To evaluate the short-term safety and efficacy of intravitreal bevacizumab for the treatment of intraretinal or subretinal fluid accumulation secondary to central serous chorioretinopathy (CSC).
Prospective interventional series non-comparative study.
Department of Ophthalmology, Al-Minya University Faculty of Medicine, Egypt.
The study included 20 eyes of 20 patients with central serous chorioretinopathy (CSC), Out of them 10 eyes with acute CSC (group I), 6 eyes with chronic CSC (defined as symptoms present for longer than 6 months) and four eyes with recurrent (defined as more than one episode of the disease) chronic and recurrent cases are considered in one group (group II), all patients were injected with intravitreal Avastin (IVA) 1.25 mg (0.05 mL) of commercially available bevacizumab [Avastin; Genentech, Inc., San Francisco, CA] as a primary treatment. At baseline and follow up visits patients had best corrected visual acuity (BCVA), IOP assessment, dilated fundus examination, fundus photography, fluorescein angiography (FA) and optical coherence tomography (OCT) imaging is used for measurement of central retinal thickness (CRT). Main outcome measures were the resolution of neurosensory detachment, improvement in visual symptoms and visual acuity, and resolution of leakage in FA. Secondary outcome and measures were the need for re-injection and the adverse effects. The mean number of injections was 2 (range 1–3 injections) 6–8 weeks intervals and follow up for 6 months (range 5–7 months). All finding at baseline and each follow up visit were reported and compared.
The mean age of all patients was 40.3 years ± 6.5 (range 25–50 years), 15 males and five females patients. In acute CSC group, the mean baseline BCVA was 20/60 (log MAR 0.48) and improved to 20/30 (log MAR 0.18) with statistically significance difference change (P < 0.003) and in (chronic and recurrent group), the mean baseline VA was 20/80 (log MAR 0.60) and improved to 20/40 (log MAR 0.30) with statistically significance difference change (P < 0.002). The mean baseline CRT for all patients was 486 ± 86 μm (range, 386–580), decreased to 316 ± 56 μm (range, 276–368) after 1 months with statistically significance difference change (P < 0.02) and to 272 ± 52 μm (range 220–338) at last follow up with statistically significance difference change from the baseline (P < 0.001).
Intravitreal Avastin (IVA) injection was associated with visual improvement and reduced neurosensory detachment without adverse events in patients with CSC. Although these results are promising, further randomized controlled studies would be helpful to understand this therapy for patients with CSC.
Central serous chorioretinopathy; Avastin (bevacizumab); FA; OCT; Intravitreal injection
Central serous chorioretinopathy (CSC) has been traditionally treated with laser photocoagulation. We thought that transpupillary thermotherapy (TTT) utilizing a lower temperature than that of conventional laser photocoagulation might minimize permanent retinal and choroidal damage. Studies suggest that undesirable effects on vision due to TTT are minimal even if it is applied to foveal and/or parafoveal lesions when TTT requires a larger irradiation spot. The aim of this study was to evaluate the efficacy of TTT in the management of atypical CSC.
We defined atypical CSC as bullous retinal detachment with diffuse or several leakages, severe leakage with fibrin formation under serous retinal detachment, or leakage within a pigment epithelium detachment. Eight consecutive patients with atypical CSC underwent visual acuity testing, ophthalmic examination, color photography, fluorescein angiography, and optical coherence tomography to evaluate the results of transpupillary thermotherapy. Retreatment of atypical CSC was based on ophthalmic examination, optical coherence tomography, and fluorescein angiography. TTT was performed on the leaking spots shown in fluorescein angiography, with a power of 50–250 mW, spot size of 500–1200 μm, and exposure time of 13–60 seconds to minimize retinal damage.
In five of eight affected eyes, serous detachments completely resolved within 1 month after the initial TTT. One eye had persistent subretinal fluid and required a second TTT treatment. Two eyes showed no resolution of CSC and were treated by conventional photocoagulation. Initial best-corrected visual acuity (BCVA) ranged from 20/600 to 20/20 (mean, 20/40; median, 20/30). Final BCVA ranged from 20/200 to 20/20 (mean, 20/25; median, 20/20). BCVA improved in all cases. Only two eyes with persistent subretinal fibrin and existing retinal pigment epithelial alternations in macular area showed limited improvement of BCVA despite the absence of subretinal exudation. The presence of retinal attachment was confirmed by optical coherence tomography in six eyes (75%).
TTT seems to be effective for the treatment of atypical CSC in the short term. Additional studies are necessary to evaluate the long-term effectiveness and safety.
transpupillary thermotherapy; central serous chorioretinopathy; optical coherence tomography; fluorescein angiography; serous detachment
To evaluate the efficacy and safety of fluorescein angiography (FA)-guided photodynamic therapy (PDT) for the treatment of severe chronic central serous chorioretinopathy (CSC).
