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Photodynamic Therapy and Central Serous Chorioretinopathy

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Abstract

Central serous chorioretinopathy is a common acquired maculopathy. Multiple studies showed that photodynamic therapy is useful treatment for acute and chronic central serous chorioretinopathy. The exact mechanism of photodynamic therapy in treating central serous chorioretinopathy is not clear, but it is thought to be caused by short-term choriocapillaris hypoperfusion and long-term choroidal vascular remodeling, leading to a reduction in choroidal congestion, vascular hyperpermeability and extravascular leakage. Furthermore, photodynamic therapy seems to be an effective means of improving or stabilizing visual acuity in patients with central serous chorioretinopathy.
Hypothesis
Medical Hypothesis, Discovery & I
nnovation
Ophthalmology Journal
Photodynamic Therapy and Central Serous Chorioretinopathy
Lina Siaudvytyte, Vaida Diliene, Goda Miniauskiene, Vilma Jurate Balciuniene
Eye Clinic, Lithuanian University of Health Sciences, Kaunas, Lithuania
ABSTRACT
Central serous chorioretinopathy is a common acquired maculopathy. Multiple studies showed that
photodynamic therapy is useful treatment for acute and chronic central serous chorioretinopathy. The
exact mechanism of photodynamic therapy in treating central serous chorioretinopathy is not clear, but it is
thought to be caused by short-term choriocapillaris hypoperfusion and long-term choroidal vascular
remodeling, leading to a reduction in choroidal congestion, vascular hyperpermeability and extravascular
leakage. Furthermore, photodynamic therapy seems to be an effective means of improving or stabilizing
visual acuity in patients with central serous chorioretinopathy.
KEY WORDS
Central serous chorioretinopathy; Photodynamic therapy; Pathophysiology
©2012, Medical Hypothesis, Discovery & Innovation (MEHDI) Ophthalmology Journal.
All rights reserved.
Correspondence to:
Dr. Vilma Jurate Balciuniene, Eye Clinic, Lithuanian University of Health Sciences, Kaunas, Lithuania, Tel/Fax: +370 37 326635,
E-mail: jurate.balciuniene@kaunoklinikos.lt
INTRODUCTION
Central serous chorioretinopathy (CSC) is characterized by a
serous detachment of the neurosensory retina in the macular
region, occasionally associated with detachment of the retinal
pigment epithelium (RPE). The most surprising aspect of the
disease is the relative preservation of retinal function
regardless prolonged separation from the RPE. Males are
mostly affected to have this condition and the average age is
between 20 and 50 years. The usual presenting symptoms are
significant loss of visual acuity and development of permanent
visual loss. Visual impairment is secondary to persistent serous
detachments of the neurosensory retina leading to cystoid
edema of the retina and diffuses decompensation of the RPE
[1]. The photoreceptors might have a critical role in this
process, because they are separated from their source of
nutrients when the retina is detached [2]. Some patients,
particularly older adults, can develop choroidal
neovascularization, which leads to severe visual loss [3].
The pathogenesis of CSC is still not completely understood.
However, it is well known that the subneural retinal fluid
originates from the choroid. At first it was believed that fluid
from the choroid drain away into subretinal space through
defects in tight junctions between the RPE cells due to
breakdown of the blood-retinal barrier. However, this theory
does not explain the beneficial effect of laser photocoagulation
which consequences in permanent RPE barrier breakdown.
Another theory suggested that lost of normal RPE cells polarity
acts as a trigger for fluid pumping from the choroid to the
retina, causing a neurosensory detachment [4]. This theory was
failed after increased using of indocyanine green angiography
(ICGA) which reveals multifocal areas of choroidal vascular
hyperpermeability in CSC, which leads to mechanical disruption
of RPE barrier with subsequent accumulation of subretinal fluid,
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supporting the theory that the underlying pathophysiology is at
the choroidal level [5,6]. No new vessels are usually present in
CSC, but the defect seems to affect choroidal vessels. Any
therapy that decreases the excess of choroidal permeability
may be potentially helpful in CSC cases [7].
