Indocyanine green enhanced subthreshold diode-laser micropulse photocoagulation treatment of chronic central serous chorioretinopathy

532 nm versus 810 nm subthreshold micropulse laser in treatment of non-resolving central serous chorioretinopathy: A randomized controlled trial

Background

The relative efficacy of 532 nm subthreshold micropulse laser in comparison to the 810 nm subthreshold micropulse laser, in the treatment of central serous chorioretinopathy is not known.

Methods

This randomized controlled trial included 99 eyes each in groups A and B. Key inclusion criteria were: (i) vision loss for minimum three months due to persistent central serous chorioretinopathy; (ii) focal leaks (upto two leaks) on fundus fluorescein angiography. Key exclusion criteria were: (i) history of prior treatment for central serous chorioretinopathy; (ii) absence of any leak/ presence of diffuse leaks/ >2 leaks on fundus fluorescein angiography; (iii) chronic central serous chorioretinopathy. All eyes were treated with subthreshold micropulse laser (group A: 532 nm green laser; group B: 810 nm diode laser). Best-corrected visual acuity, autofluorescence, spectral domain optical coherence tomography, and fundus fluorescein angiography, were evaluated at baseline and at 1, 3, and 6 months. Laser was repeated in nor-responders at 3 months.

Results

There was a statistically significant improvement in BCVA in both groups six months post laser. Between the two groups, a comparable proportion of eyes showed complete resolution of subretinal fluid at one month, three months and at six months. No adverse effect of laser was observed in either group.

Conclusion

Both 532 nm STMP laser and 810 nm STMP laser have comparable structural and functional outcomes in the treatment of non-resolving CSC. There are no adverse effects related to either of the two wavelengths.

Central Serous Chorioretinopathy: An Update on the Current State of Management

Central serous chorioretinopathy (CSCR) is a relatively common retinal disorder that leads to central vision impairment, often with a high recurrence rate. The exact etiology and pathogenetic mechanisms have not been fully elucidated but are likely to be associated with hyperpermeability of the choroidal capillaries and failure of the retinal pigment epithelium (RPE), leading to serous detachment of the neurosensory retina. Multimodal imaging plays a critical role in the diagnostic approach and monitoring of CSCR. Fortunately, the natural course of the disease is usually self-limiting, with spontaneous resolution and total fluid reabsorption. However, some patients may exhibit recurrences or persistent subretinal fluid (chronic CSCR), leading to progressive and irreversible RPE atrophy or photoreceptor damage. Thus, to prevent permanent visual loss, individualized treatment should be considered. Recent developments in the diagnostic and therapeutic approach have contributed to better outcomes in patients with CSCR. More studies are required to improve our understanding of epidemiology, pathogenesis, diagnosis, and treatment, with a significant impact on the management of this challenging clinical entity. The purpose of this review is to summarize the current knowledge about the clinical features, diagnostic workup, and therapeutic approach of CSCR.

Central serous chorioretinopathy: An evidence-based treatment guideline

Central serous chorioretinopathy (CSC) is a relatively common disease that causes vision loss due to macular subretinal fluid leakage and it is often associated with reduced vision-related quality of life. In CSC, the leakage of subretinal fluid through defects in the retinal pigment epithelial layer's outer blood-retina barrier appears to occur secondary to choroidal abnormalities and dysfunction. The treatment of CSC is currently the subject of controversy, although recent data obtained from several large randomized controlled trials provide a wealth of new information that can be used to establish a treatment algorithm. Here, we provide a comprehensive overview of our current understanding regarding the pathogenesis of CSC, current therapeutic strategies, and an evidence-based treatment guideline for CSC. In acute CSC, treatment can often be deferred for up to 3-4 months after diagnosis; however, early treatment with either half-dose or half-fluence photodynamic therapy (PDT) with the photosensitive dye verteporfin may be beneficial in selected cases. In chronic CSC, half-dose or half-fluence PDT, which targets the abnormal choroid, should be considered the preferred treatment. If PDT is unavailable, chronic CSC with focal, non-central leakage on angiography may be treated using conventional laser photocoagulation. CSC with concurrent macular neovascularization should be treated with half-dose/half-fluence PDT and/or intravitreal injections of an anti-vascular endothelial growth factor compound. Given the current shortage of verteporfin and the paucity of evidence supporting the efficacy of other treatment options, future studies-ideally, well-designed randomized controlled trials-are needed in order to evaluate new treatment options for CSC.

Association of Central serous chorioretinopathy with type of personality, anxiety and depression

PURPOSE

Central serous chorioretinopathy (CSCR) a relatively common cause of visual impairment, which is characterized by subretinal fluid accumulation in the macula and is more common in middle-aged males. Various risk factors have been reported in literature, among which substantial role of psychological factors is cited. Our aim was to look for the prevalence and association of the psychiatric factors in CSCR patients and to compare them with other non-chorioretinal ocular pathologies.

METHODS

A cross-sectional correlational study was undertaken involving 91 CSCR patients, along with 91 patients with other non-chorioretinal diseases. Their risk factors, clinical history, ocular examination, and psychiatric assessments were done using standardized tools, and the groups were compared in terms of scoring of Framingham Type A scale (FTAS), Hamilton Anxiety Rating Scale (HAM-A), and Hamilton Depression Rating Scale (HDRS).

