|Year : 1977 | Volume
| Issue : 4 | Page : 17-20
Central serous chorioretinopathy
SS Badrinath, SH Baig
Voluntary Health Services Medical Centre, Adyar, Madras, India
S S Badrinath
Voluntary Health Services Medical Centre, Adyar, Madras-600020
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Badrinath S S, Baig S H. Central serous chorioretinopathy. Indian J Ophthalmol 1977;25:17-20
Central serous chorioretinopathy is a condition characterised by the presence of large serous detachment of the retina of one or both the eyes. It occurs more oftener in men than women.
The central serous retinopathy may be paramacular or peripheral as described by Wolkowickzs in his review of the literature. The term "central serous chorioretinopathy" was coined by Duggan who opined that permanent pigmentary changes are characteristic of choroidal and not retinal lesions and the transudate is subretinal originating in the choriocapillaries. "Central angiospastic chorioretinopathy" is another term applied to this condition'. The retinal detachment in such a lesion was more diffuse including the paramacular area and it extended beyond the course of the large temporal vessels. Tremendous transudation of fluid led to a detachment of the internal limiting membrane with ten to twelve dioptres elevation. The pathogenesis of such a lesion was attributed to vasomotor lability found in conjunction with infections, allergic, endocrine and metabolic factors.
The patients may often be misdiagnosed as having a rhegmatogenous retinal detachment or secondary detachments due to Harada's disease, collagen vascular diseases, choroidal haemangiomas, malignant melanoma, metastatic choroidal carcinoma or focal choroiditis. The use of fluorescein angiography is invaluable in the correct diagnosis of these patients. Unlike others these have a good prognosis when detected early. Gass  is of the opinion that this disease entity probably represents an exaggerated form of central serous retinopathy.
| Material and Methods|| |
This study includes nine patients and among these clinical diagnosis of central serous chorio-retinopathy was made in twelve eyes. The disease was bilateral in three cases and unilateral in the remaining six cases. The fellow eye was normal in three cases. One had evidence of a fresh central serous retinopathy and two others showed evidence of old central serous retinopathy.
Eight patients were males and one was a female. Majority of the cases (five cases constituting 55.5.%) were in the 31-40 years age group. The youngest patient was 30 years old and the oldest 72 years.
Ocular examination included determination of visual acuity, refraction, ocular tension with Schiotz tonometer and slit lamp examination of anterior segment. Indirect ophthalmoscopy with depression after full mydriasis was carried out in all patients and retinal drawings were made in the lying posture and in some of the severe cases in sitting posture as well. Fluorescein ophthalmoscopy was carried out in all cases by injecting 5 c. c. of 10% Fluorescein Sodium intravenously.
Five out of the total 12 eyes, had severe degree of involvement of central serous chorioretinopathy with a very large transudation and bullous detachment of the retina. The other seven eyes were involved to a lesser degree, manifesting a shallow retinal detachment of the posterior pole tracking down inferiorly upto the ora serrata.
All the severe cases were hospitalised for a period ranging from one to three weeks. Rest of the patients received treatment as out patients.
The more frequent symptoms were failing vision, dark round shadow in the centre, persistent shadow in upper visual fields and "flashes".
Indistinct vision in twilight, floaters, difficulty in reading, metamorphopsia, chromatopsia were the other infrequent symptoms.
On examination visual acuity varied from 6/9 in the least affected eye to only hand movements in the most affected. The ocular tension was normal in all cases except in one in which it was very soft. The visual fields generally showed a defect corresponding to the inferior retina detachment.
Slit lamp examination was normal in all cases. Dust like vitreous opacities so frequent in chorioretinitis were conspicuously absent.
Fundus examination revealed in all cases serous retinal detachment. Depending upon the extent involved and the degree of transudation, we have classified the disease into severe and milder groups. Retinal breaks were not found in any of the eyes and the subretinal fluid shifted markedly with change in posture. With the patient sitting up the retinal detachment formed inferior balloons with the posterior polar area becoming flat and smooth. A flat, annular choroidal detachment which seems to be an important fundus finding in cases of "uveal effusions" described by Schepens, was conspicuously absent in our series. Signs of active chorioretinitis were also absent.
