Central serous chorioretinopathy complicating solar retinopathy treated with glucocorticoids

BACKGROUND: Solar retinopathy and central serous chorio-retinopathy are two well-defined clinical entities which affect the macular area. Their association has never been described. The relation of central serous chorioretinopathy with the exposure to glucocorticoids has been recently suggested. CASE REPORT: Central serous chorioretinopathy developed in a patient who received corticosteroid therapy for solar retinopathy. CONCLUSION: This case report provides additional evidence that central serous chorioretinopathy may develop under the effect of glucocorticoids. Retinal damage resulting from a previous insult, such as solar retinopathy, may act as the permissive factor.     

Central serous chorioretinopathy. Clinical, fluorescein angiography and demographic aspects

The purpose of this retrospective study was to analyze the demographic characteristics of central serous chorioretinopathy (CSC). METHODS: Findings of 100 consecutive subjects with CSC were evaluated. Clinical and fluorescein angiographic findings, demographic characteristics, and visual acuity were analyzed. RESULTS: The age of the patients ranged from 28 to 68 years with a mean of 43 years. No significant sex differences were found concerning age and other parameters. The highest age peak was in the group of women. The male to female ratio was 5:1. Patients with chronic CSC were significantly older (P = 0.015) than patients with the other angiographic findings. Median visual acuity was 0.5. In 40% bilateral characteristics of CSC were found. Clinical and fluorescein angiographic findings showed no significant correlation with visual acuity. CONCLUSION: The range of age distribution in CSC is wide. In older patients distinguishing CSC from age-related macular degeneration can be difficult.     

Comparison of inhaled corticosteroids

OBJECTIVE: To review the comparative studies evaluating both efficacy and safety of inhaled corticosteroids in the management of asthma. Specifically, comparative clinical trials are evaluated that allow clinicians to determine relative potencies of the various inhaled corticosteroids. METHODS: A critical review was performed of the published clinical trials, either as articles or abstracts, comparing the clinical efficacy or systemic activity of inhaled corticosteroids. No a priori criteria were applied, as this was not a meta-analysis. FINDINGS: In vitro measures of antiinflammatory activity of corticosteroids consistently demonstrate potency differences among the various corticosteroids. Traditionally, these in vitro measures have been used to develop new corticosteroids with greater topical activity. While no accepted direct measure of antiasthmatic antiinflammatory activity exists, clinical trials using surrogate measures (e.g., forced expiratory volume in 1 second, peak expiratory flow, bronchial hyperresponsiveness, symptom control) indicate that in vitro measures provide a relatively accurate assessment of antiasthmatic potency. The relative antiinflammatory potency of the inhaled corticosteroids is in the following rank order. flunisolide = triamcinolone acetonide < beclomethasone dipropionate = budesonide < fluticasone. Studies of systemic activity appear to confirm this relative order of potency. Currently, no evidence exists for greater efficacy for any of the inhaled corticosteroids when administered in their relative equipotent dosages. The preponderance of current data suggests that when administered in equipotent antiinflammatory doses as a metered-dose inhaler plus spacer or as their respective dry-powder inhaler, the existing inhaled corticosteroids have similar risks of producing systemic effects. CONCLUSIONS: Delivery systems can significantly affect both topical and systemic activity of inhaled corticosteroids. More direct comparative studies between agents are required to firmly establish comparative topical to systemic activity ratios. The preponderance of evidence suggests that the agents are not equipotent on a microgram basis.     

The long-term outcome of central serous chorioretinopathy

OBJECTIVE: To assess the long-term outcome of central serous chorioretinopathy (CSR) among a group of patients who previously participated in a prospective argon laser photocoagulation study of CSR. DESIGN: Thirty-eight of 41 surviving patients with CSR participating in an earlier study were invited to participate in a follow-up study that included history taking, ophthalmoscopy, biomicroscopy, and fundus photography. RESULTS: Thirty-seven (38 eyes) of 38 surviving patients (97%) were available for follow-up between 11 and 15 years after participation in the earlier study. There were no clinically documented or historical recurrences of CSR among the six eyes previously treated by direct laser photocoagulation. There were 13 clinically documented recurrences and four historical recurrences among the 32 eyes not treated with direct laser photocoagulation. The difference in recurrences was statistically significant (P = .02). Pigment changes indistinguishable from age-related macular degeneration frequently occurred in eyes with CSR. The difference in the development of such pigment changes between eyes with CSR (33 of 38) and nonaffected fellow eyes (12 of 35) was significant (P = .001). CONCLUSIONS: The decreased rate of CSR recurrence after direct laser photocoagulation reported in an earlier study was sustained with follow-up beyond 10 years. Pigmentary changes in the fundus indistinguishable from those associated with age-related macular degeneration developed in eyes affected with CSR, probably as a consequence of the presence of subretinal fluid accompanying the CSR rather than from early age-related macular degeneration.     

Clinical grand rounds. Idiopathic central serous chorioretinopathy

Idiopathic central serous chorioretinopathy is a very commonly seen disease process involving atypical RPE cells allowing the development of a neuroepithelial retinal detachment. Typically, this disease is self-contained and resolves spontaneously; however, on occasion, one must intervene by treating the area of atypical RPE with laser photocoagulation. Patients with ICSC should be monitored closely for any signs of choroidal neovascular membrane.     

