Long-term follow-up of idiopathic central serous chorioretinopathy by fluorescein angiography

The effect of intravitreal bevacizumab in patients with acute central serous chorioretinopathy

Purpose

To evaluate the effect of intravitreal bevacizumab injection (IVBI) in acute central serous chorioretinopathy (CSC) patients.

Methods

Patients with acute CSC received IVBI (1.25 mg/0.05 mL) or observation by randomization. Twelve eyes in each group completed 6 months of regular follow-up and were ultimately included in this study. Each patient was assessed using best corrected visual acuity measurements, fluorescein angiography, and optical coherence tomography at baseline and had regular follow-ups after treatment.

Results

All patients showed improvements in visual acuity and fluorescein angiographic leakage and had resolution of their neurosensory detachment following treatment. There were no significant differences in visual acuity, central retinal thickness, or remission duration between the IVBI group and the control group at baseline or after treatment (p>0.05).

Conclusions

Intravitreal bevacizumab showed no positive effect in acute CSC patients compared to the observation group, and there were no adverse effects of treatment. Further investigation will be helpful to understand this therapy in patients with CSC.

Intravitreal bevacizumab in treatment of idiopathic persistent central serous chorioretinopathy: a prospective, controlled clinical study

PURPOSE

To evaluate and determine the effect of intravitreal bevacizumab in treatment of persistent central serous chorioretinopathy.

METHODS

This prospective, comparative clinical study included 30 eyes of 30 patients with persistent, symptomatic central serous chorioretinopathy of 3 months' duration or more. Fifteen eyes of 15 patients were treated with intravitreal injections of 2.5 mg (0.1 ml) bevacizumab (treatment group). Fifteen eyes of 15 patients with the same characteristics who declined treatment were an acceptable control group. The visual and anatomic responses were observed with best-corrected visual acuity and central foveal thickness measured by optic coherence tomography at baseline,1, 3, and 6 months after treatment.

RESULTS

Twelve (80%) eyes in the treatment group compared with 8 (53.3%) eyes in the control group showed morphologic restitution at 6 months (P < 0.01). All 15 (100%) treated eyes had stable or improved vision, compared with 10 (66.6%) eyes in the control group (P < 0.01). At 6 months, the mean +/- SD central foveal thickness for the treatment group remained significantly lower compared to the control group, with 174 +/- 68 microm and 297 +/- 172 microm, respectively (P < 0.001). Injection-related complications were not encountered.

CONCLUSIONS

Our results indicate that intravitreal bevacizumab injection may be a new, promising treatment option for select patients with idiopathic persistent central serous chorioretinopathy. Continued studies with intravitreal bevacizumab in this population will help to establish its long-term efficacy.

Association between the efficacy of photodynamic therapy and indocyanine green angiography findings for central serous chorioretinopathy

PURPOSE

To determine the efficacy of photodynamic therapy (PDT) and indocyanine green angiography (ICGA) findings for treating chronic central serous chorioretinopathy (CSC).

DESIGN

Observational case series.

METHODS

Thirty-two eyes of 27 patients with chronic CSC and symptoms for at least 6 months were recruited. The minimum follow-up was 1 year. The total PDT energy was reduced to about 36 to 42 mJ/cm(2). The baseline middle-phase ICGA findings were classified as intense, intermediate, or no hyperfluorescence depending on the degree of hyperfluorescence. The resolution of the subretinal fluid and recurrence rates were assessed in relation to each ICGA finding at baseline.

RESULTS

ICGA before PDT showed intense hyperfluorescence in 23 eyes (72%), intermediate hyperfluorescence in 6 eyes (19%), and no hyperfluorescence in 3 eyes (9%). The subretinal fluid resolved completely 3 months after 1 application of PDT in 23 eyes (100%) with intense hyperfluorescence, 6 eyes (100%) with intermediate hyperfluorescence, and no eyes (0%) with no hyperfluorescence. In the last group, the subretinal fluid did not resolve throughout the follow-up period despite additional applications of PDT. The subretinal fluid recurred in 7 of 29 eyes (24%) in which the subretinal fluid resolved at 3 months; recurrence was frequent in eyes with intermediate hyperfluorescence (5 eyes; 83%).

CONCLUSION

The PDT success rate in eyes with chronic CSC depends on the degree of hyperpermeability on ICGA. PDT is not effective or the recurrence rate is predicted to be high in eyes without intense hyperfluorescence.

Photodynamic therapy as treatment of chronic idiopathic central serous chorioretinopathy

BACKGROUND AND OBJECTIVE

Chronic idiopathic central serous chorioretinopathy (ICSC) is characterized by persistent, recurrent, and multifocal serous detachments of the neurosensory retina. Our objective is to evaluate the visual and anatomical outcomes of patients who underwent photodynamic therapy (PDT) with Verteporfin for chronic ICSC.

STUDY DESIGN/MATERIALS AND METHODS

A retrospective review of 13 eyes of 12 patients (mean age 55, range 45-66 years) treated with PDT for chronic ICSC between June 2004 and January 2008 was conducted. Two eyes that subsequently developed choroidal neovascularization were excluded. Best corrected visual acuity (BCVA) and clinical examination prior to PDT and at most recent follow-up were recorded. Fluorescein angiography (FA) and optical coherence tomography (OCT) findings prior to and following treatment were reviewed.

RESULTS

Mean duration of symptoms prior to PDT was 26.7 months (range 3-108 months). Mean follow-up duration was 21.9 months (range 2-42 months). BCVA improved in seven of eleven eyes (mean 1.7 lines, range 1-3 lines), two eyes remained unchanged, and two eyes worsened. Complete resolution of serous detachment was demonstrated in 9 of 11 eyes by FA or OCT and 10 of 11 eyes by clinical examination. One eye showed a reduction in serous detachment by OCT and clinical exam. Three eyes required two treatments for recurrent serous detachment following initial treatment.

