Chinese Guideline on the Management of Polypoidal Choroidal Vasculopathy (2022)

Background In China's Mainland,patients with neovascular age-related macular degeneration(nAMD)have approximately an 40%prevalence of polypoidal choroidal vasculopathy(PCV).This disease leads to recurrent retinal pigment epithelium detachment(PED),extensive subretinal or vitreous hemorrhages,and severe vision loss.China has introduced various treatment modalities in the past years and gained comprehensive experience in treating PCV.Methods A total of 14 retinal specialists nationwide with expertise in PCV were empaneled to prioritize six questions and address their corresponding outcomes,regarding opinions on inactive PCV,choices of anti-vascular endothelial growth factor(anti-VEGF)monotherapy,photodynamic therapy(PDT)monotherapy or combined therapy,patients with persistent subretinal fluid(SRF)or intraretinal fluid(IRF)after loading dose anti-VEGF,and patients with massive subretinal hemorrhage.An evidence synthesis team conducted systematic reviews,which informed the recommendations that address these questions.This guideline used the GRADE(Grading of Recommendations,Assessment,Development,and Evaluation)approach to assess the certainty of evidence and grade the strengths of recommendations.Results The panel proposed the following six conditional recommendations regarding treatment choices.(1)For patients with inactive PCV,we suggest observation over treatment.(2)For treatment-na?ve PCV patients,we suggest either anti-VEGF monotherapy or combined anti-VEGF and PDT rather than PDT monotherapy.(3)For patients with PCV who plan to initiate combined anti-VEGF and PDT treatment,we suggest later/rescue PDT over initiate PDT.(4)For PCV patients who plan to initiate anti-VEGF monotherapy,we suggest the treat and extend(TE)regimen rather than the pro re nata(PRN)regimen following three monthly loading doses.(5)For patients with persistent SRF or IRF on optical coherence tomography(OCT)after three monthly anti-VEGF treatments,we suggest proceeding with anti-VEGF treatment rather than observation.(6)For PCV patients with massive subretinal hemorrhage(equal to or more than four optic disc areas)involving the central macula,we suggest surgery(vitrectomy in combination with tissue-plasminogen activator(tPA)intraocular injection and gas tamponade)rather than anti-VEGF monotherapy.Conclusions Six evidence-based recommendations support optimal care for PCV patients'management.

Long-term observation of vitrectomy without subretinal hemorrhage management for massive vitreous hemorrhage secondary to polypoidal choroidal vasculopathy

AIM: To describe the long-term observation of vitrectomy without subretinal hemorrhage(SRH) management for massive vitreous hemorrhage(VH) secondary to polypoidal choroidal vasculopathy(PCV). METHODS: This is a retrospective, consecutive case series. A total of 86 eyes of 86 patients with >14d of massive VH associated with PCV were included. All patients underwent vitrectomy without SRH management, followed by intravitreal ranibizumab injections and/or photodynamic therapy(PDT) as needed. The main outcome measures were best-corrected visual acuity(BCVA), postoperative adverse events and the recurrence of VH. RESULTS: The average follow-up period was 25.5±9.2 mo(range 12-35 mo). Mean BCVA at baseline(2.16±0.39 logM AR)had improved significantly, both 3 mo after surgery(1.42±0.66 log MAR, P<0.001) and by the last visit(1.23±0.74 logM AR, P<0.001). The common postoperative complications included macular subretinal fibrosis in 14 eyes(16.3%) and ciliary body detachment in 4 eyes(4.7%).Nineteen eyes(22.1%) received following treatment with ranibizumab injections without/with PDT, and 15(17.4%)were resolved. Four eyes(4.7%) had recurrent hemorrhage during the follow-up period. In multiple regression analysis,thicker SRH(beta=0.33, P=0.025) in the preoperative B-scan and the presence of foveal subretinal fibrosis(beta=0.28, P=0.018) in the follow up were associated with poor postoperative BCVA. CONCLUSION: Vitrectomy without SRH management for massive VH secondary to PCV improved/stabilized visual function in the long-term observation. Eyes presenting with thicker SRH preoperatively and forming foveal subretinal fibrosis in the follow-up period tended to have worse BCVA.

