|Year : 2017 | Volume
| Issue : 1 | Page : 37-43
Central serous chorioretinopathy: correlation of structural changes on optical coherence tomography with visual outcomes
Anu Malik1, Alka Gupta2, Charu Mithal3, Vivek Gupta4, Yogesh K Gupta5
1 PDCR, Department of Ophthalmology, Upgraded Department of Ophthalmology, L.L.R.M. Medical College, Meerut, Uttar Pradesh, India
2 Associate Professor, Department of Ophthalmology, Upgraded Department of Ophthalmology, L.L.R.M. Medical College, Meerut, Uttar Pradesh, India
3 Head and Assistant Professor, Department of Ophthalmology, Upgraded Department of Ophthalmology, L.L.R.M. Medical College, Meerut, Uttar Pradesh, India
4 Trainee, Plastic Surgery, IPGMER & SSKM Hospital, Kolkata, West Bengal, India
5 Hindu Rao Hospital, NDMC Medical College, New Delhi, India
|Date of Submission||21-Sep-2016|
|Date of Acceptance||13-Dec-2016|
|Date of Web Publication||6-Mar-2017|
H. No. 584, Sri Nagar, Hapur (Panchsheel Nagar) - 245 101, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background The aim of this study was to describe optical coherence tomographic (OCT) patterns in patients with central serous chorioretinopathy and to correlate them with visual outcomes.
Materials and methods In a prospective case study, 20 eyes of 20 patients diagnosed ophthalmoscopically as central serous chorioretinopathy were subjected to meticulous recording of visual acuity, ophthalmologic examination, fundus photography, fluorescein angiography, and spectral-domain optical coherence tomography.
Results In the acute phase, subretinal fluid with an area of neurosensory retinal detachment was noted on OCT in all 20 eyes. OCT showed a retinal pigment epithelial (RPE) detachment corresponding to the fluorescein angiography leak site in three (15%) eyes. A total of 10 patients at the end of follow-up with no subretinal fluid had significantly lower mean foveal thickness. The logMAR best-corrected visual acuity (BCVA) improved from 0.63 (SD=0.30; range=1.00–0.18) at presentation to 0.23 (SD=0.24; range=0.78–0.00) at 6 months (P<0.05). The mean foveal retinal thickness was 346.8 µm (SD=111.87) at presentation (range=220–622) and 150.90 µm (SD=42.32) at 6 months (range=108–250) (P<0.001). Final OCT findings that associated significantly with good visual outcome (logMAR BCVA≤0.3) were preserved outer photoreceptor layer, inner and outer segment continuity, and bulging on the RPE layer/irregularity of RPE choroid band. The present study also showed no association of existent neurosensory retinal detachment with a final BCVA of logMAR BCVA of 0.3 or less (Fischer exact test, two-sided, P=0.087). No association was found between existent pigment epithelial detachment with a final BCVA of logMAR BCVA of 0.3 or less (Fischer exact test, two-sided, P=0.200).
Conclusion Structural changes on OCT may be associated with different levels of visual function, and OCT findings could be important parameters of deciding follow-up and treatment.
