Results of 2 years of treatment with as-needed ranibizumab reinjection for polypoidal choroidal vasculopathy

Progression of Polypoidal Lesions Associated with Exudative Recurrence in Polypoidal Choroidal Vasculopathy

PURPOSE

To investigate the characteristics of the branching vascular network (BVN) and polypoidal lesions in polypoidal choroidal vasculopathy (PCV) to determine near-term indicators that may predict exudative recurrence.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients with PCV receiving anti-vascular endothelial growth factor (VEGF) monotherapy or anti-VEGF plus photodynamic therapy were followed for at least 1 year using swept-source OCT angiography (SS-OCTA) imaging.

METHODS

Patients were divided into 2 groups based on whether exudative recurrence occurred during follow-up. Multiple parameters were collected and compared between the 2 groups, such as age, gender, visual acuity, number of polypoidal lesions, lesion area at the first SS-OCTA visit, and total lesion area change from the first SS-OCTA visit to the last SS-OCTA visit. To evaluate the association between SS-OCTA imaging-based risk factors and the exudative recurrences, imaging features associated with PCV such as BVN growth and polypoidal lesion progression (enlargement, new appearance, and reappearance) at each follow-up visit were analyzed. The time intervals from the nonexudative visit with lesion progression to the corresponding exudative recurrence visit were documented to explore their association with exudative recurrences. Cox regression and logistic regression analyses were used.

MAIN OUTCOME MEASURES

Association between BVN growth and polypoidal lesion progression with exudative recurrence.

RESULTS

Thirty-one eyes of 31 patients (61% men) were included. Sixteen eyes had no recurrence of exudation, and 15 eyes had recurrence during follow-up. The average follow-up duration was 20.55 ± 6.86 months (range, 12-36 months). Overall, the recurrence group had worse best-corrected visual acuity (P = 0.019) and a greater increase in lesion area (P = 0.010). Logistical regression analysis showed that polypoidal lesion progression, including new appearance, enlargement, and reappearance of polypoidal lesions, was associated with exudative recurrences within 3 months (odds ratio, 26.67, 95% confidence interval, 3.77-188.54, P = 0.001).

CONCLUSIONS

Growth of nonexudative BVN and progression of polypoidal lesions were found to be lesion characteristics associated with exudative recurrences, and progression of polypoidal lesions might serve as a stand-alone indicator for the near-term onset of exudation. In PCV, more frequent follow-up visits are recommended when polypoidal lesions show progression.

Difference in treatment burden of neovascular age-related macular degeneration among different types of neovascularization

PURPOSE

To evaluate the difference in the treatment burden among different types of neovascular age-related macular degeneration (AMD).

METHODS

This retrospective, observational study included 431 patients who were diagnosed with neovascular AMD. Patients were divided into three groups: type 1 or 2 neovascularization group (n = 167), type 3 neovascularization group (n = 50), and polypoidal choroidal vasculopathy (PCV) group (n = 214). The number of hospital visits per year and the number of anti-vascular endothelial growth factor (VEGF) injections per year were compared among these groups. Furthermore, the incidence of bilateral involvement during the follow-up period was compared among the groups.

RESULTS

The mean follow-up period was 50.6 ± 11.3 months. The number of hospital visits per year was significantly higher in the type 1 or 2 neovascularization group (mean: 6.1 ± 1.5) and type 3 neovascularization (6.6 ± 1.6) than in the PCV group (6.0 ± 1.5) (P < 0.001). The number of anti-VEGF injections per year was significantly higher in type 3 neovascularization group (3.1 ± 1.7) than in the type 1 or 2 neovascularization group (2.3 ± 1.5) or the PCV group (2.3 ± 1.2) (P = 0.042). There was a significant difference in the incidence of bilateral involvement among patients in type 1 or 2 neovascularization group (20.4%), type 3 neovascularization group (46.0%), and the PCV group (15.4%) (P < 0.001).

CONCLUSIONS

The high frequency of hospital visits and that of anti-VEGF injections in patients with type 3 neovascularization suggests high treatment burden in these patients. The high incidence of bilateral involvement could be one of the primary reasons for high treatment burden in patients with type 3 neovascularization.

Genetic Variants Affecting Anti-VEGF Drug Response in Polypoidal Choroidal Vasculopathy Patients: A Systematic Review and Meta-Analysis

Polypoidal choroidal vasculopathy (PCV) is usually regarded as a subtype of choroidal neovascularization (CNV) that is secondary to age-related macular degeneration (AMD) characterized by choroidal vessel branching, ending in polypoidal lesions. Despite their close association, PCV and neovascular AMD have shown differences, especially regarding patients' treatment response. Currently, antivascular endothelial growth factor (anti-VEGF) drugs, such as ranibizumab, bevacizumab and aflibercept, have demonstrated their efficacy in CNV patients. However, in PCV, anti-VEGF treatments have shown inconclusive results. Many genetic polymorphisms have been associated with a variable response in exudative/wet AMD patients. Thus, the aim of this study is to explore the genetic variants affecting anti-VEGF drug response in PCV patients. In this regard, we performed a systematic review and meta-analysis. We found four variants (CFH I62V, CFH Y402H, ARMS2 A69S, and HTRA1-62A/G) that have been significantly related to response. Among them, the ARMS2 A69S variant is assessed in our meta-analysis. In conclusion, in order to implement anti-VEGF pharmacogenetics in clinical routines, further studies should be performed, distinguishing physio-pathogenic circumstances between PCV and exudative AMD and the combined effect on treatment response of different genetic variants.

The polyp regression rate and treatment prognosis of different interventions for polypoidal choroidal vasculopathy: a systematic review and meta-analysis

PURPOSE

To estimate the polyp regression rate and treatment prognosis of different interventions for polypoidal choroidal vasculopathy (PCV) and clarify its baseline characteristics.

