CHOROIDAL NEOVASCULARIZATION IN CAUCASIAN PATIENTS WITH LONGSTANDING CENTRAL SEROUS CHORIORETINOPATHY

Is tobacco consumption a risk factor for central serous chorioretinopathy? A systematic review and meta-analysis

Central serous chorioretinopathy (CSC) is a prevalent exudative maculopathy. Understanding risk factors for CSC is important for disease prevention and to provide evidence-based advice to patients. In this study, we systematically reviewed the literature and performed meta-analysis on the association between tobacco consumption and CSC. We searched 12 literature databases on May 5, 2024, and identified 11 eligible studies of 27 595 patients with CSC and 105 354 control individuals. Studies were predominantly clinic-based case-control studies. We calculated a summary estimate of tobacco consumption as a risk factor for CSC at an odds ratio of 2.99 (95% CI: 1.82-4.93, p = 0.000017), which remained statistically significant in the sensitivity analyses. The exact mechanism by which tobacco consumption contribute to the pathophysiology of CSC remains unclear, although several potential hypotheses exist. However, tobacco consumption is a modifiable behaviour and tobacco cessation is an actionable advice with which patients with CSC themselves can play a large role in disease management. Further studies are warranted to understand the impact of tobacco cessation for risk modification and for the prognosis of patients who already have CSC.

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.

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.

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.

Pachychoroid neovasculopathy can mimic wet type age-related macular degeneration

Purpose

to determine the percentage of patients with pachychoroid neovasculopathy (PNV) among patients who have been misdiagnosed and treated with wet age-related macular degeneration (AMD).

Methods

In this retrospective cross-sectional study, patients over 55 years old, who were diagnosed with wet AMD, were re-evaluated. All patients were recalled for examination and imaging. Patients with PNV were differentiated form wet AMD based on inclusion and exclusion criteria.

Results

Overall, 120 patients (137 eyes) were recorded with wet AMD in the clinic. Finally, after complete re-evaluation, 94 (106 eyes) and 26 patients (31 eyes) were assigned to the AMD and the PNV group, respectively. Thus, a total of 20% of patients with primary mistake diagnosis of wet AMD, actually had PNV. The mean sub field choroidal thickness (SFCT) in the AMD and PNV groups was 173.8 ± 69 μm and 342 ± 27 μm, respectively. Drusen and pachydrusen were found in 69.9% and 24% of the cases with AMD and PNV, respectively (P = 0.001). The average number of intravitreal injections of anti-VEGF (vascular endothelial growth factor) required in the AMD and PNV groups was about 5 and 3, respectively, which was statistically significant (P-value 0.02).

Conclusion

This study revealed that about a one-fifth of wet AMD patients are actually pachychoroid neovasculopathy. These patients were younger and had thicker SFCT, and developed less subretinal scarring. Thus, the disorder must be considered as an important differential diagnosis of AMD-CNV.

Pachychoroid disease spectrum: review article

PURPOSE

The aim of this article is to do a comprehensive literature review about the current understandings of the pachychoroid disease spectrum, describing its multimodal imaging analysis, pathophysiology, differential diagnosis, and current types of management.

METHODS

This comprehensive literature review was performed based on a search on the PubMed database, of relevant pachychoroid published papers according to our current knowledge.

DISCUSSION

The pachychoroid disease spectrum, according to some authors, includes the following: pachychoroid pigment epitheliopathy (PPE), central serous chorioretinopathy (CSC), pachychoroid neovasculopathy (PNV), polypoidal choroidal vasculopathy (PCV)/aneurysmal type 1 neovascularization (AT1), and more recently focal choroidal excavation (FCE) and peripapillary pachychoroid syndrome (PPS). Each one of these entities will be described and discussed in this article.

CONCLUSION

Significant advances in multimodal imaging have enabled a better understanding of the typical choroidal changes in pachychoroid disease spectrum. The clinical knowledge and managing options about this disease significantly increased in the last years. However, it is still unclear why some eyes with typical pachychoroid disease phenotype show no evidence of RPE damage and subretinal fluid (uncomplicated pachychoroid) while others present progressive tissue damage, neovascularization, and atrophy.

