Central Serous Chorioretinopathy/Choroidopathy (CSC) in General Terms, What Is the Pathophysiology of CSC?

1 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)

In general terms, what is the pathophysiology of CSC? 2 Q/A Central Serous Chorioretinopathy/Choroidopathy (CSC)

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinalthree words detachment  visual dysfunction (not yet)

Answer this one first--what directly causes visual dysfunction in CSC? 3 Q/A Central Serous Chorioretinopathy/Choroidopathy (CSC)

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinal detachment  visual dysfunction (not yet) 4

Central Serous Chorioretinopathy/Choroidopathy (CSC)

CSC: Serous RD 5 Q/A Central Serous Chorioretinopathy/Choroidopathy (CSC)

In general terms, what is the pathophysiology of CSC?   Choroidal hyperpermeabilitytwo words serous retinal detachment visual dysfunction + four words and an abb.

Now this one--what causes the serous RD? 6 A Central Serous Chorioretinopathy/Choroidopathy (CSC)

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinal detachment  visual dysfunction + leakage at level of RPE 7 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinal detachment  visual dysfunction + leakage at level of RPE 8 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinal detachment  visual dysfunction + leakage at level of RPE 9 Q Central Serous Chorioretinopathy/Choroidopathy (CSC) Is the loss of Snellen acuity usually mild, or severe?  Specific visual complaintsMild in CSC :  What is the typical range of Snellen acuity, and the typical value? Decreased VA The range is 20/20 - 20/200; the typical value is 20/30 or better  Metamorphopsia A refractive shift may contribute to the decreased VA. If present, what sort of refractive shift is typical?  Micropsia A hyperopic shift  Scotomata Why a hyperopic shift? Because the submacular fluid elevates the fovea, shortening the  Altered color visioneffective axial length of the eye, thus rendering it more hyperopic

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinal detachment  visual dysfunction + leakage at level of RPE 10 A Central Serous Chorioretinopathy/Choroidopathy (CSC) Is the loss of Snellen acuity usually mild, or severe?  Specific visual complaintsMild in CSC :  What is the typical range of Snellen acuity, and the typical value? Decreased VA The range is 20/20 - 20/200; the typical value is 20/30 or better  Metamorphopsia A refractive shift may contribute to the decreased VA. If present, what sort of refractive shift is typical?  Micropsia A hyperopic shift  Scotomata Why a hyperopic shift? Because the submacular fluid elevates the fovea, shortening the  Altered color visioneffective axial length of the eye, thus rendering it more hyperopic

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinal detachment  visual dysfunction + leakage at level of RPE 11 Q Central Serous Chorioretinopathy/Choroidopathy (CSC) Is the loss of Snellen acuity usually mild, or severe?  Specific visual complaintsMild in CSC :  What is the typical range of Snellen acuity, and the typical value? Decreased VA The range is 20/20 - 20/200; the typical value is 20/30 or better  Metamorphopsia A refractive shift may contribute to the decreased VA. If present, what sort of refractive shift is typical?  Micropsia A hyperopic shift  Scotomata Why a hyperopic shift? Because the submacular fluid elevates the fovea, shortening the  Altered color visioneffective axial length of the eye, thus rendering it more hyperopic

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinal detachment  visual dysfunction + leakage at level of RPE 12 A Central Serous Chorioretinopathy/Choroidopathy (CSC) Is the loss of Snellen acuity usually mild, or severe?  Specific visual complaintsMild in CSC :  What is the typical range of Snellen acuity, and the typical value? Decreased VA The range is 20/20 - 20/200; the typical value is 20/30 or better  Metamorphopsia A refractive shift may contribute to the decreased VA. If present, what sort of refractive shift is typical?  Micropsia A hyperopic shift  Scotomata Why a hyperopic shift? Because the submacular fluid elevates the fovea, shortening the  Altered color visioneffective axial length of the eye, thus rendering it more hyperopic

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinal detachment  visual dysfunction + leakage at level of RPE 13 Q Central Serous Chorioretinopathy/Choroidopathy (CSC) Is the loss of Snellen acuity usually mild, or severe?  Specific visual complaintsMild in CSC :  What is the typical range of Snellen acuity, and the typical value? Decreased VA The range is 20/20 - 20/200; the typical value is 20/30 or better  Metamorphopsia A refractive shift may contribute to the decreased VA. If present, what sort of refractive shift is typical?  Micropsia A hyperopic shift  Scotomata Why a hyperopic shift? Because the submacular fluid elevates the fovea, shortening the  Altered color visioneffective axial length of the eye, thus rendering it more hyperopic

