Effectiveness and safety of repeated photodynamic therapy in recurrent central serous chorioretinopathy

PURPOSE

To evaluate anatomical and functional outcomes after a second photodynamic therapy (PDT) in patients with central serous chorioretinopathy (CSC), who had a recurrence of subretinal fluid (SRF) after a previously successful PDT.

METHODS

In this multicentre retrospective cohort study, we included patients with CSC who underwent a second PDT because of a recurrence of SRF after an effective first PDT with complete SRF resolution. Diagnosis of CSC was based on multimodal imaging. We evaluated the complete resolution rate of SRF after a second PDT with reduced settings. Also, visual acuity (VA), subfoveal ellipsoid zone (EZ) and subfoveal external limiting membrane (ELM) integrity before and after the first and the second PDT were studied.

RESULTS

A total of 88 patients were studied, of whom 18% were female. The mean age was 51.3 ± 10.5 years at the second PDT. At the first follow-up visit after the second PDT (median of 44 days [IQR 40-51] after PDT), a complete resolution of SRF occurred in 64% of eyes. The median VA was 0.15 LogMAR before the second PDT and improved to 0.05 LogMAR (p < 0.001) after PDT. The EZ was continuous in 3% of patients before the second PDT, and EZ continuity increased to 27% at the first follow-up visit after PDT. No new atrophy was observed after the second PDT.

CONCLUSION

A second PDT with reduced settings in recurrent CSC is effective and safe in the short term, as significant anatomical and functional improvement was observed.

Outcome and safety of multiple photodynamic therapy sessions in chronic central serous chorioretinopathy

PURPOSE

This study evaluates the effectiveness and safety of multiple PDT sessions for cases of persistent and recurrent subretinal fluid (SRF) in chronic central serous chorioretinopathy (CSC).

METHODS

This multicentre, retrospective cohort study included patients aged ≥18 years with chronic CSC who received at least two sessions of PDT at Amsterdam University Medical Center or Leiden University Medical Center between August 2009 and February 2025. Outcomes included the resolution of SRF, changes in visual acuity (VA), subfoveal choroidal thickness (SFCT) and continuity of the external limiting membrane (ELM) and ellipsoid zone (EZ).

RESULTS

The study included 88 patients with chronic CSC, of whom 88.6% were male. Of the 105 eyes treated, 62.5% had persistent SRF after the first PDT, while 37.5% achieved complete SRF resolution. After the second PDT, SRF resolved completely in 62.8% of eyes overall, with 53.1% in the persistent SRF group and 64.1% in the recurrent SRF group. Following the third PDT, 67.7% of patients showed complete SRF resolution. VA improved by 3 ± 2 letters (p = 0.033) above baseline after the second PDT, with the recurrent SRF group showing greater improvements. SFCT was lower than baseline after PDT treatments in both groups. ELM and EZ continuity also generally showed improvements on optical coherence tomography, particularly in the recurrent SRF group, suggesting retinal integrity restoration rather than atrophic changes.

CONCLUSION

Repeated PDT is an effective and safe treatment for both persistent and recurrent chronic CSC, with improvements in SRF, VA, SFCT and retinal layer continuity.

Predictive Factors for Morphological and Functional Improvements in Long-Lasting Central Serous Chorioretinopathy Treated with Photodynamic Therapy

Backgrounds: Photodynamic therapy (PDT) is an established treatment modality in central serous chorioretinopathy (CSCR). The goal of our study was to evaluate the morphological and functional effects of PDT in patients with long-lasting CSCR and determine the related predictive factors for improvement. Methods: This retrospective analysis included consecutive patients with chronic CSCR who consented to PDT. The material comprised 98 eyes of 81 patients (67 males and 14 females) with a disease duration longer than 6 months followed for 6 months post treatment. All patients underwent a basic ophthalmological examination including best corrected visual acuity (BCVA) testing and imaging, spectral-domain optical coherence tomography (SD-OCT), and fluorescein angiography. Patients without macular neovascularization (MNV) were subjected to half-dose PDT (3 mg/m2) with standard fluence (50 J/cm2), guided by indocyanine green angiography. Cases complicated by MNV were subjected to full-dose PDT. Results: A morphological response, defined as complete resolution of subretinal fluid, was achieved in 76.29% of cases, and an improvement in BCVA of at least one logMAR line was obtained in 77.53% of cases. The mean BCVA gain was 1.2 logMAR line. All SD-OCT measurements (central retinal thickness, macular volume, mean subfield thickness, subretinal fluid height, and subfoveal choroidal thickness) showed a significant reduction post PDT. A multivariate analysis proved better morphological outcome associations with a younger age and male gender and better visual gains achieved in patients without intraretinal abnormalities. Univariate testing also showed strong relationships between better baseline BCVA and greater functional and morphological improvements, between shorter disease duration and morphological gains, and between the absence of MNV or intraretinal abnormalities and morphological gains. PDT was highly effective in providing a resolution of pigment epithelial detachment (p = 0.0004). The observed effect was significantly dependent upon the lower baseline central retinal thickness (p = 0.0095). Patients with intraretinal abnormalities or MNV showed moderate improvements post PDT. Conclusions: PDT in long-lasting CSCR cases provides good morphological results but generally minor visual gains. Patients' expectations of significant increases in BCVA after prolonged disease with distinct alterations of the neurosensory retina should be managed.

