Choroidal Thickness Changes After Photodynamic Therapy and Recurrence of Chronic Central Serous Chorioretinopathy

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.

Central serous chorioretinopathy: updates in the pathogenesis, diagnosis and therapeutic strategies

Central serous chorioretinopathy (CSCR), first described by Albrecht von Graefe in 1866, is characterized by focal serous detachment of the neural retina and/or retinal pigment epithelium (RPE) in the posterior pole. CSCR is the first ever described pachychoroid disease. Most recently, hypothetical venous overload choroidopathy is also proposed due to its distinguished morphological and pathological characteristics, including choroidal thickening, choriocapillaris hyperpermeability, remodelling, and intervortex venous anastomoses. Identification of genetic variants is necessary to comprehend the pathophysiology of CSCR. The novel multimodality imaging platforms, including the ultra-widefield imaging system, flavoprotein fluorescence, fluorescence lifetime imaging ophthalmoscopy, and multispectral imaging system, have been used for diagnosing and managing CSCR. Half-dose photodynamic therapy (PDT) remains the mainstay of clinical practice, with about 95% of patients with chronic CSCR improving to visual acuity (VA) of 20/30 or better. The use of oral eplerenone for routine clinical care remains controversial, and long-term randomized clinical trials are warranted to investigate its efficacy in acute and chronic CSCR. While CSCR has generally been recognized as a self-limiting disease with good prognosis, the underlying pathogenesis is still not fully understood, and treatments are often not fully effective. With new evidence emerging about pachydrusen being a disease precursor in both CSCR and polypoidal choroidal vasculopathy (PCV), it would be interesting to investigate whether CSCR can be a precursor to PCV. In this review, we highlighted the currently available evidence on the pathogenesis, diagnosis, multimodality imaging features, and management strategies, including recent findings related to CSCR.

Outer nuclear layer recovery as a predictor of visual prognosis in type 1 choroidal neovascularization of neovascular age-related macular degeneration

To investigate the changes in outer nuclear layer (ONL) thickness during anti-vascular endothelial growth factor (VEGF) treatment in type 1 choroidal neovascularization (CNV) and its impact on vision. Type 1 CNV eyes (n = 94) were retrospectively compared to normal control eyes (n = 35). Along with best-corrected visual acuity (BCVA), the location of CNV, foveal ONL thickness, and subretinal fluid height were measured using optical coherence tomography (OCT) and analyzed. Visual outcome and OCT biomarkers were compared. As a result, the CNV group had thinner foveal ONL and worse BCVA compared to the control group. ONL thickness recovered partially along with visual improvement following 3 monthly initial loading doses of aflibercept injections, and it correlated with the final BCVA during the 1-year follow-up. Eyes achieved foveal ONL recovery over + 10 µm had lower subfoveal CNV (45.5%) and showed better visual outcomes than eyes with stationary ONL or suboptimal ONL recovery (76.0%, p = 0.012). In conclusion, type 1 CNV eyes that recovered foveal ONL thickness at initial loading of anti-VEGF demonstrated good final visual outcome during the 1-year follow-up. Monitoring the foveal ONL thickness during early anti-VEGF treatment can give information about the visual outcomes in type 1 CNV.

The Choroid after Half-Dose Photodynamic Therapy in Chronic Central Serous Chorioretinopathy

PURPOSE

To characterize choroidal structure and vasculature after half-dose verteporfin photodynamic therapy (hd-vPDT) in eyes with chronic central serous chorioretinopathy using Enhanced Depth Imaging Optical Coherence Tomography (EDI OCT) and Optical Coherence Tomography Angiography (OCT-A).

METHODS

This prospective case-control study included 10 eyes. Choroid was examined before and at 1 month following hd-vPDT. We measured choroidal thickness (CT) at subfoveal area and at 750 μm nasal and temporal of fovea and thickness of Haller and choriocapillaris/Sattler layers. Whole (WA), luminal (LA) and interstitial area (IA) at EDI-OCT, and perfusion density at OCT-A were analyzed. The unaffected fellow eyes were used for comparisons.

RESULTS

Mean CT at subfoveal area and at 750 μm nasal and temporal of fovea, values of Haller and choriocapillaris/Sattler layers and those of WA, LA and IA were reduced, while PD increased at 1 month after hd-vPDT (all p < 0.001). There was a significant (p < 0.05) negative correlation (ρ = -0.658) between PD and post-treatment logMARVA. None of analyzed parameters reached values of unaffected fellow eye.

