|Year : 1985 | Volume
| Issue : 4 | Page : 217-220
Management of postoperative choroidal detachment
M Mathew Krishnan, RK Baskaran
Department of Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
M Mathew Krishnan
Jawaharlal Institute of Postgraduate Medical Education and Research, Pondichery
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Krishnan M M, Baskaran R K. Management of postoperative choroidal detachment. Indian J Ophthalmol 1985;33:217-20
Ciliochoroidal detachment is a common postoperative complication which if not properly and timely managed, may endanger the results of surgery. A ciliochoroidal detachment occurs most commonly after an intraocular surgery. Keeping this in mind a study has been undertaken to evaluate the incidence of choroidal detachment and its outcome after medical and/or surgical management.
| Materials and methods|| |
1086 patients who underwent cataract and glaucoma surgery were studied. The findings of general, systemic and local examinations were recorded and these cases were specifically investigated for evidence of cardiovascular and metabolic diseases. All operated cases were examined every day and in those showing nonformation, delayed formation or subsequent shallowing of the anterior chamber, oblique illumination, biomicroscopy, and fundus examination were done, to exclude ciliochroidal detachment. Seidel's fluorescein test was done using Slit lamp to exclude wound leak. All cases showing choroidal detachment were managed initially by medical measures, including pressure bandage, acetazolamide tablets (Diamox), alternative mydriatics and miotics, local and systemic steroids and were evaluated by direct ophthalmoscopy and Slit Lamp every day to assess the effects of palliative therapy till the anterior chamber was reformed. If the anterior chamber was not reformed, surgical intervention was done.
| Observation|| |
Out of the 1086 cases, 1010 were cataract surgery and 75 cases were antiglaucoma surgery, as given in [Table - 1]. Out of these cases, 197 cases (18.1%) developed shallow anterior chamber postoperatively. When these cases were further investigated 50 cases (4.6%) revealed ciliochoroidal detachment. Out of these 50 cases, in 3 cases there was wound leak as proved by Seidel's fluorescein test.
| Management|| |
In the management of these cases emphasis were given for the reformation of the anterior chamber rather than the choroidal detachment itself. The management of these cases is given in [Table - 2]. All these cases were observed initially with topical steroids and mydriatics for a period of 2 days. If the anterior chamber did not form they were given the schedule of medical treatment as outlined in [Table - 3]. If this has failed, they were surgically treated.
Reformation of anterior chamber occurred in 5 cases although it took a longer time for the choroidal detachment to subside fully.
Medical treatment : This was administered as follows : Pressure bandage and tab. Acetazolamide 250 mg. t.d s. were given initially for 2-3 days. If the anterior chamber has not formed, alternate pupillary constriction with 2% pilocarpine drops and dilatation with 2% homatropine drops was tried with open dressing at day time and bandage at night for another 2-3 days. If this has also failed, systemic steroids i.e. tablet prednisolone 40 mg./ day was added to the above topical regimen until the anterior chamber was formed and then tapered. The medical treatment was discontinued or tapered once the anterior chamber was formed irrespective of the persistence of choroidal detachment. 42 cases out of 50 (84%) responded to the medical treatment and it took 7-12 days for the choroidal detachment to settle after the reformation of anterior chamber.
Surgical treatment : This was necessary for only 3 patients who failed to respond to the above medical treatment. In these 3 cases suprachoroidal fluid was drained through a sclerotomy in the most dependent portion with injection of sterile air into the anterior chamber. The suprachoroidal fluid was clear, straw coloured and coagulated rapidly. The fluid was analysed for protein content biochemically and electrophoretically and was compared with that of patient's serum [Table - 4] Following suprachoroidal tap, the anterior chamber formed in the next day in all the 3 cases and choroidal detachment resolved rapidly within 5-7 days.
| Discussion|| |
The suprachoroidal space between the inner surface of sclera and outer surface of the uvea is a potential space that extends from the scleral spur to the optic nerve. The attachment between the sclera and choroid is more firm posteriorily than anteriorily and is negligible between the ora and the equator. Also the veins of the anterior uvea are anatomically blood sinuses with a single layered endothelial wall without a muscular coat. This favours the production of choroidal detachment in the anterior part upto the equator.
It is known that shallow anterior chamber is associated with choroidal detachment and may be due to (1) Wound leak; (2) Huge choroidal detachment compressing the vitreous which in turn pushes the iris forward; (3) In small detachments, it may be due to rotation of ciliary processes in the plane of cornea pushing the iris forward. In our cases choroidal detachment was produced by wound leak in only 3 cases, while in the rest other two factors might be the probable cause.
