Optical coherence tomography of idiopathic polypoidal choroidal vasculopathy

European Prevalence of Polypoidal Choroidal Vasculopathy: A Systematic Review, Meta-Analysis, and Forecasting Study

The purpose of this study was to provide an estimate of the number of current and future patients with polypoidal choroidal vasculopathy (PCV) in Europe. We systematically searched 11 literature databases on 18 May 2022 for studies on the prevalence of PCV among a consecutive and representative group of patients with suspected neovascular age-related macular degeneration (AMD). Prevalence of PCV in patients with suspected neovascular AMD was summarized and included in a prevalence meta-analysis. We then used current population data and population forecasts by Eurostat and the Office for National Statistics to determine current and future number of patients with neovascular AMD in Europe. Then, we calculated the number of patients with PCV with our calculated estimate of the prevalence of PCV among Europeans suspected with neovascular AMD. A total of five eligible studies were identified which included a total of 1359 patients. All these studies used the gold standard of indocyanine green angiography as a routine part of their diagnostic approach. Among patients undergoing detailed retinal examination for suspected neovascular AMD, our meta-analysis calculated the prevalence of PCV to be 8.3% (95% confidence interval: 6.8–9.8%). Our population estimates find that a total of 217,404 patients with PCV exist in Europe in the year 2022, which constitutes 0.04% of the entire population of Europe. This number is estimated to increase to 287,517 patients in the year 2040. Our estimates are important for different healthcare stakeholders, especially when planning and allocating expensive resources.

Clinical explainable differential diagnosis of polypoidal choroidal vasculopathy and age-related macular degeneration using deep learning

BACKGROUND

This study aims to achieve an automatic differential diagnosis between two types of retinal pathologies with similar pathological features - Polypoidal choroidal vasculopathy (PCV) and wet age-related macular degeneration (AMD) from volumetric optical coherence tomography (OCT) images, and identify clinically-relevant pathological features, using an explainable deep-learning-based framework.

METHODS

This is a retrospective study with data from a cross-sectional cohort. The OCT volume of 73 eyes from 59 patients was included in this study. Disease differentiation was achieved through single-B-scan-based classification followed by a volumetric probability prediction aggregation step. We compared different labeling strategies with and without identifying pathological B-scans within each OCT volume. Clinical interpretability was achieved through normalized aggregation of B-scan-based saliency maps followed by maximum-intensity-projection onto the en face plane. We derived the PCV score from the proposed differential diagnosis framework with different labeling strategies. The en face projection of saliency map was validated with the pathologies identified in Indocyanine green angiography (ICGA).

RESULTS

Model trained with both labeling strategies achieved similar level differentiation power (>90%), with good correspondence between pathological features detected from the projected en face saliency map and ICGA.

CONCLUSIONS

This study demonstrated the potential clinical application of non-invasive differential diagnosis using AI-driven OCT-based analysis, with minimal requirement of labeling efforts, along with clinical explainability achieved through automatically detected disease-related pathologies.

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.

Plasma levels of inflammatory chemokines in patients with polypoidal choroidal vasculopathy

PURPOSE

Chemokines are a group of cytokines that guide immune cell migration. We studied plasma levels of inflammatory chemokines in patients with polypoidal choroidal vasculopathy (PCV) and compared with healthy age-matched control individuals.

METHODS

This was a clinic-based prospective case-control study of participants (n = 60) with either PCV (n = 26) or age-matched healthy controls (n = 34). We sampled fresh venous blood and isolated plasma for analysis. We used U-PLEX Human Assays to quantify concentrations of the inflammatory chemokines MCP-1/CCL2, RANTES/CCL5, eotaxin/CCL11, IP-10/CXCL10 and fractalkine/CX3CL1.

RESULTS

Plasma levels of fractalkine was significantly higher in patients with PCV when compared to healthy controls (mean ± SD: 7291 ± 2461 pg/ml versus 5879 ± 2001 pg/ml; p = 0.021). Plasma levels of MCP-1 (p = 0.846), RANTES (p = 0.288), eotaxin (p = 0.496) and IP-10 (p = 0.352) did not differ significantly between the groups. To evaluate possible biomarker quality of fractalkine, we used a ROC analysis and found a positive but weak discriminatory ability (AUC = 0.68).

CONCLUSION

Patients with PCV have a higher plasma level of fractalkine. Although the differences do not possess strong biomarker qualities, they inform on disease processes of a poorly understood disease and suggest that the fractalkine-CX3CR1 axis may be involved. As this study did not investigate local chemokine concentrations, we are unable to confirm or disprove any local chorioretinal interaction, and our findings should be interpreted with such caution.

PREVALENCE OF POLYPOIDAL CHOROIDAL VASCULOPATHY IN WHITE PATIENTS WITH EXUDATIVE AGE-RELATED MACULAR DEGENERATION: Systematic Review and Meta-Analysis

PURPOSE

Polypoidal choroidal vasculopathy (PCV) is a disease with significant inter-ethnical differences. In this study, we systematically review the literature on the prevalence of PCV in whites referred with a diagnosis of exudative age-related macular degeneration (AMD).

METHODS

We searched PubMed, Embase, the Cochrane Library, and the Web of Science on 24 March, 2017 for studies evaluating the prevalence of PCV in white patients with exudative AMD. Data extraction and risk of bias assessments were performed in duplicate. Studies were included for a qualitative review and a meta-analysis, including subgroup analysis for differences in age and sex.

RESULTS

We included data from 11 studies (>2,200 participants). For diagnosis, indocyanine green angiography was used together with a set of supporting criteria on fundus examination and optical coherence tomography. Extramacular location was more prevalent in eyes with PCV. Drusen was present in the fellow eye in 17% to 27%. Pooled prevalence of PCV in white patients with exudative AMD was 8.7% (confidence interval 95%: 7.2%-10.3%). Patients with PCV were 3.7 years (confidence interval 95%: 2.1 years-5.3 years) younger than those with other exudative AMD. Sex did not differ significantly.

