eMedicine Specialties > Ophthalmology > Retina

Retinal Detachment, Exudative

Lihteh Wu, MD, Consulting Surgeon, Department of Ophthalmology, Vitreo-Retinal Section, Instituto De Cirugia Ocular, Costa Rica
Teodoro Evans, MD, Retina Fellow, Vitreo-Retinal Section, Instituto De Cirugia Ocular, Costa Rica

Updated: Aug 2, 2007

Introduction

Background

Anytime subretinal fluid accumulates in the space between the neurosensory retina and the underlying retinal pigment epithelium (RPE), a retinal detachment occurs. Depending on the mechanism of subretinal fluid accumulation, retinal detachments traditionally have been classified into rhegmatogenous, tractional, and exudative.

Pathophysiology

Under normal conditions, water flows from the vitreous cavity to the choroid. The direction of flow is influenced by the relative hyperosmolarity of the choroid with respect to the vitreous and the RPE that actively pumps ions and water from the vitreous into the choroid. When there is an increase in the inflow of fluid or a decrease in the outflow of fluid from the vitreous cavity that overwhelms the normal compensatory mechanisms, fluid accumulates in the subretinal space leading to an exudative retinal detachment. For instance, certain pathological conditions are characterized by the presence of abnormal blood vessels that leak profusely. Other conditions are characterized by a broken blood-retinal barrier. All these conditions increase the inflow of fluid into the vitreous cavity. On the other hand, abnormally thick sclera, as seen in nanophthalmos, decreases the outflow of fluid. Damage to the RPE prevents the pumping action of fluid.

Frequency

United States

Given the diverse nature of the underlying causes of exudative retinal detachments, no reports are available on the frequency of this condition.

Mortality/Morbidity

Mortality and morbidity depend on the underlying cause. For instance, a patient with an exudative retinal detachment from scleritis secondary to rheumatoid arthritis has a severe condition. Compare this to a healthy patient who underwent scleral buckling surgery with an exudative retinal detachment. The outlooks are very different in each case.

Race

Racial predilection depends on the underlying cause, to include the following:

• Vogt-Koyanagi-Harada syndrome appears to be more common in Asians and Hispanics than in Caucasians.
• Choroidal melanoma is more common in Caucasians than in other races.
• Exudative age-related macular degeneration is more common in Caucasians than in other races.

Sex

Sex predilection depends on the underlying cause, to include the following:

• Coats disease is more common in males than in females.
• The uveal effusion syndrome is more common in males than in females.
• Idiopathic central serous chorioretinopathy occurs more commonly in men than in women.

Age

Age predilection depends on the underlying cause, to include the following:

• Coats disease is more common in children and young adults.
• Exudative age-related macular degeneration is a condition of elderly persons.
• Idiopathic central serous retinopathy occurs most often in middle-aged people.

Clinical

History

• Patients may complain of a red eye (eg, uveitic pathologies).
• Patients may notice a decrease in vision or visual field defect.
• Pain may be present (eg, scleritis).
• Parents may notice a white pupil (leukocoria).

Physical

• Bullous retinal detachment with shifting subretinal fluid: Depending on the position of the patient, the fluid accumulates in its most dependent position.
• The retina is characterized by a smooth surface that lacks folds as seen in a rhegmatogenous retinal detachment (RRD).
• The anterior segment may show signs of inflammation (eg, episcleral injection, iridocyclitis) or even rubeosis depending on the underlying cause.
• In chronic cases, deposition of hard exudates may be seen.
• Dilated telangiectatic vessels may be seen.

Causes

An extensive list of conditions that cause exudative retinal detachments exists. The conditions have been classified according to similar pathogenic mechanisms.

• Idiopathic
  • Coats disease
  • Central serous chorioretinopathy
  • Uveal effusion syndrome
• Inflammatory
  • Vogt-Koyanagi-Harada syndrome
  • Syphilis
  • Scleritis
  • Sympathetic ophthalmia
  • Other vasculitic entities (eg, rheumatoid arthritis, Wegener granulomatosis)
  • Other uveitic conditions (eg, toxoplasmosis, cytomegalovirus [CMV] retinitis)
  • Dengue fever
  • Orbital pseudotumor
  • Lymphomatoid granulomatosis
• Congenital
  • Nanophthalmos
  • Colobomas of the optic nerve
  • Familial exudative vitreoretinopathy
• Neoplastic
  • Choroidal melanoma
  • Choroidal metastases
  • Choroidal nevus
  • Choroidal hemangioma
  • Retinoblastoma
  • Primary intraocular lymphoma
• Iatrogenic
  • Excessive panphotocoagulation
  • Scleral buckling
• Vascular factors
  • Eclampsia
  • Exudative age-related macular degeneration
  • Chronic renal failure
  • Hypertension

Differential Diagnoses

Workup

Laboratory Studies

• Although the diagnosis of an exudative retinal detachment can usually be made clinically, the underlying etiology may be difficult to elucidate. Laboratory examinations under these circumstances are warranted.
  • Venereal Disease Research Laboratory (VDRL) test and fluorescein treponema antibody (FTA) test
  • Antineutrophil cytoplasmic antibodies
  • Erythrocyte sedimentation rate
  • Rheumatoid factor

Imaging Studies

• Ultrasound is a useful adjunct when the media is hazy. It can detect choroidal thickness, the presence or absence of choroidal masses, the size and location of choroidal masses, and scleral thickness. Peripheral annular choroidal detachments are seen in nanophthalmos and uveal effusion syndrome.
• Fluorescein angiography is a useful adjunct to identify areas of leakage in central serous chorioretinopathy, Vogt-Koyanagi-Harada syndrome, and Coats disease.

