Tractional and exudative retinal detachment

Referral priority: Urgent

All patients with retinal detachment must be urgently referred to an ophthalmologist or hospital emergency room following local guidelines.

Written by
Marko Lukic
Edited by
Svein Tindlund and Jon Gjelle
Published
June 2023

Sections
01
Introduction

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02
Symptoms

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03
Clinical signs

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04
Diagnostic procedures

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05
Management and treatment

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06
References

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01

Introduction

Retinal detachment is the separation of the neurosensory retina from the retinal pigment epithelium (RPE). It occurs when fluid accumulates in the virtual subretinal space. The classic categorisation of retinal detachment is rhegmatogenous, tractional, and exudative (serous).(1)

The rhegmatogenous retinal detachment is the most common, and occurs when there is a full-thickness retinal break secondary to vitreoretinal traction (most often during the process of posterior vitreous detachment (PVD)). The break allows fluid to enter the subretinal space and separates the neurosensory retina from the RPE.(2-3)

Tractional retinal detachment is the second-most common type of retinal detachment. The vitreoretinal forces mechanically pull the retina away from the underlying RPE. The tractional forces occur within the vitreous body or on the retinal surface. In most cases, there is the presence of a retinal surface membrane which is consisted of contractile cells like fibroblasts, RPE, and glial cells.(4) The tractional retinal detachment is seen in diabetic retinopathy, proliferative vitreoretinopathy (PVR), penetrating trauma, and retinopathy of prematurity (ROP).(5,6) Due to the mechanical pulling of the retina, the tractional retinal detachment has a concave appearance.

There are cases when a tear and traction combine, and such retinal detachments are called tractional-rhegmatogenous retinal detachments. This subtype is most commonly present in proliferative diabetic retinopathy, proliferative vitreoretinopathy, proliferative sickle cell retinopathy, and penetrating eye injuries.(7)

Retinal detachments can occur without a retinal break or vitreoretinal traction. These detachments result from a collection of subretinal fluid secondary to diseases of the choroid and RPE or of the retina itself.(1,7) In normal conditions, the retinal pigment epithelium actively pumps the subretinal fluid into the choroid, keeping the neurosensory retinal adherent. Various conditions lead to the failure of the RPE pump and cause exudative (mainly serous) retinal detachments.(2,8) Those conditions are primarily inflammatory or neoplasms: Vogt-Koyanagi-Harada disease, sympathetic ophthalmia, posterior scleritis, preeclampsia, severe and diffuse central serous retinopathy, malignant hypertension, malignant melanoma, choroidal haemangioma, and choroidal metastases.

02

Symptoms

Vitreoretinal traction develops gradually, and the vision may be intact for months or years. The vision becomes affected if the macula is involved. It happens similarly in exudative retinal detachment. The patient’s vision is affected mostly when the macula is involved, so those patients will notice a decrease in vision. Some of them may complain about photopsia and light phenomena.

03

Clinical signs

The tractional retinal detachment has a concave configuration. The subretinal fluid is shallower compared to rhegmatogenous retinal detachment and rarely extends to the ora serrata. The highest retinal detachment is at the traction site, and the retina is either immobile, or the mobility is severely reduced. Compared to the exudative retinal detachment, there is no shift of subretinal fluid.

Be aware that traction can sometimes cause a full-thickness retinal break which may cause tractional-rhegmatogenous retinal detachment, where the clinical appearance will be presented with features of both types.

The exudative retinal detachment has a convex, dome-shaped clinical appearance, and there is no presence of retinal breaks or traction. If the patient changes the position of his body, ’the fluid shifts – which is one of the ways to recognise exudative retinal detachment). Exudative retinal detachments may contain blood and imitate pigmented lesions or melanoma (pseudomelanoma).

