Association of Helicobacter pylori with central serous chorioretinopathy: hypotheses regarding pathogenesis

Central Serous Chorioretinopathy: An Update on the Current State of Management

Central serous chorioretinopathy (CSCR) is a relatively common retinal disorder that leads to central vision impairment, often with a high recurrence rate. The exact etiology and pathogenetic mechanisms have not been fully elucidated but are likely to be associated with hyperpermeability of the choroidal capillaries and failure of the retinal pigment epithelium (RPE), leading to serous detachment of the neurosensory retina. Multimodal imaging plays a critical role in the diagnostic approach and monitoring of CSCR. Fortunately, the natural course of the disease is usually self-limiting, with spontaneous resolution and total fluid reabsorption. However, some patients may exhibit recurrences or persistent subretinal fluid (chronic CSCR), leading to progressive and irreversible RPE atrophy or photoreceptor damage. Thus, to prevent permanent visual loss, individualized treatment should be considered. Recent developments in the diagnostic and therapeutic approach have contributed to better outcomes in patients with CSCR. More studies are required to improve our understanding of epidemiology, pathogenesis, diagnosis, and treatment, with a significant impact on the management of this challenging clinical entity. The purpose of this review is to summarize the current knowledge about the clinical features, diagnostic workup, and therapeutic approach of CSCR.

[Central serous chorioretinopathy]

Central serous chorioretinopathy (CSC) is the fourth most common disease of the macula after age-related macular degeneration, diabetic retinopathy and retinal vein occlusion and a cause of irreversible visual loss. This article gives an overview of the epidemiology, risk factors, pathophysiology, clinical presentation, multimodal imaging and discusses current therapeutic options for CSC.

Central serous chorioretinopathy: An update on risk factors, pathophysiology and imaging modalities

Central serous chorioretinopathy (CSC) is a common form of vision loss, typically seen in working-age men. The pathophysiology behind CSC still eludes us, however significant advances have been made in understanding this disease over the last decade using information from genetic and cell-based studies and imaging modalities. This review aims to give an overview of the current pathophysiology hypotheses surrounding CSC in addition to future directions in cellular work from human induced pluripotent stem cell derived choroidal endothelial cells from CSC patients. Furthermore, this review will provide the reader with an update on the clinical aspects of CSC including risk factors, diagnostic challenges and findings from multimodal imaging.

Current Pharmacological Treatment Options for Central Serous Chorioretinopathy: A Review

Central serous chorioretinopathy (CSC) is a common cause of visual impairment in patients generally aged 20 to 60 and it is characterized by acute or chronic neurosensory detachments of the retina. Although CSC resolves spontaneously in most cases, in some patients it may cause permanent visual impairment in the working population; for this reason, several approaches, including photodynamic therapy (PDT), subthreshold micropulse laser treatment and oral mineralocorticoid receptor antagonists, have been studied as first-line treatment options for CSC. To date, half-dose PDT has provided the most encouraging results in this regard, supported by large, multicenter, randomized clinical trials such as the “Prospective Randomized Controlled Treatment Trial for Chronic Central Serous Chorioretinopathy” (PLACE) trial; however, the role of novel possible non-invasive treatment options is attracting interest. This review article aims to discuss the current pharmacological treatment options investigated for the management of CSC, including aspirin, ketoconazole, beta blockers, rifampicin and many others. In particular, further evidence about oral mineralocorticoid receptor antagonists, firstly seen as promising non-invasive alternatives for treating CSC, will be provided and discussed in light of the recent “Eplerenone for chronic central serous chorioretinopathy in patients with active, previously untreated disease for more than 4 months” (VICI) trial results, which have largely resized their role as possible first-line oral treatment options for treating CSC.

