Ophthalmic Surgery, Lasers and Imaging Retina

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Case Report 

Transpupillary Thermotherapy for Juxtafoveal Leak in Central Serous Chorioretinopathy

Tarun Sharma, MD, FRCSEd; Shaileen D. Parikh, MD

Abstract

The authors describe the use of transpupillary thermotherapy (TTT) for juxtafoveal central serous chorioretinopathy (CSC) leak. A 45-year-old man with juxtafoveal leak developed fibrinous exudate in the macular area, demonstrated on optical coherence tomography. After one session of TTT, fibrinous exudate totally disappeared with improvement in vision to 20/40 from counting finger. Subretinal fluid got absorbed with obliteration of leak on fluorescein angiogram. TTT may be useful as a treatment option in juxtafoveal leak of CSC.

Abstract

The authors describe the use of transpupillary thermotherapy (TTT) for juxtafoveal central serous chorioretinopathy (CSC) leak. A 45-year-old man with juxtafoveal leak developed fibrinous exudate in the macular area, demonstrated on optical coherence tomography. After one session of TTT, fibrinous exudate totally disappeared with improvement in vision to 20/40 from counting finger. Subretinal fluid got absorbed with obliteration of leak on fluorescein angiogram. TTT may be useful as a treatment option in juxtafoveal leak of CSC.

Transpupillary Thermotherapy for Juxtafoveal Leak in Central Serous Chorioretinopathy

From the Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, India.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Tarun Sharma, MD, FRCSEd, Director, Shri Bhagwan Mahavir Vitreoretinal Services, 18 College Road, Chennai-600006, Tamil Nadu, India.

Accepted: November 01, 2008
Posted Online: March 09, 2010

Introduction

Central serous chorioretinopathy (CSC), though considered a benign disorder, has many variants. Visual acuity gets affected in eyes with atypical presentation or if the retinal pigment epithelial leak is juxtafoveal or subfoveal1,2.

We report a case of CSC in which retinal pigment epithelial leak was evident in the juxtafovel area causing severe visual impairment. The patient was successfully treated with transpupillary thermotherapy (TTT).

Case Report

A 45-year-old man noticed decreased vision in his right eye since 3 months. Initial evaluation showed visual acuity of counting finger in the right eye, and no significant abnormality was present on slit-lamp examination. Intraocular pressure was 12 mm Hg.

Right fundus showed (Fig. 1, upper row) a circular neurosensory elevation of around 3 to 4 disc diameter in the macular region. Fundus fluorescein angiogram showed a single retinal pigment epithelium (RPE) leak (ink blot) close to foveal avascular zone in the right macula. In addition, 3 tiny pigment epithelial detachments were also evident. Patient was found to be using skin ointment containing steroid preparation; no other usage of steroid in any form was evident. The fellow eye was asymptomatic in all respects.

Upper Row (left): Right Fundus Showed a Circular Elevation in the Macular Area Suggestive of Neurosensory Detachment. Upper Row (middle & Right): Ink-Blot Type of RPE Leak Abutting Center of the Fovea Along with Three Tiny RPE Detachments. Middle Row (left): Subretinal Fibrinous Exudates Have Appeared. Middle Row (middle & Right): Persistence of RPE Leaks and RPE Detachments. Lower Row (left): Mild Alteration of RPE at the Treated Area of TTT Along with Total Disappearance of Subretinal Exudates and Fluid. Lower Row (middle & Right): Obliteration of RPE Leak at the Treated Area of TTT, RPE Detachments Are Faintly Visible.

Figure 1. Upper Row (left): Right Fundus Showed a Circular Elevation in the Macular Area Suggestive of Neurosensory Detachment. Upper Row (middle & Right): Ink-Blot Type of RPE Leak Abutting Center of the Fovea Along with Three Tiny RPE Detachments. Middle Row (left): Subretinal Fibrinous Exudates Have Appeared. Middle Row (middle & Right): Persistence of RPE Leaks and RPE Detachments. Lower Row (left): Mild Alteration of RPE at the Treated Area of TTT Along with Total Disappearance of Subretinal Exudates and Fluid. Lower Row (middle & Right): Obliteration of RPE Leak at the Treated Area of TTT, RPE Detachments Are Faintly Visible.

