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Teo KYC, Park KH, Ngah NF, Chen SJ, Ruamviboonsuk P, Mori R, Kondo N, Lee WK, Rajagopalan R, Obata R, Wong IYH, Chee C, Terasaki H, Sekiryu T, Chen SC, Yanagi Y, Honda S, Lai TYY, Cheung CMG. Six-Year Outcomes in Subjects with Polypoidal Choroidal Vasculopathy in the EVEREST II Study. Ophthalmol Ther 2024; 13:935-954. [PMID: 38308746 PMCID: PMC10912383 DOI: 10.1007/s40123-024-00888-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/11/2024] [Indexed: 02/05/2024] Open
Abstract
INTRODUCTION The EVEREST II study previously reported that intravitreally administered ranibizumab (IVR) combined with photodynamic therapy (PDT) achieved superior visual gain and polypoidal lesion closure compared to IVR alone in patients with polypoidal choroidal vasculopathy (PCV). This follow-up study reports the long-term outcomes 6 years after initiation of the EVEREST II study. METHODS This is a non-interventional cohort study of 90 patients with PCV from 16 international trial sites who originally completed the EVEREST II study. The long-term outcomes were assessed during a recall visit at about 6 years from commencement of EVEREST II. RESULTS The monotherapy and combination groups contained 41 and 49 participants, respectively. The change in best-corrected visual acuity (BCVA) from baseline to year 6 was not different between the monotherapy and combination groups; - 7.4 ± 23.0 versus - 6.1 ± 22.4 letters, respectively. The combination group had greater central subfield thickness (CST) reduction compared to the monotherapy group at year 6 (- 179.9 vs - 74.2 µm, p = 0.011). Fewer eyes had subretinal fluid (SRF)/intraretinal fluid (IRF) in the combination versus monotherapy group at year 6 (35.4% vs 57.5%, p = 0.032). Factors associated with BCVA at year 6 include BCVA (year 2), CST (year 2), presence of SRF/IRF at year 2, and number of anti-VEGF treatments (years 2-6). Factors associated with presence of SRF/IRF at year 6 include combination arm (OR 0.45, p = 0.033), BCVA (year 2) (OR 1.53, p = 0.046), and presence of SRF/IRF (year 2) (OR 2.59, p = 0.042). CONCLUSION At 6 years following the EVEREST II study, one-third of participants still maintained good vision. As most participants continued to require treatment after exiting the initial trial, ongoing monitoring and re-treatment regardless of polypoidal lesion status are necessary in PCV. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT01846273.
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Affiliation(s)
- Kelvin Yi Chong Teo
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore, 168751, Singapore
| | - Kyu-Hyung Park
- Department of Ophthalmology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | | | - Shih-Jen Chen
- Department of Ophthalmology, Taipei Veterans General Hospital, School of Medicine, National Yang Ming Chiao Yung University, 201 Shih-Pai Road, Taipei, 112, Taiwan
| | - Paisan Ruamviboonsuk
- Department of Ophthalmology, College of Medicine, Rangsit University, Rajavithi Hospital, Bangkok, Thailand
| | - Ryusaburo Mori
- Department of Ophthalmology, Nihon University School of Medicine, Tokyo, Japan
| | - Nagako Kondo
- Miyake Eye Hospital Ophthalmology, Ozone, Kita-ku, Nagoya City, Japan
| | | | - Rajesh Rajagopalan
- Tan Tock Seng Hospital, National Healthcare Group Eye Institute, Singapore, Singapore
| | - Ryo Obata
- The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
| | - Ian Y H Wong
- Hong Kong Sanatorium and Hospital, Happy Valley, Hong Kong
| | | | | | - Tetsuju Sekiryu
- Fukushima Medical University Hospital, Fukushima City, Fukushima, Japan
| | | | - Yasuo Yanagi
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore, 168751, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Shigeru Honda
- Osaka Metropolitan University Hospital, Osaka City, Osaka, Japan
| | - Timothy Y Y Lai
- Department of Ophthalmology and Visual Sciences, Hong Kong Eye Hospital, 147K Argyle Street, Kowloon, Hong Kong
| | - Chui Ming Gemmy Cheung
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore, 168751, Singapore.
- Department of Ophthalmology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
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Dong S, Fan P, Yu H, Jiang B, Sun D. A study of the relationship between cytokine levels and the response to anti-VEGF therapy in polypoid choroidal vasculopathy with different choroidal thicknesses. Front Endocrinol (Lausanne) 2024; 14:1307337. [PMID: 38260125 PMCID: PMC10802117 DOI: 10.3389/fendo.2023.1307337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/07/2023] [Indexed: 01/24/2024] Open
Abstract
Purpose Polypoidal choroidal vasculopathy (PCV) is an irreversible retinal choroidal disease. Individuals with PCV exhibit diverse baseline characteristics, including systemic characteristics, ocular traits, metabolic factor levels, and different responses to intravitreal anti-VEGF therapy. This study aims to investigate the pathogenesis of PCV by analyzing the systemic characteristics, ocular traits, and cytokine levels at baseline within a cohort of patients who exhibit different responses to anti-VEGF treatment. Methods We conducted a retrospective analysis involving 80 eyes diagnosed with PCV. Patients were categorized into two groups based on responses to suboptimal intravitreal ranibizumab injection therapy: those with suboptimal responses and optimal responses. Aqueous humor samples were collected from the experimental eyes, and cytokine expression levels were assessed using cytometric bead array analysis. All subjects were further stratified into two groups according to the median choroidal thickness. Subsequently, logistic regression analysis and the ROC curve were employed to examine the relationship between cytokine expression levels, choroidal thickness, and anti-VEGF response. Results The results revealed that compared to the group of optimal anti-VEGF response, the choroid in the suboptimal response group exhibited a significantly greater thickness. Additionally, compared to the suboptimal anti-VEGF response group, the expression levels of VEGF and VCAM-1 were markedly lower observed in the optimal anti-VEGF response group, while TNF-α showed the opposite trend. Logistic regression analysis indicated that VEGF, VCAM-1, and TNF-α in the aqueous humor were independent risk factors for a suboptimal anti-VEGF response. After adjusting other risk factors, the risk of suboptimal anti-VEGF response decreased to 0.998-fold, 0.997-fold, and 1.294-fold. The AUC values for VEGF, VCAM-1, and TNF-α were determined to be 0.805, 0.846, and 0.897, respectively. Furthermore, the risk of VEGF, VCAM-1, and TNF-α were significantly associated with an increased risk of suboptimal anti-VEGF response after correction for risk factors in the thick choroid group. Conclusions Our study demonstrated that PCV exhibits systemic and ocular characteristics variations based on different anti-VEGF responses. The levels of cytokines in aqueous humor were found to have a significant correlation with the anti-VEGF response in PCV. VEGF, VCAM-1, and TNF-α are potential targets for assessing treatment response in thick choroidal PCV.
