Standard-fluence versus low-fluence photodynamic therapy in chronic central serous chorioretinopathy: a nonrandomized clinical trial

Time-periodic characteristics in the morphology of idiopathic central serous chorioretinopathy evaluated by volume scan using spectral-domain optical coherence tomography

PURPOSE

To investigate the time-period characteristics associated with morphologic changes in idiopathic central serous chorioretinopathy (CSC) using volume scans acquired by spectral-domain optical coherence tomography (SD-OCT).

DESIGN

Retrospective, observational, cross-sectional case series.

METHODS

Patients underwent visual acuity measurements, fundus examinations, fluorescein angiography, indocyanine green angiography, and SD-OCT volume scans. Patients were classified into 5 categories-acute CSC, early chronic (EC) CSC, late chronic (LC) CSC, sequelae of CSC, or recurrent CSC-according to the chronicity and the recurrence. We investigated the relationship between our classification and the detailed morphologic changes of the retinal pigment epithelium and outer retina that were observed in the SD-OCT images.

RESULTS

A total of 76 eyes from 75 patients were included in this study. Serous retinal detachment was relatively higher in acute CSC. Low to flat pigment epithelial detachments (PEDs) were most commonly observed in all stages of CSC, especially in LC CSC, but some semicircular PEDs were occasionally observed in eyes with acute or EC CSC. Retinal dragging with fibrin was most frequently observed in eyes that were in the early stage of acute CSC. A thickened posterior surface of the detached retina was most commonly observed in eyes with acute CSC, whereas a thinned posterior surface of the detached retina was observed in eyes with LC CSC. Hyperreflective dots and subretinal exudates were more commonly observed in eyes with EC and LC CSC than in eyes with acute CSC. In eyes with recurrent CSC, 2 different patterns of SD-OCT findings were observed; these patterns resembled those that were found in either acute CSC or LC CSC.

CONCLUSIONS

SD-OCT finding patterns in CSC eyes differ according to the chronicity and the recurrence of the disease. Detailed investigation of the retinal pigment epithelium and outer retina using SD-OCT could be useful for estimating the duration of CSC.

Long-term results of half-fluence photodynamic therapy for chronic central serous chorioretinopathy

PURPOSE

To report long-term functional and anatomic results of safety-enhanced photodynamic therapy (PDT) with half-dose verteporfin for chronic central serous chorioretinopathy (CSC).

METHODS

A retrospective analysis of 29 eyes of 27 patients with chronic CSC was performed. All eyes received half-dose PDT. Visual acuity, central foveal thickness, and angiographic features were evaluated.

RESULTS

Mean follow-up time was 20 months (range 12-40). Mean best-corrected visual acuity improved from 0.45 ± 0.23 logMAR to 0.08 ± 0.08 logMAR. Twenty-five eyes (86%) had a complete resolution of the subretinal fluid after only one session and 4 eyes had recurrences, 3 of them at the same leaking area observed at baseline. At the end of the follow-up all eyes (100%) showed resolution of the subretinal fluid. There was no visual loss secondary to exaggerated response to the PDT, nor any other adverse events.

CONCLUSIONS

The long-term results of this study further support the safety and effectiveness of safety-enhanced PDT with half dose of verteporfin for the treatment of chronic CSC.

Spectral domain optical coherence tomography and angiographic findings in multifocal posterior pigment epitheliopathy treated with low-fluence photodynamic therapy

PURPOSE

The aim was to evaluate spectral domain optical coherence tomographic (SD-OCT), fluorescein angiography (FA) and indocyanine green angiography (ICGA) findings in multifocal posterior pigment epitheliopathy (MPPE) treated with low-fluence photodynamic therapy.

METHODS

A 54-year-old Japanese man with serous retinal detachment (SRD) and pigment epithelial detachment (PED) due to multifocal posterior pigment epitheliopathy in the right eye was managed with ICGA-guided low-fluence photodynamic therapy. Outcome measures included visual acuity, SD-OCT appearance and FA and ICGA findings.

RESULTS

The patient received low-fluence photodynamic therapy within two weeks after the onset of symptoms. After treatment, serous retinal detachment and PED resolved in two weeks. Visual acuity returned to 1.0, the external limiting membrane and the photoreceptor inner and outer segment junction integrity were restored and the subfoveal choroidal thickness was greatly reduced. There has been no recurrence in six months. FA demonstrated stoppage of leakage and ICGA showed a marked decrease of choroidal venous dilation and vascular hyperpermeability.