Keywords: central serous chorioretinopathy, fluorescein angiography, optical coherence tomography
|How to cite this article:|
Malik A, Gupta A, Mithal C, Gupta V, Gupta YK. Central serous chorioretinopathy: correlation of structural changes on optical coherence tomography with visual outcomes. Delta J Ophthalmol 2017;18:37-43
|How to cite this URL:|
Malik A, Gupta A, Mithal C, Gupta V, Gupta YK. Central serous chorioretinopathy: correlation of structural changes on optical coherence tomography with visual outcomes. Delta J Ophthalmol [serial online] 2017 [cited 2017 Jun 25];18:37-43. Available from: http://www.djo.eg.net/text.asp?2017/18/1/37/201619
| Introduction|| |
Central serous chorioretinopathy (CSCR) is an idiopathic syndrome of young to middle-aged adults, characterized by a serous detachment of the neurosensory retina with focal and multifocal areas of leakage at the level of the retinal pigment epithelium (RPE), predominantly affecting the macular area ,. Patients often complain of blurred central vision, micropsia, and metamorphopsia ,. Also, CSCR has been associated with type A personality , vasoconstrictive agents , endogenous hypercortisolism , smoking , the systemic use of corticosteroids ,, psychopharmacological agents , alcohol , antibiotics (oral) , antihistamines (oral) , and emotional distress . A history of migraine-type headaches may be elicited . In most cases, CSCR resolves spontaneously within 6 months, with good visual prognosis. Prolonged and recurrent macular detachment in some cases, however, may cause degenerative changes in the subfoveal RPE and neurosensory retina with poor visual outcome ,,.
The understanding of the pathophysiology of CSCR remains limited owing to the lack of significant histopathologic studies. Investigations and diagnostic tools such as fluorescein and indocyanine green angiography have provided some insight into the mechanism of this disease. The third-generation optical coherence tomography (OCT) has a high-resolution capability and allows good-quality images of the retinal layers in the macula and can supply more information about the diagnosis and prediction of prognosis in CSCR. Subtle fluid accumulation beneath the sensory retina and the RPE, which is not evident on fluorescein angiography (FA) and clinical examination, can often be picked up by OCT ,,,,.
The purpose of this study was to describe spectral-domain optical coherence tomography (SD-OCT) findings in CSCR and correlating them with visual outcomes.
| Materials and methods|| |
Patients with acute onset of visual deterioration, central scotoma, micropsia, or metamorphopsia with visual acuity (VA) in the range of 20/40 to 20/200 were included. On fundus examination, there was loss of foveolar reflex and neurosensory detachment, with or without areas of pigment epithelial detachment (PED). On fundus fluorescein angiography, active leak was seen by the presence of inkblot or smokestack type of appearance. OCT showed neurosensory detachment with subretinal fluid, with or without PED. Cases with both acute and chronic CSCR were included. The study followed the tenets of the Declaration of Helsinki and was approved by the local Institutional Review Board.
Acute CSCR was defined as a serous macular detachment caused by one or several isolated leaks seen on FA at the level of the RPE. Chronic CSCR was defined as a serous macular detachment associated with areas of RPE atrophy and pigment mottling, visible biomicroscopically, where FA displayed subtle leaks or ill-defined staining. Chronic cases had widespread RPE decompensation with or without sensory retinal detachment, associated or not with active leakage sites. Recurrent CSCR presents with an episode of acute CSCR following a previous episode with complete sensory retinal detachment resolution.
Patients excluded from the study were those with opaque media, uncontrolled systemic diseases like diabetes, hypertension, one-eyed patients, patients with leak at the papillomacular bundle and already treated with laser therapy, noncompliant and unwilling patients, and patients with any other ocular pathology such as choroidal neovascularization, choroidal inflammatory or neoplastic disorder, or a congenital optic nerve pit.
This study was a prospective case study. Written informed consent was obtained before recruitment, and patients were enrolled after the assessment of name, age, sex, occupation, address etc.; time and mode of onset of disease; history of symptoms; and various risk factors.
Uncorrected visual acuity and BCVA by Snellen’s chart were recorded, and the subjects were prescribed their manifest refractive correction and near vision using British N system cards. Slit-lamp examination for complete ocular examination was done. In all patients, fundus examination was performed using both direct and indirect ophthalmoscopy and slit-lamp biomicroscopy with +90 D lens after dilatation of pupil, and the following points were taken in consideration: media clarity, size of the optic disc, color of the disc, margin of disc, cup : disc ratio, peripapillary area, artery to vein (A/V) ratio, and foveal reflex. Each patient underwent color fundus photography, FA, and SD-OCT.