Other common fundus findings were the presence of white, yellow or brown subretinal deposits of flakes lying deep to the retinal vessels. White or yellow lesions in the choroid seen through the detached retina and clear subretinal fluid. Subretinal gliosis and bands in long standing cases.
Interrupted sheathing of arterioles, choroidal pigmentation and surface retinal haemorrhages were the other infrequent findings. One eye had pars plana cyst.
All the eyes showed evidence of leakage of dye on fluorescein angiography. Quite often the leaks were multiple, found mainly in and around the posterior polar area. In none of the cases a peripherally located leaking spot was found. In the severe cases the leaks were more evident by making the patient sit up and as the fluid settled down inferiorly.
Modalities of Treatment:
1) Photocoagulation alone
2) Photocoagulation combined with subretinal fluid drainage and injection or saline and steroids into the vitreous cavity
3) Supplementary therapy.
1. Photocoagulation alone:
Photocoagulation with Carl-Zeiss Xenon arc was carried out in six eyes. In three eyes photocoagulation was done once. In one eye the detachment completely subsided within four weeks, while in the others it took nearly six months before complete resolution was observed. One patient still under observation, has evidence of minimal amount of fluid, even after eight weeks. Three eyes needed a repeat photocoagulation, the time interval between two sittings varying from one to three weeks. The photocoagulation was repeated either to reinforce the previously treated areas or to seal newly detected leaks.
2. Subretinal Fluid Drainage and Photocoagulation:
Five eyes belonging to the "severe degree" category underwent drainage of subretinal fluid followed by photocoagulation. Four of these had photocoagulation before surgery, the time interval taken between the first coagulation and the surgery varying from fourteen days to three months. When there was no favourable response with photocoagulation alone, drainage of subretinal fluid and subsequent coagulation was carried out. The fifth case who is a recent addition was not subjected to such a photocoagulation "trial" before surgery.
Surgery is done under local anaesthesia and best results were obtained when the drainage of the subretinal fluid was done in the most dependent part with the patient's head kept in an elevated position. Patients were advised to sleep with the head propped up in order to prevent further deterioration of macular function and for the photocoagulation to be effective.
In two instances the drainage was not successful. The reason for this could be that in one the drainage was not done in the most dependent area. In the second case the tapping was dry even after observing the above precaution. An abnormally thick choroid could be a cause, making its perforation for release of subretinal fluid difficult to accomplish, even after exposure of knuckle of choroid.
Incarceration of retina occurred in two cases. In one instance lenticular opacity was noticed five days after surgery at a site corresponding to where the needle was used to pierce pars plana for injecting saline into the vitreous cavity. The cataract became mature within four months and had to be extracted. However, vision in this eye did not improve because of permanent pigmentary changes noticed in the macular area, even though the retina had settled well. latrogenic retinal break developed at the perforation site in one case. This retinal hole was sealed by a trap door buckling procedure. A repeat subretinal fluid drainage in this case, after a fortnight proved to be successful an d was followed by coagulation therapy. The visual acuity has improved to 6/36 from counting fingers at two metres before commencing treatment. A surface retinal haemorrhage was noted in one case after surgery.
In the fellow eye of one of the patients which showed a milder form of central serous chorioretinopathy improved remarkably with retrobulbar injections of steroids. He had eighteen retrobulbar injections of 0.5 cc of Decadron. The time taken for settlement of retina was six weeks from the time of the first examination.
Many of the patients were already on systemic steroids therapy. They had also received retrobulbar and subconjunctival steroid injections.
Four cases were put on systemic steroids on massive doses (60-100 mg. daily) for a period of seven to ten days. Local steroids were given either subconjunctivally or by retrobulbar route. Endoxan was used cautiously in one case (one tablet three times a day for 15 days) with frequent blood counts. It did not yield favourable response.
Associated systemic disturbances:
Efforts were made to find out the etiology. Detailed medical examination was carried out and a search for focus of sepsis was made. One case had a root abscess in relation to the left maxillary premolar and another case had a nasal allergy. These conditions were attended to immediately by the specialists concerned.
Laboratory tests were carried out as would be performed for uveitis. Three cases had a raised E.S.R. Mantoux was positive in one cast.
