Polypoidal choroidal vasculopathy with multiple polyps has poorer response to ranibizumab

Polypoidal choroidal vasculopathy with multiple polyps did not respond as well to intravitreal ranibizumab as polypoidal choroidal vasculopathy with a single polyp, according to a study conducted in Japan.

Perspective from Andrew P. Schachat, MD

“We propose that the stratification of PCV lesions by polyp number may be valuable to understand the prognosis of this condition,” the study authors said.

The retrospective case series included 48 treatment-naïve eyes of 48 patients who underwent intravitreal Lucentis (ranibizumab, Genentech) monotherapy between 2009 and 2013.

Twenty-nine eyes of 29 patients had a single polyp, and 19 eyes of 19 patients had multiple polyps. Patients received three monthly ranibizumab injections followed by as-needed injections.

Best corrected visual acuity was maintained or improved in 28 of 29 eyes in the single polyp group and in 14 of 19 eyes in the multiple polyps group at 1 year. The between-group difference was statistically significant (P = .019).

At 2 years, BCVA was maintained or improved in 21 of 27 eyes in the single polyp group and in 13 of 16 eyes in the multiple polyps group. The difference was not statistically significant.

At 1 year, mean central retinal thickness was 297.5 µm in the multiple polyps group and 226.6 µm in the single polyp group; the difference was statistically significant (P = .009). Mean change in central retinal thickness was 101.2 µm in the multiple polyps group and 168 µm in the single polyp group; the difference was significant (P = .042).

The mean number of injections required before complete disappearance of intraretinal and subretinal exudative changes and attainment of a dry macula was 3.4 in the single polyp group and 4.9 in the multiple polyps group.

Disclosures: Suzuki reports a financial relationship with Pfizer Japan Inc. and Novartis Pharmaceuticals Japan. See the study for a full list of all other authors’ relevant financial disclosures.

Perspective

Andrew P. Schachat, MD

In a retrospective study of 48 patients, Suzuki and colleagues reviewed the outcomes of ranibizumab therapy in patients with polypoidal choroidal vasculopathy (PCV). They found differences in baseline features and outcomes in subjects with single vs. multiple polyps. Single-polyp patients did better, but there were baseline differences that could explain the worse outcomes for the multiple-polyp eyes: larger greatest lesion dimension and higher prevalence of fibrovascular pigment detachment.

While PCV is common in Asia, so common that ICG is often performed, it is not as common in the United States, so you need to think of it in your wet AMD patients who are not responding well to anti-VEGF therapy. How to treat your PCV patients is less clear. While the EVEREST trial teaches that photodynamic therapy combined with ranibizumab achieved better outcomes that with ranibizumab alone, the LAPTOP study showed better outcomes with ranibizumab compared with PDT. Both studies are cited by Suzuki. Key questions for me are, what is a “non-responder” for patients being treated for wet AMD and when should we obtain ICG images? As I watch many of my colleagues treat wet AMD without even a baseline fluorescein angiogram, it is hard to suggest that both FA and ICG imaging should be done at the time of diagnosis in the U.S. where the prevalence of PCV is low.

Andrew P. Schachat, MD

Vice chairman for clinical affairs, Cole Eye Institute

Disclosures: Schachat reports he is a consultant for the American Academy of Ophthalmology, is a member of SAB, Eastern Capital, and receives royalties from Elsevier.

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Source:

Suzuki M, et al. Am J Ophthalmol. 2016;doi:10.1016/j.ajo.2016.03.024.