Patients presenting with chronic CSC with multiple areas of retinal pigment epithelium decompensation, with or without focal leaks, were treated with FA-guided full-fluence PDT. Best-corrected visual acuity (BCVA), optical coherence tomography (OCT), FA, indocyanine green angiography, and fundus autofluorescence were used to determine functional and anatomic outcomes.
Twenty-one eyes (17 patients) were treated with PDT and followed for a median of 24 months (range, 12–73). In fourteen eyes (66.66%), two PDT spots were performed within the same session. In three eyes (14.28%), three PDT spots were performed, in two eyes (9.52%) four spots, and in two eyes (9.52%) five spots. In 17 eyes (80.95%), the leakage in FA and the subretinal fluid in OCT disappeared after only one session of PDT. In four eyes (19.05%), a second session – with only one spot – of PDT was required due to persistent or recurrent leakage and subfoveal SRF. Median BCVA improved significantly from 20/63 at baseline to 20/40 at 3 months (P = 0.0002) and 20/32 at 6 months (P < 0.0001), and remained improved until the last examination (20/25, P < 0.0001). Two patients complained of a transient central scotoma after the treatment.
FA-guided full-fluence PDT with multiple PDT spots within the same session seems to be effective and safe for the treatment of chronic CSC cases with multiple areas of retinal pigment epithelium decompensation.
central serous chorioretinopathy; photodynamic therapy
Fluorescein angiography (FA) is the more common investigation performed for macular diseases.1 Frozen FA pictures are obtained but direct visualisation of the kinetics of FA is possible only once, by the investigator. The kinetics of FA examination is imagined from static FA pictures based on our experience.23 We evaluated a new software that re‐create automatic pseudo‐movie from static pictures, in order to share the visualisation of dye leakage.
EyeToolkit software (EDC Lamy EyeToolkit software, EDC LAMY, Carvin, France) performs an automatic and rapid overlay (0.5 to 3 seconds) from the different angiographic frames. Five images from the same examination, from early to late phase, are required to generate a movie. The resulting movies could be seen either with the EyeToolkit software or be exported to video format. We submitted a minimum of six images issued from printed photographs or any digital instrument (Topcon retinal camera, TRC‐50, Topcon, Tokyo, Japan; Heidelberg Retina Angiograph, HRA 2, Heidelberg Engineering, Heidelberg, Germany), to the EyeToolkit software: sequences of fluorescein angiograms of patients harbouring various patterns of exudative age‐related macular degeneration (AMD), with or without treatment, were selected in order to visualise active leakage of dye and to differentiate it from staining. In addition, we submitted to the EyeToolkit software images issued from one single FA examination (early phase to 10′) in case of central serous chorioretinopathy (CSC), in order to see the kinetics of the leakage and to visualise leakage of dye from active areas of CSC.
We evaluated two kinds of leakage: chorio‐retinal leakage from choroidal new vessels (CNVs) due to AMD, and retinal leakage from active areas of CSC. In exudative AMD patients, the rapid overlay (<10”) applied in a movie mode obviously demonstrated the progressive enlargement of the hyperfluorescence, materialising the leakage of fluorescein from CNVs. The FA movies generated with EyeToolkit permitted to clearly see the active leakage from a newly diagnosed classic CNV (Video 1), and from a newly diagnosed minimally classic CNV (Video 2). Moreover, the FA movies generated with EyeToolkit permitted to easily detect the minimal leakage from a still active classic choroidal neovascularisation previously treated by photodynamic therapy (PDT) (Video 3), and to visualise the filling of the vascularised pigment epithelium detachment from an occult choroidal neovascularisation previously treated by PDT (Video 4). In CSC, the FA movies generated with EyeToolkit permitted to see the kinetics of the classic smokestack‐type leakage (Video 5) and to easily visualise leakage of dye from active areas of CSC (Video 6). EyeToolkit software is a new automatic and efficient tool for a rapid overlay of images, obtaining an angiographic movie from any image. It leads to easy visualisation of leakage from CNVs and from active areas of CSC; thus, owing to the easy differentiation of active leakage from staining, EyeToolkit software would seem particularly helpful for the decision of treatment and re‐treatment. Easy visibility of the kinetics of the dye in angiography, in a movie mode, also represents a useful approach for teaching. Based on this preliminary analysis, this software can be considered for (1) recreating pseudo‐kinetics of dye in retinal angiography, (2) easy sharing of retinal angiograhy; voice comments can be included within the file, and (3) teaching and e‐learning. The comparative evaluation of the generated movies versus classic angiographic pictures must validate its use for diagnosis and indications of treatment.
See online video reports
To view the full report and accompanying video please go to: http://bjo.bmj.com/cgi/content/full/91/12/1685/DC1
All videos from the BJO video report collection are available from: http://bjo.bmj.com/video/collection.dtl
To evaluate the treatment of central serous chorioretinopathy (CSC) with either subthreshold diode laser MicroPulse (SDM) or intravitreal bevacizumab (BCZ).
