Characteristics of Perifoveal Exudative Vascular Anomalous Complex in Korean Patients

Current insights and challenges in the management of perifoveal vascular anomalous complex (PVAC): a systematic review of multimodal imaging features and treatment strategies

The aim of this article is to comprehensively review the multimodal imaging (MMI) features that define perifoveal vascular anomalous complex (PVAC) and to update the optimal treatment strategies for this disorder with a focus also on the underlying pathogenetic mechanisms. This systematic review was performed based on a search of the PubMed and Embase databases of relevant papers on the subject of PVAC. PVAC is characterized by well-defined MMI findings, including remarkable morphological features with optical coherence tomography (OCT) and OCT angiography (OCTA). The recognition of this lesion is important because of treatment implications as this entity is typically unresponsive to anti-vascular endothelium growth factor (VEGF) therapy. Thermal focal laser (TFL) can have better success in reducing exudation associated with PVAC. Other therapeutic modalities include subthreshold micropulse laser (SML), steroid and anti-inflammatory treatments. In total, this review captured 25 scientific articles covering the treatment of exudative PVAC cases. Accurate multimodal imaging characterization of PVAC is essential for differential diagnosis and management. There are a multitude of similar lesions described in the literature with overlapping MMI features and clinical contexts. These various lesions will be described and defined in an effort to provide clarity of differentiation. We recommend the "PVAC" nomenclature to denote a distinct, primary condition, consistent with its original definition. On the other hand, we support the consolidation of "TelCap" lexicon to characterize the secondary lesion occurring in the context of diabetic retinopathy (DR), retinal vein occlusion (RVO), and other causal retinal vascular disorders.

Perifoveal Exudative Vascular Anomalous Complex (PEVAC): Retinal Vascular Density Findings

Objectives: This study aimed to describe the clinical, optical coherence tomography (OCT) and OCT angiography (OCTA) findings and characteristics in patients with perifoveal exudative vascular anomalous complex (PEVAC) and compare the macular vascular density with the age-matched control group. Methods: We conducted a case-control study to compare demographic information, clinical observations, and OCT/OCTA findings in eyes with PEVAC (n = 5 eyes in 5 patients) and a control group of subjects matched for age (n = 9). The Advanced Retina Imaging (ARI) network algorithms were utilized to evaluate OCTA observations. Statistical analysis was performed by the nonparametric Mann-Whitney U test. Results: Patients with PEVAC had a mean (±SD) age at presentation of 70 ± 12.6 years, the mean follow-up period was 7.8 ± 5.2 months, and unilateral disease was observed. Four out of the five patients in our cohort had a history of systemically treated hypertension and dyslipidemia. Three eyes had lesions in the inner temporal retinal zone, while the remaining two eyes had lesions in the inner inferior or central zone. Retina slab analysis using OCTA showed no significant difference in vascular density parameters between the PEVAC and control groups. Conclusions: Although limited by a small sample size, our study suggests that macular vessel density shows no significant difference between PEVAC cases and control eyes.

A Brazilian case of exudative perifoveal vascular anomalous complex responsive to aflibercept intravitreal injections

PURPOSE

To report a case of exudative perifoveal exudative vascular anomalous complex (ePVAC) in a Brazilian healthy patient that underwent a complete resolution after aflibercept intravitreal injections.

CASE DESCRIPTION

A 41-year-old healthy Brazilian man complained of acute central vision loss in his right eye (RE). Fundus examination showed a perifoveal hemorrhagic aneurysmal lesion, accompanied by several hard exudates in RE. On fluorescein angiography, these abnormalities showed a progressive hyperfluorescence with surrounding leakage. Optical coherence tomography (OCT) revealed a deep, perifoveal hyporeflective cystic space with a hyperreflective wall and hyperreflective material inside of fibrin-like aspect. Around this aneurism, intraretinal hyporeflective spaces suggestive of exudation were detected. Nor pathological flow signal, or telangiectatic dilations were evidenced on OCT-angiography. Therefore, a diagnosis of exudative ePVAC in RE was hypothesized. After an initial observation, the patient underwent three monthly aflibercept intravitreal injections (0.05 ml/2 mg), with a significative anatomical and functional improvement after two weeks from first dose. On last follow-up at five months from baseline, patient experienced no evidence of new exudation and a stable visual acuity.

