Polypoidal choroidal vasculopathy

Atypical case of choroidal osteoma associated to polypoidal choroidal vasculopathy and preretinal neovascular membrane

PURPOSE

To report a very rare and atypical case of an elderly Caucasian female patient who developed perilesional multiple polypoidal choroidal vasculopathy (PCV) as a probable complication of choroidal osteoma (CO), associated to preretinal neovascular membrane overlying the lesion.

METHODS

Observational case report.

CASE OBSERVATION

A 60-year-old Caucasian woman presented with blurred vision in her right eye (RE). Fundus examination revealed a round white-yellowish calcified deep lesion in the juxta-papillary superior area, measuring 4 disc-diameters, with well-defined scalloped margins and an irregular surface. B-scan ultrasonography and orbital tomography confirmed the diagnosis of choroidal osteoma (CO). Further investigation with multimodal imaging including infracyanine green angiography, fluorescein angiography, swept source optical coherence tomography and angiography highlighted the presence of multiple aneurysmal choroidal dilations around the CO, corresponding to PCV. We also noted the presence of a preretinal neovascular membrane overlying the CO. The patient was monitored with regular follow-up since no signs of activity were detected on multimodal imaging.

CONCLUSION

Our case report represents an exceptional and atypical association between pre-retinal neovascularization, PCV and choroidal osteoma. While the mechanisms underlying the development of PCV and pre-retinal neovascularization in the setting of CO are not well understood, it is imperative for ophthalmologists to recognize this association as a potential cause of sudden vision loss in patients with CO, and to consider appropriate diagnostic and management strategies.

Predicting treatment outcomes of intravitreal brolucizumab for polypoidal choroidal vasculopathy through noninvasive assessment of polypoidal lesion blood flow with optical coherence tomography angiography

We investigated the assessment of blood flow within polypoidal lesions using optical coherence tomography angiography (OCTA) to determine intravitreal brolucizumab (IVBr) efficacy for treating polypoidal choroidal vasculopathy (PCV). We retrospectively studied 46 eyes with PCV that completed 1-year IVBr treatment. Blood flow signals within polypoidal lesions were evaluated using OCTA after loading-phase treatment, and 1-year outcomes were compared between eyes in which blood flow signals disappeared versus persisting. After loading-phase treatment, blood flow signals within polypoidal lesions disappeared in 31 eyes and persisted in 15. In the former group, visual acuity improved significantly throughout the year (P < 0.01), while in the latter there was no significant difference between baseline and after 1 year. The total number of injections was significantly lower with than without disappearance of blood flow signals (6.0 vs. 6.9, P < 0.01). The intended injection interval at the last visit was significantly longer in the former than in the latter group (15.7 weeks vs. 12.5 weeks, P < 0.01). These results indicate that PCV cases showing disappearance of blood flow signals within polypoidal lesions by OCTA after loading-phase treatment had favorable 1-year outcomes of IVBr. Therefore, evaluating blood flow within polypoidal lesions by OCTA may allow noninvasive prediction of PCV treatment outcomes.

Anti-VEGF Treatment Strategies for 3 Subtypes of Neovascular Age-Related Macular Degeneration in a Clinical Setting: A Multicenter Cohort Study in Japan

PURPOSE

Neovascular age-related macular degeneration (nAMD) is classified into typical AMD (tAMD), polypoidal choroidal vasculopathy (PCV), and retinal angiomatous proliferation (RAP). This study investigated clinical features of the 3 subtypes and visual outcome associated with treatment regimens in a large cohort of patients with nAMD in a clinical setting.

DESIGN

Retrospective multicenter cohort study.

PARTICIPANTS

Five hundred patients with treatment-naive nAMD (268 tAMD, 200 PCV, and 32 RAP) initiated with anti-VEGF agents and followed for 1 year.

METHODS

Medical records were reviewed to extract demographic data, best-corrected visual acuity at baseline and 1 year after treatment initiation, spectral-domain OCT findings, baseline fellow eye condition, systemic factors, treatment strategies, and number of intravitreal injections in the first year.

MAIN OUTCOME MEASURES

Primary outcome measures were anti-VEGF treatment strategy (ranibizumab or aflibercept, anti-VEGF regimen, concomitant photodynamic therapy, drug switch), best-corrected visual acuity at 1 year, and factors associated with visual acuity.

RESULTS

Patients with RAP were significantly older, were more commonly women, and had more macular lesions in fellow eye than patients with tAMD and PCV. Smoking history and diabetes prevalence were not different among the 3 subtypes. Frequencies of subretinal fluid were higher and intraretinal fluid were lower in tAMD and PCV than in RAP, whereas serous pigment epithelial detachment and subretinal hemorrhage were higher in PCV than in tAMD and RAP. Choice of anti-VEGF agents and treatment regimens did not differ among 3 subtypes. The aflibercept-to-ranibizumab ratio was approximately 7:3. The mean number of injections in 1 year was 5.3 ± 2.4 in nAMD overall, which was significantly less in pro re nata (PRN) than in treat and extend (TAE) regardless of the anti-VEGF agent. Best-corrected visual acuity improved in all 3 subtypes, although it was not significant in patients with RAP.

CONCLUSIONS

This clinical study demonstrates that treatment regimens were similar in 3 subtypes and aflibercept was used in 70% of all patients. Approximately 5 injections were given in the first year regardless of the anti-VEGF agent, which was significantly less in PRN regimen than in TAE. Visual acuity improvement was observed after 1-year anti-VEGF therapy in all 3 subtypes, but was not significant in RAP.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Submacular Hemorrhages Show No Significant Seasonal Variations in a European Cohort

The aim of the article is to investigate the seasonality of acute submacular hemorrhages (SMHs) in a European population and analyze the influence of the seasons, arterial hypertension, and intake of anticoagulatory/antiplatelet (AC/AP) medication on hemorrhage size. This retrospective, monocentric study included 164 eyes of 164 patients treated for acute SMH at the University Hospital Münster, Germany, between 1 January 2016 and 31 December 2021. Data on the day of occurrence, hemorrhage size, and general patient characteristics were recorded. "Test for cyclic trends in incidence data" and the Chi-Square Test were applied to investigate seasonal variations in SMH incidence. Fisher's exact test was used to investigate the influence of the seasons, arterial hypertension, and intake of AC/AP medication on hemorrhage size. A statistical analysis did not reveal significant seasonal variations in the occurrence of SMHs (p = 0.81). While the seasons and the presence of systemic arterial hypertension did not exert a significant influence, the intake of AC/AP medication significantly affected the size of SMH (p = 0.03). In this European cohort, no significant seasonal variations of SMHs were observed. However, in patients with risk factors, such as neovascular age-related macular degeneration (nAMD), the chance of an increase in hemorrhage size should be considered when initiating AC/AP therapy.

