AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Choroidal ruptures are breaks in the choroid, the Bruch membrane, and the retinal pigment epithelium (RPE) that result from blunt ocular trauma (the most common eye injury). Choroidal rupture can be secondary to indirect or direct trauma. Cases secondary to direct trauma tend to be located more anteriorly and at the site of impact and parallel to the ora, whereas those secondary to indirect trauma occur posteriorly. These ruptures have a crescent shape and are concentric to the optic disc. Indirect choroidal ruptures are almost 4 times more common than direct ruptures.

Pathophysiology

After blunt trauma, the ocular globe undergoes mechanical compression and then sudden hyperextension. Because of its tensile strength, the sclera can resist this insult; the retina is also protected because of its elasticity. The Bruch membrane does not have enough elasticity or tensile strength; therefore, it breaks.

Concurrently, the small capillaries in the choriocapillaris are damaged, leading to subretinal or sub-RPE hemorrhage. Hemorrhage in conjunction with retinal edema may obscure the choroidal rupture during the acute phases. The deep choroidal vessels are usually spared. As the blood clears, a white, curvilinear, crescent-shaped streak concentric to the optic nerve is seen.

During the healing phase, choroidal neovascularization (CNV) occurs. In most cases, it involutes spontaneously. If the rupture does not involve the fovea, good vision is expected. In 15-30% of patients, CNV may arise again and lead to a hemorrhagic or serous macular detachment with concomitant visual loss. This usually occurs during the first year but can also occur decades later. Older age and macular rupture, the length of the rupture, and the distance of the rupture to the center of the fovea may be risk factors for CNV.

Frequency

United States

Blunt ocular trauma is the most common type of eye injury. Approximately 5-10% of patients with such injury develop a choroidal rupture. Most eyes have a single rupture, but up to 25% of eyes have multiple ruptures. About 80% of ruptures occur temporal to the disc, and 66% involve the macula.

Mortality/Morbidity

Vision loss depends on whether the choroidal rupture involves the fovea and whether and where CNV occurs.

Sex

• Men appear to be more prone to ocular trauma than women.
• A male-to-female ratio of 5:1 is reported for choroidal ruptures.^{1, 2}

Age

In most series, this condition occurs in patients aged 20-40 years.^{1, 2}

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

History

• History of blunt trauma
• History of angioid streaks
• Paracentral or central scotoma
• Decreased vision

Physical

• Retinal edema
• Hemorrhagic detachment of the macula
• Serous detachment of the macula
• Subretinal hemorrhage
• White curvilinear crescent-shaped streak concentric to the optic nerve

Causes

• Blunt trauma
• Angioid streaks

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Because choroidal ruptures occur as a consequence of blunt ocular trauma, the ocular examination must be thorough to rule out orbital fractures or globe ruptures.

Imaging Studies

• Consider CT scanning and MRI of the eye and orbit under appropriate circumstances.
• Fluorescein angiography may be a useful adjunct to detect CNV.
  
  
  • If CNV is absent, hypofluorescence occurs during the early phase of the angiogram due to disruption of the choriocapillaris. During later stages, hyperfluorescence occurs from the adjacent healthy choriocapillaris.
  • If CNV is present, early hyperfluorescence followed by late leakage is present on the angiogram.
• Indocyanine green (ICG) angiography may be useful if subretinal blood blocks or hides CNV detection on a fluorescein angiogram.

Histologic Findings

Direct choroidal ruptures are characterized by a complete absence of choroid and RPE. The overlying retina is intact but atrophic.

In indirect choroidal ruptures, CNV is a common finding during the early healing phases. Most CNV is in the subretinal space (Gass type 2). With time, most CNV involutes spontaneously. In a small number of cases, a disciform scar or fibrous tissue may grow into the retina and vitreous cavity.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical Care

Conservative treatment is recommended for most choroidal ruptures. During the healing phase of virtually all choroidal ruptures, CNV is present. Most CNV involutes spontaneously.

Surgical Care

In 15-30% of patients, CNV may recur and lead to a hemorrhagic or serous macular detachment with concomitant visual loss.

• If CNV is extrafoveal, it may be treated successfully with laser photocoagulation. Recurrences seem few.
• If CNV is subfoveal or juxtafoveal, consider pars plana vitrectomy with membrane extraction.
• The role of photodynamic therapy with verteporfin is unclear; however, several case reports and case series using this treatment have shown encouraging results in these patients.
• ICG-guided photocoagulation transiently closes feeder vessels of subfoveal CNV, but, eventually, these vessels become reperfused.

Consultations

Consult a vitreoretinal specialist.

FOLLOW-UP

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Further Outpatient Care

• Most CNV occurs within the first year. However, CNV has been reported to occur as late as 35 years after the choroidal rupture.
• Regularly scheduled examinations with fluorescein angiography (as circumstances dictate) are recommended during the first year.

Complications

• In 15-30% of patients, CNV may arise and lead to a hemorrhagic or serous macular detachment with concomitant visual loss.

Prognosis

• Most patients with choroidal ruptures do not reach a final visual acuity of 20/40 or better. Poor visual acuity is associated with macular rupture and poor baseline visual acuity.
• If the rupture does not involve the fovea, good vision is expected.
• A hemorrhagic or serous macular detachment secondary to CNV may threaten visual function.
  