Oral medications for central serous chorioretinopathy: a literature review

Central serous chorioretinopathy (CSCR) is characterised by acute or chronic neurosensory detachments of the retina, usually in the posterior pole, with or without associated detachments of retinal pigment epithelium. Although the condition often resolves spontaneously, chronic and recurrent cases can lead to significant visual loss in the working population and it is thus increasingly recognised as an important public health issue. The uncertainty regarding the underlying cause of CSCR has led to a wide range of therapies being tried for this condition including photodynamic therapy, laser photocoagulation, anti-VEGF injections and a multitude of oral agents. This article aims to review the current evidence for oral agents that have been used for treatment of CSCR. A systematic literature search was conducted for articles published between 1980 to July 2018. A total of 73 articles were included. These studied the following oral medications: eplerenone, spironolactone, beta blockers, H. pylori agents, omeprazole, rifampicin, methotrexate, aspirin, acetazolamide, mifepristone, melatonin, finasteride, ketoconazole, antioxidants and curcumin phospholipid. Although none of the studies showed robust evidence of efficacy, the mineralocorticoid receptor antagonists, particularly eplerenone, appear to demonstrate the highest quality evidence for use in this condition. The review aims to give the reader an overview of the current available evidence for oral medications used in the treatment of CSCR in order to provide an evidence-based discussion with the patient and guide through possible options for treatment.

A randomized clinical trial comparing prompt photodynamic therapy with 3 months observation in patients with acute central serous chorioretinopathy with central macular leakage

PURPOSE

The purpose of the study was to demonstrate whether photodynamic therapy in patients with acute central serous chorioretinopathy, with the leakage point within one optic disk diameter from the fovea, can be safely deferred.

METHODS

A single-center, randomized, controlled trial was conducted. Patients were randomized to photodynamic therapy within a week after presentation (Group I, 26 patients) or observation during 3 months (Group II, 26 patients). If leakage or subretinal fluid was observed during any control visit, photodynamic therapy was performed (again) within a week.

PRIMARY OUTCOME

Primary outcome was change of visual acuity (Early Treatment Diabetic Retinopathy Study) after 12 months. Secondary outcomes were visual acuity, central foveal thickness, metamorphopsia, and color discrimination.

RESULTS

Photodynamic therapy procedures: group I, 26 at baseline, 2 retreatments at 3 months; group II, 10 at 3 months, 1 at 6 months (2 subjects refusing treatment), 2 retreatments at 6 months. At 12 months, mean visual acuity of all patients had improved by 6.5 letters (P < 0.001), mean central foveal thickness was 172 µm less (P < 0.001). After photodynamic therapy, visual acuity recovered faster and metamorphopsia significantly improved (3 months, P < 0.001). Differences between groups at 12 months were not significant.

CONCLUSION

The (intended) number of photodynamic therapy (re)treatments in group II (n = 15) was 46% less than in group I (n = 28). Visual acuity and central foveal thickness at 12 months were similar. Therefore, the preferred management of acute central serous chorioretinopathy at presentation appears to be observation for 3 months.

Central serous chorioretinopathy: Current update on management

Central serous chorioretinopathy (CSC), the fourth most common nonsurgical retinopathy with a usual self-limiting course, is known to present with persistent or recurrent form with distressing visual loss. Evolution of newer mutimodal imaging techniques have revolutionized the understanding about the pathophysiology of CSC, and hence the diagnosis and management. Multifactorial etiopathology of CSC promotes the use of multiple treatment modalities. With advances in investigative options, treatment options including conventional focal laser, micropulse laser, photodynamic therapy, and transpupillary thermotherapy are also advancing and refining. Medical management for CSC is also under evaluation with a wide spectrum of new drugs in vogue. However, standard of treatment is yet to be established through randomized clinical trials. This review article discusses the current approach to multimodal treatment options for CSC including conventional as well as newer therapeutic modalities.

RISK FACTORS FOR RECURRENCES OF CENTRAL SEROUS CHORIORETINOPATHY

PURPOSE

To describe recurrence patterns and investigate candidate risk factors for recurrences of central serous chorioretinopathy.

