Published in Retina

Step Up Your Game: Central Serous Chorioretinopathy and the Pachychoroid Spectrum

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7 min read

Join Daniel Epshtein, OD, FAAO, and Joseph Pizzimenti, OD, FAAO, FORS, FNAP, to review central serous chorioretinopathy and its link to the pachychoroid spectrum.

In the sixth episode of Clinical Conversations in Retina, Daniel Epshtein, OD, FAAO, and Joseph J. Pizzimenti, OD, FAAO, FORS, FNAP, professor at the Rosenberg School of Optometry and past president of the Optometric Retina Society, discuss central serous chorioretinopathy (CSCR) and its diagnosis, treatments, and link to the pachychoroid spectrum.

Classifying central serous chorioretinopathy

The wide variety of phenotypic presentations of CSCR and the lack of a standardized nomenclature often make it difficult to precisely diagnose CSCR.
The ambiguity of various terms, such as acute, persistent, and chronic, can vary amongst different eyecare practitioners (ECPs) and various research groups.

Standardizing the classification of CSCR

The Central Serous Chorioretinopathy International Group was formed in order to outline a standardized method to classify CSCR and address some of the difficulties of CSCR diagnosis.1 This standardization clarifies the various expressions of CSCR that make it difficult to classify.
In practice, however, both Dr. Pizzimenti and Dr. Epshtein note that their clinical approach rarely adheres to the exact steps outlined by the group. The standardized method offers a clear clinical definition of CSCR, describing it as a focal detachment of sensory retina and/or the retinal pigment epithelium that is typically formed over thickened, dysfunctional choroid.
With its various phenotypes, CSCR is more of a family of diseases than one condition, states Dr. Pizzimenti.

Diagnosing patients with CSCR

Dr. Pizzimenti starts the diagnosis process with a thorough history of the patient, identifying any common risk factors of CSCR, including recent steroid use, past pregnancy, sleep apnea, and kidney/heart/bone marrow transplants. Testosterone and Saw Palmetto use are also potential risk factors that Dr. Pizzimenti takes into consideration.

Imaging modalities to identify CSCR

Next, a clinical exam can help identify any serous retinal detachments and pigmentary disturbances. This can be done through optical coherence tomography (OCT), preferably with enhanced imaging, to closely examine the choroid.

1. Optical coherence tomography

Many OCTs can perform enhanced depth imaging, and Dr. Epshtein encourages ECPs to check if their OCT has this feature. It is important to further investigate any lesions that might be suggestive of macular neovascularization with OCT angiography or dye-based angiography.

2. Fundus autofluorescence

Fundus autofluorescence is another imaging method that can help identify retinal pigment epithelium changes, which can be useful for determining chronicity and aid in prognostication of CSCR. Large descending tracts imply that CSCR has been present for some time, maybe a few months.
ECPs may also form a better idea of what the patient’s vision may be if the serous retinal detachment resolves. The appearance of hypo-autofluorescence and lots of pigmentary disturbances implies a worse condition than iso-autofluorescence with minimal pigmentary disturbances.

3. Fluorescein angiography

Fluorescein angiography can assist in concluding if the condition is more localized or diffused. For instance, a localized, extrafoveal hyperfluorescence can be treated with a thermal or photodynamic laser. Though it may leave a relative scotoma, a thermal laser may photocoagulate the affected retina and resolve fluid egress.

Two scenarios for CSCR

Dr. Epshtein and Dr. Pizzimenti consider a hypothetical patient who is having their first documented episode of CSCR with the following characteristics:
  • Serous retinal detachment
  • Thickened choroid
  • Few visible changes in fundus autofluorescence
  • No testosterone supplementation
  • No pertinent medical history
In such a patient, Dr. Pizzimenti would look for retinal pigmentary abnormalities, including a search for areas of retinal pigment epithelium (RPE) atrophy in both eyes and shallow areas of subretinal fluid.
The state of the outer retina can be examined by observing the ellipsoid zone band to ensure it is intact. The doctors look to rule out choroidal neovascularization (CNV)—using standard OCT or OCT angiography—and any exogenous or endogenous hypercortisolism.
If the patient does not have CNV, then the patient can be evaluated again in 1 to 2 months to monitor any partial or complete resolution. Dr. Pizzimenti would recommend that the patient oversee their stress levels to manage the production of endogenous glucocorticoids, which would affect the progression of the condition.

