CSCR

1. Central Serous Chorioretinopathy
treatment with
Anxiolytics and Antidepressants
Ajay Dudani
K. J. Somaiya Hospital
MUMBAI RETINA CENTRE

2. CENTRAL SEROUS RETINOPATHY
Introduction :
• Von graffe : 1866 : a disease of macula characterised
by recurrent serous macular detachment: recurrent
central retinitis
• Maumenee: leak at the level of RPE results in
detachment of macula
• Bennet: 1955: central serous retinopathy
Currently accepted name is CSCR

3. INTRODUCTION
• A chorioretinal disorder
characterized by an
idiopathic localized serous
detachment of the neural
retina in the macular
region
– Unilateral
– Pigment epithelial
detachment
– Relative preservation of
visual function despite
prolonged separation of
neural retina from the
RPE

4. CLINICAL FEATURES
• Age: 20 – 50 years
• Gender: Male > female
• Increased incidence in:
– Emotional stress
– Type A personality
– Physical Strains
– People engaged in visually
demanding work
– Systemic steroids
– Vasoconstrictive agents
– Hypertension
– SLE
– Endogenous
hypercortisolism

6. COURSE & OUTCOME
• 80-90% - spontaneous resolution in 3-4 m
• 40-50% - experience one or more recurrences
• SHORT: <6m
– Normal or near normal vision
• Prolonged: 6-12 m
– No significant disability
• Chronic: >12 m
– Significant disability & occasional development of CNV
– May be a consequence of multiple recurrent attacks or
prolonged detachment.
Gilbert CM et al., Br. J. Ophthalmol 1984; vol 68.

7. CSCR
• IT IS NOT ALWAYS BENIGN
• MAY LEAD TO PERMANENT RPE
CHANGES AT MACULA
• CHRONIC OR RECURRENT CASES DO
HAVE VISUAL LOSS OF MILD TO
MODERATE DEGREE
• HENCE THE NEED FOR TREATMENT

8. DIAGNOSIS
• FFA critical to detect the extent of the retinal
abnormalities and to exclude the presence of other
ocular pathology
• Slit lamp examination:
• Indocyanin Green (ICG) Angiography: helps to
exclude other pathology when FFA is atypical
• Optical Coherence Tomography(OCT): Can be
used to quantify the amount and extent of subretinal
fluid

9. TREATMENT
• Observation: 3-4 months in most first episodes of
unilateral CSCR
• Laser photocoagulation
• Systemic beta blockers: may have a beneficial role,
but not well proven
• PDT: chronic severe, exudative CSCR
• Micro pulse Diode Laser
• Anti-Vascular Endothelial Growth Factor (Anti-
VEGF) agents

10. TREATMENT
• STRESS AND TYPE A PERSONALITYARE
RISK FACTOR
• STRESS IS COTICOSTEROID STIMULANT
• CORTICOSTEROIDS ARE KNOWN TO
CAUSE CSCR
• HENCE THE ROLE OF ANXIOLYTICS
AND ANTIDEPRESSANTS TO BREAK
THIS VICIOUS CYCLE

11. AIM
To study the effectiveness of oral anxiolytic
and antidepressants in resolution of central
serous chorioretinopathy in type A personality
patients with anxiety disorder.

12. MATERIAL AND METHODS
• About 100 patients of CSCR were evaluated
over 2 yrs
• Acute and chronic
• BCVA: Snellens chart(Near and Distance)
Retinoscopy(Dilated)
Subjective refraction
• SLITLAMP: Fundus examination

13. MATERIAL AND METHODS
• FFA: Anatomical improvement
1st Visit & 1 Month follow
• OCT: Resolution of subretinal fluid
1st Visit & as required
• Follow up – 3 weeks, 6 weeks & as required
• A random subset of 10 patients were referred
to the Psychiatric department for evaluation.

14. MATERIAL AND METHODS
• OPD papers with psychiatric evaluation.

15. MATERIAL AND METHODS
• Treatment
Monotherapy: Clonazepam(0.5mg) or
Etizolam(0.25 mg - 0.5mg)
Twin therapy: Escitalopram(10mg) added
• Lifestyle modification : Conscious effort to reduce stress
Yog Abhyas
Spa
Exercise
Relaxation therapy
Break from hectic work schedule
Vacations

16. Patient profile
• Anxiety disorders
• Panic diorder
• Generalised anxiety disorder
• Depression
• Adjustment disorder
• Acute stress

17. Drugs
• Etizolam is a benzodiazapene
derivative:theinodiazapene
• Instant relief of panic and anxiety
• Binds to GABA RECEPTORS : CNS sedation
• Side effects drowsiness ‘weakness lethargy

18. drugs
• SSRIs ; selective serotonin uptake inhibitors:
escitalopram
• Effect starts in weeks
• Increased mood and
• Decreased anxiety
• Side effects: dry mouth, nausea, dizziness,
drowsiness ,headache

19. MATERIAL AND METHODS
• Follow up : Till 6 months to 2 years in all
patients
Continue drugs till 3 months after
remission
Monitored at regular interval,
clinically and on OCT.

