Secondary Stress Induced Central Serous Chorioretinopathy in Bamako: Report of Two Cases

Introduction: Idiopathic central serous chorioretinopathy (ICSC) is characterized by the buildup of fluid leading to circumscribed elevation of the retina within the posterior pole. This condition affects young people between the ages of 20 - 50 years. The disease is seen predominantly in men as compared to women. We report the cases of two (02) patients received in consultation at IOTA-Teaching Hospital between July 2019 and February 2020. Case Presentation: We report two cases of Idiopathic stress central serous chorioretinopathy. The first case is a 37-year-old man that we received in consultation for visual acuity decrease from a sudden installation for 1 hour. The clinical and paraclinical arguments permitted us to retain the diagnosis of Idiopathic stress central serous chorioretinopathy. The patient benefited from laser treatment and the clinical evolution was good. The second case is a 42-year-old man, who consulted for a sudden reduction of visual acuity that had been evolving for 3 weeks. The clinical and paraclinical contexts were in favour of the diagnosis of Idiopathic stress central serous chorioretinopathy. The patient was treated with spironolactone. The clinical evolution was fa-vourable. Conclusion: Our study confirms the existence of central serous chorioretinopathy (CSC) in Black African patients. Studies show the connec-tion between CSC and stress.


Introduction
Von Graefe, in 1866, was the first to describe a disease of the macula with recur- rent serous detachment and to name it recurrent central retinitis [1]. In 1945, Bennet Klein and Maumenee were the first to postulate that the subretinal fluid was derived from choriocapillaris, through the retinal pigment epithelium (RPE) [2] [3]. Gass and et al, in 1966, provided the classic description of the pathogenesis and clinical features of this condition and term of Idiopathic Central Serous Choroidopathy [4]. Later, the name Central Serous Chorioretinopathy is now accepted because the disease involves both the choroid and retina [5]. The Central Serous Chorioretinopathy is the collection of fluid between the RPE and the neurosensory retina [5]. There are two forms: acute and chronic [5]. The Central Serous Chorioretinopathy is characterized by a functional macular and clinical syndrome of serous retinal detachment, most commonly found in the macular region. Its diagnosis is based on angiographic criteria. The literature reported many risk factors of Central Serous Chorioretinopathy such as: local or systemic corticosteroid therapy, Cushing's disease and pregnancy by increased production of endogenous cortisol; other risk factors independent are Type A personality, antipsychotic medication, and psychological stress [6] [7].
In Europe, in 2018, the Central Serous Chorioretinopathy was the 4th most common retinal pathology after age-related macular degeneration, diabetic retinopathy, and occlusion of the retinal vein branch. Its incidence is estimated at 9.9 cases per 100,000 men and 1.7 cases per 100,000 women [8].
In Africa, the prevalence of Central Serous Chorioretinopathy is unknown and the published data are disparate [9] [10] [11] [12] [13]. The first description of secondary stress central serous chorioretinopathy goes to the Togolese authors. The rarity of reports cases of the Secondary Stress Central Serous Chorioretinopathy leads to the realization of this study whose purpose is to contribute to the description of Stress-induced Central Serous Chorioretinopathy.

Methodology
This is the report of two clinical cases received in the IOTA-Teaching Hospital consultation boxes between June 2019 and February 2020. All methods were approved by our institution's research committee. History, physical examination, and imaging data were obtained from electronic medical records of the patient in question.

Case 1
This is a 37-year-old male admitted for Sudden Visual Acuity Decrease for 1 hour ago. The analysis of his pathological antecedents has no found the notion of local or systemic corticosteroid therapy and antipsychotic medications. At presentation, in the right eye, the distant visual acuity was 1/10 Snellen line. On fundus examination, there was a serous neuroretinal detachment of macular localization measuring about 4 papillary diameters (Figure 1(a)). In the left eye, distant visual acuity was 10/10 Snellen line, the anterior sergment and fundus examinations were found to be normal (Figure 1(b)). In the right eye, Fluorescein angiography showed "leakage points" like "vapor jet" in the form of abnormal hyperfluorescence with increasing crescendo intensity and localized in serous retinal detachment. Subsequently (Figure 2(a) and Figure 2(b)), the etiological investigation revealed in our patient a state of extreme anguish related to the survival of his only child admitted to pediatric intensive care with respiratory assistance for 1 week.
The discomfort resulting from the decrease in visual acuity motivated the therapeutic option by photo coagulation by an argon laser at the extrafoveal leakage point with impacts of 200 microns, for a period of 100 milliseconds and a power of 100 milliwatts. At one week, distant visual acuity was up to 5/10 Snellen line in the right eye. At the 3rd week, there is no serous retinal detachment at the fundus examination of the right eye and angiography control showed no recurrence, no new thrust, no long-term complication, with a distant visual acuity of 10/10 Snellen line in both eyes then referred to the psychologist for psychological support

Case 2
This is a 42-year-old male business agent of the orange company, very energetic and hyperactive, referred from the MOPTI reference health center for the investigation of Sudden Visual Acuity Decrease evolving for 3 weeks without improvement, associated with an important gene, metamorphopsia, and central scotomas. MOPTI IS one of the conflict region of northern Mali, occupied by terrorism "Jihadists". The analysis of his pathological antecedents has no found the notion of local or systemic corticosteroïde therapy and the antipsychotic medications. At presentation, in the right eye, the distant visual acuity was 3/10. On fundus examination, there was a serous neuroretinal detachment of macular localization measuring about 4 papillary diameters (Figure 3(a)). In the left eye, distant visual acuity was 10/10 Snellen line, the anterior segment and fundus examinations were found to be normal (Figure 3(b)). In the right eye, Fluorescein angiography did not show the «leakage points» ( Figure 4). Contrary, the image of radial Macula OCT confirms the diagnosis by showing the serous detachment of the neuroretina. Subsequently (Figure 5), the etiological investigation with the participation of the psychologist revealed in our patient the type-A personality associated with a state of extreme anxiety and emotion due to the uncertainty about his professional activities. He was put on spironolactone tablet 50 mg at a rate of 1 tablet per day for 1 month then referred to the psychologist for psychological support. The resorption of the subretinal liquid was slow and progressive to be complete by the 2nd month of treatment.

Discussion
The  [11], that race cannot be considered a significant predictor factor of Idiopathic Central Serous Chorioretinopathy.     [14].
As for functional signs, the sudden decrease of visual acuity and metamorphosis were present in our patients. Like the corroboree the literature data [5]- [14]. and certain personality traits such as aggression have been shown to be associated with increased levels of both catecholamines and corticosteroids [18].

Conclusion
There is no longer any doubt that the Central Serous Chorioretinopathy is also found in African black and its etiology is largely dominated by stress and anxiety, especially related to the military-political and economic crises that are shaking the African continent today. Given the relevance of the subject, it would be desirable to carry out a meta-analysis of all aspects of this affection on the African continent, at least in the melanoderm.