Visual outcomes of vitrectomy for polypoidal choroidal vasculopathy-related breakthrough vitreous haemorrhage

Optical coherence tomography-based misdiagnosis and morphological distinction in pachychoroid neovasculopathy vs. polypoidal choroidal vasculopathy

PURPOSE

To evaluate the rate of misdiagnosis of aneurysmatic pachychoroid type 1 choroidal neovascularization/polypoidal choroidal vasculopathy (PAT1/PCV) among cases diagnosed as non-aneurysmatic pachychoroid neovasculopathy (PNV) and to define optical coherence tomography (OCT) features facilitating their distinction.

METHODS

The database of the Department of Ophthalmology, Ludwig-Maximilians University Munich, was screened for patients diagnosed with PNV. Multimodal imaging was screened for the presence of choroidal neovascularization (CNV) and aneurysms/polyps. Imaging features facilitating the diagnosis of PAT1/PCV were analysed.

RESULTS

In total, 49 eyes of 44 patients with a clinical PNV diagnosis were included, of which 42 (85.7%) had PNV and 7 (14.3%) represented misdiagnosed PAT1/PCV. SFCT was comparable (PNV: 377 ± 92 vs. PAT1/PCV: 400 ± 83 µm; p = 0.39). Whereas no difference was detected in total pigment epithelium detachment (PED) diameter (p = 0.46), maximum PED height was significantly higher in the PAT1/PCV group (199 ± 31 vs. 82 ± 46, p < 0.00001). In a receiver operating characteristic (ROC) analysis, the optimum cutoff for defining "peaking PED" was 158 µm with an area under the curve of 0.969, a sensitivity of 1.0 (95% CI: 0.59-1.0), and a specificity of 0.95 (95% CI: 0.84-0.99). Sub-retinal hyperreflective material (SHRM; p = 0.04), sub-retinal ring-like structures (SRRLS; p < 0.00001), and sub-RPE fluid (p = 0.04) were significantly more frequent in eyes with PAT1/PCV.

CONCLUSION

A relevant percentage of eyes diagnosed with PNV might instead suffer from PAT1/PCV. The detection of a maximum PED height ("peaking PED") exceeding approximately 150 µm, SHRM, SRRLS, and sub-RPE fluid might greatly aid in the production of a more accurate diagnosis.

Long-Term Outcome of Eyes with Vitrectomy for Submacular and/or Vitreous Hemorrhage in Neovascular Age-Related Macular Degeneration

Purpose

To study long-term clinical outcomes in patients with submacular hemorrhage (SMH) and/or vitreous hemorrhage (VH) associated with neovascular age-related macular degeneration (nAMD) and the real-world clinical situation of adding anti-VEGF therapy after pars plana vitrectomy (PPV).

Methods

In this retrospective case series, 25 eyes with SMH and/or VH associated with nAMD were treated by PPV and followed up for at least 24 months. When exudative changes were unresolved or recurred after PPV, additional intravitreal anti-VEGF therapy was given.

Results

The reasons for performing PPV were SMH (8 eyes) and VH (17 eyes) associated with nAMD. Mean best-corrected visual acuity (BCVA) of eyes with SMH improved significantly at 6 months (P < 0.01) and 12 months (P < 0.05) after PPV. Mean BCVA of eyes with VH improved at 1, 3, 6, 12, 18, and 24 months (P < 0.01) and at the final visit (P < 0.05). Post-PPV anti-VEGF therapy was initiated in 6 of 8 (75.0%) eyes with SMH and 7 of 17 (47.1%) eyes with VH. Of the 13 eyes given anti-VEGF therapy after PPV, 11 eyes had anti-VEGF therapy initiated within 10 months after surgery. Dry macula rate after PPV was 50.0% in SMH and 70.6% in VH.

Conclusions

BCVA improved in eyes with SMH at 6 and 12 months after PPV, and the BCVA was maintained until the end of the study. BCVA improved significantly in eyes with VH at all time points after PPV. In eyes undergoing PPV for nAMD, recurrence of exudative changes after 11 months from the initial PPV was rare.