This comparative, controlled, prospective study conducted over a period of 10 months examined 52 eyes of 52 patients with (a) treatment with SDM at the active leakage site guided by fluorescein angiography (FA) (n=16 eyes), (b) intravitreal injection of 1.25 mg BCZ (n=10 eyes), or (c) observation (n=26 eyes). Outcome measures included changes in retinal pigment epithelium (RPE) leakage at FA, central macular thickness (CMT), best-corrected visual acuity (BCVA), and 10° macular perimetry.
At the end of the study, there was 12.5% persistent leakage in the SDM, compared with 60% in the BCZ and 92% in the control group. Mean CMT decreased by 94 μm in the SDM, 38 μm in the BCZ, and did not change in the control group. Mean BCVA improved more than 6 early treatment of diabetic retinopathy study letters in the SDM, decreased by one letter in the BCZ, and by two letters in the control group. In the SDM group, mean perimetric deficit improved by 1.5 decibels and corrected lost variance by 2.6. In the BCZ, it improved by 0.6, and in the control group by 0.5. Retreatment was required in 7/16 eyes of the SDM group (43.75%), and in 5/10 eyes of the BCZ group (50%).
SDM photocoagulation was superior to intravitreal injections of 1.25 mg BCZ in the treatment of CSC, which resulted in enhanced visual acuity and macular perimetry.
central serous chorioretinopathy; micropulse laser, subthreshold photocoagulation; bevacizumab
Background: Central serous chorioretinopathy is an idiopathic disorder that leads to serous neurosensory retinal detachment. The disorder is usually self-limited and resolves spontaneously; however, sometimes neurosensory retinal detachment persists. This form of the disorder is called chronic central serous chorioretinopathy (CCSC).
Objective: The aim of this study was to assess the effects of photodynamic therapy (PDT) on visual acuity with full-dose verteporfin for CCSC.
Methods: The eyes of patients with CCSC were included in the study. Ophthalmic examination including best-corrected visual acuity (BCVA), fundus examination, fluorescein angiography, and optical coherence tomography was performed before treatment and at 1, 3, 6, 9, and 12 months. PDT with full-dose verteporfin (6 μ/m2 of body surface area) was applied only to areas of active leakage. BCVA was converted to a log of the minimum angle of resolution (logMAR) equivalent for statistical analysis. Central foveal thickness and BCVA between baseline and follow-up were compared.
Results: Seventeen eyes of 16 patients (13 males, 3 females; mean [SD] age, 39.75 [7.51] years; mean duration of follow-up, 13.06 [1.82] months) were used in the study. The mean (SEM) logMAR BCVA was 0.26 (0.07) at baseline and 0.04 (0.02) at 12 months. Mean logMAR BCVA values at baseline (0.259) and after treatment (0.112, 0.053, 0.047, 0.041, and 0.041 at 1, 3, 6, 9, and 12 months, respectively) differed significantly (P = 0.006, P = 0.005, P = 0.005, P = 0.005, and P = 0.005). There was a significant difference in the mean central foveal thickness at the final visit (169 μm) compared with the baseline value (383 μm; P < 0.001). BCVA decreased in one eye (20/20 vs 20/25) and persisted during follow-up; in the other 16 eyes, BCVA either increased (n = 10) or remained stable (n = 6).
Conclusions: In this small, open-label study, patients with CCSC treated with a single course of PDT with full-dose verteporfin had significant improvement from baseline in BCVA and resolution of subretinal fluid accumulation and active leakage. Treatment was generally well tolerated, but one patient had worsening in BCVA.
central serous chorioretinopathy; photodynamic therapy; optical coherence tomography; verteporfin
Aims: To evaluate the changes in the choroidal vasculature in central serous chorioretinopathy (CSC) after photodynamic therapy (PDT) with verteporfin and to assess its potential role as a treatment option.
Methods: A prospective, non-comparative, interventional study was performed in eyes with persistent CSC or chronic CSC that had fluorescein leakage at the fovea. All eyes received one single session of PDT with verteporfin (6 mg/m2 body surface area) followed by application of 50 J/cm2 laser at 689 nm. The laser spot size was guided by findings in ICG-A.
Results: Six eyes from six patients with a mean follow up of 12.7 months were analysed. Narrowing of the original dilated choroidal vessels and decrease in extravascular leakage could be demonstrated in all (100%) PDT treated eyes. 3 months after PDT, the mean diameter of the dilated choroidal vessel reduced from 546 μm to 371 μm (p = 0.028). Five (83%) patients had improvement in visual symptoms and best corrected visual acuity. Fluorescence leakage stopped at the 1 month follow up in five eyes (83%) and at 3 months in all six eyes (100%). One eye developed choroidal neovascularisation at 3 month follow up. There was no other serious ocular or systemic complication.
