Association of Central Serous Chorioretinopathy with Psychosocial Factors is Dependent on Its Phase and Subtype

Central serous chorioretinopathy: An evidence-based treatment guideline

Central serous chorioretinopathy (CSC) is a relatively common disease that causes vision loss due to macular subretinal fluid leakage and it is often associated with reduced vision-related quality of life. In CSC, the leakage of subretinal fluid through defects in the retinal pigment epithelial layer's outer blood-retina barrier appears to occur secondary to choroidal abnormalities and dysfunction. The treatment of CSC is currently the subject of controversy, although recent data obtained from several large randomized controlled trials provide a wealth of new information that can be used to establish a treatment algorithm. Here, we provide a comprehensive overview of our current understanding regarding the pathogenesis of CSC, current therapeutic strategies, and an evidence-based treatment guideline for CSC. In acute CSC, treatment can often be deferred for up to 3-4 months after diagnosis; however, early treatment with either half-dose or half-fluence photodynamic therapy (PDT) with the photosensitive dye verteporfin may be beneficial in selected cases. In chronic CSC, half-dose or half-fluence PDT, which targets the abnormal choroid, should be considered the preferred treatment. If PDT is unavailable, chronic CSC with focal, non-central leakage on angiography may be treated using conventional laser photocoagulation. CSC with concurrent macular neovascularization should be treated with half-dose/half-fluence PDT and/or intravitreal injections of an anti-vascular endothelial growth factor compound. Given the current shortage of verteporfin and the paucity of evidence supporting the efficacy of other treatment options, future studies-ideally, well-designed randomized controlled trials-are needed in order to evaluate new treatment options for CSC.

Psychometric assessment of patients with central serous chorioretinopathy and correlation with disease stage and progression: a case control study

BACKGROUND

Central serous chorioretinopathy (CSC) has frequently been associated with increased stress levels as well as an increased prevalence of other psychiatric conditions. This study used standardized psychometric scores to assess stress, depression and anxiety levels of CSC patients and compared them to controls without retinal disease ("healthy") and with branch retinal vein occlusion (BRVO).

METHODS

Monocentric, longitudinal case control study on consecutive CSC patients seen at a tertiary referral center. Controls without retinal disease were recruited from the oculoplastics clinic and those with BRVO from the medical retina clinic. Patients completed pseudonymized tests measuring stress levels (PHQ-stress), depression (PHQ-9) and anxiety (GAD-7) at baseline and at 3- and 6-months follow-up. Higher scores indicated higher trait levels.

RESULTS

65 CSC patients, 19 healthy controls and 19 BRVO patients were included in this study. CSC patients showed significantly higher stress levels at baseline compared to controls (p = 0.009), but not compared to BRVO patients (p = 1.00). At 3- and 6-months follow-up, no significant difference between groups was observed anymore. Acute CSC patients showed higher scores than those with chronic CSC, which also subsided over time. Depression and anxiety scores did not differ between groups at any timepoint.

CONCLUSIONS

Patients with CSC do not show higher initial stress levels than patients with BRVO, while anxiety and depression levels did not differ from controls. Stress may thus rather represent a consequence of the onset of visual deterioration observed in CSC or other ocular diseases.

Evaluation of retinal and choroidal vascular structures in patients with anxiety disorder

PURPOSE

To evaluate the retinal and choroidal vascular structures in patients with anxiety disorders.

METHODS

Thirthy-four eyes of 34 patients who were diagnosed with any anxiety disorders were compared with 32 eyes of 32 age- and sex-matched controls. Central macular thickness (CMT), foveal vascular zone (FAZ) area, total retinal vascular densities of superficial and deep capillary plexus (VDSCP, VDDCP), outer retinal and choriocapillary layers (ORL, CCL) blood flow rates, central subfoveal choroidal thickness (SFCT) and choriodal vascularity index (CVI) were evaluated with optical coherence tomography angiography (OCT-A) and enhanced depth imaging optical coherence tomography (EDI-OCT).

RESULTS

No statistical differences were found between the study and control groups in terms of CMT, FAZ area, VDSCP, VDDCP, ORL and CCL blood flow rates. The mean SFCT was 346.26 ± 64.26 µm in patients with anxiety disorder and was found to be statistically significantly thicker than the control group (319.56 ± 37.19 µm) (p = 0.042). Besides, CVI was significantly lower in the study group (71.09 ± 2.64 vs 73.13 ± 3.31, p = 0.008).

