A LONG-TERM FOLLOW-UP STUDY OF SEVERE VARIANT OF CENTRAL SEROUS CHORIORETINOPATHY

SANAE OTSUKA, MD, NORIO OHBA, MD, PHD, KUMIKO NAKAO, MD, PHD
Purpose: To facilitate understanding of the long-term course and visual outcome of a severe variant of central serous chorioretinopathy. Design: Consecutive observational case series. Patients and Methods: The authors reviewed 25 patients with multifocal posterior pigment epitheliopathy and bullous retinal detachment, who had a mean follow-up time of 10.6 years (range, 6 22 years), with reference to the demographic feature, fundus changes, recurrence, and nal anatomic and visual outcome. Two patients underwent optical coherence tomography. Results: The patients were 21 men and 4 women, with a mean age at disease onset of 43.1 years (range, 30 63 years). Twenty-one patients were otherwise healthy, and four developed ocular disease during systemic corticosteroid therapy for metabolic or autoimmune diseases including systemic lupus erythematosus. The disease was bilateral in 21 patients (84%). Nine patients (36%) presented initially with classic central serous chorioretinopathy, followed by its severe variant 7 months to 9 years later. Active disease was characterized by multifocal exudative lesions in the posterior pole and bullous retinal detachment with shifting subretinal uid in the inferior periphery. Optical coherence tomography of exudative lesions disclosed cloudy and brinous subretinal uid. The exudative lesions were self-limited or responded to photocoagulation. During the follow-up period, 13 patients (52%) showed 1 to 5 recurrent disease, but the disease eventually became quiescent with multifocal atrophic scars in the posterior pole with or without atrophic tracts in the inferior periphery. Final best-corrected visual acuity was 20/20 or better in 24 of 46 affected eyes (52%) of 25 patients and 20/40 or better in 37 eyes (80.4%). Conclusions: A severe variant of central serous chorioretinopathy characterized by multifocal posterior exudations and bullous inferior retinal detachment with shifting subretinal uid may affect otherwise healthy, middle-aged males or individuals receiving systemic corticosteroid therapy for metabolic or autoimmune diseases. Exudative chorioretinal lesions are self-limited or respond to photocoagulation. Recurrence is common, but the disease eventually becomes quiescent with favorable visual acuity unless the macula is damaged. RETINA 22:2532, 2002

entral serous chorioretinopathy (CSC) is a welldened condition that has a long history of clinical investigations. In early 1970s to mid-1980s,
From the Department of Ophthalmology, Kagoshima University Faculty of Medicine, Kagoshima-shi, Japan. The authors have no proprietary interest in this study. Reprint requests: Norio Ohba, MD, Department of Ophthalmology, Kagoshima University Faculty of Medicine, Sakuragaoka 8-35-1, Kagoshima-shi 890-8521, Japan; e-mail: ohba@med5.kufm. kagoshima-u.ac.jp

a number of cases presenting with multifocal exudative lesions in the posterior pole and nonrhegmatogenous retinal detachment with shifting subretinal uid were described with various diagnostic nomenclatures, including bullous retinal detachment, peculiar type of secondary retinal detachment, multifocal serous choroidopathy, multifocal posterior pigment epitheliopathy, and peripheral retinal detachment with retinal pigment epithelial atrophic tract.112 Further
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Table 1. Clinical Information of 25 Patients With Severe Variant Idiopathic Central Serous Chorioretinopathy
Case No. Classic ICSC at Age at Eyes onset, yr affected onset? Findings at Final Examination Treatment Follow-up, Recurrence? yr Best-Corrected VA Fundus Abnormalities Macular atrophy, peripheral mottling Inferior tract atrophy Multiple atrophic scars Macular atrophy, posterior scars Multifocal scars, inferior tract atrophy Multiple posterior scars Multiple posterior scars Inferior tract atrophy Multiple posterior scars Inferior tract atrophy Inferior tract atrophy Macular atrophy Multiple posterior scars Multiple posterior scars Multiple posterior scars Multiple posterior scars Multiple posterior scars Inferior tract atrophy Multiple posterior scars Peripapillary atrophy Macular atrophy Multiple posterior scars Inferior tract atrophy Multiple posterior scars Macular atrophy

