factors associated in causing recurrence definition treatment options

1. DR BODHRAJ DHAWAN, MS
Recurrent CSCR

2. Definition of re- CSCR
 An active episode of CSCR followed by spontaneous or treatment-
induced subretinal fluid resolution, and with a follow-up longer than
12 months after resolution of the initial episode
RISK FACTORS FOR RECURRENCES OF CENTRAL SEROUS CHORIORETINOPATHY,Matet,Alexandre, MD*;
Daruich,Alejandra, MD*; Zola, Marta, MD*; Behar-Cohen, Francine, MD, PhD*,RETINA: July 2018 -Volume 38 - Issue 7 - p
1403–1414

3. How common is recurrence in CSCR cases
 Acute episodes are usually self-resolving
 ∼20% to 50%of affected eyes may later present one or
several recurrences.
 Repeated episodes -lead to irreversible photoreceptor/RPE damage.
 Identifying factors predisposing for CSCR recurrences - crucial.

4. Clinical Risk Factors of CSCR Recurrence
1. Number of subretinal hyperreflective foci at the leakage site
2. SFCT
3. Intensity of fluorescein leakage
4. Pattern of choroidal hyperpermeability on ICGA
5. significant association of irregular PED

5. 1.Subretinal material
5

6. 2.SFCT- Subfoveal Choroidal Thickness
 SFCT >395 μm
 P resent in 50% of CSCR patients' relatives
 CSCR with Pachychoroid is known for-
1. Recurrence
2. Bilateral
3. Severe

7. 3.Intensity of leak

8. 4. Pattern of choroid Hypermaebility

9. 5.Irregular PED and subretinal hyper
reflective material

10. Other Risk Factors for Re- CSCR
 Corticosteroid use
 Psychological stress
 Depression
 Cardiovascular disease,
 Recently advanced factors such as pachychoroid
 Allergic disease
 Disturbed sleep
 shift work
 Helicobacter pylori
 Pregnancy

11. Pathogenesis of a recurrent CSCR
1. Peripheral disease
2. Vortex vein congestion
3. Pachychoroid spectrum
4. Choroidal hyperpermeability and Hydrostatic dysfunction of the choroid
5. Activation of MR- Mineralocorticoid receptor in choroidal vessels

12. 1. Peripheral disease
CSC
Posterior
Hyper AF Hypo AF Mixed AF
Peripheral
HYPER/HYPO/MIX
Gravitational tracts-
arched/vertical

13. FAF Patterns- Posterior CSCR
)

14. FAF Patterns in peripheral disease

15. FAF OCT Correlation

16. 2. Vortex vein congestion

17. 3. Pachychoroid spectrum

18. 4. Hypermaeble choroid
18

19. Treatment-options
 No standardised
treatment strategies
 Low fluence PDT
 Conventional Argon
Laser therapy- Focal
Lasers
 Micropulse yellow
lasers MPL- 577 nm-
effective non invasive
 Medical care
 Supportive therapy

20. Primary treatment and thorough work up
-Removal or reduction of exogenous corticosteroid sources where possible
-Reduction of other risk factors such as psychosocial stressors
- ICGA
- FAF
- Rule out IPCV

21. Laser
 Most commonly performed treatment
modality
 Indication
1. 3- 4 months of persistent SMD
2. Early laser – in presence of risk factors /
professional requirements/ recurrence
3. Extrafoveal Leaks

22. Navigational lasers
Conventional lasers
Navigational lasers

23. Focal lasers
Mechanism of action Complications
 Photocoagulate RPE cells
at the site of the leakage
 Forming a fibrotic scar
preventing further focal
leakage
 Permitting surrounding
RPE cells to pump fluid
back into the
choriocapillaris.
 CNV- <10% of treated
patients
 Scotoma
 Foveal burn

24. Photodynamic Therapy
 Current Standard of care in Chronic Disease
 Off label Indication
 Effective in SRF resolution andVisual Improvement
 No standard Dose/ Flauence still Established for this Indication
 25 J/ cm2 better than 50 J/ cm2 – half fluence- less collateral damage
, better outcomes
 Reduced choroidal ischemia, RPE atrophy and CNV following
standard PDT,
 3 mg/m2 vs 6 mg(half-dose PDT )- stable or improved vision in most
cases

25. Problems with PDT
 Cost
 Availibility
 Recurrence
 Serious ocular side effects
 Serious Systemic Issues
 Need of ICG for exact GLD measurements

26. Mineralocorticoid antagonists in CSCR
 Results appear promising- mechanism-
 Activation of MR- Mineralocorticoid receptor in choroidal vessels is
seen in CSCR
 Significant reduction in RPE detachment and in choroid thickness
after 1 month of treatment
 Both spironolactone and eplerenone significantly reduced SRF
 Spironolactone has been known to cause gynecomastia, erectile
dysfunction, and menstrual irregularities
 Eplerenone is preferred modality.
 More studies required

27. Eplerenone
 Anti HTN
 25 mg/ day
 Side effects- flue, hyperkalemia,hypercholesterolemia, hyperTG
emia, headache, gynecomasia, altered LFTs
 Could be an answer to multifocal cscr
 Less invasive
 Reduces recurrences

28. Conclusion and Summary of Recommendations
 Recurrence marks Guarded Prognosis
 Risk stratification and avoidance is best in recurrent cases
 For CSCR that persists and recurs there are several treatment
modalities to choose from.
 For patients with focal lesions not involving the fovea, focal laser
photocoagulation with argon laser may be suitable.
 In patients with foveal involvement, photodynamic therapy or
micropulse diode laser would spare central vision.
 As our understanding of the mechanism of CSCR grows, new
therapies, such as a spironolactone or eplerenone, may develop
along the way.

29. THANK YOU
End result of re-currencies is- DRPE