Analysis of choroidal morphology and comparison of imaging findings of subtypes of polypoidal choroidal vasculopathy:a new classification system

AIM:To classify polypoidal choroidal vasculopathy(PCV)into 2 subtypes based on the subfoveal choroidal thickness(SFCT)and to further evaluate their multimodal image features.METHODS:A retrospective observational case series study.Sixty-four eyes of 64 patients with PCV were enrolled and classified into 2 groups based on SFCT(thick-choroid group/thin-choroid group).Then further analyze the spectrum domain optical coherence tomography(SD-OCT)and indocyanine green angiography(ICGA)differences of the two subtypes.Imaging analysis included measurement of SFCT,maximum vascular diameter ratio(MVDR),choroidal vascularity index(CVI),central macular thickness(CMT),and the presence of pigment epithelial detachment(PED)on SD-OCT.Polypoidal lesions(polyps)number,branching vascular network(BVN)area,greatest linear dimension(GLD),and the choroidal vascular hyperpermeability(CVH)were analyzed by ICGA.RESULTS:The distribution of SFCT was bimodal with two peaks at 195 and 285μm,and a trough at 225μm.The 225μm was taken as the cutoff point for the following classification of thick/thin choroid groups.The PCV eyes in the thick-choroid group presented with greater MVDR,CVI within 3 and 6 mm of the fovea,but lower CMT,less PED,small PED diameters on SD-OCT scans,and fewer polyps,smaller BVN and GLD,but more frequency of CVH on ICGA.CONCLUSION:The SFCT at 225μm can be used as a readily available indicator for the classification of PCV subtypes.The thick-choroid group presents much apparent enlargement of the choroidal layer and vasculature expansion,which indicates different pathogenesis of the two subtypes.

Ranibizumab alone or in combination with photodynamic therapy vs photodynamic therapy for polypoidal choroidal vasculopathy: a systematic review and Meta-analysis

AIMTo compare the efficacy of intravitreal ranibizumab (IVR) alone or in combination with photodynamic therapy (PDT) vs PDT in patients with symptomatic polypoidal choroidal vasculopathy (PCV).METHODSA systematic search of a wide range of databases (including PubMed, EMBASE, Cochrane Library and Web of Science) was searched to identify relevant studies. Both randomized controlled trials (RCTs) and non-RCT studies were included. Methodological quality of included literatures was evaluated according to the Newcastle-Ottawa Scale. RevMan 5.2.7 software was used to do the Meta-analysis.RESULTSThree RCTs and 6 retrospective studies were included. The results showed that PDT monotherapy had a significantly higher proportion in patients who achieved complete regression of polyps than IVR monotherapy at months 3, 6, and 12 (All P&#x02264;0.01), respectively. However, IVR had a tendency to be more effective in improving vision on the basis of RCTs. The proportion of patients who gained complete regression of polyps revealed that there was no significant difference between the combination treatment and PDT monotherapy. The mean change of best-corrected visual acuity (BCVA) from baseline showed that the combination treatment had significant superiority in improving vision vs PDT monotherapy at months 3, 6 and 24 (All P&#x0003c;0.05), respectively. In the mean time, this comparison result was also significant at month 12 (P&#x0003c;0.01) after removal of a heterogeneous study.CONCLUSIONIVR has non-inferiority compare with PDT either in stabilizing or in improving vision, although it can hardly promote the regression of polyps. The combination treatment of PDT and IVR can exert a synergistic effect on regressing polyps and on maintaining or improving visual acuity. Thus, it can be the first-line therapy for PCV.

