Central Serous Retinopathy: Symptoms, Causes, Diagnosis, and Treatment

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Central serous retinopathy (CSR) is a retinal condition that affects young to middle-aged people with no previous signs or symptoms of retinal disease. The average age of onset is the mid-30s, but it ranges from the late 20s to late 50s. It affects men more than women—by a 10 to 1 ratio—and more Caucasians than any other race. Interestingly, it seems to disproportionately affect people with type-A personalities, too.

Symptoms

People with CSR tend to complain of blurry or distorted central vision, usually in one eye. It can affect both eyes, but this is rare. People who develop CSR sometimes become temporarily far-sighted, and they may complain of straight lines appearing distorted or bent.

Causes

CSR is sometimes referred to as "idiopathic" central serous chorioretinopathy, because the direct cause is not known. There is controversy in the medical community as to why some people develop the disease; a common recurring theme seems to be mental stress, and the condition seems to occur when stress levels are high in a person's life. In addition, people who take oral steroids are at a slightly higher risk of developing the disease. Lack of sleep may also play a role.

The condition begins between two layers of the eye. The photoreceptor layer of the retina lies above the choroid, a layer that functions to nourish the retina. Between the choroid and the photoreceptor layer is a layer of retinal pigment epithelial cells, referred to as the RPE. The RPE layer controls the flow of nutrients and fluid into the retina.

When a person develops CSR, the RPE is affected in the macular region of the retina. The macula is a very specialized part of the central retina that ensures clear, acute central vision. Normal RPE cells have very tight junctions; tight junctions are like welded seals bracketing all the cells together side by side, and they prevent the leakage of fluid across their bonds. In CSR, something happens to allow these junctions to loosen and break down, allowing fluid to leak out. More cells break down, and the RPE layer actually detaches to form a small cyst in the area of the macula. The cyst changes the shape of the retina (similar to bending film in a camera) and distorts vision.

Using steroids, whether oral, skin creams, inhaled, intramuscular, joint injections, or intranasal, is thought to be a causative factor. All steroids, even low-dose ones, should be stopped.

Diagnosis

The following methods can be used to detect CSR:

  1. Ophthalmoscopy: Eye doctors use a variety of methods to look at the inside of the eye. This may or may not include special dilating eye drops to enlarge the pupil so the doctor can more easily examine the inside of the eye. Usually, a cyst or bubble of tissue can be seen.
  2. Optical coherence tomography (OCT): OCT uses light to visualize the different layers of the retina. This test gives the doctor a very detailed view to see if fluid leakage exists. The test is quick and painless and usually requires no drops to be instilled into the eye.
  3. Fluorescein angiography (FA): Doctors will sometimes use a method of injecting a special dye into the bloodstream, then photograph the circulation of this dye within the eye. FA can help confirm the diagnosis and also pinpoint where the leakage is coming from.

Treatment

CSR is treated only after extremely careful consideration, as most cases eventually resolve without treatment. It is recommended the patient attempt to rest and receive 8 hours of sleep per night, and regular exercise is also highly recommended. If the condition remains after 4-6 months, retinal doctors will usually treat CSR with the following methods:

  • Medications: Since there seems to be dysfunction in a mineralocorticoid receptor at the level of the RPE, mineralocorticoids such as epleronone or spironolactone have show some benefit in the resolution of CSR. Other medications thought to benefit sufferers of CSR include melatonin, which is thought to work via improvements in circadian rhythm and sleep as well as a decrease in physiological stress. Other medications that have been trialed in the treatment of CSR include mifepristone, finasteride, and metoprolol. Intravitreal anti-VEGF inhibitors have not been found to be beneficial in the treatment of CSR.
  • Laser photocoagulation: Photocoagulation is a process where the doctor applies a thermal laser to the area of fluid. The laser will cause a very mild, beneficial scar formation in the pigment epithelial cells, halting the fluid leakage. Laser photocoagulation is a consideration for persistent and stubborn CSCR; It can help decrease fluid leakage in the retina and improve visual acuity. This is better for areas that the fluid does not involve the very bulls eye center of fine vision, known as the fovea; Laser photocoagulation's risks include need for further treatment, inducing a fixed blind spot in the area that was treated, and possibly causing scarring that can lead to further vision loss or the development of new vessels that can break, bleed, and leak causing further problems;
  • Photodynamic therapy (PDT): PDT uses a certain wavelength of light along with a certain photoactive chemical, called Visudyne, to reduce fluid leakage and protect against the development of more severe forms of the disease. Unlike focal laser photocoagulation, PDT may be useful for areas of leakage that occur in the bulls eye center of the macula called the fovea as well as diffuse fluid.

Physiological stressors, including obstructive sleep apnea, can contribute to CSA and needs to be treated if it is diagnosed.

What You Should Know About CSR

Although central serous retinopathy can be detrimental to your vision, most people have a relatively good prognosis with no treatment at all. A high percentage of people recover vision to at least 20/20 or 20/40 within one to six months. Sometimes they still have some remaining distortion of vision, but it is very mild.

If CSR does not heal within six months, most physicians will consider treatment. Rarely, a serious complication can develop when blood vessels from the choroid begin to grow into the space under the retina. Scar tissue may form, which could cause significant vision loss if left untreated.

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  • Alexander, Larry J. Primary Care of the Posterior Segment, Second Edition. Appleton & Lange, 1994.