Central Serous Chorioretinopathy in Younger and Older Adults

Transcription

1 Central Serous Chorioretinopathy in Younger and Older Adults Richard F. Spaide, MD, Laura Campeas, BS, Anton Haas, MD, Lawrence A. Yannuzzi, MD, Yale L. Fisher, MD, David R. Guyer, MD, Jason S. Slakter, MD, John A. Sorenson, MD, Dennis A. Orlock, CRA Purpose: The purpose of the study is to investigate the demographic characteristics and clinical findings of central serous chorioretinopathy (CSC). Methods: This study examined a consecutive series of 130 patients with CSC seen over an 18-month period. Results: The mean age of the patients when examined was 51 years, and the male-to-female ratio was 2.6:1.0. A total of 62 patients were older than 50 years of age when first examined. Although the patients shared some clinical and angiographic similarities, the older patients had a lower mean visual acuity and were more likely to have diffuse retinal pigment epitheliopathy, bilateral involvement, and secondary choroidal neovascularization than were the younger patients. With ophthalmoscopic and angiographic examination results, it was possible to differentiate CSC in older adults from choroidal neovascularization. Conclusion: This study expands the clinical concept of CSC. The male-to-female ratio was much lower, and the range of ages of the patients was much greater than in previous studies. Disease manifestations in older adults differed somewhat from those seen in younger adults. In older patients, CSC can be distinguished from other exudative maculopathies, particularly that of choroidal neovascularization secondary to age-related macular degeneration. Ophthalmology 1996; 103: Patients with central serous chorioretinopathy (CSC) have CSC. 10 Subretinal lipid also may be found in eyes with serous sensory retinal detachments associated with leaks esc, but the prevalence is not known. at the level of the retinal pigment epithelium (RPE). Previ Although a variety of theories about the cause of CSC ous reports on this entity are reasonably consistent in the have been proposed, recent investigations using indocyadescription of the demographic profile and the clinical nine green videoangiography (ICG-V) have suggested manifestations of the patients. 1-7 The age group affected that choroidal vascular hyperpermeability may be a prin most commonly was young adults between 30 to 50 years cipal underlying pathophysiologic abnormality. - This of age. The patients frequently have had a preceding hyperpermeability may lead to excessive tissue hydrostressful event 8 and were more likely to have type A static pressure within the choroid and may cause pigment personality. 9 Men substantially outnumbered women, epithelial detachments (PEDs), disruption of the retinal with a ratio reported in older studies of at least 6: pigment epithelial barrier, and abnormal egress of fluid Subretinal deposition of a white exudate, presumably fibrin, has been reported to occur in 12% of patients with problem within the choroid, one might expect to find both into the subretinal space. If esc is because of a vascular younger and older patients affected with the disorder. With time, younger patients with CSC do become older, and sqme continue to have recurrent acute or chronic episodes of sensory retinal detachment. A few older patients have been reported in the literature with newly diagnosed cases of CSC Little is known, however, about the age-specific prevalence or the clinical findings of CSC in older adults. Sensory retinal detachments in older adults often suggest the presence of choroi Originally received: November 1, Revision accepted: July 29, From the LuEsther Mertz Retina Research Laboratory and the Macula Foundation, Manhattan Eye, Ear, and Throat Hospital, New York. Reprint requests to Richard F. Spaide, MD, Vitreous, Retina, Macula Consultants of New York, Suite 203, 519 E. 72nd St, New York, NY

2 Spaide et al CSC.. 50 Ill c.-.. c Cll I'll 30 0 Cll 20.c E z 10 :I Age Figure 1. Histogram of age distribution of patients when first diagnosed with esc. dal neovascularization (CNV) secondary to age-related macular degeneration (AMD), which is the most common cause of blindness in older adults. 17 The differentiation between these two entities is important because esc is treated conservatively, whereas CNV warrants consideration for prompt laser photocoagulation. To help determine the clinical findings of esc, particularly in older patients, a retrospective study of 130 consecutive patients with esc was performed. Patients and Methods Definitions The definitions used in this study were adapted from previous reports. 