Evolving treatment paradigms for PCV

Abstract

Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular AMD (nAMD) that accounts for a significant proportion of nAMD cases worldwide, and particularly in Asia. Contemporary PCV treatment strategies have closely followed those used in typical nAMD, though there are significant gaps in knowledge on PCV management and it remains unclear if these strategies are appropriate. Current clinical trial data suggest intravitreal anti-vascular endothelial growth factor (VEGF) therapy alone or in combination with photodynamic therapy is effective in managing haemorrhage and exudation in PCV, although the optimal treatment interval, including as-needed and treat-and-extend approaches, is unclear. Newer imaging modalities, including OCT angiography and high-resolution spectral domain OCT have enabled characterisation of unique PCV biomarkers that may provide guidance on how and when treatment and re-treatment should be initiated. Treatment burden for PCV is a major focus of future therapeutic research and several newly developed anti-VEGF agents, including brolucizumab, faricimab, and new modes of drug delivery like the port delivery system, offer hope for dramatically reduced treatment burden for PCV patients. Beyond anti-VEGF therapy, recent developments in our understanding of PCV pathophysiology, in particular the role of choroidal anatomy and lipid mediators in PCV pathogenesis, offer new treatment avenues that may become clinically relevant in the future. This article explores the current management of PCV and more recent approaches to PCV treatment based on an improved understanding of this unique disease process.

Differentially Regulated Apolipoproteins and Lipid Profiles as Novel Biomarkers for Polypoidal Choroidal Vasculopathy and Neovascular Age-Related Macular Degeneration

“…Differently expressed mRNAs including ENSG00000249572, miRNA has-miR-20a-5p in peripheral blood mononuclear cells found were to be predictors for good and poor responders to anti-VEGF therapy in patients with nAMD ( 35 ). Furthermore, OCT and OCT angiography characteristics have been used as biomarkers for diagnosis and treatment on PCV and nAMD ( 36 ). The height of the pigment epithelium detachment (PED) and reflectivity of the content of the PED may predict polypoidal lesions closure ( 36 ).…”

“…Furthermore, OCT and OCT angiography characteristics have been used as biomarkers for diagnosis and treatment on PCV and nAMD ( 36 ). The height of the pigment epithelium detachment (PED) and reflectivity of the content of the PED may predict polypoidal lesions closure ( 36 ). Re-examining the baseline scans for an inverted U-shaped elevation in anti-VEGF resistant cases was helpful for detecting polypoidal lesions closure ( 33 ).…”

Brolucizumab for the Treatment of Degenerative Macular Conditions: A Review of Clinical Studies

“…Polypoidal choroidal vasculopathy (PCV) is considered a variant of nAMD characterised by polypoidal dilation with a branching neovascular network usually located between Bruch’s membrane and RPE. 12 , 13 The presence of polypoidal lesions is best detected using indocyanine green angiography (ICGA). 14 Unlike typical AMD, drusen are absent in PCV and recurrent subretinal haemorrhages and serous retinal detachments are the most common clinical findings.…”

Initial experience in treating polypoidal choroidal vasculopathy with brolucizumab in Indian eyes – A multicenter retrospective study

“…Polypoidal choroidal vasculopathy (PCV) is now recognized as a subtype of neovascular age-related macular degeneration (nAMD) with specific and distinct characteristics on indocyanine angiography (ICGA) and optical coherence tomography (OCT). [ 1 2 3 ] Though treatment of PCV and nAMD involves the use of intravitreal anti-vascular growth factor (anti-VEGF) agents for disease control, it is still important to distinguish between these due to differences in response to anti-VEGF, with PCV eyes showing a suboptimal response[ 3 ] and higher risk of recurrence in the same and other eye in PCV as opposed to nAMD. [ 4 ] Additionally, the higher predilection of PCV to cause massive and blinding subretinal hemorrhages is another cause of concern.…”

“…The management of PCV has evolved over the past decade with the availability of more potent anti-VEGF agents that have better penetration through the retinal pigment epithelium (RPE) and higher affinity to inhibit the action of VEGF. [ 1 2 ] After the recommendations of the PLANET clinical trial,[ 6 ] which showed excellent outcomes in PCV eyes receiving intravitreal aflibercept monotherapy, and with nonavailability of the Visudyne dye in many parts of the world, the trend in management is gravitating toward anti-VEGF monotherapy for PCV. However, the treatment burden remains significantly high, and until recently, aflibercept was considered to be the drug of choice for management of eyes with PCV in view of its higher efficacy in polyp regression compared to ranibizumab.…”