Lasers Med Sci DOI 10.1007/s10103-017-2316-5

BRIEF REPORT

Subretinal fibrin absorption after 577-nm subthreshold micropulse laser therapy in a CSC case: a brief report Lijun Zhou 1 & Tao Li 1 & Kunbei Lai 1 & Chuangxin Huang 1 & Fabao Xu 1 & Zhe Zhu 2,3 & Lin Lu 1 & Chenjin Jin 1

Received: 14 February 2017 / Accepted: 27 August 2017 # Springer-Verlag London Ltd. 2017

Introduction Central serous chorioretinopathy (CSC) is a common macular disorder characterized by serous detachment of the neurosensory retina with or without retinal pigment epithelium (RPE) detachment. This disorder commonly affects young adults, especially males [1]. Typically, it is known as a self-limited disease, with spontaneous resolution within 3–4 months [2]. However, CSC with fibrin deposition is a rare but severe disease that commonly causes permanent visual loss [3, 4]. Although most CSCs respond to clinical treatment, including observation, conventional laser photocoagulation, and photodynamic therapy [5], management of CSC with subretinal fibrin deposition remains challenging for clinicians [3, 6] due to its poor prognosis, which commonly includes retinal scarring and fibrosis. In this brief report, we present a case of CSC with severe subretinal fibrin deposition that was successfully treated by

577-nm subthreshold micropulse laser (SMPL) photocoagulation without visible retinal damage, unlike the course of most CSC patients who undergo conventional photocoagulation. To the best of our knowledge, based upon a literature search, this is the first report to show the use of 577-nm SMPL photocoagulation to successfully treat a CSC patient with subretinal fibrin deposition. Our treatment was approved by the Ethics Committee of Zhongshan Ophthalmic Centre (ZOC) and adhered to the tenets of the Declaration of Helsinki.

Brief report A 34-year-old male was referred to our clinic at ZOC with a chief complaint of sudden decreased right ocular vision for 4 months. He had no unusual medical treatment history or notable family history. An ophthalmic examination showed

* Chenjin Jin [email protected]

Lin Lu [email protected]

Lijun Zhou [email protected] 1

State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Centre, Sun Yat-Sen University, No. 54 Xianlie South Road, Guangzhou City 510060, Guangdong Province, People’s Republic of China

2

Department of Stem Cell Biology and Regenerative Medicine, Cleveland Clinic, Lerner Research Institute, Cleveland, OH 44195, USA

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Present address: Sanford Consortium for Regenerative Medicine, University in California, San Diego 2880 Torrey Pines Scenic Dr, La Jolla, CA 92037, USA

Tao Li [email protected] Kunbei Lai [email protected] Chuangxin Huang [email protected] Fabao Xu [email protected] Zhe Zhu [email protected]

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Fig. 1 a Fundus photography revealed yellow-white lesion involved in the macula. b The lesion diminished gradually at 3 months after initial SMLP treatment. c Subretinal fibrin was absorbed completely at 6 months

that his best corrected visual acuity (BCVA) was 20/200 in the right eye (O.D.) and 20/20 in the left eye (O.S.). The anterior segment examination was normal. A dilated fundus examination showed a yellow-white elevated lesion in the macula (Fig. 1a). Fundus fluorescein angiography (FFA) revealed dye leakage during the early phase and subsequent pooling involving the macula (Fig. 2). Optical coherence tomography (OCT) revealed a serous retinal detachment with subretinal accumulation of highly reflective fibrin (Fig. 3a). A macular integrity assessment (MAIA) of the microperimetry showed decreased macular sensitivity (Fig. 4a). The patient was, thus, diagnosed with CSC with subretinal fibrin deposition. Halfdose photodynamic therapy was advised, but the patient refused this treatment because of its high cost. Instead, 577-nm SMPL photocoagulation therapy was administered to treat the macular lesion after informed consent. Treatment with the 577-nm yellow laser system (Supra 577Y Laser System; Quantel Medical, Clermont-Ferrand, France) was performed using the Mainster contact lens (Ocular Instruments, Bellevue, WA, USA) in micropulse mode. The laser power titration with micropulse model, the first step to determine the appropriate power for the treatment, was applied at 400 mW initially and increased gradually until getting a barely visible laser reaction on the retina using a 100-μm spot size and a 200-ms duration with a 5% duty cycle. Then, the power was reduced by 50% as the power for treating lesion area. In this case, a barely visible laser reaction was viewed when the power was up to 1000 mW, so the treatment power was 500 mW. One month after SMPL treatment, the BCVA and OCT examinations showed slight improvement. Three months later,

the patient revisited our clinic. His BCVA had improved to 20/ 100. Fundus photography (Fig. 1b) and OCT (Fig. 3b) revealed partial resolution of the subretinal fibrin deposition. A microperimetry test showed that his macular sensitivity had improved from 8.6 to 10 dB (Fig. 4b). Six months after initial SMPL treatment, his BCVA recovered to 20/20; fundus photography (Fig. 1c) and OCT revealed that the subretinal fibrin and subretinal fluid depositions had completely resolved (Fig. 3c). Additionally, his macular sensitivity recovered to 24.6 dB (Fig. 4c) and fundus autofluorescence (FAF) displayed no visible spots on the retina (Fig. 4d–f).