  
  • If CNV is extrafoveal, it may respond well to laser photocoagulation. Few recurrences are reported after laser photocoagulation.
  • If CNV is juxtafoveal or subfoveal, consider pars plana vitrectomy with membrane extraction. Gross et al reported good visual acuities in a small case series.³

Patient Education

• Teach patients to self-monitor each eye by using an Amsler grid and a near card.

MISCELLANEOUS

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Choroidal neovascularization can reoccur, and periodic examinations are necessary.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  A 23-year-old man was in a motor vehicle accident 2 months before his presentation. His visual acuity is 20/400, and an afferent pupillary defect is present. Traumatic optic neuropathy and choroidal rupture are observed. This is a red-free photograph. (Courtesy of Jorge Gutierrez, MD.)
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Media type:  Photo

Media file 2:  Mid-phase fluorescein angiogram in the same patient as in Media file 1. (Courtesy of Jorge Gutierrez, MD.)
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Media type:  Photo

Media file 3:  Late-phase fluorescein angiogram in the same patient as in Media file 1. (Courtesy of Jorge Gutierrez, MD.)
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Media type:  Photo

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Follow-up
• Miscellaneous
• Multimedia
• References

1. Liggett PE, Pince KJ, Barlow W, Ragen M, Ryan SJ. Ocular trauma in an urban population. Review of 1132 cases. Ophthalmology. May 1990;97(5):581-4. [Medline].
2. White MF Jr, Morris R, Feist RM, et al. Eye injury: prevalence and prognosis by setting. South Med J. Feb 1989;82(2):151-8. [Medline].
3. Gross JG, King LP, de Juan E Jr, Powers T. Subfoveal neovascular membrane removal in patients with traumatic choroidal rupture. Ophthalmology. Apr 1996;103(4):579-85. [Medline].
4. Aguilar JP, Green WR. Choroidal rupture. A histopathologic study of 47 cases. Retina. Fall-Winter 1984;4(4):269-75. [Medline].
5. Ament CS, Zacks DN, Lane AM, Krzystolik M, D'Amico DJ, Mukai S, et al. Predictors of visual outcome and choroidal neovascular membrane formation after traumatic choroidal rupture. Arch Ophthalmol. Jul 2006;124(7):957-66. [Medline].
6. Bellows JG. Observations on 300 cases of ocular war injuries. Am J Ophthalmol. 1947;30:309-323.
7. Conrath J, Forzano O, Ridings B. Photodynamic therapy for subfoveal CNV complicating traumatic choroidal rupture. Eye. Sep 2004;18(9):946-7. [Medline].
8. Eagling EM. Ocular damage after blunt trauma to the eye. Its relationship to the nature of the injury. Br J Ophthalmol. Feb 1974;58(2):126-40. [Medline].
9. Fuller B, Gitter KA. Traumatic choroidal rupture with late serous detachment of macula. Report of successful argon laser treatment. Arch Ophthalmol. Apr 1973;89(4):354-5. [Medline].
10. Harissi-Dagher M, Sebag M, Gauthier D, Marcil G, Labelle P, Arbour JD. Photodynamic therapy in young patients with choroidal neovascularization following traumatic choroidal rupture. Am J Ophthalmol. Apr 2005;139(4):726-8. [Medline].
11. Hart JC, Natsikos VE, Raistrick ER, Doran RM. Indirect choroidal tears at the posterior pole: a fluorescein angiographic and perimetric study. Br J Ophthalmol. Jan 1980;64(1):59-67. [Medline].
12. Hilton GF. Late serosanguineous detachment of the macula after traumatic choroidal rupture. Am J Ophthalmol. Jun 1975;79(6):997-1000. [Medline].
13. Leys A, Dralands L, Missotten L. Late complications of choroidal ruptures. Bull Soc Belge Ophtalmol. 1981;193:137-41. [Medline].
14. Luxenberg MN. Subretinal neovascularization associated with rupture of the choroid. Arch Ophthalmol. Aug 1986;104(8):1233. [Medline].
15. Mehta HB, Shanmugam MP. Photodynamic therapy of a posttraumatic choroidal neovascular membrane. Indian J Ophthalmol. Jun 2005;53(2):131-2. [Medline].
16. Mennel S, Hausmann N, Meyer CH, Peter S. Photodynamic therapy and indocyanine green guided feeder vessel photocoagulation of choroidal neovascularization secondary to choroid rupture after blunt trauma. Graefes Arch Clin Exp Ophthalmol. Jan 2005;243(1):68-71. [Medline].
17. Pearlstone AD. Delayed loss of central vision following multiple posterior segment trauma. Ann Ophthalmol. Apr 1980;12(4):409-11. [Medline].
18. Secrétan M, Sickenberg M, Zografos L, Piguet B. Morphometric characteristics of traumatic choroidal ruptures associated with neovascularization. Retina. 1998;18(1):62-6. [Medline].
19. Smith RE, Kelley JS, Harbin TS. Late macular complications of choroidal ruptures. Am J Ophthalmol. May 1974;77(5):650-8. [Medline].
20. Von Graefe A. Zwei falle von ruptur der choroida. Graefes Arch Clin Exp Ophthalmol. 1854;1:402.
21. Wood CM, Richardson J. Chorioretinal neovascular membranes complicating contusional eye injuries with indirect choroidal ruptures. Br J Ophthalmol. Feb 1990;74(2):93-6. [Medline].
22. Wyszynski RE, Grossniklaus HE, Frank KE. Indirect choroidal rupture secondary to blunt ocular trauma. A review of eight eyes. Retina. 1988;8(4):237-43. [Medline].

Article Last Updated: Jul 19, 2007