Central serous chorioretinopathy: An update on risk factors, pathophysiology and imaging modalities

A possible association between intraocular pressure changes and pigment epithelial detachment in central serous chorioretinopathy

Central serous chorioretinopathy (CSC) is a frequently occurring chorioretinal disease, that is commonly associated with subretinal fluid accumulation in a generally young population. Even though choroidal abnormalities have been found to be of importance, the exact pathogenesis of CSC is still being learned. The origin of pigment epithelial detachments, seen in many CSC patients, is also unclear. Based on the follow-up of a CSC patient for more than 5 years, we hypothesize that intraocular pressure and, by extension, the pressure gradient across the Bruch's membrane, may be one factor in the pathogenesis of pigment epithelial detachments in CSC, which might very well have implications for the occurrence of and possible ways to prevent subretinal fluid in CSC.

Perfluorocarbon liquid-assisted subretinal fluid drainage via the choroid as a treatment for bullous central serous chorioretinopathy in a nanophthalmic eye

PURPOSE

The report presents a modified surgical technique wherein the perfluorocarbon liquid (PFCL)-assisted drainage of subretinal fluid (SRF) through the choroid was combined with partial-thickness sclerectomy (PTS) and punch sclerostomy as a treatment for bullous central serous chorioretinopathy (bCSCR) in a nanophthalmic eye.

METHODS

The developed surgical approach is herein discussed together with a corresponding surgical video. Briefly, two 5 × 4 mm half-thickness sclerectomies and a punch sclerostomy (diameter: 2 mm) to the choroid were performed in the inferior quadrants. Following vitrectomy, SRF was drained through the exposed choroid in the region where the punch sclerostomy was performed, whereafter PFCL was instilled into the vitreous cavity.

RESULTS

The complete resolution of SRF accumulation was evident at one-week post-surgery, with no evidence of recurrence over an 18-month follow-up period. No abnormal fluorescent leakage or choroidal vasodilation were evident via fundus fluorescein angiography and indocyanine green angiography examination at the patient's final follow-up visit.

CONCLUSION

PFCL-assisted SRF drainage through the choroid combined with PTS and punch sclerostomy may represent a viable approach to treating patients with bCSCR and nanophthalmic eyes, providing a rapid and long-lasting means of eliminating SRF accumulation.

Analysis of optical coherence tomography biomarker probability detection in central serous chorioretinopathy by using an artificial intelligence-based biomarker detector

AIM

To adopt a novel artificial intelligence (AI) optical coherence tomography (OCT)-based program to identify the presence of biomarkers associated with central serous chorioretinopathy (CSC) and whether these can differentiate between acute and chronic central serous chorioretinopathy (aCSC and cCSC).

METHODS

Multicenter, observational study with a retrospective design enrolling treatment-naïve patients with aCSC and cCSC. The diagnosis of aCSC and cCSC was established with multimodal imaging and for the current study subsequent follow-up visits were also considered. Baseline OCTs were analyzed by an AI-based platform (Discovery® OCT Fluid and Biomarker Detector, RetinAI AG, Switzerland). This software allows to detect several different biomarkers in each single OCT scan, including subretinal fluid (SRF), intraretinal fluid (IRF), hyperreflective foci (HF) and flat irregular pigment epithelium detachment (FIPED). The presence of SRF was considered as a necessary inclusion criterion for performing biomarker analysis and OCT slabs without SRF presence were excluded from the analysis.

RESULTS

Overall, 160 eyes of 144 patients with CSC were enrolled, out of which 100 (62.5%) eyes were diagnosed with cCSC and 60 eyes (34.5%) with aCSC. In the OCT slabs showing presence of SRF the presence of biomarkers was found to be clinically relevant (> 50%) for HF and FIPED in aCSC and cCSC. HF had an average percentage of 81% (± 20) in the cCSC group and 81% (± 15) in the aCSC group (p = 0.4295) and FIPED had a mean percentage of 88% (± 18) in cCSC vs. 89% (± 15) in the aCSC (p = 0.3197).

CONCLUSION

We demonstrate that HF and FIPED are OCT biomarkers positively associated with CSC when present at baseline. While both HF and FIPED biomarkers could aid in CSC diagnosis, they could not distinguish between aCSC and cCSC at the first visit. AI-assisted biomarker detection shows promise for reducing invasive imaging needs, but further validation through longitudinal studies is needed.

Foveal atrophy in patients with active central serous chorioretinopathy at first presentation: characteristics and treatment outcomes

BACKGROUND/AIMS

This study aimed to investigate the clinical characteristics and treatment outcomes of patients with active central serous chorioretinopathy (CSC) and foveal atrophy.

METHODS

Patients diagnosed with active idiopathic CSC using multimodal imaging and followed up for at least 6 months were included. They were divided into two groups (foveal atrophy group vs foveal non-atrophy group) according to a cut-off central foveal thickness of 120 µm on baseline optical coherence tomography (OCT). Baseline characteristics, angiographic and tomographic features and treatment outcomes were compared between the two groups.

RESULTS

Of the 463 patients, 92 eyes of 92 patients (19.9%) were in the foveal atrophy group and 371 eyes of 371 patients (80.1%) were in the foveal non-atrophy group. The baseline subretinal fluid (SRF) height was 111.3±76.8 µm in the foveal atrophy group and 205.0±104.4 µm in the foveal non-atrophy group on OCT images (p<0.001). Complete resolution of SRF after treatment was noted in 60.4% and 93.5% of patients in the foveal atrophy and foveal non-atrophy groups at the final visit, respectively (p<0.001). The foveal atrophy group showed worse visual acuity at baseline (logarithm of the minimum angle of resolution, 0.43±0.33 vs 0.13±0.18, p<0.001) and final visit (0.41±0.32 vs 0.05±0.15, p=0.035).

CONCLUSIONS

CSC with foveal atrophy was associated with a shallow SRF height, low treatment efficacy and poor vision before and after treatment. We suggest that early active treatment should be considered for eyes with CSC accompanied by a persistent shallow SRF and foveal atrophy.

CHOROIDAL AND RETINAL ABNORMALITIES IN CUSHING SYNDROME: Correlation with the Cortisol Level

PURPOSE

To investigate the structure and blood flow of the retina and choroid in Cushing syndrome and their relationship with cortisol levels.

METHODS

A consecutive series of patients with Cushing syndrome with adrenocortical carcinoma were included in this study. Cortisol levels gradually returned to normal after adrenalectomy. Optical coherence tomography and optical coherence tomography angiography were used to assess patients with Cushing syndrome before and after the surgery for retina and choroid. Correlation analysis was performed between cortisol level and fundus changes.

RESULTS

Compared with normal cortisol levels, patients with Cushing syndrome had significantly lower central macular thickness with increased cortisol level (220.82 ± 16.59 µ m and 223.68 ± 15.78 µ m, P = 0.019). However, the central choroidal thickness was higher with increased cortisol level (255.18 ± 105.89 µ m and 205.94 ± 87.04 µ m, P < 0.001). The choriocapillaris flow area was higher with increased cortisol level (2.05 ± 0.14 mm 2 and 2.00 ± 0.13 mm 2 , P = 0.02). The change of choriocapillaris flow area was correlated with the score of Huaxi Emotional-distress Index and 24-hour urine-free cortisol (24h-UFC).

CONCLUSION

The increased cortisol level was correlated with lesser central macular thickness and thicker central choroidal thickness. The decrease of choriocapillaris flow area was correlated with 24h-UFC, indicating the effect of increased cortisol level on choroidal vessels.

CHRONIC CENTRAL SEROUS CHORIORETINOPATHY IN THE PEDIATRIC POPULATION: A CASE SERIES

PURPOSE

The purpose of this article was to describe 3 cases of chronic central serous chorioretinopathy (CSCR) in the pediatric patient population.

METHODS

Retrospective case series.

RESULTS

The authors report three pediatric patients with CSCR. All patients initially presented after failed vision screens or during routine office examinations. All patients presented with macula-involving subretinal fluid (SRF) and multimodal imaging features consistent with CSCR. At the last follow-up, one patient had minimal residual SRF, one patient had a small recurrence of SRF, and one patient had persistent SRF.

CONCLUSION

Although CSCR classically occurs in adults, it can be seen in pediatric patients. Given the rarity of this condition in the pediatric population, CSCR may go undetected and underreported, with diagnosis resulting from failed vision screens.

