Anti VEGF Monotherapy in Polypoidal Choroidal Vasculopathy ...

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AUTHORS’S PROFILE:
Dr. MAHESH G.: M.B.B.S. (‘95); D.O (‘97), M.S. (‘99), Medical College, Trivandrum; D.N.B.
(2000), FRCS (Edinburgh, 2001); Fellow, VR Surgery, Sankara Nethralaya, Chennai. Presently
Consultant, Vitreoretinal services, Giridhar Eye Institute, Kochi-682020, Kerala.
E-mail: maheshgopalakrishnan@yahoo.com
Anti VEGF Monotherapy in Polypoidal Choroidal Vasculopathy –
Does it work?
Dr. Mahesh G., Dr. Giridhar A., Dr. Ramkumar, Dr. Alpesh Rajpur, Dr. Sidharth Pawer
(Presenting Author: Dr. Mahesh G)
Polypoidal Choroidal Vasculopathy (PCV) first
described by Yanuzzi and colleagues in 1990,
is a distinct clinical entity characterized by
persistent, recurrent serous leakage and
haemorrhage in the macula seen in the elderly
population. [1] The disorder was poorly

648 AIOC 2010 PROCEEDINGS
understood earlier and initially designated as
‘recurrent retinal pigment epithelial detachments
and posterior uveal bleeding syndrome. [2, 3, 4, 5] The
primary abnormality as described by Yanuzzi [1,
2,13]
and colleagues involves the choroidal
circulation, and the characteristic lesion is an
inner choroidal vascular network of vessels
ending in an aneurismal bulge or outward
projection, visible clinically as a reddish orange
[7]
spheroidal, polyp like structure. The exact
pathogenesis of these vascular abnormalities is
still not known. ICGA is essential for the
diagnosis as it permits visualization of the
choroidal vasculature with enhanced specificity
and sensitivity. [13]
Several reports have suggested that the incidence
of PCV is markedly high in black people,
relatively high in Asian population and low in
white people in contrast to age related macular
degeneration. [3-8] In blacks PCV affects women
more frequently, is usually associated with
peripapillary involvement. [.2,3,4,8,9] Several reports
from Asian population have shown a male
preponderance, unilateral presentation with
macular involvement. [5,6,8,9] Many different
treatment modalities have been used to preserve
vision in patients with symptomatic PCV. Direct
[2,5]
laser photocoagulation feeder vessel
treatment, [2, 7] [2, 9]
Transpupillary thermo therapy,
photodynamic therapy [18-23] are some of the
modalities which have been described.
Intravitreal anti VEGF monotherapy is the
current gold standard for treatment of wet AMD.
Its use in PCV in Indian patients is doubtful. This
study is done to analyze the effect of anti VEGF
monotherapy and the use of thermal laser or
photodynamic therapy in PCV.Here we present a
series of 14 patients who was treated for
serosanguinous maculopathy by Anti VEGF
monotherapy and worsened.
To evaluate the effect of intravitreal anti VEGF
drugs in Polypoidal Choroidal Vasculopathy
(PCV).
Materials and Methods
It was a retrospective non comparative case
series.14 patients were enrolled in this study.
Duration of the study was between January 2007
and December 2008. There were 8 males and 6
females. Age of the patients ranges from 52 years
to 78 years with a mean age of 64.5 years. All the
patients underwent complete ocular examination
including best Corrected Visual Acuity, ETDRS
Visual Acuity, Refraction, and Intra Ocular
Pressure measurement, Colour Fundus
Photography, Fluorescein Angiography,
Indocyanine Green Angiography and Optical
Coherence Tomography. A diagnosis of
Polypoidal Choroidal Vasculopathy was made
based on ICG findings of dilated bulbous
choroidal vessels with or without interconnected
network of large choroidal vessels in ICGA.
Increase in the fluorescence with fussy margins
in the late phase of the ICG angiogram was taken
as active polyp. The exclusion criteria were:
1. Large sub macular haemorrhage which
required pneumatic displacement.
2. Any relative contra indication to systemic
antiVEGF drug
All the patients received antiVEGF monotherapy
initially. 12 patients received Bevacizumab
1.25mg, one patient received Pegaptanib Sodium
0.3mg and one patient received 0.5mg
Ranibizumab. They were followed-up monthly
for the first three months and then every 3
months. In each follow-up visit OCT was done
besides visual acuity and intra ocular pressure.
Outcome measures were
1. Best Corrected Visual Acuity
2. Mean Central Macular Thickness in OCT
3. Any complications.
Worsening of the condition was defined as drop
of more than one line Snellen’s Visual acuity or
increase in more than 100 microns of retinal
thickness. In case of worsening repeat ICG
angiogram was done and patient was selected for
laser photocoagulation. If the leaking polyps
were subfoveal, photodynamic therapy using
Visudyne was done. If the polyps leaked from
outside the foveal avascular zone, thermal laser
was used. Here whitening of the lesion using
laser was used as an end point. Following laser,
patients were reviewed every three months.
Results
All the patients enrolled in the study had either
exudative maculopathy or serosanguinous
maculopathy. The average mean follow up
duration was 8 months. All 14 patients had
worsening of the clinical conditions after
antiVEGF monotherapy. They were switched

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over to laser treatment in that situation. A total
of 31 injections were given as part of antiVEGF
monotherapy in 14 eyes with a mean injection
rate of 2.2. Since there was worsening either
photodynamic therapy or thermal laser was done
depending on the location of the polyp.
Complications of monotherapy included massive
vitreous haemorrhage in one patient with subretinal
haemorrhage. This patient underwent
vitreous surgery later with a final visual acuity of
3/60. All the 13 other eyes photodynamic
therapy was done in 6 eyes and thermal laser was
done in 7 eyes. Photodynamic therapy was
performed using reduced fluency with Visudyne.
Thermal laser was done using a double
frequency YAG laser with a spot size of 50-100
microns.
At the last follow up there was stabilization of
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vision in one eye and improvement of vision in
12 eyes. One eye with vitreous haemorrhage had
dropped in final visual acuity.
Discussion
This study evaluates the effect of intravitreal anti
VEGF injections and the effect of thermal laser
/photodynamic therapy in PCV in Indian
population. 14 eyes with PCV showed worsening
after a mean 2.2 injections of anti VEGF drugs.
Subsequently they received thermal laser (7) or
PDT (6) with improvement of vision in 12 eyes.
There are not many literature on the role of VEGF
in the pathogenesis of PCV. Laser ablation works
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inefficacy of anti VEGF monotherapy in PCV.
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