Methods

We retrospectively studied the fundus AF imaging of 30 consecutive eyes of 30 patients (23 eyes of 23 men, 7 eyes of 7 women) with primary CSC from November 2007 through June 2009 at Gunma University Hospital. The average patient age was 42.2 years (range, 27-64 years). The average duration of symptoms was 1.7 months (range, 1-6 months). All patients underwent a complete ophthalmic examination at second visit, including measurement of the best-corrected VA (BCVA) in decimal notation, slit-lamp biomicroscopy with a noncontact fundus lens (SuperField lens, Volk Optical Inc, Mentor, Ohio, USA), AF (Heidelberg Retina Angiograph [HRA]; Heidelberg Engineering, Dossenheim, Germany), fundus photography, fluorescein angiography (FA), indocyanine green angiography (ICGA) (TRC-50IX with IMAGEnet; Topcon, Tokyo, Japan), and SD-OCT (Cirrus HD-OCT; Carl Zeiss Meditec Inc, Dublin, California, USA). Patients were excluded if they had recurrent or chronic CSC or a history of another fundus disease.

The HRA is a confocal scanning laser ophthalmoscope. AF was excited by the argon blue wavelength (488 nm) used originally for FA. The barrier filter with a cutoff at 500 nm blocks excitation. A series of images was obtained, and an average image was compiled from the original series to reduce noise and provide more detailed images. The confocal detection unit uses a 400-μm pinhole aperture to suppress light from above or below the confocal plane. The scanning field was 30 degrees × 30 degrees. To avoid contaminating the fluorescence with residual dye from previous FA and ICGA examinations, the AF examination was performed before FA and ICGA.

During the SD-OCT examination, we used a 6-mm five-line raster scan, which comprised 4096 axial scans in each line. The spacing between individual line scan was 250 μm. The acquisition time was 0.76 second for a five-line raster scan. We measured the foveal thickness, which is the distance between the internal limiting membrane and the RPE at the central fovea, using the computer-based caliper measurement tool in the SD-OCT system. We also measured the length of the photoreceptor outer segment at the central fovea, which is the distance between the junction between the photoreceptor inner and outer segment (IS/OS) and the tip of the outer segment at the central fovea. To evaluate the retinal thickness and photoreceptor outer segment at the central fovea, we chose the OCT image with the steepest foveal excavation from the five-line raster scan across the foveal area.

We compared the AF patterns in CSC with the features of ophthalmoscopy and SD-OCT. We investigated the correlation between the AF patterns and the foveal thickness and the length of the photoreceptor outer segment at the central fovea using the Mann-Whitney U test.

Results

The average BCVA was 0.93 (range, 0.3-1.5). We observed patchy increased AF in the macular area in 22 of 30 eyes (73%) ( Figure 1 ). The photoreceptor outer segment at the central fovea, the average length of which was 50 μm (range, 15-130 μm) in all eyes, tended to be longer in the eyes with patchy increased AF compared with the other eyes ( P = .06) ( Figure 2 ). In one case with a serous retinal detachment (SRD) that increased in size, the patchy increased AF was in the area of the original SRD, but we observed decreased AF in the new area of SRD progression ( Figures 3 and 4 ). We observed precipitates within the area of the SRD in 17 of 30 eyes. The punctate increased AF corresponded to the ophthalmoscopic precipitates in all 17 eyes ( Figure 1 ). The precipitates were seen as highly reflective subretinal and intraretinal dots in the SD-OCT images. The SRD involved the central fovea in all 30 eyes. The area of the SRD apart from the macular area had decreased AF in 15 of 30 eyes (50%) ( Figures 1, 4, and 5 ). The average foveal thickness was 380 μm (range, 220-690 μm). The AF in the extramacular area of SRD was more decreased in eyes with a thicker fovea ( P = .017) ( Figure 6 ). We observed increased AF in the inferior SRD in eight of 30 eyes (27%) ( Figure 5 ). The patient profiles and AF, SD-OCT, and angiographic findings are shown in the Table 1 .

Patient 1, a 49-year-old woman with central serous chorioretinopathy. The best-corrected visual acuity of the right eye is 1.0 and the period of subjective symptoms lasted six months. (Top left) Color fundus photograph shows serous retinal detachment (SRD) in the macular area. The diameter of the SRD is about 2.0 disc diameters. Precipitates are seen inside the SRD. (Top right) Fundus autofluorescence (AF) shows decreased AF at the extramacular area of SRD (white arrowhead), patchy increased AF in the macular area (yellow arrowhead), and the punctate increased AF corresponding to the precipitates (yellow arrow). (Middle left) Fluorescein angiogram shows an expanding pinpoint leak (arrow) in the focal window defect. (Middle right) Indocyanine green angiogram shows focal choroidal hyperfluorescence (arrowhead) surrounding the leakage point. (Bottom) Cross-sectional macular image with a 6-mm horizontal line scan through the fovea (dashed line and in between on the color fundus photograph). The outer surface of the detached retina is irregular because the photoreceptor outer segments have elongated. The highly reflective subretinal and intraretinal dots at the detached retina correspond to precipitates (yellow arrow). The length of the photoreceptor outer segment at the central fovea (white arrow) and foveal thickness are about 130 and 440 μm, respectively.

