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Bullous retinal detachment in chronic central serous chorioretinopathy treated with photodynamic therapy
ARCH SOC ESP OFTALMOL. 2011;86(2):58–61 ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA
Vol. 85
Mayo 2010
Núm. 5
Contenido Editorial La retina como marcador biológico de daño neuronal Artículos originales Comparación de tres instrumentos de tomografía de coherencia óptica, un time-domain y dos Fourierdomain, en la estimación del grosor de la capa de fibras nerviosas de la retina Idoneidad de tratamiento en sospechosos de glaucoma. Estudio de concordancia con el grupo de estudio RAND Atrofia de la capa de fibras nerviosas de la retina en pacientes con esclerosis múltiple. Estudio prospectivo con dos años de seguimiento Comunicaciones cortas Hipercorrección secundaria a transposición muscular aumentada Crítica de libros, medios audiovisuales y páginas web oftalmológicos Clinical Neuro-Ophthalmology: The Essentials Sección histórica Del mal de la rosa y la queratoconjuntivitis pelagrosa Sección iconográfica El estrabismo de Rembrandt Sociedades y Reuniones Científicas Ofertas de trabajo
www.elsevier.es/oftalmologia
Indexada en: PubMed/MEDLINE, Scopus, EMBASE/ Excerpta Medica, IBECS, IME, SCIELO, BIOSIS, SENIOR y COMPLUDOC
www.oftalmo.com/seo www.elsevier.es/oftalmologia
Short communication
Bullous retinal detachment in chronic central serous chorioretinopathy treated with photodynamic therapy L. Arias,a R. Alcubierre,b,* D. Lorenzob aHospital
Universitari de Bellvitge, Barcelona, Spain de Oftalmología, Hospital Universitari de Bellvitge, Barcelona, Spain
bDepartamento
A RT I C L E I N F O R M AT I O N
A B S T R A C T
Article history:
Case report: We describe a case of serous retinal detachment as an atypical presentation of
Received on June 27, 2010
bilateral chronic central serous chorioretinopathy,
Accepted on Nov. 10, 2010
Discussion: We present its diferential diagnosis and therapeutical management with lowfluence photodynamic therapy, achieving satisfactory anatomical and functional results. © 2010 Sociedad Española de Oftalmología. Published by Elsevier España, S.L.
Keywords:
All rights reserved
Retinal detachment Central serous chorioretinopathy
.
Photodynamic therapy
Desprendimiento de retina bulloso en coriorretinopatía serosa central crónica tratado con terapia fotodinámica R E S U M E N
Palabras clave:
Caso clínico: Se presenta un caso de desprendimiento de retina seroso como forma de pre-
Desprendimiento de retina
sentación atípica en un paciente afecto de coriorretinopatía serosa central crónica bilateral
Coriorretinopatía serosa central
Discusión: Presentamos su diagnóstico diferencial y su manejo terapéutico mediante terapia
Terapia fotodinámica
fotodinámica de baja fluencia obteniendo resultados anatómicos y funcionales satisfactorios. © 2010 Sociedad Española de Oftalmología. Publicado por Elsevier España, S.L. Todos los derechos reservados.
Introduction Central serous chorioretinopathy (CSC) is characterized by the idiopathic serous detachment of the neurosensory retina in the macula area. The association between hyperpermeability
of the choriocapillary layer and disruption of the retina pigmentary epithelium (RPE) seems to be the mechanism producing the accumulation of subretinal fluid.1 Most CSC resolve spontaneously but there is a chronic form accompanied by diffuse RPE alteration in which detachments
*Corresponding author. E-mail: [email protected] (R. Alcubierre). 0365-6691/$ - see front matter © 2010 Sociedad Española de Oftalmología. Published by Elsevier España, S.L. All rights reserved.
ARCH SOC ESP OFTALMOL. 2011;86(2):58–61
59
Figure 1 – A) Serous retinal detachment prior to vitrectomy. B) Subsequent relapse thereof. Both images show subretinal exudation areas and pigmentary epithelium alteration (arrows).
tend to be larger and visual involvement is prolonged and frequently severe.2
occurring 1 month in follow-up. At the time, the patient had been referred to our practice with suspected bilateral chronic CSC.
