Central Serous Chorioretinopathy and White Subretinal Exudation During Pregnancy J. Donald M.
\s=b\ Six women
Gass, MD
otherwise healthy had development of
pregnant
idiopathic chorioretinopathy in one
central serous both eyes. All had one or more focal areas of white subretinal exudate, which probably was fibrinous in type. In some patients, this was misinterpreted as subretinal neovascularization or retinitis. Symptoms developed in most patients in the third trimester and following delivery, there was spontaneous resolution of retinal detachment and return of visual acuity to 20/20 or better. In a randomly selected group of 50 patients with idiopathic central serous retinopathy unassociated with pregnancy, subretinal white exudation occurred in only six (17%) of 42 men and in zero (0%) of eight women. The cause for the higher prevalence of this exudate in pregnant women is unknown. or
(Arch Ophthalmol. 1991;109:677-681)
diopathic central serous chorioreti¬ nopathy (ICSC) typically occurs in healthy young or middle-aged male subjects in one and occasionally both eyes.1 In a few patients, particularly those with a large area of serous reti¬ nal detachment, a focal deposit of white or gray-white subretinal exú¬ date may be present in an area where fluorescein angiography usually dem¬ onstrates evidence of diffusion of dye from the choroid into the subretinal space.2 This exúdate may be misinter¬ preted biomicroscopically as focal reti¬ nitis, retinal ischemia, or evidence of Accepted for publication December 19, 1991. From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Fla. Reprint requests to Bascom Palmer Eye Institute, PO Box 016880, Miami, FL 33101 (Dr Gass).
subretinal neovascularization.3 There is histopathologic evidence that this exúdate is fibrin.3 Idiopathic central serous choriore¬ tinopathy is a recognized complication of pregnancy (unpublished data, pre¬ sented at the Jules Gonin Retinal Soci¬
ety, Bruges, Belgium, September 7, 1988)."""' The purposes of this report are to
(1) summarize the findings in six
who during the course of an otherwise uncomplicated pregnancy had development of ICSC in one or both eyes, and (2) emphasize the high frequency of white, presumably fibrinous, subretinal exudation in these pa¬ tients, the importance of correct inter¬ pretation of this exudation to avoid unnecessary laboratory investigations, and the benign course of this disorder that resolves spontaneously, usually following delivery with recovery of normal or near normal visual function. women
PATIENTS, MATERIALS, AND METHODS The six subjects of this report represent my total experience with ICSC in pregnan¬ cy. They include three patients examined by me and clinical and photographic records
of three others contributed by Lawrence Reese, MD, Lawrence Singerman, MD, and Howard Schatz, MD. All patients under¬ went complete ocular examinations and fun¬ dus photography. All were receiving ob¬ stetrical care and none had toxemia or other systemic disease. Reports of the eight pre¬ viously reported cases of ICSC in patients with otherwise uncomplicated pregnancies were reviewed for evidence of subretinal white exudation. To ascertain the frequency of white subretinal exudation in nonpregnant pa¬ tients with ICSC, I reviewed the photo¬ graphic records of 50 randomly selected patients with this disorder who presented at the Bascom Palmer Eye Institute, Mi¬ ami, Fla, because of recent visual loss
caused by serous detachment of the retina confined to the macular area.
RESULTS
Table 1 summarizes the findings in the six subjects of this report. Table 2 summarizes the findings in the eight patients whose cases have been re¬
ported previously.
The age of the 14 patients ranged from 22 to 36 years (mean age, 31 years; median, 32 years). Eight of the 10 patients whose racial characteristics were stated were nonwhite. Six were primiparous. One multipara had ICSC during three previous pregnancies.4 One other multipara had evidence of previous ICSC.5 The onset of visual symptoms occurred during the third trimester in most patients. It occurred during the first trimester in only two patients. There was no predilection for either eye. Only one patient had both eyes affected. All six subjects of this,, report and at least three of four pa¬ tients whose cases had been reported previously4,7 had biomicroscopic evi¬ dence of white subretinal exúdate (Figs 1 and 2). The mean age of these nine patients was 31 years. One or more serous detachments of the pig¬ ment epithelium were recognized be¬ neath the neurosensory retinal detach¬ ment in approximately half the patients. Fluorescein angiography was done during pregnancy in patient 4 and in one of the patients whose case has been reported previously.4 It revealed evidence of focal serous detachments of the pigment epithelium and staining in the area of the white subretinal exúdate (Fig 3). Reattachment of the retina occurred spontaneously soon af¬ ter delivery in 13 patients and in one patient after argon laser treatment.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 12/28/2015
Table Time of Onset of Visual Symptoms
Obstetrical History Patient No./ Age, y Race
Gravida
(Gestation, mo)
Para
1 / 29/Hispanic
2/27/Hispanic
1.—Summary of Findings in Six Patients With Idiopathic Evidence of
Symptoms Metamorphopsi. micropsia None, blurring
Affected Eye, Visual Acuity
Fundus
Findings
R, 20/25
Retinal detachment
R, 20/20; L, 20/30
RPE
disturbance,
retinal detachment;
Subretinal Fibrin Yes
No, yes
multiple RPE detachments 7.5
3/33/Black
L, 20/20
Blurring, micropsia
R, 20/30 L, 20/40;
4/22/White
5/36/Native American
at
8 mo, 20/200
RPE indicates retinal
Yes
Retinal detachment
Yes
Retinal and RPE detachment Retinal detachment
R, 20/20
Blurring
6/ 28 /Black
Retinal and RPE detachment
Yes
pigment epithelium.