New insights on circumscribed choroidal hemangioma: "bench to bedside"

Circumscribed choroidal hemangioma is a rare vascular hamartoma of the choroid, presenting as a red-orange mass at the posterior pole on fundoscopic examination. Despite its benign origin, associated complications such as subretinal fluid, serous retinal detachment, retinoschisis and neovascular glaucoma may lead to serious visual impairment in more than half patients. Because of its similarity to amelanotic choroidal melanoma and choroidal metastasis, differential diagnosis is still challenging for specialists. Multimodal imaging such as ultrasonography, fluorescein angiography, indocyanine green angiography, optical coherence tomography, and optical coherence tomography angiography guides the clinician to the correct diagnosis and the proper follow-up. Treatment is indicated in symptomatic cases in order to resolve exudation and improve visual acuity. Treatment options include photocoagulation, transpupillary thermotherapy, radiation therapy, photodynamic therapy and anti-vascular endothelial growth factor therapy. Currently, photodynamic therapy is the treatment of choice due to its effectiveness and safety. The purpose of this review is to describe the latest knowledge in the etiopathogenesis of the circumscribed choroidal hemangioma, the most recent multimodal imaging findings, and the available treatment options.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of Focal Laser Photocoagulation on the Ganglion Cell Complex Thickness in Acute Central Serous Chorioretinopathy

This study investigated the changes in the ganglion cell complex (GCC) of patients with acute central serous chorioretinopathy (CSC) following focal laser photocoagulation (FLP) and sought to determine its correlation with visual acuity (VA). Our retrospective study was conducted on 30 patients diagnosed with acute CSC between January 2015 and April 2022, who underwent FLP within 3 months of symptom onset. The study assessed GCC changes by measuring the thickness of its inner retinal layers-retinal nerve fiber layer (RNFL), ganglion cell layer (GCL), and inner plexiform layer (IPL) using optical coherence tomography (OCT). GCC thickness was compared between the affected and unaffected eyes and a healthy control group. VA was also assessed at baseline and at 1, 3, and 6 months post-treatment. VA showed significant improvement from 0.20 ± 0.14 at baseline to 0.10 ± 0.12 logMAR at 6 months post-treatment (p = 0.003). There was no significant change in GCC thickness over the 6-month period. No significant differences in GCC thickness were observed when comparing CSC eyes with fellow eyes or with normal controls at any time point. Final VA was significantly related only to baseline VA, with no correlation found with other factors, including RNFL, GCL, and IPL thickness. In summary, for patients with acute CSC undergoing FLP, our findings indicate that there is no significant change in GCC thickness detectable by OCT before and after the resolution of subretinal fluid (SRF), despite improvements in VA post-laser treatment. This suggests that any potential impact of FLP on GCC thickness may be minimal and not discernible with the current measurement methods, such as OCT, emphasizing that VA improvements may be primarily associated with alterations in the outer retina rather than the inner retina. Further studies with extended follow-up durations are warranted to evaluate any potential long-term changes in GCC.

A randomized non-inferiority trial of 577nm subthreshold micropulse laser versus half-dose photodynamic therapy for acute central serous chorioretinopathy

PURPOSE

To compare the effectiveness of 577nm subthreshold micropulse laser (SML) with half-dose photodynamic therapy (Hd-PDT) for acute central serous chorioretinopathy (CSC).

METHOD

A non-inferiority clinical trial was performed with a non-inferiority margin of eight letters. Sixty-eight eyes of 68 patients with acute CSC were randomized to the Hd-PDT group or 577 nm SML group. Best-corrected visual acuity (BCVA ), the subretinal fluid (SRF), and the central foveal thickness (CFT) were evaluated at 6 months.

RESULTS

The visual acuity significantly improved from 70.38 ± 10.37 at baseline to 83.24 ± 3.03 at 6 months after treatment in the SML group (P < 0.001), from 71.09 ± 10.50 to 84.35 ± 2.09 in the PDT group (P < 0.001). SML was non-inferior to the PDT (mean difference: -0.41, 95% CI: -5.51 - 4.68, P = 0.0021). At the endpoint, CFT was significantly reduced in the two groups, but no statistical difference (P = 0.7694). The complete resolution of SRF reached 82.35% (28/34) in the SML group and 91.18% (31/34) in the PDT group, respectively,but no statistical difference (P = 0.3724).

CONCLUSIONS

SML was non-inferiority to half-dose PDT in improving the visual acuity for CSC, and it is a viable alternative, especially when the verteporfin in PDT is unavailable.

Central serous chorioretinopathy: An evidence-based treatment guideline

Central serous chorioretinopathy (CSC) is a relatively common disease that causes vision loss due to macular subretinal fluid leakage and it is often associated with reduced vision-related quality of life. In CSC, the leakage of subretinal fluid through defects in the retinal pigment epithelial layer's outer blood-retina barrier appears to occur secondary to choroidal abnormalities and dysfunction. The treatment of CSC is currently the subject of controversy, although recent data obtained from several large randomized controlled trials provide a wealth of new information that can be used to establish a treatment algorithm. Here, we provide a comprehensive overview of our current understanding regarding the pathogenesis of CSC, current therapeutic strategies, and an evidence-based treatment guideline for CSC. In acute CSC, treatment can often be deferred for up to 3-4 months after diagnosis; however, early treatment with either half-dose or half-fluence photodynamic therapy (PDT) with the photosensitive dye verteporfin may be beneficial in selected cases. In chronic CSC, half-dose or half-fluence PDT, which targets the abnormal choroid, should be considered the preferred treatment. If PDT is unavailable, chronic CSC with focal, non-central leakage on angiography may be treated using conventional laser photocoagulation. CSC with concurrent macular neovascularization should be treated with half-dose/half-fluence PDT and/or intravitreal injections of an anti-vascular endothelial growth factor compound. Given the current shortage of verteporfin and the paucity of evidence supporting the efficacy of other treatment options, future studies-ideally, well-designed randomized controlled trials-are needed in order to evaluate new treatment options for CSC.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Intra- and Inter-expert Validation of an Automatic Segmentation Method for Fluid Regions Associated with Central Serous Chorioretinopathy in OCT Images

Central Serous Chorioretinopathy (CSC) is a retinal disorder caused by the accumulation of fluid, resulting in vision distortion. The diagnosis of this disease is typically performed through Optical Coherence Tomography (OCT) imaging, which displays any fluid buildup between the retinal layers. Currently, these fluid regions are manually detected by visual inspection a time-consuming and subjective process that can be prone to errors. A series of six deep learning-based automatic segmentation architectural configurations of different levels of complexity were trained and compared in order to determine the best model intended for the automatic segmentation of CSC-related lesions in OCT images. The best performing models were then evaluated in an external validation study. Furthermore, an intra- and inter-expert analysis was conducted in order to compare the manual segmentation performed by expert ophthalmologists with the automatic segmentation provided by the models. Test results of the best performing configuration achieved a mean Dice of 0.868 ± 0.056 in the internal dataset. In the external validation set, these models achieved a level of agreement with human experts of up to 0.960 in terms of Kappa coefficient, contrasting with a value of 0.951 for agreement between human experts. Overall, the models reached a better agreement with either of the human experts than these experts with each other, suggesting that automatic segmentation models for the detection of CSC-related lesions in OCT imaging can be useful tools for assessing this disease, reducing the workload of manual inspection and leading to a more robust and objective diagnosis method.

Longitudinal changes in the ganglion cell complex thickness in acute central serous chorioretinopathy using spectral-domain optical coherence tomography

In this retrospective longitudinal cohort study, we investigated the temporal changes in the peripapillary retinal nerve fiber layer (pRNFL) and inner retinal thickness in patients with acute central serous chorioretinopathy (CSC) using spectral-domain optical coherence tomography (SD-OCT). We followed up with these patients for 6 months, and during this period, the thickness of the pRNFL and the ganglion cell complex (GCC) in CSC patients were compared with the eyes of normal healthy individuals. The study also examined the correlation between the pRNFL thickness, GCC thickness, and visual acuity. The research sample consisted of 67 patients (43 male and 24 female) with an average age of 49.72 ± 9.87 years. The initial findings showed no significant differences in the pRNFL and GCC thickness between the study and fellow eye, study and normal healthy eyes, and fellow and normal healthy eyes. There was no significant difference in the pRNFL and GCC thickness when comparing the study eye with the fellow eye for 6 months. In the study eye, no significant difference was observed when comparing the initial GCC and pRNFL thickness with those at 1, 3, and 6 months. Visual acuity improved significantly from 0.18 ± 0.23 logMAR to 0.04 ± 0.06 logMAR (p < 0.001). The GCC and pRNFL thickness did not significantly affect visual acuity. In conclusion, acute CSC patients did not show significant changes in the pRNFL and inner retinal thickness, suggesting that the GCC and pRNFL do not substantially influence the short-term visual prognosis in these patients.