Effects of Anti-Vascular Endothelial Growth Factor Drugs Before and After Pars Plana Vitrectomy in Patients with Polypoidal Choroidal Vasculopathy and Vitreous Hemorrhage

Purpose: To compare the clinical effects of postoperative versus perioperative injection of anti-vascular endothelial growth factor (VEGF) drugs before and after pars plana vitrectomy (PPV) in patients with vitreous hemorrhage secondary to polypoidal choroidal vasculopathy (PCV). Methods: This was a retrospective study of patients who underwent PPV due to vitreous hemorrhage between October 2013 and June 2019 at Ningbo Eye Hospital. The patients who underwent PPV surgery due to PCV-secondary vitreous hemorrhage were included. The primary outcome was the changes in best-corrected visual acuity. The secondary outcome was the central macular thickness. Results: Compared with the postoperative group (n = 20), the perioperative group (n = 18) showed a smaller number of postoperative anti-VEGF injections (5.1 ± 0.8 vs. 8.0 ± 1.5, P < 0.05) and lower frequencies of early hyphema (5.6% vs. 30.0%, P < 0.05), and recurrent vitreous hemorrhage (11.1% vs. 30.0%, P < 0.05). The logarithm of minimal angle resolution (LogMAR) was smaller in the perioperative group compared with the postoperative group at 1 week, 1 month, and 3 months after PPV (P < 0.05), but there were no differences thereafter. Compared with the postoperative group, the perioperative group had thinner fovea at 1 week, 1 month, and 3 months (P < 0.05), but the differences disappeared after 3 months. Conclusion: In patients with PCV and vitreous hemorrhage, compared with postoperative anti-VEGF, perioperative anti-VEGF could reduce the difficulty of surgery and reduce the occurrence of postoperative complications, but there were no differences in long-term vision and macular thickness after surgery.

THE INCIDENCE, CHARACTERISTICS, MANAGEMENT, PROGNOSIS, AND CLASSIFICATION OF BREAKTHROUGH VITREOUS HEMORRHAGE SECONDARY TO POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To describe breakthrough vitreous hemorrhage secondary to polypoidal choroidal vasculopathy (PCV).

METHODS

Patients with the diagnosis of PCV from January 2005 to March 2020 at Peking Union Medical College Hospital were retrospectively reviewed, cases with breakthrough vitreous hemorrhage were analyzed. Subgroup analysis was conducted regarding pachychoroid PCV and nonpachychoroid PCV.

RESULTS

Among 722 PCV patients (834 eyes), 103 eyes with breakthrough vitreous hemorrhage (12.4%) were included. Pars plana vitrectomy and proper further interventions could significantly improve the best-corrected visual acuity from logMAR 2.15 ± 0.48 (Snellen 20/2825) to 1.65 ± 0.67 (20/893). Hemorrhagic retinal detachment, baseline central macular thickness, and best-corrected visual acuity were factors associated with final best-corrected visual acuity (P < 0.05). In the pachychoroid PCV group, patients were younger, all had hemorrhagic pigment epithelial detachment, with a higher prevalence of choroidal vascular hyperpermeability and hemorrhagic retinal detachment, thicker subfoveal choroidal thickness, and thinner central macular thickness; besides, the initial pars plana vitrectomy were more complicated, more additional surgeries had to be performed. More eyes in the nonpachychoroid PCV group had received anti-vascular endothelial growth factor or photodynamic therapy, mostly fibrovascular pigment epithelial detachment, the best-corrected visual acuity and the status of the fellow eye were significantly worse. For the final ocular status, more eyes in nonpachychoroid PCV group were taking anti-vascular endothelial growth factor monotherapy, whereas more eyes in pachychoroid PCV group were stable. The choroidal parameters of these two groups were all significantly different.

