BLOG: Case study: Treating central serous chorioretinopathy with MicroPulse laser
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A 37-year-old man presented in May 2022 with central serous chorioretinopathy in his left eye. His measured vision was 20/20, but he reported significant visual discomfort.
Patients with central serous chorioretinopathy (CSCR) can be highly symptomatic and uncomfortable despite having 20/20 vision due to distortion and aniseikonia.
Fluorescein angiography showed acute CSCR, with a causative leak close to the fovea. I always use fluorescein angiography for patients with CSCR to help determine the location of the leak and plan appropriate treatment. Fluorescein angiography is also important to determine whether the patient already has underlying retinal pigment epithelium changes and diffuse leakage, which may signal chronic or recurrent CSCR.
The patient was using a topical hydrocortisone cream. I asked him to discontinue and return in a month.
At his next visit in June, the patient had a dramatic increase in subretinal fluid. His vision was 20/30 in the left eye. He reported discontinuing the steroid cream and complete steroid avoidance.
At this point, intervention was warranted, and I performed MicroPulse laser treatment the same day. The patient is a young professional, and he felt unable to work. I consider it a disservice to wait and see how the patient does. Now that we have a treatment that can reduce fluid and improve vision faster, why not consider it sooner? While I had him in the chair, I proposed the treatment to him.
The leak was juxtafoveal, and traditional thermal laser was not an option due to the risk for scotoma. Because MicroPulse technology chops a continuous-wave laser beam into short bursts, allowing the tissue to cool between each application, no visible endpoint should be discernible during or any time after laser treatment. In my experience, I have not observed thermal necrosis following MicroPulse laser. I used the IQ 532 laser system (Iridex), applying overlapping spots over an area extending beyond the fluid.
When the patient returned 1 month after the procedure, his subretinal fluid was dramatically improved. His vision was unchanged at 20/30, but he reported experiencing improved vision and had no difficulties at work. He noticed only a slight visual disturbance with monocular occlusion. No focal laser burn was visible clinically or on OCT.
By the 2-month follow-up, the subretinal fluid had completely resolved, and his vision was back to 20/20. The patient was happy with the outcome.
Once patients are dry, I see them again after 3 months. If they are still dry at that visit, as this patient was, I will see them again in a year.
In my opinion, treating subretinal fluid promptly is very important. Even when patients with chronic subretinal fluid improve and return to their baseline Snellen vision, they often feel that something is just off with their vision and can be quite frustrated, especially in this young population. I believe our paradigm for watchful waiting in CSCR may ultimately leave vision on the table.
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