Case 1
A 40-year-old male presented with history of poor vision
in the RE for the past two months with no complaints in
the left eye (LE) and no other significant systemic illness.
On examination, his visual acuity was perception of light
only in the right eye (RE) and 20/50 in the LE. Anterior
segment examination was unremarkable in both eyes.
Fundus examination revealed bullous retinal detachment
in the RE and numerous retinal pigment epithelial
detachments (PEDs) at the macula with inferior retinal
detachment in the LE. Ultrasonography and fundus
fluorescein angiography (FFA) confirmed the clinical
findings, and a diagnosis of exudative retinal detachment
secondary to CSCR in the both eyes was made.
Given the nature of the disease, the patient was asked
to follow-up monthly. At 5-month follow-up, there was
no change in exudative retinal detachment in both eyes.
Therefore, he underwent conventional external SRF
drainage in the RE with a 26G needle. As the BCVA in LE
was 20/40, observation was preferred over any intervention.
At 1-month follow-up, BCVA was counting fingers close to
face (20/4,000) in the RE and LE was stable. At 9-month
follow-up, BCVA was counting fingers at 2 feet (20/2,000)
in the RE with no recurrence of retinal detachment. At
15-month follow-up, BCVA was stable, counting fingers at
2 feet (20/2,000) in the RE and 20/25 P in the LE. Fundus
examination of both eyes showed no SRF, however, RPE
atrophy was present at the macula.
Case 2
A 46-year-old male presented with decrease in vision in
the RE since two months. He had a 2-3 years history of
hypertension and diabetes. On examination, his BCVA
was 20/60 P in the RE and 20/25 in the LE. Fundus exam
showed exudative retinal detachment with subretinal
ff brosis in the RE and pigment epithelial detachment in the
LE. Clinical findings were confirmed on FFA and optical
coherence tomography (OCT), and diagnosis of exudative
retinal detachment secondary to chronic CSCR was made
and patient underwent external SRF drainage using 26G
needle and intravitreal avastin injection (1.25 mg in 0.05 mL)
in the RE. Post-operatively his BCVA was 20/100.
At 3-week follow-up, his BCVA was counting fingers at 2
feet (20/2,000) in the RE with sub-total retinal detachment.
Now, patient could be treated with focal laser in both eyes
as the macula was attached. At 3-month follow-up, BCVA
was 20/200 in the RE with no SRF. LE was stable with
BCVA of 20/20. At 14-month follow-up, both eyes were
stable without any recurrence of SRF during follow-up.
Case 3
A 32-year-old male presented with defective vision in the
RE for 3 months and in the LE for 3-4 days. He reported
that he was on tapering oral steroids. which were stared
elsewhere considering the inflammatory ocular pathology.
On examination, BCVA was counting fingers close to face
(20/4,000) in the RE and 20/50 in the LE. Fundus exam
showed subtotal exudative detached retina in the RE and
inferior retinal detachment in the LE. The clinical findings
were confirmed on ultrasonography and FFA. In view of
active leak, the patient underwent focal laser in the LE.
Conventional external SRF drainage using 26G needle was
performed in the RE.
At 6-week follow-up, BCVA improved to 20/1,200 in
the RE and 20/40 in the LE with no SRF on fundus exam.
At 2-year follow-up, BCVA was 20/40 in the RE and 20/20
in the LE with normal intraocular pressures. No SRF was
noted on fundus exam. At six and half year follow-up, BCVA
was 20/120 in the RE and 20/20 in the LE. Fundus exam of
both eyes showed attached retina with RPE atrophy at the
macula with no evidence of SRF on OCT.
Case 4
A 51-year-old male with known history of CSCR in the LE,
satisfactorily treated with laser 20 years ago, presented with
decrease of vision in the LE since 20 days. Before presenting
to our hospital, elsewhere, he was diagnosed to have
choroiditis in the RE and was started on oral steroid for the
last 3 weeks. On examination, BCVA was 20/40 in the RE
and 20/25 in the LE. Anterior chamber was unremarkable.
Fundus exam showed SRF, inferior retinal detachment,
and RPE atrophy in the RE and SRF with exudative retinal
detachment in the LE. The clinical findings were confirmed
with FFA and OCT and diagnosis of CSCR in both eyes was
made. The patient was recommended to stop oral steroid
and follow-up after a month. At follow-up, the exam was
unchanged and patient underwent focal laser in both eyes.
Three weeks post-laser, his BCVA dropped further to
counting fingers close to face (20/4,000) in the LE. Fundus
exam revealed exudative retinal detachment involving the
macula in the LE. Patient was advised external drainage which was performed using conventional technique as
described by Charles et al. (8) However, in initial attempts
it was dry tap and indirect ophthalmoscopy showed
shifting of fluid posteriorly with no SRF in the periphery.
Therefore, decision of external drainage using Chandelier
illuminator using a 26G needle under direct visualization
was performed in the LE. The procedure was successful
and achieved complete retinal attachment at the end of
the surgery. At 2-week follow-up, his BCVA improved
to 20/200 with no signs of SRF on fundus exam. Patient
underwent half-dose PDT in both eyes. At 1-month
follow-up his BCVA in LE was 20/200 and that in RE was
20/40 with no SRF in both eyes.
