臺灣博碩士論文加值系統

背景與研究目的:
中心性漿液性視網膜脈絡膜炎 (central serous chorioretinopathy, CSCR) 是一種常見的黃斑部病變，在疾病急性期時可見黃斑部視網膜下有積水並影響視覺功能。患有此疾病之眼睛能由不同的影像學檢查發現有脈絡膜血液循環的障礙。雖然中心性漿液性視網膜脈絡膜炎已經被發現與精神壓力及使用類固醇藥物有關，然而其流行病學尚未被完整研究，也少有在亞裔族群中的發生率調查。本研究之目的在於使用台灣健保資料庫來探討中心性漿液性視網膜脈絡膜炎之流行病學。在研究的第一個部分是調查與使用類固醇藥物無關(病因不明的)中心性漿液性視網膜脈絡膜炎的發生率與危險因子。第二個部分是研究口服類固醇藥物的族群裡中心性漿液性視網膜脈絡膜炎的發生率與危險因子。第三與第四部份則是探討中心性漿液性視網膜脈絡膜炎患者罹患血液循環疾病(缺血性中風與男性性功能障礙)的風險。
研究方法:
以台灣健保資料庫百萬人抽樣歸人檔為資料來源來進行本研究。
在第一部分關於病因不明之中心性漿液性視網膜脈絡膜炎的研究中，首次被診斷為中心性漿液性視網膜脈絡膜炎且之前無使用類固醇藥物紀錄者被認定為新發生病例，並據此來計算2001至2006年的年發生率。從未有中心性漿液性視網膜脈絡膜炎診斷者，依照年齡、性別及進入研究時間進行配對，隨機抽樣為對照組。使用條件邏輯式迴歸分析(conditional logistic regressions)來估計危險因子的勝算比(odds ratios)。
　在第二部分關於口服類固醇患者罹患中心性漿液性視網膜脈絡膜炎的研究中，採用巢狀病例對照組研究設計。屢次接受口服類固醇處方的成年人收案為研究世代，從中認定新診斷為中心性漿液性視網膜脈絡膜炎的個案並計算發生率。研究世代中不曾有過中心性漿液性視網膜脈絡膜炎診斷者，依照年齡、性別及進入研究時間來配對，隨機抽樣為對照組。比較病例組與對照組使用類固醇劑量與期間。使用卜以松迴歸(Poisson regressions)及條件邏輯式迴歸分析(conditional logistic regressions)來估計危險因子的勝算比。
　　在第三部分關於中心性漿液性視網膜脈絡膜炎與缺血性中風的相關性研究裡，先認定符合收案條件的中心性漿液性視網膜脈絡膜炎新個案。再從未有中心性漿液性視網膜脈絡膜炎診斷者，依照年齡、性別、月收入、地理分區及進入研究時間進行配對，隨機抽樣為對照組。使用Kaplan-Meier法進行存活分析，並在控制其他可能干擾因子後，以Cox比例風險迴歸(Cox proportional hazard regressions)來計算缺血性中風在病例組與對照組間的危險比例(hazard ratios )。　　
在第四部分關於中心性漿液性視網膜脈絡膜炎與男性性功能障礙的相關性研究裡，先認定符合收案條件的中心性漿液性視網膜脈絡膜炎男性新個案。再從未有中心性漿液性視網膜脈絡膜炎診斷的男性，依照年齡、月收入及進入研究時間配對，隨機抽樣為對照組。在控制其他可能干擾因子後，以Cox比例風險迴歸來計算對於臨床診斷的男性性功能障礙(包括器官源性與心理源性)在病例組與對照組間的危險比例(hazard ratios )。並使用Kaplan-Meier法進行存活分析。
研究結果:
在第一部分關於病因不明之中心性漿液性視網膜脈絡膜炎的研究中，2001至2006年的平均年發生率為0.21‰ (男性為0.27‰，女性為0.15‰ ；P < 0.001)。男女發生率比例為1.74。以年齡別來看，年發生率最高的組別是35歲至39歲(0.30‰)，接著是40歲至44歲(0.26‰)。在男性中，只有服用抗焦慮用藥與病因不明的中心性漿液性視網膜脈絡膜炎有統計學上有意義的相關，其勝算比為1.63，95% 信賴區間為1.09-2.44。在女性中，則沒有任何危險因子被發現。
　　在第二部分關於口服類固醇患者罹患中心性漿液性視網膜脈絡膜炎的研究中，其發生率密度為44.4 (95%信賴區間為39.5-49.3)每十萬人年。多變項卜以松迴歸顯示男性、年齡介35至44歲間有顯著較高的發生率。口服與靜脈注射類固醇的治療劑量中位數與平均治療期間在病例組與對照組之間沒有統計學上的差異。在控制其他干擾因子後，目前服用口服類固醇被發現與發生中心性漿液性視網膜脈絡膜炎有顯著相關，其勝算比為2.40，95% 信賴區間為1.49-3.89。平均每日劑量較高的患者有較多的可能性其發病的潛伏期較短(P for lineal trend <0.001)。