CONCLUSION

Polypoidal choroidal vasculopathy is not a rare subtype of exudative AMD in whites-it is present in approximately one in 11 patients.

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.

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.

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.

Presenting characteristics and prevalence of polypoidal choroidal vasculopathy in Scandinavian patients with treatment-naïve exudative age-related macular degeneration

PURPOSE

To study presenting characteristics and prevalence of polypoidal choroidal vasculopathy (PCV) in Scandinavian Caucasians with treatment-naïve exudative age-related macular degeneration (AMD).

METHODS

We reviewed all patients referred in year 2014 and diagnosed using fundus examination, optical coherence tomography, and fluorescein and indocyanine green angiography (ICGA). Details of found PCVs and its subtypes (clinical and angiographical) were correlated to the baseline best-corrected visual acuity (BCVA).

RESULTS

Of 299 Caucasian patients with a tentative diagnosis of exudative AMD, 18 eyes of 17 patients (5.7%, CI 95%: 3.5-9.1%) had PCV. Patients with PCV were 75.8 (SD: 7.5) years old and 11 (65%) were females. Lesions were predominantly extramacular. Most eyes (56%) had subretinal haemorrhage, 39% had the exudative type and one (6%) eye had the quiescent type. Larger lesion area and disruption of the foveal inner-segment/outer-segment layer correlated with worse baseline BCVA. Polypoidal choroidal vasculopathy (PCV) type 1 was present in 50% and PCV type 2 in the other 50%. Polypoidal choroidal vasculopathy (PCV) type 1 was associated with a worse baseline BCVA and greater lesion size.

CONCLUSION

Polypoidal choroidal vasculopathy (PCV) is not a rare condition in Danes with exudative AMD and presents often extramacular and with haemorrhage. This study underscores the importance of ICGA as a part of the diagnostic repertoire in AMD and suggests its routine use in Scandinavian populations.

Understanding aneurysmal type 1 neovascularization (polypoidal choroidal vasculopathy): a lesson in the taxonomy of 'expanded spectra' - a review

The term aneurysmal type 1 neovascularization is derived from terminology, which is established in the literature but has fallen out of use. We believe that aneurysmal type 1 neovascularization accurately describes the lesions which define the entity known as polypoidal choroidal vasculopathy (PCV). Over the last three decades, the clinical spectrum of PCV has expanded to recognize the occurrence of the aneurysmal (polypoidal) lesions in different contexts, resulting in a complex and unwieldy taxonomy based sometimes on circumstantial findings rather than mechanistic considerations. Advances in multimodal imaging provides increasingly convincing evidence that the lesions which define various forms of PCV are indeed vascular and arise from type 1 neovascular networks. The understanding of PCV as type 1 neovascularization with aneurysms renews focus on the question as to why some patients with type 1 neovascularization develop aneurysms while others do not. Conceptual themes and potential for further study are discussed.

Baseline data from a multicenter, 5-year, prospective cohort study of Japanese age-related macular degeneration: an AMD2000 report

PURPOSE

To report research participants' baseline characteristics in the AMD2000 study, a prospective, multicenter, 5-year, observational cohort study of Japanese age-related macular degeneration (AMD). The characteristics were determined using multimodal imaging.

METHODS

Patients with AMD were recruited at 18 clinical sites in Japan between April 2006 and March 2009. Each patient underwent a complete ophthalmic examination, including measurement of best-corrected visual acuity (Landolt chart), indirect ophthalmoscopy, slit-lamp biomicroscopy with a contact lens, optical coherence tomography imaging, fundus photography, and fluorescein and indocyanine green angiography.

RESULTS

Four hundred sixty participants (326 men [70.9%]) were included in the study. At enrollment, 131 eyes (28.5%) had hard drusen and 125 eyes (27.2%) had soft drusen in the macular area. A total of 455 eyes (98.9%) were diagnosed as having wet AMD, and 5 eyes (1.1%), as having dry AMD. Of the 455 eyes with wet AMD, 209 eyes (45.4%) had typical AMD, 228 eyes (49.6%) had polypoidal choroidal vasculopathy (PCV), and 18 eyes (3.9%) had retinal angiomatous proliferation. The size of choroidal neovascularization (CNV) was significantly smaller with indocyanine green angiography than with fluorescein angiography (P < 0.001). Poor baseline visual acuity was associated with cystoid macular edema, older age, scar, extrafoveal macular edema, subfoveal CNV, large branching vascular network, and hard exudates.

CONCLUSION

Japanese patients with AMD are predominantly male, lack drusen, and have a high rate of PCV.

A 5-year multicenter prospective cohort study on the long-term visual prognosis and predictive factors for visual outcome in Japanese patients with age-related macular degeneration: the AMD2000 study

PURPOSE

In this study (AMD2000), we aimed to determine the visual prognosis of Japanese patients with age-related macular degeneration (AMD).

METHODS

This was a multicenter prospective observational cohort study. In total, 460 patients with AMD were recruited from April 2006 to March 2009 from 18 clinical trial sites in Japan. They were followed up for 5 years, as they continued to receive medical treatment.

RESULTS

Of the 409 study eyes followed up for at least 1 year, 243 eyes (59.4%) were treated with photodynamic therapy (PDT) using verteporfin, and 58 eyes (14.2%) were treated with intravitreal injections of antivascular endothelial growth factor agents as the initial treatment. The mean best-corrected visual acuities (BCVA) for typical AMD (tAMD; 0.688 ± 0.498) and polypoidal choroidal vasculopathy (PCV; 0.451 ± 0.395) were significantly less at 2 years (tAMD, 0.779 ± 0.632, P < 0.05; PCV, 0.534 ± 0.618, P < 0.05) and at 5 years (AMD, 0.873 ± 0.718, P < 0.05; PCV, 0.635 ± 0.668, P < 0.05) than at baseline. In eyes with tAMD, absence of blocked fluorescence was associated with 5-year maintenance of the baseline BCVA. Regarding PCV, the presence of polypoidal lesions and cystoid macular edema as well as the lesion size was associated with 5-year maintenance of the baseline BCVA. In some patients, the diagnosis changed: of the 192 eyes initially diagnosed with typical AMD, 19 were newly diagnosed with PCV during follow-up.

