Optical Coherence Tomography Parameters as Predictors of Treatment Response to Eplerenone in 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.

Optical Coherence Tomography-Based Positive Predictors of Eplerenone Therapy in Chronic Central Serous Chorioretinopathy: A Retrospective Study

PURPOSE

This study aimed to investigate optical coherence tomography (OCT) biomarkers as potential predictors of treatment response in chronic central serous chorioretinopathy (CSCR).

MATERIALS AND METHODS

It was a retrospective cohort study that included 42 patients with chronic CSCR. After complete ocular and hematological examinations, all patients received 50 mg/day of oral eplerenone for three months and were followed for at least six months. All participants were divided into two groups: Group 1 participants with a positive response to treatment (complete resolution of subretinal fluid (SRF) at six months) and Group 2 poor responders (moderate or less than 50% reduction in SRF from baseline). The primary outcome measure was the resolution of SRF, and various OCT biomarkers like central macular thickness (CMT), pigment epithelial detachments (PED), double-layer sign, elongation of the photoreceptor's outer segment, the integrity of the external limiting membrane, the integrity of the ellipsoid zone, hyperreflective foci in the outer segment, and subretinal deposits in the SRF were assessed.

RESULTS

The mean age was 41.33 ± 10.75 years, and 34 participants were male. Thirty-seven (88.1%) of the participants had good responses to eplerenone, with the mean height of SRF decreasing significantly from a maximum of 269.74 µm to a minimum of 21.86 µm at six months (p<0.001). The mean CMT decreased from the first visit time point to the third visit time (p<0.001). Logistic regression analysis assessed the absence of PED and double-layer signs associated with a good response.

CONCLUSION

The eplerenone therapy seems to be efficient for chronic CSCR, and OCT can be an invaluable aid to the treating physician.

First-Year Real-Life Experience with Intravitreal Faricimab for Refractory Neovascular Age-Related Macular Degeneration

Background: To evaluate the outcomes of intravitreal faricimab (IVF) for refractory neovascular age-related macular degeneration (nAMD) and investigate the impact of baseline optical coherence tomography, biomarkers for total IVF injections are needed. Methods: A retrospective analysis of 33 eyes of patients who completed one year (52 W) of treatment with IVF. The eyes received four IVF injections (6 mg/0.05 mL) as the upload phase. Thereafter, the treatment interval was extended to 8 or 12 weeks if disease activity was not recorded. The outcome measures included best-corrected visual acuity (BCVA), central macular thickness (CMT), subfoveal choroidal thickness (SFCT), and retinal fluid distribution. Results: A total of 33 eyes were included. CMT decreased significantly at 52 W (p < 0.01). BCVA and SFCT did not change significantly at 52 W (p > 0.05). The number of eyes with subretinal fluid decreased significantly at 52 W (p < 0.01). Complete fluid resolution was achieved in 20 eyes (60%). The total number of injections was significantly negatively correlated with the presence of hyperreflective dots at baseline (HRDs, p < 0.01) and SFCT at baseline (p < 0.01). Conclusions: IVF led to a significant reduction in CMT with stabilization of BCVA. The total number of injections was lower in eyes with HRDs and increased SFCT at baseline. This might provide clues regarding response to IVF for future studies.

BASELINE SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHIC RETINAL LAYER FEATURES IDENTIFIED BY ARTIFICIAL INTELLIGENCE PREDICT THE COURSE OF CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To identify optical coherence tomography (OCT) features to predict the course of central serous chorioretinopathy (CSC) with an artificial intelligence-based program.

METHODS

Multicenter, observational study with a retrospective design. Treatment-naïve patients with acute CSC and chronic CSC were enrolled. Baseline OCTs were examined by an artificial intelligence-developed platform (Discovery OCT Fluid and Biomarker Detector, RetinAI AG, Switzerland). Through this platform, automated retinal layer thicknesses and volumes, including intaretinal and subretinal fluid, and pigment epithelium detachment were measured. Baseline OCT features were compared between acute CSC and chronic CSC patients.

