What is the management of a polypoidal lesion in the fundus of the eye?

Management of Polypoidal Lesions in the Fundus of the Eye

The first-line treatment for polypoidal lesions in the fundus of the eye is combination therapy with intravitreal anti-VEGF injections and photodynamic therapy (PDT), as this approach has demonstrated superior efficacy compared to monotherapy in achieving polyp regression and improving visual outcomes. 1

Diagnosis and Initial Assessment

• Multimodal imaging is essential for accurate diagnosis:

  • Optical Coherence Tomography (OCT): Identifies polypoidal dilatations and associated subretinal fluid
  • Indocyanine Green Angiography (ICGA): Gold standard for visualizing polypoidal lesions, showing a well-demarcated CNV "plaque" with polypoidal components
  • OCT Angiography (OCT-A): Helps detect neovascular networks
  • Fluorescein Angiography (FA): Assists in evaluating leakage patterns

• Key diagnostic features:

  • Older age patients are more commonly affected
  • Presence of polypoidal dilatations on OCT and ICGA
  • Sometimes concurrent non-polypoidal neovascularization 2
  • Mid/hyperreflective signal below a flat irregular RPE detachment 2

Treatment Algorithm

First-Line Treatment

1. Combination therapy: Anti-VEGF injections plus PDT

   • Supported by EVEREST II and PLANET studies showing superior outcomes 1
   • Peiretti et al. reported 50% of polypoidal lesions closed after full-fluence PDT monotherapy, compared to only 25% with anti-VEGF monotherapy 2

2. Anti-VEGF protocol:

   • Initial loading phase: 3 monthly injections
   • Followed by as-needed (PRN) injections based on disease activity 3
   • Options include ranibizumab, aflibercept, or bevacizumab
   • MINERVA study showed ranibizumab improved visual acuity by 6.6 ETDRS letters at 2 months in CNV due to CSC 1

3. PDT protocol:

   • Verteporfin administration: 6 mg/m² body surface area intravenously over 10 minutes
   • Light activation: 15 minutes after start of infusion
   • Light dose: 50 J/cm² at intensity of 600 mW/cm² for 83 seconds
   • Treatment spot size: 1000 microns larger than greatest linear dimension of lesion 4

Special Considerations

1. Polypoidal lesions with submacular hemorrhage:

   • Anti-VEGF monotherapy can be effective as first-line treatment
   • In a study of 27 eyes, visual acuity improved from 20/204 to 20/115 at 12 months 5
   • Monitor for potential vitreous hemorrhage (occurred in 11.1% of cases) 5

2. Silent Type 1 CNV:

   • Common in chronic CSC but may not require immediate treatment
   • Consider deferring anti-VEGF therapy until active leakage becomes evident 2

3. Remote polypoidal lesions:

   • Some patients have polypoidal lesions distant from the macula
   • These remote lesions typically have minimal impact on visual outcomes and may not require treatment if asymptomatic 6

Monitoring and Follow-up

• Regular follow-up: Every 1-3 months with OCT imaging 3

• Treatment response indicators:

  • Resolution of subretinal fluid
  • Regression of polypoidal lesions
  • Improvement in visual acuity
  • Reduction in retinal pigment epithelial detachment 1

• Long-term management:

  • Expect frequent injections (mean 12.5 injections over 24 months in one study) 3
  • Be aware that initial visual improvements may not be sustained long-term
  • In a 3-year follow-up study, visual improvement was maintained for the first year but then deteriorated 7

Prognostic Factors

Factors associated with poorer long-term visual outcomes include:

• Larger lesion size at baseline
• Presence of pigment epithelial detachment
• Recurrence during follow-up 7

Common Pitfalls to Avoid

1. Misdiagnosis: Up to two-thirds of patients with CSC with CNV have a polypoidal component, which may be missed without ICGA 2

2. Undertreatment: Polypoidal lesions often require frequent anti-VEGF injections (comparable to typical AMD) 3

3. Delayed treatment: Prolonged observation without treatment can lead to irreversible vision loss, particularly in lesions affecting the fovea

4. Inadequate follow-up: Regular monitoring is essential as recurrence is common (66.7% in one long-term study) 7

5. Overlooking complications: Monitor for vitreous hemorrhage, which may require vitrectomy in some cases 5

By following this evidence-based approach to managing polypoidal lesions in the fundus, clinicians can optimize visual outcomes and reduce the risk of vision-threatening complications.