Subfoveal choroidal thickness as a potential predictor of treatment response after intravitreal ranibizumab injections for polypoidal choroidal vasculopathy

OBJECTIVE

To evaluate the impact of subfoveal choroidal thickness (SFCT) and other clinical biomarkers in intravitreal anti-vascular endothelial growth factor response in treatment-naive Caucasian patients diagnosed with polypoidal choroidal vasculopathy (PCV/AT1).

DESIGN

Cross-sectional study.

PARTICIPANTS

Treatment-naive patients diagnosed with PCV/AT1 recruited in a single centre from January 2013 to December 2020.

METHODS

Eligibility was determined in treatment-naive PCV patients who received a loading dose of 3 injections of 0.5 mg ranibizumab. A diagnosis of PCV/AT1 was made based on the diagnostic criteria in the efficacy and safety of verteporfin photodynamic therapy in combination with ranibizumab or alone versus ranibizumab monotherapy in patients with sumptomatic macular polypoidal choroidal vasculopathy study. Choroidal thickness was manually measured by enhanced depth imaging technology in Spectralis spectral domain optical coherence tomography.

RESULTS

Eighty-three eyes of 83 patients were included in this study, 47 patients diagnosed with PCV/AT1 with a good response to 3 intravitreal injections of ranibizumab and 36 with a poor response. The receiver operating characteristic curve of treatment effect against the SFCT revealed that the area under the curve was 0.85 (range, 0.74-0.96). Based on the Youden index, the optimal SFCT cut-off point for predicting a poor response to anti-vascular endothelial growth factor is 257 µm. In the multivariate analysis, the SFCT remained statistically significant (odds ratio 1.02 [range, 1.01-1.04]; P = 0.008). The combined effect of treatment effect against clinical biomarkers produced an area under the curve of 0.90 (range, 0.82-0.98).

CONCLUSION

SFCT is a risk factor for a poor response to the 3 loading injections of ranibizumab in treatment-naive PCV/AT1 Caucasian patients. A cut-off point of 257 µm could be a valuable parameter for defining the population at risk for an inadequate response to ranibizumab.

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.

Clinical features and outcomes of breakthrough vitreous hemorrhage secondary to polypoidal choroidal vasculopathy

Polypoidal choroidal vasculopathy (PCV) with hemorrhagic complications is at higher risk for breakthrough vitreous hemorrhage (VH). This study aimed to evaluate the clinical features and outcomes of breakthrough VH secondary to PCV. Data of patients receiving pars plana vitrectomy for breakthrough VH secondary to PCV (VH group) were evaluated retrospectively and compared statistically to data of age and sex-matched PCV patients without breakthrough VH (control group). Among PCV patients, 36 eyes with breakthrough VH and 62 eyes without VH were included. Compared with baseline, best corrected visual acuity (BCVA) was worse in the VH group (P < 0.001), and improved postoperatively (P < 0.001). Percentages of pigmented epithelial detachment (PED), hemorrhagic PED, massive subretinal hemorrhage, hemorrhagic retinal detachment (RD), and hemorrhagic choroidal detachment (CD) (P = 0.007) were higher in the VH group (P < 0.001). Incidence of choroidal vascular hyperpermeability (P < 0.001), massive subretinal hemorrhage (P = 0.001), hemorrhagic retinal detachment (P = 0.001) and hemorrhagic type PCV (P = 0.001) was higher in patients with pachychoroid PCV, while fibrovascular type had lower incidence (P < 0.001). Better initial BCVA (P < 0.001), higher frequency of anti-VEGF treatment (P = 0.009), and previous photodynamic therapy (P = 0.017) showed better visual outcomes. Breakthrough VH risk is higher in PCV patients with massive subretinal hemorrhage, hemorrhagic PED and hemorrhagic RD. BCVA and hemorrhagic complications improve significantly postoperatively. Higher frequency of anti-VEGF treatment and previous photodynamic therapy are associated with better visual prognosis in PCV patients with breakthrough VH.

Polypoidal choroidal vasculopathy—characteristics and response to treatment with bevacizumab in caucasian patients

Purpose

To investigate the features and treatment response in Caucasian patients with polypoidal choroidal vasculopathy (PCV), initially treated with bevacizumab.

Methods

45 eyes of 43 treatment-naïve patients with PCV were included in this retrospective study, all uniformly initially treated with three bevacizumab injections monthly. OCT characteristics and clinical parameters were recorded and analyzed at presentation, after the initial 3 bevacizumab injections and at the final follow up period.

Results

Following 3 monthly bevacizumab injections visual acuity significantly improved with a mean gain of one line of vision. Central macular thickness (CMT) significantly improved from a mean of 402.1 ± 130.8 μm at presentation to 322.0 ± 96.8 μm (p < 0.01). Subretinal fluid, intraretinal fluid and submacular hemorrhage significantly improved. 53% were later switched to aflibercept and showed better response in the central macular thickness in comparison to those in which bevacizumab injections were continued. No correlation was found between the presence of pachyvessels or increased choroidal thickness and the improvement in VA or CMT.

Conclusion

Fixed first-line treatment with intravitreal bevacizumab monotherapy in non-Asian PCV patients achieves satisfactory visual and anatomical outcomes.

Angiopoietin-1 Is Required for Vortex Vein and Choriocapillaris Development in Mice

BACKGROUND

The choroidal vasculature, including the choriocapillaris and vortex veins, is essential for providing nutrients to the metabolically demanding photoreceptors and retinal pigment epithelium. Choroidal vascular dysfunction leads to vision loss and is associated with age-related macular degeneration and the poorly understood pachychoroid diseases including central serous chorioretinopathy and polypoidal choroidal vasculopathy that are characterized by formation of dilated pachyvessels throughout the choroid.

METHODS

Using neural crest-specific Angpt1 knockout mice, we show that Angiopoietin 1, a ligand of the endothelial receptor TEK (also known as Tie2) is essential for choriocapillaris development and vortex vein patterning.

RESULTS

Lacking choroidal ANGPT1, neural crest-specific Angpt1 knockout eyes exhibited marked choriocapillaris attenuation and 50% reduction in number of vortex veins, with only 2 vortex veins present in the majority of eyes. Shortly after birth, dilated choroidal vessels resembling human pachyvessels were observed extending from the remaining vortex veins and displacing the choriocapillaris, leading to retinal pigment epithelium dysfunction and subretinal neovascularization similar to that seen in pachychoroid disease.

CONCLUSIONS

Together, these findings identify a new role for ANGPT1 in ocular vascular development and demonstrate a clear link between vortex vein dysfunction, pachyvessel formation, and disease.

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.

Short-Term Efficacy in Polypoidal Choroidal Vasculopathy Patients Treated With Intravitreal Aflibercept or Conbercept

Purpose

To compare the short-term efficacy in patients with polypoidal choroidal vasculopathy (PCV) treated using either aflibercept or conbercept.

