HEMORRHAGIC CHOROIDAL DETACHMENT

 

INTRODUCTION

• Hemorrhagic CDs (HCDs) are characterized by accumulation of blood in the suprachoroidal space. This occurs due to rupture of branches of short or long posterior ciliary arteries. Arterial rupture is invariably a consequence of precipitous drop in IOP intra-operatively. While post-operatively factors such as prolonged hypotony and inflammation play a role.
• The clinical severity of HCDs differs in intra-operative vs. post-operative scenarios. Intra-operative HCDs are a medical and surgical emergency due to the high risk of expulsion of the contents of the eye through the incision. Post-operative HCDs usually develop gradually and do not have the risk of expulsion of intra-ocular contents.
• A particular type of HCDs is seen following use of antimetabolites (Mitomycin-C or 5-Flurouracil) in glaucoma filtering surgery. This is apparently due to significant hypotony seen with these medications.

ETIOLOGY

• Severe globe trauma is often associated with hemorrhagic choroidal effusions.
• Sudden globe decompression intra-operatively can cause HCD. This is particularly likely if the eye is affected by glaucoma and surgery is performed in the setting of elevated IOP.
• Prolonged hypotony and inflammation predispose to HCDs. Following glaucoma surgery persistent over-filtration and chronic inflammation leading to aqueous shutdown causes hypotony. This increases the risk for HCDs.
• Systemic hypertension, intraoperative tachycardia, arteriosclerosis, high myopia, increased axial length, aphakia, and glaucoma increase the risk for HCDs. In such patients, elevated IOP pre-operatively or acute intraoperative effusion increases the risk for developing HCD.

DIAGNOSIS

PRESENTATION

• Intra-operatively, the surgeon will visualize an enlarging dark mass masking the red fundus reflex.
• The stretching of ciliary nerves causes acute, severe pain in the patient. This could lead to nausea and vomiting.
• Extrusion of intra-ocular contents can occur.
• Post-operative development of HCDs is characterized by sudden, excruciating pain and immediate loss of vision.
• This pattern of symptoms in the setting of recent glaucoma filtering surgery is nearly pathognomonic.

SIGNS

• The IOP is invariably high in HCDs, unlike serous CDs where it is usually low.
• Appearance of hemorrhagic CDs is grossly similar to serous CDs (four lobed appearance in severe cases). However, hemorrhagic CDs do not transilluminate.
• B-scan ultrasonography can distinguish serous vs. hemorrhagic CD. Serous detachments appear as rounded, peripheral lobes filled with echo-lucent fluid. In contrast, hemorrhagic detachments appear echo-dense. (See figure, above)

MANAGEMENT

MEDICAL: Similar to serous CDs

SURGICAL:

• HCDs invariably require surgical drainage. However, in post-operative cases, especially if the hemorrhage is small, conservative treatment can be opted for.
• Intra-operatively, the incision should be closed as soon as possible. Sometimes, we need thicker sutures such as 4-0 or 5-0 nylon.
• The timing of drainage for HCDs is controversial. Usually, in HCDs due to trauma, surgical drainage is delayed by 10-14 days to allow time for clot lysis, making drainage easier. In HCDs developing following glaucoma surgery, the drainage procedure can be delayed depending on the clinical situation. If there is over-filtration from the bleb, it may have to be revised.
• In cases there is associated retinal detachment, vitreo-retinal traction or vitreous hemorrhage, vitreo-retinal surgery (e.g. PPV) is required.