The Incidence of Central Serous Chorioretinopathy in Olmsted County, Minnesota, 1980–2002

Relationship between heart failure and central serous chorioretinopathy: A cohort study in Taiwan

BACKGROUND

Both central serous chorioretinopathy (CSCR) and heart failure (HF) are disorders with a complex pathogenesis, whereas the two diseases might share similar pathogenesis. This study aimed to evaluate whether patients with HF are exposed to potential risk of CSCR by using the National Health Insurance Research Database (NHIRD).

METHODS

Data were collected from the NHIRD over a 14-year period. Variables were analyzed with the Pearson chi-square test and Fisher's exact test. The risk factors for disease development were examined by adjusted hazard ratio (aHR). Kaplan-Meier analysis was performed to compare the cumulative incidence of CSCR.

RESULTS

A total of 24 426 patients with HF were enrolled in the study cohort, and there were 24 426 patients without HF in the control cohort. The incidence rate of CSCR was higher in the study cohort than in the control cohort (aHR = 4.572, p < 0.001). CSCR occurred more commonly in males than in females. The overall incidence of CSCR was 30.07 per 100 000 person-years in the study cohort and 23.06 per 100 000 person-years in the control cohort. Besides, subgroup analysis revealed that no matter in gender or age group, HF patients were in an increased risk of CSCR diagnosis (male/female, aHR = 3.268/7.701; 20-59 years/≥60 years, aHR = 3.405/5.501, p < 0.001).

CONCLUSION

HF is a significant indicator for CSCR. Patients with HF should stay alert for potential disorder of visual impairment. Further prospective studies to investigate the relationship between HF and CSCR could provide more information.

Effect of altering the regime of oral rifampicin therapy in the treatment of persistent central serous chorioretinopathy

Objective:

To study the effect of reducing the duration of rifampicin therapy in the treatment of Chronic Central Serous Chorioretinopathy.

Methods:

This is interventional study conducted in Layton Rahmatullah Benevolent Trust, Free Base Eye Hospital Korangi, Karachi from February 2017 - December 2018. This randomized controlled comparative study included two groups, Groups-A comprised of 48 eyes of 40 cases with Chronic Central Serous Chorioretinopathy who were given reduced dose of oral rifampicin i.e. 600mg for one month, and Group-B consisted of 43 eyes of 40 controls with Chronic Central Serous Chorioretinopathy who were given reduced dose of oral rifampicin i.e. 300mg once daily for three months as previously stated in literature. To access the effect of therapy in both the groups, pre-treatment visual acuity on the logMAR and Optical Coherent Tomography (OCT, Heidelberg spectralis) for CMT were performed and repeated on the 1^st and 3^rd month post-treatment. Patients were also followed for 6 months to access any recurrence.

Results:

On comparing the two groups, Group-A had improvement in VA and CMT after one month therapy of Rifampicin, Pre-treatment mean VA in Group-A was 0.85 ± 0.19 as compared to the pre-treatment mean VA in Group-B i.e. 0.74+/- 0.208, while the pre-treatment mean CMT was 609.0 ± 178.29 µm in Group-A, and 600.0 +/- 155.09 µm in Group-B respectively. After 1 month of therapy, the visual status, and CMT in Group-A was 0.29+/- 0.21 and 311.6 +/- 89.9, while Group-B, VA was 0.598 +/- 0.23 (p value 0.001%) and CMT was 512.30 +/- 148.37 (p-value 0.001%). Rifampicin was continued in Group-B till three months, and patients were re-accessed but there was no difference in VA and CMT statically. During the 3^rd and 6^th months of follow up no relapses were reported.

Conclusion:

This comparative study showed that the group receiving oral rifampicin 600mg for one month showed better outcome at one month and third month than the group receiving oral rifampicin at a dose of 300mg once daily for three months. This gives a better compliance and lower the risk of drug induced side effects.

Central serous chorioretinopathy: Towards an evidence-based treatment guideline

Central serous chorioretinopathy (CSC) is a common cause of central vision loss, primarily affecting men 20-60 years of age. To date, no consensus has been reached regarding the classification of CSC, and a wide variety of interventions have been proposed, reflecting the controversy associated with treating this disease. The recent publication of appropriately powered randomised controlled trials such as the PLACE trial, as well as large retrospective, non-randomised treatment studies regarding the treatment of CSC suggest the feasibility of a more evidence-based approach when considering treatment options. The aim of this review is to provide a comprehensive overview of the current rationale and evidence with respect to the variety of interventions available for treating CSC, including pharmacology, laser treatment, and photodynamic therapy. In addition, we describe the complexity of CSC, the challenges associated with treating CSC, and currently ongoing studies. Many treatment strategies such as photodynamic therapy using verteporfin, oral mineralocorticoid antagonists, and micropulse laser treatment have been reported as being effective. Currently, however, the available evidence suggests that half-dose (or half-fluence) photodynamic therapy should be the treatment of choice in chronic CSC, whereas observation may be the preferred approach in acute CSC. Nevertheless, exceptions can be considered based upon patient-specific characteristics.

Role of the Complement System in Chronic Central Serous Chorioretinopathy: A Genome-Wide Association Study

Importance

To date, several targeted genetic studies on chronic central serous chorioretinopathy (cCSC) have been performed; however, unbiased genome-wide studies into the genetics of cCSC have not been reported. To discover new genetic loci associated with cCSC and to better understand the causative mechanism of this disease, we performed a genome-wide association study (GWAS) on patients with cCSC.

Objective

To discover new genetic loci and pathways associated with cCSC and to predict the association of genetic variants with gene expression in patients with cCSC.

Design, Setting, and Participants

This case-control GWAS was completed in the general community, 3 referral university medical centers, and outpatient care on Europeans individuals with cCSC and population-based control participants. Genotype data was collected from May 2013 to August 2017, and data analysis occurred from August 2017 to November 2017.

Main Outcomes and Measures

Associations of single-nucleotide polymorphisms, haplotypes, genetic pathways, and predicted gene expression with cCSC.

Results

A total of 521 patients with cCSC (median age, 51 years; interquartile range [IQR], 44-59 years; 420 [80.6%] male) and 3577 European population-based control participants (median age, 52 years; IQR, 37-71 years; 1630 [45.6%] male) were included. One locus on chromosome 1 at the complement factor H (CFH) gene reached genome-wide significance and was associated with an increased risk of cCSC (rs1329428; odds ratio [OR], 1.57 [95% CI, 1.38-1.80]; P = 3.12 × 10-11). The CFH haplotypes H1 and H3 were protective for cCSC (H1: OR, 0.64 [95% CI, 0.53-0.77]; P = 2.18 × 10-6; H3: OR, 0.54 [95% CI, 0.42-0.70]; P = 2.49 × 10-6), whereas haplotypes H2, H4, H5, and the aggregate of rare CFH haplotypes conferred increased risk (H2: OR, 1.57 [95% CI, 1.30-1.89]; P = 2.18 × 10-6; H4: OR, 1.43 [95% CI, 1.13-1.80]; P = 2.49 × 10-3; H5: OR, 1.80 [95% CI, 1.36-2.39]; P = 4.61 × 10-5; rare haplotypes: OR, 1.99 [95% CI, 1.43-2.77]; P = 4.59 × 10-5). Pathway analyses showed involvement of the complement cascade and alternative open reading frame (ARF) pathway in cCSC. Using PrediXcan, we identified changes in predicted expression of complement genes CFH, complement factor H related 1 (CFHR1), complement factor related 4 (CFHR4), and membrane cofactor protein (MCP/CD46). Additionally, the potassium sodium-activated channel subfamily T member 2 (KCNT2) and tumor necrosis factor receptor superfamily member 10a (TNFRSF10A) genes were differentially expressed in patients with cCSC.

