Ophthalmic Surgery, Lasers and Imaging Retina

Clinical Science 

Oral Mineralocorticoid-Receptor Antagonists: Choroidal Parameters Changes Using OCT in Central Serous Chorioretinopathy

Houshang Faghihi, MD; Vahid Mohammadzadeh, MD; Amin Nabavi, MD; Shahin Faghihi, MD; Sakineh Kadivar, MD; Fariba Ghassemi, MD

Abstract

BACKGROUND AND OBJECTIVE:

To evaluate the efficacy and safety of oral eplerenone in the treatment of acute and chronic central serous chorioretinopathy (CSCR).

PATIENTS AND METHODS:

Treatment-naïve patients with acute (< 3 months) and chronic (≥ 3 months) CSCR were enrolled in this prospective, nonrandomized, interventional, comparative case series. Patients with acute CSCR were either treated with oral eplerenone (acute case group; n = 16) or observed only (acute control group; n = 8). All chronic patients (chronic group; n = 25) were treated with oral eplerenone. Eplerenone was prescribed 25 mg twice per day for 3 months. Best-corrected visual acuity (BCVA) and optical coherence tomography measures, including subretinal fluid (SRF) height, subfoveal choroidal thickness (CT), central CT, central choroidal volume (CV), and total CV, were assessed at baseline and 3-month follow-up (FU) visit.

RESULTS:

BCVA improvement and SRF reduction at 3-month FU relative to baseline were observed in all three study groups. SRF was completely resolved in 13 patients (81.2%) in the acute case group, four patients (50%) in the acute control group, and eight patients (32%) in the chronic group. The acute case group showed greater SRF decrease relative to baseline compared to the chronic group (P = .009), but the resolution of SRF between acute cases and an acute control group was not statistically significant (P = .076). Subfoveal CT, central CT, total CV, and central CV were significantly reduced at the 3-month FU compared to baseline in both affected and the fellow eyes in the acute case and chronic groups, whereas no change was observed in either eyes in the acute control group. At 3 months' FU, the mean logMAR visual acuity demonstrated no significant difference among the study groups (P = .08). Eplerenone was well-tolerated, and no serious side effect was detected.

CONCLUSIONS:

Oral eplerenone is a safe and effective treatment option for both acute and chronic CSCR. Resolution of SRF was more significant in acute CSR cases comparative to chronic cases.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:726–733.]

Abstract

BACKGROUND AND OBJECTIVE:

To evaluate the efficacy and safety of oral eplerenone in the treatment of acute and chronic central serous chorioretinopathy (CSCR).

PATIENTS AND METHODS:

Treatment-naïve patients with acute (< 3 months) and chronic (≥ 3 months) CSCR were enrolled in this prospective, nonrandomized, interventional, comparative case series. Patients with acute CSCR were either treated with oral eplerenone (acute case group; n = 16) or observed only (acute control group; n = 8). All chronic patients (chronic group; n = 25) were treated with oral eplerenone. Eplerenone was prescribed 25 mg twice per day for 3 months. Best-corrected visual acuity (BCVA) and optical coherence tomography measures, including subretinal fluid (SRF) height, subfoveal choroidal thickness (CT), central CT, central choroidal volume (CV), and total CV, were assessed at baseline and 3-month follow-up (FU) visit.

RESULTS:

BCVA improvement and SRF reduction at 3-month FU relative to baseline were observed in all three study groups. SRF was completely resolved in 13 patients (81.2%) in the acute case group, four patients (50%) in the acute control group, and eight patients (32%) in the chronic group. The acute case group showed greater SRF decrease relative to baseline compared to the chronic group (P = .009), but the resolution of SRF between acute cases and an acute control group was not statistically significant (P = .076). Subfoveal CT, central CT, total CV, and central CV were significantly reduced at the 3-month FU compared to baseline in both affected and the fellow eyes in the acute case and chronic groups, whereas no change was observed in either eyes in the acute control group. At 3 months' FU, the mean logMAR visual acuity demonstrated no significant difference among the study groups (P = .08). Eplerenone was well-tolerated, and no serious side effect was detected.

CONCLUSIONS:

Oral eplerenone is a safe and effective treatment option for both acute and chronic CSCR. Resolution of SRF was more significant in acute CSR cases comparative to chronic cases.

[Ophthalmic Surg Lasers Imaging Retina. 2019;50:726–733.]

