hyperpermeability of choroid (choriocapillaris) leakage at level of RPE

neurosensory RD
leakage into subretinal space
pathogenesis
impaired fluid removal from
subretinal space

healthy

35-55 years
demographics
M>F 3:1

no racial predilection

stress
thick choroid personality type
EDI-OCT tense driven personality (type A)
OCT

i, ps
(© 2020 American Academy of Ophthalmology)
endogenous hypercortisolism
(Cushing syndrome)
elevated levels of corticosteroids
corticosteroid administration systemic
etiology
systemic hypertension not intravitreal
sleep apnea

(© 2020 American Academy of Ophthalmology) psychopharmacologic

medications
posterior loculation of fluid in deep choroid

kh Ma
in areas where thickening is pregnancy
most prominent irregular wavy, shallow elevation of the RPE by a

D
CNV
layer of material with heterogeneous reflectivity +- bilateral aymmetric

blurred vision

dim vision

micropsia

symptoms suggen onset metamorphopsia

M
paracentral scotoma
white dots under retina are macrophages with accumulation of shed outer segments
fluorophores from phagocytized outer segments in subretinal space decreased color vision

prolonged afterimages

20/20-20/200 usually >20/30

visual acuity

ye d
improves with hyperopic
correction

(© 2020 American Academy of Ophthalmology) round or oval

serous detachment of sensory
retina localized often involves fovea

ha in
small whitish subretinal
precipitates
acute findings
under superior half of serous
fundus autofluorescence retinal detachment
other imaging modalities serous RPE detachment
without serous retinal
detachment

gray-white feather-edge subretinal material fibrin

as M
RPE defects focal hypoautofluorescence granular RPE pigmentation

widespread shallow detachment

photoreceptors atrophy

multiple small leaks on IVFA

chronic findings evidence of prior episodes

run-off/guttering
M gy
RPE atrophic areas thick choroid
clinical
pachychoroidal pigment
RPE alterations
(© 2020 American Academy of Ophthalmology) retinopathy
no serous retinal detachment
chronic CSC descending tracts
in ≤ 20% of patients >50 yr even without laser
lower levels of central macular
poorer vision
autofluorescence easy to detect with OCT angiography

CNV in 2% of eyes treated with

12.9.1. Central Serous photocoagulation
Chorioretinopathy (CSC)
o

in the immediate postoperative

choroidal vascular hyperpermeability BCSC 2020-2021
period in 2% of eyes after
photocoagulation

CNV
an ol

filling delays in choroidal arteries

& choriocapillaris

venous dilation

hyperpermeability of choroidal
vessels indocyanine green angiography

multifocal
m lm

choroidal vascular abnormalities

appear early
hyperfluorescent patches
slowly enlarge during angiogram

less prominent in late views

unchanged during clinically

washout pattern
inactive phases

occult CNV
helps to differentiate atypical
diffuse CSC in older patients
polypoidal choroidal
from
Ar ha

vasculopathy

detecting type 1 CNV OCT angiography

OCT demonstrates an irregular wavy, shallow elevation of the

RPE by a layer of material with heterogeneous reflectivity
type 1 CNV
differential diagnosis
FA findings overlap with CSC
(© 2020 American Academy of Ophthalmology)
polypoidal choroidal vasculopathy (PCV)
leakage from RPE appears early
chronic recurrent CSC
most common
good visual prognosis except
bullous CSC
+- multiple
t

80-90%
early phase of angiogram focal leak through RPE dot
dot form expansile dot
within 3-4 months
ph

pooling of dye in subretinal

visual recovery within 1 year space
late phase of angiogram
mild metamorphopsia 10-15 min
natural course
spontaneous resolution
faint scotomata tree-shaped
smokestack form
abnormal contrast sensitivity uncommon 10%
residual symptoms
mild color vision defictits
extensive gravity-dependent
serous retinal detachment
permanent diminished visual
acuity diffuse
extensive RPE changes
O

40-50% recurrence
without obvious leakage point
more rapid resorption of
5 weeks vs 23 weeks
subretinal fluid
fluorescein angiography
no improvement in final visual patterns
acuity
laser photocoagulation
no decrease in recurrence rate

no effect on choroidal thickness

sub-threshold laser photocoagulation

reduces or eliminates subretinal fluid

treatment
4% atrophy few complications

recurrence after successful PDT is rare photodynamic therapy with

verteporfin
decreases choroidal thickness and reduces
choroidal vascular hyperpermeability

standard (600 mW/cm2) to

reduced fluence (300 mW/cm2)

resolution of subretinal fluid in eplerenone

mineralocorticoid receptor
25% medical treatment
antagonists
spironolactone
(© 2020 American Academy of Ophthalmology)

Ophthalmology Mind Maps/Arman Mashayekhi, MD