Therefore recent studies examining the pathogenesis of CSC
support the hypothesis that RPE decompensation may be a
result of underlying choroidal vasculature hyperpermeability [8-
11]. Some authors reported that choroidal vascular
hyperpermeability was seen in most symptomatic eyes with
CSC [4,6]. Prunte et al. showed delayed choroidal capillary
lobular filling in areas of hyperpermeability and proposed that
localized capillary and venous congestion in the affected
lobules impaired the circulation, produced ischemia, and
allowed increased choroidal exudation and a focally
hyperpermeable choroid [12]. Increased choroidal permeability
along with local high perfusion and increased hydrostatic
pressure allows profusion choroidal fluid to accumulate and
produces a RPE detachment. As the detachment grows, the
target junctions between RPE cells are broken, and a focal
defect of the blood-retinal barrier develops, later resulting in
neural retinal detachment [13-14]. Some investigators revealed
that subfoveal choroid in the eyes with CSC, even in the fellow
eyes are thicker than that in normal eyes because of choroidal
vascular hyperpermeability [9,15]. They used optical coherence
tomography (OCT) to evaluate choroidal hyperpermeability by
measuring choroidal thickness. Interestingly, recent studies
reveal that corticosteroids can influence the production of the
nitric oxide, prostaglandins and free radicals within the
choroidal circulation. All three substances participate in the
autoregulation of blood flow within the choroid [16].
The treatment of central serous chorioretinopathy has not
been well-established. Different therapeutic approaches have
been tried to manage this condition, including beta-blockers,
acetazolamide, vitamins and non-steroidal anti-inflammatory
drugs, but none of these had explicit benefits [17]. In past
decades, argon laser photocoagulation of extrafoveal leakage
points was the standard of CSC treatment [18,19]. It is the only
therapy proved beneficial by large clinical trials. Laser
treatment induces a local inflammatory reaction on RPE, thus
decreasing RPE leakage while choroidal hyperpermeability
remain unchanged [20]. The evidence of long follow-up studies
shows a reduction of serous detachment with lack of
improvement in final visual acuity or a reduction in the
incidence of recurrences [21-23]. Laser photocoagulation
cannot be performed in the foveal avascular zone. Laser
therapy may result adverse effects such as secondary choroidal
neovascularization or central scotomas [24-26].
Another treatment option is photodynamic therapy (PDT). PDT
originally was intended to cause regression of choroidal
neovascularization (CNV) secondary to age related macular
degeneration and recently is used for neovascular age-related
macular degeneration, pathologic myopia and ocular
histoplasmosis caused CNV treatment. The exact mechanism of
PDT on CSC is not well-known. It has been suggested that PDT
may induce choriocapillaris damage and vascular remodeling
thus decreasing choroidal hyperpermeability [12,27-32].
Maruko et al. using enhanced depth imaging OCT, reported
reduced choroidal thickness 1 month after PDT treatment in
chronic CSC patients [20]. These findings are compatible with
ICGA showing a transitory hypoperfusion [11]. Another authors
hypothesized that PDT acts by both decreasing choroidal
hyperpermeability and tightening the blood retinal barrier at
the level of the RPE resulting in resolution of subretinal fluid
[1].
Patients with chronic forms of CSC may benefit from a
decreased choroidal vascular permeability. Some authors
suggest that verteporfin may show a high affinity for RPE [1,33].
Verteporfin is a benzoporphyrin derivate which is used as a
photo sensitizer for PDT to eliminate the abnormal blood
vessels in the eye. It is known that the primary effect of PDT
seems to be damage of the choriocapillaris endothelium,
swelling, fragmentation, detachment from its basement
membrane and degeneration [31]. Another possible
explanation for the positive effects of this therapy concerns the
inflammatory reaction precipitated by PDT. Verteporfin may be
deposited within the serous fluid under the macula and its
activation may release free radicals and pro-inflammatory
factors that induce a permanent adhesion between the
neurosensory retina and RPE. This mechanism may explain the
occurrence of inflammatory changes in the RPE [7]. Otherwise
the vascular endothelial damage known to be the major
hallmark of photodynamic tissue effects is induced by direct
interaction of singlet oxygen with the lipids of the endothelial
cytoplasmic membranes. Recanalization of the choriocapillaris
begins to occur within a short interval after doses of therapy.
Maintenance of structural integrity histologically of the
overlying photoreceptors seems to be the result of limited
hypoxia or thermally enhanced phototoxic damage [31].
Histologic studies on animal models and humans have shown
that PDT induces the regression of subretinal newly formed
vessesls as well as obliteration of the vessels of the inner
choriocapillaris [32].
The standard regime for using PDT is to give patient
intravenous verteporfin at a dose of 6 mg/m2 over 10 minutes.
Then, 5 minutes later, diode laser at a wavelength of 600-689
nm and energy of 50 mJ/cm2 over 83 seconds is directed to the
target lesion of the eye. Possible ocular side effects include RPE
atrophy and rips, secondary choroidal neovascularization, and
ischemia of choriocapillaris. To minimize adverse events,
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PHOTO DYNAMIC THERAP Y AND CENT RAL SEROU S CHOR IORE TINOP ATHY
research has targeted half-dose half fluence and minimal-
fluence PDT [35]. Half-dose or low-fluence PDT with verteporfin
is effective in inducing reabsorption of subretinal or intraretinal
fluid with some beneficial visual outcomes in the majority of
patients with CSC [33,45].
