12th EURETINA Congress 6 - 9 September 2012, Milan,Italy

LOW FLUENCE PHOTODYNAMIC LOW FLUENCE PHOTODYNAMIC THERAPY (PDT-BF) IN CHRONIC THERAPY (PDT-BF) IN CHRONIC

CENTRAL SEROUS CENTRAL SEROUS CHORIORETINOPATY (CSC): CHORIORETINOPATY (CSC): SD-OCT EVOLUTION AND ITS SD-OCT EVOLUTION AND ITS

FUNCTIONAL IMPACT.FUNCTIONAL IMPACT. G.F. Pacelli, C.Pisano, L. Baraggia,

B. Pacelli, V. Ferrara, V. Belloli,Arona ITALY

LOW FLUENCE PHOTODYNAMIC LOW FLUENCE PHOTODYNAMIC THERAPY (PDT-BF) IN CHRONIC THERAPY (PDT-BF) IN CHRONIC

CENTRAL SEROUS CENTRAL SEROUS CHORIORETINOPATY (CSC): CHORIORETINOPATY (CSC): SD-OCT EVOLUTION AND ITS SD-OCT EVOLUTION AND ITS

FUNCTIONAL IMPACT.FUNCTIONAL IMPACT. G.F. Pacelli, C.Pisano, L. Baraggia,

B. Pacelli, V. Ferrara, V. Belloli,Arona ITALY

12th EURETINA Congress 6 - 9 September 2012, Milan,Italy

Chronic Central Serous Chorio-Retinopathy (CSC). Chronic Central Serous Chorio-Retinopathy (CSC).

Chronic failure of macular Retinal Pigment Epithelium (RPE) & secondary sierous neuro-retinal detachment (SNRD) from fluid coming out through, focal or more often multifocal, permeability defects of RPE.

Bilateral in 40% of cases.

Disk materials accumulation

EPIDEMIOLOGY:EPIDEMIOLOGY:- Higher Prevalence in male (72-88%), Peak age: 45 years.

- Fourth in incidence among non surgical retinopathy.

- Stress- Type A Personality.- Endogenous or exogenous hyper cortisolism (Cushing Syndrome; Sistemic Corticosteroids th.-Malignant hypertension and Toxemia in pregnancy - Renal failure (Hemodialysis)-Organ transplant- LES,. Polyarteritis nodosa- Wegener Granulomatosys-Use of Ecstasy-

ASSOC IA T IONS

R Brancato et al, Graefe’s Arch 1987R. Levine et al, Ophthalmology 1989E. Y. Yap et al, Arch Ophthalmol 1996

- Become chronic in 5% of cases

- Recurrence in 45-50% of cases.

- Spontaneous resolution in 3-4 months, Good visual recovery.

Acute CSC

Chronic CSC years later.

Guide to LASER therapyGuide to LASER therapy

FLUORESCEIN ANGIOGRAPHY (FA):FLUORESCEIN ANGIOGRAPHY (FA):

RPE INVOLVEMENT AND CLINICAL CHARACTERIZATION OF THE DISEASE

ICGa ANGIOGRAPHY :ICGa ANGIOGRAPHY :

Choroideal involvementChoroideal involvement -Primary alterations of the Choroid.-Primary alterations of the Choroid.

- Choroideal perfusion defects

- Choroideal vascular Hyper-permeability

A. Scheider et al, Am J Ophthalmol 1993F. Cardillo Piccolino et al, Retina 1994D. R. Guyer et al, Arc Ophthalmol, 1994

Acute CSC Chronic CSC

Guide to PDT therapy

PRCL conditions directly correlated with fuctional recovery after SRD resolution.

Scarso o nessun

Recupero finzionale.

SD-OCT:SD-OCT: photoreceptor cell layer photoreceptor cell layer (PRCL) involvement(PRCL) involvement. .

Thickening

Granulation

Atrofiaphotoreceptor Atrophy

complete fuctional recovery

Scarse or none functional recovery

Cardillo Piccolino et al. - Am J Ophthalmol, 2005; 139:87

complete or partial functional recovery

• To the current state of the art, there isn’t a “gold standard” therapy for chronic central serous chorio-retinopathy.

• Recently PDT proved to be effective in: reducing neuroretinal serous detachment improving BCVA.

