Optical Coherence Tomography Angiography in Central Serous Chorioretinopathy

Inner Choroidal Fibrosis: An Optical Coherence Tomography Biomarker of Severity in Chronic Central Serous Chorioretinopathy

PURPOSE

To describe a potential biomarker termed as inner choroidal fibrosis in cases of chronic central serous chorioretinopathy (CSCR) presenting to a tertiary referral center.

DESIGN

Observational case series.

METHODS

Five eyes of 4 patients with CSCR were noted to have a gray-white subretinal lesion in the macula, which was analyzed with multimodal imaging.

RESULTS

The lesions were hypofluorescent on autofluorescence, fundus fluorescein angiography, and indocyanine angiography. In all cases, a characteristic heterogeneous, hyperreflective lesion in the inner choroid was seen on optical coherence tomography (OCT), corresponding to the white subretinal lesions. The lesion was distinct from the adjacent choroid, with greater reflectivity and greater thickness than the adjacent compressed choroidal vasculature. The dilated outer pachyvessels were pushed outward or sideways in all cases. On OCT-angiography, the corresponding lesion showed flow void areas. We have termed this zone of inner choroidal hyperreflectivity "inner choroidal fibrosis." Upon analyzing the clinical course, 3 of the patients had a history of choroidal neovascularization. The contralateral eye in 2 of these 3 patients also developed choroidal neovascularization. Three of the eyes had an overlying focal choroidal excavation.

CONCLUSIONS

We report a potential biomarker of CSCR termed "inner choroidal fibrosis" in 4 cases of chronic CSCR. It can best be identified on enhanced depth or swept source OCT as a region of heterogeneous hyperreflectivity in the inner choroid. This fibrosis could be regarded as a degenerative process secondary to more severe disease in the past.

Optical coherence tomography angiography-guided vs indocyanine green angiography-guided half-dose photodynamic therapy for acute central serous chorioretinopathy: 6-month randomized trial results

PURPOSE

This study aimed to compare the anatomic and functional results of optical coherence tomography angiography (OCTA)-guided half-dose photodynamic therapy (PDT) versus indocyanine green angiography (ICGA)-guided PDT in eyes with acute central serous chorioretinopathy (CSC).

METHODS

One hundred and thirty-one eyes of 131 patients with acute central serous chorioretinopathy (CSC) were recruited, and randomly assigned to the OCTA-guided group and ICGA-guided group. The primary outcome measures were the rates of complete subretinal fluid (SRF) resolution at 1 month, 3 months, and 6 months. The secondary outcomes included best-corrected visual acuity (BCVA), central retinal thickness (CRT), choroidal capillary flow deficit density at each scheduled visit, and recurrence rate of SRF at 3 months and 6 months.

RESULTS

There were 110 eyes that finished the follow-up, with 56 eyes in the OCTA-guided group and 54 eyes in the ICGA guided group. OCTA-guided PDT was demonstrated to be noninferior to ICGA-guided PDT for SRF resolution rate at 1 months and 6 months (P = 0.021 and P = 0.037), but not at 3 months for acute CSC (P = 0.247). The average CRT of the ICGA-guided group was significantly lower than that of the OCTA-guided group at 3-month visit (P = 0.046), but no significant difference was found between them at the 1-month and 6-month visits (P = 0.891 and 0.527). There was no significant difference between the two groups for BCVA (P = 0.359, 0.700, and 0.143, respectively) and the deficit area on CC (P = 0.537, 0.744,and 0.604, respectively) at 1, 3, and 6 months.

CONCLUSION

OCTA may replace ICGA to guide PDT for the treatment of acute CSC and their follow-up.

Volumetrically tracking retinal and choroidal structural changes in central serous chorioretinopathy

Central serous chorioretinopathy (CSCR) leads to the accumulation of subretinal fluid and retinal thickness change, which can be readily detected in clinics using optical coherence tomography (OCT). However, current quantification methods usually require sophisticated processing such as retinal layer segmentations, and volumetric visualization of structural changes is generally challenging, which can hinder fast and accurate assessment of disease progression and/or treatment efficacy. In this study, we developed an algorithm that can register the OCT scans acquired from different visits without requiring prior layer segmentation and calculated the three-dimensional (3-D) structural change maps for patients with CSCR. Our results demonstrate that this tool can be useful in monitoring the progression of CSCR and revealing the resolution of pathologies following treatment automatically with minimal pre-processing.

Optical Coherence Tomography Angiography Parameters in Indian Patients With Central Serous Chorioretinopathy

Background In this study, we aimed to evaluate optical coherence tomography angiography (OCTA) parameters among Indian patients affected with central serous chorioretinopathy (CSCR). Methodology A cross-sectional study on Indian patients having unilateral or bilateral affection with CSCR was conducted at the Department of Ophthalmology, Guru Nanak Eye Centre, and Maulana Azad Medical College, New Delhi. A history of ocular symptoms such as a diminution of vision, metamorphopsia, decreased contrast sensitivity (CS), and defective color vision (CV) and their duration were obtained. A detailed ocular examination for best-corrected visual acuity (BCVA), intraocular pressure (IOP), CV, and CS was done. Following this, fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA) were performed. OCT was done for central foveal thickness (CFT), subfoveal choroidal thickness (SFCT), neurosensory detachment (NSD), pigment epithelial detachment (PED), and choroidal neovascular membranes (CNVMs). The OCTA imaging was done to examine the foveal avascular zone (FAZ) size, perimeter and circularity, vessel density (VD), and features such as enlarged/distorted FAZ, dark areas, dark spots, abnormal vessels, and choriocapillaris island (CCI) in the retino-choroidal layers. We compared the OCTA features of affected eyes with those of fellow eyes. Results The study involved 52 eyes of 40 CSCR patients, including 32 (80%) males and eight (20%) females with a mean age of 39.3 ± 6.1 (24-49) years. Of the 40 patients, 12 (30%) had a bilateral involvement. The mean CFT was 300.3 ± 158.4 µ, and the SFCT was 258.5 ± 60.4 µ. The mean distance BCVA was the logarithm of the minimum angle of resolution (logMAR) 0.58 ± 0.32. The OCTA showed features such as enlarged/distorted FAZ (36.53% eyes), dark areas (NSD/PED) (84.61% eyes), dark spots (PED) (5.76% eyes), abnormal vessels (dilated vessels/CNVM) (96.15% eyes), and CCI (17.30% eyes). The mean FAZ area, perimeter, and circularity were 0.40 ± 0.71 mm2, 41.8 ± 280.0 mm, and 0.48 ± 0.12, respectively. The VD in the superficial capillary plexus (SCP) was 25.4 ± 14.1, deep capillary plexus (DCP) 15.0 ± 11.5, outer retina (OR) 5.9 ± 6.8, outer retinal choriocapillaris (ORCC) 33.7 ± 16.9, choriocapillaris 29.7 ± 17.5, and choroid 29.9 ± 17.5. The fellow eyes showed a mean FAZ area, perimeter, and circularity of 0.34 ± 0.23 mm2, 76.8 ± 391.2 mm, and 0.47 ± 0.11, respectively, while VD of SCP was 25.9 ± 13.6, DCP 16.5 ± 11.7, OR 14.3 ± 14.9, ORCC 38.0 ± 16.5, choriocapillaris 36.3 ± 17.7, and choroid 35.5 ± 19.2. Conclusions The CSCR eyes had a thicker fovea and sub-foveal choroid (SFC). The FAZ area of affected eyes was larger, while the perimeter was smaller than that in the fellow eye. In the affected eye, the VD in all the retino-choroidal layers was lower, although it was significantly reduced in OR whole (p = 0.006) and foveal choroid (p = 0.022).

