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Chronic and Recurrent Choroidal Detachment after Glaucoma Filtering Surgery
Chronic and Recurrent Choroidal Detachment after Glaucoma Filtering Surgery STANLEY J. BERKE, MD, A. ROBERT BELLOWS, MD, BRADFORD J. SHINGLETON, MD, CLAUDIA U. RICHTER, MD, B. THOMAS HUTCHINSON, MD
Abstract: Chronic and recurrent choroidal (ciliochoroidal) detachments developed following glaucoma filtration surgery in 14 eyes of 13 patients during a 9year period. Three specific subgroups were identified: recurrent, inflammatory, and chronic (present for more than 6 months). The factors that may be related to the development of chronic and recurrent choroidal detachments included patient age (mean, 68.8 years), systemic hypertension or atherosclerotic heart disease, hyperopia, aqueous suppressant therapy, ocular inflammation, and full-thickness filtration surgery. A total of 46 choroidal detachments in 14 eyes were recorded and required drainage of suprachoroidal fluid on 34 occasions. All eyes developed visually significant cataracts, and complete resolution of the recurrent or chronic choroidal detachment occurred following cataract extraction in six eyes. Treatment of chronic and recurrent choroidal detachments should include intense therapy of ocular inflammation, discontinuation of medications that can incite ocular inflammation, discontinuation of topical and systemic aqueous suppressant therapy, and when a visually significant cataract is present, cataract extraction combined with a choroidal tap should be performed. [Key words: acetazolamide, betaxolol, beta adrenergic antagonists, carbonic anhydrase inhibitors, cataract, choroidal detachment, choroidal tap, full-thickness filtration surgery, hypotony, glaucoma filtration surgery, intraocular inflammation, methazolamide, posterior lip sclerectomy, timolol, trabeculectomy.] Ophthalmology 94: 154-162, 1987
Choroidal (ciliochoroidal) detachments frequently follow glaucoma surgery during the early postoperative period. A choroidal detachment occurs when hypotony permits transudation of fluid across the capillary walls of the choroid and collects in the potential space between the uvea and sclera. I - 7 A frequent type of choroidal detachment following filtration surgery is transient, may be responsible for moderate shallowing of the anterior chamber, and characteristically resolves spontaneously. Less
From the Glaucoma Service, Ophthalmic Consultants of Boston. Inc., the Glaucoma Consultation Service, and the Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston. Presented at the Ninety-first Annual Meeting of the American Academy of Ophthalmology, New Orleans, Louisiana, November 9-13,1986. Reprint requests to A. Robert Bellows, MD, Ophthalmic Consultants of Boston, Inc., 50 Staniford Street, Boston, MA 02114.
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often, a choroidal detachment may be responsible for a flat anterior chamber and require surgical drainage of the suprachoroidal space with reformation of the anterior chamber (choroidal tap) within 1 month following filtration surgery.3 An even smaller number of choroidal detachments, however, may recur following surgical drainage or may persist for months. In a study describing the clinical course and management of choroidal detachments, Bellows et al 3 identified a group of nine patients with unusually persistent or recurrent choroidal detachments. More recently, Vela and Campbell8 reported four eyes that developed hypotony and significant choroidal detachment following the introduction of aqueous suppressant therapy in eyes that had previous glaucoma filtration surgery. We report the clinical findings in patients who developed chronic or recurrent choroidal detachments following glaucoma filtration surgery in an effort to clarify the possible etiology and suggest a therapeutic approach.
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Table 1. Medical and Ocular Status of Cases with Choroidal Detachment (CD)
Group A. Recurrent CO
B. Inflammatory CO C. Chronic CO
Case No. 1 2 3 4 500 OS 6 7 8 9 10 11 12 13
Medical History Htn ASHO ASHO 100M, Htn, ASHO ASHO Htn Htn Htn, AOOM Htn Htn
lOP (mmHg)
Visual Acuity
Refractive Error (diopters)
Preop
Final
Preop
Final
+2.00 +2.50 plano +150
30 30 34 23
14 8 15 41
20/25 20/20 20/30 20/25
20/20 CF 20/25 HM
plano plano +2.00 +1.75 +2.75 +2.50 -3.00 +1.50 +2.00 +2.50
23 35 28 19 45 23 36 42 32 34
16 10 3 5 19 16 5 15 14 15
20/400 20/40 20/20 20/20 20/80 20/25 20/80 20/60 20/40 20/30
CF 20/25 HM* 20/50 20/100 20/20 20/30 20/200 20/30 20/40
Mean 31.0
14.1
Bilateral Filtering Surgery + + + + + + + + +
Time After Filter to Resolution of CO (mo.) 96 64 7 7 17 12 18* 8 6 69 55 6 10 19 28
CO = choroidal detachment; lOP = intraocular pressure; ASHO = atherosclerotic heart disease; Htn = hypertension; AOOM = adult onset diabetes mellitus; 100M = insulin dependent diabetes mellitus; 00 = right eye; OS = left eye; CF = counting fingers; HM = hand motions. * Awaiting choroidal tap and cataract extraction.
PATIENTS AND METHODS Fourteen eyes in 13 patients with chronic choroidal detachment (choroidal detachment persisting longer than 6 months) or recurrent choroidal detachments (choroidal detachment recurring with two to six episodes following filtration surgery) were encountered between February 1977 and February 1986. The analysis involved a retrospective review of six men and seven women with a mean age of 68.8 years (range, 54-81). Ten patients had systemic hypertension and four of these had atherosclerotic heart disease. Two of the patients with hypertension also had diabetes mellitus and one of these developed advanced diabetic nephropathy and retinopathy with eventual blindness (case 4). Prior to glaucoma filtration surgery, ten eyes had a hyperopic refractive error (+1.50 to +2.75 diopters), three eyes were emmetropic, and one was myopic (Table 1). Two eyes had previous branch retinal vein occlusion (cases 5, right eye, and 7) (Table 2) and one eye had previous herpes zoster ophthalmicus (case 11). Only two of the eyes reported in this study (cases 2 and 12) were included in the group of chronic choroidal detachments studied previously.3 Twelve eyes had chronic open-angle glaucoma and two had open-angle glaucoma with pseudoexfoliation. Maximally tolerated medical therapy in all eyes and argon laser trabeculoplasty in seven eyes did not control the intraocular pressure prior to filtration surgery. Twelve eyes had posterior lip sclerectomies, one eye had a trabeculectomy, and one eye had both a trabeculectomy that failed and a posterior lip sclerectomy. All eyes were phakic prior to filtration surgery and 12 eyes subsequently underwent cataract extraction. In addition, three eyes underwent cy-
clodialysis and two eyes had cyclocryotherapy for further intraocular pressure control. The principle indication for choroidal tap was persistent flat anterior chamber with lens-corneal touch and corneal edema. The other indications for choroidal tap as well as the surgical technique have been reported previously.3 Eight of the 13 patients reported had bilateral filtration surgery but only one patient (case 5) had bilateral recurrent choroidal detachments.
RESULTS The choroidal detachments were classified as recurrent, inflammatory, and chronic. Eight eyes in seven patients had 33 recurrent choroidal detachments following filtration surgery that required 25 choroidal taps. Often, a choroidal detachment accumulated rapidly after the choroidal tap and necessitated a series of choroidal taps during a short period of time (cases 4, 5, right eye, and 8). Other eyes in this group had persistent choroidal detachments for 3 to 18 months and drainage of the choroidal effusion was performed when an event, such as lens-corneal touch or appositional choroidal detachments (cases 1 and 3) occurred. Three eyes in three patients had choroidal detachments temporally and clinically related to intraocular inflammation on ten separate occasions, requiring surgical drainage in five of these occasions. Two eyes in two patients had chronic choroidal detachments (cases 12 and 13). The choroidal detachments resolved following cataract extraction and choroidal tap. Table 2 summarizes the clinical course of all eyes. Aqueous suppressant therapy, topically (timolol) and/ 155
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Table 2. Summary of Cases with Chronic or Recurrent Choroidal Detachment Case No. Eye Age/Sex
Diagnosis
Surgery: date
Medication
PlS 12/77
Preop: CAl
#1 : 12/77-3/78
#1: 3/78
CD #1 persisted for 3 mos. after filter
Postop: none T-OS 5/79
#2: 3/78-1/79
#2: 1/79
CD #2 persisted lOmas.
Choroidal Detachment
Choroidal Tap
Comment
A. Recurrent choroidal detachment 00
54/F
COAG PXF
ICCE 7/80
2
as
78/M
COAG PXF
Trab. 10/79
#3: 1/79-7/80
CD #3 persisted 18 mos., resolved after cataract surgery 7/80
T,OD 3/85-10/85 B,OD 12/85
#4: 6/85-12/85
No CD for 5 yrs. CD #4 noted 3 mos. after timolol started 00, resolved 2 mos. after Iimolol discontinued. No recurrence after 9 mos. of betaxolol No surgery OS
Preop: T,OU CAl Postop: T,OD 10/79-
#1: 10/79-11/79
#1: 11/79
#2: 11/79-8/80 ICCE 3/81
CCT 1/84
75/M
COAG PlS 12/18/82
#3: 11/83
#2: 11/83
#4: 11/83
#3: 11/83
#5: 2/84 PI,OS 12/84-1/85
00
CD #2 resolved spontaneously in 9 mos.
