CENTRAL SEROUS CHORIORETINOPATHY ASSOCIATED WITH UNUSUAL ROUTES OF STEROID ADMINISTRATION Rukhsana G. Mirza, MD, Manjot Gill, MD
Purpose: To report three cases in which unusual routes of administration were associated with subsequent central serous chorioretinopathy (CSR). All three cases occurred in patients who were being treated for dermatologic conditions. Methods: Retrospective review of three cases of patients who presented with a diagnosis of CSR and use of steroids in an unusual route for treatment of various dermatologic conditions (intradermal injection to the scalp for keloids, topical cream for psoriasis, and topical solution for cradle cap). Results: Patient 1 had complete resolution and restoration of baseline visual acuity at the follow-up examination. This patient had no further injections to his keloids. Patient 2 drastically decreased the dose of topical cream and had resolution of symptoms. Patient 3 discontinued use of the steroid solution and had no new episodes of visual decline. Conclusion: This case series suggests that occult steroid use should be suspected for patients presenting with CSR who are concurrently being treated for dermatologic conditions. The knowledge gained from this thorough history is vital to the management and long-term counseling of the patient. RETINAL CASES & BRIEF REPORTS 3:99 –101, 2009
From the Department of Ophthalmology, Northwestern University, Chicago, Illinois.
quent CSR. All three cases occurred in patients who were being treated for dermatologic conditions.
C
entral serous chorioretinopathy (CSR) is a disease process characterized by the accumulation of subretinal fluid causing a neurosensory detachment in the posterior pole.1 Although the exact pathogenesis is unknown, both exogenous and endogenous glucocorticoids have been implicated. Several routes of administration of steroids have been implicated in the literature. Oral, intravenous, intramuscular, inhaled, and intranasal routes are standard routes that have been discussed.1 We report three cases in which unusual routes of administration were associated with subse-
Case Reports Case 1 A 35-year-old man presented to the retina clinic with a 5- to 7-day history of decreased vision in the right eye. He described a central scotoma in this eye. He denied any previous episodes. Ocular history was negative for any trauma or surgeries. Medical history was positive for benign nodular lesions on the occipital scalp that were excised by a dermatologist 3 months earlier. He subsequently developed keloids and was treated with a triamcinolone acetonide injection to the site 1 month before presentation. At the time of presentation, he was being treated with minocycline only. At examination, visual acuity without correction was 20/30 in the right eye with no improvement with pinhole. Visual acuity in the left eye was 20/20. External examination was unremarkable. Pupils, extraocular movements, and visual fields were within normal limits. Intraocular pressure was 20 mmHg in both eyes. Results of slit-lamp examination were normal. Dilated fundus examination of the right eye revealed a cup-to-disk of 0.3. The vessels were unremarkable. Within the macula, there was a central area of
Supported by an unrestricted grant from Research to Prevent Blindness, Inc. (New York, New York). Accepted to ASRS as a poster presentation; Cannes, France; 2006. Reprint requests: Rukhsana Mirza, MD, 645 North Michigan Avenue, Suite 440, Chicago, IL 60611-2814; e-mail: r-mirza@ northwestern.edu
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Fig. 2. Case 2, Optical coherence tomography showing neurosensory detachment.
during this time, which could be the cause of the prolonged recovery time. Fig. 1. Case 1. “Smokestack” leakage shown by fluorescein angiography.
subretinal fluid measuring ⬇1.5 disk areas in size. There was a yellow spot just nasal to the fovea. Examination of the periphery was unremarkable. Results of dilated fundus examination of the left eye were normal. Fluorescein angiography and optical coherence tomography revealed the classic appearance of central serous retinopathy (Fig. 1). The patient received no further treatment with steroids and was lost to follow-up. At the most recent examination 1 year later, visual acuity was 20/20 in the affected eye with complete resolution of fundus abnormalities.
