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Choroidal Detachment Clinical Presentation

  • Author: Carlo E Traverso, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Sep 19, 2014
 

History

See the list below:

  • Rarely, choroidal detachments form spontaneously. Recent intraocular surgery is the most common association.[3, 4, 5, 6, 7] Eye trauma and corneal ulcers are frequent, and panretinal photocoagulation can also cause choroidal detachments.[8] The use of IOP-lowering medications has also reportedly been associated with serous choroidal detachments.[9, 10, 11, 12, 13, 14]
  • 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.
  • Detachment can occur after a Valsalva maneuver, straining at stools, coughing, or sneezing. Anticoagulants and aspirin may facilitate bleeding.
  • Intraoperative hemorrhage is characterized by the development of positive pressure, visualization of an enlarging dark mass obscuring the fundus reflex, and tendency to extrude eye contents.
  • Ciliochoroidal edema/detachment without evidence of intraocular surgery or trauma should be investigated for a neoplastic, vascular, or inflammatory cause.[15, 16]
  • 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.[17]
  • Intraocular pressure can be normal, low, or elevated; as a rule, low IOP accompanies serous detachments, and high IOP accompanies hemorrhages.
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Physical

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  • The anterior chamber (AC) can be of normal depth, or it can be shallow or flat.
  • When no other causes for hypotony are evident after trauma or surgery, use gonioscopy to check for a cyclodialysis cleft.[18]
  • The fundus examination shows choroidal detachment, shown below.
    Serous choroidal detachment. Two lobes (ie, supertSerous choroidal detachment. Two lobes (ie, supertemporal, supranasal) of fluid accumulation are visible. The choroidal folds seen at the posterior pole are due to concomitant hypotony.
  • Stage the detachment.
    • The extent of detachment can be limited to one or more sectors, with the lobe(s) limited by the fibrous attachments corresponding to the vortex veins.
    • Annular detachments involve the circumference for 360°.
    • A large degree of fluid accumulation can cause contact between lobes on the visual axis, with retina-to-retina contact centrally (kissing choroidals), while little fluid accumulation can cause a flat and anterior detachment, visible only with ultrasound biomicroscopy (UBM). Kissing choroidals is shown in the image below.
      Kissing choroidal detachment. When the lobes of thKissing choroidal detachment. When the lobes of the detachment are sufficiently large, retina-to-retina contact occurs. If this is extended centrally, the clinical picture is described as kissing choroidals. The extension of the lobes of detachment/edema is important for the decision-making process regarding the clinical management.
  • Suprachoroidal hemorrhages can be accompanied by vitreous hemorrhage, retinal detachment, and retinal breaks.[1] This is shown in the image below.
    Postoperative suprachoroidal hemorrhage. In this bPostoperative suprachoroidal hemorrhage. In this buphthalmic aphakic eye, suprachoroidal hemorrhage resulted in vitreous hemorrhage, retinal detachment, and extrusion of retina and blood through the pupil into the anterior chamber.
  • Intraoperative hemorrhages can be complicated by loss of eye contents, resulting in vitreous, retina, or lens remnants incarcerated in the surgical incision or visible in the AC.
  • Retinal detachment on ophthalmoscopy
    • A nonrhegmatogenous retinal detachment can be superimposed to a choroidal detachment and characterized by shifting subretinal fluid.
    • Choroidal detachments are nontremulous.
    • Retinal vessels look normal.
    • Ora serrata may be visible without indentation.
  • B-scan ultrasonography
    • Retinal detachments are mobile and highly reflective.
    • Choroidal detachments are domed shaped and are serous or hemorrhagic.[19]
  • Chronic serous choroidal detachments
    • Solid intraocular tumors are identified by transillumination.
    • With serous detachments, transillumination reveals a bright reflex, which can be present in nonpigmented choroidal melanomas.
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Causes

See the list below:

