The use of propranolol to treat central serous chorioretinopathy: an evaluation by serial OCT

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.

Safety of intravitreal metoprolol in eyes with central serous chorioretinopathy

PURPOSE

To investigate ocular safety of intravitreal metoprolol in eyes with central serous chorioretinopathy.

METHODS

Five eyes of five patients diagnosed with chronic central serous chorioretinopathy (cCSC) previously treated unsuccessfully with oral spironolactone, micropulse laser and intravitreal anti-vascular endothelial growth factor agents were enrolled and received off-label intravitreal metoprolol (50 µg/0.05 ml). Baseline and follow-up examinations included measurement of best-corrected visual acuity (BCVA), intraocular pressure, anterior chamber cellular/flare scores, vitritis classification, fluorescein and indocyanine green angiography, spectral domain optical coherence tomography and electroretinography (ERG), recorded by means of DTL electrodes and following the standard suggested by the International Society for Clinical Electrophysiology of Vision (ISCEV). The total follow-up period was 4 weeks.

RESULTS

There were no significant differences between baseline and follow-up ERG parameters: scotopic or photopic, a- and b-wave amplitude and implicit time, nor oscillatory potentials amplitude, or whatsoever. No intraocular inflammation sign was observed. In addition, BCVA showed small improvement in 4 or kept baseline values in 1 patient. The subretinal and/or intraretinal fluid volume reduced in all patients at 1 month after treatment.

CONCLUSION

Patients with refractory cCSC treated with intravitreal 50 µg/0.05 ml metoprolol showed no signs of acute ocular toxicity, along with intraretinal fluid reduction and slight BCVA improvement 1 month after injection. This data suggest that intravitreal metoprolol may be a safe alternative for cCSC.

Alternative management of central serous chorioretinopathy using intravitreal metoprolol

Background

Beta-blockers may counteract the effect of catecholamines on central serous chorioretinopathy (CSC) pathology and accelerate the improvement of neurosensory retinal detachment. Oral propranolol has been associated with decreased duration of CSC in some studies. We describe two patients with visually symptomatic chronic CSC (cCSC) treated successfully with intravitreal metoprolol.

Case presentations

After obtaining the patients’ informed consent, two eyes of two 43-year-old men diagnosed with cCSC treated unsuccessfully with oral spirolactone, micropulse laser and intravitreal anti‐vascular endothelial growth factor (anti-VEGF) agents were treated with one off-label intravitreal injection of metoprolol (50 µg/0.05 ml). Baseline (pre-injection) and follow-up examinations (at 1 month post-injection) included best-corrected visual acuity (BCVA), anterior and posterior segment biomicroscopy, fundus autofluorescence, spectral domain optical coherence tomography (Spectralis, Heidelberg), and electroretinogaphy (ERG) according to International Society for Clinical Electrophysiology of Vision (ISCEV) full-field scotopic and photopic standard protocols. ERG results at baseline (pre-injection) and at 1 month post-injection were compared using paired t-tests.

Results

There was no significant difference in any of the ISCEV recommended ERG parameters with respect to a- and b-wave amplitude and implicit time, and oscillatory potentials maximal amplitude. BCVA improved in both patients. Neither patient developed clinical evidence of intraocular inflammation. Subretinal and/or intraretinal fluid had improved in both patients at 1 month after the metoprolol injection.

Conclusion

These preliminary findings suggest that intravitreal metoprolol may be a safe alternative therapy for patients with cCSC.

Comparison of image quality of corneal and retinal optical coherence tomography using sedation and general anesthesia protocols with or without retrobulbar anesthesia in horses

OBJECTIVE

To compare image quality and acquisition time of corneal and retinal spectral domain optical coherence tomography (SD-OCT) under 3 different sedation-anesthesia conditions in horses.

ANIMALS

6 middle-aged geldings free of ocular disease.

