Correlation between morphological characteristics in spectral-domain-optical coherence tomography, different functional tests and a patient's subjective handicap in acute central serous chorioretinopathy

Central serous chorioretinopathy: An evidence-based treatment guideline

Central serous chorioretinopathy (CSC) is a relatively common disease that causes vision loss due to macular subretinal fluid leakage and it is often associated with reduced vision-related quality of life. In CSC, the leakage of subretinal fluid through defects in the retinal pigment epithelial layer's outer blood-retina barrier appears to occur secondary to choroidal abnormalities and dysfunction. The treatment of CSC is currently the subject of controversy, although recent data obtained from several large randomized controlled trials provide a wealth of new information that can be used to establish a treatment algorithm. Here, we provide a comprehensive overview of our current understanding regarding the pathogenesis of CSC, current therapeutic strategies, and an evidence-based treatment guideline for CSC. In acute CSC, treatment can often be deferred for up to 3-4 months after diagnosis; however, early treatment with either half-dose or half-fluence photodynamic therapy (PDT) with the photosensitive dye verteporfin may be beneficial in selected cases. In chronic CSC, half-dose or half-fluence PDT, which targets the abnormal choroid, should be considered the preferred treatment. If PDT is unavailable, chronic CSC with focal, non-central leakage on angiography may be treated using conventional laser photocoagulation. CSC with concurrent macular neovascularization should be treated with half-dose/half-fluence PDT and/or intravitreal injections of an anti-vascular endothelial growth factor compound. Given the current shortage of verteporfin and the paucity of evidence supporting the efficacy of other treatment options, future studies-ideally, well-designed randomized controlled trials-are needed in order to evaluate new treatment options for CSC.

Morphological and Functional Correlations in Acute Central Serous Chorioretinopathy

PURPOSE

We evaluate morphological and functional correlations in patients with acute central serous chorioretinopathy (CSC).

METHODS

A prospective study was conducted on 50 patients with an acute CSC episode lasting less than 3 months. At baseline, assessments included optical coherence tomography (OCT), best-corrected visual acuity (BCVA), contrast sensitivity (CS), microperimetry (MP), and multifocal electroretinography (mfERG). A correlation analysis between OCT morphological parameters (maximal subretinal fluid height (SRF), central retinal thickness (CRT), and macular volume (MV)) and functional parameters was conducted on the affected eye for each patient.

RESULTS

Among the morphological parameters, SRF showed the strongest correlations with functional parameters (r absolute value range = 0.10-0.70). Weak correlations were observed between BCVA and morphological parameters (r absolute value range = 0.14-0.26). Average retinal sensitivity (MP-A) was the functional parameter displaying the most robust negative correlation with morphological parameters (r absolute value range = 0.61-0.70). In contrast, average contrast sensitivity (CS-A) and mfERG average amplitude density in the first (mfERG-A1) and second (mfERG-A2) ring showed weak to moderate (r absolute value range = 0.35-0.56) yet statistically significantly nonzero correlations.

CONCLUSIONS

SRF and CRT could serve as the most representative morphological proxies for visual function deficit in acute CSC patients. Retinal sensitivity, as measured by MP, may be superior to BCVA in clinical research studies or when an in-depth visual function evaluation is needed.

Factors for recurrence in acute central serous chorioretinopathy patients underwent one-third dose verteporfin photodynamic therapy

PURPOSE

To investigate the factors of recurrence in acute central serous chorioretinopathy (aCSC) patients underwent one-third dose verteporfin photodynamic therapy (PDT).

MATERIALS AND METHODS

A retrospective study was performed in aCSC patients treated with one-third dose PDT and followed up for 36 months. Demographic information and clinical features were compared. A logistic regression model was used to evaluate the associated factor of aCSC recurrence.