Conclusions: PDT is successful in stopping the fluorescein leakage in all six patients without recurrence of CSC. The ICG-A findings of choroidal vascular remodelling and decreased choroidal permeability after PDT are encouraging. As the sample size is small and the mean follow up period is short, further trials of PDT with verteporfin for CSC are required to address the optimal parameters in ensuring longer term safety and efficacy outcome.
choroidal vascular remodelling; indocyanine green; photodynamic therapy; central serous chorioretinopathy
To evaluate photoreceptor disruption in patients with central serous chorioretinopathy (CSC) treated by half-dose photodynamic therapy (PDT).
A total of 29 patients with symptomatic CSC were recruited and underwent half-dose verteporfin PDT covering the leakage sites as observed via fundus fluorescein angiography. The primary outcome was the percentage of patients with the presence of photoreceptor disruption, and the secondary outcome was the correlation between photoreceptor disruption and visual results at the 1-year follow-up.
Photoreceptor disruption was identified in 13 eyes (44.8%) 12 months after treatment. Twenty-seven patients experienced best-corrected visual acuity (BCVA) improvement after PDT, while two patients showed stable BCVA. The mean BCVA in patients with photoreceptor disruption at the baseline and every follow-up visit was significantly lower than that of patients without photoreceptor disruption. However, there was no correlation between the presence or absence of photoreceptor disruption and the improvement of visual acuity because the BCVA gain at the last follow-up visit between the two groups was not significant (P = 0.69). No potential ocular complication was encountered in the study.
Photoreceptor disruption was found in about 45% of CSC patients treated by PDT, which ultimately resulted in poor visual outcomes. However, a half-dose PDT might not affect or modify the photoreceptor function because it gave the same pattern of visual recovery in patients with and without photoreceptor cell loss.
photoreceptor disruption; central serous chorioretinopathy; photodynamic therapy
To compare the efficacy of low-fluence photodynamic therapy (PDT) and PDT with half-dose verteporfin in chronic central serous chorioretinopathy (CSC).
Patients and methods
The medical records of 64 eyes from 60 patients with chronic CSC were retrospectively reviewed; 36 eyes received low-fluence PDT (25 J/cm2) and 28 eyes received half-dose verteporfin PDT (3 mg/m2). The primary outcome measure was the proportion of eyes with complete resolution of subretinal fluid. Secondary outcome measures were the changes in best corrected visual acuity (BCVA) and central foveal thickness, and the proportion of eyes that showed an increase of ≥5 letters in BCVA at the last visit.
The mean follow-up period was 12.5±4.3 months and 13.1±4 months in the low-fluence group and half-dose group, respectively (P=0.568). Thirty-three eyes (91.6%) in the low-fluence group and 26 eyes (92.8%) in the half-dose verteporfin group showed complete resolution of subretinal fluid (P=0.703). BCVA increased by a mean of 7.4 letters and 4.8 letters in the low-fluence group and half-dose group, respectively (P=0.336). Seventeen eyes (52.8%) in the low-fluence group and 14 eyes (50%) in the half-dose group experienced a gain of ≥5 letters in BCVA (P=0.825). In the low-fluence and half-dose verteporfin group, the mean baseline central foveal thickness was 351±90 μm and 341±96 μm, and significantly decreased to 188±61 μm and 181±47 μm, respectively (P<0.01).
Both treatments resulted in complete subretinal fluid resolution in most of the eyes, with significantly better visual acuity outcomes compared to baseline at the last visit.
low-fluence; half-dose verteporfin; photodynamic therapy; central serous chorioretinopathy
To evaluate the effect of intravitreal bevacizumab injection (IVBI) in acute central serous chorioretinopathy (CSC) patients.
Patients with acute CSC received IVBI (1.25 mg/0.05 mL) or observation by randomization. Twelve eyes in each group completed 6 months of regular follow-up and were ultimately included in this study. Each patient was assessed using best corrected visual acuity measurements, fluorescein angiography, and optical coherence tomography at baseline and had regular follow-ups after treatment.
All patients showed improvements in visual acuity and fluorescein angiographic leakage and had resolution of their neurosensory detachment following treatment. There were no significant differences in visual acuity, central retinal thickness, or remission duration between the IVBI group and the control group at baseline or after treatment (p>0.05).
Intravitreal bevacizumab showed no positive effect in acute CSC patients compared to the observation group, and there were no adverse effects of treatment. Further investigation will be helpful to understand this therapy in patients with CSC.
Bevacizumab; Central serous chorioretinopathy; Randomized comparison; Therapeutics
To evaluate the efficacy and safety of photodynamic therapy (PDT) with half-dose verteporfin in patients with chronic central serous chorioretinopathy (CCSC) and retinal functional changes, by functional acuity contrast test (FACT).
In this study, 27 eyes of 24 patients with CCSC were treated with PDT with half-dose verteporfin. Best-corrected visual acuity (BCVA), central foveal thickness (CFT) and resolution of subretinal fluid on optical coherence tomography (OCT), and leakage on fluorescein angiography (FA) and indocyanine green angiography (ICGA) were assessed. Contrast sensitivity test was performed at baseline and at 12th month for investigating retinal functional changes.
