Purpose: To investigate multi-mode imaging characteristics for understanding the natural prognosis of large avascular retinal pigment epithelium detachment (aPED) in macular area. Methods: We retrospectively analyzed patients diagnosed with aPED at Beijing Tongren Hospital Affiliated to Capital Medical University from January 2010 to June 2021. Patients with aPED maximum diameter greater than 1500 μm underwent best-corrected visual acuity (BCVA), fundus color photography, spontaneous fluorescence, infrared photography, FFA, ICGA, and OCT tests. Based on aPED characteristics, patients were divided into serous or drusenoid PED. In addition, the imaging characteristics for different types of large aPED were explored for its natural diagnosis.Results: A total of 64 eyes of 50 cases with large aPED were recruited. 21 males and 29 females with an average age of 64.31±6.38 years. The recruited population included 14 cases with the binocular disease, whereas 13 and 51 eyes had serous and drusenoid PED, respectively. Eight eyes (61.54%) of serous PED patients had drusen. Drusenoid PED patients had drusen in 47 eyes (92.17%). The OCT of serous PED patients showed large PED with uniform low reflection and RPE hyperplasmia (n=2 eyes). In contrast, the OCT of drusenoid PED patients showed some uneven, slightly high, or high reflection and RPE hyperplasmia in all the eyes. In addition, 46 eyes were accompanied by the subretinal fluid (SRF) (90.20%), 28 eyes developed hyperreflective foci between retinal layers (54.90%), and 3 eyes had inner retinal capsules (5.88%). No abnormal blood flow signal was detected in OCTA. The independent t-test showed no significant differences in the general conditions between the two groups, including age, BCVA, PED bottom diameter, and PED height. A total of 19 eyes of 16 cases were followed up, with an average follow-up time of 21.56 ± 18.85 months. Out of these 19 eyes, 12 eyes developed enlarged PED bottom diameter (63.16%), 5 eyes had partial or entire geographic atrophy (26.32%), 1 eye had RPE laceration (5.26%) and 1 eye had no changes (5.26%). However, no case developed into vascular PED (vPED).Conclusions: Multi-mode imaging provided imaging events, contributing to a more accurate diagnosis of aPED. Different types of aPED might be the different stages of same disease, need close observation, however, the natural course of disease shifted to geographic atrophy.Trial registration: Retrospective case series study, not applicable.