Investigating the role of vortex vein anastomoses in central serous chorioretinopathy (CSC)

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Background: Central serous chorioretinopathy (CSC) is the fourth most common maculopathy worldwide and can lead to irreversible vision loss. It primarily affects men between 20 and 60 years of age. Large prospective randomized controlled trials (e.g. SPECTRA and PLACE trial) have shed new light upon the treatment of the disease. They have established photodynamic therapy (PDT) as the most effective treatment option for CSC, which induces a local hypoperfusion of choroidal vessels and a consequent vascular remodelling. However, about 20 to 30% of patients treated with PDT do not show a sufficient treatment response. The reason for this lack of therapeutic efficacy is ill defined and was suggested to depend on choroidal vascular characteristics that may impact response to PDT.Recently, it has been postulated that CSC patients show dilated choroidal anastomoses between the eye’s vortex veins. In a retrospective study of 37 patients with CSC, Pang et al. detected dilated choroidal vessels and congested vortex vein ampullas in 83% of eyes with CSC using ultra-widefield ICG angiography. Two further retrospective studies have also found larger choroidal anastomoses in CSC patients compared to healthy controls using SS-OCT imaging, which is limited to the visualization of the choroidal anatomy, but does not reflect choroidal blood flow. While the above mentioned hypothesis is intriguing and could have major clinical implications, prospective controlled studies on this subject using the current gold-standard ICGA are lacking. Furthermore, it is to date unclear if the observed vascular choroidal changes may be associated with an increased risk of CSC recurrences, chronicity or even PDT treatment response.Aim: The aim of the proposed project is a) to investigate choroidal vascular anatomy, in particular the occurrence of choroidal anastomosis, in CSC patients in a prospective and controlled manner and b) to determine their relevance as a potential prognostic factor for recurrence, chronicity and PDT treatment success.Plan: Part A: Prospective comparison of vortex vein anastomoses and other aspects of choroidal anatomy and physiology in CSC patients and controls using ultra-widefield ICG angiography and optical coherence tomography (OCT). 100 patients with a clinically confirmed diagnosis of CSC will undergo ultra-widefield ICG angiography,. 100 control patients will be recruited from non-CSC patients that undergo extensive multimodal imaging. Choroidal vascular characteristics will be compared between these groups.Part B: Multicentre retrospective analysis of widefield ICG angiography images to identify possible prognostic factors.Retrospective Analysis of widefield ICGAs from Amsterdam and Freiburg. The correlation of the identified factors with long-term visual acuity, therapy response, disease recurrence and chronicity will be analysed. Moreover, the pre- and postoperative choroidal flow in the area that received PDT treatment will be analyzed.