Summary of Findings in Eight Previously Reported Cases of Patients
Table 2. —
Obstetrical
History
Age, y/ Source
Chumbley
and
Race
Para
Abortua
Time of Onset of
Visual Symptoms During Gestation,
Symptoms Blurring,
Eye, Acuity
NS
NS
Fundus Findings Retinal and RPE detachment 'Macular edema"
Blurring
L, 20/20
Retinal detachment
NS
27/NS
Scotoma
R, 20/100
Retinal detachment
NS
32/NS
Blurring and
R, 20/100
Retinal detachment
Metamorphopsia
L, 20/15
Retinal and RPE
32/Oriental
Metamorphopsia
L, 20/30
Retinal and RPE detachment
Yes
35/Oriental
Metamorphopsia
L, 20/30
Retinal detachment
Yes
Gravida
34t/ white
mo
8
Frank*
Bedrossian5^ Cruysberg and
Evidence of Subretinal
Affected Visual
L, 20/40
micropsia 32/NS 34/NS
NS
NS
NS
and scotoma
Deutman6
Fibrin
Yes NS
scotoma
Fastenberg and
31
/Hispanic
and scotoma
Ober'
NS indicates not stated; RPE, retinal pigment epithelium. tMacular detachment during each of last three previous pregnancies. tProbable macular detachment during first pregnancy.
One patient showed evidence of partial resolution of the retinal detachment prior to delivery (Fig 2). Most patients were asymptomatic at the time of last follow-up. Some had persistent mild micropsia, metamorphopsia, and dyschromatopsia. Visual acuity re¬ turned to 20/20 or better in all pa¬ tients. At last examination, mild changes in the pigment epithelium were evident in some eyes near the sites where the white exúdate was previously present. In one patient there was a strand of subretinal fi¬ brous tissue (Fig 4). The mean age of the 50 randomly selected patients (eight women and 42 men) with ICSC unassociated with pregnancy was 41 years (range, 27 to 59 years). The mean age of the women was 44 years. Sixteen patients were nonwhite (14 Hispanics, one black, and one Oriental). Only six patients (12%),
all male (four Hispanics and two whites with a mean age of 42 years), had biomicroscopic evidence of white sub¬ retinal exúdate equal to or greater than the least amount seen in the pregnant patient (patient 6). In all patients, this was located at the site of fluorescein leakage. The present studies indicate that the prevalence of white subretinal exúdate accompanying ICSC is probably great¬ er in pregnant women (six of six pa¬ tients) than in either nonpregnant women (none of eight patients; P= .001, 2 test), and/or men (six of 42 patients; P= .001, 2 test). COMMENT
These six patients and the eight patients whose cases were previously reported had development of the typi¬ cal symptoms and biomicroscopic find-
No
detachment
ings of ICSC during otherwise uncom¬ plicated pregnancies. The only unusual finding in these patients was the pres¬
of white subretinal exúdate in all six of the newly reported cases and in at least three of four of the previously reported cases for an incidence of ap¬ proximately 90%. My experience, as well as the retrospective study of 50 patients with ICSC, suggests that white subretinal exudation occurs in 20% or less of nonpregnant patients with ICSC. When this exudation oc¬ curs, the following are noted: (1) it often is present around and partly covers a focal area of detachment of the retinal pigment epithelium (RPE); (2) it is usually associated with more than average subretinal fluid; (3) angi¬ ography usually shows streaming of dye through a defect or hole in the RPE at the edge of the RPE detach¬ ment into the subretinal fluid; and ence
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 12/28/2015
Central Serous
Choroidopathy Occurring During Pregnancy* Final Examination Time After
Fluorescein
Angiography
Delivery,
Fluorescein Visual Acuity R, 20/20
mo
None
Status of Macula
Angiography
Symptoms None
R, 20/20; L, 20/20
Normal, small
L, 20/20
Retina flat, mottling
None,
area
none
None, micropsia
paracentral subretinal fibrous metaplasia Micropsia
RPE Focal
R, 20/15 L, 20/20
None
Mild RPE defect Focal RPE defect
pigment clump
Retina flat
Slight metamorphopsia and dyschromatopsia
R, 20/20
With
Idiopathic Central Serous Choroidopathy Occurring During Pregnancy* Final Examination
Fluorescein
Fluorescein
Time After
Angiography
Treatment
Delivery
Yes
Argon
1 mo
No
No
laser
No
6
mo
Visual Acuity L, 20/30
L, 20/15 20/20
2 wk
NS
No
Status of Macula Retina flat
Angiography
Symptoms
Retina flat
Normal Normal
Yes, RPE changes
Retina flat,
No
No
slight granularity
None
No
R, 20/20
Retina flat
No
L, 20/20
Retina flat
Yes, RPE changes
None
L, 20/20
Retina flat
Yes, RPE changes
None
Retina flat, few retinal precipitates and RPE changes
No
No
No
3
mo
(4) after resolution of the subretinal
fluid, in
fibrous strands may be left beneath the retina in the area of fibrinous exudation.1,2 These findings are particularly prominent in those patients in whom bullous retinal detachment overlying multiple large RPE detachments in one or both eyes develops.2 Although most patients with this severe form of ICSC have no evidence of systemic disease, I have observed it in two women receiving hemodialysis because of renal failure,8 as well as in a woman with renal insufficiency caused by lupus some cases
erythematosus.