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinal detachment  visual dysfunction + leakage at level of RPE 14 A Central Serous Chorioretinopathy/Choroidopathy (CSC) Is the loss of Snellen acuity usually mild, or severe?  Specific visual complaintsMild in CSC :  What is the typical range of Snellen acuity, and the typical value? Decreased VA The range is 20/20 - 20/200; the typical value is 20/30 or better  Metamorphopsia A refractive shift may contribute to the decreased VA. If present, what sort of refractive shift is typical?  Micropsia A hyperopic shift  Scotomata Why a hyperopic shift? Because the submacular fluid elevates the fovea, shortening the  Altered color visioneffective axial length of the eye, thus rendering it more hyperopic

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinal detachment  visual dysfunction + leakage at level of RPE 15 Q Central Serous Chorioretinopathy/Choroidopathy (CSC) Is the loss of Snellen acuity usually mild, or severe?  Specific visual complaintsMild in CSC :  What is the typical range of Snellen acuity, and the typical value? Decreased VA The range is 20/20 - 20/200; the typical value is 20/30 or better  Metamorphopsia A refractive shift may contribute to the decreased VA. If present, what sort of refractive shift is typical?  Micropsia A hyperopic shift  Scotomata Why a hyperopic shift? Because the submacular fluid elevates the fovea, shortening the  Altered color visioneffective axial length of the eye, thus rendering it more hyperopic

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinal detachment  visual dysfunction + leakage at level of RPE 16 A Central Serous Chorioretinopathy/Choroidopathy (CSC) Is the loss of Snellen acuity usually mild, or severe?  Specific visual complaintsMild in CSC :  What is the typical range of Snellen acuity, and the typical value? Decreased VA The range is 20/20 - 20/200; the typical value is 20/30 or better  Metamorphopsia A refractive shift may contribute to the decreased VA. If present, what sort of refractive shift is typical?  Micropsia A hyperopic shift  Scotomata Why a hyperopic shift? Because the submacular fluid elevates the fovea, shortening the  Altered color visioneffective axial length of the eye and rendering it more hyperopic

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinal detachment  visual dysfunction + leakage at level of RPE 17 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia What do the terms metamorphopsia and micropsia mean?  Scotomata Metamorphopsia refers to a distortion in the shape of an object’s visual image. Micropsia occurs when an object  Altered color visionappears to be smaller than its actual size.

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinal detachment  visual dysfunction + leakage at level of RPE 18 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia What do the terms metamorphopsia and micropsia mean?  Scotomata Metamorphopsia refers to a distortion in the shape of an object’s visual image. Micropsia occurs when an object  Altered color visionappears to be smaller than its actual size.

In general terms, what is the pathophysiology of CSC? Choroidal hyperpermeability  serous retinal detachment  visual dysfunction + leakage at level of RPE 19 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: 20 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male 21 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male What is the male:female ratio? About 3:1 22 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male What is the male:female ratio? About 3:1 23 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male What is the male:female ratio? About 3:1

3:1??!! I thought it was more like 10:1, or at least 6:1. What gives? It’s true that early studies found ratios in the 6:1 to 10:1 range. However, upon further review it is clear that the early research heavily overrepresented males. So 3:1 it is. 25 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male  Age: 26 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male  Age: 35 – 55 27 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male  Age: 35 – 55

What diagnosis must you consider carefully before deciding an individual over 50 has CSC? Wet ARMD 28 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male  Age: 35 – 55

What diagnosis must you consider carefully before deciding an individual over 50 has CSC? Wet ARMD 29 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male  Age: 35 – 55  Racial predilection: 30 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male  Age: 35 – 55  Racial predilection: None 31 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male  Age: 35 – 55  Racial predilection: None  General health: 32 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male  Age: 35 – 55  Racial predilection: None  General health: Good 33 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male  Age: 35 – 55  Racial predilection: None  General health: Good  Personality: 34 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male  Age: 35 – 55  Racial predilection: None  General health: Good  Personality: ‘Type A’ 35 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male WhatAge words: 35are we– looking55 for to clue us in we’re dealing with someone predisposed personality-wise to CSC? -- Racial predilection: None -- -- General health: Good  Personality: ‘Type A’ 36 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Specific visual complaints in CSC:  Decreased VA  Metamorphopsia  Micropsia  Scotomata  Altered color vision  Classic CSC demographics:  Sex: Male WhatAge words: 35are we– looking55 for to clue us in we’re dealing with someone predisposed personality-wise to CSC? --’Tense’Racial predilection: None --’Driven’ --’Stressed’General health: Good  Personality: ‘Type A’ 37 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:

 Most common: An expansiletwo words dot (aka inktwo wordsblot) 38 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot) 39

Central Serous Chorioretinopathy/Choroidopathy (CSC)

CSC: Expansile dot 40 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot)  Less common, but more classic: Smokestackone word 41 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot)  Less common, but more classic: Smokestack 42

Central Serous Chorioretinopathy/Choroidopathy (CSC)

CSC: Smokestack pattern 43 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA: What is the shape of the classic smokestack pattern? Um, a smokestack?Most common: An expansile dot (aka ink blot)

