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Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 343-345

Exudative retinal detachment in treatment naïve aggressive posterior retinopathy of prematurity: A case report

Department of Retina and Vitreous, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Tirunelveli, Tamil Nadu, India

Date of Submission30-Jul-2020
Date of Acceptance10-Dec-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Dr. Jahnara Jaffar
Department of Retina and Vitreous, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Tirunelveli - 627 001, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2440_20

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We report the first case of bilateral exudative retinal detachment in treatment naïve zone one aggressive posterior retinopathy of prematurity. Exudative detachments in retinopathy of prematurity have been reported in literature following laser photocoagulation or cryotherapy. But exudative detachment as an initial presentation in APROP is rather rare. The abnormality in our case was noticed at the second visit. A 20-day-old infant (born at 32 weeks of gestation) was diagnosed to have APROP. He was advised intravitreal bevacizumab injection (0.625 mg) in both eyes. Two days later when the infant was brought in for injection, he was found to have bilateral exudative retinal detachments almost reaching the posterior pole. We administered the intravitreal injections of bevacizumab in both eyes and the baby was followed up at regular intervals. Review at 1-month post-injection revealed resolution of detachments.

Keywords: Aggressive posterior retinopathy of prematurity, exudative retinal detachment, intravitreal bevacizumab

How to cite this article:
Mohideen SK, Jaffar J, Halder U, Shetty AP. Exudative retinal detachment in treatment naïve aggressive posterior retinopathy of prematurity: A case report. Indian J Ophthalmol Case Rep 2021;1:343-5

How to cite this URL:
Mohideen SK, Jaffar J, Halder U, Shetty AP. Exudative retinal detachment in treatment naïve aggressive posterior retinopathy of prematurity: A case report. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 29];1:343-5. Available from: https://www.ijoreports.in/text.asp?2021/1/2/343/312380

Aggressive posterior retinopathy of prematurity (APROP) is an uncommon, severe and rapidly progressive form of retinopathy characterized by a more posterior location seen in premature infants (gestational age (GA) <28 weeks and low birth weight infants (<1000 g). Retinal detachment is seen in stage 4 or 5 of ROP. Exudative retinal detachments have been reported after cryotherapy and photocoagulation in retinopathy of prematurity (ROP).[1],[2] We report the first case of exudative retinal detachment (RD) in treatment naïve Zone one APROP.

  Case Report Top

A 20-day-old male infant was referred to us by his pediatrician for retinopathy of prematurity screening. He was the first born of a 32-year-old mother with no antenatal illnesses and no history of consanguinity. He was delivered at 30 weeks of gestation by an emergency LSCS as there was premature rupture of membranes with fetal distress. The baby was admitted in NICU for 1 month with supplemental oxygen therapy and intravenous fluids. There was no history of electrolyte imbalances, sepsis, cytopenia or renal dysfunction. The birth weight was 1400 g.

On examination, the infant was diagnosed to have APROP [Figure 1]a and [Figure 1]b. He was advised intravitreal injection of anti-VEGF Bevacizumab (0.625 mg/0.025 ml) in both eyes. When the infant was brought for intravitreal injection of bevacizumab in both eyes 3 days later, he was found to have partial exudative retinal detachment in both eyes involving the peripheral retina almost reaching up to the posterior pole [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d and [Figure 3]a, [Figure 3]b.
Figure 1: (a and b) Fundus photo of right and left eye showing APROP

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Figure 2: (a and b) Fundus photo of right eye showing partial exudative retinal detachment reaching posterior pole: (c and d) showing partial exudative retinal detachment in left eye

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Figure 3: (a and b) B scan images of right eye and left eye showing retinal detachments

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He was administered intravitreal bevacizumab 0.625 mg/0.025 ml injection in both eyes on the same day. Post injection, the baby was reviewed at 3 days, 2 weeks and 1 month. Close follow up revealed progressive reattachment of retina with resolution of subretinal fluid and regression of ROP. At 1 month of follow up, the retinal detachments had almost settled [Figure 4]a and [Figure 4]b. Review one month later revealed regressed retinopathy of prematurity in right eye and zone 2 stage 3 ROP in left eye. The baby was advised peripheral pan-retinal photocoagulation in left eye.
Figure 4: (a and b) Fundus photo of right eye and left at one month post injection showing partially regressed ROP and partial resolution of detachments

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  Discussion Top

Exudative RD has been reported in ROP after laser photocoagulation and cryotherapy. Exudative RD in treatment Naïve ROP has been rarely reported in literature. Sen et al. has reported a similar case of exudative retinal detachment in APROP, but in zone 2 disease.[3] Based on experimental studies in cat eyes, Marmor and Yao described 3 conditions necessary for an exudative retinal detachment to develop.[4] They were (1) a source of fluid pressure, (2) a defect in the blood-retinal barrier (entry site), and (3) an area of impaired fluid transport beyond the site of leakage. The inner blood–retinal barrier is poorly formed in stage 3 + ROP and the leakage of plasma from neovascular fronds may be responsible for subretinal exudation and retinal detachment. Lajko et al. have described a hyperoxia-induced proliferative vitreoretinopathy (HIPR) model in rodent eyes.[5] Unlike the oxygen-induced retinopathy (OIR) model, here the hyperoxia starts immediately after birth. They have noted the presence of fibrinogen in the vitreous and subretinal space in these eyes which in turn triggered an inflammatory reaction causing exudative RD. Similar mechanism may exist in our case as well. In cases where exudative detachments followed retinal photocoagulations, the laser-induced inflammatory insult can be held responsible for the increased permeability of the blood–retinal barrier.

