• Spironolactone or Observation for Acute CSC?

    By Lynda Seminara
    Selected By: Deepak P. Edward, MD

    Journal Highlights

    British Journal of Ophthalmology
    2018;102(8):1060-1065

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    Central serous chorioretinopathy (CSC) usually is benign and self-limiting, and most cases resolve spontaneously within 3 months of onset. Therefore, observation is indicated initially. How­ever, cases that don’t resolve on their own may become chronic.

    Corticosteroids have been implicated in the development of CSC, but their pathogenic mechanism is unclear. Re­search in rats showed expression of the mineralocorticoid receptor in ganglion cells, retinal Müller glial cells (RMGs), and cells of the inner nuclear layer. Aldosterone maintains homeostasis of retinal fluid by upregulating the ion and water channel, which is expressed in the apical region of RMGs. Sub­sequently, aldosterone was shown to increase expression of the KCa2.3 chan­nel. Since then, a novel pathogenesis was proposed: Excessive activation of the mineralocorticoid receptor signaling pathway induces dilation and leakage of choroid vessels, resulting in choroidal thickening and leading to CSC. Clinical evidence indicates that mineralocorti­coid receptor antagonism is effective in patients with chronic or recurrent CSC, leading Sun et al. to test spironolac­tone in acute CSC. They found that the treatment led to faster absorption of subretinal fluid.

    For this randomized study, the researchers included 30 patients (30 eyes) with acute CSC. Eighteen patients received oral spironolactone (40 mg twice daily) for 2 months, and 12 had observation (control group) for the same period. Outcomes of interest were complete resolution of subretinal fluid and changes in central macular thick­ness (CMT), subretinal fluid height, best-corrected visual acuity (BCVA), and subfoveal choroidal thickness.

    By 2 months, complete resolution of subretinal fluid had occurred in 10 patients (55.6%) of the spironolactone group and 1 patient (8.3%) of the con­trol group. Mean CMT and subretinal fluid height declined significantly in both groups, and the between-group differences at 2 months were significant. By 2 months, BCVA had improved in both groups. The reduction in mean subfoveal choroidal thickness from baseline to month 2 was significant in the spironolactone group but not in the control group. Between-group differ­ences in actual BCVA and subfoveal choroidal thickness were not significant.

    The authors concluded that oral spi­ronolactone is a promising treatment for acute CSC. They emphasized that, because the condition is multifactorial, the mineralocorticoid receptor may not play a major role in all cases.

    The original article can be found here.