The mean follow-up period was 25.33±11.08 months. The mean age was 43.7±8.6 years. Seventeen patients were male (70.8%) and seven patients were female (29.2%). Post PDT at 1st, 3rd, 6th, 12th month and at last follow-up, BCVA were significantly improved compared with the baseline BCVA (P<0.001), and CFT post PDT were significantly thinner than the baseline measurement (P<0.001). There was significant difference between pre- and post-PDT 12th month contrast sensitivities at all five different spatial frequency channels (P<0.01).
Half-dose PDT is an effective and safe method in the treatment of CCSC with anatomical and functional success. The measurement of contrast sensitivity by FACT can be useful for evaluating the functional effectiveness of half-dose PDT for CCSC.
central serous chorioretinopathy; photodynamic therapy; verteporfin; contrast sensitivity; functional acuity contrast test (FACT)
To prospectively compare the effects of half-dose verteporfin (3 mg/m2) photodynamic therapy (1/2 PDT) with those of one-third-dose verteporfin (2 mg/m2) PDT (1/3 PDT) for chronic central serous chorioretinopathy (CSC).
Sixteen eyes of 16 consecutive patients with chronic CSC were enrolled and followed up for a 3-month study period. The first 10 patients received 1/2 PDT and the next 6 patients received 1/3 PDT. The resolution rate of subretinal fluid (SRF) was compared between the two groups. The changes in the choroidal thickness inside and outside the PDT-applied area in both groups were also evaluated.
SRF disappeared in all eyes (100%) in the 1/2 PDT group and in two eyes (33%) in the 1/3 PDT group. In the 1/2 PDT group, choroidal thickness inside and outside the PDT-applied area reduced significantly from the baseline (inside, from 387±24 to 325±25 μm; outside, from 292±25 to 249±19 μm; both P=0.005). In the 1/3 PDT group, choroidal thickness decreased in two eyes where SRF disappeared (inside, 87.2 and 90.9% of the baseline; outside, 91.4 and 92.6% of the baseline), but did not change in the other four eyes where SRF remained (inside, 104.1, 100.0, 105.1, and 100.5% of the baseline; outside, 98.9, 103.0, 100.0, and 99.0% of the baseline).
1/2 PDT is more effective than 1/3 PDT in the resolution of SRF for chronic CSC. Decrease in the choroidal thickness after PDT may be related to the resolution of SRF in chronic CSC.
central serous chorioretinopathy; photodynamic therapy; verteporfin; choroidal thickness; subretinal fluid; choroidal vein
The purpose of this study is to determine the efficacy of half-fluence photodynamic therapy (PDT) depending on the degree of hyperfluorescence based on indocyanine green angiography (ICGA) for treatment of chronic central serous chorioretinopathy (CSC).
We conducted a prospective study of 30 eyes of 30 patients with chronic CSC. Half-fluence PDT (25 J/cm2 for 83 s) with ICGA guidance was applied to the area of choroidal hyperpermeability. The baseline middle-phase ICGA findings were classified as intense or weak hyperfluorescence depending on the degree of hyperpermeability from choriocapillaris. Changes in mean best-corrected visual acuity, resolution of subretinal fluid, recurrence rate, and complications were compared between the two groups.
The baseline ICGA findings showed intense hyperfluorescence in 16 eyes (53.3%) and weak hyperfluorescence in 14 eyes (46.7%). Subretinal fluid showed complete resolution in both the groups 1 month after a single application of half-fluence PDT. Recurrence of subretinal fluid was observed in one of 14 eyes (7.1%) with weak hyperfluorescence and in no eyes (0%) with intense hyperfluorescence. No statistically significant difference in the rate of recurrence was observed between the two groups.
Half-fluence PDT appears to be an effective and safe treatment option for patients with chronic CSC regardless of the degree of hyperfluorescence based on ICGA. According to these findings, choroidal hyperpermeability, rather than dysfunction of retinal pigment epithelium, might be more important as primary pathogenesis of chronic CSC.
