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Shift Work: a Risk Factor for Central Serous Chorioretinopathy

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Shift Work: a Risk Factor for Central Serous Chorioretinopathy Shift Work: A Risk Factor for Central Serous Chorioretinopathy ELODIE BOUSQUET, MYRIAM DHUNDASS, MATHIEU LEHMANN, PIERRE-RAPHAE¨L ROTHSCHILD, VIRGINIE BAYON, DAMIEN LEGER, CIARA BERGIN, ALI DIRANI, TALAL BEYDOUN, AND FRANCINE BEHAR-COHEN PURPOSE: To investigate if shift work or sleep distur- and focal serous detachments of the neurosensory retina bances are risk factors for central serous chorioretinop- and retinal pigment epithelium alterations. The role of athy (CSCR). choroid hyperpermeability in the pathogenesis of CSCR DESIGN: Prospective case-control study. has been well documented recently with multimodal imag- 2 METHODS: Forty patients with active CSCR and 40 ing modalities. In CSCR patients, a thick choroid has controls (age- and sex-matched) were prospectively been reported not only in the affected eye but also in the recruited from the Ophthalmology Department of Hoˆtel fellow eye, which is consistent with bilateral choroidal Dieu Hospital, Paris, between November 2013 and hyperpermeability.2,3 December 2014. All patients were asked to complete a To date, several risk factors for CSCR have been questionnaire addressing previously described risk factors identified,3 and the most consistent is corticosteroid and working hours, as well as the Insomnia Severity exposure from therapeutic administration or from endog- Index (ISI), a validated instrument for assessing sleep enous overproduction, as in Cushing syndrome.4–6 disturbances. Corticosteroids were recently shown to induce RESULTS: The mean age of the CSCR group was 44 ± 9 choroidal vasodilation through mineralocorticoid years, whereas the mean age of the control group was receptor activation in animal models.3 CSCR has also 43 ± 10 years. By use of multivariate analysis, shift been associated with increased sympathetic activity7 work (odds ratio [OR] [95% confidence interval]: 5 and sympathomimetic medication.8 Psychological stress9 [1.2–20.4]; P [ .02), steroid use (OR: 5.5 [1.1–26.2]; and type A personality10 with narcissistic traits11 P [ .03), and recent psychological stress (OR: have also been identified as contributing factors. 15.3 [4.1–54.5]; P < .001) were found to be indepen- Additional associations have been reported with hyper- dently associated with CSCR. tension, coronary heart disease, peptic ulcer disease, CONCLUSION: The outcomes of this study suggest that antihistamines, antibiotics, and psychopharmacologic shift work is an independent risk factor of CSCR. Further medications.6,12 studies are required to confirm these results and to ‘‘Shift work’’ includes work hours that fall outside the examine if work reconversion would be beneficial in the standard daylight hours (7 AM to 6/7 PM),13 including treatment of patients with chronic/recurrent evening, night, morning, rotating, and irregular shifts.14 Ó CSCR. (Am J Ophthalmol 2016;165:23–28. 2016 In industrialized countries, 15%–20% of the work force Elsevier Inc. All rights reserved.) have regular shift work.13–15 It leads to circadian misalignment and sleep disturbances that have been associated with increased risk of obesity, diabetes, ENTRAL SEROUS CHORIORETINOPATHY (CSCR) IS A cardiovascular disease, depression, and cancer.16,17 chorioretinal disease that most often affects Mechanisms underlying these health problems are not middle-aged men.1 It is characterized by posterior C fully elucidated but are thought to be related to sleep and circadian disruption.14 Indeed, sleep disturbances have Supplemental Material available at AJO.com. been associated with increased activities of the Accepted for publication Feb 15, 2016. hypothalamic-pituitary adrenal axis and the autonomic From the Department of Ophthalmology (E.B., M.D., M.L., P.-R.R., sympathoadrenal system, characterized by altered secretion T.B.) and Sleep and Vigilance Center (V.B., D.L.), Hoˆtel-Dieu of Paris, 18 Assistance Publique-Hoˆpitaux de Paris, AP-HP, Paris, France, of cortisol and catecholamine hormones. Universite´ Sorbonne Paris Cite´, Paris, France; Inserm U1138, Team 17, Since CSCR patients have higher levels of urine and Universite´ Sorbonne Paris Cite´, Universite´ Pierre et Marie Curie, plasma cortisol compared with the control group19,20 Centre de Recherche des Cordeliers, Paris, France (E.B., P.-R.R., F.B.- 21 C.); and Department of Ophthalmology University of Lausanne, Jules and increased levels of plasma catecholamines, we Gonin Ophthalmic Hospital, Fondation Asile des Aveugles, Lausanne, questioned whether shift work and/or sleep disturbance Switzerland (C.B., A.D., F.B.-C.). Inquiries to Elodie Bousquet, Hoˆpital Hoˆtel Dieu, 1 Parvis Notre Dame, evaluated by the Insomnia Severity Index (ISI) could 75004 Paris, France; e-mail: [email protected] be risk factors for CSCR. 0002-9394/$36.00 Ó 2016 ELSEVIER INC.ALL RIGHTS RESERVED. 