Importantly, Less it is common, not smokestack but-shaped. more Rather, classic: it is so Smokestack named because the dye behaves as if it’s smoke billowing from a smokestack. And the Retina book provides a particular description of this behavior. What is it? ‘Tree shaped;’ ie, a narrow, trunk-like portion below with a spread-out, canopy-like portion above

So, it’s a smokestack yielding a tree? Isn’t that a rather awkward mixing of metaphors? What can I say--I’m just the messenger… 44 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA: What is the shape of the classic smokestack pattern? Um, a smokestack?Most common: An expansile dot (aka ink blot)

So, it’s a smokestack yielding a tree? Isn’t that a rather awkward mixing of metaphors? What can I say--I’m just the messenger… 45 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA: What is the shape of the classic smokestack pattern? Um, a smokestack?Most common: An expansile dot (aka ink blot)

So, it’s a smokestack yielding a tree? Isn’t that a rather awkward mixing of metaphors? What can I say--I’m just the messenger… 46 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA: What is the shape of the classic smokestack pattern? Um, a smokestack?Most common: An expansile dot (aka ink blot)

So, it’s a smokestack yielding a tree? Isn’t that a rather awkward mixing of metaphors? What can I say--I’m just the messenger… 47

Central Serous Chorioretinopathy/Choroidopathy (CSC)

CSC: ‘Tree shaped’ FA pattern 48 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA: What is the shape of the classic smokestack pattern? Um, a smokestack?Most common: An expansile dot (aka ink blot)

So, it’s a smokestack yielding a tree? Isn’t that a rather awkward mixing of metaphors? What can I say--I’m just the messenger… 49 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA: What is the shape of the classic smokestack pattern? Um, a smokestack?Most common: An expansile dot (aka ink blot)

So, it’s a smokestack yielding a tree? Isn’t that a rather awkward mixing of metaphors? What can I say--I’m just the messenger 50 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot)  Less common, but more classic: Smokestack

Does OCT have any advantages as an imaging modality for CSC? It does indeed. In addition to being noninvasive, OCT can reveal subtle amounts of subretinal fluid (SRF) and/or sub-RPE fluid that may be too scant to be detected via FA. 51 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot)  Less common, but more classic: Smokestack

Central Serous Chorioretinopathy/Choroidopathy (CSC)

CSC: OCT 53 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot)  Less common, but more classic: Smokestack  CSC pathophysiology in a nutshell:

 Choroidal hyperpermeabilityone word + altered RPE barriertwo wordsfunction  serous retinalthree words detachment

(this question is a recapitulation of the info covered at the outset of the slide-set) 54 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot)  Less common, but more classic: Smokestack  CSC pathophysiology in a nutshell:  Choroidal hyperpermeability + altered RPE barrier function  serous retinal detachment 55 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot)  Less common, but more classic: Smokestack  CSC pathophysiology in a nutshell:  Choroidal hyperpermeability + altered RPE barrier function  serous retinal detachment  Natural course of CSC:

 90%% resorb spontaneously within 6 monthstime frame 56 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot)  Less common, but more classic: Smokestack  CSC pathophysiology in a nutshell:  Choroidal hyperpermeability + altered RPE barrier function  serous retinal detachment  Natural course of CSC:  90% resorb spontaneously within 6 months 57 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot)  Less common, but more classic: Smokestack  CSC pathophysiology in a nutshell:  Choroidal hyperpermeability + altered RPE barrier function  serous retinal detachment  Natural course of CSC:  90% resorb spontaneously within 6 months

 Snellen VA usually returnsreturns to baseline to vsbaselineremains poor 58 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot)  Less common, but more classic: Smokestack  CSC pathophysiology in a nutshell:  Choroidal hyperpermeability + altered RPE barrier function  serous retinal detachment  Natural course of CSC:  90% resorb spontaneously within 6 months  Snellen VA usually returns to baseline 59 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot)  Less common, but more classic: Smokestack  CSC pathophysiology in a nutshell:  Choroidal hyperpermeability + altered RPE barrier function  serous retinal detachment  Natural course of CSC:  90% resorb spontaneously within 6 months  Snellen VA usually returns to baseline common or  Residual mild deficits commonuncommon 60 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot)  Less common, but more classic: Smokestack  CSC pathophysiology in a nutshell:  Choroidal hyperpermeability + altered RPE barrier function  serous retinal detachment  Natural course of CSC:  90% resorb spontaneously within 6 months  Snellen VA usually returns to baseline  Residual mild deficits common 61 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot)  Less common, but more classic: Smokestack  CSC pathophysiology in a nutshell:  Choroidal hyperpermeability + altered RPE barrier function  serous retinal detachment  Natural course of CSC:  90% resorb spontaneously within 6 months  Snellen VA usually returns to baseline  Residual mild deficits common

