Current Therapeutic Approaches to Chronic Central Serous Chorioretinopathy

Clinical predictive factors and imaging biomarkers of treatment response to half dose PDT in patients with chronic central serous chorioretinopathy

PURPOSE

To determine the clinical and imaging biomarkers of the response to half-dose photodynamic therapy (HD-PDT) in patients with central serous chorioretinopathy (CSC) METHODS: Clinical records and baseline ophthalmic images of 67 chronic CSC patients who underwent HD-PDT were assessed. In addition to demographic data, optical coherence tomography (OCT), fluorescein angiography (FA) and fundus autofluorescence (FAF) images were analyzed for specific biomarkers. The patients were categorized to early responder and late responder based on the time needed for complete resolution of subretinal fluid after PDT (less than 1 month vs. more than 1 month). The baseline clinical and imaging biomarkers were compared between the two groups.

RESULTS

Seventy-three eyes of 67 patients were included in the study. The mean response time to PDT was 1.63 ± 1.48 months with 82.2% (60/73) of eyes categorized as early responder. The mean response time to PDT in delayed-response group was 4.15±1.51 months. In multivariate analysis, delayed response to PDT was associated with lacking history of systemic corticosteroid consumption, lacking history of pretreatment with eplerenone or acetazolamide before PDT and presence of hyperreflective foci in baseline OCT images (all p values < 0.05). There was no association between final visual outcome and late response to PDT.

CONCLUSION

The presence of inflammatory biomarkers such as hyperreflective foci in baseline OCT images might be indicative of resistance to PDT. Moreover, the effect of pretreatment with mineralocorticoid antagonist on the response to PDT in chronic CSC should be explored in future prospective studies.

QUANTITATIVE AUTOFLUORESCENCE IN CENTRAL SEROUS CHORIORETINOPATHY

BACKGROUND/PURPOSE

Central serous chorioretinopathy (CSC) is associated with pachychoroid and dysfunctional retinal pigment epithelium. Autofluorescence (AF) is typically altered. The authors performed this study to quantify these alterations using quantitative AF (qAF) in patients with CSC and in their fellow eye in comparison with a healthy control group.

METHODS

Patients with CSC and healthy controls were recruited prospectively. All patients received a full clinical examination including best-corrected visual acuity, enhanced depth imaging-optical coherence tomography, and qAF. Quantitative autofluorescence images were taken with a confocal scanning laser ophthalmoscope (Heidelberg Engineering). Quantitative autofluorescence values were assessed in specified regions of the inner eight and the middle ring of the Delori grid.

RESULTS

In total, 141 eyes of 77 patients with CSC were included. Ninety eyes had a manifest CSC (group 1) while 51 fellow eyes (group 2) did not show signs of CSC. There were no significant differences of qAF values between these two groups: mean qAF values were 241.3 (inner eight) and 212.8 (middle ring) in group 1 and 235.9 (inner eight) and 210.0 (middle ring) in group 2 ( P = 1.0 and 1.0). We compared these eyes with healthy controls comprising 39 eyes. Quantitative autofluorescence signals (inner eight: 164.7; middle ring: 148.9) differed significantly compared with both CSC manifest ( P < 0.001) and fellow eyes ( P < 0.001).

CONCLUSION

Our results show that patients with CSC have increased qAF values in both eyes with manifest CSC and asymptomatic, clinically unremarkable fellow eyes in comparison with healthy controls. This finding suggests that qAF alterations are present even before clinical signs can be observed.

Choroidal vascularity index as an activity criterion and a treatment response measure in chronic central serous chorioretinopathy

PURPOSE

This study aimed to evaluate the choroidal vascularity index (CVI) as an activity criterion in chronic central serous chorioretinopathy (CSC) and as a measure of treatment response after full-dose-full-fluence photodynamic therapy (fd-ff-PDT).

METHODS

This fellow-eye-controlled, retrospective cohort study included 23 patients with unilateral chronic CSC treated with fd-ff-PDT (6 mg/m2 ; 50 μcm2 ; 83 s). Subfoveal choroidal thickness (SFCT, μm) and CVI (%) of the affected and fellow eyes at baseline as well as at 1, 3 and 6 months after fd-ff-PDT were compared.

