Oral eplerenone for the management of chronic central serous chorioretinopathy

AIM: To examine eplerenone (Inspra, Pfizer), a mineralocorticoid receptor antagonist, as a treatment option for chronic central serous chorioretinopathy (CSCR). METHODS: A retrospective consecutive case series was conducted for patients receiving oral eplerenone for chronic CSCR. At baseline and each follow-up visit, spectral domain optical coherence tomography (SD-OCT) imaging was performed, including manual measurements of the height and diameter size of subretinal fluid. The primary outcome measure was the reduction in subretinal fluid following initiation of therapy. RESULTS: A total of 17 eyes of 13 patients treated with 25 and 50 mg of oral eplerenone per day were identified. Subretinal fluid (SRF) decreased over time following eplerenone therapy (P= 0.007 and P = 0.002, diameter and height respectively). Maximum SRF height decreased from a mean of 131.5 μm at baseline to 15.3 μm at day 181+. SRF diameter decreased from an average of 2174.4 μm at baseline to 46.9 μm at day 181+. LogMAR visual acuity improved from 0.42 (Snellen equivalent: 20/53) at baseline to 0.29 (Snellen equivalent: 20/39) at day 181+ (P = 0.024). Central subfield thickness (CST) decreased from 339.5 μm at baseline to 270.3 μm at day 181+ (P = 0.029). CONCLUSION: Eplerenone therapy resulted in significant anatomic and visual improvements in eyes with chronic CSCR.     

Mineralokortikoidrezeptorantagonisten als Therapieoption bei akuter und chronischer Chorioretinopathia centralis serosa

Background

It is well known that central serous chorioretinopathy (CSCR) is triggered by endogenous and exogenous glucocorticoids but the exact pathomechanism is not completely understood. According to the results of previous studies overactivation of mineralocorticoid receptors may play a decisive role in the pathogenesis of CSCR.

Methods and results

Experimental studies have shown that overactivation of mineralocorticoid receptors in endothelial cells of the choroid induces increased permeability. In a pilot study inhibition of mineralocorticoid receptors was successful in treating CSCR. This article reports about the use of spironolactone in the treatment of CSCR. In this observational case series spectral-domain optical coherence tomographv (SD-OCT) showed either reduction or complete reabsorption of subretinal fluid. In pilot studies and in this case series inhibition of mineralocorticoid receptors as a therapeutic option was effective and safe; however, the efficacy is difficult to distinguish from spontaneous recovery, especially in acute CSCR.

Conclusion

For further assessment of this treatment controlled clinical trials are urgently required as this therapy would offer a new approach for patients with chronic CSCR and no tendency towards recovery.     

The Effect of Eplerenone in Chronic Central Serous Chorioretinopathy Refractory to Photodynamic Therapy

Purpose: To evaluate the efficacy and safety of oral eplerenone in cases of central serous chorioretinopathy (CSCR) refractory to photodynamic therapy (PDT).

Methods: 19 patients with chronic CSCR and persistent subretinal fluid (SRF) were treated with oral eplerenone for 6 months, starting at a dose of 25 mg/day for 4 weeks and then 50 mg/day for 5 months. All patients underwent visual acuity measurement and optical coherence tomography (OCT), while fluorescein angiography was also performed at baseline, before treatment. Resolution of SRF, changes in retinal thickness and BCVA changes at month 6 and 12 post-treatment initiation were assessed. In addition, creatinine and electrolyte test was done on each patient every month for potential complications.

Results: Two out of 19 cases were excluded, since one presented with hyperkaliemia 15 days after eplerenone intake and one with skin rash one day after the treatment initiation. At month 12, 88.2% of patients exhibited visual acuity improvement and 76.4% SRF resolution, while in 11.8% of patients SRF remained stable.

Conclusions: This study has shown that eplerenone is safe and effective in cases of chronic CSCR, refractory to previous PDT.     

Systemic Mineralocorticoid Antagonists in the Treatment of Central Serous Chorioretinopathy

ABSTRACT

Central serous chorioretinopathy (CSCR) is a challenging disease characterized by subretinal serous fluid accumulation. The complex pathogenesis is still not fully understood, but is thought to be multifactorial and involves exogenous and endogenous factors affecting the choroid and retinal pigment epithelium. The involvement of corticosteroids is undisputed, while the contribution of mineralocorticoid pathways is under investigation. This review addresses the proposed pathogenesis models and the evidence for systemic treatment of CSCR with mineralocorticoid antagonists.     