Introduction

Central serous chorioretinopathy (CSCR) is characterized by serous detachment of the neurosensory retina, typically affecting middle-aged men.1 Although the pathogenesis of CSCR is not completely understood, choroidal vasculature has been proposed as the primary site of abnormality.2 Choroidal thickening and increased choroidal vascular permeability, documented by enhanced depth optical coherence tomography (EDI-OCT) and indocyanine green angiography, provide support for this idea.3,4

Although acute CSCR is usually self-limiting within 3 to 4 months, a considerable fraction of cases may progress to the chronic or recurrent types.5 Observation for spontaneous resolution is generally considered in acute CSCR;6 however, photoreceptor damage and retinal pigment epithelium (RPE) atrophy may occur during this period or even after resolution.7 Laser photocoagulation and verteporfin photodynamic therapy (PDT) are available local treatment options commonly used in chronic cases with variable efficacy and safety results.8,9 Systemic medications could be encouraging in recurrent, multiple, or bilateral disease.

Various recent evidences have been proposed that mineralocorticoid receptor (MR) in choroidal vascular endothelium play an important role in pathogenesis of CSCR.10,11 Intravitreal injections of aldosterone induced fluid accumulation in the outer retina in animal studies. Choroidal vascular hyperpermeability induced by glucocorticoids is now attributed to MR effects.10 It was suggested that up-regulation of a potassium channel that was identified as a target for MR activation increases the choroidal vascular permeability.12

Systemic MR antagonists, including spironolactone and eplerenone, have been used as a treatment of chronic CSCR with promising results in recent years.10,13–16 However, there are few comparative studies enrolling a control group. Moreover, using MR antagonists in acute CSCR has not yet been investigated. This study was conducted to evaluate efficacy and safety of eplerenone in treatment of both acute and chronic CSCR.

Patients and Methods

This prospective, comparative, interventional case series was conducted from November 2014 to January 2016 in Farabi Eye Hospital, Tehran, Iran. Tehran University of Medical Sciences ethical board committee approved the study protocol. After complete description about the study, a written informed consent was obtained from all participants.

Consecutive patients aged 18 years or older with unilateral treatment-naïve CSCR based on the presence of subretinal fluid (SRF) under the fovea, confirmed by spectral-domain optical coherence tomography (SD-OCT), were enrolled in this study. Exclusion criteria were the following: best-corrected visual acuity (BCVA) of 20/32 or better; previous treatment; other ocular pathology; ocular surgery history; and systemic contraindication for anti-mineralocorticoid therapy, including chronic kidney disease (glomerular filtration rate < 30 mL/min), hyperkalemia (K > 5.5 meq/L), and pregnancy. Patients with refractive error greater than 1 diopter or patients with history of refractive surgery were not included. We also omitted patients taking medication implicated in altering the choroidal vasculature, including corticosteroid and sildenafil.17,18

Chronic CSCR was defined as previous diagnosis of CSCR or persistent SRF on OCT for more than 3 months after the initial presentation to the eye clinic. Patients who reported visual symptoms for more than 3 months without clinical documentation or previously treated cases were not included. Visual symptoms persisted less than 3 months with characteristic OCT findings was considered as acute CSCR.

All patients with chronic CSCR were treated with oral eplerenone (Norman, Madrid, Spain). Patient with acute CSCR were categorized as acute case group treated with oral eplerenone and acute control group with no treatment. Grouping was performed using non-probability allocation. Randomization was not accomplished. Eplerenone was prescribed 25 mg twice per day for 3 months.

A complete ocular examination was performed in all patients at baseline. BCVA was assessed using Early Treatment Diabetic Retinopathy Study charts at 6 meters. Fluorescein angiography (Heidelberg Engineering, Heidelberg, Germany), and spectral-domain Spectralis OCT (Heidelberg Engineering, Heidelberg, Germany) were performed. Blood pressure and serum level of creatinine, blood urea nitrogen sodium, and potassium were also measured before enrolling the participants. Assessment of BCVA and OCT were repeated after 3 months.

