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| CASE REPORT |
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| Year : 2022 | Volume
: 15
| Issue : 2 | Page : 173-175 |
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Central serous chorioretinopathy in a COVID-19-positive patient with torpedo maculopathy and associated oral tadalafil intake
Pradeep Kumar Panigrahi
Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, SOA (Deemed to be) University, Bhubaneswar, Odisha, India
| Date of Submission | 24-Aug-2021 |
| Date of Acceptance | 22-Jan-2022 |
| Date of Web Publication | 24-May-2022 |
Correspondence Address:
Dr. Pradeep Kumar Panigrahi
Department of Ophthalmology, Institute of Medical Sciences and SUM Hospital, SOA (Deemed to be) University, 8-Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/kleuhsj.kleuhsj_212_21
A 46-year-old post-COVID-19-positive male patient presented with sudden onset painless loss of vision in the left eye (LE). There was history of oral tadalafil intake 10 days before vision loss. Clinical and imaging examinations led to the diagnosis of central serous chorioretinopathy with torpedo maculopathy in LE. No active intervention was done. There was complete resolution of neurosensory detachment with improvement of vision 1 month following the presentation.
Keywords: Central serous chorioretinopathy, COVID-19, tadalafil, torpedo maculopathy
How to cite this article:
Panigrahi PK. Central serous chorioretinopathy in a COVID-19-positive patient with torpedo maculopathy and associated oral tadalafil intake. Indian J Health Sci Biomed Res 2022;15:173-5 |
How to cite this URL:
Panigrahi PK. Central serous chorioretinopathy in a COVID-19-positive patient with torpedo maculopathy and associated oral tadalafil intake. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 Jun 25];15:173-5. Available from: https://www.ijournalhs.org/text.asp?2022/15/2/173/345825 |
| Introduction | |  |
Central serous chorioretinopathy (CSC) is characterized by serous neurosensory retinal detachment with or without retinal pigment epithelial detachment leading to a decrease in vision which is usually mild and recovers spontaneously within a few months in the majority of cases. The association of CSC with torpedo maculopathy (TM), phosphodiesterase-5 (PDE-5) inhibitors, and COVID-19 has been reported in the literature.[1],[2],[3] We report a unique case of CSC in a COVID-19-positive case with presumed TM and history of prior oral tadalafil intake.
| Case Report | | |
A 46-year-old male presented with sudden onset painless loss of vision and metamorphopsia in the left eye (LE) of 3-week duration. The patient gave a history of fever, sore throat, and cough 1 month ago. Reverse transcriptase-polymerase chain reaction test of nasopharyngeal swab had come positive for severe acute respiratory syndrome coronavirus-2. The patient had been advised home isolation by his physician and had been treated with oral azithromycin, ivermectin, vitamin-C tablets, zinc supplements, montelukast, and pantoprazole. The patient did not require any treatment with systemic steroids for COVID-19. The patient developed ocular symptoms in LE 1 week after testing positive for COVID-19.
On examination, best-corrected visual acuity (BCVA) in the right eye (RE) was 20/20, N6 and in LE was 20/40, N8. The anterior segment was within normal limits in both eyes. Intraocular pressure measured using Goldmann's applanation tonometer was 18 and 19 mm of hg in RE and LE, respectively. Dilated fundus examination of RE was normal. Fundus examination of LE showed clear media, normal optic disc, and neurosensory detachment in the macular area. An oval torpedo-shaped lesion was noted inferotemporal to the foveal center [Figure 1]a. The lesion appeared hypopigmented as compared to the surrounding fundus. A circular area of hyperpigmentation was noted within the oval patch at its temporal end. A small patch of old choroiditis was noted temporal to this oval lesion. There were no signs of active intraocular inflammation in either eye. Optical coherence tomography (OCT) scan of RE was normal. OCT scan of LE showed neurosensory detachment involving the foveal center and extending up to the parafoveal area temporally [Figure 1]b. We diagnosed it as a case of CSC with TM in LE. | Figure 1: (a) Color fundus photograph of the left eye showing neurosensory detachment (area highlighted in yellow circle); oval-shaped lesion of torpedo maculopathy present inferotemporal to foveal center (white arrow). (b) Optical coherence tomography scan of the left eye showing neurosensory detachment subfoveal and in parafoveal area temporally (white arrows)