CONCLUSION

To our knowledge, this is the first report to examine photoreceptor integrity, foveal choroidal thickness and choroidal circulation in a case of MPPE treated with low-fluence photodynamic therapy. Early application of the photodynamic therapy led to restoration of photoreceptor integrity with improvement of choroidal thickness and circulation.

Evaluation of verteporfin pharmakokinetics--redefining the need of photosensitizers in ophthalmology

INTRODUCTION

The benzoporphyrine derivative verteporfin has lost its importance to the treatment of the most frequent neovascular eye diseases. Nevertheless, it is still mandatory to define the remaining applications, role, and potential of verteporfin in ocular photodynamic therapy (PDT), including the dosages of administration, effectiveness, and safety profile.

AREAS COVERED

Although verteporfin PDT has forfeited the first-line status and value of treating subfoveal choroidal neovascularization (CNV) due to age-related macular degeneration or pathologic myopia, the treatment remains the standard of care for choroidal haemangioma and polypoidal choroidal vasculopathy. PDT is effective in less pigmented choroidal melanoma as well as in retinal vascular proliferations and retinal angioma. Verteporfin was granted the orphan drug designation for the treatment of chronic or recurrent central serous chorioretinopathy (CSC).

EXPERT OPINION

Evidence-based data regarding optimized parameters (low fluence, reduced dose, fractionated irradiation) adapted to the treated diseases (target structure, dosimetry, blood supply) are scarce. Prospective and large clinical trials are missing, although the scientific community agrees on the fact that the standard treatment protocol does not necessarily provide the optimal efficacy to the specific disease or individual patient. Within the reviewed indications, the adverse effect profile is favorable compared with other therapies.

Very minimal fluence photodynamic therapy for chronic central serous chorioretinopathy

OBJECTIVE

To describe the safety and efficacy of very minimal fluence photodynamic therapy (PDT) for chronic central serous chorioretinopathy (CSC).

DESIGN

Retrospective case series.

PARTICIPANTS

Five patients with chronic CSC. Two had previously failed alternative therapies, and one was taking concomitant corticosteroids.

METHODS

Patients were treated with very minimal fluence PDT (12 J/cm(2), 150 mW/cm(2), for 80 seconds). Median follow-up time after PDT was 100 days (range, 51 to 154).

RESULTS

All patients experienced an improvement in visual acuity and symptoms, as well as complete resolution of subretinal fluid.

CONCLUSIONS

Very minimal fluence PDT appears to be a safe and effective treatment for chronic CSC. Based on these preliminary findings, a randomized controlled trial is warranted.

[Experiences with chronic central serous chorioretinopathy treated with half-dose photodynamic therapy and verteporfin]

BACKGROUND

Chronic central serous chorioretinopathy (CSR) is an idiopathic, often self-limiting disease usually occurring in younger patients. A characteristic sign of CSR is a serous detachment of the neurosensory retina. Prognosis with regard to visual acuity is generally good. The disease is chronic or recurrent in up to 30% of cases. There is a risk for the development of secondary choroidal neovascularization. Therapeutic options include photocoagulation or photodynamic therapy (PDT) with verteporfin. In recent years there have been several approaches aiming to minimize the side-effects of PDT and the treatment protocols were designated half-dose, reduced fluence or low fluence PDT.

PATIENTS AND METHODS

A total of 7 eyes from 6 male patients with CSR were analyzed retrospectively. Before half-dose PDT and at the end of follow-up best corrected visual acuity and retinal thickness were measured by spectral domain-optical coherence tomography.

RESULTS

The mean age of the patients was 40.7 ± 10.3 years, 5 eyes were treated with a single session of half-dose PDT (25 J / cm(2)), 1 with 2 PDTs and 1 with a total of 3 PDTs. Mean follow-up was 79.8 ± 104.5 months. Mean visual acuity (Snellen) before PDT was 0.4 ± 0.2 and 0.4 ± 0.3 after PDT (p = 0.49). During the observation period the mean retinal thickness (RT) decreased from 479 μm ± 233 to 242 μm ± 60 (p = 0.08).

CONCLUSIONS

Half-dose PDT is a safe option for patients with long-standing CSR. All patients showed a decrease of retinal thickness, 6 eyes showed a total resolution of subretinal fluid and 5 eyes also showed functional improvement.

