|Year : 1983 | Volume
| Issue : 3 | Page : 238-241
RC Saxena, Dipak Kumar
King George's Medical College, Lucknow, India
R C Saxena
King George's Medical College, Lucknow
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Saxena R C, Kumar D. Choroidal detachment. Indian J Ophthalmol 1983;31:238-41
Every ophthalmic surgeon, in his routine surgical practice experiences choroidal detachment as a common post-operative complication which may, if not properly and timely managed, endanger results markedly. Keeping this in mind, a study has been done on 1,000 consecutive cases of intraocular operation. Cases presenting with choroidal detachment were further studied in detail and an attempt is made to present some important features which reflect on the clinical presentation, pathogenesis and the management of choroidal detachments.
| Material and Method|| |
1,000 Consecutive cases undergoing intraocular surgery and retinal photocoagulation at the ophthalmology department of G.M. and Associated Hospitals, Lucknow of King George's Medical College, Lucknow, were taken up for study. The findings of general, systemic and local examinations were recorded and these cases were specially investigated for evidence of cardiovascular or metabolic disease. Records of previous iintra-ocular surgery on the other eye were checked, wherever possible, for evidence of choroidal detachment.
All operated cases, especially those of cataract and glaucoma were examined every day and those showint non formation, delayed formation or subsequent shall owing of anterior chamber were thoroughly examined b) indirect ophthalmoscopy for evidence of choroida detachment. Wound leakage, however, was carefully excluded. All cases showing choroidal detachment were evaluated on the indirect ophthalmoscope and slit lamp every day to assess effects of palliative therapy till spontaneous resolution or surgical intervention. The critical time for surgical intervention was taken as the 7th day after shallowing of anterior chamber.
| Observations|| |
A total of 28 cases showed cboroidal detachment. [Table - 1][Table - 2].
In four cases of choroidal detachment developing after intracapsular cataract extraction, a positive history of a similar problem in the other eye, operated previously, was available.
l. Day of Onset. In all 28 cases, choroidal detachment was first observed between the 2nd and 5th day after surgery.
2. Depth of anterior chamber: There was a fairly consistent relationship between choroidal detachment and depth of A.C. Except for the cases of retinal detachment surgery (2) and pan-retinal photocoagulation (1), the A.C. was either shallow (20 cases) or flat (5 cases).
3. Pattern & Site of Ch. Detachment:
Greyish balloons were located all around the periphery. These balloons were more prominent in the lower temporal and lower nasal parts of the periphery. In cases of large detachments, the balloons encroached on the posterior fundus, both from the nasal and temporal periphery, and in two cases balloons reached very close to the optic disc. Balloons from the upper and lower periphery, unlike those of retinal detachment never encroach on the central fundus.
4. Ocular Tension: All 28 cases showed intraocular pressures of less than 10 mm. Hg. It was so low in 15 cases that wrinkling of descemets membrane was observed.
5. Resolution: Medical therapy alone was continued in cases developing Ch. detachment after photocoagulation (1 case) and retinal detachment surgery (2 cases), since the anterior chambers were not shallowed. Resolution was observed between 1 week to 3 weeks. In rest of the cases only 7 cases resolved after medical therapy within seven days. 18 cases which did not respond to medical therapy within seven days, were subjected to suprachoroidal drainage. 80% or more resolution occurred after suprachoroidal drainage and the normal depth of A.C. was restored in all cases within 24 hours, with subsequent clearing of the cornea.
6. Supra-choroidal Fluid: In 18 cases where suprachoroidal drainage was performed, the fluid was clear, straw coloured and coagulated rapidly. Protein content was between 4.3 to 6.05%. Few red blood cells were seen. This indicates origin from blood and not the aqueous.
| Discussion|| |
Results emerging from the present study are shown under the heading of `observations'. The incidence is not discussed due to constraints on space but points which reflect on the aetiopathogenesis of choroidal detachment need elaboration.
