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.
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
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
- Generally no treatment is needed, the condition is mild and it gets
better itself after about 2 months.
- For more persistent cases, for instance when the fluid and visual
disturbance has been present for more than 6 months then PDT laser treatment
- Eplerenone Retina17 EJO 15 Eye 18 Spironolactone BJO 18
- focal laser to peds BJO 18
There are other treatment that are not in general use:
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
- age 45, male (Asian...more common in Asian patients)
- 6/9 vision, variable, with headaches (eye strain)
July..a shallow ped shown; more symptoms enlarge
April...no PED visible in this cut
(other cuts did demonstrate 2 small peds)
- 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
November 2012, diplopia 3 months, and patient finding it difficult to cope enlarge
May 2012...vision 6/36 but stable
blue circle=atrophic area, long-standing, due to previous chronic CSCR damage
yellow circle=subretinal fluid, which has increased in the last 3 months
- age 44, female 6/12, vision
- lots of stress
- 4 months later, a little improved
April 2013, less fluid, sight a little better (no treatment given) enlarge
Jan 2013, greyish vision
- age 63, male 6/12, vision, minor distortion on Amsler, labelled CSCR, no symptoms
2 PEDs (pigment epithelial detachments) : appearance of CSCR, but some older patients may have early ARMD enlarge
- bilateral macula pigmentary changes with atrophy
- patient had Cushing's