CONCLUSION

Maintaining the baseline BCVA over the long term is difficult in Japanese eyes with wet AMD.

Age-related macular degeneration and polypoidal choroidal vasculopathy in Asians

Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in elderly people globally. It is estimated that there will be more Asians with AMD than the rest of the world combined by 2050. In Asian populations, polypoidal choroidal vasculopathy (PCV) is a common subtype of exudative AMD, while choroidal neovascularization secondary to AMD (CNV-AMD) is the typical subtype in Western populations. The two subtypes share many common clinical features and risk factors, but also have different epidemiological and clinical characteristics, natural history and treatment outcomes that point to distinct pathophysiological processes. Recent research in the fields of genetics, proteomics and imaging has provided further clarification of differences between PCV and CNV-AMD. Importantly, these differences have manifested as disparity in response to intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) treatment between PCV and CNV-AMD, emphasizing the need for accurate diagnosis of PCV and in distinguishing PCV from CNV-AMD, particularly in Asian patients. Current clinical trials of intravitreal anti-VEGF therapy and photodynamic therapy will provide clearer perspectives of evidence-based management of PCV and may lead to paradigm shifts in therapeutic strategies away from those currently employed in the treatment of CNV-AMD. Further research is needed to clarify the relative contribution of specific pathways in inflammation, complement activation, extracellular matrix dysregulation, lipid metabolism and angiogenesis to the pathogenesis of PCV. Findings from this research, together with improved diagnostic technology and new therapeutics, will facilitate more optimal management of Asian AMD.

Optical coherence tomography angiography characteristics of polypoidal choroidal vasculopathy

PURPOSE

To analyse the morphological characteristics of polypoidal choroidal vasculopathy (PCV) on optical coherence tomography angiography (OCT-A).

METHODS

Prospective study with consecutive patients affected with PCV were included. All patients underwent a complete ophthalmological examination including fundus photography, fluorescein angiography, indocyanine green angiography, spectral-domain OCT and OCT-A.

RESULTS

Twelve eyes of 12 patients (mean age 72.6±10.5 years; 4 men and 8 women) were included for analysis. In all eyes (12/12) the segmentation of the choriocapillaris layer on OCT-A revealed the branching vascular network (BVN) as a hyperflow lesion. OCT-A segmentation of the choriocapillaris layer in correspondence of the polypoidal lesion showed in 3/12 eyes (25%) a hyperflow round structure, surrounded by a hypointense halo, and in 9/12 eyes (75%) a hypoflow round structure.

CONCLUSIONS

The OCT-A is a non-invasive imaging modality allowing the visualisation of different structures in PCV. The BVN is constantly clearly detected. The hypoflow round structure appearance of the polyp in OCT-A, is probably due to an unusual blood flow inside the polypoidal lesions, contrasting with the BVN. Further improvement in OCT-A knowledge will provide information on the specificity of the different intensity characteristics in PCV.

En face enhanced depth imaging optical coherence tomography of polypoidal choroidal vasculopathy

PURPOSE

To analyse retinal and choroidal changes associated with polypoidal choroidal vasculopathy (PCV) using en face spectral-domain optical coherence tomography (SD-OCT).

METHODS

In this retrospective and descriptive study, we collected imaging of patients affected with PCV examined using enhanced depth imaging (EDI) SD-OCT, fluorescein and indocyanine green angiography for a qualitative analysis. The three-dimensional reconstruction of 197 transverse sections with EDI SD-OCT at 30 μm intervals provided a virtual macular brick through which 496 sections in the coronal plane resulted in a C-scan or en face OCT image.

RESULTS

30 eyes of 30 patients affected with PCV were studied. En face OCT revealed polyps as roundish structures visible deeper than pigment epithelium layer, attached to its posterior face, easily detected in all cases. Hyper-reflective dots were visible on en face OCT in all cases within the retinal layers, associated to a well-defined dark area suggesting serous exudation in 27 eyes. The abnormal choroidal network was identified in four eyes. At the Bruch membrane level, all polyps were associated with a localised back shadowing, and were no more visible at the choriocapillaris layer level. Large choroidal vessels were visible in all eyes, mainly at the polypoidal lesion periphery, not directly behind.

CONCLUSIONS

En face OCT imaging using SD-OCT is an easy, reproducible, non-invasive and effective tool to visualise and to understand retinal and choroidal changes PCV. It provides complementary morphological information, describes new semiological entities and might substitute other exams in the future, without dye injection.

Polypoidal Choroidal Vasculopathy in Asians

Age related macular degeneration (AMD) in Asians has been suggested to differ from their Western counterparts in terms of epidemiology, pathogenesis, clinical presentation and treatment. In particular, polypoidal choroidal vasculopathy (PCV) appears to be the predominant subtype of exudative AMD in Asian populations, in contrast to choroidal neovascularization secondary to AMD (CNV-AMD) in Western populations. Epidemiological data on PCV has been largely limited to hospital-based studies and there are currently no data on the incidence of PCV. Similarities and differences in risk factor profile between PCV and CNV-AMD point to some shared pathogenic mechanisms but also differential underlying mechanisms leading to the development of each phenotype. Serum biomarkers such as CRP, homocysteine and matrix metalloproteinases suggest underlying inflammation, atherosclerosis and deranged extracellular matrix metabolism as possible pathogenic mechanisms. In addition, recent advances in genome sequencing have revealed differences in genetic determinants of each subtype. While the standard of care for CNV-AMD is anti-vascular endothelial growth factor (VEGF) therapy, photodynamic therapy (PDT) has been the mainstay of treatment for PCV, although long-term visual prognosis remains unsatisfactory. The optimal treatment for PCV requires further clarification, particularly with different types of anti-VEGF agents and possible benefits of reduced fluence PDT.

