A Randomized Pilot Study of Low-Fluence Photodynamic Therapy Versus Intravitreal Ranibizumab for Chronic Central Serous Chorioretinopathy

doi:10.1016/j.ajo.2011.04.008

American Journal of Ophthalmology

Volume 152, Issue 5, November 2011, Pages 784-792.e2

https://doi.org/10.1016/j.ajo.2011.04.008 Get rights and content

Purpose

To report 6-month outcomes of a prospective, randomized study comparing the efficacy and safety between low-fluence photodynamic therapy (PDT) and intravitreal injections of ranibizumab in the treatment of chronic central serous chorioretinopathy.

Design

Prospective, randomized, single-center pilot study.

Methods

Sixteen eyes with chronic central serous chorioretinopathy were randomized to receive either low-fluence PDT or intravitreal injections of ranibizumab: 8 eyes in the low-fluence PDT group and 8 in the ranibizumab group. Rescue treatment was considered if subretinal fluid was sustained after completion of primary treatment: low-fluence PDT for the ranibizumab group and ranibizumab injection for the low-fluence PDT group. Main outcome measures were excess foveal thickness, resolution of subretinal fluid, choroidal perfusion on indocyanine green angiography, and best-corrected visual acuity.

Results

At 3 months, the mean excess foveal thickness was reduced from 74.1 ± 56.0 μm to −35.4 ± 44.5 μm in the low-fluence PDT group (P = .017) and from 26.3 ± 50.6 μm to −23.1 ± 56.5 μm in the ranibizumab group (P = .058). After a single session of PDT, 6 eyes (75%) in the low-fluence PDT group achieved complete resolution of subretinal fluid and reduction of choroidal hyperpermeability, whereas 2 (25%) eyes in the ranibizumab group achieved this after consecutive ranibizumab injections. Four eyes (50%) in the ranibizumab group underwent additional low-fluence PDT and accomplished complete resolution. At 3 months, significant improvement of best-corrected visual acuity was not demonstrated in the low-fluence PDT group (P = .075), whereas it was observed in the ranibizumab group (P = .012). However, the tendency toward improvement of best-corrected visual acuity was not maintained.

Conclusions

In terms of anatomic outcomes, the effect of ranibizumab injections was not promising compared with that of low-fluence PDT.

Section snippets

Methods

This study was a prospective, randomized, pilot study performed at the Department of Ophthalmology of the Seoul National University Hospital.

Results

A total of 16 eyes of 15 patients were recruited in this study. The mean age was 48.9 ± 7.6 years (range, 35 to 65 years). Thirteen men and 2 women participated. The duration of symptoms ranged from 6 months to 6 years, with a mean of 28.9 ± 23.6 months. The mean logMAR BCVA was 0.34 ± 0.24, and the mean excess foveal thickness was 50.2 ± 57.2 μm (range, −30 to 180 μm) before treatment. At baseline, 2 eyes (12.5%) had macular pigment epithelial detachment. The study eyes were randomized into 2

Discussion

CSC is known as a benign and self-limited disease that shows spontaneous resolution of serous neurosensory detachment.²⁸ Although a high rate of spontaneous remission favors conservative management, treatment should be considered in the condition including chronic CSC with persistent subfoveal fluid, which may result in permanent deterioration of functional and anatomic outcomes.29, 30 However, this study has a limitation in assessing the effect of treatment in CSC compared with conservative

Jang Won Heo, MD, received his medical degree from Dong-A University College of Medicine, Busan, Korea in 1995. He completed retina fellowship in Seoul National University Hospital, Seoul, Korea in 2002. He is currently an Assistant Professor at the Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea. His research interests include various vitreoretinal diseases, including uveitis.

