The patient had central serous chorioretinopathy (CSC) with a neurosensory detachment in the right eye in June 2018, and in September 2018 had had deposition of fibrinous material and possible choroidal neovascular membrane activity. He initially presented to us in April 2018 with a superotemporal pigment epithelial detachment (PED), and a small chorioretinal scar from prior laser treatment above the fovea that can be seen on the fluorescein angiogram. The left eye did not have a PED or subretinal fluid, but there was a thickened choroid (pachychoroid) with markedly enlarged deep choroidal blood vessels (pachyvessels), typical of CSC. The fluorescein angiogram of the right eye showed a window defect (indicating loss of RPE pigment) temporal to the fovea and possible late staining.
In June 2018, he had a large neurosensory detachment, as demonstrated on the OCT, and the fluorescein angiogram showed the classic “smokestack” sign of fluorescein leakage into the subneurosensory space. This subretinal fluid usually resolves spontaneously in patients with CSC. However, in September he manifested central fibrinous material that had retracted and caused retinal folds. The OCT showed a PED, subretinal fluid, and reflective fibrinous material. The fundus photo revealed the central fibrinous material, and the fluorescein angiogram showed leakage into the subneurosensory space. Such fibrinous material is sometimes seen in patients with CSC, particularly if they have been using corticosteroids. He was treated with intravitreal tissue plasminogen activator to alleviate the fibrin and anti-VEGF therapy with Lucentis to address possible choroidal neovascular membrane activity. The fibrinous material diminished and the visual acuity improved to 20/50. He received a second Lucentis treatment one month later. In December he received half-fluence photodynamic therapy with verteporfin for residual subretinal fluid. When seen in January 2019, the subretinal fluid had resolved, the fibrinous material had nearly resolved, and the retinal folds were substantially reduced. The visual acuity was 20/40. Interestingly, there is thickened choroid seen on enhanced depth imaging in June 2019, even though the pachychoroid that typically accompanies central serous chorioretinopathy generally improves markedly after photodynamic therapy. The most likely reason is that only the area with leakage on fluorescein angiography was treated with PDT and the fovea was spared. More extensive PDT would likely have had a greater effect on choroidal thickness. Also of note, there is a persistent PED with reflective material, which is likely scar tissue from a regressed choroidal neovascular membrane.