BASICS

DESCRIPTION

• Hard exudates in theundus represent leakage of lipid and protein from incompetent vessels in the retina, choroid, or optic disc.

– Hard exudates are usually present in the outer plexiform layer of the retina but can dissect into the subretinal space as well as into other retinal layers.

EPIDEMIOLOGY

Incidence

Difficult to quantify

RISK FACTORS

Underlying vascular diseases such as diabetes, hypertension, and dyslipidemia

GENERAL PREVENTION

Control of blood glucose, blood pressure, and blood lipid levels can reduce the risk of common causes of hard exudates, such as diabetic retinopathy, hypertensive retinopathy, retinal arterial macroaneurysm, and retinal vascular occlusion.

PATHOPHYSIOLOGY

Increased vascular permeability allows leakage of protein and lipid into the retina.

ETIOLOGY

• Numerous retinal vascular diseases can cause hard exudates, including:

– Diabetic retinopathy

– Hypertensive retinopathy

– Retinal vascular occlusion

– Retinal arterial macroaneurysm

– Radiation retinopathy

– Coats’ disease

– Capillary hemangioma of the retina (i.e., von Hippel lesion)

– Neuroretinitis

– Choroidal neovascularization (e.g., age-related macular degeneration)

COMMONLY ASSOCIATED CONDITIONS

Macular edema is often present with hard exudates.

DIAGNOSIS

HISTORY

• Decreased vision if hard exudates are present in the macula

• Underlying medical diseases

PHYSICAL EXAM

• Fundus examination reveals discrete, yellow–white deposits most frequently in the posterior pole.

• Can be globular, linear, circinate surrounding a leaking vessel, or large and confluent. A macular star can be seen with neuroretinitis or hypertensive retinopathy.

DIAGNOSTIC TESTS & INTERPRETATION

DIFFERENTIAL DIAGNOSIS

• Cotton-wool spots

• Myelinated nerve fiber layer

• Retinitis

• Drusen

• Chorioretinal atrophy

• Hollenhorst plaque

• Crystalline retinopathy (see the Talc retinopathy chapter)

TREATMENT

MEDICATION

First Line

Treatment of the underlying disorder is required.

Second Line

For diabetic retinopathy and diabetic macular edema, a common cause of hard exudates, treatment of the underlying macular edema with laser photocoagulation and/or injection of intraoular steroid or anti-VEGF medication can lead to resolution of the hard exudates (1,2)[C].

SURGERY/OTHER PROCEDURES

Submacular surgery has been used to remove massive diabetic submacular hard exudates.

ONGOING CARE

COMPLICATIONS

• Macular edema is often associated with hard exudates.

• Patients with neuroretinitis may have an afferent pupillary defect, but this often resolves with time.

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