Recurrent Central Serous Chorioretinopathy with Dexamethasone Eye Drop used Nasally for Rhinitis.

Central serous chorioretinopathy (CSC) is characterized by serous retinal detachment at the posterior pole. Several factors have been implicated in the pathogenesis, and endogenous or exogenous corticosteroids are thought to play a major role. Here we present a case of a 35-year-old male with complaints of a dark circle in front of his right eye. Fundus examination, optical coherence tomography and fundus fluorescein angiography were performed. The patient was diagnosed with CSC. CSC resolved completely within seven weeks. Four weeks later the CSC recurred and spontaneously resolved over eight weeks. Overall, the patient had three additional recurrences of CSC in the same eye over the next year. A detailed history taking revealed the patient was using 0.1% dexamethasone eye drops nasally for recurrent rhinitis for few days prior to each episode of CSC. This indicates the strong correlation between steroids given by any route and the pathogenesis of CSC.

INTRODUCTION

Central serous chorioretinopathy (CSC) is a focal retinal detachment due to fluid accumulation underneath the sensory retina. Endogenous and exogenous corticosteroids has been implicated in the pathogenesis of CSC.[12] This case report presents the development of CSC after the use of dexamethasone eye drops as a nasal drop. To our knowledge one case series and a case report is documented in literature, which specifically linked CSC with use of intranasal steroids.[34] In the previous publications, fluticasone or beclomethasone were used.[34] This is the first case described in literature, suggestive of CSC due to nasal use of dexamethasone drops for rhinitis.

CASE REPORT

A 35-year-old male, optometrist by profession, visited our hospital with complaint of seeing a dark circle in front of his right eye with onset three days prior to presentation. Patient was a non-smoker, non-alcoholic, non-hypertensive, was not on any medication and followed a healthy life style. Vision was 6/18 in the right eye with best corrected visual acuity (BCVA) of 6/6 with +2.0 D sphere. Anterior segment and intraocular pressure were normal. Fundus examination showed a bleb like elevation of retina. Fundus fluorescein angiography (FFA) showed ink blot leakage [Figure 1]. Coherence tomography (OCT) is shown in Figure 2a. The patient was diagnosed with CSC. The patient was prescribed 0.5% carboxymethylcellulose eye drops thrice a day and asked to return for follow up every two weeks. CSC completely resolved, clinically and on OCT, within seven weeks [Figure 2b]. Four weeks later the patient had a recurrence that again resolved spontaneously over eight weeks. In all, patient had three additional episodes of CSC in the same eye over the next year [Figure 3]. Each time patient denied any form of corticosteroid use. After detailed questioning, he admitted, that he used dexamethasone eye drops, nasally for five to seven days before each episodes. This suggests the strong correlation between steroids given by any route and pathogenesis of CSC. This is also first case ever of confirmed CSC due to nasal intake of steroid drops.

Figure 1

(a) Fundus photograph showing a fluid-filled bleb-like elevation at the posterior pole Figure (b), (c) and (d): Showing small hyperfluorescence spot in early phase, which gradually increased in size due to leakage taking an ink blot pattern

Figure 2

(a) OCT shows area of detachment as hyporeflectivity between neurosensory retina and RPE (b) Shows flattening of retinal contour after seven weeks

Figure 3

OCT showing serous retinal detachment at first and second recurrence

DISCUSSION

Emotional liability, neuroticism and introversion, hysteria, type A personality, pregnancy, have been suggested to predispose to CSC. Symptoms include sudden blurring of vision, central and paracentral scotoma, micropsia, macropsia. Von Graefe was the first to describe CSC. He called it recurrent central retinitis.[5] CSC is a serous detachment of the retina due to serum leakage from the choroidal circulation through a break in the diffusion barrier, made of tight junction around the retinal pigment epithelial (RPE) cells. The proposed pathogenesis is that steroid use leads to reduced absorption of subretinal fluid by altering the permeability of choriocapillaris and ion transport mechanism at the mineralocorticoid level.[67] Carvallo-Recchia et al. were the first to report a statistically significant relation between exogenous corticosteroid use and CSC.[8] Multiple reports have suggested the development of CSC after the use of steroids in any form.[910] To our knowledge one case series and a case report is documented in the literature which specifically links CSC with use of intranasal steroids.[34] Intranasal corticosteroids are widely used for allergic rhinitis and it is often purchased as over-the-counter drug. A position paper by joint task force for the American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma and Immunology stated that, “data suggest that the use of inhaled corticosteroids is associated with an increased risk of adverse ocular effects and that the risk increases with dose and duration of therapy,” leading them to recommend that intranasal corticosteroids not be approved for over-the-counter use.[11] Any patient using steroid in any form must be informed about the possibility of development of CSC and should immediately report to a treating doctor and ophthalmologist on the appearance of symptoms, and the drug should be discontinued. This is the first case in the literature, suggestive of CSC after use of dexamethasone eye drop in the form of nasal drop for recurrent allergic rhinitis.