|Year : 1982 | Volume
| Issue : 6 | Page : 593-596
Fluorescein angiography in central serous retinopathy
SP Garg, HK Tewari, PK Khosla, RV Azad
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi, India
S P Garg
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi-29
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Garg S P, Tewari H K, Khosla P K, Azad R V. Fluorescein angiography in central serous retinopathy. Indian J Ophthalmol 1982;30:593-6
The purpose of this paper is to study the natural course of disease on the basis of fluorescein angiography which would help in evaluating any prospective studies on the treatment of this condition.
| Materials and methods|| |
110 consecutive patients seen in the Retina Clinic during the last 3 years with macular oedema were included. Criteria for inclusion in the study were history of central visual loss with foggy vision, complaint of scotoma. macropsia and metamorphopsia.
History of duration of visual complaints of any treatment taken and its response was noted. Ocular examination included corrected visual acuity and fundus examination. Amsler grid was done and extent of scotoma was recorded. Fluorescein angiography was done to locate the number, site and size of hyperfluorescence spots.
On the basis of treatment, patients were divided into two groups
(A) no treatment (80 cases) and
(B) taking some treatment (30 cases)
The cases were further sub-divived on the basis of fluorescein angiography into : (i) Single pinpoint leakage not increasing in size; (ii) Single leak elongating upward in smokestack (A) or slowly increasing in size becoming a circular spot (B) (iii) Single leakage increasing in size and becoming irregular in early phase (iv) More than one leak (v) No leakage.
All patients were reviewed at 3 weeks interval for 6 weeks and then at three months and 6 months or till there was improvement in symptoms, vision, Amsler's grid and fluorescein angiography. The patients who were showing more than one leak were put empirically on antitubercular treatment (INH 300 mgm and PAS 15 G/day) and steroid were withdrawn if the patient was already a steroids.
| Observation|| |
Out of 110 cases, 100 cases were diagnosed as central serous retinopathy. Out of patients who did not show focal leakage on fluorescein angiography (10 cases), 4 cases were diagnosed as rhegmatogenous retinal detachment. 4 were in the stages cf resolution and 2 cases were diagnosed as cystoid macular oedema.
[Table - 1] shows the distribution of cases age and sex wise indicating a preponderance of males in the age group of 21-40 years.
[Table - 2][Table - 3] show fluorescein angiographic picture at presentation in relation to number and site of leakage. Leakage in cases with more than one leaking points was not necessarily present in the same quadrant but was distributed randomly including even peripheral leaking points.
[Table - 4] shows the fluorescein angiography findings in 6 weeks, 3 months and six months. It indicates that most of the cases with single leakage resolved by six weeks (54%) or by 3 months (85%). 4 cases did not resolve and were diagnosed as disciform degeneration.
| Discussion|| |
Central serous retinopathy is a clinically well defined entity frequently of obscure aetiopathology in which an apparently spontaneous odema in the macular area or flat serous circular detachment of posterior pole develops, with benign course usually self limiting but often recurrent in young adults without associated ocular or systemic disease.
Highest frequency of the disease in our patients occurred between 20 - 40 years of age (70%) and almost exclusively in males (80%) as in the experience of other authors.
Distribution of leakage points in this series shows that the area between the. optic disc and macula is the site of predilection (74%) and only 2L% showed leakage temporally and 4°0 in the macular area and is supported by Wessing. 1 No conclusion in regard to natural course and mode of treatment can be drawn from site distribution in single leakage cases.
In the present study 54% patients presenting with a single leak resolved within 6 weeks and 85% within three months with minimal or no less of function and is supported by Straatsma et a1 2 and Klein eta1 3 who found that 70 to 80% of cases resolved within three months.
9 cases showed point leak and were earliest to resolve (within 6 weeks) and we feel that these were cases in the last stages of resolution or cases of pigment epithelial detachment. It is concluded that point leak which does not increase in late phase is a good sign and has the best prognosis.
3 1 cases showed circular leak. These cases resolved early as compared to smokestack leak (6 weeks as compared to 3 months). Circular leak cases were also more common in patients who presented after I week (57% as compared to 40%). Hence we feel that circular leak is a late presentation in the natural process of resolution. It is surmised that high protein content in subretinal fluid brings the circulation to a complete stop as compared to initial presentation when the fluid is transudate and it fluorescein angiographic picture presents as smokestack.
