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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 57  |  Issue : 2  |  Page : 118-121

Subthreshold micropulse yellow laser in the treatment of central serous chorioretinopathy


Department of Retina-Vitreous, Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, Madurai, Tamil Nadu, India

Date of Web Publication10-Sep-2019

Correspondence Address:
Dr. T P Vignesh
Aravind Eye Hospital and Post Graduate Institute of Ophthalmology, No. 1, Anna Nagar, Madurai - 625 020, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_43_19

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  Abstract 


Purpose: The objective was to study the safety and efficacy of subthreshold micropulse yellow laser in the treatment of central serous chorioretinopathy (CSCR). Materials and Methods: This is a retrospective interventional case series in a tertiary eye care center. Patients diagnosed to have CSCR were treated with subthreshold micropulse yellow laser, over the leaks identified by fundus fluorescein angiography. Subretinal fluid (SRF) level was measured by optical coherence tomography at baseline and the follow-up visits at 1, 3, and 6 months. Results: Twelve eyes of 12 patients were included, and there was a statistically significant improvement in visual acuity as well as reduction in SRF level between baseline and the follow-up visits. Conclusion: There was a beneficial effect of subthreshold micropulse yellow laser in the treatment of CSCR in this study, with complete resolution of SRF in ten out of 12 eyes (83.3%). However, a larger study is warranted.

Keywords: Central serous chorioretinopathy, micropulse, subthreshold, yellow laser


How to cite this article:
Vignesh T P. Subthreshold micropulse yellow laser in the treatment of central serous chorioretinopathy. TNOA J Ophthalmic Sci Res 2019;57:118-21

How to cite this URL:
Vignesh T P. Subthreshold micropulse yellow laser in the treatment of central serous chorioretinopathy. TNOA J Ophthalmic Sci Res [serial online] 2019 [cited 2019 Nov 19];57:118-21. Available from: http://www.tnoajosr.com/text.asp?2019/57/2/118/266395




  Introduction Top


Central serous chorioretinopathy (CSCR) is a disease, characterized by serous retinal detachment involving the macula and is associated with serous retinal pigment epithelial detachments (PEDs). It is usually seen in young- and middle-aged individuals and affects predominantly males.[1] The exact etiology is not very clear; however, this condition is associated with type A personality,[2] any form of steroid use for various other diseases[3] as well as conditions such as Cushing's syndrome, where there is endogenous hypercortisolism.[4] In CSCR, serous macular detachment occurs due to the focal breakdown of the outer blood-retinal barrier seen as leaks in fundus fluorescein angiography (FFA).[1] The primary pathology is thought to lie in the choroids, and choroidal hyperpermeability was demonstrated by indocyanine green angiography, under the areas of outer blood-retinal breakdown[5] and may occur because of choroidal venous stasis, choroidal ischemia, and choroidal inflammation.[6]

CSCR is usually self-limiting, and it resolves spontaneously in majority of individuals within 3 months. The treatment is indicated only when the condition does not resolve beyond 3 months, or when the individual needs early visual rehabilitation within 3 months. Laser photocoagulation is generally used to treat CSCR, and the laser is directed to the area of leakage, which results in resolution of serous macular detachment as well as improvement in visual acuity (VA). However, collateral damage can occur in conventional laser photocoagulation, even though the laser is directed at the retinal pigment epithelium due to temperature rise which spreads, resulting in damage to overlying neurosensory retina as well as adjacent healthy RPE, resulting in complication of scotoma, especially in acute cases with sub-/juxta-foveal leak and chronic cases with large, diffuse leaks. Choroidal neovascularization can also occur in 5%–7% of cases treated with conventional laser photocoagulation.

Subthreshold micropulse diode infrared laser is a safer alternative, wherein the endpoint after laser application is invisible, and there is no temperature rise, thereby preventing collateral damage. Several studies have demonstrated the safety and efficacy of subthreshold micropulse diode laser in the treatment of acute as well as chronic CSCR. Solid-state yellow laser (577 nm) was recently introduced which can be delivered by a continuous wave as well as micropulse mode. It has properties similar to an infrared laser. There are only a few previous studies in the treatment of CSCR with subthreshold micropulse yellow laser done, from India. We wanted to study the efficacy of subthreshold micropulse yellow laser in the treatment of CSCR.


  Material and Methods Top


Study design

This is a retrospective interventional case series.