We investigated the type of leakage pattern and the demonstration of CSCR based on angiographic pooling of subretinal fluid and appearance of defects in the RPE. Using OCT software (RTVue-100; Optovue, Fremont, CA 94538, USA), fast macular scan and line scans were acquired by scanning 6 mm of macula centered at fovea. Retinal thickness was measured at the fovea using the macular thickness map. OCT was performed to examine neurosensory detachment; presence, size, location, and number of RPE detachment (PED); outer photoreceptor layer (OPRL) preservation in case of serous retinal detachment (RD); continuity of the inner segment (IS) and outer segment (OS) of the photoreceptor layer; and the change associated with the RPE-choroid band. The junction of the IS and OS of the photoreceptors was visualized with ultra-high-resolution OCT as a hyper-reflective layer distinct from the adjacent RPE reflectivity. The OCT images from consecutive visits were analyzed and compared. All OCT and VA parameters were stored in an MS Excel 2007 spreadsheet (Microsoft, USA).
Demographic findings were investigated such as age, race, sex, time of first diagnosis of CSCR, initial and final visual acuity (BCVA), and changes of clinical findings throughout the period of this study. The final Snellen BCVA was converted to logarithm of the minimum angle of resolution (logMAR) to investigate the statistical correlation with OCT findings on follow-up visits. Cases were followed up at 2 weeks, 1 month, 2 months, 3 months, and 6 months subsequently. After diagnosis, each patient was subjected to various modes of treatment such as medical/conservative and laser therapy (argon green laser through slit-lamp delivery).
Statistical analysis was performed using the Statistical Package for the Social Sciences 15.0 for Windows (SPSS Inc., Chicago, Illinois, USA). Continuous variables were expressed as mean, SD, or median. Categorical variables were expressed as frequency and percentage. We used paired t-test for test of significance of initial and final foveal thickness. We used Fisher’s exact test to analyze the association of the final BCVA and OCT factors, including the existence of serous RD and PED, preservation of OPRL in serous RD, IS/OS continuity in macular attachment, and abnormality of RPE-choroid band. P value of less than 0.05 was considered significant. Test of significance of postresolution foveal thickness and the postresolution VA was also compared with the baseline using the Wilcoxon signed −rank test. All statistical tests were two sided.
| Results|| |
The study included 18 male and two female patients, presenting with CSCR with a mean time of complaint of 5.2 weeks, ranging from 7 days to 20 weeks, with age ranging from 24 to 46 years (mean age of 35.55 years, SD=5.73 years) ([Table 1]).
|Table 1 Demographic profile and baseline clinical characteristics of patients with central serous chorioretinopathy|
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Of the active patients, 16 had a first episode of CSCR, three had a recurrence, one patient was known to have chronic CSCR. Overall, four patients had history of using steroids, two had a history of migraine, and three patients were started on anti-tubercular therapy during the acute phase after physician’s opinion.
At 6 months of follow-up, results showed that the average logMAR BCVA improved from 0.63 at presentation to 0.23 at 6 months (P<0.05) ([Table 2]). The final average logMAR showed statistical change compared with the initial logMAR BCVA. At the final examination, 15 of the 20 eyes showed a BCVA of 6/12 or more, and four eyes were 6/36 or less.
FA showed leakage in all eyes. Of those, one presented with multifocal leakage and the rest with focal leakage. At the initial examinations, the angiographic leakage pattern was classified as inkblot ([Figure 1]b) in 12 eyes and smokestack ([Figure 2]a and [Figure 3]b) in eight eyes. All 20 eyes with CSCR had focal neurosensory retinal detachment (NSRD) ([Figure 2]c and [Figure 3]c) in the macula at the initial visit. The NSRD resolved completely ([Figure 3]d) without treatment in four eyes, with photocoagulation in four eyes and decreased in the rest till last follow-up during the span of the study. PED was identified in three patients, and all were extrafoveal. OCT images revealed that the mean foveal retinal thickness was 346.8 μm at presentation and 150.9 μm at 6 weeks, ranging from 220 to 622 μm ([Table 1]). The retinal thickness at the center of the fovea during the acute phase was significantly greater compared with that after the resolution of the RD (P<0.001). The fovea was significantly thicker during the acute phase than after resolution (P<0.001).