T,OU 3/81 CAl
Aphakic PlS 11/83
3
Preop: T,OU Postop: none
#6: 1/85
#1: 12/82-3/83 #2: 3/83- 7/83
OS
67/M
COAG PDR
#3: 3/83 #2: 7/83
Persistent CD 4 mos. CD #2 persisted for 4 mos. PlS OS 10/82. No CD
Preop: T,OU Trab.ll/l0/81
ECCE 4/82
Postop: T,OD 11/81-
#1: 11/81 #2: 11/81 #3: 11/81
#1: 11/81 #2: 11/81 #3: 11/81
Persistent CD #1-3
#4: 4/28/82-5/7/82
#4: 5/7/82
#5: 5/13/82
#5: 5/13/82 w/vitrectomy
No CD for 5 mos. until cataract surgery Patient had advanced diabetes mellitus and renal failure, developed neovascular glaucoma
#6: 6/3/82 '
#6: 6/3/82 w/vitrectomy
( Table 2 continueSj
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CD #3 and 4 occurred after an aphakic filter CD #5 1 mo. after CCT. Resolved with systemic steroids CD #6 7 wks, after PI,OS. Resolved with systemic steroids Trephine 00 1969, 1972. No CD
ICCE 10/83 4
CD #1 following filter
No surgery 00
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Table 2(continued) Case No. 5
Eye Age/Sex 00
81/M
Diagnosis
Surgery: date
Medication
Choroidal Detachment
Choroidal Tap
Comment
Preop: T,OU
COAG BRVO PLS 5/24/84
Postop: T,OS 5/84-7/84 T,OD 3/8/853/18/B5
ECCE/IOL 2/B5
Postop
#1 : 10/16/B5 #2: 10/16/85-10/25/B5
5
OS
Bl/M
COAG
Preop: T,OU PLS 7/31/84 T,OD 3/B/B5-3/18/B5
OS
74/M
OS
63/M
#1 : 1/B5
#2: 1/11/B5-3/19/B5
#2: 3/19/B5
#3: 3/B5-6/25/B5
#3: 6/B5 ECCE-CT
CD #1 persisted 5 mos. after filter CD #2 enlarged 11 days after starting T 00
CD #4 resolved spontaneously
Preop: T,OU
COAG PLS 8/7/84
7
#1 : 7/B4-1/B5
#4: 6/B5-B/85
ECCE-CT 6/B5 10L 6
No CD for 17 mos. after filter. #1: 10/16/B5 Developed CD 1 mo. after w/vitrectomy, timololOD cyclodialysis Persistent CD after CT #1 . #2: 10/25/B5 Limited suprachoroidal hemorrhage during CT #2
COAG BRVO
Postop: T,OD B/7/B4 T,OD B/7/B4
#1 : 8/8/B4-9/7/B4 #2: 9/8/84-1/B/B5
CAl 12/B5
#3: 1/86
#1: 9/7/84 #2: 1/B/85
CD #2 persisted 5 mos. No CD for 1 yr. CD #3 developed 1 mo. after start of CAls for 00 Persistent CD with dense cataract awaits surgery Trab. 00 5/84-bleb leak repair with CT
Preop: T,OU PLS 3/27/B5 Postop: T,OD 3/B5
B
00
63/F
COAG
#1: 3/2B/B5-9/12/85 #2: 9/B5- 1/86
#1 : 9/12/B5
CD #1 persisted for 6 mos. CD #2 persisted for 4 mos. and resolved spontaneously.
#1 : B/23/B5-10/5/B5
#1: 10/5/B5
CD #1 persisted 6 wks.
#2: 10/6/B5-11/16/B5
#2: 11/16/B5
Timolol OS stopped 10/B5, CD-DO persisted CD #3 enlarged 2 wks. after timololOS.
Preop: T,OU PLS 8/22/B5
Postop: T,OS B/B5-10/5/B5
T,OS 11/22/B5-12/5/85 ECCE-IOL w/CT 2/10/B6
#3: 11/17/B5-12/3O/B5 #3: 12/30/85 #4: 12/31/B5-2/10/B6
B,OD 2/28/B6 ( Table 2 confinuesj
#4: 2/10186
CD #4 resolved after cataract surgery & CT No CD for B mos. on betaxolol 00 No surgery OS
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Table 2( continued) Case No.
Eye Age/Sex
Diagnosis
Surgery: date
Medication
Choroidal Detachment
Choroidal Tap
Comment
B. Choroidal detachment associated with inflammation 9
00
56/F
Preop: CAl
COAG Uveitis
PLS 8/76
Postop: none T,OS 5/80 CAl 3/81 T,OD 6/29/81-7/22/81 #1: 7/15/81-7/23/81
#1: 7/23/81
Timolol started 00 6/81. Developed acute iritis 00 7/8/81.
T,OD 8/21/81-4/22/82 #2: 4/21/82
#3: 4/22/82
No CD for 9 mos. until spontaneous iritis 4/19/82
#3: 5/6/82 ECCE-CT
CD #3 resolved after cataract extraction & CT #3.
ECCE-CT 5/6/82 Discission 12/82
No CD for 5 yrs.
#3: 4/22/82-5/6/82 T,OD 8/27 /82-10/30/84
PLS & CYD 10/30/84
No sequellae after aphakic PLS T,00 2/11/85
Developed spontaneous CD,OS 2/85. Resolved 1 mo. after discontinued T&P,OS Aphakic-PLS,OS 5/76
10
OS
70/F
COAG
Preop: T,OU CAl PLS 6/79
Postop: T,OD 6/79-7/79
ICCE 10/80
T,OD 5/80 OS 10/80-11/82 PI-OS 1/81-2/81
No CD after filter for 20 mos.
#1: 2/2/81-2/23/81
None
Developed iritis and CD #1 1 mo. after starting PI. Responded to topical steroids.
CYD 12/81 CCT #1 5/82 CCT #210/82 T,OS 5/83-11/83
#2: 6/6/83-6/27/83
T,OS 5/84-4/85
#3: 4/25/85-7/25/85
CAl 7/25/85-8/20/85
#4: 8/20/85-9/10/85
CAl 9/26/85
( Table 2 continues')
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lOP spike 50 mmHg 5 mos. after CCT #2 CD #2 1 mo. after timolol. Responded to topical steroids. CD #3-spontaneous. No iritis on timolol 1 yr. Resolved 3 mos. alter D/C timolol CD #4 noted 1 mo. after CAl 250 mg. qid started and resolved 3 wks. after CAID/C CAl 250 mg. bid. No CD Sensitive to CAI-dose-related steroid responder PLS,OD 7/79-No CD
BERKE, et al • CHRONIC CHOROIDAL DETACHMENT
Table 2{ continued) Case No. Eye 11
DS
Age/Sex 65/F
Diagnosis
Surgery: date
COAG,OU
Medication
Choroidal Detachment
Choroidal Tap
Comment
Preop: T,OU CAl
Herpes Zoster Ophthalmic us, as 7/84 PLS 5/1/85
Postop: T a, D 5/85
ECCE & CT 10/30/85
#1 : 6/26/85
#1 : 6/27/85
#2: 6/28/85-8/19/85
#2: 8/19/85
#3: 8/20/85-10/30/85
#3: 10/30/85 w/ECCE #4: 11/8/85
#4: 11/1/85-11/8/85
No CD after filter. Developed large corneal epithelial defect 6/5/85 6/27/85 noted CD with flat AC CO #2 & #3 persistent
Required additional CT #4 1 week after ECCE & CT #3 No surgery as
C. Chronic choroidal detachment 12
as
73/F
COAG
Preop: CAl PLS 2/15/77
Postop: none
#1: 2/77-12/77
#1 : 12/8/77 w/ECCE
ECCE & CT 12/8/77
Had CD 10 mos. after PLS Resolved with cataract extraction & CT Trab, aD 7/77. No CD
Dis 10/78 13
as
75/F
COAG
Preop: T,OU PLS 10/80
Postop: T,OO 10/80-1/83
ICCE & CT 5/82
#1 : 10/80-5/82
#1 : 5/82 w/ICCE
CD 19 mos. Resolved cataract extraction & CT. PLS, aD 1/83. No CD
aD = right eye; as = left eye; Medication: CAl = carbonic anhydrase inhibitors (acetazolimide or methazolamide); T= timolol 0.5%; B= betaxalol; PI = echothiophate iodide; P= pilocarpine. Dx: COAG = chronic open-angle glaucoma; PXF = pseudoexfoliative syndrome; PDR = proliferative diabetic retinopathy; BRVO = branch retinal vein occlusion. Surgery: CT = choroidal tap; PLS = posterior lip sclerectomy; CCT = cyclocryotherapy; CYO = cyclodialysis; ICCE = intracapsular cataract extraction; DIS = discission- membrane; ECCE = extracapsular cataract extraction; Trab = trabeculectomy; 10L = intraocular lens.