 50%% have recurrence 62 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Three leakage patterns seen on FA:  Most common: An expansile dot (aka ink blot)  Less common, but more classic: Smokestack  CSC pathophysiology in a nutshell:  Choroidal hyperpermeability + altered RPE barrier function  serous retinal detachment  Natural course of CSC:  90% resorb spontaneously within 6 months  Snellen VA usually returns to baseline  Residual mild deficits common  50% have recurrence 63 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroidscan be a drug, or not 64 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids 65 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids

Which of these corticosteroid administration routes have been associated with CSC? --PO? --IV? --Topical? --Intra-articular? --Intranasal? 66 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids

Which of these corticosteroid administration routes have been associated with CSC? --PO! --IV! --Topical! All have been implicated in CSC --Intra-articular! --Intranasal! 67 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids

Which of these corticosteroid administration routes have been associated with CSC? --PO! --IV! --Topical! All have been implicated in CSC --Intra-articular! --Intranasal! --Intravitreal? NO!

What about intravitreal steroids? Surely these can cause CSC as well? 68 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids

Which of these corticosteroid administration routes have been associated with CSC? --PO! --IV! --Topical! All have been implicated in CSC --Intra-articular! --Intranasal! --Intravitreal? NO!

What about intravitreal steroids? Surely these can cause CSC as well? You’d think so, but no--there is no evidence that it does! 69 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids

Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSC Retina book. What are they? Sildenafil and MEK inhibitors 70 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids

Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSC Retina book. What are they? Sildenafil, and MEK inhibitors 71 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids

Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSC Retina book. What are they? Sildenafil, and MEK inhibitors

What class of med is sildenafil? It is a phosphodiesterase-5 (PDE5) inhibitor

How do PDE5 inhibitors cause CSC? Probably by inducing dilation of the choroidal vasculature 72 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids

Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSC Retina book. What are they? Sildenafil, and MEK inhibitors

What class of med is sildenafil? It is a phosphodiesterase-5 (PDE5) inhibitor

How do PDE5 inhibitors cause CSC? Probably by inducing dilation of the choroidal vasculature 73 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids

Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSC Retina book. What are they? Sildenafil, and MEK inhibitors

What class of med is sildenafil? It is a phosphodiesterase-5 (PDE5) inhibitor

How do PDE5 inhibitors cause CSC? Probably by inducing dilation of the choroidal vasculature 74 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids

Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSC Retina book. What are they? Sildenafil, and MEK inhibitors

What class of med is sildenafil? It is a phosphodiesterase-5 (PDE5) inhibitor

How do PDE5 inhibitors cause CSC? Probably by inducing dilation of the choroidal vasculature 75 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

corticosteroids What does MEK stand for in this context? Don’t ask--it’s complicated Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSCWhat Retinaare MEKbook. inhibitors What (MEKIs) are they? used to treat? Metastatic cancer Sildenafil and MEK inhibitors What is MEKi-associated retinopathy called? It is called ‘MEKi-associated retinopathy’ (MEKAR)

How prevalent is MEKAR? Very--estimates run as high as 90% of MEKi users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEKi? No 76 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

How prevalent is MEKAR? Very--estimates run as high as 90% of MEKi users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEKi? No 77 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

corticosteroids What does MEK stand for in this context? Don’t ask--it’s complicated Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSCWhat Retinaare MEKbook. inhibitors What (MEKs) are they? used to treat? Metastatic cancer Sildenafil and MEK inhibitors What is MEKi-associated retinopathy called? It is called ‘MEKi-associated retinopathy’ (MEKAR)

How prevalent is MEKAR? Very--estimates run as high as 90% of MEKi users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEKi? No 78 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

corticosteroids What does MEK stand for in this context? Don’t ask--it’s complicated Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSCWhat Retinaare MEKbook. inhibitors What (MEKs) are they? used to treat? Metastatic cancer Sildenafil and MEK inhibitors What is MEKi-associated retinopathy called? It is called ‘MEKi-associated retinopathy’ (MEKAR)

How prevalent is MEKAR? Very--estimates run as high as 90% of MEKi users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEKi? No 79 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

corticosteroids What does MEK stand for in this context? Don’t ask--it’s complicated Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSCWhat Retinaare MEKbook. inhibitors What (MEKs) are they? used to treat? Metastatic cancer Sildenafil and MEK inhibitors What is MEK-associated retinopathy called? It is called ‘MEKi-associated retinopathy’ (MEKAR)

How prevalent is MEKAR? Very--estimates run as high as 90% of MEKi users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEKi? No 80 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

corticosteroids What does MEK stand for in this context? Don’t ask--it’s complicated Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSCWhat Retinaare MEKbook. inhibitors What (MEKs) are they? used to treat? Metastatic cancer Sildenafil and MEK inhibitors What is MEK-associated retinopathy called? It is called ‘MEK-associated retinopathy’ (MEKAR)

