The venous overload chorioretinal lesion (VOC) hypothesis provides a new perspective for understanding the thick choroidal spectrum disorders (PSD). This hypothesis posits that the obstruction of choroidal venous outflow is the common pathophysiological basis of PSD. The pathogenesis of VOC includes: anatomical basis (the tortuous veins are similar to "Starling resistors", with outflow obstruction leading to venous hypertension and the exacerbation of low intraocular pressure); pathophysiological cascade reaction (venous hypertension triggers venous dilation and remodeling, forming "thick-walled vessels", abnormal anastomosis, and high vascular permeability, ultimately resulting in choroidal thickening, subretinal fluid accumulation, and neovascularization). In addition, multimodal imaging techniques such as swept-source optical coherence tomography (OCT) and OCT angiography play a crucial role in the diagnosis and treatment of VOC, enabling the identification of various imaging biomarkers, such as morphological markers (thick-walled vessels, retinal detachment sign, tortuous veins interanastomosis, choroidal thickness, etc.) and hemodynamic markers (choroidal vascular index, choroidal capillary blood flow, choroidal vascular high permeability, etc.), which are helpful for diagnosis, differentiation, assessment of disease activity, prediction of prognosis, and guidance for individualized treatment. The treatment strategy should shift from simply draining fluid to reducing venous load and restoring blood flow balance. Based on the disease manifestations and imaging biomarkers, treatment options can be selected, such as photodynamic therapy, anti-vascular endothelial growth factor (VEGF) drugs, laser photocoagulation for leakage predominant cases, or anti-VEGF drugs combined with photodynamic therapy or monotherapy for neovascularization cases. Future research directions include further elucidating the complex pathogenesis of VOC (such as upstream arterial perfusion factors, abnormal neurovascular regulation), developing etiological-targeted therapies (reducing venous resistance, improving tortuous vein outflow function), using artificial intelligence to integrate multimodal imaging and genomics data to establish a precise decision-making system, and strengthening disease prevention and long-term management. The VOC hypothesis provides a theoretical basis for the precise diagnosis and treatment of PSD. With the deepening of research and the development of new therapies, it will promote the diagnosis and treatment of choroidal-retinal diseases into an era of precision medicine centered on hemodynamics.
