eMedicine Specialties > Ophthalmology > Choroid
Choroidal Detachment: Treatment & Medication
Updated: Sep 11, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
As soon as the diagnosis is confirmed, topical corticosteroids, cycloplegics, and mydriatics should be prescribed for patients. Oral steroids can be used and are indicated when inflammation is a factor. When the IOP is high, which can occur with hemorrhagic choroidal detachments, IOP-lowering drugs can be used. Osmotics and aqueous suppressants are recommended. Parasympathomimetics are contraindicated.
Surgical Care
If choroidal detachment persists longer than 1 week after the underlying cause has been identified and addressed, drainage of the suprachoroidal fluid should be considered. The 7-day limit is an indication only; individualized assessment is key. If an improvement is suspected, waiting longer and closely monitoring the patient may be warranted. Immediate action is indicated when lens-cornea touch or IOL-cornea touch exists. This condition causes endothelial corneal damage and acceleration of lens opacities.
- If the AC remains flat after the cause has been identified and addressed, injection of viscoelastics into the AC should be considered. If lens-cornea touch or IOL-cornea touch exists, the AC reformation should be performed immediately, at the slit lamp if possible, while waiting to assess the need for suprachoroidal fluid drainage.
- The AC reformation at the slit lamp is best performed through a paracentesis tract in the peripheral cornea; paracentesis tracts usually are made at the time of cataract or glaucoma surgery.
- If not present, a paracentesis should be made with extreme care because the eye is likely to be soft and sore with a peripherally flat chamber; otherwise, inadvertent iris and lens damage may result. Performing a small full thickness corneal incision with a sharp 15° knife is safer.
- A cooperative patient is mandatory if the procedure is to be performed safely at the slit lamp.
- The technique for suprachoroidal fluid drainage involves making a paracentesis in the peripheral cornea. A balanced salt solution (BSS) is injected to fill the AC. The paracentesis site made at the time of cataract or glaucoma surgery can be used.
- Preoperatively, the sectors where the most fluid is accumulated should be identified by ophthalmoscopy or B-scan ultrasonography.
- Beginning with the sector where the detachment is largest, posterior sclerostomy is performed at 4-5 mm from the limbus. Circumferential cuts are made, producing an incision of about 2 mm in length.
- As soon as the suprachoroidal space is reached, the fluid drains. Serous detachments drain clear yellow fluid. Hemorrhagic detachments drain dark red fluid, often particulated with blood clots. Gentle poking with a blunt instrument a few millimeters around the sclerostomy helps drainage when spontaneous flow slows down.
- After one quadrant is drained, the AC is filled again with BSS, and the second quadrant receives a posterior sclerostomy in the same fashion. This procedure can be repeated for all 4 quadrants.
- At the end, especially in highly myopic eyes without a lens, SF6 gas can be left in the vitreous cavity to tamponade. No agreement exists regarding the closure of sclerostomies, which some surgeons elect to leave unsutured to allow for more drainage.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Anticholinergic agents
Inhibit binding of acetylcholine to cholinergic receptor, which, in turn, produces cycloplegia and mydriasis.
Cyclopentolate hydrochloride 1% (AK-Pentolate, Cyclogyl, I-Pentolate)
Blocks muscle of ciliary body and sphincter muscle of iris from responding to cholinergic stimulation, thus causing mydriasis and cycloplegia.
Induces mydriasis in 30-60 min and cycloplegia in 25-75 min. These effects last up to 24 h.
Adult
1 gtt of 1% solution usually adequate to induce cycloplegia; if necessary, repeat in 5-10 min
Pediatric
<1 year: 1 gtt of 0.5% solution with digital pressure on lacrimal sac
>1 year: 1 gtt of 0.5%, 1%, or 2% solution to induce cycloplegia; if necessary, repeat in 5-10 min
Decreases effects of carbachol and cholinesterase inhibitors
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients (eg, elderly) where increased IOP may be present; can cause toxic anticholinergic systemic adverse effects (common in children, especially infants) but incidence rare when used sparingly; compressing lacrimal sac by digital pressure for 1-3 min, following application, may minimize systemic absorption; skin rash, abdominal distension in infants, tachycardia, vasodilation, urinary retention, diminished GI motility, decreased secretion in salivary and sweat glands, pharynx, bronchi, and nose may occur
Atropine sulfate 1% (Isopto, Atropair, Atropisol)
Acts at parasympathetic sites in smooth muscle to block response of sphincter muscle of iris and muscle of ciliary body to acetylcholine, causing mydriasis and cycloplegia.
