Punctate Hyperfluorescence Spot as a Common Choroidopathy of Central Serous Chorioretinopathy and Polypoidal Choroidal Vasculopathy SANG JUN PARK, BO HYUCK KIM, KYU HYUNG PARK, AND SE JOON WOO
PURPOSE:

To characterize punctate hyperfluorescence spot as common choroidopathy in central serous chorioretinopathy (CSC) and polypoidal choroidal vasculopathy (PCV).
DESIGN: Cross-sectional retrospective study.
METHODS: A total of 150 patients with 50 each allocated to CSC, PCV, and typical neovascular age-related macular degeneration (AMD) groups were included. Punctate hyperfluorescence spot was determined using mid-to latephase indocyanine green angiography and subfoveal choroidal thickness by enhanced depth imaging optical coherence tomography. Each group was subcategorized based on concurrent punctate hyperfluorescence spot.
RESULTS: The punctate hyperfluorescence spot incidence was higher in CSC (80.0%) and PCV (86.0%) than in AMD (40.0%, P < .001), with similar contralateral findings (86.1%, 86.7%, and 60%, respectively, P [ .014). Punctate hyperfluorescence spot lesions comprised clustered polyps connected to vascular networks mimicking PCV. Choroidal thickness was 370.7 ± 81.9 mm, 332.6 ± 101.6 mm, and 172.5 ± 80.1 mm in affected eyes (P < .001) and 323.0 ± 70.5 mm, 306.4 ± 94.4 mm, and 180.2 ± 83.6 mm in contralateral eyes (P < .001) in CSC, PCV, and AMD groups, respectively. In the AMD group, choroidal thickness was greater in eyes with punctate hyperfluorescence spot (204.8 ± 92.3 mm) than in those without punctate hyperfluorescence spot (150.2 ± 62.9 mm, P [ .028) in affected eyes; however, the difference was not observed in contralateral eyes in the AMD group and in both eyes in the CSC and PCV groups.
CONCLUSIONS: Based on angiography and OCT, punctate hyperfluorescence spot may be a form of PCV, and CSC and PCV may share common choroidopathy distinct from typical neovascular AMD. However, infrequent PHS lesions along with thickened choroids in AMD eyes suggest that AMD may encompass a wide choroidal pathologic spectrum shared in part with PCV. (Am J

Accepted for publication Aug 7, 2014. From the Department of Ophthalmology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea. Inquiries to Se Joon Woo, Department of Ophthalmology, Seoul National University Bundang Hospital, #300, Gumi-dong, Bundang-gu, Seongnam, Gyeonggi-do 463-707, South Korea; e-mail: [email protected]

0002-9394/$36.00 http://dx.doi.org/10.1016/j.ajo.2014.08.010

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Ophthalmol 2014;-:-–-. Ó 2014 by Elsevier Inc. All rights reserved.)

I

NDOCYANINE GREEN ANGIOGRAPHY (ICGA) PROVIDES

detailed images of choroidal vasculature and has generated a growing awareness of choroidal vascular diseases including central serous chorioretinopathy (CSC), polypoidal choroidal vasculopathy (PCV), and age-related macular degeneration (AMD). Typical CSC is easily diagnosed and does not require ICGA. However, atypical CSC or chronic CSC often mimics other conditions that threaten vision, such as PCV,1–4 and ICGA is enormously helpful in proper diagnosis by assessing choroidal vascular abnormalities, including filling delays in choroidal vasculature, abnormal choroidal venous dilation during the early phase, and choroidal vascular hyperpermeability.5 These ICGA findings suggest that CSC is a disease of choroidal circulation and vasculature.Interestingly, several studies reported that some CSC cases later developed into PCV,2,4 and a history of CSC is a risk factor for PCV development.6–8 PCV is also a choroidal vascular disorder and also has unique ICGA features, including a branching inner choroidal vascular network, hypofluorescent halo, and choroidal vascular hyperpermeability.5 The choroidal abnormalities observed in CSC and PCV, particularly choroidal vascular hyperpermeability, suggest a similar choroidopathy underlying both CSC and PCV. Studies have recently reported that the choroid is thicker in eyes with PCV or CSC than that observed not only in normal eyes but also in eyes with typical neovascular AMD,9 which further suggests a common pathogenesis between CSC and PCV. A punctate hyperfluorescence spot is a focal hyperfluorescent area observed during the mid to late phase of ICGA in both the CSC-affected eye and the unaffected contralateral eye. Tsujikawa and associates were the first to use the term ‘‘punctate hyperfluorescence spot,’’ although prior studies illustrated the punctate hyperfluorescence spot lesion in figures.10 They reported that punctate hyperfluorescence spot lesions frequently occurred within the macular area, outside the vascular arcade, or near the optic disc, and punctate hyperfluorescence spots seemed to arise in the inner choroid.10 Punctate hyperfluorescence spots also occur in eyes with PCV and the unaffected contralateral eye; several studies investigating ICGA findings in

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TABLE. Punctate Hyperfluorescence Spot Characteristics on Indocyanine Green Angiography and Subfoveal Choroidal Thickness on Spectral-Domain Optical Coherence Tomography in Patients With Central Serous Chorioretinopathy, Polypoidal Choroidal Vasculopathy, and Typical Neovascular Age-Related Macular Degeneration P Value

Affected Eyes

CSC

PCV

AMD

N Age (y) Men PHS Location Perifovea Peripapilla Others Subfoveal CT (mm) With PHS Without PHS P Valuec (with vs without PHS)

50 48.0 6 7.4 41 (82.0%) 40 (80.0%)

50 66.5 6 7.9 32 (64.0%) 43 (86.0%)

50 70.3 6 6.4 22 (44.0%) 20 (40.0%)

13 (26.0%) 7 (14.0%) 33 (66.0%) 370.7 6 81.9 373.9 6 81.7 357.7 6 85.9 .688

10 (20.0%) 22 (44.0%) 36 (72.0%) 332.6 6 101.6 339.8 6 99.4 288.86 6 11.9 .222

5 (10.0%) 9 (18.0%) 17 (34.0%) 172.5 6 80.1 204.8 6 92.3 150.2 6 62.9 .028