Korean J Ophthalmol.  2017 Jun;31(3):230-239. 10.3341/kjo.2016.0035.

Polypoidal Choroidal Vasculopathy with Feeder Vessels: Characteristics, Fellow Eye Findings, and Long-term Treatment Outcomes

• Hwang HJ
• Kim JH
• Chang YS
• Kim JW
• Kim CG

• KMID: 2379879
• DOI: http://doi.org/10.3341/kjo.2016.0035

Abstract

PURPOSE
To evaluate the long-term outcomes of anti-vascular endothelial growth factor (VEGF) therapy for polypoidal choroidal vasculopathy (PCV) with feeder vessels and to investigate fellow-eye findings.
METHODS
This retrospective observational study included 14 eyes with treatment-naïve PCV accompanied by feeder vessels that were treated with anti-VEGF monotherapy. The best-corrected visual acuity (BCVA) at baseline was compared with that at the last follow-up. The fellow-eye indocyanine green angiography findings were also analyzed.
RESULTS
The mean follow-up period was 28.1 ± 19.2 months (range, 12 to 60 months). During the follow-up period, 5.9 ± 2.5 anti-VEGF injections were administered. The logarithm of the minimal angle of resolution (logMAR) BCVAs at the time of diagnosis, at 3 months, and at the last follow-up were 0.81 ± 0.49, 0.55 ± 0.44, and 0.71 ± 0.54, respectively. Although the BCVA at the last follow-up was not different from the baseline value (p=0.809), an improvement of ≥0.2 logMAR BCVA was observed in seven eyes (50.0%). In 11 eyes that underwent bilateral indocyanine green angiography at diagnosis, PCV, branching vascular networks, and late geographic hyperfluorescence were noted in two (18.2%), five (45.4%), and three (27.3%) fellow eyes, respectively. During the follow-up period, the development of polypoidal lesions in the fellow eye was observed in three patients.
CONCLUSIONS
In this study, long-term improvement in BCVA was noted in 50% of the included patients who received anti-VEGF monotherapy. A relatively high incidence of pathological findings in the fellow eye and bilateral involvement suggest the need for bilateral examinations.

Keyword

Choroidal neovascularization; Macular degeneration; Polypoidal choroidal vasculopathy; Ranibizumab

MeSH Terms

Angiography
Choroid*
Choroidal Neovascularization
Diagnosis
Endothelial Growth Factors
Follow-Up Studies
Humans
Incidence
Indocyanine Green
Macular Degeneration
Observational Study
Ranibizumab
Retrospective Studies
Visual Acuity
Endothelial Growth Factors
Indocyanine Green
Ranibizumab

Figure

• 

  Fig. 1 Fluorescein angiography (A), indocyanine green angiography (B), and optical coherence tomography (C,D) findings at time of diagnosis (A,B,C) and at 57 months after diagnosis (D) in a patient with polypoidal choroidal vasculopathy. The pattern of polypoidal choroidal vasculopathy is classified as an umbrella-like pattern. The patient's visual acuity was 20 / 30 at diagnosis. During the 57-month follow-up period, the patient was treated with 10 intravitreal anti-vascular endothelial growth factor injections, including eight ranibizumab injections and two bevacizumab injections. At 57 months, there was no fluid (D) and an improvement in the visual acuity to 20 / 20.

• 

  Fig. 2 Changes in best-corrected visual acuity (BCVA, A) and central foveal thickness (CFT, B) in eyes treated with anti-vascular endothelial growth factor, according to the follow-up (FU) period. BCVA significantly improved, while CFT significantly decreased after the initial three monthly ranibizumab injections. However, the values at the last follow-up (mean, 29.6 ± 19.6 months) were not significantly different from those at baseline.

• 

  Fig. 3 A representative case of polypoidal choroidal vasculopathy (PCV) with feeder vessels. The pattern of PCV is classified as a rake-like pattern. A the time of diagnosis (A-C), polypoidal lesion (A) and subretinal fluid (C) were noted in the right eye, whereas a branching vascular network and late geographic hyperfluorescence (B, arrowheads) were noted in the left eye. The visual acuity in the right eye was 20 / 60. During the 60-month follow-up period, the right eye was treated with nine intravitreal anti-vascular endothelial growth factor injections, including seven ranibizumab injections and two bevacizumab injections. At 60 months (D-F), there is no fluid in the right eye (F) and an improvement in the visual acuity to 20 / 30. However, marked nasal extension of the PCV lesion was observed (D, arrows). In the left eye, polypoidal lesions developed at the margin of the previously noted late geographic hyperfluorescence (E, double arrowheads). (A,B,D,E) Indocyanine green angiography, (C,F) optical coherence tomography.