METHODS

In 46 patients with acute central serous chorioretinopathy and follow-up >12 months after first episode resolution, parameters influencing recurrences were retrospectively evaluated using a frailty Cox proportional hazard survival model. Covariates included baseline systemic findings: age, gender, corticosteroid use, stress, shift work, sleep disorder, depression, allergy, cardiovascular risk; baseline optical coherence tomography findings: subfoveal choroidal thickness, pigment epithelial detachment pattern (regular/bump/irregular), number of subretinal hyperreflective foci at leakage site; baseline angiographic findings: fluorescein leakage intensity (intense/moderate/subtle/absent), hyperpermeability pattern on indocyanine-green angiography (focal/multifocal); and episode-related findings: duration and treatment of previous episode.

RESULTS

Twenty of 46 subjects (43%) presented ≥1 recurrences during a mean follow-up of 29.9 ± 9.5 months (range, 15-54 months). Follow-up duration did not differ between cases with or without recurrences (P = 0.3). Worse final visual acuity levels (logarithm of the minimal angle of resolution) were associated with a higher number of episodes during follow-up (P = 0.032, r = 0.28). In a univariate analysis, higher subfoveal choroidal thickness (P = 0.021), nonintense fluorescein leakage (= moderate/subtle/absent, P = 0.033), multiple subretinal hyperreflective foci (P = 0.026), and shift work (P < 0.0001) were significantly associated with recurrences, with a near-significant influence of irregular pigment epithelial detachment (P = 0.093). In a multivariate analysis, higher subfoveal choroidal thickness (P = 0.007), nonintense fluorescein leakage (P = 0.003) and shift work (P < 0.0001) remained significant and independent risk factors for recurrences.

CONCLUSION

Multiple factors influence the risk of central serous chorioretinopathy recurrence. These findings may contribute to identify patients at higher risk, who could benefit from earlier or more intensive treatment.

Modified Qigong Breathing Exercise for Reducing the Sense of Hunger on an Empty Stomach

BACKGROUND

The aims of this study were to determine whether a modified Qigong breathing exercise can reduce the sense of hunger and identify possible mechanisms.

METHODS

The results from the test group, which performed the exercise, are compared with the control group, which performed deep breathing. Intestinal pressure measurements, stomach pH monitoring, and participant surveys were used for assessment.

RESULTS

Stomach pH was increased by 3 (0.2) and intestinal pressure was reduced by 12 (0.5) mm Hg in the experimental group and did not change significantly in the control group. The study provides strong evidence that the exercise can significantly reduce, or even suppress the sense of hunger on an empty stomach.

CONCLUSION

This breathing exercise provides comfort in different circumstances, such as lack of regular meals, limited volume or caloric diet, and even during temporary complete absence of food in therapeutic fasting.

Risk Factors for Central Serous Chorioretinopathy: Multivariate Approach in a Case-Control Study

PURPOSE

The purpose of this prospective study was to investigate the potential risk factors associated independently with central serous retinopathy (CSR) in a Greek population, using multivariate approach.

MATERIALS AND METHODS

Participants in the study were 183 consecutive patients diagnosed with CSR and 183 controls, matched for age. All participants underwent complete ophthalmological examination and information regarding their sociodemographic, clinical, medical and ophthalmological history were recorded, so as to assess potential risk factors for CSR. Univariate and multivariate analysis was performed.

RESULTS

Univariate analysis showed that male sex, high educational status, high income, alcohol consumption, smoking, hypertension, coronary heart disease, obstructive sleep apnea, autoimmune disorders, H. pylori infection, type A personality and stress, steroid use, pregnancy and hyperopia were associated with CSR, while myopia was found to protect from CSR. In multivariate analysis, alcohol consumption, hypertension, coronary heart disease and autoimmune disorders lost their significance, while the remaining factors were all independently associated with CSR.

CONCLUSIONS

It is important to take into account the various risk factors for CSR, so as to define vulnerable groups and to shed light into the pathogenesis of the disease.

