Case of the Month I January 2020

Case of the Month
January 27, 2020

The Case

The patient was a 72-year-old man without visual complaints who was found to have retinal edema in the left eye while being examined at a visit for planned refraction after cataract surgery. The visual acuity was 20/25+1  J1+ OD and 20/60-1  J1+ OS. Past medical history was remarkable for kidney cancer treated with nephrectomy in 2002 and hypertension. Ophthalmic examination was remarkable for a posterior chamber intraocular lens with a clear posterior capsule in each eye; depigmentation temporal to the fovea in the right eye; and central macular edema, inferior hard exudates, and depigmentation above the fovea in the left eye. Autofluorescence was unremarkable in both eyes. OCTs and fluorescein angiography were done.

What is the most likely diagnosis? What treatment, if any, would you recommend?

The OCT with enhanced depth imaging reveals a thickened choroid in each eye with choroidal pachyvessels (large diameter) in Haller's layer, indicating that the patient has a pachychoroid condition. There is also mild macular edema temporally in the right eye and more substantial macular edema in the left eye. Fluorescein angiography shows window defects and mild late staining, left eye greater than right, without clear leakage. OCTA does not reveal a choroidal neovascular membrane.

This patient's clinical presentation is consistent with chronic central serous chorioretinopathy (CSC). Patients with CSC often have small pigment epithelial detachments and overlying neurosensory detachments, but macular edema can occur. The thickened choroid and pachyvessels are typical of CSC. The window defects on fluorescein angiography likely reflect the disease's chronicity. Patients with CSC often respond favorably to photodynamic therapy (PDT) with Visudyne. This treatment was recently applied to our patient, using half-fluence and avoiding the fovea. PDT is generally effective and is well tolerated by patients with CSC, evidently because the thickened choroid is protective. Patients with thin choroids are more likely to develop ischemic damage from PDT.

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The OCT with enhanced depth imaging reveals a thickened choroid in each eye with choroidal pachyvessels (large diameter) in Haller's layer, indicating that the patient has a pachychoroid condition. There is also mild macular edema temporally in the right eye and more substantial macular edema in the left eye. Fluorescein angiography shows window defects and mild late staining, left eye greater than right, without clear leakage. OCTA does not reveal a choroidal neovascular membrane.

This patient's clinical presentation is consistent with chronic central serous chorioretinopathy (CSC). Patients with CSC often have small pigment epithelial detachments and overlying neurosensory detachments, but macular edema can occur. The thickened choroid and pachyvessels are typical of CSC. The window defects on fluorescein angiography likely reflect the disease's chronicity. Patients with CSC often respond favorably to photodynamic therapy (PDT) with Visudyne. This treatment was recently applied to our patient, using half-fluence and avoiding the fovea. PDT is generally effective and is well tolerated by patients with CSC, evidently because the thickened choroid is protective. Patients with thin choroids are more likely to develop ischemic damage from PDT.

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