Indocyanine green angiography and pathophysiology of multifocal posterior pigment epitheliopathy

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.

[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.

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Choroidal vascular alterations evaluated by ultra-widefield indocyanine green angiography in central serous chorioretinopathy

PURPOSE

This study aims to evaluate choroidal vascular alterations in patients with central serous chorioretinopathy (CSC) using ultra-widefield (UWF) indocyanine green angiography (ICGA).

METHODS

This was a retrospective case-control study conducted at a single tertiary eye center. In total, 36 eyes in patients with either unilateral (24 patients) or bilateral (six patients) treatment-naïve CSC and 30 eyes in 24 age-matched controls were evaluated. The number of quadrants with vortex vein engorgement on UWF ICGA was evaluated. Dilated choroidal vessels affecting the macula were regarded as extended vortex vein engorgement. Choroidal vascular hyperpermeability (CVH) area on late-phase ICGA was quantified using stereographic projection. The parameters were compared with clinical and optical coherence tomographic findings.

RESULTS

Eyes with CSC had larger CVH area, thicker choroid, and more quadrants with vortex vein engorgement and extended vortex vein engorgement compared with control eyes (all P < 0.001). In patients with unilateral CSC, affected eyes had larger CVH area, thicker choroid, and more extended vortex vein engorgements compared with unaffected fellow eyes (all P < 0.001), but vortex vein engorgement did not significantly differ. CVH was significantly correlated with extended vortex vein engorgement (P < 0.001) and subfoveal choroidal thickness (P = 0.007).

CONCLUSIONS

The increased number and binocular symmetry of engorged vortex veins suggest an anatomical predisposition for CSC. CVH area and extended vortex vein engorgement were indicators of choroidal outflow congestion. These parameters may serve as diagnostic clues or predictors of disease development in eyes with CSC.

USE OF CHOROIDAL VASCULARITY INDEX FOR CHOROIDAL STRUCTURAL EVALUATION IN CENTRAL SEROUS CHORIORETINOPATHY WITH CHOROIDAL NEOVASCULARIZATION

PURPOSE

To evaluate choroidal vascular structure in eyes with central serous chorioretinopathy (CSC) by assessing the choroidal vascular index (CVI).

METHODS

We retrospectively analyzed the medical records of 117 eyes with CSC. Subjects were divided into 4 groups according to clinical characteristics: 1) acute CSC (N = 29), 2) non-neovascularized chronic CSC without flat irregular pigment epithelial detachment (N = 49), 3) non-neovascularized chronic CSC with flat irregular pigment epithelial detachment (N = 21), and 4) chronic CSC with choroidal neovascularization (N = 18). Subfoveal choroidal area (1,500 mm) of swept source optical coherence tomography scans were divided into luminal and stromal areas by the image binarization technique. The CVI was defined as the ratio of the luminal to the total subfoveal choroidal area.

RESULTS

The CVI was significantly lower in eyes of Group 4 than those of other groups (all P < 0.05). The subfoveal choroidal thickness was significantly lower in Group 4 than in Groups 1 and 2 (P < 0.05), but regression analysis showed no association with the CVI.

CONCLUSION

Decreased CVI may reflect choroidal vascular structure changes in eyes with choroidal neovascularization complicating CSC. These findings suggest that the CVI could be useful for evaluating choroidal vascular changes in eyes with CSC.

Multimodal imaging in infectious and noninfectious intermediate, posterior and panuveitis

PURPOSE OF REVIEW

Given the heterogeneity of uveitis, markers of inflammation vary from patient to patient. Multimodal imaging has proven itself to be critical for accurate evaluation for disease activity and treatment response in uveitis.

RECENT FINDINGS

Ultra-widefield (UWF) fluorescein angiography and autofluorescence (AF) as well as optical coherence tomography angiography (OCTA) have provided insights into disease pathogenesis and monitoring not previously appreciated. In addition to structural retinal imaging, OCT can be used to assess the choroid, the posterior cortical vitreous and the retinal vasculature in eyes with uveitis.

SUMMARY

Multimodal ocular imaging in eyes with uveitis is critical for disease diagnosis and assessing response to treatment. UWF fluorescein angiography can detect retinal vasculitis even in the absence of overt vascular sheathing. UWF AF can help detect more chorioretinal lesions than clinically visible. OCT can be used to assess the posterior cortical vitreous, retina, large retinal vessels and choroid in uveitis. The use of multimodal imaging will likely be needed to determine clinical trial endpoints in studies evaluating therapeutics for uveitis.

EVALUATION OF RETINAL VESSEL DIAMETERS IN EYES WITH ACTIVE CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To compare the retinal vessel diameters of healthy eyes and active central serous chorioretinopathy (CSC) eyes, and to evaluate possible effect of retinal vessel diameter alterations on the pathogenesis of CSC.

METHODS

This retrospective study included 39 patients with CSC and 34 healthy individuals. Spectralis optical coherence tomography + HRA with an infrared reflectance image were used to evaluate structure of retinal vessels in the circular region around the optic disc. For each eye, vertical inner and outer diameters of the four major arteries and veins were measured using infrared reflectance images, and vessel wall thicknesses were also calculated based on inner and outer diameters.

RESULTS

The 304 vessels of the 39 active CSC eyes and 266 vessels of the 34 healthy eyes were used in the analyses. The mean venous wall thickness in active CSC eyes was significantly thicker than that in healthy eyes (40.0 ± 4.9 vs. 33.5 ± 4.1 μm, P = 0.001), whereas the mean venous inner diameter in active CSC eyes was significantly narrower (52.5 ± 9.7 vs. 61.3 ± 8.1 μm, P = 0.001). Also, the mean venous outer diameter was wider in CSC eyes, albeit not significantly (131.1 ± 7.0 vs. 128.5 ± 8.4 μm, P = 0.074).

CONCLUSION

Our results suggest that the alterations of retinal venous diameters may play a potential role in the pathogenesis of CSC in addition to alterations in choroidal thickness.

