Exudative Retinal Detachment

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.
The composition of the choroidal interstitial fluid plays a fundamental role in the
pathogenesis of an exudative retinal detachment. The composition of the choroidal interstitial
fluid in turn is influenced by the degree of choroidal vascular permeability. Any pathological
process that affects choroidal vascular permeability can potentially cause an exudative retinal
detachment. Alternatively, damage to the RPE prevents the pumping action of fluid and can
lead to fluid accumulation in the subretinal space. Several inflammatory, infectious, vascular,
degenerative, malignant, or genetically determined pathological conditions have been
recognized to cause exudative retinal detachments.
In preeclampsia, there is intense vasoconstriction of the choroidal arterioles, which leads to
choroidal ischemia and RPE infarction. The outer blood-retinal barrier is broken down and
causes increased vascular permeability.
Eyes with Coats disease exhibit vascular endothelial growth factor (VEGF) and VEGF
receptors.[1]

Epidemiology
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.
Exudative retinal detachment secondary to preeclampsia usually resolves without long-term complications.
After delivery, the subretinal fluid is absorbed by the RPE pump and the visual acuity returns to predetachment levels in a few weeks. However, patients with severe eclampsia may experience permanent
visual loss secondary to extensive RPE necrosis even when the retinal detachment resolves.

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.

History
See the list below:

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
See the list below:

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.
The images below show exudative retinal detachment in a patient with Coats disease.

An 8-year-old boy with Coats disease.

Notice the macular exudation.

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.

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

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Idiopathic
Coats disease
Central serous chorioretinopathy
Uveal effusion syndrome
Inflammatory
Vogt-Koyanagi-Harada syndrome
Orbital pseudotumor
Lymphomatoid granulomatosis
Scleritis
Sympathetic ophthalmia
Collagen vascular diseases
Wegener's granulomatosis
Sarcoidosis
Inflammatory bowel disease
Infectious
Syphilis
Toxoplasmosis
Cytomegalovirus [CMV] retinitis
Dengue fever
Tuberculosis
Lyme disease
Catscratch disease
Congenital
Nanophthalmos
Colobomas of the optic nerve
Familial exudative vitreoretinopathy
Neoplastic
Choroidal melanoma
Choroidal metastases
Choroidal nevus
Choroidal hemangioma
Retinoblastoma
Primary intraocular lymphoma

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Renal diseases
Lupus nephritis
Crescentic membranous nephropathy
Goodpasture syndrome
Patients on hemodialysis
IgA nephropathy
Type II membrane proliferative glomerulonephritis
Chronic renal failure
Iatrogenic
Excessive panphotocoagulation
Scleral buckling
Systemic disorders that induce an occlusive vascular choroidal disorder
Pregnancy-induced hypertension (eclampsia/preeclampsia)
Malignant hypertension
Collagen vascular diseases
Disseminated intravascular coagulopathy

Differential Diagnoses

Capillary Hemangioma

Choroidal Melanoma

Ciliary Body Melanoma

Exudative ARMD

Interstitial Keratitis

Juvenile Retinoschisis

Ocular Hypotony

Postoperative Retinal Detachment

Proliferative Retinal Detachment

Retinoblastoma Imaging

Retinopathy of Prematurity

Rhegmatogenous Retinal Detachment

Scleritis in Emergency Medicine

Senile Retinoschisis

Tractional Retinal Detachment

Uveitis, Anterior, Granulomatous

Uveitis, Anterior, Nongranulomatous

Laboratory Studies
See the list below:

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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
See the list below:

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. [2]

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.
In the acute uveitic phase of Vogt-Koyanagi-Harada syndrome, an eosinophilic exudate containing
proteinaceous material is found in the subretinal space that is not usually present in the convalescent and
chronic recurrent phases of the disease.[3]
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.

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.[4]
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 or renal dialysis. [5]
Anti-VEGF agents may play a role in the management of Coats disease. [1, 6, 7]

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.

Further Inpatient Care

See the list below:

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

Complications
See the list below:

Neovascular glaucoma
Phthisis bulbi

Prognosis
See the list below:

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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.[8]
The long-term prognosis in optic pits is probably poor because of secondary cystoid
macular changes.[9]
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. [10]
Exudative retinal detachments secondary to preeclampsia or eclampsia usually resolve
without sequelae.