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Unusual peripapillary new vessels in eye with central serous chorioretinopathy Clin Exp Optom 2015; 98: 574–576

DOI:10.1111/cxo.12281

Rupak Roy* MS Kumar Saurabh* MS Muna P Bhende† MS Debmalya Das* DNB Amit B Jain* MD * Aditya Birla Sankara Nethralaya, Kolkata, India † Sankara Nethralaya, Chennai, India E-mail: [email protected]

Submitted: 28 October 2014 Revised: 4 December 2014 Accepted for publication: 21 December 2014

Key words: central serous chorioretinopathy, optic disc, retina, retinopathy Central serous chorioretinopathy (CSC) presents most commonly in males in middle age with mild to modest disruption to central vision, which recovers spontaneously or with laser photocoagulation of focal leak;1 however, it can also result in large bullous exudative sensory retinal detachment and profound loss of central vision. We report a case, in which there was a large bullous detachment with the subsequent development of abnormal peripapillary retinal vessels. These vessels showed profuse leakage with fluorescein angiography. CASE HISTORY A 32-year-old man presented with metamorphopsia in both eyes of five months duration. This was his first visit to an eye-care provider. The patient did not have ‘type A’ personality and had not used preparations containing steroids in any form; however, he was under mental stress due to financial reasons over the last year. Visual acuity in the right eye was 6/9, N6 and in the left eye 6/12, N8. Anterior segment evaluation was normal in both eyes. Both eyes had clear vitreous with no sign of intraocular inflammation or retinal vascular occlusion. Fundus examination showed large neurosensory retinal detachment in the right eye. The left eye showed pigment epithelial detachment at the macula and subretinal fluid

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emanating from the leak temporal to the fovea and extending inferiorly to the vascular arcade causing shallow retinal detachment (Figure 1). Fundus fluorescein angiography (FFA) showed focal leaks in early phase in both eyes, increasing in size and intensity in the late phases, whereas optical coherence tomography (OCT) showed neurosensory retinal detachment in the right eye and pigment epithelial detachment with subretinal fluid in the left eye, confirming the diagnosis of central serous chorioretinopathy (Figure 1). Fluorescein angiography-guided focal laser was done to the focal chorioretinopathic leaks in both eyes. Three months later, the visual acuities in the right and left eyes were 6/6, N6 and 6/12, N12, respectively. Fundus examination revealed resolution of the subretinal fluid in the right eye. The inferior retinal detachment persisted in the left eye. Small arborising preretinal vessels originating from the superior margin of the optic disc were noted at this visit (Figure 2). Fluorescein angiography and OCT of the left eye showed focal leaks along with pigment epithelial detachment. The arborising vessels showed subtle leak in the venous phase of the angiogram (Figure 2). Focal laser to the central serous chorioretinopathic leak was repeated in the left eye. Three months later, the patient presented with stable vision of 6/6, N6 in right eye and

reduced vision of 6/60, N18 in the left. The fundus showed inferior exudative retinal detachment with pigment epithelial detachment in the left eye. The arborising vessels were more extensive and extended circumferentially around the left optic disc (Figure 3). Fluorescein angiography and OCT of the left eye showed parafoveal subretinal fluid and leaks. Arborising vessels showed diffuse leakage (Figure 3 D to G). Fluorescein angiography-guided focal laser was directed at the leak in the left eye. Complete haemogram, basic coagulation profile and carotid Doppler were normal. At the time of writing this report, the right eye was maintaining the vision with a dry macula. Left eye vision had improved to 6/24, N8; however, it showed more pronounced leakage from peripapillary arborising vessels on fluorescein angiography (Figure 3 H to K). The subretinal fluid and exudative retinal detachment had resolved. The patient was called for review after a month. DISCUSSION Chronic inferior retinal detachment is a known presentation of central serous chorioretinopathy.1 Such inferior retinal detachment is an effect of gravity on the subretinal fluid from multiple leaks.1 Gass

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New vessels in central serous chorioretinopathy Roy, Saurabh, Bhende, Das and Jain

Figure 1. Colour fundus photograph of the right eye (A) shows subretinal fluid at the macula (arrowhead) corresponding to the subretinal fluid seen on optical coherence tomography (OCT) (B). Colour fundus photograph (C) and OCT (D) of the left eye shows pigment epithelial detachment temporal to the fovea (arrowhead) along with subretinal fluid. Fluorescein angiographic images of the early (E and G) and late (F and H) phases of both eyes showing focal leakage (white bold arrow) increasing in size and intensity. Pigment epithelial detachments are seen in the left eye (white arrows). Right eye shows subretinal fluid (white arrowhead).

