Felice Cardillo Piccolino

Photodynamic Therapy for Chronic Central Serous Chorioretinopathy

Purpose To determine whether photodynamic therapy (PDT) is effective for treatment of chronic central serous chorioretinopathy (CSC). Methods Sixteen eyes with chronic CSC and macular detachment documented by optical coherence tomography (OCT) received PDT guided by indocyanine green (ICG) angiography according to the parameters outlined in the TAP Study. One or more laser spots were applied to the areas of choroidal vascular hyperpermeability that corresponded to retinal pigment epithelium decompensation. Patients were observed for 6 to 12 months. Two PDT sessions 1 month apart were performed on 2 eyes. Examinations included visual acuity measurement, fundus biomicroscopy, fluorescein and ICG angiography, and OCT. Results Macular exudation resolved completely in 13 eyes (81%) and partially regressed in 3. Choriocapillaris hypoperfusion was shown by ICG angiography for several months at the site of PDT application. Visual acuity improved 1 to 4 lines in 11 eyes and was unchanged in 5 eyes. Conclusions ICG-guided PDT performed according to the parameters outlined by the TAP Study seems effective for treating chronic CSC. Further studies are needed to verify treatment safety and the time and rate of recurrences.

CENTRAL SEROUS CHORIORETINOPATHY AND INDOCYANINE GREEN ANGIOGRAPHY

Background: Because of limitations in imaging through the retinal pigment epithelium (RPE), fluorescein angiography has not been able to characterize the choroidal abnormalities that are thought to be causative factors in central serous chorioretinopathy (CSC). Methods: Digital indocyanine green (ICG) videoangiography and fluorescein angiography were performed in 34 consecutive patients with various forms of CSC to investigate choroidal abnormalities. Results: The ICG videoangiographic studies revealed choroidal staining in association with active, spontaneously resolved, and previously photocoagulated pigment epithelial leaks documented with fluorescein angiography. In the space of a few minutes, the dye progressively spread outward from the region of choroidal staining. Conclusion: Localized hyperpermeability of the choriocapillaris, probably associated with segmental choroidal hyperperfusion, may be a causative factor of characteristic RPE and neurosensory retinal exudative changes in CSC.

Indocyanine green angiography of circumscribed choroidal hemangiomas.

Background Indocyanine green (ICG) angiography performed with the modern high resolution digital systems already has improved our knowledge of several chorioretinal disorders. It could provide new information on circumscribed choroidal hemangiomas. Methods Twelve consecutive patients with circumscribed choroidal hemangioma underwent both fluorescein angiography and ICG angiography with a digital high resolution system. In each patient, two ICG angiograms were taken—with normal and with artificially increased intraocular pressure. The latter method allowed analysis of the vascular connections of the tumor with the adjacent choroid during the induced slowdown of blood flow. Results With ICG, the authors obtained a clear delineation of the choroidal hemangiomas. In all cases, the lesion was better defined on the ICG than on the fluorescein angiogram. Nutrient and draining vessels of the tumors were identified. Nutrient vessels were represented by short posterior ciliary arteries in five eyes with severe exudative syndrome, and by ramifications of choroidal arteries in the other cases. Further special ICG findings were apparent choroidal ischemia downstream from the tumor (9 eyes), and clearing of the dye with a “washout” phenomenon. Conclusion Indocyanine green angiography can be helpful in the clinical evaluation of circumscribed choroidal hemangiomas. The blood supply to these tumors is provided directly by short posterior ciliary arteries or by ramifications of choroidal arteries. An adjacent compromised choroidal perfusion may be present.

Posterior cystoid retinal degeneration in central serous chorioretinopathy.

Purpose: To study the pattern of cystoid retinal changes in the posterior fundi of eyes with chronic central serous chorioretinopathy (CSC) using optical coherence tomography (OCT). Methods: We retrospectively studied 34 eyes with chronic CSC and cystoid retinal changes at the posterior pole documented by OCT. We analyzed the distribution of cystoid retinal changes with respect to the fovea and chorioretinal lesions. Results: Generally, cystoid retinal changes occurred in the papillomacular region (21 eyes); foveal involvement was observed in 20 eyes. Large cystoid changes in the central macula with concentric perifoveal lesion extension were detected in three eyes. Cystoid changes tended to occur where the retina adhered to subretinal fibrosis, large laser scars, or spontaneous atrophy of the retinal pigment epithelium and the choroid. Visual acuity ranged from 20/20 to 20/400. In nine eyes in which the cystoid changes spared the foveal center, visual acuity was 20/40 or better. Conclusion: Cystoid retinal degeneration in eyes with chronic CSC was distributed outside of the fovea and was not necessarily associated with severely reduced visual acuity. “Posterior cystoid retinal degeneration” defines this pathologic pattern appropriately. OCT findings suggest that intraretinal exudation and cystoid changes in chronic CSC develop through the formation of chorioretinal adherences.