OCT与mf-ERG在CSCR中的应用进展

中心性浆液性脉络膜视网膜病变(CSCR)为我国常见眼底疾病。近年来OCT在研究CSCR视网膜下渗出及分析视网膜结构改变等方面发挥着重要作用,同时脉络膜深层成像OCT(EDI-OCT)清晰地呈现了脉络膜形态学改变。此外,多焦视网膜电图(mf-ERG)证实了CSCR所引起的视网膜功能障碍,OCT和mf-ERG联合应用可以更好的理解CSCR结构和功能异常间的相关性。众多新技术的广泛应用,为CSCR的临床诊治、预后评估及随访提供了线索和依据。     

The Therapeutic Effects of Intravitreal Bevacizumab in a Patient with Recalcitrant Idiopathic Polypoidal Choroidal Vasculopathy

We describe the clinical course of a patient with therapy refractory polypoidal choroidal vasculopathy (PCV) who was treated with intravitreal bevacizumab (IVB). Prior treatments included photodynamic therapy and intravitreal pegaptanib with poor therapeutic response. Within four weeks of follow-up after a single IVB, the visual acuity improved from count fingers to 20/400 coincident to resolution of subretinal fluid. The visual acuity demonstrated sustained improvement and the macula remained without exudation for 12 months post treatment. Intravitreal injection of bevacizumab should be studied as an effective and relatively inexpensive option for patients with active polypoidal choroidal vasculopathy.     

The therapeutic effects of intravitreal bevacizumab in a patient with recalcitrant idiopathic polypoidal choroidal vasculopathy

We describe the clinical course of a patient with therapy refractory polypoidal choroidal vasculopathy (PCV) who was treated with intravitreal bevacizumab (IVB). Prior treatments included photodynamic therapy and intravitreal pegaptanib with poor therapeutic response. Within four weeks of follow-up after a single IVB, the visual acuity improved from count fingers to 20/400 coincident to resolution of subretinal fluid. The visual acuity demonstrated sustained improvement and the macula remained without exudation for 12 months post treatment. Intravitreal injection of bevacizumab should be studied as an effective and relatively inexpensive option for patients with active polypoidal choroidal vasculopathy.     

Comparing interventions for chronic central serous chorioretinopathy: A network meta-analysis

We compare efficacy of treatments for chronic central serous chorioretinopathy (CSCR) > 3 months. Four treatment classes were considered: photodynamic therapy (PDT), subthreshold laser therapies (SLT), mineralocorticoid receptor antagonists (MRA) and antivascular endothelial growth factor (anti-VEGF) agents. Pairwise and network meta-analyses (NMA) of the primary outcomes (complete resolution of subretinal fluid (SRF), mean change in best corrected visual acuity (BCVA as logMAR) and mean change in SRF) and secondary outcomes (mean change in central retinal thickness, and central choroidal thickness (μm), recurrence of SRF, and adverse events) at 3, 6, and 12 months were compared. Confidence in Network Meta-Analysis (CINeMA) informed the certainty of NMA evidence.Eleven RCTs of 458 eyes (450 patients) were included. NMA at 3 months showed that both PDT and SLT were superior to control for resolution of SRF (OR 4.83; 95% CI 1.72–13.55 and 2.27; 1.14–4.49, respectively) and SLT was superior to control for improving BCVA (MD -0.10; -0.17 to -0.04). PDT was superior to SLT for improving CRT (MD -42.88; -75.27 to -10.50). On probability ranking, PDT and SLT were consistently the best-ranked treatments for each outcome at 3 months, but low confidence of evidence and paucity of studies preclude definitive conclusions.     

Fluid state of malignant choroidal melanoma growth presenting as exudative retinal detachment

The extension of a malignant choroidal melanoma of an epithelioid cell type all through the subretinal space exhibiting a change of its solid state with its own stroma and blood supply in the choroid into a fluid growth phase resembling a tissue culture in the subretinal space is demonstrated in this case. This fluid state is represented by free-floating malignant melanoma cells living without their own stroma or direct blood supply in subretinal exudate. The transitional interface between the solid and fluid neoplastic states of this choroidal melanoma is demonstrated. The development of the fluid state indicates a potential of choroidal melanomas for isolation and survival of its cells without stroma and is related to the process of regional seeding and metastatic dispersion.     