Conclusions and Relevance

In this GWAS on cCSC, we identified a locus on chromosome 1 at the CFH gene that was significantly associated with cCSC, and we report protective and risk-conferring haplotypes in this gene. Pathway analyses were enriched for complement genes, and gene expression analysis suggests a role for CFH, CFHR1, CFHR4, CD46, KCNT2, and TNFRSF10A in the disease. Taken together, these results underscore the potential importance of the complement pathway in the causative mechanisms of cCSC.

Association of Corticosteroid Use With Incidence of Central Serous Chorioretinopathy in South Korea

Importance

Information on the incidence of central serous chorioretinopathy (CSC) in individuals who receive corticosteroids is scarce but clinically important because these agents are useful and widely used.

Objective

To estimate the annual and 5-year incidence of CSC in South Korea in the overall population and in those who have used corticosteroid medications.

Design, Setting, and Participants

A cohort study of a population-based random sample included East Asian adults for whom records are held in the Korean National Health Insurance Service database for calendar years 2011 through 2015. The data analysis was performed from July 1, 2017 to January 5, 2018.

Exposures

Any type of corticosteroid use from 2002 through 2015.

Main Outcomes and Measures

Incidence of CSC.

Results

The data set contained data from 868 939 adults (4 117 768 person-years). From 2011 through 2015, 1423 individuals (among whom the mean [SD] age was 46.8 [16.4] years and 1091 [76.7%] were male) with newly diagnosed CSC were identified. From 2002 to 2015, 783 099 individuals in the data set (90.1%) had ever used corticosteroids. The incidence of CSC per 10 000 person-years was 3.5 (5.4 in men; 1.6 in women) among the total population, 2.5 (3.0 in men; 1.2 in women) in those who had never used corticosteroids, and 3.6 (5.7 in men; 1.6 in women) among those who had ever used corticosteroids. The risk of CSCR with individuals who had ever used corticosteroids was estimated as an adjusted hazard ratio of 1.81 (95% CI, 1.47-2.23) compared with those who have never used these drugs. Current or recent corticosteroid use showed a positive association with the incidence of CSC (depending on duration of use, adjusted hazard ratio ranged from 1.54 to 2.15). Corticosteroid use in 2006 through 2009 was associated with an increased incidence of CSC after 2011 (adjusted hazard ratio 1.57 [95% CI, 1.13-2.18]).

Conclusions and Relevance

In 2002 through 2015, 90.1% of adults in Korea received corticosteroids at least once. Although there was a clear difference in relative risk, this data analysis could not replicate the more than 30-fold increase in the risk ratio of CSC that has been reported previously. The incidence of CSC in the most vulnerable group, middle-aged men, was estimated to be approximately 1 case per 1000 corticosteroid users in the year following medication use. The overall incidence among those who had ever used corticosteroids and those who had never used these drugs was 2.5 and 3.6 per 10 000 person-years, respectively. This study provides additional evidence to support the potential role of corticosteroids in CSC.

Central serous chorioretinopathy: risk factors for serous retinal detachment in fellow eyes

Background/Aims

To assess risk factors for serous retinal detachment (SRD) in the fellow eye of patients with central serous chorioretinopathy (CSC) based on clinical data and multimodal imaging findings, including baseline late-phase indocyanine green angiography (ICGA).

Methods

Consecutive patients with unilateral CSC were retrospectively assessed. Inclusion criteria were the availability of late-phase ICGA and a spectral-domain optical coherence tomography (OCT) macular cube for both eyes at baseline and over 3 months. Subsequent OCT of fellow eyes was reviewed to detect the development of SRD during the follow-up. Baseline medical data and multimodal imaging findings were analysed using Kaplan-Meier survival curves (log-rank test).

Results

Sixty-eight patients with unilateral CSC were included. An SRD was detected in 19% of fellow eyes during a mean follow-up of 25.8±18.7 months. Hyperfluorescent plaques on midphase ICGA, hypofluorescent foci on late-phase ICGA, retinal pigment epithelium changes on fundus autofluorescence and fluorescein angiography abnormalities were associated with the occurrence of SRD (log-rank test; p<0.001, p=0.02, p=0.002 and p=0.001, respectively).

Conclusion

These results suggest that the fellow eyes with specific findings on multimodal imaging in patients with unilateral CSC should be carefully followed up for possible incidence of CSC.

Optical Coherence Tomography Parameters as Predictors of Treatment Response to Eplerenone in Central Serous Chorioretinopathy

Purpose: To present data on clinical response to eplerenone over a 1-year period in patients with central serous chorioretinopathy (CSC), and to evaluate optical coherence tomography (OCT) variables as predictors of treatment response at 3- and 12-month follow-up visits. Methods: Patients with acute or chronic CSC treated with eplerenone were retrospectively included. Clinical and imaging characteristics were recorded at baseline and at the 3-month and 12-month follow-up visits. Changes from baseline in quantitative measurements were calculated at each follow-up. Logistic regression analysis was computed to correlate clinical and OCT parameters at baseline with response to treatment at 3 and 12 months of follow-up. Results: A total of 50 eyes of 50 patients were included in the study. Mean ± SD best corrected visual acuity (BCVA) was 0.20 ± 0.14 Logarithm of the Minimum Angle of Resolution (LogMAR) at baseline and significantly improved at both the 3-month (0.12 ± 0.13 LogMAR, p < 0.0001) and 12-month (0.10 ± 0.12 LogMAR, p < 0.0001) follow-up visits. At the 3-month follow-up visit, 25 out of 50 eyes (50.0%) demonstrated macular complete subretinal fluid (SRF) resolution, while 13 eyes (26.0%) showed macular partial SRF resolution, and 12 eyes (24%) had neither partial nor complete macular SRF resolution. Among those patients with macular partial or complete SRF resolution at 3 months and thus not shifted to photodynamic therapy, 36 out of 38 cases had macular complete SRF resolution at the 12-month follow-up visit. There was a significant change from baseline at both follow-up visits in all anatomical OCT parameters (except for reduction in choroidal thickness that did not reach the statistical significance at the 12-month follow-up visit). Several OCT parameters at baseline were independently significant predictors for macular subretinal fluid complete resolution at 3 months, including (i) a thicker subfoveal choroidal thickness; (ii) a smaller subretinal fluid maximum diameter; (iii) a lower number of serous pigment epithelium detachments; and (iv) a lower number of intraretinal hyperreflective foci. Conclusion: Treatment with eplerenone in CSC patients is confirmed to be beneficial for both anatomical and functional outcomes. We identified attractive OCT metrics that could potentially be used as a tool to select patients who might mainly benefit from this treatment.

[Treatment of central serous chorioretinopathy with mineralocorticoid receptor antagonists]

BACKGROUND

Over 3 years have passed since the last publication on the therapeutic principle "Mineralocorticoid receptor antagonists as treatment option for acute and chronic central serous chorioretinopathy" by Maier et al., and numerous new studies have been published on the topic. The aim of this work is to provide an update on the current literature and reevaluate the role of mineralocorticoid receptor antagonists in the treatment of central serous chorioretinopathy (CSC).

METHODS AND RESULTS

A computer-based literature search in PubMed yielded a total of 20 relevant articles published from 2013 to 2017, which were evaluated in terms of the effect of mineralocorticoid receptor antagonists in CSC treatment. Due to study protocol variability with different primary endpoints and follow-up periods, an in-depth comparison of the selected studies could not be performed. Moreover, the small study populations further limit their validity in this per se heterogeneous disease spectrum. Despite these limitations, current data indicate that aldosterone antagonists are effective in decreasing subretinal fluid and improving visual acuity in patients with CSC. The selective aldosterone antagonist eplerenone with a low side effect profile is a treatment option in patients with non-resolving CSC.

