Exudative Retinal Detachment

Detachment of the neurosensory retina caused by accumulation of fluid in the subretinal space from a leaking choroid, retinal pigment epithelium, or retinal vessels, without a retinal break or traction.

• Causes:
  • Inflammatory: Vogt-Koyanagi-Harada disease, posterior scleritis, sympathetic ophthalmia, sarcoidosis, lupus choroidopathy, and infectious choroiditis (tuberculosis, syphilis, toxoplasmosis).
  • Neoplastic: choroidal melanoma, choroidal metastasis (breast, lung), choroidal haemangioma, retinoblastoma, choroidal lymphoma, leukaemia, and multiple myeloma.
  • Vascular and exudative: Coats disease, central serous chorioretinopathy, choroidal neovascularisation, polypoidal choroidal vasculopathy, malignant hypertension, pre-eclampsia and eclampsia, renal failure, and thrombotic thrombocytopenic purpura.
  • Uveal effusion syndrome (scleral thickening and vortex vein compression, nanophthalmos), idiopathic.
  • Drug-induced: MEK inhibitors (binimetinib, trametinib), checkpoint inhibitors, and topiramate (angle closure with effusion).
  • Congenital: optic disc pit, morning glory anomaly, and coloboma.

• Painless blurred vision, distortion, and a field defect that varies with posture (the detachment settles inferiorly when upright and shifts when lying down).
• Smooth, convex, bullous retinal elevation without a break, with fluid shifting with the position of the head ("shifting fluid"), no tobacco dust, no vitreous traction, and a clear vitreous in most cases.
• Features of the underlying cause: choroidal mass, choroidal folds, white choroidal lesions, optic disc swelling, scleral thickening and injection, vitritis, hard exudates (Coats), hypertensive changes (flame haemorrhages, cotton wool spots), headache, tinnitus, and hearing loss (Vogt-Koyanagi-Harada), pain (scleritis).
• Associated angle closure from ciliary body oedema and choroidal effusion.

• Dilated fundus examination, comparison of detachment morphology in different head positions, and slit lamp examination.
• B-scan ultrasound (smooth elevated retina, thickened sclera with a "T-sign" in posterior scleritis, choroidal mass, subretinal fluid); optical coherence tomography (subretinal fluid, choroidal thickening, dome-shaped macula); fluorescein and indocyanine green angiography (pinpoint leaks in Vogt-Koyanagi-Harada, leopard-spot pattern in uveal effusion, hyperpermeable lesion in haemangioma); MRI orbits for tumours.
• Blood tests: blood pressure, urine protein, creatinine, full count, ESR, CRP, angiotensin-converting enzyme, ANA, syphilis serology, tuberculosis test, HIV, protein electrophoresis; imaging for metastasis if a primary is suspected.
• Lumbar puncture in Vogt-Koyanagi-Harada disease (pleocytosis) when diagnosis is uncertain.

• Treat the underlying cause; surgery rarely repairs the detachment itself.
• Vogt-Koyanagi-Harada disease and posterior scleritis: oral prednisolone 1 to 1.5 mg/kg daily (80 mg), or intravenous methylprednisolone 1 g daily for 3 days, then taper slowly over 6 months or more; add steroid-sparing agents (azathioprine 2 mg/kg daily, mycophenolate 1 g twice daily, ciclosporin 3 to 5 mg/kg daily, adalimumab 40 mg every 2 weeks) to prevent recurrence.
• Hypertensive and pre-eclamptic detachment: control blood pressure (labetalol 100 mg orally twice daily titrated, or 20 mg IV bolus; nifedipine 10 to 20 mg orally), magnesium sulphate 4 g IV load then 1 g/hour in eclampsia, and delivery decisions with obstetrics; the retina reattaches within weeks.
• Uveal effusion syndrome: oral steroids short term, then full-thickness sclerectomy windows (4 quadrant) with or without vortex vein decompression; nanophthalmos requires caution (risk of effusion with any intraocular surgery).
• Tumours: radiotherapy, brachytherapy, systemic therapy, and photodynamic therapy for choroidal haemangioma (verteporfin 6 mg/m2, laser 689 nm at 83 seconds); orbit and systemic oncology involvement.
• Coats disease: laser photocoagulation and cryotherapy of telangiectatic vessels, intravitreal bevacizumab (0.625 to 1.25 mg), and steroid injection.
• Central serous chorioretinopathy: observation, eplerenone 25 to 50 mg daily, or half-dose photodynamic therapy for persistent fluid; choroidal neovascularisation: intravitreal anti-VEGF therapy.
• Drug-induced: withhold or reduce the offending agent; detachment resolves within weeks.
• Follow-up with optical coherence tomography and ultrasound.