Central serous chorioretinopathy (CSCR) is a vision-threatening retinal disorder characterized by serous detachment of the neurosensory retina due to leakage of fluid through defects in the retinal pigment epithelium (RPE), often as a result of increased choroidal vascular permeability [1]. It predominantly affects men between the ages of 20 and 50 years and is often associated with symptoms such as blurred or dim vision, central scotoma, micropsia, and metamorphopsia [2]. While most cases resolve spontaneously, a substantial proportion progresses to recurrent or chronic disease, leading to lasting visual morbidity [3].

The etiopathogenesis of CSCR is multifactorial and still not completely understood. Multiple predisposing factors have been implicated, including type A personality traits, high levels of endogenous or exogenous corticosteroids, pregnancy, Cushing’s syndrome, and psychosocial stress [4]. Sleep disturbances and obstructive sleep apnea have also been linked to increased risk, suggesting a possible neuroendocrine mechanism [5]. Thes triggers are believed to affect the choroidal vasculature via dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis and increased sympathetic tone, which result in enhanced hydrostatic pressure and increased permeability of choroidal vessels [6].

Emerging research points toward the involvement of systemic biochemical imbalances, especially hypovitaminosis D, as a contributing factor in CSCR pathophysiology [5,7]. Vitamin D, a steroidal hormone synthesized in the skin through UVB exposure, plays key roles beyond mineral metabolism. It acts as a potent modulator of immune and inflammatory responses and maintains vascular endothelial stability [3,4,7]. Vitamin D deficiency has been shown to promote endothelial dysfunction, oxidative stress, and impaired RPE function—key mechanisms that overlap with CSCR pathogenesis [8,9]. Furthermore, recent evidence suggests that vitamin D may modulate angiogenic and anti-angiogenic factors within the choroid [10].

Studies have highlighted lower serum vitamin D levels in patients with various retinal disorders, including diabetic retinopathy [6,16], age-related macular degeneration [12], and central serous chorioretinopathy [5,8]. Akbar et al. [8] specifically demonstrated lower serum 25(OH)D levels in CSCR patients, with the lowest levels observed in chronic cases. Sahni et al. [17] reviewed the broad role of vitamin D in ocular health, underscoring its anti-inflammatory and neuroprotective actions. Moon et al. [15] further emphasized the correlation between serum vitamin D levels and visual acuity in retinal diseases.

Despite these findings, literature on this association in Indian populations is limited. Mandal et al. [18] reported widespread vitamin D deficiency in Indian adults with retinal disorders, attributing it to lifestyle, diet, and reduced UVB exposure. The darker skin phenotype and vegetarian dietary patterns in India may further compromise vitamin D synthesis and intake [4,11].

Given the growing body of evidence linking systemic vitamin D deficiency to various retinal diseases, including diabetic retinopathy, age-related macular degeneration, and more recently, central serous chorioretinopathy (CSCR), this study was conceived to investigate this association in greater detail [1–20]. Vitamin D’s role in immunomodulation, endothelial stability, and anti-inflammatory responses is well-established, and its deficiency may contribute to retinal pigment epithelium (RPE) dysfunction and choroidal vascular hyperpermeability—core elements of CSCR pathophysiology [4,5,8].

In the Indian context, where widespread hypovitaminosis D is attributed to lifestyle, skin pigmentation, and dietary factors, evaluating its link with CSCR becomes even more critical [11,18]. The paucity of large-scale, region-specific data on this subject, especially in Eastern India, necessitated a focused inquiry. This study thus aimed to assess serum vitamin D levels in patients diagnosed with CSCR and to compare these findings with age- and sex-matched healthy controls. Additionally, the study sought to analyze whether vitamin D levels varied across different clinical subtypes of CSCR—namely acute, recurrent, and chronic presentations—and to examine any correlation with age distribution and visual acuity at presentation.

By providing a cross-sectional snapshot of vitamin D status in a defined CSCR population, this study attempts to contribute to the growing literature that supports the integration of systemic metabolic evaluation in the management of retinal diseases. If a strong association is established, it could justify routine vitamin D screening and possibly supplementation as part of holistic CSCR care protocols.

