RETINAL MICROSTRUCTURAL ABNORMALITIES IN CENTRAL SEROUS CHORIORETINOPATHY AND POLYPOIDAL CHOROIDAL VASCULOPATHY

Serous business: Delineating the broad spectrum of diseases with subretinal fluid in the macula

A wide range of ocular diseases can present with serous subretinal fluid in the macula and therefore clinically mimic central serous chorioretinopathy (CSC). In this manuscript, we categorise the diseases and conditions that are part of the differential diagnosis into 12 main pathogenic subgroups: neovascular diseases, vitelliform lesions, inflammatory diseases, ocular tumours, haematological malignancies, paraneoplastic syndromes, genetic diseases, ocular developmental anomalies, medication-related conditions and toxicity-related diseases, rhegmatogenous retinal detachment and tractional retinal detachment, retinal vascular diseases, and miscellaneous diseases. In addition, we describe 2 new clinical pictures associated with macular subretinal fluid accumulation, namely serous maculopathy with absence of retinal pigment epithelium (SMARPE) and serous maculopathy due to aspecific choroidopathy (SMACH). Differentiating between these various diseases and CSC can be challenging, and obtaining the correct diagnosis can have immediate therapeutic and prognostic consequences. Here, we describe the key differential diagnostic features of each disease within this clinical spectrum, including representative case examples. Moreover, we discuss the pathogenesis of each disease in order to facilitate the differentiation from typical CSC.

Characteristics and treatment responses of cystoid retina associated with central serous chorioretinopathy

PURPOSE

To detect the characteristics of cystoid retina associated with central serous chorioretinopathy (CSC) using multimodal imaging and to evaluate anatomical and functional responses for treatment.

STUDY DESIGN

A retrospective case series METHOD: This retrospective study included 21 eyes of 17 patients with the treatment for combined cystoid retinal changes and submacular fluid associated with CSC. Multimodal imaging analysis including cross-sectional OCT, en face OCT, fluorescein and indocyanine green angiography, and fundus autofluorescence were performed to assess the characteristics of cystoid changes. In 21 eyes of 17 patients, clinical courses after treatment were reviewed.

RESULTS

Fourteen of 17 patients were men (82.4%), and the mean age was 63.2. Fluorescein angiography revealed one or more focal leakages in all eyes, and intense leakage, due to peripapillary atrophy and from areas showing retinal pigment epithelial atrophy, was observed in 11 eyes and 12 eyes respectively. En face OCT visualized cystoid retinal changes as honey-comb like areas, and this was observed in the papillomacular region in 16 eyes (76.2%). After reduced-fluence photodynamic therapy (PDT), combination of anti-VEGF and PDT, or photocoagulation, subretinal fluid resolved in 20 eyes (95.2%), and complete resolution of cystoid retinal changes was obtained in 13 eyes (61.9%).

CONCLUSION

Cystoid retinal changes can be associated with patchy retinal pigment epithelial atrophy and with peripapillary atrophy in CSC eyes. Laser treatment is beneficial for resolving cystoid retina as well as subretinal fluid.

Association of Vascular Versus Avascular Subretinal Hyperreflective Material With Aflibercept Response in Age-related Macular Degeneration

PURPOSE

To investigate flow signal within subretinal hyperreflective material (SHRM) using optical coherence tomography angiography (OCTA) and its association with aflibercept treatment responses in treatment-naïve neovascular age-related macular degeneration (nAMD).

DESIGN

Prospective consecutive interventional case series.

METHODS

Forty-four eyes of 44 patients with treatment-naïve nAMD manifesting SHRM on OCT were studied. All patients underwent OCTA and received 3 monthly aflibercept injections. The intrinsic flow signals within SHRM were quantitatively analyzed using OCTA, and eyes were classified into the vascular and avascular SHRM groups.

