Risk Factors and Outcomes of Choroidal Neovascularization Secondary to Central Serous Chorioretinopathy

Role of Plasma Angiopoietin-1 and VEGF Levels as Potential Biomarkers in Chronic Central Serous Chorioretinopathy with Macular Neovascularization

To evaluate the plasma levels of angiopoietin-1 and vascular endothelial growth factor (VEGF) and their association with macular neovascularization (MNV) in patients with chronic central serous chorioretinopathy (cCSC). Correlations between plasma cytokine levels, CSC duration, and mean choroidal thickness (CT) were also investigated. Of the 59 patients with cCSC, 10 patients with MNV secondary to cCSC and 10 patients with cCSC without MNV were enrolled in the study. The control group included 15 healthy volunteers matched for age, sex, smoking status, and comorbidities. Chronic CSC was diagnosed based on typical findings on swept-source optical coherence tomography (OCT), fundus fluorescein angiography, and indocyanine green angiography. Additionally, all patients underwent OCT angiography to help detect MNV. Plasma angiopoietin-1 and VEGF levels were assessed using multiplex immunoassay. The plasma angiopoietin-1 levels differed between the 3 groups (p = 0.005). The angiopoietin-1 levels were lower in patients with cCSC with MNV than in controls (p = 0.006). There were no differences in the plasma VEGF levels between all the 3 groups (p = 0.329). The VEGF levels were negatively correlated with mean CT in cCSC patients with MNV (rho = -0.683, p = 0.042) but correlated positively with disease duration in patients with cCSC without MNV (rho = 0.886, p = 0.003). Our study confirms that MNV is a common complication of cCSC and provides new insights into the role of angiopoietin-1 in cCSC and MNV. Reduced angiopoietin-1 levels in cCSC patients, regardless of MNV status, highlight the importance of the Ang-Tie2 pathway in disease pathogenesis and may point to new therapeutic targets and future novel treatments to improve the management of these patients.

Predict and Protect: Evaluating the Double-Layer Sign in Age-Related Macular Degeneration

INTRODUCTION

Advanced age-related macular degeneration (AMD) is a major cause of vision loss. Therefore, there is interest in precursor lesions that may predict or prevent the onset of advanced AMD. One such lesion is a shallow separation of the retinal pigment epithelium (RPE) and Bruch's membrane (BM), which is described by various terms, including double-layer sign (DLS).

METHODS

In this article, we aim to examine and clarify the different terms referring to shallow separation of the RPE and BM. We also review current evidence on the outcomes associated with DLS: firstly, whether DLS is predictive of exudative neovascular AMD; and secondly, whether DLS has potential protective properties against geographic atrophy.

RESULTS

The range of terms used to describe a shallow separation of the RPE and BM reflects that DLS can present with different characteristics. While vascularised DLS appears to protect against atrophy but can progress to exudation, non-vascularised DLS is associated with an increased risk of atrophy. Optical coherence tomography (OCT) angiography (OCTA) is the principal method for identifying and differentiating various forms of DLS. If OCTA is unavailable or not practically possible, simplified classification of DLS as thick or thin, using OCT, enables the likelihood of vascularisation to be approximated. Research is ongoing to automate DLS detection by applying deep-learning algorithms to OCT scans.

CONCLUSIONS

The term DLS remains applicable for describing shallow separation of the RPE and BM. Detection and classification of this feature provides valuable information regarding the risk of progression to advanced AMD. However, the appearance of DLS and its value in predicting AMD progression can vary between patients. With further research, individualised risks can be confirmed to inform appropriate treatment.

Pachychoroid Spectrum Disease: Comparison of Patients with Central Serous Chorioretinopathy Complicated with Pachychoroid Neovasculopathy

PURPOSE

This study aimed to determine the incidence and visual outcomes of pachychoroid neovasculopathy (PNV) in patients initially diagnosed with central serous chorioretinopathy (CSC).

METHODS

In this study, 144 patients aged 20 to 55 years with treatment-naive chronic CSC, defined as the persistence of subretinal fluid (SRF) for ≥6 months, were retrospectively enrolled. Patients with PNV at the initial evaluation were categorized as group 1, whereas those who developed new-onset PNV during follow-up were categorized as group 2. Patients without PNV until the end of the follow-up were categorized as group 3.

RESULTS

Over a mean follow-up period of 49.9 ± 39.9 months, new-onset PNV was diagnosed in 11.8% of patients with CSC. The time taken to reach the initial resolution was longest in group 1 (group 1, 11.13 ± 10.70 months; group 2, 8.14 ± 7.90 months; group 3, 7.32 ± 9.55 months), although these differences were not statistically significant. The numbers of injections needed to achieve initial resolution were 3.76 ± 5.90, 1.64 ± 2.06, and 1.74 ± 4.33 in groups 1, 2, and 3, respectively, with no significant differences. SRF recurrence was recorded in seven patients (29.2%) in group 1, nine (64.3%) in group 2, and 28 (26.7%) in group 3. The recurrence rates were significantly higher in group 2 than those in group 1 or 3. At the end of the follow-up period, significant improvements in best-corrected visual acuity were achieved in groups 1 and 3, compared with baseline, but not in group 2.

CONCLUSIONS

Patients with chronic CSC with new-onset PNV exhibited higher SRF recurrence and worse visual outcomes compared to those with initial PNV or those with chronic CSC without PNV. Our study emphasizes the importance of routine screening for prompt diagnoses of new-onset PNV in individuals with chronic CSC.