CONCLUSION

Prospective, randomized studies with uniform disease definition and study criteria are necessary to validate the therapeutic effect and to determine the ideal time of intervention and treatment duration.

NGRID: A novel platform for detection and progress assessment of visual distortion caused by macular disorders

This paper presents a new graphical macular interface system (GMIS) for accurate, rapid, and quantitative measurement of visual distortion (VD) in the central vision of patients suffering from macular disorders. In this system, a series of predefined graphical patterns or multiple grids (NGRID) are randomly selected from a library of patterns and visualized on the screen, then the VDs identified by the patient are recorded as binary codes using various control methods including speech recognition. Scalable Vector Graphics (SVG) is used to generate the patterns and save them into a central library. Based on the projected patterns and the patients' responses, a VD graph or so-called heatmap is generated for eye-care purposes. We demonstrate and discuss the functionality of the proposed system for the detection and progress assessment of a macular condition in patients suffering from Central Serous Chorioretinopathy (CSR). Also, we characterize the proposed technique to evaluate the systematic error and response time on healthy human subjects with normal vision. Based on these results, the voice recognition input method exhibits a lower error but a higher response time compared to other input devices. We run the proposed NGRID VD technique to evaluate the effect of CSR on the visual field of a CSR patient. The generated heatmaps are in agreement with standard Optical Coherence Tomography (OCT) images obtained at different times from both the left and right eyes. These results reveal the applicability of the proposed technique for the detection and assessment of macular disorders. Based on these results, the proposed NGRID platform shows great promise for use as an alternative solution for in-home monitoring of various macular disorders and as a means of forwarding responses to secured cloud facilities for future data analysis.

Early response to the treatment of choroidal neovascularization complicating central serous chorioretinopathy: a OCT-angiography study

PURPOSE

To analyze the quantitative and qualitative early changes of choroidal neovascularization (CNV) associated with chronic central serous chorioretinopathy (CSC) after treatment using optical coherence tomography-angiography (OCT-A).

METHODS

Charts of consecutive patients with diagnosis of chronic CSC complicated by CNV were retrospectively reviewed. Included patients were divided in photodynamic therapy (PDT) or aflibercept group on the basis of the treatment received (half-fluence PDT or aflibercept 2.0 mg/0.05 ml intravitreal injection). Main outcome measures included the changes between baseline and 1-month follow-up in CNV vessel density (VD) and area on OCT-A images after thresholding and binarization.

RESULTS

A total of 30 eyes of 26 Caucasian patients were included: 17 eyes of 15 patients in PDT group (mean age 53 ± 11 years) and 13 eyes of 11 patients in aflibercept group (mean age 58 ± 8 years [p = 0.196]). In both PDT and aflibercept groups, best-corrected visual acuity improved at 1 month, and central macular thickness and subretinal fluid significantly decreased. VD did not change after the treatment in both groups (p = 0.502 and p = 0.086) although CNV area decreased significantly (from 0.586 ± 0.449 mm² to 0.553 ± 0.453 mm² [0.041]) in the PDT group, and nonsignificantly (from 0.767 ± 0.466 mm² to 0.733 ± 0.472 mm² [p = 0.095]) in the aflibercept group. The same results were confirmed in the subanalysis of the 18 treatment-naïve eyes.

CONCLUSIONS

We demonstrated that, despite all patients showed a favorable clinical response, VD of CNVs complicating chronic CSC did not change after treatment. These findings support the idea that arteriogenesis is the main driving force of CNV in pachychoroid-related macular disorders.

Recent Advances of Computerized Graphical Methods for the Detection and Progress Assessment of Visual Distortion Caused by Macular Disorders

Recent advances of computerized graphical methods have received significant attention for detection and home monitoring of various visual distortions caused by macular disorders such as macular edema, central serous chorioretinopathy, and age-related macular degeneration. After a brief review of macular disorders and their conventional diagnostic methods, this paper reviews such graphical interface methods including computerized Amsler Grid, Preferential Hyperacuity Perimeter, and Three-dimensional Computer-automated Threshold Amsler Grid. Thereafter, the challenges of these computerized methods for accurate and rapid detection of macular disorders are discussed. The early detection and progress assessment of macular disorders can significantly enhance the required clinical procedure for the diagnosis and treatment of macular disorders.

Hair cortisol concentration in patients with active central serous chorioretinopathy is elevated - a pilot study

PURPOSE

To investigate hair cortisol concentration (HCC), a biochemical correlate of long-term cortisol output patterns, and its relationship to active central serous chorioretinopathy (CSC).

METHODS

Twenty-six participants were included in this observational pilot study (11 patients with active CSC and 15 healthy controls). Hair cortisol concentrations (HCCs) were determined from 3 cm hair strands collected near the scalp from patients and controls as an index of cumulative cortisol secretion over the 3-month period prior to hair sampling.

RESULTS

Patients with CSC exhibited higher HCCs (mean value: 20.14, 95% CI: 14.89-27.16 pg/mg) than healthy controls (mean value: 11.06, 95% CI: 8.63-14.22 pg/mg, p = 0.008). Group differences were not affected by relevant covariates (BMI, smoking status, sex).

CONCLUSION

Patients with active CSC have increased HCC, supporting the fact that cortisol is a major player in CSC pathogenesis.

Association between Central Serous Chorioretinopathy and Risk of Depression: A Population-Based Cohort Study

Purpose

To investigate the association between central serous chorioretinopathy (CSC) and the risk of developing depression. The risk factors associated with depression in CSC patients were also assessed.

Methods

A population-based retrospective cohort study using the Taiwan National Health Insurance Research Database was conducted from the beginning of 2001 through the end of 2013. CSC patients and age- and gender-matched (1 : 4 matched) control subjects without CSC were enrolled in the study. Kaplan-Meier curves were generated to compare the cumulative hazard of subsequent depression between the CSC and control groups. A Cox regression analysis estimated the crude and adjusted hazard ratios (HRs) for depression. Risk factors leading to depression were investigated among the CSC patients.

Results

25,939 CSC patients and 103,756 controls were enrolled in the study. The CSC group had a significantly higher cumulative hazard for depression compared to the control group (p value < 0.0001). The Cox regression model indicated that the CSC group had a significantly higher risk for depression (adjusted HR = 1.33). Within the CSC group, significant risk factors for depression included age, female gender, low income, first-onset CSC, peptic ulcer, and smoking. The recent use of steroids prior to CSC, by all routes of administration, also significantly increased the risk for depression. However, treatment of CSC did not significantly reduce the risk for depression.

Conclusion

Patients with CSC are at significantly greater risk of developing depression. Among CSC patients, age, female gender, low income, first-onset CSC, peptic ulcer, smoking, and recent use of steroids prior to CSC were significant risk factors for depression.