PDT is not completely harmless to ocular structures [20,30-
32,36-40]. Choriocapillaris thrombosis and choroidal perfusion
and permeability changes have been demonstrated. These
reports show no early neural retina or RPE changes with
standard verteporfin doses [30,31]. Some studies showed that
standard dose PDT might be associated with choriocapillaris
hypoperfusion that may result in decreased vision [41]. In
recent years, several different studies have supported the good
results of PDT with standard doses of verteporfin to treat
chronic CSC [7,33,35-47]. However, these studies were
performed with a small number of patients and short follow-up.
In order to avoid PDT related complications half-dose or low-
fluence PDT has been suggested by different authors. Higher
selectivity of the choriocapillaris was achieved with a lower
fluence PDT, while higher fluence emission resulted in closure
of the deeper choroidal vessels and focal alterations in the RPE.
PDT has shown better results on visual acuity and anatomical
outcome compared with photocoagulation in chronic forms of
CSC, with fewer complications [1,7,45-47,49-53]. Changes in the
average neural retina thickness of eyes treated by PDT could be
supported by the long-standing effects of vascular remodeling
in the underlying choroid [20,30]. Photodynamic therapy with
verteporfin might induce temporary choriocapillaris occlusion
and endothelial changes, this might reduce the vascular
permeability and decrease fluid passage toward the retina
[45,49]. Moreover, RPE cells damaged by light-activated
verteporfin might be replaced by new ones possible recovery
from the metabolic impairment at the RPE level [34,49].
HYPOTHESIS
Clinical and experimental evidence indicates that besides
closing the neovascular membrane this treatment also
produces ischemia of the underlying choriocapillaris, induced
by direct action on the choriocapillaris endothelium with
choriocapillaris occlusion and resulting in hypoperfusion of the
choriocapillaris in the short term and remodeling of choroidal
vascular over time. This effect of PDT on the choroid could be
used to reduce choroidal congestion and vascular
hyperpermeability, which is an important factor in CSC
pathogenesis.
CONCLUSION
PDT seems to be an effective therapy of improving or stabilizing
visual acuity in patients with central serous chorioretinopathy.
However, more studies are needed to manifest the benefits,
efficacy and long-term safety of PDT in the treatment of CSC..
DISCLOSURE
The authors report no conflicts of interest in this work.
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... [6] Verteporfin photodynamic therapy (PDT) is employed in acute CSC and chronic patients for resolution of fluid as well as to prevent relapses but can have side effects such as choroidal ischemia, RPE atrophy and development of choroidal neovascular membrane (CNVM). [7,8] Subthreshold micropulse laser (577 nm) has been recently introduced as an effective management strategy in patients with CSC involving the center of macula as it does not cause significant retinal damage. [9] Multiple studies have shown the efficacy of SML in patients with CSC, but none have clearly defined the standard protocol for performing SML in patients with non-resolving CSC. ...
... In group A, CMT was 349. 8 In group A, CSC in 5 out of 10 patients resolved. In group B, CSC in 9 out of 13 patients resolved. ...
Article
Purpose: To study the effect of subthreshold micropulse yellow laser treatment on central serous chorioretinopathy (CSC) and to compare two laser protocols. As per our knowledge, there are no studies comparing the two protocols of subthreshold laser. Methods: Twenty-three patients with non-resolving CSC of at least three months duration were treated with subthreshold laser (577 nm). Ten patients were treated with 5% duty cycle (group A) and 13 patients with 10% duty cycle (group B). At one month, best corrected visual acuity (BCVA), central macular thickness (CMT), subretinal fluid (SRF), choroidal thickness (CT) and choroidal vascularity index (CVI) were evaluated. Results: In group A, BCVA improved from 0.508 ± 504 to 0.174 ± 0.171 (P = 0.0058), CMT improved from 349.8 ± 168.9 micrometers (μm) to 183.3 ± 70.312 μm (P = 0.0093) and SRF reduced from 202.4 ± 158.024 to 43.8 ± 46.599 μm (P = 0.0069). In group B, BCVA improved from 0.437 ± 0.426 to 0.289 ± 0.470 (P = 0.0026), CMT improved from 280.846 ± 72.668 to 196.769 ± 72.62 μm (P = 0.0002) and SRF reduced from 110.385 ± 57.687 μm to 52.538 ± 52.111 μm (P = 0.0064). No significant difference was found in BCVA and CMT between the groups (P = 0.8716 and P = 0.8523, respectively). CSC completely resolved in 50% of cases in group A and in 69.2% of cases in group B. This difference was not statistically significant (0.423); however, the odds ratio of resolution was 2.25 times more with 10% duty cycle. No change was observed on fundus autofluorescence (FAF) following laser. Conclusion: Subthreshold micropulse laser can lead to resolution of SRF in 60.87% of cases (groups A and B combined). Ten per cent duty cycle had higher odds of resolution without causing any RPE damage.