Study Design and Setting:

• The study was designed as a hospital-based, observational, cross-sectional analysis to establish an association between serum vitamin D levels and CSCR.
• It was conducted in the Department of Ophthalmology at PGIMER & Capital Hospital, a tertiary care teaching hospital located in Bhubaneswar, Odisha, India.
• The duration of data collection spanned six months, from May 2024 to October 2024.
• Ethical clearance was obtained from the Institutional Ethics Committee before the commencement of the study (Ref: IEC/PGIMER & CH, BBSR/Project/2022-2023/3, dated 26/11/2024), in adherence to the ICMR guidelines for biomedical research on human participants.

2. Study Population and Sample Size:

• The study included a total of 60 patients diagnosed with CSCR, enrolled through consecutive sampling after confirmation of eligibility.
• Diagnosis was confirmed by clinical examination and optical coherence tomography (OCT) imaging criteria consistent with CSCR.
• An equal number of age- and sex-matched healthy individuals (n = 60) were recruited as controls from outpatient departments during the same period.
• Controls were selected to ensure absence of retinal pathology, systemic diseases, or any known interference with vitamin D metabolism.
• Sample size justification was based on prior prevalence estimates and studies showing an expected moderate effect size between vitamin D levels in CSCR patients versus healthy controls.
• This ensured sufficient statistical power to detect significant differences, with an alpha of 0.05 and power of 80%.

3. Inclusion Criteria (CSCR Group):

• Adults aged 20 to 50 years
• Confirmed diagnosis of CSCR via optical coherence tomography (OCT)
• Willingness to provide informed written consent

4. Exclusion Criteria:

• Use of systemic corticosteroids in the last 3 months
• Presence of chronic systemic illnesses (e.g., liver disease, chronic kidney disease, autoimmune disorders)
• Pregnant or lactating females
• Prior or ongoing vitamin D supplementation

5. Clinical and Demographic Data Collection: Each participant underwent a detailed ophthalmic examination including Best Corrected Visual Acuity (BCVA), slit-lamp biomicroscopy, and OCT imaging. Socioeconomic status was assessed using the Modified Kuppuswamy scale. Additional parameters recorded included patient age, sex, comorbidities, and clinical subtype of CSCR (acute, recurrent, or chronic). OCT-based classification (with or without pigment epithelial detachment - PED) was documented.
6. Laboratory Investigations: Venous blood samples were collected to measure serum 25-hydroxyvitamin D [25(OH)D] concentrations using a standardized chemiluminescent immunoassay (CLIA). The levels were categorized as:

• Deficient: <20 ng/mL
• Insufficient: 20–30 ng/mL
• Sufficient: >30 ng/mL

7. Data Analysis and Statistical Methods: All statistical analyses were performed using IBM SPSS version 25.0 (IBM Corp., Armonk, NY, USA). Continuous variables were reported as mean ± standard deviation (SD), while categorical data were expressed as frequencies and percentages.

• Group comparisons for continuous data were performed using the independent sample t-test.
• Proportional differences were assessed via the chi-square test.
• Pearson’s correlation coefficient was used to determine associations between vitamin D levels and clinical parameters such as age, BCVA, and CSCR subtype.
• A p-value <0.05 was considered statistically significant for all analyses.

This methodological framework ensured standardization of data acquisition and minimized bias in subject selection and assessment.

A total of 60 patients (N=60) diagnosed with central serous chorioretinopathy (CSCR) were enrolled based on strict inclusion criteria, ensuring diagnostic accuracy via OCT confirmation. Equal numbers of age- and sex-matched healthy controls (N=60) were included to facilitate comparative analysis, minimizing demographic bias. Both groups were comprehensively evaluated for demographic profiles, clinical manifestations, OCT patterns, comorbid conditions, and serum vitamin D levels. The aim was to explore correlations between vitamin D status and CSCR occurrence, subtype, and visual function. These findings have been systematically tabulated and graphically represented for clarity and scientific interpretation.

