central serous chorioretinopathy
Introduction
Introduction to central serous chorioretinopathy Central serous chorionic retinopathy (CSC) is a common fundus lesion characterized by localized serous neuroepithelial detachment in the macular area and its vicinity. It is often referred to as middle pulp in domestic clinical practice. In recent years, the emergence of indocyanine green angiography has provided a new method for further research on CSC, and also has a new understanding of its pathogenesis. Central serous chorioretinopathy, more common in young and middle-aged men, mostly monocular, with a tendency to self-healing and recurrence. basic knowledge The proportion of illness: 0.004%-0.007% Susceptible people: good for adults Mode of infection: non-infectious Complications: choroidal hemorrhage
Cause
The cause of central serous chorioretinopathy
(1) Causes of the disease
The real cause is unknown, mental stress, emotional agitation, infection, allergy, choroidal venous drainage disorder, and thermal regulation failure can all contribute to the disease. The middle sera (CSC) may be the result of multiple factors, its incidence and age, gender, Blood type, climate, general condition, pregnancy, mental stress, mood abnormalities, allergies, colds, infections, excessive fatigue and alcohol and tobacco stimulation are all related. Common causes are lack of sleep, stress, fatigue, mood swings, etc. The occurrence of medulla may be related to sympathetic excitation and elevated catecholamines in the blood circulation. Experimental adrenaline macular degeneration and aphakic adrenaline macular degeneration are similar to seroplasm. Clinically, seroderma occurs in young males and menopausal women. As well as some Cushing's lesions and pregnancy, these indicate that endogenous or exogenous corticosteroid imbalance may be a cause of serotonin.
(two) pathogenesis
The pathogenesis of cytoplasm is not well understood, and there are studies on ischemia, infection, inflammation, immune response and metabolic disorders, but there is no strong evidence. Fluorescence angiography shows that cytoplasm is mainly decompensated by RPE cells, which is characterized by continuous RPE cells. Sexual interruption, dye leakage, which is the result of the destruction of the barrier function of the RPE-linked complex, not RPE cell necrosis, which may be only one of the pathological lesions of the lesion, not the cause of the disease, due to the RPE cell barrier function Destruction and transport of ion function abnormalities, resulting in subretinal effusion, the formation of discoid retinal detachment in the macular area. In recent years, clinical application of ICG fundus angiography found that not only RPE leakage changes, but also the corresponding area of choroidal capillaries Delayed filling or hyperperfusion, enhanced permeability, it is speculated that the disease may be due to some factors leading to choroidal vasospasm or occlusion, causing choroidal perfusion abnormalities, compensatory dilatation of peripheral choroidal vessels, increased permeability, resulting in retinal pigmentation The epithelial barrier function is impaired and the fluid accumulates in the retinal pigment epithelium and neuroepithelial Experimental occlusion of choroidal capillary lobules can induce localized serous retinal detachment, similar to medullary. Some patients with laser healing or self-recovery have ICGA results showing that although RPE has no leakage point, choroidal lobules There is still a phenomenon of hyperperfusion and high permeability. Whether this phenomenon is related to recurrence remains to be further studied. It is speculated that the primary pathological site of the cytoplasm should be located in the choroidal capillaries, and the RPE changes are secondary.
Prevention
Central serous chorioretinopathy prevention
Prevention and early treatment are pre-existing problems. It is usually necessary to arrange the combination of work and rest in a reasonable way to avoid many factors that induce the disease. In case of illness, there is no need to worry, and should rest properly, avoid excessive use of brain and physical labor, and less watch TV and books and newspapers.
Complication
Central serous chorioretinopathy Complications choroidal hemorrhage
General surgical treatment can cause accidental macular, choroidal hemorrhage, subretinal neovascularization, macular scar and other complications.
Symptom
Central serous chorioretinopathy symptoms common symptoms visual distortion visual retinal detachment
Mostly healthy adults, suddenly noticed blurred vision, the center of the field of vision seems to have a light shadow block, the object can be deformed, the feeling of small, mainly manifested as central vision loss, visual distortion, the patient consciously in the center of the gaze point Shadow, gray or dark red, occasionally purple or green, such as repeated attacks, can leave permanent visual impairment, but never blind, visual disability varies, distance vision test from 1.0 to 0.1, check with Amsler checklist Often there are distortions or dark spots.
