In the name of God
Central serous chorioretinopathy
Hamid Fesharaki MD, Eye Dpt
Isfahan University of medical sciences
CSC (CSR)
Development of a well cicumscribed serous detachment of the sensory retina resulting
from altered barrier and deficient pumping functions of the RPE. Although the primary
pathology may involve the choriocapillaris. Small whitish sub-retinal precipitates, or graywhite subretinal sheets (fibrin) may be noted.
• The underlying cause of the problem is an
unexplained defect in the vascular layer
supporting the retinal pigment epithelium (the
choroicapillaris) which becomes more leaky and
creates a small blister in the retinal pigment
epithelium.
• A defect in the RPE lets fluid escape under the
retina and this is usually associated with clinical
symptoms.
• Some cases may also show serous detachments of
the RPE or PED usually under the superior half of the
serous detachment.
Symptoms of CSR
This condition usually occurs in patients between the ages
of 30 and 50 and presents with mild blurring of vision in
one eye.
Another common symptom is feeling that objects appear
smaller in the affected eye (micropsia).
CSC
• Examination may reveal that both eyes are
affected even if symptoms are confined to one eye
only.
• CSC is often bilateral with asymmetric findings.
• The condition is usually diagnosed by clinical
examination alone.
• although for more difficult cases further
investigations using F A, and O C T, may be
employed.
CSC
CSC is common in Caucasians,
Asians, and Hispanics, and rare in African Americans.
Symptomatic patients describe the sudden onset of blurred
and dim vision, micropsia (objects appear smaller than they
are),
metamorphopsia (objects appear distorted), paracentral
scotomata, or decreased color vision.
vision ranges from 20/20 to 20/200, but in most patients
vision is better
than 20/30.
The decreased vision can often be corrected with a
hyperopic correction.
In rare cases, these symptoms are accompanied by a
migraine-like headache.
CSC
Certain personality types, including type A personality,
hypochondria, hysteria, conversional neurosis, and
psychiatric medication use have been associated with
CSC, although no proven association with any personality
has been made.
Patients with elevated levels of corticosteroids
due to either corticosteroid administration (inhaled,
topical, or systemic) or Cushing syndromeare at an
increased risk of developing esc.
Finally, stress has also been implicatedas an etiologic
factor, but no conclusive proof has been presented.
Fluorescein Angiography of CSC
Three characteristic fluorescein angiographic patterns are seen in esc:
1. expansile dot pattern
2. smokestack pattern
3. diffuse pattern
FA in CSR
Expansile dot pattern
An expansile dot of hyperfluorescence is the most common presentation. The
dot representsa small, focal hyperfluorescent leak from the choroid through
the RPE that appears in the early phase of the angiogram and increases in
size and intensity as the angiogram progresses.
Smokestack & subretinal pooling
FA in CSC
Smokestack pattern
Fluorescein Angiography of CSC
Fluorescein dye also slowly pools into the sub
retinal detachment as the angiogram progresses
Late-phase frames of the angiogram at 10 or 15
minutes are often required to detect very slow leaks
or to discern the extent of fluorescein pooling in the
subsensory retinal space.
Angiogram 10 minutes post dye
injection showing leakage
Angiogram 20 minutes post dye
injection showing leakage
Diffuse leakage
Fluorescein Angiography of CSC
In rare cases, an extensive, often gravity-dependent, serous detachment
of the retina may develop from one or more leak points outside the
posterior pole. This situation producesa diffuse pattern of fluorescein
leakage, often without any obvious leakage point.
Patient s with this condition often have large areas of serous detachment and
extensive RPE changes. Thus, CSC must be considered in the differential
diagnosis of nonrhegmatogenous serous retinal detachment.
Indolent cases also occur, in which fluid moves chronically
from the choroid to the subretinal space and causes areas of
abnormal RPE to expand.
Central Serous Retinopathy (CSR)
1. a large, elevated area of serous retinal detachment can be seen occupying
much of the temporal macula.
