The Open Ophthalmology Journal




ISSN: 1874-3641 ― Volume 14, 2020

Photodynamic Therapy Rescue for Subretinal Fluid Exacerbation After Focal Laser Treatment in Idiopathic Central Serous Chorioretinopathy



Theodore Leng*, Steven R Sanislo, Robert L Jack
Department of Ophthalmology, Stanford University School of Medicine, Stanford, California, USA

Abstract

Purpose

To report a case of subretinal leakage after focal laser treatment for idiopathic central serous chorioretinopathy (ICSC). This rare complication was successfully treated with photodynamic therapy (PDT).

Methods

Interventional case report.

Results

A 36-year-old male presented with ICSC in his right eye. After a period of observation without resolution, he was treated with focal laser. That treatment resulted in a massive exacerbation of his subretinal fluid. PDT was successfully used to treat the severe exacerbation with rapid resolution of the subretinal fluid, improvement in visual acuity, decreased leakage on fluorescein angiography, and reduction of subretinal fluid on ophthalmoscopic exam and by optical coherence tomography.

Conclusions

Ophthalmologists should consider the use of PDT in cases where focal laser causes an exacerbation of subretinal fluid in ICSC.

Keywords: Idiopathic central serous chorioretinopathy, focal laser, photodynamic therapy.


Article Information


Identifiers and Pagination:

Year: 2011
Volume: 5
First Page: 6
Last Page: 9
Publisher Id: TOOPHTJ-5-6
DOI: 10.2174/1874364101105010006

Article History:

Received Date: 11/8/2010
Revision Received Date: 15/10/2010
Acceptance Date: 3/11/2010
Electronic publication date: 18/1/2011
Collection year: 2011

© Leng et al.; Licensee Bentham Open.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.


* Address correspondence to this author at the Eye Institute at Stanford, Stanford University School of Medicine, Palo Alto, CA 94303, USA; Tel: (650) 498-4264; Fax: (650) 565-8297; E-mail: tedleng@stanford.edu





INTRODUCTION

Idiopathic central serous chorioretinopathy (ICSC) is a relatively common disorder of young or middle age individuals with abnormalities of the retinal pigment epithelium (RPE), resulting in focal areas of serous retinal detachment and pigment epithelial detachment [1Bouzas EA, Karadimas P, Pournaras CJ. Central serous chorioretinopathy and glucocorticoids Surv Ophthalmol 2002; 47(5): 431-8.]. Fluorescein angiography often demonstrates focal areas of leakage at the level of the RPE with pooling of dye into the subretinal or sub-pigment epithelial space. In most cases the leakage resolves spontaneously with gradual return of good visual function. If there is chronic or recurrent leakage treatment may be indicated. In such cases, light focal laser photocoagulation to the area of RPE abnormality and leakage may be employed [2Ficker L, Vafidis G, While A, Leaver P. Long-term follow-up of a prospective trial of argon laser photocoagulation in the treatment of central serous retinopathy Br J Ophthalmol 1988; 72(11): 829-34.-5Robertson DM, Ilstrup D. Direct, indirect, and sham laser photocoagulation in the management of central serous chorioretinopathy Am J Ophthalmol 1983; 95(4): 457-66.].

Here, we report a case of ICSC where focal laser photo-coagulation resulted in a dramatic increase in fluid leakage with severe worsening of the serous macular detachment. Subsequent treatment with photodynamic therapy (PDT) resulted in prompt resolution of the leakage and reduction of subretinal fluid.

CASE REPORT

A 36 year-old Caucasian male presented with two days of blurring of the central vision in the right eye with a best-corrected visual acuity of 20/20-2. Four years ago, he had ICSC in the left eye that was successfully treated with reduced fluence PDT after an ineffective focal laser session.

Dilated fundus examination of the right eye disclosed an area of serous detachment in the superonasal macula extending toward the center of the fovea (Fig. 1A). Optical coherence tomography (OCT) confirmed the presence of subretinal fluid in the superonasal macula just sparing the foveal center (Fig. 1B). Fluorescein angiography showed a focal spot of leakage at the level of the RPE in the superonasal macula with pooling of dye into the area of subretinal fluid seen on ophthalmoscopy (Figs. 1C, D). The fellow eye had a best-corrected visual acuity of 20/20 and dilated fundus examination revealed RPE hyperpigmentation in the inferior foveal region without subretinal fluid.

Fig. (1)

(A) Color fundus photograph of the right eye showing a well demarcated area of subretinal fluid in the superonasal macula. (B) Optical coherence tomography of the right eye showing subretinal fluid within the superior macula extending very close to the foveal center. (C) Early frame fluorescein angiogram of the right eye showing focal area of leakage in the superonasal macula. (D) Late frame fluorescein angiogram of the right eye showing increasing leakage with pooling into the area of subretinal fluid.



