the IOL that may have diffused into The authors have no relevant finan- creased vision and metamorphop- the silicone material. cial interest in this article. sia in the right eye. Best-corrected Clinically significant postop- Corresponding author: Yajati visual acuity was 20/25 OD and erative opacification of hydrophilic Kumar Ghosh, FRCSEd, Department 20/20 OS. Fundus examination re- acrylic IOL (model SC60B-OUV; of Opthalmololgy, Royal Oldham Hos- sults were normal in the left eye Medical Developmental Research, pital, Rochdale Road, Oldham OL1 but in the right eye revealed a well- Inc, Clearwater, Fla) has been re- 2JH, United Kingdom (e-mail: circumscribed, shallow, serous de- ported. This has been reportedly due [email protected]). tachment of the sensory retina. to the presence of granular depos- The clinical appearance was con- its within the optic of the lens, which 1. Dhaliwal DK, Mamalis N, Olson RJ. Visual sig- sistent with CSCR, and the diagno- were naturally occurring calcium nificance of glistening seen in the Acrysof intra- sis was confirmed by means of 6 ocular lens. J Cataract Refract Surg. 1996;22: produced by the patient’s body. 452-457. fluorescein angiography, which In our department we per- 2. Anderson C, Koch DD, et al. Alcon Acrysof showed a leakage point at the supe- acrylic intraocular lens. In: Martin RG, Gills JP, formed 8 cases of routine unevent- Sanders DR, eds. In: Foldable Intraocular Lenses. rior macula, spreading slowly in an ful phacoemulsification with im- Thorofare, NJ: Slack Inc. 1993:161-177. inkblot configuration into the sub- plantation of the Aquasense IOL 3. Apple DJ, Werner L, Escobar-Gomez M, Pan- retinal space (Figure 1). dey SK. Deposits on the optical surfaces of Hy- (Ophthalmic Innovations, Inc) by 3 droview intraocular lenses [letter]. J Cataract Re- The medical history of the pa- different surgeons between Octo- fract Surg. 2000;26:796-797. tient was remarkable for sebor- ber and November 2000. This was 4. Milauskas AT. Silicone intraocular lens im- rheic dermatitis involving the cen- plant discoloration in humans [letter]. Arch Oph- a single-piece foldable hydrophilic thalmol. 1991;109:913. tral face, eyebrows, eyelids, and acrylic IOL (water content, 25%). 5. Koch DD, Heit LE. Discoloration of silicone in- scalp. The disease had been diag- traocular lenses [letter]. Arch Ophthalmol. 1992; The patients in 5 of these cases 110:319-320. nosed 2 years earlier, and 1% hy- had significant visual deterioration 6. Chang BY, Davey KG, Gupta M, Hutchinson C. drocortisone acetate cream was pre- due to total opacification of the IOL Late clouding of an acrylic intraocular lens fol- scribed for topical application. After lowing routine phaco-emulsification [letter]. Eye. more than a year after surgery. The 1999;13:807-808. the initial prescription, the patient whole lens had diffuse opacifica- used the cream without further tion within its substance and was medical consultation when symp- uniformly distributed. All of them toms were exacerbated. The 1% hy- had a similar pattern of opacifica- drocortisone acetate cream was used Central Serous tion with minimal variation. for 4 weeks, 3 to 4 times daily, be- No apparent cause for the opaci- Chorioretinopathy fore the development of CSCR. fication of the IOL could be found. After Local Application Case 2. A 37-year-old man was The company’s managing director in of Glucocorticoids referred to us for blurred vision in the United Kingdom was contacted for Skin Disorders the left eye of 1 week’s duration. He (Ophthalmic Innovations, Inc, oral had a history of CSCR in the con- communication, November 2002). Central serous chorioretinopathy tralateral eye, 5 years previously, for He explained that the opacification (CSCR) is a common disease char- which he had been treated with la- was due to an interaction between the acterized by the accumulation of ser photocoagulation at another in- silicone sleeve, used to hold the IOL subretinal fluid at the posterior pole stitution. Best-corrected visual acu- in the vial, and the acrylic material of the fundus; it typically affects ity was 20/20 OU. Funduscopy of the of the IOL itself. This apparently im- young and middle-aged adults, with right eye revealed scars from previ- parted a negative charge to the IOL men affected more commonly than ous laser photocoagulation at the su- resulting in its opacification. women. The exact pathogenic perior macula. In the left eye, there To our knowledge no other mechanism of CSCR remains un- was a well-delineated area of se- case has been reported in the litera- clear. There is accumulating evi- rous detachment temporal to the fo- ture where the whole IOL has opaci- dence that both endogenous and ex- vea. Small yellowish precipitates fied. The company refused to give ogenous glucocorticoids may be were visible at the posterior aspect out “proprietary” information on the implicated in the pathogenesis of the of the detached retina. Fluorescein exact number of IOLs that had been disease.1,2 Regarding the role of ex- angiography revealed a leakage point implanted, but an educated guess ogenous glucocorticoids, CSCR has at the upper pole of the detach- would be over 500. Apparently all been reported as a complication of ment (Figure 2). these IOLs have been withdrawn and intravenous, intramuscular, oral, The medical history of the pa- a modified version without the sili- epidural, inhaled, and intranasal glu- tient was remarkable for pityriasis cone sleeve has been introduced. Ap- cocorticoid administration.2 We de- versicolor, for which he was treated parently no opacification has been scribe 2 patients who developed with local application of 0.1% di- reported so far with this new ver- CSCR after prolonged treatment flucortolone valerate cream in com- sion. We have had no further expe- with glucocorticoids applied lo- bination with 1% isoconazole ni- rience with this IOL. cally to the skin for dermatological trate. The patient used the cream indications. occasionally and was being treated Karen L. Goodall, FRCOphth for 3 weeks before symptoms be- Yajati Kumar Ghosh, FRCSEd Report of Cases. Case 1. A 32- gan. Notably, the patient was also Oldham, England year-old man complained of de- being treated with 0.1% diflucorto-

