Pre-treatment With Ranibizumab Aggravates PDT Injury and Alleviates Inflammatory Response in Choroid-Retinal Endothelial Cells

Polypoidal choroidal vasculopathy (PCV) is the predominant subtype of exudative age-related macular degeneration in Asians. Although photodynamic therapy (PDT) is widely used for PCV treatment, its long-term beneficial effects are unsatisfactory. Accumulating clinical investigations suggest that combined therapy with anti-vascular endothelial growth factor (anti-VEGF) and PDT is superior to PDT monotherapy. However, the optimal time of anti-VEGF before or after PDT remains controversial, hence it needs to further explore the mechanism underlying combined therapy. PDT causes selective damage to endothelial cells, which determines its angio-occlusive efficiency, yet the impact of anti-VEGF on PDT-induced endothelial injury is unclear. Here, we found that pre- compared to post-treatment with anti-VEGF ranibizumab (rani) significantly aggravates PDT injury in the rhesus macaque choroid-retinal endothelial (RF/6A) cell line. PDT activates apoptosis, necroptosis and NLRP3 inflammasome in RF/6A cells. Pre-treatment with rani promotes PDT-caused apoptosis via triggering caspase 8-mediated extrinsic apoptosis, and caspase 8 might also play a pivotal role in the rani’s function of suppressing PDT-induced necroptosis and NLRP3 inflammasome activation. Our results implicate that pre-treatment with rani may enhance the angio-occlusive efficiency of PDT and alleviate endothelial inflammatory response, which gives it a great advantage over post-treatment.

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.

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.

[Contributions to the treatment of atypical forms of age-related macular degeneration]

We performed a study of the two clinical entities with a differential diagnosis with wet age-related macular degeneration, namely, idiopathic polypoidal choroidal vasculopathy (IPCV) and retinal angiomatous proliferation. We analyze the clinical and funduscopic characteristics of these entities as well as their differences with wet age-related macular degeneration. We present two cases that are representative of these two entities. The therapeutic possibilities, results and the latest publications are analyzed and compared. A statistical analysis of the latest publications is also presented.

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.

Asian Age-Related Macular Degeneration: Current Concepts and Gaps in Knowledge

Data on the epidemiology and treatment of age-related macular degeneration (AMD) in Asian populations have been scarce. Recently, significant advances in the current knowledge of AMD in Asia have been made, but deficiencies in important areas remain. Epidemiological data on AMD in those 80 years or older are lacking.There are also few incidence data on AMD or polypoidal choroidal vasculopathy (PCV), an important variant of AMD that seems to be more common in Asia. The risk factors for PCV have not been clearly defined to the extent that those for AMD have. No trials of nutritional supplementation for AMD prevention in Asia exist, and there is also a lack of long-term clinical trial data on combination therapy for PCV and indeed very few trial data on PCV. These represent opportunities for future research. With aging populations in Asia, increased data on the prevalence, risk factors, prevention, and treatment of AMD and PCV in Asian populations will be needed to formulate evidence-based public health and clinical guidelines.

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

PURPOSE

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

DESIGN

Retrospective, comparative, interventional case series.

METHODS

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

RESULTS

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

CONCLUSIONS

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

An Update in Laser and Pharmaceutical Treatment for Polypoidal Choroidal Vasculopathy

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

Treatment of polypoidal choroidal vasculopathy with photodynamic therapy combined with intravitreal injections of ranibizumab

PURPOSE

To evaluate the 1-year efficacy and safety of photodynamic therapy (PDT) combined with intravitreal injections of ranibizumab for polypoidal choroidal vasculopathy (PCV).

DESIGN

Retrospective chart review.

METHODS

We retrospectively reviewed the medical records of 63 consecutive patients (66 eyes) with subfoveal PCV who were treated with PDT combined with intravitreal injections of ranibizumab. Of the 66 eyes, 29 had no history of treatment for PCV, 10 had been treated previously with only intravitreal injections of anti-vascular endothelial growth factor agents, and 27 had been treated previously with PDT. All eyes had a minimal follow-up of 12 months.

RESULTS

The combined therapy reduced substantially the exudative change immediately after initiation of treatment. In treatment-naïve eyes, mean VA before treatment (0.47 ± 0.37 logarithm of the minimal angle of resolution [logMAR]) improved to 0.32 ± 0.30 (P < .01) at 3 months and to 0.29 ± 0.29 (P < .01) at 12 months. Polypoidal lesions were reduced in all eyes and disappeared completely in 79.1% of cases. In eyes treated previously with only anti-vascular endothelial growth factor therapy, some visual improvement was achieved, but in eyes treated previously with PDT, mean visual acuity (0.61 ± 0.45) deteriorated to 0.68 ± 0.52 at 12 months. Of all 66 eyes, 5 showed extensive postoperative subretinal hemorrhage, in 2 of which a vitreous hemorrhage developed, necessitating pars plana vitrectomy.

CONCLUSIONS

PDT combined with ranibizumab led to significant visual recovery in treatment-naïve eyes with PCV, but not in eyes with PCV that had demonstrated recurrence after previous PDT. PDT in combination with ranibizumab still has a risk of the postoperative hemorrhagic complications.