RESULTS

CSCR patients had a male:female ratio of 8:1. Chronic, bilateral, and recurrent diseases were found in 15%, 20%, and 23% cases, respectively. Anxiety disorder had a prevalence of 40%, followed by major depression with a prevalence of 24%, and these were significantly higher than non-chorioretinal disease patients (odds ratios 14.18 and 5.30, respectively). Also, these psychiatric disorders were significantly associated with an overall lower visual acuity and greater central macular thickness due to subretinal fluid accumulation.

CONCLUSION

Psychiatric comorbidities like Type A personality trait and depression and anxiety disorders were significantly more prevalent in CSCR patients, compared to non-chorioretinal pathologies. Focus on psychological health would certainly benefit these patients in terms of better management of not only CSCR, but their psychiatric morbidity as well.

Long-term follow-up of chronic central serous chorioretinopathy after successful treatment with photodynamic therapy or micropulse laser

PURPOSE

To describe the treatment outcomes and recurrence risk of chronic central serous chorioretinopathy (cCSC) in patients who had complete resolution of subretinal fluid (SRF) after either primary half-dose photodynamic therapy (PDT) or high-density subthreshold micropulse laser (HSML) in the PLACE trial.

METHODS

This multicentre prospective follow-up study evaluated cCSC patients at 1 year after completion of the PLACE trial. Outcomes included: complete resolution of SRF on OCT, best-corrected visual acuity (BCVA) in Early Treatment of Diabetic Retinopathy Study (ETDRS) letters, retinal sensitivity on microperimetry and a visual function questionnaire (NEI-VFQ25).

RESULTS

Twenty-nine out of 37 patients who received half-dose PDT and 15 out of 17 patients who received HSML could be evaluated at final visit. At final visit, 93% of the patients treated with half-dose PDT had complete resolution of SRF, compared with 53% of HSML-treated patients (p = 0.006). At final visit, the mean estimate increase in the PDT group compared with the HSML group was + 2.1 ETDRS letters, +0.15 dB for the retinal sensitivity and + 5.1 NEI-VFQ25 points (p = 0.103, p = 0.784 and p = 0.071, respectively). The mean estimated central retinal thickness in the half-dose PDT group was -7.0 µm compared with the HSML group (p = 0.566). The mean estimated subfoveal choroidal thickness in the half-dose PDT group was -16.6 µm compared with the HSML group (p = 0.359).

CONCLUSION

At 20 months after treatment, cCSC patients successfully treated with half-dose PDT are less likely to have recurrences of SRF compared with those successfully treated with HSML. However, functional outcomes did not differ.

Role of 532 nm transfoveal subthreshold micropulse laser in non-resolving central serous chorioretinopathy with subfoveal leaks

Purpose:

The purpose of this study was to evaluate the role of 532 nm transfoveal subthreshold micropulse laser in non-resolving central serous chorioretinopathy with subfoveal leak.

Methods:

A retrospective chart analysis of 23 eyes of 21 patients with central serous chorioretinopathy was performed. Inclusion criteria include vision loss ⩾3 months and focal subfoveal leak on fluorescein angiography. Exclusion criteria include prior treatment for central serous chorioretinopathy and chronic central serous chorioretinopathy. All eyes were treated with 532 nm subthreshold micropulse laser (5% duty cycle). Visual acuity score, contrast sensitivity, autofluorescence, spectral domain optical coherence tomography, and fundus fluorescein angiography were assessed at baseline, 1, 3, 6 months.

Results:

Average visual acuity score (letters) improved from 66.0 ± 8.51 (baseline) to 71.35 ± 8.48 (1 month, p < 0.01), 77.30 ± 11.34 (3 months, p < 0.01), 80.17 ± 9.30 (6 months, p < 0.01). Contrast sensitivity improved from 0.75 ± 0.30 to 1.30 ± 0.37 (p < 0.01) at 6 months. Two eyes needed rescue laser at 3 months followed by photodynamic therapy at 6 months; two eyes needed rescue laser at 6 months.

Conclusion:

The 532 nm subthreshold micropulse laser is safe in non-resolving central serous chorioretinopathy with subfoveal leaks.

Efficacy and safety of subthreshold micropulse laser compared with threshold conventional laser in central serous chorioretinopathy

PURPOSE

To compare the efficacy and safety of subthreshold micropulse laser (SML) with threshold conventional laser (TCL) in central serous chorioretinopathy (CSC).

METHODS

Prospective, randomized, double-masked, non-inferiority, 12-week clinical trial. Patients were randomly assigned 1:1 to SML group or TCL group. Patients in the SML group were treated with 577 nm micropulse laser. The spot size was 160 µm, the duty cycle was 5% and exposure time was 0.2 s. The power was 50% threshold tested. Patients in the TCL group were treated with 577 nm continuous laser. The power was 100% threshold tested. The primary outcome was the mean change in best-corrected visual acuity (BCVA) at week 12, with a non-inferiority limit of five letters on the Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity charts.

