CENTRAL SEROUS CHORIORETINOPATHY

DR SIVATEJA CHALLA

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INTRODUCTION

A Chorioretinal disorder characterized by an idiopathic localized serous detachment of the neural retina in the macular region

Usually unilateral May be associated with pigment epithelial detachment (PED) Relative preservation of visual function despite prolonged separation of

neural retina from the retinal pigment epithelium (RPE)

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INTRODUCTION Initial description by Von Graefe in 1866 as relapsing

central recurent retinitis. 1955 – Bennett – “central serous retinopathy”

Synonyms: Central Serous Retinopathy Central Serous Pigment Epitheliopathy Central Serous Retinitis

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(contd..)

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EPIDEMIOLOGY Age: 30 – 50 years Gender: Male > female 6:1 RACE: whites and asians>blacks Increased incidence in:

Emotional stress Type A personality Physical Strains,pregnancy People engaged in visually demanding work

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Also found to be associated with vasoconstrictive agents, endogenous hypercortisolism, Systemic corticosteroids, SLE, Hypertension

Helicobacter pylori infection has been reported to be associated with CSC

Smoking, Antibiotic use Antihistamine use Alcohol consumption and allergic respiratory

diseases Obstructive sleep apnea

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PATHOGENESIS RPE DYSFUNCTION THEORY

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PATHOGENESIS CHOROID DYSFUNCTION THEORY

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(contd..)

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TYPES1. Typical or Classic CSC2. Chronic CSC or Diffuse retinal pigment epitheliopathy3.Bullous retinal detachments

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CLINICAL FEATURES Presentation:

Unilateral blurred vision with a relative scotoma in the central visual field

Unilateral metamorphopsia and/or micropsia Patients with extrafoveal involvement may be

asymptomatic Visual acuity:

VA ranges from 6/5 to 6/60, usually 6/9 – 6/12 Acquired hyperopia

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CLINICAL FEATURES Fundus:

A round to oval sensory retinal detachment is present at the posterior pole

In some small PED within the serous detachment may be evident

Absent foveal reflex Small dot like deposits in the posterior of retina

which is believed to be the precipitates of plasma proteins including fibrin

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(contd..)

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CLINICAL FEATURES Other features:

Impaired Dark adaptation Colour desaturation Patients may present as bullous inferior

peripheral retinal detachment (non-rhegmatogenous)

In chronic form, diffuse retinal pigment epitheliopathy progresses in conjunction with persistent or intermittent SRF, and RDs tend to be shallower and more diffuse, and visual prognosis is more guarded in such cases

Chronic CSC may L/T CNV formation,CME,SR Lipid deposition and chorio capillary atrophy

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(contd..)

DIAGNOSIS

Basically clinical, confirmed by FFA

FFA critical to detect the extent of the retinal abnormalities and to exclude the presence of other ocular pathology

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DIAGNOSIS Fluoroscein Angiography: Characteristic features:

Ink-blot appearance: • Seen in 93% cases• Leakage point/s with uniform dye filling is appreciated.• Most common location – upper nasal quadrant.• Least common location – lower temporal quadrant

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(contd..)

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DIAGNOSIS Fluoroscein Angiography: Characteristic features:

Smoke-stack appearance: Small hyperfluorescent spot in the early

phase due to leakage of dye through the RPE Fluorescein passes into the subretinal space

and ascends vertically until the upper border, like a smoke-stack, in the late venous phase

The dye then spreads laterally, taking on a “mushroom” or “umbrella” configuration until entire area of detachment is filled

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(contd..)

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Optical Coherence Tomography(OCT): IMPORTANCE1.In diagonosis2.Following the progress3.Quantifying serous detachment

OCT reveals many aspects of pathophysiology of CSC,ranging from SRF, PED,& retinal atrophy following chronic disease OCT is especially helpful in identifying subtle, even subclinical, neurosensory & macular detachments.OCT is also helpful in identifying the dreaded complication of Choroidal Neo Vascular membrane

Increased choroidal thickening is a hallmark of CSC

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ACUTE CSR CHRONIC CSR• NSD at macula 1.Foveal atrophy or

thinning • RPED 2.cystoid changes at fovea• Combination of both

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Indocyanin Green (ICG) Angiography: ICGA is one of the most important investigations in CSC becauseit demonstrates the choroidal vascular abnormalities and can act as a guide to treatments such as photodynamic therapy.