全身使用糖皮质激素继发中心性浆液性脉络膜视网膜病变的临床特征

目的 探讨全身使用糖皮质激素患者发生中心性浆液性脉络膜视网膜病变（CSCR）的临床特征。设计 回顾性比较性病例系列。研究对象2012年10月至2018年10月间在北京同仁医院眼科就诊的全身使用糖皮质激素后继发CSCR患者35例（50眼）作为继发CSCR组；同时连续纳入61例（67眼）既往无全身糖皮质激素使用史的CSCR患者作为对照组。方法 回顾性分析研究对象的病史、视力、彩色眼底照相、荧光眼底素血管造影（FFA）等临床资料，并对两组患者之间的临床特征进行比较。主要指标 发病特点、眼底及FFA表现。结果 35例（50眼）继发CSCR患者中，双眼发病15例（42.9%），单眼20例（57.1%）；15眼（30.0%）可见黄白色神经上皮下纤维素样物质沉着；8眼（15.7%）下方视网膜可见渗出性脱离；16眼（31.4%）眼底呈弥漫萎缩性视网膜色素上皮改变（DARA）；21眼（42.0%）在FFA静脉中、晚期出现单个点状荧光素渗漏点，29眼（58.0%）出现2个或以上渗漏点或呈弥漫性荧光素渗漏。对照组61例（67眼）CSCR患者中，双眼发病6例（9.8%），单眼发病55例（90.2%）；9眼（13.4%）可见黄白色神经上皮下纤维素样物质沉着，无患眼（0%）发生下方视网膜渗出性脱离，2眼（3.0%）眼底呈DARA。59眼（88.1%）FFA静脉中、晚期出现单个荧光素渗漏点，8眼（11.9%）出现2个或以上荧光素渗漏点和/或弥漫性荧光素渗漏。上述临床特征，两组间的差异均有统计学意义（P均=0.000）。结论 与普通CSC患者相比，全身使用糖皮质激素继发CSCR患者更容易双眼发病，视网膜色素上皮功能受损更为严重。     

使用OCT评估中心性浆液性脉络膜视网膜病变患者脉络膜厚度的变化

目的:使用光谱域光学相干断层成像(SD-OCT)技术研究中心性浆液性脉络膜视网膜病变(CSCR)3mo后脉络膜厚度的变化。方法:前瞻性研究。共纳入60眼,20眼(平均年龄:33.65±5.24岁)典型急性单侧中心性浆液性脉络膜视网膜病变以及对侧正常眼,20眼为健康对照组。进行荧光素血管造影和OCT检查。测量中心凹下脉络膜厚度(SFCT),黄斑中心凹视网膜厚度(CMT),到中央凹和视网膜下液1000μm处颞部和鼻部。结果:在三个不同的位置,三组间的SFCT差异有统计学意义。中心性浆液性脉络膜视网膜病变眼中心凹下脉络膜厚度(372.40±34.39μm)在基线和随访3mo后均显著大于对侧正常眼(302.10±8.9μm)和对照组眼(279.80±14.49μm)。CSCR眼平均CMT为317±141.86μm,并且SFCT与CMT呈显著正相关。结论:不同部位脉络膜厚度的增加,以及被称为“厚脉络膜”的过度扩张和高渗透血管,似乎在包括中心性浆液性脉络膜视网膜病变在内的广泛疾病中起着重要作用。     

Choroidal (subretinal) neovascularization secondary to choroidal nevus and successful treatment with argon laser photocoagulation. Case reports and review of literature

Retinal detachment secondary to choroidal nevus may be caused by subretinal fluid accumulation or neovascularization. Foveal subretinal fluid or leakage of choroidal neovascularization may impair visual acuity. 10 cases of nevus with serous sensory retinal detachment successfully treated with laser photocoagulation are reviewed. 2 additional cases of successful laser therapy for retinal detachment secondary to choroidal neovascularization with nevus of the choroid are presented.     

Presumed choroidal metastasis secondary to clear cell sarcoma of the right knee

To present a case of choroidal metastasis of clear cell sarcoma of the tendons and aponeuroses. Observational case report. A 63-year-old woman with multiple systemic metastasis secondary to clear cell sarcoma of the tendons and aponeuroses in her right knee presented with a 3 days history of blurred vision in her left eye. At the time of presentation, her visual acuity was 20/125 in her left eye. Fundus examination of the left eye showed three amelanotic choroidal lesions associated with subretinal fluid. The patient was diagnosed with presumed choroidal metastasis secondary to clear cell sarcoma of the tendons and aponeuroses. Clear cell sarcoma of the tendons and aponeuroses rarely metastasize to the choroid.     

Choroidal hemangioma treated with photodynamic therapy using verteporfin: report of a case

PURPOSE: To report the results of treatment of circumscribed choroidal hemangioma with a single application of photodynamic therapy (PDT) with verteporfin according to the Treatment of Age-related Macular Degeneration with Photodynamic Therapy study. METHODS: A 44-year-old man with unilateral decreased vision and macular subretinal fluid secondary to a circumscribed choroidal hemangioma diagnosed by fluorescein and indocyanine green angiography and ultrasonography underwent PDT with verteporfin therapy. RESULTS: One year after PDT, subretinal fluid was absent and visual acuity improved. CONCLUSIONS: The results obtained in this case are in keeping with previously reported results; however, future randomized studies are necessary to evaluate and standardize different infusion times in order to obtain maximum efficacy of treatment.     