LASER TREATMENT OF ECCENTRIC LEAKS IN CENTRAL SEROUS CHORIORETINOPATHY RESULTING IN DISAPPEARANCE OF UNTREATED JUXTAFOVEAL LEAKS

In central serous chorioretinopathy (CSCR) laser treatment of leaking points close to the macular center should be avoided because of the possibility of producing juxtafoveal scotoma and stimulating choroidal neovascularization. Nine eyes of nine consecutive patients with CSCR had two or more leaking points within a macular detachment, one of which was foveal or near to the fovea. Photocoagulation with green argon laser was performed in all eyes, treating all the leaking points except for the central one. Visual symptoms regressed after treatment, and the serous detachment was resolved 10 days to 4 weeks after photocoagulation in all cases. Fluorescein angiography showed no leakage at either the central leakage point or the leakage point that had been treated. These results led us to believe that the central or dependent leak in our cases was not sufficient to maintain the serous detachment by itself. An alternative hypothesis is that the untreated leak did not represent real fluid movement but only diffusion of fluorescein molecules, or a false leak. In cases of CSCR with multiple leaks within a single macular detachment, we believe that a foveal leak may be a dependent or false leak and that direct treatment is not necessary.

Risk factors for posterior cystoid retinal degeneration in central serous chorioretinopathy.

Purpose: To identify factors associated with the development of posterior cystoid retinal degeneration (PCRD) in central serous chorioretinopathy (CSC). Methods: The authors retrospectively studied 51 eyes of 51 patients with chronic CSC and subretinal or intraretinal exudation documented by optical coherence tomography (OCT), and evaluated the association of hypertension, systemic use of corticosteroids, duration of symptoms, subretinal fibrosis, and large laser scars with the development of PCRD. Results: Twenty-four eyes (47%) had PCRD and 27 eyes (53%) had serous macular detachment without cystoid retinal changes. Multivariate analysis showed that a duration of symptoms exceeding 5 years (odds ratio [OR], 25.4; 95% confidence interval [CI], 2.8–233.2; P = 0.004) and subretinal fibrosis (OR, 19.1; 95% CI, 1.8–205.1; P = 0.015) were significantly associated with PCRD. Conclusion: Disease duration longer than 5 years and subretinal fibrosis are associated with the development of PCRD in CSC. Prospective evaluations could substantiate the associations found in this study and further clarify their significance.

Retinal pigment epithelium and macular diseases

Preface. 1: RPE and Bruchs Membrane: Functions/Ageing. 2: RPE Cells Proliferation and Transplantation. 3: Fundus Imaging - Instrumentation. 4: Choroidal Disorders. 5: Central Serous Chorioretinopathy and Other Maculopathies. 6: Age-Related Maculopathy: Drusen. 7: Age-Related Maculopathy: Choroidal Neovascularization. 8: Diabetes - Retinal Vascular Disorders. 9: Macular Surgery.

Optical coherence tomography angiography in age-related macular degeneration: The game changer:

Optical coherence tomography angiography is one of the biggest advances in ophthalmic imaging. It enables a depth-resolved assessment of the retinal and choroidal blood flow, far exceeding the levels of detail commonly obtained with dye angiographies. One of the first applications of optical coherence tomography angiography was in detecting the presence of choroidal neovascularization in age-related macular degeneration and establishing its position in relation to the retinal pigmented epithelium and Bruch’s membrane, and thereby classifying the CNV as type 1, type 2, type 3, or mixed lesions. Optical coherence tomography angiograms, due to the longer wavelength used by optical coherence tomography, showed a more distinct choroidal neovascularization vascular pattern than fluorescein angiography, since there is less suffering from light scattering or is less obscured by overlying subretinal hemorrhages or exudation. Qualitative and quantitative assessments of optical coherence tomography angiography findings in exudative and nonexudative age-related macular degeneration have been largely investigated within the past 3 years both in clinical and experimental settings. This review constitutes an up-to-date of all the potential applications of optical coherence tomography angiography in age-related macular degeneration in order to better understand how to translate its theoretical usefulness into the current clinical practice.

Choroidal Vascular Reactivity in Central Serous Chorioretinopathy

Purpose To investigate by optical coherence tomography angiography (OCT-A) the choroidal vascular response to experimentally increased blood pressure in patients with central serous chorioretinopathy (CSCR). Methods For this multicenter, observational, case-control study, we enrolled 35 patients with an established diagnose of CSCR and 25 age-matched healthy controls. All subjects underwent a handgrip isometric exercise to obtain elevation of blood pressure (BP). In the resting phase and during the physical effort, macular OCT-angiograms were acquired. Systemic hemodynamic data were recorded at baseline and during stress conditions using an electronic sphygmomanometer. The analysis of vascular density (VD) of the choriocapillaris (CC) was performed on OCT-angiograms. The results obtained in CSCR patients, both at baseline and during the stress test, were compared with those of healthy subjects. Results Baseline and under stress values of systolic BP, diastolic BP, and mean arterial pressure were significantly higher (P < 0.05) in CSCR patients compared to controls, reaching values in the range of hypertension during the exercise. Baseline VD values of the CC were significantly lower (P < 0.05) in CSCR cases compared to healthy subjects. We noticed a significant increase (P < 0.05) in these values under stress condition in CSCR patients and not in controls. Conclusions The present study suggests that choroidal blood flow is dysregulated in CSCR. During physical stress, CSCR patients easily reach critical values of BP that are not dampened by compensatory mechanisms in the choroidal vessels, as it happens in healthy subjects. The CC in CSCR could be particularly vulnerable to variations of systemic hemodynamics.