The association of choroidal structure and its response to anti-VEGF treatment with the short-time outcome in pachychoroid neovasculopathy

Time to initiate anti-vascular endothelial growth factor therapy and visual outcome in central retinal vein occlusion

This retrospective study aimed to investigate the progression of central retinal vein occlusion (CVO) prior to treatment initiation and its impact on prognosis. Of the 54 studied eyes with acute CVO, the average logMAR visual acuity (VA) at the initial visit was 0.65 ± 0.49 with an average time to treatment of 14.9 ± 14.5 days. VA at the initial treatment was identified as a stronger predictor of VA at the final visit compared to VA at the first visit or other factors. Patients who received treatment more than 28 days after the initial visit experienced a significant decline in VA compared to those treated within 28 days (0.21 ± 0.35 vs. 0.04 ± 0.13, p = 0.006). Additionally, patients who were treated between 15 and 28 days showed a greater decrease in VA compared to those treated within 14 days (0.12 ± 0.46 vs. 0.018 ± 0.02, p = 0.026). These findings from the current retrospective analysis suggesting that there is a possibility of VA decline at the initial treatment associating with worse prognosis even when treatment is administered within a month should be further investigated in the prospective study. Also, it may be crucial to consider frequent monitoring of acute CVO patients for initiating treatment at the optimal timing.

Long-term predictors of anti-VEGF treatment response in patients with neovascularization secondary to CSCR: a longitudinal study

PURPOSE

To identify the baseline predictors of anti-VEGF treatment response at 3 years in patients affected by choroidal neovascularization (CNV) secondary to central serous chorioretinopathy (CSCR).

METHODS

In this retrospective longitudinal study, medical records of patients diagnosed with CNV secondary to CSCR and treated using anti-VEGF injections between April 2015 and May 2020 were reviewed. The potential qualitative and quantitative predictors of treatment response were identified or measured based on the multimodal imaging examination available for each patient at the baseline, including structural OCT, fluorescein angiography (FA), indocyanine green angiography (ICGA), and OCT-angiography (OCT-A). Univariate and multivariate analyses were performed.

RESULTS

Twenty-nine eyes from 29 patients affected by CNV complicating CSCR were included in the study. At the end of the 3-year follow-up, the mean BCVA was 20/50 Snellen equivalent (0.38 ± 0.36 LogMAR), and no significant difference with baseline BCVA (0.37 ± 0.29 LogMAR) was found (p = 0.9). Twenty out of 29 eyes (69%) had active lesions at the end of the follow-up. At multivariate analysis, none of the included features was independently associated with the 3-year BCVA outcome. Pigment epithelium detachment (PED) height (ß = 0.017, p = 0.028) and outer limiting membrane (OLM) preservation at the fovea (ß = -5.637, p = 0.026) were independently associated with the CNV activity at 3 years.

CONCLUSION

PED height and OLM obliteration at the fovea might be considered baseline predictors of lesion activity at 3-year follow-up in patients with CNV secondary to CSCR treated with anti-VEGF therapy.

Pachychoroid neovasculopathy versus macular neovascularization in age-related macular degeneration with and without shallow irregular pigment epithelial detachment

To compare the choroidal neovascular features of individuals with pachychoroid neovasculopathy (PNV) and neovascular age-related macular degeneration (nAMD) with and without shallow irregular pigment epithelial detachment (SIPED). Using optical coherence tomography angiography, the choroidal neovascular complexes of 27 patients with PNV, 34 patients with nAMD and SIPED, and 15 patients with nAMD without SIPED were analyzed with FIJI and AngioTool software. PNV compared to nAMD with SIPED had a greater vessel percentage area (P = 0.034), junction density (P = 0.045), average vessel length (P < 0.001), and fractal dimension (P < 0.001). PNV, compared to nAMD without SIPED, had a greater total vessel length (P = 0.002), total number of junctions (P < 0.001), junction density (P = 0.034), and fractal dimension (P = 0.005). nAMD with SIPED, compared to nAMD without SIPED, had greater vessel area, total number of junctions, total vessel length, and average vessel length (all P values < 0.001). Patients with nAMD plus SIPED and individuals with nAMD without SIPED have similar fractal dimension values (P = 0.703). Biomarkers of choroidal neovascular complexity, such as fractal dimension, can be used to differentiate PNV from nAMD with or without SIPED.

