https://imcjms.com/public Ibrahim Medical College Journal of Medical Science https://imcjms.com/public/registration/journal_full_text/74 Tue, 02 Aug 2016 12:14:18 +0000 Central serous chorioretinopathy (CSCR) is common in adult male having sudden dimness of vision in one eye and typical pattern of leakage in fundus fluorescein angiography. Treatment of typical central serous chorioretinopathy is conservative and / or focal laser photocoagulation. But atypical central serous chorioretinopathy is uncommon having different patterns of clinical presentation and features in fundous fluorescein angiography. Treatment option of atypical central serous chorioretinopathy is not yet established. Here, we present a case of atypical central serous chorioretinopathy successfully treated with intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF, Bivacizumab). Ibrahim Med. Coll. J. 2015; 9(1): 34-36     Central serous chorioretinopathy is a common vision lowering disease after age related macular degeneration, diabetic retinopathy and vascular occlusive disease.1 First described by Vongraefe in 18662 and later OLMSTED study in Minnesota, USA reported that 9.9 per 10000 men and 1.7 per 10000 women were affected by this disease.3 Mean age of onset is 41-45 years in case of acute CSCR and for chronic CSCR it is 51yrs.In older population (age>51 years), CSCR is more likely to have bilateral involvement.4 Risk factors are type A personality,5 Cushing syndrome,6 pregnancy,7 systemic steroid use8 and collagen vascular diseases.9 Psychosomatic factor is also related with CSCR. In stress, the increased levels of stress hormones and glaucocorticoids have direct relationship with macular thickness.10 Here, we present a case of atypical central serous chorioretinopathy in a 41 years old male. Case presentation Patient underwent fundus fluorescent angiography which showed multifocal hyper fluorescence diffusely present in the macula and perimacular region extending to the temporal retina in both eyes. The hyper fluorescent increased with time (Fig-1). Optical Coherent Tomography (OCT) of both maculae showed huge sensory retinal detachment with accumulation of fluid involving the entire macular region (Fig-2). Blood biochemistry showed no abnormalities. Based on the multiple leakage in macula and perimacular region, elevation of entire macular region with entire sensory detachment and simultaneous bilateral involvement of both eye, the patient was diagnosed as a case of acute bilateral atypical CSCR and advised intraviteral injection of 1.25 mg anti-vascular endothelial growth factor (Bivacizumab). A total of three doses of Bivacizumab were given over three months period with non-steroidal anti-inflammatory (NSAID) eye drops twice daily in both eyes. One injection was given each month in each eye. Vision improved gradually after each injection of Bivacizumab. One month after the 3rd injection the vision improved to 6/12 in right eye and 6/9 in left eye. OCT after the third injection showed normal macular contour (Fig-3). The patient had 6/6 vision in both eye and normal retinal integrity both clinically and by OCT one year after the last injection.   Fig.2: Optical Cohherent Tomography (OCT) of Maculae shows areas of sensory retinal at maculae of both eyes.   Fig.3: OCT of both eyes after treatment with injection of bivaczumab show normal macular contour Discussion In our case, the clinical presentation was sudden, bilateral with profuse deterioration of vision within a very short period of time. This is unusual because the usual presentation of typical CSCR is unilateral with moderate deterioration of vision with a central scotoma.1 In our case, diminution of vision was profound, which was reduced to counting finger close to the eyes. The findings of multifocal leakage and diffuse appearance in FFA were also contrary to single smoke steak appearance seen in typical CSCR. In this aspect the presentation of our case was atypical. Several treatment options have been described for acute CSCR with variable success. The treatment of CSCR includes focal argon laser,13 photodynamic therapy with verteporfin,14 micropulse diod laser15 and Anti-VEGF injection in the intravitreal space.16 In our case the leakages in the FFA are multifocal and did not have typical smoke stack appearance. Focal laser photocoagulation could not be done. So intravitreal Bivacizumab was administered. The visual improvement after multiple intravitreal injection of Bivacizumab supported the earlier reports of its success in the treatment of acute CSCR. Acute atypical CSCR with multifocal leakage in the FFA and huge sensory retinal detachment, involving the whole macula responds well with intravitreal injection of Bivacizubab in repeated doses. Acute bilateral extensive CSCR with multifocal leakage and grossly reduced vision can be treated successfully with intravitreal injection of anti-VEGF instead of laser. References 2.    Yannuzzi LA. Type A behavior and central serous chorioretinopathy. Retina 1987; 7: 111-31. 4.    Spaide RF, Campeas L, Haas A et al. Central serous chorioretinopathy in younger and older adults. Ophthalmology 1996; 103: 2070-9. 6.    Bauzas EA, Scott MH, Mastorako SG, Chrousos GP, Kaiser Kupfer MI. Central serous corioretinopathy in endogenous hypercortisolism. Arch Opthalmol 1993; 111: 1229-33. 8.    Haimovici R, Koh S, Gagnon DR, Lehrfeld T, Wellik S. Risk factor for central serous Chorioretinopathy: a case control study. Opthalmology 2004; 111: 244-9. 10.  Garg SP, Dada T, Talwar D, Biswas NR. Endogenous cortisol profile in patients with central serous chorioretinopathy. Br J Ophthalmol 1997; 81: 962-4. 12.  Yannuzzi LA, Shakin JL, Fisher YL, Altomonte MA. Peripheral retinal detachment and retinal pigment epithelium atrophic tracts secondary to central serous pigment epitheliopathy. Ophthalmology 1984; 91: 1554-72. 14.  Taban M, Boyer SD, Thomas EL, Taban M, Chronic central serous chorioretinopalty: Photodynamic therapy. Am J Ophthalmol 2004; 137: 1073-80. 16.  Lim JW, Ryu SJ, Shin MC. The effect of intravitreal bivacizumab in patients with acute central serous chorioretinopathy. Korean J Ophthalmol 2010; 24: 155-8. 18.  Aydin E. The efficacy of intravitreal bivacizumab for acute central serous Chorioretinopathy. Journal of Ocular Pharmacology and Therapeutites 2013; 29(01): 10-13. 2026 Ibrahim Medical College. All rights reserved.