Treatment of Central Serous Chorioretinopathy

Initial Management Decision: Acute vs. Chronic CSC

For acute central serous chorioretinopathy (CSC) presenting within 2-4 months, observation for 4-6 months is recommended unless the patient is highly symptomatic, has recurrent disease, bilateral involvement, or requires rapid visual recovery, in which case half-dose or half-fluence photodynamic therapy (PDT) should be performed immediately, as per the American Academy of Ophthalmology guidelines 1, 2, 3
Observation is recommended for first episodes of acute CSC with minimal RPE changes, given the high spontaneous resolution rate within 3-4 months, with a strength of evidence rated as moderate 1, 2, 3
OCT monitoring every 1-3 months is critical to assess residual subretinal fluid and photoreceptor damage, with a high level of evidence supporting its use 3
Proceed directly to half-dose or half-fluence PDT if the patient has highly symptomatic disease, recurrent episodes, bilateral involvement, or requires rapid visual rehabilitation, with a strong recommendation based on high-quality evidence 1, 2, 3, 4

The American Academy of Ophthalmology recommends half-dose or half-fluence PDT as the first-line treatment for chronic CSC, achieving complete subretinal fluid resolution in 83-100% of cases, with a high level of evidence supporting its efficacy 7
Target hyperfluorescent areas on ICGA that correspond to leakage on FA and SRF on OCT, with a moderate level of evidence supporting this approach 4, 5, 7
Half-dose (3 mg/m²) or half-fluence PDT is preferred over full-dose to minimize side effects while maintaining efficacy, with a strong recommendation based on high-quality evidence 4, 5, 7

Focal laser photocoagulation can be considered for acute CSC with extrafoveal focal leakage, with a low level of evidence supporting its use 1, 2
Mineralocorticoid receptor antagonists (eplerenone, spironolactone) may be attempted for chronic CSC, but evidence is limited, with a weak recommendation based on low-quality evidence 6

Always discuss cessation of corticosteroid use if the patient is currently taking any form, as steroid-induced CSC may not resolve without dose reduction or discontinuation, with a high level of evidence supporting this recommendation 1, 2, 3
Do not wait the full 4 months if OCT shows outer segment atrophy or granular debris, as these indicate ongoing photoreceptor damage, with a strong recommendation based on high-quality evidence 4, 5