Half-Dose Photodynamic Therapy Versus Eplerenone in Chronic Central Serous Chorioretinopathy (SPECTRA): A Randomized Controlled Trial

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.

Perspectives and Update on the Global Shortage of Verteporfin (Visudyne®)

An ongoing global shortage of verteporfin (Visudyne®) limits the treatment possibilities for several chorioretinal diseases, including central serous chorioretinopathy, choroidal hemangioma, and polypoidal choroidal vasculopathy. Verteporfin is required to perform photodynamic therapy in these ocular diseases. Therefore, the current situation has a substantial impact on eye care worldwide. The worldwide supply of verteporfin appears to be manufactured by a single factory, which is situated in the United States. The distribution of verteporfin is done by different companies for different regions of the world. Official communication on the shortage by the responsible companies has been scarce and over the past years several promises with regards to resolution of the shortage have not been fulfilled. The delivery of new batches of verteporfin is at irregular intervals, unpredictable, and may not be fairly balanced between different regions or countries in the world. To ensure a fair distribution of available verteporfin within a country, several measures can be taken. In the Netherlands, a national committee, consisting of ophthalmologists, is in place to arrange this. On the European level, the European Union and European Medicine Agency have plans to monitor medicine shortages more closely and to intervene if necessary. With a more intensified monitoring and regulation of medicine supplies, future impending shortages may be prevented. Remarkably, the amount of medicine shortages is increasing, having a significant and sometimes irreversible impact on patient care. Thus, efforts should be undertaken to minimize the consequences and, whenever possible, to prevent future medicine shortages.

Verteporfin Photodynamic Therapy for the Treatment of Chorioretinal Conditions: A Narrative Review

Photodynamic therapy (PDT) with verteporfin involves intravenous administration of a photosensitizer followed by its laser light activation at the target site to inhibit aberrant choroidal vascularization. This narrative review provides an overview of the role verteporfin PDT plays in the management of chorioretinal conditions. A PubMed literature review of all English-language articles published through October 19, 2023, was conducted to identify relevant references. Verteporfin PDT has been shown to be safe and effective for the treatment of patients with choroidal neovascularization (CNV) due to neovascular age-related macular degeneration and is often used in combination with a vascular endothelial growth factor (VEGF) inhibitor. Additionally, patients with polypoidal choroidal vasculopathy, a subtype of neovascular age-related macular degeneration, also benefit from verteporfin PDT combined with a VEGF inhibitor for improving visual acuity. Verteporfin PDT has also been effective in treating patients with peripapillary CNV, as well as eyes with CNV due to ocular histoplasmosis and pathologic myopia. Reduced dose and/or fluence PDT protocols have been effective in patients with central serous chorioretinopathy while reducing adverse effects. In eyes with choroidal hemangioma, tumor regression and visual outcomes have been improved with verteporfin PDT treatment. Photodynamic therapy with verteporfin continues to play an important role in the management of chorioretinal conditions.

Choroidal hyperpermeability patterns correlate with disease severity in central serous chorioretinopathy: CERTAIN study report 2

PURPOSE

Choroidal vascular hyperpermeability (CVH) on indocyanine green angiography (ICGA) is a hallmark feature of central serous chorioretinopathy (CSC). We identified three distinct CVH phenotypes in CSC: uni-focal indistinct signs of choroidal hyperpermeability (uni-FISH) with one focal area of CVH, multiple areas of focal CVH (multi-FISH), and diffuse hyperpermeability covering most of the posterior pole (DISH). This report investigates the distribution of these phenotypes and their association with signs of disease chronicity.

METHODS

The CERTAIN study is a monocentric, retrospective study on consecutive CSC patients referred to a large tertiary referral centre that underwent ultra-widefield (UWF) and 55° ICGA. Two independent graders assessed CVH patterns based on mid- to late-phase UWF and 55° ICGA with a third grader acting as referee.

RESULTS

Of the 167 eyes of 91 patients included in this study, 43 (26%) showed uni-FISH, 87 (52%) multi-FISH, and 34 (20%) showed DISH based on UWF ICGA. Median age (40 vs. 45 vs. 57; p < 0.001) and logMAR visual acuity (0 vs. 0 vs. 0.1, p < 0.001) differed significantly in-between groups, as did the occurrence of cystoid retinal degeneration (PCRD; 0% vs. 1% vs. 18%, p < 0.001) or diffuse atrophic RPE alterations (DARA; 0% vs. 17% vs. 29%, p < 0.001). The same was true when grading was based on 55° ICGA.

CONCLUSIONS

The CVH patterns of uni-FISH, multi-FISH, and DISH are typical of CSC. These patterns correlate with established signs of CSC chronicity. Their predictive role in treatment response and prognosis remains to be evaluated.

Efficacy of Subthreshold Micropulse Laser for Central Serous Chorioretinopathy

PURPOSE

To evaluate the efficacy of a subthreshold micropulse laser (SML) in patients with central serous chorioretinopathy (CSCR).

METHODS

Retrospective clinical study conducted at the Departments of Ophthalmology at a university and a municipal hospital in Zurich, Switzerland. We enrolled acute and chronic CSCR patients with persistent subretinal fluid (SRF) treated with SML. Two treatment protocols (fluorescein/indocyanine green angiography or optical coherence tomography guided) were evaluated for efficacy after 3 and 6 months. The primary outcomes of the study were reduction and percentage of eyes with complete resolution of SRF 3 and 6 months after SML treatment. Secondary endpoints included changes in central subfield thickness (CST) and visual acuity (VA) after 3 and 6 months.

RESULTS

The study involved 37 eyes (35 patients, 48.6% chronic). A statistically significant reduction in SRF height and CST could be shown, irrespective of SRF duration, type of CSCR, or chosen guidance after 3 and 6 months: SRF - 40 µm (p < 0.01), CST - 52 µm (p < 0.01). Percentage of eyes with complete resolution of fluid at 3 and 6 months after SML were 24.3 and 21.6%, respectively. No statistically significant functional improvement (VA) could be shown. Multivariable regression and linear mixed regression analyses did not identify statistically significant differences in SRF reduction, CMT change, or VA improvement with respect to the type of CSCR or the treatment plan used (p > 0.05).

CONCLUSION

The effectiveness of SML in CSCR is under continuous debate. Our study findings demonstrate structural but only little functional changes with SML. In view of the shortage of verteporfin for photodynamic therapy, SML remains an important therapeutic option for CSCR patients.

Psychometric assessment of patients with central serous chorioretinopathy and correlation with disease stage and progression: a case control study

BACKGROUND

Central serous chorioretinopathy (CSC) has frequently been associated with increased stress levels as well as an increased prevalence of other psychiatric conditions. This study used standardized psychometric scores to assess stress, depression and anxiety levels of CSC patients and compared them to controls without retinal disease ("healthy") and with branch retinal vein occlusion (BRVO).