DISCUSSION

Placental growth factor (PlGF) may impact on pericytes' dropout, and thus on ePVAC development. In contrast to the other anti-VEGF drugs, aflibercept is the only molecule contrasting PlGF. Therefore, aflibercept would act on ePVAC not as an anti-VEGF drug, but rather as an anti-PlGF one.

CONCLUSION

This report encouraged the use of aflibercept as a therapeutic option for ePVAC. Further studies are required to confirm our result and the impact of PlGF on ePVAC pathogenesis.

Perifoveal exudative vascular anomalous complex and resembling lesions treated with intravitreal triamcinolone

PURPOSE

To report the use of intravitreal triamcinolone to treat macular edema associated with isolated perifoveal exudative vascular anomalous complex (PVAC) and resembling lesion (PVAC-RL).

METHODS

In this case series, three diabetic patients (3 eyes) with PVAC-RLs and one healthy patient (1 eye) with PVAC lesion associated with cystic spaces underwent three intravitreal injections of aflibercept before switching to one intravitreal triamcinolone injection in each patient.

RESULTS

Macular edema improved from 297.5  ±  8.10  μm, at baseline, to 269.2  ±  8.89  μm, after triamcinolone; whereas visual acuity improved from 20/38 to 20/26 (ETDRS).

CONCLUSION

PVAC and PVAC-RL are rare and often misdiagnosed lesions that may be associated with decreased vision. Our outcomes suggest that intravitreal injection of triamcinolone may be an effective and affordable treatment for PVAC and PVAC-RL with intraretinal fluid.

Intraretinal Macroaneurysms and Multimodal Imaging: A Retrospective Analysis

Purpose

To analyze the multimodal imaging characteristics of intraretinal macroaneurysms.

Patients and Methods

Intraretinal aneurysms larger than 150 μm in diameter on fluorescein angiography were termed as intraretinal macroaneurysm and grouped as primary and secondary according to the absence or presence of any coexisting posterior segment diseases.

Results

A total of 20 intraretinal macroaneurysms were observed in 18 eyes of 18 patients. Mean age of the cohort was 65.44 ± 9.14 years (Range; 49-82 years). Mean diameters of intraretinal macroaneurysms were 238.20 ± 61.12 μm (Range; 163.00-292.50 μm) and 242.72 ± 49.58 μm (Range; 168.00-328.00 μm) on fluorescein angiography and optical coherence tomography, respectively. Primary group had 10 eyes with 11 intraretinal macroaneurysms, whereas eight eyes had nine intraretinal macroaneurysms in the secondary group. Three of the eight eyes (37.5%) had diabetic retinopathy, four (50%), retinal vein occlusion, and one (12.5%), posterior uveitis in the secondary group. No statistically significant differences were found between the two groups in terms of age, sex, presence of intraretinal or subretinal fluid, the mean age, the mean central macular thickness, the mean distance of intraretinal macroaneurysms from the fovea, the mean diameter of intraretinal macroaneurysms measured on fluorescein angiography, and the mean diameter of intraretinal macroaneurysms measured on optical coherence tomography. Presence of intraretinal fluid was significantly more frequent than the presence of subretinal fluid in all eyes (p = 0.004).

Conclusion

Intraretinal macroaneurysms are diagnosed more and more with the utilization of multimodal imaging techniques. We propose a simple classification system in order to help achieving a standardized terminology and ensure consistent understanding. The classification can be simplified as primary or secondary intraretinal macroaneurysm according to the absence or presence of the associated posterior segment disorders.

MULTIPLE-SESSION SUBTHRESHOLD MICROPULSE LASER THERAPY FOR EXUDATIVE PERIFOVEAL VASCULAR ANOMALOUS COMPLEX: A CASE REPORT

PURPOSE

To report a case of exudative perifoveal vascular anomalous complex treated with a 532-nm subthreshold micropulse laser unresponsive to intravitreal injections.

METHODS

A case report.

RESULTS

A 65-year-old woman presented with blurred vision in the left eye for 1 month. An isolated perifoveal aneurysm surrounded by retinal hemorrhages and hard exudates was revealed in fundus examination, and optical coherent tomography showed a round lesion with a hyperreflective wall, subretinal fluid, and an intraretinal cyst. She was diagnosed with exudative perifoveal vascular anomalous complex and received four intravitreal injections. However, her best-corrected visual acuity decreased, and an aneurysmal lesion with macular edema persisted for approximately 6 months. Three sessions of 532-nm subthreshold micropulse laser therapy around the aneurysm were applied because the intravitreal injection treatment was ineffective. Since the last session, macular edema disappeared, the involuted lesion remained substantially stable without recurrence, and her best-corrected visual acuity improved without visual field defect.

