What's in this note:

1. Pachychoroid Concept - Defining features, pachyvessels, the unifying framework
2. Pachychoroid Pigment Epitheliopathy (PPE) - The earliest/mildest form
3. CSCR - Full Coverage - History (von Graefe 1866 → Gass 1967), epidemiology, pathogenesis, risk factors, classification (acute vs. chronic), clinical features, all imaging modalities (FA patterns including smokestack/inkblot, ICGA, OCT, FAF, OCT-A, adaptive optics, mfERG)
4. Differential Diagnosis - Structured comparison table (AMD, PCV, optic disc pit, VKH, dome-shaped macula)
5. Treatment Algorithms - Two flowcharts (acute CSCR + chronic CSCR) based directly on Ryan's Retina Figures 73.17 & 73.18
6. Individual treatments - Observation, argon laser, micropulse laser, PDT regimens (with the half-dose vs. half-fluence comparison), MRA evidence (VICI, EPISTAR), anti-VEGF, investigational agents
7. PNV - Type 1 MNV pathways
8. PCV - Historical context, structural diagram, EVEREST I/II, PLANET, FUJISAN trials
9. Peripapillary Pachychoroid Syndrome
10. Pathogenesis schematics - Unified pathway diagram + MCR pathway
11. Clinical Trials table - All major RCTs with results
12. Quick reference summary table
13. Pearls & Pitfalls

• Cochrane NMA, June 2025 - 67 RCTs, 4015 patients
• Huang et al. Meta-Analysis, 2025 - MRA vs PDT vs observation
• AAO Evidence Report, March 2025
• Pignataro et al., Eye 2026 - Hyperreflective choroidal foci predicting atrophy

CSCR & Pachychoroid Spectrum — 4-Part PowerPoint Series

CSCR Part1 Pachychoroid Basics

Presentation · PPTX

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CSCR Part2 Imaging DDx

Presentation · PPTX

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CSCR Part3 Treatment Trials

Presentation · PPTX

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CSCR Part4 PNV PCV PPS Pearls

Presentation · PPTX

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Latest Clinical Practice Guidelines on CSCR (2024-2026)

1. MOST IMPORTANT — APVRS/AAPPO/ARI International Consensus Guidelines (2025)

Methodology

• 26 international experts from 13 countries
• Delphi consensus process with anonymous voting (5-point Likert scale)
• 25 consensus statements covering 5 areas: disease definition, pathophysiology, investigations, current management, and future developments
• Acceptance threshold: >75% agreement required

Key Consensus Statements (All 25 achieved >75% agreement):

┌─────────────────────────────────────────────────────────────────────────┐
│     APVRS/AAPPO/ARI CONSENSUS — KEY RECOMMENDATIONS (2025)              │
├─────────────────────────────────────────────────────────────────────────┤
│                                                                         │
│  DEFINITION:                                                            │
│  CSC defined as a PACHYCHOROID-DRIVEN chorioretinal disorder            │
│  characterized by neurosensory retinal and/or RPE detachment            │
│                                                                         │
│  DIAGNOSIS:                                                             │
│  Multimodal imaging (OCT + FAF + FA + ICGA) recognized as              │
│  ESSENTIAL for diagnosis — unanimous agreement                          │
│                                                                         │
│  TREATMENT — FIRST-LINE (Chronic CSC):                                 │
│  Half-dose PDT UNANIMOUSLY ENDORSED as first-line treatment            │
│  for chronic CSC                                                        │
│                                                                         │
│  TREATMENT — MRA:                                                       │
│  Oral MRAs (eplerenone/spironolactone) LACKED CONSENSUS                │
│  for therapeutic benefit — aligned with VICI and SPECTRA trials        │
│  → MRAs are NOT routinely recommended                                   │
│                                                                         │
│  TREATMENT — Anti-VEGF:                                                 │
│  Anti-VEGF recommended SOLELY for CSC complicated by                   │
│  MACULAR NEOVASCULARIZATION — NOT for uncomplicated CSCR               │
│                                                                         │
│  FUTURE:                                                                │
│  Standardizing disease classification and exploring targeted            │
│  therapies through genetic and nanomedicine research                    │
└─────────────────────────────────────────────────────────────────────────┘

2. Evidence-Based Treatment Guideline — Feenstra, van Dijk, Cheung et al. (2024)

Guideline Recommendations:

3. Treatment Review — Kim, Sivaprasad, Aslam et al. (Eye, August 2025)

Treatment Algorithm (Kim et al., Eye 2025):

