息肉状脉络膜血管病变治疗中国指南（2022）

doi:10.24920/004213

Chinese Medical Sciences Journal ›› 2023, Vol. 38 ›› Issue (2): 77-93.doi: 10.24920/004213

• Guideline & Consensus • Next Articles

Chinese Guideline on the Management of Polypoidal Choroidal Vasculopathy (2022)

You-Xin Chen^1,², Yu-Qing Zhang^3,^4,^5,⁶, Chang-Zheng Chen⁷, Hong Dai⁸, Su-Yan Li⁹, Xiang Ma¹⁰, Xiao-Dong Sun¹¹, Shi-Bo Tang¹², Yu-Sheng Wang¹³, Wen-Bin Wei¹⁴, Feng Wen¹⁵, Ge-Zhi Xu¹⁶, Wei-Hong Yu^1,², Mei-Xia Zhang¹⁷, Ming-Wei Zhao¹⁸, Yang Zhang¹⁹, Fang Qi¹⁹, Xun Xu^20,^*(), Xiao-Xin Li^21,^22,^*()

¹Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
²Key Laboratory of Ocular Fundus Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
³Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
⁴Ningbo Nottingham GRADE center, University of Nottingham, Ningbo, China
⁵Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China
⁶CEBIM (Center for Evidence Based Integrative Medicine)-Clarity Collaboration, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
⁷Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, China
⁸Department of Ophthalmology, Beijing Hospital, Beijing, China
⁹Department of Ophthalmology, Xuzhou Municipal Hospital Affiliated to Xuzhou medical University, Xuzhou, China
¹⁰Department of Ophthalmology, the First Affiliated Hospital of Dalian Medical University, Dalian, China
¹¹Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
¹²Aire Eye Hospital, Changsha, China
¹³Department of Ophthalmology, Xijing Hospital, Fouth Military Medical University, Xi‘an, China
¹⁴Department of Ophthalmology, Beijing Tongren Hospital, Beijing, China
¹⁵State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
¹⁶Ophthalmology, the Affiliated Eye and ENT Hospital, Shanghai Medical School, Fudan University, Shanghai, China
¹⁷Department of Ophthalmology, West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
¹⁸Department of Ophthalmology, Peking University People’s Hospital, Beijing, China
¹⁹Department of Ophthalmology, Peking University People’s Hospital, Beijing, China
²⁰Department of Ophthalmology, Shanghai General Hospital, Shanghai, China
²¹Eye Center of Xiamen University, Xiamen, China
²²People Eye Center of People’s Hospital, Peking University, Beijing, China

Accepted:2023-04-06 Published:2023-06-30 Online:2023-05-31
Contact: *Xun Xu, E-mail: drxuxun@sjtu.edu.cn; Xiaoxin Li, E-mail: dr_lixiaoxin@163.com

1. supplementary material.pdf(2545KB)

Abstract

Background In mainland China, patients with neovascular age-related macular degeneration (nAMD) have approximately an 40% prevalence of polypoidal choroidal vasculopathy (PCV). This disease leads to recurrent retinal pigment epithelium detachment (PED), extensive subretinal or vitreous hemorrhages, and severe vision loss. China has introduced various treatment modalities in the past years and gained comprehensive experience in treating PCV.

Methods A total of 14 retinal specialists nationwide with expertise in PCV were empaneled to prioritize six questions and address their corresponding outcomes, regarding opinions on inactive PCV, choices of anti-vascular endothelial growth factor (anti-VEGF) monotherapy, photodynamic therapy (PDT) monotherapy or combined therapy, patients with persistent subretinal fluid (SRF) or intraretinal fluid (IRF) after loading dose anti-VEGF, and patients with massive subretinal hemorrhage. An evidence synthesis team conducted systematic reviews, which informed the recommendations that address these questions. This guideline used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach to assess the certainty of evidence and grade the strengths of recommendations.

