Sympathetic-parasympathetic activity and reactivity in central serous chorioretinopathy: a case-control study

Macular Retinal Vessel Oxygen Saturation Elevation in Chinese Central Serous Chorioretinopathy

Purpose

To evaluate the retinal vessel oxygen saturation in central serous chorioretinopathy (CSC) cases among the Chinese.

Methods

Relative oxygen saturation of retinal blood vessels was measured in 33 Chinese patients with single-eye CSC using the Oxymap T1 retinal oximeter. The contralateral eyes were the control. The mean saturation of the retinal arteriole (AS) and venule (VS), arteriovenous difference (AVS), and arteriole and venule diameters (AD, VD) was analyzed in the optic disc area and macular region.

Results

In the optic disc area, the inferotemporal quadrant (TI) AS (93.2 ± 10.2%) and inferonasal quadrant (NI) VS (61.3 ± 7.3%) were higher in the affected eyes than in the contralateral eyes (88.7 ± 7.7% and 56.9 ± 6.5%) and AVS in NI (36.7 ± 10.4%) decreased compared to the contralateral eyes (41.5 ± 11.2%). The VD in TI was expanded (19.9 ± 2.5 pixels versus 18.1 ± 3.4 pixels). Around the macular region, AS was 93.6 ± 7.6%, higher than in the contralateral eyes (89.5 ± 6.3%). No other significant changes were found.

Conclusions

AS increased in the TI, and VS decreased in the NI in the eyes with CSC. In addition, AS also increased around the macular region, suggesting that these are contributors to CSC pathophysiology.

Operating room central serous chorioretinopathy

Objectives

The operating room is a place of surgical intervention with its accompanying bodily and cognitive strain on the performers. Stress in the operating room may lead to the onset of central serous chorioretinopathy as reported hereby in a retina surgeon and is labeled as operating room central serous chorioretinopathy.

Methods

The same operator performed the optical coherence tomography scans on one retina surgeon. A masked observer estimated the maximal height of the subretinal fluid.

Results

Central serous chorioretinopathy recurred four times over a 1-year period 1 -2 days after a stressful day in the operating room, especially when cases were done under topical or subtenon anesthesia for cataract surgery, vitreous surgery or combined surgeries with complex ocular and medical problems and inability for anesthesia team to intervene. Stress management allowed resolution of subretinal fluid between 3 and 4 weeks. Adopting this strategy, no further attacks were documented by optical coherence tomography for 5 years.

Conclusions

(1) This is one of a few optical coherence tomography documentation of resolution of central serous chorioretinopathy within 3-4 weeks of its occurrence and its recurrence induced by stress in the operating room; (2) Unassisted topical anesthesia required in patients with complex medical and ocular problems causes more cognitive stress than when surgery is carried under assisted local or general anesthesia (partly due to unexpected ocular or bodily movements); and (3) the available evidence suggests that those overcommitted surgeons (type A personality) may very well be most susceptible to burnout and central serous chorioretinopathy.

Retinal vessels functionality in eyes with central serous chorioretinopathy

Purpose

To analyse static characteristics and dynamic functionality of retinal vessels in eyes with central serous chorioretinopathy (CSCR) by means of Dynamic Vessel Analyzer (DVA).

Methods

Patients presenting with treatment-naïve CSCR and normal subjects (controls) matched for age and sex between May 2015 and November 2015 were enrolled in the study. Participants underwent a complete ophthalmological examination, including dynamic and static retinal vessels analysis by DVA.

Results

A total of 28 eyes of 28 subjects (14 eyes for each group) were included in the analysis. Dynamic analysis during stimulation by flickering light showed mean venous dilation of 3.3%±2.0% in patients with CSCR and 5.5%±2.6% in controls (p=0.0258); mean arterial dilation did not differ between patients and controls (3.2%±2.5% and 4.2%±1.5%, p=0.2). No differences were reported at static retinal analysis between patients with CSCR and control subjects. Subfoveal choroidal thickness as evaluated by optical coherence tomography was 438.6±86.1 µm in CSCR eyes, significantly increased compared with control subjects (301.5±72.5 µm, p=0.0001).