Table 1: Demographic Characteristics of CSCR Patients (N=60)

• Gender Distribution: Of the 60 CSCR patients (N=60), 48 were male (80%) and 12 were female (20%), consistent with the male predominance reported in earlier studies.
• Mean Age: 36.8 ± 6.7 years.

Table 1a: Age Distribution of CSCR Patients (N=60)

The age group most commonly affected was 31–40 years (50%), consistent with global epidemiological trends in CSCR. The 20–30 year group followed at 30%, indicating that younger adults are also vulnerable. These findings reinforce the notion that CSCR predominantly affects the productive age group. Early identification in these cohorts can reduce the long-term visual burden. Preventive awareness regarding modifiable systemic and lifestyle risk factors is crucial for this demographic.

Table 2: Clinical Subtypes of CSCR (N=60)

Most cases (N=48) presented with the acute form (80%), typically characterized by sudden-onset visual symptoms and favorable prognosis. In contrast, chronic and recurrent cases combined made up 20% of the cohort and demonstrated a significantly greater burden of vitamin D deficiency. These subtypes are known for their prolonged disease course, subretinal fluid persistence, and visual deterioration. The higher prevalence of hypovitaminosis D in these patients may reflect a systemic predisposition to disease chronicity. This association underscores the need to evaluate vitamin D status as part of CSCR subtype differentiation and management.

Table 3: OCT Patterns in CSCR Patients (N=60)

CSR with pigment epithelial detachment (PED) was noted in 26.6% of patients (N=16), indicating more advanced retinal involvement. PED is considered a marker of severe dysfunction of the retinal pigment epithelium (RPE) and choroidal circulation. Its presence often correlates with more extensive subretinal fluid and a higher risk of recurrence or chronicity. These patients may experience a delayed response to treatment or persistent visual symptoms. Hence, OCT findings such as PED are clinically important in stratifying disease severity.

Table 4: Systemic Comorbidities in CSCR Patients (N=6)

Although comorbidities were present in a small proportion (N=6), they may still exert a considerable impact on CSCR pathogenesis. Conditions like hypertension and diabetes mellitus are known to compromise microvascular integrity, including in the choroidal circulation. These systemic diseases promote endothelial dysfunction and oxidative stress, potentially disrupting the blood-retina barrier. Such changes may amplify choroidal hyperpermeability, a hallmark of CSCR. Hence, even minor comorbidities warrant attention in the context of retinal vascular disorders.

Table 5: Socioeconomic Status of CSCR Patients (Modified Kuppuswamy Scale, N=60)

A majority of patients (N=54) belonged to the lower-middle-income group, reflecting limited access to nutrient-rich foods and vitamin D supplementation. Socioeconomic status directly affects dietary diversity, sun exposure, and affordability of preventive healthcare services. These individuals may face barriers in receiving regular medical checkups or lifestyle guidance. As a result, undiagnosed vitamin D deficiency could persist and worsen. This makes socioeconomic status a critical, yet often overlooked, risk factor for CSCR.

Table 6: BCVA Distribution in CSCR Patients at Presentation (N=60)

More than half (N=31; 51.6%) of the CSCR patients presented with a moderate reduction in visual acuity, ranging from 6/12 to 6/18. This indicates a significant impairment of central vision at the time of diagnosis. Such acuity loss may affect tasks like reading or driving, underscoring the clinical impact of CSCR. The most common BCVA category aligns with acute presentations of serous retinal detachment. Prompt detection at this stage is crucial for optimal visual prognosis.

Table 7: Comparison of Mean Serum Vitamin D Levels in Cases (N=60) vs Controls (N=60)

This difference in mean vitamin D levels between CSCR cases and controls was highly significant, with a p-value of less than 0.001. The result indicates that the observed association is unlikely due to chance. A p-value this low strongly supports the hypothesis that hypovitaminosis D may be linked with CSCR. It provides a statistically robust basis to consider vitamin D deficiency as a relevant biomarker. Thus, further studies may be warranted to explore causality and therapeutic implications.