Detection of morphologic alterations by spectral-domain optical coherence tomography before and after half-dose verteporfin photodynamic therapy in chronic central serous chorioretinopathy

PURPOSE

To study the morphologic features of serous retinal detachment, the photoreceptor inner and outer segment junction line, retinal pigment epithelium irregularities, pigment epithelial detachment, and the subfoveal choroid before and after treatment of chronic central serous chorioretinopathy, using spectral-domain optical coherence tomography.

METHODS

We studied 17 eyes of 17 consecutive patients (all men) with chronic central serous chorioretinopathy. We performed photodynamic therapy (PDT) with half-dose (3 mg/m2) verteporfin. We studied morphologic features using spectral-domain optical coherence tomography before and at 1, 3, 6, and 12 months after PDT.

RESULTS

Retinal detachment showed reattachment in 16 of the 17 eyes by 3 months after PDT. The inner and outer segment junction line could be visualized in 13 eyes at 6 months after PDT. Retinal pigment epithelium irregularities were confirmed in all 17 eyes before and during the year after PDT. Pigment epithelial detachment initially disappeared but then recurred in 5 eyes after PDT. Subfoveal highly reflective substances first lessened in intensity but then again became prominent in 2 eyes.

CONCLUSION

The authors identified recurrent pigment epithelial detachment and/or retinal detachment during the 1-year period after PDT. Even if retinal detachment initially disappears, retinal pigment epithelium or choroidal morphologic changes can still develop. The effect of half-dose PDT for chronic central serous chorioretinopathy may thus be temporary.

Association between the efficacy of half-dose photodynamic therapy with indocyanine green angiography and optical coherence tomography findings in the treatment of central serous chorioretinopathy

PURPOSE

To determine the efficacy of half-dose photodynamic therapy (PDT) in relation to indocyanine green angiography (ICGA) and optical coherence tomography (OCT) findings for treating chronic central serous chorioretinopathy (CSC).

DESIGN

Observational case series.

METHODS

Thirty-eight eyes of 37 patients with chronic CSC and symptoms for at least 6 months were recruited. PDT was performed using half the normal dose of verteporfin. A total light energy of 50 J/cm(2) over 83 seconds was delivered to the area of choroidal hyperfluorescence as observed on ICGA. The resolution of the subretinal fluid and recurrence rates were assessed in relation to the different degrees of choroidal hyperfluorescence and the distribution of fluid in the neuroepithelium, namely subretinal fluid or posterior retinal cystoid degeneration.

RESULTS

After half-dose PDT a dry macula was obtained in 86.8% and 92.1% of the eyes at 1 month and at the last follow-up (14.2 ± 5.8 months) respectively. ICGA at baseline showed intermediate and intense hyperfluorescence in 39.4% and 60.5% of the eyes respectively. All eyes with intermediate hyperfluorescence had only subretinal fluid at OCT and a dry macula was obtained in 87% and 100% at 1 month and at the last follow-up after half-dose PDT. In the intense hyperfluorescence group, 82.6% and 17.4% of the eyes had subretinal fluid only or both subretinal fluid and posterior retinal cystoid degeneration respectively. In the intense hyperfluorescence group with subretinal fluid only, a dry macula was obtained in 89.5% and 100% of the eyes at 1 month and at the last follow-up respectively. In the intense hyperfluorescence group with both subretinal fluid and posterior retinal cystoid degeneration, a dry macula was obtained in 75% and 25% of the eyes at 1 month and at the last follow-up respectively. Overall, of the 23 eyes with intense hyperfluorescence, 20 eyes (87%) had a dry macula starting from 1 month for the entire follow-up period.

CONCLUSION

The half-dose PDT success rate in eyes with chronic CSC depends also on the distribution of fluid in the neuroepithelium. Half-dose PDT might not be effective or the recurrence rate might be high in eyes with posterior retinal cystoid degeneration.

[Low-fluence photodynamic therapy in chronic central serous chorioretinopathy]

OBJECTIVE

To evaluate safety and efficacy of low-fluence photodynamic therapy (LFPDT) with verteporfin in patients affected with chronic central serous chorioretinopathy (CCSC), in terms of visual acuity (VA) and macular morphology measured with optical coherence tomography (OCT).

