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Patient Presentation:
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Asymptomatic male in his 40s with no relevant ocular, medical, or family history.
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Referred for retinal pigment epithelium (RPE) defect in the right eye.
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Visual acuity 20/20 in both eyes (OU).
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Diagnosed with central serous chorioretinopathy (CSCR)-related pigment epithelial detachment (PED) via optical coherence tomography (OCT).
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Clinical Course:
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Monitored for 4 years with stable visual acuity (20/20 OU) and mild metamorphopsia reported at the most recent visit.
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PED persisted but resolved temporarily on two occasions (18 months and 4 years post-presentation), only to relapse within an hour during clinic visits.
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Key Observation:
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PED resolved on initial undilated OCT but relapsed after pupil dilation with 2.5% phenylephrine, observed on slit-lamp biomicroscopy and confirmed by repeat OCT (1 hour later).
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This pattern occurred twice (at 18 months and 4 years), suggesting a temporal association between phenylephrine use and PED relapse.
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Pathophysiology Insights:
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CSCR is associated with PED in 53% to 100% of cases, indicating high prevalence.
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CSCR pathophysiology involves:
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Hyperpermeable choroid.
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Loss of RPE barrier and pump function.
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Hormonal dysregulation (e.g., catecholamines, glucocorticoids).
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Catecholamines (e.g., phenylephrine, epinephrine) may contribute to CSCR and PED:
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Higher serum catecholamine levels reported in CSCR patients.
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Case series linked CSCR to pseudoephedrine and methamphetamine use.
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Neonatal case of PED after phenylephrine use in retinopathy of prematurity.
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Animal models show epinephrine induces CSCR-like features and RPE apoptosis, impairing barrier and pump function.
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Mechanism of Phenylephrine:
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Phenylephrine (2.5% topical) may upregulate cyclic adenosine monophosphate (cAMP), impairing RPE pump function and leading to subretinal fluid accumulation.
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Temporal association suggests phenylephrine as a potential trigger for PED relapse in CSCR, though causality is not definitively proven.
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High-Yield Exam Points:
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CSCR is a common cause of PED and serous retinal detachment, often affecting young to middle-aged males.
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OCT is critical for diagnosing and monitoring CSCR and PED.
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Catecholamines (e.g., phenylephrine) are an emerging risk factor for CSCR exacerbation, alongside glucocorticoids.
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Avoiding unnecessary use of sympathomimetic agents like phenylephrine in CSCR patients may prevent PED relapse.
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Conservative management with monitoring is standard for asymptomatic CSCR with stable vision.
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Clinical Implications:
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Clinicians should consider the potential role of topical phenylephrine in CSCR patients undergoing dilated exams.
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Alternative dilation agents (e.g., tropicamide) may be safer in CSCR patients to avoid triggering PED relapse.
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Watson MJ, Yellachich D. Relapsing Pigment Epithelial Detachment in Central Serous Chorioretinopathy After Dilated Eye Examination. JAMA Ophthalmology. Published online January 30, 2020. Available at: https://jamanetwork.com/ by a Cambridge University Library User on 02/03/2020.