As soon as the reformation of anterior chamber occurred, the choroidal detachment started settling on its own. It has taken place in a shorter period with surgical treatment than with medical treatment. Medical treatment has the advantages and in majority of cases it resolved within 7-12 days. As described by Duke-Elder, 1966, Cotlier, and Jaffe, reformation of anterior chamber should be aimed at in these cases of postoperative ciliochoroidal detachment than treatment of choroidal detachment itself. This criterion proved useful in this study also for the management of postoperative choroidal detachment. Various therapeutic measures have been advocated from time to time in the management of such cases-treatment with miotics treatment with mydriatics,, and treatment with systemic acetazolamide.,,,, Along with these measures most of the authors have advised pressure bandage' of the eye for 24-48 hours. Long continued pressure on the globe may prevent excessive drainage through a leaking wound and allow the wound to close. All these measures have been tried in our cases. In this study 72% received systemic steroids (tablet prednisolone 40 mg/day for 4-7 days) when the use of topical regimen alone has failed to reform the anterior chamber [Table - 3]. Although there is no reference in the literature suggesting the use of systemic steroids in postoperative choroidal detachment Duke Elder' mentioned the use of systemic steroids in the successful management of spontaneous choroidal detachment. Also Pederson et al in their experimental study have stressed the role of uveal inflammation causing fluid transudation from the ciliochoroidal vessels during surgery leading to choroidal detachment. Therefore, the use of systemic steroids was started on the assumption that uveal inflammation due to surgical trauma may aggravate or precipitate choroidal detachment. This is well taken care of by the administration of systemic steroids.
Surgical intervention was necessary only in 3 cases for which suprachoroidal tap was done and the fluid was analysed. Most of the workers in literature,,, advised only conservative measures for the management of choroidal detachment. However, Bellows et al advised early surgical intervention by suprachoroidal tap and enumerated various indications for surgical intervention. In our study, 94% cases responded well with conservative measures alone. This concurs with that of most of the authors in the literature. Suprachoroidal tap was done where the anterior chamber remained flat for more than 8 days and the choroidal detachment was annular and extensive. On examination there was persistent and prolonged hypotomy in these cases that should have perpetuated the vicious cycle of ciliochoroidal detachment. The drainage of suprachoroidal fluid did help reattach the ciliary body and reform the anterior chamber. In these cases, the xanthochromic fluid on analysis biochemically and electrophoretically showed the protein content to be same as that of patient's serum. This is well documented in the literature thus confirming that suprachoroidal fluid is a transudate of blood
| Summary|| |
50 cases of choroidal detachment out of 1086 cases of intraocular surgery were studied for effective management. The medical management was found to be satisfactory as 84% was cured by this regime in this series.
Surgical management was resorted to only in 3 cases where anterior chamber was flat in spite of medical treatment for over 6 days. Suprachoroidal tap was done and choroidal detachment subsided rapidly.
The role of systemic steroids in the medical management of choroidal detachment is stressed.
| References|| |
Duke-Elder, S., 1966, System of Ophthalmology, Vol, IX. Diseases of the uveal tract. St. Louis, The C.V. Mosby Co., pp. 940-949,
Cotlier, E., 1972, Arch. Ophthalmol., 87 : 124.
Jaffe, N. S., 1976, 2nd edn. pp. 195-219
Swan, K.C. and Weisel, J.T., 1957, Arch. Ophthalmol , 58. 128.
Bellows, J., Liebermann, H., and Abrahamson, I, 1955, A.M.A. Arch. Ophthalmol., 54; 170.
Chandler, P., and Maumenee, A.E, 1661; Amer. J. Ophthalmol., 52 :609.
Murphy, E.U., 1955, Amer. J. Ophthalmol,, 39 : 86.
Agarwal, L.P., Sharma. K., and Malik, S.R.K. 1955, Brit. J. Ophthalmol., 39: 664.
Thorpe, H.E., 1955, A.M.A Arch. Ophthalmol., 54 : 221.
Fine, L.M., 1965, Arch. Ophthalmol., 73:119.
Pederson, J.E., Gaasterland, D.E., Mac Lellan, H. M., 1979, Arch, Ophthalmol., 97 : 536
Bellows, A.R., Chylack, L.T., and Hutchinson, B.T., 1981, Ophthalmology, 88: 1107.
[Table - 1], [Table - 2], [Table - 3], [Table - 4]