CONCLUSION

Breakthrough vitreous hemorrhage is a troublesome complication of PCV. Pars plana vitrectomy and additional interventions are required for better prognosis. Vitreous hemorrhage secondary to pachychoroid PCV or nonpachychoroid PCV have different characteristics and prognosis.

Surgical outcomes of vitrectomy for breakthrough vitreous hemorrhage in eyes with exudative age-related macular degeneration

PURPOSE

To report the outcomes of pars plana vitrectomy in cases with breakthrough vitreous hemorrhage (VH) secondary to exudative age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy. We also investigated the relationship between the preoperative b-mode ultrasonographic findings and the postoperative visual acuity to determine if the ultrasonographic findings can predict the surgical outcome after pars plana vitrectomy.

METHODS

This was a retrospective, interventional, case series. Twenty eyes of 20 patients were studied. The associations between the pre- and intraoperative factors and the final best-corrected visual acuity (BCVA) were determined. Recombinant tissue-plasminogen activator (tPA) was used in cases with massive hemorrhagic retinal detachment.

RESULTS

Ten eyes with polypoidal choroidal vasculopathy (PCV), two eyes with choroidal neovascularization (CNV), and eight eyes with an unknown type of AMD were studied. The mean BCVA was 0.73 ± 0.57 logarithm of the minimum angle of resolution (logMAR) units before developing the VH, 2.25 ± 0.45 logMAR units before the surgery, and 1.52 ± 0.87 logMAR units after the surgery. The BCVA improved significantly after the surgery (P = 0.004) but was significantly worse than that before developing the VH (P = 0.012). The cases of PCV had better final BCVA than cases of CNV (P = 0.043, Mann-Whitney test). The preoperative presence of a subretinal elevation at the macula detected by ultrasonography was significantly associated with a poorer final BCVA (P = 0.031).

CONCLUSIONS

Vitrectomy significantly improved visual function in the eyes with VH associated with exudative AMD. The eyes with PCV and no macular subretinal elevation on ultrasonography had a better visual prognosis.

Prognostic Factors and Long-term Surgical Outcomes for Exudative Age-related Macular Degeneration with Breakthrough Vitreous Hemorrhage

Purpose

We sought to evaluate the long-term outcomes for patients with exudative age-related macular degeneration (AMD) undergoing vitrectomy for breakthrough vitreous hemorrhage and to investigate possible prognostic factors.

Methods

Consecutive patients treated at two high-volume referral-based tertiary hospitals between July 2006 and December 2019 were retrospectively reviewed. Surgery was performed using the standard three-port vitrectomy. The primary outcome was the change in best-corrected visual acuity (BCVA) over long-term follow-up, while secondary outcomes included the assessment of possible prognostic factors.

Results

Among 50 eyes from 50 patients included in this study, 23 (46%) were diagnosed with polypoidal choroidal vasculopathy (PCV) and 27 (54%) were diagnosed with neovascular AMD. Preoperative vision at the time of vitreous hemorrhage onset was 20 / 3,027 (logarithm of the minimum angle of resolution [logMAR], 2.18 ± 0.34). At 12 months after surgery, the mean BCVA improved to 20 / 873 (logMAR, 1.64 ± 0.76; p < 0.001). At 24 months, the BCVA was 20 / 853 (logMAR, 1.63 ± 0.75; p < 0.001). Univariate analysis revealed that older age (odds ratio [OR], 0.879; p = 0.007] and the presence of submacular hemorrhage (OR, 0.081; p = 0.022) were factors associated with a poor 2-year visual outcome. Multivariable regression showed that older age (OR, 0.876; p = 0.026) and neovascular AMD (as compared with PCV) (OR, 0.137; p = 0.014) were significant negative factors influencing the 2-year visual outcome. The mean injection interval prior to vitrectomy was 4.53 months, which extended to 27.64 months after vitrectomy (p = 0.028).

Conclusions

Younger age, the absence of submacular hemorrhage, and PCV type were associated with a favorable 2-year visual outcome after vitrectomy for vitreous hemorrhage in patients with exudative AMD. Overall, vitrectomy resulted in improved visual acuity and patients showed a decreased need for anti-vascular endothelial growth factor therapy thereafter.

