The origins of polypoidal choroidal vasculopathy

IMAGING AND CLINICAL FEATURES OF PULSATILE POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To investigate the imaging and clinical features of polypoidal choroidal vasculopathy (PCV) with pulsation.

METHODS

The PCV eyes were classified into pulsatile and nonpulsatile PCV groups according to the pulsation on indocyanine green angiography. Imaging features including the dye filling time of the polyp and clinical features were compared.

RESULTS

A total of 75 eyes were classified into the pulsatile PCV (30 eyes) and the nonpulsatile PCV (45 eyes) groups. The initial filling time and complete filling time of the polyp of the pulsatile PCV group (2.59 ± 0.93 and 8.33 ± 3.42 seconds) were shorter than those of the nonpulsatile PCV group (4.11 ± 1.87 and 10.63 ± 3.81 seconds, P < 0.001 and P = 0.010, respectively). The pigment epithelial detachment height of the pulsatile PCV group (414.90 ± 377.15 µ m) was greater than that of the nonpulsatile PCV group (247.81 ± 164.07 µ m, P = 0.030). The pulsatile PCV group showed a higher prevalence of subretinal hemorrhage (43.33%) after intravitreal injection than the nonpulsatile PCV group (13.95%, P = 0.005) during 12 months. The mean number of injections during 12 months of the pulsatile PCV group (5.48 ± 1.46) was greater than that of the nonpulsatile PCV group (4.09 ± 1.21, P < 0.001).

CONCLUSION

Eyes with pulsatile PCV showed shorter filling time of the polyp, greater pigment epithelial detachment height, higher prevalence of subretinal hemorrhage, and more intravitreal injection numbers during 12 months. These might suggest that PCV has distinct imaging and clinical features according to the polyp pulsation.

Association between the arm-to-choroidal circulation time and clinical profile in patients with polypoidal choroidal vasculopathy

PURPOSE

To investigate the association between the arm-to-choroidal circulation time (ACT) on indocyanine green angiography (IA) and clinical profile in patients with polypoidal choroidal vasculopathy (PCV).

STUDY DESIGN

Single-center retrospective study.

METHODS

We included 38 eyes of 38 patients with PCV diagnosed using multimodal imaging and did not undergo previous treatment. All patients were treated with monthly aflibercept injections for 3 months and treat-and-extend regimens for the subsequent 12 months. Posterior vortex vein ACT was assessed on the first visit using Heidelberg IA. The patients were divided into two groups: ACT ≥20 s (L group; eight eyes) and ACT <20 s (S group; 30 eyes). The clinical profiles before and after treatment were analyzed to assess associations with ACT.

RESULTS

The mean ACT was 16.39±3.3 s (L group: 21.25±1.49 s, women:men=2:6, mean age: 77.3±6.5 years; S group: 15.10±2.17 s, women:men=7:23, mean age: 75.5±6.9 years). No significant difference was observed in the mean subfoveal choroidal thickness between the L and the S groups (176±75 μm vs. 230±79 μm, P=0.10). However, there were significant differences between the L and S groups in retinal fluid accumulation and hemorrhage recurrence (eight/eight eyes, 100% vs. 13/30 eyes, 43%, P<0.001), mean aflibercept injections (8.8±1.6 vs. 7.0±1.6, P<0.01) during the 12-month period, and the number of polypoidal lesions (1.8±0.7 vs. 1.3±0.5, P<0.05).

CONCLUSION

Patients with PCV and ACT >20 s are more likely to experience exudative change recurrence in the retina during treatment because they have more polypoidal lesions.

Macular neovascularization and polypoidal choroidal vasculopathy: phenotypic variations, pathogenic mechanisms and implications in management

Advances in imaging have led to improved ability to characterize variations in clinical sub-phenotypes of macular neovascularization (MNV) in Age-related macular degeneration (AMD). Polypoidal choroidal vasculopathy (PCV) was initially described based on characteristic features observed in indocyanine green angiography (ICGA) and was thought to be a distinct entity from AMD. However, subsequent careful observations based on confocal scanning laser ophthalmoscopy-based ICGA, optical coherence tomography (OCT) and OCT angiography have led researchers to appreciate similarities between PCV lesion and type 1 MNV in typical neovascular AMD. Concurrently, clinical trials have shown that anti-VEGF monotherapy can achieve favourable visual outcome in the majority of eyes with PCV. These learnings have led to a shift in the way PCV is managed over the past decade. Recent studies have supported the use of non-ICGA based imaging modality to screen for PCV and the adoption of anti-VEGF monotherapy as initial therapy for PCV. A focus of recent research has been in the understanding of the role of choroidal alterations in the pathogenesis of PCV. The concept of pachychoroid in leading to outer retinal ischemia has garnered increasing support. Future research in this area should evaluate the potential of choroidal morphology in guiding personalized therapy in PCV.

Polypoidal Choroidal Vasculopathy: Evaluation Based on 3-Dimensional Reconstruction of OCT Angiography

OBJECTIVE

Three-dimensional (3D) reconstruction using swept-source OCT angiography (SS-OCTA) can provide insights into the nature and structure of polypoidal choroidal vasculopathy (PCV) and its component parts, the polypoidal lesion (PL) and the branching neovascular network (BNN). This study aims to describe novel observations of PCV using 3D reconstruction of SS-OCTA, and to compare these observations with similar images of type I macular neovascularization (MNV) typical neovascular age-related macular degeneration (nAMD).

DESIGN

Clinical case series.

SUBJECTS

Patients with PCV in either eye from clinical studies conducted in a tertiary retina center.

METHODS

Images with prespecified SS-OCTA imaging protocol were obtained and reconstructed in 3D. Forty neovascularization lesions (30 PCV and 10 typical nAMD) based on SS-OCTA were analyzed.

MAIN OUTCOME MEASURES

The following 3 specific features were evaluated: (1) the pattern of flow signal within the PLs as either homogenous or showing internal vascular architecture; (2) the configuration of the BNN as hypermature, mature, or immature; and (3) the spatial arrangement of the PLs in relation to the BNN. Comparisons were made between PCV and typical nAMD.

RESULTS

All PLs exhibited internal vascular architecture in the form of coil-like loops and none exhibited homogenous flow. Small focal nodules were present within this internal vascular architecture in 70% of PLs. Branching neovascular networks exhibited a hypermature/mature configuration (100 vs. 50%, P < 0.01) and were associated with thicker choroid compared with typical nAMD type 1 MNV (238.7 ± 104.3 vs. 155.6 ± 49.2, P = 0.02). The BNN and PL were located at distinct anteroposterior planes in 81% of the eyes.