Pharmaceutical In Situ Gel for Glaucoma: Recent Trends and Development with an Update on Research and Patents

Glaucoma is a progressive visual polyneuropathy characterized by retinal ganglion cell atrophy and optic nerve head changes. It's generally triggered due to increased intraocular pressure compared with the healthy eye. Glaucoma is treated with various medications in traditional eye drops, such as prostaglandins, carbonic anhydrase inhibitors, beta-blockers, and others. Such treatments are difficult to use and produce lachrymal leakage and inadequate corneal permeability, resulting in lower availability. Ophthalmic in situ gels, introduced in past decades with tremendous effort, are among the finest various choices to solve the drawbacks of eye drops. Employing different polymers with pH-triggered, temperature-triggered, and ion-activated processes have been used to generate ophthalmic in situ gelling treatments. Once those preparations are delivered into the eye, they change phase from sol to gel, allowing the medicine to stay in the eye for longer. These formulations are known as smart gels as they turn into gelling fluids when administered into the eyes. The different mechanisms of in situ gel formulations are used for the management of glaucoma and are discussed in this review article.

Patients with central serous chorioretinopathy have high circulating alpha-klotho concentrations

Stress is a risk factor for central serous chorioretinopathy (CSC), but a suitable biomarker of this stress has not been identified. We aimed to evaluate alpha-klotho (αKl) as a potential biomarker of CSC. The circulating concentrations of αKl in patients diagnosed with acute or chronic CSC and treated at Hyogo College of Medicine between December 2019 and July 2021 were retrospectively compared with those of healthy individuals. We also compared the αKl concentrations of patients with acute or chronic CSC. Furthermore, we evaluated the relationships of age, sex, smoking status, and subfoveal choroidal thickness (SFCT) with αKl concentration. Patients in whom subretinal fluid reaccumulated in the same eye after its resolution were defined as having recurrent CSC. We studied 56 patients (46 men and 10 women) and 27 healthy controls (19 men and 8 women); and 38 and 18 eyes with acute and chronic CSC, respectively. The mean circulating concentration of αKl was higher in patients with CSC than in controls (827±232 and 724±183 pg/mL, respectively; p = 0.035). The mean SFCT was greater in patients with CSC than in controls (416±91.0 and 278±96.3 μm, respectively; p<0.0001). The mean αKl concentration was significantly higher in the patients with acute CSC than in those with chronic CSC (898±221 and 740±224 pg/mL, respectively; p = 0.038). Recurrence of CSC occurred in 10 of 56 (17.9%) eyes, of which five eyes were in the acute CSC group and five were in the chronic CSC group. Patients who experienced recurrence had significantly higher αKI concentrations than those who did not (p = 0.0219). There were no significant relationships of αKl concentration with age, sex, smoking history, or SFCT. In summary, the circulating αKI concentrations of patients with CSC are high, which suggests that αKI may be an indicator of stress in such patients.

Acute and continuous exposure of airborne fine particulate matter (PM2.5): diverse outer blood-retinal barrier damages and disease susceptibilities

BACKGROUND

The association between air pollution and retinal diseases such as age-related macular degeneration (AMD) has been demonstrated, but the pathogenic correlation is unknown. Damage to the outer blood-retinal barrier (oBRB), which consists of the retinal pigment epithelium (RPE) and choriocapillaris, is crucial in the development of fundus diseases.

OBJECTIVES

To describe the effects of airborne fine particulate matter (PM2.5) on the oBRB and disease susceptibilities.

METHODS

A PM2.5-exposed mice model was established through the administration of eye drops containing PM2.5. Optical coherence tomography angiography, transmission electron microscope, RPE immunofluorescence staining and Western blotting were applied to study the oBRB changes. A co-culture model of ARPE-19 cells with stretching vascular endothelial cells was established to identify the role of choroidal vasodilatation in PM2.5-associated RPE damage.

RESULTS

Acute exposure to PM2.5 resulted in choroidal vasodilatation, RPE tight junctions impairment, and ultimately an increased risk of retinal edema in mice. These manifestations are very similar to the pachychoroid disease represented by central serous chorioretinopathy (CSC). After continuous PM2.5 exposure, the damage to the RPE was gradually repaired, but AMD-related early retinal degenerative changes appeared under continuous choroidal inflammation.

CONCLUSION

This study reveals oBRB pathological changes under different exposure durations, providing a valuable reference for the prevention of PM2.5-related fundus diseases and public health policy formulation.

Analysis of Cytokine Levels Based on Optical Coherence Tomography Findings in Acute and Chronic Central Serous Chorioretinopathy

Purpose: To investigate the characteristics of optical coherence tomography (OCT) and aqueous humor cytokine differences between acute and chronic central serous chorioretinopathy (CSC) and to evaluate the relevance of these findings.Methods: This was a cross-sectional, observational study. Patients with CSC were divided into acute and chronic groups based on the symptom duration and were compared with normal controls. Best-corrected visual acuity (BCVA), central macular thickness (CMT), subfoveal choroidal thickness (CT), hyperreflective foci (HF), and cytokines including vascular endothelial growth factor (VEGF), interleukin (IL)-6, IL-8, IL-10, interferon-inducible protein-10 (IP-10), and monocyte chemoattractant protein-1 (MCP-1) were used as comparison metrics.Results: A total of 62 patients (62 eyes) with CSC (22 with acute CSC and 40 with chronic CSC) and 35 patients as controls were included in this study. The chronic CSC group had significantly older average ages and worse BCVA than the acute CSC group (both p < 0.05). Both CSC groups showed significant increases in CMT and CT (both p < 0.05). In chronic CSC, the CMT was thinner, with more HF in the neuroretina (p = 0.034). VEGF levels were significantly higher in patients with chronic CSC than in those with acute CSC and controls (p < 0.05). The levels of inflammatory cytokines showed no significant difference between the CSC and control groups. Spearman's correlation analysis showed that the number of HF was positively correlated with disease duration (r = 0.311, p = 0.014), logMAR BCVA (r = 0.487, P < 0.001) and MCP-1 levels (r = 0.256, p = 0.045).Conclusions: Chronicity of CSC could lead to upregulation of VEGF. HF was associated with a more severe visual impairment in CSC patients and had relations with the levels of MCP-1.

Developing and Evaluating an AI-Based Computer-Aided Diagnosis System for Retinal Disease: Diagnostic Study for Central Serous Chorioretinopathy

BACKGROUND

Although previous research has made substantial progress in developing high-performance artificial intelligence (AI)-based computer-aided diagnosis (AI-CAD) systems in various medical domains, little attention has been paid to developing and evaluating AI-CAD system in ophthalmology, particularly for diagnosing retinal diseases using optical coherence tomography (OCT) images.

OBJECTIVE

This diagnostic study aimed to determine the usefulness of a proposed AI-CAD system in assisting ophthalmologists with the diagnosis of central serous chorioretinopathy (CSC), which is known to be difficult to diagnose, using OCT images.

METHODS

For the training and evaluation of the proposed deep learning model, 1693 OCT images were collected and annotated. The data set included 929 and 764 cases of acute and chronic CSC, respectively. In total, 66 ophthalmologists (2 groups: 36 retina and 30 nonretina specialists) participated in the observer performance test. To evaluate the deep learning algorithm used in the proposed AI-CAD system, the training, validation, and test sets were split in an 8:1:1 ratio. Further, 100 randomly sampled OCT images from the test set were used for the observer performance test, and the participants were instructed to select a CSC subtype for each of these images. Each image was provided under different conditions: (1) without AI assistance, (2) with AI assistance with a probability score, and (3) with AI assistance with a probability score and visual evidence heatmap. The sensitivity, specificity, and area under the receiver operating characteristic curve were used to measure the diagnostic performance of the model and ophthalmologists.

RESULTS

The proposed system achieved a high detection performance (99% of the area under the curve) for CSC, outperforming the 66 ophthalmologists who participated in the observer performance test. In both groups, ophthalmologists with the support of AI assistance with a probability score and visual evidence heatmap achieved the highest mean diagnostic performance compared with that of those subjected to other conditions (without AI assistance or with AI assistance with a probability score). Nonretina specialists achieved expert-level diagnostic performance with the support of the proposed AI-CAD system.

