We read with great interest the case series presented by Chan et al,1 and agree that vascularised pigment epithelial detachments (vPEDs) do not flatten easily with anti-vascular endothelial growth factor (VEGF) treatment. As the authors discuss, the prospect of using a higher than conventional dose to treat this type of choroidal neovascular membrane needs evaluation, however, we question whether the cases demonstrated did in fact have vPEDs.
Case 1 shows a well-defined circular smooth area of fluorescence consistent with a serous PED next to an area of retinal pigment epithelial mottling. This may represent an adjacent area of occult, and or atrophy, judging from the colour photograph and optical coherence tomography (OCT). It is most likely that this is a retinal angiomatous proliferation (RAP) lesion that can respond well to conventional dose anti-VEGF treatment. Case 2 also appears to show serous PED. With Case 3 it is reported that there is a retinochoroidal anastomosis at the margin of the vPEDs. The colour photograph and OCT suggest that the lesion is a serous PED associated with RAP. Again in our experience this would settle well with conventional dose anti-VEGF treatment.2
Vascularised PEDs have been defined as areas of irregular elevation of the pigment epithelium and consist of a stippled hyper fluorescent appearance on angiography. These are not usually as bright or discrete as serous RPE detachments in the early phase of angiography.3, 4 Furthermore, they gradually brighten and the vascular network might be visible on ICG.
Serous PEDs can occur without a vascular component in the context of lots of drusen and do not respond to ranibizumab. They also can occur with RAP, with polypoidal choroidal vasculopathy and as part of a mixed ‘wet’ AMD picture. Indocyanide green angiography (ICG) can be useful to identify the lesion type but is best performed with high-resolution ICG with early video, such as is possible with the Heidelberg systems. As no ICG is shown, it is hard to comment on the quality of what was seen.
It is pleasing to see that the cases reported all did well but we would be interested to know whether the authors had any other cases of suspected vPED that did not respond or indeed the outcome of other types of choroidal neovascularisation that were also treated with high-dose ranibizumab. We agree that further analysis of a larger cohort is required but would require strict inclusion criteria on what constitutes a vPED before recommending monthly high-dose ranibizumab.
References
Chan CK, Abraham P, Sarraf D . High-dose ranibizumab therapy for vascularized pigment epithelial detachment. Eye 2012; 26 (6): 882–885.
Sykakis E, Malandrakis M, Pushpoth S, Browning A, Gupta R, Talks J . Intravitreal ranibizumab and intravitreal triamcinolone with PDT for the treatment of retinal angiomatous proliferation. A retrospective comparative study. AMD Clinical Trials III, ; 2 May 2011; Newcastle Upon Tyne, UK (ARVO abstract 2011: 1660/A55).
Macular Photocoagulation Study Group. Subfoveal neovascular lesions in age-related macular degeneration. Guidelines for evaluation and treatment in the macular photocoagulation study group. Arch Ophthalmol 1991; 109 (9): 1242–1257.
Barbazetto I, Burdan A, Bressler NM, Bressler SB, Haynes L, Kapetanios AD et al. Photodynamic therapy of subfoveal choroidal neovascularization with verteporfin: fluorescein angiographic guidelines for evaluation and treatment—TAP and VIP report No. 2. Arch Ophthalmol 2003; 121 (9): 1253–1268.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
J Talks has received travel expenses and or attended advisory boards for Allergan, Novartis, Bayer, Alamera Sciences. The remaining authors declare no conflict of interest.
Rights and permissions
About this article
Cite this article
Talks, S., Gupta, R. & Browning, A. Alternative diagnosis for cases presented as vPED treated with high-dose ranibizumab. Eye 26, 1599–1600 (2012). https://doi.org/10.1038/eye.2012.207
Published:
Issue Date:
DOI: https://doi.org/10.1038/eye.2012.207
This article is cited by
-
Response to Talks et al
Eye (2012)