PROCEDURES

1 randomly selected eye of each horse was evaluated via SD-OCT under the following 3 conditions: standing sedation without retrobulbar anesthetic block (RB), standing sedation with RB, and general anesthesia with RB. Five regions of interest were evaluated in the cornea (axial and 12, 3, 6, and 9 o'clock positions) and fundus (optic nerve head). Three diagnostic scans of predetermined quality were obtained per anatomical region. Image acquisition times and total scans per site were recorded. Corneal and retinal SD-OCT image quality was graded on a subjective scale from 0 (nondiagnostic) to 4 (excellent).

RESULTS

Mean values for the standing sedation without RB, standing sedation with RB, and general anesthesia conditions were 24, 23, and 17, respectively, for total cornea scan attempts; 23, 19, and 19 for total retina-scan attempts; 14.6, 13.2, and 9.2 minutes for total cornea scan time; 19.1, 9.2, and 13.0 for total retina scan time; 2.0, 2.3, and 2.5 for cornea grade; and 2.7, 2.9, and 2.5 for retina grade.

CONCLUSIONS AND CLINICAL RELEVANCE

The RB facilitated globe akinesia and improved the percentage of scans in frame and region of interest accuracy for retinal imaging via OCT in horses. Retrobulbar blocks improved clinical image acquisition while minimizing motion artifact.

Venous overload choroidopathy: A hypothetical framework for central serous chorioretinopathy and allied disorders

In central serous chorioretinopathy (CSC), the macula is detached because of fluid leakage at the level of the retinal pigment epithelium. The fluid appears to originate from choroidal vascular hyperpermeability, but the etiology for the fluid is controversial. The choroidal vascular findings as elucidated by recent optical coherence tomography (OCT) and wide-field indocyanine green (ICG) angiographic evaluation show eyes with CSC have many of the same venous patterns that are found in eyes following occlusion of the vortex veins or carotid cavernous sinus fistulas (CCSF). The eyes show delayed choroidal filling, dilated veins, intervortex venous anastomoses, and choroidal vascular hyperpermeability. While patients with occlusion of the vortex veins or CCSF have extraocular abnormalities accounting for the venous outflow problems, eyes with CSC appear to have venous outflow abnormalities as an intrinsic phenomenon. Control of venous outflow from the eye involves a Starling resistor effect, which appears to be abnormal in CSC. Similar choroidal vascular abnormalities have been found in peripapillary pachychoroid syndrome. However, peripapillary pachychoroid syndrome has intervortex venous anastomoses located in the peripapillary region while in CSC these are seen to be located in the macular region. Spaceflight associated neuro-ocular syndrome appears to share many of the pathophysiologic problems of abnormal venous outflow from the choroid along with a host of associated abnormalities. These diseases vary according to their underlying etiologies but are linked by the venous decompensation in the choroid that leads to significant vision loss. Choroidal venous overload provides a unifying concept and theory for an improved understanding of the pathophysiology and classification of a group of diseases to a greater extent than previous proposals.

Assessment of the safety of intravitreal injection of metoprolol tartrate in rabbits

PURPOSE

To verify the safety of different doses of intravitreal metoprolol tartrate (MT) after intravitreal injection in rabbit eyes.

METHODS

Animals were randomly assigned into 2 groups: group I received 50 µg of MT and group II 100 µg of MT. A volume of 0.05 mL of the drug solution was administered through an intravitreal injection, while the control eyes received an equal volume of saline solution. Safety was assessed by clinical observation, electroretinography (ERG) and histological evaluation.

RESULTS

No evidence of clinical toxicity was observed. ERG waveforms from the MT treated eyes were similar to those recorded from the control eyes in dark-adapted state, amplitude and the implicit time are similar between the groups in light-adapted state, and their retinas had no signs of toxicity by histological evaluation 7 days after intravitreal injection.

CONCLUSIONS

The intravitreal use of metoprolol at 50 and 100 µg dosages does not cause short-term retinal toxicity in rabbits.

