central serous chorioretinopathy ( cscr ) manifests as neurosensory detachment of the macula and can be attributed to focal or multifocal leakage in the retinal pigment epithelium ( rpe ) .
fibrin accumulation in the subretinal space is an unusual and heretofore unreported visually damaging manifestation of severe cscr .
the patient was followed up with the use of biomicroscopy , fluorescein angiography , and optical coherence tomography ( oct ) .
a 32-year - old woman was referred to our department complaining of metamorphopsia and decreased visual acuity in the right eye .
best - corrected visual acuity ( bcva ) was 20/40 in the right eye and 20/20 in the left eye .
oct showed a steep neurosensory retina elevation with a highly reflective material accumulation in the subretinal space , presumably fibrin .
since most of these cases resolve spontaneously , the patient was kept under observation ; 1 month later , the fibrin accumulation had expanded subfoveally ( bcva 20/200 ) .
after the initial injection , bcva improved to 20/50 and , after the 3 injections , to 20/30 .
two months later ( bcva 20/30 ) , fresh leakage was observed at the margin of the original lesion , and an additional intravitreal ranibizumab injection was performed .
after another 2 months , bcva stabilized at 20/25 and remained stable throughout the 12 months after the initial injection .
prompt recognition of cscr complicated by subretinal fibrin and immediate intervention may result in recovery from this potentially devastating complication .
ranibizumab may be an alternative treatment option in the management of refractory cscr complicated by subretinal fibrin accumulation .
central serous chorioretinopathy ( cscr ) manifests as neurosensory detachment of the macula and can be attributed to focal or multifocal leakage in the retinal pigment epithelium ( rpe ) . while described as a disease of healthy , type - a personality men , it has also been reported in women , and is associated with pregnancy .
it typically develops in the third trimester and resolves spontaneously within 12 months after delivery .
fibrin accumulation in the subretinal space is an unusual visually damaging manifestation of severe cscr [ 1 , 2 , 3 ] .
schatz et al . , reported 6 cases ( average age 40 years ) with cscr containing fibrin in the subretinal space that later developed into a subretinal fibrotic scar , with subsequent subretinal fibrosis and severe visual loss ( 20/400 or worse ) . in this case report , we present the rapid and impressive response to ranibizumab in a case of cscr complicated by accumulation of subretinal fibrin .
a 32-year - old woman was referred to our department complaining of metamorphopsia and decrease of visual acuity in the right eye .
best - corrected visual acuity ( bcva ) was 20/40 and 20/20 in the right and left eye , respectively .
in addition , fluorescein angiography ( fa ) showed partial dye masking in the affected area during the early phase followed by ink - blot leakage and subsequent pooling in the superior margin , not involving the fovea ( fig .
1 ) . in the left eye , we observed old window defects and two small rpe detachments .
optical coherence tomography ( oct ) showed a serous elevation of the retina and a shallow rpe detachment , with subretinal accumulation of highly reflective material ( presumably fibrin ) .
our initial diagnostic approach was to follow up the patient keeping in mind that this was a case of cscr complicated by fibrin deposition in the subretinal space .
after 1 month , bcva decreased to 20/200 and the oct revealed a more irregular subretinal accumulation of highly reflective material that was now involving the fovea ( fig .
after the first injection , bcva improved to 20/50 while the fa leakage had nearly diminished .
two months later , visual acuity was 20/30 , while metamorphopsia was still persisting . during the follow - up period ,
bcva stabilized at 20/25 and remained stable for the following 12 months , without any apparent significant fa leakage ( fig .
the presence of fibrin with spontaneous resolution in the majority of cscr cases has been previously reported .
subretinal fibrin and other extracellular matrix molecules appear to stimulate the rpe to undergo fibrous metaplasia , which results in subretinal fibrotic scar formation and other sequelae , all of which can lead to severe visual loss . in our patient , a steep neurosensory retinal elevation with an extrafoveal subretinal deposition of a fibrin - like material was observed several months after delivery .
