Photodynamic therapy with or without intravitreal triamcinolone acetonide for symptomatic polypoidal choroidal vasculopathy

Real world experience of the treatment outcome between photodynamic therapy combined with ranibizumab and aflibercept monotherapy in polypoidal choroidal vasculopathy

To provide real-world experiences of treating polypoidal choroidal vasculopathy (PCV) patients with photodynamic therapy (PDT) plus intravitreal injection of ranibizumab or intravitreal injection of aflibercept alone. Retrospective chart review of patients with PCV in a single tertiary referral center in Taiwan. Chart review of PCV patients treated with PDT and injection of ranibizumab or injection of aflibercept. A total of 101 eyes of 101 patients (38 females and 63 males) were reviewed. Of those, 48 and 53 eyes received primary/adjunctive PDT along with injections of ranibizumab or intravitreal injections of aflibercept only, respectively. Initial visual acuity (VA) and central subfield choroidal thickness were similar between the two groups (p > 0.05). In addition, changes in VA at 3, 6, and 12 months post treatment were similar. The central retinal thickness decreased with either treatment (p < 0.01); however, this change did not translate into VA performance (p > 0.05). In the subgroup analysis of pachychoroid and non-pachychoroid patients, better initial VA and post-treatment VA at 3 months and 6 months was noted in the latter group of patients treated with anti-vascular endothelial growth factor monotherapy (p < 0.05). Aflibercept monotherapy is comparable with PDT plus ranibizumab in PCV patients with PCV (pachychoroid and non-pachychoroid patients). In addition, better prognosis regarding VA was observed in non-pachychoroid patients treated with aflibercept monotherapy.

Systemic steroids for the management of choroidal neovascular membrane with pigment epithelial tear and recalcitrant subretinal fluid

A 67-year-old man was diagnosed to have dry age related macular degeneration in the right eye and a choroidalneovascular membrane (CNVM) with a large pigment epithelial detachment in the left eye, confirmed with clinical examination, angiography and optical coherence tomography scans. He received an intravitreal injection of bevacizumab in the right eye and developed a retinal pigment epithelial (RPE) tear 3 weeks later. 3 consecutive ranibizumab injections failed to clear the subretinal fluid (SRF). A course of systemic steroids was administered and this improved the vision. Subsequently, the patient received one more ranibizumab injection and the disease process resolved. The left eye corrected distance visual acuity (LE CDVA) was 20/30 at the final visit (1 year after the last injection). Systemic steroids may be a management option in patients with CNVM and RPE tear with recalcitrant SRF if there is no contraindication to their use.

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

Purpose of review

The aim of this review is to summarize developments in the treatment of active polypoidal choroidal vasculopathy (PCV). PCV is associated with a poor visual prognosis as a consequence the condition's hallmark polypoidal dilatation and a branching network resulting in recurrent hemorrhages and serous leakage.

Recent findings

Recent research has provided new insights into the pathogenesis of PCV. While still considered a subtype of age-related macular degeneration, suggestions that PCV belongs to a spectrum of conditions that present with a pachychoroid are increasingly well accepted. Treatment remains challenging. Combination therapy (photodynamic therapy (PDT) and intravitreal anti-vascular endothelial growth factor (VEGF)) is associated with higher polyp closure rate, but polyp closure rate has not been correlated with superior visual outcomes. Current data points to non-inferiority of anti-VEGF alone versus combined with PDT when final vision acuity is the study outcome.

Summary

PCV remains a clinical challenge. Classification and treatment of the condition continues to evolve. Combination therapy may not be superior to anti-VEGF treatment alone in terms of visual acuity outcome, however data on long-term recurrence should be compared in formulating preferred treatment plans.

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.

Effects of photodynamic therapy plus intravitreal aflibercept with subtenon triamcinolone injections for aflibercept-resistant polypoidal choroidal vasculopathy

PURPOSE

To evaluate the outcome of triple therapy of photodynamic therapy combined with injections of intravitreal aflibercept (IVA) and subtenon triamcinolone acetonide for polypoidal choroidal vasculopathy (PCV) resistant to IVA.