Methods

This prospective study included 41 patients with treatment-naive PCV (42 eyes). All the patients were treated with either aflibercept or conbercept using an initial series of 3 monthly loading injections. Changes in the best-corrected logMAR visual acuity (BCVA) and anatomic outcomes were evaluated at 3 months.

Results

BCVA was improved with reduction in central choroidal thickness (CCT), central foveal thickness (CFT), and subretinal fluid (SRF) after 3 monthly loading injections in both aflibercept (IVA) and conbercept (IVC) groups. There was no significant difference in either visual or anatomic outcomes between the two groups after 3 months of treatment. However, compared with the IVC group, significantly higher BCVA improvement was observed in the patients in the IVA group with baseline BCVA better than 1. A visual outcome improved ≥3 lines in 13 patients in the IVA group (59%), and 9 patients in the IVC group (45%). A relatively high proportion of polyp regression was observed in the IVA group (63%) compared with the IVC group (55%) via OCTA.

Conclusions

Visual and anatomic outcomes were significantly improved in both IVA and IVC groups, but the results suggest a potentially superior short-term response in the IVA group.

Clinicopathological study of the polypoidal lesions of polypoidal choroidal vasculopathy

PURPOSE

To investigate the pathogenic features of the polypoidal lesions from the specimens of polypoidal choroidal vasculopathy extracted from human subjects.

METHODS

Seven specimens of polypoidal lesions extracted from five eyes of six patients (mean age, 60.16 ± 10.41 years) of polypoidal choroidal vasculopathy were examined. The polypoidal lesions were obtained by surgical excision. Thereafter, a histopathological analysis of the specimens was performed.

RESULTS

The polypoidal lesions were oval nodules located underneath the retinal pigment epithelium. A pathological study of the lesions revealed that Bruch's membrane schisis was observed in all specimens and they were all located in the Bruch's membrane. The Bruch's membrane schisis and serosanguineous materials constituted the main structure of the lesions in five of the seven specimens, with small vessels being observed in two specimens. One specimen was composed of two polypoidal lesions of different characteristics, and one specimen had a neovessel membrane complex with several polypoidal lesions. Inflammatory cells and blood vessels were observed in the polypoidal lesion of the specimen with neovessel membrane complex.

CONCLUSION

Polypoidal lesions of polypoidal choroidal vasculopathy are abnormalities of the Bruch's membrane. The lesions are characterized by the Bruch's membrane schisis, which is filled with serosanguineous materials. The lesions are progressive and may contain inflammatory cells and blood vessels.

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.

Publication Trends of Research on Polypoidal Choroidal Vasculopathy During 2001–2020: A 20-Year Bibliometric Study

Introduction

Polypoidal choroidal vasculopathy (PCV) is a special subtype of AMD, which is one of the leading threats to vision health worldwide. At this time, many aspects of PCV, from how it works to potential treatments, remain a mystery. In this study, we explored the frontier researches and revealed the study trends within the study of PCV.

Methods

We collected all the publications in this field from 2001 to 2020, analyzed trends within them, and defined the contributions of various countries/regions, institutions, authors, and journals. Additionally, VOSviewer software was used to define the hot keywords in this field.

Results

A total of 1,190 publications were ultimately examined; We found that PCV is becoming an increasingly relevant topic of research, and that Japan has contributed the most publications (428), the most citations (14,504 in total), and the highest H-index value (62) to the field. Our keywords analysis was classified into four clusters to show the hotspots within the study of PCV, namely mechanism-related, imaging-related, prognosis-related, and therapy-related topics. The average years in which the keywords appeared the most were also calculated, and we identified anti-VEGF therapy, anti-complement therapy and angiography as having been the main focus in recent years.

Conclusions

These results helped clarify the comprehensive research progress that has been made as well as the future trends in the study of PCV, which can assist and guide future research.

Prevalence of focal lamina cribrosa defects in eyes with pachychoroid disease spectrum

AIM

To determine the prevalence of focal lamina cribrosa (LC) defect among patients with pachychoroid disease spectrum (PDS) in the absence of peripapillary retinoschisis.

METHODS

This retrospective, cross-sectional study comprised of 180 patients with PDS, including polypoidal choroidal vasculopathy (PCV), central serous chorioretinopathy, and pachychoroidal neovasculopathy. Medical records and optic nerve head evaluations conducted using spectral-domain optical coherence tomography with enhanced depth imaging were reviewed. As a control group, 236 patients who underwent ophthalmologic evaluation for vitreous floaters, without obvious ocular disease, were also included.

RESULTS

The mean age of the PDS group, which included 118 male patients (65.6%), was 57.4±11.1y. There was no significant difference between the two groups in age (P=0.710) or sex (P=0.248). Six patients (3.3%) in the PDS group and none in the control group showed focal LC defect (P=0.318). Among the six patients with focal LC defect in the PDS group, four eyes had PCV, one eye was the fellow eye of a PCV eye, and one eye had pachychoroidal neovasculopathy.

CONCLUSION

Focal LC defect can be defected in patients with PDS in the absence of peripapillary retinoschisis. However, the prevalence of focal LC defect was not different significantly between PDS patients and those who did not have PDS.

Effect of intravitreal injection of bevacizumab in treated and untreated eyes of Black African patients with polypoidal choroidal vasculopathy

OBJECTIVE

To evaluate the response of polypoidal choroidal vasculopathy (PCV) in eyes treated with intravitreal bevacizumab (BVZ) and untreated fellow eyes in black Africans.

METHODS

We studied 22 eyes (12 patients) divided into 12 treated and 10 untreated eyes from January 2017 to January 2020. Treated eyes received 1 monthly injection of BVZ 2.5mg for 3 months, with optional additional injections depending on the patient's course. Both groups of eyes were evaluated at presentation and then at 3, 6, 9, and 12 months after treatment. Outcome measures were visual acuity (VA) and ophthalmoscopic and OCT findings.

RESULTS

The mean age of the patients was 66.3±5.6 years. In treated eyes, VA remained stable from 0.10±0.12 at baseline to 0.20±0.30 at month 12, P=0.84. VA was stable in 83.3% and improved in 16.7% of eyes. On OCT, 41.7% of eyes showed decreased and another 41.7% disappearance of subretinal fluid (SRF) at 12 months. Pigment epithelial detachment (PED) height decreased in 9 eyes (75.0%) but remained unchanged in 3 eyes (25%). In untreated eyes, no difference was observed between the baseline (0.53±0.42) and 12-month VA (0.58±0.40), P=0.82. VA improved in 2 eyes, decreased in one eye, and remained unchanged in 7 eyes. OCT lesions remained stable in 6 eyes. The PED enlarged in one eye but remained stable in 3 other eyes.

