Change of Regional Choroid Thickness After Reduced-Fluence Photodynamic Therapy for Chronic Central Serous Chorioretinopathy SAKI MANABE, CHIEKO SHIRAGAMI, KAZUYUKI HIROOKA, SAEKO IZUMIBATA, AKITAKA TSUJIKAWA, AND FUMIO SHIRAGA PURPOSE:
To evaluate macular choroidal thickness after reduced-fluence photodynamic therapy (PDT) for chronic central serous chorioretinopathy (CSC). DESIGN: Prospective, consecutive, interventional case series. METHODS: Twenty-two eyes with chronic CSC were treated with reduced-fluence PDT. Macular choroidal thickness was examined using spectral-domain optical coherence tomography with a 3-dimensinonal radial scan protocol in the choroidal mode before and 1, 3, and 6 months after the treatment. The mean choroidal thickness in the Early Treatment Diabetic Retinopathy Study grid (center, inner circle, and outer circle) was compared between before and after therapy, as well as between treated eyes and 54 volunteer normal eyes. RESULTS: Chronic CSC eyes showed significantly thicker choroids in the macular area compared with normal controls (P < .0001). After the single treatment session, subretinal fluid resolved completely in all eyes, and there were no recurrences during the study period. Choroidal thickness within the center area and inner circle showed a significant reduction at all time points after treatment (P < .05). The choroidal thickness in the outer circle showed a statistically significant reduction at 1 and 3 months but not at 6 months. After treatment, the choroidal thickness reduced to the normal values at the center and inner circle, but was still significantly thicker in the outer circle (P < .01). CONCLUSION: Chronic CSC eyes showed significantly thicker choroids in the macular area. After reduced-fluence PDT, macular choroidal thickness became thinner within 6 months of treatment. (Am J Ophthalmol 2015;-: -–-. Ó 2015 by Elsevier Inc. All rights reserved.)
I
chorioretinopathy (CSC). Recent studies using indocyanine green angiography have revealed delayed choroidal infusion, choroidal venous dilation, and choroidal vascular hyperpermeability in eyes with CSC.1–7 It is now generally thought that the choroid is the primary site involved in CSC pathology.1–4 In addition, enhanced-depth imaging optical coherence tomography (OCT)8 showed that eyes with CSC have thicker choroids at the fovea than contralateral unaffected eyes9 or healthy normal eyes.10 A comparison of choroidal thickness between regions with and without choroidal vascular hyperpermeability showed greater choroidal thickness in the region with choroidal vascular hyperpermeability.1 The choroidal thickening diffuses, extending over the macula, rather than just being localized subfoveally. Photodynamic therapy (PDT) with verteporfin resolves leakage and subsequently resolves subretinal fluid in chronic CSC.6,7,9,11 A possible mechanism of action of PDT in CSC involves damage to the choriocapillaris leading to decreased choroidal vascular hyperpermeability and a subsequent reduction in leakage from the retinal pigmented epithelium. Most reports on post-PDT changes in choroidal thickness in CSC eyes, however, have focused on the subfoveal choroidal thickness; there have been few reports focusing on changes in perifoveal choroidal thickness.12 Moreover, no reports have compared whole macular choroidal thickness measurements between the reducedfluence PDT-treated eyes and normal control eyes.13 In the present study, we scanned the whole macular area of patients with CSC by high-resolution spectral-domain OCT using a 3-dimensional radial scan protocol. The choroidal thickness maps were used to study changes in choroidal thickness before and after reduced-fluence PDT and to compare reduced-fluence PDT–treated eyes and normal control eyes.
T WAS PREVIOUSLY THOUGHT THAT A BREAKDOWN
of the outer blood-retinal barrier leads to leakage from the retinal pigment epithelium in central serous
METHODS
Accepted for publication Jan 9, 2015. From the Department of Ophthalmology, Kagawa University Faculty of Medicine, Kagawa, Japan (S.M., C.S., K.H., S.I., A.T.); and Department of Ophthalmology, Okayama University, Okayama, Japan (F.S.). Inquiries to Chieko Shiragami, Department of Ophthalmology, Kagawa University Faculty of Medicine, 1750-1 Ikenobe Miki-cho, Kagawa 761-0793, Japan; e-mail: [email protected] 0002-9394/$36.00 http://dx.doi.org/10.1016/j.ajo.2015.01.006
Ó
2015 BY
THIS STUDY WAS APPROVED BY THE ETHICS COMMITTEE AT
Kagawa University Faculty of Medicine and conducted in accordance with the tenets of the Declaration of Helsinki. The current prospective, interventional study included consecutive patients presenting with unilateral
ELSEVIER INC. ALL
RIGHTS RESERVED.
