Peripheral idiopathic polypoidal choroidal vasculopathy

Association of lesion size and visual prognosis to polypoidal choroidal vasculopathy

PURPOSE

To investigate the progression of vascular lesions of polypoidal choroidal vasculopathy (PCV) as viewed with indocyanine green angiography and the visual prognosis of these eyes.

DESIGN

Retrospective case study.

METHODS

We reviewed retrospectively the medical records of 88 consecutive patients (88 eyes) with PCV who had been examined with indocyanine green angiography for more than 2 years.

RESULTS

Depending on the initial area of the vascular lesion, eyes were divided into smaller PCV (baseline area of lesion being < 1 disc area [DA], n = 22) and larger PCV (baseline area of lesion being ≥ 1 DA, n = 66). In larger PCV, the mean area of the lesion progressed significantly from 6.49 ± 8.96 mm(2) to 16.27 ± 14.19 mm(2) (P < .0001) with marked deterioration of visual acuity (P < .0001) during follow-up. In contrast, smaller PCV often showed minimal progression of the lesion, only limited exudative change, and the eyes maintained their initially good vision to the final visit. Smaller PCV lesions rarely progressed to extensive PCV lesions. Severe vision-threatening complications (ie, suprachoroidal hemorrhage, vitreous hemorrhage, and tears of the retinal pigment epithelium) were seen only in eyes with larger PCV, and in studying single nucleotide polymorphisms A69S of ARMS2 genes, there was a significant difference in T allele frequency between individuals with smaller PCV and those with larger PCV (20.2% vs 79.8%; P = .0235).

CONCLUSIONS

PCV with small vascular lesions shows minimal progression and no vision-threatening complications, and these eyes often maintain good visual acuity for a long time.

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.

[Polypoidal choroidal vasculopathy: clinical and angiographic features]

OBJECTIVES

To clarify the clinical and angiographic characteristics of idiopathic polypoidal choroidal vasculopathy (IPCV) and its natural course.

METHODS

Descriptive, prospective, consecutive case series of patients with presumed IPCV seen at Fort-de-France Hospital Center (French West Indies) between January and June 2006. All participants underwent complete eye examination and fluorescein and indocyanine green (ICG) angiography. The nature and location of the lesions were assessed in all eyes. Inclusion criteria were demonstration of characteristic lesions of IPCV on ICG angiography.

RESULTS

Diagnosis of IPCV was made in 26 eyes of 14 patients, ten women and four men, all of Afro-Caribbean origin. The mean age was 77.4 years (range 60-92 years). Drusen were present in 13 eyes (50%), age-related macular degeneration (AMD) in one eye, and branch retinal vein occlusion in one eye. Twelve patients (85.7%) had bilateral involvement. Twelve eyes (46.2%) had visual acuity (VA) (Snellen) worse than 20/200, six eyes (23.1%) had VA between 20/200 and 20/100, and eight eyes (30.8%) had VA better than 20/100. On ICG angiography, lesions were predominantly located in the peripapillary area but also in the midperiphery, the macular and interpapillomacular areas, and the far periphery.

CONCLUSION

Peripheral locations of IPCV and associations with drusen or AMD are not rare. The prognosis of the disease is poor in its natural course. Its etiology is unknown but genetic factors are probably involved. It is the main differential diagnosis for exudative AMD in black patients.