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

Fluid Biomarkers in Optical Coherence Tomography for Visual Outcome in Polypoidal Choroidal Vasculopathy

Purpose: To investigate the associations between fluid accumulation at different levels in the retina and visual outcome in polypoidal choroidal vasculopathy (PCV). Design: A retrospective observational study. Institutional setting. Study Population: A total of 91 eyes from 91 patients of PCV were included, with 65 receiving intravitreal aflibercept monotherapy and 26 receiving combined intravitreal ranibizumab and photodynamic therapy (PDT). Observation Procedures: Best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) examination results were recorded at baseline and 3, 6, and 12 months after treatment. Main Outcome Measures: The correlations between visual outcomes and fluid biomarkers including intraretinal fluid (IRF), subretinal fluid (SRF), serous pigment epithelium detachment (PED), and hemorrhage at fovea were analyzed. Results: No differences in treatment outcomes were noted between patients receiving aflibercept and those receiving combined ranibizumab and PDT. IRF and hemorrhage at baseline predicted poorer vision at 3, 6, and 12 months. The presence of IRF was associated with poorer vision at 6 months and 12 months (p < 0.05 for all). The presence of SRF or PED was not associated with better vision at any time point. No differences in the correlations between fluid markers and visual outcomes were noted between thin and thick subfoveal choroidal thickness groups. Conclusions: For PCV, IRF and hemorrhage at baseline served as surrogates for poor visual prognosis after treatment, and IRF was a biomarker for poor vision during the treatment course. No fluid markers predicted good visual prognosis or had a positive impact on vision at any time point.

Systemic Risk Factors for Vitreous Hemorrhage Secondary to Polypoidal Choroidal Vasculopathy

INTRODUCTION

It remains unclear whether systemic factors are associated with an increased risk of vitreous hemorrhage (VH) secondary to polypoidal choroidal vasculopathy (PCV), and there is no method to predict the possibility of VH occurrence in patients with PCV. This study aimed to investigate and visualize systemic risk factors for VH in patients with PCV.

METHODS

Data on the sex, age, history of systematic diseases, best-corrected visual acuity, intraocular pressure, and laboratory data of patients with PCV were collected from the medical record system. Univariate and multivariate binary logistic regression analyses were applied to investigate independent risk factors for VH in patients with PCV. Receiver operating characteristic analysis and nomograms were used to visualize the independent risk factors.

RESULTS

The patient population comprised 115 patients with VH secondary to PCV and 181 patients with PCV without VH. Binary logistic regression analyses showed that higher white blood cell count [WBC; odds ratios (OR) 1.247], higher aspartate aminotransferase/alanine aminotransferase ratio (AST/ALT; OR 2.339), and longer activated partial thromboplastin time (APTT; OR 1.196) were independent risk factors of VH in patients with PCV. Integrated application of APTT, AST/ALT, and WBC as markers showed the best performance for distinguishing patients with VH, with an area under the curve of 0.723. The nomogram was created for doctors to calculate the possibility of VH in a patient with PCV.

CONCLUSIONS

Higher WBC, higher AST/ALT, and longer APTT are independent serum risk factors of VH secondary to PCV, which may shed light on VH prevention in patients with PCV.

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.

The comparison of two different strategies of intravitreal conbercept for polypoidal choroidal vasculopathy in Chinese patients results from a 48-week randomized phase 4 study: STAR study

PURPOSE

To compare a treat-and-extend (TAE) strategy with a fixed dosing regimen of intravitreal conbercept (IVC) for the management of treatment-naïve polypoidal choroidal vasculopathy (PCV) patients.

METHODS

249 patients with treatment-naïve PCV were randomized 1:1 to fixed dosing regimen with injections every 12 weeks (3 + Q12W) group or treat-and-extend regimen(3 + TAE) group. Patients received 3 monthly intravitreal injections of 0.5 mg conbercept as loading dose in both groups. The 3 + Q12W patients were monitored monthly and received mandated injections every 12 weeks; the 3 + TAE patients were monitored and treated monthly until the resolution of exudative disease activity; the interval between visits was then individualized according to study protocol. Visual and anatomical outcomes were compared between the two groups.

RESULTS

At 48 weeks, there was no significant difference between the 3 + Q12W group and 3 + TAE group in mean BCVA improvement (p = 0.421), mean changes in central retinal thickness (CRT) (p = 0.818), maximum retinal thickness (MRT) (p = 0.448), pigment epithelial detachment (PED) height (p = 0.221), PED volume (p = 0.076), branching vascular network (BVN) area (p = 0.615), polypoidal lesion number (p = 0.701), polypoidal lesion area (p = 0.424), rates of patients who avoided vision loss of ≥15 ETDRS letters (p = 0.397) or complete polypoidal lesion regression rate (43.8% vs. 41.8%, p = 0.814). The 3 + Q12W group had more decreased retinal haemorrhage area (p = 0.014) and fewer mean numbers of injections comparing with 3 + TAE group (6.6 vs. 9.4, p < 0.001). Mean maximum extension interval between injections after loading injections was 9.6 ± 2.0 weeks for 3 + TAE group, with 27.8% of patients achieving an extension interval of 12 weeks and 61.1% patients 8 weeks or more.

