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LARGEST STUDY ON CHINESE AMERICANS PUBLISHED

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AMERICANS PUBLISHED

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Effective Treatments For Blinding Eye Diseases

EDUCATION

Case Study: A Fluid Situation

Lee Moshfeghi
Presenter: Ramon Lee, MD Discussant: Andrew Moshfeghi, MD, MBA
 

History

  • 40-year-old male presents with 10 days of dim central vision in the right eye
  • Associated with metamorphopsia and paracentral scotoma
  • Denies previous ocular history, floaters, flashes, pain, trauma
  • Post-doctoral research fellow who states he is under a great deal of pressure at work lately

Exam Findings

  • VA: 20/25, 20/20
  • IOP: 14, 16
  • Pupils: Round and reactive, no rAPD
  • Brightness sense: 80%, 100%
  • Color plates: 8/8, 8/8
  • EOM full OU
  • Anterior segment: within normal limits
  • Dilated fundus exam: subretinal fluid extending from the superior arcade to the fovea
Figure 1
Figure 1: OCT macula of the right eye with subretinal fluid. OCT macula thickness map of the right eye with superonasal macular thickening (bottom right).

 

Differential Diagnosis

  • Central serous chorioretinopathy
  • Optic pit
  • Age-related macular degeneration
  • Polypoidal choroidal vasculopathy
  • Choroidal hemangioma
  • Rhegmatogenous retinal detachment
  • Vogt-Koyanagi-Harada disease

Additional Investigations

  • Subretinal fluid in the right eye spontaneously resolved. However nine months later, the patient represented with bilateral subretinal fluid after increase in life stressors
Figure 2
Figure 2: OCT macula of the right eye with nasal subretinal fluid (left image). OCT macula of the left eye with significant subretinal fluid and PED (right image).
  • Subretinal fluid did not improve with Eplerenone 50mg daily. We then proceeded with verteporfin PDT for the left eye.

Figure 3
Figure 3: ICG angiography of the left eye with hyperfluorescence in the temporal macula and superior to superior arcades (left image). ICG angiography of the left eye with multiple areas of hyperfluorescence (right image).

 
Figure 4
Figure 4: OCT macula of the left eye with resolved subretinal fluid after PDT.

 

Diagnosis

  • Central serous chorioretinopathy

Pathophysiology

  • Central serous chorioretinopathy is characterized by development of well-circumscribed, serous detachment of the neurosensory retina. The etiology is unclear, however a combination of altered RPE barrier and choroidal hyperpermeability are postulated.

Treatment

  • Observation
  • Systemic drugs of mifepristone, ketoconazole, spironolactone, rifampin, eplerenone (use these drugs because of their impact on steroid metabolism)
  • Thermal laser photocoagulation
  • Verteporfin photodynamic therapy
    • Two step process:
      • IV verteporfin (Visudyne) localized to endothelial cells of vessels
      • Local activation of the drug by a laser preferentially absorbed by the drug
  • Photochemical reaction creates reactive oxygen species and free radicals
  • Causes endothelial cell damage, platelet adherence, vascular thrombosis and capillary closure

Prognosis and Future Directions

  • Natural course
    • 80 to 90 percent with spontaneous resorption within three to four months
    • VA recovery can take up to one year
    • Mild metamorphopsia, faint scotoma, abnormalities in contrast sensitivity and color vision frequently persist
    • 40 to 50 percent experience recurrence

References

  • Ryan S, et al. Retina, 5th Edition. Saunders, December 7, 2012.
  • Kitzmann AS, Pulido JS, Diehl NN, et al. The incidence of central serous chorioretinopathy in Olmsted County, Minnesota, 1980-2002. Ophthalmology. 2008 Jan;115(1):169-73.
  • Lim JW, Kim MU, Shin M-C. Aqueous humor and plasma levels of vascular endothelial growth factor and interleukin-8 in patients with central serous chorioretinopathy. Retina. 2010 Oct;30(9):1465-71.
  • Reibaldi M, et al. Standard-fluence versus low-fluence photodynamic therapy in chronic central serous chorioretinopathy: a nonrandomized clinical trial. Am J Ophthalmol. 2010 Feb;149(2):307-315.e2.
  • Kim H-S, Lee JH. The short-term effect of intravitreal bevacizumab for treatment of central serous chorioretinopathy. J Korean Ophthalmol Soc 2010;51:860-864.
  • Bae SH, et al. Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy: one-year results of a randomized trial. Ophthalmology. 2014 Feb;121(2):558-65.
  • Artunay O, et al. Intravitreal bevacizumab in treatment of idiopathic persistent central serous chorioretinopathy: A prospective, controlled clinical study. Curr Eye Res 2010;35:91-98.

Contact

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Produced by: Monica Chavez, John Daniel, Joseph Yim and Dr. Vivek Patel
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