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On further probing the patient about the medications used, it was found that the patient had been taking oral tadalafil (5 mg) for erectile dysfunction off and on. He had last taken the medicine 10 days before the onset of ocular symptoms. The patient also told us that over the past 3 weeks, he felt that his vision was slightly improving. No active intervention was planned at this stage and the patient was asked to avoid oral tadalafil. The patient came back for a review 1 month after the initial presentation. The patient reported marked improvement of vision in LE. BCVA in LE had improved to 20/20, N6. Fundus examination and OCT scan of LE showed complete resolution of neurosensory detachment [Figure 2]. Subtle outer retinal thinning could be seen in the area of TM. The patient was asked to avoid oral tadalafil and asked to review at periodic intervals. | Figure 2: (a) Color fundus photograph of the left eye 1 month following presentation showing complete resolution of neurosensory detachment. (b) Optical coherence tomography scan of the left eye 1 month following presentation showing complete resolution of neurosensory detachment; subtle outer retinal defects located at the site of torpedo lesion (white arrow)
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| Discussion | | |
TM is a rare congenital, usually unilateral, torpedo-shaped hypopigmented lesion which is noted temporal to the fovea.[1] The lesion usually does not involve the fovea and the nasal margin of the lesion usually disappears within one disc diameter of the fovea. Two essential features of the lesion are torpedo-shaped and being temporal to the macula. In our case too, the lesion was present in the temporal location and was torpedo-shaped. OCT findings of the lesion include an optically clear space between the neurosensory retina and retinal pigment epithelium referred to as neurosensory detachment.[4] Other OCT findings reported are mild disorganization of the outer and inner retina.[5] Similar mild disorganization of the outer retina was noted in my case. Vision is usually not affected in TM. If affected, it is usually due to associated disorder. In our case, the vision was affected due to the development of CSC and not TM.
PDE5 inhibitors such as tadalafil are routinely being prescribed to treat erectile dysfunction. These inhibitors modify the action of PDE5 on retinal and choroidal circulation. CSC has been reported following oral tadalafil intake.[2] Neurosensory detachment tends to resolve following stoppage of the drug.[2] In our case, the patient developed CSC 10 days after taking the drug and there was a prompt resolution of subretinal fluid after stopping the drug. The patient had been taking the drug as required in the past. There was no history of loss of vision after tadalafil intake in the past. It is hard to attribute the present episode of vision loss to tadalafil intake. A positive challenge and rechallenge test would have been ideal to prove a causal relationship but could not be done in our case due to ethical considerations.
Sanjay et al.[3] have reported CSC in a COVID-19-positive patient. However, they attributed the CSC to the systemic steroids used to treat the case. Systemic steroids were not used in our case. Psychological stress is a risk factor as well as a consequence of CSC.[6],[7] The patient reported being overtly stressed out during his period of COVID-19 illness. This might have been another causative factor in our case. There are multiple risk factors associated with disease causality in our case. It is hard to pinpoint a single factor responsible for the disease. The association between TM and COVID-19 with CSC in our case seems more coincidental rather than causal.
| Conclusion | | |
CSC can be associated with multiple risk factors. This case is unique as multiple risk factors associated with causation were present in the same case. The recent COVID-19 pandemic has led to increased stress among affected patients. Physicians and ophthalmologists need to be aware of CSC developing following COVID-19 and should educate the patients in seeking referral if they develop visual symptoms following recovery.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Panigrahi PK, Minj A, Satapathy J. Torpedo maculopathy with multifocal central serous chorioretinopathy: A rare case report. Indian J Ophthalmol 2018;66:330-1.  [ PUBMED] [Full text] |
| 2. | Roy R, Panigrahi PK, Saurabh K, Das D, Lobo A. Central serous chorioretinopathy following oral tadalafil intake. Clin Exp Optom 2014;97:473-4. |
| 3. | Sanjay S, Gowda PB, Rao B, Mutalik D, Mahendradas P, Kawali A, et al. Old wine in a new bottle – Post COVID-19 infection, central serous chorioretinopathy and the steroids. J Ophthalmic Inflamm Infect 2021;11:14. |
| 4. | Su Y, Gurwood AS. Neurosensory retinal detachment secondary to torpedo maculopathy. Optometry 2010;81:405-7. |
| 5. | Sanabria MR, Coco RM, Sanchidrian M. Oct findings in torpedo maculopathy. Retin Cases Brief Rep 2008;2:109-11. |
| 6. | Lahousen T, Painold A, Luxenberger W, Schienle A, Kapfhammer HP, Ille R. Psychological factors associated with acute and chronic central serous chorioretinopathy. Nord J Psychiatry 2016;70:24-30. |
| 7. | Scarinci F, Ghiciuc CM, Patacchioli FR, Palmery M, Parravano M. Investigating the hypothesis of stress system dysregulation as a risk factor for central serous chorioretinopathy: A literature mini-review. Curr Eye Res 2019;44:583-9. |
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