Choroidal and Retinal Changes After Systemic Adrenaline and Photodynamic Therapy in Non-Human Primates

Purpose

To determine the tomographic, angiographic, and histologic changes in the choroid and retina of cynomolgus monkeys after systemic adrenaline and verteporfin photodynamic therapy (vPDT).

Methods

Six cynomolgus monkeys (12 eyes) were treated with vPDT only (n = 2), adrenaline only for eight weeks (n = 2), adrenaline for eight weeks with vPDT at week 4 (n = 4), and adrenaline for 12 weeks and vPDT at week 8 (n = 4). Spectral-domain optical coherence tomography, angiography, and autofluorescence were performed at baseline and every 14 days thereafter until 28 days after adrenaline therapy or vPDT. Choroid parameters included choroidal thickness (CT) changes and structural changes using semiautomated image binarization. Histology with light and electron microscopy was performed.

Results

Adrenaline resulted in subfoveal CT increase at week 4 compared with baseline (3.4%, P = 0.010), with further increase at week 8 (3.9%, P = 0.007). This correlated with choroidal luminal area increase (16.0% at week 8 compared with baseline, P = 0.030). Outer retinal changes included subretinal fluid, ellipsoid zone (EZ) disruption, photoreceptor elongation, and sub/intraretinal bright dots. Hypocyanescent spots surrounded by leakage was observed. Histology showed dilated choroidal vessels, intracytoplasmic vacuoles, and retinal pigment epithelium (RPE) enlarged basal infoldings. The vPDT decreased subfoveal CT at four weeks after vPDT (−7.5%, P = 0.007). This correlated with choroidal stromal area decrease (−18.0%, P < 0.010). Within the treatment spot, there was outer retinal atrophy, EZ disruption, irregular RPE thickening, intense hypoautofluorescence, hyperfluorescence, and hypocyanescence. On histology, there were outer retina, RPE, and choroid changes.

Conclusions

Adrenaline induces choroidal vessel dilation and CT increase. The vPDT decreases CT because of a reduction in choroidal stromal component.

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

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

RETROSPECTIVE ANALYSIS OF THE PRESENCE OF CHOROIDAL NEOVASCULARISATION USING OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY IN THE TREATMENT OF CHRONIC CENTRAL SEROUS CHORIORETINOPATHY WITH THE AID OF PHOTODYNAMIC THERAPY

PURPOSE

Analysis of the presence of choroidal neovascularization (CNV) by optical coherence tomography angiography (OCTA) in eyes treated with photodynamic therapy in a reduced dosing regimen (HD-PDT, half dose of verteporfin) for the chronic form of central serous chorioretinopathy (cCSC).

MATERIALS AND METHODS

Retrospective evaluation of OCTA findings in 54 eyes of 52 patients treated for cCSC with HD-PDT. OCTA was performed on Angioplex Zeiss Cirrus 5000 (Carl Zeiss Meditec, Dublin, CA, USA) 1 year after HD-PDT to verify changes typical of cCSC. By analyzing the results of this examination, we evaluated in particular the presence or absence of concomitant CNV and the correlation of the present CNV with the average resulting best corrected visual acuity (BCVA).

RESULTS

We analyzed the OCTA findings of 54 eyes (52 patients), in which we demonstrated the presence of concomitant CNV in 35 eyes (35.2 %). Revealed CNV occurred in 82 % below the undulating hyperreflective RPE line. In eyes with CNV, the mean BCVA (72 letters ETDRS) was statistically significantly lower than in eyes without CNV (82.7 letters ETDRS) (p = 0.0179).

CONCLUSION

In our retrospective evaluation of a group of patients who underwent HD-PDT for cCSC, we demonstrated with OCTA the presence of CNV in 35.2 % eyes 1 year after the treatment. We believe that the presence of type I CNV is a complication of the chronic disease itself rather than an adverse effect of HD-PDT.

Bullous Central Serous Chorioretinopathy: A Rare and Atypical Form of Central Serous Chorioretinopathy. A Systematic Review

Bullous central serous chorioretinopathy (bCSCR) is a rare variant of the central serous chorioretinopathy, complicated by an exudative retinal detachment with shifting fluid. This systematic review aims to present the epidemiology, the pathogenesis, the clinical presentation, the imaging, the differential diagnosis, and the latest treatments of this disease. A total of 60 studies were identified following a literature search adhering to PRISMA guidelines. After full-text evaluation, 34 studies about bCSCR were included. bCSCR usually affects middle-aged men, and the principal risk factor is corticosteroid medications. Pathogenesis is related to an increased choroidal vessel and choriocapillaris permeability, with subsequent subretinal fluid accumulation, rich in fibrin, which may provoke the exudative retinal detachment. Clinical presentation and imaging are fundamental to distinguish bCSCR from other pathologies, avoiding unappropriated treatment. Corticosteroid withdraws (if assumed) and laser photocoagulation of leakage sites seen at angiography may speed up retinal reattachment. Verteporfin photodynamic therapy, transpupillary thermal therapy, oral eplerenone and scleral thinning surgery are other therapeutic options. An early diagnosis might prevent disease progression due to harmful medications as well as unnecessary surgery.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Identifying central serous chorioretinopathy biomarkers in coexisting diabetic retinopathy: a multimodal imaging study

BACKGROUND

To describe clinical and imaging characteristics of patients presenting with diabetic retinopathy (DR) with coexisting acute or chronic central serous chorioretinopathy (CSCR).

METHODS

This was a cross-sectional study which included 54 eyes of 27 patients with coexisting DR and CSCR. Demographic details, prior history of laser, best-corrected visual acuity (BCVA), central macular thickness (CMT), height of neurosensory detachment (NSD), subfoveal choroidal thickness (SFCT), subfoveal large choroidal vessel layer thickness (SF-LCVT), fluorescein angiography and indocyanine green angiography features were recorded. Subanalysis was done for patients with unilateral CSCR. Data was evaluated using Student t-test for quantitative data and χ² test for qualitative data. CSCR between different grades of DR was analysed using analysis of variance.

