SMACH (Stellate Multiform Amelanotic Choroidopathy) is a rare entity that should be considered for differential diagnosis of choroidal lesions with subretinal fluid, particularly in young patients. We present the case of a 15-year-old male with a yellow-orange choroidal lesion in the right eye, initially misinterpreted as an infection process due to the presence of a cutaneous erythema and environmental exposure. Multimodal imaging - including OCT, en-face OCT, and ICG - was essential in identifying the hallmark features of SMACH: dendriform projections, choroidal hyperreflectivity in absence of pachyvessels or deep vascular alteration, and a stellate hypofluorescent pattern. The self-limited nature of the subretinal fluid and the absence of inflammatory signs supported the diagnosis. Recognizing SMACH avoided unnecessary treatments such as anti-VEGF therapy or corticosteroids. This is Spain's first case, it underscores the importance of early diagnosis through multimodal imaging to prevent overtreatment and to improve both visual and emotional outcomes for the patient.

To report a case of stellate multiform amelanotic choroidopathy (SMACH) with focal hyperfluorescence on indocyanine green angiography (ICGA), successfully treated with photodynamic therapy (PDT). An 18-year-old male presented with subretinal fluid (SRF) overlying an irregular lesion in the inner choroid. A diagnosis of probable idiopathic macular neovascularization was made; treatment with intravitreal injections (IVIs) of anti-vascular endothelial growth factor (VEGF) agents showed no effect. The diagnosis was later revised to SMACH due to distinctive features on optical coherence tomography (OCT) and ICGA. Typically, no focal leakage is observed on ICGA in SMACH, and no successful treatment has been previously described. However, our case presented with focal leakage on ICGA, and treatment with full-dose PDT led to complete resolution of SRF. Diagnosing and treating SMACH can be challenging. No effective treatment has been reported to date. We describe a case with focal leakage on ICGA successfully treated with full-dose PDT. We suggest full-dose PDT as the first-line treatment of SMACH with associated focal leakage on ICGA.