RESULTS

One hundred and sixty eyes of 144 patients with CSC were enrolled, of which 100 had chronic CSC and 60 acute CSC. Retinal layer analysis of baseline OCT scans showed that the inner nuclear layer, the outer nuclear layer, and the photoreceptor-retinal pigmented epithelium complex were significantly thicker at baseline in eyes with acute CSC in comparison with those with chronic CSC ( P < 0.001). Similarly, choriocapillaris and choroidal stroma and retinal thickness (RT) were thicker in acute CSC than chronic CSC eyes ( P = 0.001). Volume analysis revealed average greater subretinal fluid volumes in the acute CSC group in comparison with chronic CSC ( P = 0.041).

CONCLUSION

Optical coherence tomography features may be helpful to predict the clinical course of CSC. The baseline presence of an increased thickness in the outer retinal layers, choriocapillaris and choroidal stroma, and subretinal fluid volume seems to be associated with acute course of the disease.

Choroidal Hyper-Reflective Foci in Geographic Atrophy

Purpose

The purpose of this study was to describe the presence of choroidal hyper-reflective foci (HRF) on optical coherence tomography (OCT) in patients with geographic atrophy (GA). The relationship between the presence and quantity of choroidal HRF and other clinical and imaging factors was also investigated.

Methods

A total of 40 participants (40 eyes) with GA and age-related macular degeneration (AMD) were retrospectively analyzed. OCT images were reviewed for the presence, characteristics, and localization of choroidal HRF. The amount of choroidal HRF was quantified in different choroidal layers by two different (i.e. threshold reflectivity and manual counting) methodologies. The primary outcome was to describe and quantify choroidal HRF and correlate them with GA lesion size.

Results

Structural OCT images showed that all patients had multiple hyper-reflective deposits in different layers of the choroid. These hyper-reflective deposits in the choroid were located near Bruch's membrane or the edges of the blood vessels, particularly in the Sattler's layer, and none were observed inside the vessels. Choroidal HRF exhibited variable size and shape and varying effects on the posterior signal, including shadowing or hypertransmission. Mean ± SD number of choroidal HRF per B-scan was 21.5 ± 15.4 using the threshold reflectivity methodology and 25.1 ± 16.0 using the manual counting methodology. A significant correlation between the untransformed GA size and number of HRF was found, considering both quantitative strategies.

Conclusions

Hyper-reflective dots in the choroid of subjects with GA may be readily identified with structural OCT. These HRF might represent a natural component of the choroid that becomes more visible due to the absence of the retinal pigment epithelium.

PREVALENCE AND MORPHOLOGIC BIOMARKERS OF METAMORPHOPSIA IN EYES WITH "RESOLVED" CHRONIC CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To assess relationships between demographics, clinical characteristics, and optical coherence tomography characteristics with persistence of metamorphopsia after resolution of subretinal fluid in eyes with chronic central serous chorioretinopathy.

METHODS

One-hundred participants with "resolved" (absence of subretinal fluid) chronic central serous chorioretinopathy were retrospectively analyzed. Patients underwent a complete ophthalmologic evaluation, including assessment of the presence of metamorphopsia. At the study visit, optical coherence tomography scans were reviewed for qualitative and quantitative features.

RESULTS

Sixty-six of 100 patients (66.0%) complained of metamorphopsia. Both the foveal and parafoveal ganglion cell complex thicknesses were thinner in central serous chorioretinopathy eyes with metamorphopsia (35.1 ± 10.6 µ m and 82.0 ± 18.1 µ m vs. 40.7 ± 11.8 µ m and 93.1 ± 13.5 µ m, P = 0.030 and P < 0.0001). In the foveal region, the outer plexiform layer and outer nuclear layer thicknesses were thinner in patients with metamorphopsia (24.6 ± 8.5 µ m and 63.1 ± 20.9 µ m vs. 29.1 ± 8.7 and 76.2 ± 18.2 µ m, P = 0.016 and P = 0.005). The ellipsoid zone band was more frequently discontinued in eyes with metamorphopsia (56.1% vs. 35.3%, P = 0.039). Multivariate stepwise linear regression analysis demonstrated that the strongest associations with the presence of metamorphopsia were with parafoveal ganglion cell complex thickness ( P = 0.004), foveal outer nuclear layer thickness ( P = 0.010), and number of previous recurrences of subretinal fluid accumulation ( P = 0.017). The time interval from the last subretinal fluid resolution was not associated with the presence of metamorphopsia.

