Choroidal detachment & Supra choroidal detachment

1. CHOROIDAL EFFUSIONS AND
DETACHMENT..
Dr.Sameera
Vitreo-Retina
MMJEI ,Hubli

2. CONTENTS
• Definition
• Anatomy
• Types
• Causes
• Diagnosis
• Management
• Prevention

3. SYNONYMS…
• First described by von Graefe in 1858
• Ciliochoroidal detachment
• Suprachoroidal effusion
• Supraciliary effusion
• the accumulation of fluid in the suprachoroidal space

4. CHOROID -FUNCTIONS
• Vasculature : major supply for the outer retina
• Choroidal blood flow : cool and warm the retina
• Contains secretory cells : modulation of vascularization and in
growth of the sclera
• Dramatic changes in choroidal thickness : move the retina
forward and back, bringing the photoreceptors into the plane of
focus
• Important role in the drainage of the aqueous humor from the
anterior chamber, via the uveoscleral pathway

5. ANATOMY
• Four layers
• Haller's layer - outermost layer consisting of
larger diameter blood vessels
• Sattler's layer - layer of medium diameter
blood vessels
• Choriocapillaris - layer of capillaries
• Bruch's membrane (synonyms: Lamina basalis,
Complexus basalis, Lamina vitra) - innermost
layer

6. NORMAL EYE
• Choroid lies in close approximation to the sclera
• Suprachoroidal space  the space between the choroid and the
sclera : a potential space
• Approximately :10 microlitre fluid seen

7. ABNORMAL….
• Fluid originates in the choriocapillaries and seeps across the
spongy choroidal tissue into the potential suprachoroidal
space
• Severe cases : fluid escape into the subretinal space 
secondary serous retinal detachment

8. TYPES..
• Clinically : depending on the characteristics of the fluid
contained between the tissue planes
•  SEROUS
•  HEMORRHAGIC

9. PATHOPHYSIOLOGY
• Choroidal effusions represent tissue edema
• Starling’s hypothesis  elucidates the balance of
hydrostatic and osmotic gradients between the choroidal
capillaries and interstitial space of the eye
 intraocular pressure (IOP) :hydrostatic pressure in the
interstitial space
 process that shifts flow from the choroidal capillaries
into the interstitium may lead to an effusion
Under normal circumstances : IOP > Pressure in
suprachoroidal space > atmospheric pressure

10. PATHOPHYSIOLOGY
• Imbalance between fluid production and fluid reabsorption
• Increased transmural pressure - forces pumping fluid into the extravascular
space > forces that cause fluid to be reabsorbed
• Increase in the permeability of the blood vessels : exudation of serum
• Combination of these mechanisms ( postoperative choroidal detachments)
• Idiopathic uveal effusion syndrome  uveal effusion with no obvious
etiology
• Accumulation of hemorrhage in the suprachoroidal space  hemorrhagic
choroidal detachment, e.g., after trauma or surgery
Globe Hypotony
Inflammation

11. PATHOPHYSIOLOGY
• 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. EPIDEMIOLOGY
• Incidence following surgery varies between 0.05-6%
• No racial / sexual predilection
• Hemorrhagic detachments are seen more often in elderly
patients

13. RISK FACTORS-GLAUCOMA
• Antimetabolites—particularly mitomycin C (MMC)—during
trabeculectomy
(5- 33% )
• Latanoprost use in eyes with prior cataract extraction
• Increased risk of subclinical choroidal effusions after laser iridotomy
• Increased association of choroidal effusion with nanophthalmos and with
Sturge-Weber syndrome
• Sturge-Weber syndrome : higher risk in the presence of choroidal
hemangiomas

14. HISTORY
• Serous choroidal detachments : painless decrease in vision
History  intraocular surgery
 trauma
 anti-glaucoma medications
 panretinal photocoagulation (PRP)/ cryotherapy
• Hemorrhagic detachments: sudden onset of severe pain / loss of vision
 Valsalva maneuver (straining at stools, coughing, sneezing)
 Anticoagulants and aspirin may facilitate bleeding

