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Bilateral exudative retinal detachment associated with central serous chorioretinopathy in a patient treated with corticosteroids
ARTICLE IN PRESS a r c h s o c e s p o f t a l m o l . 2 0 1 7;x x x(x x):xxx–xxx
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Short communication
Bilateral exudative retinal detachment associated with central serous chorioretinopathy in a patient treated with corticosteroids夽 T. Rueda-Rueda, J.L. Sánchez-Vicente, L. Llerena-Manzorro ∗ , A. Medina-Tapia, L. González-García, A. Alfaro-Juárez, C. Vital-Berral, F. López-Herrero, ˜ L.S. Ortega, Á. Herrador-Montiel A. Munoz-Morales, Hospital Universitario Virgen del Rocío, Sevilla, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
Case report: The case is presented on a 54-year-old woman with a central serous chori-
Received 25 July 2016
oretinopathy, misdiagnosed as Vogt–Koyanagi–Harada disease, and treated with systemic
Accepted 10 January 2017
corticosteroids. The patient presented with a bilateral bullous exudative retinal detachment.
Available online xxx
Discussion: Discontinuation of corticosteroid therapy, surgical drainage of subretinal fluid, and photodynamic therapy, led to anatomical and functional improvement. The recognition
Keywords:
of an atypical presentation of central serous chorioretinopathy may avoid complications of
Central serous chorioretinopathy
the inappropriate treatment with corticosteroids.
Vogt–Koyanagi–Harada disease
˜ ˜ S.L.U. All rights © 2017 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana, reserved.
Exudative retinal detachment Corticosteroids Pars plana vitrectomy Subretinal liquid drainage Photodynamic therapy
Desprendimiento de retina exudativo bilateral asociado con coriorretinopatía serosa central en una paciente tratada con corticoesteroides r e s u m e n Palabras clave:
˜ Caso clínico: Presentamos el caso de una mujer de 54 anos con una coriorretinopatía serosa
Coriorretinopatía serosa central
central diagnosticada erróneamente de enfermedad de Vogt-Koyanagi-Harada y tratada
Enfermedad de
con corticoides sistémicos. La paciente desarrolló un desprendimiento de retina exudativo
Vogt-Koyanagi-Harada
bulloso en ambos ojos.
夽 Please cite this article as: Rueda-Rueda T, Sánchez-Vicente JL, Llerena-Manzorro L, Medina-Tapia A, González-García L, Alfaro-Juárez A, et al. Desprendimiento de retina exudativo bilateral asociado con coriorretinopatía serosa central en una paciente tratada con corticoesteroides. Arch Soc Esp Oftalmol. 2017. http://dx.doi.org/10.1016/j.oftal.2017.01.002 ∗ Corresponding author. E-mail address: laurall [email protected] (L. Llerena-Manzorro). ˜ ˜ S.L.U. All rights reserved. 2173-5794/© 2017 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana,
OFTALE-1148; No. of Pages 5
ARTICLE IN PRESS 2
a r c h s o c e s p o f t a l m o l . 2 0 1 7;x x x(x x):xxx–xxx
Desprendimiento exudativo de
Discusión: La interrupción del tratamiento con corticoides junto con el drenaje quirúrgico del
retina
líquido subretiniano y la aplicación de terapia fotodinámica consiguió la mejoría anatómica
Corticoides
y funcional. El correcto diagnóstico de las formas atípicas de la enfermedad podría evitar
Vitrectomía pars plana
las complicaciones del uso inadecuado de los corticoides.
