CHOROIDAL DETACHMENT

INTRODUCTION

• Choroidal detachment occurs when the choroid becomes lifted from the sclera by an accumulation of either serous fluid or blood

SYNONYMS• Ciliochoroidal detachment• Suprachoroidal effusion• Supraciliary effusion

• These labels all describe an abnormal collection of fluid that expands the suprachoroidal space, producing internal elevation of the choroid

ANATOMY

• The suprachoroidal space is a potential space between the choroid and the sclera.

• When filled with blood or fluid, it becomes a true space of which the boundaries are the scleral spur anteriorly, and the optic disc posteriorly.

• There is, ordinarily, approximately 10 microlitre of fluid in the suprachoroidal space

PHYSIOLOGY

Under normal circumstances : IOP > Pressure in suprachoroidal space > atmospheric pressure

EPIDEMIOLOGY• Incidence following surgery varies

between 0.05-6%• No racial predilection exists.• No sexual predilection exists.• Hemorrhagic detachments are seen more

often in elderly patients.

CLASSIFICATION• (A) SEROUS CHOROIDAL DETACHMENT

often related to low intraocular pressure (hypotony) following surgery or trauma, or secondary to inflammation.

• Low intraocular pressure (IOP), particularly <5mmHg, is liable to promote transudation of serum out of the choroidal vasculature, causing lifting of the choroid.

(B) HAEMORRHAGIC CHOROIDAL DETACHMENT

This can occur spontaneously (rare), as a consequence of ocular trauma, during eye surgery, or after eye surgery .Surgery or trauma may cause rupture of the short posterior ciliary arteries or other vascular trauma leading to bleeding

(C) Choroidal detachment in the absence of apparent cause has been termed UVEAL EFFUSION SYNDROME or idiopathic ciliochoroidal effusion. 

ETIOLOGY

PATHOGENESIS SEROUS CHOROIDAL DETACHMENT

1) HYPOTONY – Decreases pressure gradient across sclera and thus rate of fluid loss from sclera.

When rate of fluid loss becomes lesser than rate of entry – fluid accumulation occurs

2) INFLAMMATION – increases colloid leakage into suprachoroidal space

• Another theory suggests that a tear in the ciliary body allows aqueous humor to flow into the suprachoroidal space - Fuchs E. Ablosung der Aderhaut nach staaroperation. Albrecht von Graefes Arch Ophthalmol.

1900;51:199-224.

HAEMORRHAGIC CHOROIDAL DETACHMENT

• Choroidal hemorrhage may occur when a fragile vessel is exposed to sudden compression and decompression events

• Hypotony – serous effusion – tension on ciliary vessels – rupture

• Retrobulbar anesthetic injection, retrobulbar hemorrhage, or excessive pressure on the globe during surgery may impede vortex venous outflow and lead to choroidal effusion and hemorrhage

• Choroidal hemorrhage may occur in a limited form or as a massive event.

• Massive choroidal hemorrhage is of sufficient volume to cause extrusion of intraocular contents outside the eye or to move retinal surfaces into or near apposition (“kissing”).

• Massive choroidal hemorrhage may be expulsive or nonexpulsive, immediate (intraoperative), or delayed hours to weeks postoperatively; it may occur spontaneously, with choroidal mass lesions (e.g., choroidal hemangioma), or with surgical or noniatrogenic trauma

• RISK FACTORS-

• Advanced age, arteriosclerosis, hypertension, diabetes mellitus, blood dyscrasias, and obesity.

• Ocular risk factors include previous surgery, aphakia, glaucoma, uveitis, high myopia, trauma, vitreous removal, laser photocoagulation, and choroidal sclerosis.

• A scleral buckle placed during vitrectomy is a risk factor for postoperative choroidal hemorrhage.

• Glaucoma procedures and previous pars plana vitrectomy serve as risk factors for appositional choroidal hemorrhage.

• A history of choroidal hemorrhage serves as a risk factor for surgery on either eye.

• Intraoperative risk factors include increased intraocular pressure, increased axial length, open-sky procedures, and Valsalva maneuvers.

• Intraoperative tachycardia has been identified as a significant risk factor or an early symptom of expulsive hemorrhage

• In patients with uveal effusion syndrome or the closely related condition of nanophthalmos, abnormal sclera, referred to here as scleropathy, is the most likely primary ocular anomaly affecting choroidal fluid dynamics

PRESENTATION

a) Recent intraocular surgery is the most common association

b) Eye trauma

c) Panretinal photocoagulation d) Use of IOP-lowering medicationse) H/o straining at stools, coughing, sneezing.f) Anticoagulants and aspirin may facilitate

bleeding.

HISTORY

S/S• Serous detachment is typically painless,

with a variable degree of vision loss.