Therapeutic interventions for chronic central serous chorioretinopathy: a comprehensive assessment of systematic reviews

BACKGROUND

A variety of different treatments have been proposed to effectively treat chronic central serous chorioretinopathy but there remains uncertainty regarding the efficacy of a number of treatment options. We aim to evaluate the efficacy of several therapeutic options for chronic central serous chorioretinopathy including photodynamic therapy, conventional laser photocoagulation, subthreshold micropulse laser, selective retina therapy, vascular endothelial growth factor (VEGF) antagonists, and mineralocorticoid receptor antagonists.

METHODS

Pubmed, Embase, and Cochrane databases were searched for systematic reviews and meta-analyses evaluating treatment modalities for chronic central serous chorioretinopathy. Primary outcome measures included improvement in best corrected visual acuity (BCVA) and resolution of subretinal fluid (SRF). Conclusions regarding the efficacy of each modality were summarized and compared to findings of several key randomized controlled trials.

RESULTS

Ten systematic reviews and meta-analyses that incorporated 58 unique randomized controlled trials and observational studies were identified. Treatments that were shown to improve BCVA and promote SRF resolution included half-fluence and half-dose photodynamic therapy, conventional laser therapy, and subthreshold micropulse laser therapy. Evidence regarding selective retina therapy was limited and inconclusive. VEGF antagonists were not effective in the absence of choroidal neovascularization and mineralocorticoid receptor antagonists were not effective.

CONCLUSION

The most effective therapeutic option for chronic central serous chorioretinopathy is half-dose or half-fluence photodynamic therapy, however, conventional laser therapy is an acceptable alternative in cases when photodynamic therapy is unavailable and when fluid leakage sites are not subfoveal or juxtafoveal. Subthreshold micropulse laser is less effective but can be considered when other options are unavailable.

Safety and Efficacy of Half-dose and Half-fluence Photodynamic Therapy in Chronic Central Serous Chorioretinopathy: A Systematic Review and Meta-analysis

PURPOSE

To investigate the comparative efficacy and safety of half-dose photodynamic therapy (PDT) and half-fluence PDT in the management of chronic central serous chorioretinopathy.

DESIGN

Systematic review and meta-analysis.

METHODS

A comprehensive literature search was conducted on Ovid MEDLINE, Embase, and the Cochrane Library, covering publications from January 2000 to March 2024. The review focused on studies reporting the efficacy and safety of half-dose PDT compared to half-fluence PDT in treating chronic central serous chorioretinopathy. The primary outcome was the best-corrected visual acuity (BCVA) at the last study observation. Secondary outcomes included retinal thickness (RT), the presence of subretinal fluid (SRF), and SRF recurrence across follow-up visits. Random effects meta-analysis was performed using RevMan 5.4.

RESULTS

A total of 10 studies (eight observational and two randomized controlled trials) were included in the analysis. The results indicated that half-dose PDT and half-fluence PDT achieved similar BCVA at 1 month (P = .24), 3 months (P = .40), and 6 months (P = .16). Similarly, there were no significant differences in RT at 1 month (P = .23), 3 months (P = .99), and at 6 months (P = .54) between the two treatment protocols. Both treatment protocols were associated with minor complications, indicating similar safety profiles in patients with CSCR.

CONCLUSIONS

The findings suggest that both half-dose and half-fluence PDT are effective and safe for treating CSCR, with no significant differences in BCVA, RT, or SRF resolution between the two modalities. These results support flexibility in selecting treatment based on individual patient needs. Further research with larger sample sizes and longer follow-up is required to optimize these protocols and confirm these results.