CONCLUSIONS

We identified proliferating vasculature in both the PL and the BNN. Comparison of the configuration suggests that the BNN represents a more chronic and inactive lesion than the PL.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Recent Advances in Imaging Polypoidal Choroidal Vasculopathy with Swept-Source Optical Coherence Tomography Angiography

The gold standard for polypoidal choroidal vasculopathy (PCV) diagnosis is indocyanine green angiography (ICGA), but optical coherence tomography angiography (OCTA) has shown promise for PCV imaging in recent years. However, earlier generations of OCTA technology lacked the diagnostic efficacy to replace ICGA. Swept-source optical coherence tomography angiography (SS-OCTA), the latest generation of OCTA technology, has significantly improved penetrating ability, scanning speed, scanning range, and overall image quality compared with earlier generations of OCTA. SS-OCTA reveals a "tangled vasculature" pattern of polypoidal lesions (PLs), providing evidence that they are neovascular rather than aneurysmal structures. New choroidal biomarkers, such as the choriocapillaris flow void (FV), have been identified to explain the development of PCV lesions. Although no direct comparison between SS-OCTA and previous OCTA generations in terms of diagnostic capability has been performed, SS-OCTA has shown several advantages in differential diagnosis and monitoring early reactivation for PCV. These improvements make SS-OCTA a valuable tool for PCV diagnosis and follow-up, and it may become more important for this disease in the future. This review summarized recent advances in PCV morphology and structure, as well as the possible pathogenesis based on SS-OCTA findings. The value of SS-OCTA for PCV management is discussed, along with remaining issues, to provide an updated understanding of PCV and OCTA-guided management.

Submacular Hemorrhages Show No Significant Seasonal Variations in a European Cohort

The aim of the article is to investigate the seasonality of acute submacular hemorrhages (SMHs) in a European population and analyze the influence of the seasons, arterial hypertension, and intake of anticoagulatory/antiplatelet (AC/AP) medication on hemorrhage size. This retrospective, monocentric study included 164 eyes of 164 patients treated for acute SMH at the University Hospital Münster, Germany, between 1 January 2016 and 31 December 2021. Data on the day of occurrence, hemorrhage size, and general patient characteristics were recorded. "Test for cyclic trends in incidence data" and the Chi-Square Test were applied to investigate seasonal variations in SMH incidence. Fisher's exact test was used to investigate the influence of the seasons, arterial hypertension, and intake of AC/AP medication on hemorrhage size. A statistical analysis did not reveal significant seasonal variations in the occurrence of SMHs (p = 0.81). While the seasons and the presence of systemic arterial hypertension did not exert a significant influence, the intake of AC/AP medication significantly affected the size of SMH (p = 0.03). In this European cohort, no significant seasonal variations of SMHs were observed. However, in patients with risk factors, such as neovascular age-related macular degeneration (nAMD), the chance of an increase in hemorrhage size should be considered when initiating AC/AP therapy.

A Comparative Study of Choroidal Vascular and Structural Characteristics of Typical Polypoidal Choroidal Vasculopathy and Polypoidal Choroidal Neovascularization: OCTA-Based Evaluation of Intervortex Venous Anastomosis

BACKGROUND

The aim of this study was to compare the choroidal characteristics of typical polypoidal choroidal vasculopathy (T-PCV) and polypoidal choroidal neovascularization (P-CNV) cases, and to investigate the presence of intervortex venous anastomoses in these PCV subtypes by using en face optical coherence tomography angiography (OCTA).

METHODS

A total of 35 eyes of 33 PCV cases were included. The PCV cases were divided into T-PCV and P-CNV groups. The choroidal vascularity index (CVI) was calculated. En face OCTA images were evaluated for the presence of intervortex venous anastomoses. The diameter of the largest anastomotic Haller vessel was measured.

RESULTS

T-PCV cases had significantly higher mean CVI values (73.9 ± 3.7 vs. 70.8 ± 4.5%) than P-CNV cases (p = 0.039). Intervortex venous anastomoses were observed in 85.7% of T-PCV eyes and in 91.7% of P-CNV eyes on en face OCTA (p = 1.000). In the cases with intervortex venous anastomosis, the mean diameter of the largest anastomotic vessel on en face OCTA was 341.2 ± 109.1 µm in the T-PCV and 280.4 ± 68.4 µm in the P-CNV group (p = 0.048).

CONCLUSIONS

The higher CVI value in T-PCV may be an important feature concerning the pathogenesis and classification of PCV. Although there was no difference between the two subtypes in terms of intervortex anastomosis, more dilated anastomotic vessels were observed in the T-PCV.

Single-Cell Transcriptome of Wet AMD Patient-Derived Endothelial Cells in Angiogenic Sprouting

Age-related macular degeneration (AMD) is a global leading cause of visual impairment in older populations. ‘Wet’ AMD, the most common subtype of this disease, occurs when pathological angiogenesis infiltrates the subretinal space (choroidal neovascularization), causing hemorrhage and retinal damage. Gold standard anti-vascular endothelial growth factor (VEGF) treatment is an effective therapy, but the long-term prevention of visual decline has not been as successful. This warrants the need to elucidate potential VEGF-independent pathways. We generated blood out-growth endothelial cells (BOECs) from wet AMD and normal control subjects, then induced angiogenic sprouting of BOECs using a fibrin gel bead assay. To deconvolute endothelial heterogeneity, we performed single-cell transcriptomic analysis on the sprouting BOECs, revealing a spectrum of cell states. Our wet AMD BOECs share common pathways with choroidal neovascularization such as extracellular matrix remodeling that promoted proangiogenic phenotype, and our ‘activated’ BOEC subpopulation demonstrated proinflammatory hallmarks, resembling the tip-like cells in vivo. We uncovered new molecular insights that pathological angiogenesis in wet AMD BOECs could also be driven by interleukin signaling and amino acid metabolism. A web-based visualization of the sprouting BOEC single-cell transcriptome has been created to facilitate further discovery research.

Relationship between Pachychoroid and Polypoidal Choroidal Vasculopathy

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

The Role of Medical Image Modalities and AI in the Early Detection, Diagnosis and Grading of Retinal Diseases: A Survey

Traditional dilated ophthalmoscopy can reveal diseases, such as age-related macular degeneration (AMD), diabetic retinopathy (DR), diabetic macular edema (DME), retinal tear, epiretinal membrane, macular hole, retinal detachment, retinitis pigmentosa, retinal vein occlusion (RVO), and retinal artery occlusion (RAO). Among these diseases, AMD and DR are the major causes of progressive vision loss, while the latter is recognized as a world-wide epidemic. Advances in retinal imaging have improved the diagnosis and management of DR and AMD. In this review article, we focus on the variable imaging modalities for accurate diagnosis, early detection, and staging of both AMD and DR. In addition, the role of artificial intelligence (AI) in providing automated detection, diagnosis, and staging of these diseases will be surveyed. Furthermore, current works are summarized and discussed. Finally, projected future trends are outlined. The work done on this survey indicates the effective role of AI in the early detection, diagnosis, and staging of DR and/or AMD. In the future, more AI solutions will be presented that hold promise for clinical applications.

Observation of a pulsatile choroidal vascular lesion in a patient with polypoidal choroid vasculopathy during vitrectomy

Purpose

To describe a patient in whom a pulsating choroidal vascular lesion was observed during vitrectomy for the treatment of vitreous hemorrhage secondary to polypoidal choroidal vasculopathy (PCV).

Observations

A 67-year-old Chinese male was referred to our department for the treatment of vitreous hemorrhage secondary to PCV in his right eye. PCV was confirmed during surgery, accompanied by extensive vitreous and subretinal hemorrhage, and exudation in the posterior pole and temporal to the fovea. A reddish-orange pulsatile lesion was observed at the inferotemporal fundus. The pulsatility of the lesion varied with changes in the intraocular infusion pressure. The pulsating lesion was not visible on fluorescein and indocyanine green angiography performed 1 month after surgery.