RESULTS

Prevalence of coexistent CSCR in eyes with DR was 0.4%. Mean age was 53.96±8.79 years, with 25 males. Mean CMT was 349.2±258 μm. Mean SFCT and SF- LCVT of 38 eyes were 376.40±86 μm and 178.80±62.8 μm, respectively. Fifteen eyes had centre involving diabetic macular oedema. Subanalysis of patients with unilateral CSCR showed that the loss of inner segment-outer segment (IS-OS) integrity (p=0.001), photoreceptor footplates at the NSD roof (p=0.001) on optical coherence tomography and dilated choroidal vessels (p=0.05) on indocyanine green angiography were found more often in the CSCR eyes compared with their fellow eyes. Features of CSCR among the different grades of DR were not significantly different between the groups.

CONCLUSION

Our study describes features of a unique subset of patients presenting with coexistent DR and CSCR. Such coexistent nature needs special attention by the clinicians as this may change the treatment approach and alter outcomes.

Hair cortisol concentration in patients with active central serous chorioretinopathy is elevated - a pilot study

PURPOSE

To investigate hair cortisol concentration (HCC), a biochemical correlate of long-term cortisol output patterns, and its relationship to active central serous chorioretinopathy (CSC).

METHODS

Twenty-six participants were included in this observational pilot study (11 patients with active CSC and 15 healthy controls). Hair cortisol concentrations (HCCs) were determined from 3 cm hair strands collected near the scalp from patients and controls as an index of cumulative cortisol secretion over the 3-month period prior to hair sampling.

RESULTS

Patients with CSC exhibited higher HCCs (mean value: 20.14, 95% CI: 14.89-27.16 pg/mg) than healthy controls (mean value: 11.06, 95% CI: 8.63-14.22 pg/mg, p = 0.008). Group differences were not affected by relevant covariates (BMI, smoking status, sex).

CONCLUSION

Patients with active CSC have increased HCC, supporting the fact that cortisol is a major player in CSC pathogenesis.

Discrepancy in current central serous chorioretinopathy classification

AIM

To report the discordance in central serous chorioretinopathy (CSCR) classification among practising retina specialists.

METHODS

The study conducted was a multicentre survey. Multimodal retinal images along with relevant clinical details of 100 cases diagnosed as CSCR (from six centres) were circulated among six retina specialists across the globe. The image sets included colour fundus photographs, fundus autofluorescence images, optical coherence tomography b-scans, fluorescein and indocyanine green angiography of the study and fellow eyes. The graders were asked to classify the disease of study eye, according to their own criteria. The graders were masked to the responses of other graders. The final analysis of the pooled response data was done based on the diagnosis of study eye only. The main outcome measure was degree of agreement between six independent observers using Fleiss Kappa statistics.

RESULTS

Grading for 100 eyes of 100 patients (men, 93%) was included in the analysis. 20 patients had a history of steroid use. The graders provided 36 different terms to classify the disease, with poor agreement among graders (Fleiss Kappa=0.134). The consistency in diagnosing acute CSCR was statistically higher than for either chronic (p=0.012) or recurrent CSCR (p<0.0001). When collapsing descriptors into six main terms, agreement remained poor (Fleiss Kappa=0.218).

CONCLUSION

The high discordance among experienced retina specialists in describing CSCR clinical subtypes is highlighted. The current work demonstrates the limitations of current empirical CSCR classification methods and the need for a more objective and refined system to bring uniformity in diagnosis and prognostication of the disease.

Unusual ocular clinical manifestation of leptospirosis

CLINICAL CASE

An uncommon case is presented of a 15 year-old girl with bilateral, multiple serous detachments of retina and retinal pigment epithelium. With clinical and laboratory (IgG 1/160 and IgM 1/160, using an indirect immunofluorescence assay) diagnoses of leptospirosis, a complete ophthalmic examination, fluorescein angiography, autofluorescence and optical coherence tomography were performed, and the patient was followed for two years.

DISCUSSION

Bilateral, multiple serous detachments of retina and retinal pigment epithelium can be a complication of systemic leptospirosis, a zoonotic disease caused by Leptospira. Without a detailed medical history it may be underdiagnosed, mainly because it can mimic other more common diseases. It may be prudent to ask patients regarding contact with pets.

Macular Retinal Vessel Oxygen Saturation Elevation in Chinese Central Serous Chorioretinopathy

Purpose

To evaluate the retinal vessel oxygen saturation in central serous chorioretinopathy (CSC) cases among the Chinese.

Methods

Relative oxygen saturation of retinal blood vessels was measured in 33 Chinese patients with single-eye CSC using the Oxymap T1 retinal oximeter. The contralateral eyes were the control. The mean saturation of the retinal arteriole (AS) and venule (VS), arteriovenous difference (AVS), and arteriole and venule diameters (AD, VD) was analyzed in the optic disc area and macular region.

Results

In the optic disc area, the inferotemporal quadrant (TI) AS (93.2 ± 10.2%) and inferonasal quadrant (NI) VS (61.3 ± 7.3%) were higher in the affected eyes than in the contralateral eyes (88.7 ± 7.7% and 56.9 ± 6.5%) and AVS in NI (36.7 ± 10.4%) decreased compared to the contralateral eyes (41.5 ± 11.2%). The VD in TI was expanded (19.9 ± 2.5 pixels versus 18.1 ± 3.4 pixels). Around the macular region, AS was 93.6 ± 7.6%, higher than in the contralateral eyes (89.5 ± 6.3%). No other significant changes were found.

Conclusions

AS increased in the TI, and VS decreased in the NI in the eyes with CSC. In addition, AS also increased around the macular region, suggesting that these are contributors to CSC pathophysiology.

FOCAL CHOROIDAL EXCAVATION AND ITS ASSOCIATION WITH PACHYCHOROID SPECTRUM DISORDERS: A Review of the Literature and Multimodal Imaging Findings

PURPOSE

To review the literature regarding focal choroidal excavation and show its association with pachychoroid features through case examples.

