A randomized pilot study of low-fluence photodynamic therapy versus intravitreal ranibizumab for chronic central serous chorioretinopathy

Advances in the treatment of central serous chorioretinopathy

Central serous chorioretinopathy is a disease that is partly understood. Novel advancements have led to further understanding of the disease, and have identified choroidal dysfunction as the principal element in CSCR development. New imaging tools have aided in better monitoring disease response to various treatment models. Enhanced depth imaging optical coherence tomography, in particular, has helped in observing choroidal thickness changes after various treatment models. To date, photodynamic therapy and focal laser remain the main stay of treatment. More understanding of disease pathophysiology in the future will help in determining the drug of choice and the best management option for such cases.

System review and meta-analysis on photodynamic therapy in central serous chorioretinopathy

PURPOSE

To evaluate the effect of photodynamic therapy (PDT) on central serous chorioretinopathy (CSC) compared with laser therapy and intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) drugs, and to find the maximum treatment effect with minimal dose and fluence of PDT.

METHODS

A systematic electronic search was conducted in Feb 2013 in PubMed, Embase, ISI Web of Knowledge and the Cochrane library. The main outcome factors were compared in best-corrected visual acuity (BCVA), central macular thickness (CMT) and resolution of subretinal fluid (SRF). Meta-analysis was performed when it is appropriate. The comparisons were designed into four groups: group 1, PDT versus laser photocoagulation; group 2, PDT versus intravitreal injection of anti-VEGF drugs; group 3, half-dose verteporfin PDT versus placebo; group 4, half-fluence PDT versus full-fluence PDT.

RESULTS

We retrieved nine reports of studies including a total of 319 patients. In group 1, the summary result indicated that PDT was superior in resolution of SRF (p = 0.005) than laser photocoagulation. In group 2, PDT could resolute SRF (p = 0.007) and decrease CMT (p = 0.002) more rapidly than intravitreal injection of anti-VEGF drugs. In group 3, half-dose PDT was effective in improving BCVA (p < 0.00001), decreasing CMT (p = 0.001) and resolving SRF (p < 0.001). In group 4, half-fluence PDT was effective and could significantly decrease the hypoxic damage which was caused by PDT (p < 0.001).

CONCLUSION

PDT is a promising therapy for CSC patients and the parameters of PDT can be adjusted to obtain the maximum treatment effect with minimal adverse effects.

What is new in central serous chorioretinopathy?

Central serous chorioretinopathy (CSCR) is considered a benign, self-limiting disease. However, as many as third of the patients have recurrent episodes or chronic disease that may cause significant functional impairment. New diagnostic tools and new treatment modalities are emerging in order to improve the functional outcomes of these patients. Spectral domain optical coherence tomography (SD-OCT) has the ability to image individual layers of the retina and choroid. SD-OCT images in CSCR patients have demonstrated increased subfoveal thickness measurements, high reflective deposits in areas of subretinal precipitates and changes in the Retinal pigment epithelium layers of the asymptomatic eyes of patients with supposedly unilateral CSCR. A positive correlation was found between the level of distribution to the layer of inner segment/outer segment junction of the photoreceptors and the visual impairment. Fundus autoflouresence images show a wide variety during different stages of the disease in CSCR patients. Minimal abnormalities during the early stages are followed by hyperautofluoresence in the detached area in later stages, often in a manner of inferior gravitation and at the borders of the detachments. The chronic phase is characterized by varying degrees of atrophy and areas of decreased autofluorescence surrounding areas of chronic leaks. These changes help differentiate an active disease from an inactive state. Multifocal electroretinography (mfERG) has the ability to demonstrate a persistent depression despite the resolution of subretinal detachments. It is therefore being investigated as a follow up tool for patients with chronic CSCR. An excellent correlation was found between changes in mfERG and visual function. Macular microperimetry, measuring retinal sensitivity within the central visual field, is intended to compensate for the underestimation of visual impairment in patients with macular diseases. Reduced retinal sensitivity was found in areas of previous subretinal fluids in CSCR patients. The device can also serve as a follow up tool in these patients. Regarding treatment in CSCR patients, focal argon laser photocoagulation treatment may be applied to small extrafoveal leaks. However, the main purpose of this treatment is to shorten disease duration, with no advantage over observation regarding final visual outcome, rate of progression to chronic CSCR or number of recurrences. Photodynamic therapy (PDT) with verteporfin has been shown to completely resolve serous detachment in 60%-80% of patients and to have a partial affect in the remaining patients. Reduced-fluence treatment is replacing full-fluence therapy in order to minimize side effects with no accompanying reduced effectiveness. Visual acuity is also improved following reduced-fluence PDT compared to placebo. It has also been found that patients with intense hyperfluorescence are more likely to show resolution of accumulating fluid compared to patients with mild or no leakage observed on indocyanine-green angiography prior to treatment. Regarding newer treatment modalities, intravitreal injections of anti-vascular endothelial growth factor agents have a limited effect in patients with CSCR. Recent reports have not demonstrated an advantage for this treatment in regards to anatomic and functional outcome. Micropulse diode laser was not proven to be safer or more effective than argon laser or PDT. Corticosteroid antagonists, not tested in controlled trials, may have a beneficial effect in patients with CSCR. Aspirin may also play a role in treating these patients, with rapid recovery of visual acuity and reduced number of recurrences observed. In conclusion, imaging is evolving rapidly while the clinical implications of these new imaging modalities are less clear. Large randomized trials investigating different treatment modalities are still lacking.

