Giant retinal pigment epithelial tear following photodynamic therapy for the bullous variant of central serous chorioretinopathy: A case report

RATIONALE

The bullous variant of central serous chorioretinopathy (CSC) is a severe form of chronic CSC. Patients with the bullous variant of CSC have an increased risk of experiencing multiple pigment epithelial detachments (PEDs) and retinal pigment epithelium (RPE) tears. Photodynamic therapy (PDT) is a treatment for the bullous variant of CSC. RPE tear is a possible postoperative complication of PDT for eyes with PEDs. To our knowledge, no cases of giant RPE tears following PDT for the bullous variant of CSC have been reported previously. This case report presents the first instance of a giant RPE tear after half-time PDT for the bullous variant of CSC, accompanied by a series of images depicting the tear development.

PATIENT CONCERNS

A 63-year-old male patient presented with rapidly deteriorating vision in his left eye over a 3-month period. He also reported a previous episode of vision loss in his right eye 2 years prior. Best-corrected visual acuity (BCVA) in the left eye was 0.2.

DIAGNOSIS

The right eye was diagnosed with chronic non-bullous CSC, while the left eye was diagnosed with the bullous variant of CSC with a large PED.

INTERVENTIONS

Half-time PDT was administered to the left eye.

OUTCOMES

One month after half-time PDT, a giant RPE tear exceeding 3 clock-hours in size was confirmed in the lower temporal quadrant of the left eye. Three months after the initial half-time PDT, a second half-time PDT was performed owing to recurrent retinal detachment. Two months after the second half-time PDT, the retinal detachment resolved, and BCVA improved to 0.4, 6 months after the second half-time PDT.

LESSONS

In cases where the bullous variant of CSC is complicated by extensive PED, clinicians should consider the potential development of a giant RPE tear as a treatment complication.

Psychometric assessment of patients with central serous chorioretinopathy and correlation with disease stage and progression: a case control study

BACKGROUND

Central serous chorioretinopathy (CSC) has frequently been associated with increased stress levels as well as an increased prevalence of other psychiatric conditions. This study used standardized psychometric scores to assess stress, depression and anxiety levels of CSC patients and compared them to controls without retinal disease ("healthy") and with branch retinal vein occlusion (BRVO).

METHODS

Monocentric, longitudinal case control study on consecutive CSC patients seen at a tertiary referral center. Controls without retinal disease were recruited from the oculoplastics clinic and those with BRVO from the medical retina clinic. Patients completed pseudonymized tests measuring stress levels (PHQ-stress), depression (PHQ-9) and anxiety (GAD-7) at baseline and at 3- and 6-months follow-up. Higher scores indicated higher trait levels.

RESULTS

65 CSC patients, 19 healthy controls and 19 BRVO patients were included in this study. CSC patients showed significantly higher stress levels at baseline compared to controls (p = 0.009), but not compared to BRVO patients (p = 1.00). At 3- and 6-months follow-up, no significant difference between groups was observed anymore. Acute CSC patients showed higher scores than those with chronic CSC, which also subsided over time. Depression and anxiety scores did not differ between groups at any timepoint.

CONCLUSIONS

Patients with CSC do not show higher initial stress levels than patients with BRVO, while anxiety and depression levels did not differ from controls. Stress may thus rather represent a consequence of the onset of visual deterioration observed in CSC or other ocular diseases.

Dysfunctional personality beliefs and psychopathology in patients with central serous chorioretinopathy

OBJECTIVES

To assess dysfunctional personality beliefs associated with specific personality disorders (PD), as well as psychopathological symptoms and psychological distress levels in central serous chorioretinopathy (CSC) patients.

MATERIAL AND METHODS

This cross-sectional study included acute and chronic CSC patients and age- and sex-matched healthy volunteers. Dysfunctional personality beliefs and psychopathological symptoms assessed with Personality Belief Questionnaire-Short Form and Symptom Check List-90 Revised (SCL-90-R), respectively, were compared between CSC patients and healthy volunteers and between acute and chronic CSC patients.

MAIN RESULTS

Of the 55 CSC patients included in the study analysis, 21 (38.2%) had acute and 34 (61.8%) chronic CSC. Avoidant PD (13.92±3.79 vs. 12.03±3.98, P=0.012) and obsessive-compulsive PD (13.94±3.95 vs. 12.27±3.75, P=0.025) scores on the PBQ-SF were significantly higher in CSC patients than in healthy volunteers. The PBQ-SF scores were similar between acute and chronic CSC patients. CSC patients scored significantly higher on the general severity index (GSI) and all symptom dimensions except phobic anxiety and psychoticism on the SCL-90-R. In addition, scores for obsessive-compulsive, depression, interpersonal sensitivity, paranoid ideation, and GSI were significantly higher in acute than in chronic CSC patients.

CONCLUSIONS

This first study investigating the relationship between CSC and dysfunctional personality beliefs indicates that CSC patients have higher levels of dysfunctional beliefs related to avoidant and obsessive-compulsive PD than healthy volunteers. These findings present a new aspect of the personality profile of CSC patients and point to a target for intervention, i.e., dysfunctional beliefs, through a cognitive-psychiatric approach.

Association of Central serous chorioretinopathy with type of personality, anxiety and depression

PURPOSE

Central serous chorioretinopathy (CSCR) a relatively common cause of visual impairment, which is characterized by subretinal fluid accumulation in the macula and is more common in middle-aged males. Various risk factors have been reported in literature, among which substantial role of psychological factors is cited. Our aim was to look for the prevalence and association of the psychiatric factors in CSCR patients and to compare them with other non-chorioretinal ocular pathologies.

METHODS

A cross-sectional correlational study was undertaken involving 91 CSCR patients, along with 91 patients with other non-chorioretinal diseases. Their risk factors, clinical history, ocular examination, and psychiatric assessments were done using standardized tools, and the groups were compared in terms of scoring of Framingham Type A scale (FTAS), Hamilton Anxiety Rating Scale (HAM-A), and Hamilton Depression Rating Scale (HDRS).

RESULTS

CSCR patients had a male:female ratio of 8:1. Chronic, bilateral, and recurrent diseases were found in 15%, 20%, and 23% cases, respectively. Anxiety disorder had a prevalence of 40%, followed by major depression with a prevalence of 24%, and these were significantly higher than non-chorioretinal disease patients (odds ratios 14.18 and 5.30, respectively). Also, these psychiatric disorders were significantly associated with an overall lower visual acuity and greater central macular thickness due to subretinal fluid accumulation.

CONCLUSION

Psychiatric comorbidities like Type A personality trait and depression and anxiety disorders were significantly more prevalent in CSCR patients, compared to non-chorioretinal pathologies. Focus on psychological health would certainly benefit these patients in terms of better management of not only CSCR, but their psychiatric morbidity as well.