18 Central serous chorioretinopathy was diagnosed in the patient who had a sensory detachment attributed to a leak or leaks from the level of the RPE without other possible cause for the exudation such as inflammation, infiltration, or CNV. Central serous chorioretinopathy was considered to be composed of two distinct subtypes, classic esc and diffuse retinal pigment epitheliopathy (DRPE) Classic CSC was defined as a localized sensory retinal detachment of the macula caused by one or several discrete isolated leaks at the level of the RPE that were termed focal leaks. These focal leaks typically are quite evident during fluorescein angiography. Diffuse retinal pigment epitheliopathy, which also has been termed chronic esc, was defined as a sensory retinal detachment associated with areas of RPE atrophy and pigment mottling that during fluorescein angiography displayed areas of granular hyperfluorescence containing one or many subtle leaks. Patients with DRPE often, but not always, have a history of classic CSC. All patients in the present study had either classic CSC or DRPE. Subretinal fibrin was thought to be present if there were gray-white translucent dots or sheets of deposition located under the retina within a sensory retinal detachment. Subretinal fibrin is seen most commonly in the proximity of an active leak. Subretinal lipid was diagnosed if there were yellow hard-edged waxy deposits also located on the underside of the retina in an area of detachment. Subretinal lipid can be found at the border of the sensory retinal detachment, or may be deposited in clumps with an apparently random distribution under the sensory retinal detachment. A PED was defined as a round or oval blister-like elevation of the RPE. During fluorescein angiography, aped shows uniform fluorescence that begins after and persists later than does the background choroidal fluorescence. Exudative AMD was defined as the presence of CNV in patients 50 years or older who had soft drusen, but did not have other possible causes of CNV such as intraocular inflammation, pathologic myopia, angioid streaks, the presumed ocular histoplasmosis syndrome, or traumatic choroidal ruptures. Angiographic Evaluations The patients had stereo fundus photography, stereo fluorescein angiography, and stereo digital ICG-V. Fluorescein angiography was performed using conventional techniques. The ICG-V was performed using a system and protocol that have been described before. 19 The system used for acquisition of the images was a fundus camera optimized for infrared light transmission (Topcon SOIA, Topcon Corporation, Paramus, NJ) connected to a 1024 line digital imaging system (Topcon Imagenet 1024, Paramus, NJ). After intravenous injection of 25 mg of indocyanine green (ICG) dye (Becton Dickenson, Franklin Lakes, NJ), the angiogram was obtained over a period of at least 40 minutes. Examinations The patients in this study were seen at the Manhattan Eye, Ear, and Throat Hospital and the private practice of the authors. A retrospective review of patients with the diagnosis of esc seen over an 18-month period was performed. All patients had a complete ophthalmic examination, including an extensive ocular and systemic history, slit-lamp biomicroscopy with fundus examination, and indirect ophthalmoscopy. The date of diagnosis of CSC was established for each patient. Statistical Analysis The data obtained were analyzed with descriptive statistics. Mean visual acuity was calculated as the geometric mean of the patient's Snellen acuity. Chi-square analysis was used for categorical analysis. The Fisher exact test was used if the expected count in a cell was 5 or less.z 0 The ip.dependent samples Student's t test was used to compare group means of continuous variables? 1 Some variables, such as the visual acuity, were not normally distributed and would not meet the assumptions of parametric tests, so the log transform of the visual acuity was done before performing any parametric tests. Eyes with CNV were excluded from analysis of variables such as 2071