METHODS

Monocentric, longitudinal case control study on consecutive CSC patients seen at a tertiary referral center. Controls without retinal disease were recruited from the oculoplastics clinic and those with BRVO from the medical retina clinic. Patients completed pseudonymized tests measuring stress levels (PHQ-stress), depression (PHQ-9) and anxiety (GAD-7) at baseline and at 3- and 6-months follow-up. Higher scores indicated higher trait levels.

RESULTS

65 CSC patients, 19 healthy controls and 19 BRVO patients were included in this study. CSC patients showed significantly higher stress levels at baseline compared to controls (p = 0.009), but not compared to BRVO patients (p = 1.00). At 3- and 6-months follow-up, no significant difference between groups was observed anymore. Acute CSC patients showed higher scores than those with chronic CSC, which also subsided over time. Depression and anxiety scores did not differ between groups at any timepoint.

CONCLUSIONS

Patients with CSC do not show higher initial stress levels than patients with BRVO, while anxiety and depression levels did not differ from controls. Stress may thus rather represent a consequence of the onset of visual deterioration observed in CSC or other ocular diseases.

Clinical Landscape of Central Serous Chorioretinopathy in Germany: Retina.net CSC Registry Report Number 1

INTRODUCTION

The German Registry of central serous chorioretinopathy (CSC) collects data on CSC patients in a nationwide multicenter approach to analyze epidemiology, risk factors, clinical presentations, as well as diagnosis and treatment patterns.

METHODS

In this multicenter cohort study, patients with CSC were enrolled in nine tertiary referral centers in Germany between January 2022 and June 2023. After consenting to the study, demographic data, risk factors, reported symptoms, best-corrected visual acuity (BCVA), funduscopic findings, disease severity, and diagnostic and treatment decisions were recorded and analyzed.

RESULTS

A total of 539 eyes of 411 CSC patients were enrolled in this study including 308 males (75%) and 103 females (25%). Patients were predominantly of Caucasian origin and had a mean age of 55.5 years (IQR 41.0-70.0). 28% of eyes were classified as acute (<4 months duration) CSC, 28% as chronic (>4 months duration) CSC, 21% as inactive CSC, 11% as chronic atrophic CSC, and 12% as CSC with secondary CNV. 128 patients (31%) demonstrated bilateral CSC. The most common risk factors reported were psychological stress (52%), smoking (38%), arterial hypertension (38%), and a history of or current use of steroids (30%). Most frequently encountered symptoms included decreased visual acuity (76%), metamorphopsia (49%), relative scotoma (47%), blurred vision (19%), and dyschromatopsia (9%). The mean logMAR BCVA on initial examination was 0.2 (≈20/30, IQR 0.2-0.4) but showed significant variation with a tendency of lower BCVA in chronic cases. At the baseline visit, 74% of the overall cohort received no treatment, while 19% underwent local treatment and only 2% underwent systemic treatment. Of the local therapies, anti-VEGF injections were the most frequently performed procedure (33%, mainly for secondary CNV), followed by micropulse laser (28%), focal nonpulsed laser (23%), verteporfin photodynamic therapy (14%), and nonsteroidal anti-inflammatory eye drops (2%). Among intravitreal anti-VEGF agents, aflibercept was used most frequently, followed by bevacizumab and ranibizumab.

CONCLUSION

This registry represents one of the largest cohorts of European patients with CSC to date. Patient age and the proportion of women were higher than expected and bilateral active disease was lower than anticipated, highlighting that neither age nor gender should be overemphasized when diagnosing CSC. Therapeutic interventions are heterogeneous and include verteporfin photodynamic therapy, micropulse laser, and anti-VEGF injections in case of secondary CNV.

BASELINE SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHIC RETINAL LAYER FEATURES IDENTIFIED BY ARTIFICIAL INTELLIGENCE PREDICT THE COURSE OF CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To identify optical coherence tomography (OCT) features to predict the course of central serous chorioretinopathy (CSC) with an artificial intelligence-based program.

METHODS

Multicenter, observational study with a retrospective design. Treatment-naïve patients with acute CSC and chronic CSC were enrolled. Baseline OCTs were examined by an artificial intelligence-developed platform (Discovery OCT Fluid and Biomarker Detector, RetinAI AG, Switzerland). Through this platform, automated retinal layer thicknesses and volumes, including intaretinal and subretinal fluid, and pigment epithelium detachment were measured. Baseline OCT features were compared between acute CSC and chronic CSC patients.

RESULTS

One hundred and sixty eyes of 144 patients with CSC were enrolled, of which 100 had chronic CSC and 60 acute CSC. Retinal layer analysis of baseline OCT scans showed that the inner nuclear layer, the outer nuclear layer, and the photoreceptor-retinal pigmented epithelium complex were significantly thicker at baseline in eyes with acute CSC in comparison with those with chronic CSC ( P < 0.001). Similarly, choriocapillaris and choroidal stroma and retinal thickness (RT) were thicker in acute CSC than chronic CSC eyes ( P = 0.001). Volume analysis revealed average greater subretinal fluid volumes in the acute CSC group in comparison with chronic CSC ( P = 0.041).

CONCLUSION

Optical coherence tomography features may be helpful to predict the clinical course of CSC. The baseline presence of an increased thickness in the outer retinal layers, choriocapillaris and choroidal stroma, and subretinal fluid volume seems to be associated with acute course of the disease.

Intravitreal Brolucizumab for Chronic Central Serous Chorioretinopathy without Choroidal Neovascular Membrane - a Pilot Study

PURPOSE

To study intravitreal brolucizumab in the management of persistent macular fluid in chronic central serous chorioretinopathy (CSCR) without choroidal neovascular membrane (CNVM).

METHODS

Retrospective case series which included eyes with chronic CSCR with persistent macular fluid for ≥ 3 months without CNVM. Intravitreal brolucizumab was administered in all eyes. Primary outcome measure was the resolution of intraretinal (IRF) and/or subretinal fluid (SRF) on OCT.

RESULTS

Five eyes (four patients) with chronic CSCR were included. All eyes showed complete resolution of SRF 1 month following injection. Minimal residual IRF was present in two eyes. Best corrected visual acuity (BCVA) was stable in three eyes, and two eyes showed improvement. Central macular thickness (CMT) and subfoveal choroidal thickness (SFCT) showed reduction.

CONCLUSION

Intravitreal brolucizumab is effective in the rapid reduction of persistent macular fluid in chronic CSCR without CNVM. Long-term follow-up data are required to study recurrence and adverse effect profile.

Examining the efficacy of verteporfin photo-dynamic therapy (PDT) at different dose & fluence levels

OBJECTIVES

Photodynamic therapy (PDT) is a vaso-occlusive treatment for a number of chorioretinal vascular pathologies. We aimed to retrospectively analyse efficiency and safety of PDT for different conditions (central serous retinopathy (CSR), age-related macular degeneration (AMD), macular telangiectasia type 2 and choroidal hemangioma) and with different verteporfin parameters.

