Persistent fluid, persistent risk: predicting pachychoroid macular atrophy in chronic central serous chorioretinopathy.

PURPOSE: To identify clinical and anatomical predictors of pachychoroid macular atrophy (pMA) development in chronic central serous chorioretinopathy (CSC) patients treated with photodynamic therapy (PDT), eplerenone, or subthreshold micropulse laser (SMLT). METHODS: Retrospective study of 74 consecutive chronic or recurrent CSC patients. All underwent baseline multimodal imaging and were treated with PDT (half-dose), eplerenone (50 mg daily), or SMLT (577 nm), per clinical protocols. Retreatment during follow-up with PDT or MLT was performed as needed based on fluid persistence or recurrence. Quantitative (SRF height, SFCT, CRT) and qualitative (SRF, SHRM, PED, EZ integrity) OCT parameters were recorded. Multivariate regression identified independent predictors of pMA, adjusting for treatment modality. RESULTS: At 12-month follow-up, persistent SRF was found in 51.4% of patients and was the strongest independent predictor of pMA (OR = 14.07; 95% CI: 1.73-114.65; p = 0.001). Additional independent predictors included reduced SRF height change (OR = 2.31; 95% CI: 1.14-4.68; p = 0.021), pronounced subfoveal choroidal thinning (OR = 1.68; 95% CI: 1.02-2.77; p = 0.045), and persistent SHRM (OR = 3.24; 95% CI: 1.32-7.95; p = 0.010). Treatment modality (PDT, eplerenone, SMLT) was not a significant independent predictor of pMA when adjusted for fluid persistence (p > 0.05). CONCLUSIONS: In chronic CSC, persistent subretinal fluid after treatment-regardless of retreatment-remains the dominant predictor of pMA. Anatomical resolution of SRF should be a primary therapeutic goal to prevent irreversible atrophic damage.