Central serous chorioretinopathy may occur in younger patients
A 27-year-old Caucasian man presented to the optometry clinic with a chief complaint of visual disturbance in his left eye for the past few days. He reported that when he looks at a sheet of paper with both eyes, he sees a blue circle in the center. When he looks at his computer binocularly, the screen also seems tinted with a brown filter, and overall colors seem brighter out of the right eye. His eyes feel watery and dry at times, and he denies high or higher than normal stress levels recently.
The patient had PRK surgery in both eyes 4 years prior and is generally a healthy member of the military. Two weeks prior to this eye exam, he was prescribed a course of Medrol (prednisone 500 mg tablets, Pfizer) at an urgent care facility for muscle pain. He took no other medications.
The patient’s uncorrected distance visual acuity was 20/15 OD, OS, and uncorrected near visual acuity was 20/20 OD, OS. He had not worn correction since his refractive surgery. During manifest refraction of the left eye, the patient reported being annoyed by a persistent spot in the upper left corner of his vision through the phoropter. Amsler grid was performed, and the right eye tested normal, while the left eye indicated a small pericentral superior temporal metamorphopsia. The Ishihara color vision test was performed, and the patient scored 7/7 in the right eye and 4/7 in the left. He denied having a history of color vision deficiency, which would have been tested prior to entering the military. Slit lamp examination revealed an unremarkable anterior segment. No post-surgical corneal haze was noted in either eye.
IOP measured with non-contact tonometry was 12 mm Hg OD and 15 mm Hg OS. No media opacities were present. Dilated fundus examination was performed and appeared normal, with a cup-to-disc ratio of 0.35 OD, OS, with optic nerve defects. A small area of retinal hyperpigmentation was noted inferiorly in the right eye. Zeiss OCT macular mapping was performed, which revealed a normal right eye and a small area of subretinal fluid under the macula in the left eye.
Differential diagnoses considered at this point included central serous chorioretinopathy, macular hole and pigment epithelial macular detachment.
Typically unilateral and affecting type A personality men in their 20s to 50s, central serous chorioretinopathy can also be associated with steroid use or autoimmune conditions. Patients may have decreased vision with metamorphopsia and reduced color vision, and OCT shows subretinal fluid beneath the macula with a sloping margin. Fluorescein angiography can be performed and often shows a pathognomonic smoke-stack leakage pattern. The prognosis is good, with visual acuity improving as the pigment epithelial detachment resolves within 3 to 6 months. Focal laser photocoagulation can be performed to speed visual recovery, but this has been shown to reduce contrast sensitivity and can promote choroidal neovascularization, so it is not frequently the treatment of choice.
More common in older women, macular holes present as a distinct round red spot in the center of the macula with or without an operculum and cuff of surrounding edema. OCT can help determine the stage of the hole, with a full thickness defect in stages 3 and 4.
When viewing pigment epithelial detachment on OCT, the margins are more distinct than sloping, and the retinal pigment epithelium is elevated.
This patient’s management
Macular OCT and exam findings led to the diagnosis of central serous chorioretinopathy in the left eye. Because the best treatment is tincture of time, this patient was told to return to the clinic in 1 month, with resolution expected in 3 to 6 months. No drops or oral medications were ordered.
The patient returned a month later for follow-up. He reported that he stopped seeing the troublesome spot in his vision about 2 weeks prior to this appointment. The patient’s uncorrected distance visual acuity was 20/15 OD, OS, and uncorrected near visual acuity was 20/20 OD, OS. Amsler grid testing was within normal limits in both eyes. Slit lamp examination revealed unremarkable anterior and posterior segments. Zeiss OCT macular testing showed almost complete resolution of subretinal fluid in the left eye, with only a trace amount remaining. The patient followed up once more in a month, and the OCT showed the subretinal fluid was completely resolved at that time. Ishihara color vision was 14/14. He was now asymptomatic and recommended to have routine exams every year or two.
During examination, the patient denied having an increase in stress at work or home and even said he has a very low stress job compared with most people. He had recently taken a prednisone dose pack, which may have caused the macular edema. His case improved quickly, and he has experienced a full recovery in a short time. The clinical pearl I took away from this case is to not immediately rule out central serous in younger patients when the chief complaint is unusual.
- Ehlers JP, et al. The Wills Eye Manual. Fifth Ed, 2008;300-301.
- Freidman NJ, et al. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology, 2009;381-383.
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- Emily Thompson, OD, FAAO, completed her residency in ocular disease and refractive and ocular surgery at the Oklahoma College of Optometry. She currently practices at Tinker Air Force Base in Oklahoma City, Okla. She can be reached at: email@example.com.