Corticosteroids
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Decline in visual acuity in elderly patients?: 3 case reports Three elderly patients who had a history of visual loss or blurred vision and had received methylprednisolone, prednisone or topical corticosteroids developed central retinal vascular occlusions (CRAO) associated with acute retinal necrosis (ARN) and decline in visual acuity. A 66-year-old man, who had severe coronary artery disease (CAD), presented with a 6-day history of headaches and visual loss in his left eye and had received IV methylprednisolone 1g [Solumedrol] for possible giant cell arteritis. Two days later, he was referred to an eye clinic because of continued decline in visual acuity. In his left eye, visual acuity was reduced to bare hand motions. Further investigations, including fluorescein angiography, revealed combined CRAO and central retinal vein occlusion. Two days later, he returned with bare light perception vision. He underwent pars plana vitrectomy. Intraoperatively, retinal necrosis with haemorrhage was noted. He received aciclovir, followed by valaciclovir, and foscarnet. PCR findings of vitreous fluid were positive for varicella zoster virus (VZV). He later developed retinal detachment. At 9-month follow-up, he had no light perception in his left eye. A 64-year-old woman had presented with a 1-month history of blurred vision in her right eye, and had started treatment with oral prednisone 60 mg/day* [duration of treatment not stated] and cotrimoxazole [sulfamethoxazole/trimethoprim; Bactrim DS] for presumptive toxoplasmosis. Her vision loss progressed over the following month, and she was referred to an eye clinic. Findings from investigations, including fluorescein angiography, were consistent with a CRAO. PCR findings of vitreous fluid were positive for herpes simplex virus type 2. She received valaciclovir and foscarnet, but her vitreous haemorrhage worsened, and her visual acuity declined to light perception. She underwent pars plana vitrectomy, membrane peel, endolaser treatment and silicone oil instillation. Her vision improved slightly postoperatively, and she was stable at 9-month follow-up. An 87-year-old man with CAD had developed blurred vision and redness in his right eye and had received topical corticosteroids [no further details provided] for iritis. Two weeks later, he had developed severe visual loss, and a CRAO was diagnosed on ophthalmic examination. He underwent anterior chamber paracentesis and started receiving oral prednisone 60 mg/day. The visual acuity in his right eye initially improved slightly. Three weeks later, he was referred to an eye clinic because the visual acuity in his right eye had significantly declined. Further investigations, including fluorescein angiography, confirmed poor arterial perfusion, consistent with a CRAO. PCR findings of vitreous fluid were positive for VZV. He received valaciclovir, followed by valaciclovir, and foscarnet. At 6-month follow-up, his symptoms were unchanged. Author comment: "All 3 patients were also treated with systemic corticosteroids prior to present
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