Download Management of Choroidal Detachment and Shallow Anterior Chamber

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10.5005/jp-journals-10008-1091
Management of Choroidal Detachment and Shallow Anterior Chamber
CLINICAL PRACTICE
Management of Choroidal Detachment and
Shallow Anterior Chamber
Parul Ichhpujani, Suresh Kumar Gupta, Sunandan Sood
Department of Ophthalmology, Government Medical College and Hospital, Chandigarh, India
Correspondence: Parul Ichhpujani, Assistant Professor, Department of Ophthalmology, Government Medical College and
Hospital, Chandigarh, India, e-mail: [email protected]
ABSTRACT
Shallow anterior chamber and choroidal detachment are common complications after trabeculectomy. This review highlights the clinical
course and management options for various scenarios which can lead to shallow anterior chamber.
Keywords: Choroidal detachment, Choroidal hemorrhage, Glaucoma filtering surgery, Shallow anterior chamber.
SHALLOW ANTERIOR CHAMBER
POSTGLAUCOMA SURGERY
A shallow or flat anterior chamber (FAC) is common in early
postoperative period, especially in patients with preoperative
shallow chambers.1,2 The reported incidence of FAC after
trabeculectomy varies widely from 2 to 41%.2,3
Possibilities
a. Excessive outflow of aqueous humor, or
b. Decreased formation of aqueous humor, or
c. Both a and b.
Spaeth’s Classification of
Flat Anterior Chamber (Fig. 1)
Grade I: Peripheral—iris apposition
Grade II: Pupillary border—corneal apposition
Grade III: Lens—corneal touch.
CLINICAL PRESENTATIONS
A. Negative Seidel test with grade I or II flat anterior chamber
and low intraocular pressure (Fig. 2).
Management
•
•
Resolves spontaneously in 1 to 2 weeks
Conservative: Topical steroids and long acting cycloplegics;
in order to reduce inflammation and stabilize the blood
aqueous barrier4
• Restriction in activity (bending, weightlifting)
• Avoid Valsalva positive conditions, especially patients at
risk for suprachoroidal hemorrhage
• Focal compression of filtration site with a pressure patch
can decrease aqueous outflow and can promote chamber
reformation.
B. Positive Seidel test with grade I flat anterior chamber and
low intraocular pressure:
• Small leaks around sutures
Fig. 1: Classification of a flat anterior chamber [From ophthalmic
surgery: Principles and Practice (2nd ed). Philadelphia: WB Saunders
1990:370]
Journal of Current Glaucoma Practice, May-August 2011;5(2):39-43
Fig. 2: Postfiltration surgery iridocorneal touch
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Parul Ichhpujani et al
Management
•
•
•
Observe, small leaking tracts close without treatment
Increase the frequency of topical antibiotic to prevent
infection
Brisk leaks: Pressure patching or therapeutic contact lens.
Patient should be monitored on a daily basis.
– Fibrin tissue glue5,6 (Fig. 3) or cyanoacrylate glue can
be used to close an early wound leak. Glue is used over
dry conjunctival surface and a bandage contact lens can
prevent it from getting dislodged due to lid movement
(Fig. 4). In order to avoid risk of infection due to fibrin
adhesive derived from pooled plasma, autologous fibrin
adhesive may be derived from patient’s own blood.
– Simmons shell7 has been used by some physicians, but
the patients have to be monitored daily for signs of
infection and ocular surface abnormalities.
C. Positive Seidel test, low bleb height with grade II or III flat
anterior chamber and low intraocular pressure:
• Conjunctival button holes or wicks of extruding Tenon’s
capsule from the conjunctival incision
• Associated with high risk of bleb failure, corneal edema
and cataract.
Management
•
•
•
Reformation of the anterior chamber: Intraocular injection
of air, balanced salt solution (BSS) or viscoelastics. Sodium
hyaluronate (Healon) injection through the paracentesis tract
is commonly done.1,7 Monitor both the depth of the chamber
and the pressure of the globe (with a finger) as BSS or a
viscoelastic is injected (Table 1)
Dehiscence of the incision of conjunctival flap (Fig. 5):
Surgical repair
Conjunctival tear: Depends on whether conjunctiva is
healthy or fragile.
Healthy conjunctiva: Purse string suture with 10-0 nylon with
a noncutting, round, tapered needle.1
Fragile conjunctiva: Do not attempt purse string suture, it may
worsen the situation.
Try pressure patch or 20 to 22 mm bandage contact lens for
a few days, as it allows for conjunctival surface re-epithelization.
Fig. 3: Tisseel fibrin glue
Fig. 4: Bandage contact lens prevents conjunctival epithelial
disruption due to repeated lid excursion
Fig. 5: Conjunctival incision dehiscence with positive Seidel test
Table 1: Possible outcomes after chamber reformation with BSS or viscoelastic
IOP
Chamber depth
Bleb height
Possible cause
Low
Shallow
(forms and collapses)
Shallow
Deep
Deep
Increases
Excessive filtration
Remains shallow
Remains shallow
Increases
Aqueous misdirection or cyclodialysis cleft
Aqueous hyposecretion with occluded fistula
Aqueous hyposecretion with patent fistula
Low
Rises
Low
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JOCGP
Management of Choroidal Detachment and Shallow Anterior Chamber
•
•
•
•
•
Fig. 6: Uniformly shallow anterior chamber in an eye with
aqueous misdirection
The mechanism may involve traction on a posterior ciliary
artery associated with anterior displacement of the lens-iris
diaphragm and, in turn, the retina and choroid
Sudden onset of severe pain and deterioration of acuity is
the hallmark presentation. Fundus examination shows
detached dark red-brown choroidal elevation.17
The risk of SCH has been reported to be higher in patients
with high myopia, aphakia or pseudophakia, prior
vitrectomy, bleeding disorders and systemic hypertension.18
Early lysis of scleral flap sutures may produce hypotony
and should be avoided in the immediate postoperative period
in eyes at high risk
The functional and anatomic results of postsurgical
suprachoroidal hemorrhages are still poor, even though the
prognosis seems to have improved.