OCTA evaluation of treatment-naïve flat irregular PED (FIPED)-associated CNV in chronic central serous chorioretinopathy before and after half-dose PDT

BACKGROUND

To qualitatively and quantitatively evaluate the features of treatment-naïve flat irregular pigment epithelial detachment (FIPED)-associated choroidal neovascularization (CNV) in chronic central serous chorioretinopathy (CSC) using swept-source (SS) optical coherence tomography angiography (OCTA) before and after half-dose photodynamic therapy (PDT).

METHODS

Retrospective case series. The multimodal imaging data of the eyes with FIPED-associated CNV in chronic CSC were reviewed. The features of FIPED-associated CNVs were evaluated by SS-OCTA.

RESULTS

Records of twenty-one patients (21 eyes) were reviewed. The mean age was 56.62 ± 6.87 years. After half-dose PDT, all patients have improved best spectacle-corrected visual acuity from 0.49 at baseline to 0.25 at 6-month visit, and subfoveal choroidal thickness decreased with subretinal fluids absorbed. By OCTA, the features of CNV at baseline included long filamentous linear vessels (21/21), branching into other large mature vessels with rare anastomoses (21/21); and/or a 'dead tree' appearance at the vessel's termini (20/21); and no perilesional hypointense halo (21/21). Compared to those at baseline, the mean vessel density of CNV showed no significant change at 1-,3-,6-month follow-up, while the mean area of CNV was significantly larger at the 6-month follow-up (p = 0.013).

CONCLUSIONS

OCT angiography allows to qualitatively and quantitatively evaluate CNV in chronic CSC. The features of FIPED-associated CNV on OCTA illustrated its quiescent characteristic and further guided therapy. Half-dose PDT showed favorable effects on chronic CSC complicated with FIPED-associated CNV.

Pachychoroid spectrum disease

Recent improvements in ophthalmic imaging have led to the identification of a thickened choroid or pachychoroid to be associated with a number of retinal diseases. The number of conditions linked to this phenotype has continued to widen with specific endophenotypes found within the pachychoroid spectrum. The spectrum includes choroidal features such as focal or diffuse choroidal thickening and thinning of the overlying inner choroid, and choroidal hyperpermeability as demonstrated by indocyanine green angiography. In addition, these diseases are associated with overlying retinal pigmentary changes and retinal pigment epithelial dysfunction and may also be associated with choroidal neovascularization. This article provides a comprehensive review of the literature looking at diseases currently described within the pachychoroid spectrum including central serous chorioretinopathy, pachychoroid pigment epitheliopathy, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy/aneurysmal type 1 neovascularization, peripapillary pachychoroid disease and focal choroidal excavation. We particularly focus on clinical imaging, genetics and pathological findings in these conditions with the aim of updating evidence suggesting a common aetiology between diseases within the pachychoroid spectrum.

Clinical course after the onset of choroidal neovascularization in eyes with central serous chorioretinopathy

Chronic central serous chorioretinopathy (CSC) can be complicated with choroidal neovascularization (CNV); however, the timing of its occurrence and its clinical significance are not well understood. This study aimed to observe the time of choroidal neovascularization detection after CSC diagnosis and determine whether clinical features and prognosis differed in patients with chronic CSC or age-related retinal degeneration.In this retrospective study, medical records of CSC patients complicated with CNV who visited Seoul St. Mary's hospital of Korea between October 2009 and December 2020 were reviewed. The presence of CNV was determined using fluorescein, indocyanine green, or optical coherent tomography angiography (OCTA). Based on the patients' medical records, we observed the change of clinical pattern, best-corrected visual acuity (BCVA) and central macular thickness (CMT) at CNV detection and at 6 months, 1 year, 3 years, and 5 years following CNV detection.Thirty eyes of 30 patients (male: female ratio of 13:17) were enrolled. Mean age at diagnosis of CSC was 54.0 ± 8.5 years (mean ± standard deviation). On average, CNV was detected 1.65 ± 2.30 years after the diagnosis of CSC. The mean CMT was significantly decreased at 6 months, 1 year, and 3 years after choroidal neovascularization detection (P < .001, P < .001, P = .001 respectively). BCVA tend to improve after CNV detection, but there was no statistical significance at 6 months, 1 year, 3 years, and 5 years (all with P > .05). There were no clinical findings suggesting age-related macular degeneration such as intraretinal, subretinal hemorrhage or drusen in any of the case during follow-up. None of the subjects had severe visual acuity loss of 1.0 logarithm of the minimum angle of resolution (logMAR) (20/200 Snellen equivalent) or greater. Among the subjects, 6 patients (20%) did not require any treatment during observation, while 24 other patients required anti-vascular endothelial growth factor (anti-VEGF) or photodynamic therapy. At the last visit, 22 patients (73.3%) remained stable for more than 6 months, without subretinal fluid recurrence.Choroidal neovascularization was detected earlier than previously reported. There was no rapid deterioration of visual acuity or clinical features even after CNV detection.

