Treatment Approach for Central Serous Retinopathy

Acute Central Serous Chorioretinopathy (aCSC)

• For acute CSC presenting within 2-4 months, observation for 4 months is the standard approach unless the patient requires rapid visual recovery for professional reasons, has recurrent episodes, or bilateral disease—in which case ICGA- and FA-guided half-dose photodynamic therapy should be performed immediately, as recommended by the American Academy of Ophthalmology 1
• Observation is preferred for first-time acute cases because spontaneous subretinal fluid (SRF) resolution occurs in the majority of patients within 3-4 months, with a recurrence rate of 51.2% in spontaneous resolution, according to the American Academy of Ophthalmology 1, 2
• Highly symptomatic patients requiring rapid visual rehabilitation for professional reasons should proceed directly to treatment without observation, as suggested by the American Academy of Ophthalmology 3
• Bilateral active disease is an indication for immediate treatment, as recommended by the American Academy of Ophthalmology 1
• Half-dose PDT is the treatment of choice when intervention is indicated, achieving faster SRF resolution, more rapid recovery of retinal sensitivity, and lower recurrence rates (25%) compared to spontaneous resolution, according to the American Academy of Ophthalmology 5
• Technical specifications for PDT include using ICGA- and FA-guided targeting of hyperfluorescent areas corresponding to focal leakage and SRF on OCT, with half-dose verteporfin preferred over half-fluence or half-time protocols, as recommended by the American Academy of Ophthalmology 1, 4, 5
• Argon laser photocoagulation can be used only when focal leakage on FA is located at a safe distance from the fovea, but carries risks of paracentral scotoma, macular neovascularization (MNV), and chorioretinal adhesion with secondary cystoid changes, according to the American Academy of Ophthalmology 2, 4, 5

Chronic Central Serous Chorioretinopathy (cCSC)

• Chronic CSC is defined by persistent SRF on OCT for longer than 4-6 months, with more than 1-2 disc areas of atrophic RPE changes, and focal or diffuse leakage on FA with hyperfluorescent choroidal abnormalities on ICGA, as defined by the American Academy of Ophthalmology 1, 3, 7
• The treatment goal is to prevent irreversible photoreceptor damage and vision loss by achieving complete SRF resolution and reversing photoreceptor/RPE dysfunction, according to the American Academy of Ophthalmology 2
• ICGA- and FA-guided half-dose (or half-fluence) PDT is the first-line treatment for chronic CSC, with large RCTs demonstrating 21-100% complete SRF resolution rates, as recommended by the American Academy of Ophthalmology 2
• If SRF persists after initial PDT, consider re-PDT guided by FA/ICGA, high-density micropulse laser, mineralocorticoid receptor antagonist, or observation, as suggested by the American Academy of Ophthalmology 1, 3, 7
• Mineralocorticoid receptor antagonists, such as eplerenone, may be considered when PDT is unavailable or as adjunctive therapy, although the evidence is limited, according to the American Academy of Ophthalmology 6
• High-density subthreshold micropulse laser has been studied but shows inferior results compared to half-dose PDT in both focal and diffuse phenotypes of chronic CSC, as reported by the American Academy of Ophthalmology 1
• Selective retina therapy (SRT) has shown variable results, but the evidence quality is insufficient to recommend it over PDT, according to the American Academy of Ophthalmology 8