I am suffering from CSR or - Central Serous Retinopathy. Thankfully this happens one eye at a time and heals by itself (though takes a very long time)
Actually the doctors were not very clear about what caused it. did have a certain eye problem since 21 years. I used to see floaters and flashes. However the Retina scpecialists had sealed (what they called holes) in my retina using laser. I am not whether I really needed that treatment. Things went on smoothly since then.
However when I was 28, and working really hard on my venture, suddenly out of nowhere a blister appeared in the retina of my right eye and devastated my vision in the right eye. For quite a while I was not able to make out much from that eye. I went to several doctors who did not have an adequate explanation of the whole thing and advised Lucentis injections. Now these were very costly injections, eash costing 1000$ and would need multiple times every year, with 1% mortality seen in the users due to stroke.
I decided to give such a treatment a pass, even though Shroff eye hospital at Daryaganj told me they havent seen any improvement in cases like mine without the strong anti - carcinogen drugs. They said it was like cancer of the retina. However they could not guarantee any improvement in vision (which was pretty bad and I had lost more than 4 lines on the reading chart)
I went with what my uncle said. I have a lot of respect and faith on him, he is a practising homeopath and naturopath. The vision returned to 6/6 (although after 7 months) by homeopathic and accupuncture treatment. There was some distortion which has since remained, but I am lucky as per conventional doctors to have the kind of vision I have. And what they had been calling TB/cancer of retina, was eventually labelled Central serous retinopathy. Cause for which is stress and which heals itself.
Today I was trying to understand how Stress can cause CSR. Here is a veyr interesting article, and I could also see a possibility that my CSR and Diabetes both could have been caused by high Cortisone (being under stress). I am a type-A individual who tends to be very aggressive and gets angry a lot.
CSR - Central Serous Retinopathy
Adapted from: Central Serous Retinopathy
What is CSR?
CSR is a condition which causes temporary or permanent impairment of vision. The symptoms are loss of sensitivity in dim light, usually in an oval shaped gray or brown area, blurring or distortion of the visual image. It is a result of the detachment of most of the layers of the retina (the back of the eye) from its supporting tissue as a result of the buildup of fluid. The buildup of fluid appears to be due to one or more small breaks in the retinal pigment epithelium.
The term "idiopathic CSR" which you may see used simply means that the cause is not known. It affects primarily males between 20-45 and is associated with stress. For example, airline pilots suffer from it at a high rate, and some people find that attacks go away if they go on vacation. There have been some attempts to classify different forms of the disease but they are tentative and not linked to different causes or treatments.
Outcomes
Usually the fluid build up disappears after a few weeks to a few months with little long term damage. During this time the condition often fluctuates wildly on a daily or hourly basis. It particularly gets worse when under stress, tired or ill.
However recurrences are quite common and damage can accumulate over time. Significant, disabling damage can accumulate over time. If the detachment persists for too long the retina is starved of nutrients and can be damaged permanently, with a permanent gray area or a blind spot. The likelihood of recurrences is higher if the initial attack is more severe.
There are wide variations in the estimates of recurrence rates. Opinions also vary on the risk of the condition occurring in the other eye. Often patients are told that recurrences are rare, and that there is no need for concern. While this may be true in many cases, there is reason to doubt that this complacent attitude is correct.
A long term study of patients with CSR found that 50% of patients get the severe and extensive form of the disease after 12 years of evolution (Reference 1). It may be that the complacent attitude of clinicians is a result of the fact that they provide no effective treatment, so patients drift away and there is no long term visibility to the evolution of the condition.
Standard Treatment
There is no effective clinical treatment for the condition.
Laser treatment has been used but research results suggest that the treatment does not improve the long term outcomes. The laser therapy effectively 'burns' the leak shut, but can cause damage.
It can be used to overcome the immediate problem, for example if an attack is preventing studying for examinations. This may also be useful if an attack goes on for a long time - more than a couple of months, depending on how severe the attack is. A long standing attack can cause permanent damage to the retina and in this case laser treatment may be a good idea as a way to prevent permanent damage.
Recently more refined laser treatments have been used as certain frequencies of light cause less damage than standard frequencies.
Stress and CSR
CSR is associated with stress. Individuals who report being under stress and people who are in objectively stressful occupations such as airline piloting are susceptible to CSR. Stress includes pain, infection, excessive heat and cold, low blood sugar, excessive exercise, hunger and crash diets, jet lag, lack of sleep, psychological stress and also very intensive exercise.
