Annular Peripheral Choroidal Detachment Simulating Aqueous Misdirection after Glaucoma Surgery

Annular Peripheral Choroidal Detachment Simulating Aqueous Misdirection after Glaucoma Surgery Pravin U. Dugel, MD, Dale K. Heuer, MD, Allen B. Thach, MD, George Baerveldt, MD, Paul P. Lee, MD, Mary Ann Lloyd, MD, DonS. Minckler, MD, Ronald L. Green, MD Purpose: The purpose of the study was to define a newly recognized complication after glaucoma surgery and to recommend a therapeutic regimen. · Methods: Eighteen patients diagnosed initially as having aqueous misdirection after glaucoma surgery, but who subsequently were found by ultrasonography to have an annular peripheral choroidal detachment that resulted in secondary angle closure glaucoma, were studied. Ten of these patients were treated with topical cycloplegics and corticosteroids, and 8 were treated with drainage of suprachoroidal fluid. Outcomes of these two treatment methods were compared. Results: Annular peripheral choroidal detachment reliably was diagnosed with ultrasonography. Of the variables studied, time elapsed before resolution of the annular peripheral choroidal detachment was noted to be statistically significant (P < 0.00005). Immediate resolution followed drainage of suprachoroidal fluid, whereas a mean of 19.6 days was required for resolution after medical therapy. Conclusions: Annular peripheral choroidal detachment should be considered in the differential diagnosis of a flat or shallow anterior chamber with normal or high intraocular pressure after glaucoma surgery. The diagnosis of annular peripheral choroidal detachment can be confirmed most reliably by ultrasonography. Medical therapy is as effective as is surgery, although a significantly longer time to resolution is required. Ophthalmology 1997; 104:439-444

A flat or shallow anterior chamber after glaucoma filtering surgery is a relatively common complication that need not necessarily be associated with hypotony. The differential diagnosis of a shallow or flat anterior chamOriginally received: May 2, 1996. Revision accepted: October 14, 1996. Department of Ophthalmology, University of Southern California School of Medicine, and the Doheny Eye Institute, Los Angeles. Dr. Dugel is currently affiliated with the Retinal Consultants of Arizona, Phoenix, Arizona. Dr. Thach is currently affiliated with Walter Reed Army Medical Center, Washington, DC. Dr. Baerveldt is currently affiliated with the Cleveland Clinic, Cleveland, Ohio. The opinions expressed herein are those of the authors and are not official opinions of the Department of the Army. Presented in part as a paper at the American Academy of Ophthalmology

ber in association with normal or even elevated intraocular pressure (lOP) includes suprachoroidal hemorrhage, pupillary block, and aqueous misdirection. 1 We recently have identified 18 patients who had undergone glaucoma surgery and in whom a shallow or flat anterior chamber developed subsequently without hypotony, but not because of suprachoroidal hemorrhage, pupillary block, or aqueous misdirection. Annual Meeting, Dallas, Texas, November 1992. Supported in part by grant EY03040, a core grant for vision research from the National Eye Institute, and a grant from Research to Prevent Blindness, Inc, New York, New York. Dr. Dugel is a recipient of the 1992-1993 Heed Ophthalmic Fellowship Award and the 1992-1993 Ronald G. Michels Vitreo-retinal Surgery Fellowship Award. Reprint requests to Ronald L. Green, MD, Doheny Eye Institute, 1450 San Pablo St, Los Angeles, CA 90033.