15. OTHER SYMPTOMS
• Small, peripheral effusions : asymptomatic
• Large effusions : refractive changes from anterior displacement of
the lens-iris diaphragm and resultant myopia
• Absolute scotoma at the site of effusion

16. ANTERIOR SEGMENT FINDINGS
• Inflammatory conditions: Congestion /AC cells/ KPs
• Associated with increased resistance to venous drainage : signs of
vascular congestion  dilated episcleral veins /blood in Schlemm’s
canal
• Shallow anterior chamber: Nanophthalmic eyes
Massive choroidal effusions
Ciliochoroidal effusions

17. IOP : normal/ low / elevated
• Low IOPs  Serous choroidal detachments ( reduced aqueous humor
production/ retinal detachment)
• Elevated IOPs  Hemorrhagic CDs
 AV malformations
 Idiopathic uveal effusion syndrome
• Angle closure glaucoma may occur with ciliochoroidal detachments of any
etiology*
*Myelodysplastic syndromes, Ig A nephropathy
ANTERIOR SEGMENT FINDINGS

18. POSTERIOR SEGMENT FINDINGS
Detachment typically begins in the periphery  an
ultrabiomicroscopy (UBM) exam
• More fluid  the choroid detaches in a distinct, mound-like
fashion
• Mounds demarcated by the fibrous attachments that correspond
to the sites of the vortex veins
• Very large detachments  the lobes can contact in the visual axis :
appositional or ‘kissing choroidals’
• Annular : involving the circumference of the globe 360°

19. POSTERIOR SEGMENT FINDINGS
• Inflammatory choroidal effusions : vitreous cells
• Visualization of the ora serrata without scleral depression :pre
equatorial choroidal detachment
• Ciliochoroidal edema/detachment without evidence of intraocular
surgery or trauma
??? Neoplastic/vascular/inflammatory cause

20. POSTERIOR SEGMENT FINDINGS
• Chronic effusions  blood-ocular barrier
break down at the RPE  Exudative RD /
Shifting SRF
• Depigmentation and multifocal hyperplasia of
the RPE  leopard spots in the fundus
• Linear areas of RPE hypertrophy and
hyperplasia  Verhoeffs lines

21. INVESTIGATIONS- B SCAN
• Most important imaging modality
• Distincts hemorrhagic versus serous effusions
• Hemorrhagic choroidal effusions (acoustically empty) vs tumors
• Delineate the extent of the choroidal detachment
• Assess the thickness of the choroid in early uveal effusion
syndrome
• Evaluate for posterior scleral thickening / retrobulbar edema
around the optic nerve  T-sign in posterior scleritis

22. INVESTIGATIONS- B SCAN
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

23. INVESTIGATIONS-UBM
• Assess anterior choroid/ciliary body
• Any fluid / anterior rotation of the ciliary body associated with
angle closure glaucoma
• Small effusions at ciliary body
 Detachment at scleral spur

24. CLASSIFICATION

25. MANAGEMENT
• Conservative
• Postoperative serous choroidal detachments :resolve on
their own within days
• Cycloplegics and corticosteroids
• Excessive leakage from a wound or after glaucoma
filtering surgery  pressure patching / glue /bandage
contact lens

26. MANAGEMENT
• Oral fluids can be given to increase aqueous humor flow
• Acetazolamide : absorption of suprachoroidal fluid
• ?? paradoxical

27. PREVENTION
• During surgery
 Good scleral flap ,sutures
 judicious use of antimetabolites
 meticulous closure of the conjunctiva
• High-risk patients
 Prophylactic sclerotomies at the time of glaucoma filtration
surgery

