Eplerenone for chronic central serous chorioretinopathy

Abstract

The VICI trial1Lotery A Sivaprasad S O'Connell A et al.Eplerenone for chronic central serous chorioretinopathy in patients with active, previously untreated disease for more than 4 months (VICI): a randomised, double-blind, placebo-controlled trial.Lancet. 2020; 395: 294-303Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar was necessary because of the uncertainty surrounding eplerenone, an off-label drug, in the management of chronic central serous chorioretinopathy (CSCR). Andrew Lotery and colleagues1Lotery A Sivaprasad S O'Connell A et al.Eplerenone for chronic central serous chorioretinopathy in patients with active, previously untreated disease for more than 4 months (VICI): a randomised, double-blind, placebo-controlled trial.Lancet. 2020; 395: 294-303Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar concluded that eplerenone was not superior to placebo for improving best-corrected visual acuity in patients with chronic CSCR after 12 months of treatment. Nevertheless, this study raises a few concerns. In the eplerenone group, treatment was stopped as soon as resolution of subretinal fluid occurred (17 [40%] of 42 patients treated). 17 (30%) of 57 patients received eplerenone for less than 3 months. However, in previous studies,2Petkovesk DS Cherfan DG Conti FF et al.Eplerenone for the treatment of chronic central serous chorioretinopathy: 3-year clinical experience.Br J Ophtalmol. 2020; 104: 182-187Crossref PubMed Scopus (8) Google Scholar, 3Zola M Daruich A Matet A Mantel I Behar-Cohen F Two-year follow-up of mineralocorticoid receptor antagonist for chronic central serous chorioretinopathy.Br J Ophthalmol. 2019; 103: 1184-1189Crossref PubMed Scopus (13) Google Scholar treatment with eplerenone of between 6 and 12 months resulted in resolution of subretinal fluid and improvement of vision in 60–80% of patients. In these same studies,2Petkovesk DS Cherfan DG Conti FF et al.Eplerenone for the treatment of chronic central serous chorioretinopathy: 3-year clinical experience.Br J Ophtalmol. 2020; 104: 182-187Crossref PubMed Scopus (8) Google Scholar, 3Zola M Daruich A Matet A Mantel I Behar-Cohen F Two-year follow-up of mineralocorticoid receptor antagonist for chronic central serous chorioretinopathy.Br J Ophthalmol. 2019; 103: 1184-1189Crossref PubMed Scopus (13) Google Scholar CSCR recurred when treatment ceased. Seven (12%) of the 57 patients in the placebo group received photodynamic therapy or subthreshold laser therapy, compared with three (5%) of 57 patients in the eplerenone group in the case of non-resolution of subretinal fluid. That such a difference did not have a role in the outcome of the study is hard to believe. The number of patients in the placebo group who had pigment epitheliopathy doubled, but no increase was observed for the treatment group. How can this difference be explained? Lotery and colleagues1Lotery A Sivaprasad S O'Connell A et al.Eplerenone for chronic central serous chorioretinopathy in patients with active, previously untreated disease for more than 4 months (VICI): a randomised, double-blind, placebo-controlled trial.Lancet. 2020; 395: 294-303Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar extrapolated their results by adding two previous randomised controlled trials of eplerenone versus placebo.4Schwartz R Habot-Wilner Z Martinez MR et al.Eplerenone for chronic central serous chorioretinopathy—a randomized controlled prospective study.Acta Ophthalmol. 2017; 95: e610-e618Crossref PubMed Scopus (46) Google Scholar, 5Rahimy E Pitcher 3rd, JD Hsu J et al.A randomized double-blind placebo-control pilot study of eplerenone for the treatment of central serous chorioretinopathy (ECSELSIOR).Retina. 2018; 38: 962-969Crossref PubMed Scopus (41) Google Scholar These trials did not use the same duration of treatment (8 weeks and 3 months) and should therefore not be considered to draw any conclusion about eplerenone in CSCR. CSCR is the second most common maculopathy after diabetic maculopathy between the third and fifth decades of life with no approved effective treatment. Eplerenone has been widely used in cardiology for more than 50 years. The safety and side-effects of eplerenone are well known and controlled. So far, no study of CSCR has described any irreversible side-effects with eplerenone. We believe that the use of eplerenone, a treatment that has shown efficacy in CSCR in numerous reports, especially when used for longer periods of time, should not be abandoned in sight-threatening conditions such as CSCR. We declare no competing interests. Eplerenone for chronic central serous chorioretinopathy in patients with active, previously untreated disease for more than 4 months (VICI): a randomised, double-blind, placebo-controlled trialEplerenone was not superior to placebo for improving BCVA in people with chronic CSCR after 12 months of treatment. Ophthalmologists who currently prescribe eplerenone for CSCR should discontinue this practice. Full-Text PDF Eplerenone for chronic central serous chorioretinopathyWe congratulate Andrew Lotery and colleagues1 for their excellent work on eplerenone for chronic central serous chorioretinopathy (CSCR). However, we have several concerns about the study. Full-Text PDF Eplerenone for chronic central serous chorioretinopathy – Authors' replyWe thank Riccardo Sacconi and colleagues and Dinu Stanescu-Segall and colleagues for their questions about the VICI trial.1 Full-Text PDF