Central serous chorioretinopathy (CSCR) is a common cause of central visual loss in young males. It is characterized by metamorphopsia and dyschromatopsia, and generally involves submacular and/or subretinal pigment epithelial (RPE) fluid. While most cases of CSCR are idiopathic, several associated risk factors have been implicated: type A personality, emotional stress, and male gender [1]. Systemic steroid use has long been associated with CSCR development [2]. These 3 case reports demonstrate the development of CSCR in patients receiving steroid-containing homeopathic drugs.

Case 1

A forty-year old man complained of decreased vision in the left eye for two months. His medical history was remarkable for hemorrhoids, for which he was being treated with homeopathic drugs (Aesculus Hip Q and Hamamelis Virg Q). On ophthalmic examination, the visual acuity of the right eye was 20/20 and of the left eye was 20/40. The fundus examination revealed a shallow accumulation of submacular fluid in the left eye. Optical coherence tomography (OCT) (Figure 1a) scanning showed a serous detachment of the retina and fundus fluorescein angiography (FFA) (Figure 1b) showed focal leakage of dye at the level of the retinal pigment epithelium. A diagnosis of CSCR was made and the homeopathic treatment was discontinued. Over the next six weeks the CSCR resolved. The patient had no further recurrence over six months and the visual acuity remained 20/20 in both eyes.

Figure 1:

Case 2

A thirty-eight year old man complained of a central black spot in the vision of the right eye for 20 days. Three months earlier, he had started treatment for hemorrhoids with the homeopathic drugs (Nux-vomica 200, Hamemalis 200 and Collosonia 30). Ophthalmic examination revealed that the visual acuity of the right eye was 20/32 and of the left eye was 20/32. A shallow accumulation of submacular fluid was seen in the right eye. Imaging with OCT (Figure 1c) and FFA (Figure 1d) confirmed the diagnosis of CSCR and the homeopathic treatment was discontinued. Over the next four weeks the CSCR resolved. After five months the patient returned with similar complaints within five days after restarting the homeopathic medicines. Again the homeopathic medicines were discontinued and the patient improved. Over the next six months the patient was free from recurrences and the visual acuity remained 20/20 in both eyes.

Case 3

A thirty-five year old man presented with decreased vision in the right eye for seven days. The visual acuity in the right eye was 20/40 and in the left eye was 20/40. A shallow accumulation of subretinal fluid was seen. Imaging with OCT (Figure 1e) and FFA (Figure 1f) confirmed the diagnosis of CSCR. A medical history revealed that the patient had started homeopathic drugs (Nux-vomica 200 and Aloe soc 200) for hemorrhoids. He discontinued the drugs after the diagnosis was made and the CSCR resolved over two weeks. After two months, the patient restarted the same homeopathic drugs and developed a recurrence of the CSCR. The homeopathic medicines were again discontinued and symptoms improved. Six months later, the patient had no further recurrence, and had visual acuities of 20/20 in both eyes.

Homeopathy is a system of alternative medicine, originated in 1796 by Samuel Hahnemann and is based on the doctrine of similiasimilibuscurentur (“like cures like”). According to homeopathy, a substance that causes the symptoms of a disease in healthy people will cure that disease in sick people [3]. Some of the most commonly used homeopathic medicines for treating hemorrhoids include: Hamamelis Q, Aesculus, Collinsonia, Graphitis, Ratanhia, Aloe, Sulphur, NuxVomica, and silicea. Of these drugs, Aesculus bark contains additional compounds which include allantoin, sterols, leucocyanidin, leucodelphinidin, catechol tannins and alkanes [4]. Aesculus leaves also contain sitosterol, stigmasterol and campesterol. Aloevera contains amino acids, lipids, sterols (lupeol, campesterol, and ß-sitosterol), tannins, and enzymes [5]. The aqueous and hydroalcoholic extracts from Strychnos nux-vomica seeds contain steroids, alkaloids and glycosides [6].

According to the natural history of CSCR, 80-90% of eyes undergo spontaneous re-absorption of sub retinal fluid within 3-4 months and 40-50% experience one or more recurrences. High dose corticosteroids have been associated with exacerbations of CSCR. Our cases are interesting because all patients had been receiving steroid-containing compounds and 2 of the 3 recurred when re-challenged with the homeopathic medication. The doses of steroids in the medications taken by these patients were very low but the temporal relationship between the medication and CSCR recurrences raises the question of a causal association. Unfortunately the small number of cases in our series does not allow us to establish a definite relationship between homeopathic medications and CSCR. However, this warrants further investigation.

In the meantime, patients with CSCR should be asked specifically for homeopathic drug intake and physicians may wish to consider discontinuing any steroid-containing drugs.