Conclusions

Dynamic analysis revealed a reduced retinal venous dilation in response to flicker light stimulation in CSCR eyes. The decreased retinal vein response to flicker light stimulation, possibly due to increased sympathetic tone and potentially leading to venous stasis, together with the increased choroidal thickness may help understand CSCR and give insights in its pathogenesis.

Choroidal Characteristics of Acute and Chronic Central Serous Chorioretinopathy Using Enhanced Depth Imaging Optical Coherence Tomography

Purpose

Central serous chorioretinopathy (CSC) is an idiopathic disorder characterized by serous detachments of the neurosensory retina and/or the retinal pigment epithelium affecting the macular area in the majority of cases. The objective of this study was to describe choroidal findings in patients with acute and chronic CSC based on enhanced depth imaging optical coherence tomography analysis.

Methods

This is a cross-sectional, noninterventional study performed at Luigi Sacco University Hospital of Milan. Inclusion criteria were the presence of diagnosed (acute or chronic) CSC and being 18 years or older. Patients were evaluated with Spectralis spectral-domain optical coherence tomography enhanced depth imaging by 2 operators. The main features analyzed were intrachoroidal hyperreflective spots and hyperreflective choroidal vessel walls, as actual measurements of wall thickness could not be performed.

Results

Patients with chronic CSC had hyperreflective spots in 83.3% of the cases and hyperreflective choroidal vessel walls in 75%, whereas patients with acute course had the same alterations in 33% and 6.7% of cases, respectively.

Conclusions

These findings, if proven, may be indicative of chronic forms, thus guiding more accurate treatments and guiding clinicians through more accurate prognosis.

Reduced Blood Serotonin Levels in Chronic Central Serous Chorioretinopathy

PURPOSE

To evaluate blood serotonin (5-hydroxytryptamine [5-HT]) levels in patients with chronic central serous chorioretinopathy (CSC).

DESIGN

A case-controlled retrospective study.

PARTICIPANTS

Forty-nine patients with CSC and 30 age-matched control subjects.

METHODS

Blood 5-HT levels were measured using high-performance liquid chromatography.

MAIN OUTCOME MEASURES

Blood 5-HT levels in patients with acute or chronic CSC were measured at the initial visit and compared with those in controls.

RESULTS

The blood 5-HT level (98.2±27.5 ng/ml) in patients with chronic CSC was significantly lower than those in patients with acute CSC (122.5±23.9 ng/ml, P = 0.0081) and controls (128.5±35.8 ng/ml, P = 0.0013). After adjusting for covariates, patients with decreased blood 5-HT levels were found to be more likely to develop chronic CSC (odds ratio, 0.97; 95% confidence interval, 0.95-0.99; P = 0.009).

CONCLUSIONS

These results suggest that serotonin may have a role in chronic CSC pathogenesis and is associated with disease progression.

Shift Work: A Risk Factor for Central Serous Chorioretinopathy

PURPOSE

To investigate if shift work or sleep disturbances are risk factors for central serous chorioretinopathy (CSCR).

DESIGN

Prospective case-control study.

METHODS

Forty patients with active CSCR and 40 controls (age- and sex-matched) were prospectively recruited from the Ophthalmology Department of Hôtel Dieu Hospital, Paris, between November 2013 and December 2014. All patients were asked to complete a questionnaire addressing previously described risk factors and working hours, as well as the Insomnia Severity Index (ISI), a validated instrument for assessing sleep disturbances.

RESULTS

The mean age of the CSCR group was 44 ± 9 years, whereas the mean age of the control group was 43 ± 10 years. By use of multivariate analysis, shift work (odds ratio [OR] [95% confidence interval]: 5 [1.2-20.4]; P = .02), steroid use (OR: 5.5 [1.1-26.2]; P = .03), and recent psychological stress (OR: 15.3 [4.1-54.5]; P < .001) were found to be independently associated with CSCR.

CONCLUSION

The outcomes of this study suggest that shift work is an independent risk factor of CSCR. Further studies are required to confirm these results and to examine if work reconversion would be beneficial in the treatment of patients with chronic/recurrent CSCR.