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Affiliation(s)
| | | | | | - Bo Jiang
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dawei Sun
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
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Liu B, Lai K, Ma Y, Gao K, Tsai C, Li J, Wei X, Chen Z, Chen Z, Liu Y, Tuxun R, Li T. Systemic Risk Factors for Vitreous Hemorrhage Secondary to Polypoidal Choroidal Vasculopathy. Ophthalmol Ther 2023; 12:2769-2780. [PMID: 37556039 PMCID: PMC10442037 DOI: 10.1007/s40123-023-00783-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 07/26/2023] [Indexed: 08/10/2023] Open
Abstract
INTRODUCTION It remains unclear whether systemic factors are associated with an increased risk of vitreous hemorrhage (VH) secondary to polypoidal choroidal vasculopathy (PCV), and there is no method to predict the possibility of VH occurrence in patients with PCV. This study aimed to investigate and visualize systemic risk factors for VH in patients with PCV. METHODS Data on the sex, age, history of systematic diseases, best-corrected visual acuity, intraocular pressure, and laboratory data of patients with PCV were collected from the medical record system. Univariate and multivariate binary logistic regression analyses were applied to investigate independent risk factors for VH in patients with PCV. Receiver operating characteristic analysis and nomograms were used to visualize the independent risk factors. RESULTS The patient population comprised 115 patients with VH secondary to PCV and 181 patients with PCV without VH. Binary logistic regression analyses showed that higher white blood cell count [WBC; odds ratios (OR) 1.247], higher aspartate aminotransferase/alanine aminotransferase ratio (AST/ALT; OR 2.339), and longer activated partial thromboplastin time (APTT; OR 1.196) were independent risk factors of VH in patients with PCV. Integrated application of APTT, AST/ALT, and WBC as markers showed the best performance for distinguishing patients with VH, with an area under the curve of 0.723. The nomogram was created for doctors to calculate the possibility of VH in a patient with PCV. CONCLUSIONS Higher WBC, higher AST/ALT, and longer APTT are independent serum risk factors of VH secondary to PCV, which may shed light on VH prevention in patients with PCV.
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Affiliation(s)
- Baoyi Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
- Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Kunbei Lai
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
- Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Yuan Ma
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
- Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Kai Gao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
- Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Chinling Tsai
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
- Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Jizhu Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
- Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Xiaoyue Wei
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
- Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Ziye Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
- Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Zitong Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
- Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Yaping Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
- Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Rebiya Tuxun
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China
- Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China
| | - Tao Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou, 510060, China.
- Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, 510060, China.
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Zhao J, Chandrasekaran PR, Cheong KX, Wong M, Teo K. New Concepts for the Diagnosis of Polypoidal Choroidal Vasculopathy. Diagnostics (Basel) 2023; 13:diagnostics13101680. [PMID: 37238165 DOI: 10.3390/diagnostics13101680] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/06/2023] [Accepted: 05/07/2023] [Indexed: 05/28/2023] Open
Abstract
Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular age-related macular degeneration (nAMD) that is characterized by a branching neovascular network and polypoidal lesions. It is important to differentiate PCV from typical nAMD as there are differences in treatment response between subtypes. Indocyanine green angiography (ICGA) is the gold standard for diagnosing PCV; however, ICGA is an invasive detection method and impractical for extensive use for regular long-term monitoring. In addition, access to ICGA may be limited in some settings. The purpose of this review is to summarize the utilization of multimodal imaging modalities (color fundus photography, optical coherence tomography (OCT), OCT angiography (OCTA), and fundus autofluorescence (FAF)) in differentiating PCV from typical nAMD and predicting disease activity and prognosis. In particular, OCT shows tremendous potential in diagnosing PCV. Characteristics such as subretinal pigment epithelium (RPE) ring-like lesion, en face OCT-complex RPE elevation, and sharp-peaked pigment epithelial detachment provide high sensitivity and specificity for differentiating PCV from nAMD. With the use of more practical, non-ICGA imaging modalities, the diagnosis of PCV can be more easily made and treatment tailored as necessary for optimal outcomes.
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Affiliation(s)
- Jinzhi Zhao
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore 168751, Singapore
- Tianjin Medical University Eye Hospital, Tianjin 300392, China
| | - Priya R Chandrasekaran
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore 168751, Singapore
| | - Kai Xiong Cheong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore 168751, Singapore
| | - Mark Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore 168751, Singapore
| | - Kelvin Teo
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore 168751, Singapore
- Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore 169857, Singapore
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Ruamviboonsuk P, Lai TYY, Chen SJ, Yanagi Y, Wong TY, Chen Y, Gemmy Cheung CM, Teo KYC, Sadda S, Gomi F, Chaikitmongkol V, Chang A, Lee WK, Kokame G, Koh A, Guymer R, Lai CC, Kim JE, Ogura Y, Chainakul M, Arjkongharn N, Hong Chan H, Lam DSC. Polypoidal Choroidal Vasculopathy: Updates on Risk Factors, Diagnosis, and Treatments. Asia Pac J Ophthalmol (Phila) 2023; 12:184-195. [PMID: 36728294 DOI: 10.1097/apo.0000000000000573] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/09/2022] [Indexed: 02/03/2023] Open
Abstract
There have been recent advances in basic research and clinical studies in polypoidal choroidal vasculopathy (PCV). A recent, large-scale, population-based study found systemic factors, such as male gender and smoking, were associated with PCV, and a recent systematic review reported plasma C-reactive protein, a systemic biomarker, was associated with PCV. Growing evidence points to an association between pachydrusen, recently proposed extracellular deposits associated with the thick choroid, and the risk of development of PCV. Many recent studies on diagnosis of PCV have focused on applying criteria from noninvasive multimodal retinal imaging without requirement of indocyanine green angiography. There have been attempts to develop deep learning models, a recent subset of artificial intelligence, for detecting PCV from different types of retinal imaging modality. Some of these deep learning models were found to have high performance when they were trained and tested on color retinal images with corresponding images from optical coherence tomography. The treatment of PCV is either a combination therapy using verteporfin photodynamic therapy and anti-vascular endothelial growth factor (VEGF), or anti-VEGF monotherapy, often used with a treat-and-extend regimen. New anti-VEGF agents may provide more durable treatment with similar efficacy, compared with existing anti-VEGF agents. It is not known if they can induce greater closure of polypoidal lesions, in which case, combination therapy may still be a mainstay. Recent evidence supports long-term follow-up of patients with PCV after treatment for early detection of recurrence, particularly in patients with incomplete closure of polypoidal lesions.
