What is Central Serous Chorioretinopathy (Fluid Behind the Retina)?
Central serous chorioretinopathy (CSCR) is an eye condition that causes fluid buildup in a part of the retina called the macula. This may cause the area to detach in certain spots. This condition mainly affects men between the ages of 20 and 45.
It was first identified as a form of recurring retinitis by Albert V Graefe in 1866, but was later termed “central serous retinopathy.” The person with this condition may notice distorted images, objects seeming smaller than they are, and blurred vision.
In most cases, these symptoms go away on their own within 3 to 6 months. If the symptoms don’t improve over time, there are treatments available such as laser photocoagulation and photodynamic therapy, which use light to correct the retina. There are also medicines that can help manage the condition.
What Causes Central Serous Chorioretinopathy (Fluid Behind the Retina)?
People with an aggressive and competitive type-A personality may have a higher risk of a condition known as Central Serous Chorioretinopathy (CSCR). These behaviors can lead to the release of specific chemicals in the body that increase the risk of this condition. Other important mental conditions that may increase the likelihood of developing CSCR include psychological stress and depression.
Evidence suggests that use of corticosteroids, a type of medication, is definitely associated with CSCR. Corticosteroids are usually taken orally or intravenously, but cases of CSCR can also occur after using corticosteroid-based nasal sprays, skin creams, or injections for joint pain, or after applying them around the eye. This condition has also been seen after kidney, heart, and bone marrow transplants.
Conditions that increase the body’s production of cortisol, a hormone, also raise the risk of CSCR. These may include conditions like Cushing’s disease and also pregnancy. It seems that the effect of corticosteroids might not work the same way in everyone and could affect how blood vessels regulate themselves. Other drugs, not just corticosteroids, have been connected with CSCR as well. These include oral MEK inhibitors, phosphodiesterase inhibitors, pseudoephedrine, and oxymetazoline.
Additionally, research has found a link between the infection H. pylori, a common cause of stomach ulcers, and development of CSCR.
Stress and issues with sleep can trigger this condition, but treating these underlying issues can resolve CSCR. Certain families seem to have a higher occurrence of CSCR, suggesting that genetics could play a role. There is evidence that some gene variations could be linked to the condition. For example, a condition related to CSCR called pachychoroid could be inherited in families.
Furthermore, a number of other conditions may be associated with CSCR. These include sleep apnea, high blood pressure, use of certain mental health medications, lupus, and acid reflux disease.
Risk Factors and Frequency for Central Serous Chorioretinopathy (Fluid Behind the Retina)
Central serous chorioretinopathy (CSCR) is the fourth most common eye condition that can potentially affect vision. It usually accounts for a greater number of cases in men, with a male to female ratio of 6:1. The average age group impacted by this disorder lies within 39 to 51 years. In circumstances where females are affected, they are typically older than the affected males.
Typically, CSCR affects one eye, but in some cases (up to 40%), it can impact both eyes. That being said, most patients exhibit signs of pigment epithelial detachment (PED) in the unaffected eye too. Modern techniques, such as optical coherence tomography (OCT) and indocyanine green angiography (ICGA), have revealed bilateral changes in the vascular layer of the eyes for many people diagnosed with CSCR.
- CSCR is the fourth most prevalent retinal vision-threatening condition.
- It most commonly affects men, with a male to female ratio of 6:1.
- The disorder typically manifests in the age group of 39-51 years.
- In cases where females are affected by CSCR, they’re generally older than affected males.
- Although generally impacting one eye, CSCR could affect both eyes in up to 40% of cases.
- Pigment epithelial detachment is also seen in the unaffected eye of many patients.
- The occurrence of CSCR is around 9.9 cases per 100,000 population.
Signs and Symptoms of Central Serous Chorioretinopathy (Fluid Behind the Retina)
If you’re suffering from blurry vision in one eye, noticing objects seem smaller (micropsia) or distorted (metamorphopsia), having difficulty noticing a spot in your field of vision (relative scotoma), or if you’re experiencing color disturbances, you might be having a medical issue. Some people also have temporary farsightedness (hyperopia). Typically, vision can range from 6/9 to 6/60, but in most cases, it’s better than 6/12.
