Eleni Kottaridou
Definition
Central Serous Chorioretinopathy, also known as CSC, is thought to occur due to choroidal hyperpermeability which leads to sub-RPE and subretinal fluid (SRF) accumulation. It is the fourth most common retinopathy after age-related macular degeneration, diabetic retinopathy and branch retinal vein occlusion (1).
Risk Factors
Central Serous Chorioretinopathy usually affects one eye of a young or middle-aged white man. It is mainly linked with Type A personality and psychosocial stress. The male to female ratio is 3:1. Numerous other risk factors include pregnancy, Cushing’s disease, use of corticosteroids, Helicobacter pylori infection, untreated hypertension, obstructive sleep apnoea, systemic lupus erythematosus (SLE) and end-stage renal disease.
Differential Diagnosis
A wide range of ocular diseases may present with subretinal fluid and, therefore, the knowledge of the differential diagnosis is highly significant (2). More specifically, it is important to consider the diseases that can cause macular neurosensory detachment. These may include: optic nerve pit, choroidal neovascularization, polypoidal choroidal vasculopathy, choroidal tumours, Vogt-Koyanagi-Harada disease, posterior scleritis and uveal effusion syndrome. Other diseases should be excluded, namely autoimmune disease, such as systemic lupus erythematosus or polyarteritis nodosa and vascular diseases, such as malignant hypertension, toxaemia of pregnancy and disseminated intravascular coagulation.
History
Typically, the patients present with central vision loss or distortion with possible central scotoma. Moreover, they may complain of micropsia, hyperopic or myopic shift and reduced contrast sensitivity and colour saturation.
Diagnosis
The diagnosis of central serous chorioretinopathy is clinical (1). However, further investigation with fundoscopy, optical coherence tomography (OCT), fundus fluorescein angiography (FFA) and indocyanine green (ICG) may identify the chronicity of the disease and guide the management. The visual acuity (VA) can typically range from 6/9 to 6/18. The correction of the hypermetropic shift with low strength convex lens may improve the visual acuity. The fundoscopy may show round or oval serous macular detachment without haemorrhage with small, yellow sub-retinal deposits in the area of neurosensory detachment. The OCT shows neurosensory retinal detachment and small retinal pigment epithelial detachment (PED). The FFA may have ink blot appearance (31%) or smokestack pattern (12%). On the ICG, there is a leakage pattern with additional hyperfluorescent areas of choroidal vascular hyperpermeability.
Management
A central serous chorioretinopathy typically resolves spontaneously within 3 to 6 months and, therefore, observation is currently standard of care. The modification of the risk factors, more specifically reduction or discontinuation of steroids, treatment of Helicobacter pylori infection, management of hypertension or renal disease, should be taken under consideration. The management of central serous chorioretinopathy can be either conservative or surgical. The conservative therapy includes the use of anti-corticosteroids, such as oral spironolactone, which result in the faster resorption of the subretinal fluid, and the intravitreal anti – vascular endothelial growth factor (anti-VEFG) agents, which can mainly benefit the patients with choroidal neovascularization. Surgical therapy is more suitable in cases with persistent visual defects or lack of improvement. One option is laser photocoagulation, including argon laser, micropulse diode laser photocoagulation or subthreshold micropulse laser photocoagulation (3). This technique targets areas with RPE detachments and allows the scarring that eventually permits the reattachment of the retina and the reabsorption of the subretinal fluid by the choroid. Another surgical treatment option in the Photodynamic therapy with verteporfin (3), which can cause damage to the endothelial cells and, therefore, inhibition of the choroidal hyperpermeability. The photodynamic therapy is used in chronic cases of central serous chorioretinopathy and is associated with considerably high improvement of the visual acuity.
Summary
The steps that should be followed for the management of a patient presented with central serous chorioretinopathy would be:
- Confirm diagnosis – multimodal imaging including OCT
- Check for risk factors
- Consider treatment based on:
- Chronicity
- Photoreceptor damage
- Risk factors
- Symptoms
- Patient preference
4) Treat
References:
- American Academy of Ophthalmology. Central Serous Chorioretinopathy. Basic and Clinical Science Course, Section 12. Retina and Vitreous. San Francisco: American Academy of Ophthalmology; 2022-2023:215-221.
- Central serous chorioretinopathy: Towards an evidence-based treatment guideline, Rijssen et al, Epub 2019 Jul 15
- An international collaborative evaluation of central serous chorioretinopathy: different therapeutic approaches and review of literature. The European Vitreoretinal Society central serous chorioretinopathy study, Romano et al, 2020 Aug;98(5):e549-e558. doi: 10.1111/aos.14319. Epub 2019 Dec 6.