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Affiliation(s)
| | - Timothy Y Y Lai
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Shih-Jen Chen
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yasuo Yanagi
- Department of Ophthalmology and Microtechnology, Yokohama City University, Yokohama, Japan
| | - Tien Yin Wong
- Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore
- School of Medicine, Tsinghua University, Beijing, China
| | - Youxin Chen
- Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Chui Ming Gemmy Cheung
- Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore
| | - Kelvin Y C Teo
- Singapore National Eye Centre, Singapore, Singapore
- Duke-NUS Medical School, National University of Singapore, Singapore
- Singapore Eye Research Institute, Singapore, Singapore
| | - Srinivas Sadda
- Doheny Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Fumi Gomi
- Department of Ophthalmology, Hyogo Medical University, Hyogo, Japan
| | - Voraporn Chaikitmongkol
- Retina Division, Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Andrew Chang
- Sydney Retina Clinic, Sydney Eye Hospital, University of Sydney, Sydney, NSW, Australia
| | | | - Gregg Kokame
- Division of Ophthalmology, Department of Surgery, University of Hawaii School of Medicine, Honolulu, HI
| | - Adrian Koh
- Eye & Retina Surgeons, Camden Medical Centre, Singapore, Singapore
| | - Robyn Guymer
- Centre for Eye Research Australia, University of Melbourne, The Royal Victorian Eye and Ear Hospital, Melbourne, Australia
| | - Chi-Chun Lai
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Judy E Kim
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee, WI
| | - Yuichiro Ogura
- Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
| | | | | | | | - Dennis S C Lam
- The C-MER International Eye Research Center of The Chinese University of Hong Kong (Shenzhen), Shenzhen, China
- The C-MER Dennis Lam & Partners Eye Center, C-MER International Eye Care Group, Hong Kong, China
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Choi YA, Jeong A, Woo CH, Cha SC, Park DY, Sagong M. Aqueous microRNA profiling in age-related macular degeneration and polypoidal choroidal vasculopathy by next-generation sequencing. Sci Rep 2023; 13:1274. [PMID: 36690666 PMCID: PMC9870898 DOI: 10.1038/s41598-023-28385-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/18/2023] [Indexed: 01/24/2023] Open
Abstract
Although many studies demonstrated the differences of clinical features, natural course, and response to treatment between typical age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV), differential microRNAs (miRNAs) expression in the aqueous humor (AH) between them has not been reported yet. We investigated the roles of miRNAs in the AH of patients with typical AMD and PCV using next-generation sequencing (NGS) and quantitative PCR (qPCR). Target genes and predicted pathways of miRNAs were investigated via pathway enrichment analysis using the Kyoto Encyclopedia of Genes and Genomes database. A total of 161 miRNAs from eyes with typical AMD and 185 miRNAs from eyes with PCV were differentially expressed. 33 miRNAs were commonly upregulated, and 77 miRNAs were commonly downregulated in both typical AMD and PCV groups. Among them, hsa-miR-140-5p, hsa-miR-374c-3p, and hsa-miR-200a-5p were differentially expressed and were predicted to regulate proteoglycans in cancer, p53 signaling pathway, Hippo signaling pathway, and adherens junction. The differential expression profiles and target gene regulation networks of AH miRNAs may contribute to the development of different pathological phenotypes in typical AMD and PCV. The results of this study provide novel insights into the pathogenesis, associated prognostic biomarkers, and therapeutic targets in AMD and PCV.
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Affiliation(s)
- Yeong A Choi
- Department of Ophthalmology, Yeungnam University College of Medicine, #170 Hyunchungro, Nam-Gu, Daegu, 42415, South Korea
- Yeungnam Eye Center, Yeungnam University Hospital, Daegu, South Korea
| | - Areum Jeong
- Department of Ophthalmology, Yeungnam University College of Medicine, #170 Hyunchungro, Nam-Gu, Daegu, 42415, South Korea
- Yeungnam Eye Center, Yeungnam University Hospital, Daegu, South Korea
| | - Chang-Hoon Woo
- Department of Pharmacology, Yeungnam University College of Medicine, Daegu, South Korea
| | - Soon Cheol Cha
- Department of Ophthalmology, Yeungnam University College of Medicine, #170 Hyunchungro, Nam-Gu, Daegu, 42415, South Korea
- Yeungnam Eye Center, Yeungnam University Hospital, Daegu, South Korea
| | - Do Young Park
- Department of Ophthalmology, Yeungnam University College of Medicine, #170 Hyunchungro, Nam-Gu, Daegu, 42415, South Korea
- Yeungnam Eye Center, Yeungnam University Hospital, Daegu, South Korea
| | - Min Sagong
- Department of Ophthalmology, Yeungnam University College of Medicine, #170 Hyunchungro, Nam-Gu, Daegu, 42415, South Korea.
- Yeungnam Eye Center, Yeungnam University Hospital, Daegu, South Korea.
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Sen P, Manayath G, Shroff D, Salloju V, Dhar P. Polypoidal Choroidal Vasculopathy: An Update on Diagnosis and Treatment. Clin Ophthalmol 2023; 17:53-70. [PMID: 36636621 PMCID: PMC9831529 DOI: 10.2147/opth.s385827] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/05/2022] [Indexed: 01/06/2023] Open
Abstract
Polypoidal choroidal vasculopathy (PCV) is a vascular disease of the choroid that leads to hemorrhagic and exudative macular degeneration. It may cause significant vision loss and thus affect the quality-of-life and psychological well-being. Non-invasive, non-ICGA-based OCT criteria have shown reliable results to plan adjunct photodynamic therapy (PDT) treatment, with the complete and consistent coverage of polypoidal lesions (PL) and branching neovascular network (BNN). The safety and efficacy of anti-vascular endothelial growth factor (anti-VEGF) monotherapy and its combination with verteporfin PDT have been established. However, treatment is still challenging due to frequent follow-ups, non-availability of PDT, and need for multiple anti-VEGF injection visits that increase the treatment burden and lead to patients being lost to follow-up. Effective treatments that prolong intervals between injections while maintaining vision and anatomical gains remain a critical unmet need. Longer acting molecules, like brolucizumab, have shown non-inferiority in BCVA gains and superior anatomical outcomes compared to other anti-VEGF agents. Newer therapies in the pipeline to enhance the efficacy and longevity of treatment include Faricimab and a port delivery system (PDS). This review summarizes the most recent diagnostic and treatment approaches in PCV to offer better treatment avenues.
