SPECTRAL DOMAIN OPTICAL COHERENCE TOMOGRAPHY–GUIDED LASER TREATMENT OF CENTRAL SEROUS CHORIORETINOPATHY IN A PREGNANT WOMAN Sandhya Narayanan, MS, DO, DNB, MNAMS, Giridhar Anantharaman, MS, Mahesh Gopalakrishnan, MS, DO DNB, FRCS (Edin), Eliza Anthony, MBBS
Purpose: To report a case of central serous chorioretinopathy treated with focal laser photocoagulation guided by spectral domain optical coherence tomography (SD-OCT) without fluorescein angiography. Methods: In this interventional case report, a 27-year-old pregnant lady with central serous chorioretinopathy was evaluated with fundus photography and SD-OCT. She was treated with focal laser photocoagulation to the area of micro rip on the summit of pigment epithelial detachment identified by SD-OCT. Results: Successful treatment of serous macular detachment using SD-OCT in a pregnant lady. Conclusion: We report a case of central serous chorioretinopathy evaluated and treated successfully with SD-OCT without the use of fluorescein angiography. RETINAL CASES & BRIEF REPORTS 9:55–58, 2015
certain characteristic features of leakage points. This can be used to guide laser treatment in situations where FA is not possible or is better avoided. Here, we report a case of CSC treated successfully with laser photocoagulation in a pregnant lady using SD-OCT findings without the aid of FA.
From the Giridhar Eye Institute, Kadavanthra, Cochin, India.
S
pectral domain optical coherence tomography (SD-OCT) has revolutionized our approach to the diagnosis and management of diseases of the macula. Central serous chorioretinopathy (CSC), characterized by serous macular detachment, is a common disease as seen typically in young and middle-aged adults. It is secondary to focal leakages at the level of retinal pigment epithelium (RPE) seen on fluorescein angiography (FA)1 and can be treated with laser photocoagulation.2 The diagnosis is usually made by biomicroscopic examination, and the leakage points are identified by FA. Recently, SD-OCT has allowed in-depth evaluation of this disorder and identified
Case Report A 27-year-old lady presented to the vitreoretinal services of our institute with a history of central scotoma and defective vision of the right eye of 2 days duration. She was 8-months pregnant. Her best-corrected visual acuity in the right eye was 20/200, N18 and in the left eye was 20/20, N6. Her anterior segment examination was unremarkable, and the intra ocular pressure was normal in both eyes. Dilated fundus examination of the right eye showed a large serous macular detachment of about eight disk diameters centered around the fovea. A yellowish white exudate of about 0.5 disk diameter was seen within the serous macular detachment, 0.5 disk diameter above the fovea. There was yet another small yellowish white area inferotemporal to the fovea (Figure 1). The left eye fundus was normal. Because the drop in visual acuity was significant and the amount of fluid large, and the patient was very anxious, we decided to
None of the authors have any financial/conflicting interests to disclose. Reprint requests: Sandhya Narayanan, MS, DO, DNB, MNAMS, Giridhar Eye Institute, Ponneth Temple Road, Kadavanthra, Cochin 682 020, India; e-mail: [email protected]
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Fig. 1. Fundus photograph of the right eye. There is a large serous macular detachment centered around the fovea. The white arrowhead shows the yellowish white subretinal exudates.
intervene. Because she was pregnant, FA was deferred, and we did SD-OCT to find out the leakage point. Spectral domain optical coherence tomography was performed in both eyes with Spectralis (Heidelberg, Germany) using super luminescent diode laser (wave
Fig. 2. A. Spectral domain optical coherence tomography of the right eye through the fovea showing serous macular detachment. B. Spectral domain optical coherence tomography of the right eye showing serous macular detachment, dipping of posterior layer of neurosensory detachment (thick white arrowhead), hyperreflective exudates (red arrow) with translucent center. The thin white arrow points the RPE micro rip on the PED. The SD-OCT scan was taken through the green horizontal arrow on fundus photograph.
