Sir,

A 71-year-old Indian male patient presented to the retina–vitreous service of our tertiary care hospital with the complaints of progressive decrease in vision in the right eye over the past 6 months. Ocular examination revealed a best-corrected visual acuity of 6/12 and 6/6 (distance vision) and N18 and N6 (near vision) in the right and the left eye, respectively. Fundus examination of the left eye was unremarkable. Indirect ophthalmoscopy of the right eye revealed a serous detachment of the macula with extensive lipid exudation and an area of thickening superior to the disc suspicious of a choroidal neovascular membrane (CNVM) (Figure 1a). Fundus fluorescein angiography (FFA) demonstrated a progressively increasing irregular hyperfluorescence in that region and pooling of dye in the serous detachment in the macula but was otherwise noncontributory to the diagnosis. Indocyanine green angiography (ICGFA) was carried out that showed a branching vascular network in the inner choroid ending in two terminal hyperfluorescent polypoidal dilatations in the superior juxtapapillary region suggestive of leaking polypoidal choroidal neovascularisation (CNV) (Figure 2a). There were also two areas of ill-defined hyperfluorescence superior and superonasal to the foveola. Based on the above findings, a diagnosis of polypoidal choroidal vasculopathy (PCV) of the right eye was made.

Figure 1
figure 1

(a) Pretreatment colour fundus photograph of the right eye of the patient showing the serous detachment of the macula ringed by subretinal lipid. (b) Post-treatment colour fundus photograph of the right eye at first month of follow-up of the patient showing the resolved macular detachment. A round reddish-orange lesion (black arrow) is seen superior to the fovea.

Full size image
Figure 2
figure 2

(a) Pretreatment indocyanine angiogram of the right eye of the patient showing two small hyperfluorescent polypoidal lesions superior to the disc (small black arrow). (b) Post-treatment indocyanine angiogram of the right eye of the patient at first month of follow-up showing a row of hyperfluorescent polypoidal lesions with surrounding leakage (small black arrow) superior and superonasal to the fovea. Note the disappearance of the previously seen polypoidal lesions superior to the disc.

Full size image

In view of the long duration of persisting poor visual acuity, the macular involvement, and the abundant lipid suggesting an active exudative process, it was decided to treat the leaking polypoidal lesions. After informed consent, the patient underwent transpupillary thermotherapy (TTT) to the juxtapapillary vascular network inclusive of the polypoidal lesions (2 spots, 2 mm in size, 250 mW power, 1 min duration, end point: no visible reaction). Follow-up at 1 month revealed a resolved macular detachment and a reddish-orange subretinal lesion superior to the fovea that was typical of PCV (Figure 1b). The ICGFA revealed the disappearance of the treated polypoidal lesions (Figure 2b). It also showed a row of aneurysmal dilatations of the inner choroidal vascular network superior to the fovea, corresponding to the reddish-orange lesion and a hyperfluorescent polypoidal lesion superonasal to the fovea. These lesions corresponded to the ill-defined hyperfluorescent lesions seen in the pretreatment ICGFA, and were in all probability previously obscured by the overlying serous detachment. Alternatively, these could represent newly opened vascular channels, following closure of the treated PCV lesions. The patient's near vision had improved to N10 in the right eye, while his distant vision was maintained at 6/12. The patient's condition remained stable when last seen at 6 months of follow-up.

Comment

PCV is a distinct form of CNV termed polypoidal CNV that is characterised by recurrent serosanguineous detachments of the macula.1 We are aware of several reports of patients with PCV who have had spontaneous resolution due to autoinfarction.1 However, in an attempt to restore the normal physiologic retinal pigment epithelium (RPE)–choroidal transport barriers and relationships in this case with a long-standing sensory detachment of the macula, we decided to treat the leaking polypoidal lesions.

Various management options including observation,1 argon,1 and diode2 laser photocoagulation, photodynamic therapy (PDT)3 have been advocated for this condition. However, there is no report till date of TTT as a treatment modality in this condition. We report a case of polypoidal CNV managed by TTT. This is the first report of its kind in English literature to the best of our knowledge (as per Medline search).

Gomez-Ulla et al2 treated a case of PCV with diode laser and have argued that its absorption at the level of the retinal pigment epithelium (RPE), enables the selective treatment of the choroidal lesions along with sparing of the overlying neurosensory retina. TTT that also uses the diode laser has been used successsfully to treat CNV in age-related macular degeneration (AMD).4 It has been suggested that TTT causes closure of the choroidal vasculature by hyperthermia-induced endothelial damage.5 We thought we could use this property of TTT and the longer wavelength of diode laser to close selectively the choroidal vascular network of the leaking juxtapapillary PCV in this case. We did not do PDT in this case since the patient could not afford it. We did not treat the hyperfluorescent lesions superior and superonasal to the fovea since they were not clearly defined in the ICGFA.

The disappearance of the leaking polypoidal lesions following treatment has been seen following laser photocoagulation and PDT as well.1, 2, 3 Our case illustrates the efficacy of TTT in the management of PCV. We do concede the need for future prospective randomised controlled studies to establish clearly the safety and efficacy of TTT in the management of PCV.