or systemically (acetazolamide or methazolamide) was used preoperatively in all patients. Postoperatively, six eyes and eight contralateral eyes were treated with timolol. Five eyes developed a choroidal detachment within 6 weeks of introduction oftimolol (cases 1,2,5,9, and 11). Often, this choroidal detachment occurred months or years following filtration surgery only when timolol was introduced to treat an elevation in intraocular pressure. Three eyes had resolution of a chronic choroidal detachment when timolol therapy was stopped (cases 1, 8, and 10). However, two of these eyes (cases 1 and 8) have been treated successfully with betaxolol for more than nine months without recurrence of the choroidal detachment. In addition, 12 contralateral eyes were treated with timolol following filtration surgery and two eyes developed a choroidal detachment (cases 5 and 8). In two eyes and eight contralateral eyes, timolol therapy was continued
during the period of persistent recurrent choroidal detachment, but there was no temporal relationship between the development of the choroidal detachment and the institution of timolol therapy. This occurred during 26 episodes of choroidal detachment. Overall, 34 of 46 choroidal detachments occurred during aqueous suppressant therapy. Two eyes (cases 6 and 10) developed choroidal detachment following introduction of carbonic anhydrase inhibitors for elevation of intraocular pressure in the contralateral eye. The discontinuation of acetazolamide led to the resolution of choroidal detachment on only one occasion (case 10). Two eyes were observed for 5 years and three eyes for at least I year without any evidence of choroidal detachment prior to aqueous suppressant therapy. Echothiophate iodide caused significant intraocular inflammation and choroidal detachment in two eyes (cases 159
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2 and 10). Cyclocryotherapy caused significant intraocular inflammation and choroidal detachment in the same two eyes (cases 2 and 10) long after filtration surgery (Table 3). All 14 eyes developed visually significant cataracts following glaucoma filtration surgery and choroidal detachment. Twelve eyes had cataract extraction 180 0 from the filtration bleb 12.4 months (mean) following filtration surgery. The final resolution of recurrent or chronic choroidal detachments occurred by stopping aqueous suppressant therapy in two eyes (cases 1 and 10), by introducing systemic steroids in one eye (case 2), using topical steroids in one eye (case 10), repeated choroidal taps in four eyes (cases 3, 4, 5, right eye, and 11), and spontaneously in two eyes (cases 5, right eye, and 7). It was necessary to perform cataract extraction combined with choroidal tap in four eyes (cases 8, 9, 12, and 13) to finally resolve the recurrent choroidal effusions. Cataract surgery alone in one eye (case 1) and with a choroidal tap 1 week following cataract extraction combined with choroidal tap in one eye (case 11) were successful in treating the effusions. The control of intraocular pressure following filtration surgery and subsequent visual acuity are reported in Table 1. Thirteen of the 14 eyes had adequate final pressure control, while case 4 developed neovascular glaucoma associated with proliferative diabetic retinopathy. Three patients had profound loss of vision: case 4 due to proliferative diabetic retinopathy, case 2 due to macular degeneration, and case 6 due to visually significant cataract. Recently, case 11 has required enucleation for corneal ulceration and scleral melting associated with herpes zoster ophthalmicus.
DISCUSSION The development of a choroidal detachment following glaucoma filtration surgery is common and usually resolves spontaneously during the early postoperative period. Less conventional forms of choroidal detachments occur uncommonly. Nanophthalmic eyes may develop prolonged choroidal detachments spontaneously or following glaucoma surgery.9 These eyes and eyes with the uveal effusion syndrome lO are believed to have abnormally thick sclera that compresses the vortex veins and obstructs blood flow from the eye. Surgical decompression of the vortex veins has resulted in resolution of this form of chronic and recurrent choroidal effusions. II It is also known that patients with elevated episcleral venous pressure may develop acute intraoperative choroidal effusion during glaucoma surgery and may form extensive, postoperative combined retinal and choroidal detachments. 3,12 A posterior sclerotomy at the time of filtration surgery has reduced the intraoperative and postoperative complications of this form of choroidal detachment. 12 Severe scleritis,13 retinal detachment surgery,14 and retinal photocoagulation l5 have been reported to create a significant choroidal detachment even in the absence of documented hypotony. Some authors believe that chronic hypotony 160
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associated with a cyclodialysis cleft is due to prolonged choroidal detachment created by aqueous directed into and collected in the suprachoroidal space. 16 Very little is known about chronic or recurrent choroidal detachment after glaucoma surgery. 3 Recently , Vela and Campbe1l8 recognized four eyes that had glaucoma filtration surgery and developed profound hypotony and choroidal detachment when topical or systemic aqueous suppressant therapy was started for elevated intraocular pressure. These eyes had been treated with aqueous suppressant therapy prior to filtration surgery, and the authors hypothesized that the reintroduction of these agents caused a dramatic reduction of aqueous humor production with hypotony and choroidal detachment. We have defined three specific groups of chronic or recurrent choroidal detachment in this study. The institution of aqueous suppressant therapy is temporally related to the development of choroidal detachment in both the recurrent and the inflammatory groups. The third category, chronic choroidal detachments, included two eyes that had persistent choroidal detachments for 10 and 19 months and resolved with cataract surgery and choroidal tap. Of these patients, case 12 was on no medication during the 10 months of choroidal detachment, while case 13 was treated with timolol in the contralateral eye during the 19 months of detachment, and no recurrent detachment occurred during 7 additional months of contralateral betaxolol therapy. The group of recurrent choroidal detachments is typified by case 1, who developed a choroidal detachment persisting for 3 months after successful filtration surgery. Despite choroidal taps, she developed recurrent choroidal detachments for 10 and 18 months, which were resolved by successful cataract surgery. The patient maintained adequate intraocular pressure control and no evidence of choroidal detachment for 5 years while on topical timolol to her contralateral eye. When topical timolol was introduced to lower the intraocular pressure in the previously filtered eye, a large choroidal detachment with shallowing of the anterior chamber occurred. When timolol was stopped, the choroidal detachment resolved. It is of interest that use of topical betaxolol in the ipsilateral eye has been tolerated for more than 9 months without evidence of recurrent choroidal detachment. Other eyes in Group A (Table 2) developed recurrent or persistent choroidal detachments that lasted from 1 to 8 months and recurred at varying intervals with a variety of inciting events. It became obvious that institution of medications (echothiophate iodide, timolol, and carbonic anhydrase inhibitors), as well as surgical procedures (aphakic filtering procedures, and cyclocryotherapy), were all temporally related to the development of recurrent choroidal detachments. It seems likely that ocular tissues and specifically choroidal vasculature may have only a few possible responses to drug and surgical insult. One patient with extensive involvement of the vascular system (case 4) had long-standing diabetes mellitus with advanced diabetic nephropathy and retinopathy. He required three choroidal taps while phakic and three additional taps following cataract surgery. Subsequently, neovascular glau-
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Table 3. Possible Factors Related to Chronic and Recurrent Choroidal Detachment (CD) Elderly (mean age) Hypertension/ASHD Hyperopia Full-thickness filtering surgery Visually significant cataract Aqueous suppressant therapy Temporal relationship No temporal relationship Inflammation Cyclocryotherapy Echothiophate iodide ASHD
=
68.8 yrs. 10/13 pts. 10/14 eyes 12/14 eyes 14/14 eyes 8 CD 26 CD 10 CD 2 CD 2 CD
(7 eyes) (10 eyes) (4 eyes) (2 eyes) (2 eyes)
atherosclerotic heart disease.