METHODS

The PubMed, EMBASE, and Ovid were searched up to January 2020 to identify related studies. R software version 3.6.3 was used to perform the statistical analyses. Results in proportion with 95% confidence interval (CI) were calculated by means of the Freeman-Tukey variant of arcsine square transformation. Chi-squared test and I² statistics were used to evaluate the statistical heterogeneity. Sensitivity analysis and subgroup analyses were performed to identify the source of heterogeneity.

RESULTS

This meta-analysis included 104 studies with 5816 patients. The pooling results indicated the general rate of complete polyp regression at post-treatment 12 months was 64% (95% CI [57~71%]), 89% (95% CI [81~95%]) for photodynamic therapy (PDT) monotherapy, 78% (95% CI [68~86%]) for PDT plus anti-vascular endothelial growth factor (anti-VEGF), and 42% (95% CI [35~49%]) for anti-VEGF monotherapy; PDT plus anti-VEGF showed the best efficacy in visual improvement and achieved the highest rate of dry macula (91%, 95% CI [78~99%]), while anti-VEGF monotherapy achieved the lowest polyp recurrence rate (14%, 95% CI [8~20%]); PDT monotherapy showed the best efficacy in pigment epithelial detachment regression (66%, 95% CI [58~83%]). Additionally, the baseline characteristics of PCV were also well described.

CONCLUSION

PDT plus anti-VEGF is still valuable for the management of PCV; it could achieve not only satisfactory anatomical outcomes like dry macula rate and polyp regression rate but also ideal visual prognosis like BCVA improvement.

Visual Prognosis in the Better-seeing Eyes of Patients with Unilateral Polypoidal Choroidal Vasculopathy

SIGNIFICANCE

In patients initially diagnosed as having unilateral polypoidal choroidal vasculopathy, the visual prognosis of the better-seeing eye is highly favorable. If patients are overly pessimistic regarding their vision in the future, physicians can encourage patients by informing them of the small possibility for visual deterioration in the better-seeing eye.

PURPOSE

The purpose of this study was to investigate the long-term changes in the visual acuity of the better-seeing eyes in patients with unilateral polypoidal choroidal vasculopathy.

METHODS

This retrospective, single-institution study was performed with 221 patients who were diagnosed as having unilateral polypoidal choroidal vasculopathy and who were treated with intravitreal anti-vascular endothelial growth factor. Only patients with an initially uninvolved eye best-corrected visual acuity (BCVA) of 20/40 or better and who were followed up for at least 24 months were included. The changes in the BCVAs of the initially involved and uninvolved eyes as well as the better-seeing eyes were measured. For patients with three or more lines of uninvolved eye visual deterioration, the cause for the visual deterioration was identified.

RESULTS

Patients were followed up for a mean of 43.1 ± 11.8 months after diagnosis. During the follow-up period, three or more lines of deterioration in the BCVA were noted in 61 initially involved eyes (27.6%) and 11 uninvolved eyes (4.9%). The reasons for uninvolved eye visual deterioration were neovascularization (n = 8), retinal vein occlusion (n = 2), and posterior capsule opacification (n = 1). At diagnosis, the BCVA of the better-seeing eye was 0.05 ± 0.08 (Snellen equivalents, 20/22). During the follow-up period, three or more lines of deterioration in the BCVA for the better-seeing eye were noted in eight patients (3.6%).

CONCLUSIONS

Visual acuity of the better-seeing eye over time remained stable in most patients who were initially diagnosed as having unilateral polypoidal choroidal vasculopathy. As a result, the visual prognosis of the better-seeing eye is highly favorable in this condition.

Therapeutic effects of ranibizumab in patients with polypoidal choroidal vasculopathy

Background

There is no consensus on the optimal initial treatment for polypoidal choroidal vasculopathy (PCV). Our study aimed to report the efficacy of repeated injections of intravitreal ranibizumab with or without photodynamic therapy for the treatment of PCV and to determine the possible factors predictive of visual outcomes.

Methods

The results of the initial treatment of 40 patients with PCV with 3 monthly injections of ranibizumab were retrospectively reviewed. We compared the results in terms of the best corrected visual acuity (BCVA), the central retinal thickness (CRT), the number of injections, the regression rates of polyps and the rates of the reduction of subretinal fluid.

Results

At the 3-month follow-up, the mean BCVA was significantly increased by 7.3 ± 12.4 letters compared to baseline (p < 0.01). At the 12-month follow-up, the mean BCVA was increased by 3.4 ± 15.4 letters compared to baseline, and there was no significant difference (p > 0.05). The mean CRT at the 12-month follow-up was 593.58 ± 243.64 μm, with an average decrease of 101.55 ± 256.07 μm compared to baseline (p < 0.01). Fifteen eyes (18.8%) showed the complete regression of polyps, and 22 eyes (27.5%) showed a reduction in polyps. The baseline VA, the reduction in subretinal fluids and the greatest lesion diameter were significant independent factors that were predictive of improved VA at the final follow-up.

Conclusions

Three monthly injections of ranibizumab as an initial treatment could significantly improve VA in PCV patients in the short term. At 12 months postinjection, ranibizumab treatment could stabilize VA in most PCV patients. The baseline VA, the reduction in subretinal fluids and the greatest lesion diameter were predictive factors for the relative improvement of VA at the final follow-up.

Prognostic factors for combined ranibizumab and prompt verteporfin photodynamic therapy for polypoidal choroidal vasculopathy

PURPOSE

To investigate the prognostic factors for the combined therapy of ranibizumab and prompt verteporfin photodynamic therapy (vPDT) for eyes with polypoidal choroidal vasculopathy (PCV).

METHODS

Sixty-two PCV eyes of 62 patients that received the initial treatment of intravitreal ranibizumab followed by vPDT within 1 week plus a 2nd intravitreal ranibizumab 1 month later in one single medical center were retrospectively enrolled. Best-corrected visual acuity (BCVA) and parameters obtained from optical coherence tomography at baseline, 3 months, 6 months and 1  year were measured and compared. Factors associated with polyp regression, recurrent hemorrhage and visual improvement were analyzed.

