DOI: 10.5301/ejo.5000403
Eur J Ophthalmol 2014; 24 ( 4 ): 559-565
original article
The impact of financial crisis on central serous chorioretinopathy in Greece: Is there any correlation? Alexandros A. Rouvas1, Irini P. Chatziralli2, Ioannis D. Ladas3, Vivi Xanthopoulou1, Emmanouela Giannakaki1, Aikaterini Karamboula1, Dimitrios Galanis1, Ioannis Datseris4, Dimitrios Alonistiotis1, Ramza Diamanti4, Miltiadis Tsilimbaris5, Aikaterini Chalkia5, Panagiotis Theodossiadis1 2nd Department of Ophthalmology, “ATTIKON” University Hospital, University of Athens, Athens - Greece 2 nd 2 Department of Ophthalmology, “Ophthalmiatrion” Hospital, Athens - Greece 3 st 1 Department of Ophthalmology, University of Athens, Athens - Greece 4 “OMMA” Eye Center, Athens - Greece 5 Department of Ophthalmology, University of Crete, Crete - Greece 1
Purpose: To investigate the impact of economic crisis on central serous chorioretinopathy (CSCR) incidence in Greece, analyzing data by 3 different ophthalmology units during the period 2005-2012. Methods: Between January 1, 2005, and December 31, 2012, all patients at 3 separate ophthalmology units, i.e., 2 public university clinics and 1 private center, presenting with the diagnosis of acute CSCR, either new cases or recurrent ones, were consecutively enrolled in the study. Patients’ data, including age and sex, as well as the date of presentation, were recorded and analyzed. Recurrent cases were also recorded. Results: The study sample included 580 new cases of CSCR (463 male, 117 female) and 97 recurrent cases (84 male, 13 female). The mean age was 48.8 ± 10.3 years (range 25-90). The number of incident as well as recurrent cases increased with more recent years. As expected, the increasing trend of cases and recurrences was reproducible upon the sex-specific analyses. Moreover, the increasing trend of cases and recurrences was reproducible upon the majority of analyses stratified by age. Conclusions: Our study suggests a potential impact of financial crisis on CSCR. Our results demonstrated that CSCR incidence, in both new and recurrent cases, has increased during the years of economic crisis in Greece, especially in 2010-2011, implying that CSCR is likely to be associated with stress or other emotional stimuli caused by financial crisis. It is also important to note that the results were similar in public and private units. Keywords: Central serous chorioretinopathy, Crisis, Economic, Financial, Mental health Accepted: November 9, 2013
INTRODUCTION Central serous chorioretinopathy (CSCR) was first described by Albrecht von Graefe in 1866 as “relapsing central luetic retinitis” (central recurrent retinitis), and is characterized by serous detachment of the neurosensory retina (1, 2). It typically affects young to middle-aged men (30-50 years old), but patients with chronic disease may continue to have the
disease even in advanced age (2). Nowadays advances in imaging, especially in optical coherence tomography (OCT) and indocyanine green angiogram, provide a better understanding of the pathophysiology of CSCR (3). It is thought that increased hydrostatic pressure in the thickened choroid and choroidal vasculature hyperpermeability cause breakdown of the retinal pigment epithelium (RPE) barrier with subsequent leakage of fluid from the choroid into subretinal
© 2013 Wichtig Editore - ISSN 1120-6721
559
Central serous chorioretinopathy and financial crisis
space (2-4). Indocyanine green angiography also revealed areas of nonperfusion, leading to choroidal venous dilation and congestion (2-4). Central serous chorioretinopathy is usually idiopathic, although it has been mostly associated with high levels of endogenous (i.e., in Cushing syndrome or in pregnancy) or exogenous (i.e., intra-articular, intranasal, systemic, or topical) corticosteroids (5-9). Other risk factors for CSCR are abnormal coagulation and platelet aggregation, infection with Helicobacter pylori, smoking, hypertension, antibiotic use, alcohol consumption, obstructive sleep apnea, and allergic respiratory diseases (5, 10). Interestingly, CSCR has been described after rhinoplasty and after refractive surgery, but the possible pathophysiologic mechanism remains elusive (11-13). Horniker first suggested in 1927 that psychiatric disturbances were linked to CSCR, through a mechanism of retinal angiospasm and macular exudation (14, 15). Subsequently, Yannuzzi in 1986 demonstrated in a cross-sectional study that CSCR was associated with stress and Type A personality (16). He supported that elevation of catecholamines levels might trigger vasoconstriction of choroidal vessels, stimulating the sympathetic nervous system and adrenergic receptors (16). So, in this personality, there is a proportional relationship between mental health and CSCR. The global financial and economic crisis poses an additional risk factor for mental health problems (17-23). Gili et al reported an increase in the frequency of mental health disorders, especially among families experiencing unemployment and mortgage payment difficulties during the financial crisis in Spain (18), in line with Meltzer et al, who also found a relationship between personal debt and common mental disorders (19). Greece has faced a prolonged financial crisis with unemployment rising steeply in 2010-2011 (24). This period caused adverse effects on the mental health of citizens, with increase of stress, anxiety, depression, and suicidal rates, as well as worsening in self-rated health trends (25-34). Notably, in 2008, prior to the economic crisis in Greece, the 1-month prevalence of suicidal ideation was 2.4% and that of suicide attempts was 0.6. Both rates are substantially lower than those in 2009 and 2011 (33, 34). These findings run parallel with the gradual increase in the prevalence of major depression in Greece during the past few years, confirming that the economic crisis in Greece has impinged on the mental health of the population (29, 32). In light of the above, the purpose of our study was to investigate the impact of economic crisis on CSCR incidence in 560
Greece, analyzing data by 3 different ophthalmology departments during the period 2005-2012.
