Polypoidal choroidal vasculopathy and exudative age-related macular degeneration in Greek population

Imaging characterization of the fellow eye in patients with unilateral polypoidal choroidal vasculopathy

INTRODUCTION

New insights on polypoidal choroidal vasculopathy (PCV) have shed light regarding its pathophysiology and associations. However, PCV characterization is still incomplete in Caucasians, which is due to presumed lower prevalence in this population. Features typically associated with AMD such as drusen, retinal pigmentary changes or atrophy are seen in PCV, as precursors and in the fellow eye. Pachychoroid spectrum, predisposing to PCV, also presents with chronic changes in the retinal pigment epithelium (RPE), such as drusen-like deposits (DLD), and in the choroid. The purpose of this study is to perform a multimodal imaging characterization of unaffected fellow eyes in a sample of Caucasian patients with unilateral PCV.

METHODS

Multicenter retrospective cohort study with a sample of 55 unaffected fellow eyes from patients diagnosed with unilateral PCV confirmed by indocyanine green angiography. The sample was characterized in the baseline by color fundus photography, spectral domain optical coherence tomography (SD-OCT), fluorescein angiography and indocyanine green angiography. Morphological characteristics of both the retina and the choroid were evaluated. The SD-OCT of the last follow-up visit was also evaluated in order to exclude evolution to PCV or choroidal neovascularization. All images captured underwent evaluation by two independent graders. Informed consent was obtained from all participants.

RESULTS

Fifty-five patients (median age, 74 ± 15 years) were included. After 15.5 ± 6.4 months of follow-up, only one developed disease (1.9%). Soft and/or hard drusen were present in 60% and pachydrusen in 23.6%. Pachychoroid signs were present in 47.2%, the double-layer sign in 36.4%, disruption of the RPE changes in 16.4% and RPE atrophy in 10.9%. ICGA revealed choroidal vascular dilation in 63.6% and punctiform hyperfluorescence in 52.7%. Branching vascular networks were identified in only 1.9% of cases.

CONCLUSION

The identification of pachychoroid signs in the OCT and ICGA were present in over half of the cases and the presence of the double-layer sign in more than a third provide crucial insights for enhanced characterization of this pathology and deeper understanding of its pathogenesis. These findings contribute significantly to the current knowledge, offering valuable markers to discern various phases of the pathology's progression.

Polypoidal Choroidal Vasculopathy Based on Non-ICGA Criteria in White Patients With Neovascular Age-Related Macular Degeneration

PURPOSE

To determine prevalence of probable polypoidal choroidal vasculopathy (PCV) among White patients with neovascular age-related macular degeneration (nAMD) using non-indocyanine green angiography (ICGA) criteria DESIGN: Multicenter, multinational, retrospective, cross-sectional study.

METHODS

A total of 208 treatment-naive eyes from Hispanic and non-Hispanic White individuals diagnosed with nAMD were included. All underwent color fundus photography (CFP), optical coherence tomography (OCT), and fluorescein angiography (FFA). De-identified images of study eyes were sent to 2 groups of graders. Group 1 reviewed CFP, OCT, and FFA to confirm nAMD diagnosis. Group 2 reviewed CFP and OCT to determine highly suggestive features for PCV. Probable PCV diagnosis defined as the presence of ≥2 of 4 highly suggestive features for PCV: notched or fibrovascular pigment epithelial detachment (PED) on CFP, sharply-peaked PED, notched PED, and hyperreflective ring on OCT.

RESULTS

Eleven eyes were excluded because of poor image quality (6) or non-nAMD diagnosis (5). Of 197 eligible eyes (197 patients), the mean age (SD) was 78.8 years (8.9), 44.2% were men, 26.4% were Hispanic, and 73.6% were non-Hispanic White individuals; 41.1%, 23.4%, 9.1%, and 2.5% had ≥1, ≥2, ≥3, and 4 highly suggestive features. Results showed that 23.4% (95% CI, 17.6%-29.9%) had probable PCV diagnosis. Predominantly occult CNV was more frequently found in probable PCV than nAMD subgroup (84.8% vs 64.9%, P = .01). Hispanic White individuals had a lower prevalence of probable PCV than non-Hispanic White individuals (9.6% vs 28.2%, P = .006) CONCLUSIONS: These findings suggest that probable PCV occurs between 17.6% and 29.9% in White individuals with nAMD, and more commonly in non-Hispanic than in Hispanic White individuals.

Comparison of 3-year outcomes of photodynamic therapy combined with intravitreal ranibizumab or aflibercept for polypoidal choroidal vasculopathy in a European cohort

PURPOSE

Combined use of photodynamic therapy (PDT) with intravitreal anti-vascular endothelial growth factors (anti-VEGF) agents, such as ranibizumab (IVR) or aflibercept (IVA), has been shown to be effective for treating polypoidal choroidal vasculopathy (PCV). However, it is currently not well established which anti-VEGF agent provides superior outcomes for performing combination therapy. The present study compares the visual outcomes and re-treatment burden of combination therapy of PDT with either IVR or IVA in a European cohort of patients with PCV.

METHODS

A retrospective analysis was done on PCV patients who had received combination therapy of PDT with either IVR or IVA. The demographic characteristics, visual outcome, and anti-VEGF re-treatment exposures were analysed and compared.

RESULTS

A total of forty-four eyes (n = 11 male, 25%) were included in the analysis: 7 patients received IVR, 19 started with IVR but switched to IVA (IVS), and 18 received IVA, in combination with PDT. The BCVA improved in all three groups at 6-, 12-, 18-, 24-, 30-, and 36-month follow-ups after PDT, although the improvement was not statistically significant in the IVR group. The number of intravitreal anti-VEGF injections required/year after PDT was significantly fewer than before PDT. Significantly less eyes in the IVS group attained a good visual acuity of more than 70 ETDRS letters at the final visit.

CONCLUSION

Both IVR and IVA combined with PDT were effective treatments for the European cohort of patients with PCV. In eyes refractory to IVR, performing PDT promptly may be more beneficial than switching to IVA.

Prevalence of Polypoidal Choroidal Vasculopathy in Eyes with Neovascular Age-Related Macular Degeneration Resistant to Intravitreal Anti-VEGF Treatment

OBJECTIVES

To determine the prevalence of polypoidal choroidal vasculopathy (PCV) in intravitreal (IV) anti-vascular endothelial growth factor (anti-VEGF)-resistant neovascular age-related macular degeneration (nvAMD) cases.

MATERIALS AND METHODS

Eyes that were diagnosed as having active and treatment-naive nvAMD in the Ege University Ophthalmology Department, Retina Unit in 2011-2018, were non-responsive to IV anti-VEGF treatment, and for which indocyanine angiography (ICGA) could be obtained were included in the study. Active nvAMD was defined as the presence of fresh hemorrhage on clinical examination or findings of subretinal, intraretinal, or sub-retinal pigment epithelial fluid on spectral domain optical coherence tomography and accompanying fluorescein dye leakage in fluorescein angiography. Eyes that had activation findings despite at least 6 consecutive intravitreal anti-VEGF injections were defined as non-responders and underwent ICGA to assess for PCV. The diagnosis of PCV was based on the Everest II study criterion.

RESULTS

A total of 97 eyes of 88 patients were included in the study. Of 88 patients, 44 (50%) were female, 44 (50%) were male, and the mean age was 75.9±8.3 years (range: 59-93). The mean number of anti-VEGF injections until the time of ICGA was 7.3±2.2 (range: 6-15). PCV was detected in 62 eyes (63.9%) on ICGA.

CONCLUSION

The prevalence of PCV is quite high among eyes with IV anti-VEGF treatment-resistant nvAMD in Turkey (63.9%). ICGA evaluation for PCV should be conducted for all nvAMD cases that are non-responsive to IV anti-VEGF treatment, both to shed light on the reason for resistance and to modify treatment as necessary.

Photodynamic Therapy-Induced Acute Exudative Maculopathy (PAEM): Prevalence, Impact and Management Strategies

Photodynamic therapy (PDT) has a niche role in treating various choroidal pathologies. PDT-induced acute exudative maculopathy (PAEM) is an uncommon complication of PDT that results in exudative retinal detachment and mild to severe decrease in vision. Successful management strategies include observation, local or systemic corticosteroids, and intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections. Most cases return to visual acuity near baseline. This review summarizes what is known about PAEM to date including etiology, prevalence, management strategies, and outcomes. We conclude that management of PAEM must take into consideration various patient-specific factors. Treatment with corticosteroids or anti-VEGF agents may expedite time to recovery, though lack of randomized controlled trials preclude firm conclusions regarding a standardized approach to managing this complication of PDT.

