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This is a condition of unknown cause in which fluid accumulates between the retina and its underlying layer, the retinal pigment epithelium, in the central macula and leads to distortion and blurred vision noted by the patient. In normal ocular health, the cells of the retinal pigment epithelium act as tiny suction devices and hold the retina in place. In this condition, a disturbance causes the fluid to flow the opposite direction leading to separate of retina and localized retinal detachment. Sometimes, the fluid accumulates both under the retina and under the retinal pigment epithelium, but in each case, the same symptoms are seen by the patient. The term “central serous retinopathy” (CSR) is the most commonly used term for this entity, but a more accurate term reflecting its pathophysiology is “central serous chorioretinopathy” (CSC). We will use the term “central serous” for this discussion.
DEMOGRAPHICS AND CLINICAL PRESENTATION
The stereotypical patient with central serous is a hard-driving businessman in his 40s. 25 years ago, the gender ratio for this condition was about 10 men for every woman. At the present time, this ratio appears to be more close to 5:1. At least in a substantial number of patients, stress appears to play a role in inciting or aggravating the condition, and the changing demographics may represent a response to changes in the workforce. This condition can be seen in patients as young as age 20, but, in general, patients in their 30s and 40s are more typical. After the age of 50 or 55, the diagnosis is more difficult to make as there is a certain degree of overlap with age-related macular degeneration. We have seen patients who presented with very typical central serous who then later evolved to age-related macular degeneration, so the prognosis in older patients is somewhat different than younger or middle-aged patients.
DIAGNOSIS
It is not unusual for us to have a fairly good idea of the diagnosis before looking at the patient. This, in part, is based on the likelihood that a 40-year-old, healthy, highly energetic man has this condition and no other. Vision is usually close to normal or reduced somewhat by the fluid that has accumulated under the macula. A grayish spot can be seen by the examining physician while the patient reports fading to some degree of color vision as well as distortion and dimming of central vision. The cornerstone to us making a diagnosis is a test called fluorescein angiography. In this test, dye is injected into the patient’s vein, and this dye is observed as it circulates through the ocular vasculature. Leaks of a fairly typical nature can be seen and clinch the diagnosis. Often, areas of previous retinal pigment epithelial disruption can be visualized elsewhere in the same eye or in the macula of the unaffected eye. A second test that has become very useful in recent years is called “optical coherence tomography”. This allows us to see a cross-section of the back of the eye and can diagnose subtle areas of subretinal fluid that cannot be seen clinically.
While most patients have one affected eye only, some patients with an anatomic predisposition are at risk for multiple episodes in each eye and a very guarded visual prognosis over time. Patients with this situation are much more likely to be offered treatment. Other settings that can lead to this condition include the use of corticosteroids elsewhere. These drugs which are commonly used for other conditions can incite central serous to occur, particularly in women.
TREATMENT
In the typical patient with central serous, no treatment is needed. Most episodes of this condition are self-limited and resolve within 2-3 months. Simple reassurance to the patient that this will occur is beneficial. In some patients, the subretinal fluid persists for longer than this time period, and, in this setting, treatment is recommended. The usual method of treatment is to use thermal laser to damage the area of pigment epithelium that is actively pumping fluid into the subretinal space. Usually, this treatment is quite effective and can be very useful when the area of leakage is well away from the center of vision. Laser treatment is often recommended early in the course of central serous if it is a recurrent episode. A newer laser modality called “photodynamic therapy” can be utilized if the leaking area is too close to the center of vision. This procedure is not always covered by insurance.
PROGNOSIS
In the typical patient, visual recovery back to 20/20 is the norm, though patients can usually tell that their vision in the affected eye is not quite as good as the normal eye even long after the fluid has resolved. 4 out of 5 patients have an episode of central serous in one eye only. Approximately 25% of patients develop a recurrent episode. In these patients, laser treatment is recommended to be applied early in the course of the attack. As noted previously, in older patients, the possibility of this condition evolving into exudative macular degeneration is present and does make the prognosis for good vision long term somewhat guarded. Lastly, there is a subset of patients with significant retinal pigment epithelial abnormalities that are predisposed to attacks to episodes in both eyes, often simultaneously, and the prognosis in this group is much less optimistic, though with treatment many can maintain reading and driving vision.
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