Manual segmentation was performed to measure SRF, choroidal thickness (CT), and choroidal volume (CV) using the contained Heidelberg eye explorer software (version 1.5.12.0). Internal limiting membrane and the RPE-Bruch layer were delineated automatically by Heidelberg Spectralis software. These slabs were used for bordering the outer border of the RPE-Bruch layer and hyperreflective inner surface of the sclera, and subfoveal CT was measured. Measurement was performed perpendicularly from the outer part of the hyperreflective line (RPE layer) to the line corresponding to the choroidal-scleral junction, perpendicularly (Figure 1). In addition, Spectralis OCT standardized 25-line grid for macular thickness map was used to assess CV. CT and CV in the central circle (1-mm diameter) were considered as central CT and central CV, respectively. Average CV in a 6-mm diameter circle was considered as total CV.19 In cases with subfoveal SRF at presentation, the maximal elevation and horizontal extension of SRF was also measured in the central foveal cut. Masked readers (VM and FG) performed all manual segmentations. Patients with measurement reliability index under 60 were excluded from the study.

Optical coherence tomography findings and thickness of an acute central serous chorioretinopathy treated with eplerenone. (A) Infrared picture of the patient with subretinal fluid measurement and shaggy surface of photoreceptor layer. Choroidal volume (B) and thickness (C) are increased significantly in the primary visit. After 3 months of consuming eplerenone, the thickness (D) and volume (E) are diminished significantly.

Figure 1.

Optical coherence tomography findings and thickness of an acute central serous chorioretinopathy treated with eplerenone. (A) Infrared picture of the patient with subretinal fluid measurement and shaggy surface of photoreceptor layer. Choroidal volume (B) and thickness (C) are increased significantly in the primary visit. After 3 months of consuming eplerenone, the thickness (D) and volume (E) are diminished significantly.

One-way analysis of variance, Mann-Whitney U test, and Chi square/Fischer's exact test were used for comparison of the study groups. Baseline and 3-month follow-up (FU) values were compared using paired t-test or Wilcoxon paired test. All statistical analyses were performed using IBM SPSS Statistics (version 16.0; IBM Corp., Chicago, IL). P values less than .05 were considered statistically significant.

Results

A total of 67 eyes from 67 patients were recruited. After excluding 18 eyes because of loss to FU and improper imaging qualities, 49 eyes from 49 patients were included in the analysis. Twenty-five eyes were diagnosed as chronic CSCR treated with oral eplerenone, and 24 eyes were diagnosed as acute CSCR, which were categorized into either the acute case group (n = 16) or the acute control group (n = 8). No serious side effects from eplerenone were observed during the study period.

Clinical and demographic characteristics are illustrated in Table 1. Age and sex distribution were similar between the three study groups. However, baseline BCVA (logMAR) in the chronic group (0.82 ± 0.24) was significantly lower than in the acute case (0.55 ± 0.27; P = .021) and acute control groups (0.53 ± 0.31; P = .004). Baseline OCT measures including SRF height, CT, and CV also did not show significant difference between the three study groups.

Demographics and Baseline Clinical and OCT Characteristics in The Study Groups

Table 1:

Demographics and Baseline Clinical and OCT Characteristics in The Study Groups

At 3 months of FU, BCVA (logMAR) increased significantly in the acute case (0.09 ± 0.07 vs. 0.55 ± 0.27; P = .001), acute control (0.15 ± 0.1 vs. 0.53 ± 0.31; P = .011), and chronic groups (0.23 ± 0.10 vs. 0.82 ± 0.24; P < .001). There was no statistically significant difference in terms of BCVA improvement between the three study groups (P = .08).

SRF height significantly decreased in the three study groups after 3 months of FU (Table 2); however, at the 3-month FU visit, the acute case group showed greater SRF decrease relative to baseline compared to the chronic group (P = .009; Table 3). SRF was completely resolved in 13 patients (81.2%) in the acute case group, eight patients (32%) in the chronic group, and four patients (50%) in the acute control group. SRF resolution rate was significantly higher in the acute treatment group than in the chronic group (P = .002). In addition, SRF absorption was associated with choroidal thinning only in our treated patients. Choroidal OCT measures including subfoveal CT, central CT, total CV, and central CV significantly reduced at the 3-month FU compared to baseline in the acute case and chronic groups (P < .05 for all comparisons), whereas no significant change was observed in the acute control group (Table 2). Mean change at 3-month FU from baseline in subfoveal CT (P = .021), central CT (P = .007), and total CV (P = .04) was significantly greater in the acute case group than in the acute control group. However, there was no significant difference between the acute case and chronic groups (Table 3).