Relationship between mean platelet volume and central serous chorioretinopathy

The aim of this study was to investigate the mean platelet volume (MPV) of patients with central serous chorioretinopathy (CSCR). Thirty patients were included in the study. Thirty healthy volunteers were recruited as the control group. All patients and control subjects underwent complete ocular examination. Hemoglobin, hematocrit, white blood cell, neutrophil, lymphocyte, platelet count, and MPV of the participants were recorded. Data of patients with CSCR were compared with the control subjects. Patients with CSCR had significantly higher MPV values (9.76 ± 1.36 fL) compared with the control subjects (8.37 ± 0.72 fL) (p = 0.004). No significant difference was found in platelet counts between the CSCR group and the control group (259 ± 53.75 and 243 ± 52.11 K/Ul, p = 0.253). According to the receiver operator characteristics curve analysis, the optimal cut-off value of MPV to predict the CSCR was >9.4, with 60.0 % sensitivity and 93.3 % specificity. Our results demonstrated that the MPV values were significantly higher in patients with CSCR. MPV may be used as a predictive tool for identifying risk for CSCR.

Is myopia a protective factor against central serous chorioretinopathy?

AIM

To evaluate if any association exists between central serous chorioretinopathy (CSCR) and the refractive status of the eye.

METHODS

This retrospective, institutional, case control study included 499 patients, wherein 262 patients diagnosed as acute CSCR, were compared with an age and gender matched control group of 237 patients. All patients were evaluated with a detailed systemic and ocular history, objective and subjective refractions for both eyes and complete ocular examination by a retina specialist, at all visits. Optical coherence tomography confirmed the diagnosis of CSCR.

RESULTS

The mean age was found to be 40±7y in the study group (Group 1) compared to 38±10y in the control group (Group 2). Most common refractive status in the study group, was emmetropia seen in 191 patients (72.9%), followed by hypermetropia seen in 47 patients (17.9%) and astigmatism seen in 21 patients (8.0%). Only 3 subjects (1.1%) had myopia, which was less than or equal to 1.0 D, compared to 70 subjects (29.5%) in the control group, suggesting a statistically significant lower incidence of CSCR among the myopic patients (P< 0.0001). With respect to the systemic factors, 26 (9.9%) patients were using systemic steroids in the study group (Group 1) compared to none in the control group (Group 2) suggesting a statistically significant association of CSCR with systemic steroid use (P<0.05). No other significant systemic risk factors were noted.

CONCLUSION

Though CSCR is a multifactorial disease, myopia serves as a protective factor for CSCR. Thus, myopic eyes are less likely to develop CSCR. Since both retinal pigment epithelium (RPE) and choriocapillaris are postulated in the pathogenesis of CSCR, chorio-retinal thinning and atrophy seen in myopic eyes are less likely to cause CSCR.

Therapeutic benefit of melatonin in refractory central serous chorioretinopathy

PURPOSE

To evaluate the efficacy and safety of melatonin for the treatment of chronic central serous chorioretinopathy (CSCR).

METHODS

Prospective comparative case series. A total of 13 patients with chronic CSCR were treated for 1 month: 8 patients were treated orally with 3 mg melatonin t.i.d., and 5 with placebo. All patients had 20/40 or worse Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA) in the affected eye or presented an incapacitating scotoma. Most of the patients had previous failed treatments for their condition. Observational procedures included ETDRS BCVA, and complete ophthalmic examination. Optical coherence tomography (OCT) was performed at day 1 and week 4. Fluorescein angiography was performed at baseline only for diagnostic purposes. Data were subjected to two-sample t-test statistical analysis. P-values of <0.05 were considered statistically significant.

RESULTS

At 1-month follow-up, BCVA significantly improved in 87.5% of patients treated with melatonin (7 of 8 patients, P<0.05). All patients showed a mean significant reduction (P<0.01) of central macular thickness (CMT) when compared with the baseline, with 3 patients (37.5%) exhibiting complete resolution of subretinal fluid at 1-month follow-up. No significant side effects were observed. No changes in BCVA or CMT were noted in the control group.

CONCLUSIONS

These results suggest that melatonin is safe, well tolerated, and effective in the treatment of chronic CSCR, as it significantly improved BCVA and CMT in patients with this pathology. Further evaluations with longer follow-up and a larger patient population are desirable.

