Top PDF Macular sensitivity after half-dose verteporfin photodynamic therapy in central serous chorioretinopathy

This study revealed comparative point-to-point macular sensitivity in both CSCR and normal fellow eyes with the automated static perimeter, and demonstrated the decrease in macular sensitivity in all areas that HD-PDT was applied despite good anatomic reattachment and normal VA. This may be explained by the result of the photoreceptors and RPE damage from chronic macular detachment. PDT itself had also been reported to cause RPE damage. 9 Therefore,

This study has its shortcomings in that it was not a prospec- tive, randomized clinical study, the follow-up duration varied between the cases, and it included a limited number of patients. Additionally, follow-up ICGA was performed only as needed, not on a regular basis, after treatment. The long-term effects of decreased choroidal perfusion on visual function were not possible to evaluate in this study, and a further investigation is needed to determine changes in choriocapillaris perfusion with time in the areas to which treatment is applied. Further research should also determine whether the damage to normal choroidal vasculature caused by PDT can be reduced, possibly by combin- ing low-fluence PDT with a reduced dose of verteporfin.

Our study had several limitations, including small sample size. We did not obtain data on choroidal thick- ness, as can be done by enhanced depth imaging OCT. It would be interesting to assess whether baseline chor- oidal thickness is significantly altered by half-dose PDT and whether this correlates with treatment response. We were also only able to report 6 months follow-up results and further research is required to assess patients at 1 year or longer. In addition, although severe damage to the retina or choroid did not occur within the trial period, further follow-up is needed to establish long- term safety. Our results are not generalizable to all CSCR patients given the small and short term nature of this study, but they do indicate that automated static perimetry may play a useful role in evaluating treatment response in this patient population.

Methods: In this prospective, non-comparative, interventional case series, 14 eyes of 14 patients with chronic CSC who received half-dose verteporfin PDT were examined. The best- corrected visual acuity (BCVA), macular sensitivity in the central 4, 8, and 12 degrees, and fixa- tion stability were evaluated at baseline and at months 1, 3, 6, and 12 after half-dose verteporfin PDT. Macular sensitivity and fixation stability were determined by MP-1 microperimetry. Results: Mean retinal sensitivity in the central 4 and 8 degrees was significantly better at 1, 3, 6, and 12 months after half-dose verteporfin PDT than at baseline. BCVA was significantly better after half-dose verteporfin PDT but only after 3 months. Fixation was relatively unstable in three eyes at baseline, but became stable at 12 months. BCVA at 12 months was significantly correlated with pre-PDT fixation stability (r = 0.7120, P = 0.0038).

As mentioned previously, there is no international consensus on the optimal treatment protocol of cCSC. Nevertheless, PDT has emerged as the treatment of choice in many centers worldwide, based on the high rate of anatomic success, the increase of visual acuity, improvement in retinal sensitivity, and an excellent safety profile reported in many retrospective studies [3, 41–43]. The PDT strategies that are generally used are either with half the dose of verteporfin and full fluency (energy) of laser treatment, half the fluency level and the full dose of verteporfin, or half the treatment time using the full dose of verteporfin and full fluency, as compared to the original protocol that was used for neo- vascular age-related macular degeneration. These PDT strategies that use either half-dose of half-fluency treat- ment have been developed because a combination of the dosage and fluency that was originally used for the treat- ment of neovascular age-related macular degeneration showed a potentially higher risk of developing choroidal ischemia and retinal atrophic changes [36, 44–46]. The half-dose or half-fluency PDT strategies, however, have been shown to be safe and effective in relatively large retrospective studies and in one noncontrolled, nonrando- mized prospective study by Chan et al. in cCSC patients with sufficient follow-up periods [3, 27, 29, 41].

