Central Serous Chorioretinopathy: Current Treatment
Last updated: September 2026
Central serous chorioretinopathy (CSCR) treatment has a genuinely important recent correction — a therapy that was widely adopted based on early promising data was subsequently shown ineffective in a rigorous trial, and residents should know this rather than continuing to reach for it reflexively.
The pachychoroid framework
CSCR is now understood as part of the "pachychoroid disease spectrum" — a thickened, hyperpermeable choroid (visible as dilated Haller's layer vessels, or "pachyvessels," on OCT/ICGA) overwhelms the RPE's capacity to keep the subretinal space dry, causing fluid accumulation at the macula. This choroidal-first understanding is why choroid-directed treatments (like photodynamic therapy) have emerged as more effective than treatments targeting the RPE defect alone.
Acute CSCR: usually just observation
Most acute cases resolve spontaneously within a few months. Observation is standard first-line management; treatment is reserved for cases where rapid visual recovery is professionally or functionally important, or where resolution doesn't occur within a reasonable window.
A genuinely important current correction: mineralocorticoid antagonists are not the answer
Oral mineralocorticoid receptor antagonists (MRAs) like eplerenone and spironolactone generated real enthusiasm as a non-invasive, low-risk oral option, based on the rationale that mineralocorticoid receptor activation in choroidal vessels contributes to pachychoroid pathophysiology. The VICI trial (a rigorous randomized controlled trial) largely deflated this enthusiasm — eplerenone did not outperform placebo in previously untreated chronic CSCR. Multiple 2024-2025 systematic reviews and network meta-analyses have since confirmed: MRAs are not an effective first-line treatment for chronic CSCR, despite their earlier promise and continued off-label use in some practices.
What the current evidence actually supports for chronic CSCR
| Treatment | Current evidence |
|---|---|
| Half-dose or half-fluence PDT | Most effective option per multiple 2024-2025 systematic reviews — supported by the PLACE trial and AAO's own 2025 technology assessment; ICGA-guided targeting of the leaking/hyperpermeable choroidal area improves precision |
| Conventional thermal laser | Acceptable alternative specifically when PDT is unavailable, and only when the leak is extrafoveal/non-subfoveal |
| Subthreshold micropulse laser (SMLT) | A reasonable non-PDT option; some trials show comparable outcomes to half-dose PDT, though PDT generally has the stronger evidence base |
| Anti-VEGF | Not effective in the absence of choroidal neovascularization — reserve anti-VEGF specifically for cases with secondary CNV (pachychoroid neovasculopathy), not for CSCR fluid alone |
| Mineralocorticoid antagonists | Not supported as first-line therapy per the VICI trial and subsequent reviews |
Practical takeaway
If your teaching included MRAs as a reasonable first-line oral option for chronic CSCR, that recommendation has been substantially walked back by more rigorous recent trial data. Half-dose/half-fluence PDT is now the treatment with the strongest current evidence base for chronic, non-resolving disease.
Key references: Therapeutic interventions for chronic CSCR: a comprehensive assessment of systematic reviews. 2025. | Therapies for Central Serous Chorioretinopathy, AAO Ophthalmic Technology Assessment. 2025. | Interventions for central serous chorioretinopathy: a network meta-analysis, Cochrane. 2025.
📘 Want the exam-ready deep dive? This topic, and much more is covered in Ophthalmology Explorer (A High-Yield Clinical Reference for Ophthalmology Residents, Fellows & Board Exams) — available on Kindle. See all my books.
Want to know more about treatment? Read about Corneal Topography at Sadbhaav or book a consultation with Dr. Dhaval Patel.