Surgical Treatment of Bullous Exudative Retinal Detachment Secondary to Atypical Bilateral Central Serous Chorioretinopathy

This study aimed to report the diagnostic process, treatment, and follow-up of a patient with bullous exudative retinal detachment (RD) associated with an atypical variant of bilateral central serous chorioretinopathy (CSCR). A 28-year-old woman was referred to our clinic for total bullous RD in the right eye with a vision level of light perception only. She had been previously diagnosed with idiopathic uveal effusion syndrome and treated with systemic corticosteroid therapy with no response, and was referred to us for scleral window surgery. Four-quadrant scleral window surgery with external drainage of the subretinal fluid was performed, resulting in a transient partial attachment of the retina. RD started to progress again within 3 weeks, which prompted comprehensive imaging together with more advanced systemic workup for systemic lupus erythematosus and other rheumatological and immunological diseases. Systemic corticosteroid therapy was initiated during this period but did not stop the progression and was discontinued after a short time. Fluorescein angiography and indocyanine green angiography revealed multifocal choroidal leakage foci and large choroidal vessels without any intraocular inflammation findings and led to the diagnosis of atypical CSCR. Pars plana vitrectomy (PPV), internal drainage of the subretinal fluid, endolaser to the focal leakage areas, and intravitreal aflibercept injection were performed. Visual acuity increased to 0.8 within 8 months after the surgery with no recurrence. Bullous exudative RD is a very rare and atypical form of CSCR, and a favorable outcome can be obtained with PPV and surgical drainage of subretinal fluid followed by laser photocoagulation.

Intravitreal Brolucizumab for Pachychoroid Neovasculopathy Associated With Chronic Central Serous Chorioretinopathy

Purpose

To evaluate the anatomical and functional outcomes of intravitreal brolucizumab in eyes with chronic central serous chorioretinopathy complicated by pachychoroid neovasculopathy.

Methods

Retrospective analysis of 34 eyes treated with intravitreal brolucizumab. Twenty-five eyes (73.5%) had been treated with other anti-vascular endothelial growth factor agents before switching to brolucizumab, whereas nine eyes were naïve. Outcome measures included the change of central foveal thickness and subfoveal choroidal thickness, evaluation of sub/intraretinal fluid on optical coherence tomography, and change in best-corrected visual acuity.

Results

Before starting brolucizumab, 23 eyes showed subretinal fluid, 8 both subretinal and intraretinal fluid, and 3 intraretinal fluid only. At the last visit, 22 eyes (64.7%) showed complete reabsorption of both intraretinal and subretinal fluid, whereas subretinal fluid was still present in 8 eyes (23.5%), and both intraretinal and subretinal fluid in 4 eyes (11.8%). The mean number of brolucizumab injections required to achieve complete fluid reabsorption was 2.8 ± 1.8. central foveal thickness decreased from 317.8 ± 109.3 µm to 239.8 ± 74.8 µm (P = 0.0005) and subfoveal choroidal thickness decreased from 399.3 ± 86.2 µm to 355.5 ± 92.7 µm at the end of the follow-up period (P = 0.0008). The mean logarithm of the minimum angle of resolution best-corrected visual acuity improved from 0.4 ± 0.2 to 0.3 ± 0.2 at 1 month after the first injection and remained stable at the same values at the end of the follow-up period (P = 0.04).

Conclusions

Intravitreal brolucizumab is effective for the treatment of naïve and recalcitrant pachychoroid neovasculopathy.

Translational Relevance

Intravitreal brolucizumab may represent an option in patients with pachychoroid neovasculopathy complicating chronic central serous chorioretinopathy.

Increased risk of glaucoma development in patients with central serous chorioretinopathy: results of a 11-year population-based cohort study

PURPOSE

To investigate whether patients with central serous chorioretinopathy (CSC) have increased risk of developing glaucoma.

METHODS

Patients diagnosed with CSC between 1 January 2008 and 31 December 2018 were included in this study using data from the Taiwanese National Health Insurance Research Database (NHIRD). The CSC cohort was matched with a non-CSC cohort using the propensity score matching method, based on sex, age (in 10-year intervals), index date year, comorbidities, and steroid use, resulting in equal numbers of patients in both cohorts. Patients were followed up until 31 December 2019 or until they were withdrawn from the NHIRD. The incidence of glaucoma was compared between the two cohorts using the Cox regression model, and the risk of developing glaucoma was estimated using the Kaplan-Meier method.

RESULTS

After adjusting for sex, age, comorbidities, and steroid use, the CSC cohort showed a significantly higher risk of developing glaucoma compared to those without CSC (adjusted HR = 3.99; 95% CI = 3.44-4.62). The cumulative incidence of glaucoma in the CSC cohort was also significantly higher than in the non-CSC cohort (log-rank test, p < 0.001). Among the glaucoma subtypes, normal tension glaucoma had the highest risk (adjusted HR = 5.79; 95% CI = 3.41-9.85), followed by primary open-angle glaucoma (adjusted HR = 2.77; 95% CI = 2.12-3.62).

CONCLUSIONS

In conclusion, our study shows that CSC patients are at a higher risk of developing glaucoma, especially NTG. Awareness and regular glaucoma screenings are essential for patients with CSC.

Clinical feature of cystoid macular degeneration in central serous chorioretinopathy

Purpose

Cystoid macular degeneration (CMD) is a feature of chronic central serous chorioretinopathy (CSCR). Present study intended to analyze the clinical presentation, risk factors, choroidal features, and outcome of CMD in CSCR.

Methods

This was a retrospective, record-based descriptive study, which included chronic CSCR eyes with CMD. Demographic profile and clinical history were obtained from medical records. Spectralis spectral domain optical coherence tomography (SDOCT; Heidelberg Engineering,Germany) was used for acquiring SDOCT images and for performing fluorescein angiography , indocyanine green angiography , and optical coherence tomography (OCT) angiography.

Results

The study included 101 eyes of 69 consecutive patients of CSCR having CMD. The mean age of patients was 56 ± 9.4 years (range 40-79 years), and majority (63, 91.3%) of the patients were male. Prior history of corticosteroid use was present in seven (10.1%) patients. Mean time interval between the first diagnosis of CSCR and appearance of CMD was 55.3 ± 33.9 months. CMD was located away from the fovea in majority of eyes (68, 67.3%). Mean subfoveal choroidal thickness was 396.71 ± 90.5 μm. Subretinal pigment epithelium choroidal neovascularization was noted in four (3.96%) eyes.

Conclusion

CMD appears as a late complication of CSCR and is usually present away from the fovea. Such eyes had thickened choroid and fewer cases had associated choroidal neovascularization. Further comparative studies would be needed to validate these findings.

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.

[Central serous chorioretinopathy: A review]

The central serous chorioretinopathy (CSCR) is characterized by serous retinal detachments SRD associated with one or several retinal pigment epithelium detachments/irregularities (PEDs). The choroid is thickened with dilated choroidal veins and choroidal hyperpermeability suggesting an underlying choroidopathy. CSCR belongs to the pachychoroid spectrum. CSCR affects mostly middle-aged men and the main risk factor is the corticosteroid intake. In most cases, the subretinal detachment resolves spontaneously with a good visual prognosis. However, recurrent or chronic form of the disease can lead to irreversible retinal damage and decreased visual acuity. Laser on an extra foveal leak point or half dose/half fluence photodynamic therapy are the first-line treatment options.

