Sequential therapy with intravitreal bevacizumab and photodynamic therapy for idiopathic polypoidal choroidal vasculopathy

A 48-year-old Indian male presented with sudden decrease in visual acuity and metamorphosia of 1 week duration in the left eye. At the initial visit the visual acuity was 6/6 in the right eye and 6/60 in the left eye. Fundoscopic examination revealed hypopigmented juxtafoveal lesions in the right eye. The left eye revealed reddish-orange subretinal lesions with exudative changes, serous pigmented epithelial detachment (PED) and neurosensory detachment involving the posterior pole. Fluorescein angiography demonstrated juxtafoveal choroidal neovascular membrane (CNVM) and leaking polyps. The right eye also revealed juxtafoveal polyps. Inodocyanine green angiography confirmed the findings (Fig. 1). The patient was given a 1.25 mg intravitreal injection of bevacizumab (Avastin®; Genentech Inc., South San Francisco, California, USA) under all aseptic precautions after written consent was obtained. The study has been registered with clinicaltrials.gov/NCT00403026. Four weeks after the injection there was resolution of PEDs and serous neurosensory elevation with improvement of vision to 6/24 and reduction of metamorphosia. The consecutive scanning laser ophthalmoscope-optical coherence tomography (SLO-OCT; Ophthalmic Technologies Inc., Toronto, Canada) cross-sectional images showed decrease in neurosensory detachment, decreased distortion of retinal structure with resolution of cystic changes in the retina. Longitudinal (B-Scan) OCT mode was selected to produce cross-sectional images. Internal fixation target was placed on the clear SLO image to scan the area of interest centred in the SLO screen because this patient had poor fixation. After 1 month, he underwent photodynamic therapy (PDT) with verteporfin according to standard protocol. The juxtafoveal CNVM was treated and vision further improved from 6/24 to 6/12 by 2 weeks after therapy and remained the same until the end of 4 months of treatment. Colour fundus photographs, fluorescein and indocyanine green angiograms and scanning laser ophthalmoscope-optical coherence tomography (SLO-OCT), oblique cross-sectional scan images of the left eye of a 48-year-old Indian male who underwent sequential therapy of intravitreal bevacizumab and photodynamic therapy with verteporfin for idiopathic polypoidal choroidal vasculopathy with choroidal neovascular membrane. (A) SLO-OCT scan showing a hyper-reflective layer of retinal pigment epithelial detachment (PED) with overlying neurosensory layer elevation. Overlying retinal structure is distorted with cystic changes in the retina. (B) SLO-OCT scan image after 1 week of intravitreal bevacizumab showing hyper-reflective layer of PED with overlying minimal neurosensory detachment and nodular hyper-reflective elevations corresponding to the polypoidal lesions. (C) SLO-OCT scan image after 1 month of injection of bevacizumab showing almost complete resolution of exudation with juxtafoveal hyper-reflective signals and heaping of retinal structure; note that the foveal contour is seen. (D) Fundus photograph showing multiple reddish-orange subretinal nodules and exudative changes involving the posterior pole. (E) Fluorescein angiography showing leaking polyps with juxtafoveal choroidal neovascular membrane (CNVM) and localized area of hyperfluorescence nasal to fovea (PED). (F) Indocyanine green angiogram early frames demonstrating the branching vascular network terminating into polypoidal dilatation with juxtafoveal hot spot. (G) Fundus photograph after 1 month of photodynamic therapy (PDT) with verteporfin showing resolution of exudation and juxtafoveal scarring. (H) The corresponding late fluorescein angiogram frames showing minimal juxtafoveal leak, suggestive of fibrosis. Polypoidal choroidal vasculopathy (PCV) often follows a remitting–relapsing course associated with multiple, recurrent serosanguinous macular detachment. When the choroidal abnormal vasculature with exudative changes extends to the subfovea, visual prognosis is expected to be poor. PDT is the only recommended treatment for lesions involving the fovea secondary to subfoveal PCV. It achieved stable or improved vision in 95% of the eyes with PCV in a prospective study by Chan et al. (2004). Herein, we report a case of PCV with CNVM and exudative changes involving the fovea. Vascular endothelial growth factors (VEGF) have been implicated as one of the causative factors for increased vascular leakage and new vessel formation. Intravitreal injection of bevacizumab therapy improved visual acuity and morphological changes in the majority cases in all subgroups of CNVM secondary to various aetiologies (Pederson et al. 2007). In a case report (Soliman et al. 2006), intravitreal bevacizumab for peripapillary subretinal neovascularization caused rapid resolution of subretinal fluid and haemorrhage with improvement in visual acuity. In this case it was not possible to perform primary PDT or laser treatment because of the wide area of neursensory detachment and PEDs with retinal oedema overlying the polypoidal lesions. Moreover, PDT is avoided in the presence of PEDs for the risk of retinal pigment epithelial tears (Axer-Siegel et al. 2004). Intravitreal bevacizumab resulted in improvement of both visual and anatomical signs in occult CNVM with PED (Aggio et al. 2006). In this case, intravitreal bevacizumab therapy probably resulted in rapid reduction of exudation, which is unlikely to be a natural remission of the disease. Also, rapid resolution of subretinal fluid and PED probably prevents advanced cellular damage to retinal pigment epithelial and photoreceptors. The combination of PDT and antiangiogenic therapy adjunct may reduce frequency of retreatments; bevacizumab therapy inhibits CNV-induced leakage and lesion growth and PDT induces thrombosis and atrophy of neovascular membrane. Therefore, sequential therapy could be an effective mode of management of such conditions involving the posterior pole in this short-term observation. However, randomized controlled trials in larger samples are warranted to elucidate the efficacy of sequential therapy.

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