Foveal atrophy in patients with active central serous chorioretinopathy at first presentation: characteristics and treatment outcomes

BACKGROUND/AIMS

This study aimed to investigate the clinical characteristics and treatment outcomes of patients with active central serous chorioretinopathy (CSC) and foveal atrophy.

METHODS

Patients diagnosed with active idiopathic CSC using multimodal imaging and followed up for at least 6 months were included. They were divided into two groups (foveal atrophy group vs foveal non-atrophy group) according to a cut-off central foveal thickness of 120 µm on baseline optical coherence tomography (OCT). Baseline characteristics, angiographic and tomographic features and treatment outcomes were compared between the two groups.

RESULTS

Of the 463 patients, 92 eyes of 92 patients (19.9%) were in the foveal atrophy group and 371 eyes of 371 patients (80.1%) were in the foveal non-atrophy group. The baseline subretinal fluid (SRF) height was 111.3±76.8 µm in the foveal atrophy group and 205.0±104.4 µm in the foveal non-atrophy group on OCT images (p<0.001). Complete resolution of SRF after treatment was noted in 60.4% and 93.5% of patients in the foveal atrophy and foveal non-atrophy groups at the final visit, respectively (p<0.001). The foveal atrophy group showed worse visual acuity at baseline (logarithm of the minimum angle of resolution, 0.43±0.33 vs 0.13±0.18, p<0.001) and final visit (0.41±0.32 vs 0.05±0.15, p=0.035).

CONCLUSIONS

CSC with foveal atrophy was associated with a shallow SRF height, low treatment efficacy and poor vision before and after treatment. We suggest that early active treatment should be considered for eyes with CSC accompanied by a persistent shallow SRF and foveal atrophy.

RISK OF EXUDATION IN EYES WITH NONEXUDATIVE POLYPOIDAL CHOROIDAL VASCULOPATHY

PURPOSE

To investigate the characteristics and natural history of treatment-naive nonexudative polypoidal choroidal vasculopathy (PCV) and to determine biomarkers predicting exudative conversion.

METHODS

Patients diagnosed with nonexudative PCV based on indocyanine green angiography and optical coherence tomography were included. Incidence of exudative conversion in nonexudative PCV patients and cumulative estimates for overall risk were assessed. Indocyanine green angiography and optical coherence tomography imaging-based features were analyzed to identify risk factors for exudative conversion.

RESULTS

The study included 42 eyes of 40 patients with nonexudative PCV. The mean follow-up duration was 54.3 ± 35.5 months. Of the 42 eyes with nonexudative PCV, exudative conversion developed in 23 eyes (54.8%) after 42.2 ± 28.3 months (range, 8-103 months). Kaplan-Meier analysis showed that the exudation-free survival at 5 years after baseline was estimated to be 53.6%. Multivariate regression analysis showed that sequentially increased protrusion of retinal pigment epithelium in the polyp area was a significant risk factor for exudation in nonexudative PCV (odds ratio = 10.16; 95% CI 1.78-57.81; P = 0.01).

CONCLUSION

Exudative conversion has been noted in nearly half of the nonexudative PCV cases in 5 years. The progressive protrusion of polypoidal lesions on optical coherence tomography examination may be a significant biomarker for predicting the near-term onset of exudation.

Three-Year Follow-Up Detecting Choroidal Neovascularization with Swept Source Optical Coherence Tomography Angiography (SS-OCTA) after Successful Half-Fluence Photodynamic Therapy for Chronic Central Serous Chorioretinopathy

Purpose: To assess the clinical course, structural changes, and choroidal neovascularization detection by SS-OCTA in long-standing and resolved patients with chronic central serous chorioretinopathy (cCSC) after successful half-fluence photodynamic therapy (hf-PDT) treatment. Methods: Twenty-four eyes presenting with cCSC were examined with SS-OCTA and were classified as choroidal neovascular (CNV) or non-choroidal neovascular (non-CNV) cCSC depending on the vascular pattern detected by SS-OCTA after one, two, and three years after hf-PDT. Two groups were compared based on the following clinical findings: demographic characteristics, time of clinical signs, best corrected visual acuity (BCVA), central retinal thickness (CRT), central choroidal thickness (CFT), subretinal fluid (SRF), flat, irregular pigment epithelial detachment (FIPED), and features of fluorescein angiography (FA) and vascular pattern by SS-OCTA. Results: All patients showed resolved cCSC during follow-up after hf-PDT. A total of 5 of 24 (20.8%) eyes showed a neovascular pattern by SS-OCTA. No differences between BCVA, CRT, SRF, FIPED, or FA features were found between both groups (p > 0.05). However, CFT and older age were associated with a neovascular pattern by SS-OCTA (p < 0.05) in follow-up. No signs of neovascular activity were detected by SS-OCT during follow-up in CNV cCSC patients, and no antiVEGF treatment was required for three-year follow-ups. Conclusions: Despite patients with cCSC showing a favorable clinical response after hf-PDT, lower foveal thickness and older age were associated with CNV patterns by SS-OCTA during follow-up.

Identification of macular neovascularization in central serous chorioretinopathy using swept-source OCT angiography

Purpose

Swept-source optical coherence tomography angiography (SS-OCTA) was used to detect the presence of macular neovascularization (MNV) in eyes with exudative central serous chorioretinopathy (CSCR).

