RPE-Targeted Laser Therapies for Central Serous Chorioretinopathy: Sublethal Modulation Versus Selective Injury and Repair—A Narrative Review

Central serous chorioretinopathy (CSC) is increasingly understood within the pachychoroid disease spectrum, with choroidal abnormalities playing a central pathogenic role. Nevertheless, the retinal pigment epithelium (RPE) remains critical to outer blood–retinal barrier function and subretinal fluid (SRF) homeostasis, and represents a potentially modifiable therapeutic target. RPE-targeted laser therapies employ biologically distinct approaches, ranging from sublethal RPE modulation with subthreshold micropulse laser and nondamaging retinal laser therapy to selective RPE injury followed by repair with selective retina therapy. We reviewed their laser–tissue interactions, dosimetry, clinical outcomes, and safety in CSC, focusing on how different RPE responses contribute to fluid resolution. Experimental and clinical observations provide a biological basis for considering how sublethal RPE modulation and selective RPE injury followed by repair may contribute to restoration of the RPE barrier and fluid homeostasis through distinct biological responses. Nevertheless, the mechanisms linking these RPE responses to SRF resolution remain incompletely understood. RPE-targeted laser therapies represent both potential therapeutic approaches and a means of gaining mechanistic insight into the contribution of RPE dysfunction to CSC. However, despite their distinct biological rationales, the clinical evidence supporting these modalities remains heterogeneous and insufficient to establish their comparative efficacy. Optimal treatment parameters, patient selection, and the long-term efficacy and safety of repeated treatment remain to be established.