Exudative Retinal Detachment

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Exudative Retinal Detachment
Retinal detachment
Exudative Retinal Detachment. From the Collections of Thomas M. Aaberg, MD and Thomas M. Aaberg Jr., MD. Retina Image Bank. 2013; Image Number 3505. © the American Society of Retina Specialists."

Disease Entity

Disease

Exudative (or serous) retinal detachment (ERD) occurs when fluid accumulates in the subretinal space between the sensory retina and the retinal pigmented epithelium (RPE) resulting in retinal detachment. Causes for fluid accumulation include inflammatory, infectious, and neoplastic diseases of the choroid or retina.[1][2]

Causes

Inflammatory
Infectious
Neoplastic
Other

Pathophysiology

The subretinal space, a remnant of the embryonic optic vesicle, is practically nonexistent in a healthy eye. However, pathologies that disrupt the integrity of the blood-retina barrier (BRB) can cause leakage of fluid that enlarges the subretinal space and separates the sensory retina from the RPE resulting in retinal detachment.[1]

The BRB has an inner and outer component. The inner blood-retina barrier (iBRB) is composed of tight junctions in between cells of the retinal endothelium whereas the outer blood-retina barrier (oBRB) is composed of tight junctions between cells of the RPE. [3]

Diagnosis

Diagnosis of ERD begins with a detailed history and ophthalmic exam.

History

ERD may develop from localized ocular disease or as a manifestation of wide-spread systemic disease and thus a thorough ocular and medial history is required.[1] Some patients report a progressive, fluctuating loss of peripheral vision. [4]

Physical Exam

Slit-lamp examination, dilated fundoscopy, and indirect ophthalmoscopy with scleral depression should all be performed. ERD can appear as shifting fluid beneath the retina. The fluid shifts with gravity and can change location according to patient position.[4] Exudative detachment looks smooth compared to a jagged, rhegmatogenous detachment.

Testing

Fluorescein angiography, Indocyanine green angiography (ICGA), Optical Coherence Tomography and echography aid in diagnosis. Blood tests, X-rays, CT scan, and Magnetic Resonance Imaging can identify systemic correlates that reveal the etiology.[1]

Diagnostic vitrectomy is crucial for infectious and neoplastic causes of ERD.

Management

Treatment

Unlike rhegmatogenous and tractional detachment which are treated surgically, ERD is generally treated medically. Treatment focuses on the underlying pathology causing the fluid buildup.

Medical

Immunosuppressive

For ERD caused by non-infectious uveitis (e.g. VKH syndrome), common treatment is high dose IV steroids followed by oral steroid taper. Intravitreal triamcinolone has also been used. Alternatives to steroids include cyclosporine A, azathioprine, methotrexate, mycophenolate mofetil and infliximab.[1]

Biologics

Tumor necrosis factor (TNF) alpha inhibitors (etanercept, infliximab, adalimumab), interferon alpha-2, interferon-beta, specific cell inhibitors (rituximab, daclizumab) and receptors antagonists (anakinra, efalizumab).

Anti-VEGF

Intravitreal bevacizumab (IVB) can be helpful for subretinal fluid exudation due to its anti-angiogenic and anti-permeability properties.[1]

Other

Eplerenone (mineralocorticoid receptor antagonist) for CSC.[1]

Interventional

Focal laser photocoagulation, cryotherapy, low-dose plaque radiotherapy, photodynamic therapy (PDT) and pars plana vitrectomy (PPV).

Prognosis

Prognosis for ERD is highly variable and heavily dependent on etiology. Acute, self-limited causes of ERD have a favorable prognosis whereas chronic, irreversible causes have a poor prognosis.[1] Prognosis is particularly poor if there is macular involvement and in cases of metastatic and paraneoplastic disease.

Additional Resources

https://www.aao.org/1-minute-video/shifting-fluid-in-patients-with-retinal-detachment

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Amer R, Nalcı H, Yalçındağ N, Exudative Retinal Detachment, Survey of Ophthalmology (2017), doi: 10.1016/j.survophthal.2017.05.001.
  2. Blair K, Czyz CN. Retinal Detachment. [Updated 2021 Aug 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551502/
  3. Cunha-Vaz J, Bernardes R, Lobo C. Blood-retinal barrier. Eur J Ophthalmol. 2011;21 Suppl 6:S3-9. doi: 10.5301/EJO.2010.6049. PMID: 23264323.
  4. 4.0 4.1 Fineman, M. S., & Ho, A. C. (2012). Color Atlas & Synopsis of Clinical Ophthalmology: Retina. Lippincott Williams & Wilkins.
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