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PUBLICATION EXCLUSIVE: Under-recognition of polypoidal choroidal vasculopathy
An accurate diagnosis and the correct identification of the polypoidal choroidal vasculopathy subtype of wet macular degeneration are necessary to determine the proper and most effective treatment route for patients.
However, the gold standard of diagnostic tools for the disease is underused in America, and polypoidal choroidal vasculopathy (PCV) is often misdiagnosed in patients as typical wet age-related macular degeneration, Raymond Wee, MD, of Retina Consultants of Hawaii, said.
“The biggest point I have is that PCV is an under-recognized disease in the United States because ICG (indocyanine green) angiography is underutilized. Recognition of PCV is extremely important because the treatment algorithm is different from wet AMD. If you are not recognizing the disease, you could be treating it like run-of-the-mill wet AMD, which is primarily a pharmacological treatment,” Wee said.
PCV can result in an abnormal subretinal vascular network with polyp formation, Wee said. Treatment routes depend on several factors, but diagnosing the disease can be difficult if ICG angiography is not used.
The diagnosis of PCV typically requires a combination of history, clinical examination and multimodal imaging, Kapil Kapoor, MD, of Wagner Macula & Retina Center in Virginia, said.
Image: Kokame GT, Wee R
A patient’s history will usually reveal painless vision loss in Asian or African women, often slightly younger than the typical age for AMD, he said.
“Given that [PCV] is not as common in the United States, its decreased prevalence often allows the cases that do present to go unrecognized. Fundus exam will sometimes reveal subtle orange-reddish bulbous lesions in the setting of exudates, hemorrhages and subretinal fluid and the absence of significant drusen. Ultimately, a panel of multimodality imaging is helpful to clinch the diagnosis. Optical coherence tomography with enhanced depth imaging is helpful to document the presence of subretinal fluid and exudates and may identify a pachychoroid,” Kapoor said.
Symptoms are similar
Because the clinical findings of PCV and wet AMD are almost identical, ICG angiography with a scanning laser ophthalmoscope video angiography is a necessity for diagnosing the disease, Gregg T. Kokame, MD, MMM, of Retina Consultants of Hawaii, said.
“Scanning laser ophthalmoscopic video angiography is more sensitive at diagnosing PCV than ICG angiography obtained on a fundus camera. A newer technique that is useful for practices is to utilize en face OCT imaging, which can show the very characteristic polypoidal dilations and subretinal vessels well, and since the data is often available on most OCT machines in use, it can be utilized on previous OCT studies, even prior to treatment was started. Polyps may regress after treatment, especially with prior photodynamic therapy,” Kokame said.
However, ICG angiography is not readily used in the U.S. to diagnose PCV. In addition, ICG angiography is expensive to perform if the scanning laser ophthalmoscope will be utilized, which is best for PCV, he noted.
“The dye is also expensive, and having diagnostician staff trained to do ICG angiography is often lacking. Retina specialists also have not been trained on how to read ICG angiograms well during their training,” Kokame said.
- Click here to read the full publication exclusive, Cover Story, published in Ocular Surgery News U.S. Edition, November 25, 2016.