Good Hope, Heartlands, and Solihull Eye Clinics

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

David Kinshuck

Introduction

CSC is described here. It was prveiously termed central serous retinopathy (CSR), and a new name iin 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 CSC is not known. In some patients stress seems to play a part. CSC is commoner in males of young adult/middle age, with darker skin.

Sometimes the blister 'CSC' 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 CSC with a PED

Technically, such PEDs (pigment epithelial detachments) are likely to be smaller than 1 disc diameter. Larger PEDs may be CSC. However, especially in older patients, they may be part of ARMD (age-related macular degeneration) with CNV (wet ARMD). The condition seems linked t  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 CSC tends to cause dimmer vision. If scarring does follow, then the sight is permanently reduced. Substantial vision problems are uncommon (5%).

CSR with atrophy

A CSC with a neurosensory detachment, but no PED

 

Treatment of CSC

  • Generally no treatment is needed, the condition is mild and it gets better itself after about 2 months.
  • Eplerenone Retina17
  • Avastin or anti-VEGF drugs are not likely to be helpful Eye 13 
  • For more persistent cases, for instance when the fluid and visual disturbance has been present for more than 6 months then treatment may help:
  • anti-steroid drugs such as ketoconazole may also be helpful, but these are very experimental. Ketoconazole has to be given in the anti-steroid dose level, a dose higher than the regular anti-fungal dose. Such a high dose may cause liver problems, increasing liver enzymes, so these have to be monitored. See reports: helpful 600mg   not helpful 200 mg od      Mifepristone Retina 2011    Eplerenone....EJO 15
  • so anti-testosterone drugs may help, no proof yet Finasteride  Eye 16         Testosterorone,
  • treatment of heliobacter may help 2011
  • betablockers may help (one case Nottingham 2011)
  • Subthreshold fluorescein angiogram targeted laser to the leaky areas helps (although often more than one treatment is needed) Eye 2012
  • foveal thinning  Retina 2013; choroidal thickening Retina 2013
  • steroids (suh as steroid tablets used to treat many conditions) can increase/contribute to CSC. Check there is no steroid use, eg 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.
  • 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 CSC"
  • 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)
  • Stress may contribute..try and reduce stress
    • reduce working hours
    • yoga, tai chi, going out with friends, regular exercise (eg walking/swimming etc)
    • shift work increases problems AJO 16
  • spironolactone Eye 15
  • some PEDs have cnv AJO 16
  • genes Retina 16
  • CSR is related to choroidal thickness  Eye 16     Steroids increase Retina 17.

Small print

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 CSC 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 CSC, no symptoms

probable CSR

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

 

Patient 5

Case

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