In 1967, it was my occasional obser¬ vation of subretinal precipitates and whitish exúdate in patients with ICSC, together with their fluorescein angio¬ graphie findings, that suggested that one or more focal choriocapillary per-
meability alterations sufficient to per¬ mit protein diffusion into the subre¬
tinal space was the cause of serous detachment of the pigment epithelium and retina in this disorder.1 Further support for this concept occurred when at the 1980 Verhoeff Ophthalmologic Society meeting, Gilbert de Venecia, MD, reported the clinical and histo¬ pathologic findings in a patient with severe ICSC that developed soon after renal transplantation.' He demon¬ strated histopathologically and histochemically that the white subretinal exúdate ophthalmoscopically observed surrounding the RPE detachments, as well as that beneath the RPE, was fibrin. While he found no light micro¬ scopic alteration of the choriocapillaris, the fibrinous exúdate attests to the presence of a focal marked increase in the permeability of the choriocapillaris
Metamorphopsia
that is sufficient to allow large mole¬ cules the size of fibrinogen to escape into the subpigment epithelial and su¬ bretinal spaces. It is difficult to offer an alternative explanation for the nature of this white subretinal exúdate. It is unlikely that it is a focal accumulation of polymorphonuclear leukocytes or other white cells. We have other clinicopathologic evidence in the eye that movement of fibrinogen across a damaged endothelial wall produces a visible white lesion in the case of white-centered hemor¬ rhages in severely anemic patients.8 The development of fibrous strands in the subretinal space in the area of white exudation as occurred in patient 4 (Fig 4), and as reported in other patients with severe ICSC,2 is further evidence suggesting the fibrinous na¬ ture of the exúdate. Fibrin is a stimu-
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 12/28/2015
Fig 1. —Arrows indicate white subretinal exúdate; arrowheads, a focal serous detachment of the pigment epithelium. Top left, Patient 1; top right, patient 2; center left, patient 3; center right, patient4; bottom left, patient5; and bottom right, patiente.
lus to the ingrowth of fibroblastic as well as angioblastic cells. In the case of ICSC, the former have greater access than the latter to the subretinal space. The cause of the permeability alter¬ ation in nonpregnant patients with ICSC and the reasons for the apparent higher incidence of white subretinal exudation when it accompanies preg¬ nancy are unknown. That ICSC occurs typically in otherwise healthy young or middle-aged adults often during peri¬ ods of stress has suggested that it may result from little more than physiologic decompensation at one or several sites of minor congenital structural defects in the choriocapillaris and Bruch's membrane during vasomotor stress.1 Observations that have implicated the possible role of hyperactivity of the adrenomedullary system in its pathogenesis include the following: the dem¬ onstration of a higher than normal incidence of a type A behavior pattern (competitive drive, sense of urgency, and aggressive and hostile tempera¬ ment in patients with ICSC)," and the experimental production of ICSC in monkeys by intravenous injection of epinephrine.1"" Elevation of serum catecholamine levels is but one of many physiologic, metabolic, and vascular al¬ terations occurring during pregnancy that may be of importance in predis¬ posing pregnant women to ICSC. Oth¬ ers include increased cardiac output and blood volume, hypo-osmolarity of the blood serum, increased levels of clotting factors and fibrinolytic activi-
Fig 2. —The course of retinal detachment in the right eye of patient 5. Left, Seventh month of pregnancy. Right, Ninth month of pregnancy. Compare with Fig 1, bottom left (eighth month of pregnancy). Note increase in size of retinal detachment and appearance of retinal pigment epithelial detachment (arrowhead) in area of white subretinal exudation between seventh and eighth month, and partial resolution of subretinal fluid by the ninth month.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 12/28/2015
Fig 3. —Late angiogram in patient 4 showing marked staining at sites of white subretinal exudation (compare with Fig 1, middle right). One month after delivery, the subretinal exúdate was gone and repeated angiography showed no evidence of staining.
ty, and increased production of corticosteroids, estrogen, thyroxine, and oth¬
levels of the sec¬ ond and third trimester may be an important factor in predisposing these patients to development of ICSC and subretinal fibrin.121. This prostaglandin is a potent vasodilator and inhibitor of er
hormones.