One-year real-world outcomes of ranibizumab 0.5 mg treatment in Taiwan Residents patients with polypoidal choroidal vasculopathy： a subgroup analysis of the REAL study

AIM： To assess the effectiveness and safety of ranibizumab 0.5 mg in Taiwan Residents patients with polypoidal choroidal vasculopathy（PCV） by performing a retrospective exploratory subgroup analysis of the REAL study.METHODS： REAL was a 12-month, observational, prospective, non-interventional phase IV post-marketing surveillance study conducted at 9 centers in Taiwan. The study collected data as part of the routine patient visits from the medical records of patients with neovascular agerelated macular degeneration treated with ranibizumab 0.5 mg according to local standard medical practice and local label and/or reimbursement guidelines. The presence of PCV at baseline was determined using indocy received prior tanine green angiography. RESULTS： At baseline, PCV was diagnosed in 64 of the 303 enrolled patients（21.1%）. Of these, 41 patients（64.1%） hadreatment; 15（23.4%） patients had received ranibizumab. The intent-to-treat population included 58 patients; 47（80%） who received ranibizumab and 11（20%） who received ranibizumab plus photodynamic therapy（PDT; 9 patients received once, 2 patients received twice）. Bevacizumab was used as a concomitant medication in a similar percentage of patients who received ranibizumab（43%, n=20） or ranibizumab plus PDT（45%, n=5）. In patients who received ranibizumab, visual acuity（VA） at baseline was 50.1±12.9 Early Treatment Diabetic Retinopathy Study letters, and the gain at month 12 was 1.1±17.8 letters. In patients who received ranibizumab plus PDT, VA at baseline was 51.4±15.9 letters, and there was a marked gain in VA at month 12（14.0±9.2 letters, P=0.0009）. In the intent-totreat population, the reduction in central retinal subfield thickness from baseline at month 12 was 69.6±122.6 μm（baseline： 310.8±109.8 μm, P=0.0004）. The safety results were consistent with the well-characterized safety profile of ranibizumab.CONCLUSION： In real-world settings, ranibizumab 0.5 mg treatment for 12 mo results in maintenance of VA and reduction in central retinal subfield thickness in Taiwan Residents patients with PCV. Improvements in VA are observed in patients who received ranibizumab plus PDT. There are no new safety findings.

Combined therapy versus anti-vascular endothelial growth factor monotherapy for polypoidal choroidal vasculopathy： a Meta-analysis

AIM： To evaluate the efficacy and safety of anti-vascular endothelial growth factor （VEGF） combined with photodynamic therapy （PDT） versus anti-VEGF monotherapy for polypoidal choroidal vasculopathy （PCV）. METHODS： We conducted a Meta-analysis of 9 studies to compare the efficacy and safety between combined therapy and anti-VEGF monotherapy for PCV. The programs of RevMan 5.3 and Stata 12.0 were used to analyze data. RESULTS： The best corrected visual acuity （BCVA） in combined therapy group were significantly better than those of anti-VEGF monotherapy group at 6, 24 and 36mo, with pooled weighted means differences （WMDs） of 0.12 （0.06, 0.18）, 0.25 （0.12, 0.38） and 0.28 （0.13, 0.43）, respectively. The central retinal thickness （CRT） reductions in combined therapy group were higher than that in anti- VEGF monotherapy group at 1, 3, 6 and 9mo, with pooled WMDs of 63.90 （20.41, 107.38）, 33.47 （4.69, 62.24）, 30.57 （0.12, 60.01） and 28.00 （2.51, 53.49）, respectively. The regression rate of polyps in combined therapy group was much higher than that in anti-VEGF monotherapy group [RD： 0.47 （0.26, 0.68）; P〈0.0001]. The adverse event retinal hemorrhage did not differ significantly between the two groups. CONCLUSION： Our findings clearly document that anti- VEGF combined with PDT is a more effective therapy for PCV compared with anti-VEGF monotherapy. Furthermore, combined therapy does not increase the incidence of retinal hemorrhage.