Fig. (2)

(A) Color fundus photograph and (B) optical coherence tomography of the right eye showing a dramatic increase in subretinal fluid after focal laser photocoagulation. (C) Early and (D) late frame fluorescein angiograms of the right eye showing a new area of leakage just below the area treated with laser photocoagulation with later leakage and pooling of dye.



Fig. (3)

(A) Color fundus photograph and (B) optical coherence tomography of the right eye showing a reduction in the amount of subretinal fluid after PDT. (C) Early and (D) late frame fluorescein angiograms showing mild dye transmission in area treated by focal laser with late staining of the laser scar in the superonasal macula.



Fig. (4)

(A) Color fundus photograph and (B) optical coherence tomography of the right eye showing complete resolution of subretinal fluid and a faint pigmented scar in the location of prior laser photocoagulation. (C) Early and (D) late frame fluorescein angiograms showing early hypofluorescence in the area of prior leakage and late staining of the laser scar with no leakage.



A diagnosis of recurrent ICSC was made and options for treatment were discussed including: observation, focal laser photocoagulation, or PDT. After an initial observation period of three months without symptomatic or funduscopic change, a decision was made to treat with focal laser photocoagulation. Twelve 200 μm light-intensity laser spots were applied with an argon laser to the area of leakage utilizing 200-400 mW at 100 msec duration. Ten days later the patient returned having noted a dramatic worsening of vision. At this point, the visual acuity in the right eye measured 20/400 without correction and improved to 20/150 with a spherical correction of +0.75 diopters.

Repeat funduscopic examination disclosed a dramatic increase in subretinal fluid (Fig. 2A) that was confirmed by OCT (Fig. 2B). Fluorescein angiography showed a new area of leakage at the inferior edge of the laser scar (Figs. 2C, D). Because of the increased leakage a decision was made to treat with PDT. Verteporfin 6 mg/m2 was administered intravenously and a 600 μm laser spot was applied to the area of leakage for 83 seconds at half-fluence. One week later visual acuity had improved to 20/60 without correction and the subretinal fluid had decreased in size both on exam and by OCT (Figs. 3A, B). Furthermore, there was no longer leakage on fluorescein angiography (Figs. 3C, D). At 3 months after PDT visual acuity recovered to 20/20. Funduscopic exam and OCT showed no subretinal fluid and FA continued to show no leakage (Fig. 4). The patient continues to do well without further recurrence of leakage at after 12 months of follow up.

DISCUSSION

Most cases of ICSC do not require any intervention and patients regain good visual function [1Bouzas EA, Karadimas P, Pournaras CJ. Central serous chorioretinopathy and glucocorticoids Surv Ophthalmol 2002; 47(5): 431-8.]. Treatment is indicated in patients with recurrent leakage because multiple episodes of leakage can result in permanently reduced vision. The most common intervention is focal laser photocoagulation, which has been shown to enhance the resolution of leakage and absorption of subretinal fluid; however, the mechanism of action is poorly understood.

PDT with verteporfin has also been utilized for treatment of some cases of ICSC [6Battaglia Parodi M, Da Pozzo S, Ravalico G. Photodynamic therapy in chronic central serous chorioretinopathy Retina 2003; 23(2): 235-7.-10Chan WM, Lai TY, Lai RY, Liu DT, Lam DS. Half-dose verteporfin photodynamic therapy for acute central serous chorioretinopathy: one-year results of a randomized controlled trial Ophthalmology 2008; 115(10): 1756-65.]. Due to the fact that there is relatively little data on the safety and efficacy of PDT in patients with ICSC, this treatment is usually reserved for cases that have not resolved spontaneously and either are not candidates for focal laser (due to poorly defined leakage or leakage too close to the center of the fovea) or have failed treatment with focal laser. The mechanism by which PDT reduces leakage in ICSC is also poorly understood; however, it may help to decrease the choroidal hyperpermeability that is the proposed pathogenetic mechanism of this disease and can be observed during indocyanine green angiography [11Inoue R, Sawa M, Tsujikawa M, Gomi F. Association between the efficacy of photodynamic therapy and indocyanine green angiography findings for central serous chorioretinopathy Am J Ophthalmol 2010; 149(3): 441-6.].