RESULTS

Eighty-eight patients were enroled. Seventy-seven patients were male. Forty-four patients were in SML group and 44 in TCL group. At week 12, SML was equivalent to TCL with a gain of 6.23 ± 8.59 and 6.61 ± 6.35 letters, respectively, (SML-TCL difference: -0.38 letters; 95% confidence interval (CI):-3.58-2.81; Pnon-inferiority = 0.0026). There was no statistically significant difference between the two groups (t = 0.240, P = 0.811). At week 12, the proportion of patients whose SRF had been totally absorbed was 63.63 and 81.82% respectively for SML and TCL groups. There was no statistically significant difference between the two groups (χ2 = 3.67, P = 0.056).

CONCLUSIONS

Both SML and TCL can improve visual acuity in CSC. SML was non-inferior to TCL in the improvement of BCVA.

Prospective evaluation of changes in choroidal vascularity index after half-dose photodynamic therapy versus micropulse laser treatment in chronic central serous chorioretinopathy

Purpose

To assess whether treatment of chronic central serous chorioretinopathy (cCSC) with photodynamic therapy (PDT) and high-density subthreshold micropulse laser (HSML) results in choroidal vascularity index (CVI) changes that may account for the treatment effect.

Methods

Patients with cCSC were prospectively included and analyzed. Patients received either half-dose PDT or HSML treatment. CVI of the affected and unaffected eye was obtained before treatment, 6 to 8 weeks after treatment, and 7 to 8 months after treatment.

Results

At baseline, 29 eyes (29 patients) were included both in the PDT and in the HSML group. The mean (± standard deviation) CVI change in the HSML group between before PDT and 6 to 8 weeks after PDT was − 0.009 ± 0.032 (p = 0.127), whereas this was 0.0025 ± 0.037 (p = 0.723) between the visit before PDT and final visit. The patients in the PDT group had a CVI change of − 0.0025 ± 0.037 (p = 0.723) between the visit before PDT and first visit after PDT, and a mean CVI change of − 0.013 ± 0.038 (p = 0.080) between the visit before PDT and final visit. There was no significant correlation between CVI and BCVA at the measured time points, in both the HSML group (p = 0.885), and in the PDT group (p = 0.904). Moreover, no significant changes in CVI occurred in the unaffected eye at any time point.

Conclusions

PDT and HSML do not significantly affect CVI, and therefore a CVI change may not be primarily responsible for the treatment effect. The positive treatment effect of both interventions may rely on other mechanisms, such as an effect on choriocapillaris and/or retinal pigment epithelium function.

Pharmacotherapy of Central Serous Chorioretinopathy: A Review of the Current Treatments

BACKGROUND

Central serous chorioretinopathy (CSC) is the fourth most frequent retinal disorder in terms of prevalence. It typically occurs in young subjects and affects men more often than women. CSC is characterized by serous retinal detachment (SRD) involving mainly the macular area. The clinical course is usually selflimited, with spontaneous resolution within 3 months. The persistence of SRD or multiple relapse may result in a chronic form of CSC distinguished by permanent retinal pigment epithelium (RPE) and photoreceptor damage. As the pathogenetic mechanism of CSC primarily involves RPE and choroidal vascularization, the current therapeutic approaches aim to restore the normal functions of RPE and normal choroidal vascular permeability. In this review, the authors aim to summarize the current therapeutic approach to CSC.

METHODS

A comprehensive review of the literature was conducted in PubMed by searching for relevant studies on the current therapeutic options for CSC, including simple observation, conventional laser treatment, subthreshold laser treatment (SLT), photodynamic therapy (PDT) with verteporfin, treatment with mineralocorticoid receptor (MR) antagonists and treatment with anti-vascular endothelial growth factor drugs.

RESULTS

Since most cases resolve spontaneously, the most common initial CSC treatment is observation. Current evidence suggests that PDT and SLT are valuable in improving visual acuity, reducing subretinal fluid and maintaining long-term effectiveness. No clear evidence of efficacy has been achieved for anti-VEGF. MR antagonists might be a viable choice for the treatment of chronic CSC.

CONCLUSION

The pathophysiology of CSC remains poorly understood and as a consequence, the gold standard of care for CSC is yet to be defined. To date, PDT and SLT continue to offer good clinical outcomes. Positive preliminary results seem to emerge from the studies of MR antagonists.

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.

Current Therapeutic Approaches to Chronic Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSCR) is the second most common maculopathy after diabetic maculopathy between the third and fifth decades of life. CSCR is characterized by serous neurosensory retinal detachment occasionally coexisting with retinal pigment epithelium (RPE) detachment. CSCR usually has good clinical prognosis, often resolving spontaneously within the first three months. However, some patients may have recurrent episodes and chronic disease. CSCR can cause permanent visual loss due to persistent neurosensory retinal detachment and RPE atrophy, especially in chronic cases. In recent years, verteporfin-photodynamic therapy applied with standard and low-dose/low-fluence protocols, anti-vascular endothelial growth factors, glucocorticoid antagonists, mineralocorticoid receptor antagonists, and subthreshold micropulse laser with varying parameters have been investigated as treatment options. In this review, we evaluated randomized and non-randomized case series conducted after 2000 that included at least 3 patients with chronic CSCR over 3 months in duration who were treated with current treatment options for chronic CSCR.