Treatment Outcomes of Simple and Complex Central Serous Chorioretinopathy

Objectives: To assess the association between clinical outcomes and the multimodal imaging-based classification of central serous chorioretinopathy (CSC). Methods: This retrospective study included 207 eyes from 155 treatment-naïve patients with CSC. The eyes were categorized into two groups, including the simple CSC group (n = 164) and the complex CSC group (n = 43), based on the presence of retinal pigment epithelial atrophy spanning two or more disc areas. All patients were initially observed without treatment for 3-6 months. For cases with persistent subretinal fluid after this observation period, treatment modalities, including continued observation, photocoagulation (PC), or photodynamic therapy (PDT), were selected. Results: Patients in the complex CSC group were more likely to be older (p = 0.01) and male (p = 0.01) than those in the simple group and to exhibit a higher prevalence of bilateral involvement (p < 0.001) and previous CSC episodes (p < 0.001) than those exhibited by patients in the simple group. Eyes with complex CSC exhibited a comparable incidence of spontaneous resolution within 6 months and a higher incidence of recurrence after spontaneous resolution within 6 months than eyes with simple CSC. In both the simple and complex CSC groups, the PDT subgroup exhibited a lower recurrence rate than that of the PC subgroup (simple CSC: p < 0.001, complex CSC: p = 0.03). Conclusions: Although CSC is typically a self-limiting disease often managed conservatively, patients with complex CSC, characterized by bilateral involvement or a history of previous episodes, are at a higher risk of subretinal fluid recurrence and may benefit from early interventions without a period of observation, such as PDT.

Laser Treatment of Central Serous Chorioretinopathy - An Update

Laser treatment has been a mainstay for management of central serous chorioretinopathy for a few decades. Different types of lasers have been used and non-damaging retinal laser is the most recent option. The aim of this review is to provide an update on this form of treatment, based on the research published during last 5 years, in comparison with earlier studies published. A MEDLINE database search was performed with a combination of the following terms: central serous chorioretinopathy and laser photocoagulation or subthreshold laser or subthreshold micropulse laser or nanosecond laser or microsecond laser or end-point management or photodynamic therapy. Results were analyzed separately for each modality of laser treatment. Reports published in recent years confirm findings of previous research and do not distinguish treatments of this clinical entity. Among all analyzed laser options, photodynamic therapy provides the fastest and most prominent morphological improvements, including subretinal fluid resorption and reduction of choroidal thickness. This modality is also associated with fewer recurrences than with other treatments. Subthreshold micropulse laser allows the physician to maintain and, in selected cases, improve the patient's vision. Conventional photocoagulation is still effective, especially with the introduction of navigated laser systems. Despite the availability of variable laser treatment options, long-term functional improvements in chronic cases are minor for each modality. Long-lasting central serous chorioretinopathy cases with significantly altered retinal morphology do not usually present with functional improvement, despite satisfactory morphological outcomes. Early initiation of treatment has the potential to prevent visual loss and to improve the patient's quality of life.

Pharmacokinetics-Based Safety Evaluation in Half-Dose Verteporfin Photodynamic Therapy

INTRODUCTION

This study was conducted to assess the systemic pharmacokinetic profiles of half-dose verteporfin photodynamic therapy (PDT) using concentration data from a previous clinical trial and to subsequently suggest safety precaution guidelines.

METHODS

Coefficients for the bi-exponential model were obtained from published data on post-infusion plasma verteporfin concentrations within a period of 0.17-4 h. Using the extrapolative forecasting method, we plotted the 48-h post-verteporfin plasma concentration model. The time required to achieve a comparable level of verteporfin 48 h after a conventional dose (6 mg/m2 body surface area, BSA) infusion was calculated for a half-dose infusion (3 mg/m2 BSA).

RESULTS

At 24 and 48 h post-verteporfin infusion, the plasma concentration following the conventional dose was 1.28 × 10-4 µg/mL and 5.06 × 10-8 µg/mL, compared to 3.57 × 10-5 µg/mL and 7.54 × 10-9 µg/mL for the half-dose PDT, representing concentrations that were 3.6 times and 6.7 times higher, respectively. The estimated time required to attain the same level of verteporfin 48 h after a conventional dose was calculated as 42-h post-half-dose PDT.

