Written BY Prof. Khalil AL-SALEM , Lecture Given By Dr. Deyaa AlBtoush
Central serous chorioretinopathy (CSCR) is a retinal condition caused by fluid collecting beneath the central retina. This fluid separates the light-sensitive retina from the underlying retinal pigment epithelium (RPE). In many patients, there is a single area of leakage. However, some patients develop multiple areas of leakage or retinal involvement. This pattern may be described as multifocal central serous chorioretinopathy. Multifocal disease deserves particular attention. It may indicate more widespread dysfunction of the choroid and RPE. It can also be associated with recurrent or chronic disease. Fortunately, modern retinal imaging allows ophthalmologists to identify these changes in considerable detail. Optical coherence tomography (OCT), fluorescein angiography and other imaging techniques can guide both diagnosis and treatment.
What Is Central Serous Chorioretinopathy?
Central serous chorioretinopathy occurs when fluid accumulates beneath the neurosensory retina. The condition usually affects the macula, which is responsible for detailed central vision. The disease is now considered part of the pachychoroid spectrum of retinal disorders.
The choroid is the vascular tissue underneath the retina. In CSCR, the choroidal vessels may become enlarged and unusually permeable. This can place stress on the overlying RPE. The RPE normally controls the movement of fluid between the retina and choroid. When this barrier becomes dysfunctional, fluid can pass beneath the retina. The result is a localized serous retinal detachment. Recent research has strengthened the concept that CSCR is primarily related to abnormal choroidal circulation and hyperpermeability rather than being an isolated defect in the retina itself.
What Causes Multifocal Central Serous Chorioretinopathy?
There is rarely one single cause. CSCR appears to develop through a combination of choroidal vascular abnormalities, RPE dysfunction and individual susceptibility. Several factors are associated with an increased risk.
Corticosteroid Use
Corticosteroids have one of the strongest associations with CSCR. This includes oral steroids, injections, inhaled steroids and sometimes topical preparations. Patients should always tell their ophthalmologist about any steroid medication they use. However, corticosteroids prescribed for an important medical condition should not be stopped suddenly without consulting the treating doctor.
Stress and Cortisol
CSCR has traditionally been associated with psychological stress and increased activity of the body’s stress-response system.
This does not mean that stress alone causes the disease. Instead, hormonal and vascular responses to stress may contribute in susceptible individuals.
Sleep Disturbance
Poor sleep and obstructive sleep apnea have also been associated with CSCR. Patients with recurrent disease and significant snoring or daytime sleepiness may therefore require further medical evaluation.
Other Associations
Hypertension, certain medications and hormonal influences have also been investigated.
Pregnancy can occasionally be associated with CSCR, particularly during later stages.
However, many patients develop the disease without an obvious trigger.
Who Usually Develops CSCR?
Central serous chorioretinopathy commonly affects adults during their working years. Men are affected more frequently than women, although the condition can occur in either sex. The clinical pattern may differ between patients. Some experience one acute episode that resolves completely. Others experience repeated episodes. A smaller group develops persistent subretinal fluid and chronic RPE changes. These patients require closer monitoring because prolonged disease can cause permanent retinal damage.
Symptoms of Multifocal Central Serous Chorioretinopathy
The symptoms depend on the location and amount of subretinal fluid. Blurred central vision is common. Patients may notice that the affected eye does not focus as clearly as the other eye. Another characteristic symptom is metamorphopsia. Straight lines may appear bent, irregular or distorted. Objects may also appear smaller than normal. This phenomenon is called micropsia. Patients can experience reduced contrast sensitivity and changes in colour perception. A dark, grey or blurred area may appear in the central visual field. Some patients notice a change in their glasses prescription, particularly a temporary shift toward farsightedness. When multiple areas are involved, the visual disturbance may be more complex.
Is Multifocal Central Serous Chorioretinopathy Dangerous?
CSCR does not usually cause complete blindness. However, this should not lead patients to assume that the condition is always harmless. Many acute cases resolve spontaneously. Subretinal fluid can disappear over several weeks or months, with significant improvement in vision.
The situation is different when fluid persists or repeatedly returns. Chronic CSCR can damage the photoreceptors and retinal pigment epithelium. This may result in permanent reduction of visual quality even after the fluid disappears. Long-standing disease may cause widespread RPE changes known as diffuse retinal pigment epitheliopathy. Therefore, persistent or recurrent symptoms deserve proper retinal assessment.
How Is Multifocal Central Serous Chorioretinopathy Diagnosed?
Diagnosis begins with a detailed eye examination. However, retinal imaging is extremely important because the visible retinal changes do not always reveal the full extent of the disease.
