Polypoidal choroidal vasculopathy: an angiographic discussion

The understanding of polypoidal choroidal vasculopathy has evolved rapidly in the past three decades. The hallmark of the disease is the presence of typical hyperfluorescent nodules in the early phase of indocyanine green angiography. Although the classical clinical presentation is recurrent serosanguinous detachment of the retinal pigment epithelium, it may present with clinical features indistinguishable from exudative age-related macular degeneration secondary to choroidal neovascularization. Some cases may present initially with submacular haemorrhage, but later with features of exudative age-related macular degeneration. Studying the associated network of vessels using confocal scanning laser ophthalmoscopy indocyanine green dynamic angiography revealed in many cases feeder vessels, branching pattern, and leakage similar to choroidal neovascularization. Owing to the overlap of clinical and angiographic features, it may be considered as a vascular subtype of exudative age-related macular degeneration. However, having seemingly better natural history, better response to photodynamic therapy, and incomplete response to anti-vascular endothelial growth factor therapy suggests that it should be studied as a separate entity from choroidal neovascularization. Combining angio-occlusion of the polyps using photodynamic therapy and anti-permeability effect of anti-vascular endothelial growth factor therapy on the branching vascular network may provide a synergistic effect. We await the result of EVEREST trial, a multi-centre randomized controlled trial comparing photodynamic therapy, with or without ranibizumab, with ranibizumab monotherapy. Eye (2010) 24, 483-490; doi:10.1038/eye.2009.323; published online 15 January 2010