Central Serous Chorioretinopathy

What is central serous chorioretinopathy?

Central serous chorioretinopathy (CSC) is a condition in which fluid collects under the retina, causing distorted vision. This fluid is thought to leak from an underlying tissue with many blood vessels called the choroid. That is why you will also find it called central serous retinopathy or chorioretinopathy. Another layer, called the retinal pigment epithelium, is responsible for preventing fluid from leaking out of the choroid. In some cases, however, and for unknown reasons, a malfunction in this area leads to fluid building up under the retina.

Page contents

1. What is central serous chorioretinopathy?
2. What causes central serous chorioretinopathy?
3. What are the main symptoms?
4. How is it diagnosed?
5. What is the right treatment?
6. How a person with central serous chorioretinopathy sees
7. Who is at increased risk
8. Acute and chronic forms
9. The tests that are needed
10. Treatment options in detail
11. What you can do yourself
12. Prognosis: will I see well again?
13. When you need an urgent examination
14. How to check your vision with the Amsler grid
15. Central serous chorioretinopathy or macular degeneration?
16. Central serous chorioretinopathy in pregnancy
17. Work, driving and daily life
18. Coffee, diet and supplements
19. Questions worth asking your ophthalmologist
20. Why stress plays such an important role
21. Recurrences: what to expect
22. The examination at the clinic step by step
23. Frequently Asked Questions about Central Serous Chorioretinopathy

It is a disease that occurs most often in men aged 20 to 45, although it appears to be more common than we thought in women and in people over 45. It is also more common in people with high-stress jobs and in particularly demanding personalities. Finally, it has been linked to the use of steroids for medical or other purposes.

What causes central serous chorioretinopathy?

The exact cause is not fully known. Today it is thought that the blood vessels of the choroid, the vascular layer beneath the retina, become more permeable and swollen. Fluid passes through a weak point in the retinal pigment epithelium and collects under the macula.

The factors most closely linked to its development are:

• Corticosteroids in any form: tablets, injections, inhalers, nasal sprays, even skin creams. This is the clearest causal factor.
• Psychological stress and a type A personality, probably through raised cortisol levels.
• Sex and age: it is more common in men aged 30 to 50.
• Pregnancy, mainly in the last trimester.
• Sleep apnoea, high blood pressure and increased cortisol production by the body.
• Helicobacter pylori infection, according to some studies.

If you are taking cortisone for another health problem, do not stop the treatment yourself. Tell the doctor who prescribed it, so they can assess whether it can be adjusted.

What are the main symptoms?

The symptoms of CSC are usually blurred vision, metamorphopsia (distorted vision) or a darker area in part of the visual field. There may also be no symptoms at all if the centre of the macula has not been affected.

In most patients (about eight in ten) the fluid is absorbed without treatment within the first 6 months, while vision may continue to improve for up to a year afterwards. However, one third of these patients will have a recurrence at some point in their lives.

How is it diagnosed?

Diagnosis starts with the medical history, with emphasis on cortisone use and stress levels, and with measuring visual acuity. This is followed by:

• Dilated fundus examination, which shows the round area of fluid at the macula.
• Optical coherence tomography (OCT), the key test. In a few minutes and without contact, it shows the fluid under the retina and the thickness of the choroid, and at every follow-up it records the course of the disease.
• Fluorescein angiography or indocyanine green angiography, when the leakage point needs to be located, mainly before laser treatment or photodynamic therapy.
• OCT angiography, to rule out the development of new blood vessels, mainly in the chronic form.

The Amsler grid helps patients monitor any changes at home. Diagnosis also requires distinguishing CSC from conditions with a similar appearance, such as wet macular degeneration, which is particularly important in patients over 50.

What is the right treatment?

Treatment of central serous chorioretinopathy is initially conservative. This means that we do not intervene but monitor how it progresses. If there is no improvement, or if there is another reason to intervene, the options involve two types of laser. The first is a non-damaging micropulse laser that does not cause scarring of the retina. The second involves activating a light-sensitive substance with a laser. In Oxford I had the pleasure of taking part in the first international multicentre study comparing these two treatment options and of carrying out treatments as part of the study. Its results have not yet been published but are awaited with great interest.