Pachychoroid neovasculopathy has clinical properties that differ from conventional neovascular age-related macular degeneration

To determine the clinical properties of pachychoroid neovasculopathy (PNV) that differ from conventional neovascular age-related macular degeneration (nAMD) and suggest that they are different clinical entities. To accomplish this, we reviewed the medical records of 100 consecutive patients diagnosed with nAMD. All of the patients were Japanese, and their mean age was 75.5 years. There were 72 men and 28 women. For the bilateral cases, only the right eye was analyzed. An eye was diagnosed with PNV when a macular neovascularization (MNV) was detected just above the dilated choroidal vessels. The Indocyanine green angiographic (ICGA) and en face optical coherence tomographic (OCT) images were used to assess the vertical symmetry of the medium and large choroidal vessels. The subfoveal choroidal thickness (SCT) was also measured manually in the OCT images. After reclassification, there were 29 (29%) patients with typical nAMD (25 with type 1 MNV, 4 with type 2 MNV), 43 (43%) with PNV, 21 (21%) with polypoidal choroidal vasculopathy, and 7 (7%) with retinal angiomatous proliferation. Of the 43 PNV, 17 (39.5%) had polypoidal lesions and 26 (60.5%) had no polypoidal lesions. The percentage of eyes with vertical asymmetry of the medium and large choroidal vessels was significantly greater in the 35 PNV (81.4%) than in the 16 non-PNV (28.1%; P < 0.01) cases. The mean SCT was significantly thicker in the PNV eyes than in the non-PNV eyes (298 ± 96 μm vs. 228 ± 82 μm; P < 0.01). The response of PNV to anti-vascular endothelial growth factor treatments was better than that of non-PNV eyes [higher dry macula rate after the loading period (90.9% vs. 59.1%), fewer total number of injections (11.0 ± 2.9 vs. 13.4 ± 3.2), and longer treatment intervals for the anti-VEGF therapy (8.4 ± 3.1 vs. 13.4 ± 3.2 weeks) at 2 years (all P < 0.01)]. These differences in the morphology and response to anti-VEGF treatments suggest that PNV is a separate clinical entity to conventional nAMD.

Two-Year Results of a Treat and Extend Regimen with Aflibercept in Caucasian Patients with Pachychoroid Neovasculopathy

INTRODUCTION

There are few reports evaluating the treatment of pachychoroid neovasculopathy (PNV) in white patients. The purpose of this study is to analyze the results of a treat and extend regimen with aflibercept in white patients with PNV after 2 years of follow-up.

METHODS

We performed a retrospective study in 31 eyes of 26 patients with PNV treated with a treat an extend regimen of intravitreal aflibercept. The mean age was 63,84 ± 7.92 years. There were 9 males (35%) and 17 females (65%). Best-corrected visual acuity (BCVA), central macular thickness (CMT), choroidal subfoveal thickness (CST), choroidal thickness (CT) under type 1 choroidal neovascularization (CNV), pigment epithelium detachment (PED) height, and presence of subretinal fluid (SRF), intraretinal fluid (IRF) and wet macula, were evaluated at baseline and after 3, 6, 12, and 24 months.

RESULTS

BCVA remained stable during the follow-up (p 0.161). A significant diminution of CMT was found (p 0.001). Conversely, PED height diminution was not significative (p 0.260). CST and CT under type 1 CNV improved significantly during the follow-up (p 0.005 and 0.009, respectively). Also, wet macula improved after 24 months (p < .001). The average number of intravitreal injections was 12.34 ± 6.01.

CONCLUSION

Treat and extend regimen with intravitreal aflibercept in white patients with PNV may be effective for improving CMT, CST, CT under type 1 CNV and wet macula, and to stabilize vision, with a personalized regimen of intravitreal injections.

