Photodynamic therapy for chronic central serous chorioretinopathy

Crossover to 689 nm laser therapy after poor responsiveness to subthreshold micropulse laser for chronic central serous chorioretinopathy

PURPOSE

To compare the visual and anatomical outcomes of 689 nm laser therapy (689-LT) and continued subthreshold micropulse laser (SML) therapy, for chronic central serous chorioretinopathy (cCSC) eyes after poor responsiveness to initial SML treatment.

METHODS

The retrospective study included 32 cCSC patients, of which 15 patients received continued SML, and 17 patients received 689-LT. Best corrected visual acuity (BCVA), central retinal thickness (CRT), the maximum height of subretinal fluid (mSRF), subfoveal choroidal thickness (SFCT), three-dimensional choroidal vascularity index (CVI), and the vascular density of choriocapillaris (CCVD) of two groups were evaluated and compared at baseline, one-month and three-month follow-up after treatment.

RESULTS

Thirty-two cCSC eyes of 32 patients (7 female, 25 male) were included in our study, with a mean age of 46.69 ± 6.56 years. Three months after treatment, complete resolution of SRF was achieved in four eyes in the 689-LT group, whereas no eyes displayed complete resolution in the SML group. There were no significant improvements in BCVA and CCVD at the three-month follow-up in both groups. In the 689-LT group, at one-month and three-month follow-ups, there was a significant reduction in CRT, mSRF, SFCT and CVI, compared to the baseline (p < 0.001 in all analyses). There were no statistically significant changes in CRT, mSRF, SFCT and CVI in the SML group (p > 0.05 in all analyses). The ANOVA test for repeated measures showed the changes in the measurements over time were significantly different between the two groups (P value using Greenhouse-Geisser test < 0.05).

CONCLUSION

689 nm laser therapy provides the opportunity for cCSC eyes with poor responsiveness to SML treatment, especially when verteporfin is unavailable. There was also a notable recovery in the abnormal dilatation of choroidal vessels in the 689-LT group. Further studies are warranted to investigate the long-term efficacy and safety of 689 nm laser therapy in the management of cCSC.

Use of a Fundus Image-Based Titration Strategy for Selective Retina Therapy for Central Serous Chorioretinopathy

Background/Objectives: This study evaluated the clinical outcomes of selective retina therapy (SRT) for treating central serous chorioretinopathy. A fundus image-based titration method was used for laser irradiation. Methods: This retrospective cohort study included 29 eyes (29 patients) that underwent SRT for CSC. Both the pulse energy and number of micropulses were adjusted according to the fundus image. Mean best-corrected visual acuity (BCVA), central foveal thickness (CFT), and subretinal fluid (SRF) height were measured 1, 2, 3, 4, and 6 months after SRT. Mean deviation (MD) was measured using microperimetry at 3 and 6 months post-treatment. Results: At 6 months after SRT treatment, SRF was completely resolved in 89.7% of cases (26/29 eyes). The mean Snellen BCVA significantly improved from 0.34 ± 0.31 logMAR (logarithm of the minimum angle of resolution) (20/40) at baseline to 0.24 ± 0.24 logMAR (20/32) at 6 months (p = 0.009). The 0.1 improvement in mean BCVA is equivalent to a 5-letter gain on the ETDRS chart. The mean CFT decreased significantly from 309.31 ± 81.6 μm at baseline to 211.07 ± 50.21 μm at 6 months (p < 0.001). The mean SRF height also decreased significantly from 138.36 ± 56.78 μm at baseline to 23.75 ± 61.19 μm at 6 months (p < 0.001). The mean MD was improved from -1.56 ± 1.47 dB at baseline to -1.03 ± 2.43 dB at 6 months (p = 0.07) after treatment. Conclusions: SRT using fundus image-based titration can yield favorable functional and anatomical outcomes in the treatment of 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.

Crossover to PDT after the unsuccessful micropulse laser treatment of central serous chorioretinopathy

Purpose

Subthreshold micropulse laser (SML) and photodynamic therapy (PDT) are among the most effective therapeutic modalities applied to central serous chorioretinopathy (CSCR). This study aimed to evaluate the efficacy and durability of PDT in CSCR cases unresponsive to at least two SML treatments.

Methods

The study included 26 consecutive eyes of 24 patients (21 males and three females) with chronic CSCR. In all cases, a lack of reduction in subretinal fluid (SRF) levels was noted after at least two consecutive SML sessions. The parameters of best corrected visual acuity (BCVA) and spectral domain optical coherence tomography (SD-OCT) were evaluated at baseline and 1, 3 and 12 months post-PDT.

Results

The mean duration of symptoms in the group was 53.81 ± 39.48 months, the mean age of the patients was 49.26 ± 12.91 years, and the mean subfoveal choroidal thickness (SFCT) was 572.11 ± 116.21 mm. Complete resorption of SRF was observed in 21 out of 26 eyes (80.77%) at 1 month and sustained in 18 cases (69.23%) at 12 months. At 12 months, in the sustained group, BCVA improved significantly from 0.39 ± 0.18 to 0.19 ± 0.2 logMAR (P = 0.01), central subfoveal thickness (CST) reduced from 316.44 ± 75.83 mm to 197.67 ± 22.99 mm (P < 0.0001), and SFCT reduced from 579.28 mm to 446.78 mm (P < 0.0001).

Conclusions

PDT provides the opportunity for the successful treatment of CSCR unresponsive to SML treatment. Improvements are possible even in cases with a long duration of symptoms and significant alterations in retinal morphology. Thus, PDT should be considered for patients with prominently increased choroidal thickness.

Acute Central Serous Chorioretinopathy Outbreak during the COVID-19 Pandemic: A Pilot Study

Background and Objectives: This study aims to investigate the potential association between the COVID-19 pandemic and a new presentation of central serous chorioretinopathy (CSCR). Materials and Methods: A retrospective analysis was conducted, comparing the incidence of new-onset CSCR cases among ophthalmology patients in a regional medical facility in southern Israel between two distinct periods: the COVID-19 pandemic era in Israel, which occurred from 27 February 2020 to 20 December 2020, and the non-pandemic period from calendar years 2018 to 2021, excluding the specific epidemic phase mentioned. Disease severity was evaluated based on recovery time, visual acuity loss, and central macular thickness via OCT. Results: Over the four-year period, 35 new cases of CSCR were recorded. During the COVID-19 pandemic, 17 new cases (0.005% per population) were identified, compared with 18 new cases (0.002% per population) in the preceding three years. The odds ratio for acute CSCR during the pandemic was 2.83 (95% CI, 1.46-5.50) with a p-value of 0.02. CSCR cases during the pandemic seemed to exhibit worse clinical characteristics, though not statistically significant. Additionally, 22.2% of the COVID-19 pandemic group had confirmed COVID-19 cases, which was statistically significantly higher than the general population's reported cases (6%). Conclusion: The study revealed a statistically significant increase of over 2.5 times in acute CSCR incidence during the COVID-19 pandemic compared with non-pandemic periods. The findings suggest that the pandemic's stressful changes may have unintended consequences on the occurrence of CSCR, highlighting the importance of mental health support and psychoeducation for affected patients.