subsequent fibrinolysis of this meshwork resulted in an amorphous , homogenous subretinal accumulation with involvement of the fovea and significant reduction of the visual acuity . due to the presence of subfoveal fluid
, we decided to offer a 3-injection course of intravitreal ranibizumab which resulted in rapid subretinal material ( fibrin ) absorption and improvement of both bcva and foveal contour confirmed by oct . according to the literature [ 1
, 2 ] , in the majority of relevant cases , there is gradual resolution of this fibrin - like material accumulation as a result of a resumption of normal rpe function ( in pregnant women , in particular it , resolves spontaneously within 12 months after delivery ) .
schatz et al . , reported 6 cases ( average age 40 years ) with cscr containing fibrin in the subretinal space which developed into a subretinal fibrotic scar .
scar formation was followed by a tenting up of the macula , vascularization of the fibrosis ( subretinal neovascularization ) , or a retinal pigment epithelial rip .
four of the 7 eyes with subretinal fibrosis had severe visual loss ( 20/400 or worse ) .
ranibizumab has been reported to be an effective treatment of choroidal neovascularization related to chronic cscr . however , residual intraretinal or subretinal fluid in addition to increased choroidal permeability persisted in a small case series .
ranibizumab has been shown to have no significant direct effect on the choriocapillaris in animal models .
conversely , recent evidence from in vitro studies suggests that ranibizumab may decrease rpe barrier function by temporarily enhancing rpe permeability for a small number of days . in this case , it is not clear whether intravitreal ranibizumab contributed to the dissolution of the fibrin - like material , and it is conceivable that resolution may have occurred without any intervention .
in contrast , the rapid response to ranibizumab may suggest that this anti - vegf agent may be an alternative treatment option in the management of refractory cscr complicated by subretinal fibrin accumulation .
further experimental studies investigating the potential anti - vegf effect on modulating rpe function ( e.g. ion pump activation ) are required to validate this hypothesis .
none of the authors has received financial support for the completion of this study . regarding the results of this study , none of the authors has any proprietary interest .
 purposecentral serous chorioretinopathy ( cscr ) manifests as neurosensory detachment of the macula and can be attributed to focal or multifocal leakage in the retinal pigment epithelium ( rpe ) . 
 fibrin accumulation in the subretinal space is an unusual and heretofore unreported visually damaging manifestation of severe cscr.methodsthe patient was followed up with the use of biomicroscopy , fluorescein angiography , and optical coherence tomography ( oct).resultsa 32-year - old woman was referred to our department complaining of metamorphopsia and decreased visual acuity in the right eye . 
 best - corrected visual acuity ( bcva ) was 20/40 in the right eye and 20/20 in the left eye . 
 biomicroscopy revealed an irregularly shaped foveal elevation and wrinkling in the right eye . 
 oct showed a steep neurosensory retina elevation with a highly reflective material accumulation in the subretinal space , presumably fibrin . 
 our diagnosis was cscr complicated by subretinal fibrin accumulation . 
 since most of these cases resolve spontaneously , the patient was kept under observation ; 1 month later , the fibrin accumulation had expanded subfoveally ( bcva 20/200 ) . 
 the patient was offered 3 intravitreal ranibizumab injections . 
 after the initial injection , bcva improved to 20/50 and , after the 3 injections , to 20/30 . 
 two months later ( bcva 20/30 ) , fresh leakage was observed at the margin of the original lesion , and an additional intravitreal ranibizumab injection was performed . 
 after another 2 months , bcva stabilized at 20/25 and remained stable throughout the 12 months after the initial injection.conclusionsprompt recognition of cscr complicated by subretinal fibrin and immediate intervention may result in recovery from this potentially devastating complication . 
 ranibizumab may be an alternative treatment option in the management of refractory cscr complicated by subretinal fibrin accumulation . 
Purpose
Methods
Results
Conclusions
Introduction
Case Report
Discussion
Disclosure Statement