This study showed a 53% resolution rate of SRF after SML in CSCR patients. Baseline SFCT of the affected eye and the presence of RPE/inner choroid alterations were the OCT biomarkers related to SML efficacy. The decline of mean SFCT after SML was only noticed in Group 1. By comparison, mean SFCT of Group 2 got slightly increased. The change of SFCT after SML was also identified as a factor influencing the anatomic outcomes of SML in CSCR in the current study.
Unlike traditional laser photocoagulation, SML avoids scarring of RPE and retina by diffusing the heat to surrounding tissue. SML can stimulate SRF absorption by inducing reactions in RPE chromophores, including the possible production of heat shock protein(16). SML has been shown to be effective in both acute and chronic CSCR. Superior visual rehabilitation was noted in SML-treated patients compared to observation in terms of BCVA, contrast sensitivity, and metamorphopsia in acute CSCR(11). Arsan et al. demonstrated SML could significantly increase BCVA and decrease SRF in non-resolving CSCR patients(17). Prasuhn et al. showed decreased central retinal thickness after SML in CSCR patients with persistent SRF either with or without secondary CNV(18). However, compared with half-dose PDT, SML has a lower SRF complete resolution rate(19). The PLACE trial, a multicenter prospective randomized clinical trial designed for chronic CSCR, showed 29% of patients with complete SRF resolution in the SML group and 67% of patients with complete SRF resolution in the half-dose PDT group at 7–8 months after the first treatment(19). In our study, the resolution rate of SRF is 53% after a single SML, which is higher than PLACT trial. The reason might be both acute and chronic CSCR were involved in this study. And Group 1 had much shorter symptoms than group 2, indicating more acute CSCR got resolved after treatment.
Both choroid and RPE contribute to the pathogenesis of CSCR (1). CSCR belongs to the pachychoroid disease spectrum(20). The choroid thickness of the affected eyes in CSCR is much thicker than the healthy eyes and the contralateral eyes(21). Increased choroid thickness indicates hyper-permeability alterations of the choroid and can be recognized as the indicator of disease activity(1, 22). Even though baseline SFCT was not significantly different between the two groups, it acted as a predictor of SRF resolution in our study. The thicker choroid of diseased eyes indicates a worse response to SML, which might be explained by the high activity of CSCR of these patients. Decreased SFCT was noticed after different treatments for CSCR(23–26). Similar alterations of choroid thickness after SML treatment were also reported by other researchers(17, 18). Compared with observation, choroidal thickness was significantly lower in the SML-treated group at eight weeks, sixteen weeks, and six months after treatment in acute CSCR(11). In our study, decreased SFCT was only noticed in the SRF-resolved group (Group 1). The decrease of SFCT may indicate less activity of the disease and improvement of choroidal hyperpermeability after SML treatment. In Group 2, no decrease of SFCT was observed at one month or three months after SML treatment, indicating the prolonged high permeability of choroid, which might be the reason for the persistence of SRF in these eyes. Our findings enhanced the importance of choroid in the pathology and prognosis of CSCR.
Diffuse RPE changes are often observed in chronic CSCR, including RPE detachment, RPE hypertrophy, and RPE atrophy(1). Diffuse RPE atrophy was described in cases of severe chronic CSC, possibly caused by long-term SRF persistent, phachychoroid vessels compression, and inner choroid ischemia(27). If the area of diffuse atrophic RPE alterations more than five disc diameters at the macula, it can be defined as severe chronic CSCR(28). Hypertransmission of RPE on OCT images indicates RPE attenuation or disruption(29). As inner choroid has a direct influence on RPE, inner choroid attenuation may cause ischemia of RPE, which may lead to RPE dysfunction eventually. Since SML was designed to target RPE, RPE and inner choroid alterations might have a certain impact on the treatment effect. This is proven by the fact that only one out of twenty-seven eyes in Group 2 was graded as having no RPE and inner choroid alterations. The presence of RPE/inner choroid alterations was also shown to be a predictive factor related to insufficient response to SML treatment.
A previous study found that age and disease duration were risk factors for persistent SRF after SML in eyes with chronic CSCR(30). But in our study, these two factors were not correlated to SML efficacy. Even symptom duration of Group 1 (2.42±1.361) was less than that of Group 2 (4.04±3.848) significantly, it is not a predictive factor for SRF resolution. The possible explanation is that both acute and chronic CSCR were involved in this study. The rate of acute CSCR in group 1 was higher than that in group2. However, when taking other factors into account, it became less important.
One limitation of this study is that many subjects only had one visit after receiving SML. So only 33 eyes got two EDI-OCT taken after SML and these eyes were selected in the subgroup analysis for investigating longitudinal SFCT change after the treatment. The possible reasons for loss of follow-up include a lack of desire for further treatment after vision rehabilitation and phased lockdown during the pandemic of COVID-19 increased the difficulty of arranging follow-ups. Another limitation of this study is using a single OCT image for choroidal thickness measurement. However, a study has demonstrated that no significant difference between SFCT and the mean of choroidal thickness in the central millimeter of cube scans by using swept-source OCT(31). We have to clarify that the change of choroid we measured in the current study is limited to the central macular region. Whether the change of choroid thickness in a larger area influents treatment effect of SML still needs further investigation.