Change of regional choroid thickness after reduced-fluence photodynamic therapy for chronic central serous chorioretinopathy

PURPOSE

To evaluate macular choroidal thickness after reduced-fluence photodynamic therapy (PDT) for chronic central serous chorioretinopathy (CSC).

DESIGN

Prospective, consecutive, interventional case series.

METHODS

Twenty-two eyes with chronic CSC were treated with reduced-fluence PDT. Macular choroidal thickness was examined using spectral-domain optical coherence tomography with a 3-dimensinonal radial scan protocol in the choroidal mode before and 1, 3, and 6 months after the treatment. The mean choroidal thickness in the Early Treatment Diabetic Retinopathy Study grid (center, inner circle, and outer circle) was compared between before and after therapy, as well as between treated eyes and 54 volunteer normal eyes.

RESULTS

Chronic CSC eyes showed significantly thicker choroids in the macular area compared with normal controls (P < .0001). After the single treatment session, subretinal fluid resolved completely in all eyes, and there were no recurrences during the study period. Choroidal thickness within the center area and inner circle showed a significant reduction at all time points after treatment (P < .05). The choroidal thickness in the outer circle showed a statistically significant reduction at 1 and 3 months but not at 6 months. After treatment, the choroidal thickness reduced to the normal values at the center and inner circle, but was still significantly thicker in the outer circle (P < .01).

CONCLUSION

Chronic CSC eyes showed significantly thicker choroids in the macular area. After reduced-fluence PDT, macular choroidal thickness became thinner within 6 months of treatment.

Changes in choroidal thickness during pregnancy detected by enhanced depth imaging optical coherence tomography

AIM

To compare the choroidal thickness measurements of healthy pregnant women obtained in the first trimester with measurements obtained in the third trimester using enhanced depth imaging optical coherence tomography (OCT).

METHODS

54 eyes of 27 healthy pregnant women and 50 eyes of 25 age matched healthy women were enrolled in this observational, cross-sectional study. The pregnant women underwent two OCT scans, one in the first trimester at gestational weeks 6-8, and the other during the third trimester at gestational weeks 32-37; the control group had OCT scanning during the follicular phase of the menstrual cycle, using the enhanced depth imaging mode. Choroidal thicknesses were measured at the fovea, at three locations nasal, and at three locations temporal to the fovea at 500 μm intervals.

RESULTS

The choroidal thickness measurements obtained in the third trimester were significantly decreased in all measured points in both eyes compared to the measurements obtained in the first trimester (p<0.05). At the fovea, the mean (±SD) choroidal thickness measured in the first trimester was 349.22±82.11 μm in the right eyes and 341.30±85.22 μm in the left eyes, which decreased to 333.56±76.61 μm in the right eyes (p=0.014) and 326.93±75.84 μm in the left eyes (p=0.024) in the third trimester. Although not statistically significant, choroidal thicknesses of the control group were less than the choroidal thicknesses of the pregnant women (p>0.05).

CONCLUSIONS

Choroidal thickness was found to be significantly decreased in healthy pregnant women during the third trimester compared to the first trimester. This finding can provide valuable information when interpreting pregnancy related ocular disorders.

Helicobacter pylori infection and eye diseases: a systematic review

The connection between Helicobacter pylori (Hp) infection and eye diseases has been increasingly reported in the literature and in active research. The implication of this bacterium in chronic eye diseases, such as blepharitis, glaucoma, central serous chorioretinopathy and others, has been hypothesized. Although the mechanisms by which this association occurs are currently unknown, this review describes shared pathogenetic mechanisms in an attempt to identify a lowest common denominator between eye diseases and Hp infection. The aim of this review is to assess whether different studies could be compared and to establish whether or not Hp infection and Eye diseases share common pathogenetic aspects. In particular, it has been focused on oxidative damage as a possible link between these pathologies. Text word search in Medline from 1998 to July 2014. 152 studies were included in our review. Were taken into considerations only studies that related eye diseases more frequent and/or known. Likely oxidative stress plays a key role. All of the diseases studied seem to follow a common pattern that implicates a cellular response correlated with a sublethal dose of oxidative stress. These alterations seem to be shared by both Hp infections and ocular diseases and include the following: decline in mitochondrial function, increases in the rate of reactive oxygen species production, accumulation of mitochondrial DNA mutations, increases in the levels of oxidative damage to DNA, proteins and lipids, and decreases in the capacity to degrade oxidatively damaged proteins and other macromolecules. This cascade of events appears to repeat itself in different diseases, regardless of the identity of the affected tissue. The trabecular meshwork, conjunctiva, and retina can each show how oxidative stress may acts as a common disease effector as the Helicobacter infection spreads, supported by the increased oxidative damage and other inflammation.