coma developed with loss of functional vision. Other evidence for vascular disease in the form of hypertension or atherosclerotic heart disease was present in all but one of the eight patients in Group A and ten of the 13 patients in the entire study. Two of the patients in Group A had evidence of previous branch retinal vein occlusion in the involved eye (cases 5, right eye, and 7). Efforts to correlate vascular disorders have not been revealing, 3 whereas in the group of patients reported to be sensitive to aqueous suppressant therapy,8 three of the four patients were hypertensive and two had diabetes mellitus. Recognition of the relationship between aqueous suppressant therapy and the development of choroidal detachment must be emphasized. All of the eyes reported in this study were treated with topical or systemic aqueous suppressant therapy prior to filtration surgery. Sensitivity to these agents is exemplified by case 9, who was entirely asymptomatic 5 years following successful filtration surgery. Topical timolol was introduced in this eye and iritis and choroidal detachment developed 2 weeks later. The timolol was discontinued after the choroidal tap, and then started 1 month later. Nine months after reintroducing timolol, the eye again developed iritis and choroidal detachment. The sensitivity to both topical and systemic aqueous suppressants are manifested in case 10, who developed inflammation and choroidal detachment while on topical timolol for 1 year. A choroidal detachment resolved 3 months after the discontinuation of timolol, but recurred when acetazolamide 250 mg four times daily was introduced. The choroidal detachment resolved when acetazolamide was discontinued and has not recurred with acetazolamide in a lower dose, 250 mg twice daily. Many eyes are apparently extremely sensitive to aqueous suppressant therapy, topical or systemic, ipsilateral or contralateral. These agents may be responsible for the development and prolongation of choroidal detachment following filtration surgery. When confronted with eyes with chronic or recurrent choroidal detachment, discontinuation of all aqueous suppressant therapy for at least 1 to 2 months should be instituted in an effort to promote spontaneous resolution. Intraocular inflammation was associated with recurrent and chronic choroidal detachment in three eyes (Group B, Table 2). Three specific etiologies are noted: case 9
with recurrent endogenous uveitis, case 10 with severe iritis induced by echothiophate iodide, and case 11 with chronic inflammation secondary to herpes zoster ophthalmicus. It is well recognized that intraocular inflammation in the form of scleritis,12 episcleritis,17 and uveitis can cause choroidal detachment. More unusual forms of spontaneous choroidal detachments have been associated with uveitis following cataract surgery from 6 to 20 years later. 18,19 Eleven recurrent choroidal detachments that occurred in Group B were distinctly different from Group A, since none of the three eyes developed a significant choroidal detachment immediately after filtration surgery. These eyes were also sensitive to aqueous suppressant therapy, and inflammation caused by echothiophate iodide and cyclocryotherapy. In the chronic choroidal detachment category, Group C, two eyes developed chronic choroidal detachments that were present for more than 6 months following successful filtration surgery. The course was not as complex as in Groups A or B, and both eyes maintained adequate pressure control with functional filtering blebs despite the presence of large choroidal detachments. When cataract formation became visually significant, choroidal tap was performed in conjunction with cataract surgery and the choroidal detachment resolved. Since the choroidal detachment did not recur, it is impossible to actually determine whether choroidal tap alone would have been successful. The type of glaucoma surgery performed may effect the incidence of postoperative choroidal detachment. It may also relate to the incidence of chronic and recurrent choroidal detachments. It is well recognized that the lower intraocular pressure in the early postoperative period following full-thickness filtration surgery may account for the higher incidence of choroidal detachment. Thirteen of 14 eyes in this study had full-thickness filtering procedures. However, six eyes had contralateral filtering surgery with full-thickness procedures and two had trabeculectomies. Only one patient with bilateral full-thickness filters had bilateral recurrent choroidal detachments. Significant or prolonged choroidal detachment did not develop in the other contralateral eyes. In the eyes reported by Vela and Campbell, 8 three had trabeculectomies and, in a study of initial filtration surgery,20 the incidence of choroidal detachment was approximately 15% in both fullthickness and trabeculectomy operations. The observation that all 14 eyes in this study developed visually significant cataracts was unexpected, since only 30% of eyes requiring filtration surgery develop significant cataracts within 2 to 5 years. 3,20-22 The incidence of cataract formation following choroidal tap increases to only 40%.20 Christiansson23 reported that 50% of eyes with intraocular pressures less than 10 mmHg following filtration surgery developed significant cataract formation. In 4 of the 14 eyes in this study, a final intraocular pressure of less than 10 mmHg was established. However, all of the eyes had an intraocular pressure of less than 10 (4-8 mmHg) during the duration of their chronic or recurrent choroidal detachment. It is possible that the prolonged hypotony during the choroidal detachment contributed 161
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to the incidence of cataract formation and that recurrent inflammation, steroid therapy, possible lens-corneal touch, and even repeated surgical manipulation would increase the incidence of cataract formation. Each of these insults could result in an alteration in aqueous humor and cause inadequate lens nutrition or a mechanical alteration of lens metabolism. Following cataract surgery alone or when cataract surgery was combined with a choroidal tap, long-standing choroidal detachment resolved in seven eyes. Previous efforts to evacuate the choroidal effusion had been unsuccessful until cataract extraction was accomplished. It may be possible that cataract surgery contributed to the resolution of the choroidal detachment by producing postoperative inflammation resulting in a decreased filtering bleb function and a rise in intraocular pressure. Alternatively, possible cataract formation with swelling of the lens could displace the lens-iris diaphragm anteriorly and result in zonular traction on the ciliary body. This internal traction is reduced by cataract extraction and the choroid is able to reassume its physiologic position adjacent to sclera. Identification of eyes with a chronic or recurrent choroidal detachment is not difficult. However, management that results in resolution of the choroidal detachment with control of the intraocular pressure and preservation of vision is sometimes difficult. We recommend that eyes with chronic or recurrent choroidal detachment should have all forms of aqueous suppressant therapy stopped and endogenous inflammation treated vigorously. Additional agents that incite intraocular inflammation should be discontinued. Cataract surgery should be performed when the cataract is visually significant because cataract surgery in this series, especially in combination with choroidal tap, was associated with visual improvement as well as definitive resolution of the chronic choroidal detachment.
REFERENCES 1. Capper SA, Leopold IH. Mechanism of serous choroidal detachment: a review and experimental study. Arch Ophthalmol1956; 55:101-13. 2. Brav SS. Serous choroidal detachment. Surv Ophthalmol 1961; 6: 395-415.
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3. Bellows AR, Chylack LT Jr, Hutchinson BT. Choroidal detachment: clinical manifestation, therapy and mechanism of formation. Ophthalmology 1981; 88:1107-15. 4. Brubaker RF, Pederson JE. Ciliochoroidal detachment. Surv Ophthalmol 1983; 27:281-9. 5. Dobree JH. The nature of choroidal detachment fluid. Electrophoresis, clinical findings and treatment in eight cases of post-operative choroidal detachment. Trans Ophthalmol Soc UK 1961; 81 :113-23. 6. Pederson JE, Gaasterland DE, MacLellan HM. Experimental ciliochoroidal detachment: effect on intraocular pressure and aqueous humor flow. Arch Ophthalmol 1979; 97 :536-41. 7. Chylack LT Jr, Bellows AR. Molecular sieving in suprachoroidal fluid formation in man. Invest Ophthalmol Vis Sci 1978; 17:420-7. 8. Vela MA, Campbell DG. Hypotony and ciliochoroidal detachment following pharmacologic aqueous suppressant therapy in previously filtered patients. Ophthalmology 1985; 92:50-7. 9. Brockhurst RJ. Nanophthalmos with uveal effusion: a new clinical entity. Arch Ophthalmol1975; 93:1289-99. 10. Gass JDM, Jallow S. Idiopathic serous detachment of the choroid, ciliary body, and retina (uveal effusion syndrome). Ophthalmology 1982; 89:1018-32. 11. Brockhurst RJ. Vortex vein decompression for nanophthalmic uveal effusion. Arch Ophthalmol1980; 98:1987-90. 12. Bellows AR, Chylack LT, Epstein DL, Hutchinson BT. Choroidal effusion during glaucoma surgery in patients with prominent episcleral vessels. Arch Ophthalmol1979; 97:493-7. 13. Sears ML. Choroidal and retinal detachments associated with scleritis. Am J OphthalmoI1964; 58:764-6. 14. Hawkins WR, Schepens CL. Choroidal detachment and retinal surgery. A clinical and experimental study. Am J Ophthalmol 1966; 62: 813-9. 15. O'Connell EJA, Patterson G, Davies EWG. Choroidal detachment following photocoagulation in diabetes. Mod Prob Ophthalmol 1979; 20: 66-70. 16. Chandler PA, Maumenee AE. A major cause of hypotony. Am J Ophthalmol1961; 52:609-18. 17. Velzeboer CMJ. Spontaneous choroidal detachment: report of two cases. Am J Ophthalmol1960; 49:898-903. 18. McGrand JC. Choroidal detachment in aphakic uveitis. Br J Ophthalmol 1969; 53:778-81. 19. McClure HL. Massive bilateral choroidal detachment occurring in an aphakic patient six years and nine months postoperatively. Am J Ophthalmol1967; 63:295-7. 20. Lamping KA, Bellows AR, Hutchinson BT, Afran SI. Long-term evaluation of initial filtration surgery. Ophthalmology 1986; 93:91-101. 21. Sugar HS. Postoperative cataract in successfully filtering glaucomatous eyes. Am J Ophthalmol1970; 69:740-6. 22. Marion JR, Shields MB. Thermal sclerostomy and posterior lip sclerectomy: a comparative study. Ophthalmic Surg 1978; 9(6):67-75. 23. Christiansson J. Ocular hypotony after fistulizing glaucoma surgery. Acta Ophthalmol1967; 45:837-45.