CONCLUSIONS

Our proposed AI-CAD system improved the diagnosis of CSC by ophthalmologists, which may support decision-making regarding retinal disease detection and alleviate the workload of ophthalmologists.

TWO-YEAR CLINICAL OUTCOMES AFTER PHOTODYNAMIC ACUTE EXUDATIVE MACULOPATHY IN PATIENTS WITH CHRONIC CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To analyze the 2-year clinical outcomes after photodynamic therapy-induced acute exudative maculopathy (PAEM) in patients with chronic central serous chorioretinopathy.

METHODS

Prospective observational study that included 64 eyes of 64 patients with chronic central serous chorioretinopathy who received half-fluence photodynamic therapy and had a 2-year follow-up. Patients were classified into two groups based on whether they had had PAEM at 3 days after treatment (PAEM+, n = 22; ≥50 µ m) increase in subretinal fluid or not (PAEM-, n = 42). Best-corrected visual acuity and subretinal fluid changes evaluated with optical coherence tomography were registered at 3 days, 1 month, 3 months, 1 year, and 2 years after photodynamic therapy. The number of recurrences, the appearance of outer retinal atrophy, and choroidal neovascularization were analyzed.

RESULTS

Best-corrected visual acuity was 75.9 ± 13.6 (20/32) and 82.0 ± 11.0 letters (20/25) at 2 years in the PAEM+ and PAEM- groups, respectively ( P = 0.055). There were no differences in the best-corrected visual acuity change (4.2 ± 7.7 vs. 3.3 ± 7.1 letters; P = 0.654) and the subretinal fluid decrease (-117.3 ± 74.2 vs. -138.5 ± 83.6 µ m; P = 0.323) at 2 years between patients with and without PAEM. No differences in the number of recurrences ( P = 0.267), the appearance of choroidal neovascularization ( P = 0.155), or outer retinal atrophy ( P = 0.273) between both groups were noted.

CONCLUSION

Patients with chronic central serous chorioretinopathy with and without PAEM presented similar results at 2 years in best-corrected visual acuity gain, subretinal fluid reduction, and complication rate.

Pupillary Light Reflex and Multimodal Imaging in Patients With Central Serous Chorioretinopathy

Purpose

The purpose of this study was to investigate and compare the corresponding alterations of the pupillary response between acute and chronic central serous chorioretinopathy (CSC) and between different disease categories.

Methods

We recruited patients with unilateral acute and chronic CSC. An eye tracker was applied to determine the pupillary light reflex (PLR) and evaluate the following PLR metrics in healthy eyes: pupil diameter, diameter changes, including relative constriction amplitude (AMP%), and re-dilation ratio (D1%). Baseline optical coherence tomography (OCT), and fluorescein and indocyanine green angiography (FA/ICGA) were performed to analyze the relationship between pupillary response and retinal/choroidal architecture.

Results

In total, 52 patients were enrolled, including 25 with acute CSC and 27 with chronic CSC. Compared to the chronic CSC group, the acute CSC group displayed a significantly larger baseline pupil diameter (BPD; of 5.51 mm, P = 0.015), lower AMP% (34.40%, P = 0.004), and higher D1% (93.01%, P = 0.002), indicating sympathetic overactivity. On OCT, the total macular volume was positively correlated with the D1% (r = 0.48, P = 0.005) and negatively with AMP (r = -0.47, P = 0.007). On ICGA, the intense choroidal vascular hyperpermeability (CVH) group displayed a greater BPD than the nonintense CVH group. Additionally, 9 cases with later recurrent episodes following therapy showed a lower AMP% and higher D1% than the nonrecurrent group.

Conclusions

The PLR revealed sympathetic excitation in patients with acute CSC. The stronger D1% was significantly associated with greater total macular volume, and it may be a potential biomarker for predicting the later recurrence of CSC.

Exploring the Potential Link between Acute Central Serous Chorioretinopathy and Trimethylamine N-Oxide, Phoenixin, Spexin, and Alarin Molecules

PURPOSE

Acute central serous chorioretinopathy (ACSCR) is a condition characterized by decreased visual acuity, macular thickening, and edema under the retinal layer. Although the underlying mechanisms of the disease are not fully understood, oxidative stress is considered to be a critical risk factor. The aim of this study was to shed light on the pathophysiology of ACSCR by investigating the levels of circulating trimethylamine N-oxide (TMAO), phoenixin (PNX), alarin (ALA), and spexin (SPX) molecules in ACSCR patients.

METHODS

The study included 30 ACSCR patients and 30 healthy individuals as controls. ACSCR was diagnosed using optical coherence tomography (OCT) imaging. Five mL blood samples were collected from all participants following overnight fasting. The levels of TMAO, PNX, ALA, and SPX in the blood samples were measured using the ELISA method.

RESULTS

Visual acuity was found to be significantly reduced in ACSCR patients compared to the control group (<0.05), while macular thickness was increased (<0.05). Furthermore, TMAO, PNX, and ALA levels were significantly higher in ACSCR patients (<0.05), while SPX levels were significantly lower compared to the control group (<0.05). In ACSCR patients, there was a positive correlation between macular thickness and TMAO, PNX, and ALA; there was, however, a negative correlation with SPX. Additionally, visual acuity was negatively correlated with TMAO, PNX, and ALA, while SPX levels decreased as visual acuity decreased.

CONCLUSIONS

These results demonstrate a correlation between the TMAO, PNX, ALA, and SPX levels of ACSCR patients and their visual acuity and macular thickness. Given the role of these molecules in ACSCR's pathophysiology, they hold promise as potential diagnostic, therapeutic, and follow-up markers in the future.

Pushing Retinal Imaging Forward: Innovations and Their Clinical Meaning - The 2022 Ophthalmologica Lecture

Retinal imaging has greatly expanded our understanding of various pathological conditions. This article presents a summary of the key points covered during the 2022 Ophthalmologica Lecture held at the Euretina Congress in Hamburg. The first part of the article focuses on the use of optical coherence tomography angiography to examine and comprehend the choroid in age-related macular degeneration (AMD). Subsequently, we delve into the discussion of the "postreceptor neuronal loss" theory in AMD, which was studied using en face structural optical coherence tomography (OCT). Following that, we explore pertinent findings obtained through cross-sectional OCT in retinal and optic nerve diseases, such as AMD, diabetic macular edema, pathologic myopia, central serous chorioretinopathy, and Leber's hereditary optic neuropathy.

High Levels of C-Reactive Protein with Low Levels of Pentraxin 3 as Biomarkers for Central Serous Chorioretinopathy

Purpose

To investigate the association between the 2 acute phase proteins, C-reactive protein (CRP) and pentraxin 3 (PTX3) with central serous chorioretinopathy (CSCR), as PTX3 is a glucocorticoid-induced protein.

Design

Cross-sectional multicenter study.

Participants

Patients with CSCR compared with age- and sex-matched healthy participants.

Methods

Patients with CSCR from 3 centers in Europe were included in the study. The clinical form of CSCR was recorded. Blood samples from patients with CSCR and healthy participants were sampled, and high-sensitivity CRP and PTX3 levels were measured in the serum.

Main Outcome Measures

C-reactive protein and PTX3 serum level comparison between patients with CSCR with age- and sex-matched healthy participants.

Results

Although CRP levels were higher in patients with CSCR (n = 216) than in age- and sex-matched controls (n = 130) (2.2 ± 3.2 mg/l vs. 1.5 mg/l ± 1.4, respectively, P = 0.037), PTX3 levels were lower in patients with CSCR (10.5 ± 19.9 pg/ml vs. 87.4 ± 73.2 pg/ml, respectively, P < 0.001). There was no significant difference in CRP or PTX3 levels between patients with acute/recurrent and chronic CSCR.

Conclusions

In patients with CSCR, high CRP and low PTX3 levels suggest a form of low-grade systemic inflammation together with a lack of glucocorticoid pathway activation, raising new hypotheses on the pathophysiology of CSCR.

Financial Disclosures

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Evaluation of the changes in choroidal macular anastomoses after photodynamic therapy and in the follow-up of central serous chorioretinopathy by en face optical coherence tomography

PURPOSE

To evaluate the changes in the choroidal macular anastomoses after photodynamic therapy (PDT) and in the follow-up of patients with central serous chorioretinopathy (CSCR) by en face optical coherence tomography (EF-OCT).