RESULTS

The patients' mean age was 43.4 ± 7.3 years, and 18 (78.3%) were male. CVI was comparable between the affected and fellow eyes at baseline (66.09 ± 1.56 vs. 65.84 ± 1.57, p = 0.59). However, it became significantly lower in the affected eyes 1 (64.45 ± 1.68 vs. 65.87 ± 1.19, p = 0.002), 3 (64.21 ± 2.08 vs. 65.71 ± 1.59, p = 0.009) and 6 (64.47 ± 2.19 vs. 65.62 ± 1.52, p = 0.045) months after fd-ff-PDT. The mean SFCT and the mean CVI were significantly decreased in the affected eyes at all follow-up visits compared with baseline after fd-ff-PDT (p < 0.001).

CONCLUSION

At baseline, CVI was comparable between affected and fellow eyes. Therefore, its use as an activity criterion in chronic CSC patients is questionable. However, it was significantly decreased in fd-ff-PDT-treated eyes, supporting its role as a measure of treatment response in chronic CSC.

Subthreshold Micropulse Treatment Laser versus Half-Dose Photo Dynamic Therapy for the Chronic Central Serous Chorioretinopathy with Parafoveal or Subfoveal Leakage STML versus PDT for Treatment of Chronic CSC

Purpose. The study aimed to compare the efficacy and safety outcomes of a subthreshold micropulse treatment laser (SMTL) versus half-dose photodynamic therapy (PDT) for treatment of chronic central serous chorioretinopathy (cCSC) with parafoveal or subfoveal leakage to persistent subretinal fluid. Methods. One hundred and forty-eight patients (148 eyes) with persistent cCSC were enrolled in this retrospective study and treated with SMTL or half-dose PDT. All patients were diagnosed according to clinical characteristics and findings on multimodal imaging. The medical records including patients with a minimum follow-up period of 3 months were reviewed. The patients were divided into two groups according to the application of the SMTL or PDT. The group of the SMTL or PDT was also divided into two subgroups according to parafoveal or subfoveal leakage. The primary outcomes included best-corrected visual acuity (BCVA) and central retinal thickness (CRT) before and 1, 2, and 3 months after treatment. The repeat treatment and resolution of subretinal fluid were also collected. Results. Seventy-nine patients (79 eyes) treated with half-dose PDT and 69 Patients (69 eyes) treated with the STML were included. The mean age was 44.20 ± 7.42 years and 80% were male. No significant difference in age, gender, baseline logMAR BCVA or CRT between the half-dose PDT group and the SMTL group ( $P=0.201$ ; 0.051) can be defined. The BCVA of the SMTL group improved at 1, 2, and 3 months after treatment, while that of the half-dose PDT group improved like the SMTL group. There were no significant differences between the SMTL and the PDT group at 1, 2, and 3 months ( $P=0.723$ ; 0.139; 0.896). The CRT for the SMTL group decreased at 1, 2, and 3 months after treatment, while that of the half-dose PDT group changed like the SMTL group. However, there were significant differences between the SMTL group and the PDT group at 1and 3 months ( $P=0.010$ ; 0.009). 13/69 (18.84%) and 9/79 (11.39%) patients underwent treatment at least twice in the SMTL and half-dose PDT group, respectively, and achieved resolution of SRF after treatment. The results of subgroups analysis showed no significant differences between the logMAR BCVA of the SMTL and PDT group which were divided into parafoveal and subfoveal leakage groups after treatment, but significant difference in CRT between subgroups can be found after treatment at 1and 3 months ( $P=0.003$ ; 0.04). Conclusions. The SMTL can be an effective candidate for the treatment of persistent cCSC where leakage occurred at parafoveal or subfoveal and improvement of logMAR BCVA, but half-dose PDT has been more effective for resolution of SRF.

Bilateral and Multiple Central Serous Chorioretinopathy Following COVID-19 Infection: A Case Report and Literature Review

Central serous chorioretinopathy (CSCR) following coronavirus disease 2019 (COVID-19) infection is rare. We describe an adult patient who survived a COVID-19 infection and received intravenous and oral corticosteroid treatment for three weeks. He presented three weeks post COVID-19 infection with central visual loss in both eyes for six days. Fundus examination showed multiple localized serous retinal detachments in both eyes. Optical coherence tomography (OCT) of the macula confirmed the presence of multiple areas of serous retinal detachment and pigment epithelial detachment. The patient was treated with topical non-steroidal anti-inflammatory eye drops and regained full visual recovery after three months. Corticosteroid treatment for COVID-19 and psychological stress induced by the disease are potential risk factors for the development of CSCR. Physicians should be aware of this side effect, as an early referral to an ophthalmologist for treatment is essential.

