A CLASSIFICATION SYSTEM FOR POLYPOIDAL CHOROIDAL VASCULOPATHY

A Comparative Study of Choroidal Vascular and Structural Characteristics of Typical Polypoidal Choroidal Vasculopathy and Polypoidal Choroidal Neovascularization: OCTA-Based Evaluation of Intervortex Venous Anastomosis

BACKGROUND

The aim of this study was to compare the choroidal characteristics of typical polypoidal choroidal vasculopathy (T-PCV) and polypoidal choroidal neovascularization (P-CNV) cases, and to investigate the presence of intervortex venous anastomoses in these PCV subtypes by using en face optical coherence tomography angiography (OCTA).

METHODS

A total of 35 eyes of 33 PCV cases were included. The PCV cases were divided into T-PCV and P-CNV groups. The choroidal vascularity index (CVI) was calculated. En face OCTA images were evaluated for the presence of intervortex venous anastomoses. The diameter of the largest anastomotic Haller vessel was measured.

RESULTS

T-PCV cases had significantly higher mean CVI values (73.9 ± 3.7 vs. 70.8 ± 4.5%) than P-CNV cases (p = 0.039). Intervortex venous anastomoses were observed in 85.7% of T-PCV eyes and in 91.7% of P-CNV eyes on en face OCTA (p = 1.000). In the cases with intervortex venous anastomosis, the mean diameter of the largest anastomotic vessel on en face OCTA was 341.2 ± 109.1 µm in the T-PCV and 280.4 ± 68.4 µm in the P-CNV group (p = 0.048).

CONCLUSIONS

The higher CVI value in T-PCV may be an important feature concerning the pathogenesis and classification of PCV. Although there was no difference between the two subtypes in terms of intervortex anastomosis, more dilated anastomotic vessels were observed in the T-PCV.

Reduction of Laser-Induced Choroidal Neovascularization in Mice With Erythropoietin RNA Interference

PURPOSE

The purpose of this study was to evaluate the pathological involvement of erythropoietin (EPO) in experimental choroidal neovascularization (CNV) and its association with neovascular age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) in the Chinese population.

METHODS

Treatment effect of recombinant EPO protein were assessed by human umbilical vein endothelial cell (HUVEC) proliferation, migration, and tube formation, and ex vivo choroid-sprouting ability. The effect of intravitreal injection of Epo siRNA against neovascularization was evaluated in the laser-induced CNV mouse model. In addition, the association of EPO variants with neovascular AMD and PCV was determined.

RESULTS

Exogenous supplementation of EPO significantly enhanced the migration and tube formation of HUVECs and promoted ex vivo choroid sprouting in mouse retinal pigment epithelium (RPE)-choroid-sclera complex culture. In the experimental CNV mouse model, Epo expression was found to be significantly upregulated by 3.5-folds in RPE-choroid-sclera complex at day 10 after laser induction as compared to the baseline. Immunofluorescence analysis showed that Epo was mainly expressed around the vascular endothelial cells in the RPE-choroid-sclera complex. Intravitreal injection of siRNA targeting Epo reduced 40% Epo expression and 40% CNV lesion areas as compared to the scramble control. However, EPO variants were not associated with neovascular AMD nor PCV in the Chinese population.

CONCLUSIONS

This study revealed the promotion of human endothelial cell tube formation in vitro and choroid sprouting ex vivo by EPO, and the reduction of laser-induced CNV in vivo by Epo RNA interference.

TRANSLATIONAL RELEVANCE

Targeting EPO could be a potential additional treatment for CNV-related diseases.

ASSOCIATION OF FLOW SIGNALS WITHIN POLYPS ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY WITH TREATMENT RESPONSES AFTER COMBINATION THERAPY FOR POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To evaluate the changes of blood circulation within the polypoidal lesions by OCT angiography in eyes with polypoidal choroidal vasculopathy after combination therapy with aflibercept and photodynamic therapy.

METHODS

A total of 46 eyes from 46 patients who underwent the combination therapy for polypoidal choroidal vasculopathy were followed for more than 6 months. OCT angiography, covering an area 6 mm2 × 6 mm2 including the macula, were performed at baseline, 2 weeks, and 3 months and 6 months post-treatment.

RESULTS

The subretinal fluid resolved within 3 months after treatment in 44 eyes (95.7%), and 27 eyes (58.7%) showed no recurrence, with no additional treatment. Seventeen eyes (37.0%) showed recurrence, and two eyes (4.3%) showed poor response. On OCT angiography at 2 weeks after treatment, flow signals were detected in 3 of 27 eyes (11.1%) without recurrence and in 8 of 19 eyes (42.1%) with recurrence or poor responses. A detectable flow signal at 2 weeks was significantly associated with recurrence or poor response (P = 0.032).

CONCLUSION

Persistent flow signals within polyps on OCT angiography at 2 weeks after combination therapy suggest less effectiveness of the initial treatment.

Pachychoroid spectrum disease

Recent improvements in ophthalmic imaging have led to the identification of a thickened choroid or pachychoroid to be associated with a number of retinal diseases. The number of conditions linked to this phenotype has continued to widen with specific endophenotypes found within the pachychoroid spectrum. The spectrum includes choroidal features such as focal or diffuse choroidal thickening and thinning of the overlying inner choroid, and choroidal hyperpermeability as demonstrated by indocyanine green angiography. In addition, these diseases are associated with overlying retinal pigmentary changes and retinal pigment epithelial dysfunction and may also be associated with choroidal neovascularization. This article provides a comprehensive review of the literature looking at diseases currently described within the pachychoroid spectrum including central serous chorioretinopathy, pachychoroid pigment epitheliopathy, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy/aneurysmal type 1 neovascularization, peripapillary pachychoroid disease and focal choroidal excavation. We particularly focus on clinical imaging, genetics and pathological findings in these conditions with the aim of updating evidence suggesting a common aetiology between diseases within the pachychoroid spectrum.

Polypoidal Choroidal Vasculopathy in Caucasians: Morphological Findings from Multimodal Retinal Imaging

PURPOSE

The aim of the study was to characterize the morphological features of polypoidal choroidal vasculopathy (PCV) in a large Caucasian population.

METHODS

We conducteda multicenter, cross-sectional study of treatment-naïve patients with PCV. Baseline fundus photography, spectral-domain optical coherence tomography (SD-OCT), fluorescein angiography (FA), and indocyanine green angiography (ICGA) were assessed by trained medical graders. Typical PCV features were explored, and retinal thickness (RT) and choroidal thickness (CT) measurements were performed.

RESULTS

Seventy-nine eyes of 73 patients (mean age, 72.6 ± 11.9 years) were included. ICGA identified macular polyps in 89.9% of cases. SD-OCT revealed mostly subretinal fluid (93.6%) and a retinal pigment epithelium (RPE) detachment in 91.4%, with sharp protrusion in 67.0% of cases. Polyp-like structures were seen in 74.3% of cases, mostly adherent to an elevated RPE (69.6%). Type 1 neovascularization (NV) was identified in 74.7% of patients, while 16.5% had a mixed NV. The mean macular CT was 220.9 ± 83.2 μm (range, 67.9-403.6). Diffuse and focal pachychoroid were observed in 26.6 and 30.4% of patients, respectively. Soft drusen were reported in 62.0% of cases, but retinal hemorrhage occurred in only 19.0% of cases.