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Patients and Methods We examined the records of all patients in whom a shallow or flat anterior chamber developed without hypotony after glaucoma surgery performed at the Los Angeles County-University of Southern California Medical Center or at the Doheny Eye Institute between January 1988 and December 1991. All of these patients had an ultrasound to determine if there were a posterior segment cause of the shallow or flat anterior chamber. Patients with annular peripheral choroidal detachment were included in the study. In each of these patients, the annular peripheral choroidal detachment was diagnosed at the time of the first ultrasonographic examination, and repeat ultrasonography was done until the choroidal detachment had resolved. Variables that were studied included age sex ocular history, refractive error, preoperative gonio;copi~ findings, intraoperative and postoperative complications, elapsed time from surgery to diagnosis of the choroidal detachment, lOP before treatment of the choroidal detachment, visual acuity before treatment of the choroidal detachment, presence of cardiovascular disease, and type of glaucoma surgery. The patients were placed into one of two groups. One group was treated with topical medications, and the other group was treated surgically. Those treated with medications were administered topical cycloplegics (atropine 1%) and corticosteroids (prednisolone acetate 1%) every 6 hours. Those patients with more severe optic nerve damage who would not tolerate elevated pressures for any period or those patients with significant compromise of the corneal endothelium were treated with surgical drainage of the choroidal detachment. After resolution of the annular peripheral choroidal detachment, the visual acuity and lOP were observed. Standardized echography (combined standardized Ascan and contact B-scan instrumentation) was performed on all patients by one of us (RLG) using the techniques first described by Ossoinig. 2 A 7200-MA Kretztechnic or Biophysic Ophthascan S or both were used for standardized A-scan echography; contact B-scan echography was performed with the Cooper Vision Ultrascan or the Biophysic Ophthascan S instrument (all of which are distributed by Alcon, Inc, Fort Worth, TX). All echographic interpretations were made by one of us (RLG) according to criteria described previously? Comparisons of age, refractive error, and lOP between the two treatment groups were made by the Student's t test. Wilcoxon rank-sum test was used to compare visual acuities, time elapsed before diagnosis, and time to resolution of the choroidal detachment. Variables such as sex and medical history, including cardiovascular disease, were compared using Fisher's exact tests. A P value of less than 0.05 was considered to be statistically significant.

Results Forty-two patients were identified with a shallow or flat anterior chamber without hypotony after glaucoma sur-

440

gery at Los Angeles County-University of Southern California Medical Center and at the Doheny Eye Institute. Twenty-four patients had no significant findings on ultrasound and were excluded from the study. Eighteen patients who originally were thought to have aqueous misdirection were found by ultrasonography to have annular peripheral choroidal detachment. The patients included in this study consisted of 8 men and 10 women. Ages ranged from 38 to 85 years (mean, 70 years). In 10 of these patients, the glaucoma surgery consisted of implantation of a seton device and 8 patients had undergone trabeculectomy, 1 of whom received 5-fluorouracil. There were no instances of major intraoperative complications or immediate postoperative hypotony that may have predisposed to choroidal detachment. After the glaucoma surgery, all patients were treated with prednisolone acetate, atropine, and tobramycin. Because of the shallow anterior chamber, postoperative gonioscopic examination was not done. However, by biomicroscopic slit-lamp examination, all patients had 360° of peripheral iridocorneal touch, indicating that the peripheral angle was closed. None of the patients had lens-endothelium touch. Elapsed time from surgery to the diagnosis of the annular peripheral choroidal detachment ranged from 1 to 56 days. In each case, the diagnosis was based on findings of ultrasonography. The patients were separated into two groups based on the treatment they received for the annular peripheral choroidal detachment. The first group consisted of 10 patients who were treated medically with topical cycloplegics and corticosteroids every 6 hours. The second group consisted of eight patients who were treated surgically with drainage of suprachoroidal fluid. Tables 1 and 2 list patient characteristics and the variables considered in this study. The only pretreatment variable studied that showed a significant difference between groups was the refractive error (P = 0.008). The patients treated medically had a mean refractive error of +0.85 diopter (range, -2.25 to +2.25 diopters), and the patients treated surgically had a mean refractive error of -0.88 diopter (range, -2.25 to +0.50 diopter). Elapsed time from diagnosis to resolution of the annular peripheral choroidal detachment was significantly different between groups (P < 0.00005). Not surprising, the time to resolution after surgery was immediate, whereas the mean time to resolution after medical therapy was 19.6 days. After treatment and resolution of the peripheral choroidal detachment, we found no differences in visual acuity or lOP between patients treated surgically by drainage of suprachoroidal fluid and those treated medically with topical cycloplegics and corticosteroids (Table 2). Within the group of patients treated medically, the average visual acuity improved from 2/200 before surgery to 4/200 after surgery (P = 0.44), and the lOP decreased from a mean of 26 mmHg (range, 10-36 mmHg) to 9 mmHg (range, 4-15 mmHg) (P < 0.0005). The patients treated surgically were noted to have the mean visual acuity improve from 5/200 before surgery to 20/200 after surgery (P = 0.006), and the lOP decreased from a mean of 25 mmHg (range, 17-36 mmHg) to 11 mmHg (range, 4-20 mmHg) (P = 0.003).