CONCLUSION

Our data suggest that PDT leads to resolution of serous detachments and visual improvement in patients with chronic ICSC. Further follow-up would be prudent to assess the long-term outcomes and safety in this patient population.

Diffuse retinal pigment epitheliopathy among the inhabitants of Brahmaputra Valley of India

PURPOSE

To analyze the patient demography and the various fluorescein angiography (FA) features of diffuse retinal pigment epitheliopathy (DRPE) cases among the inhabitants of the Brahmaputra Valley of India and to see if there is any ethnic variation in its clinical presentation and risk factors.

METHODS

This is a retrospective study in a clinical practice setting with study population of Aryan and Mongoloid races. Data analysis of 30 cases (40 eyes) of DRPE of 262 consecutive cases of central serous chorioretinopathy (CSC) was done. The various features of these cases were compared and statistically evaluated with the findings of CSC cases with symptom duration of 6 months or more and cases with recurrent episodes.

RESULTS

A total of 11.45% had DRPE that had average symptom duration of 3.50 years. Logistic regression showed high risk for DRPE if sensory retinal detachment (SRD) persists for more than 18 months. Systemic hypertension was another significant risk factor, whereas multiple RPE leaks appeared to be weakly significant. DRPE was predominant in eyes of patients having first acute episode of CSC in later age and fairly large retinal pigment epithelial detachments (PEDs) contributed to its development. Role of exogenous corticosteroid, retinotoxic drugs, and tobacco consumption could not be assessed properly due to inadequate sample size.

CONCLUSIONS

The main factor for the development of DRPE is the persistence of SRD for more than 1.50 years. Fairly large leaking PED and onset of primary CSC in later age appear to contribute towards its development. Except for these, no major variation from Western studies was observed.

Half-dose verteporfin photodynamic therapy for acute central serous chorioretinopathy: one-year results of a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of photodynamic therapy (PDT) with half-dose verteporfin for treating acute central serous chorioretinopathy (CSC).

DESIGN

Prospective, double-masked, placebo-controlled, randomized clinical trial.

PARTICIPANTS AND CONTROLS

Sixty-three eyes of 63 patients with acute symptomatic CSC of 3 months' duration or less were recruited. Forty-three eyes were randomized to indocyanine green angiography (ICGA)-guided PDT with half-dose (3 mg/m(2)) verteporfin and 21 eyes were randomized to placebo.

INTERVENTION

Patients in the verteporfin group received an infusion of half-dose verteporfin over 8 minutes, followed by ICGA-guided PDT 10 minutes from the start of infusion. Laser was applied for 83 seconds covering the choroidal abnormalities observed in ICGA, with a maximum laser spot size of 4500 mum.

MAIN OUTCOME MEASURES

The primary outcome measure was the proportion of eyes with absence of subretinal fluid at the macula at 12 months. Secondary outcome measures included changes in mean logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA), subjective symptoms, optical coherence tomography (OCT) results, central foveal thickness (CFT), and angiographic findings during the 12-month study period.

RESULTS

Thirty-nine patients in the verteporfin group and 19 patients in the placebo group completed 12 months of follow-up. Thirty-seven (94.9%) eyes in the verteporfin group compared with 11 (57.9%) eyes in the placebo group showed absence of subretinal fluid at the macula at 12 months (P = 0.001). The mean logMAR BCVA at 12 months was significantly better in the verteporfin group compared with the placebo group: -0.05 and 0.05, respectively (P = 0.008). All 39 (100%) verteporfin-treated eyes had stable or improved vision, compared with 15 (78.9%) eyes in the placebo group (P = 0.009). The mean OCT CFT for the verteporfin group also was significantly lower compared with the placebo group at 12 months (P = 0.001). No ocular or systemic adverse event was encountered in the study.

CONCLUSIONS

Photodynamic therapy with half-dose verteporfin is effective in treating acute symptomatic CSC, resulting in a higher proportion of patients with absence of exudative macular detachment and better visual acuity compared with placebo.

The natural history of pigment epithelial detachment associated with central serous chorioretinopathy

PURPOSE

To determine the visual outcome of retinal pigment epithelial detachment (PED) associated with central serous chorioretinopathy (CSC), to further characterize the natural history of these lesions, and to provide a review of previous reports.

PARTICIPANTS

Data for 340 consecutive patients with a diagnosis of CSC from January 2001 through December 2004 were retrospectively reviewed. Patients with CSC combined with angiographic evidence of PED were included in the study.

MAIN OUTCOME MEASURES

Age, sex, use of corticosteroid medications, presenting visual acuity, and final visual acuity were recorded. Lesion characteristics including location, number of lesions, and laterality were recorded. Clinical outcome measures included resolution or persistence of the PED, progression to retinal pigmentary atrophy, or development of choroidal neovascularization. Fluorescein angiograms were obtained if available.

RESULTS

Thirty-four (9%) of 319 patients with angiographic evidence of CSC were diagnosed with PED over a mean follow-up of 49 months (range, 12-165 months; median, 36 months). Mean age of the patients was 47 years (range, 32-69 years; median, 48 years), most of whom were males (68%). Mean initial visual acuity was 20/32 (range, 20/13 to 20/400; median, 20/30). PEDs were commonly unilateral (88%), unifocal (76%), and extrafoveal (82%). Overall mean final visual acuity was 20/25 (range, 20/13 to 20/250; median, 20/25) for all patients. Mean visual acuity for the group of patients with subfoveal PED (18%) was 20/50 (range, 20/25 to 20/250; median, 20/50). Complete resolution of the PED occurred in 65% of patients, with resultant mean visual acuity of 20/25 (range, 20/13 to 20/250; median, 20/25). In this group, localized retinal pigment epithelial atrophy developed in 86%, with mean final visual acuity of 20/25 (range, 20/13 to 20/250; median, 20/25). Persistent PED was observed in 35% of patients, resulting in mean visual acuity of 20/25. There were no cases of choroidal neovascularization.