RESULTS

After the loading treatment, complete and partial polyp regression was achieved in 53.6% and 39.3% of cases, respectively at Month 3. The mean logarithm of the minimum angle of resolution of BCVA improved from 0.64 ± 0.38 to 0.55 ± 0.46 (P =  0.008) at Month 12. Recurrent hemorrhage (P =  0.001) and previous anti-vascular endothelial growth factor (VEGF) treatment (P =  0.017) were associated with poorer visual improvement at Month 12. Incomplete polyp regression (P =  0.038) and previous anti-VEGF treatment (P =  0.005) were associated with a higher risk of recurrent hemorrhage.

CONCLUSIONS

Recurrent hemorrhage was associated with poor visual improvement after combined ranibizumab and vPDT for PCV. Complete polyp eradication was associated with a lower risk of recurrent hemorrhage. Patients who had previously received anti-VEGF were associated with recurrent hemorrhage and poor visual improvement; more frequent follow-ups and more aggressive subsequent treatments may be needed for these 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.

One-year outcomes of intravitreal conbercept combined rescue therapy for polypoidal choroidal vasculopathy in a Chinese population: a real-life clinical data

AIM

To evaluate the real-life clinical outcomes of intravitreal injection of conbercept combined rescue therapy for polypoidal choroidal vasculopathy (PCV).

METHODS

This was an open label, single center, and interventional study. All enrolled patients were treated initially with three consecutive monthly intravitreal conbercept injections (0.5 mg). Additional conbercept injections were administered upon substantial polyp regression with improved visual acuity (VA). Eyes with partial or no polyp regression and poor VA were rescue treated with photodynamic therapy (PDT) for subfoveal polyps or thermal laser photocoagulation for extrafoveal polyps. Best-corrected visual acuity (BCVA), central foveal thickness (CFT) and polyp regression were observed as primary outcomes. Side effects were also collected during the follow-up period.

RESULTS

A total of 56 eyes (56 patients) with PCV were included. BCVA increased significantly from the baseline of 43.52±24.21 letters to 55.88±21.94 letters (P<0.001) at 12mo, while CFT decreased significantly from 457.41±207.86 µm to 247.98±127.08 µm (P<0.001). All patients showed polyp regression. Twenty-three eyes achieved complete polyp regression after the three initial injections, which increased to 44 eyes at 12mo. Seventeen eyes underwent rescue therapy, among which 2 eyes treated with PDT and 15 eyes treated with laser photocoagulation. A mean of 4.30±1.43 injections were given per eye. No intraocular inflammation, retinal or vitreous hemorrhage, or systemic complication occurred.

CONCLUSION

Conbercept is an effective and safe option for the treatment of PCV in Chinese population. The treatment regimen of three initial conbercept injections followed by additional injections or rescue therapies is efficacious for treating PCV.

Polypoidal choroidal vasculopathy: An update on current management and review of literature

Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular age-related macular degeneration (nAMD), commonly seen in the Asian population. It is dissimilar in epidemiology, genetic heterogeneity, pathogenesis, natural history, and response to treatment in comparison to nAMD. Confocal scanning laser ophthalmoscopy-based simultaneous fluorescein angiography and indocyanine green angiography, spectral-domain optical coherence tomography (OCT) with enhanced depth imaging, swept-source OCT, and OCT angiography have improved the ability to detect PCV, understand its pathology, and monitor treatment response. A plethora of literature has discussed the efficacy of photodynamic therapy, anti-vascular endothelial growth factor (VEGF) monotherapy, and combination of both, but only a few studies with higher level of evidence and limited follow-up duration are available. This review discusses the understanding of PCV with respect to epidemiology, pathogenesis, clinical features, natural history, imaging techniques, and various treatment options. Recent clinical trials (EVEREST-II and PLANET study) have emphasized that either anti-VEGF monotherapy or combination treatment is equally capable to strike a balance between polyp regression and stabilization of visual acuity. The recurrent nature of the disease, the development of macular atrophy, and the long-term poor visual prognosis despite treatment are concerns that open avenues for further research.

Two-year outcome of treat-and-extend aflibercept after ranibizumab in age-related macular degeneration and polypoidal choroidal vasculopathy patients

Background

The purpose of the study was to evaluate the 2-year outcome and predictive factors of treat-and-extend aflibercept in patients with eyes affected by typical neovascular age-related macula degenelation (t-AMD) or polypoidal choroidal vasculopathy (PCV), who were switched from ranibizumab.

Patients and methods

The patients underwent three monthly aflibercept injections and subsequent administration following the treat-and-extend protocol. Sixty-two eyes of 62 patients were reviewed retrospectively. R statistical software was used for statistical analysis.

Results

Twenty-two eyes were t-AMD and the remaining 40 eyes were PCV. There was no significant difference in the logarithm of the minimal angle of resolution visual acuity (VA) between baseline and 2 years after switching to aflibercept (0.40 vs 0.40; P=0.99). Multivariate analyses suggested that the following factors were significantly correlated with better VA at 2 years after switching to aflibercept: patients with PCV, the absence of intraretinal fluid at baseline, and better VA at baseline.

Conclusion

In conclusion, VA was maintained and there was an anatomical improvement at 2 years in patients with t-AMD and PCV who were switched from ranibizumab to treat-and-extend aflibercept. PCV patients showed more favorable visual outcomes and less injections at 2 years compared to t-AMD patients. Intraretinal fluid and VA at baseline were predictors of VA at 2 years.

Association of ARMS2 genotype with response to anti-vascular endothelial growth factor treatment in polypoidal choroidal vasculopathy

BACKGROUND

To investigate whether genetic risk variants for age-related macular degeneration (AMD) are associated with response to intravitreal anti-vascular endothelial growth factor (VEGF) in polypoidal choroidal vasculopathy (PCV) patients.