Volumetrically tracking retinal and choroidal structural changes in central serous chorioretinopathy

Central serous chorioretinopathy (CSCR) leads to accumulation of subretinal fluid and retinal thickness change, which can be readily detected in clinics using optical coherence tomography (OCT). However, current quantification methods usually require sophisticated processing such as retinal layer segmentations, and volumetric visualization of structural changes is generally challenging, which can hinder fast and accurate assessment of disease progression and/or treatment efficacy. In this study, we developed an algorithm that can register the OCT scans acquired from different visits without requiring prior layer segmentation and calculated the three-dimensional (3-D) structural change maps for patients with CSCR. Our results demonstrate that this tool can be useful in monitoring the progression of CSCR and revealing the resolution of pathologies following treatment automatically with minimal pre-processing.

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

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

Central serous chorioretinopathy: updates in the pathogenesis, diagnosis and therapeutic strategies

Central serous chorioretinopathy (CSCR), first described by Albrecht von Graefe in 1866, is characterized by focal serous detachment of the neural retina and/or retinal pigment epithelium (RPE) in the posterior pole. CSCR is the first ever described pachychoroid disease. Most recently, hypothetical venous overload choroidopathy is also proposed due to its distinguished morphological and pathological characteristics, including choroidal thickening, choriocapillaris hyperpermeability, remodelling, and intervortex venous anastomoses. Identification of genetic variants is necessary to comprehend the pathophysiology of CSCR. The novel multimodality imaging platforms, including the ultra-widefield imaging system, flavoprotein fluorescence, fluorescence lifetime imaging ophthalmoscopy, and multispectral imaging system, have been used for diagnosing and managing CSCR. Half-dose photodynamic therapy (PDT) remains the mainstay of clinical practice, with about 95% of patients with chronic CSCR improving to visual acuity (VA) of 20/30 or better. The use of oral eplerenone for routine clinical care remains controversial, and long-term randomized clinical trials are warranted to investigate its efficacy in acute and chronic CSCR. While CSCR has generally been recognized as a self-limiting disease with good prognosis, the underlying pathogenesis is still not fully understood, and treatments are often not fully effective. With new evidence emerging about pachydrusen being a disease precursor in both CSCR and polypoidal choroidal vasculopathy (PCV), it would be interesting to investigate whether CSCR can be a precursor to PCV. In this review, we highlighted the currently available evidence on the pathogenesis, diagnosis, multimodality imaging features, and management strategies, including recent findings related to CSCR.

The Choroid after Half-Dose Photodynamic Therapy in Chronic Central Serous Chorioretinopathy

PURPOSE

To characterize choroidal structure and vasculature after half-dose verteporfin photodynamic therapy (hd-vPDT) in eyes with chronic central serous chorioretinopathy using Enhanced Depth Imaging Optical Coherence Tomography (EDI OCT) and Optical Coherence Tomography Angiography (OCT-A).

METHODS

This prospective case-control study included 10 eyes. Choroid was examined before and at 1 month following hd-vPDT. We measured choroidal thickness (CT) at subfoveal area and at 750 μm nasal and temporal of fovea and thickness of Haller and choriocapillaris/Sattler layers. Whole (WA), luminal (LA) and interstitial area (IA) at EDI-OCT, and perfusion density at OCT-A were analyzed. The unaffected fellow eyes were used for comparisons.

RESULTS

Mean CT at subfoveal area and at 750 μm nasal and temporal of fovea, values of Haller and choriocapillaris/Sattler layers and those of WA, LA and IA were reduced, while PD increased at 1 month after hd-vPDT (all p < 0.001). There was a significant (p < 0.05) negative correlation (ρ = -0.658) between PD and post-treatment logMARVA. None of analyzed parameters reached values of unaffected fellow eye.

CONCLUSION

Following hd-vPDT, choroidal thickness with both luminal and interstitial components markedly decreased, while perfusion of choriocapillaris improved.

Optical coherence tomography angiography quantification of choriocapillaris blood-flow after half-fluence photodynamic therapy for chronic central serous chorioretinopathy

PURPOSE

To quantitatively analyze characteristics of choriocapillaris flow using spectral domain optical coherence tomography angiography (SD-OCTA) in eyes with chronic central serous chorioretinopathy (CSC) before and after treatment by photodynamic therapy (PDT).

METHODS

Retrospective interventional study. Macular 3X3 SD-OCT scans were analyzed in eyes diagnosed with chronic CSC before and after treatment with half-fluence PDT. The choriocapillaris en face slabs were extracted from the SD-OCTA device after manual segmentation. En face choriocapillaris flow images were compensated with en face choriocapillaris structure images. Phansalkar local thresholding method was then used with a radius of 4 and 8 pixels. Percentage of flow deficits (FD%), number, size, and total area of FDs were computed for comparison, before and after treatment by half-fluence PDT.

RESULTS

Mean choriocapillaris FD% before PDT was of 58.36 + / - 11.88 and of 60.82 + / - 11.08 after PDT using radius 4 pixels with no significant difference (p = 0.140). Mean choriocapillaris FD% was of 58.63 + / - 11.08 before PDT and of 60.87 + / - 10.36 after PDT using radius 8 pixels with no significant difference (p = 0.200). Similarly, no significative difference was found in number, size, and total area of FDs, before and after half-fluence PDT, using radius 4 and 8 pixels in patients with chronic CSC.

CONCLUSION

Using Phansalkar local thresholding method, quantitative analysis of choriocapillaris with SD-OCTA found no significant change in choriocapillaris flow deficits before and after successful half-fluence PDT in patients with chronic CSC. Therefore, it seems that half-fluence PDT may not alter choriocapillaris perfusion, at least on a relative short-term basis.

Normative Data of Superficial Retinal Vascular Plexus and the Relationship to Retinal Layers

Objectives:

The aim of this study was to evaluate the relationship between optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) parameters in a healthy population and to detect any changes that occur with age.

Methods:

A total of 100 healthy participants were included in this prospective, observational, and comparative study. The participants were categorized in 4 groups according to age: Group 1: 21-30 years, Group 2: 31-40 years, Group 3: 41-50 years, Group 4: 51-60 years of age. Mean macular thickness, retinal nerve fiber layer (RNFL), ganglion cell inner plexiform layer (GC-IPL), and the choroidal thickness (ChT), vessel density (VD), perfusion density (PD), foveal avascular zone (FAZ), and parapapillary perfusion density parameters were recorded and analyzed.

Results:

In comparisons between groups, no significant difference in OCTA parameters was observed. There were inverse correlations between the outer VD, PD, and intraocular pressure (IOP) (r= -0.307, p=0.006 and r= -0.284, p=0.011, respectively). The correlation between parapapillary perfusion density and IOP was close to being significant (r= -0.213, p=0.059). There were significant relationships between OCTA parameters and macular, RNFL, and GC-IPL thickness. No significant relationship between ChT and OCTA parameters was seen.

Conclusion:

The size and characteristics of superficial VD, PD, parapapillary perfusion density, and FAZ were determined in a population with standardized demographic and ocular clinical features, and the relationship between these parameters and retinal layers was established.

Optical coherence tomography angiography of central serous chorioretinopathy: quantitative evaluation of the vascular pattern and capillary flow density

Background

This study aimed to evaluate the vascular pattern and capillary flow density (CFD) map on optical coherence tomography angiography (OCTA) images of patients affected by central serous chorioretinopathy (CSC).

Methods

In this retrospective cohort study, OCTA (AngioVue RTVue XR Avanti, Optovue) 3 × 3 mm macula scans of both eyes of patients with CSC were taken at baseline; the images were segmented and compared with OCTA scans of fellow eyes without CSC as well as age-matched healthy subjects. OCTA images were processed by quantitative textural analysis (ImageJ software) to provide an objective grading of choroidal capillary alterations. The texture of OCTA images was examined by the autocorrelation method.

Results

In eyes with CSC (40 eyes), we found six different morphological patterns of the choriocapillaris layer vasculature (CCL), likely corresponding to different grades of OCT choroidal hyporeflectivity and OCTA reduction of the decorrelation signal. Moreover, the OCTA capillary flow density map revealed capillary depletion in the superficial capillary plexus (p value = 0.0023), in the deep vascular network (p value =  < 0.0001), and in the CCL (p value = 0.0001). Such findings were not observed in healthy subjects (13 eyes).