CONCLUSIONS

CSC with associated retinal PED may be seen and generally has a good visual prognosis. The most frequent outcome is resolution with retinal pigment epithelial atrophy. Subfoveal PED occurs less commonly and may have a poorer visual prognosis.

Transpupillary thermotherapy for subfoveal leaks in central serous chorioretinopathy

AIM

To evaluate transpupillary thermotherapy (TTT) for the treatment of subfoveal focal leaks in central serous chorioretinopathy (CSC).

METHODS

The patients presenting with long-standing CSC, but without the features of chronicity, were offered the options of TTT, photodynamic therapy (for subfoveal leaks), photocoagulation (for extrafoveal leaks), or observation. The patients who opted for TTT or observation were enrolled in this study. TTT was performed using a spot diameter of 0.5 mm for 1 min. Best-corrected visual acuity (BCVA), status of macular detachment, and fluorescein angiographic status were evaluated at 1, 3, and 6 months.

RESULTS

This study included 39 patients (40 eyes) with CSC between 4 and 12 months, of whom 25 patients (25 eyes) opted for TTT for subfoveal leaks. Fourteen patients (15 eyes) were followed up without treatment. The groups were comparable in age, sex, and baseline BCVA. Minimum follow-up was 6 months. Within 3 months, TTT resulted in the resolution of the serous detachment in 24 (96%) eyes with a single session; one eye required a repeat treatment. Eight control eyes demonstrated persisting CSC at the last follow-up. Visual acuity improved in 23 (92%) treated and five (33%) control eyes; the difference in outcome was statistically significant (P<0.001). One case developed choroidal neovascularization, which resolved with visual recovery to 20/20 after repeat-TTT.

CONCLUSION

TTT resulted in the resolution of CSC with subfoveal angiographic leaks with significant improvement in visual outcome, in comparison to the natural history of persistent CSC.

Angiographic Characteristics of Acute Central Serous Chorioretinopathy in an Asian Population

Introduction: Acute central serous chorioretinopathy (CSCR) afflicts young middle-aged males in the Western population. We aimed to analyse patient demographics and to determine the angiographic characteristics of acute CSCR in an Asian population. Materials and Methods: This is a retrospective study of all patients presenting with acute CSCR who had fundal fluorescein angiograms performed within a 4-year period (between 1 January 1998 and 31 December 2001). Results: The fluorescein angiograms of 128 patients were analysed. The majority were male (109/128) with a male-to-female ratio of 5.7:1. The age range of patients was 26 to 60 years, with a mean age of 41 years. The majority of patients (84%) were aged 30 to 50 years. With regard to racial distribution, 83% were Chinese, 6% were Malays and 11% were Indians or of other races. Unilateral disease was found in 74 patients (58%) and 52 had bilateral disease. The macula was the most common site of fluorescein leakage and was found in 97 patients (76%). Almost half the patients (44%) had more than one site of disease involvement (i.e., multifocal). The inkblot leakage pattern was found in 103 patients (80%). Conclusions: The patient demographics of acute CSCR in our population were compared to that reported in the West. The gender ratio was similar, with males being afflicted 6 to 10 times more compared to females. There was no racial predilection found for acute CSCR in the local population. We also found a significant proportion of patients with bilateral and multifocal disease compared to the West. The inkblot pattern of leakage was the most common pattern seen on angiography. There were a significant number of cases with bilateral and multifocal involvement, exceeding those reported in non-Asian populations. Key words: Demography, Fluorescein angiography, Retinal diseases

Transpupillary thermotherapy for chronic central serous chorioretinopathy

PURPOSE

To determine whether transpupillary thermotherapy (TTT) causes resolution of neurosensory detachment associated with chronic central serous chorioretinopathy (CSCR).

METHODS

The study was a prospective interventional pilot study. All patients underwent Snellen visual acuity measurement (converted to LogMAR for analysis), slitlamp biomicroscopy, fundus examination, colour fundus photography, fluorescein and indocyanine green (ICG) angiography and optical coherence tomography (OCT). Follow-up was scheduled at 1, 2 and 3 months. Success was defined as resolution of neurosensory detachment on OCT at 3 months, and failure as persistence of the same. The primary outcome measure was resolution of OCT-measured neurosensory detachment and secondary outcome measure was change in visual acuity at the end of 3 months.

RESULTS

Fourteen eyes of 13 patients were included in the study. Twelve patients were male. The left eye was affected in seven of 14 eyes. The patients' mean age was 42.7+/-4.5 years (range 38-54 years). TTT parameters were as follows: power 156+/-47.8 mW; spot size 2.2+/-1.1 mm; duration 39.6+/-7.5 s. Following treatment, complete resolution of neurosensory detachment on OCT was seen in nine eyes (64.3%) at month 1 (P=0.004) and 11 eyes (78.6%) at months 2 and 3 (P=0.001). Three eyes (21.4%) had persistent subretinal fluid at month 3. Eight eyes (52.7%) had >or=3 lines of improvement (two eyes: five lines and six eyes three lines) at the final visit.

CONCLUSION

Transpupillary thermotherapy could be a therapeutic option in patients with chronic CSCR.

Imaging polarimetry in central serous chorioretinopathy

PURPOSE

To evaluate a noninvasive technique to detect the leakage point of central serous chorioretinopathy (CSR), using a polarimetry method.

DESIGN

Prospective cohort study.

METHODS

SETTING

Institutional practice.

PATIENTS

We examined 30 eyes of 30 patients with CSR.

MAIN OUTCOME MEASURES

Polarimetry images were recorded using the GDx-N (Laser Diagnostic Technologies). We computed four images that differed in their polarization content: a depolarized light image, an average reflectance image, a parallel polarized light image, and a birefringence image. Each polarimetry image was compared with abnormalities seen on fluorescein angiography.