METHODS

Prospective study using EF-OCT images of patients with chronic CSCR treated by PDT with a minimum follow-up of 12 months and with the presence of at least two prominent anastomoses in the macula. Scans of 6 × 6 mm and 12 × 12 mm were made to assess the changes in choroidal macular anastomoses (defined as a diameter ≥150 µm) crossing the medial raphe. EF-OCT was performed before PDT and 3 days, 3 months and at the end of the follow-up after PDT.

RESULTS

The mean follow-up time was 23.6 ± 12.1 months. The mean number of anastomoses was 2.5 ± 1.1 in the baseline examination, being 2.3 ± 1.2 in the final examination, with no differences being observed (p = 0.110). A sub-analysis was performed to assess differences in the evolution of the anastomoses between active chronic CSCR and those in which the subretinal fluid (SRF) had been resolved, with no differences being observed in the number or caliber of anastomoses (p = 0.642 and p = 0.306). A significant decrease in the size of anastomoses was found at the 3-day (p<0.01) and 3-month (p = 0.032) visits, but not at the last follow-up visit (p = 0.156).

CONCLUSIONS

There was an early decrease in the size of the major macular choroidal anastomotic vessels after PDT treatment. Long-term studies are required to assess its evolution and its possible role in the etiopathogenesis of this disease.

Choroidal Vortex Vein Drainage System in Central Serous Chorioretinopathy Using Ultra-Widefield Optical Coherence Tomography Angiography

Purpose

To evaluate differences in the choroidal vortex vein drainage system (VV) in eyes between patients with central serous chorioretinopathy (CSC) and unaffected individuals using ultra-widefield optical coherence tomography angiography (UWF-OCTA).

Methods

In this cross-sectional observational study, 40 eyes of patients with CSC and 28 eyes of healthy volunteers were included. The analysis involved the use of UWF-OCTA to analyze the proportion of the choroidal vortex vein drainage system (VV%), choroidal thickness, choroidal vascular volume (CVV), and choroidal vascularity index (CVI) of the VV in each drainage quadrant. The location relationship between the leakage points in fluorescein angiography and the VV was also explored.

Results

A within-group analysis of VV% showed a statistically significant difference in the CSC group (P < 0.001) but not in the control group (P = 0.270). Compared to healthy eyes, CSC eyes had a significantly larger CVV and higher CVI in all regions (all P < 0.05). The superotemporal (ST) drainage system had the largest CVV and thickest choroidal layer among the four drainage quadrants (all P < 0.05) in CSC eyes. The leakage rate in the ST quadrant was significantly higher than that in the inferotemporal quadrant (P < 0.001).

Conclusions

CSC eyes have an asymmetric vortex vein drainage system, with relative hyperperfusion in all VV. Further, the preferential drainage route of the submacular choroid may be the ST drainage system in CSC eyes.

Translational Relevance

Targeting the imbalanced drainage system could be a potential therapeutic approach for CSC.

[Central serous chorioretinopathy: A review]

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

Association of Risk Variants in the CFH Gene With Elevated Levels of Coagulation and Complement Factors in Idiopathic Multifocal Choroiditis

Importance

Idiopathic multifocal choroiditis (MFC) is poorly understood, thereby hindering optimal treatment and monitoring of patients.

Objective

To identify the genes and pathways associated with idiopathic MFC.

Design, Setting, and Participants

This was a case-control genome-wide association study (GWAS) and protein study of blood plasma samples conducted from March 2006 to February 2022. This was a multicenter study involving 6 Dutch universities. Participants were grouped into 2 cohorts: cohort 1 consisted of Dutch patients with idiopathic MFC and controls, and cohort 2 consisted of patients with MFC and controls. Plasma samples from patients with idiopathic MFC who had not received treatment were subjected to targeted proteomics. Idiopathic MFC was diagnosed according to the Standardization of Uveitis Nomenclature (SUN) Working Group guidelines for punctate inner choroidopathy and multifocal choroiditis with panuveitis. Data were analyzed from July 2021 to October 2022.

Main outcomes and measures

Genetic variants associated with idiopathic MFC and risk variants associated with plasma protein concentrations in patients.

Results

This study included a total of 4437 participants in cohort 1 (170 [3.8%] Dutch patients with idiopathic MFC and 4267 [96.2%] controls; mean [SD] age, 55 [18] years; 2443 female [55%]) and 1344 participants in cohort 2 (52 [3.9%] patients with MFC and 1292 [96.1%] controls; 737 male [55%]). The primary GWAS association mapped to the CFH gene with genome-wide significance (lead variant the A allele of rs7535263; odds ratio [OR], 0.52; 95% CI, 0.41-0.64; P = 9.3 × 10-9). There was no genome-wide significant association with classical human leukocyte antigen (HLA) alleles (lead classical allele, HLA-A*31:01; P = .002). The association with rs7535263 showed consistent direction of effect in an independent cohort of 52 cases and 1292 control samples (combined meta-analysis OR, 0.58; 95% CI, 0.38-0.77; P = 3.0 × 10-8). In proteomic analysis of 87 patients, the risk allele G of rs7535263 in the CFH gene was strongly associated with increased plasma concentrations of factor H-related (FHR) proteins (eg, FHR-2, likelihood ratio test, adjusted P = 1.1 × 10-3) and proteins involved in platelet activation and the complement cascade.

Conclusions and relevance

Results suggest that CFH gene variants increase systemic concentrations of key factors of the complement and coagulation cascades, thereby conferring susceptibility to idiopathic MFC. These findings suggest that the complement and coagulation pathways may be key targets for the treatment of idiopathic MFC.

Comparing treatment outcomes in randomized controlled trials of central serous chorioretinopathy

PURPOSE

To perform a qualitative analysis of outcomes published from randomized controlled trials (RCTs) on central serous chorioretinopathy (CSCR) from 1979 to 2022.

DESIGN

Systematic review.

METHODS

All RCTs (including both therapeutic and non-therapeutic interventions) on CSCR available online till July 2022 were included after an electronic search in multiple databases such as PubMed, CENTRAL, MEDLINE, EMBASE, BIOSIS, Scopus, and Cochrane database. We analyzed and compared the inclusion criteria, imaging modalities, study endpoints, duration, and the results of the study.

RESULTS

The literature search yielded 498 potential publications. After excluding duplicate studies and studies that met clear exclusion criteria, 64 were screened for further evaluation, of which 7 were removed due to a lack of necessary inclusion criteria. A total of 57 eligible studies are described in this review.

CONCLUSION

This review provides a comparative overview of key outcomes reported between RCTs investigating CSCR. We describe the current landscape of treatment modalities for CSCR and note the discrepancies between results in these published studies. Challenges arise when attempting to compare similar study designs without comparable outcome measures (i.e., clinical vs. structural) which may limit the overall evidence presented. To mitigate this issue, we present the collected data from each study in tables detailing the measures that are and are not assessed in each publication.

Real world outcomes of photodynamic therapy for chronic central serous chorioretinopathy

OBJECTIVES

We describe the real-world outcomes of photodynamic therapy (PDT) for chronic central serous chorioretinopathy (CSCR) in a single centre over nine years.

METHODS

We carried out a retrospective analysis of patients with chronic CSCR who received half dose PDT in a single centre between 2011 and 2019. Visual acuity (VA) and retinal thickness (RT) was recorded between baseline visit and first recorded review visit.

RESULTS

We included 125 eyes of 113 patients in this study. Mean age at treatment was 55.0 ± 12.1 years, with a higher male predominance (83 men, 30 women). Mean baseline VA was 0.40 ± 0.31 logMAR with a mean visual outcome gain post-PDT of 0.05 logMAR (p = 0.005). Mean baseline RT was 390 ± 82 microns with a mean reduction of RT post-PDT of 66 microns (p < 0.001). 17.6% of eyes were treated for recurrent CSCR.

CONCLUSION

We found overall a mean improvement in VA and structural outcomes after PDT. In the absence of randomised clinical trials this study supports the use of half dose PDT for treatment of chronic CSCR.

Choroidal Vein Alterations in Pachychoroid Disease With Choroidal Vascular Hyperpermeability: Evaluated by Wide-Field Indocyanine Green Angiography

Purpose

The purpose of this study was to investigate choroidal vein (ChV) morphological features in pachychoroid disease (PCD) with choroidal vascular hyperpermeability (CVH).