Case 2 A 47-year-old woman presented to the retina clinic with a 3-week history of decreased vision in the left eye. She stated that it came on fairly acutely and had been staying roughly the same since its onset. She denied any previous episodes of vision loss in either eye. Medical history was positive for psoriasis for which she had been treated with steroid creams off and on for many years. She stated that her last use of steroid cream was several weeks before presentation. This coincided with the onset of her visual symptoms. She also had a history of steroid injections for psoriasis performed every 3 to 4 months, with the last injection being ⬎1 year ago. She had a history of anemia, an ovarian cyst, depression, and fibrocystic breast disease. Current medications included calcium, ibuprofen, and multivitamins, as well as fluoxetine hydrochloride. Family history was positive for a grandmother with a detached retina. At examination, visual acuity without correction was 20/20 in the right eye and 20/25⫺2 in the left eye. External examination was unremarkable. Pupils, extraocular movements, and visual fields were within normal limits. Intraocular pressure was 12 mmHg in the right eye and 13 mmHg in the left eye. Dilated fundus examination of the right eye revealed a cup-todisk of 0.3. There were some minimal retinal pigment epithelium changes, but no fluid was identified. Dilated fundus examination of the left eye showed a cup-to-disk of 0.3. Within the macula centered on the fovea, there was a large 1.5-disk area of subretinal fluid. Fluorescein angiography and optical coherence tomography showed classic appearing images for central serous retinopathy (Fig. 2). At the most recent follow-up (9 months), the patient had resolution of symptoms and fluid. The patient did admit that she had short episodes of reuse of the steroid cream
Case 3 A 49-year-old woman presented for a second opinion after having an acute scotoma ⬇6 weeks earlier. She had seen a retina specialist who had suggested a diagnosis of age-related macular degeneration although atypical especially due to her young age. The patient stated that the vision had possibly improved. Ocular history was significant only for refractive error. Medical history was positive for eczema. She had no family history of ocular disease. The patient stated that she was taking vitamins. When questioned if she took any medications for her eczema including steroids, the patient stated that she did not. However, she then admitted to being treated for a scalp condition (cradle cap) with fluocinonide (0.05% topical solution). She also stated that she had been under an increased amount of stress for the past several months. At examination, visual acuity was 20/20 in the right eye and 20/30 in the left affected eye. She had no pupillary abnormality. Confrontation and motility were also normal. Results of anterior segment examination were within normal limits. Dilated fundus examination revealed a cup-to-disk ratio of 0.3 bilaterally. The right posterior pole had mild pigmentary changes with no fluid. The left macula had similar pigmentary changes with mild subretinal fluid. There were no drusen, hemorrhages, or exudates in either eye. Optical coherence tomography and fluorescein imaging showed a pattern consistent with CSR. The patient discontinued use of the steroid solution; at 3 months, she had resolution of the fluid and stated that she had no further worsening of symptoms.
Discussion CSR is a disease process that is characterized by the accumulation of subretinal fluid causing a neurosensory detachment in the posterior pole.1 Although the exact pathogenesis has not been uncovered, several associations have been described. These include prevalence among patients with type A personalities, after stressful periods, and pregnancy. Furthermore, both exogenous and endogenous glucocorticoids have been implicated in the development of CSR. Several routes of administration of steroids also have been discussed in the literature. Oral, intravenous, intramuscular, inhaled, and intranasal routes are standard routes that have been discussed.1 However, even more unusual
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routes have been implicated. Kanta et al2 described a patient who developed bilateral CSR 1 day after an intraarticular injection for treatment of tenosynovitis of the wrist. Baumal et al3 described the development of this clinical picture associated with periocular corticosteroid injection treatment for iritis. Iida et al4 and Kao5 reported CSR after epidural injection of corticosteroids. Even topical creams for dermal conditions were described by Fernandez et al6 and Karadimas et al7 in association with CSR. We observed three cases of CSR associated with treatment of dermatologic conditions, two cases of topical steroid use and one case of triamcinolone injection to the scalp—which to our knowledge, is the first reported case of CSR secondary to triamcinolone injection to the scalp for keloids. It is important to remember that patients will often not volunteer history of these more unusual routes of administration because they may not see the relevance to their eye problem. In all three of our cases, the patient had been seen by other ophthalmologists and had not revealed exposure to steroids. Although undoubtedly our patients all had some degree of stress in relation to their conditions, one cannot overlook the effect of a potentially causative exogenous agent. It is therefore essential to review the entire list of medical issues and medications and specifically illicit any steroid use. This case series suggests occult steroid use should be suspected for patients concurrently being treated for
dermatologic conditions. The knowledge gained from this thorough history is vital to the management and long-term counseling of the patient. Key words: central serous chorioretinopathy, intrascalp steroid injection, topical steroids, psoriasis, cradle cap. References 1.
