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a r c h s o c e s p o f t a l m o l . 2 0 1 4;8 9(7):275–278

ARCHIVOS DE LA SOCIEDADESPAÑOLA DE OFTALMOLOGÍA

www .e lsev ier .es /o f ta lmologia

hort communication

entral serous chorioretinopathy of unusual etiology: report of 2 cases�

.I. Palacios ∗, M. Rodríguez, M.D. Martín

ervicio de Oftalmología, Hospital Universitario Infanta Cristina, Universidad Complutense de Madrid, Parla, Madrid, Spain

r t i c l e i n f o

rticle history:

eceived 25 October 2012

ccepted 12 April 2013

vailable online 24 September 2014

eywords:

entral serous chorioretinopathy

nfluenza virus

accination

ocaine

ASIK

a b s t r a c t

Objective: Describe 2 rare causes of central serous chorioretinopathy.

Clinical cases: Case 1: A 35-year-old woman with loss of vision in her left eye, with a recent

history of a flu vaccination. This could have been the process that triggered an immune

response, with increased circulating immune complexes that favor choroidal ischemia.

Case 2: A 41-year-old man with loss of vision in his left eye. As history, had consumed

cocaine, which could be related to its adrenergic effect adrenergic, and earlier excimer laser

refractive surgery (LASIK).

Conclusion: In both cases there was a temporal relationship between cause and effect.

© 2012 Sociedad Espanola de Oftalmología. Published by Elsevier España, S.L.U. All rights

reserved.

Coriorretinopatía serosa central de etiología inusual: a propósitode dos casos

alabras clave:

oriorretinopatía serosa central

irus influenza

acunación

ocaína

r e s u m e n

Objetivo: Describir dos causas poco frecuentes de coriorretinopatía serosa central.

Casos clínicos: Caso 1: mujer de 35 anos con pérdida de visión del ojo izquierdo. Como

antecedente presenta vacunación reciente contra la gripe. Podría ser la causa del proceso

por desencadenar una respuesta inmune con aumento de inmunocomplejos circulantes

que favorecieran isquemia coroidea. Caso 2: varón de 41 anos con pérdida de visión del

ASIK ojo izquierdo. Como antecedente presenta toma de cocaína, que podría relacionarse por su

efecto adrenérgico, y anti

Conclusión: En ambos caso

© 2012 Sociedad Espa

� Please cite this article as: Palacios AI, Rodríguez M, Martín MD. Coros casos. Arch Soc Esp Oftalmol. 2014;89:275–278.∗ Corresponding author.

E-mail address: aisabel.palacios@salud.madrid.org (A.I. Palacios).

173-5794/$ – see front matter © 2012 Sociedad Espanola de Oftalmolog

gua cirugía refractiva con láser excimer (LASIK).

s se produce una relación temporal entre causa-efecto.

nola de Oftalmología. Publicado por Elsevier España, S.L.U. Todos

los derechos reservados.

iorretinopatía serosa central de etiología inusual: a propósito de

ía. Published by Elsevier España, S.L.U. All rights reserved.

l m o l . 2 0 1 4;8 9(7):275–278

276 a r c h s o c e s p o f t a

Introduction

Central serous chorioretinopathy (CSC) is a multifactorial dis-ease of complex etiology1 that combines choriocapillaris fluidleak with impaired retinochoroidal pumping function of theretinal pigment epithelium (RPE).

Clinical cases

Case 1

A 35-year-old woman with loss of vision in her left eye pro-gressing for 5 days. Her best corrected visual acuity (BCVA) was0.6. Her medical history included recent Mutagrip® influenzavaccination.

On examination, she presented relative afferent pupillarydefect in her left eye. The ocular fundus shows a well-definedneurosensory retinal detachment (NRD) that occupies theentire posterior pole.

Optical coherence tomography (OCT) (Cirrus HD-OCT ver-sion 4.0, Zeiss) shows a large NRD with a retinal pigment

epithelium (RPE) defect, slightly raised on the inferonasalquadrant, which coincides in the fluorescein angiography(FA) with the hyperfluorescent vanishing point in a chimney-smoke-like pattern (Figs. 1 and 2).

Fig. 1 – CSC FA typical appearance: hyperfluorescence at early stwhich, in final stages, extends laterally until filling the NRD in a

Fig. 2 – NRD with small PED (vanishing point).

The NRD was resolved a month and a half later (Fig. 3).However, her BCVA is 0.8.

Case 2

41-year-old male with decreased visual acuity in his left eye,with 24 h of progression. His medical history includes myopicLASIK intervention 6 years ago and cocaine consumption

2 days prior. BCVA in his right eye was 1, and 0.6 in the left eye.Examination of the right eye fundus shows one NRD in papillo-macular bundle, and 2 NRD in the left eye: one subfoveal and

ages, which increases vertically, reaching the NRD roofchimney-smoke-like pattern.

a r c h s o c e s p o f t a l m o l . 2

Fig. 3 – NRD Resolution 1.5 months later, with some smallP

twa

D

Cceictb

a

F

ED.

he other one temporal fovea. Macular OCT confirmed NRDithout any other abnormalities (Figs. 4 and 5). NRD resolved

t 3 months, and his BCVA was 1 in both eyes.

iscussion

SC pathogenesis remains unclear, but there is a strong asso-iation with the use of corticosteroids as described by Bouyont al. in 2 cases treated with corticosteroids in which clin-cal improvement occurred after they are removed.2 As inataracts or glaucoma, CSC may be a possible side effect ofreatment with corticosteroids and, therefore, internists must

e aware of it.