Sensitivity and specificity of spectral-domain optical coherence tomography in detecting idiopathic polypoidal choroidal vasculopathy

PURPOSE

To evaluate the efficacy of spectral-domain optical coherence tomography (SD OCT) compared to indocyanine green angiography (ICGA) in detecting idiopathic polypoidal choroidal vasculopathy (PCV) and in differentiating between PCV and occult choroidal neovascularization (CNV).

DESIGN

Retrospective observational case-control study.

METHODS

SD OCTs of 51 eyes of 44 consecutive patients who presented with 1 or more pigment epithelial detachments (PEDs) attributable to either PCV or occult CNV were retrospectively reviewed by a grader masked to the final diagnosis. A qualitative analysis based on the following tomographic findings was performed: sharp PED peak, PED notch, hyporeflective lumen within hyperreflective lesions adherent to retinal pigment epithelium. The diagnosis based on SD OCT alone was compared with the final diagnosis made using ICGA and fluorescein angiography. Sensitivity and specificity were calculated. Patients with classic CNV and central serous chorioretinopathy were excluded.

RESULTS

Among 51 eyes of 44 patients, 37 had an ICGA-confirmed diagnosis of PCV and 14 had occult CNV. SD OCT based on the features above detected 35 of 37 true-positive PCV lesions but missed 2 ICGA-confirmed lesions (false negatives). SD OCT correctly excluded 13 of 14 non-PCV lesions but misidentified 1 PCV lesion (false positive). These data showed a sensitivity of 94.6% and a specificity of 92.9% for the above SD OCT features in identifying PCV lesions.

CONCLUSIONS

SD OCT based on the features above allowed for good detection of PCV and differentiation between PCV and occult CNV in this selected clinic population. A careful qualitative analysis of the tomographic findings in patients presenting with PEDs may allow ophthalmologists to distinguish between PCV and occult CNV, decreasing the need for ICGA and the risks related to this procedure.

Pilot study of inactive polypoidal lesions in polypoidal choroidal vasculopathy

PURPOSE

This pilot study was conducted to describe the angiographic characteristics of inactive polypoidal lesions that were observed during indocyanine green angiography (ICGA) in polypoidal choroidal vasculopathy (PCV).

METHODS

This was a retrospective study involving 40 eyes of 39 consecutive Chinese patients with PCV with inactive polypoidal lesions. All patients underwent fundus fluorescein angiography and ICGA examinations. We used ICGA to make a definitive diagnosis of PCV in each patient. The clinical and angiographic characteristics of inactive polypoidal lesions were recorded and analyzed.

RESULTS

In the 40 eyes that were studied, the time between receiving an injection of indocyanine green and the initial appearance of inactive polypoidal lesions ranged from 8.2 minutes to 25.1 minutes, with a mean time of 15.1 ± 5.6 minutes. Inactive polypoidal lesions were divided into 4 groups: 5 eyes (12.5%) in the asymptomatic group; 8 eyes (20.0%) in the atrophic and/or cicatricial group; 24 eyes (60.0%) in the combined group (coexisting with active polypoidal lesions); and 3 eyes (7.5%) in the mixed group (coexisting with choroidal neovascularization). Twelve of the 40 eyes were followed up for 9 to 29 months (mean 12.4 ± 5.3 months). Over this time period, inactive polypoidal lesions completely regressed (not observed in ICGA) in 3 eyes (25.0%), partially regressed in 3 eyes (25.0%), and were stable (the same as the first visit) in 6 eyes (50.0%).

CONCLUSIONS

Inactive polypoidal lesions in patients with PCV most commonly appeared during the middle phase of ICGA and were manifested in 4 groups. These lesions represented the sites of PCV in a regressed or quiescent stage.

High-penetration optical coherence tomography with enhanced depth imaging of polypoidal choroidal vasculopathy

A combination of high-penetration spectral-domain optical coherence tomography (central wavelength: 1,020 nm) and an enhanced depth imaging protocol (HP-EDI-OCT) was used to evaluate 5 eyes of 5 patients with polypoidal choroidal vasculopathy (PCV). In all eyes, HP-EDI-OCT provided high-contrast images of PCV lesions in the subretinal pigment epithelium (sub-RPE). In the space between the RPE line and Bruch's membrane, various PCV lesions, including vascular networks, polypoidal lesions, and sub-RPE hemorrhage, were clearly identified. The chorioscleral interface was clearly observed, and the entire structure of the choroid was readily identified. Thus, HP-EDI-OCT was useful for evaluating sub-RPE lesions of PCV.

Peripapillary subretinal neovascular membranes: a review

Peripapillary subretinal neovascular membranes (PSRNVM) are most commonly associated with age-related macular degeneration and idiopathic causes in older patients. In younger patients, the condition has been linked to a wide variety of other conditions. As with the more commonly occurring macular form of choroidal neovascular membranes, PSRNVM can also lead to severe vision loss. Therefore, clinicians must take care to avoid overlooking this event to provide appropriate management and treatment. Current knowledge of PSRNVM suggests the importance of regular examinations of the affected eye in both treated and untreated cases to watch for progression and recurrence, which are unpredictable, and also of the fellow eye because there is a high risk of bilateral involvement.

Association of LOC387715 A69S genotype with visual prognosis after photodynamic therapy for polypoidal choroidal vasculopathy

PURPOSE

To investigate whether there is an association of the LOC387715 A69S genotype with visual prognosis after photodynamic therapy in eyes with polypoidal choroidal vasculopathy (PCV).