INDOCYANINE GREEN ANGIOGRAPHY OF TYPE 1 MACULAR NEOVASCULARIZATION IN AGE-RELATED MACULAR DEGENERATION AND CENTRAL SEROUS CHORIORETINOPATHY REVEALS DIFFERENT DISEASE MECHANISMS

PURPOSE

To assess the rate of late phase hyperfluorescent plaque (LPHP) in Type 1 macular neovascularization (MNV) in central serous chorioretinopathy (CSCR) and age-related macular degeneration (AMD) and to evaluate its prognostic value.

METHODS

Retrospective study including Type 1 MNV in AMD and CSCR, from 2012 to 2020. Eyes with a late indocyanine green angiography image (>20 minutes) and clear visualization of MNV on optical coherence tomography angiography (OCTA) were included. Quantitative and qualitative parameters on optical coherence tomography and best-corrected visual acuity were recorded at baseline and after three monthly antivascular endothelial growth factor injections.

RESULTS

Eighty-three eyes were included, 35 with CSCR and 48 with AMD. Patients in the CSCR group were significantly younger than in the AMD group (61.3 ± 10.4 vs. 80.2 ± 6.8 years, respectively, P < 0.001), predominantly male (68.6% CSCR vs. 35.4% AMD; P = 0.003), and with a thicker choroid (379 ± 93.3 µ m vs. 204.2 ± 93.2 µ m; P < 0.001). Type 1 MNV in CSCR showed fewer LPHP compared with AMD (31.4% vs. 77.1%; P < 0.001). The baseline visual acuity was lower in patients with LPHP (0.37 ± 0.22 vs. 0.27 ± 0.28 logarithm of the minimum angle of resolution, P = 0.03). On multivariate analysis, AMD was associated with the presence of LPHP ( P < 0.001). No significant difference in the response to antivascular endothelial growth factor was observed.

CONCLUSION

Leakage of macromolecules from MNV and accumulation in the retinal pigment epithelium and/or in the stroma imaged by the LPHP is less common in eyes with Type 1 MNV in CSCR than in AMD. Late phase indocyanine green angiography imaging offers an insight into the metabolism of the dye and the environment surrounding the neovascular membrane.

Overlap of Genetic Loci for Central Serous Chorioretinopathy With Age-Related Macular Degeneration

Importance

Central serous chorioretinopathy (CSC) is a serous maculopathy of unknown etiology. Two of 3 previously reported CSC genetic risk loci are also associated with AMD. Improved understanding of CSC genetics may broaden our understanding of this genetic overlap and unveil mechanisms in both diseases.

Objective

To identify novel genetic risk factors for CSC and compare genetic risk factors for CSC and AMD.

Design, Setting, and Participants

Using International Classification of Diseases, Ninth (ICD-9) and Tenth (ICD-10) Revision code-based inclusion and exclusion criteria, patients with CSC and controls were identified in both the FinnGen study and the Estonian Biobank (EstBB). Also included in a meta-analysis were previously reported patients with chronic CSC and controls. Data were analyzed from March 1 to September 31, 2022.

Main Outcomes and Measures

Genome-wide association studies (GWASs) were performed in the biobank-based cohorts followed by a meta-analysis of all cohorts. The expression of genes prioritized by the polygenic priority score and nearest-gene methods were assessed in cultured choroidal endothelial cells and public ocular single-cell RNA sequencing data sets. The predictive utility of polygenic scores (PGSs) for CSC and AMD were evaluated in the FinnGen study.

Results

A total of 1176 patients with CSC and 526 787 controls (312 162 female [59.3%]) were included in this analysis: 552 patients with CSC and 343 461 controls were identified in the FinnGen study, 103 patients with CSC and 178 573 controls were identified in the EstBB, and 521 patients with chronic CSC and 3577 controls were included in a meta-analysis. Two previously reported CSC risk loci were replicated (near CFH and GATA5) and 3 novel loci were identified (near CD34/46, NOTCH4, and PREX1). The CFH and NOTCH4 loci were associated with AMD but in the opposite direction. Prioritized genes showed increased expression in cultured choroidal endothelial cells compared with other genes in the loci (median [IQR] of log 2 [counts per million], 7.3 [0.6] vs 4.7 [3.7]; P = .004) and were differentially expressed in choroidal vascular endothelial cells in single-cell RNA sequencing data (mean [SD] fold change, 2.05 [0.38] compared with other cell types; P < 7.1 × 10-20). A PGS for AMD was predictive of reduced CSC risk (odds ratio, 0.76; 95% CI, 0.70-0.83 per +1 SD in AMD-PGS; P = 7.4 × 10-10). This association may have been mediated by loci containing complement genes.

Conclusions and Relevance

In this 3-cohort genetic association study, 5 genetic risk loci for CSC were identified, highlighting a likely role for genes involved in choroidal vascular function and complement regulation. Results suggest that polygenic AMD risk was associated with reduced risk of CSC and that this genetic overlap was largely due to loci containing complement genes.

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.

[Choroidal neovascularization in central serous chorioretinopathy]

The literature review discusses the features of the pathogenesis, differential diagnosis and antiangiogenic therapy of choroidal neovascularization (CNV) associated with central serous chorioretinopathy (CSC), with particular attention given to the choice of antiangiogenic drug and therapy regimen to achieve optimal anatomical and functional outcomes in patients with CSC complicated by CNV.

Aldosterone as a Possible Contributor to Eye Diseases

Aldosterone, an effector molecule of the renin-angiotensin-aldosterone system (RAAS), has been receiving more attention in the field of ophthalmology because of its possible role in the pathogenesis of various eye diseases or abnormalities; it may even become a target for their treatment. Primary aldosteronism, a typical model of a systemic aldosterone excess, may cause vision loss due to various ocular diseases, such as retinal vein occlusion, central serous chorioretinopathy, and, possibly glaucoma. RAAS components are present in various parts and types of cells present in the eye. Investigations of the local RAAS in various animal models of diabetic macular edema, retinal vein occlusion, retinopathy of prematurity, central serous chorioretinopathy, and glaucoma have found evidence that aldosterone or mineralocorticoid receptors may exacerbate the pathology of these disorders. Further studies are needed to elucidate whether the modulation of aldosterone or mineralocorticoid receptors is an effective treatment for preventing vision loss in patients with eye diseases.

Cuticular drusen presenting with central serous chorioretinopathy in both eyes: A case report

RATIONALE

Drusen are precursor lesions to advanced age-related macular degeneration. Although cuticular drusen are located between the retinal pigment epithelium and Bruch's membrane, as are conventional drusen, they possess unique characteristics that are distinct from those of conventional drusen on clinical presentations. Central serous chorioretinopathy (CSC) is a rare complication in eyes with cuticular drusen.