RESULTS

In all eyes, leakage area could be clearly visualized as a bright area in the depolarized light images. Michelson contrasts for the leakage areas were 0.58 +/- 0.28 in the depolarized light images, 0.17 +/- 0.11 in the average reflectance images, 0.09 +/- 0.09 in the parallel polarized light images, and 0.11 +/- 0.21 in the birefringence images from the same raw data. Michelson contrasts in depolarized light images were significantly higher than for the other three images (P < .0001, for all tests, paired t test). The fluid accumulated in the retina was well-visualized in the average and parallel polarized light images.

CONCLUSIONS

Polarization-sensitive imaging could readily localize the leakage point and area of fluid in CSR. This may assist with the rapid, noninvasive assessment of CSR.

ACUTE CENTRAL SEROUS CHORIORETINOPATHY AND FUNDUS AUTOFLUORESCENCE

OBJECTIVES

To describe fundus autofluorescence (FAF) in a series of patients with acute central serous chorioretinopathy (CSC).

METHODS

Nine eyes of six patients with acute CSC were evaluated with fluorescein angiography (FA) and FAF imaging to evaluate the nature of the focal retinal pigment epithelial (RPE) leak evident with FA.

RESULTS

All nine eyes in this series demonstrated hypo-autofluorescence corresponding precisely to the site of the focal RPE leak seen on FA.

CONCLUSIONS

In this group of patients, the acute focal RPE leaks seen with FA corresponded precisely to an area of hypo-autofluorescence imaged with FAF. This observation supports the concept that a mechanical defect or absence of the RPE accounts for the leakage from the inner choroid to the sub-neurosensory space in CSC. FAF is also a useful noninvasive diagnostic adjunct to identify the focal RPE leak in patients with acute CSC.

Molecular contrast optical coherence tomography: a review

This article reviews the current state of research on the use of molecular contrast agents in optical coherence tomography (OCT) imaging techniques. After a brief discussion of the basic principle of OCT and the importance of incorporating molecular contrast agent usage into this imaging modality, we shall present an overview of the different molecular contrast OCT (MCOCT) methods that have been developed thus far. We will then discuss several important practical issues that define the possible range of contrast agent choice, the design criteria for engineered molecular contrast agent and the implementability of a given MCOCT method for clinical or biological applications. We will conclude by outlining a few areas of pursuit that deserve a greater degree of research and development.

Fluorescein angiographic features of asymptomatic eyes in central serous chorioretinopathy

PURPOSE

Analysis of the fundus and fluorescein angiography (FA) features of the asymptomatic eyes in patients of central serous chorioretinopathy (CSC) at initial visit and estimation of the overall magnitude of bilateral pathology.

METHODS

Retrospective observational case series that reviewed the medical records and FA features of 229 consecutive patients between January 1999 and December 2001.

RESULTS

Seventy-three (31.88%) patients had symptoms in one eye but signs in both the eyes, of which 70 were selected. Bilateral symptomatic CSC was seen in 29 (12.66%). Thus, overall bilateral involvement was found in 102 (44.54%) patients. FA features of asymptomatic eyes were pigment epithelial detachment (32.85%), fluorescein leak (31.42%), window defect (31.42%), depigmented patches (14.29%), drusen-like deposits (12.85%), pigment clumps (4.29%), retinal pigment epithelial atrophy (4.28%), subretinal precipitate (2.85%), and sensory retinal detachment (5.71%). Forty-three (61.43%) had evidence of chronic subclinical CSC, whereas 27(38.57%) had features of clinically healed CSC. CSC developed in the asymptomatic eyes within 3 to 12 months in four of the 24 followed-up patients.

CONCLUSION

Considerable number of asymptomatic eyes had features suggestive of healed or chronic subclinical CSC. These eyes are at risk for CSC caused by occurrence of active leak(s) from the same or new site(s).

Comparative evaluation of diode laser versus argon laser photocoagulation in patients with central serous retinopathy: a pilot, randomized controlled trial [ISRCTN84128484]

BACKGROUND

To evaluate the efficacy of diode laser photocoagulation in patients with central serous retinopathy (CSR) and to compare it with the effects of argon green laser.

METHODS

Thirty patients with type 1 unilateral CSR were enrolled and evaluated on parameters like best corrected visual acuity (BCVA), direct and indirect ophthalmoscopy, amsler grid for recording scotoma and metamorphopsia, contrast sensitivity using Cambridge low contrast gratings and fluorescein angiography to determine the site of leakage. Patients were randomly assigned into 2 groups according to the statistical random table using sequence generation. In Group 1 (n = 15), diode laser (810 nm) photocoagulation was performed at the site of leakage while in Group 2 (n = 15), eyes were treated with argon green laser (514 nm) using the same laser parameters. Patients were followed up at 4, 8 and 12 weeks after laser.

RESULTS

The mean BCVA in group 1 improved from a pre-laser decimal value of 0.29 +/- 0.14 to 0.84 +/- 0.23 at 4 weeks and 1.06 +/- 0.09 at 12 weeks following laser. In group 2, the same improved from 0.32 +/- 0.16 to 0.67 +/- 0.18 at 4 weeks and 0.98 +/- 0.14 at 12 weeks following laser. The improvement in BCVA was significantly better in group 1 (p < 0.0001) at 4 weeks. At 4 weeks following laser, all the patients in group1 were free of scotoma while 6 patients in group 2 had residual scotoma (p < 0.05). The mean contrast sensitivity in group 1 improved from pre-laser value of 98.4 +/- 24.77 to 231.33 +/- 48.97 at 4 weeks and 306.00 +/- 46.57 at 12 weeks following laser. In group 2, the same improved from 130.66 +/- 31.95 to 190.66 +/- 23.44 at 4 weeks and 215.33 +/- 23.25 at 12 weeks. On comparative evaluation, a significantly better (p < 0.001) improvement was noted in group 1.

CONCLUSION

Diode laser may be a better alternative to argon green laser whenever laser treatment becomes indicated in patients with central serous retinopathy in terms of faster visual rehabilitation and better contrast sensitivity. In addition, diode laser also has the well-recognized ergonomic and economic advantages.