METHODS

A retrospective chart review at a single institution was conducted to identify patients with PCV resistant to treatment with IVA who were switched to treatment with triple therapy. In total, 13 eyes from 13 patients were included in the study. Demographic data, visual acuities, central retinal thickness (CRT) and height of pigment epithelial detachment (PED) on optical coherence tomography (OCT), complications, and number of injections were reviewed.

RESULTS

The patients had a mean age of 68 years (range 53-83). The number of prior injections with IVA ranged from 5 to 10. At 12 months follow-up after triple therapy, there was a significant improvement in visual acuity (P = 0.0039), a significant decrease in CRT (P = 0.003), and a significant reduction of the height of PED (P = 0.015). Only one patient had retinal pigment epithelium tear.

CONCLUSIONS

Triple therapy improved visual and anatomical outcomes in patients with PCV with recurrent or resistant retinal fluid and PED after multiple injections with IVA.

Polypoidal Choroidal Vasculopathy

PURPOSE OF REVIEW

The goal of this paper is to review the recent literature of polypoidal choroidal vasculopathy (PCV) and provide an update on the epidemiology, pathophysiology, clinical findings, and management.

RECENT FINDINGS

Although indocyanine-green angiography (ICGA) is still the gold standard for diagnosis of PCV, the use of en face optical coherence tomography (OCT) and OCT angiography are useful tools in the diagnosis of PCV. Studies demonstrate superior treatment outcomes with combination photodynamic therapy (PDT) and anti-vascular endothelial growth factor (VEGF) therapy.

SUMMARY

PCV is a disease most commonly in Asians and African-Americans and presents with an orange-red nodule in the macula or the peripapillary region. While ICGA remains the most accurate method to diagnose PCV, newer non-invasive imaging modalities (eg. OCT-A and en face OCT) can be used to identify PCV lesions. The combination of PDT and anti-VEGF therapy is superior to either monotherapy. Future studies of OCT modalities and other anti-VEGF agents will be important in guiding PCV diagnosis and management, respectively.

THREE-YEAR RESULTS OF POLYPOIDAL CHOROIDAL VASCULOPATHY TREATED WITH PHOTODYNAMIC THERAPY: Retrospective Study and Systematic Review

PURPOSE

To evaluate the 3-year outcome in eyes with polypoidal choroidal vasculopathy (PCV) treated with photodynamic therapy with verteporfin.

METHODS

Retrospective study and review of the literature. We performed a retrospective study of patients with PCV who were treated with photodynamic therapy between January 2007 and December 2008. Patients were excluded if they had received photodynamic therapy before the study period, but those who received previous treatment with other modalities (thermal laser or intravitreal therapies) were allowed. The main outcome measures were best-corrected visual acuity, repeat photodynamic therapy, and recurrence of PCV at the end of Years 1, 2, and 3. We further conducted a systematic review of the literature using the terms "polypoidal choroidal vasculopathy" and "photodynamic therapy" and compared the visual outcome of studies over 3 years using meta-analytical methods.

RESULTS

The retrospective study included 68 eyes. The mean best-corrected visual acuity was 0.73 ± 0.56 logMAR (20/107, Snellen equivalent) at baseline, 0.73 ± 0.70 logMAR (20/107, Snellen equivalent) at 1 year, 0.96 ± 0.76 logMAR (20/182, Snellen equivalent) at 2 years, and 1.07 ± 0.81 logMAR (20/235, Snellen equivalent) at 3 years. The cumulative recurrence rates of PCV were 16.1% (1 year), 34.9% (2 years), and 52.7% (3 years) and eyes with recurrence were more likely to suffer ≥3 lines loss compared with eyes without recurrence (63.2 vs. 17.6%, P = 0.006). The systematic review summarized results from 48 published studies and our retrospective study. The pooled analysis from 29 studies (316 eyes reporting the 3-year visual outcome) reported mean best-corrected visual acuity improvement of 0.115 logMAR at 1 year (n = 1,669), 0.066 logMAR at 2 years (n = 701), and 0.027 logMAR at 3 years (n = 316). Reported recurrence rates were 5.9% to 50.0% after 1 year, 9.1% to 83.3% after 2 years, and 40.0% to 78.6% after 3 years or longer of follow-up.

CONCLUSION

The visual outcome in eyes with PCV was stable until 2 years, but the outcome at 3 years worsened, particularly in eyes that experienced recurrence.