chronic central serous chorioretinopathy; choroidal hyperpermeability; indocyanine green angiography; photodynamic therapy
This study had been performed to investigate the anatomic and functional outcomes of nepafenac 0.1% therapy in acute central serous chorioretinopathy (CSC). The medical records of 30 patients with acute CSC were reviewed for a total of 31 eye charts. Seventeen eye records of 16 patients who were treated with topical nepafenac 0.1% three times daily for four weeks and continued until complete resolution of subretinal fluid were appraised. Fourteen patients with acute CSC (a total of 14 eye records) who did not receive treatment served as the control group also had been recorded. The proportion of eyes with complete resolution of subretinal fluid, serial changes in the mean best corrected visual acuity (BCVA), and the mean central foveal thickness (CFT) at 6 months of therapy were the outcomes measured. Mean age was 42.6±8.2 years in the treatment group and 41.1±7.1 years in the control group (p=0.85). At 6 months, 14 eyes (82.3%) in the treatment group and 6 eyes (42.8%) in the control group revealed a complete resolution in the subretinal fluid (p=0.02). In the treatment group, mean BCVA (LogMAR) significantly improved from 0.19±0.17 at baseline to 0.09±0.12 at 6 months (p=0.01). In the control group, mean BCVA (LogMAR) was 0.13±0.14 at baseline and decreased to 0.1±0.11 at 6 months (p=0.28). In the treatment group, mean CFT was 349±115 µm at baseline and significantly improved to 221±95 µm at 6 months (p<0.01). In the control group, mean CFT declined from 391±138 µm at baseline to 301±125 µm at 6 months (p=0.06). No treatment-related ocular or systemic side effects were observed. In conclusion, nepafenac 0.1% has the potential to treatment acute CSC. Further trials are warranted to study its safety and efficacy for this disease.
Topical Nepafenac; Acute Central Serous Chorioretinopathy; Central Foveal Thickness; Visual Acuity; LogMAR; Subretinal Fluid
To assess the change in subfoveal choroidal thickness (SFCT) in central serous chorioretinopathy (CSC) following spontaneous resolution and low-fluence photodynamic therapy (PDT) using the enhanced depth imaging optical coherence tomography (EDI-OCT).
A total of 36 consecutive eyes of 36 patients were included in this retrospective study: 16 eyes with spontaneously resolved CSC and 20 eyes with PDT-treated CSC. Best-corrected visual acuity and SFCT were evaluated at each visit until complete absorption of the subretinal fluid. SFCT of 32 normal subjects were also measured, as the control group. Wilcoxon's singed-rank test was used to evaluate the effects of spontaneous resolution and PDT. To compare the SFCT of the eyes with resolved CSC with that of the normal eyes, Mann–Whitney U-test with Bonferroni correction was also employed.
SFCT of patients was 459.16±77.50 μm at the baseline, and decreased to 419.31±54.49μm after a spontaneous resolution (P=0.015). However, SFCT was not normalized in comparison with that of the normal subjects (P<0.001). SFCT in PDT group was also reduced from 416.43±74.01 to 349.50±88.99 μm (P<0.001), with no significant difference with the normal value (P=0.087).
SFCT in patients with CSC decreased both after spontaneous resolution and low-fluence PDT. However, only in the PDT group, after disappearance of subretinal fluid, did it decrease to that of normal subjects.
choroidal thickness; enhanced depth imaging optical coherence tomography; low-fluence photodynamic therapy; spontaneously resolved CSC
To report a case of subretinal leakage after focal laser treatment for idiopathic central serous chorioretinopathy (ICSC). This rare complication was successfully treated with photodynamic therapy (PDT).
Interventional case report.
A 36-year-old male presented with ICSC in his right eye. After a period of observation without resolution, he was treated with focal laser. That treatment resulted in a massive exacerbation of his subretinal fluid. PDT was successfully used to treat the severe exacerbation with rapid resolution of the subretinal fluid, improvement in visual acuity, decreased leakage on fluorescein angiography, and reduction of subretinal fluid on ophthalmoscopic exam and by optical coherence tomography.
Ophthalmologists should consider the use of PDT in cases where focal laser causes an exacerbation of subretinal fluid in ICSC.
Idiopathic central serous chorioretinopathy; focal laser; photodynamic therapy.
To evaluate short term safety of an enhanced photodynamic therapy (PDT) protocol with half dose verteporfin for treating chronic central serous chorioretinopathy (CSC).
20 eyes of 18 patients with symptomatic chronic CSC underwent PDT using 3 mg/m2 verteporfin. Verteporfin was infused over 8 minutes followed by indocyanine green angiography guided laser application 2 minutes later. Serial optical coherence tomography (OCT) and multifocal electroretinography (mfERG) recordings were performed before PDT, at 4 days, 2 weeks, and 1 month after PDT. The best corrected visual acuity (BCVA), OCT central retinal thickness, and mean mfERG response amplitudes and peak latencies were compared longitudinally. Subgroup analysis was further performed for eyes with or without pigment epithelial detachment (PED).
At 1 month after PDT, the median BCVA improved from 20/40 to 20/30 (p = 0.001). The mean central retinal thickness also reduced from 276 μm to 158 μm (p<0.001) and 17 (85%) eyes had complete resolution of serous retinal detachment and/or PED. MfERG showed no significant changes in the mean N1 and P1 response amplitude and latency for all eyes. Subgroup analysis demonstrated that eyes without PED had a significant increase in the mean central mfERG P1 response amplitude with reduction in P1 peak latency at 1 month post‐PDT. For eyes with PED, transient reduction in the mean central P1 response amplitude was observed at 4 days post‐PDT.