Observations

Case 1 is a 73-year-old man using prednisolone drops with 20/40 vision and a retinal pigment epithelial detachment (PED) associated with subretinal fluid (SRF) and no clinical signs of age-related macular degeneration (AMD) in his left eye. Three months after presentation he underwent SS-OCTA imaging that revealed MNV. He received a series of intravitreal anti-vascular endothelial growth factor (VEGF) injections and SS-OCTA imaging showed a decrease in the MNV lesion size with resolution of the SRF. VA improved to 20/25. Case 2 is a 65-year-old man with recent oral steroid use, presenting with 20/20 vision, a PED, SRF, and no evidence of AMD. SS-OCTA imaging at presentation revealed MNV, which worsened on interval SS-OCTA imaging after the patient deferred treatment. Intravitreal anti-VEGF therapy was then performed with resolution of the SRF and VA improved to 20/15. A total of six cases of type 1 MNV were diagnosed with CSCR. Most were men with a history of steroid or testosterone use and were treated with good response.

Conclusions and importance

SS-OCTA imaging provides a convenient non-invasive strategy for identifying CSCR eyes with MNV without the need for dye-based angiography.

[Choroidal neovascularization in central serous chorioretinopathy]

The literature review discusses the features of the pathogenesis, differential diagnosis and antiangiogenic therapy of choroidal neovascularization (CNV) associated with central serous chorioretinopathy (CSC), with particular attention given to the choice of antiangiogenic drug and therapy regimen to achieve optimal anatomical and functional outcomes in patients with CSC complicated by CNV.

Individual vs. combined imaging modalities for diagnosing neovascular central serous chorioretinopathy

PURPOSE

To assess the diagnostic accuracy of individual and combined imaging modalities compared with multimodal imaging for the detection of choroidal neovascularization (CNV) in central serous chorioretinopathy (CSC).

METHODS

We analyzed patients with CSC with and without CNV who had indocyanine green angiography (ICGA), structural optical coherence tomography (OCT), and OCT angiography (OCTA) obtained on the same day. The presence of CNV was determined using multimodal imaging by a senior retina specialist (i.e., diagnostic reference). Individual and combined (i.e., ICGA + structural OCT) imaging modalities were then graded by two expert readers for the presence of CNV. Sensitivity, specificity, positive (PPV), and negative (NPV) predictive values were computed for individual and combined imaging modalities relative to the diagnostic reference.

RESULTS

CNV was detected in 17 eyes in 17 out of 33 CSC patients according to the reference standard. Using ICGA, the identification of CNV had a sensitivity of 66.7%, specificity of 66.7%, PPV of 70.6%, and NPV of 62.5%. Structural OCT had the following diagnostic accuracy values: 83.3% of sensitivity, 53.3% of specificity, 68.1% of PPV, and 72.7% of NPV. Using OCTA, CNV was graded to be present with a sensitivity of 77.8%, specificity of 86.7%, PPV of 87.5%, and NPV of 76.5%. The combination of ICGA and structural OCT granted the identification of CNV with a sensitivity of 83.3%, specificity of 86.7%, PPV of 88.2%, and NPV of 81.3%.

CONCLUSIONS

OCTA has an elevated diagnostic accuracy in identifying CSC-associated CNV, though a combination of ICGA and structural OCT has a comparable diagnostic efficiency.

Imaging Characteristics of Neovascular and Atrophic Pachychoroidal Spectrum Diseases

Background

This study qualitatively and quantitatively compared imaging characteristics between neovascular and atrophic pachychoroid spectrum disease (PSD) by optical coherence tomography (OCT), and OCT angiography (OCTA).

Methods

The subtypes of PSD were identified by multi-modality imaging approaches. Subfoveal choroidal thickness (SFCT), choroidal vascular index (CVI), and vascular density of choroidal neovascularization (CNV) were measured.

Results

The CVI and SFCT of 174 PSD eyes were 67.6% ± 5.48% and 362.2 ± 131.88 μm, respectively. After adjustment for age, linear regression indicated that SFCT was positively associated with CVI (p &lt; 0.001), and patched hyper-reflective lesions in choriocapillaris layers (p = 0.009). Compared with neovascular PSD eyes, atrophic PSD eyes had similar patient age (57.1 ± 16.72 years, p = 0.639), SFCT (332.0 ± 111.00 μm, p = 0.51), and CVI (67.6% ± 3.94%, p = 0.527). There were no differences between polypoidal choroidal vasculopathy (PCV) eyes with aneurysmal polypoidal lesions and PCV eyes with tangled polypoidal lesions in terms of age, CVI, SFCT, vascular density, or the occurrence of double layer signs (DLSs, all p &gt; 0.05). Logistic regression indicated that age (p = 0.003), SFCT (p = 0.003), patched hyper-reflective lesions in choriocapillaris layers (p = 0.009), and DLSs (p &lt; 0.001) were predictive factors for CNV progression in PSD eyes (all p &lt; 0.05).

Conclusions

Our study highlighted the similarities in SFCT and CVI between neovascular and atrophic PSD, both of which were late stage lesions. Besides, age, SFCT, patched hyper-reflective lesions in choriocapillaris layers, and DLSs were risk factors for CNV in PSD. Our results showed that atrophic PSD is an important change in the late stage of PSD disease, which is helpful for in-depth understanding of the pathological mechanism of PSD and corresponding intervention.