Changes in psychovisual function after central serous chorioretinopathy

BACKGROUND: There are controversies concerning the necessity of pre-school vision screening. Aim of the study: evaluation of the prevalence of pathologic ophthalmologic findings in kindergarten children. MATERIALS AND METHODS: 1030 families were offered a vision screening. Of these, a total of 948 children, aged 3 to 6 years, voluntarily underwent a screening for strabismus, amblyopia and refractive anomalies. The examination was performed in the kindergarten in the absence of the parents. METHODS OF EXAMINATION: A questionnaire concerning general and ophthalmologic history of the child and of the family was evaluated. Visual acuity, cover-uncover-test, Lang-stereotest, retinoscopy, ophthalmoscopy (undilated pupils) were performed and the glasses were evaluated. RESULTS: The screening was highly accepted by the parents and 92% of the families (n = 948) took part. The compliance of the children was very good. A total of 38.7% (n = 381) of the children showed one or more abnormal parameters. 21.4% (n = 229) showed a reduced visual acuity. Strabismus was found in 3.7%. Half of the children with abnormal findings already had had a vision screening, but only 25% had received ophthalmologic treatment. Of those who possessed glasses, 25% came without them, and another 25% had a reduced visual acuity even with their glasses. The main problems were many false-positive results and high costs. CONCLUSIONS: Ophthalmologic and orthoptic screening in kindergarten is technically easy and conclusive in experienced hands. Ideas to reduce costs and to avoid overreferrals are an age-related lowering of the visual acuity limit and a rescreening of suspected children in a screening-setting a second time before sending them to an ophthalmologist. Another possibility to reduce costs would be to perform examinations not by ophthalmologists but by "screening-orthoptists" who should be trained in retinoscopy and ophthalmoscopy.     

Long-term follow-up of severe central serous chorioretinopathy using indocyanine green angiography

BACKGROUND: The severe types of central serous chorioretinopathy (CSC) have a chronic nature, suggesting that a pathological process persists subclinically. Indocyanine green (ICG) angiography recently revealed intrachoroidal dye leakage and its static nature in CSC. As the intrachoroidal dye leakage was suspected to be relevant to the disease process, the long-term persistence of intrachoroidal ICG leakage was examined in four patients of the severe types of CSC. METHODS: ICG angiography was performed periodically over more than three years in three patients and two years in one patient. One patient had CSC with bullous retinal detachment, and the other three had chronic CSC or diffuse retinal pigment epitheliopathy. RESULTS: Intrachoroidal ICG leakage persisted in all the patients. However, a change in location of persistent intrachoroidal leakage or disappearance of intrachoroidal leakage regardless of no progression of retinal pigment epithelial alteration was noted in one eye of two patients. CONCLUSIONS: Pathology causing intrachoroidal ICG leakage persisted subclinically for a long period. However, location and extent of the intrachoroidal leakage could change during a long-term follow-up period.     

The role of "fear of corticosteroids" in nonparticipation in early intervention with inhaled corticosteroids in asthma and COPD in general practice

Treatment of chronic airflow obstruction with inhaled corticosteroids at an early stage has been shown to preserve the lung function. We tested the hypothesis that "fear of corticosteroids" may be an important reason for nonparticipation in the Detection, early Intervention and Monitoring programme on Chronic obstruction pulmonary disease (COPD) and Asthma ("DIMCA") project. One thousand seven hundred and forty nine adult subjects from 10 general practices were invited to participate in the several parts of the "DIMCA" programme. Refusers were questioned about the reason(s) for nonparticipation. Together the screening, monitoring and three drug interventions of the study showed on average 25-35% refusers. The most frequent reasons for nonparticipation were absence of pulmonary symptoms and lack of time. For those invited to take part in one of the three drug interventions, "dislike of medication" was the most important reason for nonparticipation (33, 45 and 67% of the refusers). "Fear of corticosteroids" specifically was the reason for nonparticipation in 8% of the refusers on the basis of "dislike of medication". We concluded that a specific fear of corticosteroids was not a major obstacle for early intervention with inhaled corticosteroids.     

Acute myopathy associated with combined use of corticosteroids and neuromuscular blocking agents