04

Diagnostic procedures

Visual acuity, pupillary examination, visual-field testing, and intraocular pressure measurement are essential parts of the pre-dilated ophthalmic examination. Of course, a thorough fundus examination, including peripheral fundus, is crucial. Always take a complete medical history and make a suspicion of retinal detachment based on the symptoms or conditions that may cause retinal detachment.

Slit lamp examination –essential to thoroughly examine both anterior- and posterior-eye segments. Clinical findings may lead to the correct diagnosis, which may explain the nature/cause of the detachment.

Colour fundus photography – wide field or ultra-widefield colour fundus photos help document the retinal findings and diagnose or monitor retinal detachment. Be aware that scanning laser ultra-widefield photos are pseudo-colour photos, and sometimes the features may appear differently on a slit-lamp fundoscopy.

Image 1. Colour fundus photo of tractional retinal detachment. Notice the concave configuration.
Image 2. Colour fundus photo of serous retinal detachment. The image represents Vogt-Koyanagi-Harada syndrome (VKH). Note dome-shaped, convex serous appearances.

Ultrasound – very useful when media opacities are unclear (i.e., dense vitreous haemorrhage). It differentiates posterior vitreous detachment (posterior hyaloid membrane) and tractional membranes from the detached retina. Likewise, it may be used to differentiate serous retinal detachment from choroidal detachment.

Optical coherence tomography – useful to differentiate retinal detachment from retinoschisis. It is more useful when the changes are located more centrally. However, a good technician should be able to catch the more peripheral lesion, which may help recognise retinal detachment. Likewise, OCT could be useful to differentiate rhegmatogenous retinal detachment from two other subtypes: tractional and exudative.

Image 3. OCT scan of tractional retinal detachment. Notice a fibrotic membrane pulling the neurosensory retina (subretinal fluid between neuroretina and RPE.
Image 4. OCT scan of serous retinal detachment. The case represents a Vogt-Koyanagi-Harada (VHK)case.
05

Management and treatment

Regardless of the macular involvement, all tractional and exudative retinal detachments should be urgently referred to an ophthalmologist or hospital following local guidelines.

As various causes may lead to tractional or exudative retinal detachment, it is important to know the clinical signs of entities causing it.

The treatment depends on the overlying cause. Tractional retinal detachments which involve the macula are surgically treated (with a vitrectomy). The exudative retinal detachment is not treated surgically, and it is important to properly treat the underlying cause (i.e., oral steroids in Vogt-Koyanagi-Harada or sympathetic ophthalmia).

Ophthalmologists treat the retinal detachment and underlying causes.

06

References

1 Blair K, Czyz CN. Retinal Detachment.

2 https://emedicine.medscape.com/article/1224737-overview

3 Kuhn F, Aylward B. Rhegmatogenous retinal detachment: a reappraisal of its pathophysiology and treatment. Ophthalmic research. 2014;51(1):15-31.

4 Kim LA, Wong LL, Amarnani DS, Bigger-Allen AA, Hu Y, Marko CK, Eliott D, Shah VA, McGuone D, Stemmer-Rachamimov AO, Gai X. Characterization of cells from patient-derived fibrovascular membranes in proliferative diabetic retinopathy. Molecular vision. 2015;21:673.

5 Massin P, Haouchine B, Gaudric A. Macular traction detachment and diabetic edema associated with posterior hyaloidal traction. American Journal of Ophthalmology. 2001 Oct 1;132(4):599.

6 Sanghi G, Dogra MR, Katoch D, Gupta A. Aggressive posterior retinopathy of prematurity: risk factors for retinal detachment despite confluent laser photocoagulation. American journal of ophthalmology. 2013 Jan 1;155(1):159-64.

7 Wilkinson CP et al. Ryan’s retina.6th edition. Elsevier Inc. 2018.

8 von Rückmann A, Fitzke FW, Fan J, Halfyard A, Bird AC. Abnormalities of fundus autofluorescence in central serous retinopathy. American journal of ophthalmology. 2002 Jun 1;133(6):780-6.