314 OPHTHALMOLOGY Zdrav Vestn | July – August 2023 | Volume 92 | https://doi.org/10.6016/ZdravVestn.3391 Copyright (c) 2023 Slovenian Medical Journal. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Bilateral multifocal serous retinal detachments after multiple trauma: a case report Obojestranski večžariščni serozni odstopi mrežnice po multiplih poškodbah: prikaz primera Barbara Podnar,1,2 Petra Zorman2 Abstract We present a patient with bilateral multifocal serous retinal detachments after multiple trauma in a car accident without preceding corticosteroid treatment. A 37-year-old patient was admitted to our hospital after he had suffered multiple body injuries in a car accident. After being woken from an induced coma, he complained of blurry vision in his left eye, so he underwent a complete ophthalmic examination – several serous retinal detachments were found at the posterior pole of both eyes, along with thickened choroids. As there was no intraocular inflammation, accelerated hypertension or other changes indicating other causes of serous retinal detachments, and since we observed a steady spontaneous subretinal fluid resorption, we classified our case as an atypical central serous chorioretinopathy. Alternatively, serous retinal detach- ments could have occurred due to transient alterations in choroidal circulation following cerebral injury. In conclusion, this case report adds new data on the occurrence of serous retinal detachments and discusses their possible aetiology in the trauma setting. Care must be taken not to miss any other underlying pathology needing treatment. Izvleček Članek predstavi primer bolnika, pri katerem smo po multiplih poškodbah v prometni nesreči ugotavljali tudi obojestran- ske večžariščne serozne odstope mrežnice, čeprav se poškodovanec ni zdravil s sistemskimi kortikosteroidi. 37-letni bolnik je bil sprejet v našo bolnišnico po prometni nesreči, v kateri je utrpel več telesnih poškodb. Po prebuditvi iz umetne kome je navajal meglen vid na levo oko. Temeljit očesni pregled je pokazal obojestranske posteriorne serozne odstope mrežni- ce ob zadebeljenih žilnicah. Glede na odsotnost znotrajočesnega vnetja, maligne hipertenzije ali drugih sprememb, ki bi lahko kazale na druge vzroke seroznih odstopov mrežnice, in ker se je tekočina pod mrežnico počasi spontano resorbirala, smo postavili diagnozo atipična centralna serozna horioretinopatija. Serozni odstopi mrežnice bi lahko bili tudi posledica 1 Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia 2 Department of Ophthalmology, Izola General Hospital, Izola, Slovenia Correspondence / Korespondenca: Barbara Podnar, e: barbara.podnar@gmail.com Key words: central serous chorioretinopathy; serous retinal detachment; pachychoroid; multiple trauma; case report Ključne besede: centralna serozna horioretinopatija; serozen odstop mrežnice; pahihoroidea; multipla travma; prikaz primera Received / Prispelo: 12. 10. 2022 | Accepted / Sprejeto: 17. 3. 2023 Cite as / Citirajte kot: Podnar B, Zorman P. Bilateral multifocal serous retinal detachments after multiple trauma: a case report. Zdrav Vestn. 2023;92(7–8):314–9. DOI: https://doi.org/10.6016/ZdravVestn.3391 eng slo element en article-lang 10.6016/ZdravVestn.3391 doi 12.10.2022 date-received 17.3.2023 date-accepted Ophthalmology Oftalmologija discipline Case report Klinični primer article-type Bilateral multifocal serous retinal detach- ments after multiple trauma: a case report Obojestranski večžariščni serozni odstopi mrežnice po multiplih poškodbah: prikaz primera article-title Bilateral multifocal serous retinal detach- ments after multiple trauma Obojestranski večžariščni serozni odstopi mrežnice po multiplih poškodbah alt-title central serous chorioretinopathy, serous retinal detachment, pachychoroid, multiple trauma, case report centralna serozna horioretinopatija, serozen odstop mrežnice, pahihoroidea, multipla travma, prikaz primera kwd-group The authors declare that there are no conflicts of interest present. Avtorji so izjavili, da ne obstajajo nobeni konkurenčni interesi. conflict year volume first month last month first page last page 2023 92 5 6 314 319 name surname aff email Barbara Podnar 1,2 barbara.podnar@gmail.com name surname aff Petra Zorman 2 eng slo aff-id Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia Medicinska fakulteta, Univerza Ljubljana, Ljubljana Slovenija 1 Department of Ophthalmology, Izola General Hospital, Izola, Slovenia Okulistična dejavnost, Splošna bolnišnica Izola, Izola, Slovenija 2 Slovenian Medical Journallovenian Medical Journal 315 CASE REPORT Bilateral multifocal serous retinal detachments after multiple trauma: a case report 1 Introduction Central serous chorioretinopathy (CSCR) is a mac- ular disease of mainly adult men, characterized by sub- retinal fluid accumulation at the posterior pole of the retina, causing serous retinal detachment. The exact mechanism of CSCR is unknown, but it is thought to be due to choroidal capillaries˙ hyperpermeability and associated retinal pigment dysfunction. Although con- sidered idiopathic, it has been linked to diverse factors, including arterial hypertension, H. pylori infection, type-A personality type, steroid usage, and autoim- mune disease (1). It has been shown that not only steroid treatment (exogenous steroids) but also conditions that increase endogenous steroids (Cushing syndrome, major stress) can cause CSCR (1). We report an unusual case presenting as bilateral multifocal serous retinal detach- ments after multiple trauma in a car accident. 