Conclusions

OCTA in CSC is a useful tool that allows the identification of the clinical type of CSC by means of specific CCL patterns. Moreover, CFD depletion is observed in association with the inner retinal layers, pointing to an involvement of the inner blood retinal barrier in CSC. According to our results, it is plausible that the patterns observed herein may correlate to the different clinical subtypes of the disease.

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.

Choriocapillaris: Fundamentals and advancements

The choriocapillaris is the innermost structure of the choroid that directly nourishes the retinal pigment epithelium and photoreceptors. This article provides an overview of its hemovasculogenesis development to achieve its final architecture as a lobular vasculature, and also summarizes the current histological and molecular knowledge about choriocapillaris and its dysfunction. After describing the existing state-of-the-art tools to image the choriocapillaris, we report the findings in the choriocapillaris encountered in the most frequent retinochoroidal diseases including vascular diseases, inflammatory diseases, myopia, pachychoroid disease spectrum disorders, and glaucoma. The final section focuses on the development of imaging technology to optimize visualization of the choriocapillaris as well as current treatments of retinochoroidal disorders that specifically target the choriocapillaris. We conclude the article with pertinent unanswered questions and future directions in research for the choriocapillaris.

USE OF CHOROIDAL VASCULARITY INDEX FOR CHOROIDAL STRUCTURAL EVALUATION IN CENTRAL SEROUS CHORIORETINOPATHY WITH CHOROIDAL NEOVASCULARIZATION

PURPOSE

To evaluate choroidal vascular structure in eyes with central serous chorioretinopathy (CSC) by assessing the choroidal vascular index (CVI).

METHODS

We retrospectively analyzed the medical records of 117 eyes with CSC. Subjects were divided into 4 groups according to clinical characteristics: 1) acute CSC (N = 29), 2) non-neovascularized chronic CSC without flat irregular pigment epithelial detachment (N = 49), 3) non-neovascularized chronic CSC with flat irregular pigment epithelial detachment (N = 21), and 4) chronic CSC with choroidal neovascularization (N = 18). Subfoveal choroidal area (1,500 mm) of swept source optical coherence tomography scans were divided into luminal and stromal areas by the image binarization technique. The CVI was defined as the ratio of the luminal to the total subfoveal choroidal area.

RESULTS

The CVI was significantly lower in eyes of Group 4 than those of other groups (all P < 0.05). The subfoveal choroidal thickness was significantly lower in Group 4 than in Groups 1 and 2 (P < 0.05), but regression analysis showed no association with the CVI.

CONCLUSION

Decreased CVI may reflect choroidal vascular structure changes in eyes with choroidal neovascularization complicating CSC. These findings suggest that the CVI could be useful for evaluating choroidal vascular changes in eyes with CSC.

Acute-onset central serous retinopathy after immunization with COVID-19 mRNA vaccine

Purpose

We report the case of a 33-year-old male who presented with unilateral central serous retinopathy three days after the injection of a COVID-19 vaccine.

Observations

A 33-year-old healthy Hispanic male referred to the ophthalmology service due to blurry vision and metamorphopsia in the right eye without any flashes, floaters, eye redness or pain. The patient reported that 69 hours prior to presentation he received the first dose of the Pfizer-BioNTech BNT162b2 mRNA COVID-19 vaccine. He denied any past ocular history or pertinent medical history. He does not take any medicines and denies stressful factors in his life. The clinical examination and imaging tests were consistent with central serous retinopathy that resolved in three months.

Conclusions and importance

This is the first report of an ocular complication potentially associated with a COVID-19 vaccination. Our case contributes information of a side effect potentially related to this new vaccine.

Influence of Retinal Microsecond Pulse Laser Treatment in Central Serous Chorioretinopathy: A Short-Term Optical Coherence Tomography Angiography Study

Background: Central serous chorioretinopathy (CSC) is a common macular condition characterized by detachment of the neuroretina and is a frequent cause of central vision loss in adults. Among the various therapeutic strategies, subthreshold microsecond pulsed laser (SML) treatment has become a useful option. Despite the suggested involvement of choroidal circulatory disturbances in CSC, the effects of this treatment on macular microperfusion have not been fully evaluated yet. Herein, we report the impact of SML on retinal and choroidal microvascular flow using non-invasive optical coherence tomography (OCT) angiography (OCTA). Methods: In this study, CSC patients with persistent subretinal fluid (SRF) with or without secondary choroidal neovascularization (CNV) were included (referred to as the pachychoroid neovasculopathy (PNV) group and the CSC group, respectively). SML was conducted using a yellow (577 nm) laser with a duty cycle of 10%, spot size of 200 µm and duration of 200 ms. Best corrected visual acuity (BCVA) as well as OCT and OCTA images were evaluated at baseline and 4 weeks after SML. OCTA parameters of interest included full retinal perfusion (FRP), choriocapillaris perfusion (CCP), Sattler’s layer perfusion (SLP), and Haller’s layer perfusion (HLP), which were evaluated longitudinally and compared to unaffected fellow eyes. Results: 27 affected eyes and 17 fellow eyes from 27 patients were included. Before treatment, central retinal thickness (CRT) and subfoveal choroidal thickness (SFCT) of affected eyes were significantly larger than in fellow eyes. Four weeks after SML, CRT decreased significantly, whereas perfusion parameters did not change. In subgroup analyses, the CSC group showed a significant decrease in SFCT, whereas the PNV group did not despite the decrease in CRT. Conclusion: Our results suggest that the SML may affect the SFCT of the CSC, but not the PNV patients at least within four weeks following treatment. This effect seems to be independent of the change in choroidal perfusion measured with OCTA.

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.

Choroidal Vascularity Map in Unilateral Central Serous Chorioretinopathy: A Comparison with Fellow and Healthy Eyes

Background: To map the choroidal vascularity index and compare two eyes in patients with unilateral central serous chorioretinopathy (CSCR). Methods: This was a retrospective, observational study performed in patients with unilateral CSCR. Choroidal thickness (CT) and Choroidal vascularity index (CVI) were measured and mapped in various zones according to the early treatment diabetic retinopathy (ETDRS) grid. Results: A total of 20 CSCR patients (20 study and 20 fellow eyes) were included in the study. Outer nasal region CT was seen to be significantly lower than central CT (p = 0.042) and inner nasal CT (p = 0.007); outer ring CT was significantly less than central (p = 0.04) and inner ring (p = 0.01) CT in CSCR eyes. On potting all the CVI values against the corresponding CT values, a positive correlation was seen in CSCR eyes (r = 0.54, p < 0.01), which was slightly weaker in fellow eyes (r = 0.3, p < 0.01) and a negative correlation was seen in healthy eyes (r = −0.262, p < 0.01). Conclusions: Correlation between CVI and CT was altered in CSCR eyes as compared to fellow and normal eyes with increasing CVI towards the center of the macula and superiorly in CSCR eyes.

Macular microvascular changes in resolved central serous chorioretinopaty using spectral-domain optical coherence tomography angiography

PURPOSE

The purpose of this study was to evaluate microvascular changes in the retina and choriocapillaris in central serous chorioretinopathy (CSCR) patients with resolved serous detachment using optical coherence tomography angiography (OCTA).

METHOD

49 eyes of 46 patients with CSCR were included in the study. 32 eyes of 16 age-matched controls were included in the control group. Fundus photography, fluorescein angiography, spectral-domain optical coherence tomography and OCTA were used. Choriocapillaris (CC) flow area, foveal avascular zone (FAZ), parafoveal vascular density of superficial and deep capillary plexus of the acute and chronic CSCR groups were compared with the values of the control group. Contrary to previous studies, OCTA data were obtained at a time when there was no serous detachment. This was because we aimed at minimizing erroneous measurements that might arise due to serous detachment.