Abstract: Chronic and recurrent choroidal (ciliochoroidal) detachments developed following glaucoma filtration surgery in 14 eyes of 13 patients during a 9year period. Three specific subgroups were identified: recurrent, inflammatory, and chronic (present for more than 6 months). The factors that may be related to the development of chronic and recurrent choroidal detachments included patient age (mean, 68.8 years), systemic hypertension or atherosclerotic heart disease, hyperopia, aqueous suppressant therapy, ocular inflammation, and full-thickness filtration surgery. A total of 46 choroidal detachments in 14 eyes were recorded and required drainage of suprachoroidal fluid on 34 occasions. All eyes developed visually significant cataracts, and complete resolution of the recurrent or chronic choroidal detachment occurred following cataract extraction in six eyes. Treatment of chronic and recurrent choroidal detachments should include intense therapy of ocular inflammation, discontinuation of medications that can incite ocular inflammation, discontinuation of topical and systemic aqueous suppressant therapy, and when a visually significant cataract is present, cataract extraction combined with a choroidal tap should be performed. [Key words: acetazolamide, betaxolol, beta adrenergic antagonists, carbonic anhydrase inhibitors, cataract, choroidal detachment, choroidal tap, full-thickness filtration surgery, hypotony, glaucoma filtration surgery, intraocular inflammation, methazolamide, posterior lip sclerectomy, timolol, trabeculectomy.] Ophthalmology 94: 154-162, 1987
Choroidal (ciliochoroidal) detachments frequently follow glaucoma surgery during the early postoperative period. A choroidal detachment occurs when hypotony permits transudation of fluid across the capillary walls of the choroid and collects in the potential space between the uvea and sclera. I - 7 A frequent type of choroidal detachment following filtration surgery is transient, may be responsible for moderate shallowing of the anterior chamber, and characteristically resolves spontaneously. Less
From the Glaucoma Service, Ophthalmic Consultants of Boston. Inc., the Glaucoma Consultation Service, and the Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston. Presented at the Ninety-first Annual Meeting of the American Academy of Ophthalmology, New Orleans, Louisiana, November 9-13,1986. Reprint requests to A. Robert Bellows, MD, Ophthalmic Consultants of Boston, Inc., 50 Staniford Street, Boston, MA 02114.
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often, a choroidal detachment may be responsible for a flat anterior chamber and require surgical drainage of the suprachoroidal space with reformation of the anterior chamber (choroidal tap) within 1 month following filtration surgery.3 An even smaller number of choroidal detachments, however, may recur following surgical drainage or may persist for months. In a study describing the clinical course and management of choroidal detachments, Bellows et al 3 identified a group of nine patients with unusually persistent or recurrent choroidal detachments. More recently, Vela and Campbell8 reported four eyes that developed hypotony and significant choroidal detachment following the introduction of aqueous suppressant therapy in eyes that had previous glaucoma filtration surgery. We report the clinical findings in patients who developed chronic or recurrent choroidal detachments following glaucoma filtration surgery in an effort to clarify the possible etiology and suggest a therapeutic approach.
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Table 1. Medical and Ocular Status of Cases with Choroidal Detachment (CD)
Group A. Recurrent CO
B. Inflammatory CO C. Chronic CO
Case No. 1 2 3 4 500 OS 6 7 8 9 10 11 12 13
Medical History Htn ASHO ASHO 100M, Htn, ASHO ASHO Htn Htn Htn, AOOM Htn Htn
lOP (mmHg)
Visual Acuity
Refractive Error (diopters)
Preop
Final
Preop
Final
+2.00 +2.50 plano +150
30 30 34 23
14 8 15 41
20/25 20/20 20/30 20/25
20/20 CF 20/25 HM
plano plano +2.00 +1.75 +2.75 +2.50 -3.00 +1.50 +2.00 +2.50
23 35 28 19 45 23 36 42 32 34
16 10 3 5 19 16 5 15 14 15
20/400 20/40 20/20 20/20 20/80 20/25 20/80 20/60 20/40 20/30
CF 20/25 HM* 20/50 20/100 20/20 20/30 20/200 20/30 20/40
Mean 31.0
14.1
Bilateral Filtering Surgery + + + + + + + + +
Time After Filter to Resolution of CO (mo.) 96 64 7 7 17 12 18* 8 6 69 55 6 10 19 28
CO = choroidal detachment; lOP = intraocular pressure; ASHO = atherosclerotic heart disease; Htn = hypertension; AOOM = adult onset diabetes mellitus; 100M = insulin dependent diabetes mellitus; 00 = right eye; OS = left eye; CF = counting fingers; HM = hand motions. * Awaiting choroidal tap and cataract extraction.
PATIENTS AND METHODS Fourteen eyes in 13 patients with chronic choroidal detachment (choroidal detachment persisting longer than 6 months) or recurrent choroidal detachments (choroidal detachment recurring with two to six episodes following filtration surgery) were encountered between February 1977 and February 1986. The analysis involved a retrospective review of six men and seven women with a mean age of 68.8 years (range, 54-81). Ten patients had systemic hypertension and four of these had atherosclerotic heart disease. Two of the patients with hypertension also had diabetes mellitus and one of these developed advanced diabetic nephropathy and retinopathy with eventual blindness (case 4). Prior to glaucoma filtration surgery, ten eyes had a hyperopic refractive error (+1.50 to +2.75 diopters), three eyes were emmetropic, and one was myopic (Table 1). Two eyes had previous branch retinal vein occlusion (cases 5, right eye, and 7) (Table 2) and one eye had previous herpes zoster ophthalmicus (case 11). Only two of the eyes reported in this study (cases 2 and 12) were included in the group of chronic choroidal detachments studied previously.3 Twelve eyes had chronic open-angle glaucoma and two had open-angle glaucoma with pseudoexfoliation. Maximally tolerated medical therapy in all eyes and argon laser trabeculoplasty in seven eyes did not control the intraocular pressure prior to filtration surgery. Twelve eyes had posterior lip sclerectomies, one eye had a trabeculectomy, and one eye had both a trabeculectomy that failed and a posterior lip sclerectomy. All eyes were phakic prior to filtration surgery and 12 eyes subsequently underwent cataract extraction. In addition, three eyes underwent cy-
clodialysis and two eyes had cyclocryotherapy for further intraocular pressure control. The principle indication for choroidal tap was persistent flat anterior chamber with lens-corneal touch and corneal edema. The other indications for choroidal tap as well as the surgical technique have been reported previously.3 Eight of the 13 patients reported had bilateral filtration surgery but only one patient (case 5) had bilateral recurrent choroidal detachments.
RESULTS The choroidal detachments were classified as recurrent, inflammatory, and chronic. Eight eyes in seven patients had 33 recurrent choroidal detachments following filtration surgery that required 25 choroidal taps. Often, a choroidal detachment accumulated rapidly after the choroidal tap and necessitated a series of choroidal taps during a short period of time (cases 4, 5, right eye, and 8). Other eyes in this group had persistent choroidal detachments for 3 to 18 months and drainage of the choroidal effusion was performed when an event, such as lens-corneal touch or appositional choroidal detachments (cases 1 and 3) occurred. Three eyes in three patients had choroidal detachments temporally and clinically related to intraocular inflammation on ten separate occasions, requiring surgical drainage in five of these occasions. Two eyes in two patients had chronic choroidal detachments (cases 12 and 13). The choroidal detachments resolved following cataract extraction and choroidal tap. Table 2 summarizes the clinical course of all eyes. Aqueous suppressant therapy, topically (timolol) and/ 155
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Table 2. Summary of Cases with Chronic or Recurrent Choroidal Detachment Case No. Eye Age/Sex
Diagnosis
Surgery: date
Medication
PlS 12/77
Preop: CAl
#1 : 12/77-3/78
#1: 3/78
CD #1 persisted for 3 mos. after filter
Postop: none T-OS 5/79
#2: 3/78-1/79
#2: 1/79
CD #2 persisted lOmas.
Choroidal Detachment
Choroidal Tap
Comment
A. Recurrent choroidal detachment 00
54/F
COAG PXF
ICCE 7/80
2
as
78/M
COAG PXF
Trab. 10/79
#3: 1/79-7/80
CD #3 persisted 18 mos., resolved after cataract surgery 7/80
T,OD 3/85-10/85 B,OD 12/85
#4: 6/85-12/85
No CD for 5 yrs. CD #4 noted 3 mos. after timolol started 00, resolved 2 mos. after Iimolol discontinued. No recurrence after 9 mos. of betaxolol No surgery OS
Preop: T,OU CAl Postop: T,OD 10/79-
#1: 10/79-11/79
#1: 11/79
#2: 11/79-8/80 ICCE 3/81
CCT 1/84
75/M
COAG PlS 12/18/82
#3: 11/83
#2: 11/83
#4: 11/83
#3: 11/83
#5: 2/84 PI,OS 12/84-1/85
00
CD #2 resolved spontaneously in 9 mos.
