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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 32  |  Issue : 2  |  Page : 123-127

Fundus fluorescein angiography of idiopathic central serous chorioretinopathy in the indigenous population of Manipur


Department of Ophthalmology, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication25-Oct-2018

Correspondence Address:
Dr. Chingsuingamba Meitei Yumnam
Department of Ophthalmology, Regional Institute of Medical Sciences, Imphal - 795 004, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_20_18

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  Abstract 

Background: Idiopathic central serous chorioretinopathy is a chorioretinal disease characterized by localized leakage from the choroidal circulation causing serous retinal detachment affecting the macula.
Aims: To document the leakage pattern using fundus fluorescein angiogram in idiopathic central serous chorioretinopathy in the indigenous people of Manipur.
Materials and Methods: A prospective study was conducted in all patients with clinical diagnosis of central serous chorioretinopathy attending ophthalmology outpatient department of a tertiary care hospital in Manipur, Northeast India, within a period of 1 year starting from September 2015 to August 2016. After thorough clinical evaluation of the posterior segment and after ruling out the potential contraindications, patients were subjected to fundus fluorescein angiography (FFA).
Results: Predominantly males (72%) and those mostly in their fifth decade of life were affected. Most of the patients were businessmen. The right eye was affected more (78%) than the left, with the most common presenting symptom being dark shadow or central haziness of vision in about 60% of patients. Betel nut consumption was found to be a very common food habit. Sensory retinal detachment (40%) was the most common fundus finding and depigmented patches (4%) were least commonly seen. Of the 50 eyes examined, FFA showed a single leak in 36, double and triple leaks in 7 eyes each, and no leak in 10 eyes. Inkblot pattern was the most common pattern of leakage (72%). Most common site of leakage in this study was the macular area (58%).
Conclusion: Idiopathic central serous chorioretinopathy (ICSC) predominantly affects middle-aged males having a stressful life. Most of them present with dark shadow or a central area of haziness in the visual field which is mostly attributable to sensory retinal detachment at the macula. The most common fundus fluorescein angiographic finding is a single leak inkblot pattern in the macular area.

Keywords: Fundus fluorescein angiography, idiopathic central serous chorioretinopathy, inkblot sign, smokestack sign


How to cite this article:
Laishram U, Yumnam CM, Thangjam AS. Fundus fluorescein angiography of idiopathic central serous chorioretinopathy in the indigenous population of Manipur. J Med Soc 2018;32:123-7

How to cite this URL:
Laishram U, Yumnam CM, Thangjam AS. Fundus fluorescein angiography of idiopathic central serous chorioretinopathy in the indigenous population of Manipur. J Med Soc [serial online] 2018 [cited 2018 Dec 15];32:123-7. Available from: http://www.jmedsoc.org/text.asp?2018/32/2/123/244128


  Introduction Top


Idiopathic central serous chorioretinopathy (ICSC) is characterized by a focal abnormality that lies at the level of the choriocapillaris or Bruch's membrane which results in fluid leakage from choroidal circulation into the potential space between the retinal pigment epithelium (RPE) and and neurosensory retina leading to a localized retinal detachment affecting the macula [Figure 1]. It was first described by Von Graefe in 1886 and termed it as “relapsing central syphilitic retinitis.”[1] The macula contains high concentration of cones. Therefore, sharp light sense; form sense; and visual acuity, contrast, and color sense are impaired in this disease. Patients may first notice minor blurring of vision followed by various degrees of metamorphopsia, micropsia, chromatopsia, central scotoma, increasing hyperopia, and color desaturation. Visual acuity ranges from 20/20 (6/6) to 20/200 (6/60) and averages 20/30 (6/9).[2],[3],[4] ICSC is a self-limiting disease and heals spontaneously within 4–8 weeks with full recovery of vision. However, the recurrences are common and occur in about one-third to half of all the patients after the first episode of the disease.[5],[6],[7] The diagnostic tools available are slit-lamp biomicroscopy, fundus fluorescein angiography (FFA) [Figure 2], [Figure 3], [Figure 4], and optical coherence tomography [Figure 5] and [Figure 6]. The various fluorescein angiographic patterns seen are smokestack appearance, inkblot appearance, and sometimes multiple leaks or a leaking scar in atypical cases. The only proven effective treatment of idiopathic central serous retinopathy (ICSR) is laser photocoagulation to the site of leakage using a green wavelength laser to produce light scar over the focal RPE leak and is reserved for those who fail to improve within 4–6 months. No medical therapy has been of proven value.[8],[9] This study has been done on indigenous population of Manipur to study the FFA patterns of ICSC. As the etiopathogenesis of ICSC is not exactly known, by considering the differences in angiographic patterns reported in different racial groups, a study like this may give us some insight into the etiopathogenic mechanisms of this condition and help us manage the condition better.
Figure 1: Color fundus photograph of a patient with idiopathic central serous chorioretinopathy in the left eye