Choroidal Morphology on Ultra-Widefield Indocyanine Green Angiography and Response to Aflibercept in Pachychoroid Neovasculopathy

Purpose: This study assessed the relationship between the choroidal morphology and short-term response to aflibercept treatment in pachychoroid neovasculopathy (PNV). Methods: This was a retrospective case-control study. Ultra-widefield indocyanine green angiography (UWICGA) and optical coherence tomography (OCT) images of 90 PNV eyes of 90 patients treated with aflibercept were enrolled. Responsiveness to aflibercept was defined as a complete resolution of sub- or intra-retinal fluid after three loading doses (50 dry and 40 non-dry eyes). Subfoveal choroidal thickness (SFCT) was measured on OCT images, and choroidal vessel density (CVD), CVD asymmetry, intervortex anastomosis, and choroidal vascular hyperpermeability (CVH) were assessed on UWICGA images. Results: CVD on UWICGA differed between groups in terms of the total area (0.323 ± 0.034 in dry vs. 0.286 ± 0.038 in non-dry, p < 0.001) and area of each quadrant (superotemporal: 0.317 ± 0.040 vs. 0.283 ± 0.040, superonasal: 0.334 ± 0.040 vs. 0.293 ± 0.045, inferonasal: 0.306 ± 0.051 vs. 0.278 ± 0.052, inferotemporal: 0.334 ± 0.047 vs. 0.290 ± 0.046; all p ≤ 0.010). The CVH grade differed between groups (mean 1.480 ± 0.735 vs. 1.875 ± 0.822, p = 0.013). ST and IT intervortex anastomoses were common in the dry group, while SN, ST, and IT were most common in the non-dry group (p = 0.001). Conclusions: A poor short-term response to aflibercept treatment in PNV eyes was associated with a lower Haller vessel density, higher CVH grade, and intervortex anastomosis involving more quadrants on UWICGA.

Relationship between Pachychoroid and Polypoidal Choroidal Vasculopathy

Previous clinical studies have suggested that pachychoroid can induce macular neovascularization (MNV) to develop pachychoroid neovasculopathy (PNV) and that PNV can progress to polypoidal choroidal vasculopathy (PCV). Recent studies based on the pachychoroid concept are now gradually revealing the true nature of, at least some part of, PCV. However, previous studies on PNV and/or PCV have used different frameworks for the classification of PNV, PCV, and neovascular age-related macular degeneration (nAMD). These have hampered the rapid overhaul of the understanding of PCV. Some investigators have assumed that all PCV is pachychoroid-driven whereas other investigators have classified PCV into “pachychoroid PCV” and “non-pachychoroid PCV”. Furthermore, since there is no consensus as to whether PNV includes PCV, some studies have included PCV with PNV, while other studies have excluded PCV from PNV. To address these gaps, we summarize previous studies on PCV and pachychoroid. Even before the proposal of the pachychoroid concept, previous studies had suggested that PCV could be divided into two subtypes, of which one was characterized by pachychoroid features. Previous studies had also provided keys to understand relationship between PCV and PNV. We here recommend a refined conceptual framework for future studies on PNV, PCV, and nAMD. Considering the current inconsistent understanding of PCV, we should be cautious about using the term PCV until we understand the true nature of PCV.

CHOROIDAL NEOVASCULARIZATION SECONDARY TO PHOTODYNAMIC THERAPY FOR CENTRAL SEROUS CHORIORETINOPATHY: Incidence, Risk Factors, and Clinical Outcomes

PURPOSE

To investigate the incidence, risk factors, and clinical outcomes of complicated choroidal neovascularization (CNV) after reduced-fluence photodynamic therapy (PDT) for central serous chorioretinopathy.

METHODS

This is a retrospective consecutive interventional study including 559 eyes from 520 patients treated by reduced-fluence PDT for central serous chorioretinopathy. The incidence of complicated CNV within 3 months after PDT was calculated. Baseline demographics and ocular findings were investigated to identify risk factors. The clinical course of complicated CNV was analyzed.

RESULTS

Seven cases experienced development of active CNV after PDT within 3 months with a median interval of 4 weeks (range, 2-12 weeks). The incidence was estimated as 1.25% (95% CI, 0.55-2.62%). Complicated CNV developed in 6 among 138 eyes (4.35%) with flat irregular pigment epithelial detachment and in 1 among 421 eyes (0.24%) without flat irregular pigment epithelial detachment (P < 0.001, Fisher's exact test). The median best-corrected visual acuity recovered from 20/100 at the time of CNV development to 20/20 after anti-vascular endothelial growth factor injections (median, 3 times).