Hyperplasia of the retinal pigment epithelium secondary to subthreshold laser treatment in chronic central serous chorioretinopathy

PURPOSE

To assess the development of hyperplasia of the retinal pigment epithelium (HRPE) secondary to subthreshold laser treatment (STL) in chronic central serous chorioretinopathy (CSCR).

METHODS

Prospective study including 149 eyes of 146 patients with CSCR with persistent subretinal fluid (SRF) that have undergone STL using the Navilas® device. Visual acuity (VA) optical coherence tomography (OCT) and fundus autofluorescence (FAF) were performed before and after the treatment. The HRPE was identified on OCT as a hyperreflective and dense material at the expense of the RPE that did not exist prior to the treatment. The demographics of the patients as well as the parameters of the STL treatments employed were registered.

RESULTS

Seven HRPE cases after STL were identified, observing an incidence of 4.7% (7 out of 149 eyes). The mean age was 52.1 ± 3.6 years, being 6/7 males. The mean number of STL sessions was 1.3 ± 0.5. The mean total fluence applied was 52.2 ± 12.4 J/cm2 (range 35.37 to 76.39 J/cm2), using a duty cycle of 10% in all cases. The HRPE was subfoveal in 6 of the 7 cases. The SRF was resolved in 6 of the 7 patients. The mean VA loss was -14.1 ± 14.3 ETDRS letters.

CONCLUSION

The development of HRPE secondary to STL in CSCR is an uncommon but severe adverse effect, probably related to the excessive energy employed. Further studies are warranted to minimize the incidence and to know the predictors of this complication after STL treatment to optimize the parameters that should be used.

The Uses of Photodynamic Therapy Versus Anti-vascular Endothelial Growth Factor in the Management of Acute Central Serous Chorioretinopathy: A Systematic Review and Meta-Analysis

Central serous chorioretinopathy (CSCR) is an idiopathic chorioretinal disease characterized by localized serous detachment of the neurosensory retina at the macula. To date, there is no high-quality evidence of recent updates on treating acute CSCR, focusing on photodynamic therapy (PDT) and anti-vascular endothelial growth factor (anti-VEGF). Hence, this review aims to conduct a comprehensive systematic review of the most recent therapeutic approaches for acute CSCR using the following electronic databases for a comprehensive and systematic literature review: MEDLINE, EMBASE, and Cochrane. In addition, we analyzed studies comparing PDT with placebo, anti-VEGF with placebo, or PDT with anti-VEGF in treating acute CSC eyes with no previous intervention. Seven studies were included, with a total of 292 eyes. The overall positive results were significantly higher among patients who received PDT compared to control groups (odds ratio [OR] = 7.96, 95% confidence interval [CI], 3.02 to 20.95, p < 0.001). The proportions of positive results were 81.0% and 97.1% among patients who received anti-VEGF and PDT, respectively, with no statistically significant differences between the groups. In addition, there were no significant differences between anti-VEGF and control groups. In contrast, PDT was significantly associated with lower recurrence odds than the control groups (OR = 0.12, 95% CI, 0.04 to 0.39, p = 0.042). According to our findings, PDT showed higher positive results than anti-VEGF in acute CSCR. In addition, PDT was significantly associated with a lower recurrence rate than the control group. However, the analysis needs to be confirmed and updated by large-scale, well-designed randomized clinical trials.

Anatomical and functional impact of verteporfin shortage in patients with chronic central serous chorioretinopathy

BACKGROUND

To describe the functional and anatomical impact that the worldwide shortage of verteporfin has had on patients diagnosed with chronic central serous chorioretinopathy (cCSCR) whose treatment with photodynamic therapy (PDT) had to be delayed.

METHODS

Prospective observational study. Patients were divided into two groups based on the time interval since PDT had been indicated: groups 1 and 2, with waiting times of less and more than 9 months respectively. Best corrected visual acuity (BCVA), the maximum height of the subretinal fluid (MSRF) and subfoveal choroidal thickness (SFCT) at the baseline visit and the last visit were compared.

RESULTS

49 eyes of 48 patients with cCSCR were included. The mean waiting time for PDT was 9.0 ±3.8 months. The mean BCVA was 69.0 ±17.1 letters and 68.9 ±16.4 letters for the baseline and last visit respectively, showing no difference (p= 0.958). Although there was no difference in the mean global BCVA, 15 eyes (30.5%) showed a deterioration of ≥5 letters, including 7 eyes (14%) with a decrease of ≥10 letters. Mean MSRF height was 151.4 ±97.2 μm and 98.2 ±83.1 μm for the baseline and last visit respectively (p= 0.005), persisting in 74.5% of the eyes.

CONCLUSION

No significant impact was observed in the BCVA in cCSCR due to the shortage of verteporfin. However, one-third of patients had BCVA loss. There was a significant spontaneous decrease in MSRF, but it persisted in the majority of the patients, still susceptible to PDT.

Morphological integrity of the outer retinal layers and visual prognosis in chronic central serous chorioretinopathy after half-dose photodynamic therapy: a qualitative SD-OCT analysis

The study aims to investigate the morphological integrity of the outer retinal layers (ORLs) (an ellipsoid layer (EL) + external limiting membrane) and visual prognosis in chronic central serous chorioretinopathy (CSCR) with subretinal fluid (SRF) completely resorbed after half-dose photodynamic therapy (HD PDT) using enhanced-depth imaging (EDI) spectral domain optical coherence tomography (SD-OCT). This retrospective study included 40 eyes of 38 chronic CSCR patients treated with HD PDT between December 2012 and June 2016. However, only 34 eyes (85%) with complete SRF resorption 3 months after HD PDT had their 6th and 12th month data analyzed. Morphological integrity of the ORLs was further analyzed in relation to best-corrected visual acuity (BCVA) and disease duration. Thirty-four eyes of 34 patients (male/female: 82.35/17.65%) with mean age of 49.90 ± 7.80 (32-61) years were studied. The mean logMAR BCVA improved significantly from 0.52 ± 0.31 at baseline to 0.34 ± 0.36 and 0.26 ± 0.26 at the 6th and 12th months after HD PDT, respectively (p < 0.001). The proportion of eyes with completely normal morphological ultrastructural integrity of the ORLs was 44.12% at the 6th month, which increased to 64.71% at the 12th month after HD PDT. However, the EL morphological disruption was associated with significantly lower mean logMAR BCVA 12 months after HD PDT (p = 0.029). The disease duration had no effect on mean logMAR BCVA gain. Even after complete resorption of serous neurosensory retinal detachment after HD PDT in chronic CSCR, the ORLs, especially the EL, may not be anatomically restored. The EL morphological ultrastructural integrity seems to be the most important factor influencing visual prognosis.