CONCLUSIONS

The results of this study indicate that precautionary measures should be taken to avoid sunlight following both half and conventional doses of PDT during the similar post-treatment periods of two days. Nevertheless, given the substantially higher plasma concentration levels associated with conventional-dose PDT compared with the half-dose, systemic safety should be carefully considered when administering conventional-dose PDT.

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.

Verteporfin Photodynamic Therapy for the Treatment of Chorioretinal Conditions: A Narrative Review

Photodynamic therapy (PDT) with verteporfin involves intravenous administration of a photosensitizer followed by its laser light activation at the target site to inhibit aberrant choroidal vascularization. This narrative review provides an overview of the role verteporfin PDT plays in the management of chorioretinal conditions. A PubMed literature review of all English-language articles published through October 19, 2023, was conducted to identify relevant references. Verteporfin PDT has been shown to be safe and effective for the treatment of patients with choroidal neovascularization (CNV) due to neovascular age-related macular degeneration and is often used in combination with a vascular endothelial growth factor (VEGF) inhibitor. Additionally, patients with polypoidal choroidal vasculopathy, a subtype of neovascular age-related macular degeneration, also benefit from verteporfin PDT combined with a VEGF inhibitor for improving visual acuity. Verteporfin PDT has also been effective in treating patients with peripapillary CNV, as well as eyes with CNV due to ocular histoplasmosis and pathologic myopia. Reduced dose and/or fluence PDT protocols have been effective in patients with central serous chorioretinopathy while reducing adverse effects. In eyes with choroidal hemangioma, tumor regression and visual outcomes have been improved with verteporfin PDT treatment. Photodynamic therapy with verteporfin continues to play an important role in the management of chorioretinal conditions.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Long-term follow-up of chronic central serous chorioretinopathy after successful treatment with photodynamic therapy or micropulse laser

PURPOSE

To describe the treatment outcomes and recurrence risk of chronic central serous chorioretinopathy (cCSC) in patients who had complete resolution of subretinal fluid (SRF) after either primary half-dose photodynamic therapy (PDT) or high-density subthreshold micropulse laser (HSML) in the PLACE trial.

METHODS

This multicentre prospective follow-up study evaluated cCSC patients at 1 year after completion of the PLACE trial. Outcomes included: complete resolution of SRF on OCT, best-corrected visual acuity (BCVA) in Early Treatment of Diabetic Retinopathy Study (ETDRS) letters, retinal sensitivity on microperimetry and a visual function questionnaire (NEI-VFQ25).

RESULTS

Twenty-nine out of 37 patients who received half-dose PDT and 15 out of 17 patients who received HSML could be evaluated at final visit. At final visit, 93% of the patients treated with half-dose PDT had complete resolution of SRF, compared with 53% of HSML-treated patients (p = 0.006). At final visit, the mean estimate increase in the PDT group compared with the HSML group was + 2.1 ETDRS letters, +0.15 dB for the retinal sensitivity and + 5.1 NEI-VFQ25 points (p = 0.103, p = 0.784 and p = 0.071, respectively). The mean estimated central retinal thickness in the half-dose PDT group was -7.0 µm compared with the HSML group (p = 0.566). The mean estimated subfoveal choroidal thickness in the half-dose PDT group was -16.6 µm compared with the HSML group (p = 0.359).

CONCLUSION

At 20 months after treatment, cCSC patients successfully treated with half-dose PDT are less likely to have recurrences of SRF compared with those successfully treated with HSML. However, functional outcomes did not differ.

Dose-Related Structural Effects of Photodynamic Therapy on Rabbit Choroidal Structure

INTRODUCTION

Photodynamic therapy with verteporfin (vPDT) has been shown to be effective against central serous chorioretinopathy (CSC) and was the preferred therapeutic for CSC treatment. However, alterations in choroidal structure after PDT were reported, and these effects were dose-dependent. This study aimed to compare the changes in choroidal structure after PDT with different doses of verteporfin in rabbits and may provide individualized therapeutic guidance for patients who failed to respond to initial half-dose vPDT.

METHODS

The full dose of verteporfin used in CSC was 6 mg/m2, which was used in patients with neovascular age-related macular degeneration. Laser fluence was 50 J/cm2 (irradiance, 600 mW/cm2, 83 s). There were 4 different dose groups in this study (100%, 70%, 50%, and 30%). The alterations were examined at 1 day, 1 week, and 1 month after vPDT using color fundus imaging, indocyanine green angiography, and histopathology analysis.

