Study of Subretinal Exudation and Consequent Changes in Acute Central Serous Chorioretinopathy by Optical Coherence Tomography

doi:10.1016/j.ajo.2014.06.015

American Journal of Ophthalmology

Volume 158, Issue 4, October 2014, Pages 752-756.e2

https://doi.org/10.1016/j.ajo.2014.06.015 Get rights and content

Purpose

To investigate the characteristics of subretinal exudation and consequent morphologic changes in acute central serous chorioretinopathy (CSC) using spectral-domain optical coherence tomography (OCT).

Design

Prospective, observational, cross-sectional case series.

Methods

Patients with CSC with symptom duration of fewer than 3 months underwent visual acuity measurement, fundus observation and spectral-domain OCT examinations and then were evaluated for subretinal exudation and other changes.

Results

A total of 123 patients (123 eyes) were included, all showing various retinal pigment epithelium (RPE) abnormalities on OCT. OCT also showed subretinal exudation (65 eyes, 52.8%); retinal dipping (14 eyes, 11.4%); and photoreceptor layer defects (88 eyes, 71.5%). Without exception, the locations of these pathologic changes were closely related to the abnormal sites in the RPE. Those with subretinal exudation showed shorter durations of symptoms, whereas those with photoreceptor layer defects showed longer durations. In most eyes with retinal dipping, exudation connected it to RPE abnormalities. The defects of the photoreceptor layer, which involved the photoreceptor outer segment in 68 eyes, the photoreceptor inner segment in 20 eyes, and the outer nuclear layer as well, were likely to be the consequence of retinal dipping.

Conclusions

OCT findings suggested that in eyes with acute CSC subretinal exudation, which indicated fibrin leakage through the RPE defects, might cause retinal dipping, thus leading to photoreceptor layer defects, and that spectral-domain OCT could provide a better understanding of the pathologic changes in acute CSC.

Section snippets

Methods

The research protocol and the collection of clinical data and OCT images for this prospective observational cross-sectional study were approved by the ethics committee of the Eye and Ear Nose Throat Hospital, Fudan University (KJ2009-16). Informed consent was obtained from each patient.

In the current study, we enrolled patients with consecutive acute CSC who visited the clinic of Eye and Ear Nose Throat Hospital of Fudan University, Shanghai, between January and June 2013. The clinical

Results

In total, 123 eyes of 123 patients enrolled were studied; 100 of the enrollees were male and 23 were female, 19–76 years of age; the mean age was 42.92 ± 8.87. The mean BCVA (logMAR) was 0.33 ± 0.22 (Snellen 0.47; range, 0.1–1.0) and the mean duration was 24.26 ± 24.41 days (range, 1–90). FA was performed in 48 eyes, showing that each had 1 or several leakage points at the level of the RPE and that 29 eyes presented with typical smokestack dye leaking.

The number, symptom duration and BCVA of

Discussion

Along with localized retinal detachment and RPE abnormalities, in the current study, subretinal exudation, retinal dipping and photoreceptor layer defects were found by OCT in eyes with acute CSC. The locations of the exudation, retinal dipping and photoreceptor layer defects were found, without exception, to be closely related to the site of RPE abnormalities. As indicated by the average symptom duration in the patients with varying OCT findings (Table), the manifestations seemed to occur

Jia Yu is currently a Medical Doctor student of Ophthalmology in Eye and Ear Nose Throat hospital Fudan University Shanghai, China. Her clinical and research interests are retinal disorders and retinal imaging.

