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

[Morphological and functional changes of secondary macular neovascularization in central serous chorioretinopathy under anti-VEGF treatment]

BACKGROUND

Investigation of the morphological changes by optical coherence tomography angiography (OCT-A) and the development of visual acuity in secondary macular neovascularization (sMNV) in central serous chorioretinopathy (CCS) during anti-vascular endothelial growth factor (VEGF) treatment.

PATIENTS AND METHODS

Retrospective study of all treatment-naïve eyes with respect to anti-VEGF treatment, in which sMNV in CCS was detected by fluorescein angiography (FA) and OCT‑A and which were treated at the University Eye Hospital Würzburg between July 2021 and the end of December 2022. All patients were treated according to a pro re nata injection regimen (PRN regimen) and followed up for 1 year.

RESULTS

In the study 20 eyes from 16 patients with sMNV in CCS were included. Using FA the sMNV could be confirmed in 35% of cases and using OCT‑A in 100% of cases. Morphologically, the sMNV was clearly demarcated by OCT‑A as "sea-fan"-like in 10 eyes and filamentous in 10 eyes. The decrease in area of the sMNV from 0.94 ± 1.2 mm2 at baseline to 0.72 ± 0.82 mm2 at 12 months was not statistically significant (p = 0.12). During the observational period an average of 8.7 ± 1.6 intravitreal injections (IVOM) were administered (5-12 IVOM, median 9 IVOM).

DISCUSSION

Both FA and OCT‑A were used to detect sMNV in CCS, with OCT‑A providing more reliable detection of sMNV than FA. With OCT‑A two different types of sMNV could be detected: 1) the "sea-fan" type and 2) the filamentous MNV type. Within the first year of treatment sMNV in CCS requires a comparable number of IVOMs as the treatment of neovascular age-related macular degeneration.

Association between subretinal fluid duration in central serous chorioretinopathy and chorioretinal structure in unaffected fellow eyes

This study investigated the association between the duration of subretinal fluid (SRF) persistence in affected eyes and baseline chorioretinal structure in unaffected fellow eyes among patients with unilaterally naïve central serous chorioretinopathy (CSC). This retrospective case series comprised 25 healthy control patients and 46 patients with unilaterally naïve CSC, defined as first-episode and untreated within 1 month from symptom onset, who were categorized into prolonged (> 3 months) and nonprolonged (≤ 3 months) groups according to SRF duration in affected eyes from the first visit. Central retinal thickness, outer nuclear layer thickness, central choroidal thickness (CCT), luminal area (LA), stromal area (SA), total choroidal area (TCA), and choroidal vascularity index (CVI) were measured in unaffected fellow eyes at the first visit, and the duration of SRF persistence in affected eyes was recorded. As a result, CCT, SA and TCA were significantly greater, and CVI was significantly lower in the unaffected fellow eyes compared to the healthy control eyes (all p < 0.05). The optimal model for predicting SRF persistence > 3 months in affected eyes involved CVI (p = 0.015) in fellow eyes. Baseline choroidal thickening, mainly in the choroidal stroma of unaffected fellow eyes, was shown to correlate with SRF persistence in the affected eyes in unilateral naïve CSC. This information may be valuable for the identifying cases with a heightened risk of prolonged SRF persistence and for the timely initiation of treatment.

Safety and Efficacy of Half-dose and Half-fluence Photodynamic Therapy in Chronic Central Serous Chorioretinopathy: A Systematic Review and Meta-analysis

PURPOSE

To investigate the comparative efficacy and safety of half-dose photodynamic therapy (PDT) and half-fluence PDT in the management of chronic central serous chorioretinopathy.

DESIGN

Systematic review and meta-analysis.

METHODS

A comprehensive literature search was conducted on Ovid MEDLINE, Embase, and the Cochrane Library, covering publications from January 2000 to March 2024. The review focused on studies reporting the efficacy and safety of half-dose PDT compared to half-fluence PDT in treating chronic central serous chorioretinopathy. The primary outcome was the best-corrected visual acuity (BCVA) at the last study observation. Secondary outcomes included retinal thickness (RT), the presence of subretinal fluid (SRF), and SRF recurrence across follow-up visits. Random effects meta-analysis was performed using RevMan 5.4.

RESULTS

A total of 10 studies (eight observational and two randomized controlled trials) were included in the analysis. The results indicated that half-dose PDT and half-fluence PDT achieved similar BCVA at 1 month (P = .24), 3 months (P = .40), and 6 months (P = .16). Similarly, there were no significant differences in RT at 1 month (P = .23), 3 months (P = .99), and at 6 months (P = .54) between the two treatment protocols. Both treatment protocols were associated with minor complications, indicating similar safety profiles in patients with CSCR.

CONCLUSIONS

The findings suggest that both half-dose and half-fluence PDT are effective and safe for treating CSCR, with no significant differences in BCVA, RT, or SRF resolution between the two modalities. These results support flexibility in selecting treatment based on individual patient needs. Further research with larger sample sizes and longer follow-up is required to optimize these protocols and confirm these results.

Use of a Fundus Image-Based Titration Strategy for Selective Retina Therapy for Central Serous Chorioretinopathy

Background/Objectives: This study evaluated the clinical outcomes of selective retina therapy (SRT) for treating central serous chorioretinopathy. A fundus image-based titration method was used for laser irradiation. Methods: This retrospective cohort study included 29 eyes (29 patients) that underwent SRT for CSC. Both the pulse energy and number of micropulses were adjusted according to the fundus image. Mean best-corrected visual acuity (BCVA), central foveal thickness (CFT), and subretinal fluid (SRF) height were measured 1, 2, 3, 4, and 6 months after SRT. Mean deviation (MD) was measured using microperimetry at 3 and 6 months post-treatment. Results: At 6 months after SRT treatment, SRF was completely resolved in 89.7% of cases (26/29 eyes). The mean Snellen BCVA significantly improved from 0.34 ± 0.31 logMAR (logarithm of the minimum angle of resolution) (20/40) at baseline to 0.24 ± 0.24 logMAR (20/32) at 6 months (p = 0.009). The 0.1 improvement in mean BCVA is equivalent to a 5-letter gain on the ETDRS chart. The mean CFT decreased significantly from 309.31 ± 81.6 μm at baseline to 211.07 ± 50.21 μm at 6 months (p < 0.001). The mean SRF height also decreased significantly from 138.36 ± 56.78 μm at baseline to 23.75 ± 61.19 μm at 6 months (p < 0.001). The mean MD was improved from -1.56 ± 1.47 dB at baseline to -1.03 ± 2.43 dB at 6 months (p = 0.07) after treatment. Conclusions: SRT using fundus image-based titration can yield favorable functional and anatomical outcomes in the treatment of CSC.

