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Morphologic Staging of Photoreceptor Damage as a Predictor of Visual Recovery After PDT in Chronic Central Serous
Alessandro Berni1, Giovanni Scalabrin1, Giovanni Neri2
1From the Department of Ophthalmology, IRCCS San Raffaele Scientific Institute (A.B., G.S., U.I., C.B., F.B.), Milan, Italy; Departement of Ophthalmology, Vita-Salute San Raffaele University (A.B., G.S., U.I., C.B., F.B.), Milan, Italy.
Purpose:
To evaluate whether a morphologic staging system of photoreceptor integrity on spectral-domain optical coherence tomography (SD-OCT) predicts anatomical and functional outcomes after verteporfin photodynamic therapy (PDT) in chronic central serous chorioretinopathy (CSC).
Design:
Multicenter, retrospective observational cohort study.
Participants:
A total of 139 eyes from 126 patients with chronic CSC presenting with active subfoveal subretinal fluid (SRF) and treated with half-dose or half-fluence verteporfin PDT.
Methods:
All eyes underwent standardized multimodal imaging and SD-OCT at baseline and during follow-up. Photoreceptor morphology within the central 1 mm was graded at baseline using a 6-stage OCT-based classification reflecting progressive disruption of the ellipsoid and interdigitation zones. Anatomical response was defined as complete foveal SRF resolution within 6 months. Functional outcome was the change in best-corrected visual acuity (ΔBCVA, logMAR) among eyes achieving SRF resolution. Cox regression models assessed predictors of SRF resolution, and multivariable linear and ANCOVA models evaluated determinants of visual improvement and final BCVA.
Main Outcome Measures:
Baseline photoreceptor stage, likelihood of SRF resolution, ΔBCVA among responders, and final BCVA within 6 months.
Results:
SRF resolution occurred in 58% of eyes (81/139). The probability of SRF resolution decreased with worsening photoreceptor stage in univariable analysis, but in multivariable Cox regression, symptom duration (HR 0.97 per month, P = .023) was the only independent predictor of anatomical success. Among responders, visual recovery decreased stepwise across photoreceptor stages. Compared with Stage 1A, ΔBCVA declined progressively in Stage 3 (β = -0.117, P = .005), Stage 4 (β = -0.310, P < .001), and Stage 5 (β = -0.717, P < .001). For final BCVA, photoreceptor stage remained a strong independent predictor (Stage 3-5 all P ≤ .035) together with baseline BCVA (P < .001), while symptom duration was not significant. Responders showed significantly greater reduction in CST and SCT than nonresponders (both P < .001).
Conclusions:
In chronic CSC, symptom duration determines the likelihood of anatomical recovery after PDT, whereas photoreceptor integrity is the key determinant of visual acuity recovery. The proposed 6-stage OCT classification provides a reproducible structural biomarker that captures cumulative photoreceptor injury and robustly predicts visual prognosis, offering a clinically useful framework for treatment counseling, stratification in CSC trials, and future automated imaging analysis.