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 A B

Figure 1. In case 1, the fluorescein angiogram of the right eye shows pinpoint leakage at the superior macula (A) that spreads to the subretinal space (B) at later phases.

A B

Figure 2. In case 2, the red-free photograph of the left eye shows serous retinal detachment (A), and the fluorescein angiogram of the left eye demonstrates the leakage point (B).

lone valerate cream during the first described as a complication of ex- cal steroids cause CSCR, it pro- episode of CSCR. ogenous glucocorticoids adminis- vides evidence that raises this sus- tered via various routes—oral, in- picion and suggests that further Comment. We describe 2 patients travenous, intramuscular, inhaled, study of this potential association is who developed CSCR during treat- intranasal, and epidural.2 warranted. The exact pathogenic ment with glucocorticoids applied To our knowledge, this is the mechanism by which glucocorti- locally to the skin for dermatologi- first report of patients developing coids may be implicated in the de- cal disorders. Notably, 1 had a his- CSCR after local application of glu- velopment of CSCR is unknown and tory of CSCR in the contralateral eye, cocorticoids to the skin for the treat- remains speculative. Proposed theo- which had also developed while he ment of dermatological disorders. ries incriminate the effect of gluco- was being treated with glucocorti- Percutaneous absorption of gluco- corticoids either to the choroidal vas- coid cream applied locally. corticoids applied locally to the skin culature or to the function of the The exact pathogenic mecha- is well described in the dermatologi- retinal pigment epithelium.2 nism of CSCR is unclear and is the cal literature.3-5 Application of glu- In conclusion, local skin appli- subject of considerable contro- cocorticoids may result in systemic cation of glucocorticoids may be com- versy. Accumulating evidence sug- absorption sufficient to cause hyper- plicated by the development of CSCR. gests that glucocorticoids may con- cortisolism, adrenal suppression, and In such cases, discontinuation of glu- tribute to the pathogenesis of CSCR. reduced glucose tolerance.3-5 There- cocorticoid treatment should be con- The development of CSCR has been fore, although a coincidental asso- sidered whenever possible. described in association with con- ciation cannot be excluded, the de- ditions characterized by endoge- velopment of CSCR in our patients Panagiotis Karadimas, MD nous hypercortisolism such as preg- may be related to the local skin ap- Anastasios Kapetanios, MD nancy, stress, and endogenous plication of glucocorticoids. Even if Evrydiki A. Bouzas, MD Cushing syndrome.1 It has also been this report does not prove that topi- Athens, Greece