Central Serous Chorioretinopathy: An Update on the Current State of Management

Central serous chorioretinopathy (CSCR) is a relatively common retinal disorder that leads to central vision impairment, often with a high recurrence rate. The exact etiology and pathogenetic mechanisms have not been fully elucidated but are likely to be associated with hyperpermeability of the choroidal capillaries and failure of the retinal pigment epithelium (RPE), leading to serous detachment of the neurosensory retina. Multimodal imaging plays a critical role in the diagnostic approach and monitoring of CSCR. Fortunately, the natural course of the disease is usually self-limiting, with spontaneous resolution and total fluid reabsorption. However, some patients may exhibit recurrences or persistent subretinal fluid (chronic CSCR), leading to progressive and irreversible RPE atrophy or photoreceptor damage. Thus, to prevent permanent visual loss, individualized treatment should be considered. Recent developments in the diagnostic and therapeutic approach have contributed to better outcomes in patients with CSCR. More studies are required to improve our understanding of epidemiology, pathogenesis, diagnosis, and treatment, with a significant impact on the management of this challenging clinical entity. The purpose of this review is to summarize the current knowledge about the clinical features, diagnostic workup, and therapeutic approach of CSCR.

Efficacy and Predictive Factors of Oral Spironolactone Treatment in Chronic Central Serous Chorioretinopathy

Purpose

To evaluate the efficacy of spironolactone in the treatment of chronic central serous chorioretinopathy (CSC) and identify imaging characteristics that can predict the benefit of spironolactone treatment.

Methods

Patients with chronic CSC were treated with spironolactone (20 mg/tid) and followed for 6 months. The primary outcome measure was complete resolution of the subretinal fluid (SRF), and the best-corrected visual acuity (BCVA), the SRF area, the central macular thickness (CMT), the subfoveal choroidal thickness (SFCT), and the density of the choriocapillaris vessel and adverse events were secondary outcome measures. Patients who presented complete resolution of SRF were included in the responder group and the other patients who had moderate or no resolution were included in the nonresponder group. Imaging characteristic comparisons between the responder and nonresponder groups were performed with regression analyses to identify factors that are predictive of a good response to treatment.

Results

Forty-two eyes of 42 patients with a mean age of 46.06 ± 6.66 years were included. A total of 57.1% of the patients achieved a complete resolution of SRF. The mean SRF area, CMT, and SFCT decreased significantly (all P < 0.05) throughout the follow-up period and BCVA improved slightly (P > 0.05). The vascular density of the choriocapillaris of the fellow eyes did not vary significantly during treatment. Logistic regression analysis revealed that SFCT (P=0.002) and the intact ellipsoid zone (P=0.001) were correlated with disease resolution. A relatively higher baseline SFCT was a predictive factor associated with a good response to treatment according to multivariate analysis.

Conclusions

This study suggested that oral spironolactone could be an effective and safe therapy for chronic CSC patients. Eyes with a higher baseline SFCT and intact ellipsoid zone could have a good response. These parameters are an important prognostic marker.

Evaluation of changes in macular structures after subthreshold micropulse laser therapy on chronic central serous chorioretinopathy

PURPOSE

To evaluate the changes in macular structures following subthreshold micropulse laser (SHML) treatment for chronic central serous chorioretinopathy (cCSC).

METHODS

Data of 33 eyes from 31 cCSC patients treated with SHML and followed up for at least 6 months has been included in this retrospective study. Main outcome measurements include resolution of subretinal fluid (SRF) and pigment epithelial detachment (PED), the recovery of ellipsoid zone (EZ) continuity, and the foveal outer nuclear layer (ONL) thickness along with its ratio.

RESULTS

Mean observation period is 7.355 months (ranging from 6 to 24 months) and mean number of treatments administered is 1.839 (ranging from 1 to 5). 6 months after SHML treatment, there is a significant decrease in the area of SRF and PED (P < 0.001, P = 0.010, respectively). Additionally, the frequency of continuous EZ and the foveal ONL thickness reveal a significant increase (P<0.001, P = 0.005, respectively). The ratio of foveal ONL thickness is significantly higher after laser treatment, particularly in patients with a disease duration of ≤12 months (p = 0.022, P=0.036, respectively).

CONCLUSION

SHML treatment proves to be effective in cCSC eyes, leading to satisfactory recovery of macular structures, especially the photoreceptor layer.

Association of Subretinal Fluid Duration and Baseline Chorioretinal Structure With Optical Coherence Tomography in Central Serous Chorioretinopathy

Purpose

This study investigated the association between subretinal fluid (SRF) duration and baseline chorioretinal structure in patients with naïve (first-episode and untreated) central serous chorioretinopathy (CSC).

Methods

We divided 59 patients into non-prolonged (<3 months) and prolonged (>3 months) groups based on SRF fluid persistence from the initial visit. The follow-up period varied as the shorter duration was chosen between SRF disappearance time and 3 months from the initial visit. We measured the central retinal thickness (CRT), central choroidal thickness (CCT), SRF height (SRFH), and outer nuclear layer thickness (ONL) using spectral-domain optical coherence tomography (SD-OCT) at the initial visit and recorded SRF duration. We compared these parameters between the groups, conducted multivariate analysis for SRF duration of more than 3 months, and investigated the correlation among CCT and CRT, SRFH, or ONL, and among SRF duration and CRT, CCT, SRFH, or ONL.

Results

CCT was significantly thicker in the prolonged than in the non-prolonged group at the initial visit (P = 0.044) and significantly correlated with CRT and SRFH (P = 0.007, r = 0.35 and P = 0.002, r = 0.39). SRF duration significantly correlated with CRT and SRFH (P = 0.009, r = 0.40 and P = 0.003, r = 0.41). The optimal model for SRF duration more than 3 months included age (P = 0.054) and CCT (P = 0.008).

Conclusions

Thicker baseline CCT can lead to a longer SRF duration in naïve CSC.

Translational Relevance

This association aids in early detection of cases at a higher risk of prolonged SRF.

Associations of ARMS2 and NR3C2 genes polymorphisms with central serous chorioretinopathy in a Greek population

BACKGROUND

Central serous chorioretinopathy (CSCR) is characterized by serous detachment of the central neurosensory retina and it is one of the most common retinal disorders. Various genetic polymorphisms have been associated with CSCR development.

METHODS

The aim of our study was to investigate the potential association between ARMS2 (rs10490924) and NR3C2 (rs2070951 and rs5522) genes polymorphisms and CSCR development in a well defined Greek cohort for the first time in literature. We enrolled, in our case-control study, 48 CSCR patients and 137 controls. The ARMS2 (rs10490924) and NR3C2 (rs2070951 and rs5522) genes polymorphisms were analyzed using Polymerase Chain Reaction (PCR) assays.

RESULTS

In our study, we found significant associations between ARMS2rs10490924 and NR3C2rs2070951 single nucleotide polymorphisms and CSCR development. Specifically, the GTrs10490924 genotype frequency of the ARMS2 gene was found to be significantly associated with risk of CSCR and T allele of rs10490924ARMS2 gene was also found to increase risk for CSCR. The genotype frequency GC and CC of rs2070951NR3C2 gene were observed more frequently in CSCR patients than controls and C allele of rs2070951NR3C2 gene was also observed more frequently in CSCR patients than controls. Rs5522 of NR3C2 gene polymorphism was not found to be significantly associated with CSCR.

CONCLUSION

Our findings showed, for the first time in a Greek population, that SNPs in the ARMS2 and NR3C2 genes are significantly associated with risk of CSCR. The results of this study support the involvement of extracellular matrix (ARMS2 gene) and mineralocorticoid receptor (MR) in the pathogenesis of CSCR.