CONCLUSION

The morphological features of PCV in Caucasians are similar to those reported in Asians. Pachychoroid signs were found in nearly half of our cohort. However, the mean age at presentation, high prevalence of soft drusen, and low prevalence of large subretinal hemorrhages make PCV closer to age-related macular degeneration in this ethnic group.

Efficacy of a novel personalised aflibercept monotherapy regimen based on polypoidal lesion closure in participants with polypoidal choroidal vasculopathy

PURPOSE

To compare the efficacy of aflibercept using a personalised versus fixed regimen in treatment-naïve participants with polypoidal choroidal vasculopathy (PCV).

DESIGN

A 52-week, randomised, open-label, non-inferiority, single-centre study that included participants with symptomatic PCV. Participants were randomised (3:1 ratio) to receive either personalised (n=40) or fixed 8-weekly treatment regimen (n=13). The personalised regimen allowed for either early treat and extend (T&E) after week 12 or late T&E with 3 additional 4-weekly aflibercept injections until week 24 in participants with residual polypoidal lesions (PL) on indocyanine green angiography (ICGA) at week 12.

MAIN OUTCOMES AND MEASURES

Non-inferiority of personalised to fixed regimen for mean change in best-corrected visual acuity (BCVA) from baseline to week 52 (non-inferiority margin: -5 letters). The key secondary outcomes include reduction in central subfield thickness (CSFT) on optical coherence tomography and the anatomical closure of PL on ICGA.

RESULTS

Of the 53 participants, the mean (SD) age was 69.2 (8.1) years, 19 (35.8 %) were male. Personalised group was non-inferior to fixed for the primary end point (+8.1 vs +7.9 letters at week 52, respectively; difference 0.16, 95% CI -2.8 to 2.4, p=0.79). There was greater reduction in mean CSFT (SD) in the personalised versus fixed group (-248.8 (169.9) vs -164.8 (148.9) µm, p=0.03). Closure of PL occurred in 21 (55.2%) and 5 (41.6%) of study eyes in personalised and fixed groups, respectively at week 52 (p=0.41).

CONCLUSIONS

Personalised regimen achieved non-inferior BCVA gain and numerically higher PL closure compared with fixed regimen.

TRIAL REGISTRATION NUMBER

NCT03117634.

Comparison of visual outcomes between therapy choices and subtypes of polypoidal choroidal vasculopathy (PCV) in Taiwan: a real-world study

Polypoidal choroidal vasculopathy (PCV) is a distinctive type of neovascular age-related macular degeneration prevalent in many Asian countries. However, there is still some controversy in how the subtypes of PCV are classified. This post-hoc study redefined the branching vascular network (BVN) and PCV subtypes through retrospective review of indocyanine green angiography (ICGA) and fluorescein angiography images from two observational studies (RENOWNED/REAL). Of the visual outcomes for each angiographic subtype and treatment pattern investigated, BVN was identified in 56.3% of PCV patients. The proportions and features of the re-defined PCV subtypes were 43.8%, 10.4%, and 45.8% for subtype A (without distinctive features of BVN), B (with BVN but no leakage), and C (with BVN and leakage), respectively. Subtype A had better visual outcomes when compared to subtype C. This possibly resulted from a better baseline visual acuity in subtype A. Moreover, combination therapy [photodynamic therapy plus anti-vascular endothelial growth factor (VEGF)] may lead to better visual improvement than mono-anti-VEGF treatment alone. This study provides the prevalence of PCV subtypes in Taiwan and may serve as a reference for PCV treatment strategies in a real-world setting, especially for the combination therapy and patients without distinctive features of BVN.

The spectrum of polypoidal choroidal vasculopathy in Caucasians: clinical characteristics and proposal of a classification

Purpose

To describe the clinical characteristics and outcome of polypoidal choroidal vasculopathy (PCV), also known as aneurysmal type 1 (sub-retinal pigment epithelium (RPE)) neovascularization, in Caucasian patients.

Methods

Single-centre study in 66 Caucasian patients with a diagnosis of PCV based on optical coherence tomography scan and indocyanine green angiography. Clinical characteristics and multimodal imaging were collected and assessed by an experienced retina specialist.

Results

This study involved 74 eyes of 66 patients with PCV, with a mean age at onset of 73 years and a female preponderance of 66%. The mean number of polypoidal lesions per eye was 1 (range: 1–5 lesions), out of which 75% was located in the macula and 19% in the peripapillary region. Of the 74 eyes, 37 eyes (50%) had PCV associated with a drusenoidal neovascular age-related macular degeneration (AMD) phenotype (PCV-AMD) and 18 eyes (24%) had PCV associated with non-polypoidal type 1 choroidal neovascularization/branching vascular network (PCV-BVN) without signs of drusenoidal AMD, while 19 eyes (26%) had idiopathic, isolated PCV (iPCV). The mean subfoveal choroidal thickness measured in 22 patients was 245 μm (range: 71–420 μm). In 51% of patients, the initially performed therapy showed good anatomical recovery (resolution of intra- and subretinal fluid).

Conclusions

A spectrum of PCV (aneurysmal type 1/sub-RPE neovascularization) can be seen in Caucasian patients. PCV associated with a drusenoidal neovascular AMD phenotype in Caucasians is phenotypically and presumably pathophysiologically more associated with neovascular AMD (PCV-AMD: type A PCV). However, this may not be the case for patients with PCV with non-polypoidal type 1 choroidal neovascularization or BVN and no signs of drusenoidal AMD (PCV-BVN: type B PCV), and for patients with idiopathic PCV without associated drusen or BVN (iPCV; type C PCV). Most patients have a thin choroid, even when drusen are absent. For the entire patient group, a moderate anatomical recovery was observed after treatment.

Electronic supplementary material

The online version of this article (10.1007/s00417-020-04844-z) contains supplementary material, which is available to authorized users.

Prevalence of polypoidal choroidal vasculopathy in Indian population: Risk factors, clinical and imaging characteristics

AIM

To assess prevalence, clinical presentation and multimodal imaging characteristics of polypoidal choroidal vasculopathy (PCV) in a hospital-based setting in South India.

METHODS

Electronic medical records (EMR) of new patients presenting with suspected clinical signs of wet age-related macular degeneration (AMD) in a tertiary hospital from January to December 2016 were retrospectively analyzed using keywords and filtered for patient who underwent multimodal imaging. Clinical presentations were categorized into predominantly hemorrhagic, exudative or mixed pattern. The imaging features were compared in these clinical groups. The multimodal images were graded by two masked graders and discrepancies between them were settled by a senior arbitrator.

RESULTS

Of the 147 clinically suspicious cases of PCV out of 785 patients with clinical presentation of AMD as recorded in the EMR, 73 (49.7%) patients had a multimodal imaging diagnosis of PCV. There was no difference in the demography, distribution of polyps, ICGA and OCT characteristics in eyes presenting with hemorrhagic, exudative or mixed clinical features.

CONCLUSION

Approximately half of South Asian patients presenting with clinical features of neovascular AMD harbor PCV irrespective of their clinical presentation and so we recommend that multimodal imaging is done in all cases of suspicious neovascular AMD in Indian population.