RESULTS

Various degrees of choroidal alterations were demonstrated at different dose groups. Examinations on day 1 showed that gradually reduced verteporfin dose tended to decrease photochemical reactions to the choroid in terms of the number of occlusion vessels and area of the lesion. After 1 month, choroid vessel alteration persisted in high-dose groups (100% and 70%); nevertheless, alterations of low-dose groups (50% and 30%) returned to normal.

CONCLUSIONS

vPDT can induce photochemical reactions of the choroid, high dose causes permanent change, and low dose causes recoverable change. The dose-dependent alterations need to be considered for the individual therapeutic plan according to the situation of a patient with CSC.

Comparison of half-dose versus half-fluence versus standard photodynamic therapy in chronic central serous chorioretinopathy

PURPOSE

To compare the efficacy and safety of half-dose vs. half-fluence vs. standard photodynamic therapy (PDT) in patients with chronic central serous chorioretinopathy (cCSC).

METHODS

This retrospective study included 64 eyes of 61 patients with cCSC who were treated with half-dose PDT (verteporfin 3 mg/m2 and light energy 50 J/cm2), half-fluence PDT (verteporfin 6 mg/m2 and light energy 25 J/cm2) or standard PDT (verteporfin 6 mg/m2 and light energy 50 J/cm2). The complete resorption of subretinal fluid (SRF) and changes of best corrected visual acuity (BCVA) and central retinal thickness (CRT) over the follow-up period were also assessed.

RESULTS

Fifteen eyes (65.2 %) in the half-dose PDT group, 12 eyes (80 %) in the half-fluence PDT group, and 20 eyes (76.9 %) in the standard PDT group showed complete resolution of SRF. There were no statistically significant differences in the mean BCVA improvement, CRT and SRF height reduction, number of PDT sessions, complete success, and recurrence rates between groups (p > 0.05). None of the eyes with intact EZ showed failure. There were positive correlations between higher mean CRT values of the last visit, 1st, 3rd, 6th months and failure. None of the treated eyes (0%) developed any systemic or local adverse events.

CONCLUSION

Half-dose, half-fluence or standard PDTs are all effective and safe treatment choices in cCSC with similar BCVA improvements and CRT reductions. The higher mean CRT values of the follow-up period were correlated with failure, and in eyes with intact EZ showed no failure.

Retinal Diseases that Can Masquerade as Neurological Causes of Vision Loss

PURPOSE OF REVIEW

This review aims to discuss retinal diseases that may masquerade as neurological causes of vision loss and highlights modern ophthalmic ancillary testing that can help to establish these diagnoses.

RECENT FINDINGS

Retinal diseases with signs and symptoms overlapping with neurological causes of vision loss include central serous chorioretinopathy, retinal ischemia, acute macular neuroretinopathy, Acute zonal occult outer retinopathy (AZOOR) complex diseases, paraneoplastic retinopathy, retinal dystrophy, and toxic retinopathy. Diagnosis is facilitated by electrophysiologic studies and multimodal ophthalmic imaging including optical coherence tomography and fundus autofluorescence imaging. Looking into the future, translation of adaptive optics ophthalmoscopy into clinical practice may facilitate early detection of microscopic retinal abnormalities that characterize these conditions. With conventional methods of physical examination, diagnosis of retinal diseases that may masquerade as neurological causes of vision loss can be challenging. Current advance in multimodal ophthalmic imaging along with electrophysiologic studies enhances the provider's ability to make early diagnosis and monitor progression of these conditions.

Update on the management of chronic central serous chorioretinopathy

Central serous chorioretinopathy (CSC) is one of the main causes of impaired visual acuity in patients younger than 60 years. Its pathophysiology remains partially unknown, although it has been postulated that choroidal hyper-permeability may be involved. This typically produces a neurosensory retinal detachment and/or a detachment of the retinal pigment epithelium in the posterior pole. Although acute CSC generally does not require treatment, when chronic it must be treated to avoid visual impairment. With the development of new imaging techniques, there has been an improvement in diagnosis, and different therapeutic strategies have been proposed. Various treatments for the management of chronic CSC have currently been shown to be useful to improve or stabilise visual acuity, the resolution of subretinal fluid, and to prevent recurrences. The most commonly used treatments today are photodynamic therapy, micropulse subthreshold laser, mineralocorticoid antagonists, or anti-vascular endothelial growth factor drugs. There are also other proposals and new treatments being developed, with promising results. This review aims to provide the reader with an overview of the current scientific evidence of the different treatment options available for CSC in order to help decision-making in clinical practice.