En face enhanced-depth swept-source optical coherence tomography features of chronic central serous chorioretinopathy

OBJECTIVE

To characterize en face features of the retinal pigment epithelium (RPE) and choroid in eyes with chronic central serous chorioretinopathy (CSCR) using a high-speed, enhanced-depth swept-source optical coherence tomography (SS-OCT) prototype.

DESIGN

Consecutive patients with chronic CSCR were prospectively examined with SS-OCT.

PARTICIPANTS

Fifteen eyes of 13 patients.

METHODS

Three-dimensional 6×6 mm macular cube raster scans were obtained with SS-OCT operating at 1050 nm wavelength and 100000 A-lines/sec with 6 μm axial resolution. Segmentation of the RPE generated a reference surface; en face SS-OCT images of the RPE and choroid were extracted at varying depths every 3.5 μm (1 pixel). Abnormal features were characterized by systematic analysis of multimodal fundus imaging, including color photographs, fundus autofluorescence, fluorescein angiography, and indocyanine-green angiography (ICGA).

MAIN OUTCOME MEASURES

En face SS-OCT morphology of the RPE and individual choroidal layers.

RESULTS

En face SS-OCT imaging at the RPE level revealed absence of signal corresponding to RPE detachment or RPE loss in 15 of 15 (100%) eyes. En face SS-OCT imaging at the choriocapillaris level showed focally enlarged vessels in 8 of 15 eyes (53%). At the level of Sattler's layer, en face SS-OCT documented focal choroidal dilation in 8 of 15 eyes (53%) and diffuse choroidal dilation in 7 of 15 eyes (47%). At the level of Haller's layer, these same features were observed in 3 of 15 eyes (20%) and 12 of 15 eyes (80%), respectively. In all affected eyes, these choroidal vascular abnormalities were seen just below areas of RPE abnormalities. In 2 eyes with secondary choroidal neovascularization (CNV), distinct en face SS-OCT features corresponded to the neovascular lesions.

CONCLUSIONS

High-speed, enhanced-depth SS-OCT at 1050 nm wavelength enables the visualization of pathologic features of the RPE and choroid in eyes with chronic CSCR not usually appreciated with standard spectral domain (SD) OCT. En face SS-OCT imaging seems to be a useful tool in the identification of CNV without the use of angiography. This in vivo documentation of the RPE and choroidal vasculature at variable depths may help elucidate the pathophysiology of disease and can contribute to the diagnosis and management of chronic CSCR.

Multifocal central serous chorioretinopathy associated with steroids in a patient with myasthenia gravis

We present a case of bilateral multifocal central serous chorioretinopathy in a 40-year-old male who suffered from myasthenia gravis and was receiving oral prednisolone. Due to the severity of the underlying disease, it was not possible to reduce the corticosteroid dose. After initial unsuccessful treatment with an intravitreal injection of ranibizumab, low-fluence photodynamic therapy was performed, followed by gradual tapering of the corticosteroids. Visual acuity improved significantly in both eyes. Different therapeutic approaches are discussed.

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.

Macular choroidal blood flow velocity decreases with regression of acute central serous chorioretinopathy

AIM

To quantitatively evaluate the time course of macular choroidal blood flow velocity in acute central serous chorioretinopathy (CSC).

METHODS

This retrospective observational case series included 21 eyes of 20 patients (17 men, 3 women; mean age, 53.0 years) with treatment-naïve acute CSC. Laser speckle flowgraphy was performed to calculate macular mean blur rate (MBR), an indicator of relative blood flow velocity at the first visit, 3 and 6 months thereafter. Changes in average MBR values were compared with visual improvement at 6 months.

