Grand Rounds
Shivani V. Reddy, M.D.
7/18/14
University of Louisville
Department of Ophthalmology and Visual Sciences
Patient Presentation

CC: Blurry Vision OD

HPI: 80 y/o AAF presents for yearly Plaquenil check
She states that her vision had been stable until 1 month
ago when she noticed some blurriness and dimming of
vision OD. She denies experiencing metamorphopsia,
flashes, floaters or scotomas.
History
POHx: refractive error
PMHx: Rheumatoid Arthritis, Hypertension, Hypothyroidism
FAMHx: uknown
ROS: joint pain
MEDS: Plaquenil ( 3.04 mg/kg/day (65.7kg weight), 200mg daily x 5 years)
Toprol, MTV, triamterone, synthroid
ALLERGIES: NKDA
Exam
8
20/50-2 (+0.75 +0.50 x 005)
VA
TP
20/20-2 (-0.25 +0.50 x 175)
4→3
P
12
4→3
no RAPD
EOM: full OU
CVF: full OU
Exam
OD
OS
LIDS/LASHES
WNL
WNL
CONJ
WNL
WNL
CORNEA
WNL
WNL
IRIS
WNL
WNL
LENS
2+NS, 1+CC
2+NS, 1+CC
Fundus Photos
OD
OS
OD photo demonstrates orangish-red faintly circumscribed lesions in the
peripapillary region
FAF Photos
OD
OS
1.OD
2.OD
3.OS
1. Nasal pigment epithelial detachment with associated neurosensory detachement
with sub-neurosensory fluid accumulation, some loss of foveal contour
2. Nasal pigment epithelial detachment with overlying heme and fluid
FA/ICG
Early AV Phase
00:19:45
Peripapillary staining, supero-nasal
hypofluorescence of dye
Superonasal hypofluorescence, network of
dilated peripapillary vasculature with
terminal bulb
FA/ICG
AV Phase
00:29:45
Increasing peripapillary hyperfluorescence
circular of hyperfluorescence at end of
vascular network
FA/ICG
Recirculation Phase
1:21:45
continual demonstration of peripapillary
dye leakage, increasing over area of polyp
Hyperfluorescence of polypoid lesion and
demonstration of surrounding vascular
network
FA/ICG
Late Phase
2:00:45
Persistent peripapillary dye pooling
representing leakage
Decreased hyperfluorescence of polyp
with surrounding area of hypofluorescence
Summary
80 y/o AAF presents for routine plaquenil check with 1 month history
of blurriness and dimming of vision OD. BCVA OD is 20/50-2. ICG
angiography demonstrates choroidal polyps with surrounding vascular
network and corresponding leakage on FA. OCT demonstrates PED’s
OD with overlying neurosensory retinal detachment
DDx:
 Polypoidal Choroidal Vasculopathy
 Other entities causing subretinal neovascularization
 AMD
 CSCR (central serous chorioretinopathy)
 Pathologic myopia
 Choroidal tumors or Mets
 Infection
Treatment
First Visit
20/50-2
1 month post Avastin #1
VA 20/50
1 month post Avastin #2
VA 20/40-2
Polypoidal Choroidal Vasculopathy
 Also known as posterior uveal bleeding syndrome
First described by Dr.Yannuzzi in 1982
Characterized by sub-retinal vascular lesions
associated with serous and hemorrhagic detachments
of the RPE
 Named for its network of branching, choroidal
vessels with terminal polyp-like aneurysmal dilations
Polypoidal Choroidal Vasculopathy
First described in middle -aged African
American woman
Most commonly seen in 50-65 age group
Occurs 23-55% in Asian patients presenting with
neovascular AMD
4% to 9.8% prevalence reports in Caucasian
patients with presumed AMD
Polypoidal Choroidal Vasculopathy
 Diagnosis based on ICG angiography high definition OCT and
fundus photography
 FA not helpful as it demonstrates too much dye leakage
 Classification based on imaging characteristics
 Branching vascular network vs. feeder vessel supplying
polyps
 Cluster of polyps vs. single polyp
 Juxtafoveal vs. extrafoveal polyps
Polypoidal Choroidal Vasculopathy
CNV or Not?
PCV is?
 More likely to occur in pigmented races, although
also demonstrated in Caucasians
 lesions more likely to be peripapillary
 ICG in late phases shows ‘wash-out’ of polyp in
contrast to late staining seen in occult CNV
Polypoidal Choroidal Vasculopathy
Treatment
 Anti- VEGF treatment alone not helpful
 EVEREST TRIAL
 Compared PDT monotherapy and PDT + ranibizumab to
ranibizumab alone
 Significantly higher proportion in the first 2 groups showed
regression at 6 months
 Surgical intervention based on complications such as breakthrough vitreous hemorrhage
Polypoidal Choroidal Vasculopathy
Prognosis
 Clinical outcomes in literature vary considerably
 35-68.2% of patient with reported poor outcomes
 Larger polyps, juxtafoveal location of polyps and clustering of
polyps are risk factors for massive subretinal and subsequent
vitreous hemorrhages
 In patients with large detachments, subretinal fibrosis can lead to
eventual vision loss
 PDT can lead to subretinal hemorrhage in upto 31% of eyes, VH
in 6-12.5% post treament, 8.9% of bleeding post anti-VEGF
Retrospective chart review
17 patients with massive subretinal hemorrhages (SRH)
secondary to PCV (16.7+/- 7.1 DD) and associated vitreous
hemorrhage (VH) enrolled
Patients underwent 20G Pars Plana Vitrectomy +/bevacizumab injection for new heme, PED or CME
Main outcome measure: BCVA at end of follow-up period
Mean post-op follow up of 25.2 months
Mean duration from SRH to VH was 3.5 +/- 1.2 weeks
Time from VH to PPV 1.3 +/- 0.7 months
BVCA (LogMar)
Pre VH : 0.95 +/- 0.60
Pre PPV: 2.65 +/- 0.57
3 months post-op: 1.62 +/- 0.67
Final Visit: 1.43 +/- 0.82
 VA > 20/400 in 16.7% of juxtafoveal polyp patients, 87.5% of
extraoveal polyp patients
THANK YOU
References
1.Retina and Vitreous, BSCS
2. Retina, Vitreous and Macula , David R. Guyer MD, Lawrence A. Yannuzzi MD, Stanley
Chang MD and Jerry A. Shields MD
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vasculopathy (IPCV). Retina 1990; 10(1): 1–8.
4.Koh et al. EVEREST STUDY: Efficacy and Safety of Verteporfin Photodynamic Therapy
in combination with Ranibizumab or Alone Versus Ranibizumab Monotherapy in Patients
with Symptomatic Macular Polypoidal Choroidal Vasculopathy. Retina 2012; 32:1453-1464.
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