This case is unique in that focal laser photocoagulation resulted in no improvement in leakage four years prior in the patient’s left eye, and a dramatic worsening of leakage in the fellow eye described in this report. Focal laser treatment for ICSC has been reported to have some risk, including inadvertent treatment in the fovea and development of secondary choroidal neovascularization (CNV) at the laser scar [12Matsunaga H, Nangoh K, Uyama M, Nanbu H, Fujiseki Y, Takahashi K. Occurrence of choroidal neovascularization following photocoagulation treatment for central serous retinopathy Nippon Ganka Gakkai Zasshi 1995; 99(4): 460-8., 13Simon P, Glacet-Bernard A, Binaghi M, Coscas G, Soubrane G. Choroidal neovascularization as a complication following laser treatment of central serous chorioretinopathy J Fr Ophtalmol 2001; 24(1): 64-8.]. To the best of our knowledge the complication described here (dramatically increased subretinal fluid) has not been previously reported. It is highly unlikely that the increased fluid in our patient represented development of CNV because it occurred immediately after the laser treatment; however, it is unclear why laser treatment resulted in exacerbation of leakage. Fortunately, in both eyes of this patient, treatment with PDT resulted in rapid and complete resolution of macular leakage and serous detachment, although PDT has also been associated with the possible side effect of choroidal ischemia.

Most patients with ICSC never require intervention. In those that do require treatment focal laser photocoagulation will likely remain the most common treatment. However, PDT has been found to be effective in this disorder, and use of this treatment will likely increase. Specifically, one should consider the use of PDT in cases where there is increased leakage of subretinal fluid after focal laser treatment. Additionally, for patients with ICSC where focal laser was found to be unsuccessful in one eye, consideration should be given to using PDT as initial therapy if the fellow eye should it require treatment.

DISCLOSURES AND CONFLICTS OF INTEREST

None of the authors has any commercial or financial conflicts with any of the materials or companies mentioned in this manuscript.

The material in this manuscript has not previously been presented elsewhere.

REFERENCES

[1] Bouzas EA, Karadimas P, Pournaras CJ. Central serous chorioretinopathy and glucocorticoids Surv Ophthalmol 2002; 47(5): 431-8.
[2] Ficker L, Vafidis G, While A, Leaver P. Long-term follow-up of a prospective trial of argon laser photocoagulation in the treatment of central serous retinopathy Br J Ophthalmol 1988; 72(11): 829-34.
[3] Gass JD. Photocoagulation treatment of idiopathic central serous choroidopathy Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol 1977; 83(3 Pt 1): 456-67.
[4] Landers MB 3rd, Shaw HE Jr, Anderson WB Jr, Sinyai AJ. Argon laser treatment of central serous chorioretinopathy Ann Ophthalmol 1977; 9(12): 1567-72.
[5] Robertson DM, Ilstrup D. Direct, indirect, and sham laser photocoagulation in the management of central serous chorioretinopathy Am J Ophthalmol 1983; 95(4): 457-66.
[6] Battaglia Parodi M, Da Pozzo S, Ravalico G. Photodynamic therapy in chronic central serous chorioretinopathy Retina 2003; 23(2): 235-7.
[7] Lai TY, Chan WM, Li H, Lai RY, Liu DT, Lam DS. Safety enhanced photodynamic therapy with half dose verteporfin for chronic central serous chorioretinopathy: a short term pilot study Br J Ophthalmol 2006; 90(7): 869-74.
[8] Valmaggia C, Niederberger H. Photodynamic therapy in the treatment of chronic central serous chorioretinopathy Klin Monbl Augenheilkd 2006; 223(5): 372-5.
[9] 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(3): 288-98.
[10] Chan WM, Lai TY, Lai RY, Liu DT, Lam DS. Half-dose verteporfin photodynamic therapy for acute central serous chorioretinopathy: one-year results of a randomized controlled trial Ophthalmology 2008; 115(10): 1756-65.
[11] Inoue R, Sawa M, Tsujikawa M, Gomi F. Association between the efficacy of photodynamic therapy and indocyanine green angiography findings for central serous chorioretinopathy Am J Ophthalmol 2010; 149(3): 441-6.
[12] Matsunaga H, Nangoh K, Uyama M, Nanbu H, Fujiseki Y, Takahashi K. Occurrence of choroidal neovascularization following photocoagulation treatment for central serous retinopathy Nippon Ganka Gakkai Zasshi 1995; 99(4): 460-8.
[13] Simon P, Glacet-Bernard A, Binaghi M, Coscas G, Soubrane G. Choroidal neovascularization as a complication following laser treatment of central serous chorioretinopathy J Fr Ophtalmol 2001; 24(1): 64-8.
Track Your Manuscript:


Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


Browse Contents



Table of Contents


Webmaster Contact: info@benthamopen.net
Copyright © 2020 Bentham Open