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

Abstract

Aims: To evaluate the changes in the choroidal vasculature in central serous chorioretinopathy (CSC) after photodynamic therapy (PDT) with verteporfin and to assess its potential role as a treatment option.

Methods: A prospective, non-comparative, interventional study was performed in eyes with persistent CSC or chronic CSC that had fluorescein leakage at the fovea. All eyes received one single session of PDT with verteporfin (6 mg/m2 body surface area) followed by application of 50 J/cm2 laser at 689 nm. The laser spot size was guided by findings in ICG-A.

Results: Six eyes from six patients with a mean follow up of 12.7 months were analysed. Narrowing of the original dilated choroidal vessels and decrease in extravascular leakage could be demonstrated in all (100%) PDT treated eyes. 3 months after PDT, the mean diameter of the dilated choroidal vessel reduced from 546 microm to 371 microm (p=0.028). Five (83%) patients had improvement in visual symptoms and best corrected visual acuity. Fluorescence leakage stopped at the 1 month follow up in five eyes (83%) and at 3 months in all six eyes (100%). One eye developed choroidal neovascularisation at 3 month follow up. There was no other serious ocular or systemic complication.

Conclusions: PDT is successful in stopping the fluorescein leakage in all six patients without recurrence of CSC. The ICG-A findings of choroidal vascular remodelling and decreased choroidal permeability after PDT are encouraging. As the sample size is small and the mean follow up period is short, further trials of PDT with verteporfin for CSC are required to address the optimal parameters in ensuring longer term safety and efficacy outcome.

Figure 1

Right eye of case 1, a 48 year old Chinese woman, with central serous chorioretinopathy (CSC) manifesting as persistent combined focal RPE leakage and serous pigment epithelium detachment (PED). (A) Fundus photography showing with serous PED of 800 μm in diameter and a pocket of subretinal fluid with precipitates. (B) Late phase of FA demonstrating a uniformly filled pocket of hyperfluorescence within the serous pigment epithelium and a focal retinal pigment epithelial leakage adjacent to it. (C) Early phase of the ICG-A showing dilated choriocapillaris in the macular area. The arrowheads mark the diameter of the reference retinal arteriole and the arrows mark the two sides of the most dilated choroidal vessels at fovea. Red circle represents the size and location of the laser spot delivery during PDT. (D) Late phase of the ICG-A revealing a loculated hyperfluorescence caused by the pigment epithelium detachment and a diffuse hyperfluorescence in the macula secondary to extravascular leakage from the congested choroidal vessels. (E) Late phase of FA one month after PDT, showing complete resolution of the subretinal fluid and the serous pigment epithelium detachment. (F) The calibres of the originally dilated choroidal vessels appeared narrower in size as shown by the open arrows in the early phase of the ICG-A at 1 month follow up. (G) No extravascular leakage in the late phase of the ICG-A. (H) The choroidal vasculature remodelling persisted as shown in the early phase of the ICG-A at the 2 year follow up.

Figure 2

Left eye of case 6 having CSC with pattern of chronic diffuse leakage. (A) Fundus photograph of the left eye of a 44 year old Chinese man revealing loss of the foveal reflex, unhealthy retinal pigment epithelium (RPE) with mottling and subretinal fibrinous deposition. (B) Mid phase FA demonstrating multiple angiographic leakages on a background of RPE atrophy with transmission defect. (C) Early phase of ICG-A showing congested and dilated choroidal vessels. The diameters of the reference arteriole and the most dilated choroidal vessel are marked with arrows and arrowheads, respectively. The red circle showed the location and the size of the laser spot in PDT. (D) Late phase of ICG-A demonstrating late profuse extravascular leakage. (E) Fundus photograph 3 months after PDT showing a dry macula. (F) No angiographic leakage could be seen in the late phase of the FA. (G and H) Repeated ICG-A at 3 months showed a persistent narrowing of the anterior choroidal vessels and diminished extravascular hyperfluorescence leakage in early and late phases respectively.