Methods

This retrospective study assessed subfoveal choroidal thickness (SFCT) and CVH area numbers and locations of recruited patients with PCD using multimodal images. ChV alteration patterns, including fusiform, bulbosity, sausaging, confluence, and anastomoses, as well as asymmetric ChVs, dominant ChVs, and non-dominant ChVs, were evaluated using wide-field indocyanine green angiograms.

Results

Of 68 PCD eyes from 35 patients (mean age: 46.16 ± 6.28 years, 71.4% men), 2.9% had uncomplicated pachychoroid, 32.4% had pachychoroid pigment epitheliopathy (PPE), 55.9% central serous chorioretinopathy (CSC), and 8.8% pachychoroid neovasculopathy (PNV). Mean SFCT was 468.65 ± 131.40 µm. Among 419 CVH areas, ChV fusiform, ChV bulbosity, and ChV sausaging accounted for 35.8%, 35.1%, and 29.1%, respectively; 21.2% had ChV confluence and 11.9% had ChV anastomoses. At CVH areas, 13.1% had retinal pigment epithelium (RPE) leakage. ChV fusiform is steadily declining (37.4%, 36.8%, and 22.9%, respectively), and ChV sausaging, ChV anastomoses, and ChV confluence are increased gradually in the PPE, CSC, and PNV groups (21.4%, 30.0%, and 37.1%; 11.4%, 11.1%, and 20.0%; and 19.8%, 20.9%, and 28.6%, respectively). Dominant ChVs had higher CVH area numbers than non-dominant ChVs in the PPE and CSC groups (P = 0.010, P = 0.001).

Conclusions

Different patterns of ChV alterations, including the newly identified ChV confluence, are commonly present at CVH areas in PCD. The CVH areas in PCD eyes are primarily located within the dominant ChVs. These findings provide crucial evidence for advancing our understanding of the underlying mechanisms of PCD pathogenesis.

Choroidal vascularity index in different types of central serous chorioretinopathy: A meta-analysis

PURPOSE

To evaluate the choroidal vascularity index (CVI) in different types of central serous chorioretinopathy (CSC), healthy control eyes, and fellow eyes.

METHODS

Relevant studies published up to January 2023 were identified by searching multiple databases, including PubMed, Embase, Web of Science, Cochrane Library, and China National Knowledge Infrastructure (CNKI). Studies investigating the difference in CVI between CSC and control eyes were included. Data from these studies were analyzed using Stata (version 17) software. Weighted mean difference (WMD) and 95% confidence interval (95%CI) were calculated for the CVI in CSC eyes, control eyes, and fellow eyes.

RESULTS

The meta-analysis included 15 studies, with 213 acute CSC eyes, 153 chronic CSC eyes, 92 uncategorized CSC eyes, 40 resolved CSC eyes, 409 eyes of normal healthy controls, and 318 fellow eyes. The result revealed that CVI was higher in acute CSC eyes (WMD = 5.40, 95%CI = 2.36-8.44, P = 0.001) compared to control eyes. Also, CVI in chronic CSC eyes was higher than in control eyes (WMD = 1.26, 95%CI = 0.03-2.49, p = 0.046). The fellow eyes of acute CSC had a higher CVI when compared to control eyes (WMD = 2.53, 95%CI = 0.78-4.28, p = 0.005). There was no significant difference in CVI between acute and chronic CSC eyes (WMD = 0.75, 95%CI = -0.31-1.82, P = 0.167). In the sub-analysis based on the area selected for CVI calculation, the WMDs in the whole image subgroups were lower than the main analysis for the comparisons of fellow eyes of acute CSC and control eyes, acute CSC eyes and control eyes, and acute CSC eyes and fellow eyes. In the macular area subgroups, the WMDs were higher than in the whole image subgroups, suggesting a potential regional variation of CVI in CSC eyes.

CONCLUSIONS

The results demonstrated that CVI is increased in CSC eyes and fellow eyes of acute CSC. There is no significant difference in CVI between acute and chronic CSC eyes. The area selected for CVI calculation can influence the outcome, which requires further clinical research to clarify.

Comparison of Nailfold Videocapillaroscopy with Retinal and Choroidal Vascular Parameters in Patients with Central Serous Chorioretinopathy

AIM

This study seeks to evaluate the results of nailfold videocapillaroscopies (NVCs) among patients with central serous chorioretinopathy (CSC) and their correlation with the choroid and retinal parameters.

MATERIAL AND METHODS

The examined group included 152 patients with acute, recurrent, chronic and neovascular CSC (34 F, 118 M, mean age 45.9 ± 8.9) and 41 healthy controls (12 F, 29 M, mean age 47 ± 11.5). The NVC examination, ophthalmoscopy, angio-OCT and OCT were performed. In addition, the medical history regarding chronic general disorders and known risk factors were recorded.

RESULTS

Abnormal NVC patterns and the dilated apical part of capillaries were found only in CSC patients (p = 0.000). Neoangiogenesis was observed in 25 acute (58.14%), 22 recurrent (42.31%), 16 chronic (36.36%) and 5 neovascular patients (45.45%) and 2 control subjects (4.88%) (p = 0.000). Glomerular capillaries were found in 8 acute (18.6%), 17 recurrent (31.48%), 25 chronic (56.82%) and 8 neovascular patients (72.73%) (p = 0.000). Meandering capillaries were more common in acute and recurrent CSC and glomerular capillaries were more common in chronic and aneurysmal dilations in neovascular CSC.

CONCLUSIONS

The observed digital microcirculation abnormalities in patients with CSC, such as dilation, meandering, tortuosity and glomerular, may confirm systemic micro-vasculopathy. The potential role of the NVC examination in assessing the CSC prognosis requires further evaluation.

Central serous chorioretinopathy: updates in the pathogenesis, diagnosis and therapeutic strategies

Central serous chorioretinopathy (CSCR), first described by Albrecht von Graefe in 1866, is characterized by focal serous detachment of the neural retina and/or retinal pigment epithelium (RPE) in the posterior pole. CSCR is the first ever described pachychoroid disease. Most recently, hypothetical venous overload choroidopathy is also proposed due to its distinguished morphological and pathological characteristics, including choroidal thickening, choriocapillaris hyperpermeability, remodelling, and intervortex venous anastomoses. Identification of genetic variants is necessary to comprehend the pathophysiology of CSCR. The novel multimodality imaging platforms, including the ultra-widefield imaging system, flavoprotein fluorescence, fluorescence lifetime imaging ophthalmoscopy, and multispectral imaging system, have been used for diagnosing and managing CSCR. Half-dose photodynamic therapy (PDT) remains the mainstay of clinical practice, with about 95% of patients with chronic CSCR improving to visual acuity (VA) of 20/30 or better. The use of oral eplerenone for routine clinical care remains controversial, and long-term randomized clinical trials are warranted to investigate its efficacy in acute and chronic CSCR. While CSCR has generally been recognized as a self-limiting disease with good prognosis, the underlying pathogenesis is still not fully understood, and treatments are often not fully effective. With new evidence emerging about pachydrusen being a disease precursor in both CSCR and polypoidal choroidal vasculopathy (PCV), it would be interesting to investigate whether CSCR can be a precursor to PCV. In this review, we highlighted the currently available evidence on the pathogenesis, diagnosis, multimodality imaging features, and management strategies, including recent findings related to CSCR.

En-face optical coherence tomography hyperreflective foci of choriocapillaris in central serous chorioretinopathy

The purpose of this study is to evaluate choroidal hyperreflective foci (HRF) changes in central serous chorioretinopathy (CSC) on en-face optical coherence tomography (OCT). Retrospective analysis of 42 patients with unilateral CSC (84 eyes, including fellow eyes for controls) and 42 age- and sex-matched controls. With 4.5 × 4.5 mm macular scans, structural en-face OCT choriocapillaris (CC) slabs were used to calculate the density and number of HRF in acute CSC eyes with serous retinal detachment (SRD), resolved CSC eyes without SRD, unaffected fellow eyes, control eyes, and 1-year follow-up eyes. Based on the 2-disc diameter (3000 μm), the en-face OCT scan was divided into foveal and perifoveal lesion and analyzed to consider the impact of SRF in HRF measurement. Regression analyses were performed on the several factors with HRF number and density in the acute and resolved CSC eyes. The perifoveal density and number of CC HRF was significantly lower in the resolved CSC eyes when compared to the acute CSC eyes (P = 0.002, both), fellow eyes (P = 0.042/density, 0.028/number), and controls (P = 0.021/density, P = 0.003/number). There was no significant difference between the acute CSC eyes, fellow eyes, controls, and 1-year follow-up eyes. As subfoveal choroidal thickness decreased and choroidal vascularity (CVI) increased, the perifoveal density and number of HRF was measured higher with a significant correlation in univariate regression analysis of the acute and resolved CSC eyes (all, P < 0.05). The authors hypothesized that stromal edema induced by choroidal congestion and hyperpermeability has the greatest influence on HRF measurement, possibly affected by inflammatory cells and materials extravasation.

