Mashhad University of Medical Sciences Clinical Research Development Center (MUMS) Reviews in Clinical Medicine Ghaem Hospital

A review of acute central serous chorioretinopathy

Mirnaghi Mousavi (MD), Mahdi Mokhtari (MD)*, Masoud Shafiee (MD)

Retina Research Center, Khatam Eye Hospital, Mashhad University of Medical Sciences, Mashhad, Iran

ARTICLE INFO ABSTRACT Article type Central serous chorioretinopathy is a common cause of visual morbidity. Review article It is characterized by idiopathic serous in macular or paramacular regions. The symptoms of the CSC include decreased vision, Article history micropsia and metamorphopsia. The prognosis of the disease is good and Received: 8 Apr 2014 Revised: 18 Apr 2014 almost 90% of patients obtain visual recovery in a few months. However, Accepted: 20 Apr 2014 in less than 5% of patients the chronic disease with poor prognosis is developed. Keywords The acceptable approach is to observe patients with acute central serous Acute visual loss chorioretinopathy, because central serous chorioretinopathy is self- Central serous chorioretinopathy limited. The pathophysiology of central serous chorioretinopathy is not Serous retinal detachment clear and not well understood. Therefore, various medical treatments have been suggested such as propranolol, indomethacin, bevacizumab, acetazolamide, mifepristone, labetalol, etc. However, wait and watch would be the most recommended management of the central serous chorioretinopathy.

Please cite this paper as: Mousavi M, Mokhtari M, Shafiee M. A review of acute central serous chorioretinopathy. Rev Clin Med. 2014; 1(4):207-210.

Introduction Acute Central Serous Chorioretinopathy In 1866,Von Graefe defined central serous of the CSC are micropsia, blurred vision, chorioretinopathy (CSC) as a “idiopathic impaired dark adaptation in visual acuity, detachment of the macula”(1). This disease impaired color vision and relative often affects young adults in the age range after sleep. Unilateral metamorphopsia of 25-50. CSC often manifests unilaterally is the classic sign of the CSC disease (2). which could be bilaterally. Various symptoms Some patients may develop hyperopia (due

*Corresponding author: Mahdi Mokhtari. This is an Open Access article distributed under the Research Center, Khatam Eye Hospital, terms of the Creative Commons Attribution License Mashhad University of Medical Sciences, Mashhad, (http://creativecommons.org/licenses/by/3.0), Iran which permits unrestricted use, distribution, and E-mail: [email protected] reproduction in any medium, provided the original Tel: 051-37281401 work is properly cited.

Rev Clin Med 2014; Vol 1 (No 4) 207 Published by: Mashhad University of Medical Sciences (http://rcm.mums.ac.ir) Mousavi M et al. to anterior displacement of photoreceptors with chronic CSC such as retinal pigment in fovea) (2). CSC causes are not yet fully epithelium changes and cystic changes understood and few studies have explained within the retina of severe cases (6). pathophysiology process in CSC (3). CSC is a retinal disease due to idiopathic Pathophysiology of CSC accumulation of serous fluid under the Among the factors associated with CSC, retina in the macular area (2). corticosteroids (exogenous and endogenous) A favorable prognosis is usually predicted are associated with the occurrence rate for more than 80-90% of patients which of CSC (10). In an experimental study, recovers within a few months. However, multiple injections of corticosteroids and More than 50-40% of patients have epinephrine have lead to CSC in adult relapsing disease (4). The recurrence rate monkeys (11). of the disease in the same eye is more than Other factors that are associated with CSC 30% (5). Situations with increased stress include psychological stress, type A person- hormones (corticosteroids and epinephrine) ality, systemic hypertension, gastroesopha- are associated with CSC including stress, geal reflux disease (GERD), pregnancy, systemic corticosteroid therapy, pregnancy, organ transplantation, SLE, smoking, alco- Cushing’s disease, etc (6). Type A hol consumption, glomerulonephritis and personality is another risk factor of CSC (7). autoimmune diseases (6,12). Some studies CSC incidence rate is estimated to be 6-5 reported an association between H. pylori cases per 100,000 people. This disorder is infection and CSC occurrence (13,14). Psy- more common in Caucasians and Hispanics, chological medications, methamphetamine particularly Asian but is less common in and sildenafil are associated with CSC (6). African-American (6). The incidence rate Therefore, psychiatry history and drug of the disease is 9.9 per 100,000 men and history are very important in medical 1.7 per 100,000 women approximately evaluation of CSC patients. The blood- (8). CSC is the most common cause of retinal barrier and retinal pigment epithelium after the age-related macular, is responsible for the development of retinal branch vein occlusion and diabetic abnormal subretinal fluid in CSC (15). retinopathy (6). Angiography evidence showed a CSC diagnosis is based on clinical blood circulation disorder (12). evidences. In most cases, the quite conclusive OCT (optical coherence tomography) and Differential Diagnosis of CSC angiography is necessary to confirm the Clinical and paraclinical studies are diagnosis and assess the extent and severity very beneficial in CSC diagnosis. Some of retinal dysfunction and disease follow-up of differential diagnosis parameters are (9). CSC has various forms in angiography, listed in Table 1. Wet age-related macular which include expansive dot, diffuse leak, degeneration (AMD) finding could be and Smoke Stack (6,9). presented by neurosensory macular In CSC disease, subretinal fluid would be detachment the same as CSC (16). observed on fundoscopic examination. The Optical coherence tomography is the most fluid is usually clear but can be fibrinoid. recommended diagnostic procedure in The chronic form is more superficial retinal CSC (17). Multifocal electroretinography separation than the acute form. Specific has been used to connect the signs of changes occur in the retina of patients CSC with sections of reduced retinal