How prevalent is MEKAR? Very--estimates run as high as 90% of MEKi users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEKi? No 81 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

corticosteroids What does MEK stand for in this context? Don’t ask--it’s complicated Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSCWhat Retinaare MEKbook. inhibitors What (MEKs) are they? used to treat? Metastatic cancer Sildenafil and MEK inhibitors What is MEK-associated retinopathy called? It is called ‘MEK-associated retinopathy’ (MEKAR)

How prevalent is MEKAR? Very--estimates run as high as 90% of MEKi users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEKi? No 82 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

corticosteroids What does MEK stand for in this context? Don’t ask--it’s complicated Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSCWhat Retinaare MEKbook. inhibitors What (MEKs) are they? used to treat? Metastatic cancer Sildenafil and MEK inhibitors What is MEK-associated retinopathy called? It is called ‘MEK-associated retinopathy’ (MEKAR)

How prevalent is MEKAR? Very--estimates run as high as 90% of MEK users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEKi? No 83 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

corticosteroids What does MEK stand for in this context? Don’t ask--it’s complicated Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSCWhat Retinaare MEKbook. inhibitors What (MEKs) are they? used to treat? Metastatic cancer Sildenafil and MEK inhibitors What is MEK-associated retinopathy called? It is called ‘MEK-associated retinopathy’ (MEKAR)

How prevalent is MEKAR? Very--estimates run as high as 90% of MEK users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEKi? No 84 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

corticosteroids What does MEK stand for in this context? Don’t ask--it’s complicated Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSCWhat Retinaare MEKbook. inhibitors What (MEKs) are they? used to treat? Metastatic cancer Sildenafil and MEK inhibitors What is MEK-associated retinopathy called? It is called ‘MEK-associated retinopathy’ (MEKAR)

How prevalent is MEKAR? Very--estimates run as high as 90% of MEK users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEKi? No 85 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

corticosteroids What does MEK stand for in this context? Don’t ask--it’s complicated Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSCWhat Retinaare MEKbook. inhibitors What (MEKs) are they? used to treat? Metastatic cancer Sildenafil and MEK inhibitors What is MEK-associated retinopathy called? It is called ‘MEK-associated retinopathy’ (MEKAR)

How prevalent is MEKAR? Very--estimates run as high as 90% of MEK users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEK? No 86 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

corticosteroids What does MEK stand for in this context? Don’t ask--it’s complicated Corticosteroids are the classic cause of med-induced CSC, but two other meds are mentioned in the BCSCWhat Retinaare MEKbook. inhibitors What (MEKs) are they? used to treat? Metastatic cancer Sildenafil and MEK inhibitors What is MEK-associated retinopathy called? It is called ‘MEK-associated retinopathy’ (MEKAR)

How prevalent is MEKAR? Very--estimates run as high as 90% of MEK users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEK? No 87

Central Serous Chorioretinopathy/Choroidopathy (CSC)

 Still more re CSC: Management So when faced with a pt with apparent CSCR,  Assess for highbe sure levels to inquire of endogenous about three meds: or exogenous --Steroids corticosteroids What does MEK stand for in this context? --Sildenafil Don’t ask--it’s complicated Corticosteroids are-- theMEK classic inhibitors cause of med-induced CSC, but two other meds are mentioned in the BCSCWhat Retinaare MEKbook. inhibitors What (MEKs) are they? used to treat? Metastatic cancer Sildenafil and MEK inhibitors What is MEK-associated retinopathy called? It is called ‘MEK-associated retinopathy’ (MEKAR)

How prevalent is MEKAR? Very--estimates run as high as 90% of MEK users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEK? No 88 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management So when faced with a pt with apparent CSCR,  Assess for highbe sure levels to inquire of endogenous about three meds: or exogenous --Steroids corticosteroids What doesIf the MEK pt isstand not taking for in thesethis context? meds, but s/he has --Sildenafil Don’t askevidence--it’s complicated of extensive intraocular inflammation, --MEK inhibitors the presence of bilateral serous RDs should Corticosteroids are the classic cause of medcause-induced what diagnosis CSC, tobut spring two to mind? other meds are mentioned in the BCSCWhat Retinaare MEKbook. inhibitors What (MEKIs) are they? used to treat? MetastaticVogt cancer-Koyanagi-Harada dz Sildenafil and MEK inhibitors What is MEK-associated retinopathy called? It is called ‘MEK-associated retinopathy’ (MEKAR)

How prevalent is MEKAR? Very--estimates run as high as 90% of MEK users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEK? No 89 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management So when faced with a pt with apparent CSCR,  Assess for highbe sure levels to inquire of endogenous about three meds: or exogenous --Steroids corticosteroids What doesIf the MEK pt isstand not taking for in thesethis context? meds, but s/he has --Sildenafil Don’t askevidence--it’s complicated of extensive intraocular inflammation, --MEK inhibitors the presence of bilateral serous RDs should Corticosteroids are the classic cause of medcause-induced what diagnosis CSC, tobut spring two to mind? other meds are mentioned in the BCSCWhat Retinaare MEKbook. inhibitors What (MEKIs) are they? used to treat? MetastaticVogt cancer-Koyanagi-Harada dz Sildenafil and MEK inhibitors What is MEK-associated retinopathy called? It is called ‘MEK-associated retinopathy’ (MEKAR)