Although advances have occurred in understandingutoimmune diseases, the possible mechanisms triggering

ig. 4 – Right eye NRD with foveal depression blurring.

Fig. 5 – Left eye NRD without foveal involvement.

r

0 1 4;8 9(7):275–278 277

tolerance break remain unknown. The vaccine produces anabnormal immune activation; there are reports of small ves-sel lymphocytic vasculitis cases after vaccination due toimmunoglobulin G and C3 immune complex deposits indermal vessels. It has also been linked to genetic predispo-sition to cause an autoimmune reaction, HLA-DRB1 variantspecifically.3

Bradley et al. present a CSC case within 14 days fromAnthrax vaccination4 and cited 3 cases after smallpox vac-cination reported by Rosen et al.

There are reports that indocyanine green angiography hasexposed choroidal vasoconstriction with blood flow deterio-ration in the CSC, whereby CSC may be a result of choroidalischemia with venous congestion.5

There is a clear association between cocaine use andischemic heart disease due to catecholamine reuptake block-ing caused by the drug.6 Therefore, in case 2, adrenergicsystem stimulation may also be involved in acute CSC, notjust by possible cocaine-triggered ischemia, but also by anincrease in endogenous corticosteroids, which increase adren-ergic receptor sensitivity.1 Hassan et al. already linked ecstasyuse with CSC.7

In our case, moreover, the patient had undergone LASIKrefractive surgery, albeit 6 years prior. Although there are CSCcases after PRK due to myopia reported by Moshirfar et al.,8

and cases after LASIK from hyperopia reported by Peponiset al.,9 all occurred in the first month. Risks during surgerythat could lead to CSC are: suction at submacular level andstress; however, it has not been linked to topical use of corti-costeroids.

Ascaso et al. reported the first case of rare bilateral mac-ulopathy (non-CSC) after long-lasting intranasal cocaine use,causing alteration in color vision, without alteration detectedin OCT. Early hyperfluorescence at the foveal level, maintaineduntil late stages, is commonly observed with FA.10

Conclusion

CSC could be an uncommon but significant adverse event aftervaccination, to be taken into account especially in patientswith immune disorders.

With regard to Case 2, although the link between cocaineand CSC is inconclusive, patient was informed of the highprobability of recurrence if he uses again. Therefore, patientswith acute CSC must be questioned carefully on drug use.

Both the cause–effect relationships in these two cases areonly hypotheses, and are not proven in this paper.

Conflicts of interest

The authors declare that they have no conflicts of interest.

e f e r e n c e s

1. Gemenetzi M, de Salvo G, Lotery AJ. Central serouschorioretinopathy: an update on pathogenesis and treatment.Eye. 2010;24:1743–56.

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278 a r c h s o c e s p o f t a

2. Bouyon A, Costedoat-Chalumeau N, Limal N, Fardeau C,Bodaghi B, Wechsler B, et al. Central serous chorioretinopathyand systemic diseases report of 2 cases associated withcorticotherapy. La revue de Médecine interne. 2006;27:487–91.

3. Pou MA, Díaz-Torne C, Vidal S, Corchero C, Narvaez J, NollaJM, et al. Development of autoinmune diseases aftervaccination. J Clin Rheumatol. 2008;14:243–4.

4. Foster BS, Agahigian DD. Central serous chorioretinopathyassociated with anthrax vaccination. Retina. 2004;24:624–5.

5. Wang M, Munich IC, Hasler PW, Prünte C, Larsen M. Central

serous chorioretinopathy. Acta Ophthalmol Scand.2008;86:126–45.

6. Freire E, Penas M, Castr A. Patología del corazón de origenextracardiaco. Rev Esp Cardiol. 1998;51:396–401.

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. 2 0 1 4;8 9(7):275–278

7. Hassan L, Carvalho C, Yannuzzi L, Ilda T, Negrao S. Centralserous chorioretinopathy in a patient usingmethamphetamine (MDMA) or ectasy. Retina. 2001;21:559–61.

8. Moshirfar M, Hsu M, Schulman J, Armenia J, Sikder S, HartnettME. The incidente of central Selous chorioretinopathy alterphotorefractive keratectomy and laser in situ keratomileusis.J Ophthalmol. 2012:904215.

9. Peponis VG, Chalkiadakis SE, Nikas SD, Makris Nk Ladas ID,Karagiannis DA. Bilateral central Selous retinopathy followinglaser in situ keratomileusis for miopia. J Cataract Refract

Surg. 2011;37:778–80.

0. Ascaso FJ, Cruz N, del Buey MA, Cristóbal JA. An inusual caseof cocaine-induced maculopathy. Eur J Ophthalmol.2009;19:880–2.