European Prevalence of Polypoidal Choroidal Vasculopathy: A Systematic Review, Meta-Analysis, and Forecasting Study

The purpose of this study was to provide an estimate of the number of current and future patients with polypoidal choroidal vasculopathy (PCV) in Europe. We systematically searched 11 literature databases on 18 May 2022 for studies on the prevalence of PCV among a consecutive and representative group of patients with suspected neovascular age-related macular degeneration (AMD). Prevalence of PCV in patients with suspected neovascular AMD was summarized and included in a prevalence meta-analysis. We then used current population data and population forecasts by Eurostat and the Office for National Statistics to determine current and future number of patients with neovascular AMD in Europe. Then, we calculated the number of patients with PCV with our calculated estimate of the prevalence of PCV among Europeans suspected with neovascular AMD. A total of five eligible studies were identified which included a total of 1359 patients. All these studies used the gold standard of indocyanine green angiography as a routine part of their diagnostic approach. Among patients undergoing detailed retinal examination for suspected neovascular AMD, our meta-analysis calculated the prevalence of PCV to be 8.3% (95% confidence interval: 6.8–9.8%). Our population estimates find that a total of 217,404 patients with PCV exist in Europe in the year 2022, which constitutes 0.04% of the entire population of Europe. This number is estimated to increase to 287,517 patients in the year 2040. Our estimates are important for different healthcare stakeholders, especially when planning and allocating expensive resources.

Ethnic differences on long term outcomes of polypoidal choroidal vasculopathy after predominantly bevacizumab monotherapy

Background

A 3-year single-centre, retrospective, comparative, non-randomized cohort study to describe the long-term outcomes of treatment-naïve, Caucasian and non-Caucasian eyes with polypoidal choroidal vasculopathy (PCV) after treatment with predominantly Bevacizumab monotherapy or in combination with rescue photodynamic therapy (PDT).

Methods

Demographics, visual outcomes, optical coherence tomography (OCT) and treatment data were collected up to 3 years after the first visit. Stratified analysis according to ethnicity and baseline vision was performed to identify factors predictive of long-term visual improvement and maintenance.

Results

A total of 89 eyes with PCV were identified, of which 14 received rescue verteporfin PDT. There was an equal distribution between Caucasian and non-Caucasian individuals. Non-Caucasians present at a younger age (67.3 vs. 76.0 years, p = 0.002), have a higher proportion of foveal involvement (80.9%, vs.54.2% p = 0.007), choroidal hyperpermeability (50% vs 25.8%, p = 0.013) and lower baseline visual acuity (53.1 vs. 63.3 letters, p = 0.008). Mean visual acuity (VA) gain was + 8.9 letters and + 5.0 letters at 1 and 3 years of follow-up, respectively. Non-Caucasian individuals had a lower mean final visual acuity (VA) (54.7 vs. 70.5, respectively; P < 0.001) and net gain in VA (+ 2.0 vs. + 7.6 letters, p = 0.581) compared to Caucasian individuals. The mean total number of injections given over 3 years was 14.

Conclusions

Most patients treated with predominantly Bevacizumab anti-vascular endothelial growth factor (VEGF) monotherapy achieved sustained visual acuity gains out to 3 years. Due to ethnic-specific differences in presenting PCV phenotypes, non-Caucasians presented with lower baseline VA and had poorer long-term visual outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02551-3.

Long-term characteristics of exudative age-related macular degeneration in Japanese patients

Purpose

The present study aimed to evaluate the clinical characteristics of exudative age-related macular degeneration (AMD) in Japanese patients over a 10-year period and to compare the past our report.

Methods

We retrospectively reviewed 1,600 treatment-naïve patients (1,777 eyes) with exudative AMD. The 10 years were divided into 2-year phases I to V.

Results

Of the 1,600 patients, 720 (45.0%), 733 (45.8%), 98 (6.1%), and 49 (3.1%) were diagnosed with typical AMD, polypoidal choroidal vasculopathy (PCV), retinal angiomatous proliferation, and combined subtypes, respectively. The prevalence of PCV decreased from 54.7% in phase I to 46.0% at phase V. Of the 1,777 eyes, the mean baseline logarithm of the minimum angle of resolution best-corrected visual acuities (BCVAs) in phases I, II, III, IV, and V were 0.70, 0.66, 0.55, 0.50, and 0.48, respectively. Phases III, IV, and V had significantly (P = 0.0012, P<0.0001, P<0.0001, respectively) better baseline VAs compared with phase I. The mean lesion sizes in phases I, II, III, IV, and V were 8.6, 6.7, 5.3, 5.7, and 5.7 Macular Photocoagulation Study disc areas, respectively. The sizes were significantly (P<0.0001 for all comparisons) smaller in phases III, IV, and V compared with phase I.

Conclusions

Although the prevalence of PCV decreased from 54.7% in phase I to 46.0% at phase V, PCV has nevertheless been highly prevalent in Japanese patients with AMD compared with Caucasian patients. The annual better baseline VAs and smaller lesion sizes over time might be related to development of treatment and better concerns about AMD.

Massive submacular haemorrhage in polypoidal choroidal vasculopathy versus typical neovascular age-related macular degeneration

PURPOSE

To investigate the incidence rate of massive submacular haemorrhage (SMH) and risk factors in polypoidal choroidal vasculopathy (PCV) and typical neovascular age-related macular degeneration (tnAMD).

METHODS

A total of 465 patients who were diagnosed with either PCV (n = 245) or tnAMD (n = 220) from 2003 to 2014 were enrolled. Cumulative incidence of massive SMH in PCV and that in tnAMD were compared. Risk factors of massive SMH were also analysed.

RESULTS

Massive SMH occurred in 32 patients (13.1%) with PCV and 9 patients (4.1%) with tnAMD. Incidence rates of massive SMH 5 and 10 years after the first visit were 11.1% and 29.9% in PCV and 4.3% and 9.9% in tnAMD, respectively. Incidence rates of massive SMH in PCV were significantly higher than those in tnAMD (hazard ratio [HR], 2.66; p = 0.007). Cox regression analysis revealed that mean number of photodynamic therapies (PDTs) per year (HR, 4.24; p < 0.001), cluster type of polypoidal lesion (HR, 3.42; p = 0.003) in PCV, and mean number of anti-VEGF injections per year (HR, 1.58; p < 0.001) in tnAMD were significantly associated with risk of massive SMH. For patients with severe vision loss, proportion of incident massive SMH was significantly higher in PCV (29.5%) than in tnAMD (6.9%, p < 0.001).

CONCLUSION

The incidence rate of massive SMH in eyes with PCV was about three times higher than that in eyes with tnAMD. Treatment methods that can reduce the incidence of massive SMH should be considered, especially for eyes with PCV.

One-year outcomes of fixed-dosing Aflibercept therapy for pre treated and naive polypoidal choroidal vasculopathy patient

BACKGROUND

Polypoidal choroidal vasculopathy (PCV) is a type of age-related macular degeneration that can cause permanent vision loss. The purpose of this paper was to report the one-year outcomes of fixed-dosing aflibercept therapy for the treatment of PCV.

METHODS

This was a prospective, single-arm, interventional case series study of 25 PCV patients; 12 pre-treated and 13 treatment-naïve patients. The patients were treated and monitored for 12 months. Each patient was administered with an aflibercept (2.0 mg) injection every month for the first 3 months (the loading phase), and thereafter, once every 2 months. At every follow-up visit, best-corrected visual acuity (BCVA) test, fundus examination, and optical coherence tomography for measuring the central subfield macular thickness (CSMT) were performed. Fluorescein and indocyanine green angiography were conducted at baseline and at 4 and 12 months.

RESULTS

After 12 months of aflibercept therapy, the mean BCVA of the patients significantly improved from 65.48 letters at baseline to 69.91 letters (p=0.001), and the CSMT significantly decreased from 406.92 um at baseline to 276.12 um (p< 0.001). Additionally, ten patients (40%) showed complete polyp regression. The treatment-naïve patients showed a statistically significant improvement in BCVA from 66.58 letters at baseline to 76.36 letters at 12 months, and a significant decrease in CSMT, from 462 to 243 um. In the pre-treated group, there was no change in BCVA (64.46 letters), and the decrease in CSMT from 356.08 to 303.69 um was not statistically significant.

CONCLUSIONS

The fixed-dosing aflibercept regimen is effective for treating patients with PCV and is more effective in treatment-naïve patients than in pre-treated patients.