RESULTS

Of 44 eyes, 21 (47.7%) and 23 (52.3%) showed vascular SHRM and avascular SHRM, respectively. Compared with eyes with avascular SHRM, eyes with vascular SHRM showed higher rates of external limiting membrane (ELM) disruption owing to SHRM (P = .015), classic choroidal neovascularization (CNV) (85.7% vs 26.1%, P = .87 × 10^-4), and intraretinal fluid (P = .008) at baseline. After 3 aflibercept injections, 38 eyes (86.4%) showed dry macula despite persistent SHRM in 24 eyes (54.5%). Compared with the eyes with resolved SHRM, those with persistent SHRM showed higher rate of vascular SHRM (75.0% vs 15.0%, P = .86 × 10^-4), classic CNV (P = .032), absence of polypoidal lesion (P = .020), ELM disruption owing to SHRM (P = .042), and intraretinal fluid (P = .008). Dry macula after loading injections was significantly associated with SHRM resolution (P = .025).

CONCLUSIONS

In nAMD, SHRM can be categorized as vascular and avascular by quantitative OCTA analysis. Vascular SHRM persisted after treatment and was associated with failure to achieve dry macula, suggesting that vascular SHRM is predictive of lower response to anti-VEGF therapy.

A Central Hyporeflective Subretinal Lucency Correlates With a Region of Focal Leakage on Fluorescein Angiography in Eyes With Central Serous Chorioretinopathy

BACKGROUND AND OBJECTIVE

To correlate the appearance of a hyporeflective lucency on spectral-domain optical coherence tomography (SD-OCT) with a focal leak on fluorescein angiography (FA) in eyes with central serous chorioretinopathy (CSC).

PATIENTS AND METHODS

Multimodal imaging of 18 patients with CSC who had hyperreflective fibrin surrounding a hyporeflective lucency on SD-OCT was analyzed to investigate any potential correlation with an active leak on FA. The lucent area was evaluated using en face imaging and followed for resolution of the active leak.

RESULTS

High-resolution SD-OCT images of the lucency were found to correlate with the active leak. In certain cases, the lucent area could be visualized as communicating with a defect in a pigment epithelial detachment. En face imaging of the lucency revealed a smoke-stack appearance, and resolution of the leak correlated with the disappearance of the lucency on SD-OCT.

CONCLUSION

Visualization of a lucency within surrounding fibrin may suggest an active leak. En face imaging of the lucency may provide insight into the pathophysiology of the smoke-stack leak on FA.

Effect of a topical nonsteroidal anti-inflammatory agent (0.1 % pranoprofen) on acute central serous chorioretinopathy

PURPOSE

To investigate the effects of topical pranoprofen 0.1 % on acute central serous chorioretinopathy (CSC).

METHODS

The medical records of 52 cases (52 patients) of CSC were retrospectively reviewed. Twenty-six patients were treated with topical pranoprofen 0.1 % (treatment group) and 26 patients did not receive treatment (control group). Baseline and follow-up values for visual acuity, subfoveal choroidal thickness (SCT), subretinal fluid (SRF) maximum height, and central macular thickness (CMT) were examined and compared between groups.

RESULTS

In the treatment group, mean SCT decreased from 365.5 ± 52.9 μm at baseline to 288.9 ± 36.1 μm at 6 months after initiation of treatment (p = 0.005). Both SRF maximum height and CMT were also decreased from baseline at 1 month (SRF maximum height, baseline: 221.5 ± 108.4, 1 month: 97.7 ± 54.3 μm, p = 0.002; CMT, baseline: 403.9 ± 114.6, 1 month: 270.1 ± 37.9 μm, p = 0.003). In the control group, SCT decreased throughout the follow-up period, but the change was not significant. Subretinal fluid maximum height and CMT were significantly decreased after 3 months in the control group (SRF, baseline: 265.4 ± 112.4 μm, 6 months: 64.8 ± 116.9 μm, p = 0.005; CMT, baseline: 459.1 ± 104.9 μm, 6 months: 304.6 ± 92.8 μm, p < 0.001). Visual acuity was improved from baseline in both groups after 6 months, but the improvement was only significant in the treatment group (p = 0.002). The rate of disease recurrence was lower in the treatment group (23 %) than in the control group (38 %), but this difference between groups was not statistically significant (p = 0.229, chi-square test).