Oral Treatment of Central Serous Chorioretinopathy Patients Using Propranolol Tablets

Purpose: To evaluate the pharmacological effects of propranolol treatment of patients with central serous chorioretinopathy (CSCR) over 4 months. Results: Among the 89 male and 31 female patients, the mean BCVA decreased to 0.42 ± 0.08 logMAR during CSCR attacks. Oral propranolol showed good effectiveness in reducing CSCR signs after at least 4 months of treatment. The final BCVA of the patients in groups 1 and 2 was 0.09 ± 0.01 and 0.19 ± 0.03 logMAR, respectively (p < 0.05). Moreover, the mean complete remission time in groups 1 and 2 was 1.9 and 3.5 months, respectively (p < 0.05), while the “success” rate in groups 1 and 2 was 95.0% (57/60) and 78.3% (47/60), respectively (p < 0.05). The recurrence rate in groups 1 and 2 was 5.3% (3/57) and 25.5% (12/47) after a further 5 months of follow-up, respectively (p < 0.05). Materials and Methods: One hundred and twenty patients were enrolled and randomly divided into two groups that both underwent a visual acuity test and optical coherence tomography (OCT) scanning, between April and December 2017. The 60 patients in group 1 were requested to take propranolol for 4 months, while the other 60 subjects (group 2) received placebo therapy during the same period. The best-corrected visual acuity (BCVA) of every volunteer and an OCT image of each patient were checked and recorded at the beginning of the study and each week thereafter. If the signs of CSCR disappeared completely from the OCT scans, the case was considered a “success” and treatment stopped at once. However, the “success” subjects were further evaluated in follow-ups throughout the next 5 months to determine the rate of recurrence in groups 1 and 2. The time of total complete remission of CSCR from the OCT scans was also measured in groups 1 and 2. Conclusion: CSCR patients revealed an excellent prognosis and success rate of 95.0% after taking propranolol. The treatment was able to enhance subretinal fluid (SRF) absorption, shorten the time to total complete remission, and significantly decrease CSCR recurrence. As such, we suggest that taking propranolol may be an alternative and viable choice for CSCR patients, given that the new method was shown to be safe, cheap, effective, well tolerated and convenient.

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.

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.

Central serous chorioretinopathy: Towards an evidence-based treatment guideline

Central serous chorioretinopathy (CSC) is a common cause of central vision loss, primarily affecting men 20-60 years of age. To date, no consensus has been reached regarding the classification of CSC, and a wide variety of interventions have been proposed, reflecting the controversy associated with treating this disease. The recent publication of appropriately powered randomised controlled trials such as the PLACE trial, as well as large retrospective, non-randomised treatment studies regarding the treatment of CSC suggest the feasibility of a more evidence-based approach when considering treatment options. The aim of this review is to provide a comprehensive overview of the current rationale and evidence with respect to the variety of interventions available for treating CSC, including pharmacology, laser treatment, and photodynamic therapy. In addition, we describe the complexity of CSC, the challenges associated with treating CSC, and currently ongoing studies. Many treatment strategies such as photodynamic therapy using verteporfin, oral mineralocorticoid antagonists, and micropulse laser treatment have been reported as being effective. Currently, however, the available evidence suggests that half-dose (or half-fluence) photodynamic therapy should be the treatment of choice in chronic CSC, whereas observation may be the preferred approach in acute CSC. Nevertheless, exceptions can be considered based upon patient-specific characteristics.

Modified Photodynamic Therapy Treatment of Central Serous Chorioretinopathy

PURPOSE

Central serous chorioretinopathy (CSC) is a condition characterized by serous detachment of the neurosensory retina at the level of the retinal pigmented epithelium (RPE) as a result of leakage from the choriocapillaris. The pathophysiology of CSC is not completely understood rendering treatment and management decisions more complex. When an observational approach and topical medical therapy are unsuccessful, a surgical intervention may be necessary. Here, we examine the role of modified photodynamic therapy (PDT) in recurrent CSC with multiple points of RPE leakage.

