Oral Mineralocorticoid-Receptor Antagonists: Real-Life Experience in Clinical Subtypes of Nonresolving Central Serous Chorioretinopathy With Chronic Epitheliopathy

Abstract

Purpose: To evaluate the efficacy and safety of oral mineralocorticoid-receptor antagonist (MRa) therapy in three clinical presentations of nonresolving central serous chorioretinopathy (CSCR) with chronic epitheliopathy.

Methods: Retrospective case series of consecutive patients with nonresolving CSCR treated with oral eplerenone or spironolactone. Treatment criteria were: persistent CSCR with subretinal fluid (SRF) lasting longer than 4 months; recurrent CSCR with SRF lasting longer than 2 months; persistent CSCR (SRF ≥ 4 months) with fundus autofluorescence gravitational tracks. Outcomes at 1, 3, and 6 months were: foveal SRF height, central macular thickness (CMT), subfoveal choroidal thickness (SFCT), best-corrected visual acuity (BCVA), and occurrence of side effects.

Results: Among 54 eyes from 42 patients (mean age: 53 years), mean foveal SRF, CMT, and SFCT decreased significantly at 1, 3, and 6 months after treatment initiation. Mean BCVA improved significantly at 6 months. In the subgroup analysis, mean foveal SRF, CMT, and SFCT decreased significantly at 3 and 6 months in the persistent and recurrent groups. In persistent cases with tracks, a significant diminution of mean CMT and SFCT was achieved at 6 months. Treatment-related side effects were observed in 6 patients, prompting treatment discontinuation in one case.

Conclusion: Response to treatment was observed in the three subgroups. In persistent CSCR with tracks the response was delayed compared with persistent and recurrent cases, suggesting that longer treatment durations would be beneficial in patients with gravitational tracks of RPE alteration.

Translational relevance: The clinical response to oral MRa is consistent with the involvement of the mineralocorticoid pathway in CSCR pathogenesis.

Keywords: central serous chorioretinopathy; choroid; drug-related side effects and adverse reactions; mineralocorticoid-receptor antagonist; retinal pigment epithelium; spironolactone; treatment, epleronone.

Figure 1

Treatment scheme for mineralocorticoid-receptor antagonists in patients with nonresolving CSCR. K⁺, potassium plasma level monitoring; M1, month 1; M3, month 3; MR-a, mineralocorticoid-receptor antagonists; PDT, photodynamic therapy.

Figure 2

Profile of foveal subretinal fluid in 54 eyes with nonresolving CSCR treated by mineralocorticoid-receptor antagonists (A), and in three clinical CSCR subgroups: persistent (B), recurrent (C), and persistent with tracks (D). The areas of circular marks are proportional to the number of responders (red) and nonresponders (blue). *P < 0.05 compared with baseline values (Wilcoxon paired test), color-filled band: superior and inferior 95% confidence intervals.

Figure 3

Profile of central macular thickness in 54 eyes with nonresolving CSCR treated by mineralocorticoid-receptor antagonists (A), and in three clinical CSCR subgroups: persistent (B), recurrent (C), and persistent with tracks (D). The areas of circular marks are proportional to the number of responders (red) and nonresponders (blue). *P < 0.05 compared with baseline values (Wilcoxon paired test), color-filled band: superior and inferior 95% confidence intervals.

Figure 4

Profile of subfoveal choroidal thickness in 48 eyes with nonresolving CSCR treated by mineralocorticoid-receptor antagonists (A), and in three clinical CSCR subgroups: persistent (B), recurrent (C), and persistent with tracks (D). The areas of circular marks are proportional to the number of responders (red) and nonresponders (blue). *P < 0.05 compared with baseline values (Wilcoxon paired test), color-filled band: superior and inferior 95% confidence intervals.

Figure 5

Optical coherence tomography showing the response to treatment by oral mineralocorticoid-receptor antagonists in three eyes with nonresolving CSCR. (A–E) Eye with persistent CSCR for 4 months without improvement, showing a progressive decrease in subretinal fluid after introduction of oral spironolactone, with complete resolution at 3 months, absence of recurrence and reconstitution of the ellipsoid zone by 6 months. (F–J) Eye with recurrent CSCR without improvement after 4 months of observation, progressive resolution 1 and 3 months following the introduction of oral eplerenone, with stability at 6 months. (K–O) Eye with persistent CSCR with tracks and evidence of nonresolving subretinal fluid during 4 months. After initiation of oral eplerenone, subretinal fluid was still present at 1 and 3 months, but a delayed, complete resolution was observed at 6 months.

Figure 6

Profile of foveal subretinal fluid (A, B) and central macular thickness (C, D) in 54 eyes with nonresolving CSCR treated by mineralocorticoid-receptor antagonists, according to age at treatment introduction: less than or equal to 51 years (A, C) and greater than 51 years (B, D). The areas of circular marks are proportional to the number of responders (red) and nonresponders (blue). *P < 0.05 compared with baseline values (Wilcoxon paired test), color-filled band: superior and inferior 95% confidence intervals.