CONCLUSION

In people with anxiety disorders, the SFCT was found to be thicker and CVI was found to be lower than normal subjects. Although anxiety and stress are important factors in central serous chorioretinopathy, multifactorial factors, including ocular factors, play a role in the pathophysiology of the disease. There is a need for prospective studies with larger series on the subject.

Association of Central serous chorioretinopathy with type of personality, anxiety and depression

PURPOSE

Central serous chorioretinopathy (CSCR) a relatively common cause of visual impairment, which is characterized by subretinal fluid accumulation in the macula and is more common in middle-aged males. Various risk factors have been reported in literature, among which substantial role of psychological factors is cited. Our aim was to look for the prevalence and association of the psychiatric factors in CSCR patients and to compare them with other non-chorioretinal ocular pathologies.

METHODS

A cross-sectional correlational study was undertaken involving 91 CSCR patients, along with 91 patients with other non-chorioretinal diseases. Their risk factors, clinical history, ocular examination, and psychiatric assessments were done using standardized tools, and the groups were compared in terms of scoring of Framingham Type A scale (FTAS), Hamilton Anxiety Rating Scale (HAM-A), and Hamilton Depression Rating Scale (HDRS).

RESULTS

CSCR patients had a male:female ratio of 8:1. Chronic, bilateral, and recurrent diseases were found in 15%, 20%, and 23% cases, respectively. Anxiety disorder had a prevalence of 40%, followed by major depression with a prevalence of 24%, and these were significantly higher than non-chorioretinal disease patients (odds ratios 14.18 and 5.30, respectively). Also, these psychiatric disorders were significantly associated with an overall lower visual acuity and greater central macular thickness due to subretinal fluid accumulation.

CONCLUSION

Psychiatric comorbidities like Type A personality trait and depression and anxiety disorders were significantly more prevalent in CSCR patients, compared to non-chorioretinal pathologies. Focus on psychological health would certainly benefit these patients in terms of better management of not only CSCR, but their psychiatric morbidity as well.

A multicentre study of the risk factors associated with recurrence of central serous chorioretinopathy

PURPOSE

To investigate potential clinical and multimodal imaging factors in central serous chorioretinopathy (CSC) recurrence.

METHODS

The study was performed at nine Japanese medical institutions for patients who had experienced an active CSC episode. Demographic data and medical history were reviewed retrospectively. Significant differences in chronic manifestation, leakage site, leakage point number, leakage intensity, choroidal hyperpermeability, central retinal thickness (CRT) and subfoveal choroidal thickness were analysed between the recurrence and non-recurrence groups.

RESULTS

In total, 538 eyes (538 patients) diagnosed with CSC (402 men, 136 women; mean age: 53.4 ± 11.9 years) were enrolled. Among them, 253 eyes (47.0%) developed ≥1 recurrence (follow-up: 15.9 ± 13.5 months, range 3-86 months). Univariate and multivariate analyses indicated that a history of corticosteroid use (odds ratio [OR], 5.52; 95% confidence interval [CI], 1.39-21.92; p = 0.015), bilateral disease (OR, 3.94; 95% CI, 1.47-10.6; p = 0.007), chronic manifestations (OR, 7.12; 95% CI, 2.93-17.28; p < 0.001), non-intense fluorescein leakage (OR, 3.34; 95% CI, 1.44-7.75; p = 0.005) and initial CRT (OR, 0.997; 95% CI, 0.993-0.999; p = 0.049) were significantly associated with CSC recurrence. Receiver operating characteristic curves were created, and the area under the curve for the multivariate logistic regression model of these five factors was 0.814.

CONCLUSION

Patients with CSC who received corticosteroids and had bilateral disease, chronic manifestation, non-intense fluorescein leakage on fluorescein angiography or a relatively thinner CRT should be closely monitored to identify whether they are at high risk of recurrence.

