Click here to see the Cover Story for this Point/Counter.
More common than once thought
Polypoidal choroidal vasculopathy (PCV) is more common than we used to think. Many of the cases of choroidal neovascularization (CNV) that we attribute to neovascular age-related macular degeneration (AMD) are, in fact, due to PCV. We tend to think of PCV as being more common in African American patients and those of Mediterranean heritage, but it is becoming increasingly prevalent in our AMD patient population in general.
One in five “wet AMD” patients may harbor polypoidal-like CNV lesions. While PCV can often be suspected on intravenous fluorescein angiography (IVFA), it is difficult to unequivocally make the diagnosis using IVFA alone. Indocyanine green angiography (ICGA) is usually required to detect the characteristic choroidal polypoidal lesions seen in PCV. Newer technologies, like optical coherence tomography angiography (OCTA), may make ICGA less necessary to determine if PCV lesions are contributing to or are entirely responsible for the exudation observed in patients we are currently treating as wet AMD patients. Unfortunately, OCTA is not yet widely available at all retinal physicians’ practice locations, but, then again, neither is the more invasive ICGA.
In the not too distant future, it is more likely that OCTA will be the test of choice for diagnosing and managing PCV. Currently, it is rare for me to order ICGA for all new suspected wet AMD patients, despite the high prevalence of crossover, primarily because the results of the test do not change my management: regular and consistent intravitreal anti-vascular endothelial growth factor (anti-VEGF) monotherapy. When I have a high degree of suspicion that PCV is present, I will order ICGA if it is readily available. If it is not available, I will proceed with empiric treatment of PCV/neovascular AMD based upon optical coherence tomography and IVFA findings alone.
I tend to approach the management of patients with PCV in the same manner as I treat typical wet AMD patients: by implementing the intravitreal anti-VEGF monotherapy treatment paradigm. The one way in which data from ICGA may influence my management is that I may explain the altered prognosis vis a vis the increased treatment burden the PCV patient may expect compared with a more typical wet AMD patient. I may also explain that occasionally additional therapies (for example, photodynamic therapy) may be required for more refractory PCV cases.
Andrew A. Moshfeghi, MD, MBA, is the OSN Retina/Vitreous Section Editor. Disclosure: Moshfeghi reports he is a consultant for Regeneron, Genentech, Allergan and Valeant and he receives research funding from Regeneron.
Combination therapy is effective
One month ago, my answer to this question would have been a resounding “no.” The reason would have been due to several factors. Foremost would have been the fact that in Kentucky, we see fewer patients with suspected idiopathic polypoidal choroidal vasculopathy (IPCV). Our age-related macular degeneration (AMD) patient population is primarily Caucasian. Additional factors include the fact that the quality of our indocyanine green angiograms (ICG) were less than ideal and the fact that most early, more limited cases of IPCV respond well to anti-VEGF therapy.
My enthusiasm for ICG has evolved as we have added ultrawide field ICG capabilities to our Louisville office. In addition, one of our younger photographers has embraced the Spectralis system in our Lexington office and has become quite proficient at obtaining high quality images. Adding ICG to the traditional fluorescein angiography has become more of my standard for patients with exudative AMD, regardless of ethnicity. Certainly, in an Asian or African American patient with clinical signs of IPCV, I would currently be more likely to obtain ICG to better apprise the patient of their prognosis and consider utilizing combination therapy in such a patient.
John W. Kitchens, MD, is an ophthalmologist at Retina Associates of Kentucky. Disclosure: Kitchens reports no relevant financial disclosures.