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Figure 2: Single leak, inkblot pattern on fundus fluorescein angiography

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Figure 3: Fundus fluorescein angiogram of a patient with the smokestack pattern of staining

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Figure 4: Fundus fluorescein angiogram of a patient with multiple leaks

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Figure 5: Optical coherence tomography showing central serous retinopathy on the left eye

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Figure 6: Optical coherence tomography showing cross-sectional views in a patient with central serous retinopathy

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  Materials and Methods Top


A prospective study was conducted on 50 consenting patients with clinical diagnosis of idiopathic central serous chorioretinopathy attending outpatient department of a tertiary care hospital in Manipur, Northeast India, within a period of 1 year (September 2015 to August 2016). Patients having conditions that masquerade as ICSR, those with media opacity on FFA, and those having contraindications to FFA were excluded from the study. Refraction under cycloplegia was done and best-corrected visual acuity (BCVA) was recorded using Snellen's chart. Color vision was tested with Ishihara's charts. Posterior segment was evaluated after full dilatation of the pupil using direct and indirect ophthalmoscope and slit-lamp biomicroscope with +90 diopter lens using both narrow and wide beams. FFA was performed using standard technique, and various angiographic patterns obtained were recorded. Patients were then followed up at 1 and 3 months interval. At each follow-up visit, BCVA and ophthalmological findings were recorded and fundus photographs were taken.


  Results Top


Most of the cases in this study were in the age group of 41–50 years (48%), with the mean age being 40.5 years [Figure 7]. There were 36 males and 14 females, with a ratio of 2.5:1. The occupational scenario of the study group showed that 44% of the patients were businessman and 32% were government employees, followed by homemakers (12%) and students (12%). The significant dietary habits were chewing betel nuts (44%), smoking (30%), and alcohol consumption (26%). FFA was done on all cases which showed unilateral leak (n = 26, 52%), whereas 7 (14%) eyes each had double and triple leaks. Ten eyes had no leak. Inkblot pattern was by far the most common pattern followed by the smokestack and diffuse pattern at 14% each. The most common site of leakage was the macular area (58%) followed by the parafoveal (16%), nasal to disc (14%), and outside the vascular arcade (12%). The most commonly affected quadrant is superotemporal (42%), followed by inferotemporal (18%) and inferonasal (16%), and the least affected was Superonasal (14%).
Figure 7: Age distribution

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  Discussion Top


In this study, the mean age of the patients was 40.5 years and the highest incidence was in the age group of 41–50 years (48%) [Figure 7]. A large number of patients were in the age group of 20–50 years similar to that observed in previous studies and it is probably due to increased exposure to various stress and strain. In previous studies, there is marked predilection for male sex with male: female ratio of 5:1 [Figure 8].[10],[11] In our study, this ratio was 2.5:1. Most of the patients were businessman followed by government employees, implying that the jobs demanding certain amount of stress and anxiety are more prone to ICSC. Approximately 30% of the cases had recurrences which is almost similar to that seen with other studies. In majority (78%) of the cases, the left eye was affected. The incidence of bilateral cases was 4% in this study. About 90% of the patients had unilateral involvement in a study reported by Prünte and Flammer[9] in 1996. Of 50 cases, 30 (60%) presented with dark shadow or central diminution of vision, followed by generalized diminution vision and distorted images at 24% and 16%, respectively. Fundus examination revealed well-defined oval area of shallow elevation of retina in the macular region in 40% of the patients, while the rest presented with subretinal precipitates, pigment clumping, drusen-like deposits, and depigmented patches. The most common presenting symptom was that of dark shadow or central haziness of vision in 30 (60%) patients [Figure 9]. Generalized diminution of vision (24%) and distorted images (16%) were other complaints. Ophthalmoscopically, diagnosis was made by the presence of a well-defined round or oval area of shallow elevation retina mostly in the macula surrounded by a ring reflex. Sensory retinal detachment was seen in 20 (40%) symptomatic and 2 (4%) asymptomatic patients. Other findings were subretinal precipitates (24%), pigment clumping (18%), drusen-like deposits (14%), and pigment patches (4%), which had retinal detachment. Recurrence was seen in approximately 15 (30%) cases.
Figure 8: Sex distribution

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Figure 9: Presenting symptoms