Patients diagnosed to have CSCR, with a duration of ≥3 months or recurrent cases of CSCR, were included in the study. The study was conducted according to the tenets of the Declaration of Helsinki.

All the study patients underwent best-corrected VA measurement by Snellen's VA chart, a thorough anterior segment examination by slit lamp and a complete posterior segment examination by 90D slit-lamp biomicroscopy and indirect ophthalmoscopy. They underwent FFA and spectral domain optical coherence tomography (OCT) by Topcon Triton (Topcon Medical Systems, Inc., New Jersey, USA). Patients underwent the subthreshold micropulse yellow laser with Iridex IQ 577 nm system (Iridex, Mountain View, CA, USA). A spot size of 100 μ, duration of 200 ms, and a duty cycle of 5% were set for all the patients. First test burns in the micropulse setting were given in the inferonasal quadrant to produce a visible burn, and then the power required to produce a subthreshold burn was calculated by reducing the power by 50% from the power required to produce visible burn. The area of leak or ooze was then treated with contiguous subthreshold invisible burns.

All the patients were followed up at 1, 3, and 6 months. OCT was repeated at all the follow-up visits. If significant fluid was still, persisting at 3rd-month visit, then FFA was repeated and if leak was found to be persisting, then the treatment was repeated.


  Results Top


Twelve eyes of 12 patients were included in the study, and all the study patients were male. The mean age of the study patients was 40.17 years. The mean duration of CSCR was 3.5 months, ranging from 1 to 12 months. Out of 12 patients, five patients had one previous episode and one patient had three previous episodes. Four patients gave a history of previous treatment out of 12 patients, and three out of the four patients gave a history of one previous focal laser treatment and one patient gave a history of three previous focal laser treatments. [Table 1] shows the details of the subjects and the outcome of the study.
Table 1: Subject Details and Outcome

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VA was converted into LogMAR for analysis. Wilcoxon signed-rank test was used to find out the significant difference in VA between each visit compared to baseline. P <0.05 considered as statistically significant. P value shows that there is a significant difference in VA between baseline VA and 1st month (P = 0.016), 3rd month (P = 0.016), and 6th month (P = 0.011).

Foveal subretinal fluid (SRF) level was measured at baseline and at each follow-up visit. Wilcoxon signed-rank test was used to find out the significant difference in SRF between each visit compared to baseline. P value shows that there is a significant difference in SRF between baseline and 1st month (P = 0.002), 3rd month (P = 0.002), and 6th month (P = 0.002).

Ten out of 12 eyes (83.3%) had a complete resolution of SRF at the end of 6 months, and only one patient required repeat laser at the 3rd-month visit with a decrease in SRF at the 6th-month follow-up. [Figure 1]a and [Figure 1]b shows the smokestack leak, [Figure 1]c shows the presence of SRF, and [Figure 1]d shows the complete resolution of SRF level at 6 months. [Figure 2]a and [Figure 2]b shows the leak as well as PED, [Figure 2]c shows the presence of SRF as well as a PED, just temporal to disc at baseline, and [Figure 2]d shows the complete resolution of SRF as well as PED, at 6 months.
Figure 1: (a and b) Shows a juxtafoveal smokestack leak. (c) SD-OCT at baseline reveals serous macular detachment. (d) SD-OCT reveals complete resolution of subretinal fluid at the 1st month follow-up

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Figure 2: (a and b) Shows an extrafoveal leak and a pigment epithelial detachment, just temporal to the fovea. (c) SD-OCT at baseline reveals serous macular detachment as well as pigment epithelial detachment. (d) SD-OCT reveals complete resolution of subretinal fluid as well as pigment epithelial detachment at the 1st month follow-up

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  Discussion Top


Our study has shown a beneficial effect of subthreshold micropulse yellow laser in the treatment of CSCR with a statistically significant improvement in VA as well as subfoveal fluid level from baseline to every follow-up visit, and there were no side effects. Few studies have shown the efficacy and safety of subthreshold micropulse yellow laser in the treatment of chronic CSCR.[7],[8],[9],[10],[11] Two studies had compared, photodynamic therapy (PDT) with subthreshold micropulse laser in the treatment of CSCR, one study compared with low-fluence PDT,[12] and another study compared with half-dose verteporfin,[13] both studies revealed that subthreshold micropulse yellow laser comparable to PDT in efficacy, in the resolution of CSCR. The cost of subthreshold micropulse yellow laser is a fraction of the cost of PDT, making it a very affordable option for most of the patients with CSCR requiring treatment, especially in cases of CSCR with leaks arising in the subfoveal or juxtafoveal areas, as there are no visible burns in the treatment by subthreshold micropulse yellow laser and can be treated safely in the subthreshold setting. However, prospective, randomized, and comparative large-scale studies of subthreshold micropulse yellow laser with other modalities such as PDT or oral eplerenone are needed.