CSCR中盐皮质激素受体基因-2G/C的多态性及其与血浆皮质醇水平的关系

目的：评估中心性浆液性脉络膜视网膜(CSCR)病变中盐皮质激素受体基因-2G/ C 单核苷酸多态性,以及基因多态性和血浆皮质醇水平的关系。
　　方法：选取60例中心性浆液性脉络膜视网膜病变患者和50例正常人作为研究对象。患者皆患有急性中心性浆液性脉络膜视网膜病变,即浆液性视网膜脱离和视网膜色素上皮脱离或功能障碍(排除其它可能导致渗出的疾病,比如脉络膜新生血管、炎症或浸润病变)。为避免皮质醇水平的昼夜变化,上午8时到10时之间采集外周血样,检测盐皮质激素受体基因多态性(rs2070951)和血浆皮质醇水平。
　　结果：CSCR 组的基因型频率分布为 G/ C (46.6%), G/ G (26.7%)和 C/ C (26.7%)。两组间基因型分布无统计学差异(P=0.96)。研究结果显示,CSCR 组的血浆皮质醇水平为401.2依162.1 nmol / L ,对照组为296.8依130.1 nmol / L,两组间差异有统计学意义(P<0.01)。血浆皮质醇水平在 G/ C (345.0依137.0 nmol / L), G/ G (369.2依165.3 nmol / L)和 C/ C (395.3依188.8 nmol / L)基因型之间不存在差异(P=0.50)。
　　结论：盐皮质激素受体基因多态性与中心性浆液性脉络膜视网膜病变和血浆皮质醇水平无关。     

A case of giant nodular posterior scleritis mimicking choroidal malignancy

To report a case of giant nodular posterior scleritis mimicking a choroidal tumor. A 42-year-old lady with systemic hypertension presented with a 1-week history of unilateral visual loss, pain and redness in her left eye. Examination showed sectoral anterior episcleritis in her left eye as well as a dome-shaped choroidal mass at the inferior-temporal periphery, associated with retinal hemorrhages and subretinal fluid. Systemic evaluation and imaging of the choroidal mass were performed and could not rule out amelanotic choroidal melanoma. At the same time, she was prescribed a 2-week course of oral nonsteroidal anti-inflammatory drug (NSAID) for her sectoral anterior episcleritis. The choroidal mass was found to have resolved completely right before her scheduled fine needle biospy. Diagnosis of nodular posterior scleritis and a trial of oral NSAID can be considered in patients presenting with a choroidal mass before any invasive procedure.     

Idiopathic polypoidal choroidal vasculopathy (IPCV). 1990

Eleven patients, 40 to 71 years old, had a choroidal vasculopathy that led to hemorrhagic and exudative macular degeneration. The patients had peculiar polypoidal, subretinal, vascular lesions associated with serous and hemorrhagic detachments of the retinal pigment epithelium. This macular disorder, which we have named idiopathic polypoidal choroidal vasculopathy (IPCV), appears to represent a distinct entity that differs clinically and demograph-ically from age-related macular degeneration (AMD) and other macular diseases associated with subretinal neovascularization. Recognition of this condition is important because it may have specific risk factors, natural course, and management considerations that differ from those of age-related macular degeneration     

Idiopathic polypoidal choroidal vasculopathy (IPCV).

Eleven patients, 40 to 71 years old, had a choroidal vasculopathy that led to hemorrhagic and exudative macular degeneration. The patients had peculiar polypoidal, subretinal, vascular lesions associated with serious and hemorrhagic detachments of the retinal pigment epithelium. This macular disorder, which we have named idiopathic polypoidal choroidal vasculopathy (IPCV), appears to represent a distinct entity that differs clinically and demographically from age-related macular degeneration (AMD) and other macular diseases associated with subretinal neovascularization. Recognition of this condition is important because it may have specific risk factors, natural course, and management considerations that differ from those of age-related macular degeneration.     

Retinal angiomatous mass. A complication of retinal detachment surgery

Retinal angiomatous masses were observed as a very late complication in four patients following scleral buckling procedures with drainage of subretinal fluid. The lesions manifested 5-19 years after the original surgical procedure, and the presenting complaint was decreased vision secondary to vitreous clouding. In three patients a vascularized retinal mass greater than 3 disc diameters in size was observed at the site of choroidal perforation for drainage of subretinal fluid. A fourth patient demonstrated a similar lesion in the location of a suture used to anchor the encircling element, possibly the point of accidental choroidal perforation. Three of the four patients were treated by photocoagulation or cryocoagulation with cicatrization of the angiomatous mass and obliteration of the vascular net. This resulted in clearing of vitreous opacities and subretinal exudates, with restoration of vision to a level prior to the onset of symptoms.