Clinical efficiency of Helicobacter pylori eradication in the treatment of patients with acute central serous chorioretinopathy

BACKGROUND

Although the majority of cases of acute central serous chorioretinopathy are self-limited, resolving spontaneously after a number of weeks, the recurrence rate is estimated to be 20-50 %, and some cases will be chronic, lasting 6 months or longer. The evidence of Helicobacter pylori infection appears more often in patients with central serous chorioretinopathy. The purpose of this work was to estimate the efficiency of H. pylori infection eradication in treatment of patients with acute central serous chorioretinopathy.

METHODS

Ninety-three patients with acute central serous chorioretinopathy participated in this study. Patients were divided into an experimental group (33 Helicobacter pylori-positive patients who received eradication treatment) and two control groups who did not receive eradication treatment: 29 H. pylori-positive patients and 31 H. pylori-negative patients. Research methods were best-corrected Snellen visual acuity, optical coherence tomography, fluorescein angiography. Research methods were best-corrected Snellen visual acuity, optical coherence tomography, static perimetry, and Amsler grid. The follow-up period was 2 years.

RESULTS

Helicobacter pylori eradication caused a decrease of disease duration at 3 months (p = 0.04) and recurrence frequency of 45.6 % (p = 0.03) as well as improvement of distant prognosis. After 2 years, visual acuity increased from 0.91 ± 0.07 to 0.99 ± 0.02 (p = 0.01), scotoma frequency decreased from 100 % eyes to 27.2 % (p = 0.001), and metamorphopsia frequency decreased from 57.6 % eyes to 39.4 % (p = 0.04).

CONCLUSIONS

Helicobacter pylori eradication is effective in the treatment of H. pylori-positive patients with acute central serous chorioretinopathy.

Interventions for central serous chorioretinopathy: a network meta-analysis

BACKGROUND

Central serous chorioretinopathy (CSC) is characterized by serous detachment of the neural retina with dysfunction of the choroid and retinal pigment epithelium (RPE). The effects on the retina are usually self limited, although some people are left with irreversible vision loss due to progressive and permanent photoreceptor damage or RPE atrophy. There have been a variety of interventions used in CSC, including, but not limited to, laser treatment, photodynamic therapy (PDT), and intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents. However, it is not known whether these or other treatments offer significant advantages over observation or other interventions. At present there is no evidence-based consensus on the management of CSC. Due in large part to the propensity for CSC to resolve spontaneously or to follow a waxing and waning course, the most common initial approach to treatment is observation. It remains unclear whether this is the best approach with regard to safety and efficacy.

OBJECTIVES

To compare the relative effectiveness of interventions for central serous chorioretinopathy.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2015, Issue 9), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to February 2014), EMBASE (January 1980 to October 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 5 October 2015.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that compared any intervention for CSC with any other intervention for CSC or control.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies and extracted data. We pooled data from all studies using a fixed-effect model. For interventions applied to the eye (i.e. not systemic interventions), we synthesized direct and indirect evidence in a network meta-analysis model.