The facts that the complication occurred more frequently above 60 years of age, many cases having signs of vascular disease like diabetes mellitus, hypertension and arteriosclerosis, and 4 cases having a previous history of choroidal detachment at the time of operation of the other eye, seem to indicate the existence of a `predisposing factor' in the form of vascular disease., This would facilitate the passage of fluid from the choroidal blood vessels into the suprachoroidal space under certain conditions of stress. This is further supported by the fact, as derived from our study also, that suprachoroidal fluid is possibly derived from the choroidal blood vessels , sub which have a very high rate of perfusion.
The literature does not mention a single case of choroidal detachment occurring spontaneously. It would therefore be reasonable to assume that certain "precipitating factors" responsible for its causation also exist. They seem to be in the form of: (1) surgical trauma" (2) acute hypotony, which leads to dilatation of cilio-choroidal blood vessels with subsequent extravasation of fluid into supra-choroidal space, and (3) destabilization of the vitreous with resultant traction at its base.' The one case of choroidal detachment occurring after pan-retinal photocoagulation, in our series, indicates that acute hypotony is not an absolute pre-requisite as contended by some authors.
The association of choroidal detachment with shallowing of anterior chamber is fairly consistent as is observed in this study too. The mechanism of shallowing of the A.C. can be four fold: (1) due to saggital compression of vitreous leading to an increase in the antero posterior diameter (2) blockage of the pupil by the vitreous directly or indirectly via the lens, with resultant build up of aqueous pressure in the posterior chamber (3) state of cycloasthenia produced by the choroidal detachment itself. and by the aqueous pressure in posterior chamber (4) another phenomenon needing emphasis is the anterior rotation of the base of the ciliary body, with its attached iris, due to lifting of posterior part by the choroidal detachment thus further shallowing the A.C. The anterior chamber, however, was not shallow in cases following retinal detachment surgery or pan-retinal photocoagulation. This was perhaps because the choroidal detachment was sectorial only and the vitreous displacement was minimal.
The present study also indicates that resolution of choroidal detachment takes a long time (7-21 days), with the A.C. shallow throughout, endangering results grossly. This would indicate that there are also some `maintaining factors 'delaying recovery. The high protein content of supra-choroidal fluid hampers rapid absorption.' This, in the absence of proper intra-ocular pressure due to cycloasthenia, and the diseased state of the draining vasculature, perpetuates the process.
The present study further indicates that surgical intervention by supra-choroidal drainage resolves more than 80% of the detachment immediately as the result of which, the vitreous recedes, pupillary block is relieved and the A.C. forms within 24 hours. Tension builds up and the cornea clears.
| Summary|| |
28 Cases developing choroidal detachment after intra-ocular surgery, retinal detachment surgery and pan-retinal photocoagulation are studied and analysed. This study presents the incidence of choroidal detachment, its relationship to anterior chamber depth and ocular tension, aetiopathogenesis and management of choroidal detachment.
Factors found to be related to aetiopathogenesis are:-
1. Predisposing factors: vascular disease like hypertension and arterio-sclerosis and diabetes.
2. Precipitating factors:
(a) surgical trauma (b) acute hypotony
(c) destabilization of vitreous.
The fairly consistent relation between choroidal detachment and shallowing of A.C. is shown and mechanism discussed. Main points are:
(j) saggital compression cf vitreous causing its displacement.
(ii) pupillary block by vitreous directly or via lens.
(iii) anterior rotation of ciliary body further shallowing A.C.
(,) Maintaining Factors:
(a): high protein content of fluid delaying
(b): low intra-ocular pressure.
(c): diseased blood vessels causing poor
(d): high rate of perfusion in choroidal
Lastly, the value of supra-choroidal drainage has been emphasized to deal with this problem.
| References|| |
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Bellows, J., Liberman, H., Abrahamson; Quote Capper S.A., Leopold, I.H., Arch. Ophthalmol.,55; 101, 1955-1956.
[Table - 1], [Table - 2]