PATIENT CONCERN

A 58-years-old man was referred to our institute for the treatment of persistent subretinal fluid (SRF) in both eyes. Spectral-domain optical coherence tomography revealed focal SRF that did not involve the central macula of the right eye and SRF in the central macula of the left eye. Fluorescein angiography exhibited focal leakage corresponding to SRF and hyperfluorescence resembling a "stars in the sky" appearance in both eyes. On initial presentation, the best-corrected visual acuity values were 1.2 and 0.9 in the right and left eye decimal formats, respectively.

DIAGNOSIS

Cuticular drusen presenting with CSC in both eyes.

INTERVENTIONS

No treatment was administered for CSC in the right eye, whereas photodynamic therapy was administered for CSC in the left eye.

OUTCOMES

At the 6-month visit, extrafoveal SRF persisted in the right eye and resolved in the left eye. Best-corrected visual acuity improved from 0.9 to 1.2 in the decimal format in the left eye.

LESSONS

Although cuticular drusen presenting with CSC are rare, physicians should be aware of the possibility of CSC development in eyes with cuticular drusen.

ATYPICAL CENTRAL SEROUS CHORIORETINOPATHY WITH CHOROIDAL DETACHMENT: A CASE REPORT

PURPOSE

We describe long-term follow-up of a patient with atypical chronic central serous chorioretinopathy with inferior bullous retinal detachment and 360° choroidal detachment, findings on multimodal imaging, differential diagnoses, and treatment.

METHODS

Case report.

RESULTS

A 66-year-old male patient, known case of bilateral chronic central serous chorioretinopathy on follow-up, presented to us with sudden painless worsening of vision in the right eye. The fundus examination, optical coherence tomography, and fundus fluorescein angiography showed an atypical chronic central serous chorioretinopathy with inferior bullous retinal detachment and peripheral choroidal detachment. The patient underwent half-fluence photodynamic therapy in the right eye. At 3 months post-photodynamic therapy, there was resolution of choroidal detachment and minimal subretinal fluid was persisting in the inferior periphery, with improvement in visual acuity.

CONCLUSION

Posterior choroidal loculation of fluid is a described entity in central serous chorioretinopathy. The possible explanations for anterior choroidal loculation of fluid in this case are: either a fresh excessive leakage of fluid from the posterior choroid and that fluid may have traversed to the peripheral choroid, or diffuse choroidal leakage extending up to the equatorial region, which resulted in peripheral choroidal thickening and suprachoroidal fluid accumulation.

Type one macular neovascularization in central serous chorioretinopathy: Short-term response to anti-vascular endothelial growth factor therapy

PURPOSE

The aim of this study was to assess the short-term effect of anti-vascular endothelial growth factor (VEGF) treatment on type 1 macular neovascularization (MNV) secondary to central serous chorioretinopathy (CSCR) and to identify potential predictive factors for treatment response using multimodal imaging.

METHODS

Retrospective, multicentre study in CSCR patients with MNV detected by OCT-angiography and treated with anti-VEGF injections. Clinical and multimodal imaging data before and after anti-VEGF injections was reviewed. Univariate and multivariate linear regression analyses were performed to evaluate associations between the change in central macular thickness (CMT) after anti-VEGF therapy and other factors.

RESULTS

Forty patients were included. One month after receiving a mean number of 2.7 anti-VEGF intravitreal injections, visual acuity increased significantly from 0.46 ± 0.3 logMAR at baseline to 0.38 ± 0.4 logMAR (p = 0.04). The CMT and foveal serous retinal detachment (SRD) decreased significantly from 330 ± 81.9 µm at baseline to 261.7 ± 63.1 µm after treatment (p < 0.001) and from 145.1 ± 98.8 µm at baseline to 52.6 ± 71.3 µm (p < 0.001), respectively. Subretinal fluid and/or intraretinal fluid were still present in 18 eyes (45%) one month after treatment. In the multivariate analysis, a higher SRD height was associated with a greater CMT change (p = 0.002) and a lower CMT change with the presence of subretinal hyperreflective material (SHRM) (p = 0.04).

CONCLUSION

Fluid resorption was incomplete in about half of the patients with MNV secondary to CSCR after anti-VEGF injections. Shallower SRD or the presence of SHRM were predictors of poor response to anti-VEGF.

ANGIOGRAPHIC SMOKESTACK LEAKAGE NOT ASSOCIATED WITH CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To report a series of cases with smokestack leakage on fundus fluorescein angiography outside the clinical setting of central serous chorioretinopathy.

METHODS

A multicenter, observational retrospective case series evaluating fundus fluorescein angiography on Topcon and Optos systems.

RESULTS

Seven patients with neovascularization due to ischemic retinopathy demonstrated a unique smokestack pattern of angiographic leakage. The patients' ages ranged between 44 and 71 years and were seen at 3 academic teaching hospitals in the Washington-Baltimore metropolitan area. Five patients had been diagnosed with proliferative diabetic retinopathy, one with sickle cell ischemic retinopathy, and one with branch retinal artery occlusion; none of the patients had a known history or clinical signs of current or past central serous chorioretinopathy.

CONCLUSION

This is the first published case series to the author's knowledge of ischemic retinopathy displaying a smokestack leakage pattern on fundus fluorescein angiography that is classically described with idiopathic central serous chorioretinopathy.

The Association of Pachydrusen Characteristics with Choroidal Thickness and Patient's Age in Polypoidal Choroidal Vasculopathy versus Central Serous Chorioretinopathy

We investigated the relationship between pachydrusen and choroidal thickness and age in eyes with polypoidal choroidal vasculopathy (PCV) and fellow eyes, compared to eyes with central serous chorioretinopathy (CSC). This retrospective study included 89 eyes with PCV and 146 eyes with CSC. The number, location, and shape of the pachydrusen and their association with choroidal thickness and age were analyzed. PCV eyes showed pachydrusen more frequently than eyes with CSC (52% vs. 20%, p < 0.001). Large solitary type and clustered type were more frequent in PCV eyes compared to CSC eyes (p = 0.003 and p = 0.001, respectively). Subfoveal choroidal thickness was associated with pachydrusen in eyes with PCV (odds ratio [OR] 1.006, 95% confidence interval [CI] 1.001−1.011, p = 0.027), while age was associated with pachydrusen in CSC eyes (OR 1.137, 95% CI, 1.073−1.205; p < 0.001). Pachydrusen were localized directly over the pachyvessel on optical coherence tomographic findings in approximately two thirds of PCV eyes and fellow eyes (62% and 67%, respectively). Risk factors for pachydrusen differ according to diseases. The presence of pachydrusen was associated with choroidal thickness in PCV, while the association with age was more prominent in CSC.