Conclusions and importance

A pulsatile choroidal vascular lesion was observed during vitrectomy. Future studies elucidating the relationships between pulsation, intraocular pressure, and blood flow would help our understanding of the hemodynamics of polypoidal choroidal vessels.

Hyaluronidase-1-mediated glycocalyx impairment underlies endothelial abnormalities in polypoidal choroidal vasculopathy

Background

Polypoidal choroidal vasculopathy (PCV), a subtype of age-related macular degeneration (AMD), is a global leading cause of vision loss in older populations. Distinct from typical AMD, PCV is characterized by polyp-like dilatation of blood vessels and turbulent blood flow in the choroid of the eye. Gold standard anti-vascular endothelial growth factor (anti-VEGF) therapy often fails to regress polypoidal lesions in patients. Current animal models have also been hampered by their inability to recapitulate such vascular lesions. These underscore the need to identify VEGF-independent pathways in PCV pathogenesis.

Results

We cultivated blood outgrowth endothelial cells (BOECs) from PCV patients and normal controls to serve as our experimental disease models. When BOECs were exposed to heterogeneous flow, single-cell transcriptomic analysis revealed that PCV BOECs preferentially adopted migratory-angiogenic cell state, while normal BOECs undertook proinflammatory cell state. PCV BOECs also had a repressed protective response to flow stress by demonstrating lower mitochondrial functions. We uncovered that elevated hyaluronidase-1 in PCV BOECs led to increased degradation of hyaluronan, a major component of glycocalyx that interfaces between flow stress and vascular endothelium. Notably, knockdown of hyaluronidase-1 in PCV BOEC improved mechanosensitivity, as demonstrated by a significant 1.5-fold upregulation of Krüppel-like factor 2 (KLF2) expression, a flow-responsive transcription factor. Activation of KLF2 might in turn modulate PCV BOEC migration. Barrier permeability due to glycocalyx impairment in PCV BOECs was also reversed by hyaluronidase-1 knockdown. Correspondingly, hyaluronidase-1 was detected in PCV patient vitreous humor and plasma samples.

Conclusions

Hyaluronidase-1 inhibition could be a potential therapeutic modality in preserving glycocalyx integrity and endothelial stability in ocular diseases with vascular origin.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12915-022-01244-z.

Polypoidal choroidal vasculopathy in pachychoroid: combined treatment with photodynamic therapy and aflibercept

INTRODUCTION

To evaluate the effects of combined therapy using intravitreal Aflibercept (IVA) and photodynamic therapy (PDT) on polypoidal choroidal vasculopathy related to pachychoroid disease (PPCV).

METHODS

Patients with PPCV were treated with PDT combined with 3 IVA injections on a monthly basis, followed by pro re nata criteria. The 12-month follow-up consisted of multiple revaluations of visual acuity and SS-OCT parameters of clinical activity.

RESULTS

Nineteen eyes were included in the study; mean age was 65.5 years. Visual acuity improved after 12 months (0.35 ± 0.25 to 0.2 ± 0.20 logMAR, p = 0.005). Percentage of eyes with intraretinal and subretinal fluid reduced from baseline to the 12-month follow-up (from 52.6 to 10.5%, p = 0.12, and from 89.5 to 5.3% p = 0.0009, respectively). Central retinal and mean macular thicknesses reduced (258 ± 39.6 to 204.8 ± 38.8 μm p = 0.04 and 293.8 ± 32.1 to 248.1 ± 29.6 μm p = 0.017, respectively). Central choroidal and mean choroidal thicknesses also displayed a reduction (328.6 ± 54.9 to 289.8 ± 44.6 μm p = 0.001 and 314.5 ± 55.3 to 287.9 ± 47.6 μm p = 0.015, respectively). The mean number of injections was 4.6/year.

CONCLUSION

The results support the use of a combined therapy with Aflibercept and PDT in PPCV. This treatment would act in synergy, with anti-VEGF controlling exudation and PDT closing the aneurysmal vessel and reducing choroidal congestion.

Recurrence and visual prognostic factors of polypoidal choroidal vasculopathy: 5-year results

This retrospective study aimed to evaluate the factors affecting recurrence and visual prognosis in patients with treatment-naïve subfoveal polypoidal choroidal vasculopathy (PCV). Patients who had received three consecutive intravitreal injections of ranibizumab or aflibercept and had reached remission were enrolled. They were divided into a group without recurrence (group 1, 26 eyes) and a group with recurrence (group 2, 121 eyes) and followed up for at least 5 years. Patients in group 2 received additional treatment for worsening. Logistic regression analysis revealed that a young age of onset (P = 0.001), high choroidal vascularity index (CVI; P = 0.019), and presence of choroidal vascular hyperpermeability (CVH; P = 0.037) were associated with a low risk of recurrence. Multiple regression analysis revealed that recurrence (P = 0.001), greatest linear dimension (P = 0.003), and polyp configuration (single or cluster; P = 0.043) were associated with final visual acuity. Patients without recurrence had a lower age of onset and higher CVI than those with recurrence, and they tended to have CVH. In addition, patients with recurrence, large lesion, and cluster polyps had worse final visual acuity than those without these factors. CVI and CVH may be used to predict recurrence of PCV.

Pachychoroid disease spectrum: review article

PURPOSE

The aim of this article is to do a comprehensive literature review about the current understandings of the pachychoroid disease spectrum, describing its multimodal imaging analysis, pathophysiology, differential diagnosis, and current types of management.

METHODS

This comprehensive literature review was performed based on a search on the PubMed database, of relevant pachychoroid published papers according to our current knowledge.

DISCUSSION

The pachychoroid disease spectrum, according to some authors, includes the following: pachychoroid pigment epitheliopathy (PPE), central serous chorioretinopathy (CSC), pachychoroid neovasculopathy (PNV), polypoidal choroidal vasculopathy (PCV)/aneurysmal type 1 neovascularization (AT1), and more recently focal choroidal excavation (FCE) and peripapillary pachychoroid syndrome (PPS). Each one of these entities will be described and discussed in this article.

CONCLUSION

Significant advances in multimodal imaging have enabled a better understanding of the typical choroidal changes in pachychoroid disease spectrum. The clinical knowledge and managing options about this disease significantly increased in the last years. However, it is still unclear why some eyes with typical pachychoroid disease phenotype show no evidence of RPE damage and subretinal fluid (uncomplicated pachychoroid) while others present progressive tissue damage, neovascularization, and atrophy.

Pachychoroid spectrum disease

Recent improvements in ophthalmic imaging have led to the identification of a thickened choroid or pachychoroid to be associated with a number of retinal diseases. The number of conditions linked to this phenotype has continued to widen with specific endophenotypes found within the pachychoroid spectrum. The spectrum includes choroidal features such as focal or diffuse choroidal thickening and thinning of the overlying inner choroid, and choroidal hyperpermeability as demonstrated by indocyanine green angiography. In addition, these diseases are associated with overlying retinal pigmentary changes and retinal pigment epithelial dysfunction and may also be associated with choroidal neovascularization. This article provides a comprehensive review of the literature looking at diseases currently described within the pachychoroid spectrum including central serous chorioretinopathy, pachychoroid pigment epitheliopathy, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy/aneurysmal type 1 neovascularization, peripapillary pachychoroid disease and focal choroidal excavation. We particularly focus on clinical imaging, genetics and pathological findings in these conditions with the aim of updating evidence suggesting a common aetiology between diseases within the pachychoroid spectrum.