OCT Measures Between Baseline and Three-Month Follow-Up

Table 2:

OCT Measures Between Baseline and Three-Month Follow-Up

Mean Change of OCT Measures From Baseline at Three-Month Follow-Up

Table 3:

Mean Change of OCT Measures From Baseline at Three-Month Follow-Up

Considering only patients who experienced complete SRF resolution at 3 months, CT and CV decreased significantly relative to baseline in the acute case group (P < .05 for all comparisons). Completely SRF-resolved eyes in the chronic group also demonstrated a significant reduction in subfoveal CT (P = .018) and total CV (P = .021) comparing baseline and 3-month FU. However, there was no statistical difference in any choroidal parameters between baseline and FU visit in spontaneously resolved SRF and unresolved SRF in untreated acute cases by subgroup analysis.

CT and CV in the fellow eye of all treated patients (acute and chronic) and acute control patients are shown in Table 4. Significant reduction was observed in subfoveal CT, central CT, total CV, and central CV in treated patients at the 3-month visit compared to baseline (P < .05 in all comparisons). In contrast, the acute control group did not exhibit significant difference in OCT choroidal measures from baseline at the 3-month FU.

Comparison of OCT Measures Between Baseline and Three-Month Follow-Up in Fellow Eyes

Table 4:

Comparison of OCT Measures Between Baseline and Three-Month Follow-Up in Fellow Eyes

Discussion

Choroidal OCT measures including subfoveal CT, central CT, total CV, and central CV were significantly reduced at the 3-month FU compared to baseline in the acute case and chronic groups after using eplerenone. These significant changes were not perceived in untreated eyes. SRF resolution rate was, even though not statistically significant, higher in the acute treatment group compared with the chronic group.

Treatment of CSCR with MR antagonists has drawn special attention in the recent years. Zhao et al. first described the role of MR signaling pathway in CSCR in 2012.12 Afterward, growing evidence has supported the efficacy of anti-mineralocorticoid therapy, mostly in patients with chronic CSCR in clinical setting.13–16

At 3 months' FU, BCVA was improved in all study groups despite the lower vision of chronic CSCR at baseline. There was no statistically significant difference in terms of BCVA improvement between three study groups (P = .08) attributable to eplerenone usage.

In our study, chronic CSCR patients showed significant BCVA improvement after 3 months of treatment with eplerenone. BCVA was increased by almost 6 letters. Our results are in line with most previous studies utilizing MR antagonists in chronic CSCR.13,15 Kapoor et al.15 evaluated two MR antagonists (eplerenone and spironolactone) in the treatment of CSCR and compared with a control group. They found that visual acuity (VA) improved with both MR antagonists, whereas no change was observed in the untreated group. In a prospective series of 20 eyes with nonresolving CSCR lasting longer than 6 weeks, Herold et al.17 evaluated oral spironolactone (50 mg/day) and described an improvement in BCVA after 3 months. Daruich et al. showed a significant improvement in BCVA of their entire cohort including recurrent and persistent CSCR (chronic) cases.14

In a crossover 1-month, randomized control study, Bousquet et al.13 showed no significant improvement in VA observed during treatment with spironolactone compared to the placebo group.

According to SRF persistence, the acute case group showed greater SRF decrease relative to baseline compared to the chronic group (P = .009), but the resolution of SRF between acute cases and the acute control group was not significant (P = .076; borderline). Kapoor et al.15 in evaluation of two MR antagonists (eplerenone or spironolactone) found that SRF improved with both drugs in both acute and chronic CSCR, whereas we observed no change in the untreated group in both acute and chronic cases. Daruich et al. showed a complete resolution of foveal SRF in 38% of cases at 3 months in chronic and recurrent CSCR.14

Bousquet et al. observed a statistically significant reduction in SRF with MR antagonists compared to the placebo group in chronic CSCR.13 Other investigators reached the same conclusion in their studies of chronic CSCR.12–14,16,18–20

Given the high rate of spontaneous resolution and lack of safe and effective treatment modalities, acute CSCR is generally approached conservatively.6 However, a substantial number of CSCR patients progress to a chronic or persistent form, which may be resistant to any form of therapy. Nonetheless, optimal timing for treatment of CSCR remains controversial.6 In the present study, we used eplerenone in treatment of acute CSCR at the time of the patient first examination and compared it with observation only management. Eplerenone therapy resulted in 31% more reduction in SRF after 3 months in the treated acute CSCR group, although this difference was not significant. The absence of significant improvement may be related to the high baseline BCVA levels.