RESULTS

1- The acute CSCR patients (1.705±0.292mm²) were found to have lower choriocapillaris (CC) flow area compared to the control group (2.155±0.069mm²). (P<0.001). Lower CC flow area was found in the chronic CSCR patients (1.774±0.216mm²) compared to the control group (2.155±0.069mm²) (P<0.001). 2- Chronic CSCR patients (49.27%±3.84) had a lower parafoveal density in the superficial capillary plexus compared to the control group (52.25%±2.85) (P<0.05). 3- No statistically significant difference was found between the acute CSCR group (55.07%±6.29) and chronic CSCR group (52.65%±5.18) in terms of parafoveal density in the deep capillary plexus when individually compared to the control group (53.34%±2.7). 4-A positive correlation was found between the parafoveal density in the deep capillary plexus and central foveal thickness (CFT) in the chronic CSCR group (r=0.382) (P˂0.05) 5- No statistically significant difference was found in the FAZ of the acute CSCR group (0.258±0.054mm²) and chronic CSCR group (0.342±0.124mm²) when individually compared to the control group (0.311±0.1mm²). The largest mean FAZ area was found in the chronic CSCR group.

CONCLUSION

Our study showed that the pathogenesis of CSCR is characterized by choriocapillaris and retinal microvascular changes.

CHOROIDAL NEOVASCULAR AREA AND VESSEL DENSITY COMPARISON BETWEEN TWO SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY DEVICES

PURPOSE

To compare choroidal neovascularization (CNV) area and vessel density (VD) measurements between two different swept-source optical coherence tomography angiography (SS-OCTA) devices.

METHODS

En face optical coherence tomography angiography (OCTA) images of patients affected by neovascular age-related macular degeneration were collected prospectively from two devices: Zeiss PLEX Elite 9000 (Carl Zeiss Meditec, Dublin, CA) and Topcon DRI OCT Triton SS-OCTA (Topcon, Tokyo, Japan). Choroidal neovascularization area and VD of images were measured and analyzed with ImageJ software by two readers to evaluate the agreement between two devices, with respect to different image size (3 × 3 and 6 × 6 mm) and different image segmentation (automatic vs. manual), and a Topcon equivalent Zeiss segmentation as control (i.e., the equivalent anatomical slab given by Topcon device on the Zeiss device).

RESULTS

A total of 30 eyes (30 patients) were analyzed. There was an excellent agreement between the two readers in CNV area measurements intraclass correlation coefficient >0.9 in all analyses. We found excellent agreement in CNV area measurements (manual and automatic segmentations) when comparing 3 × 3-mm or 6 × 6-mm images both for each single device and between the two devices (overall intraclass correlation coefficient > 0.9). Vessel density measurements between manual to automatic segmentation within the same device and same image size had a high intraclass correlation coefficient value, but there was a poor agreement in VD between different image sizes (3 × 3 mm vs. 6 × 6 mm) in the same device and also comparing the two devices (3 × 3 Topcon vs. 3 × 3 Zeiss; 6 × 6 Topcon vs. 6 × 6 Zeiss). There was a poor agreement between the Topcon equivalent Zeiss segmentation and all other segmentations.

CONCLUSION

There was an excellent agreement in CNV area measurements for both swept-source optical coherence tomography angiography devices in automatic and manual segmentations. However, the Topcon equivalent Zeiss segmentation was not comparable with any of the preset segmentations of Topcon and Zeiss devices. There was a poor agreement in CNV VD between different image size and different devices. For these reasons, it seems that, for accurate longitudinal analysis of VD, it is better to use the same device for each individual, even if both devices can be used interchangeably for CNV area measurements using automatic or manual segmentations.

The morphology of choroidal neovascularization in chronic central serous chorioretinopathy presenting with flat, irregular pigment epithelium detachment

Purpose

To evaluate morphological characteristics of choroidal neovascularization in chronic central serous chorioretinopathy (CSC) presenting with flat and irregular pigment epithelium detachment (FIPED) by means of innovative multimodal imaging.

Methods

In this observational cross-sectional study, we examined 10 consecutive patients affected by chronic CSC and FIPED using fluorescein angiography (FA), indocyanine-green angiography (ICGA) and optical coherence tomography angiography (OCTA). A qualitative analysis of the nature and characteristics of neovascular membrane was performed, combining available multimodal imaging and literature data.

Results

Multiple areas of retinal pigment epithelium alterations, macular hypo- and hyperpigmentation and atrophic areas were identified. Spectral domain OCT (SD-OCT) showed subretinal fluid in 80% of eyes and the ‘double layer sign’ in all patients. Late FA phases showed staining areas without leakage in all eyes; ICGA showed a hyperfluorescent plaque with surrounding hypofluorescence in 80% of patients. OCTA detected characteristic neovascular networks in the outer retina within the FIPEDs, classified as filamentous vessels with a pruned tree-like pattern in five eyes and a tangled pattern in three eyes. The choriocapillaris network showed dark areas in 80% of eyes and diffuse dark spots in all eyes.

Conclusion

Multimodal imaging completes clinical characterization of FIPEDs in chronic CSC. This study using OCTA technology describes the phenotype of hidden neovascular lesions in shape and morphology.

Early alterations in retinal microvasculature on swept-source optical coherence tomography angiography in acute central serous chorioretinopathy

The purpose of the study was to evaluate the retinal blood flow in patients with acute central serous chorioretinopathy (CSC) over an observational period of 1 month using swept-source optical coherence tomography (SS-OCTA), focusing especially on changes in the area of subretinal fluid (A-SRF). We correlated these findings with conventional indocyanine green angiography (ICGA). ICGA and SS-OCTA images were collected and analyzed of 12 eyes of 12 patients. The A-SRF was annotated and a qualitative analysis of choriocapillaris, the vessel density (VD) and perfusion density (PD) of the retinal superficial capillary plexus (SCP) and the deep capillary plexus (DCP) was performed in A-SRF and the unaffected remaining area (RA). The VD and PD in the DCP were statistically significantly lower in A-SRF than in the RA at baseline. (VD: p = 0.014; PD: p = 0.036). After 1 month, there was a statistically significant difference in the VD and PD of the DCP (VD: p = 0.015; PD: p = 0.014), and for the PD of the SCP between the A-SRF and the RA (p = 0.015), with lower values in the A-SRF. We found low perfused areas in choriocapillaris corresponding to hypofluorescent areas on ICGA. In conclusion there is a difference in VD and VD of the DCP in the area of SRF in acute CSC. These alterations may lead to a chronic change in the microvasculature and potentially to morphological changes.

RETROSPECTIVE ANALYSIS OF THE PRESENCE OF CHOROIDAL NEOVASCULARISATION USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN THE TREATMENT OF CHRONIC CENTRAL SEROUS CHORIORETINOPATHY WITH THE AID OF PHOTODYNAMIC THERAPY

PURPOSE

Analysis of the presence of choroidal neovascularization (CNV) by optical coherence tomography angiography (OCTA) in eyes treated with photodynamic therapy in a reduced dosing regimen (HD-PDT, half dose of verteporfin) for the chronic form of central serous chorioretinopathy (cCSC).

MATERIALS AND METHODS

Retrospective evaluation of OCTA findings in 54 eyes of 52 patients treated for cCSC with HD-PDT. OCTA was performed on Angioplex Zeiss Cirrus 5000 (Carl Zeiss Meditec, Dublin, CA, USA) 1 year after HD-PDT to verify changes typical of cCSC. By analyzing the results of this examination, we evaluated in particular the presence or absence of concomitant CNV and the correlation of the present CNV with the average resulting best corrected visual acuity (BCVA).

RESULTS

We analyzed the OCTA findings of 54 eyes (52 patients), in which we demonstrated the presence of concomitant CNV in 35 eyes (35.2 %). Revealed CNV occurred in 82 % below the undulating hyperreflective RPE line. In eyes with CNV, the mean BCVA (72 letters ETDRS) was statistically significantly lower than in eyes without CNV (82.7 letters ETDRS) (p = 0.0179).

CONCLUSION

In our retrospective evaluation of a group of patients who underwent HD-PDT for cCSC, we demonstrated with OCTA the presence of CNV in 35.2 % eyes 1 year after the treatment. We believe that the presence of type I CNV is a complication of the chronic disease itself rather than an adverse effect of HD-PDT.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY-GUIDED PHOTODYNAMIC THERAPY FOR ACUTE CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To compare the anatomic results of optical coherence tomography angiography (OCTA)-guided half-dose photodynamic therapy (PDT) versus indocyanine green angiography (ICGA)-guided PDT in eyes with acute central serous chorioretinopathy.