Drenaje de líquido subretiniano
˜ ˜ S.L.U. Todos de Oftalmolog´ıa. Publicado por Elsevier Espana, © 2017 Sociedad Espanola
Terapia fotodinámica
Introduction Central serous chorioretinopathy (CSC) is characterized by the presence of serous retinal detachment (SRD) or retina pigment epithelium detachment (RPED) generally limited to the macula and associated to the dissemination of liquid into the subretinal space.1 In typical CSC, SRD resolves spontaneously with visual recovery. However, atypical forms with bullous SRD associated to multiple large RPED can be confused with the Vogt–Koyanagi–Harada (VKH) disease.2 The case of a patient with chronic CSC erroneously diagnosed as VKH is presented. Systemic corticosteroid treatment worsened the condition with increased detachments and chronification of the disease. Discontinuation of corticosteroids was insufficient and it became necessary to surgically drain the subretinal fluid (SRF) through pars plana vitrectomy and the application of photodynamic therapy (PDT).
Clinical case Female, 54, without relevant history, referred due to diminished vision with over 6 months evolution. Maximum uncorrected visual acuity was 0.25 in the right eye (RE) and 0.4 in the left eye (LE). Intraocular pressure and anterior chamber biomicroscopy were normal. In RE ocular fundus, the papilla exhibited normal color and was well defined. Diffuse macular edema with perimacular hemorrhages and retina pigment epithelium alterations could be observed. The LE exhibited a diffuse macular edema, notably the presence of 2 cystic formations adjacent to the superior temporal arch. Papilla was normal (Fig. 1). Spectral domain optical coherence tomography (SD-OCT)
los derechos reservados.
The patient was diagnosed with VKH, beginning treatment with systemic corticosteroids and cyclosporine and referred to the Collagenosis and ENT Unit, discarding other associated systemic alterations. Hematimetry, biochemistry, serology and Mantoux were negative. The condition of the patient worsened and it was decided to adminster 3 intravenous bolus of corticosteroids (1 g methylprednisolone). After this treatment, the patient exhibited significant worsening with diminished VA (0.16 in RE and 0.032 in LE), the appearance of bullous SRD that compromised the inferior retina of both eyes (BE) (Fig. 4), which led to considering a diagnostic of chronic CSE. Corticosteroids and cyclosporine dosages were diminished prior to discontinuation. Due to SRD persistence in BE 8 weeks after discontinuing corticosteroid treatment that prevented laser treatment or PDT due to the height of the detachment, surgical drain was decided followed by bilateral PDT in different surgical interventions. Pars plana vitrectomy with 23 G was performed with liquid perfluorocarbon injection, external SRF drainage through 2 radial sclerostomies having a length of 3 mm, at 10 mm of the limbus on both sides of the medial rectus, intraocular laser in suspected diffusion areas and liquid-airSF6 20% exchange. After reapplication of the retina, diminished fluency PDT was performed (25 J/cm2 ) with normal dose of verteporfin (6 mg/m2 ), during 83 s over an area of approximately 3000 m corresponding to the diffusion areas, upon which the condition stabilized. At present, after 20 months follow-up, the corrected visual acuity of the patient is of 0.1 in the RE and 0.2 in the LE. The retina remains applied, with intense subretinal fibrosis with atrophy and hypertrophy of the retina pigment epithelium and macular epiretinal membranes in BE, possibly as a post-surgery complication (Fig. 5).
®
(Topcon 3 D OCT-1000, Topcon Corporation, Tokyo, Japan) showed edema with large cysts in the RE central macula with SRF in the rest of the posterior pole. LE exhibited foveal neuroepithelium detachment with SRF in the entire posterior pole. Two larger cystic formations with RPED and SRF were observed adjacent to the superior arch (Fig. 2). Fluorescein angiography evidenced diffuse retina pigment epithelium alterations in the RE, limited to posterior pole, with uneven hyperfluorescence. RPE hypertrophic areas could be observed together with stain accumulation areas. In the LE, the diffuse hyperfluorescence area was smaller, exhibiting 2 large areas of fluorescein accumulation corresponding to the cystic lesions in the superior temporal arch, as well as lesions compatible with RPED (Fig. 3).