Success of ranibizumab in central serous chorioretinopathy resistant to bevacizumab

PURPOSE

To present effectiveness of intravitreal ranibizumab (IVR) injection for central serous chorioretinopathy (CSC), resistant to intravitreal bevacizumab (IVB) injection.

METHODS

Files of the patients who had the diagnosis of CSC between 2005 and 2013 were reviewed retrospectively. Eighty-five eyes of 81 patients' files have been investigated. Ten eyes of 10 patients that were resistant to IVB, with no history of photodynamic therapy, were included in to this study. Demographic details, best-corrected visual acuity (BCVA), and central macular thickness (CMT) were studied to analyze the effectiveness of IVR.

RESULTS

The mean age of the patients was 38.8 years (SD=4.7 years). The mean follow-up time after first IVR injection was 7.9 months (SD=1.5 months). The mean number of IVB and IVR injections was 2.0 (SD=0.7) and 1.3 (SD=0.4), respectively. The mean CMT before IVR injection was 392.4 μm (SD=66.3) and decreased to 194.1 μm (SD=9.3, P<0.001) at the last visit. The mean BCVA before IVR injection was 0.50 logMAR (SD=0.23) and improved to 0.05 logMAR (SD=0.06, P<0.001) at the last visit. In all cases after IVR injection, the subretinal fluid almost resolved completely, and leakage disappeared in fundus fluorescein angiography.

CONCLUSION

Ranibizumab might be a promising option for the patients with CSC, resistant to bevacizumab in acute or early chronic stage.

Photodynamic therapy for central serous chorioretinopathy

PURPOSE

Central serous chorioretinopathy (CSCR) is an idiopathic disorder characterised by detachment of the neurosensory retina due to serous fluid accumulation between the photoreceptor outer segments and the retinal pigment epithelium. There are currently no set guidelines or protocols on its treatment. This study was undertaken to assess the current literature on the the efficacy and safety of photodynamic therapy (PDT) as a treatment option for CSCR.

METHODS

Seven databases (PubMed, CENTRAL, MEDLINE, Web of Science, Embase, Scopus, and The Cochrane Database of Systematic Reviews) were searched without restrictions on time or location. We followed PRISMA guidelines and evaluated quality according to STROBE criteria. In total, 117 citations were identified and 31 studies describing 787 eyes were included for review. Data on indications for PDT in CSCR, dosing regimens of verteprofin PDT (which includes treatment dose of vertoporfin, treatment time, fluence, and spot size), number of treatment sessions, response to treatment, mean length of follow-up, and complications were extracted and analysed.

RESULTS

Since the introduction of PDT for the treatment of CSCR in 2003, there have been three randomised controlled trials (RCTs), one for acute and two chronic CSCR and 28 further studies that met the STROBE criteria that compared the use of PDT with other treatment options. All studies showed short-term efficacy of PDT in CSCR. The studies were of small sample size and lacked sufficient follow-up to draw conclusions on long-term efficacy and safety.

CONCLUSIONS

There is sufficient scientific evidence to suggest that PDT may be a useful treatment option for chronic CSCR in the short-term. The review identifies a need for robust RCTs with longer follow-up to ascertain the role of PDT as a useful treatment option for CSCR.

Collaborative retrospective macula society study of photodynamic therapy for chronic central serous chorioretinopathy

PURPOSE

To assess the visual and anatomic outcomes of central serous chorioretinopathy (CSC) after verteporfin photodynamic therapy (PDT).

DESIGN

Retrospective case series.

PARTICIPANTS

Patients with CSC who underwent PDT.