How prevalent is MEKAR? Very--estimates run as high as 90% of MEK users will experience MEKAR

How visually significant is MEKAR? Not very--most pts are asymptomatic, or only slight affected

Is MEKAR an indication to stop the MEK? No 90 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 monthstime frame for spontaneous resolution 91 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution 92 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution

Why should intervention be considered at around the 3-month point? Because photoreceptor atrophy will begin to occur at this point 93 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution

Why should intervention be considered at around the 3-month point? Because photoreceptor atrophy will begin to occur at this juncture 94 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution  Reasons to treat sooner than 3 months:

 Recurrence in eye with previoustwo words deficit 95 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution  Reasons to treat sooner than 3 months:  Recurrence in eye with previous deficit 96 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution  Reasons to treat sooner than 3 months:  Recurrence in eye with previous deficit  Decreased visionthis reason in has fellow nothing to do eye with the currentfrom eye/episode previous episode 97 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution  Reasons to treat sooner than 3 months:  Recurrence in eye with previous deficit  Decreased vision in fellow eye from previous episode 98 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution  Reasons to treat sooner than 3 months:  Recurrence in eye with previous deficit  Decreased vision in fellow eye from previous episode  Cystic retinal changes 99 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution  Reasons to treat sooner than 3 months:  Recurrence in eye with previous deficit  Decreased vision in fellow eye from previous episode  Cystic retinal changes 100 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution  Reasons to treat sooner than 3 months:  Recurrence in eye with previous deficit  Decreased vision in fellow eye from previous episode  Cystic retinal changes  Widespread RPEabb. changes 101 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution  Reasons to treat sooner than 3 months:  Recurrence in eye with previous deficit  Decreased vision in fellow eye from previous episode  Cystic retinal changes  Widespread RPE changes 102 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution  Reasons to treat sooner than 3 months:  Recurrence in eye with previous deficit  Decreased vision in fellow eye from previous episode  Cystic retinal changes  Widespread RPE changes  Occupational needs 103 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution  Reasons to treat sooner than 3 months:  Recurrence in eye with previous deficit  Decreased vision in fellow eye from previous episode  Cystic retinal changes  Widespread RPE changes  Occupational needs 104 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution  Reasons to treat sooner than 3 months:  Recurrence in eye with previous deficit  Decreased vision in fellow eye from previous episode  Cystic retinal changes  Widespread RPE changes  Occupational needs