Short-duration multiple-session subthreshold micropulse yellow laser (577 nm) for chronic central serous chorioretinopathy: results at 3 years

OBJECTIVES

To review the 3-year follow-up results of subthreshold micropulse yellow laser (SMYL) delivered by a short-duration multiple-session method for treatment of chronic central serous chorioretinopathy (CSC).

METHODS

A total of 27 eyes from 27 patients with chronic CSC available for 3 years of follow-up were enrolled in this retrospective and interventional study. Patients were treated with 577-nm SMYL photocoagulation at a 15% duty cycle over multiple sessions, with low power ranging from 200 to 400 mW that was increased in 100 mW increments according to resolution of subretinal fluid at monthly follow-up. Laser titration was not performed. A treatment duration of 20 ms rather than the conventional duration (100-300 ms) was applied over the area of retinal pigment epithelium leakage and all areas of serous retinal detachment, including the fovea.

RESULTS

The mean follow-up period was 3.7 ± 0.8 years (range, 3-6 years). A total of 22 out of 27 eyes (81.5%) including six cases of recurrence during the follow-up period exhibited complete resolution of subretinal detachment at final follow-up, whereas only five eyes (15.5%) had either a partial or null response to SMYL treatment. The baseline best-corrected visual acuity was 0.26 ± 0.24 logarithm of the minimum angle of resolution (logMAR), which was improved to 0.08 ± 0.15 logMAR at 1-year (p = 0.005) and 3-year (p = 0.01) follow-up. The central macular thickness at baseline was 389.6 ± 103.4 μm, which was changed to 197.2 ± 40.0 μm (p < 0.001) at 1-year follow-up, 196.4 ± 40.2 μm (p < 0.001) at 3-year follow-up.

CONCLUSION

Short-duration multiple-session SMYL therapy may be effective for long-term treatment of chronic CSC.

Application of subthreshold laser therapy in retinal diseases: a review

Introduction

Laser photocoagulation has been a valuable tool in the ophthalmologist's armamentarium for decades. Conventional laser photocoagulation relies on visible retinal burns as a treatment endpoint, which is thought to result in photocoagulative necrosis of retinal tissue. Recent studies have suggested that using subthreshold (ST) laser, which does not cause detectable damage to the retina may also have therapeutic effects in a variety of retinal diseases. Areas covered: We review the proposed biological mechanisms mediating the therapeutic effects of subthreshold laser on the retina, followed by the evidence for ST laser efficacy in retinal diseases such as diabetic macular edema, central serous chorioretinopathy, age-related macular degeneration, and retinal vein occlusion.

Expert Commentary

Multiple clinical studies demonstrate that subthreshold laser does not cause structural damage to the retina based on multimodal imaging. Evidence suggests that there is a therapeutic effect on decreasing diabetic macular edema and subretinal fluid in chronic central serous retinopathy; however, the effect may be relatively modest and is not as efficacious as first line treatments for these diseases. Given the repeatability and lack of damage to the retina by this treatment, subthreshold laser deserves further study to determine its place in the retina specialist's armamentarium.

Going green - treatment outcome and safety profile of chronic central serous chorioretinopathy treated with subthreshold green laser

Aim

Subthreshold lasers have gained popularity in the treatment of chorioretinopathy central serous chorioretinopathy (CSCR) and yellow (577 nm) lasers have completely revolutionized the treatment. However, there is very little literature regarding the use of a more common and conventional – green (532 nm) subthreshold laser for the treatment of chronic CSCR. We report the use of green (532 nm) laser for the treatment of chronic CSCR and its outcome.

Methods

Eyes with nonresolving CSCR were treated with green subthreshold laser and evaluated at the end of 5 months. Visual acuity, central macular thickness (CMT), and macular volume (MV) at baseline and at 5 months following treatment were evaluated.

Results

Thirteen eyes with chronic CSCR were treated with green laser in SP-Mode™. The mean duration of CSCR was 7.64±3.77 months at the time of treatment. The median age of the patients was 41 (35–57) years. The baseline mean best-corrected visual acuity (BCVA) was 0.96 logMAR ± 0.17, with mean baseline CMT of 503.8 μm ± 181.9 and MV of 12.8 mm³ ± 3.81. The mean CMT at 5 months was 211 μm ± 31.7 and mean MV was 9.65 mm³ ± 0.60, correlating to a mean decrease of 292 μm ± 79 in CMT and mean decrease of 3.18 mm³ ± 1.87 in the MV from baseline (P<0.05). The mean BCVA after treatment was 0.18 logMAR±0.09 (P<0.05). Two cases of CSCR with pigment epithelial detachment (PED) also had complete resolution of both at 5 months.

Conclusion

Subthreshold green laser (532 nm) is a safe and effective modality for the treatment of chronic CSCR with very good and stable outcomes. It may also be beneficial in the treatment of PEDs.

Subthreshold diode micropulse laser versus observation in acute central serous chorioretinopathy

BACKGROUND

The purpose of this study was to evaluate subthreshold diode micropulse (SDM) laser as a treatment modality in acute central serous chorioretinopathy (CSC) and compare it with the current standard of care (observation).

