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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 3  |  Page : 314-318

Evaluation of intravitreal ranibizumab injection as a line of treatment for chronic central serous retinopathy


Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt

Date of Submission28-Aug-2019
Date of Decision29-Aug-2019
Date of Acceptance15-Sep-2019
Date of Web Publication26-Nov-2019

Correspondence Address:
Emad A.A Saliem
MD Ophthalmology, Tahta, Sohag, Egypt; Lecturer of Ophthalmology, Department of Ophthalmology, Faculty of Medicine, Al-Azhar University, Assiut, 71524
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_112_19

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  Abstract 


Background To assess the effectiveness of ranibizumab in the treatment of chronic central serous retinopathy (CCSR).
Patients and methods This prospective study included 10 eyes of 10 patients with CCSR treated by a single dose of ranibizumab injected intravitreally. After injection, the patients were re-evaluated at the second day, then after 1 week, and then monthly up to 6 months. Changes in vision and macular thickness were detected before and after injection.
Results The main best-corrected visual acuity increased from 0.82±0.08 logMAR before injection to 0.56±0.09 logMAR after 3 months and to 0.24±0.09 logMAR after 6 months in patients with CCSR less than 6 months, and increased from 0.78±0.16 logMAR before injection to 0.64±0.15 logMAR after 3 months and to 0.36±0.09 logMAR after 6 months in those with CCSR more than or equal to 6 months (P<0.05). The mean central macular thickness decreased from 342±36.14 μm before injection to 252±7.02 μm after 3 months and to 204±17.13 μm after 6 months in patients with CCSR less than 6 months, and decreased from 322±51.42 μm before injection to 259±26.06 μm after 3 months and to 214±18.13 μm after 6 months (P<0.05) in those with CCSR more than or equal to 6 months. The mean age of patients was 39±9.6 years.
Conclusion The use of ranibizumab for treatment CCSR was more clinically effective and generally well tolerated.

Keywords: central macular thickness, central serous retinopathy, ranibizumab


How to cite this article:
Saliem EA. Evaluation of intravitreal ranibizumab injection as a line of treatment for chronic central serous retinopathy. Al-Azhar Assiut Med J 2019;17:314-8

How to cite this URL:
Saliem EA. Evaluation of intravitreal ranibizumab injection as a line of treatment for chronic central serous retinopathy. Al-Azhar Assiut Med J [serial online] 2019 [cited 2020 Jul 15];17:314-8. Available from: http://www.azmj.eg.net/text.asp?2019/17/3/314/271673




  Introduction Top


Central serous retinopathy (CSR) is a common condition affecting the posterior segment of the eye characterized by elevation of the retina near the macula as a result of an idiopathic leakage between the outer segments of photoreceptors and the retinal pigment epithelium (RPE), resulting in serous detachment of the neurosensory retina [1]. The exact etiology of this disease is not thoroughly understood, but a variety of risk factors may be considered, such as corticosteroid exposure, psychological stress, type A personality, obstructive sleep-apnea, and hypertension. This disease is more common in males between 20 and 60 years of age; however, it may occur in females as well [2].

CSR is self-limited in most cases, and the patients can retain an excellent vision; however, in patients with persistent retinal detachment, both the RPE and the photoreceptors may be damaged, leading to impairment of vision [3]. This condition to be clinically diagnosed, and it requires fundus examination on dilated pupil, fundus fluorescein angiography (FA), in addition to Amsler-grid testing, and optical coherence tomography (OCT). In most cases, spontaneous recovery of vision is very common, so there is no need for treatment. However, in chronic cases, different lines for treatment of chronic central serous retinopathy (CCSR) can be used such as photodynamic therapy (PDT), focal laser photocoagulation, and anti-vascular endothelial growth factor (VEGF) medications [4]. Ranibizumab is a recombinant humanized antibody fragment that inhibits VEGF. It can be used in the treatment of other ocular problems as macular edema secondary to central and branch retinal vein occlusion [5], exudative age-related macular degeneration [6], and diabetic macular edema [7].


  Patients and methods Top


A prospective, noncomparative interventional clinical study was conducted that included 10 eyes of 10 (seven males and three females) patients with CCSR evidenced by persistence of symptoms more than 3 months and treated by a single dose of ranibizumab injected intravitreally at Alforsan Eye Center, Assiut. Their ages ranged from 26 to 57 years, with mean age of 39±9.6 years. An informed written consent was taken from each patient in the study.

Inclusion criteria

The included patients with neurosensory detachment were evidenced by the following:
  1. OCT.
  2. Active leak on FA.
  3. No signs of choroidal neovascularization.


