Central serous chorioretinopathy and autonomic dysfunction

The guest editorial by Chawla R came up with the hypothesis that an inherent neurovascular sympathetic regulatory effect of the choroid is responsible for the pathogenesis of central serous chorioretinopathy (CSCR).[1] This same mechanism of CSCR was proposed by Lawrence Yannuuzzi in Type-A behavior individuals who are highly competitive, time conscious, ambitious, and easily frustrated types with excessive sympathetic discharge leading to stimulation of macular region intermittently or continuously causing adverse reaction.[2] In our ongoing study using the Minnesota Multiphasic Personality Inventory (MMPI), self-report inventories for psychiatric workup of CSCR patients will lead to deciphering the correlation better. Type-A personalities often experience high stress levels leading to the release of cortisol and catecholamines affecting the milieu interieur of the choroidal circulatory balance. In our study, a double-blind trial showed a higher incidence of psychosomatic diseases and personality disorders in the CSCR subgroup as diagnosed by a psychiatrist and advised treatments for the same. This reinforced our hypothesis of increased sympathetic activity leading to a hyperpermeability of the choroid causing pachychoroid syndrome leading to serous macular blebs and pigment epithelial detachments.[3] The author has suggested controlling blood pressure and therapies to reduce choroidal blood flow to ameliorate CSCR. In our paper, the affected patients were started on anxiolytic and antidepressant drugs in view of their psychiatric diagnosis which reduced their stress and the systemic autonomic dysfunction that indirectly also rapidly resolved their CSCR. The drugs prescribed in practice are benzodiazepines (Etizolaam 0.5 mg HS) for anxiety and selective serotonin reuptake inhibitors (SSRIs) (Ecistalopram 10 mg HS) in the depressive subset or a combination are used for a period of one to three-month duration. These drugs help in rapidly resolving CSCR subretinal fluid by breaking the vicious cycle of stress leading to autonomic dysfunction and end-organ (eye) damage. In Japan during my fellowship, stellate ganglion block with bupivacaine injections monthly was the modality of treatment for CSCR, which was a local therapy to block the autonomic dysfunction in the eye.[4] Lifestyle modifications that help to reduce stress are a part of the advice given to CSCR individuals, which include eating well, exercising regularly, getting adequate sleep, practicing meditation, social support, taking breaks, and avoiding substance use. Hence a holistic approach is necessary in ameliorating and preventing the recurrence of CSCR. Acute CSCR is usually a benign condition but chronicity leads to sick retinal pigment epithelium (RPE) and macular RPE degeneration, and secondary choroidal neovascular membranes need multiple anti-vascular endothelial growth factor injections. This opens Pandora’s box for treatment modalities for CSCR along with the proven treatments with half fluence photodynamic therapy using Visudyne and focal laser treatment leading to choroidal vasculature remodeling of the pachychoroid circulation. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.