Systemic steroids as an aid to the management of Idiopathic Polypoidal Choroidal Vasculopathy (IPCV): A descriptive analysis

PURPOSE

To determine the role of systemic steroids in improving visual acuity, preventing recurrence and hastening pigment epithelial detachment resolution in IPCV patients.

METHODS

Retrospective computer assisted comparative case series of consecutive patients with documented IPCV who did and did not receive systemic steroids as part of their treatment regimen between 2007 and 2012. Patients who had systemic contraindication to steroid therapy were excluded from the steroid arm. Data collected included demographics, the best corrected visual acuity, details of the ocular and systemic exam, the treatment offered, the follow-up period and the final visual and anatomic outcomes. Outcome measures included the final BCVA, the time to resolution of the associated pigment epithelial detachment (PED, if present), the recurrence rate and the associated side effects, if any. Appropriate statistical analysis was done. Statistical significance: p < 0.05.

RESULTS

14 patients (14 eyes) had received systemic steroids in the stated period; these were compared with 26 consecutive patients (26 eyes) who did not. Mean age: 59.24 vs 62.38 years (A vs B). Mean baseline BCVA: 1.86 ± 1.24 logMAR vs 2.12 ± 1.48 logMAR (A vs B). 8 females in Group A and 14 in Group B. 11 patients in group A and 19 in group B had associated systemic hypertension. Therapy consisted of laser photocoagulation, anti-vascular endothelial growth factor therapy, photodynamic therapy or a combination of these. Mean follow-up: 43.21 ± 11.32 months (Group A) vs 48.24 ± 9.75 months (Group B). BCVA at three months was significantly better (0.84 ± 0.74 logMAR vs 1.16 ± 0.89 (p = 0.039). Final BCVA: 0.86 ± 0.78 logMAR (Group A) vs 1.29 ± 0.92 (Group B, p = 0.042). 7 patients in group A and 12 in Group B had a recurrence (insignificant difference). 1 patient in Group A and 7 in Group B had unresolved disease (persistent PED) at the end of follow-up (OR: 4.60; 95% CI 1.7-11.10).

CONCLUSION

Steroids appear to improve visual acuity and accelerate the resolution of the PEDs in patients with IPCV and large PEDs, but do not seem to influence recurrence.

Ranibizumab alone or in combination with photodynamic therapy vs photodynamic therapy for polypoidal choroidal vasculopathy: a systematic review and Meta-analysis

AIM

To compare the efficacy of intravitreal ranibizumab (IVR) alone or in combination with photodynamic therapy (PDT) vs PDT in patients with symptomatic polypoidal choroidal vasculopathy (PCV).

METHODS

A systematic search of a wide range of databases (including PubMed, EMBASE, Cochrane Library and Web of Science) was searched to identify relevant studies. Both randomized controlled trials (RCTs) and non-RCT studies were included. Methodological quality of included literatures was evaluated according to the Newcastle-Ottawa Scale. RevMan 5.2.7 software was used to do the Meta-analysis.

RESULTS

Three RCTs and 6 retrospective studies were included. The results showed that PDT monotherapy had a significantly higher proportion in patients who achieved complete regression of polyps than IVR monotherapy at months 3, 6, and 12 (All P≤0.01), respectively. However, IVR had a tendency to be more effective in improving vision on the basis of RCTs. The proportion of patients who gained complete regression of polyps revealed that there was no significant difference between the combination treatment and PDT monotherapy. The mean change of best-corrected visual acuity (BCVA) from baseline showed that the combination treatment had significant superiority in improving vision vs PDT monotherapy at months 3, 6 and 24 (All P<0.05), respectively. In the mean time, this comparison result was also significant at month 12 (P<0.01) after removal of a heterogeneous study.

CONCLUSION

IVR has non-inferiority compare with PDT either in stabilizing or in improving vision, although it can hardly promote the regression of polyps. The combination treatment of PDT and IVR can exert a synergistic effect on regressing polyps and on maintaining or improving visual acuity. Thus, it can be the first-line therapy for PCV.

Three-year visual outcome of photodynamic therapy plus intravitreal bevacizumab with or without subtenon triamcinolone acetonide injections for polypoidal choroidal vasculopathy

PURPOSE

To compare the 3-year visual outcome after double therapy of photodynamic therapy (PDT) with intravitreal bevacizumab (IVB) and triple therapy of PDT combined with IVB and subtenon triamcinolone acetonide (STTA) injections for polypoidal choroidal vasculopathy (PCV).