OCT-A in chronic central serous chorioretinopathy treated with oral eplerenone and half-fluence photodynamic therapy: A comparative study

PURPOSE

To evaluate retinal and choriocapillary vessel density (VD) changes in patients with chronic central serous chorioretinopathy (CSC) treated with half-fluence verteporfin photodynamic therapy (vPDT) or eplerenone, using optical coherence tomography angiography (OCTA).

METHODS

Patients affected by CSC and treated with vPDT and eplerenone were retrospectively studied. At baseline and 3 months after each treatment, all patients underwent a complete ophthalmological examination, including an evaluation of best-corrected visual acuity (BCVA), slit-lamp biomicroscopy, fundus examination, fluorescein angiography (FA), indocyanine green angiography (ICGA), spectral-domain optical coherence tomography (SD-OCT) and OCTA.

RESULTS

Forty-eight eyes of patients with CSC were analysed. Twenty-four eyes were placed in the vPDT group, and 24 eyes formed the eplerenone group. In both groups, OCTA showed a significant improvement in the VD of deep capillary plexus (DCP) and choriocapillaris (CC) after treatments with respect to baseline (p < 0.001), whereas the VD of superficial capillary plexus (SCP) did not show significant differences (p > 0.05). The PDT group demonstrated a statistically significant increase in the VD of DCP and CC with respect to the eplerenone group (DCP p = 0.012; CC p = 0.004). A statistically significant reduction with respect to baseline in subfoveal choroidal thickness (SFCT) (p = 0.001 for vPDT group; p = 0.001 for eplerenone group) and in central foveal thickness (CFT) (p = 0.001 for vPDT group; p = 0.001 for eplerenone group) was also found. The SFCT was significantly thinnest in the PDT group with respect to the eplerenone group (p = 0.021).

CONCLUSION

OCTA allowed us to study retinal and choriocapillary vascular changes in patients with CSC treated with vPDT and eplerenone.

Early anatomical changes and association with photodynamic therapy induced acute exudative maculopathy in patients with macular diseases

The purpose of this study was to investigate the occurrence rate and predictors of photodynamic therapy (PDT) induced acute exudative maculopathy (PAEM). This retrospective study included 39 eyes of 39 patients (32 males and 7 females), who were treated with initial PDT. PAEM was defined as an increase in central retinal thickness (CRT) of 15% or more measured by OCT on day 3 after PDT compared with baseline. Sixteen of 39 eyes (41%) were classified in the PAEM+ group. CRT and central choroidal thickness (CCT) were significantly increased at 3 days in the PAEM+ group and significantly decreased at 1 month after PDT in the PAEM- group. In a multiple comparison, neovascular age-related macular degeneration (nAMD) had a significantly higher incidence of PAEM compared to polypoidal choroidal vasculopathy (PCV) and central serous chorioretinopathy (CSC). The incidence of PAEM was lower in PCV and CSC, and higher in nAMD. BCVA at 1 month was significantly worse in the PAEM group, which may be related to visual prognosis after PDT. Since both CRT and CCT decrease at 1 month, the detection of PAEM needs to be assessed a few days after PDT.

Changes in the Foveal Outer Nuclear Layer of Central Serous Chorioretinopathy Patients Over the Disease Course and Their Response to Photodynamic Therapy

Objective:

To investigate the association between foveal outer nuclear layer (ONL) thickness and the natural course of central serous chorioretinopathy (CSC), as well as the thickness change after photodynamic therapy (PDT), exploring the PDT timing for CSC.

Methods:

This retrospective consecutive case series included 358 CSC patients between January 2014 and December 2019. All patients were divided into four groups depending on disease duration: Group A: ≤1 month; Group B: >1 and ≤3 months; Group C: >3 and≤6 months and Group D: >6 months. Foveal ONL thickness of the CSC eye and the clinically healthy fellow eye were measured and compared in all patients. Fifty-six patients were successfully treated with half-dose of PDT, showing complete subretinal fluid absorption, were followed up for more than 6 months and further investigated. The recovery of foveal ONL thickness was analyzed in the affected eyes of patients with different disease duration.

Results:

No significant reduction was found in CSC foveal ONL thickness (μm) compared to the fellow eye in patients with disease duration less than 1 week (112.3 ± 12.2 vs. 116.7 ± 15.3, P = 0.268). Patients with longer disease duration had varying degrees of ONL thinning compared to the contralateral eye (all P < 0.05) and this difference was more pronounced in patients with disease duration greater than 6 months (75.8 ± 12.9 vs. 113.0 ± 11.5, P < 0.001). At 6-month follow-up after PDT, foveal ONL thickness of patients with <1 month disease duration recovered significantly from onset (97.3 ± 18.2 to 113.6 ± 8.7, P < 0.001) and became similar to that of the healthy fellow eye. Foveal ONL thickness of patients with duration>1 and≤3 months recovered significantly (88.5 ± 11.5 to 95.8 ± 11.3, P = 0.012) but remained thinner than that of the healthy fellow eye. Foveal ONL thickness did not improve significantly in cases with disease duration longer than 3 months (P > 0.05).

Conclusion:

Foveal ONL thinning was positively associated with disease duration prior to treatment suggesting that longer disease duration limits scope for foveal ONL recovery. CSC patients should be treated with PDT as soon as possible to prevent disease development and reduced visual function.

Factors Predicting Response to Selective Retina Therapy in Patients with Chronic Central Serous Chorioretinopathy

This retrospective study aimed to assess the safety and efficacy of selective retina therapy (SRT) with real-time feedback-controlled dosimetry (RFD) for chronic central serous chorioretinopathy (CSC) and to evaluate factors predictive of treatment response. We included 137 eyes of 135 patients with chronic CSC. SRT was performed to cover each of the leakage areas on fundus fluorescein angiography. Changes in mean best-corrected visual acuity (BCVA), central macular thickness (CMT), and subretinal fluid (SRF) height were evaluated at baseline and at 3 and 6 months after treatment. Complete SRF resolution was observed in 52.6% (72/137 eyes) and 90.5% (124/137 eyes) at 3 and 6 months, respectively. Mean BCVA (logMAR) significantly improved from 0.41 ± 0.31 at baseline to 0.33 ± 0.31 at month 6 (p < 0.001). Mean CMT significantly decreased from 347.67 ± 97.38 μm at baseline to 173.42 ± 30.95 μm at month 6 (p < 0.001). Mean SRF height significantly decreased from 187.85 ± 97.56 µm at baseline to 8.60 ± 31.29 µm after 6 months (p < 0.001). Baseline SRF height was a significant predictive factor for retreatment requirement (p = 0.008). In conclusion, SRT showed favorable anatomical outcomes in patients with chronic CSC. A higher baseline SRF height was a risk factor for retreatment.

