EVEREST study report 4: Fluorescein angiography features predictive of polypoidal choroidal vasculopathy

Different Morphology of Branching Neovascular Network in Polypoidal Choroidal Vasculopathy: A Swept-Source Optical Coherence Tomography Angiography Study

Purpose: To evaluate the classification system of branching neovascular network (BNN) morphology in polypoidal choroidal vasculopathy (PCV) patients based on swept-source optical coherence tomography (SS-OCT) and swept-source optical coherence tomography angiography (SS-OCTA), and analyze the morphological features in each group as potential prognostic features. Methods: A total of 32 PCV eyes were included in this retrospective study. SS-OCT and SS-OCTA images of 6 mm × 6 mm centered on the foveal of each eye were analyzed. PCV cases were classified into three types ("trunk", "glomeruli", and "stick" type) based on the morphological features of BNN. OCT and OCTA features were compared among the three groups. The correlation of OCT/OCTA features with visual acuity at 12 months after anti-VEGF treatment was also analyzed. Results: Type 1 group had the largest BNN area and the largest numbers of polypoidal lesions. Type 2 group has the largest pigment epithelial detachment (PED) area, PED volume, subretinal fluid (SRF) area, and SRF volume. Type 3 group had better baseline BCVA, the smallest BNN area, the smallest PED size, and the smallest SRF size. Type 1 was also featured by a clear break on Bruch's membrane which corresponded to the origin of neovascular tissue. BCVA at 12 months was not significantly different among groups. Baseline BCVA and baseline central macular thickness were correlated with the final BCVA. Conclusions: The current classification system based on BNN morphology on SS-OCTA was highly applicable and revealed distinct characteristics in each group. The BNN type was not correlated with BCVA at 12 months after treatment.

Clinical features and prognosis of polypoidal choroidal vasculopathy with different morphologies of branching vascular network on optical coherence tomography angiography

This study highlights the clinical features and treatment response of polypoidal choroidal vasculopathy (PCV) among three different branching vascular network (BVN) morphologies in optical coherence tomography angiography (OCTA), and further correlates the BVN features with those under fluorescent angiography (FA) and indocyanine green angiography (ICGA). In total, we reviewed 70 eyes with PCV followed up for > 12 months. OCTA, ICGA and FA images were obtained at baseline and post-treatments. BVN was assessed using OCTA and divided into three types by a previously described BVN classification: type 1 (trunk), type 2 (glomeruli), and type 3 (stick). At baseline, type 1 BVN had the poorest vision and thinnest subfoveal choroidal thickness (SFCT), whereas type 3 had the best vision and thickest SFCT. The aforementioned trend sustained after treatments. Each BVN morphology in OCTA showed typical features in FA + ICGA and encompassed significant correlation (p = 0.004). In conclusion, OCTA is an innovative imaging tool for the detection and classification of BVN in PCV. Furthermore, OCTA has advantages of being noninvasive and free of systemic toxicities. The BVN can be divided into three types based on morphological characteristics in OCTA, which play crucial roles in clinical presentations and treatment outcomes.

Comparison of Polypoidal Choroidal Vasculopathy Lesion Sizes Measured on Multicolor Imaging and Indocyanine Green Angiography

Purpose

To evaluate the areas of lesion components of polypoidal choroidal vasculopathy (PCV) measured using multicolor imaging compared to indocyanine green angiography (ICGA).

Methods

In a prospective study of 50 consecutive treatment-naïve PCV patients, multicolor imaging and ICGA were performed. The images were independently graded by reading center-certified retinal specialists to confirm the diagnosis of PCV and identify lesion components. The areas of the respective lesion components were compared.

Results

The mean age of the participants was 67.8 years. PCV was diagnosed in 96% of eyes using multicolor imaging. The mean numbers of polypoidal lesions identified using ICGA and multicolor were 4.0 and 2.1, respectively (P < 0.001), with mean total polypoidal lesion areas of 0.32 mm² versus 0.30 mm² (P = 0.727). The area of the branching vascular network (BVN) on ICGA was 7.8 mm² compared to 5.7 mm² on multicolor imaging (P = 0.289). Patients with four or more polypoidal lesions on ICGA had larger differences in total lesion area between ICGA and multicolor imaging (4.07 vs. –0.70 mm², p = 0.039). Those with total lesion area ≥ 2.0 mm² on ICGA had larger differences in mean polypoidal lesion number compared to those with smaller areas (2.2 vs. 0.5; P = 0.026).

Conclusions

Multicolor imaging is a useful, noninvasive adjunct for detecting PCV lesion components, revealing lesion areas similar to but generally smaller than those seen on ICGA. This is important to consider when making treatment decisions with different imaging modalities

Translational Relevance

New features seen on multicolor imaging can aid in the diagnosis and treatment of PCV.

A Comparison Study of Polypoidal Choroidal Vasculopathy Imaged with Indocyanine Green Angiography and Swept-Source Optical Coherence Tomography Angiography

PURPOSE

Indocyanine green angiography (ICGA) was compared with swept-source optical coherence tomography angiography (SS-OCTA) for the detection of polypoidal choroidal vasculopathy (PCV).

