Prevalence of Polypoidal Choroidal Vasculopathy Beyond Recalcitrant Macular Neovasculopathies in a European AMD Cohort and Therapeutic Response to Brolucizumab

<b>Background</b>: Polypoidal choroidal vasculopathy (PCV) may be underdiagnosed in Europe due to the limited use of indocyanine green angiography (ICGA), in particular, in patients with occult or poorly responsive neovascular age-related macular degeneration (AMD). Based on this, we aimed to assess the prevalence of PCV beyond clinically typical recalcitrant nAMD using OCT criteria, and to report on the anatomical and functional outcomes following a switch to brolucizumab (bro). <b>Methods</b>: This retrospective case series used recently established optical coherence tomography (OCT)-based criteria to differentiate clinically typical nAMD and PCV in eyes with recalcitrant disease requiring treatment every six weeks or less. The aim was to compare the impact of switching to bro on disease activity in patients with recalcitrant nAMD and PCV over 12 months. Descriptive statistics and subgroup comparisons were performed. Data are presented as mean ± standard deviation (SD) as well as median and interquartile ranges (IQR), since data were not normally distributed. <b>Results</b>: Of the 27 eyes examined, 16 (59.3%) presented with typical recalcitrant nAMD and 11 (40.7%) with PCV. Patients with typical nAMD were older (81.4 ± 5.7 vs. 74.7 ± 7.7 years; <i>p</i> = 0.016) and exhibited less fluid (central retinal thickness in typical nAMD: 349.3 ± 95.3 µm; in PCV: 597.1 ± 348.4 µm; <i>p</i> = 0.005). This difference could be attributed to variations in pigment epithelial detachment heights (typical nAMD: 176.5 ± 102.6 µm, PCV: 384.6 ± 284.6 µm; <i>p</i> = 0.023). Twelve months after switching to bro (159 injections), the treatment interval increased from 5.7 ± 1.8 to 12.6 ± 5.1 weeks in nAMD and from 5.5 ± 1.9 to 8.0 ± 1.5 weeks in PCV patients (at switch: <i>p</i> = 0.81; after 12 months: <i>p</i> = 0.040). Visual gains after switching were maintained in two out of three patients with intraocular inflammation (IOI). <b>Conclusions</b>: PCV is remarkably underdiagnosed and overrepresented in the group of eyes with recalcitrant nAMD. Despite the inherent risk of IOI in response to bro, these results support the potential of bro as a third-line option for patients with eyes requiring anti-VEGF treatment every 6 weeks or less, provided that patients are monitored closely.