PURPOSE: To report the 1-year progression rate and associated risk factors in an Asian cohort of patients with pachychoroid disease spectrum phenotype. METHODS: The authors report the 1-year findings from a prospective observational study, recruiting subjects with subfoveal choroidal thickness of ≥300 µm. Each eye was evaluated at baseline and at month 12 according to a standardized protocol including visual acuity and multimodal imaging. RESULTS: A total of 223 eyes of 133 participants (mean age 59.23 ± 9.18 years, 27.1% female) finished 1-year follow-up. Distribution of baseline diagnosis was uncomplicated pachychoroid (43 eyes), pachychoroid pigment epitheliopathy (108 eyes), central serous chorioretinopathy (54 eyes), and pachychoroid neovasculopathy (18 eyes). There was no significant change in the mean best-corrected visual acuity or subfoveal choroidal thickness. Fourteen eyes (6.3%) evolved to a different pachychoroid disease spectrum diagnosis, but there was no significant change in the mean best corrected visual acuity (BCVA) Logarithm of the minimum angle of resolution 0.15 ± 0.18 (Snellen equivalent 20/30) versus 0.07 ± 0.11 (Snellen equivalent 20/25), (P = 0.18) or subfoveal choroidal thickness (426.8 ± 59.2 vs. 456.3 ± 89.5, P = 0.49). Incident neovascularization developed in eight eyes (3.6%, five from pachychoroid pigment epitheliopathy, three from central serous chorioretinopathy). Seven patients received treatment (three anti-vascular endothelial growth factor [VEGF] and four photodynamic therapy). Factors associated with developing neovascularization include older age, smoking, and the presence of shallow irregular retinal pigment epithelium elevation on optical coherence tomography. CONCLUSION: At 1 year, pachychoroid disease spectrum remains relatively stable with low progression rate. Older age, smoking, and the presence of shallow irregular retinal pigment epithelium elevation were associated with higher rates of neovascular complications.