Optical Coherence Tomography (OCT)
OCT is one of the most important tests for CSCR. It produces high-resolution cross-sectional images of the retina. OCT can demonstrate the exact location and amount of subretinal fluid. It may also reveal pigment epithelial detachments and abnormalities of the outer retinal layers.
Modern enhanced-depth OCT can provide additional information about the choroid. Patients with CSCR frequently demonstrate a thickened choroid and enlarged choroidal vessels. These findings support its classification within the pachychoroid spectrum. OCT is also extremely useful during follow-up because changes in subretinal fluid can be measured objectively.
Fluorescein Angiography
Fluorescein angiography helps identify areas where fluid is leaking through the RPE. Classic acute CSCR may demonstrate a focal leakage pattern. In multifocal or chronic disease, several leakage areas and widespread RPE abnormalities may be present. This information can be particularly useful when treatment is being considered.
Indocyanine Green Angiography
Indocyanine green angiography, or ICGA, provides additional information about the choroidal circulation. It can demonstrate areas of choroidal hyperpermeability that may extend beyond the visible areas of retinal fluid. ICGA can also help guide photodynamic therapy in selected patients.
Fundus Autofluorescence
Fundus autofluorescence can demonstrate the extent of RPE dysfunction. This is particularly valuable in chronic or multifocal CSCR. Areas of abnormal autofluorescence may reveal previous episodes or chronic retinal damage that are not immediately obvious during routine examination.
OCT Angiography
OCT angiography, or OCTA, allows the retinal and choroidal circulation to be examined without dye injection. One particularly important role is detecting macular neovascularization. This complication can occur in chronic CSCR and may significantly change the treatment strategy.
Acute Versus Chronic Central Serous Chorioretinopathy
Distinguishing acute disease from persistent or chronic disease is important. In a first episode of acute CSCR, spontaneous resolution is common. Observation may therefore be appropriate initially. Current evidence-based recommendations generally allow observation for approximately three to four months in uncomplicated acute disease. However, treatment may be considered earlier in selected patients.
For example, earlier intervention may be reasonable when rapid visual recovery is particularly important for the patient’s occupation. It may also be considered in recurrent disease or when the fellow eye has previously suffered significant damage. Chronic CSCR requires a different approach. Persistent subretinal fluid can progressively damage the outer retina and RPE. Treatment is therefore more commonly recommended.
Treatment of Multifocal Central Serous Chorioretinopathy
Treatment should be individualized according to disease duration, location, imaging findings and previous episodes. The first step is often identifying modifiable risk factors. Steroid exposure should be reviewed carefully. Sleep disorders, stress and associated systemic conditions may also deserve attention. However, modern treatment is primarily directed toward the abnormal choroidal circulation responsible for persistent leakage.
Photodynamic Therapy
Photodynamic therapy (PDT) with verteporfin is currently the best-supported treatment for chronic CSCR. Modern protocols usually use reduced treatment parameters, particularly half-dose or half-fluence PDT. Verteporfin is administered and activated with a specific wavelength of laser light over the abnormal choroidal area. The objective is not to burn the retina. Instead, PDT modifies abnormal choroidal circulation and reduces choroidal hyperpermeability. This can reduce the pressure exerted on the RPE and allow subretinal fluid to resolve. Recent evidence-based guidelines and international expert consensus support reduced-setting PDT as the preferred first-line treatment for chronic CSCR. PDT can be particularly valuable in multifocal disease because the underlying abnormality may involve a wider choroidal area rather than one isolated leakage point.
Conventional Focal Laser
Conventional laser photocoagulation can sometimes be used when fluorescein angiography identifies a clearly defined leakage point away from the central fovea. It can accelerate fluid resolution. However, conventional laser creates a permanent retinal scar. Therefore, it is generally unsuitable for leakage very close to the centre of vision. Its role has become more selective with the development of PDT and subthreshold laser techniques.
Subthreshold Micropulse Laser
Micropulse laser delivers energy in extremely short pulses. This reduces thermal damage compared with conventional continuous-wave laser. It may be considered in selected patients, particularly when PDT is unavailable. However, current evidence generally favours PDT for chronic CSCR, especially when widespread choroidal abnormalities are present.
Do Tablets Treat Central Serous Chorioretinopathy?
Several systemic medications have been investigated. Mineralocorticoid receptor antagonists, particularly eplerenone, attracted considerable attention because of theories involving corticosteroid and mineralocorticoid pathways in CSCR. However, high-quality clinical trials failed to demonstrate a meaningful benefit of eplerenone for chronic CSCR. It is therefore not considered a preferred routine treatment based on current evidence. This is an important change from older treatment approaches.
Are Anti-VEGF Injections Used for Central Serous Chorioretinopathy?