Sex

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

M M M M F M M M M M M M M M F M M M M F M F M M M

37 54 31 50 51 46 39 38 43 51 38 38 39 45 34 36 56 37 40 63 56 49 30 36 41

Bilateral Unilateral Bilateral Bilateral Bilateral Bilateral Unilateral Bilateral Bilateral Bilateral Bilateral Bilateral Bilateral Bilateral Bilateral Bilateral Bilateral Unilateral Bilateral Bilateral Unilateral Bilateral Bilateral Bilateral Bilateral

Yes No Yes No No Yes No Yes No No No No No Yes Yes No No No Yes No No Yes No Yes No

LPC (single) LPC (single) LPC (repeat) LPC (repeat) LPC LPC LPC No No No LPC LPC LPC LPC LPC LPC LPC No No LPC No LPC LPC No No (single) (repeat) (single)

No No Yes Yes No Yes No Yes Yes No No Yes No No No No Yes Yes Yes No No Yes Yes Yes Yes

16 9 22 12 14 13 12 12 9 9 9 8 8 17 7 6 7 8 9 7 7 7 11 6 20

RE: 20/400; LE: 20/28 RE: 20/20 (LE: normal) RE: 20/25; LE: 20/12.5 RE: 20/220; LE: 20/50 RE: 20/220; LE: 20/220 RE: 20/16; LE: 20/16 RE: 20/16 (LE: normal) RE: 20/400; LE: 20/16 RE: 20/20; LE: 20/100 RE: 20/20; LE: 20/25 RE: 20/12.5; LE: 20/16 RE: 20/400; LE: 20/100 RE: 20/16; LE: 20/12.5 RE: 20/28; LE: 20/16 RE: 20/33; LE: 20/20 RE: 20/16; LE: 20/12.5 RE: 20/16; LE: 20/33 RE: 20/16; LE: 20/16 (RE: normal) LE: 20/220 RE: 20/100; LE: 20/16 LE: 20/200 (RE: normal) RE: 20/28; LE: 20/20 RE: 20/16; LE: 20/16 RE: 20/12.5; LE: 20/25 RE: 20/200; LE: 20/16

(repeat) (repeat) (single) (single) (single) (repeat) (repeat)

(single) (repeat) (repeat)

VA, visual acuity; LPC, laser photocoagulation; RE, right eye; LE, left eye.

studies have dened the clinical characteristics of the disease and led to a view that it is a severe variant or atypical form of CSC, rather than a distinct clinical entity.1316 However, little information is available regarding the long-term course of the severe variant of CSC. We review 25 such cases with a mean follow-up time of 10.6 years and report the ultimate visual and anatomic outcome of severe CSC. Patients and Methods We reviewed clinical records of patients with central serous chorioretinopathy (CSC) between 1978 and 2000 in the Kagoshima University Hospital, and selected cases of a severe form of CSC featured by multifocal exudative lesions in the posterior pole and nonrhegmatogenous peripheral retinal detachment with shifting subretinal uid. We studied 25 patients with severe CSC who were followed up for more than 6 years and reviewed the clinical records with reference to sex, age at onset, medical history, clinical feature, treatment, and follow-up results. Routine ex-

aminations included visual acuity test, contact lens biomicroscopy, indirect binocular ophthalmoscopy, and uorescein angiography. In addition, two patients were examined by optical coherence tomography. For reference, demographic data of 445 patients with classic CSC who were seen during the same study period were also reviewed. Results Table 1 summarizes the clinical characteristics of 25 patients with severe variant CSC. They were 21 men and 4 women with an age at disease onset of 30 to 63 years (mean, 43.1 years). The male/female ratio (21/4) was comparable with that of 445 referential patients with classic CSC. The disease affected both eyes in 21 cases (84%); this bilateral involvement of severe variant CSC was signicantly more frequent than that of classic CSC33 of 445 patients (7.4%) with classic CSC having bilateral disease. As the initial presentation, 16 cases (64%) showed multifocal exudative lesions in the posterior pole with

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Fig. 1. Case 1 (in Table 1). A (right eye), Fundus photograph taken on the initial presentation at age 37 years, illustrating a serous retinal detachment in the macula. B (right eye), Seven months after presentation, the patient presented with severe visual loss and superior eld defect because of multifocal exudative lesions in the posterior pole and bullous retinal detachment in the inferior quadrants. This photograph was taken a few days after photocoagulation therapy. C (right eye) and D (left eye), At age 53 years, 16 years after disease onset. Fundus photographs show focal chorioretinal atrophies with photocoagulation-induced pigment proliferation in the posterior fundus.