TRIAL REGISTRATION

Clinical Research Information Service (CRiS), Republic of Korea. Identifer: KCT0005798, Registered: Jan 20, 2021. Retrospectively registered, URL: https://cris.nih.go.kr/cris/en/search/search_result_st01.jsp?seq=18546.

Efficacy and safety of intravitreal aflibercept for polypoidal choroidal vasculopathy: 96-week outcomes in the Japanese subgroup of the PLANET study

PURPOSE

To evaluate the efficacy and safety of intravitreal aflibercept (IVT-AFL) versus IVT-AFL plus rescue photodynamic therapy (IVT-AFL + rPDT) in the subgroup of Japanese patients with polypoidal choroidal vasculopathy (PCV) enrolled in the PLANET study.

STUDY DESIGN

A 96-week, double-masked, sham-controlled phase-3b/4 randomized clinical trial conducted at multiple centers from May 2014 to August 2016.

PATIENTS AND METHODS

Patients with PCV (BCVA 73-24 ETDRS letters [20/40-20/320 Snellen]) received 3 initial monthly doses of IVT-AFL 2 mg. At week 12, the patients were randomly assigned 1:1 to IVT-AFL + sham PDT or IVT-AFL + rPDT. Patients not requiring rescue received IVT-AFL every 8 weeks; those requiring rescue received IVT-AFL monthly plus sham/active PDT. Following week 52, the treatment intervals could be extended > 8 weeks.

RESULTS

The baseline demographics for the 159 Japanese patients were balanced. At week 96, the mean BCVA change was + 9.7 (IVT-AFL) versus + 9.5 letters (IVT-AFL + rPDT) (least-squares mean difference of - 0.3; 95% CI, - 3.7 to 3.1); the mean central subfield thickness reduction was - 148.0 µm versus - 145.9 µm. Overall, 17.1% of the patients required rescue PDT. At week 96, 25.0% (IVT-AFL) and 37.9% (IVT-AFL + rPDT) of the patients had complete polyp regression; 84.1% (IVT-AFL) and 88.4% (IVT-AFL + rPDT) of the patients had no evidence of active polyps. The mean number of injections (weeks 52-96) were 4.6 (IVT-AFL) and 4.5 (IVT-AFL + rPDT). Overall, 36.0% (IVT-AFL) and 33.8% (IVT-AFL + rPDT) of the patients experienced ocular treatment-emergent adverse events.

CONCLUSION

IVT-AFL monotherapy was efficacious for the treatment of Japanese patients with PCV, and the addition of rescue PDT did not show additional benefits.

Idiopathic polypoidal choroidal vasculopathy: a review of literature with clinical update on current management practices

PURPOSE

Polypoidal choroidal vasculopathy is a major cause of visual disability in a vast majority of Asian population due to exudative maculopathy. Although it is a distinctive disease entity with characteristic pathophysiology, genetics, immunology and clinical features, but it is still misdiagnosed as neovascular age related macular degeneration as both the diseases are a part of pachychoroid spectrum and have some similar features. Also, there are varied options for the management of this disease, but there are no clear recommendations. So, a detailed review of the literature has been done along with special attention to the recent therapeutic advances to help the readers get a better understanding of the disease and its current management practices.

METHOD

Detailed review of literature regarding polypoidal choroidal vasculopathy was done. The disease pathophysiology, genetics, risk factors, diagnostic modalities along with current treatment guidelines were extensively studied and compiled.

RESULT

A comprehensive clinical update on polypoidal choroidal vasculopathy was compiled with special emphasis on the recent diagnostic modalities and treatment guidelines.

CONCLUSION

Polypoidal choroidal vasculopathy is a distinct clinical entity which can be diagnosed based on indocyanine green angiography and optical coherence tomography. Treatment includes various options like photodynamic therapy, anti VEGF agents and thermal laser ablation. A review of literature has been done and recent diagnostic modalities with management practices have been compiled for the better understanding of the disease.

Latest Developments in Polypoidal Choroidal Vasculopathy: Epidemiology, Etiology, Diagnosis, and Treatment

Polypoidal choroidal vasculopathy (PCV) is a condition characterized by multiple, recurrent, serosanguineous pigment epithelial detachments, and neurosensory retinal detachments due to abnormal aneurysmal neovascular lesions. It is generally considered as a variant of neovascular age-related macular degeneration, but there are some differences between the clinical presentation, natural history, and treatment response between patients with PCV and typical neovascular age-related macular degeneration patients. Over the past decade, new research and technological advancements have greatly improved our understanding of the PCV disease process and the management of PCV. This review aims to summarize the recent research findings to highlight the epidemiology, pathogenesis, genetics, the application of various diagnostic tools for PCV, and the available treatment options for PCV.

Prevalence of polypoidal choroidal vasculopathy in Indian population: Risk factors, clinical and imaging characteristics

Aim

To assess prevalence, clinical presentation and multimodal imaging characteristics of polypoidal choroidal vasculopathy (PCV) in a hospital-based setting in South India.

Methods

Electronic medical records (EMR) of new patients presenting with suspected clinical signs of wet age-related macular degeneration (AMD) in a tertiary hospital from January to December 2016 were retrospectively analyzed using keywords and filtered for patient who underwent multimodal imaging. Clinical presentations were categorized into predominantly hemorrhagic, exudative or mixed pattern. The imaging features were compared in these clinical groups. The multimodal images were graded by two masked graders and discrepancies between them were settled by a senior arbitrator.

Results

Of the 147 clinically suspicious cases of PCV out of 785 patients with clinical presentation of AMD as recorded in the EMR, 73 (49.7%) patients had a multimodal imaging diagnosis of PCV. There was no difference in the demography, distribution of polyps, ICGA and OCT characteristics in eyes presenting with hemorrhagic, exudative or mixed clinical features.

Conclusion

Approximately half of South Asian patients presenting with clinical features of neovascular AMD harbor PCV irrespective of their clinical presentation and so we recommend that multimodal imaging is done in all cases of suspicious neovascular AMD in Indian population.

Polypoidal Choroidal Vasculopathy in Congolese Patients

Purpose

Polypoidal choroidal vasculopathy (PCV) is a visually debilitating disease that mostly affects people of African and Asian heritage. Indocyanine green angiography (ICGA) is the recommended exploratory method for definitive diagnosis. The disease has been extensively described in Asians and Caucasians, but not in Africans. This study was conducted to document the clinical presentation and optical coherence tomography features of polypoidal choroidal vasculopathy (PCV) in Congolese patients.

Methods

A prospective case series of patients with PCV was performed between January 2017 and June 2019. Routine ocular examination was performed including best corrected visual acuity measurement, slit-lamp examination, dilated direct fundoscopy, and spectral domain optical coherence tomography (OCT). The diagnosis was based on a combination of clinical and OCT signs.

Results

Fourteen patients were diagnosed with PCV during this period. The average age was 64.7 ± 6.9 years. There were 8 females. Ten (71.4%) patients had systemic hypertension. Most patients (n = 9, 64.3%) had bilateral involvement. Blurred vision was the most common complaint (71.4%). The main clinical presentation was subretinal exudates, seen in 19 (82.6%) eyes of 11 (78.6%) patients and subretinal hemorrhage in 10 (43.5%) eyes. Macular localization was found in 16 eyes (69.5%) of 12 (85.7%) patients. Drusen were observed in 35.7% of the patients. On OCT imaging, thumb-like pigment epithelial detachment and subretinal exudation were the most frequent features, observed in 92.9% and 71.4% of the patients, respectively.

Conclusions

PCV in Congolese patients showed features that are more similar to those observed in Caucasians. In this setting where indocyanine green angiography is not available, OCT facilitates the diagnosis of PCV.

Clinical Characteristics of Polypoidal Choroidal Vasculopathy and Anti-Vascular Endothelial Growth Factor Treatment Response in Caucasians

BACKGROUND/AIMS

To identify the clinical characteristics of polypoidal choroidal vasculopathy (PCV) in Caucasian patients and assess the prevalence of anti-vascular endothelial growth factor (anti-VEGF) resistance.

METHODS

This involved a retrospective chart review of Caucasian patients diagnosed with PCV and utilizing indocyanine green angiography with the scanning laser ophthalmoscope. Data collected included patients' demographics, disease characteristics, and treatment response.

RESULTS

There were 54 eyes of 49 patients with PCV; 51.0% were male and 49.0% were female with a mean age of 72.9 years. Forty-four patients (89.8%) had PCV unilaterally and 10.2% (5 patients) had PCV bilaterally. PCV was located in the macula in 79.6%, in the peripapillary region in 16.7%, and in both regions in 3.7%. PCV commonly presents with serous detachment (66.7%), retinal pigment epithelial detachment (RPED) (51.9%) and subretinal hemorrhage (37.0%). Twenty-nine eyes were included in the treatment response analysis, with 18 eyes (62.1%) showing persistent disease activity after 3 initial injections of anti-VEGF treatment.

