Reduced-fluence photodynamic therapy for subfoveal serous pigment epithelial detachment with choroidal vascular hyperpermeability

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.

Choroidal Volume Evaluation after Photodynamic Therapy Using New Optical Coherence Tomography Imaging Algorithm

To evaluate choroidal volume and thickness changes after photodynamic therapy (PDT) for chronic central serous chorioretinopathy (CSC). Chronic CSC eyes with a history of PDT were selected. Average choroidal volume, average choroidal thickness, the maximum and minimum choroidal thickness of the macula irradiated area and peripheral non-irradiated areas before and after one and three months of treatment were examined. A total of 14 patients with chronic CSC and 9 controls without any eye pathology were enrolled. The mean choroidal volume in CSC before and, and after one and three months of treatment were 2.36 (standard deviation: 0.70), 1.90 (0.69), 1.86 (0.66) mm³ for the central area, 1.25 (0.38), 1.14 (0.35), 1.13 (0.34) mm³ for superior nasal area, 1.47 (0.41), 1.28 (0.43), 1.26 (0.43) mm³ for superior temporal area, 1.07 (0.49), 0.95 (0.38), 0.93 (0.35) mm³ for inferior nasal area, 1.17 (0.38), 1.04 (0.32), 1.03 (0.33) mm³ for inferior temporal area. This study revealed the choroidal volume changes in a short period after PDT and a decrease in unirradiated choroidal volume was also shown after the treatment. The algorithm provided on the ARI Network enables to evaluate the choroidal changes quantitatively and qualitatively.

Clinical characteristics of central serous chorioretinopathy in patients by age

PURPOSE

To investigate the clinical characteristics of central serous chorioretinopathy (CSC) with age.

STUDY DESIGN

Retrospective, cross-sectional study.

METHODS

One-hundred and forty-seven CSC patients were classified into three age groups (aged <50 years (younger group; n=53), 50-70 years (middle group; n=68), and >70 years (senior group; n=26)) and the characteristics were compared. Bilateral ophthalmic evaluation included the best corrected visual acuity (BCVA), spherical equivalents, fundus examination, fundus autofluorescence, optical coherence tomography (OCT), fluorescein angiography (FA), and indocyanine green angiography.

RESULTS

The male/female ratio became lower at more advanced ages (P=0.011). Bilateral macular abnormalities were observed more frequently in the senior group than the other groups (p=0.018) and multiple drusen were characteristic in the senior group (p<0.0001). The more advanced age groups displayed a worse BCVA (P=0.002). The rate of eyes with flat retinal pigment epithelium (RPE) elevation on OCT was significantly higher in the middle group than the other groups (P=0.024). The mean subfoveal choroidal thickness (SCT) was thickest in the younger group (P<0.0001). Unifocal leakage on FA and choroidal vascular hyperpermeability were mostly found in eyes of the younger group (P<0.001,P=0.020).

CONCLUSION

CSC cases in those aged >70 years were associated with an increased proportion of women and having bilateral macular abnormalities, multiple drusen, and multifocal leakage sites. The BCVA and the SCT decreased with age. Patients with CSC aged 50-70 years had the highest rate of flat RPE elevation on OCT. These characteristics need to be considered to make an accurate diagnosis, particularly in elderly patients.

Optimal fluence rate of photodynamic therapy for chronic central serous chorioretinopathy

AIMS

To investigate the lowest effective fluence rate of photodynamic therapy (PDT) for treating chronic central serous chorioretinopathy (CSC).

METHODS

Fifty-one eyes of 51 patients with chronic CSC were randomly treated with 30% (n=15), 40% (n=16) or 50% (n=17) of the standard-fluence rate of PDT and followed up for 12 months. The success rate, recurrence rate, mean best-corrected visual acuity (BCVA), central foveal thickness (CFT), subfoveal choroidal thickness (SFCT), integrity of the outer retinal layer and complications were evaluated at baseline and at the follow-up periods after PDT.

RESULTS

The rate of complete subretinal fluid (SRF) resolution in the 30%-fluence, 40%-fluence and 50%-fluence groups was 60.0%, 81.2% and 100.0%, respectively, at 3 months (p=0.009), and 80.0%, 94.0% and 100.0%, respectively, at 12 months (p=0.06). The recurrence rate in the 50%-fluence group was lower than that in the 30%- and 40%-fluence groups at 12 months (30% vs 50%, 40% vs 50%; p=0.002, p=0.030, respectively (log-rank test)). The mean BCVA improved significantly 12 months after PDT only in the 40%- and 50%-fluence groups (p=0.005, p=0.003, respectively). Mean CFT and SFCT decreased significantly at 12 months in the three groups. The rate of complications did not differ significantly among the three groups.

CONCLUSIONS

A 50%-fluence rate of PDT seems to be the most effective for treating chronic CSC, considering the low recurrence rate and high rate of complete SRF resolution, compared with other low-fluence PDT.

TRIAL REGISTRATION NUMBER

NCT01630863.