METHODS

Photodynamic therapy was repeated every 3 months until the disappearance of angiographic signs of active lesions in 71 eyes of 71 patients with PCV who were followed-up for at least 12 months. All patients were genotyped for LOC387715 A69S polymorphism (rs10490924, risk-allele T).

RESULTS

Although there was no statistically significant difference in the mean baseline visual acuity (P = 0.53) among the 3 genotypes, there was a statistically significant difference in the visual acuity both at the 12-month and final visits (P = 0.002 and P < 0.001, respectively) with the poorer acuity in patients with the higher "T-"allele frequency. "T" allele was more frequently observed in those with the recurred PCV lesions (odds ratio: 5.8, 95% confidential interval: 2.3-15.1, T vs. G).

CONCLUSION

There is a pharmacogenetic association between the LOC387715 A69S variant and the long-term results after photodynamic therapy in eyes with PCV. The LOC387715 A69S genotype is of clinical importance to predict the visual prognosis after photodynamic therapy in eyes with PCV. These results should be confirmed or refuted by replication studies.

Subfoveal choroidal thickness in typical age-related macular degeneration and polypoidal choroidal vasculopathy

PURPOSE

To investigate the subfoveal choroidal thickness in eyes with typical age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV), using enhanced depth imaging optical coherence tomography.

METHODS

Retrospective observational case series of 44 eyes of 44 patients (12 females and 32 males) with typical AMD or PCV located in the subfoveal region. Cross-sectional images of the choroid of each of the involved eyes were obtained by a spectral-domain OCT. The choroidal thickness under the fovea was retrospectively studied.

RESULTS

Of the 44 eyes involved in this study, 21 eyes were diagnosed as typical AMD and the other 23 eyes were diagnosed as PCV. The difference in subfoveal choroidal thickness between the eyes with typical AMD (245 μm) and those with PCV (293 μm) was statistically significant, even after adjusting for age, spherical equivalent, and gender distribution (P = 0.045). When compared to eyes with subfoveal choroidal thickness less than 300 μm, those with subfoveal choroidal thickness of 300 μm or more were 5.6 times more likely to have PCV (adjusted odds ratio 5.60, 95% confidence interval 1.30-24.0, P = 0.021).

CONCLUSIONS

The choroid under the fovea was thicker in eyes with PCV than those with typical AMD. This result suggests that the choroidal vascular lesion seen in PCV may not be just the choroidal neovascularization accompanied by saccular capillary dilations at the border, but may have a significant structural difference in the choroid compared to typical AMD.

Polypoidal choroidal vasculopathy: a review

More than a quarter century has passed since the original description of polypoidal choroidal vasculopathy (PCV) in 1982 as a peculiar hemorrhagic disorder involving the macula characterized by recurrent subretinal pigment epithelial bleeding. In the ensuing years, numerous reports have described the expanded clinical spectrum of this entity. PCV is the principal vascular composition of patients of pigmented races experiencing neovascular maculopathies, particularly African Americans and Asians. This form of neovascularization is now known to occur in white patients with or without concomitant drusen, and the site of involvement has extended from the peripapillary area to the peripheral fundus. Indocyanine green angiography has made detection of these abnormal vascular changes more reliable and definitive. More precise diagnosis has also led to a better understanding of specific clinical features that distinguish PCV from more typical proliferations of abnormal choroidal vessels. We review the nature of PCV, including its genetic basis, demographic features, histopathology, clinical manifestations, natural course, response to treatments, and the histopathological and genetic bases. We emphasize multimodal ophthalmic imaging of these vessels, in particular fluorescein and indocyanine green angiography and optical coherence tomography.

Polypoidal choroidal vasculopathy: an angiographic discussion

The understanding of polypoidal choroidal vasculopathy has evolved rapidly in the past three decades. The hallmark of the disease is the presence of typical hyperfluorescent nodules in the early phase of indocyanine green angiography. Although the classical clinical presentation is recurrent serosanguinous detachment of the retinal pigment epithelium, it may present with clinical features indistinguishable from exudative age-related macular degeneration secondary to choroidal neovascularization. Some cases may present initially with submacular haemorrhage, but later with features of exudative age-related macular degeneration. Studying the associated network of vessels using confocal scanning laser ophthalmoscopy indocyanine green dynamic angiography revealed in many cases feeder vessels, branching pattern, and leakage similar to choroidal neovascularization. Owing to the overlap of clinical and angiographic features, it may be considered as a vascular subtype of exudative age-related macular degeneration. However, having seemingly better natural history, better response to photodynamic therapy, and incomplete response to anti-vascular endothelial growth factor therapy suggests that it should be studied as a separate entity from choroidal neovascularization. Combining angio-occlusion of the polyps using photodynamic therapy and anti-permeability effect of anti-vascular endothelial growth factor therapy on the branching vascular network may provide a synergistic effect. We await the result of EVEREST trial, a multi-centre randomized controlled trial comparing photodynamic therapy, with or without ranibizumab, with ranibizumab monotherapy.

Differences in macular morphology between polypoidal choroidal vasculopathy and exudative age-related macular degeneration detected by optical coherence tomography

PURPOSE

To evaluate the differences in the optical coherence tomographically determined macular morphology in eyes with polypoidal choroidal vasculopathy (PCV) from eyes with exudative age-related macular degeneration (AMD) quantitatively.

METHODS

The medical records of 208 eyes of 203 Japanese patients with PCV or exudative AMD who were newly treated for choroidal neovascularization were reviewed. The six linear, low-resolution, high-speed scans of 6 mm were analyzed using a manually assisted computer algorithm, which allowed us to manually draw spline lines arbitrarily on the images so that the subretinal fluid and neurosensory retina could be segmented. The thickness of the neurosensory retina and height of the serous retinal detachment (SRD) within the central 3-mm and 6-mm areas were calculated.