Anti-vascular endothelial growth factor monotherapy or combined with verteporfin photodynamic therapy for retinal angiomatous proliferation: a systematic review with meta-analysis

Purpose: To assess functional and anatomical outcomes of intravitreal anti-Vascular Endothelial Growth Factor (anti-VEGF) monotherapy versus combined with verteporfin Photodynamic Therapy (PDT) for Retinal Angiomatous Proliferation (RAP). Methods: Studies reporting outcomes of intravitreal anti-VEGF monotherapy and/or in combination with verteporfin PDT in RAP eyes with a follow-up ≥ 12 months were searched. The primary outcome was the mean change in best corrected visual acuity (BCVA) at 12 months. Mean change in central macular thickness (CMT) and mean number of injections were considered as secondary outcomes. The mean difference (MD) between pre- and post-treatment values was calculated along with 95% Confidence Interval (95% CI). Meta-regressions were performed to assess the influence of anti-VEGF number of injections on BCVA and CMT outcomes. Results: Thirty-four studies were included. A mean gain of 5.16 letters (95% CI = 3.30-7.01) and 10.38 letters (95% CI = 8.02-12.75) was shown in the anti-VEGF group and combined group, respectively (anti-VEGF group vs. combined group, p < 0.01). A mean CMT reduction of 132.45 µm (95% CI = from -154.99 to -109.90) and 213.93 µm (95% CI = from -280.04 to -147.83) was shown in the anti-VEGF group and combined group, respectively (anti-VEGF group vs. combined group, p < 0.02). A mean of 4.9 injections (95% CI = 4.2-5.6) and 2.8 injections (95% CI = 1.3-4.4) were administered over a 12-month period in the anti-VEGF group and combined group, respectively. Meta-regression analyses showed no influence of injection number on visual and CMT outcomes. High heterogeneity was found across studies for both functional and anatomical outcomes. Conclusion: A combined approach with anti-VEGF and PDT could provide better functional and anatomical outcomes in RAP eyes compared with anti-VEGF monotherapy.

The Choroid after Half-Dose Photodynamic Therapy in Chronic Central Serous Chorioretinopathy

PURPOSE

To characterize choroidal structure and vasculature after half-dose verteporfin photodynamic therapy (hd-vPDT) in eyes with chronic central serous chorioretinopathy using Enhanced Depth Imaging Optical Coherence Tomography (EDI OCT) and Optical Coherence Tomography Angiography (OCT-A).

METHODS

This prospective case-control study included 10 eyes. Choroid was examined before and at 1 month following hd-vPDT. We measured choroidal thickness (CT) at subfoveal area and at 750 μm nasal and temporal of fovea and thickness of Haller and choriocapillaris/Sattler layers. Whole (WA), luminal (LA) and interstitial area (IA) at EDI-OCT, and perfusion density at OCT-A were analyzed. The unaffected fellow eyes were used for comparisons.

RESULTS

Mean CT at subfoveal area and at 750 μm nasal and temporal of fovea, values of Haller and choriocapillaris/Sattler layers and those of WA, LA and IA were reduced, while PD increased at 1 month after hd-vPDT (all p < 0.001). There was a significant (p < 0.05) negative correlation (ρ = -0.658) between PD and post-treatment logMARVA. None of analyzed parameters reached values of unaffected fellow eye.

CONCLUSION

Following hd-vPDT, choroidal thickness with both luminal and interstitial components markedly decreased, while perfusion of choriocapillaris improved.

Central serous chorioretinopathy: A review

Central serous chorioretinopathy (CSC) is the fourth most common non-surgical retinopathy associated with fluid leakage. The pathogenesis is not yet completely understood, but changes in the choroid, sclera and RPE have been described associated with venous congestion of choroidal outflow. CSC can be categorised into acute, chronic, and recurrent subtypes with recent classifications of simple and complex based on the area of RPE change seen on fundus autofluorescence. A multimodal imaging approach is helpful in the diagnosis and management of CSC and secondary complications such as type 1 neovascularisation. Although spontaneous resolution with relatively good visual outcomes is common, treatment should be considered in patients with persistent or recurrent SRF. Treatment options include laser, systemic medications, intravitreal therapy, and surgery. Of these, argon laser for focal extramacular fluid leaks and photodynamic therapy of leakage identified by indocyanine-green angiography currently have the greatest supportive evidence.

Central serous chorioretinopathy: Treatment

Central serous chorioretinopathy (CSC) is a pachychoroid spectrum disease characterized by serous detachment of the neurosensory retina with subretinal fluid in young and middle-aged adults. The pathogenesis of CSC is not yet fully understood. However, it is considered a multifactorial disease that is strongly associated with choroidal dysfunction or vascular engorgement. Although there is no consensus on the treatment of CSC, photodynamic therapy has been effectively used to manage serous retinal detachment (SRD) in CSC. Moreover, micropulse diode laser photocoagulation and focal laser treatment have also been used. Recently, oral medications, including mineralocorticoid receptor antagonists, have been proposed for the management of CSC. Multimodal imaging plays a significant role in the diagnosis and treatment of CSC. Optical coherence tomography angiography (OCTA) has the advantage of detecting vascular flow in the retina and choroid layer, allowing for a better understanding of the pathology, severity, prognosis, and chronicity of CSC. In addition, early detection of choroidal neovascularization in CSC is possible using OCTA. This review article aims to provide a comprehensive and updated understanding of CSC, focusing on treatment.

Photodynamic Therapy with Chlorin e6 Derivative for Chronic Central Serous Chorioretinopathy (Pilot Study)

Purpose: To evaluate the use of photodynamic therapy (PDT) with chlorin e6 (Ce6) derivative in patients with chronic central serous chorioretinopathy (CSC). Methods: Participants in this interventional, single-center clinical pilot study included 39 patients (39 eyes) with chronic CSC. Primary objectives were to assess safety and change in decimal best-corrected visual acuity (BCVA) during the 12-month follow-up. Secondary objectives were to evaluate change in central retinal thickness (CRT) in fovea area, maximal height of subretinal fluid (SRF), subfoveal choroidal thickness (SFCT) on spectral-domain optical coherence tomography, and number of treatments. Results: There were no systemic adverse events and ocular side effects. Mean decimal BCVA showed a significant increase from 0.49 ± 0.25 to 0.63 ± 0.28 (P = 0.001), mean CRT and maximal height of SRF decreased significantly from 335 ± 95 to 219 ± 69 μm and from 149 ± 84 to 32 ± 86 μm respectively (P = 0.001), comparing baseline and month 12. There was no significant difference between mean SFCT before PDT and at month 12. During all follow-up periods mean number of PDT treatments was 1.3 ± 0.7. Complete SRF resolution was observed in 82% (32 eyes) during observation period. Conclusion: Results of this pilot study demonstrate that PDT with Ce6 derivative is a safe method to treat eyes with chronic CSC. PDT with Ce6 derivative is the treatment option for chronic CSC. Further randomized controlled studies with a larger sample size and longer periods of follow-up are needed to assess the effectivity and safety of PDT with Ce6 derivative in chronic CSC.

Utility of an additional photodynamic therapy session after multiple failed PDT treatments in chronic central serous chorioretinopathy

PURPOSE

To assess the efficacy of an additional photodynamic therapy (PDT) in chronic central serous chorioretinopathy (cCSCR) patients who have two or more previous failed PDTs.