METHODS

A retrospective, non-randomized and interventionist analysis was performed on 16 eyes in 15 patients with CCSC treated with LFPDT. Best corrected visual acuity (BCVA) with ETDRS optotypes and central foveal thickness (CFT) in OCT were evaluated as outcome measures.

RESULTS

The mean follow-up was 10.8 months. The mean BCVA improved from 58.12 to 68.68 ETDRS letters, and CFT decreased from 280.5 to 172.18 microns, with subretinal fluid resolution in 14 eyes (87.5%), two of them after a second LFTPD. No complications related to treatment were recorded.

CONCLUSIONS

LFPDT with verteporfin can be useful in CCSC to stabilise or improve BCVA, reabsorb subretinal fluid and reduce CFT. Randomised studies with a longer follow-up are required to assure the role of this treatment and to optimise parameters for higher efficacy and safety in CCSC patients.

Retinal sensitivity after photodynamic therapy with half-dose verteporfin for chronic central serous chorioretinopathy: short-term results

BACKGROUND

To assess retinal sensitivity after photodynamic therapy (PDT) with half-dose verteporfin in patients with chronic central serous chorioretinopathy.

METHODS

Sixteen eyes with chronic chorioretinopathy treated using PDT with half-dose verteporfin were enrolled. Microperimetry covering the central area 12 degrees in diameter was performed before and at 1 month and 3 months after PDT. Retinal sensitivities within the retinal serous detachment before PDT, the PDT spot area, and the central area 2 degrees in diameter were evaluated.

RESULTS

Fourteen of 16 eyes showed complete resolution of retinal detachment at 3 months after PDT. Mean retinal sensitivities within the retinal serous detachment before and at 1 month and 3 months after PDT were 8.9 dB, 12.1 dB, and 14.7 dB, respectively. Mean retinal sensitivities within the PDT spot area were 11.0 dB, 14.2 dB, and 15.7 dB, respectively. Mean retinal sensitivities in the central area 2 degrees in diameter were 6.0 dB, 9.9 dB, and 12.5 dB, respectively. Mean retinal sensitivities at both 1 month and 3 months after PDT showed statistically significant improvements as compared with before PDT (both, P < 0.05).

CONCLUSION

Photodynamic therapy with half-dose verteporfin appears to be an effective and safe treatment for patients with chronic chorioretinopathy, improving retinal sensitivity for at least 3 months.

Finasteride for chronic central serous chorioretinopathy

PURPOSE

To evaluate the safety and efficacy of finasteride, an inhibitor of dihydrotestosterone synthesis, in the treatment of chronic central serous chorioretinopathy.

METHODS

Five patients with chronic central serous chorioretinopathy were prospectively enrolled in this pilot study. Patients were administered finasteride (5 mg) daily for 3 months, after which study medication was withheld and patients were observed for 3 months. Main outcome measures included best-corrected visual acuity, central subfield macular thickness, and subretinal fluid volume as assessed by optical coherence tomography. Serum dihydrotestosterone, serum testosterone, and urinary cortisol were also measured.

RESULTS

There was no change in mean best-corrected visual acuity. Mean center-subfield macular thickness and subretinal fluid volume reached a nadir at 3 months and rose to levels that were below baseline by 6 months. The changes in both optical coherence tomography parameters paralleled those in serum dihydrotestosterone level. In four patients, center-subfield macular thickness and/or subretinal fluid volume increased after discontinuation of finasteride. In the remaining patient, both optical coherence tomography parameters normalized with finasteride and remained stable when the study medication was discontinued.

CONCLUSION

Finasteride may represent a novel medical treatment for chronic central serous chorioretinopathy. Larger controlled clinical trials are needed to further assess the efficacy of finasteride for the treatment of central serous chorioretinopathy.

A randomized pilot study of low-fluence photodynamic therapy versus intravitreal ranibizumab for chronic central serous chorioretinopathy

PURPOSE

To report 6-month outcomes of a prospective, randomized study comparing the efficacy and safety between low-fluence photodynamic therapy (PDT) and intravitreal injections of ranibizumab in the treatment of chronic central serous chorioretinopathy.

DESIGN

Prospective, randomized, single-center pilot study.

