What is the treatment approach for central serous retinopathy?

Treatment Approach for Central Serous Retinopathy

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. 1

Acute Central Serous Chorioretinopathy (aCSC)

Initial Management Strategy

Observation is preferred for first-time acute cases because spontaneous subretinal fluid (SRF) resolution occurs in the majority of patients within 3-4 months. 1 However, this waiting period is not without risk—retinal damage can occur during the early phases and progress as long as SRF persists, potentially leading to photoreceptor outer segment atrophy and vision loss over years. 1

Indications for Immediate Treatment

Proceed directly to treatment without observation if: 1

• Highly symptomatic patients requiring rapid visual rehabilitation for professional reasons
• Recurrent episodes of CSC
• Bilateral active disease
• Patient preference for treatment after informed discussion

Treatment Options for Acute CSC

Half-dose PDT is the treatment of choice when intervention is indicated, as it achieves faster SRF resolution, more rapid recovery of retinal sensitivity, and lower recurrence rates (25%) compared to spontaneous resolution (51.2% recurrence). 1, 2, 3

Technical specifications for PDT: 1

• Use ICGA- and FA-guided targeting of hyperfluorescent areas corresponding to focal leakage and SRF on OCT
• Half-dose verteporfin is preferred over half-fluence or half-time protocols based on large RCT evidence in chronic CSC
• For multiple focal leakage points, use a large spot including all areas or multifocal immediately sequential spots starting with the foveal area

Argon laser photocoagulation can be used only when focal leakage on FA is located at a safe distance from the fovea (outside central macula), but carries risks of paracentral scotoma, macular neovascularization (MNV), and chorioretinal adhesion with secondary cystoid changes. 1

Management of Persistent SRF After 4 Months

If SRF persists after 4 months of observation: 1

1. Obtain multimodal imaging (OCT-A, FA, ICGA) to reassess diagnosis and exclude MNV
2. If focal or diffuse leakage persists without MNV: Perform ICGA- and FA-guided half-dose PDT
3. If MNV is detected: Initiate intravitreal anti-VEGF treatment (with or without PDT)
4. If no leakage on FA/ICGA and no MNV: Consider re-PDT guided by leakage, observation, or other approaches (though evidence for alternatives is limited)

Important Caveats

Small residual SRF may warrant conservative follow-up with OCT at 1-3 months rather than immediate intervention, as it may resolve completely. 1 However, even shallow SRF undetectable on slit-lamp biomicroscopy can cause progressive photoreceptor and RPE atrophy, making OCT imaging critical for monitoring. 1

Corticosteroid cessation should be discussed with all patients prior to treatment, as corticosteroid use is a precipitating factor. 1

Chronic Central Serous Chorioretinopathy (cCSC)

Definition and Treatment Goals

Chronic CSC is defined by: 1

• Persistent SRF on OCT for longer than 4-6 months
• More than 1-2 disc areas of atrophic RPE changes
• Focal or diffuse leakage on FA with hyperfluorescent choroidal abnormalities on ICGA

The treatment goal is to prevent irreversible photoreceptor damage and vision loss by achieving complete SRF resolution and reversing photoreceptor/RPE dysfunction. 1

Primary Treatment Approach

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. 1 This approach treats the underlying choroidal dysfunction/pachychoroid pathology. 1

Management of Treatment Failures

If SRF persists after initial PDT: 1

1. Obtain OCT-A, FA, ICGA to reassess for MNV development
2. If persistent focal or diffuse leakage without MNV: Consider re-PDT guided by FA/ICGA, high-density micropulse laser, mineralocorticoid receptor antagonist, or observation
3. If MNV is present: Intravitreal anti-VEGF treatment (with or without PDT)
4. If no leakage and no MNV: Re-PDT, micropulse laser, mineralocorticoid receptor antagonist, or observation

Alternative Treatments (Limited Evidence)

Mineralocorticoid receptor antagonists (particularly eplerenone) show the highest quality evidence among oral medications, though none demonstrate robust efficacy. 4 These may be considered when PDT is unavailable or as adjunctive therapy. 1

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. 1

Selective retina therapy (SRT) has shown variable results (19-100% resolution rates) in retrospective studies, with one RCT showing 55% resolution versus 35% in sham controls at 3 months. 1 However, the evidence quality is insufficient to recommend it over PDT.

Critical Clinical Pitfalls

Do not delay treatment beyond 4 months in acute CSC if outer segment atrophy or granular debris is present, as prolonged detachment leads to irreversible photoreceptor damage. 1

Do not use thermal laser photocoagulation to treat underlying choroidal abnormalities in acute CSC—only focal leakage points away from the fovea. 1

Always exclude MNV with multimodal imaging (OCT-A, FA, ICGA) before treating persistent or recurrent SRF, as MNV requires anti-VEGF therapy rather than PDT alone. 1

Recognize that spontaneous resolution can occur in up to 30% of chronic CSC cases, making interpretation of uncontrolled studies unreliable. 1 This underscores the importance of evidence-based treatment decisions prioritizing large RCTs.