Exudative Retinal Detachment: Causes and Characteristics
In exudative retinal detachment, fluid accumulates underneath the retina without evidence of a retinal break or tear, most commonly due to central serous chorioretinopathy (CSC) or inflammatory conditions that disrupt the blood-retinal barrier. 1
Pathophysiology of Exudative Retinal Detachment
Exudative retinal detachment develops when fluid collects in the subretinal space between the photoreceptors and the retinal pigment epithelium (RPE). Unlike rhegmatogenous retinal detachment, which is caused by retinal breaks, exudative detachment occurs due to:
- Disruption of the blood-retinal barrier
- Choroidal hyperpermeability
- RPE dysfunction
- Inflammatory processes
The absence of a retinal break is the key distinguishing feature from rhegmatogenous detachment 2, 3.
Common Causes of Exudative Retinal Detachment
1. Central Serous Chorioretinopathy (CSC)
- Most common cause in young to middle-aged adults (35-50 years)
- More prevalent in men
- Characterized by choroidal abnormalities and RPE dysfunction
- Presents with serous detachment on OCT, often centered at the macula
- May be associated with corticosteroid use 1
2. Inflammatory Conditions
- Vogt-Koyanagi-Harada disease
- Rapid onset, typically bilateral
- Associated with vitritis and optic disc edema
- Treatment: Corticosteroids and immunosuppressive medications 1
3. Vascular Disorders
- Central retinal vein occlusion
- Can lead to exudative detachment 7-36 weeks after occlusion
- Associated with retinal ischemia
- Poor visual prognosis 4
4. Neovascular Diseases
- Polypoidal choroidal vasculopathy
- Neovascular age-related macular degeneration
- Pachychoroid neovasculopathy 1
5. Other Causes
- Choroidal tumors (e.g., melanoma)
- Inflammatory/infectious uveitis
- Severe hypertension
- Coagulopathies
Diagnostic Approach
Imaging Studies
Optical Coherence Tomography (OCT)
Fluorescein Angiography (FA)
- May show leakage patterns characteristic of specific conditions
- In CSC: focal leakage points at the level of RPE 1
Indocyanine Green Angiography (ICGA)
- Evaluates choroidal circulation
- Can identify choroidal hyperpermeability in CSC
- Helps detect polypoidal lesions or choroidal neovascularization 1
Fundus Autofluorescence (FAF)
- Identifies RPE alterations
- Useful for monitoring disease progression 1
B-scan Ultrasonography
- Helpful when media opacity prevents adequate examination
- Can rule out underlying masses 5
Treatment Options
Treatment depends on the underlying cause:
For Central Serous Chorioretinopathy:
- Observation for acute cases (may resolve spontaneously)
- Photodynamic therapy (reduced-settings/half-dose) for chronic cases
- Consider anti-VEGF injections if neovascularization is present 1, 6
For Inflammatory Causes:
- Corticosteroids (topical, periocular, or systemic)
- Immunosuppressive medications for steroid-resistant cases 1
For Neovascular Conditions:
- Anti-VEGF intravitreal injections
- Combination of anti-VEGF and photodynamic therapy for polypoidal lesions 1
For Persistent Exudative Detachment:
- In severe cases, external drainage of subretinal fluid may be considered
- Surgical intervention has shown promising results in selected cases 6, 7
Prognosis and Follow-up
- Prognosis varies depending on the underlying cause and duration of detachment
- Early intervention generally leads to better visual outcomes
- Regular monitoring with multimodal imaging is essential
- Patients should be educated about symptoms requiring immediate attention (increased floaters, visual field loss, decreased acuity) 5
Key Points to Remember
- Exudative retinal detachment is characterized by subretinal fluid without retinal breaks
- Multimodal imaging is crucial for accurate diagnosis and identifying the underlying cause
- Treatment should target the specific etiology rather than the detachment itself
- Early intervention can prevent irreversible photoreceptor damage and visual loss