GENETIC RISK FACTORS IN SEVERE, NONSEVERE AND ACUTE PHENOTYPES OF CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To study genetic predispositions and differences between severe chronic central serous chorioretinopathy (cCSC), nonsevere cCSC, and acute central serous chorioretinopathy (aCSC).

METHODS

One hundred seventy-three severe cCSC patients, 272 nonsevere cCSC patients, 135 aCSC patients, and 1,385 control individuals were included. Eight single-nucleotide polymorphisms were genotyped in the ARMS2 (rs10490924), CFH (rs800292, rs1061170, rs1065489, rs1329428, rs2284664, rs3753394), and NR3C2 (rs2070951). Additionally, C4B gene copy numbers were analyzed.

RESULTS

A significant association in 5 single-nucleotide polymorphisms in the CFH gene could be reproduced among severe cCSC patients, including rs800292 (P = 0.0014; odds ratio [OR] = 1.93; 95% confidence interval [CI] = 1.51-2.47), rs1065489 (P = 2.22 × 10; OR = 0.49; 95% CI = 0.34-0.72), rs1329428 (P = 0.001; OR = 1.89; 95% CI = 1.49-2.40), rs2284664 (P = 1.21× 10; OR = 1.65; 95% CI = 1.28-2.13), and rs3753394 (P = 6.10× 10; OR = 0.61; 95% CI = 0.46-0.81). Carrying three C4B copies was protective for severe cCSC (P = 0.001; OR = 0.29; 95% CI = 0.14-0.61). No significant differences in allele frequencies could be found among the CSC phenotypes.

CONCLUSION

Acute CSC, nonsevere cCSC, and severe cCSC all showed a similar association with the CFH and C4B genes, and the three phenotypes could not be distinguished based on the genetics. This shows that despite the differences in clinical presentation and severity, there is an overlap in the genetic predisposition of different CSC phenotypes. Nongenetic factors may play a more important role in determining the clinical course of CSC.

Optical coherence tomography angiography in central serous chorioretinopathy: The current clinical role and future perspectives

Optical coherence tomography angiography (OCTA) images the layers of retinal and choroidal vasculature in the absence of an injectable dye. Since its introduction, OCTA has been utilized in various posterior segment diseases, including central serous chorioretinopathy. We provide a comprehensive review of OCTA's application to central serous chorioretinopathy published between 2014 and 2020.

POLYPOIDAL CHOROIDAL VASCULOPATHY FEATURES VARY ACCORDING TO SUBFOVEAL CHOROIDAL THICKNESS

PURPOSE

To evaluate associations between choroidal thickness and features of polypoidal choroidal vasculopathy (PCV) lesions based on multimodal imaging.

METHODS

This cross-sectional analysis included treatment-naive PCV eyes from a prospectively recruited observational cohort. Associations between of subfoveal choroidal thickness (SFCT) and qualitative and quantitative morphologic features of PCV lesions on color fundus photographs, indocyanine green and fluorescein angiography, and spectral-domain optical coherence tomography were evaluated.

RESULTS

We included 100 eyes with indocyanine green angiography-proven PCV. Subfoveal choroidal thickness showed a bimodal distribution with peaks at 170 µm and 350 µm. There was a significant linear increase in the total lesion area (P-trend = 0.028) and the polypoidal lesion area (P-trend = 0.030 and P-continuous = 0.037) with increasing SFCT. Pairwise comparisons between quartiles showed that the total lesion area (4.20 ± 2.61 vs. 2.89 ± 1.43 mm2, P = 0.024) and the polypoidal lesion area (1.03 ± 1.01 vs. 0.59 ± 0.45 mm2, P = 0.042) are significantly larger in eyes in Q4 (SFCT ≥ 350 μm) than eyes in Q1 (SFCT ≤ 170 μm). Although there was no significant linear trend relating SFCT to best-corrected visual acuity, pairwise comparisons showed that eyes in Q4 (SFCT ≥ 350 μm) have significantly worse vision (0.85 ± 0.63 vs. 0.55 ± 0.27 logMAR, P = 0.030) than eyes in Q2 (SFCT 170-260 μm).

