CHOROIDAL DETACHMENT

1. CHOROIDAL
DETACHMENT

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

3. 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

4. ANATOMY

5. • 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

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

7. 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.

8. 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.

9. (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.

10. ETIOLOGY

11. 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.

12. 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

13. • 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

14. • 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

15. • 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

16. PRESENTATION
a) Recent intraocular surgery is the most
common association
b) Eye trauma
c) Panretinal photocoagulation
d) Use of IOP-lowering medications
e) H/o straining at stools, coughing, sneezing.
f) Anticoagulants and aspirin may facilitate
bleeding.
HISTORY

17. 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.)

18. • 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

19. • 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

21. • 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

22. • 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

24. • 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.

25. • 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.

26. • 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

28. DIFFERENTIAL DIAGNOSES

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

31. • 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

32. • 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

34. 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

35. • 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.

36. 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

37. • 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

38. 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

39. 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.

40. • 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

42. • 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.

44. • 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

46. • 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.]

47. 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.