METHODS

The clinical manifestations of focal choroidal excavation are illustrated with various imaging modalities inclusive of fundus photography, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, spectral domain optical coherence tomography (OCT), enhanced depth imaging OCT, and swept-source OCT.

RESULTS

Diffuse or focal areas of choroidal thickening with dilated choroidal vessels (pachyvessels) on OCT and choroidal hyperpermeability on indocyanine green angiography are present in many eyes with focal choroidal excavation. Clinical and imaging features of associated comorbidities including central serous chorioretinopathy and choroidal neovascularization are described.

CONCLUSION

Focal choroidal excavation appears to be a manifestation of pachychoroid spectrum disease associated with choroidal thickening and pachyvessels on structural OCT and choroidal hyperpermeability on indocyanine green angiography.

Choroidal Characteristics of Acute and Chronic Central Serous Chorioretinopathy Using Enhanced Depth Imaging Optical Coherence Tomography

Purpose

Central serous chorioretinopathy (CSC) is an idiopathic disorder characterized by serous detachments of the neurosensory retina and/or the retinal pigment epithelium affecting the macular area in the majority of cases. The objective of this study was to describe choroidal findings in patients with acute and chronic CSC based on enhanced depth imaging optical coherence tomography analysis.

Methods

This is a cross-sectional, noninterventional study performed at Luigi Sacco University Hospital of Milan. Inclusion criteria were the presence of diagnosed (acute or chronic) CSC and being 18 years or older. Patients were evaluated with Spectralis spectral-domain optical coherence tomography enhanced depth imaging by 2 operators. The main features analyzed were intrachoroidal hyperreflective spots and hyperreflective choroidal vessel walls, as actual measurements of wall thickness could not be performed.

Results

Patients with chronic CSC had hyperreflective spots in 83.3% of the cases and hyperreflective choroidal vessel walls in 75%, whereas patients with acute course had the same alterations in 33% and 6.7% of cases, respectively.

Conclusions

These findings, if proven, may be indicative of chronic forms, thus guiding more accurate treatments and guiding clinicians through more accurate prognosis.

Increased Choroidal Vascularity in Central Serous Chorioretinopathy Quantified Using Swept-Source Optical Coherence Tomography

PURPOSE

To investigate the choroidal vascular structural changes in eyes with central serous chorioretinopathy (CSC) by using swept-source optical coherence tomography (SS-OCT).

DESIGN

Prospective cross-sectional study.

METHODS

We prospectively examined 40 eyes of 34 consecutive patients with CSC. Three-dimensional choroidal images of the macular area, covering 3 × 3 mm and 6 × 6 mm, were obtained with SS-OCT. En face images of the microvasculature of the inner choroid and large choroidal vessel layers were converted to binary images. Choroidal vascular areas were analyzed quantitatively using the binary images.

RESULTS

The choroidal vascular area was larger in eyes with CSC (the microvasculature of the inner choroid: 53.4% ± 2.4%, P = .028; 3 × 3-mm large choroidal vessels: 66.9% ± 7.1%, P < .001; and 6 × 6-mm large choroidal vessels: 64.8% ± 7.3%, P < .001) than in age-matched normal eyes (52.2% ± 1.8%, 54.9% ± 4.4%, and 53.8% ± 4.3%, respectively). The choroidal vascular area at the microvasculature of the inner choroid level was larger in multifocal posterior pigment epitheliopathy (55.8% ± 2.2%) than in classic CSC (53.1% ± 2.1%, P = .038) and in diffuse retinal pigment epitheliopathy (52.9% ± 2.6%, P = .042). The subfoveal choroidal thickness was significantly associated with the choroidal vascular area at the level of large choroidal vessels (P < .001).

CONCLUSIONS

Increased choroidal vascular area was observed in the whole macula area in eyes with CSC. This finding suggests that CSC may originate from a choroidal circulatory disturbance.

Localized topical steroid use and central serous retinopathy

OBJECTIVES

The link between topical steroid use and central serous retinopathy (CSR) is poorly understood as there are a limited number of reported cases, with most cases typically occurring in patients using oral or inhaled steroids. CSR is a common retinal disease that can cause loss of vision as a result of accumulated subretinal fluid leading to localized serous retinal detachments. CSR is associated with systemic steroid use. The objective of this case series and the review was to further understand the relationship between localized topical steroid use and CSR.

METHODS

The medical charts of two patients who developed CSR after using topical steroids were reviewed.

RESULTS

These cases demonstrate that CSR is associated with consistent topical steroid use to even limited areas of the body. These cases are unique, as other published cases describe patients who used topical steroids either on multiple or larger areas of the body.

CONCLUSION

It is critical that dermatologists are aware of this association, and refer patients who develop ocular symptoms after using topical steroids to ophthalmology.

Optical Coherence Tomography Angiography in Central Serous Chorioretinopathy

Purpose. To analyze optical coherence tomography angiography (OCTA) findings in eyes with central serous chorioretinopathy (CSC) and to compare them with those obtained with multimodal imaging. Methods. A series of consecutive patients diagnosed with CSC, underwent OCTA and multimodal imaging, including spectral domain OCT, fluorescein, and indocyanine green angiography. OCTA images were performed at three main depth intervals: automatically segmented outer retina, manually adjusted outer retina, and automatically segmented choriocapillaris. Results. Thirty-three eyes of 32 consecutive patients were analyzed. OCTA showed 3 main anomalies at the choriocapillaris: the presence of dark areas (19/33 eyes) which were frequently associated with serous retinal detachment, presence of dark spots (7/33 eyes) which were frequently associated with retinal pigment epithelium detachment, and presence of abnormal vessels (12/33 eyes) which were frequently, but not systematically, associated with choroidal neovascularization, as confirmed by multimodal imaging. Conclusions. OCTA revealed dark areas and dark spots, which were commonly observed. An abnormal choroidal pattern was also observed in one-third of cases, even when multimodal imaging did not evidence any choroidal neovascularization. Abnormal choroidal vessels should be interpreted with caution, and we could assume that this pathological choroidal vascular pattern observed in many CSC cases could be distinct from CNV.