METHODS

Ten eyes of 10 patients with cCSCR who had received two or more PDTs without complete resolution of the subretinal fluid (SRF) or with early recurrence (before 3 months) were included. An additional half-fluence PDT was performed. Swept-source optical coherence tomography (OCT) and OCT angiography were performed before, 3 days, 1 month, 3 months, 6 months and 12 months after treatment. Age, gender, best-corrected visual acuity (BCVA), subfoveal choroidal thickness, SRF and vessel occlusion in the choriocapillaris (CC) were collected.

RESULTS

The median number of previous PDTs was 3 (range 2 to 4). BCVA before and 12 months after treatment was 72 letters (50 to 95) and 78 letters (55 to 100) (p=0.094). Median initial SRF was 94 µm (50 to 306), being 0 µm (range 0 to 81) at the end of the follow-up (p=0.007). After the additional PDT, 8 out of 10 patients had a complete SRF resorption. All the patients except one who had a complete response (7/8) had an occlusion in the CC 3 days after PDT.

CONCLUSION

Despite previous failed PDTs in cCSCR, good anatomical results can be achieved, this being more likely if an early vessel occlusion in the CC is observed. Even when the BCVA did not improve, the high rate of fluid resolution could justify the additional PDT treatment in order to maintain visual function.

Mineralocorticoid receptor antagonists for chronic central serous chorioretinopathy: systematic review and meta-analyses

BACKGROUND

Mineralocorticoid receptor antagonists (MRAs) are widely used for chronic central serous chorioretinopathy (cCSCR), but their effectiveness remains unclear. This research was conducted to evaluate the efficacy of this drugs for cCSCR.

METHODS

This is a review of randomized clinical trials (RCT) comparing MRAs to placebo in adults with cCSCR, using the effects of MRAs on best-corrected visual acuity (BCVA) and adverse events as primary outcomes and the effects of MRAs on anatomical parameters as secondary outcomes: central subfield thickness (CST), subretinal fluid height (SFH) and central choroidal thickness (CCT). Our all-language online search included Medline (via PubMed), Central, Embase, Lilacs, Ibecs, and RCT registers platforms, as late as May 2021. We used the Cochrane risk-of-bias tool (version 2) to assess the methodological quality of each study and synthesized the results in meta-analyses using a random-effects model.

RESULTS

The search identified 302 records, five of which were eligible, totaling 225 cCSCR patients (aged 45-62 years; M/F ratio 3.1:1) treated for 1 to 12 months with spironolactone (50 mg/day) or eplerenone (50 mg/day) vs. placebo. Moderate-certainty evidence suggests MRAs result in little to no improvement in BCVA compared to placebo (SMD 0.22; 95% CI - 0.04 to 0.48; studies = 5; comparisons = 6; participants = 218; I2 = 0%). Very low-certainty evidence suggests that, when compared to placebo, MRAs have a very uncertain impact on adverse effects (no meta-analysis was performed), and CST (MD 18.1; 95% CI - 113.04 to 76.84; participants = 145; studies = 2; I2 = 68%). MRAs also result in little to no difference in SFH (SMD - 0.35; 95% CI - 0.95 to 0.26; studies = 5; comparisons = 6; participants = 221; I2 = 76%; moderate certainty) and CCT (MD - 21.23; 95% CI - 64.69 to 22.24; participants = 206; studies = 4; comparisons = 5; I2 = 85%; low certainty).

CONCLUSION

MRAs have little to no effect on BCVA. Evidence for adverse events and CST is very uncertain. MRAs also have little to no effect on SFH and CCT. These findings should be considered when prescribing MRAs for cCSCR. This research was previous registration in the PROSPERO platform (CRD42020182601).

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Fundus Autofluorescence and Optical Coherence Tomography Characteristics in Different Stages of Central Serous Chorioretinopathy

Objective

To describe the morphological changes on fundus autofluorescence (FAF) and spectral-domain optical coherence tomography (SD-OCT) imaging at different chronicity of central serous chorioretinopathy (CSC).

Methods

This cross-sectional study included patients with CSC of different chronicity. Changes in FAF scans and morphological changes on SD-OCT were evaluated and compared at different stages of CSC.

Results

Sixty-nine patients were enrolled in the study, with a mean age of 52.1 ± 11.8 years. A distinct hypoautofluorescence (AF) pattern was observed at the leakage point in acute CSC (100%). The leakage site was indistinguishable in 48% of the patients with late-chronic CSC. The majority of acute CSC patients showed hyper-AF in the area of serous retinal detachment (SRD), which persisted in the early-chronic stage of CSC. In late-chronic CSC, many cases of hypo-AF (22.2%) and mixed-pattern AF (14.8%) were observed. SD-OCT revealed evolving features of retinal pigment epithelium (RPE) abnormalities in a time-dependent manner: from peaked PEDs in acute CSC to low-lying PEDs in early-chronic CSC and, eventually, flat, irregular PEDs in late-chronic CSC. The average thickness of the photoreceptor layer (inner and outer segment; IS/OS) was 79 μm in the acute group and 55.2 μm in the chronic group. The photoreceptor layer (IS/OS) height was positively associated with visual acuity (p=0.002).

Conclusion

Different stages of CSC present different patterns on FAF and SD-OCT imaging. Chronicity of CSC can be estimated using specific features in these images. Photoreceptor layer (IS/OS) height acts as a good and objective predictor of visual outcomes in CSC patients.

[Central serous chorioretinopathy]

Central serous chorioretinopathy (CSC) is the fourth most common disease of the macula after age-related macular degeneration, diabetic retinopathy and retinal vein occlusion and a cause of irreversible visual loss. This article gives an overview of the epidemiology, risk factors, pathophysiology, clinical presentation, multimodal imaging and discusses current therapeutic options for CSC.

Comparison of the efficacy and safety between subthreshold micropulse laser, standard-fluence and low-fluence photodynamic therapy for chronic central serous chorioretinopathy

PURPOSE

To compare the efficacy and safety of subthreshold micropulse laser treatment (SML), standard-fluence photodynamic therapy (PDT) and low-fluence PDT in patients with chronic central serous chorioretinopathy (cCSC).

METHODS

This retrospective study included 52 eyes of 46 patients with chronic CSC who were treated with 577nm SML (n=23), standard-fluence PDT (verteporfin 6mg/m² and light energy 50J/cm²) (n=13), or low-fluence PDT (verteporfin 6mg/m² and light energy 25J/cm²) (n=16). The mean changes in best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) parameters, including central retinal thickness (CRT), subretinal fluid (SRF) height, and ellipsoid zone (EZ) disruption, over the follow-up period were evaluated.

RESULTS

The mean follow-up period was 8.42±3.34 months. In the SML group, the SRF resolution time was longer than the other groups. At 1 month, the SML group's mean CRT was higher than the other groups. The BCVA improvement was statistically significant in all groups (P<0.05), but in the SML group, it was slower than the other groups. Three eyes in the low-fluence and one eye in the standard-fluence PDT group received a second PDT treatment. The mean number of SML treatments was 2.48±1.08. If the EZ was intact, the rate of complete resolution of SRF was higher than if the EZ was disrupted or lost.