METHODS

Members of the Macula Society were surveyed to retrospectively collect data on PDT treatment for CSC. Patient demographic information, PDT treatment parameters, fluorescein angiographic information, optical coherence tomography (OCT) metrics, pre- and post-treatment visual acuity (VA), and adverse outcomes were collected online using standardized forms.

MAIN OUTCOME MEASURES

Visual acuities over time and presence or absence of subretinal fluid (SRF).

RESULTS

Data were submitted on 265 eyes of 237 patients with CSC with a mean age of 52 (standard deviation [± 11]) years; 61 were women (26%). Mean baseline logarithm of the minimum angle of resolution (logMAR) VA was 0.39±0.36 (20/50). Baseline VAs were ≥20/32 in 115 eyes (43%), 20/40 to 20/80 in 97 eyes (37%), and ≤20/100 in 47 eyes (18%). Normal fluence was used for PDT treatment in 130 treatments (49%), half-fluence was used in 128 treatments (48%), and very low fluence or missing information was used in 7 treatments (3%). The number of PDT treatments was 1 in 89%, 2 in 7%, and 3 in 3% of eyes. Post-PDT follow-up ranged from 1 month to more than 1 year. Post-PDT VA was correlated with baseline VA (r = 0.70, P < 0.001). Visual acuity improved ≥3 lines in <1%, 29%, and 48% of eyes with baseline VA ≥20/32, 20/40 to 20/80, and ≤20/100, respectively. Subretinal fluid resolved in 81% by the last post-PDT visit. There was no difference in the response to PDT when analyzed by age, race, fluence setting, fluorescein angiography (FA) leakage type, corticosteroid exposure, or fluid location (subretinal or pigment epithelial detachment; all P > 0.01). Complications were rare: Retinal pigment epithelial atrophy was seen in 4% of patients, and acute severe visual decrease was seen in 1.5% of patients.

CONCLUSIONS

Photodynamic therapy was associated with improved VA and resolution of SRF. Adverse side effects were rare.

Profile of verteporfin and its potential for the treatment of central serous chorioretinopathy

Central serous chorioretinopathy (CSCR) is an idiopathic disorder characterized by serous retinal detachments associated with focal leakage on fluorescein angiography and pigment epithelial detachments. While the majority of cases improve spontaneously over several months, a significant subset of patients advance to a chronic recurrent form of the disease with diffuse pigment epitheliopathy, foveal atrophy, scarring, and permanent visual loss. Photodynamic therapy (PDT) with verteporfn has been extensively studied as a potential therapeutic option for chronic cases. Multiple prospective interventional studies have demonstrated the efficacy of PDT for CSCR with significant functional and anatomic improvements achieved. Refinement of the PDT protocol has subsequently been performed in an effort to minimize adverse effects. Anti-vascular endothelial growth factor (anti-VEGF) agents, such as bevacizumab, have been utilized in the treatment of CSCR. Recent advances in imaging and functional testing have shed further light on possible pathophysiologic mechanisms of disease and post treatment changes induced by PDT. While the body of evidence supports PDT as an efficacious and relatively safe treatment for CSCR, further evaluation of the long-term efficacy and safety of PDT, as well as protocol improvements are required.

Responsiveness of eyes with polypoidal choroidal vasculopathy with choroidal hyperpermeability to intravitreal ranibizumab

Background

To determine the role played by vascular endothelial growth factor (VEGF) in polypoidal choroidal vasculopathy (PCV) based on an interventional immunology theory.

Methods

Eyes with PCV were divided in a masked fashion into those with choroidal hyperpermeability (HP group) and those with normal choroidal permeability (NP group) based on the indocyanine green angiograms. The inter-rater agreement rate was evaluated using Fleiss’ kappa. Patients were treated by intravitreal ranibizumab (IVB). The central choroidal thickness and central foveal thickness (CFT) at the baseline and 7 days after the treatment were measured by optical coherence tomography.

Results

Among the 57 consecutive eyes diagnosed with PCV, 42 eyes of 42 patients met the inclusion criteria (21 eyes/HP group vs 21 eyes /NP group). Central choroidal thickness in HP group was significantly thicker than that in the NP group (P < .001, Mann–Whitney U test). The inter-rater agreement was high with a Fleiss’ kappa = 0.95, P < .0001. The percentage reduction in the CFT in HP group (14.0%) was significantly less than that in NP group (20.4%; P = .013, Mann–Whitney U test).

Conclusions

Eyes with PCV that are associated with choroidal hyper-permeability may not be strongly associated with VEGF-related pathology, and may not respond favorably to anti-VEGF monotherapy.