METHODS

Clinical parameters were ascertained from the medical records of patients undergoing PDT over a 6-year period. This included indications for PDT, dosing regimens of verteporfin PDT (which includes treatment dose of verteporfin and fluence). Response to treatment was measured by best corrected visual acuity (BCVA) and central foveal thickness (CFT) on ocular coherence tomography. Complications and side effects were recorded.

RESULTS

67.4 % (31/46) of PDT treatments performed over the last six years were for CSR. In the CSR cohort, there were significant improvements in BCVA (0.47 ± 0.24 to 0.29 ± 0.27, p < 0.05) and CFT (350.2μm ± 66.9 μm to 286.1μm ± 60.6 μm. In the AMD cohort, there was no change in BCVA (1.08 ± 0.52 to 1.07 ± 0.53, p = 0.96) but significant improvement in CFT (488.2μm ± 164.6 μm to 348.7μm ± 65.7 μm, p < 0.05). There was no significant difference in BCVA or CFT for macular telangiectasia type 2 and choroidal hemangioma.

CONCLUSIONS

PDT continues to have a role in the management of medical retina conditions. Our results show PDT is most effective in improving and stabilizing visual acuity in CSR, with earlier intervention resulting in better outcomes.

Characteristics Related to Visual Acuity Loss After Successful Photodynamic Therapy for Eyes With Central Serous Chorioretinopathy

PURPOSE

This study aimed to examine baseline characteristics for identifying factors associated with vision loss (VL) in patients with central serous chorioretinopathy (CSC) who successfully responded to photodynamic therapy (PDT).

DESIGN

A retrospective, clinical case-control study.

METHODS

This study included 85 eyes with CSC, which underwent PDT, and resolved serous retinal detachment. These eyes were classified into 2 groups: the VL group (best-corrected visual acuity 6 months after PDT was worse than that at baseline) and the vision maintenance or improved group (the others). Baseline factors were analyzed to determine the characteristics of the VL group and assess the diagnostic potential of these factors.

RESULT

Seventeen eyes were included in the VL group. The mean values of the neurosensory retinal (NSR) thickness, the internal limiting membrane-external limiting membrane thickness (IET), and the external limiting membrane-photoreceptor outer segment thickness (EOT) in the VL group were significantly thinner than those in the vision maintenance or improved group (NSR thickness, 123.2 ± 39.7 µm vs 166.3 ± 49.6 µm, P < .001; IET, 63.1 ± 17.0 µm vs 88.0 ± 25.4 µm, P < .001; EOT, 60.1 ± 28.6 µm vs 78.3 ± 33.1, P = .041). The sensitivity, specificity, and positive and negative predictive values for predicting VL were 94.1%, 50.0%, 32.0%, and 97.1% for NSR thickness; 94.1%, 51.5%, 32.7%, and 97.2% for IET; and 94.1%, 30.9%, 25.4%, and 95.5% for EOT, respectively.

CONCLUSIONS

Pretreatment sensory retinal layer thickness could predict VL after PDT for CSC and may be a helpful reference for PDT.

NOn-Pachychoroid PEripapillary Schisis (NOPPES) of the Retina: A New Phenotype and its Differential Diagnosis

PURPOSE

The presence of peripapillary intraretinal fluid (IRF) has a broad differential diagnosis, including several types of neovascular and pachychoroid-related diseases. However, the clinician may encounter cases without signs of neovascular or pachychoroid disease, or any other previously described diagnosis. For these patients, we propose the term NOn-Pachychoroid PEripapillary Schisis (NOPPES) of the retina, and we discuss the differential diagnosis.

DESIGN

A retrospective chart study set in a tertiary referral center for retinal diseases in Amsterdam, the Netherlands.

METHODS

Using multimodal imaging, cases suspected of peripapillary pachychoroid syndrome were reviewed. Cases without signs of neovascular or pachychoroid disease were included in this study. These cases were discussed in a group of senior retinal specialists to establish a diagnosis, and if there was no evidence for any previously described diagnostic entity, these cases were categorized as NOPPES.

RESULTS

Four cases of NOPPES were identified, 3 female patients and 1 male patient, aged between 58 and 75 years. Two patients were myopic, and 1 patient had a mild hyperopia. Three out of 4 cases showed unilateral peripapillary IRF, and 1 case had bilateral IRF. No improvement was seen after intravitreal bevacizumab or aflibercept, nepafenac eye drops, oral acetazolamide, vitrectomy with internal limiting membrane peeling, or surgery for carotid stenosis. One case showed a reduction in IRF after starting prednisolone eye drops.

CONCLUSIONS

We describe NOPPES, a new form of peripapillary schisis-like IRF. NOPPES seems relatively therapy-resistant. More research is needed to delineate the clinical spectrum of NOPPES and its pathogenesis and treatment.

Real-world practice patterns of eplerenone use for central serous chorioretinopathy

PURPOSE

To report eplerenone use by retina specialists worldwide for central serous chorioretinopathy (CSCR).

METHODS

A self-reporting questionnaire was distributed to retina specialists worldwide to gather clinicians' perspectives on CSCR cases treated, eplerenone dosage and duration, reasons to use it, and side effects.

RESULTS

The survey included 241 retina specialists (122 Indian and 119 international) with an average experience of 15.69 ± 9.59 years. Oral eplerenone was used to treat CSCR by 149 (62%) participants. Only 6% (n = 9) had easy access to verteporfin dye and photodynamic therapy. 30 (20%) of the 149 respondents changed their treatment with eplerenone after VICI trial results. Eplerenone was prescribed mostly for chronic CSCR (n = 86, 58%), regardless of involvement laterality. 62% (n = 92) had fewer than 25% CSCR cases treated with eplerenone. 85 (57%) respondents used eplerenone only when other treatments failed, while 36 (24%) used it as first-line treatment. 73 (49%) respondents, prescribed eplerenone at a 50 mg daily dose and 137 (92%) retina specialists used eplerenone for 0-3 months. The drug's efficacy dissatisfied 21 (14%) study participants. 124 (83%) study participants did not encounter any ocular or systemic side effects with eplerenone use. Eplerenone related kidney and electrolyte issues were noted by 11 (7%) study participants.

CONCLUSION

The treatment of CSCR varies around the world and is primarily influenced by the photodynamic therapy availability and the findings of VICI trial. Despite the limited benefit of eplerenone reported by the VICI trial, it is still used as evidenced by real-world experience.

TRIAL REGISTRATION NUMBER

Not applicable.

A Photodynamic Therapy Index for Central Serous Chorioretinopathy to Predict Visual Prognosis Using Pretreatment Factors

PURPOSE

This study aimed to establish a treatment index based on functional outcomes of photodynamic therapy (PDT) for central serous chorioretinopathy (CSC).

DESIGN

A retrospective clinical case-control study.