28. DRUGS
• Topiramate
• Warfarin
• Sulfonamides
• Tetracycline
• Diuretics
• Aspirin

29. UVEAL EFFUSION SYNDROME
• Described for the first time in 1963 by RJ Brockhurst ,Schepens
• Primary underlying cause :congenital anomaly of the sclera / the vortex veins
• Three types
• Type 1 : Nanophthalmic eyes  small eyeball (average axial length 16 mm)
,high hypermetropic (average +16 diopters)
• Type 2 : Non-nanophthalmic eyes with clinically abnormal sclera  normal
eyeball size (average axial length 21 mm) , small refractive error
• Type 3 : Non-nanophthalmic eyes with clinically normal sclera

30. PATHOGENESIS OF UVEAL EFFUSION
SYNDROME
• Suprachoroidal space : no lymphatics
• Protein escape from the choriocapillaris : osmotic fluid retention
• Healthy eyes : proteins can diffuse across the sclera
• Form of mucopolysaccharidosis -deposition of dermatan sulfates in sclera
• Egress impaired in Uveal effusion eyes

31. UVEAL EFFUSION SYNDROME
• U/L or B/L loss of vision  ciliochoroidal and subsequent retinal
detachments
• Metamorphopsia and scotomas caused by shallow macular
detachments
• Bilateral involvement in over 60% of cases

32. UVEAL EFFUSION SYNDROME
• A/S : episcleral vascular dilation/ blood in Schlemm’s canal
• No inflammatory signs
• IOP : usually normal
• Few vitreous cells +/-
• CD, Exudative RD
• Angiography : leopard-skin appearance of hyperfluorescence and
hypofluorescence
• OCT : focal thickening of the RPE corresponding to the areas of
leopard spots

34. NANOPHTHALMOS
• Small eye (less than 21 mm in axial length) but with an otherwise
normal structure
• Bilateral; both males and females
• Syndromic /Non -syndromic
• Thickened abnormal sclera  disruption of the normal
arrangement of scleral collagen bundles and a ‘fraying’ of the
collagen fibrils
• Abnormal formation and packing of the collagen bundles
• Hamper the escape of aqueous by the uveo-scleral route
• Outflow obstruction of the vortex veins

35. NANOPHTHALMOS
• High hypermetropes
• Shallow AC
• Angle closure glaucoma
• Fundus: Foveal hypoplasia/Rudimentary foveal avascular zone/Foveal
schisis
Choroidal effusions/Exudative RD

36. DIFFERENTIAL DIAGNOSIS
• Choroidal melanoma
• Multifocal, atypical central serous retinopathy
• Vogt-Koyanagi-Harada disease
• Posterior scleritis
• Hypertension
• Metastasis

37. MANAGEMENT
• Small peripheral uveal effusions :Observe
• Fluid involves or threatens the fovea :
 vortex vein decompression
 full-thickness scleral decompression (Gass et al)
Sclerectomy/Sclerotomy
• Uveal effusion with out Nanophthalmos: ? Vitrectomy – Quick
retinal reattachment

38. MANAGEMENT
• Pre-operative B-scan: identify the area of maximal effusion
• 360° peritomy / dissection of quadrants
• Isolation of extraocular muscles: care not to avulse vortex veins
• Creation of a lamellar sclerectomy: approximately ~2 × 2 mm
• 50% scleral thickness, with or without vortex vein decompression
• May or may not perform full thickness sclerotomies in sclerectomy
bed to drain choroidal fluid
• Perform in all four quadrants
• Drain subretinal fluid in severe cases at a separate sclerotomy site
• Restore IOP with saline or gas/air injection
• Consider sub-Tenon’s steroids at the end of surgery

39. VIDEO

40. OTHER EFFUSIONS
• HUNTER’S SYNDROME
systemic mucopolysaccharidosis : short stature, joint abnormalities
and mental retardation
Circular peripheral choroidal detachments /exudative RDs
• ARTERIOVENOUS FISTULAS
proptosis (often pulsatile), episcleral venous dilation
palsy of the cranial nerves in the cavernous sinus and the orbit

