Case Study

1. OCTA-guided PDT Combination Therapy for Persistent CNV in Exudative ARMD
49 year old white male with pachychoroid syndrome (299 microns) left eye with pachyvessels.
Had 7 Lucentis injections for occult membrane/arteriolarization with persistent leakage (primary anti-
VEGF failure) subsequently treated with 4 x combination therapy (half-fluence PDT, Lucentis, Triescence)
with complete resolution. Treatments have lasted about 10 months on the average. Previously, ICG was
used to identify the choroidal neovascular origin. However, OCTA allows for more precise
localization/targeting. The IVFA on the left shows the targeting of the neovascularization from a
previous combination therapy. The ICG on the right shows a more specific target (outlined below)
courtesy of the multimodaility imaging (IVFA/ICG/OCT/OCTA) used on the most recent treatment.
OCT showed the pachyvessel (red arrow) approaching a break in Bruch’s membrane and RPE
(yellow arrows) that corresponds to the origin of the enhanced CNV visible on the OCTA. Targeting the
origin of the large CNV creates an opportunity to mitigate any damage done by a larger PDT target.

2. Below is the enhanced imaging of the CNV on OCTA (right) compared to ICG (left).
Of interest are the superior denuded vessels (yellow arrow) and the more active
inferior vessels (red arrow) that are responsible for the recurrent exudation.
Are we sure that PDT combination therapy is not the answer (especially in the light of
anti-PDGF failure)? .