CASE REPORT

A 37-year-old male patient presented a case of recurrent CSC in the left eye. After an initial presentation of a large area of submacular fluid, near complete resolution was seen in 8 weeks using a topical NSAID protocol and close monitoring. Two weeks later, a second serous neurosensory detachment larger than the first occurred. The recurrent CSC was successfully treated with focal grid laser photocoagulation and modified PDT resulting in complete resolution and return of visual function 4 months after the initial presentation.

CONCLUSIONS

CSC is a multifactorial condition with the potential to severely impair daily visual function. Spectral domain optical coherence tomography retinal imaging has provided a remarkable tool in the diagnosis and monitoring of CSC. The addition of FA and ICG can create a highly precise picture of the subretinal fluid. Although most patients will spontaneously resolve, a subset of patients may benefit from medical therapy including topical nepafenac 0.1%. A smaller subset will require surgical intervention. Modified PDT with ICG-guided laser photocoagulation has a growing body of evidence as an effective treatment for recurrent CSC. Modified PDT may be the best course of action for chronic, non-resolving RPE leakage for both paramacular and foveal leaks leading to minimization of adverse visual effects.

Therapeutic benefit of melatonin in refractory central serous chorioretinopathy

PURPOSE

To evaluate the efficacy and safety of melatonin for the treatment of chronic central serous chorioretinopathy (CSCR).

METHODS

Prospective comparative case series. A total of 13 patients with chronic CSCR were treated for 1 month: 8 patients were treated orally with 3 mg melatonin t.i.d., and 5 with placebo. All patients had 20/40 or worse Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA) in the affected eye or presented an incapacitating scotoma. Most of the patients had previous failed treatments for their condition. Observational procedures included ETDRS BCVA, and complete ophthalmic examination. Optical coherence tomography (OCT) was performed at day 1 and week 4. Fluorescein angiography was performed at baseline only for diagnostic purposes. Data were subjected to two-sample t-test statistical analysis. P-values of <0.05 were considered statistically significant.

RESULTS

At 1-month follow-up, BCVA significantly improved in 87.5% of patients treated with melatonin (7 of 8 patients, P<0.05). All patients showed a mean significant reduction (P<0.01) of central macular thickness (CMT) when compared with the baseline, with 3 patients (37.5%) exhibiting complete resolution of subretinal fluid at 1-month follow-up. No significant side effects were observed. No changes in BCVA or CMT were noted in the control group.

CONCLUSIONS

These results suggest that melatonin is safe, well tolerated, and effective in the treatment of chronic CSCR, as it significantly improved BCVA and CMT in patients with this pathology. Further evaluations with longer follow-up and a larger patient population are desirable.

Advances in the treatment of central serous chorioretinopathy

Central serous chorioretinopathy is a disease that is partly understood. Novel advancements have led to further understanding of the disease, and have identified choroidal dysfunction as the principal element in CSCR development. New imaging tools have aided in better monitoring disease response to various treatment models. Enhanced depth imaging optical coherence tomography, in particular, has helped in observing choroidal thickness changes after various treatment models. To date, photodynamic therapy and focal laser remain the main stay of treatment. More understanding of disease pathophysiology in the future will help in determining the drug of choice and the best management option for such cases.

Oral Propranolol: A New Treatment for Infants with Retinopathy of Prematurity?

INTRODUCTION

Oral propranolol has improved the treatment of infantile hemangiomas, and a pediatric oral solution of propranolol has recently been licensed in the USA and Europe. In very preterm infants, infantile hemangiomas are associated with the occurrence of retinopathy of prematurity (ROP), and both diseases share a peculiar time course, featuring a lag phase after birth followed by rapid growth and then gradual regression.

OBJECTIVES

To identify clinical studies evaluating the use of oral propranolol in preterm infants with ROP.

