Clinical features and outcomes of breakthrough vitreous hemorrhage secondary to polypoidal choroidal vasculopathy

PLOS ONE RESEARCH ARTICLE Clinical features and outcomes of breakthrough vitreous hemorrhage secondary to polypoidal choroidal vasculopathy Meng-Syuan Li ID1,2, Chui-Lien Tsen ID2,3* 1 Division of Ophthalmology, Pingtung Veterans General Hospital, Pingtung, Taiwan, R.O.C, 2 Department of Ophthalmology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, R.O.C, 3 Department of Optometry, Shu-Zen Junior College of Medicine and Management, Kaohsiung, Taiwan, R.O.C * a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 OPEN ACCESS Citation: Li M-S, Tsen C-L (2022) Clinical features and outcomes of breakthrough vitreous hemorrhage secondary to polypoidal choroidal vasculopathy. PLoS ONE 17(12): e0279778. https://doi.org/10.1371/journal.pone.0279778 Editor: Sanjoy Bhattacharya, Bascom Palmer Eye Institute, UNITED STATES Received: September 25, 2022 Accepted: December 14, 2022 Published: December 30, 2022 Copyright: © 2022 Li, Tsen. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Polypoidal choroidal vasculopathy (PCV) with hemorrhagic complications is at higher risk for breakthrough vitreous hemorrhage (VH). This study aimed to evaluate the clinical features and outcomes of breakthrough VH secondary to PCV. Data of patients receiving pars plana vitrectomy for breakthrough VH secondary to PCV (VH group) were evaluated retrospectively and compared statistically to data of age and sex-matched PCV patients without breakthrough VH (control group). Among PCV patients, 36 eyes with breakthrough VH and 62 eyes without VH were included. Compared with baseline, best corrected visual acuity (BCVA) was worse in the VH group (P < 0.001), and improved postoperatively (P < 0.001). Percentages of pigmented epithelial detachment (PED), hemorrhagic PED, massive subretinal hemorrhage, hemorrhagic retinal detachment (RD), and hemorrhagic choroidal detachment (CD) (P = 0.007) were higher in the VH group (P < 0.001). Incidence of choroidal vascular hyperpermeability (P < 0.001), massive subretinal hemorrhage (P = 0.001), hemorrhagic retinal detachment (P = 0.001) and hemorrhagic type PCV (P = 0.001) was higher in patients with pachychoroid PCV, while fibrovascular type had lower incidence (P < 0.001). Better initial BCVA (P < 0.001), higher frequency of anti-VEGF treatment (P = 0.009), and previous photodynamic therapy (P = 0.017) showed better visual outcomes. Breakthrough VH risk is higher in PCV patients with massive subretinal hemorrhage, hemorrhagic PED and hemorrhagic RD. BCVA and hemorrhagic complications improve significantly postoperatively. Higher frequency of anti-VEGF treatment and previous photodynamic therapy are associated with better visual prognosis in PCV patients with breakthrough VH. Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: No funding was received for this research. Introduction Competing interests: The authors declare no competing interests. Polypoidal choroidal vasculopathy (PCV) is a vision-threatening disease characterized by polyp-like dilations of choroidal vessels. PCV may cause pigmented epithelial detachment PLOS ONE | https://doi.org/10.1371/journal.pone.0279778 December 30, 2022 1 / 11 PLOS ONE Vitreous hemorrhage in polypoidal choroidal vasculopathy (PED), serous retinal detachment (RD), massive subretinal hemorrhage and extensive macular atrophy. For many decades, PCV has been described as a subtype of neovascular agerelated macular degeneration (nAMD). In 1990, Yannuzzi et al. introduced a new term–idiopathic polypoidal choroidal vasculopathy (IPCV)—to describe their finding of an exudative form of macular disorder that did not fall into the category of AMD [1]. In 2013, Warrow et al. proposed a new term, “pachychoroid,” to describe a spectrum of disease characterized by thickened choroid with choroidal congestion and choroidal vascular hyperpermeability (CVH) [2]. Greater understanding of PCV in recent years has led ophthalmologists to consider that some PCV cases had a different pathogenesis than nAMD that may originate from pachychoroid-driven choroidal neovascularization rather than subretinal neovasculization. Furthermore, the epidemiology, risk factors, clinical presentation, and prognosis are also quite different between nAMD and PCV. Compared with nAMD, patients diagnosed with PCV are younger, female-predominant, and pigmented races are preferentially affected [3]. On indocyanine green (ICG) angiography, PCV is characterized by branched, dilated vessels with single or multiple polyp-like lesions at the level of choroid, which show dye leakage in the late phase. Before photodynamic therapy (PDT) and anti-vascular endothelial growth factor (antiVEGF) treatments were introduced, most ophthalmologists treated PCV conservatively unless persistent or progressive exudative change threatened patients’ vision [3]. Thermal laser treatment and diode laser photocoagulation were used but were limited in treating extra-foveal PCV due to their destructive nature [4, 5]. Anti-VEGF and PDT treatments have become popular treatments for PCV due to their effectiveness and safety, even in cases with subfoveal PCV. However, even while under treatment, patients with PCV may still encounter massive subretinal hemorrhage or breakthrough vitreous hemorrhage (VH), which may lead to sudden, severe, and possibly irreversible vision loss. This study aimed to identify factors influencing the final visual outcomes of PCV between patients with or without breakthrough VH. Methods Study design and sample This observational study retrospectively reviewed medical records of patients who were diagnosed with breakthrough VH secondary to PCV during treatment between December 2009 and May 2021 at Kaohsiung Veterans General Hospital, a tertiary referral center in southern Taiwan. A group of age and sex-matched patients who were diagnosed with PCV during the same period but without breakthrough VH were included as the control group. All patients underwent a comprehensive eye examination, including best corrected visual acuity (BCVA), slit-lamp biomicroscopy, dilated fundus examination, color fundus photography, optical coherence tomography (OCT), and ICG angiography. The diagnosis of PCV was made by experienced retinal specialists after reviewing results of the examination described above, according to the diagnostic criteria reported in the EVEREST study [6]. Ethical considerations This observational case-series study adhered to the tenets of the Declaration of Helsinki and was approved by the Institutional Review Board and ethics committee of Kaohsiung Veterans General Hospital (approval number: 21-CT1-30(201223-1). Patients’ informed consent was waived due to the retrospective design of this study, w (...truncated)