• What’s New With Polypoidal Choroidal Vasculopathy

    An update on polypoidal choroidal vasculopathy (PCV) capped off “Retina Around the World” (Sym44V). Gemmy Chui Ming Cheung, MBBChir, FRCOphth, discussed PCV diagnostic criteria and pathogenesis during the Saturday symposium.

    ICGA-independent diagnostic criteria. This year, the Asia-Pacific Ocular Imaging Society PCV Workgroup proposed a set of non–indocyanine green angiography (ICGA) diagnostic criteria for PCV. The criteria, recently published in Ophthalmology, include nine signs based on fundus color photography and optical coherence tomography (OCT).1

    • Subretinal pigment epithelium ring-like lesion*
    • En face OCT showing complex retinal pigment epithelium (RPE) elevation*
    • Sharp-peaked pigment epithelial detachment (PED)*
    • Extensive subretinal hemorrhage
    • Orange nodule
    • Complex or multilobular PED resembling the letter ‘M’
    • Double-layer sign or shallow irregular RPE elevation
    • Thick choroid with dilated Haller’s layer vessels
    • Fluid compartment (predominantly subretinal fluid)

    Combining the top three criteria (*)—each with an area under the curve (AUC) of approximately 0.8—led to an AUC of 0.9, with a sensitivity of 0.75 and specificity of 0.91 for distinguishing PCV from typical neovascular AMD.

    These criteria are not meant to replace ICGA, explained Dr. Cheung, but they are a useful option for physicians who do not routinely use ICGA or for when it is unavailable.

    Clinical application. Eyes meeting all three major criteria should be started and maintained on anti-VEGF monotherapy, said Dr. Cheung. Suboptimal patient response, however, could signal the need for ICGA early on and may require a shift to a new agent or the addition of photodynamic therapy. It should be noted that absence of the three major criteria does not eliminate the risk of PCV—especially if the patient initially presents with small polypoidal lesions. If these patients respond poorly to monotherapy, ICGA should be considered.

    During the discussion session, Dr. Cheung elaborated that she starts most patients on anti-VEGF monotherapy and reevaluates the treatment after three months. Most of her patients have good anatomic response and visual improvement. The only time she might consider starting with combination therapy is when a patient has advanced disease and may have limited potential for visual gains. The goal in these patients, she explained, is to achieve the best visual outcome possible while limiting the number of injections.

    PCV as a pachychoroid disease. Dr. Cheung closed her talk by highlighting new efforts to understand PCV as a pachychoroid disease. She notes that patients with PCV often have a background of bilateral choroid hyperpermeability and dilated Haller’s vessels, and may have a thickened choroid. New evidence from dynamic ICGA—specifically, extensive pulsatile filling within choroidal vessels—suggests that there may be a disturbance in choroidal perfusion pressure contributing to pachyvessel pathogenesis.   —Kanaga Rajan, PhD

    Watch the symposium in full. If you are registered for AAO 2020 Virtual, you have access to the archived presentations on the virtual meeting platform until Feb. 15, 2021. Log in to the virtual meeting platform: Next, from the Lobby screen, select “Sessions” from the top navigation; click “Agenda” from the drop-down menu; click the “Saturday” tab; and scroll down to “Sym44V: Retina Around the World.”

    Financial disclosures: Dr. Cheung: Allergan: L; Bayer Healthcare Pharmaceuticals: C,L,S; Carl Zeiss Meditec: S; Heidelberg Engineering: L; Novartis, Alcon Pharmaceuticals: C,L,S; Roche Diagnostics: C; Topcon Medical Systems: S.

    Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support. 

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