Medical Therapy for Chronic CSCR of Limited Value, Study Finds

Most clinicians opt to monitor acute CSCR rather than treat. For chronic cases with persistent fluid requiring intervention, this study notes that the less invasive option—MRA therapy—may benefit some patients in the short-term.  Photo: Mohammad Rafieetary, OD. Click image to enlarge. A recent systematic review and meta-analysis investigated the effectiveness of mineralocorticoid receptor antagonists (MRAs), specifically eplerenone and spironolactone, for treating chronic central serous chorioretinopathy (CSCR). The study, published in American Journal of Ophthalmology, revealed that while MRAs can provide short-term benefits in reducing subretinal fluid (SRF) height, their long-term effectiveness is limited compared to alternative interventions. Importantly, no significant differences in best-corrected visual acuity (BCVA) were found between MRAs and other treatment modalities over time.The meta-analysis included 646 eyes across 13 studies, consisting of four randomized controlled trials and nine observational studies, with a mean follow-up duration of seven months. Participants were all adults diagnosed with chronic CSCR. The primary endpoint measured was BCVA at specified follow-up intervals (one, three, six and 12 months). Secondary outcomes comprised retinal thickness (RT), SRF height and SRF resolution. Patients treated with eplerenone or spironolactone were compared to those who received observation, photodynamic therapy or subthreshold micropulse laser.The results demonstrated that MRAs did not significantly improve vision compared to observation; at the last study visit, there was no significant difference in mean BCVA between the two groups. When comparing SRF height outcomes, MRA therapy demonstrated a significant reduction in mean SRF height at one month vs. the observation group, with an average decrease of 69.56µm. On the other hand, the observation group exhibited a significantly lower mean SRF height at 12 months, with an average reduction of 48.23µm, suggesting better long-term outcomes for those not receiving medical therapy. Furthermore, the MRAs showed a higher rate of SRF resolution at one month, with a relative risk (RR) of 4.24, while the observation group showcased a greater resolution rate by 12 months, with an RR of 0.45.Analyzing retinal thickness effects, spironolactone indicated a significant reduction at both the one-month and final study visit compared to the observation group, with a mean decrease of 46.44µm. When comparing MRAs to photodynamic therapy, the latter resulted in a more substantial reduction in SRF height at the last study visit, outperforming MRAs with a weighted mean difference of 51.99µm. The mean BCVA and retinal thickness at the last study visit were similar between MRAs and the subthreshold micropulse laser groups, although results varied across the studies.“Given the similar visual prognosis between MRAs and alternative treatments,” the researchers wrote in their paper, some patients “may benefit from less aggressive treatments, such as MRAs, with more invasive procedures like subthreshold micropulse laser or photodynamic therapy reserved for more complex cases.” They added, “MRAs may be particularly appropriate for patients who are ineligible for subthreshold micropulse laser or photodynamic therapy due to limited access, contraindications (e.g., verteporfin allergy, systemic photosensitivity) or concerns about potential adverse effects.”The authors also caution clinicians to be aware of the contraindications associated with MRAs, noting that “spironolactone and eplerenone can pose systemic risks, particularly in patients with renal impairment, hyperkalemia or certain cardiovascular conditions. The loss of aldosterone activity in MRA-treated patients may result in decreased potassium excretion and decreased sodium reabsorption, contributing to electrolyte imbalances, which may lead to side effects of hypotension and dizziness.”In conclusion, this study found that MRAs hold no advantage over comparable treatments for central serous in terms of visual improvement, which aligns with current CSCR treatment guidelines that don’t support the use of MRAs over other interventions such as photodynamic therapy. However, the relatively short follow-up durations across studies in the literature call for longer-term data to investigate the treatment’s long-term effects. Additionally, “the potential for higher systemic adverse events with MRAs should be considered when choosing treatment options,” the authors advised.Click here for the journal source. Huang RS, Mihalache A, Benour A, et al. Eplerenone and spironolactone for chronic central serous chorioretinopathy: a systematic review and meta-analysis. Am J Ophthalmol. June 11, 2025. [Epub ahead of print].