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Affiliation(s)
- Parveen Sen
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil NaduIndia
| | - George Manayath
- Department of Retina and Vitreous Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Coimbatore, India,Correspondence: George Manayath, Department of Retina and Vitreous Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Coimbatore, Tamil Nadu, India, Email
| | - Daraius Shroff
- Vitreoretinal Services, Shroff Eye Centre, New Delhi, India
| | - Vineeth Salloju
- Medical Affairs, Novartis Healthcare Private Limited, Mumbai, India
| | - Priyanka Dhar
- Medical Affairs, Novartis Healthcare Private Limited, Mumbai, India
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Chaikitmongkol V, Ozimek M, Srisomboon T, Patikulsila D, Fraser-Bell S, Chhablani J, Choovuthayakorn J, Watanachai N, Kunavisarut P, Rodríguez-Valdés PJ, Lozano-Rechy D, Lupidi M, Al-Sheikh M, Fung AT, Busch C, Mehta H, Gabrielle PH, Zur D, Ramon D, Sangkaew A, Ingviya T, Amphornprut A, Cebeci Z, Couturier A, Mendes TS, Giancipoli E, Iglicki M, Invernizzi A, Lains I, Rehak M, Sala-Puigdollers A, Okada M, Loewenstein A, Bressler NM. Polypoidal Choroidal Vasculopathy Based on Non-ICGA Criteria in White Patients With Neovascular Age-Related Macular Degeneration. Am J Ophthalmol 2022; 244:58-67. [PMID: 35952753 DOI: 10.1016/j.ajo.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 01/30/2023]
Abstract
PURPOSE To determine prevalence of probable polypoidal choroidal vasculopathy (PCV) among White patients with neovascular age-related macular degeneration (nAMD) using non-indocyanine green angiography (ICGA) criteria DESIGN: Multicenter, multinational, retrospective, cross-sectional study. METHODS A total of 208 treatment-naive eyes from Hispanic and non-Hispanic White individuals diagnosed with nAMD were included. All underwent color fundus photography (CFP), optical coherence tomography (OCT), and fluorescein angiography (FFA). De-identified images of study eyes were sent to 2 groups of graders. Group 1 reviewed CFP, OCT, and FFA to confirm nAMD diagnosis. Group 2 reviewed CFP and OCT to determine highly suggestive features for PCV. Probable PCV diagnosis defined as the presence of ≥2 of 4 highly suggestive features for PCV: notched or fibrovascular pigment epithelial detachment (PED) on CFP, sharply-peaked PED, notched PED, and hyperreflective ring on OCT. RESULTS Eleven eyes were excluded because of poor image quality (6) or non-nAMD diagnosis (5). Of 197 eligible eyes (197 patients), the mean age (SD) was 78.8 years (8.9), 44.2% were men, 26.4% were Hispanic, and 73.6% were non-Hispanic White individuals; 41.1%, 23.4%, 9.1%, and 2.5% had ≥1, ≥2, ≥3, and 4 highly suggestive features. Results showed that 23.4% (95% CI, 17.6%-29.9%) had probable PCV diagnosis. Predominantly occult CNV was more frequently found in probable PCV than nAMD subgroup (84.8% vs 64.9%, P = .01). Hispanic White individuals had a lower prevalence of probable PCV than non-Hispanic White individuals (9.6% vs 28.2%, P = .006) CONCLUSIONS: These findings suggest that probable PCV occurs between 17.6% and 29.9% in White individuals with nAMD, and more commonly in non-Hispanic than in Hispanic White individuals.
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Affiliation(s)
- Voraporn Chaikitmongkol
- Retina Division (V.C., T.S., D.P., J.C., N.W., P.K., A.S.), Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Malgorzata Ozimek
- Department of General Ophthalmology (M.O.), Medical University in Lublin, Lublin, Poland; Eye Surgery Center Prof. Zagorski (M.O.), Nowy Sacz, Poland
| | - Titipol Srisomboon
- Retina Division (V.C., T.S., D.P., J.C., N.W., P.K., A.S.), Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Department of Ophthalmology (T.S.), Nakornping Hospital, Chiang Mai, Thailand
| | - Direk Patikulsila
- Retina Division (V.C., T.S., D.P., J.C., N.W., P.K., A.S.), Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Samantha Fraser-Bell
- Department of Ophthalmology (S.F.-B.), Save Sight Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Jay Chhablani
- Retina Division (V.C., T.S., D.P., J.C., N.W., P.K., A.S.), Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Department of Ophthalmology (J.C.), University of Pittsburgh Eye Center, Pittsburgh, Pennsylvania, USA
| | - Janejit Choovuthayakorn
- Retina Division (V.C., T.S., D.P., J.C., N.W., P.K., A.S.), Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nawat Watanachai
- Retina Division (V.C., T.S., D.P., J.C., N.W., P.K., A.S.), Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Paradee Kunavisarut
- Retina Division (V.C., T.S., D.P., J.C., N.W., P.K., A.S.), Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Patricio J Rodríguez-Valdés
- Instituto de Oftalmologia y Ciencias Visuales (P.J.R.-V.), Hospital Zambrano Hellion, Tecnologico de Monterrey, Monterrey, Mexico
| | | | - Marco Lupidi
- Eye Clinic (L.R.), Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy; Fondazione per la Macula Onlus, Di.N.O.G.Mi., Section of Ophthalmology, University of Perugia, Perugia, Italy
| | - Mayss Al-Sheikh
- Department of Ophthalmology (M.A.-S.), University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Adrian T Fung
- Westmead and Central Clinical Schools (A.T.F.), Specialty of Ophthalmology and Eye Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Ophthalmology(A.T.F.), Faculty of Medicine, Health and Human Sciences, Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Catharina Busch
- Department of Ophthalmology (C.B., M.R.), University of Leipzig, Leipzig, Germany
| | - Hemal Mehta
- Department of Ophthalmology (H.M.), Royal Free London NHS Foundation Trust, London, UK
| | | | - Dinah Zur
- Division of Ophthalmology (D.Z., D.R., A.L.), Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dan Ramon
- Division of Ophthalmology (D.Z., D.R., A.L.), Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Apisara Sangkaew
- Retina Division (V.C., T.S., D.P., J.C., N.W., P.K., A.S.), Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Thammasin Ingviya
- Department of Family Medicine and Preventive Medicine (T.I.), Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Atchara Amphornprut
- Retina Division, Department of Ophthalmology (A.A.), Faculty of Medicine, Rajvithi Hospital, Rangsit University, Bangkok, Thailand
| | - Zafer Cebeci
- Department of Ophthalmology (Z.C.), Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aude Couturier
- Ophthalmology Department A.C.), Université de Paris, AP-HP, Hôpital Lariboisière, Paris, France
| | - Thais Sousa Mendes
- Department of Ophthalmology (T.S.M.), Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Ermete Giancipoli
- Department of Ophthalmology (E.G.), "Ospedale Vito Fazzi", Piazza Filippo Muratore, Lecce, Italy
| | - Matias Iglicki
- University of Buenos Aires (M.I .), Buenos Aires, Argentina
| | - Alessandro Invernizzi
- Eye Clinic - Department of Biomedical and Clinical Science "Luigi Sacco" (A.I.)'', Luigi Sacco Hospital, University of Milan, Milan, Italy; Save Sight Institute, Discipline of Ophthalmology (A.I.), Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Ines Lains
- Department of Ophthalmology (I.L.), Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Matus Rehak
- Department of Ophthalmology (C.B., M.R.), University of Leipzig, Leipzig, Germany; Department of Ophthalmology (M.R.), Justus-Liebig University Giessen, Giessen, Germany
| | - Anna Sala-Puigdollers
- Retina Division (V.C., T.S., D.P., J.C., N.W., P.K., A.S.), Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Institut Clínic d'Oftalmologia (ICOF) (A.S.-P.), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Mali Okada
- Department of Ophthalmology (M.O.), Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Anat Loewenstein
- Division of Ophthalmology (D.Z., D.R., A.L.), Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Neil M Bressler
- Retina Division (N.M.B.), Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
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9
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Zhou H, Zhao X, Chen Y. Plasma Cytokine Profiles in Patients With Polypoidal Choroidal Vasculopathy and Neovascular Age-Related Macular Degeneration. Asia Pac J Ophthalmol (Phila) 2022; 11:536-542. [PMID: 36417678 DOI: 10.1097/apo.0000000000000577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 09/14/2022] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The concentrations of cytokines in plasma may be different between neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV). We studied plasma levels of cytokines in patients with nAMD and PCV and compared them with control individuals. METHODS This was a prospective, clinic-based, case-control study of treatment-naive participants (n=49) with PCV (n=24), nAMD (n=11), and cataract controls (n=14). We sampled fresh venous blood and isolated plasma for analysis. Plasma concentrations of 34 angiogenic and inflammatory cytokines were determined by Luminex bead-based multiplex array. RESULTS After adjusting for gender and age using multivariate logistic analysis, we found that the plasma concentrations of monocyte chemoattractant protein-1, vascular endothelial growth factor (VEGF)-A, and VEGF-D significantly higher in both nAMD and PCV patients than those in controls (all P<0.05, times in nAMD: 3.5, 4.3, and 13.8, respectively, times in PCV: 4.1, 4.0, and 11.5, respectively). In contrast, the plasma concentration of platelet-derived growth factor-BB was significantly lower in nAMD and PCV patients than those in controls (all P<0.05, times in nAMD: 1.6, times in PCV: 1.7). The plasma levels of leukemia inhibitory factor in nAMD group were significantly higher compared with PCV group (P<0.0167). CONCLUSIONS Multiple cytokines involved in systemic inflammation and angiogenesis including monocyte chemoattractant protein-1, platelet-derived growth factor-BB, VEGF-A, and VEGF-D may contribute to the pathogenesis of nAMD and PCV. Measurement of leukemia inhibitory factor in the plasma may help differentiate nAMD from PCV. This finding suggests that the 2 disorders may have different molecular mechanisms, and additional longitudinal studies will be needed to determine whether these findings have clinical relevance to influence treatment algorithms or provide novel targets for medical therapy.