Within the central area of this detachment, there appears to be a second, smaller,
ring of elevation. FA and OCT confirmed that this smaller elevated ring is a PED
within the larger area of serous retinal detachment.
2. Early views of the FA demonstrate a hot spot of
hyperflourescence that spreads to fill the PED.
3. Late views with flourescein reveal the pooling of fluid
within the serous detachement, correlating with the
clinical appearance of the fundus.
ّFA Multispot leakage in CSC
In some patients, several leaking expansile dots may be present.
If no expansile dot is seen in the macula, the extramacular
space, especially superiorly, should be evaluated.
Figure 10-2: Central serous chorioretinopathy with
sensory retinal detachment (arrows) extending into
the fovea.
Figure 10-3: Fluorescein angiogram of central serous
chorioretinopathy shows active disease with both a RPE
detachment (small arrows) and a sensory retinal
detachment (large arrows). Two foci of inactive disease
(open arrows) are also present.
Fluorescein Angiography of CSC
Leakage should not be interpreted as the only
reason for the accumulation of subretinalfluid.
Although a leak is necessary for fluid to enter the
subretinal space, this fluid would normally be
removed promptly by the RPE/ choroid.
However, the fluid continues to accumulate because
the primary disease is probably a diffuse
abnormality of the RPE/choroid that impairs fluid
removal. Thus, a localized serous detachment of the
RPE without overlying neurosensory elevation can
be seen.
persistent CSR
• Vision usually improved to 95% of its original level by 3
months without specific treatment. Recurrences occur in
30% of patients and in a very small number, the condition
may become chronic. In these patients the treatment options include Diamox tablets,
betablocker tablets and photodynamic laser therapy. This is a picture of a fundus
in a patient with persistent CSR.
This is an early FA picture of this patient
late FA picture
RPE atrophic areas indicate previous episodes of CSC
47-year-old man had CSC persisting for 6 months in the right eye. Note the subretinal precipitates and RPE
defects. (b) FFA showed a subfoveal inkblot leak, and an extrafoveal smokestack. Faint hyperfluorescence
of RPE defects was also evident. (c) The CSC resolved spontaneously over 6 months with more precipitates
and RPE mottling; vision improved marginally (20/200–20/120). (d) Angiogram confirmed the absence of
leakage, and showed RPE window defects in and around fovea.
Dry AMD
Other Imaging Modalities for CSC:
Optical coherence tomography (OCT) is an excellent,
noninvasive method to use for diagnosing
and following the resolution of the subretinal fluid in
cSc. Subtle fluid accumulation beneath the sensory
retina and the RPE not evident on fluorescein
angiography (FA)
and clinical examination can often be picked up by
OCT. Once the diagnosis is established,
OCT can be used to follow and document the
resolution of the subretinal fluid.
Other Imaging Modalities for CSC:
Optical coherence tomography (OCT) is an excellent, noninvasive method to
use for diagnosing and following the resolution of the subretinal fluid in CSC.
Subtle fluid accumulation beneath the sensory retina and the RPE not
evident on fluorescein angiography (FA) and clinical examination can
often be picked up by OCT.
Once the diagnosis is established, OCT can be used to follow and
document the resolution of the subretinal fluid.
CSR
(Patient #1). OCT fundus
photograph of the left eye showing
an area of PED (thick arrow) and a
possible leakage site (thin arrow)
(top left) in a patient with CSC.
The corresponding fluorescein
angiogram shows
hyperfluorescence corresponding
to PED (thick arrow) and
smokestack pattern of leak (thin
arrow) (top right). Raster line scan
shows dome-like elevation of PED
(thick arrow) and irregular
undulations of RPE at the leakage
site (thin arrow). The RPE breach
is not seen in this scan (bottom).