Exome sequencing in patients with chronic central serous chorioretinopathy

Chronic central serous chorioretinopathy (cCSC) is a multifactorial eye disease characterized by subretinal fluid accumulation that leads to vision loss. Clinically, cCSC is associated with stress, hypercortisolism and corticosteroid use, and is more frequent in males (80%) than in females (20%). Current genetic studies on cCSC have thus far focussed on common variants, but familial occurrence of cCSC also suggests a role for rare variants in the disease susceptibility. Therefore, in this study, we performed exome sequencing of cCSC patients to elucidate the role of rare (protein-altering) variants in the disease. Exome sequencing was performed on 269 cCSC patients and 1,586 controls. Data were processed according to the Genome-Analysis-Toolkit (GATK) best practices. Principal component analysis was performed to check for genetic ancestry and only unrelated subjects of European descent were retained. Burden, SKAT and SKAT-O tests were performed using 2 different grouping criteria. One group included protein-altering variants only, while the other contained synonymous and splice site variants as well. The gene-based analyses were performed using the SKAT R-package correcting for two principal components using two approaches; (1) on the entire cohort correcting for sex and (2) on males and females separately. Additionally, the gene-based associations of genes at previously reported cCSC loci were investigated. After filtering, the dataset contained 263 cCSC patients (208 males [79%]) and 1352 controls (671 males [50%]) carrying 197,915 protein-altering variants in 16,370 genes and 330,689 exonic variants in 18,173 genes. Analysis stratified by sex identified significant associations with the PIGZ (PSKAT = 9.19 × 10-7 & PSKAT-O = 2.48 × 10-6), DUOX1 (PSKAT = 1.03 × 10-6), RSAD1 (PSKAT = 1.92 × 10-7 & PSKAT-O = 8.57 × 10-8) and LAMB3 (PBurden = 1.40 × 10-6 & PSKAT-O = 1.14 × 10-6) genes in female cCSC patients, after correction for multiple testing. The number of rare variant carriers in these genes was significantly higher in the female cCSC cohort compared to female controls (45,5% vs. 18.5%, P = 1.92 × 10-6, OR = 3.67 [95% CI = 2.09-6.46]). No significant associations were identified in the entire cohort nor in the male patients. In this exome study on cCSC patients, we have identified PIGZ, DUOX1, RSAD1 and LAMB3 as potential new candidate genes for cCSC in females. The sex-specific associations identified here suggest a possible interaction between rare genetic factors and sex for cCSC, but replication of these findings in additional cohorts of cCSC patients is necessary.

Non-resolving, recurrent and chronic central serous chorioretinopathy: available treatment options

Central serous chorioretinopathy is one of the most frequent causes of vision reduction among middle-aged men. This disease usually has a self-limiting course, but sometimes it lasts more than 4-6 months or a second episode follows a complete resolution of the first one. Nevertheless, to date no consensus exists about the duration threshold and therapy protocols for these non-resolving central serous chorioretinopathy. Treatment as half-dose and half-fluence photodynamic therapy, subthreshold micropulse laser treatment, mineralocorticoid receptor antagonists, intravitreal anti-angiogenic drugs, transpupillary thermal therapy, anti-androgenic drugs, methotrexate, Rifampicin and melatonin are described in this review. Complications are very uncommon but end-point results like central macular thickness reduction and best-corrected visual acuity improvement are difficult to compare among different therapeutic modalities due to different duration of follow-up and lack of homogeneity in patient recruitment. The aim of this review is focusing on treatment modalities for these chronic forms with comprehensive recent management updates according to latest clinical trial results.

Central serous chorioretinopathy with and without steroids: A multicenter survey

We investigated the rates of the use of steroids in Japanese central serous chorioretinopathy (CSC) cases and differences in the characteristics of CSC with and without steroids. A total of 538 eyes of 477 patients diagnosed with CSC, with 3 months or more of follow-up between April 2013 and June 2017 at 8 institutions. Patients with CSC with more than 3 months of follow-up were identified by OCT and fluorescein angiography at 8 institutions. Data collected included patient demographics, history of corticosteroid medication and smoking, spherical errors, findings of angiography, subfoveal choroidal thickness, and changes through the follow-up period. Differences in these findings were analyzed in cases with and without corticosteroid treatment. Among the 477 patients (344 men,133 women), 74 (15.5%) (39 men, 35 women) underwent current or prior steroid treatment. Cases with steroids were higher age (p = 0.0403) and showed no male prevalence, more bilateral involvement (p < 0.0001), and the affected eyes had multiple pigment epithelial detachment (p <0.0001), more fluorescein leakage sites (p < 0.0001), greater choroidal thickness (p = 0.0287) and a higher recurrence rate (p = 0.0412). Steroids can cause severer CSC through an effect on choroidal vessels and an impairment of retinal pigment epithelium.

A pilot prospective study of 577-nm yellow subthreshold micropulse laser treatment with two different power settings for acute central serous chorioretinopathy

To compare the efficacy of 50% threshold power with 25% threshold power of 577-nm subthreshold micropulse laser (SMPL) for acute central serous chorioretinopathy (CSC). Prospective, interventional, non-randomized, comparative case series. A total of 54 patients (54 eyes) with acute CSC were enrolled. Twenty-four eyes received 25% threshold power and 30 eyes received 50% threshold power of 577-nm SMPL. Best-corrected visual acuity (BCVA), central macular thickness (CMT), and complete absorption of subretinal fluid (SRF) were evaluated at 1 month and 3 months. The complete absorption rate of SRF in the 50% power group was significantly greater than that in the 25% power group at 1 month (70.0% vs 25.0%, p < 0.001) and at 3 months (83.3% vs 54.2%, p < 0.001). Mean BCVA improved from 0.34 ± 0.20 LogMAR to 0.02 ± 0.13 LogMAR in the 50% power group and from 0.27 ± 0.15 LogMAR to 0.14 ± 0.21 LogMAR in the 25% power group with a significant difference between the two groups after 3 months (p = 0.027). In the 50% power group, the CMT decreased from 491.6 ± 154.8 μm at baseline to 231.3 ± 92.3 μm at 1 month and 228.2 ± 88.1 μm at 3 months, and in the 25% power group, the CMT decreased from 444.9 ± 164.1 to 306.8 ± 102.6 μm at 1 month and 254.5 ± 101.7 μm at 3 months. There was statistical difference of CMT at 1 month (p = 0.009) but no significant difference at 3 months between the two groups (p = 0.232). SMPL with 50% threshold power may be more effective than 25% threshold power for acute CSC.

Predictive Factors of Response to Mineralocorticoid Receptor Antagonists in Nonresolving Central Serous Chorioretinopathy

PURPOSE

To assess the efficacy and safety of mineralocorticoid receptor antagonists (MRAs) in the treatment of nonresolving central serous chorioretinopathy (CSC) and to identify factors that are predictive of treatment response.

DESIGN

Retrospective, multicenter, noncomparative, interventional case series.

METHODS

Clinical and imaging data from consecutive patients with nonresolving CSC treated with eplerenone or spironolactone for 3 to 6 months between 2012 and 2016 were reviewed. Outcome measures included the resolution of foveal subretinal detachment (SRD), changes in SRD height, central macular thickness, subfoveal choroidal thickness, best corrected visual acuity, and the occurrence of adverse events assessed at 3 and 6 months. The response to treatment was defined by a decrease by >50% in SRD height under treatment. Comparisons between responder and nonresponder groups were performed using univariate and multivariate regression analyses to identify factors that were predictive of treatment response.

RESULTS

Fifty-nine patients (64 eyes) were included. The mean SRD height and central macular thickness significantly decreased while the mean best corrected visual acuity significantly improved at 3 and 6 months. The mean subfoveal choroidal thickness significantly decreased at 3 months. Among the 64 eyes included, 67.2% responded to treatment, among which 38.3% and 40.5% had a complete resolution of the foveal SRD at 3 and 6 months, respectively. Baseline subfoveal choroidal thickness was the only factor associated with a treatment response in the multivariate analysis.

CONCLUSION

Our study suggests that MRA could be a safe and effective treatment in patients with nonresolving CSC. MRA treatment is more effective in cases with a thicker baseline choroid.

Long-term Visual Outcomes and Causes of Vision Loss in Chronic Central Serous Chorioretinopathy

PURPOSE

To evaluate the long-term visual outcomes and causes of vision loss in chronic central serous chorioretinopathy (CSC).

DESIGN

Retrospective, longitudinal study.

PARTICIPANTS

A total of 133 participants (217 eyes) with chronic CSC.

METHODS

A retrospective review of clinical and multimodal imaging data of patients with chronic CSC managed by 3 of the authors between May 1977 and March 2018. Multimodal imaging comprised color photography, fluorescein angiography, indocyanine green angiography, fundus autofluorescence (FAF), and OCT.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA) at the final visit; change in BCVA between first visit and 1-, 5-, and 10-year follow-up visits; and causes of vision loss at final visit.

