Short-pulse laser plus subthreshold diffuse laser for serous retinal detachment in dome-shaped macula

Abstract

Background: First described by Gaucher and associates in 2008, dome-shaped macula (DSM) is an anterior convex protrusion of the macula visible on OCT (optical coherence tomography). Visual impairment in DSM results mainly from sub-foveal serous retinal detachment (SRD). Herein, this original study from retrospective data analysis evaluate the anatomical and functional effects of Pascal^® short-pulse (SP) laser plus endpoint management (EpM) subthreshold diffuse laser (SDL) in patients with SRD due to DSM.

Methods: This retrospective study included seven consecutive patients (eight eyes) with SRD secondary to dome-shaped macula who underwent a comprehensive ophthalmological evaluation including logMAR BCVA, slit-lamp biomicroscopy, indirect ophthalmoscopy, and spectral-domain optical coherence tomography (SD-OCT) (Spectralis; Heidelberg Engineering, Germany) before combined Pascal^® SP laser plus EpM-SDL with 1 to 6 month intervals, postoperatively, with a mean ± standard error (SE) follow-up time of 12.92 ± 1.34 months.

Results: Eight eyes from seven patients were analyzed in this study. At baseline, mean BCVA (LogMAR) ± standard error (SE) and mean CST (central subfield thickness)(µm) ± SE were 0.6125 ± 0.14 and 412.50 ± 24.65, respectively. After a mean follow-up time of 12.92 ± 1.34 months, mean CST (µm) ± SE and BCVA (LogMAR) ± SE were 294.75 ± 19.68 (p = 0.0078) and 0.4537 ± 0.12 (p = 0.0313), respectively. A statistically significant reduction in mean CST and an improvement in mean BCVA were noted after SRD resolution with laser therapy application. The mean serous retinal detachment resolution time (months) ± SE was 3.75 ± 1.08. No adverse events were registered, including enlargement of atrophic alterations and choroidal neovascularization.

Conclusions: The novel combined laser modality with Pascal^® SP laser plus EpM-SDL treatment may induce subretinal fluid regression and BCVA improvement 1 year after treatment in DSM patients with SRD.

Keywords: Dome-shaped macula; Short-pulse laser; Subthreshold diffuse laser.

Fig. 1

Configuration of the combined laser modalities. A SD-OCT in DSM case No. 6. B Thickness map with central, inner, and partial outer subfield foveal involvement. C Ocular fundus image illustrating both modalities from SWiT laser overlapped. D Green rectangle showing retinal parafoveal section with hyperreflective outer retinal laser sign after laser therapy

Fig. 2

Step by step procedure execution of combined laser therapy and technique parameters. A Representative ETDRS map illustrating SD-OCT thickened zone (light pinkcolor) with SRD (*) involving CST, inner and partial outer subfield map. Step 1 (white): SP laser application single shots performing two or three circumferential arc precisely placed 360º around the foveal center, at a distance ranging from 500 µm far away from center foveola till 1000 µm. Step 2 (red): additional Pascal^® SP multiple full-grid spots were applied in a 1.100–1.600 radius from foveal center (Pascal^® octants grid pattern) which includes 56 spots simultaneously triggered on mode A (twice triggered) switched with 56 spots simultaneously triggered on mode B (twice triggered). Step 3 (yellow): eight extra-segmented 14 number spots of SP laser (twice trigged each) are performed outside the 1600-radius area, achieving a laser treated area that has approximately 1850 radius placed 360º around previous Pascal^® SP multiple full-grid spots marks. Step 4 (purple): EpM-SDL was applied sweeping (2 times) the posterior pole at a 3000 µm radial extension from the foveal center covering 6 mm by 6 mm square area, sparing the 300 µm distance from it and overlapping the SP laser-treated areas. B Technique parameters table: Pascal^® SP and EpM algorithm titration of each (power of mark of laser spot, laser duration and size of spot) and laser treatment mode (power, location and mean number of shots)

Fig. 3

SD-OCT data follow-up of all cases from baseline to the last visit. SD-OCT of eight eyes showing seven cases of SRD resolution, with the exception of case No. 7

Fig. 4

Patient who underwent several treatments for 2 years after symptom onset before combined laser therapy. (yellow) Fourteen months of SD-OCT follow-up with intermittent Aldactone^® treatment. (green) Acetazolamide daily therapy for 30 days of SD-OCT follow-up. (blue) Thirty days of SD-OCT follow-up after aflibercept intravitreous injection. (pink) Seventeen months of SD-OCT follow-up after combined laser therapy (*) with two additional treatments (**)(***), showing SRD resolution in four months. Baseline multimodal imaging on the day of laser therapy (white dashed square): A Near-infrared imaging showing hypereflectance dots within para- and perifoveal areas. B SD-OCT illustrating the SRD in the DSM. C Color fundus retinography. D Autofluorescence showing hyperautofluorescent dots within para- and perifoveal areas and hyperautofluorescent amorphic material inferior to the macula. Multimodal imaging on the last visit (white dashed square): E Near-infrared imaging showing faded hypereflectance dots within para- and perifoveal areas. F SD-OCT illustrating SRD resolution. G Color fundus retinography. H Autofluorescence showing hypoautofluorescent dots within para- and perifoveal areas and small hypoautofluorescent area from previous amorphic material located inferiorly to the macula

Fig. 5

Bar chart: Mean anatomical and visual results before and after laser therapy. A mean central macular thickness (CMT) bar chart before (*) and after laser therapy (**), demonstrating statistically significant CMT reduction (p = 0,0078). B BCVA bar chart before (*) and after laser theraphy (**). Demonstrating statistically significant BCVA reduction (p = 0.0313)