Discussion CSC with subretinal fibrin deposition is a severe form of chorioretinopathy [6, 7]. It should be treated early by laser photocoagulation when the leak is not limited to the subfoveal region or is very close to the central fovea [3]. Spontaneous resolution of subretinal fibrin deposition has been reported in a few cases, including pregnant female patients [4, 6]. Unfortunately, patients with subretinal fibrin deposition usually have poor visual acuity and prognoses, although spontaneous resolution can occur at times [4]. Additionally, conventional laser photocoagulation can damage the RPE, leading to the development of paracentral scotomas and subretinal neovascularization [8, 9]. Schatz reported six cases of CSC with subretinal fibrin deposition that eventually progressed to retinal scarring and subretinal fibrosis with severe visual loss despite conventional laser photocoagulation [3].

Fig. 2 FFA showed dye leakage in the early phase (a, b) and subsequent pooling involving the macula (c) at baseline

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Fig. 3 a OCT showed elevated macula accompanied with fibrin and cyst cavity between retinal neuroepithelium layer and pigment epithelium layer. b The lesion was absorbed partially at 3 months after SMLP treatment. c The lesion was absorbed completely at 6 months

In this case, the subretinal fibrin deposition was found during an OCT examination when the patient visited our clinic 4 months after the initial symptoms. We managed the patient with 577-nm SMPL treatment because the leak was close to the fovea and thus was not suitable for conventional photocoagulation treatment. SMPL photocoagulation is a novel laser delivery modality for treating retinal diseases [10–15] and is considered a very promising treatment for CSC [16]. In SMPL mode, as opposed to conventional single pulse mode, energy is dispersed as a burst of micropulses separated by intervals to allow heat dissipation, thus minimizing thermal damage to the retina and adjacent normal tissues [10, 14]. Based on the current clinical reports, this treatment is a no visible damaging retinal laser therapy for CSC with proven efficacy [17]. Multiple non-visible spots are delivered to the RPE to induce biological responses that enhance recovery of the outer bloodretinal barrier [18]. The concept of SMPL treatment relies on

stimulation and self-repair but not coagulation or scarring [14]. However, we should still take prudent strategy to treat CSC patients in our real world practice because the power we used according to titration may possibly cause damage to the targeted tissue beyond our expectation(laser stimulus effect on RPE layer only), for avoiding this unexpected damage. We need careful systemical history inquiry and eye examination before laser treatment. Any situation that could make additional laser absorption should be considered in order to make steps to avoid, for example, the pigmentation deposit on targeted lesion should be paid close attention; laser power should be turn down accordingly if it existed. One month after the initial treatment, slight absorption of the subretinal fibrin was observed in this patient. Partial resolution was achieved at 3 months of follow-up based on the OCT report (Fig. 3b). The patient recovered gradually with increased visual acuity as described at the 3-month follow-up.

Fig. 4 MAIA microperimetry showed the mean macular sensitivity was 8.6 dB before treatment (a) and was 10 dB at 3 months after treatment (b). It improved to 24.6 dB at 6 months (c). (e) and (f) represented respectively

the changes of FAF at 3 months and 6 months after SMLP treatment, which revealed no visible laser spots compared to baseline (d)

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At the 6-month follow-up, the right ocular visual acuity had improved to 20/20. OCT imaging and fundus photography also showed that the subretinal fibrin had been completely absorbed (Fig. 3c). Most importantly, no obvious laser scarring or retinal damage was observed during FAF imaging. In conclusion, our brief report shows that SMPL treatment can achieve complete absorption of subretinal fibrin and satisfactory visual acuity improvement without visible retinal impairment. Thus, clinicians should be aware that SMPL treatment may be a promising approach to potential clinical benefits for the treatment of CSC patients with subretinal fibrin.

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8. Acknowledgements The authors would like to thank all staff involved in the care of patient presented in this case report. Funding This study was supported by the Clinical Research Special Foundation of Zhongshan Ophthalmic Centre of Sun Yat-Sen University (No: PT3031101038).

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Compliance with ethical standards

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Conflict of interest The authors declare that they have no conflict of interest.

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Informed consent Written informed consent was obtained from the patient for treatment and publication of this case report and any accompanying images. A copy of the consent is available for review by the Editor of this Journal. Ethical approval This case report was approved by the Ethics Committee of Zhongshan Ophthalmic Centre of Sun Yat-Sen University and was conducted in adherence with the tenets of the Declaration of Helsinki.

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Subretinal fibrin absorption after 577-nm subthreshold micropulse laser therapy in a CSC case: a brief report.

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