RESULTS

Data from 6228 individual clinic visits were analyzed. Mean age of patients at the first visit was 60.7 years, and mean period of follow-up from first to last visit was 11.3 years. The cohort included 101 male patients (75.9%). At the final visit, 106 patients (79.7%) maintained driving-standard vision with BCVA of 20/40 or better in at least 1 eye, and 17 patients (12.8%) were legally blind with BCVA of 20/200 or worse in both eyes. Mean BCVA at first visit was not significantly different from mean BCVA at 1- or 5-year follow-up visits (both P ≥ 0.65) but was significantly better than the mean BCVA at the 10-year follow-up visit (P = 0.04). Seventy-nine percent of eyes with 20/40 or better vision at the first visit maintained the same level of vision at the 10-year follow-up visit. Ninety-two percent of eyes with 20/200 or worse vision at the first visit maintained the same level of vision at the 10-year follow-up visit. Cystoid macular degeneration, choroidal neovascularization (CNV), outer retinal disruption on OCT, and FAF changes were associated with poorer vision at the final visit (all P ≤ 0.001). Multivariable analysis revealed that greater age at first visit was associated with greater BCVA change at the 10-year follow-up visit (P = 0.001).

CONCLUSIONS

Chronic CSC can be a sight-threatening disease leading to legal blindness. Age at presentation and outer retinal changes on multimodal imaging were associated with long-term BCVA changes and may be predictors of long-term visual outcomes.

OCT Angiography of the Choriocapillaris in Central Serous Chorioretinopathy: A Quantitative Subgroup Analysis

Introduction

To quantify optical coherence tomography angiography (OCTA) signal changes at the level of the choriocapillaris (CC) in patients with different stages of central serous chorioretinopathy (CSC) and to explore any correlation between subretinal fluid (SRF) and retinal pigment epithelium (RPE) alterations and the OCTA CC signal.

Methods

One hundred one CSC eyes and 42 healthy control eyes were included in this retrospective study. CSC patients were allocated into four groups: acute, non-resolving, chronic atrophic and inactive CSC. CC OCTA images (AngioPlex^®, Zeiss) were automatically quantified using an image-processing algorithm. Spatial correlation analysis of OCTA signals was performed by overlapping macular edema heatmaps and fundus autofluorescence images with corresponding OCTA images.

Results

Active CSC subgroups demonstrated significantly more increased and decreased flow pixels in the CC compared with controls (p < 0.0001). No significant OCTA changes were seen within the active CSC groups or between the inactive and healthy subgroup. Spatial correlation analysis revealed a decreased OCTA signal in the SRF area and an increased signal outside the SRF area in acute CSC. Areas of RPE atrophy co-localized with areas of increased choriocapillaris OCTA signal, while areas with RPE alterations exhibited a normal signal compared with unaffected RPE.

Conclusion

The decreased OCTA signal in the area of SRF in acute CSC could be evidence of localized CC hypoperfusion or due to shadowing artifacts. The missing CC OCTA changes in altered RPE adjacent to atrophy argues against CC injury. Studies with higher resolution and optimized image acquisition are warranted to further validate our findings.

Electronic supplementary material

The online version of this article (10.1007/s40123-018-0159-1) contains supplementary material, which is available to authorized users.

Two-year follow-up of mineralocorticoid receptor antagonists for chronic central serous chorioretinopathy

AIMS

To evaluate the long-term oral mineralocorticoid receptor antagonist (MRa) treatment in chronic central serous chorioretinopathy (CSC).

METHODS

Patients with chronic non-resolving CSC (defined as foveal subretinal fluid (SRF) lasting >4 months with retinal pigment epithelium (RPE) alterations) treated with MRa only (eplerenone or spironolactone) for at least 6 months were retrospectively included. Clinical and imaging characteristics were recorded during visits at baseline, 6, 12, 18 and 24 months.

RESULTS

Sixteen eyes of 16 patients were included (mean age 53±11 years; 14 men, 2 women). Mean duration of SRF before treatment initiation was 11.2±19.7 months. MRa treatment was administered during 21.0±5.1 months (range, 10-24 months). There was a progressive improvement of visual acuity (p=0.05), a decrease of foveal SRF height (p=0.011), central macular thickness (p=0.004) and subfoveal choroidal thickness (p=0.002) over 24 months. Changes in SRF were correlated with subfoveal choroidal thickness at 24 months (p=0.006, Spearman r=065). The mean time to complete foveal SRF resolution was 10.5±8.0 months after treatment initiation. At 24 months, foveal SRF resolution was achieved in 13 eyes (81%). Minor side effects occurred in five patients (31%) and resolved after switching between MRa.

CONCLUSION

The visual and anatomical benefit of MRa treatment prolonged for 6 months or more in chronic, non-resolving CSC appeared to be maintained over a 24-month period. These results suggest that MRa can be proposed as an alternative therapy in severe CSC with advanced RPE alterations.

Optical Coherence Tomography Angiography Quantitative Assessment of Choriocapillaris Blood Flow in Central Serous Chorioretinopathy

PURPOSE

To investigate choriocapillaris (CC) blood flow in unaffected fellow eyes of patients with central serous chorioretinopathy (CSC) using quantitative optical coherence tomography angiography (OCTA) analysis.

DESIGN

Case-control study.

METHODS

Patients with acute, recurrent, or persistent CSC, along with healthy sex- and age-matched subjects, were included. Objective assessment of CC blood flow was performed using OCTA measurements. Total area of flow signal voids was quantified at baseline, 3 months, and 6 months. Active serous retinal detachment (SRD) was considered as a potential source of false-positive flow impairment; affected eyes were therefore excluded at onset and during follow-up, if this finding was unresolved at the time of measurement.

RESULTS

Sixty patients with CSC and 60 control subjects were included in this study. The total average flow signal void area was significantly higher in the unaffected eyes of CSC patients at baseline (2.70 ± 0.53 mm² vs 2.23 ± 0.43 mm², P < .001). At 3 months, the total average flow signal void area was greater in the affected eyes of CSC patients with resolved SRD compared with unaffected eyes (3.25 ± 0.77 mm² vs 2.67 ± 0.68 mm², P < .001). This total average flow signal void area was larger in unaffected eyes at baseline in recurrent/persistent cases of CSC compared to acute forms (3.74 ± 0.66 mm² vs 2.93 ± 0.69 mm², P = .01).

CONCLUSIONS

Vascular abnormalities in CSC involve CC hypoperfusion, suggestive of a primary choroidopathy including ischemic processes. These microvascular flow deficits may constitute one of a number of underlying subclinical changes preceding CSC and other pachychoroid spectrum disorders.