CONCLUSION

Total lesion areas and polypoidal lesion areas tend to be larger in eyes with increasing SFCT. Choroidal background may influence the phenotype or progression pattern of PCV.

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.

One-year comparison of anti-vascular endothelial growth factor and half-dose photodynamic therapies for pachychoroid neovasculopathy

BACKGROUND

To compare 1-year outcomes between anti-vascular endothelial factor (VEGF) therapy and half-dose photodynamic therapy (PDT) for treatment-naive pachychoroid neovasculopathy (PNV) with subretinal fluid (SRF).

METHODS

Consecutive patients with treatment-naive PNV patients with SRF treated with intravitreal anti-VEGF injections or half-dose PDT followed by as-needed schedule with 1-year follow-up were studied retrospectively.

RESULTS

Eighty-two eyes of 82 patients were eligible: 50 eyes underwent anti-VEGF therapy and 32 eyes underwent half-dose PDT. SRF resolved in 41 (82%) of 50 eyes after initial three monthly injections and 31 (96.9%) of 32 eyes 3 months after initial PDT, and 43 (86%) eyes and 30 (94%) eyes 1 year after initial anti-VEGF injection and half-dose PDT, respectively. No significant differences were found in SRF resolution rates 3 months and 1 year after initial treatment between the two treatment groups. Best-corrected visual acuity (BCVA) improved significantly after initial three monthly injections (P = 0.025) and initial PDT (P = 0.022) compared with baseline; the improvements were maintained 1 year after initial treatment in the two treatment groups. No significant differences were found in BCVA between the two treatment groups at baseline and throughout the 1-year follow-up period. Mean (± standard error) numbers of intravitreal injections and PDT over 12 months were 3.7 ± 0.16 and 1.1 ± 0.06, respectively.

CONCLUSIONS

Both treatments are similarly effective on SRF resolution and VA improvement 1 year after the initial treatment. Half-dose PDT may be an option for treatment for PNV. Prospective studies are required to confirm these findings.

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.

Optical coherence tomography angiography for visualization of retinal capillary plexuses in pachychoroid neovasculopathy

OBJECTIVE

To evaluate retinal capillary plexus alterations in patients with pachychoroid neovasculopathy (PNV) by optical coherence tomographic angiography (OCTA).

DESIGN

Retrospective observational study.

PARTICIPANTS

The study included 43 patients with PNV (43 eyes, PNV group) and 43 normal eyes (control group).

METHODS

All PNV participants underwent comprehensive ophthalmic examinations, including OCTA. The results were compared with those of the controls. Differences in superficial and deep vascular density between the groups were analyzed. The correlations between vascular density and subfoveal choroidal thickness (SFCT), age, best-corrected visual acuity, refraction, and axial length were analyzed.

RESULTS

The superficial vascular density of the macular region (except for the area of the fovea and the inferior parafoveal region) was significantly lower in the PNV group than the control group (p < 0.05). The deep vascular density of the macular region was significantly lower in the PNV group (p < 0.05). In the PNV group, there was no significant correlation between vascular density and SFCT, age, BVCA, refraction, or axial length (p > 0.05).

CONCLUSIONS

Superficial and deep vascular densities of the macular region were lower in the patients with PNV compared with the patients in the control group. In the patients with PNV, the macular region showed signs of inner retinal capillary dropout, which may be caused by choroidal ischemia and/or a chronic impairment of nutrient supply to the retinal pigment epithelium.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY CHARACTERISTICS OF POLYPOIDAL CHOROIDAL VASCULOPATHY SECONDARY TO CHRONIC CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To report diagnostic capability of optical coherence tomography angiography (OCTA) in detecting polypoidal choroidal vasculopathy and its morphologic characteristics in white patients with chronic central serous chorioretinopathy.

METHODS

Retrospective consecutive series of 20 eyes (17 consecutive patients) with a diagnosis of polypoidal choroidal vasculopathy secondary to chronic central serous chorioretinopathy based on clinical and multimodal imaging were included. All patients underwent a complete ophthalmologic examination, including best-correct visual acuity, fundus autofluorescence, fluorescein and indocyanine green angiography, spectral-domain optical coherence tomography, and OCTA.

