What is the recommended treatment approach for a patient with Central Serous Retinopathy (CSR)?

Treatment of Central Serous Chorioretinopathy (CSR)

For acute CSR presenting within 4 months, observe for 4 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 photodynamic therapy (PDT). 1, 2

Acute Central Serous Chorioretinopathy (aCSC)

Initial Management Strategy

• Observation for 4 months is the standard approach for first-time acute CSR because spontaneous subretinal fluid (SRF) resolution occurs in the majority of patients within 3-4 months. 3, 1, 2

• The recurrence rate after spontaneous resolution is 51.2%, which is significantly higher than the 25% recurrence rate seen with half-dose PDT treatment. 1

• Monitor with OCT every 1-3 months during the observation period to assess for residual SRF and photoreceptor damage. 2

Indications for Immediate Treatment (Skip Observation)

Proceed directly to half-dose PDT if any of the following apply:

• Highly symptomatic patients requiring rapid visual rehabilitation for professional reasons 1, 2
• Recurrent episodes of CSR 1, 2
• Bilateral active disease 1, 2
• OCT shows outer segment atrophy or granular debris, indicating ongoing photoreceptor damage 2

Treatment Technique for Acute CSR

• Half-dose PDT (3 mg/m² verteporfin) is the treatment of choice when intervention is indicated, achieving faster SRF resolution, more rapid recovery of retinal sensitivity, and lower recurrence rates compared to observation. 1, 2

• Target hyperfluorescent areas on ICGA that correspond to focal leakage on FA and SRF on OCT. For multiple leakage areas, use a large spot including all areas or multifocal immediate sequential spots, starting with the area including the fovea if involved. 3, 1

• Half-dose verteporfin is preferred over half-fluence or half-time protocols based on current evidence. 1

• Argon laser photocoagulation may 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 (MNV), and chorioretinal adhesion with secondary cystoid changes. 3, 1, 2

Chronic Central Serous Chorioretinopathy (cCSC)

Diagnostic Criteria

Chronic CSR is defined by:

• Persistent SRF on OCT for longer than 4-6 months 3, 1
• More than 1-2 disc areas of atrophic RPE changes 3, 1
• One or more focal leakage points on FA 3
• Hyperfluorescent choroidal abnormalities on ICGA 3
• No signs of MNV or other macular diseases on multimodal imaging (OCT, OCT-A, FAF, FA, ICGA) 3

First-Line Treatment

• ICGA- and FA-guided half-dose (or half-fluence) PDT is the first-line treatment for chronic CSR, with large RCTs demonstrating 21-100% complete SRF resolution rates and 83-100% efficacy in achieving complete resolution. 3, 1, 2, 4

• The PLACE trial demonstrated that ICGA-guided half-dose PDT was superior to ICGA-guided 810-nm high-density subthreshold micropulse laser (HSML) in chronic CSR for complete SRF resolution. 3

• Half-dose or half-fluence PDT is preferred over full-dose to minimize side effects while maintaining efficacy. 3, 2

Management of Persistent SRF After Initial PDT

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

1. Re-PDT guided by persistent leakage on FA/ICGA is highly effective, with the REPLACE trial showing 78% complete SRF resolution 1 year after crossover PDT following failed HSML treatment. 3

2. Re-evaluate the diagnosis using multimodal imaging (FA, ICGA, OCT-A) to exclude MNV or other conditions, as CSR has a broad differential diagnosis. 3

3. Consider high-density micropulse laser, mineralocorticoid receptor antagonist, or observation, though evidence for these approaches is modest. 3

Alternative Treatments (When PDT Unavailable)

• Laser photocoagulation to focal leakage points may be considered only for focal leakage outside the central macula, though long-term outcomes are not superior to untreated controls. 3

• Mineralocorticoid receptor antagonists (eplerenone, spironolactone) may be attempted, but evidence is limited and the SPECS trial showed that crossover to half-dose PDT after unsuccessful eplerenone treatment achieved 87% complete SRF resolution at 3 months. 3, 1, 2, 5

• High-density subthreshold micropulse laser shows inferior results compared to half-dose PDT in both focal and diffuse phenotypes of chronic CSR. 1

Critical Management Considerations

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

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

• The treatment goal is to prevent irreversible photoreceptor damage and vision loss by achieving complete SRF resolution and reversing photoreceptor/RPE dysfunction. 1

• Ultra-widefield ICGA may reveal choroidal alterations outside the central 55° area covered by traditional imaging, which could have implications for treatment efficacy. 3

Common Pitfalls

• Reported harms from PDT include Grade 1 choroidal ischemia in 3/51 eyes, though most studies report no treatment-related harms. 4

• Conventional subthreshold micropulse laser can cause significant RPE damage, making half-dose PDT the safer and more effective option. 4

• The PAINT RCT comparing half-dose PDT versus placebo is currently on hold due to verteporfin shortage, highlighting the importance of this medication's availability. 3