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ARTICLES
Year : 1983  |  Volume : 31  |  Issue : 3  |  Page : 131-134

Prospective therapeutic study in macular oedema


Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India

Correspondence Address:
H K Tewari
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


PMID: 6676197

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How to cite this article:
Tewari H K, Garg S P, Khosla P K. Prospective therapeutic study in macular oedema. Indian J Ophthalmol 1983;31:131-4

How to cite this URL:
Tewari H K, Garg S P, Khosla P K. Prospective therapeutic study in macular oedema. Indian J Ophthalmol [serial online] 1983 [cited 2024 Mar 28];31:131-4. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?1983/31/3/131/29766

Table 1

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Table 1

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Garg et al. while describing the fluorescein angiographic patterns of cases of central serous retinopathy indicated choroiditis pattern of leakage in 20% of the cases of prolonged and recurrent central serous retinopathy and also shown resolution by giving I.N.H. & PAS. After this a prospective study was planned to study in detail the role of tubercular choroiditis in cases of central serous retinopathy.


  Material and Methods Top


260 cases during the year 1977 to 1980 diagnosed clinically as central serous retinopathy were investigated in detail for evidence of systemic tuberculosis (healed or active) and also inflammatory signs suggestive of choroidal inflammation.

Fluorescein angiography was done to know the pattern and number of leaking areas. This was repeated at every follow up of 15 days, 1 month, 3 months and 6 months. X-ray PA view chest, ESR, and Mantoux test were done before starting any treatment to look for any evidence of healed or active tuberculosis.


  Results and Discussion Top


Fluorescein angiography showed that about 78% of the cases diagnosed clinically as central serous retinopathy and showing a single leak resolve without any treatment within three months. Other 25% of the cases are resistant to resolve. Among these were the cases who were put on systemic steroids by us or referred from outside on steroids. 10 cases who were taking steroids got an attack of blurred vision in the follow up while on steroids.

The steroids in these cases were then abruptly stopped and patients were put on antitubercular treatment. Cases having multiple leaks, irregular bicentral leak or leak appearing in other eye or non resolving leaks within one month were put on antitubercular treatment i.e. I.N.H. 300 mg and PAS 12 gm. The lesions in both the eyes disappeared clinically as well as fluorescein angiography did not reveal any leak in 9 cases within 6 months and after six months the antitubercular treatment was stopped.

Among the non resistant, 17 were cases where the lesions worsened within the course of time with the natural history or on systemic steroids and by fluorescein angiography also the leak increased in size and intensity within the follow up of one month. Macular detachment became much bigger in size. After stopping the systemic steroids the patients were put on antitubercular treatment and with this the 14 patients showed response i.e. oedema resolved completely and F. fluorescein angiography also did not reveal any leaks. 3 patients showed persistant leak by fluorescein angiography even after the follow up of six months. During the observa­tion of single leak cases 6 cases developed double leak and 2 cases multiple leak. So then the patient was shifted antitubercular treatment and following up for six months only one case showed persistant leak, other resolved completely leaving little pigmentation.

22 cases were having double leak at the time of first presentation. Depending on previous experience while studying the natural history these were directly put on antitubercular treatment and followed by fluorescein angiography.

19 patients responded to this therapy, 3 did not respond. 10 cases were having multiple leaks and were followed on antitubercular treatment.

7 cases showed big macular detachment more than 3 D.D. and fluorescein angiography demonstrated a big and irregular leak like a patch of choroidits. To start with only these were followed on antitubercular treatment. 5 showed complete healing with pigmentary changes at the macula whereas 2 showed persistant staining with a picture like disciform degeneration.

Central serous retinopathy is a clinical term which is conveniently used to embrace several conditions in which an apparently spontaneous oedema develops in the macular area, frequently of obscure aetiology, usually self-limiting but often recurrent. The diagnosis is established by demonstrating a leak on fluorescein angio­graphy. 80% of the cases resolve spontaneously (Garg et al, 1981) but recurrences are frequent.

Garg, et al [1] studied the natural course of clinically diagnosed central serous retinopathy by a prospective study and found that 80% of the cases presented classical picture of central serous retinopathy and resolved by itself without any treatment within three months. These had shallow, small size (less than 6 DD) central detachment with a point or smoke stack leak on fluorescein angiography. 20% cases which did not resolve had larger detachments (more than 6 DD) and big irregular circular leak in early venous phase or multiple leaks on fluorescein angiography. These non classical cases were considered to be of tubercular aetiology due to therapeutic response.

These cases of non-classical type of central serous retinopathy were investigated for any systemic focus of healed or active tuberculosis. Randomised control study was planned for investigation with cases of classical type of central serous retinopathy (total 268 cases). X-ray chest, ESR, Montaux test was performed in all the clinically diagnosed cases of central serous retinopathy. Statistically no difference was found in these groups as to the diagnosis of tuberculosis on the basis of the above investigations.

Schlgeal (1969) has stressed that the only way to diagnose ocular tuberculosis is by therapeutic response to I.N.H. and indicates that the above tests may not be true guide. (300 mg daily for 2 weeks). The patients must show a dramatic response to this test to be diagnosed as presumptive tubercular uveitis or choroiditis. Our cases fall into this category of diagnosis.

48 cases of non classical type of central serous retinopathy were put on I.N.H. 300 mg. and PAS 12 gms daily. 36 responded to the treatment within 2 weeks i.e. vision improved, oedema settled and fluorescein angiography did not demonstrate any leak and in these cases, the treatment was continued for three months. Treatment was stopped in cases who failed to respond within two weeks.

Cases with non classical presentation may be secondary to inflammation or infection i.e. central choroiditis which causes macular oedema. As the therapeutic test was positive so it is presumed that these cases might be of tuber­cular aetiology which is still considered the commonest cause of choroiditis in this part of the world. Sie-been Lian (1967) has indicated that tuberculo allergy may be responsible for cases with positive mantoux test. Some of the cases of classical central serous retinopathy either failed to show any resolution on systemic steroids or even worsened i.e; central detach­ment became bigger in size, areas of leakage increased and vision deteriorated.

In some cases, fellow eye got an attack of central serous retinopathy. 3 cases got an attack of central serous retinopathy while taking steroids for psoriasis or other systemic diseases. The disease is presumed to be infective if steroids worsen the condition in absence of specific antibiotic. So it is presumed that these cases may be of infective aetiology where the induction of steroids has flared up the latent or manifested infection.

In these cases we have stopped the steroids and put the patient on I.N.H. and PAS orally. As 20 out of 25 cases responded to this treat­ment confirming our presumption that these may be secondary to ccular tubercular pathology. The diagnosis however still remain presumptive in absence of any positive investigations and pathological proof.


  Summary and Conclusions Top


260 cases of macular odema were followed to study the natural history of central serous retinopathy. Cases having central detach­ments, marked visual deterioration and showing big irregular, circular, or double or multiple leaks were resistant to natural resolution. These cases were classified as non classical type of central serous retinopathy. As these cases responded to INH 300 mg. PAS 12 gms these were presumed to be cases of tubercular aetiology choroiditis, although the investigation for active or healed focus of tuberculosis proved to be of no value. Depending on therapeutic response only they were supposed to be of tubercular aetiology. 48 cases out of 64 responded to antitubercular treatment.

 
  References Top

1.
Garg, S.P., Tewari, H.K., Khosla, P.K., Azad, R.V., Proceeding of All India Ophthalrnological Society Udaipur, 1981.  Back to cited text no. 1
    



 
 
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