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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 29  |  Issue : 2  |  Page : 131-133

Dowsing in a case of recurrent central serous Chorioretinopathy


Department of Vitreo-Retina, M. M. Joshi Eye Institute, Hubli, Karnataka, India

Date of Web Publication10-Aug-2017

Correspondence Address:
V V Sameera
M. M. Joshi Eye Institute, Hubli . 580 021,Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_57_17

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  Abstract 


We present a case of a 34-year-old male with diminution of vision in his left eye. He was diagnosed as a case of central serous chorioretinopathy (CSCR) on clinical examination and optical coherence tomography (OCT). The episode resolved in 1 month. Nine months later, the patient had a recurrence. This time, the CSCR was imaged using spectral domain-OCT, enhanced depth imaging-OCT, fundus autofluorescence, and fundus fluorescein angiography. The patient was noted to have an associated extrafoveal subretinal fluid pocket with a focal choroidal excavation.

Keywords: Focal choroidal excavation, hyperautofluorescence, recurrent central serous chorioretinopathy


How to cite this article:
Ayachit A, Sameera V V, Joshi SM, Ayachit G. Dowsing in a case of recurrent central serous Chorioretinopathy. Kerala J Ophthalmol 2017;29:131-3

How to cite this URL:
Ayachit A, Sameera V V, Joshi SM, Ayachit G. Dowsing in a case of recurrent central serous Chorioretinopathy. Kerala J Ophthalmol [serial online] 2017 [cited 2019 Aug 24];29:131-3. Available from: http://www.kjophthal.com/text.asp?2017/29/2/131/212754




  Introduction Top


Macular focal choroidal excavation (FCE) is an entity associated with CSCR which is on the diagnostic rise owing to the advanced investigational tools at our disposal… . We present a case of extra macular FCE in a case of recurrent CSR.


  Case Report Top


A 34-year-old male presented to us in July 2016 with diminution of vision in his left eye for 1 month. Best-corrected visual acuity was noted to be 6/6 N6 OD and 6/9 N8 OS. Anterior segment examination was normal in both eyes. Fundus examination revealed a large subretinal fluid pocket in the macular area in the left eye. The right eye was within normal limits. Optical coherence tomography (OCT) of the left eye showed a large neurosensory detachment, and a diagnosis of central serous chorioretinopathy (CSCR) was made [Figure 1]. The patient was counseled about the condition, and observation was recommended for a month. At 1-month follow-up, the fluid had completely resolved. The patient was lost to follow up. He came back 9 months later with complaints of diminution of vision, again in the left eye. Clinical examination and OCT showed a large neurosensory detachment. Fundus autofluorescence revealed hypoautofluorescence around fovea, corresponding to subfoveal fluid. There was an area of hyperautofluorescence, superotemporal to the disc abutting the arcade. A raster scan through the area of hyperautofluorescence showed a pocket of subretinal fluid that was in communication with the subfoveal fluid. There was a Type 2 focal choroidal excavation (FCE) associated with the subretinal fluid. The area of FCE showed hyperreflectivity in the choroid on enhanced depth OCT [Figure 2] and [Figure 3]. Fundus fluorescein angiography (FFA) revealed multiple hyperfluorescent spots and an ascending leak in the area of FCE [Figure 4]. A diagnosis of extrafoveal Type 2 FCE with CSCR was made. The patient was treated with 577 nm MicroPulse Laser Therapy (MPLT) at the area of leak - 480 mW power, 5% duty cycle, 200 ms duration, 7 × 7 pattern, and high density in the area of leaks. At 1-month follow-up, there was resolution of serous detachment with improvement of symptoms [Figure 5].
Figure 1: Fundus photograph of first episode of central serous chorioretinopathy in the left eye (left) with optical coherence tomography line scan showing neurosensory detachment (right)

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Figure 2: Left - 30° optical coherence tomography showing neurosensory detachment (left), 55° optical coherence tomography showing raster scan through area of hyperautofluorescence revealing a Type 2 focal choroidal excavation with neurosensory detachment (right) (yellow arrow)

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Figure 3: Fundus autofluorescence of the area with corresponding enhanced depth imaging-optical coherence tomography showing focal choroidal excavation in the area of hyperautofluorescence. There is hyperreflectivity in the choroid on enhanced depth imaging-optical coherence tomography (red arrow)

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Figure 4: Successive frames of fundus fluorescein angiography showing an ascending leak in the area of focal choroidal excavation (green arrow)

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Figure 5: Resolution seen at 1-month post-MicroPulse Laser Therapy - minimal fluid at area of focal choroidal excavation