METHODS

This prospective cohort study included 95 treatment-naïve patients that underwent anti-VEGF treatment for PCV for 12 months. Patients were genotyped for 10 single nucleotide polymorphisms in eight AMD-relevant genes. Genotypic association with visual and anatomic outcome measures at 12 months after initial treatment, including mean change in best-corrected visual acuity (BCVA) and total foveal thickness, visual gain of ≥ 15 letters, dry status on optical coherence tomography (OCT), pigment epithelial detachment (PED) regression on OCT, polyp regression on indocyanine green angiography, and injection numbers, were investigated using regression models with adjustment for non-genetic covariates under additive genetic model.

RESULTS

In 81 patients who completed 12-month anti-VEGF monotherapy without photodynamic therapy, significant pharmacogenetic association was found between ARMS2 rs10490924 and PED regression on OCT. Proportions of PED regression were 26.4% for TT, 45.7% for TG, and 63.6% for GG genotype, showing additive effect of G allele for higher chance of PED regression (OR, 2.96; 95% CI, 1.38-6.36; corrected P = 0.043). For entire 95 patients, no significant association was found between candidate polymorphisms and receiving photodynamic therapy within 12 months.

CONCLUSIONS

In PCV patients, ARMS2 rs10490924 showed association with anatomic therapeutic response to anti-VEGF, suggesting pharmacogenetic relationship.

MORPHOLOGIC FEATURES ASSOCIATED WITH FIBROTIC SCARRING AFTER ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To investigate morphologic features associated with fibrotic scarring after anti-vascular endothelial growth factor therapy in polypoidal choroidal vasculopathy (PCV).

METHODS

This retrospective study included 293 patients who had been diagnosed with PCV and treated with anti-vascular endothelial growth factor monotherapy during a 12-month follow-up period. Associations of morphologic features, including type of PCV, location of the polypoidal lesion, greatest linear dimension, largest polyp diameter, choroidal vascular hyperpermeability, pigment epithelial detachment, intraretinal fluid, and subretinal hyperreflective material (SHRM) with fibrotic scar at 12 months were analyzed.

RESULTS

Fibrotic scars were noted in 15 eyes (5.1%). The incidence of fibrotic scars was higher in Type 1 PCV (8 of 76 eyes) than in Type 2 PCV (7 of 217 eyes, P = 0.028). The incidence was also higher in eyes with SHRM (14 of 124 eyes) than in eyes without SHRM (1 of 169 eyes, P < 0.001). In multivariate analysis, SHRM was associated with fibrotic scar (P = 0.005). Among the SHRM cases, the incidence of the scar was 12.9% in eyes with submacular hemorrhage and 8.5% in eyes without hemorrhage.

CONCLUSION

Although fibrotic scar is an infrequent finding in PCV, the possibility of scarring should be considered in eyes with SHRM, particularly in submacular hemorrhage cases.

Submacular hemorrhage and grape-like polyp clusters: factors associated with reactivation of the lesion in polypoidal choroidal vasculopathy

PurposeThe purpose of this study is to investigate the factors associated with reactivation of the lesion during the first year in patients with polypoidal choroidal vasculopathy (PCV) treated with intravitreal ranibizumab.Patients and methodsThis retrospective observational study included 84 eyes diagnosed with PCV and treated with 3-monthly ranibizumab injections. Only those patients who exhibited complete resolution of fluid after initial treatment and were followed up at least 12 months were included. The baseline characteristics of the patients, including their age and sex, location of the polyps, greatest linear dimensions of the lesions, largest polyp diameter, choroidal vascular hyperpermeability, submacular hemorrhages ≥1 disc area in size, presence of grape-like polyp clusters, central foveal thickness, and best-corrected visual acuity were compared between patients with and without reactivation of the lesion.ResultsDuring the 12-month follow-up period, reactivation of the lesion was observed in 60 patients (71.4%). The first reactivation was noted at a mean duration of 3.9±1.7 months after the third ranibizumab injection. Cox regression analysis revealed that the absence of submacular hemorrhages ≥1 disc area (P=0.009), presence of grape-like polyp clusters (P=0.002), and greatest linear dimension of the lesions (P=0.019) were associated with reactivation of the lesion.ConclusionThe absence of submacular hemorrhages, presence of grape-like polyp clusters, and large lesion size at diagnosis were associated with a high risk of reactivation of PCV in patients treated with intravitreal ranibizumab. Patients exhibiting these characteristics may require close monitoring.

Six-year outcomes of antivascular endothelial growth factor monotherapy for polypoidal choroidal vasculopathy

Objective

To evaluate the 6-year outcomes of anti-VEGF (vascular endothelial growth factor) monotherapy for polypoidal choroidal vasculopathy (PCV).

Methods

The charts of 66 eyes of 66 patients with newly diagnosed, symptomatic, treatment-naive PCV were reviewed retrospectively. All patients were treated with 0.5 mg intravitreal ranibizumab (IVR) injections for 3 months followed by as-needed reinjections based on monthly examinations until 3 years after the first IVR injection. Thereafter, anti-VEGF monotherapy was continued for another 3 years.

Results

The mean best-corrected visual acuity (BCVA) improved significantly (p=0.001) 3 months after the first IVR injection (0.24±0.30 logarithm of the minimum angle of resolution (logMAR) VA; 20/35 Snellen VA) compared with the baseline BCVA (0.34±0.37 logMAR VA; 20/44 Snellen VA). However, the improved VA returned to 0.32±0.39 logMAR unit (20/42 Snellen VA), which was not significantly different at 3 years. This level was maintained to the end of 6 years (0.36±0.37 logMAR unit; 20/46 Snellen VA). The mean numbers of anti-VEGF injections administered annually during 6 years were 5.6±2.4 (including the initial three monthly injections), 3.3±2.2, 3.3±2.9, 3.6±3.2, 3.5±2.9 and 3.3±2.7, respectively. The mean total number of injections during 6 years was 21.5±10.1.