RESULTS

In all eyes (100%), OCTA revealed the branching vascular network as a hyperflow lesion in both choriocapillaris and outer retina layers. Segmentation of the choriocapillaris in OCTA, in correspondence of the polypoidal dilation detected at indocyanine green angiography, showed a hyperflow round structure in 75% of cases and hypoflow round structure in 15%. Two of 20 eyes (10%) had no detectable polyps on OCTA.

CONCLUSION

Optical coherence tomography angiography is a noninvasive imaging modality allowing a good visualization of both branching vascular network and polyp dilations. Our findings suggest that OCTA is a useful tool in the investigation of chronic central serous chorioretinopathy complicated by polypoidal choroidal vasculopathy.

Distinguishing Central Serous Chorioretinopathy From Neovascular Age-Related Macular Degeneration: A Prospective Study

Purpose:

This article identifies clinical features that differentiate central serous chorioretinopathy (CSR) from neovascular age-related macular degeneration (nAMD) and uses this information to develop a diagnostic tool.

Methods:

A prospective observational study was conducted of patients with a new diagnosis of CSR, nAMD, or indeterminate presentation. All patients underwent clinical assessment, axial length measurement, enhanced-depth imaging–optical coherence tomography, and intravenous fluorescein angiography. A final consensus diagnosis was derived following review of these factors.

Results:

A total of 56 eyes of 56 patients were enrolled (CSR = 34; nAMD = 22). The subfoveal choroidal thickness was greater in the CSR group (421 ± 106 µm) than the nAMD group (219 ± 91 µm, P < .001). The following odds ratio of CSR reached statistical significance: age 70 and younger (72.00, 95% CI: 11.99-432.50), subfoveal choroidal thickness greater than or equal to 300 µm (33.92, 95% CI: 4.06-283.18), dome-shaped neurosensory detachment (13.24, 95% CI: 3.22-54.45), retinal pigment epithelial changes (0.31, 95% CI: 0.10-0.97), subretinal hyperreflective material (0.11, 95% CI: 0.03-0.42), and fibrovascular pigment epithelial detachment (0.05, 95% CI: 0.01-0.47). A stepwise CSR vs nAMD clinical decision-making algorithm is proposed.

Conclusions:

Choroidal thickness is increased in CSR when compared with nAMD. The presented odds ratios and the CSR vs nAMD clinical decision-making tool can be applied to distinguish CSR from nAMD.

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.

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.

Central serous chorioretinopathy: Towards an evidence-based treatment guideline

Central serous chorioretinopathy (CSC) is a common cause of central vision loss, primarily affecting men 20-60 years of age. To date, no consensus has been reached regarding the classification of CSC, and a wide variety of interventions have been proposed, reflecting the controversy associated with treating this disease. The recent publication of appropriately powered randomised controlled trials such as the PLACE trial, as well as large retrospective, non-randomised treatment studies regarding the treatment of CSC suggest the feasibility of a more evidence-based approach when considering treatment options. The aim of this review is to provide a comprehensive overview of the current rationale and evidence with respect to the variety of interventions available for treating CSC, including pharmacology, laser treatment, and photodynamic therapy. In addition, we describe the complexity of CSC, the challenges associated with treating CSC, and currently ongoing studies. Many treatment strategies such as photodynamic therapy using verteporfin, oral mineralocorticoid antagonists, and micropulse laser treatment have been reported as being effective. Currently, however, the available evidence suggests that half-dose (or half-fluence) photodynamic therapy should be the treatment of choice in chronic CSC, whereas observation may be the preferred approach in acute CSC. Nevertheless, exceptions can be considered based upon patient-specific characteristics.