 Treatment: Photodynamictwo words therapy 105 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution  Reasons to treat sooner than 3 months:  Recurrence in eye with previous deficit  Decreased vision in fellow eye from previous episode  Cystic retinal changes  Widespread RPE changes  Occupational needs  Treatment: Photodynamic therapy 106 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSR: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution What is photodynamic therapy? A form of phototherapyReasons for vascular to treat lesions, sooner usually within than the posterior 3 months: segment of the eye Briefly, how doesRecurrence it work? in eye with previous deficit A light-sensitive chemical is injected intravenously, and time sufficient to allow concentration of the chemical in theDecreased lesion is allowed to vision pass. Light in of fellow the wavelength eye neededfrom to previous activate the chemical episode is then delivered. The chemical is stimulated to react with oxygen to create free radicals, which degrade the lesion and/or its vasculature. Cystic retinal changes What is the nameWidespread of the infused chemical? RPE changes Verteporfin  Occupational needs  Treatment: Photodynamic therapy 107 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSR: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution What is photodynamic therapy? A form of phototherapyReasons for vascular to treat lesions, sooner usually within than the posterior 3 months: segment of the eye Briefly, how doesRecurrence it work? in eye with previous deficit A light-sensitive chemical is injected intravenously, and time sufficient to allow concentration of the chemical in theDecreased lesion is allowed to vision pass. Light in of fellow the wavelength eye neededfrom to previous activate the chemical episode is then delivered. The chemical is stimulated to react with oxygen to create free radicals, which degrade the lesion and/or its vasculature. Cystic retinal changes What is the nameWidespread of the infused chemical? RPE changes Verteporfin  Occupational needs  Treatment: Photodynamic therapy 108 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSR: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution What is photodynamic therapy? A form of phototherapyReasons for vascular to treat lesions, sooner usually within than the posterior 3 months: segment of the eye Briefly, how doesRecurrence it work? in eye with previous deficit A light-sensitive chemical is injected intravenously, and time sufficient to allow concentration of the chemical in theDecreased lesion is allowed to vision pass. Light in of fellow the wavelength eye neededfrom to previous activate the chemical episode is then delivered. The chemical is stimulated to react with oxygen to create free radicals, which degrade the lesion and/or its vasculature. Cystic retinal changes What is the nameWidespread of the infused chemical? RPE changes Verteporfin  Occupational needs  Treatment: Photodynamic therapy 109 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSR: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution What is photodynamic therapy? A form of phototherapyReasons for vascular to treat lesions, sooner usually within than the posterior 3 months: segment of the eye Briefly, how doesRecurrence it work? in eye with previous deficit A light-sensitive chemical is injected intravenously, and time sufficient to allow concentration of the chemical in theDecreased lesion is allowed to vision pass. Light in of fellow the wavelength eye neededfrom to previous activate the chemical episode is then delivered. The chemical is stimulated to react with oxygen to create free radicals, which degrade the lesion and/or its vasculature. Cystic retinal changes What is the nameWidespread of the infused chemical? RPE changes Verteporfin  Occupational needs  Treatment: Photodynamic therapy 110 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSR: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution What is photodynamic therapy? A form of phototherapyReasons for vascular to treat lesions, sooner usually within than the posterior 3 months: segment of the eye Briefly, how doesRecurrence it work? in eye with previous deficit A light-sensitive chemical is injected intravenously, and time sufficient to allow concentration of the chemical in theDecreased lesion is allowed to vision pass. Light in of fellow the wavelength eye neededfrom to previous activate the chemical episode is then delivered. The chemical is stimulated to react with oxygen to create free radicals, which degrade the lesion and/or its vasculature. Cystic retinal changes What is the nameWidespread of the infused chemical? RPE changes Verteporfin  Occupational needs  Treatment: Photodynamic therapy 111 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSR: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution What is photodynamic therapy? A form of phototherapyReasons for vascular to treat lesions, sooner usually within than the posterior 3 months: segment of the eye Briefly, how doesRecurrence it work? in eye with previous deficit A light-sensitive chemical is injected intravenously, and time sufficient to allow concentration of the chemical in theDecreased lesion is allowed to vision pass. Light in of fellow the wavelength eye neededfrom to previous activate the chemical episode is then delivered. The chemical is stimulated to react with oxygen to create free radicals, which degrade the lesion and/or its vasculature. Cystic retinal changes What is the nameWidespread of the infused chemical? RPE changes Verteporfin  Occupational needs  Treatment: Photodynamic therapy 112 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

What aboutcorticosteroids thermal laser? It is an effective treatment? Yes and no. Thermal laser does hasten fluid resorption, and thus facilitates faster visual recovery. However,Wait when studiesabout compare 3 months treated vs untreated for spontaneous eyes: resolution --Final visual acuity was no different between groups --Recurrence Reasons rate was noto different treat between sooner groups than 3 months:

What is theRecurrence rare-but-devastating in complication eye with associated previous with thermal deficit laser treatment? Inadvertent rupture of Bruch’s membrane leading to iatrogenic CNVM  Decreased vision in fellow eye from previous episode  Cystic retinal changes  Widespread RPE changes  Occupational needs  Treatment: PhotodynamicThermal laser? Meh therapy 113 A/Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

What aboutcorticosteroids thermal laser? It is an effective treatment? Yes and no. Thermal laser does hasten fluid resorption, and thus facilitates faster visual recovery. However,Wait when studiesabout compare 3 months treated vs untreated for spontaneous eyes: resolution --Final visualthree words acuity was no different between groups --Recurrence Reasonstwo words rate was noto different treat between sooner groups than 3 months:

What is theRecurrence rare-but-devastating in complication eye with associated previous with thermal deficit laser treatment? Inadvertent rupture of Bruch’s membrane leading to iatrogenic CNVM  Decreased vision in fellow eye from previous episode  Cystic retinal changes  Widespread RPE changes  Occupational needs  Treatment: PhotodynamicThermal laser? Meh therapy 114 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

What is theRecurrence rare-but-devastating in complication eye with associated previous with thermal deficit laser treatment? Inadvertent rupture of Bruch’s membrane leading to iatrogenic CNVM  Decreased vision in fellow eye from previous episode  Cystic retinal changes  Widespread RPE changes  Occupational needs  Treatment: PhotodynamicThermal laser? Meh therapy 115 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

What is theRecurrence rare-but-devastating in complication eye with associated previous with thermal deficit laser treatment? Inadvertent rupture of Bruch’s membrane leading to iatrogenic CNVM  Decreased vision in fellow eye from previous episode  Cystic retinal changes  Widespread RPE changes  Occupational needs  Treatment: PhotodynamicThermal laser? Meh therapy 116 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