Stress causes the adrenal cortex to secrete cortisol and this may be the link between stress and CSR. There have been some studies which suggest that the link is instead due to the increased adrenaline that comes with stress but these studies appear to be flawed due to lack of control for blood pressure.
High endorphin levels (a result of pain or excess exercise) or opiate levels (from use of heroin or morphine as drugs or as pain killers) are also associated with CSR.
CSR sufferers have usage rates for tranquillizers much higher than the general population, are more susceptible to high blood pressure, and are more likely to be users for cortisone steroid medications.
High cortisol levels are often but not always a result of stress. See below for the linkage between cortisol and CSR.
Cortisol and CSR
What is Cortisol?
Cortisol is a hormone secreted by the adrenal cortex which assists the body to deal with various stresses. It reduces inflammation and immune system function and triggers the breakdown of protein into sugars.
A certain amount of cortisol is necessary for life. Without cortisol even a small amount of stress will kill you. Addison's disease is a disease which causes low cortisol levels, and which is treated by cortisol replacement therapy.
Cortisol Associated with CSR
CSR is associated with high cortisol levels. That is, people with high cortisol levels are more likely to suffer from CSR, and people with CSR generally have high levels of cortisol.
CSR sufferers have high levels of cortisol made by their own adrenal gland (50-80% higher than the average, and outside the normal range) (Reference 3).
CSR is also associated with treatment by corticosteriods ("cortisone") for other conditions such as allergy and inflammation. These drugs go under names like Hydrocortisone, Cortisone and Prednisolone. There have been several cases where CSR has recurred during each of several courses of treatment with cortisone drugs and gone away each time the treatment was stopped. Usually, doctors will claim that nasal sprays and skin creams are not absorbed into the body and will not therefore cause adverse side effects. However in a number of cases this information has turned out to be unreliable and CSR attacks have ceased when the treatment was terminated. Doctors do sometimes have a psychological tendency to believe that their treatments are more effective, less painful and less damaging than they really are.
CSR is also associated with pregnancy (which generates very high cortisol levels in some cases). The high levels are cortisol in pregnancy and the body's need to protect against this may explain why women are less prone to getting CSR than men.
The association of objective and subjective stress with CSR also points to cortisol because stress raises cortisol levels. In addition, a high level of CRF, the hypothalamic hormone which drives cortisol levels, causes a subjective experience of stressfulness.
The incidence of CSR in people suffering from Cushing's syndrome is about 5%, a very high level. Cushing's syndrome consists of very high cortisol levels usually caused by a tumor in the pituitary gland or in the adrenal glands. Again this confirms the linkage between cortisol and CSR, but also suggests that high cortisol is not enough to cause the disease on its own. Presumably some other weakness plays a part.
Adverse Effects of Excess Cortisol
Cortisol is a powerful chemical and has numerous adverse effects in excess. It is therefore recommended that cortisone medication be taken in as small a dose as possible for as short a time as possible. A partial list of the adverse effects of cortisol follows:
- Immune system suppression.
- Loss of muscle tone.
- Accumulation of body fat
- Depression and anxiety. Initially, however cortisol can produce a short term euphoric effect.
- Increased permeability and fragility of the linings of blood vessels.
- Loss of bone mass, leading to osteoporosis.
- Damage to the hippocampus, a brain area associated with memory.
Controlling Cortisol Levels
Cortisol Regulation by the body
The body's control of cortisol levels is complex. The PVN area within the hypothalamus secretes a substance called CRF (corticotropin releasing factor). This is picked up by the pituitary gland which then secretes ACTH (adrenocorticotropic hormone). In turn this causes the adrenal cortex to secrete cortisol.
The hypothalamus acts as the body's stress detector and drives cortisol production in this way as a response to stress.
Negative feedback mechanisms exist between the body's cortisol levels and the pituitary and hypothalamus to keep the cortisol levels within reasonable bounds in normal circumstances. The negative feedback is more effective in controlling high cortisol that results from psychological stress than high cortisol that results from physical damage such as blood loss or illness.
One unfortunate fact about the body is its tendency to resist any change. For example if you go in a diet the body increases subjective hunger and decreases metabolic rate, thus 'helping' you not to lose weight. The same thing applies with many of the techniques to reduce cortisol levels. They may work for a while but then the body adapts and levels return to the original values. So it may be necessary to keep revising your strategies.
Factors that elevate cortisol
Drugs like caffeine and nicotine tell the hypothalamus that you are under stress, leading to increased cortisol levels, as well as increased adrenaline levels. The increase in cortisol levels from consuming 4-5 cups of coffee per day may be of the order of 50-60% and the increase is highest in people who are already prone to high levels of cortisol. There are anecdotal reports that other stimulants are also associated with CSR attacks e.g. ephedrine (found in decongestants and herbal weight loss preparations).