CONCLUSION

In approximately 1%, reduced-fluence PDT for central serous chorioretinopathy may be complicated by CNV, which can be well controlled with anti-vascular endothelial growth factor injection. Flat irregular pigment epithelial detachment increases the risk of secondary CNV following PDT.

Pachychoroid neovasculopathy: A comparative review on pathology, clinical features, and therapy

There have been major changes in our understanding of choroidal diseases in the last decade owing to multiple retinal and choroidal imaging related advances. A major conceptual pivot is establishment of pachychoroid and its spectrum of clinical disorders: pachychoroid pigment epitheliopathy, central serous chorioretinopathy, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy/aneurysmal type 1 neovascularization, peripapillary pachychoroid syndrome, and focal choroidal excavation. However, considerable overlaps in manifestations and therapeutics of these disorders make differentiation amongst them difficult. This review is focused on pathogenesis and clinical aspects of pachychoroid neovasculopathy (PNV). Since PNV was defined as a separate entity around 5 years ago, there have been numerous contrasting observations surrounding it. We review and summarize these studies, and also compare PNV with other disorders of the pachychoroid spectrum in detail. There are important differences between etiologies of neovascular age related macular degeneration and PNV. Yet the current treatment strategies for PNV have been extrapolated from the trials for the former. Future research needs to validate this assumption with long-term results.

Artificial intelligence for classifying uncertain images by humans in determining choroidal vascular running pattern and comparisons with automated classification between artificial intelligence

Purpose

Abnormalities of the running pattern of choroidal vessel have been reported in eyes with pachychoroid diseases. However, it is difficult for clinicians to judge the running pattern with high reproducibility. Thus, the purpose of this study was to compare the degree of concordance of the running pattern of the choroidal vessels between that determined by artificial intelligence (AI) to that determined by experienced clinicians.

Methods

The running pattern of the choroidal vessels in en face images of Haller’s layer of 413 normal and pachychoroid diseased eyes was classified as symmetrical or asymmetrical by human raters and by three supervised machine learning models; the support vector machine (SVM), Xception, and random forest models. The data from the human raters were used as the supervised data. The accuracy rates of the human raters and the certainty of AI’s answers were compared using confidence scores (CSs).

Results

The choroidal vascular running pattern could be determined by each AI model with an area under the curve better than 0.94. The random forest method was able to discriminate with the highest accuracy among the three AIs. In the CS analyses, the percentage of certainty was highest (66.4%) and that of uncertainty was lowest (6.1%) in the agreement group. On the other hand, the rate of uncertainty was highest (27.3%) in the disagreement group.

Conclusion

AI algorithm can automatically classify with ambiguous criteria the presence or absence of a symmetrical blood vessel running pattern of the choroid. The classification was as good as that of supervised humans in accuracy and reproducibility.

Correlation between choroidal structure and smoking in eyes with central serous chorioretinopathy

Purpose

A smoking habit can cause various health problems encompassing retinal diseases including central serous chorioretinopathy (CSC). The aim of the current study was to investigate the effect of smoking on the choroidal structure in patients with CSC.

Methods

The choroidal vascular index (CVI) was calculated using the binarized OCT images. Baseline parameters (age, refractive error [SE], subfoveal choroidal thickness [SFCT] and CVI) were compared between smokers and non-smokers using Wilcoxon rank sum test. Moreover, the associations between SFCT and the baseline parameters were analyzed using a multivariate linear regression followed by the AICc model selection.

Results

Among 75 CSC patients, 45 patients were smokers and 30 patients were non-smokers. No significant differences in age and SE were seen between the smoking group and the non-smoking group. A significant difference in the SFCT was seen between two groups (382.0 ± 68.2 μm in the smoking group vs. 339.3 ± 52.3 μm in the non-smoking group, p = 0.0038), while no significant difference was observed in the CVI (p = 0.32). The optimal model for SFCT included the variables of age, SE and past history of smoking among the baseline parameters. Additionally, increased pack years was associated with increased SFCT.

Conclusion

Cigarette smoking was associated with an increased SFCT in patients with CSC. Thicker choroid in smoking CSC patients may be an important modulator of the disease.