Case 5
A 40-year-old male presented with complaints of decreased
vision in LE>RE since 1 month. Before presenting to our
hospital, elsewhere, he was diagnosed to have choroiditis
in the RE and was started on oral steroid for the last one
month. On examination, BCVA was 20/400 in the RE and
20/1,200 in the LE. Fundus exam revealed exudative retinal
detachment in both eyes, which was confi rmed with clinical
and angiographic evaluation. He was diagnosed to have
bullous CSCR secondary to steroid exposure in both eyes.
Oral steroids were withdrawn promptly and treated with
multiple sittings of laser in both eyes.
He was on regular follow-up. At 1-year follow-up, his
BCVA was 20/200 in each eye. RE resolved well with
extensive pigment migration at the macula with BCVA of
20/400. However, there was persistent exudative retinal
detachment involving macula in the LE. It was challenging
to localize all the leaks in the LE, so he under went
conventional external SRF drainage, followed by laser
to leaking areas at 1 week post-op. Exudative retinal
detachment resolved and had no recurrences till the last
follow-up. His last BCVA in the LE was 20/160 at 6 years
of follow-up.
Case 6
A 61-year-old man presented with a complaint of “black
spot appearance” in the RE for the last 2 months. He was
a known hypertensive and diabetic on treatment since past
10 years. On examination, his BCVA was 20/100 in the RE
and 20/80 in the LE. Anterior segment was unremarkable
in both eyes. Fundus examination of the RE showed bullous
retinal detachment, pigmentary changes and LE showed retinal pigment epithelium (RPE) atrophy with pigmentary
changes. A diagnosis of exudative retinal detachment
secondary to chronic CSCR in the RE and macular scar
in the LE was made. The clinical findings were confirmed
with fluorescein angiography (FFA). Laser application to
leaks was not possible due to bullous retinal detachment.
He was advised to follow-up after 6 weeks.
At 6-week follow-up, patient’s BCVA deteriorated
to counting fingers close to face (20/4,000) in the RE.
Fundus examination of the RE showed pigmentary
changes, RPE atrophy and persistent bullous retinal
detachment. The patient underwent Chandelier-assisted
external SRF drainage using 26G needle for aspiration
of SRF under direc t visualization. The retina was
successfully attached at the end of the surgery. His BCVA
improved to 20/600 at 1-week follow-up with no SRF.
Patient was lost to follow-up.
Discussion
A variant of CSCR presenting as exudative bullous
retinal detachment leads to permanent vision loss, more
commonly in healthy males (1). This is commonly
misdiagnosed as inflammatory pathology and gets
aggravated by steroid supplementation. In our series, three
of six eyes were misdiagnosed and were treated with oral
steroid, which worsened the retinal detachment. Bullous
exudative detachment involving the macula prevents laser
photocoagulation; therefore, it becomes mandatory to
perform an external drainage of persistent fluid, to be able
to perform laser photocoagulation post-operatively.
In our series, we performed external drainage in six eyes
out of 12 eyes with exudative retinal detachment secondary
to CSCR. Out of these six eyes, in three eyes, laser was
performed as initial treatment, however, the fl uid was nonresolving,
and therefore, the external drainage followed
by laser was performed. In case 5, we performed external
drainage followed by PDT in both eyes due to persistent
activity. None of the subjects had recurrence till their last
follow-up.
Various methods of external drainage of SRF have been
reported including conventional scleral cut down, needle
aspiration, external argon endolaser probe, and suture
needle (8-11). External drainage can also be associated
with complications such as retinal incarceration, subretinal
haemorrhage, and loss of vitreous. Direct visualization using
indirect ophthalmoscopy or Chandelier illumination helps
the surgeon to identify imminent complications before the damage occurs and manage them before they endanger the
anatomic or visual outcomes.
Chen et al. reported external drainage of SRF using
perfluorocarbon liquid after pars plana vitrectomy when
the external drainage failed due to posterior shifting of
SRF (5). We also faced the similar situation in case 4,
therefore, we performed a needle drainage under direct
visualization using Chandelier illuminator.
Kang et al. introduced an instrument, subretinal
aspiration and injection device (SA-AID), designed to
facilitate controlled external drainage of SRF (7). This
device provides a safe approach to the sub retinal space
because it penetrates the eye wall obliquely and allows a
changeable, predetermined length of the needle tip. The
surgeon can also directly observe the retina with an indirect
ophthalmoscope during the drainage.
Limitations of our study include small sample size
and retrospective nature. One patient had a follow-up
of only 1 week, however, rest patients had a long followup.
A group of internal drainage would have provided
comparative results. However, fewer complications after
external drainage compared to internal drainage, makes this
procedure as preferred choice for such situation.
In conclusion, our study demonstrates that the exudative
retinal detachment secondary to CSCR can be successfully
managed with external drainage. External drainage avoids
any complication related to intraocular procedure. Longterm
results are promising with no recurrence and sustained
visual recovery. Early drainage may prevent damage to
retinal structures and helps to improve visual acuity.
