This patient is a 48 yo Caucasian male. Came in for routine exam complaining "feels distance vision could be better." Patient has a history of hypothyroid. He takes synthroid and testosterone. He is a low hyperopic, astigmatic, presbyope OU. Pupils are normal. Anterior seg is unremarkable. He is not obese and not a diabetic. 24-2 screening visual fields show no defects.
Fundus photos show subtle defects superior temporal to optic nerve head OU. OCT show definite sensory retinal detachment OU. These defects were not present a year ago. I know he will need a fluorescein angiogram but my questions are:
In response to your questions:
Since this pathology appears to be outside of the macula, follow up for these types of scenarios do not have to be urgent and a few weeks is okay. If there is any suspicion for blood or exudates in these abnormal areas, or if any macular pathology is suspected, then immediate referral is necessary and the safest choice.
There are several possible etiologies for this underlying pathology. These include:
Although classically this entity has a neurosensory detachment in the fovea, a less common type of CSCR can be in the peripheral retina with multiple pigment epithelial detachments and multiple bullous serous neurosensory detachments. Focal pigment epithelial irregularities may mark sites of previous episodes.
This entity is typically characterized by recurrent or persistent neurosensory detachments which can be associated with lipid deposition and subretinal hemorrhage. This is usually seen in the peripapillary region or macular areas.
The margins of pigment epithelial detachments can be more distinct that those of CSCR and the RPE is elevated.
In AMD you can have can have peripheral pigment epithelial alterations, but this is typically in the macular region with more classic drusen or atrophy.
Usually these are flat or minimal elevated lesions that can be amelanotic. In some cases, RPE atrophy, hyperplasia, or RPE detachments can be visible.
Other Etiologies that can cause RPE changes and/or neurosensory detachments:
Optic Pit: A serous RD near the disc may be present if a optic pit is visualized on the disc.
Ocular Histoplasmosis: atrophic round spots with RPE changes and possibly CNV can be seen
Malignant Hypertension: Elschnig spots and choroidal abnormalities may be see
Uveitic Etiologies: Posterior Scleritis, Sarcoidosis, Uveal Effusion Syndromes, Inflammatory choroidal disorders can cause RPE disruptions
Toxic Retinopathies: chloroquine or hydroxychloroquine can cause mottled hypopigmentation in areas of the retina.
At this stage there are no published reports on testosterone causing these types of changes to the retina.
The location of these lesions mirroring one another does appear to be coincidental, however, the pathology in the two eyes appears to be from the same underlying condition.