Comparison of Choroidal Hyperpermeability Change after Photodynamic Therapy and Ranibizumab for Chronic Central Serous Chorioretinopathy

Jeong Ah Kim; Joo Young Shin; So Hyun Bae; Jee Yun Ahn; Hum Chung; Jang Won Heo

doi:10.3341/jkos.2015.56.2.205

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Kim, Shin, Bae, Ahn, Chung, and Heo: Comparison of Choroidal Hyperpermeability Change after Photodynamic Therapy and Ranibizumab for Chronic Central Serous Chorioretinopathy

Original Article

J Korean Ophthalmol Soc 2015;56(2):205-212.

Published online: 6 September 2015

DOI: https://doi.org/10.3341/jkos.2015.56.2.205

Comparison of Choroidal Hyperpermeability Change after Photodynamic Therapy and Ranibizumab for Chronic Central Serous Chorioretinopathy

Jeong Ah Kim, MD¹, Joo Young Shin, MD¹, So Hyun Bae, MD², Jee Yun Ahn, MD³, Hum Chung, MD¹, Jang Won Heo, MD, PhD^1,

¹Department of Ophthalmology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea

²Department of Ophthalmology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea

³Department of Ophthalmology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea

Address reprint requests to Jang Won Heo, MD, PhD, Department of Ophthalmology, Seoul National University Hospital, #101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea, Tel: 82-2-2072-2438, Fax: 82-2-741-3187 E-mail: hjw68@snu.ac.kr

Received 1 November 201415 December 2014 Accepted 27 January 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To compare changes in choroidal hyperpermeability after half-energy photodynamic therapy (PDT) and intravitreal ranibizumab in the treatment of chronic central serous chorioretinopathy (CSC).

Methods

Post-hoc analysis was performed in a randomized, controlled trial comparing half-energy PDT versus intravitreal ranibizumab for chronic CSC; during the experiments, the other treatment was available for salvage treatment if the original was un-successful at 3 months. A commercially available image analysis program (Adobe^® Photoshop^® CS6 [Adobe Systems, Inc., San Jose, CA]) was used for quantification of change in choriodal hyperpermeability on indocyanine green angiography after half-en-ergy PDT or three consecutive intravitreal injections of ranibizumab. Post-treatment images were subtracted from pre-treatment images after adjustments were made to create images depicting the change in choroidal hyperpermeability with treatment. Integrated gray scale values per area in this image were used for analysis of change in choroidal hyperpermeability.

Results

The calculated change in choroidal hyperpermeability was significantly greater in the half-energy PDT group (17.36 ±8.74) than in the ranibizumab group (6.78 ± 5.03) (p < 0.001). All eyes in the half-energy PDT group showed complete resolution of subretinal fluid, and no significant difference in change of choroidal hyperpermeability was found in eyes that received half-en-ergy PDT as primary or salvage treatment. In the ranibizumab-treated group, subretinal fluid resolution was accomplished in 5 eyes, and these eyes showed a significantly larger decrease in choroidal hyperpermeability when compared with eyes showing poor response (10.31 ± 4.00 vs. 2.74 ± 2.16, p = 0.005). In the successfully treated eyes with ranibizumab, there was no significant difference in choroidal hypopermeability change when compared to half-energy PDT (p = 0.124).

Conclusions

Using our novel method of analysis of change in choroidal hyperpermeability following treatment for chronic CSC, greater change was found in eyes with good response, and the superior outcome of half-energy PDT over ranibizumab may be attributed to greater influence on choroidal hyperpermeability.

Keywords: Choroidal hyperpermeability, Chronic central serous chorioretinopathy, Half-energy photodynamic therapy, Intravitreal ranibizumab injection

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Figure 1.

The method of calculating choroidal hyperpermeability changes after treatment of chronic central serous chorioretinopathy. A 47-year-old female treated with half energy photodynamic therapy (HE-PDT) for chronic central serous chorioretinopathy (CSC). Hyperfluorescent dilated choroidal vessels seen before treatment (A) was disappeared after half-energy PDT (B). The dashed ovoid lines (A, B, and C) indicate the area with choroidal hypermeabity at pretreatment. We quantified the change in choroidal hyper-permeability after treatment for chronic central serous chorioretinopathy using commercially available image analysis software (Adobe® Photoshop® CS6 [Adobe Systems, Inc., San Jose, CA]). By this software, we calculated the mean gray scale in the reference area (circled area in A, B, and C) for correction the contrast difference between pretreatment indocyanine green angiography (ICGA) image and post-treatment ICGA image. We subtracted post-treatment ICGA image from pre-treatment ICGA image to make the subtracted image representing the change in choroidal hyperpermeability after treatment for chronic CSC (C). We calculate in-tegrated gray scale value per area in subtracted image for analysis of change in choroidal hyperpermeability.

Figure 2.

Flow chart of treatment progress. CSC = central serous chorioretinopathy; HE-PDT = half energy photo-dynamic therapy.

Figure 3.

The calculated changes in choroidal hyperpermeability after treatment for chronic central serous chorioretinopathy according to primary treatment methods (HE-PDT versus 3 consecutive intravitreal ranibizumab injections). HE-PDT = half ^* Between-group comparison energy photodynamic therapy. was evaluated by Mann-Whitney U-test.

Figure 4.

The comparison of change of choroidal hyper-permeability after treatment in the successfully treated eyes for chronic central serous chorioretinopathy (HE-PDT versus 3 consecutive intravitreal ranibizumab injections). HE-PDT = half energy photodynamic therapy. ^* Between-group comparison was evaluated by Mann-Whitney U-test.

Figure 5.

The comparison of change of choroidal hyper-permeability after treatment in the eyes treated with 3 consecutive intravitreal ranibizumab injections for chronic central serous chorioretinopathy. ^* Between-group comparison was evaluated by Mann-Whitney U-test.

Figure 6.

The association of the change in choroidal hyper-permeability with decrease in central forveal thickness. HE-PDT = half energy photodynamic therapy.

Table 1.

Demographic characteristics in each group

Baseline characteristics	Half-energy PDT (n = 9)	Ranibizumab (n = 13)	p-value
Sex (M:F)	8:1	12:1
Age (years)	52.89	51.80	0.929^‡
BCVA	0.36 ± 0.19	0.35 ± 0.15	0.846^‡
CFT (μ m)	303.2 ± 43.9	297.2 ± 61.4	0.421^‡
Choroidal hyperpermeability with dilated choroidal vasculature	9 (100)	13 (100)	0.999
on ICGA (n, %)

Values are presented as mean ± SD unless otherwise indicated. PDT = photodynamic therapy; BCVA = best corrected visual acuity in logarithm of the minimum angle of resolution; CFT = central forveal thickness; ICGA = indocyanine green angiography.

^∗ Analyzed with Mann-Whitney U-test.

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