MATERIALS AND METHODS Between January 1, 2005, and December 31, 2012, all patients at 3 separate ophthalmology departments—2 public university clinics (2nd Department of Ophthalmology, University of Athens, Greece, and Department of Ophthalmology, University of Crete, Heraklion, Greece) and 1 private center (“OMMA” Athens Eye Institute, Athens, Greece)—presenting with the diagnosis of acute CSCR, either new cases or recurrent ones, were consecutively enrolled in the study. After a complete ophthalmologic examination (Snellen visual acuity, slit-lamp examination, funduscopy), the diagnosis was based on typical symptoms (visual acuity decrease, metamorphopsia) and findings (serous retinal elevation). All patients had undergone OCT, confirming the detachment of the neurosensory retina and the accumulation of serous fluid between the RPE and the photoreceptors’ outer segments, as well as fluorescein angiography (FA), presenting the typical leakage point, which progressed from classical smokestack appearance of increasing hyperfluorescence to other patterns, such as inkblot (2, 35, 36). Patient data, including age and sex, as well as the date of presentation, were recorded and analyzed. Recurrent cases were also recorded. Patients with age-related macular degeneration, angioid streaks, pathologic myopia, inflammatory uveal-vitreous disorders, diabetic macular edema, or other retinal disorders were excluded from the study. Additionally, all patients having reported previous corticosteroid use, having disorders or taking medications that affect the renin-angiotensin axis, as well as those who had undergone renal transplantation were excluded from the study. The study was approved by the institutional review board. For the examination of time trends, Spearman rank correlation coefficient was calculated; apart from the overall analysis, subgroup analyses stratified by sex and age were performed. Statistical significance was defined as p
Eur J Ophthalmol 2014; 24 ( 4 ): 559-565
original article
The impact of financial crisis on central serous chorioretinopathy in Greece: Is there any correlation? Alexandros A. Rouvas1, Irini P. Chatziralli2, Ioannis D. Ladas3, Vivi Xanthopoulou1, Emmanouela Giannakaki1, Aikaterini Karamboula1, Dimitrios Galanis1, Ioannis Datseris4, Dimitrios Alonistiotis1, Ramza Diamanti4, Miltiadis Tsilimbaris5, Aikaterini Chalkia5, Panagiotis Theodossiadis1 2nd Department of Ophthalmology, “ATTIKON” University Hospital, University of Athens, Athens - Greece 2 nd 2 Department of Ophthalmology, “Ophthalmiatrion” Hospital, Athens - Greece 3 st 1 Department of Ophthalmology, University of Athens, Athens - Greece 4 “OMMA” Eye Center, Athens - Greece 5 Department of Ophthalmology, University of Crete, Crete - Greece 1
Purpose: To investigate the impact of economic crisis on central serous chorioretinopathy (CSCR) incidence in Greece, analyzing data by 3 different ophthalmology units during the period 2005-2012. Methods: Between January 1, 2005, and December 31, 2012, all patients at 3 separate ophthalmology units, i.e., 2 public university clinics and 1 private center, presenting with the diagnosis of acute CSCR, either new cases or recurrent ones, were consecutively enrolled in the study. Patients’ data, including age and sex, as well as the date of presentation, were recorded and analyzed. Recurrent cases were also recorded. Results: The study sample included 580 new cases of CSCR (463 male, 117 female) and 97 recurrent cases (84 male, 13 female). The mean age was 48.8 ± 10.3 years (range 25-90). The number of incident as well as recurrent cases increased with more recent years. As expected, the increasing trend of cases and recurrences was reproducible upon the sex-specific analyses. Moreover, the increasing trend of cases and recurrences was reproducible upon the majority of analyses stratified by age. Conclusions: Our study suggests a potential impact of financial crisis on CSCR. Our results demonstrated that CSCR incidence, in both new and recurrent cases, has increased during the years of economic crisis in Greece, especially in 2010-2011, implying that CSCR is likely to be associated with stress or other emotional stimuli caused by financial crisis. It is also important to note that the results were similar in public and private units. Keywords: Central serous chorioretinopathy, Crisis, Economic, Financial, Mental health Accepted: November 9, 2013
INTRODUCTION Central serous chorioretinopathy (CSCR) was first described by Albrecht von Graefe in 1866 as “relapsing central luetic retinitis” (central recurrent retinitis), and is characterized by serous detachment of the neurosensory retina (1, 2). It typically affects young to middle-aged men (30-50 years old), but patients with chronic disease may continue to have the
disease even in advanced age (2). Nowadays advances in imaging, especially in optical coherence tomography (OCT) and indocyanine green angiogram, provide a better understanding of the pathophysiology of CSCR (3). It is thought that increased hydrostatic pressure in the thickened choroid and choroidal vasculature hyperpermeability cause breakdown of the retinal pigment epithelium (RPE) barrier with subsequent leakage of fluid from the choroid into subretinal