Dugel et al · Annular Peripheral Choroidal Detachment Table 1. Patient Characteristics

No. of patients Age (yrs) Mean :t SO Range Sex Male Female Diabetes or vascular disease Previous intraocular surgery Refraction (spherical equivalent) (D) Mean :t SO Range

Medical Treatment

Surgical Treatment

10

8

p

68.3 :t 9.1 56-85

68.7 :t 14.6 38-80

5 3 2 6

3 (30%) 7 (70%) 2 (20%) 5 (50%) +0.85 :t 1.33 -2.25 to +2.25

0.57* 0.34t

(63%) (37%) (25%) (75%)

LOOt 0.37t

+0.88 :t 1.07 -2.25 to +0.50

0.008*

SD = standard deviation. *Student's t test.

t Fisher

exact test.

Discussion The differential diagnosis of a shallow or fiat anterior chamber in a patient with normal or elevated lOP after glaucoma surgery should include pupillary block, aqueous misdirection, suprachoroidal hemorrhage, and secondary angle closure glaucoma due to annular peripheral choroidal detachment. A suprachoroidal hemorrhage is recognized easily in most cases by indirect funduscopy. Without a patent iridectomy, it may be impossible to distinguish pupillary block from aqueous misdirection.

Similarly, it may be difficult to distinguish aqueous misdirection from secondary angle closure glaucoma due to annular peripheral choroidal detachment. Ultrasonography is the key tool in confirming the diagnosis of annular peripheral choroidal detachment, although it cannot exclude concurrent aqueous misdirection. Choroidal detachment is a relatively common complication of glaucoma surgery, and although it is usually associated with low lOP, the causal relation between lOP and choroidal detachment is unknown. 4•5 The previously proposed hypothesis that the suprachoroidal fluid is de-

Table 2. Treatment and Outcome Gonioscopy

Postoperative

prior to

Anterior

Patient No.

Original Surgery (0 )

1 2 3

Closed 270 Open 360 PAS 270 Open 360 Open 360 Open 360 Open 360 Closed superiorly Open 360 PAS 180 Narrow 360 Open 360 PAS superiorly Open 360 PAS superiorly Open 360 PAS superiorly PAS 180

4

5 6

7

8

9 10 11 12 13

14 15 16 17 18

Preoperative Intraocular

Postoperative Intraocular

Pressure

Pressure

(mmHg)

(mmHg)

2/200 1/200 6/200 20/60 20/100 20/200 LP 2/200

30 36 20 15 30 26 23 36

10 9 8 4

20/100 HM 20/80 5/200 20/400

20/80 8/200 20/80 20/300 20/40

10 30 24 36

8 9 12 20 8

Surgical Surgical

HM 20/100

1/200 20/30

32 20

4 10

1 56

Surgical Surigcal

HM 20/200

1/200 20/50

17 27

10 18

28

Surgical

20/200

20/200

18

9

Chamber Reaction

Intraoperative/ Postoperative Complications

Time (days) to Diagnosis

Treatment

CBI CMl-2 CMl Trab Trab Trab CMI CMI

3+ C&F 2+ C, 3+ F 3+ C, 2+ F 2+C&F 2+ C&F 3+ C&F 2+ C, 4+ F 3+C&F

Ligature removal Ligature removal None Wound leak None None None None

8 10 5 7 5 6 10 12

Medical Medical Medical Medical Medical Medical Medical Medical

Trab CMI-2 Trab Trab CMl

3+ C&F 2+C&F 2+C&F 2+ C&F 2+ C&F

Wound leak Vitreous loss None Wound leak None

14

Medical Medical Surgical Surgical Surgical

CMl St 11M

3+ C&F 1+ C, 3+ F

Ligature removal None

Trab Trab + 5-Fu CMl

3+ C&F 2+ C, 1+ F

None Wound leak

2+ C&F

Scleritis

Original Surgery

1 2 2 2

Time (days) to Resolution

Preoperative Visual Acuity

Postoperative Visual Acuity

28 21 14 14 21 28 21

HM HM 2/200 20/100 20/200 20/400 4/200 2/200

14 28 1 1 1

7

27

13

6 15 12

PAS= peripheral anterior synechiae; CBI = complete Baerveldt implant; CMI = complete Molteno implant; CMI-2 =complete double plate Molteno implant; Trab = trabeculectomy; St II M = stage two Molteno implant; 5-FU = 5-fluorouracil; C = cell; F = flare; HM = hand motion; LP = light perception.