Long-term Clinical Course after Vitrectomy for Breakthrough Vitreous Hemorrhage Secondary to Neovascular Age-related Macular Degeneration and Polypoidal Choroidal Vasculopathy

To investigate the long-term clinical course after vitrectomy for breakthrough vitreous hemorrhage secondary to neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV). This retrospective study included 45 eyes that underwent vitrectomy due to breakthrough vitreous hemorrhage secondary to neovascular AMD. The patients were divided into 2 groups: neovascular AMD group and PCV group. Within each group, the status of the eye within 6 months after the surgery and that at the final follow-up was identified. The visual acuity at the final visit was additionally compared between the 2 groups. The patients were followed up for a mean period of 39.9 ± 19.4 months after the surgery. In the neovascular AMD group (n = 17), re-bleeding requiring vitrectomy was noted in 4 eyes and extensive scar formation was noted in 6 eyes within 6 months after the surgery. At the final visit, treatment was discontinued due to poor visual outcome in 10 eyes. In the PCV group (n = 28), re-bleeding requiring vitrectomy was noted in 1 eye, and extensive scar formation was noted in 4 eyes within 6 months after the surgery. At the final visit, treatment was discontinued in 8 eyes. The visual acuity at the final visit was significantly better in the PCV group (P = 0.003). The long-term clinical course after vitrectomy for breakthrough vitreous hemorrhage was markedly different between neovascular AMD and PCV, showing significantly better long-term visual outcomes in PCV.

Long-term observation of vitrectomy without subretinal hemorrhage management for massive vitreous hemorrhage secondary to polypoidal choroidal vasculopathy

AIM

To describe the long-term observation of vitrectomy without subretinal hemorrhage (SRH) management for massive vitreous hemorrhage (VH) secondary to polypoidal choroidal vasculopathy (PCV).

METHODS

This is a retrospective, consecutive case series. A total of 86 eyes of 86 patients with >14d of massive VH associated with PCV were included. All patients underwent vitrectomy without SRH management, followed by intravitreal ranibizumab injections and/or photodynamic therapy (PDT) as needed. The main outcome measures were best-corrected visual acuity (BCVA), postoperative adverse events and the recurrence of VH.

RESULTS

The average follow-up period was 25.5±9.2mo (range 12-35mo). Mean BCVA at baseline (2.16±0.39 logMAR) had improved significantly, both 3mo after surgery (1.42±0.66 logMAR, P<0.001) and by the last visit (1.23±0.74 logMAR, P<0.001). The common postoperative complications included macular subretinal fibrosis in 14 eyes (16.3%) and ciliary body detachment in 4 eyes (4.7%). Nineteen eyes (22.1%) received following treatment with ranibizumab injections without/with PDT, and 15 (17.4%) were resolved. Four eyes (4.7%) had recurrent hemorrhage during the follow-up period. In multiple regression analysis, thicker SRH (beta=0.33, P=0.025) in the preoperative B-scan and the presence of foveal subretinal fibrosis (beta=0.28, P=0.018) in the follow up were associated with poor postoperative BCVA.

CONCLUSION

Vitrectomy without SRH management for massive VH secondary to PCV improved/stabilized visual function in the long-term observation. Eyes presenting with thicker SRH preoperatively and forming foveal subretinal fibrosis in the follow-up period tended to have worse BCVA.

Enucleation for haemophthalmus secondary to choroidal neovascularisation in polypoidal choroidal vasculopathy: a therapeutic and diagnostic dilemma

We report a case of enucleation for painful blind eye secondary to recurrent bleeding from choroidal neovascularisation in an eye that was irradiated following presumed metastatic breast carcinoma to the choroid. A 58-year-old woman with a history of treated breast malignancy presented with haemophthalmus and intractable glaucoma in the right eye. One year previously she had presented with right vitreous haemorrhage with subretinal mass that had been irradiated given her history of breast carcinoma. Following irradiation, vitrectomy was performed to clear the blood. Intraoperative and postoperative angiography findings suggested a diagnosis of breakthrough bleeding secondary to polypoidal choroidal vasculopathy. At this presentation, however, the intraocular bleeding was recurrent resulting in elevated intraocular pressure and pain. Despite repeat surgery and medical therapy, the eye had to be enucleated. Histopathology showed choroidal neovascularisation.