CONCLUSION

Following hd-vPDT, choroidal thickness with both luminal and interstitial components markedly decreased, while perfusion of choriocapillaris improved.

A multicentre study of the risk factors associated with recurrence of central serous chorioretinopathy

PURPOSE

To investigate potential clinical and multimodal imaging factors in central serous chorioretinopathy (CSC) recurrence.

METHODS

The study was performed at nine Japanese medical institutions for patients who had experienced an active CSC episode. Demographic data and medical history were reviewed retrospectively. Significant differences in chronic manifestation, leakage site, leakage point number, leakage intensity, choroidal hyperpermeability, central retinal thickness (CRT) and subfoveal choroidal thickness were analysed between the recurrence and non-recurrence groups.

RESULTS

In total, 538 eyes (538 patients) diagnosed with CSC (402 men, 136 women; mean age: 53.4 ± 11.9 years) were enrolled. Among them, 253 eyes (47.0%) developed ≥1 recurrence (follow-up: 15.9 ± 13.5 months, range 3-86 months). Univariate and multivariate analyses indicated that a history of corticosteroid use (odds ratio [OR], 5.52; 95% confidence interval [CI], 1.39-21.92; p = 0.015), bilateral disease (OR, 3.94; 95% CI, 1.47-10.6; p = 0.007), chronic manifestations (OR, 7.12; 95% CI, 2.93-17.28; p < 0.001), non-intense fluorescein leakage (OR, 3.34; 95% CI, 1.44-7.75; p = 0.005) and initial CRT (OR, 0.997; 95% CI, 0.993-0.999; p = 0.049) were significantly associated with CSC recurrence. Receiver operating characteristic curves were created, and the area under the curve for the multivariate logistic regression model of these five factors was 0.814.

CONCLUSION

Patients with CSC who received corticosteroids and had bilateral disease, chronic manifestation, non-intense fluorescein leakage on fluorescein angiography or a relatively thinner CRT should be closely monitored to identify whether they are at high risk of recurrence.

Longitudinal multimodal functional macular analysis after half-dose photodynamic therapy for central serous chorioretinopathy

BACKGROUND

Half-dose photodynamic therapy (HD-PDT) has been widely used for central serous chorioretinopathy (CSC) with good anatomical results. However, long-term functional outcomes after this treatment remain uncertain. This study aimed a longitudinal multimodal macular assessment, correlating functional and anatomical outcomes.

METHODS

This is a retrospective study performed in a tertiary referral center including 111 eyes from 95 CSC patients. Data on best corrected visual acuity (BCVA), central macular thickness (CMT), central retinal sensitivity (CRS) using microperimetry (MP) and multifocal electroretinography (mfERG) at baseline and 3, 6, 12, 18, 24, 36, 48 and 60 months after treatment were registered. A correlation analysis was performed.

RESULTS

Mean follow-up was 34.5 ± 26.3 months. A significant improvement in BCVA and CMT was registered in all the visits. CRS significantly improved until 24 months (p<0.001 at 12 months, p<0.05 at 24 months), worsening afterwards. The mfERG amplitude of N1 and P1 waves significantly improved in the first 12 months, aggravating afterwards. The implicit time improved until 24 months, deteriorating after 48 months. This long-term decline was also described in some inactive untreated fellow eyes CONCLUSIONS: : A multimodal longitudinal analysis of CSC patients after HD-PDT shows that, after the first 12 to 24 months, the significant sustained improvement in BCVA and CMT is not paired by a sustained improvement in macular sensitivity or electrical response. This long-term functional deterioration might result from the disease itself and not directly from the treatment.

Evaluation of Choroidal Thickness Using Optical Coherent Tomography: A Review

The choroid is the main source of blood and nourishment supply to the eye. The dysfunction of the choroid has been implicated in various retinal and choroidal diseases. The identification and in-depth understanding of pachychoroid spectrum disorders are based on the tremendous progress of optical coherence tomography (OCT) technology in recent years, although visibility of choroid is challenging in the era of the time or spectral domain OCT. The recent rapid revolution of OCTs, such as the enhanced depth imaging OCT and the swept-source OCT, has greatly contributed to the significant improvement in the analysis of the morphology and physiology of the choroid precisely, especially to the choroid-scleral boundary and vasculature. The present review highlights the recently available evidence on the measurement methodology and the clinical significance of choroidal thickness in retinal or choroidal disorders.

