BLOG: Case study: MicroPulse laser treatment for recurrent CSCR
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A 52-year-old startup CEO presented in January 2021 with distortion in the right eye. He had a large subfoveal pigment epithelial detachment but no clear subretinal fluid.
He was on testosterone replacement therapy but denied steroid exposure. His measured vision was 20/30 in the right eye with pachychoroid. This did not appear to be active central serous chorioretinopathy (CSCR) as there was no clear leak on fluorescein angiography (FA), but these symptoms, together with a high-stress job and ambitious personality, suggested a previous case of CSCR with a resultant pigment epithelial detachment (PED).
I asked him to discontinue testosterone replacement therapy and encouraged stress reduction. I then followed him monthly.
At 3 months, the patient’s PED was unchanged, and he continued to report significant visual dysfunction. His measured vision was 20/40 at this time. He was desperate for treatment. While an OCT angiography did not show evidence of type 2 choroidal neovascularization, I attempted an Avastin (bevacizumab, Genentech) injection in April 2021 with discussion of the risk for retinal pigment epithelium tear.
This had absolutely no benefit for the PED. In fact, he then presented in July 2021 with new subretinal fluid, and FA showed a classic CSCR smokestack leak in the bed of the PED. His measured vision remained stable at 20/40. We discussed his options at this time and elected to proceed with MicroPulse therapy (Iridex).
He returned for follow-up in September 2021 with subtly improved subretinal fluid and visual acuity stable at 20/40. The patient subjectively felt that his vision was less bothersome. I was hopeful but not overly optimistic at this time and began considering alternate therapies.
He then presented a month later with dramatic functional and anatomic improvement. His measured vision was 20/50, but he was significantly more comfortable with his vision. He felt he had returned to baseline and had no difficulties at home or at work. This highlights the difference between functional visual acuity, which also involves factors such as distortion and contrast sensitivity, and measured visual acuity.
He last presented to me in October 2022 with a stable OCT and vision of 20/30+1. He remains happy with his vision.
This case demonstrates the value of MicroPulse laser treatment for recurrent CSCR.
It involved a patient in the prime of his working life who desperately wanted something done, and MicroPulse laser treatment gives us something to offer these patients. Due to the safety of the treatment, I was able to apply it comfortably, despite the subfoveal nature of the leak. This case also demonstrates that while we all want the slam dunk, instant gratification results, MicroPulse laser therapy may take some time to show benefit.
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