Central Serous Chorioretinopathy

R. Fernando Auza, O.D.

Benita Tailor – Optometry Intern

CC: blurry vision

HPI: 32 y/o Hispanic male Sudden onset of blurred vision at

distance/near, OD only, x 1 month (+)metamorphopsia, denies micropsia Claims symptoms occurred after hand

soup went into the right eye

HPI cont’d• (-) pain, (-) headache, (-) bulbar injection, (-)

FBS, (-) Itching/burning/discharge, (-) flashes/floaters

No spectacle/CL Rx Modifiers: OTC drops, did not help No prior hx of similar symptoms Denies recent episode of stress

History

PMHx: +hyperlipidemia, ?HTN Meds: unknown cholesterol meds PSHx: none FHx: unremarkable Social: denies tobacco or alcohol use

Examination

OD OS

DVA 20/40

PH: NI

20/20-

NVA J2 J1+

MR -0.50sph

20/40

Plano

20/20

IOP @9:55am

16mmHg 17mmHg

EOM Full Full

Pupils Normal Rxn Normal Rxn

Slit Lamp Examination

Lids/lashes/Meib Glands - Anterior blepharitis (OU)

Cornea - Scattered SPK (OD>OS) Conjunctivae - Elastic changes A/C, Irides, Lenses - unremarkable (OU)

Dilated Fundus Examination

Vitreous - unremarkable ONH - 0.3 (OU), pink/healthy/distinct Vessels: unremarkable Maculae: OD-Elevated (1.5 DD) with

absent foveal reflex, OS-unremarkable Periphery: No breaks/detachments (OU)

Differential Diagnosis

CSCR Wet/Dry AMD Optic Pit w/ serous RD Macular Hole Pigment Epithelial Detachment (PED) Polypoidal choroidal vasculopathy Choroidal tumor

Treatment

Xibrom 1 gtt BID OD

Follow up: 2 wks

Follow up 1

VA: 20/40 (Stable) PH: NI

Fundus ExamMacular swelling significantly less than

previous visit

Continue with Xibron BID

Visit 1 Visit 2

Discussion - Epidemiology

Commonly occurs in middle-aged men with a type A personality

Incidence: 5-6 per 100,000 people. M:F 6:11

History of similar episodes is common - recurrences occur in 40% of cases

1Kitzmann A.S., Pulido J.S., Diehl N.N., et al: The incidence of central serous chorioretinopathy in Olmsted County, Minnesota, from 1980 to 2002. ﾊ Ophthalmology ﾊ 2008; 115:169-2073.

Risk Factors

2Yanoff & Duker: Ophthalmology, 3rd ed.

Symptoms

• Most common symptoms: metamorphopsia, blurred vision, and micropsia.

• Usually unilateral. • Other symptoms can include: color desaturation, impaired

dark adaptation, delayed retinal recovery time to bright light, and relative scotoma

3Wang M et al. Central serous chorioretinopathy. Acta Ophthalmol. 2008 Mar;86(2):126-45. Epub 2007 Jul 28. Review.

Signs

• VA ranges from 20/15 to 20/200 but averages 20/30

• Localized serous detachment of the neurosensory retina in the region of the macula without subretinal blood or lipid exudates

• After resolution of condition, most patients have permanent residual RPE changes within the macula

2Yanoff & Duker: Ophthalmology, 3rd ed.

44Ehlers JP., Shah CP. Ehlers JP., Shah CP. The Wills Eye ManualThe Wills Eye Manual. 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2008. 300-301.. 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2008. 300-301.

Background

Central serous chorioretinopathy (CSCR) is a disease in which a serous detachment of the neurosensory retina occurs over an area of leakage from the choriocapillaris through the retinal pigment epithelium (RPE)

Two Clinical Presentations

Classical CSCR Caused by one or more localized leaks at the level of

the RPE

Break in RPE

Clinical Presentation

CSCR may also present with diffuse RPE dysfunction characterized by neurosensory retinal detachment overlying areas of multiple RPE atrophy and pigment mottling.

Mortality/Morbidity

Typically resolve spontaneously in most patients Most patients (80-90%) return to 20/25 or better vision

Patients with classic (CSCR) (characterized by focal leaks) have a 40-50% risk of recurrence in the same eye.

Risk of choroidal neovascularization from previous CSCR is small (<5%)

5-10% of patients may fail to recover 20/30 or better. VA may be as poor as 20/200 in chronic cases

Pathophysiology Abnormal ion transport across the RPE and

choroidal vasculopathy?. ICG angiography has demonstrated both

multifocal choroidal hyperpermeability and hypofluorescent areas suggestive of focal choroidal vascular compromise. Secondary dysfunction of the overlying RPE.

Studies using multifocal electroretinography have demonstrated bilateral diffuse retinal dysfunction even when CSCR was active only in one eye. Support the belief of a systemic effect on the

choroidal vasculature.

Pathophysiology

Corticosteroids have a direct influence on the expression of adrenergic receptor genes and, thus, contribute to the overall effect of catecholamines on the pathogenesis of CSCR.

Carvalho-Recchia et al showed in a series that 52% of patients with CSCR had used exogenous steroids within 1 month of presentation as compared with 18% of control subjects.

Cotticelli et al showed associatio with Helicobacter pylori. Prevalence of H pylori infection was 78% in patients with CSCR

compared with a prevalence of 43.5% in the control group.

Systemic Associations

organ transplantation, exogenous steroid use

Carvalho-Recchia et al showed in a series that 52% of patients with CSCR had used exogenous steroids within 1 month of presentation as compared with 18% of control subjects.6

systemic hypertension sleep apnea systemic lupus erythematosus gastroesophageal reflux disease Elevated circulating cortisol and epinephrine, which

affect the autoregulation of the choroidal circulation. 

Imaging Studies

Optical Coherence Tomography (OCT)

Imanginf Studies

FA of classic CSCR shows one or more focal leaks at the level of the RPE. The classic "smokestack" appearance of the fluorescein leak is seen only in 10-15% of cases.

FA of diffuse retinal pigment epitheliopathy demonstrates focal granular hyperfluorescence corresponding to window defects

Treatment

Oral Carbonic Anhdrase Inhibitors (Acetazolamide) can be used.

They shorten the time of visual recovery but they do not change the final visual outcome

Pikkel J et al, Acetazolamide for central serous retinopathy. Ophthalmology. 2002 Sep;109(9):1723-5.

Surgical Care Laser photocoagulation should be

considered under the following circumstances: (1) persistence of a serous retinal detachment

for more than 4 months, (2) recurrence in an eye with visual deficit

from previous CSCR, (3) presence of visual deficits in opposite eye

from previous episodes of CSCR, and (4) occupational or other patient need

requiring prompt recovery of vision.

Surgical Care Laser treatment also may be considered in patients with

recurrent episodes of serous detachment with a leak located more than 300 µm from the center of the fovea.

Laser treatment shortens the course of the disease and decreases the risk of recurrence for CSCR, but it does not appear to improve the final visual prognosis.

Photodynamic therapy  Photodynamic therapy (PDT) has growing support in the

literature PDT has a direct effect on the choroidal circulation but was

limited by potential adverse effects, such as macular ischemia.

Thank you