Central serous chorioretinopathy: a pathogenetic model.

Despite numerous studies describing predominantly its demography and clinical course, many aspects of central serous chorioretinopathy (CSCR) remain unclear. Perhaps the major impediment to finding an effective therapy is the difficulty of performing studies with large enough cohorts, which has meant that clinicians have focused more on therapy than on a deeper understanding of the pathogenesis of the disease. Hypotheses on the pathogenesis of CSCR have ranged from a basic alteration in the choroid to an involvement of the retinal pigment epithelium (RPE). Starting from evidence that affected subjects often present a personality prone to stress with altered pituitary-hypothalamic axis response (HPA) and that they have higher levels of serum and urinary cortisol and catecholamines than healthy subjects, we hypothesize a cascade of events that may lead to CSCR through hypercoagulability and augmented platelet aggregation. In particular we investigated the role of tissue plasminogen activator, increasing plasminogen activator inhibitor 1 (PAI-1), and plasmin-α2- plasmin inhibitor complexes. We reviewed the different therapeutic approaches, including adrenergic antagonists, carbonic anhydrase inhibitors, mifepristone, ketoconazole, laser photocoagulation, intravitreal injection of bevacizumab, and photodynamic therapy with verteporfin (PDT) and our model of pathogenesis seems to be in agreement with the clinical effects obtained from these treatments. In accord with our thesis, we began to treat a group of patients affected by CSCR with low-dose aspirin (75-100 mg), because of its effectiveness in other vascular diseases and its low ocular and general toxicity with prolonged use. The formulation of a causative model of CSCR enables us to understand how the therapeutic approach cannot be based on a generalized therapy but should be individualized for each patient, and that sometimes a combined strategy of treatment is required. Moreover a complete knowledge of the disease will help to identify patients prone to the most persistent forms of CSCR, and thus help to find a treatment.

Low-dose aspirin as treatment for central serous chorioretinopathy.

PURPOSE: To evaluate the effectiveness of low-dose aspirin for the treatment of central serous chorioretinopathy (CSCR). PATIENTS AND METHODS: Patients with classical or multifocal CSCR were treated with aspirin 100 mg per day orally for 1 month followed by 100 mg on alternate days for 5 months. Treated patients were compared with historic controls consisting of patients with classical or multifocal CSCR previously followed up at our institution. RESULTS: Mean visual acuity in the group treated with aspirin started to improve after the first week of therapy and continued to improve throughout the following 3 months. Visual recovery was slower in the untreated control group than in the treated group and achieved better visual acuity between the first and third month from the onset of the disease. There were no adverse events related to the administration of aspirin. CONCLUSION: The results indicate that treatment with low-dose aspirin may result in more rapid visual rehabilitation with fewer recurrences in patient with CSCR compared with untreated historic controls. The effectiveness of treatment with aspirin supports our hypothesis regarding the role of impaired fibrinolysis and increased platelet aggregation in the choriocapillaris in the pathogenesis of CSCR.

Ropivacaine for topical anesthesia in pterygium surgery with fibrin glue for conjunctival autograft.

PURPOSE: To evaluate efficacy of ropivacaine 1% for topical anesthesia in pterygium surgery with conjunctival autograft using fibrin glue for attaching the graft to the bare sclera. METHODS: Thirty-seven patients affected by primary pterygium underwent surgical excision under topical anesthesia with ropivacaine 1%. We performed a surgical approach with dissection of the pterygium, scraping of corneal bed with a motorized burr, meticulous excision of underlying Tenon's capsule, preparation of a free autologous conjunctival graft in the superior sector, excision of the graft, and position of the same to cover the scleral bed exposed in the nasal area with respect to limbus and stromal orientation fixing the graft with fibrin glue. RESULTS: It was possible to perform all the procedures without any supplemental anesthesia and sedation. The pain reported by patients, recorded by a 0 to 10 scale, was low during the entire surgery. The technique with conjunctival autograft using a fibrin sealant allowed for short operative times and good aesthetic and functional results. CONCLUSIONS: Topical anesthesia with ropivacaine is safe and effective in pterygium surgery. The Long-lasting anesthesia with this agent permitted performing our surgical procedures with autograft conjunctival graft and fibrin glue to attach the flap with low pain perceived by our patients, low surgical invasivity, and short duration of surgery.

A new strategy of treatment with low-dosage acetyl salicylic acid in patients affected by central serous chorioretinopathy.

Central serous chorioretinopathy (CSCR) is an ocular disease characterized by serous detachment of the neurosensory retina at the posterior pole, with or without an associated retinal pigment epithelium (RPE) detachment. It is associated with different systemic diseases although the pathogenesis is unknown. Different therapies have been applied to treat CSCR with poor results. We reviewed the literature and found that in all the diseases associated with CSCR plasminogen activator inhibitor 1 (PAI-1) was increased. Acetyl salicylic acid (Aspirin) is effective in lowering PAI-1 levels and platelets aggregation; as such we decided to treat patients affected by CSCR with low dose Aspirin. From January 2005 to December 2008 we enrolled 107 patients, 85 male and 22 female, affected with active CSCR or the multifocal variant. Aspirin was administrated at an oral dose of 100 mg. per day for a month and then 100 mg. every other day for five months. After the first week of therapy and for the following three months the visual acuity improved and remained stable to the end of the follow-up (median follow-up 20 months). A recurrence of the disease interested the 6% of the patients. In this study low-dose Aspirin was able to treat central serous chorioretinopathy with a quick recovery of the visual acuity and a reduced number of recurrences during the follow-up. Besides the effectiveness of the treatment with Aspirin supports our observation regarding the role of impaired fibrinolysis and increased platelets aggregation in the choriocapillaris as genesis of CSCR.

Intravitreal bevacizumab for treatment of peripapillary subretinal neovascularization.

PURPOSE: To describe the effects of intravitreal bevacizumab treatment for peripapillary subretinal neovascularization. METHOD: A patient with an idiopathic peripapillary subretinal neovascular membrane in the papillomacular bundle, which led to subretinal hard exudate deposits in the fovea and decreased visual acuity, was treated with a single intravitreal injection of 0.04 mL (1 mg) of bevacizumab. Main outcomes consisted of visual acuity, fluorescein (FA) and indocyanine green (ICG) angiography, and optical coherence tomography (OCT). RESULTS: One week after the treatment the patient had less blurred vision and metamorphopsia but visual acuity was unchanged. At the 1 month visit the visual acuity improved and reduced leakage of the membrane was shown by FA and ICG. OCT demonstrated a reduction of the macular edema. At 14 months follow-up visit the membrane was not detectable with FA and ICG and only isolated remnants of the exudates were still present. OCT showed resolution of the macular edema and a residual hard exudate localized nasally to the fovea. CONCLUSIONS: Treatment of peripapillary subretinal neovascular membrane with a single intravitreal injection of bevacizumab was effective and well-tolerated without recurrence of the neovascularization after a 14-month period. Visual acuity improved and retinal edema and exudation disappeared. The authors did not observe ocular or systemic side effects. In this view intravitreal injection of bevacizumab should be evaluated as a potentially effective therapy for peripapillary subretinal neovascularization, in particular for its extension in the papillomacular bundle.