Efficacy of Navigated Laser Photocoagulation for Chronic Central Serous Chorioretinopathy: A Retrospective Observational Study

Background. No consensus has been reached regarding the management of central serous chorioretinopathy (CSCR). We aimed to investigate the efficacy of navigated laser treatment for chronic CSCR and changes in the morphology of the retinal pigment epithelium (RPE). In this retrospective observational study, 19 patients with subjective symptoms admitted to the Nanjing Medical University Affiliated Eye Hospital were included between January 2021 and August 2021. All patients underwent visual acuity and optical coherence tomography (OCT) examination during follow-up. Fluorescein angiography (FA) was performed at baseline and at the final follow-up to confirm the dye leakage sites. The mean logMAR BCVA at baseline and at the end of follow-up was 0.49 ± 0.24 and 0.24 ± 0.15, respectively. The mean logMAR BCVA 3 months after treatment was significantly better than that before treatment (p = 0.002). Significant improvements were observed in central macular thickness (CMT) and subfoveal choroidal thickness (SFCT) after navigated laser photocoagulation (p < 0.0001). Subretinal fluid was completely resolved in 13 (68%) of 19 eyes at 3 months. RPE lesions on OCT images showed RPE detachment in 17 eyes (61.5%), small protrusion of the RPE layer in 5 eyes (7.5%), and a rough RPE layer in 4 eyes (31%). After laser treatment, 9 points (35%) showed retinal detachment, and 10 (38.5%) regions showed an irregular RPE layer. An irregularly protruded RPE layer was also observed in different regions of the leakage spot in 5 (19%) eyes, and RPE defects were seen in 2 (7.5%) eyes. Navigated laser photocoagulation for chronic CSCR can achieve substantial anatomical and visual improvement. OCT outcomes may provide new information to facilitate understanding of the mechanism of chronic CSCR. Navigated laser photocoagulation should be chosen as an optimal treatment option in patients with chronic CSCR who cannot afford photodynamic therapy.

The Diagnostic Accuracy of Double-Layer Sign in Detection of Macular Neovascularization Secondary to Central Serous Chorioretinopathy

PURPOSE

To investigate the diagnostic value of elevated retinal pigment epithelium (RPE) and double-layer sign (DLS) in identifying macular neovascularization (MNV) secondary to central serous chorioretinopathy (CSCR).

DESIGN

Retrospective, cross-sectional study.

METHODS

Patients with CSCR underwent optical coherence tomography (OCT) and OCT angiography (OCT-A) scanning at Moorfields Eye Hospital. OCT scans were reviewed to identify the presence/absence of an RPE elevation. The maximum length and maximum height of the elevated RPE were measured. A minimum length of 1000 µm and a maximum height of 150 µm were used to define the "double-layer sign." Other qualitative anatomical features were also graded from OCT scans. OCT-A was examined to confirm the presence/absence of MNV. Binary logistic regression analyses were used to assess the association between OCT features and the detection of MNV on OCT-A. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to assess the diagnostic accuracy.

RESULTS

One hundred sixty-three eyes from 132 patients were included. Elevated RPE was detected in 148 eyes (91%). OCT-A-confirmed MNV was detected in 54 eyes (33%). The sensitivity and specificity of RPE elevation were 100% and 13.8%, respectively. DLS was identified in 95 eyes (58%). The sensitivity and specificity of DLS for detecting MNV were 87% and 56%, respectively. Hyperreflectivity and nonhomogeneity of the sub-RPE space were independently associated with MNV within the DLS (odds ratio, 17.7 and 14.8, P < .001 and P = .02, respectively). None of the other demographic or anatomical features were associated with MNV. The presence of nonhomogeneous hyperreflective RPE elevation had a sensitivity and specificity of 98% and 67%, with PPV and NPV of 60% and 99%, respectively.

CONCLUSIONS

Nonhomogeneous and hyperreflective space under an elevated RPE of any length or height indicates an eye with higher risk of MNV than DLS. OCT-A should at least be performed for these eyes to confirm the presence of MNV and treat accordingly.

OCT Angiography Fractal Analysis of Choroidal Neovessels Secondary to Central Serous Chorioretinopathy, in a Caucasian Cohort

Central serous chorioretinopathy (CSCR) can be complicated by different types of choroidal neovascularization (CNV). The purpose of this study was to investigate the incidence and quantitative optical coherence tomography angiography (OCT-A) features of CSCR-related CNVs. Methods: This was a retrospective multicenter study including 102 eyes of 102 Caucasian patients with acute or complex CSCR. All patients underwent a comprehensive ophthalmological examination. Quantitative OCT-A parameters, including vascular perfusion density (VPD), fractal dimension (FD), and lacunarity (LAC), were measured in CNV eyes. Results: Forty eyes (39.2%) had acute CSCR, whereas the remaining sixty-two (60.8%) had complex CSCR. CNV was observed in 37 (36.27%) eyes, all of which had the complex form. CNVs were classified as type 1 CNV in 11/37 (29.73%) cases and as polypoidal choroidal vasculopathy (PCV) in the remaining 26/37 (70.27%). Overall, the mean VPD, FD, and LAC of CSCR-related CNVs were 0.52 ± 0.20%, 1.44 ± 0.12, and 2.40 ± 1.1, respectively. No significant difference between type 1 CNV and PCV was found. Conclusion: Complex CSCR is often complicated by type 1 CNV and PCV with similar neovascular architecture and branching complexity, a finding supporting the idea that they might be different stages of the same neovascular process. Future OCT-A fractal analysis-based studies that also include other relevant parameters, such as demographics, presentation, morphology on multimodal imaging, and response to treatment, are necessary before drawing any definitive conclusions.