41. INFLAMMATIONS
• Scleritis:
generalized inflammation of the choroid  leakage from the choriocapillaris
localized or an annular choroidal detachment
Females
Severe pain, Ant scleritis+/-, Raised IOP
Disc oedema,Macular oedema , T-sign
Mx: Steroids

42. SUPRACHOROIDAL HEMORRHAGE

43. SUPRACHOROIDAL HEMORRHAGE (SCH)
• One of the most dreaded complications
• Could result in total visual loss and phthisis

44. SUPRACHOROIDAL HEMORRHAGE (SCH)
• Limited hemorrhage
• Massive hemorrhage
• Appositional (“kissing”).
• Expulsive

45. MECHANISM
• Impeding vortex vein outflow
- RBH,Retrobulbar anaesthesia,Scleral buckle,Pressure during
surgery
• Fluctuation in intra ocular fluid dynamics and pressure
Hypotony – serous effusion – tension on ciliary vessels* – rupture
-sudden compression and decompression events
• Rarely –spontaneous

46. RISK FACTORS
• Systemic : Advanced age, Arteriosclerosis,DM,HT,
Anticoagulation,IHD
• Ocular: Glaucoma, Increased axial length, Previous surgery
(Vitrectomy),Previous laser photocoagulation, Aphakia,
Uveitis,Recent trauma
• Intra operative: High IOP,High Myopia, Open sky procedures, Intra
operative tachycardia, Sudden decrease of IOP, Vitreous loss,

47. INTRA OPERATIVE SYMPTOMS AND SIGNS
• Sudden onset of severe intra operative pain
• Shallowing of anterior chamber/excessive iris movement or
prolapse
• Forward movement of lens and vitreous
• Darkening/loss of red reflex
• Excessive bleeding of conjunctiva/episclera
• Vitreous hemorrhage/RD
• Expulsion of intra ocular contents
• Tachycardia

48. DELAYED NON EXPULSIVE SUPRACHOROIDAL
HEMORRHAGE
• Decreased vision/Pain
• Shallow anterior chamber with mild cells and flare
• Smooth orange- brown elevation of the retina and
choroid
• B scan: Smooth dome shaped highly reflective solid
appearing mass

49. FUNDUS FINDINGS
Anterior to the equator
Extends in an annular fashion
Postequatorial
unilobulated or multilobulated.

50. FUNDUS FINDINGS
• Localised choroidal hemorrhage  choroidal melanoma
(DDs) pigmented choroidal nevus
subretinal pigment epithelial
hamartoma
Acoustic hollowness

51. SEROUS CD VS HEMORRHAGIC CD
• Low IOP
• Transiiluminates
• No pain
• Pre equatorial
• Resolves with in 3 weeks
• Good visual acuity
• High IOP
• No transillumination
• Painful
• More voluminous
posteriorly
• Resolves 6-25 days; resorbs
~ 4 weeks to months
• Poor visual acuity

52. SEROUS CD VS HEMORRHAGIC CD

53. MANAGEMENT: DELAYED HEMORRHAGE
• Limited hemorrhage
 Conservative: Cycloplegics and topical steroids
Usually resolves with in 1-2 months
• Delayed massive hemorrhage
 Systemic corticosteroids with serial B scans ( liquefaction of
hemorrhage
- low reflective mobile echoes )
 Surgery :7-14 days post hemorrhage

54. WHEN TO OPERATE ON A CHOROIDAL
HEMORRHAGE….
• Massive hemorrhage with severe pain
• Kissing choroidals
• Corneo lenticular touch
• Persistently high IOP
• Persistently flat AC
• Massive hemorrhage under macula/ subretinal/vitreous cavity
• Retinal/Vitreous incarceration
• Preferably after liquefaction