Results The panel proposed the following six conditional recommendations regarding treatment choices. (1) For patients with inactive PCV, we suggest observation over treatment. (2) For treatment-naïve PCV patients, we suggest either anti-VEGF monotherapy or combined anti-VEGF and PDT rather than PDT monotherapy. (3) For patients with PCV who plan to initiate combined anti-VEGF and PDT treatment, we suggest later/rescue PDT over initiate PDT. (4) For PCV patients who plan to initiate anti-VEGF monotherapy, we suggest the treat and extend (T&E) regimen rather than the pro re nata (PRN) regimen following three monthly loading doses. (5) For patients with persistent SRF or IRF on optical coherence tomography (OCT) after three monthly anti-VEGF treatments, we suggest proceeding with anti-VEGF treatment rather than observation. (6) For PCV patients with massive subretinal hemorrhage (equal to or more than four optic disc areas) involving the central macula, we suggest surgery (vitrectomy in combination with tissue-plasminogen activator (tPA) intraocular injection and gas tamponade) rather than anti-VEGF monotherapy.

Conclusions Six evidence-based recommendations support optimal care for PCV patients’ management.

Key words: polypoidal choroidal vasculopathy, anti-vascular endothelial growth factor, photodynamic therapy, surgery

You-Xin Chen, Yu-Qing Zhang, Chang-Zheng Chen, Hong Dai, Su-Yan Li, Xiang Ma, Xiao-Dong Sun, Shi-Bo Tang, Yu-Sheng Wang, Wen-Bin Wei, Feng Wen, Ge-Zhi Xu, Wei-Hong Yu, Mei-Xia Zhang, Ming-Wei Zhao, Yang Zhang, Fang Qi, Xun Xu, Xiao-Xin Li. Chinese Guideline on the Management of Polypoidal Choroidal Vasculopathy (2022)[J].Chinese Medical Sciences Journal, 2023, 38(2): 77-93.

Figures/Tables 3

BOX 1: SUMMARY OF RECOMMENDATIONS
1	For treatment-na?ve polypoidal choroidal vasculopathy (PCV) patients with inactive polypoidal lesions, the guideline panel suggests observation over the initiation of treatment (conditional recommendation, very low certainty in the estimated effects).
	Remarks: Close follow-up and monitoring are essential, especially for patients with high-risk factors (such as cigarette smoking, higher body mass index, and abnormal serum levels of inflammatory markers).
2	For treatment-na?ve PCV patients, the guideline panel suggests either anti-VEGF monotherapy or combined anti-VEGF and PDT rather than PDT monotherapy (conditional recommendation, low to very low certainty in the estimated effects).
	Remarks: The choice may depend on the patient’s condition (such as the size or location of polypoidal lesions and the height of PED) or specific types of anti-VEGF agents.
3	For PCV patients who plan to initiate anti-VEGF combined with PDT treatment, the guideline panel suggests later/rescue PDT over initial PDT (conditional recommendation, low certainty in the estimated effects).
	Remarks: The timing of later PDT may be at least after three months of anti-VEGF according to treatment criteria of PDT (such as if polypoidal lesions are seen with subretinal fluid on the ICGA images obtained)
4	For PCV patients who plan to initiate the treatment with anti-VEGF, the guideline panel suggests treat and extend (T&E) over the pro re nata (PRN) regimen following three monthly loading doses (conditional recommendation, very low certainty in the estimated effects).
	Remarks: The T&E regimen increases the number of injections compared to the PRN regimen, although it reduces the number of visits. The follow-up should consider the morphological changes of the fundus and pay more attention to the functional or conscious symptoms of the affected eye. The interval of T&E can be referred to in the ALTAIR study.
5	For PCV patients with persistent subretinal fluid (SRF) or intraretinal fluid (IRF) on optical coherence tomography (OCT) after three monthly anti-VEGF treatments, the guideline panel suggests proceeding with anti-VEGF treatment over observation (conditional recommendation, very low certainty of the estimated effects).
	Remarks: Clinicians should closely monitor the change in fundus morphology and function of the affected eye (or subjective symptoms) during follow-up and may consider stopping treatment when no clear benefit to visual acuity with further injection is expected, such as extensive subretinal scar formation.
6	For PCV patients with massive subretinal hemorrhage (equal or more than four optic disc areas) involving the central macula within the onset of 14 days, the panel suggests vitrectomy in combination with tissue-plasminogen activator (tPA) intraocular injection and gas tamponade over anti-VEGF monotherapy (conditional recommendation, very low certainty in the estimated effects).
	Remarks: Surgery may also benefit PCV patients with subretinal hemorrhage combined with vitreous hemorrhage; clinicians might consider using complementary therapy (e.g., pneumatic displacement, anti-VEGF, PDT, and tPA).

Figure 1.

Figure 2.

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