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

Treatment for Central Serous Chorioretinopathy

For acute CSC presenting within 4 months, observation is recommended unless the patient requires rapid visual recovery, has recurrent disease, or bilateral involvement—in which case proceed directly to half-dose or half-fluence photodynamic therapy (PDT) guided by ICGA and FA. 1, 2, 3

Acute Central Serous Chorioretinopathy (aCSC)

Initial Management Strategy

• Observation for 4 months is the standard approach for first-time acute CSC with minimal RPE changes (less than 1-disc area of atrophy), given spontaneous subretinal fluid (SRF) resolution occurs in the majority of patients within this timeframe. 1, 2, 3

• OCT monitoring every 1-3 months is critical to assess for residual SRF and photoreceptor damage, as even shallow SRF can cause progressive outer retinal atrophy. 1, 2

• Do not wait the full 4 months if OCT shows outer segment atrophy or granular debris, as these indicate ongoing photoreceptor damage requiring immediate intervention. 2

Indications for Immediate Treatment (Skip Observation)

Proceed directly to treatment if any of the following apply:

• Highly symptomatic patients requiring rapid visual rehabilitation for professional reasons 1, 2, 3
• Recurrent episodes of CSC 2, 3
• Bilateral active disease 2, 3
• Patient preference after informed discussion of risks and benefits 1

Treatment Options for Acute CSC

Half-dose (3 mg/m²) or half-fluence PDT is the preferred treatment when intervention is indicated, achieving 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:

• Target hyperfluorescent areas on ICGA that correspond to focal leakage on FA and SRF on OCT 1, 2, 3
• Use half-dose verteporfin (3 mg/m²) or half-fluence settings to minimize side effects while maintaining efficacy 1, 2, 4
• For multiple focal leakage areas, use a large spot including all areas or multifocal immediately sequential spots, starting with the fovea if involved 1

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

Chronic Central Serous Chorioretinopathy (cCSC)

Definition

Chronic CSC is defined by:

• Persistent SRF on OCT for longer than 4-6 months 1, 3
• More than 1-2 disc areas of atrophic RPE changes 1, 3
• Focal or diffuse leakage on FA with hyperfluorescent choroidal abnormalities on ICGA 1, 3

First-Line Treatment

ICGA- and FA-guided half-dose (3 mg/m²) or half-fluence PDT is the first-line treatment for chronic CSC, achieving complete SRF resolution in 83-100% of cases. 1, 2, 4

Treatment protocol:

• Target hyperfluorescent areas on ICGA corresponding to leakage on FA and SRF on OCT 1, 2, 3
• Half-dose or half-fluence PDT is preferred over full-dose to minimize potential side effects while maintaining efficacy 1, 2, 4
• Post-treatment precautions include avoiding direct sunlight and UV radiation for 48-72 hours 4

Management of Persistent SRF After Initial PDT

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

1. Re-PDT guided by FA/ICGA (another half-dose or half-fluence PDT can be performed, or full-dose with full-fluence may be considered) 1, 3
2. Argon laser photocoagulation to focal leakage points if leakage is exclusively extrafoveal and PDT is unavailable 1, 3
3. Observation or micropulse laser, though evidence of efficacy is modest 1, 3
4. Mineralocorticoid receptor antagonists (eplerenone or spironolactone), though evidence is limited 1, 3

Alternative Treatments with Limited Evidence

Mineralocorticoid receptor antagonists (eplerenone, spironolactone) may be attempted when PDT is unavailable or as adjunctive therapy, but evidence is limited and recurrence rates are significantly higher (compared to PDT). 1, 3, 5

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. 3

Anti-VEGF agents (bevacizumab, ranibizumab, aflibercept) have no proven efficacy for CSC without associated choroidal neovascularization, with meta-analyses failing to confirm positive effects. 1, 5

Critical Management Considerations

Corticosteroid Cessation

Always discuss cessation of corticosteroid use if the patient is currently taking any form (systemic, topical, inhaled, or intranasal), as steroid-induced CSC may not resolve without dose reduction or discontinuation. 1, 2, 3

Follow-Up Monitoring

• Follow-up imaging at 4-6 weeks post-PDT is appropriate to assess treatment response 4
• In cases of small residual SRF after treatment, a conservative approach with follow-up OCT after 1-3 months may be followed to see if SRF eventually resolves completely 1

Management of CSC with Macular Neovascularization

When a neovascular component or polypoidal choroidal vasculopathy is present, PDT (either full-dose, half-dose, or half-fluence) can be added to anti-VEGF treatment. 1

Common Pitfalls to Avoid

• Do not use anti-VEGF monotherapy for CSC without documented neovascularization, as evidence shows no benefit and may delay effective treatment 1, 5
• Do not perform argon laser photocoagulation on underlying choroidal abnormalities or near the fovea, as it does not address choroidal dysfunction and carries significant risks 1
• Do not rely on slit-lamp biomicroscopy alone to detect SRF, as it can be too shallow to visualize; OCT imaging is critical for diagnosis and monitoring 1