Effects of three consecutive monthly intravitreal injection of ranibizumab for polypoidal choroidal vasculopathy in Korea

AIM: To evaluate the efficacy and safety of three consecutive monthly injections of intravitreal ranibizumab for the treatment of polypoidal choroidal vasculopathy(PCV) in Korea.METHODS: A retrospective chart review of 25 patients(27 eyes) with PCV was conducted. Patients received three initial monthly intravitreal injections(0.5 mg) of ranibizumab and were monitored monthly for 12 mo from January 2010 to October 2011. Reinjection of ranibizumab after three initial monthly loading was administered on an as-needed basis, guided by the optical coherence tomography(OCT), fluorescein angiography(FA) and indocyanine green angiography(ICGA). The main outcomes were the changes of the mean best corrected Snellen visual acuity(VA), central macular thickness(CMT) by OCT, the changes of polyps and branching vascular network by FA and ICGA, and total number of injections received by patients during the 12 mo.RESULTS: The mean best corrected Snellen visual acuities at baseline, 1, 3, 6 and 12 mo after primary injection were 0.77 ±0.59, 0.76 ±0.53, 0.70 ±0.47, 0.63 ±0.43,0.61 ±0.43, 0.62 ±0.42 log MAR, respectively, and showed significant improvement at 3, 6, 12mo(P =0.003, P =0.002,P =0.018, Wilcoxon signed-rank test). The mean CMT at baseline, 1, 2, 3, 6, and 12 mo was 312.41 ±66.38 μm,244.59 ±71.47 μm, 232.32 ±69.41 μm, 226.69 ±69.03 μm,228.62 ±37.07 μm, 227.59 ±51.01 μm respectively, and showed significant reduction(all P 【0.001, Wilcoxon signed-rank test). Polypoidal lesions resolved on ICGA in 3 eyes(11.1%) and a branching vascular network remained in all 24 eyes(88.9%). A total of 106 injections were given in the 12-month period, which equaled to a mean of 3.92(range, 3-6) times. Sixteen of the 27 treatedeyes had additional 1.56 ±0.91 injections. The others(11eyes) had just 3 consecutive injections.CONCLUSION: An initial loading dose of three monthly ranibizumab injections is a safe and effective method in treating PCV, with visual and anatomical improvement over one year follow-up.

Long-term outcomes of focal laser photocoagulation for the treatment of polypoidal choroidal vasculopathy

AIM:To evaluate the long-term effect and safety of focal laser photocoagulation treatment in eyes with polypoidal choroidal vasculopathy(PCV).METHODS:Medical records of 13 eyes of 13 patients with PCV were followed-up for more than 2 y after focal laser photocoagulation treatment.The patients were diagnosed with PCV using indocyanine green angiography,and eyes with other comorbid ocular diseases were excluded.The measurement outcomes of the study were the post-treatment regression and recurrence of polyps,complications,and changes in visual acuities.Paired t-test was performed to compare visual outcome before and after the treatment.RESULTS:The mean age of the 13 patients was 70.2±5.5 y,and the follow-up period was 72.3±31.0(range,25-118)mo.Three eyes had juxtafoveal polyps and 10 eyes had extrafoveal polyps.Of the 13 eyes,9 eyes(69.2%)had regression of polyps 1.7±1.2(range,0.9-4)mo after focal laser photocoagulation.Five eyes(55.6%)showed recurrence of polyps during the follow-up periods,and the recurrence period was 12.8±18.9(range,1.9-48)mo.Mild subretinal hemorrhage occurred in two eyes(15.4%)27 and 72 d after laser treatment,respectively.There were no statistically significant differences in visual acuities at baseline;1,2,3 y post-treatment(all P>0.05);and last follow-up(0.63±0.5,0.73±0.70,0.67±0.57,0.75±0.7,and 0.95±0.8 log MAR,respectively).CONCLUSION:Focal laser photocoagulation is beneficial for early regression of polyps in eyes with PCV and does not result in significant submacular hemorrhage during the long-term follow-up.Furthermore,it can be primarily considered in eyes with PCV with extrafoveal or juxtafoveal polyps to regress risky polyps as well as to maintain visual acuity without serious hemorrhagic complications.