Adult
Solution (1%): 1-2 gtt in affected eye(s) qid; compress lacrimal sac by digital pressure for 1-3 min after instillation
Ointment: Apply 0.5-inch ribbon in conjunctival sac tid
Pediatric
Solution (0.5%): 1-2 gtt in affected eye(s) bid/tid
Ointment: Not established
Coadministration with other anticholinergics have additive effects; pharmacologic effects of atenolol and digoxin may increase with atropine; antipsychotic effects of phenothiazines may decrease; tricyclic antidepressants with anticholinergic activity may increase effects of atropine
Documented hypersensitivity; thyrotoxicosis; narrow angle glaucoma; tachycardia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Extreme caution in infants and children; excessive use in children and certain susceptible individuals may produce general toxic symptoms, including CNS disturbances, respiratory depression, and hypotension; coma and death reported in infants; caution in patients with Down syndrome and/or children with brain damage to prevent hyperreactive response; caution in coronary heart disease, tachycardia, congestive heart failure, cardiac arrhythmias, and hypertension; caution in peritonitis, ulcerative colitis, hepatic disease, and hiatal hernia with reflux esophagitis; in prostatic hypertrophy, prostatism can have dysuria and may require catheterization; prolonged local administration can cause vascular congestion, follicular conjunctivitis, exudates, edema, and eczematoid dermatitis
Mydriatic agents
Instillation of a long-acting cycloplegic agent relaxes any ciliary muscle spasm that causes a deep aching pain and photophobia.
Tropicamide 1% (Mydriacyl, Tropicacyl)
Blocks sphincter muscle of iris and muscle of ciliary body from responding to cholinergic stimulation.
Adult
Cycloplegia: 2 gtt in affected eye(s); may repeat in 5 min
Mydriasis: 1-2 gtt in affected eye(s) 15-20 min before examination; may repeat q30min prn
Pediatric
Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
CNS disturbances, psychotic reactions, behavioral disturbances, and cardiorespiratory collapse (especially in infants) may occur; adverse effects include transient stinging, blurred vision, mouth dryness, photophobia with or without corneal staining, tachycardia, parasympathetic stimulation, headache, and allergic reactions
Corticosteroids
Have both anti-inflammatory (glucocorticoid) and salt-retaining (mineralocorticoid) properties. Glucocorticoids have profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.
Prednisone (Deltasone, Orasone, Meticorten)
May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Adult
5-60 mg/d PO qd or divided bid/qid; taper over 2 wk as symptoms resolve
Pediatric
4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; taper over 2 wk as symptoms resolve
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Prednisolone (AK-Pred, Econopred, Inflamase Forte)
Decreases inflammation and corneal neovascularization. Suppresses migration of polymorphonuclear leukocytes and reverses increased capillary permeability.
In cases of bacterial infections, concomitant use of anti-infective agents is mandatory; if signs and symptoms do not improve after 2 days, reevaluate patient. Dosing may be reduced, but advise patients not to discontinue therapy prematurely.
Adult
Solution: 1-2 gtt in conjunctival sac q1h during day and q2h noct; once desired response is obtained, 1 gtt q4h; may reduce to 1 gtt tid/qid to control symptoms
Suspension: Shake well before using; 1-2 gtt in conjunctival sac 2-4 times/d; if necessary, may increase dosing frequency during initial 24-48 h
Pediatric
Administer as in adults
None reported
Documented hypersensitivity; viral, fungal, or tubercular infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypertension; known to cause cataract formation with long-term use; suspect fungal invasion in any persistent corneal ulceration where a corticosteroid has been used or is in use (obtain fungal cultures when appropriate)
More on Choroidal Detachment |
| Overview: Choroidal Detachment |
| Differential Diagnoses & Workup: Choroidal Detachment |
 Treatment & Medication: Choroidal Detachment |
| Follow-up: Choroidal Detachment |
| Multimedia: Choroidal Detachment |
| References |
| « Previous Page | Next Page » |
References
Abrams GW, Thomas MA, Williams GA, Burton TC. Management of postoperative suprachoroidal hemorrhage with continuous-infusion air pump. Arch Ophthalmol. Oct 1986;104(10):1455-8. [Medline].