Table 8: Distribution of Vitamin D Status Across CSCR Subtypes (N=60)

Recurrent and chronic subtypes exhibited significantly higher proportions of vitamin D deficiency. None of the patients in these groups had sufficient vitamin D levels (>30 ng/mL). In the recurrent group, 62.5% were deficient and 37.5% were insufficient. In chronic cases, deficiency and insufficiency were equally present at 50% each. This trend suggests a potential link between prolonged or relapsing CSCR and persistent hypovitaminosis D.

Table 9: Mean Serum Vitamin D Levels by Age Group in Cases (N=60) and Controls (N=60)

A clear age-dependent reduction in serum vitamin D levels was observed across both CSCR patients and control groups. Individuals in the oldest age bracket (41–50 years) had the lowest mean vitamin D concentrations. This pattern suggests an inverse correlation between age and vitamin D status. Such findings are consistent with reduced dermal synthesis and lifestyle factors in older adults. Statistical testing confirmed that these differences were significant (p < 0.05) across all age strata.

The graph shows a clear trend of declining vitamin D levels with increasing age in both CSCR patients and healthy controls.

CSCR patients consistently had lower mean serum vitamin D levels compared to controls across all age groups:

• 20–30 years: CSCR = 25.23 ng/mL vs. Controls = 31.21 ng/mL
• 31–40 years: CSCR = 23.35 ng/mL vs. Controls = 30.19 ng/mL
• 41–50 years: CSCR = 21.26 ng/mL vs. Controls = 31.26 ng/mL

The difference in vitamin D levels widens in older age groups, suggesting age may exacerbate underlying deficiency in CSCR.

These findings support the hypothesis that hypovitaminosis D is associated with CSCR, and that its severity may be more pronounced in middle-aged adults.

The statistical significance (p < 0.05) reinforces that the observed differences are unlikely due to random variation.

The bar chart illustrates the distribution of vitamin D status (Deficient, Insufficient, Sufficient) across the three CSCR subtypes: Acute, Recurrent, and Chronic.

Vitamin D deficiency (<20 ng/mL) was most prevalent in recurrent (62.5%) and chronic (50%) CSCR patients, compared to 50% in acute cases.

No patients in the recurrent or chronic groups had sufficient vitamin D levels (>30 ng/mL), indicating a strong association between persistent disease and hypovitaminosis D.

Acute CSCR cases showed a comparatively higher proportion of sufficient and insufficient vitamin D levels.

This pattern suggests that low vitamin D may be linked to disease severity, chronicity, and recurrence in CSCR.

The pie chart shows the distribution of Best Corrected Visual Acuity (BCVA) in CSCR patients at presentation, categorized into four ranges.

The majority of patients (51.6%) presented with moderate visual impairment (6/12 – 6/18), indicating a significant impact on central vision.

Around 26.6% had near-normal vision (6/6 – 6/9), suggesting early detection or milder disease in these cases.

A smaller subset had severe visual loss (6/24 – 6/36: 13.3% and 6/60: 8.3%), potentially corresponding to chronic or complicated CSCR.

This distribution highlights the clinical variability in CSCR severity and underscores the importance of timely diagnosis and intervention.

The histogram displays the frequency of two OCT patterns in CSCR patients: typical CSR and CSR with pigment epithelial detachment (PED).

The majority (73.3%) exhibited typical CSR, characterized by serous retinal detachment without PED.

About 26.6% had CSR accompanied by PED, indicating more extensive retinal pigment epithelium dysfunction.

Presence of PED is often associated with increased disease severity, risk of recurrence, and prolonged visual symptoms.

Identifying PED on OCT can therefore aid in prognostication and tailoring patient management strategies

The present study evaluated the association between serum vitamin D levels and central serous chorioretinopathy (CSCR) in a cohort of 60 patients compared with age- and sex-matched healthy controls. Our findings demonstrate a significant reduction in serum vitamin D among CSCR patients across all age groups, with the lowest levels observed in older individuals and those presenting with recurrent or chronic disease subtypes. These results align with emerging evidence implicating vitamin D deficiency as a potential systemic risk factor influencing CSCR pathogenesis.

