Spot the diagnosis.

Case

A 30-year-old woman presented with history of acute, sudden, painless loss of vision in the left eye (OS) since 1 week. On examination, visual acuity in the right eye (OD) was 6/6 and counting finger at 2 meters left eye (OS). Anterior segment examination was normal in both eyes. Dilated fundus examination revealed localized well-circumscribed round serous detachment temporal and nasal to the macula OD [Fig. 1a] and multiple serous detachments OS [Fig. 1e]. On fluorescein angiography, OD demonstrated area of early hyper fluorescence and late leakage temporal and nasal to macula. Similar but multiple scattered such lesions were seen in OS. Ink-blot appearance can be seen supero-temporal to the macula in OS [Fig. 1b, c, f, g].

Figure 1

(a) OD fundus image; (b and c) fundus fluorescein angiography OD shows areas of early hyper fluorescence and late leakage temporal and nasal to macula; (d) OCT shows neuroretinal detachment (474 μm) corresponding to the affected area; (e) OS fundus image; (f and g) FFA OS shows multiple scattered early hyperfluorescent lesions with late leakage, and ink-blot appearance can be appreciated supero-temporal to the macula; (h) OCT shows large neuroretinal detachment (1042 μm) with a small area of RPE detachment and overlying retinal thinning in OS

What is your next step?

Optical coherence tomography (OCT) and careful observation.

Photodynamic therapy with verteporfin

Therapy with Intravitreal anti vascular endothelial growth factors

Start treatment with Rifampin

Findings

OCT showed neuroretinal detachment (474 μm) corresponding to the affected area, with serous fluid underneath in OD. In addition to large neuroretinal detachment (1042 μm), there was a small area of retinal pigment epithelium (RPE) detachment and overlying retinal thinning in OS [Fig. 1d and h].

Diagnosis: Multifocal Central Serous Retinopathy

Correct answer: A

Discussion

Central serous retinopathy (CSR) typically affects young, middle-aged men with type-A personality, emotional stress, and corticosteroid use. In women, it is usually seen during pregnancy.[1] Symptoms include acute, painless loss of vision, central scotoma, metamorphopsia, micropsia, and dyschromatopsia. Multifocal CSR is a rare variant of CSR with pathogenesis in both the conditions being the same.

CSR is a self-limiting condition. Treatment is indicated after initial observation of 3 months if there is angiographic evidence of foveal leakage or in recurrent cases. Currently the options include low-fluence photodynamic therapy and focal argon laser coagulation.[2] In chronic CSR, systemic therapy targeted at inhibiting the effects of endogenous corticosteroids, such as Rifampin, mifepristone, eplerenone and ketoconazole, has also been proposed.[2] Intravitreal Aflibercept is advised in cases that develop secondary choroidal neovascularization.[3]

The patient was observed for 1 month with vision improving to 6/12 in OS. The most striking feature in this case is that it concerns a young female patient without any risk factors. Therefore, CSR should be considered in the differential diagnosis in all cases of sudden, painless loss of vision.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.