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Erdem Ergun, MD; Michael Tittl, MD; Michael Stur, MD

Arch Ophthalmol. 2004;122:37-41.

ABSTRACT
Objective  To examine the efficacy and safety of photodynamic therapy with verteporfin in the treatment of subfoveal choroidal neovascularization secondary to central serous chorioretinopathy (CSC).

Design  Prospective interventional, noncomparative case series.

Methods  After the diagnosis of a subfoveal choroidal neovascularization secondary to CSC, 26 eyes of 24 patients were treated with photodynamic therapy with verteporfin. Patients were then followed up every 2 to 3 months, with further treatments performed as deemed necessary through fluorescein angiography. The mean observation was 22.2 months (range, 6-36 months; median, 24 months).

Results  There was marked visual improvement, with patients gaining a mean of 1.6 lines after 1 year and a mean of 2.2 lines after 2 years. There was a statistically significant change in visual acuity from baseline to 12 and 24 months (mean difference, –0.16, P = .03; and mean difference, –0.22, P = .02; respectively; t test for both). There was no correlation between patients' age or greatest linear dimension of the lesions and the final outcome (P>.10 for all). No patient experienced any adverse effects.

Conclusion  Photodynamic therapy with verteporfin resulted in a beneficial outcome in the treatment of subfoveal choroidal neovascularization secondary to CSC, without serious adverse effects in this case series.

INTRODUCTION

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CENTRAL SEROUS chorioretinopathy (CSC) is a disease that typically affects middle-aged adults and involves the sensory retina, retinal pigment epithelium (RPE), and choroid.¹ Patients usually have mild visual loss. This generally resolves without therapy, although the disease can become chronic, with ensuing RPE decompensation.^2-3 Some patients, particularly older adults,⁴ can develop choroidal neovascularization (CNV), which leads to a severe loss in visual acuity.

Photodynamic therapy (PDT) with verteporfin is a new method for the treatment of subfoveal CNV in various diseases.^5-16 Briefly, patients with a subfoveal CNV receive an infusion with verteporfin. Thereafter, the CNV is treated with a modified diode laser (689 nm). Besides conventional thermal laser therapy,^17-22 this is the only method for the treatment of CNV that has a proven efficacy in large, multicenter, randomized clinical trials.^5-9

The fact that these clinical trials were efficacious and had few treatment-related adverse effects led us to examine the efficacy of PDT as a treatment for subfoveal CNV secondary to CSC, as there has hitherto been no proven treatment for this disorder. Because most patients are young and typically active in the workforce (so-called type A personalities²³), rehabilitation of these patients is particularly important.

METHODS

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Twenty-six eyes of 24 patients were treated. The age range was 36 to 78 years (mean ± SD, 57.0 ± 13.0 years; median, 55 years). Nineteen eyes from men and 7 from women were treated.

All patients were examined for best-corrected Snellen visual acuity and underwent a dilated fundus examination and fluorescein and indocyanine green (ICG) angiography. Patients with subfoveal CNV defined on a fluorescein or ICG angiogram were treated according to treatment guidelines.^24-25 Informed consent was received from each patient before treatment, and institutional review board approval was obtained.

All patients were seen at 2- to 3-month intervals, and Snellen visual acuity examination, dilated fundoscopy, and fluorescein or ICG angiography were repeated at each visit. The diagnosis of CSC was based on the patient's history and typical fluorescein angiographic and ICG leakage patterns. The existence of drusen was ruled out to avoid a misinterpretation with age-related macular degeneration.

Patients' Snellen visual acuity was converted to logMAR units for statistical assessment. The SPSS system (SPSS for Windows version 10.0; SPSS Inc, Chicago, Ill) was used for statistical computations. The t test was used to assess the effect of change in visual acuity from baseline, and the Spearman rank correlation () test and a logistic regression analysis (analysis of covariance) were used to assess the effect of individual variables on the change in visual acuity and the final outcome. All P values are results of 2-tailed tests. The chosen level of statistical significance was P = .05.

RESULTS

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Patients were followed up for 6 to 36 months (mean, 22.2 months; median, 24 months) after beginning PDT. All eyes were available for evaluation at 6 months, 24 (92%) of 26 eyes were available for follow-up after 1 year, and 19 (73%) of 26 eyes were available after 2 years. Of those patients lost to follow-up, 1 had a visual improvement of 3 lines at the last follow-up, 5 had remained stable, and 1 had a significant visual loss of 4 lines at the last follow-up examination.