Five to 15 year follow-up of resolved idiopathic central serous chorioretinopathy

PURPOSE

To recognize the long-term sequelae of resolved idiopathic central serous chorioretinopathy (ICSC) in relation to visual acuity, contrast sensitivity, and lesion size between time elapsed since disease onset.

METHODS

Patients were recruited from fluorescein angiogram records between January 1985 and December 1995 with confirmed ICSC. Visual acuity, contrast sensitivity, and digital fundus photographs were recorded on follow-up. Comparison with the initial red-free photographs were made.

RESULTS

There was no statistically significant deterioration of visual acuity over time compared to eyes with ICSC after initial resolution and the normal eyes. The change of lesion size over time was also statistically insignificant. Contrast sensitivity compared to visual acuity showed positive correlation in both ICSC and normal eyes, but the results were statistically insignificant. Lesion size correlates negatively with visual acuity and contrast sensitivity although this was statistically insignificant.

CONCLUSION

This study shows little, if any, correlation between time and progression of retinal pigment epitheliopathy following resolution of ICSC. Visual acuity did not seem to worsen over time. Our data were not statistically significant, but it does give insight into the natural history of what is still a relatively poorly understood disease.

Photodynamic therapy for chronic central serous chorioretinopathy

PURPOSE

To determine whether photodynamic therapy (PDT) is effective for treatment of chronic central serous chorioretinopathy (CSC).

METHODS

Sixteen eyes with chronic CSC and macular detachment documented by optical coherence tomography (OCT) received PDT guided by indocyanine green (ICG) angiography according to the parameters outlined in the TAP Study. One or more laser spots were applied to the areas of choroidal vascular hyperpermeability that corresponded to retinal pigment epithelium decompensation. Patients were observed for 6 to 12 months. Two PDT sessions 1 month apart were performed on 2 eyes. Examinations included visual acuity measurement, fundus biomicroscopy, fluorescein and ICG angiography, and OCT.

RESULTS

Macular exudation resolved completely in 13 eyes (81%) and partially regressed in 3. Choriocapillaris hypoperfusion was shown by ICG angiography for several months at the site of PDT application. Visual acuity improved 1 to 4 lines in 11 eyes and was unchanged in 5 eyes.

CONCLUSIONS

ICG-guided PDT performed according to the parameters outlined by the TAP Study seems effective for treating chronic CSC. Further studies are needed to verify treatment safety and the time and rate of recurrences.

Choroidal vascular remodelling in central serous chorioretinopathy after indocyanine green guided photodynamic therapy with verteporfin: a novel treatment at the primary disease level

AIMS

To evaluate the changes in the choroidal vasculature in central serous chorioretinopathy (CSC) after photodynamic therapy (PDT) with verteporfin and to assess its potential role as a treatment option.

METHODS

A prospective, non-comparative, interventional study was performed in eyes with persistent CSC or chronic CSC that had fluorescein leakage at the fovea. All eyes received one single session of PDT with verteporfin (6 mg/m2 body surface area) followed by application of 50 J/cm2 laser at 689 nm. The laser spot size was guided by findings in ICG-A.

RESULTS

Six eyes from six patients with a mean follow up of 12.7 months were analysed. Narrowing of the original dilated choroidal vessels and decrease in extravascular leakage could be demonstrated in all (100%) PDT treated eyes. 3 months after PDT, the mean diameter of the dilated choroidal vessel reduced from 546 microm to 371 microm (p=0.028). Five (83%) patients had improvement in visual symptoms and best corrected visual acuity. Fluorescence leakage stopped at the 1 month follow up in five eyes (83%) and at 3 months in all six eyes (100%). One eye developed choroidal neovascularisation at 3 month follow up. There was no other serious ocular or systemic complication.

CONCLUSIONS

PDT is successful in stopping the fluorescein leakage in all six patients without recurrence of CSC. The ICG-A findings of choroidal vascular remodelling and decreased choroidal permeability after PDT are encouraging. As the sample size is small and the mean follow up period is short, further trials of PDT with verteporfin for CSC are required to address the optimal parameters in ensuring longer term safety and efficacy outcome.

Treatment of choroidal neovascularization in central serous chorioretinopathy by photodynamic therapy with verteporfin

PURPOSE

To evaluate the safety and efficacy of photodynamic therapy (PDT) with verteporfin in the treatment of patients with choroidal neovascularization (CNV) secondary to central serous chorioretinopathy (CSC).

DESIGN

Open-label, two-center, noncomparative, prospective interventional case series.

METHODS

Consecutive patients with subfoveal or juxtafoveal CNV secondary to CSC were recruited and treated with a standard regimen of PDT with verteporfin. At regular 3-month follow-up examinations, re-treatment was considered if fluorescein angiography showed evidence of leakage. Outcome measures included the proportion of patients who had improvement (gained 2 more lines), stable, or loss (dropped in 2 or more lines) in vision at the final follow-up and the changes in best-corrected visual acuity (BCVA) from baseline.

RESULTS

Ten eyes of 10 patients were recruited into the study. The mean age of the patients was 57.3 years with a mean follow-up duration of 12.6 months. At the last follow-up, six (60%) eyes gained 2 or more lines of BCVA with four (40%) patients having final BCVA of within 1 line. No patient lost 2 or more lines of BCVA. The mean logarithm of the minimal angle of resolution BCVA improvement after PDT was 2.4 lines (Wilcoxon signed-rank test, P =.013). No patient suffered serious ocular or systemic complications from PDT.

CONCLUSIONS

Photodynamic therapy with verteporfin therapy is a safe and well-tolerated treatment in patients with CNV associated with CSC. A randomized, controlled trial with a longer follow-up period is warranted to further study the efficacy of PDT in the management of CNV secondary to CSC.

Indocyanine green angiography-guided photodynamic therapy for treatment of chronic central serous chorioretinopathy: a pilot study

BACKGROUND

Most patients with central serous chorioretinopathy (CSC) have spontaneous resolution of exudative macular detachments and a good visual prognosis. Patients with CSC have a primary choroidal hyperpermeability problem evident as multifocal areas of hyperpermeability during indocyanine green (ICG) angiography. A small percentage of patients develop chronic or progressive disease with widespread decompensation of the retinal pigment epithelium and severe vision loss. There is no known treatment for this variant of the disorder.