Histologic Findings

The histopathologic findings are similar to those of a RRD with loss of photoreceptor outer segments acutely and chronic changes exemplified by retinoschisis, cysts, and RPE proliferation. Other findings include massive leakage into the retina and subretinal space.

Biochemical analysis of subretinal fluid in Coats disease reveals high levels of protein, albumin, and cholesterol in combination with nearly normal levels of other biochemical components suggesting entrapment of larger molecules in the subretinal space with equilibrium of smaller molecules, probably by active transport of the RPE.

Treatment

Medical Care

The medical and surgical treatments of exudative retinal detachments have to be tailored to the underlying condition.

• Inflammatory conditions, such as scleritis and Vogt-Koyanagi-Harada syndrome, should be treated with anti-inflammatory agents.
• Tumors need to be treated accordingly. External beam radiation therapy or brachytherapy with a plaque may be used for choroidal melanoma. Metastatic lesions respond to chemotherapy or localized radiation therapy. Choroidal hemangiomas may respond to laser photocoagulation or plaque brachytherapy. Retinoblastomas may be shrunk with chemotherapy and then treated locally with heat, laser, or cryotherapy.
• Infectious etiologies may respond to antibiotics.
• Reports exist of patients with exudative retinal detachments secondary to chronic renal failure that have spontaneous retinal reattachment following renal transplant.

Surgical Care

The medical and surgical treatments of exudative retinal detachments have to be tailored to the underlying condition.

• Conditions with vascular anomalies, such as Coats disease, should be treated with laser, cryotherapy, or even vitrectomy to obliterate the vascular abnormalities.
• In nanophthalmos where the sclera is abnormally thick, vortex vein decompression with scleral windows and suprachoroidal fluid drainage is indicated.
• Congenital anomalies, such as optic pits or colobomas, may respond to vitrectomy and endolaser techniques.
• Central serous chorioretinopathy may respond to mild laser treatment of the focal areas that leak on fluorescein angiogram.

Consultations

Consult a vitreoretinal specialist early in the disease process. If immunosuppressive therapy is being considered, consultation with an immunologist or rheumatologist is highly recommended.

Follow-up

Further Inpatient Care

• Most ophthalmic care is rendered in an outpatient facility. For the most part, even surgical cases are treated in an ambulatory setting.

Complications

• Neovascular glaucoma
• Phthisis bulbi

Prognosis

• Depends on the underlying condition
  • In a series of 43 patients with Coats disease, 75% of treated patients had an improvement or stabilization of vision from baseline. Only 30% of untreated patients had a stable visual acuity.
  • The long-term prognosis in optic pits is probably poor because of secondary cystoid macular changes.
  • Idiopathic central serous chorioretinopathy is not as benign as previously thought. As many as 15% of patients may end up with a visual acuity of 20/200 or worse.
  • Exudative retinal detachments secondary to preeclampsia or eclampsia usually resolve without sequelae.

Miscellaneous

Medicolegal Pitfalls

• Patient must understand that the underlying medical problems may vary the outcome of their ocular treatments.

Special Concerns

• Women with preeclampsia or eclampsia may develop exudative retinal detachments. Once the baby is delivered, the subretinal fluid becomes reabsorbed by the RPE.

Multimedia

Media file 1: An 8-year-old boy with Coats disease. Notice the macular exudation.

Media file 2: An 8-year-old boy with Coats disease. Notice the peripheral vascular dilatations. This patient underwent cryotherapy months before, and the exudative retinal detachment has basically disappeared.

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Keywords

exudative retinal detachment, serous retinal detachment, nonrhegmatogenous retinal detachment, subretinal fluid accumulation, neurosensory retina, retinal pigment epithelium, RPE, retinal breaks, retinal tears

Contributor Information and Disclosures

Author

Lihteh Wu, MD, Consulting Surgeon, Department of Ophthalmology, Vitreo-Retinal Section, Instituto De Cirugia Ocular, Costa Rica
Lihteh Wu, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

Coauthor(s)

Teodoro Evans, MD, Retina Fellow, Vitreo-Retinal Section, Instituto De Cirugia Ocular, Costa Rica
Disclosure: Nothing to disclose.

Medical Editor

Vytautas A Pakainis, MD, Chief of Ophthalmology, Dorn Veterans Administration Medical Center, Professor of Ophthalmology, Ophthalmology, University of South Carolina School of Medicine
Vytautas A Pakainis, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine
Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Macula Society, and Retina Society
Disclosure: Alcon Laboratories Consulting fee Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

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