Case Report
Bilateral Idiopathic Central Serous Chorioretinopathy in a Twelve Year Old Girl
Mohamed Katta1* and Thomas Kwok2
1Department of Ophthalmology, Hillingdon Hospital, United Kingdom
2Department of Ophthalmology, East Kent University Hospital Foundation Trust, United Kingdom
*Corresponding author: Mohamed Katta, Ophthalmology department, Hillingdon Hospital, Pield Heath Road, Uxbridge, UB8 3NN, United Kingdom
Published: 30 Mar, 2018
Cite this article as: Katta M, Kwok T. Bilateral Idiopathic
Central Serous Chorioretinopathy in a
Twelve Year Old Girl. Ann Clin Case
Rep. 2018; 3: 1508.
Abstract
Central Serous Chorioretinopathy (CSCR) is an accumulation of subretinal fluid with detachment
of the neurosensory retina mainly found in young caucasian males. Presented here is a case of a
twelve year old girl with idiopathic bilateral CSCR that underwent spontaneous resolution within
three months with a return to 6/5 vision. Various treatments have been described for CSCR in
adults but due to the rarity of cases in children the management remains largely anecdotal. Simple
observation in the first few months appears to be the most appropriate.
Keywords: Central serous chorioretinopathy; Paediatric; Bilateral
Case Presentation
A 12 year old girl presented to the Eye Casualty department after referral from her optician.
The girl had been complaining of bilateral visual blurring for a week. The optician noted raised
maculae bilaterally. At presentation visual acuity was 6/60 OD and 6/18 OS uncorrected and 6/18
bilaterally with pin hole correction. Anterior segment and intraocular pressure examination were
normal with quiet anterior chambers. Pupillary reactions were normal. On fundus examination
there was a marked elevation of the macula on the right with a less extensive elevation on the left.
OCT examination confirmed serous neurosensory retinal detachment bilaterally of approximately
two disc diameters in the right eye and 300μm in the left eye (Figure 1). Fundus fluoresceinand
Indocyanine Green angiography did not show any active leaking in either eye (Figure 2 and 3).
The patient had no medical history and was systemically well. She was not using any medication
and a focussed psychiatric history revealed not mental health issues. Her blood work including full
blood count, renal function and electrolytes, CRP, ESR and morning cortisol level were all normal.
At her three week review in clinic her vision had already improved to 6/9 OD 6/12 OS with
an improvement on OCT in subretinal fluid in the right eye but slight worsening in the left. She was reviewed again at three months and at this point had made a full
recovery with vision 6/5 bilaterally corresponding to complete OCT
subretinal fluid resolution (Figure 4). No therapy was administered
during her follow up period.
Figure 1
Figure 1
Fundus photo (A), OCT (B) and retinal thickness map (C) of right and left eyes at presentation showing
extensive serous retinal detachment in the right eye and a smaller detachment in the left eye.
Figure 2
Figure 2
Right eye angiography showing red free (A), early (B) and late (C) Fluorescein angiography and early (D) and late (E) Indocyanine Green angiography.
No significant leak observed.
Figure 3
Figure 3
Left eye angiography showing red free (A), early (B) and late (C) Fluorescein angiography and early (D) and late (E) Indocyanine Green angiography.
No significant leak observed.
Discussion
Central Serous Chorioretinopathy (CSCR) is defined by the
accumulation of subretinal fluid with detachment of the neurosensory
retina. Most cases are self limiting but there is a recognised chronic,
recurrent form that results in decreased visual acuity [1]. Men are
much more likely to be affected by CSCR than women with the average
age of onset of 41 years. The exact aetiology of the disease remains
to be elucidated but risk factors other than male sex include Type
A personalities, mental stress, the use of corticosteroids, pregnancy,
Cushing’s disease or steroid producing tumours [2,3].
There have been previous reports of CSCR in children and young
adults [4-7]. We present here the first reported case of bilateral
idiopathic CSCR in a pre-pubertal girl. The youngest case of CSCR
was reported by Fine et al. [4] at 7 years old; however this was in the
context of focal choroiditis.