Six months after beginning PDT, there was a clear treatment benefit. Seven (27%) of 26 eyes showed a gain in visual acuity of 3 lines or more, whereas 16 (62%) of 26 remained stable (within 2 lines). Three (12%) of 26 eyes lost 3 lines or more. There was a mean ± SD gain of 0.09 ± 0.33 logMAR units and a mean ± SD gain of 1.00 ± 0.12 line.

After 1 year, 12 (50%) of 24 eyes had an improvement in visual acuity of 3 lines or more, and 9 (38%) of 24 remained stable. Only 3 (13%) of 24 eyes lost 3 lines or more. The mean ± SD gain was 0.16 ± 0.33 logMAR units, and the mean ± SD gain from baseline was 2.00 ± 0.22 lines.

After 2 years, 9 (47%) of 19 eyes had an improvement of 3 lines or more. Eight (42%) of 19 had stable visual acuity (within 2 lines), and 2 (11%) of 19 had lost 3 lines or more. The mean ± SD gain was 0.22 ± 0.37 logMAR units, or more than 2 lines. Figure 1 shows the changes in visual acuity throughout the treatment.

View larger version (15K): [in this window] [in a new window] Figure 1. Mean logMAR visual acuity and SD.

The greatest linear dimension (GLD) of the CNV was 2225.4 µm before treatment. The GLD remained virtually unchanged during treatment; the mean GLD at the last treatment was 2410 µm. However, 11 patients required only 1 treatment. None of the patients showed any leakage on fluorescein angiography at their last follow-up.

There was a statistically significant difference in the change in mean logMAR values from baseline at 12 and 24 months (mean difference, –0.16, P = .03; and mean difference, -0.22, P = .02), that is, patients gained 1.6 and 2.2 lines, respectively, although there was no statistically relevant change at 6 months (mean difference, –0.10; P = .07). Interestingly, neither patient age nor GLD of the lesion correlated with the change (gain or loss) in visual acuity after 1, 12, and 24 months (P>.10 for all) (Table 1). However, baseline visual acuity correlated with the change in visual acuity at 12 and 24 months. These results were confirmed on regression analysis. Furthermore, there was a statistically significant correlation between the change at 6 months and the changes at 12 and 24 months (R² = 0.87, P<.001; and R² = 0.59, P = .04; respectively).

View this table: [in this window] [in a new window] Regression Coefficient Between Visual Acuity Outcome at 6 Months, 1 Year, and 2 Years vs Age, Lesion Size, and Baseline Visual Acuity

The mean number of treatments needed per patient was 2.6 (range, 1-7; median, 2). In the first year, a median of 2 treatments was necessary; in the second, the median number was 1. None of the patients experienced adverse effects. No photosensitivity reaction was seen.

Figure 2A-C shows images from a typical patient with CSC and CNV. Before PDT, the visual acuity was 20/200 OS. The red-free image and the fluorescein angiogram show an active CNV lesion. After 2 years, the visual acuity was 20/22 OS, and angiograms show an inactive CNV (Figure 2D-F). The patient had 3 treatments with PDT.

View larger version (106K): [in this window] [in a new window] Figure 2. A, Red-free image before photodynamic therapy (PDT), visual acuity 20/200. B, Early-phase fluorescein angiogram before PDT. C, Late-phase fluorescein angiogram before PDT. D, Red-free image 2 years after first PDT, visual acuity 20/22. E, Early-phase fluorescein angiogram 2 years after first PDT. F, Late-phase fluorescein angiogram 2 years after first PDT.

COMMENT

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This study shows that PDT is a beneficial treatment for subfoveal CNV secondary to CSC. More than three quarters of all patients have stable or better visual acuity 2 years after beginning treatment. Because some patients were lost to follow-up, it is possible that there is a bias to the treatment benefit, with those losing visual acuity not coming back. However, the results indicated that most patients had at least stable visual acuity, which minimizes any possible bias, in our opinion.