CONCLUSION

In "resolved" central serous chorioretinopathy, clinical aspects (i.e., number of previous recurrences) and structural changes (i.e., ganglion cell complex and outer nuclear layer thinning) are associated with metamorphopsia after subretinal fluid resolution.

Automatic Segmentation of Hyperreflective Foci in OCT Images Based on Lightweight DBR Network

Hyperreflective foci (HF) reflects inflammatory responses for fundus diseases such as diabetic macular edema (DME), retina vein occlusion (RVO), and central serous chorioretinopathy (CSC). Shown as high contrast and reflectivity in optical coherence tomography (OCT) images, automatic segmentation of HF in OCT images is helpful for the prognosis of fundus diseases. Previous traditional methods were time-consuming and required high computing power. Hence, we proposed a lightweight network to segment HF (with a speed of 57 ms per OCT image, at least 150 ms faster than other methods). Our framework consists of two stages: an NLM filter and patch-based split to preprocess images and a lightweight DBR neural network to segment HF automatically. Experimental results from 3000 OCT images of 300 patients (100 DME,100 RVO, and 100 CSC) revealed that our method achieved HF segmentation successfully. The DBR network had the area under curves dice similarity coefficient (DSC) of 83.65%, 76.43%, and 82.20% in segmenting HF in DME, RVO, and CSC on the test cohort respectively. Our DBR network achieves at least 5% higher DSC than previous methods. HF in DME was more easily segmented compared with the other two types. In addition, our DBR network is universally applicable to clinical practice with the ability to segment HF in a wide range of fundus diseases.

Automated detection of hyperreflective foci in the outer nuclear layer of the retina

PURPOSE

Hyperreflective foci are poorly understood transient elements seen on optical coherence tomography (OCT) of the retina in both healthy and diseased eyes. Systematic studies may benefit from the development of automated tools that can map and track such foci. The outer nuclear layer (ONL) of the retina is an attractive layer in which to study hyperreflective foci as it has no fixed hyperreflective elements in healthy eyes. In this study, we intended to evaluate whether automated image analysis can identify, quantify and visualize hyperreflective foci in the ONL of the retina.

METHODS

This longitudinal exploratory study investigated 14 eyes of seven patients including six patients with optic neuropathy and one with mild non-proliferative diabetic retinopathy. In total, 2596 OCT B-scan were obtained. An image analysis blob detector algorithm was used to detect candidate foci, and a convolutional neural network (CNN) trained on a manually labelled subset of data was then used to select those candidate foci in the ONL that fitted the characteristics of the reference foci best.

RESULTS

In the manually labelled data set, the blob detector found 2548 candidate foci, correctly detecting 350 (89%) out of 391 manually labelled reference foci. The accuracy of CNN classifier was assessed by manually splitting the 2548 candidate foci into a training and validation set. On the validation set, the classifier obtained an accuracy of 96.3%, a sensitivity of 88.4% and a specificity of 97.5% (AUC 0.989).

CONCLUSION

This study demonstrated that automated image analysis and machine learning methods can be used to successfully identify, quantify and visualize hyperreflective foci in the ONL of the retina on OCT scans.

Functionality of retinal vessels in central serous retinopathy: A comparison between eplerenone and photodynamic therapy

Purpose

To investigate retinal vessels functionality in patients with acute central serous chorioretinopathy (CSC) undergoing oral eplerenone or photodynamic therapy (PDT) using Retinal Vessel Analyzer (RVA) and Dynamic Vessel Analyzer (DVA), respectively.

Methods

Treatment naïve acute CSC patients presenting between May 2017 and June 2017 were recruited. A complete ophthalmological examination was performed in all participants before and after oral eplerenone (eplerenone group) or half-dose PDT (PDT group).

Results

Eighteen eyes of 18 patients affected by acute CSC underwent either oral eplerenone (10 eyes of 10 patients, 47.6 ± 8.9 years old) or half-dose PDT (8 eyes of 8 patients, 57.4 ± 6.2 years old), respectively. After 2 months of treatment, non-significant variations of static retinal vessels analysis, dynamic arterial and venous dilatation were reported in eplerenone group. Similarly, in PDT group non-significant variations of static retinal vessels analysis, dynamic arterial and venous dilatation were found after 2 months of treatment.