length of 870 nm) as the light source. Spectral domain optical coherence tomography confirmed the presence of a large serous macular detachment with a height of 704 mm at the fovea (Figure 2A). A small pigment epithelial detachment (PED) was seen above the fovea within the yellowish white area seen on fundus examination. There was a small defect in the RPE (a micro rip) on the summit of PED. Retinal dipping and fibrinous exudation with a translucent center were seen just above the RPE defect on PED (Figure 2B). These findings were used to identify the leakage point. Since the Spectralis (Heidelberg, Germany) display the infrared fundus image by the side of OCT scans, the exact point of RPE defect on PED was traced on to the fundus photograph with the help of the reticule and was used as a guide to give focal laser photocoagulation. Green laser photocoagulation was given to the defect in RPE on the summit of PED with 3–4 shots using a power of 100 mw for 0.1 second and a spot size of 50 ms. Spectral domain optical coherence tomography of the left eye was normal. When she came for review 3 weeks later her best corrected visual acuity in the right eye had improved to 6/6, N6 and dilated fundus examination revealed a dry macula. Spectral domain optical coherence tomography performed at that time showed complete resolution of subretinal fluid with a normal foveal architecture. The external limiting membrane, inner segment–outer segment junction, and the RPE regained their normal structure at the fovea (Figure 3A). Spectral domain optical coherence tomography through the lasertreated area also showed a near-normal architecture (Figure 3B).
SD-OCT–GUIDED LASER TREATMENT OF CSCR
Discussion Morphologic changes in CSC have been described using optical coherence tomography earlier.3–5 Since the introduction of SD-OCT, studies have focused on comparing tomographic findings with FA features6 and indocyanine green angiographic features.7 Fugiro et al8 studied the morphology of leaks using frequency domain-OCT and compared it with the FA leaks in 21 eyes with CSC. In their study, 96% had RPE abnormalities and 61% PEDs at the site of leak. Fifty-two percent had hyperreflective shadow on frequency domain-OCT suggesting fibrin around the leak point, and these corresponded to the yellowish white area seen clinically. A translucent area within the hyperreflective shadow was seen in 8 of the 11 leakage sites. Forty-three percent had sagging of the posterior layer of neurosensory retina. Minute defect in the RPE was seen in 3 PEDs and that exactly
57
corresponded to the leak points on FA.8 In a study performed in South India on 100 patients with acute CSC using SD-OCT, 60% of the eyes showed a characteristic dipping pattern of neurosensory retina with intervening hyperreflective echoes over the leakage site.9 Seventy percent of their eyes had PEDs at the site of angiographic leaks and 22% had break in PEDs at the leak point.9 Hirmani et al studied 30 eyes with CSC using OCT, FA, and indocyanine green angiography. In his study, 10 of the 11 eyes with PED (91%) showed PED within the areas of choroidal vascular hyperpermeability.7 In a study by Hussain et al, 6 of the 10 eyes (60%) showed a characteristic dipping pattern of neurosensory retina with intervening hyperreflective echoes suggestive of fibrin over the leakage site. All these eyes had ink-blot leak and subretinal fibrin.6 In our case, there was a small PED within neurosensory detachment with a micro rip on it. There was
Fig. 3. A. Spectral domain optical coherence tomography through fovea 3 weeks after laser photocoagulation shows complete resolution of serous macular detachment and restoration of normal foveal architecture. B. Spectral domain optical coherence tomography through the laser-treated area. The area of treatment is shown by the red arrowhead.
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dipping of the posterior surface of the neurosensory retina and hyperreflective shadow with a translucent center around the area of micro rip. The hyperreflective shadow corresponded with the yellowish area seen on fundus examination. This area of micro rip on SD-OCT was superimposed on the fundus photograph, and focal laser was given to this area. Spectral domain optical coherence tomography performed after 3 weeks showed a near-normal foveal architecture with restoration of inner segment–outer segment junction. Fugimoto et al8 also showed reappearance of inner segment–outer segment junction after disappearance of subretinal fluid. Because the retinal layers have regained their normal architecture, the patient regained normal visual acuity. There was a significant amount of subretinal fluid before the treatment, and the fluid got reabsorbed 3 weeks after the laser procedure. Because she was still pregnant at the time of repeat scan, we believe that the disappearance of fluid is due to laser therapy and not related to the hormonal changes. Although we did not do FA to demonstrate the site of leak, SD-OCT features could precisely localize the point of leak and we could do focal laser successfully. This modality can be used to guide laser photocoagulation in patients with CSC, where FA is contraindicated or better avoided.