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rived from the aqueous humor, which then creates a ciliochoroidal detachment, most likely is incorrect. 4·6 Evidence against this hypothesis includes the finding that protein concentration in the suprachoroidal fluid is much higher than it is in the aqueous humor. 4 Chylack and Bellows7 studied the suprachoroidal fluid by electrophoretic protein analysis and concluded that it originates from the choroidal vessels with molecular sieving across the capillary endothelium. Other studies have shown that eyes with suprachoroidal fluid have a stagnation of aqueous humor flow, as estimated by systemic administration of fluorescein, 8 and clinical experience has shown that drainage of the suprachoroidal fluid alone reverses hypotony in some eyes. Some investigators have postulated that suprachoroidal fluid leads to detachment of the ciliary body and to aqueous hyposecretion that is reversed after drainage. 4 This suggests that hyposecretion of the aqueous humor is the fundamental cause of hypotony associated with choroidal detachment. 4·8 However, experimental studies have proved that hypotony itself is an etiologic factor in the development of ciliochoroidal detachment. 9-' 3 To evaluate the effect of choroidal detachment on lOP, Pederson et al 14 studied a monkey model of choroidal detachment. Silicone oil injected into the suprachoroidal space created large, multilobed billowing choroidal detachments but did not result in any lowering of lOP. This led the authors to suggest that mechanical detachment of the ciliary body alone does not lead to hyposecretion. Injection of Ringer solution or autologous serum into the suprachoroidal space did lead to hypotony, but with no alteration in aqueous humor flow rate. The authors concluded that uveal-scleral outflow is enhanced as a result of ciliochoroidal detachment and results in ciliary body edema. Thus, the aqueous hyposecretion clinically seen may result from concurrent iridocyclitis and not from ciliary body detachment per se. 4·14 We infer from this study that not all cases of ciliochoroidal detachment are necessarily associated with a low lOP. Indeed, ciliochoroidal detachment that causes an anterior rotation of the ciliary body-iris diaphragm may lead to angle closure glaucoma in patients with normal or even increased lOP, as may well have occurred in the patients described herein. To our knowledge, annular peripheral choroidal detachment that leads to secondary angle closure has not been described after glaucoma filtering surgery, although it has been described in a variety of other conditions. Fourman 15 recently reviewed all conditions that can be associated with angle closure glaucoma as a complication of ciliochoroidal detachment. These include scleritis, 16 pars planitis, 17 Harada disease, 18 acquired immune deficiency syndrome, 19'20 nanophthalmos, 21 - 23 uveal effusion syndrome, 23 - 27 cataract extraction, 28 '29 post-trauma repair,29 scleral buckle, 30·3' and pan retinal photocoagulation. 32 - 34 Similar findings have also been described in patients who have not undergone surgery? 5 The exact pathogenesis of annular peripheral choroidal detachment is not known. Beyer et ae 6 have shown that experimental suprachoroidal hemorrhage in rabbits may begin as suprachoroidal effusion in the ora serrata area, which then may lead to tearing of the ciliary body vessels.