  • Serous detachments have no specific predisposing factors except nanophthalmos.[20]
  • Causes of serous detachments include globe hypotony, trauma, and inflammation.
  • Predisposing factors for choroidal hemorrhages are old age, diffuse arteriosclerosis, glaucoma, previous eye surgery, axial myopia, a choroidal hemorrhage in the fellow eye, sickle cell anemia, and very short axial length.
  • Postoperative hypotony is the most likely causal factor.
  • Hemorrhage occurs when vessels rupture. Hemorrhage is more likely in patients with systemic hypertension, intraoperative tachycardia, or arteriosclerosis. Other predisposing factors include old age and previous eye surgery.
  • Sudden globe decompression during surgery, particularly if the eye is affected by glaucoma and surgery is initiated when the IOP is still elevated, also predisposes to choroidal detachment.[21]
  • The use of some medications has also reportedly been associated with serous choroidal detachments.[9, 10, 11, 12, 13, 14, 22]
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Contributor Information and Disclosures
Author

Carlo E Traverso, MD Professor and Chairman, Clinica Oculistica of Department of Neurosciences, Ophthalmology, Maternal and Pediatrics and Genetics, University of Genova Medical School/IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Italy

Carlo E Traverso, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, European Glaucoma Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steve Charles, MD Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Macula Society, Retina Society, Club Jules Gonin

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Richard W Allinson, MD Associate Professor, Department of Ophthalmology, Texas A&M University Health Science Center; Senior Staff Ophthalmologist, Scott and White Clinic

Richard W Allinson, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

References
  1. Healey PR, Herndon L, Smiddy W. Management of suprachoroidal hemorrhage. J Glaucoma. 2007 Sep. 16(6):577-9. [Medline].

  2. Speaker MG, Guerriero PN, Met JA, Coad CT, Berger A, Marmor M. A case-control study of risk factors for intraoperative suprachoroidal expulsive hemorrhage. Ophthalmology. 1991 Feb. 98(2):202-9; discussion 210. [Medline].

  3. Moshfeghi DM, Kim BY, Kaiser PK, Sears JE, Smith S. Appositional suprachoroidal hemorrhage: a case-control study. Am J Ophthalmol. 2004 Dec. 138(6):959-63.

  4. Berke SJ, Bellows AR, Shingleton BJ, Richter CU, Hutchinson BT. Chronic and recurrent choroidal detachment after glaucoma filtering surgery. Ophthalmology. 1987 Feb. 94(2):154-62. [Medline].

  5. Verma L, Venkatesh P, Chawla R, Tewari HK. Choroidal detachment following retinal detachment surgery: an analysis and a new hypothesis to minimize its occurrence in high-risk cases. Eur J Ophthalmol. 2004 Jul-Aug. 14(4):325-9. [Medline].

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  8. Singh R, Umapathy T, Abedin A, Eatamadi H, Maharajan S, Dua HS. Choroidal detachment in perforated corneal ulcers: frequency and management. Br J Ophthalmol. 2006 Sep. 90(9):1111-4. [Medline].

  9. Davani S, Delbosc B, Royer B, Kantelip JP. Choroidal detachment induced by dorzolamide 20 years after cataract surgery. Br J Ophthalmol. 2002 Dec. 86(12):1457-8. [Medline].

  10. Goldberg S, Gallily R, Bishara S, Blumenthal EZ. Dorzolamide-induced choroidal detachment in a surgically untreated eye. Am J Ophthalmol. 2004 Aug. 138(2):285-6. [Medline].

  11. Horgan N, Kirwan RP, O'Brien CJ. Choroidal detachment associated with latanoprost use in the fellow eye. Ann Pharmacother. 2007 Jan. 41(1):161-2. [Medline].

  12. Shapiro BL, Petrovic V, Lee SE, Flach A, McCaffery S, O'Brien JM. Choroidal detachment following the use of tamsulosin (Flomax). Am J Ophthalmol. 2007 Feb. 143(2):351-3. [Medline].

  13. Sharma T, Salmon JF. Hypotony and choroidal detachment as a complication of topical combined timolol and dorzolamide. J Ocul Pharmacol Ther. 2007 Apr. 23(2):202-5. [Medline].

  14. Sodhi PK, Sachdev MS, Gupta A, Verma LK, Ratan SK. Choroidal detachment with topical latanoprost after glaucoma filtration surgery. Ann Pharmacother. 2004 Mar. 38(3):510-1. [Medline].