Six-Year Real-World Outcomes of Antivascular Endothelial Growth Factor Monotherapy and Combination Therapy for Various Subtypes of Polypoidal Choroidal Vasculopathy

The purpose of this study was to compare 6-year visual outcomes of antivascular endothelial growth factor (anti-VEGF) monotherapy and initial combination therapy of photodynamic therapy (PDT) and anti-VEGF therapy for polypoidal choroidal vasculopathy (PCV) in a Chinese population and to investigate imaging biomarkers associated with visual outcomes. Forty-eight treatment-naive PCV eyes of 46 patients were reviewed retrospectively, which underwent anti-VEGF monotherapy or initial combination therapy. PCV was classified into 2 subtypes. Mean best-corrected visual acuity (BCVA) using logarithm of minimal angle resolution and imaging morphological features was compared. No significant differences of mean BCVA changes were noticed between anti-VEGF monotherapy and combination therapy in either subtype 1 PCV or subtype 2 PCV during 6-year period (all P values >0.05). Compared with BCVA at baseline, the mean BCVA at 72 months deteriorated significantly in eyes with subtype 1 PCV (P < 0.001), while the mean BCVA at 72 months remained stable in eyes with subtype 2 PCV (P=0.941). In subtype 2 PCV eyes with continuous retina pigment epithelium, the mean changes of BCVA in eyes treated with anti-VEGF monotherapy were better than those in eyes treated with combination therapy (P=0.020). Anti-VEGF monotherapy and combination therapy for various subtypes of PCV had comparable long-term visual outcomes in most cases in real world. Imaging biomarkers which correlate with visual outcomes and treatment response should be included in the classification of PCV and validated in real world.

Five-year real-world outcomes of anti-vascular endothelial growth factor monotherapy versus combination therapy for polypoidal choroidal vasculopathy in a Chinese population: a retrospective study

Background

To evaluate 5-year outcomes of anti-vascular endothelial growth factor (VEGF) monotherapy and combination therapy of anti-VEGF agents and photodynamic therapy (PDT) for polypoidal choroidal vasculopathy (PCV) in a real-world Chinese population.

Methods

Retrospective study. Fifty-three eyes of 46 patients with subtype 1 and 2 PCV followed up for at least 60 months were grouped into three regimens: anti-VEGF monotherapy, PDT combining with anti-VEGF therapy initially, and PDT combining with deferred anti-VEGF therapy. Main outcome measure was best-corrected visual acuity (BCVA) using logarithm of minimal angle of resolution (logMAR).

Results

The mean BCVA of eyes with subtype 1 PCV (n = 28) deteriorated from 0.69 logMAR at baseline to 1.25 logMAR at months 60 (P = 0.001), while the mean BCVA of eyes with subtype 2 PCV (n = 25) sustained stable from 0.62 logMAR at baseline to 0.57 at months 60 (P = 0.654). No significant differences of visual outcomes were found between the 3 treatment regimens for subtype 1 PCV. Anti-VEGF monotherapy and initial combination treatment had better visual outcomes in eyes with subtype 2 PCV than deferred combination group during part of follow-up significantly. Initial combination group needed a less number of PDT than deferred combination group (P < 0.001).

Conclusions

Compared with subtype 1 PCV, subtype 2 PCV has a more favorable visual outcome in real world. All the regimens presented unfavorable visual outcomes for subtype 1 PCV. Anti-VEGF monotherapy and initial combination therapy should be superior to deferred combination therapy in the long-term management of subtype 2 PCV. Prospective randomized studies of larger size are needed to determine the long-term efficacy and safety of various treatment for PCV in real world.

Different imaging characteristics between unilateral and bilateral polypoidal choroidal vasculopathy

PURPOSE

To investigate the different imaging characteristics between unilateral and bilateral polypoidal choroidal vasculopathy (PCV) cases, based on confocal scanning laser ophthalmoscope assessment.

METHODS

For this retrospective case series study, diagnostic indocyanine green angiography (ICGA) and spectral domain optical coherence tomography (SD-OCT) were performed to assess the eligible PCV eyes.

RESULTS

Among the 53 patients at baseline, 14 showed bilateral PCV lesions, including two cases of branching vessel network (BVN) without leakage. Concerning the subfoveal choroidal thickness (SFCT), unilateral PCV eyes (326 [155-547] μm) were statistically comparable to their fellow eyes (330 [163-477] μm) (p = 0.257). However, the SFCT (228[141-273] μm) from the bilateral PCV group was significantly lower compared with both the PCV (p = 0.002) and fellow eyes (p < 0.001) from the unilateral group. Moreover, ICGA related hyperfluorescent spots were shown to have a significant positive correlation with SFCT in the unilateral PCV eyes and their fellow eyes, other than bilateral PCV cases. In addition, the drusens tended to prevail in the fellow eyes of the unilateral PCV group (46.2%), compared with bilateral cases.

CONCLUSIONS

Our results indicate that SFCT, ICGA related hyperfluorescent spots, and drusen were the three main imaging characteristic differences between unilateral and bilateral PCV cases.

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.

Combined photodynamic therapy and ranibizumab for polypoidal choroidal vasculopathy: a 2-year result and systematic review

AIM

To report a cohort of patients with polypoidal choroidal vasculopathy (PCV) treated with photodynamic therapy (PDT) followed by intravitreal ranibizumab injection 24-48h later, and to compare the results between eyes with PCV treated by PDT followed by intravitreal anti-vascular endothelial growth factor (VEGF) injection and intravitreal anti-VEGF injection followed by PDT by Meta-analysis.

METHODS

Retrospective study and systematic literature review. Medical records of patients with PCV who were initially treated using PDT followed by intravitreal ranibizumab injection 24-48h after PDT and had completed at least 2y follow-up were reviewed and analyzed. Clinical data, including age, sex, best-corrected visual acuity (BCVA), fundus photograph, fluorescein angiography, indocyanine green angiography and optical coherence tomography were investigated. A systematic literature review was also conducted, and a visual outcome of studies over 1y was compared using Meta-analysis.

RESULTS

A total of 52 patients were included in the study. Mean BCVA at baseline and follow-up at 1 or 2y were 0.71±0.61, 0.51±0.36 and 0.68±0.51 logMAR, respectively. The cumulative hazard rate for recurrence at 1 and 2y follow-up was 15.4% and 30.3% respectively. The percentage of eyes with polyps regression at 3, 12 and 24mo follow-up was 88.5%, 84.6% and 67.3% respectively. A Meta-analysis based on 22 independent studies showed the overall vision improvements at 1, 2 and 3y follow-up were 0.13±0.04 (P<0.001), 0.12±0.03 (P<0.001), 0.16±0.06 (P<0.001), respectively. The proportion of polyps regression at 1y follow-up was 64.6% (95%CI: 51.5%, 77.7%, P<0.001) in 434 eyes treated by intravitreal anti-VEGF agents before PDT and 76.0% (95%CI: 64.8%, 87.3%, P=0.001) in 199 eyes treated by intravitreal anti-VEGF agents after PDT.

CONCLUSION

Intravitreal ranibizumab injection 24-48h following PDT effectively stabilizes visual acuity in the eye with PCV. PDT followed by intravitreal anti-VEGF agents may contribute to a relatively higher proportion of polyps' regression as compared to that of intravitreal anti-VEGF before PDT.