METHODS

Sixteen eyes with chronic central serous chorioretinopathy were randomized to receive either low-fluence PDT or intravitreal injections of ranibizumab: 8 eyes in the low-fluence PDT group and 8 in the ranibizumab group. Rescue treatment was considered if subretinal fluid was sustained after completion of primary treatment: low-fluence PDT for the ranibizumab group and ranibizumab injection for the low-fluence PDT group. Main outcome measures were excess foveal thickness, resolution of subretinal fluid, choroidal perfusion on indocyanine green angiography, and best-corrected visual acuity.

RESULTS

At 3 months, the mean excess foveal thickness was reduced from 74.1 ± 56.0 μm to -35.4 ± 44.5 μm in the low-fluence PDT group (P = .017) and from 26.3 ± 50.6 μm to -23.1 ± 56.5 μm in the ranibizumab group (P = .058). After a single session of PDT, 6 eyes (75%) in the low-fluence PDT group achieved complete resolution of subretinal fluid and reduction of choroidal hyperpermeability, whereas 2 (25%) eyes in the ranibizumab group achieved this after consecutive ranibizumab injections. Four eyes (50%) in the ranibizumab group underwent additional low-fluence PDT and accomplished complete resolution. At 3 months, significant improvement of best-corrected visual acuity was not demonstrated in the low-fluence PDT group (P = .075), whereas it was observed in the ranibizumab group (P = .012). However, the tendency toward improvement of best-corrected visual acuity was not maintained.

CONCLUSIONS

In terms of anatomic outcomes, the effect of ranibizumab injections was not promising compared with that of low-fluence PDT.

Visual function following photodynamic therapy for central serous chorioretinopathy: a comparison of automated macular microperimetry versus best-corrected visual acuity

BACKGROUND

The study compares the change in best-corrected visual acuity with the change in central retinal sensitivity before treatment and 6 months after treatment with photodynamic therapy in patients with symptomatic central serous chorio retinopathy.

DESIGN

Prospective, single-centre, interventional case series.

PARTICIPANTS

Eleven consecutive patients with previously untreated central serous chorio retinopathy.

METHODS

Patients had microperimetry and best-corrected visual acuity recorded before and 6 months after treatment with photodynamic therapy. Refracted best-corrected visual acuity was assessed at 2 m and adjusted to give the number of letters read at 1 m. Threshold microperimetry was performed by presenting a Goldman III stimulus to 29 points over the central 12° around fixation. Significant visual improvement at 6 months was defined as a best-corrected visual acuity ≥10 letters or, microperimetry change in mean retinal sensitivity ≥2 decibels (dB).

MAIN OUTCOME MEASURES

Improvement in best-corrected visual acuity compared with microperimetry following photodynamic therapy treatment in patients with central serous chorio retinopathy.

RESULTS

All patients reported a subjective improvement in vision and had complete resolution of subretinal fluid at 6 months. Two patients had a significant improvement in best-corrected visual acuity (mean ± SD +4.2 ± 5.8 letters), compared with all 11 patients who recorded a significant improvement in mean retinal sensitivity (mean ± SD 4.6 ± 1.9 dB) (P < 0.001).

CONCLUSIONS

These data suggest that compared with microperimetry, best-corrected visual acuity is underestimating the effectiveness of photodynamic therapy in the treatment of central serous chorio retinopathy.

[Photodynamic therapy for chronic central serous chorioretinopathy and diffuse retinal epitheliopathy]

PURPOSE

To report outcomes in patients with long-standing (more than 6 months) chronic central serous chorioretinopathy (CSC) treated with low-fluence Visudyne(®) photodynamic therapy (LFV-PDT).

PATIENTS AND METHODS

The clinical, angiographic and optical coherence tomography (OCT) results of patients with long-standing chronic central serous chorioretinopathy (CCSC) treated with LFV-PDT in the Lyon Centre Rabelais between 2002 and 2008 were retrospectively analyzed. A comprehensive check-up (macular syndrome signs, ETDRS best-corrected visual acuity [BCVA], biomicroscopy, fluorescein [FA] and indocyanine green [ICGA] angiographies, OCT scans) was performed before LFV-PDT treatment and 3 months later. Patients were then followed regularly and retreated in case of recurrence. The LFV-PDT treatment, with a fluence of 25 J/cm(2) at an irradiance of 300 mW, was guided by ICGA.

