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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 29  |  Issue : 1  |  Page : 54-56

Oral eplerenone for treatment of bullous retinal detachment secondary to chronic central serous retinopathy


1 Vitreoretina Services, Centre for Sight, New Delhi, India
2 Department of Ophthalmology, Vitreoretina Services, L.V. Prasad Eye Institute, Hyderabad, Telangana, India

Date of Web Publication19-Jun-2017

Correspondence Address:
Jay Chhablani
Vitreoretina Services, L.V. Prasad Eye Institute, Kallam Anji Reddy Campus, Banjara Hills, Opp. PVR, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_39_17

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  Abstract 


The bullous variant is a rare manifestation of central serous retinopathy (CSR). Multiple therapeutic approaches have been described to treat these bullous detachments which mainly involve laser photocoagulation or surgical drainage. Here, we demonstrate the efficacy of oral eplerenone in the treatment of the bullous variant of CSR. A 44-year-old female presented to us with diminution of vision in the left eye (OS) for 1 month. On clinical examination, she was diagnosed to have a chronic CSR in both eyes along with a bullous retinal detachment in the OS which was confirmed on multimodal imaging. She underwent focal laser, which failed to resolve the bullous variant in the OS, then the patient was started on oral eplerenone for 3 months. At 3-month follow-up, the ultrasound scan of the OS confirmed resolution of the bullous detachment, and some residual subretinal fluid could be noted at the posterior pole. This was maintained till 6-month follow-up. Oral eplerenone can be an effective, cheap, and safer alternative in treating patients with nonresolving bullous detachments secondary to chronic CSR.

Keywords: Central serous chorioretinopathy, central serous retinopathy, eplerenone


How to cite this article:
Dave PA, Chhablani J. Oral eplerenone for treatment of bullous retinal detachment secondary to chronic central serous retinopathy. Kerala J Ophthalmol 2017;29:54-6

How to cite this URL:
Dave PA, Chhablani J. Oral eplerenone for treatment of bullous retinal detachment secondary to chronic central serous retinopathy. Kerala J Ophthalmol [serial online] 2017 [cited 2019 Jan 16];29:54-6. Available from: http://www.kjophthal.com/text.asp?2017/29/1/54/208480


  Introduction Top


Bullous retinal detachment which is an extremely rare manifestation of chronic central serous retinopathy (CSR)[1] poses certain challenges as the traditional treatment of argon laser photocoagulation may not be effective due to multiple leaks or diffuse retinal pigment epithelial (RPE) damage. Internal as well as external drainage has been tried as a treatment for the bullous detachment found in CSR, but it has its own set of disadvantages.[2]

Recently, mineralocorticoid antagonists such as eplerenone have been used in the treatment of chronic CSR.[3],[4] They act on the hypothesis that CSR occurs due to excessive glucocorticoid-dependent choroidal mineralocorticoid receptor (MR) activation in the choroidal vessels, and hence, a MR antagonist will be effective. We report a case of a nonresolving bullous retinal detachment secondary to CSR which was successfully treated with oral eplerenone.


  Case Report Top


A 44-year-old female presented with complaints of diminution of vision in the left eye (OS) for 4 months. The best-corrected visual acuity in the OS was counting fingers at 1 m and 20/50 in the right eye (OD). Anterior segment examination of both eyes was normal. On a dilated fundus examination, the OS showed RPE changes on the posterior pole accompanied by yellowish subretinal lesions of approximately 2 disc diameters in size located superotemporal to the fovea along with an inferior exudative retinal detachment [Figure 1]a. Fundus fluorescein angiography (FFA), optical coherence tomography (OCT), and indocyanine green angiography confirmed the presence of chronic CSR with bullous retinal detachment [Figure 1]b and [Figure 1]c. OD examination was also suggestive of a chronic CSR. The patient underwent FFA-guided conventional focal laser (532 nm) to the leaks in both eyes. At 6-week follow-up, the subretinal fluid (SRF) had resolved in OD, but the OS showed no change. An ultrasound B-scan of the OS confirmed persistence of the exudative retinal detachment and the presence of subfoveal SRF on the posterior pole. At this stage, the patient was started on oral eplerenone with dose of 25 mg twice a day for 1 month followed by 25 mg once a day for 2 months after confirming normal serum potassium level. The patient followed up after 3 months. Her vision in OD improved to 20/40 and 20/100 in OS. On clinical examination and OCT, there was minimal SRF in both eyes at the fovea [Figure 1]d and [Figure 1]e. Ultrasonography of the OS confirmed the complete resolution of the exudative detachment in the OS [Figure 1]f. Her serum potassium levels were within normal limits throughout follow-up. She was advised to continue same treatment and review back in 3 months.
Figure 1: (a) Left eye fundus picture (color fundus) showing retinal pigment epithelial atrophic tract (white arrowheads), subretinal exudation (white arrow) temporal to macula, and inferior bullous detachment (stars). (b) Optical coherence tomography of left eye showing subfoveal subretinal fluid and pocket of subretinal fluid (white arrow) with serous pigment epithelial detachment (thick white arrow) temporal to macula. (c) Ultrasound confirming inferior bullous detachment (white arrow). (d) Color fundus after oral eplerenone showing resolution of bullous detachment. (e) Optical coherence tomography left eye showing resolution of subretinal fluid temporal to the macula (white thick arrow) and reduction of subfoveal subretinal fluid. (f) Ultrasound showing complete resolution of inferior bullous detachment