CONCLUSION

SML, standard-fluence PDT, and low-fluence PDT can all improve visual acuity in cCSC. Standard-fluence and low-fluence PDT induced a more rapid reabsorption of the fluid, improvement of BCVA, and equal safety compared with SML. More treatment sessions of SML were required than with the other treatment modalities.

One-year comparison of anti-vascular endothelial growth factor and half-dose photodynamic therapies for pachychoroid neovasculopathy

BACKGROUND

To compare 1-year outcomes between anti-vascular endothelial factor (VEGF) therapy and half-dose photodynamic therapy (PDT) for treatment-naive pachychoroid neovasculopathy (PNV) with subretinal fluid (SRF).

METHODS

Consecutive patients with treatment-naive PNV patients with SRF treated with intravitreal anti-VEGF injections or half-dose PDT followed by as-needed schedule with 1-year follow-up were studied retrospectively.

RESULTS

Eighty-two eyes of 82 patients were eligible: 50 eyes underwent anti-VEGF therapy and 32 eyes underwent half-dose PDT. SRF resolved in 41 (82%) of 50 eyes after initial three monthly injections and 31 (96.9%) of 32 eyes 3 months after initial PDT, and 43 (86%) eyes and 30 (94%) eyes 1 year after initial anti-VEGF injection and half-dose PDT, respectively. No significant differences were found in SRF resolution rates 3 months and 1 year after initial treatment between the two treatment groups. Best-corrected visual acuity (BCVA) improved significantly after initial three monthly injections (P = 0.025) and initial PDT (P = 0.022) compared with baseline; the improvements were maintained 1 year after initial treatment in the two treatment groups. No significant differences were found in BCVA between the two treatment groups at baseline and throughout the 1-year follow-up period. Mean (± standard error) numbers of intravitreal injections and PDT over 12 months were 3.7 ± 0.16 and 1.1 ± 0.06, respectively.

CONCLUSIONS

Both treatments are similarly effective on SRF resolution and VA improvement 1 year after the initial treatment. Half-dose PDT may be an option for treatment for PNV. Prospective studies are required to confirm these findings.

The Genetic Background of Central Serous Chorioretinopathy: A Review on Central Serous Chorioretinopathy Genes

Central serous chorioretinopathy is characterized by neurosensory detachment of the central retina secondary to fluid leakage through the retinal pigment epithelium. Though it has an incidence of 9,9 per 100.000 in men and 1,7 per 100.000 in women, it is the fourth most common retinal disorder. Central serous chorioretinopathy patients present with blurred vision, central scotoma, metamorphopsia, micropsia and mild color discrimination. It is usually a self-limited disorder with nearly none or minimal visual impairment but in some patients the disease persists and may cause severe visual impairment. Central serous chorioretinopathy pathophysiology is not well understood. Choroid, retinal pigment epithelium and hormonal pathways seem to play important roles in central serous chorioretinopathy pathophysiology. Also, familial cases of the disease indicate that there is a genetic background. The identification of certain disease genes could lead to the development of better diagnostic and therapeutic approaches for central serous chorioretinopathy patients.

One-year results of half-dose versus one-third-dose photodynamic therapy in chronic or recurrent central serous chorioretinopathy

Background

Central serous chorioretinopathy (CSC) is characterized by an accumulation of subretinal fluid (SRF) in the macula. It is usually treated by laser photocoagulation or photodynamic therapy (PDT) with consisting of different doses and power. This study aimed to compare the efficacy of half-dose PDT and one-third-dose PDT in chronic or recurrent CSC.

Methods

A retrospective review of patients with chronic or recurrent CSC who were treated with either a half-dose or one-third-dose PDT, and had follow up 12 months afterwards. Best-corrected visual acuity (BCVA), central retinal thickness (CRT) and resolution of subretinal fluid (SRF) at baseline as well as 1, 3, 6 and 12 months post-PDT were assessed.

Results

Forty-six eyes and 20 eyes received half-dose and one-third-dose PDT, respectively. The study showed efficacy of the one-third-dose PDT compared with half-dose PDT in BCVA improvement (0.10±0.04 logMAR for one-third-dose versus 0.17±0.04, for half-dose, P=0.148) and CRT improvement (125.6±24.6 μm for one-third-dose versus 139.1±16.54, for half-dose, P=0.933) at 12 months. The SRF recurrence rate was significantly higher in the one-third-dose PDT group compared with the half-dose PDT group (40.0% versus 15.2%, P=0.027) at 12-months.

Conclusion

At 12 months, the one-third-dose PDT was effective in terms of BCVA and CRT improvement, when compared with half-dose PDT. However, this study showed that one-third-dose PDT had a higher recurrence rate of SRF.

Factors influencing the episode duration and the anatomical and functional outcome in cases of acute central serous chorioretinopathy

Objective

To investigate the factors affecting the duration of subretinal fluid (SRF) resolution and their correlation with the final anatomical and functional outcome in cases of treatment naïve acute central serous chorioretinopathy (CSCR).

Methods and analysis

We retrospectively studied 93 eyes of 93 patients diagnosed with treatment naïve acute CSCR presenting within 30 days of onset of symptoms. The eyes were divided into two groups (1 and 2) based on the duration of SRF resolution; which was ≤3 months in group 1 and >3 months in group 2. Demographic and medical history, and spectral domain optical coherence tomography features were noted and their association with duration for SRF resolution, final central macular thickness (CMT) and final best-corrected visual acuity (BCVA) were studied. All the patients were prescribed topical non-steroidal anti-inflammatory drug for 1 month at the diagnosis of CSCR.

Results

Longer duration of symptoms, female gender and baseline OCT factors like hyper-reflective dots and retinal pigment epithelial bumps were associated with longer duration for SRF resolution (p<0.001, p=0.04, p=0.001 and p=0.01, respectively). The SRF resolution time had strong correlations with the final CMT (r=-0.589, p<0.001) and final BCVA in logarithm of minimum angle of resolution (LogMAR) (r=+0.599, p<0.001). Group 2 eyes had worse final BCVA and thinner final CMT than Group 1 (both p<0.001). The final CMT of the patients of Group 1 was statistically thinner than the normal population (p<0.001).

Conclusion

Patient's baseline clinicodemographic and OCT features can be used to predict the course and visual outcome in cases of treatment naïve acute idiopathic CSCR.

Comparison of half-dose versus half-fluence versus standard photodynamic therapy in chronic central serous chorioretinopathy

PURPOSE

To compare the efficacy and safety of half-dose vs. half-fluence vs. standard photodynamic therapy (PDT) in patients with chronic central serous chorioretinopathy (cCSC).

METHODS

This retrospective study included 64 eyes of 61 patients with cCSC who were treated with half-dose PDT (verteporfin 3 mg/m2 and light energy 50 J/cm2), half-fluence PDT (verteporfin 6 mg/m2 and light energy 25 J/cm2) or standard PDT (verteporfin 6 mg/m2 and light energy 50 J/cm2). The complete resorption of subretinal fluid (SRF) and changes of best corrected visual acuity (BCVA) and central retinal thickness (CRT) over the follow-up period were also assessed.