在第三部分關於中心性漿液性視網膜脈絡膜炎與缺血性中風的相關性研究裡，病例組(n=1814)中有45位患者(2.5%)，對照組(n=9648)中有157位 (1.6%)在追蹤平均達3.9年的過程中被診斷有缺血性中風。中心性漿液性視網膜脈絡膜炎患者較對照組有顯著較高的缺血性中風的發生率(p = 0.003)。經過控制年齡、性別與其他慢性共病病史後，中心性漿液性視網膜脈絡膜炎患者之後被診斷為缺血性中風的危險比例達1.56 (95%信賴區間為1.11至2.18)。
在第四部分關於中心性漿液性視網膜脈絡膜炎與男性性功能障礙的相關性研究裡，病例組(n=1220)中有25位患者(2.0%)，對照組(n=10870)中有103位 (0.9%)在追蹤平均達4.3年的過程中在臨床上被診斷有性功能障礙。中心性漿液性視網膜脈絡膜炎患者較對照組有顯著較高的缺血性中風的發生率(p < 0.001)。經過控制年齡、地理分區、其他慢性共病病史與用藥史後，相較於對照組，中心性漿液性視網膜脈絡膜炎男性患者之後在臨床上被診斷為性功能障礙的危險比例達2.22 (95%信賴區間為1.42至3.46)。若將性功能障礙分為器官源性與心理源性，則危險比例分別為2.14 (95%信賴區間為1.34至3.44)及3.83 (95%信賴區間為1.47至10.01)。
結論:
相較於文獻中的資料，本研究的前半段發現中心性漿液性視網膜脈絡膜炎在華裔為主的族群中的發生率高於白人為主的族群。男性、中年、目前有使用口服類固醇藥物是中心性漿液性視網膜脈絡膜病變的危險因子。類固醇治療的劑量與期間與發生中心性漿液性視網膜脈絡膜炎的風險無關。服用抗焦慮藥物只有在男性之中才與病因不明的(與類固醇無關的)中心性漿液性視網膜脈絡膜炎有顯著相關。
本研究的後半段發現中心性漿液性視網膜脈絡膜炎與一些血液循環的疾病有相關。中心性漿液性視網膜脈絡膜炎是之後被診斷為缺血性中風與男性性功能障礙的危險因子

Background:
Central serous chorioretinopathy (CSCR) is a common maculopathy characterized by serous detachment of neurosensory retina in the acute phase. Circulatory disturbance in the choroids of the CSCR eyes can be observed with the different image techniques. Though CSCR has been reported to be associated with psychological stress and exposure to exogenous corticosteroids, the epidemiology of CSCR has not been systemically surveyed and the data about CSCR incidence is rare in an Asian population. The purpose of this serial studies is to investigate the epidemiology of CSCR using the Taiwan National Health Insurance Research Database (NHIRD). The first study focused on the incidence and risk factors for corticosteroid-unrelated (idiopathic) CSCR. The second study aimed to investigate the incidence and risk factors for CSCR in adults using oral corticosteroids. The last two studies explored the association of CSCR with other circulatory disorders: erectile dysfunction in males and ischemic strokes.
