INTRODUCTION

Central serous chorioretinopathy (CSCR) is a common maculopathy that involves serous detachment of the neurosensory retina associated with focal lesions in the retinal pigment epithelium and with circulatory disturbances of choroidal vasculature⁽¹⁾. Although its etiopathogenesis is not fully understood, many precipitating factors have been revealed, including smoking, stress, pregnancy, hypercortisolemia, and inoculation. Stress and the type A personality trait are the best known risk factors. It has also been proposed that emotional conditions in combination with smoking can cause angiospasm⁽²⁾. In general, individuals with CSCR are otherwise healthy.

Fibromyalgia syndrome (FMS) is a condition characterized by chronic, diffuse musculoskeletal pain and tenderness^(3,4). It affects almost all races, ethnicities, socioeconomic classes, and age groups, including children. It is more common among woman; the female-to-male ratio is 9:1⁽³⁾. Its prevalence in developed countries has been reported as 0.5%-4%⁽⁵⁾. The incidence increases with age, and it is most frequently seen at 20-55 years⁽⁶⁾. A diagnosis of FMS is used for heterogeneous pathological conditions associated with pain, including anxiety disorder, depression, lethargy, sleep disorders, and gastrointestinal symptoms^(3,6). These may be due to the presence of psychological disorders concomitant with FMS; indeed, psychiatric symptoms are rather common and affect the course of the disease⁽⁷⁾. It has been reported that patients with FMS experience an increase in comorbid diseases, such as depression, anxiety, and bipolar disorder⁽⁷⁾. Some studies have reported disorders in personality traits in patients with FMS, supporting the idea that personality and mood disorders may predispose an individual to FMS^(8,9). Stress is an important risk factor for FMS⁽¹⁰⁾. In summary, it is known that depression and psychiatric disorders increase with FMS.

Typically, acute CSCR is a self-limiting process in which visual acuity recovers within 1 to 4 months after onset, with a few recognized visual sequelae coinciding with the reattachment of the neurosensory retina⁽¹¹⁾. However, its recurrence is common, with approximately 30%-50% of patients experiencing recurrence within one year⁽¹²⁾. Retinal pigment epithelium atrophy and changes in the neurosensory retina may develop in patients with frequent recurrences, or there may be chronic detachment of the neurosensory retina, resulting in permanent loss of visual functions such as visual acuity, color vision, and contrast sensitivity^(13-15). It is therefore important to prevent recurrence to protect ocular functions. All patients diagnosed with CSCR should be assessed for triggering and precipitating factors, which should then be modified⁽¹³⁾. FMS can accompany CSCR as these entities have similarities in etiopathogenesis (such as personality trait, stress, depression, and cortisol level). FMS and FMS-related psychiatric disorders accompanying CSCR may be involved in the recurrence of CSCR. In addition, the presence of acute stress-anxiety after a diagnosis of CSCR may play a role in the development of FMS. The aim of this prospective study was to investigate the frequency of FMS among patients with CSCR.

METHODS

RESULTS

The CSCR and control group were comparable regarding age, sex, and educational level (Table 1). The mean disease duration was 18.8 ± 16.6 months and the mean choroidal thickness was 400 ± 111 µm in the CSCR group, with 23 patients (28.4%) having acute CSCR. Table 2 presents the characteristics of the CSCR group. FMS was diagnosed in 35 patients (42.2%) from the CSCR group and in 21 individuals (10.4%) from the control group (p<0.001). In the CSCR group, 14 women (14/35, 40%) and 21 men (21/35, 60%) were diagnosed with FMS. The BDI and BAI scores, FMS criteria score, and FIQR scores were comparable between the patients and controls diagnosed with FMS (Table 3). Women constituted 40% of the patients with FMS and 8.3% of those without FMS. Familial stress and BDI and BAI scores were higher in the patients with FMS than in those without. Table 4 presents the characteristics of patients with or without FMS in the CSCR group. All of the controls with FMS and 94.3% of the patients FMS were older than 30 years. The duration of education was <8 years for 62.9% of the FMS patients in the CSCR group and 38.1% of the controls with FMS.

When independent risk factors for FMS prevalence were evaluated by logistic regression analysis, it was found that only the presence of familial stress was a significant risk factor for FMS, with an odds ratio of 11.553 (95% CI: 2.117-62.708, Table 5).

DISCUSSION

In this study, we found increased frequency of FMS in the patients with CSCR compared with the control group, as well as thicker subfoveal choroid. Although choroidal thickening in CSCR eyes has already been reported, to the best of our knowledge this is the first report to show that FMS frequency increased in both female and male patients with CSCR compared with the controls. In the CSCR group, familial stress and BDI and BAI scores were significantly higher in the patients with FMS than in those without, although logistic regression analysis showed the only significant factor associated with the presence of FMS was familial stress.