How a person with central serous chorioretinopathy sees

Central serous chorioretinopathy is caused by fluid collecting under the macula, the centre of the retina responsible for sharp vision. The fluid “lifts” the retina like a small blister and the image becomes distorted. Patients usually describe:

• a blurred or dark spot in the centre of their vision, as if looking through a dirty window
• straight lines that look bent or wavy, such as door frames or the lines of a tiled floor
• objects that look smaller or further away than they really are
• faded colours and reduced contrast
• a sudden need for glasses or difficulty reading, because the eye temporarily becomes more long-sighted
• slow adjustment when moving from light to dark

Usually one eye is affected. Patients often notice it by chance, when they close the healthy eye.

Who is at increased risk

• Men aged 30 to 50: the condition is several times more common in men of this age.
• Use of cortisone in any form: tablets, injections, asthma inhalers, nasal sprays, ointments and skin creams. This is the most important known risk factor.
• Intense or prolonged stress and a competitive, anxious lifestyle.
• Pregnancy, usually in the third trimester, with spontaneous resolution after delivery in most cases.
• Sleep disorders, such as obstructive sleep apnoea.
• Certain medicines and stimulants that affect circulation at the back of the eye.
• High blood pressure and other hormonal disorders, such as Cushing’s syndrome.

If you are taking cortisone, do not stop it yourself. Stopping or changing the treatment must be done in agreement with the doctor who prescribed it.

Acute and chronic forms

In the acute form there is a single leakage point and the fluid is usually absorbed on its own within two to three months, with very good recovery of vision. In the chronic form the fluid remains for more than three to six months or comes back frequently. The prolonged presence of fluid can damage the light-sensitive cells and the retinal pigment epithelium, causing permanent loss of vision. That is why the chronic form needs active treatment.

The tests that are needed

• Optical coherence tomography (OCT): shows the fluid under the retina and the thickness of the choroid in exceptional detail. It is the key test for diagnosis and follow-up.
• Fluorescein angiography: locates the point or points from which the fluid is leaking, information that is essential for laser treatment.
• Indocyanine green angiography: reveals changes in the blood vessels of the choroid, especially in the chronic form.
• Fundus autofluorescence: shows whether the retinal pigment epithelium has already been damaged.

Treatment options in detail

Monitoring

In a first episode without serious loss of vision, we usually monitor with OCT for about three months, since in many patients the fluid is absorbed on its own. At the same time we address the risk factors, such as cortisone, sleep and stress.

Photodynamic therapy

In the chronic or persistent form, reduced-dose photodynamic therapy is one of the most effective options. A light-sensitising medicine is given intravenously and the affected area is then illuminated with a special low-energy laser. The treatment reduces the permeability of the choroidal blood vessels and helps the fluid to be absorbed.

Laser

When the leakage point is far enough from the centre of the macula, it can be sealed with conventional thermal laser. There are also micropulse laser techniques that do not cause visible damage to the retina and are used in selected cases.

Medication

Oral medicines, such as mineralocorticoid antagonists, have been tried. Studies have shown mixed results, so their use is considered on an individual basis. If neovascularisation develops, a rare complication of the chronic form, it is treated with intravitreal injections.

What you can do yourself

• tell your ophthalmologist about every medicine you take, especially creams, sprays and inhalers
• make sure you get enough regular sleep
• find ways to manage stress, such as exercise, walking and breaks from work
• check your vision with the Amsler grid, looking with each eye separately
• keep your OCT follow-up appointments, even if you feel your vision has improved

Prognosis: will I see well again?

In the acute form the prognosis is very good. The great majority of patients recover their vision almost completely within a few months. Some notice small permanent changes, such as slightly reduced contrast or colour perception. About one in three patients will have a new episode in the future, which is why follow-up and avoiding risk factors are so important. In the chronic form, early treatment protects vision from permanent damage.

When you need an urgent examination

Any sudden change in central vision, such as a blurred spot, bent lines or a change in the size of objects, needs an eye examination without delay. The same symptoms can be caused by other macular conditions, such as macular degeneration, which need different and urgent treatment.

Dr. Vasileios Skouteris, who specialised in retinal diseases at Oxford University Hospitals, diagnoses and treats central serous chorioretinopathy at his practice in Neo Psychiko, Athens. To book an appointment, call +30 210 677 0007.

