2. Introduction
Polypoidal choroidal vasculopathy (PCV) is a disease
of the choroidal vasculature.
Serosanguineous detachments of the pigmented
epithelium and exudative changes leading to
subretinal fibrosis
3. A 78 years old female patient housewife by occupation
residing at New Panvel visited to our institute with
c/o LE blurring of vision since one month.
4. Past ocular history
h/o of using glasses since 40 years PGP 6months
BE cataract surgery with iol implantation done 12
years back.
h/o LE injection avastin 5 times and RE 3 times
9. RE LE
Lid N N
Conjunctiva Quiet Quiet
Cornea Clear Clear
AC Deep and quiet Deep and quiet
Iris CPN CPN
Pupil 7mm 7mm
Lens PCIOL PCIOL
Fundus Cup disc ratio
0.5 :1 HNRR active
CNVM
Cup disc ratio
0.5 :1 submacular
haemorrhage
25. 15 days later
BCVA RE 6/18 N6 LE 6/12N6
Fundus examintion BE reveals PED with resolving
SRF.
OCT
RE –resolving SRF
LE -resolved SRF
26. One month later
BCVA RE 6/18 N6 LE 6/12N6
Fundus examintion reveals –FVPED
Adviced intravitreal AntiVEGF injection but deferred
because of lack of compliance of the patient
27. Two months later
BCVA 6/12N6
On examination BE scleral thinning noted
Fundus examination reveals BE CNVEM with PED
with SRF
28. 3months Later
BCVA RE 6/12N8,LE6/12N10
Fundus examination reveals RE rnfl hemorrhage .
LE reveals submacular haemorrhage .
37. Prevalence and Incidence:
Most commonly diagnosed in patients between the
ages of 50 and 65 years
In Asians , Japan have higher prevalence rates are
present of approximately 23% to 54% in patients with
presumed age-related macular degeneration (AMD)
38. Etiology
The etiology is not clearly understood.
It has been proposed that there is a choroidal
vasculature propensity for dilation and aneurysmal
formation
39. Investigation of choice
ICGA - The intravascular retention of the ICG
molecule allows better resolution of the choroidal
vasculature.
Fluorescein angiography (FA) -is not as useful because
it lacks the same resolution of the choroidal
vasculature as ICGA. However, it is able to show large
polypoidal changes.
41. Investigation
FFA-
PCV lesions on FFA resemble occult CNVM lesions and
when submacular, they can be mistaken for AMD
OCT-
Helpful in identification of subretinal or sub-RPE fluid,
it can also delineate polypoidal lesions
These lesions resemble dome-like elevations of RPE
with moderate internal reflectivity.
In most cases, there is also a highly reflective line just
below these lesions consistent with location of vascular
branching network.
The dual reflective layers are also called “double-layer
sign,” and are seen in 59% of eyes with PCV
42. ICGA
The polyps present as focal hyperfluorescent spots. In
later stages, reversal pattern of dye is seen with the
center of the lesion becoming hypofluorescent and
surrounding becoming hyperfluorescent. Finally, in
the very last stage, there is “wash-out” of the lesion
that is seen in non-leaking PCV lesions
43. Spectral-domain optical coherence tomography (SD-
OCT) is currently one of the best available
noninvasive imaging tools for the management of
PCV.
45. Treatment
Medical therapy
Observation,
Photodynamic therapy,
Intravitreal injection of anti-VEGF therapy
Combination therapy
46. EVEREST trial
Multi-center, double-masked trial
Compared three treatment regimens: verteporfin
photodynamic therapy (PDT) plus the anti-VEGF
agent ranibizumab (Lucentis), ranibizumab
monotherapy, and PDT monotherapy.
47. Cont...
The patient population was sixty-one Asian patients
with symptomatic PCV.
The primary end point was complete polyp
regression as assessed by ICG.
PDT in combination with ranibizumab and PDT
monotherapy showed a significantly higher
proportion of patients with complete polyp regression
at month 6 than the ranibizumab monotherapy group
48. Medical follow up
Regardless of choice of treatment, patients should be
followed on regular intervals to detect and prevent
subretinal/subRPE fluid and hemorrhage.
49. Surgery
There is no current surgical management for PCV.
If surgical management is needed, it would be tailored
to complications and sequelae of PCV such as break-
through vitreous hemorrhage.
50. Complications
Serosanguineous detachments of the pigmented
epithelium and exudative changes
Subretinal fibrosis
Pigment epithelial hyperplasia,
Atrophic degeneration
51. Prognosis
Depending on the extent of area involved prognosis is
generally good
Symptomatic patients with PCV can have complete
regression without severe vision loss with PDT and
anti-VEGF treatment
52. General Principles of ICG Angiography
1. Binding
• 98% bound to proteins
2. Fluorescence
• Much less than fluorescein
• Less leakage from choriocapillaris
• Excitation peak 800 nm
• Emission at 835 nm
3. Filters
• Infrared barrier and excitation
4. Safer than fluorescein
53. Phases of normal ICG angiogram (1)
Early (20 sec)
• Disc hypofluorescence
• Poor perfusion of vertical
(watershed) zone near disc
• Prominent filling of choroidal arteries
• Early filling of choroidal veins
• Filling of retinal arteries but not veins
Early middle (3 min)
• Filling of watershed zone
• Fading of choroidal arterial filling
• Prominent filling of choroidal veins
• Filling of retinal arteries and veins
54. Phases of normal ICG angiogram
Late (21 min)
• Large choroidal and retinal vessels are
empty
Late middle (6 min)
• Reduced filling of choroidal vessels
• Diffuse hyperfluorescence due to
diffusion of dye from choriocapillaris
• Persistent filling of retinal vessels
• Diffuse background hyperfluorescence