Central serous chorioretinopathy (CSC) is a well-recognized retinal disease. First described by Albrecht von Graefe in 1866, it is characterized by idiopathic focal detachments of the neurosensory retina or the retinal pigment epithelium (RPE) in the macula. Often the fluid resolves spontaneously. In chronic or recurrent cases, treatment options consist of focal laser photocoagulation or photodynamic therapy, with more recent modalities including micropulse laser and anti–vascular endothelial growth factor agents.
A number of conditions are associated with CSC, including Helicobacter pylori infection, organ transplantation, autoimmune disorders, and medications such as psychotropics and sympathomimetics. Corticosteroid use is the most prevalent drug-related risk factor. Other factors include emotional stress and type A personality. In this case report, we describe a man with CSC who had no known risk factors and whose medical history was significant only for an unusual health supplement, deer antler spray.
A 41-year-old white man presented with blurry vision and darkening of vision in his left eye for the past 2 months. He had no significant ocular or medical history and did not use any medications; he denied tobacco and alcohol use. On examination, best corrected visual acuity was 20/20 in the right eye and 20/25 in the left. Pupils, applanation tonometry, confrontation visual fields, Ishihara color plates, and anterior examination findings were normal. Amsler testing results were normal in the right eye but revealed an area of central distortion in the left eye.
On fundus examination, the right eye showed pigmentary changes along with small yellowish-white dots in the central macula. The left eye showed a round, discrete elevation in the macula with similar dots (Figure 1). Spectral-domain optical coherence tomography (SD-OCT) showed a retinal pigment epithelial detachment (PED) in the right eye and subretinal fluid at the fovea in the left eye. Fluorescein angiogram of the right eye revealed a small area of leakage consistent with PED. In the left eye, multiple foci of leakage were seen surrounding the fovea (Figure 2).
Focal elevation and small white dots in macula.
Leakage surrounding fovea.
Central serous chorioretinopathy was diagnosed. The patient denied stressors and steroid use. However, he stated that he had begun using an athletic supplement known as “deer antler spray” on a daily basis, approximately 1 month prior to symptom onset. The deer antler spray was discontinued. Two weeks later, both eyes showed significant improvement on SD-OCT. At 2 months, the subretinal fluid had resolved (Figure 3) and there remained only one small PED in each eye. The patient was asymptomatic, with best corrected visual acuity of 20/20 in both eyes.
SD-OCT of left eye at initial presentation (above) and 2 months later (below).
In this report, we present a patient with CSC who was taking an over-the-counter athletic supplement, deer antler spray. Deer antler has long been used in traditional Chinese medicine and is touted to possess regenerative properties. More recently, it has come to attention in the professional athletic community. Deer antler supplements are prepared by grinding the antlers of young deer into a powder for administration in capsule form or by creating a liquid version that is sprayed into the nose or under the tongue. Young deer are chosen for their rapidly growing antlers, thought to contain anabolic substances. Deer antler supplement is now used by some as an alternative to anabolic steroids because it is supposed to be undetectable in drug tests.
Deer antler does in fact contain insulin-like growth factor 1 (IGF-1).1 IGF-1 is related to growth hormone and has similar systemwide effects. It has been implicated in angiogenesis in proliferative diabetic retinopathy and retinopathy of prematurity.2,3 A search of the current literature on MedLine shows no reports linking IGF-1 to CSC. One study showed that elevated intraocular levels of IGF-1 upregulate adhesion molecules and interrupt tight junctions, increasing vascular permeability and causing breakdown of the blood-retinal barrier.4 However, that study did not show a similar effect with elevated systemic levels of IGF-1. The growth factor also causes migration and proliferation of the RPE.5 This might be responsible for breaks in the RPE, allowing for accumulation of subretinal fluid.
Alternatively, IGF-1 may behave in the way of corticosteroids and catecholamines, acting on beta-adrenergic receptors.6 Upregulation of these receptors causes the release of second messengers such as cyclic adenosine monophosphate, predisposing to vascular permeability in the choroid.7 In fact, catecholamines have been shown to induce serous retinal detachments in animal models.8
It is unknown exactly how IGF-1 affects the choroidal circulation or whether commercially available deer antler supplements contain biologically active IGF-1. However, because deer antler supplement was the sole variable in our patient’s history whose use and subsequent cessation correlated with the timing of his symptoms, it merits consideration as a possible cause of CSC.
- Gu L, Mo E, Yang Z, et al. Expression and localization of insulin-like growth factor-I in four parts of the red deer antler. Growth Factors. 2007;24(4):264–279. doi:10.1080/08977190701773187 [CrossRef]
- Devi TS, Singh LP, Hosoya K, Terasaki T. GSK-3 /CREB axis mediates IGF-1-induced ECM/adhesion molecule expression, cell cycle progression and monolayer permeability in retinal capillary endothelial cells: Implications for diabetic retinopathy. Biochim Biophys Acta. 2011;1812(9):1080–1088. doi:10.1016/j.bbadis.2011.04.007 [CrossRef]
- Perez-Munuzuri A, Fernandez-Lorenzo JR, Couce-Pico ML, Blanco-Teijeiro MJ, Fraga-Bermúdez JM. Serum levels of IGF1 are a useful predictor of retinopathy of prematurity. Acta Paediatr. 2010;99(4):519–525. doi:10.1111/j.1651-2227.2009.01677.x [CrossRef]
- Haurigot V, Villacampa P, Ribera A, et al. Increased intraocular insulin-like growth factor-1 triggers blood-retinal barrier breakdown. J Biol Chem. 2009;284(34):22961–22969. doi:10.1074/jbc.M109.014787 [CrossRef]
- Spraul CW, Kaven C, Amann J, Lang GK, Lang GE. Effect of insulin-like growth factors 1 and 2, and glucose on the migration and proliferation of bovine retinal pigment epithelial cells in vitro. Ophthalmic Res. 2000;32(5):244–248. doi:10.1159/000055621 [CrossRef]
- Karoor V, Malbon CC. Insulin-like growth factor receptor-1 stimulates phosphorylation of the 2-adrenergic receptor in vivo on sites distinct from those phosphorylated in response to insulin. J Biol Chem. 1996;271(46):29347–29352. doi:10.1074/jbc.271.46.29347 [CrossRef]
- Sakaue M, Hoffman BB. Glucocorticoids induce transcription and expression of the 1 adrenergic receptor gene in DTTI MF-2 smooth muscle cells. J Clin Invest. 1991;88(2):385–389. doi:10.1172/JCI115315 [CrossRef]
- Miki T, Sunada I, Higaki T. Studies on chorioretinitis induced in rabbits by stress (repeated administration of epinephrine). Nippon Ganka Gakkai Zasshi. 1972;76(9):1037–1045.