METHODS

This was a single-institute study. Eighty (80) eyes with CSC, who were treated by PDT and whose subretinal fluid resolves within 6 months were divided into two groups: those with poor visual outcome (PVO) (best-corrected visual acuity [BCVA] ≤ 0.5 6 months post-PDT), and the remaining eyes (better visual outcome [BVO]). The areas under the curve (AUC) and cutoff values from receiver operating characteristic curves were examined. These was used to predict the groups using pretreatment BCVA and the thickness of each retinochoroidal layer.

RESULT

Twenty-one (21) eyes were in the PVO group and 59 eyes in the BVO group were included. The AUCs were 0.959 for BCVA, 0.959 for the thickness from the internal limiting membrane to the external limiting membrane (IET), 0.820 for the thickness from the external limiting membrane to the photoreceptor outer segment layer, 0.715 for the subfoveal retinal thickness, and 0.515 for the subfoveal choroidal thickness. The BCVA and IET cut-off values were 0.267 logMAR and 71.5 µm, respectively. Using the combination of the cutoff values of BCVA and IET, the highest values for the sensitivity, specificity, positive predictive value, and negative predictive value were 95.2%, 94.9%, 85.0%, and 98.0%, respectively.

CONCLUSION

The combination of pre-PDT BCVA and IET in CSC can accurately predict the post-treatment visual prognosis. These values could be used as a treatment index of PDT for CSC.

PREVALENCE AND MORPHOLOGIC BIOMARKERS OF METAMORPHOPSIA IN EYES WITH "RESOLVED" CHRONIC CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To assess relationships between demographics, clinical characteristics, and optical coherence tomography characteristics with persistence of metamorphopsia after resolution of subretinal fluid in eyes with chronic central serous chorioretinopathy.

METHODS

One-hundred participants with "resolved" (absence of subretinal fluid) chronic central serous chorioretinopathy were retrospectively analyzed. Patients underwent a complete ophthalmologic evaluation, including assessment of the presence of metamorphopsia. At the study visit, optical coherence tomography scans were reviewed for qualitative and quantitative features.

RESULTS

Sixty-six of 100 patients (66.0%) complained of metamorphopsia. Both the foveal and parafoveal ganglion cell complex thicknesses were thinner in central serous chorioretinopathy eyes with metamorphopsia (35.1 ± 10.6 µ m and 82.0 ± 18.1 µ m vs. 40.7 ± 11.8 µ m and 93.1 ± 13.5 µ m, P = 0.030 and P < 0.0001). In the foveal region, the outer plexiform layer and outer nuclear layer thicknesses were thinner in patients with metamorphopsia (24.6 ± 8.5 µ m and 63.1 ± 20.9 µ m vs. 29.1 ± 8.7 and 76.2 ± 18.2 µ m, P = 0.016 and P = 0.005). The ellipsoid zone band was more frequently discontinued in eyes with metamorphopsia (56.1% vs. 35.3%, P = 0.039). Multivariate stepwise linear regression analysis demonstrated that the strongest associations with the presence of metamorphopsia were with parafoveal ganglion cell complex thickness ( P = 0.004), foveal outer nuclear layer thickness ( P = 0.010), and number of previous recurrences of subretinal fluid accumulation ( P = 0.017). The time interval from the last subretinal fluid resolution was not associated with the presence of metamorphopsia.

CONCLUSION

In "resolved" central serous chorioretinopathy, clinical aspects (i.e., number of previous recurrences) and structural changes (i.e., ganglion cell complex and outer nuclear layer thinning) are associated with metamorphopsia after subretinal fluid resolution.

[Central serous chorioretinopathy: A review]

The central serous chorioretinopathy (CSCR) is characterized by serous retinal detachments SRD associated with one or several retinal pigment epithelium detachments/irregularities (PEDs). The choroid is thickened with dilated choroidal veins and choroidal hyperpermeability suggesting an underlying choroidopathy. CSCR belongs to the pachychoroid spectrum. CSCR affects mostly middle-aged men and the main risk factor is the corticosteroid intake. In most cases, the subretinal detachment resolves spontaneously with a good visual prognosis. However, recurrent or chronic form of the disease can lead to irreversible retinal damage and decreased visual acuity. Laser on an extra foveal leak point or half dose/half fluence photodynamic therapy are the first-line treatment options.

Hyperbranched Polymers: Recent Advances in Photodynamic Therapy against Cancer

Hyperbranched polymers are a class of three-dimensional dendritic polymers with highly branched architectures. Their unique structural features endow them with promising physical and chemical properties, such as abundant surface functional groups, intramolecular cavities, and low viscosity. Therefore, hyperbranched-polymer-constructed cargo delivery carriers have drawn increasing interest and are being utilized in many biomedical applications. When applied for photodynamic therapy, photosensitizers are encapsulated in or covalently incorporated into hyperbranched polymers to improve their solubility, stability, and targeting efficiency and promote the therapeutic efficacy. This review will focus on the state-of-the-art studies concerning recent progress in hyperbranched-polymer-fabricated phototherapeutic nanomaterials with emphases on the building-block structures, synthetic strategies, and their combination with the codelivered diagnostics and synergistic therapeutics. We expect to bring our demonstration to the field to increase the understanding of the structure-property relationships and promote the further development of advanced photodynamic-therapy nanosystems.

[Photodynamic therapy in Germany-Quo vadis?]

BACKGROUND

Photodynamic therapy (PDT) was originally approved for the treatment of neovascular age-related macular degeneration (nAMD) and secondary choroidal neovascularization in myopia (mCNV). In addition, it is used as an off-label treatment in patients with choroidal hemangioma, polypoidal choroidal vasculopathy (PCV), and central serous chorioretinopathy (CSC).

OBJECTIVE

To track the development of PDT treatment numbers in Germany between 2006 and 2021 and to investigate the composition of the therapeutic indications.

METHODS

In this retrospective study the quality reports of German hospitals were evaluated in the period from 2006 to 2019 and the number of PDTs performed was recorded. In addition, the range of indications for PDT was determined exemplarily for the Eye Center at Medical Center, University of Freiburg and the Eye Center at St. Franziskus Hospital in Münster between 2006 and 2021. Finally, the estimated prevalence of CSC and an estimate of cases requiring treatment were used to calculate the number of patients in need of PDT treatment in Germany.

RESULTS

The number of PDTs performed in Germany decreased from 1072 in 2006 to 202 in 2019. While PDT was used in 86% of cases in patients with nAMD and in 7% of cases with mCNV in 2006, it was mainly performed in patients with CSC (70%) and choroidal hemangiomas (21%) from 2016 to 2021. With an estimated incidence of CSC of 1:10,000 and assuming that 16% of patients develop chronic CCS requiring treatment, approximately 1330 PDTs would need to be performed per year in Germany for patients with newly diagnosed chronic CSC alone.