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Cited by (79)

Comparing interventions for chronic central serous chorioretinopathy: A network meta-analysis
2023, Survey of Ophthalmology
We compare efficacy of treatments for chronic central serous chorioretinopathy (CSCR) > 3 months. Four treatment classes were considered: photodynamic therapy (PDT), subthreshold laser therapies (SLT), mineralocorticoid receptor antagonists (MRA) and antivascular endothelial growth factor (anti-VEGF) agents. Pairwise and network meta-analyses (NMA) of the primary outcomes (complete resolution of subretinal fluid (SRF), mean change in best corrected visual acuity (BCVA as logMAR) and mean change in SRF) and secondary outcomes (mean change in central retinal thickness, and central choroidal thickness (μm), recurrence of SRF, and adverse events) at 3, 6, and 12 months were compared. Confidence in Network Meta-Analysis (CINeMA) informed the certainty of NMA evidence.
Eleven RCTs of 458 eyes (450 patients) were included. NMA at 3 months showed that both PDT and SLT were superior to control for resolution of SRF (OR 4.83; 95% CI 1.72–13.55 and 2.27; 1.14–4.49, respectively) and SLT was superior to control for improving BCVA (MD -0.10; -0.17 to -0.04). PDT was superior to SLT for improving CRT (MD -42.88; -75.27 to -10.50). On probability ranking, PDT and SLT were consistently the best-ranked treatments for each outcome at 3 months, but low confidence of evidence and paucity of studies preclude definitive conclusions.
Pathogenic Risk Factors and Associated Outcomes in the Bullous Variant of Central Serous Chorioretinopathy
2022, Ophthalmology Retina
Citation Excerpt :
These patients were identified by searching the appropriate Korean Standard Classification of Diseases 7 codes (H35.7), which is similar to the International Classification of Diseases 10, and a text search for “chronic CSC” using the Severance Clinical Research Analysis Portal and assessed for inclusion by 3 retina specialists (H.G.K., M.K., and H.S.P.) after thorough review. Chronic CSC was defined as a neurosensory detachment attributed to ≥1 sites of leakage at the level of the RPE that persisted for >6 months without any secondary causes.9 The clinical records and associated multimodal imaging of each case were reviewed by retinal specialists to confirm the diagnosis of bvCSC and chronic CSC.
To compare the clinical features, treatments, and outcomes between bullous and chronic variants of central serous chorioretinopathy (CSC).
Retrospective, observational case series.
Sixty-two eyes of 44 patients with bullous-variant CSC (bvCSC) and 97 eyes of 85 patients with nonbullous CSC.
We conducted a national survey between September 1, 2020, and March 31, 2021, of members of the Korean Retina Society and obtained data of patients with bvCSC from 11 retinal centers. A comparator group comprised consecutive chronic CSC patients without bullous detachment.
Baseline demographics and patient characteristics were compared between groups. Secondary outcomes included factors associated with visual prognosis within the bvCSC group.
Compared with the nonbullous CSC group, the bvCSC group presented at a younger age (49 vs. 52 years; P = 0.047) and with more bilateral involvement (41% vs. 14%; P < 0.001). Systemic corticosteroid use was more prevalent in the bvCSC group, both in terms of any exposure (50% vs. 20%; P = 0.001) and long-term exposure (36% vs. 9%; P < 0.001). The bvCSC group had distinct imaging features (all P < 0.05): retinal folding (64% vs. 1%), subretinal fibrin (75% vs. 13%), multiple retinal pigment epithelium tears (24% vs. 2%), and multifocal fluorescein leakages with terminal telangiectasia (36% vs. 1%). Although bvCSC patients had worse vision at diagnosis (20/80 vs. 20/44; P = 0.003), treatment response was more robust (fluid resolution by final follow-up, 84% vs. 68%; P = 0.034) even with conservative management, resulting in similar final vision (20/52 vs. 20/45; P = 0.52). History of kidney-related (odds ratio [OR] 5.4; 95% confidence interval [CI] 1.3–18.5; P = 0.045) and autoimmune/rheumatoid diseases (OR 25.4, 95% CI 2.8–195.0; P = 0.004) showed associations with the bvCSC group. Apart from vision at diagnosis (OR 0.1, 95% CI 0.05–0.36; P < 0.001), a history of renal transplantation was most predictive of visual prognoses for bvCSC eyes (OR 0.2, 95% CI 0.04–0.75; P = 0.020).
Bullous-variant CSC may be associated with pathogenic risk factors based on underlying medical conditions and systemic corticosteroid use. Poor vision at diagnosis and history of renal transplantation were associated with poor visual outcome.
Intravitreal bevacizumab administration for the treatment of chronic central serous chorioretinopathy
2019, Journal of Current Ophthalmology
Citation Excerpt :
There are controversies regarding the pathophysiology of CSC. RPE defect or dysfunction may be effective in the serous retinal detachment development in CSC.18,27,28 Gass suggested that choroidal vascular hyper-permeability is the main cause of CSC development and later ICG-based studies supported this theory.29–31
To evaluate the effects of intravitreal bevacizumab (IVB) injection on chronic central serous chorioretinopathy (CSC).
In this prospective interventional case series, a total of 22 eyes of 22 patients, diagnosed with unresolved CSC for three months or longer, received 1.25 mg IVB injection. Also, in case of failure to achieve success parameters, double dose IVB injections continued in order to reach the complete subretinal fluid (SRF) absorption. A complete ophthalmic assessment was carried out one day, one week, and one-month post-injection, and then a monthly visit was performed, and re-injection was done if needed. Visual acuity, subretinal space volume (SSV), central macular thickness (CMT), and contrast sensitivity were measured and compared among baseline values and final post-treatment values.