Clinical case
Physical exploration
Anamnesis
In the first visit, the exploration gave a visual acuity (VA) of 0.7 in the right eye (RE) and 0.05 in LE. The anterior pole exploration did not reveal significant alterations. The funduscopic exploration evidenced diffuse pigmentary epitheliopathy with bilateral macular subretinal fluid and exudative inferior retina detachment in LE (fig. 1).
Male, 44, without toxic habits or known pathological history, who initially visited another centre due to bilateral central vision reduction starting about 6 months before and more accentuated in the left eye (LE). The initial assessment revealed macular pigment alteration in both eyes, being greater in the LE and with an inferior bullous retinal detachment (RD) associated without evidencing retinal tears. The condition was approached as Harada’s disease even though the patient did not exhibit additional ophthalmological or systemic alterations, establishing treatment with oral prednisone and cyclosporine. In the absence of a response, 2 months later vitrectomy was performed in the LE at the original center. The inferior retina reapplication was achieved, with detachment relapse
Supplementary tests Fluorescein angiography revealed an alteration of the RPE with multiple leak points in the posterior pole. The LE exhibited greater contrast diffusion and RPE with scatter atrophy, communicating with the detached retina area (fig. 2). Optic coherence tomography (OCT) showed subretinal fluid in the macula area with hyper-reflecting areas at the level of the RPE (fig. 3).
Figure 2 – LE fluorescein angiography showing: A) Macular RPE diffuse alteration with multiple hyper fluorescent points. B) RPE exudation areas and scattered atrophy image formed by chronic leak (white arrow).
60
ARCH SOC ESP OFTALMOL. 2011;86(2):58–61
subretinal liquid accumulation was found. Low fluency PDT was applied in RE utilizing the same parameters as in the LE. 3 months later the reabsorption of the fluid was complete and the VA improved up to 0.65 (figs. 5 and 6).
Discussion Figure 3 – Initial LE OCT showing an accumulation of subfoveal liquid and disruption of the union between photoreceptor external and internal segments, evidencing hyper reflecting points over the fluid area (arrows).
Diagnostic The presence of diffuse pigmentary epithelium alteration in a young male associated to subretinal fluid in the macula area, supported by the angiographic finding of multiple leak points and pigmentary atrophy areas in descending tracts, lead us to confirm the diagnostic of bilateral chronic CSC. Treatment and evolution Initially, we considered the application of low fluency photodynamic therapy (PDT) in LE, utilizing the standardized parameters for ARMD with the exception of a 50% reduction in fluency and intensity.A verteporfin infusion was prepared in a dose of 6mg/m2 during 10 minutes, applying laser 5 min. later with a spot of 4.000μm focused on the macula is an intensity of 300 mW/cm2 and fluency of 25J/cm2 during 83 seconds. In month 6, the VA in LE was of 0.1, exhibiting in OCT a complete reabsorption or the subretinal fluid (fig. 4) and residual foveal atrophy associated to the loss of homogeneity of the outermost layers of the retina and choroidal hyper reflectiveness. Funduscopic exploration revealed the disappearance of the inferior retina detachment. After 6 months, the patient visited the practice again due to loss of vision in RE, which diminished to 0.5. A new macular
A careful differential diagnostic must be made for RD associated to CSC with regmatogenous RD or other serous RD secondary to Harada, severe hypertensive choroidopathy, posterior scleritis, multifocal choroiditis, metastatic tumor or uveal effusion. To achieve said diagnostic, it is useful to perform anamnesis, a detailed exploration to confirm the absence of inflammatory cells and ruptures, and fluorescein angiography to support the diagnostic in diffuse pigmentary epitheliopathy, frequently bilateral with multiple hyperfluorescente points and descending atrophic tracts.3 At present, the efficacy of treating this entity with PDT has been considered on the basis of the hypothesis that its application diminishes choriocapillary hyperpermeability and thus allows the reabsorption of the subretinal fluid. Several studies present excellent anatomic results with variable functional benefits, obtaining moderate visual improvements in most cases. Ruiz-Moreno et al described an interventionist, multicenter, nonrandomized study comprising 82 eyes with a mean follow-up of one year. The anatomic recovery occurred in all cases, the mean foveal thickness was reduced from 325 to 202 microns and the mean VA increased +1.9 lines ETDRS. Moon et al performed a retrospective analysis of 41 eyes of which 87.8% achieved complete reabsorption of the subretinal fluid and a recovery exceeding one ETDRS line in 46.3%. The chronicity of the retinal involvements with the ensuing degradation of the photoreceptor external segments could be the cause of the mismatch between anatomic and functional recovery.4,5 In order to optimize results and diminish the appearance of secondary effects in PDT, it is important to modify the standard parameters as in the case of low fluency.