Conventional laser therapy offers a proven benefit in the treatment of CNV, particularly in lesions that are outside the center of the foveal avascular zone (extrafoveal or juxtafoveal) and in small, well-demarcated classic CNV lesions that are located subfoveally.^17-22 However, subfoveal treatment leads to an immediate, marked loss of visual acuity as the overlying neurosensory retina is damaged, and extrafoveal and juxtafoveal CNVs treated with laser can also have a subfoveal recurrence. Most patients treated with PDT experience a less dramatic loss of vision, and some describe a subjective improvement in visual acuity that cannot be seen on an objective vision examination. Furthermore, as seen in the Treatment of Age-Related Macular Degeneration With Photodynamic Therapy (TAP) study,^5-7 contrast sensitivity is much better in patients treated with PDT. This makes it a viable alternative in routine clinical practice.

Central serous chorioretinopathy has a heterogeneous course. Most cases resolve spontaneously without any treatment.^{4, 24} However, some persons, particularly older patients, develop chronic disease, leading to decompensation of the RPE and other complications.^2-4,25-27 One study⁴ demonstrated in older patients that CNV, persistent pigment epithelial detachment, and the accumulation of subretinal fluid are primary causes of deteriorating visual acuity, aside from the frequent recurrences of CSC. For extrafoveal leaks, focal laser photocoagulation has been advocated^28-31; however, this procedure is known to induce CNV.³²

The exact cycle of events leading to CSC is still unknown. It is generally accepted that CSC develops primarily as a result of choroidal vascular hyperpermeability,⁴ which can be seen on ICG angiography.^33-34 This leads to an increase in choroidal tissue hydrostatic pressure, which supersedes that of the retina, thus reducing or stopping solute flow across the RPE. As a result, a serous detachment can occur, as well as a change in the RPE layer that Carvalho-Recchia et al³⁵ have described as a "blowout" of the RPE. It is not clear under what conditions CNV can develop. Our demographic results are, however, similar to those of Spaide et al⁴ in that 16 of 24 patients were older than 50 years.

Psychopharmacologic medications, corticosteroid use, and hypertension^{30, 35-38} are risk factors for CSC. Investigations in cultured pigment epithelium cells show that epinephrine can induce apoptosis of RPE cells, although dexamethasone had no effect.³⁹ Stress also plays a major role in this disease, particularly in highly motivated, eager individuals with a type A personality.²³ Also, an increased activity of the sympathetic autonomic nervous system has been seen in patients with CSC,⁴⁰ which would corroborate these findings.

Why is treatment with PDT in patients with CNV secondary to CSC successful? On the one hand, lesion size might play a role. Although no statistical significance was found in this study, the number of patients is relatively small, which does not rule out an effect in a larger cohort. All patients had a lesion size less than 4000 µm. The effect of lesion size has been shown to be an important factor in the success of PDT,⁴¹ with smaller lesions in age-related macular degeneration receiving more therapeutic benefit.

Age might be an important factor. Investigations in patients with pathologic myopia, which albeit has a different pathophysiology, have shown that younger patients benefit significantly more from therapy than older patients (E.E., unpublished data, 2003). There was no statistical correlation in the present study, but it stands to reason that the occlusive effect of PDT on CNV has a better and more long-standing effect in younger individuals. Similarly, in idiopathic CNV, favorable results have been shown with PDT with verteporfin.^{16, 42}

Another reason for the success of PDT in patients with CNV secondary to CSC might be because PDT may also treat the long-standing CSC. Yannuzzi et al⁴³ and others (F. C. Piccolino, MD, written communication, May 2002) have shown that PDT can improve visual acuity in long-standing CSC. Therefore, our patients might have had a 2-fold advantage: treatment of the disease and the CNV. This might give the method an advantage over other procedures, such as surgery, particularly because it is less invasive.⁴⁴

Our study also shows that the results after 6 months seem to set the course for further success or failure: ie, patients who experience an improvement after 6 months tend to stay improved and vice versa. This mimics results from the TAP trials for age-related macular degeneration,^5-6 which have shown that the change in the first 6 months is the decisive period for the final outcome.

In conclusion, PDT with verteporfin is a safe and efficacious method for the treatment of subfoveal CNV in CSC. A main issue is the differentiation from other diseases, particularly CNV secondary to age-related macular degeneration and secondary to polypoidal CNV.⁴⁵ The use of ICG angiography is essential in making the diagnosis.^46-47

AUTHOR INFORMATION

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Corresponding author: Erdem Ergun, MD, Department of Ophthalmology, University of Vienna Medical School, Allgemeines Krankenhaus, Waehringer Guertel 18-20, A-1090 Vienna, Austria (e-mail: erdem.ergun{at}akh-wien.ac.at).

