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Central Serous Retinopathy

Background

Central serous retinopathy is an eye condition where fluid accumulates underneath the retina causing distortion and visual loss. Patients are typically 20-50 years old and often complain of a sudden, painless loss of vision. This condition occurs 8-10 times more commonly in men than in women and is more common in Caucasians. It is felt that this may be a stress-related condition as it is more common in patients with “Type A” personalities, and can induced in rabbits and monkeys with IV injections of epinephrine.

Symptoms

Patients may be asymptomatic unless the central part of the retina (macula) is affected. In these cases, they note decreased or blurred vision, distortion (metamorphopsia), micropsia (small image size), and abnormal color vision (dyschromatopsia). Visual acuity can range from 20/20 to 20/200.

Fundus Appearance

Clinically, there is a localized retinal elevation (detachment). There may also be a detachment of the outermost layer of the retina called retinal pigment epithelium (RPE). There may be some small yellow spots in the area of detachment. There may be other areas with changes in pigmentation which are believed to correspond to previous CSR episodes.

Diagnostic Testing

Fluorescein Angiography

Fluorescein angiography is a diagnostic test in which intravenous fluorescein dye is administered and photographs are taken of the eyes. In central serous retinopathy, the angiogram typically shows an early spot of hyperfluorescence (site of leakage) with expansion into the area of serous detachment. Late in the test, dye accumulates beneath the retinal detachment but does not go beyond its borders. Most cases show one leakage point.

Fluorescein angiogram of a patient with CSR who shows one leakage point away from the fovea. This person shows the classic “smokestack” appearance due to leakage of dye into the larger area of retinal elevation. Note the large and round, area of faint hyperfluorescence in the lower two photos which represents the total area of retinal elevation.

Optical Coherence Tomography (OCT)

OCT is an excellent diagnostic test which clearly demonstrated the serous detachment, especially when the serous detachment is shallow. Some cases even show the RPE defect felt to be the leakage point.

OCT of a patient with CSR who shows an area both RPE and retinal detachment due to central serous retinopathy.
OCT of a patient with CSR who shows a more pronounced area of retinal detachment due to central serous retinopathy.

Management

For most patients, observation is all that is necessary. If possible, steps to reduce external stressors should be taken. In addition, we advise patients to avoid corticosteroids if possible, as they can worsen the disease.

Laser Treatment

Historically, ruby laser photocoagulation at site of leakage was found to accelerate resolution but did not result in a better visual acuity, and did not reduce the rate of recurrence. More recently, Burumcek et al. treated patients with non-resolved serous detachments after 4 months due to CSR. They found that treated eyes had shorter duration of serous detachment and better final visual acuity. There were no recurrences in laser group, and 7 in control group. While this study has received criticism due to its retrospective, nonrandom design, we generally treat patients who meet with the following characteristics:

  • A non-resolving serous detachment for at least two months
  • A site of leakage away from the foveal center
  • An occupational need for expedited visual recovery

Prognosis

Fortunately, spontaneous visual recovery is the very common. Approximately 40-50% will recover in less than 6 weeks. This number increases to 80-90% within 6 months. 94% of eyes will regain 20/30 visual acuity or better, but some patients may still have minor persistent visual complaints. It is very rare to have a patient with < 20/200 vision. This is a condition that may recur. As many as 40-50% of patients will have one or more recurrences, which can occur many years later. About 10% of patients will have 3 or more episodes.

OCT of a patient with CSR who underwent laser photocoagulation. The top image is before treatment and the bottom one is about 5 months after laser.