Discussion The association between corticosteroids and CSC is wellknown. Patients with extended corticosteroid treatments could develop a chronic and recurring form of CSC.3 In addition, the use of steroids could worsen existing CSC and give rise to atypical forms such as diffuse epitheliopathy, bullous SRD and SRD with exudation and subretinal fibrosis.4 These forms could be confused with other entities, particularly VKH, which require the use of corticosteroids. The differential diagnostic of these atypical forms should include regmatogenous retina detachment, VKH, hypertensive choroidopathy,
ARTICLE IN PRESS a r c h s o c e s p o f t a l m o l . 2 0 1 7;x x x(x x):xxx–xxx
3
Fig. 1 – (a) RE retinograph: diffuse macular edema with perimacular hemorrhages and retina pigment epithelium alterations. (b) LE retinograph: macular edema and cystic formations next to the superior temporal arch.
Fig. 2 – RE OCT: edema with large cysts in the central macula with presence of subretinal fluid in the rest of the posterior pole. LE OCT: foveal neuroepithelium detachment with subretinal fluid throughout the posterior pole.
posterior scleritis, multifocal choroiditis, metastasis and the uveal effusion syndrome.2 There are very few published cases reporting external drainage of SRF in patients with CSC and bullous SRD.5,6 Said
procedure enabled flattening of the retina for adequate application of PDT. This treatment was preferred against other more conservative forms such as eplerenone or melatonin7,8 or avoiding drainage sclerostomies,9 due to the aggressiveness
ARTICLE IN PRESS 4
a r c h s o c e s p o f t a l m o l . 2 0 1 7;x x x(x x):xxx–xxx
Fig. 3 – Early and late fluorescein angiography of both eyes.
Fig. 4 – Fluorescein angiography. Large bullous detachment of the inferior retina of both eyes.
ARTICLE IN PRESS a r c h s o c e s p o f t a l m o l . 2 0 1 7;x x x(x x):xxx–xxx
5
Fig. 5 – Final stage of 2 eyes. Intense subretinal fibrosis, RPE atrophy and hypertrophy and epiretinal membranes.
of the present case, the length of the evolution and the suspicion of high SRF density. Early drainage and PDT might have allowed better visual acuity preservation.
4.
Conflict of interests
5.
No conflict of interests was declared by the authors.
6.
references 7. 1. Nicholson B, Noble J, Forooghian F, Meyerle C. Central serous chorioretinopathy: update on pathophysiology and treatment. Surv Ophthalmol. 2013;58:103–26. 2. Kang JE, Kim HJ, Boo HD, Kim HK, Lee JH. Surgical management of bilateral exudative retinal detachment associated with central serous chorioretinopathy. Korean J Ophthalmol. 2006;20:131–8. 3. Loo JL, Lee SY, Ang CL. Can long-term corticosteroids lead to blindness? A case series of central serous chorioretinopathy
8.
9.
induced by corticosteroids. Ann Acad Med Singapore. 2006;35:496–9. Bouzas EA, Karadimas P, Pournaras CJ. Central serous chorioretinopathy and glucocorticoids. Surv Ophthalmol. 2002;47:431–48. Adán A, Corcóstegui B. Surgical management of exudative retinal detachment associated with central serous chorioretinopathy. Ophthalmologica. 2001;215:74–6. Chen HC, Ho JD, Chen SN. Perfluorocarbon liquid-assisted external drainage in the management of central serous chorioretinopathy with bullous serous retinal detachment. Chang Gung Med J. 2003;26:777–81. Sampo M, Soler V, Gascon P, Ho Wang Yin G, Hoffart L, Denis D, et al. Eplerenone treatment in chronic central serous chorioretinopathy. J Fr Ophtalmol. 2016;39:535–42. Gramajo AL, Marquez GE, Torres VE, Juárez CP, Rosenstein RE, Luna JD, et al. Therapeutic benefit of melatonin in refractory central serous chorioretinopathy. Eye (Lond). 2015;29:1036–45. Arias L, Alcubierre R, Lorenzo D. Bullous retinal detachment in chronic central serous chorioretinopathy treated with photodynamic therapy. Arch Soc Esp Oftalmol. 2011;86: 58–61.
