Central Serous Chorioretinopathy Management: A Decision Tree for Optometrists

Central serous chorioretinopathy may not be a condition optometrists manage on a regular basis, but with an annual incidence of 9.9 and 1.7 per 100,000 among men and women, respectively, they may possibly encounter it at some point during their career.¹ Imaging techniques such as optical coherence tomography (OCT) have made this condition much easier to diagnose and monitor. However, differences in disease severity, a poor understanding of the pathophysiology, and a lack of standardized classifications, imaging techniques, and treatment strategies present clinicians with a series of challenges that complicate management of an already complex disease. While a decision tree directing optometrists toward the most appropriate management strategy may seem simplistic, clinicians may benefit from an aid that provides them an easy-to-access guideline outlining potential treatments based on OCT imaging and potential risk factors.   

Identifying Management Options

When a clinician suspects central serous chorioretinopathy, they will consider 1 of 3 management strategies: monitoring, treatment with oral pharmaceuticals, or referral to a retinal specialist. Before making this decision, the optometrist must perform several tasks, beginning with a thorough patient history and detailed ocular examination with baseline multimodal imaging. Determining whether the patient is experiencing a first-time occurrence, an acute recurrence, or chronic disease is the first step toward identifying a potential management strategy. There is no universally-accepted length of time before an acute episode of central serous chorioretinopathy is considered chronic, but most of the literature agrees this transition occurs after 4 to 6 months of an unresolved neurosensory detachment.²

Making the Decision to Monitor

Once the clinician identifies acute central serous chorioretinopathy using high-quality diagnostic imaging, research suggests that they may monitor these patients without treatment, as a large percentage will resolve during 3 to 4 months.³ While optometrists should perform 4-week follow-up visits with repeat testing and instruct patients to regularly check their vision with an Amsler grid, they should also be on the lookout for potential systemic or lifestyle risk factors associated with central serous chorioretinopathy and work with the patient, as well their primary care physician (PCP), to decrease these risks.

Consider Reducing Corticosteroid Intake

Since exogenous and endogenous corticosteroids are associated with central serous chorioretinopathy development, reducing or eliminating their use should be one of the first steps an optometrist takes in managing the disorder. This may include reaching out to the patient’s PCP or rheumatologist and educating the patient on the role these drugs may play in their disease. Optometrists should also be sure to ask about intranasal corticosteroid use, as this type of over-the-counter medication is often overlooked when discussing a patient’s medications.

A Little Relaxation May Go a Long Way

Research identified an association between type A personality and central serous chorioretinopathy almost 40 years ago.⁴ Patients who demonstrate type A personality may experience more psychological stress, leading to an increase in systemic catecholamine and corticosteroid circulation.⁵ While the literature does not conclude that reducing stress leads to central serous chorioretinopathy resolution, it may play a role and patients can always benefit from eliminating potential stressors from their lives.  

Screen for Hypertension

Hypertension has also been associated with central serous chorioretinopathy.⁵ Optometrists must be certain to ask patients about a history of hypertension, check blood pressure, and refer individuals with suspected hypertension to a PCP.

Screen for Obstructive Sleep Apnea

Obstructive Sleep Apnea (OSA) has also been investigated as a risk factor for central serous chorioretinopathy. A 2020 database study found that OSA increased central serous chorioretinopathy risk in both men and women, but concluded that referring every patient with the disorder for a sleep evaluation is unnecessary and expensive.⁶ While these evaluations may not be warranted for all patients, individuals who are older adults and patients with a higher body mass index (BMI) may potentially benefit.⁷ Adding a few questions about sleeping habits to a patient evaluation or using a short questionnaire such as the Epworth Sleepiness Scale can help to identify individuals with OSA and refer them for appropriate treatment.

Other potential risk factors for central serous chorioretinopathy include pregnancy, Cushing syndrome, helicobacter pylori infection, gastroesophageal disorders, alcohol use, and excessive caffeine intake.^2,3,5

Initiating Oral Treatments

Once a central serous chorioretinopathy neurosensory detachment persists past 3 to 4 months and transitions into the chronic stage, treatment is indicated to prevent photoreceptor and retinal pigment epithelium (RPE) atrophy and further vision loss. Oral pharmaceuticals provide a potential treatment option that optometrists can use before referring for more invasive therapies. 