angiography. In Case 1, a 46-year-old female has been diagnosed as CSC and concurrent FCE. The baseline BCVA was 10/20. After a half-dose of PDT, complete resolution of SRF was achieved at one-month with stable BCVA. At 3 months, the patient complained of obvious metamorphosis. Multimodal images confirmed the existence of CNV, derived from the FCE, inside the zone of PDT irradiation. The development of CNV stopped promptly 1 month post the injection of ranibizumab. In Case 2, a 39 year-old male was diagnosed as bilateral CSC. The BCVA was 8/20 (od), and 16/20 (os). The multimodal images showed classic CSC manifestation in left eye, but atypical manifestation in right eye with subtle SRF and FCE. Post half-dose treatment, the SRF in left eye completely resolved at three- months, and the BCVA improved to 24/20. However, a lesion of CNV grew in the FCE after 1 month in right eye, with decreased BCVA, 4/20. One month post-injection of ranibizumab, obvious regression was witnessed, with improved BCVA, 6/20. The CNV proceeded to be a scar 2 months after injection. The BCVA maintained at 8/20. Conclusions: In this study, type II CNV was induced in two cases of CSC concurrent with FCE in 3 months post half-dose PDT. The CNV grew right from the FCE, inside the zone of PDT irradiation.

All OCT images were obtained through a dilated pupil with a line scan protocol (line scans of 30°, composed of 100 averaged images; Heidelberg Spectralis OCT, Hei- delberg Engineering, Heidelberg, Germany). In each sub- ject, this protocol was applied both vertically and horizontally and centered on the fovea in the CSC eyes. The OCT images (vertical and horizontal) that passed through the central fovea were selected for the measure- ment of the ONL thickness, as well as the height of retinal detachment, and the width of the subretinal space. OCT images taken within 1 week before half-dose PDT, 2 months (±2 weeks) after half-dose PDT, and 12 months (±2 weeks) after half-dose PDT were analyzed.

Background: To evaluate the efficacy and safety of half-dose photodynamic therapy (PDT combined with ranibizumab for polypoidal choroidal vasculopathy (PCV). PCV is commonly treated with a combination of anti-vascular endothelial growth factor and standard-dose photodynamic therapy (PDT). Choroidal ischemia and visual loss can be resulted from the standard-dose PDT. Half-dose PDT has proved to produce similar results and safety profile in treating central serous chorioretinopathy. Half-dose PDT may offer an alternative for PCV cases where the damage to choroidal vasculature maybe less. Here, we report the efficacy of treating PCV cases with combination of ranibizumab and half-dose PDT. Methods: In this prospective, non-comparative, interventional case series, 19 treatment-naive eyes were treated with combined half-dose PDT and ranibizumab. All subjects were followed up for 12 months with measurement of best-corrected visual acuity (BCVA), central foveal thickness (CFT) by optical coherence tomography. Indocyanine green angiogram (ICG) was performed every 3-monthly, and subjects assessed in terms of polyp regression rates, changes in vision and central foveal thickness, need to repeat half-dose PDT. Subgroup analysis was performed based on ICG features.

three patients in no hypercyanescence group. In addi- tion mean BCVA change was found to be increased in intense and intermediate hypercyanescence groups, and decreased in no hypercyanescence group. In another prognostic study by Moon et  al. [17], the prognostic factors related to PDT for CSC were evaluated. They reported that PDT was effective in regard to anatomic and functional outcomes in CSC patients. In addition they revealed that visual improvement might be limited in patients with prolonged disease duration, baseline RPE atrophy, foveal ellipsoid zone disintegrity, and pro- gression of RPE atrophy after PDT. Fujita et al. assessed the outcomes of half-dose verteporfin PDT for chronic CSC patients [19]. The study included 204 eyes of 204 patients and they reported that 89.2% of the patients showed complete resolution of CSC. Also they stated that the patients who did not show complete resolution at month 12 were more likely to have an intermediate hypercyanescence on ICGA and a poorer BCVA before PDT. Our poor responder also had a poorer baseline BCVA than the good responders, but this difference was not statistically significant.

correspondence in the judgment of the severity of hyper- permeability (Cohen ’ s kappa 0.06, 0.2, and 0.3; data not shown). Therefore, it would be dif fi cult to generalize the use of hyper fl uorescence as a prognostic factor. In contrast, choroidal thickness, the factor associated with the effectiv- ity of half-dose PDT, is a quantitative measure of anatomic abnormalities of the choroid. In patients with central serous chorioretinopathy, the subfoveal choroid is thicker in eyes with choroidal vascular hyperpermeability than in those without. 8 In addition to enhanced depth imaging OCT, advances in swept-source OCT have now made it possible to evaluate choroidal thickness more correctly. Thus, chor- oidal thickness may be used as a surrogate marker for functional abnormalities of the choroid in the setting of central serous chorioretinopathy.

