Sunir J. Garg

BASICS

DESCRIPTION

• Serous retinal detachment (SRD) is an elevation of the retina due to accumulation of fluid in the subretinal space and is not associated with traction or retinal hole or tear.

• An SRD is not due to a retinal break, as is the case in rhegmatogenous RD (RRD).

EPIDEMIOLOGY

Incidence

• A wide range exists depending on etiology.

– An incidence of SRD as high as 32% has been found for women with severe preeclampsia or eclampsia, with the majority of these resolving within 1 week.

– 60% of cases of optic disc pits may be complicated by SRD.

RISK FACTORS

• Underlying vasculitis or autoimmune disease

• Trauma

• Acquired immunodeficiency syndrome

• Chronic or malignant hypertension

• Renal disease

• Coagulopathy

• Neoplastic disorder

• Ocular surgery

PATHOPHYSIOLOGY

• Normally, there is a flow of fluid from the vitreous cavity, through the retina, to the hyperosmolar choroid. In addition, the retinal pigment epithelium (RPE) actively pumps ions and fluid from the retina and subretinal space into the choroid.

• A breakdown of the normal inner (retinal vascular endothelial cells) or outer blood–retinal barrier (RPE) will allow for exudation. In addition, any process that affects the choroidal vascular permeability may lead to an SRD.

ETIOLOGY

• Inflammatory

– Scleritis

– Vogt–Koyanagi–Harada (VKH) disease

– Sympathetic ophthalmia

– Orbital inflammatory syndrome

– Lymphomatoid granulomatosis

– Infectious retinochoroiditis

– Toxoplasmosis

– Syphilis

– Lyme

– Cat scratch disease

– Cytomegalovirus (CMV) retinitis

– Tuberculosis

– Vasculitis/autoimmune

Lupus

Wegener’s granulomatosis

Sarcoidosis

Inflammatory bowel disease

Polyarteritis nodosa

• Vascular

– Retinal vein occlusion

– Coats’ disease

– Retinal capillary hemangioma

– Malignant hypertension

– Preeclampsia/eclampsia

– Disseminated intravascular coagulation

– Renal disease

Renal failure

Lupus nephritis

Crescentic membranous nephropathy

Goodpasture’s syndrome

IgA nephropathy

• Neoplastic

– Choroidal melanoma, osteoma, hemangioma, or metastasis

– Primary intraocular lymphoma

– Retinoblastoma

• Iatrogenic

– Scleral buckling

– Excessive photocoagulation

• Miscellaneous

– Bullous central serous choroidopathy

– Uveal effusion syndrome

– Nanophthalmos

– Coloboma of the optic nerve

– Familial exudative vitreoretinopathy

– Topical prostaglandin use

DIAGNOSIS

HISTORY

• A progressive, fluctuating loss of peripheral vision with a variable course is common. The fluid shifts with head position.

• Pain and a red eye may be present in inflammatory conditions (e.g., scleritis).

• A white pupillary reflex (leukocoria) may be noticed in a child with retinoblastoma.

PHYSICAL EXAM

• Dome-shaped elevation of the retina with transparent and smooth retinal walls, as opposed to the corrugated folds in RRD

• The subretinal fluid shifts according to head position.

• Associated signs:

– Signs of inflammation:

– Conjunctival injection and chemosis

– Cell and flare in the anterior chamber

– Vitreous cells

– Retinal vascular sheathing

– Dilated telangiectatic vessels

– Retinal exudates

– Solid tumor

DIAGNOSTIC TESTS & INTERPRETATION

Lab

Initial lab tests

Directed according to clinical presentation

• Complete metabolic panel

• PT, PTT, fibrinogen, antithrombin III, factors V and VII

• Inflammatory workup

– Antinuclear antibodies

– Antineutrophil cytoplasmic antibodies

– Erythrocyte sedimentation rate

– Rheumatoid factor

– Angiotensin-converting enzyme

• Infectious

– CBC with differential

– Lyme titers

– Venereal Disease Research Laboratory (VDRL) test and fluorescent treponemal antibody (FTA) test

– Toxoplasma titers

– CMV titers

– Bartonella henselae and quintana titers

– Purified protein derivative (PPD) placement

Imaging

Initial approach

• Ultrasonography

– A-scan ultrasound

– Retinal tissue will show a large spike.

– Short axial length is indicative of nanophthalmos.

– B-scan ultrasound

Helpful in cases in which the retina is not able to be visualized due to media opacity

Thickened sclera or choroid may be seen in scleritis, orbital inflammation, or VKH.

Calcification suggests retinoblastoma.

Follow-up & special considerations

• Fluorescein angiography (FA)

– May reveal source of subretinal fluid and the nature of the defect causing it

• Optical coherence tomography (OCT)

– Helpful in evaluating subretinal fluid

Diagnostic Procedures/Other

• Check blood pressure

• Slit lamp exam in detection of uveitis or vitritis

• Indirect ophthalmoscopy with scleral depression to rule out a retinal tear/RRD

Pathological Findings

• As the neurosensory retina separates from the RPE, the photoreceptors lose part of their blood supply and may degenerate.

• With a chronic RD, intraretinal cysts, RPE proliferation, and massive leakage into the retina and subretinal space occur.

• In an acute case of VKH syndrome, an eosinophilic exudate containing proteinaceous material is found in the subretinal space.

• The subretinal fluid in Coats’ disease contains high levels of protein, albumin, and cholesterol.

DIFFERENTIAL DIAGNOSIS

• Retinoschisis

• RRD

• Tractional RD

• Choroidal detachment

TREATMENT

MEDICATION

Treat the underlying condition

ADDITIONAL TREATMENT

General Measures

• Intravitreal injection of bevacizumab for SRD has been demonstrated to show a significant reduction in central foveal thickness and subretinal fluid with improved visual acuity (1)[B].

• Intravitreal injection of triamcinolone acetonide is an effective treatment of SRD in patients with central retinal vein occlusion (2)[B].

Issues for Referral

• Vitreoretinal specialist—laser and surgical treatment

• Immunologist or rheumatologist—when immunosuppressive therapy is considered.

SURGERY/OTHER PROCEDURES

Must be tailored toward the underlying condition

• Tumors (e.g., choroidal melanoma)

– External beam radiation

– Brachytherapy with plaque

– Photodynamic therapy for choroidal hemangioma

• Vascular abnormalities (e.g., Coats’ disease)

– Laser photocoagulation

– Cryotherapy

– Vitrectomy

• Congenital abnormalities

– Nanophthalmos

– Vortex vein decompression with scleral windows and suprachoroidal fluid drainage

– Optic pits or colobomas

Laser photocoagulation

Vitrectomy

• Central serous chorioretinopathy

– Laser photocoagulation

IN-PATIENT CONSIDERATIONS

Initial Stabilization

Prior to surgery for SRD, patients should rest as much as possible.

Admission Criteria

Most vitreoretinal surgery is performed on an outpatient basis.

ONGOING CARE

PROGNOSIS

Depends on the underlying cause

• SRD secondary to preeclampsia or eclampsia usually resolves without any long-term complications.

• In patients with central serous chorioretinopathy, 15% have a visual acuity of 20/200 or worse.

• The SRD associated with optic pits has a poor prognosis secondary to the development of cystoid macular edema that may form.

• In Coats’ disease, 75% of treated patients show an improvement or stabilization of vision from baseline; whereas, 30% of untreated patients may have stabilization (3)[B].

COMPLICATIONS

• Neovascular glaucoma

• Choroidal neovascularization

• Phthisis bulbi

Stay updated, free articles. Join our Telegram channel

Join