METHODS

This study is a prospective, single-center, noninferiority, double-masked, randomized, controlled clinical trial. Fifty-one eyes of 45 patients with acute central serous chorioretinopathy were recruited, and randomized to an ICGA-guided group and an OCTA-guided group. The primary outcome measures were the rates of complete subretinal fluid (SRF) resolution at 1 month and 3 months.

RESULTS

Forty-six eyes of 40 patients finished the follow-up and were analyzed. In the OCTA-guided group, the SRF was completely resolved in 13 (56.5%) eyes within 1 month and in 21 (91.3%) eyes within 3 months. In the ICGA-guided group, the SRF was resolved in 16 (69.6%) of the eyes within 1 month and in 22 (95.7%) of the eyes by 3 months. Optical coherence tomography angiography-guided PDT was demonstrated noninferior to ICGA-guided PDT for SRF resolution rate at 3 months (P = 0.016), but not at 1 month (P = 0.311) for acute central serous chorioretinopathy patients. Subretinal fluid did not recur in any of the eyes in the OCTA-guided group, but did recur in 2 eyes (8.7%) of the ICGA-guided group during the 3-month follow-up period.

CONCLUSION

Optical coherence tomography angiography-guided PDT seemed to be noninferior to ICGA-guided PDT for resolution of SRF at 3 months in eyes with acute central serous chorioretinopathy.

Comparison of Retinal Layer Thickness and Capillary Vessel Density in the Patients with Spontaneously Resolved Acute Central Serous Chorioretinopathy

We investigate retinal layer thickness and capillary vessel density (VD) in the patients with central serous chorioretinopathy (CSC) who recovered spontaneously and evaluate the correlation between the changes in these values and visual outcomes using swept-source optical coherence tomography (SS-OCT) and OCT angiography (OCTA). This retrospective case–control study included 34 eyes of 34 patients with spontaneously resolved acute CSC. The changes in retinal layer thickness and capillary VD were examined using SS-OCT and OCTA after complete resolution of subretinal fluid (SRF). The fellow eyes and 34 healthy eyes were used as controls. In the eyes with CSC, the outer retinal layer was significantly thinner than in the eyes of fellow and healthy controls. The foveal avascular zone area and VDs in the superficial and deep capillary plexus in the eyes with CSC were not significantly different from those in the eyes of fellow and healthy controls. The VD of the choriocapillaris in the eyes with CSC was significantly lower than that in the eyes of fellow and healthy controls. Correlation analyses revealed that the outer retinal layer thickness and initial visual acuity were positively correlated with the final visual acuity. Furthermore, the initial SRF area and height were negatively correlated with the outer retinal layer thickness after SRF resolution. Attenuation of outer retinal layer thickness and decreased VD of the choriocapillaris were observed in the eyes with spontaneously resolved acute CSC. The outer retinal layer thickness could be an important visual predictor of CSC.

Current Choroidal Imaging Findings in Central Serous Chorioretinopathy

Background: Central serous chorioretinopathy (CSCR) is a chorioretinal disease affecting mostly middle age males. It is marked by the serous detachment of the neurosensory layer at the macula. This review of the literature provides a framework of the current characteristic/relevant imaging findings of CSCR. Although the pathogenesis of CSCR is unclear, the choroid plays a major role and its changes are fundamental to the diagnosis and treatment of CSCR. Methods: A systematic literature search focusing on current multimodal imaging for CSCR was performed. Only articles reporting on original clinical data were selected, studies in a language other than English were included only if an English abstract was provided. Additional sources included articles cited in the references list of the first selected articles. We deduced imaging findings based on current and relevant literature on the topic. Results: We found that sub foveal choroidal thickness (SFCT) and choroidal vascularity index (CVI) were greater in eyes with acute CSCR than in eyes with chronic CSCR or normal eyes. There was increased choroidal thickness (CT) in the macula compared to peripapillary region. In healthy eyes, the highest CVI was found in the nasal region followed by the inferior, temporal, and superior quadrant. The area with the least CVI was the macula. In eyes with CSCR, 100% had asymmetric dominant vortex veins compared to 38% in normal eyes. Conclusion: Choroidal imaging has advanced the diagnosis of CSCR. This has led to numerous imaging biomarkers like CVI, CT, and hyper-reflective dots for early detection and possible prognostication of CSCR. More techniques like wide field scans and en face imaging are being employed to characterize the choroid in CSCR.

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.

Analysis of choriocapillaris perfusion and choroidal layer changes in patients with chronic central serous chorioretinopathy randomised to micropulse laser or photodynamic therapy

PURPOSE

The purpose of this study was to investigate the signal changes in choriocapillaris flow deficits and choroidal thickness changes using swept-source optical coherence tomography angiography (OCTA) following different treatments.

DESIGN

A double-blind, randomised controlled trial.

METHODS

Patients with unilateral chronic central serous chorioretinopathy (CSC) were randomised to receive subthreshold micropulse laser therapy (MLT) or half-dose photodynamic therapy (PDT). Choroidal thickness and choriocapillaris flow deficit signals were investigated.

RESULTS

Eighteen patients were randomised into the MLT group and 15 patients into the PDT group. Areas with flow deficit signals were identified in all baseline OCTA images of the choriocapillaris, with mean areas of 0.420 and 0.465 mm² in the MLT and PDT groups, respectively. These flow deficit signal areas were significantly reduced at 6 months (p=0.011) in the MLT group and at 3 months (p=0.008) in the PDT group. Patients from the PDT group were shown to have smaller flow deficit areas than patients from the MLT group at all time points after treatment (p=0.001, analyses of variance). The mean choroidal volume of the fovea showed a significant reduction at 1 month (p=0.003), 3 months (p=0.199) and 6 months (p=0.006) in the PDT group.

CONCLUSION

The flow deficit areas identified in the choriocapillaris layer may suggest possible relative choroidal ischaemia. With measurement of choroidal volume reduction and faster rates of flow deficit area change, PDT has a stronger effect than MLT in promoting choriocapillaris recovery.

Outer retinal tubulations in central serous chorioretinopathy associated with choroidal neovascularisation

AIM

To report the prevalence and characteristics of outer retinal tubulations in eyes with choroidal neovascularisation associated with chronic central serous chorioretinopathy.

METHODS

Retrospective case series which included evaluation of optical coherence tomography B-scans and enface optical coherence tomography scans of eyes with choroidal neovascularisation associated with chronic central serous chorioretinopathy. The characteristics of outer retinal tubulations such as number, shape and distribution were noted. The location of the outer retinal tubulations was correlated with autofluorescence.

RESULTS

Outer retinal tubulations were detected in 9.1% of the eyes (9 out of 87 eyes). The average number of outer retinal tubulations in each eye was 4.7 ± 4.6. Spheroidal outer retinal tubulations were more common than the branching tubules. Although presence of outer retinal tubulations was mostly associated with inactive disease, two eyes had coexistent subretinal fluid.

CONCLUSION

Outer retinal tubulations associated with choroidal neovascularisation in chronic central serous chorioretinopathy, though less frequent, when present are more numerous, mostly extrafoveal and more spheroidal in shape compared to outer retinal tubulations associated with age-related macular degeneration and other degenerative conditions.

Swept-source optical coherence tomography angiography alleviates shadowing artifacts caused by subretinal fluid

Purpose

To characterize the choriocapillaris (CC) structure in relation to subretinal fluid (SRF) as a possible systematic error source using spectral domain (SD-OCTA) compared to swept-source optical coherence tomography angiography (SS-OCTA).

Methods

This is a prospective case-control study of 23 eyes. Ten patients with acute central serous chorioretinopathy (CSC), three patients with partial macular-off retinal detachment (RD) and ten healthy, age-matched controls were included. Abnormal CC decorrelation signals were quantitatively compared in CSC and controls by means of custom image processing. To investigate the influence of SRF on CC OCTA signal, the extent of SRF was quantified with a macular heatmap and compared with the corresponding OCTA signal of the CC.