References 1. Gass JDM. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. 4th ed. Vol 1. St Louis, MO: Mosby; 1997: 52–70. 2. Gass JDM. Pathogenesis of disciform detachment of neuroepithelium, II: idiopathic central serous chorioretinopathy. Am J Ophthalmol 1967;63:587–615. 3. Hee MR, Puliafito CA, Wong C, et al. Optical coherence tomography of central serous chorioretinopathy. Am J Ophthalmol 1995;120:65–74. 4. Iida T, Hagimura N, Sato T, Kishi S. Evaluation of central serous chorioretinopathy with optical coherence tomography. Am J Ophthalmol 2000;129:16–20. 5. Montero JA, Ruiz-Moreno JM. Optical coherence tomography characterisation of idiopathic central serous chorioretinopathy. Br J Ophthalmol 2005;89:562–564. 6. Hussain N, Baskar A, Ram LM, Das T. Optical coherence tomographic pattern of fluorescein angiographic leakage site in acute central serous chorioretinopathy. Clin Experiment Ophthalmol 2006;34:137–140. 7. Hirami Y, Sujikawa AT, Sasahara M, et al. Alteration of retinal pigment epithelium in central serous chorioretinopathy. Clin Experiment Ophthalmol 2007;35:225–230. 8. Fugimoto H, Gomi F, Wakabayashi T, et al. Morphologic changes in acute central serous chorioretinopthy evaluated by fourier-domain optical coherence tomography. Ophthalmology 2008;115:1494–1500. 9. Nair U, Ganekal S, Soman M, et al. Correlation of spectral domain optical coherence tomography findings in acute central serous chorioretinopathy with visual acuity. Clin Ophthalmol.2012;6:1949–1954.
Purpose: To report a case of central serous chorioretinopathy treated with focal laser photocoagulation guided by spectral domain optical coherence tomography (SD-OCT) without fluorescein angiography. Methods: In this interventional case report, a 27-year-old pregnant lady with central serous chorioretinopathy was evaluated with fundus photography and SD-OCT. She was treated with focal laser photocoagulation to the area of micro rip on the summit of pigment epithelial detachment identified by SD-OCT. Results: Successful treatment of serous macular detachment using SD-OCT in a pregnant lady. Conclusion: We report a case of central serous chorioretinopathy evaluated and treated successfully with SD-OCT without the use of fluorescein angiography. RETINAL CASES & BRIEF REPORTS 9:55–58, 2015
certain characteristic features of leakage points. This can be used to guide laser treatment in situations where FA is not possible or is better avoided. Here, we report a case of CSC treated successfully with laser photocoagulation in a pregnant lady using SD-OCT findings without the aid of FA.
From the Giridhar Eye Institute, Kadavanthra, Cochin, India.