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.

COMPARISON OF MULTICOLOR IMAGING AND COLOR FUNDUS PHOTOGRAPHY IN THE DETECTION OF PATHOLOGICAL FINDINGS IN EYES WITH POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To compare the appearance and frequency of detection of common features in eyes with polypoidal choroidal vasculopathy using multicolor imaging (MC) or color fundus photography (CFP).

METHODS

Thirty-eight eyes with indocyanine green angiography-proven polypoidal choroidal vasculopathy, imaged with both MC and CFP, were graded by three independent retinal specialists. The presence of five prespecified pathological features (blood, exudation, polypoidal lesions, pigment epithelial detachments, and atrophy) was graded on each modality independently. Multimodal imaging including optical coherence tomography, fluorescein, and indocyanine green angiography was used as the gold standard.

RESULTS

Overall, there was no statistically significant difference in the ability of MC imaging compared with CFP in detecting the pathological features. Polypoidal lesions appear as small, dark green, round lesions which have higher contrast on MC compared with a nodular orange appearance seen on CFP. Polypoidal lesions can be identified noninvasively using both MC and CFP in about half of the cases.

CONCLUSION

There are differences in the appearance of polypoidal choroidal vasculopathy-associated features on MC compared with CFP. Both modalities are comparable for the detection of pathological features in eyes with polypoidal choroidal vasculopathy. MC imaging may be considered as an alternative to CFP.

Replacement of polyps with type 1 macular neovascularization in polypoidal choroidal vasculopathy imaged with swept source OCT angiography

Purpose

To investigate the morphological changes of polyps in eyes with polypoidal choroidal vasculopathy (PCV) after treatment with vascular endothelial growth factor (VEGF) inhibitors using swept source optical coherence tomography angiography (SS-OCTA).

Observations

Following anti-VEGF therapy, polyps were found to evolve into typical type 1 macular neovascularization (MNV) in five eyes. In all of these five eyes, a polypoidal lesion was detected adjacent to a serous or hemorrhagic retinal pigment epithelial detachment (PED).

Conclusions and importance

Polypoidal lesions in PCV can evolve into typical type 1 MNV. This morphological evolution suggests that these polyps are clusters of tangled vessels that can proliferate into a more typical neovascular pattern, and this evolution may be facilitated by being adjacent to a PED. Since this morphological appearance could be associated with a better prognosis, SS-OCTA might be helpful in identifying cases of transformed polyps that may be associated with a decreased risk for vision loss.

Comparison of visual outcomes between therapy choices and subtypes of polypoidal choroidal vasculopathy (PCV) in Taiwan: a real-world study

Polypoidal choroidal vasculopathy (PCV) is a distinctive type of neovascular age-related macular degeneration prevalent in many Asian countries. However, there is still some controversy in how the subtypes of PCV are classified. This post-hoc study redefined the branching vascular network (BVN) and PCV subtypes through retrospective review of indocyanine green angiography (ICGA) and fluorescein angiography images from two observational studies (RENOWNED/REAL). Of the visual outcomes for each angiographic subtype and treatment pattern investigated, BVN was identified in 56.3% of PCV patients. The proportions and features of the re-defined PCV subtypes were 43.8%, 10.4%, and 45.8% for subtype A (without distinctive features of BVN), B (with BVN but no leakage), and C (with BVN and leakage), respectively. Subtype A had better visual outcomes when compared to subtype C. This possibly resulted from a better baseline visual acuity in subtype A. Moreover, combination therapy [photodynamic therapy plus anti-vascular endothelial growth factor (VEGF)] may lead to better visual improvement than mono-anti-VEGF treatment alone. This study provides the prevalence of PCV subtypes in Taiwan and may serve as a reference for PCV treatment strategies in a real-world setting, especially for the combination therapy and patients without distinctive features of BVN.

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.

The spectrum of polypoidal choroidal vasculopathy in Caucasians: clinical characteristics and proposal of a classification

Purpose

To describe the clinical characteristics and outcome of polypoidal choroidal vasculopathy (PCV), also known as aneurysmal type 1 (sub-retinal pigment epithelium (RPE)) neovascularization, in Caucasian patients.

Methods

Single-centre study in 66 Caucasian patients with a diagnosis of PCV based on optical coherence tomography scan and indocyanine green angiography. Clinical characteristics and multimodal imaging were collected and assessed by an experienced retina specialist.

Results

This study involved 74 eyes of 66 patients with PCV, with a mean age at onset of 73 years and a female preponderance of 66%. The mean number of polypoidal lesions per eye was 1 (range: 1–5 lesions), out of which 75% was located in the macula and 19% in the peripapillary region. Of the 74 eyes, 37 eyes (50%) had PCV associated with a drusenoidal neovascular age-related macular degeneration (AMD) phenotype (PCV-AMD) and 18 eyes (24%) had PCV associated with non-polypoidal type 1 choroidal neovascularization/branching vascular network (PCV-BVN) without signs of drusenoidal AMD, while 19 eyes (26%) had idiopathic, isolated PCV (iPCV). The mean subfoveal choroidal thickness measured in 22 patients was 245 μm (range: 71–420 μm). In 51% of patients, the initially performed therapy showed good anatomical recovery (resolution of intra- and subretinal fluid).

Conclusions

A spectrum of PCV (aneurysmal type 1/sub-RPE neovascularization) can be seen in Caucasian patients. PCV associated with a drusenoidal neovascular AMD phenotype in Caucasians is phenotypically and presumably pathophysiologically more associated with neovascular AMD (PCV-AMD: type A PCV). However, this may not be the case for patients with PCV with non-polypoidal type 1 choroidal neovascularization or BVN and no signs of drusenoidal AMD (PCV-BVN: type B PCV), and for patients with idiopathic PCV without associated drusen or BVN (iPCV; type C PCV). Most patients have a thin choroid, even when drusen are absent. For the entire patient group, a moderate anatomical recovery was observed after treatment.

Electronic supplementary material

The online version of this article (10.1007/s00417-020-04844-z) contains supplementary material, which is available to authorized users.

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

PURPOSE

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

DESIGN

Evaluation of diagnostic test results.

PARTICIPANTS

Panel of retina specialists.

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

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

Analysis of choroidal morphology and comparison of imaging findings of subtypes of polypoidal choroidal vasculopathy: a new classification system

AIM

To classify polypoidal choroidal vasculopathy (PCV) into 2 subtypes based on the subfoveal choroidal thickness (SFCT) and to further evaluate their multimodal image features.