  15. Brubaker RF, Pederson JE. Ciliochoroidal detachment. Surv Ophthalmol. 1983 Mar-Apr. 27(5):281-9. [Medline].

  16. Katz LJ. Ciliochoroidal detachment. Ophthalmic Surg. 1987 Mar. 18(3):175. [Medline].

  17. Goldman DR, Hubschman JP, Aldave AJ, Chiang A, Huang JS, Bourges JL, et al. POSTOPERATIVE POSTERIOR SEGMENT COMPLICATIONS IN EYES TREATED WITH THE BOSTON TYPE I KERATOPROSTHESIS. Retina. 2012 Oct 15. [Medline].

  18. Maumenee AE, Stark WJ. Management of persistent hypotony after planned or inadvertent cyclodialysis. Am J Ophthalmol. 1971 Jan. 71(1 Part 2):320-7. [Medline].

  19. Viola F, Dell'Arti L, Benatti E, Invernizzi A, Mapelli C, Ferrari F, et al. Choroidal Findings in Dome-Shaped Macula in Highly Myopic Eyes: a longitudinal study. Am J Ophthalmol. 2014 Sep 19. [Medline].

  20. Yalvac IS, Satana B, Ozkan G, Eksioglu U, Duman S. Management of glaucoma in patients with nanophthalmos. Eye. 2007 Feb 9. [Medline].

  21. Chikako S, Mita S, Hori S. Choroidal detachment after uncomplicated small incision cataract surgery. Case Report Ophthalmol. 2012 May. 3(2):175-9. [Medline]. [Full Text].

  22. Kwon SJ, Park DH, Shin JP. Bilateral transient myopia, angle-closure glaucoma, and choroidal detachment induced by methazolamide. Jpn J Ophthalmol. 2012 Sep. 56(5):515-7. [Medline].

  23. Kanamoto T, Takamatsu M. Systemic steroid-pulse therapy in a patient with idiopathic choroidal detachment: a case report. Case Report Ophthalmol. 2012 Jan. 3(1):65-70. [Medline]. [Full Text].

  24. Grzybowski A, Prasad S. Anticoagulant therapy is not a risk factor for choroidal haemorrhage. Graefes Arch Clin Exp Ophthalmol. 2014 Oct 3. [Medline].

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  26. Sharma T, Gopal L, Reddy RK, Kasinathan N, Shah NA, Sulochana KN, et al. Primary vitrectomy for combined rhegmatogenous retinal detachment and choroidal detachment with or without oral corticosteroids: a pilot study. Retina. 2005 Feb-Mar. 25(2):152-7. [Medline].

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Serous choroidal detachment. Two lobes (ie, supertemporal, supranasal) of fluid accumulation are visible. The choroidal folds seen at the posterior pole are due to concomitant hypotony.
B-scan ultrasonography examination of choroidal detachment. Fluid appears to be serum on one side (upper) and blood on the other side (below). Retina-to-retina contact, or kissing choroidal detachment, is present.
Kissing choroidal detachment. When the lobes of the detachment are sufficiently large, retina-to-retina contact occurs. If this is extended centrally, the clinical picture is described as kissing choroidals. The extension of the lobes of detachment/edema is important for the decision-making process regarding the clinical management.
Postoperative suprachoroidal hemorrhage. In this buphthalmic aphakic eye, suprachoroidal hemorrhage resulted in vitreous hemorrhage, retinal detachment, and extrusion of retina and blood through the pupil into the anterior chamber.
Drainage of suprachoroidal space. After the posterior sclerostomies are performed, gentle infusion in the anterior chamber through a paracentesis tract helps the globe to maintain a tone while the fluid exit from the suprachoroidal space is facilitated.
Drainage of suprachoroidal space. The hemorrhagic fluid is darker than fresh blood. Mechanical gaping of the radial incisions facilitates the egress of fluid.
Drainage of suprachoroidal hemorrhage. At least two quadrants, guided by B-scan images. Careful sclerostomies are performed at 4-5 mm from the limbus. The anterior chamber (AC) should be frequently reformed or a low-pressure AC infusion line should be placed. Gentle pressure on the surrounding sclera will help drainage. Serum is yellow and clear, blood is very dark red. Do not grab or pull from inside the sclerostomies. The technique is the same for drainage of serous choroidal detachment.
 
 
 
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