|Year : 1974 | Volume
| Issue : 2 | Page : 6-10
Photocoagulation in central serous retinopathy
Bijayananda Patnaik, Rajinder Kalsi, S.R.K Malik
Deptt. of Ophthalmology, Maulana Azad Medical College, New Delhi, India
Deptt. of Ophthalmology, Maulana Azad Medical College, New Delhi
|How to cite this article:|
Patnaik B, Kalsi R, Malik S. Photocoagulation in central serous retinopathy. Indian J Ophthalmol 1974;22:6-10
|How to cite this URL:|
Patnaik B, Kalsi R, Malik S. Photocoagulation in central serous retinopathy. Indian J Ophthalmol [serial online] 1974 [cited 2013 May 25];22:6-10. Available from: http://www.ijo.in/text.asp?1974/22/2/6/31365
Whatever may be the etiology, the direct cause of central serous detachment of the retina is a defect in the pigment epithelium through which systemically administered fluorescein from the choroid leaks into the subretinal space. Pinpoint photocoagulation of this spot invariably leads to the stoppage of the dye leak with subsequent disappearance of the subretinal fluid. ,,,,
The aim of this paper is to report on the results of the first 15 cases of central serous retinopathy (C.S.R.) treated by photocoagulation.
| Method and Material|| |
A serial fluorescein fundus photography is carried out starting with pre-arterial phase of the circulation. The leaking point is localised in relation to the fine vascular landmarks. This spot may be associated with subtle charge in translucency of the subretinal exudation or a disturbance in pigmentation of the pigment epithelium. A copy of the fluorescence photograph is kept handy for reference during photocoagulation. Occasionally when the lesion is too close to the fovea, besides all these guide lines, fluorescein is injected while the patient's retina is being observed through the coagulator. Leakage point then can be seen as the greenish dye (fluorescein under white light) which spreads out.
A retrobulbar injection of 2ml of 2% lignocain hydrochloride is given. Pupil must be widely dilated by the use of both homatropine hydrobromide 2% and phenylephrine hydrochloride 10%. Using a l° target (smallest available in the Zeiss-Jena coagulator) and minimal energy, a ½° coagulation can be achieved. If the subretinal exudates are too abundant, we prefer not to go on increasing the energy till one sees the reaction of coagulation. The effect of photocoagulation starts becoming obvious by the end of a week. The leakage of the dye either stops completely or becomes slower. The scotoma becomes thinner, or smaller, or both. The visual acuity improves.
Fifteen cases of central serous retinopathy with local fluorescein leakage treated by photocoagulation at the Retina Care Unit of Ophthalmology Department of Maulana Azad Medical College are the material for this paper.
| Observations|| |
Case notes of the first 15 cases of central serous retinopathy treated by photocoagulation have been summerised in [Table - 1]. All but two cases were males. The majority (10 out of 15) belonged to the fourth decade, while the rest were more than 40 years of age. Nine cases were treated during their first attack ; five cases during their second and one case during his third attack. The duration of the current attack varied from 1 week to 68 weeks. The visual acuity varied from 6/5 to counting finger at 0.5 meter with varying size and density of the scotoma.
All but three cases had had systemic steroids of varying dosage and duration. Five of these patients had various types of vasodilators. Six cases were treated with different types of antibiotics.
While only one spot of photocoagulation for each leaking spot was sufficient for a cure, in the majority of cases, in presence of massive detachment repeated exposure (upto 3) of coagulator energy had to be used in 2 cases.
The subjective improvement of visual acuity and/or thinning and shrinkage of the size of the scotoma was usually noticed by the end of the week. However, when there was more than one point of dye leakage patient had to wait for as long as 30 days before noticing visual improvement.
All retinae settled completely. The improvement of visual acuity was uniformly impressive. In 5 cases small thin paracentral scotomas could be demonstrated on careful scotometry. None of the patients complained of them. Three of ;these did correspond to photocoagulation site. Two others were due to small areas of pigment epithelial detachments. There has not been a case of recurrence in this series. The follow up period was one to 30 months with an average of 10.5 months.