Evaluation of the choriocapillaris after photodynamic therapy for chronic central serous chorioretinopathy. A review of optical coherence tomography angiography (OCT-A) studies

PURPOSE

Emerging evidence suggests that choroidal microcirculation and microstructural changes after verteporfin photodynamic therapy (vPDT) for chronic central serous chorioretinopathy (CSC) can be shown in detail using OCT-Angiography (OCT-A). The use of OCT-A for the examination of choriocapillaris (CC) has attracted significant attention as the technique offers potential explanations for the effects of vPDT on choroidal tissue.

METHODS

A meticulous literature search was performed in the PubMed database without restriction on year of publication until June 2021. The reference list of all electronically retrieved articles was carefully reviewed for potentially relevant articles that had not been identified.

RESULTS

We identified and reviewed 11 studies reporting a comprehensive update on microvasculature and morphologic changes of the CC layer as seen on OCT-A in chronic CSC. The reviewed articles extensively analyze both the qualitative and quantitative characteristics of the CC flow pattern after applying vPDT safety-enhanced protocols. The changes in the CC plexus indicate the potential of beneficial or deleterious treatment effect on choroidal tissue remodeling. The reviewed series have revealed variability of flow pattern, vessel density, and perfusion of the CC over time.

CONCLUSION

The CC plexus alterations during the post-vPDT period in chronic CSC may imply the treatment effect on choroidal tissue, indicating the potential of anatomical or functional recovery over time. The reviewed literature may confirm the diagnostic value of OCT-A in the assessment of the pathophysiology of eyes with CSC.

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.

Foveal and Extrafoveal Effects of Half-Dose Photodynamic Therapy in Chronic Central Serous Chorioretinopathy: A Cohort Study

PURPOSE

To compare the efficacy and safety of foveal and extrafoveal half-dose photodynamic therapy (HD-PDT) for chronic Central Serous Chorioretinopathy (cCSC).

METHODS

This retrospective, cohort study included cCSC eyes submitted to HD-PDT on foveal (F) or extrafoveal (E) areas. Patients were evaluated at baseline and 12 weeks after treatment for best corrected visual acuity (BCVA) and the following spectral-domain optical coherence tomography (SD-OCT) subfoveal parameters: central macular thickness (CMT), outer nuclear layer, external limiting membrane, ellipsoid zone, interdigitation zone, choroidal thickness and subretinal fluid (SRF).

RESULTS

F group comprised 33 eyes (47.1%) and E group comprised 37 eyes (52.9%). Both groups showed an improvement of BCVA after HD-PDT with no significant differences in final BCVA (p = .41). CMT and SRF showed a significant improvement after HD-PDT in both groups, but the rate of disruption of the external retinal layers remained stable. During follow-up, SD-OCT parameters and the rate of anatomical success showed no significant differences regarding the treatment location. No major sequelae were noticed.

CONCLUSION

Foveal and extrafoveal applications of HD-PDT for cCSC showed comparable efficacy and safety.

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.

Current Pharmacological Treatment Options for Central Serous Chorioretinopathy: A Review

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

Study of vessel density by optical coherence tomography angiography in patients with central serous chorioretinopathy after low-fluence photodynamic therapy

BACKGROUND

To perform a quantitative analysis of retinal and choriocapillaris vessel density (VD) in patients with central serous chorioretinopathy (CSC) after low-fluence verteporfin photodynamic therapy (vPDT), using Optical Coherence Tomography Angiography (OCTA).

METHODS

A total of 28 eyes of 27 patients with CSC (21 females, 6 males, mean age 47 ± 11 years) were included in this retrospective study. At baseline and after 6 months after vPDT, we evaluated VD of the superficial capillary plexus (SCP), the deep capillary plexus (DCP) and the choriocapillaris (CC) in different macular areas (whole image, parafovea and fovea). We also analyzed the central foveal thickness (CFT) and subfoveal choroidal thickness (SFCT) with Enhanced Depth Imaging-Optical Coherence Tomography (EDI-OCT).

RESULTS

Eighteen eyes and ten eyes were responders and non responders to low-fluence vPDT, respectively. The responders group showed a significant increase in VD in DCP and CC after treatment (p < 0.05). In the non responders group the VD in SCP, DCP and CC did not differ before and after treatment. We also found a significant correlation in responders group between Best-Corrected Visual Acuity (BCVA) and CFT (r = 0.566; p = 0.014) and between BCVA and the increased VD of CC (r= -0.559; p = 0.016). In non responders group, the correlation between OCT, OCTA parameters and BCVA was not statistically significant.

CONCLUSIONS

OCTA allowed us to enhance our knowledge regarding the pathophysiology of vascular changes in retinal and CC networks after low-fluence vPDT. OCTA may represent a new biomarker to evaluate the efficacy of low-fluence vPDT in the treatment of CSC.