Choroidal thickness changes in non-treated acute and ranibizumab-treated chronic central serous chorioretinopathy

To evaluate the changes in subfoveal retinal, and choroidal thicknesses (CT) in the non-treated acute and the ranibizumab-treated chronic central serous chorioretinopathy (CSCR) patients.This retrospective study included 32 eyes of 32 consecutive patients with CSCR. There were 12 patients who presented with a spontaneous resolution of CSCR (Group 1) and 20 patients who were treated with ranibizumab for persistent subretinal fluid (SRF) (Group 2). Optical coherence tomography (OCT) imaging of subfoveal retinal thickness and enhanced depth imaging OCT of CT at subfoveal; at nasal and temporal 500 μm (T500); at nasal and temporal 1500 μm (T1500) were analyzed. The Student t test and multivariate analysis were used to compare variables within and between groups, respectively and correlations were analyzed using Pearson correlation coefficient. A P value of P < .05 was accepted as significant.The mean patient age was 38.94 ± 8.41 years (range, 20-53 years). Female/male ratio was 4/28. The mean duration of follow-up was 21.6 ± 8.2 months in the chronic CSCR group. Visual acuity improved and central foveal thickness (FT) decreased significantly in both groups. CT decreased significantly only at nasal 1500 μm (N1500) in the acute group and at all measured points in the chronic group compared with baseline, except at T500 (P = .07). No significant difference in central FT was detected between the 2 groups. Compared with the acute group, baseline subfoveal CT was significantly higher in chronic patients. There was a significant difference between the groups in baseline and final CT at T500. No significant difference was found at T1500. At nasal 500 μm and N1500, the difference between the groups was significant only for final CT values.Chronic CSCR was associated with higher baseline CT values in the subfoveal region and at T500. CT significantly decreased at most of the measured points in ranibizumab-treated chronic CSCR patients, whereas it significantly decreased only at 1 point in spontaneously resolved acute CSCR patients.

Eplerenone in the treatment of central serous chorioretinopathy: a review of the literature

Purpose

The purpose of this review is to examine the role of eplerenone in the treatment of central serous chorioretinopathy (CSCR).

Methods

A comprehensive search of the PubMed database has been conducted regarding eplerenone for CSCR, while studies using spironolactone were excluded. Articles and book chapters cited in the reference lists of articles obtained by this method were reviewed and included when considered appropriate, while the retrieved articles were filtered manually to exclude duplicates.

Results

Oral eplerenone at a dose of 25–50 mg/day has been found to be effective and well-tolerated for the treatment of chronic CSCR. The published studies have shown significant improvement in visual acuity and decrease or total absorption of subretinal fluid in patients with CSCR treated with oral eplerenone. However, it should be noted that the majority of studies were retrospective with limited number of patients and short follow-up. On the other hand, patients presenting widespread retinal pigment epithelium changes are less likely to benefit from eplerenone treatment, which may argue for an earlier intervention.

Conclusions

CSCR is a challenging disease to understand and treat, since its pathogenesis remains elusive and multifactorial. Pharmacologic approaches, like eplerenone, are intriguing, as they target several pathophysiological pathways and may lead to visual acuity improvement and more rapid recovery.

Poor Sleep Quality Is the Risk Factor for Central Serous Chorioretinopathy

Purpose

Whether sleep disturbance is related with central serous chorioretinopathy (CSC) is still in controversy. This study is designed to investigate sleep status in CSC using definite and well-established methods.

Methods

A total of 134 CSC patients and 134 age- and sex-matched normal controls were recruited in the study. Demographic data were collected through a questionnaire. Body mass index (BMI) was calculated by weight divided by height squared. The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were administered to all subjects to assess the sleep quality and daytime sleepiness, respectively. Depression Anxiety Stress Scales 21-item version (DASS-21) was also used to evaluate the emotion status as a positive control. Poor sleep quality was defined as PSQI > 5 and sleep apnea tendency as ESS > 10. Positive criteria scores were ≥10 for depression, ≥8 for anxiety, and ≥15 for stress.

Results

There was no significant difference of BMI between the two groups (p=0.075). The prevalence of poor sleep quality (58.2% versus 23.9%; p < 0.001) in CSC patients was significantly higher than normal. Specifically, CSC patients presented worse performance in certain components of sleep quality, that is, sleep latency, sleep duration, and sleep efficiency. More participants had stress (23.9% versus 3%, p < 0.001), depression (25.4% versus 10.4%; p=0.001), and anxiety (28.4% versus 14.9%; p=0.008) emotions in CSC than that in normal. No significant difference was observed in sleep apnea tendency. Through logistic regression analysis, CSC patients were more likely to be in poor sleep quality (p < 0.001; OR 3.608 (2.071–6.285)) and stress emotion (p=0.002, OR 6.734 (1.997–22.711)).

Conclusion

Poor sleep quality is risk factor for CSC patients. Attention of sleep quality should be paid when treating them.

Central Serous Chorioretinopathy: Clinical Characteristics Associated with Visual Outcomes

PURPOSE

Retrospective cohort study to identify clinical characteristics associated with poor visual acuity in central serous chorioretinopathy (CSC).

MATERIALS AND METHODS

Charts of patients in a tertiary referral clinic diagnosed with CSC over a 13-year period were reviewed. Multivariate logistic regression analyses were performed to assess the relationship between several clinical characteristics and final visual acuity.

RESULTS

Of 353 subjects with CSC, 258 had a minimum of 2 clinical assessments and adequate follow-up. Multivariate analysis showed that the followings were significantly associated with worse final visual acuity: older age at diagnosis, history of photodynamic therapy, choroidal neovascularization (CNV), hypertension, and either prostate cancer or benign prostatic hypertrophy. Diabetes mellitus was associated with better final visual acuity. In a subgroup analysis of 150 subjects with at least 1 year of follow-up, CNV, hypertension, and gastroesophageal reflux disease were significantly associated with worsening of visual acuity over the study period. Use of a psychiatric medication at presentation was protective.

CONCLUSION

Poor visual outcomes in CSC are associated with older age at diagnosis, CNV, hypertension, and history of prostate disease. Several clinical characteristics that have been identified as risk factors for developing CSC also appear to be associated with worse visual outcomes.

RISK FACTORS FOR RECURRENCES OF CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To describe recurrence patterns and investigate candidate risk factors for recurrences of central serous chorioretinopathy.

METHODS

In 46 patients with acute central serous chorioretinopathy and follow-up >12 months after first episode resolution, parameters influencing recurrences were retrospectively evaluated using a frailty Cox proportional hazard survival model. Covariates included baseline systemic findings: age, gender, corticosteroid use, stress, shift work, sleep disorder, depression, allergy, cardiovascular risk; baseline optical coherence tomography findings: subfoveal choroidal thickness, pigment epithelial detachment pattern (regular/bump/irregular), number of subretinal hyperreflective foci at leakage site; baseline angiographic findings: fluorescein leakage intensity (intense/moderate/subtle/absent), hyperpermeability pattern on indocyanine-green angiography (focal/multifocal); and episode-related findings: duration and treatment of previous episode.

RESULTS

Twenty of 46 subjects (43%) presented ≥1 recurrences during a mean follow-up of 29.9 ± 9.5 months (range, 15-54 months). Follow-up duration did not differ between cases with or without recurrences (P = 0.3). Worse final visual acuity levels (logarithm of the minimal angle of resolution) were associated with a higher number of episodes during follow-up (P = 0.032, r = 0.28). In a univariate analysis, higher subfoveal choroidal thickness (P = 0.021), nonintense fluorescein leakage (= moderate/subtle/absent, P = 0.033), multiple subretinal hyperreflective foci (P = 0.026), and shift work (P < 0.0001) were significantly associated with recurrences, with a near-significant influence of irregular pigment epithelial detachment (P = 0.093). In a multivariate analysis, higher subfoveal choroidal thickness (P = 0.007), nonintense fluorescein leakage (P = 0.003) and shift work (P < 0.0001) remained significant and independent risk factors for recurrences.

CONCLUSION

Multiple factors influence the risk of central serous chorioretinopathy recurrence. These findings may contribute to identify patients at higher risk, who could benefit from earlier or more intensive treatment.

Patient characteristics and risk factors for central serous chorioretinopathy: an analysis of 811 patients

Aims

To determine the demographic and morphological characteristics of patients with central serous chorioretinopathy (CSC) and describe risk factors for CSC.

Methods

We retrospectively reviewed medical records of 811 patients with CSC and 816 healthy controls referred from 2002 to 2018.