Mineralocorticoid Receptor Antagonists (MRAs)

When making the decision to initiate oral treatment, MRAs, such as eplerenone or spironolactone, have the largest body of evidence supporting their safety and efficacy.⁸ Research theorizes that glucocorticoids, which are known to be associated with inducing and aggravating central serous chorioretinopathy, bind to receptors within the choroid and activate them, causing vasodilation, leakage, and fluid accumulation within the retina.⁹ MRAs work by blocking these receptors, with the ultimate goal of reducing subretinal fluid and improving visual acuity.

While the literature supports the use of oral treatments, it does not always show consistency on the recommended dosage amount or treatment duration, and does not indicate whether tapering is needed upon resolution. 

When deciding between eplerenone or spironolactone, spironolactone is the more cost-effective option, but it is less selective when targeting receptors, which may lead to more systemic side effects. Both agents are potassium-sparing medications with the potential to increase serum potassium levels. Therefore, metabolic monitoring is recommended shortly after initiating the medication and occasionally throughout treatment.¹⁰ MRA use with hyperkalemia, renal dysfunction (including diabetic kidney disease), pregnancy, or medications that can result in drug-drug interaction is contraindicated.¹⁰ Optometrists must be sure to check with a patient’s PCP before starting a medication if unsure.

Despite some studies showing their efficacy, the use of MRAs is a somewhat controversial treatment. Two prospective, randomized studies questioned the efficacy of MRAs for central serous chorioretinopathy, one comparing eplerenone vs placebo (VICI) and one comparing eplerenone vs photodynamic therapy (SPECTRA).^11,12 Regardless, optometrists may still consider MRAs in the earlier stages of central serous chorioretinopathy if there has been no substantial resolution of subretinal fluid at the 1 or 2-month follow-up visits.

Other systemic medications, which include beta blockers and carbonic anhydrase inhibitors, have received attention as potential oral treatment options in the past, but MRAs are currently receiving the most attention as oral central serous chorioretinopathy treatments.⁹  

Making the Decision to Refer

If subretinal fluid persists and a referral for chronic central serous chorioretinopathy becomes necessary, it is important to document the patient’s entire clinical course, risk factors, and prior management strategies to aid the retinal specialist in choosing the best course of treatment. While the optometrist may be handing off treatment to another clinician during this phase, it is still important to continue to educate patients and prepare them for their evaluation.

Laser Photocoagulation

Thermal energy produced during laser photocoagulation attempts to seal an area of leakage from the RPE after being identified by fluorescein or indocyanine green angiography.² Patients with small, localized areas of extramacular leaking may benefit from this treatment, as laser damage too close to the macula can result in paracentral scotomas.

PDT With Verteporfin

Although the pathophysiology of central serous chorioretinopathy is not fully understood, choroidal hyperpermeability may play a key role in the subretinal fluid development observed in the disorder.³ PDT uses a specific wavelength of laser to activate verteporfin, a photosensitive dye that creates free radicals when activated. These free radicals create localized damage and remodel the choroidal vasculature, ultimately reducing fluid leakage.¹³ Verteporfin is administered intravenously, and the laser is applied to areas of leakage noted on angiography.

Research shows that PDT treatment can cause subretinal fluid resolution in a large percentage of patients and it seems to be the treatment of choice for chronic central serous chorioretinopathy.^12,14 The treatment also demonstrates a favorable safety profile with a low risk of systemic and ocular adverse events. Because verteporfin is a photosensitive dye, a patient must avoid exposure of the skin or eyes to direct sunlight or bright indoor light for 5 days following treatment.

Anti-Vascular Endothelial Growth Factor (VEGF) Injections

Anti-VEGF agents have also been used to treat central serous chorioretinopathy, with varying degrees of success. This is a viable option when choroidal neovascularization is present and highlights the importance of OCT-angiography imaging to detect subtle choroidal neovascularization that may be the cause of continued leakage.³

Using the Decision Tree

When it comes to managing central serous chorioretinopathy, the diagnostic decision tree is wide and branching. The best course of management is often patient-dependent and should be determined on a case-by-case basis. The optometrist’s role is especially important during the acute stages of the disease and requires an accurate diagnosis, extensive patient education, and reduction of identifiable risk factors for the best patient outcomes. Timely referral is also important to reduce the risk of further vision loss. While the decision tree provided above will not provide optometrists with a comprehensive understanding of central serous chorioretinopathy, it can guide clinical decision making and serve as a quick referral for selecting the most appropriate treatment.