MAIN RESULTS

We included 25 studies with 1098 participants (1098 eyes) and follow-up from 16 weeks to 12 years. Studies were conducted in Europe, North and South America, Middle East, and Asia. The trials were small (most trials enrolled fewer than 50 participants) and poorly reported; often it was unclear whether key aspects of the trial, such as allocation concealment, had been done. A substantial proportion of the trials were not masked.The studies considered a variety of treatments: anti-VEGF (ranibizumab, bevacizumab), PDT (full-dose, half-dose, 30%, low-fluence), laser treatment (argon, krypton and micropulse laser), beta-blockers, carbonic anhydrase inhibitors, Helicobactor pylori treatment, and nutritional supplements (Icaps, lutein); there were only one or two trials contributing data for each comparison. We downgraded for risk of bias and imprecision for most analyses, reflecting study limitations and imprecise estimates. Network meta-analysis (as planned in our protocol) did not help to resolve this uncertainty due to a lack of trials, and problems with intransitivity, particularly with respect to acute or chronic CSC.Low quality evidence from two trials suggested little difference in the effect of anti-VEGF (ranibizumab or bevacizumab) or observation on change in visual acuity at six months in acute CSC (mean difference (MD) 0.01 LogMAR (logarithm of the minimal angle of resolution), 95% confidence interval (CI) -0.02 to 0.03; 64 participants). CSC had resolved in all participants by six months. There were no significant adverse effects noted.Low quality evidence from one study (58 participants) suggested that half-dose PDT treatment of acute CSC probably results in a small improvement in vision (MD -0.10 logMAR, 95% CI -0.18 to -0.02), less recurrence (risk ratio (RR) 0.10, 95% CI 0.01 to 0.81) and less persistent CSC (RR 0.12, 95% CI 0.01 to 1.02) at 12 months compared to sham treatment. There were no significant adverse events noted.Low quality evidence from two trials (56 participants) comparing anti-VEGF to low-fluence PDT in chronic CSC found little evidence for any difference in visual acuity at 12 months (MD 0.03 logMAR, 95% CI -0.08 to 0.15). There was some evidence that more people in the anti-VEGF group had recurrent CSC compared to people treated with PDT but, due to inconsistency between trials, it was difficult to estimate an effect. More people in the anti-VEGF group had persistent CSC at 12 months (RR 6.19, 95% CI 1.61 to 23.81; 34 participants).Two small trials of micropulse laser, one in people with acute CSC and one in people with chronic CSC, provided low quality evidence that laser treatment may lead to better visual acuity (MD -0.20 logMAR, 95% CI -0.30 to -0.11; 45 participants). There were no significant adverse effects noted.Other comparisons were largely inconclusive.We identified 12 ongoing trials covering the following interventions: aflibercept and eplerenone in acute CSC; spironolactone, eplerenone, lutein, PDT, and micropulse laser in chronic CSC; and micropulse laser and oral mifepristone in two trials where type of CSC not clearly specified.

AUTHORS' CONCLUSIONS

CSC remains an enigmatic condition in large part due to a natural history of spontaneous improvement in a high proportion of people and also because no single treatment has provided overwhelming evidence of efficacy in published RCTs. While a number of interventions have been proposed as potentially efficacious, the quality of study design, execution of the study and the relatively small number of participants enrolled and followed to revealing endpoints limits the utility of existing data. It is not clear whether there is a clinically important benefit to treating acute CSC which often resolves spontaneously as part of its natural history. RCTs comparing individual treatments to the natural history would be valuable in identifying potential treatment groups for head-to-head comparison. Of the interventions studied to date, PDT or micropulse laser treatment appear the most promising for study in future trials.

Association between Helicobacter pylori and extra-gastric diseases

Helicobacter pylori (H. pylori) is confirmed to be associated with many diseases such as gastric cancer, peptic ulcer, gastritis and mucosa-associated lymphoid tissue lymphoma. Recent studies found that H. pylori is associated with many extra-gastric diseases. The underlying mechanism involves autoimmunity, inflammation and oxidative stress. Here we review the association between H. pylori and extra-gastric diseases.

Advances in the treatment of central serous chorioretinopathy

Central serous chorioretinopathy is a disease that is partly understood. Novel advancements have led to further understanding of the disease, and have identified choroidal dysfunction as the principal element in CSCR development. New imaging tools have aided in better monitoring disease response to various treatment models. Enhanced depth imaging optical coherence tomography, in particular, has helped in observing choroidal thickness changes after various treatment models. To date, photodynamic therapy and focal laser remain the main stay of treatment. More understanding of disease pathophysiology in the future will help in determining the drug of choice and the best management option for such cases.

