Appearance of Polypoidal Lesions in Patients With Polypoidal Choroidal Vasculopathy Using Swept-Source Optical Coherence Tomographic Angiography

Abstract

Importance: Polypoidal choroidal vasculopathy (PCV) is a major cause of visual loss worldwide, particularly in Asia, and the appropriate understanding of the structures in PCV previously described as polypoidal lesions is important for understanding their pathogenesis, diagnosis, and prognosis.

Objective: To report the morphologic characteristics of polypoidal lesions and their association with branching vascular networks (BVNs) in eyes with PCV using swept-source optical coherence tomographic angiography (SS-OCTA).

Design, setting, and participants: This cross-sectional observational study included 20 participants recruited from Shanghai General Hospital with a diagnosis of PCV based on the presence of focal hyperfluorescent spots on indocyanine green angiography (ICGA). Data were collected from December 1, 2017, to September 1, 2018, and analyzed from June 1 through September 30, 2018.

Main outcomes and measures: Polypoidal lesions in eyes with PCV were characterized using multimodal imaging that included fundus photography, fluorescein angiography, ICGA, SS-OCT, and SS-OCTA, and the images were anatomically aligned. Subfoveal choroidal thickness was manually measured as the distance between the Bruch membrane and the sclerochoroidal interface on the SS-OCT images.

Results: Of the 20 Asian patients, 5 (25%) were women and 15 (75%) were men. The mean (SD) age was 61.1 (7.6) years, and the mean (SD) logMAR visual acuity was 0.358 (0.294) (Snellen equivalent, 20/50 [20/40]). Twenty-three eyes underwent imaging and were diagnosed with PCV. Indocyanine green angiography identified 43 polypoidal lesions, and all corresponded to the structures that appeared as clusters of tangled vessels on SS-OCTA images. In addition, SS-OCTA detected 16 tangled vascular structures not seen on ICGA. Branching vascular networks were detected on SS-OCTA imaging in all eyes, but ICGA identified BVNs in only 17 of 23 eyes (74%). Of the 43 tangled vascular structures, 40 (93%) were located at the edge of a BVN and 3 (7%) were associated with type 2 neovascularization.

Conclusions and relevance: In eyes with PCV undergoing SS-OCTA imaging, previously described polypoidal lesions may appear as tangled vascular structures associated with BVN or type 2 neovascularization. The identification of polypoidal lesions in patients with PCV as neovascular tangles rather than actual polypoidal lesions or aneurysmal dilatations may help facilitate understanding of their pathogenesis and response to treatment.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Rosenfeld reported receiving grants and personal fees from Carl Zeiss Meditec, Inc, outside the submitted work. Dr Wang reported receiving grants from National Natural Science Foundation of China during the conduct of the study and grants from Carl Zeiss Meditec, Inc, outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. Tangled Vascular Polypoidal Lesions on Indocyanine Green Angiography (ICGA) and Swept-Source Optical Coherence Tomographic Angiography (SS-OCTA)

A, ICGA shows 5 hyperfluorescent spots (arrowheads). B, ICGA shows 1 focal hyperfluorescent spot (arrowhead). C, SS-OCTA shows 8 multiform tangle vessel structures (pink and yellow arrowheads) at the edge of a medusalike branching vascular network. Polypoidal lesions (pink arrowheads) were not detected on ICGA. D, SS-OCTA shows 3 tangle vessel balls (pink and yellow arrowheads). Polypoidal lesions (pink arrowheads) were not detected on ICGA. Squares represent the region on the ICGA that corresponds to the en face SS-OCTA images below.

Figure 2.. Multimodal Imaging in Patient 6

A, The fundus photograph shows orange-red polypoidal lesions (arrowheads). B, Enlarged early-phase indocyanine green angiography shows polypoidal lesions (arrowheads) in a cluster configuration around a branching vascular network (BVN). C, Swept-source optical coherence tomographic angiography (OCTA) shows the vascular flow signals of polypoidal lesions (arrowheads) and BVN. Numbers 1 to 4 represent the serial number of lesions and suggest that there are 4 polypoidal lesions in this patient. D, Schematic drawing shows the tangled vessel structure of polypoidal lesions.

Figure 3.. Multimodal Imaging in Patient 1

A, The fundus photograph shows an orange-red polypoidal lesion (arrowhead). B, Early-phase indocyanine green angiography shows a focal polypoidal lesion (arrowhead) and branching vascular network (BVN). C, Swept-source optical coherence tomographic angiography (SS-OCTA) shows BVN (pink arrowheads) and a polypoidal lesion (yellow arrowhead) that appear as tangled vessels before anti–vascular endothelial growth factor treatment. D, Two months after the second ranibizumab injection, SS-OCTA shows regression of the terminal vessels in the polypoidal lesion (yellow arrowhead) and appears as tangled dilated vessels connected to the BVN (pink arrowheads).

Figure 4.. Swept-Source Optical Coherence Tomographic Angiography (SS-OCTA) and OCT B-scan in Patient 2

A, One part of branching vascular networks (BVNs) (pink arrowheads) and polypoidal lesions (yellow arrowheads) were clearly detected on SS-OCTA. B, Type 2 neovascularization (pink arrowhead), another part of BVN, and polypoidal lesions (yellow arrowheads) connected to them were observed on SS-OCTA. C, The BVN and polypoidal lesions above corresponded to the double layer sign (pink arrowheads) and notched pigment epithelial detachment (yellow arrowheads) on the OCT B-scan. D, The type 2 neovascularization above corresponded to the highly reflective material overlying the retinal pigment epithelium (arrowhead) on the OCT B-scan. Each set of scans was obtained from a different location.