CONCLUSION

PCV in Caucasian patients is more often unilateral and presents more commonly in the macular region than the peripapillary region. Serous detachment and RPED are the 2 most common findings. Resistance to current anti-VEGF treatment was noted frequently; it is thus extremely important to identify this subtype of type I subretinal neovascularization.

Efficacy and Safety of Intravitreal Aflibercept for Polypoidal Choroidal Vasculopathy in the PLANET Study: A Randomized Clinical Trial

Importance

Polypoidal choroidal vasculopathy (PCV) is common in Asian populations, but an optimal treatment approach remains to be confirmed.

Objective

To evaluate intravitreal aflibercept injection (IAI) in participants with PCV and compare IAI monotherapy with IAI plus rescue photodynamic therapy (PDT).

Design, Setting, and Participants

This 96-week, double-masked, sham-controlled phase 3b/4 randomized clinical trial was conducted at multiple centers in Australia, Germany, Hong Kong, Hungary, Japan, Singapore, South Korea, and Taiwan from May 2014 to August 2016, and included adults 50 years or older with symptomatic macular PCV and a best-corrected visual acuity of 73 to 24 Early Treatment Diabetic Retinopathy Study letters (20/40-20/320 Snellen equivalent).

Interventions

Participants received 2 mg of IAI at weeks 0, 4, and 8. At week 12, participants with a suboptimal response were randomized 1:1 to receive IAI plus sham PDT (IAI monotherapy) or a "rescue" of IAI plus rescue PDT (IAI/PDT). Participants who did not qualify for rescue received IAI every 8 weeks; those qualifying for rescue received IAI every 4 weeks plus sham/active PDT. When the rescue criteria were no longer met, injection intervals were gradually extended to 8 weeks.

Main Outcomes and Measures

Noninferiority of IAI monotherapy to IAI/PDT for mean change in best-corrected visual acuity from baseline to week 52 (95% CI of the difference entirely above -5 letters).

Results

Of the 318 participants, the mean (SD) age was 70.6 (8.2) years, 96 (30.2%) were women, and 152 (47.8%) were Japanese. Monotherapy with IAI was noninferior to IAI/PDT for the primary end point (+10.7 vs +10.8 letters, respectively; 95% CI, -2.9 to 1.6; P = .55), with few participants requiring rescue therapy (19 [12.1%] vs 23 [14.3%], respectively). Participants in both treatment groups had similar reductions in central subfield thickness from baseline to week 52 (-137.7 [IAI monotherapy] vs -143.5 μm [IAI/PDT]). At week 52, 49 (38.9%) and 60 participants (44.8%) had no polypoidal lesions observed on indocyanine green angiography in the IAI monotherapy and IAI/PDT groups, respectively. Furthermore, 116 (81.7%) and 136 (88.9%), respectively, had no polypoidal lesions with leakage. The most frequent ocular adverse events were conjunctival hemorrhage (IAI monotherapy, 8 [5.1%]) and dry eye (IAI/PDT, 9 [5.6%]).

Conclusions and Relevance

Improvement in visual and/or functional outcomes was achieved in more than 85% of participants who were treated with IAI monotherapy, with no signs of leakage from polypoidal lesions in more than 80%. As fewer than 15% met the criteria of a suboptimal response to receive PDT, the potential benefit of adding PDT cannot be determined.

Trial Registration

ClinicalTrials.gov Identifier: NCT02120950.

PREVALENCE OF POLYPOIDAL CHOROIDAL VASCULOPATHY IN WHITE PATIENTS WITH EXUDATIVE AGE-RELATED MACULAR DEGENERATION: Systematic Review and Meta-Analysis

PURPOSE

Polypoidal choroidal vasculopathy (PCV) is a disease with significant inter-ethnical differences. In this study, we systematically review the literature on the prevalence of PCV in whites referred with a diagnosis of exudative age-related macular degeneration (AMD).

METHODS

We searched PubMed, Embase, the Cochrane Library, and the Web of Science on 24 March, 2017 for studies evaluating the prevalence of PCV in white patients with exudative AMD. Data extraction and risk of bias assessments were performed in duplicate. Studies were included for a qualitative review and a meta-analysis, including subgroup analysis for differences in age and sex.

RESULTS

We included data from 11 studies (>2,200 participants). For diagnosis, indocyanine green angiography was used together with a set of supporting criteria on fundus examination and optical coherence tomography. Extramacular location was more prevalent in eyes with PCV. Drusen was present in the fellow eye in 17% to 27%. Pooled prevalence of PCV in white patients with exudative AMD was 8.7% (confidence interval 95%: 7.2%-10.3%). Patients with PCV were 3.7 years (confidence interval 95%: 2.1 years-5.3 years) younger than those with other exudative AMD. Sex did not differ significantly.

CONCLUSION

Polypoidal choroidal vasculopathy is not a rare subtype of exudative AMD in whites-it is present in approximately one in 11 patients.

Anti-Vascular Endothelial Growth Factor Resistance in Exudative Macular Degeneration and Polypoidal Choroidal Vasculopathy

PURPOSE

To evaluate the prevalence of polypoidal choroidal vasculopathy (PCV) in different ethnic populations and to determine the prevalence of PCV in eyes with exudative age-related macular degeneration (AMD) that is sensitive and resistant to anti-vascular endothelial growth factor (VEGF) therapy.

DESIGN

Retrospective chart review.

PARTICIPANTS

Two hundred fifty-three eyes of 221 patients with exudative AMD.

METHODS

Baseline data were collected on all eyes diagnosed with exudative AMD, which included ethnic data. Polypoidal choroidal vasculopathy was diagnosed using indocyanine green angiography (ICGA) with the scanning laser ophthalmoscope. Exudative AMD eyes were separated into 2 groups: anti-VEGF-resistant eyes with persistent subretinal fluid, subretinal hemorrhage, or macular edema after 4 anti-VEGF injections and anti-VEGF-sensitive eyes defined as eyes without residual disease activity. The prevalence of PCV was determined in each group based on ICGA.

MAIN OUTCOME MEASURES

Prevalence of PCV in exudative AMD, and in different ethnic populations, and prevalence of anti-VEGF resistance in eyes with and without PCV.

RESULTS

Exudative AMD was diagnosed in 253 eyes of 221 patients. Polypoidal choroidal vasculopathy was noted to have a prevalence of 45.1% (114/253 eyes) in the overall population. Polypoidal choroidal vasculopathy was noted in 51.6% (81/157) of eyes with wet AMD in Asians, 31.9% (23/72 eyes) of eyes with wet AMD in white persons, and 28.6% (4/14 eyes) in a small group of Pacific Islanders. Polypoidal choroidal vasculopathy was diagnosed in 50% (60/120 eyes) of eyes in the anti-VEGF-resistant group, which is more prevalent than the 30.2% (29/96 eyes) in the anti-VEGF-sensitive group (P < 0.001).

CONCLUSIONS

Polypoidal choroidal vasculopathy is more prevalent in Asian patients with exudative AMD, but is more prevalent than generally recognized in white patients. Polypoidal choroidal vasculopathy is more prevalent in anti-VEGF-resistant eyes in both white and Asian patients, which could help to predict therapeutic response.

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.

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.

The Use of Vascular Endothelial Growth Factor Inhibitors and Complementary Treatment Options in Polypoidal Choroidal Vasculopathy: A Subtype of Neovascular Age-Related Macular Degeneration

Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular age-related macular degeneration (AMD; nAMD) which occurs more commonly in Asian populations as compared to Caucasians. PCV and nAMD share pathological mechanisms, including pathological expression of vascular endothelial growth factor (VEGF). The advent of anti-vascular endothelial growth factor (VEGF) revolutionized the treatment of nAMD. Despite being a subtype of nAMD, PCV responds less well to VEGF inhibitors; thus, photodynamic therapy (PDT) in combination with anti-VEGF treatment may be considered. This review aims to summarize the current evidence for the treatment of PCV, especially whether VEGF inhibitors should be used alone or in combination with PDT.

Color Fundus Photography, Optical Coherence Tomography, and Fluorescein Angiography in Diagnosing Polypoidal Choroidal Vasculopathy

PURPOSE

To determine sensitivity and specificity of polypoidal choroidal vasculopathy (PCV) diagnosis using color fundus photography (CFP), optical coherence tomography (OCT), and fundus fluorescein angiography (FFA) without indocyanine green angiography (ICGA).