Results

SS-OCTA yielded a more homogeneous OCTA signal from the CC than SD-OCTA, offering less signal dispersion and variability in healthy and diseased eyes. Both devices demonstrated CC signal voids in CSC and RD, respectively. In CCS, the voids were predominantly located in the area with SRF. Compared to SD-OCTA, SS-OCTA delivered a more homogenous OCTA signal and reduced signal voids in the CC underneath SRF in both RD and CSC (CSC, 7.6% ± 6.3% vs, 19.7% ± 9.6%, p < 0.01). Despite this significant attenuation of signal voids, SS-OCTA continued to reveal signal voids below SRF and more pixels with reduced OCTA signals in CSC patients compared to controls (7.6% ± 6.3%, 0.1% ± 0.1%, p < 0.0001).

Conclusion

Understanding OCTA artifacts is critical to ensure accurate clinical evaluations. In this study, we describe the presence of SRF as an important shadow-causing artifact source for CC OCTA analysis which can be mitigated but not completely eliminated by employing SS-OCTA.

Optical coherence tomography angiography of flat irregular pigment epithelial detachments in central serous chorioretinopathy

Background

To identify and analyse the character and relationship between flat irregular pigment epithelial detachment feature (FIPED), choroidal thickness and choroidal neovascularisation (CNV) network seen on optical coherence tomography angiography (OCTA) in eyes with central serous chorioretinopathy (CSCR) in Chinese patients.

Method

In the present study, 152 eyes of 144 Chinese patients, who were previously diagnosed with CSCR, were retrospectively studied. Patients’ baseline characteristics, the course of CSCR, best-corrected visual acuity, the pattern of CNV on OCTA, FIPED and choroidal thickness detected by enhanced depth imaging-OCT (EDI-OCT) were analysed.

Results

It was disclosed that 7.23% of CSCR patients had CNV. Age and the course of CSCR were found to be correlated with the occurrence of CNV. Among the eyes with CNV network (11 eyes), 100% of them had FIPED, whereas, among the eyes without CNV (141 eyes), 18.04% had FIPED. The maximum width and en-face area of PED were greater in the CNV group compared with that in the non-CNV group (p<0.001). It also was revealed that female gender and a poor vision were risk factors for CNV in eyes with CSCR. The choroidal thickness detected by EDI-OCT was also statistically significant between eyes with CNV and eyes without CNV. The patients who have CNV complicated with FIPED are susceptible to have low vision.

Conclusion

The present research demonstrated that the majority of CNV cases were linked to FIPED, and the thinner thickness of choroid. The greater width and en-face area of PED may point towards the presence of an underlying CNV network.

TWELVE-MONTH EFFICACY OF INTRAVITREAL BEVACIZUMAB INJECTION FOR CHRONIC, ATYPICAL, OR RECURRENT CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To evaluate intravitreal bevacizumab (IVB) injection efficacy for the treatment of chronic, atypical, or recurrent central serous chorioretinopathy (CSC).

METHODS

Clinical data from 77 eyes of 71 patients with chronic, atypical, or recurrent CSC treated with IVB were retrospectively analyzed. After initial 6-weekly IVB administration until no subretinal fluid remained at the fovea, additional as-needed IVBs were administered, based on optical coherence tomography findings. Best-corrected visual acuity and central retinal thickness (CRT) were analyzed at baseline and 3, 6, 9, and 12 months after initial IVB.

RESULTS

The significant improvement of baseline logarithm of minimum angle of resolution best-corrected visual acuity and CRT at 3 months (both P < 0.001) was maintained throughout the 12-month follow-up period. Best-corrected visual acuity improved significantly in patients with chronic and recurrent CSC, at all time points (all P < 0.05), but not in patients with atypical CSC. The CRT reduction was significant in all subgroups during the follow-up period (all P < 0.05). Definite leakage on initial fluorescein angiography correlated with improved reduction in CRT (P = 0.039).

CONCLUSION

As-needed optical coherence tomography-based IVB was effective for reducing CRT in patients with chronic, atypical, or recurrent CSC, and for vision improvement in chronic and recurrent CSC over the 1-year follow-up period.

CHANGES IN CHORIOCAPILLARIS, SATTLER, AND HALLER LAYER THICKNESSES IN CENTRAL SEROUS CHORIORETINOPATHY AFTER HALF-FLUENCE PHOTODYNAMIC THERAPY

PURPOSE

To determinate the variation in thickness of the individual choroidal layers in patients with central serous chorioretinopathy treated with half-fluence photodynamic therapy.

METHODS

Twenty-two eyes were evaluated with spectral-domain optical coherence tomography. The images were taken before photodynamic therapy, 3 months, and 6 months after the treatment. Two investigators performed these measurements: 1) choroidal thickness (CT), 2) Haller layer thickness, defined as the most external layer containing a 100-μm vessel, and 3) choriocapillaris + Sattler layer (C&S). Nine measurements were taken in the macular region.

RESULTS

Choroidal thickness before photodynamic therapy was 471.8 µm ± 145.8. The Haller layer was 358.4 µm ± 122.6, and C&S was 114.3 µm ± 27.8. At 3-month follow-up, CT was 441.1 µm ± 150.7, Haller layer 348.8 µm ± 127.6, and C&S 92.4 µm ± 27.9. At 6-month follow-up, CT was 420.4 µm ± 118.4, Haller layer 331.8 µm ± 97.2, and C&S 89.5 µm ± 28.0. Using a multilevel mixed-effects linear regression, CT was found to be reduced at both 3 months (P < 0.03) and at 6 months (P < 0.001), Haller layer showed no significant reduction at 3 months (P = 0.483) or at 6 months (P = 0.055), and C&S showed reduction at 3 months (P < 0.001) and at 6 months (P < 0.001). Fellow nonaffected eyes showed no statistical variation at 3-month and 6-month follow-up.

CONCLUSION

Reduction in CT in patients affected by central serous chorioretinopathy after half-fluence photodynamic therapy occurs primarily in the choriocapillaris and medium diameter vessel layers of the choroid in a short- and medium-term follow-up.

Association of Irregular Pigment Epithelial Detachment in Central Serous Chorioretinopathy with Genetic Variants Implicated in Age-related Macular Degeneration

We evaluated phenotype and genotype correlation of central serous chorioretinopathy (CSC) patients with or without irregular pigment epithelial detachment (PED) on optical coherence tomography (OCT). For CSC, a flat, irregular protrusion of retinal pigment epithelium (RPE) with hyper-reflective sub-RPE fluid on OCT was defined as an irregular PED. Participants were classified into 5 subgroups; (1) total CSC (n = 280) (2) CSC with irregular PED (n = 126) (3) CSC without irregular PED (n = 154) (4) typical choroidal neovascularization (CNV) (n = 203) and (5) polypoidal choroidal vasculopathy (PCV) (n = 135). Ten known major AMD-associated single-nucleotide polymorphisms (SNPs) were analyzed. Age, sex adjusted logistic regression was performed for the association between subgroups. Association analysis between CSC without irregular PED and CNV revealed that significant difference for rs10490924 in ARMS2, rs10737680 in CFH, and marginally significant difference for rs800292 in CFH. Between CSC without irregular PED and PCV, rs10490924, rs10737680, and rs800292 were significantly different. In contrast, CSC with irregular PED and CNV revealed no SNP showing significant difference. Between CSC with irregular PED and PCV, only rs10490924 was significantly different. CSC with irregular PED and CSC without irregular PED revealed significant difference for rs800292, and marginal difference for rs10737680. These findings suggest CSC patients with irregular PED are genetically different from those without irregular PED and may have genetic and pathophysiologic overlap with AMD patients.

OCTA characterisation of microvascular retinal alterations in patients with central serous chorioretinopathy

PURPOSE

This study aimed to describe the characteristics of microvascular retinal alterations in eyes with chronic central serous chorioretinopathy (CSC) employing optical coherence tomography angiography (OCTA) analysis.