Helicobacter pylori infection and eye diseases: a systematic review

The connection between Helicobacter pylori (Hp) infection and eye diseases has been increasingly reported in the literature and in active research. The implication of this bacterium in chronic eye diseases, such as blepharitis, glaucoma, central serous chorioretinopathy and others, has been hypothesized. Although the mechanisms by which this association occurs are currently unknown, this review describes shared pathogenetic mechanisms in an attempt to identify a lowest common denominator between eye diseases and Hp infection. The aim of this review is to assess whether different studies could be compared and to establish whether or not Hp infection and Eye diseases share common pathogenetic aspects. In particular, it has been focused on oxidative damage as a possible link between these pathologies. Text word search in Medline from 1998 to July 2014. 152 studies were included in our review. Were taken into considerations only studies that related eye diseases more frequent and/or known. Likely oxidative stress plays a key role. All of the diseases studied seem to follow a common pattern that implicates a cellular response correlated with a sublethal dose of oxidative stress. These alterations seem to be shared by both Hp infections and ocular diseases and include the following: decline in mitochondrial function, increases in the rate of reactive oxygen species production, accumulation of mitochondrial DNA mutations, increases in the levels of oxidative damage to DNA, proteins and lipids, and decreases in the capacity to degrade oxidatively damaged proteins and other macromolecules. This cascade of events appears to repeat itself in different diseases, regardless of the identity of the affected tissue. The trabecular meshwork, conjunctiva, and retina can each show how oxidative stress may acts as a common disease effector as the Helicobacter infection spreads, supported by the increased oxidative damage and other inflammation.

Helicobacter pylori as a risk factor for central serous chorioretinopathy: Literature review

Helicobacter pylori (H. pylori), a Gram-negative bacterium, is one of the most frequent causes of gastrointestinal infections worldwide. It has been associated as a pathogen for the human body with many systemic diseases, including different eye diseases. We will focus on a specific eye disease called idiopathic central serous chorioretinopathy (ICSCR). This disease is characterized by a serous detachment of the neurosensory retina in the macular region, which affects the vision to different degrees. Currently, the pathophysiology of ICSCR is not clear and there is no effective treatment. However, several potential risk factors have been elucidated. One of the factors that has more frequently been associated with ICSCR is stress. As H. pylori was identified as a possible etiological factor for occlusive arterial diseases in young people who were particularly stressed, it was thought that H. pylori might also be present in ICSCR. Therefore, some physicians started to test its presence in patents with ICSCR. If H. pylori happened to be associated with ICSCR, the treatment of gastrointestinal infection could also improve visual symptoms and help to remediate this eye disease. Although H. pylori is highly prevalent in the general population, a true correlation seems to exist. We present a review on the relationship between ICSCR and H. pylori.

Central serous chorioretinopathy: update on pathophysiology and treatment

Recent technological advances--new pathophysiological insights, new imaging techniques for diagnosis and management, and new treatments--have led to an improved understanding of central serous chorioretinopathy (CSC). The primary role of the choroid has become more widely accepted with widespread use of indocyanine green angiography. Optical coherence tomography (OCT), and particularly enhanced depth imaging OCT, demonstrate a thickened and engorged choroid. Adaptive optics, fundus autofluorescence, multifocal electroretinography, microperimetry, and contrast sensitivity testing reveal that patients with even a mild course suffer previously undetected anatomic and functional loss. Although focal laser and photodynamic therapy are the current standard of care for persistent subretinal fluid in CSC, they are not appropriate in all cases, and the optimal timing of intervention remains unclear.

Central serous chorioretinopathy: a review of epidemiology and pathophysiology

Central serous chorioretinopathy (CSCR) is a common retinal cause of vision loss. This review surveys the epidemiology, risk factors, clinical presentation, natural history and pathophysiology of CSCR. Studies suggest an annual incidence rate of 10 per 100 000 in men, with CSCR occurring six times more commonly in men compared with women. Most acute CSCR cases resolve spontaneously within 2-3 months. Prognosis is highly dependent on presenting visual acuity; patients with initial visual acuities of 6/6 remain at that level, while patients with initial visual acuities of less than 6/9 recover on average two to three Snellen lines over the next few years. The main risk factors for CSCR are systemic corticosteroid use, type A personality, pregnancy and endogenous Cushing's syndrome. The pathophysiology of CSCR remains obscure, although disorders in both the choroidal circulation and retinal pigment epithelium are implicated.