RESULTS

Subretinal fluid completely resolved in all eyes within 6 months, while best-corrected visual acuity (BCVA) significantly improved at 6 months compared to the initial BCVA. During the follow-up period, the average MBR significantly decreased to 92.8% and 82.3% at 3 and 6 months, respectively, against baseline (100%). Importantly, there was a negative correlation between the BCVA recovery and the MBR decrease, showing the possible association of MBR increase with poor visual prognosis. Multiple regression analysis demonstrated no significant correlation between MBR and ocular perfusion pressure.

CONCLUSIONS

These results indicate that macular choroidal blood flow velocity decreases concurrently with regression of CSC, suggesting a validity of choroidal blood flow elevation in the pathogenesis of acute CSC.

Central serous chorioretinopathy: a review of epidemiology and pathophysiology

Central serous chorioretinopathy (CSCR) is a common retinal cause of vision loss. This review surveys the epidemiology, risk factors, clinical presentation, natural history and pathophysiology of CSCR. Studies suggest an annual incidence rate of 10 per 100 000 in men, with CSCR occurring six times more commonly in men compared with women. Most acute CSCR cases resolve spontaneously within 2-3 months. Prognosis is highly dependent on presenting visual acuity; patients with initial visual acuities of 6/6 remain at that level, while patients with initial visual acuities of less than 6/9 recover on average two to three Snellen lines over the next few years. The main risk factors for CSCR are systemic corticosteroid use, type A personality, pregnancy and endogenous Cushing's syndrome. The pathophysiology of CSCR remains obscure, although disorders in both the choroidal circulation and retinal pigment epithelium are implicated.

Enhanced depth imaging optical coherence tomography

Imaging the choroid with conventional commercial spectral-domain optical coherence tomography (SD-OCT) has been difficult, mainly because of difficulty in signal transmission beyond the retinal pigment epithelium. A recent modification to the standard technique, termed enhanced depth imaging optical coherence tomography (EDI-OCT), was able to image the choroid with reasonable clarity using commercial SD-OCTs. The aim of this article was to review the technique, principle, recent findings, and possible future developments regarding EDI-OCT. A MEDLINE search on all published articles on EDI-OCT was performed up to December 2010. The principle behind EDI-OCT was discussed. Modification to the conventional technique in image acquisition was described and illustrated with figures. EDI-OCT findings in various retinal and choroidal diseases were discussed. Advantages and disadvantages were also discussed. EDI-OCT has proved to be a promising novel technique in imaging the choroid.

Central serous chorioretinopathy: a pathogenetic model

Despite numerous studies describing predominantly its demography and clinical course, many aspects of central serous chorioretinopathy (CSCR) remain unclear. Perhaps the major impediment to finding an effective therapy is the difficulty of performing studies with large enough cohorts, which has meant that clinicians have focused more on therapy than on a deeper understanding of the pathogenesis of the disease. Hypotheses on the pathogenesis of CSCR have ranged from a basic alteration in the choroid to an involvement of the retinal pigment epithelium (RPE). Starting from evidence that affected subjects often present a personality prone to stress with altered pituitary–hypothalamic axis response (HPA) and that they have higher levels of serum and urinary cortisol and catecholamines than healthy subjects, we hypothesize a cascade of events that may lead to CSCR through hypercoagulability and augmented platelet aggregation. In particular we investigated the role of tissue plasminogen activator, increasing plasminogen activator inhibitor 1 (PAI-1), and plasmin-α2- plasmin inhibitor complexes. We reviewed the different therapeutic approaches, including adrenergic antagonists, carbonic anhydrase inhibitors, mifepristone, ketoconazole, laser photocoagulation, intravitreal injection of bevacizumab, and photodynamic therapy with verteporfin (PDT) and our model of pathogenesis seems to be in agreement with the clinical effects obtained from these treatments. In accord with our thesis, we began to treat a group of patients affected by CSCR with low-dose aspirin (75–100 mg), because of its effectiveness in other vascular diseases and its low ocular and general toxicity with prolonged use. The formulation of a causative model of CSCR enables us to understand how the therapeutic approach cannot be based on a generalized therapy but should be individualized for each patient, and that sometimes a combined strategy of treatment is required. Moreover a complete knowledge of the disease will help to identify patients prone to the most persistent forms of CSCR, and thus help to find a treatment.

