Central serous chorioretinopathy complicating solar retinopathy treated with glucocorticoids

Central serous chorioretinopathy secondary to solar retinopathy: an unusual presentation

Solar retinopathy (SR) results from unprotected solar eclipse viewing and also from gazing at the sun for a long duration. It has been known for a long that direct viewing of the sun causes visual disruption. Usually, there is a disruption of the inner segment-outer segment junction, but an association of central serous chorioretinopathy (CSCR) with SR is quite rare. We report a case of CSCR associated with solar eclipse viewing.

Retinal and choroidal changes in steroid-associated central serous chorioretinopathy

Background

To evaluate the retinal and choroidal alterations in steroid-associated central serous chorioretinopathy (CSC) in comparison to idiopathic CSC.

Methods

In this retrospective cohort study, swept source optical coherence tomography scans of eyes with steroid-associated CSC (group A) were compared with the same in idiopathic CSC (group B). The key features included central subfield retinal thickness, subfoveal choroidal thickness, subfoveal large choroidal vessel diameter, subretinal deposits, retinal pigment epithelial irregularities, double layer sign, hyperreflective dots, intraretinal fluid, and choroidal vascularity index (ratio of choroidal luminal area and total choroidal area, measured on a high definition horizontal 9 mm OCT B-scan.

Results

There were 20 eyes in group A and 30 in group B. Group A had a higher female proportion (60 vs. 16.67%; P < 0.01) and higher bilaterality (30 vs. 6.67%; P = 0.03). The height of neurosensory detachment was lower in group A (153.1 ± 175.70 µm vs. 312.9 ± 223.06 µm; P < 0.01). There was no significant difference in the prevalence of subretinal deposits, retinal pigment epithelial irregularities, pigment epithelial detachments, double layer sign, outer retinal layer disruption, and intraretinal fluid. Hyperreflective dots (HRDs) were less common in group A (15 vs. 46.67%; P = 0.03). The subfoveal choroidal thickness (P = 0.65) and subfoveal large choroidal vessel diameter (P = 0.78) were comparable. There was a trend towards a higher choroidal vascularity index (CVI) in group A (A: mean, 82%, 95% CI, 66–99%; B: mean, 58%, 95% CI, 57–59%; P = 0.10).

Conclusion

Steroid-associated CSC has a marginally higher CVI and less common association with HRDs as compared to idiopathic CSC.

Pediatric Bilateral Blue Laser Pointer-Induced Maculopathy

Background

We report the first case of pediatric bilateral blue laser pointer maculopathy with complete resolution of visual symptoms.

Case

A 12-year-old boy presented with bilateral decreased visual acuity and central scotomata after blue laser pointer exposure. He was treated with a Medrol Dosepak and topical nonsteroidal anti-inflammatory drug (NSAID), with gradual visual acuity improved from 20/40 OU to 20/20 OU over 22 weeks, but with persistent evidence of outer retinal layer disruption from the external limiting membrane to the interdigitation zone.

Conclusion

Oral steroids and topical NSAIDs may be effective in improving visual outcomes in laser pointer maculopathy in the pediatric population.

Central serous chorioretinopathy: from glucocorticoids to light intensity

Central serous chorioretinopathy (CSC) is characterized by a localized accumulation of subretinal fluid and an idiopathic focal leakage from choroidal vessels. The exact pathogenesis of CSC, however, still remains obscure. In this paper, we hypothesized that CSC may result from a response of choroidal vessels to an acute increase in the environmental light intensity leading to a focal leakage from the choroidal vessels. High levels of glucocorticoids, in our proposed model, may cause persistence rather than initiation of the focal leakage, probably by suppressing the synthesis of collagen and extracellular matrix components and inhibiting fibroblastic activity.

Oral administration of a curcumin-phospholipid delivery system for the treatment of central serous chorioretinopathy: a 12-month follow-up study

BACKGROUND

The therapeutic effects of Meriva®, a curcumin-phospholipid (lecithin) delivery system (formulated as Norflo® tablets), on visual acuity and retinal thickness in patients with acute and chronic central serous chorioretinopathy was previously investigated in a six-month open-label study.