The mean best corrected visual acuity increased significantly from 0.70 ± 0.22 to 0.17 ± 0.15 logMAR (P <0.001), and the CMT showed a significant reduction from 557.36 ± 129.12 to 259.50 ± 116.73 μm (P <0.001 ). In addition, SSV decreased significantly from 10.53 ± 2.03 to 6.63 ± 1.80 (P = 0.001), and contrast sensitivity improved significantly from 13.8182 ± 2.64820 dB to 17.6818 ± 1.80967 dB (P <0.001).
In this series, SRF absorption occurred and visual acuity improved after IVB injections, however, further comparative studies are needed to show the effect of IVB in chronic CSC.
Central serous chorioretinopathy: Towards an evidence-based treatment guideline
2019, Progress in Retinal and Eye Research
Citation Excerpt :
In a prospective study of 20 patients with aCSC who received ranibizumab and 20 patients who received no treatment, SRF resolved in 4 weeks compared to 13 weeks, respectively (Kim et al., 2013). In a randomised, non-controlled pilot study involving 8 cCSC eyes treated with 3 intravitreal injections of ranibizumab, 2 eyes (25%) had complete resolution of SRF at 3 months (Bae et al., 2011). However, in a subsequent prospective study with ranibizumab, Bae and colleagues reported complete resolution in only 13% of cCSC eyes treated with ranibizumab after 12 months, compared to 89% of eyes treated using low-fluence PDT (Bae et al., 2014).
Central serous chorioretinopathy (CSC) is a common cause of central vision loss, primarily affecting men 20–60 years of age. To date, no consensus has been reached regarding the classification of CSC, and a wide variety of interventions have been proposed, reflecting the controversy associated with treating this disease. The recent publication of appropriately powered randomised controlled trials such as the PLACE trial, as well as large retrospective, non-randomised treatment studies regarding the treatment of CSC suggest the feasibility of a more evidence-based approach when considering treatment options. The aim of this review is to provide a comprehensive overview of the current rationale and evidence with respect to the variety of interventions available for treating CSC, including pharmacology, laser treatment, and photodynamic therapy. In addition, we describe the complexity of CSC, the challenges associated with treating CSC, and currently ongoing studies. Many treatment strategies such as photodynamic therapy using verteporfin, oral mineralocorticoid antagonists, and micropulse laser treatment have been reported as being effective. Currently, however, the available evidence suggests that half-dose (or half-fluence) photodynamic therapy should be the treatment of choice in chronic CSC, whereas observation may be the preferred approach in acute CSC. Nevertheless, exceptions can be considered based upon patient-specific characteristics.
Long-term Visual Outcomes and Causes of Vision Loss in Chronic Central Serous Chorioretinopathy
2019, Ophthalmology
To evaluate the long-term visual outcomes and causes of vision loss in chronic central serous chorioretinopathy (CSC).
Retrospective, longitudinal study.
A total of 133 participants (217 eyes) with chronic CSC.
A retrospective review of clinical and multimodal imaging data of patients with chronic CSC managed by 3 of the authors between May 1977 and March 2018. Multimodal imaging comprised color photography, fluorescein angiography, indocyanine green angiography, fundus autofluorescence (FAF), and OCT.
Best-corrected visual acuity (BCVA) at the final visit; change in BCVA between first visit and 1-, 5-, and 10-year follow-up visits; and causes of vision loss at final visit.
Data from 6228 individual clinic visits were analyzed. Mean age of patients at the first visit was 60.7 years, and mean period of follow-up from first to last visit was 11.3 years. The cohort included 101 male patients (75.9%). At the final visit, 106 patients (79.7%) maintained driving-standard vision with BCVA of 20/40 or better in at least 1 eye, and 17 patients (12.8%) were legally blind with BCVA of 20/200 or worse in both eyes. Mean BCVA at first visit was not significantly different from mean BCVA at 1- or 5-year follow-up visits (both P ≥ 0.65) but was significantly better than the mean BCVA at the 10-year follow-up visit (P = 0.04). Seventy-nine percent of eyes with 20/40 or better vision at the first visit maintained the same level of vision at the 10-year follow-up visit. Ninety-two percent of eyes with 20/200 or worse vision at the first visit maintained the same level of vision at the 10-year follow-up visit. Cystoid macular degeneration, choroidal neovascularization (CNV), outer retinal disruption on OCT, and FAF changes were associated with poorer vision at the final visit (all P ≤ 0.001). Multivariable analysis revealed that greater age at first visit was associated with greater BCVA change at the 10-year follow-up visit (P = 0.001).
Chronic CSC can be a sight-threatening disease leading to legal blindness. Age at presentation and outer retinal changes on multimodal imaging were associated with long-term BCVA changes and may be predictors of long-term visual outcomes.
Comparative efficacy of brolucizumab, half-dose photodynamic therapy, and aflibercept in managing chronic central serous chorioretinopathy
2024, Graefe's Archive for Clinical and Experimental Ophthalmology

