central serous chorioretinopathy ( cscr ) is a condition characterized by the accumulation of subretinal fluid at the posterior pole of the fundus , causing single or multiple areas of serous retinal detachment .
the pathophysiology of the disease is thought to involve retinal pigment epithelial ( rpe ) dysfunction , increased leakage of choriocapillaris vessels and bruch 's membrane dysfunction [ 1 , 2 ] .
the result of localized exudation is the formation of retinal edema and small rpe detachments at the macular and perimacular areas . although the aetiology and triggering factors of cscr are not clearly understood , the condition is commonly associated with the use of systemic or topical steroids [ 2 , 3 ] .
consequently , a critical therapeutic step is the withdrawal of any steroids the patient might be using .
unfortunately , when steroids are indispensable for the treatment of a patient 's systemic disease , the management of cscr becomes challenging .
a 40-year - old white male was referred to our clinic due to a 15-day history of bilaterally blurred vision and metamorphopsia . he had a history of myasthenia gravis for which he had been treated with oral prednisolone and azathioprine during the last 2 years .
his best - corrected visual acuity ( bcva ) was 8/10 in the right eye ( od ) and 9/10 in the left eye ( os ) .
fundoscopy revealed a few small , yellow - whitish circumscribed macular elevations and one larger , irregularly shaped parafoveal elevation in od ( fig .
fluorescein angiography showed multiple areas of early hyperfluorescence and late leakage in od ( fig .
optical coherence tomography ( oct ) revealed rpe detachment , elevation of the neurosensory retina and highly reflective subretinal fluid mostly in od ( fig .
the diagnosis of multifocal cscr was made . as the patient 's myasthenia could not be optimally controlled at the time ,
unfortunately , we noticed further deterioration of the bcva and subfoveal expansion of the subretinal fluid in od , so it was decided to administer an intravitreal injection of ranibizumab in this eye .
one month later , his bcva had deteriorated to 3/10 in od and 7/10 in os .
fundoscopy revealed that the area below the fovea in od was enlarged with the deposition of material presumed to be fibrin in the subretinal space .
oct demon - strated further elevation of the neurosensory retina and a more irregular subretinal accumulation of highly reflective material ( fig .
m over 10 min , waited for 5 min and then directed the diode laser at the larger lesion of leakage in od , using a wavelength of 689 nm and laser energy of 25 mj / cm .
after the first application , the laser spot was directed at the second and the third lesion of leakage in od ( fig .
as the patient 's myasthenic symptoms improved , it became possible for the attending neurologist to reduce the dose of prednisolone , increase the dose of azathioprine and add neostigmine .
one month later , and while undergoing prednisolone tapering , his bcva in od had improved to 6/10 with no subretinal fluid , while the area with the fibrin deposition had nearly disappeared ( fig .
the bcva in os improved to 10/10 over the next couple of months . to date , 1 year after treatment , the patient 's bcva remains stable at 6/10 in od and 10/10 in os with no signs of active disease .
although the aetiology and triggering factors of cscr are not clearly understood , the condition has been associated with the use of steroids through virtually any route of administration .
furthermore , type a personality , emotional stress , endogenous hypercorti - solism as well as an imbalance between sympathetic and parasympathetic activity have also been suggested as risk factors for cscr [ 2 , 4 , 5 , 6 ] .
corticosteroids may be implicated in these changes by virtue of their propensity to change rpe ionic pump function or alter the permeability of ocular barriers .
in addition , steroids increase platelet aggregation and may favor conditions promoting microthrombus formation and increased blood viscosity , thus altering choroidal microcircu - lation .
nevertheless , as shown in our case , the competing interests of continuing steroids for a systemic condition versus the necessity to withhold them in patients with cscr can lead to therapeutic dilemmas and may call for close cooperation between clinicians of different specialties . in our patient ,
pdt with verteporfin acts by decreasing choroidal permeability and tightening the blood - retinal barrier at the level of the retinal pigment epithelium .
lately , it has been suggested that reducing the light dose ( fluence ) is safer because standard pdt may cause severe choroidal ischaemia , while low - fluence pdt minimizes the risk of bruch 's membrane rupture .
intravitreal anti - vascular endothelial growth factor administration is an alternative approach to cscr management   which has been recently suggested .
it is believed that anti - vascular endothelial growth factor exerts its effects by reducing the permeability of the choriocapillaris vessels and tightening the blood - retina barrier .
other therapies that have been proposed include the use of focal argon laser photocoagulation targeted at the leakage sites , micropulse diode laser photocoagulation , transpupillary thermotherapy and cortico - steroid antagonists , such as mifepristone and ketoconazole [ 1 , 11 , 12 , 13 ] . notwithstanding the various treatment modalities ,
the discontinuation of any exogenous steroids remains the cornerstone of cscr treatment . in our case , as discontinuation of prednisolone was initially contraindicated , it was first decided to proceed with an intravitreal injection of ranibizumab .
contrary to previous reports , however , the result was disappointing as the patient 's bcva continued to decline [ 10 , 14 ] .
another possible therapeutic option in our patient was the use of focal argon laser coagulation at sites of leakage .
this treatment can be a very useful choice in patients with lesions located away from the fovea .
however , in this particular case , it was not attempted because it was thought that laser photocoagulation would entail a high risk of rupture of these very prominent pigment epithelial detachments .
in addition , it was felt that photo - coagulation through the presumed fibrin that had accumulated in the subretinal space would be of questionable effectiveness . after performing low - fluence pdt and tapering the steroids , the patient 's condition improved dramatically in od .
interestingly , the clinical picture and bcva in os had also markedly improved over a period of a few months without any intervention other than steroid withdrawal .
it should be noted that the improvement in od could , in principle , be attributed to the discontinuation of prednisolone , rather than pdt .
we believe , however , that pdt was essential in our case because the resolution of cscr in od was immediate , whereas the resolution in os occurred over the course of some weeks .
additionally , the bcva achieved immediately after pdt remained practically unchanged during our patient 's 1-year follow - up ; this indicates that the maximal therapeutic benefit for od should be attributed to pdt .
it is worth mentioning that the existence of yellow - whitish hyperreflective subretinal material presumed to be fibrin is typically associated with severe forms of cscr and may signify a poor prognosis .
luckily , our patient 's final bcva in od ( 6/10 ) was only moderately reduced compared to the bcva at presentation ( 8/10 ) .
our report indicates that low - fluence pdt may be helpful when immediate steroid withdrawal is not an option in patients with cscr .
the authors have not received grant support or research funding and they do not have any proprietary interests in the materials described in the article .
 we present a case of bilateral multifocal central serous chorioretinopathy in a 40-year - old male who suffered from myasthenia gravis and was receiving oral prednisolone . due to the severity of the underlying disease , it was not possible to reduce the corticosteroid dose . 
 after initial unsuccessful treatment with an intravitreal injection of ranibizumab , low - fluence photodynamic therapy was performed , followed by gradual tapering of the corticosteroids . 
 visual acuity improved significantly in both eyes . 
 different therapeutic approaches are discussed . 
Introduction
Case Report
Discussion
Disclosure Statement