La tunisie Medicale - 2019 ; Vol 97 ( n°01 ) : 157 - 162
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Résumé

Introduction : La néo-vascularisation choroïdienne est une complication rare après photocoagulation pour une choriorétinopathie séreuse. Son management est sujet de discussion et aucun consensus n’est encore établi. La thérapie des anti VEGF a émergé comme le traitement de choix. Nous rapportons le cas d’une patiente qui a développé des néo-vaisseaux choroïdiens iatrogène suite une photocoagulation rétinienne par laser argon pour une choriorétinopathie séreuse centrale. La patiente a été traitée par des injections intra-vitréennes de Bivacizumab. Le but de notre papier est de montrer l’efficacité et la sécurité des injections des anti VEGF et de discuter les alternatives thérapeutiques au laser argon pour le traitement de la choriorétinopathie séreuse.
Observation : Nous rapportons le cas d’une femme enceinte, âgée de 35 ans, diagnostiqué en aout 2014 avec une choriorétinopatie séreuse aigue de l’œil droit. La patiente a été traitée par photocoagualation focale au laser argon pour les points de fuite. En décembre 2015, la patiente se plaint de métamorphosie du même œil. L’acuité visuelle a été à conservée à 10/10. Le fond d’œil a montré une membrane néo-vasculaire, correspondant à la zone de photocoagulation antérieure. L’OCT ainsi que l’OCT-A ont démontré la membrane néo-vasculaire. La patiente a reçu 3injections intra vitréenne de Bivacizumab et a été suivi régulièrement. Elle est asymptomatique au bout de 3 ans de traitement.
Conclusion : La néo vascularisation choroïdienne est une complication iatrogène rare à la photocoagulation au laser Argon. Les injections intra vitréennes des anti VEGF semble être un traitement promoteur pour une telle complication.

Mots Clés
Article

INTRODUCTION:
Central serous chorioretinopathy (CSCR) is a chorioretinal disorder (1) that affects typically men between 20 and 50 years old; but it was reported in women, particularly in pregnancy (2,3)
 Generally, CSCR is characterized by a good prognosis with spontaneous recovery on few weeks, in approximately 90% of patients (2,4).However, it can leads to an irreversible vision loss, due to progressive and permanent photoreceptor damage or retinal pigment epithelium (RPE) atrophy, especially in chronic CSCR (1,2). There is no standard for the treatment of a persistent focal leakage: many tools can be used; laser photocoagulation is often successful in achieving retinal reattachment (1,2,3,5,6). However, choroidal neovascularization (CNV) is a rare but a well recognized complication of laser photocoagulation for CSCR. We report the clinical course of a patient with CSCR who developed an iatrogenic CNV after argon photocoagulation of the leakage point.
CASE REPORT:
A 35-year-old pregnant woman with an acute CSCR (figure 1) of the right eye diagnosed on August 2014 and treated with argon laser of the leakage point.).In December 2015(18 months later), the patient was referred to us, she was complaining of metamorphopsia in the right eye. The best corrected visual acuity (BCVA) in the right eye was 10/10. The fundus examination and the auto-fluo photography of the right eye showed grayish-white neovascular membrane, which corresponded to the area of the previous photocoagulation (figure 2), with a subretinal hemorrhage (figure 2).  Multimodal imaging (fluorescein angiography (FA), spectral domain OCT (OCT SD), OCT angiography (OCT A)) confirm the presence of neovascular membrane (fig 2).The patient received an intravitreal injection (IVI) of 1.25 mg Bevacizumab in the right eye (figure 3). We decided to consolidate the positive outcome with 2 others IVI of Bevacizumab at monthly interval and monitoring with PRN monitoring. The patient is monitored since three years with stable acuity, fundus examination, SD OCT and OCT A .No more injection was required during three years.
DISCUSSION:
The CNV is a rare complication of the laser photocoagulation in CSCR. It has been reported that 1-5% of patients developed CNV after laser photocoagulation for CSCR (7,8).
The pathogenesis still discussed. The literature review concluded that the photocoagulation induces a focal rupture of the bruch’s membrane and the development of the CNV consequently (3,2,5).But the chronic decompensation of the RPE is not removed as responsible of the CNV and the development of choroidal neovascularization can also occur without photocoagulation (3,2,5).
 In our case, the neovasularization was related to the photocoagulation: considering the temporal sequence of the events and the fact that the areas of CNV in the current case corresponded to the spots of photocoagulation.
In the other hand, this neovascularization was diagnosed 18 months after photocoagulation; in the literature, the mean period of the development of CNV was from 1 to 24 months (3). This interval can be related to a late diagnosis or a juxta-foveal CNV with slow progression and without remarkable loss of vision.
The management of CSCR complicated by CNV can evolve from a simple observation without any intervention to submacular surgery, PDT and anti-VEGF injections (3,5,6).
The anti VEGF therapy is considered as a revolution in the treatment of the CNV, whatever the pathology (3,9). The injection’s protocol is not yet defined. Many regimens are proposed; from one injection and PRN to 3 successive injections and PRN . The choice of the molecule is still controversial and whatever bevacizumab or ranibizumab seems to have the same efficacy in this indication (3,10).
Recently, the micropulse diode laser was suggested as a better alternative to argon laser in patients with CSCR :choroidal neovascularization have thus far not been described with the micropulse laser(6).
Little is known about the natural course of iatrogenic choroidal neovascularization secondary to photocoagulation for CSCR. Anti VEGF therapy seems to be a promising treatment option but further verifications are needed.
CONCLUSION:
When CSCR is not spontaneously resolved in 3 to 4months a treatment should be considered. The argon laser photocoagulation is a promoted treatment for leaking point. However, this treatment can cause collateral damage such as iatrogenic CNV which can be a major cause of definitive loss of vision. The anti VEGF appears to be a promising treatment option for CNV due to photocoagulation.Larger studies are required to confirm that efficacy and to compare the different anti VEGF agents in the management of the laser induced CNV.