Applications of Multimodal Imaging in Central Serous Chorioretinopathy Evaluation

Central serous chorioretinopathy (CSCR) is a macular disease characterized by serous retinal detachment commonly involving the macular region. CSCR has a wide spectrum of clinical presentations. Although a significant proportion of CSCR cases are self-limiting, patients can suffer from persistent or recurrent disease, sometimes complicated with choroidal neovascularization, resulting in permanent visual loss. Multimodal imaging, including fluorescein angiography, indocyanine green angiography, fundus autofluorescence, and optical coherence tomography, has advanced the diagnosis and classification of CSCR cases. Evolution of new imaging techniques including optical coherence tomography angiography, wide-field imaging, and en face reconstruction imaging has also contributed to better understandings of the pathophysiology of CSCR. This review article summarizes the features of multimodal imaging for CSCR and discusses the application of such features in evaluating the disease.

Incidence of central serous chorioretinopathy (2011-2018): a nationwide population-based cohort study of Japan

AIMS

The aim of this study was to elucidate the epidemiological background of central serous chorioretinopathy (CSC), including its incidence and treatment pattern.

METHODS

This was a population-based longitudinal cohort study using a nationwide health insurance claims database of the Japan Ministry of Health, Labour and Welfare (MHLW). As Japan employs universal health coverage, the database covers more than 95% of claims issued in Japan. We accessed all data stored in the database with permission from the MHLW. We traced all individuals aged 30 years or older and identified individuals with new onset of CSC between January 2011 and December 2018. CSC cases were categorised by age and sex for each year, and incidence rate was calculated. We also identified major treatments for CSC to elucidate the initial treatment pattern.

RESULTS

During the 8-year period, 247 930 incidences of CSC were identified, among which 75.9% were men. The crude incidence rate (per 100 000 person-years) in the general population aged 30 years or older was 34.0 (95% CI 33.9 to 34.2), in men was 54.2 (95% CI 53.9 to 54.4) and in women was 15.7 (95% CI 15.5 to 15.8). The mean age of onset was lower in men than in women (50.5±12.5 years vs 54.7±13.5 years). Most of the patients with newly diagnosed CSC (86.8%) did not receive major treatment.

CONCLUSIONS

The current study provides the nationwide population-based evidence to clarify the detailed epidemiology of CSC. These results could help to understand the pathogenesis and mechanisms of CSC in the future.

Foveal and Extrafoveal Effects of Half-Dose Photodynamic Therapy in Chronic Central Serous Chorioretinopathy: A Cohort Study

PURPOSE

To compare the efficacy and safety of foveal and extrafoveal half-dose photodynamic therapy (HD-PDT) for chronic Central Serous Chorioretinopathy (cCSC).

METHODS

This retrospective, cohort study included cCSC eyes submitted to HD-PDT on foveal (F) or extrafoveal (E) areas. Patients were evaluated at baseline and 12 weeks after treatment for best corrected visual acuity (BCVA) and the following spectral-domain optical coherence tomography (SD-OCT) subfoveal parameters: central macular thickness (CMT), outer nuclear layer, external limiting membrane, ellipsoid zone, interdigitation zone, choroidal thickness and subretinal fluid (SRF).

RESULTS

F group comprised 33 eyes (47.1%) and E group comprised 37 eyes (52.9%). Both groups showed an improvement of BCVA after HD-PDT with no significant differences in final BCVA (p = .41). CMT and SRF showed a significant improvement after HD-PDT in both groups, but the rate of disruption of the external retinal layers remained stable. During follow-up, SD-OCT parameters and the rate of anatomical success showed no significant differences regarding the treatment location. No major sequelae were noticed.

CONCLUSION

Foveal and extrafoveal applications of HD-PDT for cCSC showed comparable efficacy and safety.

Correlation between choroidal structure and smoking in eyes with central serous chorioretinopathy

Purpose

A smoking habit can cause various health problems encompassing retinal diseases including central serous chorioretinopathy (CSC). The aim of the current study was to investigate the effect of smoking on the choroidal structure in patients with CSC.

Methods

The choroidal vascular index (CVI) was calculated using the binarized OCT images. Baseline parameters (age, refractive error [SE], subfoveal choroidal thickness [SFCT] and CVI) were compared between smokers and non-smokers using Wilcoxon rank sum test. Moreover, the associations between SFCT and the baseline parameters were analyzed using a multivariate linear regression followed by the AICc model selection.