Association between retinal sensitivity and the presence of quiescent choroidal neovascularization in pachychoroid diseases

This study was conducted to examine retinal sensitivity (RS) in eyes with pachychoroid diseases and to analyze its association with the presence or absence of quiescent choroidal neovascularization (CNV), that can be protective against retinal dysfunction or atrophy in other macular diseases such as age-related macular degeneration. A total of 12 eyes of 12 patients aged ≥45 years having the characteristic findings of central serous chorioretinopathy but not presenting any exudative changes were included in this study. Choroidal vascular hyper permeability (CVH) was identified by indocyanine green angiography, and the presence or absence of CNV was evaluated by optical coherence tomography angiography. RS at 68 points was examined by microperimetry. The average RS corresponding to within and outside CVH was compared. The association between the difference in RS and the presence or absence of CNV was also analyzed. CNV was detected in six eyes (50%). In eyes without CNV, the RS within CVH was similar compared with that outside CVH. However, in eyes with CNV, the RS within CVH was significantly decreased compared with that outside CVH. Multiple regression analysis revealed the presence of CNV as an independent factor associated with RS. In eyes with pachychoroid diseases, RS decreased within the CVH area under the coexistence of nonexudative CNV.

Carotid dissection and central serous chorioretinopathy related to sarcoidosis-antiphospholipid syndrome: a case report

Sarcoidosis is a chronic multisystemic disease, which can be rarely associated with autoimmune disorders, such as antiphospholipid syndrome (APS). Although amaurosis fugax is an uncommon complication, its presentation can unmask a carotid artery dissection (CAD) in these diseases. In addition, central serous chorioretinopathy (CSC) has been related to vascular disorders too.

We presented a case of a Caucasian middle-aged man, who developed CAD symptoms, such as amaurosis fugax in the right eye (RE) and headache. His medical history included arterial hypertension, hypothyroidism, and Lofgren’s syndrome. On examination, retinal pigment epithelium (RPE) atrophy and subretinal fluid (SRF) in the macular area of the RE were observed. These findings were confirmed by optical coherence tomography (OCT), which also revealed an increase in choroidal thickness. However, these differed significantly from the contralateral eye. These clinical symptoms and imaging findings suggested a CSC in the RE, but not all clinical processes were justified. Subsequently, a CT angiography was performed and confirmed a significant occlusion in the right internal carotid artery and progressive sharpening of the lumen with an intimal flap due to a carotid dissection. In addition, the laboratory results were compatible with antiphospholipid syndrome (APS). To the authors’ knowledge, the patient returned to the ED due to an anterior uveitis and he is currently asymptomatic with Cemidon and Adalimumab treatment.

We described for the first time a case of carotid dissection and central serous chorioretinopathy in the context of two autoimmune-based pathologies, such as sarcoidosis and antiphospholipid syndrome.

Abbreviations: APS = Antiphospholipid syndrome, BCVA = Best-corrected visual acuity, CAD = Carotid artery dissection, CNV = Choroidal neovascular membrane, CSC = Central serous chorioretinopathy, CT = Computed tomography, ED = Emergency Department, ICAD = Internal carotid artery dissection, LE = Left eye, OCT = Optical coherence tomography, RAPD = Relative afferent pupillary defect, RPE = Retinal pigment epithelium, RE = Right eye, SRF = Subretinal fluid

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.

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

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

CILIOCHOROIDAL EFFUSION IN CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To investigate the prevalence of ciliochoroidal effusion (CE) in central serous chorioretinopathy (CSC) using anterior-segment optical coherence tomography and its association with the clinical features of CSC.

METHODS

Overall, 164 eyes of 164 patients with CSC and 51 eyes of 51 age- and sex-matched normal control participants were retrospectively examined. Anterior-segment optical coherence tomography was used to assess patients with CSC and control subjects for CE and scleral thickness. Central serous chorioretinopathy eyes were divided into two groups: eyes with CE (CE group) and eyes without CE (non-CE group). Scleral thickness was measured at the point that was 6 mm posterior to the scleral spur in four directions.

RESULTS

Among the 164 eyes with CSC, 32 eyes (19.5%) displayed CE, and this proportion was significantly higher than that in control subjects (2.0%) (P = 0.001). Scleral thickness was significantly greater in the CE group compared with the non-CE group at all four directions (P < 0.05 for all). Multivariable analysis revealed that the mean scleral thickness (odds ratio: 1.01; 95% confidence interval: 1.00-1.02; P = 0.007) was significantly associated with the incidence of CE.

CONCLUSION

Central serous chorioretinopathy may accompany fluid accumulation in the anterior segment more frequently than previously expected in association with thick sclera.

EFFICACY OF HALF-DOSE PHOTODYNAMIC THERAPY VERSUS HIGH-DENSITY SUBTHRESHOLD MICROPULSE LASER FOR TREATING PIGMENT EPITHELIAL DETACHMENTS IN CHRONIC CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

Comparing the effect of half-dose photodynamic therapy and high-density subthreshold micropulse laser treatment on retinal pigment epithelial detachments (PEDs) in chronic central serous chorioretinopathy.

METHODS

This study included data from the PLACE trial, a prospective randomized controlled trial comparing half-dose photodynamic therapy and high-density subthreshold micropulse laser treatment in chronic central serous chorioretinopathy. Main outcome measurements were changes in both the foveal PED and the highest PED within the macula at baseline compared with first and final evaluation visit.

RESULTS

At baseline, a macular PED was detected in 76.9% of patients (123/160), and a PED within 1,500 µm from the foveal center in 37.5% of patients (60/160). In the half-dose photodynamic therapy arm (61 patients), there was a significantly larger decrease in the highest macular PED compared with the high-density subthreshold micropulse laser treatment arm (62 patients) at both first and final evaluation visits (P < 0.001 and P = 0.012, respectively). The decrease of highest foveal PED was significant at first visit (P = 0.025).

CONCLUSION

Half-dose photodynamic therapy is superior to high-density subthreshold micropulse laser treatment with regard to a statistically significant reduction in the height of macular PEDs in active chronic central serous chorioretinopathy. These findings may also have implications for other diseases within the pachychoroid disease spectrum that can present with PEDs.

The Diagnostic Accuracy of Double-Layer Sign in Detection of Macular Neovascularization Secondary to Central Serous Chorioretinopathy

PURPOSE

To investigate the diagnostic value of elevated retinal pigment epithelium (RPE) and double-layer sign (DLS) in identifying macular neovascularization (MNV) secondary to central serous chorioretinopathy (CSCR).

DESIGN

Retrospective, cross-sectional study.

METHODS

Patients with CSCR underwent optical coherence tomography (OCT) and OCT angiography (OCT-A) scanning at Moorfields Eye Hospital. OCT scans were reviewed to identify the presence/absence of an RPE elevation. The maximum length and maximum height of the elevated RPE were measured. A minimum length of 1000 µm and a maximum height of 150 µm were used to define the "double-layer sign." Other qualitative anatomical features were also graded from OCT scans. OCT-A was examined to confirm the presence/absence of MNV. Binary logistic regression analyses were used to assess the association between OCT features and the detection of MNV on OCT-A. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to assess the diagnostic accuracy.