peripheral retinal detachment. Nine cases (36%) presented initially with features of classic CSC, followed by development of severe CSC 7 months to 9 years later; 6 of these had severe CSC in association with systemic corticosteroid therapy for the initial disease. With regard to medical history, 21 cases (84%) were otherwise healthy. The remaining 4 cases (16%) developed severe variant CSC during systemic corticosteroid therapy for systemic disorders, including systemic lupus erythematosus, renal insufciency, and rheumatoid arthritis. There was no difference in the ocular signs and symptoms between the idiopathic cases and those with systemic disorder. Biomicroscopy and ophthalmoscopy during the active phase revealed multiple focal lesions in the posterior pole, characterized by doughnut-shaped, 0.5- to

2-disk diameter, yellowwhite exudative retinal changes. Bullous retinal detachment was invariable in the inferior periphery, characterized by accumulation of subretinal uid shifting towards the posterior pole on a supine position. Fluorescein angiography of posterior exudative lesions disclosed early hyperuorescent foci due to marked dye leakage from the choroid, followed by its extension and later staining of the surrounding retina (Figures 1 through 3). Optical coherence tomography through the exudative lesions demonstrated a domelike detachment of thickened neurosensory retina and semitransparent subretinal space due to light reections from brinous contents (Figure 4). Of 46 affected eyes of 25 cases, 14 eyes of 8 cases showed spontaneous regression of exudative lesions

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Five patients had atrophic tracts in the inferior periphery. The nal best-corrected visual acuity in a total of 46 affected eyes of 25 patients was 20/20 or better in 24 eyes (52%) and 20/40 or better in 37 (80.4%) eyes. Four of the 46 affected eyes (8.7%) had poor visual acuity results of 20/200 or less because of macular atrophies. Figure 5 compares the best-corrected visual acuity between the active and convalescent phase of the disease, illustrating that the ultimate visual outcome is similar between cases with and without photocoagulation therapy. Selected Case Reports Case 1
A previously healthy 37-year-old man presented with mild blurred vision in the right eye (Table 1). Best-corrected visual acuity was 20/25 in the right eye and 20/12.5 in the left eye. Anterior segments and media were unremarkable. Ophthalmoscopic examination of the right eye revealed a round area of serous retinal detachment in the macula that was compatible with classic CSC (Figure 1A). Seven months later, he reported severe visual loss in the right eye and upper visual eld loss in both eyes, with best-corrected visual acuity of 20/1000 in the right eye and 20/12.5 in the left. Ophthalmoscopic examination disclosed in both eyes yellowish, discrete, exudative lesions of approximately 1 disk diameter in the posterior pole and bullous retinal detachment in the inferior peripheral fundus; the subretinal uid shifted towards the posterior pole on a supine position. Fluorescein angiography revealed early hyperuorescent leakage foci from the choroid, which increased in intensity and size in the late phase of angiography. Argon-laser photocoagulation was given to the exudative lesions (Figure 1B), which resolved the posterior exudations in 1 month. The patient was observed for the subsequent 16 years with no further recurrence. On the last examination at age 53 years, ophthalmoscopy of the right eye demonstrated several atrophic scars in the posterior fundus and mottled appearance in the inferior peripheral fundus (Figure 1C), with best-visual acuity of 20/400 because of macular atrophy. Ophthalmoscopy of the left eye disclosed a 3-disk diameter atrophic scar in the posterior pole that spared the fovea, with best-corrected visual acuity of 20/28 (Figure 1D).

Fig. 2. Case 3. A, Fundus photograph of recurrent disease 8 years after disease onset, illustrating multifocal exudative lesions of variable size in the posterior pole and shallow retinal detachment with numerous subretinal yellow deposits in the inferior periphery. B, Fundus photograph taken 22 years after disease onset, illustrating chorioretinal atrophic scars in the posterior pole.

and reattachment of the inferior retina in a few months. Thirty-two eyes of 17 cases underwent argonlaser photocoagulation to the exudative lesionssingle procedure in 8 cases and repeat in 9 casesand they showed resolution of choroidal exudations within 1 to 2 months. Recurrence of severe CSC was not uncommon. During a mean follow-up of 10.6 years (range, 6 22 years), 13 cases (52%) had recurrence: one recurrence in 8 cases, 2 recurrences in 3 cases, and 3 to 5 recurrences in 2 cases. The interval between recurrences ranged from 6 months to 11 years (mean of all recurrences, 4.7 years). Recurrence was common, but the disease eventually became quiescent with multifocal atrophic scars.