... However, occurrence of irreversible damage still remains a concern. Studies reported the possibility of choriocapillaris hypoperfusion and resultant decreased vision with PDT 15 . Bearing this in mind, the chances of complications would increase with the application of higher laser energy by including more extensive areas in PDT. ...
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To compare the functional and anatomical outcome of fluorescein angiography (FA) versus indocyanine green angiography (ICGA) guided photodynamic therapy (PDT) in the treatment of non-resolving central serous chorioretinopathy (CSCR). In this prospective interventional case series, all patients with non-resolving CSCR, defined as persistent SRF involving subfoveal area for at least three months, were nonrandomly assigned to receive either FA or ICGA-guided half dose PDT. Baseline and 4 months post-treatment data including best corrected visual acuity (BCVA), the status of foveal subretinal fluid, subfoveal choroidal thickness, choroidal vascularity index, pigment epithelial detachment area, treatment and PDT spot numbers were collected. Thirty-six eyes were included; 24 received ICGA-guided and 12 received FA-guided PDT. Overall, improvement in BCVA and choroidal parameters were observed in all patients. There was no significant difference in baseline parameters as well as follow-up measurements between groups. However, the mean total energy dose and spot number in the IGCA-guided PDT were significantly higher than the FA-guided PDT group (P = 0.001). Both FA-guided and ICGA-guided half-dose PDT were effective in the treatment of non-resolving CSCR, with favorable functional and anatomical outcome. In FA group, PDT with smaller spot sizes and fewer numbers of spots were applied.
... Central serous chorioretinopathy (CSC) is characterized by a localized, serous detachment of the neurosensory retina in the macular region, and occasionally associated with detachment of the retinal pigment epithelium [137]. Although the exact mechanism of PDT on CSC is not well-known, PDT may decrease choroidal hyperpermeability by inducing choriocapillaris damage and vascular remodeling [138]. Van Dijk et al. performed a multicenter randomized controlled trial with verteporfin [139]. ...
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Phototherapy is widely applied to various human diseases. Nanomedicine-based phototherapy can be classified into photodynamic therapy (PDT) and photothermal therapy (PTT). Activated photosensitizer kills the target cells by generating radicals or reactive oxygen species in PDT while generating heat in PTT. Both PDT and PTT have been employed for treating various diseases, from preclinical to randomized controlled clinical trials. However, there are still hurdles to overcome before entering clinical practice. This review provides an overview of nanomedicine-based phototherapy, especially in non-oncologic diseases. Multiple clinical trials were undertaken to prove the therapeutic efficacy of PDT in dermatologic, ophthalmologic, cardiovascular, and dental diseases. Preclinical studies showed the feasibility of PDT in neurologic, gastrointestinal, respiratory, and musculoskeletal diseases. A few clinical studies of PTT were tried in atherosclerosis and dry eye syndrome. Although most studies have shown promising results, there have been limitations in specificity, targeting efficiency, and tissue penetration using phototherapy. Recently, nanomaterials have shown promising results to overcome these limitations. With advanced technology, nanomedicine-based phototherapy holds great potential for broader clinical practice.
... Furthermore, adrenomedullin is known to increase microvascular permeability [6], which induces CSC occurrence. The mechanism through which PDT affects CSC is thought to involve induction of choriocapillaris damage, short-term choriocapillaris hypoperfusion, and vascular remodeling, thus decreasing choroidal hyperpermeability [15]. Therefore, we suggest that short-term PDT can help repair the hyperpermeability of choroidal vessels, which may be influenced by different SNPs in the CFH gene. ...
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Purpose To evaluate the association between single nucleotide polymorphisms (SNPs) in the complement factor H (CFH) gene and response to PDT in patients with CSC. Methods 103 eyes from 93 patients with CSC were enrolled from Department of Ophthalmology of the People’s Hospital Peking University. Genotyping for selected SNPs in the CFH gene was performed, and multivariate linear analysis was used to identify factors influencing PDT treatment outcomes. Genetics associations between SNPs in the CFH gene and response to PDT in patients with CSC were analyzed. Results None of the seven SNPs examined in this study (rs800292, rs1061170, rs3753394, rs3753396, rs2284664, rs1329428, and rs1065489) showed significant associations with 1-month outcomes after PDT in patients with CSC (P > 0.05). Baseline BCVA changed at 1 month after PDT (P < 0.001), and baseline retinal thickness was associated with changes in retinal thickness at 1 month after PDT (P < 0.001). Age was significantly associated with resolution of SRF at 1 month after PDT (P = 0.004). Conclusions There were no significant associations between SNPs in the CFH gene and 1-month outcomes after PDT in patients with CSC. However, baseline BCVA, baseline retinal thickness, and age were significantly associated with response to PDT in patients with CSC. Larger studies with more power are necessary to further determine whether an association exists between SNPs in the CFH gene and PDT in patients with CSC.