1
FIGURE 1. Choroidal thickness map with a grid from the Early Treatment Diabetic Retinopathy Study. (Top left) The macular area was examined with the RS-3000 Advance system in the choroidal mode. Radial scans consisting of 9-mm line scans in 6 radial directions were obtained. (Top right) The lines of the retinal pigment epithelium–Bruch membrane complex (pink) and the chorioscleral border (blue) were segmented automatically by the equipped software. (Bottom left) Choroidal thickness maps of the macular area. (Bottom right) Mean choroidal thickness of the Early Treatment Diabetic Retinopathy Study grid.
FIGURE 2. Definition of the 3 areas for the comparison of the regional choroidal thickness. The Early Treatment Diabetic Retinopathy Study grid was fused into 3 areas, shown as a lattice pattern: (Left) center, the central circle within a 1-mm diameter; (Middle) inner circle, a donut-shaped ring with an inner diameter of 1 mm and an outer diameter of 3 mm; and (Right) outer circle, a donutshaped ring with an inner diameter of 3 mm and an outer diameter of 6 mm.
treatment-naı¨ve active chronic CSC between July 2, 2012 and March 29, 2013 at the Kagawa University Hospital. Inclusion criteria were as follows: age >20 years and diagnosis of active CSC for at least 6 months, defined as the presence of subretinal fluid involving the macula. The leakage points were unclear with idiopathic diffuse leaks from the damaged retinal pigment epithelium or involved the fovea in fluorescein angiography. The control group consisted of 54 normal eyes (28 eyes in 21 men and 26 eyes in 16 women; mean age, 54.1 6 16.8 years). No significant differences existed between the control and CSC patient groups with respect to age, 2
sex, and refractivity. The criteria for exclusion from the study included multiple retinal pigment epitheliopathy, ocular hypertension >21 mm Hg, myopia
To evaluate macular choroidal thickness after reduced-fluence photodynamic therapy (PDT) for chronic central serous chorioretinopathy (CSC). DESIGN: Prospective, consecutive, interventional case series. METHODS: Twenty-two eyes with chronic CSC were treated with reduced-fluence PDT. Macular choroidal thickness was examined using spectral-domain optical coherence tomography with a 3-dimensinonal radial scan protocol in the choroidal mode before and 1, 3, and 6 months after the treatment. The mean choroidal thickness in the Early Treatment Diabetic Retinopathy Study grid (center, inner circle, and outer circle) was compared between before and after therapy, as well as between treated eyes and 54 volunteer normal eyes. RESULTS: Chronic CSC eyes showed significantly thicker choroids in the macular area compared with normal controls (P < .0001). After the single treatment session, subretinal fluid resolved completely in all eyes, and there were no recurrences during the study period. Choroidal thickness within the center area and inner circle showed a significant reduction at all time points after treatment (P < .05). The choroidal thickness in the outer circle showed a statistically significant reduction at 1 and 3 months but not at 6 months. After treatment, the choroidal thickness reduced to the normal values at the center and inner circle, but was still significantly thicker in the outer circle (P < .01). CONCLUSION: Chronic CSC eyes showed significantly thicker choroids in the macular area. After reduced-fluence PDT, macular choroidal thickness became thinner within 6 months of treatment. (Am J Ophthalmol 2015;-: -–-. Ó 2015 by Elsevier Inc. All rights reserved.)
