Korean J Ophthalmol 2012;26(2):139-142
http://dx.doi.org/10.3341/kjo.2012.26.2.139
pISSN: 1011-8942 eISSN: 2092-9382
Case Report
Intravitreal Bevacizumab for Treatment of Refractory Central
Serous Choroidoretinopathy
Morteza Entezari1, Alireza Ramezani1, Mehdi Yaseri2
1
Ophthalmic Research Center, Department of Ophthalmology, Imam Hossein Medical Center, Shahid Beheshti University (MC),
Tehran, Iran
2
Ophthalmic Research Center, Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University (MC),
Tehran, Iran
In a clinical case series, 5 patients with not-resolved central serous choroidoretinopathy (CSC) lasting more
than 1 year received one intravitreal bevacizumab injection (IVB, 1.25 mg) injection. All patients underwent a
through ophthalmic examination 1 day, 1 week, and 1, 2, and 6 months after the injection. Best corrected visual
acuity (BCVA) and central macular thickness were compared before and after treatment by optical coherence
tomography. Mean BCVA was improved significantly (p = 0.020) from 0.60 ± 0.25 to 0.50 ± 0.18 and 0.29 ± 0.19
logarithm of minimum angle of resolution at 6 and 18 weeks, respectively. Central macular thickness was also
decreased significantly (p = 0.010) from 370 ± 65 to 208 ± 23 µm at 4 months. No recurrence was occurred
during follow-up. IVB injection may have beneficial effect in the treatment of refractory CSC.
Key Words: Bevacizumab, Central serous choroidoretinopathy, Optical coherence tomography
Central serous chorioretinopathy (CSC) is one of the
several chorioretinal disorders characterized by serous
detachment of the neurosensory retina and/or the retinal
pigment epithelium (RPE). CSC occurs most frequently
in middle-aged men. Major symptoms are blurred vision,
usually in one eye only and perceived typically by the
patient as a dark spot in the center of the visual field with
associated micropsia and metamorphopsia. Normal vision
often recurs spontaneously within a few months. The condition can be precipitated by psychosocial stress [1].
Resolution of detachment can usually be achieved in
80% to 90% of acute CSC spontaneously within 3 months.
In acute stage, observation is usually the first proposed
treatment option. In recurrent or persistent detachment,
which is often associated with more diffuse RPE change,
Received: April 22, 2010 Accepted: August 1, 2010
Corresponding Author: Morteza Entezari, MD. Ophthalmic Research
Center, Labbafinejad Medical Center, Boostan 9th Pasdaran St., Tehran,
Iran. Tel: 98-21-22591616, Fax: 98-21-2225621, E-mail: entmort@hotmail.
com
however, laser photocoagulation of RPE leakage site(s)
is also recommended. It can hasten resolution of associated serous macular detachment, shortens the duration of
the disease and reduces the recurrence rate. Nonetheless,
this treatment modality is not without risk. It may cause
permanent scotoma which may enlarge over time with
RPE scar expansion as well as choroidal neovascularization (CNV) development [2,3]. There are also a few reports
about beneficial effect of photodynamic therapy (PDT) in
chronic CSC. However, it is expensive and cases of CNV
have been reported following this treatment [4-6].
Anti-vascular endothelial growth factors, through their
anti-permeability characteristics and hence leakage reduction, may be useful in the treatment of cases with refractory CSC and may be helpful as an alternative management. Recently, there are a few case reports with limited
number of patients evaluating the effect of intravitreal
bevacizumab for treatment of refractory CSC [7-9]. Nevertheless, the literature still suffers from lack of sufficient
data in this field. Performing another case series, we also
tried to assess the effect of single injection of intravitreal
bevacizumab for treatment of refractory CSC.
This paper was presented as a poster in the AAO/PAAO Joint Meeting,
October 2009, San Francisco, CA, USA.
© 2012 The Korean Ophthalmological Society
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses
/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
139
Korean J Ophthalmol Vol.26, No.2, 2012
Case Report
This prospective interventional case series was approved
by the review board/ethics committee of the Ophthalmic
Research Center of the university. An informed consent
was obtained from each patient.
Five eyes of 5 patients with diagnosis of refractory CSC
(lasting more than 1 year) were included in this study.
Diagnosis was made by the history of recurrent blurred
vision and metamorphopsia for more than one year, detection of neurosensory detachment in ophthalmoscopy and
optical coherence tomography (OCT), and observation of
active RPE leakage in flourscein angiography. Exclusion
criteria consisted of any accompanying macular disease,
severe media haziness which precludes OCT evaluation,
and noncompliance. Each participant underwent a thorough ophthalmic examination.
All eyes received a single injection of 0.05 mL (1.25 mg)
intravitreal bevacizumab (Avastin; Genentech Inc., South
San Francisco, CA, USA [made for F. Haffmann-La Roche
Ltd., Basel, Switzerland]) performed by a 30-guage needle
through supratemporal quadrant 4 mm from the limbus
under sterile condition.