CONCLUSION

The decreasing numbers of PDT treatment performed in Germany is mainly due to a change to intravitreal injections as the preferred treatment for nAMD and mCNV. As PDT is currently the recommended treatment of choice for chronic CSC, an underprovision of PDT in Germany can be assumed. To enable an appropriate treatment for patients, a reliable verteporfin production, a simplified approval process by health insurance companies and a close cooperation between ophthalmologists in private practice and larger centers are urgently needed.

SINGLE-SESSION BILATERAL REDUCED-SETTINGS PHOTODYNAMIC THERAPY FOR BILATERAL CHRONIC CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

We performed a multicenter, retrospective study on patients with bilateral chronic central serous chorioretinopathy (cCSC) who received single-session bilateral reduced-settings photodynamic therapy (ssbPDT) and assessed anatomical (resolution of subretinal fluid [SRF]) and functional (best-corrected visual acuity [BCVA]) outcomes and safety.

METHODS

Patients who underwent ssbPDT between 01/01/2011 and 30/09/2022 were included. The resolution of SRF at first, second, and final follow-up was assessed on optical coherence tomography (OCT), and BCVA measurements were collected at these visits. When fovea-involving ssbPDT was performed, ellipsoid zone (EZ) and external limiting membrane (ELM) integrity was graded before and after treatment.

RESULTS

Fifty-five patients were included in this study. Sixty-two of hundred and eight eyes (56%) showed a complete resolution of SRF at the first follow-up, which increased to 73/110 (66%) at the final follow-up. The mean logMAR BCVA improved by -0.047 ( P = 0.02) over follow-up. EZ integrity increased from 14/21 (67%) to 24/30 (80%) while ELM integrity increased from 22/30 (73%) to 29/30 (97%).

CONCLUSION

Patients with cCSC with bilateral SRF at baseline showed significant anatomical and functional improvements after ssbPDT, both at short-term and long-term follow-up. No relevant adverse events were noted.

Comparing treatment outcomes in randomized controlled trials of central serous chorioretinopathy

PURPOSE

To perform a qualitative analysis of outcomes published from randomized controlled trials (RCTs) on central serous chorioretinopathy (CSCR) from 1979 to 2022.

DESIGN

Systematic review.

METHODS

All RCTs (including both therapeutic and non-therapeutic interventions) on CSCR available online till July 2022 were included after an electronic search in multiple databases such as PubMed, CENTRAL, MEDLINE, EMBASE, BIOSIS, Scopus, and Cochrane database. We analyzed and compared the inclusion criteria, imaging modalities, study endpoints, duration, and the results of the study.

RESULTS

The literature search yielded 498 potential publications. After excluding duplicate studies and studies that met clear exclusion criteria, 64 were screened for further evaluation, of which 7 were removed due to a lack of necessary inclusion criteria. A total of 57 eligible studies are described in this review.

CONCLUSION

This review provides a comparative overview of key outcomes reported between RCTs investigating CSCR. We describe the current landscape of treatment modalities for CSCR and note the discrepancies between results in these published studies. Challenges arise when attempting to compare similar study designs without comparable outcome measures (i.e., clinical vs. structural) which may limit the overall evidence presented. To mitigate this issue, we present the collected data from each study in tables detailing the measures that are and are not assessed in each publication.

Real world outcomes of photodynamic therapy for chronic central serous chorioretinopathy

OBJECTIVES

We describe the real-world outcomes of photodynamic therapy (PDT) for chronic central serous chorioretinopathy (CSCR) in a single centre over nine years.

METHODS

We carried out a retrospective analysis of patients with chronic CSCR who received half dose PDT in a single centre between 2011 and 2019. Visual acuity (VA) and retinal thickness (RT) was recorded between baseline visit and first recorded review visit.

RESULTS

We included 125 eyes of 113 patients in this study. Mean age at treatment was 55.0 ± 12.1 years, with a higher male predominance (83 men, 30 women). Mean baseline VA was 0.40 ± 0.31 logMAR with a mean visual outcome gain post-PDT of 0.05 logMAR (p = 0.005). Mean baseline RT was 390 ± 82 microns with a mean reduction of RT post-PDT of 66 microns (p < 0.001). 17.6% of eyes were treated for recurrent CSCR.

CONCLUSION

We found overall a mean improvement in VA and structural outcomes after PDT. In the absence of randomised clinical trials this study supports the use of half dose PDT for treatment of chronic CSCR.

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 by Autofluorescence, Enface and SLO-Retromode Imaging

The aim of our study was to investigate the clinical features of central serous chorioretinopathy (CSC) with autofluorescence (AF), retromode (RM), and enface imaging. This retrospective study was conducted at Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome (Italy), between September and December 2022. Each patient underwent a complete ophthalmological examination, which included optical coherence tomography (OCT), enface image analysis, AF, and RM imaging. We further evaluated the presence and area of extension of serous retinal detachment and retinal pigment epithelium (RPE) atrophy through AF, RM, and enface imaging. We included 32 eyes from 27 patients (mean age: 52.7 ± 13.3 years). The median AF area was 19.5 mm² (IQR 6.1-29.3), while the median RM area was 12.3 mm² (IQR 8.1-30.8), and the median enface area was 9.3 mm² (IQR 4.8-18.6). RPE atrophy was diagnosed in 26 cases (81.3%) with RM imaging and in 75% of cases with AF. No difference emerged between AF and RM analysis in the detection of central serous detachment in CSC. However, RM imaging showed a high specificity (91.7%) and negative predictive value (84.6%) to detect RPE changes when compared to the AF standard-of-care technique. Thus, RM imaging could be considered an adjunctive imaging method in CSC.

Functional Outcomes and Safety Profile of Trans-Foveal Subthreshold Micropulse Laser in Persistent Central Serous Chorioretinopathy

Our study evaluated visual function changes after subthreshold micropulse laser (SML) treatment in persistent central serous chorioretinopathy (CSC) and SML safety profile. We conducted a prospective study including 31 fovea-involving CSC patients. The natural course was observed for the first 3 months, SML was performed at 3 months, and SML effectiveness was observed at 6 months. At all three clinical visits, optical coherence tomography (OCT), best corrected visual acuity (BCVA), contrast sensitivity (CS) in five spatial frequencies (1.5, 3.0, 6.0, 12.0, and 18.0 cycles per degree (cpd)), microperimetry (MP), and multifocal electroretinography (mfERG) were performed. The SML safety profile was evaluated with functional and morphological parameters. In the cohort of all CSC patients treated with SML, the statistically significant average improvement was observed in BCVA (p = 0.007), CS-1.5 (p = 0.020), CS-3.0 (p = 0.050), CS-12.0 (p < 0.001), CS-18.0 (p = 0.002), CS (CS-A) (p < 0.001), MP in the central ring (MP-C) (p = 0.020), peripheral ring (MP-P) (p = 0.042), and average retinal sensitivity (MP-A) (p = 0.010). After the SML treatment, mean changes in mfERG amplitudes and implicit times in our cohort were not statistically significant. No morphological or functional adverse effects of SML treatment were observed. SML treatment in persistent CSC episodes leads to significant functional improvement and has an excellent safety profile.