Helicobacter pylori as a potential target for the treatment of central serous chorioretinopathy

OBJECTIVES

The objective of this study was to evaluate the relationship between the treatment of Helicobacter pylori gastric infection and changes in best-corrected visual acuity and macular detachment in patients with chronic central serous chorioretinopathy.

METHODS

Seventeen patients diagnosed with central serous chorioretinopathy were examined for gastric infection with Helicobacter pylori using the urease test and gastric biopsy. Helicobacter pylory-positive patients were treated with the appropriate medication. The response to therapy was monitored by evaluating the best-corrected visual acuity and optical coherence tomography. The data were analyzed using Student's t-test before and after treatment.

RESULTS

Fourteen patients (15 eyes) aged 30-56 years (mean 43.4 ± 8.3 years) were positive for Helicobacter pylori. Most of the positive patients had gastric symptoms (78.5%); one had bilateral central serous chorioretinopathy. The mean baseline best-corrected visual acuity was 20/98 (logMAR = 0.53 ± 0.28). Three months after starting treatment with antibiotics, the serous detachment had resolved in 14 of 15 eyes, but two cases required laser treatment. The follow-up period ranged from 6 to 27 months. The mean final best-corrected visual acuity differed significantly from baseline.

CONCLUSION

Our findings suggest that Helicobacter pylori infection may be present in many chronic central serous chorioretinopathy patients and that treatment for the infection may have a favorable effect on the outcome of chronic central serous chorioretinopathy. Due to the possibility of the spontaneous regression of chronic central serous chorioretinopathy and the high prevalence of the infection in the general population, prospective and masked clinical trials are necessary to confirm that treatment for Helicobacter pylori infection may benefit patients with chronic central serous chorioretinopathy.

Cure of alopecia areata after eradication of Helicobacter pylori: a new association?

Alopecia areata is a disease of the hair follicles, with strong evidence supporting autoimmune etiology. Alopecia areata is frequently associated with immune-mediated diseases with skin manifestations such as psoriasis and lichen planus, or without skin manifestations such as autoimmune thyroiditis and idiopathic thrombocytopenic purpura. Helicobacter pylori (H. pylori) infection is present in around 50% of the world's population and has been associated with a variety of immune-mediated extra-digestive disorders including autoimmune thyroiditis, idiopathic thrombocytopenic purpura, and psoriasis. A case of a 43-year old man with an 8-mo history of alopecia areata of the scalp and beard is presented. The patient was being treated by a dermatologist and had psychiatric support, without any improvement. He had a history of dyspepsia and the urea breath test confirmed H. pylori infection. The patient went into remission from alopecia areata after H. pylori eradication. If such an association is confirmed by epidemiological studies designed for this purpose, new therapeutic options could be available for these patients, especially in areas where infection with H. pylori is highly prevalent.

Review and update of central serous chorioretinopathy

PURPOSE OF REVIEW

Greater understanding of central serous chorioretinopathy (CSCR) has changed initial beliefs that CSCR is a benign condition affecting young men with almost complete resolution. CSCR has a spectrum of presentations with more diffuse retinal dysfunction and variations between races. CSCR can affect older individuals and in a subset of patients may lead to significant ocular morbidity.

RECENT FINDINGS

Advances in imaging, particularly in indocyanine green angiography and optical coherence tomography, have led to a greater understanding of the pathophysiology of this condition. Treatments for CSCR are still evolving, in particular photodynamic dynamic therapy using lower doses and reduced fluence showing promising results. More research is required on ideal dosage. Anti-vascular endothelial growth factor treatment offers a new medical treatment modality with promising results.

SUMMARY

There have been recent imaging developments in addition to therapeutic advances for refractory CSCR.

