Central serous chorioretinopathy: A review

The role of inflammation in central serous chorioretinopathy: From mechanisms to therapeutic prospects

Central serous chorioretinopathy (CSC) is a leading cause of permanent vision loss, ranking fourth among macular diseases, trailing only age-related macular degeneration, diabetic retinopathy, and retinal vein obstruction. While mounting evidence implicates inflammation as a pivotal factor in the onset and advancement of CSC, the specific pathophysiological process and molecular mechanisms underlying inflammation remain incompletely understood. A complex network of cytokines, chemokines, and adhesion molecules interplay to trigger inflammatory and pathological cascades, highlighting the need for a comprehensive comprehension of the inflammation-related mechanisms behind CSC progression. In this piece, we examine the existing comprehension of CSC's pathology and pathogenesis. Additionally, we present an overview of the mechanisms underlying the onset and progression of CSC inflammation, followed by a thorough analysis and discussion of the potential of targeted inflammatory intervention for both preventing and treating CSC.

Improvement in Central Serous Chorioretinopathy Following Multiwavelength Photobiomodulation Treatment - Case Report

INTRODUCTION

Central serous chorioretinopathy (CSCR) is a condition where fluid build-up accumulates underneath the retina, resulting in retinal pigment epithelium (RPE) detachment and vision loss. Irreversible retinal functional and anatomical changes are possible consequences. Research into novel strategies to aid in recovery are of interest. Photobiomodulation (PBM) uses light wavelengths to improve cellular function and shows positive effects in several conditions including those with edema.

METHODS

This prospective case report details a 39-year-old woman with CSCR. Multiwavelength PBM treatment was initiated with the Valeda® Light Delivery System. A series of treatment included nine sessions delivered over 3-5 weeks. Follow-up treatments were conducted. Optical coherence tomography (OCT) imaging and best-corrected visual acuity (BCVA) measures were taken. The patient has been followed for approximately 1 year.

RESULTS

The patient presented with blurred vision and a BCVA score of 65 letters in the left eye. After 3 weeks of observation, the patient's vision had further declined two lines on the Early Treatment Diabetic Retinopathy Study (ETDRS) chart to 55 letters. Fluorescein angiography was performed, confirming CSCR diagnosis, and PBM was initiated. PBM treatment improved BCVA and fluid build-up in the RPE within 1 week of treatment (three treatment sessions). Following the full series of treatment (nine PBM treatment sessions), fluid was completely resolved and BCVA scored at 80 letters. The patient had a repeat PBM treatment series ~ 6 months later and has shown stable vision and no fluid present on OCT scan. The patient was seen again ~ 1 year later with continued stable vision and no fluid detection.

CONCLUSIONS

PBM is a non-invasive treatment option that may provide benefit in CSCR to resolve fluid build-up, macular change, and vision loss. Research into PBM as an immediate treatment option for CSCR, especially those with chronic presentations or those posed to have irreversible damage, is warranted to confirm effectiveness.

QUANTITATIVE AUTOFLUORESCENCE IN CENTRAL SEROUS CHORIORETINOPATHY

BACKGROUND/PURPOSE

Central serous chorioretinopathy (CSC) is associated with pachychoroid and dysfunctional retinal pigment epithelium. Autofluorescence (AF) is typically altered. The authors performed this study to quantify these alterations using quantitative AF (qAF) in patients with CSC and in their fellow eye in comparison with a healthy control group.

METHODS

Patients with CSC and healthy controls were recruited prospectively. All patients received a full clinical examination including best-corrected visual acuity, enhanced depth imaging-optical coherence tomography, and qAF. Quantitative autofluorescence images were taken with a confocal scanning laser ophthalmoscope (Heidelberg Engineering). Quantitative autofluorescence values were assessed in specified regions of the inner eight and the middle ring of the Delori grid.

RESULTS

In total, 141 eyes of 77 patients with CSC were included. Ninety eyes had a manifest CSC (group 1) while 51 fellow eyes (group 2) did not show signs of CSC. There were no significant differences of qAF values between these two groups: mean qAF values were 241.3 (inner eight) and 212.8 (middle ring) in group 1 and 235.9 (inner eight) and 210.0 (middle ring) in group 2 ( P = 1.0 and 1.0). We compared these eyes with healthy controls comprising 39 eyes. Quantitative autofluorescence signals (inner eight: 164.7; middle ring: 148.9) differed significantly compared with both CSC manifest ( P < 0.001) and fellow eyes ( P < 0.001).

CONCLUSION

Our results show that patients with CSC have increased qAF values in both eyes with manifest CSC and asymptomatic, clinically unremarkable fellow eyes in comparison with healthy controls. This finding suggests that qAF alterations are present even before clinical signs can be observed.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Inner Choroidal Fibrosis: An Optical Coherence Tomography Biomarker of Severity in Chronic Central Serous Chorioretinopathy

PURPOSE

To describe a potential biomarker termed as inner choroidal fibrosis in cases of chronic central serous chorioretinopathy (CSCR) presenting to a tertiary referral center.

DESIGN

Observational case series.

METHODS

Five eyes of 4 patients with CSCR were noted to have a gray-white subretinal lesion in the macula, which was analyzed with multimodal imaging.