2 Case presentation A 37-year-old Caucasian male was admitted to our hospital after being injured in a car accident. Head CT showed a left frontobasal haematoma, left orbital roof fracture with an intraorbital haematoma, a focal sub- arachnoid haemorrhage in the left insula, and a few smaller intracerebral haemorrhagic contusions on the right side of the brain, mainly deeper in the temporal lobe. He also suffered lung contusion, sternum frac- ture, and fractures of transverse processes of vertebrae L1, L2, and L3. In the acute setting, left lateral canthot- omy was made due to proptosis of the left eye. After being woken from an induced coma on the second day after the accident, he complained of blurry vision in his left eye and was subsequently seen by a consultant ophthalmologist. Given the patient´s gradu- al recuperation, a first thorough visual function assess- ment and slit-lamp examination were possible only on the 11th day after the accident. The patient complained of prolonged light and dark adaptation and had already reported some improvement in the visual acuity of both eyes. He denied any ocular pain. Best-corrected visual acuity (BCVA) was 6/9 in his right eye (OD) and 6/10 in his left eye (OS). There was no more proptosis of OS. Ishihara´s test was within normal limits for both eyes. Pupillary reactions were normal bilaterally with a negative RAPD. A visual field examination (Octopus, Haag-Streit) revealed left homonymous hemianopsia. Fundus examination showed normal optic discs and multiple serous retinal detachments perifoveolarly in the right and left macula. Swept-source OCT imag- ing (Triton, Topcon) confirmed serous retinal detach- ments perifoveolarly bilaterally and showed focal areas of subtle RPE rarefaction. Outer choroidal vessels were focally dilated (pachyvessels), which correlated spatial- ly with serous retinal detachments (Figure 1A). Subfo- veolar choroidal thickness measured 607 micrometers in OD and 612 micrometers in OS (as measured with the help of a built-in caliper tool from swept-source OCT scans). There were no cells in the vitreous body and no ret- inal pigment epithelial detachments. Autofluorescence retinal imaging showed multiple focal decreased auto- fluorescence in the posterior pole (Figure 2). Laboratory tests showed a normal complete blood count except for mild blood-loss anaemia and slightly increased CRP (37.7 mg/L), which decreased to a nor- mal value only a few days after the accident. The patient´s past medical history was unremark- able except for a juvenile euthyroid goitre in adoles- cence and a tonsillectomy in childhood. The patient was without regular medical therapy before the acci- dent. He denied prior eye problems, stress, regular al- cohol consumption, smoking, or illicit drug use. During the patient´s hospital stay, we observed an improvement of his visual acuity and a relatively fast and steady resorption of subretinal fluid (Figure 1). At the time of the acute stage of CSCR, the patient was systemically too unwell to hold out longer-lasting diagnostic imaging such as fluorescein and indocy- anine angiography. Due to convincing spontaneous improvement in serous retinal detachments, we con- sidered it unnecessary later on. BCVA at the control examination nine weeks after the accident was 6/6 bi- laterally. There was only a trace of subretinal fluid left prehodnih sprememb v prekrvitvi žilnice po poškodbi možganov. Opisani primer dopolnjuje znanje o pojavnosti seroznih odstopov mrežnice; poleg poročila o primeru konkretnega poškodovanca predstavljamo možne vzroke zanje v povezavi s poškodbami. Pozorni moramo biti, da ne spregledamo morebitnih drugih vzrokov, ki bi morda potrebovali zdravljenje. 