Bilateral choroidal osteoma with unilateral polypoidal choroidal vasculopathy treated with conbercept

Dear Editor,Chorodial osteoma(CO) is a rare choroidal tumor characterized by the presence of mature bone tissue predominantly in the juxtapapillary or macularregion.CO mostly affects young healthy females in the second or third decades of life.It is unilateral in approximately 80%of cases[1],as patients have no obvious visual symptoms during the early stage of CO,and the growth of CO is slow.CO patients usually visit the eye clinic during the later stages of CO and have poor vision.Gradual decline in vision in CO patients is related to changes in retinal pigment epithelium(RPE)and photoreceptor atrophy.Choroidal neovascularization(CNV)and the resultant subretinal fluid and hemorrhage are the most frequent causes of sudden vision loss in CO[2].We report a rare case of bilateral CO with unilateral polypoidal choroidal vasculopathy(PCV)in a middle-aged male.

Combined photodynamic therapy and ranibizumab for polypoidal choroidal vasculopathy：a 2-year result and systematic review

AIM：To report a cohort of patients with polypoidal choroidal vasculopathy（PCV）treated with photodynamic therapy（PDT）followed by intravitreal ranibizumab injection 24-48 h later,and to compare the results between eyes with PCV treated by PDT followed by intravitreal anti-vascular endothelial growth factor（VEGF）injection and intravitreal anti-VEGF injection followed by PDT by Meta-analysis.METHODS：Retrospective study and systematic literature review. Medical records of patients with PCV who were initially treated using PDT followed by intravitreal ranibizumab injection 24-48 h after PDT and had completed at least 2y follow-up were reviewed and analyzed. Clinical data,including age,sex,best-corrected visual acuity（BCVA）,fundus photograph,fluorescein angiography,indocyanine green angiography and optical coherence tomography were investigated. A systematic literature review was also conducted,and a visual outcome of studies over 1y was compared using Meta-analysis. RESULTS：A total of 52 patients were included in the study. Mean BCVA at baseline and follow-up at 1 or 2y were 0.71± 0.61,0.51±0.36 and 0.68±0.51 log MAR,respectively. The cumulative hazard rate for recurrence at 1 and 2y followup was 15.4% and 30.3% respectively. The percentage of eyes with polyps regression at 3,12 and 24 mo follow-up was 88.5%,84.6% and 67.3% respectively. A Meta-analysis based on 22 independent studies showed the overall vision improvements at 1,2 and 3y follow-up were 0.13±0.04（P〈0.001）,0.12±0.03（P〈0.001）,0.16±0.06（P〈0.001）,respectively. The proportion of polyps regression at 1y follow-up was 64.6%（95%CI：51.5%,77.7%,P〈0.001）in 434 eyes treated by intravitreal anti-VEGF agents beforePDT and 76.0%（95%CI：64.8%,87.3%,P=0.001）in 199 eyes treated by intravitreal anti-VEGF agents after PDT. CONCLUSION：Intravitreal ranibizumab injection 24-48 h following PDT effectively stabilizes visual acuity in the eye with PCV. PDT followed by intravitreal anti-VEGF agents may contribute to a relatively higher proportion of polyps＇ regression as compared to that of intravitreal anti-VEGF before PDT.

Giant non-pulsatile polypoidal choroidal vasculopathy

Polypoidal choroidal vasculopathy （PCV） was first described by Yannuzzi et al in the 1980s as a distinct choroidal abnormality. Clinically, PCV is seen as orange-red subretinal nodules frequently presenting with submacular haemorrhage or serosanguinous pigment epithelial detachments （PED） .

