Central Serous Chorioretinopathy

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  • Wet/Dry AMD - Patient is usually >50 y/o Optic Pit Macular Hole - round, red spot in the center of the macula PED - Margins of PED are more distinct than those of CSCR Polypoidal choroidal vasculopathy - hemorrhagic disorder of the macula, recurrent sub-retinal pigment epithelium bleeding
  • Margins of the detachment are sloping and merge gradually into the attached retina
  • Central Serous Chorioretinopathy

    1. 1. Central Serous Chorioretinopathy R. Fernando Auza, O.D. Benita Tailor – Optometry Intern
    2. 2. CC: blurry vision <ul><li>HPI: </li></ul><ul><li>32 y/o Hispanic male </li></ul><ul><li>Sudden onset of blurred vision at distance/near, OD only, x 1 month </li></ul><ul><li>(+)metamorphopsia, denies micropsia </li></ul><ul><li>Claims symptoms occurred after hand soup went into the right eye </li></ul>
    3. 3. HPI cont’d <ul><li>(-) pain, (-) headache, (-) bulbar injection, (-) FBS, (-) Itching/burning/discharge, (-) flashes/floaters </li></ul><ul><li>No spectacle/CL Rx </li></ul><ul><li>Modifiers: OTC drops, did not help </li></ul><ul><li>No prior hx of similar symptoms </li></ul><ul><li>Denies recent episode of stress </li></ul>
    4. 4. History <ul><li>PMHx: +hyperlipidemia, ?HTN </li></ul><ul><li>Meds: unknown cholesterol meds </li></ul><ul><li>PSHx: none </li></ul><ul><li>FHx: unremarkable </li></ul><ul><li>Social: denies tobacco or alcohol use </li></ul>
    5. 5. Examination Normal Rxn Normal Rxn Pupils Full Full EOM 17mmHg 16mmHg IOP @9:55am Plano 20/20 -0.50sph 20/40 MR J1+ J2 NVA 20/20- 20/40 PH: NI DVA OS OD
    6. 6. Slit Lamp Examination <ul><li>Lids/lashes/Meib Glands - Anterior blepharitis (OU) </li></ul><ul><li>Cornea - Scattered SPK (OD>OS) </li></ul><ul><li>Conjunctivae - Elastic changes </li></ul><ul><li>A/C, Irides, Lenses - unremarkable (OU) </li></ul>
    7. 7. Dilated Fundus Examination <ul><li>Vitreous - unremarkable </li></ul><ul><li>ONH - 0.3 (OU), pink/healthy/distinct </li></ul><ul><li>Vessels: unremarkable </li></ul><ul><li>Maculae: OD-Elevated (1.5 DD) with absent foveal reflex, OS-unremarkable </li></ul><ul><li>Periphery: No breaks/detachments (OU) </li></ul>
    8. 8. Differential Diagnosis <ul><li>CSCR </li></ul><ul><li>Wet/Dry AMD </li></ul><ul><li>Optic Pit w/ serous RD </li></ul><ul><li>Macular Hole </li></ul><ul><li>Pigment Epithelial Detachment (PED) </li></ul><ul><li>Polypoidal choroidal vasculopathy </li></ul><ul><li>Choroidal tumor </li></ul>
    9. 10. Treatment <ul><li>Xibrom 1 gtt BID OD </li></ul><ul><li>Follow up: 2 wks </li></ul>
    10. 11. Follow up 1 <ul><li>VA: 20/40 (Stable) PH: NI </li></ul><ul><li>Fundus Exam </li></ul><ul><ul><li>Macular swelling significantly less than previous visit </li></ul></ul><ul><li>Continue with Xibron BID </li></ul>
    11. 13. Visit 1 Visit 2
    12. 14. Discussion - Epidemiology <ul><li>Commonly occurs in middle-aged men with a type A personality </li></ul><ul><li>Incidence: 5-6 per 100,000 people. M:F 6:1 1 </li></ul><ul><li>History of similar episodes is common - recurrences occur in 40% of cases </li></ul>1 Kitzmann 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 O phthalmology ハ 2 008; 115:169-2073.
    13. 15. Risk Factors 2 Yanoff & Duker: Ophthalmology, 3rd ed.
    14. 16. Symptoms <ul><li>Most common symptoms: metamorphopsia, blurred vision, and micropsia. </li></ul><ul><li>Usually unilateral. </li></ul><ul><li>Other symptoms can include: color desaturation, impaired dark adaptation, delayed retinal recovery time to bright light, and relative scotoma </li></ul>3 Wang M et al. Central serous chorioretinopathy. Acta Ophthalmol. 2008 Mar;86(2):126-45. Epub 2007 Jul 28. Review.
    15. 17. Signs <ul><li>VA ranges from 20/15 to 20/200 but averages 20/30 </li></ul><ul><li>Localized serous detachment of the neurosensory retina in the region of the macula without subretinal blood or lipid exudates </li></ul><ul><li>After resolution of condition, most patients have permanent residual RPE changes within the macula </li></ul>2 Yanoff & Duker: Ophthalmology, 3rd ed. 4 Ehlers JP., Shah CP. The Wills Eye Manual . 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2008. 300-301.