20. case1
• 45 yr lady
• Severe stress
• Daughters wedding
• Twin therapy

21. 18.03.2013 (pre treatment) 01.05.2013 (post treatment)

22. 03.06.2013 (post treatment)

23. Case2
• 40 yr lady
• Bank employee
• monotherapy

24. 22.02.2013 (pre treatment) 16.05.2013 (post treatment)

25. case3
• 40 yr male
• Working in dubai
• Family in india
• Chronic cscr
• 2 yr recurrence

26. 06-01-2013 (pre treatment)
11-02-2013 (post treatment)

27. 23-06-2013 (pre treatment)
24-07-2013 (post treatment)

28. case4
• 35 male
• Immigrating to canada

29. 19.06.2013 (pre treatment) 30.07.2013 (post treatment)

30. case5
• Builder ‘s sister
• Family dispute
• No resolution with twin therapy
• Half fluence PDT
• EXUDATIVE CSR resolved in 2 weeks
• PL to 6/12
• Macular atrophy

31. 20.11.2012 (pre treatment) 26.03.2013 (post treatment)

32. Post PDT (1 week) Post PDT (1 month)

33. 07.01.2013 (pre treatment)
02.02.2013 (post treatment)

34. 20.01.2013 (pre treatment)
19.02.2013 (post treatment)

35. 09.06.2013 (pre treatment)
15.07.2013 (post treatment)

36. OBSERVATIONS AND RESULTS
• Vision improvement in all acute case 6/6 – 6/9
• 2 PDT patients 6/9 – 6/12
• Chronic CSR ≤ 6/12

37. OBSERVATIONS AND RESULTS
• Acute cases – rapid resolution of fluid
90% -- resolved in 2-3 weeks
Mono/twin
therapy
08% -- resolved in 2-3 months
02% -- exudative CSCR Half
fluence PDT

38. OBSERVATIONS AND RESULTS
• Rapid resolution of CSCR fluid in acute cases within 2-3 weeks ,in 90%
eyes with Monotherapy Etizolam treatment vs. natural history of 1-6
months leading to dry macula.
• 8/10 patients -rapid improvement in vision and total resolution with twin or
monotherapy,
• 2/10 patients - with exudative CSCR needed half fluence PDT with
Visudyne. However these patients had macular atrophy due to damage to
chorio capillaries and improved only till 6/12 from 6/60, with complete
anatomical resolution.

39. OBSERVATIONS AND RESULTS
BCVA OF 10 PATIENTS
1 2 3
3 pts
2 pts
5 pts
6/60
6/24
6/12
6/9
6/6

40. OBSERVATIONS AND RESULTS
0
1
2
3
4
5
6
BCVA 20/20 20/40 20/60 total
CSR patients
Acute
Chronic

41. HYPOTHESIS
Anxiety disorder
Less emotionally stable
High anxiety level
Tend to experience certain event more
specific than other
Catastrophisation
(thinking of problem as catastrophe)

42. HYPOTHESIS
Migrant population social isolation
Inability to adapt to stress
Depression
Repeat release of stress hormone
Dysfunctional HPA
Disrupts normal level of serotonin(well being)

43. CSCR
delays d healing of RPE defect
Suppressing the synthesis of extra cellular matrix components
Increases capillary fragility & permeability
Anti-inflammatory property
Increases capillary fragility & permeability
Reduce formation of NO
Corticosteroids
STRESS

44. OTHER FACTORS
Catecholamines
alteration of blood flow
in choroid circulation.
vasoconstriction
Catecholamines

45. • YANNUZZI HYPOTHESIS
“Biochemically mediated (adrenergic) alteration in
macula, damage and hyperpermiability of
choriocapillaries leading to degeneration of few RPE
cells breakdown in posterior blood – retinal barrier.”
In people genetically prone to retinal disorder ,high
level of glucocorticoids may cause temporary
problems.
If Stress is alleviated hormones normal
reduced glucocorticoids.
Study done by National Eye Institute,Macular degeneration Support, Inc. May 7,2000

46. CSCR
delays d healing of RPE defect
Suppressing the synthesis of extra cellular matrix components
Increases capillary fragility & permeability
Anti-inflammatory property
Increases capillary fragility & permeability
Reduce formation of NO
Corticosteroids
STRESS
SSRIs

47. Anxiety and corticosteroids
Stress
Glucocorticoids
Activation of
catechoalmines
CSCR
Anxiety
Disorder
Science. 2013 Jan 18;339(6117):332-5. doi: 10.1126/science.1226767.
Chronic stress triggers social aversion via glucocorticoids receptor in dopaminoceptive neurons. Baric J, Marti
F, Morel C, Fernandez SP, Lantern C, Godhead G, Dassin JP, Mombereau C, Faure P, Tronche F.

48. CONCLUSION
The study demostrated the effectiveness of
anxiolytics in CSCR management leading to
rapid resolution and reduction in recurrence,
along with life style modifications.

49. THANK YOU