RESULTS

SRDs were observed in 53% (63/119) of the eyes with exudative AMD and in 78% (69/89) of the eyes with PCV (P < 0.001). The height of the SRD was 21.9 +/- 3.7 microm (+/-SEMs) in eyes with exudative AMD and 56.3 +/- 7.4 microm in eyes with PCV (P < 0.001). The thickness of the neurosensory retina was 300.0 +/- 5.2 microm in eyes with exudative AMD and 275.8 +/- 4.7 microm in eyes with PCV (P < 0.001).

CONCLUSION

Eyes with PCV are characterized by a higher incidence of SRDs, greater SRD height, and less intraretinal edema than eyes with exudative AMD.

Clinical characteristics and visual outcome of non-traumatic suprachoroidal haemorrhage in Taiwan

PURPOSE

This study aimed to evaluate the clinical features and visual outcomes of non-traumatic suprachoroidal haemorrhage (SH) in Taiwan.

METHODS

We report a retrospective, non-comparative, interventional case series study carried out in an institutional setting. Thirty-nine eyes with non-traumatic SH were studied using a new system for grading the severity of SH. The aetiologies of SH were analysed. The correlations between grades and prognoses of SH were studied. Multiple logistic regression was used to assess factors associated with final visual outcome.

RESULTS

Conditions causing SH in the eyes considered in this study included cataract surgery (43.59%), age-related macular degeneration (AMD) (17.95%), filtering operation and vitrectomy (both 10.26%), scleral buckling (5.13%) and others. Twelve eyes (12/39, 30.77%) had a final visual outcome of no light perception. Only 12 eyes (12/39, 30.77%) had final visual acuity (VA) > 4/200. Grade of SH correlated significantly with need for surgical drainage and with final visual outcome (Spearman rank correlations 0.313 and - 0.408, p = 0.010 and p = 0.00317, respectively). 'Good' and 'poor' final VA was significantly associated with VA at the time of SH (multiple logistic regression coefficients 2.132 and - 2.809, p = 0.015 and p = 0.008, respectively), as well as initial retinal detachment (multiple logistic regression coefficients - 2.267 and 2.223, p = 0.036 and p = 0.006, respectively). Higher grades of SH and increased age were associated with poor final visual outcome (multiple logistic regression coefficients - 1.332 and - 0.122, p = 0.013 and p = 0.022, respectively).

CONCLUSIONS

Suprachoroidal haemorrhage is a devastating ocular problem. Complications of intraoperative surgery and AMD are common causes. The new SH grading system provides a simple method for evaluating the need for drainage and for predicting visual prognosis. Visual acuity and retinal detachment at the time of SH are major factors associated with good and poor final VA, respectively.

Polypoidal choroidal vasculopathy and treatments

PURPOSE OF REVIEW

This review assesses the current knowledge of the clinical characteristics of polypoidal choroidal vasculopathy and treatments.

RECENT FINDINGS

Polypoidal choroidal vasculopathy is a disease with characteristic choroidal vascular abnormalities. Indocyanine green angiography is essential for diagnosis. The prevalence is higher in Asian people than in Caucasians. Photodynamic therapy is efficacious for treating polypoidal choroidal vasculopathy; 1-year results have shown greater benefit of photodynamic therapy than choroidal neovascularization secondary to age-related macular degeneration. Recurrence, however, seriously affects vision long term during follow-up after photodynamic therapy. The lower efficacy of bevacizumab- a full-length antibody of vascular endothelial growth factor- has been shown for polypoidal choroidal vasculopathy.

SUMMARY

Although the polypoidal choroidal vasculopathy and age-related macular degeneration have been known to share common genetic factors, its clinical characteristics including the different responses to photodynamic therapy suggest that polypoidal choroidal vasculopathy is a separate clinical entity from age-related macular degeneration. The results of photodynamic therapy for polypoidal choroidal vasculopathy are encouraging; however, recurrence may affect vision over time. Therapeutic modalities to inhibit development of the exudative choroidal vasculature of polypoidal choroidal vasculopathy are desirable.

Polypoidal choroidal vasculopathy examined with en face optical coherence tomography

BACKGROUND

To study the morphologic features of polypoidal choroidal vasculopathy (PCV) with the use of en face optical coherence tomography (OCT).

METHODS

We reviewed retrospectively 57 eyes of 57 patients with PCV. The macular region was examined with OCT en face planes scanned at different sequential depths, following which detailed scanning was performed of arbitrarily selected longitudinal planes.

RESULTS

In 48 of the cases (84.2%), en face OCT allowed us to detect round protrusions of the retinal pigment epithelium (RPE) that corresponded to the polypoidal lesions seen on indocyanine green angiography (ICGA); the branching vascular networks seen on ICGA often induced slight elevation of the overlying RPE, which typically assumed a geographical shape. In 30 cases (52.6%), branching vascular networks were detected as elevations of the RPE. With en face OCT, serous pigment epithelial detachments, most of which were seen as round protrusions of the RPE, were often accompanied by adjacent smaller round protrusions of the RPE, consistent with polypoidal lesions. These protrusions of the RPE were often fused and typically appeared as a 'snowman'. Subsequent longitudinal examination revealed the polypoidal lesions to be sharp protrusions of the RPE with moderate inner reflectivity. Consistent with the location of the branching vascular network, a highly reflective line was seen often just beneath the slightly elevated reflective line of RPE.

CONCLUSIONS

En face examination using OCT has an advantage in screening lesions of PCV and in examination of the detailed relationship of each component of these lesions.

Argon laser photocoagulation for the treatment of polypoidal choroidal vasculopathy

AIM

To evaluate the efficacy of conventional argon laser for the treatment of serosanguineous maculopathy secondary to polypoidal choroidal vasculopathy (PCV).

METHODS

A retrospective audit of patients who had argon laser photocoagulation to angiographically determined polypoidal lesions and subsequently followed up at 1, 3, 6, and 12 months post treatment.

