CENTRAL SEROUS CHORIORETINOPATHY IN POSTMENOPAUSAL WOMEN RECEIVING EXOGENOUS TESTOSTERONE

Central serous chorioretinopathy: Pathophysiology, systemic associations, and a novel etiological classification

Central serous chorioretinopathy (CSC) has remained an enigmatic disease since its initial description by Von Graefe. Over the years, multiple risk factors have been recognized: these include psychological stress, behavioral traits, and corticosteroids. The basic pathophysiology of CSC involves choroidal thickening, vascular congestion, altered choroidal blood flow (ChBF), and choroidal hyperpermeability, leading to retinal pigment epithelium decompensation and subsequent neurosensory detachment. Multiple organ systems, mainly the nervous, cardiovascular, endocrinal, and renal systems participate in the control of the vascular tone and the ChBF via hypothalamus-pituitary-adrenal axis and renin-angiotensin-aldosterone system, while others such as the hepatic system regulate the enzymatic degradation of corticosteroids. Many vasoactive and psychotropic drugs also modulate the ocular perfusion. In addition, there are anatomical and genetic predispositions that determine its progression to the chronic or recurrent form, through cellular response and angiogenesis. We herein review the basic pathophysiology and immunogenetics in CSC along with the role of multiple organ systems. With this background, we propose an etiological classification that should provide a framework for customized therapeutic interventions.

The Association Between Circulating Sex Hormones and Central Serous Chorioretinopathy: A Case-Control Study

Background

Central serous chorioretinopathy (CSC) is preferential cocurated in males, however the associations between sex hormones and CSC incidence or progression remains unclear. The sex hormone concentration assessments in CSC cases and healthy controls will update the knowledge in CSC management.

Methods

This case-control study included 59 CSC cases and 30 healthy controls, from January 2019 to December 2020. The CSC cases would be defined as spontaneous resolved if the subretinal fluid were absorbed within three months. The concentrations of total testosterone (TT), free testosterone (FT), estradiol (E2), sex hormone-binding globulin (SHBG), progesterone, leuteinizing hormone (LH) and dehydroepiandrosterone sulfate (DHEA-S) were detected in all the participants. The relationships between sex hormone concentrations and CSC-related characteristics were analyzed with Pearson correlation analyses.

Results

Significantly increased TT, FT, FT/E2 ratio, SHBG concentrations as well as decreased DHEA-S level were detected in non-resolved CSC group compared with the control group. Comparing with the resolved ones, it was found that TT, FT and SHBG concentrations were increased in the non-resolved CSC. A significant positive correlation between TT concentrations and CMT (R²=0.168, P=0.031) as well as SRF height (R²=0.146, P=0.045) were detected in the non-solved CSC group.

Conclusion

Different concentrations of TT, FT, FT/E2 ratio, DHEA-S and SHBG were detected in resolved and non-resolved CSC cases. Sex hormones were related to CSC symptom durations and related parameters.

Incidence of central serous chorioretinopathy (2011-2018): a nationwide population-based cohort study of Japan

AIMS

The aim of this study was to elucidate the epidemiological background of central serous chorioretinopathy (CSC), including its incidence and treatment pattern.

METHODS

This was a population-based longitudinal cohort study using a nationwide health insurance claims database of the Japan Ministry of Health, Labour and Welfare (MHLW). As Japan employs universal health coverage, the database covers more than 95% of claims issued in Japan. We accessed all data stored in the database with permission from the MHLW. We traced all individuals aged 30 years or older and identified individuals with new onset of CSC between January 2011 and December 2018. CSC cases were categorised by age and sex for each year, and incidence rate was calculated. We also identified major treatments for CSC to elucidate the initial treatment pattern.

RESULTS

During the 8-year period, 247 930 incidences of CSC were identified, among which 75.9% were men. The crude incidence rate (per 100 000 person-years) in the general population aged 30 years or older was 34.0 (95% CI 33.9 to 34.2), in men was 54.2 (95% CI 53.9 to 54.4) and in women was 15.7 (95% CI 15.5 to 15.8). The mean age of onset was lower in men than in women (50.5±12.5 years vs 54.7±13.5 years). Most of the patients with newly diagnosed CSC (86.8%) did not receive major treatment.