DESIGN

Validity analysis.

METHODS

Treatment-naïve eyes with serous/serosanguinous maculopathy undergoing CFP, OCT, FFA, and ICGA imaging before treatment at a university hospital in Thailand (January 1, 2013 to June 30, 2015) were identified. Images of each subject were categorized into 4 sets (set A: CFP; set B: CFP+OCT; set C: CFP+FFA; set D: CFP+OCT+FFA). Six graders, 3 from Thailand (PCV endemic area) and 3 from the United States (nonendemic area), individually reviewed each set (without ICGA), and determined if the presumed diagnosis was PCV. In parallel, 2 other graders confirmed if each case had PCV or not using EVEREST criteria (including ICGA). Sensitivity and specificity of a PCV diagnosis with each set (without ICGA) were analyzed compared with diagnoses including ICGA.

RESULTS

Of 119 study eyes (113 subjects, 57% male, mean age ± SD 59.9 ± 13.8 years), definite PCV diagnosis was 40.3%. Sensitivity of sets A, B, C, D: 0.63 (95% confidence interval [CI]: 0.47-0.76), 0.83 (95% CI: 0.69-0.92), 0.54 (95% CI: 0.39-0.68), 0.67 (95% CI: 0.51-0.79); specificities: 0.93 (95% CI: 0.84-0.97), 0.83 (95% CI: 0.72-0.91), 0.97 (95% CI: 0.89-0.99), 0.92 (95% CI: 0.82-0.97); accuracies: 0.81 (95% CI: 0.73-0.88), 0.83 (95% CI: 0.76-0.90), 0.79 (95% CI: 0.73-0.87), 0.82 (95% CI: 0.74-0.88). Discrepancies between Thai and US graders existed through sets A, C, and D.

CONCLUSIONS

These data suggest that without ICGA, fundus photography combined with OCT provides high sensitivity and high specificity to diagnose PCV; adding FFA does not improve accuracy.

Polypoidal choroidal vasculopathy: Pearls in diagnosis and management

Polypoidal choroidal vasculopathy (PCV) is increasingly recognized as an important cause of exudative maculopathy in Asians as against Wet age-related macular degeneration in Caucasians. A panel of retinal experts methodically evaluated pertinent updated literature on PCV with thorough PubMed/MEDLINE search. Based on this, the panel agreed upon and proposed the current consensus recommendations in the diagnosis (clinical and imaging), management and follow-up schedule of PCV. Diagnosis of PCV should be based on the gold standard indocyanine green angiography which demonstrates early nodular hyperfluorescence signifying the polyp with additional features such as abnormal vascular network (AVN). Optical coherence tomography is an excellent adjuvant for diagnosing PCV, monitoring disease activity, and decision-making regarding the treatment. Current treatment modalities for PCV include photodynamic therapy, anti-vascular endothelial growth factor agents, and thermal laser. Choice of specific treatment modality and prognosis depends on multiple factors such as the location and size of PCV lesion, presence or absence of polyp with residual AVN, amount of submacular hemorrhage, presence or absence of leakage on fundus fluorescein angiography, visual acuity, and so on. Current recommendations would be invaluable for the treating physician in diagnosing PCV and in formulating the best possible individualized treatment strategy for optimal outcomes in PCV management.

Clinical outcomes in Caucasian patients with polypoidal choroidal vasculopathy

PURPOSE

To describe treatment outcomes in a cohort of Caucasian patients with polypoidal choroidal vasculopathy (PCV).

METHODS

Clinical charts from 48 eyes of 45 Caucasian patients with PCV were retrospectively reviewed. All cases were diagnosed with indocyanine green angiography. Best corrected visual acuity (BCVA) and optical coherence tomography (OCT) imaging were analyzed at baseline and final follow-up.

RESULTS

Eyes were treated with a combination of verteporfin photodynamic therapy (PDT) and anti-vascular endothelial growth factor (VEGF) (n = 24), or PDT monotherapy (n = 9), or anti-VEGF monotherapy (n = 8), or no treatment (n = 7). Aflibercept was the anti-VEGF agent in 30 out of 32 eyes. Sixteen out of 24 eyes in the combination treatment group received initial PDT at diagnosis. All treatments led to stabilization of BCVA at final visit with a trend for better visual acuity in the anti-VEGF monotherapy group. There was a substantial reduction in central retinal thickness associated with resolution of subfoveal fluid and improvement in retinal pigment epithelial detachment in all treatment groups. BCVA and OCT findings remained stable in eyes which received no treatment. The use of PDT was associated with 0.5 fewer intravitreal injections per annum, which was not statistically significant.

CONCLUSIONS

In the largest series of Caucasian patients with PCV presented to date, anti-VEGF monotherapy, PDT, or their combination preserved visual acuity and improved subfoveal exudative changes. Combination treatment was not superior to anti-VEGF monotherapy.

Association of Genes in the High-Density Lipoprotein Metabolic Pathway with Polypoidal Choroidal Vasculopathy in Asian Population: A Systematic Review and Meta-Analysis

Purpose

To assess the association of genes in the high-density lipoprotein metabolic pathway (HDLMP) with polypoidal choroidal vasculopathy (PCV) and the genetic difference in the HDLMP between PCV and age-related macular degeneration (AMD).

Methods

We performed a literature search in EMBASE, PubMed, and Web of Science for genetic studies on 7 single nucleotide polymorphisms (SNPs) from 5 genes in the HDLMP including cholesteryl ester transfer protein (CETP), hepatic lipase (LIPC), lipoprotein lipase (LPL), ATP-binding cassette transporter A1 (ABCA1), and ATP-binding cassette transporter G1 (ABCG1) in PCV. All studies were published before September 30, 2017, without language restriction. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) of each polymorphism were estimated. We also compared the association profiles between PCV and AMD and performed a sensitivity analysis.

Results

Our result is based on 43 articles. After excluding duplicates and articles without complete information, 7 studies were applicable to meta-analysis. 7 polymorphisms were meta-analyzed: CETP rs2303790/rs3764261, LIPC rs10468017/rs493258, LPL rs12678919, ABCA1 rs1883025, and ABCG1 rs57137919. We found that in Asian population, CETP rs3764261 (T allele; OR = 1.46; 95% CI: 1.28–1.665, P < 0.01), CETP rs2303790 (G allele; OR = 1.57; 95% CI: 1.258–1.96, P < 0.01), and ABCG1 rs57137919 (A allele; OR = 1.168; 95% CI: 1.016–1.343, P < 0.01) were significantly associated with PCV, and ABCG1 rs57137919 (A allele; OR = 1.208, 95% CI: 1.035–1.411, P < 0.01) has different effects in PCV and AMD. The other 4 polymorphisms in LIPC/LPL/ABCA1 had no significant association with PCV (P > 0.05). The sensitivity analysis validated the significance of our analysis.

Conclusions

Our study revealed 7 polymorphisms in 5 genes. Among them, CETP (rs3764261/rs2303790) and ABCG1 (rs57137919) were the major susceptibility genes for PCV in Asian population and ABCG1 (rs57137919) showed allelic diversity between PCV and AMD. Since the size for PCV and AMD was small, we need to study these genes genotyping in larger samples.

Management of recalcitrant polypoidal choroidal vasculopathy by feeder vessel laser photocoagulation

Purpose

To describe management of residual branch vascular network (BVN) in polypoidal choroidal vasculopathy (PCV) by thermal laser photocoagulation of feeder vessel.

Observations

Case report of sixty-four year old female with polypoidal choroidal vaculopathy (PCV) with moderate response to seven doses of intravitreal ranibizumab, six doses of intravitreal bevacizumab and one session of photodynamic therapy (PDT). The patient has resolved polyps but persistence of disease activity due to residual BVN and large pigment epithelial detachment (PED). Patient underwent thermal laser photocoagulation of feeder vessel of BVN identified on indocyanine green angiography (ICGA). There was complete resolution of residual BVN and large PED, which was confirmed on ICGA.

Conclusions and Importance

Recalcitrant cases of PCV without polyps but having BVN with feeder vessel can be managed by ICGA guided thermal laser photocoagulation. The case report illustrates the importance of utilizing multimodal imaging such as video indocyanine green angiography (ICGA) for identification of feeder vessel and its deployment for optimal management of refractory PCV.

