CaseWise 17

Polypoidal choroidal vasculopathy  

Dr. Neha Shah, Dr Sarang Lambat, Dr. Vinay Nangia 
Suraj Eye Institute, Nagpur, India

Introduction :    

Polypoidal choroidal vasculopathy (PCV) is a retinal disease involving the choroidal vasculature characterised by the presence of polypoidal lesions with or without branching vascular network best seen on indocyanine green angiography (ICGA). The clinical features of PCV include recurrent sub-retinal haemorrhage; serosanguineous pigment epithelial detachment, sub-retinal exudation and serous retinal detachment.1         

Case Report :

A woman, 59 years of age, diagnosed case of age related macular degeneration had received multiple intravitreal anti-VEGF injections (3-4 injections per year) since 4 years. She also had undergone 1 session of photo dynamic therapy for both eyes. Her vision was 6/60 in the right eye and  CF 3 mt in the left eye. She was pseudophakic in both eyes with an intra ocular pressure of 16 mmHg in both eyes. She had significant macular edema with extensive hard exudates in both eyes (Fig 1A and 1B). OU FFA showed substantial amount of hyper-fluorescence from undetermined source suggestive of an occult choroidal neovascularisation CNV (Fig. 2A and 3A). Simultaneous ICG showed presence of bulb like projections from choroidal vasculature suggestive of polypoidal choroidal vasculopathy (Fig. 2B and 3B). SDOCT of RE showed presence of intra-retinal cysts and sub retinal fluid(SRF) with a fibrovascular pigment epithelial detachment (PED) (Fig. 4). SDOCT of LE showed presence of a large degenerative cyst at fovea with sub-retinal scarring (Fig 5). Inspite of  multiple anti-VEGF injections there was persistence of PED and retinal oedema. We planned to do a direct thermal photocoagulation of the polyps in both eyes. 1 month post laser right eye PED had resolved and there was significant reduction in SRF and intra-retinal cysts, with improvement in vision to 6/36 (Fig 6). In the left eye the SRF decreased and vision improved to CF 5mt. Post laser the number of injections in both her eyes decreased from 4-5 a year to 1-2 a year. She has been advised regular follow-up for further management

Discussion :

PCV is a common retinal condition in Asian countries and affects 25-50% of Asian patients with presumed neovascular AMD1. ICGA is essential in the diagnosis of PCV and should be performed in cases suspected of PCV or in cases of neovascular AMD refractory to anti-VEGF therapy since the choice of treatment and visual prognosis is different for the two conditions. If the symptomatic polyps and branching vascular network (BVN) are located at a safe distance away from the fovea, direct thermal laser photocoagulation can be considered2. For symptomatic polyps with juxta-foveal or sub-foveal involvement, Verteporfin PDT with or without intravitreal injection of an anti-VEGF agent should be considered.3 There are no reports of a specific type of anti-VEGF agent which is beneficial for the resolution of PED. Following treatment, patients should be monitored regularly with imaging in order to assess the activity of the polypoidal lesions and to determine the need for re-treatment. In our case there was a persistent edema of retinal layers with sub RPE fluid which was not resolving with injections. On ICG we could locate that the polyps were away from the fovea. Laser photocoagulation of the polyps may have helped in the resolution of the PED and subsequently reducing the number of injections required every year.

References
1) Wong RL, Lai TY. Polypoidal choroidal vasculopathy: an update on therapeutic approaches. J Ophthalmic Vis Res. 2013;8(4):359‐371.(https://pubmed.ncbi.nlm.nih.gov/24653824/)
2) Lai TY, Chan WM. An update in laser and pharmaceutical treatment for polypoidal choroidal vasculopathy. Asia-Pac J Ophthalmol 2012;1:97-104.(https://pubmed.ncbi.nlm.nih.gov/26107131/)
3) Chan WM, Lam DS, Lai TY, Liu DT, Li KK, Yao Y, et al. Photodynamic therapy with verteporfin for symptomatic polypoidal choroidal vasculopathy: one-year results of a prospective case series. Ophthalmology 2004;111:1576-1584. (https://pubmed.ncbi.nlm.nih.gov/15288991/)
4) Chan WM, Liu DT, Lai TY, et al. Extensive submacular haemorrhage in polypoidal choroidal vasculopathy managed by sequential gas displacement and photodynamic therapy: a pilot study of one-year follow up. Clin Exp Ophthalmol. 2005;33:611Y618. (https://pubmed.ncbi.nlm.nih.gov/16402954/)

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