What can we say about treatments ?

As expected, most of us just observe when we first meet a CSCR patient and maybe the 30% of cases that we immediately treat are the most aggressive ones.The duration of observation had a mean of 11 months but was extended in a minority up to 7 years.

Most of us but less than 25% are choosing PDT.The second choice was as you can see “observation”, because many colleagues wrote observation in the column of the first treatment and this was a problem because we had to decide how to realign the active treatments and the following controls.The second problem was that 20% choose OTHER as treatment.Thermal laser was chosen by 13% and micropulse laser by less than 5% but as you will see it reaveals to be significant !

Extremely interesting was the list of the OTHERS which could vary from combinations of the main proposed treatments to completely different proposals from eplenerone, spironolactone, acetazolamide, betablockers, anti anxiety drugs aspirin folic acid methotrexate statins vitis vinifera extract and vitrectomy !

Notice the high column of complete success with PDT at 1 month. However it seems that also OTHER treatments and observation, may obtain a partial resolution.

However, since anti-VEGF, from the statistical calculations, seemed the less significant treatment, the odds ratio of obtaining either a partial or complete resolution where calculated against anti-VEGF.In this case the odds ratio favours thermal laser, micropulse laser and PDT with less variability of result !

Which are the factors that favor the anatomical resolution?If we look at the univariate analisys the positive predicting factors are:– age less than 60 y– no previous observation– short duration of the disease– absence of sign in the fellow eye– involvement outside the arcades– and a height of fluid higher than 500 microns

If we look at the multivariate analisys the positive predicting factors are:– short duration of the disease– involvement outside the arcades– height of fluid higher than 500 microns– the use of thermal laser, micropulse, pdt– here observation results better than anti-VEGF

What happens after the first month ?

Evolution of OCTThe analisys of the following months does not show any significant variation with respect to 1 month.When considering one single treatment at baseline and no change of treatment.The analysis of combination of treatments is not presented:– too complicated– too many missing– possible misinterpretation

What about functional results ?

Let’s start with the change in VA at 1 month.

It seems that every choice bring to an improvement around 1 logmar line, but the variability of results is very wide for every treatment.

This graph better shows the improvement in BCVA from baseline to 1 month.Please notice that the anti-VEGF group starts from a lower VA (and this makes me thinking again about problem with differential diagnosis with amd).The average improvement is 1 line.

Which are the factors that favor the functional resolution ?If we look at the univariate analisys the positive predicting factors are:– first episode– height of fluid higher than 500 microns– short duration of the observation

If we look at the multivariate analisys, the positive predicting factors are:– first episode– height of fluid higher than 500 microns– the choice of a treatment excluding observation

Let’s see the evolution of the disease from baseline to 1 year.

Notice that many data are missing !!!Difficult to withdraw conclusions.It seems that vision keeps improving up to 3 months and than stabilize to one year.There is a statistically significant different pattern of the VA on the 4 times for the 5 considered treatments (interaction time by treatments: P = 0.0037). For all the treatments there is a statistically significant increase of the VA from the baseline; the interaction is due mainly to a curvilinear trend WITH A DECREASE FROM 3 MONTHS AND 12 MONTHS for THE LASER, A PRACTICALLY NO CHANGE FROM 3 MONTHS AND 12 MONTHS FOR PDT AND ANTIVEGF AND A FURTHER increase for OBSERVATION AND TOPICAL EYE DROPS.Finally, there is no statistically significant differences among the treatments at 12 months.

Among all the surveys organized by EVRS, I think this was the survey that led to the most uncertain conclusions.It was very difficult to analyze the data, probably they were too many with a lot of confounding factors.

The only attendible conclusion that I can present you today is:No certain indications for treatment can be withdrawn from this survey although only thermal laser, micropulse laser and PDT lead to convincing results.We must highlight the great variety of proposed treatment. I would say too many and this leads to face the fact that a higher knowledge of the disease is needed to improve the management of our patients.