CONCLUSION

To our knowledge, this is the first report of a successful subthreshold micropulse laser treatment for an exudative perifoveal vascular anomalous complex lesion, and it could be a safe and effective method for the patient unresponsive to intravitreal injections.

Selective Focal Laser Therapy as the Primary Treatment for Exudative Perifoveal Vascular Anomalous Complex (ePVAC): Case Series and Literature Review

Perifoveal anomalous exudative vascular complex (PEVAC) was first described in 2011. Since then, individual clinical cases and a couple of case series have been published, and their characteristics have been studied in multi-modal images. To date, there is no consensus on its treatment. Initially, it was thought that PEVACs could be left to spontaneous evolution because they presented a slow progression. But it has been shown that the growth of the lesion covers a spectrum from non-exudative lesions to PEVAC with vision impairment over time. We present an updated bibliographic review of this pathology. We explain the changes in the diagnostic criteria that have been undergone. And we focus the discussion on selective treatment with focal laser, which has shown an excellent anatomical response and visual improvement or stabilization in the cases described and in our series of three patients systematically treated with focal laser. [Ophthalmic Surg Lasers Imaging Retina 2023;54:43-49.].

Atypical case of perifoveal exudative vascular anomalous complex associated with pachychoroid pigment epitheliopathy

Purpose

Observations

Conclusion and importance

Multimodal imaging comparison of perifoveal exudative vascular anomalous complex and resembling lesions

Purpose

Perifoveal exudative vascular anomalous complex (PEVAC) was initially described as an isolated aneurysmal lesion in healthy eyes. Similar aneurysmal abnormalities may occur in association with retinal vascular diseases such as diabetic retinopathy or retinal vein occlusions (PEVAC‐resembling). The aim of this study was to compare several imaging characteristics of PEVAC and PEVAC‐resembling lesions.

Methods

Ten eyes with a PEVAC and 27 eyes with a PEVAC‐resembling lesion were included in this cross‐sectional study. They were all imaged with optical coherence tomography (OCT), OCT angiography (OCT‐A) and colour fundus photography (CFP). Several clinical, morphological and vascular characteristics were assessed and compared between both PEVAC types.

Results

All PEVAC lesions were unilateral, while PEVAC‐resembling lesions appeared bilateral in 23% of patients (p > 0.05). Unilateral multifocal PEVAC‐resembling lesions were more frequently observed (56%) than unilateral multifocal PEVAC lesions (10%, p < 0.01). Furthermore, 90% of the PEVAC lesions were located within 500 µm from the centre of the fovea, while this was only true for 56% of the PEVAC‐resembling lesions (p > 0.05). No notable differences were observed in other studied characteristics.

Conclusions

The clinical, morphological and vascular features of PEVAC and PEVAC‐resembling lesions are similar based on multimodal imaging. Given the bilaterality and multifocality seen in PEVAC‐resembling lesions, an underlying retinal vascular disease may stimulate the quantity of aneurysmal abnormalities. Due to the similarities with PEVAC‐resembling lesions, PEVAC may also be considered a microangiopathy but with an unknown origin.

ANATOMICAL CHANGES ON SEQUENTIAL MULTIMODAL IMAGING IN PERIFOVEAL EXUDATIVE VASCULAR ANOMALOUS COMPLEX

PURPOSE

To report a series of 21 patients with perifoveal exudative vascular anomalous complex (PEVAC) and to investigate the anatomical changes over time.

METHODS

We conducted a retrospective study. Clinical data of consecutive patients, presenting at the Rotterdam Eye Hospital between 2014 and 2019, were analyzed. The data collected included best-corrected visual acuity, fundus photography, optical coherence tomography (OCT), OCT-angiography, fluorescence angiography, and indocyanine green angiography.

RESULTS

We included 21 patients with a PEVAC lesion with a mean follow-up of 24.3 ± 13.8 months (range, 9-46 months). Patients with PEVAC were on average 75.3 ± 11.1 years (range, 53-90 years). The large perifoveal vascular aneurysmal abnormality was associated with small retinal hemorrhages in six patients and hard exudates in three patients. The PEVAC lesion was associated with intraretinal cystic spaces on OCT in 15 patients. Twelve of 21 patients showed no changes in cystic spaces on OCT during follow-up: 9 patients had stable cystic spaces and 3 patients had no cystic spaces. In contrast, in 9 of 21 patients, we observed changes in cystic spaces on OCT during follow-up. In two patients, cystic spaces appeared during follow-up, and in seven patients, there was a spontaneous resolution of cystic spaces. In three of these seven patients, the PEVAC lesion completely disappeared. Two patients, with stable intraretinal cystic spaces on OCT, were treated with intravitreal injections of anti-vascular endothelial growth factor without improvement.