Anti-VEGF injections are widely used for several retinal diseases. However, uncomplicated CSCR is not primarily a VEGF-driven disease. Therefore, anti-VEGF injections are generally not indicated for routine CSCR without neovascularization. The situation changes when chronic CSCR develops secondary macular neovascularization. In these cases, anti-VEGF injections may become an important part of treatment. PDT may also be considered depending on the individual findings. This is one reason why OCT angiography and careful multimodal imaging are important in chronic cases.
Can Multifocal Central Serous Chorioretinopathy Come Back?
Yes. Recurrence is one of the characteristic features of central serous chorioretinopathy.A patient may recover completely from the first episode and develop another episode months or years later. Repeated attacks can gradually damage the RPE and photoreceptor layer. Patients who have previously experienced CSCR should therefore seek ophthalmic assessment if distortion or blurred central vision returns. Regular OCT imaging may be useful in patients with chronic or recurrent disease.
What Is the Prognosis?
The prognosis depends largely on the duration and recurrence of subretinal fluid. A first acute episode often has a favourable outcome.
Visual acuity may return close to normal once the fluid resolves. However, some patients continue to notice reduced contrast, mild distortion or altered colour perception despite good visual acuity. Chronic multifocal disease carries a greater risk of permanent visual changes. Long-standing fluid can damage the photoreceptors. Widespread RPE abnormalities may also develop. Early recognition of persistent disease is therefore important. The goal of treatment is not simply to improve the number of letters seen on an eye chart. It is also to protect the structure and long-term function of the macula.
When Should You See an Ophthalmologist?
New distortion, central blurring or a grey spot in the vision should be evaluated. These symptoms are not specific to CSCR. Other retinal diseases can produce similar symptoms, including macular neovascularization and inflammatory retinal disorders. This becomes particularly important in older patients or when the clinical appearance is unusual. A retinal examination combined with OCT can often establish the diagnosis quickly. Additional imaging may then be performed when necessary.
Frequently Asked Questions About Multifocal CSCR
Does central serous chorioretinopathy always require treatment?
No. Many first episodes resolve spontaneously. Observation is often appropriate for uncomplicated acute CSCR. Persistent, recurrent or chronic disease is more likely to require treatment.
How long does CSCR take to resolve?
Many acute episodes improve over several weeks to a few months. Persistent fluid beyond approximately three to four months raises greater concern about chronic disease and potential retinal damage.
Can stress cause central serous chorioretinopathy?
Stress is associated with CSCR, but the relationship is complex. Stress-related hormonal responses may contribute to the disease in susceptible individuals. However, CSCR should not simply be regarded as a psychological or stress-related disorder.
Can steroids make CSCR worse?
Yes. Corticosteroid exposure is strongly associated with CSCR and may trigger or worsen the disease. Patients should inform both their ophthalmologist and treating physician about steroid use. Prescribed steroids should not be stopped abruptly without medical advice.
What is the best treatment for chronic CSCR?
Current evidence supports reduced-setting photodynamic therapy, particularly half-dose or half-fluence PDT, as the preferred treatment for many patients with chronic CSCR. Treatment must still be individualized according to retinal imaging and the patient’s clinical situation.
Can CSCR affect both eyes?
Yes. Fluid may be clinically apparent in only one eye, while imaging reveals pachychoroid or RPE changes in both eyes. Patients with multifocal or chronic disease may therefore benefit from careful examination of both eyes.
The Importance of Modern Retinal Imaging
Our understanding of central serous chorioretinopathy has changed considerably. It was once viewed mainly as a focal leakage problem. Today, CSCR is increasingly understood as a disease involving abnormal choroidal circulation, choroidal congestion and secondary RPE dysfunction. This concept is especially relevant in multifocal central serous chorioretinopathy. The visible retinal fluid may represent only one part of a broader choroidal disorder. OCT, OCT angiography, fluorescein angiography, indocyanine green angiography and fundus autofluorescence allow the ophthalmologist to examine different aspects of the disease. This multimodal approach helps distinguish acute from chronic disease. It can identify complications and guide treatment toward the areas most likely to benefit.
Final Thoughts
Multifocal central serous chorioretinopathy is more than simply fluid beneath the retina. It reflects a complex interaction between the choroidal circulation, retinal pigment epithelium and outer retina. Many acute cases recover well. However, recurrent or persistent disease should not be ignored. Chronic subretinal fluid can eventually produce permanent structural changes and reduced visual quality. Modern OCT and multimodal retinal imaging allow us to diagnose the disease earlier and understand its extent more accurately. When treatment is required, current evidence increasingly supports reduced-dose or reduced-fluence photodynamic therapy for chronic disease. Anti-VEGF treatment should generally be reserved for cases complicated by macular neovascularization. The most appropriate approach therefore depends on whether the disease is acute, recurrent, chronic or complicated by additional retinal changes. Early retinal assessment remains the best way to establish the diagnosis, determine the extent of disease and select the appropriate treatment.