Features
A choroidal rupture is defined as a break in the choriocapillaris, Bruch’s membrane, and retinal pigment epithelium. Choroidal ruptures occur after 5 to 10% of blunt force trauma. They may be direct ruptures that occur anteriorly at the site of impact or, more commonly, indirect ruptures that occur in the posterior globe away from the site of impact (contrecoup force).
Indirect choroidal ruptures are often seen after nonpenetrating, closed-globe blunt trauma that causes anteroposterior compression of the globe. The elasticity of the retina and tensile strength of the sclera protect these structures from rupture, while Bruch’s membrane is most susceptible to rupture (▶ Fig. 77.1). The mechanism of rupture also explains why patients with underlying weakness of Bruch’s membrane, such as those with angioid streaks, are more susceptible to choroidal rupture.
Fig. 77.1 Mechanism of choroidal rupture. (a,b) Blunt trauma results in sudden compression of the globe. (c) As the eye abruptly relaxes, a tear of the choriocapillaris, Bruch’s membrane, and retinal pigment epithelium occurs forming the choroidal rupture which often results in subretinal hemorrhage.
(Reprinted with permission, Cleveland Clinic Center for Medical Art and Photography © 2017. All Rights Reserved.)
A choroidal rupture differs from sclopetaria in that sclopetaria is defined as a rupture of both the choroid and retina after the transmission of shock waves through the eye wall. Sclopetaria typically occurs after a high-speed concussion-type, nonpenetrating injury (e.g., bullet in orbit). While the sclera is intact, the injury heals with a white proliferative scar tissue over the site.
77.1.1 Common Symptoms
Most often decreased visual acuity, scotoma, or floaters; may be completely asymptomatic if the rupture site and associated hemorrhage does not involve the macula.
77.1.2 Exam Findings
Choroidal ruptures are often associated with subretinal hemorrhage due to trauma to the choriocapillaris. Often during the initial presentation, this subretinal hemorrhage could obscure visualization of the choroidal rupture and thus choroidal ruptures should be suspected with subretinal hemorrhages that present after trauma (▶ Fig. 77.2). The choroidal rupture appears as a yellow, curvilinear line often concentric to the disc (▶ Fig. 77.3). Choroidal neovascular membrane can also develop after a rupture due to a break in Bruch’s membrane. Rate of CNV development ranges between 11 and 37.5%. CNV associated with choroidal ruptures usually presents late (a median time of 8 months later in one study) and underscores the importance of follow-up in these patients.
Fig. 77.2 Fundus image of subretinal hemorrhage that obscures a choroidal rupture. Choroidal ruptures should be suspected with subretinal hemorrhage after trauma.
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