... 7,8 Steroid use is believed to increase the permeability of choroid capillaries and RPE by inhibiting collagen synthesis and disrupting ion pump function. 9,10 Glucocorticoids are also known to alter blood-aqueous barrier permeability and disrupt the external blood-retinal barrier by increasing cAMP levels in RPE cells. 11 Steroids administered by various routes (oral, inhaled, intranasal, intravitreal, epidural) contribute to the development CSCR. ...
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Central serous chorioretinopathy (CSCR) is characterized by a well-defined serous choroidal detachment of the retinal pigment epithelium with one or more focal lesions of the neurosensory retina. Risk factors for CSCR are psychosocial stress, increased endogenous catecholamine, and increased endogenous cortisol. Systemic steroids can cause ocular side effects such as cataract development, increased intraocular pressure, and less frequently the development of CSCR, which can resolve spontaneously with close follow-up and simple treatment modification. CSCR should be considered in patients who complain of worsening vision under steroid treatment for pathologies requiring steroid therapy. In this study we present two patients, one man and one woman, who developed acute CSCR while under systemic steroid treatment for Behçet’s disease.
... Several compounds approved for treating neovasculariza- tion of the eye are on the market, including pegaptanib (Macugen, Eyetech Pharma- ceuticals/Pfizer), bevacizumab (Avastin, Genentech, Inc./Roche), and ranibizumab (Lucentis, Genentech/Novartis) [12]. In additional to targeting angiogenic mole- cules, clinical treatments such as laser coagulation and photodynamic therapy (PDT) have also been employed in targeting choroidal vascular permeability and edema [17,18]. ...
Chapter
Due to the fact that ~ 80% of all sensory input is received via the eyes, suffering from chronic retinal diseases that lead to blindness causes a significant decrease in the quality of life. In addition, retinal diseases are common in the elderly; developing pathological analyses and treatments for retinal diseases have become an urgent issue especially in superaging countries such as Japan. Although evaluation of drug candidates against retinal diseases has been done on animal models, serious concerns arise regarding the ethics and costs in addition to the limitations of translating data from animal models to clinical settings. Pathophysiology of neovascularization in diabetic retinopathy and age-related macular degeneration (AMD) is complicated due to various factors involved, which include but are not limited to aging, oxygen concentration, energy metabolism, pressure, blood flow, and genetics. For more reliable outcomes, it is essential to understand the pathological mechanisms of eye diseases. in vitro cell culture models, an alternative to animal models, enable investigations on specific molecule of interest and simply recapitulate complex and chronic conditions. Recently, studies on organ-on-a-chip for drug discovery have been extensively carried out. This chapter describes organ-on-a-chip approaches that target the retinal tissue particularly focusing on the blood-retinal barriers and related diseases.
... It has been postulated that steroids cause inhibition of collagen synthase, increased permeability of choroidal capillaries, and dysfunction of ionic pump in the retinal pigment epithelium [21,22] leading to the accumulation of subretinal fluid. Corticosteroids are known to stimulate release of catecholamines and also to potentiate their effects, which could potentially cause microcirculatory changes in the choroidal vasculature leading to CSC [23]. ...
Article
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Background To evaluate the retinal and choroidal alterations in steroid-associated central serous chorioretinopathy (CSC) in comparison to idiopathic CSC. Methods In this retrospective cohort study, swept source optical coherence tomography scans of eyes with steroid-associated CSC (group A) were compared with the same in idiopathic CSC (group B). The key features included central subfield retinal thickness, subfoveal choroidal thickness, subfoveal large choroidal vessel diameter, subretinal deposits, retinal pigment epithelial irregularities, double layer sign, hyperreflective dots, intraretinal fluid, and choroidal vascularity index (ratio of choroidal luminal area and total choroidal area, measured on a high definition horizontal 9 mm OCT B-scan. Results There were 20 eyes in group A and 30 in group B. Group A had a higher female proportion (60 vs. 16.67%; P < 0.01) and higher bilaterality (30 vs. 6.67%; P = 0.03). The height of neurosensory detachment was lower in group A (153.1 ± 175.70 µm vs. 312.9 ± 223.06 µm; P < 0.01). There was no significant difference in the prevalence of subretinal deposits, retinal pigment epithelial irregularities, pigment epithelial detachments, double layer sign, outer retinal layer disruption, and intraretinal fluid. Hyperreflective dots (HRDs) were less common in group A (15 vs. 46.67%; P = 0.03). The subfoveal choroidal thickness (P = 0.65) and subfoveal large choroidal vessel diameter (P = 0.78) were comparable. There was a trend towards a higher choroidal vascularity index (CVI) in group A (A: mean, 82%, 95% CI, 66–99%; B: mean, 58%, 95% CI, 57–59%; P = 0.10). Conclusion Steroid-associated CSC has a marginally higher CVI and less common association with HRDs as compared to idiopathic CSC.