T,OU 3/81 CAl
Aphakic PlS 11/83
3
Preop: T,OU Postop: none
#6: 1/85
#1: 12/82-3/83 #2: 3/83- 7/83
OS
67/M
COAG PDR
#3: 3/83 #2: 7/83
Persistent CD 4 mos. CD #2 persisted for 4 mos. PlS OS 10/82. No CD
Preop: T,OU Trab.ll/l0/81
ECCE 4/82
Postop: T,OD 11/81-
#1: 11/81 #2: 11/81 #3: 11/81
#1: 11/81 #2: 11/81 #3: 11/81
Persistent CD #1-3
#4: 4/28/82-5/7/82
#4: 5/7/82
#5: 5/13/82
#5: 5/13/82 w/vitrectomy
No CD for 5 mos. until cataract surgery Patient had advanced diabetes mellitus and renal failure, developed neovascular glaucoma
#6: 6/3/82 '
#6: 6/3/82 w/vitrectomy
( Table 2 continueSj
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CD #3 and 4 occurred after an aphakic filter CD #5 1 mo. after CCT. Resolved with systemic steroids CD #6 7 wks, after PI,OS. Resolved with systemic steroids Trephine 00 1969, 1972. No CD
ICCE 10/83 4
CD #1 following filter
No surgery 00
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• CHRONIC CHOROIDAL DETACHMENT
Table 2(continued) Case No. 5
Eye Age/Sex 00
81/M
Diagnosis
Surgery: date
Medication
Choroidal Detachment
Choroidal Tap
Comment
Preop: T,OU
COAG BRVO PLS 5/24/84
Postop: T,OS 5/84-7/84 T,OD 3/8/853/18/B5
ECCE/IOL 2/B5
Postop
#1 : 10/16/B5 #2: 10/16/85-10/25/B5
5
OS
Bl/M
COAG
Preop: T,OU PLS 7/31/84 T,OD 3/B/B5-3/18/B5
OS
74/M
OS
63/M
#1 : 1/B5
#2: 1/11/B5-3/19/B5
#2: 3/19/B5
#3: 3/B5-6/25/B5
#3: 6/B5 ECCE-CT
CD #1 persisted 5 mos. after filter CD #2 enlarged 11 days after starting T 00
CD #4 resolved spontaneously
Preop: T,OU
COAG PLS 8/7/84
7
#1 : 7/B4-1/B5
#4: 6/B5-B/85
ECCE-CT 6/B5 10L 6
No CD for 17 mos. after filter. #1: 10/16/B5 Developed CD 1 mo. after w/vitrectomy, timololOD cyclodialysis Persistent CD after CT #1 . #2: 10/25/B5 Limited suprachoroidal hemorrhage during CT #2
COAG BRVO
Postop: T,OD B/7/B4 T,OD B/7/B4
#1 : 8/8/B4-9/7/B4 #2: 9/8/84-1/B/B5
CAl 12/B5
#3: 1/86
#1: 9/7/84 #2: 1/B/85
CD #2 persisted 5 mos. No CD for 1 yr. CD #3 developed 1 mo. after start of CAls for 00 Persistent CD with dense cataract awaits surgery Trab. 00 5/84-bleb leak repair with CT
Preop: T,OU PLS 3/27/B5 Postop: T,OD 3/B5
B
00
63/F
COAG
#1: 3/2B/B5-9/12/85 #2: 9/B5- 1/86
#1 : 9/12/B5
CD #1 persisted for 6 mos. CD #2 persisted for 4 mos. and resolved spontaneously.
#1 : B/23/B5-10/5/B5
#1: 10/5/B5
CD #1 persisted 6 wks.
#2: 10/6/B5-11/16/B5
#2: 11/16/B5
Timolol OS stopped 10/B5, CD-DO persisted CD #3 enlarged 2 wks. after timololOS.
Preop: T,OU PLS 8/22/B5
Postop: T,OS B/B5-10/5/B5
T,OS 11/22/B5-12/5/85 ECCE-IOL w/CT 2/10/B6
#3: 11/17/B5-12/3O/B5 #3: 12/30/85 #4: 12/31/B5-2/10/B6
B,OD 2/28/B6 ( Table 2 confinuesj
#4: 2/10186
CD #4 resolved after cataract surgery & CT No CD for B mos. on betaxolol 00 No surgery OS
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Table 2( continued) Case No.
Eye Age/Sex
Diagnosis
Surgery: date
Medication
Choroidal Detachment
Choroidal Tap
Comment
B. Choroidal detachment associated with inflammation 9
00
56/F
Preop: CAl
COAG Uveitis
PLS 8/76
Postop: none T,OS 5/80 CAl 3/81 T,OD 6/29/81-7/22/81 #1: 7/15/81-7/23/81
#1: 7/23/81
Timolol started 00 6/81. Developed acute iritis 00 7/8/81.
T,OD 8/21/81-4/22/82 #2: 4/21/82
#3: 4/22/82
No CD for 9 mos. until spontaneous iritis 4/19/82
#3: 5/6/82 ECCE-CT
CD #3 resolved after cataract extraction & CT #3.
ECCE-CT 5/6/82 Discission 12/82
No CD for 5 yrs.
#3: 4/22/82-5/6/82 T,OD 8/27 /82-10/30/84
PLS & CYD 10/30/84
No sequellae after aphakic PLS T,00 2/11/85
Developed spontaneous CD,OS 2/85. Resolved 1 mo. after discontinued T&P,OS Aphakic-PLS,OS 5/76
10
OS
70/F
COAG
Preop: T,OU CAl PLS 6/79
Postop: T,OD 6/79-7/79
ICCE 10/80
T,OD 5/80 OS 10/80-11/82 PI-OS 1/81-2/81
No CD after filter for 20 mos.
#1: 2/2/81-2/23/81
None
Developed iritis and CD #1 1 mo. after starting PI. Responded to topical steroids.
CYD 12/81 CCT #1 5/82 CCT #210/82 T,OS 5/83-11/83
#2: 6/6/83-6/27/83
T,OS 5/84-4/85
#3: 4/25/85-7/25/85
CAl 7/25/85-8/20/85
#4: 8/20/85-9/10/85
CAl 9/26/85
( Table 2 continues')
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lOP spike 50 mmHg 5 mos. after CCT #2 CD #2 1 mo. after timolol. Responded to topical steroids. CD #3-spontaneous. No iritis on timolol 1 yr. Resolved 3 mos. alter D/C timolol CD #4 noted 1 mo. after CAl 250 mg. qid started and resolved 3 wks. after CAID/C CAl 250 mg. bid. No CD Sensitive to CAI-dose-related steroid responder PLS,OD 7/79-No CD
BERKE, et al • CHRONIC CHOROIDAL DETACHMENT
Table 2{ continued) Case No. Eye 11
DS
Age/Sex 65/F
Diagnosis
Surgery: date
COAG,OU
Medication
Choroidal Detachment
Choroidal Tap
Comment
Preop: T,OU CAl
Herpes Zoster Ophthalmic us, as 7/84 PLS 5/1/85
Postop: T a, D 5/85
ECCE & CT 10/30/85
#1 : 6/26/85
#1 : 6/27/85
#2: 6/28/85-8/19/85
#2: 8/19/85
#3: 8/20/85-10/30/85
#3: 10/30/85 w/ECCE #4: 11/8/85
#4: 11/1/85-11/8/85
No CD after filter. Developed large corneal epithelial defect 6/5/85 6/27/85 noted CD with flat AC CO #2 & #3 persistent
Required additional CT #4 1 week after ECCE & CT #3 No surgery as
C. Chronic choroidal detachment 12
as
73/F
COAG
Preop: CAl PLS 2/15/77
Postop: none
#1: 2/77-12/77
#1 : 12/8/77 w/ECCE
ECCE & CT 12/8/77
Had CD 10 mos. after PLS Resolved with cataract extraction & CT Trab, aD 7/77. No CD
Dis 10/78 13
as
75/F
COAG
Preop: T,OU PLS 10/80
Postop: T,OO 10/80-1/83
ICCE & CT 5/82
#1 : 10/80-5/82
#1 : 5/82 w/ICCE
CD 19 mos. Resolved cataract extraction & CT. PLS, aD 1/83. No CD
aD = right eye; as = left eye; Medication: CAl = carbonic anhydrase inhibitors (acetazolimide or methazolamide); T= timolol 0.5%; B= betaxalol; PI = echothiophate iodide; P= pilocarpine. Dx: COAG = chronic open-angle glaucoma; PXF = pseudoexfoliative syndrome; PDR = proliferative diabetic retinopathy; BRVO = branch retinal vein occlusion. Surgery: CT = choroidal tap; PLS = posterior lip sclerectomy; CCT = cyclocryotherapy; CYO = cyclodialysis; ICCE = intracapsular cataract extraction; DIS = discission- membrane; ECCE = extracapsular cataract extraction; Trab = trabeculectomy; 10L = intraocular lens.