S
pectral domain optical coherence tomography (SD-OCT) has revolutionized our approach to the diagnosis and management of diseases of the macula. Central serous chorioretinopathy (CSC), characterized by serous macular detachment, is a common disease as seen typically in young and middle-aged adults. It is secondary to focal leakages at the level of retinal pigment epithelium (RPE) seen on fluorescein angiography (FA)1 and can be treated with laser photocoagulation.2 The diagnosis is usually made by biomicroscopic examination, and the leakage points are identified by FA. Recently, SD-OCT has allowed in-depth evaluation of this disorder and identified
Case Report A 27-year-old lady presented to the vitreoretinal services of our institute with a history of central scotoma and defective vision of the right eye of 2 days duration. She was 8-months pregnant. Her best-corrected visual acuity in the right eye was 20/200, N18 and in the left eye was 20/20, N6. Her anterior segment examination was unremarkable, and the intra ocular pressure was normal in both eyes. Dilated fundus examination of the right eye showed a large serous macular detachment of about eight disk diameters centered around the fovea. A yellowish white exudate of about 0.5 disk diameter was seen within the serous macular detachment, 0.5 disk diameter above the fovea. There was yet another small yellowish white area inferotemporal to the fovea (Figure 1). The left eye fundus was normal. Because the drop in visual acuity was significant and the amount of fluid large, and the patient was very anxious, we decided to
None of the authors have any financial/conflicting interests to disclose. Reprint requests: Sandhya Narayanan, MS, DO, DNB, MNAMS, Giridhar Eye Institute, Ponneth Temple Road, Kadavanthra, Cochin 682 020, India; e-mail: [email protected]
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Fig. 1. Fundus photograph of the right eye. There is a large serous macular detachment centered around the fovea. The white arrowhead shows the yellowish white subretinal exudates.
intervene. Because she was pregnant, FA was deferred, and we did SD-OCT to find out the leakage point. Spectral domain optical coherence tomography was performed in both eyes with Spectralis (Heidelberg, Germany) using super luminescent diode laser (wave
Fig. 2. A. Spectral domain optical coherence tomography of the right eye through the fovea showing serous macular detachment. B. Spectral domain optical coherence tomography of the right eye showing serous macular detachment, dipping of posterior layer of neurosensory detachment (thick white arrowhead), hyperreflective exudates (red arrow) with translucent center. The thin white arrow points the RPE micro rip on the PED. The SD-OCT scan was taken through the green horizontal arrow on fundus photograph.
length of 870 nm) as the light source. Spectral domain optical coherence tomography confirmed the presence of a large serous macular detachment with a height of 704 mm at the fovea (Figure 2A). A small pigment epithelial detachment (PED) was seen above the fovea within the yellowish white area seen on fundus examination. There was a small defect in the RPE (a micro rip) on the summit of PED. Retinal dipping and fibrinous exudation with a translucent center were seen just above the RPE defect on PED (Figure 2B). These findings were used to identify the leakage point. Since the Spectralis (Heidelberg, Germany) display the infrared fundus image by the side of OCT scans, the exact point of RPE defect on PED was traced on to the fundus photograph with the help of the reticule and was used as a guide to give focal laser photocoagulation. Green laser photocoagulation was given to the defect in RPE on the summit of PED with 3–4 shots using a power of 100 mw for 0.1 second and a spot size of 50 ms. Spectral domain optical coherence tomography of the left eye was normal. When she came for review 3 weeks later her best corrected visual acuity in the right eye had improved to 6/6, N6 and dilated fundus examination revealed a dry macula. Spectral domain optical coherence tomography performed at that time showed complete resolution of subretinal fluid with a normal foveal architecture. The external limiting membrane, inner segment–outer segment junction, and the RPE regained their normal structure at the fovea (Figure 3A). Spectral domain optical coherence tomography through the lasertreated area also showed a near-normal architecture (Figure 3B).