Conclusions

The results emphasised the efficacy of anti-VEGF therapy for preserving vision and the limitations of anti-VEGF therapy in that continuous treatment is required over an extended follow-up period.

ANGIOGRAPHIC FINDINGS OF RANIBIZUMAB-RESISTANT POLYPOIDAL CHOROIDAL VASCULOPATHY AFTER SWITCHING TO A TREAT-AND-EXTEND REGIMEN WITH INTRAVITREAL AFLIBERCEPT

PURPOSE

The aim of this study was to study the angiopathic findings of ranibizumab-resistant polypoidal choroidal vasculopathy after switching to a treat-and-extend regimen with intravitreal aflibercept.

METHODS

The authors retrospectively reviewed 17 eyes of 17 Japanese patients with polypoidal choroidal vasculopathy (10 men and 7 women, age: 73.8 ± 7.4 years) who were treated with intravitreal aflibercept (2 mg/0.05 mL) injections from February 2013 to August 2014 at Tokyo University Hospital. All patients had switched to aflibercept because their polypoidal choroidal vasculopathy had been refractory to ranibizumab.

RESULTS

The mean logMAR best-corrected visual acuity at baseline and after 12 months of therapy was 0.30 ± 0.29 (Snellen equivalent: 20/40) and 0.17 ± 0.26 (20/30) (paired t-test P < 0.001). Visual acuity remained stable in 5 cases (29%), deteriorated in 3 (18%), and improved in 9 (53%). Branching vascular networks persisted in all 17 eyes but shrank in 15 (88%). The mean lesion diameter was 3329 ± 1261 μm at baseline and 3180 ± 1247 μm after 12 months (P = 0.0002).

CONCLUSION

A treat-and-extend regimen with intravitreal aflibercept for ranibizumab-resistant patients resulted in branching vascular network shrinkage over a 1-year period.

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.

EFFICACY OF INTRAVITREAL INJECTION OF CONBERCEPT IN POLYPOIDAL CHOROIDAL VASCULOPATHY: Subgroup Analysis of the Aurora Study

PURPOSE

To evaluate the efficacy of different doses of conbercept in patients with polypoidal choroidal vasculopathy in the AURORA study.

METHODS

Retrospective subgroup analyses of 12-month data from the AURORA study. Fifty-three patients (32 in 0.5-mg group and 21 in 2.0-mg group) diagnosed with polypoidal choroidal vasculopathy in AURORA study were retrospectively evaluated. Efficacy outcomes were compared between the two dosage groups.

RESULTS

At Month 12, mean changes in best-corrected visual acuity from baseline were 14.4 ± 14.1 letter scores for the 0.5-mg group and 14.2 ± 21.0 letter scores for the 2.0-mg group; mean central retinal thickness decreased by 104.5 ± 127.3 μm in the 0.5-mg group and 140.7 ± 127.9 μm in the 2.0-mg group; mean total macular volume decreased by 0.9 ± 2.3 mm and 1.0 ± 1.2 mm in the 0.5-mg and 2.0-mg groups, respectively. The mean subretinal fluid thickness decreased by 111.9 ± 122.5 μm and 76.3 ± 112.6 μm in the 0.5-mg and 2.0-mg groups, respectively. The mean pigment epithelial detachment height decreased by 79.3 ± 217.8 μm and 61.3 ± 161.5 μm in the 0.5-mg and 2.0-mg groups, respectively. The mean area of polyps decreased by 0.46 ± 0.76 mm and 0.55 ± 1.34 mm in the 0.5-mg and 2.0-mg groups, respectively. The mean total lesion area decreased by 2.51 ± 5.94 mm (P = 0.088) and 4.62 ± 5.51 mm in the 0.5-mg group and 2.0-mg groups, respectively. Complete regression of polyps was observed in 56.5% of patients in the 0.5-mg group and 52.9% of those in the 2.0-mg group, whereas partial regression was observed in 26.1% and 35.3% of patients in the 0.5-mg and 2.0-mg groups, respectively.

CONCLUSION

Intravitreal injection of conbercept appears to significantly improve visual acuity and anatomical outcomes in patients with polypoidal choroidal vasculopathy.

Three-year visual outcomes of intravitreal ranibizumab with or without photodynamic therapy for polypoidal choroidal vasculopathy

PURPOSE

To compare 3-year visual outcomes after intravitreal ranibizumab (IVR) monotherapy and combination therapy of photodynamic therapy (PDT) with IVR for polypoidal choroidal vasculopathy (PCV).

METHODS

Medical records for 45 eyes in 45 patients (34 men, 11 women; mean age, 73.8 years old; range, 62-86 years old) with treatment-naïve PCV were reviewed retrospectively. Of the 45 eyes, 20 were treated with IVR monotherapy and 25 with combination therapy. Mean change in best-corrected visual acuity, numbers of injections of IVR and length of treatment-free period from baseline at month 36 were observed. Adverse events were monitored.

RESULTS

The change in visual acuity after combination therapy was significantly better than that after IVR monotherapy (p = 0.0399). At 36 months, improvement in visual acuity was seen in five eyes (25.0%) in the IVR monotherapy group and 13 eyes (52.0%) in the combination therapy group. The treatment-free period was significantly longer in the combination therapy group (p = 0.0008). Additional IVR therapy was required significantly more frequently in the IVR monotherapy group (p = 0.0026). Post-treatment subretinal haemorrhage or retinal pigment epithelium tear occurred only in the IVR monotherapy group, in one eye (5.0%) and one eye (5.0%), respectively.

CONCLUSION

Initial therapy consisting of a single session of PDT combined with IVR improves vision in treatment-naïve PCV. Compared with IVR monotherapy, this combination therapy may be more effective for PCV.