or systemically (acetazolamide or methazolamide) was used preoperatively in all patients. Postoperatively, six eyes and eight contralateral eyes were treated with timolol. Five eyes developed a choroidal detachment within 6 weeks of introduction oftimolol (cases 1,2,5,9, and 11). Often, this choroidal detachment occurred months or years following filtration surgery only when timolol was introduced to treat an elevation in intraocular pressure. Three eyes had resolution of a chronic choroidal detachment when timolol therapy was stopped (cases 1, 8, and 10). However, two of these eyes (cases 1 and 8) have been treated successfully with betaxolol for more than nine months without recurrence of the choroidal detachment. In addition, 12 contralateral eyes were treated with timolol following filtration surgery and two eyes developed a choroidal detachment (cases 5 and 8). In two eyes and eight contralateral eyes, timolol therapy was continued
during the period of persistent recurrent choroidal detachment, but there was no temporal relationship between the development of the choroidal detachment and the institution of timolol therapy. This occurred during 26 episodes of choroidal detachment. Overall, 34 of 46 choroidal detachments occurred during aqueous suppressant therapy. Two eyes (cases 6 and 10) developed choroidal detachment following introduction of carbonic anhydrase inhibitors for elevation of intraocular pressure in the contralateral eye. The discontinuation of acetazolamide led to the resolution of choroidal detachment on only one occasion (case 10). Two eyes were observed for 5 years and three eyes for at least I year without any evidence of choroidal detachment prior to aqueous suppressant therapy. Echothiophate iodide caused significant intraocular inflammation and choroidal detachment in two eyes (cases 159
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2 and 10). Cyclocryotherapy caused significant intraocular inflammation and choroidal detachment in the same two eyes (cases 2 and 10) long after filtration surgery (Table 3). All 14 eyes developed visually significant cataracts following glaucoma filtration surgery and choroidal detachment. Twelve eyes had cataract extraction 180 0 from the filtration bleb 12.4 months (mean) following filtration surgery. The final resolution of recurrent or chronic choroidal detachments occurred by stopping aqueous suppressant therapy in two eyes (cases 1 and 10), by introducing systemic steroids in one eye (case 2), using topical steroids in one eye (case 10), repeated choroidal taps in four eyes (cases 3, 4, 5, right eye, and 11), and spontaneously in two eyes (cases 5, right eye, and 7). It was necessary to perform cataract extraction combined with choroidal tap in four eyes (cases 8, 9, 12, and 13) to finally resolve the recurrent choroidal effusions. Cataract surgery alone in one eye (case 1) and with a choroidal tap 1 week following cataract extraction combined with choroidal tap in one eye (case 11) were successful in treating the effusions. The control of intraocular pressure following filtration surgery and subsequent visual acuity are reported in Table 1. Thirteen of the 14 eyes had adequate final pressure control, while case 4 developed neovascular glaucoma associated with proliferative diabetic retinopathy. Three patients had profound loss of vision: case 4 due to proliferative diabetic retinopathy, case 2 due to macular degeneration, and case 6 due to visually significant cataract. Recently, case 11 has required enucleation for corneal ulceration and scleral melting associated with herpes zoster ophthalmicus.
DISCUSSION The development of a choroidal detachment following glaucoma filtration surgery is common and usually resolves spontaneously during the early postoperative period. Less conventional forms of choroidal detachments occur uncommonly. Nanophthalmic eyes may develop prolonged choroidal detachments spontaneously or following glaucoma surgery.9 These eyes and eyes with the uveal effusion syndrome lO are believed to have abnormally thick sclera that compresses the vortex veins and obstructs blood flow from the eye. Surgical decompression of the vortex veins has resulted in resolution of this form of chronic and recurrent choroidal effusions. II It is also known that patients with elevated episcleral venous pressure may develop acute intraoperative choroidal effusion during glaucoma surgery and may form extensive, postoperative combined retinal and choroidal detachments. 3,12 A posterior sclerotomy at the time of filtration surgery has reduced the intraoperative and postoperative complications of this form of choroidal detachment. 12 Severe scleritis,13 retinal detachment surgery,14 and retinal photocoagulation l5 have been reported to create a significant choroidal detachment even in the absence of documented hypotony. Some authors believe that chronic hypotony 160
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associated with a cyclodialysis cleft is due to prolonged choroidal detachment created by aqueous directed into and collected in the suprachoroidal space. 16 Very little is known about chronic or recurrent choroidal detachment after glaucoma surgery. 3 Recently , Vela and Campbe1l8 recognized four eyes that had glaucoma filtration surgery and developed profound hypotony and choroidal detachment when topical or systemic aqueous suppressant therapy was started for elevated intraocular pressure. These eyes had been treated with aqueous suppressant therapy prior to filtration surgery, and the authors hypothesized that the reintroduction of these agents caused a dramatic reduction of aqueous humor production with hypotony and choroidal detachment. We have defined three specific groups of chronic or recurrent choroidal detachment in this study. The institution of aqueous suppressant therapy is temporally related to the development of choroidal detachment in both the recurrent and the inflammatory groups. The third category, chronic choroidal detachments, included two eyes that had persistent choroidal detachments for 10 and 19 months and resolved with cataract surgery and choroidal tap. Of these patients, case 12 was on no medication during the 10 months of choroidal detachment, while case 13 was treated with timolol in the contralateral eye during the 19 months of detachment, and no recurrent detachment occurred during 7 additional months of contralateral betaxolol therapy. The group of recurrent choroidal detachments is typified by case 1, who developed a choroidal detachment persisting for 3 months after successful filtration surgery. Despite choroidal taps, she developed recurrent choroidal detachments for 10 and 18 months, which were resolved by successful cataract surgery. The patient maintained adequate intraocular pressure control and no evidence of choroidal detachment for 5 years while on topical timolol to her contralateral eye. When topical timolol was introduced to lower the intraocular pressure in the previously filtered eye, a large choroidal detachment with shallowing of the anterior chamber occurred. When timolol was stopped, the choroidal detachment resolved. It is of interest that use of topical betaxolol in the ipsilateral eye has been tolerated for more than 9 months without evidence of recurrent choroidal detachment. Other eyes in Group A (Table 2) developed recurrent or persistent choroidal detachments that lasted from 1 to 8 months and recurred at varying intervals with a variety of inciting events. It became obvious that institution of medications (echothiophate iodide, timolol, and carbonic anhydrase inhibitors), as well as surgical procedures (aphakic filtering procedures, and cyclocryotherapy), were all temporally related to the development of recurrent choroidal detachments. It seems likely that ocular tissues and specifically choroidal vasculature may have only a few possible responses to drug and surgical insult. One patient with extensive involvement of the vascular system (case 4) had long-standing diabetes mellitus with advanced diabetic nephropathy and retinopathy. He required three choroidal taps while phakic and three additional taps following cataract surgery. Subsequently, neovascular glau-
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Table 3. Possible Factors Related to Chronic and Recurrent Choroidal Detachment (CD) Elderly (mean age) Hypertension/ASHD Hyperopia Full-thickness filtering surgery Visually significant cataract Aqueous suppressant therapy Temporal relationship No temporal relationship Inflammation Cyclocryotherapy Echothiophate iodide ASHD
=
68.8 yrs. 10/13 pts. 10/14 eyes 12/14 eyes 14/14 eyes 8 CD 26 CD 10 CD 2 CD 2 CD
(7 eyes) (10 eyes) (4 eyes) (2 eyes) (2 eyes)
atherosclerotic heart disease.