RESULTS

Two small bicentric, pilot, randomized controlled trials found a nonsignificant reduction of ROP requiring intervention by laser treatment or bevacizumab injection of similar magnitude. Together, 6 of 35 (17%) infants who had been receiving oral propranolol underwent ROP intervention, as opposed to 14 of 36 (39%) controls (relative risk 0.42, 95% CI: 0.15-1.16). Randomized controlled trials are ongoing that investigate early preventive oral propranolol starting at 1 week of age and propranolol eye drops in preterm infants with stage 2 ROP.

CONCLUSION

Further, large interventional studies are required to determine the clinical benefit-risk ratio of oral propranolol to prevent vision-threatening ROP in very preterm infants.

System review and meta-analysis on photodynamic therapy in central serous chorioretinopathy

PURPOSE

To evaluate the effect of photodynamic therapy (PDT) on central serous chorioretinopathy (CSC) compared with laser therapy and intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) drugs, and to find the maximum treatment effect with minimal dose and fluence of PDT.

METHODS

A systematic electronic search was conducted in Feb 2013 in PubMed, Embase, ISI Web of Knowledge and the Cochrane library. The main outcome factors were compared in best-corrected visual acuity (BCVA), central macular thickness (CMT) and resolution of subretinal fluid (SRF). Meta-analysis was performed when it is appropriate. The comparisons were designed into four groups: group 1, PDT versus laser photocoagulation; group 2, PDT versus intravitreal injection of anti-VEGF drugs; group 3, half-dose verteporfin PDT versus placebo; group 4, half-fluence PDT versus full-fluence PDT.

RESULTS

We retrieved nine reports of studies including a total of 319 patients. In group 1, the summary result indicated that PDT was superior in resolution of SRF (p = 0.005) than laser photocoagulation. In group 2, PDT could resolute SRF (p = 0.007) and decrease CMT (p = 0.002) more rapidly than intravitreal injection of anti-VEGF drugs. In group 3, half-dose PDT was effective in improving BCVA (p < 0.00001), decreasing CMT (p = 0.001) and resolving SRF (p < 0.001). In group 4, half-fluence PDT was effective and could significantly decrease the hypoxic damage which was caused by PDT (p < 0.001).

CONCLUSION

PDT is a promising therapy for CSC patients and the parameters of PDT can be adjusted to obtain the maximum treatment effect with minimal adverse effects.

What is new in central serous chorioretinopathy?

Central serous chorioretinopathy (CSCR) is considered a benign, self-limiting disease. However, as many as third of the patients have recurrent episodes or chronic disease that may cause significant functional impairment. New diagnostic tools and new treatment modalities are emerging in order to improve the functional outcomes of these patients. Spectral domain optical coherence tomography (SD-OCT) has the ability to image individual layers of the retina and choroid. SD-OCT images in CSCR patients have demonstrated increased subfoveal thickness measurements, high reflective deposits in areas of subretinal precipitates and changes in the Retinal pigment epithelium layers of the asymptomatic eyes of patients with supposedly unilateral CSCR. A positive correlation was found between the level of distribution to the layer of inner segment/outer segment junction of the photoreceptors and the visual impairment. Fundus autoflouresence images show a wide variety during different stages of the disease in CSCR patients. Minimal abnormalities during the early stages are followed by hyperautofluoresence in the detached area in later stages, often in a manner of inferior gravitation and at the borders of the detachments. The chronic phase is characterized by varying degrees of atrophy and areas of decreased autofluorescence surrounding areas of chronic leaks. These changes help differentiate an active disease from an inactive state. Multifocal electroretinography (mfERG) has the ability to demonstrate a persistent depression despite the resolution of subretinal detachments. It is therefore being investigated as a follow up tool for patients with chronic CSCR. An excellent correlation was found between changes in mfERG and visual function. Macular microperimetry, measuring retinal sensitivity within the central visual field, is intended to compensate for the underestimation of visual impairment in patients with macular diseases. Reduced retinal sensitivity was found in areas of previous subretinal fluids in CSCR patients. The device can also serve as a follow up tool in these patients. Regarding treatment in CSCR patients, focal argon laser photocoagulation treatment may be applied to small extrafoveal leaks. However, the main purpose of this treatment is to shorten disease duration, with no advantage over observation regarding final visual outcome, rate of progression to chronic CSCR or number of recurrences. Photodynamic therapy (PDT) with verteporfin has been shown to completely resolve serous detachment in 60%-80% of patients and to have a partial affect in the remaining patients. Reduced-fluence treatment is replacing full-fluence therapy in order to minimize side effects with no accompanying reduced effectiveness. Visual acuity is also improved following reduced-fluence PDT compared to placebo. It has also been found that patients with intense hyperfluorescence are more likely to show resolution of accumulating fluid compared to patients with mild or no leakage observed on indocyanine-green angiography prior to treatment. Regarding newer treatment modalities, intravitreal injections of anti-vascular endothelial growth factor agents have a limited effect in patients with CSCR. Recent reports have not demonstrated an advantage for this treatment in regards to anatomic and functional outcome. Micropulse diode laser was not proven to be safer or more effective than argon laser or PDT. Corticosteroid antagonists, not tested in controlled trials, may have a beneficial effect in patients with CSCR. Aspirin may also play a role in treating these patients, with rapid recovery of visual acuity and reduced number of recurrences observed. In conclusion, imaging is evolving rapidly while the clinical implications of these new imaging modalities are less clear. Large randomized trials investigating different treatment modalities are still lacking.