3 Ophthalmology Volume 103, Number 12, December 1996 Figure 2. A, left eye of a 66-year-old man with a sensory retinal detachment bounded by subretinal lipid; visual acuity was 20/40. B, temporal to the region shown in A, the patient had a smaller sensory retinal detachment with two pigment epithelial detachments (arrows) that had overlying subretinal fibrin. C, the fluorescein angiogram showed several areas of diffuse dye leakage. The pigment epithelial detachments are readily visible. D, one year later, the patient had a change in the distribution of the subretinal lipid. The visual acuity remained 20/40. E, the corresponding fluorescein angiogram shows prominent leakage superior to the fovea adjacent to the temporal arcades... Figure 3. A, the left eye of a 58-year-old man with a sensory retinal detachment with subretinallipid in the inferior macula. His visual acuity was 20/ 50. B, fluorescein angiogram (276 seconds postinjection) taken on the same day as A showing diffuse retinal pigment epitheliopathy with several subtle leaks (arrows). C, midphase indocyanine green angiogram taken on the same day as A showing multifocal choroidal vascular hyperpermeability. D, late phase indocyanine green angiogram showing dispersion of dye and silhouetting of the larger choroidal vessels. E, color photograph taken 9 months after A showing resorbtion of most of the subretinal lipid. The visual acuity was 20/30. F, fluorescein angiogram (387 seconds postinjection) corresponding to E showing less leakage, particularly superior to the fovea. G, color photograph taken 5 months after E showing accumulation of more subretinallipid. The visual acuity was 20/40. H, fluorescein angiogram (294 seconds postinjection) corresponding tog showing more leaks within the macular region (small arrows) and along the inferotemporal arcade (large arrow). 2072

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5 Ophthalmology Volume 103, Number 12, December 1996 visual acuity, presence of PEDs, subretinal fibrin, or subretinal lipid. One eye of one patient was phthisical from a long-standing rhegmatogenous retinal detachment and that eye was excluded from analysis. Results A total of 130 consecutive patients with CSC were evaluated in this study. There were 123 white patients (94.6%), 4 Hispanic patients (3.1 %), 2 Asian patients (1.5%), and 1 black (0.8%) patient. The mean visual acuity at the time of presentation was slightly better than 20/40 in each eye. The mean follow-up time was 2.7 years. The final mean visual acuity also was slightly better than 20/40 and was not significantly different from the initial mean visual acuity (P = 0.45, right eye; P = 0.11, left eye, paired sample Student's t test). The mean age at the time of diagnosis with CSC was 49.8 years with a range of 22.2 to 82.9 years (Fig 1). The mean age of the patients at the time of their initial examination by the authors was 51 years with a range 22.4 to 82.9 years. A total of 62 patients were 50 years of age or older when examined initially in our office, and 57 (43.8%) had the diagnosis of esc made originally after 50 years of age. Of the patients who received a diagnosis after 50 years of age, 20 were referred because of decreased or distorted vision, 16 had the incorrect diagnosis of AMD, 16 were correctly diagnosed with CSC, and 5 were referred for other reasons. Patients 50 years or older had lower mean visual acuity in each eye on presentation than did younger patients (P = 0.031, right eye; P = 0.013, left eye, Student's t test). In the younger patients, the esc was unilateral in 48 (71.6%), whereas in patients 50 years of age or older, esc was unilateral in 30 (50%), a difference that was significant (P = , chi-square test). The male:female ratio was 2.6 to 1.0. This ratio was not J!! 15 s:: Gl ~ D Gl..Q E :I z 5 20r ~======~ 0 EEl Classic esc Age Figure 4. Histogram of type of central serous chorioretinopathy versus the age of diagnosis for the left eyes. The distribution for the right eyes was similar. significantly different in patients younger than 50 years of age compared to the older patients (P = 0.95, chi-square test). Male patients were not more likely to have PEDs, subretinal lipid, drusen, or CNV than were female patients. The mean visual acuity of the male patients was not significantly different from the female patients (P = 0.73, right eye; P = 0.38, left eye, Student's t test). Subretinal deposits of either fibrin or lipid were seen in 35 patients. Subretinal fibrin was found in 19 male patients (20.2%) and in 2 female patients (5.6%), a difference that was significant (P = 0.042, chi-square test). Subretinal fibrin was more common in patients with diabetes (P = , chi-square) and in patients with PEDs (P = 0.003, right eye, chi-square test; P = 0.003, left eye, chi-square test). Subretinal fibrin was not more common in patients 50 years of age or older. The visual acuity of patients with subretinal fibrin was not significantly different from those without fibrin (P = 0.84, right eye; P = 0.8, left eye, Student's t test). Subretinal lipid was found in 20 patients (Fig 2). The visual acuity of patients with subretinal lipid showed an inconsistent association with visual acuity (P = 0.03, right eye; P = 