(Patient
#2) Fundus
fluorescein angiogram of
the left eye of a patient with
acute CSC. The arrow
indicates the leakage site to
be studied (top left). OCT
fundus photograph shows
the placement of the slice
navigator at the point of
interest to be studied
further (top right). The
Raster line scan through
the leakage site shows
irregular retinal pigment
epithelium (RPE) with a
microrip (arrow) (bottom
left).
OCT images demonstrate a
discrete blister of fluid
underneath the RPE just
temporal to the foveal
depression. This defines the
PED. The overlying serous
retinal detachement is also
evident.
CSR
Other Imaging Modalities for CSC:
Fundus autofluorescence demonstrates
hypoautofluorescence corresponding
precisely to the site of the focal RPE leak seen
on FA, as well as pigment mottling in the area
of the RPE disturbance.
In addition, central macular autofluorescence
correlates with the level of central geographic
retinal pigment epithelial atrophy, and lower
levels are associated with poorer vision.
Central Serous Retinopathy
Acute - Fundus Autofluorescence
42-year-old man was seen in the
office on October 5, 2011. He had
noticed starting in August after a
course of antibiotic and steroids,
that he developed new spots in his
vision in the right eye. He may have
had an episode like this sometime
in the past. He did take steroids a
few years ago and his vision did
change at that time, but then
returned.
Central Serous Retinopathy
Acute - Fluorescein Angiogram
42-year-old man was seen in the
office on October 5, 2011. He had
noticed starting in August after a
course of antibiotic and steroids,
that he developed new spots in his
vision in the right eye. He may have
had an episode like this sometime
in the past. He did take steroids a
few years ago and his vision did
change at that time, but then
returned.
Chorioretinal atrophy - areas of cell
death within the RPE and adjacent tissue
layers - is a key feature of AMD.
Other Imaging Modalities for CSC:
Indocyanine green (ICG) angiography can be used to
show choroidal vascular abnormalities, including filling
delays in the choroidal arteries and choriocapillaris, venous
dilation, hyperpermeability of the choroidal vessels, and
characteristic multifocal choroidal hyperfluorescent patches
that appear early in the angiogram.These areas slowly
enlargeduring the angiogram but are less prominent in late views.
In addition, a characteristic washout pattern is often evident
that remains unchanged during clinicallyinactive phases.
ICG can be useful in helping to distinguish atypical diffuse
CSC in older patients from occult CNV in exudative AMD,
idiopathic polypoidal choroidal vasculopathy.
ICG in CSC
Central Serous Retinopathy Acute
- Indocyanine Green Angiogram Leaky Choriocapillaris
42-year-old man was seen in the
office on October 5, 2011. He had
noticed starting in August after a
course of antibiotic and steroids, that
he developed new spots in his vision
in the right eye. He may have had an
episode like this sometime in the
past. He did take steroids a few years
ago and his vision did change at that
time, but then returned.
Differential Diagnosis
The presence of subretinal fluid in older patients with CSC requires the physician
to also considera diagnosis of
CNV associated with age-related macular degeneration
optic nerve pits
idiopathic polypoidal choroidal vasculopathy
idiopathic uveal effusion syndrome (lUES).
Features that help to differentiate CSC from these other entities include the
following:
A pinpoint leak relative to a large area of subretinal fluid most likely
representsCSC.
whereas the area of subretinal fluid associated with CNV and idiopathic
polypoidal choroidal vasculopathy usually corresponds closely to the area of
leakageon angiography.
The leakage in lUES is usually diffuse.
Dry AMD
Dry AMD
Wet AMD
Wet AMD
Occult CNV
Multilobulated PED
Dlsciform scar
Differential diagnosis:
Optic nerve pits are often visible on the nerve and are contiguous with
the schisiscavity and/or subretinal fluid accumulation. No pinpoint
leakage is seen.
.Multifocal RPE abnormalities, including small serous pigment epithelial
detachments(PED) in 1 or both eyes, more likely represent CSC
whereas the presence of large drusen more likely represents age-related macular
degeneration
The yellow-white exudates of Vogt-Koyanagi-Harada syndrome can appear similar
to CSC; however, the granulomatous uveitis seen in the former helps differentiate
the diseases.
