Oral Bisoprolol for the treatment of non-resolving central serous chorioretinopathy: A case report

Central serous chorioretinopathy (CSC) is a spontaneous serous detachment of neurosensory retina localized in the macular region which typically affects males between 20 and 40 years of age [1]. The pathophysiology of CSC remains obscure, although disorders in both the choroidal circulation and the retinal pigment epithelium (RPE) seem to be involved [2]. It seems that a choroidal vascular hyperpermeability leads to an increase in tissue hydrostatic pressure under the RPE which can eventually result in an interruption of his continuity [3]. The symptoms depend on the amount of sub-retinal fl uid (SRF) and may include reduction of visual acuity, metamorphopsia and perception of blind spots [4]. While acute CSC generally resolves spontaneously with a full visual recovery within one to four months, [5] the chronic form, also known as “diffuse retina pigment epitheliopathy”, [6] may lead to a permanent loss of visual acuity due to the changes in the neurosensory retina [7]. The diagnosis is based on fundus exam combined with imaging of retina and choroid through optical coherence tomography (OCT), fluorescein angiography (FA) and indocyanine green angiography (ICGA). It has been reported that the prevalence of CSC is higher among patients taking glucocorticoids [8]. Other risk factors allegedly involved in the development of CSC are type A personality, [9] hypertension, pregnancy, sleeping apnea, Helicobacter pylori infection, autoimmune disease and psychopharmacologic medication use [10].


Introduction
Central serous chorioretinopathy (CSC) is a spontaneous serous detachment of neurosensory retina localized in the macular region which typically affects males between 20 and 40 years of age [1]. The pathophysiology of CSC remains obscure, although disorders in both the choroidal circulation and the retinal pigment epithelium (RPE) seem to be involved [2]. It seems that a choroidal vascular hyperpermeability leads to an increase in tissue hydrostatic pressure under the RPE which can eventually result in an interruption of his continuity [3]. The symptoms depend on the amount of sub-retinal fl uid (SRF) and may include reduction of visual acuity, metamorphopsia and perception of blind spots [4]. While acute CSC generally resolves spontaneously with a full visual recovery within one to four months, [5] the chronic form, also known as "diffuse retina pigment epitheliopathy", [6] may lead to a permanent loss of visual acuity due to the changes in the neurosensory retina [7].
The diagnosis is based on fundus exam combined with imaging of retina and choroid through optical coherence tomography (OCT), fluorescein angiography (FA) and indocyanine green angiography (ICGA). It has been reported that the prevalence of CSC is higher among patients taking glucocorticoids [8].
Other risk factors allegedly involved in the development of CSC are type A personality, [9] hypertension, pregnancy, sleeping apnea, Helicobacter pylori infection, autoimmune disease and psychopharmacologic medication use [10].
The high adrenergic activity observed in patients with type-A personality led to assume a positive effect of beta-blockers in the treatment of CSC [16]. However, only few studies investigated this treatment modality for recurrent CSC. We report two cases of non-resolving CSC and chronic epitheliopathy successfully treated with oral Bisoprolol 2,5 mg once a day for three months.

Materials and methods
Five patients, three males and two women, mean age 32  Figure 1A shows the OCT of 2 patients.

1-month follow-up
At fi rst follow-up, there was no improvement in BCVA.  Figure 1B shows the OCT of 2 patients.

2-month follow-up
At month 2, the patients achieved a greater improvement in visual acuity, with a mean of 68 ETDRS letters (20/32). Mean CMT showed a decrease to 261 microns and mean SRF diameter measured 723 microns, achieving total reabsorption of fl uid in 3 cases of 5. Figure 1C shows the OCT of 2 patients.

3-month follow-up
All the patients achieved a full visual recovery after 3 months of treatment with a mean BCVA of 84 ETDRS letters (20/20). There was no evidence of SRF at OCT follow-up in all of the 5 patients treated and the mean CMT was 232 microns. Figure 1D shows the OCT of 2 patients.

Discussion
In our non-resolving CSC patients treated with oral   In all cases, they achieved a complete remission of the disease and no difference was found in the action of 1 selective and non-selective blockers [19]. Later, in 2002, also Chrapek et al. used Trimepranol for the treatment of 13 CSC patients, but compared to Fabianova, they used a lower dose. They found that 5 mg of Trimeprolol twice a day were ineffective as a medicamentous treatment of CSC [19]. Tatham and Macfarlane demonstrated that recovery, remission, and subsequent recovery of the signs and symptoms in one patient with CSC coincided with the commencement, cessation, and retreatment with oral propranolol, 40 mg twice a day. Therefore they confi rmed that the blockage of -adrenergic receptors may play a role in chronic CSC [20]. However Chrapek again, in a recent clinical trial conducted on 23 patients, investigated the effect of 10 mg of metipranol twice a day compared to placebo and he demonstrated no effect on the duration of CSC [22].
Based on these arguments, it is clear that further studies with a greater number of patients are needed to prove the value of -blockers in the treatment of CSC. However from our perspective, it seems to be appropriate to recommend Bisoprolol 2,5 mg one a day for patients suffering from CSC without signs of resolution within the fi rst 8-12 weeks. Our work has some limitations: fi rst it is a case series, and also a short number of case are provided. However, based on the interesting fi ndings of our case series other clinical studies with larger amount of patients may be advantageous, in order to confi rm our results and understand whether bisoprolol may be a real game changer in the treatment of CSC.