The Effect of Selective Retina Therapy for Bevacizumab-Resistant Chronic Central Serous Chorioretinopathy

PURPOSE

The aim of this study was to evaluate the efficacy of selective retina therapy (SRT), used in conjunction with real-time feedback dosimetry (RFD), in the treatment of bevacizumab-resistant chronic central serous chorioretinopathy (CSC).

PATIENTS AND METHODS

In this retrospective cohort study, 22 eyes of 22 patients with bevacizumab-resistant chronic CSC, showing focal or diffuse foveal leakages on fundus fluorescein angiography (FFA), were included. After evaluation of the test spots at temporal arcades, SRT (wavelength, 527 nm; pulse repetition rate, 100 Hz; ramping over maximal 15 micropulses; and spot diameter, 200 μm) using RFD was applied to the leakage sites observed on FFA. Changes in the mean best-corrected visual acuity (BCVA), central macular thickness (CMT), and subretinal fluid (SRF) height were evaluated at baseline and at 1, 3, 6, 9, and 12 months following treatment.

RESULTS

SRF completely resolved in 81.8% (18/22 eyes) cases at 12 months post-treatment. The mean BCVA (logarithm of the minimum angle of resolution [logMAR]) improved from 0.49 ± 0.29 at baseline to 0.43 ± 0.36 at 12 months (p = 0.067). The mean BCVA gain was 0.06 logMAR, equivalent to 3 ETDRS letters. The CMT significantly decreased from 323 ± 85.6 μm at baseline to 221.5 ± 60.4 μm at 12 months (p < 0.001). The mean SRF height also significantly decreased from 174.6 ± 86.4 μm at baseline to 35.1 ± 75.4 μm at 12 months (p < 0.001).

CONCLUSION

SRT showed favorable visual and anatomical outcomes in patients with bevacizumab-resistant chronic CSC.

Comparison of the efficacy and safety of subthreshold micropulse laser with photodynamic therapy for the treatment of chronic central serous chorioretinopathy: A meta-analysis

BACKGROUND

This meta-analysis was conducted to compare the therapeutic effect and safety of subthreshold micropulse laser (SML) vs photodynamic therapy (PDT) in treatment of chronic central serous chorioretinopathy (cCSC).

METHODS

PubMed, EMBASE, and the Cochrane Library were searched for all relevant studies published up to August 17, 2020. Data of interest were analyzed by STATA (version 14.0) software.

RESULTS

Four randomized clinical trials (RCTs) and 5 retrospective studies with 790 eyes were included in this meta-analysis after study selection. The results showed that SML significantly improved the best-corrected visual acuity (BCVA) compared with PDT at 6 to 8 weeks, 6 months, and 7 to 8 months in patients with cCSC (weighted mean difference (WMD) = -0.15, 95% confidence intervals (CI): -0.23 to -0.07, P < .01; WMD = -2.83, 95% CI: -4.79 to -0.87, P < .01; and WMD = -2.61, 95% CI: -4.23 to -1.24, P = .026, respectively). There was also a statistically significant difference between SML and PDT groups in the differences in the complete resolution of subretinal fluid (SRF) (risk radios = 0.388, 95% CI: 0.307 to 0.491, P < .01). There were no significant differences between the SML and PDT in the overall effect with central macular thickness (CMT), adverse events, complete resolution of SRF and treatment response.

CONCLUSIONS

Based on the available evidence, this meta-analysis demonstrated that SML may be considered as a competitive alternative to PDT for treating cCSC, and as the first-line treatment of cCSC.

Photodynamic Therapy with Verteporfin for Chronic Central Serous Chorioretinopathy: A Review of Data and Efficacy

Central serous chorioretinopathy represents the fourth most frequent retinal disorder, occurring especially in young age. Central serous chorioretinopathy is mainly characterized by macular serous retinal detachment and although the clinical course moves frequently toward a spontaneous resolution, the subretinal fluid may persist for a long time, thus evolving to the chronic form, and leading to a potential damage of the retinal pigment epithelium and to photoreceptors. The photodynamic therapy with verteporfin plays an important role in the armamentarium among the many therapeutic options employed in this complex retinal disorder. In this review, the authors aim to summarize data of efficacy and safety of PDT focusing especially on mechanisms of action of the PDT and providing comparative outcomes with the alternative therapeutic approaches, including especially the subthreshold laser treatment.

Current Pharmacological Treatment Options for Central Serous Chorioretinopathy: A Review

Central serous chorioretinopathy (CSC) is a common cause of visual impairment in patients generally aged 20 to 60 and it is characterized by acute or chronic neurosensory detachments of the retina. Although CSC resolves spontaneously in most cases, in some patients it may cause permanent visual impairment in the working population; for this reason, several approaches, including photodynamic therapy (PDT), subthreshold micropulse laser treatment and oral mineralocorticoid receptor antagonists, have been studied as first-line treatment options for CSC. To date, half-dose PDT has provided the most encouraging results in this regard, supported by large, multicenter, randomized clinical trials such as the “Prospective Randomized Controlled Treatment Trial for Chronic Central Serous Chorioretinopathy” (PLACE) trial; however, the role of novel possible non-invasive treatment options is attracting interest. This review article aims to discuss the current pharmacological treatment options investigated for the management of CSC, including aspirin, ketoconazole, beta blockers, rifampicin and many others. In particular, further evidence about oral mineralocorticoid receptor antagonists, firstly seen as promising non-invasive alternatives for treating CSC, will be provided and discussed in light of the recent “Eplerenone for chronic central serous chorioretinopathy in patients with active, previously untreated disease for more than 4 months” (VICI) trial results, which have largely resized their role as possible first-line oral treatment options for treating CSC.