Submitted for publication January 7, 2003; final revision received August 11, 2003; accepted September 10, 2003.

Dr Stur was principal investigator in 2 studies of verteporfin (TAP and Verteporfin in Photodynamic Therapy [VIP] trials) and is principal investigator and vice-chair in an ongoing verteporfin study (Verteporfin in Early Retreatment [VER] trial), as well as a permanent member of the Verteporfin Studies Advisory Group. Dr Ergun is a coinvestigator in the VER trial.

This study was presented in part as a poster at the American Academy of Ophthalmology; November 12, 2001; New Orleans, La.

From the Departments of Ophthalmology, University of Vienna Medical School (Drs Ergun and Stur) and Danube Hospital (Dr Tittl), Vienna, Austria. The authors have no relevant financial interest in this article.

REFERENCES

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1. Maguire JI. Central serous chorioretinopathy. In: Tasman WS, ed. Clinical Decisions in Medical Retinal Disease. St Louis, Mo: Mosby–Year Book; 1994. 2. Frederick AR. Multifocal and recurrent serous choroidopathy (MARC) syndrome: a new variety of idiopathic central serous chorioretinopathy. Doc Ophthalmol. 1984;56:203-235. PUBMED 3. Jalkh AE, Jabbour N, Avila MP, et al. Retinal pigment epithelium decompression, I: clinical features and natural course. Ophthalmology. 1984;91:1544-1548. ISI | PUBMED 4. Spaide RF, Campeas L, Haas A, et al. Central serous chorioretinopathy in younger and older adults. Ophthalmology. 1996;103:2070-2080. ISI | PUBMED 5. Treatment of Age-Related Macular Degeneration With Photodynamic Therapy (TAP) Study Group. Photodynamic therapy of subfoveal choroidal neovascularization in age-related macular degeneration with verteporfin: one-year results of 2 randomized clinical trials: TAP Report 1. Arch Ophthalmol. 1999;117:1329-1345. FREE FULL TEXT 6. Treatment of Age-Related Macular Degeneration With Photodynamic Therapy (TAP) Study Group. Photodynamic therapy of subfoveal choroidal neovascularization in age-related macular degeneration with verteporfin: two-year results of 2 randomized clinical trials: TAP Report 2. Arch Ophthalmol. 2001;119:198-207. FREE FULL TEXT 7. Blumenkranz MS, Bressler NM, Bressler SB, et al. Verteporfin therapy for subfoveal choroidal neovascularization in age-related macular degeneration: three-year results of an open-label extension of 2 randomized clinical trials. Arch Ophthalmol. 2002;120:1307-1314. FREE FULL TEXT 8. Verteporfin in Photodynamic Therapy (VIP) Study Group. Photodynamic therapy of subfoveal choroidal neovascularization in age-related macular degeneration: two-year results of a randomized clinical trial including lesions with occult with no classic choroidal neovascularization: VIP Report 2. Am J Ophthalmol. 2001;131:541-560. FULL TEXT | ISI | PUBMED 9. Verteporfin in Photodynamic Therapy (VIP) Study Group. Photodynamic therapy of subfoveal choroidal neovascularization in pathologic myopia with verteporfin: 1-year results of a randomized clinical trial: VIP Report 1. Ophthalmology. 2001;108:841-852. FULL TEXT | ISI | PUBMED 10. Spaide RF, Freund KB, Slakter J, et al. Treatment of subfoveal choroidal neovascularization associated with multifocal choroiditis and panuveitis with photodynamic therapy. Retina. 2002;22:545-549. FULL TEXT | PUBMED 11. Saperstein DA, Rosenfeld PJ, Bressler NM, et al. Photodynamic therapy of subfoveal choroidal neovascularization with verteporfin in the ocular histoplasmosis syndrome: one-year results of an uncontrolled prospective case series. Ophthalmology. 