Representative case note
M.S.47 years male (Fl.No.992)
Two weeks back, on closing left eye, the patient discovered that there was a marked diminution of vision in the right eye. A week before his vision had been recorded as 6/5 in each eye. The vision continued to deteriorate for another week. Two and a half years ago he had a similar attack of diminution of vision in the same eye which was restored on medical treatment in three weeks time. He had no history of emotional disturbance and apparently did not suffer any systemic disease.
His vision in the right eye was counting fingers at 50 cms. Projection of rays was accurate from all quadrants. There were no signs of anterior uveal inflammation. The pupillary size and reactions to light were normal. Fundus examination revealed a clear media and a normal disc. There was a large disciform detachment of the retina involving the macula. There were fine yellowish white subretinal deposits. There was a large central scotoma as charted on the Amslers grid. Photostress time was 5 minutes in the right eye against 30 seconds in the left. On intravenous fluorescein injection there was a focal leakage of the dye in to the subretinal space through pigment epithelium originating about 1° above the fovea. The dye did move upwards to spread across the upper part of the detachment [Figure - 1].
While a disciform detachment of the macula confined within the large temporal blood vessls, as in this case, is typical, a care ful indirect ophthamoscopy often (in 6 out of 15 cases) reveals an extension of the detachment towards lower retinal periphery [Figure - 2].
Treatment : The leaking spot was reidentified through the photocoagulator on intravenous injection of 5 ml. of 10% Sodium fluorescein. A single photocoagulation mark was produced using a 1° coagulation spot at intensity III and aperture (pupillary) 8 of the Zeiss Jena photocoagulator. By the end of the week, the vision had improved to 6/36, the scotoma became thinner and smaller. By the end of the month, his vision improved to 6/5 and scotoma disappeard. There was no dye leakage [Figure - 3]. After one year he still maintains 6/5 vision. Even on suggestion the patient was unable to identify any scotoma corresponding to the photocoagulation site.
| Discussion|| |
What causes the fluorescein to leak to the subretinal space in C. S. R. is not known. There could be multiple causes of damage to the pigment epithelium.
The futility of massive dosage of steroids, vasodilators and antibiotics in the treatment of this condition is only too obvious. One case (no. 4) alone was treated elsewhere with penicillin, streptomycin, Reverin (rolitetracycline`Hoechst'), Omnamycine (penicillin, streptomycin and omnadin-'Hoechst') and Restecline (tetracycline hydrochloride and ascorbic acid-Squibb) besides heavy dosase of systemic steroids and ACTH. All to no effect whatsoever. His vision of counting fingers at 50 cms. was restored to 6/9 (part) by a single exposure of the photocoagulator. He was maintaining this vision after 12 months.
On the other hand photocoagulation of the leaking spot leads to a dramatic cures; shortens the course of the disease and perhaps reduces the chances of recurrences. It is possible to photocoagulate a leaking spot even when it is as close as 1° from the fovea (Case No. 7). When the retina is well detached over the leaking site usually there is no damage to the overlying retina. As such photocoagulation may be considered the treatment of choice in cases of central serous retinopathy with focal leakage of fluorescein.
| Summary|| |
The results of photocoagulation in the treatment of the first 15 cases of central serous retinopathy have been uniformly good. The cure has been definite and prompt.
| References|| |
|1.||Gass, J.D.M., 1967, Amer. J. Ophthal, 63, 587, |
|2.||Harris G.S., 1969, Canad. J. Ophthal, 4, 16. |
|3.||Peabody R.R., Zweng H.S., Little H.L., 1968, AMA Arch. Ophthal, 79, 166. |
|4.||Schneider R.J. 1970, Canad. J. Ophthal, 5, 117. |
|5.||Spatter H.F. 1968, AMA Arch. Ophthal, 79, 247. |
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1]