Incidence, outcomes, and risk factors for hemorrhagic complications in eyes with polypoidal choroidal vasculopathy following photodynamic therapy in Indian subjects

Polypoidal Choroidal Vasculopathy: An Update on Diagnosis and Treatment

Polypoidal choroidal vasculopathy (PCV) is a vascular disease of the choroid that leads to hemorrhagic and exudative macular degeneration. It may cause significant vision loss and thus affect the quality-of-life and psychological well-being. Non-invasive, non-ICGA-based OCT criteria have shown reliable results to plan adjunct photodynamic therapy (PDT) treatment, with the complete and consistent coverage of polypoidal lesions (PL) and branching neovascular network (BNN). The safety and efficacy of anti-vascular endothelial growth factor (anti-VEGF) monotherapy and its combination with verteporfin PDT have been established. However, treatment is still challenging due to frequent follow-ups, non-availability of PDT, and need for multiple anti-VEGF injection visits that increase the treatment burden and lead to patients being lost to follow-up. Effective treatments that prolong intervals between injections while maintaining vision and anatomical gains remain a critical unmet need. Longer acting molecules, like brolucizumab, have shown non-inferiority in BCVA gains and superior anatomical outcomes compared to other anti-VEGF agents. Newer therapies in the pipeline to enhance the efficacy and longevity of treatment include Faricimab and a port delivery system (PDS). This review summarizes the most recent diagnostic and treatment approaches in PCV to offer better treatment avenues.

Updated guidelines for the management of polypoidal choroidal vasculopathy: Recommendations from the Indian Polypoidal Choroidal Vasculopathy Panel and the Vitreoretinal Society of India

In Asians, polypoidal choroidal vasculopathy (PCV) is becoming more widely recognized as a significant cause of exudative maculopathy. The previous set of Indian guidelines on the management of PCV were published in 2018, with a literature search updated up to November 2015. As the treatment of PCV evolves, retinal physicians must constantly modify their current practice. The current guidelines are based on the most up-to-date information on PCV and are an update to the previous set of guidelines. These guidelines were developed by a panel of Indian retinal experts under the aegis of the Vitreoretinal Society of India (VRSI), based on a comprehensive search and assessment of literature up to September 2021. The final guidelines i) provide the updated nomenclature in PCV; ii) discusses the newer diagnostic imaging features of PCV, especially in the absence of indocyanine green angiography (ICGA); and iii) recommends the best possible therapeutic approach in the management of PCV, including the choice of anti-vascular endothelial growth factor (anti-VEGF) agents, treatment regimen, and the role of switching between the anti-VEGF agents. In the face of non-availability of photodynamic therapy (PDT) in India, we constructed practical recommendations on anti-VEGF monotherapy in PCV. The current updated recommendations would provide a broader framework to the treating retinal physician for the diagnosis and management of PCV for optimal therapeutic outcomes.

Comparing efficacy of reduced-fluence and standard-fluence photodynamic therapy in the treatment of polypoidal choroidal vasculopathy

Background

The EVEREST II study reported superior polyp closure rates and visual outcomes using combination standard photodynamic therapy (PDT) with intravitreal ranibizumab in the treatment of polypoidal choroidal vasculopathy (PCV). The optimal PDT protocol remains controversial and it is postulated that less intensive PDT strategies may reduce complications. We aimed to compare the efficacy of reduced and standard-fluence PDT.

Methods

Case-control review of 38 consecutive PDT-naïve macular PCV patients who underwent verteporfin PDT using one of two PDT regimens at a tertiary referral centre in an Asian population. Comparison of outcomes between standard-fluence PDT (light dose, 50 J/cm2; dose rate, 600 mW/cm2; wavelength, 689 nm PDT applied to the treatment eye for 83 s) and reduced-fluence PDT (light dose, 25 J/cm2; dose rate, 600 mW/cm2; wavelength, 689 nm PDT applied to the treatment eye for 42 s). Primary outcome measure was best corrected LogMAR visual acuity (VA). Secondary outcome measures included OCT measurements such as central retinal thickness (CRT), height of subfoveal sub-retinal fluid (SRF), central choroid thickness (CCT), mean number of PDT treatments needed, mean number of anti-VEGF injections needed, polyp closure and recurrence rates.

Results

Of these 38 eyes of 38 patients, an equal number of eyes (19 in each arm) were treated with standard-fluence and reduced-fluence PDT. Mean letter gain at 12 months for the standard-fluence group was 6.0 compared to 4.3 letters for the reduced-fluence group (p = 0.61). Similar results were observed at all time points. There was no statistically significant difference between the retinal and choroidal anatomical OCT outcomes, rates of polyp closure and recurrences between the two PDT regimens.