Three months later, after discontinuation of the steroid ointment, his visual acuity remained counting finger, fundus showed appearance of fibrinous exudates in the subretinal space and persistence of RPE leak on fluorescein angiogram (Fig. 1, middle row). The optical coherence tomography (Fig. 2, left) showed high reflective fibrinous exudates right under the center of the fovea, fluid in the subretinal space and a tiny RPE detachment; foveal contour was convex. After explaining the clinical settings, TTT (0.5 mm, 100 mw and 1 min.) was performed to contain the RPE leak.

Left (pretreatment): The Optical Coherence Tomography Image Shows Loss of Foveal Contour, Presence of High Reflective Globular Mass (fibrinous Exudates), Subretinal Fluid, and a Tiny RPE Detachment. Right (posttreatment): The Optical Coherence Tomography Image Shows Restoration of Foveal Contour and Disappearance of Subretinal Exudates and Fluid and Somewhat Flattened Tiny Pigment Epithelial Detachment.

Figure 2. Left (pretreatment): The Optical Coherence Tomography Image Shows Loss of Foveal Contour, Presence of High Reflective Globular Mass (fibrinous Exudates), Subretinal Fluid, and a Tiny RPE Detachment. Right (posttreatment): The Optical Coherence Tomography Image Shows Restoration of Foveal Contour and Disappearance of Subretinal Exudates and Fluid and Somewhat Flattened Tiny Pigment Epithelial Detachment.

The patient was recommended to return after 2 months. He came for review after 4 months. His visual acuity was 20/40 with complete resolution of subretinal fluid and subretinal exudates (Fig.1, lower row). Fundus fluorescein angiogram showed complete obliteration of RPE leak. Tiny RPE detachments were the same as were noted when he reported first. The scar of TTT was faintly visible. The OCT (Fig. 2, right) showed disappearance of subretinal fluid, restoration of normal foveal contour, and disappearance of subretinal exudates; pigment epithelial detachment appeared to be somewhat flattened.

Discussion

This case illustrates that TTT is a potential option to treat focal leak(s), which are in proximity of fovea (Juxta–or subfoveal). Considering laser photocoagulation would have definitely compromised the central vision. Waiting for spontaneous resolution would not have resulted in desired effect, as persistence of subretinal exudates invariably results in fibrosis further compromising visual return even after the obliteration of leak and subretinal fluid.2 Costa et al.3 reported using indocyanine-green (ICG) mediated photothrombosis as a treatment modality to treat chronic CSC, not focal as in this report. They used low-intensity 810 nm light directly at the active leakage sites. Ten of 11 showed visual improvement. Ricci et al.4 treated a case of CSC with ICG dye-enhanced subthreshold micopulsed diode laser photocoagulation aimed at active leakage site and noted improved vision. Recently, some reports have used ICG. Guided photodynamic therapy for treating chronic and persistence CSC with diffuse leaks and observed encouraging results.5,6 However, an important issue here is the expense with PDT, which is not the case with TTT.

References

  1. Jalkh AE, Jabbour N, Avila MP, et al. Retinal pigment epithelium decompensation. I. Clinical features and natural course. Ophthalmology. 1984;91:1544–1548.
  2. Sharma T, Badrinath SS, Gopal L, et al. Subretinal fibrosis and nonrhegmatogenous retinal detachment associated with multifocal central serous chorioretinopathy. Retina. 1988;18:23–29.
  3. Costa RA, Scapucin L, Moraes NS, et al. Indocyanine green-mediated photothrombosis as a new technique of treatment for persistent central serous chorioretinopathy. Curr Eye Res. 2002;25: 287–297. doi:10.1076/ceyr.25.5.287.13496 [CrossRef]
  4. Ricci F, Missiroli F, Cerulli L. Indocyanine green dye-enhanced micropulsed diode laser: a novel approach to subthreshold RPE treatment in a case of central serous chorioretinopathy. Eur J Ophthalmol. 2004;14:74–82.
  5. Yannuzzi LA, Slakter JS, Gross NE, et al. Indocyanine green angiography-guided photodynamic therapy for treatment of chronic central serous chorioretinopathy. A Pilot study. Retina. 2003;23:288–298. doi:10.1097/00006982-200306000-00002 [CrossRef]
  6. Taban M, Boyer DS, Thomas EL, et al. Chronic central serous chorioretinopathy: photodynamic therapy. Am J Ophthalmol. 2004; 137:1073–1080. doi:10.1016/j.ajo.2004.01.043 [CrossRef]
Authors

From the Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, India.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Tarun Sharma, MD, FRCSEd, Director, Shri Bhagwan Mahavir Vitreoretinal Services, 18 College Road, Chennai-600006, Tamil Nadu, India.

10.3928/15428877-20100215-23

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