337 Pak J Ophthalmol. 2021, Vol. 37 (3): 337-338 LETTER TO EDITOR Dear Sir! I would like to bring my few queries in your notice regarding a case report “Polypoidal Choroidal Vasculopathy (PCV)” which is published in the recent issue of the journal, Pak j Ophthalmol. 2021; 37 (2). The author has diagnosed it with the case of Right eye PCV. They have also mentioned the presence of drusens in an old-age female with unilateral disease (right eye). Indocyanine green angiography (ICGA) was not done due to unavailability. My queries related to this case report are: 1. Drusens are usually not present in PCV and presence of drusens are more indicative of Choroidal Neovasularization 2. PCV is usually present in young age. 3. PCV Usually presents with Asymmetrical Bilateral disease. 4. ICG is the diagnostic investigation for PCV and without it; it is only diagnosis of exclusion which is made after all other more common causes are ruled out. As in this case, presence of bilateral drusens in an old lady are suggestive of Age Related Macular degeneration. 5. EVEREST CRITERIA which was a, Phase 4 multi centered randomized active control double masked exploratory study, is not met for the diagnosis of PCV. I would appreciate if these queries are answered. Regards Dr. Syed Abdullah Mazhar MBBS FCPS MRCS (Edin.UK) Assistant Professor Rashid Latif Medical College, Lahore RESPONSE TO LETTER TO THE EDITOR It gives me great pleasure to share my thoughts on PCV and to be provided a platform for this, by the prestigious Pakistan Journal of Ophthalmology. I would also like to thank the author for taking time to read my article and raise queries about this interesting entity. We believe PCV to be similar to the AMD spectrum and its variant although different theories exist and there are different schools of thought. 1 It is not right to eliminate the presence of any entity in the diagnosis of any disease. The author believes that drusen cannot coexist with PCV, although there have been several studies mentioning the presence of drusen in coexistence with PCV. 2-4 Contrary to the belief of the author of the letter, PCV is not seen in young age rather older age is a risk factor for PCV and is usually diagnosed between 60 – 70 years of age and a mean age of 68.4 years, although some believe it is earlier than AMD. 5,6 I agree that PCV is asymmetrical and bilateral as mentioned in literature. ICG angiography is mentioned to be the definitive diagnostic modality, but being ophthalmologists in a developing country we must accept our limitations and the lack of one investigation should not hold us back in reporting useful literature. FFA and OCT are useful modalities in its diagnosis and are available. Also, orange, aneurysmal dilatations can clearly be seen in the Figure 1, which I have encircled now for more clarity. Figure 1: Orange aneurysmal lesions observed on fundus photography in the right eye. OPEN ACCESS Letter to Editor Pak J Ophthalmol. 2021, Vol. 37 (3): 337-338 338 Moreover, such large pigment epithelial detachments are not seen in any other disorder rather than PCV, and what else could it be provided all the images and imaging modalities in the case report? The EVEREST criteria again requires ICG angiography, which we were unable to acquire as the ICG dye was unavailable, but I am sure that if that was done, it would have yielded a diagnosis of PCV. OCT has been deemed an excellent diagnostic modality with high sensitivity and specificity 7-9 and we have demonstrated its use in diagnosing the large, multiple PEDs as well as resolution following treatment with Bevacizumab injections in the right eye. The rationale of publishing a case report is to help others come up with similar diagnoses in the event of paucity of multimodal imaging, especially in developing countries. This also helps in managing such patients. Respectfully Dr. Sana Nadeem Assistant Professor MBBS FCPS ACMEd Department of Ophthalmology Foundation University Medical College & Fauji Foundation Hospital, Islamabad – Pakistan Email: sana.nadeem@fui.edu.pk How to Cite this Article: Mazhar SA. Letter to Editor. Pak J Ophthalmol. 2021; 37 (3): 337-338. Doi: 10.36351/pjo.v37i3.1251 REFERENCES 1. Chaikitmongkol V, Cheung CMG, Koizumi H, Govindahar V, Chhablani J, Lai TYY. Latest Developments in Polypoidal Choroidal Vasculopathy: Epidemiology, Etiology, Diagnosis, and Treatment. Asia Pac J Ophthalmol (Phila). 2020; 9 (3): 260-268. Doi: 10.1097/01.APO.0000656992.00746.48. 2. Iwama D, Tsujikawa A, Sasahara M, Hirami Y, Tamura H, Yoshimura N. Polypoidal choroidal vasculopathy with drusen. JPN J Ophthalmol. 2008; 52 (2): 116-121. Doi: 10.1007/s10384-007-0503-9. 3. Vella G, Sacconi R, Borrelli E, Bandello F, Querques G. Polypoidal choroidal vasculopathy in a patient with early-onset large colloid drusen. Am J Ophthalmol Case Rep. 2021; 22.101085. https://doi.org/10.1016/j.ajoc.2021.101085. 4. Singh SR, Chakurkar R, Goud A, Rasheed MA, Vupparaboina KK, Chhablani J. Pachydrusen in polypoidal choroidal vasculopathy in an Indian cohort, Indian J Ophthalmol. 2019; 67 (7): 1121-1126. Doi: 10.4103/ijo.IJO_1757_18 5. Coscas G, Lupidi M, Coscas F, Benjelloun F, Zerbib J, Ali Dirani A, et al. Toward a Specific Classification of Polypoidal Choroidal Vasculopathy: Idiopathic Disease or Subtype of Age-Related Macular Degeneration. Invest Ophthalmol Vis Sci. 2015; 56 (5): 3187-3195. Doi: https://doi.org/10.1167/iovs.14-16236. 6. Honda S, Matsumiya W, Negi A. Polypoidal Choroidal Vasculopathy: Clinical Features and Genetic Predisposition. Ophthalmologica. 2014; 231: 59-74. Doi: 10.1159/000355488 6. Anantharaman G, Sheth J, Bhende M, Narayanan R, Natarajan S, Rajendran A, et al. Polypoidal choroidal vasculopathy: Pearls in diagnosis and management. Indian J Ophthalmol. 2018; 66 (7): 896- 908. Doi: 10.4103/ijo.IJO_1136_17. 7. Dansingani KK, Gal-Or O, Sadda SR, Yannuzzi LA, Freund KB. Understanding aneurysmal type 1 neovascularization (polypoidal choroidal vasculopathy): a lesson in the taxonomy of 'expanded spectra' – a review. Clin Exp Ophthalmol. 2018; 46 (2): 189-200. doi:10.1111/ceo.13114 8. Chang YS, Kim JH, Kim JW, Lee TG, Kim CG. Optical Coherence Tomography-based Diagnosis of Polypoidal Choroidal Vasculopathy in Korean Patients. Korean J Ophthalmol. 2016; 30 (3): 198-205. Doi: 10.3341/kjo.2016.30.3.198 .…  …. https://doi.org/10.1016/j.ajoc.2021.101085 https://doi.org/10.1167/iovs.14-16236