Assessment of the choroidal structure in pregnant women in the first trimester

We investigated the anatomical differences in the choroidal structure between pregnant women in the first trimester of pregnancy and age-matched healthy nonpregnant women using enhanced depth imaging optical coherence tomography (EDI-OCT) and choroidal binarization analysis. The main parameters measured in the two study groups, namely, pregnant women in the first trimester and healthy nonpregnant women, were choroidal thickness and the choroidal luminal area. Binarization of the EDI-OCT images from each patient was performed, and the choroidal vascularity index (CVI) was calculated. The correlations between the baseline characteristics of the subjects and the CVI were investigated using linear mixed model analysis. As a result, there was no statistically significant difference in the mean age, best-corrected visual acuity, axial length, central retinal thickness, subfoveal choroidal thickness, systolic blood pressure (BP), or diastolic BP between the two study groups. Conversely, a significant difference was observed in the CVI (P = 0.012) between the two groups. The multivariate analysis identified a significant correlation between the CVI and the systolic BP (P = 0.0044, linear mixed test). Taken together, a larger choroidal luminal area was associated with a higher systolic BP, especially in the first trimester of pregnancy. Our findings may provide further insight into the choroidal changes that occur during pregnancy.

Rate of misdiagnosis and clinical usefulness of the correct diagnosis in exudative neovascular maculopathy secondary to AMD versus pachychoroid disease

The aim of this study was to explore the relative prevalence and clinical differences between age-related macular degeneration (AMD) and pachychoroid disease in patients older than 50 years with newly diagnosed exudative neovascular maculopathy, and also assess the rate of misdiagnosis between these two disorders. In this retrospective observational study, we reviewed data from patients 50 years of age and older with newly diagnosed treatment-naïve exudative macular neovascularization (MNV) secondary to AMD or pachychoroid disease. Of the 139 patients (139 eyes) who fulfilled the inclusion criteria, 35 patients were graded as being affected by pachychoroid disease complicated by exudative MNV and 104 subjects had neovascular AMD. Therefore, prevalence of pachychoroid disease complicated by exudative MNV was 25.2% (confidence interval—CI 18.2–33.2%). Mean ± SD age was 67.0 ± 8.8 years in the pachychoroid disease group and 80.6 ± 6.6 years in the neovascular AMD group (P < 0.0001). At baseline, BCVA was better in patients with pachychoroid disease complicated by exudative MNV (0.4 ± 0.3 LogMAR vs. 0.7 ± 0.5 LogMAR, P = 0.003). At the 1-year follow-up visit, BCVA was still better in patients with pachychoroid-associated MNV (0.34 ± 0.32 LogMAR vs. 0.59 ± 0.52 LogMAR; P = 0.005). In our study cohort, 19 patients were graded to be affected by pachychoroid disease complicated by exudative MNV even though a diagnosis of neovascular AMD was erroneously reported in their medical records at baseline. In conclusion, pachychoroid disease is a frequent cause of exudative MNV in aged patients with a high rate of misdiagnosis. A correct diagnosis may be important as these two disorders differ in terms of clinical characteristics and prognosis.

Current diagnosis and management strategies in pachychoroid spectrum of diseases (Review)

This review presents a systematic analysis of the literature regarding the pachychoroid disease spectrum nomenclature, diagnosis criteria and therapeutic options. Pachychoroid related diseases are a new concept, introduced into the ophthalmological nomenclature in 2013 and evolving both as concept and as classification since then. The six disorders included in this phenotype have some common characteristics (thick choroid, pachyvessels, attenuation of the choriocapillaris), but also show individual features. The classification of the pachychoroid spectrum was revised many times, with the recent addition of the focal choroidal excavation (FCE) and peripapillary pachychoroid syndrome (PPS). As the terminology is developing, so is the number of case reports and case series from the initial report in 2013 to 57 reports in 2019. This review takes into account both the current literature and the clinical experience of the authors, emphasizing the understanding of the pathogenesis and aiming to update the therapeutic options available.