Results

Among 75 CSC patients, 45 patients were smokers and 30 patients were non-smokers. No significant differences in age and SE were seen between the smoking group and the non-smoking group. A significant difference in the SFCT was seen between two groups (382.0 ± 68.2 μm in the smoking group vs. 339.3 ± 52.3 μm in the non-smoking group, p = 0.0038), while no significant difference was observed in the CVI (p = 0.32). The optimal model for SFCT included the variables of age, SE and past history of smoking among the baseline parameters. Additionally, increased pack years was associated with increased SFCT.

Conclusion

Cigarette smoking was associated with an increased SFCT in patients with CSC. Thicker choroid in smoking CSC patients may be an important modulator of the disease.

Dynamic changes and correlation analysis of outer retinal microstructure in macular area of central serous chorioretinopathy patients during restoration period

PURPOSE

To investigate the dynamic changes and possible affecting variables of outer retinal microstructure in macular area of central serous chorioretinopathy (CSC) patients.

METHODS

This was a retrospective study. The data of optical coherence tomography (OCT) and autofluoroscopy (AF) of 36 CSC patients admitted to our hospital from February 2012 to February 2013 were included. Dynamic variations and possible correlated variables of central retinal thickness (CRT), subretinal fluid diameter (SRFD), ellipsoid zone (EZ), interdigitation zone (IZ) and/or hyperautofluorescent spot (HAS) were analyzed.

RESULTS

The outer retinal microstructure was gradually restored along with the subretinal fluid absorption during the follow-up. EZ in 94.4% (34/36) and the IZ in 100% (36/36) eyes were completely disappeared at baseline and restored (completed or incomplete) in 88.9% (8/9) and 44.4% (4/9) eyes, respectively, after 6-month follow-up. HAS was evident in 25% eyes (8/32 eyes) at baseline, and the density was initially increased and then declined during follow-up. Correlation analysis demonstrated that the restoration of EZ and IZ was correlated with the restoration period and subretinal fluid absorption.

CONCLUSION

The outer retinal microstructure was restored during the subretinal fluid absorption in CSC patients, with EZ restored earlier than IZ. The restoration period and the absorption of subretinal fluid were two closely correlated variables of macular microstructure restoration.

Long-term visual and anatomic outcomes of patients with peripapillary pachychoroid syndrome

Background/Aims

To analyse the long-term anatomic and visual outcomes of patients with peripapillary pachychoroid syndrome (PPS), a recently described entity in the pachychoroid disease spectrum.

Methods

This study retrospectively included patients from several retina centres worldwide. Visual acuity (VA), retinal thickness and choroidal thickness at baseline, 6 months and final follow-up were assessed. Temporal trends in VA and anatomic characteristics were evaluated. Visual and anatomic outcomes in eyes that were observed versus those that were treated were analysed.

Results

Fifty-six eyes of 35 patients were included with mean follow-up of 27±17 months. Median VA was 20/36 at baseline and remained stable through follow-up (p=0.77). Retinal thickness significantly decreased subfoveally (p=0.012), 1.5 mm nasal to the fovea (p=0.002) and 3.0 mm nasal to the fovea (p=0.0035) corresponding to areas of increased thickening at baseline. Choroidal thickness significantly decreased subfoveally (p=0.0030) and 1.5 mm nasal to the fovea (p=0.0030). Forty-three eyes were treated with modalities including antivascular endothelial growth factor injection, photodynamic therapy, and others. VA remained stable in treated eyes over follow-up (p=0.67). An isolated peripapillary fluid pocket in the outer nuclear layer was characteristic of PPS.

Conclusion

Patients with PPS experienced decreased retinal oedema and decreased choroidal thickening throughout the course of disease. While some patients experienced visual decline, the overall visual outcome was relatively favourable and independent of trends in retinal or choroidal thickening.

Improved thickness measurement method for choroidal hyperpermeability in central serous chorioretinopathy

AIM

To observe choroidal thickness changes in the choroidal hyperpermeability area (CHA) in patients with central serous chorioretinopathy (CSC) after photodynamic therapy (PDT) using indocyanine green angiography (ICGA) combined with optical coherence tomography (OCT).

METHODS

This was a cohort study of 17 eyes (17 patients) with CSC. In all patients, the range of CHA was determined by ICGA. The patients were divided into two groups based on CHA covered the fovea (group A) or not (group B). All patients received half-dose verteporfin PDT over CHA in ICGA. Choroidal thickness was measured by OCT before, 1, and 3mo after treatment. The choroidal thickness values of the fovea and CHAs were obtained for each measurement. Secondary outcomes were changes in the best-corrected visual acuity (BCVA) and amount of subretinal fluid (SRF).