Increased
prostacyclin occurring during
platelet aggregation. The finding in this report that white subretinal exúdate accompanying
ICSC occurred in nonwhites in seven of nine pregnant women and in four of six patients, all male, in the nonpregnant group suggests that racial charac¬ teristics may be important in the pathogenesis of white subretinal exu¬ dation in both groups. Sex and age, except as they relate to the pregnant state, do not appear to be important factors. It is unlikely that the pathogenesis of retinal detachment in pregnant women with ICSC is the same as that
Fig 4. Residual strand of subretinal fibrous tissue (arrow) after reso¬ lution of macular detachment in patient 2 (compare with Fig 1, top —
right).
·
associated with severe toxemia. In the latter patients multicentric areas of retinal detachment typically develop that become confluent to form a bullous retinal detachment. This may be associated with multiple ill-defined placoid areas of ischemie whitening of the pigment epithelium, but not with serous detachments of the pigment epithelium."1' These changes are ac¬ companied by angiographie evidence of multifocal areas of choriocapillaris ob¬ struction and pigment epithelial necro¬ sis similar to that in other nonpregnant patients with retinal detachment caused by malignant hypertension. "·" Awareness of the frequency of sub¬ retinal white exúdate accompanying ICSC in pregnancy is important to avoid misdiagnoses, unnecessary diag¬ nostic tests, and incorrect treatment. Fluorescein angiography to exclude the presence of occult subretinal neo¬ vascularization is generally unneces¬ sary, especially in the absence of other
suggest its presence, eg, blood, lipid exudation, pig¬ or other ocular changes that might predispose the eye to choroidal neovascularization, eg, chorioretinal scars, angioid streaks, and myopic de¬ generation. Confinement of the white lesion to the outer retinal layers and absence of overlying vitreous cells are biomicroscopic clues that it is probably
findings
to
subretinal ment ring,
by acute retinitis or retinal arteriolar occlusion. While the diagnosis of ICSC in pregnant women is usually straightforward, they should be followed up closely by their ophthal¬ mologist and obstetrician with the ex¬ pectation that the visual acuity and the appearance of the fundus will return to normal or near normal. This investigation was supported in part by not caused either
Public Health Service research grant EY02549 and core grant EY02180, Department of Health and Human Services, National Institutes of Health, National Eye Institute, Bethesda, Md, and in part by Research to Prevent Blindness, Inc, New York City.
References 1. Gass JDM.
Pathogenesis of disciform detachneuroepithelium, II: idiopathic central serous choroidopathy. Am J Ophthalmol. 1967;63: ment of the
587-615.
2. Gass JDM. Bullous retinal detachment: an unusual manifestation of idiopathic central serous choroidopathy. Am J Ophthalmol. 1973;75:810\x=req-\ 821.
3. Gass JDM. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. 3rd ed. St Louis, Mo: CV Mosby Co; 1987:46-59. 4. Chumbley LC, Frank RN. Central serous retinopathy and pregnancy. Am J Ophthalmol. 1974;77:158-160. 5. Bedrossian RH. Central serous retinopathy and pregnancy. Am J Ophthalmol. 1974;78:152.
6. Cruysberg JRM, Deutman AF. Visual disturbances during pregnancy caused by central serous choroidopathy. Br J Ophthalmol. 1982;66:240-241. 7. Fastenberg DM, Ober RR. Central serous choroidopathy in pregnancy. Arch Ophthalmol.
tral
hemorrhages: their significance. Ophthalmology. mology. 1980;87:66-69. 9. Yannuzzi LA. Type A behavior and central serous chorioretinopathy. Trans Am Ophthalmol
71;122-137.
1983;101:1055-1058. 8. Duane TD, Osher RH, Green WR. White cen-
tered
Soc. 1986;84:799-845. 10. Yoshioka H, Katsume Y, Akune H. Experimental central serous chorioretinopathy, I: clinical findings. Jpn J Ophthalmol. 1981;25:112-118. 11. Yoshioka H, Katsume Y. Experimental cen-
serous chorioretinopathy, III: ultrastructural findings. Jpn J Ophthalmol. 1982;26:397-409. 12. Lewis PJ, Boylan P, Friedman LA, Hensby CN, Downing I. Prostacyclin in pregnancy. BMJ.
1980:280;1581-1582.
13. Friedman SA. Preeclampsia: a review of the role of prostaglandins. Obstet Gynecol. 1988: 14. Gitter KA, Houser BP, Sarin LK, Justice J Jr. Toxemia of pregnancy: an angiographic interpretation of fundus changes. Arch Ophthalmol.
1968;80:449-454.
15. Gass JDM, Pautler SE. Toxemia of pregnan-
cy pigment epitheliopathy masquerading as a here-
domacular dystrophy. Trans Am 1985;83:114-130.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 12/28/2015
Ophthalmol Soc.