Stress increases cortisol levels. This includes all the forms of stress described above. However the body is better able to control cortisol levels that result from psychological stress than those that result from physical stress.
Cortisone steroid drugs mimic the effect of high cortisol levels.
There is a lot of evidence that a stressful childhood leads to a permanently increase susceptibility to stress and increased CRF levels from the hypothalamus leading to higher cortisol levels. The stresses in childhood can range from separation from the mother through to physical and sexual abuse, hunger and disease. This can sensitize the hypothalamus and make it "trigger happy".
Stress in CSR Sufferers
While many CSR sufferers live objectively stressful lives as pilots etc, others suffer from high levels of subjective stress although their lives do not appear to be inherently stressful. For these people, it is not entirely clear why they would have high levels of subjective stress.
This may be due to an inherent metabolic tendency to over-produce adrenaline and cortisol which produce subjective feelings of stress via brain receptors for those hormones.
Another explanation is that a stressful childhood can lead to an overactive hypothalamic stress detector, leading to the production of adrenaline and cortisol in relatively normal circumstances. There is considerable animal research to suggest this does occur.
It is also possible that the person may have poor strategies for dealing with stresses. Studies have suggested that many CSR sufferers have 'Type A' personality which describes a tendency to be unable to relax. Do not assume that the cause is psychological though. In the past many conditions thought to be of psychological causes have turned out to have significant or dominant physical causes, for example severe depression and schizophrenia. In a sense then, psychological explanations are the explanation of last resort for the clinician who has no answers, and often amounts to a strategy of 'blame the patient'. The so-called 'schizophrenogenic mother' is a notorious example of this syndrome.
Having said that, there are a lot of effective stress management techniques available. See below.
Finding Someone Qualified
The condition is fairly unusual so it is difficult to find someone who is fully qualified to treat it, or even to diagnose it. It is quite common for serious and obvious illnesses to go undiagnosed for years. A recent study found that the average time to diagnose Cushing's Syndrome, a very serious illness sometimes associated with CSR, was 3 1/2 years.
There are several conditions that can be confused with CSR, such as Age Related Macular Degeneration and diabetic retinopathy, which are more common. It is important to have the diagnosis confirmed and tests are available to verify the leakage of fluid that is characteristic of CSR.
A retinologist, not just an ordinary ophthalmologist, can diagnose the condition. Because the condition initially causes a quite subtle loss of vision, an ophthalmologist may even tell you that there is nothing wrong.
You should then be able to get your cortisol tested without too much trouble to confirm the link with high cortisol in your case, unless you are using cortisone medication or are already aware of a high cortisol level.
In theory the best person for dealing with the high cortisol is an endocrinologist. However the levels of cortisol in CSR are generally not high enough to qualify as a case of Cushing's syndrome. Cushing's syndrome is the classic high cortisol disease. As anti-cortisol drugs can have adverse side-effects, you are likely to find a high degree of reluctance to provide any treatment.
This is very frustrating. Doctors prescribe cortisone treatments quite freely, even though it has severe side effects. On the other hand there is a high degree of reluctance to prescribe anti-cortisol treatments even when cortisol levels are high, in the name of 'accepted clinical practice'.
The other problem with endocrinologists is that in most cases of CSR the root cause of the high cortisol seems to be the hypothalamus which is part of the brain, and so is not in the jurisdiction of the endocrinologist. The brain is also far more complicated than the endocrine system.
Potentially a neurologist may be able to help if, as appears often to be the case, the condition is driven in many cases by an overactive hypothalamus. However you will probably find an even greater reluctance to do anything about the hypothalamus than is the case for the adrenal gland and its cortisol. The hypothalamus is very complex and plays a critical role in many vital body functions.
If you have high cortisol levels but do not have the tumor characteristic of Cushing's disease, your condition is likely to be labeled as "pseudo-Cushing's syndrome". The term is unfortunate because the high cortisol and the damage that results, is just as real as in the real thing. Pseudo-Cushing's syndrome is believed to be due to excessive alcohol consumption or psychological depression or stress. However a recent study has established that a significant proportion of the population has a genetic predisposition to high cortisol levels, so it may not all be in your mind after all.
On the positive side, practitioners will most likely find your condition interesting.
What you can do
Reduce stress levels. This is easier said than done. How do you measure your stress level? You need to find some objective thing that relates to stress e.g. overeating, nervous habits etc, or you could monitor your cortisol levels as a proxy for stress. To the extent that CSR sufferers are type A personalities, they are "Stress junkies" and may find ways to bring stress/excitement back up to a level they feel happy with. So you need to find a way to have a less stressful life that does not seem dull.