RESULTS

The differences in center choroidal thickness at baseline and at 1 and 3mo post-PDT were statistically significant in group A and all patients (both P<0.001). There was no significant difference in group B (P=0.059). The differences of thickness of CHA and BCVA at baseline and 1 and 3mo post-PDT were statistically significant in group A, group B, and all patients (all P<0.01). All patients showed complete SRF absorption at 3mo post-PDT.

CONCLUSION

Center choroidal thickness does not accurately reflect changes in CHA of patients whose CHA does not covered the fovea center. Using CHA as the observation target can make up for this limitation, expand the scope of application, and reduce bias.

Biomarkers for central serous chorioretinopathy

Central serous chorioretinopathy (CSCR) is a common chorioretinal disease characterized by serous retinal detachment that most commonly involves the macular region. Although the natural history of the acute form shows a self-limiting course, a significant number of patients suffer from recurrent episodes leading to chronic disease, often leaving patients with residual visual impairment. Visual morbidity is often worsened by a delay in the diagnosis due to the incorrect understanding of the particular biomarkers of the disease. The aim of this review is to provide clinical understanding of the biomarkers of CSCR with an emphasis on the most recent findings in patient demographics, risk factors, clinical imaging findings, and management options. Patients with these biomarkers, age 30–44 years, male gender, increased stress levels, hypercortisolism (endogenous and exogenous exposures), sleep disturbance, pregnancy, and genetic predisposition have increased susceptibility to CSCR. Also, biomarkers on optical coherence tomography (OCT) such as choroidal thickness (CT) and choroidal vascularity index (CVI) showed good diagnostic and prognostic significance in the management of CSCR. There are nonspecific features of CSCR on OCT and OCT angiography such as choroidal neovascularization, photoreceptor alteration/cone density loss, and flat irregular pigment epithelium detachment. We described rare complications of CSCR such as cystoid macular edema (CME) and cystoid macular degeneration (CMD). Patients with CME recovered some vision when treated with anti-vascular endothelial growth factors (anti-VEGFs). Patients with CMD had irreversible macular damage even after treatment with anti-VEGFs.

Association between CFH single nucleotide polymorphisms and response to photodynamic therapy in patients with central serous chorioretinopathy

PURPOSE

To evaluate the association between single nucleotide polymorphisms (SNPs) in the complement factor H (CFH) gene and response to PDT in patients with CSC.

METHODS

103 eyes from 93 patients with CSC were enrolled from Department of Ophthalmology of the People's Hospital Peking University. Genotyping for selected SNPs in the CFH gene was performed, and multivariate linear analysis was used to identify factors influencing PDT treatment outcomes. Genetics associations between SNPs in the CFH gene and response to PDT in patients with CSC were analyzed.

RESULTS

None of the seven SNPs examined in this study (rs800292, rs1061170, rs3753394, rs3753396, rs2284664, rs1329428, and rs1065489) showed significant associations with 1-month outcomes after PDT in patients with CSC (P > 0.05). Baseline BCVA changed at 1 month after PDT (P < 0.001), and baseline retinal thickness was associated with changes in retinal thickness at 1 month after PDT (P < 0.001). Age was significantly associated with resolution of SRF at 1 month after PDT (P = 0.004).

CONCLUSIONS

There were no significant associations between SNPs in the CFH gene and 1-month outcomes after PDT in patients with CSC. However, baseline BCVA, baseline retinal thickness, and age were significantly associated with response to PDT in patients with CSC. Larger studies with more power are necessary to further determine whether an association exists between SNPs in the CFH gene and PDT in patients with CSC.

Chorioretinal response to intravitreal aflibercept injection in acute central serous chorioretinopathy

AIM

To evaluate chorioretinal responses to intravitreal aflibercept injection (IAI) in patients with acute central serous chorioretinopathy (CSC).

METHODS

Seventy-one eyes from 71 patients with symptomatic CSC for less than six months were included. Thirty-five eyes received a single IAI and 36 eyes were observed without treatment. Best-corrected visual acuity (BCVA), central subfield foveal thickness (CSFT), and subfoveal choroidal thickness (SFCT) were assessed at baseline and at 1, 2, and 3mo.