DESIGN

Retrospective, comparative, interventional case series.

METHODS

Medical records for 36 eyes in 36 patients (33 men, 3 women; mean age 73.5 years old; range 63-82 years old) with treatment-naive subfoveal PCV were reviewed retrospectively. Of the 36 eyes, 17 were treated with double therapy and 19 with triple therapy.

RESULTS

The change in visual acuity after triple therapy was significantly better than that after double therapy (p<0.05). At 36 months, improvement in visual acuity was seen in 5 eyes (29.4%) in the double therapy group and 10 eyes (52.6%) in the triple therapy group. Retreatment using the initial treatment was performed for six eyes (35.3%) in the double therapy group and five eyes (26.3%) in the triple therapy group, and treatment-free period was significantly longer in the triple therapy group (p<0.05). The mean number of additional antivascular endothelial growth factor therapy was higher in the double therapy group. Post-treatment vitreous haemorrhage or retinal pigment epithelium tear occurred only in the double therapy group, in one eye (5.9%) and one eye (5.9%), respectively.

CONCLUSIONS

Initial therapy consisting of a single session of PDT combined with IVB and STTA improves vision in treatment-naive subfoveal PCV. Compared with double therapy, this triple therapy may be more effective for PCV.

Polypoidal choroidal vasculopathy: evidence-based guidelines for clinical diagnosis and treatment

BACKGROUND

Polypoidal choroidal vasculopathy (PCV) is an exudative maculopathy affecting vision, with clinical features distinct from neovascular age-related macular degeneration. Currently, no evidence-based guidelines exist for its diagnosis and treatment.

METHODS

A panel of experts analyzed a systematic literature search on PCV together with results of the EVEREST trial, the only published randomized controlled clinical trial in PCV. At a subsequent Roundtable meeting, recommendations for the management of PCV were agreed based on this analysis and their own expert opinion.

RESULTS

Diagnosis of PCV should be based on early-phase nodular hyperfluorescence from choroidal vasculature visualized using indocyanine green angiography. Recommended initial treatment of juxtafoveal and subfoveal PCV is either indocyanine green angiography-guided verteporfin photodynamic therapy or verteporfin photodynamic therapy plus 3 × 0.5 mg ranibizumab intravitreal injections 1 month apart. If there is incomplete regression of polyps by indocyanine green angiography, eyes should be retreated with verteporfin photodynamic therapy monotherapy or verteporfin photodynamic therapy plus ranibizumab. If there is complete regression of polyps by indocyanine green angiography, but there is leakage on fluorescein angiography and other clinical or anatomical signs of disease activity, eyes should be retreated with ranibizumab.

CONCLUSION

Practical guidance on the clinical management of PCV is proposed based on expert evaluation of current evidence.

Photodynamic therapy with or without intravitreal bevacizumab for polypoidal choroidal vasculopathy: two years of follow-up

PURPOSE

To compare the long-term results of the efficacy of photodynamic therapy (PDT) with or without intravitreal bevacizumab (IVB) injections for polypoidal choroidal vasculopathy.

DESIGN

Retrospective, comparative, interventional case series.

METHODS

We included 69 eyes of 69 patients with macula-involved polypoidal choroidal vasculopathy. All patients were followed up for more than 2 years. We compared the treatment outcomes between groups and investigated the factors influencing visual improvement at 24 months of follow-up.

RESULTS

Thirty-six patients received PDT combined with IVB and 33 patients received PDT monotherapy. At 3 months, the mean logarithm of minimal angle of resolution (logMAR) best-corrected visual acuity (BCVA) improved from 0.73 to 0.53 in the combined therapy group (P < .001) and from 0.79 to 0.72 in the PDT monotherapy group (P = .02), with a significant difference in treatment efficacy between the 2 groups (P < .001). However, the improvements in BCVA were not statistically significant after 21 months in the combined therapy group and 15 months in the monotherapy group. The difference in treatment efficacy between the 2 groups was not significant after 6 months. Initial BCVA (P = .005), lesion size (P = .011), patient age (P = .018), and location of polyps (P = .006) significantly predicted the final visual outcome rather than treatment modality (P = .243).