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 The authors have no relevant finan- crescentic glomerulonephritis. The myeloperoxidase and proteinase 3 cial interest in this article. sensitivity and specificity of both antibodies were positive concur- Corresponding author: Panagiotis tests are high for a vasculitic pro- rently. Magnetic resonance imag- Karadimas, MD, Medical Retina Unit, cess frequently associated with a sys- ing of the orbits showed enlarged ex- First Department of Ophthalmology, temic disease that requires prompt traocular muscles, and renal biopsy Henry Dunant Hospital, 107 Meso- immunosuppressive therapy.1,2 results showed florid necrotizing glo- gion Ave, 11526 Athens, Greece (e-mail: We report 4 cases of p-ANCA merulonephritis. After treatment [email protected]). positivity showing a spectrum of se- with high-dose steroids and azathio- vere ocular involvement. Two pa- prine sodium, the patient’s signs re- 1. Bouzas EA, Scott MH, Mastorakos G, Chrousos tients had been systemically un- solved dramatically, leaving some re- GP, Kaiser-Kupfer MI. Central serous chorio- well previously, but it was the ocular sidual diplopia controlled by prisms. retinopathy in endogenous hypercortisolism. Arch Ophthalmol. 1993;111:1229-1233. disease that prompted ANCA mea- Case 3. A 67-year-old man with 2. Bouzas EA, Karadimas P, Pournaras CJ. Cen- surement. ulcerative colitis and a previous right tral serous chorioretinopathy and glucocorti- serous retinal detachment had coids. Surv Ophthalmol. 2002;47:431-448. 3. Aalto-Korte K, Turpeinen M. Pharmacokinet- Report of Cases. Case 1. A 76-year- deteriorating vision in the left eye. ics of topical hydrocortisone at plasma level af- old man had a 12-month history of Visual acuities were hand move- ter applications once or twice daily in patients with widespread dermatitis. Br J Dermatol. 1995; red smarting eyes. Examination re- ments OD and 20/200 OS. Exami- 133:259-263. vealed bilateral peripheral ulcer- nation showed marked retinal pig- 4. Cook LJ, Freinkel RK, Zugerman C, Levin DL, ative keratitis with normal visual acu- ment epithelial mottling and macular Radtke R. Iatrogenic hyperadrenocorticism dur- ing topical steroid therapy: assessment of sys- ity and no proptosis. Investigations edema in both eyes and serous reti- temic effects by metabolic criteria. J Am Acad revealed chronic renal failure and nal detachment in the left eye. Re- Dermatol. 1982;6:1054-1060. positive levels of p-ANCA (1/160) but sults of fluorescein angiography and 5. Garden JM, Freinkel RK. Systemic absorption of topical steroids: metabolic effects as an index of not c-ANCA. Systemic treatment with B-scan ultrasonography were used mild hypercortisolism. Arch Dermatol. 1986; immunosuppressants was com- to confirm posterior scleritis. After 122:1007-1010. menced. Despite treatment, the kera- therapy with immunosuppres- topathy progressed, and p-ANCA lev- sants, the patient’s visual acuity im- els remained high. The patient then proved to 20/20 OS. Two years later, Ocular Involvement stopped treatment and developed vas- a relapse occurred, and p-ANCA in Systemic Vasculitis culitic anterior ischemic optic neu- findings were positive. His titre sub- Associated With ropathy in the right eye, with a vi- sequently normalized with treat- Perinuclear Antineutrophil sual acuity of 20/200 OD. ment, although his vision contin- Cytoplasmic Antibodies Case2.A37-year-oldwomanhad ued to deteriorate. an 8-week history of painless, swol- Case 4. A 58-year-old man had Antineutrophil cytoplasmic anti- len eyelids, variable diplopia, and in- a 15-month history of progressive body (ANCA) formation to myeloper- termittent arthralgia for the past year. left-sided headache, poor appetite, oxidase or perinuclear (p-ANCA) is Examination revealed impaired eleva- weight loss, and deafness. Cranial infrequent in ocular disease and is tion of both eyes, periorbital edema, nerve examination revealed left tri- reported in approximately 10% of and erythema (Figure 1) but no geminal nerve involvement and sen- patients with Wegener granuloma- visual changes, proptosis, or scleral sorineural deafness. Visual acuity tosis 1,2 as opposed to cytoplasmic injection. was normal. Fundoscopy demon- (c-ANCA) positivity (antibodies to Investigations revealed an in- strated a swollen right optic disc and proteinase 3), which is well recog- creased erythrocyte sedimentation bilateral white, elevated retinal pig- nized. Higher levels of p-ANCA are rate (107 mm/h) and C-reactive pro- ment epithelial lesions (Figure 2). also identified in microscopic poly- tein level (14.8 mg/L). Urinalysis re- These lesions showed early hypo- angiitis, Churg-Strauss syndrome, sults showed proteinuria and re- inflammatory bowel disease, and duced creatinine clearance. Both

Figure 2. Fundus photograph of the right eye showing a swollen optic disc and creamy white, Figure 1. Photograph showing right convergent squint, periorbital edema, and eyelid erythema but no elevated lesions at the level of the retinal pigment proptosis in case 2. epithelium at the posterior pole in case 4.

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