What are the treatment options for central serous chorioretinopathy (CSC)?

Treatment for Central Serous Chorioretinopathy (CSC)

For central serous chorioretinopathy, observation for 4 months is recommended for first episodes, while ICGA and FA-guided half-dose photodynamic therapy (PDT) is the most effective intervention when treatment is needed. 1, 2

Initial Management Approach

Acute CSC (symptoms < 4 months)

• First-line approach: Observation for 4 months after onset of first episode
  • Approximately 95% of patients recover to 20/30 vision or better spontaneously 2
  • Despite high spontaneous resolution rate, retinal damage can occur in early stages 1

When to Consider Early Intervention

Early treatment should be considered for:

• Highly symptomatic patients
• Recurrent episodes
• Bilateral disease
• Professional need for rapid visual recovery
• Patient preference for treatment 1, 2

Treatment Options (Evidence-Based Algorithm)

First-line Treatment (When Intervention is Needed)

• ICGA and FA-guided half-dose PDT
  • Targets both RPE and underlying choroidal abnormalities
  • Achieves complete SRF resolution in 67% of patients
  • Half-dose preferred over half-fluence PDT (minimizes side effects while maintaining efficacy) 1, 2
  • Treat hyperfluorescent areas on ICGA that correspond to leakage on FA and subretinal fluid on OCT 1

Alternative Options (When PDT is Unavailable)

1. Laser photocoagulation

   • Only for focal leakage points located away from the fovea
   • Caution: Risk of paracentral scotoma, macular neovascularization, and chorioretinal adhesion 1, 2

2. Subthreshold micropulse laser

   • Less effective than PDT but safer than conventional laser
   • Can be considered when PDT is unavailable 2, 3

3. Mineralocorticoid receptor antagonists

   • Limited evidence of efficacy
   • Recent trials (VICI) have largely resized their role as first-line treatment 3, 4

For Chronic CSC (Persistent SRF > 4 months)

• First-line: Half-dose or half-fluence PDT
• If SRF persists after initial PDT:
  1. Consider repeat PDT guided by leakage on FA/ICGA
  2. Consider full-dose PDT if half-dose was ineffective 1

For CSC with Macular Neovascularization

• Intravitreal anti-VEGF treatment (with or without PDT)
• Anti-VEGF therapy alone is not effective for CSC without neovascularization 1, 3

Monitoring and Follow-up

• Regular OCT imaging to assess SRF resolution and detect photoreceptor damage
• In case of only small residual SRF, follow-up with OCT after 1-3 months 1
• If SRF persists or increases, proceed with treatment

Important Considerations

• If the patient is taking corticosteroids, discuss possible cessation 1
• Chronic untreated CSC can lead to irreversible photoreceptor damage and permanent vision loss 2
• PDT and subthreshold laser target the underlying pathophysiology by improving RPE function and normalizing choroidal vascular permeability 5
• Multimodal imaging (OCT, OCT-A, FA, ICGA) is essential for proper diagnosis and treatment planning 1

Treatment Efficacy Comparison

• Half-dose PDT has shown superior outcomes compared to micropulse laser and mineralocorticoid receptor antagonists in randomized controlled trials 2, 3
• VEGF antagonists are not effective in the absence of choroidal neovascularization 3
• Other investigational treatments (rifampicin, aspirin, ketoconazole, beta blockers) have limited evidence and are not recommended as first-line options 1, 4