CONCLUSION

Intravitreal injection of BVZ 2.5mg led to stabilization of VA, resorption of SRF, and reduction in the size of the PED in the majority of eyes with PCV but was ineffective on the polyps. The one-year prognosis in untreated eyes with PCV was favorable and marked by functional and structural stability.

Pachychoroid disease spectrum: review article

PURPOSE

The aim of this article is to do a comprehensive literature review about the current understandings of the pachychoroid disease spectrum, describing its multimodal imaging analysis, pathophysiology, differential diagnosis, and current types of management.

METHODS

This comprehensive literature review was performed based on a search on the PubMed database, of relevant pachychoroid published papers according to our current knowledge.

DISCUSSION

The pachychoroid disease spectrum, according to some authors, includes the following: pachychoroid pigment epitheliopathy (PPE), central serous chorioretinopathy (CSC), pachychoroid neovasculopathy (PNV), polypoidal choroidal vasculopathy (PCV)/aneurysmal type 1 neovascularization (AT1), and more recently focal choroidal excavation (FCE) and peripapillary pachychoroid syndrome (PPS). Each one of these entities will be described and discussed in this article.

CONCLUSION

Significant advances in multimodal imaging have enabled a better understanding of the typical choroidal changes in pachychoroid disease spectrum. The clinical knowledge and managing options about this disease significantly increased in the last years. However, it is still unclear why some eyes with typical pachychoroid disease phenotype show no evidence of RPE damage and subretinal fluid (uncomplicated pachychoroid) while others present progressive tissue damage, neovascularization, and atrophy.

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

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

Pachychoroid spectrum disease

Recent improvements in ophthalmic imaging have led to the identification of a thickened choroid or pachychoroid to be associated with a number of retinal diseases. The number of conditions linked to this phenotype has continued to widen with specific endophenotypes found within the pachychoroid spectrum. The spectrum includes choroidal features such as focal or diffuse choroidal thickening and thinning of the overlying inner choroid, and choroidal hyperpermeability as demonstrated by indocyanine green angiography. In addition, these diseases are associated with overlying retinal pigmentary changes and retinal pigment epithelial dysfunction and may also be associated with choroidal neovascularization. This article provides a comprehensive review of the literature looking at diseases currently described within the pachychoroid spectrum including central serous chorioretinopathy, pachychoroid pigment epitheliopathy, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy/aneurysmal type 1 neovascularization, peripapillary pachychoroid disease and focal choroidal excavation. We particularly focus on clinical imaging, genetics and pathological findings in these conditions with the aim of updating evidence suggesting a common aetiology between diseases within the pachychoroid spectrum.

Fluorescein angiographic characteristic in predominantly classic and occult types of neovascular age-related macular degeneration treated with ranibizumab

Background and purpose:

Randomised-controlled clinical trials (the ANCHOR and MARINA) examined the intravitreal anti-vascular endothelial growth factor (anti-VEGF) efficacy for eyes having fluorescein angiographic classic and occult (OCC) neovascular lesions. No significant difference in the treatment response between the lesion types was observed. Fundus fluorescein angiography and optical coherence tomography (OCT) are complementary devices that provide information about neovascular age-related macular degeneration (n-AMD). The aim of this retrospective study was to compare the clinical aspects of fluorescein angiographic characteristics in predominantly classic (PDC) and OCC subtypes of n-AMD treated with intravitreal ranibizumab.

Methods:

Treatment-naive fluorescein angiographic OCC-n-AMD and PDC-n-AMD patients, who received monthly intravitreal ranibizumab for 3 months after baseline, and were followed-up with pro re nata injections between March 2013 and February 2018, were included. Means of the visual acuity (VA), central macular thickness (CMT), and intravitreal injection and visit numbers of the groups were compared throughout 24 months.

Results:

We included 41 eyes of PDC-n-AMD patients and 36 eyes of OCC-n-AMD patients. The mean ages were 74.5 ± 10.6 and 71.9 ± 9.4, respectively. The baseline, and 3-, 6-, 12-, 18-, and 24-month VA results of the OCC group were significantly better than those in the PDC. However, VA gain in the PDC group at 3, 6, and 12 months was significantly higher than that in the OCC group. The mean of baseline CMT of the PDC (353 ± 118 µm) was significantly higher than that in the OCC group (293 ± 64 µm). No significant differences in terms of the number of visits or injections, or CMT change from the baseline values between groups were observed.

Conclusion:

The OCC-n-AMD patients had better baseline and follow-up VA and CMT means than the PDC-n-AMD patients. However, the PDC-n-AMD patients are expected to benefit more than the OCC-n-AMD patients in terms of VA gains.

Replacement of polyps with type 1 macular neovascularization in polypoidal choroidal vasculopathy imaged with swept source OCT angiography

Purpose

To investigate the morphological changes of polyps in eyes with polypoidal choroidal vasculopathy (PCV) after treatment with vascular endothelial growth factor (VEGF) inhibitors using swept source optical coherence tomography angiography (SS-OCTA).

Observations

Following anti-VEGF therapy, polyps were found to evolve into typical type 1 macular neovascularization (MNV) in five eyes. In all of these five eyes, a polypoidal lesion was detected adjacent to a serous or hemorrhagic retinal pigment epithelial detachment (PED).

Conclusions and importance

Polypoidal lesions in PCV can evolve into typical type 1 MNV. This morphological evolution suggests that these polyps are clusters of tangled vessels that can proliferate into a more typical neovascular pattern, and this evolution may be facilitated by being adjacent to a PED. Since this morphological appearance could be associated with a better prognosis, SS-OCTA might be helpful in identifying cases of transformed polyps that may be associated with a decreased risk for vision loss.

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.

Comparison of visual outcomes between therapy choices and subtypes of polypoidal choroidal vasculopathy (PCV) in Taiwan: a real-world study

Polypoidal choroidal vasculopathy (PCV) is a distinctive type of neovascular age-related macular degeneration prevalent in many Asian countries. However, there is still some controversy in how the subtypes of PCV are classified. This post-hoc study redefined the branching vascular network (BVN) and PCV subtypes through retrospective review of indocyanine green angiography (ICGA) and fluorescein angiography images from two observational studies (RENOWNED/REAL). Of the visual outcomes for each angiographic subtype and treatment pattern investigated, BVN was identified in 56.3% of PCV patients. The proportions and features of the re-defined PCV subtypes were 43.8%, 10.4%, and 45.8% for subtype A (without distinctive features of BVN), B (with BVN but no leakage), and C (with BVN and leakage), respectively. Subtype A had better visual outcomes when compared to subtype C. This possibly resulted from a better baseline visual acuity in subtype A. Moreover, combination therapy [photodynamic therapy plus anti-vascular endothelial growth factor (VEGF)] may lead to better visual improvement than mono-anti-VEGF treatment alone. This study provides the prevalence of PCV subtypes in Taiwan and may serve as a reference for PCV treatment strategies in a real-world setting, especially for the combination therapy and patients without distinctive features of BVN.