CONCLUSIONS

PDT combined with IVB for symptomatic PCV was temporarily superior to PDT monotherapy, and the treatment efficacy decreased with time. Initial BCVA, lesion size, and location were more significant than treatment modality as the factors influencing final visual improvement.

Two-year outcome of photodynamic therapy combined with intravitreal injection of bevacizumab and triamcinolone acetonide for polypoidal choroidal vasculopathy

PURPOSE

To compare the 2-year results after photodynamic therapy (PDT) alone and PDT combined with intravitreal injections of bevacizumab and triamcinolone acetonide (triple therapy) for polypoidal choroidal vasculopathy (PCV).

METHODS

We retrospectively reviewed the medical records of 40 consecutive patients (40 eyes) with subfoveal PCV. Of these 40 eyes, 16 were treated with PDT alone and 24 were treated with triple therapy.

RESULTS

The change in visual acuity in the triple therapy group was significantly better than that in the PDT group (P < 0.001). At 24 months, improvement in visual acuity was seen in only two eyes (12.5 %) of the PDT group, while it was seen in ten eyes (41.7 %) of the triple therapy group. Retreatment was given to 12 eyes (75.0 %) in the PDT group and to nine eyes (37.5 %) in the triple therapy group, although the retreatment-free period was significantly longer in the triple therapy group than in the PDT group (P < 0.001). Post-treatment vitreous hemorrhage was seen in only two eyes (12.5 %), all of which were in the PDT group.

CONCLUSION

Compared with PDT alone, triple therapy appears to reduce the postoperative hemorrhagic complications and recurrences of PCV and to improve the 2-year visual outcomes of PCV.

An Update in Laser and Pharmaceutical Treatment for Polypoidal Choroidal Vasculopathy

Polypoidal choroidal vasculopathy (PCV) is a condition characterized by multiple, recurrent, serosanguineous pigment epithelium detachment and neurosensory retinal detachment due to abnormal choroidal polypoidal lesions. Polypoidal choroidal vasculopathy is particularly prevalent in Asians and occurs in up to 30% of patients presenting with neovascular age-related macular degeneration. In recent years, various treatment modalities have been described in the literature for the treatment of PCV. This review article aims to provide an overview and to summarize the current nonsurgical treatment for PCV.

Intravitreal ranibizumab with or without photodynamic therapy for the treatment of symptomatic polypoidal choroidal vasculopathy

PURPOSE

To evaluate the efficacy of intravitreal ranibizumab with or without verteporfin photodynamic therapy (PDT) in the treatment of symptomatic polypoidal choroidal vasculopathy.

METHODS

Twenty-three eyes of 23 patients received 3 monthly intravitreal ranibizumab injections with or without indocyanine green angiography-guided PDT at baseline. All patients had follow-up of ≥12 months. Visual and anatomical outcomes were compared between the two groups and a PDT monotherapy group.

RESULTS

Seven eyes had ranibizumab monotherapy, 16 had combined ranibizumab injections and verteporfin PDT, and 12 had PDT monotherapy. At 3 months, the mean logarithm of minimal angle of resolution best-corrected visual acuity improved from 0.92 to 0.74 in the ranibizumab group (P = 0.18), from 0.70 to 0.59 in the combined group (P = 0.037), and from 0.74 to 0.57 in the PDT monotherapy group (P = 0.014). Complete regression of polypoidal lesions in indocyanine green angiography was found in 1 (14.3%) eye in the ranibizumab group, compared with 15 (93.8%) eyes in the combined group (P = 0.001). Additional PDT and ranibizumab injections in eyes with persistent polyps and fluorescein leakage resulted in regression of polyps in all eyes. At 12 months, no significant difference in logarithm of minimal angle of resolution best-corrected visual acuity and visual change was found between eyes initially treated with ranibizumab monotherapy, combined ranibizumab and PDT, or PDT monotherapy (P = 1.00 and P = 0.11, respectively).

CONCLUSION

Intravitreal ranibizumab appeared to result in stabilization of vision in patients with symptomatic polypoidal choroidal vasculopathy. However, combined ranibizumab and PDT appeared to be more effective in causing complete regression of the polypoidal lesions in indocyanine green angiography compared with ranibizumab monotherapy.