RESULTS

Fifteen eyes (65.2 %) in the half-dose PDT group, 12 eyes (80 %) in the half-fluence PDT group, and 20 eyes (76.9 %) in the standard PDT group showed complete resolution of SRF. There were no statistically significant differences in the mean BCVA improvement, CRT and SRF height reduction, number of PDT sessions, complete success, and recurrence rates between groups (p > 0.05). None of the eyes with intact EZ showed failure. There were positive correlations between higher mean CRT values of the last visit, 1st, 3rd, 6th months and failure. None of the treated eyes (0%) developed any systemic or local adverse events.

CONCLUSION

Half-dose, half-fluence or standard PDTs are all effective and safe treatment choices in cCSC with similar BCVA improvements and CRT reductions. The higher mean CRT values of the follow-up period were correlated with failure, and in eyes with intact EZ showed no failure.

Photodynamic Therapy with Verteporfin for Chronic Central Serous Chorioretinopathy: A Review of Data and Efficacy

Central serous chorioretinopathy represents the fourth most frequent retinal disorder, occurring especially in young age. Central serous chorioretinopathy is mainly characterized by macular serous retinal detachment and although the clinical course moves frequently toward a spontaneous resolution, the subretinal fluid may persist for a long time, thus evolving to the chronic form, and leading to a potential damage of the retinal pigment epithelium and to photoreceptors. The photodynamic therapy with verteporfin plays an important role in the armamentarium among the many therapeutic options employed in this complex retinal disorder. In this review, the authors aim to summarize data of efficacy and safety of PDT focusing especially on mechanisms of action of the PDT and providing comparative outcomes with the alternative therapeutic approaches, including especially the subthreshold laser treatment.

Current Pharmacological Treatment Options for Central Serous Chorioretinopathy: A Review

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

Update on the management of chronic central serous chorioretinopathy

Central serous chorioretinopathy (CSC) is one of the main causes of impaired visual acuity in patients younger than 60 years. Its pathophysiology remains partially unknown, although it has been postulated that choroidal hyper-permeability may be involved. This typically produces a neurosensory retinal detachment and/or a detachment of the retinal pigment epithelium in the posterior pole. Although acute CSC generally does not require treatment, when chronic it must be treated to avoid visual impairment. With the development of new imaging techniques, there has been an improvement in diagnosis, and different therapeutic strategies have been proposed. Various treatments for the management of chronic CSC have currently been shown to be useful to improve or stabilise visual acuity, the resolution of subretinal fluid, and to prevent recurrences. The most commonly used treatments today are photodynamic therapy, micropulse subthreshold laser, mineralocorticoid antagonists, or anti-vascular endothelial growth factor drugs. There are also other proposals and new treatments being developed, with promising results. This review aims to provide the reader with an overview of the current scientific evidence of the different treatment options available for CSC in order to help decision-making in clinical practice.

Comparison between the outcomes of fluorescein angiography-guided and indocyanine green angiography-guided half-time photodynamic therapy for central serous chorioretinopathy

BACKGROUND AND OBJECTIVES

This study aimed to compare the efficacy of fluorescein angiography (FA)-guided and indocyanine green angiography (ICGA)-guided half-time photodynamic therapy (PDT) for central serous chorioretinopathy (CSC).

SUBJECTS AND METHODS

Medical records of 61 eyes of 61 CSC patients who underwent half-time PDT were retrospectively reviewed. The irradiation area was determined using information from FA or ICGA with physicians' discretion. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), subfoveal choroidal thickness (SCT), and resolution of subretinal fluid (SRF) were evaluated at baseline and 1, 3, 6, and 12 months after PDT.

RESULTS

A total of 29 and 32 eyes received FA-guided PDT (irradiation area, 2898.3 ± 705.7 μm) and ICGA-guided PDT (irradiation area, 4993.8 ± 333.1 μm), respectively. A significant improvement in the mean BCVA was found at 1 month in the FA-guided group (P = 0.02), but not in the ICGA-guided group (P = 0.88). BCVA was significantly improved in both groups at 3, 6, and 12 months with no significant intergroup difference at any time points. CRT and SCT were significantly reduced in both groups at all time points with no significant intergroup differences. No significant intergroup differences were observed in the rate of recurrence and persistent SRF. However, there was a significant difference between groups in the rate of recurrence and/or persistent SRF (P = 0.04). Multivariate analysis revealed that choice of FA-guided was significantly associated with recurrence and/or persistent SRF (P = 0.04).

CONCLUSION

Half-time PDT with ICGA-guided irradiation spot might be more effective than that with FA-guided in treating CSC patients in complete resolution of SRF.

Long-Term Effects of Half-Time Photodynamic Therapy on Retinal Sensitivity in Eyes with Chronic Central Serous Chorioretinopathy

The purpose of this study was to evaluate the long-term effects of half-time photodynamic therapy (PDT) on the retinal sensitivity in eyes with chronic central serous chorioretinopathy (CSC). Twenty-two eyes of 22 patients with chronic CSC were studied. PDT was applied with full-dose verteporfin and half-time laser duration. The best-corrected visual acuity (BCVA) and retinal sensitivity in the central 2 and 10 degrees were evaluated at the baseline, and at 12 and 24 months after the half-time PDT. The retinal sensitivity was determined by Macular Integrity Assessment microperimetry (MAIA, Centervue, Padova, Italy). The results showed that the mean retinal sensitivities in the central 2 and 10 degrees were significantly improved at 12 months (25.6 ± 2.79 dB, median; 26.11 dB, 25.6 ± 2.25 dB, median; 25.65 dB, respectively; P < 0.001) and at 24 months (26.3 ± 2.62 dB, median; 27.38 dB, 26.6 ± 2.21 dB, median; 27.45 dB, respectively; P < 0.001) after the treatment compared to that at the baseline (19.2 ± 3.93 dB, median; 19.34 dB, 20.9 ± 2.92 dB, median; 20.9 dB, respectively). The BCVA was also significantly improved from 0.18 ± 0.19 median; 0.15 logarithm of the minimum angle of resolution (logMAR) units at the baseline to 0.07 ± 0.15 median; 0 logMAR units at 12 months (P < 0.001) and to 0.049 ± 0.16 median; -0.039 logMAR units at 24 months (P < 0.001). We conclude that half-time PDT results in a significant improvement of the mean central retinal sensitivity for at least 24 months in eyes with chronic CSC. Thus, half-time PDT is beneficial in resolving chronic CSC for a relatively long period.

An international collaborative evaluation of central serous chorioretinopathy: different therapeutic approaches and review of literature. The European Vitreoretinal Society central serous chorioretinopathy study

PURPOSE

To study and compare the efficacy of different therapeutic options for the treatment of central serous chorioretinopathy (CSCR).

METHODS

This is a nonrandomized, international multicentre study on 1719 patients (1861 eyes) diagnosed with CSCR, from 63 centres (24 countries). Reported data included different methods of treatment and both results of diagnostic examinations [fluorescein angiography and/or optical coherent tomography (OCT)] and best-corrected visual acuity (BCVA) before and after therapy. The duration of observation had a mean of 11 months but was extended in a minority of cases up to 7 years. The aim of this study is to evaluate the efficacy of the different therapeutic options of CSCR in terms of both visual (BCVA) and anatomic (OCT) improvement.