Managing recurrent CSCR

More aggressive treatments are considered for repeat and recurrent CSCR episodes. Dye-based angiography may be necessary to inform treatment options. The longer a serous retinal or RPE detachment is permitted to linger, the higher the likelihood of functional vision loss.
Treatment must be individualized for each patient, utilizing both clinical and diagnostic data to guide treatment. Patients who exhibit signs of functional vision loss must be referred for treatment.

CSCR and the pachychoroid spectrum

There is compelling data demonstrating that CSCR patients tend to have an especially thick choroid,2 leading Dr. Pizzimenti to believe that the pachychoroid spectrum is somehow associated with the pathogenesis of CSCR.
Dr. Epshtein has noted that he detects pachychoroid pigment epitheliopathy in the fellow eyes of CSCR patients 90% to 95% of the time, suggesting that this is most likely a bilateral asymmetric condition and both eyes should be examined.
This does not significantly change the method of treatment but can assist in differential diagnosis. Measuring an unusually thick choroid can allow ECPs to narrow treatment options. With advancing research regarding CSCR, better treatments for CSCR will hopefully emerge soon.

Conclusion

There are many factors to consider when classifying CSCR and various tests to help identify signs of CSCR. Care for CSCR must be individualized to each patient, relying on factors such as vision, retinal/RPE alterations, and history of previous episodes.
Newer theories suggesting that CSCR is part of the pachychoroid spectrum will hopefully advance our understanding of the disease, allowing us to provide better treatments for our patients with CSCR.
  1. Chhablani J, Cohen FB, Aymard P, et al. Multimodal Imaging-Based Central Serous Chorioretinopathy Classification. Ophthalmol Retina. 2020;4(11):1043-1046. doi: https://doi.org/10.1016/j.oret.2020.07.026
  2. Brandl C, Helbig H, Gamulescu MA. Choroidal thickness measurements during central serous chorioretinopathy treatment. Int Ophthalmol. 2014;34(1):7-13. doi: 10.1007/s10792-013-9774-y
Joseph J. Pizzimenti, OD, FAAO, FORS, FNAP
About Joseph J. Pizzimenti, OD, FAAO, FORS, FNAP

Joseph J. Pizzimenti, OD, FAAO, FORS, FNAP, earned his Doctor of Optometry from the Illinois College of Optometry and subsequently completed a residency in ocular disease and rehabilitative optometry at the University of Houston.

He joined the faculty of the University of the Incarnate Word Rosenberg School of Optometry in 2016. Dr. Pizzimenti is a fellow of both the American Academy of Optometry (AAO) and the Optometric Retina Society (ORS) and served as ORS President from 2012 to 2014.

In 2006, he was awarded a fellowship by the World Council of Optometry, resulting in an appointment to teach and evaluate optometric education programs in central Europe.

Dr. Pizzimenti has completed funded clinical research in the areas of diabetes, age-related macular degeneration, vitreomacular adhesion, oculo-systemic disease, and low vision. He co-authored a chapter on Diabetic Retinopathy in the textbook entitled Diabetes in Black America.

Joseph J. Pizzimenti, OD, FAAO, FORS, FNAP
Daniel Epshtein, OD, FAAO
About Daniel Epshtein, OD, FAAO

Dr. Daniel Epshtein is an assistant professor in the ophthalmology department of Mount Sinai Morningside in New York City. Previously, he held a position in a high-volume multispecialty ophthalmology practice where he supervised fourth-year optometry students as an adjunct assistant clinical professor of the SUNY College of Optometry. Dr. Epshtein’s research focuses on using the latest ophthalmic imaging technologies to elucidate ocular disease processes and to simplify equivocal clinical diagnoses. He developed and lectures in the perioperative care course at the SUNY College of Optometry. Dr. Epshtein writes and lectures on numerous topics including glaucoma, retinal disease, multimodal imaging, ocular surface disease, and perioperative care.

Daniel Epshtein, OD, FAAO
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