Common findings in patients with CSC are multi focal areas of hyper fluorescence in the early and midphases of the study,which then fade in the late phase of the study

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Fundus autofluorescence FAF typically shows hypofluorescence at the leakage point and over the area of neurosensory detachment due to blockage by subretinal fluid.The subretinal yellow dots observed clinically might demonstrate hyperfluorescenceIn chronic-recurrent CSC,hyperfluorescence is common in areas of residual neurosensory detachment.Other testsMultifocal ERG has been used to identify focal regions of decreased retinal function, even in asymptomatic or clinically inactive eyes.Microperimetry has also shown that, despite clinical resolution of CSR, there is lower retinal sensitivity in the macula even once visual acuity returned to 20/20

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DIFFERENTIAL DIAGNOSES

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COURSE AND OUTCOME Self-limiting and 90% of the cases will show

spontaneous recovery within a few months CSC recurs in about 50% of the patients within the

first year. A history of psychiatric illness is associated with a

higher rate of recurrence Small proportion of patients develop RPE atrophy,

CNV development (in up to 6% of patients), and transformation into PCV

Patients whose VA recovered might be left with residual symptoms such as metamorphopsia, scotoma, and reduced contrast sensitivity.

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TREATMENTOBSERVATIONappropriate first-line approachControl of steroid levelsLifestyle modificationPsychosocial therapies

It has been recommended that if symptoms persist for more than 3 months, further active treatments should be considered

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LASER PHOTOCOAGULATIONAccelerates the resolution of the detachmentlowers the recurrence rate

MOA: Beam destroys the cluster of diseased pigment epithelium cells, thus stopping the secretion of fluid beneath the neurosensory retina. Resulting scar helps to transport fluid back into the choriocapillaris.

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Indications: Persistence of serous detachment beyond 3-4 months Recurrences in eyes with visual deficit from previous

episodes Presence of permanent visual deficit from previous

episodes in the fellow eye Development of chronic signs such as cystic changes

in the neurosensory retina or widespread RPE abnormalities

Occupational or other patient needs that require prompt restoration of vision or stereopsis

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Technique:

2 – 3 low to moderate intensity burns applied to the leakage site (spot size of 200µm, for 0.1 seconds), to produce mild graying of the RPE

Decreases of duration of detachment.

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Advantages Decreased duration Decreased recurrence

Complications Choroidal neovascularization Central scotoma

Should be avoided if the leak is within 500m from the centre of the foveal avascular zone

Careful follow up required as 2 – 5% of eyes treated with photocoagulation develop CNV

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Pre Treatment

Post Treatment

PHOTODYNAMIC THERAPYINDICATIONS・ Juxtafoveal lesion.・ Subfoveal lesion.・ Lack of a clearly defined leakage hot spot. . Concern about the potential induction of CNV.

MOAchoriocapillaris narrowing, choroidal hypoperfusion, reduction of choroidal exudation and choroidal vascular remodeling

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Safety-enhanced PDT was performed using half the normal dose of verteporfin at 3 mg/m2.

Infusion of verteporfin was performed over 8 minutes, delivery of laser at 692 nm 10 minutes afterwards

CONCLUSIONThe modified safety enhanced PDT protocol with half dose verteporfin appeared to be a beneficial treatment option for patients with chronic CSC, especially in eyes without serous PED

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OTHER RX MODALITIES ANTI-VEGF suggested that combined PDT and

intravitreal anti-VEGF has a beneficial role to play for CSC patients

 Small series exist to support a number of agents, including mifepristone, ketoconazole, rifampin,

finesteride,  and eplerenone. Patients with chronic severe CSC that is recalcitrant to local therapy may consider these agents

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THANK YOU

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