We thank Dr Chhablani for his interest in and comments on our article. There seems to be a racial difference in clinical characteristics of polypoidalchoroidal vasculopathy (PCV) among East Asians, including patients of Japanese, Korean or Chinese, and Asian Indian origins. More than 50% of the Japanese patients who are diagnosed with neovascular age-related macular degeneration actually have PCV. Most PCV lesions are located within the macula (peripapillary lesions are rare), and their greatest linear dimension usually is less than 7000 μm. Therefore, PCV lesions in Japanese patients are superficially similar to typical AMD lesions.
First, as we said, PCV lesions in the Japanese patient were mostly in the macula, and the large vascular lesion that cannot be covered by the 1 irradiation area is rare. Second, if a peripapillary PCV lesion is located temporal to the optic disc, we perform reduced-fluence photodynamic therapy (PDT) so that an irradiation spot does not cover the optic disc. We perform laser photocoagulation for a PCV lesion located nasal to the optic disc. Third, in eyes with PCV lesions and a large pigment epithelial detachment, we treat those with indocyanine green-guided reduced-fluence PDT. For a rare case with a large submacular hemorrhage, we do not treat with PDT, but rather with an intravitreal injection of tissue plasminogen activator and an expansile gas. Fourth, although multiple PDT may increase the risk of choroidal atrophy, reduced-fluence PDT leads to less damage to the choroid compared with standard-fluence PDT. In our study, neither severe subretinal or subretinal pigment epithelial hemorrhages nor retinal pigment epithelial tears were encountered after reduced-fluence PDT.
Monthly intravitreal injection of ranibizumab in PCV can be effective in improving or stabilizing vision. However, intravitreal ranibizumab is a high-cost therapy and needs multiple treatments. In contrast, reduced-fluence PDT is effective in improving or stabilizing the central vision and in reducing the number of treatments. In terms of cost effectiveness, reduced-fluence PDT could be considered for PCV. Naturally, for PCV lesions accompanied by marked exudative changes, combined reduced-fluence PDT and intravitreal ranibizumab may be considered.