Predicting Post-Therapeutic Visual Acuity and OCT Images in Patients With Central Serous Chorioretinopathy by Artificial Intelligence

To predict visual acuity (VA) and post-therapeutic optical coherence tomography (OCT) images 1, 3, and 6 months after laser treatment in patients with central serous chorioretinopathy (CSC) by artificial intelligence (AI). Real-world clinical and imaging data were collected at Zhongshan Ophthalmic Center (ZOC) and Xiamen Eye Center (XEC). The data obtained from ZOC (416 eyes of 401 patients) were used as the training set; the data obtained from XEC (64 eyes of 60 patients) were used as the test set. Six different machine learning algorithms and a blending algorithm were used to predict VA, and a pix2pixHD method was adopted to predict post-therapeutic OCT images in patients after laser treatment. The data for VA predictions included clinical features obtained from electronic medical records (20 features) and measured features obtained from fundus fluorescein angiography, indocyanine green angiography, and OCT (145 features). The data for OCT predictions included 480 pairs of pre- and post-therapeutic OCT images. The VA and OCT images predicted by AI were compared with the ground truth. In the VA predictions of XEC dataset, the mean absolute errors (MAEs) were 0.074–0.098 logMAR (within four to five letters), and the root mean square errors were 0.096–0.127 logMAR (within five to seven letters) for the 1-, 3-, and 6-month predictions, respectively; in the post-therapeutic OCT predictions, only about 5.15% (5 of 97) of synthetic OCT images could be accurately identified as synthetic images. The MAEs of central macular thickness of synthetic OCT images were 30.15 ± 13.28 μm and 22.46 ± 9.71 μm for the 1- and 3-month predictions, respectively. This is the first study to apply AI to predict VA and post-therapeutic OCT of patients with CSC. This work establishes a reliable method of predicting prognosis 6 months in advance; the application of AI has the potential to help reduce patient anxiety and serve as a reference for ophthalmologists when choosing optimal laser treatments.

To evaluate the microcirculation of retinochoroid capillary between acute and chronic central serous chorioretinopathy with OCTA

To investigate the difference in chorioretinal microcirculation between acute central serous chorioretinopathy (aCSC) and chronic central serous chorioretinopathy (cCSC) using optical coherence tomography angiography.In total, 65 patients previously diagnosed with central serous chorioretinopathy (33 aCSC and 32 cCSC) were included in our cross-sectional study. All patients underwent complete ophthalmologic assessment including logarithm of the minimum angle of resolution best-corrected visual acuity, fundus fluorescein angiography, and optical coherence tomography angiography. Sixty eyes of 60 refractive error and age matched healthy people were selected as control.The vessel density of inner retina in patients with aCSC were higher than that in patients with cCSC (51.32 ± 2.01 vs 49.15 ± 3.68, P = .004), however, the vessel density of superficial choroid layer in aCSC were significantly lower than that in cCSC (49.83 ± 6.96 vs 53.42 ± 6.28, P = .033). Further analysis of the data reveals the presence of a distinct choroidal neovascularization (CNV) in 8 patients (25%) with cCSC while there was no evidence of CNV in patients with aCSC.Our study can contribute to a better understanding of the difference in retinochoroid microcirculation between aCSC and cCSC. The vessel density of inner retina was lower and the vessel density of superficial choroid was higher in cCSC, and patients with cCSC were more susceptible to CNV than patients with aCSC.

Treatment outcomes of photodynamic therapy and findings predicting treatment success in pachychoroid-associated neovascularization

PURPOSE

To investigate the treatment outcomes and predictive factors affecting treatment success of half-fluence photodynamic therapy (hf-PDT) in pachychoroid-associated neovascularization (PNV).

METHODS

Twenty-four eyes of 23 PNV patients who underwent hf-PDT were included in this study. The results of optical coherence tomography (OCT) and OCT-angiography imaging were analyzed. The total choroidal area (CA), luminal area (LA), and stromal area (SA) were measured using ImageJ software. Baseline characteristics of the eyes showing complete response (group 1) and the eyes with partial response or unresponsive to hf-PDT (group 2) were compared.

RESULTS

The mean age of the patients was 54.2±9.6 years. The mean follow-up time after hf-PDT was 20.7 ± 13.6 months. Three months after hf-PDT, the subretinal fluid had completely regressed in 18 eyes (75.0%), partial resolution was observed in 3 eyes (12.5%), and 3 eyes (12.5%) were unresponsive to hf-PDT. When the baseline characteristics before hf-PDT were evaluated between the groups, the mean central choroidal thickness (411.5 ± 115.1 µm vs 284.8 ± 69.4 µm), the mean CA (1.082 ± 0.315 mm² vs 0.795 ± 0.242 mm²) and the mean LA (0.795 ± 0.234 mm² vs 0.578 ± 0.200 mm²) was significantly higher in group 1 compared to group 2 (p = 0.019, p = 0.018, p = 0.018, respectively).

CONCLUSION

Hf-PDT is an effective treatment method usually providing total resolution of subretinal fluid in PNV cases. A high baseline central choroidal thickness and large luminal area may be positive predictive factors in terms of full anatomical response to hf-PDT. It may be possible to plan a more effective treatment strategy by keeping these factors in mind.