CONCLUSION

Perifoveal exudative vascular anomalous complex is an idiopathic perifoveal retinal vascular abnormality that is associated with intraretinal cystic spaces. These intraretinal cystic spaces associated with a PEVAC lesion, and even the PEVAC lesion itself, can have a spontaneous resolution over time.

Nonexudative Perifoveal Vascular Anomalous Complex: The Subclinical Stage of Perifoveal Exudative Vascular Anomalous Complex?

PURPOSE

To describe the pre-exudative stage of exudative perifoveal vascular anomalous complex (ePVAC), referred to as nonexudative PVAC (nePVAC).

DESIGN

Retrospective noncomparative case series.

METHODS

Patients diagnosed with nePVAC were identified at 4 retina referral centers worldwide. Multimodal retinal imaging, including structural optical coherence tomography (OCT) and OCT-angiography (OCT-A), were performed at baseline and follow-up visits.

RESULTS

Six eyes (6 patients, mean 75 ± 10 years of age) were included. Unrelated chorioretinal diseases were diagnosed in the affected eyes in 5 of 6 cases. At baseline, nePVAC is characterized by microvascular abnormalities featuring an isolated, perifoveal, large intraretinal aneurysm surrounded by capillary rarefaction at OCT-A examination, without any sign of exudation with structural OCT, and without visual impairment. Four patients were followed for a mean of 21 ± 14 months. During the follow-up, 3 of 4 eyes (75%) developed signs of exudation after a mean of 15 ± 9 months, associated with metamorphopsia and visual decline at the time of exudation. Best-corrected visual acuity decreased from 20/25 to 20/40 Snellen equivalent (P = .035) and central macular thickness increased from 268 ± 27 μm to 339 ± 65 μm (P = .145). Three patients were treated with 2.3 ± 0.6 intravitreal injections of anti-vascular endothelial growth factor without significant improvement of best-corrected visual acuity or macular edema.

CONCLUSIONS

nePVAC may represent the subclinical pre-exudative stage of ePVAC, notable for an absence of exudation or visual impairment. nePVAC and ePVAC should be considered as part of the same spectrum, namely PVAC. Typically, nePVAC develops signs of exudation over time, causing metamorphopsia and visual decline and therefore these lesions warrant continued close monitoring with multimodal retinal imaging.

Atypical perifoveal exudative vascular anomalous complex (PEVAC) with multifocal and bilateral presentation

Purpose

To report an unusual case of multifocal and bilateral perifoveal exudative vascular anomalous complex (PEVAC) lesions in an otherwise healthy patient.

Observations

A 62-year-old male with complaints of long-term progressive blurred vision in both eyes. There was no history of diabetes, arterial hypertension or inflammatory disease. Best-corrected visual acuity was 75 and 80 letters in his right eye (OD) and left eye (OS) respectively. Fundus examination showed three perifoveal isolated large aneurysmal lesions in his OD and an additional one in his OS, associated with smaller microaneurysms, haemorrhages and intraretinal exudation. On optical coherence tomography PEVAC appeared as a round lesions with a hyperreflective wall and lumen containing variably reflective material, typically surrounded by intraretinal fluid. Dye-based angiography demonstrated three and one well-defined large hyperfluorescent aneurysmal lesions in his OD and OS respectively, with no leakage. The optical coherence tomography angiography images showed flow signal within the intraretinal aneurysmal lesions. No anomalous flow signal in the outer retina and choriocapillaris was present. After one bilateral anti-vascular endothelial growth factor intravitreal injection no anatomical or functional improvement was observed, and no changes in the lesions or visual acuity were observed at 6 months follow-up.

Conclusions and importance

We describe an atypical case of PEVAC, an uncommon and poorly known macular disorder, with bilateral presentation and multifocal lesions in one eye. To our knowledge, this is the first reported case of bilateral PEVAC lesions. Hence, PEVAC should be included in the differential diagnosis of bilateral perifoveal aneurysmal lesions with macular edema.