Upon a medical inspection, there can be a circular or oval region of lifted nerve sensory layer at the backside of the eye. Sometimes, there could also be a yellowish material under the retina, which is presumably fibrin, and a ‘pigment epithelial detachment’ or PED can be seen.
This condition, termed an ‘acute episode’, generally sorts out within 3 to 6 months. If the fluid remains beyond this duration, it is known as “chronic CSCR”. This often happens with older patients or those being treated with corticosteroids for a long time. There’s also an “atypical CSCR” which exhibits as a lower bulgy retinal detachment and might be associated with multiple PEDs, multiple retinal detachments, and multiple leaks as determined in a fundus fluorescein angiogram (FFA).
Testing for Central Serous Chorioretinopathy (Fluid Behind the Retina)
Several tests are used to diagnose and monitor Central serous chorioretinopathy (CSCR), a condition where fluid accumulates under the retina, causing vision disturbance.
The first test typically used is the optical coherence tomography (OCT), which uses light waves to capture high-resolution images of the eye and can reveal the presence and progress of the fluid accumulation. It can also sometimes identify areas where fluid may leak in the future. In chronic CSCR, OCT can reveal certain changes in the retina such as swelling or thickening.
Another common test is fundus autofluorescence (FAF), which uses a special camera to visualize the back of the eye (the fundus) and can reveal patterns of light absorption that correspond to leaking fluid. In chronic CSCR, this test can reveal tracks of light absorption due to pigment accumulation.
Fundus fluorescein angiography (FFA) provides further insights into the leakage patterns in CSCR by injecting a fluorescein dye into the bloodstream and capturing images as it flows through the blood vessels in the retina. Three leakage patterns can emerge: the inkblot pattern, the smokestack pattern, and the diffuse pattern, which all have distinct appearances on the images taken. FFA can also reveal other abnormalities in chronic CSCR, such as areas of the retina deteriorating or abnormal fluid accumulation.
Indocyanine green angiography (ICGA) helps to visualize blood flow in the choroid, the layer of the eye underneath the retina. With the help of an injected dye, it may reveal reduced blood flow and excessive permeability in the choroid vessels as well as other changes. Notably, ICGA can also help detect the presence of a new, abnormal blood vessel network that forms in chronic CSCR.
Lastly, OCT angiography (OCTA) is a non-invasive method that can also be used to detect these new blood vessels, as well as changes in the choroid. Like ICGA, OCTA can reveal patterns of blood flow in CSCR. It is being increasingly used to identify abnormal blood vessels, which can be seen in up to 20% of chronic CSCR cases.
Treatment Options for Central Serous Chorioretinopathy (Fluid Behind the Retina)
Central Serous Chorioretinopathy (CSCR), a condition affecting the eyes, usually clears up on its own, so doctors generally prefer to simply monitor it for around 3 to 6 months. However, if the condition lasts longer or it comes back, active treatment might be necessary, especially since long-lasting CSCR can lead to a progressive decline in vision.
Spotting a CSCR episode early and reducing stress factors can help, as over 80% of cases improve naturally. Early treatment might be necessary for those who rely heavily on their vision for their jobs, such as pilots, or if the disease keeps coming back, or one eye has already significantly lost vision due to chronic CSCR.
One method of treatment is laser photocoagulation. This involves using a laser to seal the spots where the retina in the eye is leaking, helping to solve the issue of fluid accumulating under the retina. While this doesn’t cut the risk of CSCR recurring, it can speed up recovery.
Another option is Photodynamic Therapy (PDT). This treatment involves the use of a drug that’s activated by a laser targeting the leakage points—great for situations where leakage is happening in multiple spots. PDT has shown promising results and is usually tolerated well by patients.