Polypoidal Choroidal Vasculopathy Associated with Doyne'S Familial Choroiditis: Treatment with Thermal Laser

Purpose

To report the unusual occurrence of polypoidal choroidal vasculopathy (PCV) in a patient with Doyne's familial honeycomb choroiditis (DFHC) and its course after laser treatment.

DESIGN

Interventional case report.

METHODS

Indocyanine green (ICG) angiography guided laser was performed on active polypoidal lesions.

Results

A 45-year-old man with a 15-year history of bilateral DFCH and a scarred macular choroidal neovascularization in the right eye (RE) was referred to us with exudative maculopathy in the left eye (LE). His best-corrected visual acuity (BCVA) was 20/800 in the RE and 20/40 in the LE. ICG angiography revealed a picture that was characteristic for PCV in both eyes. ICG guided argon green laser was performed on the active parapapillary and perifoveal polypoidal lesions of the LE. Eight months after the laser photocoagulation treatment, the macular exudative lesions had subsided and the BCVA improved to 20/20. The favorable anatomic and functional results have remained stable over 3 years.

CONCLUSIONS

This is, to our knowledge, the first case of a PCV that occurred secondary to DFHC.

Comparison of two-year outcomes after photodynamic therapy with ranibizumab or aflibercept for polypoidal choroidal vasculopathy

Photodynamic therapy (PDT) combined with intravitreal anti-vascular endothelial growth factor (VEGF) agents is currently the first-line treatment for polypoidal choroidal vasculopathy (PCV), along with anti-VEGF monotherapy. In this study, 100 eyes with treatment-naïve PCV were initially treated with PDT combined with intravitreal ranibizumab (IVR; n = 57) or aflibercept (IVA; n = 43). We compared two-year outcomes between these two groups and investigated factors associated with visual improvement and retreatment over 24 months. Best-corrected visual acuity (BCVA) was significantly improved in both groups (P < 0.001) at 24 months. Multiple regression analysis revealed that visual improvement at 24 months was associated with female (P = 0.030), worse baseline BCVA (P = 3.0 × 10⁻⁶), smaller greatest linear dimension (GLD; P = 2.0 × 10⁻⁴), and treatment with IVA rather than IVR (P = 0.016). Multiple logistic regression analysis revealed that absence of retreatment was associated with younger age (P = 2.2 × 10⁻⁴), female (P = 1.2 × 10⁻³), and the non-risk variants of ARMS2 A69S (P = 6.0 × 10⁻⁴). Although there were no significant differences in the retreatment rate between the two groups, PDT/IVA may be superior to PDT/IVR in terms of visual improvement at 24 months.

Age-related macular degeneration: is polypoidal choroidal vasculopathy recognized and treated?

OBJECTIVE

To assess how polypoidal choroidal vasculopathy (PCV) is recognized and treated, and to assess whether treatment outcomes are different between Chinese and Caucasian Canadian patients with age-related macular degeneration (AMD).

DESIGN

Retrospective chart review.

PARTICIPANTS

154 eyes from 135 Chinese patients and 2291 eyes from 1792 Caucasian patients who were newly diagnosed with either AMD or PCV and had more than 1 year of follow-up were included.

METHODS

All newly diagnosed AMD patients presenting to the Retina Service of 3 Toronto University Hospitals, between March 25, 2008, to September 30, 2014, were reviewed.

RESULTS

10/154 eyes (6.5%) in Chinese Canadians and 16/2291 eyes (0.7%) in Caucasian Canadians were diagnosed as having PCV. Indocyanine green angiography (ICGA) was used to diagnose PCV in 20% of Chinese Canadians and 8.8% of Caucasian Canadians. Clinical practices with a larger percentage of Chinese patients were more likely to diagnose PCV in both Chinese (p = 0.004) and Caucasian patients (p = 0.03), were more likely to use photodynamic therapy (PDT) (p < 0.01), and had significantly greater central retinal thickness decrease (p < 0.001).

CONCLUSION

Our study has shown that PCV is under-recognized in a Canadian population, and ICGA is underutilized. In clinical practices with a greater portion of Chinese patients, PCV is more often recognized and PDT is used more liberally.

A genome-wide association study identified a novel genetic loci STON1-GTF2A1L/LHCGR/FSHR for bilaterality of neovascular age-related macular degeneration

Bilateral neovascular age-related macular degeneration (AMD) causes much more handicaps for patients than unilateral neovascular AMD. Although several AMD-susceptibility genes have been evaluated for their associations to bilaterality, genome-wide association study (GWAS) on bilaterality has been rarely reported. In the present study, we performed GWAS using neovascular AMD cases in East Asian. The discovery stage compared 581,252 single nucleotide polymorphisms (SNPs) between 803 unilateral and 321 bilateral Japanese cases but no SNP showed genome-wide significance, while SNPs at six regions showed P-value < 1.0 × 10⁻⁵, STON1-GTF2A1L/LHCGR/FSHR, PLXNA1, CTNNA3, ARMS2/HTRA1, LHFP, and FLJ38725. The first replication study for these six regions comparing 36 bilateral and 132 unilateral Japanese cases confirmed significant associations of rs4482537 (STON1-GTF2A1L/LHCGR/FSHR), rs2284665 (ARMS2/HTRA1), and rs8002574 (LHFP) to bilaterality. In the second replication study comparing 24 bilateral and 78 unilateral cases from Singapore, rs4482537 (STON1-GTF2A1L/LHCGR/FSHR) only showed significant association. Meta-analysis of discovery and replication studies confirmed genome-wide level significant association (P = 2.61 × 10⁻⁹) of rs4482537 (STON1-GTF2A1L/LHCGR/FSHR) and strong associations (P = 5.76 × 10⁻⁷ and 9.73 × 10⁻⁷, respectively) of rs2284665 (ARMS2/HTRA1) and rs8002574 (LHFP). Our GWAS for neovascular AMD bilaterality found new genetic loci STON1-GTF2A1L/LHCGR/FSHR and confirmed the previously reported association of ARMS2/HTRA1.

Polypoidal choroidal vasculopathy: a common type of neovascular age-related macular degeneration in Caucasians

AIMS

To describe the prevalence of polypoidal choroidal vasculopathy (PCV) in a Caucasian population with neovascular age-related macular degeneration (NAMD).

METHODS

All patients referred to a city AMD service over a 2-year period underwent imaging including Indocyanine Green Angiography at baseline. A panel of experts confirmed the patients with NAMD and diagnosed the lesion type including PCV. The proportion of Caucasian patients with PCV was identified. Two authors independently reviewed clinical imaging and recorded data of patients with PCV on lesion characteristics. Further information including treatments received and visual acuity at different time points was analysed.

RESULTS

A total of 492 patients were diagnosed with NAMD during the 2-year study period. Of these patients, 204 had occult lesions (41.5%). PCV was identified in 45 patients (22.1% of occult NAMD and 9.1% of all NAMD). 23 patients received anti-vascular endothelial growth factor (VEGF) monotherapy, 8 received verteporfin photodynamic therapy (PDT) monotherapy and the remaining 14 patients were managed with combined PDT and anti-VEGF treatment.

CONCLUSIONS

The prevalence of PCV in Caucasians is higher than previously reported. Indocyanine Green Angiography should be a standard investigation for all new patients with NAMD, particularly those with occult NAMD, to avoid missing this important subset.

Idiopathic polypoidal choroidal vasculopathy in Thai patients with clinical and angiographic choroidal neovascularization

OBJECTIVE

This study aimed to study the prevalence and characteristics of idiopathic polypoidal choroidal vasculopathy (IPCV) in Thai patients with clinical and angiographic choroidal neovascularization (CNV).

PATIENTS AND METHODS

A consecutive case study of 140 patients presenting with CNV was conducted in nine large referral eye centers throughout Thailand. The demographic data, fundus photographs, fundus fluorescein angiography and indocyanine green angiography of the patients were analyzed.

RESULTS

Of 129 patients with clinical and angiographic CNV, IPCV was diagnosed in 100 patients (77.52%), idiopathic CNVs in 16 patients (12.40%) and age-related macular degeneration (AMD) in 12 patients (9.30%). Of the 107 eyes with IPCV, 90 eyes (84.11%) had both branching venous networks (BVNs) and polypoidal lesions. Most IPCV patients (93%) had unilateral involvement and were at a younger age than AMD patients. In all, 79 eyes (73.83%) had lesions found in the macular area, 14 eyes (13.08%) in the temporal to vascular arcades, ten eyes (9.35%) in the peripapillary area and four eyes (3.74%) in both macular and peripapillary areas. The clinical manifestations of IPCV at presentation were categorized into two patterns. There were 95 eyes (88.79%) of a hemorrhagic pattern and 12 eyes (11.21%) of an exudative pattern.