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Affiliation(s)
- Huiying Zhou
- Department of Ophthalmology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinyu Zhao
- Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Youxin Chen
- Department of Ophthalmology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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10
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Liu P, Lavine JA, Fawzi A, Quaggin SE, Thomson BR. Angiopoietin-1 Is Required for Vortex Vein and Choriocapillaris Development in Mice. Arterioscler Thromb Vasc Biol 2022; 42:1413-1427. [PMID: 36172864 PMCID: PMC9613622 DOI: 10.1161/atvbaha.122.318151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/16/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The choroidal vasculature, including the choriocapillaris and vortex veins, is essential for providing nutrients to the metabolically demanding photoreceptors and retinal pigment epithelium. Choroidal vascular dysfunction leads to vision loss and is associated with age-related macular degeneration and the poorly understood pachychoroid diseases including central serous chorioretinopathy and polypoidal choroidal vasculopathy that are characterized by formation of dilated pachyvessels throughout the choroid. METHODS Using neural crest-specific Angpt1 knockout mice, we show that Angiopoietin 1, a ligand of the endothelial receptor TEK (also known as Tie2) is essential for choriocapillaris development and vortex vein patterning. RESULTS Lacking choroidal ANGPT1, neural crest-specific Angpt1 knockout eyes exhibited marked choriocapillaris attenuation and 50% reduction in number of vortex veins, with only 2 vortex veins present in the majority of eyes. Shortly after birth, dilated choroidal vessels resembling human pachyvessels were observed extending from the remaining vortex veins and displacing the choriocapillaris, leading to retinal pigment epithelium dysfunction and subretinal neovascularization similar to that seen in pachychoroid disease. CONCLUSIONS Together, these findings identify a new role for ANGPT1 in ocular vascular development and demonstrate a clear link between vortex vein dysfunction, pachyvessel formation, and disease.
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Affiliation(s)
- Pan Liu
- Section of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago IL, USA
- Feinberg Cardiovascular and Renal Research Inst. Chicago, IL, USA
| | - Jeremy A. Lavine
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Amani Fawzi
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Susan E Quaggin
- Section of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago IL, USA
- Feinberg Cardiovascular and Renal Research Inst. Chicago, IL, USA
| | - Benjamin R. Thomson
- Feinberg Cardiovascular and Renal Research Inst. Chicago, IL, USA
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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11
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Sirks MJ, van Dijk EHC, Rosenberg N, Hollak CEM, Aslanis S, Cheung CMG, Chowers I, Eandi CM, Freund KB, Holz FG, Kaiser PK, Lotery AJ, Ohno-Matsui K, Querques G, Subhi Y, Tadayoni R, Wykoff CC, Zur D, Diederen RMH, Boon CJF, Schlingemann RO. Clinical impact of the worldwide shortage of verteporfin (Visudyne®) on ophthalmic care. Acta Ophthalmol 2022; 100:e1522-e1532. [PMID: 35388619 PMCID: PMC9790583 DOI: 10.1111/aos.15148] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/23/2022] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Since July 2021, a worldwide shortage of verteporfin (Visudyne®) occurred: an essential medicine required for photodynamic therapy (PDT). PDT with verteporfin has a broad range of indications in ophthalmology, including chronic central serous chorioretinopathy, polypoidal choroidal vasculopathy and choroidal haemangioma. For these disorders, PDT is either the first-choice treatment or regarded as a major treatment option. MATERIALS AND METHODS A questionnaire was sent to key opinion leaders in the field of medical retina throughout the world, to assess the role of PDT in their country and the effects of the shortage of verteporfin. In addition, information on the application of alternative treatments during shortage of verteporfin was obtained, to further assess the impact of the shortage. RESULTS Our questionnaire indicated that the shortage of verteporfin had a major impact on ophthalmic care worldwide and was regarded to be a serious problem by most of our respondents. However, even though there is ample evidence to support the use of PDT in several chorioretinal diseases, we found notable differences in its use in normal patient care throughout the world. Various alternative management strategies were noted during the verteporfin shortage, including lowering the dose of verteporfin per patient, the use of alternative treatment strategies and the use of a centralized system for allocating the remaining ampoules of verteporfin in some countries. CONCLUSION The shortage of verteporfin has had a large effect on the care of ophthalmic patients across the world and may have resulted in significant and irreversible vision loss. Mitigation strategies should be developed in consultation with all stakeholders to avoid future medication shortages of verteporfin and other unique ophthalmic medications. These strategies may include mandatory stock keeping, compulsory licensing to an alternative manufacturer or incentivizing the development of competition, for example through novel public-private partnerships.
