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central serous chorioretinopathy ( csc ) is defined as a circumscribed neurosensory retinal detachment caused by focal retinal pigment epithelium ( rpe ) incompetence .
it is generally a self - limiting condition , in which patients complain of metamorphopsia , micropsia , relative central scotoma , and a moderate decrease of visual acuity .
fluorescein angiography ( fa ) typically shows single or multiple  inkblot early leakage points at the rpe followed by progressive localized subretinal leakage .
optical coherence tomography ( oct ) shows a localized dome - shaped macular detachment , with a normal neurosensory retina .
fine and owens   reported the only case in the literature of csc in a child .
when the clinical presentation is typical , diagnosis is forthcoming , based on ophthalmoscopic and fa findings . in atypical patients , however , a diagnosis of exclusion and further examination are warranted .
a healthy 12-year - old female presented with a 3-day history of acute - onset blurred vision in her right eye without any prodromal symptoms .
initial best - corrected visual acuity was 20/40 in the right eye and 20/15 in the left eye .
fundus examination of the right eye revealed a normal coloration of the optic nerve and a retinal elevation at the fovea and inferior macula secondary to subretinal fluid without any signs of intraocular inflammation ( fig .
right eye oct showed an accumulation of subretinal fluid which did not show an extension to the optic nerve head , excluding the presence of optic nerve pit ( fig .
angiography demonstrated multifocal leakage at the level of the rpe at the papillomacular bundle region .
late phases of the fa showed subretinal leakage and pooling , with a very discrete hyperfluorescence of the optic nerve head ( fig .
based on these findings , we decided to observe this patient without any treatment or intervention .
after three months , visual acuity spontaneously improved to 20/15 and fundus evaluation was without any abnormal findings .
repeated fa and oct showed complete resolution of the multifocal leakage and subretinal fluid ( fig .
the patient has been periodically checked for 30 months without recurrence or any signs of inflammation in either eye .
csc is a clinical entity affecting middle - aged patients , usually males , in whom clinical appearance and fa are usually sufficient to confirm the diagnosis [ 1 , 4,5,6 ] . in patients outside the usual age range of this condition ( 20 - 50 years ) ,
localized serous retinal detachment ( srd ) in childhood could be secondary to inflammatory , neoplastic , or developmental conditions .
infectious diseases or inflammatory conditions that produce multifocal choroiditis , which may simulate csc , include presumed ocular histoplasmosis syndrome ( pohs ) , punctate inner choroidopathy ( pic ) , and vogt - koyanagi - harada ( vkh ) disease .
pohs has characteristic  punched - out choroidal lesions in the mid - periphery and peripapillary atrophy , which were not present in our patient .
pic , considered to be one of the white dot syndromes ( wds ) , affects young and middle - aged myopic women ( age range 15 - 55 years ) .
pic presents with blurred central vision and photopsias , and posterior pole examination reveals multiple ( 12 - 25 ) small ( 100300 mm ) opaque round lesions with an srd occasionally overlying them .
other wds include multifocal choroiditis with panuveitis , multiple evanescent wds , acute multifocal posterior placoid pigment epitheliopathy , and birdshot chorioretinopathy .
all of these have characteristic choroidal lesions and are mostly associated with a degree of anterior chamber inflammatory cells and vitritis , which were not associated with the lesions in our patient
. based on the multifocal leakage at the site of the srd and the discrete hyperfluorescent appearance of the optic nerve head on the late phases of the angiogram , the most important differential diagnosis is vkh disease .
vkh disease can have very different clinical manifestations depending on the stage of the disease .
there are some reports occurring in children , and this group has been estimated to represent 3% of all patients with vkh disease [ 9 , 10 ] . in our case , in contrast to the classic fa findings in csc , a late - phase , very discrete hyperfluorescence of the optic nerve head was found .
however , the course of the disease seen in this case was incompatible with any presentation of vkh disease , since all patients with vkh disease present more than one sign of inflammation .
furthermore , vkh disease always requires treatment with no reported spontaneous resolution present in any case .
clinically observable chorioretinal pigmentary changes follow healing of the leakage spots , while in our case , no residual fundus changes were noticed after spontaneous resolution of the subretinal fluid .
optic nerve pit , which can manifest with serous macular detachment that communicates with the optic nerve , was not clinically detected in this patient .
moreover , our patient showed multifocal leakage on fa which is not associated with optic pit maculopathy .
another cause of fluid at the macular area is x - linked retinoschisis - this was ruled out since it is a bilateral condition that only affects males .
hemopoietic or intraocular neoplasia was excluded clinically and by complete blood count as the etiology of srd in this patient . in a report on 312 cases of csc
, it was demonstrated that systemic steroid use , pregnancy , stress and type a personality were risk factors as shown in previous studies [ 4 , 5 ] . in a study of csc in women only
, it was reported that a higher than average age at onset , namely 53 years ( range 40 - 60 years ) , and high levels of cortisol play important roles .
an important cause - effect relationship between serum cortisol levels and csc presentation has been established . in the present case ,
cortisol was normal ( 22.1 g / dl , normal range 6.99 - 25 g / dl ) .
another contributing risk factor is high mean arterial blood pressure [ 4 , 5 ] .
our patient had a mean arterial blood pressure of 100/60 mm hg ( measured twice / day for 1 week ) . in conclusion , based on the clinical appearance and the natural course of the disease ,
this case is compatible with csc . to our knowledge , this is only the second case of a presumed idiopathic csc in a prepubertal female and the first one documented by fa and oct , as well as other studies to exclude secondary causes .
csc may affect females at a young age and should be included in the differential diagnosis of multifocal localized srd in that age group .
none of the authors have any financial / conflicting interests or funding sources to disclose .
the content of this case report has not been published or submitted for publication elsewhere nor has it been presented at any conference .
idiopathic central serous chorioretinopathy ( csc ) typically affects middle - aged males . to date , only one case of idiopathic csc in a prepubertal subject has been reported . 
 atypical idiopathic csc presentation may be challenging to diagnose . 
 exclusion of secondary causes of serous retinal detachment ( srd ) is warranted . 
 we describe the atypical case of a 12-year - old female with a circumscribed srd that resolved spontaneously and with fluorescein angiography ( fa ) findings that were compatible with idiopathic csc . 
 optical coherence tomography ( oct ) and systemic assessment were performed to exclude other etiologies . fa demonstrated multiple focal leaks in early phases , with subretinal leakage and pooling in late phases . 
 oct showed a localized circumscribed retinal detachment . 
 complete blood count was within normal limits . 
 serum cortisol was normal ( 22.1 g / dl ) and mean arterial blood pressure was 100/60 mm hg , thereby excluding secondary causes of csc . 
 this is the second reported case of idiopathic csc in a prepubertal female and the first one documented by fa and oct , as well as other studies to exclude secondary causes . 
 albeit rare , idiopathic csc should be considered in the differential diagnosis of srd in this ( prepubertal ) age group , after excluding secondary ocular or systemic etiologies .