Plasma level of lipocalin 2 is increased in neovascular age-related macular degeneration patients, particularly those with macular fibrosis

Background

Previously, we and others have reported higher populations of circulating neutrophils in patients with neovascular age-related macular degeneration (nAMD). Neutrophil gelatinase-associated lipocalin (NGAL, also known as lipocalin-2, LCN2), an important innate immune mediator, is known to be critically involved in sterile inflammation-mediated organ failure, fibrosis, cancer progression and retinal degeneration. This study investigated the plasma levels of LCN2, matrix metalloproteinase 9 (MMP9) and LCN2/MMP9 complex in different types of nAMD and examined whether the levels were related to patients’ responsiveness to anti-VEGF therapy.

Results

One hundred and seventy-four nAMD patients, including 108 with choroidal neovascularisation (CNV), 32 with retinal angiomatous proliferation (RAP), 23 with polypoidal choroidal vasculopathy (PCV) and 11 unclassified patients, and 43 healthy controls were recruited to this case-control study. Fifty-eight nAMD patients had macular fibrosis and 110 patients did not. Out of the 174 nAMD patients, 80 patients responded completely, 90 responded partially, and 4 did not respond to the anti-VEGF therapy. The plasma levels of LCN2 in nAMD patients (181.46 ± 73.62 ng/ml) was significantly higher than that in healthy controls (152.24 ± 49.55 ng/ml, P = 0.047). However, the difference disappeared after adjusting for age. A positive correlation between plasma level of LCN2 and age was observed in nAMD patients (r = 0.29, P = 0.0002) but not in healthy controls. The plasma level of LCN2 was also positively correlated with circulating neutrophils in nAMD patients (r = 0.34, p = 0.0007) but not in healthy controls (r = 0.057, p = 0.77). No correlation was observed between age and circulating neutrophils. Further analysis of nAMD subtypes uncovered a significantly higher level of LCN2 in patients with macular fibrosis even after adjusting for age. No relationship was observed between plasma levels of LCN2 and patients’ responsiveness to anti-VEGF therapy. The plasma levels of MMP9 and LCN2/MMP9 complex were comparable between nAMD and controls.

Conclusions

Our results suggest that higher plasma levels of LCN2 in nAMD are related to ageing and increased population of circulating neutrophils. Our results also suggest that higher levels of LCN2 may increase the risk of macular fibrosis in nAMD.

Deep phenotype unsupervised machine learning revealed the significance of pachychoroid features in etiology and visual prognosis of age-related macular degeneration

Unsupervised machine learning has received increased attention in clinical research because it allows researchers to identify novel and objective viewpoints for diseases with complex clinical characteristics. In this study, we applied a deep phenotyping method to classify Japanese patients with age-related macular degeneration (AMD), the leading cause of blindness in developed countries, showing high phenotypic heterogeneity. By applying unsupervised deep phenotype clustering, patients with AMD were classified into two groups. One of the groups had typical AMD features, whereas the other one showed the pachychoroid-related features that were recently identified as a potentially important factor in AMD pathogenesis. Based on these results, a scoring system for classification was established; a higher score was significantly associated with a rapid improvement in visual acuity after specific treatment. This needs to be validated in other datasets in the future. In conclusion, the current study demonstrates the usefulness of unsupervised classification and provides important knowledge for future AMD studies.

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.

Characteristics of the inner retinal layer in the fellow eyes of patients with unilateral exudative age-related macular degeneration

OBJECTIVE

To investigate the thicknesses of the ganglion cell-inner plexiform layer (GC-IPL) and retinal nerve fiber layer (RNFL) of the fellow eyes of patients with unilateral exudative age-related macular degeneration (AMD).

METHODS

A total of 107 patients with unilateral exudative AMD [34 of typical choroidal neovascularization (tCNV), Group A; 73 of polypoidal choroidal vasculopathy (PCV), Group B] and 73 normal control eyes (Group C) were included. Drusen and subretinal drusenoid deposits were assessed in all participants using fundus photography, autofluorescence, and optical coherence tomography (OCT). The GC-IPL and RNFL thicknesses were measured using Cirrus HD-OCT and compared among groups. Linear regression analyses were used to evaluate the factors associated with GC-IPL thicknesses.

RESULTS

The average GC-IPL thicknesses of Groups A, B, and C were 77.09 ± 3.87, 80.10 ± 6.61, and 80.88 ± 6.50 μm, respectively (p = 0.022). Sectoral GC-IPLs and central macular thicknesses (CMTs) were significantly different among groups (all, p <0.05), whereas none of the RNFL parameters differed significantly (all, p >0.05). Multivariate linear regression analyses revealed that age (p <0.001), CMT (p <0.001), and tCNV (p = 0.013) were significantly associated with average GC-IPL thickness, and the rate of reduction of GC-IPL thickness with increasing age in the fellow eyes of tCNV patients was higher than those in the PCV and control groups.

CONCLUSIONS

Unilateral tCNV patients exhibited statistically significant reduction of the GC-IPL thickness in the fellow eyes, compared to values of the fellow eyes of unilateral PCV patients or control patients. RNFL values trended to be lower but did not reach statistical significance.

Fractal analysis of polypoidal choroidal neovascularisation in age-related macular degeneration

Aim

To describe optical coherence tomography angiography (OCTA) features of polypoidal choroidal neovascularisation (PCNV) secondary to age-related macular degeneration.

Methods

A retrospective consecutive series of 51 patients with a diagnosis of PCNV, based on clinical and multimodal imaging, was analysed. All patients with PCNV underwent a comprehensive ophthalmological examination, including fluorescein and indocyanine green angiography, structural optical coherence tomography (OCT) and OCTA. Two blinded retinal specialists carefully reviewed OCTA slabs in order to assess the morphological patterns of PCNV lesions. Furthermore, fractal analysis of PCNV en face images on OCTA, including vascular perfusion density (VPD), fractal dimension (FD) and lacunarity (LAC), was performed.

Results

Fifty-one PCNV eyes were included in the study. In all, the branching vascular network appeared hyper-reflective. Polyps showed two different patterns: in 34/51 (67%) eyes, they corresponded to hypo-reflective structures, whereas in the remaining 17 (33%) eyes, they appeared as hyper-reflective lesions. In all PCNV eyes, mean VPD, FD and LAC were 0.76±0.17%, 1.46±0.12 and 2.4±0.87, respectively. No significant difference was found between PCNVs showing a different OCTA pattern, in terms of quantitative OCTA parameters.

Conclusion

Fractal analysis provides quantitative parameters demonstrating that PCNVs with different OCTA patterns share the same neovascular architecture and branching complexity. These new findings improve our ability to interpret OCTA slabs, opening new areas of discussion about this type of neovascular lesion.

