Visual Outcomes of Polypoidal Choroidal Vasculopathy Treated with Intravitreal Ranibizumab with or Without Photodynamic Therapy

Editor, I n a recent article, Kessel et al. (2016) reported improvement in mean visual acuity (VA) among a cohort of patients with neovascular age-related macular degeneration (AMD) who underwent cataract surgery. In the 6 months following cataract surgery, VA improved by a mean of 7.1 ETDRS letters. Their results provide additional evidence on the potential benefit of cataract surgery among patients with neovascular AMD. The authors reported that the frequency of antivascular endothelial growth factor (VEGF) injections did not change following cataract surgery. It is important to note, however, that among 19 patients who were injectionfree for more than 1 year prior to cataract surgery, 11 (57.9%) required an injection following the surgery. We are curious whether there were any predisposing clinical factors or features on optical coherence tomography (OCT) that may predict the need for resumption of anti-VEGF injections. This would be important to allow ophthalmologists to predict those who may experience recurrence of the disease and to monitor these patients even more closely. It would also be interesting to know if there were any cases of polypoidal choroidal vasculopathy (PCV) identified among the cohort in this study. Polypoidal choroidal vasculopathy (PCV) is an important variant of AMD which occurs more frequently among some populations such as Asians (Tan et al. 2014, 2015). One of the possible sequelae of active PCV is the development of sudden, massive submacular haemorrhage which could result in permanent visual loss (Tan et al. 2007; Kim et al. 2012). Among patients presenting with PCV, the frequency of massive submacular haemorrhage had been reported to vary between 7.5%and 13.1% (Tan et al. 2014, 2015). Although the risk factors associated with massive submacular haemorrhage remains uncertain, it is believed that one of the factors that may precipitate this is a sudden change in intraocular pressure. Intraocular pressure is known to vary considerably during cataract surgery. It has been suggested that shearing forces occurring as a result of the changes in intraocular pressure may result in haemorrhage from choroidal vessels. This is especially so among patients with hypertension and arteriosclerosis, which increases the fragility of the vessels and their susceptibility to mechanical shearing forces. In a paper by Kim et al. (2012) a patient with asymptomatic PCV developed submacular haemorrhage 1 week after cataract surgery, which required treatment with photodynamic therapy and intravitreal bevacizumab. In summary, we agree with the authors that patients with AMD will tend to benefit from cataract surgery. However, in a patient with PCV, it is important to assess the degree of activity of the PCV lesion, and consider optimizing management of PCV before performing cataract surgery.