Methods:
These nationwide population-based studies were based on data obtained from the 1,000,000 beneficiaries sampling files of Taiwan NHIRD.
In the first study about idiopathic CSCR, we identified newly diagnosed CSCR patients, with no history of corticosteroid prescription, as incident cases of idiopathic CSCR and calculated the annual incidence from 2001 to 2006. Subjects without CSCR diagnosis, matched for age, gender and the time of enrollment, were randomly selected as the control group. Conditional logistic regression was used to estimate the odds ratios (ORs) for potential risk factors of idiopathic CSCR.
In the second study about CSCR in oral corticosteroids users, we used the nested case-control study design. Adults who were repetitively prescribed oral corticosteroids were included as the study cohort. Of those, we identified newly diagnosed CSCR cases and calculated the CSCR incidence. Subjects matched for age, gender and the enrollment time were randomly selected as the controls. Corticosteroids use was compared between the cases and controls. Poisson and conditional logistic regressions were used to analyze the potential risk factors for CSCR.
In the third study about the association between CSCR and ischemic stroke, we identified eligible cases with incident CSCR. Using stratified random sampling, enrollees who had no history of CSCR and matched with the study subjects in terms of sex, age, monthly income, geographic location and time of enrollment were selected as the control group. Stroke-free survival analysis was assessed using a Kaplan-Meier method. Cox proportional hazard regressions were performed to calculate the hazard ratios (HR) of ischemic stroke for the 2 groups after adjusting for possible confounding variables.
In the fourth study about the association between CSCR and erectile dysfunction in males, we identified eligible cases with incident CSCR. Males who had no history of CSCR and matched for age, monthly income and time of enrollment were randomly selected as the control group. Cox proportional hazard regressions were performed to calculate the hazard ratios of clinically diagnosed erectile dysfunction (including organic origin and/or psychogenic origin) for the two groups. Erectile dysfunction-free survival analysis was assessed using a Kaplan-Meier method.
Results:
In the first study about idiopathic CSCR, the mean annual incidence was 0.21‰ between 2001 and 2006 (0.27‰ for males, and 0.15‰ for females; P < 0.001), with a male/female ratio of 1.74. The peak incidence was in the 35- to 39-year-old age group (0.30‰), followed by the 40- to 44-year-old age group (0.26‰). Only exposure to anti-anxiety drugs (OR, 1.63; 95% confidence interval [CI], 1.09-2.44) was found to be independently associated with idiopathic CSCR among males. No risk factors of idiopathic CSCR were found for females.
In the second study about CSCR in oral corticosteroids users, the incidence rate of CSCR was 44.4 (95% CI, 39.5-49.3) cases per 100 000 person-years. Multivariate Poisson regression showed that male patients and those aged 35 to 44 years had significantly higher incidence rates of CSCR. There were no differences in either median dosage or mean duration of systemic corticosteroid treatment between the cases and controls. After adjusting for other confounders, current use of oral corticosteroids was found to be significantly associated with the risk of CSCR (OR = 2.40; 95% CI, 1.49-3.89). CSCR patients with higher average daily dosages were more likely to have shorter latency period (P for lineal trend <0.001).
In the third study about the association between CSCR and ischemic stroke, 45 patients (2.5%) from the CSCR cohort (n=1814) and 157 patients (1.6%) from the control group (n=9648) developed ischemic stroke during a mean follow-up period of 3.9 years. CSCR patients had a significantly higher incidence of ischemic stroke than those without a diagnosis of CSCR (p = 0.003). After adjusting for age, sex and chronic comorbidities at baseline, CSCR patients were found to have a 1.56-fold (95% CI, 1.11– 2.18) risk of a subsequent ischemic stroke than the matched controls.