Intravitreal Anti-vascular Endothelial Growth Factor for Treating Polypoidal Choroidal Vasculopathy with Grape-like Polyp Clusters

Purpose

To evaluate 12-month outcomes of anti-vascular endothelial growth factor (VEGF) therapy for polypoidal choroidal vasculopathy (PCV) with grape-like polyp clusters.

Methods

This retrospective observational study included 23 eyes of 23 patients who were newly diagnosed with PCV with grape-like polyp clusters, and who were subsequently treated with anti-VEGF monotherapy. The study compares the best-corrected visual acuity (BCVA) of the patients at diagnosis, at 3 months, and at 12 months after diagnosis. In addition, 12-month changes in BCVA values were compared between cases with subfoveal or juxtafoveal polyps and cases with extrafoveal polyps.

Results

The baseline, 3-month, and 12-month logarithm of the minimal angle of resolution BCVA was 0.62 ± 0.35, 0.50 ± 0.43, and 0.58 ± 0.48, respectively. Compared to the baseline, patient BCVA was not significantly different at 12 months after diagnosis (p = 0.764). Six eyes (26.1%) gained ≥0.2 logarithm of the minimal angle of resolution BCVA. In cases with subfoveal or juxtafoveal polyps, BCVA values at baseline and at 12 months after diagnosis were 0.66 ± 0.37 and 0.69 ± 0.53, respectively. In cases with extrafoveal polyps, the values were 0.54 ± 0.33 and 0.37 ± 0.31, respectively. Changes in BCVA values were significantly different between the two groups (p = 0.023).

Conclusions

Although anti-VEGF therapy has favorable short-term efficacy for treating PCV with grape-like polyp clusters, long-term visual improvements are generally limited in the majority of afflicted eyes. The presence of subfoveal or juxtafoveal polyps may suggest unfavorable treatment outcomes.

One-year outcome of intravitreal aflibercept injection for age-related macular degeneration resistant to ranibizumab: rapid morphologic recovery and subsequent visual improvement

OBJECTIVE

To describe the 1-year efficacy of aflibercept in Japanese patients with age-related macular degeneration (AMD) who were resistant to ranibizumab treatment.

DESIGN

Retrospective case series.

PARTICIPANTS

Fourteen consecutive eyes of 14 patients with AMD were enrolled who had no substantial response or developed resistance to intravitreal ranibizumab injections.

METHODS

All patients were subcategorized into one of two subtypes of AMD: seven patients with occult choroidal neovascularization (CNV) and seven with polypoidal choroidal vasculopathy (PCV). Serial intravitreal aflibercept (IVA) injections were administered. Comprehensive ophthalmic examinations, including optical coherence tomography, were conducted at baseline and at follow-up examinations at 1, 3, 6, and 12 months after the initial IVA injection. The best-corrected visual acuity converted to logarithm of the minimum angle of resolution (logMAR) and central macular thickness (CMT) at each follow-up visit were compared with the baseline values. The anatomic response was also assessed with absorption or reduction of fluid in the subretina or subretinal pigment epithelial space.

RESULTS

The logMAR best-corrected visual acuity improved significantly at 3, 6, and 12 months in the total cohort: at 3 and 6 months in patients with occult CNV and at 3 and 12 months in patients with PCV. The CMT decreased significantly at all follow-up visits in the total cohort as well as in both subtypes, except for the CMT at 6 months in PCV patients. The anatomic improvement was also demonstrated in all cases, and pigment epithelial detachments tended to be resolved more rapidly in patients with PCV than in patients with occult CNV.

CONCLUSION

Conversion to IVA was effective in patients with AMD resistant to ranibizumab, showing rapid morphologic improvement. The logMAR visual acuity was raised significantly within 12 months, and the clinical course of visual acuity improvement may differ according to the AMD subtypes.

Intravitreal Aflibercept and Ranibizumab Injections for Polypoidal Choroidal Vasculopathy

PURPOSE

To compare the effectiveness of intravitreal injection of aflibercept and ranibizumab for patients with polypoidal choroidal vasculopathy (PCV).

DESIGN

Retrospective, interventional case series.

METHODS

Ninety-eight treatment-naïve PCV eyes were included. The eyes had received intravitreal aflibercept or ranibizumab injections. All patients were treated using an initial series of 3 monthly loading injections, followed by further injections as required. The visual and anatomic outcomes of treatment were evaluated after 12 months.

RESULTS

The mean best-corrected visual acuity (BCVA) in the aflibercept-treated group (38 eyes), expressed as the logarithm of the minimal angle of resolution (logMAR), had decreased from 0.63 ± 0.49 to 0.44 ± 0.37 after 12 months of treatment (P = .012). Similarly, in the ranibizumab-treated group (60 eyes), the BCVA had decreased from 0.66 ± 0.43 to 0.49 ± 0.36 (P = .018). The central foveal thickness had decreased in the aflibercept-treated group from 396 ± 167 μm to 212 ± 144 μm, and in the ranibizumab-treated group from 402 ± 198 μm to 240 ± 183 μm (P < .001 in both cases). However, there was no significant difference between the groups with regard to either BCVA improvement or decrease in central foveal thickness. Polyp regression was significantly more frequent in the aflibercept-treated group, occurring in 39.5% of eyes, than in the ranibizumab-treated group (21.6% of eyes; P = .007).

CONCLUSIONS

In PCV patients, the visual acuity improvement achieved after 12 months of intravitreal aflibercept did not differ significantly from that achieved using intravitreal ranibizumab. However, aflibercept treatment more often led to polyp regression than did treatment using ranibizumab.

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.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

High-dose ranibizumab monotherapy for neovascular polypoidal choroidal vasculopathy in a predominantly non-Asian population

PURPOSE

To determine safety and efficacy of intravitreal high-dose ranibizumab in the treatment of active neovascular polypoidal choroidal vasculopathy (PCV).