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Table1. Differential diagnosis of central serous cho- studied the efficacy of intravitreal avastin in rioretinopathy the treatment of CSC, it failed to obtain any Choroidal Neovascularization due to positive association between using avastin and the treament of CSC (22). Antifungal • Exudative AMD (age-related ) medications such as ketoconazole has been • Multifocal choroiditis also used for the treatment of CSC (23). • Degenerative and Angi- oid streaks Conclusion Vogt- Koyanagi- Harada disease CSC is described by an exudative serousal Macular hole macular detachment. This disease is a self- Idiopathic serous RPE (Retinal pigment epitheli- limited disease and most of the time just um) detachment wait and follow-up method is the most Choroidal tumors recommended management. However, clinical • Hemangioma and paraclinical studies should be performed • Metastasis for rolling out other differential diagnosis. • Melanoma Less than 50% of patients will experience Acute lymphocytic leukemia(ALL) relapse periods. Therefore, pharmacotherapy and patient follow-up are more important than function and to examine the response to disease treatment methods. therapy (3). Vogt-Koyanagi-Harada (VKH) disease is a granulomatous , which Acknowledgement is characterized with exudative retinal We would like to thank Clinical Research detachment (9). Development Center of Ghaem Hospital for their assistant in this manuscript. This study Treatments was supported by a grant from the Vice CSC disease cures spontaneously in Chancellor for Research of the Mashhad most cases and it is a self-limited disease. University of Medical Sciences for the Therefore, most of the physicians follow research project as a medical student thesis up their patients without treatment (18). with approval number of 0910265. Laser treatment of retina and photodynamic therapy are the recommended treatment Conflict of Interest methods for the disease (1,9). The authors declare no conflict of interest. Trimepranol as a non-specific beta- blocker, with the dose of 5 mg twice per day, References 1. Tarantola RM, Law JC, Recchia FM, et al. Pho- is reported as a influential medication in the todynamic therapy as treatment of chronic idio- treatment of 84.6% of cases in Chrapek et pathic central serous chorioretinopathy. Lasers al. study (19). Surg Med. 2008;40:671-675. In another report, the subretinal serous 2. Yanoff M, Duker JS, Augsburger JJ. Ophthalmol- ogy. 3 ed. Philadelphia: Mosby Elsevier; 2009. fluid in CSC deceased with applying 3. Marcuson J, Riley T. Central serous chorioretinop- acetazolamide (20). athy. Optometry. 2008;79:241-251. In one case report, a patient with CSC was 4. Yap EY, Robertson DM. The long-term outcome treated with administration of mifepristone, of central serous chorioretinopathy. Arch Oph- thalmol. 1996;114:689-692. an antagonist of progesterone (21). 5. Bujarborua D, Chatterjee S, Choudhury A, et According to the different reports of al. Fluorescein angiographic features of asymp- a great A meta-analysis in 2013, which tomatic eyes in central serous chorioretinopa-

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