Sharing the Same Perspective. Mental Disorders and Central Serous Chorioretinopathy: A Systematic Review of Evidence from 2010 to 2020

Background: The relevance of the association between mental disorders and other conditions might have been underestimated due to its complexity. Central Serous Chorioretinopathy (CSC) is an ophthalmological disorder associated with many psychiatric factors. The aim of this systematic review is to evaluate the association between mental disorders and CSC. Methods: Articles about studies performed on humans on CSC published in peer-reviewed journals from 1 January 2010 to 31 December 2020 were included in the review. Results: We selected 21 research papers. Nine studies measured stress and anxious depressive symptoms, which are associated with CSC onset and recurrences, emerging as a state marker of the disease. Four out of the five studies focused on sleep disorders suggested a reliable association with CSC. Four studies evaluated other various psychiatric factors. The role of psychopharmacological medication has still not been elucidated (three studies). Conclusion: Multiple pieces of evidence highlights that CSC might arise in the context of systemic disease. This notion, together with the increasing evidence supporting a link between psychiatric disorders and choroidal thickness, suggests that CSC and mental disorders may share some etiopathogenetic pathways. Further research is needed to better investigate possible common etiopathogenetic pathways, especially vascular, immunological and endocrinological systems.

UNCOMPLICATED PACHYCHOROID IN RELATION TO OBSESSIVE-COMPULSIVE DISORDER: AN OCT-ANGIOGRAPHY STUDY

BACKGROUND

The aim of this study was to evaluate potential changes in choroidal flow in patients with newly diagnosed obsessive-compulsive disorder based on optical coherence tomography angiography findings and to investigate the relationship between subfoveal choroidal thickness and choriocapillaris flow area.

METHODS

This prospective study included newly diagnosed obsessive-compulsive disorder patients and healthy controls. All patients underwent enhanced depth imaging-optical coherence tomography imaging to assess the subfoveal choroidal thickness and optical coherence tomography angiography imaging to evaluate the choriocapillaris flow area.

RESULTS

A total of 55 patients with obsessive-compulsive disorder and 50 controls were included. The mean subfoveal choroidal thickness was significantly greater in the obsessive-compulsive disorder group compared to the control group (p˂0.001). Regarding the choriocapillaris flow area, the values for area with a radius of 1 mm, 2 mm and 3 mm were significantly lower in the obsessive-compulsive disorder group than in the control group (p=0.019, p=0.014, and p=0.004, respectively). There was a significant negative correlation between subfoveal choroidal thickness and choriocapillaris flow area with a radius of 1mm (r=-0.387, p=0.024).

CONCLUSION

Choroidal changes in obsessive-compulsive disorder patients suggest the choroidal features of uncomplicated pachychoroid. Obsessive-compulsive disorder may be prone to a spectrum of conditions characterized by pachychoroid features.

Psychiatric evaluation in patients with central serous chorioretinopathy in Asian Indians

Purpose:

This study aimed at psychiatric evaluation of patients with central serous chorioretinopathy (CSCR) and its association.

Material:

Consecutive patients diagnosed to have CSCR were included in the study. The participants underwent a routine eye examination. After informed consent, participants were subjected to psychiatric evaluation by a qualified psychiatrist. Details of evaluation and psychiatric disorders were documented and if treatment required were given by the psychiatrist. The outcome measure was the incidence of psychological disorder.

Results:

Cross-sectional observational data analysis of 40 patients diagnosed to have treatment-naive CSCR who agreed to undergo psychiatric evaluation were included in the study. The ethnic origin of the patients was Asian Indian. The mean age was 39.55 ± 8.33 years with a male to female ratio of 33:7. After a thorough psychiatric evaluation, 31 individuals (77.5%) diagnosed to have mixed anxiety disorders, 4 (10%) had the major depressive disorder, and 5 (12.5%) had adjustment disorder. All 40 patients had stressed personality. All 40 patients had treatment with anti-anxiolytics and advised lifestyle modification. Of these 40 patients, one patient (2.5%) underwent treatment additionally with an antidepressant.

Conclusion:

All patients with acute CSCR had some form of psychiatric disorder. Psychiatric evaluation in acute treatment naïve CSCR may contribute to the management besides other factors known in the management.