Photodynamic Therapy for Chorioretinal Diseases: A Practical Approach

Photodynamic therapy (PDT) using verteporfin (Visudyne®; Bausch + Lomb) is a treatment that is widely used to elicit cell and tissue death. In ophthalmology, PDT targets choroidal vascular abnormalities and induces selective occlusion of vessels. PDT was originally used in combination with full-dose verteporfin to treat neovascular age-related macular degeneration. Since the introduction of treatment with vascular endothelial growth factor receptor inhibitors, the clinical targets of PDT have shifted to other chorioretinal conditions, such as central serous chorioretinopathy, polypoidal choroidal vasculopathy, and choroidal hemangioma. In recent years, clinical studies have facilitated the optimization of treatment outcomes through changes in protocols, including the introduction of reduced treatment settings, such as PDT with half-dose verteporfin and half-fluence PDT. Here, we review PDT and its use for chorioretinal diseases from a practical perspective.

Pharmacotherapy of Central Serous Chorioretinopathy: A Review of the Current Treatments

BACKGROUND

Central serous chorioretinopathy (CSC) is the fourth most frequent retinal disorder in terms of prevalence. It typically occurs in young subjects and affects men more often than women. CSC is characterized by serous retinal detachment (SRD) involving mainly the macular area. The clinical course is usually selflimited, with spontaneous resolution within 3 months. The persistence of SRD or multiple relapse may result in a chronic form of CSC distinguished by permanent retinal pigment epithelium (RPE) and photoreceptor damage. As the pathogenetic mechanism of CSC primarily involves RPE and choroidal vascularization, the current therapeutic approaches aim to restore the normal functions of RPE and normal choroidal vascular permeability. In this review, the authors aim to summarize the current therapeutic approach to CSC.

METHODS

A comprehensive review of the literature was conducted in PubMed by searching for relevant studies on the current therapeutic options for CSC, including simple observation, conventional laser treatment, subthreshold laser treatment (SLT), photodynamic therapy (PDT) with verteporfin, treatment with mineralocorticoid receptor (MR) antagonists and treatment with anti-vascular endothelial growth factor drugs.

RESULTS

Since most cases resolve spontaneously, the most common initial CSC treatment is observation. Current evidence suggests that PDT and SLT are valuable in improving visual acuity, reducing subretinal fluid and maintaining long-term effectiveness. No clear evidence of efficacy has been achieved for anti-VEGF. MR antagonists might be a viable choice for the treatment of chronic CSC.

CONCLUSION

The pathophysiology of CSC remains poorly understood and as a consequence, the gold standard of care for CSC is yet to be defined. To date, PDT and SLT continue to offer good clinical outcomes. Positive preliminary results seem to emerge from the studies of MR antagonists.

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.

Focal and Diffuse Chronic Central Serous Chorioretinopathy Treated With Half-Dose Photodynamic Therapy or Subthreshold Micropulse Laser: PLACE Trial Report No. 3

PURPOSE

To compare the outcome between high-density subthreshold micropulse laser (HSML) treatment and half-dose photodynamic therapy (PDT) in chronic central serous chorioretinopathy (cCSC) patients, subdivided based on either focal or diffuse leakage on fluorescein angiography (FA).

DESIGN

Retrospective analysis of multicenter randomized controlled trial data.

METHODS

Patients were treated with either half-dose PDT or HSML (both indocyanine green angiography-guided) and categorized in 2 groups, based on focal or diffuse leakage on FA. Clinical outcomes were evaluated at baseline and during follow-up.

RESULTS

In the focal leakage group (63 patients), both at first evaluation and at final visit, more PDT-treated than HSML-treated patients demonstrated a resolution of subretinal fluid (evaluation visit 1: 57% in the PDT group and 17% in the HSML group, P = .007; final visit: 75% and 38%, P = .012). In the diffuse leakage group (93 patients), both at first evaluation and at final visit, more PDT-treated than HSML-treated patients showed a resolution of subretinal fluid (evaluation visit: 1:48% in the PDT group and 16% in the HSML group, P = .002; final visit: 67% and 21%, P = .002). PDT-treated patients in the focal and diffuse leakage group had a higher retinal sensitivity increase, comparing baseline and final visit (+3.1 ± 3.1 dB vs +1.2 ± 4.0 dB, P = .048, and +2.7 ± 3.3 dB vs +1.0 ± 3.8 dB, P = .036, respectively). Only in the diffuse leakage group, the increase in ETDRS letters was higher in the PDT-treated group when comparing baseline and first evaluation visit (+4.4 ± 6.1 vs +0.9 ± 10.0, P = .049).

CONCLUSIONS

Half-dose PDT is superior to HSML treatment in cCSC patients, regardless of the presence of focal or diffuse leakage on FA.

Current Therapeutic Approaches to Chronic Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSCR) is the second most common maculopathy after diabetic maculopathy between the third and fifth decades of life. CSCR is characterized by serous neurosensory retinal detachment occasionally coexisting with retinal pigment epithelium (RPE) detachment. CSCR usually has good clinical prognosis, often resolving spontaneously within the first three months. However, some patients may have recurrent episodes and chronic disease. CSCR can cause permanent visual loss due to persistent neurosensory retinal detachment and RPE atrophy, especially in chronic cases. In recent years, verteporfin-photodynamic therapy applied with standard and low-dose/low-fluence protocols, anti-vascular endothelial growth factors, glucocorticoid antagonists, mineralocorticoid receptor antagonists, and subthreshold micropulse laser with varying parameters have been investigated as treatment options. In this review, we evaluated randomized and non-randomized case series conducted after 2000 that included at least 3 patients with chronic CSCR over 3 months in duration who were treated with current treatment options for chronic CSCR.

Central serous chorioretinopathy: Current update on management

Central serous chorioretinopathy (CSC), the fourth most common nonsurgical retinopathy with a usual self-limiting course, is known to present with persistent or recurrent form with distressing visual loss. Evolution of newer mutimodal imaging techniques have revolutionized the understanding about the pathophysiology of CSC, and hence the diagnosis and management. Multifactorial etiopathology of CSC promotes the use of multiple treatment modalities. With advances in investigative options, treatment options including conventional focal laser, micropulse laser, photodynamic therapy, and transpupillary thermotherapy are also advancing and refining. Medical management for CSC is also under evaluation with a wide spectrum of new drugs in vogue. However, standard of treatment is yet to be established through randomized clinical trials. This review article discusses the current approach to multimodal treatment options for CSC including conventional as well as newer therapeutic modalities.

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

PURPOSE

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

PROCEDURES

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

RESULTS

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

CONCLUSION

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

Sex-Dependent Choroidal Thickness Differences in Healthy Adults: A Study Based on Original and Synthesized Data

PURPOSE

The purpose of this study is to determine the influence of sex on choroidal thickness (CT) in healthy adults.