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA www.elsevier.es/oftalmologia
Short communication
Bilateral exudative retinal detachment associated with central serous chorioretinopathy in a patient treated with corticosteroids夽 T. Rueda-Rueda, J.L. Sánchez-Vicente, L. Llerena-Manzorro ∗ , A. Medina-Tapia, L. González-García, A. Alfaro-Juárez, C. Vital-Berral, F. López-Herrero, ˜ L.S. Ortega, Á. Herrador-Montiel A. Munoz-Morales, Hospital Universitario Virgen del Rocío, Sevilla, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
Case report: The case is presented on a 54-year-old woman with a central serous chori-
Received 25 July 2016
oretinopathy, misdiagnosed as Vogt–Koyanagi–Harada disease, and treated with systemic
Accepted 10 January 2017
corticosteroids. The patient presented with a bilateral bullous exudative retinal detachment.
Available online xxx
Discussion: Discontinuation of corticosteroid therapy, surgical drainage of subretinal fluid, and photodynamic therapy, led to anatomical and functional improvement. The recognition
Keywords:
of an atypical presentation of central serous chorioretinopathy may avoid complications of
Central serous chorioretinopathy
the inappropriate treatment with corticosteroids.
Vogt–Koyanagi–Harada disease
˜ ˜ S.L.U. All rights © 2017 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana, reserved.
Exudative retinal detachment Corticosteroids Pars plana vitrectomy Subretinal liquid drainage Photodynamic therapy
Desprendimiento de retina exudativo bilateral asociado con coriorretinopatía serosa central en una paciente tratada con corticoesteroides r e s u m e n Palabras clave:
˜ Caso clínico: Presentamos el caso de una mujer de 54 anos con una coriorretinopatía serosa
Coriorretinopatía serosa central
central diagnosticada erróneamente de enfermedad de Vogt-Koyanagi-Harada y tratada
Enfermedad de
con corticoides sistémicos. La paciente desarrolló un desprendimiento de retina exudativo
Vogt-Koyanagi-Harada
bulloso en ambos ojos.
夽 Please cite this article as: Rueda-Rueda T, Sánchez-Vicente JL, Llerena-Manzorro L, Medina-Tapia A, González-García L, Alfaro-Juárez A, et al. Desprendimiento de retina exudativo bilateral asociado con coriorretinopatía serosa central en una paciente tratada con corticoesteroides. Arch Soc Esp Oftalmol. 2017. http://dx.doi.org/10.1016/j.oftal.2017.01.002 ∗ Corresponding author. E-mail address: laurall [email protected] (L. Llerena-Manzorro). ˜ ˜ S.L.U. All rights reserved. 2173-5794/© 2017 Sociedad Espanola de Oftalmolog´ıa. Published by Elsevier Espana,
OFTALE-1148; No. of Pages 5
ARTICLE IN PRESS 2
a r c h s o c e s p o f t a l m o l . 2 0 1 7;x x x(x x):xxx–xxx
Desprendimiento exudativo de
Discusión: La interrupción del tratamiento con corticoides junto con el drenaje quirúrgico del
retina
líquido subretiniano y la aplicación de terapia fotodinámica consiguió la mejoría anatómica
Corticoides
y funcional. El correcto diagnóstico de las formas atípicas de la enfermedad podría evitar
Vitrectomía pars plana
las complicaciones del uso inadecuado de los corticoides.
Drenaje de líquido subretiniano
˜ ˜ S.L.U. Todos de Oftalmolog´ıa. Publicado por Elsevier Espana, © 2017 Sociedad Espanola
Terapia fotodinámica
Introduction Central serous chorioretinopathy (CSC) is characterized by the presence of serous retinal detachment (SRD) or retina pigment epithelium detachment (RPED) generally limited to the macula and associated to the dissemination of liquid into the subretinal space.1 In typical CSC, SRD resolves spontaneously with visual recovery. However, atypical forms with bullous SRD associated to multiple large RPED can be confused with the Vogt–Koyanagi–Harada (VKH) disease.2 The case of a patient with chronic CSC erroneously diagnosed as VKH is presented. Systemic corticosteroid treatment worsened the condition with increased detachments and chronification of the disease. Discontinuation of corticosteroids was insufficient and it became necessary to surgically drain the subretinal fluid (SRF) through pars plana vitrectomy and the application of photodynamic therapy (PDT).
