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Steroid-induced central serous retinopathy Samidh P. Shah, Chetna K. Desai, Mira K. Desai, R.K. Dikshit

ABSTRACT Department of Pharmacology, A-24 year-old male was prescribed prednisolone (60 mg/day) for left sided facial palsy. B. J. Medical College, Ahmedabad, Gujarat, India After three days of therapy, the patient complained of black spots in his vision in right eye. Fluorescein angiography of right eye showed evidence of central serous retinopathy RReceived:eceived: 13-03-2011 (CSR). Prednisolone dose was withdrawn gradually and the patient improved within a RRevised:evised: 17-04-2011 week. There were no other systemic or ophthalmic diseases reported by the patient, AAccepted:ccepted: 01-07-2011 which could have caused this condition. An improvement after dechallenge confirmed steroid-induced CSR. Recurrent CSR is known to cause permanent loss of vision. Hence, CCorrespondenceorrespondence to:to: awareness regarding this adverse drug reaction (ADR) with steroids and its reporting can Dr. Samidh Shah, minimize this complication and help in better patient management. E-mail: [email protected] KKEYEY WWORDS:ORDS: Adverse drug reaction, central serous retinopathy, corticosteroids

Introduction Figure 1: Hyperfl uorescence at site of the leakage Central serous chorioretinopathy (CSR) is a well-established clinical entity known to occur in individuals with type A personality. Its incidence is 9.9 per 100000 for men and 1.7 for women.[1] Systemic corticosteroid therapy triggers this condition.[2] The prevalence of steroid-induced CSR is less than 10%.[3] We report here a case of CSR due to oral prednisolone therapy. Case Report A 24- year -old man with left sided facial palsy was prescribed tablet prednisolone 60 mg per day for five days. Three days after initiation of prednisolone, the patient reported seeing black spots in his vision in the right eye. Primary investigations (perimetry and fundus examination) revealed central scotoma in the right eye. Fluorescein angiography showed an early spot of hyperfluorescence at the site of leakage with expansion into the area of serous detachment [Figure 1]. Based on these observations, the patient was diagnosed as a Discussion case of central serous retinopathy. The dose of prednisolone was gradually reduced after the appearance of ADR. It was reduced There are various causes of CSR, including stress, type A to 40 mg for seven days and then it was stopped. Ketorolac eye personality and treatment with corticosteroids. However, it drops (0.3%) and antioxidant capsules containing L-arginine may also be idiopathic. In the present case, the patient was and vitamin E were prescribed. The visual disturbances abated prescribed systemic steroids for five days. Symptom of black gradually within one week after prednisolone was withdrawn. spots in vision and fluorescein angiography confirmed the diagnosis of central serous retinopathy. Symptoms abated after AAccessccess thisthis articlearticle onlineonline prednisolone was withdrawn. Other possible causes of CSR QQuickuick ResponseResponse Code:Code: were ruled out. There was no history of systemic diseases or WWebsite:ebsite: www.ijp-online.com other ophthalmological causes that could have contributed to DDOI:OI: 10.4103/0253-7613.84985 this ADR. The time course of the onset of ADR and response to dechallenge suggests the probability of prednisolone as the causal drug. Causality assessment using WHO-UMC scale[4] and Naranjo’s algorithm[5] categorized “probable” for prednisolone. Rechallenge was not carried out for ethical reasons. An analysis

Indian Journal of Pharmacology | October 2011 | Vol 43 | Issue 5 607 Shah, et al.: Steroid induced central serous retinopathy of the ADR on the Hartwig scale, showed that the ADR was References [6] moderate in nature. Further, the preventability assessment 1. Kitzmann AS, Pulido JS, Diehl NN, Hodge DO, Burke JP. The incidence of carried out using modified Schumock and Thornton criteria central serous chorioretinopathyin Olmsted County, Minnesota 1980-2002. showed that the ADR was not preventable.[7] Ophthalmology 2008;115:169-73. Central serous retinopathy is attributed to the disruption 2. Gregory DL, Jones DC, Denton ER, Harnett AN. Acute visual loss induced by of the ionic pump of the retinal pigmented epithelial cells dexamethasone during neoadjuvant docetaxol. Clin Med Oncol 2008;2:37-42. (RPE) or hyperpermeability of the choroidal vasculature.[8] 3. Hardwig PW, Silva AO, Pulido JS. Forgotten exogenous corticosteroid as a cause of central serous chorioretinopathy. Clin Ophthalmol 2008;2:199-201. Glucocorticoids are known to cause CSR probably by increasing 4. Who-umc.org. The Uppsala Monitoring Centre. Available from: http://www. cAMP in RPE cells, and hence changing the ionic pump function who-umc.org/DynPage.aspx?id = 22682. [Last accessed on 2010 Sep 24]. or by altering the permeability of blood aqueous barrier and 5. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method disrupting the outer blood retinal barrier.[9] Central serous for estimating the probability of adverse drug reactions. Clin Pharmacol Ther retinopathy attributed to steroids has also been reported by 1981;30:239-45. Tandon et al.,[6] where a patient had posterior globe rupture 6. Hartwing SC, Siegel J, Schnelder PJ. Preventability and severity assessment in reporting adverse drug reactions. Am J Hosp Pharm 1992;49:2229-32. and was prescribed analgesics, intravenous antibacterials and 7. Schumock GT, Thornton JP. Focusing on the preventability of adverse drug oral prednisolone (1 mg/day). The patient developed CSR after reactions. Hosp Pharm 1992;27:538. 15 days of therapy. Prednisolone was gradually tapered and the 8. Tandon R, Vanathi M, Verma L, Bharadwaj A. Central serous retinopathy patient improved within five days. masquerading as sympathetic ophthalmia. Eye (Lond) 2003;17:666-7. Facial palsy is a common condition in young adults caused 9. Zamir E. Central serous retinopathy associated with adrenocorticotrophic by viral infections like herpes zoster, mycoplasma infection or hormone therapy. A case report and hypothesis. Arch Clin Exp Ophthalmol 1997;235:339-44. [10] idiopathic. Central serous retinopathy usually presents with 10. Facial palsy (Online). Available from: http://www.emedicine.medscape.com/ loss of visual acuity, color vision and depth of perception. In article/791311-overview. [Last accessed on 2010 May 9]. 97% of cases, visual acuity returns to normal but in some cases 11. Wynn PA. Idiopathic central serous chorioretinopathy–A physical complication of it may affect the vision permanently.[11] However, the condition stress? Occup Med (Chic Ill) 2001;51:139-40. is reversible if detected early and aggravating factors are withdrawn in time. Therefore, early detection, reporting and Cite this article as: Shah SP, Desai CK, Desai MK, Dikshit RK. Steroid-induced dissemination of this rare yet important and disabling ADR can central serous retinopathy. Indian J Pharmacol 2011;43:607-8. minimize its occurrence and help in better patient management. Source of Support: Nil. Confl ict of Interest: None declared.

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