METHODS

In this follow-up study, visual acuity was again assessed by ophthalmologic evaluation and retinal thickness by optical coherence tomography (OCT). Norflo tablets were administered twice daily to patients with central serous chorioretinopathy. The study group consisted of 12 patients (total 18 eyes) who completed 12 months of follow-up. The primary endpoint was change in visual acuity before and after treatment with Norflo, and change in neuroretinal or retinal pigment epithelium detachment on OCT was the secondary endpoint.

RESULTS

After 12 months of therapy, no eyes showed further reduction in visual acuity, 39% showed stabilization, and 61% showed statistically significant improvement (P = 0.0001 by Student's t-test and P = 0.0005 by Wilcoxon signed rank test). Ninety-five percent of eyes showed a reduction in neuroretinal or retinal pigment epithelium detachment and 5% showed stabilization. The difference in retinal thickness after 12 months was statistically significant (P = 0.0001 by Student's t-test and P = 0.0004 by Wilcoxon signed rank test).

CONCLUSION

These results, albeit preliminary, confirm our previous finding that this curcumin delivery system is effective in the management of central serous chorioretinopathy. When administered in a bioavailable formulation, curcumin is worth considering as a therapeutic agent for the management of inflammatory and degenerative eye conditions involving activation of retinal microglial cells.

Getting serious with retinopathy: approaching an integrated hypothesis for central serous chorioretinopathy

Development of the prefrontal cortex is believed to play an important role in the maturation of higher cognitive functions such as decision making, cognition and control of part of the neural element of the stress response. The prefrontal cortex undergoes considerable maturation during childhood, including a reduction of synaptic and neural density, a growth of dendrites, and an increase in white matter volume, thereby forming distributed neural networks appropriate for complex cognitive processing, but maturation is not complete until approximately 25 years of age. Serotonin and its receptors (HTRs) play critical roles in brain development and in the regulation of cognition, mood, and anxiety. HTRs are highly expressed in the human prefrontal cortex and exert control over prefrontal excitability. Studies of post-mortem prefrontal brain tissue found distinct developmental patterns of expression of these receptors occurring in early postnatal development and also into adulthood. The general pattern of improved cognitive control and emotion regulation with maturation of the prefrontal cortex, suggests a linear increase in development from childhood to adulthood. Animal studies have shown that dopamine is crucial for communication between the accumbens, amygdala, and prefrontal cortex. Dopamine projections to the prefrontal cortex continue to develop into early adulthood. Central Serous Chorioretinopathy (CSC) is an eye disease affecting people of working age, commonly resulting in repeated unpredictable visually disabling serous retinal detachments and occasionally leading to irreversible reduction in central vision. The disease has been closely linked to the stress response. Despite a concerted effort to understand aetiopathogenesis, disease mechanisms are still largely unclear. This paper, supported by evidence in the literature, proposes a systemic approach to CSC and explains how interactions of the eye with the cerebral cortex could lead to disease. We propose that the lack of development of the neural element of the stress response and in particular the prefrontal cortex is the reason for the absence of CSC in childhood and adolescence. Additionally, we attempt to explain why excess stress hormones do not always result in CSC and why acute attacks occur only once in over half of cases. Finally, we summarise the implications that an integrated systemic hypothesis has for future CSC research and the requirement of a holistic management practice for the identification and treatment of patients with CSC.

Pilot study of oral administration of a curcumin-phospholipid formulation for treatment of central serous chorioretinopathy

Background

The purpose of this open-label study was to investigate the effect of a curcumin-phospholipid (lecithin, Meriva^®) formulation (Norflo^® tablet) on visual acuity and retinal thickness in patients with acute or chronic central serous chorioretinopathy.

Methods

Visual acuity was assessed by ophthalmologic evaluation, and optical coherence tomography was used to measure retinal thickness. Norflo tablets were administered twice a day to patients affected by central serous chorioretinopathy. The study included 18 eyes from 12 patients who completed a 6-month follow-up period. Visual acuity before and after Norflo treatment was the primary endpoint. The secondary endpoints were neuroretinal or pigment epithelial detachment, as measured by optical coherence tomography.

Results

After 6 months of therapy, 0% of eyes showed reduction in visual acuity, 39% showed stabilization, and 61% showed improvement. The improvement was statistically significant (P = 0.08). After 6 months of therapy, 78% of eyes showed reduction of neuroretinal or retinal pigment epithelium detachment, 11% showed stabilization, and 11% showed an increase.

