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Make your diagnosis – Answer

(Click for article: Make your diagnosis)

By Dr Dirk Booysen

This patient has with-the-rule corneal astigmatism which correlates well with his refractive error. The right eye has a small choroidal nevus in the superior temporal arcade. Although around 5% of the population have choroidal nevi, these lesions need to be documented and followed regularly to rule out choroidal melanoma. Nevi are normally flat, less than 2mm thick, have no sub-retinal fluid, and may have surface drusen which indicate chronicity. Risk factors for malignant transformation include; > 2mm, sub-retinal fluid, presence of symptoms such as coloured lights, floaters and flashes, prominent orange pigment (lipofuscin) over the lesion, and location < 3 mm from the disc. If two or more of these risk factors are present, the lesion is likely to be a small choroidal melanoma rather than a nevus. Yearly follow-up with colour photographs are recommended for any choroidal pigmented lesions [1, 2].

The left eye has central serous chorioretinopathy (CSCR). The lesion in the macular area clearly shows a localised serous detachment of the sensory retina without blood or lipid exudates. The fundus photograph and especially the fundus auto-fluorescence photograph, clearly show the extent of the lesion. The margins (OCT image) of the lesion are sloping and move gradually into the attached retina. Visual acuity was moderately affected and he has a small afferent pupillary defect indicating pathology at the level of the retina. The differential diagnosis includes; ARMD, choroidal tumours, pigment epithelial detachments, and idiopathic choroidal effusion [1, 2].

CSCR is idiopathic and occur commonly in men aged 25 – 50 years of age. In women it occurs at a slightly older age and is associated with pregnancy and lupus erythematosus. CSCR is also associated with increased levels of endogenous cortisol (psychological and physiological stress or type A personalities), and exogenous cortisol use including nasal sprays and topical creams or steroid use for muscle development [1, 2].

Treatment includes observation and follow-up as the prognosis for spontaneous recovery is good. Typically, visual acuity can return to 20/30 or better. Laser therapy accelerates visual recovery, but does not improve final outcomes. Steroid use should be stopped and patients counselled regarding the associations with CSCR. If choroidal neovascular membranes develop anti-VEGF therapy should be considered [1, 2].

Finally, CSCR can recur.


[1] Ehlers JP, Shah CP, Hospital WE. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease: Lippincott Williams & Wilkins; 2008.

[2] Yanoff M, Duker J. Yanoff: Ophthalmology: Elsevier Science Health Science Division; 1998.