DESIGN

Retrospective, cross-sectional.

METHODS

Patients with treatment-naïve PCV based on ICGA imaging underwent same-day SS-OCTA imaging at Kyung Hee University Medical Center between April 2017 and November 2018. ICGA and SS-OCTA images were graded independently. SS-OCTA images were graded using both flow and structural information. Images were graded for the number of polypoidal lesions and the total lesion area, which included both the polypoidal lesions and the branching vascular networks (BVNs).

RESULTS

A total of 31 eyes from 30 patients were enrolled. Polypoidal lesions were identified in all eyes using both modalities, and there was agreement on the number of polypoidal lesions in 17 eyes (55%). In 12 eyes (39%), SS-OCTA graders identified a greater number of polypoidal lesions, and in 2 eyes (6%) ICGA graders identified more lesions. There was no significant difference in the lesion area measurements (standard deviation = 1.09, P = .08). The lesion with the largest difference in area measurements resulted from focal areas of atrophy, misdiagnosed as polypoidal lesions on ICGA, and a low-lying serous retinal pigment epithelial detachment erroneously identified as part of the BVN by ICGA graders. SS-OCTA imaging correctly diagnosed the focal areas of atrophy and the serous retinal pigment epitheial detachment.

CONCLUSIONS

SS-OCTA imaging was comparable to ICGA for the diagnosis of treatment-naïve PCV. However, SS-OCTA might be better than ICGA in correctly identifying both polypoidal lesions and BVNs in treatment-naïve PCV.

Predictors of persistent disease activity following anti-VEGF loading dose for nAMD patients in Singapore: the DIALS study

Background

To determine the frequency of persistent disease activity following 3 loading doses of anti- vascular endothelial growth factor (VEGF) agents, and the anatomic and demographic predictors of early persistent disease activity among patients with neovascular age-related macular degeneration (nAMD).

Methods

In a retrospective real-world cohort study, 281 consecutive patients with nAMD were reviewed at baseline and after 3 anti-VEGF injections for pre-defined indicators of disease activity. Optical coherence tomography (OCT) features such as subretinal fluid, intraretinal cysts and intraretinal fluid were assessed by reading-center certified graders. Multiple logistic regression was performed on demographic and anatomic factors.

Results

At month 3, 66.1% of patients had persistent disease activity. The best-corrected visual acuity (BCVA) improvement was 0.16 LogMAR for those with no disease activity compared to 0 for patients with persistent activity (p < 0.001). The significant risk factors for persistent activity at 3 months were male gender (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.32–0.93, p = 0.025), intraretinal cysts at baseline (OR 2.95, 95% CI 1.67–5.20, p < 0.001) and subretinal fluid at baseline (OR 3.17, 95% CI 1.62–6.18, p = 0.002). At 3 months, 58% of patients had features of activity on OCT. Patients with intraretinal cysts and intraretinal fluid at baseline had worse BCVA at month 3 compared to patients without these OCT features (0.69 vs. 0.43, p < 0.001, and 0.62 vs. 0.43, p < 0.001, respectively).

Conclusions

In a real-world study, 66.1% of nAMD patients have persistent disease activity after the initial loading dose, with poorer BCVA compared to those without. Baseline OCT features (intraretinal cysts and subretinal fluid) are useful predictors of persistent disease activity at month 3.

EVEREST study report 4: Fluorescein angiography features predictive of polypoidal choroidal vasculopathy

Importance

It is important to identify features of polypoidal choroidal vasculopathy (PCV) that differentiate it from typical neovascular age‐related macular degeneration (nAMD) on various imaging modalities, including fluorescein angiography (FA).

Background

PCV was thought to be indistinguishable from nAMD using FA alone. In real‐world practice, indocyanine‐green angiography may often be unavailable or contraindicated.

Design

Analysis of FA images from a prospective, multicentre study.

Participants

Study images of both PCV and nAMD patients from the EVEREST study.

Methods

FA features at baseline were independently graded by masked graders (fellowship‐trained ophthalmologists) using standardized diagnostic algorithms.

Main Outcome Measures

Predictive indicators (sensitivity, specificity, positive and negative predictive values) for PCV.

Results

Of the 95 patients screened, 61 had PCV. Of the 34 screening failures, 15 were diagnosed as nAMD. Hyperfluorescent nodules on FA were observed in 80% of patients with PCV vs 20% with nAMD (P < 0.001). Blocked fluorescence on FA, which corresponded to the presence of subretinal haemorrhage, occurred more frequently among patients with PCV vs nAMD (61.7% vs 13.3%, P = 0.001). Similarly, the leakage characteristic of occult choroidal neovascularization occurred more frequently among patients with PCV vs nAMD (95.0% vs 73.3%, P = 0.026). The positive predictive value for PCV was 94.1% for hyperfluorescent nodules, 94.9% for blocked fluorescence, 83.8% for occult choroidal neovascularization and 82.0% for pigment epithelial detachment.

Conclusions and Relevance

This study demonstrated that certain FA features can be predictive of PCV and may be considered as an indication for retina specialists to perform indocyanine green angiography as confirmatory test.