METHODS

A retrospective observational case series study. Sixty-four eyes of 64 patients with PCV were enrolled and classified into 2 groups based on SFCT (thick-choroid group/thin-choroid group). Then further analyze the spectrum domain optical coherence tomography (SD-OCT) and indocyanine green angiography (ICGA) differences of the two subtypes. Imaging analysis included measurement of SFCT, maximum vascular diameter ratio (MVDR), choroidal vascularity index (CVI), central macular thickness (CMT), and the presence of pigment epithelial detachment (PED) on SD-OCT. Polypoidal lesions (polyps) number, branching vascular network (BVN) area, greatest linear dimension (GLD), and the choroidal vascular hyperpermeability (CVH) were analyzed by ICGA.

RESULTS

The distribution of SFCT was bimodal with two peaks at 195 and 285 µm, and a trough at 225 µm. The 225 µm was taken as the cutoff point for the following classification of thick/thin choroid groups. The PCV eyes in the thick-choroid group presented with greater MVDR, CVI within 3 and 6 mm of the fovea, but lower CMT, less PED, small PED diameters on SD-OCT scans, and fewer polyps, smaller BVN and GLD, but more frequency of CVH on ICGA.

CONCLUSION

The SFCT at 225 µm can be used as a readily available indicator for the classification of PCV subtypes. The thick-choroid group presents much apparent enlargement of the choroidal layer and vasculature expansion, which indicates different pathogenesis of the two subtypes.

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.

Pachychoroid disease: a new perspective on exudative maculopathy

BACKGROUND

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

CONCLUSION

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

Using optical coherence tomography angiography in assessment of the anti-vascular endothelial growth factor effect for pathological vascular tissue in age-related macular degeneration and polypoidal choroidal vasculopathy

PURPOSE

Using optical coherence tomography angiography to assess and compare changes in pathological vascular tissue, including choroidal neovascularization in neovascular age-related macular degeneration and polypoidal complex in polypoidal choroidal vasculopathy, after treatment with anti-vascular endothelial growth factor.

METHODS

This is a retrospective observational case series study. Clinical data were collected, including that on the best-corrected visual acuity and images of spectrum domain optical coherence tomography and optical coherence tomography angiography of consecutive patients with macula-involved lesions, active pathological vascular tissue in neovascular age-related macular degeneration, and polypoidal complex in polypoidal choroidal vasculopathy who were treated with anti-vascular endothelial growth factor injection. The primary outcome measures were the lesion area, flow density, and flow area of the pathological vascular tissue obtained in optical coherence tomography angiography before treatment, as well as week-1 (W1) and week-5 (W5) after treatment. The secondary outcome measures were the best-corrected visual acuity and the anatomic changes in spectrum domain optical coherence tomography at the same periods.

RESULTS

A total of 86 eyes in 79 patients (mean age: 73.10 ± 10.10 (range = 50-91) years, 45 males (57%), of which two eyes were treatment-naïve) underwent one section of intravitreal treatment. Of which 44 eyes (40 patients) were diagnosed as typical neovascular age-related macular degeneration and 42 eyes (39 patients) as polypoidal choroidal vasculopathy. The sensitivity for detecting choroidal neovascularization in neovascular age-related macular degeneration and polypoidal complex in polypoidal choroidal vasculopathy was 75.00% (33/44) and 69.05% (29/42), respectively. There was no significant difference in the detection rate between neovascular age-related macular degeneration and polypoidal choroidal vasculopathy (p = 0.54). In the detectable group, there were significant decrease in lesion area and flow area in the optical coherence tomography angiography images after anti-vascular endothelial growth factor treatment in both the neovascular age-related macular degeneration group (lesion area: W1 = -26.94 ± 19.50%, W5 = -35.52 ± 30.85%, all ps < 0.001; flow area: W1 = -26.22 ± 25.23%, W5 = -32.24 ± 32.07%, all ps < 0.001) and the polypoidal choroidal vasculopathy group (lesion area: W1 = -25.19 ± 20.27%, W5 = -31.55 ± 27.04%, all ps < 0.001; flow area: W1 = -21.83 ± 26.29%, W5 = -28.31 ± 30.72%, all ps < 0.001). The central subfield retinal thickness in spectrum domain optical coherence tomography also showed similar amelioration in both groups. However, the flow density in optical coherence tomography angiography image and the visual outcome did not reveal any significant difference before or after intravitreal injections, and neither were there significant differences between the neovascular age-related macular degeneration and polypoidal choroidal vasculopathy groups. Concerning the effect on the optical coherence tomography angiography images of pathological vascular tissue, there were no statistical differences among different anti-vascular endothelial growth factor agents (i.e. aflibercept, ranibizumab, and bevacizumab).

CONCLUSION

Our study revealed that optical coherence tomography angiography can be used noninvasively and quantitatively to assess the detailed pathologic vascular structures in both neovascular age-related macular degeneration and polypoidal choroidal vasculopathy. Our study also demonstrated that anti-vascular endothelial growth factor could effectively decrease the lesion size and flow area of both the choroidal neovascularization in neovascular age-related macular degeneration cases and the polypoidal complex in polypoidal choroidal vasculopathy cases; the effects were similar in both diseases.

Numerous retinal pigment epithelial elevations and drusen associated with unusual dilated choroidal vessels seen at choriocapillaris level in macular area

Purpose

To report the ocular findings in a patient with extensive diffuse elevations of the retinal pigment epithelium (RPE) and drusen associated with dilated choroidal vessels.

Observations

The eye of a 72-year-old woman with numerous drusen and dilated choroidal vessels in the macular and surrounding areas of the right eye was studied. Her visual acuity was 20/16 in this eye and she was asymptomatic although the Amsler grid testing showed mild metamorphopsia. Indocyanine green angiography showed dilated choroidal vessels that collected blood from their branches in the macular and surrounding areas and flowed out of the eye at the entry site of a short posterior ciliary artery. A large choroidal vein ran from the nasal quadrants toward the superotemporal quadrant. Optical coherent tomography (OCT) showed two types of RPE elevations over an extensive area: one was a relatively steep dome-shaped RPE elevation, and the other was a flatter placoid-shaped RPE detachment. Detailed examinations including OCT angiography showed that the dome-shaped RPE elevation coincided with the course of the dilated choroidal vessels which were seen at the level of the choriocapillaris. The visual acuity and the ocular findings remained stable during the 2.5-year follow-up period, and this condition did not require any treatments.

Conclusions and importance

We conclude that the dilated choroidal vessels are most likely parts of the posterior ciliary venous system, and they function as a posterior route of choroidal outflow. Because such eyes might be diagnosed and treated as age-related macular degeneration based on the presence of drusen, RPE detachments, and abnormal vessels beneath the RPE, knowledge of these observations in a functionally normal eye is important to avoid unnecessary treatments.

Appearance of Polypoidal Lesions in Patients With Polypoidal Choroidal Vasculopathy Using Swept-Source Optical Coherence Tomographic Angiography

Importance

Polypoidal choroidal vasculopathy (PCV) is a major cause of visual loss worldwide, particularly in Asia, and the appropriate understanding of the structures in PCV previously described as polypoidal lesions is important for understanding their pathogenesis, diagnosis, and prognosis.

Objective

To report the morphologic characteristics of polypoidal lesions and their association with branching vascular networks (BVNs) in eyes with PCV using swept-source optical coherence tomographic angiography (SS-OCTA).