RESULTS

Twenty-one eyes (75%) had stable or improved vision at 12 months. Twenty-three eyes had extrafoveal, two eyes had juxtafoveal, and three eyes had subfoveal polyps. In the extrafoveal group, 18 eyes (78%) had stable or improved vision at 12 months. Eighteen eyes (64.3%) showed clinical or angiographic resolution of maculopathy. Three eyes (10.7%) had recurrence of polyps subfoveally, three eyes (10.7%) had subsequent choroidal neovascularisation, and four eyes (14.3%) had persistent leakage with neurosensory detachment.

CONCLUSION

In our study, 18 of the 23 eyes which had extrafoveal polyps had stable or improved best-corrected visual acuity and showed complete resolution of maculopathy at 12 months follow-up. Argon laser photocoagulation would appear to be most beneficial for extrafoveal PCV. However, in view of the retrospective nature of this study, the true efficacy of argon laser treatment would have to be evaluated with a larger, prospective and randomised controlled trial.

Tomographic features of branching vascular networks in polypoidal choroidal vasculopathy

PURPOSE

To identify the tomographic features of the branching vascular networks in patients with polypoidal choroidal vasculopathy (PCV).

METHODS

We prospectively performed third-generation optical coherence tomography (OCT) and fluorescein angiography for 44 eyes of 42 patients (mean age +/- SD, 67.1 +/- 9.1 years) with PCV. All eyes had branching vascular networks and polypoidal lesions that were confirmed by indocyanine green angiography.

RESULTS

OCT showed double reflective layers that consisted of retinal pigment epithelium (RPE) and another highly reflective layer beneath the RPE ("double-layer sign") in the area of the branching network vessels in 26 (59%) of 44 eyes. The remaining 18 eyes had no double-layer sign, but 17 (94%) of 18 eyes had a slightly elevated RPE. A serous retinal detachment was present in 23 (88%) of 26 eyes with a double-layer sign, while only 1 (6%) of 18 eyes without the sign had a serous retinal detachment.

CONCLUSIONS

In PCV, the double-layer sign is seen frequently in the area of the network vessels, particularly in eyes with a serous retinal detachment. The sign may reflect fluid accumulation between RPE and Bruch membrane resulting from leakage from the network of abnormal vessels.

Angiographic lesion of polypoidal choroidal vasculopathy on indocyanine green and fluorescein angiography

BACKGROUND

Before treating polypoidal choroidal vasculopathy (PCV), the extent of the lesion should be determined, but the angiographic lesion size of PCV is sometimes different when comparing indocyanine green angiography (ICGA) and fluorescein angiography (FA). The purpose of this study was to evaluate angiographic findings and compare the lesion sizes of PCV on ICGA and FA using confocal scanning laser ophthalmoscopy (SLO) and fundus camera.

METHODS

Thirty-seven eyes of 37 patients with PCV were examined by ICGA and FA using confocal SLO and a fundus camera, and the findings and the lesion sizes were compared during the early, mid, and late-phases of ICGA and FA.

RESULTS

The polyps with abnormal vessel networks were depicted on ICGA in all eyes and the lesion showed classic-type leakage on FA in 15 eyes. Ten eyes with a pigment epithelial detachment (PED) had the maximal lesion size on FA because hyperfluorescent areas involving PED were determined as the lesions; although on ICGA, a PED distinguished from abnormal vessels was not included in the lesion. In 27 eyes without a PED, the early-phase of ICGA using confocal SLO showed the maximal lesion size in 24 eyes (89%) and the late-phase in three eyes (11%), and the maximal size on ICGA agreed on FA. While FA depicted the maximal lesion sizes in 24 eyes (89%), another three eyes showed the maximal lesion size on early-phase ICGA on confocal SLO. The maximal lesion size on ICGA using a fundus camera was smaller than when using confocal SLO in seven eyes (19%).

CONCLUSIONS

The ICGA on confocal SLO could visualize the more detailed findings of the abnormal vasculature of PCV and the FA showed hyperfluorescent regions overlaying the lesions. To determine the maximal lesion size on angiograms, early-phase ICGA using confocal SLO and FA should be referred.

Photodynamic therapy with verteporfin in the treatment of exudative idiopathic polypoidal choroidal vasculopathy

PURPOSE

To determine the safety and efficacy of photodynamic therapy with verteporfin (V-PDT) in the treatment of exudative idiopathic polypoidal choroidal vasculopathy (IPCV) lesions that were not suitable for laser photocoagulation.

METHODS

This was a prospective, open label study in two centers involving 30 consecutive patients (31 eyes) diagnosed with exudative IPCV using fluorescein angiography (FA), indocyanine green angiography (ICGA), and optical coherence tomography (OCT). All patients underwent complete ophthalmologic examination including best-corrected visual acuity (VA) measurement, contrast sensitivity (CS) testing, FA, ICGA, and OCT. OCT was used to assess the stage of the polypoidal dilations (active or scarred) and the evolution of the signs associated with exudation. Study patients were treated with V-PDT and followed up at 6 weeks and 3, 6, and 12 months. Re-treatment was applied, at an interval of 3 months, until there was an absence of leakage on FA and hyperfluorescence on ICGA.

RESULTS

Thirty eyes (29 patients) completed the 12 months post-treatment visit and were retained for further analysis. The mean number of V-PDT treatments was 2.5 (SD 1.1). At 12 months post-treatment, the mean foveal thickness had significantly (p<0.03) decreased to 224 (SD 104) microm from the baseline 292 (SD 124) microm while the mean VA had significantly (p<0.02) improved to 0.50 (SD O.38) from the baseline 0.38 (SD 0.24). Serous detachment of the macula completely resolved in 83.3% of the eyes while 73.3% of the polypoidal dilations were occluded at 12 months.

CONCLUSIONS

The results suggest that V-PDT is effective and relatively safe in treating exudative IPCV.