Exclusion criteria

The followings were the exclusion criteria:
  1. Patients who had been previously treated by laser photocoagulation or PDT.
  2. Previous treatment by intravitreal steroid or anti-VEGF injection.
  3. Patients with uncontrolled glaucoma.
  4. Those who underwent previous vitrectomy.


Preoperative ophthalmic assessment of patients should be considered including detailed history involving the age, sex, and duration of symptoms; assessment of the visual acuity; intraocular pressure; anterior segment examination by slit-lamp; and fundus examination. Moreover, fundus FA and OCT were done for all patients. Each patient had received ranibizumab (0.5 mg/0.05 ml) by a single intravitreal injection, followed by re-evaluation at each visit along the follow-up period. When the diagnosis got evidenced, intravitreal ranibizumab was injected into the midvitreous under complete aseptic condition. After injection, antibiotic drop and ointment were applied to the conjunctival sac, and the eye was bandaged for 1 day. Then, the patient was advised to instill a drop of an antibiotic six times daily for 1 week.

The study end points were decreased leakage on FA, resolution of subretinal fluid and neurosensory retinal detachment on OCT, and improvement of vision.

All the patients were revaluated on the second day, after 1 week, and then monthly up to 6 months. At each visit, the following items should be assessed:
  1. Best-corrected visual acuity (BCVA).
  2. Anterior segment examination.
  3. Assessment of intraocular pressure by applanation tonometry.
  4. Fundus examination.
  5. Fundus FA at 3 and 6 months.
  6. OCT images were also taken at 3 and 6 months to assess the central macular thickness (CMT).


Statistical analysis

Statistical analyses were performed using SPSS version 22 (IBM Corporation, Chicago, Illinois, USA). Snellen BCVA values were converted into logMAR for statistical analysis. Mean±SD were estimated. Changes in CMT and BCVA were assessed with the analysis of variance test followed by Tukey test, and P values of less than 0.05 were deemed statistically significant.


  Results Top


Ten eyes of 10 patients were included in this study who received ranibizumab intravitreally at once for treatment of CCSR. The demographic data of patients revealed that seven (70%) patients were males and three (30%) patients were females.

The main BCVA increased from 0.82±0.08 logMAR before injection to 0.56±0.09 logMAR at third month and to 0.24±0.09 logMAR at sixth month in patients with CCSR less than 6 months, and increased from 0.78±0.16 logMAR before injection to 0.64±0.15 logMAR at third month and to 0.36±0.09 logMAR at sixth month in those with CCSR more than or equal to 6 months (P<0.05; [Table 1] and [Figure 1]).
Table 1 The best-corrected visual acuity at baseline and after third and sixth months after injection of ranibizumab for treatment
of chronic central serous retinopathy


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Figure 1

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The mean central macular thickness decreased from 342±36.14 μm before injection to 252±7.02 μm at third month and to 204±17.13 μm at sixth month in patients with CCSR less than 6 months, and decreased from 322±51.42 μm before injection to 259±26.06 μm at third month and to 214±18.13 μm at sixth month in those with CCSR more than or equal to 6 months (P<0.05; [Table 2] and [Figure 2]).
Table 2 The mean central macular thickness at baseline, after third and sixth months after injection of ranibizumab for treatment of chronic central serous retinopathy

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Figure 2

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The injection was safe and tolerated in all patients without any evidence of intraoperative or postoperative complications such as increased intraocular pressure, vitreous hemorrhage, or retinal detachment. Regarding the age, sex, lens status, and laterality, there is no statistically significant differences ([Figure 3] and [Figure 4]).
Figure 3

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Figure 4

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  Discussion Top


CSR is a pathologic condition affecting middle-aged adults. In most cases, it is unilateral, but may be bilateral in ∼18% of the cases. CSCR is characterized by persistent or recurrent neurosensory detachment occurring over RPE atrophy and pigment mottling [2]. Changes occurring in choroidal circulation secondary to CSR are believed to alter an overlying RPE, affecting its function, and leading to occurrence of a serous retinal detachment [8].

Definitely, the prognosis of CSR is good regarding the changes in vision, which is mostly recovered after spontaneous visual improvement. The neurosensory retinal detachment usually resolves within 3–4 months. In ∼20% of cases, persistent serous detachment may develop with visual impairment as well as subjective symptoms such as micropsia or dyschromatopsia, so if subretinal fluid is not resolved within 3 months, the condition is recognized as chronic or persistent CSR with recommendations for additional treatment. The recurrence rate was noticed in one-third to one-half of the patients with CCSR [9].