Long-term follow-up of chronic central serous chorioretinopathy patients after primary treatment of oral eplerenone or half-dose photodynamic therapy and crossover treatment: SPECTRA trial report No. 3

PURPOSE

Comparing anatomic and functional efficacy and safety of primary treatment with either half-dose photodynamic therapy (PDT) or oral eplerenone, or crossover treatment in chronic central serous chorioretinopathy patients.

METHODS

After the SPECTRA trial baseline visit, patients were randomized to either half-dose PDT or eplerenone and received crossover treatment if persistent subretinal fluid (SRF) on optical coherence tomography (OCT) was present at first follow-up (at 3 months). Presence of SRF and best-corrected visual acuity (BCVA) was evaluated at 12 months.

RESULTS

Out of the 90 patients evaluated at 12 months, complete SRF resolution was present on OCT in 43/48 (89.6%) of patients who were primarily randomized to half-dose PDT and in 37/42 (88.1%) who were primarily randomized to eplerenone. Out of the 42 patients that were primarily randomized to eplerenone, 35 received crossover treatment with half-dose PDT. The BCVA improved significantly more at 12 months in patients who had received primary half-dose PDT as compared to the primary eplerenone group (p = 0.030).

CONCLUSIONS

Twelve months after baseline visit, most patients treated with half-dose PDT (either primary or crossover treatment) still had complete SRF resolution. The long-term BCVA in patients who receive primary half-dose PDT is better than in patients in whom PDT is delayed due to initial eplerenone treatment with persistent SRF.

Comparative efficacy of treatments for chronic central serous chorioretinopathy: A systematic review with network meta-analyses

Treatment of chronic central serous chorioretinopathy (cCSC) remains a topic of controversy. As cCSC is a disease that can wax and wane, treatment efficacy is difficult to assess especially when trials compare active treatments without any placebo/control group. In this study, we systematically reviewed short-term efficacies of any cCSC treatment tested in randomized controlled trials (RCT) and employed network meta-analyses to compare to non-treatment controls. We searched 11 literature databases on 20 March 2022 for RCTs of treatment of cCSC. We identified 17 RCTs including a total of 1172 eyes. Treatments included conventional laser (44 eyes), half-dose or half-fluence photodynamic therapy (PDT) (298 eyes), ranibizumab (16 eyes), antioxidants (50 eyes), mineralocorticoid receptor antagonists (187 eyes), rifampicin (91 eyes), selective retina therapy (SRT) (67 eyes) and subthreshold micropulse laser (192 eyes). Compared with controls, significant benefit on complete subretinal fluid resolution was only obtained from half-dose or half-fluence PDT (OR: 20.6; 95% CI: 6.3-66.7; p < 0.0001) and conventional laser (OR: 36.4; 95% CI: 2.0-655.7; p = 0.015), and at an order of magnitude lower degree from SRT (OR: 3.4; 95% CI: 1.7-6.8; p = 0.00075). Compared with controls and after sensitivity analyses, significant benefit in the change in best-corrected visual acuity was only obtained by half-dose/-fluence PDT (-0.13 logMAR; 95% CI: -0.20 to -0.06 logMAR; p = 0.00021). In conclusion, three treatment options provide significant improvement over no treatment: half-dose/-fluence PDT, conventional laser and to a much lesser degree SRT. Considering that conventional laser can only be applied for extrafoveal leaks, and the long-term data available for PDT-based treatments finding persisting treatment results, half-dose or half-fluence PDT is the only viable treatment option for patients with cCSC. Shortage issues with verteporfin should not lead to employment of ineffective treatment modalities, as they put patients at unnecessary risk of adverse events.

Fuji sign: Prevalence and predictive power to photodynamic therapy in chronic central serous chorioretinopathy

AIM

To determine the prevalence of Fuji sign in central serous chorioretinopathy (cCSC) patients and its predictive power of good response to photodynamic therapy (PDT).

METHODS

Retrospective study, including 135 eyes of 130 patients diagnosed with cCSC treated with PDT between 2017 and 2021. Optical Coherence Tomography (OCT) images from these patients were compiled and analyzed. The presence of the Fuji sign, an anatomical finding recently described as a predictor of spontaneous resolution of the subretinal fluid (SRF) in cCSC, as assessed in basal images and the maximum height of SRF pre- and post-PDT OCT was measured.

RESULTS

Mean age was 56.6 years, 69.4% were men and the percentage of partial or complete resolution of the SRF after PDT was 75.55%. Only 8.9% of patients (12/135) had positive Fuji sign at baseline OCT. Among them, 50% (6/12) presented a complete response to the PDT (pre-PDT SRF: 109.00 (29.61) µm), 8.3% (1/12) had a partial resolution of the SRF (127 µm to 66 µm) and 41.6% (5/12) did not respond to PDT (pre-PDT SRF: 71.00 (22.82) µm, post-PDT SRF: 83.60 (36.13) µm).

CONCLUSIONS

Fuji sign has a low prevalence in cCSC and its presence is not associated with a good response to PDT.

OCT and OCT Angiography Update: Clinical Application to Age-Related Macular Degeneration, Central Serous Chorioretinopathy, Macular Telangiectasia, and Diabetic Retinopathy

Similar to ultrasound adapting soundwaves to depict the inner structures and tissues, optical coherence tomography (OCT) utilizes low coherence light waves to assess characteristics in the eye. Compared to the previous gold standard diagnostic imaging fluorescein angiography, OCT is a noninvasive imaging modality that generates images of ocular tissues at a rapid speed. Two commonly used iterations of OCT include spectral-domain (SD) and swept-source (SS). Each comes with different wavelengths and tissue penetration capacities. OCT angiography (OCTA) is a functional extension of the OCT. It generates a large number of pixels to capture the tissue and underlying blood flow. This allows OCTA to measure ischemia and demarcation of the vasculature in a wide range of conditions. This review focused on the study of four commonly encountered diseases involving the retina including age-related macular degeneration (AMD), diabetic retinopathy (DR), central serous chorioretinopathy (CSC), and macular telangiectasia (MacTel). Modern imaging techniques including SD-OCT, TD-OCT, SS-OCT, and OCTA assist with understanding the disease pathogenesis and natural history of disease progression, in addition to routine diagnosis and management in the clinical setting. Finally, this review compares each imaging technique's limitations and potential refinements.