CONCLUSION

IPCV is the most common macular disease in Thai patients with CNV. Most IPCVs have both BVNs and polypoidal lesions located in the macular area and present with a hemorrhagic pattern.

Characteristics of Neovascular Age-Related Macular Degeneration in Brazilian Patients

Purpose: To report features of neovascular age-related macular degeneration (AMD) in Brazilian patients. Procedures: Data were prospectively collected from patients diagnosed with neovascular AMD. Eyes were classified as having typical neovascular AMD, polypoidal choroidal vasculopathy (PCV), or retinal angiomatous proliferation (RAP). Results: In total, 265 eyes of 207 patients of predominantly Caucasian ancestry were included; 166 (62.6%) eyes had typical neovascular AMD, 65 (24.5%) eyes had PCV, and 34 (12.8%) eyes had RAP. RAP demonstrated a higher percentage of bilateral cases (p = 0.015). The mean foveal subfield thickness was significantly lower in eyes with PCV (p < 0.001). Cases with typical neovascular AMD had a higher percentage of predominantly classic and minimally classic lesions on fluorescein angiography (FA; p = 0.005). Conclusions: In Brazilian patients, PCV and RAP represented 24.5 and 12.8% of neovascular AMD cases. Neovascular AMD subtypes differ in relation to clinical features, mean foveal subfield thickness and FA presentation.

Subfoveal choroidal thickness in polypoidal choroidal vasculopathy after switching to intravitreal aflibercept injection

PURPOSE

To investigate the changes in subfoveal thickness after switching to intravitreal aflibercept injection for polypoidal choroidal vasculopathy (PCV).

METHODS

We retrospectively reviewed 66 eyes of 65 PCV patients (mean age 75.7 years) which were refractory to ranibizumab. The choroidal thickness was measured by optical coherence tomography (OCT) using an enhanced depth imaging technique. Intravitreal aflibercept (2 mg/0.05 ml) was administered with three consecutive monthly injections as a loading dose, followed by further injections bimonthly (every two months).

RESULTS

The mean subfoveal choroidal thickness significantly decreased from 203 μm at baseline to 171 μm at month 6 (P < 0.0001). The mean logMAR best-corrected visual acuity levels significantly improved from 0.40 at baseline to 0.33 at 6 months (P < 0.001). The central retinal thickness significantly decreased from 249 μm at baseline to 161 μm at 6 months (P < 0.0001). At month 6, 41 (62.1%) eyes had dry macula by OCT. Of 46 eyes with polypoidal lesions at baseline, complete regression of polypoidal lesions was achieved in 26 (56.5%) eyes at 3 months.

CONCLUSIONS

The choroidal thickness in PCV eyes significantly decreased after switching to intravitreal aflibercept injection. Aflibercept may help prevent choroidal neovascularization near or under the retinal pigment epithelium, which might help achieve greater occlusion of polypoidal lesions compared with ranibizumab.

Polypoidal choroidal vasculopathy in white patients

PURPOSE

To report on a series of white patients in the United States with polypoidal choroidal vasculopathy (PCV).

METHODS

This is a retrospective chart review of 27 patients at a single center with PCV.

RESULTS

The mean age was 74.3 with 48% being male. The most common presenting diagnosis was exudative age-related macular degeneration in 59%, and it took 17.5 months to diagnose PCV. During this time, patients received one antivascular endothelial growth factor injection every 1.3 months. The most common reason for suspecting PCV was a large retinal pigment epithelial detachment or a poor response to antivascular endothelial growth factor therapy. Once PCV was diagnosed, most underwent photodynamic therapy. In those who received photodynamic therapy, the fluid and/or age-related macular degeneration decreased in 86%. The vision improved in 41% with 36% maintaining stable vision. Patients received only one additional injection every 3.95 months after photodynamic therapy.

CONCLUSION

This is one of the larger series of PCV in an entirely white population. It emphasizes the importance of diagnosis in whites as PCV can masquerade as recalcitrant exudative age-related macular degeneration. Common findings were a temporal or peripapillary location and the presence of lipid. After photodynamic therapy, the patients still required antivascular endothelial growth factor therapy, but the injection burden was decreased by 67% and vision was found to be improved or maintained in 77% of patients.

Switching to intravitreal aflibercept injection for polypoidal choroidal vasculopathy refractory to ranibizumab

PURPOSE

To clarify the efficacy of switching to intravitreal aflibercept injection to treat polypoidal choroidal vasculopathy refractory to ranibizumab.

METHODS

In this retrospective study, 43 eyes of 42 patients (mean age, 76.5 years) with polypoidal choroidal vasculopathy treated with aflibercept (2 mg/0.05 mL) were reviewed. A treatment history of 3 consecutive monthly intravitreal injections of ranibizumab as an induction phase followed by a pro re nata maintenance phase over 12 months was seen for all patients. All patients who were refractory to ranibizumab (defined as having persist subretinal or intraretinal fluid by optical coherence tomography and unchanged or decreased visual acuity compared with the time of the first ranibizumab injection, despite receiving the last 3 consecutive monthly intravitreal ranibizumab injections after 12 months).

RESULTS

The mean logarithm of the minimum angle of resolution best-corrected visual acuity levels (Snellen equivalent) improved significantly (P = 0.0074) from 0.38 (20/48) at baseline to 0.34 (20/43) 3 months after switching to aflibercept (Month 3) (mean best-corrected visual acuity improvement, 0.47 line). The central retinal thickness decreased significantly (P < 0.0001) from 245 μm at baseline to 131 μm at Month 3. Of 30 eyes with polypoidal lesions at baseline, the polypoidal lesions regressed completely in 15 eyes (50%) at Month 3.

CONCLUSION

Administering intravitreal aflibercept injection for patients with polypoidal choroidal vasculopathy refractory to ranibizumab maintained or improved visual acuity and reduced or eliminated exudative lesions and occluding polypoidal lesions without adverse events with short-term follow-up.

Prognostic phenotypic and genotypic factors associated with photodynamic therapy response in patients with age-related macular degeneration

BACKGROUND

This study aimed to demonstrate the phenotypic and genotypic factors associated with photodynamic therapy (PDT) for age-related macular degeneration (AMD).

METHODS

The study included 149 patients with exudative AMD treated by PDT. Eight phenotypic factors and ten genotypic factors for three single nucleotide polymorphisms (SNPs; rs800292, rs1061170, rs1410996) in the complement factor H (CFH) gene, rs 11200638-SNP in the high temperature requirement A-1 (HTRA1) gene, two SNPs (rs699947, rs2010963) in the vascular endothelial growth factor (VEGF) gene, and four SNPs (rs12948385, rs12150053, rs9913583, rs1136287) in the pigment epithelium-derived factor (PEDF) gene were evaluated.

RESULTS

A significant association with best-corrected visual acuity change was demonstrated in the greatest linear dimension, presence or absence of pigment epithelial detachment, and HTRA1-rs11200638 genotype statistically (P=3.67×10(-4), 1.95×10(-2), 1.24×10(-3), respectively). Best-corrected visual acuity in patients with AA genotype of HTRA1-rs11200638 significantly decreased compared with that in patients with GG genotype (P=1.33×10(-3)). Logistic regression analyses demonstrated HTRA1-rs11200638 genotype was most strongly associated with best-corrected visual acuity outcome from baseline at 12 months after photodynamic therapy (P=4.60×10(-3); odds ratio 2.363; 95% confidence interval 1.303-4.285).

CONCLUSION

The HTRA1-rs11200638 variant showed the most significant association. Therefore, this variant may be used as a prognostic factor to estimate the PDT response with significant predictive power.

Treating the untreatable patient: current options for the management of treatment-resistant neovascular age-related macular degeneration

Anti-vascular endothelial growth factor (anti-VEGF) agents represent the current standard of care for neovascular age-related macular degeneration (nAMD). Although effective in a majority of cases, a significant proportion of patients have persisting retinal exudation despite regular anti-VEGF therapy. This exudation is considered to produce poorer visual outcomes in these patients. Some of these patients may have misdiagnosed nAMD variants such as polypoidal choroidal vasculopathy; however, the majority of these eyes have what has been termed treatment-resistant nAMD. Currently, the best way to care for these patients is uncertain. Here, we review the evidence for different approaches to the management of treatment-resistant nAMD, including high-dose anti-VEGF therapy, combination regimes and switching of anti-VEGF agents, and discuss possible therapeutic approaches for patients with treatment-resistant nAMD.

Early signs of exudative age-related macular degeneration in Asians

Supplemental digital content is available in the text.