METHODS

Healthy Chinese adults were recruited and complete ophthalmic examinations were performed. The choroid was imaged by swept-source optical coherence tomography and the macular CT in Early Treatment Diabetic Retinopathy Study grids was obtained by the intrinsic automated segmentation software. CT in males and females was compared after controlling other factors. All of the published studies in PubMed were systemically tracked, and a syntheses analysis of the combined data of the present study and previous studies was performed to address this issue further.

RESULTS

A total of 104 healthy adults were included, of whom 38 (37%) were male and 66 (63%) were female. Older age and longer axial length (AL) each were significantly associated with thinner CT. After controlling for age and AL, the foveal CT and average macular CT were 25.5 μm (95% CI: 0.5-50.4 μm) and 22.1 μm (95% CI: 2.7-41.4 μm) thicker in men than in women, respectively. Significant differences in CT between males and females were also observed in inner and outer rings after controlling for age and AL (P < 0.05). After strict screening, 15 previously reported studies were determined to be eligible for inclusion. The combination of data collected from 2821 males and 3389 females provided further evidence that the choroid is thicker in males, with a pooled mean difference of 19.5 μm (95% CI: 11.4 to 27.6) for foveal CT and 14.7 μm (95% CI: 6.8 to 22.6) for average CT.

CONCLUSION

Our study of Chinese subjects, along with the syntheses analysis, strengthens the evidence that CT is greater in males than in females, based on OCT measurements. This observation may be pertinent for the sex disparities in some clinical conditions related to CT.

Anatomical Retinal Changes after Photodynamic Therapy in Chronic Central Serous Chorioretinopathy

Purpose

To evaluate anatomical retinal changes measured by spectral-domain optical coherence tomography (SD-OCT), after applying photodynamic therapy (PDT) for treatment of chronic central serous chorioretinopathy (CSC).

Methods

A retrospective analysis was conducted on 43 patients (48 eyes) with chronic CSC treated with PDT. Visual acuity (VA), central retinal thickness (CRT), outer nuclear layer (ONL) thickness, subretinal fluid (SRF), and photoreceptor ellipsoid zone (EZ) measured by SD-OCT were collected at baseline and at 3, 6, and 12 months after PDT. Differences between normally distributed variables were calculated by a paired-sample t-test; p < 0.05 was considered statistically significant.

Results

Mean age was 50 ± 9.8 years. Mean time from diagnosis to PDT was 12.5 months. Baseline VA was 0.51 ± 0.24 and significantly improved (p < 0.001) to 0.74 ± 0.26 one year after PDT. CRT and SRF significantly decreased (p < 0.001) at 3, 6, and 12 months after treatment. ONL thickness and EZ did not significantly change at any point during follow-up.

Conclusions

Not significant changes were found in the ONL or EZ 12 months after PDT.

Scleral resection in chronic central serous chorioretinopathy complicated by exudative retinal detachment

BACKGROUND

Effective therapeutic options are limited for the management of chronic central serous chorioretinopathy (CSCR) complicated by exudative retinal detachments (RD). The authors describe the resolution of one such case following partial thickness scleral resection with mitomycin C.

CASE PRESENTATION

This 39-year-old male presented with a unilateral inferior exudative RD in the right eye. There was no history of steroid use either locally or systemically. The fundus fluorescein angiogram showed window defects and leaks typical of chronic CSCR. The axial length was 21.06 mm in the right eye and 21 mm in the left eye. Thickening of the ocular coats was evident on ocular ultrasound. Considering an axial length in the borderline-low range inferotemporal and inferonasal partial thickness scleral resection with mitomycin C was performed. The exudative RD resolved at 4 months.

CONCLUSION

Partial thickness scleral resection may be considered as an option for treating chronic CSCR patients with borderline-low axial length complicated by exudative RD.

Preferred practice pattern in central serous chorioretinopathy

PURPOSE

Central serous chorioretinopathy (CSC) management lacks well-defined guidelines given the variable natural history of this disease and the lack of prospective trials. We conducted an online preferred physician practice survey to track international trends and variations in the management of CSC data.

METHODS

We designed and distributed an online 27-item questionnaire with secure confidential access to retina specialists with a publication record in CSC. Physicians with at least one publication as first or corresponding author in any national or international peer reviewed journal in the English language on CSC within the last 2 years on PubMed were included. Participants were masked to the responses from other participants.

RESULTS

The response rate was 82.3% (107 out of 130). 79.1% physicians preferred to observe cases of acute CSC. For chronic cases, 66.7% offered photodynamic therapy (PDT) as first line treatment. The most commonly used PDT protocol was full dose and half-fluence (60.6%). For chronic cases with intraretinal cystic changes, 43.1% opted for observation. Enhanced depth imaging, optical tomography was a common diagnostic tool for 59.8%, while indocyanine green angiography was only used by 37.8%. One regional difference was a preference for focal laser in Asia for initial treatment.

CONCLUSIONS

While there are some common practice patterns for of CSC, there are still variations in regional and individual practice patterns indicating the need to establish more definitive practice guidelines. This survey data could be useful to plan a prospective study to address many unanswered questions.

Half-dose Versus Half-time Photodynamic Therapy for Central Serous Chorioretinopathy

PURPOSE

To compare the efficacy of half-dose vs half-time photodynamic therapy (PDT) guided by fluorescein angiography (FA) for the treatment of central serous chorioretinopathy (CSC).

DESIGN

Two-center, retrospective, comparative case series.

METHODS

Sixty-one eyes with acute or chronic CSC involving fovea were recruited; 35 eyes received half-dose PDT and 26 eyes received half-time PDT. Improvement in best-corrected visual acuity (BCVA), resolution of subretinal fluid (SRF) demonstrated by optical coherence tomography (OCT), and recurrence of CSC after PDT were compared between the 2 groups.

RESULTS

The mean follow-up time after PDT was 14.8 ± 13.3 months. Both groups showed significant improvement in BCVA at months 1, 3, 6, and 12 after PDT (P < .05 for all times). Multiple regression analysis showed that PDT type was not correlated with visual improvement (P > .05 for all times). All eyes that received half-time PDT showed complete resolution of SRF within 6 months after PDT, but 3 eyes that received half-dose PDT had persistent SRF before loss to follow-up at months 5, 7, and 8 (P = .21 between 2 groups). Three of 32 eyes in the half-dose group and 2 of 26 eyes in the half-time group had recurrence of CSC during follow-up; all recurrent cases had complete SRF resolution after another PDT treatment. No adverse systemic or ocular side effects were observed in any cases.

CONCLUSIONS

Half-dose and half-time FA-guided PDT were both effective and safe in treating CSC and showed similar efficacy in visual improvement and SRF resolution.

