Central Serous Chorioretinopathy- Case Presentation by Toqua Saflo

Central serous chorioretinopathy (CSCR) is characterized by focal serous detachment of the neural retina and/or retinal pigment epithelium (RPE) in the posterior pole.

1. Central serous chorioretinopathy Toqua Saflo

2. Patient Background Demographics: 38 year-old WM Chief complaint: Blurred vision involving right eye at all distances for 1week, patient describes a circular spot in vision that appears darker/dimmer Medical History: None reported Ocular History: Recent eye infection diagnosed as viral conjunctivitis for which he was seen by urgent care and was prescribed polymixin B QID x2 days, ketorolac QID ×4-5 days, and a 5-day course of oral pred. Medications: None reported

3. July 9, 2024 No PH improvement

4. July 9, 2024 Slit lamp exam: Cornea: OD: Abnormal tear break up time and anterior basement dystrophy EBMD w/ concentrated circular appearance OS: Abnormal tear break up time Anterior chamber: deep and quiet OU Iris: normal OU Lens: Clear OU Optic nerve findings: OD: Flat and well-perfused OS: Flat and well-perfused

5. July 9, 2024 Retina findings: OD: Vitreous: clear, (-) Shafer’s sign Vessels: normal caliber, no neovascularization Fundus: Flat, no hemorrhages, or exudates Macula: Flat and intact, no blood, fluid or exudates Periphery: no tears or detachments OS: Vitreous: clear, (-) Shafer’s sign Vessels: normal caliber, no neovascularization Fundus: Flat, no hemorrhages, or exudates Macula: Flat and intact, no blood, fluid or exudates Periphery: no tears or detachments

6. July 9, 2024 Diagnosis: Anterior Basement Membrane Dystrophy OD - Based on patient history, of viral conjunctivitis about 2 weeks ago and was using polymixin B then switched to ketorolac and was also prescribed oral pred and no longer taking EBMD OD>OS, significant swirling of map-dot centrally, appears to be circular around visual axis. Ddx : EBMD vs limbal stem cell deficiency brought on by topical meds/preservatives Plan and follow up: D/C all meds, heavily lubricate w/ PF-ATs, gel QHS. RTC 1 week for FU/complete exam.

7. July 16, 2024 No PH improvement

8. July 16, 2024 Slit lamp exam: Cornea: OD: Abnormal tear break up time and anterior basement dystrophy EBMD w/ concentrated circular appearance OS: Abnormal tear break up time Anterior chamber: deep and quiet OU Iris: normal OU Lens: Clear OU Optic nerve findings: OD: Flat and well-perfused OS: Flat and well-perfused

9. July 16, 2024 Retina findings: OCT performed OD: Vitreous: clear, (-) Shafer’s sign Vessels: normal caliber, no neovascularization Fundus: Flat, no hemorrhages, or exudates Macula: Central serous chorioretinopathy Periphery: no tears or detachments OS: Vitreous: clear, (-) Shafer’s sign Vessels: normal caliber, no neovascularization Fundus: Flat, no hemorrhages, or exudates Macula: Flat and intact, no blood, fluid or exudates Periphery: no tears or detachments

10. July 16, 2024 Diagnosis: Central Serous Chorioretinopathy OD: h/o oral steroid use last month (started 6/29 - 40mg BID x5 days). Expected resolution within 2-3 months. RTC for routine exam/contact lens fit when resolved. Plan and follow up: The patient should be scheduled for the following in 2 Months: - DFE - OD - DFE - OS

11. OCT image July 16, 2024

12. Overview of CSRC

13. Pathophysiology CSCR is caused by serous fluid from the choroid accumulating beneath the retina resulting a in sensory RD. It is secondary to retinal pigment epithelial decompensation and choroidal vascular changes May also see a concurrent RPE detachment.

14. Differentials CNV Tumors Inflammatory conditions Vascular pathology Rhegmatogenous RD

15. CNV vs CSCR Most important to differentiate. Particularly occult CNV: CNV CSCR May reveal subretinal or intraretinal hemorrhages , exudates , and fluid . Characterized by a serous detachment of the neurosensory retina. Presence of a grayish-green membrane under the retina May see a well-demarcated area of detachment without hemorrhage. Possible signs of AMD like drusen Retinal pigment epithelial (RPE) changes may be present. OCT: Shows subretinal or intraretinal fluid, hyperreflective material suggestive of neovascular membranes, and often associated RPE detachment. OCT: Demonstrates a serous retinal detachment with clear fluid beneath the retina and often a focal RPE detachment (PED). There is usually no hyperreflective material indicative of neovascularization.

16. Tumors vs CSCR Tumors, Leukemia, Amelanotic melanoma Infiltrative lesions different color than surrounding choroid Thickening on ultrasound No serous PED

17. Rhegmatogenous RD vs cscr Rhegmatogenous RD Elevation of macula can mimic cscr Associated retinal hole or tear No leaks on FA

18. Natural course Most will spontaneously and completely resolve. Average resolution time is 3 months 94% eyes had 20/30 Va after 24 months Many still have complaints of: decreased color vision, relative scotomas, micropsia and metamorphopsia Even though the neurosensory detachment resolves, there has still been damage to photoreceptors Irregular re pigmentation, atrophy and subretinal fibrosis

19. Treatment No medical therapy shown to be effective....Yet? Beta blockers, barbiturates, ketoconazole not shown to be effective Laser Photocoagulation or Photodynamic Therapy Goal is to reduce leakage through RPE Apply laser to site of leakage seen on FA Shorten duration of the macular detachment Does not seem to affect final VA

20. Extra pearls Let’s talk about treatment of viral conductivities, shall we: the most common cause is adenovirus and most adenoviral infections result from an upper respiratory tract or nasal mucosa infection. It is typically a self-limiting condition that resolves on its own within one to two weeks. Treatment depends on the severity of the infection: Mild/moderate cases can be treated with supportive measures including cold compresses, mild vasoconstrictors, and/or artificial tears. If the infection is severe or if the patient presents with subepithelial infiltrates (e.g., EKC), a mild topical ophthalmic steroid should be considered ( e.g : Lotemax ® QID x 1-2 weeks, followed by a short taper)

21. Extra pearls Oral steroids are generally not recommended for viral conjunctivitis. Viral conjunctivitis, commonly caused by adenoviruses, is typically a self-limiting condition that resolves on its own within one to two weeks. The use of oral steroids in viral conjunctivitis can be problematic for several reasons: Prolonged Viral Shedding: Steroids can suppress the immune response, potentially leading to prolonged viral shedding and a longer duration of the infection. Increased Risk of Secondary Infections: Immunosuppression caused by steroids can increase the risk of secondary bacterial infections. Side Effects: Oral steroids can have significant systemic side effects, including weight gain, mood changes, increased blood sugar, and in this case CSCR!

22. Questions? Thank you!