Clinical case Female, 54, without relevant history, referred due to diminished vision with over 6 months evolution. Maximum uncorrected visual acuity was 0.25 in the right eye (RE) and 0.4 in the left eye (LE). Intraocular pressure and anterior chamber biomicroscopy were normal. In RE ocular fundus, the papilla exhibited normal color and was well defined. Diffuse macular edema with perimacular hemorrhages and retina pigment epithelium alterations could be observed. The LE exhibited a diffuse macular edema, notably the presence of 2 cystic formations adjacent to the superior temporal arch. Papilla was normal (Fig. 1). Spectral domain optical coherence tomography (SD-OCT)
los derechos reservados.
The patient was diagnosed with VKH, beginning treatment with systemic corticosteroids and cyclosporine and referred to the Collagenosis and ENT Unit, discarding other associated systemic alterations. Hematimetry, biochemistry, serology and Mantoux were negative. The condition of the patient worsened and it was decided to adminster 3 intravenous bolus of corticosteroids (1 g methylprednisolone). After this treatment, the patient exhibited significant worsening with diminished VA (0.16 in RE and 0.032 in LE), the appearance of bullous SRD that compromised the inferior retina of both eyes (BE) (Fig. 4), which led to considering a diagnostic of chronic CSE. Corticosteroids and cyclosporine dosages were diminished prior to discontinuation. Due to SRD persistence in BE 8 weeks after discontinuing corticosteroid treatment that prevented laser treatment or PDT due to the height of the detachment, surgical drain was decided followed by bilateral PDT in different surgical interventions. Pars plana vitrectomy with 23 G was performed with liquid perfluorocarbon injection, external SRF drainage through 2 radial sclerostomies having a length of 3 mm, at 10 mm of the limbus on both sides of the medial rectus, intraocular laser in suspected diffusion areas and liquid-airSF6 20% exchange. After reapplication of the retina, diminished fluency PDT was performed (25 J/cm2 ) with normal dose of verteporfin (6 mg/m2 ), during 83 s over an area of approximately 3000 m corresponding to the diffusion areas, upon which the condition stabilized. At present, after 20 months follow-up, the corrected visual acuity of the patient is of 0.1 in the RE and 0.2 in the LE. The retina remains applied, with intense subretinal fibrosis with atrophy and hypertrophy of the retina pigment epithelium and macular epiretinal membranes in BE, possibly as a post-surgery complication (Fig. 5).
®
(Topcon 3 D OCT-1000, Topcon Corporation, Tokyo, Japan) showed edema with large cysts in the RE central macula with SRF in the rest of the posterior pole. LE exhibited foveal neuroepithelium detachment with SRF in the entire posterior pole. Two larger cystic formations with RPED and SRF were observed adjacent to the superior arch (Fig. 2). Fluorescein angiography evidenced diffuse retina pigment epithelium alterations in the RE, limited to posterior pole, with uneven hyperfluorescence. RPE hypertrophic areas could be observed together with stain accumulation areas. In the LE, the diffuse hyperfluorescence area was smaller, exhibiting 2 large areas of fluorescein accumulation corresponding to the cystic lesions in the superior temporal arch, as well as lesions compatible with RPED (Fig. 3).
