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ORIGINAL ARTICLE
Year : 1984  |  Volume : 32  |  Issue : 3  |  Page : 143-147

Choroidal detachment in association with retinal detachment


Dr. Rajendra Prasad Centre for Ophthalmic Sciences New Delhi, India

Correspondence Address:
Rajvardhan Azad
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


PMID: 6519729

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How to cite this article:
Azad R, Tewari HK, Khosla P K. Choroidal detachment in association with retinal detachment. Indian J Ophthalmol 1984;32:143-7

How to cite this URL:
Azad R, Tewari HK, Khosla P K. Choroidal detachment in association with retinal detachment. Indian J Ophthalmol [serial online] 1984 [cited 2020 Dec 2];32:143-7. Available from: https://www.ijo.in/text.asp?1984/32/3/143/27407



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Choroidal detachment after intraocular surgery is a well known entity. Its occurrence in association with retinal detachment is of grave concern with regard to its therapy and prognosis so recognition of this association needs alertness while screening retinal detachment cases as frequency of mis­diagnosis is well documented[1],[2]. The diagnos­tic features of this association are not clear cut. In this paper, we are presenting our experience of such an association emphasiz­ing important diagnostic features and management.


  Material and methods Top


20 cases of choroidal detachment in association with retinal detachment were the subject of this study. These cases were selected out of 500 cases of retinal detachment admit­ted at the Dr. Rajendra Prasad Centre for Ophthalmic Sciences New Delhi, during the years 1979-81. These cases were allotted one to each therapeutic groups consecutively and the following regime in addition was insti­tuted for a week

Group I Subconjunctival steroids (1/2 cc Decadron daily)

Group II Topical steroids eye drops (Betnesol-every 2 hours daily)

Group III Systemic steroids (40 mgm Pred­nisolone orally daily)

­Group IV Control (No other treatment)

[Table - 1] shows that majority (60%) were above 50 years of age, with male prepon­derance (75%). Left eye was commonly involved (55%) with Aphakia (45%) and Myopia (30%) as commonest refractive error.

13 cases had quadrantic choroidal detach­ment while 7 cases showed typical annular choroidal detachment [Figure - 1][Figure - 2][Figure - 3]. Retinal detachment was total in 17 cases and subtotal in 3 cases. Annular choroidal detachment was always associated with total retinal detach­ment. 12 cases showed improvement (reces­sion and not total disappearance) in choroidal detachment following steroid medication.

Intraocular pressure was unrecordably low in 16 cases (75%) and markedly low (Less than 5 mm) in 5 cases (25%). The intraocular ten­sion was again assessed in various groups at the end of one week. This indicated that mean rise in all the treated groups was nearly the same and was-significantly more than the control group. The improvement in intra­ocular pressure could be correlated well with the improvement in choroidal detachment [Table - 2].

All cases showed some amount of aqueous turbidity indicative of iritis but media was significantly hazy in 9 cases (Iritis=4 cases: small vessel leak=5 cases). All but one case in first three groups responded favourably to steroid therapy with improvement in the clarity of media. Retinal breaks were found in 14 cases on first examination. More retinal breaks were visible in 6 cases after recession of choroidal detachment. However, in two cases (case No. 18 & 20) of aphakic total retinal detachment no retinal break was found.

Surgery was done in 17 out of 20 cases. Sur­gery was not done in two cases as they had total aphakic retinal detachment with annular choroidal detachment without a vis­ible retinal break. These cases also showed changes of massive vitreous retraction in addi­tion during the observation period. One case was medically unfit to undergo surgery.

Encerclage with local buckle with SRF drainage was done in all cases : Intravitreal air injection was given in 4 cases in addition to built up the tension and help in drainage of S.R.F. drainage. Anatomical success was achieved in 12 cases (70%) while vision improved only in 11 cases (64%). All anatomi­cal unsuccessful cases went into massive vit­reous retraction. Success rate was much better in treated groups (78%) than in the control-­group (33%) but was not significantly dif­ferent in various subgroups treated with steroids.


  Discussion Top


Postoperative choroidal detachment follow­ing intraocular surgery is a frequent phenomenon but preoperative association with retinal detachment is uncommonly reported. We are reporting 20 cases of choroidal detachment with primary retinal detachment which constitute 4% of cases admitted for retinal detachment surgery. against 4.5%, and 2%, reported by earlier authors.[1],[2]

Higher age bracket in this series may have significance as to the aetiology of choroidal detachment due to vascular sclerosis. Only 4 of our cases (20%) were females but sex possibly does not have any relevance.

