2. OVERVIEW
• Central serous chorioretinopathy (CSR) is an idiopathic disorder characterized by a
localized serous detachment of the sensory retina at the macula secondary to
leakage from the choriocapillaris through one or more hyperpermeable RPE sites.
• CSR typically affects one eye of a young or middle-aged white man. The male to
female ratio is 3 : 1; females with CSR tend to be older.
3. • It presents in two forms: acute (self-resolving within 3–6 months) and chronic.
A SNP involving the compliment factor H gene on chromosome 1 predisposes to
the chronic form of CSR in whites.
• The use of steroids in any form (including endogenous Cushing syndrome) is
significantly linked to this condition. Numerous other risk factors and associations
have been reported (including Helicobacter pylori infection, renal dialysis, systemic
hypertension, psychological stress, pregnancy and sleep apnoea syndrome).
4. CLINICAL FEATURES
• Symptoms
○ Unilateral blurring, metamorphopsia, micropsia and mild dyschromatopsia.
• Course
○ Spontaneous resolution within 3–6 months, with return to near-normal or normal
vision in around 80%.
○ Recurrence is seen in up to 50%.
○ Some patients (about 15%) follow a chronic course lasting more than 12 months.
6. ○ Prolonged detachment is associated with gradual photoreceptor and RPE
degeneration and permanently reduced vision. Multiple recurrent attacks may also
give a similar clinical picture.
○ CMO, CNV or RPE tears develop in a small minority.
• Bullous CSR
○ characterized by large single or multiple serous retinal and RPE detachments.
7. • Signs
○ VA is typically 6/9–6/18, but may improve with a low strength convex lens
(correction of acquired hypermetropia from retinal elevation).
○ Round or oval detachment of the sensory retina at the macula .
○ The subretinal fluid may be clear (particularly in early lesions) or turbid.
may be present on the posterior retinal surface.
9. ○ One or more depigmented RPE foci (often small PEDs) of variable size may be
visible within the neurosensory detachment. Small patches of RPE atrophy and
hyperplasia elsewhere in the posterior pole may indicate the site of previous
lesions and are typically seen easily on FAF imaging.
○ Chronic lesions may be associated with substantial underlying atrophic change.
Fluid can sometimes track downwards in a gravity-dependent fashion (gravitational
tract), best shown on FAF imaging and can occasionally progress to bullous CSR.
○ The optic disc should be examined to exclude a congenital pit as the cause of a
neurosensory detachment.
10. INVESTIGATION
• Amsler grid
• Confirms metamorphopsia corresponding to the neurosensory detachment.
• OCT
• An optically empty neurosensory elevation.
• Other findings may include one or more smaller RPE detachments , precipitates on the posterior surface of
detached retina and thickened choroid.
• Degenerative changes may be seen in chronic or recurrent cases.
• FA
• An early hyperfluorescent spot that gradually enlarges (an ‘ink blot’ ( or, less commonly, forms a vertical
column (‘smokestack’ ( followed by diffusion throughout the detached area.
• An underlying PED may be demonstrated.
• Multiple focal leaks or diffuse areas of leakage can be evident, particularly in chronic or recurrent disease.
13. FFA in CSR showing " smoke stalk " appearance.
14. • FAF
• A focal decrease in fundus autofluorescence at the leakage site and at sites of
old lesions .
• A gravitational tract is sometimes seen.
• ICGA
• The early phase may show dilated or compromised choroidal vessels at the
posterior pole and the mid-stage areas of hyperfluorescence due to choroidal
hyperpermeability.
• Subclinical foci are commonly visible.
16. MANAGEMENT
• Observation is appropriate in many cases. All treatment modalities can be associated with
RPE tear formation, which can also occur spontaneously.
• Oral spironolactone (40 mg twice daily) results in faster resorption of subretinal fluid than
no treatment in acute CSR.
• Corticosteroid treatment should be discontinued if possible, particularly in chronic,
recurrent or severe cases.
√ X
17. • Laser
• Subthreshold (micropulse) diode laser to the RPE site of leakage has shown good
results in several studies and is associated with significantly less retinal damage on
OCT than conventional photocoagulation.
• PDT
• At 30–50% of the dose used for CNV in conjunction with 50% light intensity typically
leads to complete resolution, including in severe chronic cases and is associated
with a considerably lower incidence of significant choroidal ischaemia than
higher-intensity regimens.
19. • Intravitreal anti-VEGF agent
• Are commonly used in conjunction with PDT.
• Others
• Case reports show benefit with a variety of agents including aspirin, beta-blockers,
mifepristone and eplerenone, but controlled assessment is limited to date.
