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

背景：中心性浆液性脉络膜视网膜病变(CSC)是全球第四大最常见的黄斑病变，可导致不可逆转的视力丧失。它主要影响20到60岁的男性。大型前瞻性随机对照试验(如SPECTRUM和PLACE试验)为该病的治疗提供了新的线索。他们已经确定光动力疗法(PDT)是治疗CSC的最有效的选择，CSC导致脉络膜血管局部低灌流，从而导致血管重塑。然而，接受PDT治疗的患者中，约有20%至30%的患者没有表现出足够的治疗反应。这种缺乏疗效的原因尚不清楚，并被认为取决于脉络膜血管的特性，这可能会影响PDT的反应。最近，有人推测CSC患者眼部涡旋静脉之间的脉络膜吻合扩张。在一项对37例CSC患者的回顾性研究中，Pang等人。在83%的CSC患者眼中，超宽视野ICG血管造影术检测到脉络膜血管扩张和涡状静脉壶腹部充血。两项进一步的回顾性研究还发现，与健康对照组相比，使用SS-OCT成像的CSC患者的脉络膜吻合口更大，该成像仅限于脉络膜解剖的可视化，但不能反映脉络膜血流。虽然上述假设很耐人寻味，可能具有重大的临床意义，但使用当前金标准ICGA进行的前瞻性对照研究尚不多见。此外，到目前为止，尚不清楚所观察到的脉络膜变化是否与CSC复发、慢性化甚至PDT治疗反应的风险增加有关。目的：本研究的目的是以前瞻性和可控性的方式研究CSC患者的脉络膜血管解剖，特别是脉络膜吻合口的发生，并确定它们作为复发、慢性化和PDT治疗成功的潜在预后因素的相关性。计划：A部分：使用超宽域ICG血管成像和光学相干断层扫描(OCT)对CSC患者和对照组的涡状静脉吻合和脉络膜解剖和生理的其他方面进行前瞻性比较。100名临床确诊为CSC的患者将接受超宽视野ICG血管造影。100名对照患者将从接受广泛多模式成像的非CSC患者中招募。B部分：宽视场ICG血管造影图像的多中心回顾分析以确定可能的预后因素。阿姆斯特丹和弗莱堡宽视场ICGA的回顾分析。将分析确定的因素与长期视力、治疗反应、疾病复发和慢性化的相关性。此外，还将分析接受PDT治疗的区域在治疗前后的脉络膜血流情况。

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.