Polypoidal Choroidal Vasculopathy: Consensus Nomenclature and Non-Indocyanine Green Angiograph Diagnostic Criteria from the Asia-Pacific Ocular Imaging Society PCV Workgroup

PURPOSE

To develop consensus terminology in the setting of polypoidal choroidal vasculopathy (PCV) and to develop and validate a set of diagnostic criteria not requiring indocyanine green angiography (ICGA) for differentiating PCV from typical neovascular age-related macular degeneration (nAMD) based on a combination of OCT and color fundus photography findings.

DESIGN

Evaluation of diagnostic test results.

PARTICIPANTS

Panel of retina specialists.

METHODS

As part of the Asia-Pacific Ocular Imaging Society, an international group of experts surveyed and discussed the published literature regarding the current nomenclature and lesion components for PCV, and proposed an updated consensus nomenclature that reflects our latest understanding based on imaging and histologic reports. The workgroup evaluated a set of diagnostic features based on OCT images and color fundus photographs for PCV that may distinguish it from typical nAMD and assessed the performance of individual and combinations of these non-ICGA features, aiming to propose a new set of diagnostic criteria that does not require the use of ICGA. The final recommendation was validated in 80 eyes from 2 additional cohorts.

MAIN OUTCOME MEASURES

Consensus nomenclature system for PCV lesion components and non-ICGA-based criteria to differentiate PCV from typical nAMD.

RESULTS

The workgroup recommended the terms polypoidal lesion and branching neovascular network for the 2 key lesion components in PCV. For the diagnosis of PCV, the combination of 3 OCT-based major criteria (sub-retinal pigment epithelium [RPE] ring-like lesion, en face OCT complex RPE elevation, and sharp-peaked PED) achieved an area under the receiver operating characteristic curve of 0.90. Validation of this new scheme in a separate subset 80 eyes achieved an accuracy of 82%.

CONCLUSIONS

We propose updated terminology for PCV lesion components that better reflects the nature of these lesions and is based on international consensus. A set of practical diagnostic criteria applied easily to spectral-domain OCT results can be used for diagnosing PCV with high accuracy in clinical settings in which ICGA is not performed routinely.

Pachychoroid neovasculopathy: a type-1 choroidal neovascularization belonging to the pachychoroid spectrum-pathogenesis, imaging and available treatment options

PURPOSE

The purpose of this paper is to provide a meaningful literature review about the epidemiology, pathogenesis, imaging and treatment of pachychoroid neovasculopathy (PNV).

METHODS

A computerized search from inception up to December 2019 of the online electronic database PubMed was performed using the following search string: "pachychoroid neovasculopathy". The reference list in each article was scanned for additional relevant publications.

RESULTS

PNV is a type-1 choroidal neovascularization, overlying focal areas of choroidal thickening and dilated choroidal vessels. It can develop in patients affected by pachychoroid pigment epitheliopathy or chronic central serous chorioretinopathy. The absence of drusen, the presence of pachydrusen, younger age of onset and choroidal thickening distinguish it from neovascular age-related macular degeneration (AMD). PNV incidence and prevalence data are lacking. Its pathophysiology is not fully understood, but angiogenic mechanisms involved in neovascular AMD may be different from those in PNV. Due to optical coherence tomography (OCT) improvements, PNV can be diagnosed more easily than before. In particular, PNV shows a shallow pigment epithelium detachment with an undulating retinal pigment epithelium over a subfoveal choroidal thickening, associated with vein enlargement in Haller's layer (named pachyvessels) and choriocapillaris thinning. On OCT angiography, PNV reveals tangled hyper-reflective filamentous neovessels in the choriocapillaris itself. The current first-line PNV treatment is intravitreal anti-VEGF (vascular endothelial growth factor) injections with a treat-and-extend regimen. In particular, aflibercept shows a higher rate of fluid absorption than others. In the case of fluid recurrence or persistence, photodynamic therapy is a valid alternative.

CONCLUSION

Ongoing research into pathophysiology and imaging improvements may be helpful in defining prognostic criteria and stratifying patient risk, allowing responsible monitoring and management of PNV.

