Central serous chorioretinopathy (CSC) is a common macular disease and often presents with well-circumscribed serous retinal detachment in the macular region on clinical examination, with one or several leakage points at the level of the retinal pigment epithelium (RPE) on fluorescein angiography (FA) [
The purpose of this case-control study was to investigate the risk factors for persistent or recurrent CSC in a Chinese population using a multivariate approach, thus to help to select the appropriate management strategy for CSC, waiting or PDT.
The approval of the Ethics Committee of Eye and Ear Nose Throat Hospital of Fudan University was obtained, and written informed consent was obtained from all patients before their enrolment in the study. The study adhered to the tenets of the Declaration of Helsinki.
The participants in this study were consecutive Chinese patients diagnosed with CSC at the clinic of the Eye and Ear Nose Throat Hospital of Fudan University between January 2017 and October 2018.
The clinical diagnosis of CSC was based on symptoms, reduced visual acuity with or without metamorphopsia or micropsia; the presence of serous retinal detachment on both fundus and optical coherence tomography (OCT) examinations; the presence of active angiographic leakage in FA (TRC-50IX; Topcon Corp., Tokyo, Japan); and/or abnormally dilated choroidal vasculature and other features in indocyanine green angiography (Spectralis HRA + OCT; Heidelberg Engineering, Heidelberg, Germany) consistent with the diagnosis of CSC [
The subjects included were those who had not been treated with PDT or laser and with clear symptom duration. Excluded were those with other ocular pathologies, such as age-related macular degeneration, diabetic retinopathy, uveitis, optic disc edema, Harada disease, or choroidal infiltrates. Previous studies have identified corticosteroids as a risk factor for the development of CSC, either high levels of exogenous (i.e., intra-articular, intranasal, systemic, or topical) or endogenous (i.e., Cushing’s syndrome or pregnancy) [
All patients were asked to complete questionnaires, which included previously described risk factors for the development of CSC [
The patients were divided into two groups. Group 1 had acute CSC, including those in the first episode, having spontaneous resolution of subretinal fluid within 3 months, and with no recurrence within 1 year. All these patients were monitored with OCT every 4 weeks for 1 year. Group 2 had persistent or recurrent CSC, including those in the first episode with persistent subretinal fluid (>3 m) and in the second or subsequent episode. The patients in Group 2 were prescribed half-dose PDT once the persistent or recurrent CSC was established.
The data were analyzed with SPSS for Windows version 21.0 (SPSS, Chicago, IL, USA). The calculated values are presented as frequencies (proportions), means ± standard deviations, or medians (P25, P75). The Kolmogorov–Smirnov test was used to confirm the normality of the data. For the evaluation of the factors possibly associated with persistent or recurrent CSC, a standard two-step approach was followed: univariate and multivariate logistic regression analysis. The outcome of CSC was treated as a dichotomous variable (0 = acute CSC and 1 = persistent or recurrent CSC). In the univariate analysis, Student’s
In total, 138 patients were enrolled in the study. Of these, there were 20 (14.5%) with acute CSC and 118 (85.5%) with persistent or recurrent CSC. The latter included 46 with persistent CSC and 72 with recurrent CSC. Table
Demographic and clinical data and univariate and multivariate analysis of risk factors for persistent or recurrent central serous chorioretinopathy.
