|Year : 1974 | Volume
| Issue : 2 | Page : 17-21
HN Chhabra, DP Sharma, YC Misra, R Sahai
Department of Ophthalmology, S.M.S. Medical College and Hospital, Jaipur, India
H N Chhabra
Department of Ophthalmology, S.M.S. Medical College and Hospital, Jaipur
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chhabra H N, Sharma D P, Misra Y C, Sahai R. Ciliochoroidal detachment. Indian J Ophthalmol 1974;22:17-21
Delayed or nonformation of the anterior chamber after intraocular surgery is an intriguing problem encountered by all eye surgeons. Leakage of aqueous from inadequately coopted wound accounts for large majority of them. Pupillary block due to iridohyloidal adhesions comes next in frequency. Some of these cases however show additional accompaniment of choroidal or ciliochoroidal detachment. The latter poses little more trying situation than nonformation of anterior chamber alone. Since the exact mechanism and sequence of events leading to choroidal detachment are not fully understood, there are diverse approaches in the management of this condition. Thus there are equally strong claims about the efficacy of miotic and mydriatic therapy in these cases. ,,,,
The present study records the incidence of this complication following cataract, glaucoma and combined cataract cum glaucoma operations to evaluate its possible relation with the method of extraction, the type of section, iridectomy, number of sutures etc. The management of the condition has also been evaluated.
| Material and Methods|| |
Patients operated for cataract, glaucoma and combined cataract and glaucoma, who had post-operative non-formation, delayed formation or sballowing of anterior chamber were carefully looked for wound leakage, pupillary block and choroidal detatchment. The incidence of choroidal detatchment was calculated among all such operations done in continuation during that period. The cases showing choroidal detatchment were reviewed in light of the type of operation and surgical details of the techniques adopted in each.
The leakage through section was looked for in these cases by locating obvious gaping of the wound and in doubtful cases by fluorescein instillation into the conjunctival sac and watching its entry into the anterior chamber. The pupillary block was looked for with the help of slit lamp biomicroscopy. The position of the anterior face of hyloid was also recorded by this method. The intraocular pressure was assessed digitally in early post-operative period and by tonometry subsequently. For purpose of evaluating the management of this condition the cases showing wound leakage were excluded. The rest of them were divided for this purpose into three groups
Group I Patients in this group were given diamox (one tablet of 250 mg, 8 hrly) and local atropine 1% drops 2-3 times.
Group II Diamox tablets in same doses as in group I and strong miotics (pilocarpine nitrate 2% with eserine salicylate 1% ointment) once daily.
Group III In addition to diamox and miotics as used in group II,1/2 cc. of hydrocortisone (Roussel) was given subconjunctively once only.
The cases failing to respond to above lines of treatment in 3 days were taken for injection of air into anterior chamber. The results in various groups were evaluated in terms of time taken to restore the anterior chamber, disappearance of choroidal detatchment and late complications if any during a follow up of 3 to 6 months.
| Observations|| |
Incidence: Overall incidence of choroidal detatchment was 7.89%. The incidence was highest in those who under-went combined glaucoma and cataract surgery (19.2%) and least following extracapsular extraction of cataract (6.9%) [Table - 1],[Table - 2].
Ab-externo operations with keratoma and scissor had slightly higher incidence than in those opened with knife. [Table - 3] Cataract extraction done without any stitch were followed by more cases of choroidal detachment than those with stitches [Table - 4].
Although the incidence was least with 5 interrupted sutures there was no linear relationship between the number of sutures and the incidence percentage.
In combined extraction done for lens induced glaucoma or primary glaucoma associated with cataract, the incidence of choroidal detachment was higher with broad basal iridectomy than with peripheral button hole iridectomy. The higher the initial intraocular pressure, (recorded at the time of admission in uncontrolled state), the higher was the incidence of this complication specially so in the lens induced glaucoma.
| Management|| |
It was observed that conservative treatment almost always restored the anterior chamber and achieved settlement of detached choroid. In a very small number of cases (9 cases) where this was delayed, the air had to be injected. Surgical drainage of suprachoroidal space, was not required in any case.
While diamox was a constant adjunct in all the three groups in this study the cases of choroidal detachment subjected to miotic therapy showed quicker improvement than those treated with mydriatics. The third group in whom sub-conjunctival hydrocortisone was given in addition to miotics showed quickest response so far as formation of anterior chamber was concerned. In most of the cases, the anterior chamber started forming 24 hrs. after the injection and application of strong miotics. The choroidal detachment however took one to four weeks after the restoration of anterior chamber to settle completely.
