Non ICGA treatment criteria for Suboptimal Anti VEGF Response for Polypoidal Choroidal Vasculopathy: APOIS PCV Workgroup Report 2.

ABSTRACT Purpose To develop and validate optical coherence tomography (OCT) and color fundus photography (CFP) criteria in differentiating polypoidal choroidal vasculopathy (PCV) from typical neovascular age-related macular degeneration (nAMD) in eyes with suboptimal response to anti-vascular endothelial growth factor (VEGF) monotherapy, and to determine whether OCT alone can be used to guide photodynamic therapy (PDT) treatment. Design Clinical study evaluating diagnostic accuracy. Participants Patients with nAMD who received 3-monthly anti-VEGF monotherapy but had persistent activity defined as subretinal fluid and/or intraretinal fluid at month 3 assessments. Methods In phase 1, international retina experts evaluated OCT and CFP of eyes with nAMD to identify the presence or absence of features attributable to PCV. The performance of individual and combinations of these features were compared to ICGA. In phase 2, these criteria were applied to an independent image set to assess generalizability. In a separate exercise, retinal experts drew proposed PDT treatment spots using only OCT and near-infra red (NIR) images in eyes with PCV and persistent activity. The location and size of proposed spot was compared to ICGA to determine the extent of coverage of polypoidal lesions (PL) and branching neovascular network (BNN). Main Outcome Measures Sensitivity and specificity of CFP and OCT criteria to differentiate PCV from nAMD, and accuracy of coverage of OCT-guided PDT compared to ICGA. Results In eyes with persistent activity, the combination of 3 non-ICGA-based criteria (sharp-peaked pigment epithelial detachment (PED), sub-retinal pigment epithelium (RPE) ring-like lesion, and orange nodule) to detect PCV showed good agreement compared to ICGA, with an area under the receiver operating characteristic curve of 0.85. Validation using both an independent image set and assessors achieved an accuracy of 0.77. Compared to ICGA, the OCT-guided PDT treatment spot covered 100% of PL and 90% of the BNN. Conclusions In nAMD eyes with persistent activity, OCT and CFP can differentiate PCV from typical nAMD, which may allow the option of adjunct PDT treatment. Furthermore, OCT alone can be used to plan adjunct PDT treatment without the need for ICGA, with consistent and complete coverage of PL.