RESULTS

One thousand seven hundred nineteen patients (1861 eyes) diagnosed with CSCR were included. Treatments performed were nonsteroidal anti-inflammatory eye drops, laser photocoagulation, micropulse diode laser photocoagulation, photodynamic therapy (PDT; Standard PDT, Reduced-dose PDT, Reduced-fluence PDT), intravitreal (IVT) antivascular endothelial growth factor injection (VEGF), observation and other treatments. The list of the OTHERS included both combinations of the main proposed treatments or a variety of other treatments such as eplerenone, spironolactone, acetazolamide, beta-blockers, anti-anxiety drugs, aspirin, folic acid, methotrexate, statins, vitis vinifera extract medication and pars plana vitrectomy. The majority of the patients were men with a prevalence of 77%. The odds ratio (OR) showed a partial or complete resolution of fluid on OCT with any treatment as compared with observation. In univariate analysis, the anatomical result (improvement in subretinal fluid using OCT at 1 month) was favoured by age <60 years (p < 0.005), no previous observation (p < 0.0002), duration less than 3 months (p < 0.0001), absence of CSCR in the fellow eye (p = 0.04), leakage outside of the arcade (p = 0.05) and fluid height >500 μm (p = 0.03). The OR for obtaining partial or complete resolution showed that anti-VEGF and eyedrops were not statistically significant; whereas PDT (8.5), thermal laser (11.3) and micropulse laser (8.9) lead to better anatomical results with less variability. In univariate analysis, the functional result at 1 month was favoured by first episode (p = 0.04), height of subretinal fluid >500 μm (p < 0.0001) and short duration of observation (p = 0.02). Finally, there was no statistically significant difference among the treatments at 12 months.

CONCLUSION

Spontaneous resolution has been described in a high percentage of patients. Laser (micropulse and thermal) and PDT seem to lead to significant early anatomical improvement; however, there is little change beyond the first month of treatment. The real visual benefit needs further clarification.

Optimal fluence rate of photodynamic therapy for chronic central serous chorioretinopathy

AIMS

To investigate the lowest effective fluence rate of photodynamic therapy (PDT) for treating chronic central serous chorioretinopathy (CSC).

METHODS

Fifty-one eyes of 51 patients with chronic CSC were randomly treated with 30% (n=15), 40% (n=16) or 50% (n=17) of the standard-fluence rate of PDT and followed up for 12 months. The success rate, recurrence rate, mean best-corrected visual acuity (BCVA), central foveal thickness (CFT), subfoveal choroidal thickness (SFCT), integrity of the outer retinal layer and complications were evaluated at baseline and at the follow-up periods after PDT.

RESULTS

The rate of complete subretinal fluid (SRF) resolution in the 30%-fluence, 40%-fluence and 50%-fluence groups was 60.0%, 81.2% and 100.0%, respectively, at 3 months (p=0.009), and 80.0%, 94.0% and 100.0%, respectively, at 12 months (p=0.06). The recurrence rate in the 50%-fluence group was lower than that in the 30%- and 40%-fluence groups at 12 months (30% vs 50%, 40% vs 50%; p=0.002, p=0.030, respectively (log-rank test)). The mean BCVA improved significantly 12 months after PDT only in the 40%- and 50%-fluence groups (p=0.005, p=0.003, respectively). Mean CFT and SFCT decreased significantly at 12 months in the three groups. The rate of complications did not differ significantly among the three groups.

CONCLUSIONS

A 50%-fluence rate of PDT seems to be the most effective for treating chronic CSC, considering the low recurrence rate and high rate of complete SRF resolution, compared with other low-fluence PDT.

TRIAL REGISTRATION NUMBER

NCT01630863.

Oral Eplerenone Versus Observation in the Management of Acute Central Serous Chorioretinopathy: A Prospective, Randomized Comparative Study

In this prospective, interventional case-control study, 58 patients with unilateral acute central serous chorioretinopathy (CSCR) were recruited. Patients ≥ 18 years age, presenting with first episodes of acute CSCR, were included. Acute CSCR was defined by the presence of subretinal fluid (SRF) and symptoms for <12 weeks duration with no clinical or imaging features of chronicity. Patients were alternately divided into treatment (Table Eplerenone 50 mg/day for minimum 1 month) and observation groups. Vision, SRF height and subfoveal choroidal thickness (SFCT) were checked at 1-, 2- and 3-months in both eyes of each group. Each group had 29 eyes. Mean age was 40.4 ± 7.1 and 43.3 ± 8.34 years in treatment and observation group, respectively. Mean symptom duration was 6.46 ± 1.45 and 5.87 ± 2.09 weeks, respectively. Vision improvement to 6/6 was seen in 92%, 100% and 100% cases in treatment group and 74%, 86% and 100% in control group at each visit, respectively. Complete SRF resolution in the treatment group was noted in 45%, 55% and 62% cases at each respective monthly visit. In the observation group, complete SRF resolution was noted in 10%, 21% and 31% at 1-, 2- and 3-month visits, respectively. SRF (p < 0.001) and SFCT (p < 0.001) reduction was noted in the affected eye of both groups. SFCT was reduced in the fellow eye after treatment (p = 0.005) compared to the observation group (p = 0.276). In conclusion, oral eplerenone achieves faster SRF resolution and vision improvement in acute CSCR. Additionally, it shows beneficial effects on the fellow eye.

Oral medications for central serous chorioretinopathy: a literature review

Central serous chorioretinopathy (CSCR) is characterised by acute or chronic neurosensory detachments of the retina, usually in the posterior pole, with or without associated detachments of retinal pigment epithelium. Although the condition often resolves spontaneously, chronic and recurrent cases can lead to significant visual loss in the working population and it is thus increasingly recognised as an important public health issue. The uncertainty regarding the underlying cause of CSCR has led to a wide range of therapies being tried for this condition including photodynamic therapy, laser photocoagulation, anti-VEGF injections and a multitude of oral agents. This article aims to review the current evidence for oral agents that have been used for treatment of CSCR. A systematic literature search was conducted for articles published between 1980 to July 2018. A total of 73 articles were included. These studied the following oral medications: eplerenone, spironolactone, beta blockers, H. pylori agents, omeprazole, rifampicin, methotrexate, aspirin, acetazolamide, mifepristone, melatonin, finasteride, ketoconazole, antioxidants and curcumin phospholipid. Although none of the studies showed robust evidence of efficacy, the mineralocorticoid receptor antagonists, particularly eplerenone, appear to demonstrate the highest quality evidence for use in this condition. The review aims to give the reader an overview of the current available evidence for oral medications used in the treatment of CSCR in order to provide an evidence-based discussion with the patient and guide through possible options for treatment.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment of the efficacy of photodynamic therapy in patients with chronic central serous chorioretinopathy

PURPOSE

The aim of this prospective clinical study was to evaluate the anatomical and functional results of the treatment of 54 eyes with chronic form of central serous chorioretinopathy (CSC) using photodynamic therapy in a reduced (half) verteporfin (HD-PDT) dosing regimen.

MATERIALS AND METHODS

Our prospective study included 54 eyes of 52 patients (40 males, 12 females) at an average age of 50.1 years (median 49.5, range 30-75 years) treated at the Ophthalmology Clinic of the First Faculty of Medicine and Military University Hospital in Prague from January 2012 to January 2018 for chronic form of CSC with a minimum disease duration of 3 months. In our study, we evaluated the improvement of the best corrected visual acuity (BCVA) and central retinal thickness (CRT) before treatment and at 1, 3, 6 and 12 months after HD-PDT.

