A 41-year-old male presents to the ophthalmology clinic with a complaint of a few days of blurriness in his right eye after passing out candy for Halloween at his house. He reports no pain in either eye but notes that objects appear slightly smaller and “weirdly bent” when looking at them with his affected eye. His past medical history is significant for seasonal allergies for which he uses fluticasone. He appears anxious during the encounter and reports he has been under significant stress at work for the past few weeks. Vital signs within normal limits. Visual acuity is 20/40 OD and 20/20 OS. Slit lamp examination is unremarkable. Dilated fundus exam reveals a localized, circular, dome-shaped elevation of the retina in the central macula without hemorrhage, exudates, or drusen. Optical coherence tomography (OCT) demonstrates subretinal fluid accumulation with a serous detachment of the neurosensory retina. What is the most appropriate next step in management?
A. Discontinuation of the fluticasone nasal spray
B. Immediate focal laser photocoagulation
C. Oral prednisone 60 mg daily followed by a taper
D. Intravitreal ranibizumab injection
E. Urgent pars plana vitrectomy
Correct answer: A - Discontinuation of the fluticasone nasal spray
This patient has central serous chorioretinopathy (CSCR), a condition that commonly presents with unilateral blurred vision, micropsia, metamorphopsia, and a central scotoma. The pathophysiology of this condition is from choroidal hyperpermeability and breakdown of blood-retinal barrier that leads to serous fluid accumulation beneath the neurosensory retina. Common demographics of CSCR are middle-aged men with high stress levels and use of exogenous corticosteroids in any formulation. The OCT findings in this case are diagnostic. Initial management includes stopping the exogenous corticosteroid. Most cases resolve spontaneously over a few months once stopping the offending agent.
B) Focal laser photocoagulation can accelerate fluid absorption in persistent or chronic CSCR (lasting 3–6+ months) or recurrent cases with visual impairment. There is a risk of scotoma and choroidal neovascularization. It is not indicated as an initial step for acute CSCR.
C) Intravitreal anti-VEGF therapy (e.g. bevacizumab) is indicated for choroidal neovascularization (CNV) associated with wet age-related macular degeneration or chronic CSCR complicated by secondary CNV, but not for acute, uncomplicated CSCR.
D) Oral prednisone is contraindicated since exogenous corticosteroids are the primary etiology of CSCR in this case. This would exacerbate choroidal hyperpermeability and subretinal fluid accumulation.
E) Pars plana vitrectomy is an invasive surgical procedure reserved for rhegmatogenous retinal detachments, macular holes, or vitreous hemorrhages. It plays no role in the management of serous macular detachments from CSCR.
Liew G, Quin G, Gillies M, Fraser-Bell S. Central serous chorioretinopathy: a review of epidemiology and pathophysiology. Clin Exp Ophthalmol. 2013 Mar;41(2):201-14. doi: 10.1111/j.1442-9071.2012.02848.x. Epub 2012 Sep 21. PMID: 22788735.=