STEP 1 — RISK FACTOR REDUCTION (ALL CASES):
  → Discontinue ALL corticosteroids (any route)
  → Lifestyle modification, psychosocial therapy, treat sleep apnoea

STEP 2 — EXTRAFOVEAL CSC (focal leakage on FA/ICGA):
  → Acute or chronic: Focal laser OR half-dose/half-fluence PDT
  → No focal leakage: Observe 3-4 months for spontaneous resolution

STEP 3 — SUBFOVEAL ACUTE CSC (no Type 1 CNV):
  → Observe 3-4 months first
  → If no improvement: Half-dose/half-fluence PDT
  → Consider earlier treatment if: ↓ VA, recurrent episodes, cystoid
    changes, RPE atrophy, photoreceptor damage, only eye, occupation

STEP 4 — SUBFOVEAL CHRONIC CSC (no Type 1 CNV):
  → Half-dose/half-fluence PDT (first-line)
  → Subthreshold laser: if extensive RPE damage, previous poor PDT
    response, PDT contraindicated, or PDT unavailable

STEP 5 — CHRONIC CSC WITH TYPE 1 CNV (on OCT-A):
  → Anti-VEGF treatment should be considered
  → ± PDT for the pachychoroid component

4. Upcoming Trial — PAINT Trial (Planned 2026)

• Design: Prospective, multicenter, placebo-controlled RCT
• Focus: Half-dose PDT for chronic CSCR
• Expected launch: January 2026 (UK-based, NIHR-funded)
• Goal: Provide the highest-quality evidence to date on PDT protocols, using standardized outcome measures including anatomical AND visual endpoints
• Significance: Addresses the critical gap left by the relatively small VICI and PLACE trials

5. Ongoing RCT — BRICS Trial (2026, Published Protocol)

• Full name: Brolucizumab for Chronic CSCR without CNVM
• Design: Prospective RCT | N=42 | 1:1 brolucizumab vs. placebo (oral multivitamins)
• Primary endpoint: Fluid resolution on OCT at 1 and 3 months
• Secondary endpoints: BCVA, microperimetry, NEI-VFQ-25
• Significance: First dedicated RCT of brolucizumab in cCSCR WITHOUT CNV — tests the role of anti-VEGF in non-neovascular chronic CSCR

6. Psychological Dimension — New Systematic Review 2025 (Frontiers in Medicine)

• First comprehensive systematic review (PRISMA 2020) quantitatively linking anxiety and depression with CSCR
• 20 studies included (19 case-control, 1 longitudinal cohort)
• Key finding: Depressive symptoms significantly higher in CSCR patients across most studies
• Guideline implication: Recommends routine psychological screening and integrative management in ophthalmology practice for CSCR patients

Summary: What the Guidelines Agree On (Consensus Points, 2024-2026)

╔══════════════════════════════════════════════════════════════════════╗
║       GUIDELINE CONSENSUS ON CSCR MANAGEMENT (2024-2026)            ║
╠══════════════════════════════════════════════════════════════════════╣
║                                                                      ║
║  AGREED — STRONG CONSENSUS:                                         ║
║  ✓ Half-dose or half-fluence PDT = FIRST-LINE for chronic CSCR      ║
║  ✓ Acute CSCR: Observe 3-4 months before treating                   ║
║  ✓ Remove all steroids as first step in ALL cases                    ║
║  ✓ Multimodal imaging (OCT + FAF + FA + ICGA) is essential          ║
║  ✓ Anti-VEGF only for CSC with confirmed MNV/CNV                    ║
║  ✓ CSCR is a pachychoroid-driven disorder                           ║
║                                                                      ║
║  AGREED — MRAs ARE NOT STANDARD TREATMENT:                          ║
║  ✗ MRAs (eplerenone/spironolactone) lacked consensus for benefit    ║
║    (APVRS/AAPPO/ARI 2025; VICI trial; Cochrane NMA 2025;            ║
║     Huang meta-analysis 2025)                                        ║
║                                                                      ║
║  STILL CONTROVERSIAL / UNANSWERED:                                  ║
║  ? Optimal PDT parameters (half-dose vs. half-fluence)              ║
║  ? Role of anti-VEGF without CNV (BRICS trial ongoing)              ║
║  ? Standardized disease classification system                        ║
║  ? Long-term outcomes — no consensus RCT data >24 months            ║
║  ? Role of brolucizumab, faricimab in CSCR                          ║
║  ? Verteporfin shortage — urgent alternative protocols needed        ║
╚══════════════════════════════════════════════════════════════════════╝

Key Guideline Documents — Quick Reference