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Central Serous Chorioretinopathy

ROUTINE — Retina

Symptoms

Presentation

  • Central scotoma, blurred or dim vision (acuity 20/20 to 20/200).
  • Metamorphopsia: Distorted vision.
  • Micropsia: Objects appear smaller than actual size.
  • Acquired hyperopia due to anterior displacement of the retina.
  • Faded color perception and reduced contrast sensitivity.

Laterality

  • Usually unilateral at onset.
  • Bilateral involvement is more common in older patients and may be asymptomatic.

Clinical Findings

Demographics

  • Typically young to middle-aged men (ages 20–50; M:F ≈ 6:1).
  • Often associated with a "Type A" personality (driven, competitive, stressed).
  • Note: Suspect wet AMD or choroidal tumor in patients over 60 or women.

Clinical exam

  • Localized, dome-shaped serous detachment of the neurosensory retina in the macula.
  • Absence of subretinal blood or hard exudates (presence suggests CNV).
  • Possible associated serous pigment epithelial detachments (PEDs).
  • Focal RPE mottling may indicate prior episodes.

Imaging (OCT & angiogaphy)

  • OCT: Subretinal fluid (hypo-reflective dome) and thickened choroid (pachychoroid).
  • EDI-OCT: Choroidal thickness often >390 μm (normal ~260 μm).
  • Fluorescein Angiography: "Inkblot" (common) or "smokestack" (10–20%, pathognomonic) leakage patterns.
  • ICG Angiography: Shows diffuse choroidal hyperpermeability.
  • OCTA: Essential in older/atypical patients to rule out secondary CNV.

Clinical course

  • Acute: 80–90% of episodes resolve spontaneously within 3–4 months.
  • Chronic: Fluid persisting beyond 3–4 months leads to progressive outer-retinal atrophy.
  • Recurrence: Occurs in 30–50% of cases.

Etiology

Primary mechanism

  • Choroidal hyperpermeability and RPE dysfunction.
  • Part of the "pachychoroid spectrum" of retinal disorders.

Exogenous steroids (critical risk)

  • Odds ratio for exposure is ~37; includes all routes (oral, inhaled, nasal spray, topical creams, intra-articular).
  • Steroid discontinuation is the most vital management step.

Lifestyle and systemic factors

  • High endogenous cortisol (stress, Cushing syndrome).
  • Obstructive sleep apnea (OSA): Up to 61% of CSCR patients; screen with STOP-BANG.
  • Pregnancy: Typically occurs in the third trimester; resolves postpartum.
  • Other: Sympathomimetics, PDE-5 inhibitors (sildenafil), and methamphetamine.

Red Flags

  • Chronic fluid (>3 months): Risk of permanent photoreceptor loss and RPE decompensation.
  • Recent steroid use: Must be tapered or discontinued immediately.
  • CSCR in patients over 50: High risk for occult CNV; mandates OCTA/ICG.
  • Subretinal blood or hard exudates: Rule out neovascular AMD or polypoidal choroidal vasculopathy (PCV).

Investigations

Clinical and bedside

  • Amsler grid: To map and monitor the area of visual distortion.
  • Slit-lamp biomicroscopy: Use 60/90-D lens to evaluate for fluid, PEDs, or optic pits.
  • Dilated fundus exam: Rule out peripheral RRD or choroidal tumors.

Multimodality imaging

  • OCT: Demonstrate subretinal fluid and monitor for resolution.
  • OCTA: Mandatory for older patients to distinguish chronic CSCR from secondary CNV.
  • FA/ICG: For diagnostic uncertainty or to localize a leak before laser treatment.

Systemic screening

  • STOP-BANG questionnaire: To screen for obstructive sleep apnea.
  • Cortisol levels: If Cushing syndrome is clinically suspected.

Treatment

Observation (first-line)

  • Standard for the first 3–4 months of an acute episode.
  • Focus on removing triggers (steroids, stress, caffeine).

Intervention for chronic/recurrent disease

  • Photodynamic therapy (PDT): Half-dose/half-fluence verteporfin is the gold standard (superior to anti-VEGF).
  • Micropulse (subthreshold) diode laser: To the site of the leak.
  • Conventional focal laser: Restricted to extrafoveal leaks identified on FA.

Pharmacologic and secondary management

  • Anti-VEGF: Indicated if secondary CNV develops.
  • Mineralocorticoid antagonists (eplerenone/spironolactone): Randomised trials (VICI/SPECTRA) showed no benefit over placebo; not recommended as primary therapy.
  • Adjuncts: Rifampin or melatonin (limited evidence).

Clinical Pearl

Always ask about steroid use by all routes (nasal sprays, skin creams, inhalers)—steroids have an odds ratio of 37 for CSCR. Mineralocorticoid antagonists (eplerenone) are ineffective despite their theoretical rationale. Half-dose PDT is the gold standard for chronic cases.

Differential Diagnosis

  • Neovascular age-related macular degeneration (AMD)
  • Polypoidal choroidal vasculopathy (PCV)
  • Optic pit maculopathy
  • Choroidal hemangioma or metastasis
  • Vogt-Koyanagi-Harada (VKH) disease

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