What are the top ten exacerbating factors for central serous chorioretinopathy in otherwise healthy adults, especially men aged 30‑50?

Top 10 Exacerbating Factors for Central Serous Chorioretinopathy

The most critical exacerbating factors for CSC are corticosteroid use (any route of administration), psychological stress, and hypertension—all of which are modifiable and should be aggressively addressed to prevent disease progression and recurrence. 1, 2

Primary Exacerbating Factors (Strongest Evidence)

1. Corticosteroid Use (Any Route)

• Systemic, inhaled, intranasal, topical, and periocular corticosteroids all trigger or exacerbate CSC 3, 2
• Steroid-associated CSC occurs bilaterally in 20% of patients and can develop days to years after initiation of therapy 3
• Patients have developed CSC after three separate types of corticosteroid administration routes 3
• Corticosteroid use carries an odds ratio of 3.17 (95% CI: 1.30-7.70) for CSC development 2
• Critical pitfall: Even low-dose or "topical-only" steroids can trigger CSC—no route is safe 3

2. Psychological Stress and Psychiatric Disorders

• Emotional stress and psychiatric illness are present in 35.71% of CSC patients 4
• Psychopharmacologic medication use carries an odds ratio of 2.6 (95% CI: 1.30-5.19) for CSC 2
• Historically recognized since 1955 as associated with "tense obsessional mental make-up" and stressful life situations 1

3. Type A Personality Trait

• Present in 26.19% of CSC patients 4
• Characterized by competitive, time-urgent, and hostile behavioral patterns 5, 6
• Predominantly affects men with this personality type 5

4. Hypertension

• Found in 11.90% of CSC patients 4
• Carries an odds ratio of 2.25 (95% CI: 1.39-3.63) for CSC development 2
• Represents a modifiable risk factor that may influence disease morbidity 2

5. Elevated Endogenous Cortisol

• Endogenous Cushing's syndrome is an established risk factor 6
• Elevated serum cortisol levels documented in CSC patients 4
• Suggests dysregulation of the hypothalamic-pituitary-adrenal axis 6

Secondary Exacerbating Factors (Moderate Evidence)

6. Smoking

• Present in 19.04% of CSC patients 4
• Likely contributes through vascular effects on choroidal circulation 4

7. Pregnancy

• Established risk factor, likely related to elevated endogenous cortisol and hormonal changes 6, 2
• Associated with increased choroidal hyperpermeability 6

8. Elevated Testosterone Levels

• Documented in CSC patients, contributing to male predominance 4
• Men develop CSC 3.5-fold more frequently than women (54.2 vs 15.7 per 100,000 person-years) 1

9. Acid Peptic Disease

• Found in 9.52% of CSC patients 4
• May reflect shared stress-related pathophysiology 4

10. Organ Transplantation

• Associated with CSC development, likely through both immunosuppressive medication use and physiologic stress 3, 5
• Transplant recipients often require chronic corticosteroid therapy, creating dual risk 5

Additional Recognized Factors

• Phosphodiesterase-5 inhibitors (e.g., sildenafil) are associated with CSC 3
• Obstructive sleep apnea contributes to CSC risk 3
• Helicobacter pylori infection has been implicated 3
• Elevated catecholamines related to stress response 3

Clinical Management Algorithm

Step 1: Identify and eliminate modifiable factors

• Discontinue all corticosteroids if medically feasible (coordinate with prescribing physician) 3, 5, 2
• Address hypertension with appropriate antihypertensive therapy 2
• Recommend smoking cessation 4

Step 2: Address psychological factors

• Screen for stress, anxiety, and Type A personality traits 4, 2
• Consider referral for stress management or psychiatric evaluation 4
• Review and optimize psychopharmacologic medications with psychiatry 2

Step 3: Monitor for recurrence

• 45% of patients experience recurrences, typically triggered by re-exposure to risk factors 3
• Patients with chronic CSC (>3 months) require more aggressive risk factor modification 3, 6

Critical Pitfalls to Avoid

• Never assume topical or inhaled steroids are safe—all routes of administration can trigger CSC 3
• Do not overlook psychiatric medications—these carry significant risk independent of stress itself 2
• Recognize that risk factors are cumulative—patients with multiple factors have higher recurrence rates 4, 2
• In transplant recipients, coordinate carefully with transplant team before modifying immunosuppression, as demonstrated by the case requiring nephrologist consultation to reduce prednisone from 60mg to 5mg daily 5