Central serous chorioretinopathy: A review

Central serous chorioretinopathy (CSC) is the fourth most common non-surgical retinopathy associated with fluid leakage. The pathogenesis is not yet completely understood, but changes in the choroid, sclera and RPE have been described associated with venous congestion of choroidal outflow. CSC can be categorised into acute, chronic, and recurrent subtypes with recent classifications of simple and complex based on the area of RPE change seen on fundus autofluorescence. A multimodal imaging approach is helpful in the diagnosis and management of CSC and secondary complications such as type 1 neovascularisation. Although spontaneous resolution with relatively good visual outcomes is common, treatment should be considered in patients with persistent or recurrent SRF. Treatment options include laser, systemic medications, intravitreal therapy, and surgery. Of these, argon laser for focal extramacular fluid leaks and photodynamic therapy of leakage identified by indocyanine-green angiography currently have the greatest supportive evidence.

Effect of photodynamic therapy on choroid of the medial area from optic disc in patients with central serous chorioretinopathy

PURPOSE

To explore the effect of photodynamic therapy (PDT) on the choroid of medial area from optic disc and factors correlated with treatment outcomes, we evaluated choroidal changes using ultra-widefield optical coherence tomography (UWF-OCT) after PDT for central serous chorioretinopathy (CSC).

METHODS

In this retrospective case-series, we included CSC patients who received a standard-dose of full-fluence PDT. UWF-OCT were examined at baseline and 3 months after treatment. We measured choroidal thickness (CT), classified into central, middle, and peripheral sectors. We examined CT changes after PDT by sectors and treatment outcome.

RESULTS

Twenty-two eyes of 21 patients (20 males; mean age 58.7 ± 12.3 years) were included. CT reduction after PDT was significant in all sectors, including peripheral areas: supratemporal, 330.5 ± 90.6 μm vs. 237.0 ± 53.2 μm; infratemporal, 240.0 ± 89.4 μm vs. 209.9 ± 55.1 μm; supranasal, 237.7 ± 59.8 vs 209.3 ± 69.3 μm; infranasal, 172.6 ± 47.2 μm vs. 155.1 ± 38.2 μm (P < 0.001, for all). In patients with retinal fluid resolution, despite no apparent difference in baseline CT, there was more significant reduction after PDT in supratemporal and supranasal peripheral sectors, compared with patients without resolution: supratemporal, 41.9 ± 30.3 μm vs. -1.6 ± 22.7 μm; supranasal, 24.7 ± 15.3 μm vs. 8.5 ± 3.6 μm (P < 0.019, for both).

CONCLUSIONS

Whole CT decreased after PDT, including in medial areas from optic disc. This may be associated with the treatment response of PDT for CSC.

Choroidal arteriovenous anastomoses: a hypothesis for the pathogenesis of central serous chorioretinopathy and other pachychoroid disease spectrum abnormalities

The pachychoroid disease spectrum (PDS) includes several chorioretinal diseases that share specific choroidal abnormalities. Although their pathophysiological basis is poorly understood, diseases that are part of the PDS have been hypothesized to be the result of venous congestion. Within the PDS, central serous chorioretinopathy is the most common condition associated with vision loss, due to an accumulation of subretinal fluid in the macula. Central serous chorioretinopathy is characterized by distinct risk factors, most notably a high prevalence in males and exposure to corticosteroids. Interestingly, sex differences and corticosteroids are also strongly associated with specific types of arteriovenous anastomoses in the human body, including dural arteriovenous fistula and surgically created arteriovenous shunts. In this manuscript, we assess the potential of such arteriovenous anastomoses in the choroid as a causal mechanism of the PDS. We propose how this may provide a novel unifying concept on the pathophysiological basis of the PDS, and present cases in which this mechanism may play a role.

Clinical impact of the worldwide shortage of verteporfin (Visudyne®) on ophthalmic care

INTRODUCTION

Since July 2021, a worldwide shortage of verteporfin (Visudyne®) occurred: an essential medicine required for photodynamic therapy (PDT). PDT with verteporfin has a broad range of indications in ophthalmology, including chronic central serous chorioretinopathy, polypoidal choroidal vasculopathy and choroidal haemangioma. For these disorders, PDT is either the first-choice treatment or regarded as a major treatment option.

MATERIALS AND METHODS

A questionnaire was sent to key opinion leaders in the field of medical retina throughout the world, to assess the role of PDT in their country and the effects of the shortage of verteporfin. In addition, information on the application of alternative treatments during shortage of verteporfin was obtained, to further assess the impact of the shortage.

RESULTS

Our questionnaire indicated that the shortage of verteporfin had a major impact on ophthalmic care worldwide and was regarded to be a serious problem by most of our respondents. However, even though there is ample evidence to support the use of PDT in several chorioretinal diseases, we found notable differences in its use in normal patient care throughout the world. Various alternative management strategies were noted during the verteporfin shortage, including lowering the dose of verteporfin per patient, the use of alternative treatment strategies and the use of a centralized system for allocating the remaining ampoules of verteporfin in some countries.

CONCLUSION

The shortage of verteporfin has had a large effect on the care of ophthalmic patients across the world and may have resulted in significant and irreversible vision loss. Mitigation strategies should be developed in consultation with all stakeholders to avoid future medication shortages of verteporfin and other unique ophthalmic medications. These strategies may include mandatory stock keeping, compulsory licensing to an alternative manufacturer or incentivizing the development of competition, for example through novel public-private partnerships.

Crossover to Half-Dose Photodynamic Therapy or Eplerenone in Chronic Central Serous Chorioretinopathy Patients

PURPOSE

To compare the efficacy and safety of crossover treatment to half-dose photodynamic therapy (PDT) and eplerenone treatment after the failure of primary treatment in patients with chronic central serous chorioretinopathy (cCSC).

DESIGN

Multicenter crossover clinical trial.

SUBJECTS

At 3 months after the baseline visit of the SPECTRA (Half-Dose Photodynamic Therapy Versus Eplerenone: Treatment Trial for Chronic Central Serous Chorioretinopathy) randomized controlled trial, either half-dose PDT or eplerenone treatment was evaluated for each patient, and patients who still demonstrated subretinal fluid (SRF) were included in the current study, the SPECS (Central Serous Chorioretinopathy Treated with Half-Dose PDT or Eplerenone Crossover Study) trial.

METHODS

At the baseline visits for the current SPECS trial, crossover treatment was performed for patients who still demonstrated SRF. These patients received either half-dose PDT or oral eplerenone for 12 weeks. Both anatomic and functional parameters were evaluated 3 months after crossover treatment.

MAIN OUTCOME MEASURES

Complete resolution of SRF on OCT.

RESULTS

Forty-nine patients were included in the SPECS trial (38 received primary eplerenone treatment; 11 received half-dose PDT). At 3 months after crossover treatment, 32 of 37 (86.5%) in the crossover to half-dose PDT group and 2 of 9 (22.2%) in the crossover to eplerenone group had complete SRF resolution (P = 0.030). The mean foveal sensitivity increased significantly more in the crossover to half-dose PDT group (mean, +3.08 dB) compared with the crossover to eplerenone group (mean, -0.27 dB; P = 0.009).