2002;109:1499-1505. FULL TEXT | ISI | PUBMED 12. Dantas MA, Slakter JS, Negrao S, et al. Photodynamic therapy with verteporfin in malattia leventinese. Ophthalmology. 2002;109:296-301. FULL TEXT | ISI | PUBMED 13. Potter MJ, Szabo SM, Chan EY, Morris AH. Photodynamic therapy of a subretinal neovascular membrane in type 2A idiopathic juxtafoveal retinal telangiectasis. Am J Ophthalmol. 2002;133:149-151. PUBMED 14. Wang LK, Kansai S, Pulido JS. Photodynamic therapy for the treatment of choroidal neovascularization secondary to rubella retinopathy. Am J Ophthalmol. 2002;134:790-792. PUBMED 15. Spaide RF, Martin ML, Slakter J, et al. Treatment of idiopathic subfoveal choroidal neovascular lesions using photodynamic therapy. Am J Ophthalmol. 2002;134:62-68. FULL TEXT | ISI | PUBMED 16. Farah ME, Costa RA, Muccioli C, Gula TA, Belfort R. Photodynamic therapy with verteporfin for subfoveal choroidal neovascularization in Vogt-Koyanagi-Harada syndrome. Am J Ophthalmol. 2002;134:137-139. FULL TEXT | ISI | PUBMED 17. Macular Photocoagulation Study Group. Argon laser photocoagulation for neovascular maculopathy: five-year results from randomized clinical trials. Arch Ophthalmol. 1991;109:1109-1114. ABSTRACT 18. Macular Photocoagulation Study Group. Laser photocoagulation of subfoveal neovascular lesions in age-related macular degeneration: updated findings from two clinical trials. Arch Ophthalmol. 1993;111:1200-1209. ABSTRACT 19. Macular Photocoagulation Study Group. Krypton laser photocoagulation for neovascular lesions of age-related macular degeneration: results of a randomized clinical trial. Arch Ophthalmol. 1996;114:400-412. ABSTRACT 20. Macular Photocoagulation Study Group. Laser photocoagulation of subfoveal neovascular lesions in age-related macular degeneration: results of a randomized clinical trial. Arch Ophthalmol. 1991;109:1220-1231. ABSTRACT 21. Macular Photocoagulation Study Group. Recurrent choroidal neovascularization after argon laser photocoagulation for neovascular maculopathy. Arch Ophthalmol. 1986;104:503-512. ABSTRACT 22. Macular Photocoagulation Study Group. Visual outcome after laser photocoagulation for subfoveal choroidal neovascularization secondary to age-related macular degeneration: the influence of initial lesion size and initial visual acuity. Arch Ophthalmol. 1994;112:480-488. ABSTRACT 23. Yannuzzi LA. Type-A behavior and central serous chorioretinopathy. Retina. 1987;7:111-131. FULL TEXT | ISI | PUBMED 24. Verteporfin Roundtable 2000 and 2001 Participants, Treatment of Age-Related Macular Degeneration With Photodynamic Therapy (TAP) Study Group Principal Investigators, Verteporfin in Photodynamic Therapy (VIP) Study Group Principal Investigators. Guidelines for using verteporfin (Visudyne) in photodynamic therapy to treat choroidal neovascularization due to age-related macular degeneration and other causes. Retina. 2002;22:6-18. FULL TEXT | ISI | PUBMED 25. Loo RH, Scott IU, Flynn HW, et al. Factors associated with reduced visual acuity during long-term follow-up of patients with idiopathic central serous chorioretinopathy. Retina. 2002;22:19-24. FULL TEXT | PUBMED 26. Bujaborua D. Long-term follow-up of idiopathic central serous chorioretinopathy without laser. Acta Ophthalmol Scand. 2001;79:417-421. PUBMED 27. Shanmugam MP, Bhende M. Retinal pigment epithelial tears associated with idiopathic central serous chorioretinopathy. Indian J Ophthalmol. 2000;48:315-317. PUBMED 28. Brancato R, Scialdone A, Pece A, Coscas G, Binaghi M. Eight-year follow-up of central serous chorioretinopathy with and without laser treatment. Graefes Arch Clin Exp Ophthalmol. 