METHODS

A randomised controlled trial was conducted on 68 eyes (34 eyes in SDM laser group and 34 eyes in observation group) with acute CSC, with a single angiographic leak and duration of complaints less than two months. Detailed history, examination and investigations were performed at the baseline and at regular intervals until six months.

RESULTS

Eyes in the laser group had significantly higher best-corrected visual acuity at two weeks (p = 0.002), four weeks (p < 0.001), eight weeks (p < 0.001), 16 weeks (p = 0.042) and six months (p = 0.008), and higher contrast sensitivity at eight weeks (p = 0.008), 16 weeks (p < 0.001) and six months (p < 0.001). A recurrent/persistent neurosensory detachment was observed at the end of six months in 11.76 per cent of SDM laser treated eyes versus 29.41 per cent of eyes in the observation group (p = 0.036).

CONCLUSION

SDM laser produces faster and superior visual rehabilitation without any adverse effects. It also reduces the chances of CSC going into chronicity and recurrence compared to the current standard of care (observation).

Early Focal Laser Photocoagulation in Acute Central Serous Chorioretinopathy: A Prospective, Randomized Study

BACKGROUND AND OBJECTIVE

To evaluate the role of early focal laser photocoagulation in acute central serous chorioretinopathy (CSC).

PATIENTS AND METHODS

A total of 58 eyes with acute naïve CSC (less than 2 months' duration) with focal leak on fundus fluorescein angiography (FFA) were randomized into either a laser or a sham laser group. Eyes with chronic CSC and subfoveal leak were excluded. Visual acuity assessment, microperimetry, optical coherence tomography, and FFA were done at baseline, 1 month (minus FFA), 3 months, and 6 months after treatment.

RESULTS

There was a significant improvement in best-corrected visual acuity, low-contrast visual acuity, retinal sensitivity, and central macular thickness at all visits in both groups (P < .001); however, there was no significant difference between the groups regarding time of resolution. Four eyes in the sham laser group needed rescue laser compared with one eye in early laser group (P = .16).

CONCLUSION

Early laser photocoagulation is not superior to sham laser for acute CSC; therefore, observation appears to the safest and most effective strategy. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:564-571.].

A Review of Subthreshold Micropulse Laser for Treatment of Macular Disorders

Micropulse laser treatment is an alternative to the conventional continuous-wave laser for the treatment of retinal or macular diseases. In contrast to the conventional laser, the therapeutic effect of the subthreshold micropulse laser is not accompanied by thermal retinal damage. This fact is of particular importance when a treatment near the fovea is required. Micropulse treatment is applied in indications such as central serous chorioretinopathy (CSC), diabetic macular edema (DME), or macular edema due to retinal vein occlusion (RVO). This review outlines and discusses the published literature of subthreshold micropulse laser treatment for CSC, DME, and macular edema after RVO.

Yellow Pattern 577-nm Micropulse Laser: Treatment of Macular Edema from Radiation Retinopathy - A Case Report

We report a case of a 60-year-old Asian male who developed radiation retinopathy 23 years after initial radiotherapy for nasopharyngeal carcinoma and was successfully treated with yellow pattern 577-nm micropulse laser. Secondary macular edema and visual acuity improved following a single treatment session with minimal scarring. Yellow pattern micropulse laser is a safe and effective treatment for macular edema secondary to radiation retinopathy.

Low-Fluence Photodynamic Therapy versus Subthreshold Micropulse Yellow Wavelength Laser in the Treatment of Chronic Central Serous Chorioretinopathy

Purpose. To compare the efficacy and safety of subthreshold micropulse yellow wavelength laser (SMYL) and low-fluence photodynamic therapy (PDT) in the treatment of chronic central serous chorioretinopathy (CSC). Methods. Thirty-three eyes of 30 patients with chronic CSC received either PDT (18 eyes) or SMYL (15 eyes) therapy. Best corrected visual acuity (BCVA), subretinal fluid (SRF) height, and central macular thickness (CMT) were evaluated at the baseline visit and one, three, six, nine, and 12 months after the therapy. Results. After 12 months, mean BCVA improved from 67.3 ± 14.2 to 71.5 ± 21.4 ETDRS letters in SMYL group and from 60.7 ± 16.3 to 64.4 ± 24.9 ETDRS letters in PDT group (p = 0.285 and p = 0.440, resp.). Mean CMT decreased from 242.8 ± 80 μm to 156.9 ± 60 μm in the PDT group and from 287.3 ± 126 μm to 138.0 ± 40 μm in the SMYL group (p = 0.098 and p = 0.003, resp.). SRF resolved completely in 72.2% and 80.0% of the eyes in the PDT and SMYL groups, respectively. Mean SRF height decreased from 117.2 ± 58 μm to 31.3 ± 56 μm in the PDT group and from 130.0 ± 104 μm to 12.5 ± 21 μm in the SMYL group (p = 0.031 and p = 0.014, resp.). Conclusions. Subthreshold micropulse yellow wavelength laser seems to be effective in the treatment of chronic CSC without any side effect and results in the resorption of SRF without causing visible retinal scarring.

Microsecond yellow laser for subfoveal leaks in central serous chorioretinopathy

Purpose

To evaluate the role of navigated yellow microsecond laser in treating subfoveal leaks in nonresolving central serous chorioretinopathy (CSC).

