A Rare Ocular Complication of Crohn’s Disease

2010

Question: A 43-year-old man with extensive Crohn's disease was referred with a 5-week history of diarrhea and mild abdominal pain. Blood results showed hemoglobin, 16.0 g/dL; mean corpuscular volume, 91.5fL; white blood count, 16.3 109/L; neutrophils, 13.3 109/L; platelet, 368 109/L, C-reactive protein, 9; and albumin, 41g/L. The Harvey–Bradshaw index was 9. He was commenced on 40 mg of oral prednisolone. He presented after a month with symptoms of right central blurred vision and micropsia. There were no signs of uveitis on examination. The patient was simply observed by the ophthalmologist. His ocular symptoms gradually resolved within 2 months of Crohn's disease remission. Figure A shows the eye photo in this patient. A subsequent flare up of his Crohn's disease was treated with 40 mg of prednisolone metasulphobenzoate (Predocol) in an attempt to minimize systemic corticosteroid exposure. Azathioprine was also initiated, but was discontinued within a few weeks owing to severe myalgia. Similar eye symptoms recurred after a month, but this time of a lesser severity.

What is the diagnosis?

Answer to the Clinical Challenges and Images in GI Question: Image 4: Central Serous Retinopathy
Central serous retinopathy (CSR) is characterized by fluid leakage and accumulation in the macula between the retinal pigment epithelium and the outer neurosensory retina. It can present with blurred vision, micropsia, central scotoma, metamorphopsia, or decreased color vision. Exogenous steroid therapy is one of the recognized causes of CSR although it has only reported in a handful of case reports in association with inflammatory bowel disease.1–3 Although unusual, an awareness of this complication is important to enable it to be differentiated from inflammatory ocular manifestations of Crohn’s disease so that alternative treatment to corticosteroid is sought. As this patient’s serous retinopathy was mild, it was treated conservatively with complete resolution of his symptoms after steroid cessation but, in a minority of patients, healing may only be partial. If the condition becomes chronic, laser photocoagulation therapy can be applied to contain retinal detachment. Figure B shows the patient’s ocular angiography in the acute phase and Figure C shows the optical coherence tomography scan in the recovery phase.

References

  1. Paspatis GA, Koutentakis P, Triantafyllou K, et al. Crohn’s disease complicated by central serous retinopathy. Dig Dis Sci 2001;46:2219 –2221.
  2. Knox DL, Schachat AP, Mustonen E. Primary, secondary, coincidental ocular complications of Crohn’s disease. Ophthalmology 1984;91:163–173.
  3. Schreiber JB, Lakhanpal V, Nasrallah SM. Crohn’s disease complicated by idiopathic central serous chorioretinopathy with bullous retinal detachment. Dig Dis Sci 1989;34:118 –122.