1987;225:166-168. PUBMED 29. Piccolino FC. Laser treatment of eccentric leaks in central serous chorioretinopathy resulting in disappearance of untreated juxtafoveal leaks. Retina. 1992;12:96-102. PUBMED 30. Yap EY, Robertson DM. The long-term outcome of central serous chorioretinopathy. Arch Ophthalmol. 1996;114:689-692. ABSTRACT 31. Robertson DM. Argon laser photocoagulation treatment in central serous chorioretinopathy. Ophthalmology. 1986;93:972-974. ISI | PUBMED 32. Schatz H, Yannuzzi LA, Gitter KA. Subretinal neovascularization following argon photocoagulation treatment for central serous chorioretinopathy: complication or misdiagnosis. Trans Am Acad Ophthalmol Otolaryngol. 1977;83:893-906. PUBMED 33. Guyer DR, Yannuzzi LA, Slakter JS, et al. Digital indocyanine green videoangiography of central serous chorioretinopathy. Arch Ophthalmol. 1994;112:1057-1062. ABSTRACT 34. Spaide RF, Hall L, Haas A, et al. Indocyanine green videoangiography of central serous chorioretinopathy in older adults. Retina. 1996;16:203-213. FULL TEXT | PUBMED 35. Carvalho-Recchia CA, Yannuzzi LA, Negrao S, Spaide RF, Freund KB. Corticosteroids and central serous chorioretinopathy. Ophthalmology. 2002;109:1834-1837. FULL TEXT | ISI | PUBMED 36. Bouzas EA, Karadimas P, Pournaras CJ. Central serous chorioretinopathy and glucocorticoids. Surv Ophthalmol. 2002;47:431-438. PUBMED 37. Tittl MK, Spaide RF, Wong D, et al. Systemic findings associated with central serous chorioretinopathy. Am J Ophthalmol. 1999;128:63-68. FULL TEXT | ISI | PUBMED 38. Quillen DA, Gass DM, Brod RD, et al. Central serous chorioretinopathy in women. Ophthalmology. 1996;103:72-79. ISI | PUBMED 39. Sibayan SA, Kobuch K, Spiegel D, et al. Epinephrine, but not dexamethasone, induces apoptosis in retinal pigment epithelium cells in vitro: possible implications on the pathogenesis of central serous chorioretinopathy. Graefes Arch Clin Exp Ophthalmol. 2000;238:515-519. FULL TEXT | PUBMED 40. Bernasconi P, Messmer E, Bernasconi A, Tholen A. Assessment of the sympatho-vagal interaction in central serous chorioretinopathy measured by power spectral analysis of heart rate variability. Graefes Arch Clin Exp Ophthalmol. 1998;236:571-576. FULL TEXT | ISI | PUBMED 41. Blinder K, Bradley S, Bressler NM, et al. Effect of lesion size, visual acuity, and lesion composition on visual acuity change with and without verteporfin therapy for choroidal neovascularization secondary to age-related macular degeneration: TAP and VIP report no. 1. Am J Ophthalmol. 2003;136:407-418. FULL TEXT | ISI | PUBMED 42. Rogers AH, Duker JS, Nichols N, Baker BJ. Photodynamic therapy of idiopathic and inflammatory choroidal neovascularization in young adults. Ophthalmology. 2003;110:1315-1320. FULL TEXT | ISI | PUBMED 43. Yannuzzi LA, Slakter JS, Gross NE, et al. Indocyanine green angiography–guided photodynamic therapy for treatment of chronic central serous chorioretinopathy: a pilot study. Retina. 2003;23:288-298. FULL TEXT | PUBMED 44. Cooper BA, Thomas MA. Submacular surgery to remove choroidal neovascularization associated with central serous chorioretinopathy. Am J Ophthalmol. 2000;130:187-191. PUBMED 45. Yannuzzi LA, Freund KB, Goldbaum M, et al. Polypoidal choroidal vasculopathy masquerading as central serous chorioretinopathy. Ophthalmology. 2001;107:767-777. FULL TEXT | ISI | PUBMED 46. Lafaut BA, Salati C, Priem H, De Laey JJ. Indocyanine green angiography is of value for the diagnosis of central serous chorioretinopathy in elderly patients. Graefes Arch Clin Exp Ophthalmol. 1998;236:513-521. PUBMED 47. Slakter JS, Yannuzzi LA, Guyer DR, Sorenson JA, Orlock DA. Indocyanine-green angiography. Curr Opin Ophthalmol. 1995;6:25-32. PUBMED