• 

  Fig. 4 A representative case of polypoidal choroidal vasculopathy with feeder vessels. At diagnosis (A-D), polypoidal lesions (A) and subretinal fluid (B) were observed in the right eye, whereas the left eye showed type 3 neovascularization without fluid accumulation (C,D). The visual acuity in the right eye was 20 / 100. During the 42-month follow-up period, the right eye was treated with 11 intravitreal anti-vascular endothelial growth factor injections, including eight ranibizumab injections and three bevacizumab injections. At 42 months (E,F), a small amount of subretinal fluid was observed in the right eye (E). The visual acuity in the right eye improved to 20 / 50. In the left eye, however, polypoidal lesions (F, arrowheads) developed. (A,C,F) Indocyanine green angiography, (B,D,E) optical coherence tomography.

Reference

1. Spaide RF, Yannuzzi LA, Slakter JS, et al. Indocyanine green videoangiography of idiopathic polypoidal choroidal vasculopathy. Retina. 1995; 15:100–110.

2. Yannuzzi LA, Sorenson J, Spaide RF, Lipson B. Idiopathic polypoidal choroidal vasculopathy (IPCV). Retina. 1990; 10:1–8.

3. Yuzawa M, Mori R, Kawamura A. The origins of polypoidal choroidal vasculopathy. Br J Ophthalmol. 2005; 89:602–607.

4. Kawamura A, Yuzawa M, Mori R, et al. Indocyanine green angiographic and optical coherence tomographic findings support classification of polypoidal choroidal vasculopathy into two types. Acta Ophthalmol. 2013; 91:e474–e481.

5. Tan CS, Ngo WK, Lim LW, Lim TH. A novel classification of the vascular patterns of polypoidal choroidal vasculopathy and its relation to clinical outcomes. Br J Ophthalmol. 2014; 98:1528–1533.

6. Miki A, Honda S, Kondo N, Negi A. The association of age-related maculopathy susceptibility 2 (ARMS2) and complement factor H (CFH) variants with two angiographic subtypes of polypoidal choroidal vasculopathy. Ophthalmic Genet. 2013; 34:146–150.

7. Tanaka K, Nakayama T, Mori R, et al. Associations of complement factor H (CFH) and age-related maculopathy susceptibility 2 (ARMS2) genotypes with subtypes of polypoidal choroidal vasculopathy. Invest Ophthalmol Vis Sci. 2011; 52:7441–7444.

8. Yanagisawa S, Sakurada Y, Miki A, et al. The association of elastin gene variants with two angiographic subtypes of polypoidal choroidal vasculopathy. PLoS One. 2015; 10:e0120643.

9. Honda S, Miki A, Yanagisawa S, et al. Comparison of the outcomes of photodynamic therapy between two angiographic subtypes of polypoidal choroidal vasculopathy. Ophthalmologica. 2014; 232:92–96.

10. Rosenfeld PJ, Brown DM, Heier JS, et al. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med. 2006; 355:1419–1431.

11. Cho M, Barbazetto IA, Freund KB. Refractory neovascular age-related macular degeneration secondary to polypoidal choroidal vasculopathy. Am J Ophthalmol. 2009; 148:70–78.e1.

12. Oishi A, Kojima H, Mandai M, et al. Comparison of the effect of ranibizumab and verteporfin for polypoidal choroidal vasculopathy: 12-month LAPTOP study results. Am J Ophthalmol. 2013; 156:644–651.

13. Lim JY, Lee SY, Kim JG, et al. Intravitreal bevacizumab alone versus in combination with photodynamic therapy for the treatment of neovascular maculopathy in patients aged 50 years or older: 1-year results of a prospective clinical study. Acta Ophthalmol. 2012; 90:61–67.

14. Kim JH, Lee DW, Choi SC, et al. Intravitreal anti-vascular endothelial growth factor for newly diagnosed symptomatic polypoidal choroidal vasculopathy with extrafoveal polyps. Korean J Ophthalmol. 2015; 29:404–410.

15. Lee SY, Kim JG, Joe SG, et al. The therapeutic effects of bevacizumab in patients with polypoidal choroidal vasculopathy. Korean J Ophthalmol. 2008; 22:92–99.

16. Hikichi T, Higuchi M, Matsushita T, et al. Factors predictive of outcomes 1 year after 3 monthly ranibizumab injections and as-needed reinjections for polypoidal choroidal vasculopathy in Japanese patients. Retina. 2013; 33:1949–1958.

17. Spaide RF, Koizumi H, Pozzoni MC. Enhanced depth imaging spectral-domain optical coherence tomography. Am J Ophthalmol. 2008; 146:496–500.