• PDT cause: 1) choriocapillar endothelial damage ( trombosys of the lumen).2) choriocapillar Transient hypoperfusion.

3) Choroideal Vascular remodeling ( long term period ), 4) Reduction in congestion and secondary extravascular leakage.

• However described not negligible complications1) CNV development. 2) Persistent

choriocapillar ischemia. 3) RPE

atrophy in exposed areas.

• Recently developed modified protocols of PDT ( half dosage of veterporfine, reduced fluence PDT). Low fluence PDT results are surely promising as several clinic study has allready demonstrated.

• Minimal Choroideal hypoperfusion in eyes treated with low fluence PDT of 25 J/cm2.

• The majority of patients treated with Standard PDT (50 J/cm2) showed an important choriocapillar hypoperfusion one week later that persisted up to three months

Invest Ophthalmol Vis Sci. 2006;47:371–376

Materials and Methods:Materials and Methods:

• CSC:CSC: 22 eyes 22 eyes of 19 consecutive patients of 19 consecutive patients • 14 14 ♂♂ e 5 e 5 ♀♀; mean age 64 yrs; Mean FU: 12.5 mos). ; mean age 64 yrs; Mean FU: 12.5 mos). • SRD Onset > 6 months ; SRD Onset > 6 months ;

LOW-FLUENCE PDT LOW-FLUENCE PDT (25 J/cm2);Mean of treatments: 1.2Treatment Strategy guided by: Angiography (FA&ICGa). Treatment Strategy guided by: Angiography (FA&ICGa).

Evaluation at baseline and quarterly later on:Evaluation at baseline and quarterly later on:• BCVA logBCVA log (ETDRS charts). (ETDRS charts). • SD-OCT RMT SD-OCT RMT ( eye tracking system ).( eye tracking system ).

• After 6 months of follow up:After 6 months of follow up: Microperimetry with central 20° strategy pattern. Microperimetry with central 20° strategy pattern.

• FA & ICGa repeated in case of clinical unsuccess after 3-6 months.FA & ICGa repeated in case of clinical unsuccess after 3-6 months.

Statistic Significativity: calculated comparing trated area parameters with diffuse macular sensitivity with Wilcoxon Test for paired datas

(reference values P=0.001).

BCVA: 0.3 logmar

chronic CRC : ♂ 51 years old, SNRD for >8 months; follow-up 15 months

F-U 15 months BCVA: 0.0 logmar

BCVA: 0.38 logmar

BCVA: 0.2 logmar

Chronic CSC : ♂ 31 years old; First episode 10 years later (5 recurrences): Macular SRD for > than 10 mos

F-U 15 mos BCVA: 0.2 logmar

Chronic CSC : ♀ 76 years old, SRD for 6 months without resolution.

BCVA: 0.14 logmar

BCVA: 0.0 logmar12 months later

405

284 283 282 275,13

100150200250300350400450500

Follow-up

RMT

micr

ons

405 284 283 282 275,13

pre-laser 3 months 6 months 9 months 12 months

Mean percentage increment (%) of BCVA : 58% (P<0.001*).

Initial BCVA : 0.36 log.;Final BCVA: 0.21 log. Increment in 89.5 % of cases. ( 2 stable)

Mean percentage Reduction of RMT: 31 % (P<0.01*). MEAN Initial RMT: 475 μμmm. Final mean RMT: 275.13 μμmm. Reduction in 94 % of cases.

0,36

0,250,220,210,21

0,00

0,05

0,10

0,15

0,20

0,25

0,30

0,35

0,40

pre-laser3 months6 months9 months12 months

Follow-up

BCVA

Log

mar

No significant differences between sensitivity in the treated area compared to mean global sensitivity except in rare cases of preexisting alterations

of RPE integrity on Autofluorescence and/or deep photoreceptor layers atrophy on SD-OCT.

Results:Results:

Conclusions:

• The good results of our study, even with the limitations related to the absence of a control group, confirmed the effectiveness and safety of Low Fluence PDT in the treatment of chronic CSCR.

• The older age of our cohort confirm the efficacy of LF-PDT even if some patients allready had important RPE distrophy.

• Only three patients experimented a single recurrence none of these located in the same area ( 1 treated with extrafoveal direct laser, 1 with PDT and the last one left untreated for diffuse RPE distrophy without any angiographic leakage).

Thanks for your attention!!.