Lack of positive effect of intravitreal bevacizumab in central serous chorioretinopathy: meta-analysis and review

PURPOSE

To review and evaluate the effects of intravitreal bevacizumab injection (IVB) in centralserous chorioretinopathy (CSC) by meta-analysis.

PATIENTS AND METHODS

Clinical controlled studies that evaluated the effect of IVB in CSC were identified through systematic searches of Embase, PubMed, and the Cochrane Central Register of Controlled Trials. Data on the best-corrected visual acuity (BCVA) in logMAR and central macular thickness (CMT) in μm at baseline and 6 months after IVB were extracted and compared with those treated by simple observation.

RESULTS

Four clinical controlled studies were included in the meta-analysis. The IVB injection group achieved better BCVA at a follow-up of 6 months. However, the analysis showed that there were no significant differences of BCVA at 6 months after injection between IVB group and the observation group (-0.02 logMAR, 95% CI -0.14 to 0.11, P=0.80). The analysis of the reduction in CMT revealed that the difference between groups was not statistically significant (-8.37 μm, 95% CI -97.26 to 80.52, P=0.85). No report assessed severe complications or side effects of IVB in patients with CSC.

CONCLUSIONS

Meta-analysis failed to verify the positive effect of IVB in CSC based on the epidemiological literature published to date.

Central Serous Chorioretinopathy: A Review of the Literature

Central serous chorioretinopathy (CSCR) is an incompletely understood multifactorial disease of those who are middle aged characterized by the collection of fluid between the retinal pigment epithelium and the neurosensory retina. The exact etiology of CSCR and the reason of its predominance in middle-aged males are still unknown. Many pharmacologic modalities are suggested for CSCR with no proven efficacy. So this article was written to give a review of the relevant and recent literature on CSCR and to summarize the etiology, clinical features, and diagnostic modalities for CSCR with special emphasis on the treatment options available and those that are still under trial and can be of help in the future to fasten the recovery and reduce the recurrences.

Central serous chorioretinopathy: a review of epidemiology and pathophysiology

Central serous chorioretinopathy (CSCR) is a common retinal cause of vision loss. This review surveys the epidemiology, risk factors, clinical presentation, natural history and pathophysiology of CSCR. Studies suggest an annual incidence rate of 10 per 100 000 in men, with CSCR occurring six times more commonly in men compared with women. Most acute CSCR cases resolve spontaneously within 2-3 months. Prognosis is highly dependent on presenting visual acuity; patients with initial visual acuities of 6/6 remain at that level, while patients with initial visual acuities of less than 6/9 recover on average two to three Snellen lines over the next few years. The main risk factors for CSCR are systemic corticosteroid use, type A personality, pregnancy and endogenous Cushing's syndrome. The pathophysiology of CSCR remains obscure, although disorders in both the choroidal circulation and retinal pigment epithelium are implicated.