Serous detachments following laser photocoagulation was first described by Noonan and Clark.[1] They have suggested that use of phenylephrine 2.5% can cause changes in the choriocapillaries and retinal pigment epithelium. Factors like multiple gestation, very low birth weight, early development and treatment of ROP have been implicated as inciting factors.

Brown et al. have described a series of patients with retinopathy of prematurity that developed an exudative retinopathy in the third to fourth decades of life.[6] They postulated that the subretinal fluid and exudate developed from retinal telangiectatic vascular changes, but the inciting factor for the breakdown of the blood–retinal barrier was unknown. Ittiara et al. have also reported a similar case were an infant treated with bilateral intravitreal Bevacizumab had presented one year later with exudative RD.[7] Large areas of avascular retina even after vessels have grown anteriorly may continue to produce VEGF which may be responsible for the late exudative detachments. In these cases, periphery showed microaneurysms and telangiectatic changes and massive lipid exudation similar to Coats disease.

Being a rare entity, there is no consensus regarding the treatment of exudative RD in ROP. Moshgfeghi et al. and Moinuddin et al. had successfully treated exudative detachments following laser photocoagulation in infants with ROP using topical and systemic steroids.[8],[9] Noonan and Clark and Mulvihill et al. reported spontaneous resolution of serous macular detachment following laser photocoagulation in ROP.[1],[2] Lalwani et al. have described cases where exudative detachments following laser photocoagulation were treated by intravitreal Bevacizumab.[10] It is been found that level of VEGF is high in the subretinal fluid and vitreous cavity in stage 4 and stage 5 ROP. This makes the role of anti-VEGF important in management of exudative detachment where laser photocoagulation is impossible. Bevacizumab reduces the choroidal and retinal permeability, stabilizing the blood–retinal barrier and thereby limiting exudation into subretinal space. Laser photocoagulation was added to peripheral retina after resolution of Exudative RD so as to prevent recurrence.

  Conclusion Top

Exudative RD as a primary presentation of APROP is very rare. We stress the role of anti VEGF drugs as salvage therapy in such cases where a good outcome can be achieved with a non-surgical modality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Noonan CP, Clark DI. Acute serous detachment with argon laser photocoagulation in retinopathy of prematurity. J AAPOS 1997;1:183-4.  Back to cited text no. 1
Mulvihill A, Lanigan B, O'Keefe M. Bilateral serous retinal detachments following diode laser treatment for retinopathy of prematurity. Arch Ophthalmol 2003;121:129-30.  Back to cited text no. 2
Sen P, Yusufali H, Khetan V, Rao C, Banerjee A. Exudative retinal detachment, a primary presentation in retinopathy of prematurity. Can J Ophthalmol 2018;53:e74-7.  Back to cited text no. 3
Marmor MF, Yao XY. Conditions necessary for the formation of serous detachment. Experimental evidence from the cat. Arch Ophthalmol 1994;112:830-8.  Back to cited text no. 4
Lajko M, Cardona HJ, Taylor JM, Shah RS, Farrow KN, Fawzi AA. Hyperoxia-induced proliferative retinopathy: Early interruption of retinal vascular development with severe and irreversible neurovascular disruption. PLoS One 2016;11:e0166886.  Back to cited text no. 5
Brown MM, Brown GC, Duker JS, Tasman WS, Augsburger JJ. Exudative retinopathy of adults: A late sequela of retinopathy of prematurity. Int Ophthalmol 1994-1995;18:281-5.  Back to cited text no. 6
Ittiara S, Blair MP, Shapiro MJ, Lichtenstein SJ. Exudative retinopathy and detachment: A late reactivation of retinopathy of prematurity after intravitreal bevacizumab. J AAPOS 2013;17:323-5.  Back to cited text no. 7
Moinuddin O, Bonaffini S, Besirli CG. Exudative retinal detachment following laser photocoagulation for retinopathy of prematurity: A rare complication. Ophthalmic Surg Lasers Imaging Retina 2019;50:242-6.  Back to cited text no. 8
Moshfeghi DM, Silva RA, Berrocal AM. Exudative retinal detachment following photocoagulation in older premature infants for retinopathy of prematurity: Description and management. Retina 2014;34:83-6.  Back to cited text no. 9
Lalwani GA, Berrocal AM, Murray TG, Buch M, Cardone S, Hess D, et al. Off-label use of intravitreal bevacizumab (Avastin) for salvage treatment in progressive threshold retinopathy of prematurity. Retina 2008;28 (3 Suppl):S13-8.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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