Visual prognosis of vitrectomy for polypoidal choroidal vasculopathy with breakthrough vitreous hemorrhage

Aim:The objective of this study was to investigate the prognosis of massive vitreous hemorrhage(VH)secondary to polypoidal choroidal vasculopathy(PCV)after vitrectomy.Methods:Forty-nine eyes in 48 patients with PCV and breakthrough VH who underwent 23-gauge pars plana vitrectomy between January 2015 and December 2020 were enrolled.The main outcome parameters were best-corrected visual acuity,postoperative adverse events,and reoperation.Results:The average follow-up time was 20.0±15.82 months.The average preoperative best-corrected visual acuity(BCVA)was 2.12±0.65 logarithm of the minimum angle of resolution(logMAR),the BCVA at six monthswas 1.65±0.64 logMAR,and the six-month follow-up BCVA was 1.67±0.76 logMAR.Compared to the average preoperative BCVA,the six-months and last follow-up BCVA after vitrectomy improved(P<0.05).The BCVA at the final follow-up was better than 1.3 logMAR only in 14 eyes(28.6%).Postoperative complications were observed in 10 eyes(20.4%),including recurrent retinal detachment,recurrent vitreous hemorrhage,macular hole,hyphema and lens dislocation.Fourteen eyes(28.6%)underwent cataract surgery procedure an average of 10.16±5.14 months after vitrectomy.BCVA one week and three monthsafter cataract surgery improved compared toBCVA before cataract surgery(P<0.05).Hypertension was associated with BCVA six months after vitrectomy(P=0.017).The BCVA at baseline and three months after PPV were worse in patients who underwent vitrectomy combined with silicone oil filling(P<0.05).Eyes with postoperative complications had worse BCVA at six months,12 months,and at the final follow-up after PPV(P<0.05).The duration of VH is related to the BCVA 12 months after PPV visual acuity after surgery.Patients who underwent vitrectomy within one month of the onset of vitreous hemorrhage had better BCVA 12 months after vitrectomy than those who underwent vitrectomy surgery one month later(P=0.015).Conclusions:Although the prognosis of vitrectomy varies greatly,cataract surgery could be considered to improve BCVA if polypoidal lesions are inactive six months after vitrectomy.

Comparison of the 1-year Outcomes of Conbercept Therapy between Two Different Angiographic Subtypes of Polypoidal Choroidal Vasculopathy

Background：Polypoidal choroidal vasculopathy （PCV） is characterized by the presence of polyps with or without a branching vascular network and more prevalent among Asians.The aim of this study was to compare the outcomes of conbercept therapy between two different angiographic subtypes of PCV.Methods：Fifty-eight patients of PCV were classified into two phenotypes according to indocyanine green angiography （ICGA）.In Type 1,both feeder and draining vessels are visible on ICGA and network vessels are numerous.In Type 2,neither feeder nor draining vessels are detectable,and the number of network vessels is small.The patients were treated with intravitreal conbercept （IVC） for 3 months.Additional 1VC was given at subsequent monthly visits,if needed.The patients were followed up for 12 months,and changes in mean best-corrected visual acuity （BCVA）,central retinal thickness （CRT）,subretinal fluid （SRF） thickness,pigmented epithelial detachment （PED）,hemorrhage,and number of polypoidal lesions were evaluated.Results：The mean BCVA in Type 2 PCV （15.92 ± 9.76 letters） achieved a significantly greater improvement than that in the Type 1 （14.10± 9.07 letters） at month 12 （t=2.37,P〈 0.01）.Moreover,the mean CRTdecrease was numerically greater in Type 2 （120.44± 73.81μm） compared with Type 1 （106.48 ± 72.33 μm） at month 6 （t =4.31,P 〈 0.01）,and greater in Type 2 （130.21 ± 76.28 μm） compared with Type 1 （111.67 ± 79.57μm） at month 9 （t =1.87,P 〈 0.0l）.There was no significant difference between the two types for the decrease in SRF thickness,PED height,and regression of polyps from month 3 to 12 （t =2.97,P〉 0.05）.Conclusion：Classification systems for PCV will show differences in presentation,natural history,or response to anti-vascular endothelial growth factor treatment and might,therefore,provide a new key to the choice of treatment for the disease.