Mean change at 3-month FU from baseline in subfoveal CT, central CT, and total CV was significantly greater in the treated acute group than in the acute control group. However, there was no significant difference between the acute case and chronic treated groups. Bousquet et al.13 noted a statistically significant reduction of CT during treatment with spironolactone compared to the placebo group. A similar decrease in CT was observed in other studies in chronic CSCR.16

We observed an association between SRF resolution and choroidal thinning only in our treated patients. The acute control group did not show diminution in CT, even in the subgroup analysis of patients who experienced complete SRF resolution. It could be postulated that MR antagonists enroll different mechanism for SRF resolving compared with spontaneous retinal pigmentary epitheliopathy healing. In accordance to our results, Kang et al.21 found only a 9% decrease in subfoveal CT in spontaneously resolved CSCR, which was not normalized as the control normal subjects. Differences in CT between spontaneous and eplerenone-induced CSCR resolution in the present study also may have clinical importance. In our study, the reduction of the subfoveal CT, central CT, and total CV is nearly 10 times more in the treated acute CSCR cases compared to control acute cases. Some longitudinal investigations proposed that higher CT is a powerful risk factor for recurrence of CSCR.22,23 Kim et al.23 found that recurrence rates were lower in patients with a large amount of choroidal thinning after SRF resolution. It could be suggested that treatment of acute CSCR with MR antagonists may reduce the recurrence episodes. Patients with a higher risk of progression to chronic and recurrent forms may benefit from this earlier intervention. However, a longitudinal study with more cases and longer FU period is required to evaluate these ideas.

In the current study, we showed that choroidal values in the fellow eye of unilateral CSCR patients decreased significantly with eplerenone therapy (Table 4). It is now well established that CSCR patients have bilateral choroidal dysfunction, even in unilateral clinical manifestations.4,24,25 Bilateral and diffuse choroidal hyperpermeability, bilateral choroidal thickening, and high rate of bilateral involvement in longitudinal studies suggest bilateral disturbance.4,24,25 Choroidal thinning in the fellow eyes of unilateral CSCR patients may theoretically decrease in the risk of bilateral involvement. However, this suggestion also needs further investigation.

Our study has several limitations including short FU period, small sample size in each subgroup, and being a single-center study. In addition, allocation to the case and control groups was not randomized. We also did not use placebo tablets in the control group. Regarding the convincing evidences for efficacy of MR antagonists in CSCR and eligibility of chronic CSCR patients for other treatment modalities including PDT,19,20 the control group was not considered in chronic CSCR patients. We did not follow patients after cessation of therapy to test the treatment effect duration. Recurrence of CSCR after MR antagonists is a subject to be studied.

In conclusion, eplerenone is safe and effective treatment in acute and chronic CSCR. Using eplerenone in acute and chronic phases may be associated with a decrease in choroidal thickness and SRF resolution.

References

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Demographics and Baseline Clinical and OCT Characteristics in The Study Groups

VariablesChronic (n = 25)Acute (n = 24)P Value*
Case (n = 16)Control (n = 8)Total (n = 24)
Age (years)39.8 ± 8.238.1 ± 6.340 ± 10.338.7 ± 7.7.77
Sex (male)19 (76%)12 (75%)8 (100%)20 (83.3%).32
Laterality (right eye)11 (44%)9 (56.2%)5 (62.5%)14 (58.3%).34
BCVA (logMAR)0.82 ± 0.240.55 ± 0.270.53 ± 0.310.55 ± 0.28.002a
SRF height (μm)170.7 ± 119.0263.1 ± 138.6180.8 ± 182.5234.4 ± 156.3.109
Subfoveal CT (μm)449.9 ± 85.3453.4 ± 92.1437.2 ± 53.3448.1 ± 80.4.872
Central CT (μm)440.8 ± 75.5447.7 ± 80.9431.6 ± 57.7442.3 ± 73.1.883
Total CV (mm3)11.08 ± 1.9211.15 ± 2.0411.01 ± 0.5911.1 ± 1.58.983
Central CV (mm3)0.34 ± 0.060.35 ± 0.060.34 ± 0.050.35 ± 0.6.965

OCT Measures Between Baseline and Three-Month Follow-Up

TotalComplete SRF Resolution After 3 MonthsNo or Incomplete SRF Resolution After 3 Months

