Features

A choroidal detachment is a collection of serous fluid or blood that forms in the space separating the choroid and sclera (the suprachoroidal space). Other common terms for choroidal detachments include choroidal effusion, ciliochoroidal effusion, ciliochoroidal detachment, choroidal hemorrhage, suprachoroidal hemorrhage, uveal effusion, and the colloquial term “choroidals.” Though they may be asymptomatic and can resolve with time, choroidal detachments can also be severe, leading to significant and/or permanent changes in vision in the affected eye. This is particularly true of choroidal detachments either caused by or leading to suprachoroidal hemorrhages, which tend to have worse outcomes.

The most frequent cause of this combination is glaucoma surgery, particularly if overfiltration or leakage occurs postoperatively, leading to chronic hypotony. All forms of intraocular surgery, however, can be associated with hypotony and inflammation. Laser surgery has also been known to lead to choroidal detachments, including both retinal and anterior segment procedures. Advancing age, hypertension, prior vitrectomy, nanophthalmos, and certain conditions such as Sturge-Weber are associated with increased risk for developing choroidal detachments after surgeries. If choroidal hemangiomas are present with Sturge-Weber, the risk is increased even further.

Idiopathic chronic detachment, uveal effusion syndrome (UES), is rare, but is usually chronic in nature and can lead to significant visual loss. UES is a diagnosis of exclusion and tends to occur with intraocular pressures in the normal range, compared to classic choroidal detachment.

Hemorrhagic choroidal detachments, known as suprachoroidal hemorrhages, occur due to disruption of the choroidal blood vessels that pass through the space. While this may occasionally occur with no inciting factors, they are more often associated with trauma or during acute hypotony with choroidal detachments from another cause, usually intraocular surgery, which can lead to stretching and possible rupture of these blood vessels. The subsequent bleeding into the suprachoroidal space can lead to rapid development or worsening of a choroidal detachment. One dreaded potential complication of suprachoroidal hemorrhage during intraocular surgery is expulsive hemorrhage, as the rapidly enlarging hemorrhagic detachment leads to expulsion of intraocular contents out of the surgical wound(s). Previous ocular surgery is a risk factor for spontaneous suprachoroidal hemorrhages, as is a history of glaucoma, advancing age, and extremes of axial length.

85.1.1 Common Symptoms

Variable symptoms depending on the size, location, and nature of the detachment. Serous detachments are likely to be smaller; most postsurgical detachments are small, peripheral, self-limited, and often subclinical, with minimal to no pain or vision changes. Larger or more central effusions are likely to affect vision; decreased acuity or scotoma at the areas of detachment, or through refractive changes due to pressure and displacement of the lens and iris. Compared to serous detachments, hemorrhagic detachments most often present with acute, severe pain in the affected eye; more likely to cause vision changes.

85.1.2 Exam Findings

Choroidal detachments are most often noted during physical exam, but appearance and ease of visualization may vary. They usually appear as smooth, orange, or light brown, dome-shaped elevations. If large, the elevations may have a lobulated appearance, due to the fibrous attachments between the choroid and the vortex veins as they pass through the sclera. If the detachments are large, the lobes may come into appositional contact with each other (“kissing choroidals”). In severe cases, they may even come into contact with the posterior surface of the lens. With the chronic, relapsing-remitting choroidal detachments of UES, diffuse pigmented spots can develop, often described as “leopard skin” spots. On slit lamp examination, detachments may cause narrowing of the peripheral anterior chamber and angles, shallowing of the entire anterior chamber, and/or anterior rotation of the ciliary body. Acute, rapidly progressing choroidal detachments during intraocular surgery at risk of leading to expulsive hemorrhage may first present as loss of the red reflex during surgery.

85.2 Key Diagnostic Tests and Findings

85.2.1 Optical Coherence Tomography

When exam is limited, optical coherence tomography may also be useful in differentiating choroidal detachment from other causes of postoperative posterior pole elevation (e.g., retinal detachment).

85.2.2 Ultrasonography

B-scan ultrasonography of the eye can be valuable in identifying and differentiating choroidal detachments (▶ Table 85.1), may locate detachments not visible or noted on the clinical exam, and can differentiate between a hemorrhagic choroidal detachment (in which the suprachoroidal space is filled with hyperechoic blood) and a serous choroidal detachment (in which the suprachoroidal space is filled with hypoechoic transudate). Ultrasonography can be critical for preoperative planning for choroidal drainage.

85.3 Critical Work-up

Differentiate choroidal detachments from other similarly presenting conditions, particularly retinal detachments (▶ Table 85.1). Compared to retinal detachments, choroidal detachments have a more fixed, lobulated, or hourglass appearance on ultrasound. Also common on the differential are choroidal masses, but these typically present less acutely.

85.4 Management

85.4.1 Treatment Options

Observation

The majority of choroidal detachments are self-limited and resolve slowly with time; observe smaller, nonvisually significant detachments, particularly if any underlying or contributing factors have been alleviated. Addressing the inciting cause (e.g., hypotony) is critical.

Medication

If the choroidal detachments are thought to be medication related, those medications can be decreased or halted as tolerated in order to promote resolution. Topical or oral steroid treatments are also often used to treat underlying inflammation. Cycloplegic agents are also often started in order to counteract the anterior rotation of the ciliary body, as well as deepen the anterior chamber. There may occasionally be elevations of intraocular pressure as the detachment develops, which may necessitate temporary use of medications to lower ocular pressure instead.

Surgical Treatment

In cases of large choroidal detachments and “kissing choroidals,” surgical drainage is often indicated. For hemorrhagic detachments, it is often necessary to wait 7 to 14 days to allow the blood to liquefy, which is usually evaluated with ultrasonography. While exact techniques can differ, surgical drainage usually involves creation of one or more sclerotomies with maintenance of the anterior chamber during the surgery to express fluid/hemorrhage through the sclerotomies posteriorly. The sclerotomies may be left open following the surgery for continuing drainage. Vitrectomy and/or gas exchange may also be indicated, depending on the exact circumstances of the case.

Prevention

Steps that may help prevent choroidal detachment development include the decreased use of pressure-reducing medications peri- and postoperatively, avoidance of overfiltration or leak, cessation of anticoagulants in the perioperative period, and judicious use of antimetabolites.

85.4.2 Follow-up

Close monitoring in the acute period around the time of choroidal development is necessary. Serial ultrasounds or serial wide-field photography (if the media is clear) can be helpful in monitoring the slow resolution process (▶ Fig. 85.1, ▶ Fig. 85.2).

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