for post graduates

1. CENTRAL SEROUS
CHORIORETINOPATHY
DR. K VASANTHA M.S., F.R.C.S.
Director RIO Chennai (Rtd)

2. • Central serous chorioretinopathy (CSC) also
called as central serous retinopathy (CSR) is an
idiopathic macular serous detachment.
• First described by von Graefe
• Maumenee described the leakage through
RPE
• Gass suggested that CSR be named as CSC

3. • Common in young middle aged males
• Type A personality
• H/O migraine, hypochondria, hysteria,
conversion reactions
• After organ transplants
• Pregnancy
• Elevated levels of corticosteroids (Cushing’s)

4. • H.pylori infection
• Drugs like sorafenib, vermurafenib used in
malignancies
• Obstructive sleep apnea and increased
sympathetic activity
• Lupus erythematosis – due to choroidal
ischemia
• End stage renal disease

5. Symptoms
• Decreased vision
• Metamorphopsia
• Micropsia
• Central positive scotoma
• Prolonged after images

6. Symptoms
• Visual loss is often minimum and can be
improved with convex lenses.
• Near vision will be affected
• So if an young patient complains of sudden
loss of near and distant vision along with
positive scotoma think of CSR

7. Signs
• Serous detachment of retina at the macula
• Often with serous RPE detachment
• Subretinal precipitates
• RPE atrophic tracts
• Retinal and RPE detachments in other
quadrants
• RPE atrophy

8. Edema at the macula
• Well delineated edema around the fovea.
• Bright light will form a circle around the
fovea
• Around 2 disc diameter in size

9. RPE detachment
• Detachment of RPE is seen as an yellowish or
yellowish grey spot ¼ disc D in size
• Well demarcated with a dark halo
• Often seen above the fovea within the serous
detachment
• Atypical CSC multiple bullous retinal and RPE
detachments will be seen.

10. Sub retinal precipitates
• Fibrin deposits – a. white, multiple dots in the
inner surface of the retinal detachment
• b. diffuse grey white sheets which may lie on an
area of leakage. In OCT if you see a clear area in
the center of this sheet, that is the leaking spot.
• Sub retinal lipid deposits – discrete, clear cut at
the edge of the detachment.
• Central yellow spot is ? due to increased
xanthophyll activity.

11. Extra macular RPE atrophic tracts
• Rare
• Usually seen in lower quadrants
• May lead on to RD
• RPE atrophy denotes previous deachments
which have healed.

12. F.F.A
• A leak will cause dot like hyper fluorescence
which fills the detached area.
• Smoke stack type is rare. Due to convection
currents and pressure gradients between sub
retinal fluid and the dye the dye goes up and
spreads. Rare
• Pressure gradient may be due to difference in
the protein concentration.

13. F.F.A
• Often only a minimally enlarging spot like
leak is seen.
• A leak can be higher up, the gravity bringing
the fluid down
• If a leak is not seen it means it has healed.
These cases will regain vision in weeks.

14. F.F.A
• Rarely more than one leak may be seen
• Usual location is supero nasal to fovea and
within one mm
• Granular hyperflourescence at the level of
RPE- chronic CSR

15. • Indo cyanine green angiography shows
choroidal hyper permeability.
• OCT – wavy RPE in infection associated
conditions.
• Thickening of choroid in the uninvolved eye
also.

16. Course
• Heals in three to four months
• Recurrences can occur even after years
• In recurrences the leak occurs with in one
mm of the previous leak.

17. Complications
• Rare
• RPE atrophy
• RD if peripheral tracts were present
• Choroidal thickening
• Choroidal neovascularisation
• Damage to photo receptors – reduced vision

18. Patho physiology
• Epinephrine mediated vasospasm which is
increased by cortico steroids ( psychogenic?)
• This leads on to increased vascular
permeability of choroidal vessels and
ischemia.
• Increased oncotic pressure in the choroid
causes RPE rip and dysfunctions – barrier is
compromised

19. D.D
• Retinal hole – macular hole in myopia
• Peripheral hole
• Optic pit – here the fluid collection is intra
retinal
• Sequelae of trauma or surgery esp. retinal
surgeries
• Sarcoidosis- will show a granuloma

20. D.D
• Infections and inflammations
• Posterior scleritis – pain, ultra sound showing
scleral thickening, intra ocular inflammation
• Sympathetic ophthalmia, VKH, collagen
vascular disorders.
• Retinal pigment epithelialitis. After healing
may show RPE changes which can resemble
resolved CSR

21. D.D
• Idiopathic uveal effusion syndrome which can
start as macular edema
• Malignant hypertension, toxemia
• AMD – here also RPE detachment can occur
but no leakage, old age
• Best disease, leukaemia with choroidal
infiltration, multiple myeloma
• Idiopathic polypoidal choroidal vasculopathy

22. D.D
• Disseminated intra vascular coagulopathy
• Benign lymphoid hyperplasia of choroid
• Presumed ocular Histoplasmosis syndrome

23. Treatment
• Anti mineralocorticoids like Spiranolactone
and Eplerenone
• Rifampin accelerates the metabolism of
steroids
• Melatonin inhibits steroids
• Aspirin reduces the level of plasminogen
activator inhibitor

24. • Anti VEGF not useful
• Sub threshold micropulse laser can be
applied even over the fovea. This reduces
cytokines and hence the inflammation.
• P.D.T for juxta foveal and sub foveal serous
PED. This causes narrowing of chorio
capillaries, there by reducing the leak.

25. • Direct laser treatment to the leakage
shortens the course of CSR.
• Done only when the vocation demands it,
one eyed patients, recurrences
• Lesion atleast 500 microns away from the
fovea
• Can cause traction lines and CNV