|Year : 2021 | Volume
| Issue : 2 | Page : 212
Commentary: Multimodal imaging in pachychoroid disease spectrum
Jay U Sheth
Vitreo-Retina Consultant and Head of Research, Surya Eye Institute and Research Centre, Mumbai, Maharashtra; Clinical Research Lead, Chaitanya Eye Hospital and Research Institute, Trivandrum, Kerala, India
|Date of Web Publication||01-Apr-2021|
Dr. Jay U Sheth
Surya Eye Institute and Research Centre, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sheth JU. Commentary: Multimodal imaging in pachychoroid disease spectrum. Indian J Ophthalmol Case Rep 2021;1:212
The pachychoroid disease spectrum encompasses an array of chorioretinal pathologies ranging from pachychoroid pigment epitheliopathy, Central serous chorioretinopathy (CSCR), pachychoroid neovasculopathy (PNV), polypoidal choroidal vasculopathy (PCV), focal choroidal excavation, and peripapillary pachychoroid syndrome. As our expertise strengthens into the multimodal imaging (MMI) facet of choroid and retina, we have started gaining better insight into its pathogenesis, diagnosis, and management aspects. For optimal treatment outcome of this spectrum, timely advice of MMI including color fundus photography/multicolor imaging, spectral domain optical coherence tomography enhanced depth imaging, fundus autofluorescence, Fundus fluorescein angiography (FFA), indocyanine green angiography (ICGA), and optical coherence tomography angiography (OCTA) is imperative.
In the article “A Tale of Two Leaks – Pachychoroid Spectrum,” the authors describe an interesting case of pachychoroid spectrum. In this report, when the patient came with recurrence, she was injected with an anti-VEGF agent in view of being a known case of PCV under treatment. However, there was worsening of subretinal fluid (SRF) postinjection. The deferred FFA + ICGA showed polyp on ICGA and a CSCR leak on FFA, respectively, which were promptly lasered along with anti-VEGF injection, with good visual outcome. However, this case highlights the necessity for promptly performing MMI when a patient of pachychoroid spectrum presents with a recurrence. It is imperative to note that pachychoroidopathy is a dynamic disease spectrum, which can have varied disease manifestations at different points of time. Additionally, multiple entities can be present simultaneously, as described in the literature.
Nonresponse or suboptimal response to anti-VEGF agents is frequently encountered while treating PNV/PCV., In a scenario when such patients demonstrate disease activity in the form of SMD, it is imperative to rule out underlying CSCR by performing an FFA, along with an ICGA. It may not be surprising to note an underlying active CSCR to be the source of SRF rather than the CNVM (PNV/PCV). This CNVM could very well be quiescent, while the symptoms and/or imaging biomarkers of disease activity are present due to an active CSCR. In such a scenario, the patient can be easily treated by thermal focal laser (for extrafoveal leaks) rather than anti-VEGF injection.
ICGA is considered to be the gold standard for PCV/PNV management. However, access to ICGA is limited in many parts of the world. Furthermore, branching vascular networks are seen more clearly on OCTA as compared to an ICGA. Hence, many retinal physicians rely upon OCTA to detect a network in case of recurrence of disease activity. Occasional, no clear network may be ascertained on OCTA, but in view of OCT biomarkers such as SMD, an empirical treatment with anti-VEGF may be initiated if the patient is a known case of PCN/PCV. Even in such a scenario with absence of network on OCTA and with simultaneous presence of SMD on SD-OCT, performing a FFA can be very helpful to rule out active CSCR.
Based on our current understanding of the pachychoroidopathy, we should consider the following as definitive indications for performing MMI in this spectrum, including ICGA + FFA ± OCTA:
- Treatment-naive cases
- Sudden drop in visual acuity
- Clinical appearance of fresh hemorrhage/exudation
- Appearance of new pigment epithelial detachments (PEDs) or change in configuration of PED on SD-OCT
- Appearance or worsening of SRF on SD-OCT
- Appearance or worsening of intraretinal fluid on SD-OCT
- Nonresponse/worsening with treatment.
To conclude, performing MMI forms the crux in diagnosis and optimal management of pachychoroid disease spectrum. A simple investigation such as FFA, which is universally available, can alter the treatment modality to match with the concurrent underlying pathology, thereby greatly reducing the burden of injections.
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