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Choroidal detachment -Nov 2017
- 1.
- 2. CONTENTS • Definition • Anatomy •Types • Causes • Diagnosis • Management • Prevention
- 3. SYNONYMS… • First describedby 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 • Choroidlies 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 originatesin 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 effusionsrepresent 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 betweenfluid 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 followingsurgery varies between 0.05-6% • No racial / sexual predilection • Hemorrhagic detachments are seen more often in elderly patients
- 13. RISK FACTORS-GLAUCOMA • Antimetabolites—particularlymitomycin 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 choroidaldetachments : 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 Detachmenttypically 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 anteriorchoroid/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.
- 25. MANAGEMENT • Conservative • Postoperativeserous 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 fluidscan 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 UVEALEFFUSION 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 • Choroidalmelanoma • Multifocal, atypical central serous retinopathy • Vogt-Koyanagi-Harada disease • Posterior scleritis • Hypertension • Metastasis
- 37. MANAGEMENT • Small peripheraluveal 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.
- 40. OTHER EFFUSIONS • HUNTER’SSYNDROME 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 inflammationof 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.
- 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 vortexvein 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 SYMPTOMSAND 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 EXPULSIVESUPRACHOROIDAL 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 tothe equator Extends in an annular fashion Postequatorial unilobulated or multilobulated.
- 50. FUNDUS FINDINGS • Localisedchoroidal hemorrhage choroidal melanoma (DDs) pigmented choroidal nevus subretinal pigment epithelial hamartoma Acoustic hollowness
- 51. SEROUS CD VSHEMORRHAGIC 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 VSHEMORRHAGIC 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 OPERATEON 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 • AssocitedRD/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 INTRAUMA • 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.
- 61. SURGICAL TECHNIQUE • Trocarin 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 THEWISE…. • 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/limitedhemorrhage 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 AROUTE 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…. • Choroidsupply 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.
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Editor's Notes
- #10 A decrease in IOP allows fluid to accumulate in the interstitial spaces, while inflammation increases the permeability of the choroidal capillaries
- #15 some cases of postsurgical choroidal effusions, forward rotation of the lens–iris diaphragm can precipitate angle closure with relative pupillary block. This is another indication for surgical relief of the choroidal effusion. proposed mechanism is inflammation, that increases the permeability of the choriocapillaris
- #20 In some instances, the choroidal detachments and associated retinal detachments may be so massive as to cause contact between the posterior lens surface and the retina. The exudative retinal detachments in these instances are characterized by shifting subretinal fluid, i.e., the subretinal fluid has a tendency to shift and settle into the dependent area on shifting head position and this phenomenon can be mapped out by visual field testing.11,12 This is, in part, because of the high protein (more than 26.5 g/dL
- #24 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
- #28 ?? paradoxical - aqueous humor suppressant Vasoconstrictive properties : lessen fluid extravasation from choroidal vessels
- #38 posterior scleral thickness of greater than 2 mm is abnormal
- #40 local episcleral instillation of corticosteroids prior to conjunctival closure, to prevent closure of the sclerectomies.9 Some surgeons also report re-formation of the anterior chamber using BSS through a paracentesis site as the effusion is drained, or the injection of SF6 gas or air into the vitreous cavity for maintaining IOP. Some authors have also suggested that, in cases of large exudative retinal detachments, subretinal fluid be drained through a separate sclerotomy site. This site is made in full-thickness sclera, diathermizing the scleral edges to fishmouth the sclera and better expose the choroidal knuckle. A 4–0 polyester mattress suture is then preplaced to close the sclerotomy at the end, and the choroidal knuckle is perforated using a sharp perforating needle (e.g., a 30 gauge 0.5 in needle). After drainage, the drainage sclerotomy is closed using the 4–0 mattress suture.