Angiographic Subtypes of Neovascular Age-related Macular Degeneration in Korean: A New Diagnostic Challenge

Neovascular age-related macular degeneration (AMD) is the leading cause of irreversible blindness in elderly population. Several classifications schemes have been developed to provide subtypes of neovascular AMD, which are known to be associated with visual prognosis. However, there is still a large proportion of patient with ambiguous findings according to current classification criteria. In this study, we classified treatment-naïve neovascular AMD patients using novel angiographic classification system and investigated the incidence and clinical characteristics of AMD subtypes. Among 339 eyes, five AMD subtypes were identified: 41 (12.1%) with classic choroidal neovascularization (CNV), 30 (8.8%) with occult CNV, 91 (26.8%) with microaneurysmal choroidal vasculopathy (MCV), 123 (36.3%) with polypoidal choroidal vasculopathy (PCV), and 54 (15.9%) with retinal angiomatous proliferation (RAP). MCV was younger than RAP (P < 0.001). Classic CNV presented with worse visual acuity compared with MCV at baseline (P < 0.001). Central macular subfield thickness was highest in RAP, and lowest in MCV (P = 0.036). Subfoveal choroidal thickness was highest in MCV, and lowest in RAP (P < 0.001). There was a significant difference in visual acuity at 12 months among five subtypes (P = 0.046). Our results highlight the importance of angiography for identifying AMD subtypes, particularly the novel MCV group being distinct from other subtypes.

Retinal pigment epithelium apertures as a late complication of longstanding serous pigment epithelium detachments in chronic central serous chorioretinopathy

BACKGROUND

To report retinal pigment epithelium (RPE) apertures as a possible evolution of serous pigment epithelium detachment (PED) in patients with chronic central serous chorioretinopathy (CSC) and to analyze their progression over time.

DESIGN

Retrospective case series.

METHODS

Fifteen patients (17 eyes) with a diagnosis of avascular PED in chronic CSC were retrospectively evaluated based on multimodal imaging. All patients had documented records of clinical examination, best correct visual acuity (BCVA), fundus autofluorescence (FAF), fluorescein and indocyanine green angiography, spectral-domain optical coherence tomography, and optical coherence tomography angiography (OCT-A). Primary outcomes measures were RPE aperture imaging analysis along with their temporal course.

RESULTS

All eyes showed the RPE aperture as an interruption of the RPE in correspondence of the PED with neither sign of rippling nor retraction. Mean age was 59.4 ± 8.1 years and mean BCVA was 0.34 ± 0.24 logMAR. In all eyes, FAF displayed a well-circumscribed roundish hypoautofluorescence. Multimodal imaging and OCT-A confirmed the absence of any vascular network beneath the aperture in all study eyes. The mean time of follow-up was 19.3 ± 14.3 months, and RPE discontinuities showed an increase in size over time from 0.81 ± 0.39 mm² to 0.95 ± 0.45 (P = 0.005).

CONCLUSIONS

RPE aperture is a new finding in the setting of chronic CSC and it should be distinguished by RPE tears for the different pathogenesis and evolution in time.

Long-term Visual Outcomes and Causes of Vision Loss in Chronic Central Serous Chorioretinopathy

PURPOSE

To evaluate the long-term visual outcomes and causes of vision loss in chronic central serous chorioretinopathy (CSC).

DESIGN

Retrospective, longitudinal study.

PARTICIPANTS

A total of 133 participants (217 eyes) with chronic CSC.

METHODS

A retrospective review of clinical and multimodal imaging data of patients with chronic CSC managed by 3 of the authors between May 1977 and March 2018. Multimodal imaging comprised color photography, fluorescein angiography, indocyanine green angiography, fundus autofluorescence (FAF), and OCT.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA) at the final visit; change in BCVA between first visit and 1-, 5-, and 10-year follow-up visits; and causes of vision loss at final visit.

RESULTS

Data from 6228 individual clinic visits were analyzed. Mean age of patients at the first visit was 60.7 years, and mean period of follow-up from first to last visit was 11.3 years. The cohort included 101 male patients (75.9%). At the final visit, 106 patients (79.7%) maintained driving-standard vision with BCVA of 20/40 or better in at least 1 eye, and 17 patients (12.8%) were legally blind with BCVA of 20/200 or worse in both eyes. Mean BCVA at first visit was not significantly different from mean BCVA at 1- or 5-year follow-up visits (both P ≥ 0.65) but was significantly better than the mean BCVA at the 10-year follow-up visit (P = 0.04). Seventy-nine percent of eyes with 20/40 or better vision at the first visit maintained the same level of vision at the 10-year follow-up visit. Ninety-two percent of eyes with 20/200 or worse vision at the first visit maintained the same level of vision at the 10-year follow-up visit. Cystoid macular degeneration, choroidal neovascularization (CNV), outer retinal disruption on OCT, and FAF changes were associated with poorer vision at the final visit (all P ≤ 0.001). Multivariable analysis revealed that greater age at first visit was associated with greater BCVA change at the 10-year follow-up visit (P = 0.001).