Methods

This prospective study included ten eyes of ten consecutive patients with nonresolving CSC with subfoveal leaks. All eyes were treated with 577 nm navigated yellow microsecond laser (5% duty cycle). Key inclusion criteria include a vision loss for a duration of minimum 3 months duration due to focal subfoveal leak on fluorescein angiography. Key exclusion criteria include prior treatment for CSC and any signs of chronic CSC. Comprehensive examination, in addition to low-contrast visual acuity assessment, microperimetry, autofluorescence, spectral domain optical coherence tomography, and fundus fluorescein angiography, was done at baseline, 1, 3, and 6 months after treatment. Rescue laser was performed as per predefined criteria at 3 months.

Results

The average best-corrected visual acuity improved from 73.3±16.1 letters to 75.8±14.0 (P=0.69) at 3 months and 76.9±13.0 (P=0.59) at 6 months, but was not statistically significant. Low-contrast visual acuity assessment (logMAR) improved from 0.41±0.32 to 0.35±0.42 (P=0.50) at 3 months and 0.28±0.33 (P=0.18) at 6 months. Average retinal sensitivity significantly improved from baseline 18.93±7.19 dB to 22.49±6.67 dB (P=0.01) at 3 months and 21.46±8.47 dB (P=0.04) at 6 months. Rescue laser was required only in one eye at 3 months; however, laser was required in three eyes at 6 months.

Conclusion

Microsecond laser is a safe and effective modality for treating cases of nonresolving CSC with subfoveal leaks.

Randomized Clinical Trial to Compare Micropulse Photocoagulation Versus Half-dose Verteporfin Photodynamic Therapy in the Treatment of Central Serous Chorioretinopathy

BACKGROUND AND OBJECTIVE

To evaluate subthreshold diode-laser micropulse (SDM) versus half-dose verteporfin photodynamic therapy (hd-PDT) in central serous chorioretinopathy (CSC).

PATIENTS AND METHODS

62 eyes of 62 patients were prospectively followed for changes in fluorescein angiography (FA), fundus autofluorescence (FAF), central macular thickness (CMT), best-corrected visual acuity (BCVA), and contrast visual acuity (CVA) after SDM (n=20) or hdPDT (n=24). CSC observation served as control group (n=18).

RESULTS

Both treatment groups (60% SDM vs. 66.7% hdPDT) showed significant improvement in reduction of leakage activity compared to the control group (37.5%) at 16 weeks. CMT decreased by 69.7 µm (SDM), 109.8 µm (hdPDT), and 89 µm (control). BCVA improved by +6.7 (SDM group), +8.5 (hdPDT), and +1.5 ETDRS letters (control). CVA was best improved in the hdPDT group. No secondary RPE alterations could be detected by FAF after any intervention.

CONCLUSION

In comparison to the control group, hdPDT and SDM resulted in reduced leakage activity in FA and enhanced photopic and scotopic visual acuity in patients with CSC.

Half-dose photodynamic therapy followed by diode micropulse laser therapy as treatment for chronic central serous chorioretinopathy: evaluation of a prospective treatment protocol

PURPOSE

To evaluate the outcome of a prospective protocol for the treatment of chronic central serous chorioretinopathy (CSC).

METHODS

Interventional prospective case series in 59 eyes (59 patients) with active chronic CSC. All patients were first treated with indocyanine green angiography (ICGA)-guided half-dose photodynamic therapy (PDT). In case of persistent serous subretinal fluid (SRF) after a follow-up period of at least 6 weeks, ICGA-guided PDT was repeated. If the SRF persisted after two PDT treatments, additional ICGA-guided high-density subthreshold diode micropulse laser (HSML) therapy was performed. Clinical evaluation included best-corrected visual acuity (BCVA), fundoscopy, OCT, fundus autofluorescence, fluorescein angiography and ICGA.

RESULTS

After a single PDT treatment, complete resolution of SRF was seen in 37 of 59 eyes. Of the 22 eyes with no complete resolution of SRF, 19 eyes received a second PDT treatment, after which seven eyes of the 19 eyes showed a complete resolution of SRF. Ten eyes underwent HSML, of which one eye had complete resolution of SRF within 7 weeks. At final follow-up a complete resolution of SRF was present in 80% of all eyes. The mean BCVA improved from 0.28 logMAR at baseline to 0.16 logMAR at final follow-up. Improvement of BCVA was highest after the first treatment (-0.12 logMAR, p < 0.001).

CONCLUSIONS

The proposed treatment strategy using half-dose PDT and HSML in active chronic CSC resulted in an anatomical success rate of 80%. The first half-dose PDT treatment has the highest likelihood of a favourable treatment response on OCT and BCVA increase.

Subthreshold micropulse yellow laser treatment for nonresolving central serous chorioretinopathy

Purpose

To report the efficacy and safety of micropulse 577 nm yellow laser in the treatment of nonresolving central serous chorioretinopathy (CSC) cases.