Comparison of the 1-year Outcomes of Conbercept Therapy between Two Different Angiographic Subtypes of Polypoidal Choroidal Vasculopathy

Background:

Polypoidal choroidal vasculopathy (PCV) is characterized by the presence of polyps with or without a branching vascular network and more prevalent among Asians. The aim of this study was to compare the outcomes of conbercept therapy between two different angiographic subtypes of PCV.

Methods:

Fifty-eight patients of PCV were classified into two phenotypes according to indocyanine green angiography (ICGA). In Type 1, both feeder and draining vessels are visible on ICGA and network vessels are numerous. In Type 2, neither feeder nor draining vessels are detectable, and the number of network vessels is small. The patients were treated with intravitreal conbercept (IVC) for 3 months. Additional IVC was given at subsequent monthly visits, if needed. The patients were followed up for 12 months, and changes in mean best-corrected visual acuity (BCVA), central retinal thickness (CRT), subretinal fluid (SRF) thickness, pigmented epithelial detachment (PED), hemorrhage, and number of polypoidal lesions were evaluated.

Results:

The mean BCVA in Type 2 PCV (15.92 ± 9.76 letters) achieved a significantly greater improvement than that in the Type 1 (14.10 ± 9.07 letters) at month 12 (t = 2.37, P < 0.01). Moreover, the mean CRT decrease was numerically greater in Type 2 (120.44 ± 73.81 μm) compared with Type 1 (106.48 ± 72.33 μm) at month 6 (t = 4.31, P < 0.01), and greater in Type 2 (130.21 ± 76.28 μm) compared with Type 1 (111.67 ± 79.57 μm) at month 9 (t = 1.87, P < 0.01). There was no significant difference between the two types for the decrease in SRF thickness, PED height, and regression of polyps from month 3 to 12 (t = 2.97, P > 0.05).

Conclusion:

Classification systems for PCV will show differences in presentation, natural history, or response to anti-vascular endothelial growth factor treatment and might, therefore, provide a new key to the choice of treatment for the disease.

Combined argon laser photocoagulation and antivascular endothelial growth factor for management of macular polypoidal choroidal vasculopathy

Aim:

To evaluate the efficacy of combination therapy of argon laser photocoagulation and intravitreal antivascular endothelial growth factor (VEGF) injection in idiopathic polypoidal choroidal vasculopathy (PCV) involving macula.

Materials and Methods:

A retrospective interventional study involving 12 eyes of 11 patients diagnosed with PCV involving the macula on indocyanine green angiography (ICGA). Intravitreal anti-VEGF was given in eyes with significant subretinal/sub retinal pigment epithelium hemorrhage or exudation. ICGA-guided focal laser was done to extrafoveal leaking polyps. Mean change in best-corrected visual acuity (BCVA) and regression of polyp as seen on ICGA were evaluated at the final follow-up.

Statistical Analysis:

It was done using SPSS 17.0. – Mann-Whitney test.

Results:

12 eyes of 11 patients underwent argon laser with intravitreal anti-VEGF injection. Ten patients were males and one female. Mean age was 65.75 ± 5.2 years. The mean number of injections given was 3.66 ± 1.5 (2–6) per eye. Mean number of laser sessions required was 1.33 ± 0.65 (1–3) per eye. BCVA improved in 25% (n = 3), remained stable in stable in 50% (n = 6) eyes, and decreased in 25% (n = 3) eyes. The regression of polypoidal lesions on ICGA was seen in 75% (n = 9) of eyes. Persistent subretinal fluid seen in 25% (n = 3) of eyes. The mean duration of follow-up was 15.41 ± 10.27 (3–36) months.

Conclusion:

Combined argon laser photocoagulation with intravitreal anti-VEGF injection helps in decreasing exudation and results in stabilization of the disease with visual improvement in eyes with PCV involving macula.

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

PURPOSE

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

DESIGN

Retrospective cohort study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

HTRA1 promoter variant differentiates polypoidal choroidal vasculopathy from exudative age-related macular degeneration

Exudative age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) share similar abnormal choroidal vasculature, but responses to treatments are different. In this study, we sequenced the whole HTRA1 gene and its promoter by direct sequencing in a Hong Kong Chinese PCV cohort. We identified rs11200638, c.34delCinsTCCT, c.59C>T, rs1049331 and rs2293870 significantly associated with PCV. Notably, rs2672598 was significantly associated with exudative AMD (p = 1.31 × 10(-4)) than PCV (p = 0.11). Logistic regression indicated that rs2672598 (p = 2.27 × 10(-3)) remained significant after adjusting for rs11200638 in exudative AMD. Moreover, the rs11200638-rs2672598 joint genotype AA-CC conferred higher risk to exudative AMD (43.11 folds) than PCV (3.68 folds). Promoter analysis showed that rs2672598 C-allele showed higher luciferase expression than wildtype T-allele (p = 0.026), independent of rs11200638 genotype (p = 0.621). Coherently, vitreous humor HTRA1 expression with rs2672598 CC genotype was significantly higher than that with TT genotype by 2.56 folds (p = 0.02). Furthermore, rs2672598 C-allele was predicted to alter the transcription factor binding sites, but not rs11200638 A-allele. Our results revealed that HTRA1 rs2672598 is more significantly associated with exudative AMD than PCV in ARMS2/HTRA1 region, and it is responsible for elevated HTRA1 transcriptional activity and HTRA1 protein expression.

Age-related macular degeneration and polypoidal choroidal vasculopathy in Asians

Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in elderly people globally. It is estimated that there will be more Asians with AMD than the rest of the world combined by 2050. In Asian populations, polypoidal choroidal vasculopathy (PCV) is a common subtype of exudative AMD, while choroidal neovascularization secondary to AMD (CNV-AMD) is the typical subtype in Western populations. The two subtypes share many common clinical features and risk factors, but also have different epidemiological and clinical characteristics, natural history and treatment outcomes that point to distinct pathophysiological processes. Recent research in the fields of genetics, proteomics and imaging has provided further clarification of differences between PCV and CNV-AMD. Importantly, these differences have manifested as disparity in response to intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) treatment between PCV and CNV-AMD, emphasizing the need for accurate diagnosis of PCV and in distinguishing PCV from CNV-AMD, particularly in Asian patients. Current clinical trials of intravitreal anti-VEGF therapy and photodynamic therapy will provide clearer perspectives of evidence-based management of PCV and may lead to paradigm shifts in therapeutic strategies away from those currently employed in the treatment of CNV-AMD. Further research is needed to clarify the relative contribution of specific pathways in inflammation, complement activation, extracellular matrix dysregulation, lipid metabolism and angiogenesis to the pathogenesis of PCV. Findings from this research, together with improved diagnostic technology and new therapeutics, will facilitate more optimal management of Asian AMD.

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.

Baseline polyp size as a potential predictive factor for recurrence of polypoidal choroidal vasculopathy

PURPOSE

To investigate the predictive factors for recurrence of polypoidal choroidal vasculopathy (PCV).

METHODS

The medical records of 78 consecutive patients (78 eyes) with treatment-naïve PCV who responded to first-line treatment and completed at least a 3-year follow-up after the first remission were retrospectively analyzed. In this comparative cohort study, baseline characteristics were compared between the patients who had at least one recurrence (the recurrence group) and those without recurrence (the non-recurrence group) during at least 3-year follow-up periods. In addition, possible predictive factors for recurrence of PCV were investigated by using Cox regression analysis.

