Intravitreal bevacizumab injection for central serous chorioretinopathy. Retina. 2010;30:1323-1324; author reply 1324. [PMID: 20661171 DOI: 10.1097/iae.0b013e3181e46b09]

What is new in central serous chorioretinopathy?

Central serous chorioretinopathy (CSCR) is considered a benign, self-limiting disease. However, as many as third of the patients have recurrent episodes or chronic disease that may cause significant functional impairment. New diagnostic tools and new treatment modalities are emerging in order to improve the functional outcomes of these patients. Spectral domain optical coherence tomography (SD-OCT) has the ability to image individual layers of the retina and choroid. SD-OCT images in CSCR patients have demonstrated increased subfoveal thickness measurements, high reflective deposits in areas of subretinal precipitates and changes in the Retinal pigment epithelium layers of the asymptomatic eyes of patients with supposedly unilateral CSCR. A positive correlation was found between the level of distribution to the layer of inner segment/outer segment junction of the photoreceptors and the visual impairment. Fundus autoflouresence images show a wide variety during different stages of the disease in CSCR patients. Minimal abnormalities during the early stages are followed by hyperautofluoresence in the detached area in later stages, often in a manner of inferior gravitation and at the borders of the detachments. The chronic phase is characterized by varying degrees of atrophy and areas of decreased autofluorescence surrounding areas of chronic leaks. These changes help differentiate an active disease from an inactive state. Multifocal electroretinography (mfERG) has the ability to demonstrate a persistent depression despite the resolution of subretinal detachments. It is therefore being investigated as a follow up tool for patients with chronic CSCR. An excellent correlation was found between changes in mfERG and visual function. Macular microperimetry, measuring retinal sensitivity within the central visual field, is intended to compensate for the underestimation of visual impairment in patients with macular diseases. Reduced retinal sensitivity was found in areas of previous subretinal fluids in CSCR patients. The device can also serve as a follow up tool in these patients. Regarding treatment in CSCR patients, focal argon laser photocoagulation treatment may be applied to small extrafoveal leaks. However, the main purpose of this treatment is to shorten disease duration, with no advantage over observation regarding final visual outcome, rate of progression to chronic CSCR or number of recurrences. Photodynamic therapy (PDT) with verteporfin has been shown to completely resolve serous detachment in 60%-80% of patients and to have a partial affect in the remaining patients. Reduced-fluence treatment is replacing full-fluence therapy in order to minimize side effects with no accompanying reduced effectiveness. Visual acuity is also improved following reduced-fluence PDT compared to placebo. It has also been found that patients with intense hyperfluorescence are more likely to show resolution of accumulating fluid compared to patients with mild or no leakage observed on indocyanine-green angiography prior to treatment. Regarding newer treatment modalities, intravitreal injections of anti-vascular endothelial growth factor agents have a limited effect in patients with CSCR. Recent reports have not demonstrated an advantage for this treatment in regards to anatomic and functional outcome. Micropulse diode laser was not proven to be safer or more effective than argon laser or PDT. Corticosteroid antagonists, not tested in controlled trials, may have a beneficial effect in patients with CSCR. Aspirin may also play a role in treating these patients, with rapid recovery of visual acuity and reduced number of recurrences observed. In conclusion, imaging is evolving rapidly while the clinical implications of these new imaging modalities are less clear. Large randomized trials investigating different treatment modalities are still lacking.

Changing paradigms of anti-VEGF in the Indian scenario

Anti-vascular endothelial growth factors (VEGF) agents have revolutionized the treatment of retinal diseases. Use of anti-VEGF agents in the Indian Scenario present some unique challenges considering the absence of compounding pharmacies, poor penetrance of health insurance and limited affordability of the citizens of a developing economy. To study the changing paradigms of anti-VEGF use in the Indian scenario, all articles published by Indian authors, data from web-based surveys amongst Indian vitreo-retinal specialists were reviewed. In the paucity of compounding pharmacies in India, fractionation and injection techniques differ from those of developed countries. Frequent anti-VEGF monotherapy offers the best anatomical and visual results, but economics of scale do not allow the same in the Indian scenario, resulting in PRN dosing and combination of anti-VEGF with laser photocoagulation, being the commonly employed treatment protocols.