Case 3
A 31-year-old man rst noted central visual loss of the right eye and was diagnosed with classic CSC, which resolved in response to argon-laser photocoagulation (Table 1). Five years later at age 36 years, he had a recurrent episode in the same eye that resolved spontaneously. At age 39 years, he again felt an acute blurring in the right eye, with best-corrected visual acuity of 20/28 in the right eye and 20/16 in the left. Visual eld test revealed superior eld defect in the right eye. Ophthalmoscopy of the right eye revealed multiple, yellowish, doughnut-shaped exudative lesions of a variable size in the posterior pole and shallow inferior peripheral retinal detachment accompanied by numerous yellow subretinal deposits (Figure 2A). Fluorescein angiography of the right eye disclosed intense subretinal leakage in areas corresponding to exudative lesions. The asymptomatic left eye showed mild ophthalmoscopic and uorescein angiographic abnormalities. Laser photocoagulations to the exudative lesions resolved the posterior

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Fig. 3. Case 16. A (right eye), Fundus photograph taken at an aggravated condition following systemic corticosteroid therapy, illustrating multiple exudative lesions in the posterior pole and extensive bullous retinal detachment accompanied with choroidal detachment in the periphery. B (right eye), Fluorescein angiogram, showing several leakage points in the posterior pole. C (left eye), Fundus photograph taken on the same day as photograph A, demonstrating multiple exudative lesions sparing the macula. D (right eye) and E (left eye), Fundus photographs taken 6 years after disease onset, illustrating a complete resolution of exudative lesions with retention of multiple chorioretinal atrophic scars.

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Fig. 4. Case 22. A, Ophthalmoscopic features of a doughnut-shaped focal lesion with yellow-appearing exudation with central dark red region. The straight line indicates 5-mm length area scanned by optical coherence tomography. B, Early phase of uorescein angiogram, illustrating a leakage point of a major lesion from the choroid (arrow) and two other minor lesions. C, Late phase of uorescein angiogram, illustrating multifocal areas of intense uorescein dye staining. D, Cross-sectional scan through the exudative lesion by optical coherence tomography, illustrating detachment of thickened retina with cloudy subretinal space underneath an ophthalmoscopically yellow area and an optically clear subretinal space corresponding to a dark brown leakage area.

lesions and the inferior retinal detachment in 2 months, with return to nearly normal visual acuity. Four years later, the patient reported acute blurred vision in the right eye, with best-corrected visual acuity of 20/40 in the right eye and 20/12.5 in the left. The right eye had serous retinal detachment in the posterior pole associated with de novo focal exudative lesions that subsided spontaneously in 3 months, with visual acuity improvement to 20/25. At age 48 years, the patient had recurrence that resolved spontaneously in 2 months. A subsequent follow-up showed no further recurrence disease. At age 54 years, best-corrected visual acuity was 20/25 for the right eye and 20/12.5 for the left. The fundus of both eyes had multiple chorioretinal atrophic scars in the posterior pole and diffuse mottled appearance in the inferior periphery (Figure 2B).

Case 16
A 40-year-old man with a short history of blurred vision at age 36 years presented with acute mild visual loss in the right eye. Best-corrected visual acuity was 20/33 in the right eye and 20/16 in the left (Table 1). Contact lens biomicroscopy and ophthalmoscopy

of the right eye disclosed multifocal exudative lesions in the posterior pole and nonrhegmatogenous retinal detachment with shifting subretinal uid in the inferior periphery. The patient was treated with a large dose of oral prednisolone tapered over 2 months, which aggravated the condition so that peripheral retinal detachment became more bullous and accompanied with choroidal detachment (Figure 3A). Fluorescein angiography was compatible with multifocal posterior pigment epitheliopathy (Figure 3B). The left eye had several focal exudative lesions in the posterior pole, but not inferior retinal or choroidal detachment, with normal visual acuity because the macula was spared (Figure 3C). Repeated sessions of argon-laser photocoagulation on the posterior exudative lesions led to a slow resolution of the retinal and choroidal detachment. The patient was observed for the next 6 years, during which no recurrence occurred. At the last examination, best-corrected visual acuity was 20/16 in the right eye and 20/12.5 in the left. Both eyes had multiple atrophic scars in the posterior pole and mottled appearance of the periphery due to atrophy of the retinal pigment epithelium (Figure 3, D and E).

