Risk Factors for Persistent or Recurrent Central Serous Chorioretinopathy

Central serous chorioretinopathy: An evidence-based treatment guideline

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

Assessment of metacognition and retinal optical coherence tomography findings in shift workers

It is known that working in the shift system, especially the night shift, affects physical, mental, and social well-being. We investigated the changes in the inner retinal layers and choroidal layer of the eyes of nurses working night and day shifts using optical coherence tomography (OCT). We also explored the effect of night shift work on metacognition and the relationships between these variables. A total of 79 nurses participated in the study, of whom 40 worked night shifts. The researcher gave the participants sociodemographic information and the Metacognition Questionnaire-30 (MCQ-30) form. Retinal nerve fiber layer (RNFL) thickness, ganglion cell layer (GCL) thickness, inner nuclear layer (INL) thickness, inner plexiform layer (IPL) thickness, central macular thickness (CMT), and subfoveal choroidal thickness (SFCT) were measured with OCT. It was found that the level of metacognitive activity associated with cognitive confidence was higher (p = 0.044) for nurses who worked night shifts and that the level of metacognitive activity associated with cognitive awareness was lower (p = 0.015) for nurses who worked night shifts. RNFL-nasal superior (NS) thickness was lower in night shift workers than the day shift group (p = 0.017). Our study revealed significant relationships between metacognition and the OCT findings among night and day shift workers. Our study revealed that RNFL measurements and metacognitive activity may differ and there may be a relationship between these parameters in nurses who work shifts. Further research is needed to investigate the long-term effects of night shift work on retinal health.

Changes in Aqueous Concentrations of Various Cytokines after Intravitreal Bevacizumab Injection for Chronic Central Serous Chorioretinopathy

PURPOSE

This study aimed to investigate changes in cytokine levels after intravitreal bevacizumab injection in patients with chronic central serous chorioretinopathy (CSC).

METHODS

In a prospective interventional trial, 12 eyes from 12 patients with chronic CSC and six eyes from six patients who underwent cataract surgery were included as controls. Patients diagnosed as with CSC received a single intravitreal injection of bevacizumab (1.25 mg/0.05 mL). Aqueous humor samples were collected from the patients and controls. Best-corrected visual acuity and foveal thickness were evaluated, and aqueous samples were obtained before and 4 weeks after injection. The aqueous concentrations of interleukin (IL)-6, IL-8, interferon-induced protein (IP)-10, monocyte chemotactic protein (MCP)-1, platelet-derived growth factor (PDGF)-AA, and vascular endothelial growth factor (VEGF) were measured using a multiplex bead assay.

RESULTS

After injection, the foveal thickness decreased significantly from 328.08 μm (range, 210-477 μm) to 283.91 μm (range, 168-356 μm; p = 0.048), but the best-corrected visual acuity was not significantly different (p = 0.066). The aqueous levels of IL-8 increased significantly from 3.3 pg/mL (range, 1.5-8.3 pg/mL) to 4.7 pg/mL (range, 2.2-11.6 pg/mL) at 4 weeks after the injection (p = 0.046). The aqueous levels of VEGF decreased significantly from 31.4 pg/mL (range, 17.0-53.3 pg/mL) to 15.2 pg/mL (range, 7.7-21.5 pg/mL; p < 0.01). No significant changes in levels of IL-6 (p = 0.455), IP-10 (p = 0.055), MCP-1 (p = 0.076), and PDGF-AA (p = 0.339) were noted 4 weeks after injection.

CONCLUSIONS

In this study we found intravitreal bevacizumab injection decreased VEGF and increased IL-8 in the eyes of patients with chronic CSC. This study suggests the possibility that the pathogenesis of CSC may be related to abnormal circulation of the choroidal blood vessels through VEGF and IL-8 cytokine level changes.

Functional Outcomes and Safety Profile of Trans-Foveal Subthreshold Micropulse Laser in Persistent Central Serous Chorioretinopathy

Our study evaluated visual function changes after subthreshold micropulse laser (SML) treatment in persistent central serous chorioretinopathy (CSC) and SML safety profile. We conducted a prospective study including 31 fovea-involving CSC patients. The natural course was observed for the first 3 months, SML was performed at 3 months, and SML effectiveness was observed at 6 months. At all three clinical visits, optical coherence tomography (OCT), best corrected visual acuity (BCVA), contrast sensitivity (CS) in five spatial frequencies (1.5, 3.0, 6.0, 12.0, and 18.0 cycles per degree (cpd)), microperimetry (MP), and multifocal electroretinography (mfERG) were performed. The SML safety profile was evaluated with functional and morphological parameters. In the cohort of all CSC patients treated with SML, the statistically significant average improvement was observed in BCVA (p = 0.007), CS-1.5 (p = 0.020), CS-3.0 (p = 0.050), CS-12.0 (p < 0.001), CS-18.0 (p = 0.002), CS (CS-A) (p < 0.001), MP in the central ring (MP-C) (p = 0.020), peripheral ring (MP-P) (p = 0.042), and average retinal sensitivity (MP-A) (p = 0.010). After the SML treatment, mean changes in mfERG amplitudes and implicit times in our cohort were not statistically significant. No morphological or functional adverse effects of SML treatment were observed. SML treatment in persistent CSC episodes leads to significant functional improvement and has an excellent safety profile.