23 http://dx.doi.org/10.1016/j.ajo.2016.02.012 METHODS TABLE 1. Univariate Risk Factors for Central Serous STUDY PATIENTS: Patients were prospectively included Chorioretinopathy between November 4, 2013 and December 31, 2014 at Control 95% the Department of Ophthalmology in the Hoˆtel Dieu Hos- Patients With Patients Odds Confidence pital, Paris, France. The Ethics Committee of the French Exposure CSCR (n ¼ 40) (n ¼ 40) Ratio Interval P Value Society of Ophthalmology approved this study. Informed Age, years 44.1 6 8.6 43 6 10.1 - - .6 signed consent was obtained from all subjects in compli- (mean 6 SD) ance with the tenets of the Helsinki agreement. Male (%) 85 85 - - 1 Patients of working age between 20 and 60 years and Sleep disorders 23 (57.5%) 6 (15%) 7.6 2.7–21.7 <.001 presenting symptoms of CSCR were enrolled. Active (ISI >10), n (%) CSCR was defined as a localized serous retinal detachment Shift work, n (%) 17 (42.5%) 6 (15%) 4.6 1.5–11.9 .007 on optical coherence tomography associated with angio- Steroid use, 15 (37.5%) 4 (10%) 5.4 1.7–17.3 .007 graphic leakage on fluorescein angiography without signs n (%) < of choroidal neovascularization, polypoidal choroidal Stress, n (%) 27 (67.5%) 5 (12.5%) 14.5 4.8–44.1 .001 vasculopathy, or inflammation. Chronic CSCR was defined Hypertension, 9 (22.5%) 3 (7.5%) 3.6 0.96–13.3 .06 n (%) by the persistence of serous retinal detachment (SRD) for Depression, n (%) 7 (17.5%) 9 (22.5%) 0.7 0.2–2.1 .6 more than 6 months and/or with recurrent SRD associated Allergic disease, 13 (32.5%) 14 (35%) 0.9 0.4–2.2 .8 with widespread decompensation of the retinal pigment n (%) 22 epithelium. Tobacco use, 17 (42.5%) 12 (30%) 1.7 0.7–4.3 .2 Control patients were matched for age and sex at a ratio n (%) of 1:1 and recruited at the emergency consultation with Alcohol use, 6 (15%) 4 (10%) 1.6 0.4–5.8 .5 ocular complaint but with no previous or ongoing retinal n (%) pathology. The frequency of diseases including conjuncti- ¼ ¼ vitis, blepharitis, chalazion, dry eye, keratitis, anterior CSCR central serous chorioretinopathy; ISI insomnia severity index. uveitis, refractive disorders, vitreous floaters, eye contu- sion, endophthalmitis, and migraine could not exceed 10% of the whole sample. off score of 10 has been previously selected to detect insomnia (86.1% sensitivity and 87.7% specificity).17 STUDY PROTOCOL: All patients were asked to complete study questionnaires, which included an ISI questionnaire STATISTICAL ANALYSIS: The data obtained were in addition to questions addressing previously identified analyzed with independent t test or Mann-Whitney test for risk factors such as history of systemic diseases (hyperten- continuous variables. Categorical variables were compared sion, depression, allergic disease), current medication (cur- using x2 or Fisher exact test. Risk factors were initially rent or recent [<3 months] corticosteroid intake [oral, analyzed using univariate linear regression analysis. Those intranasal, inhalational, topical skin application, intrave- with statistical significance on univariate analysis were nous, intramuscular, eye drop]), and degree of alcohol or included in multivariate analysis using logistic regression tobacco use. Recent psychological stresses including life with forward stepwise selection (stepAIC, MASS package). changes (death, divorce, familial strife, layoff) and stress Statistical analyses were performed with R version 3.1.3 (R at work were also assessed. Participants provided informa- foundation of Statistical Computing, Vienna, Austria). A tion on present and past (<1 year) working hours. Shift P value of less than .05 was considered significant. work was defined as work starting before 7:00 AM or finish- ing after 7:00 PM, and thus included evening, night, or early morning working within this broader schema. RESULTS INSOMNIA SEVERITY INDEX: Sleep disturbances were PATIENT CHARACTERISTICS: A total of 40 CSCR evaluated using the ISI, which is a widely used instrument patients were compared with 40 sex- and age-matched con- for evaluating insomnia symptoms and severity.23 The ISI trol patients (Table 1). The mean age (6 standard devia- is a 7-item self-report questionnaire assessing the severity tion [SD]) of the CSCR group was 44.1 6 8.6 years, of sleep onset, sleep maintenance, early-morning awak- whereas the mean age of the control group was 43 6 10.1 ening problems, sleep dissatisfaction, interference of sleep years (P ¼ .6). Both the CSCR and the control groups difficulties with daytime functioning, noticeability of sleep were composed of 34 male (85%) and 6 female patients problems by others, and distress caused by the sleep diffi- (15%), with a male-to-female ratio of 5.6:1. culties, with a total score ranging from 0 to 28 In the CSCR group, 26 patients (65%) had an acute form (Supplementary Material, available at AJO.com).17 A cut- of the disease and 14 patients (35%) had a chronic CSCR, 24 AMERICAN JOURNAL OF OPHTHALMOLOGY MAY 2016 FIGURE. Insomnia Severity Index (ISI) score obtained in central serous chorioretinopathy (CRSC) and control group. (Left) The mean of the ISI score was significantly higher in the CSCR group (9.6 ± 6.2) than in the control group (4.1 ± 4.5; P < .001).
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