The reported cases of CSCR in children appear to resolve
spontaneously. Kim et al. described a case of a 12 year old boy with
unilateral idiopathic CSCR who initially improved spontaneously
at his 2 month review from 0.5 LogMAR to 0.8, but then had a
deterioration at which point he was treated with a single Bevacizumab
injection with visual acuity returning to 1.0 LogMAR at 18 months.
The authors however, admit that it would be impossible to tell how
much of the improvement could be ascribed to the anti-VEGF
therapy.
Most cases of CSCR resolve spontaneously within three months
[8], as seen in this case. Current treatment approaches include
simple observation, focal laser, photodynamic therapy (PDT) with
verteporfin, intravitreal anti-VEGF and mineralocorticoid receptor
antagonists such as Spironolactone or Eplerenone [1]. Chung et al.
concluded in a meta-analysis that there was no clear positive effect of
intravitreal anti-VEGF due to the lack of large randomised control trials
and significant heterogeneity between studies examining the relative
efficacy of intravitreal Bevacizumab with short follow up periods [9].
The efficacy of PDT has been analysed against Ranibizumab in a small
randomised trial of 34 eyes in which the investigators found that there
were significant short term improvements in the PDT group over the
Ranibizumab group [10]. Central retinal thickness was significantly
improved in the PDT group up to month 6 at which point they tailed
off and were not significantly different to the Ranibizumab group.
There were more modest improvements in visual acuity which were
not significantly different.
It would appear that cases of CSCR in children follow a similar
course to that described in adults and the most appropriate initial
treatment is watchful waiting. Should the disease take a more chronic
or recurrent form after three months the evidence points slightly in
the favour of PDT as the next line of management, and most likely
better tolerated by children.
Figure 4
Figure 4
Fundus photo (A), OCT (B) and retinal thickness map (C) of right and left eyes at 3 months follow up showing complete resolution.
References
- Iacono P, Battaglia Parodi M, Falcomata B, Bandello F. Central Serous Chorioretinopathy Treatments: A Mini Review. Ophthalmic Res. 2015; 55: 76-83.
- Haimovici R, Rumelt S, Melby J. Endocrine abnormalities in patients with central serous chorioretinopathy. Ophthalmology. 2003; 110: 698-703.
- Haimovici R, Koh S, Gagnon DR, Lehrfeld T, Wellik S; Central Serous Chorioretinopathy Case-Control Study Group. Risk factors for central serous chorioretinopathy: a case-control study. Ophthalmology. 2004; 111: 244-249.
- Fine SL, Owens SL. Central serous retinopathy in a 7-year-old girl. Am J Ophthalmol. 1980; 90: 871-873.
- Alwassia AA, Adhi M, Duker JS. Bilateral simultaneous central serous chorioretinopathy in a teenage girl with systemic arterial hypertension. Int Ophthalmol. 2013; 33: 79-82.
- Kim YC, Kim SD, Kim KS. A case of idiopathic central serous chorioretinopathy in a 12-year-old male treated with bevacizumab. Korean J Ophthalmol. 2012; 26: 391-393.
- Velazquez-Martin JP, Fulda E, Domville D, Graue-Wiechers F, Krema H. Presumed idiopathic central serous chorioretinopathy in a 12-year-old girl. Case Rep Ophthalmol. 2012; 3: 5-10.
- Gilbert CM, Owens SL, Smith PD, Fine SL. Long-term follow-up of central serous chorioretinopathy. The Br J Ophthalmol. 1984; 68: 815-820.
- Chung YR, Seo EJ, Lew HM, Lee KH. Lack of positive effect of intravitreal bevacizumab in central serous chorioretinopathy: meta-analysis and review. Eye (Lond). 2013; 27:1339-1346.
- Bae SH, Heo J, Kim C, Kim TW, Shin JY, Lee JY, et al. Low-fluence photodynamic therapy versus ranibizumab for chronic central serous chorioretinopathy: one-year results of a randomized trial. Ophthalmology. 2014; 121:558-565.