In the fundus examination, only the posterior pole retina has a flickering reflex, and the foveal light reflection is slightly diffused. In the severe case, the retina has a circular bulge in the retina, and the edge has a reflective wheel. There is a yellow-white exudation point in the detachment zone. The slit lamp is in contact with the lens. The neuroepithelial layer is separated from the pigment epithelial layer from the optical section. The nerve layer is bulged forward. The posterior wall of the detachment chamber has yellow-white dots and intracavitary effusion. It can be transparent or slightly turbid. In some extremely severe cases, there is too much liquid under the retina, which flows downward due to gravity, causing the peripheral retina to detach. After liquid absorption, the pigment epithelium is often atrophied in the lower part of the fundus. The band clearly shows the traces and extent of the subretinal fluid channel.
For patients with recurrence or in concealed cases, under the ophthalmoscope, except for those who have severe exudate, the discoid detachment can be reproduced. Most of them only show pigmentation disorder in the macula, or abnormal foveal reflex, only from the fundus performance can not determine whether Recurrence or concealment of the disease, and the patient's visual acuity is often not parallel with the progression of the disease. For patients with suspected chronic lesions, fluorescein angiography should be performed, because the contrast image shows a great effect on the fundus. Differently, the angiogram can specifically show the degree of damage and the extent of the lesion of the pigment epithelium, and whether the condition is recurrent or atrophic.
Although the disease has a large degree of self-limiting, after vertical tracking observation, some cases can be continued for many years, the time is obvious, the lesion range is gradually enlarged, and the pigment epithelium atrophy is also serious. According to statistics, about 1/3 or half of the disease The eye can recur, 10% of cases can recur multiple times, 50% of cases have a recurrence period of about 1 year, and stubborn cases can last up to 10 years. After a few episodes of eye disease, the central vision can be permanently damaged.
According to the symptoms, clinical manifestations and fluorescein angiography, the diagnosis of the disease is generally not difficult.
Examine
Central serous chorioretinopathy
Fluorescein fundus angiography
FFA is an indispensable means for the diagnosis of sizing, and it is also the basis of laser treatment of sizing. Its manifestations are diverse and can be summarized as follows:
(1) Leakage point type: for the typical performance of CSC, there are 3 types of leakage points:
1 dot enlargement type (also known as ink stain dispersion type): it is expanded around the point of dye leakage, the most common, accounting for 70% to 80%.
2 spray type (also known as smoke type): it is smoke-like, which is caused by the formation of a disc-shaped fluorescent pool in the subretinal space of the late FFA dye, which accounts for 10% to 20%.
3 atypical leakage point type: the lesion is often cluster-like distribution, showing a fluorescent staining point and/or a window-like defect or a vitreous-like fluorescent bright spot on the periphery of the bright central black, the leakage is not obvious or very slow, without accompanying Discoid serous retinal detachment is more common in chronic recurrent, subacute or convalescent cases.
There may be more than one leakage point in the same eye. The above three types of leakage can also exist at the same time, both appear after the fluorescing venous phase, and only a few occur in the arterial phase. This is the medullary and choroidal neovascular membrane. One of the important identification points, the latter's leakage time is in the early stage of the artery.
(2) Restricted area RPE leakage staining type: manifested as localized RPE strong fluorescent staining, leakage is very slow, the corresponding area with or without discoid serous retinal detachment, often accompanied by extensive RPE decompensation and (or) RPE atrophy band.
(3) RPE serous detachment type: FFA is fluorescing in the early stage, and gradually increases. In the late stage of angiography, there is a clear boundary, the morphological size is unchanged, and the fluorescent pool is uniformly dyed. In some cases, the detached RPE can be accompanied by serous retinal detachment. In this case, there is a leak point in the early stage of FFA, and there is disc-like fluorescence in the later stage.
(4) Mixed complex: In addition to leakage lesions [leakage point and/or RPE staining and/or RPE detachment], it is accompanied by RPE atrophy and/or peripheral peripheral serous retinal detachment. The range of RPE atrophy can be wide, extending from the posterior pole to the lower part, and sometimes the peripheral part of the fundus can have the manifestation of deltoid syndrome.
(5) Types of normal fluorescein angiography: Although rare, it does exist. It is speculated that the RPE barrier function may not be significantly damaged, enough to leak fluorescein, but it may leak water molecules, or because of RPE leakage. Very slow, the observation time is not long enough, or it is the recovery period, the leakage point is closed, and the subretinal fluid has not been completely absorbed.
2. Indocyanine green fluorescent angiography
In 1986, Hayashi used indocyanine green fluorescent angiography (ICGA) to observe 5 patients with CSC. Firstly, it was suggested that the damage of cytoplasmic retinal pigment epithelial function is related to choroidal dysfunction. At present, ICGA has become an important method to study the pathological changes of CSC. One of the main means of diagnosing the disease, especially for patients with atypical clinical manifestations such as elderly patients or CSC patients with atypical pigment epithelial atrophy, ICGA's main performances are:
(1) Choroidal vascular hypoperfusion: 1 or more choroidal vascular filling delays can be seen in the early stage of ICGA, showing irregular dark areas with a diameter of 1 to 1.5 PD. After 10 to 15 s, the dark area gradually disappears, and FFA is in the background stage. A weak fluorescent region appears at the corresponding position and disappears rapidly.
