What supplements can help prevent the recurrence of central serous retinopathy (CSR)?

Supplements for Preventing Recurrence of Central Serous Retinopathy

Half-dose photodynamic therapy (PDT) is the most effective treatment for preventing recurrence of central serous retinopathy, with limited evidence supporting the use of supplements alone for this purpose. 1

Current Evidence on Supplements for CSR

• High-dose antioxidant supplements containing vitamins A, C, E, riboflavin, zinc, copper, selenium, manganese, and lutein/zeaxanthin have shown some promise in a small randomized placebo-controlled trial, with 76% of patients achieving complete subretinal fluid (SRF) resolution compared to 48% in the placebo group 1

• Oral vitamin B supplements have been used as part of "conservative treatment" approaches, though with limited evidence of efficacy compared to more established treatments like PDT 1

• Some retrospective studies have included vitamin B supplements as part of conservative management protocols, but with lower success rates (32% complete SRF resolution) compared to other treatment options 1

Primary Treatment Recommendations

For Acute Central Serous Retinopathy (aCSC):

• Observation is generally recommended for the first 3-4 months due to high rates of spontaneous resolution 1
• For patients requiring rapid visual recovery or with recurrent episodes, half-dose PDT is the treatment of choice 1
• Half-dose PDT has been shown to:
  • Increase likelihood of SRF resolution
  • Improve visual outcomes
  • Significantly reduce recurrence rates compared to other treatments 1

For Chronic Central Serous Retinopathy (cCSC):

• Half-dose PDT is superior to other treatments based on large randomized controlled trials 1
• The PLACE trial demonstrated half-dose PDT achieved complete SRF resolution in 67% of patients at 7-8 months post-treatment, compared to only 29% with high-safety micropulse laser (HSML) 1
• Long-term follow-up shows patients successfully treated with half-dose PDT have significantly lower recurrence rates compared to other treatments 1

Pharmacological Options

• Mineralocorticoid receptor antagonists (spironolactone, eplerenone):

  • Some studies show benefit with 57% complete SRF resolution compared to 32% with conservative treatment (including vitamin B supplements) 1
  • However, large randomized controlled trials (SPECTRA and VICI) found relatively low efficacy of eplerenone (16-17% resolution) compared to placebo or half-dose PDT 1
  • Recurrence rates are significantly higher with spironolactone compared to half-dose PDT 1

• Mifepristone (glucocorticoid receptor antagonist):

  • Limited evidence from small studies
  • One prospective study showed improvement in visual acuity in 31% of patients, but did not report complete SRF resolution rates 1

Clinical Approach to Prevent CSR Recurrence

1. First-line approach: Half-dose PDT is the most effective treatment for preventing recurrence 1

2. For patients unable to access PDT:

   • Consider high-dose antioxidant supplements containing vitamins A, C, E, zinc, and lutein/zeaxanthin 1
   • Consider mineralocorticoid receptor antagonists (spironolactone 25mg twice daily) as an alternative, though with higher recurrence rates 1

3. For steroid-induced CSR:

   • Discontinuation of steroids when possible is crucial 2
   • Spironolactone (50mg daily) may be beneficial in these cases 1

Important Caveats

• The evidence for supplements alone in preventing CSR recurrence is limited and of lower quality than evidence for PDT 1
• Patients with focal leakage spots on fluorescein angiography may have better outcomes with targeted treatments than with supplements alone 1
• Supplements should be considered adjunctive therapy rather than primary treatment for preventing recurrence 1
• Long-term follow-up is essential regardless of treatment approach, as recurrence can occur even after successful treatment 1