PURPOSE

To study ICG-guided photodynamic therapy (PDT) with verteporfin as a potential treatment for patients with chronic CSC.

METHODS

Twenty eyes of 15 patients were studied with fluorescein angiography, optical coherence tomography, and ICG angiography to diagnose the maculopathy, monitor the detachments, and localize the choroidal hyperpermeability of the disorder. PDT with ICG guidance was applied to areas of choroidal hyperpermeability, and the patients were observed to determine the anatomic and functional outcomes.

RESULTS

Photodynamic therapy guided by ICG was associated with complete resolution of exudative macular detachments in 12 patients and incomplete resolution in the remaining eight eyes. The vision improved in six eyes and remained unchanged in 14 eyes during a mean follow-up of 6.8 months. Six weeks after treatment, the mean visual acuity improved by 0.55 lines, an amount that was marginally significant. There was a significant inverse correlation between the baseline visual acuity and the amount of improvement in acuity at 6 weeks. No patient had any treatment-related side effects.

CONCLUSIONS

Indocyanine green angiography-guided PDT with verteporfin seems to aid in the resolution of exudative detachments in patients with chronic CSC. This treatment was associated with a rapid reduction in subretinal fluid and improvement in visual acuity. Although the follow-up time and number of patients in this pilot study were limited, the encouraging results and lack of complications suggest that further study is indicated.

Cystoid macular degeneration in chronic central serous chorioretinopathy

PURPOSE

To describe the optical coherence tomography (OCT) and fluorescein angiography findings in the macula of eyes with chronic central serous chorioretinopathy (CSC) and reduced central vision.

METHODS

Using OCT, clinical examination, and fluorescein and indocyanine green (ICG) angiography, the authors examined eight eyes of seven patients with CSC, an attached macula, and reduced central vision of 20/200 or worse. All had a history of chronic CSC with resolution of the subretinal fluid in the macular area and poor vision.

RESULTS

Patient ages ranged from 55 to 82 years (mean, 66 years). All eight eyes had some parafoveal, patchy RPE atrophy with corresponding transmission hyperfluorescence (window defect) on fluorescein angiography. Five eyes also had a window defect in the foveal area. With OCT, the foveal area revealed variable areas of cystoid change and atrophy in seven of the eight eyes. In four of these eyes, the cystoid changes were not seen on clinical examination or fluorescein angiography. The seven eyes with cystoid changes imaged with OCT had no intraretinal leakage of fluorescein in the foveal region. The authors categorized these eyes as having cystoid macular degeneration (CMD). One other eye had foveal thinning or atrophy without cystoid changes.

CONCLUSIONS

Intraretinal cystoid spaces without intraretinal leakage, or CMD, was a common finding in eyes with chronic CSC and reduced central vision after resolution of subretinal fluid. OCT was useful to establish the presence of CMD and foveal atrophy, even when these changes were not clearly evident on clinical examination or fluorescein angiography. Chronic foveal detachment and antecedent intraretinal leakage were proposed to be the mechanisms for the development of the changes. CMD in conjunction with foveal atrophy was an important clinical finding to account for the poor visual outcome in patients with CSC.

Corticosteroids and central serous chorioretinopathy

PURPOSE

The purpose of this study is to investigate the relationship between corticosteroid use and central serous chorioretinopathy (CSC).

DESIGN

A prospective, case-controlled study.

PARTICIPANTS AND CONTROLS

A consecutive series of patients with acute manifestations of CSC and a control group matched for age, race, and gender were recruited between January 2000 and July 2000.

METHODS

A detailed clinical history was taken, and fundus examination with slit-lamp biomicroscopy was performed on all patients. Fluorescein angiography was obtained on the study patients.

RESULTS

A total of 50 patients was recruited. Twenty-six patients (52%) had a history of exogenous steroid use, including oral, intravenous, intranasal, and intraarticular administration. Two additional patients had a history of endogenous hypercortisolism (Cushing's syndrome). In a matched control group, eight patients (18%) had a history of steroid use. The difference in corticosteroid exposure between study patients and controls was statistically significant (P < 0.0001).

MAIN OUTCOME MEASURES

History of corticosteroid use or Cushing's syndrome.

CONCLUSIONS

This study is consistent with previous reports associating steroid use with CSC. It identifies corticosteroids as a significant risk factor for the development of acute, exudative macular manifestation and implicates hypercortisolism as a factor in the pathogenesis of this disorder. Several forms of corticosteroid administration were observed to be a risk factor for CSC. Accordingly, susceptible patients in need of corticosteroids should be advised of the risk of developing acute manifestations of CSC.

Central serous chorioretinopathy and glucocorticoids

Central serous chorioretinopathy is a relatively common retinal disease characterized by the accumulation of subretinal fluid at the posterior pole of the fundus, creating a circumscribed area of serous retinal detachment. It typically affects young and middle-aged men with no previous medical and family history, and no systemic symptoms or signs. However, it has been noted that central serous chorioretinopathy is associated with different conditions, characterized by exposure to increased levels of endogenous or exogenous glucocorticoids. In fact, central serous chorioretinopathy has been described in patients with endogenous Cushing's syndrome. It is also prevalent in patients with type-A behavior, and following stressful events, and pregnancy probably represents a risk factor for central serous chorioretinopathy; these conditions are characterized by endogenous hypercortisolism. In addition, many cases of central serous chorioretinopathy have been described during or following treatment with glucocorticoids, administrated by any route, for various systemic or ocular conditions. Central serous chorioretinopathy, when related to the exposure to exogenous glucocorticoids, has a less prominent male predilection, presents more often with a chronic or atypical form, and is frequently bilateral. Furthermore, treatment of central serous chorioretinopathy with glucocorticoids was found to exacerbate the clinical picture. Based on these observations it could be suggested that glucocorticoids may be involved in the development of central serous chorioretinopathy, even though the exact pathogenic mechanism remains unclear. Glucocorticoids should not be used in the treatment of central serous chorioretinopathy and central serous chorioretinopathy should be added to the list of ocular complications of glucocorticoids.