Design, Setting, and Participants

This cross-sectional observational study included 20 participants recruited from Shanghai General Hospital with a diagnosis of PCV based on the presence of focal hyperfluorescent spots on indocyanine green angiography (ICGA). Data were collected from December 1, 2017, to September 1, 2018, and analyzed from June 1 through September 30, 2018.

Main Outcomes and Measures

Polypoidal lesions in eyes with PCV were characterized using multimodal imaging that included fundus photography, fluorescein angiography, ICGA, SS-OCT, and SS-OCTA, and the images were anatomically aligned. Subfoveal choroidal thickness was manually measured as the distance between the Bruch membrane and the sclerochoroidal interface on the SS-OCT images.

Results

Of the 20 Asian patients, 5 (25%) were women and 15 (75%) were men. The mean (SD) age was 61.1 (7.6) years, and the mean (SD) logMAR visual acuity was 0.358 (0.294) (Snellen equivalent, 20/50 [20/40]). Twenty-three eyes underwent imaging and were diagnosed with PCV. Indocyanine green angiography identified 43 polypoidal lesions, and all corresponded to the structures that appeared as clusters of tangled vessels on SS-OCTA images. In addition, SS-OCTA detected 16 tangled vascular structures not seen on ICGA. Branching vascular networks were detected on SS-OCTA imaging in all eyes, but ICGA identified BVNs in only 17 of 23 eyes (74%). Of the 43 tangled vascular structures, 40 (93%) were located at the edge of a BVN and 3 (7%) were associated with type 2 neovascularization.

Conclusions and Relevance

In eyes with PCV undergoing SS-OCTA imaging, previously described polypoidal lesions may appear as tangled vascular structures associated with BVN or type 2 neovascularization. The identification of polypoidal lesions in patients with PCV as neovascular tangles rather than actual polypoidal lesions or aneurysmal dilatations may help facilitate understanding of their pathogenesis and response to treatment.

Associations of systemic, serum lipid and lipoprotein metabolic pathway gene variations with polypoidal choroidal vasculopathy in China

BACKGROUND

To investigate the association of systemic, serum lipids and genetic variants in the high-density lipoprotein (HDL) metabolic pathway with polypoidal choroidal vasculopathy (PCV) in China.

METHODS

The case-control study was included 150 controls and 66 cases with PCV. Serum levels of total cholesterol (TC), low-density lipoprotein (LDL), HDL, triglycerides (TG), apolipoprotein A1 (APOA1), apolipoprotein B (APOB) together with systemic risk factors including gender, hyperlipidemia, diabetes mellitus (DM), hypertension, coronary artery disease (CAD) and asthma were identified. All subjects were genotyped for four single nucleotide polymorphisms (SNPs) from three genes in the HDL metabolic pathway: rs10468017 of hepatic lipase (LIPC), rs12678919 of lipoprotein lipase (LPL), rs3764261 and rs173539 of cholesterol ester transfer protein (CETP) with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS). Student's t-tests, chi-square tests, anova and logistic regression were used to evaluate associations.

RESULTS

Hyperlipidemia was a risk factor (odds ratio (OR) = 1.19, P = 0.001) for PCV. HDL, LDL and APOB levels were associated with PCV (OR = 0.001, P = 0.004; OR = 0.099, P = 0.010; OR = 0.839, P = 0.018). Higher level of TC was potently associated with increased risk of PCV (OR = 109.8, P = 0.000). LIPC rs10468017 was a risk factor for PCV (OR = 11.68, P = 0.000). CETP rs3764261 conferred a decreased risk for PCV (OR = 0.08, P = 0.000). No associations of LPL rs12678919 or CETP rs173539 with PCV were found. Mean level of HDL increased with T allele of the CETP gene (p = 0.026): 1.24 mmol/L (±0.31) for the GG genotype and 1.66 mmol/L (±0.54) for the TT genotype. Additionally, T allele was associated with the following increase in APOA1: 136.78 mg/dl (±20.53) for the CC genotype and 149.57 mg/dl (±22.67) for the TT genotype of LIPC and 137.91 mg/dl (±20.36) for the GG genotype and 162.67 mg/dl (±22.50) for the TT genotype of CETP gene.

CONCLUSION

Our study suggested that the significant association was found between hyperlipidemia, the serum levels of TC, HDL, LDL and APOB and PCV. The result of present study also showed that the association of LIPC rs10468017 and CETP rs3764261 with PCV.

Lateral elongation of flat irregular pigment epithelial detachment: A novel optical coherence tomography biomarker in polypoidal choroidal vasculopathy

Purpose

To explore novel Optical Coherence Tomography (OCT) biomarkers and precursor lesions in Polypoidal Choroidal Vasculopathy (PCV).

Methods

This retrospective cohort study included 76 treatment naïve fellow eyes of PCV. Focus was given to analyse the various morphological changes in the clinically unaffected fellow retina during the follow-up period.

Results

11 fellow eyes (14.47%) developed disease activity in the form of Sub Retinal Fluid (SRF) or Intra Retinal Fluid (IRF) within a mean follow-up of 17 months. All 11 eyes (100%) showed the presence of flat irregular pigment epithelial detachment (FIPED) and a peculiar property of lateral elongation of FIPED during disease activity. A positive correlation with the disease progression was found for the same (P < 0.0001). The mean horizontal dimension of the flat irregular PED at the enrolment was 1984 ± 376u and the mean expansion of FIPED at SRF formation was 461 ± 152u. ICG taken at the time of disease activity in the fellow eye revealed branching vascular network (BVN) in 9 (81.8%) eyes, polyps in 7 (63.6%) eyes, a combination of both in 5 (45.4%) eyes. Type one BVN with interconnecting channels showed faster disease progression than type two BVN. Eye tracking ICG illustrated that BVN corresponded to the FIPED in OCT and polypoidal lesions developed at the end of expanding FIPED.

Conclusion

Flat irregular pigment epithelial detachment with its characteristic property of lateral elongation may be considered as a precursor lesion for PCV and as a novel OCT biomarker for the disease activity. Fellow eyes with FIPED need close monitoring to identify development of disease activity at the earliest.

Different imaging characteristics between unilateral and bilateral polypoidal choroidal vasculopathy

PURPOSE

To investigate the different imaging characteristics between unilateral and bilateral polypoidal choroidal vasculopathy (PCV) cases, based on confocal scanning laser ophthalmoscope assessment.

METHODS

For this retrospective case series study, diagnostic indocyanine green angiography (ICGA) and spectral domain optical coherence tomography (SD-OCT) were performed to assess the eligible PCV eyes.

RESULTS

Among the 53 patients at baseline, 14 showed bilateral PCV lesions, including two cases of branching vessel network (BVN) without leakage. Concerning the subfoveal choroidal thickness (SFCT), unilateral PCV eyes (326 [155-547] μm) were statistically comparable to their fellow eyes (330 [163-477] μm) (p = 0.257). However, the SFCT (228[141-273] μm) from the bilateral PCV group was significantly lower compared with both the PCV (p = 0.002) and fellow eyes (p < 0.001) from the unilateral group. Moreover, ICGA related hyperfluorescent spots were shown to have a significant positive correlation with SFCT in the unilateral PCV eyes and their fellow eyes, other than bilateral PCV cases. In addition, the drusens tended to prevail in the fellow eyes of the unilateral PCV group (46.2%), compared with bilateral cases.