Pigment epithelial detachment in polypoidal choroidal vasculopathy

PURPOSE

To study the morphological features of serosanguineous pigment epithelial detachments (PEDs) with accompanying polypoidal lesions in eyes with polypoidal choroidal vasculopathy (PCV).

DESIGN

Retrospective observational case series.

METHODS

For this observational case study, we retrospectively reviewed 93 consecutive eyes of 85 patients with PCV. The lesions in eyes with PCV were examined with indocyanine green angiography (IA) and optical coherence tomography (OCT).

RESULTS

Of 93 eyes with PCV, 51 eyes (55%) had serous or hemorrhagic PEDs. Of these 51 eyes, a notch in the PED was found in 27 eyes (53%) by angiography, most of which showed polypoidal lesions by IA that corresponded in location to the notch observed by angiography. Polypoidal lesions were detected outside the PED in one eye (2%), at the margin of the PED in 33 eyes (65%), and inside the PED in 12 eyes (24%). OCT revealed that PED had a notch observed tomographically in 29 eyes (57%), most of which corresponded in location to polypoidal lesions seen by IA. In eight eyes, polypoidal lesions, which were adherent to the inner surface of the serous PED, appeared to be detached from the Bruch membrane and the choroid.

CONCLUSIONS

Polypoidal lesions are located at the margin of PED and make a notch in the accompanying PED that is visible by angiography and tomographically. When the polypoidal lesions have increased exudate, the fluid from the lesions infiltrates under the polypoidal lesions themselves, which results in the lesions detaching from the Bruch membrane and appearing to be located inside the PED.

Ultrasonographic characteristics and treatment outcomes of surgery for vitreous hemorrhage in idiopathic polypoidal choroidal vasculopathy

PURPOSE

To describe the ultrasonographic characteristics and treatment outcomes of surgery in vitreous hemorrhage (VH) associated with idiopathic polypoidal choroidal vasculopathy (IPCV).

DESIGN

Retrospective interventional and observational case series.

METHODS

Clinical, ultrasound, and surgical data of 10 consecutive patients operated for VH due to IPCV in a tertiary eye institute was studied by chart review. Data were analyzed to determine the clinical features, ultrasonographic characteristics, and surgical outcomes. An additional five patients with IPCV without VH were evaluated by ultrasound in various stages of the disease.

RESULTS

Between January 1998 and March 2005, 10 eyes of 10 patients underwent vitreous surgery for VH associated with IPCV. Characteristic ultrasonographic features that helped the diagnosis preoperatively included focal choroidal thickening without excavation or acoustic hollowing with associated low reflective echoes of dispersed VH, or diffuse choroidal thickening and low-intensity echoes of dispersed hemorrhage on either side of the retinal spike, often without vitreous detachment spike. Oral corticosteroids were provided preoperatively to patients with associated exudative retinal detachment. Indocyanine green angiography (ICGA) confirmed IPCV postoperatively. Focal lesions were treated with laser photocoagulation. Anatomical success was seen in nine of 10 eyes. Visual acuity improved in five of 10 eyes but was limited by macular pathology in other five eyes. The most common complication was iatrogenic tears. Some eyes had recurrent IPCV lesions in follow-up.

CONCLUSIONS

Characteristic ultrasonographic features could identify IPCV in eyes with VH. Anatomical and visual outcomes of our management approach were encouraging and need further study.

The origins of polypoidal choroidal vasculopathy

BACKGROUND/AIM

There are two theories on the pathogenesis of polypoidal choroidal vasculopathy (PCV): variants in choroidal neovascularisation (CNV) and inner choroidal vessel abnormalities. On indocyanine green angiography (IGA) with a video camera system, PCV has a characteristic appearance, but inadequate image quality has made detailed interpretation difficult. This study aims to improve imaging, using confocal scanning laser ophthalmoscopy (SLO), to elucidate the pathogenesis of PCV.

METHODS

High speed IGA with confocal SLO of 45 eyes (44 patients) showed typical PCV findings of a branching vascular network and polypoidal lesions.

RESULTS

Vessels comprising branching networks began to fill simultaneously with the surrounding choroidal arteries in 38 eyes. Small numbers of vessels filling within a branching network, in the arterial and arteriovenous phases of IGA, showed focal dilatation, constriction, and tortuousity. Vessel abnormalities, corresponding to polypoidal lesions, existed within a network in eight eyes and included loops similar in calibre to network vessels, and numerous microaneurysmal dilatations of small vessels. Vessel pulsation was seen in 24 eyes.

CONCLUSION

PCV is caused by inner choroidal vessel abnormalities, not CNV.

Polypoidal choroidal vasculopathy

BACKGROUND

Polypoidal choroidal vasculopathy (PCV) is a unique form of occult choroidal neovascular membrane. The clinical presentation and angiographic findings distinguish idiopathic PCV from other known neovascular and choroidal degenerative disorders. The characteristic morphology of PCV includes the presence of a branching network of inner choroidal vessels with terminal aneurysmal dilations. Other key findings include subtle nodular protrusions, which may precede multiple serosanguineous retinal pigment epithelial detachments. If Bruch's membrane is compromised, there is an additional risk of exudative retinopathy or vitreal hemorrhage.

CASE REPORTS

Three patients with polypoidal choroidal vasculopathy are described with visual impairment secondary to irregular choroidal vascular lesions producing recurrent subretinal hemorrhages and exudative retinopathy.

CONCLUSIONS

The characteristic presentation and clinical course of polypoidal choroidal vasculopathy distinguish it from the typical presentation of age-related macular degeneration and other causes of hemorrhagic and exudative retinopathy. Imaging techniques such as fluorescein angiography, indocyanine green angiography, and optical coherence tomography may assist in the accurate diagnosis of PCV, so that appropriate treatment and management can be provided. In patients who manifest exudative, hemorrhagic retinopathy, with no signs of active inflammation or an anatomic predisposition to choroidal neovascularization, PCV should be considered.