This is a 29-year-old male patient with a history of posttraumatic corneal wound in left eye (LE), sutured on the same day of the accident, without intraocular foreign body, and treated with antibiotics, topical and systemic cycloplegics.
After steroid withdrawal, she had decreased visual acuity of the non-traumatized eye, so oral prednisone was restarted and she was sent to our institution with the diagnosis of sympathetic ophthalmia.
At admission, a month and a half after the trauma, the patient reported decreased visual acuity (VA) of the right eye (OD) of 21 days of evolution and a relative central scotoma in BE.
Examination revealed VA of 20 RE and 20/400 LE, intraocular pressure of 11 mmHg RE and 12 mmHg LE.
The RE also showed pigment cells 1/2 + in the anterior chamber, without flare.
The anterior segment of the left eye showed a hyperemic conjunctiva, a corneal wound sutured with temporal leukoma, posterior synechiae, and posterior opacity +.
Funduscopy of the right eye showed folds in the macula and two white lesions with subretinal fluid; the left eye had three similar lesions, with no signs of bilateral panuveitis.
Treatment consisted of prednisone 75 mg/day po, prednisolone acetate 1% every 2 h, cyclolactate 1% bid, phenylephrine 10% bid.
The clinical aspect led to suspicion of CSC.
Ultrasound and angiographic study were requested.
Ultrasound showed posterior hyaloid detachment in the right eye and RSD in macular area in the left eye; choroid thickness was normal in the left eye.
The angiographic study showed two hyperfluorescence zones that progressively increased in the RE and three similar lesions in the LE.
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The definitive diagnosis was bilateral CSC of multiple foci.
Cycloplegic treatment was discontinued and topical and systemic steroids were rapidly reduced.
One month later visual acuity was 1 RE and 0.2 LE; the clinical aspect of the eye fundus showed pigmented lesions without subretinal fluid in BE.