Article
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Introduction Central serous chorioretinopathy (CSRC) is often related to systemic corticosteroids, widely used in clinical practice by internists. However, its prognosis is generally good but in some cases, it can lead to important functional visual alterations for patients, It is imperative to distinguish this pathology from other diseases involving retinal detachment. Especially when central serous chorioretinopathy and uveitis coexist, it is imperative to distinguish serous retinal detachment from an inflammatory flare, as the respective treatments may be radically different. Observation We report the case of central serous chorioretinopathy in patients taking systemic corticosteroids because of uveitis complicating Behçet's disease. They were diagnosed and managed in our multidisciplinary uveitis clinic. The clinical picture and the para-clinical work-up were in favor of a CRSC. The cessation of corticosteroid therapy after a rapid degression allowed a disappearance of the RSD with important functional improvement. Discussion CRSC is an ocular complication requiring the discontinuation of corticosteroids because of the risk of blindness. It would be due to the stimulation by corticoids of the mineral receptors present in the choroidal vessels, which leads to choroidal hyperpermeability causing a leakage point and a retinal detachment. Conclusion CRSC is a rare diagnosis, but due to its seriousness it should be kept in mind by rheumatologists in front of any decrease in visual acuity in a patient on corticosteroids
Article
Purpose To evaluate levels of plasma cerebellin, cortisol, adrenaline and noradrenaline in patients with central serous chorioretinopathy (CSC). Materials and Methods This prospective study included 30 patients diagnosed with acute CSC (Group 1) and a control group of 30 age-matched, healthy subjects without CSC (Group 2). Levels of plasma cerebellin, cortisol, adrenaline and noradrenaline were examined in blood samples taken after 8-12 hours of fasting. A value of p < 0.05 was considered statistically significant in the comparative analyses. Results The mean plasma cerebellin level was found to be 232.56 ± 113.28 pg/ml in Group 1 and 174.07 ± 82.04 pg/ml in Group 2 (p = 0.02). Mean plasma cortisol was 13.19 ± 3.87 μg/ml in Group 1 and 9.55 ± 2.92 μg/ml in Group 2 (p < 0.01). Mean plasma adrenaline was 60.62 ± 26.67 pg/ml in Group 1 and 46.17 ± 19.20 pg/ml in Group 2 (p = 0.03). Mean plasma noradrenaline was 206.66 ± 73.90 pg/ml in Group 1 and 149.96 ± 51.36 pg/ml in Group 2 (p < 0.01). Conclusion It can be concluded that increased cerebellin may have a role in the etiology of CSC by increasing catecholamine expression from the adrenal medulla and indirectly by increasing cortisol levels via a paracrine effect from the adrenal cortex.
Article
1. 1. The clinical and fluorescein funduscopic findings in 15 patients with the syndrome of idiopathic central serous choroidopathy are presented. 2. 2. Intravenous fluorescein funduscopy is of value in the diagnosis, evaluation and treatment of this syndrome. 3. 3. The results of photocoagulation of one patient with intractable central serous choroidopathy are presented. 4. 4. Evidence is presented that the serous detachment of the retinal pigment epithelium and retina in these patients is caused by one or more focal areas of abnormal capillary permeability in the underlying choriocapillaris. 5. 5. The etiology of this abnormal capillary permeability is unknown. 6. 6. Although the pathogenesis of idiopathic central serous choroidopathy may share some common denominators with that of juvenile and senile hemorrhagic disciform macular degeneration, the underlying causes of these diseases or syndromes are probably not identical.