\s=b\ Six women
Gass, MD
otherwise healthy had development of
pregnant
idiopathic chorioretinopathy in one
central serous both eyes. All had one or more focal areas of white subretinal exudate, which probably was fibrinous in type. In some patients, this was misinterpreted as subretinal neovascularization or retinitis. Symptoms developed in most patients in the third trimester and following delivery, there was spontaneous resolution of retinal detachment and return of visual acuity to 20/20 or better. In a randomly selected group of 50 patients with idiopathic central serous retinopathy unassociated with pregnancy, subretinal white exudation occurred in only six (17%) of 42 men and in zero (0%) of eight women. The cause for the higher prevalence of this exudate in pregnant women is unknown. or
(Arch Ophthalmol. 1991;109:677-681)
diopathic central serous chorioreti¬ nopathy (ICSC) typically occurs in healthy young or middle-aged male subjects in one and occasionally both eyes.1 In a few patients, particularly those with a large area of serous reti¬ nal detachment, a focal deposit of white or gray-white subretinal exú¬ date may be present in an area where fluorescein angiography usually dem¬ onstrates evidence of diffusion of dye from the choroid into the subretinal space.2 This exúdate may be misinter¬ preted biomicroscopically as focal reti¬ nitis, retinal ischemia, or evidence of Accepted for publication December 19, 1991. From the Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Fla. Reprint requests to Bascom Palmer Eye Institute, PO Box 016880, Miami, FL 33101 (Dr Gass).
subretinal neovascularization.3 There is histopathologic evidence that this exúdate is fibrin.3 Idiopathic central serous choriore¬ tinopathy is a recognized complication of pregnancy (unpublished data, pre¬ sented at the Jules Gonin Retinal Soci¬
ety, Bruges, Belgium, September 7, 1988)."""' The purposes of this report are to
(1) summarize the findings in six
who during the course of an otherwise uncomplicated pregnancy had development of ICSC in one or both eyes, and (2) emphasize the high frequency of white, presumably fibrinous, subretinal exudation in these pa¬ tients, the importance of correct inter¬ pretation of this exudation to avoid unnecessary laboratory investigations, and the benign course of this disorder that resolves spontaneously, usually following delivery with recovery of normal or near normal visual function. women
PATIENTS, MATERIALS, AND METHODS The six subjects of this report represent my total experience with ICSC in pregnan¬ cy. They include three patients examined by me and clinical and photographic records
of three others contributed by Lawrence Reese, MD, Lawrence Singerman, MD, and Howard Schatz, MD. All patients under¬ went complete ocular examinations and fun¬ dus photography. All were receiving ob¬ stetrical care and none had toxemia or other systemic disease. Reports of the eight pre¬ viously reported cases of ICSC in patients with otherwise uncomplicated pregnancies were reviewed for evidence of subretinal white exudation. To ascertain the frequency of white subretinal exudation in nonpregnant pa¬ tients with ICSC, I reviewed the photo¬ graphic records of 50 randomly selected patients with this disorder who presented at the Bascom Palmer Eye Institute, Mi¬ ami, Fla, because of recent visual loss
caused by serous detachment of the retina confined to the macular area.
RESULTS
Table 1 summarizes the findings in the six subjects of this report. Table 2 summarizes the findings in the eight patients whose cases have been re¬
ported previously.
The age of the 14 patients ranged from 22 to 36 years (mean age, 31 years; median, 32 years). Eight of the 10 patients whose racial characteristics were stated were nonwhite. Six were primiparous. One multipara had ICSC during three previous pregnancies.4 One other multipara had evidence of previous ICSC.5 The onset of visual symptoms occurred during the third trimester in most patients. It occurred during the first trimester in only two patients. There was no predilection for either eye. Only one patient had both eyes affected. All six subjects of this,, report and at least three of four pa¬ tients whose cases had been reported previously4,7 had biomicroscopic evi¬ dence of white subretinal exúdate (Figs 1 and 2). The mean age of these nine patients was 31 years. One or more serous detachments of the pig¬ ment epithelium were recognized be¬ neath the neurosensory retinal detach¬ ment in approximately half the patients. Fluorescein angiography was done during pregnancy in patient 4 and in one of the patients whose case has been reported previously.4 It revealed evidence of focal serous detachments of the pigment epithelium and staining in the area of the white subretinal exúdate (Fig 3). Reattachment of the retina occurred spontaneously soon af¬ ter delivery in 13 patients and in one patient after argon laser treatment.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 12/28/2015
Table Time of Onset of Visual Symptoms
Obstetrical History Patient No./ Age, y Race
Gravida
(Gestation, mo)
Para
1 / 29/Hispanic
2/27/Hispanic
1.—Summary of Findings in Six Patients With Idiopathic Evidence of
Symptoms Metamorphopsi. micropsia None, blurring
Affected Eye, Visual Acuity
Fundus
Findings
R, 20/25
Retinal detachment
R, 20/20; L, 20/30
RPE
disturbance,
retinal detachment;
Subretinal Fibrin Yes
No, yes
multiple RPE detachments 7.5
3/33/Black
L, 20/20
Blurring, micropsia
R, 20/30 L, 20/40;
4/22/White
5/36/Native American
at
8 mo, 20/200
RPE indicates retinal
Yes
Retinal detachment
Yes
Retinal and RPE detachment Retinal detachment
R, 20/20
Blurring
6/ 28 /Black
Retinal and RPE detachment
Yes
pigment epithelium.