OBJECTIVE: To review the occurrence and pathophysiology of myopathy associated with combined use of neuromuscular blocking agents (NMBAs) and systemic corticosteroids. DATA SOURCES: A MEDLINE search (1985 to July 1995, English language) yielded case reports and clinical studies involving myopathy or weakness associated with the use of NMBAs and/or corticosteroids. References cited in those articles were reviewed. DATA SYNTHESIS: Prolonged muscle weakness has been reported in intubated patients in the intensive care unit (ICU) who were receiving NMBAs and/or corticosteroids. Many cases involved the use of both agents in individuals with no underlying risk factors. The term "blocking agent-corticosteroid myopathy" (BACM) has been used to describe this myopathy when it develops following combined use of these agents. Features common to BACM include prolonged weakness, elevated creatine kinase concentrations, myopathic features on electromyography, normal nerve conduction and sensation, and reduced deep tendon reflexes. Muscle biopsy results vary, but tend to show type 1 and/or 2 fiber atrophy without inflammation. Some recently reported cases revealed thick myosin myofilament loss, which is consistent with findings in denervated rat muscle after exposure to corticosteroids. Two small prospective studies reported that 36-50% of mechanically ventilated patients receiving either one or both drugs developed prolonged weakness. CONCLUSIONS: NMBAs and corticosteroids alone have both been reported to cause myopathy in patients in the ICU. When coadministered, these agents appear to confer an even greater risk of myopathy; the exact pathology is not understood. Concomitant use of NMBAs and corticosteroids should be avoided if possible. Guidelines for cautious use and careful monitoring are suggested when combined use is deemed necessary.     

Assessment of the sympatho-vagal interaction in central serous chorioretinopathy measured by power spectral analysis of heart rate variability

The long-term prognosis of decompensated benign nephrosclerosis (DBN) was investigated by a retrospective analysis of the fate of 170 patients with this disease, which yielded the following results: 1) DBN carries a particularly poor prognosis. The renal survival rate (RSR) was 35.9% at 5 years and 23.6% at 10 years. The prognosis is therefore worse than that of any other primary glomerulopathy, with the exception of rapidly progressive glomerulonephritis. 2) DBN mainly affects males (sex ratio 5:1) and differs in this respect, among others, from focal sclerosing glomerulonephritis, in which the male:female ratio is 1.2:1. 3) The prognosis for females is no better than for males. 4) The severity of proteinuria at the time of biopsy has no influence on the prognosis. 5) The prognosis is particularly poor in cases in which the serum creatinine concentration is already elevated to more than 2.0 mg% at the time of biopsy. We conclude from these findings that not only the blood pressure, but also the serum creatinine concentration, should be assessed at regular intervals in all hypertensive individuals, so that DBN can be treated at an early stage, when it is still amenable to treatment.     

The efficacy of inhaled corticosteroids in the management of non asthmatic chronic airflow obstruction

AIMS: The aims of this investigation were to evaluate the efficacy of regular inhaled beclomethasone in the control of symptoms and lung function with non-asthmatic smoking related obstructive pulmonary disease and to evaluate the relationship between clinical responses to a short course of oral prednisone and longer term outcomes using inhaled steroid. METHODS: The study was a randomised, double blind, placebo controlled, crossover investigation in 18 patients. The active treatment was inhaled beclomethasone 1000 micrograms given twice daily for three months by metered dose inhaler. At the end of each treatment period, patients received oral prednisone 30 mg/day for ten days. The two treatment phases were separated by a one month washout interval. Peak flow rates, symptom scores and "rescue" bronchodilator use were recorded twice daily. Lung function (FEV1, FVC and lung volumes) and bronchial hyperresponsiveness (PC20 methacholine) were measured at monthly visits. The number of exacerbations requiring intervention therapy were also recorded. RESULTS: There were no consistent benefits attributable to beclomethasone. Lung function was not significantly better as a result of active treatment. Sputum production improved but other symptom scores were similar during active and placebo therapy. Three patients exhibited an increase in FEV1 of 15% or more during active treatment but did not do so when oral prednisone was administered immediately after the period of placebo treatment. A further three patients showed an improvement in FEV1 of 15% or more with oral prednisone but failed to improve during treatment with inhaled beclomethasone. The predictive value of the "trial of steroid" was 0% and 81.3% for positive and negative outcomes respectively. CONCLUSIONS: Our results indicate that in non-asthmatic chronic obstructive pulmonary disease inhaled corticosteroid fails to achieve significant improvements in either lung function or symptoms. The response to a "trial of steroid" using oral prednisone is not clinically helpful in selecting the small number of patients who may subsequently benefit from this form of therapy.     

Perception of the role and potential side effects of inhaled corticosteroids among asthmatic patients

BACKGROUND: Misunderstanding of the role of asthma medication and fear of untoward side effects may reduce compliance to therapy, potentially resulting in poor asthma control and increased risk of severe asthma events. METHODS: We report the results of a recent Canadian survey of 603 asthmatic patients recruited from the general population, aimed at determining their perception of the role and potential side effects of inhaled corticosteroids (ICS). RESULTS: The survey revealed that a large proportion of asthmatic patients do not understand the role of their medications and have many misconceptions and fears in regard to ICS, reducing their willingness to use them. Among the most common fears are those concerning troublesome side effects, particularly in regard to corporeal image, bone density, and a reduction in efficacy of medication over time. More than half of the population said they were very or somewhat concerned using ICS on a regular basis; two thirds of patients had not discussed their concerns about ICS with their physicians or other health-care professionals. Finally, in a large number of asthma patients, asthma was not adequately controlled, according to recent asthma consensus guidelines. CONCLUSIONS: These observations stress the importance for those involved in asthma care of questioning patients about their understanding of the role of asthma medications, particularly ICS, their fears and misconceptions, and what they consider to be adequate asthma control, in order to provide appropriate education and counseling.