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Affiliation(s)
- Marc J Sirks
- Department of Ophthalmology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Elon H C van Dijk
- Department of Ophthalmology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Noa Rosenberg
- Medicine for Society, Platform at Amsterdam University Medical Centres - University of Amsterdam, Amsterdam, The Netherlands.,Department of Endocrinology and Metabolism, Amsterdam UMC - University of Amsterdam, Amsterdam, The Netherlands
| | - Carla E M Hollak
- Medicine for Society, Platform at Amsterdam University Medical Centres - University of Amsterdam, Amsterdam, The Netherlands.,Department of Endocrinology and Metabolism, Amsterdam UMC - University of Amsterdam, Amsterdam, The Netherlands.,Sphinx, Amsterdam Lysosome Center, Amsterdam, The Netherlands
| | | | - Chui Ming Gemmy Cheung
- Singapore National Eye Center, Singapore, Singapore.,Singapore Eye Research Institute, Singapore, Singapore
| | - Itay Chowers
- Department of Ophthalmology, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Chiara M Eandi
- Department of Ophthalmology, University of Lausanne, Jules Gonin Eye Hospital, Fondation Asile Des Aveugles, Lausanne, Switzerland.,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - K Bailey Freund
- Vitreous Retina Macula Consultants of New York, New York, New York, USA.,Department of Ophthalmology, New York University Grossman School of Medicine, New York, New York, USA
| | - Frank G Holz
- Department of Ophthalmology, University of Bonn, Bonn, Germany
| | | | - Andrew J Lotery
- Faculty of Medicine, University of Southampton, Southampton, UK
| | | | - Giuseppe Querques
- IRCCS San Raffaele Scientific Institute, University Vita Salute San Raffaele, Milan, Italy
| | - Yousif Subhi
- Department of Ophthalmology, Rigshospitalet, Glostrup, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ramin Tadayoni
- University of Paris, Paris, France.,Hôpital Lariboisière, AP-HP, Paris, France.,Hôpital Fondation Adolphe de Rothschild, Paris, France
| | - Charles C Wykoff
- Retina Consultants of Texas, Retina Consultants of America, Houston, Texas, USA.,Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Dinah Zur
- Ophthalmology Division, Tel Aviv Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roselie M H Diederen
- Department of Ophthalmology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Camiel J F Boon
- Department of Ophthalmology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands.,Department of Ophthalmology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Reinier O Schlingemann
- Department of Ophthalmology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands.,Department of Ophthalmology, University of Lausanne, Jules Gonin Eye Hospital, Fondation Asile Des Aveugles, Lausanne, Switzerland
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12
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Chaikitmongkol V, Chaovisitsaree T, Patikulsila D, Kunavisarut P, Phasukkijwatana N, Watanachai N, Choovuthayakorn J, Isipradit S, Boonyot P, Sangkaew A, Ingviya T, Bressler SB, Bressler NM. Optical Coherence Tomography Features for Identifying Posttreatment Complete Polypoidal Regression in Polypoidal Choroidal Vasculopathy. Asia Pac J Ophthalmol (Phila) 2022; 11:408-416. [PMID: 36179334 DOI: 10.1097/apo.0000000000000551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 06/09/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To determine accuracy and relative risk (RR) of posttreatment optical coherence tomography (OCT) features in identifying complete or incomplete polypoidal regression in polypoidal choroidal vasculopathy (PCV). DESIGN Validity analysis. METHODS Treatment-naive PCV eyes undergoing OCT and indocyanine green angiography (ICGA) at baseline and posttreatment were included. Two graders confirmed diagnosis and identified posttreatment complete or incomplete regression on ICGA. Two other graders classified OCT characteristics of pigment epithelial detachment (PED) (polypoidal lesion) based on 5 prespecified features: "A," no PED; "B," PED with internal homogeneous reflectivity with predominant "BUN" (blended retinal pigment epithelium with underlying structure) sign; "C," PED with internal homogeneous reflectivity with minimal "BUN"; "D," heterogeneous PED; and "E," PED with hyporeflectivity. RESULTS Among 130 polypoidal lesions (65 pretreatment and 65 posttreatment) of 39 PCV eyes (39 patients; 54% female; mean age±SD: 64.6±8.2), all pretreatment lesions showed feature D on OCT. Posttreatment lesions with complete regression (31 lesions) showed OCT features A, B, C, D, and E in 32%, 45%, 13%, 10%, and 0%, respectively. Posttreatment lesions with incomplete regression (34 lesions) showed OCT features A, B, C, D, and E in 0%, 6%, 15%, 79%, and 0%, respectively. Presence of either feature A or B had highest accuracy (86%; 95% confidence interval: 75%-93%); 77% sensitivity; 94% specificity; RR 5.0 (3.5-7.1, P<0.001) for complete regression. Presence of feature D had highest accuracy (85%; 95% confidence interval: 74%-92%); 79% sensitivity; 90% specificity; RR 4.6 (3.0-6.9, P<0.001) for incomplete regression. CONCLUSIONS Without ICGA, OCT features could provide high accuracy in identifying posttreatment complete or incomplete polypoidal regression in PCV.
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Affiliation(s)
- Voraporn Chaikitmongkol
- Department of Ophthalmology, Retina Division, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | | | - Direk Patikulsila
- Department of Ophthalmology, Retina Division, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Paradee Kunavisarut
- Department of Ophthalmology, Retina Division, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nopasak Phasukkijwatana
- Department of Ophthalmology, Retina Division, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nawat Watanachai
- Department of Ophthalmology, Retina Division, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Janejit Choovuthayakorn
- Department of Ophthalmology, Retina Division, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sirawit Isipradit
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pawinee Boonyot
- Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand
| | - Apisara Sangkaew
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Thammasin Ingviya
- Department of Family Medicine and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Susan B Bressler
- Retina Division, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Neil M Bressler
- Retina Division, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD
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13
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Mauschitz MM, Finger RP. Age-Related Macular Degeneration and Cardiovascular Diseases: Revisiting the Common Soil Theory. Asia Pac J Ophthalmol (Phila) 2022; 11:94-99. [PMID: 35213420 DOI: 10.1097/apo.0000000000000496] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Age-related macular degeneration (AMD), a complex disease associated with aging, remains one of the leading causes of visual loss in high-income countries and its prevalence is expected to increase over the next decades. Polypoidal choroidal vasculopathy has been considered a variant of neovascular AMD and is highly prevalent in Asian populations. Similarly, cardiovascular disease (CVD)-another complex disease associated with aging-is a leading cause of morbidity and mortality in high-income countries and its prevalence is also expected to increase due to population aging. Previous studies reported an increased risk for CVD in AMD patients, indicating an underlying "common soil." Reviewing the current literature, consistent evidence for common risk factors and mutual comorbidity was identified for both diseases. Cardiovascular risk factors include smoking, diet, and low levels of physical activity, which also play a role in AMD pathogenesis. Several studies demonstrated AMD patients to be at higher risk for CVD compared to the general older population. The complexity of both diseases, however, complicates research on their relation, and thus studies ought to be interpreted with caution. Herein we present an overview of selected studies and their main "take-home messages" on this topic, and hypothesize on the patho-etiologic "common ground" of these 2 diseases.