Summary of Findings in Eight Previously Reported Cases of Patients
Table 2. —
Obstetrical
History
Age, y/ Source
Chumbley
and
Race
Para
Abortua
Time of Onset of
Visual Symptoms During Gestation,
Symptoms Blurring,
Eye, Acuity
NS
NS
Fundus Findings Retinal and RPE detachment 'Macular edema"
Blurring
L, 20/20
Retinal detachment
NS
27/NS
Scotoma
R, 20/100
Retinal detachment
NS
32/NS
Blurring and
R, 20/100
Retinal detachment
Metamorphopsia
L, 20/15
Retinal and RPE
32/Oriental
Metamorphopsia
L, 20/30
Retinal and RPE detachment
Yes
35/Oriental
Metamorphopsia
L, 20/30
Retinal detachment
Yes
Gravida
34t/ white
mo
8
Frank*
Bedrossian5^ Cruysberg and
Evidence of Subretinal
Affected Visual
L, 20/40
micropsia 32/NS 34/NS
NS
NS
NS
and scotoma
Deutman6
Fibrin
Yes NS
scotoma
Fastenberg and
31
/Hispanic
and scotoma
Ober'
NS indicates not stated; RPE, retinal pigment epithelium. tMacular detachment during each of last three previous pregnancies. tProbable macular detachment during first pregnancy.
One patient showed evidence of partial resolution of the retinal detachment prior to delivery (Fig 2). Most patients were asymptomatic at the time of last follow-up. Some had persistent mild micropsia, metamorphopsia, and dyschromatopsia. Visual acuity re¬ turned to 20/20 or better in all pa¬ tients. At last examination, mild changes in the pigment epithelium were evident in some eyes near the sites where the white exúdate was previously present. In one patient there was a strand of subretinal fi¬ brous tissue (Fig 4). The mean age of the 50 randomly selected patients (eight women and 42 men) with ICSC unassociated with pregnancy was 41 years (range, 27 to 59 years). The mean age of the women was 44 years. Sixteen patients were nonwhite (14 Hispanics, one black, and one Oriental). Only six patients (12%),
all male (four Hispanics and two whites with a mean age of 42 years), had biomicroscopic evidence of white sub¬ retinal exúdate equal to or greater than the least amount seen in the pregnant patient (patient 6). In all patients, this was located at the site of fluorescein leakage. The present studies indicate that the prevalence of white subretinal exúdate accompanying ICSC is probably great¬ er in pregnant women (six of six pa¬ tients) than in either nonpregnant women (none of eight patients; P= .001, 2 test), and/or men (six of 42 patients; P= .001, 2 test). COMMENT
These six patients and the eight patients whose cases were previously reported had development of the typi¬ cal symptoms and biomicroscopic find-
No
detachment
ings of ICSC during otherwise uncom¬ plicated pregnancies. The only unusual finding in these patients was the pres¬
of white subretinal exúdate in all six of the newly reported cases and in at least three of four of the previously reported cases for an incidence of ap¬ proximately 90%. My experience, as well as the retrospective study of 50 patients with ICSC, suggests that white subretinal exudation occurs in 20% or less of nonpregnant patients with ICSC. When this exudation oc¬ curs, the following are noted: (1) it often is present around and partly covers a focal area of detachment of the retinal pigment epithelium (RPE); (2) it is usually associated with more than average subretinal fluid; (3) angi¬ ography usually shows streaming of dye through a defect or hole in the RPE at the edge of the RPE detach¬ ment into the subretinal fluid; and ence
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 12/28/2015
Central Serous
Choroidopathy Occurring During Pregnancy* Final Examination Time After
Fluorescein
Angiography
Delivery,
Fluorescein Visual Acuity R, 20/20
mo
None
Status of Macula
Angiography
Symptoms None
R, 20/20; L, 20/20
Normal, small
L, 20/20
Retina flat, mottling
None,
area
none
None, micropsia
paracentral subretinal fibrous metaplasia Micropsia
RPE Focal
R, 20/15 L, 20/20
None
Mild RPE defect Focal RPE defect
pigment clump
Retina flat
Slight metamorphopsia and dyschromatopsia
R, 20/20
With
Idiopathic Central Serous Choroidopathy Occurring During Pregnancy* Final Examination
Fluorescein
Fluorescein
Time After
Angiography
Treatment
Delivery
Yes
Argon
1 mo
No
No
laser
No
6
mo
Visual Acuity L, 20/30
L, 20/15 20/20
2 wk
NS
No
Status of Macula Retina flat
Angiography
Symptoms
Retina flat
Normal Normal
Yes, RPE changes
Retina flat,
No
No
slight granularity
None
No
R, 20/20
Retina flat
No
L, 20/20
Retina flat
Yes, RPE changes
None
L, 20/20
Retina flat
Yes, RPE changes
None
Retina flat, few retinal precipitates and RPE changes
No
No
No
3
mo
(4) after resolution of the subretinal
fluid, in
fibrous strands may be left beneath the retina in the area of fibrinous exudation.1,2 These findings are particularly prominent in those patients in whom bullous retinal detachment overlying multiple large RPE detachments in one or both eyes develops.2 Although most patients with this severe form of ICSC have no evidence of systemic disease, I have observed it in two women receiving hemodialysis because of renal failure,8 as well as in a woman with renal insufficiency caused by lupus some cases
erythematosus.