Indocyanine green angiography in posterior uveitis

Literature review for indocyanine green angiography and evaluate the role of indocyanine green angiogram (ICGA) in patients with posterior uveitis seen at a tertiary referral eye care centre. Detailed review of the literature on ICGA was performed. Retrospective review of medical records of patients with posterior uveitis and dual fundus and ICGA was done after institutional board approval. Eighteen patients (26 eyes) had serpiginous choroiditis out of which 12 patients had active choroiditis and six patients had healed choroiditis, six patients (12 eyes) had ampiginous choroiditis, six patients (12 eyes) had acute multifocal posterior placoid pigment epitheliopathy, eight patients (10 eyes) had multifocal choroiditis, four patients (eight eyes) had presumed ocular histoplasmosis syndrome, four patients (eight eyes) had presumed tuberculous choroiditis, two patients (four eyes) had multiple evanescent white dot syndrome and two patients (four eyes) had Vogt Koyanagi Harada (VKH) syndrome. The most characteristic feature noted on ICGA was the presence of different patterns of hypofluorescent dark spots, which were present at different stages of the angiogram. ICGA provides the clinician with a powerful adjunctive tool in choroidal inflammatory disorders. It is not meant to replace already proven modalities such as the fluorescein angiography, but it can provide additional information that is useful in establishing a more definitive diagnosis in inflammatory chorioretinal diseases associated with multiple spots. It still needs to be determined if ICGA can prove to be a follow up parameter to evaluate disease progression.

Focal choroidal excavation in eyes with central serous chorioretinopathy

PURPOSE

To study the prevalence and 3-dimensional (3-D) tomographic features of focal choroidal excavations in eyes with central serous chorioretinopathy (CSC) using swept-source optical coherence tomography (OCT).

DESIGN

Prospective, cross-sectional study.

METHODS

We examined 116 consecutive eyes with CSC with a prototype 3-D swept-source OCT. 3-D images of the shape of the macular area, covering 6 × 6 mm(2), were reconstructed by segmentation of the outer surface of the retinal pigment epithelium (RPE).

RESULTS

The 3-D swept-source OCT detected focal choroidal excavations in 9 eyes (7.8%). The 3-D scanning protocol, coupled with en face scans, allowed for clear visualization of the excavation morphology. In 5 eyes with focal excavations, unusual choroidal tissue was found beneath the excavation, bridging the bottom of the excavation and the outer choroidal boundary. Additionally, 3 of those 5 eyes showed a suprachoroidal space below the excavation, as if the outer choroidal boundary is pulled inward by this bridging tissue. The focal choroidal excavations were located within fluorescein leakage points and areas of choroidal hyperpermeability. Eyes with focal choroidal excavations were more myopic (-4.42 ± 2.92 diopters) than eyes without excavations (-0.27 ± 1.80 diopters, P = .001). Subfoveal choroidal thickness was significantly thinner (301.3 ± 60.1 μm) in eyes with focal excavations than in eyes without the excavations (376.6 ± 104.8 μm, P = .036).

CONCLUSIONS

Focal choroidal excavations were present in 7.8% of eyes with CSC. In these eyes, focal choroidal excavations may have formed from RPE retraction caused by focal scarring of choroidal connective tissue.

Responsiveness of eyes with polypoidal choroidal vasculopathy with choroidal hyperpermeability to intravitreal ranibizumab

Background

To determine the role played by vascular endothelial growth factor (VEGF) in polypoidal choroidal vasculopathy (PCV) based on an interventional immunology theory.

Methods

Eyes with PCV were divided in a masked fashion into those with choroidal hyperpermeability (HP group) and those with normal choroidal permeability (NP group) based on the indocyanine green angiograms. The inter-rater agreement rate was evaluated using Fleiss’ kappa. Patients were treated by intravitreal ranibizumab (IVB). The central choroidal thickness and central foveal thickness (CFT) at the baseline and 7 days after the treatment were measured by optical coherence tomography.

Results

Among the 57 consecutive eyes diagnosed with PCV, 42 eyes of 42 patients met the inclusion criteria (21 eyes/HP group vs 21 eyes /NP group). Central choroidal thickness in HP group was significantly thicker than that in the NP group (P < .001, Mann–Whitney U test). The inter-rater agreement was high with a Fleiss’ kappa = 0.95, P < .0001. The percentage reduction in the CFT in HP group (14.0%) was significantly less than that in NP group (20.4%; P = .013, Mann–Whitney U test).

Conclusions

Eyes with PCV that are associated with choroidal hyper-permeability may not be strongly associated with VEGF-related pathology, and may not respond favorably to anti-VEGF monotherapy.

Central serous chorioretinopathy: update on pathophysiology and treatment

Recent technological advances--new pathophysiological insights, new imaging techniques for diagnosis and management, and new treatments--have led to an improved understanding of central serous chorioretinopathy (CSC). The primary role of the choroid has become more widely accepted with widespread use of indocyanine green angiography. Optical coherence tomography (OCT), and particularly enhanced depth imaging OCT, demonstrate a thickened and engorged choroid. Adaptive optics, fundus autofluorescence, multifocal electroretinography, microperimetry, and contrast sensitivity testing reveal that patients with even a mild course suffer previously undetected anatomic and functional loss. Although focal laser and photodynamic therapy are the current standard of care for persistent subretinal fluid in CSC, they are not appropriate in all cases, and the optimal timing of intervention remains unclear.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Assessment of macular choroidal thickness by optical coherence tomography and angiographic changes in central serous chorioretinopathy

OBJECTIVE

To investigate the relationship between macular choroidal thickness measured by high-penetrating swept-source optical coherence tomography (SS-OCT) and angiographic findings in central serous chorioretinopathy (CSC).

DESIGN

Prospective cross-sectional case series.

PARTICIPANTS AND CONTROLS

Thirty-four patients with CSC (44 eyes) and 17 volunteer subjects (17 normal eyes).