0.68, left eye, Student's t test); otherwise, subretinallipid was not found to be associated with any covariate (Fig 3). Fluorescein angiography was performed on 120 of the 130 patients. The remaining patients had fluorescein angiography elsewhere to help establish their diagnosis. At the time of their first examination in our office, younger patients were more likely to have classic esc with focal leaks, whereas patients 50 years of age or older were more likely to have DRPE (P = , right eye; P = , left eye, chisquare test). The records of the patients were checked to determine the type of esc according to their age at the time of diagnosis. Younger patients were more likely to have focal leaks and classic esc, whereas patients 50 years of age or older were more likely to have DRPE at the time of initial diagnosis (Fig 4). The ICG-V was performed on 22 patients younger than 50 years of age and on 36 patients 50 years of age and older. The ICG-V findings of these patients were sufficiently consistent to warrant a summarization. Initially after injection, the ICG dye was seen within the choroidal vessels. During the midphase of the angiographic evaluation (8-15 minutes), there were multiple patches of hyperftuorescence that appeared in the inner choroid by stereoscopic evaluation (Fig 3C). These areas seemed to disperse somewhat in the later phases of the ICG-V, with the hyperftuorescent patches appearing larger and deeper by stereoscopic examination. In all cases, there was a characteristic silhouetting of the larger choroidal vessels in the late phases of the ICG-V (Fig 3D). The temporal characteristics of the hyperpermeable regions did not appear to vary according to tlie age of the patient (Fig 5). The CNV was seen in 12 patients, 10 of whom were 50 years of age or older (P = , chi-square test). The CNV was seen on initial evaluation by us in nine patients and was seen in three others with follow-up. The mean visual acuity of eyes with CNV was 20/140, which was significantly worse 2074

6 Spaide et al CSC Figure 5. A, fluorescein angiogram of a 60-year-old man with a visual acuity of 20/60. He was thought to have macular degeneration and was treated elsewhere with topical and subconjunctival corticosteroids for the same. An atrophic tract extends inferiorly (arrows). B, early phase indocyanine green angiogram showing filling of the choroidal vessels with no new vessel growth apparent. C, midphase indocyanine green angiogram showing multifocal choroidal vascular hyperpermeability. than eyes without CNV (P < 0.001, Student's t test). Patients with CNV had subretinal hemorrhage, thickening at the level of the RPE, and frequently had subretinallipid radiating from the area of neovascularization. They had a conspicuous lack of drusen, lacquer cracks, angioid streaks, or signs ofintraocular inflammation. Because of widespread pigmentary changes, scattered points of leakage, and PEDs related to the CSC, localization of CNV with fluorescein angiography generally was difficult (Fig 6). During ICG angiography, patients with CNV showed a unifocal area of hyperfluorescence that remained localized to the inner choroid throughout the angiographic sequence, in addition to the areas of choroidal vascular hyperpermeability related to the esc (Fig 7). Discussion This study examined the demographic, ophthalmoscopic, and angiographic findings of 130 consecutive patients with CSC. Generally, patients with CSC had good visual acuity, the male-to-female ratio was 2.6 to 1.0, and patients were distributed across a wide range of ages. Although the hallmark of esc is serous sensory retinal detachment of the macula, esc in older adults appears to have different clinical characteristics than does esc in younger adults. In older adults, CSC may mimic, and also may be secondarily complicated by, CNV. The present study found that patients with esc who were older than 50 years of age had a lower visual acuity and were more likely to have bilateral involvement, decompensation of the RPE, and secondary CNV than were patients younger than 50 years of age. The male-to-female ratio was 2.6 to 1.0. This is significantly different from previous reports where the weighted average of the male-to-female ratio was approximately 6: There are several possible reasons for this discrepancy. The present study, as well as past studies, 2075