METHODS

In this Phase I/II, single-center, randomized, controlled, double-masked study, predominantly non-Asian, previously treated or treatment-naive, male and female adult patients were randomized to receive high-dose (1.0/0.1 ml or 2.0 mg/0.05 ml; n=15) or standard-dose (0.5 mg/0.05 ml; n=5) ranibizumab in 3 monthly loading doses, followed by 9 months of criteria-based, as-needed retreatment. Safety was evaluated by a descriptive analysis of all non-serious and serious adverse events, angiographic assessments, physical examinations, vital signs, ocular examinations, and visual acuity measurements. Visual acuity and anatomic outcomes are described for the high-dose group.

RESULTS

Twenty patients (aged 35-76 years; 8 Black, 11 White, 1 Asian) were enrolled. At baseline, in the high-dose group, mean best-corrected visual acuity (BCVA) was 63.5 letters (Snellen equivalent ~20/50), and mean baseline central foveal thickness (CFT) was 253.7 μm. High-dose ranibizumab was generally well tolerated without evidence of ocular or systemic severe adverse events, including arterial thromboembolic events. At month 12, in the high-dose group, the mean overall change from baseline in BCVA was +6.7 letters and in CFT was -49.7 μm.

CONCLUSION

High-dose ranibizumab monotherapy is safe and efficacious for treating patients with PCV.

One-year result of aflibercept treatment on age-related macular degeneration and predictive factors for visual outcome

PURPOSE

To investigate the efficacy of periodic injection of aflibercept in each subtype of age-related macular degeneration (AMD) and to explore the predictive factors for visual outcome in clinical settings.

DESIGN

Prospective nonrandomized interventional case series.

METHODS

Patients with AMD were recruited and were administered aflibercept injections once a month for 3 months followed by once every 2 months for 8 months. The logarithm of the minimal angle of resolution (logMAR) at 12 months and improvement of vision from baseline were compared among polypoidal choroidal vasculopathy (PCV), retinal angiomatous proliferation (RAP), and typical AMD. Regression rate of polypoidal lesions was assessed. We also performed regression analysis with logMAR at 12 months as the dependent variable.

RESULTS

The study sample consisted of 98 patients: 46 had typical AMD, 42 had PCV, and 10 had RAP. Mean logMAR improved from 0.36 to 0.21 in 12 months. While there was no difference in visual improvement between typical AMD and PCV, final logMAR was better in PCV (0.32 ± 0.09 vs 0.08 ± 0.04, P = .016). Thirty-nine PCV patients underwent follow-up angiography, and regression of polyps was observed in 27 cases (69.2%). Multiple regression analysis showed that the presence of external limiting membrane (ELM), smaller greatest linear dimension, and the presence of polypoidal lesion were associated with better visual outcome (R(2) = 0.53, P = 2.73 × 10(-14)).

CONCLUSIONS

Periodic injection of aflibercept is effective for PCV as well as for typical AMD. The statuses of ELM, greatest linear dimension, and polypoidal lesion are predictive for visual outcome.

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.

Individualized ranibizumab therapy strategies in year 3 after as-needed treatment for polypoidal choroidal vasculopathy

BACKGROUND

To investigate the third-year results of ranibizumab monotherapy for polypoidal choroidal vasculopathy (PCV) in individualized treatment regimens based on the outcomes during 2 years.

METHODS

One hundred seventy-two consecutive eyes of 163 prospective treatment-naïve patients with PCV were treated with three monthly intravitreal ranibizumab injections followed by as-needed reinjections and completed a 2-year follow-up. Treatment regimens during the third year were selected individually based on their outcomes from the following treatment regimens: as-needed injections based on quarterly examinations, as-needed injections based on monthly examinations, a monthly ranibizumab injection schedule, and the treat-and-extend schedule. Visual acuity (VA) and foveal thickness at the end of the third year and the prevalence of discontinuous follow-up examinations during the third year were evaluated.

RESULTS

Of 163 patients, 35 (21%) patients were excluded; nine patients had discontinuous follow-up examinations during the third year. In 128 eyes of 128 patients studied during the third year, the significant improvements in VA and foveal thickness 2 years after the first injection compared to baseline were maintained at the end of the third year. Six (18%, 6/34) patients treated with as-needed injections based on quarterly examinations had discontinuous follow-up examinations, the prevalence of which differed significantly (P = 0.025) from the other groups.

CONCLUSIONS

The individualized treatment strategies in the third year based on each patient's outcomes during 2 years maintained the improved VA and avoided discontinuation of follow-up during the third year.

Treatment outcomes in eyes with polypoidal choroidal vasculopathy with poor baseline visual acuity

PURPOSE

To evaluate treatment outcomes of intravitreal vascular endothelial growth factor (VEGF) in eyes with polypoidal choroidal vasculopathy (PCV) that exhibited poor baseline visual acuity.

METHODS

This retrospective, observational study included 47 eyes with treatment-naïve PCV with baseline visual acuity of 20/200 or worse treated with intravitreal anti-VEGF. Eyes were divided into 2 groups according to the presence of submacular hemorrhage (hemorrhage and no-hemorrhage groups). The best-corrected visual acuity (BCVA) at baseline was compared with that measured at 3 and 6 months after treatment.

RESULTS

A mean of 3.3±0.9 intravitreal anti-VEGF injections were performed during the 6-month follow-up period. In the hemorrhage group (n=23), 6 patients additionally underwent pneumatic displacement with or without intravitreal tissue plasminogen activator. The logarithm of minimal angle of resolution BCVA at diagnosis, 3, and 6 months was 1.47±0.49, 0.91±0.79, and 0.81±0.83, respectively. Compared with baseline, BCVA was significantly better at 3 and 6 months (P=0.007 and P=0.001, respectively). In the no-hemorrhage group (n=24), the BCVA at defined time points was 1.23±0.32, 1.06±0.33, and 1.02±0.35, respectively. BCVA was significantly better at 3 and 6 months compared with baseline (P=0.006 and P=0.025, respectively).