Cardillo et al. [10] concluded that PDT seems to treat this condition and improves the visual acuity in patients with CCSR. PDT is believed to reduce blood flow in choriocapillaris and also reduces the choroidal exudation in areas of subretinal fluid production. However, adverse effects such as persistent hypoperfusion of the choriocapillaris may occur.

Shams and Ianchulev [11] reported that VEGF is responsible for ocular angiogenesis and vascular permeability associated with CSR, and this will lead to increased choroidal permeability, which is claimed to be one of the most common causes of CSR, so it seems logical to treat such cases with anti-VEGF such as ranibizumab.

Kim and Lee [12] evaluated the effectiveness of ranibizumab for treatment of acute CSR (symptomatic for<3 months) on 20 patients (0.5 mg/0.05 ml) who were followed up for 6 months. This study concluded that BCVA had increased, CMT had decreased, and subretinal fluid had resolved in all cases.

In this study, 10 eyes of 10 patients presented by chronic CSR were treated by a single dose of intravitreal ranibizumab (0.5 mg/0.05 ml) with no evidence of intraoperative or postoperative complications, and good results could be obtained during the follow-up period without any evidence of recurrence. Improvement in vision and reduction of CMT rely on the duration of the disease and the amount of photoreceptor damage. However, all eyes revealed improvement of vision and reduction of CMT when compared with data before injection, leading to complete resolution of subretinal fluid.


  Conclusion Top


This study concluded the following:
  1. Intravitreal injection of ranibizumab for treatment of CCSR was more clinically effective and generally well tolerated.
  2. Resolution of macular edema with restoration of the structural anatomy and improvement of vision after intravitreal ranibizumab injection suggests that VEGF plays an important role in fluid leakage in patients with CCSR.


Acknowledgements

Emad A.A. Saliem gratefully thanks his dear colleagues for providing advice and suggestions during this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wang M, Munch IC, Hasler PW. Central serous chorioretinopathy. Acta Ophthalmol 2008; 86:126–145.  Back to cited text no. 1
    
2.
Quillen DA, Gass JDM, Brod RD, Gardner TW, Blankenship GW, Gottlieb JL. Central serous chorioretinopathy in women. Ophthalmology 1996; 103:72–79.  Back to cited text no. 2
    
3.
Ober MD, Yannuzzi LA, Do DV. Photodynamic therapy for focal retinal pigment epithelial leaks secondary to central serous chorioretinopathy. Ophthalmology 2005; 112:2088–2094.  Back to cited text no. 3
    
4.
Jordanova VD. Intravitral avastin in the treatment of central serous retinopathy. Acta Ophthalmol 2015; 41:5–13.  Back to cited text no. 4
    
5.
Brown DM, Campochiaro PA, Singh RP, Li Z, Grav S, Saroi N et al. Ranibizumab for macular edema following central retinal vein occlusion: six-month primary end point results of a phase III study. Ophthalmology 2010; 117:1124–1133.  Back to cited text no. 5
    
6.
Rosenfeld PJ, Brown DM, Heier JS, Boyer DS, Kaiser PK, Chung CY et al. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med 2006; 355:1419–1431.  Back to cited text no. 6
    
7.
Mitchell P, Bandello F, Schmidt-Erfurth U, Lang GE, Massin P, Schlingemann RO et al. The RESTORE study: ranibizumab monotherapy or combined with laser versus laser monotherapy for diabetic macular edema. Ophthalmology 2011; 118:615–625.  Back to cited text no. 7
    
8.
Mahany SA, Shawkat AM, Sayed MF, Mourad KM. Role of avastin in management of central serous chorioretinopathy. Saudi J Ophthalmol 2010; 24:69–75.  Back to cited text no. 8
    
9.
Bujarborua D. Long-term follow-up of idiopathic central serous chorioretinopathy without laser. Acta Ophthalmol Scand 2001; 79:417–421.  Back to cited text no. 9
    
10.
Cardillo PF, Eandi CM, Ventre L, Rigaultde LRC, Grignolo FM. Photodynamic therapy for chronic central serous chorio-retinopathy. Retina 2003; 23:752–763.  Back to cited text no. 10
    
11.
Shams N, Ianchulev T. Role of vascular endothelial growth factor in ocular angiogenesis. Ophthalmol Clin North Am 2006; 19:335–344.  Back to cited text no. 11
    
12.
Kim M, Lee S. Intravitreal ranibizumab for acute central serous chorioretinopathy. Ophthalmologica 2013; 229:152–157.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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