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  Discussion Top


The bullous variant of CSR is a rare entity which can lead to permanent visual loss if left untreated. Laser photocoagulation is an effective treatment modality in treating the focal leaks found in CSR; however, many times, laser is not possible due to bullous detachment.[1] Internal or external drainage of the fluid has been reported as the treatment modalities for exudative bullous detachment secondary to central serous chorioretinopathy (CSCR),[5],[6] but surgical intervention is associated with risk of complications. We tried a safer yet effective alternative.

Eplerenone, a mineralocorticoid antagonist, is similar to spironolactone except that the 17α-thoacetyl group of spironolactone is replaced with carbomethoxy group, resulting in lower affinity for other steroid receptors, thereby making it more specific and tolerable as compared to spironolactone.[7] Singh et al. demonstrated a significant improvement in patients treated with oral eplerenone for chronic CSCR.[4] Oral eplerenone is contraindicated in hyperkalemia and renal disorders as it can cause increase in serum potassium.

We experienced complete resolution of exudative detachment during eplerenone therapy; however, follow-up protocol is still not known. Case reports by Zhao et al. noted no recurrence of CSR up to 5 months after discontinuation of drug treatment in a case of chronic CSR. In view of persistent shallow fluid, we continued our patient on same treatment.


  Conclusion Top


We report successful outcome of eplerenone therapy in a case of nonresolving exudative retinal detachment secondary to CSR. Oral eplerenone therapy could be an effective, cheap, medical treatment for exudative detachments secondary to CSC. Larger studies with longer follow-up are warranted to improve understanding about the follow-up protocol before considering it as primary therapy for such situations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Balaratnasingam C, Freund KB, Tan AM, Mrejen S, Hunyor AP, Keegan DJ, et al. Bullous variant of central serous chorioretinopathy: Expansion of phenotypic features using multimethod imaging. Ophthalmology 2016;123:1541-52.  Back to cited text no. 1
    
2.
Bondalapati S, Pathengay A, Chhablani J. External drainage for exudative retinal detachment secondary to central serous chorioretinopathy. Eye Sci 2015;30:204-8.  Back to cited text no. 2
    
3.
Bousquet E, Beydoun T, Zhao M, Hassan L, Offret O, Behar-Cohen F. Mineralocorticoid receptor antagonism in the treatment of chronic central serous chorioretinopathy: A pilot study. Retina 2013;33:2096-102.  Back to cited text no. 3
    
4.
Singh RP, Sears JE, Bedi R, Schachat AP, Ehlers JP, Kaiser PK. Oral Eplerenone for the management of chronic central serous chorioretinopathy. Int J Ophthalmol 2015;8:310-4.  Back to cited text no. 4
    
5.
Chen HC, Ho JD, Chen SN. Perfluorocarbon liquid-assisted external drainage in the management of central serous chorioretinopathy with bullous serous retinal detachment. Chang Gung Med J 2003;26:777-81.  Back to cited text no. 5
    
6.
John VJ, Mandelcorn ED, Albini TA. Internal drainage for chronic macula-involving serous retinal detachment in idiopathic central serous chorioretinopathy. Int Ophthalmol 2014;34:91-5.  Back to cited text no. 6
    
7.
Delyani JA. Mineralocorticoid receptor antagonists: The evolution of utility and pharmacology. Kidney Int 2000;57:1408-11.  Back to cited text no. 7
    


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