Morphologic changes and visual outcomes in resolved central serous chorioretinopathy treated with ranibizumab

CONTEXT

Central serous chorioretinopathy (CSC).

OBJECTIVE

To evaluate the effect of intravitreal ranibizumab injection and the correlation between foveal morphologic changes and visual outcomes in patients with resolved CSC.

MATERIALS AND METHODS

We measured outer nuclear layer (ONL) thickness, outer layer (OL) thickness and evaluated the integrity of the photoreceptor inner-outer segment (IS/OS) junction, the status of the external limiting membrane (ELM) at the central fovea using spectral-domain optical coherence tomography (OCT) in 35 eyes of 35 patients with resolved CSC. The eyes were divided into two groups: The initial medical treatment administered to Group1 (n = 17) then received intravitreal ranibizumab injections, Group 2 (n = 18) received medical treatment. Group 3 was composed of normal eyes (n = 20, as a control). We also investigated a correlation between the ONL thickness and best corrected visual acuity (BCVA).

RESULTS

The mean age was 45.7 ± 7.2 (ranged from 27 to 55 years). The mean follow-up period was 14.2 months (minimum 6, maximum 24 months). The mean ONL and OL thickness in Group 1 were significantly thinner than Group 3 (p < 0.005). The ONL thickness was correlated with the BCVA (r = 0.681, p = 0.001). Thirty-tree patients had improvement in BCVA after treatment. Discontinuity of the IS/OS junction was found in 15 eyes (88.2%) in Group 1, in 5 eyes (27.7%) in Group 2 and in no eyes in Group 3.

DISCUSSION

We demonstrated that prolonged serous detachment results in photoreceptor cell loss (apoptosis) and thinning of the ONL. Thinning of the ONL correlates with poorer vision, which has been found by other investigators. Furthermore, vascular endothelial growth factor (VEGF) may be neuroprotective to the photoreceptors which might explain the additional thinning in the patients treated with ranibizumab. This raises the possibility that treatment with VEGF inhibitors may be unfavourable to patients with CSC, even though it speeds recovery and vision does improve.

CONCLUSION

Intravitreal ranibizumab injection leads to thinning of the ONL and the OL in patients with resolved CSC. The ONL thickness reduction and discontinuity of the IS/OS junction results in poor visual prognosis in resolved CSC eyes.

Central serous chorioretinopathy: update on pathophysiology and treatment

Recent technological advances--new pathophysiological insights, new imaging techniques for diagnosis and management, and new treatments--have led to an improved understanding of central serous chorioretinopathy (CSC). The primary role of the choroid has become more widely accepted with widespread use of indocyanine green angiography. Optical coherence tomography (OCT), and particularly enhanced depth imaging OCT, demonstrate a thickened and engorged choroid. Adaptive optics, fundus autofluorescence, multifocal electroretinography, microperimetry, and contrast sensitivity testing reveal that patients with even a mild course suffer previously undetected anatomic and functional loss. Although focal laser and photodynamic therapy are the current standard of care for persistent subretinal fluid in CSC, they are not appropriate in all cases, and the optimal timing of intervention remains unclear.

An Update on the Diagnosis and Management of Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSC) is a complicated disease with still unclear causes, pathogenesis and management strategy despite active research. CSC has been traditionally considered as a self-limiting disease where spontaneous recovery occurs in 90% of the patients within a few months. This proclaimed "benign" nature of CSC, however, has been queried by increasing scientific evidence that permanent photoreceptors damage and neurosensory-cystoid degeneration of macula occur in the event of chronic CSC. CSC is probably not a benign disease. Treatments for CSC are still evolving. It is very difficult to define the proper timing for active treatment of CSC because it is not easy to define a universally accepted cut-off time point for active intervention. There is a recent suggestion that active CSC treatment should be considered if symptoms last longer than 3 months as atrophy of photoreceptors may occur as early as 4 months after initial presentation. The CSC patients may be stratified into two groups based on the initial presenting visual acuity and duration of symptom: the good visual prognosis group and the dubious visual prognosis group. The management may then be tailor-made based on the visual prognosis group. "Safety-enhanced'" photodynamic therapy (PDT) using lower doses and reduced fluence is still the mainstay of treatment. Newer treatment modalities like intravitreal anti-VEGF therapy, micropulsed diode laser treatment, and the use of corticosteroid antagonists do warrant further investigation. Combination therapies involving two or more of the above modalities of treatments may have a role to play in this actively researched area.