Exploring the Biopsychosocial Pathways Shared by Obstructive Sleep Apnea (OSA) and Central Serous Chorioretinopathy (CSC): A Literature Overview

This study addressed the following question: “Is it possible to highlight the link between obstructive sleep apnea (OSA) and central serous chorioretinopathy (CSC) through common biopsychosocial pathogenetic pathways?”. The study was conducted through electronic searches of the PubMed, Web of Science, and Scopus databases. All relevant selected human research studies published from January 2003 to December 2020 were included. The scientific literature search was performed through repeated use of the words “OSA” and/or “acute/chronic CSC” paired with “biomedical/biopsychosocial illness model”, “psychopathology”, “stress”, “personality characteristics”, “functional diseases”, “comorbidity”, and “quality of life” in different combinations. Our literature search identified 213 reports, of which 54 articles were ultimately reviewed in this paper. Taken together, the results indicate that there is a cross-link between OSA and CSC that can be classified among biopsychological disorders in which various major biological variables integrate with psychological-functional and sociological variables; many of these variables appear in both diseases. This concept can have important implications for improving patients’ quality of life, thus providing the necessary strategies to cope with challenging life events even through nonpharmacological approaches.

Early alterations in retinal microvasculature on swept-source optical coherence tomography angiography in acute central serous chorioretinopathy

The purpose of the study was to evaluate the retinal blood flow in patients with acute central serous chorioretinopathy (CSC) over an observational period of 1 month using swept-source optical coherence tomography (SS-OCTA), focusing especially on changes in the area of subretinal fluid (A-SRF). We correlated these findings with conventional indocyanine green angiography (ICGA). ICGA and SS-OCTA images were collected and analyzed of 12 eyes of 12 patients. The A-SRF was annotated and a qualitative analysis of choriocapillaris, the vessel density (VD) and perfusion density (PD) of the retinal superficial capillary plexus (SCP) and the deep capillary plexus (DCP) was performed in A-SRF and the unaffected remaining area (RA). The VD and PD in the DCP were statistically significantly lower in A-SRF than in the RA at baseline. (VD: p = 0.014; PD: p = 0.036). After 1 month, there was a statistically significant difference in the VD and PD of the DCP (VD: p = 0.015; PD: p = 0.014), and for the PD of the SCP between the A-SRF and the RA (p = 0.015), with lower values in the A-SRF. We found low perfused areas in choriocapillaris corresponding to hypofluorescent areas on ICGA. In conclusion there is a difference in VD and VD of the DCP in the area of SRF in acute CSC. These alterations may lead to a chronic change in the microvasculature and potentially to morphological changes.

Central serous chorioretinopathy: An update on risk factors, pathophysiology and imaging modalities

Central serous chorioretinopathy (CSC) is a common form of vision loss, typically seen in working-age men. The pathophysiology behind CSC still eludes us, however significant advances have been made in understanding this disease over the last decade using information from genetic and cell-based studies and imaging modalities. This review aims to give an overview of the current pathophysiology hypotheses surrounding CSC in addition to future directions in cellular work from human induced pluripotent stem cell derived choroidal endothelial cells from CSC patients. Furthermore, this review will provide the reader with an update on the clinical aspects of CSC including risk factors, diagnostic challenges and findings from multimodal imaging.

Central choroidal thickness in children and adolescents with anxiety disorders: enhanced depth imaging optical coherence tomography findings

AIM

To measure the central choroidal thickness (ChT) in children and adolescents with anxiety disorders.

METHODS

Totally 41 anxiety patients (8-16y) and 35 healthy controls (age-matched) were evaluated. Complete ophthalmic examination was performed. Inclusion criteria were best corrected visual acuity ≥20/20, normal intraocular pressure (IOP; 10-21 mm Hg), and no systemic or ocular diseases according to history. The diagnosis of psychiatric disorders was determined using Schedule for Affective Disorders and Schizophrenia for School Aged Children Present-Lifetime Version (K-SADS-PL). Enhanced depth imaging optical coherence tomography (EDI-OCT) was used to measure the central ChT.

RESULTS

The mean age was 12.18±3.24y in the patient group and 12.86±3.15y in the control group. Age and gender distribution of the two groups was similar. Central ChT mean value was 353.26±31.9 µm in anxiety patients while 318.75±60.9 µm in the control group. Mean central ChT was statistically significantly higher in the children and adolescents with anxiety disorders than healthy controls (P=0.002).

CONCLUSION

The children and adolescents with anxiety disorders have significantly thicker central ChT than controls. In the larger sample, longitudinal studies will contribute to the use of choroidal differences as a clinical marker for monitoring anxiety disorders.