Legend:


Figure 1: Fundus photograph, red free fundus photograph, Fluorescein angiography and optical coherence tomography  (OCT) showing the serous retinal detachment and leakage point.


Figure 2 : Fundus photograph, red free fundus photograph, Fluorescein angiography ,optical coherence tomography  (OCT) and angio OCT  demonstrating the subfoveal choroidal neovascular membrane, corresponded to the area of the previous photocoagulation.


Figure 3: One month after the first injection of Bevacizumab: fundus examination: disappearance of the hemorragy near to the neovascular membrane.  OCT SD: disappearance of the serous retinal detachement and fibrosis’s formation.

Références
  1. Wang M , Munch IC , Hasler PW , Prünte C , Larsen M . Central serous chorioretinopathy. Acta ophtalmol.2008; 86:126-45.
  2. Salehi M, Wenik AS, Law HA, Evans JR, Gehlbach P. Interventions for central serous chorioretinopathy:a network meta-analysis. Cochrane Data base Review. 2015.
  3. Roy R, Saurabh K, Das D, Panigrahi PK, Das S, Pal SS and al. Variation in Visual Outcome to Anti-Vascular Endothelial Growth Factors in Choroidal Neovascular Membrane Developing in Eyes with Previously Untreated Versus Focal Laser-Treated Central Serous Chorioretinopathy.. Semin Ophthalmol. 2017;32:781-786.
  4. Maruko I, Iida T, Sugano Y, Ojima A, OgasawaraM, Spaide RF. Subfoveal choroidal thickness after treatment of central serous chorioretinopathy. Ophthalmology. 2010;117:1792–9.
  5. Cooper BA, Thoams MA. Submacular surgery to remove choroidal neovascularization associated with central serouschorioretinopathy. Am J Ophtlamol. 2000;130:187-91.
  6. Scholz P, Ersoy L, Boon CJ, Fauser S. Subthreshold Micropulse Laser (577 nm) Treatment in Chronic Central Serous Chorioretinopathy. Ophthalmologica.2015;234:189-94.
  7. Nomur Y, Obata R, Yanagi Y. intravitral bivacizumab for iatrogenic choroidal neovasculazation due to laser photocoagulation in central serous chorioretinopathy. JPN J Ophtalmol. 2012;56: 245-9
  8. Matsunaga H, Nangoh K, Uyama M. Occurrence of choroidal neovascularization following photocoagulation treatment for central serous retinopathy. Nihon Ganka Gakkai Zasshi. 1995;99:460–468.
  9. Lim SJ, Roh MI, Kwon OW. Intravitreal bevacizumab injection for central serous chorioretinopathy. Retina. 2010;1:100–06.
  10. Chhabalni J, Pichi F, Silva R, Casella AM, Murthy H, Banker A and all. antiangiogenic in choroidal neovascularization associated with laser in central serous chorioretinopathy. Retina. 2016;36:901-8.
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