Anti-vascular endothelial growth factor therapy in polypoidal choroidal vasculopathy

The diagnosis and management of polypoidal choroidal vasculopathy (PCV), a complex chorioretinal disease which constitutes 60% of neovascular age-related macular degeneration cases among Asians, have evolved significantly in the last decade. SD-OCT biomarkers can reliably diagnose and monitor PCV, restricting the role of invasive indocyanine green angiography to situations like suboptimal responders to therapy where it helps to clarify the diagnosis and explore other treatment options like laser. The introduction of Aflibercept resulted in a paradigm shift in the treatment from combination therapy (photodynamic therapy plus injection of anti-VEGF drugs) to anti-VEGF monotherapy after it was proven noninferior to the former in the PLANET trial. The limited availability of PDT also favored this shift. The longer half-life of Aflibercept led to adoption of proactive treatment regimens like treat and extend guided by fluid markers on OCT, reducing the treatment burden. Newer molecules with more potency and durability like Brolucizumab and Faricimab demonstrated superior drying effects and achieved a longer treatment interval of up to 16 weeks, offering additional options for anti-VEGF monotherapy. HAWK and HARRIER trials proved the noninferiority of Brolucizumab to Aflibercept, though there were safety concerns of inflammation. Interim analysis of the on-going SALWEEN trial for Faricimab in PCV has also shown favorable outcomes. Characterizing the different phenotypes of PCV based on OCT and choosing the appropriate drug and treatment regimen are important to maximize visual outcome while reducing the treatment burden. This article reviews the evolution of anti-VEGF therapy in PCV and provides recommendations for optimal management in the real world.