RESULTS

Forty-one eyes of 34 patients (27 males; mean age: 53 years) were included, of which 18 eyes had already been treated with laser photocoagulation. Several leaking points were visible on FA in most of the cases (n=38), mainly in the macula (35 cases). Before treatment, metamorphopsia was noted in 51% of the cases, intraretinal edema (IRE) was present on OCT scans in 71%, serous retinal detachment (SRD) in 85%, and pigment epithelial detachment (PED) in 10%. Thirty-nine eyes had only one treatment session and one eye was retreated once. At 3 months after LFV-PDT, IRE was present in 15% of the cases, SRD in 12%, and PED in 2%. At the end of the 20-month follow-up, IRE was present in 14% of the cases, SRD in 15%, and PED in 0%. Macular atrophy was observed on OCT in most of the cases at the end of the follow-up (mean central thickness, 144.5 μm). Compared to the initial BCVA, at 3 months after LFV-PDT, BCVA decreased in 22% of the cases, stabilized in 39%, and increased in 39%, while at the end of the follow-up, BCVA decreased in 12% of the cases, stabilized in 17%, and increased in 71%. No complication was observed.

DISCUSSION

LFV-PDT treatment for patients with long-standing chronic central serous chorioretinopathy results in anatomical and functional improvement (sustained disappearance of the exudative phenomenon in most cases and increased BCVA in more than two-thirds of the cases). The macular atrophy observed may be due to the treatment or the natural course of the disease.

Review and update of central serous chorioretinopathy

PURPOSE OF REVIEW

Greater understanding of central serous chorioretinopathy (CSCR) has changed initial beliefs that CSCR is a benign condition affecting young men with almost complete resolution. CSCR has a spectrum of presentations with more diffuse retinal dysfunction and variations between races. CSCR can affect older individuals and in a subset of patients may lead to significant ocular morbidity.

RECENT FINDINGS

Advances in imaging, particularly in indocyanine green angiography and optical coherence tomography, have led to a greater understanding of the pathophysiology of this condition. Treatments for CSCR are still evolving, in particular photodynamic dynamic therapy using lower doses and reduced fluence showing promising results. More research is required on ideal dosage. Anti-vascular endothelial growth factor treatment offers a new medical treatment modality with promising results.

SUMMARY

There have been recent imaging developments in addition to therapeutic advances for refractory CSCR.

Functional retinal changes measured by microperimetry in standard-fluence vs low-fluence photodynamic therapy in chronic central serous chorioretinopathy

PURPOSE

To evaluate the effect of low-fluence photodynamic therapy (PDT) on central retinal sensitivity and fixation stability as compared with standard-fluence PDT for treating chronic central serous chorioretinopathy (CSC).

DESIGN

Prospective longitudinal follow-up of patients enrolled in a nonrandomized clinical trial of standard-fluence vs low-fluence PDT in chronic CSC.

METHODS

Forty-two eyes (42 patients) with chronic CSC were enrolled; 19 eyes received indocyanine green angiography-guided standard-fluence PDT (50 J/cm(2)) and 23 received indocyanine green angiography-guided low-fluence PDT (25 J/cm(2)). Retinal sensitivity in the central 12 degrees and fixation stability were evaluated by MP-1 microperimeter at baseline and at 3 and 12 months after PDT.

RESULTS

Mean central retinal sensitivity improved significantly at all time points (at 12 months vs baseline P < .01, Tukey-Kramer test), in the standard-fluence group from 11.9 to 14.4 at 12 months, and in the low-fluence-group from 11.8 to 16.3, with a significant difference between the 2 groups (P = .04, t test). Fixation stability did not change in either group (not significant, analysis of variance). At 12 months' follow-up the retinal sensitivity significantly correlated with best-corrected visual acuity in both groups (standard-fluence, r = -0.52, P = .02; low-fluence, r = -0.54, P = .01).

CONCLUSIONS

The study shows a significant improvement in macular sensitivity after PDT in eyes with chronic CSC, with greater efficacy in low-fluence-treated eyes. Microperimetry data suggest that low-fluence PDT may be a good treatment option in patients with chronic CSC.

Single-session combined photodynamic therapy with verteporfin and intravitreal anti-vascular endothelial growth factor therapy for chronic central serous chorioretinopathy: a pilot study at 12-month follow-up

BACKGROUND

To report the anatomic and functional outcomes of a single-session combined photodynamic therapy with verteporfin (PDT) and intravitreal (IVT) anti-vascular endothelial growth factor (anti-VEGF) in patients with chronic central serous chorioretinopathy (CCSCR).