7 Ophthalmology Volume 103, Number 12, December 1996 Figure 6. A, a 57-year-old man with a visual acuity of 20/40 in the left eye secondary to central serous chorioretinopathy. The fundus photograph shows pigmentary changes in the nasal macula and a nevus along the inferior arcade. B, fluorescein angiography shows an area of pigmentary atrophy with a descending atrophic tract extending below the inferior arcade. The area of retinal pigment epithelial involvement did not involve the fovea, possibly explaining the good visual acuity. C, 6 years after B was taken. The patient has thickening at the level of the RPE, subretinal hemorrhage, and lipid radiating from this area. The visual acuity was 20/80. D, fluorescein angiogram showing hyperfluorescence in the area of retinal pigment epithelial atrophy and an ill-defined area of hyperfluorescence visible through the blood (arrows). This area within the hemorrhage was thought to be the location of the choroidal neovascularization and was given laser treatment. E, fluorescein angiogram of the left eye 6 years after laser photocoagulation. The patient did not have any subretinal hemorrhage. The area of previous photocoagulation appears as a circular ~ea of hypofluorescence with a surrounding ring of hyperfluorescence. The visual acuity was 20/100. was retrospective. It is possible that biases introduced may have affected the observed ratio in all of these studies. There may be a more pervasive reason, one related to stress, a suspected risk factor for CSC. 8 The role of women in society has been undergoing large changes since the publication of the older studies. It is possible that with the ascension of women in the workplace and increased stress from work and home, women may be put at greater risk for stress-related conditions such as esc. The classification of leakage type varied with age. younger patients were more likely to have classic esc with focal leaks. These leaks are quite evident during fluorescein angiography, with most patients having blot or dot-like leaks and the remainder having smokestack leaks. The older patients in this study were more likely to have DRPE with leaks that usually were subtle and indistinct. No patient with DRPE in the present study had a smokestack leak. Not uncommonly, the leakage around 2076

8 Spaide et al CSC Figure 7. A, left eye of a 73-year-old man showing a crescentic area of subretinal hemorrhage surrounding a pigment epithelial detachment also containing blood. The visual acuity was 20/200. B, fluorescein angiography shows scattered areas of granular hyperfluorescence corresponding to diffuse retinal pigment epitheliopathy. The pigment epithelial detachment shows some visible staining despite the presence of blood. C, early phase indocyanine green angiography showing a nodular area of hyperfluorescence within the pigment epithelial de>tachment. D, midphase indocyanine green angiogram showing multifocal areas of choroidal vascular hyperfluorescence. The area of staining within the pigment epithelial detachment is more intense than in C. This particular area was thought to harbor choroidal neovascularization. The patient was given laser photocoagulation to this area and recovered to a visual acuity of 20/30. areas of DRPE seemed to arise from a diffuse ooze that was difficult to attribute to a particular source, either within or adjacent to the decompensated RPE. Although some patients with DRPE had a history of esc, many patients in the present study and in past studies4 5 did not. It is possible that some patients had chronic asymptomatic sensory retinal detachments that caused damage to the underlying RPE. With eventual foveal involvement, visual symptoms developed in ~e patients. This may explain why patients, examined when they were older, had DRPE. However, the patients in the present study had prior ocular examination results that apparently did not show any sensory retinal detachments. When we looked at the findings of the patients on their initial presentation, the association between DRPE and age was still present. This may suggest the subtype of CSC, either as classic CSC or DRPE, may be related to age of onset as well as to chronicity of disease. Although the fluorescein angiographic appearance of classic esc differs from that of DRPE, it is noteworthy that the underlying ICG angiographic features are quite similar. It is possible that the differi!jg fluorescein angiographic appearance between classic CSC and DRPE is dominated by changes in the RPE, which, in tum, may be secondarily related to the age at onset or chronicity of the abnormal fluid accumulation from choroidal vascular hyperpermeability. Subretinal fibrin was seen in 21 patients and was more common in men, patients with diabetes, and patients with 2077