442

If their hypothesis is applicable to humans, the annular peripheral choroidal detachment in our patients may have been an aborted stage of postoperative suprachoroidal hemorrhage. The clinical differentiation of postoperative angle closure due to choroidal detachment from that secondary to aqueous misdirection is often difficult. Both present with shallow or flat anterior chamber associated with moderate conjunctival injection, trace stromal corneal edema, moderate inflammation of the anterior chamber, and a forward bowing of the peripheral iris root that can be seen with gonioscopy. The annular peripheral choroidal detachment was not visualized in our patients because a peripheral retinal examination with scleral depression was not performed for fear of wound dehiscence. In such postoperative cases, the diagnosis of secondary angle closure due to annular peripheral choroidal detachment was confirmed with ultrasonography. A choroidal detachment can be recognized on B-scan as a smooth, thick, dome-shaped membrane on the periphery, with little aftermovement on kinetic evaluation (Figs 1 and 2). If the choroidal detachment is shallow, the configuration may be flatter. A transverse B-scan approach may show multiple elevations that produce a scalloped appearance, characteristic of an annular choroidal detachment. Annular peripheral serous choroidal detachments typically do not extend posterior to the equator (Fig 1), whereas hemorrhagic choroidal detachments may extend as far as the posterior pole. A thick, steeply rising, 100% high double-peaked spike may be seen on A-scan at tissue sensitivity with a perpendicular sound beam incidence (Fig 1). The location, height, appearance, and slight aftermovement of the choroidal spike on the A-scan will usually easily differentiate choroidal detachment from retinal detachment. 37 Although we have implied that annular peripheral choroidal detachment after glaucoma surgery is a new clinical entity, it may actually co-exist with or be a variation of aqueous misdirection. The aqueous misdirection syndrome is a difficult diagnosis to establish and often is made by exclusion of other possible conditions. There are no characteristic clinical or ultrasonographic features and only rarely can intravitreous loculation of aqueous humor be identified. Therefore, although ultrasonography can confirm the diagnosis of annular peripheral choroidal detachment, it cannot exclude concurrent aqueous misdirection. Furthermore, most cases of aqueous misdirection resolve spontaneously or with topical corticosteroids and cycloplegics, the same treatment as was used in 10 of 18 patients in the current study. In our series, all 10 patients who were treated with topical cycloplegic and corticosteroids alone ultimately showed complete resolution of the annular peripheral choroidal detachment. Presumably, this treatment tightens the zonules and thereby pulls the lens back onto the plane of the ciliary body, against the force of the vitreous. This counterforce against the vitreous may rotate the iris-ciliary body complex enough to open the trabecular meshwork and reduce the lOP. Alternatively, our medical regimen actually may have had no therapeutic effect at all. The peripheral choroidal detachment may have resolved

Dugel et al · Annular Peripheral Choroidal Detachment low-grade inflammation and the use of intensive topical corticosteroids may have contributed to this. The purpose of this study was twofold: (1) to define a newly recognized clinical entity that occurs after glaucoma surgery and (2) to recommend a treatment for this condition. As expected, surgery provides immediate resolution of the annular peripheral choroidal detachment, whereas it may remain for up to 28 days with medical therapy. We recommend that if the lOP is not high enough to be harmful to the optic nerve, and if the anterior chamber is not so flat that it jeopardizes the corneal endothelium and crystalline lens, medical therapy consisting of topical cycloplegics and corticosteroids is sufficient. Permanent corneal decompensation was not seen in either treatment group. However, the long-term effects of prolonged anterior chamber shallowing on lens clarity could not be assessed. The two post-treatment variables that we assessed, visual acuity and lOP (Table 2), were not statistically different in the two treatment groups, although the number of patients in each group was small. However, both the ophthalmologist and the patient must be aware that if surgery is not performed, it may take up to 28 days for the choroidal detachment to resolve. If the corneal endothelium, crystalline lens, or optic nerve is in jeopardy, surgery is recommended. We do not have the

Figure 1. A, longitudinal B scan shows flat posterior pole with peripheral choroidal detachment. B, transverse B-scan shows a shallow annular peripheral choroidal detachment. C, A-scan shows a double-peaked spike, indicative of a choroidal detachment (right).

spontaneously, aided perhaps by the high lOP that allowed for the outward rotation of the iris-ciliary body complex and drainage of the aqueous humor through the trabecular meshwork. Either mechanism would be effective only if there were no significant, widespread synechiae within the angle. Remarkably, permanent, complete angle closure was not seen, despite the presence of a shallow anterior chamber for up to 56 days. The relatively

Figure 2. Transverse B scan shows the typical shallow, annular peripheral choroidal detachment in two different patients (A and B).

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data to determine the total number of patients operated on during the period of our study, and thus cannot provide the actual incidence of this complication. We believe that annular peripheral choroidal detachment should be included in the differential diagnosis of shallow or flat anterior chamber after glaucoma surgery, especially if the lOP is higher than expected. To confirm the diagnosis, careful A- and B-scan ultrasonography of the periphery is essential. Only after more clinicians become aware of this clinical entity, and more patients are available for study, can a definitive therapeutic regimen be recommended. Until such time, we believe the management strategies described herein are safe and effective.

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