In the fourth study about the association between CSCR and erectile dysfunction in males, 25 patients (2.0%) from the CSCR cohort (n=1220) and 103 (0.9%) from the control group (n=10870) were diagnosed erectile dysfunction clinically during a mean observation period of 4.3 years. CSCR patients had a significantly higher incidence of erectile dysfunction diagnosis than those without CSCR (P <0.001). After adjusting for age, geographic location, chronic comorbidities, and medication habits, CSCR patients were found to have a 2.22-fold (95% CI, 1.42 – 3.46) higher hazard ratio of a subsequent erectile dysfunction diagnosis than the matched controls. The adjusted hazard ratios for organic and psychogenic erectile dysfunction were 2.14 (95% CI: 1.34 – 3.44) and 3.83 (95% CI: 1.47 – 10.01), respectively.
Conclusions:
The present study provides nationwide, population-based data on the incidence of CSCR in Taiwan. Compared to the published literature, the incidence of CSCR seems higher in the Chinese-ethnicity population than in the predominant Caucasian one. Male gender, middle age, and current use of corticosteroids were shown to be the significant risk factors for CSCR. We also found that the dosage and duration of corticosteroid treatment were not associated with the risk for CSCR. However, exposure to anti-anxiety drugs was significantly associated with idiopathic (corticosteroid-unrelated) CSCR among males only.
In the last two studies, CSCR has been proven to be associated with the future development of some circulatory disorders. CSCR is an independent indicator for the increased risk of subsequent ischemic stroke development and the clinically diagnosed erectile dysfunction in males.

Chinese Abstract …..…………………………………………...…………… i
English Abstract ……..………..………………………………...………….. v
Table of Contents …....…………………………………………………….. ix
List of Tables …....…………………………………...…………...………….xi
List of Figures…....…………………………………...…………………..…xiii
Chapter 1: Introduction …….………………………………………...….….1
1.1 Background ...…………………………………...………..…..2
1.2 Objectives ...………………...…………………...…….….…..4
Chapter 2: Literature Review …………………..…………..………………5
2.1 Clinical Manifestations and Diagnosis...……...……….……6
2.2 Pathophysiology ……....………...……………...……….…...9
2.3 Risk Factors …………....……….……………...………..…..13
2.4 Steroids and Central Serous Chorioretinopathy ...……….15
2.5 National Health Insurance Research Database ……..…..18
Chapter 3: Epidemiology of Idiopathic Central Serous Chorioretinopathy……………………………………………………………22
3.1 Introduction ...……………......…………………...………….23
3.2 Methods ……………………..…………………...…………..24
3.3 Results ………………………………………………………..27
3.4 Discussions …………………………………………………..37
Chapter 4: Risk of Central Serous Chorioretinopathy among Oral Corticosteroids Users ……………………..……………………..………...42
4.1 Introduction ...…………………..………………...………….43
4.2 Methods ……………………..….………………...………….44
4.3 Results ………………………………………………………..47
4.4 Discussions …………………………………………………..54
Chapter 5: Risk of Ischemic Stroke and among Patients with Central Serous Chorioretinopathy…….........................................……………...58
5.1 Introduction ...……………………......…………...………….59
5.2 Methods ……………………..…..……………...……………60
5.3 Results ...…………………………..……………...………….63
5.4 Discussions …………………..………………...……………69
Chapter 6: Risk of Erectile Dysfunction among Male Patients with Central Serous Chorioretinopathy ………..……………..………………..74
6.1 Introduction ...……………………......…………...………….75
6.2 Methods ……………………..…..……………...……………76
6.3 Results ...………………………………………...……………79
6.4 Discussions ……………………………………...…………...84
Chapter 7: Conclusions .…………………..……………..………………...89
References ...………………….…………………...………………………..92
Appendix: Published Papers……………………………………………...105

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