Evaluation of the association of C5 with neovascular age-related macular degeneration and polypoidal choroidal vasculopathy

Background:Neovascular age-related macular degeneration(AMD)and polypoidal choroidal vasculopathy(PCV)are sight-threatening maculopathies with both environmental and genetic risk factors.We have previously shown relative risks posed by genes of the complement pathways to neovascular AMD and PCV.Methods:In this study,we investigated the haplotype-tagging single nucleotide polymorphisms(SNPs)in the complement component 5(C5)gene in 708 unrelated Chinese individuals:200 neovascular AMD patients,233 PCV patients and 275 controls.Six tagging SNPs in C5 were genotyped.Univariate single SNP association analysis,haplotype-based association analysis and gene-gene interaction analysis between C5 and other AMD-associated genes were performed.Results:The results revealed none of the six tagging SNPs of the C5 gene had a significant association with neovascular AMD or PCV(P>0.05).We also found insignificant haplotype-based association,and no significant SNPSNP interaction between C5 and other genes(including C2-CFB-RDBP-SKIV2L,SERPING1,CETP,ABCG1,PGF,ANGPT2,CFH and HTRA1)for neovascular AMD and PCV.Conclusions:This study showed no statistical significance in the genetic association of C5 with neovascular AMD or PCV in a Hong Kong Chinese population.Further studies in large samples from different populations are warranted to elucidate the role of C5 in the genetic susceptibility of AMD and PCV.

Comparison of OCT and OCTA manifestations among untreated PCV, neovascular AMD, and CSC in Chinese population

AIM: To compare the qualitative and quantitative features among untreated polypoidal choroidal vasculopathy(PCV), neovascular age-related macular degeneration(nv-AMD) and central serous chorioretinopathy(CSC) using optical coherence tomography(OCT) and OCT angiography(OCTA).METHODS: This retrospective study included 16 eyes with thin-choroid PCV, 18 eyes with thick-choroid PCV, 16 eyes with nv-AMD and 17 eyes with CSC, respectively. The indicators were obtained by OCT and OCTA.RESULTS: Sub-foveal choroidal thickness(SFCT) in CSC was thicker compared to other groups(all P<0.05). SFCT in nv-AMD was thicker compared to thin-choroid PCV, but thinner compared with thick-choroid PCV(both P<0.05). As the ratio of thickness of Haller's layer to thickness of SFCT, which of thin-choroid PCV was significantly higher than CSC(P<0.001). Likewise, thick-choroid PCV had significantly higher ratio than nv-AMD(P=0.016) or CSC(P<0.001). There were differences among them in pigment epithelium detachment(PED). The whole-superficial retinal vessel density(RVD), deep RVD and choroidal capillary vessel density(CCVD) in CSC were significantly higher compared to other three groups, respectively(all P<0.05). The whole CCVD in nv-AMD was higher compared to thick-choroid PCV(P=0.032). Cross-sectional local angiographic form was 87.50%, 83.33%, 0 and 35.29% in thin-choroid PCV, thickchoroid PCV, nv-AMD and CSC, respectively. Cross-sectional diffuse angiographic form was 12.50%, 16.67%, 100% and 5.88% in thin-choroid PCV, thick-choroid PCV, nv-AMD and CSC, respectively.CONCLUSION: Combination of OCT and OCTA can effectively observe the significant alterations existed in PCV, CSC and nv-AMD, and there are distinctive differences among them. The pathogenesis is not exactly the same between PCV and nv-AMD, or PCV and CSC.