Purpose

To investigate the relationship between the early signs of age-related macular degeneration (AMD) and the risk of developing exudative AMD (typical AMD or polypoidal choroidal vasculopathy [PCV]) in the fellow eye of Japanese patients with unilateral exudative AMD, focusing particularly on eyes with only pigmentary abnormality.

Methods

This study is a retrospective observational consecutive case series. We retrospectively reviewed the medical charts of patients who revisited the AMD clinic from 2010 to 2011 and confirmed 129 cases with unilateral exudative AMD at their first visit (baseline). The non-affected eyes at baseline (the second eye) were categorized by the presence of early signs of AMD. The incidence of exudative AMD (typical AMD or PCV) in the fellow eye was confirmed by fluorescein and indocyanine green angiography.

Results

Of the 129 patients, 14 (10.9%) developed exudative AMD in the fellow eye (median follow-up, 3.2 years; n = 7 typical AMD and n = 7 PCV). Eyes with both pigmentary abnormalities and large drusen were more likely to develop typical AMD (age- and sex-adjusted odds ratio = 9.46, 95% confidence interval = 1.05 to 85.0), whereas pigmentary abnormalities without large drusen were associated with PCV (age- and sex-adjusted odds ratio = 15.9, 95% confidence interval = 1.8 to 140.5).

Conclusions

There was a difference in the association between early signs of AMD and incident development of either typical AMD or PCV. Further research is warranted to determine whether pigmentary abnormalities alone may be an important risk factor for PCV in Asians.

Comparison of exudative age-related macular degeneration subtypes in Japanese and French Patients: multicenter diagnosis with multimodal imaging

PURPOSE

To compare and analyze differences and similarities between Japanese and French patients in subtype diagnosis of exudative age-related macular degeneration (AMD) as determined by fundus photography (FP) and fluorescein angiography (FA), and a multimodal imaging involving FP, FA, indocyanine green angiography (ICGA), and optical coherence tomography (OCT).

DESIGN

Retrospective chart review.

METHODS

We determined the subtype diagnosis for 99 consecutive Japanese eyes and 94 consecutive French eyes with exudative AMD. The first-step diagnosis was made using FP and FA, while the second-step diagnosis was made using FP, FA/ICGA, and OCT. The diagnoses made by Japanese and French physicians were compared, and when the diagnoses differed, a third institute was consulted to arrive at a final consensus and diagnosis.

RESULTS

The first-step diagnosis showed 20%-30% disagreement against the final diagnosis, but the second-step diagnosis showed only 10% disagreement. Polypoidal choroidal vasculopathy (PCV) was observed more in Japanese patients (48%) than in French (9%), and the rate of PCV with type 1 or 2 choroidal neovascularization (CNV) was extremely low: 3% in Japanese and 0% in French. Type 1 CNV was found significantly more in French cases (53.3% vs 35.1%, P=.018), while the rate of eyes with type 2 CNV only or chorioretinal anastomosis was similar between populations.

CONCLUSIONS

Multimodality imaging significantly improved the sub-classification of AMD. There were significant differences between the 2 series in the proportions of type 1 CNV and PCV, while the proportions of type 2 CNV only and chorioretinal anastomosis were similar between groups.

Prevalence and characteristics of age-related macular degeneration in the Japanese population: the Nagahama study

PURPOSE

To estimate the age- and sex-specific prevalence of early age-related macular degeneration (AMD; drusen and retinal pigment abnormalities) and late AMD (exudative AMD and geographic atrophy) in the Japanese population.

DESIGN

Community-based, cross-sectional study.

METHODS

The study was held in Nagahama, Japan, and included 6065 Japanese individuals (aged ≥50 years) recruited in 2008-2010. We graded fundus photographs of both eyes for the AMD phenotype based on drusen size, the presence of retinal pigment abnormalities, and late AMD. The associations between smoking and AMD phenotypes were also evaluated.

RESULTS

We assessed 5595 subjects (women, 65%) with a gradable macular condition. Early and late AMD prevalence increased from 16.1% and 0.27% at 50-59 years to 31.2% and 0.98%, respectively, at 70-74 years and was predominant in male subjects in each age group. Smoking was associated with both early and late AMD stages and retinal pigment abnormalities (P < .0001), but not with drusen (P = .305). The prevalence of retinal pigment abnormalities was significantly higher in men (P < .0001), which was associated with high rates of cigarette smoking. We found no sex difference for the prevalence of large drusen (P = .264).

CONCLUSIONS

The prevalence of early AMD among adult Japanese persons was similar to the rates in white populations. The prevalence of late AMD in Japanese people aged <70 years was similar to that observed in white populations, whereas that in Japanese people aged ≥70 years was relatively lower.

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.

Two-year results of intravitreal ranibizumab for polypoidal choroidal vasculopathy with recurrent or residual exudation

AIM

To clarify the 2-year efficacy of ranibizumab for patients with polypoidal choroidal vasculopathy (PCV) with recurrent or residual exudation from branching vascular networks after previous photodynamic therapy (PDT).

METHODS

We retrospectively reviewed 26 eyes of 26 Japanese patients (22 men, 4 women) in this pilot study. All eyes had PCV with complete regression of polypoidal lesions resulting from PDT detected by indocyanine green angiography (ICGA), but recurrent or residual leakage from branching vascular networks on fluorescein angiography and evidence of persistent fluid on optical coherence tomography (OCT). Three consecutive intravitreal injections of ranibizumab (0.5 mg/0.05 ml) were administered to all eyes.

RESULTS

The mean logarithm of the minimum angle of resolution best-corrected visual acuity (BCVA) improved significantly from 0.55 at baseline to 0.35 at 12 months (P<0.0001) and 0.43 at 24 months (P=0.0012). The mean increases in the BCVA 12 and 24 months after baseline were 1.95 and 1.23 lines, respectively. The mean central retinal thickness significantly decreased from 295 μm at baseline to 189 μm at 12 months (P<0.0038) and 163 μm at 24 months (P<0.001). The mean numbers of intravitreal ranibizumab (IVR) injections at months 12 and 24, including the initial treatments, were 5.8 and 8.8, respectively. Five (19.2%) eyes had recurrent polypoidal lesions on ICGA at a mean of 15.7 months after baseline. At month 24, OCT showed no exudation in 17 (65.4%) of the 26 eyes. No adverse events developed.

CONCLUSIONS

IVR injections maintained or improved the VA and retinal thickness at 24 months in eyes with PCV with recurrent or residual exudation from branching vascular networks after previous PDT.

Argon laser with and without anti-vascular endothelial growth factor therapy for extrafoveal polypoidal choroidal vasculopathy

PURPOSE

To describe the clinical characteristics and outcome of eyes with extrafoveal polypoidal choroidal vasculopathy (PCV) treated with argon laser.

DESIGN

Prospective cohort, noninterventional study.

METHODS

A prospective study of Asian patients with extrafoveal PCV, confirmed on indocyanine green angiography and treated with argon laser with and without anti-vascular endothelial growth factor (VEGF) therapy. Patients were followed-up over 12 months with visual, angiographic, and structural outcomes recorded.

RESULTS

Of the 93 eyes with PCV at baseline, 33 eyes (35.5%) in 31 patients had extrafoveal involvement and were treated with argon laser. Foveal involvement with fluid or blood at baseline was apparent in 23 eyes (69.7%), despite the extrafoveal location of 1 or more polyps. Of these 33 eyes, 12 (36.4%) also received anti-VEGF injections (median, 2.5 injections) over the 12-month period. Two eyes received photodynamic therapy rescue during subsequent follow-up and were excluded for visual outcome analysis. In the remaining 31 eyes, mean visual acuity improved from 0.57 logarithm of the minimal angle of resolution (logMAR) units (range, 0.00 to 2.0 logMAR; standard deviation, 0.51 logMAR) at baseline to 0.39 logMAR (range, 0.00 to 2.0 logMAR; standard deviation, 0.43 logMAR) at month 12 (P = .01), with a mean gain in visual acuity of 9.0 letters at month 12. Stable or improved vision (defined as losing 5 letters or fewer) was achieved in 28 eyes (90.3%). Use of anti-VEGF was associated with significantly thicker central subfield at baseline (347.6 vs 258.1 μm; P = .02) and resulted in similar vision and OCT results at month 3 and 12 compared with eyes that did not receive anti-VEGF.

CONCLUSIONS

Argon laser treatment with selected use of anti-VEGF therapy achieves stable or improved visual outcome in most eyes with extrafoveal PCV, including eyes with fluid or blood affecting the fovea at presentation.

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.