Subgroup analysis was performed, with 11/21 patients presenting with an initial CSCR episode and 10/21 patients presenting with a recurrent episode. All eyes in both groups demonstrated complete resorption of subretinal fluid after 4 months. Microperimetry testing at 4 months demonstrated improvement in retinal sensitivity in both groups. In the initial episode group, mean foveal sensitivity increased from 12.1 dB at baseline to 15.8 dB after 4 months (P = 0.005). In eyes with recurrent episodes, mean foveal sensitivity increased from 10.5 dB at baseline to 15.5 dB at baseline (P = 0.001). Both subgroups demonstrated mean deficits in foveal sensitivity compared to unaffected fellow eyes, with mean deficits of 3.1 (P = 0.008) and 2.7 dB (P = 0.028) in the initial and recurrent episode groups, respectively. In both groups, post-treatment foveal thickness was significantly lower than foveal thickness in the fellow unaffected eye. There was no association between subretinal deposit grade and foveal thickness after treatment. While PDT may result in resolution of subretinal fluid, this data suggests that patients with CSCR and subretinal deposits demonstrate residual functional deficits and anatomical changes after treatment. Similarly, Ratanasukon et al found photoreceptor disruption in a significant number of CSCR patients following half dose PDT. 44 While no correlation with

Figure 3 Clinical features on multimodal imaging of the right eye of a 63-year-old female patient with severe chronic central serous chorioretinopathy (A–C). Black arrow on color fundus photography image (A) shows the scanning plane, which is depicted on the sD-OCT scans (D, E). FAF shows multiple speckled hyperautofluorescent changes in the macula together with an irregular surface of hypoautofluorescence, expanding from the fovea to the superior and inferior vascular arcades (B). Fluorescein angiography imaging (C) revealed a limited area of fluorescein leakage with a clear central focus. The areas of hypofluorescence were located more temporal from the fovea and were smaller than on FaF. an sD-OCT scan (D) at first presentation and prior to treatment revealed a subretinal serous fluid accumulation together with a posterior cystoid retinal degeneration in the outer nuclear layer of the retina. at ~2 months after half-dose photodynamic therapy, both subretinal and intraretinal fluid on OCT had resolved completely (E).

ICSCR is a serous macular detachment disease that often attacks young patients. Gray spots and blurred vision in the central visual field are common symptoms; reduced BCVA and central retinal sensitivity may persist after the fluid disappears. Treatments such as regular laser photocoagula- tion and photodynamic therapy seem to be good choices, but both therapies have limitations. In this study, we evaluated the effect of H. pylori eradication on ICSCR patients. To our knowledge, we were the first to demonstrate that H. pylori eradication could elevate the central retinal sensitivity in ICSCR patients, but this does not improve BCVA and the disappearance rate of SRF.

Of the eight patients included in this report, there were seven males (87.5%) and one female (12.5%) with a mean age of 46.25 ± 11.18 years (range 35–70). Three right eyes (37.5%) and five left eyes (62.5%) were treated, with an average duration of subretinal fluid associated with CSC prior to initiation of combination therapy of 4.25 months. Frank CNV was not identified in these cases on FA or ICGA studies (Figure 1). All eight cases received full-dose half-fluence PDT with the addition of anti-VEGF. Seven cases (87.5%) were treated with bevacizumab and one case (12.5%) with aflibercept. The clinical characteristics of each patient are demonstrated in Table 1.

an opposite outcome. In that study, Uetani et al compared the effects of a half-dose of verteporfin with those of a one-third dose of verteporfin for ICSCR. In the half-dose photodynamic therapy group, choroidal thickness reduced significantly from baseline. However, in the 1/3 dose photodynamic therapy group, choroidal thickness decreased in two eyes in which subretinal fluid disappeared, but did not change in the other eyes. However, only six patients were assigned to the photo- dynamic therapy group in that study, so the sample size was relatively small which might have led to bias.

