Decreased vision or asymptomatic in a serous choroidal detachment. Decreased vision may occur if the choroidal detachments extend posteriorly and involve the macula or induce a refractive change. Moderate-to-severe pain and red eye may also occur with a hemorrhagic choroidal detachment.

(See Figure 11.27.1.)

Figure 11.27.1: Choroidal detachment.

Critical

Smooth and bullous elevation of the retina and choroid that usually extends 360 degrees around the periphery in a lobular configuration in the case of serous choroidal detachment. The elevation is orange-brown in the case of hemorrhagic choroidal detachment. The ora serrata can be seen without scleral depression in some cases.

Other

Serous choroidal detachment: Low IOP (often <6 mm Hg), shallow anterior chamber with mild cell and flare, positive transillumination.

Hemorrhagic choroidal detachment: High IOP (if detachment is large), shallow anterior chamber with mild cell and flare, no transillumination. 

• Melanoma of the ciliary body: Not typically multilobular or symmetric in each quadrant of the globe. Pigmented melanomas do not transilluminate. B-scan US usually helps to differentiate between the two. See 11.36, Choroidal Nevus and Malignant Melanoma of the Choroid.

• RRD: Appears corrugated and undulates with eye movements. A break is always present in the retina and pigment cells are often present in the vitreous. Serous choroidal detachment can occur as the result of chronic RRD. See 11.3, Retinal Detachment.

Serous

• Intraoperative or postoperative: Wound leak, unrecognized scleral perforation, iritis, cyclodialysis cleft, leakage or excess filtration from a filtering bleb, after RD repair by scleral buckling or vitrectomy, or after laser photocoagulation or cryotherapy.

• Medications: Sulfa drugs, such as topiramate and diuretics, tetracycline antibiotics, and selective serotonin reuptake inhibitors.

• Traumatic: Often associated with a ruptured globe.

• Uveitis: posterior uveitis, scleritis, and drug-induced uveitis with anticancer therapies.

• Other: Chronic RRD, nanophthalmos, malignant HTN, uveal effusion syndrome, carotid–cavernous fistula, primary or metastatic tumor, etc. See specific sections.

Hemorrhagic

• Intraoperative or postoperative: From anterior displacement of the ocular contents and rupture of the short posterior ciliary arteries.

• Spontaneous (e.g., after perforation of a corneal ulcer). May have no inciting event, especially if on anticoagulants.

1. History: Recent ocular surgery or trauma? Known eye or medical problems? Any new medications?

2. Slit-lamp examination: Check for presence of a filtering bleb and perform Seidel test to rule out a wound leak. See Appendix 5, Seidel Test to Detect a Wound Leak. Seidel test all recent surgical wounds. Assess for cell and flare the anterior chamber.

3. Gonioscopy of the anterior chamber angle: Look for a cyclodialysis cleft.

4. Dilated fundus examination: Assess for vitreous cells. Determine whether there is SRF and a retinal break, indicating a concomitant RRD, and whether an underlying choroidal disease or tumor is present. Examination of the contralateral eye may be helpful in diagnosis.

5. In cases suggestive of melanoma, B-scan US and transillumination of the globe are helpful in making a diagnosis. B-scan US is also useful in distinguishing between serous and hemorrhagic choroidal detachment and in determining if hemorrhage is mobile or coagulated. See Video: B-scan Ultrasound Tutorial.

General Treatment

1. Observation if small.

2. Cycloplegic (e.g., atropine 1% t.i.d.).

3. Topical steroid (e.g., prednisolone acetate 1% four to six times per day).

4. Consider oral steroids.

5. Consider patching the eye depending on etiology.

6. Surgical drainage of the suprachoroidal fluid may be indicated for a flat or progressively shallow anterior chamber, particularly in the presence of inflammation (because of the risk of peripheral anterior synechiae), or corneal decompensation resulting from lens–cornea touch. “Kissing” choroidals (apposition of two lobules of detached choroid) can usually be tolerated as long as there is not intractable pain or IOP elevation.

Specific Treatment: Repair the Underlying Problem

1. Serous:

   • Wound or filtering bleb leak: Patch for 24 hours, decrease steroids and add aqueous suppressants, suture the site, use cyanoacrylate glue, place a bandage contact lens on the eye, or a combination of these.

   • Cyclodialysis cleft: Laser therapy, diathermy, cryotherapy, or suture the cleft to close it.

   • Uveitis: Topical cycloplegic and steroid as discussed previously. 

   • Inflammatory disease: See the specific entity.

   • RRD: Surgical repair. Proliferative vitreoretinopathy after repair is common.

2. Hemorrhagic: Drainage of the choroidal detachment using intraocular infusion with or without vitrectomy is performed for severe cases. More successful if hemorrhage is liquefied, which occurs 7 to 10 days after the initial event. Otherwise use general treatment.

In accordance with the underlying problem.