True, true and related?

Rapid Resolution of Graft-versus-Host-Disease-Related Central Serous Chorioretinopathy

We present a 23-year-old female patient who developed bilateral, multifocal CSCR three months after BMT and two months after developing GvHD. At the time of diagnosis, her medications included cyclosporine and high-dose oral steroid for GvHD. CSCR resolved quickly after the resolution of GvHD, along with rapid tapering of steroids and restoration of emotional wellbeing. Rapid tapering of systemic steroids under close monitoring of a hematologist in the setting of resolved mild GvHD may facilitate prompt resolution of CSCR.

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.

Laser Photocoagulation for Central Serous Retinopathy Associated with Graft-Versus-Host Disease

PURPOSE

To describe the clinical characteristics and treatment of recurrent central serous retinopathy (CSR) following bone marrow transplantation (BMT).

METHODS

Between June 1998 and September 1999, 116 patients underwent allogeneic BMT at Hadassah Medical Center. Ocular complaints were expressed by 57.8% of these patients, who were examined and followed by the same ophthalmologist every 2-4 weeks. The ocular examination included Schirmer's test, slit-lamp examination, tonometry, and dilated funduscopy. If fundus abnormalities were noted, fluorescein angiography and indocyanine-green chorioangiography were performed.

RESULTS

Three patients presented with BMT-induced relapsing CSR. The severity of the CSR correlated well with the dosage of the systemic corticosteroids. These patients were eventually treated with laser photocoagulation, which, in all cases, resolved the CSR and improved visual acuity. During a 3-4 year follow-up period, no recurrence of CSR was documented despite continuous systemic corticosteroid treatment.

CONCLUSIONS

In BMT patients, chronic corticosteroid treatment can cause a persistent/relapsing CSR. Since corticosteroids cannot be discontinued in such cases, photocoagulation should be considered at an early stage to prevent continuous ocular morbidity.

Autoimmune retinopathy with RPE hypersensitivity and 'negative ERG' in X-linked hyper-IgM syndrome

PURPOSE

To report the clinical, electrophysiological, and immunological features of a patient with X-linked hyper-IgM immunodeficiency syndrome type 1 (HIGM1) accompanied by a novel type of autoimmune retinopathy, including retinal pigment epithelium (RPE) hypersensitivity.

METHODS

Comprehensive ophthalmological examinations, electrophysiological function testing, and inquiries into the immunological status of a 13-year-old presenting with subacute loss of vision in association with a molecularly confirmed diagnosis of HIGM1 were performed. The patient was genotyped by a PCR-based sequence tag content mapping strategy to define the genetic defect within the causative X-HIM gene TNFSF5. Since conventional allogenic bone marrow transplantation has been reported to cure HIGM1, a peripheral blood stem-cell transplantation was performed.

RESULTS

(1) The patient's reduced visual acuity included prolonged dark adaptation and visual field constriction. Electrophysiology revealed a 'negative ERG' indicating post-receptoral dysfunction. (2) Initial immunological examination of the patient's serum identified abnormal antibody activity with components of the photoreceptors and the inner nuclear layer. The patient later developed indications of RPE hypersensitivity. A massively reduced light-peak to dark-trough ratio of the EOG slow oscillations (L/D ratio) corresponded to impaired RPE-photoreceptor complex function. (3) Molecular genetic analyses revealed the patient to be nullizygous for the tumor necrosis factor ligand member 5 gene (TNFSF5; CD40LG). A large chromosomal deletion of approximately 27.6-32.3 kb in size was identified in Xq26. (4) The transplant with its associated immunomodulation appeared to worsen rather than improve the patient's condition.

CONCLUSIONS

The fundus appearance and electrophysiological function testing revealed indications of atypical retinal degeneration. However, the clinical course and the serological findings were consistent with those of ocular autoimmunity involving both antiretinal activity and RPE hypersensitivity. In this case, peripheral stem-cell transfusion with its associated chemotherapy failed to benefit the patient's vision; indications of autoimmunity appeared to increase following this treatment.