Results

The female/male ratio of patients with CSC was 1/2.7. Mean age of onset was 45.2 years. The peak prevalence for men occurred at 45–49 years. Women had two prevalence peaks, the higher at 55–59 years and the other at 45–49 years. Of these patients, 56.8% had unilateral disease, 42.1% had bilateral disease and 1.1% had only one eye. 671 (82.7%) patients had spectral domain optical coherence tomography (SD-OCT) images and 598 (73.7%) had enhanced depth choroidal images. Pigment epithelial detachment (PED) was detected in 763 (80.7%) of 945 eyes with SD-OCT images. Chronic cases were more likely to be bilateral and multifocal and to have PED (all p<0.001). Subfoveal choroidal thickness (SFCT) did not differ between chronic and classic cases (p=0.74), but SFCT was greater in multifocal cases than unifocal cases (p<0.001). In multivariate regression analyses, older age of onset, longer duration of disease and hyperopia were positively associated with having chronic disease rather than classic disease, and myopia and thyroid hormone replacement were negatively associated. Steroid use, antidepressant or anxiolytic drug use, smoking, pregnancy and hyperopia were risk factors, and myopia was a protective factor for CSC.

Conclusion

This is the largest case-control study of CSC to evaluate demographic morphological characteristics and risk factors. Multiple factors are associated with CSC.

Gender variation in central serous chorioretinopathy

BACKGROUND

Comparison of presentation and outcomes of central serous chorioretinopathy (CSC) between male and female subjects in different ethnic populations.

METHODS

Retrospective comparison between male and female subjects with CSC was completed. Demographic details, clinical presentations, imaging features and treatment outcomes were compared at baseline and at last follow-up.

RESULTS

This study included 155 male and 155 female subjects with a mean (CSD) age of 43.8 ± 10.3 and 57.0 ± 12.1 years, respectively, and a mean duration of follow-up of 8.49 ± 12.6 months. At presentation, there was no difference in visual acuity; however, visual acuity was significantly higher for female subjects at last follow-up (p = 0.02). Optical coherence tomography (OCT) analysis showed that subretinal deposits (p < 0.001), hyperreflective foci (p = 0.001), retinal pigment epithelial detachment (p = 0.01) and retinal pigment epithelium (RPE) irregularities (p = 0.03) were higher in male subjects at presentation. Angiographic analysis showed that diffuse leakage and RPE tracts were common in males (p = 0.01 and p = 0.02). No significant differences in choroidal dilatation or diffuse choroidal leakages were noted.

CONCLUSIONS

Female subjects with CSC appear to have better outcomes, with less chances of diffuse RPE damage and other OCT features compared to males.

CFH and VIPR2 as susceptibility loci in choroidal thickness and pachychoroid disease central serous chorioretinopathy

Although central serous chorioretinopathy (CSC) presumptively shares pathophysiological basis with age-related macular degeneration (AMD), the CFH risk alleles for AMD are reportedly protective against CSC development. Our finding, that the CFH risk allele for AMD is protective against choroidal thickening in a Japanese cohort, indicates that CFH affects CSC development through its choroid-thickening effects rather than its association with AMD, highlighting the need for a new AMD classification, with CSC/pachychoroid-associated choroidal neovascularization as a distinct disease. Furthermore, our genome-wide association study (GWAS) addressing choroidal thickness successfully discovered a susceptibility gene for CSC: VIPR2. Future GWASs on choroidal thickness will likely discover additional CSC susceptibility genes and provide key molecules to elucidate the pathophysiological difference between CSC and AMD.

Central serous chorioretinopathy (CSC) is a common disease affecting younger people and may lead to vision loss. CSC shares phenotypic overlap with age-related macular degeneration (AMD). As recent studies have revealed a characteristic increase of choroidal thickness in CSC, we conducted a genome-wide association study on choroidal thickness in 3,418 individuals followed by TaqMan assays in 2,692 subjects, and we identified two susceptibility loci: CFH rs800292, an established AMD susceptibility polymorphism, and VIPR2 rs3793217 (P = 2.05 × 10⁻¹⁰ and 6.75 × 10⁻⁸, respectively). Case–control studies using patients with CSC confirmed associations between both polymorphisms and CSC (P = 5.27 × 10⁻⁵ and 5.14 × 10⁻⁵, respectively). The CFH rs800292 G allele is reportedly a risk allele for AMD, whereas the A allele conferred risk for thicker choroid and CSC development. This study not only shows that susceptibility genes for CSC could be discovered using choroidal thickness as a defining variable but also, deepens the understanding of differences between CSC and AMD pathophysiology.

Central Serous Chorioretinopathy in African Americans at Wilmer Eye Institute

OBJECTIVE

To evaluate the frequency of central serous chorioretinopathy (CSC) in African Americans/blacks within an academic center in a predominantly African American city, as the current belief is that CSC is rare in this population.

METHODS

A retrospective review of all patients' charts diagnosed with CSC at Wilmer Eye Institute/Johns Hopkins University from August 2009-August 2015 was conducted via an electronic health record search (EPIC). The charts were categorized by self-reported race and gender. The diagnosis was confirmed by multiple physician consensus through chart and imaging review. Fluorescein angiograms were classified as single versus multiple point leakage. OCTs were evaluated for subfoveal thickness, location of fluid, presence or absence of pigment epithelial detachment. Color photos were categorized as to the extent of retinal pigment epithelial changes.

RESULTS

Of the 590 charts identified via EPIC as CSC patients, 407 were confirmed as CSC through chart and imaging review. 45 patients (11.1%) were African Americans and 298 patients (73.2%) were Caucasians. Of all patients seen during the study period, 0.09% of African Americans at Wilmer had CSC and 0.18% of Caucasians had CSC. While three fold more Caucasians were seen during the study period as compared to African Americans, this study's prevalence rate in African Americans/blacks at Wilmer Eye Institute was half of that in Caucasian/whites.

CONCLUSIONS

CSC has been reported as exceedingly rare in African Americans, but our study suggests that CSC may be underestimated in this population. A large nationally representative population based study is needed to determine true racial prevalence to ensure that the diagnosis of CSC is not overlooked in African Americans.

The relationship between the central serous chorioretinopathy, choroidal thickness, and serum hormone levels

PURPOSE

The purpose of this study were to compare the levels of serum cortisol, aldosterone, testosterone, dehydroepiandrosterone (DHEA), and renin hormone between patients with central serous chorioretinopathy (CSC) and a control group, and to investigate whether there was a difference regarding serum hormone levels in patients with acute/chronic CSC.

METHODS

This prospective study included 30 CSC eyes, 30 fellow eyes, and 32 normal eyes of 32 healthy volunteers who were age and sex matched. The patients were classified as acute or chronic depending on the clinical, fluorescein angiography (FFA), and optical coherence tomography (OCT) findings. Serum cortisol, aldosterone, renin, total testosterone, and DHEA levels were measured. The levels of hormones were compared with the values of the control group. Choroidal thickness and central macular thickness were measured with spectral domain OCT.

RESULTS

Fifteen patients had acute CSC, and 15 patients had chronic CSC. Serum testosterone levels were 357 ± 10.4 ng/ml in the CSC group, and 255.94 ± 7.43 ng/ml in the control group. The difference between them was statistically significant (p < 0.001). The difference between the levels of cortisol, renin, aldosterone, and DHEA was not statistically significant. Serum hormone levels were within the normal range for all patients and were not statistically different between the acute and chronic CSC groups.

CONCLUSION

According to our results, CSC is related to elevated total testosterone levels. Testosterone may play a role in predisposing males to CSC.

INSTRUMENTAL DIFFERENCE IN ASSESSING CHOROIDAL HYPERPERMEABILITY AND PHOTODYNAMIC THERAPY IN CHRONIC CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To investigate the difference in choroidal hyperpermeability (CH) assessed using digital fundus camera (DFC) and scanning laser ophthalmoscope (SLO) and its effect on photodynamic therapy (PDT) outcomes in chronic central serous chorioretinopathy.