Patients and methods

The study included 15 eyes with nonresolving CSC lasting more than 3 months. All the patients were subjected to complete ophthalmic examination, in addition to contrast sensitivity measurement, fundus fluorescein angiography, and optical coherence tomography. All eyes were subjected to 577 nm subthreshold micropulse laser treatment, using the IQ 577 device, and followed up after 4 weeks, 2 months, 3 months, and 6 months. The outcome measures were change in best-corrected visual acuity, contrast sensitivity, subretinal fluid height, and change in macular thickness measured by optical coherence tomography.

Results

The average age of the patients was 36.4 years; eleven were males and four were females. Average duration of the leakage was 4.6 months. The mean best-corrected visual acuity measured 6 months after laser treatment was 0.85±0.097, in comparison to 0.67±0.097 before laser treatment (statistically significant [SS], P<0.05). The mean central macular thickness before laser was 389.6±46.4 µm, in comparison to 263.6±24 µm after 6 months (SS, P<0.05). The mean post-laser log contrast sensitivity measured using the Pelli–Robson contrast sensitivity chart was 1.73±0.14, while the initial log contrast sensitivity was 1.48±0.28 (SS, P<0.05).

Conclusion

Subthreshold micropulse laser treatment is an effective and safe treatment option for patients with nonresolving CSC.

Central Serous Chorioretinopathy Treatments: A Mini Review

Central serous chorioretinopathy (CSC) is a retinal disorder that primarily affects young (20- to 50-year-old) white men, although it is seen occasionally in older patients and females. CSC is characterized by avascular focal leakage through the retinal pigment epithelium (RPE), resulting in serous detachment of the neurosensory retina. The course is usually self-limiting and in most cases resolves spontaneously within a 3-month period, with visual acuity usually recovering to 20/30 or better. However, chronic CSC may develop as a consequence of recurrences or persistent neurosensory detachment, and can result in progressive RPE atrophy and permanent visual loss. A primary involvement of the RPE and choroidal vascularization play a significant role in the pathogenesis of CSC and the current treatment options attempt to restore the functions of the RPE and the normal choroidal vasculature. The aim of the current review is to provide an overview of the current therapeutical approaches to CSC, including observation, laser treatment, photodynamic therapy with verteporfin, intravitreal anti-vascular endothelial growth factor therapy and the mineralocorticoid receptor antagonists.

Advances in the treatment of central serous chorioretinopathy

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

Subthreshold micropulse yellow laser (577 nm) in chronic central serous chorioretinopathy: safety profile and treatment outcome

PURPOSE

To assess the safety and efficacy of a single session of subthreshold micropulse (SM) yellow laser (577 nm) in the treatment of chronic central serous chorioretinopathy (CSCR).

METHODS

This was a retrospective analysis of 15 eyes of 13 patients with CSCR of >3 months duration who had been treated with SM yellow laser (577 nm). All patients had been treated using multiple spots of laser with a duty cycle of 10% over areas of focal and diffuse leak, as seen on fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA). Reduction in subretinal fluid height on spectral domain optical coherence tomography (SD-OCT) was used to measure the response to treatment.

RESULTS

The mean follow-up was at 8 weeks (4-19 weeks). All eyes responded to treatment. The mean subretinal fluid height pre and post treatment was 232 and 49 μm, respectively, showing a 79% average reduction (P<0.001) in fluid height. There was no evidence of retinal pigment epithelium or retinal damage on SD-OCT, FFA, or fundus autofluorescence. Median visual improvement was one line on Snellen's visual acuity chart (P=0.015). Microperimetry was performed in eight eyes of which six eyes (75%) showed an improvement in the threshold values post treatment.

CONCLUSION

SM yellow laser is an effective treatment option for chronic CSCR.

Recent developments in retinal lasers and delivery systems

Photocoagulation is the standard of care for several ocular disorders and in particular retinal conditions. Technology has offered us newer lasing mediums, wavelengths and delivery systems. Pattern scan laser in proliferative diabetic retinopathy and diabetic macular edema allows laser treatment that is less time consuming and less painful. Now, it is possible to deliver a subthreshold micropulse laser that is above the threshold of biochemical effect but below the threshold of a visible, destructive lesion thereby preventing collateral damage. The advent of solid-state diode yellow laser allows us to treat closer to the fovea, is more effective for vascular structures and offers a more uniform effect in patients with light or irregular fundus pigmentation. Newer retinal photocoagulation options along with their advantages is discussed in this review.

Navigated focal laser photocoagulation for central serous chorioretinopathy

Background and objective

To assess the efficacy of navigated laser (Navilas^®) treatment for central serous chorioretinopathy.

Materials and methods

Prospective study included 16 eyes of 15 subjects with nonresolving central serous chorioretinopathy. Fluorescein-angiography guided Navilas^® treatment was performed. Pre- and posttreatment best-corrected visual acuity, pre- and posttreatment central macular thickness, number of leaks on fluorescein angiography, and various treatment parameters were analyzed. Pain experience was evaluated using the visual analog pain scale.

Results

Sixteen eyes from 15 subjects (mean age 42.2±9.9 years) were analyzed. Mean duration of symptoms was 11.45±6.6 months. Average number of leaks per eye was 2.8 and one laser spot per leak was performed. There was complete resolution of subretinal fluid in 15 out of 16 eyes at 2 months. Average visual analog pain scale score was 0.63±1.41.