METHODS

All subjects underwent a comprehensive ophthalmologic and SS-OCT prototype examination. All patients with CSC also underwent simultaneous fluorescein angiography (FA) and indocyanine green angiography (IA). Mean regional choroidal thickness measurements on the Early Treatment Diabetic Retinopathy Study (ETDRS) layout and squared sector grids were obtained by 3-dimensional raster scanning using SS-OCT.

MAIN OUTCOME MEASURES

Macular choroidal thickness and angiographic abnormalities.

RESULTS

Mean whole macular choroidal thickness in eyes with CSC (total, 329.3±83.0 μm; classic CSC, 326.9±83.1 μm; chronic CSC, 325.4±93.3 μm; and multifocal posterior pigment epitheliopathy, 359.0±15.5 μm) was greater than that in normal eyes (233.0±67.0 μm) (P < 0.001). In unilateral cases, mean whole macular choroidal thickness was greater in eyes with unilateral CSC than in unaffected fellow eyes (P=0.021). There was no significant difference in choroidal thickness between active eyes and resolved eyes in any of the ETDRS sectors. Mean choroidal thickness was greater in areas with leakage on FA than in areas without leakage (P=0.001). Mean choroidal thickness was greater in areas with choroidal vascular hyperpermeability and in areas with punctate hyperfluorescent spots on IA than in unaffected areas (P<0.001 for both).

CONCLUSIONS

Increased choroidal thickness was observed in the whole macular area of eyes with any of the CSC subtypes. Choroidal thickness was related to leakage from the retinal pigment epithelium, choroidal vascular hyperpermeability, and punctate hyperfluorescent lesions. These findings provide evidence that CSC may be caused by focally increased hydrostatic pressure in the choroid.

RPE barrier breakdown in diabetic retinopathy: seeing is believing

Diabetic retinopathy (DR) is a major complication of diabetes and a leading cause of blindness in working-age Americans. DR is traditionally regarded as a disorder of blood-retina barriers, and the leakage of blood content is a major pathological characteristic of the disease. While the breakdown of the endothelial barrier in DR has been investigated extensively, the vascular leakage through the retinal pigment epithelium (RPE) barrier in the disease has not been widely acknowledged. As the blood content leaked through the RPE barrier causes excessive water influx to the retina, the breakdown of the RPE barrier is likely to play a causative role in the development of some forms of diabetic macular edema, a major cause of vision loss in DR. In this article, we will discuss the clinical evidences of the diabetes-induced RPE barrier breakdown, the alteration of the RPE in diabetes, the molecular and cellular mechanism of RPE barrier breakdown, and the research tools for the analysis of RPE barrier leakage. Finally, we will discuss the methodology and potential applications of our recently developed fluorescent microscopic imaging for the diabetes- or ischemia-induced RPE barrier breakdown in rodents.

Aqueous humor and plasma levels of vascular endothelial growth factor and interleukin-8 in patients with central serous chorioretinopathy

PURPOSE

The purpose of this study was to determine aqueous vascular endothelial growth factor (VEGF) and interleukin-8 (IL-8) levels in patients with central serous chori-oretinopathy (CSC) before a single intravitreal bevacizumab injection.

METHODS

Twelve eyes with symptomatic CSC were included. Samples from patients with cataracts served as controls. The levels of VEGF and IL-8 concentrations were measured in aqueous humor and plasma by multiplex bead assays.

RESULTS

All patients with CSC showed an improvement in visual acuity and resolved neurosensory detachment after intravitreal bevacizumab injection. The aqueous humor levels of VEGF and IL-8 were not significantly increased in patients with CSC compared with the healthy control group (18.2 ± 24.8 vs. 35.3 ± 28.5 pg/mL, P > 0.05; 2.3 ± 0.4 vs. 2.8 ± 0.3 pg/mL, P > 0.05, respectively). The plasma levels of VEGF and IL-8 in patients with CSC were not different from those in the healthy control group.

CONCLUSION

Vascular endothelial growth factor and IL-8 were not increased in the aqueous humor and plasma of patients with CSC. The effect of intravitreal bevacizumab injection as a treatment for CSC must be fully understood, and the true effect of anti-VEGF treatment in patients with CSC remains to be elucidated.

Chronic central serous chorioretinopathy associated with serous retinal detachment in a series of Asian patients

PURPOSE

To determine clinical features of patients with severe chronic central serous chorioretinopathy (diffuse retinal pigment epitheliopathy, DRPE) associated with bullous retinal detachment in Thailand.

METHODS

The authors reviewed clinical and imaging characteristics, visual outcomes, and complications of 7 patients with severe DRPE associated with bullous retinal detachment.

RESULTS

Included were 6 males and 1 female with average age at onset of 39 years (range 30-46 years) diagnosed with DRPE. Although 4 patients had unilateral complaints, retinal pigment epithelium (RPE) changes on fluorescein angiography (FA) were visible in both eyes in all patients and 10 out of 14 affected eyes exhibited large exudative bullous retinal detachments (RD) and evidence of multiple characteristic leakage points. The disease was induced by steroid medications in 3 patients and an additional 3 patients received steroid treatment after they were initially considered to have Harada disease. The administration of steroids caused worsening in all cases.

CONCLUSION

Chronic central serous chorioretinopathy associated with bullous retinal detachment is a severe variant of DRPE, which might be mistaken for Harada disease. The early diagnosis of DRPE might prevent the complications from harmful medications as well as unnecessary surgery and visual loss.

Inferior sclerotomies without subretinal fluid drainage for exudative retinal detachment in diffuse retinal pigment epitheliopathy

PURPOSE

To evaluate the efficacy of inferior sutureless sclerotomies without subretinal fluid drainage for the treatment of bullous exudative retinal detachment secondary to diffuse retinal pigment epitheliopathy.

METHODS

A retrospective interventional case series of eyes treated with two inferior postequatorial full-thickness sclerotomies without subretinal fluid drainage. Patients were placed in an upright position 24 hours after surgery. Main outcomes were visual acuity and retinal reattachment rate.