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14
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Permadi AC, Djatikusumo A, Adriono GA. Optical coherence tomography in diagnosing polypoidal choroidal vasculopathy. Looking into the future: a systematic review and meta-analysis. Int J Retina Vitreous 2022; 8:14. [PMID: 35227320 PMCID: PMC8883730 DOI: 10.1186/s40942-022-00365-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/14/2022] [Indexed: 11/21/2022] Open
Abstract
Background Polypoidal choroidal vasculopathy (PCV) is an exudative maculopathy with features similar to wet age macular degeneration. The incidence of PCV is known to be higher in the Asian population compared to Caucasians. Imaging modality is needed to make the diagnosis of PCV. Although Indocyanine green angiography (ICGA) is still the gold standard, it is not routinely performed in vitreoretinal practice. Thus another imaging modality is currently a popular research area. Spectral domain optical coherence tomography (SD-OCT) has emerged as a new imaging modality mostly available in clinics. Some studies have reported the sensitivity and specificity of SD-OCT in diagnosing PCV with different results and thresholds. Methods Relevant studies from PubMed, Science Direct and Google Scholar databases were systematically searched. In random effect models using STATA 14 software, a meta-analysis was performed to determine the pooled diagnostic accuracy. QUADAS 2 was used to evaluate the risk of bias of each study by Revman 5.4 software. Results Seven eligible studies which met the inclusion and exclusion criteria were enrolled in this study. A total of 911 eyes were included to investigate the diagnostic accuracy of SD-OCT. As a result, the pooled sensitivity was 0.91 (95% CI 0.87–0.93), specificity 0.88 (95% 0.83–0.92), positive likelihood ratio 8, negative likelihood ratio 11, the area under the summary receiver operating characteristic curve 0.95 (95% CI 0.93–0.97), and diagnostic odds ratio 71.81 (95% CI 38.89–132.74). Conclusion SD-OCT provided a high diagnostic value for detecting PCV. Sharply peaked pigment epithelial detachment (PED), notched PED, bubble sign, multiple PED, and double-layer sign were the most common features found in PCV.
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15
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Xue Y, Qinhua C. Short-Term Efficacy in Polypoidal Choroidal Vasculopathy Patients Treated With Intravitreal Aflibercept or Conbercept. Front Med (Lausanne) 2022; 9:835255. [PMID: 35252267 PMCID: PMC8891458 DOI: 10.3389/fmed.2022.835255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/10/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose To compare the short-term efficacy in patients with polypoidal choroidal vasculopathy (PCV) treated using either aflibercept or conbercept. Methods This prospective study included 41 patients with treatment-naive PCV (42 eyes). All the patients were treated with either aflibercept or conbercept using an initial series of 3 monthly loading injections. Changes in the best-corrected logMAR visual acuity (BCVA) and anatomic outcomes were evaluated at 3 months. Results BCVA was improved with reduction in central choroidal thickness (CCT), central foveal thickness (CFT), and subretinal fluid (SRF) after 3 monthly loading injections in both aflibercept (IVA) and conbercept (IVC) groups. There was no significant difference in either visual or anatomic outcomes between the two groups after 3 months of treatment. However, compared with the IVC group, significantly higher BCVA improvement was observed in the patients in the IVA group with baseline BCVA better than 1. A visual outcome improved ≥3 lines in 13 patients in the IVA group (59%), and 9 patients in the IVC group (45%). A relatively high proportion of polyp regression was observed in the IVA group (63%) compared with the IVC group (55%) via OCTA. Conclusions Visual and anatomic outcomes were significantly improved in both IVA and IVC groups, but the results suggest a potentially superior short-term response in the IVA group.
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16
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Chaikitmongkol V, Sagong M, Lai TYY, Tan GSW, Ngah NF, Ohji M, Mitchell P, Yang CH, Ruamviboonsuk P, Wong I, Sakamoto T, Rajendran A, Chen Y, Lam DSC, Lai CC, Wong TY, Cheung CMG, Chang A, Koh A. Treat-and-Extend Regimens for the Management of Neovascular Age-related Macular Degeneration and Polypoidal Choroidal Vasculopathy: Consensus and Recommendations From the Asia-Pacific Vitreo-retina Society. Asia Pac J Ophthalmol (Phila) 2021; 10:507-518. [PMID: 34839342 PMCID: PMC8673847 DOI: 10.1097/apo.0000000000000445] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/20/2021] [Indexed: 12/26/2022] Open
Abstract
PURPOSE Review and provide consensus recommendations on use of treat-and-extend (T&E) regimens for neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV) management with relevance for clinicians in the Asia-Pacific region. METHODS A systematic search of MEDLINE, EMBASE, and Cochrane databases, and abstract databases of the Asia-Pacific Vitreo-retina Society, European Society of Retina Specialists, American Academy of Ophthalmology, and Controversies in Ophthalmology: Asia-Australia congresses, was conducted to assess evidence for T&E regimens in nAMD. Only studies with ≥100 study eyes were included. An expert panel reviewed the results and key factors potentially influencing the use of T&E regimens in nAMD and PCV, and subsequently formed consensus recommendations for their application in the Asia-Pacific region. RESULTS Twenty-seven studies were included. Studies demonstrated that T&E regimens with aflibercept, ranibizumab, or bevacizumab in nAMD, and with aflibercept in PCV, were efficacious and safe. The recommendation for T&E is, after ≥3 consecutive monthly loading doses, treatment intervals can be extended by 2 to 4 weeks up to 12 to 16 weeks. When disease activity recurs, the recommendation is to reinject and shorten intervals by 2 to 4 weeks until fluid resolution, after which treatment intervals can again be extended. Intraretinal fluid should be treated until resolved; however, persistent minimal subretinal fluid after consecutive treatments may be tolerated with treatment intervals maintained or extended if the clinical condition is stable. CONCLUSIONS T&E regimens are efficacious and safe for nAMD and PCV, can reduce the number of visits, and minimize the overall burden for clinicians and patients.
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Affiliation(s)
- Voraporn Chaikitmongkol
- Retina Division, Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Min Sagong
- Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, South Korea
| | - Timothy Y Y Lai
- Hong Kong Eye Hospital, Department of Ophthalmology & Visual Sciences, The Chinese University of Hong Kong, Hong Kong
- 2010 Retina & Macula Centre, Kowloon, Hong Kong
| | - Gavin S W Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, Duke-NUS Medical School, National University of Singapore, Singapore
| | | | - Masahito Ohji
- Department of Ophthalmology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Paul Mitchell
- University of Sydney (Westmead Institute for Medical Research), Sydney, NSW, Australia
| | - Chang-Hao Yang
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Paisan Ruamviboonsuk
- Department of Ophthalmology, College of Medicine, Rangsit University, Rajavithi Hospital, Bangkok, Thailand
| | - Ian Wong
- Department of Ophthalmology, The University of Hong Kong, Hong Kong, China
| | - Taiji Sakamoto
- Department of Ophthalmology, Kagoshima University, Kagoshima, Japan
| | - Anand Rajendran
- Retina-Vitreous Service, Aravind Eye Care System, Chennai, India
| | - Youxin Chen
- Department of Ophthalmology, Peking Union Medical College Hospital, Beijing, China
| | - Dennis S C Lam
- C-MER Dennis Lam & Partners Eye Center, C-MER International Eye Care Group, Hong Kong, China; C-MER International Eye Research Center of The Chinese University of Hong Kong (Shenzhen), Shenzhen, China
| | - Chi-Chun Lai
- Department of Ophthalmology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Chui Ming Gemmy Cheung
- Singapore Eye Research Institute, Singapore National Eye Centre, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Andrew Chang
- Sydney Retina Clinic, Sydney Eye Hospital, University of Sydney, Sydney, NSW, Australia
| | - Adrian Koh
- Eye & Retina Surgeons, Camden Medical Centre, Singapore
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17
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Kaiser PK. OCT Alone to Diagnose and Manage Polypoidal Choroidal Vasculopathy: Are We There? Ophthalmol Retina 2021; 5:943-944. [PMID: 34579872 DOI: 10.1016/j.oret.2021.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/23/2021] [Indexed: 10/20/2022]
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18
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Differences in the Quantity and Composition of Extracellular Vesicles in the Aqueous Humor of Patients with Retinal Neovascular Diseases. Diagnostics (Basel) 2021; 11:diagnostics11071276. [PMID: 34359359 PMCID: PMC8306174 DOI: 10.3390/diagnostics11071276] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 07/11/2021] [Accepted: 07/12/2021] [Indexed: 12/16/2022] Open
Abstract
Extracellular vesicles (EVs) are secreted by various cells in the body fluid system and have been found to influence vessel formation and inflammatory responses in a variety of diseases. However, which EVs and their subtypes are involved in vascular retinal diseases is still unclear. Therefore, the aim of this study was to explore the particle distribution of EVs in retinal neovascular diseases, including age-related macular degeneration, polypoidal choroidal vasculopathy, and central retinal vein occlusion. The aqueous humor was harvested from 20 patients with different retinal neovascular diseases and six patients with cataracts as the control group. The particle distribution was analyzed using nanoparticle tracking analysis (NTA) and transmitting electron microscopy (TEM). The results revealed that the disease groups had large amounts of EVs and their subtypes compared to the control group. After isolating exosomes, a higher expression of CD81+ exosomes was shown in the disease groups using flow cytometry. The exosomes were then further classified into three subtypes of exomeres, small exosomes, and large exosomes, and their amounts were shown to differ depending on the disease type. To the best of our knowledge, this is the first study to elucidate the dynamics of EVs in retinal neovascular diseases using clinical cases. Our findings demonstrated the possible functionality of microvesicles and exosomes, indicating the potential of exosomes in the diagnosis and therapy of retinal neovascular diseases.