Conclusions

Static and dynamic retinal functionalities in acute CSC may not be significantly improved by oral eplerenone and half-dose PDT. Although their choroidal effects, these treatments could not exert a significant effect on retinal vessels motility. Thus, both local and systemic therapies might not help avoiding the onset of vascular and other retinal known alterations of CSC.

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.

Association between inflammatory cytokines in the aqueous humor and hyperreflective foci on optical coherence tomography in patients with neovascular age-related macular degeneration and polypoidal choroidal vasculopathy

Purpose

To investigate the associations between cytokine levels in the aqueous humor (AH) and hyperreflective foci (HF) on spectral-domain optical coherence tomography (SD-OCT) in neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV).

Methods

The prospective study included 63 eyes with nAMD, 44 with PCV, and 43 with cataracts (Controls). AH samples were obtained before anti-vascular endothelial growth factor (VEGF) therapy or cataract surgery. Cytokines interleukin 6 (IL-6), IL-8, IL-10, interferon-inducible protein 10 (IP-10), monocyte chemotactic protein 1 (MCP-1), and VEGF were measured by multiplex bead assay. Best-corrected visual acuity (BCVA), central macular thickness (CMT), and the number of HF were evaluated at baseline and 1 month after anti-VEGF treatment.

Results

No significances difference in IL-6 and IL-8 levels were noted among the three groups (P = 0.370 and P = 0.067). VEGF, IP-10, and IL-10 levels were significantly higher in nAMD and PCV groups than in Controls (all P &lt; 0.05). In nAMD, HF was positively correlated with VEGF (rs = 0.300, P = 0.025) and in eyes with HF group, VEGF and IL-10 were significantly higher than those without HF (P = 0.008 and P = 0.022). In PCV, no correlation was observed between HF and cytokines (all P &gt; 0.05). After anti-VEGF treatment, patients with HF in nAMD and PCV were predisposed to worse visual outcomes (P = 0.022 and P = 0.015) and a significantly greater reduction in CMT (P = 0.001 and P = 0.057). And nAMD patients with HF were more sensitive to anti-VEGF treatment than those without HF (P = 0.029).

Conclusions

In the nAMD group, HF was positively correlated with VEGF. Patients in nAMD with HF had elevated levels of VEGF and IL-10 and responded favorably to anti-VEGF. HF might serve as an inflammatory biomarker and a predictive factor for therapeutic efficacy in patients with nAMD.

Morphological parameters predicting subthreshold micropulse laser effectiveness in central serous chorioretinopathy

PURPOSE

The purpose of this prospective study was to predict the effectiveness of subthreshold micropulse laser (SML) based on morphological parameters in patients with central serous chorioretinopathy (CSC).

METHODS

Thirty-one patients were examined at presentation, 3 months, and 6 months after the disease onset. In patients with persistent subretinal fluid (SRF) at 3 months, SML was performed. The following morphological parameters were observed just before treatment: central retinal thickness (CRT), maximal SRF, choroidal thickness (CT), pigment epithelial detachment (PED) height and width, number of hyperreflective foci (HF) at fovea and leakage site, secondary choroidal neovascularization (CNV), and severity of retinal pigment epithelium (RPE) alterations using multimodal imaging.

RESULTS

Good response was associated with lower SRF (p = 0.038), narrower PED (p = 0.078), and decreasing number of HF at fovea (difHFf) (p = 0 .016) just before the treatment. From a bivariate and multivariate point of view, the two groups differed significantly in the pair (SRF, PED width) (p = 0.048) and in the triple (SRF, PED width, difHFf) (p = 0.026).

CONCLUSION

Lower SRF, narrower PED, and decreasing HF could be associated with good response to SML in CSC patients.

