Laser Photocoagulation Sparing the Papillomacular Bundle for Peripapillary Polypoidal Choroidal Vasculopathy Lesions

Case Report

Austin J Clin Ophthalmol. 2014;1(3): 1015.

Laser Photocoagulation Sparing the Papillomacular Bundle for Peripapillary Polypoidal Choroidal Vasculopathy Lesions

Fumio Shiraga1*, Yukari Shirakata2, Chieko Shiragami2, Ayana Yamashita2, Atsushi Fujiwara1, Mio Hosokawa1, Shuhei Kimura1 and Yuki Morizane1

11Department of Ophthalmology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan

22Department of Ophthalmology, Kagawa University Faculty of Medicine, Japan

*Corresponding author: Fumio Shiraga, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho Kitaku Okayama 700-8558, Japan

Received: February 14, 2014; Accepted: March 12, 2014; Published: March 21, 2014

Abstract

Purpose: To evaluate the safety and effectiveness of laser photocoagulation for indocyanine green angiography (ICGA)–identified peripapillarypolypoidal choroidal vasculopathy (PPCV) lesions.

Design: Retrospective, interventional, consecutive case series.

Methods: Twenty–two consecutive PPCV eyes with serous retinal detachments in the macula, which were treated with direct laser photocoagulation,were retrospectively reviewed. No patient had undergone previous treatment for PCV. All 22 eyes were treated with multicolor red (659 nm) laser photocoagulation. The laser spot was focused on the retinal pigment epithelium underneath the detached retina to spare the papillomacular bundle. Laser photocoagulation targeted the entire ICGA–identified lesion, including both the polypoidal lesions and the abnormal network.

Results: The mean follow–up period after the first treatment was 27.2 months (range, 6–77 months). The logMAR BCVA was stable or improved by ≥0.3 logMAR in 19 eyes (86.4%). Three cases had recurrent leakage requiring retreatment, resulting in visual acuity loss ≥0.3 logMAR. Eighteen (81.9%) of the 22 studied eyes required no additional treatment during follow–up.

Conclusion: For PPCV, laser photocoagulation was effective in maintaining or improving visual acuity with only a single treatment session, since laser photocoagulation was administered for all vascular lesions, sparing the papillomacular bundle.

Keywords: Polypoidal choroidal vasculopathy; Peripapillary lesion; Laser photocoagulation; Papillomacular bundle; Perimetry.

Introduction

Polypoidal choroidal vasculopathy (PCV) is a distinct clinical entity associated with multiple recurrent serosanguineous detachments of the retinal pigment epithelium and neurosensory retina, caused by leakage and bleeding from a peculiar choroidal vascular lesion [1]. Indocyanine green angiography (ICGA) can clearly demonstrate these characteristic changes of PCV in the choroidal vasculature as branching vascular networks with polypoidal dilatations at the terminals of the network beneath the retinal pigment epithelium [2]. The incidence of PCV in Japanese appears to be high (54.7% of neovascular AMD); the polypoidal lesions appear to have a predilection for the macular area and are relatively rarely detected in the peripapillary area in Japanese patients [3,4].

Peripapillary PCV (PPCV) frequently causes serous⁄ hemorrhagic neurosensory retinal detachments in the macular area, and the prospect for visual recovery is uncertain and often poor. Although photodynamic therapy (PDT) with verteporfin has been used to stabilize the vision [5–8], PDT is not applicable to PPCV because the lesions are close to the optic disc. Intravitreal vascular endothelial growth factor (VEGF) antagonist monotherapy may require constant treatment regimens and frequent intravitreal injections, because it seems to be ineffective for diminishing choroidal vascular changes [9,10]. However, frequent injections may increase the risks of endophthalmitis and systemic side effects.

Laser photocoagulation is suitable for the treatment of PCV lesions located in the extrafoveal area. As demonstrated by Yuzawa et al in 2003, which evaluated the efficacy of photocoagulation for 47 PCV eyes [11], several reports of laser photocoagulation for PCV have been described, and these results have been variable [11–13]. Direct laser photocoagulation may cause unfavorable side effects, such as retinal pigment epithelium rupture and subretinal or vitreous hemorrhage. In addition, direct photocoagulation for PPCV may damage the papillomacular bundle.

The purpose of this study was to evaluate the safety and effectiveness of laser photocoagulation of ICGA–identified PPCV lesions.

Patients and Methods

Twenty–two treatment–naïve eyes of 21 consecutive Japanese patients (14 men, 7 women) with PPCV and serous neurosensory retinal detachment (SRD) in the macular area, treated with direct laser photocoagulation between July 2003 and December 2011, were retrospectively reviewed. They were followed–up for at least 6 months after photocoagulation. No patient had undergone previous treatment for PCV. The potential risks and benefits were explained in detail, and written, informed consent was obtained from all patients. The exclusion criteria included: previous treatment for PCV, such as laser photocoagulation, submacular surgery, and PDT; glaucoma; tears in the retinal pigment epithelium (RPE); and the presence of macular diseases causing visual loss, such as diabetic maculopathy, retinal vascular occlusion, or idiopathic juxtafoveal macular telangiectasia. The treatment was approved by the Institutional Review Board⁄Ethics Committee at Kagawa University Faculty of Medicine.