How to check your vision with the Amsler grid

The Amsler grid is a simple square of straight lines with a dot in the centre. It helps you notice a recurrence or a change in your central vision early. The check is done as follows:

1. hold the grid at reading distance, about 30 to 35 centimetres away, in good light and wearing your reading glasses
2. cover one eye
3. look steadily at the central dot
4. notice whether all the lines look straight, whether all the squares are the same size and whether any area is missing or blurred
5. repeat with the other eye

If you notice new curves, shadows or gaps, contact your ophthalmologist. Comparing with the previous time is more important than how the grid looks on any one day.

Central serous chorioretinopathy or macular degeneration?

Both conditions affect the macula and cause similar symptoms. However, they differ significantly. Central serous chorioretinopathy occurs mainly in younger adults, often during a period of stress or cortisone use, and usually resolves. Age-related macular degeneration mainly affects people over 55 to 60 and, in its wet form, needs immediate treatment with injections. In older patients the distinction can be difficult, which is why imaging with OCT and angiography is decisive.

Central serous chorioretinopathy in pregnancy

The hormonal changes of pregnancy, especially in the last months, can cause central serous chorioretinopathy even in women with no other risk factors. In most cases the fluid is absorbed on its own within a few months of delivery. During pregnancy we avoid treatments such as photodynamic therapy and limit ourselves to monitoring with OCT, which is completely safe.

Work, driving and daily life

In the weeks when there is fluid under the macula, reading and screen work can be tiring, because the image in the affected eye is distorted. Usually the other eye “takes over” and most patients carry on with their activities. It helps to increase the text size on screen and take breaks. Take care when driving, especially at night, and if the vision in your other eye is not good, discuss it with your doctor.

Coffee, diet and supplements

Many patients ask whether they should give up coffee. Caffeine affects circulation and some studies link it with the condition, but the evidence is not clear. A sensible approach is to limit it to moderate amounts while there is active fluid. There is no special diet or supplement that cures central serous chorioretinopathy. A balanced diet, exercise and good sleep help indirectly by reducing stress on the body.

Questions worth asking your ophthalmologist

• Is this the acute or the chronic form?
• Do I need treatment now or can we wait?
• Could any of the medicines I take be related?
• How often should I have an OCT scan?
• Is there anything in the other eye that we need to monitor?

Why stress plays such an important role

The link between central serous chorioretinopathy and stress is no coincidence. During periods of intense stress, the body increases its production of cortisol and adrenaline. These hormones affect the blood vessels of the choroid, the vascular layer beneath the retina, making them more permeable. This allows fluid to pass under the macula. Many patients report that the episode appeared during a particularly demanding period, such as a change of job, a family matter or weeks of little sleep.

Managing stress is therefore not just general advice but an essential part of treatment and prevention. Regular physical exercise, consistent sleep, breaks at work and, where needed, support from a mental health professional help reduce recurrences.

Recurrences: what to expect

After a first episode, the same eye or the other eye may have a new episode in the following years. Recurrences are more common when the risk factors continue. A new episode does not necessarily mean a worse prognosis, but repeated or long-standing fluid increases the risk of permanent damage. That is why, in patients with frequent recurrences, we discuss active treatment earlier.

The examination at the clinic step by step

At the first visit we start by measuring vision and refraction, because the condition often causes a small change in the glasses prescription. This is followed by examination of the macula with the slit lamp after dilating the pupil, and optical coherence tomography, which takes a few minutes and is completely painless. If the leakage point needs to be located or a chronic form is suspected, angiography is scheduled. Because the dilating drops blur your vision for a few hours, it is best to come with someone or not to drive straight afterwards.

At follow-up visits the OCT is repeated to compare the amount of fluid. This comparison determines whether we continue monitoring or whether it is time for treatment.

Early examination and proper follow-up are the best way to protect your central vision.

If you are worried about any change in your central vision, do not wait for it to pass on its own. A short OCT examination gives answers on the same day.

Frequently Asked Questions about Central Serous Chorioretinopathy

Medically reviewed by: Dr. Vasileios Skouteris MD, FEBO