Studies tend to suggest that biofeedback, meditation, taking a philosophical approach to adversity etc are not that effective in controlling this condition. However in my experience by reducing both objective stress and by working on how you react to stress, it is possible to help control the attacks. Your mileage may vary but I have found the techniques in "Ultimate Power" by Tony Robbins very helpful, and yoga also helps, though the slow pace of it is infuriating to the Type A personality.
In the case of excess alcohol consumption reducing alcohol intake is effective in dealing with pseudo Cushing's syndrome.
- Monitor cortisol levels. For this you need a friendly doctor to order the tests. However do some extent you can get a feel for your cortisol levels. Some signs of high cortisol are a dark or sunken look around the eyes, fatigue but having trouble sleeping, and lack of motivation. See other symptoms on the Checklist.
Give up caffeine and other stimulants - cocoa, coffee, tea, chocolate etc. Also give up smoking if you smoke. Caffeine is a dangerous, addictive and destructive drug. Even the levels in decaf may be harmful - the author has been able to turn CSR on and off by starting and stopping coffee drinking and even decaf has the same effect.
Caffeine has a number of effects. One is the stimulating effect on the pituitary which peps you up and drives up cortisol. The other is the increased levels of dopamine, which is the same neurotransmitter that makes heroin, amphetamines and cocaine so appealing to many. This is one reason why you may find caffeine difficult to give up.
Avoid "cortisone" treatments (corticosteriod treatments) for other diseases if you can avoid them as they may "have disastrous results" (Reference 13) for CSR sufferers. Generally cortisone treatments are heavy medicine and can cause numerous side effects including depression, immune system damage, loss of muscle tone and accumulation of fat, osteoporosis and damage to certain parts of the brain. Unless you are actually deficient in cortisol, be wary of using these treatments.
Avoid unnecessary stress. This includes disease, excessive exercise, crash diets, jet lag, pain, lack of sleep, as well as psychological stress. Meditation and other relaxation techniques may assist, in spite of the studies mentioned above. In relation to psychological stress, the big stressors are babies, job changes, moving house, financial difficulties, death of someone close, marriage and divorce. You cannot go through life and avoid all these things, but you may be able to time them better and avoid clusters of big stressors. Financially you may choose to get less involved in "keeping up with the Joneses" type activities, and avoid high levels of debt. Pets in particular dogs have been shown to reduce stress levels, and taking a dog for a walk is also good for you.
CSR may get worse even during a cold or sore throat so it is important to avoid being exposed to these diseases. Tooth decay is another form of infection and should be treated as soon as possible. Any form of infection will push up cortisol levels.
Review your use of aspirin. Reduce if excessive. There is some evidence that aspirin may increase the leakage of fluid from capillaries. However aspirin can reduce high cortisol levels that result from pain (Reference 12), and can be an alternative to steroid medications.
The following vitamins and minerals may assist within a balanced program of supplements: Minerals zinc, magnesium, manganese, calcium, and vitamins B6, Pantothenic Acid (B5) and vitamin C. A person with high cortisol levels will also be susceptible to osteoporosis and should take care to get adequate calcium, vitamin D and Magnesium as well as protein. Bioflavinoids may also help as a deficiency is known to increase the fragility of capillary and other membranes.
Here are some recommendations from "Prescription for Nutritional Healing: A Practical A-Z Reference to Drug-Free Remedies Using Vitamins, Minerals, Herbs, and Food Supplements" by James and Phylis Balch. Note that some of these are pretty high doses especially A C and B - be careful and always wean gradually of vitamins due to the risk of induced deficiency with sudden withdrawal.
- Calcium 1000mg daily
- Magnesium 500mg daily (a 2:1 ratio of Ca to Mg helps microcirculation in the eye)
- Selenium (100-200 mcg daily) and Superoxide dismutase (SOD) as directed on the label. Potent free radical scavengers. Free radicals have been implicated in damage to the retina and microcirculation in the eye.
- Vitamin A 75,000 IU daily. If you are pregnant, do not exceed 10,000 IU daily. Use emulsion foam for easier assimilation and greater safety in higher doses.
- Vitamin C 2,000 mg three times daily
- Vitamin E 400 IU daily
- Vitamin B complex 100mg daily. Improves intraocular cellular metabolism
- Fresh fruits, yellow and yellow-orange vegetables.