CONCLUSIONS

Chronic CSC can be a sight-threatening disease leading to legal blindness. Age at presentation and outer retinal changes on multimodal imaging were associated with long-term BCVA changes and may be predictors of long-term visual outcomes.

Pachychoroid disease

Pachychoroid is a relatively novel concept describing a phenotype characterized by attenuation of the choriocapillaris overlying dilated choroidal veins, and associated with progressive retinal pigment epithelium dysfunction and neovascularization. The emphasis in defining pachychoroid-related disorders has shifted away from simply an abnormally thick choroid (pachychoroid) toward a detailed morphological definition of a pathologic state (pachychoroid disease) with functional implications, which will be discussed in this review. Several clinical manifestations have been described to reside within the pachychoroid disease spectrum, including central serous chorioretinopathy, pachychoroid pigment epitheliopathy, pachychoroid neovasculopathy, polypoidal choroidal vasculopathy/aneurysmal type 1 neovascularization, focal choroidal excavation, peripapillary pachychoroid syndrome. These conditions all exhibit the characteristic choroidal alterations and are believed to represent different manifestations of a common pathogenic process. This review is based on both the current literature and the clinical experience of our individual authors, with an emphasis on the clinical and imaging features, management considerations, as well as current understanding of pathogenesis of these disorders within the context of the recent findings related to pachychoroid disease.

Clinical Features of Central Serous Chorioretinopathy With Type 1 Choroidal Neovascularization

PURPOSE

To evaluate the type 1 choroidal neovascularization (CNV) incidence and associated factors in eyes with central serous chorioretinopathy (CSC).

DESIGN

Retrospective case series.

METHODS

Records of 363 eyes (324 patients) with CSC were reviewed. Age, sex, CSC type, choroidal vascular hyperpermeability (CVH), best-corrected visual acuity (BCVA), subfoveal choroidal thickness (SCT), and systemic hypertension (HT) were assessed and compared between subjects with and without neovascular CSC.

RESULTS

We identified 219 and 144 eyes with chronic and acute CSC, respectively. The mean participant age was 55.2 ± 12.0 years, and 58 (15.6%) eyes had neovascular CSC. Age (no CNV: 54.8 ± 12.1 years, CNV: 57.3 ± 10.9 years; P = .118) and SCT (no CNV: 388.0 ± 104.5 μm, CNV: 377.4 ± 108.9 μm; P = .487) were comparable between eyes with and without CNV. However, BCVA (logarithm of the minimum angle of resolution) was significantly worse in subjects with CNV (0.28 ± 0.33 [20/38] vs 0.15 ± 0.29 [20/28]; P = .014). Neovascular CSC occurred more often in women (72 [23.6%] vs 20 [34.5%], P = .099) and in cases of chronic CSC (171 [56.1%] vs 48 [82.8%], P < .001), CVH (205 [67.2%] vs 58 [100%], P < .001), and HT (91 [29.8%] vs 24 [41.4%], P = .092). Chronic CSC (P = .001), female sex (P = .075), and poor BCVA (P = .091) were associated with neovascular CSC (multiple regression).

CONCLUSIONS

Chronic CSC, female sex, CVH, and poor BCVA are risk factors for CNV in eyes with CSC.

Etiologies and Characteristics of Choroidal Neovascularization in Young Chinese Patients

PURPOSE

To investigate the etiologies and characteristics of choroidal neovascularization (CNV) in young Chinese patients.

METHODS

A retrospective review of young Chinese patients (< 50 years of age) with CNV from January 2010 to June 2016 was performed.

RESULTS

Of the 501 patients (537 eyes) with CNV, 58.7% were female, and 7.2% had bilateral CNV. The mean age was 35 years. The etiologies were idiopathic CNV (ICNV, 43.9%), pathologic myopia (PM, 21.9%), punctate inner choroidopathy (PIC, 17.4%), polypoidal choroidal vasculopathy (4.4%), multifocal choroiditis with panuveitis (3.6%), and other disorders (8.8%). Five hundred and six CNVs (94.2%) showed a predominantly classic CNV composition on fundus fluorescein angiography (FFA) and 316 CNVs (96.6%) were type 2 CNV on optical coherence tomography (OCT).

