Grand Rounds A Case of Unilateral Subretinal Fluid

Grand Rounds “A Case of Unilateral Subretinal Fluid” Mohammad Ali Sadiq, MD – PGY 2 October 12, 2018 Department of Ophthalmology and Visual Sciences

Patient Presentation CC “I see floaters in my left eye” HPI 61 year old white female presented with - Floaters in OS for the past 3 -5 days - Associated with occasional flashes in OS. - No decrease in vision.

History Past Ocular Hx: Chronic allergic conjunctivitis OU and moderate myopia OU Past Medical Hx: Rheumatoid arthritis Fam Hx: Noncontributory Meds: Oral steroids intermittently, NSAID, Estradiol, Lisinopril

History Allergies: None Social Hx: No smoking/alcohol/drugs ROS: Negative except as in the HPI

$External Exam OD OS BCVA 20/20 Refraction -4. 50 Sph Pupils 3→ 2 mm,$

External Exam OD OS BCVA 20/20 Refraction -4. 50 Sph Pupils 3→ 2 mm, No r. APD IOP 23 mm. Hg 20 mm. Hg EOM Full CVF Full

Anterior Segment Exam SLE OD OS External/Lids WNL Conj/Sclera White and quiet Cornea Clear Ant Chamber Deep and quiet Iris WNL Lens 1+ NS

Posterior Segment Exam OD OS Nerve Pink and Sharp. C/D 0. 3 Macula Good foveal reflex. Small area of SRF Inferonasal to the fovea. Good foveal reflex Vessels Normal Caliber Vitreous Clear PVD Periphery No Holes or Tears. Attached 360 Degrees.

OCT - OU

FAF - OU

FA - OD

ICG - OD

FA and ICG - OS

Assessment and Plan A 61 year old white female who has an intermittent history of using oral steroids for rheumatoid arthritis who presents with subretinal fluid in OD. Differential Diagnosis: • Central Serous Chorioretinopathy • Choroidal Neovascularization • Polypoidal Choroidal Vasculopathy • VKH Plan: Close Observation

Central Serous Chorioretinopathy – A Brief History • 1866 – First recognized by Von Graefe as recurrent central retinitis. • 1940 s – Became known as CSR • “Tense obsessional personality” or with “worry or over work”

Central Serous Chorioretinopathy – A Brief History • Maumanee performed FA on patients with CSC and found a leak at the level of the RPE • Gass hypothesized that the disease was secondary to hyperpermeability of the choriocapillaris.

Demographics • 35 -55 years old • Male-Female ratio of 6: 1 – Males also have a higher recurrence rate • No association with race • Associated with a tense, driven personality • Bilateral in 14 to 40% – Incidence of bilateral/multifocal CSCR is higher in Asians – More likely in patients >50 years old

Risk Factors • Systemic Conditions: – – – Hypercortisolism Hypertension Sleep apnea Pregnancy Depression (increased recurrence) H. Pylori Infection • Systemic Steroids • Ecstacy • Sildenafil • Alcohol use

Pathophysiology Autonomic dysfunction (Increased sympathetic activity) Impaired choroidal circulation Choroidal Hyperperfusion Increased subretinal fluid

Pathophysiology • In short, it is thought to be a combination of: – Choroidal hyperpermeability – Increased choroidal hydrostatic pressure. – RPE dysfunction

Imaging - FP / OCT

OCT – Choroid

Fundus Autofluorescence

Fluorescein Angiography

ICG

OCT Angiography

Prognosis • Most cases (80 -90%) undergo spontaneous resolution • Recurrences documented in up to 50% of cases in 1 year • 15% of cases may be diagnosed with chronic CSCR

Treatment • Observation • Discontinuation of exogenous steroid use • Eplerenone/Spirinolactone • Verteporfin Photodynamic Therapy (PDT) • Subthreshold Micropulse Laser Photocoagulation

Complications Chronic cases may progress to: • Foveal Atrophy • CNV • Polypoidal Choroidal Vasculopathy

Acknowledgements • • Douglas Sigford, MD Efrat Fleissig, MD Mehreen Adhi, MD Nilofar Piri, MD

References 1. Lauermann JL, Eter N, Alten F. Optical Coherence Tomography Angiography Offers New Insights into Choriocapillaris Perfusion. Ophthalmologica Journal international d'ophtalmologie International journal of ophthalmology Zeitschrift fur Augenheilkunde. 2018; 239(2 -3): 74 -84. 2. Bonini Filho MA, de Carlo TE, Ferrara D, et al. Association of Choroidal Neovascularization and Central Serous Chorioretinopathy With Optical Coherence Tomography Angiography. JAMA ophthalmology. 2015; 133(8): 899 -906. 3. Manayath GJ, Ranjan R, Shah VS, Karandikar SS, Saravanan VR, Narendran V. Central serous chorioretinopathy: Current update on pathophysiology and multimodal imaging. Oman journal of ophthalmology. 2018; 11(2): 103 -112. 4. Borrelli E, Sarraf D, Freund KB, Sadda SR. OCT angiography and evaluation of the choroid and choroidal vascular disorders. Progress in retinal and eye research. 2018.

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