View all citing articles on Scopus

So Hyun Bae, MD, received her medical degree from Seoul National University College of Medicine, Seoul, Korea in 2004. She completed residency at Kangnam Sacred Heart Hospital, Hallym University, Korea. She is currently pursuing a retinal fellowship in Ophthalmology at Seoul National University Hospital, Seoul, Korea. Her field of interest includes surgical procedures associated with vitreoretinal disease.

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Original articleA Randomized Pilot Study of Low-Fluence Photodynamic Therapy Versus Intravitreal Ranibizumab for Chronic Central Serous Chorioretinopathy

Purpose

Design

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Am J Ophthalmol

Am J Ophthalmol

Surv Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Retina

Am J Ophthalmol

Pathogenesis of disciform detachment of the neuroepithelium: IIIdiopathic central serous choroidopathy

Am J Ophthalmol

Indocyanine green angiography of central serous chorioretinopathy

Int Ophthalmol

Digital indocyanine green videoangiography of central serous chorioretinopathy

Arch Ophthalmol

Pathogenesis of central serous retinopathy: a new working hypothesis

Graefes Arch Clin Exp Ophthalmol

Cystoid macular degeneration in chronic central serous chorioretinopathy

Retina

Photodynamic effects on choroidal neovascularization and physiological choroid

Invest Ophthalmol Vis Sci

Choroidal vascular remodeling in central serous chorioretinopathy after indocyanine green angiography guided photodynamic therapy with verteporfin: a novel treatment at the primary disease level

Br J Ophthalmol

Photodynamic therapy for chronic central serous chorioretinopathy

Retina

Ocular changes after photodynamic therapy

Invest Ophthalmol Vis Sci

Long-term follow-up of a prospective trial of argon laser photocoagulation in the treatment of central serous retinopathy

Br J Ophthalmol

Original article
A Randomized Pilot Study of Low-Fluence Photodynamic Therapy Versus Intravitreal Ranibizumab for Chronic Central Serous Chorioretinopathy