RESULTS

One hundred sixty-three eyes from 132 patients were included. Elevated RPE was detected in 148 eyes (91%). OCT-A-confirmed MNV was detected in 54 eyes (33%). The sensitivity and specificity of RPE elevation were 100% and 13.8%, respectively. DLS was identified in 95 eyes (58%). The sensitivity and specificity of DLS for detecting MNV were 87% and 56%, respectively. Hyperreflectivity and nonhomogeneity of the sub-RPE space were independently associated with MNV within the DLS (odds ratio, 17.7 and 14.8, P < .001 and P = .02, respectively). None of the other demographic or anatomical features were associated with MNV. The presence of nonhomogeneous hyperreflective RPE elevation had a sensitivity and specificity of 98% and 67%, with PPV and NPV of 60% and 99%, respectively.

CONCLUSIONS

Nonhomogeneous and hyperreflective space under an elevated RPE of any length or height indicates an eye with higher risk of MNV than DLS. OCT-A should at least be performed for these eyes to confirm the presence of MNV and treat accordingly.

CHORIORETINAL FOLDS IN PATIENTS WITH CENTRAL SEROUS CHORIORETINOPATHY

BACKGROUND AND PURPOSE

To the best of our knowledge, there is no study of patients with central serous chorioretinopathy associated with chorioretinal folds, since a short mention in Gass' stereoscopic atlas. We report here six cases with this association.

METHODS

Six patients with both conditions were examined in our institution and underwent fluorescein angiography and optical coherence tomography.

RESULTS

Patients were 3 men and 3 women, aged 44 years to 82 years. All patients were hyperopic and two received corticosteroids. Fluorescein angiography showed pigmentary changes, diffuse leakage areas typical of chronic central serous chorioretinopathy, and chorioretinal folds mainly located in the upper temporal part of the fundus. Enhanced depth imaging optical coherence tomography was performed in 5 cases and revealed a thick choroid in all cases (mean subfoveal choroidal thickness: 381 µm, range: 280-510 µm).

CONCLUSION

Although possibly coincidental, the presence of chorioretinal folds in hyperopic central serous chorioretinopathy eyes could be due to the excessive thickness of the choroid in eyes with hyperopia related to short axial length.

Bilateral retinal pigment epithelial tears in acute central serous chorioretinopathy without bullous retinal detachment: A case report

RATIONALE

Several reports have described retinal pigment epithelial (RPE) tears in central serous chorioretinopathy (CSC). However, there have been no reports of spontaneously large RPE tears in acute CSC without bullous retinal detachment (RD). Herein, we report and provide sequential images of a case of bilateral spontaneous large RPE tears in patient with acute CSC without bullous RD.

PATIENT CONCERNS

An 88-year-old female patient was admitted with impaired vision in both eyes, which began 10 days prior. The visual acuity was 0.4 and 0.5 in the right and left eye, respectively. She had started taking oral steroids 2 weeks prior for polymyalgia.

DIAGNOSIS

Ophthalmologic examinations, including fundus photography, optical coherence tomography, and fluorescence angiography, were performed, and she was diagnosed with steroid-induced acute CSC in both eyes with large pigment epithelial detachment (PED) of approximately 4-disc diameter. Discontinuation of steroids and follow-up ophthalmic examinations were performed. However, a spontaneous large RPE tear occurred in the right eye.

INTERVENTIONS

We performed follow-ups more frequently and CSC treatment such as laser photocoagulation, photodynamic therapy, and anti-vascular endothelial growth factor injections were not performed.

OUTCOMES

Nine months later, a spontaneous large RPE tear occurred sequentially in the left eye. Her final visual acuity was 0.3 and 0.15 in the right and left eye, respectively.

LESSONS

Patients may spontaneously develop large RPE tears in both eyes, despite no treatment for acute CSC with non-bullous RD. Large PED and old age may affect this. Therefore, for a CSC patient with a large PED and advanced age, attention must be paid when determining treatment.

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.

THE INCIDENCE OF NEOVASCULARIZATION IN CENTRAL SEROUS CHORIORETINOPATHY BY OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY

PURPOSE

To evaluate the incidence of neovascularization (NV) secondary to central serous chorioretinopathy (CSC)-a condition belonging to the spectrum of pachychoroid disorders by means of optical coherence tomography angiography.

METHODS

One hundred and seventy five eyes with CSC were evaluated in this retrospective observational study. The eyes with acute or chronic CSC with no NV were included in Group 1, and those with NV were evaluated in Group 2. Only eyes that had undergone structural optical coherence tomography and optical coherence tomography angiography were included. Age, best-corrected visual acuity, and subfoveal choroidal thickness were evaluated in all eyes. In Group 2, the type and morphology of NV and the occurrence of exudation were considered.

RESULTS

Of a total of 175 eyes with CSC, 86 had the acute form and 89 the chronic. Approximately 140 belonged to Group 1 (80%) and 35 to Group 2 (20%). Approximately 39.2% of all patient with chronic CSC developed NV. Mean age in Groups 1 and 2 was 53.3 years (±10.9) and 66.6 years (±10.2), respectively. Mean best-corrected visual acuity in Groups 1 and 2 was 45.7 (±11.7) and 30.9 (±17.9) early treatment diabetic retinopathy study letters, respectively. Mean CCT in Group 1 and 2 was 417.5 µm (±123) and 344.2 µm (±165.9), respectively. In Group 2, all patients had Type 1 NV (100%); 29 eyes (83%) had filamentous feature, and 6 eyes (17%) had irregular shape. Silent nonexudative NV was observed in 7 eyes (20%), all belonging to Group 2.

CONCLUSION

The use of optical coherence tomography angiography in everyday clinical practice allows for the accurate analysis of the chorioretinal vascular setting, with the identification of new vessels that could remain misdiagnosed.

Intravitreal ranibizumab for the management of serous maculopathy secondary to optic disc coloboma-associated choroidal neovascularisation

We report the case of a 19-year-old patient with symptomatic unilateral serous maculopathy associated with an optic nerve coloboma. Fluorescein angiography detected a focal late leak at the temporal edge of the coloboma which was later found to correspond with an area of choroidal neovascularisation on optical coherence tomography angiography. A course of intravitreal ranibizumab achieved good clinical and structural response. This report contributes to the evidence that maculopathies associated with cavitary optic nerve anomalies may in some instances result from choroidal neovascularisation. It also highlights the importance of angiography to identify potential choroidal neovascular membranes, particularly in the absence of haemorrhages and neovascular membranes on fundus examination and conventional optical coherence tomography.

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.

Stress and vision-related quality of life in acute and chronic central serous chorioretinopathy

BACKGROUND

To compare vision-related quality of life (VRQOL) between acute and chronic Central serous chorioretinopathy (CSC) and correlate this with Cohen's Perceived Stress Scale (PSS) questionnaire.