    16. 18. Background <ul><li>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) </li></ul>
    17. 19. Two Clinical Presentations <ul><li>Classical CSCR </li></ul><ul><ul><li>Caused by one or more localized leaks at the level of the RPE </li></ul></ul>
    18. 20. Break in RPE
    19. 22. Clinical Presentation <ul><li>CSCR may also present with diffuse RPE dysfunction characterized by neurosensory retinal detachment overlying areas of multiple RPE atrophy and pigment mottling . </li></ul>
    20. 23. Mortality/Morbidity <ul><li>Typically resolve spontaneously in most patients </li></ul><ul><li>Most patients (80-90%) return to 20/25 or better vision </li></ul><ul><li>Patients with classic (CSCR) (characterized by focal leaks) have a 40-50% risk of recurrence in the same eye. </li></ul><ul><li>Risk of choroidal neovascularization from previous CSCR is small (<5%) </li></ul><ul><li>5-10% of patients may fail to recover 20/30 or better. VA may be as poor as 20/200 in chronic cases </li></ul>
    21. 24. Pathophysiology <ul><li>Abnormal ion transport across the RPE and choroidal vasculopathy?. </li></ul><ul><li>ICG angiography has demonstrated both multifocal choroidal hyperpermeability and hypofluorescent areas suggestive of focal choroidal vascular compromise. </li></ul><ul><ul><li>Secondary dysfunction of the overlying RPE. </li></ul></ul><ul><li>Studies using multifocal electroretinography have demonstrated bilateral diffuse retinal dysfunction even when CSCR was active only in one eye. </li></ul><ul><ul><li>Support the belief of a systemic effect on the choroidal vasculature. </li></ul></ul>
    22. 25. Pathophysiology <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Cotticelli et al showed associatio with Helicobacter pylori . </li></ul><ul><ul><li>Prevalence of H pylori infection was 78% in patients with CSCR compared with a prevalence of 43.5% in the control group. </li></ul></ul>
    23. 26. Systemic Associations <ul><ul><li>organ transplantation, </li></ul></ul><ul><ul><li>exogenous steroid use </li></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><li>systemic hypertension </li></ul></ul><ul><ul><li>sleep apnea </li></ul></ul><ul><ul><li>systemic lupus erythematosus </li></ul></ul><ul><ul><li>gastroesophageal reflux disease </li></ul></ul><ul><ul><li>Elevated circulating cortisol and epinephrine, which affect the autoregulation of the choroidal circulation.  </li></ul></ul>
    24. 27. Imaging Studies <ul><li>Optical Coherence Tomography (OCT) </li></ul>
    25. 28. Imanginf Studies <ul><li>FA of classic CSCR shows one or more focal leaks at the level of the RPE. The classic &quot;smokestack&quot; appearance of the fluorescein leak is seen only in 10-15% of cases. </li></ul><ul><li>FA of diffuse retinal pigment epitheliopathy demonstrates focal granular hyperfluorescence corresponding to window defects </li></ul>
    26. 29. Treatment <ul><li>Oral Carbonic Anhdrase Inhibitors (Acetazolamide) can be used. </li></ul><ul><li>They shorten the time of visual recovery but they do not change the final visual outcome </li></ul>Pikkel J et al, Acetazolamide for central serous retinopathy. Ophthalmology. 2002 Sep;109(9):1723-5.
    27. 30. Surgical Care <ul><li>Laser photocoagulation should be considered under the following circumstances: </li></ul><ul><ul><li>(1) persistence of a serous retinal detachment for more than 4 months, </li></ul></ul><ul><ul><li>(2) recurrence in an eye with visual deficit from previous CSCR, </li></ul></ul><ul><ul><li>(3) presence of visual deficits in opposite eye from previous episodes of CSCR, and </li></ul></ul><ul><ul><li>(4) occupational or other patient need requiring prompt recovery of vision. </li></ul></ul>
    28. 31. Surgical Care <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Photodynamic therapy  </li></ul><ul><ul><li>Photodynamic therapy (PDT) has growing support in the literature </li></ul></ul><ul><ul><li>PDT has a direct effect on the choroidal circulation but was limited by potential adverse effects, such as macular ischemia. </li></ul></ul>
    29. 32. Thank you

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