coma developed with loss of functional vision. Other evidence for vascular disease in the form of hypertension or atherosclerotic heart disease was present in all but one of the eight patients in Group A and ten of the 13 patients in the entire study. Two of the patients in Group A had evidence of previous branch retinal vein occlusion in the involved eye (cases 5, right eye, and 7). Efforts to correlate vascular disorders have not been revealing, 3 whereas in the group of patients reported to be sensitive to aqueous suppressant therapy,8 three of the four patients were hypertensive and two had diabetes mellitus. Recognition of the relationship between aqueous suppressant therapy and the development of choroidal detachment must be emphasized. All of the eyes reported in this study were treated with topical or systemic aqueous suppressant therapy prior to filtration surgery. Sensitivity to these agents is exemplified by case 9, who was entirely asymptomatic 5 years following successful filtration surgery. Topical timolol was introduced in this eye and iritis and choroidal detachment developed 2 weeks later. The timolol was discontinued after the choroidal tap, and then started 1 month later. Nine months after reintroducing timolol, the eye again developed iritis and choroidal detachment. The sensitivity to both topical and systemic aqueous suppressants are manifested in case 10, who developed inflammation and choroidal detachment while on topical timolol for 1 year. A choroidal detachment resolved 3 months after the discontinuation of timolol, but recurred when acetazolamide 250 mg four times daily was introduced. The choroidal detachment resolved when acetazolamide was discontinued and has not recurred with acetazolamide in a lower dose, 250 mg twice daily. Many eyes are apparently extremely sensitive to aqueous suppressant therapy, topical or systemic, ipsilateral or contralateral. These agents may be responsible for the development and prolongation of choroidal detachment following filtration surgery. When confronted with eyes with chronic or recurrent choroidal detachment, discontinuation of all aqueous suppressant therapy for at least 1 to 2 months should be instituted in an effort to promote spontaneous resolution. Intraocular inflammation was associated with recurrent and chronic choroidal detachment in three eyes (Group B, Table 2). Three specific etiologies are noted: case 9
with recurrent endogenous uveitis, case 10 with severe iritis induced by echothiophate iodide, and case 11 with chronic inflammation secondary to herpes zoster ophthalmicus. It is well recognized that intraocular inflammation in the form of scleritis,12 episcleritis,17 and uveitis can cause choroidal detachment. More unusual forms of spontaneous choroidal detachments have been associated with uveitis following cataract surgery from 6 to 20 years later. 18,19 Eleven recurrent choroidal detachments that occurred in Group B were distinctly different from Group A, since none of the three eyes developed a significant choroidal detachment immediately after filtration surgery. These eyes were also sensitive to aqueous suppressant therapy, and inflammation caused by echothiophate iodide and cyclocryotherapy. In the chronic choroidal detachment category, Group C, two eyes developed chronic choroidal detachments that were present for more than 6 months following successful filtration surgery. The course was not as complex as in Groups A or B, and both eyes maintained adequate pressure control with functional filtering blebs despite the presence of large choroidal detachments. When cataract formation became visually significant, choroidal tap was performed in conjunction with cataract surgery and the choroidal detachment resolved. Since the choroidal detachment did not recur, it is impossible to actually determine whether choroidal tap alone would have been successful. The type of glaucoma surgery performed may effect the incidence of postoperative choroidal detachment. It may also relate to the incidence of chronic and recurrent choroidal detachments. It is well recognized that the lower intraocular pressure in the early postoperative period following full-thickness filtration surgery may account for the higher incidence of choroidal detachment. Thirteen of 14 eyes in this study had full-thickness filtering procedures. However, six eyes had contralateral filtering surgery with full-thickness procedures and two had trabeculectomies. Only one patient with bilateral full-thickness filters had bilateral recurrent choroidal detachments. Significant or prolonged choroidal detachment did not develop in the other contralateral eyes. In the eyes reported by Vela and Campbell, 8 three had trabeculectomies and, in a study of initial filtration surgery,20 the incidence of choroidal detachment was approximately 15% in both fullthickness and trabeculectomy operations. The observation that all 14 eyes in this study developed visually significant cataracts was unexpected, since only 30% of eyes requiring filtration surgery develop significant cataracts within 2 to 5 years. 3,20-22 The incidence of cataract formation following choroidal tap increases to only 40%.20 Christiansson23 reported that 50% of eyes with intraocular pressures less than 10 mmHg following filtration surgery developed significant cataract formation. In 4 of the 14 eyes in this study, a final intraocular pressure of less than 10 mmHg was established. However, all of the eyes had an intraocular pressure of less than 10 (4-8 mmHg) during the duration of their chronic or recurrent choroidal detachment. It is possible that the prolonged hypotony during the choroidal detachment contributed 161
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to the incidence of cataract formation and that recurrent inflammation, steroid therapy, possible lens-corneal touch, and even repeated surgical manipulation would increase the incidence of cataract formation. Each of these insults could result in an alteration in aqueous humor and cause inadequate lens nutrition or a mechanical alteration of lens metabolism. Following cataract surgery alone or when cataract surgery was combined with a choroidal tap, long-standing choroidal detachment resolved in seven eyes. Previous efforts to evacuate the choroidal effusion had been unsuccessful until cataract extraction was accomplished. It may be possible that cataract surgery contributed to the resolution of the choroidal detachment by producing postoperative inflammation resulting in a decreased filtering bleb function and a rise in intraocular pressure. Alternatively, possible cataract formation with swelling of the lens could displace the lens-iris diaphragm anteriorly and result in zonular traction on the ciliary body. This internal traction is reduced by cataract extraction and the choroid is able to reassume its physiologic position adjacent to sclera. Identification of eyes with a chronic or recurrent choroidal detachment is not difficult. However, management that results in resolution of the choroidal detachment with control of the intraocular pressure and preservation of vision is sometimes difficult. We recommend that eyes with chronic or recurrent choroidal detachment should have all forms of aqueous suppressant therapy stopped and endogenous inflammation treated vigorously. Additional agents that incite intraocular inflammation should be discontinued. Cataract surgery should be performed when the cataract is visually significant because cataract surgery in this series, especially in combination with choroidal tap, was associated with visual improvement as well as definitive resolution of the chronic choroidal detachment.
REFERENCES 1. Capper SA, Leopold IH. Mechanism of serous choroidal detachment: a review and experimental study. Arch Ophthalmol1956; 55:101-13. 2. Brav SS. Serous choroidal detachment. Surv Ophthalmol 1961; 6: 395-415.
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3. Bellows AR, Chylack LT Jr, Hutchinson BT. Choroidal detachment: clinical manifestation, therapy and mechanism of formation. Ophthalmology 1981; 88:1107-15. 4. Brubaker RF, Pederson JE. Ciliochoroidal detachment. Surv Ophthalmol 1983; 27:281-9. 5. Dobree JH. The nature of choroidal detachment fluid. Electrophoresis, clinical findings and treatment in eight cases of post-operative choroidal detachment. Trans Ophthalmol Soc UK 1961; 81 :113-23. 6. Pederson JE, Gaasterland DE, MacLellan HM. Experimental ciliochoroidal detachment: effect on intraocular pressure and aqueous humor flow. Arch Ophthalmol 1979; 97 :536-41. 7. Chylack LT Jr, Bellows AR. Molecular sieving in suprachoroidal fluid formation in man. Invest Ophthalmol Vis Sci 1978; 17:420-7. 8. Vela MA, Campbell DG. Hypotony and ciliochoroidal detachment following pharmacologic aqueous suppressant therapy in previously filtered patients. Ophthalmology 1985; 92:50-7. 9. Brockhurst RJ. Nanophthalmos with uveal effusion: a new clinical entity. Arch Ophthalmol1975; 93:1289-99. 10. Gass JDM, Jallow S. Idiopathic serous detachment of the choroid, ciliary body, and retina (uveal effusion syndrome). Ophthalmology 1982; 89:1018-32. 11. Brockhurst RJ. Vortex vein decompression for nanophthalmic uveal effusion. Arch Ophthalmol1980; 98:1987-90. 12. Bellows AR, Chylack LT, Epstein DL, Hutchinson BT. Choroidal effusion during glaucoma surgery in patients with prominent episcleral vessels. Arch Ophthalmol1979; 97:493-7. 13. Sears ML. Choroidal and retinal detachments associated with scleritis. Am J OphthalmoI1964; 58:764-6. 14. Hawkins WR, Schepens CL. Choroidal detachment and retinal surgery. A clinical and experimental study. Am J Ophthalmol 1966; 62: 813-9. 15. O'Connell EJA, Patterson G, Davies EWG. Choroidal detachment following photocoagulation in diabetes. Mod Prob Ophthalmol 1979; 20: 66-70. 16. Chandler PA, Maumenee AE. A major cause of hypotony. Am J Ophthalmol1961; 52:609-18. 17. Velzeboer CMJ. Spontaneous choroidal detachment: report of two cases. Am J Ophthalmol1960; 49:898-903. 18. McGrand JC. Choroidal detachment in aphakic uveitis. Br J Ophthalmol 1969; 53:778-81. 19. McClure HL. Massive bilateral choroidal detachment occurring in an aphakic patient six years and nine months postoperatively. Am J Ophthalmol1967; 63:295-7. 20. Lamping KA, Bellows AR, Hutchinson BT, Afran SI. Long-term evaluation of initial filtration surgery. Ophthalmology 1986; 93:91-101. 21. Sugar HS. Postoperative cataract in successfully filtering glaucomatous eyes. Am J Ophthalmol1970; 69:740-6. 22. Marion JR, Shields MB. Thermal sclerostomy and posterior lip sclerectomy: a comparative study. Ophthalmic Surg 1978; 9(6):67-75. 23. Christiansson J. Ocular hypotony after fistulizing glaucoma surgery. Acta Ophthalmol1967; 45:837-45.