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What is the eye telling us?
Central serous chorioretinopathy (CSC) has captured the attention of physicians for nearly 150 years. Psychic stress and behavioural traits were originally described as potential contributing factors in the development of this disorder by Horniker in 1927.1 Since that time, many others have attempted to better define this relation. Gelber and Schatz reported results of detailed psychiatric interviews (which included the gold standard structured interview) with CSC patients.2 Of the 33 patients studied, 91% described a disturbing psychological event immediately preceding their loss of vision. These patients had type A personality scores comparable to patients with myocardial infarction. In 1987, Yannuzzi reported a higher proportion of type A behaviour pattern as measured by the Jenkins Activity Survey in patients with CSC compared to control subjects with other forms of central vision loss.3 These two studies would suggest that the constitution of the patient in combination with psychic stress have a role in the development of CSC.
Just as fundus biomicroscopy, angiography, and optical coherence tomography have aided our understanding of the pathological response of the retina and choroid in CSC, our understanding of the psychosocial aspects of disease have been enhanced by standardised questionnaires which have been validated and can be compared to large sample populations of normal subjects. In this issue of the BJO (p 704), Spahn and coworkers performed psychometric studies (Symptom Checklist, Symptom List, Sixteen Personality Factor Questionnaire, and Questionnaire on Social Support) on patients diagnosed with CSC up to 6 weeks earlier. Thirty seven per cent of these patients had elevated psychic stress within the week before testing. CSC patients were found to have greater social support and no evidence of abnormal psychosomatic symptoms compared to normal sample populations. Personality testing revealed increased emotional instability and insecurity as well as greater spontaneity and flexibility, suggesting to the authors that inner turmoil may be a cause of the stress reaction and an avenue for further investigation. Based on the inconsistent results of all psychological testing performed to date, the authors see no scientific evidence that psychosocial factors have a dominant role in the pathogenesis of CSC.
While this or other studies have not proved the psychogenic induced hypothesis of CSC, an intriguing pattern remains. Repeated studies have shown an association with steroids, both endogenous and exogenous.4,5 Also, CSC has been associated with hypertension and disease states that result in elevated levels of serum cortisol (Cushing’s disease) or are commonly treated with steroid medications.4,6,7 Jampol and coworkers have recently summarised the possible genomic and non-genomic pathways that corticosteroids may affect in the chorioretinal complex in CSC.8
CSC remains a unique ophthalmic condition in which a definite link between psychological profile and end organ alterations may one day be made
As previously mentioned, an association between the type A behaviour pattern (TABP) and CSC has been described.2,3 The TABP has been extensively studied as it relates to cardiovascular disease. Investigators feel that this behaviour pattern acts on the adrenomedullary sympathetic system to alter cardiovascular tone, blood rheology, lipid profiles, and serum hormone levels.9 Interestingly, subjects who demonstrate the TABP share many physiological changes that have been described in CSC, including elevated blood pressure and increased serum stress hormones such as cortisol and catecholamines.9,10 Promising research has demonstrated that the TABP is modifiable and that behavioural changes can, in turn, lower the patients’ risk of recurrent myocardial infarction.11
Is the TABP measured by the psychometric tests performed by Spahn and coworkers? While a controversial issue, the TABP as measured by the Jenkins Activity Survey appears unrelated to factors assessed by the tests reported in this study. In fact, others have shown an inverse correlation between TABP and psychopathology.12
CSC remains a unique ophthalmic condition in which a definite link between psychological profile and end organ alterations may one day be made. Our continued attention to this disease is vital. The clinical and psychological findings as well as the neuroendocrine associations may lead to a better understanding not only of CSC but also of other macular and, possibly, vascular diseases. Alternatively, treatments directed at behaviour modification or neuroendocrine alteration in patients with TABP and cardiovascular disease may translate to improved treatments for CSC.
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What is the eye telling us?