RESULTS

The mean SFCT in the IAI group decreased at 1mo, rebounded at 2mo and remained stable at 3mo compared to the baseline, while significant change was not noted in the observation group. The mean CSFT decreased significantly during the 3-month study period in both groups, and was significantly lower in the IAI group at 1mo (P<0.001). A rebound of CSFT between 1 and 2mo was noted in 14 eyes (40.0%) in the IAI group and in 1 eye (2.8%) in the observation group (P<0.001). The significant visual improvement was achieved from 1mo in the IAI group, and from 2mo in the observation group. The rate of complete absorption of subretinal fluid at 3mo did not differ between the two groups. (45.7% vs 41.7%, P=0.813).

CONCLUSION

A single IAI for acute CSC induce a transient decrease in SFCT and CSFT, which implies that IAI may have a pharmacological effect on the underlying hyperpermeable choroid in acute CSC.

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.

Abnormal choroidal flow on optical coherence tomography angiography in central serous chorioretinopathy

IMPORTANCE

Analysing choroidal flow in central serous chorioretinopathy (CSC) with novel device.

BACKGROUND

To examine the abnormal morphology of choriocapillary flow with optical coherence tomography angiography (OCTA) according to the presence of subretinal fluid (SRF) in CSC.

DESIGN

A hospital-based retrospective study.

PARTICIPANTS

We analysed OCTA results of 68 eyes (68 patients) diagnosed as CSC with or without SRF (active and resolved CSC, respectively) at the Asan Medical Center.

METHODS

We classified OCTA choriocapillary images into three pattern groups: mixed perfusion, hyper-perfusion and normal perfusion. Data analysis included age, follow-up duration, treatment modalities, number of treatments, subfoveal choroidal thickness and SRF height.

MAIN OUTCOME MEASURES

The relationship between CSC activity and choriocapillary pattern.

RESULTS

Abnormal choroidal flow (mixed and hyper-perfusion) was more frequently found in eyes with active CSC (100%) than resolved CSC (47.5%, P < 0.001). In active CSC eyes, mixed perfusion was predominant (71.4%), while hyper-perfusion was predominant in those with resolved CSC (73.7%). Eyes with recently resolved CSC (SRF absorption present for <2 months) had abnormal choriocapillary flow more often than the remaining eyes with resolved CSC (83.3% vs 32.1%, P = 0.005). Resolved CSC eyes with abnormal choriocapillary flow demonstrated more recurrence than eyes with normal choriocapillary flow (42.1% vs 9.5%, P = 0.017).

CONCLUSIONS AND RELEVANCE

The pattern of choriocapillary flow abnormalities on OCTA can indicate CSC disease activity. Because eyes with resolved CSC showing abnormal choroidal flow have a high recurrence rate, they should be carefully followed-up.

Long-Term Outcomes of Full-Fluence and Half-Fluence Photodynamic Therapy for Chronic Central Serous Chorioretinopathy

PURPOSE

To evaluate the efficacy and safety of full-fluence photodynamic therapy (PDT) and half-fluence PDT in chronic central serous chorioretinopathy (CSC).

PROCEDURES

A retrospective review of CSC patients treated with full-fluence or half-fluence PDT for 12 months was performed. Best-corrected visual acuity (BCVA), central macular thickness (CMT), neural retinal thickness, subfoveal choroidal thickness (SFCT), resolution of subretinal fluid (SRF), and incidence of retinal pigment epithelium (RPE) atrophy at 12, 24, and 36 months were assessed.

RESULTS

Thirty-seven and 30 eyes received full-fluence and half-fluence PDT, respectively. The BCVA and CMT improved significantly in both the full-fluence and half-fluence groups at 36 months, without a significant difference between the groups. Both groups showed significant reductions in SFCT with full-fluence (416.8-316.8 µm) being better overall than half-fluence (409.7-349.1 µm, p = 0.002). All patients achieved complete resolution without recurrence after one PDT treatment per eye. A few cases of RPE atrophy occurred, which could be correlated to PDT in both groups during the follow-up.

CONCLUSION

Both treatments were effective and safe in chronic CSC, with significant improvements in anatomic and visual parameters, without recurrence of SRF.

Elevated Choroidal Thickness and Central Serous Chorioretinopathy in the Fellow Eyes of Patients with Circumscribed Choroidal Hemangioma

Objective

To determine whether increased choroidal thickness (CT) is associated with circumscribed choroidal hemangioma (CCH) and whether patients with CCH are predisposed to central serous chorioretinopathy (CSCR).

Methods

We performed a retrospective consecutive observational study of 15 fellow eyes of 15 patients who had CCH. A- and B-scan ultrasonography, fluorescein angiography (FA), and optical coherence tomography (OCT) findings were reviewed to confirm the diagnosis of CCH. Fellow eye CT was measured using enhanced depth imaging OCT. FA, indocyanine green angiography, and OCT images of fellow eyes were reviewed for signs of CSCR.