Selective Retina Therapy in Acute and Chronic-Recurrent Central Serous Chorioretinopathy

PURPOSE

Selective retina therapy (SRT), the confined laser heating and destruction of retinal pigment epithelial cells, has been shown to treat acute types of central serous chorioretinopathy (CSC) successfully without damaging the photoreceptors and thus avoiding laser-induced scotoma. However, a benefit of laser treatment for chronic forms of CSC is questionable. In this study, the efficacy of SRT by means of the previously used 1.7-µs and shorter 300-ns pulse duration was evaluated for both types of CSC, also considering re-treatment for nonresponders.

MATERIAL AND METHODS

In a two-center trial, 26 patients were treated with SRT for acute (n = 10) and chronic-recurrent CSC (n = 16). All patients presented with subretinal fluid (SRF) in OCT and leakage in fluorescein angiography (FA). SRT was performed using a prototype SRT laser system (frequency-doubled Q-switched Nd:YLF-laser, wavelength 527 nm) with adjustable pulse duration. The following irradiation settings were used: a train of 30 laser pulses with a repetition rate of 100 Hz and pulse durations of 300 ns and 1.7 µs, pulse energy 120-200 µJ, retinal spot size 200 µm. Because SRT lesions are invisible, FA was always performed 1 h after treatment to demonstrate laser outcome (5-8 single spots in the area of leakage). In cases where energy was too low, as indicated by missing FA leakage, energy was adjusted and the patient re-treated immediately. Observation intervals were after 4 weeks and 3 months. In case of nonimprovement of the disease after 3 months, re-treatment was considered.

RESULTS

Of 10 patients with active CSC that presents focal leakage in FA, 5 had completely resolved fluid after 4 weeks and all 10 after 3 months. Mean visual acuity increased from 76.6 ETDRS letters to 85.0 ETDRS letters 3 months after SRT. Chronic-recurrent CSC was characterized by less severe SRF at baseline in OCT and weaker leakage in FA than in acute types. Visual acuity changed from baseline 71.6 to 72.8 ETDRS letters after 3 months. At this time, SRF was absent in 3 out of 16 patients (19%), FA leakage had come to a complete stop in 6 out of 16 patients (38%). In 6 of the remaining chronic CSC patients, repeated SRT with higher pulse energy was considered because of persistent leakage activity. After the re-treatment, SRF resolved completely in 5 patients (83.3%) after only 25 days.

CONCLUSION

SRT showed promising results in treating acute CSC, but was less effective in chronic cases. Interestingly, re-treatment resulted in enhanced fluid resolution and dry conditions after a considerably shorter time in most patients. Therefore, SRT including re-treatment if necessary might be a valuable CSC treatment alternative even in chronic-recurrent cases.

Clinical characteristics of responders to intravitreal bevacizumab in central serous chorioretinopathy patients

PURPOSE

To investigate factors associated with good response to intravitreal bevacizumab (IVB) in central serous chorioretinopathy (CSC) patients.

METHODS

We retrospectively reviewed 42 eyes of CSC patients of symptom duration more than 3 months who received a single or multiple successive IVBs on an as-needed basis (0.05 ml, 1.25 mg). High responders (HRs) were defined as complete resolution of subretinal fluid (SRF) on spectral domain optical coherence tomography (SD-OCT). Moderate responders (MRs) were defined as SRF resolution of 50-99% of pretreatment volume and poor responders (PRs) as SRF resolution <50%. Clinical, SD-OCT, fluorescein, and indocyanine green angiography findings were analyzed to find factors associated with HR. Descriptive statistics for all demographic and clinical variables were calculated, and comparisons were made using Wilcoxon's matched-pairs signed-rank test, the Mann-Whitney U-test for means with continuous data, Pearson's χ(2) test, and Fisher's exact test for categorical data.

RESULTS

The mean number of IVB was 1.9. At postoperative 1 month, there were 10 (24%) HRs, 18 (43%) MRs, and 14 (33%) PRs. At the last follow-up (the mean 8.6 months), there were 25 HRs (60%), 9 MRs (21%), and 8 PRs (19%). Thicker subfoveal choroid (P=0.036), smaller lesion diameter (P=0.019), and better baseline best-corrected visual acuity (P=0.002) predicted HRs at postoperative 1 month. HR at the last follow-up was associated with classic pattern fluorescein angiography finding.

CONCLUSIONS

Suboptimal effects of IVB on persistent CSC suggest primary IVB on selective cases with better vision, smaller lesion, and thicker choroid at baseline.

Advances in the treatment of central serous chorioretinopathy

Central serous chorioretinopathy is a disease that is partly understood. Novel advancements have led to further understanding of the disease, and have identified choroidal dysfunction as the principal element in CSCR development. New imaging tools have aided in better monitoring disease response to various treatment models. Enhanced depth imaging optical coherence tomography, in particular, has helped in observing choroidal thickness changes after various treatment models. To date, photodynamic therapy and focal laser remain the main stay of treatment. More understanding of disease pathophysiology in the future will help in determining the drug of choice and the best management option for such cases.

Long-term follow-up of standard photodynamic therapy with standardized small spot size for diffuse retinal pigment epitheliopathy

PURPOSE

To evaluate the long-term efficacy and safety of standard-fluence photodynamic therapy (PDT) with verteporfin using the minimum PDT spot size in patients with diffuse retinal pigment epitheliopathy (DRPE).

METHODS

This is a retrospective study of 67 DRPE cases treated with PDT using a standardized minimum spot size of 850 μm. Indocyanine green angiography (ICGA) was used to guide and determine the outcome of PDT treatment. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), recurrences, and adverse events were recorded and analyzed.

RESULTS

The mean follow-up period of the study was 35.8 ± 16.6 months. There was a statistically significant difference in BCVA between baseline and the end of the follow-up (p&lt;0.001). The BCVA improved in 41 eyes (61.2%), remained stable in 20 eyes (29.9%), and deteriorated in 6 eyes (9%). Accordingly, there was a statistically significant difference in CRT between the baseline and the last follow-up visit (p&lt;0.001). The recurrence rate was 13.4% and only one eye presented a recurrence at the same site as the laser treatment. No adverse events were noted.

CONCLUSIONS

Application of ICGA-guided standard PDT, with a laser spot size of minimum diameter, on the site of active leakage seems to be effective and safe in a long-term follow-up period, presenting improvement in BCVA, decrease in CRT, and low rate of recurrence.

Photodynamic therapy for central serous chorioretinopathy

PURPOSE

Central serous chorioretinopathy (CSCR) is an idiopathic disorder characterised by detachment of the neurosensory retina due to serous fluid accumulation between the photoreceptor outer segments and the retinal pigment epithelium. There are currently no set guidelines or protocols on its treatment. This study was undertaken to assess the current literature on the the efficacy and safety of photodynamic therapy (PDT) as a treatment option for CSCR.