Chronic Systemic Dexamethasone Regulates the Mineralocorticoid/Glucocorticoid Pathways Balance in Rat Ocular Tissues

Central serous chorioretinopathy (CSCR) is a retinal disease affecting the retinal pigment epithelium (RPE) and the choroid. This is a recognized side-effect of glucocorticoids (GCs), administered through nasal, articular, oral and dermal routes. However, CSCR does not occur after intraocular GCs administration, suggesting that a hypothalamic-pituitary-adrenal axis (HPA) brake could play a role in the mechanistic link between CSCR and GS. The aim of this study was to explore this hypothesis. To induce HPA brake, Lewis rats received a systemic injection of dexamethasone daily for five days. Control rats received saline injections. Baseline levels of corticosterone were measured by Elisa at baseline and at 5 days in the serum and the ocular media and dexamethasone levels were measured at 5 days in the serum and ocular media. The expression of genes encoding glucocorticoid receptor (GR), mineralocorticoid receptors (MR), and the 11 beta hydroxysteroid dehydrogenase (HSD) enzymes 1 and 2 were quantified in the neural retina and in RPE/ choroid. The expression of MR target genes was quantified in the retina (Scnn1A (encoding ENac-α, Kir4.1 and Aqp4) and in the RPE/choroid (Shroom 2, Ngal, Mmp9 and Omg, Ptx3, Plaur and Fosl-1). Only 10% of the corticosterone serum concentration was measured in the ocular media. Corticosterone levels in the serum and in the ocular media dropped after 5 days of dexamethasone systemic treatment, reflecting HPA axis brake. Whilst both GR and MR were downregulated in the retina without MR/GR imbalance, in the RPE/choroid, both MR/GR and 11β-hsd2/11β-hsd1 ratio increased, indicating MR pathway activation. MR-target genes were upregulated in the RPE/ choroid but not in the retina. The psychological stress induced by the repeated injection of saline also induced HPA axis brake with a trend towards MR pathway activation in RPE/ choroid. HPA axis brake causes an imbalance of corticoid receptors expression in the RPE/choroid towards overactivation of MR pathway, which could favor the occurrence of CSCR.

Significance of Hyperreflective Foci as an Optical Coherence Tomography Biomarker in Retinal Diseases: Characterization and Clinical Implications

Hyperreflective foci (HRF) is a term coined to depict hyperreflective dots or roundish lesions within retinal layers visualized through optical coherence tomography (OCT). Histopathological correlates of HRF are not univocal, spacing from migrating retinal pigment epithelium cells, lipid-laden macrophages, microglial cells, and extravasated proteinaceous or lipid material. Despite this, HRF can be considered OCT biomarkers for disease progression, treatment response, and prognosis in several retinal diseases, including diabetic macular edema, age-related macular degeneration (AMD), retinal vascular occlusions, and inherited retinal dystrophies. The structural features and topographic location of HRF guide the interpretation of their significance in different pathological conditions. The presence of HRF less than 30 μm with reflectivity comparable to the retinal nerve fiber layer in the absence of posterior shadowing in diabetic macular edema indicates an inflammatory phenotype with a better response to steroidal treatment. In AMD, HRF overlying drusen are associated with the development of macular neovascularization, while parafoveal drusen and HRF predispose to macular atrophy. Thus, HRF can be considered a key biomarker in several common retinal diseases. Their recognition and critical interpretation via multimodal imaging are vital to support clinical strategies and management.

OCT Risk Factors for 3-Year Development of Macular Complications in Eyes With "Resolved" Chronic Central Serous Chorioretinopathy

PURPOSE

To assess the relationship between demographics, clinical characteristics, and structural optical coherence tomography (OCT) findings and the development of sight-threatening macular complications (choroidal neovascularization [CNV], large areas of retinal pigment epithelium [RPE] atrophy, and cystoid macular degeneration [CMD]) in a cohort of eyes with "resolved" chronic central serous chorioretinopathy (CSC) at study baseline.

DESIGN

Retrospective cohort study.

METHODS

In this study, a total of 71 eyes with "resolved" (absence of subretinal fluid) chronic CSC at baseline and 36 months of regular follow-up examinations were retrospectively enrolled. Structural OCT scans were reviewed. Baseline OCT qualitative features reflecting distress of the neuroretina, RPE, or choroid were assessed and included ellipsoid zone discontinuity, outer nuclear layer (ONL) thinning; presence of hyper-reflective intraretinal foci; dome-shaped pigment epithelium detachment (PED); hyper-reflective flat, irregular PED; hyporeflective flat, irregular PED; and inner choroidal attenuation. OCT images obtained at follow-up visits were also reviewed for development of macular complications (CNV, large areas of RPE atrophy [at least 250 μm in diameter], and CMD). Main outcome measurements included incidence of macular complications and hazard ratio (HR) for demographics, clinical characteristics, and OCT risk factors.