Longitudinal follow-up and outcome analysis in central serous chorioretinopathy

OBJECTIVES

To analyse the longitudinal changes in visual acuity and risk factors for recurrence or development of choroidal neovascularisation (CNV) in eyes with acute or chronic central serous chorioretinopathy (CSCR).

METHODS

This was a retrospective, multicentric, longitudinal, observational study done in patients with a diagnosis of unilateral or bilateral CSCR and having at least 4 years of follow-up between the years 1999 and 2020. Kaplan-Meier curves were used for assessing cumulative risks. Multivariate logistic, linear and cox regression models were used for risk factor analyses. The trend in visual acuity, cumulative risks of recurrence and CNV formation was analysed.

RESULTS

A total of 117 out of 175 eyes (66.8%) had stable or improvement in vision at last follow-up, while 24 eyes had more than/equal to 3 line loss of vision. Four eyes (7.7%) with acute CSCR at initial presentation developed features of chronic CSCR at the final presentation. Thirty-seven eyes had recurrence during the follow-up with a 10-year cumulative recurrence rate of around 30%. On Cox proportional hazard regression analysis, history of previous treatment and male gender (p = 0.03) were associated with a lower risk of recurrence. Twenty-four developed de novo CNV by the end of follow-up and higher age (p = 0.001) and a higher number of recurrences (p = 0.05) were associated with a higher risk of early de novo CNV formation. The cumulative 10-year CNV development rate was 17.4%.

CONCLUSION

A non-temporal relationship between acute and chronic CSCR was seen. Previous treatment, smoking and baseline RPE abnormality affected recurrence of SRF or CNV formation.

Biomarkers predicting central serous chorioretinopathy episode persistence

PURPOSE

The purpose of this study was to identify biomarkers at presentation that are associated with a persistent central serous chorioretinopathy (CSC) episode.

METHODS

The prospective study included 35 patients with an acute CSC episode. Potential clinical and imaging biomarkers were evaluated at baseline and 3 months from the episode onset. As biomarkers age, sex, steroid use, episode recurrence, central retinal thickness (CRT), macular volume (MV), choroidal thickness (CT), pigment epithelial detachment (PED) height, and width, number of retinal hyperreflective foci (HF), leakage pattern, and area of retinal pigment epithelial (RPE) alterations were investigated.

RESULTS

At 3 months from the CSC episode onset, spontaneous resolution occurred in 19 patients, while 16 patients had a persistent CSC episode. The group of patients with a persistent episode was statistically significantly associated with female sex (p = 0.032), older age (p = 0.015), wider PED (p = 0.005), and higher number of HF (p = 0.02). Moreover, this group of patients had a significant association with thinner choroid and diffuse RPE alterations as a pair (p = 0.008).

CONCLUSIONS

Older and female CSC patients with wider PED, increased number of HF, thinner choroid, and diffuse RPE alterations at presentation are inclined to episode persistence and could benefit from earlier treatment.

Diagnostic and Therapeutic Challenges in a Patient with Radiation Retinopathy Complicated by Corticosteroid-Induced Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSC) is a common chorioretinal disorder. It has been postulated that impaired retinal pigment epithelium and hyperpermeability of the choriocapillaris may be involved in the development of CSC, but the exact pathomechanism has not been established. We report an unusual case of a middle-aged man who developed CSC after triamcinolone acetonide injection for macular edema. Edema developed as a late complication of radiation retinopathy after brachytherapy for childhood retinoblastoma. Steroid treatment is an important risk factor for CSC, but the underlying causative mechanisms have not been fully elucidated. It is important to increase the awareness of this link among clinicians who prescribe exogenous corticosteroids, irrespective of the route of administration.

Clinical Characteristics of Pregnancy-Associated Central Serous Chorioretinopathy in the Chinese Population

Purpose

To investigate the clinical characteristics of pregnancy-associated central serous chorioretinopathy (CSC) in the Chinese population.