RESULTS

Three eyes with recent diagnoses of diffuse retinal pigment epitheliopathy and bullous inferior retinal detachment were included in the study. In all cases, a very thick sclera was evident during surgery. The day after surgery the retina was completely attached in the three eyes. Preoperative visual acuity was light perception, 20/200, and counting fingers. After surgery, visual acuity improved to 20/200, 20/70, and 20/50, respectively. No intra- or postoperative complications occurred.

CONCLUSIONS

The performance of inferior sutureless sclerotomies without a draining procedure in cases of diffuse retinal pigment epitheliopathy with inferior bullous retinal detachment is a simple and effective technique. It achieves retinal reattachment the day after surgery, allowing laser photocoagulation of the leaking lesions disclosed in fluorescein angiography.

Central serous chorioretinopathy

Central serous chorioretinopathy (CSC) is a disease of the retina characterized by serous detachment of the neurosensory retina secondary to one or more focal lesions of the retinal pigment epithelium (RPE). CSC occurs most frequently in mid-life and more often in men than in women. Major symptoms are blurred vision, usually in one eye only and perceived typically by the patient as a dark spot in the centre of the visual field with associated micropsia and metamorphopsia. Normal vision often recurs spontaneously within a few months. The condition can be precipitated by psychosocial stress and hypercortisolism. Ophthalmoscopic signs of CSC range from mono- or paucifocal RPE lesions with prominent elevation of the neurosensory retina by clear fluid - typical of cases of recent onset - to shallow detachments overlying large patches of irregularly depigmented RPE. The spectrum of lesions includes RPE detachments. Granular or fibrinous material may accumulate in the subretinal cavity. Serous detachment often resolves spontaneously. From first contact, counselling about the potential relation to stress and glucocorticoid medication is warranted. After 3 months without resolution of acute CSC or in chronic CSC, treatment should be considered. Resolution of detachment can usually be achieved in acute CSC by focal photocoagulation of leaking RPE lesions or, in chronic CSC, by photodynamic therapy. The effect of therapy on long-term visual outcome is insufficiently documented. Reattachment within 4 months of onset is considered a relevant therapeutic target because prolonged detachment is associated with photoreceptor atrophy. This suggests that the value of treatment depends upon proper selection of cases that will not resolve without therapy. Chronic CSC may be difficult to differentiate from occult choroidal neovascularization secondary to CSC. Patients with chronic CSC who receive glucocorticoid treatment for systemic disease can often be managed without having to discontinue this medication.

Choroidopathy with serous retinal detachment in a patient with polymyositis

PURPOSE

The authors report a unique case of multifocal choroidopathy in association with polymyositis.

METHODS

The clinical presentation, laser treatment, and subsequent change in ocular findings are described.

RESULTS

A 65-year-old Japanese man with polymyositis experienced mid acute vision impairment in both eyes during systemic corticosteroid treatment for interstitial pneumonia. Fundus examination revealed a gray-white subretinal exudate with serous retinal detachment. Angiographic examination disclosed partial dilatation of the choroidal vein at the posterior pole and dye leakage points in the retinal pigment epithelium. The patient's left eye developed bullous retinal detachment and multi focal choroidal nodules at the posterior pole during the period of tapering of oral corticosteroid administration. Retinal burns were applied to the dye leakage points in the right eye using an argon laser. Vision in the right eye showed rapid recovery due to regression of the serous retinal detachment. However, in the left eye without retinal burns visual acuity decreased to light perception only even after regression of the bullous retinal detachment and choroidopathy.

CONCLUSIONS

In serous retinal detachment with choroidopathy associated with polymyositis, laser photocoagulation at leakage points may be useful for rapid restoration of vision and for the prevention of permanent severe vision loss.

Central serous chorioretinopathy after solid organ transplantation

PURPOSE

To describe the demographic and clinical characteristics of central serous chorioretinopathy (CSC) after solid organ transplantation.

DESIGN

Case series.

PARTICIPANTS

Fifteen patients who presented to the authors with CSC after solid organ transplantation.

METHODS

We performed a retrospective chart review to identify patient demographics and clinical features of disease, including angiographic changes.

MAIN OUTCOME MEASURES

Patterns of CSC. These patterns were compared with type of organ received, demographics, and visual outcome.

RESULTS

We identified 25 eyes of 7 women (46.7%) and 8 men (53.3%) that developed CSC after solid organ transplantation. Patient ages ranged from 27 to 55 years (median, 40). Seven of the 15 patients (46.7%) were Caucasian, including 3 Hispanic patients (20%). Of the 8 remaining patients (53.3%), 2 were African American (13.3%), 2 were Filipino (13.3%), and 4 were Asian (26.7%). The organs received included 13 kidneys (86.7%), 1 liver (6.7%), and 1 heart (6.7%). Systemic hypertension was reported in 14 of 15 patients (93.3%). All patients were receiving systemic immunosuppressive drugs at presentation; 14 of 15 (93.3%) were also receiving systemic corticosteroids. Visual acuity at presentation ranged from 20/20 to counting fingers. Patterns of CSC included (1) geographic or diffuse alterations in the retinal pigment epithelium (5 eyes; 2 bilateral, 1 unilateral), (2) focal CSC (6 eyes, all unilateral), (3) multifocal CSC (6 eyes; 2 bilateral, 2 unilateral), and (4) CSC with bullous retinal detachment (8 eyes, all bilateral). Follow-up, available for 21 affected eyes of 13 patients, ranged from 1 month to 6 years (median, 12 months). Compared with other solid organ transplant recipients at our institutions, renal transplant recipients (P = 0.003), as well as Hispanic and Asian patients (P = 0.05), were more prevalent in this cohort.

CONCLUSION

Central serous chorioretinopathy after solid organ transplantation varies in presentation and severity. Our observations support a role for choroidal vascular compromise in the pathogenesis of this disorder.