CONCLUSION

The etiologies of CNV in young Chinese patients were diverse, and ICNV, PM, and PIC were the three most common etiologies. Most CNVs were classic on FFA and type 2 on OCT.

Clinical characteristics and long-term visual outcome of severe phenotypes of chronic central serous chorioretinopathy

Purpose

The aim of this study was to investigate disease onset and disease progression in patients with severe chronic central serous chorioretinopathy (cCSC).

Patients and methods

The medical records of 143 cCSC patients (199 eyes) were reviewed. All cases had visual complaints for >6 months and showed signs of a severe disease phenotype on optical coherence tomography (OCT) and fluorescein angiography (FA). Clinical presentation at onset was evaluated, together with disease progression on multimodal imaging and final treatment outcome.

Results

Twenty-eight cases (14%) had a documented history of an acute episode of CSC, whereas 145 cases (73%) showed pre-existing features of chronicity already at first presentation. The first clinical presentation could not be evaluated in 13% of cases. Best-corrected visual acuity (BCVA) was 70 ± 18 Early Treatment of Diabetic Retinopathy Study (ETDRS) letters at onset and 70 ± 22 ETDRS letters at final visit (p = 0.770). Among all studied cases, 173 eyes (87%) were treated, which resulted in complete resolution of subretinal fluid (SRF) in 76% of eyes at final visit. In eyes with fluorescein angiographic follow-up, the area of diffuse atrophic retinal pigment epithelium (RPE) abnormalities (diffuse atrophic RPE alterations [DARA]) had increased significantly in 43 eyes (68%) at final visit.

Conclusion

CSC encompasses a clinical spectrum that includes a range of severe phenotypes, in which retinal abnormalities tend to be progressive. Nevertheless, the long-term visual acuity may remain fairly stable with treatment. Few patients with severe chronic CSC have a history of acute CSC, which could indicate that there may be pathogenetic differences between these 2 CSC variants.

Real-World Experience with Half-Time Versus Half-Dose Photodynamic Therapy in Chronic Central Serous Chorioretinopathy

PURPOSE

To evaluate the real-world experience with half-time photodynamic therapy (PDT) versus half-dose PDT for chronic central serous chorioretinopathy (CSC).

METHODS

This multicenter retrospective study enrolled patients who received half-time PDT (with irradiation time shortened to 42 s) or half-dose PDT (with the dosage of verteporfin reduced to 3 mg/m²) for chronic CSC and who were followed up for ≧12 months. The success rate, central subfield retinal thickness (CST), and best-corrected visual acuity (BCVA) were documented in each group of patients.

RESULTS

A total of 53 eyes from 49 patients were enrolled in this study. Seventeen eyes (15 patients) received half-time PDT and 36 eyes (34 patients) received half-dose PDT. The success rates in both groups were similar at 12 months (94.1% vs. 94.4%; P = 0.543). The mean CST at 1, 6, 12 months decreased significantly when compared with the baseline in both groups (all P < 0.001). The BCVA significantly improved at 6 and 12 months in both groups (all P < 0.05). There were no significant differences in changes of BCVA and changes of CST between the 2 groups at any time point.

CONCLUSIONS

Half-time PDT is a feasible treatment for chronic CSC. It has success rates similar to half-dose PDT at 12 months. There were no significant differences in changes of BCVA and changes of CST between the 2 groups at 1, 6, and 12 months after treatment.

Detection of Choroidal Neovascularization in Central Serous Chorioretinopathy Using Optical Coherence Tomographic Angiography

Purpose: To demonstrate the detection of choroidal neovascularization (CNV) in clinically diagnosed central serous chorioretinopathy (CSC) by optical coherence tomographic angiography (OCTA). Methods: Seventy-five eyes of 70 patients were included. OCTA was performed on each patient. Two trained readers evaluated the images independently to confirm the diagnosis and identify CNV at the level of the outer retina. Results: All studied eyes presented characteristics consistent with CSC based on eye examination and traditional imaging technologies, including fundus fluorescein angiography, which showed no evidence of CNV. However, OCTA revealed definite abnormal vascularization at the level of the outer retina in 8 eyes (10.7%) of 8 patients (11.4%). Conclusion: This study suggests that in some cases of CSC, OCTA could be an alternative option to detect CNV that is undetectable by other conventional imaging techniques.