Exposure | Acute CSC patients ( |
Patients with persistent or recurrent CSC ( |
Univariate analysis | Multivariate analysis | ||
---|---|---|---|---|---|---|
cOR (95% CI) |
|
aOR (95% CI) |
|
|||
Male sex | 14 (70.0) | 95 (80.5) | 1.770 (0.614–5.106) | 0.291 | 5.634 (1.023–31.024) | 0.047 |
Age | 41.00 ± 7.06 | 46.29 ± 8.84 | 1.086 (1.016–1.161) | 0.015 | 1.137 (1.034–1.249) | 0.008 |
Hypertension | 1 (5.0) | 26 (22.0) | 5.370 (0.686–42.023) | 0.109 | 2.140 (0.228–20.116) | 0.506 |
Depression | 4 (20.0) | 24 (20.3) | 1.021 (0.313–3.336) | 0.972 | 1.474 (0.338–6.434) | 0.606 |
Allergic diseases | 4 (20.0) | 23 (19.5) | 0.968 (0.296–3.172) | 0.958 | 3.670 (0.826–16.310) | 0.088 |
Tobacco use | 7 (35.0) | 52 (44.1) | 1.463 (0.545–3.930) | 0.450 | 0.870 (0.227–3.332) | 0.839 |
Life changes | 3 (15.0) | 17 (14.4) | 0.954 (0.252–3.608) | 0.944 | 0.603 (0.119–3.066) | 0.542 |
Stress at work | 11 (55.0) | 47 (39.8) | 0.542 (0.208–1.407) | 0.208 | 0.520 (0.163–1.661) | 0.270 |
Monthly amount of alcohol consumed (standard drink) | 0.00 (0.00, 10.14, range 0.00–84.55) | 3.38 (0.00, 33.81, range 0.00–169.07) | 1.019 (0.995–1.043) | 0.121 | 1.020 (0.993–1.048) | 0.146 |
Monthly shift work hours | 0.00 (0.00, 10.25, range 0–171) | 0.00 (0.00, 45.75, range 0–360) | 1.009 (0.995–1.023) | 0.232 | 1.008 (0.992–1.025) | 0.338 |
Sleep beginning time |
−1 (−2, 0, range −3–1) | −1 (−2, 0, range −4–7) | 1.115 (0.823–1.511) | 0.483 | 0.966 (0.542–1.720) | 0.906 |
Sleep hours per day | 7.5 (7, 8 range 5–8) | 7.0 (6, 8 range 2–11) | 0.805 (0.584–1.110) | 0.185 | 1.207 (0.677–2.154) | 0.523 |
ISI score | 1 (1, 4, range 0–10) | 3 (1, 9, range 0–22) | 1.174 (1.011–1.364) | 0.035 | 1.298 (1.051–1.604) | 0.015 |
aOR = accurate odds ratio; CI = confidence interval; cOR = crude odds ratio; CSC = central serous chorioretinopathy; ISI = Insomnia Severity Index; age is presented as mean ± standard deviation; other continuous variables are presented as median (P25, P75, range); all categorical variables are presented as number (%).
The present case-control study showed that male sex, older age, and higher ISI score were independent risk factors for the persistent or recurrent CSC in a Chinese population.
The present case-control study showed that male sex, older age, and higher ISI score were independent risk factors for the persistent or recurrent CSC in a Chinese population.
The reported male : female ratios in CSC patients ranged from 2.6 : 1 to 7 : 1 [
Consistent with previous studies [
It has been reported that sleep disturbance is significantly more frequently observed in CSC patients than in matched control individuals [
Haimovici reported that alcohol use was an independent risk factor for the onset of CSC [
Previous studies have compared CSC patients with normal controls to identify the risk factors for the development of CSC. However, we are more interested in the difference between patients with acute CSC and those with persistent or recurrent CSC. Therefore, our results should offer practical suggestions for the management of CSC patients. For patients considered to experience acute CSC (who are female, young, and enjoy good-quality sleep), a waiting strategy with regular follow-ups is reasonable, with PDT an optional therapy. However, for those deemed to suffer persistent or recurrent CSC (who are male, elderly, and/or have poor sleep quality), PDT is better applied early. The management of the risk factor by the treatment of sleep disorders should be recommended to the appropriate CSC patients. These risk factors could also be useful in designing future randomized studies of CSC, to limit any potential bias. We hope that the identification of these risk factors sheds some light on the mechanism of CSC.
The limitation of this study included the small sample and especially the small group of patients with acute CSC. Ozkaya reported that approximately 1/4 CSC patients experienced spontaneous resolution of subretinal fluid and without recurrence within 1 year [
This study has shown that male sex, age, and sleep disorder are risk factors for persistent or recurrent CSC in the natural history. Male patients, older patients, and those suffering poor sleep quality may require early PDT. Treatment for sleep disorder should be strongly recommended. All the CSC patients may require careful and periodic follow-up.
Acetaldehyde
Central serous chorioretinopathy
Fluorescein angiography
Insomnia Severity Index
Optical coherence tomography
Photodynamic therapy
Retinal pigment epithelium.
The questionnaire data used to support the findings of this study are restricted by the Ethics Committee of Eye and Ear Nose Throat Hospital of Fudan University in order to protect patient privacy. Data are available from Qing Chang (
The authors declare that they have no conflicts of interest.
Qing Chang and Xiaofeng Ye contributed equally to this work as corresponding authors.
This work was supported by the National Natural Science Foundation of China (Grant no. 81570854), the Science and Technology Commission of Shanghai Municipality (Grant nos. 16411953700 and 18411965100), the Shanghai Hospital Development Center (Grant no. SHDC12016116), the National Key Research & Development Plan (Grant no. 2017YFC0108200), and the Youth Project of the Shanghai Municipal Commission of Health and Family Planning (Grant no. 20164Y0061).