Article
Objective: This study evaluated the effect of repeated photodynamic therapy (PDT) applications on normal primate retina and choroid using an intravenous infusion of liposomal benzoporphyrin derivative (verteporfin). Design: This was an experimental study in a primate model. ANIMALS/CONTROLS: Six cynomolgus monkeys were used as experimental subjects and one monkey was used as a control subject. Intervention: Three consecutive PDT treatments at 2-week intervals were applied over the center of the fovea or the optic nerve of each eye. Verteporfin was delivered by intravenous infusion at a dose of 6 mg/m2, 12 mg/m2, or 18 mg/m2. Laser irradiation was then applied using a diode laser (689 nm) with light doses and spot sizes kept constant. Main outcome measures: Findings were documented by fundus photography, fluorescein angiography, and light and electron microscopy. Results: A cumulative dose response was seen angiographically and histologically with more severe damage to the retina and choroid noted at higher dye doses. Photodynamic therapy applied to the macula using the 6-mg/m2 verteporfin dose showed recovery of choriocapillaris, with mild retinal pigment epithelium and outer photoreceptor damage at 6 weeks. At this dose, the optic nerve showed few focal sites of axon atrophy and capillary loss. Treatments over the macula using the 12-mg/m2 and 18-mg/m2 doses led to chronic absence of choriocapillaris and photoreceptors at 6 weeks. One of two optic nerves became atrophic after PDT applications using dye doses of 12 mg/m2, and both optic nerves became atrophic in the 18-mg/m2 dye dose group. Conclusion: Limited damage to the retina, choroid, and optic nerve was present in primates treated with multiple PDT sessions using 6 mg/m2 verteporfin with light doses and the timing of irradiation kept constant. However, PDT using higher dye doses of 12 mg/m2 and 18 mg/m2 led to significant chronic damage to the normal retina, choroid, and optic nerve.
Article
To describe the safety and efficacy of very minimal fluence photodynamic therapy (PDT) for chronic central serous chorioretinopathy (CSC). Retrospective case series. Five patients with chronic CSC. Two had previously failed alternative therapies, and one was taking concomitant corticosteroids. Patients were treated with very minimal fluence PDT (12 J/cm(2), 150 mW/cm(2), for 80 seconds). Median follow-up time after PDT was 100 days (range, 51 to 154). All patients experienced an improvement in visual acuity and symptoms, as well as complete resolution of subretinal fluid. Very minimal fluence PDT appears to be a safe and effective treatment for chronic CSC. Based on these preliminary findings, a randomized controlled trial is warranted.
Article
To retrospectively evaluate choroidal thickness 1 year after photodynamic therapy in eyes with central serous chorioretinopathy using optical coherence tomography. Central serous chorioretinopathy was diagnosed using fluorescein angiography, and indocyanine green angiography was used to evaluate choroidal vascular hyperpermeability. We measured the subfoveal choroidal thickness using enhanced depth imaging optical coherence tomography. Thirteen eyes (13 patients; average age, 56.8 years) with central serous chorioretinopathy were observed 1 year after half-dose photodynamic therapy with verteporfin. The mean subfoveal choroidal thickness decreased significantly from 397 ± 108 μm at baseline to 323 ± 120 μm at 1 month, 312 ± 117 μm at 3 months, 317 ± 117 μm at 6 months, and 321 ± 122 μm at 1 year (P < 0.01, for each comparison with baseline). However, the subfoveal choroid thickness significantly increased 2 days after photodynamic therapy to 441 ± 120 (P < 0.01) compared with baseline. Central serous chorioretinopathy did not recur in any patient. Indocyanine green angiography images at 3 months showed less choroidal vascular hyperpermeability compared with baseline. Half-dose photodynamic therapy for central serous chorioretinopathy resulted in thinner subfoveal choroidal thickness 1 month after treatment, decreased the choroidal vascular hyperpermeability, and maintained the remission for 1 year. Enhanced depth imaging optical coherence tomography was helpful for monitoring the pathophysiologic choroidal changes in central serous chorioretinopathy.
Article
To compare the efficacy and safety of half-fluence photodynamic therapy (PDT) and conventional PDT in chronic central serous chorioretinopathy. A multicenter retrospective comparison study. Retrospective review of 60 patients including 29 patients (34 eyes) who received half-fluence PDT and 31 patients (33 eyes) who received conventional PDT for the treatment of chronic central serous chorioretinopathy. Best-corrected visual acuity, central fovea retinal thickness and resolution of subretinal fluid on optical coherence tomography, and choroidal perfusion decrease on indocyanine green angiography were assessed. Choriocapillaris perfusion decrease was quantified as mean gray value ratio of treated and nontreated areas using commercial imaging software. Treatment success without recurrence was achieved in 32 of 34 eyes (94.1%) treated with half-fluence PDT and 33 of 33 eyes (100%) treated with conventional PDT (P = 0.493). There was no difference in final best-corrected visual acuity (logarithm of the minimal angle of resolution) between the 2 groups (0.17 ± 0.32 vs. 0.21 ± 0.39; P = 0.603). Choriocapillaris perfusion decrease quantified from post-PDT indocyanine green angiography was significantly more severe in the conventional PDT group (P = 0.006), and it showed a positive correlation with retinal thinning after PDT (R = 0.380; P < 0.001). Half-fluence PDT is as effective as conventional PDT, while minimizing the deleterious effect on choriocapillaris perfusion and retinal thickness.