Bellows AR, Chylack LT Jr, Epstein DL, Hutchinson BT. Choroidal effusion during glaucoma surgery in patients with prominent episcleral vessels. Arch Ophthalmol. Mar 1979;97(3):493-7. [Medline].
Berke SJ, Bellows AR, Shingleton BJ, Richter CU, Hutchinson BT. Chronic and recurrent choroidal detachment after glaucoma filtering surgery. Ophthalmology. Feb 1987;94(2):154-62. [Medline].
Brubaker RF, Pederson JE. Ciliochoroidal detachment. Surv Ophthalmol. Mar-Apr 1983;27(5):281-9. [Medline].
Chu TG, Cano MR, Green RL, Liggett PE, Lean JS. Massive suprachoroidal hemorrhage with central retinal apposition. A clinical and echographic study. Arch Ophthalmol. Nov 1991;109(11):1575-81. [Medline].
Costa VP, Smith M, Spaeth GL, Gandham S, Markovitz B. Loss of visual acuity after trabeculectomy. Ophthalmology. May 1993;100(5):599-612. [Medline].
Davani S, Delbosc B, Royer B, Kantelip JP. Choroidal detachment induced by dorzolamide 20 years after cataract surgery. Br J Ophthalmol. Dec 2002;86(12):1457-8. [Medline].
Goldberg S, Gallily R, Bishara S, Blumenthal EZ. Dorzolamide-induced choroidal detachment in a surgically untreated eye. Am J Ophthalmol. Aug 2004;138(2):285-6. [Medline].
Horgan N, Kirwan RP, O'Brien CJ. Choroidal detachment associated with latanoprost use in the fellow eye. Ann Pharmacother. Jan 2007;41(1):161-2. [Medline].
Katz LJ. Ciliochoroidal detachment. Ophthalmic Surg. Mar 1987;18(3):175. [Medline].
Maumenee AE, Stark WJ. Management of persistent hypotony after planned or inadvertent cyclodialysis. Am J Ophthalmol. Jan 1971;71(1 Part 2):320-7. [Medline].
Shapiro BL, Petrovic V, Lee SE, Flach A, McCaffery S, O'Brien JM. Choroidal detachment following the use of tamsulosin (Flomax). Am J Ophthalmol. Feb 2007;143(2):351-3. [Medline].
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. Feb-Mar 2005;25(2):152-7. [Medline].
Sharma T, Salmon JF. Hypotony and choroidal detachment as a complication of topical combined timolol and dorzolamide. J Ocul Pharmacol Ther. Apr 2007;23(2):202-5. [Medline].
Singh R, Umapathy T, Abedin A, Eatamadi H, Maharajan S, Dua HS. Choroidal detachment in perforated corneal ulcers: frequency and management. Br J Ophthalmol. Sep 2006;90(9):1111-4. [Medline].
Sodhi PK, Sachdev MS, Gupta A, Verma LK, Ratan SK. Choroidal detachment with topical latanoprost after glaucoma filtration surgery. Ann Pharmacother. Mar 2004;38(3):510-1. [Medline].
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. Feb 1991;98(2):202-9; discussion 210. [Medline].
Stalmans I, Gillis A, Lafaut AS, Zeyen T. Safe trabeculectomy technique: long term outcome. Br J Ophthalmol. Jan 2006;90(1):44-7. [Medline].
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. Jul-Aug 2004;14(4):325-9. [Medline].
Yalvac IS, Satana B, Ozkan G, Eksioglu U, Duman S. Management of glaucoma in patients with nanophthalmos. Eye. Feb 9 2007;[Medline].
Further Reading
Keywords
serous choroidal detachment, choroidals, choroidal effusion, delayed suprachoroidal hemorrhage, nonexpulsive suprachoroidal hemorrhage, hemorrhagic choroidal detachment, expulsive hemorrhage, intraoperative choroidal detachment/hemorrhage, choroidal vascular plexus
