Acute central loss of vision in a teen

A 19-year-old female, a college student presented with a 3-day history of painless blurred central vision left eye (OS). Past ocular history shows low myopia. Medical history shows migraine for which she was being treated with verapamil. Her family history was unremarkable.

Best-corrected visual acuity was 1.0 (–1.50 DS) right eye (OD) and 1.0 (+0.25 DS–0.25 DC×65°) OS. Anterior segment was unremarkable in both eyes (OU). Dilated fundus exam was unremarkable OD and abnormal OS [Figure 1a].

Figure 1.

Fundus photograph (a), macular optical coherence tomography (b) and late phase of fundus fluorescein angiography (c) OS at presentation

Questions

1. What are the fundus findings?

2. What is the differential diagnosis?

3. What is the most likely diagnosis based on history, clinical exam, and ancillary tests?

4. What is the natural course of this condition?

Answers for Clinical Quiz

Answers

1. Fundus findings are as follows

   1. Figure 1a: Fundus photograph shows subretinal fluid (arrows) more evident inferotemporal to the disc (gravity effect)
   2. Figure 1b: Macular OCT shows subfoveal fluid and no PED.
   3. Figure 1c: Late phase of FFA shows diffuse, nonhomogeneous hyperflorescence with leakage of fluorescein dye into the subretinal space inferotemporal to the disc outlining the serous retinal detachment (arrows).

2. Differential diagnosis:

   1. Acute central serous chorioretinopathy (CSC)
   2. Optic nerve pit with serous RD
   3. Pigment epithelial detachment (PED)
   4. Choroidal neovacular membrane (CNVM)
   5. Optic neuritis
   6. Harada disease
   7. Macular hole RD
   8. Choroidal tumor (amelanotic melanoma or metastasis)

3. Most likely diagnosis: Acute CSC

4. Natural course of an acute CSC:

Generally, the visual prognosis after an acute CSC is good. The majority of patients will recover most of their central visual loss within 3–4 months spontaneously. However, few patients may experience residual metamorphopsia which is usually visually insignificant. This is probably due to a photoreceptor misalignment. Patients with recurrent CSC or persistent acute CSC (more than 6 months) in the same eye may suffer a significant visual damage. Untreated chronic CSC may results in RPE atrophy, a metallic sheen at the level of the RPE, drusen, and choroidal neovascularization.

The clinical presentation in this young lady revealed unilateral limited serous RD with foveal involvement, hyperopic shift without signs of ocular inflammation. Clinically, there was no evidence of optic nerve pit, CNVM, PED, or optic neuritis. Harada disease is in the differential diagnosis of serous RD; however, it is typically bilateral and presents with inflammatory signs and symptoms. Macular hole RD occurs predominantly in highly myopic eyes and/or after blunt ocular trauma. The clinical picture in this young lady is highly suggestive of an acute CSC. Therefore, conservative management was offered. Three months later, patient reported gradual visual improvement and the clinical examination revealed resolved subretinal fluid OS as shown in the fundus photograph and macular OCT [Figure 2a and b].

Figure 2.

Fundus photograph (a) and macular optical coherence tomography (b) left eye after 3 months of observation