Topical Corticosteroid-induced Central Serous Retinopathy: A Vision Lost and Regained

Dear Editor, Corticosteroids are the cornerstone of the dermatologist’s therapeutic armamentarium. They are hormone analogs to natural steroid hormones, possessing mainly glucocorticoid effects, and are available in various formulations depending upon the potency, with Class I being the most potent and VII, the least potent. While central serous chorioretinopathy (CSCR) is well documented with systemic corticosteroids, the incidence of CSCR following topical corticosteroid application remains a rare and underreported entity. Here, we report a case of topical corticosteroid-induced CSCR to highlight the need for increased awareness among dermatologists. A 45-year-old female from rural Tamil Nadu, who is a mason by occupation, was prescribed topical corticosteroid (0.05% clobetasol propionate) for bilateral hand eczema. Following improvement, the patient self-medicated with topical corticosteroids (0.05% clobetasol propionate) intermittently when the lesions flared up for almost a year. She presented to our out patient department with a flare-up of hand eczema and a recent (3 weeks) decrease of vision in the left eye. An ophthalmology opinion was sought for decreased vision. The fundoscopy showed subretinal fluid in the left eye temporal to fovea. On macular optical coherence tomography (OCT) examination in the left eye, it showed a large serous retinal detachment involving the posterior pole and detachment of the neurosensory retina in the macular region as in Figure 1. Hence, she was diagnosed with CSCR secondary to topical corticosteroid application after ruling out other causes like hypertension, coronary artery disease, recent stressful events, sleep disturbances, and familial history.Figure 1: (a) Optical coherence tomography at baseline shows serous macular detachment as hypo reflective space between neurosensory retina and retinal pigment epithelium in left eye. (b) Optical coherence tomography taken after 5 months of stopping corticosteroid. (c) Optical coherence tomography shows near normal macula in left eye following corticosteroid cessation after 8 monthsCSCR occurs due to fluid accumulation between neurosensory layer (NSL) and retinal pigment epithelium (RPE) and is often associated with focal RPE detachment from choroid. It happens when there is excessive leakage of fluid in the choroid and defective RPE is not able to prevent seepage of fluid into retina, causing serous retinal detachment.[1] The pathogenesis of topical steroid related CSCR includes dysregulation of mineralocorticoid receptors, increased choroidal vascular permeability, dysfunctional RPE, and cortisol-induced vasoconstriction. Additionally, impaired skin barrier and presence of polyethylene glycol (PEG) in topical formulations may enhance systemic absorption, further increasing CSCR risk.[2] Previous case reports have documented CSCR and symptoms following topical steroid use [Table 1].[2-6] Risk factors for CSCR include prolonged use of high potency topical steroids, a history of CSCR, hypertension, chronic stress, and occlusive dressing.[7]Table 1: Summary of Studies Linking Steroid Use to Central Serous ChorioretinopathyUpon discontinuation of corticosteroids and initiation of 0.1% tacrolimus ointment, the patient showed improvement in hand eczema and visual symptoms. Her neurosensory retina reattached within 8 months, aligning with the self-limiting nature of acute CSCR. However, chronic CSCR may require treatments such as eplerenone, retinal laser therapy, and photodynamic therapy.[8] Corticosteroids are the mainstay of treatment in hand eczema as in our case with significant antipruritic and anti-inflammatory properties by inhibiting the transcriptional activity of various proinflammatory genes. It has been found that CSCR caused by topical corticosteroids is an idiosyncratic response in vulnerable individuals rather than a dose-dependent one. The amount and quantity required for a topical corticosteroid to cause central serous retinopathy are not found in the literature. This case underscores the need for judicious corticosteroid use and heightened awareness of CSCR as a potential adverse effect. Dermatologists should carefully balance therapeutic benefits with risk of systemic absorption and ocular complications, ensuring both provider and patient awareness.[9] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent form. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Use of artificial intelligence (AI) The preparation of this manuscript was carried out entirely by the authors without the use of artificial intelligence technologies.