RESULTS

There were 162 patients with aCSC included in current study. 36-month after one-third dose PDT, good recovery was identified in 131 patients (80.86%), whereas 31 cases (19.14%) developed recurrence. Significant between-group differences were observed in baseline age, the right, left and both eyes, best-corrected visual acuity (BCVA), presenting with pigment epithelium detachment (PED), retinal pigment epithelium (RPE) damage and subfoveal choroidal thickness (SCT) level (P = 0.005, P < 0.001, P < 0.001, P < 0.001, P = 0.006, and P < 0.001, respectively). The recurrence of aCSC was associated with presenting with PED (odds ratio = 1.78; 95% CI, 1.45 - 1.98; P < 0.001), RPE damage (OR = 1.13; 95%CI: 1.08 - 1.23; P < 0.001), baseline BCVA (OR = 0.96; 95%CI: 0.95 - 0.99; P = 0.001), and SCT level (OR = 1.18; 95%CI: 1.02 - 1.20; P < 0.001).

CONCLUSION

In acute CSC after treatment of one-third dose PDT, recurrence is associated with RPE damage, baseline BCVA and SCT level. Our findings will assist clinicians to evaluate aCSC in clinical practice and provide insights into the prevention of recurrence.

Macular Hole Detection Using a New Hybrid Method: Using Multilevel Thresholding and Derivation on Optical Coherence Tomographic Images

Optical coherence tomography (OCT) is a noninvasive imaging test. OCT imaging is analogous to ultrasound imaging, except that it uses light instead of sound. In this type of image, microscopic quality intratissue images are provided. In addition, fast and direct imaging of tissue morphology and reproducibility of results are the advantages of this imaging. Macular holes are a common eye disease that leads to visual impairment. The macular perforation is a rupture in the central part of the retina that, if left untreated, can lead to vision loss. A novel method for detecting macular holes using OCT images based on multilevel thresholding and derivation is proposed in this paper. This is a multistep method, which consists of segmentation, feature extraction, and feature selection. A combination of thresholding and derivation is used to diagnose the macular hole. After feature extraction, the features with useful information are selected and finally the output image of the macular hole is obtained. An open-access data set of 200 images with the size of 224 × 224 pixels from Sankara Nethralaya (SN) Eye Hospital, Chennai, India, is used in the experiments. Experimental results show better-diagnosing results than some recent diagnosing methods.

Central Serous Chorioretinopathy - an Overview

Central serous chorioretinopathy (CSCR) is characterised by retinal serous detachment usually localised in the macular region. CSCR predominantly affects men between 30 and 50 years of age. Traditional classification differentiates between acute (duration shorter than 4 to 6 months) and chronic disease (duration longer than 4 to 6 months). The pathogenesis is multifactorial and current thinking assumes the presence of localised choroidal hyperpermeability with subsequent secondary changes in the retinal pigment epithelium (RPE). The symptoms of acute CSCR include central blurred vision, often with deterioration in visual acuity. Optical coherence tomography (OCT) reveals subretinal fluid (SRF) and/or single retinal pigment epithelial detachments. Fluorescein angiography (FA) usually shows a leaking point with absent or only minor RPE changes in the acute phase and indocyanine green angiography (ICG) highlights circumscribed areas of thickened and hyperpermeable choroid. Acute cases may show spontaneous resolution of SRF, but may also recur and/or become chronic. After the initial diagnosis, spontaneous remission is seen in about 70 to 80% of cases, with a recurrence rate of about 50%. Due to the favourable spontaneous course, it is recommended to wait for 4 to 6 months after the first symptoms manifest. Steroid therapy is considered as a major risk factor. Chronic cases are characterised by slow deterioration in visual acuity with reduced contrast and colour perception. There are extensive RPE changes, with secondary degenerative changes of the photoreceptors. The disease can by complicated by choroidal neovascularisation (CNV), especially in elderly patients. The literature lists a number of treatments: The leakage point (visible in the FA) can be treated by focal laser therapy, either micropulse laser or, if sufficiently distant from the fovea, by argon laser coagulation. Randomised trials in chronic CSCR demonstrated good outcomes with photodynamic therapy. With observation periods ranging from 3 to 6 months, several case series reports found improvement after systemic administration of mineralocorticoid receptor antagonists, carbonic anhydrase inhibitors or non-steroidal anti-inflammatory drugs. In the presence of secondary CNV, anti-VEGF treatment should be initiated. It is unclear whether the combination with PDT might be useful.

Routine Clinical Practice Treatment Outcomes of Eplerenone in Acute and Chronic Central Serous Chorioretinopathy

Purpose: To evaluate efficacy of eplerenone therapy vs. observation on resolution of subretinal fluid (SRF) in patients with acute and chronic central serous chorioretinopathy (CSCR) in routine clinical practice.