METHODS

We collected data from 472 eyes with chronic CSC from 336 patients who had OCTA obtained. Each OCTA image was graded by two readers to assess the presence of microvascular retinal alterations, including regions of vascular rarefaction/retinal hypoperfusion, enlargement of the foveal avascular zone (FAZ) and presence of telangiectasias or microaneurysms. Volume spectral domain optical coherence tomography (SD-OCT) scans were obtained through the macula and the OCT was correlated with the OCTA findings in eyes with retinal vascular alterations.

RESULTS

OCTA displayed microvascular retinal alterations in 18 out of 474 eyes (3.6%) from 14 patients (13 male and 1 female; mean±SD age was 54.7±11.1 years). One eye displayed the presence of retinal telangiectasias, while 17 out of 18 eyes were graded as having areas of retinal vascular rarefactions, and 3 out of 17 eyes were also characterised by an enlargement of the FAZ. The parafoveal region was the location most involved by retinal vascular changes (66,7%), followed by foveal (22,2%) and perifoveal (11.1%) regions, respectively.

CONCLUSION

Although CSC is known to represent a choroidal disorder, retinal vascular alterations may be present in these eyes and OCTA may represent a useful tool to identify and describe them.

Longitudinal Analysis of the Choriocapillaris Using Optical Coherence Tomography Angiography Reveals Subretinal Fluid as a Substantial Confounder in Patients with Acute Central Serous Chorioretinopathy

INTRODUCTION

To describe the influence of subretinal fluid (SRF) in analysis of the flow signal from the choriocapillaris (CC) via optical coherence tomography angiography (OCTA) in patients with acute central serous chorioretinopathy (CSC).

METHODS

Observational, longitudinal, cross-sectional case-control study. Twenty-three eyes of 22 patients with acute CSC were compared with 20 eyes of 20 healthy controls. OCTA images (AngioPlex®, Zeiss) were recorded at baseline and follow-up examination and automatically quantified using an image-processing algorithm. Abnormal CC decorrelation signals (increased and decreased flow, IF and DF) were quantified using a custom image-processing algorithm. To analyze the spatial correlation between SRF and OCTA, CC signal heat-map images containing macular thickness information were used.

RESULTS

Choriocapillaris flow alterations were significantly more pronounced at baseline than at follow-up examination in patients with acute CSC and resolving SRF (IF: p < 0.002; DF: p < 0.003). The extent of SRF correlated significantly with the abnormal CC decorrelation signals when comparing baseline with follow-up examinations (IF: rho = 0.56, p < 0.005; DF: rho = 0.64, p < 0.001). In particular, the reduced OCTA flow signal in the area occupied by SRF at baseline disappeared at follow-up examination (p < 0.02). In comparison with controls, CSC patients with complete resorption of SRF continued to show a reduced OCTA flow signal in the CC (p < 0.008).

CONCLUSIONS

The temporospatial association between SRF and reduced OCTA signal from the CC demonstrates that fluid might be a significant confounder for OCTA analysis in patients with CSC. CSC patients with complete absorption of the SRF at follow-up, however, show persistently reduced CC flow signals.

Optical coherence tomography angiography versus fluorescein angiography in diagnosing choroidal neovascularization in chronic central serous chorioretinopathy

Purpose

Diagnosis of choroidal neovascular membrane (CNVM) is difficult in chronic central serous chorioretinopathy (CCSC) due to overlapping features of both on conventional dye angiography. Optical coherence tomography angiography (OCTA) allows a quick and noninvasive detection of CNVM in these eyes. We compared the fluorescein angiography (FA) features of CNVM with those of OCTA to assess the role of FA in detecting CNVM in CCSC eyes.

Methods

Patients with CCSC undergoing FA, spectral domain (SD)-OCT, and OCTA were identified (March 2015-June 2015). Four retina specialists individually reviewed FA images (without OCTA and SD-OCT) to determine whether CNVM was present. In parallel, two other retina specialists reviewed all images (FA/SD-OCT/OCTA) for CCSC features and confirmed whether CNVM was present using OCTA as the gold standard. The inter- and intraobserver variability was measured by Kappa (k) coefficient. The FA features of CNVM were compared and correlated with those on OCTA.

Results

Of 43 eyes (26 patients, mean age 45.6 ± 8.5 years, all males), a definite CNVM (detected by OCTA) was present in nine (20.9%) eyes. FA alone detected CNVM in 13 (30.2%) eyes [sensitivity 44.4% (95% confidence interval (CI): 11.9-76.9), specificity 73.5% (95% CI: 58.7-88.3), positive and negative predictive values 30.8% and 83.3%, respectively, and accuracy 67.44% (95% CI: 53.4-81.4)].

Conclusion

When compared with OCTA, the FA was unable to characterize CNVM in CCSC (with a very low sensitivity and moderate specificity) as none of the specific dye leakage patterns on FA correlated with CNVM seen on OCTA, limiting its usefulness and accuracy in detecting CNVM in these eyes.

Multicolor imaging in central serous chorioretinopathy - a quantitative and qualitative comparison with fundus autofluorescence

Central serous chorioretinopathy (CSCR) is characterised by choroidal hyperpermeability which results in neurosensory detachments (NSD) along with numerous retinal pigment epithelium (RPE) alterations such as RPE atrophy. Fundus autofluorescence (FAF) demonstrates the functionality of the RPE while multicolor imaging(MCI), by means of its three incident wavelengths, provides insight into clinical changes at various levels of the retina and choroid in CSCR. This study compares various clinical findings in CSCR (NSD, subretinal deposits, RPE atrophy, pigment epithelial detachments (PED) and pachyvessels) on the above mentioned imaging modalities both qualitatively and quantitatively. MCI showed higher mean cumulative area of RPE atrophic patches (6.3 ± 6.02 vs 5.7 ± 5.7 mm2, p = 0.046), PED (1.3 ± 1.4 vs 1.1 ± 1.2 mm2, p = 0.068) and NSD (17.2 ± 11.4 vs 15.7 ± 10.7 mm2, p = 0.033). MCI demonstrated better defined lesions (NSD, PED, RPE atrophy) and more number of eyes with PED and pachyvessels in comparison to FAF.Both investigations had a 100% sensitivity in detecting NSD and 100% specificity for sub retinal deposits. This study demonstrates the ability of MCI to quantitatively and qualitatively define various clinical features in CSCR and the advantages it holds over FAF. MCI can hence be considered as a useful imaging modality in documenting and monitoring various structural changes in eyes with CSCR.

Impairment of visual acuity and retinal morphology following resolved chronic central serous chorioretinopathy

Purpose

Central serous chorioretinopathy (CSCR) is a complex ocular entity that, in its chronic form, can lead to serious visual impairment and morphological damage to the retina.

The aim of the current retrospective study was to evaluate the damage present after long-standing but resolved central serous chorioretinopathy and refer it to healthy individuals. Correlations between measurable factors—for example, duration of the disease, baseline retinal morphological parameters, or patient age and/or their degree of impairment—were also assessed.

Materials and methods

The study group consisted of thirty-two eyes (13 female and 19 male, mean age 49.6 years SD +/− 10.5) with chronic central serous chorioretinopathy (mean duration 18.9 months SD +/− 15.4) in which complete resolution of subretinal fluid was achieved after subthreshold micropulse laser treatment. Inclusion criterion was a lack of subretinal fluid within the whole area of the central retina scanned by the spectral domain optical coherence tomography. The group was extracted out of 51 cases of chronic CSCR that were treated with that method. They were analyzed according to final best-corrected visual acuity and retinal morphological parameters as measured by spectral optical coherence tomography with angiography option (OCTA). Results were compared with the outcomes of a control group, which consisted of 40 eyes of healthy individuals with full distance visual acuity (0.0 logMAR, 1.0 Snellen) never treated with subthreshold micropulse laser. Statistical analysis included regarding correlation between final visual acuity and final central retinal thickness and retinal and functional parameters prior to treatment.