There are several limitations within this study. As a retro- spective review, the lack of a control group may limit gener- alizations and limit definitive comparisons of half-dose PDT with other treatment modifications. Nonetheless, this does not detract from the observations of this study cohort dem- onstrating favorable outcomes after half-dose PDT, with safe and durable effects noted as early as 6 weeks posttreatment. Second, some variations did exist in the exact initial follow-up

In 2003, photodynamic therapy (PDT) with full-dose verteporfin was reported as a new treatment for chronic CSC [8]. However, complication such as second- ary choroidal neovascularization (CNV), pigmentary changes of the RPE, and persistent choroidal ischemia can occur after full-dose verteporfin PDT [8] [9] [10] [11]. In recent years, PDT with half-dose verteporfin has been conducted in chronic CSC with similar effects and reduced complications [12] [13] [14] [15] [16]. Although the dose verteporfin is half, there are also some complications such as the CNV, atrophy of RPE [3] [17]. There are some reports showing that 1/3-dose verteporfin PDT was safe and effective in chronic CSC [18]. The pur- pose of this study was to determine the safety and efficacy of 1/3-dose vertepor- fin PDT in subacute CSC. We investigated the results of the LogMAR BCVA af- ter 1/3-dose verteporfin PDT at deferent time. The choroidal thickness and neuroretinal thickness had also been assessed. The subacute CSC was diagnosed that symptoms were more than 3 months but shorter than 6 months. The timing of treatment was also concerned.

Prince of Songkla University, Thailand between March 2006 and February 2011. Patients with symptomatic acute CSC, undergoing PDT using a half-dose of verteporfin (Visudyne; Novartis AG, Bülach, Switzerland) were studied. The patients underwent fundus examinations and had their best-corrected visual acuity (BCVA) measured using the logarithm of the minimum angle of resolution (logMAR). CSC was diagnosed when there was focal retinal detachment with or without pigment epithelial detachment in the macular area and focal point leakage on FFA. The inclusion criteria included: (1) age more than 20 years, (2) typical CSC characteristics confirmed by FFA and OCT, (3) follow-up fundus examinations and OCT tests more than 12 months after the half-dose PDT, (4) single half-dose PDT treatment with no other accompanying treatment, and (5) no recurrent attack after half-dose PDT treatment within 1 year of follow-up. The exclusion criteria included: (1) complicated CSC presentation such as choroidal neovascular membrane, multiple retinal pigment epithelial detachment, large pigment epithelial detachment more than one disc diameter, and diffuse pigment epitheliopathy before the treatment; (2) treatment via focal laser or intravitreal injection before and after the half-dose PDT; and (3) patients with fluorescein and verteporfin allergy.

Despite the significant findings, our study is limited by its retrospective design. The number of investigated eyes was relatively small, and the follow-up period was relatively short. Further prospective studies with large numbers are therefore needed to confirm our results. Other limitations were the lack of evaluation at the early phase within 1–2 weeks after PDT and insufficient evaluation of retinal function. Analysis of sequence changes in the retina after PDT are therefore required both morphologically and functionally, allowing us to determine the mechanism of temporal impairment of the retina induced by PDT. Our study showed that a total of 17 of 21 eyes (81%) had complete reabsorption at 6 months. In contrast, Fujita et al studied totally 204 eyes with chronic CSC and reported 182 eyes (89%) with resolution of SRD at 12 months after the half-dose PDT. 35 Our treatment outcome

Currently available efficacy and safety data for pegap- tanib are from clinical trials, which may not accurately reflect pegaptanib ’ s real-world use and potential visual outcomes. Further, there is a need to understand which disease characteristics define earlier lesions in order to identify patients who may have a better response to anti-VEFG therapy (i.e. pegaptanib). We performed a retrospective chart review study in newly diagnosed NV- AMD patients initially treated with 0.3 mg pegaptanib in the US to evaluate actual clinical experience with intravitreal pegaptanib monotherapy and to explore the characteristics of lesions in patients in whom a better response to pegaptanib monotherapy was observed.