9 Ophthalmology Volume 103, Number 12, December 1996 PEDs. In the past, subretinallipid commonly has not been associated with esc, but in the present study it was found in 20 patients. Subretinallipid commonly is seen in conditions causing chronic subretinal exudation, such as in idiopathic polypoidal choroidal vasculopathy or in CNV. Although the chronicity of leakage was not measured in the present study, subretinal lipid appeared to be more common in patients with chronic subretinal fluid. The presence of subretinal deposition of material in esc is consistent with the hypothesis of hyperpermeability of the choroidal vasculature with leakage of macromolecules such as fibrinogen and lipoproteins into the subretinal space. Choroidal neovascularization as a secondary manifestation was more common in patients 50 years of age or older. The appearance of CSC, particularly in an older patient, is manifested by sensory retinal detachment seen in association with PEDs, mottled depigmentation, hyperpigmentation, areas of RPE atrophy, dependent RPE atrophic tracts, 22 and subretinal deposits of fibrin and lipid Any or all of these findings may suggest the presence of occult CNV. Eyes with CSC, however, do not have blood or turbid fluid under the RPE or retina, thickening at the level of the RPE, or notched PEDs. The ICG-V findings of CSC are quite different from those seen with CNV. 18 Eyes with CSC had a characteristic pattern of multifocal patchy hyperfluorescence best seen in the midphase of the angiogram with dispersion of the dye and silhouetting of the larger choroidal vessels against a brighter background later in the angiographic sequence.19 The ICG-V findings of CNV, conversely, are characterized by unifocal hyperfluorescence localized to the inner choroid that usually increases in contrast throughout the ICG-V study. 18 This study expands the clinical concept of CSC. In the present study of 130 consecutive patients, the male-tofemale ratio was much lower than reported previously. Central serous chorioretinopathy occurred throughout a much larger range of ages than recognized previously, and, in particular, there was a significant number of older patients with CSC. These demographic features may be related to the actual underlying characteristics of esc, to an ascertainment bias of only unusual cases of esc being seen in referral, or a combination of both. A strong factor arguing against ascertainment bias was that most of the older patients were referred with a diagnosis other than esc, and the correct diagnosis was established only after ophthalmoscopic and angiographic examinations in our office. Many of these older patients were thought to have occult CNV. With the advent of ICG angiography, an improved characterization of occult CNV is possible. 18 We previously have delineated the ICG characteristics of younger 14 and older patients 19 with CSC. We believe the large number of older patients in this series is related, in part, to increased recognition of esc in this age group through application of a consistent definition for esc without regard for age, and recognition of fluorescein and ICG angiographic features of CSC. Indocyanine green angiography, in particular, enabled us to both detect choroidal vascular abnormalities suggestive of esc and to exclude cases of CNV. The older patients in this study were more likely to have DRPE, bilateral involvement, and lower visual acuity and were more likely to have secondary CNV develop. The findings in these patients initially may be suggestive of exudative AMD, but, ultimately, it is possible to diagnose esc based on specific ophthalmoscopic and angiographic findings. The occurrence of esc in older patients may be related, in part, to a lifetime of stress-related insult to the choroidal vessels. Treatment of CSC and its ocular sequelae may hinge on altering the abnormalities of choroidal hyperpermeability. References 1. Gass JDM. Stereoscopic Atlas of Macular Diseases. St. Louis: CV Mosby Co, 1987; Cassel GH, Brown GC, Annesley WH. Central serous chorioretinopathy: a seasonal variation? Br J Ophthalmol 1984;68: Gilbert CM, Owens SL, Smith PD, Fine SL. Long-term follow-up of central serous chorioretinopathy. Br J Ophthalmol 1984;68: Jalkh AE, Jabbour N, Avila MP, et al. Retinal pigment epithelium decompensation. I. Clinical features and natural course. Ophthalmology 1984;91: Frederick AR Jr. Multifocal and recurrent (serous) choroidopathy (MARC) syndrome: a new variety of idiopathic central serous choroidopathy. Doc Ophthalmo1 1984; 56: Spitznas M, Huke J. Number, shape, and topography of leakage points in acute type I central serous retinopathy. Graefes Arch Clin Exp Ophthalmol 1987; Castro-Correia J, Coutinho MF, Rosas V, Maia J. Longterm follow-up of central serous