18. Guyer DR, Puliafito CA, Mones JM, et al. Digital indocyanine-green angiography in chorioretinal disorders. Ophthalmology. 1992; 99:287–291.

19. Tsujikawa A, Ojima Y, Yamashiro K, et al. Punctate hyperfluorescent spots associated with central serous chorioretinopathy as seen on indocyanine green angiography. Retina. 2010; 30:801–809.

20. Kang SW, Chung SE, Shin WJ, Lee JH. Polypoidal choroidal vasculopathy and late geographic hyperfluorescence on indocyanine green angiography. Br J Ophthalmol. 2009; 93:759–764.

21. Guyer DR, Yannuzzi LA, Slakter JS, et al. Classification of choroidal neovascularization by digital indocyanine green videoangiography. Ophthalmology. 1996; 103:2054–2060.

22. Kim SW, Oh J, Kwon SS, et al. Comparison of choroidal thickness among patients with healthy eyes, early age-related maculopathy, neovascular age-related macular degeneration, central serous chorioretinopathy, and polypoidal choroidal vasculopathy. Retina. 2011; 31:1904–1911.

23. Koizumi H, Yamagishi T, Yamazaki T, et al. Subfoveal choroidal thickness in typical age-related macular degeneration and polypoidal choroidal vasculopathy. Graefes Arch Clin Exp Ophthalmol. 2011; 249:1123–1128.

24. Pang CE, Freund KB. Pachychoroid neovasculopathy. Retina. 2015; 35:1–9.

25. Hikichi T, Higuchi M, Matsushita T, et al. One-year results of three monthly ranibizumab injections and as-needed reinjections for polypoidal choroidal vasculopathy in Japanese patients. Am J Ophthalmol. 2012; 154:117–124.e1.

26. Tsujikawa A, Ojima Y, Yamashiro K, et al. Association of lesion size and visual prognosis to polypoidal choroidal vasculopathy. Am J Ophthalmol. 2011; 151:961–972.e1.

27. Kim YT, Kang SW, Chung SE, et al. Development of polypoidal choroidal vasculopathy in unaffected fellow eyes. Br J Ophthalmol. 2012; 96:1217–1221.

28. Sho K, Takahashi K, Yamada H, et al. Polypoidal choroidal vasculopathy: incidence, demographic features, and clinical characteristics. Arch Ophthalmol. 2003; 121:1392–1396.

29. Byeon SH, Lee SC, Oh HS, et al. Incidence and clinical patterns of polypoidal choroidal vasculopathy in Korean patients. Jpn J Ophthalmol. 2008; 52:57–62.

30. Ueta T, Iriyama A, Francis J, et al. Development of typical age-related macular degeneration and polypoidal choroidal vasculopathy in fellow eyes of Japanese patients with exudative age-related macular degeneration. Am J Ophthalmol. 2008; 146:96–101.

31. Khan S, Engelbert M, Imamura Y, Freund KB. Polypoidal choroidal vasculopathy: simultaneous indocyanine green angiography and eye-tracked spectral domain optical coherence tomography findings. Retina. 2012; 32:1057–1068.

32. Fung AT, Yannuzzi LA, Freund KB. Type 1 (sub-retinal pigment epithelial) neovascularization in central serous chorioretinopathy masquerading as neovascular age-related macular degeneration. Retina. 2012; 32:1829–1837.

33. Sasahara M, Tsujikawa A, Musashi K, et al. Polypoidal choroidal vasculopathy with choroidal vascular hyperpermeability. Am J Ophthalmol. 2006; 142:601–607.

34. Koizumi H, Yamagishi T, Yamazaki T, Kinoshita S. Relationship between clinical characteristics of polypoidal choroidal vasculopathy and choroidal vascular hyperpermeability. Am J Ophthalmol. 2013; 155:305–313.e1.

35. Kim JH, Chang YS, Lee TG, Kim CG. Choroidal vascular hyperpermeability and punctate hyperfluorescent spot in choroidal neovascularization. Invest Ophthalmol Vis Sci. 2015; 56:1909–1915.

36. Hikichi T, Kitamei H, Shioya S. Prognostic factors of 2-year outcomes of ranibizumab therapy for polypoidal choroidal vasculopathy. Br J Ophthalmol. 2015; 99:817–822.

37. Park SJ, Kim BH, Park KH, Woo SJ. Punctate hyperfluorescence spot as a common choroidopathy of central serous chorioretinopathy and polypoidal choroidal vasculopathy. Am J Ophthalmol. 2014; 158:1155–1163.e1.