Vitamin D is well known for its classical role in calcium metabolism, but it also exerts crucial immunomodulatory and vascular effects. Deficiency in vitamin D has been linked to endothelial dysfunction, increased oxidative stress, and impaired immune regulation—all mechanisms that may disrupt the integrity of the retinal pigment epithelium (RPE) and promote choroidal hyperpermeability, key features of CSCR pathophysiology [4,8,9]. Our study's consistent finding of lower vitamin D levels in CSCR patients supports the hypothesis that hypovitaminosis D contributes to disease development and severity.

The age-related decline in vitamin D levels observed both in patients and controls echoes prior studies suggesting reduced cutaneous synthesis, lifestyle factors limiting sun exposure, and dietary insufficiencies as major contributors to widespread hypovitaminosis D, especially in middle-aged and older adults [4,11]. The accentuated deficiency in older CSCR patients may exacerbate disease chronicity and poor visual outcomes. Notably, recurrent and chronic CSCR subtypes showed a higher prevalence of vitamin D deficiency, highlighting a possible role of persistent insufficiency in disease progression and relapse. This finding aligns with the notion that vitamin D status may influence the repair and maintenance of the RPE barrier over time.

Best corrected visual acuity (BCVA) at presentation varied, with the majority of patients exhibiting moderate impairment (6/12 to 6/18), consistent with the acute stage of CSCR [7]. Visual outcomes are influenced by the extent and duration of subretinal fluid, with chronic disease and pigment epithelial detachment (PED) often resulting in worse prognosis [14]. Our OCT analysis confirmed PED presence in approximately one-quarter of patients, reinforcing its role as a marker of severity and potential predictor of poorer response to treatment.

Socioeconomic factors may also interplay with vitamin D status and CSCR risk. Most patients in this study belonged to the lower-middle-income group, which may limit access to vitamin D-rich nutrition and healthcare resources. This socioeconomic gradient underscores the need for public health strategies addressing nutritional deficiencies in vulnerable populations [18].

Although this study adds to the growing body of literature linking vitamin D deficiency with retinal diseases, several limitations must be acknowledged. The cross-sectional design precludes causal inference, and seasonal variation in vitamin D levels was not controlled. Additionally, confounding factors such as sun exposure habits, body mass index, and dietary intake were not assessed. Future longitudinal studies with larger sample sizes and interventional trials are warranted to explore whether vitamin D supplementation can modify disease course or improve outcomes in CSCR.

In conclusion, our findings demonstrate a significant association between low serum vitamin D levels and CSCR, particularly in recurrent and chronic cases. These data support the integration of vitamin D assessment in routine CSCR evaluation and highlight the potential therapeutic value of correcting hypovitaminosis D in mitigating disease progression

This study offers compelling and robust evidence supporting a significant association between serum vitamin D deficiency and central serous chorioretinopathy (CSCR), particularly pronounced in patients who exhibit recurrent and chronic disease subtypes. These findings emphasize that vitamin D insufficiency may not only predispose individuals to the initial onset of CSCR but also play a pivotal role in the persistence, recurrence, and potentially the severity of the condition. The mechanistic basis of this relationship likely stems from vitamin D’s influence on the integrity and function of the retinal pigment epithelium (RPE) and choroidal vascular system. Vitamin D deficiency can exacerbate endothelial dysfunction, promote inflammatory pathways, and increase oxidative stress, all of which compromise the homeostasis of the choroid-RPE interface critical for retinal health.

Importantly, this study reinforces the notion of hypovitaminosis D as a modifiable systemic risk factor within the pathogenesis of CSCR, expanding the traditional view of CSCR as a predominantly localized ocular disorder to one that is influenced by systemic metabolic health. Recognizing vitamin D deficiency as a contributing factor underscores the interconnectedness of systemic biochemical milieu and ocular disease processes, advocating for a more holistic approach in patient evaluation.