- Desiccated liver - numerous nutrients
- Free form amino acids - for protein
- Zinc - 50mg daily
- Carrot juice
- Cut out sugar and white flour
- Limit ultraviolet rays, by using glasses that keep them out, but do not wear dark sunglasses, because you need some light to keep the pineal gland working, to avoid seasonal affective disorder and insomnia.
- Avoid drugs that damage the eyes - ACTH (Acthar, Cortrosyn)
- Include green vegetables (broccoli, raw cabbage, carrots, cauliflower, squash, sunflower seeds and watercress.
- Increase lean protein consumption. This may improve the integrity of the membranes that retain the sometimes-leaking fluid. Cortisol is known to 'burn' protein so this seems like a prudent precaution in any case. This is particularly an issue if you are on a low protein diet, such as many vegetarian diets, or the Pritikin Diet or its variants such as the Ornish Diet.
- Some people have found that drinking vegetable juices such as carrot, celery, parsley, spinach along with wheatgrass juice also helps.
- An endocrinologist may be able to reduce your cortisol level via medications but it is unlikely they will be prepared to do so. See drug treatment below.
- Tranquillizers, including diazepam, Prozac and tri-cyclic anti-depressants, may also reduce cortisol levels. The anti-stress herb St John's Wort is also reported to reduce CRF and Cortisol levels, with fewer side effects than prescribed medicines.
There are not many good drugs to control cortisol levels. They all seem to have side effects. The most benign seem to operate on the adrenal, but have the problem that they indirectly cause the pituitary to emit larger amounts of ACTH, which may not be good because ACTH drives the production of other hormones, which may cause fluid retention or masculinization. There is some research going on in this area because high cortisol levels seem to speed the progress of AIDS.
The following drugs have been suggested as possible aids to CSR treatment. Note that none can be considered proven treatments and all may have side effects, and should be used only with great caution if at all.
- St John's Wort is reported to reduce CRF and Cortisol levels. Recently it has been claimed that St John's Wort leads to an increase in anti-oxidants and therefore may increase the risk of cataracts, although there was no direct evidence that cataracts are caused by St John's Wort.
- Acycloguanosine. This is an anti-viral and in two cases CSR resolved unusually quickly with Acycloguanosine treatment. Reference 4. I am personally somewhat sceptical about this as it was only two cases and there is no known reason why anti-virals should assist.
- Procaine HCl (AntiCort). Anti Cortisol drug developed for use in AIDS cases (who often have high Cortisol). Reference 5 refers to an unpublished study by Alfred T Sapse.
- Acetazolamide (also known as Diamox) - a diuretic, Methazolamide, Dichlororphenamide. Anti glaucoma medication. May also be of assistance in CSR. Other anti glaucoma medications include Timolol and Pilocarpine Reference 6.
- Picogenol. Picogenol is an antioxident extracted from Pine Bark. The active ingredients are called proanthcyadins (or similar) that are also found in grape seeds.
- Beta blockers. There is some speculation that beta blockers may have a calming effect on CSR sufferers. See the link to the Review of Opthalmology article below.
- Diazepam based tranquillizers like Valium may reduce CRF production and thereby reduce cortisol levels. Tri-cyclic antidepressants may also have similar effects.
- Imipramine, antidepressant, has been reported to reduce CRF levels.
- Indomethacin, a non steroidal anti inflammatory is reported to be useful in reducing the length of attacks. See the Optometry handbook
- Cushing's syndrome (very high cortisol levels) has been treated with cyproheptaline (a 5-hydroxytramine receptor blocker)
- Alpha helical CRF has been used as a CRF antagonist in experimental work.
- Acetyl-L-carnitine, which is supposed to assist with the use of fat as a fuel and is available in health food stores, and phosphatidylserine (seriphos) may reduce cortisol
- The abortion pill RU-486 works by interfering with the body's cortisol receptors so it may also be useful.
- Bilberry - shown to improve both night and normal vision - see "Prescription for Nutritional Healing" by James and Phylis Balch. Bilberry can make one feel tired and lethargic, although night vision may be improved.
- Eyebright - see "Prescription for Nutritional Healing" by James and Phylis Balch
- Bayberry bark, cayenne (capsicum) red raspberry leaves - see "Prescription for Nutritional Healing" by James and Phylis Balch
- "The Diet Cure" by Julia Ross Bayberry recommends Seriphos (phosphorylated serine, a CRF antagonist), GABA "a natural valium", l-tryptophan or 5-HTP (anti stress preparations - 5-HTP is similar to l-tryptophan which is hard to get), d-phenylaniline (increases endorphins). This is a very interesting book, about a number of conditions.