METHODS

Midphase indocyanine green angiography (ICGA) images were acquired using both DFC and SLO in 38 consecutive eyes with chronic central serous chorioretinopathy in this retrospective study. Scanning laser ophthalmoscope-ICGA was taken immediately after DFC-ICGA. Photodynamic therapy was applied to the area of CH associated with subretinal fluid (CH-SRF). The main outcome measures included the areas of CH in the macula and CH-SRF, resolution of SRF, and change in the best-corrected visual acuity.

RESULTS

Areas of CH (5.187 ± 2.625 mm vs. 3.170 ± 1.661 mm, P < 0.001) and CH-SRF (2.315 ± 1.111 mm vs. 1.465 ± 0.709 mm, P < 0.001) were greater in DFC than in SLO. Sixteen eyes underwent DFC ICGA-guided PDT (DFC-PDT group) and 22 underwent SLO ICGA-guided PDT (SLO-PDT group). Subretinal fluid resolution at 12 months was 100.0% and 90.9% in the DFC-PDT and SLO-PDT groups, respectively, without statistical differences. The improvement of best-corrected visual acuity was earlier in the SLO-PDT group than in the DFC-PDT group (3 months, P = 0.002 vs. 6 months, P = 0.003), but the final best-corrected visual acuity showed no difference.

CONCLUSION

In chronic central serous chorioretinopathy, larger areas of CH and CH-SRF were observed with DFC than with SLO, which caused the ophthalmologists performing ICGA-guided PDT to determine a larger laser spot. This seemed to affect the time of visual recovery, but not the final outcome.

Eplerenone Versus Observation in the Treatment of Acute Central Serous Chorioretinopathy: A Retrospective Controlled Study

INTRODUCTION

To investigate the effects of eplerenone compared to observation in the treatment of acute central serous chorioretinopathy (CSC).

METHODS

Charts of consecutive patients with a diagnosis of acute CSC (visual symptoms < 12 weeks) were reviewed. Included patients were divided into a treatment group (treated with eplerenone) and a control group (observation). Main outcome measures included changes in best-corrected visual acuity (BCVA), central macular thickness (CMT), height of subretinal fluid (SRF) and subfoveal choroidal thickness (CT) at 1 and 3 months in the two groups.

RESULTS

Fifteen eyes of 15 patients (2 female, 13 male) and 12 eyes of 12 patients (1 female, 11 male [p = 1.000]) were included in the treatment and control groups, respectively. The mean age was 44 ± 9 (30-65) and 47 ± 11 years (28-66 years, p = 0.493), respectively. In the treatment group, BCVA improved significantly at 1 month (p = 0.018) and 3 months of follow-up (p = 0.011), while a non-significant improvement was seen in the control group. At 3 months, 12 of 15 eyes (80%) in the treatment group demonstrated complete SRF resolution, versus 3 of 12 eyes (25%) in the control group (p = 0.007). In the treatment group, SRF and CMT were significantly reduced at the 1-month follow-up (p = 0.014, p = 0.028, respectively) and the 3-month follow-up (p < 0.001 for both analyses), while in the control group the changes were not statistically significant. Eplerenone was well tolerated in all patients.

CONCLUSION

Patients affected by acute CSC treated with eplerenone achieved greater and faster resolution of the disease compared to the observation group. Eplerenone may represent an attractive new first-line treatment option for acute CSC.

Selective Retina Therapy with Real-Time Feedback-Controlled Dosimetry for Treating Acute Idiopathic Central Serous Chorioretinopathy in Korean Patients

PURPOSE

To evaluate short-term treatment outcomes following selective retina therapy (SRT) with real-time feedback-controlled dosimetry in Korean patients with acute idiopathic central serous chorioretinopathy (CSC).

METHODS

Sixteen eyes (16 patients) with acute idiopathic CSC (symptom duration < 3 months) were included in this retrospective study. All patients underwent a single session of SRT with real-time feedback-controlled dosimetry. Best-corrected visual acuity (BCVA) and central foveal thickness (CFT) before and 3 months after treatment were examined and compared.

RESULTS

The logarithm of minimal angle of resolution BCVA was significantly better 3 months after treatment (0.16 ± 0.18) than at the time of diagnosis (0.27 ± 0.18, P = 0.002). Additionally, subretinal fluid had resolved in all 16 eyes 3 months after treatment and CFT was significantly lower 3 months after treatment (215.6 ± 17.9 μm) than at baseline (441.4 ± 124.8 μm, P < 0.001). No notable SRT-related complications were observed during the study period.

CONCLUSION

The results of the present study suggest that SRT is a useful therapeutic option for patients with acute idiopathic CSC. Further studies are required to better understand the long-term efficacy of this treatment. This trial is registered with clinical trial registration number NCT03339856.

Antiretinal antibodies in central serous chorioretinopathy: prevalence and clinical implications

PURPOSE

To investigate the possible role of autoimmune reactions directed against retinal tissue in central serous chorioretinopathy (CSC), by analysing the presence of serum antiretinal antibodies (ARAs) and establishing their clinical relevance.

METHODS

Sixty-three patients with CSC were included, and clinical characteristics were collected. Serum samples of all patients with CSC, 101 uveitis patients and 60 healthy donors were analysed for the presence of ARAs by indirect immunofluorescence. Furthermore, all CSC serum samples were analysed on Western blot. Correlations between laboratory findings and clinical features of CSC were determined by logistic regression.

RESULTS

Antiretinal antibodies (ARAs) were present in 54% of the patients with CSC, in 46% of uveitis patients (p = 0.153) and in 17% of healthy controls (p < 0.001). The majority of ARAs in CSC were directed against photoreceptors (27%), which occurred significantly more often compared to uveitis patients (15%, p = 0.039) and to healthy controls (5%, p = 0.003). No associations between clinical CSC characteristics and the presence of ARAs were found.

CONCLUSION

Serum ARAs are present in more than half of the patients with CSC, and especially, ARAs directed against photoreceptors were detected more frequently compared to both healthy controls and uveitis patients. Further research is warranted to unravel the role of ARAs in the pathogenesis of CSC.

Response of central serous chorioretinopathy evaluated by multimodal retinal imaging

PurposeTo identify predictive biomarkers of treatment outcomes by multimodal retinal imaging in patients affected by central serous chorioretinopathy (CSC).Patients and methodsIn this interventional non-randomized clinical study, 27 treatment-naive CSC patients were prospectively enrolled and treated with oral eplerenone for 5-13 weeks. Primary outcomes included presence of pathological findings on indocyaine green angiography (ICGA), structural optical coherence tomography (OCT) and OCT-angiography (OCT-A) at baseline associated with different response to the treatment.ResultsA total of 29 eyes of 27 patients (2 females, 25 males) met the inclusion criteria and were included in the study (mean age was 45±7 years). Mean CSC duration at baseline was 13.5±4.4 weeks. After a mean of 10.5 weeks of treatment, mean central macular thickness significantly reduced (P<0.001), and mean best-corrected visual acuity improved (P<0.001). Seventeen eyes (61%) demonstrated total reabsorption of subretinal fluid on structural OCT, five eyes (18%) presented a partial response to eplerenone therapy and six eyes (21%) showed no response. The complete response to the treatment was associated with absence of CNV at OCT-A and the presence of hotspot at ICGA (P<0.001 and P=0.002, respectively). None of eight eyes with CNV in OCT-A imaging had a complete response to eplerenone and none of three eyes without hotspot at ICGA showed a complete response to the treatment.ConclusionsMultimodal retinal imaging allowed us to propose predictive biomarkers (ie, absence of CNV on OCT-A and presence of hotspot on ICGA) for treatment outcomes.