Polypoidal Choroidal Vasculopathy: Updates on Risk Factors, Diagnosis, and Treatments

Responsiveness of anti-VEGF treatment for polypoidal choroidal vasculopathy based on aqueous humour proteomics: A preliminary study

OBJECTIVES

Patients with polypoidal choroidal vasculopathy (PCV) exhibit variability in response to anti-VEGF therapy. This study aimed to analyse the aqueous humour proteomic profiles of PCV patients and provide preliminary insights for the identification of biomarkers associated with anti-VEGF drug responsiveness.

METHODS

PCV patients who were treatment-naïve or untreated for more than 3 months were prospectively recruited from two hospitals in Beijing and Tianjin. Based on the relative changes in central macular thickness (ΔCMT/baseline-CMT) before and after anti-VEGF treatment, the PCV patients were divided into a good response (GR) group (≤-25%) and a poor response (PR) group (>-25%). Aqueous humour proteomics was performed by the Data-independent Acquisition-Mass Spectrometry (DIA-MS) method, and differentially expressed proteins (DEPs) analysis between the different PCV groups and the control group was conducted. Key DEPs were selected for preliminary validation in the aqueous humour using the Luminex method retrospectively.

RESULTS

A total of 31 PCV patients (31 eyes) were included, 13 in the GR group and 18 in the PR group. A total of 414 DEPs were identified, including 36 significantly upregulated proteins, such as G protein regulatory factor 10 (RGS10), podocin (PODN) and epidermal growth factor (EGF), and 32 downregulated proteins, including RAB11FIP4 (Rab11 family-interacting protein 4), α-synuclein (SNCA), haemoglobin subunit δ (HBD) and interleukin 6 (IL6). Compared to the cataract control group (10 eyes), 134 proteins were significantly upregulated, and 72 were downregulated. KEGG pathway enrichment analysis revealed that the GR and PR groups differ in terms of cell communication, and cell signal transduction. Protein-protein interaction analysis revealed interactions between EGF and various DEPs. Validation of aqueous humour proteins using the Luminex method revealed that changes in the levels of EGF were associated with the anti-VEGF treatment response in PCV patients.

CONCLUSIONS

PCV patients with good or poor anti-VEGF responses exhibit distinct aqueous humour proteomic profiles. Aqueous EGF may serve as a biomarker for the 'precise treatment' of PCV.

Exploring the Ability of Novel Choroidal Biomarkers in Predicting Treatment Outcomes of Polypoidal Choroidal Vasculopathy

INTRODUCTION

The aim of this study was to explore the relationship between choroidal biomarkers and the response to anti-VEGF in PCV eyes.

METHODS

We conducted a hospital-based retrospective study. We included 54 patients diagnosed with PCV who had received standard 3 monthly anti-VEGF monotherapy and had finished regular follow-ups. Choroidal thickness (CT), three-dimensional choroidal vascularity index (CVI), and the vascular density of choriocapillaris (CCVD) were measured utilizing swept-source optical coherence tomography angiography (SS-OCTA). Effective and poor responders were classified based on the changes in morphologic features. Multivariate linear regression models were performed for the outcomes to determine independent prognostic factors. Receiver operating characteristic (ROC) curves were used to compare the predictive ability of CT and CVI as biomarkers between effective and poor responders.

RESULTS

A higher CVI at baseline was the only factor that correlated with the poor response after 3 monthly injections of anti-VEGF (p = 0.038). The greater change of central macular thickness (CMT) was significantly correlated with increased CMT (p = 0.030), decreased CT (p = 0.042), and decreased CVI (p = 0.038) at baseline. Using ROC curves, we found that the CVI value demonstrated superior predictive ability compared to the CT value, with AUC of 0.842 and the best cut-off value of 0.445.

CONCLUSION

A higher three-dimensional CVI using SS-OCTA is a promising biomarker to predict the poor anatomical response to anti-VEGF treatment in PCV patients.

Characterization of Vortex Vein Drainage System in Healthy Individuals Imaged by Ultra-Widefield Optical Coherence Tomography Angiography

Purpose

The purpose of this study was to investigate the choroidal characteristics of vortex vein (VV) drainage systems in healthy individuals using ultra-widefield optical coherence tomography angiography.

Methods

The mean choroidal thickness (ChT) and choroidal vascularity index (CVI) of each VV quadrant (24 × 20 mm2 scan mode; superotemporal [ST], superonasal [SN], inferonasal [IN], and inferotemporal [IT] quadrants) were calculated. Furthermore, intervortex venous anastomosis (IVA) was classified into temporal, superior, inferior, and nasal types.

Results

A total of 207 healthy eyes were analyzed to find that the ST quadrant had the thickest choroidal layer and highest CVI (all P < 0.05). Among the four VV drainage quadrants, the mean ChT and CVI decreased in the sequence of ST, SN, IT, and IN (all P < 0.05). Moreover, men had a higher CVI than women in all VV quadrants (all P < 0.05). IVA was observed in all VV quadrants of 91 eyes (43.96%), and in the macular region of 33 eyes (15.94%).

