| Objective:Functional adrenal tumor,including Cushing’s syndrome,primary aldosteronism and pheochromocytomas is associated with an increased risk of fundus changes.We aim to investigate anatomical and functional changes of retina and choroid,and evaluate their correlation with hormone level in patients with functional adrenal tumor.This research may give us a better understanding of the pathogenic mechanism of retinal and choroidal disease and provide more choices for the treatment of chorioretinopathy.Materials and Methods:The first part of this study was a cross-sectional study comparing Cushing’s syndrome,primary aldosteronism and pheochromocytomas patients with essential hypertension and healthy controls.All participants underwent Enhanced depth imaging optical coherence tomography(EDI-OCT)and optical coherence tomography angiography(OCTA)in the afternoon.All participants had fundus examination including the thickness of retina and choroid in different directions and level,the vessel density of retinal superficial capillary plexus and retinal deep capillary plexus,the flow signal of the choriocapillaris and choroidal large vessel.The OCTA images of the choroid were analyzed by Image J software.We analyzed the relationship between the fundus change and hormone level in patients with functional adrenal tumor.The second part of this study was a prospective study that included functional adrenal tumor patients treated by adrenalectomy.Cushing’s syndrome,primary aldosteronism and pheochromocytomas patients underwent a series of ophthalmologic examinations on the day before surgery and after the hormone level test was normal.The ophthalmologic examinations including visual acuity,retinal thickness and choroid thickness in different directions and level,the vessel density of retinal superficial capillary plexus and retinal deep capillary plexus,the flow signal of the choriocapillaris and choroidal large vessel.After the surgery of adrenalectomy,the hormone level of Cushing’s syndrome,primary aldosteronism and pheochromocytomas patients was evaluated by a urologist.We followed up with the patients after the hormone test was normal.The EDI-OCT and The OCTA images of the choroid were converted to binary images by Image J software,and the luminal and interstitial areas of the choroid were calculated.The relationship of hormone level and baseline information,and the fundus change was evaluated in patients with functional adrenal tumor.Results:Twenty-two patients(44 eyes)with Cushing’s syndrome,44 patients(86 eyes)with primary aldosteronism and 18 patients(36 eyes)with pheochromocytomas were included in this cross-sectional study.Thirteen patients(19 eyes)with essential hypertension and 13 healthy volunteers(25 eyes)were screened.Compared with essential hypertension(220.33±15.49μm,p=0.02)and healthy volunteers(237.17±11.47μm,p<0.001),Cushing’s syndrome(297.09±18.67μm)had significantly higher central choroidal thickness.Compared with essential hypertension(220.33±15.49μm,p<0.001)and healthy volunteers(237.17±11.47μm,p<0.001),primary aldosteronism(326.56±10.95μm)had significantly higher central choroidal thickness.Compared with essential hypertension(220.33±15.49μm,p<0.001)and healthy volunteers(237.17±11.47μm,p<0.001),pheochromocytomas(277.86±18.56μm)had significantly higher central choroidal thickness.Removing the confounding factors of axial length,the vessel density of choriocapillaris in Cushing’s syndrome was 57.54±4.56%,which is higher than the essential hypertension(53.33±3.24%,p=0.002).The flow signal of choroidal large vessel was66.55±6.12%,which is lower than healthy volunteers(69.22±2.05%,p=0.042).The flow area of choriocapillaris layer in primary aldosteronism was 1.934±0.205 mm~2,which is lower than healthy volunteers(2.034±0.176 mm~2,p=0.02).The vessel density of choriocapillaris in primary aldosteronism was 56.07±4.74%,which is higher than the essential hypertension(53.33±3.24%,p=0.014).The vessel density of choriocapillaris in pheochromocytomas was 56.24±5.04%,which is higher than the essential hypertension(53.68±1.03%,p=0.005).The flow signal of choroidal large vessel was greater than two control group without statistical significance.Retinal thickness measurements were lower in patients with Cushing’s syndrome,primary aldosteronism and pheochromocytomas than in the healthy control group.Choroidal thickness in Cushing’s syndrome were found to be correlated with disease duration and 24-hour urine-free cortisol.Choroidal thickness in primary aldosteronism were found to be correlated with plasma renin activity,angiotensinⅡ,cholesterol levels,blood sodium and potassium.Subfoveal retinal thickness in Cushing’s syndrome was significantly correlated with disease duration,the maximum area of cross-sectional CT and 24-hour urine-free cortisol.Subfoveal retinal thickness in primary aldosteronism was significantly correlated with 24-hour urine-free cortisol and potassium.Subfoveal retinal thickness in pheochromocytomas was significantly correlated with disease duration and serum cortisol at 8 a.m.In the prospective self-control study,we included 116 eyes of 58 patients of functional adrenal tumor underwent adrenoectomy,including Cushing’s syndrome(116 eyes of 58 patients),primary aldosteronism(56 eyes of 28 patients)and pheochromocytomas(22 eyes of 11 patients).Functional adrenal tumor patients had significantly greater central choroidal thickness before adrenoectomy than the central choroidal thickness after adrenoectomy(305.56±111.72μm and 250.63±99.36μm,p=0.004).The subfoveal retinal thickness in functional adrenal tumor patients was higher before adrenoectomy than after adrenoectomy(218.08±18.51μm and223.20±27.08μm,p<0.001).The total area of choroid before adrenoectomy was5150.423±733.726μm~2,which is higher than total area of choroid after adrenoectomy(4588.021±672.817μm~2,p<0.001).Before adrenoectomy,The average area of the luminal to choroidal was 3216.874±492.212μm~2,which is significantly higher than that after adrenoectomy(2886.238±489.016μm~2,p<0.001).The central retinal thickness in functional adrenal tumor patients was less before adrenoectomy than after adrenoectomy(218.08±18.51μm and 223.20±27.08μm,p<0.001),especially in the inferior part of fovea.Conclusion:Cushing’s syndrome patients with high cortisol,primary aldosteronism patients with high aldosterone levels,and pheochromocytoma patients with high catecholamine levels had significantly increased choroidal thickness and slightly reduced retinal thickness,compared with healthy group.The increase of hormone secreted by adrenal increased the volume of the choroid and the area of the choroidal vascular area,and dilated the choroidal vessels.The vessel density was lower in the high adrenal hormone state in analysis of choriocapillaris and choroidal large vessels,which may imply insufficient choroidal blood perfusion.Patients with high cortisol level,high aldosterone level,and high catecholamine level had a thicker choroid,larger choroidal volume and vascular area,and lower blood flow density in the choroid,compared to themselves with normal hormone levels after the surgery.It is suggested that the increase of hormones secreted by adrenal glands leads to the dilatation of choroidal vessels,the increase of choroidal volume.This finding may suggest the pathogenesis of chorioretinopathy.Last but not least,when patients with functional adrenal tumor had visual symptoms,doctors should recommend eye exam to avoid irreversible visual loss. |
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