RESULTS

Within 3 years of the first remission, 50 eyes (64 %) showed at least one recurrence (mean 1.5; 1 to ∼2 times). There were no significant differences in the baseline characteristics between the recurrence group and the non-recurrence group. However, the largest polyp diameter was significantly different: the mean largest polyp diameter (524 ± 340 μm) was significantly larger in the recurrence group compared to that of the non-recurrence group (352 ± 173 μm; P = 0.038). Cox regression analysis showed that the largest polyp diameter at baseline significantly correlated with recurrence of PCV (B = 1.470, P = 0.015).

CONCLUSIONS

The largest polyp diameter at baseline may be predictive for PCV recurrence, as it was significantly larger in patients who had at least one recurrence.

Intravitreal Anti-vascular Endothelial Growth Factor for Newly Diagnosed Symptomatic Polypoidal Choroidal Vasculopathy with Extrafoveal Polyps

PURPOSE

To evaluate the 12-month outcome of anti-vascular endothelial growth factor (VEGF) treatment for extrafoveal polypoidal choroidal vasculopathy (PCV).

METHODS

This retrospective observational study included 32 eyes of 32 patients newly diagnosed with extrafoveal PCV (polyps located more than 500 µm from the center of the fovea). Patients were treated with intravitreal ranibizumab, bevacizumab, or both. The best-corrected visual acuity (BCVA) and central foveal thickness (CFT) at diagnosis and at 12 months were compared. Eyes were divided into two groups according to the presence of submacular hemorrhage. The BCVA in each group was compared at baseline and at 12 months.

RESULTS

During the 12-month study period, patients received an average of 4.0 ± 1.1 anti-VEGF injections. The BCVA at baseline, three-month post-diagnosis, and 12-month post-diagnosis was 0.59 ± 0.40, 0.34 ± 0.38, and 0.38 ± 0.38, respectively. The BCVA at 12 months was significantly better than the baseline value (p = 0.002). The CFT at baseline, three-month, and 12-month post-diagnosis was 477.1 ± 194.2 µm, 214.5 ± 108.8 µm, and 229.8 ± 106.1 µm, respectively. The CFT at 12 months was significantly lower than the baseline value (p < 0.001). A significant improvement in BCVA was noted in eyes with and without submacular hemorrhage (n = 13, p = 0.032 and n = 19, p = 0.007, respectively).

CONCLUSIONS

Anti-VEGF therapy was beneficial in extrafoveal PCV, regardless of the presence of submacular hemorrhage.

Interleukin-1β Level Is Increased in Vitreous of Patients with Neovascular Age-Related Macular Degeneration (nAMD) and Polypoidal Choroidal Vasculopathy (PCV)

Purpose

To examine the expression of pro-interleukin-1β (pro-IL-1β) and interleukin-1β (IL-1β) in the vitreous body of patients with neovascular age-related macular degeneration(nAMD), polypoidal choroidal vasculopathy (PCV), proliferative diabetic retinopathy (PDR), retinal vein occlusion (RVO) or Eales’ disease to further elucidate the role of IL-1β and inflammation in the pathogenesis of neovascular retinal disease.

Design

Prospective clinical laboratory investigation study.

Methods

All patients enrolled had vitreous hemorrhage due to nAMD, PCV, PDR, RVO or Eales’ disease that required vitrectomy. Patients were excluded for any history of active intraocular inflammation, or other ophthalmic surgery besides vitrectomy. Control samples were obtained from patients with idiopathic macular epiretinal membrane. A total of fifty vitreous samples were collected from patient during vitrectomy. Pro-IL-1β and IL-1β expression were measured by enzyme-linked immunosorbent assay (ELISA). Results were analyzed statistically using nonparametric tests.

Results

Expression of pro-IL-1β protein was increased by 2.83-fold and 9.19-fold in PCV and nAMD vitreous samples relative to control, respectively. Expression of IL-β protein was increased by 10-fold and 4.83-fold in PCV and nAMD vitreous samples relative to control, respectively.

Conclusions

Our results demonstrate that expression of pro-IL-1β and IL-1β proteins is higher in PCV and nAMD. The roles of pro-IL-1β and IL-1β as inflammatory mediators in the development of PCV and nAMD may be associated with photoreceptor degeneration and neovascularization which necessitates further study.

Polypoidal Choroidal Vasculopathy in Asians

Age related macular degeneration (AMD) in Asians has been suggested to differ from their Western counterparts in terms of epidemiology, pathogenesis, clinical presentation and treatment. In particular, polypoidal choroidal vasculopathy (PCV) appears to be the predominant subtype of exudative AMD in Asian populations, in contrast to choroidal neovascularization secondary to AMD (CNV-AMD) in Western populations. Epidemiological data on PCV has been largely limited to hospital-based studies and there are currently no data on the incidence of PCV. Similarities and differences in risk factor profile between PCV and CNV-AMD point to some shared pathogenic mechanisms but also differential underlying mechanisms leading to the development of each phenotype. Serum biomarkers such as CRP, homocysteine and matrix metalloproteinases suggest underlying inflammation, atherosclerosis and deranged extracellular matrix metabolism as possible pathogenic mechanisms. In addition, recent advances in genome sequencing have revealed differences in genetic determinants of each subtype. While the standard of care for CNV-AMD is anti-vascular endothelial growth factor (VEGF) therapy, photodynamic therapy (PDT) has been the mainstay of treatment for PCV, although long-term visual prognosis remains unsatisfactory. The optimal treatment for PCV requires further clarification, particularly with different types of anti-VEGF agents and possible benefits of reduced fluence PDT.

FPR1 interacts with CFH, HTRA1 and smoking in exudative age-related macular degeneration and polypoidal choroidal vasculopathy

PURPOSE

To determine the genetic association of an inflammation-related gene, formyl peptide receptor 1 (FPR1), in exudative age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV).

METHODS

The coding region of FPR1 gene was sequenced in 554 unrelated Chinese individuals: 155 exudative AMD patients, 179 PCV patients, and 220 controls. Interactions and combined effects of FPR1 with complement factor H (CFH), high temperature requirement factor A1 (HTRA1), and smoking were also investigated.

RESULTS

A total of 28 polymorphisms in FPR1 were identified. Single nucleotide polymorphisms (SNP) rs78488639 increased the risk to exudative AMD (P=0.043) and PCV (P=0.016), whereas SNP rs867229 decreased the risk to exudative AMD (P=0.0026), but not PCV. Homozygous G allele of rs1042229 was associated with exudative AMD (P=0.0394, odds ratio (OR)=2.27, 95% confident interval: 1.08-4.74), but not with PCV. Exudative AMD, but not PCV, was associated with the heterozygous genotypes of rs2070746 (P=0.019, OR=0.57) and rs867229 (P=0.0082, OR=0.54). Significantly, interactions were identified among FPR1 rs78488639, CFH rs800292, and HTRA1 rs11200638 in both exudative AMD and PCV. Combined heterozygous risk alleles of CFH rs800292 GA and FPR1 rs78488639 CA were posed to PCV (P=2.22 × 10(-4), OR=10.47), but not exudative AMD. Furthermore, FPR1 rs78488639 CA combining with HTRA1 rs11200638 and smoking was also predisposed risks to exudative AMD and PCV.