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The lesion boundary of central serous chorioretinopathy (CSCR) is the guarantee to guide the ophthalmologist to accurately arrange the laser spots, so as to enable this ophthalmopathy to be treated precisely. Currently, the accuracy and rapidity of manually locating CSCR lesion boundary in clinic based on single-modal fundus image are limited by imaging quality and ophthalmologist experience, which is also accompanied by poor repeatability, weak reliability and low efficiency. Consequently, a multi-modal fundus image-based lesion boundary auxiliary location method is developed. Firstly, the initial location module (ILM) is employed to achieve the preliminary location of key boundary points of CSCR lesion area on the optical coherence tomography (OCT) B-scan image, then followed by the joint location module (JLM) created based on reinforcement learning for further enhancing the location accuracy. Secondly, the scanning line detection module (SLDM) is constructed to realize the location of lesion scanning line on the scanning laser ophthalmoscope (SLO) image, so as to facilitate the cross-modal mapping of key boundary points. Finally, a simple yet effective lesion boundary location module (LBLM) is designed to assist the automatic cross-modal mapping of key boundary points and enable the final location of lesion boundary. Extensive experiments show that each module can perform well on its corresponding sub task, such as JLM, which makes the correction rate (CR) of ILM increase to 92.11%, comprehensively indicating the effectiveness and feasibility of this method in providing effective lesion boundary guidance for assisting ophthalmologists to precisely arrange the laser spots, and also opening a new research idea for the automatic location of lesion boundary of other fundus diseases.
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As a common macular disease, the effect of CSCR on vision also should not be underestimated. CSCR is characterized by neurosensory retinal detachment (NRD, as shown in Fig. 1) with or without pigment epithelium detachment (PED, as shown in Fig. 14) [5–7], and usually leads to blurred vision, central scotoma, deformed vision and even permanent visual loss in serious cases. Although CSCR is a self-limited ophthalmic disease, that is, some patients can achieve self-healing without any intervention within three to six months, there are still many patients with prolonged course of disease that cannot be autonomously able to reach re-attachment of the neurosensory retina occurring [8].
The diameter of central serous chorioretinopathy (CSCR) lesion is one of the important indicators to evaluate the severity of CSCR and the efficacy of corresponding treatment schemes. Traditional manual measurement by ophthalmologists is usually based on a single or a small number of optical coherence tomography (OCT) B-scan images. This measurement scheme may not be convincing, vulnerable to subjective factors and lower efficiency. To alleviate the above situation, this paper proposes an intelligent key boundary point location method for all B-scan images of a single patient to assist in the rapid and accurate diameter measurement of the CSCR lesion area. Firstly, an initial location module (ILM) based on the multi-task learning paradigm is appropriately adjusted and introduced into the key boundary point location task, which preliminarily realizes the rapid location of key boundary points. Secondly, to further ameliorate the ILM, a gradient based correction module (GBCM) is designed, followed by the construction of the cascade model (ILM-GBCM) which improves the location accuracy of key boundary points as a whole. Extensive experiments based on five different convolutional neural network (CNN) backbones are carried out, revealing the feasibility of ILM in this task and the effectiveness of ILM-GBCM. On 912 testing images, the maximum correction ratio reaches 83.66%, and the minimum location time at the image level is as low as 0.1754 s, which not only confirms the necessity of correction operation, but also greatly reduce the time cost of ophthalmologists' manual measurement operation in clinic.
Weakly supervised detection of central serous chorioretinopathy based on local binary patterns and discrete wavelet transform
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In this work, we further apply ML technology and image processing technology to the detection of CSCR in fundus diseases, and carry out detail innovation to improve the detection accuracy of this disease. Many researchers have done clinical studies on CSCR which is caused by the impairment of retinal pigment epithelium (RPE) function due to the increased choroidal permeability, characterized by neurosensory retinal detachment (NRD) with or without pigment epithelium detachment (PED) [5–7], as shown in Fig. 1. The main symptoms of CSCR are blurred vision, decreased vision and deformed vision.
Central serous chorioretinopathy (CSCR) is a common fundus disease. Early detection of CSCR is of great importance to prevent visual loss. Therefore, a novel automatic detection method is presented in this paper which integrates technologies including discrete wavelet transform (DWT) image decomposition, local binary patterns (LBP) based texture feature extraction, and multi-instance learning (MIL). LBP is selected due to its robustness to low contrast and low quality images, which can reduce the interference of image itself on the detection method. DWT image decomposition provides high-frequency components with rich details for extracting LBP texture features, which can remove redundant information that is not necessary for diagnosis of CSCR in the raw image. The tedious task of accurately locating and segmenting CSCR lesions is avoided by using MIL. Experiments on 358 optical coherence tomography (OCT) B-scan images demonstrate the effectiveness of our method. Even under the condition of single threshold, the accuracy of 99.58% is obtained at K = 35 by only using a high-frequency feature fusion scheme, which is competitive with the existing methods. Additionally, through further detail innovation, such as multi-threshold optimization (MTO) and integrated decision-making (IDM), the performance of our method is further improved and the detection accuracy is 100% at K = 40.
Central serous chorioretinopathy: Towards an evidence-based treatment guideline
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However, subretinal hyperreflective dots can also represent plasma proteins from the choriocapillaris and inflammatory debris (Wang et al., 2005). OCT can reveal fibrin clots that result from fibrinogen leaking through a defect in the RPE (Yu et al., 2014). Although changes in choroidal haemodynamics have been observed in aCSC using laser speckle flowgraphy (Saito et al., 2015), subfoveal choroidal thickness does not appear to be correlated with the amount of SRF (Goktas, 2014).
Central serous chorioretinopathy (CSC) is a common cause of central vision loss, primarily affecting men 20–60 years of age. To date, no consensus has been reached regarding the classification of CSC, and a wide variety of interventions have been proposed, reflecting the controversy associated with treating this disease. The recent publication of appropriately powered randomised controlled trials such as the PLACE trial, as well as large retrospective, non-randomised treatment studies regarding the treatment of CSC suggest the feasibility of a more evidence-based approach when considering treatment options. The aim of this review is to provide a comprehensive overview of the current rationale and evidence with respect to the variety of interventions available for treating CSC, including pharmacology, laser treatment, and photodynamic therapy. In addition, we describe the complexity of CSC, the challenges associated with treating CSC, and currently ongoing studies. Many treatment strategies such as photodynamic therapy using verteporfin, oral mineralocorticoid antagonists, and micropulse laser treatment have been reported as being effective. Currently, however, the available evidence suggests that half-dose (or half-fluence) photodynamic therapy should be the treatment of choice in chronic CSC, whereas observation may be the preferred approach in acute CSC. Nevertheless, exceptions can be considered based upon patient-specific characteristics.
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Chunhui Jiang MD, PhD is a professor in the Department of Ophthalmology at Eye and Ear Nose Thoat hostipal Fudan University Shanghai, China. He got his doctor degree from Fudan University. His clinical and research work mainly focus on retinal imaging by OCT, as well as vitrectomy to treat various vitroretinal entities.

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Original articleStudy of Subretinal Exudation and Consequent Changes in Acute Central Serous Chorioretinopathy by Optical Coherence Tomography

Purpose

Design

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Am J Ophthalmol

Original article
Study of Subretinal Exudation and Consequent Changes in Acute Central Serous Chorioretinopathy by Optical Coherence Tomography