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Journal of Postgraduate Medicine, Vol. 53, No. 1, January-March, 2007, pp. 80-81 Letters Progestogen and retinopathy due to stasis in the central retinal vein Osborne SF, Rotchford A St. Pauls Eye Unit, Royal Liverpool Hospital, Prescott St, Liverpool L7 8XP Code Number: jp07030 Sir, A 32-year-old lady presented with a one-day history of cloudy vision in her left eye on awakening. She was otherwise a healthy nonsmoker with no significant ophthalmic or medical history. She took no regular medication. However, on the previous morning she had taken 15 mg of Utovlan (norethisterone) as prescribed by her general practitioner in order to postpone menstruation for her wedding. On examination, visual acuity was 6/5 in both eyes and there was no afferent pupillary defect. Anterior segments and intraocular pressures were normal. Dilated fundoscopy revealed retinopathy due to stasis in the central retinal vein [Figure - 1], which was confirmed by fluorescein angiography [Figure - 2]. There was no abnormality in the right eye. Further investigations failed to identify any underlying risk factors. Blood pressure was 117/76 mmHg, pulse 72/min in sinus rhythm. Full blood count, plasma glucose, urea and electrolytes, serum immunoglobulin levels, hematocrit, erythrocyte sedimentation rate, C reactive protein, serum angiotensin converting enzyme, fasting lipid and homocysteine levels were all within their normal ranges. Antinuclear antibody, lupus anticoagulant and rheumatoid factor tests were negative. Factor V Leiden and Factor II (prothrombin) mutations were not detected and anti-phospholipid antibody and activated protein C resistance assays were within normal limits. She was prescribed 75 mg aspirin daily and her fundal appearance had returned to normal by six weeks, although the symptom of cloudy vision had not fully resolved after six months. An increased incidence of thrombo-embolic events is well-recognized for combined sex hormone preparations.[1] Combined oral contraceptives (COC), hormone replacement[1] and post-coital contraception[2] have all been linked to retinal vein occlusion. This effect is mainly attributable to the estrogen component, the role of progestogens in thrombogenesis is less conclusive but it appears that they too may contribute to thrombogenesis. The type of progestogen used in the COC modifies the vascular event risk.[1] Furthermore, synthetic progestogens have been recorded to cause endothelial disruption, platelet activation and clot formation. This effect is not seen with natural progestogens or estrogens.[3] A case of retinal arteriolar occlusion has been reported after high-dose progesterone only therapy.[4] To our knowledge this case represents the first report of retinopathy due to stasis in the central retinal vein in association with the use of progestogens in isolation. To assess the probability of Utovlan causing a retinopathy due to stasis in the central retinal vein the Naranjo algorithm was used. This scale suggests that there is a 'probable' probability that Utovlan caused this adverse reaction.[5] This episode was reported as an adverse drug reaction to the Committee on Safety of Medicines who have no other recorded cases. Extensive investigation failed to identify any alternative cause. The relatively high dose of progestogen necessary for the purpose of delaying menstruation compared with the level in the COC or progestogen only pill is notable. While it is possible that the association in this case may be coincidental rather than causative in nature, it would seem prudent to consider the risks of venous thrombosis before prescribing any sex hormone. References
Copyright 2007 - Journal of Postgraduate Medicine The following images related to this document are available:Photo images[jp07030f1.jpg] [jp07030f2.jpg] |
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