Conclusions

The ST drainage system was identified as the preferred VV drainage route in healthy eyes. Among the four VV drainage quadrants, the drainage system adhered to the ST-SN-IT-IN order of descending perfusion. Furthermore, age- and sex-related differences were noted in the choroidal VV drainage systems of healthy eyes. Additionally, almost half of the healthy eyes had IVA in their choroidal vessel networks.

Translational Relevance

The VV drainage system may be considered a novel imaging biomarker for ocular diseases.

Development and validation of optical coherence tomography (OCT) and OCT angiography prediction model for short-term vitreous haemorrhage secondary to polypoidal choroidal vasculopathy

AIMS

To construct and validate an optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) image model for predicting the occurrence of short-term vitreous haemorrhage (VH) in polypoidal choroidal vasculopathy (PCV) patients.

METHODS

We retrospectively collected clinical and imaging information from patients diagnosed with PCV at Peking Union Medical College Hospital, Beijing, China, between January 2015 and October 2022. Six different screening strategies, including univariate analysis, multivariate analysis, least absolute shrinkage and selection operator, stepwise logistic regression, random forest and clinical-data-only approach, were used to select variables and build models. The nomogram was constructed based on the model with the best area under the curve (AUC) and was evaluated using receiver operating characteristic curves, calibration curves, decision curve analysis and clinical impact curves.

RESULTS

A total of 147 PCV patients were included and randomly divided into a training set (103 patients) and a validation set (44 patients), with an average follow-up time of 17.56±14.99 months. The optimal model that achieved higher AUC in both training and validation sets incorporated seven significant variables identified through univariate analysis: male [OR=2.76, p=0.022], central macular thickness [OR=1.003, p=0.002], the presence of haemorrhagic pigment epithelial detachment (HPED) [OR=6.99, p<0.001], the height of HPED [OR=1.002, p<0.001], the area of HPED [OR=1.16, p<0.001], the presence of multiple PEDs [OR=2.94, p=0.016] and the presence of subretinal haemorrhage [OR=3.11, p=0.011]. A predictive nomogram based on these variables yielded an AUC of 0.896 (95% CI 0.827 to 0.965) in the training set and 0.861 (95% CI 0.749 to 0.973) in the validation set, demonstrating good calibration and clinical usefulness.

CONCLUSION

The proposed OCT/OCTA-based image nomogram, as a novel and non-invasive tool, achieved satisfactory prediction of VH secondary to PCV.

Verteporfin Photodynamic Therapy for the Treatment of Chorioretinal Conditions: A Narrative Review

Photodynamic therapy (PDT) with verteporfin involves intravenous administration of a photosensitizer followed by its laser light activation at the target site to inhibit aberrant choroidal vascularization. This narrative review provides an overview of the role verteporfin PDT plays in the management of chorioretinal conditions. A PubMed literature review of all English-language articles published through October 19, 2023, was conducted to identify relevant references. Verteporfin PDT has been shown to be safe and effective for the treatment of patients with choroidal neovascularization (CNV) due to neovascular age-related macular degeneration and is often used in combination with a vascular endothelial growth factor (VEGF) inhibitor. Additionally, patients with polypoidal choroidal vasculopathy, a subtype of neovascular age-related macular degeneration, also benefit from verteporfin PDT combined with a VEGF inhibitor for improving visual acuity. Verteporfin PDT has also been effective in treating patients with peripapillary CNV, as well as eyes with CNV due to ocular histoplasmosis and pathologic myopia. Reduced dose and/or fluence PDT protocols have been effective in patients with central serous chorioretinopathy while reducing adverse effects. In eyes with choroidal hemangioma, tumor regression and visual outcomes have been improved with verteporfin PDT treatment. Photodynamic therapy with verteporfin continues to play an important role in the management of chorioretinal conditions.

Six-Year Outcomes in Subjects with Polypoidal Choroidal Vasculopathy in the EVEREST II Study

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.

Advances in multi-modal non-invasive imaging techniques in the diagnosis and treatment of polypoidal choroidal vasculopathy

Polypoidal choroidal vasculopathy (PCV) is a disease characterized by subretinal pigment epithelium (RPE) orange-red polypoidal lesions and abnormal branching neovascular networks (BNNs). In recent years, various non-invasive imaging technologies have rapidly developed, especially the emergence of optical coherence tomography angiography (OCTA), multi-spectral imaging, and other technologies, which enable the observation of more features of PCV. In addition, these technologies are faster and less invasive compared to indocyanine green angiography (ICGA). Multi-modal imaging, which combined multiple imaging techniques, provides important references for the diagnosis and treatment of PCV with the assistance of regression models, deep learning, and other algorithms. In this study, we reviewed the non-invasive imaging techniques, multi-modal imaging diagnosis, and multi-scene therapeutic applications of PCV, with the aim of providing a reference for non-invasive multi-modal diagnosis and treatment of PCV.