The best–corrected visual acuity (BCVA) measured with a standard decimal VA chart was recorded, and the mean BCVA was calculated using the logarithm of the minimum angle of resolution (logMAR) scale. All patients underwent a standard examination including slitlamp biomicroscopy using a 78–D lens, fundus color photography, imaging and fluorescein angiography (FA) using the Topcon TRC– 50DX fundus camera (Topcon, Tokyo, Japan), ICGA, and spectral domain optical coherence tomography (SD–OCT) using a confocal scanning laser ophthalmoscope (Spectralis™⁄HRA Heidelberg Retina Angiograph 2, Heidelberg Engineering, Heidelberg, Germany). The visual fields were assessed by a Humphrey Field Analyzer (HFA, Humphrey Instruments, Germany) in seven eyes and/or MAIA (MAIA; CenterVue, Topcon Japan, Tokyo, Japan) in six eyes. MAIA is a nonmydriatic, near–infrared, line–scanning, laser ophthalmoscope, which incorporates a high–frequency eye tracker and an automated threshold fundus microperimeter.

The diagnosis of PCV was made based on ICGA findings. FA and ICGA were performed to identify polypoidal lesions and abnormal vascular networks, as well as to determine the location and activity of the PCV vascular lesions. FA and ICGA were performed before treatment and when there was recurrence of exudative and/or hemorrhagic manifestation. SD–OCT was performed before and at every visit after treatment to evaluate the morphologic changes of the retina. Regular follow–up examinations were performed at 1 month, 3 months, 6 months, and 1 year after photocoagulation and every 6 months thereafter, and also when patients noticed symptoms. In 7 of the 22 eyes, HFA and/or MAIA was performed at the last visit to measure retinal sensitivity influenced by laser photocoagulation.

All 22 eyes were treated with laser photocoagulation using a multicolor red (659 nm) laser photocoagulation system (Novus Varia, Lumenis Japan, Tokyo, Japan). Patients were treated using the slitlamp microscope with a Goldmann’s three mirror contact lens (with a spot–size magnification factor of 1× to focus the laser. The following laser settings were used: pulse duration, 0.2 s; spot size, 200 µm; power, 200 to 350 mW (until a ‘grayish–white’ lesion was attained). The laser spot was focused on the retinal pigment epithelium underneath the detached retina. Photocoagulation targeting the whole lesion, including both the polypoidal lesions and the abnormal network, was performed because the vascular lesion was present outside the fovea.

Baseline and post–treatment values were compared using the paired t–test, with P values < 0.05 considered statistically significant. All statistical analyses were performed using SPSS for Windows, Version 17.0 (SPSS, Inc., Chicago, IL). Data are presented as means ± SD.

Results

Patient characteristics

Twenty–two eyes of 21 patients who had completed at least 6 months of follow–up were included in this study. There were 14 men 66.7%) and 7 women (33.3%). The mean age at baseline was 72.9 years, with a range of 56 to 83 years. The patients underwent their first laser photocoagulation for PPCV at our hospital. The follow–up period after the first photocoagulation ranged from 6 to 77 months, with a mean of 27.2 months. At baseline, all 22 eyes showed SRD including the fovea, resulting from leakage from the lesion. The characteristics and clinical data of the 21 patients (22 eyes) at baseline and after treatment are shown in the Table.

Visual outcomes

The logMAR BCVA (mean ± standard deviation) was 0.27 ± 0.25 at baseline compared with 0.22 ± 0.53 at the last visit; the difference was not significant (paired t–test). The logMAR BCVA was stable or improved by ≥ 0.3 logMAR in 19 eyes (86.4%). In three eyes, logMAR BCVA deteriorated by ≥ 0.3 logMAR; these three cases had recurrences of leakage and needed retreatment during the follow–up period, resulting in visual acuity loss ≥ 0.3 logMAR. In all 12 eyes with visual acuity better than 20⁄40 at baseline, the visual acuity was maintained or improved. The final logMAR VA was significantly correlated with the logMAR at baseline (Pearson’s correlation test, p=0.021, r=0.488) (Figure1).

Anatomic changes

At baseline, all 22 eyes showed SRD in the macula including the fovea, resulting from leakage from the lesion. The vascular lesion was present outside the foveal vascular zone in all 22 eyes. SRD disappeared within one month after photocoagulation. In 18 eyes (81.8%), recurrence of subretinal fluid, leakage, bleeding, or subsequent development of classic CNV did not occur during the follow–up period after a single laser treatment.