Methods

The medical records of patients diagnosed with pregnancy-associated CSC from February 2012 to October 2019 were retrospectively reviewed. Best-corrected visual acuity (BCVA), symptom duration, pregnancy-related medical information, and optical coherence tomography (OCT) images were collected.

Results

Nine patients (11 eyes) were included. Five women were in their first pregnancy and four were in their second pregnancy, two of whom experienced CSC in their first pregnancy as well. The mean age was 35.00 ± 3.97 years. The mean symptom duration at the initial visit was 19.73 ± 13.65 days. The mean gestational age at the time of development of CSC was 27.11 ± 2.09 weeks. The mean BCVA (logarithm of the minimum angle of resolution (logMAR)) at the initial visit was 0.36 ± 0.18 (Snellen 20/45, range 20/100–20/25). All eyes showed subretinal hyperreflective fibrin on OCT images at the initial visit. Four patients (4 eyes) were lost to follow-up before fluid resolution. The mean BCVA at the final visit was logMAR 0.10 ± 0.15 (Snellen 20/25, range 20/50–20/20)). One eye in the oldest patient had persistent subretinal fluid at 26 months postpartum. The subretinal fluid resolved completely after half-dose photodynamic therapy (PDT); however, the ellipsoid zone at the fovea remained discontinuous at 30 months after half-dose PDT. The remaining six eyes all showed spontaneous resolution of subretinal fluid around delivery and regained intact ellipsoid zone.

Conclusions

Pregnancy-associated CSC in Chinese developed mostly in the third trimester and usually recovered spontaneously around delivery with good final visual acuity. However, patients might require long-term follow-up until complete resolution of subretinal fluid and to detect recurrences. Half-dose PDT can be administered early if there is little reduction in the amount of subretinal fluid after delivery.

Predicting Central Serous Chorioretinopathy Recurrence Using Machine Learning

Purpose: To predict central serous chorioretinopathy (CSC) recurrence 3 and 6 months after laser treatment by using machine learning.

Methods: Clinical and imaging features of 461 patients (480 eyes) with CSC were collected at Zhongshan Ophthalmic Center (ZOC) and Xiamen Eye Center (XEC). The ZOC data (416 eyes of 401 patients) were used as the training dataset and the internal test dataset, while the XEC data (64 eyes of 60 patients) were used as the external test dataset. Six different machine learning algorithms and an ensemble model were trained to predict recurrence in patients with CSC. After completing the initial detailed investigation, we designed a simplified model using only clinical data and OCT features.

Results: The ensemble model exhibited the best performance among the six algorithms, with accuracies of 0.941 (internal test dataset) and 0.970 (external test dataset) at 3 months and 0.903 (internal test dataset) and 1.000 (external test dataset) at 6 months. The simplified model showed a comparable level of predictive power.

Conclusion: Machine learning achieves high accuracies in predicting the recurrence of CSC patients. The application of an intelligent recurrence prediction model for patients with CSC can potentially facilitate recurrence factor identification and precise individualized interventions.

Deep Learning for Detecting Subretinal Fluid and Discerning Macular Status by Fundus Images in Central Serous Chorioretinopathy

Subretinal fluid (SRF) can lead to irreversible visual loss in patients with central serous chorioretinopathy (CSC) if not absorbed in time. Early detection and intervention of SRF can help improve visual prognosis and reduce irreversible damage to the retina. As fundus image is the most commonly used and easily obtained examination for patients with CSC, the purpose of our research is to investigate whether and to what extent SRF depicted on fundus images can be assessed using deep learning technology. In this study, we developed a cascaded deep learning system based on fundus image for automated SRF detection and macula-on/off serous retinal detachment discerning. The performance of our system is reliable, and its accuracy of SRF detection is higher than that of experienced retinal specialists. In addition, the system can automatically indicate whether the SRF progression involves the macula to provide guidance of urgency for patients. The implementation of our deep learning system could effectively reduce the extent of vision impairment resulting from SRF in patients with CSC by providing timely identification and referral.

Sharing the Same Perspective. Mental Disorders and Central Serous Chorioretinopathy: A Systematic Review of Evidence from 2010 to 2020

Background: The relevance of the association between mental disorders and other conditions might have been underestimated due to its complexity. Central Serous Chorioretinopathy (CSC) is an ophthalmological disorder associated with many psychiatric factors. The aim of this systematic review is to evaluate the association between mental disorders and CSC. Methods: Articles about studies performed on humans on CSC published in peer-reviewed journals from 1 January 2010 to 31 December 2020 were included in the review. Results: We selected 21 research papers. Nine studies measured stress and anxious depressive symptoms, which are associated with CSC onset and recurrences, emerging as a state marker of the disease. Four out of the five studies focused on sleep disorders suggested a reliable association with CSC. Four studies evaluated other various psychiatric factors. The role of psychopharmacological medication has still not been elucidated (three studies). Conclusion: Multiple pieces of evidence highlights that CSC might arise in the context of systemic disease. This notion, together with the increasing evidence supporting a link between psychiatric disorders and choroidal thickness, suggests that CSC and mental disorders may share some etiopathogenetic pathways. Further research is needed to better investigate possible common etiopathogenetic pathways, especially vascular, immunological and endocrinological systems.

