How to manage choroidal detachment

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Although surgical intervention is not always necessary in eyes with choroidal detachment, drainage should be performed if spontaneous resolution does not occur in order to restore normal anatomy and prevent trabeculectomy failure.

Dr. Moster

By Cheryl Guttman Krader; Reviewed by Marlene R. Moster, MD

Philadelphia-Intervention is usually not necessary in eyes that develop a choroidal detachment after glaucoma filtering surgery because the condition is self-limiting about 80% of the time. However, surgical drainage of the choroidal fluid is indicated if it does not resolve spontaneously in order to ensure a successful trabeculectomy moving forward, said Marlene R. Moster, MD.

“Choroidal detachments are common in eyes that become hypotonous because of over filtration and are a sign that the eye has essentially shut down. If the choroidal detachment does not resolve on its own, intervention is usually needed. When the eye does not establish adequate aqueous production, the bleb that the surgeon worked so hard to obtain during a trabeculectomy will fail,” said Dr. Moster, professor of ophthalmology, Jefferson Medical College, and attending surgeon, Wills Eye Hospital, Philadelphia. “Just as we restart a computer that has stopped working, draining the choroidals reboots the eye. Done with minimal trauma through a 3.0-mm infra-nasal or infra-temporal incision, it re-establishes normal anatomy and allows aqueous production to resume, preserving the bleb and restoring vision.”

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Examining choroidal detachment

In eyes with a choroidal detachment, the anterior chamber may have a normal configuration, but usually it becomes progressively more shallow, first as the lens iris diaphragm moves forward and then as continued low pressure results in further accumulation of choroidal fluid.

A dilated examination is key for making an accurate diagnosis, and ultrasound is an extremely helpful adjunct, Dr. Moster said.

Clinical examination in eyes with a choroidal detachment will show mounds of fluid under the choroid. The evaluation should rule out kissing choroidals, retinal detachment, and suprachoroidal hemorrhage in order to guide appropriate management and patient counseling.

“With choroidal detachment, there is serous fluid in the choroidal space,” Dr. Moster explained. “If the choroidals are kissing, there may be vitreoretinal traction, and then I refer the patient to a retinal specialist. I also defer to a retina colleague if there is a massive suprachoroidal hemorrhage with breakthough heme into the vitreous cavity. Referral is not necessary if the suprachoroidal hemorrhage is only moderate, but it is important to wait at least 10 days before draining the fluid so that the blood will liquefy.

“Also, the outcome may be poorer for patients with a suprachoroidal hemorrhage, and they need to be informed of this prognosis,” she added.

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Patients with a choroidal detachment can be managed conservatively for 2 to 4 weeks while waiting to see if the situation resolves. They should be given atropine for dilation, wear a shield at night since the IOP is low, and be cautioned to absolutely avoid rubbing the eye.

After an appropriate waiting period, Dr. Moster said she would drain the fluid if the bleb is failing, vision is affected, and/or a significant amount of fluid persists.

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Choroidal drainage can be done without an anesthetic block. Dr. Moster said she first puts non-preserved lidocaine into the anterior chamber and under the conjunctiva, and after opening the conjunctiva, uses a cannula to introduce more anesthetic into the pocket so that the patient remains pain free.

Entering the sclera 3.5 mm from the limbus with a #67 blade, a 3-mm horizontal incision is made parallel to the limbus to enter into the suprachoroidal space.

“It is important to make sure the incision is made 3.5 mm from the limbus and without beveling the blade,” Dr. Moster said.

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After drainage is completed, Dr. Moster closes the sclerostomy with an “X” suture using 9-0 polyglactin, although she noted some surgeons do not perform any closure. The conjunctiva is closed with a running 9-0 polyglactin suture.

Marlene R. Moster, MD

E: marlenemoster@gmail.com

Dr. Moster has no relevant financial interests to disclose.