Central serous retinopathy (CSR) is an idiopathic disease that typically affects people from 20 to 50 years old. The disease predominantly affects men and is more common in whites. It is a well-established disorder, leading to serous retinal detachment and elevation of the central macula. The acute form of the disease is associated with focal leakage at the level of the retinal pigment epithelium.

The disease is generally self-limited. Most patients have spontaneous resolution within 2 months, and visual acuity usually resolves to 20/30 or better without treatment. A few patients may develop chronic or progressive disease, resulting in vision loss. For these patients, focal laser photocoagulation, photodynamic therapy, and micropulse laser are treatment options. In my experience, micropulse laser with the IQ 577 is a safe and effective procedure to treat CSR, as the following cases illustrate.

CASE 1
A 36-year-old man had a history of reduced visual acuity in the right eye (20/80) for about 8 months. The fundus examination showed a foveal detachment on the right eye. In the early and late phases, the angiogram (Figure 1, top) shows a small leakage close to the center of the fovea. Spectral domain optical coherence tomography (OCT) shows the retinal detachment involving the fovea (Figure 1, bottom).

We treated this patient with the following MicroPulse settings on the Iridex IQ 577 laser: 200 µm spot, 120 mW, 15% duty cycle for micropulse (0.3 milliseconds on and 1.7 milliseconds off), 215 shots at 300 milliseconds per shot (delivering 150 micropulses with each shot).

After 14 days, the patient's visual acuity had improved to 20/20 partial. The post-treatment angiogram (Figure 2) shows no laser burns and no leakage.

CASE 2
A 47-year-old man had a history of reduced visual acuity (20/80) in the left eye for 18 months. On autofluorescence and infrared (Figure 3), we see alterations of the retina and hypo- and hyperautofluorescent spots in the center of the macula where the detachment was located. On the angiogram and the ICG (Figure 4), we see leakage close to the center of the fovea. The OCT (Figure 5) shows a detachment of the retina in the center of the macula.

This patient was treated with bevacizumab (Avastin, Genentech, Inc.). When he returned 30 days later, his visual acuity had not changed, and OCT showed no change. We treated him with the IQ 577 laser in its MicroPulse treatment mode. We delivered 471 shots in the center of the macula using a 300 msec pulse duration, 200 mW, 200 µm spot size, and 15% duty cycle. Nine days later, the patient's vision had improved to 20/60. There were small changes in the infrared but no changes in the autofluorescence after treatment (Figure 6) and almost complete resolution of the retinal detachment.

The patient returned 7 days later, and his visual acuity was 20/70. I saw a recurrence, a bigger detachment than before. I re-treated with 566 shots on the detached area of the retina, using a 300 msec pulse duration, 160 mW, 200 µm spot size, and 15% duty cycle.

Fifteen days later, the patient's visual acuity had improved to 20/25 and, as shown on the OCT, the retina was almost flat (Figure 7). The angiogram shows no changes in the RPE, autofluorescence, or infrared due to laser treatment. This patient was treated twice with this technique with no changes in fluorescence, autofluorescence, or infrared, and his visual acuity improved after an 18- month history. In my opinion, this is an incredible case.

SUMMARY
I believe 577 nm micropulse is a very effective laser treatment for chronic CSR. It may cause less or no damage to the retina. We need new studies, so that long-term results can be analyzed. Our goal should be to have absolutely no scars on the retina with this treatment. Most patients respond very well within 30 days of treatment.

André Maia, MD, PhD, practices in São Paulo, Brazil. He completed his residency and PhD at the University Federal of São Paulo, and he completed his clinical fellowship at McGill University in Montreal, Canada.