eMedicine Specialties > Ophthalmology > Choroid

Choroidal Detachment

Carlo E Traverso, MD, Associate Professor, University Eye Clinic, Genova; Consulting Staff and Head of Glaucoma and Cornea Clinical Unit, University of Genova Medical School, Italy
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Updated: Sep 11, 2007

Introduction

Background

The suprachoroidal space is normally virtual because the choroid is in close apposition to the sclera. As fluid accumulates, this space becomes real, and the choroid is displaced from its normal position. Fluid accumulation, either serumlike or blood, also can occur within the choroid, which is a spongy tissue.

Serous choroidal detachment involves transudation of serum into the suprachoroidal space. This transudation may be due to increased transmural pressure, most frequently caused by globe hypotony of any etiology or trauma, or exudation of serum, most frequently caused by inflammation.

Hemorrhagic choroidal detachment is a hemorrhage in the suprachoroidal space or within the choroid caused by the rupture of choroidal vessels. This can occur spontaneously (rare), as a consequence of ocular trauma, during eye surgery, or after eye surgery. Except for posttraumatic cases, the clinical picture is very similar in all forms of choroidal detachment, the only difference being the time of presentation. The outcome is generally worse for intraoperative hemorrhages, which often are accompanied by loss of eye contents.

Pathophysiology

The exact triggering mechanism is unknown. An increase in transmural pressure in the choroidal vascular plexus can be caused by elevated blood pressure, low intraocular pressure (IOP), or a combination. An increase in vascular permeability is caused by inflammation. The consequence is passage of serum, with large protein molecules into the suprachoroidal space. Since the protein content of the fluid accumulating in the normally virtual suprachoroidal space is similar to plasma with an equal oncotic pressure, its spontaneous reabsorption is unlikely, unless the underlying cause (ie, inflammation, hypotony) is treated. A breakdown of the blood-aqueous barrier across the pigmented epithelium may cause a superimposed nonrhegmatogenous retinal detachment. As a sequela, linear areas of pigmented epithelium hypertrophy, called Verhoeff streaks, indicate the posterior limits of the retinal detachment after its reabsorption.

Frequency

International

Serous choroidal detachments are recognized easily when large. More subtle, anterior, shallow ciliochoroidal detachments, although relatively common after glaucoma filtration surgery, are undetected or unreported. Suprachoroidal hemorrhage is a rare occurrence. Reported data vary between 0.05-6%, depending on the sample. See Causes for predisposing factors.

Mortality/Morbidity

No mortality has been reported. Morbidity in serous choroidal detachment is significant. In phakic eyes, lens opacities can progress rapidly. Cyclitic pupillary membranes may develop. When a flat chamber is present, corneal endothelial damage and peripheral anterior synechiae can occur. Chronic choroidal detachment can lead to maculopathy and globe phthisis. In hemorrhagic detachment, morbidity is the same as for serous detachment, but the prognosis is worse. Loss of useful vision is reported in up to 40% of cases.

Race

No racial predilection exists.

Sex

No sexual predilection exists.

Age

Hemorrhagic detachments are seen more often in elderly patients.

Clinical

History

• Rarely, choroidal detachments form spontaneously. Recent intraocular surgery is the most common association. Eye trauma and corneal ulcers are frequent, and panretinal photocoagulation can also cause choroidal detachments. The use of IOP-lowering medications has also reportedly been associated with serous choroidal detachments.
• Serous detachment is typically painless, with a variable degree of vision loss.
• Postoperative hemorrhagic detachments are characterized by sudden excruciating throbbing pain with an immediate loss of vision; both symptoms are almost pathognomonic.
• Detachment can occur after a Valsalva maneuver, straining at stools, coughing, or sneezing. Anticoagulants and aspirin may facilitate bleeding.
• Intraoperative hemorrhage is characterized by the development of positive pressure, visualization of an enlarging dark mass obscuring the fundus reflex, and tendency to extrude eye contents.
• Ciliochoroidal edema/detachment without evidence of intraocular surgery or trauma should be investigated for a neoplastic, vascular, or inflammatory cause.
• Visual acuity usually is reduced, including light perception, depending on the degree of interference with the visual axis.
• Inflammation in the anterior and posterior segment varies.
• Intraocular pressure can be normal, low, or elevated; as a rule, low IOP accompanies serous detachments, and high IOP accompanies hemorrhages.

Physical

• The anterior chamber (AC) can be of normal depth, or it can be shallow or flat.
• When no other causes for hypotony are evident after trauma or surgery, use gonioscopy to check for a cyclodialysis cleft.
• The fundus examination shows choroidal detachment (see Media file 1).
• Stage the detachment (see Media file 3).
  • The extent of detachment can be limited to one or more sectors, with the lobe(s) limited by the fibrous attachments corresponding to the vortex veins.
  • Annular detachments involve the circumference for 360°.
  • A large degree of fluid accumulation can cause contact between lobes on the visual axis, with retina-to-retina contact centrally (kissing choroidals), while little fluid accumulation can cause a flat and anterior detachment, visible only with ultrasound biomicroscopy (UBM).
• Suprachoroidal hemorrhages can be accompanied by vitreous hemorrhage, retinal detachment, and retinal breaks.
• Intraoperative hemorrhages can be complicated by loss of eye contents, resulting in vitreous, retina, or lens remnants incarcerated in the surgical incision or visible in the AC (see Media file 4).  
• Retinal detachment on ophthalmoscopy
  • A nonrhegmatogenous retinal detachment can be superimposed to a choroidal detachment and characterized by shifting subretinal fluid.
  • Choroidal detachments are nontremulous.
  • Retinal vessels look normal.
  • Ora serrata may be visible without indentation.
• B-scan ultrasonography
  • Retinal detachments are mobile and highly reflective.
  • Choroidal detachments are domed shaped and are serous or hemorrhagic.
• Chronic serous choroidal detachments
  • Solid intraocular tumors are identified by transillumination.
  • With serous detachments, transillumination reveals a bright reflex, which can be present in nonpigmented choroidal melanomas.

Causes

• Serous detachments have no specific predisposing factors except nanophthalmos.
• Causes of serous detachments include globe hypotony, trauma, and inflammation.
• Predisposing factors for choroidal hemorrhages are old age, diffuse arteriosclerosis, glaucoma, previous eye surgery, axial myopia, a choroidal hemorrhage in the fellow eye, sickle cell anemia, and very short axial length.
• Postoperative hypotony is the most likely causal factor.
• Hemorrhage occurs when vessels rupture. Hemorrhage is more likely in patients with systemic hypertension, intraoperative tachycardia, or arteriosclerosis. Other predisposing factors include old age and previous eye surgery.
• Sudden globe decompression during surgery, particularly if the eye is affected by glaucoma and surgery is initiated when the IOP is still elevated, also predisposes to choroidal detachment.
• The use of some medications has also reportedly been associated with serous choroidal detachments.

References

• Glaucoma, Malignant
• Melanoma, Choroidal
• Pupillary Block, Aphakic
• Pupillary Block, Pseudophakic
• Retinal Detachment, Exudative
• Retinal Detachment, Postoperative
• Retinal Detachment, Tractional