What is the initial approach for a young to middle-aged adult with no significant past medical history, presenting with the first episode of Central Serous Chorioretinopathy (CSCR) in an outpatient setting (OPD)?

Outpatient Management of First Episode Acute Central Serous Chorioretinopathy

For a first episode of acute CSCR presenting within 2-4 months, observation for 4-6 months is the recommended initial approach unless the patient has highly symptomatic disease, requires rapid visual recovery for professional reasons, has bilateral involvement, or shows evidence of photoreceptor damage on OCT—in which cases immediate half-dose or half-fluence photodynamic therapy should be performed. 1, 2

Initial Assessment and Risk Factor Modification

• Immediately discuss cessation of any corticosteroid use (topical, systemic, inhaled, or intranasal), as steroid-induced CSCR may not resolve without dose reduction or discontinuation 1, 2
• Counsel the patient about the association with psychosocial stress and recommend stress reduction strategies 3
• Address modifiable risk factors including hypertension control 4
• Confirm diagnosis with multimodal imaging: OCT showing subretinal fluid, fluorescein angiography demonstrating focal leakage points, and ideally ICGA showing choroidal hyperpermeability 1

Decision Algorithm for Treatment vs. Observation

Choose Observation (4-6 months) if:

• First episode with symptoms less than 2-4 months duration 1
• Single focal leak with minimal RPE atrophy (less than 1-2 disc areas) 1
• Patient can tolerate temporary visual symptoms 1
• No evidence of outer segment atrophy or granular debris on OCT 2

Rationale: Spontaneous resolution occurs in 70-80% of acute cases within 3-4 months, making observation a safe initial strategy 1, 5

Choose Immediate Half-Dose or Half-Fluence PDT if:

• Patient requires rapid visual recovery for professional reasons 1, 2
• Recurrent episode (history of previous CSCR) 1, 2
• Bilateral active disease 1, 2
• Highly symptomatic patient who cannot tolerate waiting 2
• OCT shows outer segment atrophy or granular debris indicating ongoing photoreceptor damage 2

Rationale: Half-dose PDT achieves faster subretinal fluid resolution, more rapid recovery of retinal sensitivity, and lower recurrence rates compared to observation, based on prospective randomized controlled trial data 1

Monitoring Protocol During Observation Period

• Perform OCT every 1-3 months to assess for residual subretinal fluid and photoreceptor damage 1, 2
• Monitor for signs that should trigger intervention: persistent or increasing subretinal fluid, development of outer segment atrophy, or accumulation of granular debris 1
• Do not wait the full 4 months if OCT demonstrates photoreceptor damage, as residual subfoveal fluid can lead to irreversible photoreceptor outer segment atrophy and vision loss over time 1, 2

Alternative Treatment Options (Second-Line)

Focal Laser Photocoagulation

• Consider only if focal leak on FA is located at a safe distance from the fovea (extrafoveal) 1, 4
• Avoid this approach for juxtafoveal or subfoveal leaks due to risks of symptomatic paracentral scotoma, choroidal neovascularization, and chorioretinal adhesion with secondary cystoid macular edema 1

High-Density Subthreshold Micropulse Laser

• May be attempted as an alternative if PDT is unavailable 1
• Evidence is limited compared to PDT 1

Mineralocorticoid Receptor Antagonists

• Eplerenone or spironolactone may be considered if PDT is unavailable 1, 2
• Evidence remains limited with weak recommendations 2

Critical Pitfalls to Avoid

• Do not perform thermal laser photocoagulation on underlying choroidal abnormalities, as this does not address the primary pathology and carries significant risks 1
• Do not rely solely on slit-lamp biomicroscopy to assess for subretinal fluid, as it can be too shallow to detect clinically; OCT is essential for diagnosis and monitoring 1
• Do not assume observation is always safe—residual subretinal fluid can cause progressive photoreceptor and RPE atrophy even in "resolved" cases 1
• Avoid ketoconazole, as studies show no significant effect on visual acuity or subretinal fluid resolution, with potential side effects including erectile dysfunction and nausea 1

Management After 4-6 Months of Observation

If Subretinal Fluid Persists:

• Obtain repeat FA and ICGA to reassess leakage patterns 1
• Proceed with ICGA- and FA-guided half-dose or half-fluence PDT targeting hyperfluorescent areas on ICGA that correspond to leakage on FA and subretinal fluid on OCT 1, 2
• If only minimal residual subretinal fluid remains, consider conservative follow-up with OCT in 1-3 months before intervening 1

If Subretinal Fluid Resolves:

• Continue monitoring as recurrence occurs in approximately 50% of cases 5
• Educate patient about symptoms requiring urgent re-evaluation 5