Results

Final best-corrected visual acuity after chronic central serous chorioretinopathy was 0.23 logMAR (0.6 Snellen) and central retinal thickness was 39.32 μm smaller than in controls. No correlation was found between final visual acuity and retinal thickness and duration of the disease, patient age, and baseline morphological retinal parameters. OCTA scans revealed impaired choriocapillaries flow signal even following resolution of the disease.

Conclusion

Chronic central serous chorioretinopathy is a potentially damaging clinical entity that results in serious visual impairment, retinal thinning, and choroidal flow defects. Further research is needed to determine precisely the timepoint of this damage.

Immediate effects of smoking on optic nerve and macular perfusion measured by optical coherence tomography angiography

The aim of this study was the assessment of the relationship between cigarette smoking and optic nerve and macular vessel density measured by optical coherence tomography angiography. We examined 30 eyes from 30 healthy habitual smokers. The examination was performed using a high-speed and high-resolution spectral-domain optical coherence tomography RTVue XR Avanti with AngioVue (Optovue, Fremont, CA, USA) with a split-spectrum amplitude-decorrelation angiography algorithm. Blood pressure, heart rate, vascular density in the area of the optic nerve head (4.5*4.5 mm) and vascular density with the foveal avascular zone in the central macula (3.0*3.0 mm) were measured and analyzed before, immediately after and 30 minutes after cigarette smoking. Quantitative measurements were carried out by AngioAnalytics Phase 7 software. Immediately after smoking both heart rate and blood pressure increased significantly (p < 0.001) compared to values before smoking and then significantly decreased after 30 minutes comparing to values obtained right after smoking (p < 0.001). The mean area of the foveal avascular zone, parafoveal vessel density, and peripapillary vessel density did not change significantly. Our results show no immediate influence of smoking on vessel density parameters measured by specific OCTA machine in healthy habitual smokers.

Anterior Segment Applications of Optical Coherence Tomography Angiography

Purpose: To review the current literature regarding optical coherence tomography angiography (OCT-A) applications in the anterior segment. Methods: A literature search was performed for terms including OCT-Angiography, anterior segment, cornea, conjunctiva, iris, applications and use in ophthalmology. Results: Fifteen studies were identified, 14 in human subjects. Studies with OCT-A of the conjunctiva, episclera, cornea, and iris were identified, some with normal eyes imaged and others with various pathologies. Most of these studies imaged corneal neovascularization. Three studies described protocols used for image acquisition, one of which was referenced by two later papers. Conclusions: OCT-A is a noninvasive technology with recent applications in the anterior segment. Several pilot studies have been performed on various anterior segment structures and disease states however standardization of image acquisition techniques is still needed. Future imaging could allow noninvasive and serial monitoring of pathology as well as recurrence after therapeutic intervention.

Mapping diurnal variations in choroidal sublayer perfusion in patients with idiopathic epiretinal membrane: an optical coherence tomography angiography study

Background

Optical coherence tomography angiography (OCTA) is a non-invasive tool for imaging and quantifying the choroidal vasculature and perfusion state. In this index study, OCTA was used to investigate diurnal changes in choroidal sublayer perfusion in eyes with idiopathic epiretinal membrane (ERM) and to identify impacting factors.

Methods

A prospective study was conducted on volunteers with symptomatic ERM, each of whom underwent repeated measurements of subfoveal choroidal thickness (SFCT) using enhanced-depth imaging optical coherence tomography and perfusion of choroidal vascular sublayers using OCTA at 7 a.m., 12 p.m., 4 p.m., and 8 p.m. Possible interactions between diurnal variations and other factors, such as gender and age, were evaluated.

Results

A total of 21 eyes of 21 participants (mean age 72.43 ± 7.06 years) were analysed. A significant pattern of diurnal variation was observed for SFCT (p = 0.008) as well as perfusion of Haller's layer (HLP, p = 0.001). SFCT and HLP both demonstrated a quadratic relation to time of the day, decreasing from morning to afternoon, before increasing again in the evening. No significant differences with regard to gender or age were detectable.

Conclusion

OCTA-based analysis of choroidal sublayer perfusion demonstrated significant diurnal variations in patients with symptomatic ERM, which are quite different from changes reported in healthy eyes. Therefore, it is important to account for time of day, when comparing longitudinal OCTA data.

Clinical evaluation of neovascular and non-neovascular chronic central serous chorioretinopathy (CSC) diagnosed by swept source optical coherence tomography angiography (SS OCTA)

PURPOSE

To evaluate the clinical characteristics of eyes with chronic central serous chorioretinopathy based on swept source optical coherence tomography angiography (SS OCTA).

METHODS

Twenty-nine eyes presenting with chronic central serous chorioretinopathy (CSC) were examined with the Topcon SS OCTA, using the DRI optical coherence tomography (OCT) Triton machine, and were classified as neovascular or non-neovascular CSC depending on whether a vascular pattern was detected in the outer retina on OCT angiogram. The two groups were compared based on the following clinical findings: best corrected distance and reading visual acuity (BCDVA, best corrected reading acuity (BCRA)), rate of subretinal fluid, intraretinal fluid, hyperreflective flat pigment epithelial detachment (PED), and serous PED.

RESULTS

Of 29 eyes with chronic CSC, 10 (34.5%) showed a neovascular pattern, suggesting neovascular CSC, in the outer retina of SS OCTA. Eyes with neovascular CSC showed a significantly worse initial and final BCDVA, with a mean value of 0.39 ± 0.20 logMAR (Snellen equivalent 20/49) and 0.33 ± 0.36 logMAR (Snellen equivalent 20/43), compared to eyes with non-neovascular CSC with a mean value of 0.16 ± 0.15 logMAR (Snellen equivalent 20/29) and 0.04 ± 0.11 logMAR (Snellen equivalent 20/22) (p < 0.05), respectively. Final mean BCRA was 0.14 ± 0.20 logRAD for non-neovascular CSC compared to 0.34 ± 0.28 logRAD (p = 0.031) for neovascular CSC. The mean time between the first and final visits was 3 years for both groups. The mean anti-VEGF injection rate was 6.4 for neovascular CSC and 2.9 for non-neovascular CSC, whereas 26.3% of non-neovascular CSC eyes had an additional half fluence photodynamic therapy (PDT).

CONCLUSION

SS OCTA provides a promising CNV detection rate, secondary to chronic CSC, in a clinical setting. Neovascular CSC is associated with a worse outcome in terms of visual and reading acuity compared to non-neovascular CSC.

Retinal Vascular Reactivity in Central Serous Chorioretinopathy

Purpose

To investigate the retinal vascular response to the isometric exercise in patients with central serous chorioretinopathy (CSCR) by using optical coherence tomography angiography (OCT-A).

Methods

This was a multicenter case-control study including 35 CSCR patients and 25 age-matched healthy controls. All subjects underwent macular OCT-A scans in resting conditions and during a handgrip isometric exercise. Hemodynamic data, such as systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and ocular perfusion pressure (OPP), were recorded at baseline and during the stress test. Qualitative and quantitative assessments of the retinal superficial capillary plexus (SCP) and deep capillary plexus (DCP) were performed on OCT angiograms. The results obtained in CSCR patients were then compared with those of healthy subjects.

Results

At baseline and during the isometric exercise, SBP, DBP, MAP, and OPP were significantly higher (P < 0.05) in CSCR patients than controls. Under stress conditions, the hemodynamic values significantly increased both in patients and controls. The qualitative and quantitative analyses of OCT angiograms evidenced an increased blood flow during exercise only in CSCR patients. Baseline vascular perfusion density (VPD) values of SCP and DCP were significantly lower (P < 0.05) in CSCR cases than in healthy subjects. A significant increase (P < 0.05) of VPD values was obtained during the exercise in CSCR patients and not in controls.

Conclusions

Unlike healthy subjects, retinal blood flow in patients with CSCR seems affected by rapid increases in BP and OPP. Our study suggests that the autoregulatory mechanisms controlling retinal microcirculation are not entirely able to counteract overperfusion in patients with CSCR.