Caroline Helwick

November 27, 2013

NEW ORLEANS — Patients with central serous choroidopathy treated with nonsteroidal anti-inflammatory drug (NSAID) eyedrops recover faster than when they are not treated, according to a new study.

"We found that we could cut the average time to resolution by 50% with the NSAID eyedrops, which is the way we have been treating patients in our own practice," said Michael Singer, MD, from Medical Center Ophthalmology in San Antonio.

He presented the results here at the American Academy of Ophthalmology 2013 Annual Meeting.

Central serous choroidopathy is characterized by spontaneous serous detachment of the neurosensory retina in the macular region, with or without retinal pigment epithelium detachment. Its cause is not known, but one theory suggests that increased tissue hydrostatic pressure results in pigment epithelial detachments, and then serous detachments of the retina.

It is also possible that impaired choroidal vascular autoregulation is induced by steroids, catecholamines, or sympathomimetic agents. The role of the pigment epithelium in this disease is poorly understood, but damage from chronic leakage could be due to choroidal ischemia, Dr. Singer explained.

Regardless of the cause, the condition is usually self-limiting. "In about 80% of patients, there is spontaneous resolution of subretinal fluid within 6 months and visual acuity improves to 20/30 or better," he said.

The remaining 20% of patients have symptoms that persist longer than 6 months but resolve within 12 months. However, even if visual acuity returns to normal, some degree of subjective visual impairment — such as micropsia or impaired color perception — can linger because of damage to the photoreceptors and the retinal pigment epithelium.

We found that we could cut the average time to resolution by 50% with the NSAID eyedrops.

About 30% to 50% of patients experience disease recurrence, and in chronic disease, which lasts more than 6 months, progressive changes in retinal pigment epithelium can occur and can permanently impair visual function.

Dr. Singer explained that NSAIDs have shown benefit in postoperative cystoid macular edema. They block cyclooxygenase-1 and -2 and can reduce cortisol levels during stress in both humans and animals. Because of that, the researchers hypothesized that daily NSAIDs given over an extended period of time would shorten the time to resolution of edema and the restoration of vision in patients with acute central serous choroidopathy.

Dr. Singer and his team have been using NSAIDs in their practice, but formal data on the benefit of this approach have been lacking.

The retrospective analysis evaluated 38 patients treated with NSAIDs — topical bromfenac 0.09% or nepafenac 0.1% — in Dr. Singer's practice, and 73 untreated control subjects from outside ophthalmology practices.

The mean time to resolution was significantly shorter in the NSAID group than in the control group (42 vs 131 days; P < .0002).

"That was in all-comers so we wanted to also look at patients whose disease resolved within 6 months," Dr. Singer said. For that group, which is the more typical disease course, disease resolution was also significantly shorter in the NSAID group (42 vs 84 days; P < .002).

"Even in this tighter group, NSAIDs were still twice as good, cutting the average time to resolution by 50%," Dr. Singer said. "This means that patients will have about 6 additional weeks without blurred vision."

He added that "there was no statistically significant difference between bromfenac and nepafenac, but each of them was statistically superior to the controls." Mean time to resolution of fluid and restoration of vision with the NSAIDs was about 45 days.

Dr. Singer acknowledged that this was a small retrospective study with variable time points for assessment and that patients received higher-than-standard concentrations of drugs.

"Nevertheless, we think the study suggests that NSAID drops may be a good way to increase the speed of recovery in patients with the acute form of central serous choroidopathy," he said. "A prospective randomized clinical trial is necessary to provide a more definitive answer."

Session moderator Allen Kreiger, MD, from the Jules Stein Eye Institute at the University of California, Los Angeles, told Medscape Medical News that NSAIDs seem to be effective for central serous choroidopathy, and "would certainly be low risk."

The demonstration of safety is important. "We know that steroids actually increase the risk for central serous choroidopathy, and there has been a fear that NSAIDs would be the same," Dr. Kreiger said. However, "they work through different pathways, so rather than being harmful, NSAIDs may improve this condition."

Dr. Singer reports financial relationships with Acucela, Alcon Laboratories, Allergan, Bausch + Lomb, Eli Lilly, Eyegate, Genentech, Optos, Regeneron, and Santen. Dr. Kreiger has disclosed no relevant financial relationships.

American Academy of Ophthalmology (AAO) 2013 Annual Meeting: Poster PO472. Presented November 15, 2013.


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