Impact of sub-foveal choroidal thickness on clinical features and long-term clinical outcomes in polypoidal choroidal vasculopathy

PURPOSE

To study the clinical features and long-term clinical outcomes in polypoidal choroidal vasculopathy (PCV) in eyes with different sub-foveal choroidal thickness (SFCT).

METHODS

In this retrospective, observational comparative study, treatment-naïve eyes diagnosed with PCV using the 'EVEREST-2' study criteria were included. The eyes were divided into three groups of thin, medium and thick choroids, based on the SFCT data of total study eyes. Demographic, clinical, imaging features and treatment outcomes between the 3 groups were compared.

RESULTS

Sixty-three eyes in 63 patients were included. Right eye was involved in 39 (61%) cases and left eye in 24 (39%) cases. Mean age was 68.3 ± 6.82 years (range 54-85 years). Mean SFCT was 274 µm (median = 269 µm), and one standard deviation was 79.2 µm. Totally, 11, 43 and 9 eyes were included in the thin, medium and thick choroid groups, respectively. The mean SFCT was 161 ± 24.1 µm, 275 ± 39.6 µm and 412 ± 26.2 µm in the thin, medium and thick choroid groups, respectively. There was no statistically significant difference in the clinical and imaging features and treatment outcomes between eyes with thin, medium and thick SFCT.

CONCLUSION

Eyes with PCV can have a choroid of varying thicknesses. Clinical, imaging and treatment responses were similar between the three sub-foveal choroidal thickness groups in this study. In future, more studies are required to evaluate the role of the choroidal thickness and its relationship to treatment in PCV.

The Application of Enhanced Depth Imaging Spectral-Domain Optical Coherence Tomography in Macular Diseases

The choroid plays an essential role in the pathogenesis of various posterior segment diseases. However, traditional imaging methods still have limited cross-sectional observation of choroid. Enhanced depth imaging in spectral-domain optical coherence tomography (EDI SD-OCT) uses a closer scanning position to the eye to create an inverted SD-OCT image with the advantage of better depth sensitivity, which can observe choroidal structure and measure choroidal thickness (CT) accurately. At present, more and more choroidal thickness measurements have been made in normal and pathologic states, in order to understand the pathogenesis and differential diagnosis and prognosis of various diseases, especially for macular lesions. This paper would review relevant original literatures published from January 1, 2008, to February 1, 2020, to evaluate the relationship between the changes of CT with EDI SD-OCT and macular diseases.

Characteristics of Pachychoroid Diseases and Age-Related Macular Degeneration: Multimodal Imaging and Genetic Backgrounds

The emergence of pachychoroid disease is changing the concept of age-related macular degeneration (AMD). The concept of pachychoroid diseases was developed through clinical observation of multimodal images of eyes with AMD and central serous chorioretinopathy; however, recent genetic studies have provided a proof of concept for pachychoroid spectrum disease, which should be differentiated from drusen-driven AMD. The genetic confirmation of pachychoroid concept further provides novel viewpoints to decode previously reported findings, which facilitates an understanding of the true nature of pachychoroid diseases and AMD. The purpose of this review was to elucidate the relationship between pachychoroid diseases and AMD by interpreting previous findings on pachychoroid diseases and AMD from the novel viewpoints of genetic associations. We confirmed that previous genetic studies supported the concept of pachychoroid diseases. From a genetic viewpoint, the presence of thick choroid and the presence of choroidal vascular hyperpermeability were important characteristics of pachychoroid spectrum diseases. Previous studies have also suggested the classification of polypoidal choroidal vasculopathy (PCV) into two subtypes, pachychoroid neovasculopathy and drusen-driven PCV. Genetic viewpoints will be beneficial to rearrange subtypes of drusen-driven AMD and pachychoroid spectrum diseases. Further genetic studies are needed to investigate pachyvessels, pachydrusen and the significance of polypoidal lesions in pachychoroid neovasculopathy and drusen-driven AMD/PCV.

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.

Longitudinal Changes in Ganglion Cell-Inner Plexiform Layer of Fellow Eyes in Unilateral Neovascular Age-Related Macular Degeneration

PURPOSE

To determine longitudinal changes in the ganglion cell-inner plexiform layer (GC-IPL) thickness of the fellow eyes of patients with neovascular age-related macular degeneration (AMD).

DESIGN

Prospective cohort study.

METHODS

Patients with unilateral neovascular AMD, unilateral polypoidal choroidal vasculopathy (PCV), and control subjects were included. After the initial visit, GC-IPL thickness was measured twice more with at least a 1-year interval between examinations using spectral domain optical coherence tomography.

RESULTS

Twenty-seven fellow eyes of patients with unilateral choroidal neovascularization (CNV), 33 fellow eyes of patients with unilateral PCV, and 35 eyes of control subjects were enrolled. The GC-IPL thickness of the fellow eyes was 78.41 ± 9.23, 81.20 ± 5.52, and 81.60 ± 3.83 μm in the CNV, PCV, and control groups, respectively, and they showed a significant change over time (P < .001, P = .001, and P = .003, respectively). The reduction rate of GC-IPL thickness was -0.88, -0.41, and -0.31 μm per year in the fellow eyes of the CNV, PCV, and control groups, respectively (CNV > PCV, control, P < .001). In a linear mixed model determination of factors associated with GC-IPL reduction in the fellow eyes of the CNV group, the interaction between baseline GC-IPL thickness and duration showed a significant result (P < .001).

CONCLUSIONS

The fellow eyes of patients with neovascular AMD showed a greater reduction rate of GC-IPL thickness compared with fellow eyes of patients with unilateral PCV and control subjects. In patients with unilateral neovascular AMD, fellow eyes with a thicker GC-IPL at baseline showed a greater reduction in GC-IPL thickness over time.

Risk factors for progression of age-related macular degeneration

Purpose

Age‐related macular degeneration (AMD) is a degenerative disease of the macula, often leading to progressive vision loss. The rate of disease progression can vary among individuals and has been associated with multiple risk factors. In this review, we provide an overview of the current literature investigating phenotypic, demographic, environmental, genetic, and molecular risk factors, and propose the most consistently identified risk factors for disease progression in AMD based on these studies. Finally, we describe the potential use of these risk factors for personalised healthcare.

Recent findings

While phenotypic risk factors such as drusen and pigment abnormalities become more important to predict disease progression during the course of the disease, demographic, environmental, genetic and molecular risk factors are more valuable at earlier disease stages. Demographic and environmental risk factors such as age and smoking are consistently reported to be related to disease progression, while other factors such as sex, body mass index (BMI) and education are less often associated. Of all known AMD variants, variants that are most consistently reported with disease progression are rs10922109 and rs570618 in CFH, rs116503776 in C2/CFB/SKIV2L, rs3750846 in ARMS2/HTRA1 and rs2230199 in C3. However, it seems likely that other AMD variants also contribute to disease progression but to a lesser extent. Rare variants have probably a large effect on disease progression in highly affected families. Furthermore, current prediction models do not include molecular risk factors, while these factors can be measured accurately in the blood. Possible promising molecular risk factors are High‐Density Lipoprotein Cholesterol (HDL‐C), Docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), zeaxanthin and lutein.