  Conclusion Top


The subthreshold micropulse yellow laser has been shown to effective in the treatment of CSCR in our study and has advantages over conventional laser photocoagulation in terms of safety and it is a low cost treatment, in comparison to PDT. Subthreshold micropulse yellow laser can be considered to be a preferred laser for the treatment of CSCR in Indian scenario because of its safety, efficacy and affordability.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gass JD. Stereoscopic Atlas of Macular Diseases. St. Louis, MO: Mosby; 1997.  Back to cited text no. 1
    
2.
Yannuzzi LA. Type-A behavior and central serous chorioretinopathy. Retina 1987;7:111-31.  Back to cited text no. 2
    
3.
Haimovici R, Gragoudas ES, Duker JS, Sjaarda RN, Eliott D. Central serous chorioretinopathy associated with inhaled or intranasal corticosteroids. Ophthalmology 1997;104:1653-60.  Back to cited text no. 3
    
4.
Bouzas EA, Scott MH, Mastorakos G, Chrousos GP, Kaiser-Kupfer MI. Central serous chorioretinopathy in endogenous hypercortisolism. Arch Ophthalmol 1993;111:1229-33.  Back to cited text no. 4
    
5.
Guyer DR, Yannuzzi LA, Slakter JS, Sorenson JA, Ho A, Orlock D, et al. Digital indocyanine green videoangiography of central serous chorioretinopathy. Arch Ophthalmol 1994;112:1057-62.  Back to cited text no. 5
    
6.
Iijima H, Iida T, Murayama K, Imai M, Gohdo T. Plasminogen activator inhibitor 1 in central serous chorioretinopathy. Am J Ophthalmol 1999;127:477-8.  Back to cited text no. 6
    
7.
Yadav NK, Jayadev C, Mohan A, Vijayan P, Battu R, Dabir S, et al. Subthreshold micropulse yellow laser (577 nm) in chronic central serous chorioretinopathy: Safety profile and treatment outcome. Eye (Lond) 2015;29:258-64.  Back to cited text no. 7
    
8.
Kim JY, Park HS, Kim SY. Short-term efficacy of subthreshold micropulse yellow laser (577-nm) photocoagulation for chronic central serous chorioretinopathy. Graefes Arch Clin Exp Ophthalmol 2015;253:2129-35.  Back to cited text no. 8
    
9.
Ambiya V, Goud A, Mathai A, Rani PK, Chhablani J. Microsecond yellow laser for subfoveal leaks in central serous chorioretinopathy. Clin Ophthalmol 2016;10:1513-9.  Back to cited text no. 9
    
10.
Maruko I, Koizumi H, Hasegawa T, Arakawa H, Iida T. Subthreshold 577 nm micropulse laser treatment for central serous chorioretinopathy. PLoS One 2017;12:e0184112.  Back to cited text no. 10
    
11.
Arsan A, Kanar HS, Sonmez A. Visual outcomes and anatomic changes after sub-threshold micropulse yellow laser (577-nm) treatment for chronic central serous chorioretinopathy: Long-term follow-up. Eye (Lond) 2018;32:726-33.  Back to cited text no. 11
    
12.
Özmert E, Demirel S, Yanık Ö, Batıoǧlu F. Low-fluence photodynamic therapy versus subthreshold micropulse yellow wavelength laser in the treatment of chronic central serous chorioretinopathy. J Ophthalmol 2016;2016:3513794.  Back to cited text no. 12
    
13.
Roca JA, Wu L, Fromow-Guerra J, Rodríguez FJ, Berrocal MH, Rojas S, et al. Yellow (577 nm) micropulse laser versus half-dose verteporfin photodynamic therapy in eyes with chronic central serous chorioretinopathy: Results of the Pan-American Collaborative Retina Study (PACORES) group. Br J Ophthalmol 2018;102:1696-700.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

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Introduction
Material and Methods
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