Comment on: Spectral domain optical coherence tomography predates fluorescein angiography in diagnosing central seruos chorioretinopathy

We submit as follows: Both eyes at first presentation showed almost identical findings. Fundus fluorescein angiography (FFA) in both eyes revealed diffuse granular hyperfluorescence,[2] suggestive of chronic central serous chorioretinopathy (CSCR) [diffuse retinal pigmentary epitheliopathy (DRPE)].[2] Multiple pigment epithelial detachments seen on FFA in right eye (RE) (forme fruste)[3] and subretinal white deposits[3] in left eye (LE) further support the diagnosis. CSCR should have been diagnosed in both eyes (BE). CSCR can be asymptomatic.[4]


Authors' reply
Dear Editor, First, we appreciate the details with which Chalisgaonkar et al. [1] have read our case report [2] and searched the literature of retinoblasotoma in adults.
In the case report by Biswas et al., [3] on the computed tomogram (CT), 'a speck of calcification' was noted. No gross calcified areas were found. In the remaining cases no calcification was noted.
In all case reports of retinoblastoma in adults, retinocytoma was diagnosed as benign appearing areas in malignant tumor tissue and not as pre-existing lesions that turned malignant on follow-up. [4] In our case no such benign appearing cells were noted in the malignant tissue, in the multiple tissue sections that were taken. [1] Ours is the only case reported in literature where retinoblastoma was found in pregnancy. There is one case reported by Takahashi et al., [5] six months postpartum. We have stated that new cases and further study is needed for establishing this relationship. Pregnancy may have an effect on retinoblastoma due to circulating mutagens and immunosuppression. [6] Comment on: Spectral domain optical coherence tomography predates fluorescein angiography in diagnosing central seruos chorioretinopathy Dear Editor, This is with reference to the article by Gupta [1] claiming that "spectral domain HD OCT could pick up the presence of the sub retinal fluid and RPE changes even before they could manifest angiographically in CSCR".
We submit as follows: Both eyes at first presentation showed almost identical findings. Fundus fluorescein angiography (FFA) in both eyes revealed diffuse granular hyperfluorescence, [2] suggestive of chronic central serous chorioretinopathy (CSCR) [diffuse retinal pigmentary epitheliopathy (DRPE)]. [2] Multiple pigment epithelial detachments seen on FFA in right eye (RE) (forme fruste) [3] and subretinal white deposits [3] in left eye (LE) further support the diagnosis. CSCR should have been diagnosed in both eyes (BE). CSCR can be asymptomatic. [4] Considering the right eye at first presentation, line-scan optical coherence tomography (OCT) reveals one pigment epithelial detachment and neurosensory elevation. The retinal pigment epithelium (RPE) layer scan shows two pigment epithelial detachments and areas of irregularities. These findings can be seen in several other conditions such as presumed ocular histoplasmosis syndrome, idiopathic choroidal neovascularisation (CNV), Harada's disease, posterior scleritis, etc. FFA at this point shows three distinct pigment epithelial detachments in addition to classical granular hyperfluorescence of chronic CSCR and gives a definite diagnosis. The authors have mentioned absence of smoke stack sign as an observation against the diagnosis of CSCR. Smoke stack sign is present in only 10% of acute cases. [5] At second presentation, while the patient became symptomatic in RE, line-scan OCT did not show any increase in pigment epithelial detachment (PED) or neurosensory elevation. However, the single-layer RPE scan shows three points of pigment epithelial detachments, which were identified by FFA at the first presentation itself. Besides, FFA documents classical expanding dot sign, which corresponds to the patient becoming symptomatic due to acute attack. Obviously, FFA scores over OCT in early definitive diagnosis and follow-up of patients.
We wish to mention that OCT cannot predate any pathognomonic changes in CSCR. Sequential OCTs can only show the status of neurosensory and RPE detachments whereas FFA not only confirms the diagnosis but also helps in ruling out conditions that mimic CSCR, such as choroidal tumors and CNV that is not benign as CSCR.

Authors' reply
Dear Editor, This case report is not about the diagnosis of idiopathic central serous chorioretinopathy (ICSC) at the time of presentation as that is really not the objective of our case report. [1,2] The report is about the optical coherence tomography (OCT) showing changes of acute ICSC before the development of expanding dot sign on fluorescein angiogram. As mentioned in the letter, the fluorescein angiogram in the right eye at presentation is suggestive of forme fruste of ICSC or chronic ICSC and, by no stretch of imagination, appears like a precursor to the development of acute ICSC.
Regarding the question of the inability of raster line scan to pick up all the pigment epithelium detachment (PEDs) seen on the map, we would like to mention the very basic fact that the raster line scan shows the morphological alterations seen at one particular line scan through which the slice navigator is passing. The changes that are seen on the 3D retinal pigment epithelium (RPE) map are mapping the entire area of the cube and thus all the changes seen on the map cannot be seen in a single line scan. [3] None of the other conditions mentioned in the letter, including ICSC, can be diagnosed based on OCT alone and thus this query has no relevance. [4] The OCT scan in this patient showed changes consistent with acute ICSC even before the development of expanding dot sign that is required to make the diagnosis of acute ICSC and thus it definitely scores over fluorescein angiography. Regarding the statement, "We wish to mention that OCT cannot predate any pathognomonic changes in CSCR," it would be interesting to see the reference to this statement.

Disadvantages of photodynamic therapy for polypoidal choroidal vasculopathy
Dear Editor, We read the article by Mitamura et al. [1] with interest. The article compares the short-term therapeutic effects of intravitreal bevacizumab (IVB) to those of photodynamic therapy (PDT) for polypoidal choroidal vasculopathy (PCV).
We would like to comment about the application of PDT in PCV. PDT is associated with several disadvantages. First, PCV often presents as multiple widely distributed lesions, so it might be difficult to treat all lesions, including multiple polyps and interconnecting vessels, with a single beam of PDT. Treatment of leaking polypoidal dilations only without treating the entire vascular complex can result in persistence or worsening of exudation. Second, it can be difficult to treat nodules in the peripapillary area with a round PDT beam. Third, features commonly associated with PCV such as a large PED or a large submacular hemorrhage are not usually amenable to PDT treatment. Fourth, PCV tends to recur repeatedly so multiple PDT treatments are often necessary, which can increase the risk of long-term choroidal atrophy. Cases of massive subretinal/ suprachoroidal hemorrhage have been reported soon after PDT. [2] Even 50% reduced light fluence PDT can produce a retinal pigment epithelial tear in pigment epithelial detachment. [3] Recently, Kokame et al. [4] reported stabilization of vision at 6 months, with monthly intravitreal injection of ranibizumab in PCV. Lai et al. reported stabilization of vision and reduction in exudative detachment with IVB but its limited role in regression of polypoidal lesions in indocyanine green angiography (ICGA). [5] Complete regression of polypoidal lesions in ICGA may not be the therapeutic target but the close follow-up is mandatory. Polyps showing "washout phenomenon" on ICGA can be watched. Considering the disadvantages and economic burden associated with PDT, anti-VEGF drugs alone could be the preferred treatment for symptomatic PCV.