Complete regression of branching vascular network in polypoidal choroidal vasculopathy by ranibizumab and photodynamic therapy, two case reports

A 68-year-old man with left vision deterioration presented to our outpatient clinic in August 2011. His best corrected visual acuity (BCVA) was 20/20 in the right eye and 20/40 in the left eye. Anterior segment examination was unremarkable. Dilated fundus examination revealed red-orange lesions in the macula associated with RPE damage. IA (Spectralis HRA, Heidelberg Engineering, Heidelberg, Germany) revealed a BVN and polyps. OCT (Carl Zeiss Meditec, Dublin, CA) disclosed significant subretinal fluid with RPE detachment. Based on these findings, a diagnosis of PCV was made and IVRs were initiated in a pro re nata (PRN) regimen. After 42 anti-VEGF injections, 7 initial IVRs and subsequent 35 IVAs, over 5 years and 7 months, his left vision remained at 20/40, but OCT showed persistent subretinal fluid and RPE detachment. As IA demonstrated a polyp associated with the BVN (Fig. 1a), his treatment strategy was switched to combination IVR and PDT according to the EVEREST II study [17]. IA 3 months subsequent to PDT confirmed complete regression of polyp, with the BVN persisting without apparent regression (Fig. 1b).

In this patient, the first OCT-A (PLEX Elite 9000; Carl Zeiss Meditec, Dublin, CA) image (Fig. 2a) was acquired 9 months prior to combination therapy and disclosed the BVN and polyp in the corresponding locations as indicated by IA (Fig. 1a). Before PDT incorporation, the eye received 9 additional IVRs, but OCT-A after each injection showed no apparent changes in the BVN or polyp (Fig. 2b). Based on these findings, the treatment strategy was switched to combined therapy of IVR and PDT. Standard full-fluence PDT was performed 3 days after the 43rd IVR, followed by PRN-IVR for subretinal or intraretinal fluid. In full fluence PDT, patients were infused with verteporfin (6 mg/m²). Fifteen minutes after the start of infusion, PDT at standard fluence (light dose, 50 J/cm²; dose rate, 600 mW/cm²; wavelength, 689 nm) was applied to the eye for 83 s. The laser spot size was derived by adding 1000 mm to the greatest linear dimension. Thus, both BVN and polyps were included in the verteporfin PDT treatment area. The effects of combination therapy on the BVN and polyp were investigated by frequent OCT-A performed at every visit to our outpatient clinic. As early as 1 week after PDT, OCT-A revealed complete regression of both the BVN and polyp (Fig. 2c). Right vision improved from 20/40 to 20/30. The BVN showed gradual reperfusion at 1 month (Fig. 2d) and 2 months (Fig. 2e), and had virtually restored its original appearance at 3 months while the polyp remained closed (Fig. 2f).

We confirmed the changes observed in en face OCT-A images using corresponding OCT-A cross-sectional scans. The en face OCT-A data acquired just before PDT showed the polyp as an aneurysm-like dilatation of the BVN (Fig. 3a). A cross-sectional OCT-A (Fig. 3b) image of the PED (the space between Bruch’s membrane and the RPE layer) contained a toal of 3 major flow signals corresponding to the polyp and 2 branches of the BVN, respectively. One week after PDT when en face OCT-A demonstrated complete regression of the BVN and polyp (Fig. 3c), the residual space between Bruch’s membrane and the RPE layer on cross-sectional OCT-A suggested that the BVN was occluded but the vessel structures were still preserved (Fig. 3d). The en face OCT-A taken 3 months after PDT demonstrated a very similar BVN to that beforehand except for the absence of the polyp (Fig. 3e). Cross-sectional OCT-A confirmed that the flow signals corresponding to branches of the BVN were indeed restored but the polyp remained absent (Fig. 3f). At 3 months after PDT, IA also visualized the BVN, which showed a near-identical appearance as that before combination therapy, along with absence of the polyp (Fig. 1b).

A 65-year-old woman presented with left vision deterioration in July 2017. Her BCVA was 20/20 in the right eye and 20/22 in the left eye. Anterior segment examination was unremarkable. Dilated fundus examination revealed orange nodular lesions in the macula associated with exudative changes. IA uncovered a BVN and polyps. OCT disclosed subretinal fluid with PED. Based on these findings, a diagnosis of PCV was made and she began IVA treatment. After 5 consecutive monthly IVAs, OCT showed persistent subretinal fluid and PED, and so we switched her to combination therapy of IVR and PDT according to the EVEREST II study [17]. En face OCT-A just before PDT revealed a fan-shaped BVN and a polyp (Fig. 4a), and corresponding cross-sectional OCT-A at the plane of the polyp demonstrated dome-shaped PED containing flow signals (Fig. 4b). Two weeks after PDT, OCT-A showed a trace of the BVN and complete regression of the polyp (Fig. 4c). Cross sectional OCT-A revealed flattened PED that was devoid of flow signals (Fig. 4d). Left vision improved from 20/60 to 20/20. En face OCT-A at 2 months indicated that the BVN had largely restored its original shape but the polyp was still absent (Fig. 4e). In corresponding cross-sectional OCT-A, the PED had mildly restored its height, with no apparent restoration of flow signals (Fig. 4f). The patient was lost to follow-up after her 2-month visit.