From a clinical perspective, routine assessment of serum vitamin D levels in patients presenting with CSCR may provide valuable prognostic information and aid in stratifying patients at greater risk for recurrent or chronic disease. Early identification of vitamin D deficiency in this population could facilitate timely intervention, allowing clinicians to tailor treatment strategies beyond symptomatic management of retinal fluid accumulation to include metabolic correction. Vitamin D supplementation, as an adjunct to conventional therapies, has the potential to restore vascular stability, enhance immune regulation, and reduce low-grade inflammation, thereby possibly slowing or preventing disease progression and improving visual outcomes.

This integrative clinical approach highlights the broader significance of systemic health maintenance in the management of ophthalmic conditions and emphasizes the need for interdisciplinary collaboration between ophthalmologists, primary care physicians, and nutrition specialists. Furthermore, it invites a paradigm shift in public health strategies to incorporate education about vitamin D sufficiency, particularly in populations with prevalent hypovitaminosis D due to lifestyle, environmental, or dietary factors.

In conclusion, this study not only fills a critical gap in the understanding of CSCR etiology but also opens new avenues for research and clinical practice by suggesting that addressing systemic vitamin D deficiency could be a vital component of comprehensive CSCR management. Further large-scale prospective studies and randomized controlled trials are warranted to explore the causal pathways and therapeutic efficacy of vitamin D supplementation in this context, ultimately aiming to reduce the burden of vision loss associated with this disease.

Limitations

1. Cross-sectional nature: The study’s observational cross-sectional design limits the ability to draw definitive conclusions about causality between vitamin D deficiency and CSCR development or progression. Longitudinal data are needed to establish temporal relationships.
2. Seasonal variation unaccounted: Vitamin D levels fluctuate seasonally depending on sun exposure; lack of control for seasonality may have introduced variability in measurements.
3. Unmeasured confounding factors: Variables such as participants’ dietary vitamin D intake, outdoor activity, skin pigmentation, body mass index, and genetic predispositions were not assessed but may influence vitamin D status and disease risk.
4. Sample size and single-center design: The relatively modest sample size and recruitment from a single tertiary care hospital may limit generalizability of findings to broader populations.
5. Absence of intervention and follow-up: Without supplementation or longitudinal follow-up, the study cannot determine if correcting vitamin D deficiency alters CSCR outcomes or recurrence rates.

Recommendations

1. Prospective cohort studies: Future research should adopt longitudinal designs to evaluate the causal role of vitamin D deficiency in CSCR incidence, recurrence, and long-term visual outcomes.
2. Interventional trials: Randomized controlled trials investigating the effect of vitamin D supplementation on CSCR progression and visual recovery are warranted to establish therapeutic benefits.
3. Comprehensive lifestyle assessment: Incorporating assessments of dietary patterns, sun exposure, physical activity, and body composition will help identify modifiable factors influencing vitamin D status and disease risk.
4. Public health initiatives: Education and preventive strategies promoting adequate vitamin D intake and safe sun exposure are essential, especially in populations with high prevalence of deficiency.
5. Routine clinical screening: Ophthalmologists and primary care physicians should consider routine vitamin D screening in CSCR patients, especially those with recurrent or chronic disease, to guide holistic management.

Strengths

1. This investigation is among the first to explore vitamin D status specifically in an Indian CSCR cohort, addressing a significant knowledge gap in a population with high rates of hypovitaminosis D.
2. The inclusion of age- and sex-matched healthy controls strengthens the validity of comparative analyses and reduces demographic confounding.
3. Use of optical coherence tomography (OCT) for rigorous diagnostic confirmation ensured homogeneity of CSCR case definitions.
4. Stratification into acute, recurrent, and chronic subtypes enabled detailed evaluation of vitamin D’s potential role across disease stages and severities.

Reliable, standardized measurement of serum 25(OH) vitamin D by chemiluminescent immunoassay enhanced the accuracy and reproducibility of biochemical.

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