Attenuation of age- and sucrose-induced insulin resistance and syndrome X by a synergistic antioxidant cocktail: the AMIS syndrome and HISS hypothesis

Absence of meal-induced insulin sensitization (AMIS) results in a predictable progression of dysfunctions, including postprandial hyperglycemia, compensatory hyperinsulinemia, resultant hyperlipidemia, increased oxidative stress, and obesity, progressing to syndrome X and diabetes. To one year of age, rats show a slow development of AMIS, but this can be potentiated by addition of a low-dose sucrose supplement to the diet. Provision of a synergistic antioxidant cocktail consisting of S-adenosylmethionine, vitamin E, and vitamin C (Samec) attenuates the rate and extent of development of AMIS in both normal aging animals and in aging animals on the sucrose diet. Adiposity, assessed from weighed regional fat masses and from bioelectrical impedance to estimate whole-body adiposity, correlated strongly with AMIS (r2 = 0.7-0.8). Rats given the sucrose supplement had accelerated AMIS and developed fasting hyperinsulinemia and postprandial hyperglycemia, hyperlipidemia, hyperinsulinemia, and adiposity. Samec completely compensated for the negative impact of this sucrose supplement and attenuated development of the associated dysfunctions. AMIS is explained by the HISS (hepatic insulin-sensitizing substance) hypothesis, which is outlined in the paper.

Low-dose aspirin as treatment for central serous chorioretinopathy

PURPOSE

To evaluate the effectiveness of low-dose aspirin for the treatment of central serous chorioretinopathy (CSCR).

PATIENTS AND METHODS

Patients with classical or multifocal CSCR were treated with aspirin 100 mg per day orally for 1 month followed by 100 mg on alternate days for 5 months. Treated patients were compared with historic controls consisting of patients with classical or multifocal CSCR previously followed up at our institution.

RESULTS

Mean visual acuity in the group treated with aspirin started to improve after the first week of therapy and continued to improve throughout the following 3 months. Visual recovery was slower in the untreated control group than in the treated group and achieved better visual acuity between the first and third month from the onset of the disease. There were no adverse events related to the administration of aspirin.

CONCLUSION

The results indicate that treatment with low-dose aspirin may result in more rapid visual rehabilitation with fewer recurrences in patient with CSCR compared with untreated historic controls. The effectiveness of treatment with aspirin supports our hypothesis regarding the role of impaired fibrinolysis and increased platelet aggregation in the choriocapillaris in the pathogenesis of CSCR.

Enhanced depth imaging optical coherence tomography of the choroid in central serous chorioretinopathy

PURPOSE

The purpose of the study was to evaluate the choroidal thickness in patients with central serous chorioretinopathy, a disease attributed to increased choroidal vascular hyperpermeability.

METHODS

Patients with central serous chorioretinopathy underwent enhanced depth imaging spectral-domain optical coherence tomography, which was obtained by positioning a spectral-domain optical coherence tomography device close enough to the eye to acquire an inverted image. Seven sections, each comprising 100 averaged scans, were obtained within a 5 degrees x 30 degrees rectangle to encompass the macula. The subfoveal choroidal thickness was measured from the outer border of the retinal pigment epithelium to the inner scleral border.

RESULTS

The mean age of subjects undergoing enhanced depth imaging spectral-domain optical coherence tomography was 59.3 years (standard deviation, 15.8 years). Seventeen of 19 patients (89.5%) were men, and 12 (63.2%) patients had bilateral clinical disease. The choroidal thickness measured in 28 eligible eyes of the 19 patients was 505 microm (standard deviation, 124 microm), which was significantly greater than the choroidal thickness in normal eyes (P < or = 0.001).

CONCLUSION

Enhanced depth imaging spectral-domain optical coherence tomography demonstrated a very thick choroid in patients with central serous chorioretinopathy. This finding provides additional evidence that central serous chorioretinopathy may be caused by increased hydrostatic pressure in the choroid.