Retinal circulation and its role in macular disorders in patients without systemic disease

AIM: To determine whether retinal circulatory changes play a role in the pathogenesis of macular disorders in patients who are otherwise healthy. METHODS: Patients with macular disorders that required angiographic imaging were included in this prospective case series. After a complete ocular exam,fluorescein angiography was performed using a standardized technique on the HRA-II(Heidelberg Engineering, Heidelberg, Germany) with special focus on the posterior pole. Only patients with good quality images were included in the analysis. Circulatory parameters recorded included the arm-choroid time,choroid-retinal artery, and finally the retinal artery-vein time. Zonal asymmetry(between the upper and lower zones divided by a line passing through the centre of the fovea) in transit times, if any was also noted. Appropriate statistical analysis was done. Circulation times were compared with age matched historical controls. Changes in retinal dye transit times relative to historical age matched controls, if any, were noted and compared between various disorders.RESULTS: A total of 156 eyes of 156 patients(120 males)were included in the study. Mean age: 49.14 ±14.93 y.Macular disorders studied were age related degeneration,polypoidal vasculopathy, central serous chorioretinopathy(CSCR) and parafoveal telangiectasia. Delayed circulation time was noted in CSCR patients only.CONCLUSION: CSCR patients appear to have delayed arterial filling, retinal circulatory disturbances do not seem to contribute to the pathogenesis of other macular disorders.

Prevalence of focal lamina cribrosa defects in eyes with pachychoroid disease spectrum

AIM:To determine the prevalence of focal lamina cribrosa(LC)defect among patients with pachychoroid disease spectrum(PDS)in the absence of peripapillary retinoschisis.METHODS:This retrospective,cross-sectional study comprised of 180 patients with PDS,including polypoidal choroidal vasculopathy(PCV),central serous chorioretinopathy,and pachychoroidal neovasculopathy.Medical records and optic ner ve head evaluations conducted using spectral-domain optical coherence tomography with enhanced depth imaging were reviewed.As a control group,236 patients who underwent ophthalmologic evaluation for vitreous floaters,without obvious ocular disease,were also included.RESULTS:The mean age of the PDS group,which included 118 male patients(65.6%),was 57.4±11.1 y.There was no significant difference between the two groups in age(P=0.710)or sex(P=0.248).Six patients(3.3%)in the PDS group and none in the control group showed focal LC defect(P=0.318).Among the six patients with focal LC defect in the PDS group,four eyes had PCV,one eye was the fellow eye of a PCV eye,and one eye had pachychoroidal neovasculopathy.CONCLUSION:Focal LC defect can be defected in patients with PDS in the absence of peripapillar y retinoschisis.However,the prevalence of focal LC defect was not different significantly between PDS patients and those who did not have PDS.

Management of subretinal hemorrhage

Subretinal hemorrhage is a vision threatening complication of exudative age related macular degeneration(AMD) and polypoidal choroidal vasculopathy(PCV). Timely removal or displacement of subretinal hemorrhage from the central macula, ideally within 7 to 10 days after onset, is critical to allowing potential recovery of vision. Surgical techniques with the use of a bubble to displace the subretinal hemorrhage can now be performed with tissue plasminogen activator to lyze the blood and with or without vitrectomy.

Submacular hemorrhage:treatment update and remaining challenges

Submacular haemorrhage(SMH)is a sight threatening complication that can occur in exudative age related macular degeneration(AMD),but has been described to occur more frequently in eyes with polypoidal choroidal vasculopathy(PCV).Left untreated,SMH carries a grave visual prognosis.Thus,expedient diagnosis and effective management of this complication is of paramount importance.The treatment strategies for SMH include(I)displacement of blood from the fovea,usually by injection of an expansile gas;(II)pharmacologic clot lysis such as with recombinant tissue plasminogen activator(rtPA);and(III)treatment of the underlying choroidal neovascularization(CNV)or PCV,such as with anti-vascular endothelial growth factor(anti-VEGF)agents.These three strategies have been employed in isolation or in combination,some concurrently and others in stages.rtPA has demonstrable effect on the liquefaction of submacular clots but there are remaining uncertainties with regards to the dose,safety and the timing of initial and repeat treatments.Potential side effects of rtPA include retinal pigment epithelial toxicity,increased risk of breakthrough vitreous haemorrhage and systemic toxicity.In cases presenting early,pneumatic displacement alone with anti-VEGF may be sufficient.Anti-VEGF monotherapy is a viable treatment option particularly in patients with thinner SMH and those who are unable to posture post pneumatic displacement.