2.
3.
4.
5.
6.
7.
Bouzas EA, Karadimas P, Pournaras CJ. Central serous chorioretinopathy and glucocorticoids. Surv Ophthalmol 2002;47: 431–448. Kanta ML, Krishnendu S, Himadri D, Ranjan CP. Acute bilateral central serous chorioretinopathy following intra-articular injection of corticosteroid. Indian J Ophthalmol 2005;53: 132–134. Baumal CR, Martidis A, Truong SN. Central serous chorioretinopathy associated with periocular corticosteroid injection treatment for HLA-B27-associated iritis. Arch Ophthalmol 2004;122:926–968. Iida T, Spaide RF, Negrao SG, et al. Central serous chorioretinopathy after epidural corticosteroid injection. Am J Ophthalmol 2002;132:423–425. Kao LY. Bilateral serous retinal detachment resembling central serous chorioretinopathy following epidural injection. Retina 1998;18:479–481. Fernandez CF, Mendoza AJ, Arevalo JF. Central serous chorioretinopathy associated with topical dermal corticosteroids. Retina 2004;24:471. Karadimas P, Kapetanios A, Bouzas EA. Central serous chorioretinopathy after local application of glucocorticoids for skin disorders. Arch Ophthalmol 2004;122:784–786.
Purpose: To report three cases in which unusual routes of administration were associated with subsequent central serous chorioretinopathy (CSR). All three cases occurred in patients who were being treated for dermatologic conditions. Methods: Retrospective review of three cases of patients who presented with a diagnosis of CSR and use of steroids in an unusual route for treatment of various dermatologic conditions (intradermal injection to the scalp for keloids, topical cream for psoriasis, and topical solution for cradle cap). Results: Patient 1 had complete resolution and restoration of baseline visual acuity at the follow-up examination. This patient had no further injections to his keloids. Patient 2 drastically decreased the dose of topical cream and had resolution of symptoms. Patient 3 discontinued use of the steroid solution and had no new episodes of visual decline. Conclusion: This case series suggests that occult steroid use should be suspected for patients presenting with CSR who are concurrently being treated for dermatologic conditions. The knowledge gained from this thorough history is vital to the management and long-term counseling of the patient. RETINAL CASES & BRIEF REPORTS 3:99 –101, 2009
From the Department of Ophthalmology, Northwestern University, Chicago, Illinois.
quent CSR. All three cases occurred in patients who were being treated for dermatologic conditions.
