Published on: Mar 4, 2016
Transcripts - Polypoidal Choroidal
Dr. Md Mominul Islam
Fellow Vitreo - Retina
PCV is an exudative maculopathy with features similar
to neovascular AMD with hemorrhage, pigment
epithelium detachment and neurosensory
Pathogenesis mostly unknown
It remains controverial as to weather PCV represents a
sub type of neovascular AMD
• In 1982 By Yannuzzi et al
• At annual meeting of American academy of
ophthalmology as :-
Polypoidal , subretinal, vascular lesions associated
with serous and hemorrhagic detachments of the RPE
in a series of patients (10/11 patients were woman).
The entitity was initially called Idiopathic
polypoidal choroidal vasculopathy.
History (contd) In 1984 Kleiner et al Described as:-
A peculiar hemorrhagic disorder of the macula and
sub retinal pigment epithelium bleeding in middle
aged black woman ,which they term posterior uveal
Later a study from the same group of authors showed
an expanded clinical spectrum for PCV
It is a primary abnormality of the choroidal
circulation, characterized by :-
An inner choroidal vascular network of vessels ending
in an aneurysmal bulged or outward projection often
visible as a reddish – orange, spheroid ,polyp like
PCV primarily involves the inner choroidal vasculature
that is well differentiated from the middle and larger
choroidal vessels by histology.
Kuroiwa reported from surgically excised specimens
from 5 patients with PCV had been diagnosed by ICGA
Results - arteriosclerosis appears to be an important
pathological feature in the choroidal vessels of PCV
Histopathological Features (Contd)
In another histopathologic group :
• Nakashizuka et al, who also examined from surgically
excised specimens from 5 patients with PCV
Results :- little granulation tissue from any of the
On the other hand all the specimen exhibited:-
• Massive exudative change and leaking ,all the vessels
exhibited hyalinization and chorio-capillaris had
disappeared ,in which RPE had been preserved.
Immuno ChemistryThis group demonstrated that :
• PCV is not the same as choroidal neovascularization.
• CD-34 is a marker of vascular endothelial growth factor
• CD-34 staining revealed
Discontinuity in the vascular
Smooth muscle actin was negative in
There was disruption and injury of
smooth cells causing dilation of vessels
Prevalence of PCV in presumed neovascular AMD
• US -7.8%
• Belgian – 4.0%
• Italian - 9.8 %
• Greek – 8.2%
• Japanese – 23.0-54.7%
• Chinese – 22.3%
• Korean – 24.6%
Varies with age
Predominantly middle aged ,one or two decade earlier
than classical AMD
Commonly occur both gender ( more in Asian man
More prevalent in black, Japanese and other Asian
than in white.
Incidence is high in Asian.
Natural course of disease is Variable:-
May be relatively stable
May repeated bleeding and leakage with vision loss and
With or without fibroitic scarring
Reddish- orange nodules alone or nodule and small sub-
retinal hemorrhage and absence of hard exudates.
May association with other condition like
thrombocytopenia and massive hemorrhage has been
Also association with sickle cell disease and irradiation.
Clinical feature Usually bilateral
Protruding orange –red elevated lesion often with
nodular elevations of RPE.
Also described as –
Polypoidal lesion ,polyp like or grasp like
Association serous exudation and hemorrhage
, that may lead to detachment of the RPE and
sometimes neurosensory retina
Sometime associated features recurrent
hemorrhage and vitreous hemorrhage.
Clinical feature (contd)
Location of the lesion:
In the macular area -69.5%
Under the temporal retinal vascular arcade
Peripapillary area (within one disc
diameter of disc edge -4.5%.
Also mid peripheral area
Clinical feature (contd)Lesions may active or inactive.
• Lesions considered as active on the evidence of
clinical, OCT, FFA any one of the following:
1. Vision loss of 5 or more letters (ETDRS
2. Subretinal fluid with or without
4. Subretinal hemorrhage or fluorescence
• Accepted as the gold standared for diagnosis of PCV.
• Better visualization in ICGA than FFA
ICG absorbs and
emit near infrared
light, which readily
penetrates the RPE
and enhancing veiwing
of choroidal lesions
ICG binding affinity
proteins, that means –
it does not leak from
chorio-capillaries in the
same way as
choroidal lesions are
Characteristics feature of PCV in ICGA:-
A branching network of inner choroidal vessels.
Nodular polypoidal aneurysm or dilations at the edge
of these abnormal vessels network, which correspond
to orange sub-retinal nodules.
Presence of single or multiple focal nodular areas of
hyperfluorescence arising from choroidal circulation
within the first 6 minutes
According to Japanese group on PCV
Quiescent: Polyps in the absence of subretinal or intraretinal fluid
Exudative : Exudation without hemorrhage, which may include
sensory retinal thickening, Neuro-sensory retinal
detachment, PED, subretinal lipid exudation.
Hemorrhagic: Any hemorrhage with or without other exudative
Thermal laser Photocoagulation:
To be beneficial ,albeit it with short term follow up
and for extra foveal lesion.
In some studies
Improve and stabilize vision- in 55-100%
Vision loss – in 13-45%
Whole lesion compared with polyps only appears to
be more efficacious.
Regression or resolution of the polyp by in angio
occlusive mechanism of action
Restrict loss of letters on ETDRS chart to less than
15 letters or improved vision 80-100% patient after 1
Anti VEGF therapy:
Intravitreal Ranibizumab resolving the macular
oedema, polypoidal complexes decreased in 4/12 (33%)
Intravitreal Bevacizumab 1/11 (9.09%) eyes
Both combination therapy and vertiporfin PDT
monotherapy superior to ranibizumab monotherapy
in achieving complete polyp regression at 6 months.
Improvement in BCVA and central retinal thickness
also favored combination therapy.