PMC8138223_01
Multimodal imaging of both eyes at baseline in July 2014. First row showing SD-OCT scans of the right (a) and left (b) eye with the corresponding central choroidal thickness (green arrows). Second row showing the FAG of the right (c) and left (d) eye in the early (left) and late (right) phases. ICG imaging of the right (e) and left (f) eye is shown in the last row with early (left) and late (right) phases. SD-OCT, spectral-domain optical coherence tomography; ICG, indocyanine green angiography.
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F1
In both eyes, the performed investigations revealed type 1 neovascularization (see Fig. 1) without signs of polypoid choroidal vasculopathy (PCV) and intravitreal injections using aflibercept 2 mg (Eylea , Bayer, Switzerland) were started following a treat-and-extend schema as described before. As shown in Figure 3 angiographies revealed a type 1 neovascularization pattern in both eyes with multiple polyps surrounding the neovascular network only in the right eye. Figure 1 shows the location of the type 1 choroidal neovascularization and the newly developed polyps in relation to the central 4-mm spot.
Follow-up of SD-OCT scans of the right eye from baseline to November 2020. a Note the amount of subretinal fluid at baseline in July 2014 (VA 20/40). b Persistent subretinal fluid after 6 injections of aflibercept and 4 times ranibizumab in a 4-week interval (pre-SRT) in April 2015 with VA gain to 20/32. c One month post-SRT, the subretinal fluid was reduced, up to complete dryness 2 months post-SRT and VA improved to 20/25 which remained stable in the consecutive OCT scans (d). After the exit of the TER in September 2016 (e), a mild recurrence occurred in February 2017 (f). The subretinal fluid was initially responsive to ranibizumab (g) and later to aflibercept (h). Despite strict intervals of 4 weeks with aflibercept, hemorrhages occurred in November 2019 (i) and March 2020, leading to a VA loss to 20/50 in January 2020 which recovered to 20/25 in March 2020 (j). Due to persistence of subretinal fluid, a therapy switch to brolucizumab was performed on 2 November 2020 (k) and resulted in decrease of subretinal fluid on 30 November 2020 (l). SD-OCT, spectral-domain optical coherence tomography; VA, visual acuity; TER, treat and extend regimen.
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F2
However, with ranibizumab injected every 4 weeks, there was still persisting subretinal fluid especially in the right eye (Fig. 2b). As soon as 1 month after adjunct SRT, subretinal fluid was already markedly reduced (see Fig. 2c; VA 20/25), 2 months after SRT there were no signs of sub- or intraretinal fluid in the right eye (see Fig. 2d; VA 20/25). Twenty-one months after SRT and 5 months after stopping intravitreal ranibizumab injections, a first recurrence occurred in the right eye (see Fig. 2f; VA 20/25). In the right eye, despite strict 4-week intervals, subretinal hemorrhages occurred in November 2019 and March 2020 (see Fig. 2i, j) with VA deteriorating to 20/50 in January 2020 but recovering to previous values of 20/25-20/20 under continued aflibercept therapy in March 2020. In the right eye, a switch to brolucizumab 6 mg (Beovu , Novartis, Basel, Switzerland) was performed due to persisting subretinal fluid on 2 November 2020 (Fig. 2k). Four weeks later, subretinal fluid had resolved in almost all SD-OCT sections (Fig. 2l) and brolucizumab treatment was continued.
Multimodal imaging of both eyes in June 2020. First 2 rows showing SD-OCT scans of the right (a, c) and left (b, d) eye with a "double-layer sign" in the right eye and decreased central choroidal thickness. Third row showing the FAG of the right (e) and left (f) eye in the early (left) and late (right) phases. g Note the presence of a single-foveal polyp and a cluster of polyps juxtafoveally inferiorly on ICG imaging of the right eye in the early (left) and late (right) phases. h The left eye shows an AMD-like neovascularization on ICG without PCV. Note the branching vascular network in the OCTA scan on the right (i) in contrast to the membrane on the left (j). Color fundus photography reveals hemorrhages in the macular and juxtafoveal inferior area of the right eye (k) and no hemorrhage in the left eye (l). SD-OCT, spectral-domain optical coherence tomography; ICG, indocyanine green angiography; PCV, polypoid choroidal vasculopathy.
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F3
As shown in Figure 3 angiographies revealed a type 1 neovascularization pattern in both eyes with multiple polyps surrounding the neovascular network only in the right eye.