Baseline3 MonthsP Value*Baseline3 MonthsP Value*Baseline3 MonthsP Value*

ChronicSRF (μm)170.7 ± 119.032.3 ± 3.2<0.001NANANANANANA
Subfoveal CT (μm)449.9 ± 85.3389.3 ± 67.7< .001498.7 ± 65.9406.8 ± 53.40.018426.1 ± 82.3380.11 ± 73.3< .001
Central CT (μm)440.8 ± 75.5390.9 ± 72.5< .001479.2 ± 57.1416.6 ± 56.1.056422.8 ± 77.7378.9 ± 78.6< .001
Total CV (mm3)11.08 ± 1.9210.16 ± 1.2.01411.88 ± 1.7810.78 ± 1.24.02110.7 ± 1.929.86 ± 1.84< .001

Acute CasesSRF (μm)263.1 ± 138.69.5 ± 2.2.001NANANANANANA
Subfoveal CT (μm)453.4 ± 92.1402.7 ± 71.6.002452.8 ± 98393.1 ± 68.7.007455.7 ± 77.7444 ± 53.6.709
Central CT (μm)447.7 ± 80.9402.1 ± 69.7< .001447.9 ± 82.7394.7 ± 62.4.003446.6 ± 89.3434.1 ± 106.374
Total CV (mm3)11.15 ± 2.0410.36 ± 1.78< .00111.28 ± 1.5610.42 ± 1.44.00110.57 ± 3.5910.1 ± 3.34.077
Central CV (mm3)0.35 ± 0.060.32 ± 0.05< .0010.35 ± 0.060.31 ± 0.05< .0010.35 ± 0.070.34 ± 0.1.423

Acute ControlsSRF (μm)180.8 ± 182.552.8 ± 5.7.028NANANANANANA
Subfoveal CT (μm)437.2 ± 53.3431.6 ± 61.2.484451.5 ± 40.7442.2 ± 42.8.568422.5 ± 66.1417.7 ± 80.7.760
Central CT (μm)431.6 ± 57.7428.4 ± 65.9.327449.2 ± 47.3443.5 ± 44.3.391414.1 ± 68.7413.2 ± 86.9.953
Total CV (mm3)11.01 ± 0.5910.94 ± 0.42.31011.15 ± 0.3411.01 ± 0.46.49210.87 ± 0.3110.86 ± 0.38.894
Central CV (mm3)0.34 ± 0.050.33 ± 0.04.1120.33 ± 0.020.33 ± 0.02.2150.34 ± 0.050.33 ± 0.04.125

Mean Change of OCT Measures From Baseline at Three-Month Follow-Up

VariablesChange From BaselineP Value*P Value**
Chronic Cases (n = 25)Acute Cases (n = 16)Acute Control (n = 8)
SRF height (μm)−137.1±123.9−253.5±146−128±163.1.009.076
Subfoveal CT (μm)−60.6 ±57.4−50.7±64.3−5.6±22.8.517.021
Central CT (μm)−49.9±47.1−45.6±50.6−3.2±17.4.534.007
Total CV (mm3)−0.92±0.75−0.79±0.65−0.07±0.24.490.04
Central CV (mm3)−0.04±0.04−0.03±0.02−0.01±0.01.605.12

Comparison of OCT Measures Between Baseline and Three-Month Follow-Up in Fellow Eyes

VariablesBaseline3 MonthsP Value*

All Intervention (n = 41)Subfoveal CT (μm)440.9 ± 57.8416.9 ± 64.8.023
Central CT (μm)436.5 ± 60.5407.2 ± 57.5.04
Total CV (mm3)11.07 ± 1.210.48 ± 1.18< .001
Central CV (mm3)0.35 ± 0.040.32 ± 0.04.004

Acute Control (n = 8)Subfoveal CT (μm)417.2 ± 48.8410.5 ± 34.5.417
Central CT (μm)412 ± 51.3405.7 ± 37.1.457
Total CV (mm3)10.95 ± 1.3210.86 ± 1.19.303
Central CV (mm3)0.34 ± 0.070.33 ± 0.08.11
Authors

From the Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran (HF, AN, SF, FG); Retina & Vitreous Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran (HF, FG); the Department of Ophthalmology, Amiralmomenin Eye Hospital, Guilan University of Medical Sciences, Rasht, Iran (SK); and the Department of Ophthalmology, Stein Eye Institute, UCLA, Los Angeles (VM).

The authors report no relevant financial disclosures.

Address correspondence to Fariba Ghassemi, MD, Eye Research Center, Farabi Eye Hospital, Qazvin Square, Tehran, Iran 1336616351; email: ghasemi_f@sina.tums.ac.ir, fariba.ghassemi@gmail.com.

Received: October 12, 2018
Accepted: April 22, 2019

10.3928/23258160-20191031-08

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