Results

Mean subfoveal CT was significantly greater in the fellow eyes of patients with CCH than in age-matched normal eyes (p = 0.004). Three of 15 (20.0%) fellow eyes of CCH patients had retinal pigment epithelium disruptions and/or pigment epithelial detachments indicative of previous asymptomatic CSCR.

Conclusion

In this pilot study, elevated CT was associated with a risk of developing CCH as well as CSCR in patients of varying ages. Patients diagnosed with CCH should be screened for CSCR in the fellow eye. Further exploration of this association may reveal useful clues about the biology of abnormally elevated choroidal hyperpermeability and its various clinical manifestations.

SUBFOVEAL CHOROIDAL THICKNESS AND VASCULAR DIAMETER IN ACTIVE AND RESOLVED CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To determine the subfoveal choroidal thickness and analyze Haller's layer, Sattler's layer, and large choroidal vessel diameter in eyes with active central serous chorioretinopathy (CSC) and after resolution of CSC.

METHODS

Ocular and clinical features of 32 eyes with CSC were analyzed retrospectively from October 2014 to September 2015. Subfoveal choroidal thickness and thicknesses of Haller's layer and Sattler's layer were measured in the active and resolved states. The diameter of the subfoveal choroidal hyporeflective lumen (i.e., the large choroidal vessel in Haller's layer) was also measured.

RESULTS

The mean subfoveal choroidal thickness, mean thickness of Haller's layer, and mean choroidal vessel diameter were significantly less after the resolution of CSC (P < 0.001). However, the thickness of Sattler's layer did not change after the resolution of CSC (P = 0.731). There were no significant differences among the different treatment modalities.

CONCLUSION

After the resolution of CSC, the subfoveal choroidal thickness and thickness of Haller's layer declined, but the reduced diameter of subfoveal choroidal vessels accounted for only about half of the total thickness changes in the choroid. These results suggest that nonvascular smooth muscle cells might play a role in the thickening of the choroid during CSC and possibly in the pathogenesis and progression of CSC.

Long-term outcomes in half-dose verteporfin photodynamic therapy for chronic central serous retinopathy

Objective

To evaluate the short- and long-term outcomes of half-dose verteporfin with photodynamic therapy (PDT) in the treatment of chronic central serous retinopathy (CSR).

Design

Retrospective case series.

Participants

45 eyes in 39 patients with chronic CSR were included. Diagnosis of chronic CSR was confirmed by fluorescein angiography and persistence of subretinal fluid by optical coherence tomography for a minimum of 3 months duration.

Methods

Each patient underwent treatment with half-dose verteporfin with full-fluence PDT; initial follow-up was defined as a 6–8 week visit following the treatment, and final follow-up ranged from 5 to 70 months.

Results

The average follow-up period for treatment was 19.3 months. Best-corrected visual acuity increased from logMAR means of 0.52 to 0.42 (p<0.05). Central retinal thickness and choroidal thickness also significantly decreased at last follow-up (p<0.05). Eight of 45 eyes (18%) demonstrated a recurrence of CSR following treatment within the follow-up period. At the final follow-up, 41 out of the 45 eyes (91%) had complete resolution of subretinal fluid accumulation.

Conclusion

Half-dose PDT is an effective treatment option for chronic CSR in a Canadian population, and it is both safe and durable. The positive treatment effect is realized rapidly, with the initial 6-week result highly correlated with the final follow-up result.

Acupuncture for chronic central serous chorioretinopathy: a prospective case series

OBJECTIVE

The aim of this prospective observational study was to evaluate the effects of acupuncture at Erjian on chronic central serous chorioretinopathy (CSC).

STUDY DESIGN

Prospective case series.

METHODS

Nine patients with chronic CSC were recruited and each patient received 12 sessions of acupuncture treatment. Subjective symptom measures included complications, best-corrected visual acuity (BCVA), fluorescein leakage (via fluorescein fundus angiography), and central subfield foveal subretinal fluid (on optical coherence tomography (OCT)) at 3 months. Successful treatment was defined as the complete resolution of subretinal fluid observed by the OCT following completion of treatment.