Figure 4 – A) Post-PDT LE retinography. Pigmentary atrophy areas in the macular region (black arrows). B) Post-PDT LE OCT, showing total reabsorption of the subretinal fluid with residual foveal atrophy, associating alteration in the regularity of the hyper reflective line (arrow tip) and increased choroidal reflectiveness (arrows). Central foveal thickness of 104μm.
ARCH SOC ESP OFTALMOL. 2011;86(2):58–61
61
Figure 5 – A) RE retinography prior to PDT. B) RE OCT prior to PDT showing subfoveal accumulation of SRL. In this case there is greater conservation of the integrity of the union between internal and external segments of the photoreceptors.
Figure 6 – A) Post-PDT RE retinography, showing residual macular pigmentary alteration (arrow). B) Post- PDT RE OCT showing complete reabsorption of SRL and normal foveal structure (Central foveal thickness of 189μm); as well as lower degree of choroidal hyper reflectiveness as regards the LE.
Conflict of interest None of the authors have declared any conflict of interest.
R e f e r e n c e s
1. Piccolino FC, Borgia L, Zinicola E, Zingirian M. Indocyanine green angiographic findings in central serous chorioretinopathy. Eye. 1995;9:324-32. 2. Sahu DK, Namperumalsamy P, Hilton GF, de Sousa NF. Bullous variant of idiopathic central serous chorioretinopathy. Br J Ophthalmol. 2000;84:485-92.
3. Hung-Chiao Chen , Jau-Der Ho, San-Ni Chen. 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. 4. Ruiz-Moreno JM, Lugo F, Armadá F, Silva R, Montero JA, Arevalo JF, et al. Photodynamic therapy for chronic central serous chorioretinopathy. Acta Ophthalmol. 2010; 88:371–6. Epub 2009 Nov 27. 5. Moon JW, Yu HG, Kim TW, Kim HC, Chung H. Prognostic factors related to photodynamic therapy for central serous chorioretinopathy. Graefes Arch Clin Exp Ophthalmol. 2009;247:1315-23.
ARCHIVOS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGÍA
Vol. 85
Mayo 2010
Núm. 5
Contenido Editorial La retina como marcador biológico de daño neuronal Artículos originales Comparación de tres instrumentos de tomografía de coherencia óptica, un time-domain y dos Fourierdomain, en la estimación del grosor de la capa de fibras nerviosas de la retina Idoneidad de tratamiento en sospechosos de glaucoma. Estudio de concordancia con el grupo de estudio RAND Atrofia de la capa de fibras nerviosas de la retina en pacientes con esclerosis múltiple. Estudio prospectivo con dos años de seguimiento Comunicaciones cortas Hipercorrección secundaria a transposición muscular aumentada Crítica de libros, medios audiovisuales y páginas web oftalmológicos Clinical Neuro-Ophthalmology: The Essentials Sección histórica Del mal de la rosa y la queratoconjuntivitis pelagrosa Sección iconográfica El estrabismo de Rembrandt Sociedades y Reuniones Científicas Ofertas de trabajo
www.elsevier.es/oftalmologia
Indexada en: PubMed/MEDLINE, Scopus, EMBASE/ Excerpta Medica, IBECS, IME, SCIELO, BIOSIS, SENIOR y COMPLUDOC
www.oftalmo.com/seo www.elsevier.es/oftalmologia
Short communication
Bullous retinal detachment in chronic central serous chorioretinopathy treated with photodynamic therapy L. Arias,a R. Alcubierre,b,* D. Lorenzob aHospital
Universitari de Bellvitge, Barcelona, Spain de Oftalmología, Hospital Universitari de Bellvitge, Barcelona, Spain
bDepartamento
A RT I C L E I N F O R M AT I O N
A B S T R A C T
Article history:
Case report: We describe a case of serous retinal detachment as an atypical presentation of
Received on June 27, 2010
bilateral chronic central serous chorioretinopathy,
Accepted on Nov. 10, 2010
Discussion: We present its diferential diagnosis and therapeutical management with lowfluence photodynamic therapy, achieving satisfactory anatomical and functional results. © 2010 Sociedad Española de Oftalmología. Published by Elsevier España, S.L.
