What is the recommended treatment for a patient with mild Non-Proliferative Diabetic Retinopathy (NPDR) and superimposed idiopathic polypoidal choroidovasculopathy (IPCV)?

Treatment of Mild NPDR with Superimposed Idiopathic Polypoidal Choroidovasculopathy

Treat the polypoidal choroidovasculopathy with intravitreal anti-VEGF therapy (aflibercept preferred) while managing the mild NPDR with systemic optimization and observation—the PCV requires active treatment regardless of the concurrent mild diabetic retinopathy.

Primary Treatment Approach

The presence of PCV fundamentally changes the management paradigm from observation-only to active intervention:

Anti-VEGF Therapy for PCV

• Initiate intravitreal aflibercept injections using a loading dose regimen (2 mg at weeks 0,4, and 8), as this has demonstrated superior outcomes for PCV with improvement in visual acuity of approximately 10 letters at 52 weeks 1
• Aflibercept monotherapy achieved elimination of polypoidal lesion leakage in more than 80% of patients and complete polypoidal lesion regression in approximately 40% of cases 1
• The PLANET study demonstrated that fewer than 15% of PCV patients required rescue photodynamic therapy when treated with aflibercept, indicating monotherapy is highly effective 1

Management of Concurrent Mild NPDR

• Continue observation with systemic optimization for the mild NPDR component—no ocular intervention is indicated specifically for mild diabetic retinopathy 2
• Focus on glycemic control (hemoglobin A1c), blood pressure management, and lipid control as these systemic factors directly impact DR progression 2
• Schedule follow-up examinations every 6-12 months to monitor for NPDR progression 3, 2

Treatment Algorithm

Initial Phase (Weeks 0-12):

• Administer aflibercept 2 mg at weeks 0,4, and 8 for the PCV 1
• Assess response at week 12 using OCT and clinical examination 1
• Monitor for treatment-related complications including conjunctival hemorrhage (5% incidence) 1

Maintenance Phase (After Week 12):

• If adequate response achieved: extend injection intervals gradually to every 8 weeks 1
• If suboptimal response: continue every 4 weeks and consider adding rescue PDT, though this is rarely needed 1
• Continue monitoring NPDR severity at each visit—escalate treatment if progression to moderate NPDR or worse occurs 2

Critical Monitoring Parameters

For PCV Component:

• OCT assessment of central subfield thickness—expect reduction of approximately 140 μm with successful treatment 1
• Indocyanine green angiography to assess polypoidal lesion regression and leakage 1, 4
• Visual acuity measurements at each visit 1

For NPDR Component:

• Watch for progression beyond mild NPDR (development of venous beading, intraretinal microvascular abnormalities, or increased hemorrhages/microaneurysms) 3, 2
• Assess for development of diabetic macular edema, which would require additional anti-VEGF therapy 3
• Monitor for progression to proliferative diabetic retinopathy 3

Important Clinical Considerations

Why Anti-VEGF is Appropriate Despite Mild NPDR:

• The anti-VEGF therapy administered for PCV will simultaneously provide benefit for the diabetic retinopathy component, potentially reducing progression risk 5
• Mild NPDR alone does not require anti-VEGF treatment, but the presence of PCV necessitates it regardless 2, 1
• There is no contraindication to anti-VEGF therapy in patients with mild NPDR 3

Common Pitfalls to Avoid:

• Do not defer PCV treatment simply because the NPDR is mild—these are separate pathologies requiring independent assessment 1, 4
• Do not apply panretinal photocoagulation for mild NPDR, as this is not indicated and could complicate PCV management 2, 6
• Do not assume the anti-VEGF therapy for PCV eliminates the need for NPDR monitoring—continue surveillance for diabetic retinopathy progression 3, 2

Patient Compliance Considerations:

• Anti-VEGF therapy requires frequent visits and injections, which demands excellent patient compliance 1
• Ensure the patient understands the need for continued systemic diabetes management alongside ocular treatment 3, 2
• Establish clear follow-up schedules addressing both conditions: monthly initially for PCV treatment, with concurrent NPDR assessment 1, 2

Escalation Criteria

Immediate referral or treatment intensification if:

• NPDR progresses to moderate or worse severity 2
• Development of any diabetic macular edema 2
• Progression to proliferative diabetic retinopathy 3
• Inadequate PCV response after 12 weeks of aflibercept therapy 1
• Development of vitreous hemorrhage or tractional changes 3