Structural OCT Parameters Associated with Treatment Response and Macular Neovascularization Onset in Central Serous Chorioretinopathy

INTRODUCTION

This study aimed to assess quantitative factors associated with treatment response and macular neovascularization (MNV) onset in central serous chorioretinopathy (CSC) through an artificial intelligence-based approach.

METHODS

The study was designed as an interventional, prospective case series with a planned follow-up of 36 months. We included only eyes demonstrating the first episode of CSC. All the patients underwent eplerenone or photodynamic therapy (PDT) treatment. Eyes developing MNV underwent anti-VEGF injections. We developed an artificial intelligence-based model to assess predictive quantitative structural optical coherence tomography (OCT) factors related to treatment response and onset of MNV. Main outcome measures were best-correct visual acuity (BCVA), central macular thickness (CMT), retinal thickness (RT), retinal pigment epithelium (RPE) thickness, choroidal thickness, Sattler's layer thickness (SLT), Haller's layer thickness, retinal and choroidal hyperreflective foci (HF), and MNV.

RESULTS

We included 96 naïve CSC eyes (96 patients). Baseline BCVA was 0.18 ± 0.25 logMAR, which increased to 0.16 ± 0.27 logMAR after 3 years (p > 0.05). Baseline CMT was 337 ± 126 µm, which improved to 229 ± 40 µm after 3 years (p < 0.01). We observed good response to eplerenone in 40/78 (51%) eyes, whereas 38/78 (49%) eyes underwent PDT. The artificial intelligence model showed choroidal HF and age as determining factors of good response to eplerenone or PDT. RPE thickness < 36 µm, RT < 300 µm, and SLT < 50 µm increased probability of 50% of having MNV.

CONCLUSIONS

CSC response to eplerenone or PDT is influenced by choroidal HF and patient age. RPE and SLT represent relevant factors for onset of MNV.

OCT Risk Factors for 3-Year Development of Macular Complications in Eyes With "Resolved" Chronic Central Serous Chorioretinopathy

PURPOSE

To assess the relationship between demographics, clinical characteristics, and structural optical coherence tomography (OCT) findings and the development of sight-threatening macular complications (choroidal neovascularization [CNV], large areas of retinal pigment epithelium [RPE] atrophy, and cystoid macular degeneration [CMD]) in a cohort of eyes with "resolved" chronic central serous chorioretinopathy (CSC) at study baseline.

DESIGN

Retrospective cohort study.

METHODS

In this study, a total of 71 eyes with "resolved" (absence of subretinal fluid) chronic CSC at baseline and 36 months of regular follow-up examinations were retrospectively enrolled. Structural OCT scans were reviewed. Baseline OCT qualitative features reflecting distress of the neuroretina, RPE, or choroid were assessed and included ellipsoid zone discontinuity, outer nuclear layer (ONL) thinning; presence of hyper-reflective intraretinal foci; dome-shaped pigment epithelium detachment (PED); hyper-reflective flat, irregular PED; hyporeflective flat, irregular PED; and inner choroidal attenuation. OCT images obtained at follow-up visits were also reviewed for development of macular complications (CNV, large areas of RPE atrophy [at least 250 μm in diameter], and CMD). Main outcome measurements included incidence of macular complications and hazard ratio (HR) for demographics, clinical characteristics, and OCT risk factors.

RESULTS

At month 36, 20 eyes (28.2%) developed macular complications. Nine eyes (12.7%) displayed CNV, 9 eyes (12.7%) had large areas of RPE atrophy, and 2 eyes (2.8%) developed cystoid macular degeneration. The following factors were associated with an increased risk of development of CNV: intraretinal hyper-reflective foci had an HR of 11.58 (95% confidence interval [CI]: 1.10-37.24; P = .040); inner choroidal attenuation had an HR of 9.66 (95% CI: 1.07-22.34; P = .043); and the presence of macular complications in the fellow eye had an HR of 20.17 (95% CI: 1.34-39.41; P = .030). Factors associated with the development of RPE atrophy were also identified: ONL thinning had an HR of 13.47 (95% CI: 1.10-39.86; P = .042); dome-shaped PED had an HR of 21.40 (95% CI: 1.50-41.10; P = .031); and inner choroidal attenuation had an HR of 13.20 (95% CI: 1.07-39.32; P = .044).

CONCLUSIONS

OCT risk factors were identified for the development of macular complications in eyes with chronic CSC. Findings may help in the identification of high-risk patients.

THE INCIDENCE OF NEOVASCULARIZATION IN CENTRAL SEROUS CHORIORETINOPATHY BY OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

PURPOSE

To evaluate the incidence of neovascularization (NV) secondary to central serous chorioretinopathy (CSC)-a condition belonging to the spectrum of pachychoroid disorders by means of optical coherence tomography angiography.

METHODS

One hundred and seventy five eyes with CSC were evaluated in this retrospective observational study. The eyes with acute or chronic CSC with no NV were included in Group 1, and those with NV were evaluated in Group 2. Only eyes that had undergone structural optical coherence tomography and optical coherence tomography angiography were included. Age, best-corrected visual acuity, and subfoveal choroidal thickness were evaluated in all eyes. In Group 2, the type and morphology of NV and the occurrence of exudation were considered.