Central Serous Chorioretinopathy and Personality Characteristics: A Systematic Review of Scientific Evidence over the Last 10 Years (2010 to 2020)

Background and Objectives: to investigate the current state of art in the study of personality disorders in central serous chorioretinopathy (CSC), also taking into account the dimensional approach. Materials and Methods: this systematic review was conducted according to PRISMA guidelines. We included articles written in English or Italian, published in peer reviewed journals from 1 January 2010 to 31 December 2020. Results: after the screening, 10 studies were included. The results suggest that CSC patients are not characterized by the prevalence of a formal personality disorder, but they are better explained by typical personality traits that may alter their relationship with others. CSC patients seems to be characterized by high levels of aggressiveness and anxiety traits along with low sociability. We propose a model of disease where stress exacerbates prior specific traits in a vicious circle where some traits might be involved in disease progression and manifestation. Conclusions: maladaptive personality traits might be an essential feature of the disease and may represent a possible link between psychiatric symptoms, such as insomnia, anxiety, and depression, and endocrinological patterns. Further research should use a specific assessment scale evaluating both the level of interpersonal functioning and specific maladaptive traits.

Central Serous Chorioretinopathy and Blood Serotonin Concentrations

BACKGROUND

To investigate blood serotonin (5-hydroxytryptamine (5-HT)) concentrations and their relationships with selected characteristics in patients with central serous chorioretinopathy (CSC).

METHODS

This was a prospective study including 93 patients with active CSC. Blood concentrations of 5-HT, adrenocorticotropic hormone, and cortisol were measured in patients with CSC. Selected patient characteristics, including disease history (acute or chronic), medication use, smoking history, mood status, best-corrected visual acuity (BCVA), subfoveal choroidal thickness (SCT), findings on fluorescein and indocyanine green angiography, and anatomical changes were evaluated during follow-up.

RESULTS

Eleven of the 93 patients had low 5-HT concentrations (<57 ng/mL) (12%, eight men and three women; mean age 55 years); we identified no significant relationship with acute/chronic disease status. The patients with low 5-HT were significantly more likely to have five or more fluorescein leakage sites (p = 0.0275), recurrence of subretinal fluids (p < 0.0001), and failure to achieve significant improvement in BCVA during follow-up (p = 0.862) than patients with 5-HT within the normal range.

CONCLUSIONS

Blood serotonin concentrations may influence the pathophysiology and prognosis of CSC.

Intravitreal linezolid in the management of vancomycin-resistant enterococcal endophthalmitis

Purpose

Linezolid is a synthetic antibiotic, the first of the oxazolidinone class, used for the treatment of infections caused by multi-resistant bacteria including Streptococcus, methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). We report on a case of endophthalmitis caused by vancomycin-resistant Enterococcus feacium treated with intravitreal linezolid. It has proved efficacious in animal models but its safety in humans is not fully known.

Observations

An 84-year-old man who had phacoemulsification surgery and anterior chamber intraocular lens due to posterior capsule rent. Visual acuity (VA) following surgery was 6/24 uncorrected. The following week he developed signs of endophthalmitis, characterized by corneal infiltration and keratic precipitates, with anterior chamber and vitreous haze. Cultures yielded no growth, while repeated treatments with intravitreal vancomycin, ceftazidime, and amphotericin B did not control the infection. Vitrectomy was performed twice during the patient's course, with intravitreal amikacin injection after the second vitrectomy, but poor control of the endophthalmitis persisted. After several weeks of limited response to treatments, the diagnosis was finally made using Giemsa stain of direct smear which showed characteristic morphology of Enterococcus faecium. Linezolid, one of the oxazo-lidinones, was initially given in oral form 600 mg BID for three weeks, but did not prove efficacious. Subsequently, intravitreal linezolid 200 mcg in 0.1ml was injected, which cleared the vitreous and cornea infection within a week. However, there was a residual exudative detachment of the retina in the posterior pole, leaving the patient with a final vision of hand movement.

Conclusion and importance

Vancomycin-resistant enterococcus is a rare cause of endophthalmitis. Intravitreal linezolid is an effective treatment, but the subsequent exudative retinal detachment may have been related to this novel therapy.