Bilateral simultaneous central serous chorioretinopathy in a teenage girl with systemic arterial hypertension

We present a case of bilateral simultaneous central serous chorioretinopathy (CSCR) in a teenage girl with a history of systemic arterial hypertension. A 19-year-old Caucasian female, with a history of systemic arterial hypertension, presented with gradual decrease in her central vision for 1 month. She was diagnosed with bilateral simultaneous CSCR, based on the findings of spectral domain optical coherence tomography (SD-OCT), indocyanine green angiography (ICG), fundus auto-fluorescence, fluorescein angiography and color fundus photographs, which are described. Blood pressure was 134/95 mmHg at presentation. Systemic evaluation failed to reveal a cause for the high blood pressure, and included a panel of blood tests, which were all normal. Her best-corrected visual acuity was 20/30 OD and 20/25 OS. Dilated fundus examination showed normal optic discs and retinal vasculature, with no evidence of hypertensive retinopathy. However, shallow retinal fluid associated with pigmentary changes was noted in the center of both maculae. OCT and ICG findings were consistent with the diagnosis of bilateral CSCR. CSCR can manifest in patients with demographics outside the range of those previously reported. This is the first report of CSCR occurring in a teenage girl, with a history of systemic arterial hypertension. It is important to consider this disease in any patient who has a clinically compatible presentation.

An Update on the Diagnosis and Management of Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSC) is a complicated disease with still unclear causes, pathogenesis and management strategy despite active research. CSC has been traditionally considered as a self-limiting disease where spontaneous recovery occurs in 90% of the patients within a few months. This proclaimed "benign" nature of CSC, however, has been queried by increasing scientific evidence that permanent photoreceptors damage and neurosensory-cystoid degeneration of macula occur in the event of chronic CSC. CSC is probably not a benign disease. Treatments for CSC are still evolving. It is very difficult to define the proper timing for active treatment of CSC because it is not easy to define a universally accepted cut-off time point for active intervention. There is a recent suggestion that active CSC treatment should be considered if symptoms last longer than 3 months as atrophy of photoreceptors may occur as early as 4 months after initial presentation. The CSC patients may be stratified into two groups based on the initial presenting visual acuity and duration of symptom: the good visual prognosis group and the dubious visual prognosis group. The management may then be tailor-made based on the visual prognosis group. "Safety-enhanced'" photodynamic therapy (PDT) using lower doses and reduced fluence is still the mainstay of treatment. Newer treatment modalities like intravitreal anti-VEGF therapy, micropulsed diode laser treatment, and the use of corticosteroid antagonists do warrant further investigation. Combination therapies involving two or more of the above modalities of treatments may have a role to play in this actively researched area.

Choroidal thickness in both eyes of patients with unilaterally active central serous chorioretinopathy

OBJECTIVE

To assess the change in the choroidal thickness of the unaffected eyes in patients with unilateral central serous chorioretinopathy (CSC).

METHODS

Thirty eyes with unilateral idiopathic CSC and 30 age-matched normal eyes were included in this study. Choroidal thickness was evaluated from images obtained by enhanced depth image optical coherence tomography. The choroidal thicknesses of the affected eyes, unaffected eyes, and normal eyes were analyzed. Choroidal vascular dilation and hyperpermeability on indocyanine green angiography (ICGA) were analyzed and correlated with the changes in choroidal thickness.