Keywords:
All rights reserved
Retinal detachment Central serous chorioretinopathy
.
Photodynamic therapy
Desprendimiento de retina bulloso en coriorretinopatía serosa central crónica tratado con terapia fotodinámica R E S U M E N
Palabras clave:
Caso clínico: Se presenta un caso de desprendimiento de retina seroso como forma de pre-
Desprendimiento de retina
sentación atípica en un paciente afecto de coriorretinopatía serosa central crónica bilateral
Coriorretinopatía serosa central
Discusión: Presentamos su diagnóstico diferencial y su manejo terapéutico mediante terapia
Terapia fotodinámica
fotodinámica de baja fluencia obteniendo resultados anatómicos y funcionales satisfactorios. © 2010 Sociedad Española de Oftalmología. Publicado por Elsevier España, S.L. Todos los derechos reservados.
Introduction Central serous chorioretinopathy (CSC) is characterized by the idiopathic serous detachment of the neurosensory retina in the macula area. The association between hyperpermeability
of the choriocapillary layer and disruption of the retina pigmentary epithelium (RPE) seems to be the mechanism producing the accumulation of subretinal fluid.1 Most CSC resolve spontaneously but there is a chronic form accompanied by diffuse RPE alteration in which detachments
*Corresponding author. E-mail: [email protected] (R. Alcubierre). 0365-6691/$ - see front matter © 2010 Sociedad Española de Oftalmología. Published by Elsevier España, S.L. All rights reserved.
ARCH SOC ESP OFTALMOL. 2011;86(2):58–61
59
Figure 1 – A) Serous retinal detachment prior to vitrectomy. B) Subsequent relapse thereof. Both images show subretinal exudation areas and pigmentary epithelium alteration (arrows).
tend to be larger and visual involvement is prolonged and frequently severe.2
occurring 1 month in follow-up. At the time, the patient had been referred to our practice with suspected bilateral chronic CSC.
Clinical case
Physical exploration
Anamnesis
In the first visit, the exploration gave a visual acuity (VA) of 0.7 in the right eye (RE) and 0.05 in LE. The anterior pole exploration did not reveal significant alterations. The funduscopic exploration evidenced diffuse pigmentary epitheliopathy with bilateral macular subretinal fluid and exudative inferior retina detachment in LE (fig. 1).
Male, 44, without toxic habits or known pathological history, who initially visited another centre due to bilateral central vision reduction starting about 6 months before and more accentuated in the left eye (LE). The initial assessment revealed macular pigment alteration in both eyes, being greater in the LE and with an inferior bullous retinal detachment (RD) associated without evidencing retinal tears. The condition was approached as Harada’s disease even though the patient did not exhibit additional ophthalmological or systemic alterations, establishing treatment with oral prednisone and cyclosporine. In the absence of a response, 2 months later vitrectomy was performed in the LE at the original center. The inferior retina reapplication was achieved, with detachment relapse
Supplementary tests Fluorescein angiography revealed an alteration of the RPE with multiple leak points in the posterior pole. The LE exhibited greater contrast diffusion and RPE with scatter atrophy, communicating with the detached retina area (fig. 2). Optic coherence tomography (OCT) showed subretinal fluid in the macula area with hyper-reflecting areas at the level of the RPE (fig. 3).
Figure 2 – LE fluorescein angiography showing: A) Macular RPE diffuse alteration with multiple hyper fluorescent points. B) RPE exudation areas and scattered atrophy image formed by chronic leak (white arrow).
60
ARCH SOC ESP OFTALMOL. 2011;86(2):58–61
subretinal liquid accumulation was found. Low fluency PDT was applied in RE utilizing the same parameters as in the LE. 3 months later the reabsorption of the fluid was complete and the VA improved up to 0.65 (figs. 5 and 6).
Discussion Figure 3 – Initial LE OCT showing an accumulation of subfoveal liquid and disruption of the union between photoreceptor external and internal segments, evidencing hyper reflecting points over the fluid area (arrows).