CONCLUSION

FPR1 is associated with exudative AMD and PCV in a Hong Kong Chinese cohort. FPR1 rs78488639 interacted with CFH rs800292, HTRA1 rs11200638, and smoking, enhancing risk to exudative AMD and PCV.

Hyperhomocysteinemia in patients with polypoidal choroidal vasculopathy: a case control study

Purpose

To determine whether elevated plasma homocysteine and serum high sensitivity C-reactive protein (hsCRP) levels, two established risk factors of vascular diseases, are associated with polypoidal choroidal vasculopathy (PCV).

Design

Retrospective case-control study.

Methods

One hundred and nineteen consecutive patients with PCV and 119 matched controls were enrolled in a tertiary hospital from September 2008 to June 2013. Plasma homocysteine and serum hsCRP levels were measured. Associations among plasma homocysteine, serum hsCRP levels and PCV were further evaluated using multivariable logistic regression analysis.

Results

The median plasma homocysteine level was significantly higher in patients with PCV than in the controls (12.20 µmol/L vs. 9.80 µmol/L, p<0.001). The median serum hsCRP level was slightly higher in the PCV group (0.16 mg/dl vs. 0.11 mg/dl in control group, p = 0.07). After multivariable logistic regression analysis, each 1 µmol/L increase of plasma homocysteine was associated with a 1.5-fold increase in likelihood of having PCV (OR, 1.54; 95% confidence interval (CI), 1.33–1.79, p<0.001).

Conclusions

Hyperhomocysteinemia was associated with PCV and might play a role in the pathogenesis of PCV.

Ranibizumab for the treatment of degenerative ocular conditions

Degenerative ocular conditions, such as age-related macular degeneration, diabetic retinopathy, retinal vein occlusions, and myopic degeneration, have become a major public health problem and a leading cause of blindness in developed countries. Anti-vascular endothelial growth factor (VEGF) drugs seem to be an effective and safe treatment for these conditions. Ranibizumab, a humanized monoclonal antibody antigen-binding fragment, which inhibits all biologically active isoforms of VEGF-A, is still the gold standard treatment for the majority of these pathological entities. In this review, we present the results of the most important clinical trials concerning the efficacy and safety of ranibizumab for the treatment of degenerative ocular conditions.

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

PURPOSE

To evaluate the long-term visual outcomes of pars plana vitrectomy (PPV) for polypoidal choroidal vasculopathy (PCV)-associated vitreous haemorrhage (VH).

METHOD

We retrospectively reviewed the records of patients with PCV-related VH who underwent PPV. The main outcome measures were best-corrected visual acuity (BCVA) and fundus findings at 3 months postoperatively and final visit.

RESULTS

Seventeen eyes of 17 patients with massive subretinal haemorrhage (16.7±7.1 disc size of mean subretinal haemorrhage area) were enrolled. The mean postoperative follow-up period was 25.2 months. Four eyes received intravitreal bevacizumab injections, and three eyes underwent photodynamic therapy before the onset of VH. The mean BCVA improved from logarithm of the minimum angle of resolution (LogMAR) of 2.63±0.57 preoperatively to 1.43±0.82 at final visit (P<0.001). Among the eyes with initial polyps at subfoveal or juxtafoveal area, 16.70% achieved final BCVA ≥20/400 (LogMAR 1.3), whereas 87.50% of eyes with initial polyps at extrafoveal area had final BCVA ≥20/400 (Fisher's exact test, P=0.026).

CONCLUSIONS

PCV with massive subretinal haemorrhage is at risk for breakthrough VH. The visual prognosis in eyes with PCV-related breakthrough VH is variable after vitrectomy. Initial polyps at the extrafoveal area led to better functional outcomes. Early vitrectomy may be beneficial for visual recovery after PCV-related VH.

Angiographic features of transgenic mice with increased expression of human serine protease HTRA1 in retinal pigment epithelium

PURPOSE

Polypoidal choroidal vasculopathy (PCV) is characterized by a branching vascular network (BVN) of choroid that terminates in polypoidal dilations. We have previously reported the generation of the first PCV model by transgenically expressing human HTRA1 (hHTRA1(+)), a multifunctional serine protease, in mouse RPE. The purpose of this study was to perform a comprehensive examination of the PCV phenotypes (e.g., lesion type and distribution) of hHTRA1(+) mice by a variety of in vivo imaging techniques.

METHODS

We generated improved hHTRA1(+) mice with a more consistent phenotype. Transgenic mice were examined by indocyanine green angiography (ICGA), fluorescein angiography, funduscopy, and spectral-domain optical coherence tomography. In particular, we performed ICGA by tail vein injection of ICG to obtain high-quality ICGA comparable to human studies in terms of the three phases (early, middle, and late) of angiography.

RESULTS

The polyps can be detected in the early "fill-in" phase of ICGA, and most lesions become visible in the middle phase and are more distinct in the late phase with the fading of surrounding vessels. In addition to the two key features of PCV (polypoidal dilations and BVNs), hHTRA1(+) mice exhibit other features of PCV (i.e., late geographic hyperfluorescence, pigment epithelial detachment, and hyperfluorescent plaque). Polypoidal lesions appear as reddish orange nodules on funduscopy.

CONCLUSIONS

Transgenic hHTRA1(+) mice exhibit a rich spectrum of "clinical" features that closely mimic human PCV. This animal model will serve as an invaluable tool for future mechanistic and translational studies of PCV and other forms of choroidal vasculopathies.

Combined photodynamic therapy with intravitreal bevacizumab injections for polypoidal choroidal vasculopathy: long-term visual outcome

PURPOSE

To evaluate the long-term visual outcome after combination therapy of photodynamic therapy (PDT) with intravitreal bevacizumab injections for polypoidal choroidal vasculopathy (PCV).

DESIGN

Retrospective observational study.

METHODS

The medical records of 34 eyes (34 patients) with naïve PCV who were treated with combination therapy were analyzed. All patients completed at least 3 years of follow-up. All clinical data, including age, best-corrected visual acuity (BCVA, logarithm of the minimal angle of resolution [logMAR]), imaging data of fluorescein angiography, indocyanine green angiography, and optical coherence tomography, were investigated.

RESULTS

During a mean follow-up period of 46.8 ± 5.2 months, a mean of 1.4 ± 0.71 times of PDT and 9.2 ± 6.6 intravitreal bevacizumab injections were performed. During follow-up, 21 eyes (61.8%) showed at least 1 recurrence. Mean BCVA was 0.59 ± 0.35 logMAR (20/77 Snellen equivalent) at baseline and 0.39 ± 0.34 logMAR (20/49 Snellen equivalent) at 3 years (P = .004). At 3 years, 14 patients (41.2%) gained 0.3 logMAR or more BCVA and 4 patients (11.8%) lost 0.3 logMAR or more BCVA than baseline. Baseline polyp size (β = .551; P = .005) and location of polyps (β = -.400; P =.033) were significantly correlated with long-term visual outcome after combination therapy for PCV.

CONCLUSIONS

Combination therapy of PDT with intravitreal bevacizumab injections showed favorable visual outcomes, and significant visual improvement was maintained in PCV patients. A total of 88.2% of patients avoided visual loss at 3 years after treatments. Largest polyp size at baseline and location of polypoidal lesions were prognostic factors for long-term visual outcomes in these patients.