Management
If it does not show signs of healing by third day, plan meticulous
conjunctival repair to salvage the glaucoma procedure.
•
D. Uniformly shallow anterior chamber with elevated
intraocular pressure.
Causes: Aqueous misdirection8 or suprachoroidal hemorrhage.
•
Aqueous Misdirection
•
•
Predisposing factors include patients with angle closure
glaucoma (postfiltration surgery incidence of aqueous
misdirection being 2-4%), hyperopia or nanophthalmos
Rule out pupillary block (aqueous misdirection is seen in
presence of a patent iridectomy) (Fig. 6).
Management
•
•
•
•
•
Initial medical management with cycloplegic-mydriatic
agents, such as atropine 1% and phenylephrine 2.5% (to
relax the ciliary muscle, pull iris-lens diaphragm posteriorly
and deepen the central chamber) and an osmotic agent (20%
intravenous mannitol 1-2 mg/kg over 30 minutes)9
Aqueous secretion should be suppressed with beta blockers
or carbonic anhydrase inhibitors. Miotics are contraindicated
In cases unresponsive to medical therapy, anterior
hyaloidotomy in pseudophakic or aphakic patients and pars
plana vitrectomy in phakic patients can be considered.10,11
The most common method involves Nd:YAG laser
photodisruption of the anterior vitreous face through an
iridectomy or iridotomy hole or through the pupil
Lens extraction12 and intraoperative capsulotomy13 can be
considered, if vitrectomy alone fails to reverse the condition
Cyclodiode photocoagulation may also be done in refractory
cases.14
Suprachoroidal Hemorrhage
•
Seen in first postoperative week and is usually associated
with postoperative hypotony15,16
•
•
Drainage is more effective when the clot liquefies, typically
after 7 to 10 days. If there are no signs of resolution at this
juncture and the effusion is large, drainage might be
pursued17
A standard technique for drainage of choroidals includes
simultaneous anterior segment infusion of balanced salt
combined with a full-thickness radial sclerotomy 3 or 4 mm
posterior to the limbus, ideally over the meridian of the
highest choroidal effusion. Usually two separate quadrants
(commonly diametrically posed) are placed19,20
Vitrectomy is typically reserved only, if there is vitreous
incarceration in the anterior segment wound. Scleral
buckling is done, if there is true rhegmatogenous retinal
detachment or unresolvable peripheral vitreoretinal traction
Trabeculectomy techniques should be modified in eyes at
high risk. For example, as eyes with reduced structural
rigidity (e.g. prior vitrectomy) are at increased risk for
choroidal hemorrhage, one should avoid creating a large
sclerostomy, small scleral flap and loose scleral flap sutures
with rapid aqueous egress.
Choroidal Detachment
•
•
•
Choroidal detachments due to serous effusions in the
suprachoroidal space are a frequent occurrence after
glaucoma filtering or tube shunt surgery, especially in
association with hypotony (Fig. 7)21
Predisposing factors: Hyperopia, ocular inflammation,
systemic hypertension, atherosclerosis, aqueous suppressant
therapy22
With the use of adjunctive antimetabolites during
trabeculectomy, prolonged hypotony may lead to prolonged
or persistent choroidal detachments.
Clinical Scenario
•
•
Journal of Current Glaucoma Practice, May-August 2011;5(2):39-43
Low intraocular pressure (usually < 6 mm Hg, below episcleral
venous pressure), shallow peripheral anterior chamber
Fundus examination reveals a dome-shaped elevation of
the retinochoroid that is acoustically hollow on B scan
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Parul Ichhpujani et al
•
•
A deep anterior chamber can be maintained by an infusion
line connected to an anterior chamber maintainer through
the paracentesis (Fig. 8)23,24
In some cases, reformation of anterior chamber with sodium
hyaluronate can transiently elevate the intraocular pressure,
which can decrease the effusion, stimulate aqueous secretion
and break the vicious cycle of ciliary shutdown-choroidal
effusion.
Key Tips
•
•
Fig. 7: Shallow choroidal detachment
•
ultrasonography (Figs 8A and B). Ultrasonography helps
to evaluate the presence, extent and location of choroidal
detachment.
Management
Mild to Moderate Choroidal Detachment
•
•
•
Well tolerated with spontaneous resolution in most cases,
as intraocular pressure increases
Medical management includes frequent topical steroids and
cycloplegics as atropine 1%. Systemic steroids may be
needed in some cases
Systemic and topical aqueous suppressants in the fellow
eye should be discontinued.
Massive Choroidal Detachment with Prolonged
Retinal Apposition at the Posterior Pole
(Kissing Choroidals)
•
Surgical drainage: Sclerostomy is performed in one or both
inferior quadrants and a tangential incision is performed in
the sclera 4 mm posterior to the limbus
Treatment should aim at stabilizing the inflow of aqueous
and outflow through the fistula
Immediate intervention is required for grade III shallow
chambers while grade I or II can be managed conservatively
in the absence of a brisk wound leak
Serous choroidal detachment is usually self resolving while
hemorrhagic choroidal detachment needs surgical
evacuation after clot lyses.
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Figs 8A and B: Horizontal B-scan showing choroidal detachment, (A) shallow remnant choroidal detachment on third day
postchoroidal drainage, (B) anterior chamber reformation
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