Discussion
RECURRENCES
To date, no large randomized controlled trial has been reported on the long-term results of oral eplerenone in comparison to half-dose PDT in cCSC. In the current trial, we evaluated the long-term outcomes after treatment with half-dose PDT, eplerenone, and, in some cases (especially in primary eplerenone-treated patients), with crossover treatment. This study included a wide variety of cCSC patients, from focal to diffuse variants. We show that almost all patients treated with half-dose PDT still have a complete SRF resolution at 12 months after baseline, including the patients who received half-dose PDT as crossover treatment. Remarkably, BCVA also increases significantly more in the patients originally randomized to half-dose PDT compared to patients who were primarily randomized to eplerenone treatment, despite the crossover treatment with half-dose PDT which most of these patients received because of persistent SRF on OCT.The odds ratio of complete SRF resolution on OCT at 12 months after baseline visit (evaluation visit 3) did not differ statistically between the 2 treatment groups to which patients were primarily randomized to. However, it should be noted that due to the intention-to-treat design of the trial, 82.6% of the patients who were primarily randomized to the eplerenone group received crossover treatment with half-dose PDT due to persistence of SRF on OCT at evaluation visit 1, whereas only 22.0% of patients from the primary half-dose PDT group required crossover treatment with eplerenone (Fig. The results of the current study suggest that cCSC patients benefit most from treatment with half-dose PDT, even after previous unsuccessful treatment with eplerenone for 3 months. This is in line with the available evidence from randomized controlled trials (SPECTRA, SPECS, PLACE, REPLACE, and VICI) which have shown that half-dose PDT is superior to high-density subthreshold micropulse laser treatment and oral eplerenone in achieving a complete SRF resolution on OCT in the short term [This study has some limitations. Firstly, this study was powered for the 2 treatment groups the patients were randomized to at baseline. After crossover treatment, statistical analysis with a mixed model would be biased, as the 4 groups were not divided at random. Therefore, we used an intention-to-treat model for the statistical analysis of this study. Moreover, these groups were largely disproportionate after evaluation visit 1, due to the much higher success rate of half-dose PDT compared to oral eplerenone treatment. Another bias is the fact that a minority of cCSC patients did not attend evaluation visit 3.In conclusion, most cCSC patients treated with half-dose PDT, either as primary treatment or crossover treatment after initial unsuccessful eplerenone treatment, achieve a complete resolution of SRF on OCT without recurrences at 12 months after baseline. BCVA improved significantly more in cCSC patients who received half-dose PDT as their first treatment compared to patients who first received unsuccessful oral eplerenone treatment followed by crossover half-dose PDT, although retinal sensitivity, microperimetry, and NEI VFQ-25 score did not differ between these groups. The results of our study add to the growing evidence that relatively early half-dose PDT is the first treatment of choice for cCSC, both in terms of anatomical and functional outcomes.