Incidence Rate of Massive Submacular Hemorrhage and its Risk Factors in Polypoidal Choroidal Vasculopathy

PURPOSE

To investigate the incidence rate of massive submacular hemorrhage (SMH) in patients with polypoidal choroidal vasculopathy (PCV) and analyze the associated risk factors.

DESIGN

Retrospective cohort study.

METHODS

Patients diagnosed with PCV from May 2003 to May 2014 were included. Two hundred forty-five eyes of 245 patients were enrolled. The time between the initial visit to the clinic with subjective visual symptoms and the date of massive SMH was recorded. SMH larger than 4 disc diameters was defined as massive SMH. Age; hypertension; visual acuity (VA); indocyanine green angiography findings, including the greatest linear dimension, largest polyp size, and PCV type (cluster vs non-cluster); and treatment methods were reviewed for risk factor analysis using Kaplan-Meier survival and Cox regression analyses.

RESULTS

The incidence rate of massive SMH within 1 year after the initial visit was 2.45%. Massive SMH occurred within 3, 5, and 10 years after the first visit in 6.17%, 11.09%, and 29.85% of patients, respectively. Cox regression analysis revealed that the cluster type of PCV was significantly associated with massive SMH (hazard ratio [HR], 3.418; P = .003). Photodynamic therapy followed by anti-vascular endothelial growth factor injection lowered the risk of massive SMH (HR = .242; P = .047]. Final VA in eyes with massive SMH was significantly lower than that in patients without massive SMH (1.34 ± 0.66 vs 0.63 ± 0.53 logMAR; P < .001).

CONCLUSIONS

Patients with PCV who develop massive SMH experience severe vision loss. The incidence rate of massive SMH in PCV increases with time. The cluster type of polyp in PCV is a significant risk factor for massive SMH.

Vitreous haemorrhage in massive hemorrhagic polypoidal choroidal vasculopathy: clinical characteristics and surgical outcomes: Vitreous hemorrhage in PCV

Background

To report the outcomes of vitreous hemorrhage (VH) associated with hemorrhagic polypoidal choroidal vasculopathy (PCV).

Methods

A retrospective study of 28 eyes of 27 consecutive patients of hemorrhagic PCV with VH, which were managed surgically between January 2003 and December 2011, was performed. All patients underwent pars plana vitrectomy for VH associated with PCV. The main outcome measure was best-corrected visual acuity (BCVA) at baseline, at 1, 3 and 6 months post operatively and at last follow up.

Results

The visual acuity measured on early treatment diabetic retinopathy study (ETDRS) chart improved in 16 eyes (57.1 %) by two or more lines, remained unchanged in nine eyes (32.1 %) and decreased in three (10.7 %) after surgery when compared to baseline VA. The mean baseline VA was 2.69 ± 0.57 logMAR units (<20/2000) which improved to 1.65 ± 0.93 logMAR units (20/800) at 1 month post operative visit and was sustained at 1.72 ± 1.12 (20/800) with an improvement of 0.96 logMAR units (p < 0.001, 95 % CI 0.54–1.37). The average postoperative follow up was for 14.2 months (range 1–84). The complications noted in postoperative follow up were cataract (n = 10), macular scaring (n = 9), organised dehemoglobinised blood (n = 7), retinal tear or detachment (n = 5), recurrent VH (n = 3) and choroidal detachment (n = 1).

Conclusion

Majority of patients with loss of vision due to VH secondary to hemorrhagic PCV have sustained improvement in visual acuity following surgery.