Time-dependent recurrence and resolution of pigment epithelial detachment in central serous chorioretinopathy

BACKGROUND

Cortisol plays a role in the pathogenesis of central serous chorioretinopathy (CSC). CSC patients have abnormal time-dependent changes in cortisol levels. Here we report a rare case of a patient with central serous chorioretinopathy whose pigment epithelial detachment (PED) exhibited time-dependent recurrence and resolution.

CASE PRESENTATION

A 47-year-old man presented in 2016 for vision loss in the left eye related to recurrent CSC. During follow-up, his PED was observed to resolve spontaneously while he was still in our clinic and recurred the next morning. Such time-dependent changes of the PED were observed in several next follow-ups without any intervention. After excluding possible external factors, the abnormal diurnal variation of cortisol was considered as the internal factor affecting PED.

CONCLUSIONS

This is the first article that described the spontaneous time-dependent recurrence and resolution of PED without external interference, where endogenous cortisol may be responsible. Interventions against the abnormal cortisol level might be a potential treatment strategy for CSC. More research is urged to explore the impact of the diurnal change in cortisol levels on eyes with CSC.

Long-Term Multimodal Imaging Analysis of Selective Retina Therapy Laser Lesions

This study evaluates the long-term effects of selective retina therapy (SRT) on the retinal pigment epithelium (RPE) and neuroretina in patients with central serous chorioretinopathy. SRT was performed on 36 patients using a Nd:YLF-Laser at 527 nm (R:GEN®, Lutronic, Goyang-Si, Republic of Korea). A total of 994 titration spots were examined using up to three years’ multimodal imaging. Leakage in fluorescein angiography (FA) was observed after SRT in 523 lesions and resolved after one month. SRT lesions were not visible clinically, but appeared as brightly reflective areas in infrared and multicolor images. Normal morphology was observed in optical coherence tomography (OCT) immediately after SRT. After one month, thickening of the RPE and interdigitation zone changes were seen and disappeared after 539 ± 308 days. No RPE atrophies occurred during the observation period. Decreased fundus autofluorescence (FAF) was mostly observed directly after SRT followed by increased FAF at one month, which faded over time. A significant decrease in the number of visible lesions in the FA and FAF was observed within the three-year follow-up. OCT findings are consistent with animal studies showing SRT-related defect closure by hypertrophy and migration of neighboring cells without RPE atrophy or photoreceptor damage. This suggests that SRT is a safe treatment option for macular diseases and does not lead to retinal atrophy.

Intervortex Venous Anastomosis in the Macula in Central Serous Chorioretinopathy Imaged by En Face Optical Coherence Tomography

PURPOSE

To assess the presence of macular intervortex venous anastomosis in central serous chorioretinopathy (CSCR) patients using en face optical coherence tomography (EF-OCT).

METHODS

A cross-sectional study where EF-OCT 6 × 6 and 12 × 12 mm macular scans of patients with unilateral chronic CSCR were evaluated for anastomosis between vortex vein systems in the central macula. The presence of prominent anastomoses was defined as a connection with a diameter ≥150 µm between the inferotemporal and superotemporal vortex vein systems which crossed the temporal raphe. Three groups were studied: CSCR eyes (with an active disease with the presence of neurosensorial detachment; n = 135), fellow unaffected eyes (n = 135), and healthy eyes as controls (n = 110). Asymmetries, abrupt termination, sausaging, bulbosities and corkscrew appearance were also assessed.

RESULTS

In 79.2% of the CSCR eyes there were prominent anastomoses in the central macula between the inferotemporal and superotemporal vortex vein systems, being more frequent than in fellow eyes and controls (51.8% and 58.2% respectively). The number of anastomotic connections was higher in the affected eye group (2.9 ± 1.8) than in the unaffected fellow eye group (2.1 ± 1.7) and the controls (1.5 ± 1.6) (p < 0.001). Asymmetry, abrupt terminations and the corkscrew appearance of the choroidal vessels were more frequent in the affected eyes, although no differences in sausaging or bulbosities were observed.

CONCLUSIONS

Intervortex venous anastomoses in the macula were common in CSCR, being more frequently observed in affected eyes than in fellow unaffected eyes and healthy controls. This anatomical variation could have important implications concerning the pathogenesis and classification of the disease.

Latest Development on Genetics of Common Retinal Diseases

Many complex forms of retinal diseases are common and pan-ethnic in occurrence. Among them, neovascular age-related macular degeneration, polypoidal choroidal vasculopathy, and central serous choroid retinopathy involve both choroidopathy and neovascularization with multifactorial etiology. They are sight-threatening and potentially blinding. Early treatment is crucial to prevent disease progression. To understand their genetic basis, candidate gene mutational and association analyses, linkage analysis, genome-wide association studies, transcriptome analysis, next-generation sequencing, which includes targeted deep sequencing, whole-exome sequencing, and whole genome sequencing have been conducted. Advanced genomic technologies have led to the identification of many associated genes. But their etiologies are attributed to complicated interactions of multiple genetic and environmental risk factors. Onset and progression of neovascular age-related macular degeneration and polypoidal choroidal vasculopathy are affected by aging, smoking, lifestyle, and variants in over 30 genes. Although some genetic associations have been confirmed and validated, individual genes or polygenic risk markers of clinical value have not been established. The genetic architectures of all these complex retinal diseases that involve sequence variant quantitative trait loci have not been fully delineated. Recently artificial intelligence is making an impact in the collection and advanced analysis of genetic, investigative, and lifestyle data for the establishment of predictive factors for the risk of disease onset, progression, and prognosis. This will contribute to individualized precision medicine for the management of complex retinal diseases.

Fuji sign: Prevalence and predictive power to photodynamic therapy in chronic central serous chorioretinopathy

AIM

To determine the prevalence of Fuji sign in central serous chorioretinopathy (cCSC) patients and its predictive power of good response to photodynamic therapy (PDT).

METHODS

Retrospective study, including 135 eyes of 130 patients diagnosed with cCSC treated with PDT between 2017 and 2021. Optical Coherence Tomography (OCT) images from these patients were compiled and analyzed. The presence of the Fuji sign, an anatomical finding recently described as a predictor of spontaneous resolution of the subretinal fluid (SRF) in cCSC, as assessed in basal images and the maximum height of SRF pre- and post-PDT OCT was measured.

RESULTS

Mean age was 56.6 years, 69.4% were men and the percentage of partial or complete resolution of the SRF after PDT was 75.55%. Only 8.9% of patients (12/135) had positive Fuji sign at baseline OCT. Among them, 50% (6/12) presented a complete response to the PDT (pre-PDT SRF: 109.00 (29.61) µm), 8.3% (1/12) had a partial resolution of the SRF (127 µm to 66 µm) and 41.6% (5/12) did not respond to PDT (pre-PDT SRF: 71.00 (22.82) µm, post-PDT SRF: 83.60 (36.13) µm).

CONCLUSIONS

Fuji sign has a low prevalence in cCSC and its presence is not associated with a good response to PDT.

Choroidal Thickness is Increased following Restraint Stress in Rats

PURPOSE

Central serous chorioretinopathy is a stress-induced disease and often shows pachychoroid; however, the relationship between stress and choroid remains unlear. The purpose of this study was to investigate, using optical coherence tomography, whether the choroid thickens when rats are subjected to restraint stress.

METHODS

Eight-week-old male F334/Jcl rats were subjected to 30 min of restraint stress, and choroidal thickness was measured before and after stress loading using optical coherence tomography. In addition, salivary corticosterone levels were measured before and after stress loading.

RESULTS

Choroidal thickness was significantly increased from 30.1 ± 6.4 µm to 39.7 ± 9.2 µm just after stress loading (p = 0.001). Significant choroidal thickening was not observed on the next day. The salivary corticosterone concentration increased from 1575.3 ± 1040.6 pg/mL before stress loading to 6022.2 ± 6742.6 pg/mL after stress loading, but the difference was not significant (p = 0.10).

