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

Central serous retinopathy (CSR) is an eye condition of the retina 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. The condition can affect both eyes, but this is rare. People who develop CSR sometimes become temporarily farsighted (distant objects are clear, while those up close are blurry), 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 since the condition seems to occur when a person's stress levels are high. 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, causing fluid to leak out. More cells break down, and the RPE layer detaches, forming 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 observed.
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 and 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 eight hours of sleep per night, and regular exercise is also highly recommended. If the condition remains after four to six months, retinal doctors will usually treat CSR with the following methods:

• Medications: Since there seems to be dysfunction in what's known as a mineralocorticoid receptor at the level of the RPE, mineralocorticoids, such as Inspra (epleronone) or Aldactone (spironolactone), have show some benefit in treating CSR. Other medications that may help people with CSR include melatonin, which can improve circadian rhythms and sleep, as well as decrease physiological stress. Other medications that have been studied for treating 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 in which the doctor applies a thermal laser to the area of fluid. The laser causes a very mild, beneficial scar to form in the pigment epithelial cells, stopping leakage. Laser photocoagulation is considered for persistent and stubborn CSR. It can help decrease fluid leakage in the retina and improve visual acuity. This works better in areas of the eye that do not involve the very center of the macula, called the fovea, which provides the clearest vision of any area. Laser photocoagulation's risks include a need for further treatment, creating a fixed blind spot in the area that was treated, and causing scarring that can lead to further vision loss or the development of new vessels that can break, bleed, and leak and cause further problems.
• Photodynamic therapy (PDT): PDT uses a certain wavelength of light along with a certain photoactive chemical, called Visudyne (verteporfin injection), 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 fovea, as well as for fluid that spreads.

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

A Word From Verywell

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 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.