A new strategy of treatment with low-dosage acetyl salicylic acid in patients affected by central serous chorioretinopathy

Central serous chorioretinopathy (CSCR) is an ocular disease characterized by serous detachment of the neurosensory retina at the posterior pole, with or without an associated retinal pigment epithelium (RPE) detachment. It is associated with different systemic diseases although the pathogenesis is unknown. Different therapies have been applied to treat CSCR with poor results. We reviewed the literature and found that in all the diseases associated with CSCR plasminogen activator inhibitor 1 (PAI-1) was increased. Acetyl salicylic acid (Aspirin) is effective in lowering PAI-1 levels and platelets aggregation; as such we decided to treat patients affected by CSCR with low dose Aspirin. From January 2005 to December 2008 we enrolled 107 patients, 85 male and 22 female, affected with active CSCR or the multifocal variant. Aspirin was administrated at an oral dose of 100 mg. per day for a month and then 100 mg. every other day for five months. After the first week of therapy and for the following three months the visual acuity improved and remained stable to the end of the follow-up (median follow-up 20 months). A recurrence of the disease interested the 6% of the patients. In this study low-dose Aspirin was able to treat central serous chorioretinopathy with a quick recovery of the visual acuity and a reduced number of recurrences during the follow-up. Besides the effectiveness of the treatment with Aspirin supports our observation regarding the role of impaired fibrinolysis and increased platelets aggregation in the choriocapillaris as genesis of CSCR.

HISS-dependent insulin resistance (HDIR) in aged rats is associated with adiposity, progresses to syndrome X, and is attenuated by a unique antioxidant cocktail

The hypotheses were: HISS-dependent insulin resistance (HDIR) accounts for insulin resistance that occurs with aging; HDIR is the initiating metabolic defect that leads progressively to type 2 diabetes and the metabolic syndrome; a synergistic antioxidant cocktail in chow confers protection against HDIR, subsequent symptoms of diabetes, and the metabolic syndrome. Male Sprague Dawley rats were tested at 9, 26, and 52 weeks to determine their dynamic response to insulin, the HISS (hepatic insulin sensitizing substance)-dependent component of insulin action, and the HISS-independent (direct) insulin action using a dynamic insulin sensitivity test. In young rats, the HISS component accounted for 52.3+/-2.1% of the response to a bolus of insulin (50mU/kg) which decreased to 29.8+/-3.4% at 6 months and 17.0+/-2.7% at 12 months. HISS action correlated negatively with whole body adiposity and all regional fat depots (r(2) = 0.67-0.87). The antioxidants (vitamin C, vitamin E, and S-adenosylmethionine) conferred protection of HISS action, fat mass at all sites, blood pressure, postprandial insulin and glucose. Data are consistent with the hypotheses. Early detection and therapy directed towards treatment of HDIR offers a novel therapeutic target.

First and second-order kernel multifocal electroretinography abnormalities in acute central serous chorioretinopathy

PURPOSE

To evaluate the first and second-order kernel multifocal electroretinogram (mfERG) response abnormalities in patients with acute central serous chorioretinopathy (CSC).

METHODS

This was a cross-sectional observational study in which 45 eyes of 45 patients with acute CSC underwent mfERG recordings. Peak amplitudes and implicit times of the first and second-order kernel responses were analyzed and compared with 20 age-matched normal controls. Correlation analyses were performed between the patients' visual acuity and the first and second-order amplitudes and implicit times.

RESULTS

The first-order N1 and P1 mfERG amplitudes in the central three concentric rings were reduced in eyes with acute CSC compared with controls (P < 0.05). The first-order P1 implicit times of the central four rings were also delayed (P < 0.05). For the second-order mfERG response, there were significant reductions in the second-order P1 and N1 amplitudes in rings 3-5 compared with controls (P < 0.05). No significant difference between the second-order P1 and N1 implicit times was found compared with controls (P > 0.05). Correlation analyses showed significant correlations between visual acuity and the first-order N1 response amplitudes of rings 1 and 2, and for the first-order N1 and P1 implicit times of rings 1-4 (P < 0.05).

CONCLUSION

Both first and second-order mfERG response abnormalities occur in eyes with acute CSC. These results suggest that in acute CSC, while outer retinal dysfunction is mostly localized to the central macula, there might be more widespread impairment in adaptive mechanisms of the inner retina or outer plexiform layer dysfunction in the more peripheral macula.