Saccular outpouchings are characteristic of idiopathic polypoidal choroidal
vasculopathy; these can be differentiated from the multifocal hyperfluorescent
patches of CSC through ICG angiography.
Optic disc Pit
The patient underwent a standard vitrectomy, removal of the posterior hyaloid, with
perfluorocarbon, laser photocoagulation, fluid-gas exchange and 12% perfluoropropane
(C3F8) injection. The whole procedure was explained to the patient beforehand. The drainage
of subretinal fluid was performed under direct visualization (Landers flat lens) through a 39gauge cannula. In addition, a sample of the vitreous humor was taken for comparative
analysis. There were no intercurrent events during the surgical procedure
Polypoidal lesions in AMD Patients with typical wet age-related macular degeneration
(AMD) may also have signs of polypoidal choroidal lesions using indocyanine green
angiography (ICGA), according to a new study. Polypoidal choroidal vasculopathy (PCV)
is a condition characterized by multiple, recurrent, serosanguinous PED
late geographic hyperfluorescence (LGH) on indocyanine green angiography (ICGA)
in cases of polypoidal choroidal vasculopathy (PCV).
Polypoidal choroidal vasculopathy
FA1
ICG1
FA2
ICG2
VKH
VKH
VMT
Differential diagnosis:
In elderly patients, lymphoma can appear similar to CSC, but lymphoma is
usually multifocal and bilateral.
.Absence of blood or significant lipid is more likely to represent CSC,
whereas thepresence of these signs is more likely to represent CNV or
idiopathic polypoidal choroidal vasculopathy.
Older patients presenting with CNV occasionally may show evidence
suggestive of previous CSC.
lymphoma
nanophthalmic uveal effusion syndrome
Preoperative fundus photography (a) revealed
almost total exudative retinal detachment and
bilateral retinal vascular dilation and tortuosity.
Fundus photographic (b), FA (c), ICGA (d), FAF (e),
and SD-OCT (f) images at 2 months after the final
surgery. Red circles (c, d, e and f) indicate the same
location in the fundus. Green lines indicate the scan
positions on SD-OCT image (f). Scattered
pigmentary spots appeared in the fundus photograph
(b). FA showed the leopard-spot pattern of
hypofluorescence (c) and ICGA demonstrated
hypofluorescent spots on a background of diffuse
hyperfluorescence of the choroid (d). Scattered
hyperfluorescent spots were observed on FAF
imaging (e). SD-OCT revealed multiple focal
thickening of the RPE layer. (f). Comparing the
images in the red circles, the RPE lesion appeared
hypofluorescent on FA (c) and ICGA (d), and
hyperfluorescent on FAF imaging (e)
IUES
Inferior RD
CME
Swelling in the macular edema
results from fluid build up and
thickening within the layers of
retinal tissue. Tiny blood vessels
which surround the macula are
usually responsible for the leakage.
Many disorders including diabetes,
vein occlusions, uveitis
(inflammation), and cataract
surgery can cause macular edema
Cellophane maculopathy
X-LINKED HEREDITARY
RETINOSCHISIS
FAMILIAL EXUDATIVE
VITREORETINOPATHY
Macular schisis in a case of juvenile
retinoschisis is shown in the fundus image
above
Commotio Retinae
Macular hole
CRAO
Natural Course and Management
.The
visual prognosis of CSC is usually good except in
chronic, recurrent cases and in casesof bullous CSC
Most eyes with CSC (80%-90%) undergo spontaneous
resorption of subretinalfluid within 3-4 months; recovery of
visual acuity usually follows, but can take upto a year.
Mild metamorphopsia, faint scotomata, abnormalities in
contrast sensitivity, andmild color vision deficits frequently
persist.
Some eyes suffer permanently diminished visual acuity, and
many (40%-50%) experience one or more recurrences.
A small subset of patients have poor visual outcomes.
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