Updated guidelines for the management of polypoidal choroidal vasculopathy: Recommendations from the Indian Polypoidal Choroidal Vasculopathy Panel and the Vitreoretinal Society of India

Abstract

In Asians, polypoidal choroidal vasculopathy (PCV) is becoming more widely recognized as a significant cause of exudative maculopathy. The previous set of Indian guidelines on the management of PCV were published in 2018, with a literature search updated up to November 2015. As the treatment of PCV evolves, retinal physicians must constantly modify their current practice. The current guidelines are based on the most up-to-date information on PCV and are an update to the previous set of guidelines. These guidelines were developed by a panel of Indian retinal experts under the aegis of the Vitreoretinal Society of India (VRSI), based on a comprehensive search and assessment of literature up to September 2021. The final guidelines i) provide the updated nomenclature in PCV; ii) discusses the newer diagnostic imaging features of PCV, especially in the absence of indocyanine green angiography (ICGA); and iii) recommends the best possible therapeutic approach in the management of PCV, including the choice of anti-vascular endothelial growth factor (anti-VEGF) agents, treatment regimen, and the role of switching between the anti-VEGF agents. In the face of non-availability of photodynamic therapy (PDT) in India, we constructed practical recommendations on anti-VEGF monotherapy in PCV. The current updated recommendations would provide a broader framework to the treating retinal physician for the diagnosis and management of PCV for optimal therapeutic outcomes.

Keywords: Indocyanine green angiography; optical coherence tomography; polypoidal choroidal vasculopathy; vitreoretinal society of India.

Figure 1

Color fundus photograph showing clinical features of polypoidal choroidal vasculopathy

Figure 2

Indocyanine green angiography showing the presence of polypoidal lesions (red arrows) and the branching neovascular network (yellow arrows)

Figure 3

Spectral domain optical coherence tomography images showing characteristic features of polypoidal choroidal vasculopathy: (a) sharp-peaked pigment epithelial detachment (PED; white asterisk); (b) complex or multilobar PED (red arrow showing the notch); (c) sub-retinal pigment epithelial (RPE) ring-like lesion

Figure 4

Spectral domain optical coherence tomography (SD-OCT) showing the presence of double-layer sign (a), represented by two hyperreflective lines, inner signifying shallow retinal pigment epithelium elevation (red arrow), and outer signifying Bruch’s membrane (yellow arrow) indicative of the branching neovascular network (BNN). Thumb-like pigment epithelial detachment, also called thumb-like polyp (b; white asterisk) is noted in the other SD-OCT section which corresponds to the polypoidal lesion seen on the indocyanine green angiography (c; blue arrow)

Figure 5

Pretreatment color fundus photograph (a) of a patient with hemorrhagic polypoidal choroidal vasculopathy (PCV) that was confirmed on the indocyanine green angiography (ICGA; c) and the eye-tracked ICGA with spectral domain optical coherence tomography (SD-OCT; b). After three loading doses of intravitreal aflibercept monotherapy, there was complete resolution of the polypoidal lesions on the ICGA (e) with a dry macula on SD-OCT (d)

Figure 6

Pretreatment color fundus photograph (CFP; a) of a patient showing exudative maculopathy due to polypoidal choroidal vasculopathy (PCV) with a double-layer sign (DLS) on the spectral domain optical coherence tomography (SD-OCT; b) and polypoidal lesions on the indocyanine green angiography (ICGA; c). After treatment with five monthly aflibercept injections, there was complete resolution of the polypoidal lesions on the ICGA (f) with trace intraretinal fluid (IRF) on the SD-OCT and few residual hard exudates on the CFP (d) trace intraretinal fluid (IRF) on the SD-OCT (e)