APVRS delivers consensus on polypoidal choroidal vasculopathy at EURETINA 2024 On Day 3 of the 24th Congress of the European Society of Retina Specialists (EURETINA 2024), the Asia-Pacific Vitreo-retina Society (APVRS) took over the podium to present their consensus statements on polypoidal choroidal vasculopathy (PCV). Highlighting new links to neovascular age-related macular degeneration (nAMD) and future breakthroughs on the horizon, the session delivered the latest insights into this complex retinal disease.
Polypoidal choroidal vasculopathy has long been recognized as a distinct, recurrent exudative maculopathy, but as Dr. Yasuo Yanagi (Japan) emphasized during the APVRS session, recent findings have redefined PCV as a subtype of nAMD.
PCV is marked by aneurysmal dilations at the ends of branching neovascular networks. While its roots were once thought to lie purely in choroidal vascular disease, today it is considered a variant of type 1 macular neovascularization (MNV).
Dr. Yanagi detailed the genetic overlap between PCV and typical nAMD, with both conditions sharing susceptibility loci such as ARMS2 and HTRA1.
“There is a genetic overlap between PCV and cardiovascular AMD,” he noted, emphasizing that, despite these similarities, certain features—like its predilection for Asian and other pigmented populations—set PCV apart.
Additionally, PCV tends to arise from localized ischemic or inflammatory responses, sometimes linked to pachychoroid conditions.
This reclassification underscores the importance of viewing PCV through the broader lens of nAMD, while recognizing its unique characteristics and risk factors.
A spotlight on non-invasive techniques
While indocyanine green angiography (ICGA) remains the gold standard for diagnosing PCV, Prof. Timothy Lai (Hong Kong) highlighted the growing role of non-invasive imaging, like spectral-domain (SD) and swept-source (SS) optical coherence tomography (OCT) in identifying key PCV features. “PCV can be differentiated from non-PCV neovascular AMD using OCT in the majority of cases,” he explained.
Prof. Lai highlighted that multimodal imaging—incorporating fundus photography, fluorescence angiography, OCT, and OCT angiography (OCTA)—is recommended for a comprehensive initial assessment. “We should use multiple imaging modalities to diagnose and manage them properly,” he said.
SD-OCT’s ability to visualize polyps as anterior dome-shaped elevations of the retinal pigment epithelium (RPE) is pivotal. In particular, OCTA’s potential to detect blood flow irregularities in polypoidal lesions provides additional diagnostic insight. While not a complete replacement for ICGA, these tools allow clinicians to monitor disease progression and treatment response with greater precision.
For cases with suboptimal anti-VEGF response, Prof. Lai stressed that non-ICGA features—such as the sharp peak PED—guide photodynamic therapy (PDT), reinforcing the vital role of OCT-based diagnostics in modern PCV management.
Balancing efficacy and vision preservation
Medical treatment options for PCV need to balance efficacy and long-term vision maintenance. Prof. Seung-Young Yu (South Korea) noted that “the closure of active polypoidal lesions is crucial for achieving both optimal visual improvement and long-term visual maintenance in PCV treatment.”
Prof. Yu detailed two primary approaches: Anti-VEGF monotherapy and combination therapy, each with strong clinical backing. The PLANET trial supports anti-VEGF monotherapy, while combination therapy—anti-VEGF and verteporfin photodynamic therapy (PDT)—has shown great results in trials like EVEREST and EVEREST II.1,2,3
“Anti-VEGF monotherapy can be used as the first-line treatment based on outcomes from the PLANET trial, while combination therapy is also supported by the EVEREST trials,” she noted.
Prof. Yu also discussed the potential of a treat-and-extend approach, offering patients fewer injections with sustained outcomes. Additionally, longer-lasting anti-VEGF agents present new possibilities, further enhancing treatment flexibility and durability.
The need for urgent surgical intervention
PCV patients may suffer hemorrhaging, which will require surgical treatment. “Submacular hemorrhages have poor visual prognosis due to fibrosis or atrophic scars,” explained Prof. Dr. Paisan Ruamviboonsuk (Thailand), highlighting the urgency of treatment.
For medium to large hemorrhages, Prof. Ruamviboonsuk presented various options, including pneumatic gas displacement, vitrectomy, and submacular injections of anti-VEGF and tissue plasminogen activator (TPA). He emphasized that “surgery achieved better visual improvement and higher displacement of blood” compared to other methods, especially in large hemorrhages.
For instance, he shared a case where a patient with extensive submacular hemorrhage was treated with vitrectomy and gas. “After a month, the blood in the macular area dispersed, and the acuity improved,” Prof. Ruamviboonsuk noted.
Innovative treatments in the pipeline
Prof. Gemmy Cheung (Singapore) illuminated several novel treatments on the horizon for PCV. Among the most anticipated developments is faricimab, which targets both VEGF and Ang-2, offering “dual action” and “longer durability,” which could lead to fewer injections and sustained efficacy for PCV patients.
The 16-week analysis of this study will be presented during the upcoming APVRS 2024 congress in November.
Another innovation is the port delivery system, designed to maintain a consistent drug level in the eye.
“The port delivery system may offer an advantage in keeping the drug level at a very narrow therapeutic window,” Prof. Cheung explained, noting that it could alleviate the need for frequent treatments.
Prof. Cheung also spotlighted therapies targeting VEGF-C and VEGF-D, which are elevated in PCV. A promising Phase 2b study combines an anti-VEGF-C/D agent with ranibizumab, showing superior visual acuity gains in PCV patients compared to standard treatments. This novel approach is now advancing to Phase 3 trials, with a specific focus on PCV outcomes.
These emerging treatments reflect a deeper understanding of PCV’s unique biology. Prof. Cheung stressed the importance of developing therapies tailored specifically to the condition, rather than repurposing those designed for AMD.
Unlocking effective solutions
From breakthroughs in imaging techniques to the introduction of innovative treatments like faricimab and the port delivery system, it’s clear that the future holds promising advancements.
As novel therapies continue to emerge, the consensus remains clear: Understanding the intricacies of PCV will be key to unlocking more effective, long-lasting solutions.
Editor’s Note: A version of this article was first published on PIE magazine Issue 32.
References
- Lee WK, Iida T, Ogura Y, et al. Efficacy and safety of intravitreal aflibercept for polypoidal choroidal vasculopathy in the PLANET Study: A randomized clinical trial. JAMA Ophthalmol. 2018;136(7):786-793.
- Koh A, Lee WK, Chen LJ, et al. EVEREST study: efficacy and safety of verteporfin photodynamic therapy in combination with ranibizumab or alone versus ranibizumab monotherapy in patients with symptomatic macular polypoidal choroidal vasculopathy. Retina. 2012;32(8):1453-1464.
- Lim TH, Lai TYY, Takahashi K, et al. Comparison of ranibizumab with or without verteporfin photodynamic therapy for polypoidal choroidal vasculopathy: The EVEREST II randomized clinical trial. JAMA Ophthalmol. 2020;138(9):935-942.
