Evidence supports association between CSC and exogenous glucocorticoid use

Central serous chorioretinopathy (CSC) is a common idiopathic retinal disease characterized by central vision loss from serous detachment of the neurosensory retina, serous pigment epithelial detachments and leakage of fluid through the retinal pigment epithelium into the subretinal space. The concept of an association between CSC and exogenous glucocorticoid use is widely accepted among ophthalmologists.

Sophie J. Bakri, M.D., and researchers with Ophthalmology at Mayo Clinic's campus in Rochester, Minnesota, analyzed the evidence for and against an association between glucocorticoids and CSC. Results of their study were published in Survey of Ophthalmology in 2018.

"CSC has been associated with several risk factors, including male sex, hypertension, alcohol use, gastroesophageal reflux disease, pregnancy and use of psychotropic medications. It is also traditionally and controversially associated with psychological stress and the Type A personality," says Dr. Bakri. "Perhaps the most widely accepted association, however, is that with use of corticosteroid medication. We wanted to determine whether that assumption was accurate."

The researchers conducted a systematic review of the literature using PubMed databases (search terms: "central serous chorioretinopathy," "central serous retinopathy" and "central serous") to identify studies for evaluation. Articles with data on steroids were identified via reviews of PubMed abstracts and citations in previous work on the subject. The researchers included case reports only if they contributed original information about steroid and CSC.

"Although our study also documents evidence related to other specific risk factors, we ultimately identified two large, case-control studies that found strong associations and a smaller, population-based study that found no association between CSC and corticosteroid medication," notes Dr. Bakri.

Research published in American Journal of Ophthalmology in 1999 studied systemic factors associated with CSC. The study included a total of 230 patients with CSC and 230 age- and sex-matched controls. Steroid use was defined as treatment for any medical condition with corticosteroids via parenteral, inhalational or topical steroid, excluding those who were treated with steroid for CSC itself. At presentation, 21 patients with CSC were using corticosteroid medications, whereas seven controls were using corticosteroids. This difference yielded an odds ratio of 3.2. Asthma and renal transplantation were the most frequent reasons for steroid treatment.

"The numbers were not sufficient for statistical analysis of route of administration, although three cases of CSC were associated with inhalational steroid use," says Dr. Bakri. Other statistically significant associations were identified, including hypertension and psychopharmacological medication use.

The second large case-control study, published in Ophthalmology in 2004, was a multicenter, retrospective study with 312 cases of both acute CSC and chronic CSC. Cases were compared with 312 age- and sex-matched controls. Only systemic steroid use was considered.

Forty-five cases and just five controls were using steroid medication at presentation, for an odds ratio of 10.3. Bivariate logistic regression analysis showed that steroid use remained a risk factor when corrected for autoimmune diseases. There were several additional statistically significant associations with CSC shown in this study, including alcohol use, antibiotic treatment, pregnancy, uncontrolled hypertension and allergic respiratory disease.

In contrast to these studies, a retrospective, population-based study from Olmsted County, Minnesota, failed to identify an association between CSC and steroid medication. This study, published in Ophthalmology in 2008, included 74 cases of CSC over a 22-year period that ended in 2002. Six (8 percent) patients with CSC were using corticosteroids at the time of diagnosis, and six of 74 controls were taking corticosteroids at the time of the study visit.

"This is the only major study that does not support an association between corticosteroid use and CSC, and the results of a long-term population-based study cannot be ignored," says Dr. Bakri. "Nonetheless, the sample size is small, and the retrospective design is a limitation."

Significant association

Dr. Bakri notes: "The preponderance of the literature on CSC and steroid medication suggests a significant association. Both exogenous and endogenous glucocorticoids have been implicated, and CSC has been associated with most routes of steroid administration. The association offers a potential target for treatment trials, although the mechanism of association remains to be established.

"The association deserves broader recognition among physicians who prescribe glucocorticoids. Also, CSC is uncommonly mentioned as a side effect of steroid use by nonophthalmologists. Patients would likely benefit from a broader understanding of this disease."

For more information

Nicholson BP, et al. Central serous chorioretinopathy and glucocorticoids: An update on evidence for association. Survey of Ophthalmology. 2018;63:1.

Tittl MK, et al. Systemic findings associated with central serous chorioretinopathy. American Journal of Ophthalmology. 1999;128:63.

Haimovici R, et al. Risk factors for central serous chorioretinopathy: A case-control study. Ophthalmology. 2004;111:244.

Kitzmann AS, et al. The incidence of central serous chorioretinopathy in Olmsted County, Minnesota, 1980-2002. Ophthalmology. 2008;115:169.