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Fig. 5. Best-corrected visual acuity in 46 eyes of 25 cases of severe variant of central serous chorioretinopathy, measured at the exudative phase (abscissa) and at the nal examination (ordinate). White circles represent 32 eyes of 17 cases undergoing argon-laser photocoagulation, and closed circles 14 eyes of 8 cases without photocoagulation.

Discussion These results elucidate the clinical picture, demographic feature, and long-term course of the severe variant of CSC. During the active stage of the disease, ophthalmoscopic ndings are characterized by multifocal exudative lesions in the posterior pole and inferior retinal detachment with shifting subretinal uid, and the uorescein angiographic ndings by intense focal dye leakage from the choroid. The typical lesions appear doughnut shaped with a dark brown central area surrounded by yellowish turbid exudates.116 The optical coherence tomograms in our two patients showed that the yellow-appearing focal exudates are optically cloudy. This new observation is distinct from optical coherence tomograms of classic CSC, in which the posterior retinal detachment area contains optically clear, serous subretinal uid.17,18 Thus, intense subretinal uid accumulation of more brinous, weighty contents is likely to cause bullous inferior retinal detachment with moveable subretinal uid. The severe variant or atypical presentation is thought to belong to the exaggerated end of the spectrum of CSC.7,13 The condition affects predominantly middle-aged males.116 In our case series, the mean age at onset was 43.5 years, and the male-to-female ratio was 5.3, similar to our referential data of 445

patients with classic CSC. The ratio of bilateral/unilateral involvement 21/4 in our series is in agreement with 17/1 and 28/9 in previous reports of severe variant CSC.10,13 Thus, severe CSC is predominantly bilateral, in contrast to classic CSC, as our referential data showed that 33 of 445 patients (7.4%) with classic CSC were bilateral. Limited information is available about the longterm course of the severe variant CSC. The severe condition may occur from the beginning or may follow classic CSC. In our case series, 9 of 25 cases (36%) presented initially with features of classic CSC, followed by manifestation of multifocal posterior pigment epitheliopathy and inferior bullous retinal detachment 7 months to 9 years later. The multifocal, exudative lesions are apparently self-limited or rapidly resolve in response to photocoagulation, but recurrence is not uncommon.13 In this long-term follow-up study (mean, 10.6 years; range, 6 22 years), 13 of 25 cases (52%) showed recurrences months to years after complete regression. The number of recurrences was variable up to ve times, and the longest interval between recurrences was 11 years. Recurrence of the severe variant CSC is common, but the disease eventually becomes quiescent, with multifocal atrophic scars with or without peripheral retinal atrophic tract. The ultimate visual outcome is favorable unless the macula is involved. Argon-laser photocoagulation to active focal lesions has been recommended for its rapid resolution.10,13 We performed argon-laser photocoagulation in 17 of 25 cases and conrmed its efcacy. It is, however, remarkable that the ultimate visual results were comparable between the eyes with and without photocoagulation therapy. Similar results have been reported previously.14 A randomized control study with long-term follow-up is needed to determine if photocoagulation treatment confers any advantage. The severe variant of CSC is composed of two etiologically distinct types. One type affects otherwise healthy adults with a yet-undened underlying cause that is probably similar to classic CSC. The other type is involved by systemic corticosteroid therapy for metabolic or autoimmune disorders such as systemic lupus erythematosus, sarcoidosis, multiple myositis, and by corticosteroid therapy following renal transplantation.2,13,19 21 A number of cases of corticosteroid-induced severe variant CSC have been reported in recent years, in which classic CSC is aggravated to severe CSC after inappropriate systemic corticosteroid therapy.3,4,13,18,19 This was also seen in our case series. Lastly, although the severe variant of CSC is probably rare as compared with classic CSC, reports from Asian countries, particularly Japan,1,3,4,7,10,1216,18 out-

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number those from the Western world. Whether the severe variant of CSC has ethnic predilection remains to be elucidated. Acknowledgement
The authors thank Dr. Takashi Mizushima for technical assistance in optical coherence tomography.

10. 11. 12.

Key words: central serous chorioretinopathy, severe variant, long-term outcome, optical coherence tomography. References
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