RESULTS

Of a total of 175 eyes with CSC, 86 had the acute form and 89 the chronic. Approximately 140 belonged to Group 1 (80%) and 35 to Group 2 (20%). Approximately 39.2% of all patient with chronic CSC developed NV. Mean age in Groups 1 and 2 was 53.3 years (±10.9) and 66.6 years (±10.2), respectively. Mean best-corrected visual acuity in Groups 1 and 2 was 45.7 (±11.7) and 30.9 (±17.9) early treatment diabetic retinopathy study letters, respectively. Mean CCT in Group 1 and 2 was 417.5 µm (±123) and 344.2 µm (±165.9), respectively. In Group 2, all patients had Type 1 NV (100%); 29 eyes (83%) had filamentous feature, and 6 eyes (17%) had irregular shape. Silent nonexudative NV was observed in 7 eyes (20%), all belonging to Group 2.

CONCLUSION

The use of optical coherence tomography angiography in everyday clinical practice allows for the accurate analysis of the chorioretinal vascular setting, with the identification of new vessels that could remain misdiagnosed.

The Role of Imaging in Planning Treatment for Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSC) is a controversial disease both in terms of clinical classification and choice of therapeutic strategy. Choroidal layers, retinal pigment epithelium (RPE), photoreceptors, and retina are involved to varying degrees. Beyond well-known symptoms raising the clinical suspect of CSC and slit-lamp fundus examination, multimodal imaging plays a key role in assessing the extent of chorioretinal structural involvement. Subretinal fluid (SRF) originating from the choroid leaks through one or multiple RPE defects and spreads into the subretinal space. Spontaneous fluid reabsorption is quite common, but in some eyes, resolution can be obtained only after treatment. Multiple therapeutic strategies are available, and extensive research identified the most effective procedures. Imaging has carved a significant role in guiding the choice of the most appropriate strategy for each single CSC eye. Multiple biomarkers have been identified, and all of them represent a diagnostic and prognostic reference point. This review aims to provide an updated and comprehensive analysis of the current scientific knowledge about the role of imaging in planning the treatment in eyes affected by CSC.

Macular neovascularization in AMD, CSC and best vitelliform macular dystrophy: quantitative OCTA detects distinct clinical entities

BACKGROUND

To perform a quantitative optical coherence tomography (OCT) angiography (OCTA) analysis of macular neovascularization (MNV) secondary to age-related macular degeneration (AMD), central serous chorioretinopathy (CSC) and best vitelliform macular dystrophy (BVMD), with the aim of highlighting quantitative features indicating different clinical entities.

METHODS

Study design: prospective, interventional. We recruited patients affected by AMD, CSC or BVMD, complicated by naive MNV. All patients underwent complete ophthalmologic examination and multimodal imaging. They were treated with anti-VEGF injections, following a pro-re-nata regimen. The ensuing follow-up lasted 1 year. Quantitative dye-based angiography, OCT, and OCTA parameters were analysed to obtain cutoff values able to distinguish two clinically different patient subgroups for each retinal disease. The main outcome measures were best-corrected visual acuity (BCVA), central macular thickness, vessel density of superficial, deep and choriocapillaris plexa, vessel tortuosity (VT) of MNV, vessel dispersion of MNV, number of injections, MNV/leakage ratio, MNV size, speckled fluorescence, and outer retinal atrophy.

RESULTS

Ninety-eight eyes affected by MNV (98 patients) were analysed. These included 66 eyes affected by AMD, 18 displaying CSC, and 14 eyes with BVMD. BCVA was alike in the three groups, both at baseline and after 1 year (p > 0.05). An MNV VT cutoff of 8.40 at baseline detected two patient subgroups differing significantly in terms of morpho-functional features, found both at baseline and at the end of the follow-up.

CONCLUSIONS

Quantitative OCTA suggested that the MNV's VT might be able to provide a better characterization of two different morpho-functional manifestations in AMD, CSC and BVMD.

Choriocapillaris Island: an optical coherence tomography angiography finding observed in central serous chorioretinopathy

Purpose

To report the observation of the choriocapillaris island (CCI) on optical coherence tomography angiography (OCTA) in eyes with active central serous chorioretinopathy (CSCR), and to investigate its associated clinical features.

Design

Retrospective observational study.

Methods

Patients diagnosed with active CSCR underwent OCTA imaging (Optovue Inc, Fremont, California, USA), and the software built-in en face choriocapillaris slab was examined to demonstrate CCI, defined as an area of detectable choriocapillaris flow surrounded by an area of undetectable or diminished flow. Electronic medical records (EMR) were reviewed for demographics, clinical data, other imaging modalities and any intervention, and these parameters were correlated with CCI findings.

Results

25 eyes of 25 patients were recruited. CCI was detected in all examined eyes and was best elucidated on the en face choriocapillaris density maps. 24 eyes had focal retinal pigment epithelium (RPE) alterations overlying CCI. All 14 eyes with simultaneous fundus fluorescein angiography (FA) showed actively leaking point(s) well corresponding to the CCI location. Resolution of sub-retinal fluid in 4 eyes was associated with disappearance of CCI on follow-up OCTA scans. 1 eye showed complicating neovascularization 5 months after the initial presentation at the same location of the CCI.

Conclusion

We demonstrate the observation of the “choriocapillaris island” an OCTA finding in eyes with active CSCR underneath the area of neurosensory detachment. CCI may constitute an angiographic representation of the focal area of choriocapillaris structural and functional affection, with secondary RPE alteration jeopardizing its barrier function. Larger longitudinal studies are needed to further elucidate this finding.

