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

Treatment of Central Serous Chorioretinopathy

For acute CSC presenting within 2-4 months, observation for 4-6 months is the standard approach unless the patient is highly symptomatic, has recurrent disease, bilateral involvement, or requires rapid visual recovery for professional reasons—in which case ICGA- and FA-guided half-dose or half-fluence photodynamic therapy (PDT) should be performed immediately. 1

Initial Management Decision: Acute vs. Chronic CSC

Acute CSC (Symptoms <2-4 months)

Observation Strategy:

• Observation is recommended for first episodes with minimal RPE changes (<1-2 disc areas) given the high spontaneous resolution rate within 3-4 months 1
• However, waiting 4 months is not strongly evidence-based and fails to account for progressive photoreceptor damage that can occur even during early phases 1
• OCT monitoring every 1-3 months is critical, as residual subretinal fluid can cause photoreceptor outer segment atrophy even when not visible on slit-lamp examination 1

Immediate Treatment Indications: Proceed directly to half-dose or half-fluence PDT if any of the following apply 1:

• Highly symptomatic patients requiring rapid visual rehabilitation (e.g., professional pilots, surgeons)
• Recurrent episodes
• Bilateral disease activity
• Patient preference for treatment
• Evidence of outer segment atrophy or granular debris on OCT

If Persistent SRF After 4-6 Months:

• Obtain multimodal imaging (OCT-A, FA, ICGA) to reassess diagnosis 1
• If focal or diffuse leakage persists on FA/ICGA without macular neovascularization (MNV): proceed to half-dose/half-fluence PDT 1
• If MNV is detected: initiate intravitreal anti-VEGF therapy 1
• If no leakage on FA/ICGA and no MNV: consider re-PDT, focal laser (if leakage is extrafoveal), or continued observation 1

Chronic CSC (Symptoms >4-6 months)

Diagnostic Criteria: 1

• Persistent SRF on OCT for >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 ICGA

Primary Treatment: Half-Dose or Half-Fluence PDT

PDT is the first-line treatment for chronic CSC, achieving complete subretinal fluid resolution in 83-100% of cases by targeting the abnormal choroid, which is the primary pathophysiological mechanism. 2

• Target hyperfluorescent areas on ICGA that correspond to leakage on FA and SRF on OCT 1, 2
• Half-dose (3 mg/m²) or half-fluence PDT is preferred over full-dose to minimize side effects while maintaining efficacy 1, 2
• For multiple focal leakage areas, use a large spot including all areas or multifocal sequential spots starting with the fovea 1
• PDT provides faster SRF resolution, more rapid recovery of retinal sensitivity, and higher best-corrected visual acuity compared to observation 2

Post-PDT Management:

• Follow-up imaging at 4-6 weeks to assess treatment response 2
• Patients must avoid direct sunlight and UV radiation for 48-72 hours post-treatment 2
• If persistent SRF on OCT after initial PDT: obtain OCT-A, FA, ICGA to evaluate for MNV 1

If Persistent SRF After Initial PDT: Consider the following options 1:

1. Re-PDT guided by FA/ICGA leakage (half-dose/half-fluence, or consider full-dose)
2. High-density micropulse laser treatment
3. Mineralocorticoid receptor antagonist (eplerenone or spironolactone)
4. Observation

If MNV Develops:

• Intravitreal anti-VEGF is the primary treatment 1
• PDT (full-dose, half-dose, or half-fluence) may be added for polypoidal choroidal vasculopathy or aneurysmal type 1 neovascularization 1

Alternative Treatments When PDT is Unavailable

For acute CSC with extrafoveal focal leakage: 1

• Focal laser photocoagulation can be considered if the leakage point is outside the central macula
• Argon laser for focal extramacular fluid leaks has supportive evidence 3

Other options with limited evidence: 1, 4

• Micropulse laser: no good evidence to suggest efficacy in acute CSC, though some data exists for chronic cases
• Mineralocorticoid receptor antagonists (eplerenone, spironolactone): may be attempted but evidence is limited
• Anti-VEGF therapy: not effective as monotherapy for CSC without MNV

Critical Management Considerations

Corticosteroid Assessment:

• Always discuss cessation of corticosteroid use if the patient is currently taking any form (systemic, topical, inhaled, or topical dermatologic) 1
• Steroid-induced CSC may not resolve without dose reduction or discontinuation 5

Common Pitfalls to Avoid:

• Do not wait the full 4 months if OCT shows outer segment atrophy or granular debris—these indicate ongoing photoreceptor damage 1
• Do not assume minimal residual SRF is benign—it can cause progressive photoreceptor atrophy over years 1
• Do not use conventional thermal laser near the fovea—risk of significant RPE damage 6
• Patients with pre-existing foveal atrophy may achieve SRF resolution but limited visual improvement 2

Evidence Quality Note: The 2024 Progress in Retinal and Eye Research guideline 1 represents the most recent evidence-based consensus, superseding the 2019 version 1. A 2025 Cochrane network meta-analysis found low-dose PDT, supplements, and eplerenone had the highest SUCRA values for visual improvement, though confidence in this evidence ranges from very low to moderate 4. The American Academy of Ophthalmology supports PDT for chronic CSC with symptoms persisting >3 months 2.