Peripapillary choroidal neovascularisation (PPCNV) comprises about 10% of all cases of choroidal neovascularisation.¹ Starting at the nasal margin of the disc the condition does not become symptomatic until fluid, exudate, blood, or the membrane itself have extended from the disc toward the macula, threatening central vision. Very large PPCNVs are defined as more than 3.5 disc areas or greater in size and involve 180° or more of the disc circumference.² Although less common than smaller PPCNVs, the very large ones may lead to severe visual loss.³ Over time, scar contraction at the edge of the PPCNV causes breaks in Bruch’s membrane, and the associate haemorrhage leads to a new circle of “reparative” fibrovascular ingrowth that manifests as progression or extension of the PPCNV complex.¹

PPCNVs can be idiopathic or secondary to various conditions. In a recent survey,⁴ Browning and Fraser reported that PPCNV was associated with age related macular degeneration (AMD) in 45% of cases, while 39% were idiopathic, so at least 84% of the patients will be over the age of 55 years. Although the diagnosis of “idiopathic” PPCNV⁵ is unsatisfactory, the presence of these lesions in clinically normal eyes has been demonstrated in pathological studies.^6,7 The remaining cases of PPCNV occur secondary to multifocal choroiditis, angioid streaks, histoplasmosis, choroidal osteoma, optic disc drusen, congenital disc anomaly, pattern dystrophy, and peripapillary pseudopodal pigment epithelium and choroidal atrophy.⁴

In patients over 70, involvement of the second eye in PPCNV can be expected in 20–62% of all cases.^4,8 At this age, 75% of untreated cases have lost visual acuity (VA) to a level of 3/60 or less. The time between the involvement …