RESULTS

The mean baseline BCVA was 68.91 ± 10.5 ETDRS letters (median 71; range 35-85) and the mean baseline CRT was 385.6 ± 118.5 µm (median 367, 5 µm; range 245-1000 µm). At the end of the follow-up period, the average BCVA was 79 ± 11 ETDRS letters (median 82; range 38-93). The improvement in BCVA before and after treatment was statistically significant in all measurements (p &lt; 0.0001). The mean CRT at the end of the follow-up period was 263.5 ± 52 µm (median 258.5 µm; range 162-404 µm). The decrease in CRT at all timepoints was statistically significant compared to baseline (p &lt; 0.0001). In our set of patients, at the end of the follow-up period, the retinal finding was improved or stabilized in 50 eyes (92.6 %). In this study, we observed in 2 cases the development of secondary choroidal neovascularization (CNV).

CONCLUSION

HD-PDT is a long-term safe and effective method of treating chronic forms of CSC. However, despite a reduced dose of verteporfin, complications may occur.

Long-term results of focal laser photocoagulation and photodynamic therapy for the treatment of central serous chorioretinopathy

PURPOSE

To evaluate the long-term results of focal laser photocoagulation and photodynamic therapy (PDT) for treatment of central serous chorioretinopathy (CSC).

STUDY DESIGN

Retrospective chart review.

METHODS

Sixty-two patients with CSC, thirty-three of whom were treated with focal laser photocoagulation, and 29 with PDT and who were followed up for > 6 months, were enrolled. The focal laser was performed at sites of focal leakage (but not subfoveal leaks) shown in fluorescein angiography. PDT was performed at sites of subfoveal or juxtafoveal focal leakage or not definite focal leakages. Best corrected visual acuity (BCVA), central macular thickness (CMT), resolution of subretinal fluid (SRF) and recurrence were analyzed.

RESULTS

The follow-up duration of the focal laser group was 35.2 ± 22.6 and of the PDT group, 46.4 ± 21.5 months. Time to resolution of SRF was 1.8 ± 1.5 months for the focal laser group and 1.2 ± 0.5 months for the PDT group. SRF was rapidly absorbed in the PDT group. In both groups, the CMT was decreased 1 month after treatment. The BCVA improved significantly 1 month after treatment in the focal laser group and 3 months after treatment in the PDT group. However, there was no significant difference in CMT reduction and BCVA improvement between the two groups. It subsequently remained similar for up to 3 years. Ten patients (30.3%) in the focal laser group and three patients (10%) in the PDT group recurred during the follow-up period.

CONCLUSIONS

PDT showed early resolution of the SRF compared to focal laser. In CSC patients, both the CMT and BCVA remained stable for 3 years after treatment. After 3 or more years of follow-up, PDT showed a lower recurrence rate than focal laser.

Differential flow signal strength of choroidal neovascular membrane on optical coherence tomography angiography in central serous chorioretinopathy

A 62-year-old woman with no associated risk factors was diagnosed as a case of type 1 choroidal neovascularisation (CNV) associated with central serous chorioretinopathy in both the eyes based on clinical features and multimodal imaging. She was primarily treated with low fluence photodynamic therapy and responded well to the treatment. There was persistence of neovascular network seen on optical coherence tomography angiography (OCTA) without any signs of activity on optical coherence tomography. However, after 5 years she developed recurrent CNV in the left eye with a new type 2 CNV as seen on OCTA which had a higher flow signal strength as compared with the previous type 1 CNV. Following two doses of intravitreal ziv-aflibercept, the new type 2 CNV network regressed as evident on OCTA along with improvement in best corrected visual acuity.

Central Serous Chorioretinopathy: Pathogenesis and Management

Central serous chorioretinopathy (CSC) is a common retina disease and has a relative high recurrence rate, etiology, and pathogenesis of which remains largely ambiguous. The effects on the retina are usually self-limited, although some people are left with permanent vision loss due to progressive and irreversible photoreceptor damage or retinal pigment epithelium atrophy. There have been a number of interventions used in CSC, including, but not limited to, laser treatment, photodynamic therapy (PDT), intravitreal injection of anti-vascular endothelial growth factor agents, and subthreshold lasers. It is not clear whether there is a clinically important benefit to treating acute CSC, which often resolves spontaneously as part of its natural history. Of the interventions studied to date, PDT and micropulse laser treatment appear the most promising. 

Pharmacotherapy of Central Serous Chorioretinopathy: A Review of the Current Treatments

BACKGROUND

Central serous chorioretinopathy (CSC) is the fourth most frequent retinal disorder in terms of prevalence. It typically occurs in young subjects and affects men more often than women. CSC is characterized by serous retinal detachment (SRD) involving mainly the macular area. The clinical course is usually selflimited, with spontaneous resolution within 3 months. The persistence of SRD or multiple relapse may result in a chronic form of CSC distinguished by permanent retinal pigment epithelium (RPE) and photoreceptor damage. As the pathogenetic mechanism of CSC primarily involves RPE and choroidal vascularization, the current therapeutic approaches aim to restore the normal functions of RPE and normal choroidal vascular permeability. In this review, the authors aim to summarize the current therapeutic approach to CSC.

METHODS

A comprehensive review of the literature was conducted in PubMed by searching for relevant studies on the current therapeutic options for CSC, including simple observation, conventional laser treatment, subthreshold laser treatment (SLT), photodynamic therapy (PDT) with verteporfin, treatment with mineralocorticoid receptor (MR) antagonists and treatment with anti-vascular endothelial growth factor drugs.

RESULTS

Since most cases resolve spontaneously, the most common initial CSC treatment is observation. Current evidence suggests that PDT and SLT are valuable in improving visual acuity, reducing subretinal fluid and maintaining long-term effectiveness. No clear evidence of efficacy has been achieved for anti-VEGF. MR antagonists might be a viable choice for the treatment of chronic CSC.

CONCLUSION

The pathophysiology of CSC remains poorly understood and as a consequence, the gold standard of care for CSC is yet to be defined. To date, PDT and SLT continue to offer good clinical outcomes. Positive preliminary results seem to emerge from the studies of MR antagonists.

Current Therapeutic Approaches to Chronic Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSCR) is the second most common maculopathy after diabetic maculopathy between the third and fifth decades of life. CSCR is characterized by serous neurosensory retinal detachment occasionally coexisting with retinal pigment epithelium (RPE) detachment. CSCR usually has good clinical prognosis, often resolving spontaneously within the first three months. However, some patients may have recurrent episodes and chronic disease. CSCR can cause permanent visual loss due to persistent neurosensory retinal detachment and RPE atrophy, especially in chronic cases. In recent years, verteporfin-photodynamic therapy applied with standard and low-dose/low-fluence protocols, anti-vascular endothelial growth factors, glucocorticoid antagonists, mineralocorticoid receptor antagonists, and subthreshold micropulse laser with varying parameters have been investigated as treatment options. In this review, we evaluated randomized and non-randomized case series conducted after 2000 that included at least 3 patients with chronic CSCR over 3 months in duration who were treated with current treatment options for chronic CSCR.