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FFA, the gold standard investigation for the diagnosis of ICSC, was performed in all cases. A single leak was seen in the majority (52%) of cases and 20% had no leakage. However, double and triple leaks were also not infrequently seen, i.e., 14% each. The absence of leakage point has been attributed to a healed leak point or a leak point that has occurred outside the macular area. Multiple leaks, 4–7 in number, have also been reported by Spitznas and Huke[12] in 1987. The inkblot pattern was the most common pattern seen in FFA (72%), whereas smokestack and diffuse pattern was seen in 14% each [Figure 10]. Gilbert et al.,[13] Spintaz,[14] Wessing and Meyer-Schwickerath,[15] and How and Koh have separately reported the incidence of inkblot pattern as the most common in their studies, i.e., 60%–87%. Macula is known to be the most common site of leakage and this was consistent with the results of our study which showed 58% of the leaks in macula, followed by parafoveal (16%), nasal to the disc (14%), and beyond the vascular arcade (12%) [Figure 11]. In our study, the most commonly involved quadrant for the site of leakage was the superonasal (42%), followed by inferotemporal (18%), inferonasal (16%), and superotemporal quadrants (14%) [Figure 12]. Similar observations have also been made by Bennet[10] and Wessing and Meyer-Schwickerath.[15]
Figure 10: Pattern of leakage

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Figure 11: Site of leakage

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Figure 12: Quadrant involved

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  Conclusion Top


Patients in the age group of 41–50 years were most commonly affected, which can be attributed to the increased to the increased amount of stress and strain in this age group. Increased propensity was also seen with male gender and Type A personality. Dark shadow or a central area of haziness was the most common presenting feature while the most common fundus finding was sensory retinal detachment followed by subretinal precipitates and pigment clumping. The most common fundus fluorescein angiographic finding was a single leak inkblot pattern in the macular area, with superonasal quadrant of the macula being the most commonly involved site of leakage.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Von Graefe A. Veber Central receidivirende retinitis. Albert Von Graefes Arch Ophthalmol 1886;12:211-5.  Back to cited text no. 1
    
2.
Klein ML, Van Buskirk EM, Friedman E, Gragoudas E, Chandra S. Experience with nontreatment of central serous choroidopathy. Arch Ophthalmol 1974;91:247-50.  Back to cited text no. 2
    
3.
Klien BA. Retinal lesions associated with uveal disease. I. Am J Ophthalmol 1956;42:831-47.  Back to cited text no. 3
    
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Peymen GA, Bok D. Peroxidase diffusion in normal and laser photocoagulated primate. Invest Ophthalmol Vis Sci 1972;11:35-45.  Back to cited text no. 4
    
5.
Gass JD. Pathogenesis of disciform detachment of neuroepithelium: I. General concept and classification. Am J Ophthalmol 1967;63:573-85.  Back to cited text no. 5
    
6.
Steinberg RH, Miller SS. Transport and membrane properties of retinal pigment epithelium. In: Marmor MF, Zinn KM, editors. The Retinal Pigment Epithelium. Cambridge: Harvard University Press; 1979. p. 205-25.  Back to cited text no. 6
    
7.
Watzke RC, Burton TC, Leaverton PE. Ruby laser photocoagulation therapy of central serous retinopathy. I. A controlled clinical study. II. Factors affecting prognosis. Trans Am Acad Ophthalmol Otolaryngol 1974;78:OP205-11.  Back to cited text no. 7
    
8.
Robertson DM, Ilstrup D. Direct, indirect, and sham laser photocoagulation in the management of central serous chorioretinopathy. Am J Ophthalmol 1983;95:457-66.  Back to cited text no. 8
    
9.
Prünte C, Flammer J. Choroidal capillary and venous congestion in central serous chorioretinopathy. Am J Ophthalmol 1996;121:26-34.  Back to cited text no. 9
    
10.
Bennett G. Central serous retinopathy. Br J Ophthalmol 1955;39:605-18.  Back to cited text no. 10
    
11.
How AC, Koh AH. Angiographic characteristics of acute central serous chorioretinopathy in an Asian population. Ann Acad Med Singapore 2006;35:77-9.  Back to cited text no. 11
    
12.
Spitznas M, Huke J. Number, shape, and topography of leakage points in acute type I central serous retinopathy. Graefes Arch Clin Exp Ophthalmol 1987;225:437-40.  Back to cited text no. 12
    
13.
Gilbert CM, Owens SL, Smith PD, Fine SL. Long-term follow-up of central serous chorioretinopathy. Br J Ophthalmol 1984;68:815-20.  Back to cited text no. 13
    
14.
Spintaz M. Central serous chorioretinopathy. Ophthalmology 1980;87:88.  Back to cited text no. 14
    
15.
Wessing A, Meyer-Schwickerath G. Lichtchirurgische behind lung and sonstige chirurgische massnahman. Berl Dtsch Ophthalmol Ges1971;73:585-93.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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