Twenty-three patients were included in the study. Mean age was 64.6 years, and 12 patients were female (52.2%), 11 were male (47.8%). 10 of the 23 patients were in group A (large PEDs), and this group did not show a significant reduction in SRF or an extension of the injection interval. 13 of the 23 patients were in group B and had predominantly chronic subretinal fluid with an absence of medium-large pigment epithelial detachments. In group B, mean initial CMT was 305.3 μm and mean final CMT was 240.6 μm (p < 0.05). Mean initial injection interval was 40.25 days and mean final injection interval was 54.61 days (p < 0.05). The mean extension of the injection interval in this group was 14.36 days.
An overall optimal response was noted in patients that had a shaggy photoreceptor outer layer, were pachychoroid for age, and had an absence of moderate-large pigment epithelial detachments. 8 of the 13 patients in group B had all these characteristics. In this subgroup, mean initial CMT was 319.4 μm and mean final CMT was 236.1 μm. The mean initial injection interval was 39.5 days and the mean final injection interval was 60.7 days (p < 0.05), for a mean extension of the injection interval in this group of 21.2 days.
Two cases are presented of patients from group B. Case 1 (Fig. 1a–e) was a 72-year-old female who presented with 20/200 vision and typical findings of neovascular wet AMD with minimal subretinal fluid and significant cystoid macular edema due to evident choroidal neovascularization on FA. After three months of serial intravitreal bevacizumab, her vision improved to 20/60 and her significant CME had largely resolved, with some persistence of trace subretinal fluid. At month 6, all of her CME had resolved, the subretinal fluid had slightly increased, some shagginess of the photoreceptor outer layer had become evident, and vision had decreased to 20/70. At this point, the patient was switched to aflibercept, and after three months of serial aflibercept, the patient presented a further increase in subretinal fluid and shagginess of the photoreceptor outer layer, with vision remaining at 20/70. At this point, the patient was started on oral eplerenone 25 mg PO BID, and two months later all the subretinal fluid had resolved, and vision had improved to 20/50.
Case 2 (Fig. 2a–e) was an 80-year-old female. She initially presented with significant CME and SRF with a BCVA of 20/150. After three months of bevacizumab, all the CME had resolved, and vision had improved to 20/80, but she had persistent subretinal fluid and a shaggy photoreceptor outer layer, so she was switched to aflibercept. After 6 months of aflibercept, there was only a very slight reduction in pigment epithelial detachment subretinal fluid height, and oral eplerenone was initiated. After 2 months of oral eplerenone, most of the subretinal fluid had resolved, pigment epithelial detachment height had decreased further, and vision had improved to 20/40. One month later (3 months after starting oral eplerenone), all subretinal fluid had resolved, and vision remained at 20/40.