Diagnostic The presence of diffuse pigmentary epithelium alteration in a young male associated to subretinal fluid in the macula area, supported by the angiographic finding of multiple leak points and pigmentary atrophy areas in descending tracts, lead us to confirm the diagnostic of bilateral chronic CSC. Treatment and evolution Initially, we considered the application of low fluency photodynamic therapy (PDT) in LE, utilizing the standardized parameters for ARMD with the exception of a 50% reduction in fluency and intensity.A verteporfin infusion was prepared in a dose of 6mg/m2 during 10 minutes, applying laser 5 min. later with a spot of 4.000μm focused on the macula is an intensity of 300 mW/cm2 and fluency of 25J/cm2 during 83 seconds. In month 6, the VA in LE was of 0.1, exhibiting in OCT a complete reabsorption or the subretinal fluid (fig. 4) and residual foveal atrophy associated to the loss of homogeneity of the outermost layers of the retina and choroidal hyper reflectiveness. Funduscopic exploration revealed the disappearance of the inferior retina detachment. After 6 months, the patient visited the practice again due to loss of vision in RE, which diminished to 0.5. A new macular
A careful differential diagnostic must be made for RD associated to CSC with regmatogenous RD or other serous RD secondary to Harada, severe hypertensive choroidopathy, posterior scleritis, multifocal choroiditis, metastatic tumor or uveal effusion. To achieve said diagnostic, it is useful to perform anamnesis, a detailed exploration to confirm the absence of inflammatory cells and ruptures, and fluorescein angiography to support the diagnostic in diffuse pigmentary epitheliopathy, frequently bilateral with multiple hyperfluorescente points and descending atrophic tracts.3 At present, the efficacy of treating this entity with PDT has been considered on the basis of the hypothesis that its application diminishes choriocapillary hyperpermeability and thus allows the reabsorption of the subretinal fluid. Several studies present excellent anatomic results with variable functional benefits, obtaining moderate visual improvements in most cases. Ruiz-Moreno et al described an interventionist, multicenter, nonrandomized study comprising 82 eyes with a mean follow-up of one year. The anatomic recovery occurred in all cases, the mean foveal thickness was reduced from 325 to 202 microns and the mean VA increased +1.9 lines ETDRS. Moon et al performed a retrospective analysis of 41 eyes of which 87.8% achieved complete reabsorption of the subretinal fluid and a recovery exceeding one ETDRS line in 46.3%. The chronicity of the retinal involvements with the ensuing degradation of the photoreceptor external segments could be the cause of the mismatch between anatomic and functional recovery.4,5 In order to optimize results and diminish the appearance of secondary effects in PDT, it is important to modify the standard parameters as in the case of low fluency.
Figure 4 – A) Post-PDT LE retinography. Pigmentary atrophy areas in the macular region (black arrows). B) Post-PDT LE OCT, showing total reabsorption of the subretinal fluid with residual foveal atrophy, associating alteration in the regularity of the hyper reflective line (arrow tip) and increased choroidal reflectiveness (arrows). Central foveal thickness of 104μm.
ARCH SOC ESP OFTALMOL. 2011;86(2):58–61
61
Figure 5 – A) RE retinography prior to PDT. B) RE OCT prior to PDT showing subfoveal accumulation of SRL. In this case there is greater conservation of the integrity of the union between internal and external segments of the photoreceptors.
Figure 6 – A) Post-PDT RE retinography, showing residual macular pigmentary alteration (arrow). B) Post- PDT RE OCT showing complete reabsorption of SRL and normal foveal structure (Central foveal thickness of 189μm); as well as lower degree of choroidal hyper reflectiveness as regards the LE.
Conflict of interest None of the authors have declared any conflict of interest.
R e f e r e n c e s
1. Piccolino FC, Borgia L, Zinicola E, Zingirian M. Indocyanine green angiographic findings in central serous chorioretinopathy. Eye. 1995;9:324-32. 2. Sahu DK, Namperumalsamy P, Hilton GF, de Sousa NF. Bullous variant of idiopathic central serous chorioretinopathy. Br J Ophthalmol. 2000;84:485-92.
3. Hung-Chiao Chen , Jau-Der Ho, San-Ni Chen. 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. 4. Ruiz-Moreno JM, Lugo F, Armadá F, Silva R, Montero JA, Arevalo JF, et al. Photodynamic therapy for chronic central serous chorioretinopathy. Acta Ophthalmol. 2010; 88:371–6. Epub 2009 Nov 27. 5. Moon JW, Yu HG, Kim TW, Kim HC, Chung H. Prognostic factors related to photodynamic therapy for central serous chorioretinopathy. Graefes Arch Clin Exp Ophthalmol. 2009;247:1315-23.