Anti-vascular growth factor (VEGF) therapy reduces the leakiness of the blood vessels in the eyes. While some studies suggest that popular drugs bevacizumab, ranibizumab, and aflibercept can help with CSCR, the results are not definitive.
Possible treatments facing issues due to high cortisol levels include the antifungal drug ketoconazole, the abortion drug mifepristone (RU-486), the anti-androgen finasteride, and the diuretic eplerenone, although these require further study in relation to CSCR treatment.
The drug rifampicin, used to treat tuberculosis, helps to break down steroids in the body and can aid in treating CSCR. However, it has to be used with caution due to potential liver damage.
Beta-blockers like metoprolol have shown some improvement in CSCR patients with high blood pressure, but the actual role of these drugs in treating the condition needs further research.
Lastly, management of Helicobacter pylori-related peptic ulcer disease has shown varied effects in CSCR. Nonetheless, looking for signs of peptic ulcer disease in patients with chronic CSCR can help in its management.
What else can Central Serous Chorioretinopathy (Fluid Behind the Retina) be?
There are other conditions that affect the retina and choroid, the layers of tissue at the back of the eye, which can have similar symptoms to Central Serous Chorioretinopathy (CSCR). These include Age-Related Macular Degeneration (ARMD), Idiopathic Polypoidal Choroidal Vasculopathy (IPCV), and optic disc pit related macular changes. ARMD is typically found in patients over 50, and chronic CSCR can evolve into this condition following laser treatment or during examination.
Tests called OCT angiography and EDI OCT can help doctors distinguish between these conditions. These can show characteristics like a thick or thin choroid, a layer of the eye affected in CSCR and ARMD. IPCV can create fluid-detached areas in the macula and changes in the RPE, two layers of the eye, similar to CSCR. But the presence of the polyp and branching blood network on an ICGA test is a key characteristic of IPCV.
An optic disc pit can also cause fluid detachment in the macula. Detailed examination of the eye can show an indentation or ‘pit’ on the temporal part of the optic disc. Another condition, retinal schisis, is commonly seen in optic disc pit but less frequently in chronic CSCR. The formation of a cavity under a layer in the retina (the internal limiting membrane) after haemorrhage or due to the disease Valsalva retinopathy may similarly mimic CSCR on a quick check-up.
What to expect with Central Serous Chorioretinopathy (Fluid Behind the Retina)
Most cases naturally get better by themselves within 3 to 6 months. However, some cases continue past 6 months and these long-term cases of CSCR need treatment. It’s also important to note that up to half of the cases that aren’t treated may come back.
Possible Complications When Diagnosed with Central Serous Chorioretinopathy (Fluid Behind the Retina)
If chronic Central Serous Chorioretinopathy (CSCR) isn’t treated, it can lead to serious complications. One possible complication is that CSCR with Pigment Epithelial Detachment (PED) could lead to a rip in the Retinal Pigment Epithelium (RPE) causing a secondary exudative retinal detachment. This means that the fluid accumulates under the retina and can cause vision loss. Sometimes, patients with this complication experience a sudden decrease in their vision. Other possible complications are Choroidal Neovascular Membrane (CNVM) and macular degeneration, both serious eye conditions which can also lead to vision loss. Sometimes, if a person has CSCR, they can develop a condition called diffuse retinal pigment epitheliopathy. This means damage to a layer in the back of the eye, which could result in irreversible vision loss.
Common Complications:
- Rip in the Retinal Pigment Epithelium (RPE) leading to secondary exudative retinal detachment
- Sudden decrease in vision
- Choroidal Neovascular Membrane (CNVM)
- Macular degeneration
- Diffuse retinal pigment epitheliopathy leading to irreversible vision loss
Preventing Central Serous Chorioretinopathy (Fluid Behind the Retina)
It’s important for the patient to be well-informed about the expected outcome of Central Serous Chorioretinopathy (CSCR). In cases where the cause is unknown, the recommended approach usually involves close monitoring and avoiding factors that could worsen the condition.