FULL-THICKNESS MACULAR HOLE COMBINED WITH PIGMENT EPITHELIAL DETACHMENT USING MULTIMODAL IMAGING

PURPOSE

To describe two patients who showed full-thickness macular holes (FTMH) combined with pigment epithelial detachments (PED) and had contrasting outcomes to treatment.

METHODS

A retrospective report of two cases.

RESULTS

Case 1 was treated with intravitreal antivascular endothelial growth factor and photodynamic therapy, and the PED flattened. Subsequently, a vitrectomy was performed and the FTMH closed. Her visual acuity improved from 20/200 to 20/25. In Case 2, the same medical therapy, with less frequency compared with Case 1, did not affect the PED, and the FTMH failed to close with surgery. Later, a spontaneous collapse of the PED occurred but the FTMH was persistent with an associated poor visual acuity of 20/200.

CONCLUSION

Full-thickness macular hole is rare, but can occur in association with large PEDs. Although the pathologic mechanism was uncertain, visual outcomes were dependent on response to treatments of the PED, as well as anatomical closure of the FTMH.

Reduced-fluence photodynamic therapy in polypoidal choroidal vasculopathy nonresponsive to ranibizumab

BACKGROUND AND OBJECTIVE

To evaluate the effect of reduced-fluence photodynamic therapy (PDT) on polypoidal choroidal vasculopathy (PCV) unresponsive to intravitreal ranibizumab.

PATIENTS AND METHODS

Patients with PCV unresponsive to ranibizumab administered 3 months consecutively who then received reduced-fluence PDT were retrospectively surveyed. Nonresponders were defined as patients having no reduction in intraretinal and/or subretinal fluid after 3 consecutive treatments.

RESULTS

In total, 22 of 104 eyes (21.2%) were non-responders, and 16 of 22 nonresponders received reduced-fluence PDT. Nine eyes achieved complete fluid resolution, and six had reduced but persistent fluid. In one eye, fluid persisted at 6 months despite an additional anti-vascular endothelial growth factor (anti-VEGF) injection after reduced-fluence PDT. Mean macular thickness decreased significantly at 3 and 6 months after PDT, but the mean visual acuity was worse than baseline.

CONCLUSION

Reduced-fluence PDT in nonresponders gradually decreased intraretinal and/or subretinal fluid over several months but did not maintain visual acuity.

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

PURPOSE

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

DESIGN

Retrospective case series.

PARTICIPANTS

Patients with CSC who underwent PDT.

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Intravitreal anti-VEGF therapy for vascularized pigment epithelium detachment in age-related macular degeneration

PURPOSE

To assess the efficacy of intravitreal anti-vascular endothelial growth factor (VEGF) treatment of vascularized pigment epithelial detachment (PED) due to age-related macular degeneration (AMD).

METHODS

A total of 26 patients with vascularized PED secondary to AMD were retrospectively analyzed and treated with anti-VEGF intravitreal injections according to a PRN regimen after 3 initial injections. Best-corrected visual acuity (BCVA), optical coherence tomography, and fluorescein angiography were performed at baseline and quarterly.

RESULTS

Mean follow-up ranged from 9 to 26 months (mean 13.5). There was a deterioration in mean BCVA from 0.46 at baseline to 0.79 logMAR at 12 months (p<0.001). The mean PED greatest linear diameter (GLD) increased from 4499 at baseline to 5206 μm at 1-year follow-up (p<0.001). The mean PED maximum height decreased from 669 μm at baseline to 305 μm at 1-year follow-up (p = 0.001). The mean central retinal thickness (CRT) was unchanged (from 277 to 209 μm at 1 year follow-up) (p = 0.099). No effect was seen on the change of VA according to groups of baseline predictors as defined by the medial value: baseline VA, PED height, and CRT (p>0.10).There was a borderline trend (p = 0.064) that GLD affected response to treatment. The mean number of injections was 5.5 (3 to 9). Seven out of 26 (27%) patients developed a retinal pigment epithelium (RPE) tear.

CONCLUSIONS

Intravitreal anti-VEGF therapy, with a PRN regimen, did not prevent visual acuity loss or RPE tear.

Efficacy of reduced-fluence photodynamic therapy for serous retinal pigment epithelial detachment with choroidal hyperpermeability

BACKGROUND

Very few reports have addressed methods of treatment for idiopathic serous (IS) pigment epithelial detachment (PED).

OBJECTIVE

The purpose of this report was to describe clinical courses of two patients with ISPED in whom reduced-fluence photodynamic therapy (RFPDT) was performed.

CASE REPORTS

Two patients (a 38-year-old woman and a 42-year-old man) were diagnosed with ISPED. In both patients, indocyanine green angiography revealed an area of choroidal vascular hyperpermeability including hyperfluorescent PED, which was evident at the subfoveal area. Both patients underwent RFPDT at an energy of 25 J/cm(2). The PED was seen to have resolved 1 month after the treatment and visual acuity was maintained or improved. There was no posttreatment recurrence of PED after 6 months to 1 year, and no treatment-related adverse events were observed.

CONCLUSION

RFPDT may be an effective and safe method of treatment for ISPED with choroidal vascular hyperpermeability.