The mean length of the outer segment at the central fovea (μm, mean ± SD) in eyes with and without patchy increased autofluorescence (AF). The outer segment tended to be longer in the eyes with patchy increased AF than in the other eyes ( P = .06).

Patient 2, a 51-year-old woman with central serous chorioretinopathy. The best-corrected visual acuity of the right eye is 1.0 and the period of subjective symptoms lasted two months. (Top) Color fundus photograph shows serous retinal detachment (SRD) in the macular area. The diameter of the SRD is about 1.5 disc diameters. (Bottom) Cross-sectional macular image with a 6-mm vertical line scan through the fovea (dashed line and in between on the color fundus photograph). A small pigment epithelial detachment below the detached retina is seen (arrowhead).

Patient 2, a 51-year-old woman with central serous chorioretinopathy, two weeks after the first visit. The best-corrected visual acuity of the right eye is 1.0. (Top right) Color fundus photograph shows the serous retinal detachment (SRD), which has expanded downward. (Top left) Fundus autofluorescence (AF) shows patchy increased AF at the original SRD (yellow arrowhead) and the decreased AF at the new area of the SRD (white arrowhead). (Bottom) Cross-sectional macular image with a 6-mm vertical line scan through the fovea (dashed line and in between on the color fundus photograph). The slightly elongated photoreceptor outer segments are seen. The length of the photoreceptor outer segment at the central fovea (yellow arrow) and foveal thickness are about 80 and 350 μm, respectively.

Patient 3, a 33-year-old man with central serous chorioretinopathy. The best-corrected visual acuity of the right eye is 1.2 and the period of subjective symptoms lasted two months. (Top left) Color fundus photograph shows serous retinal detachment (SRD) in the macular area. The diameter of the SRD is about 3.0 disc diameters. (Top right) Fundus autofluorescence (AF) shows decreased AF in the superior SRD, increased AF in the inferior SRD (arrowhead). (Bottom) Cross-sectional macular image with a 6-mm vertical line scan through the fovea (dashed line and in between on the color fundus photograph). The length of the photoreceptor outer segment at the central fovea (yellow arrow) and foveal thickness are about 50 and 300 μm, respectively.

The mean foveal thickness at the central fovea (μm, mean ± SD) in eyes with and without decreased autofluorescence (AF) in the extramacular area of serous retinal detachment (SRD). The foveal thickness is significantly ( P = .017) greater in eyes with decreased AF in the extramacular area of SRD than the other eyes.

TABLE 1

Clinical Profiles of Patients With Central Serous Chorioretinopathy

Patient No.	Age (Years)	Gender	BCVA	Duration of Symptoms (Months)	Foveal Thickness (μm)	Length of OS (μm)	Patchy Increased AF	Punctate Increased AF	Decreased AF in Extramacular Area of SRD	Increased AF at the Inferior SRD
1	49	F	1.0	6	440	130	+	+	+
2	51	F	1.0	2	350	80	+	+	+
3	33	M	1.2	2	300	50	+	+	+	+
4	36	M	0.8	1	420	50	+	+
5	50	M	0.6	1	470	45	+		+
6	34	F	1.0	1	410	60	+			+
7	34	F	1.0	4	480	50		+	+
8	42	M	0.7	1	460	45	+		+
9	46	M	1.0	1	510	35	+		+
10	30	M	1.2	1	390	30
11	36	M	0.3	1	290	40
12	54	M	1.2	1	230	95	+
13	41	M	1.2	1	270	55	+			+
14	50	M	1.0	1	470	55	+		+	+
15	48	F	0.9	1	690	50	+		+
16	47	M	1.0	1	370	80	+	+
17	37	F	0.7	1	240	30	+	+		+
18	27	M	1.5	1	380	35	+	+
19	52	M	1.2	1	350	70	+	+	+
20	37	M	0.5	3	310	30	+		+	+
21	40	M	1.2	3	690	50	+	+	+
22	41	F	0.7	1	280	35	+
23	48	M	1.0	1	410	30
24	41	M	1.2	3	230	15		+		+
25	44	M	1.2	3	530	70	+		+
26	34	M	1.2	2	270	35	+	+
27	44	M	0.9	2	310	50	+
28	64	M	0.7	1	300	35			+
29	42	M	1.2	1	220	65
30	33	M	1.0	1	320	50		+	+	+

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