IDIOPATHIC CENTRAL SEROUS CHORIORETINOPATHY

SIGNS AND SYMPTOMS
Patients with idiopathic central serous chorioretinopathy (ICSC) usually present with complaints of sudden onset, unilateral distortion or blurring of central vision. They may report metamorphopsia, decreased color perception, or even a relative central scotoma. There is typically no pain and no history of recent trauma.

Evaluation reveals no external signs of disease nor inflammation, although a hyperopic refractive shift is often noted in the affected eye. Funduscopic examination shows a serous elevation of the macula with a loss of the foveal light reflex. There may also be an underlying area of RPE detachment. Patients with ICSC are typically young, with most cases occurring in the early to mid-thirties; white males appear to be the most commonly affected group. Those individuals with "Type A" personalities seem to be particularly predisposed to this condition.

PATHOPHYSIOLOGY
Although the true etiology of ICSC is unknown, emotional stress or anxiety appears to be a common element. It is believed that, in certain individuals, vasomotor instability from sympathetic nervous stimulation may induce local weaknesses in Bruch's membrane. Such weaknesses allow serous fluid to extravasate from the choriocapillaris under the macula (through a defect in the RPE), creating a focal detachment of the sensory retina. In most instances, the fluid eventually resolves, but the condition may be recurrent in as many as 50 percent of affected individuals. In these patients, cystic yellow lesions known as "lemon drops" and areas of mild RPE hyperplasia are often seen.

MANAGEMENT
Most cases of ICSC are self-limiting, and resolve spontaneously over a period of weeks to months. The prognosis for visual recovery is excellent-up to 60 percent can expect to regain 20/20 acuity. While many cases of ICSC require no intervention, recent studies have supported the use of oral indomethacin to hasten the recovery time. In addition, focal laser photocoagulation may be effective in repairing the RPE at the site of the leakage. Most practitioners, however, will consider this therapy only in cases that fail to recover within a reasonable period of time, highly recurrent cases, or cases in which the patients are overtly symptomatic and insist on definitive treatment.

CLINICAL PEARLS

An experienced, astute clinician can often diagnose ICSC based solely upon the history and chief complaint-a young, anxious patient who presents with unilateral metamorphopsia of recent onset.

The classic fundus appearance is usually best seen with binocular indirect ophthalmoscopy.

In subtle or atypical cases, fluorescein angiography offers the definitive diagnosis.

Patients presenting with ICSC for the first time should be reassured, counseled as to the natural course of the condition, and monitored every three to four weeks for three to four months as resolution occurs. Failure to resolve within six months is probably an indication for more aggressive therapy, such as focal laser photocoagulation.

Longstanding ICSC may result in a "sick RPE" with permanent visual reduction.