CONCLUSIONS

Our results indicate that SFCT, ICGA related hyperfluorescent spots, and drusen were the three main imaging characteristic differences between unilateral and bilateral PCV cases.

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.

Comparison of the effects of photodynamic therapy, intravitreal ranibizumab and combination for polypoidal choroidal vasculopathy under 1 + PRN regimen

Background

The optimal treatment for polypoidal choroidal vasculopathy (PCV) is still under debate. Little knowledge is known about the treatment effect of “1+pro re nata(PRN)” treatment regimen for PCV. The aim of this study was to compare the outcomes of photodynamic therapy (PDT), intravitreal ranibizumab injection (IVR) and combination therapy under the “1 + PRN” treatment regimen for PCV.

Methods

Fifty-seven eyes of 57 patients completed the 12 months’ follow-up in this prospective study. The patients in the PDT arm(n = 23), ranibizumab arm(n = 18), or combination arm(n = 16) underwent a session of PDT, IVR or combination of both at baseline followed by additional IVR as needed. Mean change of logarithm of the minimal angle of resolution (logMAR) visual acuity (VA), central foveal thickness (CFT) and the regression rate of polyps were evaluated. Cost-benefit analysis was also performed.

Results

At Month 12, the mean logMAR VA improved from 0.90 ± 0.52 to 0.75 ± 0.57 in the PDT group (P < 0.05), from 0.96 ± 0.58 to 0.77 ± 0.41 in the IVR group (P < 0.05), and from 0.94 ± 0.55 to 0.72 ± 0.44 in the combination group (P < 0.05), respectively. The CFT decreased from 478.04 ± 156.70 μm, 527.5 ± 195.90 μm, and 522.63 ± 288.40 μm at the baseline to 366.43 ± 148.28 μm, 373.17 ± 134.88 μm and 328.44 ± 103.25 in the PDT group (P < 0.05), IVR group (P < 0.01), and the combination group (P < 0.05), respectively. However, no statistical difference was found between groups (P > 0.05). PDT treatment (60.87%) was superior to the IVR therapy (22.22%) in achieving complete regression of polyps (P < 0.05). Cost-benefit analysis showed that IVR treatment cost the least money for improving per 0.1logMAR units and the combination therapy demanded the least money for reducing per 100 μm of CFT.

Conclusions

PDT, IVR and the combination therapy have similar efficacy in the VA improvement as well as the reduction of CFT under the “1 + PRN” treatment regimen.

Trial registration

Current Controlled Trials NCT03459144. Registered retrospectively on March 2, 2018.

A comparison of risk factors for age-related macular degeneration and polypoidal choroidal vasculopathy in Chinese patients

PURPOSE

Neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV) are important vision-threatening diseases worldwide. For effective treatment, the risk factors for the diseases merit investigation. This study aimed to compare the risk factors for nAMD vs. PCV in Chinese patients.

METHODS

A total of 946 participants were recruited in this case-control study, including 281 patients with nAMD, 306 patients with PCV, and 359 controls. All participants underwent comprehensive ophthalmic examinations. Information on risk factors were collected by questionnaire. Multivariate logistic regression analyses were performed to investigate the difference in risk factors between nAMD and PCV. In a subgroup of subjects, serum lipid data were obtained and analyzed.

RESULTS

Risk factors for nAMD included older age (OR 1.03, P = 0.001), male gender (OR 1.55, P = 0.020), asthma (OR 2.50, P = 0.028), smoking (OR 1.92, P = 0.001), and family history (OR 6.82, P = 0.001), while smoking (OR 1.67, P = 0.013) was the only risk factor for PCV. Compared to patients with PCV, patients with nAMD were more likely to be older and suffer from hyperlipidemia, coronary artery disease, rheumatism, and tumor. Interestingly, higher levels of high-density lipoprotein were positively associated with PCV in the subgroup analysis (OR 7.74, P = 0.011). Besides, results were quite different between the combination of patients with nAMD and PCV and patients with nAMD or PCV alone.

CONCLUSIONS

The risk factors for nAMD and PCV is varying with the exception of smoking. Our findings suggest that different strategies might be applied in the clinical management and scientific research on nAMD and PCV.

Assessment of focal laser photocoagulations' early effect on polypoidal choroidal vasculopathy with optical coherence tomography angiography

Polypoidal choroidal vasculopathy (PCV) is seen with polypoidal lesions and branching vascular networks (BVNs) (Spaide et al. in Retina 15(2):100-110, 1995; Yannuzzi et al. in Retina 10(1):1-8, 1990). There are reports about laser photocoagulation for PCV (Yuzawa et al. in Japan J Ophthalmol 47(4):379-384, 2003; Lee et al. in Eye 23(1):145-148, 2009); however, all these reports are about final vision and frequent relapses. Therefore, this treatment merits rigorous scrutiny using optical coherence tomography angiography (OCTA).

Understanding aneurysmal type 1 neovascularization (polypoidal choroidal vasculopathy): a lesson in the taxonomy of 'expanded spectra' - a review

The term aneurysmal type 1 neovascularization is derived from terminology, which is established in the literature but has fallen out of use. We believe that aneurysmal type 1 neovascularization accurately describes the lesions which define the entity known as polypoidal choroidal vasculopathy (PCV). Over the last three decades, the clinical spectrum of PCV has expanded to recognize the occurrence of the aneurysmal (polypoidal) lesions in different contexts, resulting in a complex and unwieldy taxonomy based sometimes on circumstantial findings rather than mechanistic considerations. Advances in multimodal imaging provides increasingly convincing evidence that the lesions which define various forms of PCV are indeed vascular and arise from type 1 neovascular networks. The understanding of PCV as type 1 neovascularization with aneurysms renews focus on the question as to why some patients with type 1 neovascularization develop aneurysms while others do not. Conceptual themes and potential for further study are discussed.

Proteolytic Degradation and Inflammation Play Critical Roles in Polypoidal Choroidal Vasculopathy

Polypoidal choroidal vasculopathy (PCV) is a common subtype of wet age-related macular degeneration in Asian populations, whereas choroidal neovascularization is the typical subtype in Western populations. The cause of PCV is unknown. By comparing the phenotype of a PCV mouse model expressing protease high temperature requirement factor A1 (HTRA1) in retinal pigment epithelium with transgenic mice expressing the inactive HTRA1S328A, we showed that HTRA1-mediated degradation of elastin in choroidal vessels is critical for the development of PCV, which exhibited destructive extracellular matrix remodeling and vascular smooth muscle cell loss. Compared with weak PCV, severe PCV exhibited prominent immune complex deposition, complement activation, and infiltration of inflammatory cells, suggesting inflammation plays a key role in PCV progression. More important, we validated these findings in human PCV specimens. Intravitreal delivery of an HTRA1 inhibitor (DPMFKLboroV) was effective (36% lesion reduction; P = 0.009) in preventing PCV initiation but ineffective in treating existing lesions. Anti-inflammatory glucocorticoid was effective in preventing PCV progression but ineffective in preventing PCV initiation. These results suggest that PCV pathogenesis occurs through two stages. The initiation stage is mediated by proteolytic degradation of extracellular matrix proteins attributable to increased HTRA1 activity, whereas the progression stage is driven by inflammatory cascades. This study provides a basis for understanding the differences between PCV and choroidal neovascularization, and helps guide the design of effective therapies for PCV.