316 OPHTHALMOLOGY Zdrav Vestn | July – August 2023 | Volume 92 | https://doi.org/10.6016/ZdravVestn.3391 perifoveolarly superotemporally on the left eye , which had completely resolved by the following examination seven months after the accident. Homonymous hemi- anopsia has persisted to date. 3 Discussion Connection of CSCR to blunt eye trauma and rare- ly to orbital trauma has been reported previously, usu- ally describing an ipsilateral CSCR (2-6). Only two reports describe CSCR development in a contralateral eye (7,8). Bilateral CSCR after trauma is described on- ly as an occurrence after systemic corticosteroid treat- ment for trauma-related complications like traumatic optic neuropathy or Berlin´s oedema (9,10). Our case is, to the best of our knowledge, the first describing bilateral serous chorioretinopathy after trauma in the absence of preceding corticosteroid treatment. The cause could lie in the fact that our pa- tient suffered multiple body injuries rather than only an eye or an orbital injury, which could lead to a higher increase in endogenous corticosteroids (11,12). More- over, CSCR in our case presented multifocally peri- foveolarly in both eyes and not as a monofocal sub- foveolar serous retinal detachment as classically. Our patient also didn´t exhibit serous pigment epithelial detachments, which are otherwise common in CSCR. Our patient showed no signs of intraocular in- flammation, accelerated hypertension or neoplastic process (choroidal infiltration or metastatic disease), indicating other potential causes of exudative retinal detachment (13-16). After excluding the latter, the question remains whether serous retinal detachments after trauma should even be categorized as central se- rous chorioretinopathy (17). Firstly, CSCR is consid- ered idiopathic, i.e., without a known cause. However, Figure 1: OCT images showing serous fluid resolution with time. The images were taken on the 11th (A), 16th (B), and 66th (C) day after the accident; the left column represents the right eye, and the right column the left eye. On the 66th day after the accident, there was only a trace of subretinal fluid left perifoveolarly superotemporally on the left eye, not visible in the bottom right image due to a central cross-section of the OCT image. Source: archives of the Department of Ophthalmology, Izola General Hospital. 317 CASE REPORT Bilateral multifocal serous retinal detachments after multiple trauma: a case report trauma could be considered as a precipitating factor rather than a direct cause of CSCR by increasing en- dogenous corticosteroids, which then cause CSCR in predisposed eyes (6). Secondly, CSCR has known atyp- ical presentations, and our knowledge about them and the pachychoroid spectrum has been evolving lately. Since any other possible causes of multiple serous ret- inal detachments seemed clinically highly unlikely, since there was a pachychoroid present and since we observed a steady spontaneous resorption of subret- inal fluid, we believe that the most appropriate char- acterization of our case is an atypical trauma-related Figure 2: Colour fundus photography (the upper two) and fundus autofluorescence (the lower two images). Images were taken on the 20th day after the accident. Autofluorescence imaging shows multiple focal hypo- and hyperautofluorescences at the posterior pole of both eyes, corresponding to serous retinal detachments faintly visible on the colour fundus photographs. Source: archives of the Department of Ophthalmology, Izola General Hospital. 318 OPHTHALMOLOGY Zdrav Vestn | July – August 2023 | Volume 92 | https://doi.org/10.6016/ZdravVestn.3391 CSCR presentation. Alternatively, transient alteration in choroidal circulation could have been the cause of serous retinal detachments in our case. Transiently increased intracranial pressure after head injury (due to haemorrhage or cerebral oedema) can lead to hin- dered venous outflow, causing choroidal congestion and fluid leakage into the subretinal space. A traumat- ic caroticocavernous fistula could result in the same consequences by increasing the intraorbital venous pressure (18), but this was not the case in our patient. 4 Conclusions Our case report expands the knowledge about the possible occurrence of serous retinal detachments. Bilateral multiple serous retinal detachments after a traumatic insult in the absence of preceding cortico- steroid treatment could present a case of atypical cen- tral serous chorioretinopathy or alternatively occur as a consequence of transient post-traumatic alterations in choroidal circulation. Other causes of serous reti- nal detachments should be excluded, and care must be taken not to miss any underlying pathology needing treatment. Declaration of conflicting interests The authors declare no potential conflicts of inter- est with respect to the research, authorship, and/or publication of this article. Declaration of patient consent The authors confirm that they have obtained the patient´s consent to report his clinical information and images in the journal. The patient understands that his name will not be revealed. Funding The authors received no financial support for the research, authorship, and/or publication of this article. References 1. Liu B, Deng T, Zhang J. Risk factors for central serous chorioretinopathy: A Systematic review and meta-analysis. Retina. 2016;36(1):9-19. DOI: 10.1097/IAE.0000000000000837 PMID: 26710181 2. Gunna NT, C Parameswarappa D, Rani PK. Bullous central serous chorioretinopathy and retinal pigment epithelium sequelae postblunttrauma. 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