Summary

Phenotypic, demographic, environmental, genetic and molecular risk factors can be combined in prediction models to predict disease progression, but the selection of the proper risk factors for personalised risk prediction will differ among individuals and is dependent on their current disease stage. Future prediction models should include a wider set of genetic variants to determine the genetic risk more accurately, and rare variants should be taken into account in highly affected families. In addition, adding molecular factors in prediction models may lead to preventive strategies and personalised advice.

Lateral elongation of flat irregular pigment epithelial detachment: A novel optical coherence tomography biomarker in polypoidal choroidal vasculopathy

Purpose

To explore novel Optical Coherence Tomography (OCT) biomarkers and precursor lesions in Polypoidal Choroidal Vasculopathy (PCV).

Methods

This retrospective cohort study included 76 treatment naïve fellow eyes of PCV. Focus was given to analyse the various morphological changes in the clinically unaffected fellow retina during the follow-up period.

Results

11 fellow eyes (14.47%) developed disease activity in the form of Sub Retinal Fluid (SRF) or Intra Retinal Fluid (IRF) within a mean follow-up of 17 months. All 11 eyes (100%) showed the presence of flat irregular pigment epithelial detachment (FIPED) and a peculiar property of lateral elongation of FIPED during disease activity. A positive correlation with the disease progression was found for the same (P < 0.0001). The mean horizontal dimension of the flat irregular PED at the enrolment was 1984 ± 376u and the mean expansion of FIPED at SRF formation was 461 ± 152u. ICG taken at the time of disease activity in the fellow eye revealed branching vascular network (BVN) in 9 (81.8%) eyes, polyps in 7 (63.6%) eyes, a combination of both in 5 (45.4%) eyes. Type one BVN with interconnecting channels showed faster disease progression than type two BVN. Eye tracking ICG illustrated that BVN corresponded to the FIPED in OCT and polypoidal lesions developed at the end of expanding FIPED.

Conclusion

Flat irregular pigment epithelial detachment with its characteristic property of lateral elongation may be considered as a precursor lesion for PCV and as a novel OCT biomarker for the disease activity. Fellow eyes with FIPED need close monitoring to identify development of disease activity at the earliest.

Five-Year Follow-Up of Unaffected Fellow Eyes in Patients with Polypoidal Choroidal Vasculopathy

PURPOSE

To evaluate the incidence and risk factors of neovascular age-related macular degeneration (nAMD) including polypoidal choroidal vasculopathy (PCV) or any type of choroidal neovascularization (CNV) in fellow eyes of unilateral PCV.

METHODS

This retrospective study included 48 patients with unilateral PCV. For the initial PCV diagnosis, optical coherence tomography and indocyanine green angiography were performed, and patients with and without neovascularization were compared.

RESULTS

Of 48 fellow eyes, 10 (20.8%) had drusen, 9 (18.8%) had retinal pigment epitheliopathy, 9 (18.8%) had irregular retinal pigment epithelium (RPE) elevation, 13 (27.1%) had choroidal vascular dilation, 12 (25%) had choroidal vascular hyperpermeability, and 9 (18.8%) had branching vascular network (BVN) at baseline. The development of nAMD was noted in 8 eyes (17%). The subfoveal choroidal thickness (p = 0.001), irregular RPE elevation (p < 0.001), choroidal vascular dilation (p < 0.001), choroidal vascular hyperpermeability (p < 0.001), and BVN (p < 0.001) in fellow eyes were significantly correlated with development of PCV. After multivariate analysis, BVN (p = 0.045, odds ratio = 24.66) in the fellow eye was the only significant risk factor for the development of nAMD.

CONCLUSIONS

PCV or CNV developed in 17% of fellow eyes during the 5 years. Unilateral PCV with contralateral BVN requires careful monitoring for future development of PCV or CNV in fellow eyes.

Polypoidal Choroidal Vasculopathy: Outer Retinal and Choroidal Changes and Neovascularization Development in the Fellow Eye

Purpose

We investigated the outer retinal, RPE, and choroidal changes and the development of choroidal neovascularization (CNV) in fellow eyes of patients with unilateral polypoidal choroidal vasculopathy or aneurysmal type 1 neovascularization (PCV/AT1).

Methods

In this retrospective observational cohort study, 263 patients with unilateral PCV/AT1 were enrolled. Fundus photography, enhanced depth imaging optical coherence tomography, and indocyanine green angiography at baseline and follow-up were analyzed. Incidence and risk factors for the development of CNV were analyzed.

Results

In fellow eyes of unilateral PCV/AT1 cases, RPE and outer retinal abnormalities were observed in 222 (84%) eyes, and dilated Haller vessels (pachyvessel) were identified in the corresponding abnormality area in 157 (71%) eyes. Follow-up data were available for 233 patients. During a 27.6-month mean follow-up period, 20/233 (9%) eyes had CNV (12 PCV/AT1 and eight type 1 CNV). In 18 eyes (90%), CNV developed at the RPE or outer retinal abnormality areas accompanied by pachyvessel. A significantly higher risk for CNV was observed if RPE and outer retinal abnormalities were accompanied by pachyvessel (hazard ratio, 9.3; 95% confidence interval, 1.1-75.9, P = 0.037).

Conclusions

RPE and outer retinal abnormalities were common in fellow eyes of patients presenting with unilateral PCV/AT1. CNV developed in fellow eyes of 9% of patients, frequently in the areas with RPE and outer retinal abnormality accompanied by pachyvessel.

Angiographic Subtypes of Neovascular Age-related Macular Degeneration in Korean: A New Diagnostic Challenge

Neovascular age-related macular degeneration (AMD) is the leading cause of irreversible blindness in elderly population. Several classifications schemes have been developed to provide subtypes of neovascular AMD, which are known to be associated with visual prognosis. However, there is still a large proportion of patient with ambiguous findings according to current classification criteria. In this study, we classified treatment-naïve neovascular AMD patients using novel angiographic classification system and investigated the incidence and clinical characteristics of AMD subtypes. Among 339 eyes, five AMD subtypes were identified: 41 (12.1%) with classic choroidal neovascularization (CNV), 30 (8.8%) with occult CNV, 91 (26.8%) with microaneurysmal choroidal vasculopathy (MCV), 123 (36.3%) with polypoidal choroidal vasculopathy (PCV), and 54 (15.9%) with retinal angiomatous proliferation (RAP). MCV was younger than RAP (P < 0.001). Classic CNV presented with worse visual acuity compared with MCV at baseline (P < 0.001). Central macular subfield thickness was highest in RAP, and lowest in MCV (P = 0.036). Subfoveal choroidal thickness was highest in MCV, and lowest in RAP (P < 0.001). There was a significant difference in visual acuity at 12 months among five subtypes (P = 0.046). Our results highlight the importance of angiography for identifying AMD subtypes, particularly the novel MCV group being distinct from other subtypes.