CONCLUSIONS

Patients with cCSC with the persistence of SRF after primary eplerenone treatment can benefit from half-dose PDT, which can induce a relatively fast and complete SRF resolution, along with an improvement in foveal sensitivity.

Utility of an additional photodynamic therapy session after multiple failed PDT treatments in chronic central serous chorioretinopathy

PURPOSE

To assess the efficacy of an additional photodynamic therapy (PDT) in chronic central serous chorioretinopathy (cCSCR) patients who have two or more previous failed PDTs.

METHODS

Ten eyes of 10 patients with cCSCR who had received two or more PDTs without complete resolution of the subretinal fluid (SRF) or with early recurrence (before 3 months) were included. An additional half-fluence PDT was performed. Swept-source optical coherence tomography (OCT) and OCT angiography were performed before, 3 days, 1 month, 3 months, 6 months and 12 months after treatment. Age, gender, best-corrected visual acuity (BCVA), subfoveal choroidal thickness, SRF and vessel occlusion in the choriocapillaris (CC) were collected.

RESULTS

The median number of previous PDTs was 3 (range 2 to 4). BCVA before and 12 months after treatment was 72 letters (50 to 95) and 78 letters (55 to 100) (p=0.094). Median initial SRF was 94 µm (50 to 306), being 0 µm (range 0 to 81) at the end of the follow-up (p=0.007). After the additional PDT, 8 out of 10 patients had a complete SRF resorption. All the patients except one who had a complete response (7/8) had an occlusion in the CC 3 days after PDT.

CONCLUSION

Despite previous failed PDTs in cCSCR, good anatomical results can be achieved, this being more likely if an early vessel occlusion in the CC is observed. Even when the BCVA did not improve, the high rate of fluid resolution could justify the additional PDT treatment in order to maintain visual function.

Effects of Ketoconazole on the Clinical Recovery in Central Serous Chorioretinopathy

Purpose

Patients with hypercortisolism have been associated with a higher prevalence of the pachychoroid spectrum including central serous chorioretinopathy (CSCR), which may explain the inconsistency of therapeutic responses of the mineralocorticoid receptor antagonist because hyperaldosteronism has rarely been detected in patients with CSCR. Therefore, this study aimed to evaluate the effects of ketoconazole, the first-line cortisol inhibitor, on the resolution of subretinal fluid (SRF) in CSCR and to analyze correlations between choroidal thickness and steroid hormones.

Patients and Methods

This retrospective cohort study included 41 naïve CSCR eyes of 41 patients categorized into control (20 eyes) and treatment (21 eyes) groups. Patients in the treatment group were administered oral ketoconazole at a daily dose of 400 or 600 mg for 3–6 weeks. At week 12, rescue laser therapy was applied to patients exhibiting persistent SRF. Thus, a survival analysis was performed to determine the time interval from presentation to clinical resolution of SRF. Secondary outcomes consisted of eyes with persistent SRF and factors affecting the therapeutic response.

Results

The mean 24-hour urinary free cortisol (UFC) levels were elevated at 181 ± 70 and 150 ± 68 µg/day (range: 20–150) in the treatment and control groups, respectively (p = 0.21). After controlling for age and gender, baseline UFC levels were significantly associated with choroidal thickness in both eyes (p < 0.05). Ketoconazole significantly increased the CSCR resolution with the median time to resolution of 7 vs 16 weeks (p < 0.01) and decreased the proportion of eyes receiving rescue therapy at 12 weeks (23.8% vs 50%; p = 0.01). Prolonged CSCR durations were likely found in elderly patients with thick choroids in fellow eyes.

Conclusion

Patients with CSCR showed elevated glucocorticoids, which further correlated with their choroidal thickness. Using cortisol blockers may shorten the duration of existing SRF.

EFFICACY OF HALF-DOSE PHOTODYNAMIC THERAPY VERSUS HIGH-DENSITY SUBTHRESHOLD MICROPULSE LASER FOR TREATING PIGMENT EPITHELIAL DETACHMENTS IN CHRONIC CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

Comparing the effect of half-dose photodynamic therapy and high-density subthreshold micropulse laser treatment on retinal pigment epithelial detachments (PEDs) in chronic central serous chorioretinopathy.

METHODS

This study included data from the PLACE trial, a prospective randomized controlled trial comparing half-dose photodynamic therapy and high-density subthreshold micropulse laser treatment in chronic central serous chorioretinopathy. Main outcome measurements were changes in both the foveal PED and the highest PED within the macula at baseline compared with first and final evaluation visit.

RESULTS

At baseline, a macular PED was detected in 76.9% of patients (123/160), and a PED within 1,500 µm from the foveal center in 37.5% of patients (60/160). In the half-dose photodynamic therapy arm (61 patients), there was a significantly larger decrease in the highest macular PED compared with the high-density subthreshold micropulse laser treatment arm (62 patients) at both first and final evaluation visits (P < 0.001 and P = 0.012, respectively). The decrease of highest foveal PED was significant at first visit (P = 0.025).

CONCLUSION

Half-dose photodynamic therapy is superior to high-density subthreshold micropulse laser treatment with regard to a statistically significant reduction in the height of macular PEDs in active chronic central serous chorioretinopathy. These findings may also have implications for other diseases within the pachychoroid disease spectrum that can present with PEDs.

The Cortisol Response of Male and Female Choroidal Endothelial Cells: Implications for Central Serous Chorioretinopathy

CONTEXT

Central serous chorioretinopathy (CSC) is a severe ocular disease characterized by fluid accumulation under the retina and abnormalities in the underlying vascular layer, the choroid. CSC has a striking prevalence in males of 80% to 90% of total patients. Corticosteroids are the most pronounced extrinsic risk factor for CSC. Choroidal endothelial cells (CECs) are important for the vascular integrity of the choroid, but the effects of corticosteroid effects in these cells are unknown.

OBJECTIVE

We aimed to reveal the potential steroidal contribution to CSC.

METHOD

We characterized the expression of the glucocorticoid, mineralocorticoid, and androgen receptor in the human choroid using immunohistochemistry. Using RNA-sequencing, we describe the cortisol response in human CECs derived from 5 male and 5 female postmortem donors.

RESULTS

The glucocorticoid receptor was highly expressed in the human choroid, whereas no to minimal expression of the mineralocorticoid and androgen receptors was observed. The extensive transcriptional response to cortisol in human primary cultured CECs showed interindividual differences but very few sex differences. Several highly regulated genes such as ZBTB16 (log2 fold change males 7.9; females 6.2) provide strong links to choroidal vascular regulation.

CONCLUSIONS

The glucocorticoid receptor predominantly mediates the response to cortisol in human CECs. Interindividual differences are an important determinant regarding the cortisol response in human cultured CECs, whereas intrinsic sex differences appear less pronounced. The marked response of particular target genes in endothelial cells to cortisol, such as ZBTB16, warrants further investigation into their potential role in the pathophysiology of CSC and other vascular conditions.