retrospective observational study. Institutional setting. Study Population: A total of 91 eyes from 91 patients of PCV were included, with 65 receiving intravitreal aflibercept monotherapy and 26 receiving combined intravitreal ranibizumab and photodynamic therapy (PDT). Observation Procedures: Best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) examination results were recorded at baseline and 3, 6, and 12 months after treatment. Main Outcome Measures: The correlations between visual outcomes and fluid biomarkers including intraretinal fluid (IRF), subretinal fluid (SRF), serous pigment epithelium detachment (PED), and hemorrhage at fovea were analyzed. Results: No differences in treatment outcomes were noted between patients receiving aflibercept and those receiving combined ranibizumab and PDT. IRF and hemorrhage at baseline predicted poorer vision at 3, 6, and 12 months. The presence of IRF was associated with poorer vision at 6 months and 12 months (p < 0.05 for all). The presence of SRF or PED was not associated with better vision at any time point. No differences in the correlations between fluid markers and visual outcomes were noted between thin and thick subfoveal choroidal thickness groups. Conclusions: For PCV, IRF and hemorrhage at baseline served as surrogates for poor visual prognosis after treatment, and IRF was a biomarker for poor vision during the treatment course. No fluid markers predicted good visual prognosis or had a positive impact on vision at any time point.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Timing of Complete Polypoidal Regression after Intravitreous Aflibercept Treatments in Polypoidal Choroidal Vasculopathy

PURPOSE

To understand timing of complete polypoidal regression on indocyanine green angiography (ICGA) after aflibercept injections for polypoidal choroidal vasculopathy (PCV).

DESIGN

Multicenter prospective study.

PARTICIPANTS

Adults with treatment-naïve PCV.

METHODS

After institutional review board approval, participants were enrolled and followed up for 1 year, from Apr 1, 2016, through Dec 30, 2018, at 2 university-based centers in Thailand. Diagnosis of PCV was based on the Efficacy and Safety of Verteporfin Photodynamic Therapy in Combination with Ranibizumab or Alone versus Ranibizumab Monotherapy in Patients with Symptomatic Macular Polypoidal Choroidal Vasculopathy criteria. Eligible eyes received fixed-dose aflibercept injections (3 monthly then every 8 weeks), or monthly if fluid persisted on OCT. Photodynamic therapy (PDT) was administered when fluid persisted despite 6 consecutive injections. Indocyanine green angiography was performed at baseline and then every 8 weeks. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was administered at baseline, 6 months, and 1 year. Two retina specialists reviewed posttreatment ICGA, categorized into: complete regression (complete disappearance of polypoidal lesions), partial regression (reduced in size or number), or no regression. Disagreements were resolved through open adjudication.

MAIN OUTCOME MEASURES

Timing of complete regression over 1 year.

RESULTS

Final analysis included 40 eyes (39 participants; 100% Thai, 59% women; mean age±standard deviation, 64 ± 8.3 years). At baseline, 90% had 5 or more polypoidal lesions. Ninety-five percent received aflibercept monotherapy, and 5% received rescue PDT per protocol. Polypoidal statuses at 1 year were 55% complete, 40% partial, and 5% no regression. Cumulative rates of complete regression at 2, 4, 6, and 12 months were 28%, 33%, 43%, and 55%. Of 22 eyes with complete regression at 1 year, complete regression was identified first at 2, 4, 6, 8, 10, 12 months in 50%, 9%, 18%, 5%, 9%, and 9%, respectively. Cumulative rates of complete regression among these eyes at 2, 6, and 12 months were 50%, 77%, and 100%, respectively. Median duration of complete regression was 3 months (interquartile range, 2-6 months). Median visual acuity improved from 20/125 (Snellen equivalent) to 20/50; median NEI VFQ-25 scores improved from 80 to 93 from baseline to 1 year.

CONCLUSIONS

Complete polypoidal regression could occur as early as 2 months after aflibercept injections. Most PCV eyes with complete polypoidal regression at 1 year already showed complete regression within the first 6 months. These findings support consideration of aflibercept for PCV to achieve both anatomic and visual outcomes.