CONCLUSIONS

Both 3 + Q12W and 3 + TAE regimens of IVC could result in improvement in visual and anatomical outcomes in PCV patients.

Effects of Anti-Vascular Endothelial Growth Factor Drugs Before and After Pars Plana Vitrectomy in Patients with Polypoidal Choroidal Vasculopathy and Vitreous Hemorrhage

Purpose: To compare the clinical effects of postoperative versus perioperative injection of anti-vascular endothelial growth factor (VEGF) drugs before and after pars plana vitrectomy (PPV) in patients with vitreous hemorrhage secondary to polypoidal choroidal vasculopathy (PCV). Methods: This was a retrospective study of patients who underwent PPV due to vitreous hemorrhage between October 2013 and June 2019 at Ningbo Eye Hospital. The patients who underwent PPV surgery due to PCV-secondary vitreous hemorrhage were included. The primary outcome was the changes in best-corrected visual acuity. The secondary outcome was the central macular thickness. Results: Compared with the postoperative group (n = 20), the perioperative group (n = 18) showed a smaller number of postoperative anti-VEGF injections (5.1 ± 0.8 vs. 8.0 ± 1.5, P < 0.05) and lower frequencies of early hyphema (5.6% vs. 30.0%, P < 0.05), and recurrent vitreous hemorrhage (11.1% vs. 30.0%, P < 0.05). The logarithm of minimal angle resolution (LogMAR) was smaller in the perioperative group compared with the postoperative group at 1 week, 1 month, and 3 months after PPV (P < 0.05), but there were no differences thereafter. Compared with the postoperative group, the perioperative group had thinner fovea at 1 week, 1 month, and 3 months (P < 0.05), but the differences disappeared after 3 months. Conclusion: In patients with PCV and vitreous hemorrhage, compared with postoperative anti-VEGF, perioperative anti-VEGF could reduce the difficulty of surgery and reduce the occurrence of postoperative complications, but there were no differences in long-term vision and macular thickness after surgery.

Real world experience of the treatment outcome between photodynamic therapy combined with ranibizumab and aflibercept monotherapy in polypoidal choroidal vasculopathy

To provide real-world experiences of treating polypoidal choroidal vasculopathy (PCV) patients with photodynamic therapy (PDT) plus intravitreal injection of ranibizumab or intravitreal injection of aflibercept alone. Retrospective chart review of patients with PCV in a single tertiary referral center in Taiwan. Chart review of PCV patients treated with PDT and injection of ranibizumab or injection of aflibercept. A total of 101 eyes of 101 patients (38 females and 63 males) were reviewed. Of those, 48 and 53 eyes received primary/adjunctive PDT along with injections of ranibizumab or intravitreal injections of aflibercept only, respectively. Initial visual acuity (VA) and central subfield choroidal thickness were similar between the two groups (p > 0.05). In addition, changes in VA at 3, 6, and 12 months post treatment were similar. The central retinal thickness decreased with either treatment (p < 0.01); however, this change did not translate into VA performance (p > 0.05). In the subgroup analysis of pachychoroid and non-pachychoroid patients, better initial VA and post-treatment VA at 3 months and 6 months was noted in the latter group of patients treated with anti-vascular endothelial growth factor monotherapy (p < 0.05). Aflibercept monotherapy is comparable with PDT plus ranibizumab in PCV patients with PCV (pachychoroid and non-pachychoroid patients). In addition, better prognosis regarding VA was observed in non-pachychoroid patients treated with aflibercept monotherapy.

Long-term prognosis of polypoidal choroidal vasculopathy with a 5-year remission after an initial combination therapy

PURPOSE

To investigate the visual prognosis of patients with polypoidal choroidal vasculopathy (PCV) with a 5-year remission after an initial combination therapy involving photodynamic therapy (PDT) and intravitreal ranibizumab (IVR) or aflibercept injection (IVA).

METHODS

Medical records of 69 consecutive patients with PCV treated with PDT with IVR/IVA were retrospectively reviewed, and 17 eyes were identified with a 5-year remission after the initial combination therapy. The eyes that did not require additional treatment during the 1^st-5^th year were assigned to the remission group and the eyes requiring additional treatment during the 1^st-5^th year were assigned to the recurrence group.

