Report of concurrent peripapillary and macular detachment in central serous papillopathy

The authors describe the first reported case of concurrent peripapillary and macular detachment in a patient with central serous papillopathy (CSP) associated with optic disc drusen. The patient, a 38-year-old man, presented with a five-day history of progressive vision loss in his right eye. Fundus examination showed bilateral optic nerve head drusen (ONHD), and optical coherence tomography showed bilateral peripapillary serous detachment, as well as right macular detachment. The authors conclude that CSP should be considered as a potential cause of acute vision loss in patients with ONHD.

Upon presentation, the patient's previous systemic and ocular history was unremarkable, but he reported having the flu three weeks earlier. Another physician had diagnosed bilateral viral papillitis. Visual acuity was 20/30 in the right eye and 20/20 in the left eye.

The right eye showed a serous detachment extending from the optic nerve to the macula. Fluorescein angiography showed autofluorescence of the disc drusen and abnormal hyperfluorescence from temporal optic discs in early phases. There was also one hyperfluorescent focus in the lower part of the right optic nerve head and multiple pinpoint foci of hyperfluorescence within the temporal inferior veins in late frames. A cranial tomography scan showed calcium density bodies at both head optic nerves. Automated static perimetry demonstrated bilateral enlargement of the blind spot.

After two months, most of subretinal fluid disappeared without treatment, and visual acuity improved to 20/20 in both eyes. No relapses occurred during one year of follow up.

The authors say that spontaneous reabsorption of fluid and "benign" evolution ruled out peripapillary choroidal neovascularization, suggesting CSP as a final diagnosis. They say this is the second case in the literature describing simultaneous occurrence of optic nerve drusen and CSP but the first one in which both bilateral peripapillary and macular detachment were observed.

They say that optic nerve drusen seems to alter the normal barrier between the prelaminar optic nerve and the peripapillary retina. This anomalous peripapillary area joined to focal hyperpermeability seen in CSC may act together in the subretinal fluid production in patients with ONHD. The authors conclude that it is critical to correctly diagnose patients with CSP in order to avoid unnecessary testing and overlooking potential serious conditions such as true papilledema.