METHODS

Patients who were diagnosed with both acute and chronic CSC were recruited in this study. Vision-related quality of life (VRQOL) was assessed with Rasch revised National Eye Institute Visual Functioning Questionnaire 25 (NEI-VFQ25) and perceived stress with Cohen's PSS questionnaire in 118 subjects with either acute or chronic CSC. The quality of life score was compared between patients with acute and chronic CSC. Correlations between the functional score and visual acuity (VA), stage of CSC, and stress were studied.

RESULTS

There was no significant difference in VRQOL between Acute and Chronic CSC. In Acute CSC, affected eye VA correlated significantly with near vision question of the visual function subscale. Better eye VA correlated significantly with distance vision, social function, role limitation and dependency of the socioeconomic subscale. In chronic CSC, affected eye VA correlated with social function question of the socioemotional subscale and the better eye VA correlated with driving and distance vision of the visual function subscale. No other significant correlations with VA were noted. No correlations were observed between outcome of Cohen's PSS questionnaire and NEI-VFQ25 scores of acute and chronic CSC.

CONCLUSION

The VRQOL is similar between acute and chronic CSC. Perceived stress was not found to influence the VRQOL in CSC.

The Correlation of Central Serous Chorioretinopathy and Subsequent Cardiovascular Diseases of Different Types: A Population-Based Cohort Study

The aim of the present study was to survey the relationship between central serous chorioretinopathy (CSC) and several cardiovascular diseases (CVDs) with different severities using the National Health Insurance Research Database. A retrospective cohort study was conducted. Subjects with CSC were enrolled according to the relevant diagnostic codes, and an age- and gender-matched population was used as the control group with a 1:4 ratio. The main outcome being considered was the development of CVD after CSC exposure. Cox proportional hazard regression was applied to calculate the adjusted hazard ratio (aHR) of CSC and CVD of different types. A total of 2865 patients that were diagnosed with CSC were enrolled in the study group, while another 11,460 non-CSC subjects were selected as the control group. There were 171 events of CVD which occurred in the study group, while another 557 cases were found in the control group. No significant differences were observed among the CVD cases between the study and control group, whether they had an acute or chronic form, according to the aHR. In the subgroup analysis, there was a significantly higher risk of CVD development in the male population aged from 40 to 59 years (aHR: 1.351, confidence interval (CI): 1.063–1.716), which was mainly due to the higher risk of mild CVD (aHR: 1.391, CI: 1.062–1.822). On the contrary, there was no significant difference in CVD development in any of the age subgroups of the female population. In conclusion, the existence of CSC is correlated with a higher rate of chronic CVD occurrence in the middle-aged male population.

Risk Factors and Outcomes of Choroidal Neovascularization Secondary to Central Serous Chorioretinopathy

We identified clinical characteristics and risk factors of choroidal neovascularization (CNV) in eyes with prior episode of central serous chorioretinopathy (CSC). This retrospective case-control study included those initially diagnosed with CSC and developed CNV secondarily (Group 1, n = 16), those diagnosed with CNV in eyes of previous putative CSC (Group 2, n = 14), and those initially diagnosed with CSC, and did not develop CNV secondarily, as a control group for Group 1 (Group 3, n = 250). Clinical characteristics including treatment outcomes were assessed. Demographics and multimodal imaging at the time of CSC diagnosis of secondary CNV were compared between the groups to identify risk factors. Duration from diagnosis of CSC to development of CNV in Group 1 was 40.2 ± 42.0 months. Classic CNV was noted in 23 (76.7%) eyes. After treatment with intravitreal antiangiogenics with average of 4.9 times, visual acuity improved in Group 1 and Group 2 (p = 0.002). Multivariate analysis revealed that systemic hypertension, pigmentary changes, and double layer sign were associated with development of CNV secondary to CSC (p < 0.05). Hypertension, pigmentary changes, and double layer sign were independent risk factors for CNV secondary to CSC. The CNV's responded well to treatment, resulting in improved vision.

CYSTOID MACULAR EDEMA AND CYSTOID MACULAR DEGENERATION AS A RESULT OF MULTIPLE PATHOGENIC FACTORS IN THE SETTING OF CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To report the pathogenic factors that account for cystoid macular edema and cystoid macular degeneration in chronic central serous chorioretinopathy (CSC).

METHODS

The clinical course and multimodal imaging findings, including fundus color photography, fundus autofluorescence, spectral-domain optical coherence tomography, and fluorescein angiography, of one eye with cystoid macular edema due to chronic CSC was documented.

RESULTS

A 44-year old woman with a history of chronic CSC presented with progressive visual decline in the right eye. Best-corrected visual acuity was 20/40. Funduscopic examination revealed diffuse retinal pigment epithelial changes and macular edema. Fluorescein angiography demonstrated perifoveal microaneurysms and leakage in a petaloid configuration. Spectral-domain optical coherence tomography demonstrated cysts at the level of the inner nuclear layer, an epiretinal membrane, vitreomacular traction, and an attenuated retinal pigment epithelial band. Central subfield thickness was 486 μm. Three intravitreal injections of aflibercept were administered over 16 weeks following which there was resolution of leakage, release of vitreomacular traction, and resolution of microaneurysms. Central subfield thickness reduced to 379 μm, but persistent intraretinal cysts were observed. There was subjective improvement in visual symptoms, but Snellen acuity remained at 20/40.

CONCLUSION

Intraretinal cystic changes in chronic CSC may be the result of multifactorial pathogenic factors and may represent the coexistence of cystoid macular edema and cystoid macular degeneration. Anti-vascular endothelial growth factor may play an important role in the treatment of cystoid macular edema caused by CSC.

[Differential diagnostic OCT-criteria of acute and chronic central serous chorioretinopathy]

Principal differences in natural history, therapeutic approaches, and functional prognosis of acute and chronic central serous chorioretinopathy (CSC) requires that they were distinguished.

AIM

to define differential diagnostic criteria for acute and chronic CSC basing on the chorioretinal complex analysis by EDI-optical coherence tomography (OCT).

MATERIAL AND METHODS

A retrospective analysis was performed that included data of 112 patients with CSC, who were assigned to either the 'acute' (52 patients) or 'chronic' (60 patients) group depending on symptoms duration (3 months) and fluorescein angiography findings. With the enhanced depth imaging (EDI) module mounted on OCT (Spectralis, Heidelberg, Germany), the structure of the chorioretinal complex was studied.

RESULTS

In acute CSC, the height of the neuroepithelium detachment (310.73±113.63 μm) was greater than that in chronic CSC (205.68±90.80 μm), p=0.03. The frequency of subretinal deposits also differed (17.3% and 100% of cases, respectively), p<0.01. The subfoveal choroidal thicknesses were similar (462.7±110.7 and 494.7±132.1 μm, respectively, p=0.6), however, in acute CSC, diffuse thickening of the choroid was noted (39 patients, 75% of cases), while chronic CSC was marked by local dilatation of the Haller's layer (39 eyes, 65% of cases). The diameter of hyporeflective pockets in the Haller's layer in the 'acute' (324±98.1 μm) and 'chronic' (352.0±84.3 μm) groups correlated with choroidal thicknesses (r=0.68, r=0.75). Hyperreflective intrachoriodal dots were more common in the 'chronic' group (acute - 1.9%, chronic - 68.3%), so did hyperreflective vascular walls -13.5% and 68.3%, respectively, p<0.01. Dome-shaped RPE detachments were observed equally often in both groups (acute - 67.3%, chronic - 68.3%, p=0.9), while the 'double-layer sign' was only characteristic of chronic CSC (86.7%).