SD-OCT–GUIDED LASER TREATMENT OF CSCR
Discussion Morphologic changes in CSC have been described using optical coherence tomography earlier.3–5 Since the introduction of SD-OCT, studies have focused on comparing tomographic findings with FA features6 and indocyanine green angiographic features.7 Fugiro et al8 studied the morphology of leaks using frequency domain-OCT and compared it with the FA leaks in 21 eyes with CSC. In their study, 96% had RPE abnormalities and 61% PEDs at the site of leak. Fifty-two percent had hyperreflective shadow on frequency domain-OCT suggesting fibrin around the leak point, and these corresponded to the yellowish white area seen clinically. A translucent area within the hyperreflective shadow was seen in 8 of the 11 leakage sites. Forty-three percent had sagging of the posterior layer of neurosensory retina. Minute defect in the RPE was seen in 3 PEDs and that exactly
57
corresponded to the leak points on FA.8 In a study performed in South India on 100 patients with acute CSC using SD-OCT, 60% of the eyes showed a characteristic dipping pattern of neurosensory retina with intervening hyperreflective echoes over the leakage site.9 Seventy percent of their eyes had PEDs at the site of angiographic leaks and 22% had break in PEDs at the leak point.9 Hirmani et al studied 30 eyes with CSC using OCT, FA, and indocyanine green angiography. In his study, 10 of the 11 eyes with PED (91%) showed PED within the areas of choroidal vascular hyperpermeability.7 In a study by Hussain et al, 6 of the 10 eyes (60%) showed a characteristic dipping pattern of neurosensory retina with intervening hyperreflective echoes suggestive of fibrin over the leakage site. All these eyes had ink-blot leak and subretinal fibrin.6 In our case, there was a small PED within neurosensory detachment with a micro rip on it. There was
Fig. 3. A. Spectral domain optical coherence tomography through fovea 3 weeks after laser photocoagulation shows complete resolution of serous macular detachment and restoration of normal foveal architecture. B. Spectral domain optical coherence tomography through the laser-treated area. The area of treatment is shown by the red arrowhead.
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dipping of the posterior surface of the neurosensory retina and hyperreflective shadow with a translucent center around the area of micro rip. The hyperreflective shadow corresponded with the yellowish area seen on fundus examination. This area of micro rip on SD-OCT was superimposed on the fundus photograph, and focal laser was given to this area. Spectral domain optical coherence tomography performed after 3 weeks showed a near-normal foveal architecture with restoration of inner segment–outer segment junction. Fugimoto et al8 also showed reappearance of inner segment–outer segment junction after disappearance of subretinal fluid. Because the retinal layers have regained their normal architecture, the patient regained normal visual acuity. There was a significant amount of subretinal fluid before the treatment, and the fluid got reabsorbed 3 weeks after the laser procedure. Because she was still pregnant at the time of repeat scan, we believe that the disappearance of fluid is due to laser therapy and not related to the hormonal changes. Although we did not do FA to demonstrate the site of leak, SD-OCT features could precisely localize the point of leak and we could do focal laser successfully. This modality can be used to guide laser photocoagulation in patients with CSC, where FA is contraindicated or better avoided.
References 1. Gass JDM. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. 4th ed. Vol 1. St Louis, MO: Mosby; 1997: 52–70. 2. Gass JDM. Pathogenesis of disciform detachment of neuroepithelium, II: idiopathic central serous chorioretinopathy. Am J Ophthalmol 1967;63:587–615. 3. Hee MR, Puliafito CA, Wong C, et al. Optical coherence tomography of central serous chorioretinopathy. Am J Ophthalmol 1995;120:65–74. 4. Iida T, Hagimura N, Sato T, Kishi S. Evaluation of central serous chorioretinopathy with optical coherence tomography. Am J Ophthalmol 2000;129:16–20. 5. Montero JA, Ruiz-Moreno JM. Optical coherence tomography characterisation of idiopathic central serous chorioretinopathy. Br J Ophthalmol 2005;89:562–564. 6. Hussain N, Baskar A, Ram LM, Das T. Optical coherence tomographic pattern of fluorescein angiographic leakage site in acute central serous chorioretinopathy. Clin Experiment Ophthalmol 2006;34:137–140. 7. Hirami Y, Sujikawa AT, Sasahara M, et al. Alteration of retinal pigment epithelium in central serous chorioretinopathy. Clin Experiment Ophthalmol 2007;35:225–230. 8. Fugimoto H, Gomi F, Wakabayashi T, et al. Morphologic changes in acute central serous chorioretinopthy evaluated by fourier-domain optical coherence tomography. Ophthalmology 2008;115:1494–1500. 9. Nair U, Ganekal S, Soman M, et al. Correlation of spectral domain optical coherence tomography findings in acute central serous chorioretinopathy with visual acuity. Clin Ophthalmol.2012;6:1949–1954.