In 1967, it was my occasional obser¬ vation of subretinal precipitates and whitish exúdate in patients with ICSC, together with their fluorescein angio¬ graphie findings, that suggested that one or more focal choriocapillary per-
meability alterations sufficient to per¬ mit protein diffusion into the subre¬
tinal space was the cause of serous detachment of the pigment epithelium and retina in this disorder.1 Further support for this concept occurred when at the 1980 Verhoeff Ophthalmologic Society meeting, Gilbert de Venecia, MD, reported the clinical and histo¬ pathologic findings in a patient with severe ICSC that developed soon after renal transplantation.' He demon¬ strated histopathologically and histochemically that the white subretinal exúdate ophthalmoscopically observed surrounding the RPE detachments, as well as that beneath the RPE, was fibrin. While he found no light micro¬ scopic alteration of the choriocapillaris, the fibrinous exúdate attests to the presence of a focal marked increase in the permeability of the choriocapillaris
Metamorphopsia
that is sufficient to allow large mole¬ cules the size of fibrinogen to escape into the subpigment epithelial and su¬ bretinal spaces. It is difficult to offer an alternative explanation for the nature of this white subretinal exúdate. It is unlikely that it is a focal accumulation of polymorphonuclear leukocytes or other white cells. We have other clinicopathologic evidence in the eye that movement of fibrinogen across a damaged endothelial wall produces a visible white lesion in the case of white-centered hemor¬ rhages in severely anemic patients.8 The development of fibrous strands in the subretinal space in the area of white exudation as occurred in patient 4 (Fig 4), and as reported in other patients with severe ICSC,2 is further evidence suggesting the fibrinous na¬ ture of the exúdate. Fibrin is a stimu-
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 12/28/2015
Fig 1. —Arrows indicate white subretinal exúdate; arrowheads, a focal serous detachment of the pigment epithelium. Top left, Patient 1; top right, patient 2; center left, patient 3; center right, patient4; bottom left, patient5; and bottom right, patiente.
lus to the ingrowth of fibroblastic as well as angioblastic cells. In the case of ICSC, the former have greater access than the latter to the subretinal space. The cause of the permeability alter¬ ation in nonpregnant patients with ICSC and the reasons for the apparent higher incidence of white subretinal exudation when it accompanies preg¬ nancy are unknown. That ICSC occurs typically in otherwise healthy young or middle-aged adults often during peri¬ ods of stress has suggested that it may result from little more than physiologic decompensation at one or several sites of minor congenital structural defects in the choriocapillaris and Bruch's membrane during vasomotor stress.1 Observations that have implicated the possible role of hyperactivity of the adrenomedullary system in its pathogenesis include the following: the dem¬ onstration of a higher than normal incidence of a type A behavior pattern (competitive drive, sense of urgency, and aggressive and hostile tempera¬ ment in patients with ICSC)," and the experimental production of ICSC in monkeys by intravenous injection of epinephrine.1"" Elevation of serum catecholamine levels is but one of many physiologic, metabolic, and vascular al¬ terations occurring during pregnancy that may be of importance in predis¬ posing pregnant women to ICSC. Oth¬ ers include increased cardiac output and blood volume, hypo-osmolarity of the blood serum, increased levels of clotting factors and fibrinolytic activi-
Fig 2. —The course of retinal detachment in the right eye of patient 5. Left, Seventh month of pregnancy. Right, Ninth month of pregnancy. Compare with Fig 1, bottom left (eighth month of pregnancy). Note increase in size of retinal detachment and appearance of retinal pigment epithelial detachment (arrowhead) in area of white subretinal exudation between seventh and eighth month, and partial resolution of subretinal fluid by the ninth month.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 12/28/2015
Fig 3. —Late angiogram in patient 4 showing marked staining at sites of white subretinal exudation (compare with Fig 1, middle right). One month after delivery, the subretinal exúdate was gone and repeated angiography showed no evidence of staining.
ty, and increased production of corticosteroids, estrogen, thyroxine, and oth¬
levels of the sec¬ ond and third trimester may be an important factor in predisposing these patients to development of ICSC and subretinal fibrin.121. This prostaglandin is a potent vasodilator and inhibitor of er
hormones.