Multimodal Imaging in the Management of Choroidal Neovascularization Secondary to Central Serous Chorioretinopathy

The diagnosis and treatment of choroidal neovascularization (CNV) in eyes with chronic central serous chorioretinopathy (CSCR) can be challenging. The purpose of this study was to classify eyes with suspected CNV using multimodal imaging. The effect of intravitreal anti-vascular endothelial growth factor (VEGF) was assessed and compared to controls. This retrospective study included chronic CSCR patients with suspected secondary CNV who received intravitreal bevacizumab. Eyes were divided into "definite CNV" and "no CNV" based on optical coherence tomography angiography (OCTA). Eyes that did not undergo OCTA imaging were considered as "presumed CNV". One-year outcome in visual acuity (VA) and central foveal thickness (CFT) were investigated and compared to non-treated control patients to assess the response to anti-VEGF. Logistic regression analysis was used to explore predictive biomarkers of CNV detection and improvement after anti-VEGF. Ninety-two eyes with chronic CSCR from 88 participants were included in this study. Sixty-one eyes received bevacizumab and 31 eyes were non-treated control subjects. The presence of subretinal hyperreflective material (SHRM) and shallow irregular retinal pigment epithelium (RPE) elevation (SIRE) with sub-RPE hyperreflectivity on OCT was associated with a significantly increased risk of detecting CNV on OCTA. Intravitreal anti-VEGF caused significant functional and anatomical improvement in patients with neovascular CSCR as compared to non-treated eyes. In contrast, VA and CFT changes were not significantly different between treated and non-treated CSCR with no evidence of CNV on OCTA. No clinical or anatomical biomarkers were found to be associated with response to treatment. In conclusion, OCTA should be used to confirm the presence CNV in suspected chronic CSCR patients. Intravitreal anti-VEGF treatment resulted in a significantly better one-year outcome in patients with definitive OCTA evidence of CNV.

Ranibizumab non-response in pachychoroid neovasculopathy: Effects of switching to aflibercept

Non-response to intravitreal ranibizumab represents a frequent problem in pachychoroid neovasculopathy (PNV). To investigate the effectivity of switching to aflibercept, the database of the Ludwig Maximilians University, Munich, was screened for patients fulfilling the following inclusion criteria: (i) diagnosis of PNV; (ii) inadequate response to ≥ 3 ranibizumab injections, in spite of monthly dosing, defined as persistence of subretinal-fluid four weeks after the last ranibizumab injection; (iii) resulting switch to aflibercept administered as three monthly injections. Primary outcome measure was percentage of eyes with a dry macula four weeks after the third aflibercept injection. Secondary outcome measures included changes in maximum subretinal fluid (SRF), central subfield thickness (CST) and subfoveal choroidal thickness (SFCT). In total, 14 eyes of 14 patients were included. Mean age was 64.1 ± 7.5 (range: 51–78) years. Switching to aflibercept was performed after mean 8.4 ± 4.1 (3–15) ranibizumab injections. While no eye (0%) achieved a dry macula status during ranibizumab treatment, switching to aflibercept achieved a dry macula status in eight eyes (57.1%) after three injections. While both ranibizumab and aflibercept showed an effect on CST (p = 0.027, p = 0.003), only aflibercept showed a significant effect on SRF (p = 0.0009) and SFCT (p = 0.044). In cases of PNV not responding to intravitreal ranibizumab, switching treatment to aflibercept induces a favorable short-term response resolving persistent fluid and achieving a dry macula. Further studies with longer follow-up are warranted.

Choroidal Neovascularization Secondary to Central Serous Chorioretinopathy: OCT Angiography Findings and Risk Factors

Purpose

To identify the clinical characteristics and risk factors for secondary choroidal neovascularization (CNV) in central serous chorioretinopathy (CSC).

Methods

In this retrospective study, we included a total of 108 eyes in 106 CSC patients. Group A was defined as patients initially diagnosed with CSC who developed secondary CNV, and group B was defined as patients who did not develop secondary CNV. Clinical and demographic characteristics, optical coherence tomography (OCT) findings at CSC diagnosis and OCT angiography (OCTA) at the time of secondary CNV diagnosis, were compared between the groups.

Results

Thirty-one eyes had CNV (group A) and 77 eyes did not (group B). The mean age of group A was higher than that of group B (52.28 ± 6.87 vs. 46.78 ± 9.45 years; P < 0.001). Although there was no difference in pigment epithelial detachment (PED) height, group A had larger PED width than group B at CSC diagnosis. The foveal and parafoveal choriocapillary flow densities were significantly lower in group A than group B (P < 0.001). Although there was no difference in pigment epithelial detachment (PED) height, group A had larger PED width than group B at CSC diagnosis. The foveal and parafoveal choriocapillary flow densities were significantly lower in group A than group B (P < 0.001). Although there was no difference in pigment epithelial detachment (PED) height, group A had larger PED width than group B at CSC diagnosis. The foveal and parafoveal choriocapillary flow densities were significantly lower in group A than group B (

Conclusion

We identified that older age, wider PED width at diagnosis, and recurrent episodes of CSC were independent risk factors for development of secondary CNV. Therefore, patients with these risk factors should be monitored to allow early detection and prompt treatment of secondary CNV.