Good Hope, Heartlands, and Solihull Eye Clinics

Polypoidal choroidal vasculopathy wet ARMD

David Kinshuck

 

Polypoidal choroidal vasculopathy

This is another type of CNV. The condition is seen as a branching choroidal network of vessels with vascular dilatation.

  • more common in Chinese and Afro-Caribbeans.
  • The choroidal neovascularisation often occurs with a serous haemorrhagic PED.  
  • Polypoidal choroidal vasculopathy page.   
  • multiple PEDS, subretinal haemorrhages, visible polyps: deep orange lesions
  • lipid exudates, subretinal fluid, RPE atrophy, peripapillary lesions
  • classic & occult cnv, peripheral lesions: Features see
  • distinguishing polypoidal choroidal vasculopathy from typical neovascular age-related macular degeneration based on spectral domain optical coherence tomography Retina16
  • Wilki
  • type 1 and type 2 IOVS; this depends on he presence or absence of feeder vessels Retina 18

Features of PCV, after Yang 2012

 

  • really need ICG
  • features vascular and secondary components
  • Vascular
    • nodular choroidal lesions
    • branching vascular networks
    • associated classic/occult CNV
  • Secondary features:
    • serous PED
    • subretinal haemorrhage
    • preretinal haemorrhage
    • haemorrhagic PED
    • lipid exudation
    • SRF
    • CSR
    • fibrosis  and atrophy

 

PCV paper...look for the polyps

look for the polpyps...the white blobs

 

 

BJO diagram PCV features

 

Look for the polyps and branching vascular network (BVN)

Look for polyps on the ICG, or suspect the condition if the features above are present. On the ICG, the polyps occur on a local dark patch on the ICG. Also, look for the feeding branching vascular network (BVN). The polyps occur in nodules, loops, or coils. The polyps show up late at 4 minutes on the ICG. It may be the BVN is simply CNV confined to one retinal layer.

 

close up of PCV with its BVN  (from photo above)

the arrow points to the BVN, the white blobs are the polyps (ICG photo)

 

cot diagram of pcv findings

look for the notch and the polyps

polyps and branching vascular network in PCV

polyps and branching vascular network (BVN) in PCV

 

polypoidalcnv

 

Haemorrhagic PEDs

haemorhagic PED...typical of pcv

haemorrhagic PED..typical of PCV

66% of these are due to PCV (the remainder are due to other types of CNV (wet ARMD). Peripheral Retina 2013.

With vitreous haemorrhage Eye 14

 

 

Type 1 or 2 PCV

 

type 1 and type 2 IOVS type 1 type 2
polyps & pigment epithelial detachments most 100%
cnv 0 100%
branching vascular network most  a few
drusen a few most
2 subtypes depending on choroidal vascularity  Retina17    

 

 

 

Everest Study & treatment

  • Retina 2102 this confirms that PDT and anti-VEGF treatment is 70% effective for PCV
  • Anti-VEGF alone closes 30%
  • Anti-VEGF helps Retina 2013
  • treat and extend Retina17

Some notes

  • Anti-VEGF alone Eye 18 regular dosing
  • combination reatment Retina 18
  • OCTa Retina17
  • BJO 14    EYE 14   
  • ICG will identify this condition
  • paper and diagram     BJO 2012
  • PDT any well defined lesions, 80% resolution, although anti-VEGF treatment is routine
  • if not well defined, anti-VEGF, and then when retina drier proceed with PDT; with PDT Retina 2012
  • anti-VEGF not very effective Gomi BJO 2008   limited Lai BJO 2008
  • Afro-Caribean..female; Asian...male; Caucasian ..bilateral peripapillary
  • Yanuzzi      Argon laser      PDT alone Retina 2010    PDT and anti-VEGF Retina 2012
  • Cackett     haemorrhagic ped is predictive of PCV 2010
  • Cackett, classification
  • PDT and and anti-vegf combined are effective BJO 2010  Eye 14
  • there may be polyps in most chronic cnv membranes Eye 2011  FFA was used to identify lesions: perhaps we need to look harder. Combined Retina 2011  Retina 2011
  • Avastin works Retina 2011 ; Lucentis Retina 2011
  • assess appearance Eye 11
  • Natural course unfavourable Retina 2011
  • Avstin just as effective as Lucentis Eye 2012
  • choroid is thicker Graefes 2011
  • larger lesions less responsive BJO 2011
  • other eye risk BJO 2012
  • genes for PCV are similar to ARMD generally
  • low power laser may help if PDT not available.
  • treatment guidelines Retina 2013, ICG, then VPT & Anti-VEGF
  • BJO 2013
  • anti-VEGF and PDT are effective Eye 2013  Eye 2013
  • Review 2013 JOVR
  • may be related to previous CSR Eye 14
  • white patients  Retina 14 ;  different types BJO 14
  • aflibercept may be more effective Retina14  (seemed to be more effective refactory PCV)
  • still  problem in white patients..patients also treated with PDT Retina 14
  • aflibercept helps Retina14     BJO 15   Retina16   
  • but 25% recur Retina16 
  • Response BJO 15   
  • high dose anti-VEGF none-Asian Eye 15
  • review Retina15
  • on-going treatment is needed BJO17
  • "The absence of submacular hemorrhages, presence of grape-like polyp clusters, and large lesion size at diagnosis were associated with a high risk of reactivation of PCV"      Eye17
  • Continued follow up is needed BJO 17
  • commoner in Asia
  • Halo pcv hypoflourescent, pulsatile polyp, oOrange red subretinal nodules, mMassive subretinal haemorrhage, lLarge haemorrhagic ped, notched ped
  • Chronic csc, nNo soft drusen, patchy drusen, younger, unlateral, poor early repsonse
  • Without full resolution of fluid, 8 or more injections year
  • Laser none Foveal helps.. light to moderate laser may may recur more that 50%
  • After pdt can bleed, can leak
  • combination treatment pcv and pdt, wait 3m
  • No need to defer....deferring more injections
  • low risk no pcv regular injection, at 3m no or poor response ask for icg
  • High risk icg at baseline, severe cases pdt first
  • Antivegf none responders....Pdt at 3m