C
entral serous chorioretinopathy (CSR) is a disease process characterized by the accumulation of subretinal fluid causing a neurosensory detachment in the posterior pole.1 Although the exact pathogenesis is unknown, both exogenous and endogenous glucocorticoids have been implicated. Several routes of administration of steroids have been implicated in the literature. Oral, intravenous, intramuscular, inhaled, and intranasal routes are standard routes that have been discussed.1 We report three cases in which unusual routes of administration were associated with subse-
Case Reports Case 1 A 35-year-old man presented to the retina clinic with a 5- to 7-day history of decreased vision in the right eye. He described a central scotoma in this eye. He denied any previous episodes. Ocular history was negative for any trauma or surgeries. Medical history was positive for benign nodular lesions on the occipital scalp that were excised by a dermatologist 3 months earlier. He subsequently developed keloids and was treated with a triamcinolone acetonide injection to the site 1 month before presentation. At the time of presentation, he was being treated with minocycline only. At examination, visual acuity without correction was 20/30 in the right eye with no improvement with pinhole. Visual acuity in the left eye was 20/20. External examination was unremarkable. Pupils, extraocular movements, and visual fields were within normal limits. Intraocular pressure was 20 mmHg in both eyes. Results of slit-lamp examination were normal. Dilated fundus examination of the right eye revealed a cup-to-disk of 0.3. The vessels were unremarkable. Within the macula, there was a central area of
Supported by an unrestricted grant from Research to Prevent Blindness, Inc. (New York, New York). Accepted to ASRS as a poster presentation; Cannes, France; 2006. Reprint requests: Rukhsana Mirza, MD, 645 North Michigan Avenue, Suite 440, Chicago, IL 60611-2814; e-mail: r-mirza@ northwestern.edu
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Fig. 2. Case 2, Optical coherence tomography showing neurosensory detachment.
during this time, which could be the cause of the prolonged recovery time. Fig. 1. Case 1. “Smokestack” leakage shown by fluorescein angiography.
subretinal fluid measuring ⬇1.5 disk areas in size. There was a yellow spot just nasal to the fovea. Examination of the periphery was unremarkable. Results of dilated fundus examination of the left eye were normal. Fluorescein angiography and optical coherence tomography revealed the classic appearance of central serous retinopathy (Fig. 1). The patient received no further treatment with steroids and was lost to follow-up. At the most recent examination 1 year later, visual acuity was 20/20 in the affected eye with complete resolution of fundus abnormalities.
Case 2 A 47-year-old woman presented to the retina clinic with a 3-week history of decreased vision in the left eye. She stated that it came on fairly acutely and had been staying roughly the same since its onset. She denied any previous episodes of vision loss in either eye. Medical history was positive for psoriasis for which she had been treated with steroid creams off and on for many years. She stated that her last use of steroid cream was several weeks before presentation. This coincided with the onset of her visual symptoms. She also had a history of steroid injections for psoriasis performed every 3 to 4 months, with the last injection being ⬎1 year ago. She had a history of anemia, an ovarian cyst, depression, and fibrocystic breast disease. Current medications included calcium, ibuprofen, and multivitamins, as well as fluoxetine hydrochloride. Family history was positive for a grandmother with a detached retina. At examination, visual acuity without correction was 20/20 in the right eye and 20/25⫺2 in the left eye. External examination was unremarkable. Pupils, extraocular movements, and visual fields were within normal limits. Intraocular pressure was 12 mmHg in the right eye and 13 mmHg in the left eye. Dilated fundus examination of the right eye revealed a cup-todisk of 0.3. There were some minimal retinal pigment epithelium changes, but no fluid was identified. Dilated fundus examination of the left eye showed a cup-to-disk of 0.3. Within the macula centered on the fovea, there was a large 1.5-disk area of subretinal fluid. Fluorescein angiography and optical coherence tomography showed classic appearing images for central serous retinopathy (Fig. 2). At the most recent follow-up (9 months), the patient had resolution of symptoms and fluid. The patient did admit that she had short episodes of reuse of the steroid cream
Case 3 A 49-year-old woman presented for a second opinion after having an acute scotoma ⬇6 weeks earlier. She had seen a retina specialist who had suggested a diagnosis of age-related macular degeneration although atypical especially due to her young age. The patient stated that the vision had possibly improved. Ocular history was significant only for refractive error. Medical history was positive for eczema. She had no family history of ocular disease. The patient stated that she was taking vitamins. When questioned if she took any medications for her eczema including steroids, the patient stated that she did not. However, she then admitted to being treated for a scalp condition (cradle cap) with fluocinonide (0.05% topical solution). She also stated that she had been under an increased amount of stress for the past several months. At examination, visual acuity was 20/20 in the right eye and 20/30 in the left affected eye. She had no pupillary abnormality. Confrontation and motility were also normal. Results of anterior segment examination were within normal limits. Dilated fundus examination revealed a cup-to-disk ratio of 0.3 bilaterally. The right posterior pole had mild pigmentary changes with no fluid. The left macula had similar pigmentary changes with mild subretinal fluid. There were no drusen, hemorrhages, or exudates in either eye. Optical coherence tomography and fluorescein imaging showed a pattern consistent with CSR. The patient discontinued use of the steroid solution; at 3 months, she had resolution of the fluid and stated that she had no further worsening of symptoms.