The modified safety enhanced PDT protocol with half dose verteporfin appeared to be a beneficial treatment option for patients with chronic CSC, especially in eyes without serous PED. Further controlled study is warranted to demonstrate the long term safety and efficacy of this treatment option.
central serous chorioretinopathy; photodynamic therapy; verteporfin; multifocal electroretinography; optical coherence tomography
To evaluate the safety and efficacy of finasteride, an inhibitor of dihyroxytestosterone (DHT) synthesis, in the treatment of chronic central serous chorioretinopathy (CSC).
Five patients with chronic CSC were prospectively enrolled in this pilot study. Patients were administered finasteride (5mg) daily for 3 months, following which study medication was withheld and patients were observed for 3 months. Main outcome measures included best-corrected visual acuity (BCVA), center-subfield macular thickness and subretinal fluid volume as assessed by optical coherence tomography (OCT). Serum DHT, serum testosterone, and urinary cortisol were also measured.
There was no change in mean BCVA. Mean center-subfield macular thickness and subretinal fluid volume reached a nadir at 3 months, and rose to levels that were below baseline by 6 months. The changes in both OCT parameters paralleled changes in serum DHT level. In four patients, center-subfield macular thickness and/or subretinal fluid volume increased following discontinuation of finasteride. In the remaining patient, both OCT parameters normalized with finasteride and remained stable when the study medication was discontinued.
Finasteride may represent a novel medical treatment for chronic CSC. Larger controlled clinical trials are needed to further assess the efficacy of finasteride for the treatment of CSC.
Pilot study to evaluate finasteride for treatment of chronic central serous chorioretinopathy suggests efficacy and tolerability.
Finasteride; Chronic Central Serous Chorioretinopathy; Retina; Optical Coherence Tomography
Central serous chorioretinopathy (CSC) is characterized by leakage of fluid from the choroid into the subretinal space and, consequently, loss of central vision. The disease is triggered by endogenous and exogenous corticosteroid imbalance and psychosocial stress and is much more prevalent in men. We studied the association of genetic variation in 44 genes from stress response and corticosteroid metabolism pathways with the CSC phenotype in two independent cohorts of 400 CSC cases and 1,400 matched controls. The expression of cadherin 5 (CDH5), the major cell–cell adhesion molecule in vascular endothelium, was downregulated by corticosteroids which may increase permeability of choroidal vasculature, leading to fluid leakage under the retina. We found a significant association of four common CDH5 SNPs with CSC in male patients in both cohorts. Two common intronic variants, rs7499886:A>G and rs1073584:C>T, exhibit strongly significant associations with CSC; P = 0.00012; odds ratio (OR) = 1.5; 95%CI [1.2;1.8], and P = 0.0014; OR = 0.70; 95%CI [0.57;0.87], respectively. A common haplotype was present in 25.4% male CSC cases and in 35.8% controls (P = 0.0002; OR = 0.61, 95% CI [0.47–0.79]). We propose that genetically predetermined variation in CDH5, when combined with triggering events such as corticosteroid treatment or severe hormonal imbalance, underlie a substantial proportion of CSC in the male population.
CDH5; Cadherin 5; central serous chorioretinopathy; genetic association; retinal disease
The authors report a case of a 46-year-old Hispanic male with central serous chorioretinopathy (CSC) following blunt trauma to the left eye. The patient presented with a complaint of throbbing headache and blurry vision in left eye. The patient was diagnosed with diabetes mellitus 1 year previous to the event. On examination, uncorrected visual acuity was 20/20 OD, 20/200 OS. No anisocoria or afferent pupillary defect was present. Intraocular pressure was normal. Subconjunctival haemorrhage and lid ecchymosis were present in OS and fundus examination showed serous macular detachment and central retinal pigment epithelium detachment, and no evidence of diabetic retinopathy. Optical coherence tomography OS showed subretinal fluid and fluorescein angiography demonstrated the typical ‘smokestack’ pattern of leakage into the subretinal space. The patient received observational therapy for 4 months and the CSC spontaneously resolved with visual acuity of 20/20 in left eye.
To investigate morphologic changes of acute central serous chorioretinopathy (CSC) using spectral domain optical coherence tomography (SD-OCT) and confocal scanning laser ophthalmoscopy.
This retrospective study included 63 eyes of 63 patients with unilateral acute CSC. All patients underwent simultaneous SD-OCT and fluorescein angiography examination using Spectralis HRA+OCT.
The external limiting membrane could be seen on SD-OCT, although the junction between photoreceptor inner and outer segments (IS/OS) was not detected in all eyes with retinal detachment (RD). However, IS/OS became visible after resolution of serous RD in 51 eyes (81.0%). SD-OCT images at the leakage sites showed a bump of retinal pigment epithelium (RPE) in in 47 cases (68.1%) and pigment epithelial detachment (PED) in 22 of 69 leakage sites (31.9%). In 14 of 69 leakage sites (20.3%), highly reflective areas suggesting fibrinous exudate were observed in the subretinal space. In nine leakage sites (13.0%), sagging or dipping of the posterior retinal layer was seen. Abnormal RPE changes such as RPE bump and PED were observed in 12 of 22 fellow eyes (54.5%).
