Alternating central serous chorioretinopathy in two consecutive pregnancies.

To highlight the similarity in onset, clinical course, and resolution of central serous chorioretinopathy in two eyes, in two consecutive pregnancies in the same patient. A case report. Snellen visual acuity, slit-lamp examination, and optical coherence tomography (OCT). A 31-year-old female had central serous chorioretinopathy with sub-retinal exudates in left eye during the sixth month of her first pregnancy and later in right eye also during the sixth month of her second pregnancy two years later. Both eyes had spontaneous resolution of the lesions with final visual acuity of 1.0 each eye. To the best of our knowledge, there have been no reports of alternating CSCR with sub-retinal exudates, occurring exactly in the sixth month of two consecutive pregnancies, two years apart, with spontaneous resolution after deliveries.

Introduction

Central serous chorioretinopathy (CSCR) is a spontaneous serous detachment of the retinal pigment epithelium and neurosensory retina due to accumulation of sub-retinal fluid with or without exudates at the level of retinal pigment epithelium. Patients usually present with metamorphopsia and moderately reduced visual acuity. It usually affects adults between second and fourth decade, being more common in males. It is an infrequent but benign complication of pregnancy. The condition usually resolves spontaneously after delivery with minimal or no sequel. No cases of OCT documented alternating CSCR with sub-retinal exudates, occurring in exactly sixth month of two consecutive pregnancies, two years apart, with complete resolution after deliveries, have been reported.

Case Report

A 31-year-old pregnant patient from Arabian Peninsula with dark skin complained of reduced vision in right eye since five days. At the time of onset of symptoms, she was in sixth month of her pregnancy. Her uncorrected visual acuity (second pregnancy) was: OD: 0.1 and OS = 1.0. The best corrected visual acuity was OD: 0.13 with plus sphere 1.5 and OS: 1.0 During her second pregnancy, the blood pressure on the day of her visit to eye clinic was 140:88, blood sugar (random): 5.5 mosm/l. From her history and obstetric electronic patient record (EPR), she had no pedal edema, no proteinuria, and ultrasound carried out one month before presenting to our clinic reported no fetal abnormalities.

She had similar episode of symptoms in left eye in her sixth month of first pregnancy two years earlier, which was diagnosed as CSCR [Figure 1]. From patient's electronic record (EPR), the gestational histories and deliveries in both pregnancies were found to be without any complications. Obstetric and medical history did not show any evidence of eclampsia, diabetes, hypertension, or autoimmune condition. The patient had normal social life, an appeasing personality, and denied intake of any systemic or topical medications. She denied being a smoker or alcoholic. Slit lamp examination for anterior segments was normal for both eyes. Intraocular pressure was 14 mmHg in right eye and 13 mmHg in left eye. Dilated fundus examination in right eye showed typical serous elevation of retina in the macular area measuring about three disc diameters with sub-retinal fibrinous exudates [Figure 2]. Optical coherence tomography (OCT) measured central macular thickness of 519 microns with retinal pigment epithelial detachment [Figure 3]. Although fluorescein angiography (FA) is not a contraindication in pregnancy, it was not deemed to be necessary. FA was avoided on physician's discretion due to pregnancy. OCT and clinical examination were clearly suggestive of CSCR. Similar to the spontaneous resolution of CSCR in her left eye two years ago, she had spontaneous resolution of CSCR after delivery in right eye as well, with uncorrected visual acuity of 1.0 in both eyes. Twelve weeks after complete resolution, there were only fine stippled changes in the RPE.

Figure 1

Fundus photograph showing typical central serous chorioretinopathy in left eye in sixth month of first pregnancy

Figure 2

Fundus photograph (same patient as Figure 1) showing typical central serous chorioretinopathy in right eye in sixth month of pregnancy, two years later

Figure 3

Optical coherence tomography (right eye, first pregnancy) showing central serous chorioretinopathy with RPE detachment asterix

Discussion

CSCR is 6-8 times more common in men and commonly occurs between the ages of 20-50 years. It may be bilateral in 20% to 40% patients.[1] An incidence of 0.01% has been reported in general population and 0.008% per year in pregnancy.[23]

The pathogenesis of CSCR involves a focal leak in RPE and subsequent collection in the subneural retinal space. Increasing evidence implicates an abnormal choroidal circulation as the cause of CSCR. Capillary and venous congestion in affected choroidal lobules produces ischemia and increased choroidal exudation due to hyperpermeability. There is excessive choroidal fluid accumulation, which leads to RPE detachment. Choroidal fluid passes through this opening into neural sub-retinal space and produces a neural retinal detachment.[4] As the detachment grows, the junctions between RPE cells get broken and a focal defect of the blood-retinal barrier develops. The serous retinal detachment (RD) usually resolves within 5-6 months with good final visual acuity. Thirty to 50% of patients have one or more recurrences. Five percent may develop prolonged and/or recurrent episodes of sensory RD.

Steroids,[5] pregnancy,[67] Cushing's syndrome,[8] systemic hypertension,[9] lupus erythematosus,[10] have been implicated in the pathogenesis of CSCR. Studies reveal that corticosteroids do influence the production of nitric oxide, prostaglandins, and free radicals within the choroidal circulation and all three are known to play a role in the autoregulation of choroidal blood flow.[11] The condition has been reported to be occasionally familial.[12] New risk factors such as antibiotics, alcohol, and allergic respiratory disease have been identified in CSCR.[13] Psychopharmacologic medications, amphetamines, antacids and anti-reflux medications, over-the-counter sympathomimetics, antihistamines, and sildenafil citrate are other medications implicated in the risk factors and associations with CSCR.

The differential diagnosis of CSCR includes numerous diseases of the choroid, RPE, and retina, which cause serous elevations of the neurosensory retina in the macular region. These include choroidal neovascularization, optic disc pits, polypoidal choroidal vasculopathy, choroidal melanoma, choroidal metastasis, choroidal hemangioma, retinal breaks, uveitis, Harada disease, vitreous traction, macular holes, and hypertensive maculopathy. The history, clinical examination, laboratory tests, and OCT excluded all these differentials.

Though different treatment modalities have been proposed for the treatment of CSCR, vast majority of such cases resolve spontaneously over time ranging from six weeks to one year. Photodynamic therapy and laser treatment remain controversial; however, this may not be always true in chronic cases of CSCR where symptoms persist for months or years and intervention may be justified. Corticosteroids, wherever possible, should be discontinued. Role of anti-VEGF is not established yet in the treatment of CSCR.[1415] Also, persistent detachment of fovea in chronic CSCR may lead to atrophic degeneration of retinal photoreceptors and retinal pigment epithelium, with no scope of improvement of vision even after resolution of the detachment. Our patient had spontaneous resolution in both eyes without any intervention.

Though presence of sub-retinal exudates is common in CSCR accompanying pregnancy (50-90%),[6] Quillen et al. have reported the occurrence of such exudates more commonly in those patients who were on corticosteroids.[16] Our patient had no history of corticosteroid use. These exudates, believed to be fibrin, may be misinterpreted as focal retinitis or sub-retinal neovascularization.

It is difficult to say race of our patient (black Arab) did not have any influence on her disease process. Though Sunness et al., have reported sub-retinal exudates in three out of four of their patients (all whites), such precipitates have been reported to be independent of race.[6] Mayo and Tolentino reported sub-retinal exudate in a 32-year-old black pregnant woman with CSCR.[7] However, CSCR in pregnancy may be without any sub-retinal exudates as has been reported by and Al-Mujaini et al.[17]