Author: Christian Enders (Germany)
Co-authors: Gabriele Lang, Benjamin Mayer, Jens Werner
Purpose
Central serous chorioretinopathy (CSCR) presents itself as a serous detachment of the central neurosensory retina (NR), which may be accompanied by focal detachment of the retinal pigment epithelium (RPE) as well as changes in the RPE itself. It is a rare disorder affecting approximately 1.7 per 100’000 women and 9.9 per 100’000 men. It usually appears unilaterally and can follow an acute or chronic-atrophic course. It is often self-limiting, however if the macular region is affected, visual impairment can be serious. As spontaneous remissions are common (approximately 68%), the initial therapeutic strategy is watch-and-wait. However, if remission does not occur, data on the effectiveness of further treatment options is sparse. We therefore decided to examine the effectiveness of subthreshold laser photocoagulation (ST-LP) on best-corrected visual acuity (BCVA) and subretinal fluid (SRF) resorption.
Setting/Venue
We conducted a retrospective analysis of all patients age 18 years or older who underwent ST-LP based on the diagnosis of CSCR in a German university eye hospital from 2009 to 2014. Exclusion criteria included other retinal diseases, status post recent intraocular surgery, insufficient quality of optical coherence tomography (OCT) images and presence of comorbidities of the anterior or posterior segment, which could have an influence on visual acuity. ST-LP was performed to all source points identified in fluorescence angiography (FA)
Methods
The study was approved by the local ethics committee (application No. 395/15) and was conducted in compliance with the tenets of the Declaration of Helsinki. The diagnosis of CSCR was based on following criteria: 1. detachment of the NR and possibly the RPE visible on ophthalmoscopy 2. evidence of SRF on OCT 3. visualization of one or more source points typical for CSCR in FA and 4. exclusion of differential diagnoses. Written informed consent was obtained for ST-LP. The indication for ST-LP was based on the following criteria: - diagnosis of CSCR with foveal involvement, - SRF not resorbed over a period of up to 4 months or recurrence of CSCR. - At least one source point accessible to ST-LP (location at least 500 µm from the fovea centralis and a papillary diameter away from the optic nerve). The time between anamnestic onset of symptomatic complaints and ST-LP was determined as well as BCVA and OCT before ST-LP. ST-LP was performed as a subthreshold thermal laser coagulation with a frequency-doubled Nd:YAG continous wave laser. Follow-up examinations were scheduled at 4, 8 and 12 weeks after ST-LP.
Results
54 eyes of 49 patients were included in the study. The median age of patients was 47 years. The median duration until laser coagulation was 9 weeks since symptom onset. A median of 9 laser foci were applied. 89% of the included patients were male. Of the eyes treated, 46% were the right eye, 54% the left eye. 20% of patients had a first manifestation of CSCR, 69% had a recurrence, and 11% had persistent SRF for > 6 months. 15% had 1 prior LP, 2% 2 prior LP and 2% a prior photodynamic therapy. Median visual acuity rose from 0.30 at baseline to 0.10 at 4 weeks and 0.00 at 8 weeks, before dropping slightly to 0.05 at 12 weeks. The changes of visual acuity in comparison to baseline were statistically significant (p<0.05). The initial median retinal thickness of 397µm at baseline decreased to 26 4µm at 4 weeks, to 236µm at 8 weeks and to 239µm at 12 weeks (decreases to baseline all statistically significant (p<0.05). Complete SRF resorption increased from 0% at baseline to 26% at 4 weeks, 52% at 8 weeks and 67% at 12 weeks (results significant with p<0.0001). No adverse events occured.
Conlusions
In our cohort, which resembles those previously described, we were able to achieve substantial and significant clinical benefit through ST-LP measured by improvement in BCVA. Furthermore, we were also able to demonstrate measurable, significant morphological improvements as decreased retinal thickness and increased resorption of SRF as probable mechanisms explaining clinical improvement of CSCR with ST-LP. The advantage of ST-LP over other methods is the low risk of adverse events and its high availability. Controlled, randomized studies are necessary to confirm the data and demonstrate the effect over a longer period of time.
Financial Disclosure
none
Comments
-