All patients underwent a through ophthalmic examination 1 day, 1 week, and 1, 2, and 6 months after the injection. Best corrected visual acuity (BCVA) of the eyes was
checked by a masked optometrist. It was changed to the
logarithm of minimum angle of resolution (logMAR) scale
for statistical purposes and compared at months 2 and 6
with the baseline values. Central macular thickness (CMT)
measured by OCT (3D OCT-1000; Topcon Corporation,
Tokyo, Japan) was performed at presentation and repeated
6 months after the intervention. It was measured in a
1-mm circle centered on the fovea by an optician who was
masked to the study. The data were analyzed by paired t-
test. Statistical level of significance was preset at 0.05.
The initial characteristics are listed in Table 1. None of
the patients had history of intraocular surgery, diabetes
mellitus, hypertension, cardiovascular disease and smoking. An increase of BCVA was noticed during the followup in all eyes except case 1. Mean BCVA at baseline was
0.60 ± 0.25 that improved to 0.42 ± 0.16 and 0.24 ± 0.21
logMAR up to the month 2 and 6, respectively. This improvement at 2 months did not reach to a meaningful level
( p = 0.064); however, it was statistically significant at 6
months ( p = 0.025). No recurrence was observed in any
of the eyes during the follow-up period. Central macular
thickness decreased significantly from 370 ± 65 µm at
baseline to 210 ± 24 µm at 6 months after injections ( p =
0.009) (Table 2). Figure 1 demonstrates the OCT pictures
of 4 cases before and after treatment. No major ocular or
systemic complication was encountered in this study. None
of the eyes had intraocular pressure rise (>21 mmHg) or
cataract progression during the follow-up period.
Discussion
Various medications have been suggested for the treatment of CSC by different authors. They include acetazolamide, beta-blockers, vitamins, and non-steroidal antiinflammatory drugs. None of them has been proved to be
beneficial. On the other hand, there are some controversial
recommendations in the literature on the use of laser photocoagulation in this field. Some authors reporting that laser photocoagulation shortens the duration of disease and
reduces recurrence rate, while others maintain that it does
not affect final vision and recurrence rate. Furthermore, laser may be associated with permanent scotoma which may
enlarge over time with RPE scar expansion, as the possible
development of CNV [2,3].
Table 1. Initial characteristics of the cases
Case 1
Male
36
Left
6
4
-
Sex
Age (yr)
Laterality
Duration of symptoms (yr)
No. of attacks
Previous fellow eye involvement
Case 2
Male
47
Left
2
5
-
Case 3
Male
40
Left
2
3
+
Case 4
Male
36
Left
1
2
+
Case 5
Female
39
Right
3
2
-
Case 4
0.5
0.4
0.2
280
224
Case 5
1.0
0.7
0.5
350
182
Table 2. Best corrected visual acuity and central macular thickness changes during follow-up
Visual acuity (logMAR)
Central macular thickness (μm)
140
Before
Month 2
Month 6
Before
Month 6
Case 1
0.4
0.4
0.5
380
224
Case 2
0.7
0.3
0.1
378
238
Case 3
0.4
0.3
0.0
461
189
M Entezari, et al. Intravitreal Bevacizumab for CSC
Before
After
A
Case 1
B
Case 2
C
Case 3
D
Case 4
E
Case 5
Fig. 1. OCT pictures of 4 cases before and after treatment by IVB
showing nearly complete (cases 1 [A], 2 [B], and 3 [C]) and partial
(cases 4 [D] and 5 [E]) resolutions of subretinal fluid.
Photodynamic therapy has also been attempted with
some success for treatment of refractory CSC. It may hasten resolution of exudation by reducing choroidal blood
f low and hence favoring cessation of leakage [10]. Most
recently, several case series have reported the use of indocyanine green guided PDT in the treatment of chronic
CSC [11]. Ober et al. [12] reported the successful treatment
of focal RPE leaks in CSC by PDT in a small pilot series
which showed resolution and visual improvement. Cardillo
Piccolino et al. [6] performed indocyanine green guided
PDT in 16 eyes with chronic CSC and treatment resulted in
complete resolution of serous retinal detachment 1 month
after treatment in 75% of eyes. At 3 months after PDT,
69% of eyes had visual improvement of 1 or more lines.
However, 31% of their cases developed secondary RPE
changes at the site of PDT, which were thought to be due
to hypoxic damage caused by choriocapillaris occlusion.
Moreover, PDT is an expensive treatment and may cause
CNV formation [13].
Our study showed a significant visual improvement and
CMT reduction following single injection of IVB (1.25 mg)
in 5 cases suffering from refractory CSC for more than
one year. In a similar study on 5 cases with CSC, Torres-
Soriano et al. noticed an improvement in BCVA, fluorescein angiographic leakage, and reduced or resolved neurosensory detachment. However, they injected 2.5 mg IVB
and included cases with history of decreased visual acuity
more than 3 months, recurrent episodes of CSC or even
acute cases with excessive discomfort about visual acuity
[7].
In a case series on 12 eyes, Schaal et al. [9] showed that
in cases with chronic CSC IVB injection improved BCVA
and reduced CMT. However, they performed multiple injections of 2.5 mg IVB at 6 to 8 week intervals (range, 1 to
4 weeks). However, recurrence did not occur in any case of
our study during follow up period.
In summery, the present study demonstrated a promising effect of IVB in the treatment of refractory CSC; however, we can not make specific treatment recommendations
based on this small, uncontrolled case series. Further clinical trials with control group are warranted. Further studies
with large sample size are warranted.
Conflict of Interest
No potential conflict of interest relevant to this article
was reported.
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