RESULTS

At month 36, 20 eyes (28.2%) developed macular complications. Nine eyes (12.7%) displayed CNV, 9 eyes (12.7%) had large areas of RPE atrophy, and 2 eyes (2.8%) developed cystoid macular degeneration. The following factors were associated with an increased risk of development of CNV: intraretinal hyper-reflective foci had an HR of 11.58 (95% confidence interval [CI]: 1.10-37.24; P = .040); inner choroidal attenuation had an HR of 9.66 (95% CI: 1.07-22.34; P = .043); and the presence of macular complications in the fellow eye had an HR of 20.17 (95% CI: 1.34-39.41; P = .030). Factors associated with the development of RPE atrophy were also identified: ONL thinning had an HR of 13.47 (95% CI: 1.10-39.86; P = .042); dome-shaped PED had an HR of 21.40 (95% CI: 1.50-41.10; P = .031); and inner choroidal attenuation had an HR of 13.20 (95% CI: 1.07-39.32; P = .044).

CONCLUSIONS

OCT risk factors were identified for the development of macular complications in eyes with chronic CSC. Findings may help in the identification of high-risk patients.

The Role of Imaging in Planning Treatment for Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSC) is a controversial disease both in terms of clinical classification and choice of therapeutic strategy. Choroidal layers, retinal pigment epithelium (RPE), photoreceptors, and retina are involved to varying degrees. Beyond well-known symptoms raising the clinical suspect of CSC and slit-lamp fundus examination, multimodal imaging plays a key role in assessing the extent of chorioretinal structural involvement. Subretinal fluid (SRF) originating from the choroid leaks through one or multiple RPE defects and spreads into the subretinal space. Spontaneous fluid reabsorption is quite common, but in some eyes, resolution can be obtained only after treatment. Multiple therapeutic strategies are available, and extensive research identified the most effective procedures. Imaging has carved a significant role in guiding the choice of the most appropriate strategy for each single CSC eye. Multiple biomarkers have been identified, and all of them represent a diagnostic and prognostic reference point. This review aims to provide an updated and comprehensive analysis of the current scientific knowledge about the role of imaging in planning the treatment in eyes affected by CSC.

Efficacy and safety of the mineralocorticoid receptor antagonist treatment for central serous chorioretinopathy: a systematic review and meta-analysis

OBJECTIVES

We performed a systematic review and meta-analysis to assess the efficacy and safety of the mineralocorticoid receptor antagonist (MRA) treatment for central serous chorioretinopathy (CSC).

METHODS

We searched the PubMed, Embase, and the Cochrane Library to identify relevant clinical studies published prior to March 2020. The primary outcome was change in best-corrected visual acuity (BCVA), and the secondary outcomes included the subretinal fluid (SRF), subfoveal choroidal thickness (SFCT), and central macular thickness (CMT).

RESULTS

Five randomized controlled trials (RCT) and four cohort studies met the inclusion criteria with a total of 352 eyes. The MRA treatment was not superior to placebo in BCVA at 1 month (WMD = -0.06, 95% CI -0.15-0.02, P = 0.15, I² = 86%), 3 months (WMD = -0.04, 95% CI -0.14-0.06, P = 0.44, I² = 77%) and 6 months (WMD = -0, 95% CI -0.05-0.05, P = 0.92, I² = 0%). The MRA treatment resulted in significant reduction than the placebo in the SRF (WMD = -60.64, 95% CI -97.91 to -23.37, P = 0.001, I² = 49%), SFCT (WMD = -39.15, 95% CI -52.58 to -25.72, P < 0.001, I² = 0%), and CMT (WMD = -60.75, 95% CI -97.85 to -23.65, P = 0.01, I² = 53%).

CONCLUSIONS

Our meta-analysis shows that the MRA treatment can improve anatomical structure in CSC patients, but it is not effective for achieving BCVA gain. The applicant of the MRA is safe and have no severe effect.