(2) choroidal vascular hyperpermeability: 1 or more abnormal choroidal hyperfluorescence in the posterior pole of the early stage of ICGA, some strong fluorescence areas are significantly associated with the choroidal hypoperfusion area, adjacent to the choroidal hypoperfusion area, or coincident with the low perfusion area In some strong fluorescent regions, dilated choroidal vessels are seen. FFA has strong fluorescence at the corresponding sites, and the appearance time is consistent with ICGA, but the number of lesions is generally less than ICGA.
(3) Fluorescence leakage: Isolated strong fluorescent spots appear in the weak fluorescence region of ICGA.
(4) RPE detachment: ICGA showed strong fluorescence in the early stage, the range was slightly larger than FFA, and the late stage showed weak fluorescence.
(5) Retinal neuroepithelial detachment: After the late stage of ICGA, the poles showed round or round-like strong fluorescence, regular morphology, smooth edges, and the diameter of 2~4PD, which was basically consistent with the pattern of "disc-shaped" in the absence of red light examination.
3. Center view
There are relative or absolute central dark spots in the acute phase, especially the Amsler table is more clear, and there is visual distortion. After the recovery period, the central visual field can be normal, but for cases with long course of disease, or repeated episodes, central field of view There may be relative dark spots. In some cases, the visual acuity recovery is very good, but the relative dark spots of the Amsler table examination center still exist, and the visual deformation is more common. The contrast sensitivity, post-image recovery time, etc. are often impossible to fully recover.
Diagnosis
Diagnosis and diagnosis of central serous chorioretinopathy
diagnosis
According to the symptoms, fundus performance and fluorescein angiography changes, the diagnosis of medlar is not difficult.
Differential diagnosis
According to the symptoms, fundus manifestations and fluorescein angiography changes, the diagnosis of medlar is not difficult, but in the clinical time from time to time misdiagnosis, missed diagnosis occurs, mainly need to be identified with the following diseases.
1. Lower rhegmatogenous retinal detachment
There is a small hole in the retina of the lower peripheral part, and the retinal detachment is shallow. The incidence is very slow. When the retinal detachment involves the macula, the visual distortion or visual acuity occurs. If the small pupil examination may lead to misdiagnosis, it is necessary to emphasize this type of patient. The pupils are scattered, and the peripheral retina is examined in detail. The neuroepithelial detachment of the retinal detachment reaches the peripheral part. The peripheral margin is often found under the three-sided microscopic examination, and the lesion area of the central serous chorioretinopathy is confined to the posterior pole. The peripheral retina is normal and there are no retinal tears.
2. Idiopathic choroidal neovascularization (idiopathic CNV)
Idiopathic choroidal neovascularization occurs in young adults, more women than men, and visual impairment is more serious. If the lesion is located in the foveal area, the visual acuity can be as low as 0.3 or less, and the yellow-spotted gray-yellow oozing plaque with bleeding can be seen at the fundus. The middle pulp is easy to identify, but some small CNV without bleeding, the fundus performance is not easy to identify with the middle pulp. At this time, the fluoroscopy is very important. Generally, the sulphur leakage point appears after the venous phase, and the CNV leakage appears in the artery. Early.
3. Cystic macular edema (CME)
Clinically typical CME is honeycombed under ophthalmoscope and will not be confused with medlar, but some macular edema has not undergone cystic changes, and only honeycomb staining appears when fluorescein.
4. Idiopathic polypoid choroidal vasculopathy (PCV)
Some older patients with chronic or recurrent CSC have pigment epithelial detachment, neuroepithelial detachment and RPF pigmentation changes in the fundus, FFA manifested as atypical fluorescein leakage, and some fundus only showed exudation and RPE changes. The PCV performance is similar, and the ICGA performance of the two is significantly different, providing an important basis for identification.
5. Middle part of uveitis
Or peripheral uveal retinitis, ciliary body flattening inflammation, its pathological toxicity products from the posterior chamber through the Berger gap, along the Cloquer tube backward invasion of the macula, causing edema, resulting in small vision, change of vision and other septic disease Similar symptoms, but there is dusty turbidity in the anterior vitreous of the disease, and sometimes a small amount of post-corneal sedimentation; the posterior capsule of the crystal (ie, within the Berger gap) has a burnt-yellow-like inflammatory exudate, fully expanded and then used on three sides. Microscopic examination revealed inflammatory exudation, hemorrhage and retinal white sheath near the serrated edge.