Increased
prostacyclin occurring during
platelet aggregation. The finding in this report that white subretinal exúdate accompanying
ICSC occurred in nonwhites in seven of nine pregnant women and in four of six patients, all male, in the nonpregnant group suggests that racial charac¬ teristics may be important in the pathogenesis of white subretinal exu¬ dation in both groups. Sex and age, except as they relate to the pregnant state, do not appear to be important factors. It is unlikely that the pathogenesis of retinal detachment in pregnant women with ICSC is the same as that
Fig 4. Residual strand of subretinal fibrous tissue (arrow) after reso¬ lution of macular detachment in patient 2 (compare with Fig 1, top —
right).
·
associated with severe toxemia. In the latter patients multicentric areas of retinal detachment typically develop that become confluent to form a bullous retinal detachment. This may be associated with multiple ill-defined placoid areas of ischemie whitening of the pigment epithelium, but not with serous detachments of the pigment epithelium."1' These changes are ac¬ companied by angiographie evidence of multifocal areas of choriocapillaris ob¬ struction and pigment epithelial necro¬ sis similar to that in other nonpregnant patients with retinal detachment caused by malignant hypertension. "·" Awareness of the frequency of sub¬ retinal white exúdate accompanying ICSC in pregnancy is important to avoid misdiagnoses, unnecessary diag¬ nostic tests, and incorrect treatment. Fluorescein angiography to exclude the presence of occult subretinal neo¬ vascularization is generally unneces¬ sary, especially in the absence of other
suggest its presence, eg, blood, lipid exudation, pig¬ or other ocular changes that might predispose the eye to choroidal neovascularization, eg, chorioretinal scars, angioid streaks, and myopic de¬ generation. Confinement of the white lesion to the outer retinal layers and absence of overlying vitreous cells are biomicroscopic clues that it is probably
findings
to
subretinal ment ring,
by acute retinitis or retinal arteriolar occlusion. While the diagnosis of ICSC in pregnant women is usually straightforward, they should be followed up closely by their ophthal¬ mologist and obstetrician with the ex¬ pectation that the visual acuity and the appearance of the fundus will return to normal or near normal. This investigation was supported in part by not caused either
Public Health Service research grant EY02549 and core grant EY02180, Department of Health and Human Services, National Institutes of Health, National Eye Institute, Bethesda, Md, and in part by Research to Prevent Blindness, Inc, New York City.
References 1. Gass JDM.
Pathogenesis of disciform detachneuroepithelium, II: idiopathic central serous choroidopathy. Am J Ophthalmol. 1967;63: ment of the
587-615.
2. Gass JDM. Bullous retinal detachment: an unusual manifestation of idiopathic central serous choroidopathy. Am J Ophthalmol. 1973;75:810\x=req-\ 821.
3. Gass JDM. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. 3rd ed. St Louis, Mo: CV Mosby Co; 1987:46-59. 4. Chumbley LC, Frank RN. Central serous retinopathy and pregnancy. Am J Ophthalmol. 1974;77:158-160. 5. Bedrossian RH. Central serous retinopathy and pregnancy. Am J Ophthalmol. 1974;78:152.
6. Cruysberg JRM, Deutman AF. Visual disturbances during pregnancy caused by central serous choroidopathy. Br J Ophthalmol. 1982;66:240-241. 7. Fastenberg DM, Ober RR. Central serous choroidopathy in pregnancy. Arch Ophthalmol.
tral
hemorrhages: their significance. Ophthalmology. mology. 1980;87:66-69. 9. Yannuzzi LA. Type A behavior and central serous chorioretinopathy. Trans Am Ophthalmol
71;122-137.
1983;101:1055-1058. 8. Duane TD, Osher RH, Green WR. White cen-
tered
Soc. 1986;84:799-845. 10. Yoshioka H, Katsume Y, Akune H. Experimental central serous chorioretinopathy, I: clinical findings. Jpn J Ophthalmol. 1981;25:112-118. 11. Yoshioka H, Katsume Y. Experimental cen-
serous chorioretinopathy, III: ultrastructural findings. Jpn J Ophthalmol. 1982;26:397-409. 12. Lewis PJ, Boylan P, Friedman LA, Hensby CN, Downing I. Prostacyclin in pregnancy. BMJ.
1980:280;1581-1582.
13. Friedman SA. Preeclampsia: a review of the role of prostaglandins. Obstet Gynecol. 1988: 14. Gitter KA, Houser BP, Sarin LK, Justice J Jr. Toxemia of pregnancy: an angiographic interpretation of fundus changes. Arch Ophthalmol.
1968;80:449-454.
15. Gass JDM, Pautler SE. Toxemia of pregnan-
cy pigment epitheliopathy masquerading as a here-
domacular dystrophy. Trans Am 1985;83:114-130.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 12/28/2015
Ophthalmol Soc.