Central serous chorioretinopathy and heart rate variability analysis with a smartphone application

The purpose of this study was to quantitatively analyze heart rate variability (HRV) in patients with central serous chorioretinopathy (CSC) by using a smartphone-based application (ANBAI: DUMSCO Inc.) for measurement, and to clarify its relationships with CSC. The subjects were 64 CSC patients (mean age 48.7 ± 7.6 years, 57 males and 7 females). After providing consent, the patients downloaded ANBAI apps to their smartphones. HRV was measured by photoelectric volume pulse wave measurement with a smartphone camera each morning for a minimum of 1 week. The primary outcome was to analyze HRV by calculating log LF/HF (Low Frequency/High Frequency components), an index of autonomic tone, which was then compared with a control group of 35,226 individuals from the application. Secondary outcome measures included disease duration, body mass index, exercise habits, smoking history, steroid use, occupation, lifestyle regularity, psychological fatigue, physical fatigue, and average sleep time. The log LF/HF was significantly higher in the patient group than in the control group (P < 0.001). Log LF/HF was significantly lower in patients with exercise habits as a factor contributing to log LF/HF in the patient group (P = 0.019). Analysis of HRV in CSC patients showed an impairment of the autonomic nervous system. Exercise habits may also be associated with CSC.

Increased Risk of Central Serous Chorioretinopathy among Patients with Nonorganic Sleep Disturbance

Purpose

Patients with central serous chorioretinopathy (CSC) typically present with acute visual impairment and metamorphopsia. The disease previously has been associated with psychological stress. Population-based cohort studies on the risk of CSC among patients with nonorganic sleep disturbance (NOSD) are limited. An early sign of psychiatric disorder was probably sleep disturbance. Furthermore, psychological stress may be caused by sleep disturbance. We investigated the relationship between NOSD and the incidence of CSC.

Design

Longitudinal cohort study. Participants. We used the Longitudinal Health Insurance Database and collected the data of 53,743 NOSD patients without CSC between 2000 and 2005 as the study group. Four-fold controls were selected randomly from those without neither sleep disturbance nor a CSC history with frequency matching of age, sex, and index-year.

Methods

The difference in sex, age group, comorbidities, and steroid use between the two groups was analyzed by the χ ² test. Cox-proportional hazard regression was utilized to estimate the hazard ratio (HR) and 95% confidence intervals (95% CI) for comparison of the two groups. Kaplan-Meier analysis was applied to measure the cumulative incidence of CSC. Furthermore, the log-rank test was used to test the incidence difference between the two groups. Main Outcome Measures. The incidence rate of CSC in the following years until 2011 was detected.

Results

During a mean follow-up of 7.36 ± 2.88 years, NOSD patients had a higher incidence of CSC than the controls (3.10 vs. 1.86 per 10,000 person-years; adjusted HR, 1.65; 95% CI, 1.34-2.02). Men had a higher risk of CSC than women. Sensitivity analyses stratified by sex, age group, or comorbidity condition showed consistently that NOSD patients had a higher risk of CSC than their controls. Dose-response showed that higher NOSD severity had even higher CSC risk.

Conclusions

NOSD is an independent indicator for the increased risk of subsequent CSC development.

Central serous chorioretinopathy: Towards an evidence-based treatment guideline

Central serous chorioretinopathy (CSC) is a common cause of central vision loss, primarily affecting men 20-60 years of age. To date, no consensus has been reached regarding the classification of CSC, and a wide variety of interventions have been proposed, reflecting the controversy associated with treating this disease. The recent publication of appropriately powered randomised controlled trials such as the PLACE trial, as well as large retrospective, non-randomised treatment studies regarding the treatment of CSC suggest the feasibility of a more evidence-based approach when considering treatment options. The aim of this review is to provide a comprehensive overview of the current rationale and evidence with respect to the variety of interventions available for treating CSC, including pharmacology, laser treatment, and photodynamic therapy. In addition, we describe the complexity of CSC, the challenges associated with treating CSC, and currently ongoing studies. Many treatment strategies such as photodynamic therapy using verteporfin, oral mineralocorticoid antagonists, and micropulse laser treatment have been reported as being effective. Currently, however, the available evidence suggests that half-dose (or half-fluence) photodynamic therapy should be the treatment of choice in chronic CSC, whereas observation may be the preferred approach in acute CSC. Nevertheless, exceptions can be considered based upon patient-specific characteristics.