• Postoperative hemorrhagic detachments are characterized by sudden excruciating throbbing pain with an immediate loss of vision both symptoms are almost pathognomonic (paroxysmal onset of severe intraoperative pain despite akinesia and previously adequate analgesia. Classically, the pain radiates from the brow to the vertex of the head along the V1 dermatome and is often refractory to further retrobulbar analgesia.)

• Visual acuity usually is reduced, including light perception, depending on the degree of interference with the visual axis.

• Inflammation in the anterior and posterior segment varies

• The anterior chamber (AC) can be of normal depth, or it can be shallow or flat

• Intraocular pressure can be normal, low, or elevated; as a rule, low IOP accompanies serous detachments, and high IOP accompanies hemorrhages

• Ophthalmoscopy demonstrates a smooth, bullous, orange-brown elevation of the retina and choroid

• Choroidal detachment that occurs anterior to the equator often extends in an annular fashion around the globe; whereas postequatorial choroidal detachment often is unilobulated or multilobulated, secondary to the periequatorial attachment of the choroid at the vortex vein ampullae

• Visualization of the ora serrata without scleral depression may be a sign of pre-equatorial choroidal detachment

• Ciliochoroidal edema/detachment without evidence of intraocular surgery or trauma should be investigated for a neoplastic, vascular, or inflammatory cause

• In a chronic ciliochoroidal effusion, breakdown of the blood-ocular barrier at the level of the retinal pigment epithelium (RPE) may occur, leading to a nonrhegmatogenous retinal detachment characterized by shifting subretinal fluid.

• Linear areas of RPE hypertrophy and hyperplasia may also be observed –Verhoeffs lines

• The intraoperative signs of massive choroidal hemorrhage may include :

• Tachycardia and excessive iris movement or prolapse.

• Progressive shallowing of the anterior chamber• Vitreous extrusion, loss or partial obscuration of

the red reflex and the appearance of a dark mound behind the pupil

• In severe cases, posterior segment contents may be extruded into the anterior chamber and through the incision This usually is accompanied by forward movement of the lens and vitreous body, as the globe tenses.

• Anterior-segment examination in a patient with uveal effusion syndrome may reveal dilation of the episcleral blood vessels.

• Blood may be present in the Schlemm’s canal on gonioscopy.

• The anterior chamber is free of any signs of inflammation

• Intraocular pressure is normal• There is greater absorption of fluid from the

subretinal space compared with protein outflow, which results in rising protein concentration and marked shifting of subretinal fluid with changes in head position.

• Progressive subretinal fluid accumulation may lead to total retinal detachment. Chronic serous effusion and subretinal fluid accumulation may result indiffuse depigmentation and multifocal hyperplasia of the retinal pigment epithelium, forming the characteristic clinical finding of leopard spots in the fundus

DIFFERENTIAL DIAGNOSES

INVESTIGATIONS• B- Scan USG shows following features:1) TOPOGRAPHIC- • Smooth dome or flat elevation• No disc insertion• Inserts at Ora or ciliary body2) QUANTITATIVE• Steeply rising ,thick , double peaked spike• 100% amplitude3)KINETIC• Mild to none after movement

• The first peak may represent the surface of the overlying detached retina or the anterior surface of the choroid. Alternatively, the double peak may represent both the anterior and posterior surfaces of the choroid

• Serous detachment is characterized by low-reflective fluid in the domed spaces. Hemorrhagic detachment with fresh blood clots is seen echographically as a high-reflective, solid-appearing mass, with irregular internal structure and irregular shape.

• Serial ultrasonography may demonstrate liquefaction of hemorrhage; the suprachoroidal space is filled with low-reflective mobile opacities, which have replaced the hemorrhagic clot

• UBM can detect very small effusions over ciliary body without clinically detectable choroidal detachment-Ciliary body is detached at scleral spur

• In uveal effusion syndrome• Angiography may demonstrate a leopard-skin

appearance of hyperfluorescence and hypofluorescence

• OCT may show focal thickening of the retinal pigment epithelium layer corresponding to the areas ofleopard spots

MANAGEMENT• The management of serous choroidal detachment

usually is conservative.• Postoperative serous choroidal detachments often

resolve on their own within days.• Cycloplegia and corticosteroids are general

management measures. • Most commonly, serous choroidal detachments occur

after excessive leakage from a wound or after glaucoma filtering surgery. These cases usually respond to measures that reduce over-filtration and consequent hypotony, such as pressure patching and glue or bandage contact lens use

• Oral fluids can be given to increase aqueous humor flow.

• Acetazolamide has been noted to cause rapid (within hours) absorption of suprachoroidal fluid.

• This effect seems paradoxical since acetazolamide is a hypotensive agent and a suppressor of aqueous humor formation. However, this drug has some vasoconstrictive properties and might lessen fluid extravasation from choroidal vessels.

