The fundus photo of the right eye reveals some pigment mottling temporal to the fovea and below the disc. The fundus photo of the left eye reveals central macular RPE disturbances associated some inferior depigmentation. Autofluorescence of the right eye reveals mottled autofluorescence superotemporal and temporal to the fovea with a ring of hyperautofluorescence surrounding the area of mottled autofluorescence temporal to the fovea, and there was also some subtle mottled autofluorescence changes below the disc. The left macula has central mottled autofluorescence and adjacent inferior hypoautofluorescence with surround hyperautofluorescence, and there is more subtle mottled autofluorescence above and temporal to the fovea. OCT of the right macula reveals disruption of the outer retinal layers in the temporal macula. OCT of the left macula reveals marked disruption of the outer retinal layers and the choriocapillaris centrally as well as nasal to the fovea, and there is a small amount of subretinal fluid under the fovea. OCT below the fovea reveals similar disruption of the outer retinal layers and the choriocapillaris as well as a larger collection of subretinal fluid. OCT images of both eyes reveal marked thickening of the choroid and pachyvessels. OCTA of the left eye shows severe disruption of the choriocapillaris, but there is no clear choroidal neovascular membrane.
These findings point to a diagnosis of chronic central serous chorioretinopathy (CSC) with much more damage to the left eye than the right. The distribution and character of the retinal and RPE changes and the characteristic thickened choroid with pachyvessels in each eye point to this diagnosis. The male sex of the patient as well as the age of onset of about 40 years is typical of this condition. In this particular case, longstanding subretinal fluid in the left eye damaged the neurosensory retina and the underlying retinal pigment epithelium, and there was gravitational tracking of subretinal fluid below the fovea.
It is doubtful that the rust in the left eye was causally related to this patient’s retinal condition. Siderotic toxicity from an intraocular iron-containing foreign body results in much more diffuse degeneration of the retina and RPE.
If there were more substantial central subretinal fluid and if the visual prognosis were better, photodynamic therapy (PDT) with Visudyne would be a reasonable consideration. The ophthalmic literature has conclusively demonstrated that this treatment is very efficacious in relieving subretinal fluid in patients with central serous chorioretinopathy. Nonetheless, many insurance programs, including Medicare, do not cover PDT with Visudyne for treatment of CSC.
