What is the treatment for central serous chorioretinopathy?

Treatment of Central Serous Chorioretinopathy (CSC)

Half-dose photodynamic therapy (PDT) is the most effective treatment for chronic central serous chorioretinopathy, while observation for 4 months is appropriate for acute cases that often resolve spontaneously. 1

Classification and Initial Approach

Acute CSC

• First episode with symptoms for less than 2-4 months
• Presence of subretinal fluid (SRF) on OCT
• One or more focal leakage points on fluorescein angiography (FA)
• No extensive atrophic retinal pigment epithelium (RPE) changes

Chronic CSC

• Persistent SRF for longer than 4-6 months
• More than 1-2 disc areas of atrophic RPE changes
• One or more focal leakage points on FA
• Hyperfluorescent choroidal abnormalities on indocyanine green angiography (ICGA)

Treatment Algorithm for Acute CSC

1. Initial Management: Observation for 4 months in first episodes 1

   • Approximately 95% of patients recover to 20/30 vision or better 2
   • Despite high spontaneous resolution rate, retinal damage can occur in early stages 1

2. Exceptions requiring earlier intervention:

   • Recurrent episodes
   • Bilateral disease activity
   • Professional need for rapid visual rehabilitation
   • Patient preference for active treatment

3. Treatment options when intervention is needed:

   • First choice: ICGA and FA-guided half-dose PDT 1
   • Alternative options (if PDT unavailable):
     • Laser photocoagulation (only for focal leakage points away from fovea)
     • High-density subthreshold micropulse laser
     • Mineralocorticoid receptor antagonists (less effective)

Treatment Algorithm for Chronic CSC

1. First-line treatment: ICGA and FA-guided half-dose (or half-fluence) PDT 1, 3

   • Targets both RPE and underlying choroidal abnormalities
   • Superior to other treatments in randomized controlled trials 1
   • Achieves complete SRF resolution in 67% of patients (vs. 29% with micropulse laser) 1

2. If SRF persists after PDT:

   • Re-evaluate diagnosis with OCT-A, FA, and ICGA to rule out choroidal neovascularization
   • Consider repeat PDT if persistent leakage is identified 1

3. Alternative options (if PDT unavailable or ineffective):

   • Subthreshold micropulse laser (less effective than PDT but better than observation) 3, 4
   • Conventional laser photocoagulation (only for non-subfoveal leakage points) 3
   • Mineralocorticoid receptor antagonists (eplerenone/spironolactone) have shown limited efficacy 3, 5

Special Considerations

• Steroid-induced CSC: Consider discontinuation or dose reduction of corticosteroids when possible 2
• Anti-VEGF agents: Not effective for CSC without choroidal neovascularization 3, 5
• Monitoring: Regular OCT imaging to assess SRF resolution and detect photoreceptor damage
• Chronic untreated CSC: Can lead to irreversible photoreceptor damage and permanent vision loss 1

Pitfalls and Caveats

• Waiting the full 4 months before intervention is not strongly supported by evidence and may allow photoreceptor damage to progress 1
• Thermal laser photocoagulation carries risks of symptomatic paracentral scotoma, macular neovascularization, and chorioretinal adhesion with secondary intraretinal cystoid edema 1
• PDT is superior to micropulse laser and mineralocorticoid receptor antagonists in randomized controlled trials 1
• Half-dose PDT is preferred over half-fluence PDT as it minimizes side effects while maintaining efficacy 1

The evidence strongly supports half-dose PDT as the most effective treatment for chronic CSC, with observation being appropriate for most first episodes of acute CSC. Early intervention should be considered for patients with risk factors for progression or professional need for rapid visual recovery.