What is the initial treatment approach for central serous chorioretinopathy (CSC)?

Initial Treatment Approach for Central Serous Chorioretinopathy

For acute CSC presenting within the first 2-4 months, observation for 4 months is the standard initial approach, but proceed immediately to ICGA- and FA-guided half-dose photodynamic therapy if the patient has recurrent episodes, bilateral disease, or requires rapid visual recovery for professional reasons. 1, 2, 3

Acute Central Serous Chorioretinopathy (aCSC)

When to Observe

• Observation is appropriate for first-time acute CSC cases with minimal RPE changes (<1 disc area of atrophy) because 70-80% resolve spontaneously within 3-4 months. 1, 2, 4

• Monitor with OCT every 1-3 months during the observation period to detect residual subretinal fluid and early photoreceptor damage. 3

• Do not wait the full 4 months if OCT shows outer segment atrophy or granular debris in the subretinal space, as these indicate ongoing irreversible photoreceptor damage. 3

• The recurrence rate after spontaneous resolution is approximately 51%, which is significantly higher than the 25% recurrence rate following PDT treatment. 2, 5

When to Treat Immediately (Skip Observation)

Proceed directly to half-dose PDT without observation in the following scenarios:

• Recurrent acute CSC (patient has had previous episodes). 1, 2, 3

• Bilateral active disease. 1, 2, 3

• Highly symptomatic patients requiring rapid visual rehabilitation for professional reasons (e.g., pilots, surgeons, professional drivers). 1, 2, 3

• Persistent subretinal fluid beyond 4 months from initial presentation. 1, 2

Treatment Technique for Acute CSC

• Half-dose PDT (3 mg/m² verteporfin) is the treatment of choice, targeting hyperfluorescent areas on ICGA that correspond to focal leakage on FA and subretinal fluid on OCT. 1, 2, 3

• Half-dose PDT achieves faster subretinal fluid resolution, more rapid recovery of retinal sensitivity, and lower recurrence rates (25%) compared to spontaneous resolution (51% recurrence). 2, 5

• Half-dose PDT is preferred over half-fluence or half-time protocols because large RCTs demonstrate superior efficacy in chronic CSC, and using half the standard dose minimizes systemic side effects while allowing one vial of verteporfin to treat two patients. 1

• Argon laser photocoagulation can be used only when focal leakage on FA is located at a safe distance (>500 microns) from the fovea, but carries significant risks including paracentral scotoma, choroidal neovascularization, and chorioretinal adhesion with secondary cystoid changes. 1, 2, 3

Chronic Central Serous Chorioretinopathy (cCSC)

Definition and Treatment Goals

• Chronic CSC is defined by persistent subretinal fluid on OCT for longer than 4-6 months, with more than 1-2 disc areas of atrophic RPE changes, and diffuse leakage on FA with hyperfluorescent choroidal abnormalities on ICGA. 2

• The treatment goal is to prevent irreversible photoreceptor damage and permanent vision loss by achieving complete subretinal fluid resolution. 2, 3

First-Line Treatment

• ICGA- and FA-guided half-dose (or half-fluence) PDT is the first-line treatment for chronic CSC, achieving complete subretinal fluid resolution in 67-100% of cases. 1, 2

• In the PLACE trial (the only large prospective multicenter RCT), half-dose PDT was superior to high-density subthreshold micropulse laser, achieving complete subretinal fluid resolution in 67% versus 29% of patients at 7-8 months, with significantly greater improvements in visual acuity and retinal sensitivity. 1

Management of Persistent Subretinal Fluid After Initial PDT

If subretinal fluid persists after initial PDT, consider the following options in order:

1. Repeat ICGA- and FA-guided half-dose or half-fluence PDT (can also consider full-dose with full-fluence PDT for refractory cases). 1

2. Mineralocorticoid receptor antagonists (eplerenone or spironolactone) as adjunctive therapy or when PDT is unavailable, though evidence is limited. 2, 3

3. High-density subthreshold micropulse laser, though this shows inferior results compared to half-dose PDT in both focal and diffuse phenotypes. 2

4. Observation with close OCT monitoring if there is evidence of gradual improvement. 1

Critical Management Considerations

• Always discuss cessation or dose reduction of corticosteroid use (systemic, topical, inhaled, or intranasal) if the patient is currently taking any form, as steroid-induced CSC may not resolve without discontinuation. 3, 6

• Counsel patients about the potential relationship between CSC and psychosocial stress at the first visit. 6

• Screen for secondary choroidal neovascularization, especially in elderly patients with chronic CSC, as this complication requires anti-VEGF treatment. 4

• Residual subretinal fluid, even when shallow and not visible on slit-lamp biomicroscopy, can cause photoreceptor and RPE atrophy with subsequent vision loss over years, making OCT monitoring essential. 1