Time-periodic characteristics in the morphology of idiopathic central serous chorioretinopathy evaluated by volume scan using spectral-domain optical coherence tomography

PURPOSE

To investigate the time-period characteristics associated with morphologic changes in idiopathic central serous chorioretinopathy (CSC) using volume scans acquired by spectral-domain optical coherence tomography (SD-OCT).

DESIGN

Retrospective, observational, cross-sectional case series.

METHODS

Patients underwent visual acuity measurements, fundus examinations, fluorescein angiography, indocyanine green angiography, and SD-OCT volume scans. Patients were classified into 5 categories-acute CSC, early chronic (EC) CSC, late chronic (LC) CSC, sequelae of CSC, or recurrent CSC-according to the chronicity and the recurrence. We investigated the relationship between our classification and the detailed morphologic changes of the retinal pigment epithelium and outer retina that were observed in the SD-OCT images.

RESULTS

A total of 76 eyes from 75 patients were included in this study. Serous retinal detachment was relatively higher in acute CSC. Low to flat pigment epithelial detachments (PEDs) were most commonly observed in all stages of CSC, especially in LC CSC, but some semicircular PEDs were occasionally observed in eyes with acute or EC CSC. Retinal dragging with fibrin was most frequently observed in eyes that were in the early stage of acute CSC. A thickened posterior surface of the detached retina was most commonly observed in eyes with acute CSC, whereas a thinned posterior surface of the detached retina was observed in eyes with LC CSC. Hyperreflective dots and subretinal exudates were more commonly observed in eyes with EC and LC CSC than in eyes with acute CSC. In eyes with recurrent CSC, 2 different patterns of SD-OCT findings were observed; these patterns resembled those that were found in either acute CSC or LC CSC.

CONCLUSIONS

SD-OCT finding patterns in CSC eyes differ according to the chronicity and the recurrence of the disease. Detailed investigation of the retinal pigment epithelium and outer retina using SD-OCT could be useful for estimating the duration of CSC.

Evaluation of verteporfin pharmakokinetics--redefining the need of photosensitizers in ophthalmology

INTRODUCTION

The benzoporphyrine derivative verteporfin has lost its importance to the treatment of the most frequent neovascular eye diseases. Nevertheless, it is still mandatory to define the remaining applications, role, and potential of verteporfin in ocular photodynamic therapy (PDT), including the dosages of administration, effectiveness, and safety profile.

AREAS COVERED

Although verteporfin PDT has forfeited the first-line status and value of treating subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration or pathologic myopia, the treatment remains the standard of care for choroidal haemangioma and polypoidal choroidal vasculopathy. PDT is effective in less pigmented choroidal melanoma as well as in retinal vascular proliferations and retinal angioma. Verteporfin was granted the orphan drug designation for the treatment of chronic or recurrent central serous chorioretinopathy (CSC).

EXPERT OPINION

Evidence-based data regarding optimized parameters (low fluence, reduced dose, fractionated irradiation) adapted to the treated diseases (target structure, dosimetry, blood supply) are scarce. Prospective and large clinical trials are missing, although the scientific community agrees on the fact that the standard treatment protocol does not necessarily provide the optimal efficacy to the specific disease or individual patient. Within the reviewed indications, the adverse effect profile is favorable compared with other therapies.

Mineralocorticoid receptor is involved in rat and human ocular chorioretinopathy

Central serous chorioretinopathy (CSCR) is a vision-threatening eye disease with no validated treatment and unknown pathogeny. In CSCR, dilation and leakage of choroid vessels underneath the retina cause subretinal fluid accumulation and retinal detachment. Because glucocorticoids induce and aggravate CSCR and are known to bind to the mineralocorticoid receptor (MR), CSCR may be related to inappropriate MR activation. Our aim was to assess the effect of MR activation on rat choroidal vasculature and translate the results to CSCR patients. Intravitreous injection of the glucocorticoid corticosterone in rat eyes induced choroidal enlargement. Aldosterone, a specific MR activator, elicited the same effect, producing choroid vessel dilation -and leakage. We identified an underlying mechanism of this effect: aldosterone upregulated the endothelial vasodilatory K channel KCa2.3. Its blockade prevented aldosterone-induced thickening. To translate these findings, we treated 2 patients with chronic nonresolved CSCR with oral eplerenone, a specific MR antagonist, for 5 weeks, and observed impressive and rapid resolution of retinal detachment and choroidal vasodilation as well as improved visual acuity. The benefit was maintained 5 months after eplerenone withdrawal. Our results identify MR signaling as a pathway controlling choroidal vascular bed relaxation and provide a pathogenic link with human CSCR, which suggests that blockade of MR could be used therapeutically to reverse choroid vasculopathy.