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Taiwan Journal of Ophthalmology 3 (2013) 12

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Taiwan Journal of Ophthalmology


journal homepage: www.e-tjo.com

Editorial

Treatment of central serous chorioretinopathy: Might medical treatment play


a role?

Central serous chorioretinopathy (CSCR) was rst described by von


Graefe about 100 years ago as relapsing detachment of the macula.
The pathogenesis of CSCR remained unknown for a long time until
recently, when new imaging techniques evolved, shedding some
light on the understanding of this old disease. Abnormalities of
choroidal circulation including stasis, ischemia, or other changes that
lead to serial events, such as increased choriocapillaris permeability,
RPE detachment, mechanical disruption of RPE, and neurosensory
retinal detachment, are now considered by most ophthalmologists to
be the pathophysiologic events underlying CSCR.1,2
The mainstay of treatment for CSCR has been laser therapy for
the past few decades.
Generally speaking, laser therapy may shorten the duration of
CSCR35 but has a doubtful effect on its recurrence rate.6,7 In addition, although rare, some dreadful complications, including accidental foveolar coagulation, retinal distortion, and choroidal
neovascularization, are associated with this therapy. Gass set the
following guidelines for laser treatment in CSCR: (1) allow 4
months for spontaneous resolution if the patient has had no previous history or ophthalmologic evidence of previous detachment;
(2) wait for 6 months or longer before photocoagulation if the
RPE leak is found within less than one-fourth the disc diameter
from the fovea; (3) allow 1 month for spontaneous resolution in patients with a history of several episodes of detachment in the same
eye, if after each episode the patient has regained normal macular
function; and (4) perform prompt laser therapy if the patient has
any evidence of permanent loss of acuity or paracentral scotoma
in either eye secondary to previous episodes of detachment or if
the patients occupation demands good vision. Photodynamic therapy (PDT) is another option for the treatment of CSCR, especially in
patients with chronic CSCR or juxtafoveal leakage. A better success
rate in eradicating subretinal uid and a possibly low mid-term
recurrent rate make PDT more popular. However, decreased amplitude in ERG waves, choroidal hypoperfusion, choroidal

neovascularization, and retinal pigment epithelial atrophy have


been reported as possible complications of PDT.8,9
Because of its unwanted side effects, most doctors would prefer
to observe for several months before implementing traditional laser
or PDT treatment. However, irreversible changes in the outer nuclear layer, shown on optical coherence tomography, lasting for
more than 4 months in patients with CSCR have been reported by
Wang et al.10 Thus, administration of an effective and less invasive
treatment during the observation period may be preferable.
Because of a lack of evidence-based studies, the role of medical
treatment in the management of CSCR is not clear. Administration
of beta-blockers, which are targeted at lowering the sympathetic
tone, and systemic catecholamines has been proved ineffective.11
In one report, acetazolamide 500 mg three times daily for 2 weeks,
which aims to enhance subretinal uid absorption, has been reported to be effective in shortening the duration of serous detachment. However, it has shown no effect on either nal visual
acuity or recurrence rate.12 In addition, the dose is beyond toleration for most patients. Other medical treatment options reported
include certain antifungal and steroid-related agents. In a study
by Caccavale et al,13 aspirin, an antiplatelet and nonsteroidal antiinammatory agent, which aims to treat the choroidal circulation
abnormality and possible hypercoagulability status, has been
shown to improve visual acuity more rapidly and reduce recurrence
rate during a 1-year follow-up. In this issue of the Taiwan Journal of
Ophthalmology, Lee et al report that oral clopidogrel, an antiplatelet
agent that is commonly used in the prevention of atherothrombogenesis, may be effective for the resolution of subretinal uid.
Following treatment with clopidogrel for a mean duration of 8.07
weeks, BCVA improved or stabilized in 85.7% of eyes and complete
resolution of subretinal uid was achieved in 64.3% of eyes. The
rationale for the treatment is that the antiplatelet and antithrombotic effects of clopidogrel may improve the congestion of choroidal
vessels, which is directly related to the pathogenesis of CSC.
Although the results of Lee et als study are inspiring, the small
number of patients enrolled in the study and the lack of a control
group weaken the power of the study. In addition, 35.74% of patients still need to be treated further by laser or PDT. Whether clopidogrel is effective in shortening the duration of CSCR and
improving the nal visual outcome is still not clear. Moreover, the
difference between clopidogrel and aspirin, both of which are antiplatelet drugs, is also of concern. Further well-designed controlled
studies with a large number of patients are necessary to determine
whether medical treatment plays a role in the management of
CSCR. This will not only help us treat CSCR patients, but also
advance our understanding of the pathogenesis of the disease.

2211-5056/$ see front matter Copyright 2013, The Ophthalmologic Society of Taiwan. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.tjo.2013.01.002

Editorial / Taiwan Journal of Ophthalmology 3 (2013) 12

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San-Ni Chen*
Department of Ophthalmology, Chang Hua Christian Hospital,
Changhua City, Taiwan
School of Medicine, Chung Shan Medical University,
Taichung City, Taiwan
* Department of Ophthalmology, Chang Hua Christian Hospital,
Changhua City, Taiwan.
E-mail address: tjo@oph.org.tw
Available online 1 March 2013