Do you combine anti-VEGF with PDT for polypoidal choroidal vasculopathy upfront or reserve PDT for refractory cases?

Having considered EVEREST, EVEREST II, and PLANET, I tend to start with monthly aflibercept, with a low threshold for applying PDT during the first 3 months, before the vessel complex is too established to undergo regression.

In practice, I only uncommonly encounter PCV early in its clinical course; most patients have already been treated for a while as NV AMD, prior to seeing me. The first time they see me, I note the absence of drusen and the often young age of the patient (60s), raising suspicion for polypoidal.

PDT performed later in the condition might be less efficacious and, if performed more aggressively (full fluence) or repeatedly, could cause significant choroidal atrophy.

Due to how good the anti-VEGF medications are now, I only occasionally need PDT, but when I add it, it is very effective. I have been burned by cases that resolved with PDT only to have a large bleed years later, so now I do some maintenance anti-VEGF every 3 months even if I did combo PDT/antiVEGF.