CONCLUSIONS

Intravitreal anti-VEGF was found to be beneficial in PCV eyes with poor baseline visual acuity, regardless of the presence of submacular hemorrhage. The magnitude of visual improvement was relatively greater in eyes with submacular hemorrhage.

Prognostic factors of 2-year outcomes of ranibizumab therapy for polypoidal choroidal vasculopathy

PURPOSE

To determine predictors of 2-year outcomes after three, monthly, intravitreal ranibizumab (IVR) injections followed by as-needed injections for treatment-naive polypoidal choroidal vasculopathy (PCV).

METHODS

This trial included 85 Japanese patients with symptomatic treatment-naive PCV who received one 0.5 mg IVR injection monthly for 3 months followed by as-needed retreatments. PCV with subfoveal leakage on fluorescein angiography with or without actual choroidal neovascularisation were included. Analyses evaluated independent baseline predictors of better and improved visual acuity (VA) and need for fewer reinjections 2 years after the first injection.

RESULTS

After the three monthly injections, 1.3±1.4 and 1.5±2.0 (mean±SD) as-needed injections were administered during years 1 and 2, respectively. The baseline logarithm of the minimum angle of resolution, VA (0.60±0.49) improved significantly (p=0.001) (0.41±0.47) 2 years after the first injection. Younger patients' eyes with a better baseline VA and no cluster of grape-like polypoidal lesions were significant independent predictors of better VA 2 years after treatment. No baseline factors predicted fewer ranibizumab reinjections during 2 years. At 2 years, resolution of polypoidal lesions 1 month after the three monthly injections did not affect VA and number of reinjections during 2 years.

CONCLUSIONS

Patient age, baseline VA and clusters of grape-like polypoidal lesions predicted VA outcomes 2 years after treatment with IVR for PCV.

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

PURPOSE

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

DESIGN

Retrospective, comparative, interventional case series.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Polypoidal choroidal vasculopathy: an update on therapeutic approaches

Polypoidal choroidal vasculopathy (PCV) is a retinal disease involving the choroidal vasculature characterized by the presence of polypoidal lesions with or without branching vascular network best seen on indocyanine green angiography (ICGA). Clinical features of PCV include recurrent subretinal hemorrhage; serosanguineous pigment epithelial detachment, subretinal exudation and serous retinal detachment. PCV is more prevalent among Asians and Blacks as compared to Caucasians and has been found to account for 25 to 50% of cases of presumed neovascular age-related macular degeneration in Asian patients. Treatment is indicated in patients with symptomatic PCV due to potentially irreversible visual loss. Various treatment modalities for symptomatic PCV have been described in the literature, including thermal laser photocoagulation, ICGA-guided photodynamic therapy (PDT) with verteporfin, anti-vascular endothelial growth factor (VEGF) therapy, and combined PDT and anti-VEGF therapy. This review aims to provide an update on the therapeutic options for PCV, with particular reference to recent studies published in the past two years.

Comparison of the effect of ranibizumab and verteporfin for polypoidal choroidal vasculopathy: 12-month LAPTOP study results

PURPOSE

To compare the effect of photodynamic therapy (PDT) and intravitreal ranibizumab in patients with polypoidal choroidal vasculopathy (PCV).

DESIGN

Randomized clinical trial.

METHODS

SETTING

Multicenter.

STUDY POPULATION

Total of 93 patients with treatment-naïve PCV.

INTERVENTION

Patients were randomized to 2 arms. Patients in the PDT arm underwent a single session of PDT with verteporfin, and patients in the ranibizumab arm received 3 monthly ranibizumab injections at baseline. Additional treatment was performed as needed in each arm.

MAIN OUTCOME MEASURES

Primary outcome measurement was the proportion of patients gaining or losing more than 0.2 logarithm of minimal angle of resolution (logMAR) units from baseline. Mean change of logMAR and central retinal thickness (CRT) were also evaluated.

RESULTS

In the PDT arm (n = 47), 17.0% achieved visual acuity gain, 55.3% had no change, and 27.7% experienced visual acuity loss. The results were 30.4%, 60.9%, and 8.7%, respectively, in the ranibizumab arm (n = 46), significantly better than the PDT arm (P = .039). In the PDT arm, mean CRT improved (366.8 ± 113.6 μm to 289.1 ± 202.3 μm, P < .001), but logMAR was unchanged (0.57 ± 0.31 to 0.62 ± 0.40). The ranibizumab arm demonstrated improvement in both CRT (418.9 ± 168.6 μm to 311.2 ± 146.9 μm, P < .001) and logMAR (0.48 ± 0.27 to 0.39 ± 0.26, P = .003). Mean change of logMAR was also greater in the ranibizumab arm (P = .011).

CONCLUSION

Intravitreal injection of ranibizumab is more effective than PDT for treatment-naïve PCV.

Intravitreal aflibercept for polypoidal choroidal vasculopathy after developing ranibizumab tachyphylaxis

Purpose

To evaluate the effect of aflibercept treatment after developing ranibizumab tachyphylaxis for the treatment of polypoidal choroidal vasculopathy (PCV).

Patients and methods

Ten eyes from ten patients with PCV who developed ranibizumab tachyphylaxis were reviewed. Tachyphylaxis was defined as when repeated intravitreal ranibizumab (IVR) resulted in a complete lack of response after initial treatment response. All treatments were converted to intravitreal aflibercept (IVA) after development of ranibizumab tachyphylaxis. Central retinal thickness (CRT) was compared at baseline, at complete resolution after IVR, at reactivation after IVR, at initial IVA, and at 4 and 12 weeks after initial IVA.

Results

Mean number of IVR treatments before conversion to IVA was 11.3 (range 5–16). All eyes had positive therapeutic responses after conversion to IVA. Mean CRT at 4 and 12 weeks after initial IVA was significantly decreased from baseline initial IVA (P = 0.005).

Conclusion

Switching therapy to aflibercept is effective for patients with PCV who develop tachyphylaxis to ranibizumab.