CONCLUSIONS

Topical pranoprofen 0.1 % was effective in treating acute CSC, as demonstrated by an increase in visual acuity and a decrease in SRF, SCT, and CMT after treatment. These results suggest that topical pranoprofen 0.1 % may be useful in treating patients with acute CSC.

Punctate hyperfluorescence spot as a common choroidopathy of central serous chorioretinopathy and polypoidal choroidal vasculopathy

PURPOSE

To characterize punctate hyperfluorescence spot as common choroidopathy in central serous chorioretinopathy (CSC) and polypoidal choroidal vasculopathy (PCV).

DESIGN

Cross-sectional retrospective study.

METHODS

A total of 150 patients with 50 each allocated to CSC, PCV, and typical neovascular age-related macular degeneration (AMD) groups were included. Punctate hyperfluorescence spot was determined using mid-to late-phase indocyanine green angiography and subfoveal choroidal thickness by enhanced depth imaging optical coherence tomography. Each group was subcategorized based on concurrent punctate hyperfluorescence spot.

RESULTS

The punctate hyperfluorescence spot incidence was higher in CSC (80.0%) and PCV (86.0%) than in AMD (40.0%, P < .001), with similar contralateral findings (86.1%, 86.7%, and 60%, respectively, P = .014). Punctate hyperfluorescence spot lesions comprised clustered polyps connected to vascular networks mimicking PCV. Choroidal thickness was 370.7 ± 81.9 μm, 332.6 ± 101.6 μm, and 172.5 ± 80.1 μm in affected eyes (P < .001) and 323.0 ± 70.5 μm, 306.4 ± 94.4 μm, and 180.2 ± 83.6 μm in contralateral eyes (P < .001) in CSC, PCV, and AMD groups, respectively. In the AMD group, choroidal thickness was greater in eyes with punctate hyperfluorescence spot (204.8 ± 92.3 μm) than in those without punctate hyperfluorescence spot (150.2 ± 62.9 μm, P = .028) in affected eyes; however, the difference was not observed in contralateral eyes in the AMD group and in both eyes in the CSC and PCV groups.

CONCLUSIONS

Based on angiography and OCT, punctate hyperfluorescence spot may be a form of PCV, and CSC and PCV may share common choroidopathy distinct from typical neovascular AMD. However, infrequent PHS lesions along with thickened choroids in AMD eyes suggest that AMD may encompass a wide choroidal pathologic spectrum shared in part with PCV.

Predicting visual outcomes for macular disease using optical coherence tomography

In recent years, the management of macular disease has undergone radical changes, in part because of new therapeutic approaches, but also due to the introduction of a new imaging modality - optical coherence tomography (OCT). The application of OCT imaging has clarified many aspects of chorioretinal disease pathophysiology and elucidated many hitherto unrecognized disease characteristics. From an early stage in its development, OCT has also been revolutionary in attempting to extract clinically useful measurements from image data in an automated fashion. As a result, OCT-derived measurements of retinal thickness have been rapidly embraced in clinical and research settings. However, as knowledge of OCT image analysis has developed, it has become increasingly clear that even accurate measurements of retinal thickness may fail to predict visual outcomes for many diseases. As a result, the focus of much current clinical imaging research is on the identification of other OCT-derived anatomic biomarkers predictive of visual outcomes - such biomarkers could serve as surrogate endpoints in clinical trials and provide prognostic information in clinical practice. In this review, we begin by highlighting the importance of accurate visual function assessment and describing the fundamentals of OCT image evaluation, before describing the current state-of-the-art with regard to predicting visual outcomes, for a variety of macular diseases, using OCT.