CONCLUSION

OCT criteria of acute CSC include a dome-shaped detachment of neuroepithelium and diffuse thickening of the choroid in the absence of deposits; of chronic CSC - subretinal deposits, local dilatation of the Haller's layer vessels, hyperreflective vascular walls, intrachoroidal dots, and the 'double-layer sign'.

External drainage for exudative retinal detachment secondary to central serous chorioretinopathy

BACKGROUND

To report the outcomes of external drainage of subretinal fluid (SRF) in exudative retinal detachment secondary to central serous chorioretinopathy (CSCR).

METHODS

Retrospective observational analysis of six eyes with exudative retinal detachment secondary to CSCR who underwent external drainage of SRF between 2004 and 2014 was performed. Collected data included demographics, steroid usage, surgical details, and visual acuity preoperatively and postoperative visual acuity and clinical examination data were collected.

RESULTS

Six eyes of six subjects were included with mean age of 45 years (range, 32 to 61 years). All subjects were male. Mean duration of symptoms was 4.6 months (range, 3 to 8 months). The pre-operative best-corrected visual acuity (BCVA) ranged from perception of light to 20/60. Four eyes were treated with conventional external drainage and two underwent Chandelier-assisted external drainage. Three cases had laser treatment before drainage and one case underwent photodynamic therapy (PDT) after drainage. The BCVA at last follow-up ranged from 20/2,000 (counting fingers at 2 feet) to 20/20. No recurrences were noted in any of the cases till the last follow-up. Mean duration of follow-up was 38 months.

CONCLUSIONS

Our study demonstrates successful management of exudative retinal detachment secondary to CSCR with external SRF drainage without any complications.

Optical Coherence Tomography Angiography of Shallow Irregular Pigment Epithelial Detachments In Pachychoroid Spectrum Disease

PURPOSE

To determine the proportion of shallow irregular pigment epithelial detachments in eyes with pachychoroid features that harbor neovascular tissue and to study the morphology of this tissue with optical coherence tomography (OCT) angiography.

DESIGN

Prospective consecutive cohort study.

METHODS

Patients with pachychoroid spectrum diagnoses and shallow irregular pigment epithelial detachment in at least 1 eye (study eye) were included. Charts and multimodal imaging were reviewed to determine a dye angiography detection rate for type 1 neovascularization in study eyes. All patients then underwent OCT angiography prospectively, followed by masked segmentation and grading.

RESULTS

Twenty-two eyes of 16 patients were included. Mean age was 71 (range 57-95) years. Mean subfoveal choroidal thickness was 381 μm (standard deviation: 141 μm). Four out of 22 study eyes (18%) exhibited polypoidal lesions. Dye angiography demonstrated specific features of neovascularization in 5 out of 17 eyes (29%) with suspected nonpolypoidal pachychoroid neovasculopathy. With OCT angiography, type 1 neovascular tissue was visualized in 21 out of 22 study eyes (95%).

CONCLUSIONS

Our data suggest that, in eyes with pachychoroid features, the finding of a shallow irregular pigment epithelial detachment on OCT has greater diagnostic value for type 1 neovascularization than previously thought and that dye angiography may underestimate the prevalence of neovascularization compared to OCT angiography.

Central serous retinopathy: an unusual cause of acute visual loss

Ophthalmologic complaints represent approximately 2% of emergency department (ED) visits. Acute vision loss is the most serious of such presentations and requires prompt assessment for a treatable cause. The differential diagnosis for acute vision loss includes retinal detachment, macular disorders, vaso-occlusive disorders, temporal arteritis, neuro-ophthalmologic disorders, and functional disorders. We report the case of a previously healthy 33-year-old man who presented to the ED with acute bilateral vision loss that was ultimately diagnosed as central serous retinopathy (CSR), an idiopathic, self-limited condition that typically affects males age 20 to 50 years. This condition is not mentioned in standard emergency medicine textbooks or the emergency medicine literature, and our hope is that our report will serve to illustrate a typical case of CSR and help prompt emergency physicians to consider this diagnosis in the appropriate circumstances.

[Patient with recurrent central serous chorioretinopathy who developed multiple evanescent white dots and serous retinal detachment immediately following bevacizumab administration]

BACKGROUND

A patient developed choroidal neovascularization (CNV) in one eye during treatment for bilateral recurrent central serous chorioretinopathy (CSC) and was intravitreously injected with bevacizumab; she developed multiple evanescent white dots and serous retinal detachment(SRD).

CASE

A 50-year-old women had a history of CSC OD at the age of 29 years. On initial examination, CSC OD was noted, and multiple detachments of the retinal pigment epithelium OU were observed. While the CSC in the right eye was successfully treated by laser photocoagulation, it spread to both eyes following this episode. Examination of the right eye by optical coherence tomography (OCT) following the recurrence of the CSC showed slight elevation of the retinal pigment epithelial layer in the central fovea, but this finding disappeared with the resolution of the CSC. However, as the CSC combined with CNV (Gass type 2) recurred within 1 year, the patient was intravitreously injected with bevacizumab. On the day following the injection, SRD OD occurred, and on the 7th day following the injection many white lesions varying in size appeared in the deep layer of the retina, but they healed 3 weeks later, leaving only the CNV. The CNV was cured later by additional photodynamic therapy.

CONCLUSION

Since the lesions of the fundus observed immediately after the bevacizumab administration resolved spontaneously without sequelae, they were retrospectively diagnosed as a white dot syndrome-like disease. The white dot syndrome-like disease is suggested as a rare complication of bevacizumab.

Central serous chorioretinopathy associated with topical corticosteroids in a patient with psoriasis

BACKGROUND

Central serous chorioretinopathy (CSC), also known as central serous retinopathy (CSR), is a visual impairment, often temporary, usually in a single eye, which mostly affects males in the age group of 20 to 50 but may also affect women. CSC occurring after prolonged use of topical steroids in a patient with psoriasis is a novel complication in the English literature.

OBSERVATIONS

We describe a case of a 25-year-old male, with a 15-year history of corticoid ointment use for psoriasis, who presented with loss of vision secondary to CSR.

CONCLUSIONS

All topical steroid treatments were discontinued and the patient recovered his vision completely. Although topical corticosteroids are frequently utilized for psoriasis management with a low rate of complication, clinicians should be familiar with this rare yet distressing condition. Furthermore, patients with increased production of endogenous corticosteroids (e.g., those with Cushing's syndrome, hypertension, or obstructive sleep apnea) should be warned of the potential of chorioretinopathy following prolonged use of topical corticosteroids.