Conclusion

Navilas^® without a contact lens achieved resolution of subretinal fluid with a single laser spot for each single leak and minimum iatrogenic damage.

Central serous chorioretinopathy: update on pathophysiology and treatment

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

Subthreshold diode laser micropulse photocoagulation for the treatment of diabetic macular edema

Diabetic macular edema (DME) is a sight-threatening complication of diabetic retinopathy, the leading cause of visual loss in the working-age population in the industrialized and emerging world. The standard of care for DME is focal/grid laser photocoagulation, which is proven effective in reducing the risk of vision loss, but inherently destructive and associated with tissue damage and collateral effects. Subthreshold diode laser micropulse photocoagulation is a nondestructive tissue-sparing laser procedure, which, in randomized controlled trials for the treatment of DME, has been found equally effective as conventional photocoagulation. Functional and anatomical outcomes from four independent randomized controlled trials provide level one evidence that vision stabilization/improvement and edema resolution/reduction can be elicited with less or no retinal damage, and with fewer or no complications. This review describes the principles of subthreshold diode laser micropulse photocoagulation, its treatment modalities and clinical outcomes in the context of standard laser treatments and of emerging nonlaser therapies for DME.

An Update on the Diagnosis and Management of Central Serous Chorioretinopathy

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

Review and update of central serous chorioretinopathy

PURPOSE OF REVIEW

Greater understanding of central serous chorioretinopathy (CSCR) has changed initial beliefs that CSCR is a benign condition affecting young men with almost complete resolution. CSCR has a spectrum of presentations with more diffuse retinal dysfunction and variations between races. CSCR can affect older individuals and in a subset of patients may lead to significant ocular morbidity.

RECENT FINDINGS

Advances in imaging, particularly in indocyanine green angiography and optical coherence tomography, have led to a greater understanding of the pathophysiology of this condition. Treatments for CSCR are still evolving, in particular photodynamic dynamic therapy using lower doses and reduced fluence showing promising results. More research is required on ideal dosage. Anti-vascular endothelial growth factor treatment offers a new medical treatment modality with promising results.

SUMMARY

There have been recent imaging developments in addition to therapeutic advances for refractory CSCR.

Retinal light toxicity

The ability of light to enact damage on the neurosensory retina and underlying structures has been well understood for hundreds of years. While the eye has adapted several mechanisms to protect itself from such damage, certain exposures to light can still result in temporal or permanent damage. Both clinical observations and laboratory studies have enabled us to understand the various ways by which the eye can protect itself from such damage. Light or electromagnetic radiation can result in damage through photothermal, photomechanical, and photochemical mechanisms. The following review seeks to describe these various processes of injury and many of the variables, which can mitigate these modes of injury.

Central serous chorioretinopathy: an update on pathogenesis and treatment

Central serous chorioretinopathy (CSC) is a chorioretinal disease, incompletely understood with systemic associations, a multifactorial aetiology, and a complex pathogenesis. Increased permeability from the choriocapillaris leads to focal or diffuse dysfunction of the retinal pigment epithelium causing a detachment of the neurosensory retina. CSC has been described in patients with endogenously high levels of corticosteroids as well as in patients with hypercortisolism due to the treatment of ocular or systemic diseases. It is therefore the only 'inflammatory' choroiditis, not proven to be associated with infection that is precipitated or worsened by glucocorticoids. Foveal attenuation, chronic macular oedema, and damage of the foveal photoreceptor layer have been reported as causes of visual loss in CSC. Photoreceptor atrophy in the fovea, despite successful retinal reattachment, typically occurs after a duration of symptoms of approximately 4 months. Treatment should therefore be considered after 3 months if there is angiographic evidence of ongoing foveal leakage in recurrent chronic CSC or in a single CSC episode accompanied by signs of chronic CSC alterations. Based on results of trials conducted so far, it appears that photodynamic therapy with verteporfin is effective and safer than argon laser treatment and should be considered as the treatment of choice, whereas micropulse diode laser photocoagulation seems to be an effective alternative. Glucocorticoid inhibitors are an interesting alternative treatment. Clinical trials are ongoing to test their efficacy. In addition, it is important, where possible, to discontinue any corticosteroid treatment. The possible association of CSC with stress should also be discussed with patients.

Micropulsed diode laser therapy: evolution and clinical applications

Many clinical trials have demonstrated the clinical efficacy of laser photocoagulation in the treatment of retinal vascular diseases, including diabetic retinopathy. There is, however, collateral iatrogenic retinal damage and functional loss after conventional laser treatment. Such side effects may occur even when the treatment is appropriately performed because of morphological damage caused by the visible endpoint, typically a whitening burn. The development of the diode laser with micropulsed emission has allowed subthreshold therapy without a visible burn endpoint. This greatly reduces the risk of structural and functional retinal damage, while retaining the therapeutic efficacy of conventional laser treatment. Studies using subthreshold micropulse laser protocols have reported successful outcomes for diabetic macular edema, central serous chorioretinopathy, macular edema secondary to retinal vein occlusion, and primary open angle glaucoma. The report includes the rationale and basic principles underlying micropulse diode laser therapy, together with a review of its current clinical applications.