A new strategy of treatment with low-dosage acetyl salicylic acid in patients affected by central serous chorioretinopathy

Central serous chorioretinopathy (CSCR) is an ocular disease characterized by serous detachment of the neurosensory retina at the posterior pole, with or without an associated retinal pigment epithelium (RPE) detachment. It is associated with different systemic diseases although the pathogenesis is unknown. Different therapies have been applied to treat CSCR with poor results. We reviewed the literature and found that in all the diseases associated with CSCR plasminogen activator inhibitor 1 (PAI-1) was increased. Acetyl salicylic acid (Aspirin) is effective in lowering PAI-1 levels and platelets aggregation; as such we decided to treat patients affected by CSCR with low dose Aspirin. From January 2005 to December 2008 we enrolled 107 patients, 85 male and 22 female, affected with active CSCR or the multifocal variant. Aspirin was administrated at an oral dose of 100 mg. per day for a month and then 100 mg. every other day for five months. After the first week of therapy and for the following three months the visual acuity improved and remained stable to the end of the follow-up (median follow-up 20 months). A recurrence of the disease interested the 6% of the patients. In this study low-dose Aspirin was able to treat central serous chorioretinopathy with a quick recovery of the visual acuity and a reduced number of recurrences during the follow-up. Besides the effectiveness of the treatment with Aspirin supports our observation regarding the role of impaired fibrinolysis and increased platelets aggregation in the choriocapillaris as genesis of CSCR.

No association between Helicobacter pylori infection or CagA-bearing strains and glaucoma

BACKGROUND AND PURPOSE

Accumulating evidence indicates that a variety of infections contribute to the pathogenesis of glaucoma. The role of Helicobacter pylori infection in glaucoma is controversial.

DESIGN

Prospective, population-based study.

PARTICIPANTS

Patients with various types of glaucoma and a control group of patients with cataract.

METHODS

We evaluated seropositivity to H. pylori and to its cytotoxin-associated gene A (CagA) product in patients with various types of glaucoma and compared the findings to those of a control group of patients with cataract.

RESULTS

H. pylori infection and CagA seropositivity were detected in 31/51 (60.8%) and 26/51 (51%) glaucoma patients compared with 22/36 (61.1%) and 19/36 (52%) control patients, respectively (P=0.88, 0.67, not significant). Similar rates of H. pylori infection and CagA-positive strain were found in all glaucoma subgroups, and none of them was statistically different from those of controls.

CONCLUSIONS

Neither H. pylori infection nor seropositivity for virulent CagA-bearing H. pylori strains have significant association with the occurrence of glaucoma of any type.

Noxious compounds in exhaled air, a potential cause for ocular manifestations of H. pylori gastrointestinal infection

Helicobacter pylori infection is one of the most common chronic bacterial infections worldwide. In the past few years, a variety of extradigestive disorders have been associated with H. pylori infection. This infection has also been linked to some ophthalmic disorders, including glaucoma, central serous chorioretinopathy, uveitis and blepharitis. Several possible theories to explain pathogenetic mechanism underlying the observed associations have been provided. H. pylori infection causes elaboration of some noxious compounds, including ammonia, hydrogen nitrate and hydrogen cyanide, in exhaled breath of infected individuals. Herein we hypothesize that chronic exposure of ocular surface to these compounds may explain some ophthalmic and also respiratory manifestations of the chronic gastrointestinal infection.

Central serous chorioretinopathy after epidural steroid injection

Central serous chorioretinopathy (CSC) is a condition characterized by serous detachment of the neurosensory retina in the posterior pole. Corticosteroids administered by various routes is reported as a possible cause of CSC. We report the cases of two patients who developed CSC after receiving a corticosteroid injection in the epidural space for the treatment of back pain. In both patients, the accumulation of subretinal fluid spontaneously resolved within several weeks. Patients who develop CSC after epidural analgesia with corticosteroids should be alerted to the possible relationship between CSC and this treatment. Clinicians should advise all patients with CSC to avoid systemic corticosteroids administered by any route, unless they have a compelling medical indication. Pharmacists should advise patients to seek evaluation if visual changes occur during or after corticosteroid therapy.