Discussion The association between corticosteroids and CSC is wellknown. Patients with extended corticosteroid treatments could develop a chronic and recurring form of CSC.3 In addition, the use of steroids could worsen existing CSC and give rise to atypical forms such as diffuse epitheliopathy, bullous SRD and SRD with exudation and subretinal fibrosis.4 These forms could be confused with other entities, particularly VKH, which require the use of corticosteroids. The differential diagnostic of these atypical forms should include regmatogenous retina detachment, VKH, hypertensive choroidopathy,
ARTICLE IN PRESS a r c h s o c e s p o f t a l m o l . 2 0 1 7;x x x(x x):xxx–xxx
3
Fig. 1 – (a) RE retinograph: diffuse macular edema with perimacular hemorrhages and retina pigment epithelium alterations. (b) LE retinograph: macular edema and cystic formations next to the superior temporal arch.
Fig. 2 – RE OCT: edema with large cysts in the central macula with presence of subretinal fluid in the rest of the posterior pole. LE OCT: foveal neuroepithelium detachment with subretinal fluid throughout the posterior pole.
posterior scleritis, multifocal choroiditis, metastasis and the uveal effusion syndrome.2 There are very few published cases reporting external drainage of SRF in patients with CSC and bullous SRD.5,6 Said
procedure enabled flattening of the retina for adequate application of PDT. This treatment was preferred against other more conservative forms such as eplerenone or melatonin7,8 or avoiding drainage sclerostomies,9 due to the aggressiveness
ARTICLE IN PRESS 4
a r c h s o c e s p o f t a l m o l . 2 0 1 7;x x x(x x):xxx–xxx
Fig. 3 – Early and late fluorescein angiography of both eyes.
Fig. 4 – Fluorescein angiography. Large bullous detachment of the inferior retina of both eyes.
ARTICLE IN PRESS a r c h s o c e s p o f t a l m o l . 2 0 1 7;x x x(x x):xxx–xxx
5
Fig. 5 – Final stage of 2 eyes. Intense subretinal fibrosis, RPE atrophy and hypertrophy and epiretinal membranes.
of the present case, the length of the evolution and the suspicion of high SRF density. Early drainage and PDT might have allowed better visual acuity preservation.
4.
Conflict of interests
5.
No conflict of interests was declared by the authors.
6.
references 7. 1. Nicholson B, Noble J, Forooghian F, Meyerle C. Central serous chorioretinopathy: update on pathophysiology and treatment. Surv Ophthalmol. 2013;58:103–26. 2. Kang JE, Kim HJ, Boo HD, Kim HK, Lee JH. Surgical management of bilateral exudative retinal detachment associated with central serous chorioretinopathy. Korean J Ophthalmol. 2006;20:131–8. 3. Loo JL, Lee SY, Ang CL. Can long-term corticosteroids lead to blindness? A case series of central serous chorioretinopathy
8.
9.
induced by corticosteroids. Ann Acad Med Singapore. 2006;35:496–9. Bouzas EA, Karadimas P, Pournaras CJ. Central serous chorioretinopathy and glucocorticoids. Surv Ophthalmol. 2002;47:431–48. Adán A, Corcóstegui B. Surgical management of exudative retinal detachment associated with central serous chorioretinopathy. Ophthalmologica. 2001;215:74–6. Chen HC, Ho JD, Chen SN. Perfluorocarbon liquid-assisted external drainage in the management of central serous chorioretinopathy with bullous serous retinal detachment. Chang Gung Med J. 2003;26:777–81. Sampo M, Soler V, Gascon P, Ho Wang Yin G, Hoffart L, Denis D, et al. Eplerenone treatment in chronic central serous chorioretinopathy. J Fr Ophtalmol. 2016;39:535–42. Gramajo AL, Marquez GE, Torres VE, Juárez CP, Rosenstein RE, Luna JD, et al. Therapeutic benefit of melatonin in refractory central serous chorioretinopathy. Eye (Lond). 2015;29:1036–45. Arias L, Alcubierre R, Lorenzo D. Bullous retinal detachment in chronic central serous chorioretinopathy treated with photodynamic therapy. Arch Soc Esp Oftalmol. 2011;86: 58–61.