|Figure 1 Color fundus photograph of a 34-year-old patient shows subretinal fluid with a yellowish white substance (a). The inkblot pattern can be seen in the early phase (b). The leakage point corresponds to the retinal pigment epithelial (RPE) protrusion on optical coherence tomography (OCT) (c). Shortly after the presentation, eye underwent extrafoveal laser photocoagulation treatment. This was followed by resolution of the subretinal fluid within 2 weeks and precipitation of subretinal material that was resorbed slowly over 6 months (d).|
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|Figure 2 Fundus fluorescein angiogram of a 50-year-old male showing smokestack pattern in the early phase and gradual but increasingly marked leakage. The optical coherence tomography (OCT) image showing central macular thickness and neurosensory detachment (b and c).|
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|Figure 3 OCT image of central macula in a 50 year old male patient with a recent episode of cscr. The OCT section shows an outer photoreceptor layer preserved and with an even profile along the detachment (a) OCT image of the central macula after laser photocoagulation showing resolution of the detachment with a preserved photoreceptor layer with the inner and outer segment junction visible at fovea (b).|
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The signs associated with an RPE-choroid band were small bulging on the band in five eyes and an irregular change of thickness with undulation in one eye at the final examination. OPRL ([Figure 3]a) was seen in nine of 20 eyes initially and in 14 eyes finally ([Figure 3]b), and most of the eyes showed an even profile appearance. The preserved OPRL was associated with the final BCVA of logMAR 0.3 or less (P<0.05). The continuity of IS/OS on OCT was observed in six of 20 eyes in CSCR initially and in 14 eyes finally. This visible continuity of IS/OS was statistically associated with a final BCVA of logMAR 0.3 or less (P<0.05).
Fisher’s exact test was used to analyze the association of the final BCVA and OCT factors, including the existence of neurosensory detachment and PED, preservation of OPRL in serous RD, IS/OS continuity, and abnormality of RPE-choroid band ([Table 3]). Statistically significant result was found for the retinal thickness at the center of the fovea and the BCVA levels (Wilcoxon signed-rank test, P<0.05). PED was identified in three patients initially and in one patient finally.
|Table 3 Optical coherence tomographic findings in correlation with final best-corrected visual acuity|
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| Discussion|| |
This study included 18 (90%) male and two female patients, with a sex ratio of 9 : 1. The male preponderance is, as already explained, a feature of CSCR. The age group in our study, 24–46 years (mean=35.55), is also conforming to the usual age of presentation.The mean period of CSCR history was 5.2 weeks, ranging from 7 days to 20 weeks.
Along with demographic findings, we investigated initial and final VA (BCVA). Initial BCVA may be a reliable predictor of the visual outcome in CSCR. Better VA at baseline and shorter period from symptom onset to the treatment appeared to have greater improvement of VA during 6 months. BCVA preceding macular reattachment highly predicts final vision, and a long duration of CSCR is associated with limited visual prognosis. Furuta et al.  studied retrospectively 15 patients with symptoms for 6 months with a mean follow-up of 9.4 months. In their study, the duration of symptoms was not correlated either with BCVA or with foveal thickness after resolution of subretinal fluid.
To study the changes in the detached retina, neurosensory detachment, and subretinal lesion in CSCR, we examined patients repeatedly with OCT during the acute disease phase and after resolution. OCT can also show small RPE detachment and changes of the RPE-choroid layer and the OPRL . OCT demonstrated changes in the foveal photoreceptor layer that were correlated with the actual BCVA and had prognostic value for visual recovery in cases of foveal reattachment and provided information about the actual state of deterioration of the photoreceptors.
