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Metamorphopsia in a Middle-aged Man

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 47-year-old man presented with gradual onset of blurry vision in both eyes for several months. Best-corrected visual acuity was 20/20 OD and 20/40 OS. Intraocular pressure was 23 mm Hg in both eyes and was more than 21 mm Hg in both eyes on multiple visits. Medical history included hypertension, obesity, left adrenalectomy, and pterygium excision surgery in the left eye. The patient denied previous episodes of blurry vision, history of corticosteroid use, sleep apnea, or type-A personality. Complete review of systems was otherwise negative. Amsler grid testing revealed paracentral metamorphopsia in both eyes. Extraocular motility, pupillary light reactions, and confrontational visual fields were normal. Slitlamp examination and gonioscopy results were normal in both eyes. An external photograph of the patient is shown in Figure 1A. Fluorescein angiography demonstrated multiple areas of late pinpoint leakage and patches of mottled hyperfluorescence in both eyes (Figure 1B).

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Bilateral central serous chorioretinopathy secondary to pituitary microadenoma

C. Draw morning plasma cortisol levels

This patient exhibited signs of hypercortisolism, including central obesity (Figure 1). He had systemic hypertension, which occurs in most patients with endogenous hypercortisolism,1,2 and elevated intraocular pressure, which has been reported in endogenous hypercortisolism and can be caused by corticosteroid use.3,4 His hemoglobin A1c level was elevated (6.8%), which is consistent with impaired glucose metabolism in endogenous hypercortisolism.2

Fluorescein angiography showed multiple areas of late pinpoint leakage and guttering, which is patchy, mottled hyperfluorescence caused by gravity-related descending tracts of subretinal fluid (Figure 1). These fluorescein angiography findings are typical of central serous chorioretinopathy (CSC), which is characterized by serous detachment of neurosensory retina/retinal pigment epithelium (Figure 2) and choroidal hyperpermeability. The leakage on fluorescein angiography is most consistent with active CSC, whereas the patches of mottled fluorescence are more typical of chronic CSC.

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Article Information

Corresponding Author: Jayanth Sridhar, MD, Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL 33136 (jsridhar1@med.miami.edu).

Published Online: July 15, 2021. doi:10.1001/jamaophthalmol.2020.7095

Conflict of Interest Disclosures: Dr Sridhar reported personal fees from Alcon, DORC, Oxurion, and Regeneron Pharmaceuticals. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Isidori  AM , Graziadio  C , Paragliola  RM ,  et al; ABC Study Group.  The hypertension of Cushing’s syndrome.   J Hypertens. 2015;33(1):44-60.PubMedGoogle ScholarCrossref
2.
Li  D , El Kawkgi  OM , Henriquez  AF , Bancos  I .  Cardiovascular risk and mortality in patients with active and treated hypercortisolism.   Gland Surg. 2020;9(1):43-58.PubMedGoogle ScholarCrossref
3.
Habib  SN , Lin  Z , Puvanachandra  N .  Ocular hypertension secondary to high endogenous steroid load in Cushing’s disease.   BMJ Case Rep. 2019;12(1):bcr-2018-226738.PubMedGoogle Scholar
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Kersey  JP , Broadway  DC .  Corticosteroid-induced glaucoma: a review of the literature.   Eye (Lond). 2006;20(4):407-416.PubMedGoogle ScholarCrossref
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Chung  YR , Seo  EJ , Lew  HM , Lee  KH .  Lack of positive effect of intravitreal bevacizumab in central serous chorioretinopathy.   Eye (Lond). 2013;27(12):1339-1346.PubMedGoogle ScholarCrossref
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Ji  S , Wei  Y , Chen  J , Tang  S .  Clinical efficacy of anti-VEGF medications for central serous chorioretinopathy.   Int J Clin Pharm. 2017;39(3):514-521.PubMedGoogle ScholarCrossref
7.
Lotery  A , Sivaprasad  S , O’Connell  A ,  et al; VICI trial investigators.  Eplerenone for chronic central serous chorioretinopathy in patients with active, previously untreated disease for more than 4 months (VICI).   Lancet. 2020;395(10220):294-303.PubMedGoogle ScholarCrossref
8.
Schwartz  R , Habot-Wilner  Z , Martinez  MR ,  et al.  Eplerenone for chronic central serous chorioretinopathy.   Acta Ophthalmol. 2017;95(7):e610-e618.PubMedGoogle ScholarCrossref
9.
Carvalho-Recchia  CA , Yannuzzi  LA , Negrão  S ,  et al.  Corticosteroids and central serous chorioretinopathy.   Ophthalmology. 2002;109(10):1834-1837.PubMedGoogle ScholarCrossref
10.
Bouzas  EA , Scott  MH , Mastorakos  G , Chrousos  GP , Kaiser-Kupfer  MI .  Central serous chorioretinopathy in endogenous hypercortisolism.   Arch Ophthalmol. 1993;111(9):1229-1233.PubMedGoogle ScholarCrossref
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