Describe central serous chorioretinopathy and macular hole.

Central Serous Chorioretinopathy

• The classical patient is a young or middle-aged male, often with a driven, "type A" personality, under stress
• The single most important association IS corticosteroid exposure, by any route — oral, inhaled, nasal, topical skin creams, intra-articular and intravenous. It must be asked about explicitly, because patients do not regard creams and inhalers as drugs, and stopping the steroid is often the whole treatment
• Other associations — endogenous hypercortisolism (Cushing syndrome); pregnancy, in which it resolves after delivery; sympathomimetics; obstructive sleep apnoea; Helicobacter pylori; and psychological stress

Macular Hole and Epiretinal Membrane

• A full-thickness macular hole is a defect of the neurosensory retina at the fovea, caused by anteroposterior and tangential vitreomacular traction as the vitreous separates
• an idiopathic condition of women in the sixth and seventh decades; also follows trauma and high myopia
• Symptoms — gradual central blurring, metamorphopsia and a central scotoma; acuity falls to around 6/60
• GASS staging — stage 1, impending hole with a foveal cyst and loss of the foveal depression; stage 2, a small full-thickness hole; stage 3, a full hole over 400 micrometres with the vitreous still attached; stage 4, a full hole with complete posterior vitreous detachment
• The WATZKE-ALLEN test — a narrow slit beam across the fovea appears broken or thinned to the patient in a full-thickness hole, and merely distorted in a pseudohole. OCT is now diagnostic and has replaced clinical staging
• Differential — a lamellar hole (partial thickness); a pseudohole in an epiretinal membrane, in which the retina is intact but the membrane creates the appearance of a hole; and vitreomacular traction
• Treatment — pars plana vitrectomy with internal limiting membrane peeling and gas tamponade, with face-down posturing afterwards. Closure rates exceed 90%, and the outcome depends on the duration and size of the hole, so referral should not be delayed. Ocriplasmin is an enzymatic alternative for selected small holes with traction
• Epiretinal membrane (macular pucker, cellophane maculopathy) — a fibrocellular sheet on the internal limiting membrane which contracts and wrinkles the retina. idiopathic in most, following posterior vitreous detachment; or secondary to retinal tear or detachment surgery, vein occlusion, uveitis, diabetes or trauma