Single leakage becoming an irregular hyperfluorescent patch in early phases of angiogram do not seem to resolve as other single leakage cases and took more than 3 months to resolve. As these cases responded to antitubercular treatment leaving behind a scar it is presumed that this a presentation of inflammatory pathology.
It is assumed that the disease is self limiting, and the serous fluid induces some inflammatory changes affecting the pigment epithelium which proliferates and closes the defect through which the fluid was coming from the choriocapillaries., Pigmentary changes left in the area in most of the cases after the resolution of the disease, support this hypothesis. However, rest of the residual fluid in the detachment area gets absorbed. Photo coagulation of leaking area might be inducting aseptic epithelitis leading to resolution.
More than one leak i.e. double leak or multiple leaks are well known in cases of central serous retinopathy. These leaks may all be located in posterior pole or may lie outside it. In the present study, 10% cases showed double leak and 10% multiple leaks which supports Wessing who reported 12% having double leak and 9% having more than two leaks.
The patients who presented with double or multiple leak or showed double leak during follow up and did not show resolution were put on antitubercular treatment. In cases who do not resolve it is always advisable to look for other leaking points in the periphery. Wessing and Kalsi et a1 4 have started worsening of clinical condition on steroids, It seems that either the process gets aggravated by systemic steroids or becomes manifest from latent stage and we think that these are cases of tubercular aetiology, because of the therapeutic response we got in these cases 5. The treatment was continued for three months provided the patient showed some response during initial 15 days' Out of 20 patients on antitubercular treatment 18 patients responded and completely resolved within three months.
We do not advocate photocoagulation as initial treatment of C.S.R. Photocoagulation may reduce the time for resolution if at all but the results in natural course of disease are as good as with photocoagulation.
Group B consisted of patients (30 cases) who were on treatment but did not improve subjectively (20 cases) or deteriorated (10 cases). 22 were taking systemic steroids, 4 were on antibiotics and 4 were on Retrobulbar Priscol or Duvadilon. All cases reported to us after one week of treatment. Fluorescein angiography in these cases showed well defined circular leak (5 cases) or intense irregular leak in early phase (3 cases) while majority showed more than one leak (14 cases). 8 cases did not show any leak. The patients showing no leakage points on fluorescein angiography turned out to be cases of retinal detachment extending to macular area due to inferior temporal dialysis (2 cases) and cystoid macular odema (2 cases) while 4 were in process of resolution. It is emphasized that if no leakage is found and when the anterior limit of macular oedema is not clearly visible. One should look for other pathology like rhegmatogenous retinal detachment. Cases showing multiple leaks were those who were not responding to earlier treatment. These were put on antitubercular therapy after stopping the' previous treatment.
Cases with smokestack, circular or pint point leaks usually present clinically early with less marked visual disturbance and show detachment of less than 4 disc diameters. On follow up these have good prognosis resolve within 3 months and no treatment is recommended. It was observed that single leaks in natural history progress from smokestack to circular to pinpoint leaks. If, however, resolution does not occur or another leakage point appears these cases should be given antitubercular treatment.
Cases presenting with marked loss of vision or with history of either nonresponding or deteriorating to earlier treatment are bad prognostically if not treated. The cases show detachment of more than 4 disc diameters and on fluorescein angiography show either irregular big circular leakage appearing in early phase or double or multiple leaks. We feel these are cases of inflammation of choroid with presumptive tubercular aetiology as these respond to antitubercular treatment. A prospective randomised study is being conducted to prove this fact.
| References|| |
Wessing, A., 1973, Trans.Amer.Acad, Ophthalmol. and Otolaryn. 77 :272.
Straatasma. B.R., Allen, R.A. and Petil T.H, 1966, Trans. Pacific Coast Oto ophthalmol 47 : 107.
Klein, M.L., Ven Buskirk, E. M. ; Friedman, E,; Gragoudas, E. and Chndra, S. 1974: Ophthalmol 91: 247.
Kalsi, R. Patnaik. B.; Natarajan, R. and Deshpande, M., 1977, Proc. All Ind. Ophthalmol, Soc. 33. 212.
Garg, S.P. Tewari, H.K. and Khosla, P.K. 1980 Paper presented to V1I Afro Asian Conferercc held at Tunis.
[Table - 1], [Table - 2], [Table - 3], [Table - 4]