What is the recommended management approach for a patient with Central Serous Chorioretinopathy (CSCR)?

Management of Central Serous Chorioretinopathy

For acute CSCR presenting within 2-4 months, observe for 4-6 months unless the patient requires rapid visual recovery, has recurrent episodes, or bilateral disease—in which case proceed immediately to ICGA- and FA-guided half-dose or half-fluence photodynamic therapy. 1, 2, 3

Acute CSCR Management Algorithm

Initial Assessment and Risk Stratification

• Confirm the diagnosis using multimodal imaging: OCT to document subretinal fluid, FA to identify focal leakage points, and ICGA to assess choroidal hyperfluorescence 1
• Rule out macular neovascularization (MNV) using OCT-angiography, as this changes management entirely 1, 3
• Document symptom duration less than 2-4 months, presence of focal leakage on FA, and absence of extensive RPE atrophy (>1-2 disc areas) to classify as acute CSCR 1

Treatment Decision Pathway

Observation is the standard approach for first-episode acute CSCR because spontaneous resolution occurs in the majority within 3-4 months, though recurrence rates reach 51.2% 1, 3

Proceed immediately to treatment without observation if:

• Patient requires rapid visual recovery for professional reasons 1, 2, 3
• Recurrent episode of CSCR 2, 3
• Bilateral active disease 3
• OCT shows outer segment atrophy or granular debris indicating ongoing photoreceptor damage 2

Treatment Options for Acute CSCR

Half-dose or half-fluence PDT is the treatment of choice when intervention is indicated, achieving faster subretinal fluid resolution, more rapid recovery of retinal sensitivity, and lower recurrence rates (25%) compared to spontaneous resolution 1, 3

Technical specifications for PDT:

• Use ICGA- and FA-guided targeting of hyperfluorescent areas corresponding to focal leakage and subretinal fluid on OCT 1, 2
• Half-dose verteporfin (3 mg/m²) is preferred over half-fluence protocols 1, 3
• Treat all hyperfluorescent areas with a large spot including all areas, or use multifocal immediate sequential spots starting with the foveal area if involved 1

Argon laser photocoagulation can be used only when focal leakage on FA is located at a safe distance from the fovea, but carries significant risks of paracentral scotoma, MNV, and chorioretinal adhesion with secondary cystoid changes 1, 3

Monitoring During Observation Period

• Perform OCT every 1-3 months to assess residual subretinal fluid and photoreceptor damage 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
• If subretinal fluid persists beyond 4-6 months, transition to chronic CSCR management pathway 1

Chronic CSCR Management Algorithm

Diagnostic Criteria

Chronic CSCR is defined by:

• Persistent subretinal fluid on OCT for longer than 4-6 months 1, 3
• More than 1-2 disc areas of atrophic RPE changes 1, 3
• One or more focal leakage points on FA 1
• Hyperfluorescent choroidal abnormalities on ICGA 1

First-Line Treatment

ICGA- and FA-guided half-dose (or half-fluence) PDT is the first-line treatment for chronic CSCR, achieving complete subretinal fluid resolution in 83-100% of cases in large randomized controlled trials 1, 2, 4

Half-dose PDT is superior to:

• High-density subthreshold micropulse laser in both focal and diffuse phenotypes 1, 3
• Observation alone for preventing irreversible photoreceptor damage 3
• Mineralocorticoid receptor antagonists based on recent VICI trial results 4, 5

Management of Persistent Subretinal Fluid After Initial PDT

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

1. Re-PDT guided by FA/ICGA leakage as the preferred approach 1, 3
2. Argon laser photocoagulation to focal leakage points if located outside the central macula and PDT is unavailable 1
3. Observation or micropulse laser, though evidence of efficacy is modest 1
4. Mineralocorticoid receptor antagonists (eplerenone, spironolactone) may be attempted, but evidence is limited and recent trials have not demonstrated superiority 1, 4, 5

Alternative Treatments When PDT is Unavailable

If PDT access is limited:

• Consider argon laser photocoagulation for extrafoveal focal leakage points, acknowledging the risks and inferior long-term outcomes compared to PDT 1
• Mineralocorticoid receptor antagonists may be attempted as adjunctive therapy, though the VICI trial has largely resized their role as first-line treatment 4, 5

Critical Management Considerations

Corticosteroid Management

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

Risk Factors to Address

• Discuss stress reduction strategies and control of hypertension, as these are modifiable risk factors 6, 7
• Screen for and treat H. pylori if the patient presents with associated gastrointestinal symptoms 1

Monitoring for Complications

• Assess for MNV development using OCT-angiography at follow-up visits, as this complication requires anti-VEGF treatment with or without PDT 1
• Monitor for residual subretinal fluid with OCT at 1-3 month intervals, as even small amounts can lead to photoreceptor outer segment atrophy and vision loss over years 1, 2

Treatment of MNV Complicating CSCR

If MNV develops:

• Initiate intravitreal anti-VEGF treatment 1
• Consider adding half-dose or half-fluence PDT to address the underlying choroidal dysfunction, particularly for polypoidal choroidal vasculopathy (aneurysmal type 1 neovascularization) 1