It has been shown that depression and anxiety disorders are increased in patients with FMS when compared with other conditions with chronic pain⁽⁷⁾. Several suggestions have been proposed to explain the frequent association of FMS with depression and anxiety disorders⁽⁸⁾. One hypothesis is that psychiatric disorders develop as a response to FMS. Conversely, another hypothesis advocates that psychiatric disorders can trigger FMS symptoms. A third hypothesis suggests shared mechanisms in the pathophysiology of FMS and the psychiatric disorders⁽²²⁾. For instance, prolonged stress causes the release of pro-inflammatory cytokines in brain, which, in turn, can predispose an individual to both psychiatric disorders and pain perception⁽²³⁾. In addition, it is possible that acute emotional alterations experienced after a diagnosis of CSCR could trigger FMS. In our study, BDI and BAI scores were higher in patients with CSCR with FMS than in those without. There is a need for further studies with a larger sample size to clarify the association between CSCR and FMS. However, our results indicate that patients with CSCR should be assessed for concomitant FMS. The recurrence of CSCR could be prevented by the treatment of concomitant FMS, which is important for the protection of ocular functions.

FMS is more common among women. In the USA, the prevalence of FMS has been reported as 3.4% among women and 0.5% among men⁽²⁴⁾. In our study, FMS was detected in 22.7% of women and 7.0% of men in the control group, which is a higher frequency than found in previous studies. This finding may be due to the selection of the control group from among hospital employees, who were all active workers and were at ages where peak FMS prevalence is observed. In the CSCR group, FMS was detected in 77.7% of the women and 32.3% of the men; this frequency was significantly higher than in the controls, and the difference between men and women was also statistically significant.

In previous studies, it has been reported that FMS prevalence increases with advancing age⁽²⁵⁾, with the likelihood of FMS lower in young adults than in middle-aged individuals. In our study, we found that FMS frequency did not change with age. However, all of the controls with FMS and 94.3% of the patients with FMS were older than 30 years.

In previous studies, FMS prevalence has been reported to be lower in single individuals^(5,24). However, we found that marital status did not affect FMS frequency in our study. In addition, education level was lower in patients with FMS than in those without, although this difference did not reach statistical significance. All potential parameters that could be associated with FMS frequency were assessed in logistic regression analysis, but only the presence of familial stress was found to be significantly associated with FMS frequency.

It is well known that depression and psychiatric disorders are increased by FMS. Stress is one of the most important factors implied in the pathogenesis of CSCR. Several recent studies have reported increased psychological distress in patients with CSCR in comparison to healthy controls⁽²⁶⁾. Conversely, stress may be experienced as a result of the CSCR symptoms, given that a sudden loss of visual acuity can cause a considerable degree of psychological distress⁽²⁶⁾. Stress may therefore contribute to an undesirable vicious circle in patients with CSCR, counteracting therapeutic efforts. A higher incidence of critical life events has been proposed as an important trigger in these patients⁽²⁷⁾.

FMS is important for both the identification of comorbid psychiatric conditions and for developing the CSCR treatment plan. It has been suggested that depression observed in patients with FMS has different characteristics from those in other individuals; for example, negative ideation, helplessness, and anxiety are more commonly seen in patients with FMS⁽²⁸⁾. It has also been reported that patients with FMS experience difficulty in recognizing self-emotions and coping with these emotions⁽²⁹⁾. A relationship between CSCR and the type A personality trait has also been identified. Individuals with this personality trait may have insufficient ability to cope with the distress.

The most common symptom in patients with FMS is pain, with fatigue, poorer quality of life, insomnia, cognitive problems, morning stiffness, depression, and anxiety also being common⁽¹⁰⁾. Pain is the most important of these for causing a poorer quality of life. Prolonged pain results in physical, psychosocial, and social problems; thus, psychosocial and behavioral interventions and education are as important as medical therapies⁽³⁰⁾. The successful management of FMS requires a multidisciplinary approach.

In conclusion, this is the first study to evaluate the prevalence of FMS in patients with CSCR. We found that FMS was more prevalent among patients with CSCR than in controls. The management of classic CSCR usually involves careful observation with risk factor modification. In most cases, a three-month period is sufficient to allow subretinal fluid to resolve spontaneously. Visual acuity typically returns to normal after a first episode. However, recurrent attacks lead to a progression to chronic CSCR and disrupted visual functions. It is therefore important to correct modifiable risk factors and to prevent recurrence in patients with CSCR. These patients should be assessed for the presence of FMS, and FMS should be taken into consideration when making a treatment plan. We consider the treatment of FMS to be important for reducing stress factors that play a role in the pathogenesis of CSCR. However, further studies are needed to clarify the association between FMS and CSCR.