© 2013 Wichtig Editore - ISSN 1120-6721
559
Central serous chorioretinopathy and financial crisis
space (2-4). Indocyanine green angiography also revealed areas of nonperfusion, leading to choroidal venous dilation and congestion (2-4). Central serous chorioretinopathy is usually idiopathic, although it has been mostly associated with high levels of endogenous (i.e., in Cushing syndrome or in pregnancy) or exogenous (i.e., intra-articular, intranasal, systemic, or topical) corticosteroids (5-9). Other risk factors for CSCR are abnormal coagulation and platelet aggregation, infection with Helicobacter pylori, smoking, hypertension, antibiotic use, alcohol consumption, obstructive sleep apnea, and allergic respiratory diseases (5, 10). Interestingly, CSCR has been described after rhinoplasty and after refractive surgery, but the possible pathophysiologic mechanism remains elusive (11-13). Horniker first suggested in 1927 that psychiatric disturbances were linked to CSCR, through a mechanism of retinal angiospasm and macular exudation (14, 15). Subsequently, Yannuzzi in 1986 demonstrated in a cross-sectional study that CSCR was associated with stress and Type A personality (16). He supported that elevation of catecholamines levels might trigger vasoconstriction of choroidal vessels, stimulating the sympathetic nervous system and adrenergic receptors (16). So, in this personality, there is a proportional relationship between mental health and CSCR. The global financial and economic crisis poses an additional risk factor for mental health problems (17-23). Gili et al reported an increase in the frequency of mental health disorders, especially among families experiencing unemployment and mortgage payment difficulties during the financial crisis in Spain (18), in line with Meltzer et al, who also found a relationship between personal debt and common mental disorders (19). Greece has faced a prolonged financial crisis with unemployment rising steeply in 2010-2011 (24). This period caused adverse effects on the mental health of citizens, with increase of stress, anxiety, depression, and suicidal rates, as well as worsening in self-rated health trends (25-34). Notably, in 2008, prior to the economic crisis in Greece, the 1-month prevalence of suicidal ideation was 2.4% and that of suicide attempts was 0.6. Both rates are substantially lower than those in 2009 and 2011 (33, 34). These findings run parallel with the gradual increase in the prevalence of major depression in Greece during the past few years, confirming that the economic crisis in Greece has impinged on the mental health of the population (29, 32). In light of the above, the purpose of our study was to investigate the impact of economic crisis on CSCR incidence in 560
Greece, analyzing data by 3 different ophthalmology departments during the period 2005-2012.
MATERIALS AND METHODS Between January 1, 2005, and December 31, 2012, all patients at 3 separate ophthalmology departments—2 public university clinics (2nd Department of Ophthalmology, University of Athens, Greece, and Department of Ophthalmology, University of Crete, Heraklion, Greece) and 1 private center (“OMMA” Athens Eye Institute, Athens, Greece)—presenting with the diagnosis of acute CSCR, either new cases or recurrent ones, were consecutively enrolled in the study. After a complete ophthalmologic examination (Snellen visual acuity, slit-lamp examination, funduscopy), the diagnosis was based on typical symptoms (visual acuity decrease, metamorphopsia) and findings (serous retinal elevation). All patients had undergone OCT, confirming the detachment of the neurosensory retina and the accumulation of serous fluid between the RPE and the photoreceptors’ outer segments, as well as fluorescein angiography (FA), presenting the typical leakage point, which progressed from classical smokestack appearance of increasing hyperfluorescence to other patterns, such as inkblot (2, 35, 36). Patient data, including age and sex, as well as the date of presentation, were recorded and analyzed. Recurrent cases were also recorded. Patients with age-related macular degeneration, angioid streaks, pathologic myopia, inflammatory uveal-vitreous disorders, diabetic macular edema, or other retinal disorders were excluded from the study. Additionally, all patients having reported previous corticosteroid use, having disorders or taking medications that affect the renin-angiotensin axis, as well as those who had undergone renal transplantation were excluded from the study. The study was approved by the institutional review board. For the examination of time trends, Spearman rank correlation coefficient was calculated; apart from the overall analysis, subgroup analyses stratified by sex and age were performed. Statistical significance was defined as p