METHODS

Retrospective interventional comparative case series of eyes with symptomatic CCSCR (duration ≥ 4 months) and macular neurosensory retinal detachment (MNSRD). The study group, eight eyes (six patients), received a single session of combined full-fluence PDT and IVT anti-VEGF [bevacizumab (2.5 mg), four eyes; pegaptanib sodium [0.3 mg], four eyes). A matched control group, ten eyes (seven patients), treated with full-fluence PDT alone, was included. All patients had 12 months of follow-up.

RESULTS

The mean CCSCR duration was 12.5 ± 14.2 months (range: 4-47 months) in the study group. In the control group, the mean CCSCR duration was 15.3 ± 7.5 months (range: 4-24 months). In the study group, the mean logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) improved from 0.6 (20/80) to 0.2 (20/30) (P = 0.011). Central macular thickness (CMT) measured by optical coherence tomography (OCT) decreased from 288.4 μ (range: 165-375 μ) at baseline to a CMT of 163.1 μ (range: 120-200 μ) (P = 0.005) at 12 months. In the control group, the mean logMAR BCVA improved from 0.7 (20/100) to 0.6 (20/80) (P = 0.43). CMT decreased from 332.9 μ (range: 171-495 μ) at baseline to a CMT of 213.1 μ (range: 133-307 μ) (P = 0.002) at 12 months. At 12 months, MNSRD resolved completely in eight eyes (100%) and in seven eyes (70%), in the study group and the control group respectively. In the control group, four eyes (40%) required more than one PDT session (mean: 2.6 sessions; range: 2-4) due to persistent MNSRD. Retinal pigment epithelium (RPE) atrophy changes but no leakage were seen by fluorescein angiography in all eight eyes (100%) in the study group, and in three out of ten eyes (30%) in the control group. No systemic adverse events were observed.

CONCLUSIONS

Combined PDT and IVT anti-VEGF therapy seems to aid in the resolution of MNSRD in patients with CCSCR. Combination therapy was associated with a rapid reduction in MNSRD and improvement in BCVA with no recurrences at 12 months. However, combination therapy with full-fluence PDT has the potential to accelerate RPE atrophy, and this needs further study.

Comparison of efficacy and safety between half-fluence and full-fluence photodynamic therapy for chronic central serous chorioretinopathy

PURPOSE

To compare the efficacy and safety of half-fluence photodynamic therapy (PDT) and conventional PDT in chronic central serous chorioretinopathy.

METHODS

A multicenter retrospective comparison study. Retrospective review of 60 patients including 29 patients (34 eyes) who received half-fluence PDT and 31 patients (33 eyes) who received conventional PDT for the treatment of chronic central serous chorioretinopathy. Best-corrected visual acuity, central fovea retinal thickness and resolution of subretinal fluid on optical coherence tomography, and choroidal perfusion decrease on indocyanine green angiography were assessed. Choriocapillaris perfusion decrease was quantified as mean gray value ratio of treated and nontreated areas using commercial imaging software.

RESULTS

Treatment success without recurrence was achieved in 32 of 34 eyes (94.1%) treated with half-fluence PDT and 33 of 33 eyes (100%) treated with conventional PDT (P = 0.493). There was no difference in final best-corrected visual acuity (logarithm of the minimal angle of resolution) between the 2 groups (0.17 ± 0.32 vs. 0.21 ± 0.39; P = 0.603). Choriocapillaris perfusion decrease quantified from post-PDT indocyanine green angiography was significantly more severe in the conventional PDT group (P = 0.006), and it showed a positive correlation with retinal thinning after PDT (R = 0.380; P < 0.001).

CONCLUSION

Half-fluence PDT is as effective as conventional PDT, while minimizing the deleterious effect on choriocapillaris perfusion and retinal thickness.

Microperimetric changes after photodynamic therapy for central serous chorioretinopathy

PURPOSE

To evaluate the effect of half-dose verteporfin photodynamic therapy (PDT) on macular function in cases of central serous chorioretinopathy (CSC).

DESIGN

Interventional case series.