Comparison of optical coherence tomography angiography and green indocyanine angiography in polypoidal choroidal vasculopathy: A prospective study

PURPOSE

To compare optical coherence tomography angiography (OCTA) and indocyanine green angiography (ICGA) findings in polypoidal choroidal vasculopathy (PCV) according to polyp type, polyp size and pigment epithelial detachment (PED) size.

METHOD

Seventeen patients with PCV were included this study. The participants were divided into two groups according to ICGA images. Participants who had type I PCV formed group 1, and group 2 was comprised of patients with type II PCV. OCTA was performed for all participants. Polyp detection rates with OCTA and factors affecting this detection were assessed.

RESULTS

The mean age of all patients was 68.85±4.77 years (group 1 70.4±2.54 years, group 2 67.45±5.93 years). The rate of polyps seen in OCTA images was statistically significantly correlated with polyp type, polyp size, and PED size (r=0.633, p=0.002; r=0.64, P=0.001 and r=0.59, p<0.001, respectively). In group 1, the mean polyp size was 230.8±82.94μm, and the mean PED size was 161.3±73.87μm. In group 1, 10 patients with PCV were detected with ICGA, while only 1 (10%) PCV was detected with OCTA. In group 2, the mean polyp size was 387.90±245.90μm, and the mean PED size was 345.18±276.26μm. In group 2, 11 patients with PCV were detected with ICGA, while 8 (72.7%) of these patients were detected using OCTA.

CONCLUSIONS

OCTA showed a greater percentage of detection of type II PCV than type I PCV. Polyp and PED size are important for the detection of PCV using OCTA.

Enlargement of polypoidal choroidal vasculopathy lesion without exudative findings assessed in en face optical coherence tomography images

PURPOSE

This study aimed to investigate growth of polypoidal choroidal vasculopathy (PCV) without exudative findings assessed in en face optical coherence tomography (OCT) images and its clinical implications.

METHODS

Fifty patients who were diagnosed with PCV and had no disease activity after treatment with intravitreal anti-vascular endothelial growth factor (anti-VEGF) were included. Patients were followed up for at least 12 months. Measurement of best-corrected visual acuity and volume scan using swept-source OCT was performed at each visit. The neovascular area of PCV was assessed using en face OCT. Growth group comprised patients who showed increase in neovascular area in the en face images without exudative findings. The main outcome measure was relationship between growth of PCV and recurrence.

RESULTS

Among 50 eyes of 50 patients with average age of 68.5 ± 8.6 years, 25 (50%) eyes were included in the growth group. Exudative recurrence was noted more frequently in the growth group (18 eyes, 72%) than in the non-growth group (6 eyes, 24%, P = .002, odds ratio = 8.143). More injections were performed in the growth group (4.7 ± 2.1 vs. 1.9 ± 2.4, P = .002), but there was no difference in visual acuity at 1 year. After an exudative recurrence following the lesion growth, more frequent injections were required than before the recurrence to achieve no disease activity (P = .002).

CONCLUSION

PCV lesion growth without fluid preceded exudative recurrence and worsening of response to anti-VEGF treatment.

One-year outcome of combination therapy with intravitreal aflibercept and photodynamic therapy for polypoidal choroidal vasculopathy

Background

To investigate the one-year visual and anatomical outcomes of combination therapy with intravitreal aflibercept (IVA) and photodynamic therapy (PDT) for treating polypoidal choroidal vasculopathy (PCV).

Methods

This was a retrospective case-series study, including 30 eyes from 30 patients with treatment-naïve PCV treated by combination therapy with IVA and PDT. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), complete polyp regression rate, and dry macula rate were recorded every 3 months during 12-month follow-up. Clinical factors associated with final visual outcome and retreatment were investigated.

Results

The mean LogMAR BCVA was significantly improved from 0.73 ± 0.65 at baseline to 0.51 ± 0.60 (p = 0.01), and the mean CRT was also significantly improved from 339 ± 96 μm at baseline to 244 ± 43 μm at 12-month follow-up (p <  0.001). Complete regression of polypoidal lesions was 76.7%, and dry macula rate was 100% at 12 months. Better final BCVA was associated with younger age and better baseline BCVA (p = 0.02 and p <  0 001). The patients without complete polyp regression at 3-month follow-up were associated with retreatment (p = 0.03).

Conclusion

In this study, combination therapy with IVA and PDT had significant visual and anatomical improvements to PCV patients during one-year follow-up. Better baseline BCVA and younger age were found to be associated with better visual outcome.

Electronic supplementary material

The online version of this article (10.1186/s40360-019-0310-1) contains supplementary material, which is available to authorized users.

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.

EVEREST study report 4: Fluorescein angiography features predictive of polypoidal choroidal vasculopathy

Importance

It is important to identify features of polypoidal choroidal vasculopathy (PCV) that differentiate it from typical neovascular age‐related macular degeneration (nAMD) on various imaging modalities, including fluorescein angiography (FA).

Background

PCV was thought to be indistinguishable from nAMD using FA alone. In real‐world practice, indocyanine‐green angiography may often be unavailable or contraindicated.

Design

Analysis of FA images from a prospective, multicentre study.

Participants

Study images of both PCV and nAMD patients from the EVEREST study.

Methods

FA features at baseline were independently graded by masked graders (fellowship‐trained ophthalmologists) using standardized diagnostic algorithms.

Main Outcome Measures

Predictive indicators (sensitivity, specificity, positive and negative predictive values) for PCV.

Results

Of the 95 patients screened, 61 had PCV. Of the 34 screening failures, 15 were diagnosed as nAMD. Hyperfluorescent nodules on FA were observed in 80% of patients with PCV vs 20% with nAMD (P < 0.001). Blocked fluorescence on FA, which corresponded to the presence of subretinal haemorrhage, occurred more frequently among patients with PCV vs nAMD (61.7% vs 13.3%, P = 0.001). Similarly, the leakage characteristic of occult choroidal neovascularization occurred more frequently among patients with PCV vs nAMD (95.0% vs 73.3%, P = 0.026). The positive predictive value for PCV was 94.1% for hyperfluorescent nodules, 94.9% for blocked fluorescence, 83.8% for occult choroidal neovascularization and 82.0% for pigment epithelial detachment.

Conclusions and Relevance

This study demonstrated that certain FA features can be predictive of PCV and may be considered as an indication for retina specialists to perform indocyanine green angiography as confirmatory test.