Conclusion

Our results, albeit preliminary, show that curcumin administered as Norflo tablets is efficacious for the management of central serous chorioretinopathy, a relapsing eye disease, and suggest that bioavailable curcumin is worth considering as a therapeutic agent for the management of inflammatory and degenerative eye conditions, including those that activate the retinal microglia.

Central serous chorioretinopathy: an update on pathogenesis and treatment

Central serous chorioretinopathy (CSC) is a chorioretinal disease, incompletely understood with systemic associations, a multifactorial aetiology, and a complex pathogenesis. Increased permeability from the choriocapillaris leads to focal or diffuse dysfunction of the retinal pigment epithelium causing a detachment of the neurosensory retina. CSC has been described in patients with endogenously high levels of corticosteroids as well as in patients with hypercortisolism due to the treatment of ocular or systemic diseases. It is therefore the only 'inflammatory' choroiditis, not proven to be associated with infection that is precipitated or worsened by glucocorticoids. Foveal attenuation, chronic macular oedema, and damage of the foveal photoreceptor layer have been reported as causes of visual loss in CSC. Photoreceptor atrophy in the fovea, despite successful retinal reattachment, typically occurs after a duration of symptoms of approximately 4 months. Treatment should therefore be considered after 3 months if there is angiographic evidence of ongoing foveal leakage in recurrent chronic CSC or in a single CSC episode accompanied by signs of chronic CSC alterations. Based on results of trials conducted so far, it appears that photodynamic therapy with verteporfin is effective and safer than argon laser treatment and should be considered as the treatment of choice, whereas micropulse diode laser photocoagulation seems to be an effective alternative. Glucocorticoid inhibitors are an interesting alternative treatment. Clinical trials are ongoing to test their efficacy. In addition, it is important, where possible, to discontinue any corticosteroid treatment. The possible association of CSC with stress should also be discussed with patients.

Ketoconazole in the treatment of central serous chorioretinopathy: a pilot study

PURPOSE

The aim of this study was to evaluate a possible effect of systemic ketoconazole on visual acuity (VA) and retinal thickness in patients with acute central serous chorioretinopathy (CSCR).

METHODS

Fifteen consecutive patients were treated with ketoconazole 200 mg/day for a period of 4 weeks. Another 15 patients served as a control group. Baseline examination and review after 4 weeks included VA testing and measurement of neuroretinal or pigment epithelial detachment by optical coherence tomography (OCT). Fluorescein angiography was performed to verify the diagnosis.

RESULTS

At baseline, mean VA in Snellen units was 0.6+/-0.2 (logMAR 0.2+/-0.7) in the treatment group and 0.7+/-0.3 (logMAR 0.2+/-0.5) in the control group. On OCT, mean neuroretinal or pigment epithelial detachment measured 288+/-163 microm in the ketoconazole group and 225+/-51 microm in the control group, respectively. Four weeks later, mean VA improved in both groups. On OCT, neuroretinal or pigment epithelial detachment decreased in both the treatment and control groups. The differences were not statistically significant.

CONCLUSIONS

Although a pharmacological decrease in endogenous cortisol synthesis appears to be a rational approach in the treatment of CSCR, systemic ketoconazole at 200 mg/day was not associated with a significantly better outcome in this preliminary study.

Visual outcome after discontinuation of corticosteroids in atypical severe central serous chorioretinopathy

PURPOSE

To elucidate the effect of discontinuation of corticosteroids in patients with atypical severe central serous chorioretinopathy (CSC) on retinal reattachment, resolution of retinal pigment epithelium (RPE) leaks, and improvement in visual acuity (VA).

DESIGN

Prospective, noncomparative, observational case series.

PARTICIPANTS

Twenty-four eyes of 17 patients who were being treated with corticosteroids for atypical severe CSC. Of these 17 patients, 16 were treated inappropriately with corticosteroids for their ocular condition; presumably, these patients' conditions were misdiagnosed, and they were thought to have choroiditis, Harada's syndrome, or similar entities, and not central serous chorioretinopathy.

INTERVENTION

Observation or laser photocoagulation.

