BASICS

DESCRIPTION

• Choroidal effusion is the accumulation of fluid (serous) or blood (hemorrhagic) into the suprachoroidal potential space due to increased intramural pressure.

• Often occur after trauma, perioperatively, postoperatively, or spontaneously (rare)

EPIDEMIOLOGY

Incidence

• Frequency varies between 0.05–6%

• No racial or sexual predilection

• Hemorrhagic choroidal detachments are more common in the elderly

RISK FACTORS

• Serous choroidal effusion: Nanophthalmos, uveal effusion syndrome, carotid-cavernous fistula, primary or metastatic tumor, scleritis, Vogt-Koyanagi-Harada syndrome, globe hypotony, trauma, inflammation, iatrogenic (i.e., isoniazid)

• Hemorrhagic choroidal effusion: Older age, arteriosclerosis, uncontrolled glaucoma, previous eye surgery, myopia, history of choroidal hemorrhage in fellow eye, sickle cell disease, systemic hypertension

• Intraoperative or postoperative: Wound leak, perforation of sclera from superior rectus, bridle suture, cyclodialysis cleft, leakage from filtering bleb, laser photocoagulation or cryotherapy

GENERAL PREVENTION

See “Risk Factors”.

PATHOPHYSIOLOGY

• Pressure within the suprachoroidal space is dependent upon intraocular pressure, intracapillary blood pressure, and oncotic pressure.

• Choroidal effusions result from increased vascular permeability leading to the exudation of large serum proteins into the suprachoroidal space leading to choroid edema.

ETIOLOGY

Choroidal effusion is commonly caused by hypotony of any etiology, trauma, and rarely occur spontaneously.

COMMONLY ASSOCIATED CONDITIONS

• Trauma

• Perioperatively or postoperatively following cataract and glaucoma surgery

DIAGNOSIS

• Signs of recent surgery or trauma: Filtering bleb, intraocular lens, photocoagulation, cyclodialysis cleft

– Perform Seidel test

– Perform gonioscopy

• Smooth, bullous, orange elevation of retina and choroid on funduscopic examination

– Bullous elevation often extends 360 degrees around the periphery in a lobular configuration

• Serous choroidal effusion is often asymptomatic or noted with painless decrease in vision

• Often associated with low intraocular pressure (IOP <6 mm Hg), shallow anterior chamber with mild cell and flare

• Hemorrhagic choroidal effusion is often sudden, severely painful loss of vision associated with a red eye

• Often associated with elevated intraocular pressure, shallow anterior chamber with mild cell and flare

HISTORY

• Past ocular history

– Recent surgery, ocular trauma, corneal ulcer, laser therapy, IOP-lowering medications?

• Recent Valsalva, straining, coughing?

• Use of aspirin or anticoagulants?

PHYSICAL EXAM

• Scalp and cutaneous examination

– Look for alopecia and vitiligo to rule-out Vogt-Koyanagi-Harada syndrome

DIAGNOSTIC TESTS & INTERPRETATION

Diagnostic Procedures/Other

• B-scan may demonstrate domed-shaped lesions, choroidal thickening, and low-medium internal reflectivity.

– Helps to differentiate between serous and hemorrhagic choroidal effusion

– Helps to determine if hemorrhage is mobile or coagulated

– May note large degree of fluid accumulation resulting in retina-to-retinal contact centrally known as kissing choroidals

• Transillumination is present in serous choroidal detachment, but also in nonpigmented choroidal tumors.

– Hemorrhagic choroidal effusions do not transilluminate

• CT scan shows a semilunar or ring-shaped lesion of variable attenuation.

• MR demonstrates crescentic or ring-shaped area of hyperintensity on both T1-weighted and T2-weighted images.

– Helps to differentiate between choroidal effusion and choroidal melanoma, which is hyperintense on T1-weighted images and hypointense on T2-weighted images

– May be difficult to differentiate between subacute choroidal hematomas from choroidal effusion

Pathological Findings

Accumulation of serous or serosanguineous material in the suprachoroidal potential space.

DIFFERENTIAL DIAGNOSIS

• Malignant glaucoma

• Choroidal melanoma

• Aphakic pupillary block

• Pseudophakic pupillary block

• Exudative retinal detachment

• Postoperative retinal detachment

• Tractional retinal detachment

• Rhegmatogenous retinal detachment

• Melanoma of the ciliary body

• Vogt-Koyanagi-Harada syndrome

• Uveal effusion syndrome

• Wegener’s granulomatosis

• Anterior and posterior scleritis

• Carotid-cavernous or dural-sinus fistula

TREATMENT

ADDITIONAL TREATMENT

General Measures

• Topical corticosteroids

• Topical cycloplegics

• Intraocular pressure-lowering medication (topical and systemic)

• Oral steroids if inflammation implicated

• Parasympathomimetics are contraindicated

SURGERY/OTHER PROCEDURES

• Posterior sclerotomy if choroidal detachment persists greater than 1 week

• Anterior chamber paracentesis to drain suprachoroidal fluid

• Injection of viscoelastics if anterior chamber is flattened

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Ophthalmologist

PROGNOSIS

• No mortality

• Prognosis dependent on cause of choroidal effusion

• Loss of useful vision in 40%

• Worse prognosis with hemorrhagic detachment

COMPLICATIONS

• Loss of useful vision

• Phthisis

• Retinal detachment

• Cataract formation

• Cyclitic pupillary membranes

• Corneal endothelial damage

• Peripheral anterior synechiae

• Intractable secondary glaucoma

ADDITIONAL READING

• Mafee MF, Linder B, Peyman GA, et al. Choroidal hematoma and effusion: Evaluation with MR imaging. Radiology 1988;168:781–6.

CODES

ICD9

• 363.70 Choroidal detachment, unspecified

• 363.71 Serous choroidal detachment

• 363.72 Hemorrhagic choroidal detachment

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