Retinal Imaging Conference

Eric Downing MD
University of Louisville
Department of Ophthalmology and Visual Sciences
9/4/2014
 Subjective
CC/HPI: “Since yesterday, I have noticed a blue
spot in my vision.”

 39 year old white male with ↓VA x 1 day OS,

with decreased near VA and intermittent
diplopia. No pain, flashes, or irritation.
 History
POH: none
PMH: Chronic Inflammatory Demyelinating
Polyneuropathy 3 weeks prior
Eye Meds: none
Meds: Solumedrol 1000mg x 1 week, Prednisone
50mg PO daily x 3 days
 Objective
OD OS
VAsc: 20/20 20/30-
VAcc: 20/20-(+0.50 sph)
Pupils: 4→3 4→3, no rAPD
IOP: 11 11
EOM: full full

Anterior Segment: WNL

 Exam
DFE:
Red Free
Autofluorescence
OCT OD
OCT OS
Fluorescein Angiogram
Fluorescein Angiogram
Fluorescein Angiogram
 Assessment/Plan
 39M recently diagnosed with CIDP, and started
on high dose steroids who presented with one
day of blurry vision OS. OCT revealed a
neurosensory detachment and FA showed an
expansile dot pattern.
 Dx: Central Serous Chorioretinopathy

 Plan: Discuss steroid taper with neurologist.

Follow up in one week.
 Follow-up
 One month later…“my colors are off”
 VA OS now 20/50, BCVA to only 20/30
OCT OS
 Follow-up
 Pt started on IVIg and tapering off of steroids
 One month later…“Vision still blurry, but a
little better”
 VA objectively stable
OCT OS
FA
 Plan
 Con’t steroid taper, f/u in one month
Central Serous Chorioretinopathy
 Characterized by a serous detachment of the
neurosensory retina
 Idiopathic etiology
 Two distinct presentations
 One or more discrete isolated leaks at the level of
the RPE
 Diffuse RPE dysfunction characterized by
neurosensory retinal detachment overlying areas of
RPE atrophy and/or pigment mottling
 CSCR
 Associated with Type A personalities,
Obstructive Sleep Apnea, exogenous steroid use,
Cushing’s Syndrome, SLE, HTN, GERD, and
pregnancy
 Epidemiology
 Affects males 6-10 times more than women, with a
predominance from 20-55 years of age
 More common in whites, Hispanics and Asians
 Morbidity
 80-90% resolve spontaneously to a VA of 20/25 or
better
 5-10% have recurrent serous detachments, progressive
RPE atrophy, and can have permanent VA loss to
20/200 or worse
 Can be associated with a 1.6-fold increased risk for
ischemic stroke2
 Presentation
 History
 Acute visual loss, usually centrally
 Metamorphopsia
 Central or paracentral scotoma
 Loss of color saturation
 Loss of contrast sensitivity
 Exam
 Serous retinal detachment without blood
 Can show RPE mottling and/or atrophy
 Rarely subretinal lipid is present
 Work-up
FA patterns

Expansile dot
Smokestack pattern
Diffuse pattern
 Treatment
 Observation
 Focal laser photocoagulation (classically)
 Shortens duration, but does not improve prognosis
 PDT
 ½ dose Verteporfin (3mg/m2 over 8 mins) accompanied
by ICG guided PDT with 85% resolution
 Treatment
 Finasteride: DHT inhibitor
 Case series demonstrating ↓subretinal fluid which
recurred immediately upon cessation
 Rifampin: ?Alteration of endogenous steroid
metabolism
 Methotrexate

 Eplerenone: mineralocorticoid receptor antagonist

 Indications for Treatment
 Only considered if serous detachement persists for >4 months
 Recurrence in an eye with previous deficit from CSCR
 Presence of visual deficits in opposite eye from previous episode
 Patient is need of prompt recovery
 Multicenter retrospective study
 56 patients
 28 received half-fluence PCT
 28 received have-dose PDT
 BCVA, CFT, and resolution of SRF measured at 1 and 12
months
 SRF resolved in 25/28 pts in the half-dose group vs. 19/28 in
the half-fluence group at month one
 5 eyes had recurrence in the half-dose group vs. 15 in the half-
fluence group over the follow-up period
 Conclusion: Half-dose PDT induced faster, longer lasting
resolution, with an equal safety profile
 References
1. BCSC: Retina and Vitreous: Central Serous Chorioretinopathy. Pgs 171-176.
2. Tsai DC, Huang CC, Chen SJ, et al. Central serous choroiretinapathy and risk of
ischaemic stroke: a population-based cohort study. Br J Ophthalmol. Dec
2012;96(12):1484-8.
3. Burumcek E, Mudun A, Karacorlu S, Arslan MO. Laser photocoagulation for persistent
central serous retinopathy: results of long-term follow-up. Ophthalmology. Apr
1997;104(4):616-22
4. Lai TY, Chan WM, Li H, Lai RY, Liu DT, Lam DS. Safety enhanced photodynamic
therapy with half dose verteporfin for chronic central serous chorioretinopathy: a short
term pilot study. Br J Ophthalmol. Jul 2006;90(7):869-74
5. Kurup SK, Oliver A, Emanuelli A, Hau V, Callanan D. Low-dose methotrexate for the
treatment of chronic central serous chorioretinopathy: a retrospective analysis. Retina.
Nov-Dec 2012;23(2):488-9.
6. Nicholson B, Noble J, Forooghian F, et al. Central serous chorioretinopathy: update on
pathophysiology and treatment. Surv Ophthalmol. Mar 2013;58(2):103-126.
7. Nicolo M, Eandi CM, Alovisi C, et al. Half-fluence vs. half-dose photodynamic therapy in
chronic central serous chorioretinopathy. Am J of Ophthalmol;Vol 157(5);May 2014:1033-
37.