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19
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Chong Teo KY, Sadda SR, Gemmy Cheung CM, Chakravarthy U, Staurenghi G, Invernizzi A, Ogura Y, Ruamviboonsuk P, Chen SJ, Gupta V, Tan C, Chhablani J, Corvi F, Kim JE, Gomi F, Koh AH, Kokame G, Mitchell P, Wong TY, Lee WK, Lai TYY. Non-ICGA treatment criteria for Suboptimal Anti-VEGF Response for Polypoidal Choroidal Vasculopathy: APOIS PCV Workgroup Report 2. Ophthalmol Retina 2021; 5:945-953. [PMID: 33866022 DOI: 10.1016/j.oret.2021.04.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/27/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To develop and validate OCT and color fundus photography (CFP) criteria in differentiating polypoidal choroidal vasculopathy (PCV) from typical neovascular age-related macular degeneration (nAMD) in eyes with suboptimal response to anti-vascular endothelial growth factor (VEGF) monotherapy and to determine whether OCT alone can be used to guide photodynamic therapy (PDT) treatment. DESIGN Clinical study evaluating diagnostic accuracy. PARTICIPANTS Patients with nAMD who received 3-month anti-VEGF monotherapy but had persistent activity defined as subretinal fluid or intraretinal fluid at month 3 assessments. METHODS In phase 1, international retina experts evaluated OCT and CFP of eyes with nAMD to identify the presence or absence of features due to PCV. The performance of individual and combinations of these features were compared with ICGA. In phase 2, these criteria were applied to an independent image set to assess generalizability. In a separate exercise, retinal experts drew proposed PDT treatment spots using only OCT and near-infrared (NIR) images in eyes with PCV and persistent activity. The location and size of proposed spot were compared with ICGA to determine the extent of coverage of polypoidal lesions (PLs) and branching neovascular network (BNN). MAIN OUTCOME MEASURES Sensitivity and specificity of CFP and OCT criteria to differentiate PCV from nAMD and accuracy of coverage of OCT-guided PDT compared with ICGA. RESULTS In eyes with persistent activity, the combination of 3 non-ICGA-based criteria (sharp-peaked pigment epithelial detachment [PED], subretinal pigment epithelium [RPE] ring-like lesion, and orange nodule) to detect PCV showed good agreement compared with ICGA, with an area under the receiver operating characteristic curve of 0.85. Validation using both an independent image set and assessors achieved an accuracy of 0.77. Compared with ICGA, the OCT-guided PDT treatment spot covered 100% of PL and 90% of the BNN. CONCLUSIONS In nAMD eyes with persistent activity, OCT and CFP can differentiate PCV from typical nAMD, which may allow the option of adjunct PDT treatment. Furthermore, OCT alone can be used to plan adjunct PDT treatment without the need for ICGA, with consistent and complete coverage of PL.
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Affiliation(s)
- Kelvin Yi Chong Teo
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Duke-NUS Medical School, National University of Singapore, Singapore; Save Sight Institute, The University of Sydney, Faculty of Health and Medicine, Sydney, New South Wales, Australia
| | - Srinivas R Sadda
- Doheny Eye Institute, David Geffen, School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Chui Ming Gemmy Cheung
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Duke-NUS Medical School, National University of Singapore, Singapore.
| | - Usha Chakravarthy
- Duke-NUS Medical School, National University of Singapore, Singapore; School of Medicine, Dentistry and Biomedical Sciences, Queens University Belfast, Belfast, United Kingdom
| | - Giovanni Staurenghi
- Eye Clinic, Department of Biomedical and Clinical Sciences "Luigi Sacco" University of Milan, Milan, Italy
| | - Alessandro Invernizzi
- Eye Clinic, Department of Biomedical and Clinical Sciences "Luigi Sacco" University of Milan, Milan, Italy; Save Sight Institute, The University of Sydney, Faculty of Health and Medicine, Sydney, New South Wales, Australia
| | - Yuichiro Ogura
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Paisan Ruamviboonsuk
- Department of Ophthalmology, College of Medicine, Rangsit University, Rajavithi Hospital, Bangkok, Thailand
| | - Shih-Jen Chen
- Department of Ophthalmology, Taipei Veterans General Hospital, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Vishali Gupta
- Advanced Eye Center, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Colin Tan
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore
| | - Jay Chhablani
- Vitreo-Retinal Consultant, University of Pittsburgh Eye Center, Pittsburgh, Pennsylvania
| | - Federico Corvi
- Eye Clinic, Department of Biomedical and Clinical Sciences "Luigi Sacco" University of Milan, Milan, Italy
| | - Judy E Kim
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Fumi Gomi
- Department of Ophthalmology, Hyogo College of Medicine, Hyogo, Japan
| | - Adrian H Koh
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Duke-NUS Medical School, National University of Singapore, Singapore; Eye and Retina Surgeons, Camden Medical Centre, Singapore
| | - Gregg Kokame
- Division of Ophthalmology, Department of Surgery, University of Hawaii School of Medicine, Honolulu, Hawaii
| | - Paul Mitchell
- University of Sydney, Westmead Institute for Medical Research, Sydney, Australia
| | - Tien Y Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Duke-NUS Medical School, National University of Singapore, Singapore
| | | | - Timothy Y Y Lai
- Department of Ophthalmology and Visual Sciences The Chinese University of Hong Kong Hong Kong Eye Hospital, Hong Kong
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