Conclusions

Reduced-fluence PDT was comparable to standard-fluence PDT in the treatment of PCV in terms of visual gains, clinical and anatomical OCT outcomes.

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.

Current management strategy of polypoidal choroidal vasculopathy

Polypoidal choroidal vasculopathy (PCV) is a retinal disorder commonly found in Asians presenting as neovascular age-related macular degeneration and is characterized by serous macular detachment, serous or hemorrhagic pigment epithelial detachment, subretinal hemorrhage, and occasionally visible orange-red subretinal nodular lesions. PCV is diagnosed using indocyanine green angiography (ICGA), and the lesions appear as polypoidal aneurysmal vascular lesions with or without abnormal branching vascular network. Although ICGA remains the gold standard for the diagnosis of PCV, various imaging modalities have also facilitated the diagnosis and monitoring of PCV. Recent advances in imaging technology including the use of high resolution spectral domain optical coherence tomography (OCT) and OCT angiography have provided new insights on the pathogenesis of PCV, suggesting a link between PCV and pachychoroid spectrum of macular disorders. With the evolving understanding on the pathogenesis and clinical characteristics of PCV, different therapeutic options have been proposed. These include intravitreal anti-vascular endothelial growth factor (anti-VEGF) monotherapy, combination therapy with anti-VEGF and verteporfin photodynamic therapy, and thermal laser photocoagulation. In recent years, major multi-center randomized clinical trials such as EVEREST, EVEREST II, and PLANET studies have been conducted to compare the efficacy and safety of various treatment options for PCV. This review aims to summarize the results of recent literature, clinical trials and studies to provide an update on the management options of PCV. An overall management strategy for PCV will also be proposed.

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.

Long-term efficacy and safety of verteporfin photodynamic therapy in combination with anti-vascular endothelial growth factor for polypoidal choroidal vasculopathy

Purpose:

The aim of the study was to analyze the outcomes of photodynamic therapy (PDT) with intravitreal anti-vascular endothelial growth factor (anti-VEGF) for patients with polypoidal choroidal vasculopathy (PCV) having visual acuity (VA) better than 20/60 in a real-world scenario in India.

Methods:

Retrospective review of 42 eyes of 40 patients (mean age 64.3 years) with best-corrected VA (BCVA) 20/60 or better and mean follow-up of 40 months (median 38 months; range 12–71 months) treated with PDT and anti-VEGF or triamcinolone for indocyanine green angiography (ICGA)-proven subfoveal PCV.

Results:

Mean BCVA improved from 0.22 logMAR at baseline to 0.15 at last visit (P < 0.001). On ICGA, polyp was observed in 42 eyes (100%) and branching vascular network (BVN) in 37 eyes (88.1%). Polyp regressed in 33 (78.6%) of 42 eyes and BVN in 26 (70.3%) of 37 eyes after combined therapy at 3 months. Mean greatest linear diameter reduced significantly (P < 0.001) from 7.22 mm to 4.11 mm. Standard-fluence PDT was performed in 35 eyes and reduced-fluence in 7 eyes. The mean number of PDT was 1.17 with mean number of injections being 6.38 at the end of follow-up. In five eyes, more than one PDT was administered. Of 42 eyes, 40 showed complete resolution of serous macular detachment (SMD) after the combined therapy at 3 months; 17 (42.5%) of the 40 eyes showed no recurrence of fluid on spectral domain optical coherence tomography till the last visit with a mean follow-up of 27 months. On long-term follow-up, SMD reoccurred in 23 eyes with a mean follow-up period of 9.64 ± 5.24 months. Of 38 eyes having a double-layer sign (DLS) on optical coherence tomography at baseline, 37 eyes were having regression of the DLS, that is, it either reduced or resolved at the final visit. At the final visit, 66.7% (P < 0.001) eyes were having fluid-free retina. No complication of subretinal hemorrhage was noted. Of the 42 eyes, only one eye had BCVA worse than 20/60 on the final visit.

Conclusion:

To the best of our knowledge, this is the first study to look into the long-term effect of combined PDT with anti-VEGF in PCV in eyes having good VA. Long-term effect of combined PDT appears to be a safe and effective treatment for PCV in eyes having good VA with better outcomes in real-world setting. This study further strengthens the superiority of the combined treatment modality for treatment of subfoveal PCV with no or minimal risk of complication on long-term follow-up.