CONCLUSIONS

The current study provides the nationwide population-based evidence to clarify the detailed epidemiology of CSC. These results could help to understand the pathogenesis and mechanisms of CSC in the future.

Central serous chorioretinopathy associated with high-dose follistatin-344: a retrospective case series

PURPOSE

To present 11 bodybuilding athletes who developed central serous chorioretinopathy (CSCR) following high-dose subcutaneous follistatin-344, a peptide-based performance and image enhancing drug, injections to increase muscle mass.

METHODS

This is a retrospective case series from one institution. Demographic and clinical data of 11 patients who were admitted to our clinic with decreased visual acuity after high-dose follistatin-344 injections and optical coherence tomography (OCT) findings consistent with CSCR were analyzed.

RESULTS

All 11 patients were male, and the mean age was 36.8 ± 8.1 years. All patients had a history of injecting complete 1 mg vials of follistatin-344 subcutaneously in the abdomen. There was a history of a single previous high-dose follistatin-344 injection in eight patients and multiple previous injections in three patients. At the time of diagnosis, ten patients had unilateral CSCR findings and one had bilateral CSCR findings. In all eight patients with a history of only one injection, subretinal fluid completely disappeared after an average of 2.3 ± 0.7 months and symptoms regressed. Recurrent CSCR developed in three patients with a history of multiple follistatin-344 injections.

CONCLUSION

Follistatin-344 injection can be considered as a risk factor for CSCR. To take medical history from CSCR patients including follistatin-344 use may be important to reveal the CSCR etiology.

Acute bilateral serous central chorioretinopathy after emergency contraceptive therapy with ulipristal acetate

CASE REPORT

The case concerns a 31 year-old woman with no previous history who consulted due to decreased vision in both eyes. She mentioned taking 1 pill of ulipristal acetate (30mg) as an emergency contraceptive four days before the visual symptoms appeared. In the examination, a better corrected visual acuity of 0.6 was found in the right eye and 0.8 in left eye (by Snellen chart), and bilateral macular serous detachment. It was decided to observe, and 15 days later she showed a functional and anatomical improvement.

DISCUSSION

Ulipristal acetate could lead to serous central chorioretinopathy due to its activity on the progesterone receptors present in choroidal and retinal pigment epithelium.

The relationship between the central serous chorioretinopathy, choroidal thickness, and serum hormone levels

PURPOSE

The purpose of this study were to compare the levels of serum cortisol, aldosterone, testosterone, dehydroepiandrosterone (DHEA), and renin hormone between patients with central serous chorioretinopathy (CSC) and a control group, and to investigate whether there was a difference regarding serum hormone levels in patients with acute/chronic CSC.

METHODS

This prospective study included 30 CSC eyes, 30 fellow eyes, and 32 normal eyes of 32 healthy volunteers who were age and sex matched. The patients were classified as acute or chronic depending on the clinical, fluorescein angiography (FFA), and optical coherence tomography (OCT) findings. Serum cortisol, aldosterone, renin, total testosterone, and DHEA levels were measured. The levels of hormones were compared with the values of the control group. Choroidal thickness and central macular thickness were measured with spectral domain OCT.

RESULTS

Fifteen patients had acute CSC, and 15 patients had chronic CSC. Serum testosterone levels were 357 ± 10.4 ng/ml in the CSC group, and 255.94 ± 7.43 ng/ml in the control group. The difference between them was statistically significant (p < 0.001). The difference between the levels of cortisol, renin, aldosterone, and DHEA was not statistically significant. Serum hormone levels were within the normal range for all patients and were not statistically different between the acute and chronic CSC groups.

CONCLUSION

According to our results, CSC is related to elevated total testosterone levels. Testosterone may play a role in predisposing males to CSC.