Article
The purpose of this study was to evaluate the results of fluorescein angiography-guided photodynamic therapy with half-dose verteporfin in the treatment of chronic central serous chorioretinopathy with focal leakage areas. Eight cases with a history of central serous chorioretinopathy of ≥6 months were included. All eyes had one or more focal areas of active retinal pigment epithelial leak. Photodynamic therapy was applied with half-dose verteporfin (3 mg/m²), and the spot size was set limited to the area of active leakage shown on fluorescein angiography. The mean duration of the last central serous chorioretinopathy episode was 12.50 months. The mean best-corrected visual acuity improved from 20/122 to 20/60 the first month (P = 0.017) and to 20/55 the first year after treatment (P = 0.018). Seven eyes (87.5%) had improved vision 1 year after treatment, and 1 eye (12.5%) had stable vision with a mean number of 3.61 gained lines. The mean central macular thickness was reduced from 366 ± 95 μm to 217 ± 32 μm the first month (P = 0.006). Fluorescein angiography-guided photodynamic therapy with half-dose verteporfin seems to be a rational and effective alternative to other methods in the treatment of chronic central serous chorioretinopathy with focal leakage on fluorescein angiography.
Article
To evaluate the subfoveal choroidal thickness after treatment of central serous chorioretinopathy (CSC) visualized by enhanced depth imaging spectral-domain optical coherence tomography (EDI OCT) and indocyanine green angiography (ICGA). Retrospective, comparative series. Twenty patients (20 eyes). The subfoveal choroidal thickness and height of the serous retinal detachment before and after treatment was measured using EDI OCT. Areas of choroidal vascular hyperpermeability were visualized with ICGA. Eyes with classic CSC were treated with laser photocoagulation (LP), whereas eyes with chronic CSC, which are not amenable to LP, were treated with half-dose verteporfin photodynamic therapy (PDT). Change in choroidal thickness and height of the serous retinal detachment after treatment. There were 12 eyes in the LP group and 8 eyes in the PDT group. The serous subretinal fluid resolved in both groups after treatment. In the LP group, the mean choroidal thickness was 345+/-127 microm at baseline and 340+/-124 microm at 4 weeks, a difference that was not significant (P = 0.2). The mean choroidal thickness in the PDT group increased significantly from 389+/-106 microm at baseline to 462+/-124 microm (P = 0.008) by 2 days after treatment, and then reduced rapidly to 360+/-100 microm (P = 0.001) at 1 week and 330+/-103 microm (P<0.001) after 4 weeks as compared with baseline. Indocyanine green angiography showed decreased hyperpermeability in the PDT group after treatment. The subretinal fluid resolved in both disease groups; however, the choroidal thickness and hyperpermeability seen during ICGA was reduced after PDT. These findings suggest that PDT reduces the choroidal vascular hyperpermeability seen in CSC and may work by a different mechanism than LP.
Article
This study aimed to evaluate the efficacy of photodynamic therapy (PDT) in treating chronic central serous chorioretinopathy (CSC). We describe a non-randomized, multicentre, interventional case series. A total of 82 eyes of 72 patients with chronic CSC were treated by conventional PDT. LogMAR best corrected visual acuity (BCVA) (ETDRS charts) and central foveal thickness (CFT) measured by optical coherence tomography before and after PDT, number of PDT treatments and complications were used as outcome indicators. Mean follow-up was 12 +/- 10 months and mean age was 46 +/- 10 years. Mean logMAR BCVA changed from 0.53 (standard deviation [SD] 0.43) before PDT to 0.38 (SD 0.41) at 3 months and 0.48 (SD 0.50) at 6 months (p < 0.0001 and p = 0.007, respectively, Student's t-test for paired data). Mean BCVA at the end of follow-up was 0.37 (SD 0.45; p < 0.0001 from baseline). Macular detachment was resolved and subretinal fluid (SRF) disappeared in all cases. Central foveal thickness decreased from 325 microm (SD 95), to 229 microm (SD 70) at 1 month after PDT, 206 microm (SD 68) at 3 months, and 202 microm (SD 76) at 6 months (all p < 0.0001, Student's t-test for paired data). No cases developed severe visual loss or complications derived from PDT. Reactive retinal pigment epithelium hypertrophy appeared in nine cases after PDT. Photodynamic therapy with verteporfin may be useful in chronic CSC for improving BCVA and reducing SRF and CFT. Randomized studies with longer follow-up are needed to assess the real role of this treatment in chronic CSC.