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Literature review - Jampol et al. in 2006 first described this “baffling” OCT finding of a choroidal excavation with normal overlying retina in a myopic patient with good visual acuity.[1] It is thought to be a congenital malformation although acquired cases have been reported. FCE can be of two types - an abrupt excavation with a short horizontal extent termed Type 1 FCE and an excavation with more gradual slopes termed Type 2 FCE.[2] In the area of FCE, there are two forces acting on the photoreceptor layer. The retinal pigment epithelium (RPE) attempts to keep the outer retina pulled in the direction of the excavation, and the inner retina attempts to pull it inward.[2] The anteroposterior force is more concentrated over a smaller area; hence, the photoreceptor tips get separated from the RPE in a smaller Type 1 excavation. This nonconforming type of FCE is more common with a Type 1 FCE. Conversely, a conforming FCE, wherein the photoreceptor layer is in contact with the RPE, is seen more commonly with a Type 2 FCE.[3] Foveal and extrafoveal FCEs are defined based on the distance of the posterior border of the FCE from the foveal center (>200 μ being extrafoveal).[4]

FCEs are being increasingly diagnosed because of multiple imaging modalities at our disposal. They are rarely detected clinically except for an occasional yellowish discoloration or rarely pigment mottling. Owing to the choroidal and RPE abnormalities in the areas of excavation, these eyes have a higher incidence of CSCR, choroidal neovascular membrane (CNVM), and polypoidal choroidal vasculopathy (PCV).[2],[3],[5] Wang et al. described multimodal imaging in 19 eyes with FCE-associated CSC.[5] Margolis et al. and Wang et al. found a higher prevalence of hypoautofluorescence than hyperautofluorescence in areas of FCE.[2],[5] Enhanced depth OCT imaging has helped further in elucidating that the subfoveal choroidal thickness is reduced in areas of excavation. Lee described hyperreflective choroidal tissue beneath the FCE which suggested scarring of the choroid. These eyes may also show a suprachoroidal space that suggests an inward contraction of the scarred choroid, in turn leading to a reduced choroidal thickness.[4] The choroidal thickness may be increased, however, in FCE-associated CSC.[5],[6],[7] Suzuki et al. in their study demonstrated leaks at the border of FCE on FFA in eyes with FCE-associated CSCR. They postulated that there were small areas of RPE attenuation owing to choroidal ischemia in the area of FCE explained further by indocyanine green that showed early hypofluorescence and late hyperfluorescence in all eyes in their study. The finding of choroidal hyperpermeability in normal fellow eyes in their study gives credence to the theory that FCE adds insult to an eye already damaged by choroidal vascular hyperpermeability and leads to serous retinal detachment.[8]

Our patient had an extrafoveal, Type 2 FCE with a recurrent CSCR. The posterior border of FCE was located 2221 μ from the fovea. In our case, hyperautofluorescence was seen in the area of FCE although hypoautofluorescence is more commonly reported. We demonstrate leaks in the area of FCE. The fluid resolved with MPLT 577 nm at 1-month follow-up. FCE is associated with CSCR, PCV, and CNVM because of diseased choroid and RPE in the region of FCE. These patients will need regular follow-up for future development of these pathologies. This patient's FCE was missed the first time because of a conventional 6 mm scan. We recommend 12 mm scans in patients of CSCR to pick up extrafoveal FCEs. This case report highlights the possibility of extrafoveal, distant FCEs causing recurrent attacks of CSCR and the multimodal imaging of the same.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jampol LM, Shankle J, Schroeder R, Tornambe P, Spaide RF, Hee MR. Diagnostic and therapeutic challenges. Retina 2006;26:1072-6.  Back to cited text no. 1
    
2.
Margolis R, Mukkamala SK, Jampol LM, Spaide RF, Ober MD, Sorenson JA, et al. The expanded spectrum of focal choroidal excavation. Arch Ophthalmol 2011;129:1320-5.  Back to cited text no. 2
    
3.
Guo J, Zhong L, Jiang C, Zhou X, Xu G, Wang W, et al. Clinical and optic coherence tomography findings of focal choroidal excavation in Chinese patients. BMC Ophthalmol 2014;14:63.  Back to cited text no. 3
    
4.
Lee CS, Woo SJ, Kim YK, Hwang DJ, Kang HM, Kim H, et al. Clinical and spectral-domain optical coherence tomography findings in patients with focal choroidal excavation. Ophthalmology 2014;121:1029-35.  Back to cited text no. 4
    
5.
Wang Y, Chen ZQ, Wang W, Fang XY. Multimodal imaging evaluations of focal choroidal excavations in eyes with central serous chorioretinopathy. J Ophthalmol 2016;2016:7073083.  Back to cited text no. 5
    
6.
Luk FO, Fok AC, Lee A, Liu AT, Lai TY; Medscape. Focal choroidal excavation in patients with central serous chorioretinopathy. Eye (Lond) 2015;29:453-9.  Back to cited text no. 6
    
7.
Ellabban AA, Tsujikawa A, Ooto S, Yamashiro K, Oishi A, Nakata I, et al. Focal choroidal excavation in eyes with central serous chorioretinopathy. Am J Ophthalmol 2013;156:673-83.  Back to cited text no. 7
    
8.
Suzuki M, Gomi F, Hara C, Sawa M, Nishida K. Characteristics of central serous chorioretinopathy complicated by focal choroidal excavation. Retina 2014;34:1216-22.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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