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LETTER TO EDITOR

Major ocular complications after organ transplantation

Vedantham, V

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Indian Journal of Ophthalmology: Oct–Dec 2004 - Volume 52 - Issue 4 - p 343-345
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Dear Editor,

I read with interest the editorial by Lanzetta et al[1] on “Major ocular complications after organ transplantation”. The authors deserve to be commended for their concise yet comprehensive review of the subject. There are certain points that I would like to add in this regard.

Although it is true that central serous chorioretino-pathy (CSCR) described after transplantation is associated with the use of systemic corticosteroids and cyclosporine, a reverse condition could also occur, necessitating treatment with corticosteroids for relief. Cheng et al have described this paradoxical condition in a case report of bilateral conjunctival chemosis and CSCR in a patient with graft - versus - host disease (GVH) following bone marrow transplantation.[2] CSCR was postulated to be due to choroidal infiltrates that occur in GVH causing choroidal hyperpermeability leading to CSCR. Treatment with high dose systemic corticosteroids and cyclosporine led to the resolution of both chemosis and CSCR. It is therefore of paramount importance to rule out GVH diseases causing CSCR in a post-transplant patient.

The above fact assumes greater importance in view of the interesting, recently postulated association between CSCR and Helicobacter pylori (HP) infection, suggesting the role of HP-dependent antigens expressed on the bacterium and homologous host protein like those of the endothelial cells, as well in the pathology of CSCR.[3] In fact, CSCR is secondary to generalised involvement of choroidal microcircularion (with localised vasoconstriction and impaired fibrinolysis) due to an immune process, corticosteroids should be beneficial. But administration of steroids in an otherwise uncomplicated CSCR does lead to worsening with subretinal fibrosis and scarring. This is illustrated in the fundus fluorescein angiography and optical coherence tomography pictures [Figure - 1A,B,C,D and 2A, and B]) of a 30-year-old patient who presented to us after receiving corticosteroids elsewhere as a treatment for CSCR in the right eye. The visual acuity in both eyes were hand movements, and dense subretinal bands under the foveae were seen in both the eyes.

F1-21
Figure
F2-21
Figure

CSCR seems to have a malignant course in men, especially in those taking exogenous corticosteroids or suffering from endogenous hypercortisolism as in Cushing’s diseases, characterised by subretinal fibrin that leads to fibrosis and scarring. In contrast, CSCR occurring in third trimester of pregnancy in women has abenign course despite the subretinal fibrin and resolves spontaneously after delivery.[4] This is probably due to the differences in the mean cortisol responses to stress between the genders (1.5 to 2 fold higher response in men compared to women). Indeed, much remains to be discovered in the fragile relationship between corticosteroids and CSCR.

In addition to CSCR occurring after retinal transplant, patients on haemodialysis and chronic renal failure (CRF) can also develop CSCR even prior to transplant. This has been postulated to occur due to hypothalamic pituitary dysfunction with the resultant elevated serum cortisol levels.[5]

Finally, I would like to add infection as another important retinal complication of transplantations to the others. This occurs presumably due to immunosuppression.[6]

Source of Support:

None

Conflict of Interest:

None

1. Lanzetta P, Monaco P. Major ocular complications after organ transplantation Indian J Ophthalmol. 2004;52:95–97
2. Cheng LL, Kwok AK, Wat NM, Neoh EL, Jon HC, Lam DS. Graft-vs-host-disease-associated conjunctival chemosis and central serous chorioretinopathy after bone marrow transplant Am J Ophthalmol. 2002;134:293–95
3. Giusti C. Association of Helicobacter pylori withcentral serous chorioretinopathy:hypotheses regarding pathogenesis Med Hypotheses. 2004;63:524–27
4. Quillen DA, Gass JDM, Brod RD, Gardner TW, Blankenship GW, Gottlieb JL. Central serous chorioretinopathy in women Ophthalmology. 1996;103:72–79
5. Gass JDM. Bullous retinal detachment and multiple retinal pigment epithelial detachments in patients receiving hemodialysis Graefes'Arch Clin Exp Ophthalmol. 1992;230:454–58
6. Moon SJ, Mieler WF. Retinal complications of bone marrow and solid organ transplantation Curr Opin Ophthalmol. 2003;14:433–42
© 2004 Indian Journal of Ophthalmology | Published by Wolters Kluwer – Medknow