Morphologic Criteria of Lesion Activity in Neovascular Age-Related Macular Degeneration: A Consensus Article

Intravitreal antivascular endothelial growth factor drugs represent the current standard of care for neovascular age-related macular degeneration (nAMD). Individualized treatment regimens aim at obtaining the same visual benefits of monthly injections with a reduced number of injections and follow-up visits, and, consequently, of treatment burden. The target of these strategies is to timely recognize lesion recurrence, even before visual deterioration. Early detection of lesion activity is critical to ensure that clinical outcomes are not compromised by inappropriate delays in treatment, but questions remain on how to effectively monitor the choroidal neovascularization (CNV) activity. To assess the persistence/recurrence of lesion activity in patients undergoing treatment for nAMD, an expert panel developed a decision algorithm based on the morphological features of CNV. After evaluating all current retinal imaging techniques, the panel identified optical coherent tomography as the most reliable tool to ascertain lesion activity when funduscopy is not obvious.

CLINICAL RELEVANCE OF AQUEOUS VASCULAR ENDOTHELIAL GROWTH FACTOR LEVELS IN POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To investigate vascular endothelial growth factor (VEGF) level according to the clinical and imaging features, and to explore its relationship with the responsiveness to anti-VEGF treatment in eyes with polypoidal choroidal vasculopathy.

METHODS

Aqueous samples were collected from 62 eyes of 62 patients with treatment-naïve polypoidal choroidal vasculopathy. Vascular endothelial growth factor levels were measured using enzyme-linked immunosorbent assay. Baseline best-corrected visual acuity, central macular thickness, subfoveal choroidal thickness, greatest linear dimension of the lesion, and the presence of hemorrhage were included in the analysis. The effects of 3 monthly intravitreal ranibizumab injections on best-corrected visual acuity and central macular thickness were assessed.

RESULTS

Baseline VEGF level was negatively correlated with subfoveal choroidal thickness (r = -0.33, P = 0.01). Other variables had no correlation with VEGF level. The mean change in central macular thickness after anti-VEGF treatment was -51 ± 64 μm, which is positively correlated with VEGF concentration (r = 0.30, P = 0.04) and negatively correlated with subfoveal choroidal thickness (r = -0.35, P = 0.02).

CONCLUSION

Vascular endothelial growth factor level demonstrated a negative correlation with baseline subfoveal choroidal thickness and was associated with response to anti-VEGF treatment. These findings suggest that VEGF has a variable contribution to the pathogenesis of polypoidal choroidal vasculopathy depending on choroid thickness.

MORPHOLOGIC FEATURES ASSOCIATED WITH FIBROTIC SCARRING AFTER ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY IN POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To investigate morphologic features associated with fibrotic scarring after anti-vascular endothelial growth factor therapy in polypoidal choroidal vasculopathy (PCV).

METHODS

This retrospective study included 293 patients who had been diagnosed with PCV and treated with anti-vascular endothelial growth factor monotherapy during a 12-month follow-up period. Associations of morphologic features, including type of PCV, location of the polypoidal lesion, greatest linear dimension, largest polyp diameter, choroidal vascular hyperpermeability, pigment epithelial detachment, intraretinal fluid, and subretinal hyperreflective material (SHRM) with fibrotic scar at 12 months were analyzed.

RESULTS

Fibrotic scars were noted in 15 eyes (5.1%). The incidence of fibrotic scars was higher in Type 1 PCV (8 of 76 eyes) than in Type 2 PCV (7 of 217 eyes, P = 0.028). The incidence was also higher in eyes with SHRM (14 of 124 eyes) than in eyes without SHRM (1 of 169 eyes, P < 0.001). In multivariate analysis, SHRM was associated with fibrotic scar (P = 0.005). Among the SHRM cases, the incidence of the scar was 12.9% in eyes with submacular hemorrhage and 8.5% in eyes without hemorrhage.

CONCLUSION

Although fibrotic scar is an infrequent finding in PCV, the possibility of scarring should be considered in eyes with SHRM, particularly in submacular hemorrhage cases.

Intravitreal Aflibercept for Neovascular Polypoidal Choroidal Vasculopathy in a Predominantly Non-Asian Population: RIVAL Results

BACKGROUND AND OBJECTIVE

To evaluate safety and efficacy of intravitreal aflibercept (Eylea; Regeneron, Tarrytown, NY) injection (IAI) for the treatment of neovascular polypoidal choroidal vasculopathy (PCV) in a predominantly non-Asian population.

PATIENTS AND METHODS

This was an open-label, prospective, unmasked, nonrandomized clinical trial. Twenty eyes with neovascular PCV received monthly 2.0 mg IAI for 3 months followed by mandatory IAI every 2 months for 12 months.

RESULTS

The mean change in ETDRS best-corrected visual acuity from baseline to 1 year was +11 letters in the treatment-naïve group, +5 letters in the treatment non-naïve group, and +9 letters overall. There was an overall mean reduction of 70 µm from baseline central subfield thickness (CST) at 1 year. Patients received a mean of 6.2 mandatory and 0.7 additional IAI injections overall during the course of 1 year. No serious ocular adverse events were reported.

CONCLUSION

At 1 year, neovascular PCV in a predominantly non-Asian population treated with IAI demonstrated favorable visual, anatomic, and safety outcomes. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:34-44.].

Evaluating Polypoidal Choroidal Vasculopathy With Optical Coherence Tomography Angiography

Purpose

We observed and analyzed the morphologic characteristics of polypoidal lesions and abnormal branching vascular network (BVN) in patients with polypoidal choroidal vasculopathy (PCV) by optical coherence tomography angiography (OCTA).

Methods

A retrospective observational case series was done of patients with PCV. All patients were scanned with a 70-kHz spectral-domain OCT system using the split-spectrum amplitude-decorrelation angiography (SSADA) algorithm to distinguish blood flow from static tissue. The OCTA images of these patients were compared to those from indocyanine green angiography (ICGA). Semiautomated segmentation was used to further analyze the polypoidal lesion and the BVN.

Results

We studied 13 eyes of 13 patients 51 to 69 years old. A total of 11 patients were treatment-naive. Two patients had multiple anti-VEGF injections and one underwent photodynamic therapy (PDT). Optical coherence tomography angiography was able to detect the BVN in all cases. Using cross-sectional OCTA, BVN locations were shown to be in the space between the RPE and Bruch's membrane. Using en face OCTA, the BVN vascular pattern could be shown more clearly than by ICGA. Polypoidal lesions showed high flow signals in different patterns in 12 cases in the outer retina slab. Using cross-sectional OCTA, the polyps were shown to be just below the top of the pigment epithelial detachment (PED). In one case, the polypoidal lesion was not detectable at the outer retina slab.

Conclusions

Optical coherence tomography angiography is a noninvasive imaging tool for detecting vascular changes in PCV. Branching vascular networks showed more clearly on OCTA than on ICGA. Polypoidal lesions had variable patterns on OCTA and were not always detected. The OCTA patterns of the polypoidal lesions and the BVN are helpful in understanding the pathology of PCV.