Methods: Retrospective comparative case series of eyes diagnosed with CSCR treated with eplerenone or observation. Primary outcome measure was maximum height of SRF at 12 months. Secondary outcome was percentage of eyes with complete resolution of SRF, percentage of eyes with reduction of SRF ≥50%, and best corrected visual acuity (VA) at 12 months. Separate analysis was conducted for eyes with acute and chronic CSCR.

Results: Sixty-eight eyes of 60 patients (82% male) were included. Eleven of the 38 eyes with acute CSCR, and seven of the 30 eyes with chronic CSCR, received eplerenone. Subretinal fluid decreased from baseline to 12 months in acute (287 ± 221 to 31 ± 63 µm) and chronic (148 ± 134 to 40 ± 42 µm) CSCR. Kaplan-Meier curves were similar for treated and observed eyes and COX regression analysis did not show a significant difference in SRF resolution in treated vs. observed eyes (p = 0.6 for acute, p = 0.2 for chronic CSCR).

Conclusion: This routine clinical practice outcome study did not show evidence of efficacy of eplerenone on resolution of SRF in acute nor chronic CSCR.

Fundus-controlled perimetry (microperimetry): Application as outcome measure in clinical trials

Fundus-controlled perimetry (FCP, also called 'microperimetry') allows for spatially-resolved mapping of visual sensitivity and measurement of fixation stability, both in clinical practice as well as research. The accurate spatial characterization of visual function enabled by FCP can provide insightful information about disease severity and progression not reflected by best-corrected visual acuity in a large range of disorders. This is especially important for monitoring of retinal diseases that initially spare the central retina in earlier disease stages. Improved intra- and inter-session retest-variability through fundus-tracking and precise point-wise follow-up examinations even in patients with unstable fixation represent key advantages of these technique. The design of disease-specific test patterns and protocols reduces the burden of extensive and time-consuming FCP testing, permitting a more meaningful and focused application. Recent developments also allow for photoreceptor-specific testing through implementation of dark-adapted chromatic and photopic testing. A detailed understanding of the variety of available devices and test settings is a key prerequisite for the design and optimization of FCP protocols in future natural history studies and clinical trials. Accordingly, this review describes the theoretical and technical background of FCP, its prior application in clinical and research settings, data that qualify the application of FCP as an outcome measure in clinical trials as well as ongoing and future developments.

Vision-related quality of life and visual function in a 70-year-old Swedish population

PURPOSE

To investigate vision-related quality of life (VRQoL), visual function and predictors of poor vision in a population of 70-year-olds.

METHODS

Self-reported ocular morbidity and responses to the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) in a cross-sectional population study (N = 1203) in Gothenburg, Sweden, were compared with results from ophthalmic examination (N = 560).

RESULTS

The most common self-reported ophthalmic morbidities were cataract (23.4%), age-related macular degeneration (AMD; 4.7%), glaucoma (4.3%) and diabetic retinopathy (1.4%). Cataract was more prevalent in women (p = 0.001). The composite score from NEI VFQ-25 for the entire cohort was 91.4 (standard deviation: 27.5). When comparing composite score for different eye diseases, persons with cataract or AMD exhibited lower scores (p = 0.029 and 0.018, respectively). Best-corrected visual acuity (BCVA) was normal (≥0.5 decimal) in 98.9%; two individuals had low vision (<0.3). Men exhibited better BCVA (median: -0.08 logMAR) than women (-0.06; p = 0.005). Visual field defects were observed in 16.3% and uncorrected refractive errors in 61.5%. Poor vision was reported by 7.4% of participants with presenting visual acuity (PVA) ≥0.5 (decimal), while 66.7% with PVA <0.5 reported good vision. Of 27 individuals with PVA <0.5, 55.6% obtained a BCVA of ≥1.0 with the right correction. Low contrast sensitivity was a significant predictor of experiencing poor vision (p = 0.008), while PVA and visual field defects were not.

CONCLUSIONS

Low contrast sensitivity is a predictor of experiencing poor vision. There is a discrepancy between subjective/objective visual function and a high prevalence of uncorrected refractive errors. Women have more cataract, and men demonstrate slightly better visual acuity.

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.