Central Serous Chorioretinopathy (CSCR)

Overview

Epidemiology & Risk Factors

• Corticosteroid use (any route — oral, inhaled, nasal spray, topical skin creams, endogenous Cushing syndrome) — strongly linked
• Type A personality / psychological stress
• Systemic hypertension
• Pregnancy (women)
• Lupus (SLE)
• Helicobacter pylori infection
• Renal dialysis
• Sleep apnoea syndrome
• A SNP in the complement factor H gene (chromosome 1) predisposes to the chronic form in White individuals

Presentation

• Unilateral blurred or dim vision
• Metamorphopsia (distortion) and micropsia (objects appear smaller)
• Central scotoma
• Mild dyschromatopsia (faded colors)
• May be asymptomatic

• VA typically 6/9–6/18 (20/30–20/60); improves with a low-strength convex/plus lens (acquired hypermetropia from retinal elevation)
• Round or oval serous detachment of the neurosensory retina at the macula — sloping margins that merge gradually into the attached retina
• Subretinal fluid (clear or turbid); precipitates may be on the posterior retinal surface
• One or more depigmented RPE foci or small PEDs within the detachment
• FAF imaging reveals RPE atrophy/hyperplasia from prior episodes; gravitational tract visible in chronic cases

Fundus Appearance

Fundus photo: localized serous detachment of the neurosensory retina in the macula — Wills Eye Manual, Fig. 11.15.1

Investigations

1. Amsler grid — documents area of field distortion
2. Slit-lamp biomicroscopy — rule out concurrent CNV; examine optic disc for pit
3. OCT (enhanced-depth imaging) — gold standard for demonstrating subretinal fluid, PEDs, and choroidal thickening (pachychoroid)
4. IVFA (fluorescein angiography) — nearly pathognomonic "smoke-stack" pattern of dye leakage in 10–20% of cases; "ink blot" pattern in others
5. ICGA (indocyanine green angiography) — choroidal artery/choriocapillaris filling delays; multifocal hyperfluorescent patches in early phase
6. For chronic CSCR: systemic workup including cortisol levels and renal function

IVFA: classic "smoke-stack" pattern of dye leakage — Wills Eye Manual, Fig. 11.15.2

EDI-OCT: subretinal fluid (black cavity) and underlying choroidal thickening — Wills Eye Manual, Fig. 11.15.3

Course & Prognosis

Differential Diagnosis

• AMD — patient usually ≥50 years, drusen, often bilateral, may have CNV
• Optic pit — contiguous serous RD with the optic disc
• Rhegmatogenous retinal detachment / macular hole
• Choroidal tumor (hemangioma, melanoma)
• Hypertensive retinopathy
• PED — more distinct, elevated margins (may accompany CSCR or AMD)
• Uveal effusion syndrome, inflammatory choroidal disorders, chronic renal failure

Management

1. Observation

• First-line for acute CSCR — usually self-limited with good visual prognosis.

2. Stop Corticosteroids

• Discontinue all forms if possible (oral, topical, nasal, inhaled).

Key tip (Kanski): All forms of corticosteroid treatment should be discontinued in patients with chronic or recurrent CSCR.

3. Laser Photocoagulation

• May accelerate visual recovery but long-term benefit is unclear and may increase CNV risk.
• Consider when:
  • Detachment persists for several months
  • Recurrence with residual visual deficit
  • Contralateral eye involvement after a prior episode
  • Occupational necessity for prompt visual recovery

4. Photodynamic Therapy (PDT)

• Useful for chronic CSCR.
• Half-dose PDT may be considered for rapid SRF resolution in acute CSCR.

5. Mineralocorticoid Receptor Antagonists

• Eplerenone and spironolactone — associated with improved anatomic and visual outcomes in chronic CSCR.
• A 2025 meta-analysis (PMID: 40513762) specifically evaluated both agents for chronic CSCR.

6. Anti-VEGF Therapy

• If choroidal neovascularization (CNV) develops as a complication.