Followup of cases for three to six months revealed mild to moderate herniation of hyaloid face in a significant number of cases but only 3 cases presented with secondary glaucoma and required cyclodialysis.
| Discussion|| |
Following cataract extraction Castern  reported the incidence to be 10%, Beguel put it as 6%, Kuchle  10% and Shah  as 2.6%. The intracapsular extractions are reported to have higher incidence than extra-capsular. We too recorded higher percentage in intracapsular than following extracapsular extractions (5.1%). In present study incidence following iridencleisis was 10.9%.
The incidence of choroidal detachment after intraocular operotions is, therefore, higher than commonly expected. Its possible association should be borne in mind in cases of shallow anterior chamber specially with hypotony, with or without demonstrable wound leakage. It has been observed the anterior chamber forms earlier than the settlement of the detachment. Conversely shallow anterior chamber can be seen without detatchment of the choroid. ,
Besides associated hypotony the other common accompaniments of choroidal detachment observed were (i) mild to moderate herniation of the anterior hyloid face through the pupil producing sometimes a complete pupillary block and (ii) a leaking section in some cases. The existance of these associations makes the genesis of choroidal detachment more speculative because one cannot conclude with certainty as to which comes first.
The higher incidence of vitreous herniation recorded in this study and by other authors , suggests that the role of vitreous herniation is more than incidental. It is possible that choroidal detachment occured first and pushed the vitreous forwards. Conversely the herniation could have occured first and was followed by transudation due to negative pressure in the suprachoroidal space. Clinically however the incidence of choroidal detachment in cataract extraction complicated by vitreous prolapse is not high. Besides, the choroidal detachment occurs more frequently following glaucoma surgery where vitreous prolapse does not occur as a rule. It is therefore infered that herniation of vitreous is probably the result and not the cause.
Although shallow anterior chamber per-se may exist with normal or high intraocular pressure, the detachment of choroid is almost always associated with hypotony. The causal relationship of the two is again debatable. Theoretically ocular hypotony due to postoperative ciliary shock or leaking wound could lead to transudation in suprachoroidal space with consequential choroidal detachment. In practice however persistant hypotony due to overfiltering blebs of glaucoma surgery, traumatic hypotony and postoperative cycloasthenia is seldom accompanied with choroidal detachment. Conversely, the detatchment of choroid which almost always starts in the periphery (anterior choroid) may possibly extend forwards leading to a cleavage between the ciliary body and sclera (cyclodialysis). The latter can possibly lead to hypotony. It is, therefore, more plausible that clinically what we see as choroidal detachment exists actually as ciliochoroidal detachment and that hypotony is consequential to cyclodialysis. The higher incidence of choroidal detachment in cataract extractions with broad iridectomy, after glaucoma surgery and following combined glaucoma and cataract surgery could possibly be due to excessive manipulations required near the filtering angle and root of the ciliary body in these operations.
The prime object in the management of choroidal detatchment lies in early reformation of the anterior chamber. If the anterior chamber depth can be restored in time, the settlement of choroidal detatchment can wait and calls for no anxiety. Proponants of both mydriatic , and miotic , schools claim dramatic results in restoration of anterior chamber depth. Mydriatics are believed to relieve pupillary block and help in restoration of anterior chamber by establishment of communication between anterior and posterior chambers. The aqueous in the anterior chamber balances the hyloid pressure on iris diaphragm. The hyloid body in turn supports the sagging choroid and positivates the pressure in suprachoroidal space, thereby reducing further extravasation of fluid in this space.
The miotics on the other hand seem to support the anterior hyloid by splinting back the iris diaphragm. By their action on ciliary muscle, miotics narrow the ciliary ring which probably helps to open the iridohyloid block at site of iridectomy thereby re-establishing the communication between the anterior and posterior chambers [Figure - 1]. Subconjunctival hydrocortisone probably helps by reducing capillary permeability and thereby transudation in suprachoroidal space. The use of diamox results in relative deturgesence of vitreous and minimises the impact of hyloid at the pupil and iridectomy hole. Its use is therefore indicated in spite of hypotony.
Surgical intervention such as air injection or suprachoroidal drainage are required in few cases in whom the anterior chamber is not formed with conservative means within 3 to 5 days of the collapse. This may have to be repeated till effective chamber depth is restored and maintained. The detachment of choroid takes variable, time usually in weeks, to settle. The intraocular pressure is restored soon after formation of anterior chamber. The secondary glaucoma that follows in some cases, manifests 4 to 6 weeks after settlement of choroidal detatchment.
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[Figure - 1]
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]