OCT showed that the retina was thickened where it was detached from the RPE in all eyes with CSCR. The retinal thickness returned to normal when the subretinal fluid was absorbed.
The present study investigated the correlation of final BCVA of logMAR of 0.3 or less and the continuity of IS and OS on OCT and showed statistical significance. Final OCT findings that correlated significantly with BCVA of logMAR of 0.3 or less were preserved OPRL and IS/OS continuity. Piccolino et al.  reported that patients with a well-preserved OPRL can sustain good VA despite serous RD and will have a good visual prognosis after macula attachment.
The outer nuclear layer (ONL) thickness was positively correlated with the BCVA in resolved CSCR. Discontinuity of the IS/OS line was prevalent in eyes with a thinner ONL and lower BCVA.
RPE irregularities were detected at the initial examination in 10 cases. The absence of bulging on the RPE layer and irregularity of the RPE choroid band was associated with better visual outcomes. RPE irregularities had not changed remarkably at the final examination in six eyes, toward the end of follow-up, out of which only four registered poor visual outcomes (logMAR>+0.3).
The current study also showed no correlation of existent NSRD with a final VA of logMAR 0.3 or less than 20/40. This could be because of the fact that we had patients with extramacular and subtle subretinal fluid, and preservation of OPRL on OCT was seen in most of our patients with NSRD.
Fujimoto et al.  examined 23 leakage points (LPs) in 21 eyes using SD-OCT and observed a PED in 61% and a protruding or irregular RPE layer in 35%, with a total of 22 LPs (96%) showing RPE abnormalities. In the present study, the results suggested that RPE morphological abnormalities invariably occur when there is leakage in acute CSCR. PED was recognized in 6% of our cases, a much lower frequency than in past reports describing rates of 61 and 63% ,.
Hee et al.  studied 17 eyes of 16 patients with CSCR using OCT. They concluded that OCT was potentially useful as a noninvasive diagnostic technique for quantitative examination and objectively monitoring the clinical course of the serous RD in this disease. They also reported tomographic features in a case of CSCR with intraretinal edema and cystic changes. Loo et al.  reported that serous RD and RPE detachment are correlated with a final VA of 0.5 or less. However, the current study showed no statistical correlation of BCVA and RPE detachment, probably because only three patients had RPE detachment, and it had a smaller sample size. In addition, the limited follow-up observations should be confirmed by longer follow-up studies. However, it was found that cases with RPE detachment had poor VA in comparison with those with pure neurosensory detachment, irrespective of the height and extent.
Gass  reported that RPE defects are present at PED margins and that leakage occurs through these defects. Krishan et al.  reported that the PED margin is under greater stress than the inside of the PED, making the margin more susceptible to damage. However, in our study, we found that leakage can occur at any PED site.
CSCR is considered a multifactorial disease in which focal defects of RPE origin leak into the subretinal space, and there are secondary RPE and retinal changes. We have found RPE bulging or irregularities in FA and OCT in 14 of 20 eyes with CSCR. They might represent minimal RPE detachments or focal defects of RPE.
| Conclusion|| |
Our results suggest that tomographic sections of the central macula obtained with high-resolution OCT may provide information about the potential for visual recovery. Our results suggest that tomographic sections of the central macula obtained with high-resolution OCT may provide information about the actual state of deterioration of the photoreceptors and the potential for visual recovery. We must consider that BCVA at presentation is highly predictive of the final vision and that a long duration of CSCR is associated with limited visual prognosis. OCT provides a reconstructed image through which we can follow morphological changes in the RPE at the leakage point during the clinical course of CSCR.
A larger sampled study, including both acute cases and chronic cases, is warranted to confirm these preliminary results, and we anticipate that it will become possible to investigate the morphology of CSCR in even greater detail through simultaneous imaging.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]