retinopathy in 150 patients. Doc Ophthalmol1992;81: Gelber GS, Schatz H. Loss of vision due to central serous chorioretinopathy following psychological stress. Am J Psychiatry 1987; 144: Yannuzzi LA. Type-A behavior and central serous chorioretinopathy. Retina 1987;7: Gass JDM. Central serous chorioretinopathy and white subretinal exudation during pregnancy. Arch Ophthalmol 1991; 109: Hayashi K, Hasegawa Y, Tokoro T. Indocyanine green angiography of central serous chorioretinopathy. Int Ophthalmo1 1986; 9: Scheider A, Nasemann JE, Lund OE. Fluorescein and indocyanine green angiographies of central serous choroidopathy by scanning laser ophthalmoscopy. Am J Ophthalmol 1993; 115: Piccolino FC, Borgia L. Central serous chorioretinopathy and indocyanine green angiography. Retina 1994; 14: Guyer DR, Yannuzzi LA, Slakter JS, et al. Digital indocyanine green videoangiography of central serous chorioretinopathy. Arch Ophthalmol 1994; 112: Schatz H, Madeira D, Johnson RN, McDonald HR. Central serous chorioretinopathy occurring in patients 60 years of age or older. Ophthalmology 1992; 99:

10 Spaide et al CSC 16. Berger AR, Olk RJ, Burgess D. Central serous choroidopathy in patients over 50 years of age. Ophthalmic Surg 1991;22: Leibowitz HM, Kreuger DE, Maunder LR, et al. The Framingham Eye Study Monograph: an ophthalmological and epidemiological study of cataract, glaucoma, diabetic retinopathy, macular degeneration and visual acuity in a general population of 2631 adults. Surv Ophthalmol 1980; 24: Spaide RF, Hall L, Haas A, et al. Indocyanine green videoangiography of central serous chorioretinopathy in older adults. Retina 1996; 16: Yannuzzi LA, Slakter JS, Sorenson JA, et al. Digital indocyanine green videoangiography and choroidal neovascularization. Retina 1992; 12: Fleiss JL. Statistical Methods for Rates and Proportions. 2nd ed. New York: John Wiley and Sons, 1981; Norusis MJ. SPSS for Windows Base System User's Guide. Release 6.0. Chicago, IL: SPSS, 1993; Yannuzzi LA, Shakin JL, Fisher YI, Altomonte MA. Peripheral retinal detachments and retinal pigment epithelial atrophic tracts secondary to central serous pigment epitheliopathy. Ophthalmology 1984;91: Ie D, Yannuzzi LA, Spaide RF, et al. Subretinal exudative depostis in central serous chorioretinopathy. Br J Ophthalmol 1993;77: Discussion by Lee M. Jampol, MD The classic description of central serous retinopathy (CSR) is a young patient, usually a male, with initially unilateral focal disease. On follow-up, some patients show resolution with no further episodes, whereas others experience recurrent episodes involving both eyes. The concept of CSR as a disease with its onset after age 50 or 60 is not widely appreciated. In the early 1990s, two papers appeared that suggested that CSR could occur in patients after age 50 or even after age 60Y In these older patients, the distinction of CSR from choroidal neovascularization is crucial in regards to the institution of photocoagulation therapy and the technique of photocoagulation. Dr. Spaide and coauthors have applied their extensive experience with CSR to answers questions about CSR in older patients. They evaluated a series of 130 patients with CSR seen over an 18-month period. This is indeed an impressive number of patients. Surprisingly, 62 of these 130 patients were older than 50 years of age. In 57 of these 62 patients, the onset of CSR was after age 50. (Thus, these were not predominantly young patients with CSR who had been observed as they aged. Apparently most of those patients showed resolution of their disease and were not being seen after the age of 50.) In reviewing their experience, Howard Schatz and coauthors 1 found that of 664 patients with CSR, only 13 patients were older than age 60. In reviewing 402 cases of CSR, Berger and coauthors 2 found 47 patients older than age 50. The present paper, thus, has a much higher percentage of older patients with the onset of CSR after age 50 than previous reports. Why? A possible explanation is that the present authors' definition of CSR is broader than the other two papers or the generally accepted definition. They define CSR as serous elevation of the retina with one or more leaks without evidence of inflammation, infiltration, or choroidal neovascularization. These leaks were not necessarily focal and apparently, especially in older patients, they were often subtle and diffuse. This may be part of the explanation. The interpretation of the physical findings and the fluorescein angiograms may also have been different than other investigators. 