RESULTS

The mean choroidal thicknesses of the affected eyes, unaffected fellow eyes, and normal individuals were 445.58±100.25, 378.35±117.44, and 266.80±55.45 μm, respectively. Compared with normal eyes, subfoveal choroidal thickness was increased significantly in the eyes with active CSC and in the unaffected fellow eyes (P<0.001 in both groups). The choroidal thickness was significantly greater in the eyes with active CSC than in the unaffected fellow eyes (P=0.003). ICGA revealed choroidal vascular hyperpermeability in 28 (93.3%) eyes with CSC and in 23 (73.3%) unaffected fellow eyes. Choroidal vascular dilation was detected in 21 (70.0%) eyes with CSC and in 18 (60.0%) unaffected fellow eyes.

CONCLUSION

Increased choroidal thickness in patients with unilateral CSC was noted not only in the affected eyes, but also in the unaffected fellow eyes. The results of this study suggest that CSC might be an essentially bilateral disorder.

Review and update of central serous chorioretinopathy

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Early laser photocoagulation treatment as an option in central serous chorioretinopathy

BACKGROUND AND OBJECTIVE

To investigate the effect of early photocoagulation in central serous chorioretinopathy.

PATIENTS AND METHODS

In a prospective study, 15 consecutive patients with central serous chorioretinopathy and single leakage points were treated with photocoagulation between 2 days and 8 weeks after onset of symptoms. The main outcome measures were best-corrected visual acuity and metamorphopsias (Amsler grid) at months 1 and 4 compared with baseline.

RESULTS

Mean visual acuity improved by 1.53 lines 1 month after treatment. The mean squares involved in the Amsler grid were reduced by 2.07 squares. No relapse occurred during the follow-up period.

CONCLUSION

Considering the characteristics of individuals affected by central serous chorioretinopathy, a fast recovery would be advantageous. This study identified early laser photocoagulation in central serous chorioretinopathy as an effective treatment regarding resorption of subretinal fluid, recovery of visual acuity, and improvement of metamorphopsia.

Half-dose verteporfin photodynamic therapy for acute central serous chorioretinopathy: one-year results of a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of photodynamic therapy (PDT) with half-dose verteporfin for treating acute central serous chorioretinopathy (CSC).

DESIGN

Prospective, double-masked, placebo-controlled, randomized clinical trial.

PARTICIPANTS AND CONTROLS

Sixty-three eyes of 63 patients with acute symptomatic CSC of 3 months' duration or less were recruited. Forty-three eyes were randomized to indocyanine green angiography (ICGA)-guided PDT with half-dose (3 mg/m(2)) verteporfin and 21 eyes were randomized to placebo.

INTERVENTION

Patients in the verteporfin group received an infusion of half-dose verteporfin over 8 minutes, followed by ICGA-guided PDT 10 minutes from the start of infusion. Laser was applied for 83 seconds covering the choroidal abnormalities observed in ICGA, with a maximum laser spot size of 4500 mum.

MAIN OUTCOME MEASURES

The primary outcome measure was the proportion of eyes with absence of subretinal fluid at the macula at 12 months. Secondary outcome measures included changes in mean logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA), subjective symptoms, optical coherence tomography (OCT) results, central foveal thickness (CFT), and angiographic findings during the 12-month study period.

RESULTS

Thirty-nine patients in the verteporfin group and 19 patients in the placebo group completed 12 months of follow-up. Thirty-seven (94.9%) eyes in the verteporfin group compared with 11 (57.9%) eyes in the placebo group showed absence of subretinal fluid at the macula at 12 months (P = 0.001). The mean logMAR BCVA at 12 months was significantly better in the verteporfin group compared with the placebo group: -0.05 and 0.05, respectively (P = 0.008). All 39 (100%) verteporfin-treated eyes had stable or improved vision, compared with 15 (78.9%) eyes in the placebo group (P = 0.009). The mean OCT CFT for the verteporfin group also was significantly lower compared with the placebo group at 12 months (P = 0.001). No ocular or systemic adverse event was encountered in the study.

CONCLUSIONS

Photodynamic therapy with half-dose verteporfin is effective in treating acute symptomatic CSC, resulting in a higher proportion of patients with absence of exudative macular detachment and better visual acuity compared with placebo.