Discussion CSR is a disease process that is characterized by the accumulation of subretinal fluid causing a neurosensory detachment in the posterior pole.1 Although the exact pathogenesis has not been uncovered, several associations have been described. These include prevalence among patients with type A personalities, after stressful periods, and pregnancy. Furthermore, both exogenous and endogenous glucocorticoids have been implicated in the development of CSR. Several routes of administration of steroids also have been discussed in the literature. Oral, intravenous, intramuscular, inhaled, and intranasal routes are standard routes that have been discussed.1 However, even more unusual
101
CSR AND UNUSUAL ROUTES OF STEROID ADMINISTRATION
routes have been implicated. Kanta et al2 described a patient who developed bilateral CSR 1 day after an intraarticular injection for treatment of tenosynovitis of the wrist. Baumal et al3 described the development of this clinical picture associated with periocular corticosteroid injection treatment for iritis. Iida et al4 and Kao5 reported CSR after epidural injection of corticosteroids. Even topical creams for dermal conditions were described by Fernandez et al6 and Karadimas et al7 in association with CSR. We observed three cases of CSR associated with treatment of dermatologic conditions, two cases of topical steroid use and one case of triamcinolone injection to the scalp—which to our knowledge, is the first reported case of CSR secondary to triamcinolone injection to the scalp for keloids. It is important to remember that patients will often not volunteer history of these more unusual routes of administration because they may not see the relevance to their eye problem. In all three of our cases, the patient had been seen by other ophthalmologists and had not revealed exposure to steroids. Although undoubtedly our patients all had some degree of stress in relation to their conditions, one cannot overlook the effect of a potentially causative exogenous agent. It is therefore essential to review the entire list of medical issues and medications and specifically illicit any steroid use. This case series suggests occult steroid use should be suspected for patients concurrently being treated for
dermatologic conditions. The knowledge gained from this thorough history is vital to the management and long-term counseling of the patient. Key words: central serous chorioretinopathy, intrascalp steroid injection, topical steroids, psoriasis, cradle cap. References 1.
2.
3.
4.
5.
6.
7.
Bouzas EA, Karadimas P, Pournaras CJ. Central serous chorioretinopathy and glucocorticoids. Surv Ophthalmol 2002;47: 431–448. Kanta ML, Krishnendu S, Himadri D, Ranjan CP. Acute bilateral central serous chorioretinopathy following intra-articular injection of corticosteroid. Indian J Ophthalmol 2005;53: 132–134. Baumal CR, Martidis A, Truong SN. Central serous chorioretinopathy associated with periocular corticosteroid injection treatment for HLA-B27-associated iritis. Arch Ophthalmol 2004;122:926–968. Iida T, Spaide RF, Negrao SG, et al. Central serous chorioretinopathy after epidural corticosteroid injection. Am J Ophthalmol 2002;132:423–425. Kao LY. Bilateral serous retinal detachment resembling central serous chorioretinopathy following epidural injection. Retina 1998;18:479–481. Fernandez CF, Mendoza AJ, Arevalo JF. Central serous chorioretinopathy associated with topical dermal corticosteroids. Retina 2004;24:471. Karadimas P, Kapetanios A, Bouzas EA. Central serous chorioretinopathy after local application of glucocorticoids for skin disorders. Arch Ophthalmol 2004;122:784–786.