I
chorioretinopathy (CSC). Recent studies using indocyanine green angiography have revealed delayed choroidal infusion, choroidal venous dilation, and choroidal vascular hyperpermeability in eyes with CSC.1–7 It is now generally thought that the choroid is the primary site involved in CSC pathology.1–4 In addition, enhanced-depth imaging optical coherence tomography (OCT)8 showed that eyes with CSC have thicker choroids at the fovea than contralateral unaffected eyes9 or healthy normal eyes.10 A comparison of choroidal thickness between regions with and without choroidal vascular hyperpermeability showed greater choroidal thickness in the region with choroidal vascular hyperpermeability.1 The choroidal thickening diffuses, extending over the macula, rather than just being localized subfoveally. Photodynamic therapy (PDT) with verteporfin resolves leakage and subsequently resolves subretinal fluid in chronic CSC.6,7,9,11 A possible mechanism of action of PDT in CSC involves damage to the choriocapillaris leading to decreased choroidal vascular hyperpermeability and a subsequent reduction in leakage from the retinal pigmented epithelium. Most reports on post-PDT changes in choroidal thickness in CSC eyes, however, have focused on the subfoveal choroidal thickness; there have been few reports focusing on changes in perifoveal choroidal thickness.12 Moreover, no reports have compared whole macular choroidal thickness measurements between the reducedfluence PDT-treated eyes and normal control eyes.13 In the present study, we scanned the whole macular area of patients with CSC by high-resolution spectral-domain OCT using a 3-dimensional radial scan protocol. The choroidal thickness maps were used to study changes in choroidal thickness before and after reduced-fluence PDT and to compare reduced-fluence PDT–treated eyes and normal control eyes.
T WAS PREVIOUSLY THOUGHT THAT A BREAKDOWN
of the outer blood-retinal barrier leads to leakage from the retinal pigment epithelium in central serous
METHODS
Accepted for publication Jan 9, 2015. From the Department of Ophthalmology, Kagawa University Faculty of Medicine, Kagawa, Japan (S.M., C.S., K.H., S.I., A.T.); and Department of Ophthalmology, Okayama University, Okayama, Japan (F.S.). Inquiries to Chieko Shiragami, Department of Ophthalmology, Kagawa University Faculty of Medicine, 1750-1 Ikenobe Miki-cho, Kagawa 761-0793, Japan; e-mail: [email protected] 0002-9394/$36.00 http://dx.doi.org/10.1016/j.ajo.2015.01.006
Ó
2015 BY
THIS STUDY WAS APPROVED BY THE ETHICS COMMITTEE AT
Kagawa University Faculty of Medicine and conducted in accordance with the tenets of the Declaration of Helsinki. The current prospective, interventional study included consecutive patients presenting with unilateral
ELSEVIER INC. ALL
RIGHTS RESERVED.
1
FIGURE 1. Choroidal thickness map with a grid from the Early Treatment Diabetic Retinopathy Study. (Top left) The macular area was examined with the RS-3000 Advance system in the choroidal mode. Radial scans consisting of 9-mm line scans in 6 radial directions were obtained. (Top right) The lines of the retinal pigment epithelium–Bruch membrane complex (pink) and the chorioscleral border (blue) were segmented automatically by the equipped software. (Bottom left) Choroidal thickness maps of the macular area. (Bottom right) Mean choroidal thickness of the Early Treatment Diabetic Retinopathy Study grid.
FIGURE 2. Definition of the 3 areas for the comparison of the regional choroidal thickness. The Early Treatment Diabetic Retinopathy Study grid was fused into 3 areas, shown as a lattice pattern: (Left) center, the central circle within a 1-mm diameter; (Middle) inner circle, a donut-shaped ring with an inner diameter of 1 mm and an outer diameter of 3 mm; and (Right) outer circle, a donutshaped ring with an inner diameter of 3 mm and an outer diameter of 6 mm.
treatment-naı¨ve active chronic CSC between July 2, 2012 and March 29, 2013 at the Kagawa University Hospital. Inclusion criteria were as follows: age >20 years and diagnosis of active CSC for at least 6 months, defined as the presence of subretinal fluid involving the macula. The leakage points were unclear with idiopathic diffuse leaks from the damaged retinal pigment epithelium or involved the fovea in fluorescein angiography. The control group consisted of 54 normal eyes (28 eyes in 21 men and 26 eyes in 16 women; mean age, 54.1 6 16.8 years). No significant differences existed between the control and CSC patient groups with respect to age, 2
sex, and refractivity. The criteria for exclusion from the study included multiple retinal pigment epitheliopathy, ocular hypertension >21 mm Hg, myopia