CONCLUSIONS

Choroidal thickness increased when rats were subjected to restraint stress, supporting the hypothesis that stress is one of the causes of pachychoroid spectrum disease, as exemplified by central serous chorioretinopathy.

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.

Dilated choroidal vascular channels in pachychoroid neovasculopathy

BACKGROUND

To elucidate the pattern of the choroidal vasculature in exudative pachychoroid neovasculopathy (PNV) and its correlation with the clinical course and treatment outcomes.

METHODS

The retrospective study included consecutive patients in National Taiwan University Hospital between 2014 and 2020 who fulfilled the criteria for exudative PNV defined as active type 1 macular neovascularization (MNV) on optical coherence tomography angiography (OCTA) and with leakage on fluorescein angiography (FA) or indocyanine green angiography (ICGA) associated with pachychoroid features. The corrected distance visual acuity (CDVA), FA, ICGA, and OCT images obtained by Optovue (Optovue Inc, Freemont CA, USA) spectral domain OCT were evaluated at baseline and various time points during the 12-month treatment period. The correlations between the choroidal vascular patterns, specifically those with or without dilated choroidal vascular channels (DCVC) revealed by ICGA, and baseline characteristics and treatment outcomes were evaluated using multiple regression models.

RESULTS

The study enrolled 34 eyes of 31 patients. The average age was 59.0 ± 9.3 years, and 20 participants were men. ICGA revealed DCVCs in 21 eyes, while the remaining 13 eyes did not have DCVCs. At baseline, DCVC group was older (p = 0.03) and had a longer duration of visual symptoms (p = 0.02), with a higher vessel density (defined as the percentage of the measured area occupied by flow area) of MNV (p = 0.04), higher proportion of ellipsoid zone disruption (p = 0.01), and poorer CDVA (p = 0.03). After the 12-month treatment period, the frequency of requirement of anti-VEGF injections (p < 0.01) was higher, and the risk for CDVA <20/40 was higher (adjusted OR: 5.29, 95% CI: 1.24-22.48, p = 0.02) in eyes with DCVCs.

CONCLUSIONS

For PNV, eyes with DCVCs were associated with higher vessel density of macular neovascularization and poorer CDVA at baseline, and had poorer visual and anatomical outcomes although more anti-VEGF injections were given.

The role of the gut microbiome in eye diseases

The gut microbiome is a complex ecosystem of microorganisms and their genetic entities colonizing the gastrointestinal tract. When in balanced composition, the gut microbiome is in symbiotic interaction with its host and maintains intestinal homeostasis. It is involved in essential functions such as nutrient metabolism, inhibition of pathogens and regulation of immune function. Through translocation of microbes and their metabolites along the epithelial barrier, microbial dysbiosis induces systemic inflammation that may lead to tissue destruction and promote the onset of various diseases. Using whole-metagenome shotgun sequencing, several studies have shown that the composition and associated functional capacities of the gut microbiome are associated with age-related macular degeneration, retinal artery occlusion, central serous chorioretinopathy and uveitis. In this review, we provide an overview of the current knowledge about the gut microbiome in eye diseases, with a focus on interactions between the microbiome, specific microbial-derived metabolites and the immune system. We explain how these interactions may be involved in the pathogenesis of age-related macular degeneration, retinal artery occlusion, central serous chorioretinopathy and uveitis and guide the development of new therapeutic approaches by microbiome-altering interventions for these diseases.

Prevalence of choroidal nevi in patients with central serous chorioretinopathy

Background

A number of articles report the association of polypoidal lesions and choroidal nevi; however, the relationship between choroidal nevi and pachychoroidal disorders has not been studied.

Objectives

To study the prevalence of choroidal nevi in central serous chorioretinopathy (CSCR) patients and to elucidate potential differences in the clinical characteristics of CSCR in patients with and without choroidal nevi.

Design

Case-control study.

Methods

This study included a retrospective analysis of medical records and multimodal imaging data of CSCR patients and a prospective evaluation of the prevalence of the choroidal nevi in age- and sex-matched healthy controls. All participants received comprehensive ophthalmic examination and multimodal imaging including infrared scanning laser ophthalmoscopy in dark-field mode to detect choroidal nevi in the central 40° × 60° region.

Results

A total of 199 CSCR patients (160 males and 39 females, 47.9 ± 9.4 years) and 184 age-matched healthy individuals (139 males and 45 females, 44.8 ± 12.5 years) were included. Choroidal nevi were detected in 24 (12.1%) CSCR patients and 10 (5.4%) healthy controls (p = 0.01). CSCR patients with choroidal nevi had statistically significantly higher subfoveal choroidal thickness, lower best-corrected visual acuity, and lower central retinal thickness (p < 0.05) than CSCR patients without choroidal nevi. The odds ratio for the presence of chronic CSCR in patients with choroidal nevi was 27.0 (95% CI: 3.1-231.9, p = 0.003).

Conclusion

The prevalence of choroidal nevi among patients with CSCR is higher than in age- and sex-matched healthy population. Choroidal nevi may be associated with chronic CSCR.

One-year follow-up of choroidal and macular thickness in acute non-treated central serous chorioretinopathy

CLINICAL RELEVANCE

Choroidal and macular thickness assessments are essential to understand the evolution of central serous chorioretinopathy and could help in identifying patients more prone to recurrence.

BACKGROUND

The aim of this work was to evaluate changes in the choroidal thickness and macular thickness in acute non-treated central serous chorioretinopathy during a one-year follow-up.

METHODS

A prospective longitudinal study of 38 patients with central serous chorioretinopathy and 35 healthy controls at a tertiary care facility (Fundación Alcorcón University Hospital) was conducted. Choroidal and macular thicknesses were measured using enhanced-depth-imaging optical coherence tomography and subretinal fluid resolution and best-corrected visual acuity were evaluated, at baseline and 1, 3, 6 and 12 months. Prognostic factors determining the need for treatment were evaluated.

RESULTS

Choroidal thickness decreased in eyes with central serous chorioretinopathy (p < 0.001) but not in fellow eyes (p = 0.24) during one-year follow-up since the acute episode. The estimated mean choroidal thickness in symptomatic eyes was 465 µm (SE: 17.18) at baseline and decreased 58.1 µm (CI 95%: 30.1-85.9) at 12 months (p < 0.001). Best-corrected visual acuity improved over time (p = 0.037), with a decrease of logMAR 0.086 (CI95%: 0-0.172).The macular thickness changed over time (p < 0.001), with a decrease from baseline of 124.6 µm (CI95%: 61.4-187.9). Subretinal fluid resolved in 67% (CI 95%: 51-82) of patients at 6 months. There was no significant association between baseline choroidal thickness, macular thickness, best-corrected visual acuity, age or sex and the need for treatment.

CONCLUSIONS

The choroidal thickness decreased in acute central serous chorioretinopathy episodes during a one-year follow-up. Subretinal fluid persisted in less than 20% of patients at the end of the one-year follow-up. No prognostic factors determining the need for treatment were found.

En Face Choroidal Vascularity in Both Eyes of Patients with Unilateral Central Serous Chorioretinopathy

The aim of this study was to evaluate the choroidal vascularity analyzing en face optical coherence tomography (OCT) images in patients with unilateral central serous chorioretinopathy (CSC). We retrospectively evaluated 40 eyes of 20 CSC patients and 20 eyes of 10 gender- and age-matched healthy individuals. The sample consisted of: (1) CSC affected eyes; (2) unaffected fellow eyes; (3) healthy eyes. Multiple cross-sectional enhanced depth imaging OCT scans were obtained to create a volume scan. En face scans of the whole choroid were obtained at 5μm intervals and were binarized to calculate the choroidal vascularity index (CVI). The latter, defined as the proportion of the luminal area to the total choroidal area, was calculated at the level of choriocapillaris, superficial, medium and deep layers. No significant differences between choriocapillaris, superficial, medium and deep CVI were found in both eyes of CSC patients, whereas a significant different trend of changes was found in healthy eyes. Nevertheless, the en face CVI shows no difference between affected fellow and healthy eyes. In conclusion, CSC-affected eyes and fellow eyes showed a similar vascular architecture, with no statistical difference between all choroidal layers.

Aldosterone as a Possible Contributor to Eye Diseases

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