Optical coherence tomography parameters as predictors of treatment response to a 577-nm subthreshold micropulse laser in chronic central serous chorioretinopathy

To determine the relation between retinal microstructural changes and the response to 577-nm subthreshold micropulse laser (SML) treatment in chronic central serous chorioretinopathy (cCSC). This retrospective study included 39 eyes of 39 patients with cCSC, treated with the 577-nm SML. The eyes were evaluated in three groups: complete remission, partial remission, and failure groups. The presence of some baseline retinal microstructural changes, thickness of the outer nuclear layer (ONL), status of the ellipsoid zone (EZ), and retinal pigment epithelium (RPE) were evaluated. The changes in central macular thickness (CMT), subretinal fluid (SRF) height, and best-corrected visual acuity (BCVA) were calculated. There were 14, 13, and 12 eyes in the complete remission, partial remission, and failure group, respectively. The baseline EZ and RPE were found intact in 71.4% and 64.3% of the eyes in the complete remission group, respectively; however, these rates were respectively 25% and 16.7% in the failure group (p < 0.05). Extrafoveal foci were present in 35.7% of the eyes in the complete remission group, but none was found in the failure group (p < 0.05). Although there was no statistically significant difference, the baseline ONL thickness was higher, and the hyperreflective dots, retinal bumps, subretinal fibrinous exudates, and PEDs were seen less in the complete remission group. The changes of the BCVA were not significant in any of the groups at the last visit (p > 0.05). The presence of baseline intact EZ and RPE, and extrafoveal foci can potentially be used as predictors of the SML treatment success in cCSC.

Nailfold Videocapillaroscopy in Patients with Central Serous Chorioretinopathy and Its Relationship to Morphological and Functional Findings

The aim of the study was to evaluate the results of nailfold videocapillaroscopy (NVC) in patients with central serous chorioretinopathy (CSC) and their correlation with different functional, morphological features and general risk factors. Material and methods: The examined group included 59 CSC patients (14 F, 45 M, mean age 47.2 ± 9.4) and 53 healthy controls (13 F, 40 M, mean age 46 ± 11.5). The NVC was qualified as a normal or abnormal pattern. In the CSC group, the ophthalmoscopy, angio-Optical Coherence Tomography (OCT-A), OCT and microperimetry were performed. The medical history regarding CSC, chronic general disorders and known risk factors was recorded. Results: In the CSC group an abnormal NVC pattern was more common (33.88% CSC vs. 7.54%, p < 0.001). Dilated apical part of capillaries, microaneurysmal dilatation, megacapillaries, fresh microhaemorrhages, bizarre and broken capillaries were observed only in CSC patients. Dilation of capillaries (47.56% vs. 13.21%, p = 0.004), ramified capillaries and neoangiogenesis (38.98% vs. 5.66%, p < 0.001), glomerular loops (32.20% vs. 1.88% p < 0.001) were more frequent in the CSC group. Conclusions: The presence of various NVC abnormalities confirms microvascular involvement in CSC pathogenesis. The results correlate with visual acuity, microperimetry, OCT data and stress. The NVC technique may play a useful diagnostic and prognostic role in CSC.

Choroidal Rift: A New OCT Finding in Eyes with Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSC) is a complex and not entirely understood retinal disease. The aim of our research was to describe a novel optical coherence tomography (OCT) finding named “choroidal rift”, which may be identified in the choroid of eyes with CSC. We collected data from 357 patients (488 eyes) with CSC who had structural OCT and OCT angiography (OCTA) scans obtained. Choroidal rifts were identified as polygonal (and not round-shaped) hyporeflective lesions without hyperreflective margins. Choroidal rifts had to be characterized by a size superior to that of the largest choroidal vessel. Finally, hyporeflective lesions were graded as choroidal rifts only if these lesions had a main development perpendicular to the retinal pigment epithelium. OCT analysis allowed the identification of choroidal rifts in ten eyes from nine patients, all with chronic CSC, with an estimated prevalence rate of 2.1%. In three out of ten cases with choroidal rifts, these lesions spanned all the choroidal layers. In the remaining cases, choroidal rifts only partially spanned the choroidal thickness. In OCTA, choroidal rifts were characterized by the absence of flow. Combining structural OCT and OCTA information, we hypothesized that choroidal rifts may represent interruptions of the choroidal stroma in correspondence of fragile regions (in between expanded larger-sized choroidal vessels). Choroidal rift represents a novel OCT feature, which may characterize eyes with chronic CSC and may have a role in the development of irreversible chorio-retinal changes.

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.