What is theRecurrence rare-but-devastating in complication eye with associated previous with thermal deficit laser treatment? Inadvertent rupture of Bruch’s membrane leading to iatrogenic CNVM  Decreased vision in fellow eye from previous episode  Cystic retinal changes  Widespread RPE changes  Occupational needs  Treatment: PhotodynamicThermal laser? Meh therapy 117 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

What is theRecurrence rare-but-devastating in complication eye with associated previous with thermal deficit laser treatment? Inadvertent rupture of Bruch’s membrane leading to iatrogenic CNVM  Decreased vision in fellow eye from previous episode Can CSC pts develop CNVM spontaneously?  Cystic retinal changesYes  Widespread RPE changes  Occupational needs  Treatment: PhotodynamicThermal laser? Meh therapy 118 A Central Serous Chorioretinopathy/Choroidopathy (CSC)  Still more re CSC: Management  Assess for high levels of endogenous or exogenous

What is theRecurrence rare-but-devastating in complication eye with associated previous with thermal deficit laser treatment? Inadvertent rupture of Bruch’s membrane leading to iatrogenic CNVM  Decreased vision in fellow eye from previous episode Can CSC pts develop CNVM spontaneously?  Cystic retinal changesYes  Widespread RPE changes  Occupational needs  Treatment: PhotodynamicThermal laser? Meh therapy 119

Central Serous Chorioretinopathy/Choroidopathy (CSC)

 Still more re CSC: Management  Assess for high levels of endogenous or exogenous corticosteroids  Wait about 3 months for spontaneous resolution  Reasons to treat sooner than 3 months: Remember, Recurrence the treatment in eye of choice with previousin most CSC deficit cases is observation  Decreased vision in fellow eye from previous episode  Cystic retinal changes  Widespread RPE changes  Occupational needs  Treatment: Photodynamic therapy 120 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)

 Differential for CSC:  Optic nerve pit  VKH  Wet ARMD  PED  Toxemia of pregnancy  Choroidal nevi 121 A Central Serous Chorioretinopathy/Choroidopathy (CSC)

 Differential for CSC:  Optic nerve pit  Vogt-Koyanagi-Harada (VKH) disease  Wet age-related macular degeneration (ARMD)  Pigment epithelial detachment (PED)  Toxemia of pregnancy  Choroidal nevi  Polypoidal choroidal vasculopathy 122 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC ? Yes No No No Thicker Yes

ARMD ? No Yes Yes Yes Thinner No 123 A Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes Yes Thinner No 124 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF ? Yes Yes Yes Thinner No 125 A Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes Yes Thinner No 126 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No ? Yes Yes Thinner No 127 A Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Thinner No 128 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes ? Thinner No 129 A Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes Thinner No 130 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes ? Thinner No 131 A Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes Yes Thinner No 132 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes Yes ? 133 A Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes Yes Thinner 134 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes Yes Thinner ? 135 A Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes Yes Thinner No 136 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes Yes Thinner No

In the context of CSC, what are descending tracts? Long, narrow areas of RPE change extending inferiorly from the areas of SRF

What is the cause? Gravity-dependent ‘dripping’ of the SRF

By what other name is this phenomenon known? ‘Guttering’ 137 A Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes Yes Thinner No

In the context of CSC, what are descending tracts? Long, narrow areas of RPE change extending inferiorly from the areas of SRF

What is the cause? Gravity-dependent ‘dripping’ of the SRF

By what other name is this phenomenon known? ‘Guttering’ 138

Central Serous Chorioretinopathy/Choroidopathy (CSC)

CSC: Descending tracts 139 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes Yes Thinner No

In the context of CSC, what are descending tracts? Long, narrow areas of RPE change extending inferiorly from the areas of SRF

What is the cause? Gravity-dependent ‘dripping’ of the SRF

By what other name is this phenomenon known? ‘Guttering’ 140 A Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes Yes Thinner No

In the context of CSC, what are descending tracts? Long, narrow areas of RPE change extending inferiorly from the areas of SRF

What is the cause? Gravity-dependent ‘dripping’ of the SRF

By what other name is this phenomenon known? ‘Guttering’ 141 Q Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes Yes Thinner No

In the context of CSC, what are descending tracts? Long, narrow areas of RPE change extending inferiorly from the areas of SRF

What is the cause? Gravity-dependent ‘dripping’ of the SRF

By what other name is this phenomenon known? ‘Guttering’ 142 A Central Serous Chorioretinopathy/Choroidopathy (CSC)

Is it CSC or wet ARMD? An important distinction to make—can you make it?

Choroidal Size of leak Multiple Drusen Blood Lipid thickness Descending relative to size of small PED present? present? present? c/w tracts SRF area present? normal present?

CSC Leak<

ARMD Leak ≈ SRF No Yes Yes Yes Thinner No

In the context of CSC, what are descending tracts? Long, narrow areas of RPE change extending inferiorly from the areas of SRF

What is the cause? Gravity-dependent ‘dripping’ of the SRF

By what other name is this phenomenon known? ‘Guttering’