Characteristics of Pachychoroid Diseases and Age-Related Macular Degeneration: Multimodal Imaging and Genetic Backgrounds

The emergence of pachychoroid disease is changing the concept of age-related macular degeneration (AMD). The concept of pachychoroid diseases was developed through clinical observation of multimodal images of eyes with AMD and central serous chorioretinopathy; however, recent genetic studies have provided a proof of concept for pachychoroid spectrum disease, which should be differentiated from drusen-driven AMD. The genetic confirmation of pachychoroid concept further provides novel viewpoints to decode previously reported findings, which facilitates an understanding of the true nature of pachychoroid diseases and AMD. The purpose of this review was to elucidate the relationship between pachychoroid diseases and AMD by interpreting previous findings on pachychoroid diseases and AMD from the novel viewpoints of genetic associations. We confirmed that previous genetic studies supported the concept of pachychoroid diseases. From a genetic viewpoint, the presence of thick choroid and the presence of choroidal vascular hyperpermeability were important characteristics of pachychoroid spectrum diseases. Previous studies have also suggested the classification of polypoidal choroidal vasculopathy (PCV) into two subtypes, pachychoroid neovasculopathy and drusen-driven PCV. Genetic viewpoints will be beneficial to rearrange subtypes of drusen-driven AMD and pachychoroid spectrum diseases. Further genetic studies are needed to investigate pachyvessels, pachydrusen and the significance of polypoidal lesions in pachychoroid neovasculopathy and drusen-driven AMD/PCV.

Association between pachychoroid and long-term treatment outcomes of photodynamic therapy with intravitreal ranibizumab for polypoidal choroidal vasculopathy

We investigated long-term treatment responses in patients with treatment-naïve polypoidal choroidal vasculopathy (PCV) undergoing photodynamic therapy (PDT) with intravitreal ranibizumab (IVR). The medical charts of 14 patients with treatment-naïve PCV who underwent PDT with IVR were retrospectively reviewed. Patients were followed up and treated with additional IVR for ≥3 years. Best-corrected visual acuity (BCVA), central foveal thickness (CFT), greatest linear dimension (GLD) on angiography, polyp regression and central choroidal thickness (CCT) were assessed. Associations between these functional or anatomic outcomes with age, baseline CCT, baseline GLD or choroidal vascular hyperpermeability (CVH) were investigated using univariate and multivariate analysis. Mean logMAR BCVA improved significantly at 3 years (0.34 ± 0.24 to 0.12 ± 0.29, p = 0.003). Greater BCVA improvement and longer time to first recurrence was significantly associated with CVH. Fewer number of IVR retreatment within 3 years was associated with thicker baseline CCT. Mean CCT significantly decreased at 3 years (217 ± 33 µm to 197 ± 48 µm, p = 0.003). Greater decrease of CCT was significantly associated both with greater number of IVR retreatment within 3 years and absence of CVH. These results showed that pachychoroid characteristics at baseline was associated long-term functional and anatomic outcomes in patients with treatment-naïve PCV who had undergone combination PDT and IVR.

Pachychoroid disease: a new perspective on exudative maculopathy

BACKGROUND

Pachychoroid, or the structural and functional abnormalities of the choroid, is one of the most important causes of exudative maculopathies. The purpose of this article is to review the current definitions of pachychoroid and their potential consequences. Most publications are from Asian countries. Although no consensus diagnosis has been reached, pachychoroid is defined by thickened choroid and choroidal vascular hyperpermeability, pachyvessels with inner choroidal attenuation; it is closely linked to pachydrusen. Although some studies suggest choroidal congestion may play a role in its pathogenesis, the exact causes of this condition are still unknown. Pachychoroid is associated with exudative maculopathies including central serous chorioretinopathy, pachychoroid neovasculopathy and polypoidal choroidal vasculopathy (PCV). It is widely accepted that macular neovascular membranes may develop secondary to pachychoroid. Recent clinical observations illustrate the importance of pachychoroid in the etiology of macular neovascularization including neovascular age-related macular degeneration (nAMD).

CONCLUSION

Pachychoroid is an important cause of exudative maculopathies. Both drusen and pachychoroid are increasingly recognized as important causes of macular neovascularization, and eyes formally categorized as typical nAMD or PCV can be further sub-categorized based on the presence or absence of pachychoroid and drusen. There is a need to develop a consensus definition, which will greatly enhance our understanding of pachychoroid and facilitate the development of individual interventions in pachychoroid diseases.