Factors associated with reduced visual acuity during long-term follow-up of patients with idiopathic central serous chorioretinopathy

PURPOSE

To investigate factors associated with reduced visual acuity during long-term follow-up of patients with idiopathic central serous chorioretinopathy (ICSC).

METHODS

Retrospective consecutive case series that included patients with ICSC who were younger than 50 years of age at the time of initial examination and were followed up for > or =3 years.

RESULTS

The mean follow-up for 101 involved eyes of 61 patients was 9.8 years (median, 8.0 years). Eyes were stratified into two groups based on visual acuity at the final examination: Group 1, visual acuity of 2040 or better; and Group 2, visual acuity of worse than 2040. Findings identified as potential risk factors for reduced vision at the final follow-up examinations for Group 1 versus Group 2 included the following: macular retinal pigment epithelium atrophy (90.8% versus 96.0%, respectively; P = 0.68); persistent pigment epithelial detachment or persistent subretinal fluid (5.3% versus 28.0%, respectively; P = 0.004); recurrences (39.5% versus 68.0%, respectively; P = 0.020); laser treatment (28.9% versus 32.0%, respectively; P = 0.80); and submacular choroidal neovascularization (0.0 versus 8.0%, respectively; P = 0.059).

CONCLUSIONS

Factors associated with reduced visual acuity during long-term follow-up of patients with ICSC included persistent pigment epithelial detachment and/or subretinal fluid, recurrences, and submacular choroidal neovascularization.

Long-term follow-up of idiopathic central serous chorioretinopathy without laser

PURPOSE

The purpose of this study was to observe the varied types of manifestations in the fundus of patients with idiopathic central serous chorioretinopathy (ICSC) without laser treatment and also to assess the ultimate visual outcome in such cases in a long-term follow-up ranging from 7 to 23 years.

METHODS

This study is confined to 5 selected cases of ICSC which fairly represent the different types of late stage manifestations of the disease in the fundus. Case records from our hospital, as well as available records of previous treatment elsewhere were reviewed. A complete ophthalmological examination, routine laboratory investigations and fluorescein fundus angiography (FFA) were repeated in each case on the day of final evaluation.

RESULTS

Pigmentary disturbances in the macular area resembling to some extent age-related macular degeneration (AMD), extensive retinal pigment epithelial (RPE) atrophy and macular haemorrhage have been observed in the fundus of the reviewed cases.

CONCLUSIONS

ICSC runs an unpredictable course and there are no definitive clinical clues to predict its ultimate outcome. Recurrence of the condition is a possibility for a considerable period of time.

Polypoidal choroidal vasculopathy masquerading as central serous chorioretinopathy

OBJECTIVE

To differentiate polypoidal choroidal vasculopathy (PCV) from central serous chorioretinopathy (CSC).

DESIGN

A retrospective, observational case series.

PARTICIPANTS

Thirteen patients originally diagnosed with CSC proved to have PCV after more extensive evaluation and follow-up.

METHODS

A clinical and angiographic review of patients with manifestations of CSC, including macular detachment.

MAIN OUTCOME MEASURES

Demographic data, funduscopic examination, and fluorescein and indocyanine green (ICG) angiographic findings.

RESULTS

Thirteen patients initially suspected of having CSC were ultimately diagnosed as having PCV. These eyes had exudative macular detachments secondary to a small caliber, polypoidal choroidal vascular abnormality or so-called polypoidal choroidal neovascularization. The clinical manifestations in the fundus varied. They included multiple, variably sized serous pigment epithelial detachments, neurosensory retinal detachment, lipid deposition, patchy atrophy of the pigment epithelium and indistinct staining from decompensation of the posterior blood-retinal barrier on fluorescein angiography. In reality, the suspected PEDs proved to be polypoidal lesions of PCV when imaged with ICG angiography.

CONCLUSIONS

The clinical diagnosis of CSC or PCV generally poses little challenge to the experienced retinal specialist. However, in CSC with persistent and/or recurrent exudation, a myriad of retinal pigment epithelial changes may evolve that make it difficult to differentiate these two entities. In such patients, ICG angiography is useful in differentiating CSC from PCV. An accurate clinical diagnosis is important since each of these entities, CSC and PCV, may differ in terms of their risk factors, natural course, and visual prognosis.

Long-term follow-up of severe central serous chorioretinopathy using indocyanine green angiography

BACKGROUND

The severe types of central serous chorioretinopathy (CSC) have a chronic nature, suggesting that a pathological process persists subclinically. Indocyanine green (ICG) angiography recently revealed intrachoroidal dye leakage and its static nature in CSC. As the intrachoroidal dye leakage was suspected to be relevant to the disease process, the long-term persistence of intrachoroidal ICG leakage was examined in four patients of the severe types of CSC.

METHODS

ICG angiography was performed periodically over more than three years in three patients and two years in one patient. One patient had CSC with bullous retinal detachment, and the other three had chronic CSC or diffuse retinal pigment epitheliopathy.

RESULTS

Intrachoroidal ICG leakage persisted in all the patients. However, a change in location of persistent intrachoroidal leakage or disappearance of intrachoroidal leakage regardless of no progression of retinal pigment epithelial alteration was noted in one eye of two patients.

CONCLUSIONS

Pathology causing intrachoroidal ICG leakage persisted subclinically for a long period. However, location and extent of the intrachoroidal leakage could change during a long-term follow-up period.

Laser photocoagulation for persistent central serous retinopathy: results of long-term follow-up

PURPOSE

The authors evaluated the effect of laser photocoagulation for persistent central serous retinopathy (CSR).

