Severe visual loss secondary to central serous chorioretinopathy following prolonged immune suppression with oral prednisolone

摘要

DECLARATIONSCompeting interestsNone declaredEthical approvalWritten informed consent to publication has been obtained from the patient or next of kinGuarantorSPContributorshipSP and AH wrote the case report. SP was the patient's ophthalmic consultant and obtained the images. KA was the renal consultant involved in the patient's care and editor the report prior to submission. SP was the supervising author for the paperReviewerBalini BalasubramaniamCentral serous chorioretinopathy (CSCR) is often self-limiting but can have serious ocular complications. We present a case of severe visual loss secondary to chronic CSCR in a renal transplant patient on long-term corticosteriods.Case history Section:A 50-year-old man presented to the eye clinic with a 12-month history of a gradual loss of vision in the right eye. He had no significant past ocular history but had been diagnosed at the age of 10 years with Henoch-Schonlein nephritis. He had a renal transplant in 1997 and had been taking oral prednisolone for the past 12 years as part of his immunosuppression regime. He also suffered from hyperparathyroidism and had recently been diagnosed with type 2 diabetes. At the time of presentation his medication included immunosuppression with cyclosporin 50 mg twice daily, azothiaprine 100 mg and prednisolone 7.5 mg. He was also on candesartan, atenolol, furosemide, simvastatin, alfacalcidol, darbepoetin alfa and cinacalcet.On examination his visual acuities were 2/60 in the right eye and 6/4 in the left eye. The anterior segments, intraocular pressures and crystalline lenses were normal in both eyes. A dilated ophthalmic examination revealed diffuse nonspecific retinal pigment epithelial (RPE) changes in both eyes. There were no clinical signs of subretinal fluid or neurosensory or pigment epithelial retinal detachments in either eye although the ocular coherence tomogram (OCT) detected shallow extrafoveal subretinal fluid in the left eye. The OCT, fundus autofluorescence (FA) and fundus fluorescein angiogram (FFA) findings are shown in Figure 1. The optic discs were healthy.DownloadOpen in new tabDownload in PowerPointFigure 1 Showing the OCT, fundus autofluorescence and angiographic findings in the right and left eyes at presentation. A and B: OCT images captured on the Topcon 3D OCT 1000. No subretinal fluid seen in the right eye (1A). Left eye shows disruption of the retinal pigment epithelium associated with shallow subretinal fluid localized to the superotemporal macular area (red arrow) (1B). C and D: Fundus autofluorescence images captured on the Heidelberg retina angiograph 2 (HRA 2). There is an area of mottled reduced autofluorescence with bright margins, a gravitational distribution and extensive foveal involvement in the right eye (1C). The left eye shows a localized and relatively uniform area of increased autofluorescence, sparing the macula (1D). E and F: Fundus fluorescein angiogram images captured on HRA 2. There is mottled hyperfluorescence in the right eye at 1 minute corresponding to the area of abnormal fundus autofluorescence (1E). The left eye at 45 seconds shows a triangular area of hypofluorescence (corresponding to a similar shaped area of increased fundus autofluorescence) surrounded by mottled hyperfluorescence (1F). Neither eye showed any area of focal hyperfluorescence or choroidal neovascularizationA diagnosis of steroid-induced chronic central serous retinopathy was made. The right eye had inactive end-stage disease. However, the presence of shallow subretinal fluid in the left eye indicated residual disease activity in this eye. If left untreated there remained the threat of foveal involvement and loss of vision. After discussion with the treating renal physician and the patient it was decided to reduce the oral prednisolone while jointly monitoring both the renal function and the ophthalmic condition. His oral prednisolone has been gradually reduced over three months from 7.5 mg to 2 mg. Both his transplant