|Year : 1984 | Volume
| Issue : 3 | Page : 143-147
Choroidal detachment in association with retinal detachment
Rajvardhan Azad, Hem K Tewari, PK Khosla
Dr. Rajendra Prasad Centre for Ophthalmic Sciences New Delhi, India
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|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
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,. 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|| |
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|| |
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.,
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. 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|| |
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|| |
Gottlieb, F., 1972, Arch. Ophthalmol. 88:48 1.
Seelen, Freund, M.H.; Kraushar, M.F.; Schepens, C.L. and Freiliclt,;I'D., 1974, Arch. Ophthalmol. 91: 254.
Sinha, A.:Khosla, P.K:and Tewari. H-.x.1981. Prec. All Ind. Opth. Udaipur.
[Figure - 1], [Figure - 2], [Figure - 3]
[Table - 1], [Table - 2]