CHOROIDAL HEMORRHAGE• INTRA OP• a The AC is filled with a cohesive viscoelastic and

the incision is sutured.   b    The viscoelastic should be left in the eye to raise the intraocular pressure and tamponade the bleeding vessel.   c    IOP-lowering medication such as oral acetazolamide is given to address the resultant pressure spike.   d    Intravenous mannitol may be given if necessary although reducing the IOP too rapidly should be avoided.   e    Postoperatively, topical and systemic steroids should be used aggressively to reduce intraocular inflammation

• POSTOP• Limited choroidal hemorrhage usually resolves

spontaneously within 1–2 months without ophthalmoscopic evidence of damage.

• Management remains conservative in this situation and includes the use of cycloplegics and topical corticosteroids.

• The management of delayed, nonexpulsive, massive choroidal hemorrhage, by contrast, remains controversial. Systemic corticosteroids are employed by some investigators , surgery by others

Following are the indication for undertaking prompt surgical

intervention:• 1. Lenticulo-endothelial touch• 2. Progressive corneal edema• 3. Failing filtering bleb in an inflamed eye• 4. Wound leak with flat anterior chamber• 5. Kissing choroidal’s for > 48 hrs• 6. Shallow AC with colarette iridocorneal touch for more

than 3 days or peripheral iridocorneal touch for more than 1 week

SCLEROTOMY• Preoperatively, Indirect ophthalmoscopy and/or B-scan ultrasonography should be done to identify the site of

maximum fluid accumulation or choroidal detachment This should be the site for fluid drainage

Choroidal drainage is done under peribulbar block with 2 percent xylocaine, 0.75 percent Bupivacaine mixed with 1:200,000 epinephrine and hyaluronidase.

• A paracentesis is made with a myringotome directed from the temporal limbus in clear cornea .

• If a previous paracentesis had been made as part of a previous surgery efforts are made to re-use the same entry site, since making a new entry in a soft eye is difficult.

• The anterior chamber is deepened by injecting balanced salt solution (BSS) or air injected with a 30-gauge needle

• A circumferential conjunctival incision is made 4 mm from the limbus in the inferior temporal quadrant/ the site of maximum fluid localization.

• Using calipers, the site for the choroidal drainage procedure is marked .

• While grasping the globe firmly and exposing the quadrant to be drained, a 2 to 3 mm long, radial incision (sclerotomy) is made at about 4 to 5 mm from the surgical limbus in the selected quadrant with a 15 no. Bard Parker blade

• A more posterior incision should better be avoided to minimize the risk of inadvertent retinal perforation and vitreous loss

• The edge of the incision should be cauterized with wet field cautery, so that the edge of wound gets retracted

• As the suprachoroidal space is reached, a spontaneous gush of fluid is seen

• As the spontaneous flow slows down, gentle pressure with a blunt instrument like iris repositor a few millimeters around the sclerotomy site helps in draining residual fluid

• A full-length cyclodialysis spatula can be inserted under the sclera to drainthe fluid from the loculated pockets. However, it should be avoided to reduce the chances of damage to perforating branches of anterior ciliary artery or one of the long posterior ciliary arteries.

• Care should be taken to fill the anterior chamber with air or BSS to prevent any endothelial damage

• At the end, air bubble should be left in the anterior chamber. • The sclerostomy site should be left open, and may be cauterized a

little more to ensure further drainage of suprachoroidal fluid in the post-operative period.

• Conjunctiva is sutured in a continuous mattress fashion with 8-0 vicryl sutures.

• Similarly the procedure can be repeated in other quadrants if indicated.

• This procedure can be repeated for all 4 quadrants in the same or separate sittings.

• Postoperatively, a course of topical antibiotics, topical steroids and cycloplegics are advised

• If vitreous is incarcerated in the original surgical wound, a vitrectomy probe may be introduced through a second limbal incision and an anterior vitrectomy performed to minimize vitreoretinal traction during the choroidal drainage procedure.

• Once adequate initial drainage has been achieved, a posterior vitrectomy with scleral depression is performed

• For rhegmatogenous retinal detachment, -the insertion of a 6 mm infusion cannula through the anterior pars plana is necessary to prevent suprachoroidal infusion.

• Relaxing peripheral retinotomy or retinectomy may be necessary to relieve incarceration of the retina or severe anterior vitreous traction.

• The use of perfluorocarbon liquids may facilitate the drainage of suprachoroidal hemorrhage and facilitate reattachment of the retina.

• Scleral buckling or long-term intraocular tamponade with silicone oil may minimize the chances of recurrent retinal detachment in these eyes.]

PROGNOSIS• Delayed, nonexpulsive, limited choroidal hemorrhage

generally carries a good prognosis.• Retinal detachment in an eye with choroidal

detachment or with choroidal hemorrhage in all four quadrants correlates with a poor visual outcome

• The extension of suprachoroidal hemorrhage into the posterior pole has been associated with worse visual and anatomical outcomes.

• In eyes with appositional choroidal detachment, duration of apposition greater than 30 days, a history of uveitis, macular degeneration, or extracapsular cataract extraction are associated with poor visual acuity outcomes.