Polypoidal choroidal vasculopathy: clinical features and genetic predisposition

Polypoidal choroidal vasculopathy (PCV) is currently recognized as a phenotype of age-related macular degeneration (AMD). PCV is believed to be a type of choroidal neovascularization, although some cases of PCV show a distinct vascular abnormality of the choroidal vessels. PCV often shows several unique clinical manifestations which are apparently different from typical neovascular AMD (tAMD). In addition, the natural course and response to treatment are often different between tAMD and PCV. Moreover, recent genetic studies suggested a possible difference in the genetic susceptibility to disease between tAMD and PCV, as well as the existence of heterogeneity among PCV cases. In viewing the accumulation of knowledge about PCV, we have summarized the recent literature regarding PCV in this review article to improve the understanding of this clinical entity including possible susceptibility genes. We will also discuss the optimal treatment strategies for PCV in accordance with the results of recent clinical and genetic studies.

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.

Long-term visual outcome and prognostic factors after intravitreal ranibizumab injections for polypoidal choroidal vasculopathy

PURPOSE

To evaluate long-term visual outcome and investigate the prognostic factors after anti-vascular endothelial growth factor (VEGF) therapy for polypoidal choroidal vasculopathy (PCV).

DESIGN

Retrospective study.

METHODS

Analyses were done among 36 eyes (36 patients) with naïve PCV that were treated with intravitreal ranibizumab injections and completed at least 3-year follow-up. All clinical data, including baseline characteristics; imaging data from fluorescein angiography, indocyanine green angiography, and optical coherence tomography; presence of recurrence; and best-corrected visual acuity (BCVA) were investigated.

RESULTS

During mean follow-up of 42.58 ± 12.59 months, mean numbers of anti-VEGF injection were 11.45 ± 7.81. Twenty-four eyes (66.7%) showed at least 1 recurrence during follow-up. Mean baseline BCVA was 0.68 ± 0.43 logMAR (20/95 Snellen equivalent), and 0.78 ± 0.53 logMAR (20/120 Snellen equivalent) at 36 months (P = .307). Mean BCVA was significantly improved at 1 month (P = .018), and improvement was maintained until 12 months (P = .044), then deteriorated. Among baseline characteristics, greatest lesion diameter (B = 0.219, P = .001) and pigment epithelial detachment (B = 0.362, P = .025) were significantly correlated with long-term visual outcome. Recurrence during follow-up (B = 0.371, P = .024) was also significantly correlated with long-term visual outcome.

CONCLUSION

Significant visual improvement by anti-VEGF therapy was maintained during the first year of initial treatment; however, vision then deteriorated during long-term follow-up. Smaller lesion size, absence of pigment epithelial detachment at baseline, and no recurrence during follow-up were significantly correlated with better long-term visual outcome.

Argon laser with and without anti-vascular endothelial growth factor therapy for extrafoveal polypoidal choroidal vasculopathy

PURPOSE

To describe the clinical characteristics and outcome of eyes with extrafoveal polypoidal choroidal vasculopathy (PCV) treated with argon laser.

DESIGN

Prospective cohort, noninterventional study.

METHODS

A prospective study of Asian patients with extrafoveal PCV, confirmed on indocyanine green angiography and treated with argon laser with and without anti-vascular endothelial growth factor (VEGF) therapy. Patients were followed-up over 12 months with visual, angiographic, and structural outcomes recorded.

RESULTS

Of the 93 eyes with PCV at baseline, 33 eyes (35.5%) in 31 patients had extrafoveal involvement and were treated with argon laser. Foveal involvement with fluid or blood at baseline was apparent in 23 eyes (69.7%), despite the extrafoveal location of 1 or more polyps. Of these 33 eyes, 12 (36.4%) also received anti-VEGF injections (median, 2.5 injections) over the 12-month period. Two eyes received photodynamic therapy rescue during subsequent follow-up and were excluded for visual outcome analysis. In the remaining 31 eyes, mean visual acuity improved from 0.57 logarithm of the minimal angle of resolution (logMAR) units (range, 0.00 to 2.0 logMAR; standard deviation, 0.51 logMAR) at baseline to 0.39 logMAR (range, 0.00 to 2.0 logMAR; standard deviation, 0.43 logMAR) at month 12 (P = .01), with a mean gain in visual acuity of 9.0 letters at month 12. Stable or improved vision (defined as losing 5 letters or fewer) was achieved in 28 eyes (90.3%). Use of anti-VEGF was associated with significantly thicker central subfield at baseline (347.6 vs 258.1 μm; P = .02) and resulted in similar vision and OCT results at month 3 and 12 compared with eyes that did not receive anti-VEGF.

CONCLUSIONS

Argon laser treatment with selected use of anti-VEGF therapy achieves stable or improved visual outcome in most eyes with extrafoveal PCV, including eyes with fluid or blood affecting the fovea at presentation.

Responses to photodynamic therapy in patients with polypoidal choroidal vasculopathy consisting of polyps resembling grape clusters

PURPOSE

To investigate the responses to photodynamic therapy (PDT) in patients with polypoidal choroidal vasculopathy (PCV) that show large aneurysmal dilation with internal angio-architecture consisting of diverse patterns of curvilinear vessels and polyps resembling grape clusters.

DESIGN

Retrospective, interventional case series.

METHODS

Twenty-two eyes of 22 patients were included. All patients initially received PDT monotreatment. The main outcome measures were the rates of complete polyp regression on indocyanine green angiography and initial favorable responses observed clinically. Also, the rates of recurrent exudative changes were evaluated at the 2-year follow-up. We focused on changes in the vascular features and their clinical association.

RESULTS

Complete regression of polypoidal lesions was observed in 21 eyes (95%) after a mean of 1.7 PDTs. However, favorable clinical responses were achieved in only 9 eyes (41%), and 6 of them had recurrent exudation. Main vessels, previously consisting of the polypoidal lesion frame, persisted. Additionally, aberrant vessels with a thin radiating or tortuous configuration were observed in the area where large aneurysmal dilation was present. Leakage from this vascular complex or an expanded vascular complex was observed in a total of 14 eyes (64%) during the 2-year follow-up, contributing to persistent (8 eyes) or recurrent (6 eyes) exudation. This seemed to represent secondary choroidal neovascularization (CNV). In another 4 eyes (18%), fibrous changes developed immediately after PDT. Polyps recurred in 8 eyes (38%).

CONCLUSIONS

This PCV pattern frequently evolved into typical CNV after PDT, resulting in persistent or recurrent exudation despite the disappearance of polypoidal structures.

Management of peripheral polypoidal choroidal vasculopathy with intravitreal bevacizumab and indocyanine green angiography-guided laser photocoagulation

A 69-year-old lady presented with complaints of decreased vision in left eye since one month. Best Corrected Visual Acuity (BCVA) was 6/18 in that eye. Fundus examination revealed non-central geographic atrophy and soft drusens at macula in both eyes. Temporal periphery of left eye revealed subretinal exudates with altered sub-RPE hemorrhage mimicking peripheral exudative hemorrhagic chorioretinopathy (PEHCR). Fundus Fluorescein Angiogram showed window defects at macula and blocked fluorescence at temporal periphery in left eye. However, Indocyanine green angiography (ICGA) revealed active peripheral choroidal polyps. The patient was successfully treated with intravitreal bevacizumab and ICGA-guided laser photocoagulation. 27 months after laser treatment, BCVA improved to 6/9. Rationale of consecutive anti-vascular endothelial growth factor (VEGF) treatment followed by more definitive laser photocoagulation is that anti-VEGF aids in resolution of subretinal fluid, thus making the polyp more amenable to focal laser photocoagulation which stabilizes the choroidal vasculature and prevents further leakage.