Adrenomedullin in the eye

Adrenomedullin (AM) is a multifunctional regulatory peptide that is produced and secreted by various types of cells. We showed the presence of high concentrations of adrenomedullin-immunoreactivity in the vitreous fluid, and the levels were elevated in patients with proliferative vitreoretinopathy. Furthermore, adrenomedullin mRNA expression levels were elevated in the tissues of intraocular tumors and orbital tumors. Adrenomedullin is produced and secreted by cultured human retinal pigment epithelial (RPE) cells. Inflammatory cytokines and hypoxia are strong stimulators for the adrenomedullin expression in retinal pigment epithelial cells. Adrenomedullin stimulated the proliferation of retinal pigment epithelial cells both under normoxia and hypoxia. Dexamethasone (DEX) increased the adrenomedullin expression in two cultured cell lines of human retinal pigment epithelial cells; ARPE-19 cells and D407 cells, while it had no noticeable effects on the cytokine-induced adrenomedullin expression. These findings suggest that adrenomedullin is involved in the pathophysiology of inflammatory and neoplastic eye diseases as an autocrine or paracrine growth stimulator. The findings on glucocorticoid-induced AM expression raise the possibility that it may be related to the pathogenesis of some eye diseases, such as central serous chorioretinopathy and multifocal posterior pigment epitheliopathy, which are frequently seen in patients treated with high doses of glucocorticoids.

Indocyanine green angiography in chorioretinal diseases: indications and interpretation: an evidence-based update

TOPIC/PURPOSE: To assess the clinical usefulness and relevance of indocyanine green angiography (ICG) in the investigation of chorioretinal disorders and assess specifically in what conditions it may add useful information to that obtained using standard fluorescein angiography.

CLINICAL RELEVANCE

Many publications on ICG have appeared in recent years touting its use in ophthalmology. These publications have led to increasing use of this technique and to its application in numerous retinal diseases in which the fluorescein angiographic findings have been thoroughly described.

METHODS/LITERATURE REVIEWED

During this systematic literature review, we identified and reviewed a total of 376 articles, from among which we selected 92 that we considered most relevant to our purpose of evaluating published evidence as to the efficacy of ICG. We excluded many articles with weak study designs and those that simply duplicated previously published information. Our literature search used PubMed and was confined to articles in English or that included an English abstract.

RESULTS

Our systematic review suggests that ICG has relatively few specific indications for use as justified by previously published peer-reviewed studies. In keeping with the requirements for this Journal's evidence-based articles, we have divided our clinical recommendations for the use of ICG into three categories: (A) strongly recommended and supported by strong evidence; (B) recommended with moderately strong supporting evidence; (C) not recommended at present because supported only by anecdotal or group consensus evidence. We highly recommended ICG for (1) identification of polypoidal choroidal vasculopathy, (2) occult choroidal neovascularization, (3) neovascularization associated with pigment epithelial detachments, and (4) recurrent choroidal neovascular membranes. These are all conditions in which ICG contributes to the identification of lesions that may be treatable. We recommend ICG with some enthusiasm for identifying feeder vessels in age-related macular degeneration, choroidal neovascular membranes, chronic central serous retinopathy, multiple evanescent white dot syndrome, vasculitis, acute multifocal placoid pigment epitheliopathy, Vogt-Koyanagi-Harada syndrome, macular lesions associated with angioid streaks, and birdshot retinopathy. In all these conditions, ICG may help establish a diagnosis and provide some useful guidance for therapy. At present, we do not recommend ICG for scleritis and posterior scleritis, drusen differentiation, Behçet's disease, or sarcoidosis, because it has not been demonstrated to add useful clinical information.

CONCLUSIONS

ICG, although now a well established technique, has clear advantage over fluorescein angiography in relatively few chorioretinal disorders. It has, however, contributed to the understanding of pathologic processes in many ocular diseases. As yet, no published randomized controlled clinical trials show any benefit to the use of ICG in the management of any specific ocular disease.

Chorioretinopathy and discoid plaque-like lesions of the eyelids as useful indicators of systemic lupus erythematosus (SLE) progression

Choroidal involvement in systemic lupus erythematosus (SLE) occurs infrequently. We report a 45-y-old woman with bilateral chorioretinopathy associated with SLE. Diagnosis was performed using indirect ophthalmoscopy, retinal fluorescein angiography (FA) and green indocianin angiography (ICG). In this patient chorioretinopathy and discoid-like plaque of the lids represented the only signs of SLE progression after 15 y of apparent remission of systemic disease.

"On" response dysfunction in multifocal posterior pigment epitheliopathy

PURPOSE

To determine the electroretinographic properties of one patient with multifocal posterior pigment epitheliopathy.

METHODS

Rod and cone electroretinograms (ERGs) and photopic ERGs elicited by long-duration stimuli were studied in a patient with multifocal posterior pigment epitheliopathy.

RESULTS

The amplitudes of both the rod and cone ERGs were significantly reduced. Photopic ERGs elicited by long-duration stimuli demonstrated that the b-wave ("on" response) was abolished but the d-wave ("off" response) was reduced by only amplitude.

CONCLUSION

The ERG findings in multifocal posterior pigment epitheliopathy indicate that there is dysfunction not only of the photoreceptors but also in the signal transmission specific for the "on" pathway.

Fluorescence properties and metabolic features of indocyanine green (ICG) as related to angiography

Indocyanine green (ICG) is a fluorescent dye that has been used for the imaging of retinal and choroidal vasculatures for more than 30 years. Its high molecular weight, specific metabolic features, and its infrared spectra make the specificity of the images obtained with this dye in ophthalmology. The focus of this paper is to review the basic properties of ICG and to show how some clinical features related to basic properties also depend on the instrumentation used to perform ICG angiography. Indocyanine green has a complex molecular structure that leads to amphiphilic properties, that is, both hydrophilic and lipophilic properties. These properties explain that a specific interaction with phospholipids influences the emission spectrum and the fluorescence yield of ICG. The composition of cell membranes mainly composed of phospholipid bilayers is consistent with a binding and/or a diffusion of ICG molecules observed on angiograms. Likewise, ICG can bind to the lipid component of miliary drusen, explaining their hyperfluorescence. A knowledge of ICG basic properties and interactions may allow a better understanding of angiograms performed with this dye.