Choroidal detachment was either seen as a quadrantic gray dome shaped elevation in association with retinal detachment or as annular detachment where the choroidal balloons were delineable and were separated by the vortex veins. The choroidal detach­ment was more often quadrantic (65%) than annular (35%). The annular choroidal detachment was always associated with total retinal detachment. In these cases one could appreciate dragging of ora (even the ciliary body) posteriorly indicative of associated ciliary detachment which might well he res­ponsible for low intraocular tension. The retinal breaks could not he located in the area of choroidal detachment due to covering of the area by overhanging of the balloons but could he suspected if the balloon covered the continuation of the peripheral retinal degeneration patch. However, the retinal breaks were visible once the choroidal detachment receded. Hence. we feel that major cause of non localisation of retinal breaks in these cases is the associated choroidal detachment, so a periodic fundus examination is a must to localise all the retinal breaks as the choroidal detachment recedes. In this series all cases showed res­ponse to steroids with the increasing clarity of media allowing better visualization of fundus.

All our patients had low intraocular pre­ssure and 80% of them had total retinal detachment and it is but natural that these cases should have low tension as intraocular pressure is inversely related to extent of retinal detachment[3]. Hypotony might subse­quently lead to choroidal detachment par­ticularly in an eye which has vascular instability due to sclerotic process. Extension of choroidal detachment to the ciliary body area (ciliary body detachment) which is sup­ported by the finding of drag of the ora or even of ciliary body is responsible for additional hypotony which accentuates the condition. Hence we feel that an associated choroidal detachment must be looked for in all cases of retinal detachment where hypotony is out of proportion.

Our results indicate overall beneficial effects within two weeks of steroid therapy given either subconjunctivally or topically, or systemically. These are in the form of reces­sion of choroidal detachment clearing of media, control of iritis and normalisation of intraocular pressure. Administration of steroids help by controlling the inflammatory process and breaking the vicious cycle of more hypotony and more choroidal detach­ment. Presence of significant iritis in 4 cases with annular choroidal detachment and minimal iritis in rest of cases supports that! inflammation does play a part in its aetiology. It is not certain whether inflammation is added later on as explained or is the causative factor. Choriocapillaries leak excess fluid in the the cases of choroidal detachment which may possibly be under some inflammatory stimulus. Our observations do not support earlier authors who reported equally good results with mere bed rest, mydricin probably ruling out role of inflammatory process.

Presence of hypotony and scleral oedema pose technical problems in surgical pro­cedures like subretinal fluid drainage, passing of scleral sutures and leads to poor postoperative chorioretinal scar. In our series, anatomical success was achieved only in patients who showed recordable I.O.P. i.e. above 5 mm of Hg Schiotz intraocular pre­ssure after steroid therapy. In all these cases the choroidal detachment had regressed and the media was clearer for proper preoperative evaluation of fundus. We achieved a functional success of 64% which was less. than in consecutive cases and failures were attri­butable to persistent hypotony and subse­quent vitreous traction. We suggest little over cryo to have a good chorioretinal scar even in cases where tension is tending to normalise after steroid therapy, because of thickened sclera and choroid. Too tight encerclage should be avoided as it will have strangulat­ing effect once the IOP is built up in pos­toperative period.


  Summary Top


Hypotony out of proportion to the extent of retinal detachment is indicative of associated choroidal detachment.

Response to steroids in the form of reduc­tion of iritis recession of choroidal detach­ment and building up of intraocular pressure indicates role of inflammation in evolution of choroidal detachments associated with retinal detachment although basic factor may be hypotony itself.

Surgical prognosis in such cases is poorer particularly when it responds poorly to steroids preoperatively.

 
  References Top

1.
Gottlieb, F., 1972, Arch. Ophthalmol. 88:48 1.  Back to cited text no. 1
    
2.
Seelen, Freund, M.H.; Kraushar, M.F.; Schepens, C.L. and Freiliclt,;I'D., 1974, Arch. Ophthalmol. 91: 254.  Back to cited text no. 2
    
3.
Sinha, A.:Khosla, P.K:and Tewari. H-.x.1981. Prec. All Ind. Opth. Udaipur.  Back to cited text no. 3
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]
 
 
    Tables

  [Table - 1], [Table - 2]



 

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