MAIN OUTCOME MEASURES

Reattachment of the retina, obliteration of RPE leaks on fundus fluorescein angiography, and improvement in Snellen VA.

RESULTS

Discontinuation of corticosteroids resulted in reattachment of the retina in 21 eyes (87.5%), with median time to reattachment of 49 days (range, 32-400); only 3 eyes required laser photocoagulation. Fundus fluorescein angiography showed obliteration of RPE leaks at a median period of 75 days (range, 32-400) in the observed eyes; the median VA improved from 20/80 to 20/30. The mean follow-up was 16.5 months.

CONCLUSIONS

Discontinuation of corticosteroids in atypical CSC helped in obliteration of RPE leaks and retinal reattachment in 87.5% of the eyes without laser treatment, and improvement in VA was observed.

Corticosteroids and central serous chorioretinopathy

PURPOSE

The purpose of this study is to investigate the relationship between corticosteroid use and central serous chorioretinopathy (CSC).

DESIGN

A prospective, case-controlled study.

PARTICIPANTS AND CONTROLS

A consecutive series of patients with acute manifestations of CSC and a control group matched for age, race, and gender were recruited between January 2000 and July 2000.

METHODS

A detailed clinical history was taken, and fundus examination with slit-lamp biomicroscopy was performed on all patients. Fluorescein angiography was obtained on the study patients.

RESULTS

A total of 50 patients was recruited. Twenty-six patients (52%) had a history of exogenous steroid use, including oral, intravenous, intranasal, and intraarticular administration. Two additional patients had a history of endogenous hypercortisolism (Cushing's syndrome). In a matched control group, eight patients (18%) had a history of steroid use. The difference in corticosteroid exposure between study patients and controls was statistically significant (P < 0.0001).

MAIN OUTCOME MEASURES

History of corticosteroid use or Cushing's syndrome.

CONCLUSIONS

This study is consistent with previous reports associating steroid use with CSC. It identifies corticosteroids as a significant risk factor for the development of acute, exudative macular manifestation and implicates hypercortisolism as a factor in the pathogenesis of this disorder. Several forms of corticosteroid administration were observed to be a risk factor for CSC. Accordingly, susceptible patients in need of corticosteroids should be advised of the risk of developing acute manifestations of CSC.

Central serous chorioretinopathy and glucocorticoids

Central serous chorioretinopathy is a relatively common retinal disease characterized by the accumulation of subretinal fluid at the posterior pole of the fundus, creating a circumscribed area of serous retinal detachment. It typically affects young and middle-aged men with no previous medical and family history, and no systemic symptoms or signs. However, it has been noted that central serous chorioretinopathy is associated with different conditions, characterized by exposure to increased levels of endogenous or exogenous glucocorticoids. In fact, central serous chorioretinopathy has been described in patients with endogenous Cushing's syndrome. It is also prevalent in patients with type-A behavior, and following stressful events, and pregnancy probably represents a risk factor for central serous chorioretinopathy; these conditions are characterized by endogenous hypercortisolism. In addition, many cases of central serous chorioretinopathy have been described during or following treatment with glucocorticoids, administrated by any route, for various systemic or ocular conditions. Central serous chorioretinopathy, when related to the exposure to exogenous glucocorticoids, has a less prominent male predilection, presents more often with a chronic or atypical form, and is frequently bilateral. Furthermore, treatment of central serous chorioretinopathy with glucocorticoids was found to exacerbate the clinical picture. Based on these observations it could be suggested that glucocorticoids may be involved in the development of central serous chorioretinopathy, even though the exact pathogenic mechanism remains unclear. Glucocorticoids should not be used in the treatment of central serous chorioretinopathy and central serous chorioretinopathy should be added to the list of ocular complications of glucocorticoids.

Ocular complications of topical, peri-ocular, and systemic corticosteroids

Topical ophthalmic, oral, and intravenous corticosteroids have long been associated with ocular side effects. Recent data suggest that inhaled corticosteroids are also associated with the development of cataract and increased intraocular pressure. Thus far, nasally administered steroids have not been associated with the same effects. Local injection of steroids, even at sites far from the eye, have been associated with the development of cataract, glaucoma, and even retinal and choroidal emboli. Any physician prescribing corticosteroids should be aware of these potential ocular side effects and should advise patients accordingly.