Fluorescein angiography of a patient with central serous chorioretinopathy (CSCR) shows a classic 'smokestack' pattern of hyperfluorescence. What does this pattern represent pathophysiologically?
- A A focal RPE defect through which fluorescein leaks into the subretinal space, rising and spreading as a billowing cloud ✓
- B Choroidal neovascularisation penetrating through the RPE
- C Retinal arteriolar leakage producing perivascular staining
- D Pooling of fluorescein under the RPE creating a dome-shaped PED
Explanation
In CSCR, increased choroidal permeability drives fluid through a focal RPE break; fluorescein leaks through this pinpoint RPE defect into the subretinal space. The thermodynamically buoyant dye-laden fluid rises like smoke, then spreads laterally under the detached neurosensory retina, creating the pathognomonic 'smokestack' pattern on FFA. The ink-blot pattern (gradual centrifugal spread) is the other common FFA pattern in CSCR. A PED (RPE detachment) would show pooling under the RPE without smokestack morphology. CNV leaks as a lacy network with late leakage. Retinal vascular leakage produces perivascular staining/oedema patterns.
Reference: Khurana Comprehensive Ophthalmology, 7th ed.
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Written and medically reviewed by the StethoPrep medical team.