A variety of morphologic changes could be identified on SD-OCT, and those findings may contribute more information to our understanding of the pathophysiology of CSC.
Central serous chorioretinopathy; Fluorescein angiography; Indocyanine green angiography; Leakage site; Spectral domain optical coherence tomography
Purpose. To describe topographical changes in choroidal thickness as measured by optical coherence tomography following photodynamic therapy (PDT) for central serous chorioretinopathy (CSC). Methods. Case report. Results. By 1 month following PDT, mean (SD) choroidal thickness decreased from 562 microns (24) to 424 microns (27) (P < 0.01) at 3 mm temporal to fovea, 483 microns (9) to 341 microns (21) (P < 0.01) at 1.5 mm temporal to fovea, 576 microns (52) to 370 microns (81) (P < 0.01) under the fovea, 442 microns (30) to 331 microns (54) (P < 0.04) at 1.5 mm nasal to fovea, and 274 microns (39) to 171 microns (17) (P < 0.01) at 3 mm nasal to fovea. The Location of greatest choroidal thickness (648 microns) prior to treatment was at point of leakage on fluorescein angiogram (FA). This region decreased to 504 microns following treatment. Conclusion. A decrease in choroidal thickness can be seen following PDT for CSC as far as 3 mm temporal and 3 mm nasal to fovea. The Location of greatest choroidal thickness may be at point of leakage on FA.
Purpose. To analyze microstructural changes in the external limiting membrane (ELM) and photoreceptor layer before and after early and late conventional laser treatment in central serous chorioretinopathy (CSC) in 12 months follow-up study. Methods. A retrospective observational study included Group A: 19 patients (19 eyes) with symptomatic acute CSC and Group B: 16 patients (16 eyes) with symptomatic chronic CSC. Retinal microstructural changes were analyzed with SD-OCT paying a particular role in examining the photoreceptor layer and ELM. Results. The length of the photoreceptors, prior to treatment, was approximately 84 μm in Group A and 82,5 μm in Group B. Twelve months after laser treatment, photoreceptor length was approximately 49 μm in Group A and 43 μm (range 20–55 μm) in Group B. No patients in Group A had noticeable photoreceptor defects nor ELM defects, but in 15 eyes in Group B photoreceptor and ELM defects were detected (P < 0.0001). Conclusions. When analyzing the photoreceptor layer and ELM during active CSC, it is not possible to evaluate any irreversible changes which have already occurred in this layer. Damage to the photoreceptor layer and ELM in patients with chronic CSC was only found after laser treatment and the absorption of subretinal fluid.
Background. To describe the standard autofluorescence (FAF), the near infrared autofluorescence (NIA) and optical coherence tomography (OCT) patterns in central serous chorioretinopathy, correlating them with fluorescein angiography. Methods. Cross-sectional observational study, in which patients with at least seven months of CSC underwent ophthalmologic examination, fundus photography, FAF, NIA, fluorescein angiography (FA), and spectral-domain OCT. Results. Seventeen eyes of thirteen patients were included. The presentation features were a mottled hyperFAF in the detached area and areas with pigment mottling. NIA images showed areas of hyperNIA similar to FAF and localized areas of hypoNIA, which correlated with the points of leakage in the FA. OCT showed pigment epithelium detachment at the location of these hypoNIA spots. Discussion. FAF showed increased presence of fluorophores in the area of retinal detachment, which is believed to appear secondary to lipofuscin accumulation in the RPE or the presence of debris in the subretinal fluid. NIA has been related to the choroidal melanin content and there were areas of both increased and decreased NIA, which could be explained by damage ahead the retina, basically RPE and choroid. These findings, along with the PEDs found in the areas of hypoNIA, support the notion of a primary choroidal disease in CSC.
To report a case of bilateral bullous exudative retinal detachment in central serous chorioretinopathy (CSC) which was attached by vitrectomy and internal drainage of the subretinal fluid.
A 47-year-old man affected by bilateral atypical CSC with a bullous retinal detachment with subretinal exudate. A fluorescein angiogram (FAG) showed multiple points of leakage and staining of subretinal fibrosis. A tentative diagnosis of Vogt-Koyanagi-Harada (VKH) syndrome was made and the patient was treated with systemic corticosteroids and immunosuppressive agents. However, the subretinal fluid was not absorbed. He was then treated with vitrectomy and internal drainage of subretinal fluid.
The retina was attached successfully in both eyes. Visual acuity improved to 20/50 in his left eye but did not improve in the right eye due to subretinal fibrotic scarring and atropic changes on the macula.
Our case suggests that the surgical management of bullous exudative retinal detachment is safe and necessary.
Bullous retinal detachment; Central serous chorioretinopathy; Subretinal fluid drainage; Vitrectomy