Newly recognized serous macular detachment in retinal vascular disease.

Newly Recognized Serous Macular Detachment in Retinal Vascular Disease Serous macular detachment has only recently been recognized to occur in a significant number of eyes with retinal vascular leakage, including diabetic macular edema,1,2 branch retinal vein occlusion,3–5 central retinal vein occlusion (CRVO),6 and hypotony maculopathy.7 These serous retinal detachments associated with retinal vascular leakage were not suspected clinically or angiographically but were diagnosed with optical coherence tomography beneath the edematous neurosensory retina. In a recent issue of Retina, Ozdemir et al6 found a surprisingly high frequency (82%) of serous retinal detachment in eyes with acute CRVO and macular edema. Serous retinal detachment was not suspected clinically or by angiography but was demonstrated with a remarkably high incidence by optical coherence tomography. The ability of optical coherence tomography to provide cross-sectional, high resolution imaging of the macula has enabled demonstration of previously unrecognized serous detachment beneath the thickened and cystic macula. The presence of serous detachment in retinal vascular disease may have important implications in therapy for macular edema associated with retinal vascular leakage. Serous retinal detachment associated with macular edema has been demonstrated in 15% to 46% of eyes with diabetic macular edema,1,2 37.8% to 71.4% of eyes with branch retinal vein occlusion,3–5 and 82% of eyes with CRVO.6 The presence of serous retinal detachment may significantly limit the ability to perform effective macular laser treatment and to achieve the usual light gray treatment spot during macular laser. In macular edema associated branch retinal vein occlusion, the presence of serous retinal detachment is a negative prognostic factor for resolution of macular edema and for visual acuity after grid macular laser treatment.3 The high percentage of serous retinal detachment in CRVO reported by Ozdemir et al6 may have played a previously unrecognized role in the poor response of macular edema associated with CRVO to grid macular laser in the multicenter trial on CRVO by the Central Retinal Vein Occlusion Study Group.8 The reasons for this high incidence of serous retinal detachment in CRVO are unknown but could be related to the acute blockage of the entire central retinal venous system that results in acute leakage diffusely throughout the retinal capillaries, leading to edema of the retinal tissue and leakage into the subretinal space (which is not able to be absorbed by the retinal pigment epithelium). Serous retinal detachment has also been clinically recognized to be associated with other retinal vascular diseases, such as retinal angiomas, Coats disease, and retinal vasculitis.9 The mechanism is probably due to excessive fluid flow from the abnormal retinal vessels, which overwhelms the retinal pigment epithelium pump and leads to serous retinal detachment.9 Potentially, future therapies stimulating the retinal pigment epithelium pump may be important to treat serous retinal detachments, such as acetazolamide10 or newer investigative retinal pigment epithelium pump stimulators.11 Alternative therapies, such as intravitreal steroid injections and intravitreal anti–vascular endothelial growth factor injections, may also allow resolution of edema and serous retinal detachment. The natural history of serous retinal detachment associated with macular edema and the response of serous retinal detachment associated with macular edema to therapeutic interventions, such as macular laser and intravitreal pharmacologic agents, are currently unknown, and further research should be directed at following the course of serous detachment in macular edema. Reprint requests: Gregg T. Kokame, MD, The Retina Center at Pali Momi, 98-1079 Moanalua Road, Suite 470, Aiea, Hawaii 96701.