RESULTS

After 2 months of treatment, two patients showed improvements in visual acuity, a significant reduction in subretinal fluid and an improvement in BCVA to 0.5±0.10 (mean±SD). By contrast, four patients experienced no significant changes. After 3 months of treatment, four patients showed improvements in visual acuity and complete resolution of the subretinal fluid (mean BCVA=0.6), while parameters in two patients remained unchanged. Compared to baseline (before treatment), the proportions of patients experiencing visual improvement at 2 and 3 months were 33% (n=2) and 67% (n=4), respectively. No major complications were observed during the treatment course.

CONCLUSIONS

Acupuncture might be a promising supplementary therapy for patients with CSC. However, this is ultimately only an exploratory study with a small sample size and no untreated comparator group to control for the natural history of the condition. Randomised controlled trials will be needed to demonstrate the efficacy and effectiveness of this approach.

A Multicenter Study on the Long-term Outcomes of Half-dose Photodynamic Therapy in Chronic Central Serous Chorioretinopathy

PURPOSE

To investigate long-term efficacy and prognostic factors of half-dose photodynamic therapy (PDT) in chronic central serous chorioretinopathy (CSCR).

DESIGN

Retrospective multicenter interventional case series.

METHODS

Patients with chronic CSCR undergoing half-dose PDT between 2005 and 2011 were reviewed. Main outcome measures included resolution of serous retinal detachment (SRD) with single PDT, change in best-corrected visual acuities (BCVAs), and recurrence rate of CSCR at 36 months after PDT. Prognostic factors of visual outcome and recurrence of CSCR after PDT were identified with multivariate regression analysis.

RESULTS

A total of 136 eyes of 123 patients were followed up for 57.7 ± 16.2 months. At 36 months after PDT, 132 eyes (97.1%) achieved complete resolution of SRD with single PDT and 4 eyes (2.9%) had CSCR recurrence. The mean logMAR BCVA improved from 0.36 ± 0.29 (Snellen equivalent 20/46; range: 0.1-1.2) at baseline to 0.15 ± 0.23 at 36 months (Snellen equivalent 20/28; range: 0.1-1.5; P < .001) and 0.16 ± 0.24 (Snellen equivalent: 20/29; range: 0.1-1.5; P < .001) at final follow-up. Forty-four eyes (32.4%) had ≥3 lines of BCVA gain while 5 eyes (3.7%) had ≥3 lines of BCVA loss at 36 months after PDT. Nine eyes (6.6%) developed CSCR recurrence at final follow-up. Baseline BCVA was significantly associated with the BCVA (P = .009) and the improvement in BCVA (P < .001) at final follow-up. History of bilateral CSCR was significantly associated with CSCR recurrence at final follow-up (P = .036; odds ratio = 15.84, 95% confidence interval = 1.20-208.32). Eight eyes (5.9%) had complications related to PDT.

CONCLUSIONS

Chronic CSCR patients treated with half-dose PDT can achieve long-term stable visual acuity and resolution of SRD. Patients with chronic CSCR are recommended to undergo half-dose PDT before they have significant visual deterioration. Patients with bilateral CSCR are more likely to develop CSCR recurrence after half-dose PDT.

The time of resolution and the rate of recurrence in acute central serous chorioretinopathy following spontaneous resolution and low-fluence photodynamic therapy: a case-control study

PurposeTo evaluate the resolution time and the recurrence rate of acute central serous chorioretinopathy (CSC) after spontaneous resolution and low-fluence photodynamic therapy (PDT).MethodsCase-control study: The CSC patients who were admitted to our clinic for the first time were included. No treatment was given during the first 6 months. Patients were treated with PDT after 6 months from the initial signs of the disease, if they did not show any sign of resolution. The patients who showed a significant decrease in subretinal fluid after month 6 were not scheduled for PDT. The primary outcomes were the resolution time and the recurrence rate after the first episode. Secondary outcome measures were the change in BCVA and CRT during the follow up.ResultsA total of 77 consecutive eyes of 77 patients were included, 41 eyes (53.2%) with spontaneously resolved CSC and 36 eyes (46.8%) with PDT-treated CSC. The initial resolution time was 4.1±3.2 months in spontaneous resolution group, and 8.1±0.8 months in PDT group, respectively (P<0.001). The recurrence rate was 51.2% in spontaneous resolution group, and 25% in PDT group (P=0.01). The change in BCVA from baseline to the last follow-up visit was statistically significant in both groups (P=0.002, P=0.003, respectively). The change in CRT from baseline to the last follow up was also statistically significant in both groups (P=0.002, P=0.003, respectively).ConclusionsThe recurrence rate of acute CSC was lower in PDT-treated patients than the spontaneously resolved patients.