BLOG: Should we stop treating patients with eplerenone for central serous chorioretinopathy?
Central serous retinopathy occurs in middle-age adults, typically spontaneously, and is associated with accumulation of fluid below the retina. It can be commonly mistaken for age-related macular degeneration and lacks a unified treatment approach. The common treatment for acute central serous is observation. However, for central serous lasting longer than 4 months, the chronicity of disease can lead to photoreceptor loss and damage and ultimately decreased vision.
For the past 5 years, I have treated many patients with eplerenone for central serous with good results and reported my findings in multiple journals. Unfortunately, these were non-randomized cases series of patients, yet almost all patients responded over 90 days. So I was astonished when the VICI investigators released their results of a recent randomized study and found a very different outcome — that eplerenone had no benefit in central serous retinopathy (CSR), and in fact, the study investigators encouraged patients to tell their doctors about the lack of efficacy. That’s pretty strong language from any clinical trial.
Reviewing the paper, published in The Lancet, you can get a clearer understanding of why they saw the outcome they did. First, patients were assigned to eplerenone, and when their fluid improved, the eplerenone was discontinued. The hallmark of chronic CSR is just that — chronicity. So to discontinue the medication is something that we do not do in clinical practice, and it likely led to the same outcome as the placebo and potentially worse outcomes due to the rebound effect. Second, the primary endpoint was mean best corrected visual acuity at 12 months. Given that patients entered with good vision (20/32 on average for both groups), there was little room to improve vision, and those who treat CSR know that chronic CSR rarely has significant vision improvement. Chronic CSR treatment does see improvements in the amounts of subretinal fluid, and this was not examined fully by the study because the volume of subretinal fluid was not measured, simply the height.
So what should we pull away from this study? The study clearly shows that short-term eplerenone utilization does not affect vision at 12 months. I explain to my patients that they are not being treated as they were in the study and to date we still lack prospective clinical trial data to officially say that eplerenone is not useful in CSR. And as always, its always best to read the entire study rather than the headline to understand the true outcome.
Reference:
Lotery A, et al. Lancet. 2020;doi:10.1016/S0140-6736(19)32981-2.
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Disclosure: Singh reports he is a consultant to Zeiss, Novartis, Regeneron, Genentech and Alcon and receives grant support from Apellis and Graybug.