RESULTS

The lesions were hypofluorescent on autofluorescence, fundus fluorescein angiography, and indocyanine angiography. In all cases, a characteristic heterogeneous, hyperreflective lesion in the inner choroid was seen on optical coherence tomography (OCT), corresponding to the white subretinal lesions. The lesion was distinct from the adjacent choroid, with greater reflectivity and greater thickness than the adjacent compressed choroidal vasculature. The dilated outer pachyvessels were pushed outward or sideways in all cases. On OCT-angiography, the corresponding lesion showed flow void areas. We have termed this zone of inner choroidal hyperreflectivity "inner choroidal fibrosis." Upon analyzing the clinical course, 3 of the patients had a history of choroidal neovascularization. The contralateral eye in 2 of these 3 patients also developed choroidal neovascularization. Three of the eyes had an overlying focal choroidal excavation.

CONCLUSIONS

We report a potential biomarker of CSCR termed "inner choroidal fibrosis" in 4 cases of chronic CSCR. It can best be identified on enhanced depth or swept source OCT as a region of heterogeneous hyperreflectivity in the inner choroid. This fibrosis could be regarded as a degenerative process secondary to more severe disease in the past.

Artificial intelligence in retinal imaging: current status and future prospects

INTRODUCTION

The steadily growing and aging world population, in conjunction with continuously increasing prevalences of vision-threatening retinal diseases, is placing an increasing burden on the global healthcare system. The main challenges within retinology involve identifying the comparatively few patients requiring therapy within the large mass, the assurance of comprehensive screening for retinal disease and individualized therapy planning. In order to sustain high-quality ophthalmic care in the future, the incorporation of artificial intelligence (AI) technologies into our clinical practice represents a potential solution.

AREAS COVERED

This review sheds light onto already realized and promising future applications of AI techniques in retinal imaging. The main attention is directed at the application in diabetic retinopathy and age-related macular degeneration. The principles of use in disease screening, grading, therapeutic planning and prediction of future developments are explained based on the currently available literature.

EXPERT OPINION

The recent accomplishments of AI in retinal imaging indicate that its implementation into our daily practice is likely to fundamentally change the ophthalmic healthcare system and bring us one step closer to the goal of individualized treatment. However, it must be emphasized that the aim is to optimally support clinicians by gradually incorporating AI approaches, rather than replacing ophthalmologists.

Hyperplasia of the retinal pigment epithelium secondary to subthreshold laser treatment in chronic central serous chorioretinopathy

PURPOSE

To assess the development of hyperplasia of the retinal pigment epithelium (HRPE) secondary to subthreshold laser treatment (STL) in chronic central serous chorioretinopathy (CSCR).

METHODS

Prospective study including 149 eyes of 146 patients with CSCR with persistent subretinal fluid (SRF) that have undergone STL using the Navilas® device. Visual acuity (VA) optical coherence tomography (OCT) and fundus autofluorescence (FAF) were performed before and after the treatment. The HRPE was identified on OCT as a hyperreflective and dense material at the expense of the RPE that did not exist prior to the treatment. The demographics of the patients as well as the parameters of the STL treatments employed were registered.

RESULTS

Seven HRPE cases after STL were identified, observing an incidence of 4.7% (7 out of 149 eyes). The mean age was 52.1 ± 3.6 years, being 6/7 males. The mean number of STL sessions was 1.3 ± 0.5. The mean total fluence applied was 52.2 ± 12.4 J/cm2 (range 35.37 to 76.39 J/cm2), using a duty cycle of 10% in all cases. The HRPE was subfoveal in 6 of the 7 cases. The SRF was resolved in 6 of the 7 patients. The mean VA loss was -14.1 ± 14.3 ETDRS letters.

CONCLUSION

The development of HRPE secondary to STL in CSCR is an uncommon but severe adverse effect, probably related to the excessive energy employed. Further studies are warranted to minimize the incidence and to know the predictors of this complication after STL treatment to optimize the parameters that should be used.

Evaluation of the Retinal Vessel Density and Subfoveal Choroidal Thickness in Central Cerous Chorioretinopathy Using Optical Coherence Tomography

PURPOSE

The purpose of this study was to quantitatively assess changes in the subfoveal choroidal thickness (SFCT) and superficial retinal vessel density (SRVD) in acute and chronic central serous chorioretinopathy (CSCR) patients, and estimate the correlation of SFCT and SRVD with best-corrected visual acuity (BCVA), respectively, using spectral domain optical coherence tomography (SD-OCT) and optical coherence tomography angiography (OCTA).

METHODS

This was a cross-sectional, case-control study. The study included CSCR patients treated at the Ho Chi Minh City Eye Hospital from May 2022 to October 2022.

RESULTS

A total of 91 subjects (182 eyes) were included in this study, with 74 eyes in the unilateral acute CSCR group and 17 eyes in the unilateral chronic CSCR group; 91 eyes in the control group were patients' unaffected other eyes. The mean age was 40.78 ± 1.26 years (ranging from 31 to 45 years). The proportions of male and female patients were 78.0% and 22.0%, respectively. The major symptom was reduced vision, and the mean BCVA was 0.36 ± 0.05 logMAR. The mean SFCT of CSCR eyes was 357.2 ± 11.8 μm, which was 290.4 ± 8.5 μm in the control group (p < 0.05). The mean SRVD of chronic CSCR (24.2 ± 4.94%) and acute CSCR (28 ± 2.33%) eyes was lower compared with the control group (21.7 ± 1.87%). SFCT had a correlation with BCVA (r = -0.490, p < 0.05) in chronic CSCR; the center region of SRVD was likewise correlated with BCVA (r = -0.384, p < 0.05) and the parafoveal region of SRVD was also correlated with BCVA (r = -0.271, p < 0.05).

CONCLUSION

Both altered SFCT and SRVD were identified in CSCR patients by SD-OCT and 6 x 6 mm OCT angiography scans, and both were found to be correlated with BCVA. SD-OCT along with OCTA could be a good technique for quantitatively evaluating different CSCR courses.