METHODS

The authors evaluated 45 eyes of 38 patients who had been offered laser photocoagulation for CSR that did not resolve after 4 months of observation. Sixteen eyes of 14 patients who did not accept laser photocoagulation were followed as the control group. The remaining 29 eyes of 24 patients comprised the study group. Argon green laser photocoagulation was performed on 9 eyes, dye-yellow laser photocoagulation was performed on 12 eyes, and dye-orange laser photocoagulation was performed on 8 eyes. Mean follow-up was 4.8 years (range, 1-7 years).

RESULTS

In the group that received laser treatment, duration of the serous detachment was shorter (P < 0.0001) and final best-corrected visual acuity (BCVA) was better (P = 0.006) than those of the control group. Although none of the eyes in the laser photocoagulation group had a recurrence, seven eyes in the control group had one or more recurrences during the mean follow-up period of 4.8 years (P = 0.0003). Although the duration of the serous detachment was shorter in the dye-yellow laser photocoagulation subgroup than in the argon green laser treatment subgroup (P = 0.01), there were no other differences between the laser photocoagulation subgroups with respect to the duration of the serous detachments or the final BCVA.

CONCLUSION

Direct laser photocoagulation of the leakage site(s) for CSR that persists for 4 months is safe and effective to shorten the duration of the serous detachment, to improve final BCVA, and to decrease the incidence of recurrence.

Central serous chorioretinopathy in women

BACKGROUND

Central serous chorioretinopathy is a disorder that typically affects young and middle-aged men. Although extensive information is available pertaining to the clinical features of central serous chorioretinopathy in men, little is known about this condition in women.

MATERIALS AND METHODS

The authors reviewed the medical records and photographic files of women who received a diagnosis of central serous chorioretinopathy. The women were divided into three groups for data analysis: idiopathic, exogenous corticosteroid use, and pregnancy.

RESULTS

Fifty-one women with active central serous chorioretinopathy were evaluated. These findings in women with idiopathic serous chorioretinopathy were similar to those described in men, with the exception that women tend to be older at the time of onset. Central serous chorioretinopathy in women taking exogenous corticosteroids more likely was characterized by bilateral involvement and subretinal fibrin. Central serous chorioretinopathy in pregnant women typically developed in the third trimester and resolved spontaneously within 1-2 months after delivery.

CONCLUSION

Idiopathic central serous chorioretinopathy is similar in women and men, with the exception that women tend to be more older at the time of onset. The finding of exogenous corticosteroid use in a significant number of women in our study provides further support that cortisol may play a role in the development of central serous chorioretinopathy. The mechanism by which cortisol influences the development of central serous chorioretinopathy is unclear.

Subretinal fibrosis in central serous chorioretinopathy

PURPOSE

To report unusual and heretofore unreported visually damaging manifestations of severe central serous chorioretinopathy.

METHODS

Case studies.

RESULTS

Each of six male patients (average age, 40 years) had a form of severe central serous chorioretinopathy with at least one eye containing fibrin in the subretinal space that then developed into a subretinal fibrotic scar. Scar formation was followed by a tenting up of the macula, vascularization of the fibrosis (subretinal neovascularization), or a retinal pigment epithelial rip. Four of the seven eyes with subretinal fibrosis had severe visual loss (20/400 or worse).

CONCLUSION

Subretinal fibrin and other extracellular matrix molecules appear to stimulate the retinal pigment epithelium to undergo fibrous metaplasia, which results in subretinal fibrotic scar formation and other sequelae, all of which can lead to severe visual loss.

Indocyanine green angiographic findings in central serous chorioretinopathy

The purpose of this study is to better characterise, on the basis of a large number of cases and follow-up evaluations, choroidal abnormalities recently observed with indocyanine green (ICG) angiography in central serous chorioretinopathy (CSC). Digital ICG videoangiography was performed in 145 patients with active or inactive, acute or chronic CSC. Forty-eight patients were re-examined in a follow-up period of 6-22 months (mean 10 months). Areas of choroidal leakage attributable to hyperpermeability of the choriocapillaris were found in 98.6% of patients in association with active or resolved pigment epithelial leaks and pigment epithelial detachments. Diffusion of ICG into the choroid was characterised by rapid centrifugal spreading of the dye with a wash-out pattern which was particularly evident in areas corresponding to pigment epithelial detachments. In patients with a long-standing disease, when choroidal hyperfluorescence faded, hypofluorescent spots became increasingly evident revealing pigment epithelial alterations not shown by fluorescein angiography. Areas of choroidal leakage remained unchanged in each patient during the follow-up period, even when subretinal exudation resolved either spontaneously or after photocoagulation. In 5 eyes we observed the appearance of leakage points on pre-existing areas of choroidal leakage. Zonal hyperpermeability of the choriocapillaris characterises all the evolutional stages of CSC and seems to be the primary alteration of this disease. When it corresponds to pigment epithelial detachments choriocapillaris hypermeability is probably associated with local hyperperfusion.

Long-term follow-up of central serous retinopathy in 150 patients

To study the evolution of the retinal pigment epithelial lesions in the central serous retinopathy, the authors studied 150 patients with ages between 20 and 49 years at the first examination, during periods varying between 6 months and 14 years. It was found a greater incidence of the disease in the males (83.3%); bilaterality in 23.3%; only one point of leakage in 62.7%; 3 different types of diffusion (inkblot 71.4%; mushroom 23.8%; with serous pigment epithelial detachment 4.9%). The final visual acuity was < 20/40 in a quarter of the cases and the frequency of the recurrences was 30%. The laser treatment did not influence the recurrences. In 50 patients with a follow-up superior to 3 years, 8 (16%) developed lesions similar to those described as diffuse retinal pigment epitheliopathy with visual field defects and subnormal EOG. Actuarial calculus suggests that 50% of the patients may get the most severe and extensive form of the disease after 12 years of evolution. The results allow to conclude that the diffuse retinal pigment epitheliopathy is only the terminal state of the most severe cases of central serous retinopathy.