METHODS

Seven databases (PubMed, CENTRAL, MEDLINE, Web of Science, Embase, Scopus, and The Cochrane Database of Systematic Reviews) were searched without restrictions on time or location. We followed PRISMA guidelines and evaluated quality according to STROBE criteria. In total, 117 citations were identified and 31 studies describing 787 eyes were included for review. Data on indications for PDT in CSCR, dosing regimens of verteprofin PDT (which includes treatment dose of vertoporfin, treatment time, fluence, and spot size), number of treatment sessions, response to treatment, mean length of follow-up, and complications were extracted and analysed.

RESULTS

Since the introduction of PDT for the treatment of CSCR in 2003, there have been three randomised controlled trials (RCTs), one for acute and two chronic CSCR and 28 further studies that met the STROBE criteria that compared the use of PDT with other treatment options. All studies showed short-term efficacy of PDT in CSCR. The studies were of small sample size and lacked sufficient follow-up to draw conclusions on long-term efficacy and safety.

CONCLUSIONS

There is sufficient scientific evidence to suggest that PDT may be a useful treatment option for chronic CSCR in the short-term. The review identifies a need for robust RCTs with longer follow-up to ascertain the role of PDT as a useful treatment option for CSCR.

Focal Laser Photocoagulation and Photodynamic Therapy for Lupus Choroidopathy

Purpose

To describe the results of photodynamic therapy (PDT) and/or focal laser photocoagulation in the treatment of serous retinal detachments secondary to lupus choroidopathy.

Methods

The medical records of three patients with serous detachments secondary to lupus choroidopathy who were treated with PDT and/or focal laser photocoagulation were reviewed. Concomitant systemic medical therapy as well as visual acuity and optical coherence tomography (OCT) outcomes were recorded.

Results

All patients received systemic immunosuppressive therapy and had control of their extraocular manifestations prior to PDT and/or laser photocoagulation. One patient received only focal laser photocoagulation and had complete resolution of the subretinal fluid on OCT. The two other patients received a combination of PDT and focal laser treatment. One had improvement in vision and resolution of subretinal fluid on OCT. The second patient, who had longstanding lupus choroidopathy and associated subretinal fluid and macular edema, had only a significant decrease in fluid on OCT but no vision improvement.

Conclusion

In conjunction with control of systemic disease, PDT and/or focal laser photocoagulation can be successful in resolving subretinal fluid secondary to lupus choroidopathy.

Half-dose photodynamic therapy targeting the leakage point on the fluorescein angiography in acute central serous chorioretinopathy: a pilot study

PURPOSE

To evaluate the efficacy of half-dose photodynamic therapy (PDT) targeting only the focal leakage point on fluorescein angiography for acute central serous chorioretinopathy.

DESIGN

Nonrandomized, retrospective, comparative, interventional case series.

METHODS

Ten consecutive eyes with acute central serous chorioretinopathy underwent PDT, and later, 11 eyes were observed without treatment. Main outcome measures included achievement of complete resolution of subretinal fluid, change in best-corrected visual acuity, and central retinal sensitivity.

RESULTS

Complete resolution of subretinal fluid was achieved in 80.0% and 18.2% of eyes in the PDT group and the observation group at 1 month (P = .009), 100% and 27.3% at 3 months (P = .001), and 90% and 63.6% at 12 months (P = .311), respectively. At 12 months, 3 eyes (27%) in the observation group had a persistent lesion, whereas no such lesions were observed in the eyes in the PDT group. One eye in each group showed recurrence during the 12-month follow-up period. Visual acuity improved significantly in both groups at each time point, and the differences between groups were not significant. The mean central retinal sensitivity at 3 months was significantly higher in the PDT group compared with the observation group.

CONCLUSIONS

Fluorescein angiography-guided half-dose PDT seems to facilitate faster resolution of subretinal fluid in acute central serous chorioretinopathy without, however, convincing long-term anatomic and functional benefits. This protocol may enhance the safety of PDT further.

Choroidal vessel diameter in central serous chorioretinopathy

PURPOSE

To measure the hyporeflective lumen in the choroid of patients with central serous choroidopathy (CSC) and to compare the diameter with that of a control group.

METHODS

The prospective comparative observational clinical study included patients with unilateral CSC and a control group of normal subjects, matched in age, gender and refractive error with the study group. Subfoveal choroidal thickness (SFCT) and the largest diameter of choroidal hyporeflective lumen as surrogates for the choroidal vessels were measured by enhanced depth imaging optical coherence tomography (OCT).

RESULTS

The study group included 15 Chinese patients and the control group 15 control subjects. Mean SFCT was significantly (p = 0.04) larger in the affected eyes (455 ± 73 μm) than in the contralateral unaffected eyes (387 ± 94 μm), in which it was significantly (p = 0.005) larger than in the control group (289 ± 71 μm). In a parallel manner, the mean diameter of the largest hyporeflective lumen was larger, but not significantly larger (p = 0.18) in the affected eyes (305 ± 101 μm) than in the in the contralateral unaffected eyes (251 ± 98 μm), in which it was significantly (p = 0.001) larger than in the control group (140 ± 40 μm). Largest vessel diameter was significantly (p < 0.001; correlation coefficient: 0.73) correlated with the thickness of the total choroid.

CONCLUSIONS

In patients with CSC, the affected eyes show larger hyporeflective lumen than the contralateral clinically unaffected eyes and significantly larger than normal control eyes. Assuming these hyporeflective lumens to be choroidal vessels, macular swelling in CSC is markedly associated with vascular engorgement. As also the clinically unaffected eyes showed macular choroidal significant swelling, CSC may have a systemic component with usually asymmetric ocular involvement.

Central serous chorioretinopathy: update on pathophysiology and treatment

Recent technological advances--new pathophysiological insights, new imaging techniques for diagnosis and management, and new treatments--have led to an improved understanding of central serous chorioretinopathy (CSC). The primary role of the choroid has become more widely accepted with widespread use of indocyanine green angiography. Optical coherence tomography (OCT), and particularly enhanced depth imaging OCT, demonstrate a thickened and engorged choroid. Adaptive optics, fundus autofluorescence, multifocal electroretinography, microperimetry, and contrast sensitivity testing reveal that patients with even a mild course suffer previously undetected anatomic and functional loss. Although focal laser and photodynamic therapy are the current standard of care for persistent subretinal fluid in CSC, they are not appropriate in all cases, and the optimal timing of intervention remains unclear.