1. Case Conference
서울성모병원 안과
Pf.이원기/R2최승용

2. Clinical History M/49, PS Park, 26829343
C.C. Dec. VA(OU) o/s) 3 months ago
P.I.
M/49 pt. complaining dec. VA(OU) for 3 mo and metamorphopsia(OU) for 2mo.
Diagnosed as CSC and treated by laser(x2), but he showed no improvement.
Past History
DM/HTN(-/+), 5yrs, PO medication
Ocular trauma/op(-/-)
Familial history of eye disease(-)

3. Ocular Examination Fd VA 1.0/ 0.125 (n-c) IOP 9/8 mmHg by NCT
Conj. OU not injected
Cornea OU clear
AC OU deep & cell(-)
Pupil OU round & nl .sized, LR(+/+)
Lens OU mild cortical opacity Fd
OD nl. disc c multiple focal SRF c RPE atrophy
OS nl. disc c multiple focal SRF c RPE atrophy
large bullous RD at inf. (cannot detect tear)

4. Macular OCT(OU)

5. B-scan (OS)

6. Differential diagnosis
ERD > RRD
Leopard retina in FAG, Annular peripheral choroidal detachment, Scleral thickening in B-scan
Possibly elevated IOP
No retinal tear and retinal folding
Multifocal choroiditis
Smooth detached retinal surface
Accompanied by uveitis
Fluid shifting depends on position
Atypical CSC
Exudative RD
Focal leaking point in FAG
Harada disease
Other causes of ERD
Granulomatous uveitis
Hypertensive retinopathy
Extraocular symptoms (Neurologic, Auditory, Dermatologic)
ARMD
Coat’s disease
Post. Scleritis
Choroidal tumor
T-sign in B-scan, Ocular pain
Vasculitis d/t rheumatic disease
Idiopathic uveal effusion
FEVR
Nanophthalmos
Review Previous FAG, ICG
Review Previous Uveitis lab
FAG(OS->OD)

7. Laboratory finding CBC, BC : WNL Viral marker (-)
Toxoplasma (-), Syphilis (-)
Chest PA : WNL
ANA(-), Rheumatic factor(-)

8. Review - 2m ago : VA 1.0/0.7

9. Review – 2m ago : FAG

11. Review - 1m ago : VA 1.0/0.6

12. Review – 1m ago : FAG

13. FAG(OS->OD)

14. Cue lists A) Atypical CSC P) Large Bullous RD (unable to Tx by Laser)
Bullous RD at inf.(OS)
No retinal tear, Smooth surface
Middle-aged male
Idiopathic disease
Yellowish colored lesion, No ocular pain
No chamber cell, vitreous cell
B-scan : No scleral thickening
OCT : Multiple PED & SRF
FAG : Diffuse RPE atrophy, Focal leaking point, No disc leakage
Continuous atrophic RPE lesions
ICG : Choroidal vessel dilatation
A) Atypical CSC
P) Large Bullous RD
(unable to Tx by Laser)
 ppV(OS)
Harada disease R/O
Post. scleritis R/O
Typical sign of CSC

15. Operation

16. Progress note #1->#9 VA OS HM  LP(+) Fundus OS Plan
Filled with gas
 Decreased gas level
Increased SRF
Plan
pppV+Endolaser+SO inj.

17. Second operation

18. Progress note #18/#8 -> #25/#15
VA OS HM
Fundus OS
Filled with SO, well applied laser scar
Position : Prone -> Free

19. Review -Atypical CSC c ERD-
서울성모병원 안과
Pf.이원기/R2최승용

20. CSC (Central Serous Chorioretinopathy)
Detachment of macula
Accumulation of transparent fluid at post. Pole
Leak from RPE level (Choroid -> Retina)
Clinical features
Male>Female, middle-age (30~50)
Risk factor
Type A personality, Stress, Increased cortisol/catecholamine

21. Pathogenesis
A. Choroidal hyperpermeability with congestion of the choriocapillaris along exudation of protein and fluid
B. RPE pump decompensation(choroid 에서 retina 방향으로) occurs over time with the formation of a PED
C. 결국, RPE defect가 생기고, subretina space 에 누출이 생긴다.
D. 이것은 neurosensory retina elevation을 만들고 neurosensory retinal detachment 를 일으킨다.

