Multimodal and 3D imaging presentation of the evolution of pressure-related CNV.

This study reports a unique case that visually demonstrates the six-year evolution of a pressure-related choroidal neovascularization (CNV) using multimodal image registration and three-dimensional (3D) reconstruction. A 65-year-old female with neovascular age-related macular degeneration received 33 anti-VEGF injections over six years but experienced continued vision decline. Through precise registration of indocyanine green angiography, and optical coherence tomography angiography images, combined with 3D modeling of swept-source OCTA volume data. We found that the main trunk of this large, tree-like type II CNV originated from an abnormally dilated great vein, which exhibited an anastomosis with an accompanying great vein. Furthermore, the 3D reconstruction viewed from the scleral side revealed that this vein was closely opposed to and shared a shunt branch with an underlying choroidal great artery. The CNV appeared to function as a "pressure-relief valve," sprouting from the venous trunk to alleviate pressure. This case underscores the critical role of deep multimodal imaging integration in tracing CNV origins and reveals that some anti-VEGF-resistant CNVs may represent hemodynamic compensatory disorders secondary to pre-existing large vessel structural abnormalities, rather than purely neovascular diseases.