Good Hope, Heartlands, and Solihull Eye Clinics

Central serous chorio- retinopathy (CSCR/CSR), Pachychoroid pigment epitheliopathy

David Kinshuck

Introduction

CSCR is described here. It was previously termed central serous retinopathy (CSR), and a new name in Europe is Pachychoroid pigment epitheliopathy. Essentially a little blister of fluid develops under the retina. The fluid develops but then usually disappears itself leaving a tiny scar. Occasionally later more blisters form and the further scars reduce the vision. The cause of CSCR is not known. In some patients stress seems to play a part. CSCR is commoner in males of young adult/middle age, with darker skin.

Sometimes the blister 'CSCR' occurs by itself, but sometimes in the middle of the blister there is also a tiny blister of the pigment epithelial layer underneath, causing a pigment epithelial detachment (PED), as in the photo and diagram below. Autofluorescence and OCT are helpful Eye16.

central serous retinopathy with a pigment epithelial detachment

A CSCR with a PED

Technically, such PEDs (pigment epithelial detachments) are likely to be smaller than 1 disc diameter. Larger PEDs may be CSCR. However, especially in older patients, they may be part of ARMD (age-related macular degeneration) with CNV (wet ARMD). The condition seems linked to  a thicker choroid, the layer under the retina, and is now believed to be one of the 'Pachychoroid Diseases of the Macula' see 2014. Fluid may accumulate in the choroid AJO 15

An area of CSCR tends to cause dimmer vision. If scarring does follow, then the sight is permanently reduced. Substantial vision problems are uncommon (5%).

Risk factors Retina16 "The authors concluded that hypertension, H. pylori infection, steroid usage, sleeping disturbance, autoimmune disease, psychopharmacologic medication use, and Type-A behavior were possible risk factors relating to the occurrence of CSCR"

Stress may contribute..try and reduce stress

  • reduce working hours
  • yoga, tai chi, going out with friends, regular exercise (e.g. walking/swimming etc)
  • shift work increases problems AJO 16
  • sleep apnoea Retina 18
  • complement JAMA 18

Steroids (such as steroid tablets used to treat many conditions) can increase/contribute to CSCR. Check there is no steroid use, e.g. using cream for eczema, or Cushings disease. Steroid in any form fer atopy may contribute Allergy15. Even a partner using steroid creams, or a child in the family, might be relevant. The increase choroidal thickness Retina 17

The duration of the episode  Retina 17.  An OCTa or autofluorescence will identify atrophic changes and indicate the prognosis. If there are a lot of changes, PDT laser or other treatment will not improve sight. IJO17   2014

CSR with atrophy

A CSCR with a neurosensory detachment, but no PED

 

CSR with flat iregular PEDs (pigment epithelial detachments)

  • These have a 30% risk of CNV  as seen with OCTa  Eye 18
  • commoner in patients ~55y
  • Retina 18    

Treatment of CSCR

There are other treatment that are not in general use:

  • anti-steroid drugs such as ketoconazole may also be helpful, but these have been replaces with Eplerenone.  Mifepristone Retina 2011     spironolactone Eye 15  Finasteride  Eye 16         Testosterone,
  • subthreshold laser Retina 2013     Retina 17   Eye 2012   Eye 18
  • Avastin or anti-VEGF drugs are not likely to be helpful Eye 13   anti-VEGF  more
  • treatment of heliobacter may help 2011  It has been suggested that GPs test patients for H. pylori infection and treat it if its present (we know of 2 cases successfully treated (there were the only 2 tested positive for H Pylori).
  • betablockers may help (one case Nottingham 2011)
  • very light laser Eye18   guided by FFA

Related features

Patient 1

  • age 45, male (Asian...more common in Asian patients)
  • 6/9 vision, variable, with headaches (eye strain)
csr with a small ped

July..a shallow ped shown; more symptoms enlarge

April...no PED visible in this cut
(other cuts did demonstrate 2 small peds)

 
 
 

 

Patient 2

 

  • age 44, male 6/36, vision
  • the increase in fluid is 'acute'; the atrophic patch is chronic and long-standing
  • no treatment offered at this stage, will consider PDT if no better in 3 months

CSR with atrophy

November 2012, diplopia 3 months, and patient finding it difficult to cope  enlarge

May 2012...vision 6/36 but stable

CSR with neurosensory detachment

 

 

 

blue circle=atrophic area, long-standing, due to previous chronic CSCR damage

 

yellow circle=subretinal fluid, which has increased in the last 3 months

 

 

 

 

Patient 3

  • age 44, female 6/12, vision
  • lots of stress
  • 4 months later, a little improved

CSR, subretinal fluid, femal patient, lots of stress

April 2013, less fluid, sight a little better (no treatment given)  enlarge

Jan 2013, greyish vision

 

 

 

Patient 4

  • age 63, male 6/12, vision, minor distortion on Amsler, labelled CSCR, no symptoms

probable CSR

2 PEDs (pigment epithelial detachments) : appearance of CSCR, but some older patients may have early ARMD enlarge

 

Patient 5

Case

  • bilateral macula pigmentary changes with atrophy
  • patient had Cushing's