22. Classification Typical (classic) CSC Atypical CSC  older age
Acute localized SRF, One or a few focal leaks in FAG, mild to mod. loss of VA
Atypical CSC  older age
Ex. Corticosteroid usage, After organ transplantation, etc.
Chronic CSC (Recurrent)
Diffuse retinal pigment epitheliopathy (Wide spread RPE alteration)
Severe loss of VA, Bilateral
Bullous CSC
Bullous RD at inf. -> Fluid shifting
Bilateral > Unilateral
Multiple PED & leaking -> Fusion (in FAG)

23. Bullous CSC Rare condition Yellow-white SRF in the post. Pole
Inf. Bullow RD extending up to sup. arcade in the supine position
“Teardrop” RD
Localized post. pole RD connected to a large inf. bullous RD
Leakage point
Can be hidden by SRF
Leakage from PED : Larger than typical CSC, From the edges
Leakage without PED

24. Diagnosis of Bullous CSC
Misdiagnosis – Complex and Confusing
Complicated during corticosteroid usage, After Organ transplantation, During pregnancy, Hemodialysis
Spontaneous aggravation and resolution
DDx
RRD
RD d/t other causes
Harada disease, Posterior scleritis, Multifocal chorioretinitis, Choroidal tumor, Uveal effusion syndrome
Some reports -> S.buckling, Steroid Tx.

25. Differential diagnosis
ERD > RRD
Leopard retina in FAG, Annular peripheral choroidal detachment, Scleral thickening in B-scan
Possibly elevated IOP
No retinal tear and retinal folding
Multifocal choroiditis
Smooth detached retinal surface
Accompanied by uveitis
Fluid shifting depends on position
Atypical CSC
Exudative RD
Focal leaking point in FAG
Harada disease
Other causes of ERD
Granulomatous uveitis
Hypertensive retinopathy
Extraocular symptoms (Neurologic, Auditory, Dermatologic)
ARMD
Coat’s disease
Post. Scleritis
Choroidal tumor
T-sign in B-scan, Ocular pain
Vasculitis d/t rheumatic disease
Idiopathic uveal effusion
FEVR
Nanophthalmos

26. Findings of Bullous CSC
Ophthalmoscopic / Angiographic findings
Yellowish colored lesion (d/t Xantophyll)
Confinement of yellow-white lesion to the outer retinal layers
Absence of vitreous cells
With single or multiple PEDs
Shifting nature of the SRF with fluctuating VA
Absence of retinal break
Typical FAG findings of CSC

27. Typical Angiographic findings
FAG findings
Presence of one or several hyperfluorescent leaks in the level of the RPE
“Smoke stack”(common), “Ink-blot”
Leakage point
1mm wide ring-like zone immediately adjacent to the fovea
Superonasal>Inferonasal>Superotemporal>Inferotemporal
In some cases, leaking point cannot be found
Chronic CSC : Mottled hyperfluorescence (Atrophic RPE tract)
ICG findings
Hyperpermeability of the choroid (mid-phase)

28. Angiographic findings

29. Treatment of CSC Spontaneous resolution 5%, Severe visual loss
대부분 수개월 내, 시력 20/25 이상 회복
5%, Severe visual loss
Photocoagulation
Shorten course of the disease (Acclerating resoption of the fluid)
No effect of final VA
Severe form, permanent VA loss를 일으킨 반대안
Photodynamic therapy
reduction of blood flow in hyperpermeable choriocapillaris
Anti-VEGF
Decrease endothelial permeability by changing tight junctions of RPE and fenestration of choriocapillary

30. Treatment of Bullous CSC
Spontaneous resolution
악화 요인 제거 : Steroid, Pregnancy 등
Fibrin in exudation captured in SRF
Fibroblast ingrowth를 통해 Partial resolusion d/t subretinal fibrotic membrane
Laser Treatment
Efficacy has not been well extablished
No significant difference (?)
Resolution of the disease, Final visual outcome
Surgery

31. Surgical drainage for SRF
Drainage of SRF
When Laser is unavailable d/t SRF
Ext. drainage
Need buckling
Can be assisted by intraocular surgery (gas injection or ppV)
Can avoid retinotomy, risk of intraocular surgery
Complete transscleral drainage is very difficult d/t Fluid shifting
Risk of subretinal, choroidal hemorrhage

32. Surgical drainage for SRF
Int. drainage
Need ppV
ppV, FAE , int. SRFD, Endolaser
Usage of PFCL
Can be assisted by buckling
Risk of RRD
Re-opening of retinotomy site
Fluid accumulation around the retinotomy site
Silicone oil tamponade for prevention of RRD