1 The lower male-to-female ratio (2.6: 1.0) in the present series compared to the usually quoted value of approximately 6:1 suggests that other processes than, classic CSR may be included here. The authors' explanation that a changing role of females in our society may be one factor From the Department of Ophthalmology, Northwestern University Medical School, Chicago. in the lower male/female rate certainly cannot be excluded, but it is also possible that their group includes patients with a different clinical picture and possibly a different pathophysiology than classic CSR. The authors describe subretinallipid as present in 20 of their cases as a manifestation of CSR. Classic teaching has always been that when subretinallipid (or hemorrhage) is seen, choroidal neovascularization should be strongly suspected. The authors also describe the concurrent presence of choroidal neovascularization in at least 10 of these older CSR cases (and 2 younger patients). It is unclear whether this choroidal neovascularization was thought to be a direct complication of the previous changes of CSR or perhaps was a manifestation of a diffuse degenerative change of the retinal pigment epithelium (RPE). In view of the high percentage of patients with subretinal lipid and the additional substantial number of patients with choroidal neovascularization, one has to wonder whether the more widespread entity that the authors are including as CSR with diffuse degeneration of the RPE is necessarily the same process as classic CSR. The authors use a relatively new tool in helping distinguish between choroidal neovascularization and CSR. They show that indocyanine green is an effective method for distinguishing the hyperperrneable picture of central serous retinopathy from the persistent pattern ofleakage seen with choroidal neovascularization. The fact that the hyperperrneable indocyanine green picture of focal CSR and diffuse CSR appeared to be identical does suggest that these two clinical pictures may be the same disease process. Some patients' classic CSR presents as a localized disease and then progresses to multiple leaks and widespread degenerative changes. Other patients have widespread RPE disease when first seen. These two presentations have been given various names, including diffuse retinal pigment epitheliopathy. The authors call this decompensation of the RPE. Many of the older patients with the onset of central serous retinopathy after 50 did not begin as the classic focal disease but instead, at the onset had more widespread degenerative disease of the RPE. Because macular dysfunction, lipid exudation, and choroidal neovascularization may develop in these patients, the long-term prognosis may well be worse than classic CSR. I am hopeful that the authors' technique of distinguishing choroidal neovascularization from the hyperperrneability picture of CSR does tum out to be foolproof. This would allow identification of patients with diffuse RPE disease and serous 2079

11 Ophthalmology Volume 103, Number 12, December 1996 elevation but no choroidal neovascularization and allow them to be characterized into the category of diffuse CSR rather than choroidal neovascularization from age-related macular degeneration. However, it does appear that choroidal neovascularization is a serious risk of both age-related macular degeneration and diffuse CSR based on the authors' experience of finding it in at least 12 of these cases of CSR. References 1. Schatz H, Madeira D, Johnson RN, McDonald HR. Central serous chorioretinopathy occurring in patients 60 years of age and older. Ophthalmology 1992; 99: Berger AR, Olk RJ, Burgess D. Central serous choroidopathy in patients over 50 years of age. Ophthalmic Surg 1991;22: Centennial Advertisement From the Illustrated Catalogue of Ophthalmological Apparatus and Instruments, Merry Optical Co, Kansas City, Missouri, Trachoma Forceps and Electro Magnets.* Cl..861 C/..867 Ct..8i3 Ct..879 Ct..899 Cl..891 Ct..903 C!..897 TRACHOMA FORCEP.S.-Continued. Ct..861 Noyes' oval blade $ 1 50 Ct..867 Prince's Ct..873.Snellen's Ct..879 Week's grattage forceps c; Rust's angular ELECTRO MAONETS. Cl Oruening's...,..., Cl.,894 Haab's. for use with 110 volt direct current, on stand, with switch ct..895 Haab's, with adjustable magnet. Price on application C/..897 Hirschberg's....' Ct..899 Johnson's, for use with 110 volt direct current C/ 894 Ct..903 Luer's Special Pamphlet on new and improved patterns of Electro-Magnets will be sent upon application. * Centennial advertisement provided courtesy of the Museum of Ophthalmology, Foundation of the American Academy of Ophthalmology, San Francisco, California 2080

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