METHODS

A total of 24 eyes from 24 cases of CSC were included in this study. In each eye, at baseline and 1, 3, and 6 months after half-dose PDT, logMAR best-corrected visual acuity (BCVA); central 10-degree, 20-degree, and paracentral 10-degree to 20-degree retinal sensitivity; and also mean retinal sensitivity results for each case over the area that was treated with half-dose PDT (PDT spot area) by MP-1 microperimetry and optical coherence tomography (OCT) foveal morphologic changes were assessed. The MP-1 microperimetry sensitivity map was overlaid onto an indocyanine green angiography image recorded on a Heidelberg scanning laser ophthalmoscope using dedicated MP-1 software to evaluate the PDT laser spot area.

RESULTS

After treatment, BCVA and central 10-degree, 20-degree, paracentral 10-degree to 20-degree, and PDT laser spot area retinal sensitivity were improved significantly. In OCT in 20 of 24 eyes (83%), subretinal fluid (SRF) was resolved 1 month after half-dose PDT. At 3 and 6 months after treatment, SRF was resolved at all eyes. None of the patients in this study developed any systemic or ocular adverse events associated with verteporfin treatment.

CONCLUSION

Half-dose verteporfin PDT induced a significant increase in central 10-degree, 20-degree, paracentral 10-degree to 20-degree, and also PDT laser spot area retinal sensitivity over 6 months in cases of CSC.

Long-term results of photodynamic therapy for choroidal neovascularization in Japanese patients with pathologic myopia

OBJECTIVE

To determine the results of photodynamic therapy (PDT) in highly myopic eyes with choroidal neovascularization (CNV).

DESIGN

Open-label, consecutive, interventional case series.

METHODS

Forty-eight eyes of 46 consecutive Japanese patients with a myopic CNV were studied. The eyes were treated with PDT and were followed up from 1 to 4 years. The best-corrected visual acuities (BCVAs) at the baseline and after the PDT were compared. Multivariate regression analyses were used to determine the factors that were significantly associated with the BCVA at 3 or 4 years.

RESULTS

The mean follow-up period was 3.2 years. Sixty-nine percent of the patients obtained angiographic closure by a single PDT treatment, and the average number of PDT treatments was 1.4. Chorioretinal atrophy developed in 61% of the eyes at 3 years and in 70% of the eyes at 4 years. The BCVA did not change significantly after the PDT. Multivariate regression analyses showed that the BCVA at 3 years was significantly correlated with the baseline BCVA and area of chorioretinal atrophy. Analyses of the 20 patients at 4 years or more showed that in 5 of 7 (71.4%) patients with juxtafoveal CNV, chorioretinal atrophy did not develop and that all had BCVA of 0.5 or better. However, in 12 of the 13 patients with a subfoveal CNV, chorioretinal atrophy developed at 4 years, and 10 of these patients had BCVA of 0.1 or worse.

CONCLUSIONS

In highly myopic patients, 69% obtained angiographic closure by a single PDT treatment, and recurrence was rare. These findings indicate that PDT is still a good option for treating CNVs in highly myopic patients.

Central serous chorioretinopathy: an update on pathogenesis and treatment

Central serous chorioretinopathy (CSC) is a chorioretinal disease, incompletely understood with systemic associations, a multifactorial aetiology, and a complex pathogenesis. Increased permeability from the choriocapillaris leads to focal or diffuse dysfunction of the retinal pigment epithelium causing a detachment of the neurosensory retina. CSC has been described in patients with endogenously high levels of corticosteroids as well as in patients with hypercortisolism due to the treatment of ocular or systemic diseases. It is therefore the only 'inflammatory' choroiditis, not proven to be associated with infection that is precipitated or worsened by glucocorticoids. Foveal attenuation, chronic macular oedema, and damage of the foveal photoreceptor layer have been reported as causes of visual loss in CSC. Photoreceptor atrophy in the fovea, despite successful retinal reattachment, typically occurs after a duration of symptoms of approximately 4 months. Treatment should therefore be considered after 3 months if there is angiographic evidence of ongoing foveal leakage in recurrent chronic CSC or in a single CSC episode accompanied by signs of chronic CSC alterations. Based on results of trials conducted so far, it appears that photodynamic therapy with verteporfin is effective and safer than argon laser treatment and should be considered as the treatment of choice, whereas micropulse diode laser photocoagulation seems to be an effective alternative. Glucocorticoid inhibitors are an interesting alternative treatment. Clinical trials are ongoing to test their efficacy. In addition, it is important, where possible, to discontinue any corticosteroid treatment. The possible association of CSC with stress should also be discussed with patients.