55. INTRA OPERATIVE MANAGEMENT
• Direct digital pressure on open wounds
• Rapid wound closure
• Post PK: Immediate cardinal sutures to be put
• Reform AC with viscoelastic
• Posterior sclerotomy done only if wound apposition not
possible
• Post operatively : Control IOP/Inflammation/Pain

56. SECONDARY MANAGEMENT
• Associted RD/VH
• VR traction
• Dislocated lens/fragments :treated accordingly
• PFCL injected to flatten the retina and drain the
hemorrhage
• Silicon oil/Long acting gas for a long term tamponade

57. CHOROIDAL HEMORRHAGE IN TRAUMA
• Intraocular structural damage +
• High likelihood of RD and associated PVR
• B-scan : hemorrhage tend to be more diffuse and less
elevated

58. SUPRA CHOROIDAL DRAINAGE
• Optimal drainage site : highest point of choroidal elevation, as
determined by echography or ophthalmoscopy
• Sclerotomies : radial and created with a cut –down incision
• Isolation of the rectus muscle using silk ties/ traction sutures :
good exposure of the sclera

59. DRAINAGE
• Conjunctival peritomy  2 to 3 mm radial incision made in the sclera : 3 to 4
mm posterior to the limbus
• Incision deepened until the suprachoroidal space is entered  fluid is
released
• Fluid : clear and yellowish in serous CDs
• dark red with blood clots in hemorrhagic CDs
• Incision’s edges may be pulled apart by forceps or cautery to facilitate fluid
egress
• Sclerotomy site left open with closure of overlying conjunctiva
• Eye should be kept pressurized with injection of BSS / viscoelastic in AC /
ACmaintainer

60. VIDEO

61. SURGICAL TECHNIQUE
• Trocar in tangential angle inserted into the
suprachoroidal space
• Place the anterior chamber infusion, the
choroidal fluid/hemorrhage drains
spontaneously through the cannulas
• Pars plana vitrectomy +/-

62. WORD TO THE WISE….
• Non-valved cannulas ; preferable to drain the infero-temporal quadrant first
• Serous CD : one drainage site
• Hemorrhagic CD : more than one drainage site may be needed
“Dry tap”
• Hemorrhagic CD  clot blocking the cannula
Turn the cannula side to side /gentle scleral depression with a cotton swab
• Serous CD  intra-scleral cannula position / cannula is too anterior and is
blocked by choroid, retina or vitreous (if so, sclerotomy placement at 7 mm from
limbus)
• Avoid 3 and 9 o’clock meridians : Traumatise ciliary nerve

63. OUTCOME
• Good prognosis
Delayed/limited hemorrhage
seen after a week
Hemorrhage after cataract
surgery
Good visual acuity
• Poor prognosis
RD
Hemorrhage all quadrants
Retinal incarceration
Extention to posterior post
pole

64. THE SUPRACHOROIDAL SPACE: FROM POTENTIAL SPACE TO A
SPACE WITH POTENTIAL
• Suprachoroidal buckling
 illuminated catheter inserted into the SCS and
navigated to any desired location
 long-lasting hyaluronic acid filler can be injected to
create internal choroidal indentation
 Vitrectomy +/-
 myopic tractional maculopathies, RD

65. SCS AS A ROUTE FOR DRUG DELIVERY
• bypasses the internal limiting membrane barrier and
outer blood-retina-barrier
• preferred route for drug delivery targeting RPE
• Triamcinolone (Uveitis)
• “SAPPHIRE” : SCS steroid vs Aflibercept

66. INTERESTING FACTS….
• Choroid supply the inner retina (Guinea pigs) as well..!!
• In humans, the choroid is approximately 200 μm thick at
birth and decreases to about 80 μm by age 90
• Choroids are thick at night….. Thin at day.. !
• Teleosts : choroidal gland  supplemental oxygen
carrier

67. REFERENCES

68. THANK YOU…

69. DRAINAGE OF CHOROIDAL
HEMORRHAGE