Association of lesion size and visual prognosis to polypoidal choroidal vasculopathy

PURPOSE

To investigate the progression of vascular lesions of polypoidal choroidal vasculopathy (PCV) as viewed with indocyanine green angiography and the visual prognosis of these eyes.

DESIGN

Retrospective case study.

METHODS

We reviewed retrospectively the medical records of 88 consecutive patients (88 eyes) with PCV who had been examined with indocyanine green angiography for more than 2 years.

RESULTS

Depending on the initial area of the vascular lesion, eyes were divided into smaller PCV (baseline area of lesion being < 1 disc area [DA], n = 22) and larger PCV (baseline area of lesion being ≥ 1 DA, n = 66). In larger PCV, the mean area of the lesion progressed significantly from 6.49 ± 8.96 mm(2) to 16.27 ± 14.19 mm(2) (P < .0001) with marked deterioration of visual acuity (P < .0001) during follow-up. In contrast, smaller PCV often showed minimal progression of the lesion, only limited exudative change, and the eyes maintained their initially good vision to the final visit. Smaller PCV lesions rarely progressed to extensive PCV lesions. Severe vision-threatening complications (ie, suprachoroidal hemorrhage, vitreous hemorrhage, and tears of the retinal pigment epithelium) were seen only in eyes with larger PCV, and in studying single nucleotide polymorphisms A69S of ARMS2 genes, there was a significant difference in T allele frequency between individuals with smaller PCV and those with larger PCV (20.2% vs 79.8%; P = .0235).

CONCLUSIONS

PCV with small vascular lesions shows minimal progression and no vision-threatening complications, and these eyes often maintain good visual acuity for a long time.

Relationship of smoking and cardiovascular risk factors with polypoidal choroidal vasculopathy and age-related macular degeneration in Chinese persons

PURPOSE

Polypoidal choroidal vasculopathy (PCV) has been described as a distinct clinical entity from choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). The present study aimed to determine risk factors for PCV and to compare associations with those for CNV secondary to AMD.

DESIGN

Case-control study.

PARTICIPANTS

Patients of Chinese ethnicity with clinically and angiographically diagnosed PCV (n = 123) or CNV secondary to AMD (n = 128) were recruited from a tertiary eye hospital in Singapore. Controls without signs of PCV, CNV secondary to AMD, or other retinal pathologic features (n = 1489) were selected from a population-based study.

METHODS

Patients underwent an ophthalmologic examination including digital color fundus photography, stereoscopic fluorescein angiography (FA), and indocyanine green angiography (ICGA). Classification into PCV or CNV secondary to AMD was based on FA and ICGA findings. Risk factors were determined from a standardized interview, with blood pressure recorded using a digital automatic blood pressure monitor.

MAIN OUTCOME MEASURES

Polypoidal choroidal vasculopathy or CNV secondary to AMD.

RESULTS

Persons who smoked were more likely to have PCV (39.9% vs. 13.4%) or CNV secondary to AMD (45.0% vs. 12.3%) than those who did not smoke. After controlling for age, gender, diabetes, hypercholesterolemia, and hypertension, persons who smoked were 4 times more likely to have PCV (odds ratio [OR], 4.4; 95% confidence interval [CI], 2.5-7.7; P<0.001) and CNV secondary to AMD (OR, 4.9; 95% CI, 2.7-8.8; P<0.001). A significant, negative association also was found between diastolic blood pressure and CNV secondary to AMD (OR, 0.7; 95% CI, 0.5-0.9; P = 0.017, adjusted for age, gender, smoking, diabetes, and hypercholesterolemia), but diastolic blood pressure was not associated with PCV.

CONCLUSIONS

Smoking but not other vascular risk factors is significantly associated with both PCV and CNV secondary to AMD in Chinese persons. The similarity of associations suggests that there may be common risk factors and pathological mechanisms.

Clinical features, management and visual outcome of polypoidal choroidal vasculopathy in Indian patients

Aims:

To present the clinical, indocyanine green angiography (ICGA) features and results of treatment for polypoidal choroidal vasculopathy (PCV) in Indian patients by a retrospective chart review.

Materials and Methods:

Forty five patients with PCV underwent complete ocular examination, fluorescein angiography (FFA) and ICGA. Treatment was advised for patients with macular involvement and progressive loss of visual acuity. Demographic data, clinical features and results of treatment were analyzed.

Results:

Mean age at presentation was 61.06 years. Mean follow up was 18 months. The disease was more prevalent in males. Forty three patients had unilateral disease. The most common location of polyps in ICGA was subfoveal (42.5%). Exudative form was seen in 34 of the 47 eyes and the remaining 13 eyes had a hemorrhagic presentation. Thirty four eyes underwent treatment which included thermal laser (n = 11), photodynamic therapy (PDT) (n = 11) and transpupillary thermo therapy (TTT) (n = 12). Statistical analysis was done using the Chi-square test. Subgroup analysis of visual outcome following various modalities of treatment showed that the results of PDT (P < 0.001) and thermal laser (P < 0.001) were statistically significant.

Conclusions:

PCV is an important differential diagnosis in patients presenting with serosanginous maculopathy and submacular hemorrhage. The disease was more prevalent in males and was unilateral in the Indian population. Timely intervention in cases with symptomatic polyps could achieve stabilization of visual acuity. Thermal laser and PDT were safe and effective.

Polypoidal choroidal vasculopathy masquerading as neovascular age-related macular degeneration refractory to ranibizumab

PURPOSE

To report a neovascular age-related macular degeneration pattern refractory to ranibizumab.

DESIGN

Retrospective, observational case series.

METHODS

Between March and May 2009, cases with neovascular age-related macular degeneration refractory to ranibizumab were investigated with indocyanine green angiography. We identified 12 eyes of 12 patients with polypoidal choroidal vasculopathy. Refractory to treatment were defined cases with persistent subretinal or intraretinal fluid, or both, after 3 or more consecutive monthly ranibizumab injections regardless of best-corrected visual acuity.

RESULTS

All patients identified were white, of whom 6 were male. Mean age ± standard deviation at presentation was 75 ± 5.6 years (range, 64 to 81 years); diagnosis, based on fluorescein angiography, comprised occult choroidal neovascularization (CNV) in 8 eyes, and 1 case each of classic-no-occult CNV, minimally classic CNV, predominantly classic CNV, and retinal angiomatous proliferation. Eight cases had switched from courses of other therapy (5 pegaptanib, 1 photodynamic therapy, 1 photodynamic therapy then pegaptanib, 1 bevacizumab). After a mean follow-up of 10.2 ± 4.8 months (range, 3 to 18 months) and 7.6 ± 3.9 ranibizumab injections (range, 3 to 14 injections), indocyanine green angiography revealed polypoidal choroidal vasculopathy lesions in all cases.

CONCLUSIONS

Neovascular age-related macular degeneration refractory to a course of ranibizumab injections may harbor polypoidal choroidal vasculopathy. In such cases, indocyanine green angiography is a valuable tool for revealing polypoidal lesions.