RESULTS

During the 7-year follow-up, the mean logarithm of the minimal angle resolution best-corrected visual acuity (logMAR BCVA) significantly improved from 0.39±0.27 to 0.17±0.38 (p=2.9 × 10^-4) in the remission group, whereas the mean logMAR BCVA was maintained throughout the follow-up period (0.58±0.27 to 0.60±0.48) in the recurrence group. In the remission group, only two (11.8%) of the 17 eyes experienced recurrence during the 5^th-7^th year. Comparison of baseline characteristics between the two groups revealed that a higher proportion of female (p=0.012), better baseline BCVA (p=3.1 × 10^-3), and lower risk allele frequency in ARMS2 A69S (p=0.029) were observed in the remission group.

CONCLUSIONS

The combination therapy showed a favourable outcome for PCV over a 7-year follow-up, especially in the eyes without recurrence during the 1^st-5^th year. Physicians should be careful of recurrent exudation in the eyes without recurrence during the 1^st-5^th years, although the recurrence rate was low.

Association Between the Degree of Inclusion of Components Identified on Fluorescein or Indocyanine Green Angiography in Target Spots and Relapse of Exudate in Eyes with Polypoidal Choroidal Vasculopathy and Typical Age-Related Macular Degeneration After Photodynamic Therapy

Purpose

To investigate the association between the inclusion of components identified on images in target spots of photodynamic therapy (PDT) and exudate relapse in eyes with age-related macular degeneration (AMD).

Methods

Forty-one eyes (39 patients) with polypoidal choroidal vasculopathy (PCV) and 32 eyes (31 patients) with typical AMD (tAMD) who underwent PDT were retrospectively investigated. Each component identified on fluorescein (FA) or indocyanine angiography (IA), optical coherence tomography (OCT), or color photography was graded as not depicted, covered with a margin ≥500 µm or <500 µm, and protruding. Associations between these grades and the dry rate (proportion of subjects with continuous absence of exudate over following 12-month period) and the relapse index (2 × number of injections administered + accumulation of exudate for 12 months post-PDT) were investigated.

Results

In PCV, the association between worse coverage and decreasing dry rates for feeder vessels and polyps approached statistical significance. With coverage margins ≥500 µm, dry rate tended to be greater than with coverage margins <500 µm for feeder vessels, classic lesions, and occult lesions on FA. In the tAMD group, coverage with margins ≥500 µm tended to yield a higher dry rate than coverage with margins <500 µm for CNV on IA. Coverage with margins ≥500 µm for occult and classic lesions on FA yielded no dry subjects, and all subjects with classic lesions or staining had recurrence (P = 0.009 and 0.050). Worse coverage and worse dry rate in PCV and worse relapse index in tAMD were related to pigment epithelial detachment on OCT (P = 0.040 and 0.006).

Conclusion

Polyps in PCV and pigment epithelial detachment (PED) in tAMD were verified as appropriate targets, corresponding to the existing guidelines, and feeder vessels, classic lesion, occult lesion, and PED in PCV and CNV on IA in tAMD were suggested as further targets. OCT was superior to FA for evaluating PED.

Five-year outcomes of photodynamic therapy combined with intravitreal injection of ranibizumab or aflibercept for polypoidal choroidal vasculopathy

We report 5-year visual and anatomical outcomes after combination therapy of photodynamic therapy (PDT) and intravitreal injection of ranibizumab or aflibercept for polypoidal choroidal vasculopathy (PCV) and predictive factors for visual outcomes at 5-year and time to recurrence. Medical charts were retrospectively reviewed for 43 consecutive eyes with PCV treated with combination therapy of PDT and intravitreal injection of ranibizumab(n = 13) or aflibercept(n = 30) and completed 5-year follow-up. The variants of ARMS2 A69S and CFH I62V were genotyped using TaqMan assay. Best corrected visual acuity (BCVA) significantly improved at 5-year (P = 0.01) with 20% reduction of subfoveal choroidal thickness irrespective of presence or absence of recurrence. Visual improvement was associated with baseline shorter greatest linear dimension (GLD) (P = 1.0×10-4). Mean time to recurrence was 28.6±23.1 months (95% CI: 21.5-35.7, Median:18.0) and time to recurrence was associated with G allele (protective allele) of ARMS2 A69S and GLD (P = 4.0×10-4 and 1.0×10-2, respectively). Multiple regression analysis revealed that time to recurrence extended by 15.5 months when the G allele of ARMS2 A69S increased by one allele (TT: 15.7±17.0, TG: 30.8±23.5, GG: 41.1±22.6 months). The combination therapy resulted in a favorable visual outcome for PCV during 5-year follow-up.