The Eysenck Personality Profile in Selected Groups of Ophthalmological Patients

Personality correlates in patients with eye diseases have bidirectional influence. It is possible that personality variables lead to behaviours that may influence the cause of eye problems, but the opposite is also possible, that eye problems could have a direct effect on personality. The aim of this study was to evaluate personality traits in patients with glaucoma, diabetic retinopathy and cataract using the Eysenck Personality Questionnaire. Obtained results showed similar personality profiles in patients with glaucoma, diabetic retinopathy and cataract. However, extraversion and neuroticism were higher in patients with diabetes, while the psychopathic traits are the highest in the group of cataract. Age and gender of patients do not influence the scores obtained on the questionnaire confirmed with one way ANOVA. Not significant difference in parameters (tested with Student t-test) was obtained between groups. It is proposed psychological evaluation to be included in the assessment of more serious eye diseases for helping patients to adjust and adapt to the condition and treatment.

Risk Factors for Persistent or Recurrent Central Serous Chorioretinopathy

Purpose

To investigate the risk factors for persistent or recurrent central serous chorioretinopathy (CSC).

Materials and Methods

Consecutive treatment-naïve CSC patients were included from January 2017 to October 2018. All patients were asked to complete questionnaires, addressing previously described risk factors for the development of CSC. Patients were divided into two groups: those with acute CSC, who were in the first episode, with spontaneous resolution of subretinal fluid within 3 months, and with no recurrence within 1 year; and those with persistent or recurrent CSC, the remaining patients.

Results

In total, 138 patients were enrolled: 20 (14.5%) with acute CSC and 118 (85.5%) with persistent or recurrent CSC. Using multivariate analysis, male sex (odds ratio (OR), 95% confidence interval: 5.63 [1.02–31.02]; p=0.047), older age (OR: 1.14 [1.03–1.25]; p=0.008), and higher Insomnia Severity Index score (OR: 1.30 [1.05–1.60]; p=0.015) were found to be independently associated with persistent or recurrent CSC.

Conclusions

Male sex, age, and sleep disorders are risk factors for persistent or recurrent CSC in the natural history. These patients may require early photodynamic therapy. Treatment for sleep disorders is strongly recommended. All CSC patients may require careful and periodic follow-up.

Investigating the Hypothesis of Stress System Dysregulation as a Risk Factor for Central Serous Chorioretinopathy: A Literature Mini-Review

Background: This mini-review addressed the question "what do we know about the association between the dysregulation of stress systems (HPA axis and SAM) and the onset and prognosis of CSC in adult populations?" Methods: The literature mini-review was conducted through electronic searches using the PubMed, Web of Science, and Scopus databases. All published human and animal studies with both observational and experimental designs from 1966 to October 2018 were included. Results: Our search identified 229 reports, of which 32 articles were ultimately identified to be reviewed in this paper. Among these key articles, twenty-three were related to exogenous and/or endogenous high glucocorticoids as risk factors for CSC, seven were related to Type-A behavior and chronic psychological distress as risk factors for idiopathic CSC, and two were related to stress-induced animal models of CSC. Nineteen out of twenty-three studies in the first group reported a consistent association between high circulating corticosteroids and the onset and prognosis of CSC. Six out of seven studies in the second group reported a consistent association between stress-induced allostatic (over)load and the appearance of more- or less-severe CSC disorders, assuming that elevated circulating steroids may constitute a kind of risk factor for the eye through dysregulation of the HPA axis. All the selected studies reported HPA axis dysregulation as a possible common factor to explain the association between high circulating corticosteroids and CSC. In contrast, the involvement of the SAM system is only indirectly taken into consideration through the PA and HR measures and/or plasma and 24-h urinary catecholamine levels. Therefore, information regarding the involvement of SAM system dysregulation in the onset and prognosis of CSC is lacking. This observation is particularly relevant in view of the fact that animal models of CSC in monkeys are primarily induced by adrenergic hypertonia and that the course of experimental CSC is not further exacerbated by the administration of corticosteroids.