Central Serous Retinopathy (CSR)

What happens in central serous retinopathy

The retina lines the back of the eye. Beneath it lies a pigment layer (the retinal pigment epithelium) and a blood-rich layer called the choroid. In CSR, the choroid becomes thickened and leaky, and the pigment layer develops a weak spot. Fluid seeps through and pools under the macula, forming a small dome-shaped detachment.

Because the macula is lifted, light is focused slightly "behind" it, which is why many people become a little more farsighted and see objects as smaller.

Symptoms

Usually in one eye:

• blurred or dim central vision
• a gray, brown or dark spot in the center
• straight lines looking wavy or bent (distorted vision)
• objects appearing smaller (micropsia) or farther away
• colors looking washed out
• reduced contrast and difficulty in dim light
• sudden need for stronger reading glasses

Side vision stays normal, and the eye is not red or painful.

Causes and risk factors

Types

• Acute CSR: a single episode lasting up to 3 to 4 months. Most resolve on their own.
• Recurrent CSR: further episodes in the same or other eye; up to half of people have a recurrence.
• Chronic CSR: fluid persisting over 4 to 6 months, or widespread pigment changes. This can cause permanent vision loss and, rarely, abnormal blood vessel growth.

Diagnosis

An eye doctor will check vision, use an Amsler grid (a square grid that shows distortion), and examine the retina after dilating the pupils.

• Optical coherence tomography (OCT): a quick, painless scan that shows fluid under the retina and a thick choroid. It is the main test for diagnosis and follow-up.
• Fluorescein angiography and indocyanine green angiography: dye tests that locate the leak and guide laser treatment.
• OCT angiography: checks for abnormal new blood vessels in chronic cases.

CSR must be told apart from wet macular degeneration, macular edema and other causes of fluid at the macula, which need different treatment.

Treatment

Watch and wait

For a first episode, doctors often observe for about 3 months, since most fluid resolves without treatment.

Remove triggers

• Review all steroid use with your doctors, including creams, inhalers, nasal sprays and injections. Do not stop prescribed steroids suddenly; some need to be tapered or replaced.
• Manage stress and improve sleep.
• Treat sleep apnea if present.

Treatments for persistent or recurrent CSR

• Photodynamic therapy (PDT): a light-activated drug (verteporfin), often at half dose or half fluence, that seals the leaky choroid. It is the most widely used treatment for chronic CSR.
• Thermal laser: seals a single leaking spot that lies away from the very center.
• Subthreshold micropulse laser: an option in some centers.
• Eplerenone or spironolactone: tablets that block a hormone receptor; a large trial found little benefit, so they are now used less.
• Anti-VEGF injections: used if abnormal new blood vessels develop.

Outlook

Most people with acute CSR recover good vision within a few months, though some notice subtle lasting changes in contrast, color or slight distortion. Recurrences are common. Chronic CSR can cause permanent damage to the central retina, so persistent cases should be treated rather than watched indefinitely.

Frequently asked questions

What causes central serous retinopathy?

CSR is caused by leakage from a thickened, overactive choroid under the retina. The strongest trigger is corticosteroid use in any form. Stress, being male and aged 30 to 50, pregnancy, Cushing syndrome and sleep apnea also increase risk.

Does central serous retinopathy go away on its own?

Often, yes. Most first episodes resolve without treatment within 1 to 4 months as the fluid is reabsorbed. Recurrences are common, and fluid that persists beyond 3 to 6 months is usually treated to prevent permanent vision loss.

Can stress cause central serous retinopathy?

Stress is a well-recognized risk factor. Stress hormones such as cortisol and adrenaline appear to make the choroid leaky. Many people develop CSR during periods of high stress, and managing stress may help prevent recurrences.

Can steroids cause central serous retinopathy?

Yes. Corticosteroids are the strongest known trigger, including tablets, injections, inhalers, nasal sprays and skin creams. If you develop CSR, tell all your doctors, but do not stop prescribed steroids suddenly without medical advice.

Can central serous retinopathy cause blindness?

CSR does not cause total blindness, because it affects only the central retina and side vision is preserved. Most people recover good vision. Chronic or repeated episodes can cause lasting loss of central sharpness, which is why persistent cases are treated.