Figure 2. Colour fundus photograph of the left eye (A) shows alterations in the retinal pigment epithelium and a small pigment epithelial detachment temporal to fovea. Arborising vessels (arrowhead) emanating from the disc margin are noted. (B) Red-free image of the left eye showing arborising vessels arising from the disc (arrowhead). Fundus angiography of the left eye shows focal leakage temporal to the fovea increasing in size and intensity (C and D). Note the pigment epithelial detachment (bold arrows). Small vessels arising from the disc with very minimal leakage (white arrowhead) seen in the venous phase of the angiogram (D). and Little2 had reported that inferior exudative retinal detachment may lead to compromised blood flow in the overlying retinal blood vessels. Eventually, it may cause capillary non-perfusion and retinal neovascularisation,2 which in these cases are limited to the area of inferior retinal detachment. Apart from retinal detachment, inferior retinoschisis in juvenile X-linked retinoschisis has also been noted to cause retinal and optic disc neovascularisation. This retinoschisis leads to splitting of retinal layers and the mechanism of optic disc neovascularisation in these eyes has been thought to be the ischaemia of the peripheral retina, secondary to obliteration of retinal capillaries in the split layers of © 2015 Optometry Australia

the peripheral retina.3 Our patient had inferior retinal detachment and eventually developed arborising peripapillary vessels. Apart from these vessels, the eye had all the characteristic features of central serous chorioretinopathy and responded to fluorescein angiography-guided focal laser to the leak. These peripapillary vessels may be a manifestation of retinal ischaemia due to compromised blood flow in the detached inferior retina. We did not note any capillary non-perfusion on fluorescein angiography in the posterior pole of the left eye, which again supports the diagnosis of central serous chorioretinopathy and rules out the possibility of other retinal

vasculopathies, like old retinal vascular occlusions or retinal vasculitis. Such abnormal arborising peripapillary vessels have not been reported before in central serous chorioretinopathy probably because inferior retinal detachment in central serous chorioretinopathy is a rare manifestation of this disease.4 This is the first report of such leaking peripapillary new vessels in an eye with central serous chorioretinopathy. During the follow-up we noticed that these vessels persisted after resolution of the central serous chorioretinopathy, although the patient will require continuous follow-up even after resolution of central serous chorioretinopathy. Clinical and Experimental Optometry 98.6 November 2015

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New vessels in central serous chorioretinopathy Roy, Saurabh, Bhende, Das and Jain

Figure 3. Colour (A) and red-free (B) fundus photographs of the left eye show a network of tortuous, vessels around the disc (black arrow). A small pigment epithelial detachment is present temporal to the fovea, as confirmed by optical coherence tomography (C). Fluorescein angiography of the left eye shows leakage from the network of peripapillary vessels emanating from the disc (white arrows) (D to G). Also note a small active focal leakage temporal to the fovea. At the final visit, fluorescein angiography of the left eye shows progressive leakage from the peripapillary vessels (H to K).

REFERENCES 1. Otsuka S, Ohba N, Nakao K. A long-term follow-up study of severe variant of central serous chorioretinopathy. Retina 2002; 22: 25–32. 2. Gass JD, Little H. Bilateral bullous exudative retinal detachment complicating idiopathic central serous chorioretinopathy during systemic corticosteroid therapy. Ophthalmology 1995; 102: 737–747. 3. Pearson R, Jagger J. Sex linked juvenile retinoschisis with optic disc and peripheral retinal neovascularisation. Br J Ophthalmol 1989; 73: 311–313. 4. Kang JE, Kim HJ, Boo HD, Kim HK, Lee JH. Surgical management of bilateral exudative retinal detachment associated with central serous chorioretinopathy. Korean J Ophthalmol 2006; 20: 131–138.

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Unusual peripapillary new vessels in eye with central serous chorioretinopathy.

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