NEWS & EVENTS
Retinal Review, Issue 48
Authored by Burton Wisotsky, M.D.
A 51 year old woman was referred for exudation in her left eye. She reported no significant medical or ocular history. She noted the onset of moderate visual blur with difficulty focusing in her left eye over the past few weeks. She also noted micropsia and metamorphopsia. On examination, VA measured OD: 20/20 and OS: 20/60 ph 20/25. IOP’s and the SLE were normal OU. Amsler grid demonstrated central metamorphopsia and micropsia OS. An OCT of the right eye was normal. In the left eye macular subretinal fluid was noted (see below). DFE of the right eye was normal. In the left eye there was serous subretinal fluid with RPE changes superior to the macula:
The patient was diagnosed with central serous retinopathy (CSR). She had subretinal fluid present on OCT and a well circumscribed area of macular fluid on her color photos. There were a few unusual aspects of the case. First, CSR is found in males in over 90% of cases. Second, most CSR patients are in their 20s, 30s, and 40’s. Our patient was 51. Third, while most CSR patients have RPE mottling, ours had a prominent area of RPE change within the serous detachment, with a second focus just superotemporal to the main macular detachment. Although these features were unusual, we were certain that the patient had CSR and recommended a course of observation. Most CSR resolves over the course of a few weeks or months. Vision typically returns to normal or close to normal. Treatment can speed the recovery of vision but is not thought to enhance the final visual result. If treatment is necessary, it is usually by thermal laser to the leakage site. Photodynamic therapy (cold laser) is occasionally used if the leakage is subfoveal or juxtafoveal. Anti VEGF agents have been used with minimal success in CSR.
The patient was satisfied with waiting and returned a month later reporting significant worsening of her vision. VA OS measured 20/200, ph 20/70. Dilated examination showed a significant change in the retinal status:
There was a significant increase in the area of subretinal fluid. Although the OCT showed a flatter serous detachment, the fluid now extended all the way to the inferotemporal arcade. In addition, there was increased exudation with hemorrhage at the site of RPE mottling. Fluorescein angiography confirmed a choroidal neovascular membrane (CNVM). There are several reasons a patient with CSR can markedly worsen. These can include increased exudation from the leakage site, RPE scarring from chronic subretinal fluid, subretinal fibrosis, and the development of a CNVM. Most CNVM’s in patients with CSR develop after laser treatment because of the disturbance to the RPE. In our case an unusual event happened – the patient developed a CNVM spontaneously, without laser intervention. We discussed treatment options including laser and antiVEGF therapy. Laser was an option because the CNVM was not subfoveal. However, due to the proximity to the macula, we explained that laser would likely result in a significant scotoma. Therefore we suggested avastin therapy. The patient underwent two avastin injections a month apart and had a remarkable recovery. One month after her second treatment her visual acuity returned to 20/25. The subretinal fluid had fully resolved and only a superior area of RPE disturbance remained. She has since had three more avastin injections and has maintained 20/25 vision. She is very happy with her result and will continue to be monitored carefully for recurrence of exudation:
Dr. Burton Wisotsky
Dr. Danielle Strauss
Dr. George Veliky (Iselin office)
Dr. Mike Veliky (Rochelle Park office)
Dr. Allison Lafata (West Orange office)
Dr. Nazreen Esack (Parsippany office)
Dr. Katherine Mastrota (New York office)
Ann Lacey (Marketing Director)