Case 1
A 46 year-old Chinese female patient presented with 5 months of central scotoma in her right eye, without prodromic symptoms. There were no histories of traumatic, systematic illnesses, or the family history of eye disorders. Visual acuity of the suffered eye can be corrected from 8/20 to 10/20. The anterior segment and vitreous were normal. The fundus photo (Topcon TRC50LX; Topcon,Tokyo, Japan) results showed atypical pigmentary alterations and local serous detachment involved the central fovea (figure 1). The optical coherence tomography (OCT, Heidelberg Engineering, Heidelberg, Germany) revealed the persistent sub-retinal fluid (SRF), and FCE (figure 1). This patient had been diagnosed as CSC two months before and given the order for observation, but no visual benefits occurred until this visit. The fluorescent angiograph (FA) displayed typical inkblot leakage of classic CSC. Given the symptom durations that lasted for more than 3 months, half-dose photodynamic therapy (PDT) was chosen to cease the development of the disease. After obtaining written informed consent, half-dose (3 mg/m2) PDT (Opal Photoactivator; Lumenis, Beijing, China) was performed as standard protocol[9], with a spot size for 2500 μm covering the leaking sites juxta-fovea involved the FCE. One month post-treatment, the best-corrected visual acuity (BCVA) was 10/20. The OCT presented the complete resolution of SRF. At three-month, the patient complaint of obvious metamorphosis, but the BCVA result was stable. The fundus photo showed sub-macular hemorrhage and a round hypopigmentary site inferior-nasal to the fovea. The OCT revealed, right in FCE, a lesion of CNV broke through the retinal pigment epithelium (RPE), companied with SRF, hemorrhage and limited retinal edema. The FA confirmed the occurrence of CNV. Promptly, the patient received intravitreal injection of anti- vascular epithelial growth factor (VEGF) - ranibizumab 0.5 mg. One month post-injection, the CNV promptly proceeded to be a scar precisely at the sites of FCE, presented as RPE elevation with hyper-reflective material. Only the area nasal to the scar there laid a little residue FCE. Both the BCVA and metamorphosis did not change. No obvious changes occurred at the 3 months post- injection.
Case 2
A 39 year-old Chinese male patient presented with 6 months of visual loss in both eyes (figure 2, 3). There were no histories of traumatic, systematic illnesses, or the family history of eye disorders. The BCVA was 8/20 (od), and 16/20 (os). The fundus findings were pigment alteration inferior-temporal to the fovea (od) and serous retinal detachment involved the macular (os). The OCT in left eye showed SRF. The mid-phase angiography showed multi-focal leaking spots in FA and correspondingly hyperfluorescence in indocyanine green angiography (ICGA) (figure 2). The OCT in right eye showed subtle SRF with FCE. The mid-phase angiography showed suspicious leaking spot inferior to the fovea in FA and correspondingly hyperfluorescence in ICGA (figure 3). Given the manifestations and durations, bilateral chronic CSC was diagnosed. After obtaining written informed consent, half-dose PDT was operated with spot size of 3500μm (od) and 5400μm (os). The spot in right eye covered the FCE. The SRF in left eye partly resolved at one-month, and completely resolved at three-month. The angiography in left eye presented without active leaking. The BCVA (os) improved to 20/20 at one month, 24/20 at three-month, and remained stable to the six-month. Unexpectedly, the recovery of his right eye did not go well. At one month, the patient complaint of further visual loss in right eye. The fundus examination showed serous retinal detachment and subretinal hemorrhage. The OCT showed CNV emerged, passed through RPE, leading to fluid and hemorrhage accumulated. The CNV blurred the existence of FCE. The BCVA declined to 4/20.The patient received intravitreal injection of 0.5 mg ranibizumab, immediately. One month post-injection, apparent regression of CNV and SRF was witnessed on OCT and fundus photo. The BCVA improved to 6/20. Two months later, the CNV proceeded to be a scar. The BCVA returned to baseline, 8/20. Five months post injection, OCT and angiography confirmed the stabilization of CNV. The BCVA maintained at 8/20.