The `virus culture' of the subretinal fluid done at I.C.M.R. Virus Research Centre was negative.
Visual recovery was slow and varied from 6/5 to counting fingers at two metres. In general the mild cases have a very favourable prognosis. In eight eyes the visual acuity improved after treatment and in four others it was atleast maintained. None exhibited deterioration.
Field defects show persistence of moderate size defects in upper fields in two of the seven cases and persistence of a central scotoma in a severely affected eye. In a mild case there has been a complete resolution of field defect.
Up to now none of the cases had any recurrences. Probably the participation of the choroid deprives the attacks of their fleeting character  . Since the longest follow-up has been only 20 months in our study group, one cannot be dogmatic about the disease being not recurrent.
| Discussion|| |
Following were the common clinical features observed in the nine patients.
Except for the unusual amount of subretinal fluid, rapidly shifting and extending all the way upto the ora serrata, many of the features are characteristics of central serous retinopathy. Fluorescein angiography has demonstrated the origin of subretinal fluid to be in the choriocapillaries rather than in retinal vessels.  The serous exudate is trapped initially beneath small focal areas of retinal pigment epithelium detachment prior to spreading into subretinal space.
In the presence of serous detachment of retinal pigment epithelium, fluorescein diffuses across the full thickness of Bruch's membrane and into subpigment epithelial exudate to outline precisely the area of retinal pigment epithelial detachment, underlying the serous retinal detachment  . Focal loss of adherence of basement membrane of retinal pigment epithelium to the collagen portion of Bruch's membrane is the key factor in producing this clinical picture.
The diagnosis in each of the 9 cases is believed to be severe form of idiopathic central serous choroidopathy (ICSC) and are unusual in two ways.
1. Multiple large leaks indicative of many large sized retinal pigment epithelial detachments.
2. Large amount of subretinal fluid.
The cases with bilateral affection, may be misdiagnosed as "Harada's disease".
The use of fluorescein angiography is recommended to detect the size and source of leakage of subretinal fluid in any patient where the origin of fluid is uncertain. This is particularly important in those patients suspected of having a rhegmatogenous detachment where the retinal break is not to be found. The presence of leakage from choroid into subretinal fluid is indicative of secondary detachment.
In patients with bullous retinal detachment the absence of fluorescein leakage suggests that the detachment is rhegmatogenous. Notable exception would be serous detachment of retina secondary to congenital pit of the optic disc. In such cases the retinal detachment is always continous with the optic nerve head and the optic pit is usually visible opthalmoscopically. Hole-less detachment, Philips  has also been described in high myopia with posterior staphyloma. None of our cases had a congenital pit of optic discs and none had high degree of myopia.
The mild cases (seven eyes) showed a very good response to photocoagulation directed towards the area of retinal pigment epithelial detachments as is true in patients with typical central serous retinopathy. The severe cases would benefit if photocoagulation is combined with the release of subretinal fluid. Retinal drawings and angiography in lying and sitting positions would uncover larger number of retinal pigment epithelial datachments. So also photocoagulation in such cases in sitting posture would enable good adhesion and quick repair. Suplementary therapy with corticosteroids would be of additional help in combating this disease.
| Summary|| |
Nine healthy, mostly middle aged men developed rapid visual loss secondary to serous retinal detachment in the posterior pole and inferior fundus of one or both eyes. The subretinal fluid extended upto ora serrata and shifted rapidly. Absence of retinal breaks ruled out rhegmatogenous retinal detachment. None of the patients had any other evidence of intra ocular or systemic disease.
Immense value of fluorescein angigraphy both in differential diagnosis and prognosis of the disease has been stressed. Modalities of treatments with special reference to photocoagulation in sitting posture and following subretinal fluid drainage has been discussed.
| References|| |
Bertha Klien, 1953, Amer. J. Ophthal.,
Calbert I. Philips, 1958, Brit. J. Ophthal., 42,
Donald M. Gass, 1967, Amer. J. Ophthal.,
63, 573, 587.
Donald M. Gass, 1970, Amer. J. Ophthal., 67,
Gass J.D.M., 1973, Amer. J. Ophthal., 75,
Wolkowicz M., 1956, Amer. J. Ophthal., 42,